Madison Medical Center

All Charges

Charge

Type

Setting

Price

LIDOCAINE VISCOUS 2% SOL 10ML

Facility

$32.00

Service Code	NDC 998030010
Hospital Charge Code	2654226
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$22.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$18.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$22.85
Rate for Payer: Cash Price	$28.80
Rate for Payer: UnitedHealthcare Commercial	$21.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.52

LIDOCAINE VISCOUS 2% SOL 15ML UD

Facility

$32.00

Service Code	NDC 998030010
Hospital Charge Code	2627195
Hospital Revenue Code	250
Rate for Payer: Cash Price	$28.80

LIDOCAINE VISCOUS 2% SOL 15ML UD

Facility

$32.00

Service Code	NDC 998030010
Hospital Charge Code	2627195
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$22.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$18.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$22.85
Rate for Payer: Cash Price	$28.80
Rate for Payer: UnitedHealthcare Commercial	$21.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.52

LIDOCAINE (XYLOC)2% 40MG INJ 2ML SDV

Facility

$65.00

Service Code	HCPCS J2001
Hospital Charge Code	2626544
Hospital Revenue Code	250
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$46.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$38.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$46.41
Rate for Payer: Cash Price	$58.50
Rate for Payer: UnitedHealthcare Commercial	$43.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$23.40

LIDOCAINE (XYLOC)2% 40MG INJ 2ML SDV

Facility

$65.00

Service Code	HCPCS J2001
Hospital Charge Code	2626544
Hospital Revenue Code	250
Rate for Payer: Cash Price	$58.50

LIDOCAINE (XYLOCAINE) 1% 10ML INJ MDV

Facility

$79.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2626412
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 (XYLOCAINE) 1% 10ML INJ MDV

Facility

$79.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2626412
Hospital Revenue Code	250
Rate for Payer: Cash Price	$71.10

LIDOCAINE (XYLOCAINE) 1% 20ML INJ

Facility

$79.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2697275
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 (XYLOCAINE) 1% 20ML INJ

Facility

$79.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2697275
Hospital Revenue Code	250
Rate for Payer: Cash Price	$71.10

LIDOCAINE (XYLOCAINE) 1% MPF 30ML

Facility

$101.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2697056
Hospital Revenue Code	250
Rate for Payer: Cash Price	$90.90

LIDOCAINE (XYLOCAINE) 1% MPF 30ML

Facility

$101.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2697056
Hospital Revenue Code	250
Min. Negotiated Rate	$36.36
Max. Negotiated Rate	$72.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$59.79
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$72.11
Rate for Payer: Cash Price	$90.90
Rate for Payer: UnitedHealthcare Commercial	$67.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$36.36

LIDOCAINE (XYLOCAINE) 1% PF 5ML SDV

Facility

$48.00

Service Code	NDC 143959501
Hospital Charge Code	2697054
Hospital Revenue Code	250
Min. Negotiated Rate	$17.28
Max. Negotiated Rate	$34.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$28.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$34.27
Rate for Payer: Cash Price	$43.20
Rate for Payer: UnitedHealthcare Commercial	$32.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.28

LIDOCAINE (XYLOCAINE) 1% PF 5ML SDV

Facility

$48.00

Service Code	NDC 143959501
Hospital Charge Code	2697054
Hospital Revenue Code	250
Rate for Payer: Cash Price	$43.20

LIDOCAINE (XYLOCAINE) 2% 20MG/ML 5ML INJ

Facility

$81.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2696423
Hospital Revenue Code	250
Rate for Payer: Cash Price	$72.90

LIDOCAINE (XYLOCAINE) 2% 20MG/ML 5ML INJ

Facility

$81.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2696423
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 (XYLOCAINE) 5% 35.44GM OINT

Facility

$195.00

Service Code	NDC 168020437
Hospital Charge Code	2626467
Hospital Revenue Code	250
Rate for Payer: Cash Price	$175.50

LIDOCAINE (XYLOCAINE) 5% 35.44GM OINT

Facility

$195.00

Service Code	NDC 168020437
Hospital Charge Code	2626467
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 (XYLOCAINE) MPF 1% 2ML VIAL

Facility

$42.00

Service Code	NDC 409471342
Hospital Charge Code	2698157
Hospital Revenue Code	250
Rate for Payer: Cash Price	$37.80

LIDOCAINE (XYLOCAINE) MPF 1% 2ML VIAL

Facility

$42.00

Service Code	NDC 409471342
Hospital Charge Code	2698157
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

LIDOCAI/PRILOCAI(EMLA) 30GM DOSE CRM

Facility

$95.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2626390
Hospital Revenue Code	250
Rate for Payer: Cash Price	$85.50

LIDOCAI/PRILOCAI(EMLA) 30GM DOSE CRM

Facility

$95.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2626390
Hospital Revenue Code	250
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$67.83
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$56.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$67.83
Rate for Payer: Cash Price	$85.50
Rate for Payer: UnitedHealthcare Commercial	$63.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$34.20

LIDO/DEXTROSE 2GM/500ML PREMIX

Facility

$124.00

Service Code	HCPCS J2001
Hospital Charge Code	2655409
Hospital Revenue Code	250
Min. Negotiated Rate	$44.64
Max. Negotiated Rate	$88.54
Rate for Payer: Cash Price	$111.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$73.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$88.54
Rate for Payer: UnitedHealthcare Commercial	$82.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$44.64

LIDO/DEXTROSE 2GM/500ML PREMIX

Facility

$124.00

Service Code	HCPCS J2001
Hospital Charge Code	2655409
Hospital Revenue Code	250
Rate for Payer: Cash Price	$111.60

LIDO / EPI 2% INJ 20ML VIAL (SURGERY)

Facility

$79.00

Service Code	NDC 409318301
Hospital Charge Code	2697308
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

LIDO / EPI 2% INJ 20ML VIAL (SURGERY)

Facility

$79.00

Service Code	NDC 409318301
Hospital Charge Code	2697308
Hospital Revenue Code	250
Rate for Payer: Cash Price	$71.10

Know your out-of-pocket cost for care.

All Charges