Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- BENZ INFLUENZA VACCINE 3 YEARS AND O

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	9590658
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- BENZ INFLUENZA VACCINE 3 YEARS AND O

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	9590658
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- BENZ INFLUENZA VACCINE 6 - 35 MONTH

Facility

$35.00

Service Code	HCPCS 90657
Hospital Charge Code	9590657
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- BENZ INFLUENZA VACCINE 6 - 35 MONTH

Facility

$35.00

Service Code	HCPCS 90657
Hospital Charge Code	9590657
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- BENZ PENICILLIN - BICILLIN 1,200,000

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	9500540
Hospital Revenue Code	636
Min. Negotiated Rate	$19.52
Max. Negotiated Rate	$121.38
Rate for Payer: Aetna Medicare Advantage	$19.52
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: Cigna Commercial HMO & PPO	$19.52
Rate for Payer: Home State Health Plan Medicare Advantage	$19.52
Rate for Payer: Humana Commercial	$39.04
Rate for Payer: Humana Medicare Advantage	$19.52
Rate for Payer: UnitedHealthcare Commercial	$19.52
Rate for Payer: UnitedHealthcare Medicare Advantage	$61.20

CL- BENZ PENICILLIN - BICILLIN 1,200,000

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	9500540
Hospital Revenue Code	636
Min. Negotiated Rate	$113.39
Max. Negotiated Rate	$113.39
Rate for Payer: Cash Price	$153.00
Rate for Payer: UnitedHealthcare Commercial	$113.39

CL- BENZ PHENERGAN 50 MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	9502550
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 PHENERGAN 50 MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	9502550
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 PNEUMO 23 VACCINE

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	9590732
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- BENZ PNEUMO 23 VACCINE

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	9590732
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- BENZ PREVNAR 13

Facility

$541.00

Service Code	HCPCS 90670
Hospital Charge Code	9598312
Hospital Revenue Code	636
Min. Negotiated Rate	$360.85
Max. Negotiated Rate	$360.85
Rate for Payer: Cash Price	$486.90
Rate for Payer: UnitedHealthcare Commercial	$360.85

CL- BENZ PREVNAR 13

Facility

$541.00

Service Code	HCPCS 90670
Hospital Charge Code	9598312
Hospital Revenue Code	636
Min. Negotiated Rate	$194.76
Max. Negotiated Rate	$386.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$320.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$386.27
Rate for Payer: Cash Price	$486.90
Rate for Payer: UnitedHealthcare Commercial	$360.85
Rate for Payer: UnitedHealthcare Medicare Advantage	$194.76

CL- BENZ REGLAN 5 MG

Facility

$20.50

Service Code	HCPCS J2765
Hospital Charge Code	9502765
Hospital Revenue Code	636
Min. Negotiated Rate	$13.67
Max. Negotiated Rate	$13.67
Rate for Payer: Cash Price	$18.45
Rate for Payer: UnitedHealthcare Commercial	$13.67

CL- BENZ REGLAN 5 MG

Facility

$20.50

Service Code	HCPCS J2765
Hospital Charge Code	9502765
Hospital Revenue Code	636
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$14.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.64
Rate for Payer: Cash Price	$18.45
Rate for Payer: UnitedHealthcare Commercial	$13.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.38

CL- BENZ ROCEPHIN 500 MG

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	9500696
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- BENZ ROCEPHIN 500 MG

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	9500696
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

CL- BENZ SOLU MEDROL 40MG

Facility

$50.00

Service Code	HCPCS J2919
Hospital Charge Code	9502902
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- BENZ SOLU MEDROL 40MG

Facility

$50.00

Service Code	HCPCS J2919
Hospital Charge Code	9502902
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- BENZ TD AGE 7 & > IMMUNIZATION

Facility

$33.00

Service Code	HCPCS 90714
Hospital Charge Code	9590703
Hospital Revenue Code	636
Min. Negotiated Rate	$22.01
Max. Negotiated Rate	$22.01
Rate for Payer: Cash Price	$29.70
Rate for Payer: UnitedHealthcare Commercial	$22.01

CL- BENZ TD AGE 7 & > IMMUNIZATION

Facility

$33.00

Service Code	HCPCS 90714
Hospital Charge Code	9590703
Hospital Revenue Code	636
Min. Negotiated Rate	$11.88
Max. Negotiated Rate	$23.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$19.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$23.56
Rate for Payer: Cash Price	$29.70
Rate for Payer: UnitedHealthcare Commercial	$22.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.88

CL- BENZ TORADOL-KETORALAC 30 MG

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	9501885
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- BENZ TORADOL-KETORALAC 30 MG

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	9501885
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- BENZ TRIAMCINOLONE ACETONID 40 MG

Facility

$105.00

Service Code	HCPCS J3301
Hospital Charge Code	9503301
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- BENZ TRIAMCINOLONE ACETONID 40 MG

Facility

$105.00

Service Code	HCPCS J3301
Hospital Charge Code	9503301
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- BENZ VISTARIL 50MG

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	9503410
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

Know your out-of-pocket cost for care.

All Charges