|
PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION [10245]
|
Facility
|
OP
|
$28.76
|
|
|
Service Code
|
NDC 6131463705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.85 |
| Max. Negotiated Rate |
$28.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$28.18
|
| Rate for Payer: Aetna of WY Medicare |
$18.98
|
| Rate for Payer: Altius Auto/Workers Compensation |
$27.61
|
| Rate for Payer: Altius Commercial |
$27.61
|
| Rate for Payer: Beech Street Commercial |
$28.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.61
|
| Rate for Payer: Cash Price |
$20.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.90
|
| Rate for Payer: Cigna of WY Commercial |
$28.18
|
| Rate for Payer: Entrust Commercial |
$27.32
|
| Rate for Payer: First Choice Health Commercial |
$27.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$27.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.68
|
| Rate for Payer: HealthUtah PPO |
$28.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.90
|
| Rate for Payer: Multiplan Medicare/VA |
$15.85
|
| Rate for Payer: One Health Plan of WY PPO |
$28.18
|
| Rate for Payer: PacificSource Commercial |
$25.88
|
| Rate for Payer: PHCS PPO |
$28.18
|
| Rate for Payer: Three Rivers PPO |
$21.57
|
| Rate for Payer: TriWest Veterans Administration |
$16.68
|
| Rate for Payer: United Healthcare Commercial |
$25.02
|
| Rate for Payer: United Healthcare Medicare |
$16.68
|
| Rate for Payer: WINHealth Partners Commercial |
$28.18
|
| Rate for Payer: Wise Provider Network Commercial |
$27.32
|
|
|
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION [2113]
|
Facility
|
OP
|
$1.76
|
|
|
Service Code
|
HCPCS J7510
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.72
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.86
|
| Rate for Payer: Aetna of WY Medicare |
$1.16
|
| Rate for Payer: Aetna of WY Medicare |
$0.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.69
|
| Rate for Payer: Altius Commercial |
$1.69
|
| Rate for Payer: Altius Commercial |
$0.84
|
| Rate for Payer: Beech Street Commercial |
$0.86
|
| Rate for Payer: Beech Street Commercial |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.72
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.85
|
| Rate for Payer: Cigna of WY Commercial |
$0.86
|
| Rate for Payer: Cigna of WY Commercial |
$1.72
|
| Rate for Payer: Entrust Commercial |
$1.67
|
| Rate for Payer: Entrust Commercial |
$0.84
|
| Rate for Payer: First Choice Health Commercial |
$0.84
|
| Rate for Payer: First Choice Health Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.51
|
| Rate for Payer: HealthUtah PPO |
$0.88
|
| Rate for Payer: HealthUtah PPO |
$1.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.85
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.71
|
| Rate for Payer: Multiplan Medicare/VA |
$0.97
|
| Rate for Payer: Multiplan Medicare/VA |
$0.48
|
| Rate for Payer: One Health Plan of WY PPO |
$0.86
|
| Rate for Payer: One Health Plan of WY PPO |
$1.72
|
| Rate for Payer: PacificSource Commercial |
$1.58
|
| Rate for Payer: PacificSource Commercial |
$0.79
|
| Rate for Payer: PHCS PPO |
$0.86
|
| Rate for Payer: PHCS PPO |
$1.72
|
| Rate for Payer: Three Rivers PPO |
$0.66
|
| Rate for Payer: Three Rivers PPO |
$1.32
|
| Rate for Payer: TriWest Veterans Administration |
$1.02
|
| Rate for Payer: TriWest Veterans Administration |
$0.51
|
| Rate for Payer: United Healthcare Commercial |
$0.77
|
| Rate for Payer: United Healthcare Commercial |
$1.53
|
| Rate for Payer: United Healthcare Medicare |
$1.02
|
| Rate for Payer: United Healthcare Medicare |
$0.51
|
| Rate for Payer: WINHealth Partners Commercial |
$0.86
|
| Rate for Payer: WINHealth Partners Commercial |
$1.72
|
| Rate for Payer: Wise Provider Network Commercial |
$0.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1.67
|
|
|
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION [2113]
|
Facility
|
IP
|
$1.76
|
|
|
Service Code
|
HCPCS J7510
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.72
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.84
|
| Rate for Payer: Altius Commercial |
$0.84
|
| Rate for Payer: Altius Commercial |
$1.69
|
| Rate for Payer: Beech Street Commercial |
$1.72
|
| Rate for Payer: Beech Street Commercial |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.71
|
| Rate for Payer: Cigna of WY Commercial |
$1.72
|
| Rate for Payer: Cigna of WY Commercial |
$0.86
|
| Rate for Payer: Entrust Commercial |
$0.84
|
| Rate for Payer: Entrust Commercial |
$1.67
|
| Rate for Payer: First Choice Health Commercial |
$0.84
|
| Rate for Payer: First Choice Health Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.58
|
| Rate for Payer: HealthUtah PPO |
$1.76
|
| Rate for Payer: HealthUtah PPO |
$0.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.85
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.71
|
| Rate for Payer: Multiplan Medicare/VA |
$1.10
|
| Rate for Payer: Multiplan Medicare/VA |
$0.55
|
| Rate for Payer: One Health Plan of WY PPO |
$1.72
|
| Rate for Payer: One Health Plan of WY PPO |
$0.86
|
| Rate for Payer: PacificSource Commercial |
$1.58
|
| Rate for Payer: PacificSource Commercial |
$0.79
|
| Rate for Payer: PHCS PPO |
$0.86
|
| Rate for Payer: PHCS PPO |
$1.72
|
| Rate for Payer: Three Rivers PPO |
$0.66
|
| Rate for Payer: Three Rivers PPO |
$1.32
|
| Rate for Payer: TriWest Veterans Administration |
$1.16
|
| Rate for Payer: TriWest Veterans Administration |
$0.58
|
| Rate for Payer: United Healthcare Commercial |
$0.77
|
| Rate for Payer: United Healthcare Commercial |
$1.53
|
| Rate for Payer: United Healthcare Medicare |
$1.16
|
| Rate for Payer: United Healthcare Medicare |
$0.58
|
| Rate for Payer: WINHealth Partners Commercial |
$0.84
|
| Rate for Payer: WINHealth Partners Commercial |
$1.67
|
| Rate for Payer: Wise Provider Network Commercial |
$0.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1.67
|
|
|
PREDNISONE 1 MG TABLET [11242]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 6021917051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.38
|
| Rate for Payer: Altius Commercial |
$0.38
|
| Rate for Payer: Beech Street Commercial |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.39
|
| Rate for Payer: Cigna of WY Commercial |
$0.39
|
| Rate for Payer: Entrust Commercial |
$0.38
|
| Rate for Payer: First Choice Health Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.26
|
| Rate for Payer: HealthUtah PPO |
$0.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.25
|
| Rate for Payer: One Health Plan of WY PPO |
$0.39
|
| Rate for Payer: PacificSource Commercial |
$0.36
|
| Rate for Payer: PHCS PPO |
$0.39
|
| Rate for Payer: Three Rivers PPO |
$0.30
|
| Rate for Payer: TriWest Veterans Administration |
$0.26
|
| Rate for Payer: United Healthcare Commercial |
$0.35
|
| Rate for Payer: United Healthcare Medicare |
$0.26
|
| Rate for Payer: WINHealth Partners Commercial |
$0.38
|
| Rate for Payer: Wise Provider Network Commercial |
$0.38
|
|
|
PREDNISONE 1 MG TABLET [11242]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 6021917051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.39
|
| Rate for Payer: Aetna of WY Medicare |
$0.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.38
|
| Rate for Payer: Altius Commercial |
$0.38
|
| Rate for Payer: Beech Street Commercial |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.39
|
| Rate for Payer: Cigna of WY Commercial |
$0.39
|
| Rate for Payer: Entrust Commercial |
$0.38
|
| Rate for Payer: First Choice Health Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.23
|
| Rate for Payer: HealthUtah PPO |
$0.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.22
|
| Rate for Payer: One Health Plan of WY PPO |
$0.39
|
| Rate for Payer: PacificSource Commercial |
$0.36
|
| Rate for Payer: PHCS PPO |
$0.39
|
| Rate for Payer: Three Rivers PPO |
$0.30
|
| Rate for Payer: TriWest Veterans Administration |
$0.23
|
| Rate for Payer: United Healthcare Commercial |
$0.35
|
| Rate for Payer: United Healthcare Medicare |
$0.23
|
| Rate for Payer: WINHealth Partners Commercial |
$0.39
|
| Rate for Payer: Wise Provider Network Commercial |
$0.38
|
|
|
PREDNISONE 20 MG TABLET [4755]
|
Facility
|
OP
|
$0.79
|
|
|
Service Code
|
HCPCS J7512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.77
|
| Rate for Payer: Aetna of WY Medicare |
$0.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.76
|
| Rate for Payer: Altius Commercial |
$0.76
|
| Rate for Payer: Beech Street Commercial |
$0.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.65
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.77
|
| Rate for Payer: Cigna of WY Commercial |
$0.77
|
| Rate for Payer: Entrust Commercial |
$0.75
|
| Rate for Payer: First Choice Health Commercial |
$0.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.46
|
| Rate for Payer: HealthUtah PPO |
$0.79
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.77
|
| Rate for Payer: Multiplan Medicare/VA |
$0.44
|
| Rate for Payer: One Health Plan of WY PPO |
$0.77
|
| Rate for Payer: PacificSource Commercial |
$0.71
|
| Rate for Payer: PHCS PPO |
$0.77
|
| Rate for Payer: Three Rivers PPO |
$0.59
|
| Rate for Payer: TriWest Veterans Administration |
$0.46
|
| Rate for Payer: United Healthcare Commercial |
$0.69
|
| Rate for Payer: United Healthcare Medicare |
$0.46
|
| Rate for Payer: WINHealth Partners Commercial |
$0.77
|
| Rate for Payer: Wise Provider Network Commercial |
$0.75
|
|
|
PREDNISONE 20 MG TABLET [4755]
|
Facility
|
IP
|
$0.79
|
|
|
Service Code
|
HCPCS J7512
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.77
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.76
|
| Rate for Payer: Altius Commercial |
$0.76
|
| Rate for Payer: Beech Street Commercial |
$0.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.65
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.77
|
| Rate for Payer: Cigna of WY Commercial |
$0.77
|
| Rate for Payer: Entrust Commercial |
$0.75
|
| Rate for Payer: First Choice Health Commercial |
$0.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.52
|
| Rate for Payer: HealthUtah PPO |
$0.79
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.77
|
| Rate for Payer: Multiplan Medicare/VA |
$0.50
|
| Rate for Payer: One Health Plan of WY PPO |
$0.77
|
| Rate for Payer: PacificSource Commercial |
$0.71
|
| Rate for Payer: PHCS PPO |
$0.77
|
| Rate for Payer: Three Rivers PPO |
$0.59
|
| Rate for Payer: TriWest Veterans Administration |
$0.52
|
| Rate for Payer: United Healthcare Commercial |
$0.69
|
| Rate for Payer: United Healthcare Medicare |
$0.52
|
| Rate for Payer: WINHealth Partners Commercial |
$0.75
|
| Rate for Payer: Wise Provider Network Commercial |
$0.75
|
|
|
PREDNISONE 5 MG TABLET [5282]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 6068712211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.64
|
| Rate for Payer: Altius Commercial |
$0.64
|
| Rate for Payer: Beech Street Commercial |
$0.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.65
|
| Rate for Payer: Cigna of WY Commercial |
$0.66
|
| Rate for Payer: Entrust Commercial |
$0.64
|
| Rate for Payer: First Choice Health Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.44
|
| Rate for Payer: HealthUtah PPO |
$0.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.65
|
| Rate for Payer: Multiplan Medicare/VA |
$0.42
|
| Rate for Payer: One Health Plan of WY PPO |
$0.66
|
| Rate for Payer: PacificSource Commercial |
$0.60
|
| Rate for Payer: PHCS PPO |
$0.66
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.44
|
| Rate for Payer: United Healthcare Commercial |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
| Rate for Payer: WINHealth Partners Commercial |
$0.64
|
| Rate for Payer: Wise Provider Network Commercial |
$0.64
|
|
|
PREDNISONE 5 MG TABLET [5282]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 6068712201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.64
|
| Rate for Payer: Altius Commercial |
$0.64
|
| Rate for Payer: Beech Street Commercial |
$0.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.65
|
| Rate for Payer: Cigna of WY Commercial |
$0.66
|
| Rate for Payer: Entrust Commercial |
$0.64
|
| Rate for Payer: First Choice Health Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.44
|
| Rate for Payer: HealthUtah PPO |
$0.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.65
|
| Rate for Payer: Multiplan Medicare/VA |
$0.42
|
| Rate for Payer: One Health Plan of WY PPO |
$0.66
|
| Rate for Payer: PacificSource Commercial |
$0.60
|
| Rate for Payer: PHCS PPO |
$0.66
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.44
|
| Rate for Payer: United Healthcare Commercial |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
| Rate for Payer: WINHealth Partners Commercial |
$0.64
|
| Rate for Payer: Wise Provider Network Commercial |
$0.64
|
|
|
PREDNISONE 5 MG TABLET [5282]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 6068712211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.66
|
| Rate for Payer: Aetna of WY Medicare |
$0.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.64
|
| Rate for Payer: Altius Commercial |
$0.64
|
| Rate for Payer: Beech Street Commercial |
$0.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.65
|
| Rate for Payer: Cigna of WY Commercial |
$0.66
|
| Rate for Payer: Entrust Commercial |
$0.64
|
| Rate for Payer: First Choice Health Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.39
|
| Rate for Payer: HealthUtah PPO |
$0.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.65
|
| Rate for Payer: Multiplan Medicare/VA |
$0.37
|
| Rate for Payer: One Health Plan of WY PPO |
$0.66
|
| Rate for Payer: PacificSource Commercial |
$0.60
|
| Rate for Payer: PHCS PPO |
$0.66
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.39
|
| Rate for Payer: United Healthcare Commercial |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
| Rate for Payer: WINHealth Partners Commercial |
$0.66
|
| Rate for Payer: Wise Provider Network Commercial |
$0.64
|
|
|
PREDNISONE 5 MG TABLET [5282]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 6068712201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.66
|
| Rate for Payer: Aetna of WY Medicare |
$0.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.64
|
| Rate for Payer: Altius Commercial |
$0.64
|
| Rate for Payer: Beech Street Commercial |
$0.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.65
|
| Rate for Payer: Cigna of WY Commercial |
$0.66
|
| Rate for Payer: Entrust Commercial |
$0.64
|
| Rate for Payer: First Choice Health Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.39
|
| Rate for Payer: HealthUtah PPO |
$0.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.65
|
| Rate for Payer: Multiplan Medicare/VA |
$0.37
|
| Rate for Payer: One Health Plan of WY PPO |
$0.66
|
| Rate for Payer: PacificSource Commercial |
$0.60
|
| Rate for Payer: PHCS PPO |
$0.66
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.39
|
| Rate for Payer: United Healthcare Commercial |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
| Rate for Payer: WINHealth Partners Commercial |
$0.66
|
| Rate for Payer: Wise Provider Network Commercial |
$0.64
|
|
|
PREGABALIN 100 MG CAPSULE [39104]
|
Facility
|
OP
|
$5.39
|
|
|
Service Code
|
NDC 6068750611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.28
|
| Rate for Payer: Aetna of WY Medicare |
$3.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.17
|
| Rate for Payer: Altius Commercial |
$5.17
|
| Rate for Payer: Beech Street Commercial |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.43
|
| Rate for Payer: Cash Price |
$3.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.23
|
| Rate for Payer: Cigna of WY Commercial |
$5.28
|
| Rate for Payer: Entrust Commercial |
$5.12
|
| Rate for Payer: First Choice Health Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.13
|
| Rate for Payer: HealthUtah PPO |
$5.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.23
|
| Rate for Payer: Multiplan Medicare/VA |
$2.97
|
| Rate for Payer: One Health Plan of WY PPO |
$5.28
|
| Rate for Payer: PacificSource Commercial |
$4.85
|
| Rate for Payer: PHCS PPO |
$5.28
|
| Rate for Payer: Three Rivers PPO |
$4.04
|
| Rate for Payer: TriWest Veterans Administration |
$3.13
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$3.13
|
| Rate for Payer: WINHealth Partners Commercial |
$5.28
|
| Rate for Payer: Wise Provider Network Commercial |
$5.12
|
|
|
PREGABALIN 100 MG CAPSULE [39104]
|
Facility
|
OP
|
$5.39
|
|
|
Service Code
|
NDC 6068750601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.28
|
| Rate for Payer: Aetna of WY Medicare |
$3.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.17
|
| Rate for Payer: Altius Commercial |
$5.17
|
| Rate for Payer: Beech Street Commercial |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.43
|
| Rate for Payer: Cash Price |
$3.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.23
|
| Rate for Payer: Cigna of WY Commercial |
$5.28
|
| Rate for Payer: Entrust Commercial |
$5.12
|
| Rate for Payer: First Choice Health Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.13
|
| Rate for Payer: HealthUtah PPO |
$5.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.23
|
| Rate for Payer: Multiplan Medicare/VA |
$2.97
|
| Rate for Payer: One Health Plan of WY PPO |
$5.28
|
| Rate for Payer: PacificSource Commercial |
$4.85
|
| Rate for Payer: PHCS PPO |
$5.28
|
| Rate for Payer: Three Rivers PPO |
$4.04
|
| Rate for Payer: TriWest Veterans Administration |
$3.13
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$3.13
|
| Rate for Payer: WINHealth Partners Commercial |
$5.28
|
| Rate for Payer: Wise Provider Network Commercial |
$5.12
|
|
|
PREGABALIN 100 MG CAPSULE [39104]
|
Facility
|
IP
|
$5.39
|
|
|
Service Code
|
NDC 6068750601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.17
|
| Rate for Payer: Altius Commercial |
$5.17
|
| Rate for Payer: Beech Street Commercial |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.43
|
| Rate for Payer: Cash Price |
$3.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.23
|
| Rate for Payer: Cigna of WY Commercial |
$5.28
|
| Rate for Payer: Entrust Commercial |
$5.12
|
| Rate for Payer: First Choice Health Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.56
|
| Rate for Payer: HealthUtah PPO |
$5.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.23
|
| Rate for Payer: Multiplan Medicare/VA |
$3.38
|
| Rate for Payer: One Health Plan of WY PPO |
$5.28
|
| Rate for Payer: PacificSource Commercial |
$4.85
|
| Rate for Payer: PHCS PPO |
$5.28
|
| Rate for Payer: Three Rivers PPO |
$4.04
|
| Rate for Payer: TriWest Veterans Administration |
$3.56
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$3.56
|
| Rate for Payer: WINHealth Partners Commercial |
$5.12
|
| Rate for Payer: Wise Provider Network Commercial |
$5.12
|
|
|
PREGABALIN 100 MG CAPSULE [39104]
|
Facility
|
IP
|
$5.39
|
|
|
Service Code
|
NDC 6068750611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.17
|
| Rate for Payer: Altius Commercial |
$5.17
|
| Rate for Payer: Beech Street Commercial |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.43
|
| Rate for Payer: Cash Price |
$3.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.23
|
| Rate for Payer: Cigna of WY Commercial |
$5.28
|
| Rate for Payer: Entrust Commercial |
$5.12
|
| Rate for Payer: First Choice Health Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.56
|
| Rate for Payer: HealthUtah PPO |
$5.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.23
|
| Rate for Payer: Multiplan Medicare/VA |
$3.38
|
| Rate for Payer: One Health Plan of WY PPO |
$5.28
|
| Rate for Payer: PacificSource Commercial |
$4.85
|
| Rate for Payer: PHCS PPO |
$5.28
|
| Rate for Payer: Three Rivers PPO |
$4.04
|
| Rate for Payer: TriWest Veterans Administration |
$3.56
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$3.56
|
| Rate for Payer: WINHealth Partners Commercial |
$5.12
|
| Rate for Payer: Wise Provider Network Commercial |
$5.12
|
|
|
PREGABALIN 200 MG CAPSULE [39106]
|
Facility
|
IP
|
$6.65
|
|
|
Service Code
|
NDC 0904700304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.17 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6.38
|
| Rate for Payer: Altius Commercial |
$6.38
|
| Rate for Payer: Beech Street Commercial |
$6.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.46
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.45
|
| Rate for Payer: Cigna of WY Commercial |
$6.52
|
| Rate for Payer: Entrust Commercial |
$6.32
|
| Rate for Payer: First Choice Health Commercial |
$6.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.39
|
| Rate for Payer: HealthUtah PPO |
$6.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.45
|
| Rate for Payer: Multiplan Medicare/VA |
$4.17
|
| Rate for Payer: One Health Plan of WY PPO |
$6.52
|
| Rate for Payer: PacificSource Commercial |
$5.98
|
| Rate for Payer: PHCS PPO |
$6.52
|
| Rate for Payer: Three Rivers PPO |
$4.99
|
| Rate for Payer: TriWest Veterans Administration |
$4.39
|
| Rate for Payer: United Healthcare Commercial |
$5.79
|
| Rate for Payer: United Healthcare Medicare |
$4.39
|
| Rate for Payer: WINHealth Partners Commercial |
$6.32
|
| Rate for Payer: Wise Provider Network Commercial |
$6.32
|
|
|
PREGABALIN 200 MG CAPSULE [39106]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 6586276390
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.30
|
| Rate for Payer: Aetna of WY Medicare |
$0.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.30
|
| Rate for Payer: Altius Commercial |
$0.30
|
| Rate for Payer: Beech Street Commercial |
$0.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.30
|
| Rate for Payer: Cigna of WY Commercial |
$0.30
|
| Rate for Payer: Entrust Commercial |
$0.29
|
| Rate for Payer: First Choice Health Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.18
|
| Rate for Payer: HealthUtah PPO |
$0.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.30
|
| Rate for Payer: Multiplan Medicare/VA |
$0.17
|
| Rate for Payer: One Health Plan of WY PPO |
$0.30
|
| Rate for Payer: PacificSource Commercial |
$0.28
|
| Rate for Payer: PHCS PPO |
$0.30
|
| Rate for Payer: Three Rivers PPO |
$0.23
|
| Rate for Payer: TriWest Veterans Administration |
$0.18
|
| Rate for Payer: United Healthcare Commercial |
$0.27
|
| Rate for Payer: United Healthcare Medicare |
$0.18
|
| Rate for Payer: WINHealth Partners Commercial |
$0.30
|
| Rate for Payer: Wise Provider Network Commercial |
$0.29
|
|
|
PREGABALIN 200 MG CAPSULE [39106]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 6586276390
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.30
|
| Rate for Payer: Altius Commercial |
$0.30
|
| Rate for Payer: Beech Street Commercial |
$0.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.30
|
| Rate for Payer: Cigna of WY Commercial |
$0.30
|
| Rate for Payer: Entrust Commercial |
$0.29
|
| Rate for Payer: First Choice Health Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.20
|
| Rate for Payer: HealthUtah PPO |
$0.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.30
|
| Rate for Payer: Multiplan Medicare/VA |
$0.19
|
| Rate for Payer: One Health Plan of WY PPO |
$0.30
|
| Rate for Payer: PacificSource Commercial |
$0.28
|
| Rate for Payer: PHCS PPO |
$0.30
|
| Rate for Payer: Three Rivers PPO |
$0.23
|
| Rate for Payer: TriWest Veterans Administration |
$0.20
|
| Rate for Payer: United Healthcare Commercial |
$0.27
|
| Rate for Payer: United Healthcare Medicare |
$0.20
|
| Rate for Payer: WINHealth Partners Commercial |
$0.29
|
| Rate for Payer: Wise Provider Network Commercial |
$0.29
|
|
|
PREGABALIN 200 MG CAPSULE [39106]
|
Facility
|
OP
|
$6.65
|
|
|
Service Code
|
NDC 0904700304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.52
|
| Rate for Payer: Aetna of WY Medicare |
$4.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6.38
|
| Rate for Payer: Altius Commercial |
$6.38
|
| Rate for Payer: Beech Street Commercial |
$6.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.46
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.45
|
| Rate for Payer: Cigna of WY Commercial |
$6.52
|
| Rate for Payer: Entrust Commercial |
$6.32
|
| Rate for Payer: First Choice Health Commercial |
$6.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.86
|
| Rate for Payer: HealthUtah PPO |
$6.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.45
|
| Rate for Payer: Multiplan Medicare/VA |
$3.66
|
| Rate for Payer: One Health Plan of WY PPO |
$6.52
|
| Rate for Payer: PacificSource Commercial |
$5.98
|
| Rate for Payer: PHCS PPO |
$6.52
|
| Rate for Payer: Three Rivers PPO |
$4.99
|
| Rate for Payer: TriWest Veterans Administration |
$3.86
|
| Rate for Payer: United Healthcare Commercial |
$5.79
|
| Rate for Payer: United Healthcare Medicare |
$3.86
|
| Rate for Payer: WINHealth Partners Commercial |
$6.52
|
| Rate for Payer: Wise Provider Network Commercial |
$6.32
|
|
|
PREGABALIN 50 MG CAPSULE [39102]
|
Facility
|
OP
|
$5.39
|
|
|
Service Code
|
NDC 6068748411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.28
|
| Rate for Payer: Aetna of WY Medicare |
$3.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.17
|
| Rate for Payer: Altius Commercial |
$5.17
|
| Rate for Payer: Beech Street Commercial |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.43
|
| Rate for Payer: Cash Price |
$3.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.23
|
| Rate for Payer: Cigna of WY Commercial |
$5.28
|
| Rate for Payer: Entrust Commercial |
$5.12
|
| Rate for Payer: First Choice Health Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.13
|
| Rate for Payer: HealthUtah PPO |
$5.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.23
|
| Rate for Payer: Multiplan Medicare/VA |
$2.97
|
| Rate for Payer: One Health Plan of WY PPO |
$5.28
|
| Rate for Payer: PacificSource Commercial |
$4.85
|
| Rate for Payer: PHCS PPO |
$5.28
|
| Rate for Payer: Three Rivers PPO |
$4.04
|
| Rate for Payer: TriWest Veterans Administration |
$3.13
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$3.13
|
| Rate for Payer: WINHealth Partners Commercial |
$5.28
|
| Rate for Payer: Wise Provider Network Commercial |
$5.12
|
|
|
PREGABALIN 50 MG CAPSULE [39102]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 6586275990
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.26
|
| Rate for Payer: Aetna of WY Medicare |
$0.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.26
|
| Rate for Payer: Beech Street Commercial |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.26
|
| Rate for Payer: Cigna of WY Commercial |
$0.26
|
| Rate for Payer: Entrust Commercial |
$0.26
|
| Rate for Payer: First Choice Health Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.16
|
| Rate for Payer: HealthUtah PPO |
$0.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.26
|
| Rate for Payer: Multiplan Medicare/VA |
$0.15
|
| Rate for Payer: One Health Plan of WY PPO |
$0.26
|
| Rate for Payer: PacificSource Commercial |
$0.24
|
| Rate for Payer: PHCS PPO |
$0.26
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.16
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.16
|
| Rate for Payer: WINHealth Partners Commercial |
$0.26
|
| Rate for Payer: Wise Provider Network Commercial |
$0.26
|
|
|
PREGABALIN 50 MG CAPSULE [39102]
|
Facility
|
OP
|
$5.39
|
|
|
Service Code
|
NDC 6068748401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.28
|
| Rate for Payer: Aetna of WY Medicare |
$3.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.17
|
| Rate for Payer: Altius Commercial |
$5.17
|
| Rate for Payer: Beech Street Commercial |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.43
|
| Rate for Payer: Cash Price |
$3.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.23
|
| Rate for Payer: Cigna of WY Commercial |
$5.28
|
| Rate for Payer: Entrust Commercial |
$5.12
|
| Rate for Payer: First Choice Health Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.13
|
| Rate for Payer: HealthUtah PPO |
$5.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.23
|
| Rate for Payer: Multiplan Medicare/VA |
$2.97
|
| Rate for Payer: One Health Plan of WY PPO |
$5.28
|
| Rate for Payer: PacificSource Commercial |
$4.85
|
| Rate for Payer: PHCS PPO |
$5.28
|
| Rate for Payer: Three Rivers PPO |
$4.04
|
| Rate for Payer: TriWest Veterans Administration |
$3.13
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$3.13
|
| Rate for Payer: WINHealth Partners Commercial |
$5.28
|
| Rate for Payer: Wise Provider Network Commercial |
$5.12
|
|
|
PREGABALIN 50 MG CAPSULE [39102]
|
Facility
|
IP
|
$5.39
|
|
|
Service Code
|
NDC 6068748411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.17
|
| Rate for Payer: Altius Commercial |
$5.17
|
| Rate for Payer: Beech Street Commercial |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.43
|
| Rate for Payer: Cash Price |
$3.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.23
|
| Rate for Payer: Cigna of WY Commercial |
$5.28
|
| Rate for Payer: Entrust Commercial |
$5.12
|
| Rate for Payer: First Choice Health Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.56
|
| Rate for Payer: HealthUtah PPO |
$5.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.23
|
| Rate for Payer: Multiplan Medicare/VA |
$3.38
|
| Rate for Payer: One Health Plan of WY PPO |
$5.28
|
| Rate for Payer: PacificSource Commercial |
$4.85
|
| Rate for Payer: PHCS PPO |
$5.28
|
| Rate for Payer: Three Rivers PPO |
$4.04
|
| Rate for Payer: TriWest Veterans Administration |
$3.56
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$3.56
|
| Rate for Payer: WINHealth Partners Commercial |
$5.12
|
| Rate for Payer: Wise Provider Network Commercial |
$5.12
|
|
|
PREGABALIN 50 MG CAPSULE [39102]
|
Facility
|
IP
|
$5.39
|
|
|
Service Code
|
NDC 6068748401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.17
|
| Rate for Payer: Altius Commercial |
$5.17
|
| Rate for Payer: Beech Street Commercial |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.43
|
| Rate for Payer: Cash Price |
$3.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.23
|
| Rate for Payer: Cigna of WY Commercial |
$5.28
|
| Rate for Payer: Entrust Commercial |
$5.12
|
| Rate for Payer: First Choice Health Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.56
|
| Rate for Payer: HealthUtah PPO |
$5.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.23
|
| Rate for Payer: Multiplan Medicare/VA |
$3.38
|
| Rate for Payer: One Health Plan of WY PPO |
$5.28
|
| Rate for Payer: PacificSource Commercial |
$4.85
|
| Rate for Payer: PHCS PPO |
$5.28
|
| Rate for Payer: Three Rivers PPO |
$4.04
|
| Rate for Payer: TriWest Veterans Administration |
$3.56
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$3.56
|
| Rate for Payer: WINHealth Partners Commercial |
$5.12
|
| Rate for Payer: Wise Provider Network Commercial |
$5.12
|
|
|
PREGABALIN 50 MG CAPSULE [39102]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 6586275990
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.26
|
| Rate for Payer: Beech Street Commercial |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.26
|
| Rate for Payer: Cigna of WY Commercial |
$0.26
|
| Rate for Payer: Entrust Commercial |
$0.26
|
| Rate for Payer: First Choice Health Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.18
|
| Rate for Payer: HealthUtah PPO |
$0.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.26
|
| Rate for Payer: Multiplan Medicare/VA |
$0.17
|
| Rate for Payer: One Health Plan of WY PPO |
$0.26
|
| Rate for Payer: PacificSource Commercial |
$0.24
|
| Rate for Payer: PHCS PPO |
$0.26
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.18
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.18
|
| Rate for Payer: WINHealth Partners Commercial |
$0.26
|
| Rate for Payer: Wise Provider Network Commercial |
$0.26
|
|
