Madison Medical Center

All Charges

Charge

Type

Setting

Price

FENTANYL 100MCG PATCH C2

Facility

$402.00

Service Code	NDC 6.0506E+10
Hospital Charge Code	2621428
Hospital Revenue Code	250
Rate for Payer: Cash Price	$361.80

FENTANYL 50MCG/ML INJ 2ML

Facility

$75.00

Service Code	HCPCS J3010
Hospital Charge Code	2626455
Hospital Revenue Code	250
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$53.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$44.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$53.55
Rate for Payer: Cash Price	$67.50
Rate for Payer: UnitedHealthcare Commercial	$50.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$27.00

FENTANYL 50MCG/ML INJ 2ML

Facility

$75.00

Service Code	HCPCS J3010
Hospital Charge Code	2626455
Hospital Revenue Code	250
Rate for Payer: Cash Price	$67.50

FENTANYL 75MCG PATCH C2

Facility

$268.00

Service Code	NDC 406907576
Hospital Charge Code	2621429
Hospital Revenue Code	250
Min. Negotiated Rate	$96.48
Max. Negotiated Rate	$191.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$158.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$191.35
Rate for Payer: Cash Price	$241.20
Rate for Payer: UnitedHealthcare Commercial	$178.76
Rate for Payer: UnitedHealthcare Medicare Advantage	$96.48

FENTANYL 75MCG PATCH C2

Facility

$268.00

Service Code	NDC 406907576
Hospital Charge Code	2621429
Hospital Revenue Code	250
Rate for Payer: Cash Price	$241.20

FENTANYL AND METABOLITE

Facility

$317.00

Service Code	CPT 80299
Hospital Charge Code	2282146
Hospital Revenue Code	301
Rate for Payer: Cash Price	$285.30

FENTANYL AND METABOLITE

Facility

$317.00

Service Code	CPT 80299
Hospital Charge Code	2282146
Hospital Revenue Code	301
Min. Negotiated Rate	$16.78
Max. Negotiated Rate	$226.34
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.78
Rate for Payer: Aetna Medicare Advantage	$18.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$187.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$226.34
Rate for Payer: Cash Price	$285.30
Rate for Payer: Cash Price	$285.30
Rate for Payer: Cash Price	$285.30
Rate for Payer: Cigna Commercial HMO & PPO	$18.64
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.78
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.95
Rate for Payer: Home State Health Plan Medicare Advantage	$18.64
Rate for Payer: Humana Commercial	$37.28
Rate for Payer: Humana Medicare Advantage	$18.64
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.78
Rate for Payer: UnitedHealthcare Medicare Advantage	$114.12

FENTANYL DRIP 2500MCG/50ML EMTY 50ML BAG

Facility

$165.00

Service Code	HCPCS J3010
Hospital Charge Code	2624330
Hospital Revenue Code	250
Rate for Payer: Cash Price	$148.50

FENTANYL DRIP 2500MCG/50ML EMTY 50ML BAG

Facility

$165.00

Service Code	HCPCS J3010
Hospital Charge Code	2624330
Hospital Revenue Code	250
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$117.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$97.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$117.81
Rate for Payer: Cash Price	$148.50
Rate for Payer: UnitedHealthcare Commercial	$110.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$59.40

FENTANYL (DURAGESIC) 12MCG PATCH C2

Facility

$163.00

Service Code	NDC 781724055
Hospital Charge Code	2626512
Hospital Revenue Code	250
Rate for Payer: Cash Price	$146.70

FENTANYL (DURAGESIC) 12MCG PATCH C2

Facility

$163.00

Service Code	NDC 781724055
Hospital Charge Code	2626512
Hospital Revenue Code	250
Min. Negotiated Rate	$58.68
Max. Negotiated Rate	$116.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$96.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$116.38
Rate for Payer: Cash Price	$146.70
Rate for Payer: UnitedHealthcare Commercial	$108.72
Rate for Payer: UnitedHealthcare Medicare Advantage	$58.68

FENTANYL (DURAGESIC) 25MCG PATCH C4

Facility

$155.00

Service Code	NDC 6.0506E+10
Hospital Charge Code	2626321
Hospital Revenue Code	250
Rate for Payer: Cash Price	$139.50

FENTANYL (DURAGESIC) 25MCG PATCH C4

Facility

$155.00

Service Code	NDC 6.0506E+10
Hospital Charge Code	2626321
Hospital Revenue Code	250
Min. Negotiated Rate	$55.80
Max. Negotiated Rate	$110.67
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$91.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$110.67
Rate for Payer: Cash Price	$139.50
Rate for Payer: UnitedHealthcare Commercial	$103.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$55.80

FENTANYL (DURAGESIC) 50MCG PATCH C2

Facility

$275.00

Service Code	NDC 4.7781E+10
Hospital Charge Code	2626323
Hospital Revenue Code	250
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$196.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$162.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$196.35
Rate for Payer: Cash Price	$247.50
Rate for Payer: UnitedHealthcare Commercial	$183.43
Rate for Payer: UnitedHealthcare Medicare Advantage	$99.00

FENTANYL (DURAGESIC) 50MCG PATCH C2

Facility

$275.00

Service Code	NDC 4.7781E+10
Hospital Charge Code	2626323
Hospital Revenue Code	250
Rate for Payer: Cash Price	$247.50

FENTANYL INJ 0.05MG/ML

Facility

$43.00

Service Code	CPT J3010
Hospital Charge Code	2016075
Hospital Revenue Code	370
Rate for Payer: Cash Price	$38.70

FENTANYL INJ 0.05MG/ML

Facility

$43.00

Service Code	CPT J3010
Hospital Charge Code	2016075
Hospital Revenue Code	370
Min. Negotiated Rate	$15.48
Max. Negotiated Rate	$30.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$25.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$30.70
Rate for Payer: Cash Price	$38.70
Rate for Payer: UnitedHealthcare Commercial	$28.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.48

.FENTANYL REFLEX CONFIRMATION

Facility

$110.00

Service Code	CPT 80354
Hospital Charge Code	221324
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$78.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$65.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$78.54
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$39.60

.FENTANYL REFLEX CONFIRMATION

Facility

$110.00

Service Code	CPT 80354
Hospital Charge Code	221324
Hospital Revenue Code	301
Rate for Payer: Cash Price	$99.00

FENTANYL(SUBLIMAZE)50MCG/ML 5ML INJ C2

Facility

$171.00

Service Code	HCPCS J3010
Hospital Charge Code	2626456
Hospital Revenue Code	250
Min. Negotiated Rate	$61.56
Max. Negotiated Rate	$122.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$101.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$122.09
Rate for Payer: Cash Price	$153.90
Rate for Payer: UnitedHealthcare Commercial	$114.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$61.56

FENTANYL(SUBLIMAZE)50MCG/ML 5ML INJ C2

Facility

$171.00

Service Code	HCPCS J3010
Hospital Charge Code	2626456
Hospital Revenue Code	250
Rate for Payer: Cash Price	$153.90

FENTANYL, URINE (CONFIRMATION)

Facility

$69.00

Service Code	CPT 80354
Hospital Charge Code	2280354
Hospital Revenue Code	301
Rate for Payer: Cash Price	$62.10

FENTANYL, URINE (CONFIRMATION)

Facility

$69.00

Service Code	CPT 80354
Hospital Charge Code	2280354
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$49.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$40.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$49.27
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cash Price	$62.10
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$24.84

FERRIC CARBOXYMALTOSE INJ 100MG/2MLSDV

Facility

$728.00

Service Code	NDC 517060201
Hospital Charge Code	2626141
Hospital Revenue Code	250
Rate for Payer: Cash Price	$655.20

FERRIC CARBOXYMALTOSE INJ 100MG/2MLSDV

Facility

$728.00

Service Code	NDC 517060201
Hospital Charge Code	2626141
Hospital Revenue Code	250
Min. Negotiated Rate	$262.08
Max. Negotiated Rate	$519.79
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$430.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$519.79
Rate for Payer: Cash Price	$655.20
Rate for Payer: UnitedHealthcare Commercial	$485.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$262.08

Know your out-of-pocket cost for care.

All Charges