Madison Medical Center

All Charges

Charge

Type

Setting

Price

GLUCOSE TOLERANCE TEST (82952)

Facility

$19.00

Service Code	CPT 82952
Hospital Charge Code	4282952
Hospital Revenue Code	521
Rate for Payer: Cash Price	$17.10

.GLU LOADING DOSE CHARGE

Facility

$17.00

Hospital Charge Code	227112
Hospital Revenue Code	272
Rate for Payer: Cash Price	$15.30

.GLU LOADING DOSE CHARGE

Facility

$17.00

Hospital Charge Code	227112
Hospital Revenue Code	272
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$12.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$10.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$12.14
Rate for Payer: Cash Price	$15.30
Rate for Payer: UnitedHealthcare Commercial	$11.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.12

.GLUTEN IGE

Facility

$202.00

Service Code	CPT 86003
Hospital Charge Code	22086003
Hospital Revenue Code	302
Rate for Payer: Cash Price	$181.80

.GLUTEN IGE

Facility

$202.00

Service Code	CPT 86003
Hospital Charge Code	22086003
Hospital Revenue Code	302
Min. Negotiated Rate	$4.70
Max. Negotiated Rate	$144.23
Rate for Payer: Aetna Better Health Medicaid/QHP	$4.70
Rate for Payer: Aetna Medicare Advantage	$5.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$119.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$144.23
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cigna Commercial HMO & PPO	$5.22
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4.70
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5.03
Rate for Payer: Home State Health Plan Medicare Advantage	$5.22
Rate for Payer: Humana Commercial	$10.44
Rate for Payer: Humana Medicare Advantage	$5.22
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$72.72

.GLUTEN IGG

Facility

$210.00

Service Code	CPT 86001
Hospital Charge Code	22086001
Hospital Revenue Code	302
Min. Negotiated Rate	$7.04
Max. Negotiated Rate	$149.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$7.04
Rate for Payer: Aetna Medicare Advantage	$7.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$124.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$149.94
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cigna Commercial HMO & PPO	$7.82
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$7.04
Rate for Payer: Home State Health Plan Medicaid Managed Care	$7.53
Rate for Payer: Home State Health Plan Medicare Advantage	$7.82
Rate for Payer: Humana Commercial	$15.64
Rate for Payer: Humana Medicare Advantage	$7.82
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$7.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$75.60

.GLUTEN IGG

Facility

$210.00

Service Code	CPT 86001
Hospital Charge Code	22086001
Hospital Revenue Code	302
Rate for Payer: Cash Price	$189.00

GLUTEN SENS ANTIBODIES W/REFLEX CASCADE

Facility

$383.00

Service Code	CPT 86258
Hospital Charge Code	22086000
Hospital Revenue Code	302
Min. Negotiated Rate	$10.85
Max. Negotiated Rate	$273.46
Rate for Payer: Aetna Better Health Medicaid/QHP	$10.85
Rate for Payer: Aetna Medicare Advantage	$12.05
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$226.74
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$273.46
Rate for Payer: Cash Price	$344.70
Rate for Payer: Cash Price	$344.70
Rate for Payer: Cash Price	$344.70
Rate for Payer: Cigna Commercial HMO & PPO	$12.05
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$10.85
Rate for Payer: Home State Health Plan Medicaid Managed Care	$11.61
Rate for Payer: Home State Health Plan Medicare Advantage	$12.05
Rate for Payer: Humana Commercial	$24.10
Rate for Payer: Humana Medicare Advantage	$12.05
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$10.85
Rate for Payer: UnitedHealthcare Medicare Advantage	$137.88

GLUTEN SENS ANTIBODIES W/REFLEX CASCADE

Facility

$383.00

Service Code	CPT 86258
Hospital Charge Code	22086000
Hospital Revenue Code	302
Rate for Payer: Cash Price	$344.70

GLYBURIDE 2.5MG TAB EMP

Facility

$21.00

Service Code	NDC 93834301
Hospital Charge Code	2622101
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

GLYBURIDE 2.5MG TAB EMP

Facility

$21.00

Service Code	NDC 93834301
Hospital Charge Code	2622101
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

GLYCERIN ADULT SUPPOSITORY 1 SUPP

Facility

$24.00

Service Code	NDC 713010113
Hospital Charge Code	2697141
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

GLYCERIN ADULT SUPPOSITORY 1 SUPP

Facility

$24.00

Service Code	NDC 713010113
Hospital Charge Code	2697141
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$17.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.14
Rate for Payer: Cash Price	$21.60
Rate for Payer: UnitedHealthcare Commercial	$16.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.64

GLYCERIN PEDIATRIC SUPP

Facility

$20.00

Service Code	NDC 713010209
Hospital Charge Code	2655105
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

GLYCERIN PEDIATRIC SUPP

Facility

$20.00

Service Code	NDC 713010209
Hospital Charge Code	2655105
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

GLYCOHEMOGLOBIN

Facility

$60.00

Service Code	CPT 83036
Hospital Charge Code	4283036
Hospital Revenue Code	521
Rate for Payer: Cash Price	$54.00

GLYCOHEMOGLOBIN

Facility

$60.00

Service Code	CPT 83036
Hospital Charge Code	4283036
Hospital Revenue Code	521
Min. Negotiated Rate	$7.87
Max. Negotiated Rate	$173.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$8.74
Rate for Payer: Aetna Medicare Advantage	$9.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$35.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$42.84
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial HMO & PPO	$9.71
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$7.87
Rate for Payer: Home State Health Plan Medicaid Managed Care	$9.35
Rate for Payer: Home State Health Plan Medicare Advantage	$9.71
Rate for Payer: Humana Commercial	$19.42
Rate for Payer: Humana Medicare Advantage	$9.71
Rate for Payer: UnitedHealthcare Commercial	$40.02
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

GLYCOPYROLATE 0.4MG 2ML VIAL

Facility

$156.00

Service Code	NDC 517460225
Hospital Charge Code	2058048
Hospital Revenue Code	370
Min. Negotiated Rate	$56.16
Max. Negotiated Rate	$111.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$92.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$111.38
Rate for Payer: Cash Price	$140.40
Rate for Payer: UnitedHealthcare Commercial	$104.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$56.16

GLYCOPYROLATE 0.4MG 2ML VIAL

Facility

$156.00

Service Code	NDC 517460225
Hospital Charge Code	2058048
Hospital Revenue Code	370
Rate for Payer: Cash Price	$140.40

GLYCOPYRROLATE 0.4MG INJ (ROBINUL) 2ML

Facility

$171.00

Service Code	NDC 517460225
Hospital Charge Code	2655110
Hospital Revenue Code	250
Min. Negotiated Rate	$61.56
Max. Negotiated Rate	$122.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$101.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$122.09
Rate for Payer: Cash Price	$153.90
Rate for Payer: UnitedHealthcare Commercial	$114.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$61.56

GLYCOPYRROLATE 0.4MG INJ (ROBINUL) 2ML

Facility

$171.00

Service Code	NDC 517460225
Hospital Charge Code	2655110
Hospital Revenue Code	250
Rate for Payer: Cash Price	$153.90

GM1 IgG Autoantibodies

Facility

$318.00

Service Code	CPT 83520
Hospital Charge Code	2283502
Hospital Revenue Code	305
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$227.05
Rate for Payer: Aetna Better Health Medicaid/QHP	$15.54
Rate for Payer: Aetna Medicare Advantage	$17.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$188.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$227.05
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial HMO & PPO	$17.27
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15.54
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16.63
Rate for Payer: Home State Health Plan Medicare Advantage	$17.27
Rate for Payer: Humana Commercial	$34.54
Rate for Payer: Humana Medicare Advantage	$17.27
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15.54
Rate for Payer: UnitedHealthcare Medicare Advantage	$114.48

GM1 IgG Autoantibodies

Facility

$318.00

Service Code	CPT 83520
Hospital Charge Code	2283502
Hospital Revenue Code	305
Rate for Payer: Cash Price	$286.20

GM1 IgM Autoantibodies

Facility

$318.00

Service Code	CPT 83520
Hospital Charge Code	2283503
Hospital Revenue Code	305
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$227.05
Rate for Payer: Aetna Better Health Medicaid/QHP	$15.54
Rate for Payer: Aetna Medicare Advantage	$17.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$188.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$227.05
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial HMO & PPO	$17.27
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15.54
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16.63
Rate for Payer: Home State Health Plan Medicare Advantage	$17.27
Rate for Payer: Humana Commercial	$34.54
Rate for Payer: Humana Medicare Advantage	$17.27
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15.54
Rate for Payer: UnitedHealthcare Medicare Advantage	$114.48

GM1 IgM Autoantibodies

Facility

$318.00

Service Code	CPT 83520
Hospital Charge Code	2283503
Hospital Revenue Code	305
Rate for Payer: Cash Price	$286.20

Know your out-of-pocket cost for care.

All Charges