Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- MCGRAW TRIAMACILONE ACETONID 20 MG

Facility

$105.00

Service Code	HCPCS J3301
Hospital Charge Code	4203301
Hospital Revenue Code	636
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$74.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$62.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$74.97
Rate for Payer: Cash Price	$94.50
Rate for Payer: UnitedHealthcare Commercial	$70.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$37.80

CL- MCGRAW TRIAMACILONE ACETONID 20 MG

Facility

$105.00

Service Code	HCPCS J3301
Hospital Charge Code	4203301
Hospital Revenue Code	636
Min. Negotiated Rate	$70.03
Max. Negotiated Rate	$70.03
Rate for Payer: Cash Price	$94.50
Rate for Payer: UnitedHealthcare Commercial	$70.03

CL- MCGRAW VARICELLA VARIVAX VACCINE

Facility

$95.00

Service Code	HCPCS 90716
Hospital Charge Code	4290716
Hospital Revenue Code	636
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$67.83
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: UnitedHealthcare Commercial	$63.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$34.20

CL- MCGRAW VARICELLA VARIVAX VACCINE

Facility

$95.00

Service Code	HCPCS 90716
Hospital Charge Code	4290716
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 VISTARIL UP TO 25 MG

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	4203410
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- MCGRAW VISTARIL UP TO 25 MG

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	4203410
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- MCGRAW ZOSTAVAX

Facility

$200.00

Service Code	HCPCS 90736
Hospital Charge Code	4290736
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 ZOSTAVAX

Facility

$200.00

Service Code	HCPCS 90736
Hospital Charge Code	4290736
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 - MENACTRA

Facility

$130.00

Service Code	HCPCS 90734
Hospital Charge Code	9690734
Hospital Revenue Code	521
Min. Negotiated Rate	$76.96
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.82
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: UnitedHealthcare Commercial	$86.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL - MENACTRA

Facility

$130.00

Service Code	HCPCS 90734
Hospital Charge Code	9690734
Hospital Revenue Code	521
Rate for Payer: Cash Price	$117.00

CL- MENACTRA DAVIS

Facility

$130.00

Service Code	HCPCS 90734
Hospital Charge Code	9890734
Hospital Revenue Code	636
Min. Negotiated Rate	$46.80
Max. Negotiated Rate	$92.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.82
Rate for Payer: Cash Price	$117.00
Rate for Payer: UnitedHealthcare Commercial	$86.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$46.80

CL- MENACTRA DAVIS

Facility

$130.00

Service Code	HCPCS 90734
Hospital Charge Code	9890734
Hospital Revenue Code	636
Min. Negotiated Rate	$86.71
Max. Negotiated Rate	$86.71
Rate for Payer: Cash Price	$117.00
Rate for Payer: UnitedHealthcare Commercial	$86.71

CL - MENACTRA VACCINE

Facility

$130.00

Service Code	HCPCS 90734
Hospital Charge Code	5290734
Hospital Revenue Code	521
Rate for Payer: Cash Price	$117.00

CL - MENACTRA VACCINE

Facility

$130.00

Service Code	HCPCS 90734
Hospital Charge Code	9290734
Hospital Revenue Code	521
Rate for Payer: Cash Price	$117.00

CL - MENACTRA VACCINE

Facility

$130.00

Service Code	HCPCS 90734
Hospital Charge Code	9290734
Hospital Revenue Code	521
Min. Negotiated Rate	$76.96
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.82
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: UnitedHealthcare Commercial	$86.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL - MENACTRA VACCINE

Facility

$130.00

Service Code	HCPCS 90734
Hospital Charge Code	5290734
Hospital Revenue Code	521
Min. Negotiated Rate	$76.96
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.82
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: UnitedHealthcare Commercial	$86.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL - MENINGOCOCCAL GRP B

Facility

$225.00

Service Code	HCPCS 90620
Hospital Charge Code	9690620
Hospital Revenue Code	521
Rate for Payer: Cash Price	$202.50

CL - MENINGOCOCCAL GRP B

Facility

$225.00

Service Code	HCPCS 90620
Hospital Charge Code	9690620
Hospital Revenue Code	521
Min. Negotiated Rate	$133.20
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$133.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$160.65
Rate for Payer: Cash Price	$202.50
Rate for Payer: Cash Price	$202.50
Rate for Payer: UnitedHealthcare Commercial	$150.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL - MENINGOCOCCAL MENACTRA VACCINE

Facility

$125.00

Service Code	HCPCS 90734
Hospital Charge Code	4290734
Hospital Revenue Code	521
Min. Negotiated Rate	$74.00
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$74.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$89.25
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cash Price	$112.50
Rate for Payer: UnitedHealthcare Commercial	$83.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL - MENINGOCOCCAL MENACTRA VACCINE

Facility

$125.00

Service Code	HCPCS 90734
Hospital Charge Code	4290734
Hospital Revenue Code	521
Rate for Payer: Cash Price	$112.50

CL- MENZ DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	9701030
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- MENZ DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	9701030
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- MENZ DEPO MEDROL 80 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	9701040
Hospital Revenue Code	521
Rate for Payer: Cash Price	$103.50

CL- MENZ DEPO MEDROL 80 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	9701040
Hospital Revenue Code	521
Min. Negotiated Rate	$68.08
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$68.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$82.11
Rate for Payer: Cash Price	$103.50
Rate for Payer: Cash Price	$103.50
Rate for Payer: UnitedHealthcare Commercial	$76.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- MENZ DIPHENHYDRAMINE 50 MG

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	9701200
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

Know your out-of-pocket cost for care.

All Charges