Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- FLUZONE 6 MO+

Facility

$90.00

Service Code	HCPCS 90686
Hospital Charge Code	9290686
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- FLUZONE 6 MO+

Facility

$90.00

Service Code	HCPCS 90686
Hospital Charge Code	9290686
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- FLUZONE 6 MO+

Facility

$90.00

Service Code	HCPCS 90686
Hospital Charge Code	9790686
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- FLUZONE 6 MONTHS +

Facility

$90.00

Service Code	HCPCS 90686
Hospital Charge Code	5290686
Hospital Revenue Code	521
Min. Negotiated Rate	$53.28
Max. Negotiated Rate	$173.53
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: Cash Price	$81.00
Rate for Payer: UnitedHealthcare Commercial	$60.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- FLUZONE 6 MONTHS +

Facility

$90.00

Service Code	HCPCS 90686
Hospital Charge Code	5290686
Hospital Revenue Code	521
Rate for Payer: Cash Price	$81.00

CL-FLUZONE 6 MONTHS +

Facility

$90.00

Service Code	HCPCS 90686
Hospital Charge Code	3990686
Hospital Revenue Code	771
Rate for Payer: Cash Price	$81.00

CL-FLUZONE 6 MONTHS +

Facility

$90.00

Service Code	HCPCS 90686
Hospital Charge Code	3990686
Hospital Revenue Code	771
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- FLUZONE VACCINE 6MO - 35 MO

Facility

$35.00

Service Code	HCPCS 90657
Hospital Charge Code	5290657
Hospital Revenue Code	521
Min. Negotiated Rate	$20.72
Max. Negotiated Rate	$173.53
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: Cash Price	$31.50
Rate for Payer: UnitedHealthcare Commercial	$23.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- FLUZONE VACCINE 6MO - 35 MO

Facility

$35.00

Service Code	HCPCS 90657
Hospital Charge Code	5290657
Hospital Revenue Code	521
Rate for Payer: Cash Price	$31.50

CL- FLUZONE VACCINE AGES 3+

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	5290658
Hospital Revenue Code	521
Rate for Payer: Cash Price	$58.50

CL- FLUZONE VACCINE AGES 3+

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	5290658
Hospital Revenue Code	521
Min. Negotiated Rate	$38.48
Max. Negotiated Rate	$173.53
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: Cash Price	$58.50
Rate for Payer: UnitedHealthcare Commercial	$43.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL - GARDISAL

Facility

$150.00

Service Code	HCPCS 90649
Hospital Charge Code	9690649
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 - GARDISAL

Facility

$150.00

Service Code	HCPCS 90649
Hospital Charge Code	9690649
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- GARDISAL HPV DAVIS

Facility

$150.00

Service Code	HCPCS 90649
Hospital Charge Code	9890649
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- GARDISAL HPV DAVIS

Facility

$150.00

Service Code	HCPCS 90649
Hospital Charge Code	9890649
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- GARDISIL OLIVERO

Facility

$150.00

Service Code	HCPCS 90649
Hospital Charge Code	5490649
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- GARDISIL OLIVERO

Facility

$150.00

Service Code	HCPCS 90649
Hospital Charge Code	5490649
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 - HEP A ADULT VACCINE

Facility

$25.00

Service Code	HCPCS 90632
Hospital Charge Code	5290632
Hospital Revenue Code	521
Min. Negotiated Rate	$14.80
Max. Negotiated Rate	$173.53
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: Cash Price	$22.50
Rate for Payer: UnitedHealthcare Commercial	$16.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL - HEP A ADULT VACCINE

Facility

$25.00

Service Code	HCPCS 90632
Hospital Charge Code	9290632
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 - HEP A ADULT VACCINE

Facility

$25.00

Service Code	HCPCS 90632
Hospital Charge Code	5290632
Hospital Revenue Code	521
Rate for Payer: Cash Price	$22.50

CL - HEP A ADULT VACCINE

Facility

$25.00

Service Code	HCPCS 90632
Hospital Charge Code	9290632
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 - HEP A ADULT VAX

Facility

$25.00

Service Code	HCPCS 90632
Hospital Charge Code	9790632
Hospital Revenue Code	521
Rate for Payer: Cash Price	$22.50

CL - HEP A ADULT VAX

Facility

$25.00

Service Code	HCPCS 90632
Hospital Charge Code	9790632
Hospital Revenue Code	521
Min. Negotiated Rate	$14.80
Max. Negotiated Rate	$173.53
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: Cash Price	$22.50
Rate for Payer: UnitedHealthcare Commercial	$16.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL - HEPATITIS A

Facility

$25.00

Service Code	HCPCS 90633
Hospital Charge Code	9690633
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 - HEPATITIS A

Facility

$25.00

Service Code	CPT 90632
Hospital Charge Code	9690632
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

Know your out-of-pocket cost for care.

All Charges