Madison Medical Center

All Charges

Charge

Type

Setting

Price

DILATION OF ANAL SPHINCTA

Facility

$274.00

Service Code	CPT 45905
Hospital Charge Code	4145905
Hospital Revenue Code	521
Min. Negotiated Rate	$162.21
Max. Negotiated Rate	$2,445.12
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,078.71
Rate for Payer: Aetna Medicare Advantage	$1,222.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$162.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$195.64
Rate for Payer: Cash Price	$246.60
Rate for Payer: Cash Price	$246.60
Rate for Payer: Cash Price	$246.60
Rate for Payer: Cash Price	$246.60
Rate for Payer: Cigna Commercial HMO & PPO	$1,222.56
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$970.84
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,154.22
Rate for Payer: Home State Health Plan Medicare Advantage	$1,222.56
Rate for Payer: Humana Commercial	$2,445.12
Rate for Payer: Humana Medicare Advantage	$1,222.56
Rate for Payer: UnitedHealthcare Commercial	$182.76
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,078.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DILATION OF ANAL SPHINCTER (SEP PROC)ANE

Professional

Both

$446.00

Service Code	CPT 45905
Hospital Charge Code	5445905
Hospital Revenue Code	975
Min. Negotiated Rate	$127.70
Max. Negotiated Rate	$157.81
Rate for Payer: Aetna Commercial/Medicare Advantage	$157.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$127.70
Rate for Payer: Cash Price	$401.40
Rate for Payer: Cash Price	$401.40
Rate for Payer: Cigna Commercial HMO & PPO	$157.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$127.70
Rate for Payer: Home State Health Plan Medicaid Managed Care	$140.47
Rate for Payer: Home State Health Plan Medicare Advantage	$157.81
Rate for Payer: Optum Medicare Advantage	$156.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$127.70

DILATION OF ESOPHAGUS, SINGLE OR MULTIPL

Professional

Both

$600.00

Service Code	CPT 43450
Hospital Charge Code	9343450
Hospital Revenue Code	975
Min. Negotiated Rate	$69.38
Max. Negotiated Rate	$210.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$69.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$145.13
Rate for Payer: Cash Price	$540.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Cigna Commercial HMO & PPO	$69.38
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$145.13
Rate for Payer: Home State Health Plan Medicaid Managed Care	$159.64
Rate for Payer: Home State Health Plan Medicare Advantage	$69.38
Rate for Payer: Optum Medicare Advantage	$210.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$145.13

DILATOR PHILIPS FOLL

Facility

$251.00

Hospital Charge Code	284778
Hospital Revenue Code	271
Min. Negotiated Rate	$90.36
Max. Negotiated Rate	$179.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$148.59
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$179.21
Rate for Payer: Cash Price	$225.90
Rate for Payer: UnitedHealthcare Commercial	$167.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$90.36

DILATOR PHILIPS FOLL

Facility

$251.00

Hospital Charge Code	284778
Hospital Revenue Code	271
Rate for Payer: Cash Price	$225.90

DILATOR SYRINGE

Facility

$208.00

Hospital Charge Code	1269048
Hospital Revenue Code	271
Min. Negotiated Rate	$74.88
Max. Negotiated Rate	$148.51
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$123.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$148.51
Rate for Payer: Cash Price	$187.20
Rate for Payer: UnitedHealthcare Commercial	$138.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$74.88

DILATOR SYRINGE

Facility

$208.00

Hospital Charge Code	1269048
Hospital Revenue Code	271
Rate for Payer: Cash Price	$187.20

DILTIAZEM 125MG VIAL 25ML FOR DRIP ONLY

Facility

$125.00

Service Code	HCPCS J3490
Hospital Charge Code	2626452
Hospital Revenue Code	250
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$89.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$74.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$89.25
Rate for Payer: Cash Price	$112.50
Rate for Payer: UnitedHealthcare Commercial	$83.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.00

DILTIAZEM 125MG VIAL 25ML FOR DRIP ONLY

Facility

$125.00

Service Code	HCPCS J3490
Hospital Charge Code	2626452
Hospital Revenue Code	250
Rate for Payer: Cash Price	$112.50

DILTIAZEM 25MG VIAL 5ML SDV

Facility

$106.00

Service Code	HCPCS J3490
Hospital Charge Code	2655574
Hospital Revenue Code	250
Rate for Payer: Cash Price	$95.40

DILTIAZEM 25MG VIAL 5ML SDV

Facility

$106.00

Service Code	HCPCS J3490
Hospital Charge Code	2655574
Hospital Revenue Code	250
Min. Negotiated Rate	$38.16
Max. Negotiated Rate	$75.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$62.75
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$75.68
Rate for Payer: Cash Price	$95.40
Rate for Payer: UnitedHealthcare Commercial	$70.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$38.16

DILTIAZEM 30MG TAB EMP

Facility

$12.00

Service Code	NDC 5.1079E+10
Hospital Charge Code	2698195
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.80

DILTIAZEM 30MG TAB EMP

Facility

$12.00

Service Code	NDC 5.1079E+10
Hospital Charge Code	2698195
Hospital Revenue Code	250
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$8.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$8.57
Rate for Payer: Cash Price	$10.80
Rate for Payer: UnitedHealthcare Commercial	$8.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.32

DILTIAZEM 50MG VIAL 10ML SDV

Facility

$106.00

Service Code	HCPCS J3490
Hospital Charge Code	2621889
Hospital Revenue Code	250
Min. Negotiated Rate	$38.16
Max. Negotiated Rate	$75.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$62.75
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$75.68
Rate for Payer: Cash Price	$95.40
Rate for Payer: UnitedHealthcare Commercial	$70.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$38.16

DILTIAZEM 50MG VIAL 10ML SDV

Facility

$106.00

Service Code	HCPCS J3490
Hospital Charge Code	2621889
Hospital Revenue Code	250
Rate for Payer: Cash Price	$95.40

DILTIAZEM 90MG TAB EMP

Facility

$12.00

Service Code	NDC 93032001
Hospital Charge Code	2623752
Hospital Revenue Code	250
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$8.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$8.57
Rate for Payer: Cash Price	$10.80
Rate for Payer: UnitedHealthcare Commercial	$8.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.32

DILTIAZEM 90MG TAB EMP

Facility

$12.00

Service Code	NDC 93032001
Hospital Charge Code	2623752
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.80

DILTIAZEM (CARDIZEM) 300MG CD CAP

Facility

$36.00

Service Code	NDC 6.2584E+10
Hospital Charge Code	2626270
Hospital Revenue Code	250
Rate for Payer: Cash Price	$32.40

DILTIAZEM (CARDIZEM) 300MG CD CAP

Facility

$36.00

Service Code	NDC 6.2584E+10
Hospital Charge Code	2626270
Hospital Revenue Code	250
Min. Negotiated Rate	$12.96
Max. Negotiated Rate	$25.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$21.31
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$25.70
Rate for Payer: Cash Price	$32.40
Rate for Payer: UnitedHealthcare Commercial	$24.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.96

DILTIAZEM (CARDIZEM) 60MG TAB

Facility

$21.00

Service Code	NDC 6.3739E+10
Hospital Charge Code	2654832
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

DILTIAZEM (CARDIZEM) 60MG TAB

Facility

$21.00

Service Code	NDC 6.3739E+10
Hospital Charge Code	2654832
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

DILTIAZEM (CARTIA XT) 180MG ER CAP

Facility

$12.00

Service Code	NDC 6.0687E+10
Hospital Charge Code	2622413
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.80

DILTIAZEM (CARTIA XT) 180MG ER CAP

Facility

$12.00

Service Code	NDC 6.0687E+10
Hospital Charge Code	2622413
Hospital Revenue Code	250
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$8.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$8.57
Rate for Payer: Cash Price	$10.80
Rate for Payer: UnitedHealthcare Commercial	$8.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.32

DILTIAZEM (CARTIA XT) 240MG CAP EMP

Facility

$12.00

Service Code	NDC 6.3304E+10
Hospital Charge Code	2622704
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.80

DILTIAZEM (CARTIA XT) 240MG CAP EMP

Facility

$12.00

Service Code	NDC 6.3304E+10
Hospital Charge Code	2622704
Hospital Revenue Code	250
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$8.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$8.57
Rate for Payer: Cash Price	$10.80
Rate for Payer: UnitedHealthcare Commercial	$8.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.32

Know your out-of-pocket cost for care.

All Charges