Madison Medical Center

All Charges

Charge

Type

Setting

Price

GABAPENTIN 800MG TAB EMP

Facility

$21.00

Service Code	NDC 5.0228E+10
Hospital Charge Code	2621384
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

GABAPENTIN (NEURONTIN) 100MG CAP

Facility

$20.00

Service Code	NDC 6.8084E+10
Hospital Charge Code	2626280
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

GABAPENTIN (NEURONTIN) 100MG CAP

Facility

$20.00

Service Code	NDC 6.8084E+10
Hospital Charge Code	2626280
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

GABAPENTIN (NEURONTIN) 300MG CAP

Facility

$21.00

Service Code	NDC 4.9483E+10
Hospital Charge Code	2626304
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

GABAPENTIN (NEURONTIN) 300MG CAP

Facility

$21.00

Service Code	NDC 4.9483E+10
Hospital Charge Code	2626304
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

GABAPENTIN (NEURONTIN) 300MG CAP EMP

Facility

$21.00

Service Code	NDC 71080524
Hospital Charge Code	2697213
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

GABAPENTIN (NEURONTIN) 300MG CAP EMP

Facility

$21.00

Service Code	NDC 71080524
Hospital Charge Code	2697213
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

GABAPENTIN (NEURONTIN) 600MG TAB

Facility

$21.00

Service Code	NDC 904682361
Hospital Charge Code	2626554
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

GABAPENTIN (NEURONTIN) 600MG TAB

Facility

$21.00

Service Code	NDC 904682361
Hospital Charge Code	2626554
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

GABAPENTIN ORAL SOL 250MG 5ML

Facility

$18.00

Service Code	NDC 1E+11
Hospital Charge Code	2619353
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.20

GABAPENTIN ORAL SOL 250MG 5ML

Facility

$18.00

Service Code	NDC 1E+11
Hospital Charge Code	2619353
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

GAD65

Facility

$321.00

Service Code	CPT 86341
Hospital Charge Code	2283519
Hospital Revenue Code	301
Rate for Payer: Cash Price	$288.90

GAD65

Facility

$321.00

Service Code	CPT 86341
Hospital Charge Code	2283519
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$229.19
Rate for Payer: Aetna Better Health Medicaid/QHP	$21.21
Rate for Payer: Aetna Medicare Advantage	$23.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$190.03
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$229.19
Rate for Payer: Cash Price	$288.90
Rate for Payer: Cash Price	$288.90
Rate for Payer: Cash Price	$288.90
Rate for Payer: Cigna Commercial HMO & PPO	$23.57
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$21.21
Rate for Payer: Home State Health Plan Medicaid Managed Care	$22.69
Rate for Payer: Home State Health Plan Medicare Advantage	$23.57
Rate for Payer: Humana Commercial	$47.14
Rate for Payer: Humana Medicare Advantage	$23.57
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$21.21
Rate for Payer: UnitedHealthcare Medicare Advantage	$115.56

GALACTOGRAM SINGLE DIRECT

Facility

$391.00

Service Code	CPT 76086
Hospital Charge Code	3776086
Hospital Revenue Code	401
Min. Negotiated Rate	$111.00
Max. Negotiated Rate	$279.17
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$231.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$279.17
Rate for Payer: Cash Price	$351.90
Rate for Payer: Cash Price	$351.90
Rate for Payer: UnitedHealthcare Commercial	$111.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$140.76

GALACTOGRAM SINGLE DIRECT

Facility

$391.00

Service Code	CPT 76086
Hospital Charge Code	3776086
Hospital Revenue Code	401
Rate for Payer: Cash Price	$351.90

GALANTAMINE (RAZADYNE) ER 16MG TAB

Facility

$40.00

Service Code	NDC 591349730
Hospital Charge Code	2626521
Hospital Revenue Code	250
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$28.56
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: UnitedHealthcare Commercial	$26.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.40

GALANTAMINE (RAZADYNE) ER 16MG TAB

Facility

$40.00

Service Code	NDC 591349730
Hospital Charge Code	2626521
Hospital Revenue Code	250
Rate for Payer: Cash Price	$36.00

GALECTIN-3

Facility

$300.00

Service Code	CPT 82777
Hospital Charge Code	2282777
Hospital Revenue Code	301
Rate for Payer: Cash Price	$270.00

GALECTIN-3

Facility

$300.00

Service Code	CPT 82777
Hospital Charge Code	2282777
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$214.20
Rate for Payer: Humana Commercial	$88.50
Rate for Payer: Aetna Better Health Medicaid/QHP	$39.83
Rate for Payer: Aetna Medicare Advantage	$44.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$177.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$214.20
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial HMO & PPO	$44.25
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$39.83
Rate for Payer: Home State Health Plan Medicaid Managed Care	$42.62
Rate for Payer: Home State Health Plan Medicare Advantage	$44.25
Rate for Payer: Humana Medicare Advantage	$44.25
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$39.83
Rate for Payer: UnitedHealthcare Medicare Advantage	$108.00

GASTRECTOMY,PART W/ESOPAGOENTEROSTOMY

Professional

Both

$3,337.00

Service Code	CPT 43631
Hospital Charge Code	4143631
Hospital Revenue Code	975
Min. Negotiated Rate	$1,096.35
Max. Negotiated Rate	$1,301.78
Rate for Payer: Aetna Commercial/Medicare Advantage	$1,301.78
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$1,096.35
Rate for Payer: Cash Price	$3,003.30
Rate for Payer: Cash Price	$3,003.30
Rate for Payer: Cigna Commercial HMO & PPO	$1,301.78
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,096.35
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,205.98
Rate for Payer: Home State Health Plan Medicare Advantage	$1,301.78
Rate for Payer: Optum Medicare Advantage	$1,167.95
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,096.35

GASTRECTOMY,PART W/GASTROIEJEJUNOSTOMY

Professional

Both

$3,683.00

Service Code	CPT 43632
Hospital Charge Code	4143632
Hospital Revenue Code	975
Min. Negotiated Rate	$1,289.05
Max. Negotiated Rate	$1,807.18
Rate for Payer: Aetna Commercial/Medicare Advantage	$1,807.18
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$1,535.46
Rate for Payer: Cash Price	$3,314.70
Rate for Payer: Cash Price	$3,314.70
Rate for Payer: Cigna Commercial HMO & PPO	$1,807.18
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,535.46
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,689.01
Rate for Payer: Home State Health Plan Medicare Advantage	$1,807.18
Rate for Payer: Optum Medicare Advantage	$1,289.05
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,535.46

GASTRECTOMY,PART W/ROUX-EN-Y RECONSTRUCT

Professional

Both

$4,287.00

Service Code	CPT 43633
Hospital Charge Code	4143633
Hospital Revenue Code	975
Min. Negotiated Rate	$1,451.79
Max. Negotiated Rate	$1,710.49
Rate for Payer: Aetna Commercial/Medicare Advantage	$1,710.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$1,451.79
Rate for Payer: Cash Price	$3,858.30
Rate for Payer: Cash Price	$3,858.30
Rate for Payer: Cigna Commercial HMO & PPO	$1,710.49
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,451.79
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,596.97
Rate for Payer: Home State Health Plan Medicare Advantage	$1,710.49
Rate for Payer: Optum Medicare Advantage	$1,500.45
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,451.79

GASTRECTOMY,TEMPORARY

Professional

Both

$1,786.00

Service Code	CPT 43830
Hospital Charge Code	4143830
Hospital Revenue Code	975
Min. Negotiated Rate	$533.57
Max. Negotiated Rate	$641.53
Rate for Payer: Aetna Commercial/Medicare Advantage	$641.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$533.57
Rate for Payer: Cash Price	$1,607.40
Rate for Payer: Cash Price	$1,607.40
Rate for Payer: Cigna Commercial HMO & PPO	$641.53
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$533.57
Rate for Payer: Home State Health Plan Medicaid Managed Care	$586.93
Rate for Payer: Home State Health Plan Medicare Advantage	$641.53
Rate for Payer: Optum Medicare Advantage	$625.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$533.57

GASTRECTOMY,TOTAL W/ESOPAGOENTEROSTOMY

Professional

Both

$4,879.00

Service Code	CPT 43620
Hospital Charge Code	4143620
Hospital Revenue Code	975
Min. Negotiated Rate	$1,500.14
Max. Negotiated Rate	$1,767.47
Rate for Payer: Aetna Commercial/Medicare Advantage	$1,767.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$1,500.14
Rate for Payer: Cash Price	$4,391.10
Rate for Payer: Cash Price	$4,391.10
Rate for Payer: Cigna Commercial HMO & PPO	$1,767.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,500.14
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,650.15
Rate for Payer: Home State Health Plan Medicare Advantage	$1,767.47
Rate for Payer: Optum Medicare Advantage	$1,707.65
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,500.14

GASTRIC FUNDOPLICATION

Facility

$38,455.37

Service Code	APR-DRG 2324
Min. Negotiated Rate	$38,455.37
Max. Negotiated Rate	$38,455.37
Rate for Payer: Aetna Better Health Medicaid/QHP	$38,455.37
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$38,455.37
Rate for Payer: Home State Health Plan Medicaid Managed Care	$38,455.37
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$38,455.37

Know your out-of-pocket cost for care.

All Charges