Madison Medical Center

All Charges

Charge

Type

Setting

Price

CLAVICLE RT

Facility

$465.00

Service Code	CPT 73000
Hospital Charge Code	323117
Hospital Revenue Code	320
Rate for Payer: Cash Price	$418.50

CLAVICLE SPLINT EX-LARGE

Facility

$67.00

Hospital Charge Code	283255
Hospital Revenue Code	271
Min. Negotiated Rate	$24.12
Max. Negotiated Rate	$47.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$39.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$47.84
Rate for Payer: Cash Price	$60.30
Rate for Payer: UnitedHealthcare Commercial	$44.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$24.12

CLAVICLE SPLINT EX-LARGE

Facility

$67.00

Hospital Charge Code	283255
Hospital Revenue Code	271
Rate for Payer: Cash Price	$60.30

CLAVICLE SPLINT INFANT

Facility

$67.00

Hospital Charge Code	283251
Hospital Revenue Code	271
Min. Negotiated Rate	$24.12
Max. Negotiated Rate	$47.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$39.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$47.84
Rate for Payer: Cash Price	$60.30
Rate for Payer: UnitedHealthcare Commercial	$44.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$24.12

CLAVICLE SPLINT INFANT

Facility

$67.00

Hospital Charge Code	283251
Hospital Revenue Code	271
Rate for Payer: Cash Price	$60.30

CLAVICLE SPLINT LARGE

Facility

$67.00

Hospital Charge Code	283254
Hospital Revenue Code	271
Rate for Payer: Cash Price	$60.30

CLAVICLE SPLINT LARGE

Facility

$67.00

Hospital Charge Code	283254
Hospital Revenue Code	271
Min. Negotiated Rate	$24.12
Max. Negotiated Rate	$47.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$39.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$47.84
Rate for Payer: Cash Price	$60.30
Rate for Payer: UnitedHealthcare Commercial	$44.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$24.12

CLAVICLE SPLINT SMALL (CHILD)

Facility

$67.00

Hospital Charge Code	283252
Hospital Revenue Code	271
Min. Negotiated Rate	$24.12
Max. Negotiated Rate	$47.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$39.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$47.84
Rate for Payer: Cash Price	$60.30
Rate for Payer: UnitedHealthcare Commercial	$44.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$24.12

CLAVICLE SPLINT SMALL (CHILD)

Facility

$67.00

Hospital Charge Code	283252
Hospital Revenue Code	271
Rate for Payer: Cash Price	$60.30

CLAVICLE SPLINT YOUTH #3004-03 (MED)

Facility

$67.00

Hospital Charge Code	283253
Hospital Revenue Code	271
Min. Negotiated Rate	$24.12
Max. Negotiated Rate	$47.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$39.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$47.84
Rate for Payer: Cash Price	$60.30
Rate for Payer: UnitedHealthcare Commercial	$44.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$24.12

CLAVICLE SPLINT YOUTH #3004-03 (MED)

Facility

$67.00

Hospital Charge Code	283253
Hospital Revenue Code	271
Rate for Payer: Cash Price	$60.30

CL- B-12 OLIVERO

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	5403420
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- B-12 OLIVERO

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	5403420
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

CL- BENZ CLINDAMICIIN 600 MG INJECTION

Facility

$110.00

Service Code	HCPCS J3490
Hospital Charge Code	9503490
Hospital Revenue Code	636
Min. Negotiated Rate	$73.37
Max. Negotiated Rate	$73.37
Rate for Payer: Cash Price	$99.00
Rate for Payer: UnitedHealthcare Commercial	$73.37

CL- BENZ CLINDAMICIIN 600 MG INJECTION

Facility

$110.00

Service Code	HCPCS J3490
Hospital Charge Code	9503490
Hospital Revenue Code	636
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$78.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$65.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$78.54
Rate for Payer: Cash Price	$99.00
Rate for Payer: UnitedHealthcare Commercial	$73.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$39.60

CL- BENZ DEPO ESTRADIOL 5 MG

Facility

$150.00

Service Code	HCPCS J1000
Hospital Charge Code	9501000
Hospital Revenue Code	636
Min. Negotiated Rate	$100.05
Max. Negotiated Rate	$100.05
Rate for Payer: Cash Price	$135.00
Rate for Payer: UnitedHealthcare Commercial	$100.05

CL- BENZ DEPO ESTRADIOL 5 MG

Facility

$150.00

Service Code	HCPCS J1000
Hospital Charge Code	9501000
Hospital Revenue Code	636
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$107.10
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: UnitedHealthcare Commercial	$100.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$54.00

CL- BENZ DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	9501030
Hospital Revenue Code	636
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$42.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$35.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$42.84
Rate for Payer: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.60

CL- BENZ DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	9501030
Hospital Revenue Code	636
Min. Negotiated Rate	$40.02
Max. Negotiated Rate	$40.02
Rate for Payer: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02

CL- BENZ DEPO MEDROL 1 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	9501040
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- BENZ DEPO MEDROL 1 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	9501040
Hospital Revenue Code	636
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$82.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$68.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$82.11
Rate for Payer: Cash Price	$103.50
Rate for Payer: UnitedHealthcare Commercial	$76.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$41.40

CL- BENZ DIPHENHYDRAMINE 50 MG

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	9501200
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- BENZ DIPHENHYDRAMINE 50 MG

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	9501200
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- BENZ GI COCKTAIL

Facility

$6.00

Service Code	HCPCS Y7506
Hospital Charge Code	9556217
Hospital Revenue Code	636
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$4.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$3.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$4.28
Rate for Payer: Cash Price	$5.40
Rate for Payer: UnitedHealthcare Commercial	$4.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$2.16

CL- BENZ GI COCKTAIL

Facility

$6.00

Service Code	HCPCS Y7506
Hospital Charge Code	9556217
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.40
Rate for Payer: UnitedHealthcare Commercial	$4.00

Know your out-of-pocket cost for care.

All Charges