Madison Medical Center

All Charges

Charge

Type

Setting

Price

MIDAZOLAM (VERSED) 2MG INJ 2ML C4

Facility

$185.00

Service Code	HCPCS J2250
Hospital Charge Code	2657169
Hospital Revenue Code	250
Min. Negotiated Rate	$66.60
Max. Negotiated Rate	$132.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$109.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$132.09
Rate for Payer: Cash Price	$166.50
Rate for Payer: UnitedHealthcare Commercial	$123.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$66.60

MIDAZOLAM (VERSED) 2MG INJ 2ML C4

Facility

$185.00

Service Code	HCPCS J2250
Hospital Charge Code	2657169
Hospital Revenue Code	250
Rate for Payer: Cash Price	$166.50

MIDAZOLAM (VERSED) 2MG/ML SYRUP C4

Facility

$20.00

Service Code	NDC 574015004
Hospital Charge Code	2697043
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

MIDAZOLAM (VERSED) 2MG/ML SYRUP C4

Facility

$20.00

Service Code	NDC 574015004
Hospital Charge Code	2697043
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

MIDAZOLAM (VERSED) 50MG INJ 10ML C4

Facility

$185.00

Service Code	HCPCS J2250
Hospital Charge Code	2624304
Hospital Revenue Code	250
Min. Negotiated Rate	$66.60
Max. Negotiated Rate	$132.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$109.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$132.09
Rate for Payer: Cash Price	$166.50
Rate for Payer: UnitedHealthcare Commercial	$123.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$66.60

MIDAZOLAM (VERSED) 50MG INJ 10ML C4

Facility

$185.00

Service Code	HCPCS J2250
Hospital Charge Code	2624304
Hospital Revenue Code	250
Rate for Payer: Cash Price	$166.50

MIDODRINE 10MG TAB EMP

Facility

$24.00

Service Code	NDC 4.9884E+10
Hospital Charge Code	2625523
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

MIDODRINE 10MG TAB EMP

Facility

$24.00

Service Code	NDC 4.9884E+10
Hospital Charge Code	2625523
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

MIDODRINE 2.5MG TAB

Facility

$24.00

Hospital Charge Code	2697381
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

MIDODRINE 2.5MG TAB

Facility

$24.00

Hospital Charge Code	2697381
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

MIDODRINE 5MG TAB EMP

Facility

$24.00

Service Code	NDC 245021211
Hospital Charge Code	2623119
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

MIDODRINE 5MG TAB EMP

Facility

$24.00

Service Code	NDC 245021211
Hospital Charge Code	2623119
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

MIDODRINE 5MG TAB UD

Facility

$24.00

Service Code	NDC 904681806
Hospital Charge Code	2625734
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

MIDODRINE 5MG TAB UD

Facility

$24.00

Service Code	NDC 904681806
Hospital Charge Code	2625734
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

MIGRAINE AND OTHER HEADACHES

Facility

$4,066.03

Service Code	APR-DRG 0541
Min. Negotiated Rate	$4,066.03
Max. Negotiated Rate	$4,066.03
Rate for Payer: Aetna Better Health Medicaid/QHP	$4,066.03
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4,066.03
Rate for Payer: Home State Health Plan Medicaid Managed Care	$4,066.03
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4,066.03

MIGRAINE AND OTHER HEADACHES

Facility

$5,823.55

Service Code	APR-DRG 0542
Min. Negotiated Rate	$5,823.55
Max. Negotiated Rate	$5,823.55
Rate for Payer: Aetna Better Health Medicaid/QHP	$5,823.55
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5,823.55
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5,823.55
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5,823.55

MIGRAINE AND OTHER HEADACHES

Facility

$6,410.61

Service Code	APR-DRG 0543
Min. Negotiated Rate	$6,410.61
Max. Negotiated Rate	$6,410.61
Rate for Payer: Aetna Better Health Medicaid/QHP	$6,410.61
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$6,410.61
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6,410.61
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$6,410.61

MIGRAINE AND OTHER HEADACHES

Facility

$18,293.46

Service Code	APR-DRG 0544
Min. Negotiated Rate	$18,293.46
Max. Negotiated Rate	$18,293.46
Rate for Payer: Aetna Better Health Medicaid/QHP	$18,293.46
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$18,293.46
Rate for Payer: Home State Health Plan Medicaid Managed Care	$18,293.46
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$18,293.46

MILK OF MAGNESIA 30ML

Facility

$20.00

Service Code	NDC 536247085
Hospital Charge Code	2655585
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

MILK OF MAGNESIA 30ML

Facility

$20.00

Service Code	NDC 536247085
Hospital Charge Code	2655585
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

MILNACIPRAN (SAVELLA) 100MG TAB EMP

Facility

$34.00

Service Code	NDC 1E+11
Hospital Charge Code	2622295
Hospital Revenue Code	250
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$24.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$20.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$24.28
Rate for Payer: Cash Price	$30.60
Rate for Payer: UnitedHealthcare Commercial	$22.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.24

MILNACIPRAN (SAVELLA) 100MG TAB EMP

Facility

$34.00

Service Code	NDC 1E+11
Hospital Charge Code	2622295
Hospital Revenue Code	250
Rate for Payer: Cash Price	$30.60

MILNACIPRAN (SAVELLA) 25MG TAB EMP

Facility

$34.00

Service Code	NDC 456151060
Hospital Charge Code	2625884
Hospital Revenue Code	250
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$24.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$20.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$24.28
Rate for Payer: Cash Price	$30.60
Rate for Payer: UnitedHealthcare Commercial	$22.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.24

MILNACIPRAN (SAVELLA) 25MG TAB EMP

Facility

$34.00

Service Code	NDC 456151060
Hospital Charge Code	2625884
Hospital Revenue Code	250
Rate for Payer: Cash Price	$30.60

MILNACIPRAN (SAVELLA) 4 WK TITRTN PK EMP

Facility

$34.00

Service Code	NDC 456150055
Hospital Charge Code	2624579
Hospital Revenue Code	250
Rate for Payer: Cash Price	$30.60

Know your out-of-pocket cost for care.

All Charges