Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- ALLEN DEPO MEDROL 1 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	4401040
Hospital Revenue Code	636
Min. Negotiated Rate	$76.70
Max. Negotiated Rate	$76.70
Rate for Payer: Cash Price	$103.50
Rate for Payer: UnitedHealthcare Commercial	$76.70

CL- ALLEN DIPHENHYDRAMINE 50 MG

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	4401200
Hospital Revenue Code	636
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

CL- ALLEN DIPHENHYDRAMINE 50 MG

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	4401200
Hospital Revenue Code	636
Min. Negotiated Rate	$30.02
Max. Negotiated Rate	$30.02
Rate for Payer: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02

CL- ALLEN DT < 7 YRS OLD

Facility

$14.00

Service Code	HCPCS 90702
Hospital Charge Code	4490702
Hospital Revenue Code	636
Min. Negotiated Rate	$9.34
Max. Negotiated Rate	$9.34
Rate for Payer: Cash Price	$12.60
Rate for Payer: UnitedHealthcare Commercial	$9.34

CL- ALLEN DT < 7 YRS OLD

Facility

$14.00

Service Code	HCPCS 90702
Hospital Charge Code	4490702
Hospital Revenue Code	636
Min. Negotiated Rate	$5.04
Max. Negotiated Rate	$10.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$8.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$10.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: UnitedHealthcare Commercial	$9.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.04

CL- ALLEN HEPATITIS A

Facility

$25.00

Service Code	CPT 90632
Hospital Charge Code	4490632
Hospital Revenue Code	636
Min. Negotiated Rate	$16.68
Max. Negotiated Rate	$16.68
Rate for Payer: Cash Price	$22.50
Rate for Payer: UnitedHealthcare Commercial	$16.68

CL- ALLEN HEPATITIS A

Facility

$25.00

Service Code	CPT 90632
Hospital Charge Code	4490632
Hospital Revenue Code	636
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$17.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.85
Rate for Payer: Cash Price	$22.50
Rate for Payer: UnitedHealthcare Commercial	$16.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.00

CL- ALLEN IMOGAM 300 IU 2 ML

Facility

$600.00

Service Code	HCPCS 90376
Hospital Charge Code	4490376
Hospital Revenue Code	636
Min. Negotiated Rate	$400.20
Max. Negotiated Rate	$400.20
Rate for Payer: Cash Price	$540.00
Rate for Payer: UnitedHealthcare Commercial	$400.20

CL- ALLEN IMOGAM 300 IU 2 ML

Facility

$600.00

Service Code	HCPCS 90376
Hospital Charge Code	4490376
Hospital Revenue Code	636
Min. Negotiated Rate	$216.00
Max. Negotiated Rate	$704.88
Rate for Payer: Aetna Medicare Advantage	$352.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$355.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$428.40
Rate for Payer: Cash Price	$540.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Cigna Commercial HMO & PPO	$352.44
Rate for Payer: Home State Health Plan Medicare Advantage	$352.44
Rate for Payer: Humana Commercial	$704.88
Rate for Payer: Humana Medicare Advantage	$352.44
Rate for Payer: UnitedHealthcare Commercial	$352.44
Rate for Payer: UnitedHealthcare Medicare Advantage	$216.00

CL- ALLEN INFLUENZA VACCINATION

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	4490658
Hospital Revenue Code	636
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$43.35
Rate for Payer: Cash Price	$58.50
Rate for Payer: UnitedHealthcare Commercial	$43.35

CL- ALLEN INFLUENZA VACCINATION

Facility

$35.00

Service Code	CPT 90657
Hospital Charge Code	4490657
Hospital Revenue Code	636
Min. Negotiated Rate	$23.34
Max. Negotiated Rate	$23.34
Rate for Payer: Cash Price	$31.50
Rate for Payer: UnitedHealthcare Commercial	$23.34

CL- ALLEN INFLUENZA VACCINATION

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	4490658
Hospital Revenue Code	636
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

CL- ALLEN INFLUENZA VACCINATION

Facility

$35.00

Service Code	CPT 90657
Hospital Charge Code	4490657
Hospital Revenue Code	636
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

CL- ALLEN KENALOG 40 mg

Facility

$47.00

Service Code	HCPCS J1885
Hospital Charge Code	4401880
Hospital Revenue Code	636
Min. Negotiated Rate	$31.35
Max. Negotiated Rate	$31.35
Rate for Payer: Cash Price	$42.30
Rate for Payer: UnitedHealthcare Commercial	$31.35

CL- ALLEN KENALOG 40 mg

Facility

$47.00

Service Code	HCPCS J1885
Hospital Charge Code	4401880
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$33.56
Rate for Payer: Aetna Medicare Advantage	$0.29
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: Cigna Commercial HMO & PPO	$0.29
Rate for Payer: Home State Health Plan Medicare Advantage	$0.29
Rate for Payer: Humana Commercial	$0.58
Rate for Payer: Humana Medicare Advantage	$0.29
Rate for Payer: UnitedHealthcare Commercial	$0.29
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.92

CL- ALLEN PHENERGAN 50MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	4402550
Hospital Revenue Code	636
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

CL- ALLEN PHENERGAN 50MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	4402550
Hospital Revenue Code	636
Min. Negotiated Rate	$30.02
Max. Negotiated Rate	$30.02
Rate for Payer: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02

CL- ALLEN PNEUMO 23 VACCINE

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	4490732
Hospital Revenue Code	636
Min. Negotiated Rate	$166.75
Max. Negotiated Rate	$166.75
Rate for Payer: Cash Price	$225.00
Rate for Payer: UnitedHealthcare Commercial	$166.75

CL- ALLEN PNEUMO 23 VACCINE

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	4490732
Hospital Revenue Code	636
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$178.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$148.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$178.50
Rate for Payer: Cash Price	$225.00
Rate for Payer: UnitedHealthcare Commercial	$166.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$90.00

CL- ALLEN PREVNAR 13 VACCINATION

Facility

$536.00

Service Code	HCPCS 90670
Hospital Charge Code	4498312
Hospital Revenue Code	636
Min. Negotiated Rate	$357.51
Max. Negotiated Rate	$357.51
Rate for Payer: Cash Price	$482.40
Rate for Payer: UnitedHealthcare Commercial	$357.51

CL- ALLEN PREVNAR 13 VACCINATION

Facility

$536.00

Service Code	HCPCS 90670
Hospital Charge Code	4498312
Hospital Revenue Code	636
Min. Negotiated Rate	$192.96
Max. Negotiated Rate	$382.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$317.31
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$382.70
Rate for Payer: Cash Price	$482.40
Rate for Payer: UnitedHealthcare Commercial	$357.51
Rate for Payer: UnitedHealthcare Medicare Advantage	$192.96

CL- ALLEN RABAVERT VACCINE FOR IM USE

Facility

$350.00

Service Code	HCPCS 90675
Hospital Charge Code	4490675
Hospital Revenue Code	636
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$663.96
Rate for Payer: Aetna Medicare Advantage	$331.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$207.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$249.90
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cigna Commercial HMO & PPO	$331.98
Rate for Payer: Home State Health Plan Medicare Advantage	$331.98
Rate for Payer: Humana Commercial	$663.96
Rate for Payer: Humana Medicare Advantage	$331.98
Rate for Payer: UnitedHealthcare Commercial	$331.98
Rate for Payer: UnitedHealthcare Medicare Advantage	$126.00

CL- ALLEN RABAVERT VACCINE FOR IM USE

Facility

$350.00

Service Code	HCPCS 90675
Hospital Charge Code	4490675
Hospital Revenue Code	636
Min. Negotiated Rate	$233.45
Max. Negotiated Rate	$233.45
Rate for Payer: Cash Price	$315.00
Rate for Payer: UnitedHealthcare Commercial	$233.45

CL- ALLEN ROCEPHIN 500 MG

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	4400696
Hospital Revenue Code	636
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$142.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$118.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$142.80
Rate for Payer: Cash Price	$180.00
Rate for Payer: UnitedHealthcare Commercial	$133.40
Rate for Payer: UnitedHealthcare Medicare Advantage	$72.00

CL- ALLEN ROCEPHIN 500 MG

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	4400696
Hospital Revenue Code	636
Min. Negotiated Rate	$133.40
Max. Negotiated Rate	$133.40
Rate for Payer: Cash Price	$180.00
Rate for Payer: UnitedHealthcare Commercial	$133.40

Know your out-of-pocket cost for care.

All Charges