Madison Medical Center

All Charges

Charge

Type

Setting

Price

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

CL- MCGRAW FLUZONE AGE 6 MONTHS TO 36 MO

Facility

$35.00

Service Code	HCPCS 90657
Hospital Charge Code	4290657
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- MCGRAW FLUZONE AGE 6 MONTHS TO 36 MO

Facility

$35.00

Service Code	HCPCS 90657
Hospital Charge Code	4290657
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- MCGRAW FLUZONE VACCINE AGES 3+

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	4290658
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- MCGRAW FLUZONE VACCINE AGES 3+

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	4290658
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- MCGRAW NORFLEX 60 MG

Facility

$94.00

Service Code	HCPCS J2360
Hospital Charge Code	4202360
Hospital Revenue Code	636
Min. Negotiated Rate	$33.84
Max. Negotiated Rate	$67.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$55.65
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$67.12
Rate for Payer: Cash Price	$84.60
Rate for Payer: UnitedHealthcare Commercial	$62.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$33.84

CL- MCGRAW NORFLEX 60 MG

Facility

$94.00

Service Code	HCPCS J2360
Hospital Charge Code	4202360
Hospital Revenue Code	636
Min. Negotiated Rate	$62.70
Max. Negotiated Rate	$62.70
Rate for Payer: Cash Price	$84.60
Rate for Payer: UnitedHealthcare Commercial	$62.70

CL- MCGRAW PENICILLIN

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	4200540
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- MCGRAW PENICILLIN

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	4200540
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- MCGRAW PHENERGAN 50 MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	4202550
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- MCGRAW PHENERGAN 50 MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	4202550
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- MCGRAW PNEUMOVAX 23 VACCINE DAVIS

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	4290732
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- MCGRAW PNEUMOVAX 23 VACCINE DAVIS

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	4290732
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- MCGRAW PREVNAR 13

Facility

$536.00

Service Code	HCPCS 90670
Hospital Charge Code	4290670
Hospital Revenue Code	636
Min. Negotiated Rate	$192.96
Max. Negotiated Rate	$382.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$317.31
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$382.70
Rate for Payer: Cash Price	$482.40
Rate for Payer: UnitedHealthcare Commercial	$357.51
Rate for Payer: UnitedHealthcare Medicare Advantage	$192.96

CL- MCGRAW PREVNAR 13

Facility

$536.00

Service Code	HCPCS 90670
Hospital Charge Code	4290670
Hospital Revenue Code	636
Min. Negotiated Rate	$357.51
Max. Negotiated Rate	$357.51
Rate for Payer: Cash Price	$482.40
Rate for Payer: UnitedHealthcare Commercial	$357.51

CL- MCGRAW ROCEPHIN PER 250 MG

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	4200696
Hospital Revenue Code	636
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$142.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$118.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$142.80
Rate for Payer: Cash Price	$180.00
Rate for Payer: UnitedHealthcare Commercial	$133.40
Rate for Payer: UnitedHealthcare Medicare Advantage	$72.00

CL- MCGRAW ROCEPHIN PER 250 MG

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	4200696
Hospital Revenue Code	636
Min. Negotiated Rate	$133.40
Max. Negotiated Rate	$133.40
Rate for Payer: Cash Price	$180.00
Rate for Payer: UnitedHealthcare Commercial	$133.40

CL- MCGRAW TB PPD INTRADERMAL

Facility

$45.00

Service Code	HCPCS 86580
Hospital Charge Code	4286580
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- MCGRAW TB PPD INTRADERMAL

Facility

$45.00

Service Code	HCPCS 86580
Hospital Charge Code	4286580
Hospital Revenue Code	636
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$59.10
Rate for Payer: Aetna Better Health Medicaid/QHP	$26.07
Rate for Payer: Aetna Medicare Advantage	$29.55
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: Cash Price	$40.50
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial HMO & PPO	$29.55
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$26.07
Rate for Payer: Home State Health Plan Medicaid Managed Care	$27.89
Rate for Payer: Home State Health Plan Medicare Advantage	$29.55
Rate for Payer: Humana Commercial	$59.10
Rate for Payer: Humana Medicare Advantage	$29.55
Rate for Payer: UnitedHealthcare Commercial	$29.55
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$26.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.20

CL- MCGRAW TDAP ADACEL >7 YRS OF AGE

Facility

$40.00

Service Code	HCPCS 90715
Hospital Charge Code	4290715
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 TDAP ADACEL >7 YRS OF AGE

Facility

$40.00

Service Code	HCPCS 90715
Hospital Charge Code	4290715
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 TETNUS TOXOID

Facility

$33.00

Service Code	HCPCS 90714
Hospital Charge Code	4290703
Hospital Revenue Code	636
Min. Negotiated Rate	$22.01
Max. Negotiated Rate	$22.01
Rate for Payer: Cash Price	$29.70
Rate for Payer: UnitedHealthcare Commercial	$22.01

CL- MCGRAW TETNUS TOXOID

Facility

$33.00

Service Code	HCPCS 90714
Hospital Charge Code	4290703
Hospital Revenue Code	636
Min. Negotiated Rate	$11.88
Max. Negotiated Rate	$23.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$19.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$23.56
Rate for Payer: Cash Price	$29.70
Rate for Payer: UnitedHealthcare Commercial	$22.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.88

CL- MCGRAW TORADOL PER 15 MG

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	4201885
Hospital Revenue Code	636
Min. Negotiated Rate	$63.37
Max. Negotiated Rate	$63.37
Rate for Payer: Cash Price	$85.50
Rate for Payer: UnitedHealthcare Commercial	$63.37

CL- MCGRAW TORADOL PER 15 MG

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	4201885
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$67.83
Rate for Payer: Aetna Medicare Advantage	$0.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$56.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$67.83
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial HMO & PPO	$0.29
Rate for Payer: Home State Health Plan Medicare Advantage	$0.29
Rate for Payer: Humana Commercial	$0.58
Rate for Payer: Humana Medicare Advantage	$0.29
Rate for Payer: UnitedHealthcare Commercial	$0.29
Rate for Payer: UnitedHealthcare Medicare Advantage	$34.20

Know your out-of-pocket cost for care.

All Charges