Madison Medical Center

All Charges

Charge

Type

Setting

Price

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

CL- SYNVISC OLIVERO

Facility

$818.00

Service Code	HCPCS J7325
Hospital Charge Code	5407325
Hospital Revenue Code	636
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$584.05
Rate for Payer: Aetna Medicare Advantage	$6.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$484.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$584.05
Rate for Payer: Cash Price	$736.20
Rate for Payer: Cash Price	$736.20
Rate for Payer: Cigna Commercial HMO & PPO	$6.02
Rate for Payer: Home State Health Plan Medicare Advantage	$6.02
Rate for Payer: Humana Commercial	$12.04
Rate for Payer: Humana Medicare Advantage	$6.02
Rate for Payer: UnitedHealthcare Commercial	$6.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$294.48

CL- SYNVISC OLIVERO

Facility

$818.00

Service Code	HCPCS J7325
Hospital Charge Code	5407325
Hospital Revenue Code	636
Min. Negotiated Rate	$545.61
Max. Negotiated Rate	$545.61
Rate for Payer: Cash Price	$736.20
Rate for Payer: UnitedHealthcare Commercial	$545.61

CL- TB PPD INTRADERMAL DAVIS

Facility

$45.00

Service Code	HCPCS 86580
Hospital Charge Code	9886580
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- TB PPD INTRADERMAL DAVIS

Facility

$45.00

Service Code	HCPCS 86580
Hospital Charge Code	9886580
Hospital Revenue Code	636
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$59.10
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: Cigna Commercial HMO & PPO	$29.55
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$26.07
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	$29.55
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$26.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.20

CL - TD 7 YEARS AND OLDER

Facility

$70.00

Service Code	HCPCS 90714
Hospital Charge Code	3900073
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 - TD 7 YEARS AND OLDER

Facility

$70.00

Service Code	HCPCS 90714
Hospital Charge Code	3900073
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- TDAP 7 AND > OLIVERO

Facility

$50.00

Service Code	HCPCS 90715
Hospital Charge Code	5490715
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- TDAP 7 AND > OLIVERO

Facility

$50.00

Service Code	HCPCS 90715
Hospital Charge Code	5490715
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 - TDAP > 7 YEARS OF AGE

Facility

$40.00

Service Code	HCPCS 90715
Hospital Charge Code	9290715
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 - TDAP > 7 YEARS OF AGE

Facility

$40.00

Service Code	HCPCS 90715
Hospital Charge Code	9290715
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 - TDAP > 7 YEARS OF AGE

Facility

$70.00

Service Code	CPT 90715
Hospital Charge Code	4490715
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 - TDAP > 7 YEARS OF AGE

Facility

$70.00

Service Code	CPT 90715
Hospital Charge Code	4490715
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- TDAP > 7 YEARS OF AGE

Facility

$87.00

Service Code	HCPCS 90717
Hospital Charge Code	5290703
Hospital Revenue Code	521
Rate for Payer: Cash Price	$78.30

CL- TDAP > 7 YEARS OF AGE

Facility

$87.00

Service Code	HCPCS 90717
Hospital Charge Code	5290703
Hospital Revenue Code	521
Min. Negotiated Rate	$51.50
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$51.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$62.12
Rate for Payer: Cash Price	$78.30
Rate for Payer: Cash Price	$78.30
Rate for Payer: UnitedHealthcare Commercial	$58.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL - TDAP 7 YRS OLD AND OVER

Facility

$50.00

Service Code	HCPCS 90715
Hospital Charge Code	5290715
Hospital Revenue Code	521
Min. Negotiated Rate	$29.60
Max. Negotiated Rate	$173.53
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: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL - TDAP 7 YRS OLD AND OVER

Facility

$50.00

Service Code	HCPCS 90715
Hospital Charge Code	5290715
Hospital Revenue Code	521
Rate for Payer: Cash Price	$45.00

CL - TDAP AGE 7 AND >

Facility

$50.00

Service Code	HCPCS 90715
Hospital Charge Code	9690715
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 - TDAP AGE 7 AND >

Facility

$50.00

Service Code	HCPCS 90715
Hospital Charge Code	9690715
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- TDAP DAVIS

Facility

$50.00

Service Code	HCPCS 90715
Hospital Charge Code	9890715
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- TDAP DAVIS

Facility

$50.00

Service Code	HCPCS 90715
Hospital Charge Code	9890715
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- TETNUS INJECTION DAVIS

Facility

$33.00

Service Code	HCPCS 90714
Hospital Charge Code	9890703
Hospital Revenue Code	636
Min. Negotiated Rate	$11.88
Max. Negotiated Rate	$23.56
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: UnitedHealthcare Commercial	$22.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.88

CL- TETNUS INJECTION DAVIS

Facility

$33.00

Service Code	HCPCS 90714
Hospital Charge Code	9890703
Hospital Revenue Code	636
Min. Negotiated Rate	$22.01
Max. Negotiated Rate	$22.01
Rate for Payer: Cash Price	$29.70
Rate for Payer: UnitedHealthcare Commercial	$22.01

CL- TORADOL 30 MG

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	5201885
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- TORADOL 30 MG

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	5201885
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

Know your out-of-pocket cost for care.

All Charges