Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL - HEPATITIS A

Facility

$25.00

Service Code	CPT 90632
Hospital Charge Code	9690632
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 - HEPATITIS A

Facility

$25.00

Service Code	HCPCS 90633
Hospital Charge Code	9690633
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 - HIB

Facility

$25.00

Service Code	HCPCS 90647
Hospital Charge Code	9690647
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 - HIB

Facility

$25.00

Service Code	HCPCS 90647
Hospital Charge Code	9690647
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 - HIB 3 DOSE

Facility

$25.00

Service Code	HCPCS 90647
Hospital Charge Code	5290647
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 - HIB 3 DOSE

Facility

$25.00

Service Code	HCPCS 90647
Hospital Charge Code	5290647
Hospital Revenue Code	521
Rate for Payer: Cash Price	$22.50

CL - HIGHDOSE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	9290662
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 - HIGHDOSE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	9290662
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 - HIGHDOSE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	9690662
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 - HIGHDOSE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	9690662
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- HIGHDOSE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	4490662
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- HIGHDOSE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	9490662
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- HIGHDOSE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	4290662
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- HIGHDOSE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	9490662
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- HIGHDOSE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	9790662
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- HIGHDOSE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	9790662
Hospital Revenue Code	521
Rate for Payer: Cash Price	$81.00

CL- HIGHDOSE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	4490662
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- HIGHDOSE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	9890662
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- HIGHDOSE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	9890662
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- HIGHDOSE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	4290662
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- HIGHDOSE FLU 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	3990662
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- HIGHDOSE FLU 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	3990662
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- HIGHDOSE FLU 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	5290662
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- HIGHDOSE FLU 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	5290662
Hospital Revenue Code	521
Rate for Payer: Cash Price	$81.00

CL- HIGH DOSE VACCINE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	9590662
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

Know your out-of-pocket cost for care.

All Charges