Madison Medical Center

All Charges

Charge

Type

Setting

Price

WEGOVY 4MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627151
Hospital Revenue Code	250
Min. Negotiated Rate	$49.32
Max. Negotiated Rate	$97.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$81.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$97.82
Rate for Payer: Cash Price	$123.30
Rate for Payer: UnitedHealthcare Commercial	$91.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$49.32

WEGOVY 9MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627152
Hospital Revenue Code	250
Min. Negotiated Rate	$49.32
Max. Negotiated Rate	$97.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$81.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$97.82
Rate for Payer: Cash Price	$123.30
Rate for Payer: UnitedHealthcare Commercial	$91.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$49.32

WEGOVY 9MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627152
Hospital Revenue Code	250
Rate for Payer: Cash Price	$123.30

WEST NILE IGG IGM

Facility

$364.00

Hospital Charge Code	2286780
Hospital Revenue Code	302
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$259.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$215.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$259.90
Rate for Payer: Cash Price	$327.60
Rate for Payer: Cash Price	$327.60
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$131.04

WEST NILE IGG IGM

Facility

$364.00

Hospital Charge Code	2286780
Hospital Revenue Code	302
Rate for Payer: Cash Price	$327.60

WET PREP

Facility

$79.00

Service Code	CPT 87210
Hospital Charge Code	3087206
Hospital Revenue Code	306
Min. Negotiated Rate	$5.24
Max. Negotiated Rate	$56.41
Rate for Payer: Aetna Better Health Medicaid/QHP	$5.24
Rate for Payer: Aetna Medicare Advantage	$5.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$46.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$56.41
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial HMO & PPO	$5.82
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5.24
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5.61
Rate for Payer: Home State Health Plan Medicare Advantage	$5.82
Rate for Payer: Humana Commercial	$11.64
Rate for Payer: Humana Medicare Advantage	$5.82
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5.24
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.44

WET PREP

Facility

$79.00

Service Code	CPT 87210
Hospital Charge Code	3087206
Hospital Revenue Code	306
Rate for Payer: Cash Price	$71.10

WHITE BLOOD CELL COUNT (WBC)

Facility

$42.00

Service Code	CPT 85048
Hospital Charge Code	2223103
Hospital Revenue Code	305
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$29.99
Rate for Payer: Aetna Better Health Medicaid/QHP	$2.29
Rate for Payer: Aetna Medicare Advantage	$2.54
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: Cash Price	$37.80
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial HMO & PPO	$2.54
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$2.29
Rate for Payer: Home State Health Plan Medicaid Managed Care	$2.45
Rate for Payer: Home State Health Plan Medicare Advantage	$2.54
Rate for Payer: Humana Commercial	$5.08
Rate for Payer: Humana Medicare Advantage	$2.54
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$2.29
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.12

WHITE BLOOD CELL COUNT (WBC)

Facility

$42.00

Service Code	CPT 85048
Hospital Charge Code	2223103
Hospital Revenue Code	305
Rate for Payer: Cash Price	$37.80

WIKI POUCH

Facility

$7.00

Hospital Charge Code	285333
Hospital Revenue Code	271
Rate for Payer: Cash Price	$6.30

WIKI POUCH

Facility

$7.00

Hospital Charge Code	285333
Hospital Revenue Code	271
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$4.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$5.00
Rate for Payer: Cash Price	$6.30
Rate for Payer: UnitedHealthcare Commercial	$4.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$2.52

WITCH HAZEL PREMOISTENED PADS #40

Facility

$28.00

Service Code	NDC 5.0289E+10
Hospital Charge Code	2620526
Hospital Revenue Code	250
Rate for Payer: Cash Price	$25.20

WITCH HAZEL PREMOISTENED PADS #40

Facility

$28.00

Service Code	NDC 5.0289E+10
Hospital Charge Code	2620526
Hospital Revenue Code	250
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$19.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$16.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.99
Rate for Payer: Cash Price	$25.20
Rate for Payer: UnitedHealthcare Commercial	$18.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.08

WOOL, LAMBS

Facility

$15.00

Hospital Charge Code	4070020
Hospital Revenue Code	271
Rate for Payer: Cash Price	$13.50

WOOL, LAMBS

Facility

$15.00

Hospital Charge Code	4070020
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

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$52,601.86

Service Code	MSDRG 464
Min. Negotiated Rate	$26,300.93
Max. Negotiated Rate	$52,601.86
Rate for Payer: Aetna Medicare Advantage	$26,300.93
Rate for Payer: Cigna Commercial HMO & PPO	$26,300.93
Rate for Payer: Home State Health Plan Medicare Advantage	$26,300.93
Rate for Payer: Humana Commercial	$52,601.86
Rate for Payer: Humana Medicare Advantage	$26,300.93

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$93,612.08

Service Code	MSDRG 463
Min. Negotiated Rate	$46,806.04
Max. Negotiated Rate	$93,612.08
Rate for Payer: Aetna Medicare Advantage	$46,806.04
Rate for Payer: Cigna Commercial HMO & PPO	$46,806.04
Rate for Payer: Home State Health Plan Medicare Advantage	$46,806.04
Rate for Payer: Humana Commercial	$93,612.08
Rate for Payer: Humana Medicare Advantage	$46,806.04

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$32,222.04

Service Code	MSDRG 465
Min. Negotiated Rate	$16,111.02
Max. Negotiated Rate	$32,222.04
Rate for Payer: Aetna Medicare Advantage	$16,111.02
Rate for Payer: Cigna Commercial HMO & PPO	$16,111.02
Rate for Payer: Home State Health Plan Medicare Advantage	$16,111.02
Rate for Payer: Humana Commercial	$32,222.04
Rate for Payer: Humana Medicare Advantage	$16,111.02

WOUND DEBRIDEMENTS FOR INJURIES WITH CC

Facility

$33,652.46

Service Code	MSDRG 902
Min. Negotiated Rate	$16,826.23
Max. Negotiated Rate	$33,652.46
Rate for Payer: Aetna Medicare Advantage	$16,826.23
Rate for Payer: Cigna Commercial HMO & PPO	$16,826.23
Rate for Payer: Home State Health Plan Medicare Advantage	$16,826.23
Rate for Payer: Humana Commercial	$33,652.46
Rate for Payer: Humana Medicare Advantage	$16,826.23

WOUND DEBRIDEMENTS FOR INJURIES WITH MCC

Facility

$69,754.02

Service Code	MSDRG 901
Min. Negotiated Rate	$34,877.01
Max. Negotiated Rate	$69,754.02
Rate for Payer: Aetna Medicare Advantage	$34,877.01
Rate for Payer: Cigna Commercial HMO & PPO	$34,877.01
Rate for Payer: Home State Health Plan Medicare Advantage	$34,877.01
Rate for Payer: Humana Commercial	$69,754.02
Rate for Payer: Humana Medicare Advantage	$34,877.01

WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC

Facility

$21,948.02

Service Code	MSDRG 903
Min. Negotiated Rate	$10,974.01
Max. Negotiated Rate	$21,948.02
Rate for Payer: Aetna Medicare Advantage	$10,974.01
Rate for Payer: Cigna Commercial HMO & PPO	$10,974.01
Rate for Payer: Home State Health Plan Medicare Advantage	$10,974.01
Rate for Payer: Humana Commercial	$21,948.02
Rate for Payer: Humana Medicare Advantage	$10,974.01

WOUND REPAIR

Professional

Both

$1,786.00

Service Code	CPT 13121
Hospital Charge Code	1813121
Hospital Revenue Code	981
Min. Negotiated Rate	$205.33
Max. Negotiated Rate	$625.10
Rate for Payer: Aetna Commercial/Medicare Advantage	$205.33
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$323.51
Rate for Payer: Cash Price	$1,607.40
Rate for Payer: Cash Price	$1,607.40
Rate for Payer: Cigna Commercial HMO & PPO	$205.33
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$323.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$355.86
Rate for Payer: Home State Health Plan Medicare Advantage	$205.33
Rate for Payer: Optum Medicare Advantage	$625.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$323.51

WOUND REPAIR

Professional

Both

$457.00

Service Code	CPT 12053
Hospital Charge Code	4112053
Hospital Revenue Code	975
Min. Negotiated Rate	$159.95
Max. Negotiated Rate	$304.91
Rate for Payer: Aetna Commercial/Medicare Advantage	$176.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$277.19
Rate for Payer: Cash Price	$411.30
Rate for Payer: Cash Price	$411.30
Rate for Payer: Cigna Commercial HMO & PPO	$176.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$277.19
Rate for Payer: Home State Health Plan Medicaid Managed Care	$304.91
Rate for Payer: Home State Health Plan Medicare Advantage	$176.93
Rate for Payer: Optum Medicare Advantage	$159.95
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$277.19

WOUND VAC DRESSING AND CANNISTERS

Facility

$460.00

Hospital Charge Code	2897607
Hospital Revenue Code	272
Min. Negotiated Rate	$165.60
Max. Negotiated Rate	$328.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$272.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$328.44
Rate for Payer: Cash Price	$414.00
Rate for Payer: UnitedHealthcare Commercial	$306.82
Rate for Payer: UnitedHealthcare Medicare Advantage	$165.60

WOUND VAC DRESSING AND CANNISTERS

Facility

$460.00

Hospital Charge Code	2897607
Hospital Revenue Code	272
Rate for Payer: Cash Price	$414.00

Know your out-of-pocket cost for care.

All Charges