Madison Medical Center

All Charges

Charge

Type

Setting

Price

DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	9601030
Hospital Revenue Code	636
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$42.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$35.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$42.84
Rate for Payer: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.60

DEPO MEDROL 1 MG

Facility

$115.00

Service Code	CPT J1010
Hospital Charge Code	4101040
Hospital Revenue Code	636
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$82.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$68.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$82.11
Rate for Payer: Cash Price	$103.50
Rate for Payer: UnitedHealthcare Commercial	$76.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$41.40

DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	4101030
Hospital Revenue Code	636
Min. Negotiated Rate	$40.02
Max. Negotiated Rate	$40.02
Rate for Payer: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02

DEPO MEDROL 1 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	9601040
Hospital Revenue Code	636
Min. Negotiated Rate	$76.70
Max. Negotiated Rate	$76.70
Rate for Payer: Cash Price	$103.50
Rate for Payer: UnitedHealthcare Commercial	$76.70

DEPO MEDROL 1 MG

Facility

$115.00

Service Code	CPT J1010
Hospital Charge Code	4101040
Hospital Revenue Code	636
Min. Negotiated Rate	$76.70
Max. Negotiated Rate	$76.70
Rate for Payer: Cash Price	$103.50
Rate for Payer: UnitedHealthcare Commercial	$76.70

DEPO MEDROL 1 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	4101030
Hospital Revenue Code	636
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$42.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$35.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$42.84
Rate for Payer: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.60

DEPO MEDROL 1 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	9601040
Hospital Revenue Code	636
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$82.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$68.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$82.11
Rate for Payer: Cash Price	$103.50
Rate for Payer: UnitedHealthcare Commercial	$76.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$41.40

DEPO MEDROL 1 MG OLIVERO

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	5401040
Hospital Revenue Code	636
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$82.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$68.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$82.11
Rate for Payer: Cash Price	$103.50
Rate for Payer: UnitedHealthcare Commercial	$76.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$41.40

DEPO MEDROL 1 MG OLIVERO

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	5401040
Hospital Revenue Code	636
Min. Negotiated Rate	$76.70
Max. Negotiated Rate	$76.70
Rate for Payer: Cash Price	$103.50
Rate for Payer: UnitedHealthcare Commercial	$76.70

DEPO MEDROL 40 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	9101030
Hospital Revenue Code	636
Min. Negotiated Rate	$40.02
Max. Negotiated Rate	$40.02
Rate for Payer: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02

DEPO MEDROL 40 MG

Facility

$60.00

Service Code	HCPCS J1010
Hospital Charge Code	9101030
Hospital Revenue Code	636
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$42.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$35.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$42.84
Rate for Payer: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.60

DEPO MEDROL 80 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	9101040
Hospital Revenue Code	636
Min. Negotiated Rate	$76.70
Max. Negotiated Rate	$76.70
Rate for Payer: Cash Price	$103.50
Rate for Payer: UnitedHealthcare Commercial	$76.70

DEPO MEDROL 80 MG

Facility

$115.00

Service Code	HCPCS J1010
Hospital Charge Code	9101040
Hospital Revenue Code	636
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$82.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$68.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$82.11
Rate for Payer: Cash Price	$103.50
Rate for Payer: UnitedHealthcare Commercial	$76.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$41.40

DEPO PROVERA 104MG SUB-Q INJ EMP SYRINGE

Facility

$479.00

Service Code	NDC 9470913
Hospital Charge Code	2622731
Hospital Revenue Code	250
Rate for Payer: Cash Price	$431.10

DEPO PROVERA 104MG SUB-Q INJ EMP SYRINGE

Facility

$479.00

Service Code	NDC 9470913
Hospital Charge Code	2622731
Hospital Revenue Code	250
Min. Negotiated Rate	$172.44
Max. Negotiated Rate	$342.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$283.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$342.01
Rate for Payer: Cash Price	$431.10
Rate for Payer: UnitedHealthcare Commercial	$319.49
Rate for Payer: UnitedHealthcare Medicare Advantage	$172.44

DEPO PROVERA 150MG IM SUSP EMP SYRINGE

Facility

$479.00

Service Code	NDC 9737611
Hospital Charge Code	2623725
Hospital Revenue Code	250
Min. Negotiated Rate	$172.44
Max. Negotiated Rate	$342.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$283.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$342.01
Rate for Payer: Cash Price	$431.10
Rate for Payer: UnitedHealthcare Commercial	$319.49
Rate for Payer: UnitedHealthcare Medicare Advantage	$172.44

DEPO PROVERA 150MG IM SUSP EMP SYRINGE

Facility

$479.00

Service Code	NDC 9737611
Hospital Charge Code	2623725
Hospital Revenue Code	250
Rate for Payer: Cash Price	$431.10

DEPO TESTOSTERONE CYP 200MG/ML 1ML EMP

Facility

$108.00

Service Code	NDC 9041701
Hospital Charge Code	2624158
Hospital Revenue Code	250
Rate for Payer: Cash Price	$97.20

DEPO TESTOSTERONE CYP 200MG/ML 1ML EMP

Facility

$108.00

Service Code	NDC 9041701
Hospital Charge Code	2624158
Hospital Revenue Code	250
Min. Negotiated Rate	$38.88
Max. Negotiated Rate	$77.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$63.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$77.11
Rate for Payer: Cash Price	$97.20
Rate for Payer: UnitedHealthcare Commercial	$72.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$38.88

DEPRESSIVE DISORDERS

Facility

$22,497.32

Service Code	APR-DRG 7513
Min. Negotiated Rate	$22,497.32
Max. Negotiated Rate	$22,497.32
Rate for Payer: Aetna Better Health Medicaid/QHP	$22,497.32
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$22,497.32
Rate for Payer: Home State Health Plan Medicaid Managed Care	$22,497.32
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$22,497.32

DEPRESSIVE DISORDERS

Facility

$40,537.42

Service Code	APR-DRG 7514
Min. Negotiated Rate	$40,537.42
Max. Negotiated Rate	$40,537.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$40,537.42
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$40,537.42
Rate for Payer: Home State Health Plan Medicaid Managed Care	$40,537.42
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$40,537.42

DEPRESSIVE DISORDERS

Facility

$13,163.97

Service Code	APR-DRG 7512
Min. Negotiated Rate	$13,163.97
Max. Negotiated Rate	$13,163.97
Rate for Payer: Aetna Better Health Medicaid/QHP	$13,163.97
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13,163.97
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13,163.97
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13,163.97

DEPRESSIVE DISORDERS

Facility

$10,497.80

Service Code	APR-DRG 7511
Min. Negotiated Rate	$10,497.80
Max. Negotiated Rate	$10,497.80
Rate for Payer: Aetna Better Health Medicaid/QHP	$10,497.80
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$10,497.80
Rate for Payer: Home State Health Plan Medicaid Managed Care	$10,497.80
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$10,497.80

DEPRESSIVE NEUROSES

Facility

$18,369.02

Service Code	MSDRG 881
Min. Negotiated Rate	$9,184.51
Max. Negotiated Rate	$18,369.02
Rate for Payer: Aetna Medicare Advantage	$9,184.51
Rate for Payer: Cigna Commercial HMO & PPO	$9,184.51
Rate for Payer: Home State Health Plan Medicare Advantage	$9,184.51
Rate for Payer: Humana Commercial	$18,369.02
Rate for Payer: Humana Medicare Advantage	$9,184.51

DERMA CARE PAD 30 40

Facility

$119.00

Hospital Charge Code	284424
Hospital Revenue Code	271
Rate for Payer: Cash Price	$107.10

Know your out-of-pocket cost for care.

All Charges