Madison Medical Center

All Charges

Charge

Type

Setting

Price

HYDROXYZINE (ATARAX) HCL 25MG TAB UD

Facility

$22.00

Service Code	NDC 904661761
Hospital Charge Code	2655235
Hospital Revenue Code	250
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

HYDROXYZINE (ATARAX) HCL 25MG TAB UD

Facility

$22.00

Service Code	NDC 904661761
Hospital Charge Code	2655235
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.80

HYDROXYZINE HCL 25MG TAB EMP

Facility

$22.00

Service Code	NDC 6.8462E+10
Hospital Charge Code	2619366
Hospital Revenue Code	250
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

HYDROXYZINE HCL 25MG TAB EMP

Facility

$22.00

Service Code	NDC 6.8462E+10
Hospital Charge Code	2619366
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.80

HYDROXYZINE HCL 50MG TAB EMP

Facility

$13.00

Service Code	NDC 2.3155E+10
Hospital Charge Code	2622821
Hospital Revenue Code	250
Rate for Payer: Cash Price	$11.70

HYDROXYZINE HCL 50MG TAB EMP

Facility

$13.00

Service Code	NDC 2.3155E+10
Hospital Charge Code	2622821
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$9.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$9.28
Rate for Payer: Cash Price	$11.70
Rate for Payer: UnitedHealthcare Commercial	$8.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.68

HYDROXYZINE PAM 25MG CAP EMP

Facility

$13.00

Service Code	NDC 185061501
Hospital Charge Code	2619687
Hospital Revenue Code	250
Rate for Payer: Cash Price	$11.70

HYDROXYZINE PAM 25MG CAP EMP

Facility

$13.00

Service Code	NDC 185061501
Hospital Charge Code	2619687
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$9.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$9.28
Rate for Payer: Cash Price	$11.70
Rate for Payer: UnitedHealthcare Commercial	$8.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.68

HYDROXYZINE PAM 50MG CAP EMP

Facility

$13.00

Service Code	NDC 185061501
Hospital Charge Code	2621796
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$9.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$9.28
Rate for Payer: Cash Price	$11.70
Rate for Payer: UnitedHealthcare Commercial	$8.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.68

HYDROXYZINE PAM 50MG CAP EMP

Facility

$13.00

Service Code	NDC 185061501
Hospital Charge Code	2621796
Hospital Revenue Code	250
Rate for Payer: Cash Price	$11.70

HYDROXYZINE PAM (VISTARIL)25MG CAP

Facility

$25.00

Service Code	NDC 555032302
Hospital Charge Code	2626594
Hospital Revenue Code	250
Rate for Payer: Cash Price	$22.50

HYDROXYZINE PAM (VISTARIL)25MG CAP

Facility

$25.00

Service Code	NDC 555032302
Hospital Charge Code	2626594
Hospital Revenue Code	250
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$17.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.85
Rate for Payer: Cash Price	$22.50
Rate for Payer: UnitedHealthcare Commercial	$16.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.00

HYDROXYZINE (VISTARIL) 50MG/ML INJ

Facility

$63.00

Service Code	HCPCS J3410
Hospital Charge Code	2655245
Hospital Revenue Code	250
Rate for Payer: Cash Price	$56.70

HYDROXYZINE (VISTARIL) 50MG/ML INJ

Facility

$63.00

Service Code	HCPCS J3410
Hospital Charge Code	2655245
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

HYOSCYAMINE SULF 0.125MG ODT TAB

Facility

$11.00

Service Code	NDC 4.2192E+10
Hospital Charge Code	2626197
Hospital Revenue Code	250
Rate for Payer: Cash Price	$9.90

HYOSCYAMINE SULF 0.125MG ODT TAB

Facility

$11.00

Service Code	NDC 4.2192E+10
Hospital Charge Code	2626197
Hospital Revenue Code	250
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$7.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$6.51
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$7.85
Rate for Payer: Cash Price	$9.90
Rate for Payer: UnitedHealthcare Commercial	$7.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$3.96

HYOSCYAMINE SULF 0.125MG ODT TAB EMP

Facility

$12.00

Service Code	NDC 7.0156E+10
Hospital Charge Code	2624282
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.80

HYOSCYAMINE SULF 0.125MG ODT TAB EMP

Facility

$12.00

Service Code	NDC 7.0156E+10
Hospital Charge Code	2624282
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

HYOSCYAMINE SULF ER 0.375MG TAB EMP

Facility

$12.00

Service Code	NDC 5.1525E+10
Hospital Charge Code	2621849
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

HYOSCYAMINE SULF ER 0.375MG TAB EMP

Facility

$12.00

Service Code	NDC 5.1525E+10
Hospital Charge Code	2621849
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.80

HYPERTENSION

Facility

$15,140.21

Service Code	APR-DRG 1993
Min. Negotiated Rate	$15,140.21
Max. Negotiated Rate	$15,140.21
Rate for Payer: Aetna Better Health Medicaid/QHP	$15,140.21
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15,140.21
Rate for Payer: Home State Health Plan Medicaid Managed Care	$15,140.21
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15,140.21

HYPERTENSION

Facility

$8,246.52

Service Code	APR-DRG 1992
Min. Negotiated Rate	$8,246.52
Max. Negotiated Rate	$8,246.52
Rate for Payer: Aetna Better Health Medicaid/QHP	$8,246.52
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8,246.52
Rate for Payer: Home State Health Plan Medicaid Managed Care	$8,246.52
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8,246.52

HYPERTENSION

Facility

$6,146.43

Service Code	APR-DRG 1991
Min. Negotiated Rate	$6,146.43
Max. Negotiated Rate	$6,146.43
Rate for Payer: Aetna Better Health Medicaid/QHP	$6,146.43
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$6,146.43
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6,146.43
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$6,146.43

HYPERTENSION

Facility

$23,213.53

Service Code	APR-DRG 1994
Min. Negotiated Rate	$23,213.53
Max. Negotiated Rate	$23,213.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$23,213.53
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$23,213.53
Rate for Payer: Home State Health Plan Medicaid Managed Care	$23,213.53
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$23,213.53

HYPERTENSION WITH MCC

Facility

$22,267.26

Service Code	MSDRG 304
Min. Negotiated Rate	$11,133.63
Max. Negotiated Rate	$22,267.26
Rate for Payer: Aetna Medicare Advantage	$11,133.63
Rate for Payer: Cigna Commercial HMO & PPO	$11,133.63
Rate for Payer: Home State Health Plan Medicare Advantage	$11,133.63
Rate for Payer: Humana Commercial	$22,267.26
Rate for Payer: Humana Medicare Advantage	$11,133.63

Know your out-of-pocket cost for care.

All Charges