Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- TORADOL KETORALAC 30 MG OLIVERO

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	5401885
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

CL- TORADOL KETORALAC 30 MG OLIVERO

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	5401885
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- TRIAMCINOLONE ACETONID 40 MG

Facility

$105.00

Service Code	HCPCS J3301
Hospital Charge Code	5203301
Hospital Revenue Code	521
Rate for Payer: Cash Price	$94.50

CL- TRIAMCINOLONE ACETONID 40 MG

Facility

$105.00

Service Code	HCPCS J3301
Hospital Charge Code	5203301
Hospital Revenue Code	521
Min. Negotiated Rate	$62.16
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$62.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$74.97
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cash Price	$94.50
Rate for Payer: UnitedHealthcare Commercial	$70.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL - TWINRIX ADULT HEP A B VACCINE

Facility

$150.00

Service Code	CPT 90636
Hospital Charge Code	9290636
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 - TWINRIX ADULT HEP A B VACCINE

Facility

$150.00

Service Code	CPT 90636
Hospital Charge Code	9290636
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 - VARICELLA VAC

Facility

$100.00

Service Code	HCPCS 90716
Hospital Charge Code	9690716
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 - VARICELLA VAC

Facility

$100.00

Service Code	HCPCS 90716
Hospital Charge Code	9690716
Hospital Revenue Code	636
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$71.40
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: UnitedHealthcare Commercial	$66.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$36.00

CL - VARICELLA VACCINE

Facility

$100.00

Service Code	HCPCS 90716
Hospital Charge Code	9290716
Hospital Revenue Code	636
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$71.40
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: UnitedHealthcare Commercial	$66.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$36.00

CL - VARICELLA VACCINE

Facility

$100.00

Service Code	HCPCS 90716
Hospital Charge Code	9290716
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- VARIVAX DAVIS

Facility

$100.00

Service Code	HCPCS 90716
Hospital Charge Code	9890716
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- VARIVAX DAVIS

Facility

$100.00

Service Code	HCPCS 90716
Hospital Charge Code	9890716
Hospital Revenue Code	636
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$71.40
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: UnitedHealthcare Commercial	$66.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$36.00

CL- VISTARIL 50MG

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	5203410
Hospital Revenue Code	521
Min. Negotiated Rate	$53.28
Max. Negotiated Rate	$173.53
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: Cash Price	$81.00
Rate for Payer: UnitedHealthcare Commercial	$60.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- VISTARIL 50MG

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	5203410
Hospital Revenue Code	521
Rate for Payer: Cash Price	$81.00

CL- VISTARIL 50MG DAVIS

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	9803410
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- VISTARIL 50MG DAVIS

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	9803410
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- VISTARIL MENZ 25MG

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	9703410
Hospital Revenue Code	521
Min. Negotiated Rate	$53.28
Max. Negotiated Rate	$173.53
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: Cash Price	$81.00
Rate for Payer: UnitedHealthcare Commercial	$60.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- VISTARIL MENZ 25MG

Facility

$90.00

Service Code	HCPCS J3410
Hospital Charge Code	9703410
Hospital Revenue Code	521
Rate for Payer: Cash Price	$81.00

CL- VITAMIN B12

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	5203420
Hospital Revenue Code	521
Rate for Payer: Cash Price	$36.00

CL- VITAMIN B12

Facility

$40.00

Service Code	HCPCS J3420
Hospital Charge Code	5203420
Hospital Revenue Code	521
Min. Negotiated Rate	$23.68
Max. Negotiated Rate	$173.53
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: Cash Price	$36.00
Rate for Payer: UnitedHealthcare Commercial	$26.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CL- VITAMIN K DAVIS

Facility

$45.00

Service Code	HCPCS J3430
Hospital Charge Code	9803430
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- VITAMIN K DAVIS

Facility

$45.00

Service Code	HCPCS J3430
Hospital Charge Code	9803430
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- ZOFRAN INJ 4 MG DAVIS

Facility

$64.00

Service Code	HCPCS J0270
Hospital Charge Code	9800270
Hospital Revenue Code	636
Min. Negotiated Rate	$23.04
Max. Negotiated Rate	$45.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$37.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$45.70
Rate for Payer: Cash Price	$57.60
Rate for Payer: UnitedHealthcare Commercial	$42.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$23.04

CL- ZOFRAN INJ 4 MG DAVIS

Facility

$64.00

Service Code	HCPCS J0270
Hospital Charge Code	9800270
Hospital Revenue Code	636
Min. Negotiated Rate	$42.69
Max. Negotiated Rate	$42.69
Rate for Payer: Cash Price	$57.60
Rate for Payer: UnitedHealthcare Commercial	$42.69

CL- ZOOSTER SHINGLES VACCINE OLIVERO

Facility

$600.00

Service Code	HCPCS 90750
Hospital Charge Code	5490750
Hospital Revenue Code	636
Min. Negotiated Rate	$216.00
Max. Negotiated Rate	$428.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$355.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$428.40
Rate for Payer: Cash Price	$540.00
Rate for Payer: UnitedHealthcare Commercial	$400.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$216.00

Know your out-of-pocket cost for care.

All Charges