Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- HIGH DOSE VACCINE 65+

Facility

$90.00

Service Code	HCPCS 90662
Hospital Charge Code	9590662
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 - HPV GARDISIL VACCINE

Facility

$150.00

Service Code	HCPCS 90649
Hospital Charge Code	4290649
Hospital Revenue Code	521
Min. Negotiated Rate	$88.80
Max. Negotiated Rate	$173.53
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: Cash Price	$135.00
Rate for Payer: UnitedHealthcare Commercial	$100.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL - HPV GARDISIL VACCINE

Facility

$150.00

Service Code	HCPCS 90649
Hospital Charge Code	4290649
Hospital Revenue Code	521
Rate for Payer: Cash Price	$135.00

CL - IMMUNIZATION PEDIATRIC

Facility

$50.00

Service Code	HCPCS 90460
Hospital Charge Code	9690460
Hospital Revenue Code	636
Min. Negotiated Rate	$33.35
Max. Negotiated Rate	$33.35
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35

CL - IMMUNIZATION PEDIATRIC

Facility

$50.00

Service Code	HCPCS 90460
Hospital Charge Code	9690460
Hospital Revenue Code	636
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$35.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$29.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$35.70
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.00

CL- IMMUNIZATION PEDIATRIC

Facility

$50.00

Service Code	HCPCS 90460
Hospital Charge Code	5290460
Hospital Revenue Code	521
Rate for Payer: Cash Price	$45.00

CL- IMMUNIZATION PEDIATRIC

Facility

$50.00

Service Code	HCPCS 90460
Hospital Charge Code	9290460
Hospital Revenue Code	636
Min. Negotiated Rate	$33.35
Max. Negotiated Rate	$33.35
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35

CL- IMMUNIZATION PEDIATRIC

Facility

$50.00

Service Code	HCPCS 90460
Hospital Charge Code	9490460
Hospital Revenue Code	636
Min. Negotiated Rate	$33.35
Max. Negotiated Rate	$33.35
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35

CL- IMMUNIZATION PEDIATRIC

Facility

$50.00

Service Code	HCPCS 90460
Hospital Charge Code	9490460
Hospital Revenue Code	636
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$35.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$29.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$35.70
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.00

CL- IMMUNIZATION PEDIATRIC

Facility

$50.00

Service Code	HCPCS 90460
Hospital Charge Code	5290460
Hospital Revenue Code	521
Min. Negotiated Rate	$29.60
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$29.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$35.70
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- IMMUNIZATION PEDIATRIC

Facility

$50.00

Service Code	HCPCS 90460
Hospital Charge Code	4490460
Hospital Revenue Code	636
Min. Negotiated Rate	$33.35
Max. Negotiated Rate	$33.35
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35

CL- IMMUNIZATION PEDIATRIC

Facility

$50.00

Service Code	HCPCS 90460
Hospital Charge Code	9290460
Hospital Revenue Code	636
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$35.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$29.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$35.70
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.00

CL- IMMUNIZATION PEDIATRIC

Facility

$50.00

Service Code	HCPCS 90460
Hospital Charge Code	4490460
Hospital Revenue Code	636
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$35.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$29.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$35.70
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.00

CL-IMMUNIZATION PEDIATRIC

Facility

$70.00

Service Code	HCPCS 90460
Hospital Charge Code	9890460
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-IMMUNIZATION PEDIATRIC

Facility

$50.00

Service Code	HCPCS 90460
Hospital Charge Code	3990460
Hospital Revenue Code	771
Rate for Payer: Cash Price	$45.00

CL-IMMUNIZATION PEDIATRIC

Facility

$50.00

Service Code	HCPCS 90460
Hospital Charge Code	3990460
Hospital Revenue Code	771
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$35.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$29.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$35.70
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.00

CL-IMMUNIZATION PEDIATRIC

Facility

$70.00

Service Code	HCPCS 90460
Hospital Charge Code	9890460
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- IMOGAM 300 IU 2 ML

Facility

$600.00

Service Code	HCPCS 90376
Hospital Charge Code	3990376
Hospital Revenue Code	636
Min. Negotiated Rate	$400.20
Max. Negotiated Rate	$400.20
Rate for Payer: Cash Price	$540.00
Rate for Payer: UnitedHealthcare Commercial	$400.20

CL- IMOGAM 300 IU 2 ML

Facility

$600.00

Service Code	HCPCS 90376
Hospital Charge Code	3990376
Hospital Revenue Code	636
Min. Negotiated Rate	$216.00
Max. Negotiated Rate	$704.88
Rate for Payer: Aetna Medicare Advantage	$352.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$355.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$428.40
Rate for Payer: Cash Price	$540.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Cigna Commercial HMO & PPO	$352.44
Rate for Payer: Home State Health Plan Medicare Advantage	$352.44
Rate for Payer: Humana Commercial	$704.88
Rate for Payer: Humana Medicare Advantage	$352.44
Rate for Payer: UnitedHealthcare Commercial	$352.44
Rate for Payer: UnitedHealthcare Medicare Advantage	$216.00

CLINDAGEL 1% TOPICAL GEL 75ML EMP

Facility

$25.00

Service Code	NDC 1E+11
Hospital Charge Code	2622537
Hospital Revenue Code	250
Rate for Payer: Cash Price	$22.50

CLINDAGEL 1% TOPICAL GEL 75ML EMP

Facility

$25.00

Service Code	NDC 1E+11
Hospital Charge Code	2622537
Hospital Revenue Code	250
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

CLINDAMYC + BENZ GEL 45GM EMP

Facility

$381.00

Service Code	NDC 1E+11
Hospital Charge Code	2625475
Hospital Revenue Code	250
Min. Negotiated Rate	$137.16
Max. Negotiated Rate	$272.03
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$225.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$272.03
Rate for Payer: Cash Price	$342.90
Rate for Payer: UnitedHealthcare Commercial	$254.13
Rate for Payer: UnitedHealthcare Medicare Advantage	$137.16

CLINDAMYC + BENZ GEL 45GM EMP

Facility

$381.00

Service Code	NDC 1E+11
Hospital Charge Code	2625475
Hospital Revenue Code	250
Rate for Payer: Cash Price	$342.90

CLINDAMYCIN 150MG CAP EMP

Facility

$28.00

Service Code	NDC 4.2571E+10
Hospital Charge Code	2621913
Hospital Revenue Code	250
Rate for Payer: Cash Price	$25.20

CLINDAMYCIN 150MG CAP EMP

Facility

$28.00

Service Code	NDC 4.2571E+10
Hospital Charge Code	2621913
Hospital Revenue Code	250
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$19.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$16.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.99
Rate for Payer: Cash Price	$25.20
Rate for Payer: UnitedHealthcare Commercial	$18.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.08

Know your out-of-pocket cost for care.

All Charges