Beloit Memorial Hospital

All Charges

Charge

Type

Setting

Price

EAPG 368: LEVEL II ORAL SURGERY PROCEDURES

Facility

$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

$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

$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

$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

$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

$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

$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

$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

$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

$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

$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

EAPG 379: LEVEL II ORTHODONTICS

Facility

$641.28

Service Code	EAPG 00379
Min. Negotiated Rate	$270.31
Max. Negotiated Rate	$641.28
Rate for Payer: Anthem Medicaid	$616.62
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$270.31
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$616.62
Rate for Payer: Dean Health Medicaid	$616.62
Rate for Payer: Independent Care Health Plan Medicaid	$616.62
Rate for Payer: Managed Health Services Medicaid	$641.28
Rate for Payer: Molina Healthcare Medicaid	$270.31
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$616.62
Rate for Payer: United Healthcare Medicaid	$616.62
Rate for Payer: WMAP Medicaid	$616.62

EAPG 37: LEVEL I ARTHROSCOPY

Facility

$1,622.61

Service Code	EAPG 00037
Min. Negotiated Rate	$888.79
Max. Negotiated Rate	$1,622.61
Rate for Payer: Anthem Medicaid	$888.79
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,622.61
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$888.79
Rate for Payer: Dean Health Medicaid	$888.79
Rate for Payer: Independent Care Health Plan Medicaid	$888.79
Rate for Payer: Managed Health Services Medicaid	$924.34
Rate for Payer: Molina Healthcare Medicaid	$1,622.61
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$888.79
Rate for Payer: United Healthcare Medicaid	$888.79
Rate for Payer: WMAP Medicaid	$888.79

EAPG 380: ANESTHESIA

Facility

$18.64

Service Code	EAPG 00380
Min. Negotiated Rate	$9.45
Max. Negotiated Rate	$18.64
Rate for Payer: Anthem Medicaid	$9.45
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$18.64
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$9.45
Rate for Payer: Dean Health Medicaid	$9.45
Rate for Payer: Independent Care Health Plan Medicaid	$9.45
Rate for Payer: Managed Health Services Medicaid	$9.83
Rate for Payer: Molina Healthcare Medicaid	$18.64
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$9.45
Rate for Payer: United Healthcare Medicaid	$9.45
Rate for Payer: WMAP Medicaid	$9.45

EAPG 381: LEVEL I DENTAL IMPLANTS

Facility

$954.56

Service Code	EAPG 00381
Min. Negotiated Rate	$538.00
Max. Negotiated Rate	$954.56
Rate for Payer: Anthem Medicaid	$538.00
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$954.56
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$538.00
Rate for Payer: Dean Health Medicaid	$538.00
Rate for Payer: Independent Care Health Plan Medicaid	$538.00
Rate for Payer: Managed Health Services Medicaid	$559.52
Rate for Payer: Molina Healthcare Medicaid	$954.56
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$538.00
Rate for Payer: United Healthcare Medicaid	$538.00
Rate for Payer: WMAP Medicaid	$538.00

EAPG 382: LEVEL II DENTAL IMPLANTS

Facility

$1,050.01

Service Code	EAPG 00382
Min. Negotiated Rate	$591.80
Max. Negotiated Rate	$1,050.01
Rate for Payer: Anthem Medicaid	$591.80
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,050.01
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$591.80
Rate for Payer: Dean Health Medicaid	$591.80
Rate for Payer: Independent Care Health Plan Medicaid	$591.80
Rate for Payer: Managed Health Services Medicaid	$615.47
Rate for Payer: Molina Healthcare Medicaid	$1,050.01
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$591.80
Rate for Payer: United Healthcare Medicaid	$591.80
Rate for Payer: WMAP Medicaid	$591.80

EAPG 384: LEVEL III CHEMISTRY TESTS

Facility

$23.88

Service Code	EAPG 00384
Min. Negotiated Rate	$22.96
Max. Negotiated Rate	$23.88
Rate for Payer: Anthem Medicaid	$22.96
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$22.96
Rate for Payer: Dean Health Medicaid	$22.96
Rate for Payer: Independent Care Health Plan Medicaid	$22.96
Rate for Payer: Managed Health Services Medicaid	$23.88
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$22.96
Rate for Payer: United Healthcare Medicaid	$22.96
Rate for Payer: WMAP Medicaid	$22.96

EAPG 385: LEVEL I COMPLEX LABORATORY, MOLECULAR PATHOLOGY AND GENETIC TESTS

Facility

$31.60

Service Code	EAPG 00385
Min. Negotiated Rate	$15.70
Max. Negotiated Rate	$31.60
Rate for Payer: Anthem Medicaid	$15.70
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$31.60
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$15.70
Rate for Payer: Dean Health Medicaid	$15.70
Rate for Payer: Independent Care Health Plan Medicaid	$15.70
Rate for Payer: Managed Health Services Medicaid	$16.33
Rate for Payer: Molina Healthcare Medicaid	$31.60
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$15.70
Rate for Payer: United Healthcare Medicaid	$15.70
Rate for Payer: WMAP Medicaid	$15.70

EAPG 386: LEVEL II COMPLEX LABORATORY, MOLECULAR PATHOLOGY AND GENETIC TESTS

Facility

$102.89

Service Code	EAPG 00386
Min. Negotiated Rate	$55.49
Max. Negotiated Rate	$102.89
Rate for Payer: Anthem Medicaid	$55.49
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$102.89
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$55.49
Rate for Payer: Dean Health Medicaid	$55.49
Rate for Payer: Independent Care Health Plan Medicaid	$55.49
Rate for Payer: Managed Health Services Medicaid	$57.71
Rate for Payer: Molina Healthcare Medicaid	$102.89
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$55.49
Rate for Payer: United Healthcare Medicaid	$55.49
Rate for Payer: WMAP Medicaid	$55.49

EAPG 387: LEVEL III COMPLEX LABORATORY, MOLECULAR PATHOLOGY AND GENETIC TESTS

Facility

$291.98

Service Code	EAPG 00387
Min. Negotiated Rate	$121.08
Max. Negotiated Rate	$291.98
Rate for Payer: Anthem Medicaid	$121.08
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$291.98
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$121.08
Rate for Payer: Dean Health Medicaid	$121.08
Rate for Payer: Independent Care Health Plan Medicaid	$121.08
Rate for Payer: Managed Health Services Medicaid	$125.92
Rate for Payer: Molina Healthcare Medicaid	$291.98
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$121.08
Rate for Payer: United Healthcare Medicaid	$121.08
Rate for Payer: WMAP Medicaid	$121.08

EAPG 388: LEVEL III MICROBIOLOGY TESTS

Facility

$71.49

Service Code	EAPG 00388
Min. Negotiated Rate	$68.74
Max. Negotiated Rate	$71.49
Rate for Payer: Anthem Medicaid	$68.74
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$68.74
Rate for Payer: Dean Health Medicaid	$68.74
Rate for Payer: Independent Care Health Plan Medicaid	$68.74
Rate for Payer: Managed Health Services Medicaid	$71.49
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$68.74
Rate for Payer: United Healthcare Medicaid	$68.74
Rate for Payer: WMAP Medicaid	$68.74

EAPG 389: LEVEL II CONVENTIONAL RADIOLOGY

Facility

$51.14

Service Code	EAPG 00389
Min. Negotiated Rate	$49.17
Max. Negotiated Rate	$51.14
Rate for Payer: Anthem Medicaid	$49.17
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$49.17
Rate for Payer: Dean Health Medicaid	$49.17
Rate for Payer: Independent Care Health Plan Medicaid	$49.17
Rate for Payer: Managed Health Services Medicaid	$51.14
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$49.17
Rate for Payer: United Healthcare Medicaid	$49.17
Rate for Payer: WMAP Medicaid	$49.17

EAPG 38: LEVEL II ARTHROSCOPY

Facility

$3,871.99

Service Code	EAPG 00038
Min. Negotiated Rate	$2,241.51
Max. Negotiated Rate	$3,871.99
Rate for Payer: Anthem Medicaid	$2,241.51
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$3,871.99
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,241.51
Rate for Payer: Dean Health Medicaid	$2,241.51
Rate for Payer: Independent Care Health Plan Medicaid	$2,241.51
Rate for Payer: Managed Health Services Medicaid	$2,331.17
Rate for Payer: Molina Healthcare Medicaid	$3,871.99
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,241.51
Rate for Payer: United Healthcare Medicaid	$2,241.51
Rate for Payer: WMAP Medicaid	$2,241.51

EAPG 390: LEVEL I PATHOLOGY TESTS

Facility

$25.44

Service Code	EAPG 00390
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$25.44
Rate for Payer: Anthem Medicaid	$1.67
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$25.44
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1.67
Rate for Payer: Dean Health Medicaid	$1.67
Rate for Payer: Independent Care Health Plan Medicaid	$1.67
Rate for Payer: Managed Health Services Medicaid	$1.74
Rate for Payer: Molina Healthcare Medicaid	$25.44
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1.67
Rate for Payer: United Healthcare Medicaid	$1.67
Rate for Payer: WMAP Medicaid	$1.67

EAPG 391: LEVEL II PATHOLOGY TESTS

Facility

$27.98

Service Code	EAPG 00391
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$27.98
Rate for Payer: Anthem Medicaid	$11.05
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$27.98
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$11.05
Rate for Payer: Dean Health Medicaid	$11.05
Rate for Payer: Independent Care Health Plan Medicaid	$11.05
Rate for Payer: Managed Health Services Medicaid	$11.49
Rate for Payer: Molina Healthcare Medicaid	$27.98
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$11.05
Rate for Payer: United Healthcare Medicaid	$11.05
Rate for Payer: WMAP Medicaid	$11.05

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