Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- ROCEPHIN 500 MG

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	5200696
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- ROCEPHIN 500 MG

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	5200696
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 500 MG DAVIS

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	9800696
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 500 MG DAVIS

Facility

$200.00

Service Code	HCPCS J0696
Hospital Charge Code	9800696
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 - ROTAVIRUS

Facility

$75.00

Service Code	HCPCS 90680
Hospital Charge Code	9690680
Hospital Revenue Code	636
Min. Negotiated Rate	$50.02
Max. Negotiated Rate	$50.02
Rate for Payer: Cash Price	$67.50
Rate for Payer: UnitedHealthcare Commercial	$50.02

CL - ROTAVIRUS

Facility

$75.00

Service Code	HCPCS 90680
Hospital Charge Code	5290680
Hospital Revenue Code	636
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$53.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$44.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$53.55
Rate for Payer: Cash Price	$67.50
Rate for Payer: UnitedHealthcare Commercial	$50.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$27.00

CL - ROTAVIRUS

Facility

$75.00

Service Code	HCPCS 90680
Hospital Charge Code	9690680
Hospital Revenue Code	636
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$53.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$44.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$53.55
Rate for Payer: Cash Price	$67.50
Rate for Payer: UnitedHealthcare Commercial	$50.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$27.00

CL - ROTAVIRUS

Facility

$75.00

Service Code	HCPCS 90680
Hospital Charge Code	5290680
Hospital Revenue Code	636
Min. Negotiated Rate	$50.02
Max. Negotiated Rate	$50.02
Rate for Payer: Cash Price	$67.50
Rate for Payer: UnitedHealthcare Commercial	$50.02

CLSD TX GREATER HUMERAL TUBUB W/O MANIPU

Facility

$1,110.00

Service Code	CPT 23620
Hospital Charge Code	9323620
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$792.54
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$657.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$792.54
Rate for Payer: Cash Price	$999.00
Rate for Payer: Cash Price	$999.00
Rate for Payer: Cash Price	$999.00
Rate for Payer: Cash Price	$999.00
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$740.37
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CLSD TX GREATER HUMERAL TUBUB W/O MANIPU

Facility

$1,110.00

Service Code	CPT 23620
Hospital Charge Code	9323620
Hospital Revenue Code	521
Rate for Payer: Cash Price	$999.00

CL - SHINGRIX

Facility

$225.00

Service Code	HCPCS 90750
Hospital Charge Code	9290750
Hospital Revenue Code	636
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$160.65
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: UnitedHealthcare Commercial	$150.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$81.00

CL - SHINGRIX

Facility

$225.00

Service Code	HCPCS 90750
Hospital Charge Code	4490750
Hospital Revenue Code	636
Min. Negotiated Rate	$150.07
Max. Negotiated Rate	$150.07
Rate for Payer: Cash Price	$202.50
Rate for Payer: UnitedHealthcare Commercial	$150.07

CL - SHINGRIX

Facility

$225.00

Service Code	HCPCS 90750
Hospital Charge Code	9290750
Hospital Revenue Code	636
Min. Negotiated Rate	$150.07
Max. Negotiated Rate	$150.07
Rate for Payer: Cash Price	$202.50
Rate for Payer: UnitedHealthcare Commercial	$150.07

CL - SHINGRIX

Facility

$225.00

Service Code	HCPCS 90750
Hospital Charge Code	4490750
Hospital Revenue Code	636
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$160.65
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: UnitedHealthcare Commercial	$150.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$81.00

CL- SHINGRIX

Facility

$225.00

Service Code	HCPCS 90750
Hospital Charge Code	9890750
Hospital Revenue Code	636
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$160.65
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: UnitedHealthcare Commercial	$150.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$81.00

CL- SHINGRIX

Facility

$225.00

Service Code	HCPCS 90750
Hospital Charge Code	9890750
Hospital Revenue Code	636
Min. Negotiated Rate	$150.07
Max. Negotiated Rate	$150.07
Rate for Payer: Cash Price	$202.50
Rate for Payer: UnitedHealthcare Commercial	$150.07

CL- SOLUMEDROL 40MG

Facility

$47.00

Service Code	HCPCS J2919
Hospital Charge Code	5202920
Hospital Revenue Code	636
Min. Negotiated Rate	$31.35
Max. Negotiated Rate	$31.35
Rate for Payer: Cash Price	$42.30
Rate for Payer: UnitedHealthcare Commercial	$31.35

CL- SOLUMEDROL 40MG

Facility

$47.00

Service Code	HCPCS J2919
Hospital Charge Code	5202920
Hospital Revenue Code	636
Min. Negotiated Rate	$16.92
Max. Negotiated Rate	$33.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$27.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$33.56
Rate for Payer: Cash Price	$42.30
Rate for Payer: UnitedHealthcare Commercial	$31.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.92

CL- SOLU MEDROL 40MG DAVIS

Facility

$50.00

Service Code	HCPCS J2919
Hospital Charge Code	9802902
Hospital Revenue Code	636
Min. Negotiated Rate	$33.35
Max. Negotiated Rate	$33.35
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35

CL- SOLU MEDROL 40MG DAVIS

Facility

$50.00

Service Code	HCPCS J2919
Hospital Charge Code	9802902
Hospital Revenue Code	636
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$35.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$29.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$35.70
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.00

CL- SOLU MEDROL 40MG OLIVERO

Facility

$50.00

Service Code	HCPCS J1010
Hospital Charge Code	5402902
Hospital Revenue Code	636
Min. Negotiated Rate	$33.35
Max. Negotiated Rate	$33.35
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35

CL- SOLU MEDROL 40MG OLIVERO

Facility

$50.00

Service Code	HCPCS J1010
Hospital Charge Code	5402902
Hospital Revenue Code	636
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$35.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$29.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$35.70
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.00

CL- STOMATITIS GI COCKTAIL DAVIS

Facility

$6.00

Service Code	HCPCS Y7506
Hospital Charge Code	9856217
Hospital Revenue Code	636
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$4.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$3.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$4.28
Rate for Payer: Cash Price	$5.40
Rate for Payer: UnitedHealthcare Commercial	$4.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$2.16

CL- STOMATITIS GI COCKTAIL DAVIS

Facility

$6.00

Service Code	HCPCS Y7506
Hospital Charge Code	9856217
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.40
Rate for Payer: UnitedHealthcare Commercial	$4.00

CL- STOOK TB PPD INTRADERMAL

Facility

$45.00

Service Code	HCPCS 86580
Hospital Charge Code	9786580
Hospital Revenue Code	521
Min. Negotiated Rate	$23.46
Max. Negotiated Rate	$173.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$26.07
Rate for Payer: Aetna Medicare Advantage	$29.55
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: Cash Price	$40.50
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial HMO & PPO	$29.55
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$23.46
Rate for Payer: Home State Health Plan Medicaid Managed Care	$27.89
Rate for Payer: Home State Health Plan Medicare Advantage	$29.55
Rate for Payer: Humana Commercial	$59.10
Rate for Payer: Humana Medicare Advantage	$29.55
Rate for Payer: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$26.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

Know your out-of-pocket cost for care.

All Charges