Madison Medical Center

All Charges

Charge

Type

Setting

Price

D5 1/2NS 500ML IV

Facility

$129.00

Service Code	NDC 338008503
Hospital Charge Code	2697179
Hospital Revenue Code	258
Min. Negotiated Rate	$86.04
Max. Negotiated Rate	$86.04
Rate for Payer: Cash Price	$116.10
Rate for Payer: UnitedHealthcare Commercial	$86.04

D5NS 1000ML IV

Facility

$129.00

Service Code	NDC 338008904
Hospital Charge Code	2659120
Hospital Revenue Code	258
Min. Negotiated Rate	$86.04
Max. Negotiated Rate	$86.04
Rate for Payer: Cash Price	$116.10
Rate for Payer: UnitedHealthcare Commercial	$86.04

D5NS 1000ML IV

Facility

$129.00

Service Code	NDC 338008904
Hospital Charge Code	2659120
Hospital Revenue Code	258
Min. Negotiated Rate	$46.44
Max. Negotiated Rate	$92.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.11
Rate for Payer: Cash Price	$116.10
Rate for Payer: UnitedHealthcare Commercial	$86.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$46.44

D5W 1000ML IV

Facility

$129.00

Service Code	NDC 338001704
Hospital Charge Code	2659108
Hospital Revenue Code	250
Min. Negotiated Rate	$46.44
Max. Negotiated Rate	$92.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.11
Rate for Payer: Cash Price	$116.10
Rate for Payer: UnitedHealthcare Commercial	$86.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$46.44

D5W 1000ML IV

Facility

$129.00

Service Code	NDC 338001704
Hospital Charge Code	2659108
Hospital Revenue Code	250
Rate for Payer: Cash Price	$116.10

D5W 20MEQ K++1000ML

Facility

$66.00

Service Code	NDC 338067104
Hospital Charge Code	260358
Hospital Revenue Code	258
Min. Negotiated Rate	$44.02
Max. Negotiated Rate	$44.02
Rate for Payer: Cash Price	$59.40
Rate for Payer: UnitedHealthcare Commercial	$44.02

D5W 20MEQ K++1000ML

Facility

$66.00

Service Code	NDC 338067104
Hospital Charge Code	260358
Hospital Revenue Code	258
Min. Negotiated Rate	$23.76
Max. Negotiated Rate	$47.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$39.07
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$47.12
Rate for Payer: Cash Price	$59.40
Rate for Payer: UnitedHealthcare Commercial	$44.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$23.76

D5W 250ML IV 2B0062Q

Facility

$129.00

Service Code	NDC 338001702
Hospital Charge Code	2626040
Hospital Revenue Code	258
Min. Negotiated Rate	$86.04
Max. Negotiated Rate	$86.04
Rate for Payer: Cash Price	$116.10
Rate for Payer: UnitedHealthcare Commercial	$86.04

D5W 250ML IV 2B0062Q

Facility

$129.00

Service Code	NDC 338001702
Hospital Charge Code	2626040
Hospital Revenue Code	258
Min. Negotiated Rate	$46.44
Max. Negotiated Rate	$92.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.11
Rate for Payer: Cash Price	$116.10
Rate for Payer: UnitedHealthcare Commercial	$86.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$46.44

D5W 250ML IV FLUID

Facility

$129.00

Service Code	NDC 6.5219E+10
Hospital Charge Code	2626765
Hospital Revenue Code	258
Min. Negotiated Rate	$46.44
Max. Negotiated Rate	$92.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.11
Rate for Payer: Cash Price	$116.10
Rate for Payer: UnitedHealthcare Commercial	$86.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$46.44

D5W 250ML IV FLUID

Facility

$129.00

Service Code	NDC 6.5219E+10
Hospital Charge Code	2626765
Hospital Revenue Code	258
Min. Negotiated Rate	$86.04
Max. Negotiated Rate	$86.04
Rate for Payer: Cash Price	$116.10
Rate for Payer: UnitedHealthcare Commercial	$86.04

D5W 500ML IV 2B0063Q

Facility

$129.00

Service Code	NDC 338001703
Hospital Charge Code	2659115
Hospital Revenue Code	258
Min. Negotiated Rate	$86.04
Max. Negotiated Rate	$86.04
Rate for Payer: UnitedHealthcare Commercial	$86.04
Rate for Payer: Cash Price	$116.10

D5W 500ML IV 2B0063Q

Facility

$129.00

Service Code	NDC 338001703
Hospital Charge Code	2659115
Hospital Revenue Code	258
Min. Negotiated Rate	$46.44
Max. Negotiated Rate	$92.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.11
Rate for Payer: Cash Price	$116.10
Rate for Payer: UnitedHealthcare Commercial	$86.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$46.44

D5W AVIVA BAG 6E0063 500ML IV SOL

Facility

$129.00

Service Code	HCPCS J7060
Hospital Charge Code	2626564
Hospital Revenue Code	250
Min. Negotiated Rate	$46.44
Max. Negotiated Rate	$92.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.11
Rate for Payer: Cash Price	$116.10
Rate for Payer: UnitedHealthcare Commercial	$86.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$46.44

D5W AVIVA BAG 6E0063 500ML IV SOL

Facility

$129.00

Service Code	HCPCS J7060
Hospital Charge Code	2626564
Hospital Revenue Code	250
Rate for Payer: Cash Price	$116.10

DABIGATRAN ETEX 150MG CAP EMP

Facility

$21.00

Service Code	NDC 597036055
Hospital Charge Code	2627177
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

DABIGATRAN ETEX 150MG CAP EMP

Facility

$21.00

Service Code	NDC 597036055
Hospital Charge Code	2627177
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

DABIGATRAN ETEX 75MG CAP EMP

Facility

$21.00

Service Code	NDC 6.0505E+10
Hospital Charge Code	2627107
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

DABIGATRAN ETEX 75MG CAP EMP

Facility

$21.00

Service Code	NDC 6.0505E+10
Hospital Charge Code	2627107
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

DAILY RT EDUCATION

Facility

$151.00

Service Code	CPT 98960
Hospital Charge Code	4500513
Hospital Revenue Code	460
Rate for Payer: Cash Price	$135.90

DAILY RT EDUCATION

Facility

$151.00

Service Code	CPT 98960
Hospital Charge Code	4500513
Hospital Revenue Code	460
Min. Negotiated Rate	$54.36
Max. Negotiated Rate	$107.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$89.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$107.81
Rate for Payer: Cash Price	$135.90
Rate for Payer: UnitedHealthcare Commercial	$100.72
Rate for Payer: UnitedHealthcare Medicare Advantage	$54.36

DALBAVANCIN (DALVANCE) 500MG IVPB

Facility

$8,222.00

Service Code	HCPCS J0875
Hospital Charge Code	2622975
Hospital Revenue Code	250
Min. Negotiated Rate	$11.29
Max. Negotiated Rate	$5,870.51
Rate for Payer: Aetna Medicare Advantage	$11.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$4,867.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$5,870.51
Rate for Payer: Cash Price	$7,399.80
Rate for Payer: Cash Price	$7,399.80
Rate for Payer: Cigna Commercial HMO & PPO	$11.29
Rate for Payer: Home State Health Plan Medicare Advantage	$11.29
Rate for Payer: Humana Commercial	$22.58
Rate for Payer: Humana Medicare Advantage	$11.29
Rate for Payer: UnitedHealthcare Commercial	$5,484.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$2,959.92

DALBAVANCIN (DALVANCE) 500MG IVPB

Facility

$8,222.00

Service Code	HCPCS J0875
Hospital Charge Code	2622975
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7,399.80

DALBAVANCIN KIT IVPB

Facility

$8,528.00

Service Code	HCPCS J0875
Hospital Charge Code	2625937
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7,675.20

DALBAVANCIN KIT IVPB

Facility

$8,528.00

Service Code	HCPCS J0875
Hospital Charge Code	2625937
Hospital Revenue Code	250
Min. Negotiated Rate	$11.29
Max. Negotiated Rate	$6,088.99
Rate for Payer: Aetna Medicare Advantage	$11.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$5,048.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$6,088.99
Rate for Payer: Cash Price	$7,675.20
Rate for Payer: Cash Price	$7,675.20
Rate for Payer: Cigna Commercial HMO & PPO	$11.29
Rate for Payer: Home State Health Plan Medicare Advantage	$11.29
Rate for Payer: Humana Commercial	$22.58
Rate for Payer: Humana Medicare Advantage	$11.29
Rate for Payer: UnitedHealthcare Commercial	$5,688.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,070.08

Know your out-of-pocket cost for care.

All Charges