Madison Medical Center

All Charges

Charge

Type

Setting

Price

D L U 3.5

Facility

$715.00

Hospital Charge Code	283972
Hospital Revenue Code	271
Min. Negotiated Rate	$257.40
Max. Negotiated Rate	$510.51
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$423.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$510.51
Rate for Payer: Cash Price	$643.50
Rate for Payer: UnitedHealthcare Commercial	$476.90
Rate for Payer: UnitedHealthcare Medicare Advantage	$257.40

D L U 3.5

Facility

$715.00

Hospital Charge Code	283972
Hospital Revenue Code	271
Rate for Payer: Cash Price	$643.50

DNA (ds) ANTIBODY

Facility

$106.00

Service Code	CPT 86225
Hospital Charge Code	2286225
Hospital Revenue Code	302
Min. Negotiated Rate	$12.37
Max. Negotiated Rate	$75.68
Rate for Payer: Aetna Better Health Medicaid/QHP	$12.37
Rate for Payer: Aetna Medicare Advantage	$13.74
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: Cash Price	$95.40
Rate for Payer: Cash Price	$95.40
Rate for Payer: Cigna Commercial HMO & PPO	$13.74
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$12.37
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13.24
Rate for Payer: Home State Health Plan Medicare Advantage	$13.74
Rate for Payer: Humana Commercial	$27.48
Rate for Payer: Humana Medicare Advantage	$13.74
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$12.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$38.16

DNA (ds) ANTIBODY

Facility

$106.00

Service Code	CPT 86225
Hospital Charge Code	2286225
Hospital Revenue Code	302
Rate for Payer: Cash Price	$95.40

DNA (ds) CRITHIDIA

Facility

$333.00

Service Code	CPT 86255
Hospital Charge Code	2286220
Hospital Revenue Code	302
Rate for Payer: Cash Price	$299.70

DNA (ds) CRITHIDIA

Facility

$333.00

Service Code	CPT 86255
Hospital Charge Code	2286220
Hospital Revenue Code	302
Min. Negotiated Rate	$10.85
Max. Negotiated Rate	$237.76
Rate for Payer: Aetna Better Health Medicaid/QHP	$10.85
Rate for Payer: Aetna Medicare Advantage	$12.05
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$197.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$237.76
Rate for Payer: Cash Price	$299.70
Rate for Payer: Cash Price	$299.70
Rate for Payer: Cash Price	$299.70
Rate for Payer: Cigna Commercial HMO & PPO	$12.05
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$10.85
Rate for Payer: Home State Health Plan Medicaid Managed Care	$11.61
Rate for Payer: Home State Health Plan Medicare Advantage	$12.05
Rate for Payer: Humana Commercial	$24.10
Rate for Payer: Humana Medicare Advantage	$12.05
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$10.85
Rate for Payer: UnitedHealthcare Medicare Advantage	$119.88

DOBUTAMINE 250MG VIAL 20ML

Facility

$67.00

Service Code	NDC 409234402
Hospital Charge Code	2620435
Hospital Revenue Code	250
Rate for Payer: Cash Price	$60.30

DOBUTAMINE 250MG VIAL 20ML

Facility

$67.00

Service Code	NDC 409234402
Hospital Charge Code	2620435
Hospital Revenue Code	250
Min. Negotiated Rate	$24.12
Max. Negotiated Rate	$47.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$39.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$47.84
Rate for Payer: Cash Price	$60.30
Rate for Payer: UnitedHealthcare Commercial	$44.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$24.12

DOBUTAMINE (DOBUTREX) 250MG PREMIX 250ML

Facility

$1,150.00

Service Code	NDC 409234632
Hospital Charge Code	2657155
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,035.00

DOBUTAMINE (DOBUTREX) 250MG PREMIX 250ML

Facility

$1,150.00

Service Code	NDC 409234632
Hospital Charge Code	2657155
Hospital Revenue Code	250
Min. Negotiated Rate	$414.00
Max. Negotiated Rate	$821.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$680.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$821.10
Rate for Payer: Cash Price	$1,035.00
Rate for Payer: UnitedHealthcare Commercial	$767.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.00

DOCUSATE (COLACE) 100MG CAP

Facility

$20.00

Service Code	NDC 904718361
Hospital Charge Code	2655387
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

DOCUSATE (COLACE) 100MG CAP

Facility

$20.00

Service Code	NDC 904718361
Hospital Charge Code	2655387
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

DOCUSATE (COLACE) 100MG ORAL SOL 10ML

Facility

$16.00

Service Code	NDC 5.7896E+10
Hospital Charge Code	2654886
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

DOCUSATE (COLACE) 100MG ORAL SOL 10ML

Facility

$16.00

Service Code	NDC 5.7896E+10
Hospital Charge Code	2654886
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

DOLASETRON (ANZEMET) 12.5MG INJ

Facility

$192.00

Service Code	HCPCS J1260
Hospital Charge Code	2626373
Hospital Revenue Code	250
Min. Negotiated Rate	$69.12
Max. Negotiated Rate	$137.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$113.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$137.09
Rate for Payer: Cash Price	$172.80
Rate for Payer: UnitedHealthcare Commercial	$128.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$69.12

DOLASETRON (ANZEMET) 12.5MG INJ

Facility

$192.00

Service Code	HCPCS J1260
Hospital Charge Code	2626373
Hospital Revenue Code	250
Rate for Payer: Cash Price	$172.80

DOME PASTE BANDAGE 3 INCH BANDAGE

Facility

$84.00

Service Code	NDC 26261101
Hospital Charge Code	2654890
Hospital Revenue Code	250
Rate for Payer: Cash Price	$75.60

DOME PASTE BANDAGE 3 INCH BANDAGE

Facility

$84.00

Service Code	NDC 26261101
Hospital Charge Code	2654890
Hospital Revenue Code	250
Min. Negotiated Rate	$30.24
Max. Negotiated Rate	$59.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$49.73
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$59.98
Rate for Payer: Cash Price	$75.60
Rate for Payer: UnitedHealthcare Commercial	$56.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$30.24

DOME PASTE BANDAGE 4INCH BANDAGE

Facility

$84.00

Service Code	NDC 26500301
Hospital Charge Code	2654900
Hospital Revenue Code	250
Min. Negotiated Rate	$30.24
Max. Negotiated Rate	$59.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$49.73
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$59.98
Rate for Payer: Cash Price	$75.60
Rate for Payer: UnitedHealthcare Commercial	$56.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$30.24

DOME PASTE BANDAGE 4INCH BANDAGE

Facility

$84.00

Service Code	NDC 26500301
Hospital Charge Code	2654900
Hospital Revenue Code	250
Rate for Payer: Cash Price	$75.60

DONALDSON

Facility

$111.00

Hospital Charge Code	1220720
Hospital Revenue Code	272
Min. Negotiated Rate	$39.96
Max. Negotiated Rate	$79.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$65.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$79.25
Rate for Payer: Cash Price	$99.90
Rate for Payer: UnitedHealthcare Commercial	$74.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$39.96

DONALDSON

Facility

$111.00

Hospital Charge Code	1220720
Hospital Revenue Code	272
Rate for Payer: Cash Price	$99.90

DONALDSON- ULTRASIL

Facility

$126.00

Hospital Charge Code	1220729
Hospital Revenue Code	272
Rate for Payer: Cash Price	$113.40

DONALDSON- ULTRASIL

Facility

$126.00

Hospital Charge Code	1220729
Hospital Revenue Code	272
Min. Negotiated Rate	$45.36
Max. Negotiated Rate	$89.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$74.59
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$89.96
Rate for Payer: Cash Price	$113.40
Rate for Payer: UnitedHealthcare Commercial	$84.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.36

DONEPEZIL 5MG TAB EMP

Facility

$45.00

Service Code	NDC 3.1722E+10
Hospital Charge Code	2620746
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

Know your out-of-pocket cost for care.

All Charges