Madison Medical Center

All Charges

Charge

Type

Setting

Price

GENTAMICIN (GARAMYCIN) OP OINT 3.5GM

Facility

$93.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2684637
Hospital Revenue Code	250
Min. Negotiated Rate	$33.48
Max. Negotiated Rate	$66.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$55.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$66.40
Rate for Payer: Cash Price	$83.70
Rate for Payer: UnitedHealthcare Commercial	$62.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$33.48

GENTAMICIN (GARAMYCIN) OP OINT 3.5GM

Facility

$93.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2684637
Hospital Revenue Code	250
Rate for Payer: Cash Price	$83.70

GENTAMICIN PEAK

Facility

$119.00

Service Code	CPT 80170
Hospital Charge Code	227302
Hospital Revenue Code	301
Rate for Payer: Cash Price	$107.10

GENTAMICIN PEAK

Facility

$119.00

Service Code	CPT 80170
Hospital Charge Code	227302
Hospital Revenue Code	301
Min. Negotiated Rate	$14.74
Max. Negotiated Rate	$84.97
Rate for Payer: Aetna Better Health Medicaid/QHP	$14.74
Rate for Payer: Aetna Medicare Advantage	$16.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$70.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$84.97
Rate for Payer: Cash Price	$107.10
Rate for Payer: Cash Price	$107.10
Rate for Payer: Cash Price	$107.10
Rate for Payer: Cigna Commercial HMO & PPO	$16.38
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14.74
Rate for Payer: Home State Health Plan Medicaid Managed Care	$15.77
Rate for Payer: Home State Health Plan Medicare Advantage	$16.38
Rate for Payer: Humana Commercial	$32.76
Rate for Payer: Humana Medicare Advantage	$16.38
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$42.84

GENTAMICIN RANDOM

Facility

$119.00

Service Code	CPT 80170
Hospital Charge Code	227300
Hospital Revenue Code	301
Min. Negotiated Rate	$14.74
Max. Negotiated Rate	$84.97
Rate for Payer: Aetna Better Health Medicaid/QHP	$14.74
Rate for Payer: Aetna Medicare Advantage	$16.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$70.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$84.97
Rate for Payer: Cash Price	$107.10
Rate for Payer: Cash Price	$107.10
Rate for Payer: Cash Price	$107.10
Rate for Payer: Cigna Commercial HMO & PPO	$16.38
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14.74
Rate for Payer: Home State Health Plan Medicaid Managed Care	$15.77
Rate for Payer: Home State Health Plan Medicare Advantage	$16.38
Rate for Payer: Humana Commercial	$32.76
Rate for Payer: Humana Medicare Advantage	$16.38
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$42.84

GENTAMICIN RANDOM

Facility

$119.00

Service Code	CPT 80170
Hospital Charge Code	227300
Hospital Revenue Code	301
Rate for Payer: Cash Price	$107.10

GENTAMICIN SULF 0.1% CRM 15GM

Facility

$119.00

Service Code	NDC 713068315
Hospital Charge Code	2626316
Hospital Revenue Code	250
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$84.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$70.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$84.97
Rate for Payer: Cash Price	$107.10
Rate for Payer: UnitedHealthcare Commercial	$79.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$42.84

GENTAMICIN SULF 0.1% CRM 15GM

Facility

$119.00

Service Code	NDC 713068315
Hospital Charge Code	2626316
Hospital Revenue Code	250
Rate for Payer: Cash Price	$107.10

GENTAMICIN SULF 0.1% OINT 15GM

Facility

$119.00

Service Code	NDC 713068215
Hospital Charge Code	2624507
Hospital Revenue Code	250
Rate for Payer: Cash Price	$107.10

GENTAMICIN SULF 0.1% OINT 15GM

Facility

$119.00

Service Code	NDC 713068215
Hospital Charge Code	2624507
Hospital Revenue Code	250
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$84.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$70.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$84.97
Rate for Payer: Cash Price	$107.10
Rate for Payer: UnitedHealthcare Commercial	$79.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$42.84

GENTAMICIN SULF 0.1% OINT. 15GM EMP

Facility

$119.00

Service Code	NDC 713068215
Hospital Charge Code	2621635
Hospital Revenue Code	250
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$84.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$70.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$84.97
Rate for Payer: Cash Price	$107.10
Rate for Payer: UnitedHealthcare Commercial	$79.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$42.84

GENTAMICIN SULF 0.1% OINT. 15GM EMP

Facility

$119.00

Service Code	NDC 713068215
Hospital Charge Code	2621635
Hospital Revenue Code	250
Rate for Payer: Cash Price	$107.10

GENTAMICIN TROUGH

Facility

$119.00

Service Code	CPT 80170
Hospital Charge Code	227301
Hospital Revenue Code	301
Rate for Payer: Cash Price	$107.10

GENTAMICIN TROUGH

Facility

$119.00

Service Code	CPT 80170
Hospital Charge Code	227301
Hospital Revenue Code	301
Min. Negotiated Rate	$14.74
Max. Negotiated Rate	$84.97
Rate for Payer: Aetna Better Health Medicaid/QHP	$14.74
Rate for Payer: Aetna Medicare Advantage	$16.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$70.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$84.97
Rate for Payer: Cash Price	$107.10
Rate for Payer: Cash Price	$107.10
Rate for Payer: Cash Price	$107.10
Rate for Payer: Cigna Commercial HMO & PPO	$16.38
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14.74
Rate for Payer: Home State Health Plan Medicaid Managed Care	$15.77
Rate for Payer: Home State Health Plan Medicare Advantage	$16.38
Rate for Payer: Humana Commercial	$32.76
Rate for Payer: Humana Medicare Advantage	$16.38
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$42.84

GGT

Facility

$79.00

Service Code	CPT 82977
Hospital Charge Code	227280
Hospital Revenue Code	301
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$56.41
Rate for Payer: Aetna Better Health Medicaid/QHP	$6.48
Rate for Payer: Aetna Medicare Advantage	$7.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$46.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$56.41
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial HMO & PPO	$7.20
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$6.48
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6.93
Rate for Payer: Home State Health Plan Medicare Advantage	$7.20
Rate for Payer: Humana Commercial	$14.40
Rate for Payer: Humana Medicare Advantage	$7.20
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$6.48
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.44

GGT

Facility

$79.00

Service Code	CPT 82977
Hospital Charge Code	227280
Hospital Revenue Code	301
Rate for Payer: Cash Price	$71.10

.GGT CPT 82977

Facility

$55.00

Service Code	CPT 82977
Hospital Charge Code	22282977
Hospital Revenue Code	307
Rate for Payer: Cash Price	$49.50

.GGT CPT 82977

Facility

$55.00

Service Code	CPT 82977
Hospital Charge Code	22282977
Hospital Revenue Code	307
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$39.27
Rate for Payer: Aetna Better Health Medicaid/QHP	$6.48
Rate for Payer: Aetna Medicare Advantage	$7.20
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: Cash Price	$49.50
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial HMO & PPO	$7.20
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$6.48
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6.93
Rate for Payer: Home State Health Plan Medicare Advantage	$7.20
Rate for Payer: Humana Commercial	$14.40
Rate for Payer: Humana Medicare Advantage	$7.20
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$6.48
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.80

G I A

Facility

$973.00

Hospital Charge Code	287268
Hospital Revenue Code	271
Min. Negotiated Rate	$350.28
Max. Negotiated Rate	$694.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$576.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$694.72
Rate for Payer: Cash Price	$875.70
Rate for Payer: UnitedHealthcare Commercial	$648.99
Rate for Payer: UnitedHealthcare Medicare Advantage	$350.28

G I A

Facility

$973.00

Hospital Charge Code	287268
Hospital Revenue Code	271
Rate for Payer: Cash Price	$875.70

GIARDIA ANTIGEN

Facility

$61.00

Service Code	CPT 87329
Hospital Charge Code	308014
Hospital Revenue Code	306
Min. Negotiated Rate	$10.78
Max. Negotiated Rate	$43.55
Rate for Payer: Aetna Better Health Medicaid/QHP	$10.78
Rate for Payer: Aetna Medicare Advantage	$11.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$36.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$43.55
Rate for Payer: Cash Price	$54.90
Rate for Payer: Cash Price	$54.90
Rate for Payer: Cash Price	$54.90
Rate for Payer: Cigna Commercial HMO & PPO	$11.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$10.78
Rate for Payer: Home State Health Plan Medicaid Managed Care	$11.53
Rate for Payer: Home State Health Plan Medicare Advantage	$11.98
Rate for Payer: Humana Commercial	$23.96
Rate for Payer: Humana Medicare Advantage	$11.98
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$10.78
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.96

GIARDIA ANTIGEN

Facility

$61.00

Service Code	CPT 87329
Hospital Charge Code	308014
Hospital Revenue Code	306
Rate for Payer: Cash Price	$54.90

G I A STAPLES

Facility

$332.00

Hospital Charge Code	287269
Hospital Revenue Code	271
Rate for Payer: Cash Price	$298.80

G I A STAPLES

Facility

$332.00

Hospital Charge Code	287269
Hospital Revenue Code	271
Min. Negotiated Rate	$119.52
Max. Negotiated Rate	$237.05
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$196.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$237.05
Rate for Payer: Cash Price	$298.80
Rate for Payer: UnitedHealthcare Commercial	$221.44
Rate for Payer: UnitedHealthcare Medicare Advantage	$119.52

GI COCKTAIL

Facility

$6.00

Service Code	CPT Y7506
Hospital Charge Code	9656217
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.40
Rate for Payer: UnitedHealthcare Commercial	$4.00

Know your out-of-pocket cost for care.

All Charges