Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL - PNEUMO 23 VACCINE

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	9690732
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- PNEUMO 23 VACCINE OLIVERO

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	5490732
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- PNEUMO 23 VACCINE OLIVERO

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	5490732
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- PNEUMOCOCCAL VAC

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	5290732
Hospital Revenue Code	521
Rate for Payer: Cash Price	$225.00

CL- PNEUMOCOCCAL VAC

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	5290732
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- PNEUMOVAX 23 VACCINE DAVIS

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	9890732
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- PNEUMOVAX 23 VACCINE DAVIS

Facility

$250.00

Service Code	HCPCS 90732
Hospital Charge Code	9890732
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- POLIO DAVIS

Facility

$200.00

Service Code	HCPCS 90713
Hospital Charge Code	9890713
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- POLIO DAVIS

Facility

$200.00

Service Code	HCPCS 90713
Hospital Charge Code	9890713
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 - PREVNAR 13

Facility

$541.00

Service Code	HCPCS 90670
Hospital Charge Code	9690670
Hospital Revenue Code	636
Min. Negotiated Rate	$360.85
Max. Negotiated Rate	$360.85
Rate for Payer: Cash Price	$486.90
Rate for Payer: UnitedHealthcare Commercial	$360.85

CL - PREVNAR 13

Facility

$541.00

Service Code	HCPCS 90670
Hospital Charge Code	9690670
Hospital Revenue Code	636
Min. Negotiated Rate	$194.76
Max. Negotiated Rate	$386.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$320.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$386.27
Rate for Payer: Cash Price	$486.90
Rate for Payer: UnitedHealthcare Commercial	$360.85
Rate for Payer: UnitedHealthcare Medicare Advantage	$194.76

CL -PREVNAR 13

Facility

$135.00

Service Code	HCPCS 90670
Hospital Charge Code	5290670
Hospital Revenue Code	521
Rate for Payer: Cash Price	$121.50

CL -PREVNAR 13

Facility

$135.00

Service Code	HCPCS 90670
Hospital Charge Code	5290670
Hospital Revenue Code	521
Min. Negotiated Rate	$79.92
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$79.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$96.39
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cash Price	$121.50
Rate for Payer: UnitedHealthcare Commercial	$90.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- PREVNAR 13 DAVIS

Facility

$541.00

Service Code	HCPCS 90670
Hospital Charge Code	9898312
Hospital Revenue Code	636
Min. Negotiated Rate	$194.76
Max. Negotiated Rate	$386.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$320.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$386.27
Rate for Payer: Cash Price	$486.90
Rate for Payer: UnitedHealthcare Commercial	$360.85
Rate for Payer: UnitedHealthcare Medicare Advantage	$194.76

CL- PREVNAR 13 DAVIS

Facility

$541.00

Service Code	HCPCS 90670
Hospital Charge Code	9898312
Hospital Revenue Code	636
Min. Negotiated Rate	$360.85
Max. Negotiated Rate	$360.85
Rate for Payer: Cash Price	$486.90
Rate for Payer: UnitedHealthcare Commercial	$360.85

CL-PREVNAR 13 OLIVERO

Facility

$541.00

Service Code	HCPCS 90670
Hospital Charge Code	5490670
Hospital Revenue Code	636
Min. Negotiated Rate	$360.85
Max. Negotiated Rate	$360.85
Rate for Payer: Cash Price	$486.90
Rate for Payer: UnitedHealthcare Commercial	$360.85

CL-PREVNAR 13 OLIVERO

Facility

$541.00

Service Code	HCPCS 90670
Hospital Charge Code	5490670
Hospital Revenue Code	636
Min. Negotiated Rate	$194.76
Max. Negotiated Rate	$386.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$320.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$386.27
Rate for Payer: Cash Price	$486.90
Rate for Payer: UnitedHealthcare Commercial	$360.85
Rate for Payer: UnitedHealthcare Medicare Advantage	$194.76

CL- PREVNAR 20 VACCINE DAVIS

Facility

$918.00

Service Code	HCPCS 90677
Hospital Charge Code	9890677
Hospital Revenue Code	636
Min. Negotiated Rate	$330.48
Max. Negotiated Rate	$655.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$543.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$655.45
Rate for Payer: Cash Price	$826.20
Rate for Payer: UnitedHealthcare Commercial	$612.31
Rate for Payer: UnitedHealthcare Medicare Advantage	$330.48

CL- PREVNAR 20 VACCINE DAVIS

Facility

$918.00

Service Code	HCPCS 90677
Hospital Charge Code	9890677
Hospital Revenue Code	636
Min. Negotiated Rate	$612.31
Max. Negotiated Rate	$612.31
Rate for Payer: Cash Price	$826.20
Rate for Payer: UnitedHealthcare Commercial	$612.31

CL - PROQUAD

Facility

$250.00

Service Code	HCPCS 90710
Hospital Charge Code	9690710
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 - PROQUAD

Facility

$250.00

Service Code	HCPCS 90710
Hospital Charge Code	9690710
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- RABAVERT VACCINE FOR IM USE

Facility

$350.00

Service Code	HCPCS 90675
Hospital Charge Code	5290675
Hospital Revenue Code	636
Min. Negotiated Rate	$233.45
Max. Negotiated Rate	$233.45
Rate for Payer: Cash Price	$315.00
Rate for Payer: UnitedHealthcare Commercial	$233.45

CL- RABAVERT VACCINE FOR IM USE

Facility

$350.00

Service Code	HCPCS 90675
Hospital Charge Code	5290675
Hospital Revenue Code	636
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$663.96
Rate for Payer: Aetna Medicare Advantage	$331.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$207.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$249.90
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cigna Commercial HMO & PPO	$331.98
Rate for Payer: Home State Health Plan Medicare Advantage	$331.98
Rate for Payer: Humana Commercial	$663.96
Rate for Payer: Humana Medicare Advantage	$331.98
Rate for Payer: UnitedHealthcare Commercial	$331.98
Rate for Payer: UnitedHealthcare Medicare Advantage	$126.00

CL- ROCEPHIN 250 MG OLIVERO

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	5400696
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- ROCEPHIN 250 MG OLIVERO

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	5400696
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

Know your out-of-pocket cost for care.

All Charges