Madison Medical Center

All Charges

Charge

Type

Setting

Price

GOLD PROBE

Facility

$706.00

Hospital Charge Code	1269112
Hospital Revenue Code	271
Min. Negotiated Rate	$254.16
Max. Negotiated Rate	$504.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$417.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$504.08
Rate for Payer: Cash Price	$635.40
Rate for Payer: UnitedHealthcare Commercial	$470.90
Rate for Payer: UnitedHealthcare Medicare Advantage	$254.16

GOLD PROBE

Facility

$706.00

Hospital Charge Code	1269112
Hospital Revenue Code	271
Rate for Payer: Cash Price	$635.40

GOLDVAC

Facility

$236.00

Hospital Charge Code	1251113
Hospital Revenue Code	271
Min. Negotiated Rate	$84.96
Max. Negotiated Rate	$168.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$139.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$168.50
Rate for Payer: Cash Price	$212.40
Rate for Payer: UnitedHealthcare Commercial	$157.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$84.96

GOLDVAC

Facility

$236.00

Hospital Charge Code	1251113
Hospital Revenue Code	271
Rate for Payer: Cash Price	$212.40

GOLYTELY PEG 3350 & ELECTROLYTE SOL

Facility

$214.00

Service Code	NDC 5.2268E+10
Hospital Charge Code	2655117
Hospital Revenue Code	250
Rate for Payer: Cash Price	$192.60

GOLYTELY PEG 3350 & ELECTROLYTE SOL

Facility

$214.00

Service Code	NDC 5.2268E+10
Hospital Charge Code	2655117
Hospital Revenue Code	250
Min. Negotiated Rate	$77.04
Max. Negotiated Rate	$152.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$126.69
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$152.80
Rate for Payer: Cash Price	$192.60
Rate for Payer: UnitedHealthcare Commercial	$142.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$77.04

GOMCO

Facility

$121.00

Hospital Charge Code	287801
Hospital Revenue Code	271
Rate for Payer: Cash Price	$108.90

GOMCO

Facility

$121.00

Hospital Charge Code	287801
Hospital Revenue Code	271
Min. Negotiated Rate	$43.56
Max. Negotiated Rate	$86.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$71.63
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$86.39
Rate for Payer: Cash Price	$108.90
Rate for Payer: UnitedHealthcare Commercial	$80.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$43.56

GONADOTROPIN RELEASING HORMONE

Facility

$685.00

Service Code	CPT 83727
Hospital Charge Code	2283727
Hospital Revenue Code	307
Min. Negotiated Rate	$15.47
Max. Negotiated Rate	$489.09
Rate for Payer: Aetna Better Health Medicaid/QHP	$15.47
Rate for Payer: Aetna Medicare Advantage	$17.19
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$405.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$489.09
Rate for Payer: Cash Price	$616.50
Rate for Payer: Cash Price	$616.50
Rate for Payer: Cash Price	$616.50
Rate for Payer: Cigna Commercial HMO & PPO	$17.19
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15.47
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16.55
Rate for Payer: Home State Health Plan Medicare Advantage	$17.19
Rate for Payer: Humana Commercial	$34.38
Rate for Payer: Humana Medicare Advantage	$17.19
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15.47
Rate for Payer: UnitedHealthcare Medicare Advantage	$246.60

GONADOTROPIN RELEASING HORMONE

Facility

$685.00

Service Code	CPT 83727
Hospital Charge Code	2283727
Hospital Revenue Code	307
Rate for Payer: Cash Price	$616.50

GOWNS, ISOLATION

Facility

$22.00

Hospital Charge Code	287787
Hospital Revenue Code	271
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

GOWNS, ISOLATION

Facility

$22.00

Hospital Charge Code	287787
Hospital Revenue Code	271
Rate for Payer: Cash Price	$19.80

GOWNS, ISOLATION XLG

Facility

$22.00

Hospital Charge Code	287700
Hospital Revenue Code	271
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

GOWNS, ISOLATION XLG

Facility

$22.00

Hospital Charge Code	287700
Hospital Revenue Code	271
Rate for Payer: Cash Price	$19.80

GOWN, SPECIALTY MEDLINE #DYNJP2004S

Facility

$125.00

Hospital Charge Code	127796
Hospital Revenue Code	271
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$89.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$74.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$89.25
Rate for Payer: Cash Price	$112.50
Rate for Payer: UnitedHealthcare Commercial	$83.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.00

GOWN, SPECIALTY MEDLINE #DYNJP2004S

Facility

$125.00

Hospital Charge Code	127796
Hospital Revenue Code	271
Rate for Payer: Cash Price	$112.50

GOWNS, SURGICAL #90012

Facility

$43.00

Hospital Charge Code	287789
Hospital Revenue Code	271
Rate for Payer: Cash Price	$38.70

GOWNS, SURGICAL #90012

Facility

$43.00

Hospital Charge Code	287789
Hospital Revenue Code	271
Min. Negotiated Rate	$15.48
Max. Negotiated Rate	$30.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$25.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$30.70
Rate for Payer: Cash Price	$38.70
Rate for Payer: UnitedHealthcare Commercial	$28.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.48

GOWNS, SURGICALXLG

Facility

$34.00

Hospital Charge Code	127789
Hospital Revenue Code	271
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$24.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$20.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$24.28
Rate for Payer: Cash Price	$30.60
Rate for Payer: UnitedHealthcare Commercial	$22.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.24

GOWNS, SURGICALXLG

Facility

$34.00

Hospital Charge Code	127789
Hospital Revenue Code	271
Rate for Payer: Cash Price	$30.60

GOWNS, ULTRA SURGICAL W/ TOWEL XXLARGE

Facility

$125.00

Service Code	CPT Y7506
Hospital Charge Code	127788
Hospital Revenue Code	271
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$89.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$74.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$89.25
Rate for Payer: Cash Price	$112.50
Rate for Payer: UnitedHealthcare Commercial	$83.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.00

GOWNS, ULTRA SURGICAL W/ TOWEL XXLARGE

Facility

$125.00

Service Code	CPT Y7506
Hospital Charge Code	127788
Hospital Revenue Code	271
Rate for Payer: Cash Price	$112.50

GRALISE ER 300MG TAB EMP

Facility

$21.00

Service Code	NDC 5.2427E+10
Hospital Charge Code	2624432
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

GRALISE ER 300MG TAB EMP

Facility

$21.00

Service Code	NDC 5.2427E+10
Hospital Charge Code	2624432
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

GRAM STAIN

Facility

$60.00

Service Code	CPT 87205
Hospital Charge Code	308012
Hospital Revenue Code	306
Rate for Payer: Cash Price	$54.00

Know your out-of-pocket cost for care.

All Charges