Madison Medical Center

All Charges

Charge

Type

Setting

Price

KETAMINE 500MG INJ 10ML VIAL C3

Facility

$192.00

Service Code	NDC 143950801
Hospital Charge Code	2624303
Hospital Revenue Code	250
Rate for Payer: Cash Price	$172.80

KETAMINE 500MG INJ 10ML VIAL C3

Facility

$192.00

Service Code	NDC 143950801
Hospital Charge Code	2624303
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

KETAMINE 500MG INJ 5ML VIAL C3

Facility

$192.00

Service Code	NDC 6.5219E+10
Hospital Charge Code	2627123
Hospital Revenue Code	250
Rate for Payer: Cash Price	$172.80

KETAMINE 500MG INJ 5ML VIAL C3

Facility

$192.00

Service Code	NDC 6.5219E+10
Hospital Charge Code	2627123
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

KETAMINE INJ.

Facility

$48.00

Hospital Charge Code	209774
Hospital Revenue Code	370
Rate for Payer: Cash Price	$43.20

KETAMINE INJ.

Facility

$48.00

Hospital Charge Code	209774
Hospital Revenue Code	370
Min. Negotiated Rate	$17.28
Max. Negotiated Rate	$34.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$28.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$34.27
Rate for Payer: Cash Price	$43.20
Rate for Payer: UnitedHealthcare Commercial	$32.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.28

KETOCONAZOLE 2% CRM 15GM EMP

Facility

$221.00

Service Code	NDC 5.4868E+10
Hospital Charge Code	2655727
Hospital Revenue Code	250
Min. Negotiated Rate	$79.56
Max. Negotiated Rate	$157.79
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$130.83
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$157.79
Rate for Payer: Cash Price	$198.90
Rate for Payer: UnitedHealthcare Commercial	$147.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$79.56

KETOCONAZOLE 2% CRM 15GM EMP

Facility

$221.00

Service Code	NDC 5.4868E+10
Hospital Charge Code	2655727
Hospital Revenue Code	250
Rate for Payer: Cash Price	$198.90

KETOCONAZOLE 2% CRM 30GM EMP

Facility

$221.00

Service Code	NDC 2.1922E+10
Hospital Charge Code	2624836
Hospital Revenue Code	250
Rate for Payer: Cash Price	$198.90

KETOCONAZOLE 2% CRM 30GM EMP

Facility

$221.00

Service Code	NDC 2.1922E+10
Hospital Charge Code	2624836
Hospital Revenue Code	250
Min. Negotiated Rate	$79.56
Max. Negotiated Rate	$157.79
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$130.83
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$157.79
Rate for Payer: Cash Price	$198.90
Rate for Payer: UnitedHealthcare Commercial	$147.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$79.56

KETOCONAZOLE SHAMPOO 2% 4OZ EMP

Facility

$47.00

Service Code	NDC 4.5802E+10
Hospital Charge Code	2624258
Hospital Revenue Code	250
Rate for Payer: Cash Price	$42.30

KETOCONAZOLE SHAMPOO 2% 4OZ EMP

Facility

$47.00

Service Code	NDC 4.5802E+10
Hospital Charge Code	2624258
Hospital Revenue Code	250
Min. Negotiated Rate	$16.92
Max. Negotiated Rate	$33.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$27.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$33.56
Rate for Payer: Cash Price	$42.30
Rate for Payer: UnitedHealthcare Commercial	$31.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.92

KETO DIASTIX

Facility

$89.00

Hospital Charge Code	2811295
Hospital Revenue Code	271
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$63.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$52.69
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$63.55
Rate for Payer: Cash Price	$80.10
Rate for Payer: UnitedHealthcare Commercial	$59.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$32.04

KETO DIASTIX

Facility

$89.00

Hospital Charge Code	2811295
Hospital Revenue Code	271
Rate for Payer: Cash Price	$80.10

KETOROLAC 0.5% OP SOL 10ML EMP

Facility

$499.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2622249
Hospital Revenue Code	250
Min. Negotiated Rate	$179.64
Max. Negotiated Rate	$356.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$295.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$356.29
Rate for Payer: Cash Price	$449.10
Rate for Payer: UnitedHealthcare Commercial	$332.83
Rate for Payer: UnitedHealthcare Medicare Advantage	$179.64

KETOROLAC 0.5% OP SOL 10ML EMP

Facility

$499.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2622249
Hospital Revenue Code	250
Rate for Payer: Cash Price	$449.10

KETOROLAC 0.5% OP SOL 5ML EMP

Facility

$499.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2622691
Hospital Revenue Code	250
Min. Negotiated Rate	$179.64
Max. Negotiated Rate	$356.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$295.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$356.29
Rate for Payer: Cash Price	$449.10
Rate for Payer: UnitedHealthcare Commercial	$332.83
Rate for Payer: UnitedHealthcare Medicare Advantage	$179.64

KETOROLAC 0.5% OP SOL 5ML EMP

Facility

$499.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2622691
Hospital Revenue Code	250
Rate for Payer: Cash Price	$449.10

KETOROLAC 30MG/ML 1ML INJ (IV OR IM)

Facility

$127.00

Service Code	HCPCS J1885
Hospital Charge Code	2626332
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$90.68
Rate for Payer: Aetna Medicare Advantage	$0.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$75.18
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$90.68
Rate for Payer: Cash Price	$114.30
Rate for Payer: Cash Price	$114.30
Rate for Payer: Cigna Commercial HMO & PPO	$0.29
Rate for Payer: Home State Health Plan Medicare Advantage	$0.29
Rate for Payer: Humana Commercial	$0.58
Rate for Payer: Humana Medicare Advantage	$0.29
Rate for Payer: UnitedHealthcare Commercial	$84.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.72

KETOROLAC 30MG/ML 1ML INJ (IV OR IM)

Facility

$127.00

Service Code	HCPCS J1885
Hospital Charge Code	2626332
Hospital Revenue Code	250
Rate for Payer: Cash Price	$114.30

KETOROLAC 60MG/2ML INJ (IM)

Facility

$161.00

Service Code	HCPCS J1885
Hospital Charge Code	2656422
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$114.95
Rate for Payer: Aetna Medicare Advantage	$0.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$95.31
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$114.95
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cigna Commercial HMO & PPO	$0.29
Rate for Payer: Home State Health Plan Medicare Advantage	$0.29
Rate for Payer: Humana Commercial	$0.58
Rate for Payer: Humana Medicare Advantage	$0.29
Rate for Payer: UnitedHealthcare Commercial	$107.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$57.96

KETOROLAC 60MG/2ML INJ (IM)

Facility

$161.00

Service Code	HCPCS J1885
Hospital Charge Code	2656422
Hospital Revenue Code	250
Rate for Payer: Cash Price	$144.90

KETOROLAC 60MG/2ML INJ (IM) EMP

Facility

$161.00

Service Code	HCPCS J1885
Hospital Charge Code	2627124
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$114.95
Rate for Payer: Aetna Medicare Advantage	$0.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$95.31
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$114.95
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cigna Commercial HMO & PPO	$0.29
Rate for Payer: Home State Health Plan Medicare Advantage	$0.29
Rate for Payer: Humana Commercial	$0.58
Rate for Payer: Humana Medicare Advantage	$0.29
Rate for Payer: UnitedHealthcare Commercial	$107.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$57.96

KETOROLAC 60MG/2ML INJ (IM) EMP

Facility

$161.00

Service Code	HCPCS J1885
Hospital Charge Code	2627124
Hospital Revenue Code	250
Rate for Payer: Cash Price	$144.90

KETOROLAC (TORADOL) 15MG/ML 1 ML INJ SDV

Facility

$100.00

Service Code	HCPCS J1885
Hospital Charge Code	2626333
Hospital Revenue Code	250
Rate for Payer: Cash Price	$90.00

Know your out-of-pocket cost for care.

All Charges