Madison Medical Center

All Charges

Charge

Type

Setting

Price

LICOCAINE (LIDODERM) 5% PATCH #30 EMP

Facility

$58.00

Service Code	NDC 603188016
Hospital Charge Code	2623393
Hospital Revenue Code	250
Min. Negotiated Rate	$20.88
Max. Negotiated Rate	$41.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$34.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$41.41
Rate for Payer: Cash Price	$52.20
Rate for Payer: UnitedHealthcare Commercial	$38.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.88

LIDOCAIN 2% GLYDO 11ML (REPLACES UROJET)

Facility

$52.00

Service Code	NDC 2.5021E+10
Hospital Charge Code	2624873
Hospital Revenue Code	250
Rate for Payer: Cash Price	$46.80

LIDOCAIN 2% GLYDO 11ML (REPLACES UROJET)

Facility

$52.00

Service Code	NDC 2.5021E+10
Hospital Charge Code	2624873
Hospital Revenue Code	250
Min. Negotiated Rate	$18.72
Max. Negotiated Rate	$37.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$30.78
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$37.13
Rate for Payer: Cash Price	$46.80
Rate for Payer: UnitedHealthcare Commercial	$34.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.72

LIDOCAINE 0.5% 50ML MDV (5MG/ML)

Facility

$58.00

Service Code	NDC 8290305200
Hospital Charge Code	2619748
Hospital Revenue Code	250
Min. Negotiated Rate	$20.88
Max. Negotiated Rate	$41.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$34.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$41.41
Rate for Payer: Cash Price	$52.20
Rate for Payer: UnitedHealthcare Commercial	$38.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.88

LIDOCAINE 0.5% 50ML MDV (5MG/ML)

Facility

$58.00

Service Code	NDC 8290305200
Hospital Charge Code	2619748
Hospital Revenue Code	250
Rate for Payer: Cash Price	$52.20

LIDOCAINE 2% 1000MG INJ 50ML MDV EMP

Facility

$81.00

Service Code	NDC 409427702
Hospital Charge Code	2624248
Hospital Revenue Code	250
Min. Negotiated Rate	$29.16
Max. Negotiated Rate	$57.83
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$47.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$57.83
Rate for Payer: Cash Price	$72.90
Rate for Payer: UnitedHealthcare Commercial	$54.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$29.16

LIDOCAINE 2% 1000MG INJ 50ML MDV EMP

Facility

$81.00

Service Code	NDC 409427702
Hospital Charge Code	2624248
Hospital Revenue Code	250
Rate for Payer: Cash Price	$72.90

LIDOCAINE 2% 10ML

Facility

$111.00

Service Code	CPT J2001
Hospital Charge Code	4059106
Hospital Revenue Code	370
Rate for Payer: Cash Price	$99.90

LIDOCAINE 2% 10ML

Facility

$111.00

Service Code	CPT J2001
Hospital Charge Code	4059106
Hospital Revenue Code	370
Min. Negotiated Rate	$39.96
Max. Negotiated Rate	$79.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$65.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$79.25
Rate for Payer: Cash Price	$99.90
Rate for Payer: UnitedHealthcare Commercial	$74.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$39.96

LIDOCAINE 2% 10ML mdv

Facility

$58.00

Service Code	HCPCS J2001
Hospital Charge Code	2059106
Hospital Revenue Code	370
Rate for Payer: Cash Price	$52.20

LIDOCAINE 2% 10ML mdv

Facility

$58.00

Service Code	HCPCS J2001
Hospital Charge Code	2059106
Hospital Revenue Code	370
Min. Negotiated Rate	$20.88
Max. Negotiated Rate	$41.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$34.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$41.41
Rate for Payer: Cash Price	$52.20
Rate for Payer: UnitedHealthcare Commercial	$38.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.88

LIDOCAINE 2% 20MG/ML 30ML INJ

Facility

$81.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2620734
Hospital Revenue Code	250
Min. Negotiated Rate	$29.16
Max. Negotiated Rate	$57.83
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$47.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$57.83
Rate for Payer: Cash Price	$72.90
Rate for Payer: UnitedHealthcare Commercial	$54.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$29.16

LIDOCAINE 2% 20MG/ML 30ML INJ

Facility

$81.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2620734
Hospital Revenue Code	250
Rate for Payer: Cash Price	$72.90

LIDOCAINE 2% TOP JELLY 30ML

Facility

$60.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2626320
Hospital Revenue Code	250
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$42.84
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: UnitedHealthcare Commercial	$40.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.60

LIDOCAINE 2% TOP JELLY 30ML

Facility

$60.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2626320
Hospital Revenue Code	250
Rate for Payer: Cash Price	$54.00

LIDOCAINE 2% TOP JELLY 5ML TUBE

Facility

$56.00

Hospital Charge Code	2621650
Hospital Revenue Code	250
Rate for Payer: Cash Price	$50.40

LIDOCAINE 2% TOP JELLY 5ML TUBE

Facility

$56.00

Hospital Charge Code	2621650
Hospital Revenue Code	250
Min. Negotiated Rate	$20.16
Max. Negotiated Rate	$39.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$33.15
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.98
Rate for Payer: Cash Price	$50.40
Rate for Payer: UnitedHealthcare Commercial	$37.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.16

LIDOCAINE 2% URO-JET 20ML

Facility

$61.00

Service Code	NDC 7.6329E+10
Hospital Charge Code	2622751
Hospital Revenue Code	250
Min. Negotiated Rate	$21.96
Max. Negotiated Rate	$43.55
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: UnitedHealthcare Commercial	$40.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.96

LIDOCAINE 2% URO-JET 20ML

Facility

$61.00

Service Code	NDC 7.6329E+10
Hospital Charge Code	2622751
Hospital Revenue Code	250
Rate for Payer: Cash Price	$54.90

LIDOCAINE 4% CREAM 15GM EMP

Facility

$63.00

Service Code	NDC 536126720
Hospital Charge Code	2627242
Hospital Revenue Code	250
Rate for Payer: Cash Price	$56.70

LIDOCAINE 4% CREAM 15GM EMP

Facility

$63.00

Service Code	NDC 536126720
Hospital Charge Code	2627242
Hospital Revenue Code	250
Min. Negotiated Rate	$22.68
Max. Negotiated Rate	$44.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$37.30
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$44.98
Rate for Payer: Cash Price	$56.70
Rate for Payer: UnitedHealthcare Commercial	$42.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$22.68

LIDOCAINE 5% 35.44GM OINT EMP

Facility

$195.00

Service Code	NDC 168020437
Hospital Charge Code	2624837
Hospital Revenue Code	250
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$139.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$115.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$139.23
Rate for Payer: Cash Price	$175.50
Rate for Payer: UnitedHealthcare Commercial	$130.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$70.20

LIDOCAINE 5% 35.44GM OINT EMP

Facility

$195.00

Service Code	NDC 168020437
Hospital Charge Code	2624837
Hospital Revenue Code	250
Rate for Payer: Cash Price	$175.50

LIDOCAINE CARDIAC 2% INJ

Facility

$149.00

Hospital Charge Code	2058030
Hospital Revenue Code	370
Rate for Payer: Cash Price	$134.10

LIDOCAINE CARDIAC 2% INJ

Facility

$149.00

Hospital Charge Code	2058030
Hospital Revenue Code	370
Min. Negotiated Rate	$53.64
Max. Negotiated Rate	$106.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$88.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$106.39
Rate for Payer: Cash Price	$134.10
Rate for Payer: UnitedHealthcare Commercial	$99.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$53.64

Know your out-of-pocket cost for care.

All Charges