Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- INFLUENZA VACCINE HI DOSE OLIVERO

Facility

$90.00

Service Code	HCPCS 90658
Hospital Charge Code	5490662
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- INFLUENZA VACCINE HI DOSE OLIVERO

Facility

$90.00

Service Code	HCPCS 90658
Hospital Charge Code	5490662
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 - INFLUENZA VACCINE NASAL FLUMIST

Facility

$65.00

Service Code	HCPCS 90660
Hospital Charge Code	3990672
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 - INFLUENZA VACCINE NASAL FLUMIST

Facility

$65.00

Service Code	HCPCS 90660
Hospital Charge Code	3990672
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- INFLUENZA VACCINE OLIVERO

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	5490658
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- INFLUENZA VACCINE OLIVERO

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	5490658
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

CLIP II ML ER320

Facility

$1,345.00

Hospital Charge Code	125350
Hospital Revenue Code	271
Rate for Payer: Cash Price	$1,210.50

CLIP II ML ER320

Facility

$1,345.00

Hospital Charge Code	125350
Hospital Revenue Code	271
Min. Negotiated Rate	$484.20
Max. Negotiated Rate	$960.33
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$796.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$960.33
Rate for Payer: Cash Price	$1,210.50
Rate for Payer: UnitedHealthcare Commercial	$897.12
Rate for Payer: UnitedHealthcare Medicare Advantage	$484.20

CLIPPERS & BLADES

Facility

$50.00

Hospital Charge Code	2818600
Hospital Revenue Code	271
Rate for Payer: Cash Price	$45.00

CLIPPERS & BLADES

Facility

$50.00

Hospital Charge Code	2818600
Hospital Revenue Code	271
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

CLIP REMOVER

Facility

$16.00

Hospital Charge Code	283779
Hospital Revenue Code	271
Rate for Payer: Cash Price	$14.40

CLIP REMOVER

Facility

$16.00

Hospital Charge Code	283779
Hospital Revenue Code	271
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$11.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$9.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$11.42
Rate for Payer: Cash Price	$14.40
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.76

CL - KINRIX

Facility

$100.00

Service Code	HCPCS 90696
Hospital Charge Code	9690696
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 - KINRIX

Facility

$100.00

Service Code	HCPCS 90696
Hospital Charge Code	9690696
Hospital Revenue Code	636
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$71.40
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: UnitedHealthcare Commercial	$66.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$36.00

CL- LINCOCIN HCI UP TO 300 MG

Facility

$21.00

Service Code	HCPCS J2010
Hospital Charge Code	5202010
Hospital Revenue Code	521
Rate for Payer: Cash Price	$18.90

CL- LINCOCIN HCI UP TO 300 MG

Facility

$21.00

Service Code	HCPCS J2010
Hospital Charge Code	5202010
Hospital Revenue Code	521
Min. Negotiated Rate	$12.43
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- LIPO B INJECTION DAVIS

Facility

$15.00

Service Code	HCPCS J3490
Hospital Charge Code	9803490
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- LIPO B INJECTION DAVIS

Facility

$15.00

Service Code	HCPCS J3490
Hospital Charge Code	9803490
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- MCGRAW B-12 INJECTION

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	4203420
Hospital Revenue Code	636
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$28.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$28.56
Rate for Payer: Cash Price	$36.00
Rate for Payer: UnitedHealthcare Commercial	$26.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.40

CL- MCGRAW B-12 INJECTION

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	4203420
Hospital Revenue Code	636
Min. Negotiated Rate	$26.68
Max. Negotiated Rate	$26.68
Rate for Payer: Cash Price	$36.00
Rate for Payer: UnitedHealthcare Commercial	$26.68

CL- MCGRAW DEMEROL 50 MG INJECTION

Facility

$41.00

Service Code	HCPCS J2180
Hospital Charge Code	4202180
Hospital Revenue Code	636
Min. Negotiated Rate	$27.35
Max. Negotiated Rate	$27.35
Rate for Payer: Cash Price	$36.90
Rate for Payer: UnitedHealthcare Commercial	$27.35

CL- MCGRAW DEMEROL 50 MG INJECTION

Facility

$41.00

Service Code	HCPCS J2180
Hospital Charge Code	4202180
Hospital Revenue Code	636
Min. Negotiated Rate	$14.76
Max. Negotiated Rate	$29.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$24.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$29.27
Rate for Payer: Cash Price	$36.90
Rate for Payer: UnitedHealthcare Commercial	$27.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.76

CL- MCGRAW DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	4201030
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- MCGRAW DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	4201030
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- MCGRAW DEPO MEDROL 1 MG INJ

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	4201040
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

Know your out-of-pocket cost for care.

All Charges