Madison Medical Center

All Charges

Charge

Type

Setting

Price

DONEPEZIL 5MG TAB EMP

Facility

$45.00

Service Code	NDC 3.1722E+10
Hospital Charge Code	2620746
Hospital Revenue Code	250
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

DONEPEZIL (ARICEPT) 5MG TAB UD

Facility

$45.00

Service Code	NDC 904647761
Hospital Charge Code	2626278
Hospital Revenue Code	250
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

DONEPEZIL (ARICEPT) 5MG TAB UD

Facility

$45.00

Service Code	NDC 904647761
Hospital Charge Code	2626278
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

DO NOT USE (ALBUTEROL 6.7GM INH EMP)

Facility

$184.00

Service Code	NDC 6.9097E+10
Hospital Charge Code	2621891
Hospital Revenue Code	250
Min. Negotiated Rate	$66.24
Max. Negotiated Rate	$131.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$108.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$131.38
Rate for Payer: Cash Price	$165.60
Rate for Payer: UnitedHealthcare Commercial	$122.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$66.24

DO NOT USE (ALBUTEROL 6.7GM INH EMP)

Facility

$184.00

Service Code	NDC 6.9097E+10
Hospital Charge Code	2621891
Hospital Revenue Code	250
Rate for Payer: Cash Price	$165.60

DO NOT USE, CELEBREX, DO NOT USE

Facility

$18.00

Service Code	NDC 1.6714E+10
Hospital Charge Code	2623234
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.20

DO NOT USE, CELEBREX, DO NOT USE

Facility

$18.00

Service Code	NDC 1.6714E+10
Hospital Charge Code	2623234
Hospital Revenue Code	250
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$12.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$10.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$12.85
Rate for Payer: Cash Price	$16.20
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.48

DOPAMINE

Facility

$36.00

Service Code	CPT 82491
Hospital Charge Code	224265
Hospital Revenue Code	301
Rate for Payer: Cash Price	$32.40

DOPAMINE

Facility

$36.00

Service Code	CPT 82491
Hospital Charge Code	224265
Hospital Revenue Code	301
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: Cash Price	$32.40
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.96

DOPAMINE 400/5ML INJ

Facility

$38.00

Service Code	HCPCS J1265
Hospital Charge Code	2654906
Hospital Revenue Code	250
Rate for Payer: Cash Price	$34.20

DOPAMINE 400/5ML INJ

Facility

$38.00

Service Code	HCPCS J1265
Hospital Charge Code	2654906
Hospital Revenue Code	250
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$27.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$22.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.13
Rate for Payer: Cash Price	$34.20
Rate for Payer: UnitedHealthcare Commercial	$25.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.68

DOPAMINE 400MG SDV 10ML VIAL

Facility

$29.00

Service Code	HCPCS J1265
Hospital Charge Code	2626073
Hospital Revenue Code	250
Min. Negotiated Rate	$10.44
Max. Negotiated Rate	$20.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.17
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$20.71
Rate for Payer: Cash Price	$26.10
Rate for Payer: UnitedHealthcare Commercial	$19.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.44

DOPAMINE 400MG SDV 10ML VIAL

Facility

$29.00

Service Code	HCPCS J1265
Hospital Charge Code	2626073
Hospital Revenue Code	250
Rate for Payer: Cash Price	$26.10

DOPAMINE 800MG IN 250ML D5W KIT

Facility

$135.00

Service Code	HCPCS J1265
Hospital Charge Code	2626074
Hospital Revenue Code	250
Rate for Payer: Cash Price	$121.50

DOPAMINE 800MG IN 250ML D5W KIT

Facility

$135.00

Service Code	HCPCS J1265
Hospital Charge Code	2626074
Hospital Revenue Code	250
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$96.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$79.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$96.39
Rate for Payer: Cash Price	$121.50
Rate for Payer: UnitedHealthcare Commercial	$90.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$48.60

DOPAMINE 800MG PREMIX 250ML BAG

Facility

$135.00

Service Code	HCPCS J1265
Hospital Charge Code	2622116
Hospital Revenue Code	250
Rate for Payer: Cash Price	$121.50

DOPAMINE 800MG PREMIX 250ML BAG

Facility

$135.00

Service Code	HCPCS J1265
Hospital Charge Code	2622116
Hospital Revenue Code	250
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$96.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$79.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$96.39
Rate for Payer: Cash Price	$121.50
Rate for Payer: UnitedHealthcare Commercial	$90.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$48.60

DOPAMINE (INOTROPIN) 800MG PREMIX 500ML

Facility

$135.00

Service Code	HCPCS J1265
Hospital Charge Code	2697273
Hospital Revenue Code	250
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$96.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$79.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$96.39
Rate for Payer: Cash Price	$121.50
Rate for Payer: UnitedHealthcare Commercial	$90.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$48.60

DOPAMINE (INOTROPIN) 800MG PREMIX 500ML

Facility

$135.00

Service Code	HCPCS J1265
Hospital Charge Code	2697273
Hospital Revenue Code	250
Rate for Payer: Cash Price	$121.50

DOPPLER-FHT,BP,PULSE CHECK

Facility

$112.00

Hospital Charge Code	1824483
Hospital Revenue Code	271
Rate for Payer: Cash Price	$100.80

DOPPLER-FHT,BP,PULSE CHECK

Facility

$112.00

Hospital Charge Code	1824483
Hospital Revenue Code	271
Min. Negotiated Rate	$40.32
Max. Negotiated Rate	$79.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$66.30
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$79.97
Rate for Payer: Cash Price	$100.80
Rate for Payer: UnitedHealthcare Commercial	$74.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$40.32

DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK

Facility

$91,227.84

Service Code	APR-DRG 3044
Min. Negotiated Rate	$91,227.84
Max. Negotiated Rate	$91,227.84
Rate for Payer: Aetna Better Health Medicaid/QHP	$91,227.84
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$91,227.84
Rate for Payer: Home State Health Plan Medicaid Managed Care	$91,227.84
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$91,227.84

DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK

Facility

$17,893.14

Service Code	APR-DRG 3041
Min. Negotiated Rate	$17,893.14
Max. Negotiated Rate	$17,893.14
Rate for Payer: Aetna Better Health Medicaid/QHP	$17,893.14
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$17,893.14
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17,893.14
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$17,893.14

DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK

Facility

$53,952.16

Service Code	APR-DRG 3043
Min. Negotiated Rate	$53,952.16
Max. Negotiated Rate	$53,952.16
Rate for Payer: Aetna Better Health Medicaid/QHP	$53,952.16
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$53,952.16
Rate for Payer: Home State Health Plan Medicaid Managed Care	$53,952.16
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$53,952.16

DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK

Facility

$28,074.87

Service Code	APR-DRG 3042
Min. Negotiated Rate	$28,074.87
Max. Negotiated Rate	$28,074.87
Rate for Payer: Aetna Better Health Medicaid/QHP	$28,074.87
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$28,074.87
Rate for Payer: Home State Health Plan Medicaid Managed Care	$28,074.87
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$28,074.87

Know your out-of-pocket cost for care.

All Charges