Beloit Memorial Hospital

All Charges

Charge

Type

Setting

Price

Each Additional 90472 - Admin Hep B Charge

Facility

$56.00

Service Code	CPT 90472
Hospital Charge Code	3013440
Hospital Revenue Code	771
Min. Negotiated Rate	$27.44
Max. Negotiated Rate	$51.52
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper	$48.16
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO	$29.68
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna Commercial	$51.52
Rate for Payer: Health EOS Commercial	$49.84
Rate for Payer: HFN Commercial	$51.52
Rate for Payer: Multiplan Commercial	$44.80
Rate for Payer: NAPHCARE Commercial	$33.60
Rate for Payer: Preferred Network Access Commercial	$51.52
Rate for Payer: Quartz Beloit One Network	$27.44
Rate for Payer: Quartz Commercial	$33.60
Rate for Payer: WEA Trust Commercial	$30.80
Rate for Payer: WPS Commercial	$41.48

Each Additional 90472 - Admin Hep B Charge

Professional

Both

$56.00

Service Code	CPT 90472
Hospital Charge Code	3013440
Hospital Revenue Code	771
Min. Negotiated Rate	$17.87
Max. Negotiated Rate	$53.20
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper	$48.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$28.00
Rate for Payer: Dean Health DHI/DHP/ASO	$33.60
Rate for Payer: Health EOS Commercial	$50.96
Rate for Payer: HFN Commercial	$53.20
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO	$17.87
Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO	$17.87
Rate for Payer: Multiplan Commercial	$44.80
Rate for Payer: Preferred Network Access Commercial	$53.20
Rate for Payer: Quartz Beloit One Network	$24.64
Rate for Payer: Quartz Commercial	$31.92
Rate for Payer: The Alliance Commercial	$28.00
Rate for Payer: WEA Trust Commercial	$30.80
Rate for Payer: WPS Commercial	$41.48

Each Additional 90472 - Admin Hep B Charge

Facility

$56.00

Service Code	CPT 90472
Hospital Charge Code	3013440
Hospital Revenue Code	771
Min. Negotiated Rate	$15.68
Max. Negotiated Rate	$224.00
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper	$48.16
Rate for Payer: Aetna Managed Medicare	$15.68
Rate for Payer: Anthem Blue Access PPO/Blue Traditional	$36.40
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus	$28.00
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI	$26.88
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO	$29.68
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna Commercial	$51.52
Rate for Payer: Dean Health DHI/DHP/ASO	$31.34
Rate for Payer: Health EOS Commercial	$49.84
Rate for Payer: HFN Commercial	$51.52
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO	$42.00
Rate for Payer: Multiplan Commercial	$44.80
Rate for Payer: NAPHCARE Commercial	$33.60
Rate for Payer: Preferred Network Access Commercial	$51.52
Rate for Payer: Quartz Beloit One Network	$27.44
Rate for Payer: Quartz Commercial	$36.40
Rate for Payer: Quartz Medicare Advantage	$33.60
Rate for Payer: The Alliance Commercial	$224.00
Rate for Payer: United Healthcare PPO	$42.00
Rate for Payer: WEA Trust Commercial	$30.80
Rate for Payer: WPS Commercial	$41.48

Each Additional 90472 - Admin Immunization Charge

Professional

Both

$56.00

Service Code	CPT 90472
Hospital Charge Code	2473257
Hospital Revenue Code	771
Min. Negotiated Rate	$17.87
Max. Negotiated Rate	$53.20
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper	$48.16
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$28.00
Rate for Payer: Dean Health DHI/DHP/ASO	$33.60
Rate for Payer: Health EOS Commercial	$50.96
Rate for Payer: HFN Commercial	$53.20
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO	$17.87
Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO	$17.87
Rate for Payer: Multiplan Commercial	$44.80
Rate for Payer: Preferred Network Access Commercial	$53.20
Rate for Payer: Quartz Beloit One Network	$24.64
Rate for Payer: Quartz Commercial	$31.92
Rate for Payer: The Alliance Commercial	$28.00
Rate for Payer: WEA Trust Commercial	$30.80
Rate for Payer: WPS Commercial	$41.48

Each Additional 90472 - Admin Immunization Charge

Facility

$56.00

Service Code	CPT 90472
Hospital Charge Code	2473257
Hospital Revenue Code	771
Min. Negotiated Rate	$15.68
Max. Negotiated Rate	$224.00
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper	$48.16
Rate for Payer: Aetna Managed Medicare	$15.68
Rate for Payer: Anthem Blue Access PPO/Blue Traditional	$36.40
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus	$28.00
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI	$26.88
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO	$29.68
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna Commercial	$51.52
Rate for Payer: Dean Health DHI/DHP/ASO	$31.34
Rate for Payer: Health EOS Commercial	$49.84
Rate for Payer: HFN Commercial	$51.52
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO	$42.00
Rate for Payer: Multiplan Commercial	$44.80
Rate for Payer: NAPHCARE Commercial	$33.60
Rate for Payer: Preferred Network Access Commercial	$51.52
Rate for Payer: Quartz Beloit One Network	$27.44
Rate for Payer: Quartz Commercial	$36.40
Rate for Payer: Quartz Medicare Advantage	$33.60
Rate for Payer: The Alliance Commercial	$224.00
Rate for Payer: United Healthcare PPO	$42.00
Rate for Payer: WEA Trust Commercial	$30.80
Rate for Payer: WPS Commercial	$41.48

Each Additional 90472 - Admin Immunization Charge

Facility

$56.00

Service Code	CPT 90472
Hospital Charge Code	2473257
Hospital Revenue Code	771
Min. Negotiated Rate	$27.44
Max. Negotiated Rate	$51.52
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper	$48.16
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO	$29.68
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna Commercial	$51.52
Rate for Payer: Health EOS Commercial	$49.84
Rate for Payer: HFN Commercial	$51.52
Rate for Payer: Multiplan Commercial	$44.80
Rate for Payer: NAPHCARE Commercial	$33.60
Rate for Payer: Preferred Network Access Commercial	$51.52
Rate for Payer: Quartz Beloit One Network	$27.44
Rate for Payer: Quartz Commercial	$33.60
Rate for Payer: WEA Trust Commercial	$30.80
Rate for Payer: WPS Commercial	$41.48

Each Additional 90472 - Pnuemococcal 23, 2 years+

Facility

$54.00

Service Code	CPT 90472
Hospital Charge Code	3013446
Hospital Revenue Code	771
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

Each Additional 90472 - Pnuemococcal 23, 2 years+

Facility

$54.00

Service Code	CPT 90472
Hospital Charge Code	3013446
Hospital Revenue Code	771
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: United Healthcare PPO	$40.50
Rate for Payer: WEA Trust Commercial	$29.70
Rate for Payer: WPS Commercial	$40.00

Each Additional 90472 - Pnuemococcal 23, 2 years+

Professional

Both

$54.00

Service Code	CPT 90472
Hospital Charge Code	3013446
Hospital Revenue Code	771
Min. Negotiated Rate	$17.87
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper	$46.44
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$27.00
Rate for Payer: Dean Health DHI/DHP/ASO	$32.40
Rate for Payer: Health EOS Commercial	$49.14
Rate for Payer: HFN Commercial	$51.30
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO	$17.87
Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO	$17.87
Rate for Payer: Multiplan Commercial	$43.20
Rate for Payer: Preferred Network Access Commercial	$51.30
Rate for Payer: Quartz Beloit One Network	$23.76
Rate for Payer: Quartz Commercial	$30.78
Rate for Payer: The Alliance Commercial	$27.00
Rate for Payer: WEA Trust Commercial	$29.70
Rate for Payer: WPS Commercial	$40.00

EAPG 00001: PHOTOCHEMOTHERAPY

Facility

$78.43

Service Code	EAPG 00001
Min. Negotiated Rate	$78.43
Max. Negotiated Rate	$78.43
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$78.43
Rate for Payer: Molina Healthcare Medicaid	$78.43

EAPG 00006: LEVEL I SKIN DEBRIDEMENT AND DESTRUCTION

Facility

$242.32

Service Code	EAPG 00006
Min. Negotiated Rate	$242.32
Max. Negotiated Rate	$242.32
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$242.32
Rate for Payer: Molina Healthcare Medicaid	$242.32

EAPG 00007: LEVEL II SKIN DEBRIDEMENT AND DESTRUCTION

Facility

$659.25

Service Code	EAPG 00007
Min. Negotiated Rate	$659.25
Max. Negotiated Rate	$659.25
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$659.25
Rate for Payer: Molina Healthcare Medicaid	$659.25

EAPG 00008: LEVEL III SKIN DEBRIDEMENT AND DESTRUCTION

Facility

$946.29

Service Code	EAPG 00008
Min. Negotiated Rate	$946.29
Max. Negotiated Rate	$946.29
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$946.29
Rate for Payer: Molina Healthcare Medicaid	$946.29

EAPG 00012: LEVEL I SKIN REPAIR

Facility

$227.35

Service Code	EAPG 00012
Min. Negotiated Rate	$227.35
Max. Negotiated Rate	$227.35
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$227.35
Rate for Payer: Molina Healthcare Medicaid	$227.35

EAPG 00013: LEVEL II SKIN REPAIR

Facility

$391.59

Service Code	EAPG 00013
Min. Negotiated Rate	$391.59
Max. Negotiated Rate	$391.59
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$391.59
Rate for Payer: Molina Healthcare Medicaid	$391.59

EAPG 00014: LEVEL III SKIN REPAIR

Facility

$1,251.87

Service Code	EAPG 00014
Min. Negotiated Rate	$1,251.87
Max. Negotiated Rate	$1,251.87
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,251.87
Rate for Payer: Molina Healthcare Medicaid	$1,251.87

EAPG 00015: LEVEL IV SKIN REPAIR

Facility

$1,385.19

Service Code	EAPG 00015
Min. Negotiated Rate	$1,385.19
Max. Negotiated Rate	$1,385.19
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,385.19
Rate for Payer: Molina Healthcare Medicaid	$1,385.19

EAPG 00030: GENERAL MUSCULOSKELETAL PROCEDURES

Facility

$1,406.81

Service Code	EAPG 00030
Min. Negotiated Rate	$1,406.81
Max. Negotiated Rate	$1,406.81
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,406.81
Rate for Payer: Molina Healthcare Medicaid	$1,406.81

EAPG 00065: RESPIRATORY THERAPY

Facility

$191.68

Service Code	EAPG 00065
Min. Negotiated Rate	$191.68
Max. Negotiated Rate	$191.68
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$191.68
Rate for Payer: Molina Healthcare Medicaid	$191.68

EAPG 00088: LEVEL I CARDIOTHORACIC PROCEDURES W OR W/O VASCULAR DEVICE

Facility

$2,462.59

Service Code	EAPG 00088
Min. Negotiated Rate	$2,462.59
Max. Negotiated Rate	$2,462.59
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,462.59
Rate for Payer: Molina Healthcare Medicaid	$2,462.59

EAPG 00089: LEVEL II CARDIOTHORACIC PROCEDURES W OR W/O VASCULAR DEVICE

Facility

$3,146.45

Service Code	EAPG 00089
Min. Negotiated Rate	$3,146.45
Max. Negotiated Rate	$3,146.45
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$3,146.45
Rate for Payer: Molina Healthcare Medicaid	$3,146.45

EAPG 00101: LEVEL III CARDIOTHORACIC PROCEDURES W OR W/O VASCULAR DEVICE

Facility

$8,483.47

Service Code	EAPG 00101
Min. Negotiated Rate	$8,483.47
Max. Negotiated Rate	$8,483.47
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$8,483.47
Rate for Payer: Molina Healthcare Medicaid	$8,483.47

EAPG 00131: ESOPHAGEAL DILATION WITHOUT ENDOSCOPY

Facility

$546.19

Service Code	EAPG 00131
Min. Negotiated Rate	$546.19
Max. Negotiated Rate	$546.19
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$546.19
Rate for Payer: Molina Healthcare Medicaid	$546.19

EAPG 00132: ANOSCOPY WITH BIOPSY AND DIAGNOSTIC PROCTOSIGMOIDOSCOPY

Facility

$518.40

Service Code	EAPG 00132
Min. Negotiated Rate	$518.40
Max. Negotiated Rate	$518.40
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$518.40
Rate for Payer: Molina Healthcare Medicaid	$518.40

EAPG 00133: PROCTOSIGMOIDOSCOPY WITH EXCISION OR BIOPSY

Facility

$628.87

Service Code	EAPG 00133
Min. Negotiated Rate	$628.87
Max. Negotiated Rate	$628.87
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$628.87
Rate for Payer: Molina Healthcare Medicaid	$628.87

Know your out-of-pocket cost for care.

All Charges