Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- NFLUENZA FLUBLOK

Facility

$90.00

Service Code	HCPCS 90682
Hospital Charge Code	9590682
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- NFLUENZA FLUBLOK

Facility

$90.00

Service Code	HCPCS 90682
Hospital Charge Code	9590682
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- NFLUENZA PEDIATRIC

Facility

$70.00

Service Code	HCPCS 90460
Hospital Charge Code	9590460
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- NFLUENZA PEDIATRIC

Facility

$70.00

Service Code	HCPCS 90460
Hospital Charge Code	9590460
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- NFLUENZA QUAD

Facility

$70.00

Service Code	HCPCS 90686
Hospital Charge Code	9590686
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- NFLUENZA QUAD

Facility

$70.00

Service Code	HCPCS 90686
Hospital Charge Code	9590686
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

CLOBAZAM

Facility

$224.00

Service Code	CPT 80299
Hospital Charge Code	2280293
Hospital Revenue Code	301
Min. Negotiated Rate	$16.78
Max. Negotiated Rate	$159.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.78
Rate for Payer: Aetna Medicare Advantage	$18.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$132.61
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$159.94
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cigna Commercial HMO & PPO	$18.64
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.78
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.95
Rate for Payer: Home State Health Plan Medicare Advantage	$18.64
Rate for Payer: Humana Commercial	$37.28
Rate for Payer: Humana Medicare Advantage	$18.64
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.78
Rate for Payer: UnitedHealthcare Medicare Advantage	$80.64

CLOBAZAM

Facility

$224.00

Service Code	CPT 80299
Hospital Charge Code	2280293
Hospital Revenue Code	301
Rate for Payer: Cash Price	$201.60

CLOBETASOL 0.05% CRM 30GM EMP

Facility

$1,264.00

Service Code	NDC 7.07E+10
Hospital Charge Code	2624321
Hospital Revenue Code	250
Min. Negotiated Rate	$455.04
Max. Negotiated Rate	$902.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$748.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$902.50
Rate for Payer: Cash Price	$1,137.60
Rate for Payer: UnitedHealthcare Commercial	$843.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$455.04

CLOBETASOL 0.05% CRM 30GM EMP

Facility

$1,264.00

Service Code	NDC 7.07E+10
Hospital Charge Code	2624321
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,137.60

CLOBETASOL 0.05% CRM 45GM EMP

Facility

$1,264.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2623062
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,137.60

CLOBETASOL 0.05% CRM 45GM EMP

Facility

$1,264.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2623062
Hospital Revenue Code	250
Min. Negotiated Rate	$455.04
Max. Negotiated Rate	$902.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$748.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$902.50
Rate for Payer: Cash Price	$1,137.60
Rate for Payer: UnitedHealthcare Commercial	$843.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$455.04

CLOBETASOL 0.05% CRM 60GM EMP

Facility

$1,264.00

Service Code	NDC 6.2559E+10
Hospital Charge Code	2625504
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,137.60

CLOBETASOL 0.05% CRM 60GM EMP

Facility

$1,264.00

Service Code	NDC 6.2559E+10
Hospital Charge Code	2625504
Hospital Revenue Code	250
Min. Negotiated Rate	$455.04
Max. Negotiated Rate	$902.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$748.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$902.50
Rate for Payer: Cash Price	$1,137.60
Rate for Payer: UnitedHealthcare Commercial	$843.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$455.04

CLOBETASOL 0.05% OINT 15GM EMP

Facility

$1,264.00

Service Code	NDC 6.8462E+10
Hospital Charge Code	2623521
Hospital Revenue Code	250
Min. Negotiated Rate	$455.04
Max. Negotiated Rate	$902.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$748.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$902.50
Rate for Payer: Cash Price	$1,137.60
Rate for Payer: UnitedHealthcare Commercial	$843.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$455.04

CLOBETASOL 0.05% OINT 15GM EMP

Facility

$1,264.00

Service Code	NDC 6.8462E+10
Hospital Charge Code	2623521
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,137.60

CLOBETASOL 0.05% OINT 30GM EMP

Facility

$1,264.00

Service Code	NDC 1E+11
Hospital Charge Code	2626943
Hospital Revenue Code	250
Min. Negotiated Rate	$455.04
Max. Negotiated Rate	$902.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$748.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$902.50
Rate for Payer: Cash Price	$1,137.60
Rate for Payer: UnitedHealthcare Commercial	$843.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$455.04

CLOBETASOL 0.05% OINT 30GM EMP

Facility

$1,264.00

Service Code	NDC 1E+11
Hospital Charge Code	2626943
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,137.60

CLOBETASOL 0.05% OINT 60GM EMP

Facility

$1,264.00

Service Code	NDC 1E+11
Hospital Charge Code	2621934
Hospital Revenue Code	250
Min. Negotiated Rate	$455.04
Max. Negotiated Rate	$902.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$748.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$902.50
Rate for Payer: Cash Price	$1,137.60
Rate for Payer: UnitedHealthcare Commercial	$843.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$455.04

CLOBETASOL 0.05% OINT 60GM EMP

Facility

$1,264.00

Service Code	NDC 1E+11
Hospital Charge Code	2621934
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,137.60

CLOBETASOL PROP 0.05% LOTION 59ML BOTTLE

Facility

$342.00

Service Code	NDC 1E+11
Hospital Charge Code	2622086
Hospital Revenue Code	250
Rate for Payer: Cash Price	$307.80

CLOBETASOL PROP 0.05% LOTION 59ML BOTTLE

Facility

$342.00

Service Code	NDC 1E+11
Hospital Charge Code	2622086
Hospital Revenue Code	250
Min. Negotiated Rate	$123.12
Max. Negotiated Rate	$244.19
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$202.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$244.19
Rate for Payer: Cash Price	$307.80
Rate for Payer: UnitedHealthcare Commercial	$228.11
Rate for Payer: UnitedHealthcare Medicare Advantage	$123.12

CLOBETASOL PROP. 0.05% OINT 45GM EMP

Facility

$1,264.00

Service Code	NDC 7.07E+10
Hospital Charge Code	2626660
Hospital Revenue Code	250
Min. Negotiated Rate	$455.04
Max. Negotiated Rate	$902.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$748.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$902.50
Rate for Payer: Cash Price	$1,137.60
Rate for Payer: UnitedHealthcare Commercial	$843.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$455.04

CLOBETASOL PROP. 0.05% OINT 45GM EMP

Facility

$1,264.00

Service Code	NDC 7.07E+10
Hospital Charge Code	2626660
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,137.60

CLOBETASOL PROP 0.05% SOL 50ML EMP

Facility

$342.00

Service Code	NDC 472040250
Hospital Charge Code	2623079
Hospital Revenue Code	250
Min. Negotiated Rate	$123.12
Max. Negotiated Rate	$244.19
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$202.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$244.19
Rate for Payer: Cash Price	$307.80
Rate for Payer: UnitedHealthcare Commercial	$228.11
Rate for Payer: UnitedHealthcare Medicare Advantage	$123.12

Know your out-of-pocket cost for care.

All Charges