Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- ALLEN RSV

Facility

$85.00

Service Code	CPT 87807
Hospital Charge Code	4487807
Hospital Revenue Code	636
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$56.70
Rate for Payer: Cash Price	$76.50
Rate for Payer: UnitedHealthcare Commercial	$56.70

CL- ALLEN RSV

Facility

$85.00

Service Code	CPT 87807
Hospital Charge Code	4487807
Hospital Revenue Code	636
Min. Negotiated Rate	$11.79
Max. Negotiated Rate	$60.69
Rate for Payer: Aetna Better Health Medicaid/QHP	$11.79
Rate for Payer: Aetna Medicare Advantage	$13.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$50.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$60.69
Rate for Payer: Cash Price	$76.50
Rate for Payer: Cash Price	$76.50
Rate for Payer: Cash Price	$76.50
Rate for Payer: Cigna Commercial HMO & PPO	$13.10
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$11.79
Rate for Payer: Home State Health Plan Medicaid Managed Care	$12.62
Rate for Payer: Home State Health Plan Medicare Advantage	$13.10
Rate for Payer: Humana Commercial	$26.20
Rate for Payer: Humana Medicare Advantage	$13.10
Rate for Payer: UnitedHealthcare Commercial	$13.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$11.79
Rate for Payer: UnitedHealthcare Medicare Advantage	$30.60

CL- ALLEN SOLU-MEDROL 125 MG

Facility

$47.00

Service Code	HCPCS J2919
Hospital Charge Code	4402930
Hospital Revenue Code	636
Min. Negotiated Rate	$16.92
Max. Negotiated Rate	$33.56
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: UnitedHealthcare Commercial	$31.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.92

CL- ALLEN SOLU-MEDROL 125 MG

Facility

$47.00

Service Code	HCPCS J2919
Hospital Charge Code	4402930
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 SOLU MEDROL 40MG

Facility

$50.00

Service Code	HCPCS J2919
Hospital Charge Code	4402902
Hospital Revenue Code	636
Min. Negotiated Rate	$33.35
Max. Negotiated Rate	$33.35
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35

CL- ALLEN SOLU MEDROL 40MG

Facility

$50.00

Service Code	HCPCS J2919
Hospital Charge Code	4402902
Hospital Revenue Code	636
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$35.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$29.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$35.70
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.00

CL- ALLEN SYNVISC 1 MG

Facility

$818.00

Service Code	HCPCS J7325
Hospital Charge Code	9807325
Hospital Revenue Code	636
Min. Negotiated Rate	$545.61
Max. Negotiated Rate	$545.61
Rate for Payer: Cash Price	$736.20
Rate for Payer: UnitedHealthcare Commercial	$545.61

CL- ALLEN SYNVISC 1 MG

Facility

$818.00

Service Code	HCPCS J7325
Hospital Charge Code	9807325
Hospital Revenue Code	636
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$584.05
Rate for Payer: Aetna Medicare Advantage	$6.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$484.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$584.05
Rate for Payer: Cash Price	$736.20
Rate for Payer: Cash Price	$736.20
Rate for Payer: Cigna Commercial HMO & PPO	$6.02
Rate for Payer: Home State Health Plan Medicare Advantage	$6.02
Rate for Payer: Humana Commercial	$12.04
Rate for Payer: Humana Medicare Advantage	$6.02
Rate for Payer: UnitedHealthcare Commercial	$6.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$294.48

CL- ALLEN TD AGES 7 AND >

Facility

$50.00

Service Code	HCPCS 90714
Hospital Charge Code	4490703
Hospital Revenue Code	636
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$35.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$29.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$35.70
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.00

CL- ALLEN TD AGES 7 AND >

Facility

$50.00

Service Code	HCPCS 90714
Hospital Charge Code	4490703
Hospital Revenue Code	636
Min. Negotiated Rate	$33.35
Max. Negotiated Rate	$33.35
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35

CL- ALLEN TORADOL- KETORALAC TROMETHAMIN

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	4401885
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$67.83
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	$56.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$67.83
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cash Price	$85.50
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	$34.20

CL- ALLEN TORADOL- KETORALAC TROMETHAMIN

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	4401885
Hospital Revenue Code	636
Min. Negotiated Rate	$63.37
Max. Negotiated Rate	$63.37
Rate for Payer: Cash Price	$85.50
Rate for Payer: UnitedHealthcare Commercial	$63.37

CL- ALLEN TRIAMCINOLONE ACETONID 40 MG

Facility

$105.00

Service Code	HCPCS J3301
Hospital Charge Code	4403301
Hospital Revenue Code	636
Min. Negotiated Rate	$70.03
Max. Negotiated Rate	$70.03
Rate for Payer: Cash Price	$94.50
Rate for Payer: UnitedHealthcare Commercial	$70.03

CL- ALLEN TRIAMCINOLONE ACETONID 40 MG

Facility

$105.00

Service Code	HCPCS J3301
Hospital Charge Code	4403301
Hospital Revenue Code	636
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$74.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$62.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$74.97
Rate for Payer: Cash Price	$94.50
Rate for Payer: UnitedHealthcare Commercial	$70.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$37.80

CL- ALLEN VISTARIL 50MG

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	4403410
Hospital Revenue Code	636
Min. Negotiated Rate	$60.03
Max. Negotiated Rate	$60.03
Rate for Payer: Cash Price	$81.00
Rate for Payer: UnitedHealthcare Commercial	$60.03

CL- ALLEN VISTARIL 50MG

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	4403410
Hospital Revenue Code	636
Min. Negotiated Rate	$32.40
Max. Negotiated Rate	$64.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$53.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$64.26
Rate for Payer: Cash Price	$81.00
Rate for Payer: UnitedHealthcare Commercial	$60.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$32.40

CL- ALLEN VIT B-12 CYANOOCOBALAMI 1000MC

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	4403420
Hospital Revenue Code	636
Min. Negotiated Rate	$26.68
Max. Negotiated Rate	$26.68
Rate for Payer: Cash Price	$36.00
Rate for Payer: UnitedHealthcare Commercial	$26.68

CL- ALLEN VIT B-12 CYANOOCOBALAMI 1000MC

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	4403420
Hospital Revenue Code	636
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$28.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$28.56
Rate for Payer: Cash Price	$36.00
Rate for Payer: UnitedHealthcare Commercial	$26.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.40

CLAMP DRAIN BAG

Facility

$28.00

Hospital Charge Code	283700
Hospital Revenue Code	271
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

CLAMP DRAIN BAG

Facility

$28.00

Hospital Charge Code	283700
Hospital Revenue Code	271
Rate for Payer: Cash Price	$25.20

CLARITHROMYCIN (BIAXIN) 500MG TAB

Facility

$43.00

Service Code	NDC 54003721
Hospital Charge Code	2626284
Hospital Revenue Code	250
Rate for Payer: Cash Price	$38.70

CLARITHROMYCIN (BIAXIN) 500MG TAB

Facility

$43.00

Service Code	NDC 54003721
Hospital Charge Code	2626284
Hospital Revenue Code	250
Min. Negotiated Rate	$15.48
Max. Negotiated Rate	$30.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$25.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$30.70
Rate for Payer: Cash Price	$38.70
Rate for Payer: UnitedHealthcare Commercial	$28.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.48

CLAVICLE LT

Facility

$465.00

Service Code	CPT 73000
Hospital Charge Code	323118
Hospital Revenue Code	320
Min. Negotiated Rate	$78.45
Max. Negotiated Rate	$332.01
Rate for Payer: Aetna Better Health Medicaid/QHP	$78.45
Rate for Payer: Aetna Medicare Advantage	$88.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$275.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$332.01
Rate for Payer: Cash Price	$418.50
Rate for Payer: Cash Price	$418.50
Rate for Payer: Cash Price	$418.50
Rate for Payer: Cigna Commercial HMO & PPO	$88.91
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$78.45
Rate for Payer: Home State Health Plan Medicaid Managed Care	$83.94
Rate for Payer: Home State Health Plan Medicare Advantage	$88.91
Rate for Payer: Humana Commercial	$177.82
Rate for Payer: Humana Medicare Advantage	$88.91
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$78.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$167.40

CLAVICLE LT

Facility

$465.00

Service Code	CPT 73000
Hospital Charge Code	323118
Hospital Revenue Code	320
Rate for Payer: Cash Price	$418.50

CLAVICLE RT

Facility

$465.00

Service Code	CPT 73000
Hospital Charge Code	323117
Hospital Revenue Code	320
Min. Negotiated Rate	$78.45
Max. Negotiated Rate	$332.01
Rate for Payer: Aetna Better Health Medicaid/QHP	$78.45
Rate for Payer: Aetna Medicare Advantage	$88.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$275.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$332.01
Rate for Payer: Cash Price	$418.50
Rate for Payer: Cash Price	$418.50
Rate for Payer: Cash Price	$418.50
Rate for Payer: Cigna Commercial HMO & PPO	$88.91
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$78.45
Rate for Payer: Home State Health Plan Medicaid Managed Care	$83.94
Rate for Payer: Home State Health Plan Medicare Advantage	$88.91
Rate for Payer: Humana Commercial	$177.82
Rate for Payer: Humana Medicare Advantage	$88.91
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$78.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$167.40

Know your out-of-pocket cost for care.

All Charges