Madison Medical Center

All Charges

Charge

Type

Setting

Price

PHENYTOIN 250MG INJ 5ML SDV

Facility

$62.00

Service Code	HCPCS Q2009
Hospital Charge Code	2697045
Hospital Revenue Code	250
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$44.27
Rate for Payer: Aetna Medicare Advantage	$0.67
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: Cash Price	$55.80
Rate for Payer: Cigna Commercial HMO & PPO	$0.67
Rate for Payer: Home State Health Plan Medicare Advantage	$0.67
Rate for Payer: Humana Commercial	$1.34
Rate for Payer: Humana Medicare Advantage	$0.67
Rate for Payer: UnitedHealthcare Commercial	$41.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$22.32

PHENYTOIN 250MG INJ 5ML SDV

Facility

$62.00

Service Code	HCPCS Q2009
Hospital Charge Code	2697045
Hospital Revenue Code	250
Rate for Payer: Cash Price	$55.80

PHENYTOIN (DILANTIN) 100MG/2ML INJ

Facility

$63.00

Service Code	HCPCS J1165
Hospital Charge Code	2626461
Hospital Revenue Code	250
Rate for Payer: Cash Price	$56.70

PHENYTOIN (DILANTIN) 100MG/2ML INJ

Facility

$63.00

Service Code	HCPCS J1165
Hospital Charge Code	2626461
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

PHENYTOIN (DILANTIN) 100MG ER CAP

Facility

$18.00

Service Code	NDC 904618761
Hospital Charge Code	2655880
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.20

PHENYTOIN (DILANTIN) 100MG ER CAP

Facility

$18.00

Service Code	NDC 904618761
Hospital Charge Code	2655880
Hospital Revenue Code	250
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$12.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$10.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$12.85
Rate for Payer: Cash Price	$16.20
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.48

PHENYTOIN (DILANTIN) 100MG ER CAP EMP

Facility

$18.00

Service Code	NDC 6.5162E+10
Hospital Charge Code	2622746
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.20

PHENYTOIN (DILANTIN) 100MG ER CAP EMP

Facility

$18.00

Service Code	NDC 6.5162E+10
Hospital Charge Code	2622746
Hospital Revenue Code	250
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$12.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$10.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$12.85
Rate for Payer: Cash Price	$16.20
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.48

PHENYTOIN (DILANTIN) 50MG TAB

Facility

$18.00

Service Code	NDC 71000724
Hospital Charge Code	2655882
Hospital Revenue Code	250
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$12.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$10.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$12.85
Rate for Payer: Cash Price	$16.20
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.48

PHENYTOIN (DILANTIN) 50MG TAB

Facility

$18.00

Service Code	NDC 71000724
Hospital Charge Code	2655882
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.20

PHENYTOIN FREE

Facility

$131.00

Service Code	CPT 80186
Hospital Charge Code	2280186
Hospital Revenue Code	301
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$93.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$12.38
Rate for Payer: Aetna Medicare Advantage	$13.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$77.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$93.53
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cigna Commercial HMO & PPO	$13.76
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$12.38
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13.25
Rate for Payer: Home State Health Plan Medicare Advantage	$13.76
Rate for Payer: Humana Commercial	$27.52
Rate for Payer: Humana Medicare Advantage	$13.76
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$12.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$47.16

PHENYTOIN FREE

Facility

$131.00

Service Code	CPT 80186
Hospital Charge Code	2280186
Hospital Revenue Code	301
Rate for Payer: Cash Price	$117.90

PHENYTOIN-LABCORP

Facility

$155.00

Service Code	CPT 80185
Hospital Charge Code	224300
Hospital Revenue Code	301
Min. Negotiated Rate	$11.93
Max. Negotiated Rate	$110.67
Rate for Payer: Aetna Better Health Medicaid/QHP	$11.93
Rate for Payer: Aetna Medicare Advantage	$13.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$91.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$110.67
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cigna Commercial HMO & PPO	$13.25
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$11.93
Rate for Payer: Home State Health Plan Medicaid Managed Care	$12.77
Rate for Payer: Home State Health Plan Medicare Advantage	$13.25
Rate for Payer: Humana Commercial	$26.50
Rate for Payer: Humana Medicare Advantage	$13.25
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$11.93
Rate for Payer: UnitedHealthcare Medicare Advantage	$55.80

PHENYTOIN-LABCORP

Facility

$155.00

Service Code	CPT 80185
Hospital Charge Code	224300
Hospital Revenue Code	301
Rate for Payer: Cash Price	$139.50

PH FLUIDS

Facility

$40.00

Service Code	CPT 83986
Hospital Charge Code	2283986
Hospital Revenue Code	301
Rate for Payer: Cash Price	$36.00

PH FLUIDS

Facility

$40.00

Service Code	CPT 83986
Hospital Charge Code	2283986
Hospital Revenue Code	301
Min. Negotiated Rate	$3.22
Max. Negotiated Rate	$28.56
Rate for Payer: Aetna Better Health Medicaid/QHP	$3.22
Rate for Payer: Aetna Medicare Advantage	$3.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$28.56
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial HMO & PPO	$3.58
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$3.22
Rate for Payer: Home State Health Plan Medicaid Managed Care	$3.45
Rate for Payer: Home State Health Plan Medicare Advantage	$3.58
Rate for Payer: Humana Commercial	$7.16
Rate for Payer: Humana Medicare Advantage	$3.58
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$3.22
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.40

PHISOHEX WASH

Facility

$62.00

Hospital Charge Code	2816530
Hospital Revenue Code	271
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

PHISOHEX WASH

Facility

$62.00

Hospital Charge Code	2816530
Hospital Revenue Code	271
Rate for Payer: Cash Price	$55.80

PHLEBOTOMY, THERAPEUTIC

Facility

$18.00

Service Code	CPT 99195
Hospital Charge Code	4499195
Hospital Revenue Code	250
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$271.86
Rate for Payer: Aetna Better Health Medicaid/QHP	$119.94
Rate for Payer: Aetna Medicare Advantage	$135.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$10.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$12.85
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial HMO & PPO	$135.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$119.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$128.34
Rate for Payer: Home State Health Plan Medicare Advantage	$135.93
Rate for Payer: Humana Commercial	$271.86
Rate for Payer: Humana Medicare Advantage	$135.93
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.48

PHLEBOTOMY, THERAPEUTIC

Facility

$18.00

Service Code	CPT 99195
Hospital Charge Code	4499195
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.20

PHLEBOTOMY THERAPUTIC

Facility

$452.00

Service Code	CPT 99195
Hospital Charge Code	2299195
Hospital Revenue Code	300
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$322.73
Rate for Payer: Aetna Better Health Medicaid/QHP	$119.94
Rate for Payer: Aetna Medicare Advantage	$135.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$267.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$322.73
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cigna Commercial HMO & PPO	$135.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$119.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$128.34
Rate for Payer: Home State Health Plan Medicare Advantage	$135.93
Rate for Payer: Humana Commercial	$271.86
Rate for Payer: Humana Medicare Advantage	$135.93
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$162.72

PHLEBOTOMY THERAPUTIC

Facility

$452.00

Service Code	CPT 99195
Hospital Charge Code	2299195
Hospital Revenue Code	300
Rate for Payer: Cash Price	$406.80

.PHOSPHATIDYLETHANOLAMINE IGG

Facility

$174.00

Service Code	CPT 86148
Hospital Charge Code	2286142
Hospital Revenue Code	301
Rate for Payer: Cash Price	$156.60

.PHOSPHATIDYLETHANOLAMINE IGG

Facility

$174.00

Service Code	CPT 86148
Hospital Charge Code	2286142
Hospital Revenue Code	301
Min. Negotiated Rate	$14.46
Max. Negotiated Rate	$124.24
Rate for Payer: Aetna Better Health Medicaid/QHP	$14.46
Rate for Payer: Aetna Medicare Advantage	$16.07
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$103.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$124.24
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cigna Commercial HMO & PPO	$16.07
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14.46
Rate for Payer: Home State Health Plan Medicaid Managed Care	$15.47
Rate for Payer: Home State Health Plan Medicare Advantage	$16.07
Rate for Payer: Humana Commercial	$32.14
Rate for Payer: Humana Medicare Advantage	$16.07
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$62.64

.PHOSPHATIDYLETHANOLAMINE IGM

Facility

$174.00

Service Code	CPT 86148
Hospital Charge Code	2286144
Hospital Revenue Code	301
Min. Negotiated Rate	$14.46
Max. Negotiated Rate	$124.24
Rate for Payer: Aetna Better Health Medicaid/QHP	$14.46
Rate for Payer: Aetna Medicare Advantage	$16.07
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$103.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$124.24
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cigna Commercial HMO & PPO	$16.07
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14.46
Rate for Payer: Home State Health Plan Medicaid Managed Care	$15.47
Rate for Payer: Home State Health Plan Medicare Advantage	$16.07
Rate for Payer: Humana Commercial	$32.14
Rate for Payer: Humana Medicare Advantage	$16.07
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$62.64

Know your out-of-pocket cost for care.

All Charges