St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

EMITRI/RILP/TENO 200-25-300MG TAB

Facility

$120.89

Hospital Charge Code	41647048
Hospital Revenue Code	250
Min. Negotiated Rate	$42.31
Max. Negotiated Rate	$96.71
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$66.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$60.44
Rate for Payer: Aetna Government	$60.44
Rate for Payer: Brighton Health Commercial	$90.67
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$96.71
Rate for Payer: Cigna LocalPlus Benefit Plan	$82.21
Rate for Payer: Group Health Inc Commercial	$60.44
Rate for Payer: Group Health Inc Medicare	$42.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$60.44
Rate for Payer: Hamaspik Choice Inc Medicare	$60.44
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$78.58

EMPTY SCREW DISC FOR 1.7 MM

Facility

$568.00

Service Code	HCPCS C1713
Hospital Charge Code	40201334
Hospital Revenue Code	278
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$596.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$312.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$134.20
Rate for Payer: Aetna Government	$134.20
Rate for Payer: Brighton Health Commercial	$340.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$284.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$326.60
Rate for Payer: EmblemHealth Commercial	$284.00
Rate for Payer: Fidelis Medicare Advantage	$596.40
Rate for Payer: Group Health Inc Commercial	$284.00
Rate for Payer: Group Health Inc Medicare	$198.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$284.00
Rate for Payer: Hamaspik Choice Inc Medicare	$284.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$369.20

EMPTY SCREW DISC FOR 1.7 MM

Facility

$568.00

Service Code	HCPCS C1713
Hospital Charge Code	40201334
Hospital Revenue Code	278
Min. Negotiated Rate	$284.00
Max. Negotiated Rate	$284.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$284.00
Rate for Payer: Hamaspik Choice Inc Medicare	$284.00

EMPTY STERILIZED MISC [2795]

Facility

$1.36

Service Code	NDC 63323000110
Hospital Charge Code	63323000110
Hospital Revenue Code	250
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$1.08
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.68
Rate for Payer: Aetna Government	$0.68
Rate for Payer: Brighton Health Commercial	$1.02
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.08
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.92
Rate for Payer: Group Health Inc Commercial	$0.68
Rate for Payer: Group Health Inc Medicare	$0.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.68
Rate for Payer: Hamaspik Choice Inc Medicare	$0.68
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.88

EMTRICITABINE 200 MG CAP

Facility

$27.73

Hospital Charge Code	41653207
Hospital Revenue Code	250
Min. Negotiated Rate	$9.71
Max. Negotiated Rate	$22.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$15.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$13.86
Rate for Payer: Aetna Government	$13.86
Rate for Payer: Brighton Health Commercial	$20.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$22.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$18.86
Rate for Payer: Group Health Inc Commercial	$13.86
Rate for Payer: Group Health Inc Medicare	$9.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.86
Rate for Payer: Hamaspik Choice Inc Medicare	$13.86
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$18.02

EMTRICITABINE 200 MG CAP

Facility

$27.73

Hospital Charge Code	41643207
Hospital Revenue Code	250
Min. Negotiated Rate	$9.71
Max. Negotiated Rate	$22.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$15.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$13.86
Rate for Payer: Aetna Government	$13.86
Rate for Payer: Brighton Health Commercial	$20.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$22.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$18.86
Rate for Payer: Group Health Inc Commercial	$13.86
Rate for Payer: Group Health Inc Medicare	$9.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$13.86
Rate for Payer: Hamaspik Choice Inc Medicare	$13.86
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$18.02

EMTRICITABINE 200 MG PO CAPS [36252]

Facility

$19.31

Service Code	NDC 69097064202
Hospital Charge Code	69097064202
Hospital Revenue Code	250
Min. Negotiated Rate	$6.76
Max. Negotiated Rate	$15.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$10.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.66
Rate for Payer: Aetna Government	$9.66
Rate for Payer: Brighton Health Commercial	$14.48
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$15.45
Rate for Payer: Cigna LocalPlus Benefit Plan	$13.13
Rate for Payer: Group Health Inc Commercial	$9.66
Rate for Payer: Group Health Inc Medicare	$6.76
Rate for Payer: Hamaspik Choice Inc Medicaid	$9.66
Rate for Payer: Hamaspik Choice Inc Medicare	$9.66
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$12.55

EMTRICITABINE TENOF EFAVRIENZ TAB

Facility

$114.40

Hospital Charge Code	41647004
Hospital Revenue Code	250
Min. Negotiated Rate	$40.04
Max. Negotiated Rate	$91.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$62.92
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$57.20
Rate for Payer: Aetna Government	$57.20
Rate for Payer: Brighton Health Commercial	$85.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$91.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$77.79
Rate for Payer: Group Health Inc Commercial	$57.20
Rate for Payer: Group Health Inc Medicare	$40.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$57.20
Rate for Payer: Hamaspik Choice Inc Medicare	$57.20
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$74.36

EMTRICITABINE-TENOFOVIR 100-150MG

Facility

$0.01

Hospital Charge Code	41640353
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

EMTRICITABINE-TENOFOVIR 100-150MG

Facility

$0.01

Hospital Charge Code	41650353
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

EMTRICITABINE-TENOFOVIR 133-200MG

Facility

$0.01

Hospital Charge Code	41650354
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

EMTRICITABINE-TENOFOVIR 133-200MG

Facility

$0.01

Hospital Charge Code	41640354
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

EMTRICITABINE-TENOFOVIR 167-250MG

Facility

$0.01

Hospital Charge Code	41650355
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

EMTRICITABINE-TENOFOVIR 167-250MG

Facility

$0.01

Hospital Charge Code	41640355
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.01
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.01
Rate for Payer: Aetna Government	$0.01
Rate for Payer: Brighton Health Commercial	$0.01
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.01
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.01
Rate for Payer: Group Health Inc Commercial	$0.01
Rate for Payer: Group Health Inc Medicare	$0.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.01
Rate for Payer: Hamaspik Choice Inc Medicare	$0.01
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.01

EMTRICITABINE-TENOFOVIR AF 200-25 MG PO TABS [132397]

Facility

$88.09

Service Code	NDC 61958200201
Hospital Charge Code	61958200201
Hospital Revenue Code	250
Min. Negotiated Rate	$30.83
Max. Negotiated Rate	$70.47
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$48.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.05
Rate for Payer: Aetna Government	$44.05
Rate for Payer: Brighton Health Commercial	$66.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$70.47
Rate for Payer: Cigna LocalPlus Benefit Plan	$59.90
Rate for Payer: Group Health Inc Commercial	$44.05
Rate for Payer: Group Health Inc Medicare	$30.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.05
Rate for Payer: Hamaspik Choice Inc Medicare	$44.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$57.26

EMTRICITABINE-TENOFOVIR AF 200-25 MG PO TABS [132397]

Facility

$88.09

Service Code	NDC 61958200202
Hospital Charge Code	61958200202
Hospital Revenue Code	250
Min. Negotiated Rate	$30.83
Max. Negotiated Rate	$70.47
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$48.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$44.05
Rate for Payer: Aetna Government	$44.05
Rate for Payer: Brighton Health Commercial	$66.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$70.47
Rate for Payer: Cigna LocalPlus Benefit Plan	$59.90
Rate for Payer: Group Health Inc Commercial	$44.05
Rate for Payer: Group Health Inc Medicare	$30.83
Rate for Payer: Hamaspik Choice Inc Medicaid	$44.05
Rate for Payer: Hamaspik Choice Inc Medicare	$44.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$57.26

EMTRICITABINE-TENOFOVIR DF 100-150 MG PO TABS [132351]

Facility

$70.01

Service Code	NDC 69238209203
Hospital Charge Code	69238209203
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: 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 133-200 MG PO TABS [132352]

Facility

$70.01

Service Code	NDC 69238209303
Hospital Charge Code	69238209303
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: 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 167-250 MG PO TABS [132353]

Facility

$70.01

Service Code	NDC 69238209403
Hospital Charge Code	69238209403
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: 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 [39255]

Facility

$70.01

Service Code	NDC 00093770456
Hospital Charge Code	00093770456
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: 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 [39255]

Facility

$70.01

Service Code	NDC 70710136703
Hospital Charge Code	70710136703
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: 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 [39255]

Facility

$70.01

Service Code	NDC 60505420203
Hospital Charge Code	60505420203
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: 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 [39255]

Facility

$70.01

Service Code	NDC 42385095330
Hospital Charge Code	42385095330
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: 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 [39255]

Facility

$73.69

Service Code	NDC 61958070101
Hospital Charge Code	61958070101
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: 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

EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS [39255]

Facility

$70.01

Service Code	NDC 65862035430
Hospital Charge Code	65862035430
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: 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

Know your out-of-pocket cost for care.

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