Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- MENZ DIPHENHYDRAMINE 50 MG

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	9701200
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- MENZ INFLUENZA VACCINE 3 YEARS +

Facility

$35.00

Service Code	HCPCS 90658
Hospital Charge Code	9790724
Hospital Revenue Code	521
Rate for Payer: Cash Price	$31.50

CL- MENZ INFLUENZA VACCINE 3 YEARS +

Facility

$35.00

Service Code	HCPCS 90658
Hospital Charge Code	9790724
Hospital Revenue Code	521
Min. Negotiated Rate	$20.72
Max. Negotiated Rate	$173.53
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: Cash Price	$31.50
Rate for Payer: UnitedHealthcare Commercial	$23.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- MENZ INFLUENZA VACCINE 3 YRS +

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	9790658
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- MENZ INFLUENZA VACCINE 3 YRS +

Facility

$65.00

Service Code	HCPCS 90658
Hospital Charge Code	9790658
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- MENZ INFLUENZA VACCINE 6 - 35 MO

Facility

$30.00

Service Code	HCPCS 90657
Hospital Charge Code	9790657
Hospital Revenue Code	521
Rate for Payer: Cash Price	$27.00

CL- MENZ INFLUENZA VACCINE 6 - 35 MO

Facility

$30.00

Service Code	HCPCS 90657
Hospital Charge Code	9790657
Hospital Revenue Code	521
Min. Negotiated Rate	$17.76
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: UnitedHealthcare Commercial	$20.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- MENZ PENICILLIN

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	9700540
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- MENZ PENICILLIN

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	9700540
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- MENZ PNEUMO 23 VACCINE

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	9790732
Hospital Revenue Code	521
Rate for Payer: Cash Price	$225.00

CL- MENZ PNEUMO 23 VACCINE

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	9790732
Hospital Revenue Code	521
Min. Negotiated Rate	$148.00
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: Cash Price	$225.00
Rate for Payer: UnitedHealthcare Commercial	$166.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- MENZ ROCEPHIN 500 MG

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	9700696
Hospital Revenue Code	521
Rate for Payer: Cash Price	$180.00

CL- MENZ ROCEPHIN 500 MG

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	9700696
Hospital Revenue Code	521
Min. Negotiated Rate	$118.40
Max. Negotiated Rate	$173.53
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: Cash Price	$180.00
Rate for Payer: UnitedHealthcare Commercial	$133.40
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- MENZ TD 7 AND > IMMUNIZATION

Facility

$33.00

Service Code	HCPCS 90714
Hospital Charge Code	9790703
Hospital Revenue Code	521
Min. Negotiated Rate	$19.54
Max. Negotiated Rate	$173.53
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: Cash Price	$29.70
Rate for Payer: UnitedHealthcare Commercial	$22.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- MENZ TD 7 AND > IMMUNIZATION

Facility

$33.00

Service Code	HCPCS 90714
Hospital Charge Code	9790703
Hospital Revenue Code	521
Rate for Payer: Cash Price	$29.70

CL- MENZ TORADOL- KETORALAC TROMETHAMIN

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	9701885
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- MENZ TORADOL- KETORALAC TROMETHAMIN

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	9701885
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

CL- MENZ VIT B12 CYANOOCOBALAMI 1000MCG

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	9703420
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- MENZ VIT B12 CYANOOCOBALAMI 1000MCG

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	9703420
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 - MMR

Facility

$60.00

Service Code	HCPCS 90707
Hospital Charge Code	9690707
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 - MMR

Facility

$60.00

Service Code	HCPCS 90707
Hospital Charge Code	9690707
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 - MMR VACCINE

Facility

$55.00

Service Code	HCPCS 90707
Hospital Charge Code	4290707
Hospital Revenue Code	636
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$39.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.80

CL - MMR VACCINE

Facility

$55.00

Service Code	HCPCS 90707
Hospital Charge Code	4290707
Hospital Revenue Code	636
Min. Negotiated Rate	$36.69
Max. Negotiated Rate	$36.69
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69

CL - MMRV VACCINE

Facility

$110.00

Service Code	HCPCS 90710
Hospital Charge Code	4290706
Hospital Revenue Code	636
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$78.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$65.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$78.54
Rate for Payer: Cash Price	$99.00
Rate for Payer: UnitedHealthcare Commercial	$73.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$39.60

CL - MMRV VACCINE

Facility

$110.00

Service Code	HCPCS 90710
Hospital Charge Code	4290706
Hospital Revenue Code	636
Min. Negotiated Rate	$73.37
Max. Negotiated Rate	$73.37
Rate for Payer: Cash Price	$99.00
Rate for Payer: UnitedHealthcare Commercial	$73.37

Know your out-of-pocket cost for care.

All Charges