Madison Medical Center

All Charges

Charge

Type

Setting

Price

GRAM STAIN

Facility

$60.00

Service Code	CPT 87205
Hospital Charge Code	308012
Hospital Revenue Code	306
Min. Negotiated Rate	$3.84
Max. Negotiated Rate	$42.84
Rate for Payer: Aetna Better Health Medicaid/QHP	$3.84
Rate for Payer: Aetna Medicare Advantage	$4.27
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: Cigna Commercial HMO & PPO	$4.27
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$3.84
Rate for Payer: Home State Health Plan Medicaid Managed Care	$4.11
Rate for Payer: Home State Health Plan Medicare Advantage	$4.27
Rate for Payer: Humana Commercial	$8.54
Rate for Payer: Humana Medicare Advantage	$4.27
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$3.84
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.60

GRANISETRON (KYTRIL) 1MG/ML 1ML INJ

Facility

$814.00

Service Code	HCPCS J2405
Hospital Charge Code	2626581
Hospital Revenue Code	335
Min. Negotiated Rate	$293.04
Max. Negotiated Rate	$581.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$481.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$581.20
Rate for Payer: Cash Price	$732.60
Rate for Payer: UnitedHealthcare Commercial	$542.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$293.04

GRANISETRON (KYTRIL) 1MG/ML 1ML INJ

Facility

$814.00

Service Code	HCPCS J2405
Hospital Charge Code	2626581
Hospital Revenue Code	335
Rate for Payer: Cash Price	$732.60

GRIPPER HINGED KNEE BRACE

Facility

$81.00

Hospital Charge Code	4619001
Hospital Revenue Code	274
Min. Negotiated Rate	$29.16
Max. Negotiated Rate	$65.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$54.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$65.77
Rate for Payer: Cash Price	$72.90
Rate for Payer: UnitedHealthcare Commercial	$54.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$29.16

GRIPPER HINGED KNEE BRACE

Facility

$81.00

Hospital Charge Code	4619001
Hospital Revenue Code	274
Min. Negotiated Rate	$54.03
Max. Negotiated Rate	$65.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$54.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$65.77
Rate for Payer: Cash Price	$72.90
Rate for Payer: UnitedHealthcare Commercial	$54.03

GROSHONG CATH.L

Facility

$1,642.00

Hospital Charge Code	127791
Hospital Revenue Code	271
Rate for Payer: Cash Price	$1,477.80

GROSHONG CATH.L

Facility

$1,642.00

Hospital Charge Code	127791
Hospital Revenue Code	271
Min. Negotiated Rate	$591.12
Max. Negotiated Rate	$1,172.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$972.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,172.39
Rate for Payer: Cash Price	$1,477.80
Rate for Payer: UnitedHealthcare Commercial	$1,095.21
Rate for Payer: UnitedHealthcare Medicare Advantage	$591.12

GROUP B STREP ANTIGEN

Facility

$142.00

Service Code	CPT 87802
Hospital Charge Code	2286406
Hospital Revenue Code	302
Min. Negotiated Rate	$11.46
Max. Negotiated Rate	$101.39
Rate for Payer: Aetna Better Health Medicaid/QHP	$11.46
Rate for Payer: Aetna Medicare Advantage	$12.73
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$84.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$101.39
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cigna Commercial HMO & PPO	$12.73
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$11.46
Rate for Payer: Home State Health Plan Medicaid Managed Care	$12.26
Rate for Payer: Home State Health Plan Medicare Advantage	$12.73
Rate for Payer: Humana Commercial	$25.46
Rate for Payer: Humana Medicare Advantage	$12.73
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$11.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$51.12

GROUP B STREP ANTIGEN

Facility

$142.00

Service Code	CPT 87802
Hospital Charge Code	2286406
Hospital Revenue Code	302
Rate for Payer: Cash Price	$127.80

GROWTH HORMONE HGH

Facility

$485.00

Service Code	CPT 83003
Hospital Charge Code	227262
Hospital Revenue Code	301
Min. Negotiated Rate	$15.00
Max. Negotiated Rate	$346.29
Rate for Payer: Aetna Better Health Medicaid/QHP	$15.00
Rate for Payer: Aetna Medicare Advantage	$16.67
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$287.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$346.29
Rate for Payer: Cash Price	$436.50
Rate for Payer: Cash Price	$436.50
Rate for Payer: Cash Price	$436.50
Rate for Payer: Cigna Commercial HMO & PPO	$16.67
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15.00
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16.05
Rate for Payer: Home State Health Plan Medicare Advantage	$16.67
Rate for Payer: Humana Commercial	$33.34
Rate for Payer: Humana Medicare Advantage	$16.67
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$174.60

GROWTH HORMONE HGH

Facility

$485.00

Service Code	CPT 83003
Hospital Charge Code	227262
Hospital Revenue Code	301
Rate for Payer: Cash Price	$436.50

GROWTH HORM RELEASING HORMONE

Facility

$583.00

Service Code	CPT 83519
Hospital Charge Code	227263
Hospital Revenue Code	301
Rate for Payer: Cash Price	$524.70

GROWTH HORM RELEASING HORMONE

Facility

$583.00

Service Code	CPT 83519
Hospital Charge Code	227263
Hospital Revenue Code	301
Min. Negotiated Rate	$16.56
Max. Negotiated Rate	$416.26
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.56
Rate for Payer: Aetna Medicare Advantage	$18.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$345.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$416.26
Rate for Payer: Cash Price	$524.70
Rate for Payer: Cash Price	$524.70
Rate for Payer: Cash Price	$524.70
Rate for Payer: Cigna Commercial HMO & PPO	$18.40
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.56
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.72
Rate for Payer: Home State Health Plan Medicare Advantage	$18.40
Rate for Payer: Humana Commercial	$36.80
Rate for Payer: Humana Medicare Advantage	$18.40
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.56
Rate for Payer: UnitedHealthcare Medicare Advantage	$209.88

GUAIF/DM(MUCINEXDMMAX)XR1200/60MGTB

Facility

$18.00

Service Code	NDC 6.3824E+10
Hospital Charge Code	2626483
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

GUAIF/DM(MUCINEXDMMAX)XR1200/60MGTB

Facility

$18.00

Service Code	NDC 6.3824E+10
Hospital Charge Code	2626483
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.20

GUAIF/DM(MUCINEX DM)XR 600/30MGTAB

Facility

$18.00

Service Code	NDC 6.3824E+10
Hospital Charge Code	2626482
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.20

GUAIF/DM(MUCINEX DM)XR 600/30MGTAB

Facility

$18.00

Service Code	NDC 6.3824E+10
Hospital Charge Code	2626482
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

GUAIFEN 200MG SYR SF AF 10ML

Facility

$20.00

Service Code	NDC 121148810
Hospital Charge Code	2655120
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

GUAIFEN 200MG SYR SF AF 10ML

Facility

$20.00

Service Code	NDC 121148810
Hospital Charge Code	2655120
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

GUAIFEN/COD (CHERATUSS AC) SYP 180ML C5

Facility

$42.00

Service Code	NDC 182001737
Hospital Charge Code	2698106
Hospital Revenue Code	250
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$29.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$24.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$29.99
Rate for Payer: Cash Price	$37.80
Rate for Payer: UnitedHealthcare Commercial	$28.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.12

GUAIFEN/COD (CHERATUSS AC) SYP 180ML C5

Facility

$42.00

Service Code	NDC 182001737
Hospital Charge Code	2698106
Hospital Revenue Code	250
Rate for Payer: Cash Price	$37.80

GUAIFEN/COD (CHERATUSS AC) SYP 240ML C5

Facility

$42.00

Service Code	NDC 182001737
Hospital Charge Code	2697690
Hospital Revenue Code	250
Rate for Payer: Cash Price	$37.80

GUAIFEN/COD (CHERATUSS AC) SYP 240ML C5

Facility

$42.00

Service Code	NDC 182001737
Hospital Charge Code	2697690
Hospital Revenue Code	250
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$29.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$24.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$29.99
Rate for Payer: Cash Price	$37.80
Rate for Payer: UnitedHealthcare Commercial	$28.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.12

GUAIFEN/CODIENE ORAL SOL 5ML C5

Facility

$20.00

Service Code	NDC 121174410
Hospital Charge Code	2655121
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

GUAIFEN/CODIENE ORAL SOL 5ML C5

Facility

$20.00

Service Code	NDC 121174410
Hospital Charge Code	2655121
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

Know your out-of-pocket cost for care.

All Charges