Madison Medical Center

All Charges

Charge

Type

Setting

Price

CLOTRIM/BETAMETH DIP CREAM 45GM

Facility

$255.00

Service Code	NDC 5.1672E+10
Hospital Charge Code	2697395
Hospital Revenue Code	250
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$182.07
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$150.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$182.07
Rate for Payer: Cash Price	$229.50
Rate for Payer: UnitedHealthcare Commercial	$170.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$91.80

CLOTRIM/BETAMETH DIP CREAM 45GM

Facility

$255.00

Service Code	NDC 5.1672E+10
Hospital Charge Code	2697395
Hospital Revenue Code	250
Rate for Payer: Cash Price	$229.50

CLOTRIM/BETAMETH DIP CREAM 45GM EMP

Facility

$273.00

Service Code	NDC 1.6714E+10
Hospital Charge Code	2623236
Hospital Revenue Code	250
Rate for Payer: Cash Price	$245.70

CLOTRIM/BETAMETH DIP CREAM 45GM EMP

Facility

$273.00

Service Code	NDC 1.6714E+10
Hospital Charge Code	2623236
Hospital Revenue Code	250
Min. Negotiated Rate	$98.28
Max. Negotiated Rate	$194.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$161.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$194.92
Rate for Payer: Cash Price	$245.70
Rate for Payer: UnitedHealthcare Commercial	$182.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$98.28

CLOZAPINE

Facility

$56.00

Service Code	CPT 80159
Hospital Charge Code	2222492
Hospital Revenue Code	301
Min. Negotiated Rate	$18.14
Max. Negotiated Rate	$40.30
Rate for Payer: Aetna Better Health Medicaid/QHP	$18.14
Rate for Payer: Aetna Medicare Advantage	$20.15
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$33.15
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.98
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial HMO & PPO	$20.15
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$18.14
Rate for Payer: Home State Health Plan Medicaid Managed Care	$19.41
Rate for Payer: Home State Health Plan Medicare Advantage	$20.15
Rate for Payer: Humana Commercial	$40.30
Rate for Payer: Humana Medicare Advantage	$20.15
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$18.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.16

CLOZAPINE

Facility

$56.00

Service Code	CPT 80159
Hospital Charge Code	2222492
Hospital Revenue Code	301
Rate for Payer: Cash Price	$50.40

CLOZAPINE 100MG TAB

Facility

$25.00

Service Code	NDC 1E+11
Hospital Charge Code	2697903
Hospital Revenue Code	250
Rate for Payer: Cash Price	$22.50

CLOZAPINE 100MG TAB

Facility

$25.00

Service Code	NDC 1E+11
Hospital Charge Code	2697903
Hospital Revenue Code	250
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$17.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.85
Rate for Payer: Cash Price	$22.50
Rate for Payer: UnitedHealthcare Commercial	$16.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.00

CL - PEDIARIX

Facility

$150.00

Service Code	HCPCS 90723
Hospital Charge Code	9690723
Hospital Revenue Code	636
Min. Negotiated Rate	$100.05
Max. Negotiated Rate	$100.05
Rate for Payer: Cash Price	$135.00
Rate for Payer: UnitedHealthcare Commercial	$100.05

CL - PEDIARIX

Facility

$80.00

Service Code	HCPCS 90723
Hospital Charge Code	5290698
Hospital Revenue Code	521
Rate for Payer: Cash Price	$72.00

CL - PEDIARIX

Facility

$150.00

Service Code	HCPCS 90723
Hospital Charge Code	9690723
Hospital Revenue Code	636
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$107.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$88.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$107.10
Rate for Payer: Cash Price	$135.00
Rate for Payer: UnitedHealthcare Commercial	$100.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$54.00

CL - PEDIARIX

Facility

$80.00

Service Code	HCPCS 90723
Hospital Charge Code	5290698
Hospital Revenue Code	521
Min. Negotiated Rate	$47.36
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$47.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$57.12
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: UnitedHealthcare Commercial	$53.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- PENC G PROCAIN 1,200,000 BICILLIN

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	5200540
Hospital Revenue Code	521
Rate for Payer: Cash Price	$153.00

CL- PENC G PROCAIN 1,200,000 BICILLIN

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	5200540
Hospital Revenue Code	521
Min. Negotiated Rate	$19.52
Max. Negotiated Rate	$173.53
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: 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	$113.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- PENICILLIN INJECTION DAVIS

Facility

$100.00

Service Code	CPT J0558
Hospital Charge Code	980540
Hospital Revenue Code	636
Min. Negotiated Rate	$19.52
Max. Negotiated Rate	$71.40
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	$59.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$71.40
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cash Price	$90.00
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	$36.00

CL- PENICILLIN INJECTION DAVIS

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	9800540
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- PENICILLIN INJECTION DAVIS

Facility

$170.00

Service Code	HCPCS J0558
Hospital Charge Code	9800540
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- PENICILLIN INJECTION DAVIS

Facility

$100.00

Service Code	CPT J0558
Hospital Charge Code	980540
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- PHENERGAN 50 MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	5202550
Hospital Revenue Code	521
Rate for Payer: Cash Price	$40.50

CL- PHENERGAN 50 MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	5202550
Hospital Revenue Code	521
Min. Negotiated Rate	$26.64
Max. Negotiated Rate	$173.53
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: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- PHENERGAN 50 MG DAVIS

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	9802550
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- PHENERGAN 50 MG DAVIS

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	9802550
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- PHENERGAN MENZ 50MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	9702550
Hospital Revenue Code	521
Min. Negotiated Rate	$26.64
Max. Negotiated Rate	$173.53
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: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- PHENERGAN MENZ 50MG

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	9702550
Hospital Revenue Code	521
Rate for Payer: Cash Price	$40.50

CL - PNEUMO 23 VACCINE

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	9690732
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

Know your out-of-pocket cost for care.

All Charges