Madison Medical Center

All Charges

Charge

Type

Setting

Price

LORAZEPAM 2MG/ML INJ PFS C4

Facility

$223.00

Service Code	HCPCS J2060
Hospital Charge Code	2626868
Hospital Revenue Code	250
Min. Negotiated Rate	$80.28
Max. Negotiated Rate	$159.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$132.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$159.22
Rate for Payer: Cash Price	$200.70
Rate for Payer: UnitedHealthcare Commercial	$148.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$80.28

LORAZEPAM 2MG/ML ORAL SOL 30ML C4

Facility

$195.00

Service Code	NDC 54353244
Hospital Charge Code	2697042
Hospital Revenue Code	250
Rate for Payer: Cash Price	$175.50

LORAZEPAM 2MG/ML ORAL SOL 30ML C4

Facility

$195.00

Service Code	NDC 54353244
Hospital Charge Code	2697042
Hospital Revenue Code	250
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$139.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$115.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$139.23
Rate for Payer: Cash Price	$175.50
Rate for Payer: UnitedHealthcare Commercial	$130.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$70.20

LORAZEPAM 2MG TAB EMP C4

Facility

$21.00

Service Code	NDC 1.3107E+10
Hospital Charge Code	2624237
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

LORAZEPAM 2MG TAB EMP C4

Facility

$21.00

Service Code	NDC 1.3107E+10
Hospital Charge Code	2624237
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

LORAZEPAM 4MG/ML INJ 10ML MDV C4

Facility

$223.00

Service Code	HCPCS J2060
Hospital Charge Code	2626118
Hospital Revenue Code	250
Rate for Payer: Cash Price	$200.70

LORAZEPAM 4MG/ML INJ 10ML MDV C4

Facility

$223.00

Service Code	HCPCS J2060
Hospital Charge Code	2626118
Hospital Revenue Code	250
Min. Negotiated Rate	$80.28
Max. Negotiated Rate	$159.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$132.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$159.22
Rate for Payer: Cash Price	$200.70
Rate for Payer: UnitedHealthcare Commercial	$148.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$80.28

LORAZEPAM 4MG/ML INJ 1ML SDV C4

Facility

$223.00

Service Code	HCPCS J2060
Hospital Charge Code	2626900
Hospital Revenue Code	250
Min. Negotiated Rate	$80.28
Max. Negotiated Rate	$159.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$132.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$159.22
Rate for Payer: Cash Price	$200.70
Rate for Payer: UnitedHealthcare Commercial	$148.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$80.28

LORAZEPAM 4MG/ML INJ 1ML SDV C4

Facility

$223.00

Service Code	HCPCS J2060
Hospital Charge Code	2626900
Hospital Revenue Code	250
Rate for Payer: Cash Price	$200.70

LORAZEPAM (ATIVAN) 0.5MG TAB C4

Facility

$20.00

Service Code	NDC 6.0687E+10
Hospital Charge Code	2655445
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

LORAZEPAM (ATIVAN) 0.5MG TAB C4

Facility

$20.00

Service Code	NDC 6.0687E+10
Hospital Charge Code	2655445
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

LORAZEPAM (ATIVAN) 2MG INJ 1ML C4

Facility

$223.00

Service Code	HCPCS J2060
Hospital Charge Code	2654252
Hospital Revenue Code	250
Min. Negotiated Rate	$80.28
Max. Negotiated Rate	$159.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$132.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$159.22
Rate for Payer: Cash Price	$200.70
Rate for Payer: UnitedHealthcare Commercial	$148.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$80.28

LORAZEPAM (ATIVAN) 2MG INJ 1ML C4

Facility

$223.00

Service Code	HCPCS J2060
Hospital Charge Code	2654252
Hospital Revenue Code	250
Rate for Payer: Cash Price	$200.70

LOSARTAN 100MG TAB EMP

Facility

$21.00

Service Code	NDC 93736598
Hospital Charge Code	2622096
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

LOSARTAN 100MG TAB EMP

Facility

$21.00

Service Code	NDC 93736598
Hospital Charge Code	2622096
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

LOSARTAN 50MG TAB EMP

Facility

$21.00

Service Code	NDC 93736598
Hospital Charge Code	2697378
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

LOSARTAN 50MG TAB EMP

Facility

$21.00

Service Code	NDC 93736598
Hospital Charge Code	2697378
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

LOSARTAN (COZAAR) 100MG TAB

Facility

$24.00

Service Code	NDC 3.1722E+10
Hospital Charge Code	2626576
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

LOSARTAN (COZAAR) 100MG TAB

Facility

$24.00

Service Code	NDC 3.1722E+10
Hospital Charge Code	2626576
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$17.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.14
Rate for Payer: Cash Price	$21.60
Rate for Payer: UnitedHealthcare Commercial	$16.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.64

LOSARTAN (COZAAR) 25MG TAB

Facility

$21.00

Service Code	NDC 6.8382E+10
Hospital Charge Code	2626260
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

LOSARTAN (COZAAR) 25MG TAB

Facility

$21.00

Service Code	NDC 6.8382E+10
Hospital Charge Code	2626260
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

LOSARTAN (COZAAR) 25MG TAB EMP

Facility

$21.00

Service Code	NDC 6.2332E+10
Hospital Charge Code	2622367
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

LOSARTAN (COZAAR) 25MG TAB EMP

Facility

$21.00

Service Code	NDC 6.2332E+10
Hospital Charge Code	2622367
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

LOSARTAN (COZAAR) 50MG TAB EMP

Facility

$21.00

Service Code	NDC 3.1722E+10
Hospital Charge Code	2623659
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

LOSARTAN (COZAAR) 50MG TAB EMP

Facility

$21.00

Service Code	NDC 3.1722E+10
Hospital Charge Code	2623659
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

Know your out-of-pocket cost for care.

All Charges