Madison Medical Center

All Charges

Charge

Type

Setting

Price

LIDOCAINE/EPI 1% 20ML VIAL

Facility

$81.00

Service Code	NDC 409317801
Hospital Charge Code	2655400
Hospital Revenue Code	250
Rate for Payer: Cash Price	$72.90

LIDOCAINE/EPI 1% 20ML VIAL

Facility

$81.00

Service Code	NDC 409317801
Hospital Charge Code	2655400
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/ GLUCOSE

Facility

$112.00

Hospital Charge Code	2058073
Hospital Revenue Code	370
Rate for Payer: Cash Price	$100.80

LIDOCAINE/ GLUCOSE

Facility

$112.00

Hospital Charge Code	2058073
Hospital Revenue Code	370
Min. Negotiated Rate	$40.32
Max. Negotiated Rate	$79.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$66.30
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$79.97
Rate for Payer: Cash Price	$100.80
Rate for Payer: UnitedHealthcare Commercial	$74.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$40.32

LIDOCAINE (GLYDO) 2% TOP JELLY 6ML PFS

Facility

$60.00

Service Code	NDC 2.5021E+10
Hospital Charge Code	2625179
Hospital Revenue Code	250
Rate for Payer: Cash Price	$54.00

LIDOCAINE (GLYDO) 2% TOP JELLY 6ML PFS

Facility

$60.00

Service Code	NDC 2.5021E+10
Hospital Charge Code	2625179
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 JELLY

Facility

$110.00

Hospital Charge Code	2058074
Hospital Revenue Code	370
Rate for Payer: Cash Price	$99.00

LIDOCAINE JELLY

Facility

$110.00

Hospital Charge Code	2058074
Hospital Revenue Code	370
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$78.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$65.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$78.54
Rate for Payer: Cash Price	$99.00
Rate for Payer: UnitedHealthcare Commercial	$73.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$39.60

LIDOCAINE (LIDODERM) 5% PATCH

Facility

$58.00

Service Code	NDC 4.2858E+10
Hospital Charge Code	2626388
Hospital Revenue Code	250
Rate for Payer: Cash Price	$52.20

LIDOCAINE (LIDODERM) 5% PATCH

Facility

$58.00

Service Code	NDC 4.2858E+10
Hospital Charge Code	2626388
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-MPF 0.5% 5mg/ml 50ml sdv

Facility

$126.00

Hospital Charge Code	2058076
Hospital Revenue Code	370
Min. Negotiated Rate	$45.36
Max. Negotiated Rate	$89.96
Rate for Payer: Cash Price	$113.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$74.59
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$89.96
Rate for Payer: UnitedHealthcare Commercial	$84.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.36

LIDOCAINE-MPF 0.5% 5mg/ml 50ml sdv

Facility

$126.00

Hospital Charge Code	2058076
Hospital Revenue Code	370
Rate for Payer: Cash Price	$113.40

LIDOCAINE-MPF 1% 10ML INJ STERILE (SURG)

Facility

$79.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2620469
Hospital Revenue Code	250
Min. Negotiated Rate	$28.44
Max. Negotiated Rate	$56.41
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: UnitedHealthcare Commercial	$52.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.44

LIDOCAINE-MPF 1% 10ML INJ STERILE (SURG)

Facility

$79.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2620469
Hospital Revenue Code	250
Rate for Payer: Cash Price	$71.10

LIDOCAINE MPF 1% 5ML INJ

Facility

$80.00

Service Code	HCPCS J2003
Hospital Charge Code	2626539
Hospital Revenue Code	250
Rate for Payer: Cash Price	$72.00

LIDOCAINE MPF 1% 5ML INJ

Facility

$80.00

Service Code	HCPCS J2003
Hospital Charge Code	2626539
Hospital Revenue Code	250
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$57.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$47.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$57.12
Rate for Payer: Cash Price	$72.00
Rate for Payer: UnitedHealthcare Commercial	$53.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.80

LIDOCAINE - PF 1% AMP 5ML (SURG)

Facility

$43.00

Service Code	NDC 409471302
Hospital Charge Code	2697515
Hospital Revenue Code	250
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

LIDOCAINE - PF 1% AMP 5ML (SURG)

Facility

$43.00

Service Code	NDC 409471302
Hospital Charge Code	2697515
Hospital Revenue Code	250
Rate for Payer: Cash Price	$38.70

LIDOCAINE PFS 2% 20MG/ML 5ML

Facility

$155.00

Service Code	NDC 409132305
Hospital Charge Code	2655405
Hospital Revenue Code	250
Min. Negotiated Rate	$55.80
Max. Negotiated Rate	$110.67
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$91.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$110.67
Rate for Payer: Cash Price	$139.50
Rate for Payer: UnitedHealthcare Commercial	$103.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$55.80

LIDOCAINE PFS 2% 20MG/ML 5ML

Facility

$155.00

Service Code	NDC 409132305
Hospital Charge Code	2655405
Hospital Revenue Code	250
Rate for Payer: Cash Price	$139.50

LIDOCAINE VISCOUS 2% SOL 100ML BOTTLE

Facility

$63.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2620547
Hospital Revenue Code	250
Rate for Payer: Cash Price	$56.70

LIDOCAINE VISCOUS 2% SOL 100ML BOTTLE

Facility

$63.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2620547
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 VISCOUS 2% SOL 100ML EMP

Facility

$63.00

Service Code	NDC 998030010
Hospital Charge Code	2622915
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 VISCOUS 2% SOL 100ML EMP

Facility

$63.00

Service Code	NDC 998030010
Hospital Charge Code	2622915
Hospital Revenue Code	250
Rate for Payer: Cash Price	$56.70

LIDOCAINE VISCOUS 2% SOL 10ML

Facility

$32.00

Service Code	NDC 998030010
Hospital Charge Code	2654226
Hospital Revenue Code	250
Rate for Payer: Cash Price	$28.80

Know your out-of-pocket cost for care.

All Charges