Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL - DTAP/HEPB/IPV

Facility

$80.00

Service Code	CPT 90723
Hospital Charge Code	9290723
Hospital Revenue Code	636
Min. Negotiated Rate	$53.36
Max. Negotiated Rate	$53.36
Rate for Payer: Cash Price	$72.00
Rate for Payer: UnitedHealthcare Commercial	$53.36

CL - DTAP/IPV/HIB

Facility

$80.00

Service Code	CPT 90698
Hospital Charge Code	9290698
Hospital Revenue Code	636
Min. Negotiated Rate	$53.36
Max. Negotiated Rate	$53.36
Rate for Payer: Cash Price	$72.00
Rate for Payer: UnitedHealthcare Commercial	$53.36

CL - DTAP/IPV/HIB

Facility

$80.00

Service Code	CPT 90698
Hospital Charge Code	9290698
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

CLEAN CATCH KIT

Facility

$22.00

Hospital Charge Code	283707
Hospital Revenue Code	271
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

CLEAN CATCH KIT

Facility

$22.00

Hospital Charge Code	283707
Hospital Revenue Code	271
Rate for Payer: Cash Price	$19.80

CLEANSING & DEBRIDEMENT OF TISSUE

Professional

Both

$640.00

Service Code	CPT 97597
Hospital Charge Code	1811042
Hospital Revenue Code	981
Min. Negotiated Rate	$30.42
Max. Negotiated Rate	$224.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$30.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$77.08
Rate for Payer: Cash Price	$576.00
Rate for Payer: Cash Price	$576.00
Rate for Payer: Cigna Commercial HMO & PPO	$30.42
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$77.08
Rate for Payer: Home State Health Plan Medicaid Managed Care	$84.79
Rate for Payer: Home State Health Plan Medicare Advantage	$30.42
Rate for Payer: Optum Medicare Advantage	$224.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$77.08

CLEFT LIP AND PALATE REPAIR

Facility

$14,675.81

Service Code	APR-DRG 0953
Min. Negotiated Rate	$14,675.81
Max. Negotiated Rate	$14,675.81
Rate for Payer: Aetna Better Health Medicaid/QHP	$14,675.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14,675.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14,675.81
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14,675.81

CLEFT LIP AND PALATE REPAIR

Facility

$11,404.87

Service Code	APR-DRG 0952
Min. Negotiated Rate	$11,404.87
Max. Negotiated Rate	$11,404.87
Rate for Payer: Aetna Better Health Medicaid/QHP	$11,404.87
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$11,404.87
Rate for Payer: Home State Health Plan Medicaid Managed Care	$11,404.87
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$11,404.87

CLEFT LIP AND PALATE REPAIR

Facility

$9,987.58

Service Code	APR-DRG 0951
Min. Negotiated Rate	$9,987.58
Max. Negotiated Rate	$9,987.58
Rate for Payer: Aetna Better Health Medicaid/QHP	$9,987.58
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$9,987.58
Rate for Payer: Home State Health Plan Medicaid Managed Care	$9,987.58
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$9,987.58

CLEFT LIP AND PALATE REPAIR

Facility

$26,540.17

Service Code	APR-DRG 0954
Min. Negotiated Rate	$26,540.17
Max. Negotiated Rate	$26,540.17
Rate for Payer: Aetna Better Health Medicaid/QHP	$26,540.17
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$26,540.17
Rate for Payer: Home State Health Plan Medicaid Managed Care	$26,540.17
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$26,540.17

CL- FISCHER DEPO ESTRADIOL 5 MG

Facility

$150.00

Service Code	HCPCS J1000
Hospital Charge Code	3901000
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- FISCHER DEPO ESTRADIOL 5 MG

Facility

$150.00

Service Code	HCPCS J1000
Hospital Charge Code	3901000
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- FISCHER DEPO MEDROL 1 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	3901040
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- FISCHER DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	3901030
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- FISCHER DEPO MEDROL 1 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	3901040
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- FISCHER DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	3901030
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- FISCHER DEPOPROVERA

Facility

$197.00

Service Code	HCPCS J1050
Hospital Charge Code	3901050
Hospital Revenue Code	636
Min. Negotiated Rate	$70.92
Max. Negotiated Rate	$140.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$116.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$140.66
Rate for Payer: Cash Price	$177.30
Rate for Payer: UnitedHealthcare Commercial	$131.40
Rate for Payer: UnitedHealthcare Medicare Advantage	$70.92

CL- FISCHER DEPOPROVERA

Facility

$197.00

Service Code	HCPCS J1050
Hospital Charge Code	3901050
Hospital Revenue Code	636
Min. Negotiated Rate	$131.40
Max. Negotiated Rate	$131.40
Rate for Payer: Cash Price	$177.30
Rate for Payer: UnitedHealthcare Commercial	$131.40

CL- FISCHER DIPHENHYDRAMINE 50 MG

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	3901200
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- FISCHER DIPHENHYDRAMINE 50 MG

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	3901200
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- FISCHER DTAP IPV 4-6 YRS OLD VACCINE

Facility

$55.00

Service Code	HCPCS 90696
Hospital Charge Code	3990696
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- FISCHER DTAP IPV 4-6 YRS OLD VACCINE

Facility

$55.00

Service Code	HCPCS 90696
Hospital Charge Code	3990696
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- FISCHER HEP A ADULT VACCINE

Facility

$25.00

Service Code	HCPCS 90632
Hospital Charge Code	3990632
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- FISCHER HEP A ADULT VACCINE

Facility

$25.00

Service Code	HCPCS 90632
Hospital Charge Code	3990632
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- FISCHER HPV GARDISAL VACCINE

Facility

$150.00

Service Code	HCPCS 90649
Hospital Charge Code	3990649
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

Know your out-of-pocket cost for care.

All Charges