Madison Medical Center

All Charges

Charge

Type

Setting

Price

DIPHENHYDRAMINE (BENADRYL) 25MG CAP/TAB

Facility

$20.00

Service Code	NDC 536375801
Hospital Charge Code	2654840
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

DIPHENHYDRAMINE (BENADRYL) 2% CRM 28GM

Facility

$39.00

Service Code	NDC 2.4385E+10
Hospital Charge Code	2626511
Hospital Revenue Code	250
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$27.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.85
Rate for Payer: Cash Price	$35.10
Rate for Payer: UnitedHealthcare Commercial	$26.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.04

DIPHENHYDRAMINE (BENADRYL) 2% CRM 28GM

Facility

$39.00

Service Code	NDC 2.4385E+10
Hospital Charge Code	2626511
Hospital Revenue Code	250
Rate for Payer: Cash Price	$35.10

DIPHENHYDRAMINE (BENADRYL) 50MG/ML INJ

Facility

$63.00

Service Code	HCPCS J1200
Hospital Charge Code	2654855
Hospital Revenue Code	250
Rate for Payer: Cash Price	$56.70

DIPHENHYDRAMINE (BENADRYL) 50MG/ML INJ

Facility

$63.00

Service Code	HCPCS J1200
Hospital Charge Code	2654855
Hospital Revenue Code	250
Min. Negotiated Rate	$22.68
Max. Negotiated Rate	$44.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$37.30
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$44.98
Rate for Payer: Cash Price	$56.70
Rate for Payer: UnitedHealthcare Commercial	$42.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$22.68

DIPHENHYDRAMINE HCI

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	4201200
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

DIPHENHYDRAMINE HCI

Facility

$45.00

Service Code	HCPCS J1200
Hospital Charge Code	4201200
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 INJ

Facility

$58.00

Service Code	HCPCS J1200
Hospital Charge Code	2058008
Hospital Revenue Code	370
Min. Negotiated Rate	$20.88
Max. Negotiated Rate	$41.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$34.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$41.41
Rate for Payer: Cash Price	$52.20
Rate for Payer: UnitedHealthcare Commercial	$38.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.88

DIPHENHYDRAMINE INJ

Facility

$58.00

Service Code	HCPCS J1200
Hospital Charge Code	2058008
Hospital Revenue Code	370
Rate for Payer: Cash Price	$52.20

DIPHENOXYL/ATROPINE (LOMOTIL) TAB C5

Facility

$20.00

Service Code	NDC 6.9315E+10
Hospital Charge Code	2654860
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

DIPHENOXYL/ATROPINE (LOMOTIL) TAB C5

Facility

$20.00

Service Code	NDC 6.9315E+10
Hospital Charge Code	2654860
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

DIPHENOXYL/ATROPINE (LOMOTIL) TAB C5 EMP

Facility

$20.00

Service Code	NDC 378041501
Hospital Charge Code	2623299
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

DIPHENOXYL/ATROPINE (LOMOTIL) TAB C5 EMP

Facility

$20.00

Service Code	NDC 378041501
Hospital Charge Code	2623299
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

DIPTHERIA ANTITOXOID AB

Facility

$174.00

Service Code	CPT 86648
Hospital Charge Code	2286648
Hospital Revenue Code	301
Rate for Payer: Cash Price	$156.60

DIPTHERIA ANTITOXOID AB

Facility

$174.00

Service Code	CPT 86648
Hospital Charge Code	2286648
Hospital Revenue Code	301
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$124.24
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.69
Rate for Payer: Aetna Medicare Advantage	$15.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$103.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$124.24
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cigna Commercial HMO & PPO	$15.21
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13.69
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14.65
Rate for Payer: Home State Health Plan Medicare Advantage	$15.21
Rate for Payer: Humana Commercial	$30.42
Rate for Payer: Humana Medicare Advantage	$15.21
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$62.64

DIRECT BILI (LABCORP)

Facility

$44.00

Service Code	CPT 82248
Hospital Charge Code	221222
Hospital Revenue Code	301
Rate for Payer: Cash Price	$39.60

DIRECT BILI (LABCORP)

Facility

$44.00

Service Code	CPT 82248
Hospital Charge Code	221222
Hospital Revenue Code	301
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$31.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$4.52
Rate for Payer: Aetna Medicare Advantage	$5.02
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: Cash Price	$39.60
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cigna Commercial HMO & PPO	$5.02
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4.52
Rate for Payer: Home State Health Plan Medicaid Managed Care	$4.84
Rate for Payer: Home State Health Plan Medicare Advantage	$5.02
Rate for Payer: Humana Commercial	$10.04
Rate for Payer: Humana Medicare Advantage	$5.02
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4.52
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.84

DISCHARE HOSP INPT OVER 30 MIN

Professional

Both

$285.00

Service Code	CPT 99239
Hospital Charge Code	4199239
Hospital Revenue Code	987
Min. Negotiated Rate	$86.23
Max. Negotiated Rate	$102.35
Rate for Payer: Aetna Commercial/Medicare Advantage	$102.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$86.23
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cigna Commercial HMO & PPO	$102.35
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$86.23
Rate for Payer: Home State Health Plan Medicaid Managed Care	$94.85
Rate for Payer: Home State Health Plan Medicare Advantage	$102.35
Rate for Payer: Optum Medicare Advantage	$99.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$86.23

DISCHARGE (HOSPITAL EVAL.)

Professional

Both

$202.00

Service Code	CPT 99238
Hospital Charge Code	4199238
Hospital Revenue Code	987
Min. Negotiated Rate	$58.97
Max. Negotiated Rate	$71.86
Rate for Payer: Aetna Commercial/Medicare Advantage	$71.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$58.97
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cigna Commercial HMO & PPO	$71.86
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$58.97
Rate for Payer: Home State Health Plan Medicaid Managed Care	$64.87
Rate for Payer: Home State Health Plan Medicare Advantage	$71.86
Rate for Payer: Optum Medicare Advantage	$70.70
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$58.97

DISCHARGE IP HOSP ADMIT >30 MIN

Facility

$250.00

Service Code	CPT 99239
Hospital Charge Code	9699239
Rate for Payer: Cash Price	$225.00

DISCHARGE NH <30 MIN

Facility

$170.00

Service Code	CPT 99315
Hospital Charge Code	9899315
Hospital Revenue Code	521
Rate for Payer: Cash Price	$153.00

DISCHARGE NH <30 MIN

Facility

$170.00

Service Code	CPT 99315
Hospital Charge Code	9899315
Hospital Revenue Code	521
Min. Negotiated Rate	$100.64
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$100.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$121.38
Rate for Payer: Cash Price	$153.00
Rate for Payer: Cash Price	$153.00
Rate for Payer: UnitedHealthcare Commercial	$113.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DISCHARGE NH >30 MIN

Facility

$230.00

Service Code	CPT 99316
Hospital Charge Code	9899316
Hospital Revenue Code	521
Min. Negotiated Rate	$136.16
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$136.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$164.22
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: UnitedHealthcare Commercial	$153.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DISCHARGE NH >30 MIN

Facility

$230.00

Service Code	CPT 99316
Hospital Charge Code	9899316
Hospital Revenue Code	521
Rate for Payer: Cash Price	$207.00

DISCHARGE OBSERV. CARE .

Professional

Both

$204.00

Service Code	CPT 99238
Hospital Charge Code	4199217
Hospital Revenue Code	975
Min. Negotiated Rate	$58.97
Max. Negotiated Rate	$71.86
Rate for Payer: Aetna Commercial/Medicare Advantage	$71.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$58.97
Rate for Payer: Cash Price	$183.60
Rate for Payer: Cash Price	$183.60
Rate for Payer: Cigna Commercial HMO & PPO	$71.86
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$58.97
Rate for Payer: Home State Health Plan Medicaid Managed Care	$64.87
Rate for Payer: Home State Health Plan Medicare Advantage	$71.86
Rate for Payer: Optum Medicare Advantage	$71.40
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$58.97

Know your out-of-pocket cost for care.

All Charges