Madison Medical Center

All Charges

Charge

Type

Setting

Price

OMEPRAZOLE (PRILOSEC) 20MG CAP

Facility

$62.00

Service Code	NDC 904691761
Hospital Charge Code	2655442
Hospital Revenue Code	250
Min. Negotiated Rate	$22.32
Max. Negotiated Rate	$44.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$36.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$44.27
Rate for Payer: Cash Price	$55.80
Rate for Payer: UnitedHealthcare Commercial	$41.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$22.32

OMEPRAZOLE (PRILOSEC) 20MG CAP EMP

Facility

$20.00

Service Code	NDC 6.2175E+10
Hospital Charge Code	2697211
Hospital Revenue Code	250
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$14.28
Rate for Payer: UnitedHealthcare Commercial	$13.34
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 Medicare Advantage	$7.20

OMEPRAZOLE (PRILOSEC) 20MG CAP EMP

Facility

$20.00

Service Code	NDC 6.2175E+10
Hospital Charge Code	2697211
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

ONABOTULINUMTOXINA 100U VIAL INJECTION

Facility

$2,608.00

Service Code	NDC 23114501
Hospital Charge Code	2625010
Hospital Revenue Code	335
Min. Negotiated Rate	$938.88
Max. Negotiated Rate	$1,862.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,543.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,862.11
Rate for Payer: Cash Price	$2,347.20
Rate for Payer: UnitedHealthcare Commercial	$1,739.54
Rate for Payer: UnitedHealthcare Medicare Advantage	$938.88

ONABOTULINUMTOXINA 100U VIAL INJECTION

Facility

$2,608.00

Service Code	NDC 23114501
Hospital Charge Code	2625010
Hospital Revenue Code	335
Rate for Payer: Cash Price	$2,347.20

ONABOTULINUMTOXINA 200U VIAL INJECTION

Facility

$12,373.00

Service Code	NDC 23392102
Hospital Charge Code	2698105
Hospital Revenue Code	335
Rate for Payer: Cash Price	$11,135.70

ONABOTULINUMTOXINA 200U VIAL INJECTION

Facility

$12,373.00

Service Code	NDC 23392102
Hospital Charge Code	2698105
Hospital Revenue Code	335
Min. Negotiated Rate	$4,454.28
Max. Negotiated Rate	$8,834.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7,324.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$8,834.32
Rate for Payer: Cash Price	$11,135.70
Rate for Payer: UnitedHealthcare Commercial	$8,252.79
Rate for Payer: UnitedHealthcare Medicare Advantage	$4,454.28

ONDANSETRON (ZOFRAN) 4MG/2ML VL INJ

Facility

$221.00

Service Code	HCPCS J2405
Hospital Charge Code	2656029
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

ONDANSETRON (ZOFRAN) 4MG/2ML VL INJ

Facility

$221.00

Service Code	HCPCS J2405
Hospital Charge Code	2656029
Hospital Revenue Code	250
Rate for Payer: Cash Price	$198.90

ONDANSETRON (ZOFRAN) 4MG ODT

Facility

$127.00

Service Code	HCPCS Q0162
Hospital Charge Code	2697199
Hospital Revenue Code	250
Rate for Payer: Cash Price	$114.30

ONDANSETRON (ZOFRAN) 4MG ODT

Facility

$127.00

Service Code	HCPCS Q0162
Hospital Charge Code	2697199
Hospital Revenue Code	250
Min. Negotiated Rate	$45.72
Max. Negotiated Rate	$90.68
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: UnitedHealthcare Commercial	$84.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.72

ONDANSETRON (ZOFRAN) 4MG ODT EMP

Facility

$127.00

Service Code	HCPCS Q0162
Hospital Charge Code	2623570
Hospital Revenue Code	250
Rate for Payer: Cash Price	$114.30

ONDANSETRON (ZOFRAN) 4MG ODT EMP

Facility

$127.00

Service Code	HCPCS Q0162
Hospital Charge Code	2623570
Hospital Revenue Code	250
Min. Negotiated Rate	$45.72
Max. Negotiated Rate	$90.68
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: UnitedHealthcare Commercial	$84.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.72

ONDANSETRON (ZOFRAN) 4MG ORAL SOL 5ML

Facility

$165.00

Service Code	NDC 54006447
Hospital Charge Code	2626354
Hospital Revenue Code	250
Rate for Payer: Cash Price	$148.50

ONDANSETRON (ZOFRAN) 4MG ORAL SOL 5ML

Facility

$165.00

Service Code	NDC 54006447
Hospital Charge Code	2626354
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

ONDANSETRON (ZOFRAN) 4MG TAB

Facility

$125.00

Service Code	NDC 5.7237E+10
Hospital Charge Code	2626285
Hospital Revenue Code	250
Rate for Payer: Cash Price	$112.50

ONDANSETRON (ZOFRAN) 4MG TAB

Facility

$125.00

Service Code	NDC 5.7237E+10
Hospital Charge Code	2626285
Hospital Revenue Code	250
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$89.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$74.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$89.25
Rate for Payer: Cash Price	$112.50
Rate for Payer: UnitedHealthcare Commercial	$83.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.00

ONDANSETRON (ZOFRAN) 4MG TAB EMP

Facility

$125.00

Service Code	NDC 5.5111E+10
Hospital Charge Code	2622812
Hospital Revenue Code	250
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$89.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$74.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$89.25
Rate for Payer: Cash Price	$112.50
Rate for Payer: UnitedHealthcare Commercial	$83.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.00

ONDANSETRON (ZOFRAN) 4MG TAB EMP

Facility

$125.00

Service Code	NDC 5.5111E+10
Hospital Charge Code	2622812
Hospital Revenue Code	250
Rate for Payer: Cash Price	$112.50

ONDANSETRON (ZOFRAN) 8MG TAB EMP

Facility

$125.00

Service Code	NDC 6.5862E+10
Hospital Charge Code	2622842
Hospital Revenue Code	250
Rate for Payer: Cash Price	$112.50

ONDANSETRON (ZOFRAN) 8MG TAB EMP

Facility

$125.00

Service Code	NDC 6.5862E+10
Hospital Charge Code	2622842
Hospital Revenue Code	250
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$89.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$74.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$89.25
Rate for Payer: Cash Price	$112.50
Rate for Payer: UnitedHealthcare Commercial	$83.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.00

ONDANSETRON (ZOFRAN) 8MG TAB EMP

Facility

$125.00

Service Code	NDC 5.5111E+10
Hospital Charge Code	2623310
Hospital Revenue Code	250
Rate for Payer: Cash Price	$112.50

ONDANSETRON (ZOFRAN) 8MG TAB EMP

Facility

$125.00

Service Code	NDC 5.5111E+10
Hospital Charge Code	2623310
Hospital Revenue Code	250
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$89.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$74.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$89.25
Rate for Payer: Cash Price	$112.50
Rate for Payer: UnitedHealthcare Commercial	$83.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.00

ONLINE TELEPHONE CONS 11 - 20 MIN

Facility

$150.00

Service Code	CPT 99447
Hospital Charge Code	9899447
Hospital Revenue Code	521
Min. Negotiated Rate	$88.80
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$88.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$107.10
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: UnitedHealthcare Commercial	$100.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

ONLINE TELEPHONE CONS 11 - 20 MIN

Facility

$150.00

Service Code	CPT 99447
Hospital Charge Code	9899447
Hospital Revenue Code	521
Rate for Payer: Cash Price	$135.00

Know your out-of-pocket cost for care.

All Charges