Madison Medical Center

All Charges

Charge

Type

Setting

Price

SPLINT WRIST COCKUP SM RIGHT

Facility

$240.00

Hospital Charge Code	2819916
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 XLG LEFT

Facility

$240.00

Hospital Charge Code	2819920
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 XLG LEFT

Facility

$240.00

Hospital Charge Code	2819920
Hospital Revenue Code	271
Rate for Payer: Cash Price	$216.00

SPLINT WRIST COCKUP XLG RIGHT

Facility

$240.00

Hospital Charge Code	2819921
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 XLG RIGHT

Facility

$240.00

Hospital Charge Code	2819921
Hospital Revenue Code	271
Rate for Payer: Cash Price	$216.00

SPLINT WRIST ECONOMY

Facility

$141.00

Hospital Charge Code	2819904
Hospital Revenue Code	271
Rate for Payer: Cash Price	$126.90

SPLINT WRIST ECONOMY

Facility

$141.00

Hospital Charge Code	2819904
Hospital Revenue Code	271
Min. Negotiated Rate	$50.76
Max. Negotiated Rate	$100.67
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$83.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$100.67
Rate for Payer: Cash Price	$126.90
Rate for Payer: UnitedHealthcare Commercial	$94.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$50.76

SPLINT WRIST ELASTIC

Facility

$106.00

Hospital Charge Code	2819905
Hospital Revenue Code	271
Rate for Payer: Cash Price	$95.40

SPLINT WRIST ELASTIC

Facility

$106.00

Hospital Charge Code	2819905
Hospital Revenue Code	271
Min. Negotiated Rate	$38.16
Max. Negotiated Rate	$75.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$62.75
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$75.68
Rate for Payer: Cash Price	$95.40
Rate for Payer: UnitedHealthcare Commercial	$70.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$38.16

SPLINT, WRIST STAT DEROYAL

Facility

$52.00

Hospital Charge Code	4070011
Hospital Revenue Code	271
Rate for Payer: Cash Price	$46.80

SPLINT, WRIST STAT DEROYAL

Facility

$52.00

Hospital Charge Code	4070011
Hospital Revenue Code	271
Min. Negotiated Rate	$18.72
Max. Negotiated Rate	$37.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$30.78
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$37.13
Rate for Payer: Cash Price	$46.80
Rate for Payer: UnitedHealthcare Commercial	$34.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.72

SPONGE 4X4 NON-STERILE

Facility

$39.00

Hospital Charge Code	2819438
Hospital Revenue Code	271
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$27.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.85
Rate for Payer: Cash Price	$35.10
Rate for Payer: UnitedHealthcare Commercial	$26.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.04

SPONGE 4X4 NON-STERILE

Facility

$39.00

Hospital Charge Code	2819438
Hospital Revenue Code	271
Rate for Payer: Cash Price	$35.10

SPONGE CURITY 4X4 (10 PAK)

Facility

$42.00

Hospital Charge Code	2819440
Hospital Revenue Code	271
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$29.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$24.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$29.99
Rate for Payer: Cash Price	$37.80
Rate for Payer: UnitedHealthcare Commercial	$28.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.12

SPONGE CURITY 4X4 (10 PAK)

Facility

$42.00

Hospital Charge Code	2819440
Hospital Revenue Code	271
Rate for Payer: Cash Price	$37.80

SPONGE,CURITY 4X4 GAUZE (2 PER PK)

Facility

$16.00

Hospital Charge Code	283350
Hospital Revenue Code	271
Rate for Payer: Cash Price	$14.40

SPONGE,CURITY 4X4 GAUZE (2 PER PK)

Facility

$16.00

Hospital Charge Code	283350
Hospital Revenue Code	271
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$11.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$9.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$11.42
Rate for Payer: Cash Price	$14.40
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.76

SPONGE GAUZE 2INX2IN STERILE

Facility

$16.00

Hospital Charge Code	2819437
Hospital Revenue Code	272
Rate for Payer: Cash Price	$14.40

SPONGE GAUZE 2INX2IN STERILE

Facility

$16.00

Hospital Charge Code	2819437
Hospital Revenue Code	272
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$11.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$9.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$11.42
Rate for Payer: Cash Price	$14.40
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.76

SPONGE, LAP

Facility

$39.00

Hospital Charge Code	2819483
Hospital Revenue Code	271
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$27.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.85
Rate for Payer: Cash Price	$35.10
Rate for Payer: UnitedHealthcare Commercial	$26.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.04

SPONGE, LAP

Facility

$39.00

Hospital Charge Code	2819483
Hospital Revenue Code	271
Rate for Payer: Cash Price	$35.10

SPONGE,PEANUT

Facility

$18.00

Hospital Charge Code	123350
Hospital Revenue Code	271
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$12.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$10.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$12.85
Rate for Payer: Cash Price	$16.20
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.48

SPONGE,PEANUT

Facility

$18.00

Hospital Charge Code	123350
Hospital Revenue Code	271
Rate for Payer: Cash Price	$16.20

SPONGE X-RAY 4IN 4IN #7317

Facility

$39.00

Hospital Charge Code	2824440
Hospital Revenue Code	271
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$27.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.85
Rate for Payer: Cash Price	$35.10
Rate for Payer: UnitedHealthcare Commercial	$26.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.04

SPONGE X-RAY 4IN 4IN #7317

Facility

$39.00

Hospital Charge Code	2824440
Hospital Revenue Code	271
Rate for Payer: Cash Price	$35.10

Know your out-of-pocket cost for care.

All Charges