Madison Medical Center

All Charges

Charge

Type

Setting

Price

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

CL- FISCHER INFLUENZA VAC 6-36 MONTHS

Facility

$35.00

Service Code	HCPCS 90657
Hospital Charge Code	3990657
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- FISCHER INFLUENZA VAC 6-36 MONTHS

Facility

$35.00

Service Code	HCPCS 90657
Hospital Charge Code	3990657
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- FISCHER INFLUENZA VACCINE

Facility

$35.00

Service Code	HCPCS 90658
Hospital Charge Code	3990724
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- FISCHER INFLUENZA VACCINE

Facility

$35.00

Service Code	HCPCS 90658
Hospital Charge Code	3990724
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- FISCHER INFLUENZA VACCINE 3 YRS &OLD

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	3990658
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- FISCHER INFLUENZA VACCINE 3 YRS &OLD

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	3990658
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- FISCHER LIPO B INJECTION

Facility

$15.00

Service Code	HCPCS J3490
Hospital Charge Code	3903490
Hospital Revenue Code	636
Min. Negotiated Rate	$10.01
Max. Negotiated Rate	$10.01
Rate for Payer: Cash Price	$13.50
Rate for Payer: UnitedHealthcare Commercial	$10.01

CL- FISCHER LIPO B INJECTION

Facility

$15.00

Service Code	HCPCS J3490
Hospital Charge Code	3903490
Hospital Revenue Code	636
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$10.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$8.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$10.71
Rate for Payer: Cash Price	$13.50
Rate for Payer: UnitedHealthcare Commercial	$10.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.40

CL- FISCHER MENACTRA VACCINE

Facility

$130.00

Service Code	HCPCS 90734
Hospital Charge Code	3990734
Hospital Revenue Code	636
Min. Negotiated Rate	$86.71
Max. Negotiated Rate	$86.71
Rate for Payer: Cash Price	$117.00
Rate for Payer: UnitedHealthcare Commercial	$86.71

CL- FISCHER MENACTRA VACCINE

Facility

$130.00

Service Code	HCPCS 90734
Hospital Charge Code	3990734
Hospital Revenue Code	636
Min. Negotiated Rate	$46.80
Max. Negotiated Rate	$92.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.82
Rate for Payer: Cash Price	$117.00
Rate for Payer: UnitedHealthcare Commercial	$86.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$46.80

CL- FISCHER MMR VACCINE

Facility

$55.00

Service Code	HCPCS 90707
Hospital Charge Code	3990707
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 MMR VACCINE

Facility

$55.00

Service Code	HCPCS 90707
Hospital Charge Code	3990707
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 PENICILLIN INJECTION

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	3900540
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- FISCHER PENICILLIN INJECTION

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	3900540
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- FISCHER PENICILLIN INJECTION

Facility

$100.00

Service Code	HCPCS J0558
Hospital Charge Code	390540
Hospital Revenue Code	636
Min. Negotiated Rate	$19.52
Max. Negotiated Rate	$71.40
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	$59.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$71.40
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cash Price	$90.00
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	$36.00

CL- FISCHER PENICILLIN INJECTION

Facility

$100.00

Service Code	HCPCS J0558
Hospital Charge Code	390540
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- FISCHER PHENERGAN 50 MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	3902550
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 PHENERGAN 50 MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	3902550
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 PNEUMO 23 VACCINE

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	3990732
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- FISCHER PNEUMO 23 VACCINE

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	3990732
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- FISCHER PREVNAR 13

Facility

$541.00

Service Code	HCPCS 90670
Hospital Charge Code	3998312
Hospital Revenue Code	636
Min. Negotiated Rate	$194.76
Max. Negotiated Rate	$386.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$320.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$386.27
Rate for Payer: Cash Price	$486.90
Rate for Payer: UnitedHealthcare Commercial	$360.85
Rate for Payer: UnitedHealthcare Medicare Advantage	$194.76

CL- FISCHER PREVNAR 13

Facility

$541.00

Service Code	HCPCS 90670
Hospital Charge Code	3998312
Hospital Revenue Code	636
Min. Negotiated Rate	$360.85
Max. Negotiated Rate	$360.85
Rate for Payer: Cash Price	$486.90
Rate for Payer: UnitedHealthcare Commercial	$360.85

CL- FISCHER RABAVERT VACCINE FOR IM USE

Facility

$350.00

Service Code	HCPCS 90675
Hospital Charge Code	3990675
Hospital Revenue Code	636
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$663.96
Rate for Payer: Aetna Medicare Advantage	$331.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$207.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$249.90
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cigna Commercial HMO & PPO	$331.98
Rate for Payer: Home State Health Plan Medicare Advantage	$331.98
Rate for Payer: Humana Commercial	$663.96
Rate for Payer: Humana Medicare Advantage	$331.98
Rate for Payer: UnitedHealthcare Commercial	$331.98
Rate for Payer: UnitedHealthcare Medicare Advantage	$126.00

CL- FISCHER RABAVERT VACCINE FOR IM USE

Facility

$350.00

Service Code	HCPCS 90675
Hospital Charge Code	3990675
Hospital Revenue Code	636
Min. Negotiated Rate	$233.45
Max. Negotiated Rate	$233.45
Rate for Payer: Cash Price	$315.00
Rate for Payer: UnitedHealthcare Commercial	$233.45

Know your out-of-pocket cost for care.

All Charges