Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- BUFORD MMR VACCINE

Facility

$55.00

Service Code	HCPCS 90707
Hospital Charge Code	9290707
Hospital Revenue Code	636
Min. Negotiated Rate	$36.69
Max. Negotiated Rate	$36.69
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69

CL- BUFORD MMR VACCINE

Facility

$55.00

Service Code	HCPCS 90707
Hospital Charge Code	9290707
Hospital Revenue Code	636
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$39.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.80

CL- BUFORD PENICILLIN

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	9200540
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- BUFORD PENICILLIN

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	9200540
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- BUFORD PHENERGAN 50MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	9202550
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 PHENERGAN 50MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	9202550
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 PNEUMO 23 VACCINE

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	9290732
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- BUFORD PNEUMO 23 VACCINE

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	9290732
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- BUFORD ROCEPHIN 500 MG

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	9200696
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- BUFORD ROCEPHIN 500 MG

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	9200696
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- BUFORD SOLU MEDROL 125 MG

Facility

$38.00

Service Code	HCPCS J2919
Hospital Charge Code	9202930
Hospital Revenue Code	636
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$27.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$22.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.13
Rate for Payer: Cash Price	$34.20
Rate for Payer: UnitedHealthcare Commercial	$25.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.68

CL- BUFORD SOLU MEDROL 125 MG

Facility

$38.00

Service Code	HCPCS J2919
Hospital Charge Code	9202930
Hospital Revenue Code	636
Min. Negotiated Rate	$25.35
Max. Negotiated Rate	$25.35
Rate for Payer: Cash Price	$34.20
Rate for Payer: UnitedHealthcare Commercial	$25.35

CL- BUFORD SOLU MEDROL 40 MG

Facility

$50.00

Service Code	HCPCS J2919
Hospital Charge Code	9202902
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 SOLU MEDROL 40 MG

Facility

$50.00

Service Code	HCPCS J2919
Hospital Charge Code	9202902
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 TB PPD INTRADERMAL

Facility

$45.00

Service Code	HCPCS 86580
Hospital Charge Code	9286580
Hospital Revenue Code	636
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$59.10
Rate for Payer: Aetna Better Health Medicaid/QHP	$26.07
Rate for Payer: Aetna Medicare Advantage	$29.55
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: Cash Price	$40.50
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial HMO & PPO	$29.55
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$26.07
Rate for Payer: Home State Health Plan Medicaid Managed Care	$27.89
Rate for Payer: Home State Health Plan Medicare Advantage	$29.55
Rate for Payer: Humana Commercial	$59.10
Rate for Payer: Humana Medicare Advantage	$29.55
Rate for Payer: UnitedHealthcare Commercial	$29.55
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$26.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.20

CL- BUFORD TB PPD INTRADERMAL

Facility

$45.00

Service Code	HCPCS 86580
Hospital Charge Code	9286580
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 TD 7 & > IMMUNIZATION

Facility

$33.00

Service Code	HCPCS 90714
Hospital Charge Code	9290703
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- BUFORD TD 7 & > IMMUNIZATION

Facility

$33.00

Service Code	HCPCS 90714
Hospital Charge Code	9290703
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- BUFORD TORADOL KETORALAC 30MG

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	9201885
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- BUFORD TORADOL KETORALAC 30MG

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	9201885
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- BUFORD TRIAMCINOLONE ACETONID 40 MG

Facility

$105.00

Service Code	HCPCS J3301
Hospital Charge Code	9203301
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- BUFORD TRIAMCINOLONE ACETONID 40 MG

Facility

$105.00

Service Code	HCPCS J3301
Hospital Charge Code	9203301
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- BUFORD VISTARIL 50MG

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	9203410
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- BUFORD VISTARIL 50MG

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	9203410
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- BUFORD VITAMIN B-12

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	9203420
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

Know your out-of-pocket cost for care.

All Charges