Madison Medical Center

All Charges

Charge

Type

Setting

Price

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC

Facility

$60,392.82

Service Code	MSDRG 279
Min. Negotiated Rate	$30,196.41
Max. Negotiated Rate	$60,392.82
Rate for Payer: Aetna Medicare Advantage	$30,196.41
Rate for Payer: Cigna Commercial HMO & PPO	$30,196.41
Rate for Payer: Home State Health Plan Medicare Advantage	$30,196.41
Rate for Payer: Humana Commercial	$60,392.82
Rate for Payer: Humana Medicare Advantage	$30,196.41

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM

Facility

$50,413.94

Service Code	MSDRG 173
Min. Negotiated Rate	$25,206.97
Max. Negotiated Rate	$50,413.94
Rate for Payer: Humana Commercial	$50,413.94
Rate for Payer: Aetna Medicare Advantage	$25,206.97
Rate for Payer: Cigna Commercial HMO & PPO	$25,206.97
Rate for Payer: Home State Health Plan Medicare Advantage	$25,206.97
Rate for Payer: Humana Medicare Advantage	$25,206.97

ULTRASOUND/AMMINO

Facility

$282.00

Service Code	CPT 76946
Hospital Charge Code	4276946
Hospital Revenue Code	521
Rate for Payer: Cash Price	$253.80

ULTRASOUND/AMMINO

Facility

$282.00

Service Code	CPT 76946
Hospital Charge Code	4276946
Hospital Revenue Code	521
Min. Negotiated Rate	$166.94
Max. Negotiated Rate	$201.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$166.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$201.35
Rate for Payer: Cash Price	$253.80
Rate for Payer: Cash Price	$253.80
Rate for Payer: UnitedHealthcare Commercial	$188.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

ULTRASOUND/COMPLETE OB

Facility

$358.00

Service Code	CPT 76805
Hospital Charge Code	4276805
Hospital Revenue Code	521
Rate for Payer: Cash Price	$322.20

ULTRASOUND/COMPLETE OB

Facility

$358.00

Service Code	CPT 76805
Hospital Charge Code	4276805
Hospital Revenue Code	521
Min. Negotiated Rate	$84.82
Max. Negotiated Rate	$255.61
Rate for Payer: Aetna Better Health Medicaid/QHP	$94.24
Rate for Payer: Aetna Medicare Advantage	$106.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$211.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$255.61
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cigna Commercial HMO & PPO	$106.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$84.82
Rate for Payer: Home State Health Plan Medicaid Managed Care	$100.84
Rate for Payer: Home State Health Plan Medicare Advantage	$106.81
Rate for Payer: Humana Commercial	$213.62
Rate for Payer: Humana Medicare Advantage	$106.81
Rate for Payer: UnitedHealthcare Commercial	$238.79
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$94.24
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

ULTRASOUND GUIDANCE FOR NEEDLE PLACEMENT

Professional

Both

$720.00

Service Code	CPT 76942
Hospital Charge Code	9376942
Hospital Revenue Code	975
Min. Negotiated Rate	$58.43
Max. Negotiated Rate	$252.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$58.43
Rate for Payer: Cash Price	$648.00
Rate for Payer: Cash Price	$648.00
Rate for Payer: Cigna Commercial HMO & PPO	$58.43
Rate for Payer: Home State Health Plan Medicare Advantage	$58.43
Rate for Payer: Optum Medicare Advantage	$252.00

ULTRASOUND/LIMITED OB

Facility

$170.00

Service Code	CPT 76815
Hospital Charge Code	4276815
Hospital Revenue Code	521
Rate for Payer: Cash Price	$153.00

ULTRASOUND/LIMITED OB

Facility

$170.00

Service Code	CPT 76815
Hospital Charge Code	4276815
Hospital Revenue Code	521
Min. Negotiated Rate	$84.82
Max. Negotiated Rate	$213.62
Rate for Payer: Aetna Better Health Medicaid/QHP	$94.24
Rate for Payer: Aetna Medicare Advantage	$106.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$100.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$121.38
Rate for Payer: Cash Price	$153.00
Rate for Payer: Cash Price	$153.00
Rate for Payer: Cash Price	$153.00
Rate for Payer: Cash Price	$153.00
Rate for Payer: Cigna Commercial HMO & PPO	$106.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$84.82
Rate for Payer: Home State Health Plan Medicaid Managed Care	$100.84
Rate for Payer: Home State Health Plan Medicare Advantage	$106.81
Rate for Payer: Humana Commercial	$213.62
Rate for Payer: Humana Medicare Advantage	$106.81
Rate for Payer: UnitedHealthcare Commercial	$113.39
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$94.24
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

ULTRASOUND TRANSRECTAL

Professional

Both

$750.00

Service Code	CPT 76872
Hospital Charge Code	9376872
Hospital Revenue Code	975
Min. Negotiated Rate	$68.70
Max. Negotiated Rate	$262.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$106.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$68.70
Rate for Payer: Cash Price	$675.00
Rate for Payer: Cash Price	$675.00
Rate for Payer: Cigna Commercial HMO & PPO	$106.80
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$68.70
Rate for Payer: Home State Health Plan Medicaid Managed Care	$75.57
Rate for Payer: Home State Health Plan Medicare Advantage	$106.80
Rate for Payer: Optum Medicare Advantage	$262.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$68.70

UNA BOOT

Facility

$150.00

Service Code	CPT 29580
Hospital Charge Code	9229580
Hospital Revenue Code	521
Min. Negotiated Rate	$88.80
Max. Negotiated Rate	$332.04
Rate for Payer: Aetna Better Health Medicaid/QHP	$146.48
Rate for Payer: Aetna Medicare Advantage	$166.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$88.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$107.10
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial HMO & PPO	$166.02
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$131.83
Rate for Payer: Home State Health Plan Medicaid Managed Care	$156.73
Rate for Payer: Home State Health Plan Medicare Advantage	$166.02
Rate for Payer: Humana Commercial	$332.04
Rate for Payer: Humana Medicare Advantage	$166.02
Rate for Payer: UnitedHealthcare Commercial	$100.05
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$146.48
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

UNA BOOT

Facility

$150.00

Service Code	CPT 29580
Hospital Charge Code	9429580
Hospital Revenue Code	521
Min. Negotiated Rate	$88.80
Max. Negotiated Rate	$332.04
Rate for Payer: Aetna Better Health Medicaid/QHP	$146.48
Rate for Payer: Aetna Medicare Advantage	$166.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$88.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$107.10
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial HMO & PPO	$166.02
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$131.83
Rate for Payer: Home State Health Plan Medicaid Managed Care	$156.73
Rate for Payer: Home State Health Plan Medicare Advantage	$166.02
Rate for Payer: Humana Commercial	$332.04
Rate for Payer: Humana Medicare Advantage	$166.02
Rate for Payer: UnitedHealthcare Commercial	$100.05
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$146.48
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

UNA BOOT

Facility

$150.00

Service Code	CPT 29580
Hospital Charge Code	9429580
Hospital Revenue Code	521
Rate for Payer: Cash Price	$135.00

UNA BOOT

Facility

$150.00

Service Code	CPT 29580
Hospital Charge Code	9229580
Hospital Revenue Code	521
Rate for Payer: Cash Price	$135.00

UNCOMPLICATED PEPTIC ULCER WITH MCC

Facility

$25,252.78

Service Code	MSDRG 383
Min. Negotiated Rate	$12,626.39
Max. Negotiated Rate	$25,252.78
Rate for Payer: Aetna Medicare Advantage	$12,626.39
Rate for Payer: Cigna Commercial HMO & PPO	$12,626.39
Rate for Payer: Home State Health Plan Medicare Advantage	$12,626.39
Rate for Payer: Humana Commercial	$25,252.78
Rate for Payer: Humana Medicare Advantage	$12,626.39

UNCOMPLICATED PEPTIC ULCER WITHOUT MCC

Facility

$17,021.62

Service Code	MSDRG 384
Min. Negotiated Rate	$8,510.81
Max. Negotiated Rate	$17,021.62
Rate for Payer: Aetna Medicare Advantage	$8,510.81
Rate for Payer: Cigna Commercial HMO & PPO	$8,510.81
Rate for Payer: Home State Health Plan Medicare Advantage	$8,510.81
Rate for Payer: Humana Commercial	$17,021.62
Rate for Payer: Humana Medicare Advantage	$8,510.81

UNDER BUTTOCKS DRAPE

Facility

$18.00

Hospital Charge Code	124776
Hospital Revenue Code	271
Rate for Payer: Cash Price	$16.20

UNDER BUTTOCKS DRAPE

Facility

$18.00

Hospital Charge Code	124776
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

UNDERCAST PADDING 4 X40

Facility

$21.00

Hospital Charge Code	2823331
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

UNDERCAST PADDING 4 X40

Facility

$21.00

Hospital Charge Code	2823331
Hospital Revenue Code	271
Rate for Payer: Cash Price	$18.90

UNDERPAD LARGE, SINGLE

Facility

$20.00

Hospital Charge Code	2821706
Hospital Revenue Code	271
Rate for Payer: Cash Price	$18.00

UNDERPAD LARGE, SINGLE

Facility

$20.00

Hospital Charge Code	2821706
Hospital Revenue Code	271
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$14.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$11.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.28
Rate for Payer: Cash Price	$18.00
Rate for Payer: UnitedHealthcare Commercial	$13.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.20

UNDERPAD/PKG

Facility

$39.00

Hospital Charge Code	2821708
Hospital Revenue Code	271
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$27.85
Rate for Payer: Cash Price	$35.10
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: UnitedHealthcare Commercial	$26.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.04

UNDERPAD/PKG

Facility

$39.00

Hospital Charge Code	2821708
Hospital Revenue Code	271
Rate for Payer: Cash Price	$35.10

UNITHROID 125MCG TAB EMP

Facility

$45.00

Service Code	NDC 74706890
Hospital Charge Code	2698417
Hospital Revenue Code	250
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$32.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$32.13
Rate for Payer: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.20

Know your out-of-pocket cost for care.

All Charges