Madison Medical Center

All Charges

Charge

Type

Setting

Price

DIAG INJ FOR FLU VACCINE

Facility

$8.00

Service Code	CPT G0008
Hospital Charge Code	4200008
Hospital Revenue Code	521
Rate for Payer: Cash Price	$7.20

DIAGNOSTIC LAPAROSCOPY

Professional

Both

$1,890.00

Service Code	CPT 49320
Hospital Charge Code	5449320
Hospital Revenue Code	975
Min. Negotiated Rate	$248.54
Max. Negotiated Rate	$661.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$300.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$248.54
Rate for Payer: Cash Price	$1,701.00
Rate for Payer: Cash Price	$1,701.00
Rate for Payer: Cigna Commercial HMO & PPO	$300.35
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$248.54
Rate for Payer: Home State Health Plan Medicaid Managed Care	$273.39
Rate for Payer: Home State Health Plan Medicare Advantage	$300.35
Rate for Payer: Optum Medicare Advantage	$661.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$248.54

DIAGNOSTIC LAPROSCOPY

Facility

$1,111.00

Service Code	CPT 49320
Hospital Charge Code	4256300
Rate for Payer: Cash Price	$999.90

DIAPER, EACH

Facility

$7.00

Hospital Charge Code	284775
Hospital Revenue Code	271
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$4.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$5.00
Rate for Payer: Cash Price	$6.30
Rate for Payer: UnitedHealthcare Commercial	$4.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$2.52

DIAPER, EACH

Facility

$7.00

Hospital Charge Code	284775
Hospital Revenue Code	271
Rate for Payer: Cash Price	$6.30

DIAPERS, BOX

Facility

$44.00

Hospital Charge Code	284773
Hospital Revenue Code	271
Rate for Payer: Cash Price	$39.60

DIAPERS, BOX

Facility

$44.00

Hospital Charge Code	284773
Hospital Revenue Code	271
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$31.42
Rate for Payer: Cash Price	$39.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.05
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$31.42
Rate for Payer: UnitedHealthcare Commercial	$29.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.84

DIAPERS-NEWBORN/BX

Facility

$40.00

Hospital Charge Code	284750
Hospital Revenue Code	271
Rate for Payer: Cash Price	$36.00

DIAPERS-NEWBORN/BX

Facility

$40.00

Hospital Charge Code	284750
Hospital Revenue Code	271
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

DIAPHRAM FITTING

Facility

$95.00

Service Code	CPT 57170
Hospital Charge Code	4257170
Hospital Revenue Code	521
Min. Negotiated Rate	$56.24
Max. Negotiated Rate	$413.10
Rate for Payer: Aetna Medicare Advantage	$206.55
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: Cash Price	$85.50
Rate for Payer: Cigna Commercial HMO & PPO	$206.55
Rate for Payer: Home State Health Plan Medicare Advantage	$206.55
Rate for Payer: Humana Commercial	$413.10
Rate for Payer: Humana Medicare Advantage	$206.55
Rate for Payer: UnitedHealthcare Commercial	$63.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DIAPHRAM FITTING

Facility

$95.00

Service Code	CPT 57170
Hospital Charge Code	4257170
Hospital Revenue Code	521
Rate for Payer: Cash Price	$85.50

DIAZEPAM 10MG/2ML PFS INJ 2ML C4

Facility

$156.00

Service Code	HCPCS J3360
Hospital Charge Code	2697125
Hospital Revenue Code	250
Rate for Payer: Cash Price	$140.40

DIAZEPAM 10MG/2ML PFS INJ 2ML C4

Facility

$156.00

Service Code	HCPCS J3360
Hospital Charge Code	2697125
Hospital Revenue Code	250
Min. Negotiated Rate	$56.16
Max. Negotiated Rate	$111.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$92.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$111.38
Rate for Payer: Cash Price	$140.40
Rate for Payer: UnitedHealthcare Commercial	$104.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$56.16

DIAZEPAM (DIASTAT) 10MG RECTAL GEL C4

Facility

$568.00

Service Code	HCPCS J3360
Hospital Charge Code	2626533
Hospital Revenue Code	250
Rate for Payer: Cash Price	$511.20

DIAZEPAM (DIASTAT) 10MG RECTAL GEL C4

Facility

$568.00

Service Code	HCPCS J3360
Hospital Charge Code	2626533
Hospital Revenue Code	250
Min. Negotiated Rate	$204.48
Max. Negotiated Rate	$405.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$336.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$405.55
Rate for Payer: Cash Price	$511.20
Rate for Payer: UnitedHealthcare Commercial	$378.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$204.48

DIAZEPAM (VALIUM) 5MG TAB C4

Facility

$20.00

Service Code	HCPCS J3360
Hospital Charge Code	2654775
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

DIAZEPAM (VALIUM) 5MG TAB C4

Facility

$20.00

Service Code	HCPCS J3360
Hospital Charge Code	2654775
Hospital Revenue Code	250
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$14.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$11.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.28
Rate for Payer: Cash Price	$18.00
Rate for Payer: UnitedHealthcare Commercial	$13.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.20

DIBUCAINE (NUPERCAINAL) 30GM OINT

Facility

$51.00

Service Code	NDC 4.5802E+10
Hospital Charge Code	2626411
Hospital Revenue Code	250
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$36.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$30.19
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$36.41
Rate for Payer: Cash Price	$45.90
Rate for Payer: UnitedHealthcare Commercial	$34.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.36

DIBUCAINE (NUPERCAINAL) 30GM OINT

Facility

$51.00

Service Code	NDC 4.5802E+10
Hospital Charge Code	2626411
Hospital Revenue Code	250
Rate for Payer: Cash Price	$45.90

DICLOFENAC POT (ZIPSOR) 25MG CAP EMP

Facility

$13.00

Service Code	NDC 1.3913E+10
Hospital Charge Code	2624215
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$9.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$9.28
Rate for Payer: Cash Price	$11.70
Rate for Payer: UnitedHealthcare Commercial	$8.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.68

DICLOFENAC POT (ZIPSOR) 25MG CAP EMP

Facility

$13.00

Service Code	NDC 1.3913E+10
Hospital Charge Code	2624215
Hospital Revenue Code	250
Rate for Payer: Cash Price	$11.70

DICLOFENAC SOD 50MG TAB EMP

Facility

$13.00

Service Code	NDC 1.6571E+10
Hospital Charge Code	2620304
Hospital Revenue Code	250
Rate for Payer: Cash Price	$11.70

DICLOFENAC SOD 50MG TAB EMP

Facility

$13.00

Service Code	NDC 1.6571E+10
Hospital Charge Code	2620304
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$9.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$9.28
Rate for Payer: Cash Price	$11.70
Rate for Payer: UnitedHealthcare Commercial	$8.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.68

DICLOFENAC SOD 75MG DR TAB EMP

Facility

$13.00

Service Code	NDC 6.1442E+10
Hospital Charge Code	2620733
Hospital Revenue Code	250
Rate for Payer: Cash Price	$11.70

DICLOFENAC SOD 75MG DR TAB EMP

Facility

$13.00

Service Code	NDC 6.1442E+10
Hospital Charge Code	2620733
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$9.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$9.28
Rate for Payer: Cash Price	$11.70
Rate for Payer: UnitedHealthcare Commercial	$8.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.68

Know your out-of-pocket cost for care.

All Charges