Madison Medical Center

All Charges

Charge

Type

Setting

Price

DILTIAZEM CD 120MG CAP EMP

Facility

$21.00

Service Code	NDC 1.037E+10
Hospital Charge Code	2621554
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 CD 120MG CAP EMP

Facility

$21.00

Service Code	NDC 1.037E+10
Hospital Charge Code	2621554
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

DILTIAZEM CD 180MG CAP EMP

Facility

$12.00

Service Code	NDC 6.2037E+10
Hospital Charge Code	2623075
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 CD 180MG CAP EMP

Facility

$12.00

Service Code	NDC 6.2037E+10
Hospital Charge Code	2623075
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.80

DILTIAZEM CD (CARDIZEM) 120MG CAP

Facility

$21.00

Service Code	NDC 6.0687E+10
Hospital Charge Code	2654678
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

DILTIAZEM CD (CARDIZEM) 120MG CAP

Facility

$21.00

Service Code	NDC 6.0687E+10
Hospital Charge Code	2654678
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 CD (CARDIZEM) 180MG CAP

Facility

$28.00

Service Code	NDC 6.0687E+10
Hospital Charge Code	2654676
Hospital Revenue Code	250
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$19.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$16.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.99
Rate for Payer: Cash Price	$25.20
Rate for Payer: UnitedHealthcare Commercial	$18.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.08

DILTIAZEM CD (CARDIZEM) 180MG CAP

Facility

$28.00

Service Code	NDC 6.0687E+10
Hospital Charge Code	2654676
Hospital Revenue Code	250
Rate for Payer: Cash Price	$25.20

DILTIAZEM CD(CARDIZEM CD) 360MG CAP EMP

Facility

$27.00

Service Code	NDC 2.4979E+10
Hospital Charge Code	2627006
Hospital Revenue Code	250
Min. Negotiated Rate	$9.72
Max. Negotiated Rate	$19.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$15.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.28
Rate for Payer: Cash Price	$24.30
Rate for Payer: UnitedHealthcare Commercial	$18.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.72

DILTIAZEM CD(CARDIZEM CD) 360MG CAP EMP

Facility

$27.00

Service Code	NDC 2.4979E+10
Hospital Charge Code	2627006
Hospital Revenue Code	250
Rate for Payer: Cash Price	$24.30

DILTIAZEM DRIP : 125MG+NS100ML IVPB

Facility

$640.00

Service Code	HCPCS J1815
Hospital Charge Code	2619722
Hospital Revenue Code	250
Min. Negotiated Rate	$230.40
Max. Negotiated Rate	$456.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$378.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$456.96
Rate for Payer: Cash Price	$576.00
Rate for Payer: UnitedHealthcare Commercial	$426.88
Rate for Payer: UnitedHealthcare Medicare Advantage	$230.40

DILTIAZEM DRIP : 125MG+NS100ML IVPB

Facility

$640.00

Service Code	HCPCS J1815
Hospital Charge Code	2619722
Hospital Revenue Code	250
Rate for Payer: Cash Price	$576.00

DILUTE PROTHROMBIN TIME (LA)

Facility

$92.00

Service Code	CPT 85705
Hospital Charge Code	22285705
Hospital Revenue Code	305
Min. Negotiated Rate	$8.67
Max. Negotiated Rate	$65.69
Rate for Payer: Aetna Better Health Medicaid/QHP	$8.67
Rate for Payer: Aetna Medicare Advantage	$9.63
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$54.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$65.69
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial HMO & PPO	$9.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8.67
Rate for Payer: Home State Health Plan Medicaid Managed Care	$9.28
Rate for Payer: Home State Health Plan Medicare Advantage	$9.63
Rate for Payer: Humana Commercial	$19.26
Rate for Payer: Humana Medicare Advantage	$9.63
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$33.12

DILUTE PROTHROMBIN TIME (LA)

Facility

$92.00

Service Code	CPT 85705
Hospital Charge Code	22285705
Hospital Revenue Code	305
Rate for Payer: Cash Price	$82.80

DIPEHNHYDRAMINE HCI

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	5201200
Hospital Revenue Code	521
Rate for Payer: Cash Price	$40.50

DIPEHNHYDRAMINE HCI

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	9101200
Hospital Revenue Code	521
Min. Negotiated Rate	$26.64
Max. Negotiated Rate	$173.53
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: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DIPEHNHYDRAMINE HCI

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	5201200
Hospital Revenue Code	521
Min. Negotiated Rate	$26.64
Max. Negotiated Rate	$173.53
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: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DIPEHNHYDRAMINE HCI

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	9101200
Hospital Revenue Code	521
Rate for Payer: Cash Price	$40.50

DIPEHNHYDRAMINE HCI

Facility

$45.00

Service Code	CPT J1200
Hospital Charge Code	4101200
Hospital Revenue Code	636
Min. Negotiated Rate	$30.02
Max. Negotiated Rate	$30.02
Rate for Payer: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02

DIPEHNHYDRAMINE HCI

Facility

$45.00

Service Code	CPT J1200
Hospital Charge Code	4101200
Hospital Revenue Code	636
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

DIPEHNYDRAMINE HCI

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	9601200
Hospital Revenue Code	636
Min. Negotiated Rate	$30.02
Max. Negotiated Rate	$30.02
Rate for Payer: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02

DIPEHNYDRAMINE HCI

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	9601200
Hospital Revenue Code	636
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

DIPHENHYDRAMINE 12.5MG OR SOL 5ML UD

Facility

$16.00

Service Code	NDC 5.4838E+10
Hospital Charge Code	2697183
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

DIPHENHYDRAMINE 12.5MG OR SOL 5ML UD

Facility

$16.00

Service Code	NDC 5.4838E+10
Hospital Charge Code	2697183
Hospital Revenue Code	250
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$11.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$9.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$11.42
Rate for Payer: Cash Price	$14.40
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.76

DIPHENHYDRAMINE (BENADRYL) 25MG CAP/TAB

Facility

$20.00

Service Code	NDC 536375801
Hospital Charge Code	2654840
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

Know your out-of-pocket cost for care.

All Charges