Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- DEFRAN SOLU MEDROL 125 MG

Facility

$38.00

Service Code	HCPCS J2919
Hospital Charge Code	9402930
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- DEFRAN SOLU MEDROL 40 MG

Facility

$50.00

Service Code	HCPCS J2919
Hospital Charge Code	9402902
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- DEFRAN SOLU MEDROL 40 MG

Facility

$50.00

Service Code	HCPCS J2919
Hospital Charge Code	9402902
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- DEFRAN TB PPD INTRADERMAL

Facility

$45.00

Service Code	HCPCS 86580
Hospital Charge Code	9486580
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- DEFRAN TB PPD INTRADERMAL

Facility

$45.00

Service Code	HCPCS 86580
Hospital Charge Code	9486580
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 TDAP >7 YEARS OF AGE

Facility

$50.00

Service Code	HCPCS 90715
Hospital Charge Code	9490715
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- DEFRAN TDAP >7 YEARS OF AGE

Facility

$50.00

Service Code	HCPCS 90715
Hospital Charge Code	9490715
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- DEFRAN TD IMMUNIZATION

Facility

$33.00

Service Code	HCPCS 90714
Hospital Charge Code	9490703
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- DEFRAN TD IMMUNIZATION

Facility

$33.00

Service Code	HCPCS 90714
Hospital Charge Code	9490703
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- DEFRAN TORADOL KETORALAC 30MG

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	9401885
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- DEFRAN TORADOL KETORALAC 30MG

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	9401885
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- DEFRAN TRIAMCINOLONE ACETONID 40 MG

Facility

$105.00

Service Code	HCPCS J3301
Hospital Charge Code	9403301
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- DEFRAN TRIAMCINOLONE ACETONID 40 MG

Facility

$105.00

Service Code	HCPCS J3301
Hospital Charge Code	9403301
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- DEFRAN VARICELLA VACCINE

Facility

$100.00

Service Code	HCPCS 90716
Hospital Charge Code	9490716
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 VARICELLA VACCINE

Facility

$100.00

Service Code	HCPCS 90716
Hospital Charge Code	9490716
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 VISTARIL 50MG

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	9403410
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- DEFRAN VISTARIL 50MG

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	9403410
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- DEFRAN VITAMIN B-12

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	9403420
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- DEFRAN VITAMIN B-12

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	9403420
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- DEMEROL 50 MG DAVIS

Facility

$46.00

Service Code	HCPCS J2180
Hospital Charge Code	9802180
Hospital Revenue Code	636
Min. Negotiated Rate	$16.56
Max. Negotiated Rate	$32.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$27.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$32.84
Rate for Payer: Cash Price	$41.40
Rate for Payer: UnitedHealthcare Commercial	$30.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.56

CL- DEMEROL 50 MG DAVIS

Facility

$46.00

Service Code	HCPCS J2180
Hospital Charge Code	9802180
Hospital Revenue Code	636
Min. Negotiated Rate	$30.68
Max. Negotiated Rate	$30.68
Rate for Payer: Cash Price	$41.40
Rate for Payer: UnitedHealthcare Commercial	$30.68

CL- DEPO ESTRADIOL 5 MG DAVIS

Facility

$150.00

Service Code	HCPCS J1000
Hospital Charge Code	9801000
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- DEPO ESTRADIOL 5 MG DAVIS

Facility

$150.00

Service Code	HCPCS J1000
Hospital Charge Code	9801000
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- DEPO ESTRADIOL CYPIONATE UP TO 5 MG

Facility

$150.00

Service Code	HCPCS J1000
Hospital Charge Code	5201000
Hospital Revenue Code	521
Min. Negotiated Rate	$88.80
Max. Negotiated Rate	$173.53
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: Cash Price	$135.00
Rate for Payer: UnitedHealthcare Commercial	$100.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- DEPO ESTRADIOL CYPIONATE UP TO 5 MG

Facility

$150.00

Service Code	HCPCS J1000
Hospital Charge Code	5201000
Hospital Revenue Code	521
Rate for Payer: Cash Price	$135.00

Know your out-of-pocket cost for care.

All Charges