Madison Medical Center

All Charges

Charge

Type

Setting

Price

SUMATRIPTAN (IMITREX) 6MG/0.5ML INJ

Facility

$496.00

Service Code	HCPCS J3030
Hospital Charge Code	2656236
Hospital Revenue Code	250
Rate for Payer: Cash Price	$446.40

SUMATRIPTAN (IMITREX) 6MG/0.5ML INJ

Facility

$496.00

Service Code	HCPCS J3030
Hospital Charge Code	2656236
Hospital Revenue Code	250
Min. Negotiated Rate	$178.56
Max. Negotiated Rate	$354.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$293.63
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$354.14
Rate for Payer: Cash Price	$446.40
Rate for Payer: UnitedHealthcare Commercial	$330.83
Rate for Payer: UnitedHealthcare Medicare Advantage	$178.56

SUPENSORY

Facility

$96.00

Hospital Charge Code	2819180
Hospital Revenue Code	271
Min. Negotiated Rate	$34.56
Max. Negotiated Rate	$68.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$56.83
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$68.54
Rate for Payer: Cash Price	$86.40
Rate for Payer: UnitedHealthcare Commercial	$64.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$34.56

SUPENSORY

Facility

$96.00

Hospital Charge Code	2819180
Hospital Revenue Code	271
Rate for Payer: Cash Price	$86.40

SUPREP BOWEL PREP KIT

Facility

$439.00

Service Code	NDC 5.2268E+10
Hospital Charge Code	2623442
Hospital Revenue Code	250
Min. Negotiated Rate	$158.04
Max. Negotiated Rate	$313.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$259.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$313.45
Rate for Payer: Cash Price	$395.10
Rate for Payer: UnitedHealthcare Commercial	$292.81
Rate for Payer: UnitedHealthcare Medicare Advantage	$158.04

SUPREP BOWEL PREP KIT

Facility

$439.00

Service Code	NDC 5.2268E+10
Hospital Charge Code	2623442
Hospital Revenue Code	250
Rate for Payer: Cash Price	$395.10

SUPREP BOWEL PREP KIT EMP

Facility

$439.00

Service Code	NDC 5.2268E+10
Hospital Charge Code	2623501
Hospital Revenue Code	250
Rate for Payer: Cash Price	$395.10

SUPREP BOWEL PREP KIT EMP

Facility

$439.00

Service Code	NDC 5.2268E+10
Hospital Charge Code	2623501
Hospital Revenue Code	250
Min. Negotiated Rate	$158.04
Max. Negotiated Rate	$313.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$259.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$313.45
Rate for Payer: Cash Price	$395.10
Rate for Payer: UnitedHealthcare Commercial	$292.81
Rate for Payer: UnitedHealthcare Medicare Advantage	$158.04

SURGERY CAPS

Facility

$15.00

Hospital Charge Code	283851
Hospital Revenue Code	271
Rate for Payer: Cash Price	$13.50

SURGERY CAPS

Facility

$15.00

Hospital Charge Code	283851
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

SURGERY MINOR (1ST 1/2 HOUR)

Facility

$1,771.00

Hospital Charge Code	1219199
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,593.90

SURGERY MINOR (1ST 1/2 HOUR)

Facility

$1,771.00

Hospital Charge Code	1219199
Hospital Revenue Code	360
Min. Negotiated Rate	$637.56
Max. Negotiated Rate	$1,181.26
Rate for Payer: Cash Price	$1,593.90
Rate for Payer: UnitedHealthcare Commercial	$1,181.26
Rate for Payer: UnitedHealthcare Medicare Advantage	$637.56

SURGERY MINOR (ADDITIONAL 1/2 HR)

Facility

$1,294.00

Hospital Charge Code	1219200
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,164.60

SURGERY MINOR (ADDITIONAL 1/2 HR)

Facility

$1,294.00

Hospital Charge Code	1219200
Hospital Revenue Code	360
Min. Negotiated Rate	$465.84
Max. Negotiated Rate	$863.10
Rate for Payer: Cash Price	$1,164.60
Rate for Payer: UnitedHealthcare Commercial	$863.10
Rate for Payer: UnitedHealthcare Medicare Advantage	$465.84

SURGERY-OUTPATIENT

Facility

$2,361.00

Hospital Charge Code	1219102
Hospital Revenue Code	360
Min. Negotiated Rate	$849.96
Max. Negotiated Rate	$1,574.79
Rate for Payer: Cash Price	$2,124.90
Rate for Payer: UnitedHealthcare Commercial	$1,574.79
Rate for Payer: UnitedHealthcare Medicare Advantage	$849.96

SURGERY-OUTPATIENT

Facility

$2,361.00

Hospital Charge Code	1219102
Hospital Revenue Code	360
Rate for Payer: Cash Price	$2,124.90

SURGICAL NERVE LOCATOR

Facility

$168.00

Hospital Charge Code	1256950
Hospital Revenue Code	271
Rate for Payer: Cash Price	$151.20

SURGICAL NERVE LOCATOR

Facility

$168.00

Hospital Charge Code	1256950
Hospital Revenue Code	271
Min. Negotiated Rate	$60.48
Max. Negotiated Rate	$119.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$99.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$119.95
Rate for Payer: Cash Price	$151.20
Rate for Payer: UnitedHealthcare Commercial	$112.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$60.48

SURGICAL PATTIES #80-1400

Facility

$65.00

Hospital Charge Code	128865
Hospital Revenue Code	271
Rate for Payer: Cash Price	$58.50

SURGICAL PATTIES #80-1400

Facility

$65.00

Hospital Charge Code	128865
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

SURGICAL SPECIMEN

Facility

$114.00

Service Code	CPT 76098
Hospital Charge Code	3776098
Hospital Revenue Code	329
Rate for Payer: Cash Price	$102.60

SURGICAL SPECIMEN

Facility

$114.00

Service Code	CPT 76098
Hospital Charge Code	3776098
Hospital Revenue Code	329
Min. Negotiated Rate	$41.04
Max. Negotiated Rate	$1,116.50
Rate for Payer: Aetna Better Health Medicaid/QHP	$492.57
Rate for Payer: Aetna Medicare Advantage	$558.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$67.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$81.40
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial HMO & PPO	$558.25
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$492.57
Rate for Payer: Home State Health Plan Medicaid Managed Care	$527.05
Rate for Payer: Home State Health Plan Medicare Advantage	$558.25
Rate for Payer: Humana Commercial	$1,116.50
Rate for Payer: Humana Medicare Advantage	$558.25
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$492.57
Rate for Payer: UnitedHealthcare Medicare Advantage	$41.04

SURGICAL TRAY

Facility

$47.00

Service Code	CPT A4550
Hospital Charge Code	4299073
Hospital Revenue Code	521
Rate for Payer: Cash Price	$42.30

SURGICAL TRAY

Facility

$47.00

Service Code	CPT A4550
Hospital Charge Code	4299073
Hospital Revenue Code	521
Min. Negotiated Rate	$27.82
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$27.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$33.56
Rate for Payer: Cash Price	$42.30
Rate for Payer: Cash Price	$42.30
Rate for Payer: UnitedHealthcare Commercial	$31.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

SURGICEL

Facility

$448.00

Hospital Charge Code	1219809
Hospital Revenue Code	271
Rate for Payer: Cash Price	$403.20

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All Charges