Gifford Medical Center

All Charges

Charge

Type

Setting

Price

LEVOFLOXACIN 500 MG/100 ML PRE

Facility

$8.14

Service Code	NDC 143972101
Hospital Charge Code	636J195602
Hospital Revenue Code	636
Min. Negotiated Rate	$3.61
Max. Negotiated Rate	$7.73
Rate for Payer: Aetna of VT Commercial	$7.73
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$7.29
Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan	$3.61
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$7.29
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange	$4.90
Rate for Payer: Blue Cross Blue Shield of Vermont Commercial	$6.92
Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care	$6.59
Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage	$3.66
Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan	$6.47
Rate for Payer: Cash Price	$4.07
Rate for Payer: Cigna Commercial	$6.51
Rate for Payer: Harvard Pilgrim Health Care HMO	$6.51
Rate for Payer: Harvard Pilgrim Health Care PPO	$6.51
Rate for Payer: Martins Point Health Care Commercial	$3.66
Rate for Payer: Multiplan Commercial	$7.57
Rate for Payer: MVP Health Care of NY Commercial	$6.92
Rate for Payer: MVP Health Care of NY Medicare Advantage	$3.66
Rate for Payer: United Healthcare Commercial	$7.73
Rate for Payer: United Healthcare Medicare Advantage	$3.66
Rate for Payer: United Healthcare VA CCN	$3.66

LEVOFLOXACIN 500 MG/100 ML PRE

Facility

$8.14

Service Code	NDC 143972101
Hospital Charge Code	636J195602
Hospital Revenue Code	636
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$7.73
Rate for Payer: Aetna of VT Commercial	$7.73
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$6.02
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$6.02
Rate for Payer: Blue Cross Blue Shield of Vermont Commercial	$6.92
Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care	$6.84
Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan	$6.51
Rate for Payer: Cash Price	$4.07
Rate for Payer: Cigna Commercial	$6.51
Rate for Payer: Harvard Pilgrim Health Care HMO	$6.51
Rate for Payer: Harvard Pilgrim Health Care PPO	$6.51
Rate for Payer: Multiplan Commercial	$7.57
Rate for Payer: MVP Health Care of NY Commercial	$6.92
Rate for Payer: United Healthcare Commercial	$7.73

LIDOCAINE 1% 10 ML VIAL

Facility

$9.21

Hospital Charge Code	2500000166
Hospital Revenue Code	250
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$8.75
Rate for Payer: Aetna of VT Commercial	$8.75
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$8.25
Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan	$4.08
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$8.25
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange	$5.54
Rate for Payer: Blue Cross Blue Shield of Vermont Commercial	$7.83
Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care	$7.46
Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage	$4.14
Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan	$7.32
Rate for Payer: Cash Price	$4.61
Rate for Payer: Cigna Commercial	$7.37
Rate for Payer: Harvard Pilgrim Health Care HMO	$7.37
Rate for Payer: Harvard Pilgrim Health Care PPO	$7.37
Rate for Payer: Martins Point Health Care Commercial	$4.14
Rate for Payer: Multiplan Commercial	$8.57
Rate for Payer: MVP Health Care of NY Commercial	$7.83
Rate for Payer: MVP Health Care of NY Medicare Advantage	$4.14
Rate for Payer: United Healthcare Commercial	$8.75
Rate for Payer: United Healthcare Medicare Advantage	$4.14
Rate for Payer: United Healthcare VA CCN	$4.14

LIDOCAINE 1% 10 ML VIAL

Facility

$9.21

Hospital Charge Code	2500000166
Hospital Revenue Code	250
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$8.75
Rate for Payer: Aetna of VT Commercial	$8.75
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$6.82
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$6.82
Rate for Payer: Blue Cross Blue Shield of Vermont Commercial	$7.83
Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care	$7.74
Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan	$7.37
Rate for Payer: Cash Price	$4.61
Rate for Payer: Cigna Commercial	$7.37
Rate for Payer: Harvard Pilgrim Health Care HMO	$7.37
Rate for Payer: Harvard Pilgrim Health Care PPO	$7.37
Rate for Payer: Multiplan Commercial	$8.57
Rate for Payer: MVP Health Care of NY Commercial	$7.83
Rate for Payer: United Healthcare Commercial	$8.75

LIDOCAINE 1% 10ML VIAL

Facility

$9.21

Service Code	HCPCS J2003
Hospital Charge Code	636J200306
Hospital Revenue Code	636
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$8.75
Rate for Payer: Aetna of VT Commercial	$8.75
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$6.82
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$6.82
Rate for Payer: Blue Cross Blue Shield of Vermont Commercial	$7.83
Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care	$7.74
Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan	$7.37
Rate for Payer: Cash Price	$4.61
Rate for Payer: Cigna Commercial	$7.37
Rate for Payer: Harvard Pilgrim Health Care HMO	$7.37
Rate for Payer: Harvard Pilgrim Health Care PPO	$7.37
Rate for Payer: Multiplan Commercial	$8.57
Rate for Payer: MVP Health Care of NY Commercial	$7.83
Rate for Payer: United Healthcare Commercial	$8.75

LIDOCAINE 1% 10ML VIAL

Facility

$9.21

Service Code	HCPCS J2003
Hospital Charge Code	636J200306
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$8.75
Rate for Payer: Aetna of VT Commercial	$8.75
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan	$4.08
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange	$5.54
Rate for Payer: Blue Cross Blue Shield of Vermont Commercial	$7.83
Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care	$7.46
Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage	$4.14
Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan	$7.32
Rate for Payer: Cash Price	$4.61
Rate for Payer: Cash Price	$4.61
Rate for Payer: Cigna Commercial	$7.37
Rate for Payer: Harvard Pilgrim Health Care HMO	$7.37
Rate for Payer: Harvard Pilgrim Health Care PPO	$7.37
Rate for Payer: Martins Point Health Care Commercial	$4.14
Rate for Payer: Multiplan Commercial	$8.57
Rate for Payer: MVP Health Care of NY Commercial	$7.83
Rate for Payer: MVP Health Care of NY Medicare Advantage	$4.14
Rate for Payer: United Healthcare Commercial	$8.75
Rate for Payer: United Healthcare Medicare Advantage	$4.14
Rate for Payer: United Healthcare VA CCN	$4.14

LIDOCAINE 1% 20 ML VIAL

Facility

$0.01

Service Code	HCPCS J2003
Hospital Charge Code	636J200308
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$0.01

LIDOCAINE 1% 20 ML VIAL

Professional

Both

$0.03

Service Code	HCPCS J2001
Hospital Charge Code	636J200102
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of VT Commercial	$0.03
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$0.03
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$0.03
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Martins Point Health Care Commercial	$0.03
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: United Healthcare Commercial	$0.03
Rate for Payer: United Healthcare VA CCN	$0.01

LIDOCAINE 1% 20 ML VIAL

Professional

Both

$0.03

Service Code	HCPCS J2003
Hospital Charge Code	636J200308
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of VT Commercial	$0.03
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Harvard Pilgrim Health Care HMO	$0.01
Rate for Payer: Harvard Pilgrim Health Care PPO	$0.01
Rate for Payer: Martins Point Health Care Commercial	$0.01
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: United Healthcare Commercial	$0.03
Rate for Payer: United Healthcare VA CCN	$0.01

LIDOCAINE 2% 5ML ABBOJECT

Professional

Both

$0.03

Service Code	HCPCS J2003
Hospital Charge Code	636J200301
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of VT Commercial	$0.03
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Harvard Pilgrim Health Care HMO	$0.01
Rate for Payer: Harvard Pilgrim Health Care PPO	$0.01
Rate for Payer: Martins Point Health Care Commercial	$0.01
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: United Healthcare Commercial	$0.03
Rate for Payer: United Healthcare VA CCN	$0.01

LIDOCAINE 2% 5ML ABBOJECT

Facility

$0.01

Service Code	HCPCS J2003
Hospital Charge Code	636J200301
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$0.01

LIDOCAINE 2% JELLY 20 ML

Professional

Both

$7.74

Hospital Charge Code	2500000171
Hospital Revenue Code	250
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$7.28
Rate for Payer: Aetna of VT Commercial	$7.28
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$6.93
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$6.93
Rate for Payer: Cash Price	$3.87
Rate for Payer: Multiplan Commercial	$7.20
Rate for Payer: United Healthcare Commercial	$6.58
Rate for Payer: United Healthcare VA CCN	$3.10

LIDOCAINE 2% JELLY 20 ML

Professional

Both

$7.74

Service Code	NDC 7632930155
Hospital Charge Code	2500000171
Hospital Revenue Code	250
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$7.28
Rate for Payer: Aetna of VT Commercial	$7.28
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$6.93
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$6.93
Rate for Payer: Cash Price	$3.87
Rate for Payer: Multiplan Commercial	$7.20
Rate for Payer: United Healthcare Commercial	$6.58
Rate for Payer: United Healthcare VA CCN	$3.10

LIDOCAINE 2% JELLY 5 ML

Professional

Both

$4.31

Service Code	NDC 7632930125
Hospital Charge Code	2500000182
Hospital Revenue Code	250
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$4.05
Rate for Payer: Aetna of VT Commercial	$4.05
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$3.86
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$3.86
Rate for Payer: Cash Price	$2.15
Rate for Payer: Multiplan Commercial	$4.01
Rate for Payer: United Healthcare Commercial	$3.66
Rate for Payer: United Healthcare VA CCN	$1.72

LIDOCAINE 2% JELLY 5 ML

Professional

Both

$4.31

Hospital Charge Code	2500000182
Hospital Revenue Code	250
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$4.05
Rate for Payer: Aetna of VT Commercial	$4.05
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$3.86
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$3.86
Rate for Payer: Cash Price	$2.15
Rate for Payer: Multiplan Commercial	$4.01
Rate for Payer: United Healthcare Commercial	$3.66
Rate for Payer: United Healthcare VA CCN	$1.72

LIDOCAINE 4% PATCH

Facility

$1.36

Service Code	NDC 536120207
Hospital Charge Code	2500000598
Hospital Revenue Code	250
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of VT Commercial	$1.29
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$1.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$1.01
Rate for Payer: Blue Cross Blue Shield of Vermont Commercial	$1.16
Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care	$1.14
Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan	$1.09
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna Commercial	$1.09
Rate for Payer: Harvard Pilgrim Health Care HMO	$1.09
Rate for Payer: Harvard Pilgrim Health Care PPO	$1.09
Rate for Payer: Multiplan Commercial	$1.26
Rate for Payer: MVP Health Care of NY Commercial	$1.16
Rate for Payer: United Healthcare Commercial	$1.29

LIDOCAINE 4% PATCH

Facility

$1.36

Service Code	NDC 536120207
Hospital Charge Code	2500000598
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of VT Commercial	$1.29
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$1.22
Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan	$0.60
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$1.22
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange	$0.82
Rate for Payer: Blue Cross Blue Shield of Vermont Commercial	$1.16
Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care	$1.10
Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage	$0.61
Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan	$1.08
Rate for Payer: Cash Price	$0.68
Rate for Payer: Cigna Commercial	$1.09
Rate for Payer: Harvard Pilgrim Health Care HMO	$1.09
Rate for Payer: Harvard Pilgrim Health Care PPO	$1.09
Rate for Payer: Martins Point Health Care Commercial	$0.61
Rate for Payer: Multiplan Commercial	$1.26
Rate for Payer: MVP Health Care of NY Commercial	$1.16
Rate for Payer: MVP Health Care of NY Medicare Advantage	$0.61
Rate for Payer: United Healthcare Commercial	$1.29
Rate for Payer: United Healthcare Medicare Advantage	$0.61
Rate for Payer: United Healthcare VA CCN	$0.61

LIDOCAINE VISCOUS 2% 100ML SOL

Professional

Both

$0.01

Service Code	NDC 54350049
Hospital Charge Code	2500000162
Hospital Revenue Code	637
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of VT Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$0.01
Rate for Payer: Multiplan Commercial	$0.01
Rate for Payer: United Healthcare Commercial	$0.01
Rate for Payer: United Healthcare VA CCN	$0.00

LIDOCAINE VISCOUS 2% 100ML SOL

Professional

Both

$0.01

Hospital Charge Code	2500000162
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of VT Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$0.01
Rate for Payer: Multiplan Commercial	$0.01
Rate for Payer: United Healthcare Commercial	$0.01
Rate for Payer: United Healthcare VA CCN	$0.00

LIDOCAINE VISCOUS 2% 15 ML SOL

Professional

Both

$0.01

Service Code	NDC 9999999969
Hospital Charge Code	2500000170
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of VT Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$0.01
Rate for Payer: Multiplan Commercial	$0.01
Rate for Payer: United Healthcare Commercial	$0.01
Rate for Payer: United Healthcare VA CCN	$0.00

LIDOCAINE VISCOUS 2% 15 ML SOL

Professional

Both

$10.68

Hospital Charge Code	2500000169
Hospital Revenue Code	250
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$10.04
Rate for Payer: Aetna of VT Commercial	$10.04
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$9.57
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$9.57
Rate for Payer: Cash Price	$5.34
Rate for Payer: Multiplan Commercial	$9.93
Rate for Payer: United Healthcare Commercial	$9.08
Rate for Payer: United Healthcare VA CCN	$4.27

LIDOCAINE VISCOUS 2% 15 ML SOL

Professional

Both

$0.01

Hospital Charge Code	2500000170
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of VT Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$0.01
Rate for Payer: Multiplan Commercial	$0.01
Rate for Payer: United Healthcare Commercial	$0.01
Rate for Payer: United Healthcare VA CCN	$0.00

LIDOC-MPF 1% W/EPI 20 ML VIAL

Facility

$27.92

Service Code	HCPCS J2004
Hospital Charge Code	636J200402
Hospital Revenue Code	636
Min. Negotiated Rate	$20.66
Max. Negotiated Rate	$26.52
Rate for Payer: Aetna of VT Commercial	$26.52
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$20.66
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$20.66
Rate for Payer: Blue Cross Blue Shield of Vermont Commercial	$23.73
Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care	$23.45
Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan	$22.34
Rate for Payer: Cash Price	$13.96
Rate for Payer: Cigna Commercial	$22.34
Rate for Payer: Harvard Pilgrim Health Care HMO	$22.34
Rate for Payer: Harvard Pilgrim Health Care PPO	$22.34
Rate for Payer: Multiplan Commercial	$25.97
Rate for Payer: MVP Health Care of NY Commercial	$23.73
Rate for Payer: United Healthcare Commercial	$26.52

LIDOC-MPF 1% W/EPI 20 ML VIAL

Facility

$27.92

Service Code	HCPCS J2004
Hospital Charge Code	636J200402
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$26.52
Rate for Payer: Aetna of VT Commercial	$26.52
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan	$12.37
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$0.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange	$16.81
Rate for Payer: Blue Cross Blue Shield of Vermont Commercial	$23.73
Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care	$22.62
Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage	$12.56
Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan	$22.20
Rate for Payer: Cash Price	$13.96
Rate for Payer: Cash Price	$13.96
Rate for Payer: Cigna Commercial	$22.34
Rate for Payer: Harvard Pilgrim Health Care HMO	$22.34
Rate for Payer: Harvard Pilgrim Health Care PPO	$22.34
Rate for Payer: Martins Point Health Care Commercial	$12.56
Rate for Payer: Multiplan Commercial	$25.97
Rate for Payer: MVP Health Care of NY Commercial	$23.73
Rate for Payer: MVP Health Care of NY Medicare Advantage	$12.56
Rate for Payer: United Healthcare Commercial	$26.52
Rate for Payer: United Healthcare Medicare Advantage	$12.56
Rate for Payer: United Healthcare VA CCN	$12.56

LIDO-MPF 1% W/EPI 1:100,000

Facility

$27.92

Hospital Charge Code	2500000175
Hospital Revenue Code	250
Min. Negotiated Rate	$12.37
Max. Negotiated Rate	$26.52
Rate for Payer: Aetna of VT Commercial	$26.52
Rate for Payer: Blue Cross Blue Shield of New Hampshire Commercial	$25.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire Qualified Health Plan	$12.37
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP Off Exchange	$25.01
Rate for Payer: Blue Cross Blue Shield of New Hampshire SHOP On Exchange	$16.81
Rate for Payer: Blue Cross Blue Shield of Vermont Commercial	$23.73
Rate for Payer: Blue Cross Blue Shield of Vermont Managed Care	$22.62
Rate for Payer: Blue Cross Blue Shield of Vermont Medicare Advantage	$12.56
Rate for Payer: Blue Cross Blue Shield of Vermont Vermont Health Plan	$22.20
Rate for Payer: Cash Price	$13.96
Rate for Payer: Cigna Commercial	$22.34
Rate for Payer: Harvard Pilgrim Health Care HMO	$22.34
Rate for Payer: Harvard Pilgrim Health Care PPO	$22.34
Rate for Payer: Martins Point Health Care Commercial	$12.56
Rate for Payer: Multiplan Commercial	$25.97
Rate for Payer: MVP Health Care of NY Commercial	$23.73
Rate for Payer: MVP Health Care of NY Medicare Advantage	$12.56
Rate for Payer: United Healthcare Commercial	$26.52
Rate for Payer: United Healthcare Medicare Advantage	$12.56
Rate for Payer: United Healthcare VA CCN	$12.56

Know your out-of-pocket cost for care.

All Charges