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All Charges

Charge

Type

Setting

Price

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS

Facility

OP

$70.01

Service Code	NDC 6586235430
Hospital Charge Code	6586235430
Hospital Revenue Code	250
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$56.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$38.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.00
Rate for Payer: Aetna Government	$35.00
Rate for Payer: Brighton Health Commercial	$52.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$56.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$47.60
Rate for Payer: EmblemHealth Commercial	$35.00
Rate for Payer: Group Health Inc Commercial	$35.00
Rate for Payer: Group Health Inc Medicare	$24.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.00
Rate for Payer: Hamaspik Choice Inc Medicare	$35.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$45.50

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS

Facility

IP

$70.01

Service Code	NDC 7071013673
Hospital Charge Code	7071013673
Hospital Revenue Code	250
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$35.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.00

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS

Facility

IP

$70.01

Service Code	NDC 6586235430
Hospital Charge Code	6586235430
Hospital Revenue Code	250
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$35.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.00

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS

Facility

IP

$70.01

Service Code	NDC 4238595330
Hospital Charge Code	4238595330
Hospital Revenue Code	250
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$35.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.00

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS

Facility

OP

$70.01

Service Code	NDC 4238595330
Hospital Charge Code	4238595330
Hospital Revenue Code	250
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$56.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$38.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.00
Rate for Payer: Aetna Government	$35.00
Rate for Payer: Brighton Health Commercial	$52.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$56.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$47.60
Rate for Payer: EmblemHealth Commercial	$35.00
Rate for Payer: Group Health Inc Commercial	$35.00
Rate for Payer: Group Health Inc Medicare	$24.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.00
Rate for Payer: Hamaspik Choice Inc Medicare	$35.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$45.50

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS

Facility

OP

$70.01

Service Code	NDC 7071013673
Hospital Charge Code	7071013673
Hospital Revenue Code	250
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$56.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$38.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.00
Rate for Payer: Aetna Government	$35.00
Rate for Payer: Brighton Health Commercial	$52.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$56.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$47.60
Rate for Payer: EmblemHealth Commercial	$35.00
Rate for Payer: Group Health Inc Commercial	$35.00
Rate for Payer: Group Health Inc Medicare	$24.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.00
Rate for Payer: Hamaspik Choice Inc Medicare	$35.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$45.50

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS

Facility

OP

$70.01

Service Code	NDC 6050542023
Hospital Charge Code	6050542023
Hospital Revenue Code	250
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$56.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$38.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.00
Rate for Payer: Aetna Government	$35.00
Rate for Payer: Brighton Health Commercial	$52.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$56.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$47.60
Rate for Payer: EmblemHealth Commercial	$35.00
Rate for Payer: Group Health Inc Commercial	$35.00
Rate for Payer: Group Health Inc Medicare	$24.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.00
Rate for Payer: Hamaspik Choice Inc Medicare	$35.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$45.50

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS

Facility

IP

$70.01

Service Code	NDC 0093770456
Hospital Charge Code	0093770456
Hospital Revenue Code	250
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$35.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.00

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS

Facility

OP

$70.01

Service Code	NDC 6438071904
Hospital Charge Code	6438071904
Hospital Revenue Code	250
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$56.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$38.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.00
Rate for Payer: Aetna Government	$35.00
Rate for Payer: Brighton Health Commercial	$52.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$56.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$47.60
Rate for Payer: EmblemHealth Commercial	$35.00
Rate for Payer: Group Health Inc Commercial	$35.00
Rate for Payer: Group Health Inc Medicare	$24.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.00
Rate for Payer: Hamaspik Choice Inc Medicare	$35.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$45.50

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS

Facility

IP

$70.01

Service Code	NDC 6050542023
Hospital Charge Code	6050542023
Hospital Revenue Code	250
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$35.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.00

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS

Facility

IP

$70.01

Service Code	NDC 6438071904
Hospital Charge Code	6438071904
Hospital Revenue Code	250
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$35.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.00

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS

Facility

OP

$70.01

Service Code	NDC 0093770456
Hospital Charge Code	0093770456
Hospital Revenue Code	250
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$56.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$38.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$35.00
Rate for Payer: Aetna Government	$35.00
Rate for Payer: Brighton Health Commercial	$52.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$56.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$47.60
Rate for Payer: EmblemHealth Commercial	$35.00
Rate for Payer: Group Health Inc Commercial	$35.00
Rate for Payer: Group Health Inc Medicare	$24.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$35.00
Rate for Payer: Hamaspik Choice Inc Medicare	$35.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$45.50

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS

Facility

IP

$73.69

Service Code	NDC 6195807011
Hospital Charge Code	6195807011
Hospital Revenue Code	250
Min. Negotiated Rate	$36.85
Max. Negotiated Rate	$36.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.85

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS

Facility

OP

$73.69

Service Code	NDC 6195807011
Hospital Charge Code	6195807011
Hospital Revenue Code	250
Min. Negotiated Rate	$25.79
Max. Negotiated Rate	$58.95
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$40.53
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$36.85
Rate for Payer: Aetna Government	$36.85
Rate for Payer: Brighton Health Commercial	$55.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$58.95
Rate for Payer: Cigna LocalPlus Benefit Plan	$50.11
Rate for Payer: EmblemHealth Commercial	$36.85
Rate for Payer: Group Health Inc Commercial	$36.85
Rate for Payer: Group Health Inc Medicare	$25.79
Rate for Payer: Hamaspik Choice Inc Medicaid	$36.85
Rate for Payer: Hamaspik Choice Inc Medicare	$36.85
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$47.90

EMTRICITAB-RILPIVIR-TENOFOV AF 200-25-25 MG PO TABS

Facility

IP

$144.93

Service Code	NDC 6195821011
Hospital Charge Code	6195821011
Hospital Revenue Code	250
Min. Negotiated Rate	$72.46
Max. Negotiated Rate	$72.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$72.46

EMTRICITAB-RILPIVIR-TENOFOV AF 200-25-25 MG PO TABS

Facility

OP

$144.93

Service Code	NDC 6195821011
Hospital Charge Code	6195821011
Hospital Revenue Code	250
Min. Negotiated Rate	$50.72
Max. Negotiated Rate	$115.94
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$79.71
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$72.46
Rate for Payer: Aetna Government	$72.46
Rate for Payer: Brighton Health Commercial	$108.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$115.94
Rate for Payer: Cigna LocalPlus Benefit Plan	$98.55
Rate for Payer: EmblemHealth Commercial	$72.46
Rate for Payer: Group Health Inc Commercial	$72.46
Rate for Payer: Group Health Inc Medicare	$50.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$72.46
Rate for Payer: Hamaspik Choice Inc Medicare	$72.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$94.20

EMTRICITAB-RILPIVIR-TENOFOV DF 200-25-300 MG PO TABS

Facility

IP

$144.93

Service Code	NDC 6195811011
Hospital Charge Code	6195811011
Hospital Revenue Code	250
Min. Negotiated Rate	$72.46
Max. Negotiated Rate	$72.46
Rate for Payer: Hamaspik Choice Inc Medicaid	$72.46

EMTRICITAB-RILPIVIR-TENOFOV DF 200-25-300 MG PO TABS

Facility

OP

$144.93

Service Code	NDC 6195811011
Hospital Charge Code	6195811011
Hospital Revenue Code	250
Min. Negotiated Rate	$50.72
Max. Negotiated Rate	$115.94
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$79.71
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$72.46
Rate for Payer: Aetna Government	$72.46
Rate for Payer: Brighton Health Commercial	$108.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$115.94
Rate for Payer: Cigna LocalPlus Benefit Plan	$98.55
Rate for Payer: EmblemHealth Commercial	$72.46
Rate for Payer: Group Health Inc Commercial	$72.46
Rate for Payer: Group Health Inc Medicare	$50.72
Rate for Payer: Hamaspik Choice Inc Medicaid	$72.46
Rate for Payer: Hamaspik Choice Inc Medicare	$72.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$94.20

ENALAPRILAT 1.25 MG/ML IV SOLN

Facility

IP

$6.37

Service Code	NDC 0143978701
Hospital Charge Code	0143978701
Hospital Revenue Code	258
Min. Negotiated Rate	$3.19
Max. Negotiated Rate	$3.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.19

ENALAPRILAT 1.25 MG/ML IV SOLN

Facility

OP

$6.37

Service Code	NDC 0143978710
Hospital Charge Code	0143978710
Hospital Revenue Code	258
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$5.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.19
Rate for Payer: Aetna Government	$3.19
Rate for Payer: Brighton Health Commercial	$4.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.33
Rate for Payer: EmblemHealth Commercial	$3.19
Rate for Payer: Group Health Inc Commercial	$3.19
Rate for Payer: Group Health Inc Medicare	$2.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.19
Rate for Payer: Hamaspik Choice Inc Medicare	$3.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.14

ENALAPRILAT 1.25 MG/ML IV SOLN

Facility

IP

$5.69

Service Code	NDC 0143978601
Hospital Charge Code	0143978601
Hospital Revenue Code	258
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$2.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.85

ENALAPRILAT 1.25 MG/ML IV SOLN

Facility

IP

$6.37

Service Code	NDC 0143978710
Hospital Charge Code	0143978710
Hospital Revenue Code	258
Min. Negotiated Rate	$3.19
Max. Negotiated Rate	$3.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.19

ENALAPRILAT 1.25 MG/ML IV SOLN

Facility

OP

$5.69

Service Code	NDC 0143978610
Hospital Charge Code	0143978610
Hospital Revenue Code	258
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$4.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.84
Rate for Payer: Aetna Government	$2.84
Rate for Payer: Brighton Health Commercial	$4.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.55
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.87
Rate for Payer: EmblemHealth Commercial	$2.84
Rate for Payer: Group Health Inc Commercial	$2.84
Rate for Payer: Group Health Inc Medicare	$1.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.84
Rate for Payer: Hamaspik Choice Inc Medicare	$2.84
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.70

ENALAPRILAT 1.25 MG/ML IV SOLN

Facility

IP

$5.69

Service Code	NDC 0143978610
Hospital Charge Code	0143978610
Hospital Revenue Code	258
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$2.84
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.84

ENALAPRILAT 1.25 MG/ML IV SOLN

Facility

OP

$6.37

Service Code	NDC 0143978701
Hospital Charge Code	0143978701
Hospital Revenue Code	258
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$5.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.19
Rate for Payer: Aetna Government	$3.19
Rate for Payer: Brighton Health Commercial	$4.78
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.33
Rate for Payer: EmblemHealth Commercial	$3.19
Rate for Payer: Group Health Inc Commercial	$3.19
Rate for Payer: Group Health Inc Medicare	$2.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.19
Rate for Payer: Hamaspik Choice Inc Medicare	$3.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.14

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