Beloit Memorial Hospital

All Charges

Charge

Type

Price

EAPG 355: LEVEL III PROSTHODONTICS, FIXED

Facility OP

$348.68

Service Code	EAPG 00355
Min. Negotiated Rate	$196.54
Max. Negotiated Rate	$348.68
Rate for Payer: Anthem Medicaid	$196.54
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$348.68
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$196.54
Rate for Payer: Dean Health Medicaid	$196.54
Rate for Payer: Independent Care Health Plan Medicaid	$196.54
Rate for Payer: Managed Health Services Medicaid	$204.40
Rate for Payer: Molina Healthcare Medicaid	$348.68
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$196.54
Rate for Payer: United Healthcare Medicaid	$196.54
Rate for Payer: WMAP Medicaid	$196.54

EAPG 356: LEVEL I PROSTHODONTICS, REMOVABLE

Facility OP

$152.74

Service Code	EAPG 00356
Min. Negotiated Rate	$86.07
Max. Negotiated Rate	$152.74
Rate for Payer: Anthem Medicaid	$86.07
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$152.74
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$86.07
Rate for Payer: Dean Health Medicaid	$86.07
Rate for Payer: Independent Care Health Plan Medicaid	$86.07
Rate for Payer: Managed Health Services Medicaid	$89.51
Rate for Payer: Molina Healthcare Medicaid	$152.74
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$86.07
Rate for Payer: United Healthcare Medicaid	$86.07
Rate for Payer: WMAP Medicaid	$86.07

EAPG 357: LEVEL II PROSTHODONTICS, REMOVABLE

Facility OP

$188.80

Service Code	EAPG 00357
Min. Negotiated Rate	$106.43
Max. Negotiated Rate	$188.80
Rate for Payer: Anthem Medicaid	$106.43
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$188.80
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$106.43
Rate for Payer: Dean Health Medicaid	$106.43
Rate for Payer: Independent Care Health Plan Medicaid	$106.43
Rate for Payer: Managed Health Services Medicaid	$110.69
Rate for Payer: Molina Healthcare Medicaid	$188.80
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$106.43
Rate for Payer: United Healthcare Medicaid	$106.43
Rate for Payer: WMAP Medicaid	$106.43

EAPG 358: LEVEL III PROSTHODONTICS, REMOVABLE

Facility OP

$224.85

Service Code	EAPG 00358
Min. Negotiated Rate	$126.75
Max. Negotiated Rate	$224.85
Rate for Payer: Anthem Medicaid	$126.75
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$224.85
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$126.75
Rate for Payer: Dean Health Medicaid	$126.75
Rate for Payer: Independent Care Health Plan Medicaid	$126.75
Rate for Payer: Managed Health Services Medicaid	$131.82
Rate for Payer: Molina Healthcare Medicaid	$224.85
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$126.75
Rate for Payer: United Healthcare Medicaid	$126.75
Rate for Payer: WMAP Medicaid	$126.75

EAPG 359: LEVEL I MAXILLOFACIAL PROSTHETICS

Facility OP

$659.06

Service Code	EAPG 00359
Min. Negotiated Rate	$42.42
Max. Negotiated Rate	$659.06
Rate for Payer: Anthem Medicaid	$633.71
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$42.42
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$633.71
Rate for Payer: Dean Health Medicaid	$633.71
Rate for Payer: Independent Care Health Plan Medicaid	$633.71
Rate for Payer: Managed Health Services Medicaid	$659.06
Rate for Payer: Molina Healthcare Medicaid	$42.42
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$633.71
Rate for Payer: United Healthcare Medicaid	$633.71
Rate for Payer: WMAP Medicaid	$633.71

EAPG 35: LEVEL I FOOT PROCEDURES

Facility OP

$1,491.40

Service Code	EAPG 00035
Min. Negotiated Rate	$888.02
Max. Negotiated Rate	$1,491.40
Rate for Payer: Anthem Medicaid	$888.02
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,491.40
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$888.02
Rate for Payer: Dean Health Medicaid	$888.02
Rate for Payer: Independent Care Health Plan Medicaid	$888.02
Rate for Payer: Managed Health Services Medicaid	$923.54
Rate for Payer: Molina Healthcare Medicaid	$1,491.40
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$888.02
Rate for Payer: United Healthcare Medicaid	$888.02
Rate for Payer: WMAP Medicaid	$888.02

EAPG 360: LEVEL II MAXILLOFACIAL PROSTHETICS

Facility OP

$1,483.19

Service Code	EAPG 00360
Min. Negotiated Rate	$221.58
Max. Negotiated Rate	$1,483.19
Rate for Payer: Anthem Medicaid	$1,426.14
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$221.58
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,426.14
Rate for Payer: Dean Health Medicaid	$1,426.14
Rate for Payer: Independent Care Health Plan Medicaid	$1,426.14
Rate for Payer: Managed Health Services Medicaid	$1,483.19
Rate for Payer: Molina Healthcare Medicaid	$221.58
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,426.14
Rate for Payer: United Healthcare Medicaid	$1,426.14
Rate for Payer: WMAP Medicaid	$1,426.14

EAPG 361: LEVEL I DENTAL RESTORATIONS

Facility OP

$1,298.10

Service Code	EAPG 00361
Min. Negotiated Rate	$833.09
Max. Negotiated Rate	$1,298.10
Rate for Payer: Anthem Medicaid	$833.09
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,298.10
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$833.09
Rate for Payer: Dean Health Medicaid	$833.09
Rate for Payer: Independent Care Health Plan Medicaid	$833.09
Rate for Payer: Managed Health Services Medicaid	$866.41
Rate for Payer: Molina Healthcare Medicaid	$1,298.10
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$833.09
Rate for Payer: United Healthcare Medicaid	$833.09
Rate for Payer: WMAP Medicaid	$833.09

EAPG 362: LEVEL II DENTAL RESTORATIONS

Facility OP

$1,405.98

Service Code	EAPG 00362
Min. Negotiated Rate	$1,031.13
Max. Negotiated Rate	$1,405.98
Rate for Payer: Anthem Medicaid	$1,031.13
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,405.98
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,031.13
Rate for Payer: Dean Health Medicaid	$1,031.13
Rate for Payer: Independent Care Health Plan Medicaid	$1,031.13
Rate for Payer: Managed Health Services Medicaid	$1,072.38
Rate for Payer: Molina Healthcare Medicaid	$1,405.98
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,031.13
Rate for Payer: United Healthcare Medicaid	$1,031.13
Rate for Payer: WMAP Medicaid	$1,031.13

EAPG 363: LEVEL III DENTAL RESTORATIONS

Facility OP

$1,546.59

Service Code	EAPG 00363
Min. Negotiated Rate	$1,134.25
Max. Negotiated Rate	$1,546.59
Rate for Payer: Anthem Medicaid	$1,134.25
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,546.59
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,134.25
Rate for Payer: Dean Health Medicaid	$1,134.25
Rate for Payer: Independent Care Health Plan Medicaid	$1,134.25
Rate for Payer: Managed Health Services Medicaid	$1,179.62
Rate for Payer: Molina Healthcare Medicaid	$1,546.59
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,134.25
Rate for Payer: United Healthcare Medicaid	$1,134.25
Rate for Payer: WMAP Medicaid	$1,134.25

EAPG 364: LEVEL I ENDODONTICS

Facility OP

$103.52

Service Code	EAPG 00364
Min. Negotiated Rate	$58.34
Max. Negotiated Rate	$103.52
Rate for Payer: Anthem Medicaid	$58.34
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$103.52
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$58.34
Rate for Payer: Dean Health Medicaid	$58.34
Rate for Payer: Independent Care Health Plan Medicaid	$58.34
Rate for Payer: Managed Health Services Medicaid	$60.67
Rate for Payer: Molina Healthcare Medicaid	$103.52
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$58.34
Rate for Payer: United Healthcare Medicaid	$58.34
Rate for Payer: WMAP Medicaid	$58.34

EAPG 365: LEVEL II ENDODONTICS

Facility OP

$186.16

Service Code	EAPG 00365
Min. Negotiated Rate	$104.92
Max. Negotiated Rate	$186.16
Rate for Payer: Anthem Medicaid	$104.92
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$186.16
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$104.92
Rate for Payer: Dean Health Medicaid	$104.92
Rate for Payer: Independent Care Health Plan Medicaid	$104.92
Rate for Payer: Managed Health Services Medicaid	$109.12
Rate for Payer: Molina Healthcare Medicaid	$186.16
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$104.92
Rate for Payer: United Healthcare Medicaid	$104.92
Rate for Payer: WMAP Medicaid	$104.92

EAPG 366: LEVEL III ENDODONTICS

Facility OP

$187.53

Service Code	EAPG 00366
Min. Negotiated Rate	$125.00
Max. Negotiated Rate	$187.53
Rate for Payer: Anthem Medicaid	$125.00
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$187.53
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$125.00
Rate for Payer: Dean Health Medicaid	$125.00
Rate for Payer: Independent Care Health Plan Medicaid	$125.00
Rate for Payer: Managed Health Services Medicaid	$130.00
Rate for Payer: Molina Healthcare Medicaid	$187.53
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$125.00
Rate for Payer: United Healthcare Medicaid	$125.00
Rate for Payer: WMAP Medicaid	$125.00

EAPG 367: LEVEL I ORAL SURGERY PROCEDURES

Facility OP

$546.77

Service Code	EAPG 00367
Min. Negotiated Rate	$497.13
Max. Negotiated Rate	$546.77
Rate for Payer: Anthem Medicaid	$497.13
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$546.77
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$497.13
Rate for Payer: Dean Health Medicaid	$497.13
Rate for Payer: Independent Care Health Plan Medicaid	$497.13
Rate for Payer: Managed Health Services Medicaid	$517.02
Rate for Payer: Molina Healthcare Medicaid	$546.77
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$497.13
Rate for Payer: United Healthcare Medicaid	$497.13
Rate for Payer: WMAP Medicaid	$497.13

EAPG 368: LEVEL II ORAL SURGERY PROCEDURES

Facility OP

$785.41

Service Code	EAPG 00368
Min. Negotiated Rate	$568.50
Max. Negotiated Rate	$785.41
Rate for Payer: Anthem Medicaid	$755.20
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$568.50
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$755.20
Rate for Payer: Dean Health Medicaid	$755.20
Rate for Payer: Independent Care Health Plan Medicaid	$755.20
Rate for Payer: Managed Health Services Medicaid	$785.41
Rate for Payer: Molina Healthcare Medicaid	$568.50
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$755.20
Rate for Payer: United Healthcare Medicaid	$755.20
Rate for Payer: WMAP Medicaid	$755.20

EAPG 369: LEVEL III ORAL SURGERY PROCEDURES

Facility OP

$1,220.52

Service Code	EAPG 00369
Min. Negotiated Rate	$625.35
Max. Negotiated Rate	$1,220.52
Rate for Payer: Anthem Medicaid	$1,173.58
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$625.35
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,173.58
Rate for Payer: Dean Health Medicaid	$1,173.58
Rate for Payer: Independent Care Health Plan Medicaid	$1,173.58
Rate for Payer: Managed Health Services Medicaid	$1,220.52
Rate for Payer: Molina Healthcare Medicaid	$625.35
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,173.58
Rate for Payer: United Healthcare Medicaid	$1,173.58
Rate for Payer: WMAP Medicaid	$1,173.58

EAPG 36: LEVEL II FOOT PROCEDURES

Facility OP

$3,468.47

Service Code	EAPG 00036
Min. Negotiated Rate	$2,264.23
Max. Negotiated Rate	$3,468.47
Rate for Payer: Anthem Medicaid	$2,264.23
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$3,468.47
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,264.23
Rate for Payer: Dean Health Medicaid	$2,264.23
Rate for Payer: Independent Care Health Plan Medicaid	$2,264.23
Rate for Payer: Managed Health Services Medicaid	$2,354.80
Rate for Payer: Molina Healthcare Medicaid	$3,468.47
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,264.23
Rate for Payer: United Healthcare Medicaid	$2,264.23
Rate for Payer: WMAP Medicaid	$2,264.23

EAPG 371: LEVEL I ORTHODONTICS

Facility OP

$582.98

Service Code	EAPG 00371
Min. Negotiated Rate	$245.75
Max. Negotiated Rate	$582.98
Rate for Payer: Anthem Medicaid	$560.56
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$245.75
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$560.56
Rate for Payer: Dean Health Medicaid	$560.56
Rate for Payer: Independent Care Health Plan Medicaid	$560.56
Rate for Payer: Managed Health Services Medicaid	$582.98
Rate for Payer: Molina Healthcare Medicaid	$245.75
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$560.56
Rate for Payer: United Healthcare Medicaid	$560.56
Rate for Payer: WMAP Medicaid	$560.56

EAPG 372: SEALANT

Facility OP

$33.95

Service Code	EAPG 00372
Min. Negotiated Rate	$17.21
Max. Negotiated Rate	$33.95
Rate for Payer: Anthem Medicaid	$17.21
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$33.95
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$17.21
Rate for Payer: Dean Health Medicaid	$17.21
Rate for Payer: Independent Care Health Plan Medicaid	$17.21
Rate for Payer: Managed Health Services Medicaid	$17.90
Rate for Payer: Molina Healthcare Medicaid	$33.95
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$17.21
Rate for Payer: United Healthcare Medicaid	$17.21
Rate for Payer: WMAP Medicaid	$17.21

EAPG 373: LEVEL I DENTAL IMAGING

Facility OP

$44.28

Service Code	EAPG 00373
Min. Negotiated Rate	$12.76
Max. Negotiated Rate	$44.28
Rate for Payer: Anthem Medicaid	$12.76
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$44.28
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$12.76
Rate for Payer: Dean Health Medicaid	$12.76
Rate for Payer: Independent Care Health Plan Medicaid	$12.76
Rate for Payer: Managed Health Services Medicaid	$13.27
Rate for Payer: Molina Healthcare Medicaid	$44.28
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$12.76
Rate for Payer: United Healthcare Medicaid	$12.76
Rate for Payer: WMAP Medicaid	$12.76

EAPG 374: LEVEL II DENTAL IMAGING

Facility OP

$121.43

Service Code	EAPG 00374
Min. Negotiated Rate	$48.77
Max. Negotiated Rate	$121.43
Rate for Payer: Anthem Medicaid	$48.77
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$121.43
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$48.77
Rate for Payer: Dean Health Medicaid	$48.77
Rate for Payer: Independent Care Health Plan Medicaid	$48.77
Rate for Payer: Managed Health Services Medicaid	$50.72
Rate for Payer: Molina Healthcare Medicaid	$121.43
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$48.77
Rate for Payer: United Healthcare Medicaid	$48.77
Rate for Payer: WMAP Medicaid	$48.77

EAPG 375: DENTAL ANESTHESIA

Facility OP

$33.86

Service Code	EAPG 00375
Min. Negotiated Rate	$14.56
Max. Negotiated Rate	$33.86
Rate for Payer: Anthem Medicaid	$14.56
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$33.86
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$14.56
Rate for Payer: Dean Health Medicaid	$14.56
Rate for Payer: Independent Care Health Plan Medicaid	$14.56
Rate for Payer: Managed Health Services Medicaid	$15.14
Rate for Payer: Molina Healthcare Medicaid	$33.86
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$14.56
Rate for Payer: United Healthcare Medicaid	$14.56
Rate for Payer: WMAP Medicaid	$14.56

EAPG 376: DIAGNOSTIC DENTAL PROCEDURES

Facility OP

$180.68

Service Code	EAPG 00376
Min. Negotiated Rate	$43.73
Max. Negotiated Rate	$180.68
Rate for Payer: Anthem Medicaid	$43.73
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$180.68
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$43.73
Rate for Payer: Dean Health Medicaid	$43.73
Rate for Payer: Independent Care Health Plan Medicaid	$43.73
Rate for Payer: Managed Health Services Medicaid	$45.48
Rate for Payer: Molina Healthcare Medicaid	$180.68
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$43.73
Rate for Payer: United Healthcare Medicaid	$43.73
Rate for Payer: WMAP Medicaid	$43.73

EAPG 377: PREVENTIVE DENTAL PROCEDURES

Facility OP

$136.89

Service Code	EAPG 00377
Min. Negotiated Rate	$45.92
Max. Negotiated Rate	$136.89
Rate for Payer: Anthem Medicaid	$45.92
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$136.89
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$45.92
Rate for Payer: Dean Health Medicaid	$45.92
Rate for Payer: Independent Care Health Plan Medicaid	$45.92
Rate for Payer: Managed Health Services Medicaid	$47.76
Rate for Payer: Molina Healthcare Medicaid	$136.89
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$45.92
Rate for Payer: United Healthcare Medicaid	$45.92
Rate for Payer: WMAP Medicaid	$45.92

EAPG 378: LEVEL II PERIODONTICS

Facility OP

$826.33

Service Code	EAPG 00378
Min. Negotiated Rate	$465.75
Max. Negotiated Rate	$826.33
Rate for Payer: Anthem Medicaid	$465.75
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$826.33
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$465.75
Rate for Payer: Dean Health Medicaid	$465.75
Rate for Payer: Independent Care Health Plan Medicaid	$465.75
Rate for Payer: Managed Health Services Medicaid	$484.38
Rate for Payer: Molina Healthcare Medicaid	$826.33
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$465.75
Rate for Payer: United Healthcare Medicaid	$465.75
Rate for Payer: WMAP Medicaid	$465.75

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