Madison Medical Center

All Charges

Charge

Type

Setting

Price

DICLOFENAC (VOLTAREN) 1% 100GM GEL

Facility

$168.00

Service Code	NDC 4.5802E+10
Hospital Charge Code	2626485
Hospital Revenue Code	250
Rate for Payer: Cash Price	$151.20

DICLOFENAC (VOLTAREN) 1% 100GM GEL

Facility

$168.00

Service Code	NDC 4.5802E+10
Hospital Charge Code	2626485
Hospital Revenue Code	250
Min. Negotiated Rate	$60.48
Max. Negotiated Rate	$119.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$99.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$119.95
Rate for Payer: Cash Price	$151.20
Rate for Payer: UnitedHealthcare Commercial	$112.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$60.48

DICLOFENAC (VOLTAREN) 1% 100GM GEL EMP

Facility

$168.00

Service Code	NDC 6.9097E+10
Hospital Charge Code	2622204
Hospital Revenue Code	250
Min. Negotiated Rate	$60.48
Max. Negotiated Rate	$119.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$99.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$119.95
Rate for Payer: Cash Price	$151.20
Rate for Payer: UnitedHealthcare Commercial	$112.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$60.48

DICLOFENAC (VOLTAREN) 1% 100GM GEL EMP

Facility

$168.00

Service Code	NDC 6.9097E+10
Hospital Charge Code	2622204
Hospital Revenue Code	250
Rate for Payer: Cash Price	$151.20

DICLOFENAC (VOLTAREN) 3% 100GM GEL EMP

Facility

$168.00

Service Code	NDC 5.1672E+10
Hospital Charge Code	2625929
Hospital Revenue Code	250
Min. Negotiated Rate	$60.48
Max. Negotiated Rate	$119.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$99.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$119.95
Rate for Payer: Cash Price	$151.20
Rate for Payer: UnitedHealthcare Commercial	$112.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$60.48

DICLOFENAC (VOLTAREN) 3% 100GM GEL EMP

Facility

$168.00

Service Code	NDC 5.1672E+10
Hospital Charge Code	2625929
Hospital Revenue Code	250
Rate for Payer: Cash Price	$151.20

DICYCLOMINE (BENTYL) 10MG/5ML SOL

Facility

$20.00

Service Code	NDC 603116158
Hospital Charge Code	2697079
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

DICYCLOMINE (BENTYL) 10MG/5ML SOL

Facility

$20.00

Service Code	NDC 603116158
Hospital Charge Code	2697079
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

DICYCLOMINE (BENTYL) 10MG CAP

Facility

$20.00

Service Code	NDC 6.0687E+10
Hospital Charge Code	2654795
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

DICYCLOMINE (BENTYL) 10MG CAP

Facility

$20.00

Service Code	NDC 6.0687E+10
Hospital Charge Code	2654795
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

DICYCLOMINE (BENTYL) 10MG CAP EMP

Facility

$20.00

Service Code	NDC 591079401
Hospital Charge Code	2622680
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

DICYCLOMINE (BENTYL) 10MG CAP EMP

Facility

$20.00

Service Code	NDC 591079401
Hospital Charge Code	2622680
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

DICYCLOMINE (BENTYL) 20MG/2ML AMP INJ

Facility

$247.00

Service Code	NDC 5.8914E+10
Hospital Charge Code	2654794
Hospital Revenue Code	250
Rate for Payer: Cash Price	$222.30

DICYCLOMINE (BENTYL) 20MG/2ML AMP INJ

Facility

$247.00

Service Code	NDC 5.8914E+10
Hospital Charge Code	2654794
Hospital Revenue Code	250
Min. Negotiated Rate	$88.92
Max. Negotiated Rate	$176.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$146.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$176.36
Rate for Payer: Cash Price	$222.30
Rate for Payer: UnitedHealthcare Commercial	$164.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$88.92

DICYCLOMINE (BENTYL) 20MG TAB EMP

Facility

$20.00

Service Code	NDC 591079401
Hospital Charge Code	2697465
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

DICYCLOMINE (BENTYL) 20MG TAB EMP

Facility

$20.00

Service Code	NDC 591079401
Hospital Charge Code	2697465
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

DICYCLOMINE (BENTYL) 20MG TAB UD

Facility

$20.00

Service Code	NDC 5.1079E+10
Hospital Charge Code	2697122
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

DICYCLOMINE (BENTYL) 20MG TAB UD

Facility

$20.00

Service Code	NDC 5.1079E+10
Hospital Charge Code	2697122
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

DIFFERIN 0.1% CREAM 45GM EMP

Facility

$273.00

Service Code	NDC 299591545
Hospital Charge Code	2623858
Hospital Revenue Code	250
Rate for Payer: Cash Price	$245.70

DIFFERIN 0.1% CREAM 45GM EMP

Facility

$273.00

Service Code	NDC 299591545
Hospital Charge Code	2623858
Hospital Revenue Code	250
Min. Negotiated Rate	$98.28
Max. Negotiated Rate	$194.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$161.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$194.92
Rate for Payer: Cash Price	$245.70
Rate for Payer: UnitedHealthcare Commercial	$182.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$98.28

DIGESTIVE MALIGNANCY

Facility

$8,206.03

Service Code	APR-DRG 2401
Min. Negotiated Rate	$8,206.03
Max. Negotiated Rate	$8,206.03
Rate for Payer: Aetna Better Health Medicaid/QHP	$8,206.03
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8,206.03
Rate for Payer: Home State Health Plan Medicaid Managed Care	$8,206.03
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8,206.03

DIGESTIVE MALIGNANCY

Facility

$15,571.67

Service Code	APR-DRG 2403
Min. Negotiated Rate	$15,571.67
Max. Negotiated Rate	$15,571.67
Rate for Payer: Aetna Better Health Medicaid/QHP	$15,571.67
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15,571.67
Rate for Payer: Home State Health Plan Medicaid Managed Care	$15,571.67
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15,571.67

DIGESTIVE MALIGNANCY

Facility

$24,620.87

Service Code	APR-DRG 2404
Min. Negotiated Rate	$24,620.87
Max. Negotiated Rate	$24,620.87
Rate for Payer: Aetna Better Health Medicaid/QHP	$24,620.87
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$24,620.87
Rate for Payer: Home State Health Plan Medicaid Managed Care	$24,620.87
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$24,620.87

DIGESTIVE MALIGNANCY

Facility

$8,899.42

Service Code	APR-DRG 2402
Min. Negotiated Rate	$8,899.42
Max. Negotiated Rate	$8,899.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$8,899.42
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8,899.42
Rate for Payer: Home State Health Plan Medicaid Managed Care	$8,899.42
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8,899.42

DIGESTIVE MALIGNANCY WITH CC

Facility

$22,573.98

Service Code	MSDRG 375
Min. Negotiated Rate	$11,286.99
Max. Negotiated Rate	$22,573.98
Rate for Payer: Aetna Medicare Advantage	$11,286.99
Rate for Payer: Cigna Commercial HMO & PPO	$11,286.99
Rate for Payer: Home State Health Plan Medicare Advantage	$11,286.99
Rate for Payer: Humana Commercial	$22,573.98
Rate for Payer: Humana Medicare Advantage	$11,286.99

Know your out-of-pocket cost for care.

All Charges