Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- BENZ VISTARIL 50MG

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	9503410
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- BENZ VITAMIN B-12

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	9503420
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- BENZ VITAMIN B-12

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	9503420
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- BICILLIN LA 1.2 MU 2 ML

Facility

$170.00

Service Code	HCPCS J0561
Hospital Charge Code	9200561
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- BICILLIN LA 1.2 MU 2 ML

Facility

$170.00

Service Code	HCPCS J0561
Hospital Charge Code	9200561
Hospital Revenue Code	636
Min. Negotiated Rate	$32.59
Max. Negotiated Rate	$121.38
Rate for Payer: Aetna Medicare Advantage	$32.59
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	$32.59
Rate for Payer: Home State Health Plan Medicare Advantage	$32.59
Rate for Payer: Humana Commercial	$65.18
Rate for Payer: Humana Medicare Advantage	$32.59
Rate for Payer: UnitedHealthcare Commercial	$32.59
Rate for Payer: UnitedHealthcare Medicare Advantage	$61.20

CL- BICILLIN LA 600000 UNITS

Facility

$82.00

Service Code	HCPCS J0558
Hospital Charge Code	4400558
Hospital Revenue Code	636
Min. Negotiated Rate	$54.69
Max. Negotiated Rate	$54.69
Rate for Payer: Cash Price	$73.80
Rate for Payer: UnitedHealthcare Commercial	$54.69

CL- BICILLIN LA 600000 UNITS

Facility

$82.00

Service Code	HCPCS J0558
Hospital Charge Code	4400558
Hospital Revenue Code	636
Min. Negotiated Rate	$19.52
Max. Negotiated Rate	$58.55
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	$48.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$58.55
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cash Price	$73.80
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	$29.52

CL- BUFORD CLONIDINE .1 MG

Facility

$10.00

Service Code	HCPCS J0735
Hospital Charge Code	9200735
Hospital Revenue Code	636
Min. Negotiated Rate	$6.67
Max. Negotiated Rate	$6.67
Rate for Payer: Cash Price	$9.00
Rate for Payer: UnitedHealthcare Commercial	$6.67

CL- BUFORD CLONIDINE .1 MG

Facility

$10.00

Service Code	HCPCS J0735
Hospital Charge Code	9200735
Hospital Revenue Code	636
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$7.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$5.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$7.14
Rate for Payer: Cash Price	$9.00
Rate for Payer: UnitedHealthcare Commercial	$6.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$3.60

CL- BUFORD DEMEROL 50 MG

Facility

$50.00

Service Code	HCPCS J2175
Hospital Charge Code	9255471
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- BUFORD DEMEROL 50 MG

Facility

$50.00

Service Code	HCPCS J2175
Hospital Charge Code	9255471
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- BUFORD DEPO ESTRADIOL 5 MG

Facility

$150.00

Service Code	HCPCS J1000
Hospital Charge Code	9201000
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- BUFORD DEPO ESTRADIOL 5 MG

Facility

$150.00

Service Code	HCPCS J1000
Hospital Charge Code	9201000
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- BUFORD DEPO MEDROL 1 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	9201040
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- BUFORD DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	9201030
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- BUFORD DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	9201030
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- BUFORD DEPO MEDROL 1 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	9201040
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- BUFORD DIPHENHYDRAMINE 50 MG

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	9201200
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- BUFORD DIPHENHYDRAMINE 50 MG

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	9201200
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- BUFORD GARDISAL HPV VACCINE

Facility

$150.00

Service Code	HCPCS 90649
Hospital Charge Code	9290649
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- BUFORD GARDISAL HPV VACCINE

Facility

$150.00

Service Code	HCPCS 90649
Hospital Charge Code	9290649
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- BUFORD INFLUENZA VACCINE 3 YEARS +

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	9290658
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- BUFORD INFLUENZA VACCINE 3 YEARS +

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	9290658
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- BUFORD INFLUENZA VACCINE 6 - 35 MO

Facility

$35.00

Service Code	HCPCS 90657
Hospital Charge Code	9290657
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- BUFORD INFLUENZA VACCINE 6 - 35 MO

Facility

$35.00

Service Code	HCPCS 90657
Hospital Charge Code	9290657
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

Know your out-of-pocket cost for care.

All Charges