Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- DEFRAN HIB

Facility

$25.00

Service Code	HCPCS 90647
Hospital Charge Code	9490647
Hospital Revenue Code	636
Min. Negotiated Rate	$16.68
Max. Negotiated Rate	$16.68
Rate for Payer: Cash Price	$22.50
Rate for Payer: UnitedHealthcare Commercial	$16.68

CL- DEFRAN HIB

Facility

$25.00

Service Code	HCPCS 90647
Hospital Charge Code	9490647
Hospital Revenue Code	636
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$17.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.85
Rate for Payer: Cash Price	$22.50
Rate for Payer: UnitedHealthcare Commercial	$16.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.00

CL- DEFRAN INFLUENZA VACCINE 3 YEARS A

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	9490658
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- DEFRAN INFLUENZA VACCINE 3 YEARS A

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	9490658
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- DEFRAN INFLUENZA VACCINE 6 - 35 MON

Facility

$35.00

Service Code	HCPCS 90657
Hospital Charge Code	9490657
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- DEFRAN INFLUENZA VACCINE 6 - 35 MON

Facility

$35.00

Service Code	HCPCS 90657
Hospital Charge Code	9490657
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- DEFRAN KINRIX

Facility

$100.00

Service Code	HCPCS 90696
Hospital Charge Code	9490696
Hospital Revenue Code	636
Min. Negotiated Rate	$66.70
Max. Negotiated Rate	$66.70
Rate for Payer: Cash Price	$90.00
Rate for Payer: UnitedHealthcare Commercial	$66.70

CL- DEFRAN KINRIX

Facility

$100.00

Service Code	HCPCS 90696
Hospital Charge Code	9490696
Hospital Revenue Code	636
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$71.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$59.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$71.40
Rate for Payer: Cash Price	$90.00
Rate for Payer: UnitedHealthcare Commercial	$66.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$36.00

CL- DEFRAN MENECTRA

Facility

$230.00

Service Code	HCPCS 90734
Hospital Charge Code	9490734
Hospital Revenue Code	636
Min. Negotiated Rate	$82.80
Max. Negotiated Rate	$164.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$136.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$164.22
Rate for Payer: Cash Price	$207.00
Rate for Payer: UnitedHealthcare Commercial	$153.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$82.80

CL- DEFRAN MENECTRA

Facility

$230.00

Service Code	HCPCS 90734
Hospital Charge Code	9490734
Hospital Revenue Code	636
Min. Negotiated Rate	$153.41
Max. Negotiated Rate	$153.41
Rate for Payer: Cash Price	$207.00
Rate for Payer: UnitedHealthcare Commercial	$153.41

CL- DEFRAN MMR LIVE SUBCUTANEOUS USE

Facility

$55.00

Service Code	HCPCS 90707
Hospital Charge Code	9490707
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- DEFRAN MMR LIVE SUBCUTANEOUS USE

Facility

$55.00

Service Code	HCPCS 90707
Hospital Charge Code	9490707
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- DEFRAN PENICILLIN

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	9400540
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- DEFRAN PENICILLIN

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	9400540
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- DEFRAN PHENERGAN 50MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	9402550
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- DEFRAN PHENERGAN 50MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	9402550
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- DEFRAN PNEUMO 23 VACCINE

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	9490732
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- DEFRAN PNEUMO 23 VACCINE

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	9490732
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- DEFRAN POLIO VACCINE

Facility

$35.00

Service Code	HCPCS 90713
Hospital Charge Code	9490713
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- DEFRAN POLIO VACCINE

Facility

$35.00

Service Code	HCPCS 90713
Hospital Charge Code	9490713
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- DEFRAN PROQUAD

Facility

$250.00

Service Code	HCPCS 90710
Hospital Charge Code	9490710
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- DEFRAN PROQUAD

Facility

$250.00

Service Code	HCPCS 90710
Hospital Charge Code	9490710
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- DEFRAN ROCEPHIN 500 MG

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	9400696
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- DEFRAN ROCEPHIN 500 MG

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	9400696
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- DEFRAN SOLU MEDROL 125 MG

Facility

$38.00

Service Code	HCPCS J2919
Hospital Charge Code	9402930
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

Know your out-of-pocket cost for care.

All Charges