Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	5201030
Hospital Revenue Code	521
Min. Negotiated Rate	$35.52
Max. Negotiated Rate	$173.53
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: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	5201030
Hospital Revenue Code	521
Rate for Payer: Cash Price	$54.00

CL- DEPO MEDROL 1 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	5201040
Hospital Revenue Code	521
Rate for Payer: Cash Price	$103.50

CL- DEPO MEDROL 1 MG

Facility

$21.00

Service Code	HCPCS J1010
Hospital Charge Code	5201020
Hospital Revenue Code	521
Min. Negotiated Rate	$12.43
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- DEPO MEDROL 1 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	5201040
Hospital Revenue Code	521
Min. Negotiated Rate	$68.08
Max. Negotiated Rate	$173.53
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: Cash Price	$103.50
Rate for Payer: UnitedHealthcare Commercial	$76.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- DEPO MEDROL 1 MG

Facility

$21.00

Service Code	HCPCS J1010
Hospital Charge Code	5201020
Hospital Revenue Code	521
Rate for Payer: Cash Price	$18.90

CL- DEPO MEDROL 1 MG DAVIS

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	9801030
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- DEPO MEDROL 1 MG DAVIS

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	9801030
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- DEPO MEDROL 1 MG DAVIS

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	9801040
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- DEPO MEDROL 1 MG DAVIS

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	9801040
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- DEPO MEDROL 1 MG HOFFMAN

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	9301030
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- DEPO MEDROL 1 MG HOFFMAN

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	9301030
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- DEPO MEDROL 1 MG OLIVERO

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	5401030
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- DEPO MEDROL 1 MG OLIVERO

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	5401030
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- DEXAMETHASONE 1 ML

Facility

$140.00

Service Code	HCPCS J1100
Hospital Charge Code	9701100
Hospital Revenue Code	636
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$99.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$82.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$99.96
Rate for Payer: Cash Price	$126.00
Rate for Payer: UnitedHealthcare Commercial	$93.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$50.40

CL- DEXAMETHASONE 1 ML

Facility

$140.00

Service Code	HCPCS J1100
Hospital Charge Code	9701100
Hospital Revenue Code	636
Min. Negotiated Rate	$93.38
Max. Negotiated Rate	$93.38
Rate for Payer: Cash Price	$126.00
Rate for Payer: UnitedHealthcare Commercial	$93.38

CL- DEXAMETHASONE SOD PHOS 10 MG

Facility

$26.00

Service Code	HCPCS J1100
Hospital Charge Code	5201100
Hospital Revenue Code	521
Min. Negotiated Rate	$15.39
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$15.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$18.56
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: UnitedHealthcare Commercial	$17.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- DEXAMETHASONE SOD PHOS 10 MG

Facility

$26.00

Service Code	HCPCS J1100
Hospital Charge Code	5201100
Hospital Revenue Code	521
Rate for Payer: Cash Price	$23.40

CL - DTAP <7 YEARS OF AGE

Facility

$25.00

Service Code	CPT 90700
Hospital Charge Code	9290700
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 - DTAP <7 YEARS OF AGE

Facility

$25.00

Service Code	CPT 90700
Hospital Charge Code	9290700
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 - DTAP <7 YEARS OF AGE

Facility

$35.00

Service Code	HCPCS 90700
Hospital Charge Code	9690700
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 - DTAP <7 YEARS OF AGE

Facility

$35.00

Service Code	HCPCS 90700
Hospital Charge Code	9690700
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 - DTAP <7 YRS OF AGE

Facility

$70.00

Service Code	HCPCS 90700
Hospital Charge Code	9800073
Hospital Revenue Code	636
Min. Negotiated Rate	$46.69
Max. Negotiated Rate	$46.69
Rate for Payer: Cash Price	$63.00
Rate for Payer: UnitedHealthcare Commercial	$46.69

CL - DTAP <7 YRS OF AGE

Facility

$70.00

Service Code	HCPCS 90700
Hospital Charge Code	9800073
Hospital Revenue Code	636
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$49.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$41.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$49.98
Rate for Payer: Cash Price	$63.00
Rate for Payer: UnitedHealthcare Commercial	$46.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$25.20

CL - DTAP/HEPB/IPV

Facility

$80.00

Service Code	CPT 90723
Hospital Charge Code	9290723
Hospital Revenue Code	636
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$57.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$47.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$57.12
Rate for Payer: Cash Price	$72.00
Rate for Payer: UnitedHealthcare Commercial	$53.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.80

Know your out-of-pocket cost for care.

All Charges