Madison Medical Center

All Charges

Charge

Type

Setting

Price

SPLINT SCOTCHCAST 3 X12

Facility

$24.00

Hospital Charge Code	2819434
Hospital Revenue Code	271
Rate for Payer: Cash Price	$21.60

SPLINT SHRT FOREARM TO HAND

Professional

Both

$326.00

Service Code	CPT 29125
Hospital Charge Code	1829125
Hospital Revenue Code	981
Min. Negotiated Rate	$38.01
Max. Negotiated Rate	$114.10
Rate for Payer: Aetna Commercial/Medicare Advantage	$38.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$48.74
Rate for Payer: Cash Price	$293.40
Rate for Payer: Cash Price	$293.40
Rate for Payer: Cigna Commercial HMO & PPO	$38.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$48.74
Rate for Payer: Home State Health Plan Medicaid Managed Care	$53.61
Rate for Payer: Home State Health Plan Medicare Advantage	$38.01
Rate for Payer: Optum Medicare Advantage	$114.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$48.74

SPLINTS,J&J SPECIALIST 3

Facility

$15.00

Hospital Charge Code	4070019
Hospital Revenue Code	271
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$10.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$8.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$10.71
Rate for Payer: Cash Price	$13.50
Rate for Payer: UnitedHealthcare Commercial	$10.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.40

SPLINTS,J&J SPECIALIST 3

Facility

$15.00

Hospital Charge Code	4070019
Hospital Revenue Code	271
Rate for Payer: Cash Price	$13.50

SPLINTS,J&J SPECIALIST 4

Facility

$15.00

Hospital Charge Code	4070021
Hospital Revenue Code	271
Rate for Payer: Cash Price	$13.50

SPLINTS,J&J SPECIALIST 4

Facility

$15.00

Hospital Charge Code	4070021
Hospital Revenue Code	271
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$10.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$8.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$10.71
Rate for Payer: Cash Price	$13.50
Rate for Payer: UnitedHealthcare Commercial	$10.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.40

SPLINTS,J&J SPECIALIST 5

Facility

$15.00

Hospital Charge Code	4070023
Hospital Revenue Code	271
Rate for Payer: Cash Price	$13.50

SPLINTS,J&J SPECIALIST 5

Facility

$15.00

Hospital Charge Code	4070023
Hospital Revenue Code	271
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$10.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$8.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$10.71
Rate for Payer: Cash Price	$13.50
Rate for Payer: UnitedHealthcare Commercial	$10.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.40

SPLINT, WRIST-ALL SIZES

Facility

$65.00

Hospital Charge Code	4070009
Hospital Revenue Code	271
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$46.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$38.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$46.41
Rate for Payer: Cash Price	$58.50
Rate for Payer: UnitedHealthcare Commercial	$43.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$23.40

SPLINT, WRIST-ALL SIZES

Facility

$65.00

Hospital Charge Code	4070009
Hospital Revenue Code	271
Rate for Payer: Cash Price	$58.50

SPLINT WRIST COCKUP LG LEFT

Facility

$240.00

Hospital Charge Code	2819918
Hospital Revenue Code	271
Min. Negotiated Rate	$86.40
Max. Negotiated Rate	$171.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$142.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$171.36
Rate for Payer: Cash Price	$216.00
Rate for Payer: UnitedHealthcare Commercial	$160.08
Rate for Payer: UnitedHealthcare Medicare Advantage	$86.40

SPLINT WRIST COCKUP LG LEFT

Facility

$240.00

Hospital Charge Code	2819918
Hospital Revenue Code	271
Rate for Payer: Cash Price	$216.00

SPLINT WRIST COCKUP LG RIGHT

Facility

$240.00

Hospital Charge Code	2819919
Hospital Revenue Code	271
Min. Negotiated Rate	$86.40
Max. Negotiated Rate	$171.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$142.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$171.36
Rate for Payer: Cash Price	$216.00
Rate for Payer: UnitedHealthcare Commercial	$160.08
Rate for Payer: UnitedHealthcare Medicare Advantage	$86.40

SPLINT WRIST COCKUP LG RIGHT

Facility

$240.00

Hospital Charge Code	2819919
Hospital Revenue Code	271
Rate for Payer: Cash Price	$216.00

SPLINT WRIST COCKUP MED LEFT

Facility

$240.00

Hospital Charge Code	2819917
Hospital Revenue Code	271
Min. Negotiated Rate	$86.40
Max. Negotiated Rate	$171.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$142.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$171.36
Rate for Payer: Cash Price	$216.00
Rate for Payer: UnitedHealthcare Commercial	$160.08
Rate for Payer: UnitedHealthcare Medicare Advantage	$86.40

SPLINT WRIST COCKUP MED LEFT

Facility

$240.00

Hospital Charge Code	2819917
Hospital Revenue Code	271
Rate for Payer: Cash Price	$216.00

SPLINT WRIST COCKUP MED RIGHT

Facility

$240.00

Hospital Charge Code	2819903
Hospital Revenue Code	271
Rate for Payer: Cash Price	$216.00

SPLINT WRIST COCKUP MED RIGHT

Facility

$240.00

Hospital Charge Code	2819903
Hospital Revenue Code	271
Min. Negotiated Rate	$86.40
Max. Negotiated Rate	$171.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$142.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$171.36
Rate for Payer: Cash Price	$216.00
Rate for Payer: UnitedHealthcare Commercial	$160.08
Rate for Payer: UnitedHealthcare Medicare Advantage	$86.40

SPLINT WRIST COCKUP PED LEFT

Facility

$240.00

Hospital Charge Code	2819913
Hospital Revenue Code	271
Rate for Payer: Cash Price	$216.00

SPLINT WRIST COCKUP PED LEFT

Facility

$240.00

Hospital Charge Code	2819913
Hospital Revenue Code	271
Min. Negotiated Rate	$86.40
Max. Negotiated Rate	$171.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$142.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$171.36
Rate for Payer: Cash Price	$216.00
Rate for Payer: UnitedHealthcare Commercial	$160.08
Rate for Payer: UnitedHealthcare Medicare Advantage	$86.40

SPLINT WRIST COCKUP PED RIGHT

Facility

$240.00

Hospital Charge Code	2819914
Hospital Revenue Code	271
Min. Negotiated Rate	$86.40
Max. Negotiated Rate	$171.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$142.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$171.36
Rate for Payer: Cash Price	$216.00
Rate for Payer: UnitedHealthcare Commercial	$160.08
Rate for Payer: UnitedHealthcare Medicare Advantage	$86.40

SPLINT WRIST COCKUP PED RIGHT

Facility

$240.00

Hospital Charge Code	2819914
Hospital Revenue Code	271
Rate for Payer: Cash Price	$216.00

SPLINT WRIST COCKUP SM LEFT

Facility

$240.00

Hospital Charge Code	2819915
Hospital Revenue Code	271
Min. Negotiated Rate	$86.40
Max. Negotiated Rate	$171.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$142.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$171.36
Rate for Payer: Cash Price	$216.00
Rate for Payer: UnitedHealthcare Commercial	$160.08
Rate for Payer: UnitedHealthcare Medicare Advantage	$86.40

SPLINT WRIST COCKUP SM LEFT

Facility

$240.00

Hospital Charge Code	2819915
Hospital Revenue Code	271
Rate for Payer: Cash Price	$216.00

SPLINT WRIST COCKUP SM RIGHT

Facility

$240.00

Hospital Charge Code	2819916
Hospital Revenue Code	271
Rate for Payer: Cash Price	$216.00

Know your out-of-pocket cost for care.

All Charges