Madison Medical Center

All Charges

Charge

Type

Setting

Price

AMOX 400MG/5ML SUSP 100ML EMP

Facility

$55.00

Service Code	NDC 143988880
Hospital Charge Code	2697584
Hospital Revenue Code	250
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$39.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.80

AMOX 400MG/5ML SUSP 50ML

Facility

$55.00

Service Code	NDC 143988750
Hospital Charge Code	2698055
Hospital Revenue Code	250
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$39.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.80

AMOX 400MG/5ML SUSP 50ML

Facility

$55.00

Service Code	NDC 143988750
Hospital Charge Code	2698055
Hospital Revenue Code	250
Rate for Payer: Cash Price	$49.50

AMOX 400MG/5ML SUSP 50ML EMP

Facility

$55.00

Service Code	NDC 143988750
Hospital Charge Code	2622807
Hospital Revenue Code	250
Rate for Payer: Cash Price	$49.50

AMOX 400MG/5ML SUSP 50ML EMP

Facility

$55.00

Service Code	NDC 143988750
Hospital Charge Code	2622807
Hospital Revenue Code	250
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$39.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.80

AMOX/CLAV 250MG/5ML 100ML SUSP

Facility

$548.00

Service Code	NDC 6.0432E+10
Hospital Charge Code	2622724
Hospital Revenue Code	250
Rate for Payer: Cash Price	$493.20

AMOX/CLAV 250MG/5ML 100ML SUSP

Facility

$548.00

Service Code	NDC 6.0432E+10
Hospital Charge Code	2622724
Hospital Revenue Code	250
Min. Negotiated Rate	$197.28
Max. Negotiated Rate	$391.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$324.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$391.27
Rate for Payer: Cash Price	$493.20
Rate for Payer: UnitedHealthcare Commercial	$365.52
Rate for Payer: UnitedHealthcare Medicare Advantage	$197.28

AMOX/CLAV 250MG/5ML 75ML SUSP

Facility

$548.00

Service Code	NDC 4.3598E+10
Hospital Charge Code	2697080
Hospital Revenue Code	250
Rate for Payer: Cash Price	$493.20

AMOX/CLAV 250MG/5ML 75ML SUSP

Facility

$548.00

Service Code	NDC 4.3598E+10
Hospital Charge Code	2697080
Hospital Revenue Code	250
Min. Negotiated Rate	$197.28
Max. Negotiated Rate	$391.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$324.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$391.27
Rate for Payer: Cash Price	$493.20
Rate for Payer: UnitedHealthcare Commercial	$365.52
Rate for Payer: UnitedHealthcare Medicare Advantage	$197.28

AMOX/CLAV 500/125MG TAB

Facility

$45.00

Service Code	NDC 781183120
Hospital Charge Code	2654264
Hospital Revenue Code	250
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

AMOX/CLAV 500/125MG TAB

Facility

$45.00

Service Code	NDC 781183120
Hospital Charge Code	2654264
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

AMOX/CLAV 500/125MG TAB EMP

Facility

$45.00

Service Code	NDC 6.5862E+10
Hospital Charge Code	2622018
Hospital Revenue Code	250
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

AMOX/CLAV 500/125MG TAB EMP

Facility

$45.00

Service Code	NDC 6.5862E+10
Hospital Charge Code	2622018
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

AMOX/CLAV 875/125MG TAB

Facility

$45.00

Service Code	NDC 6.5862E+10
Hospital Charge Code	2626268
Hospital Revenue Code	250
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

AMOX/CLAV 875/125MG TAB

Facility

$45.00

Service Code	NDC 6.5862E+10
Hospital Charge Code	2626268
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

AMOX/CLAV 875/125MG TAB EMP

Facility

$45.00

Service Code	NDC 6.5862E+10
Hospital Charge Code	2621893
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

AMOX/CLAV 875/125MG TAB EMP

Facility

$45.00

Service Code	NDC 6.5862E+10
Hospital Charge Code	2621893
Hospital Revenue Code	250
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

AMOXICILLIN 500MG CAP

Facility

$21.00

Service Code	NDC 6.5862E+10
Hospital Charge Code	2654185
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

AMOXICILLIN 500MG CAP

Facility

$21.00

Service Code	NDC 6.5862E+10
Hospital Charge Code	2654185
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

AMOXICILLIN 500MG CAP EMP

Facility

$21.00

Service Code	NDC 5.5953E+10
Hospital Charge Code	2622037
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

AMOXICILLIN 500MG CAP EMP

Facility

$21.00

Service Code	NDC 5.5953E+10
Hospital Charge Code	2622037
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

AMOXICILLIN 875MG TAB EMP

Facility

$15.00

Service Code	NDC 143995120
Hospital Charge Code	2697644
Hospital Revenue Code	250
Rate for Payer: Cash Price	$13.50

AMOXICILLIN 875MG TAB EMP

Facility

$15.00

Service Code	NDC 143995120
Hospital Charge Code	2697644
Hospital Revenue Code	250
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$10.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$8.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$10.71
Rate for Payer: Cash Price	$13.50
Rate for Payer: UnitedHealthcare Commercial	$10.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.40

AMOXICILLIN (AMOXIL) 250MG/5ML SUSP

Facility

$10.00

Service Code	NDC 29600818
Hospital Charge Code	2654175
Hospital Revenue Code	250
Rate for Payer: Cash Price	$9.00

AMOXICILLIN (AMOXIL) 250MG/5ML SUSP

Facility

$10.00

Service Code	NDC 29600818
Hospital Charge Code	2654175
Hospital Revenue Code	250
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$7.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$5.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$7.14
Rate for Payer: Cash Price	$9.00
Rate for Payer: UnitedHealthcare Commercial	$6.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$3.60

Know your out-of-pocket cost for care.

All Charges