Madison Medical Center

All Charges

Charge

Type

Setting

Price

SURG TECH COMP 88313

Facility

$273.00

Service Code	CPT 88313
Hospital Charge Code	228802
Hospital Revenue Code	305
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$271.86
Rate for Payer: Aetna Better Health Medicaid/QHP	$119.94
Rate for Payer: Aetna Medicare Advantage	$135.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$161.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$194.92
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cigna Commercial HMO & PPO	$135.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$119.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$128.34
Rate for Payer: Home State Health Plan Medicare Advantage	$135.93
Rate for Payer: Humana Commercial	$271.86
Rate for Payer: Humana Medicare Advantage	$135.93
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$98.28

SURG TECH COMP 88313

Facility

$273.00

Service Code	CPT 88313
Hospital Charge Code	228802
Hospital Revenue Code	305
Rate for Payer: Cash Price	$245.70

SUSEQ HOSP CARE I/P

Facility

$128.00

Service Code	CPT 99231
Hospital Charge Code	5499231
Rate for Payer: Cash Price	$115.20

SUTAB 1.479GM TAB 24 EMP

Facility

$439.00

Service Code	NDC 5.2268E+10
Hospital Charge Code	2626093
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

SUTAB 1.479GM TAB 24 EMP

Facility

$439.00

Service Code	NDC 5.2268E+10
Hospital Charge Code	2626093
Hospital Revenue Code	250
Rate for Payer: Cash Price	$395.10

SUTURE, 0 NUROLON CT-2--C527D

Facility

$55.00

Hospital Charge Code	2819071
Hospital Revenue Code	272
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$39.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.80

SUTURE, 0 NUROLON CT-2--C527D

Facility

$55.00

Hospital Charge Code	2819071
Hospital Revenue Code	272
Rate for Payer: Cash Price	$49.50

SUTURE, 0 PROLENE CT-2--8412H

Facility

$15.00

Hospital Charge Code	2819072
Hospital Revenue Code	272
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

SUTURE, 0 PROLENE CT-2--8412H

Facility

$15.00

Hospital Charge Code	2819072
Hospital Revenue Code	272
Rate for Payer: Cash Price	$13.50

SUTURE, 1 PROLENE CT-1

Facility

$15.00

Hospital Charge Code	2818038
Hospital Revenue Code	272
Rate for Payer: Cash Price	$13.50

SUTURE, 1 PROLENE CT-1

Facility

$15.00

Hospital Charge Code	2818038
Hospital Revenue Code	272
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

SUTURE, 2-0 SILK SA65H

Facility

$22.00

Hospital Charge Code	2819075
Hospital Revenue Code	271
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

SUTURE, 2-0 SILK SA65H

Facility

$22.00

Hospital Charge Code	2819075
Hospital Revenue Code	271
Rate for Payer: Cash Price	$19.80

SUTURE, 3-0 PERMA HAND SILK #A184H

Facility

$22.00

Hospital Charge Code	2819074
Hospital Revenue Code	271
Rate for Payer: Cash Price	$19.80

SUTURE, 3-0 PERMA HAND SILK #A184H

Facility

$22.00

Hospital Charge Code	2819074
Hospital Revenue Code	271
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

SUTURE, 4-0 VICRYL 27 PS-2 J426H

Facility

$22.00

Hospital Charge Code	2819076
Hospital Revenue Code	271
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

SUTURE, 4-0 VICRYL 27 PS-2 J426H

Facility

$22.00

Hospital Charge Code	2819076
Hospital Revenue Code	271
Rate for Payer: Cash Price	$19.80

SUTURE, 4-0 VICRYL P-3 18 J494G

Facility

$21.00

Hospital Charge Code	2819066
Hospital Revenue Code	271
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

SUTURE, 4-0 VICRYL P-3 18 J494G

Facility

$21.00

Hospital Charge Code	2819066
Hospital Revenue Code	271
Rate for Payer: Cash Price	$18.90

SUTURE,5.0 CHROMIC GUT P3 #687G

Facility

$35.00

Hospital Charge Code	2819045
Hospital Revenue Code	271
Rate for Payer: Cash Price	$31.50

SUTURE,5.0 CHROMIC GUT P3 #687G

Facility

$35.00

Hospital Charge Code	2819045
Hospital Revenue Code	271
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$24.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$20.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$24.99
Rate for Payer: Cash Price	$31.50
Rate for Payer: UnitedHealthcare Commercial	$23.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.60

SUTURE, 5-0 VICRYL P-2

Facility

$21.00

Hospital Charge Code	2819088
Hospital Revenue Code	271
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

SUTURE, 5-0 VICRYL P-2

Facility

$21.00

Hospital Charge Code	2819088
Hospital Revenue Code	271
Rate for Payer: Cash Price	$18.90

SUTURE, 6.0 CHROMIC GUT PS-4 #1641G

Facility

$35.00

Hospital Charge Code	2819046
Hospital Revenue Code	271
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$24.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$20.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$24.99
Rate for Payer: Cash Price	$31.50
Rate for Payer: UnitedHealthcare Commercial	$23.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.60

SUTURE, 6.0 CHROMIC GUT PS-4 #1641G

Facility

$35.00

Hospital Charge Code	2819046
Hospital Revenue Code	271
Rate for Payer: Cash Price	$31.50

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All Charges