Madison Medical Center

All Charges

Charge

Type

Setting

Price

GC CHLAMYDIA DNA PROBE

Facility

$105.00

Service Code	CPT 87491
Hospital Charge Code	308000
Hospital Revenue Code	306
Rate for Payer: Cash Price	$94.50

GC CULTURE

Facility

$21.00

Service Code	CPT 87081
Hospital Charge Code	5287081
Hospital Revenue Code	521
Min. Negotiated Rate	$5.37
Max. Negotiated Rate	$173.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$5.97
Rate for Payer: Aetna Medicare Advantage	$6.63
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: Cash Price	$18.90
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial HMO & PPO	$6.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5.37
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6.39
Rate for Payer: Home State Health Plan Medicare Advantage	$6.63
Rate for Payer: Humana Commercial	$13.26
Rate for Payer: Humana Medicare Advantage	$6.63
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5.97
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

GC CULTURE

Facility

$21.00

Service Code	CPT 87081
Hospital Charge Code	5287081
Hospital Revenue Code	521
Rate for Payer: Cash Price	$18.90

GELFOAM

Facility

$168.00

Hospital Charge Code	127393
Hospital Revenue Code	271
Min. Negotiated Rate	$60.48
Max. Negotiated Rate	$119.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$99.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$119.95
Rate for Payer: Cash Price	$151.20
Rate for Payer: UnitedHealthcare Commercial	$112.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$60.48

GELFOAM

Facility

$168.00

Hospital Charge Code	127393
Hospital Revenue Code	271
Rate for Payer: Cash Price	$151.20

GEMCITABINE 2GM SUV IV

Facility

$652.00

Service Code	NDC 409018225
Hospital Charge Code	2626068
Hospital Revenue Code	335
Rate for Payer: Cash Price	$586.80

GEMCITABINE 2GM SUV IV

Facility

$652.00

Service Code	NDC 409018225
Hospital Charge Code	2626068
Hospital Revenue Code	335
Min. Negotiated Rate	$234.72
Max. Negotiated Rate	$465.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$385.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$465.53
Rate for Payer: Cash Price	$586.80
Rate for Payer: UnitedHealthcare Commercial	$434.88
Rate for Payer: UnitedHealthcare Medicare Advantage	$234.72

GEMFIBROZIL 600MG TAB EMP

Facility

$28.00

Service Code	NDC 7.5834E+10
Hospital Charge Code	2698467
Hospital Revenue Code	250
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$19.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$16.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.99
Rate for Payer: Cash Price	$25.20
Rate for Payer: UnitedHealthcare Commercial	$18.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.08

GEMFIBROZIL 600MG TAB EMP

Facility

$28.00

Service Code	NDC 7.5834E+10
Hospital Charge Code	2698467
Hospital Revenue Code	250
Rate for Payer: Cash Price	$25.20

GEMFIBROZIL (LOPID) 600MG TABLET

Facility

$28.00

Service Code	NDC 1.6714E+10
Hospital Charge Code	2657132
Hospital Revenue Code	250
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$19.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$16.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.99
Rate for Payer: Cash Price	$25.20
Rate for Payer: UnitedHealthcare Commercial	$18.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.08

GEMFIBROZIL (LOPID) 600MG TABLET

Facility

$28.00

Service Code	NDC 1.6714E+10
Hospital Charge Code	2657132
Hospital Revenue Code	250
Rate for Payer: Cash Price	$25.20

GENDER RELATED PROCEDURES

Facility

$24,274.17

Service Code	APR-DRG 8512
Min. Negotiated Rate	$24,274.17
Max. Negotiated Rate	$24,274.17
Rate for Payer: Aetna Better Health Medicaid/QHP	$24,274.17
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$24,274.17
Rate for Payer: Home State Health Plan Medicaid Managed Care	$24,274.17
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$24,274.17

GENDER RELATED PROCEDURES

Facility

$31,281.10

Service Code	APR-DRG 8513
Min. Negotiated Rate	$31,281.10
Max. Negotiated Rate	$31,281.10
Rate for Payer: Aetna Better Health Medicaid/QHP	$31,281.10
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$31,281.10
Rate for Payer: Home State Health Plan Medicaid Managed Care	$31,281.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$31,281.10

GENDER RELATED PROCEDURES

Facility

$96,305.30

Service Code	APR-DRG 8514
Min. Negotiated Rate	$96,305.30
Max. Negotiated Rate	$96,305.30
Rate for Payer: Aetna Better Health Medicaid/QHP	$96,305.30
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$96,305.30
Rate for Payer: Home State Health Plan Medicaid Managed Care	$96,305.30
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$96,305.30

GENDER RELATED PROCEDURES

Facility

$24,274.17

Service Code	APR-DRG 8511
Min. Negotiated Rate	$24,274.17
Max. Negotiated Rate	$24,274.17
Rate for Payer: Aetna Better Health Medicaid/QHP	$24,274.17
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$24,274.17
Rate for Payer: Home State Health Plan Medicaid Managed Care	$24,274.17
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$24,274.17

GENETIC DISORDERS

Facility

$46,620.81

Service Code	APR-DRG 4283
Min. Negotiated Rate	$46,620.81
Max. Negotiated Rate	$46,620.81
Rate for Payer: Aetna Better Health Medicaid/QHP	$46,620.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$46,620.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$46,620.81
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$46,620.81

GENETIC DISORDERS

Facility

$9,918.89

Service Code	APR-DRG 4281
Min. Negotiated Rate	$9,918.89
Max. Negotiated Rate	$9,918.89
Rate for Payer: Aetna Better Health Medicaid/QHP	$9,918.89
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$9,918.89
Rate for Payer: Home State Health Plan Medicaid Managed Care	$9,918.89
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$9,918.89

GENETIC DISORDERS

Facility

$16,417.79

Service Code	APR-DRG 4282
Min. Negotiated Rate	$16,417.79
Max. Negotiated Rate	$16,417.79
Rate for Payer: Aetna Better Health Medicaid/QHP	$16,417.79
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16,417.79
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16,417.79
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16,417.79

GENETIC DISORDERS

Facility

$85,747.84

Service Code	APR-DRG 4284
Min. Negotiated Rate	$85,747.84
Max. Negotiated Rate	$85,747.84
Rate for Payer: Aetna Better Health Medicaid/QHP	$85,747.84
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$85,747.84
Rate for Payer: Home State Health Plan Medicaid Managed Care	$85,747.84
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$85,747.84

GENTAMIC (GARAMYCIN) 0.3% 5ML OPSOL

Facility

$91.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2655090
Hospital Revenue Code	250
Rate for Payer: Cash Price	$81.90

GENTAMIC (GARAMYCIN) 0.3% 5ML OPSOL

Facility

$91.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2655090
Hospital Revenue Code	250
Min. Negotiated Rate	$32.76
Max. Negotiated Rate	$64.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$53.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$64.97
Rate for Payer: Cash Price	$81.90
Rate for Payer: UnitedHealthcare Commercial	$60.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$32.76

GENTAMICIN 800MG/20ML MDV

Facility

$55.00

Service Code	HCPCS J1580
Hospital Charge Code	2622440
Hospital Revenue Code	250
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$39.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.80

GENTAMICIN 800MG/20ML MDV

Facility

$55.00

Service Code	HCPCS J1580
Hospital Charge Code	2622440
Hospital Revenue Code	250
Rate for Payer: Cash Price	$49.50

GENTAMICIN (GARAMYCIN) 80MG INJ 2ML

Facility

$106.00

Service Code	HCPCS J1580
Hospital Charge Code	2655085
Hospital Revenue Code	250
Min. Negotiated Rate	$38.16
Max. Negotiated Rate	$75.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$62.75
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$75.68
Rate for Payer: Cash Price	$95.40
Rate for Payer: UnitedHealthcare Commercial	$70.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$38.16

GENTAMICIN (GARAMYCIN) 80MG INJ 2ML

Facility

$106.00

Service Code	HCPCS J1580
Hospital Charge Code	2655085
Hospital Revenue Code	250
Rate for Payer: Cash Price	$95.40

Know your out-of-pocket cost for care.

All Charges