|
SOL 5%S.C.500 GLASS 1586-03
|
Facility
|
OP
|
$50.00
|
|
| Hospital Charge Code |
3000486
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$45.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.00
|
| Rate for Payer: Aetna Managed Medicare |
$14.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.50
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$46.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.98
|
| Rate for Payer: Health EOS Commercial |
$44.50
|
| Rate for Payer: HFN Commercial |
$46.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.50
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: NAPHCARE Commercial |
$30.00
|
| Rate for Payer: Preferred Network Access Commercial |
$46.00
|
| Rate for Payer: Quartz Beloit One Network |
$24.50
|
| Rate for Payer: Quartz Commercial |
$32.50
|
| Rate for Payer: Quartz Medicare Advantage |
$30.00
|
| Rate for Payer: The Alliance Commercial |
$200.00
|
| Rate for Payer: WEA Trust Commercial |
$27.50
|
| Rate for Payer: WPS Commercial |
$37.04
|
|
|
SOL 5%S.C.500 GLASS 1586-03
|
Facility
|
IP
|
$50.00
|
|
| Hospital Charge Code |
3000486
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$46.00 |
| Rate for Payer: Aetna Commercial |
$45.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.50
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$46.00
|
| Rate for Payer: Health EOS Commercial |
$44.50
|
| Rate for Payer: HFN Commercial |
$46.00
|
| Rate for Payer: Multiplan Commercial |
$40.00
|
| Rate for Payer: NAPHCARE Commercial |
$30.00
|
| Rate for Payer: Preferred Network Access Commercial |
$46.00
|
| Rate for Payer: Quartz Beloit One Network |
$24.50
|
| Rate for Payer: Quartz Commercial |
$30.00
|
| Rate for Payer: WEA Trust Commercial |
$27.50
|
| Rate for Payer: WPS Commercial |
$37.04
|
|
|
SOL .9 SOD CHL 250 0990-7983-02
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
2963795
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$13.23 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$16.20
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
SOL .9 SOD CHL 250 0990-7983-02
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
2963795
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Aetna Managed Medicare |
$7.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.11
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.25
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$17.55
|
| Rate for Payer: Quartz Medicare Advantage |
$16.20
|
| Rate for Payer: The Alliance Commercial |
$108.00
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
SOL.D5/.45SC W/POT CHL 1000ml 20meq
|
Facility
|
OP
|
$54.00
|
|
| Hospital Charge Code |
3000476
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$15.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.22
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.50
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$32.40
|
| Rate for Payer: The Alliance Commercial |
$216.00
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
SOL.D5/.45SC W/POT CHL 1000ml 20meq
|
Facility
|
IP
|
$54.00
|
|
| Hospital Charge Code |
3000476
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Solesta 1 unit Charge
|
Facility
|
OP
|
$8,249.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2958966
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,309.72 |
| Max. Negotiated Rate |
$32,996.00 |
| Rate for Payer: Aetna Commercial |
$7,424.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,094.14
|
| Rate for Payer: Aetna Managed Medicare |
$2,309.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,361.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,124.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,959.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,371.97
|
| Rate for Payer: Cash Price |
$2,474.70
|
| Rate for Payer: Cigna Commercial |
$7,589.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,616.14
|
| Rate for Payer: Health EOS Commercial |
$7,341.61
|
| Rate for Payer: HFN Commercial |
$7,589.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,186.75
|
| Rate for Payer: Multiplan Commercial |
$6,599.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,949.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,589.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,042.01
|
| Rate for Payer: Quartz Commercial |
$5,361.85
|
| Rate for Payer: Quartz Medicare Advantage |
$4,949.40
|
| Rate for Payer: The Alliance Commercial |
$32,996.00
|
| Rate for Payer: WEA Trust Commercial |
$4,536.95
|
| Rate for Payer: WPS Commercial |
$6,110.03
|
|
|
Solesta 1 unit Charge
|
Facility
|
IP
|
$8,249.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2958966
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,042.01 |
| Max. Negotiated Rate |
$7,589.08 |
| Rate for Payer: Aetna Commercial |
$7,424.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,094.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,371.97
|
| Rate for Payer: Cash Price |
$2,474.70
|
| Rate for Payer: Cigna Commercial |
$7,589.08
|
| Rate for Payer: Health EOS Commercial |
$7,341.61
|
| Rate for Payer: HFN Commercial |
$7,589.08
|
| Rate for Payer: Multiplan Commercial |
$6,599.20
|
| Rate for Payer: NAPHCARE Commercial |
$4,949.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,589.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,042.01
|
| Rate for Payer: Quartz Commercial |
$4,949.40
|
| Rate for Payer: WEA Trust Commercial |
$4,536.95
|
| Rate for Payer: WPS Commercial |
$6,110.03
|
|
|
Solesta 1 unit Charge
|
Professional
|
Both
|
$8,249.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2958966
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,629.56 |
| Max. Negotiated Rate |
$7,836.55 |
| Rate for Payer: Aetna Commercial |
$7,836.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,094.14
|
| Rate for Payer: Cash Price |
$2,474.70
|
| Rate for Payer: Cigna Commercial |
$7,836.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,124.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,949.40
|
| Rate for Payer: Health EOS Commercial |
$7,506.59
|
| Rate for Payer: HFN Commercial |
$7,836.55
|
| Rate for Payer: Multiplan Commercial |
$6,599.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,836.55
|
| Rate for Payer: Quartz Beloit One Network |
$3,629.56
|
| Rate for Payer: Quartz Commercial |
$4,701.93
|
| Rate for Payer: The Alliance Commercial |
$4,124.50
|
| Rate for Payer: WEA Trust Commercial |
$4,536.95
|
| Rate for Payer: WPS Commercial |
$6,110.03
|
|
|
SOL.GLYCINE 3000 NDC 0990797408
|
Facility
|
OP
|
$147.00
|
|
| Hospital Charge Code |
2963682
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$588.00 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.42
|
| Rate for Payer: Aetna Managed Medicare |
$41.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$95.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.91
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.26
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$110.25
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$88.20
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$95.55
|
| Rate for Payer: Quartz Medicare Advantage |
$88.20
|
| Rate for Payer: The Alliance Commercial |
$588.00
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
SOL.GLYCINE 3000 NDC 0990797408
|
Facility
|
IP
|
$147.00
|
|
| Hospital Charge Code |
2963682
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$72.03 |
| Max. Negotiated Rate |
$135.24 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.91
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$88.20
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$88.20
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
SOL.IV 0.9% S.C. 1000ML 7983-09
|
Facility
|
IP
|
$47.00
|
|
| Hospital Charge Code |
2962817
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$23.03 |
| Max. Negotiated Rate |
$43.24 |
| Rate for Payer: Aetna Commercial |
$42.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$40.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.91
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$43.24
|
| Rate for Payer: Health EOS Commercial |
$41.83
|
| Rate for Payer: HFN Commercial |
$43.24
|
| Rate for Payer: Multiplan Commercial |
$37.60
|
| Rate for Payer: NAPHCARE Commercial |
$28.20
|
| Rate for Payer: Preferred Network Access Commercial |
$43.24
|
| Rate for Payer: Quartz Beloit One Network |
$23.03
|
| Rate for Payer: Quartz Commercial |
$28.20
|
| Rate for Payer: WEA Trust Commercial |
$25.85
|
| Rate for Payer: WPS Commercial |
$34.81
|
|
|
SOL.IV 0.9% S.C. 1000ML 7983-09
|
Facility
|
OP
|
$47.00
|
|
| Hospital Charge Code |
2962817
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$13.16 |
| Max. Negotiated Rate |
$188.00 |
| Rate for Payer: Aetna Commercial |
$42.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$40.42
|
| Rate for Payer: Aetna Managed Medicare |
$13.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.91
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cigna Commercial |
$43.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.30
|
| Rate for Payer: Health EOS Commercial |
$41.83
|
| Rate for Payer: HFN Commercial |
$43.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$35.25
|
| Rate for Payer: Multiplan Commercial |
$37.60
|
| Rate for Payer: NAPHCARE Commercial |
$28.20
|
| Rate for Payer: Preferred Network Access Commercial |
$43.24
|
| Rate for Payer: Quartz Beloit One Network |
$23.03
|
| Rate for Payer: Quartz Commercial |
$30.55
|
| Rate for Payer: Quartz Medicare Advantage |
$28.20
|
| Rate for Payer: The Alliance Commercial |
$188.00
|
| Rate for Payer: WEA Trust Commercial |
$25.85
|
| Rate for Payer: WPS Commercial |
$34.81
|
|
|
SOL IV 0.9% S.C. 100ML
|
Facility
|
OP
|
$73.00
|
|
| Hospital Charge Code |
2963375
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$20.44 |
| Max. Negotiated Rate |
$292.00 |
| Rate for Payer: Aetna Commercial |
$65.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.78
|
| Rate for Payer: Aetna Managed Medicare |
$20.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$47.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.69
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$67.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.85
|
| Rate for Payer: Health EOS Commercial |
$64.97
|
| Rate for Payer: HFN Commercial |
$67.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.75
|
| Rate for Payer: Multiplan Commercial |
$58.40
|
| Rate for Payer: NAPHCARE Commercial |
$43.80
|
| Rate for Payer: Preferred Network Access Commercial |
$67.16
|
| Rate for Payer: Quartz Beloit One Network |
$35.77
|
| Rate for Payer: Quartz Commercial |
$47.45
|
| Rate for Payer: Quartz Medicare Advantage |
$43.80
|
| Rate for Payer: The Alliance Commercial |
$292.00
|
| Rate for Payer: WEA Trust Commercial |
$40.15
|
| Rate for Payer: WPS Commercial |
$54.07
|
|
|
SOL IV 0.9% S.C. 100ML
|
Facility
|
IP
|
$73.00
|
|
| Hospital Charge Code |
2963375
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$35.77 |
| Max. Negotiated Rate |
$67.16 |
| Rate for Payer: Aetna Commercial |
$65.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.69
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$67.16
|
| Rate for Payer: Health EOS Commercial |
$64.97
|
| Rate for Payer: HFN Commercial |
$67.16
|
| Rate for Payer: Multiplan Commercial |
$58.40
|
| Rate for Payer: NAPHCARE Commercial |
$43.80
|
| Rate for Payer: Preferred Network Access Commercial |
$67.16
|
| Rate for Payer: Quartz Beloit One Network |
$35.77
|
| Rate for Payer: Quartz Commercial |
$43.80
|
| Rate for Payer: WEA Trust Commercial |
$40.15
|
| Rate for Payer: WPS Commercial |
$54.07
|
|
|
SOL.IV 0.9% S.C. 500ML 7983-03
|
Facility
|
OP
|
$27.00
|
|
| Hospital Charge Code |
2963772
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Aetna Managed Medicare |
$7.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.11
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.25
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$17.55
|
| Rate for Payer: Quartz Medicare Advantage |
$16.20
|
| Rate for Payer: The Alliance Commercial |
$108.00
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
SOL.IV 0.9% S.C. 500ML 7983-03
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
2963772
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$13.23 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna Commercial |
$24.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cigna Commercial |
$24.84
|
| Rate for Payer: Health EOS Commercial |
$24.03
|
| Rate for Payer: HFN Commercial |
$24.84
|
| Rate for Payer: Multiplan Commercial |
$21.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$24.84
|
| Rate for Payer: Quartz Beloit One Network |
$13.23
|
| Rate for Payer: Quartz Commercial |
$16.20
|
| Rate for Payer: WEA Trust Commercial |
$14.85
|
| Rate for Payer: WPS Commercial |
$20.00
|
|
|
SOL.IV S.C. 150
|
Facility
|
OP
|
$31.00
|
|
| Hospital Charge Code |
2963681
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$27.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Managed Medicare |
$8.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.43
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$28.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.35
|
| Rate for Payer: Health EOS Commercial |
$27.59
|
| Rate for Payer: HFN Commercial |
$28.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.25
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.60
|
| Rate for Payer: Preferred Network Access Commercial |
$28.52
|
| Rate for Payer: Quartz Beloit One Network |
$15.19
|
| Rate for Payer: Quartz Commercial |
$20.15
|
| Rate for Payer: Quartz Medicare Advantage |
$18.60
|
| Rate for Payer: The Alliance Commercial |
$124.00
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: WPS Commercial |
$22.96
|
|
|
SOL.IV S.C. 150
|
Facility
|
IP
|
$31.00
|
|
| Hospital Charge Code |
2963681
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$15.19 |
| Max. Negotiated Rate |
$28.52 |
| Rate for Payer: Aetna Commercial |
$27.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.43
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$27.59
|
| Rate for Payer: HFN Commercial |
$28.52
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.60
|
| Rate for Payer: Preferred Network Access Commercial |
$28.52
|
| Rate for Payer: Quartz Beloit One Network |
$15.19
|
| Rate for Payer: Quartz Commercial |
$18.60
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: WPS Commercial |
$22.96
|
|
|
SOL. LAC/RINGERS 500CC 7953-03
|
Facility
|
IP
|
$36.00
|
|
| Hospital Charge Code |
2963716
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$17.64 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.08
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$33.12
|
| Rate for Payer: Health EOS Commercial |
$32.04
|
| Rate for Payer: HFN Commercial |
$33.12
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$33.12
|
| Rate for Payer: Quartz Beloit One Network |
$17.64
|
| Rate for Payer: Quartz Commercial |
$21.60
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$26.67
|
|
|
SOL. LAC/RINGERS 500CC 7953-03
|
Facility
|
OP
|
$36.00
|
|
| Hospital Charge Code |
2963716
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Aetna Managed Medicare |
$10.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.08
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$33.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.15
|
| Rate for Payer: Health EOS Commercial |
$32.04
|
| Rate for Payer: HFN Commercial |
$33.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$33.12
|
| Rate for Payer: Quartz Beloit One Network |
$17.64
|
| Rate for Payer: Quartz Commercial |
$23.40
|
| Rate for Payer: Quartz Medicare Advantage |
$21.60
|
| Rate for Payer: The Alliance Commercial |
$144.00
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$26.67
|
|
|
SOL LACTATED RINGERS 1000cc NDC 0409-7953-09
|
Facility
|
IP
|
$55.00
|
|
| Hospital Charge Code |
2963881
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$26.95 |
| Max. Negotiated Rate |
$50.60 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$33.00
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$33.00
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
SOL LACTATED RINGERS 1000cc NDC 0409-7953-09
|
Facility
|
OP
|
$55.00
|
|
| Hospital Charge Code |
2963881
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$220.00 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.78
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.25
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$33.00
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$35.75
|
| Rate for Payer: Quartz Medicare Advantage |
$33.00
|
| Rate for Payer: The Alliance Commercial |
$220.00
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
SOL.L./R.IRRIG.3000 NDC 0409-7828-08
|
Facility
|
IP
|
$154.00
|
|
| Hospital Charge Code |
2963707
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$75.46 |
| Max. Negotiated Rate |
$141.68 |
| Rate for Payer: Aetna Commercial |
$138.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.62
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$141.68
|
| Rate for Payer: Health EOS Commercial |
$137.06
|
| Rate for Payer: HFN Commercial |
$141.68
|
| Rate for Payer: Multiplan Commercial |
$123.20
|
| Rate for Payer: NAPHCARE Commercial |
$92.40
|
| Rate for Payer: Preferred Network Access Commercial |
$141.68
|
| Rate for Payer: Quartz Beloit One Network |
$75.46
|
| Rate for Payer: Quartz Commercial |
$92.40
|
| Rate for Payer: WEA Trust Commercial |
$84.70
|
| Rate for Payer: WPS Commercial |
$114.07
|
|
|
SOL.L./R.IRRIG.3000 NDC 0409-7828-08
|
Facility
|
OP
|
$154.00
|
|
| Hospital Charge Code |
2963707
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$43.12 |
| Max. Negotiated Rate |
$616.00 |
| Rate for Payer: Aetna Commercial |
$138.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.44
|
| Rate for Payer: Aetna Managed Medicare |
$43.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$100.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$77.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.62
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$141.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$86.18
|
| Rate for Payer: Health EOS Commercial |
$137.06
|
| Rate for Payer: HFN Commercial |
$141.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.50
|
| Rate for Payer: Multiplan Commercial |
$123.20
|
| Rate for Payer: NAPHCARE Commercial |
$92.40
|
| Rate for Payer: Preferred Network Access Commercial |
$141.68
|
| Rate for Payer: Quartz Beloit One Network |
$75.46
|
| Rate for Payer: Quartz Commercial |
$100.10
|
| Rate for Payer: Quartz Medicare Advantage |
$92.40
|
| Rate for Payer: The Alliance Commercial |
$616.00
|
| Rate for Payer: WEA Trust Commercial |
$84.70
|
| Rate for Payer: WPS Commercial |
$114.07
|
|
