Beloit Memorial Hospital

All Charges

Charge

Type

Setting

Price

LEVEL I ANAL AND RECTAL PROCEDURES

Facility

$779.63

Service Code	EAPG 00141
Min. Negotiated Rate	$749.64
Max. Negotiated Rate	$779.63
Rate for Payer: Anthem Medicaid	$749.64
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$749.64
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$749.64
Rate for Payer: Dean Health Medicaid	$749.64
Rate for Payer: Independent Care Health Plan Medicaid	$749.64
Rate for Payer: Managed Health Services Medicaid	$779.63
Rate for Payer: Molina Healthcare Medicaid	$749.64
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$749.64
Rate for Payer: United Healthcare Medicaid	$749.64

LEVEL I ANCILLARY THERAPEUTIC SERVICES

Facility

$18.34

Service Code	EAPG 00493
Min. Negotiated Rate	$17.64
Max. Negotiated Rate	$18.34
Rate for Payer: Anthem Medicaid	$17.64
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$17.64
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$17.64
Rate for Payer: Dean Health Medicaid	$17.64
Rate for Payer: Independent Care Health Plan Medicaid	$17.64
Rate for Payer: Managed Health Services Medicaid	$18.34
Rate for Payer: Molina Healthcare Medicaid	$17.64
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$17.64
Rate for Payer: United Healthcare Medicaid	$17.64

LEVEL I ANTERIOR SEGMENT EYE PROCEDURES

Facility

$1,170.10

Service Code	EAPG 00234
Min. Negotiated Rate	$1,125.09
Max. Negotiated Rate	$1,170.10
Rate for Payer: Anthem Medicaid	$1,125.09
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,125.09
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,125.09
Rate for Payer: Dean Health Medicaid	$1,125.09
Rate for Payer: Independent Care Health Plan Medicaid	$1,125.09
Rate for Payer: Managed Health Services Medicaid	$1,170.10
Rate for Payer: Molina Healthcare Medicaid	$1,125.09
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,125.09
Rate for Payer: United Healthcare Medicaid	$1,125.09

LEVEL I ARTHROPLASTY

Facility

$2,173.79

Service Code	EAPG 00046
Min. Negotiated Rate	$2,090.17
Max. Negotiated Rate	$2,173.79
Rate for Payer: Anthem Medicaid	$2,090.17
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,090.17
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,090.17
Rate for Payer: Dean Health Medicaid	$2,090.17
Rate for Payer: Independent Care Health Plan Medicaid	$2,090.17
Rate for Payer: Managed Health Services Medicaid	$2,173.79
Rate for Payer: Molina Healthcare Medicaid	$2,090.17
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,090.17
Rate for Payer: United Healthcare Medicaid	$2,090.17

LEVEL I ARTHROSCOPY

Facility

$1,303.75

Service Code	EAPG 00037
Min. Negotiated Rate	$1,253.60
Max. Negotiated Rate	$1,303.75
Rate for Payer: Anthem Medicaid	$1,253.60
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,253.60
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,253.60
Rate for Payer: Dean Health Medicaid	$1,253.60
Rate for Payer: Independent Care Health Plan Medicaid	$1,253.60
Rate for Payer: Managed Health Services Medicaid	$1,303.75
Rate for Payer: Molina Healthcare Medicaid	$1,253.60
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,253.60
Rate for Payer: United Healthcare Medicaid	$1,253.60

LEVEL I BLADDER AND URETERAL PROCEDURES

Facility

$1,159.62

Service Code	EAPG 00173
Min. Negotiated Rate	$1,115.01
Max. Negotiated Rate	$1,159.62
Rate for Payer: Anthem Medicaid	$1,115.01
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,115.01
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,115.01
Rate for Payer: Dean Health Medicaid	$1,115.01
Rate for Payer: Independent Care Health Plan Medicaid	$1,115.01
Rate for Payer: Managed Health Services Medicaid	$1,159.62
Rate for Payer: Molina Healthcare Medicaid	$1,115.01
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,115.01
Rate for Payer: United Healthcare Medicaid	$1,115.01

LEVEL I BLOOD AND BLOOD PRODUCT EXCHANGE

Facility

$387.85

Service Code	EAPG 00113
Min. Negotiated Rate	$372.93
Max. Negotiated Rate	$387.85
Rate for Payer: Anthem Medicaid	$372.93
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$372.93
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$372.93
Rate for Payer: Dean Health Medicaid	$372.93
Rate for Payer: Independent Care Health Plan Medicaid	$372.93
Rate for Payer: Managed Health Services Medicaid	$387.85
Rate for Payer: Molina Healthcare Medicaid	$372.93
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$372.93
Rate for Payer: United Healthcare Medicaid	$372.93

LEVEL I BLOOD AND TISSUE TYPING TESTS

Facility

$34.07

Service Code	EAPG 00486
Min. Negotiated Rate	$32.76
Max. Negotiated Rate	$34.07
Rate for Payer: Anthem Medicaid	$32.76
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$32.76
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$32.76
Rate for Payer: Dean Health Medicaid	$32.76
Rate for Payer: Independent Care Health Plan Medicaid	$32.76
Rate for Payer: Managed Health Services Medicaid	$34.07
Rate for Payer: Molina Healthcare Medicaid	$32.76
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$32.76
Rate for Payer: United Healthcare Medicaid	$32.76

LEVEL I BLOOD PRODUCTS

Facility

$387.85

Service Code	EAPG 02061
Min. Negotiated Rate	$372.93
Max. Negotiated Rate	$387.85
Rate for Payer: Anthem Medicaid	$372.93
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$372.93
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$372.93
Rate for Payer: Dean Health Medicaid	$372.93
Rate for Payer: Independent Care Health Plan Medicaid	$372.93
Rate for Payer: Managed Health Services Medicaid	$387.85
Rate for Payer: Molina Healthcare Medicaid	$372.93
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$372.93
Rate for Payer: United Healthcare Medicaid	$372.93

LEVEL I BRACHYTHERAPY SOURCES

Facility

$704.94

Service Code	EAPG 00335
Min. Negotiated Rate	$677.83
Max. Negotiated Rate	$704.94
Rate for Payer: Anthem Medicaid	$677.83
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$677.83
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$677.83
Rate for Payer: Dean Health Medicaid	$677.83
Rate for Payer: Independent Care Health Plan Medicaid	$677.83
Rate for Payer: Managed Health Services Medicaid	$704.94
Rate for Payer: Molina Healthcare Medicaid	$677.83
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$677.83
Rate for Payer: United Healthcare Medicaid	$677.83

LEVEL I BREAST PROCEDURES

Facility

$1,122.93

Service Code	EAPG 00020
Min. Negotiated Rate	$1,079.73
Max. Negotiated Rate	$1,122.93
Rate for Payer: Anthem Medicaid	$1,079.73
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,079.73
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,079.73
Rate for Payer: Dean Health Medicaid	$1,079.73
Rate for Payer: Independent Care Health Plan Medicaid	$1,079.73
Rate for Payer: Managed Health Services Medicaid	$1,122.93
Rate for Payer: Molina Healthcare Medicaid	$1,079.73
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,079.73
Rate for Payer: United Healthcare Medicaid	$1,079.73

LEVEL I CENTRAL VENOUS ACCESS PROCEDURES

Facility

$166.41

Service Code	EAPG 00075
Min. Negotiated Rate	$160.01
Max. Negotiated Rate	$166.41
Rate for Payer: Anthem Medicaid	$160.01
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$160.01
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$160.01
Rate for Payer: Dean Health Medicaid	$160.01
Rate for Payer: Independent Care Health Plan Medicaid	$160.01
Rate for Payer: Managed Health Services Medicaid	$166.41
Rate for Payer: Molina Healthcare Medicaid	$160.01
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$160.01
Rate for Payer: United Healthcare Medicaid	$160.01

LEVEL I CHEMISTRY TESTS

Facility

$9.17

Service Code	EAPG 00400
Min. Negotiated Rate	$8.82
Max. Negotiated Rate	$9.17
Rate for Payer: Anthem Medicaid	$8.82
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$8.82
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$8.82
Rate for Payer: Dean Health Medicaid	$8.82
Rate for Payer: Independent Care Health Plan Medicaid	$8.82
Rate for Payer: Managed Health Services Medicaid	$9.17
Rate for Payer: Molina Healthcare Medicaid	$8.82
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$8.82
Rate for Payer: United Healthcare Medicaid	$8.82

LEVEL I CLOTTING TESTS

Facility

$10.48

Service Code	EAPG 00406
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$10.48
Rate for Payer: Anthem Medicaid	$10.08
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$10.08
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$10.08
Rate for Payer: Dean Health Medicaid	$10.08
Rate for Payer: Independent Care Health Plan Medicaid	$10.08
Rate for Payer: Managed Health Services Medicaid	$10.48
Rate for Payer: Molina Healthcare Medicaid	$10.08
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$10.08
Rate for Payer: United Healthcare Medicaid	$10.08

LEVEL I COMPUTED TOMOGRAPHY

Facility

$213.58

Service Code	EAPG 00299
Min. Negotiated Rate	$205.36
Max. Negotiated Rate	$213.58
Rate for Payer: Anthem Medicaid	$205.36
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$205.36
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$205.36
Rate for Payer: Dean Health Medicaid	$205.36
Rate for Payer: Independent Care Health Plan Medicaid	$205.36
Rate for Payer: Managed Health Services Medicaid	$213.58
Rate for Payer: Molina Healthcare Medicaid	$205.36
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$205.36
Rate for Payer: United Healthcare Medicaid	$205.36

LEVEL I CONVENTIONAL RADIOLOGY

Facility

$24.90

Service Code	EAPG 00471
Min. Negotiated Rate	$23.94
Max. Negotiated Rate	$24.90
Rate for Payer: Anthem Medicaid	$23.94
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$23.94
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$23.94
Rate for Payer: Dean Health Medicaid	$23.94
Rate for Payer: Independent Care Health Plan Medicaid	$23.94
Rate for Payer: Managed Health Services Medicaid	$24.90
Rate for Payer: Molina Healthcare Medicaid	$23.94
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$23.94
Rate for Payer: United Healthcare Medicaid	$23.94

LEVEL I CORNEAL AND OTHER ANTERIOR SURFACE EYE PROCEDURES

Facility

$1,151.75

Service Code	EAPG 00247
Min. Negotiated Rate	$1,107.45
Max. Negotiated Rate	$1,151.75
Rate for Payer: Anthem Medicaid	$1,107.45
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,107.45
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,107.45
Rate for Payer: Dean Health Medicaid	$1,107.45
Rate for Payer: Independent Care Health Plan Medicaid	$1,107.45
Rate for Payer: Managed Health Services Medicaid	$1,151.75
Rate for Payer: Molina Healthcare Medicaid	$1,107.45
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,107.45
Rate for Payer: United Healthcare Medicaid	$1,107.45

LEVEL I CRANIOFACIAL BONE PROCEDURES

Facility

$1,818.70

Service Code	EAPG 00227
Min. Negotiated Rate	$1,748.74
Max. Negotiated Rate	$1,818.70
Rate for Payer: Anthem Medicaid	$1,748.74
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,748.74
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,748.74
Rate for Payer: Dean Health Medicaid	$1,748.74
Rate for Payer: Independent Care Health Plan Medicaid	$1,748.74
Rate for Payer: Managed Health Services Medicaid	$1,818.70
Rate for Payer: Molina Healthcare Medicaid	$1,748.74
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,748.74
Rate for Payer: United Healthcare Medicaid	$1,748.74

LEVEL I DENTAL FILM

Facility

$17.03

Service Code	EAPG 00373
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$17.03
Rate for Payer: Anthem Medicaid	$16.38
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$16.38
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$16.38
Rate for Payer: Dean Health Medicaid	$16.38
Rate for Payer: Independent Care Health Plan Medicaid	$16.38
Rate for Payer: Managed Health Services Medicaid	$17.03
Rate for Payer: Molina Healthcare Medicaid	$16.38
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$16.38
Rate for Payer: United Healthcare Medicaid	$16.38

LEVEL I DENTAL RESTORATIONS

Facility

$86.48

Service Code	EAPG 00361
Min. Negotiated Rate	$83.15
Max. Negotiated Rate	$86.48
Rate for Payer: Anthem Medicaid	$83.15
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$83.15
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$83.15
Rate for Payer: Dean Health Medicaid	$83.15
Rate for Payer: Independent Care Health Plan Medicaid	$83.15
Rate for Payer: Managed Health Services Medicaid	$86.48
Rate for Payer: Molina Healthcare Medicaid	$83.15
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$83.15
Rate for Payer: United Healthcare Medicaid	$83.15

LEVEL I DEVICE PLACEMENT FOR RADIATION THERAPY

Facility

$593.57

Service Code	EAPG 00334
Min. Negotiated Rate	$570.73
Max. Negotiated Rate	$593.57
Rate for Payer: Anthem Medicaid	$570.73
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$570.73
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$570.73
Rate for Payer: Dean Health Medicaid	$570.73
Rate for Payer: Independent Care Health Plan Medicaid	$570.73
Rate for Payer: Managed Health Services Medicaid	$593.57
Rate for Payer: Molina Healthcare Medicaid	$570.73
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$570.73
Rate for Payer: United Healthcare Medicaid	$570.73

LEVEL I DIAGNOSTIC NUCLEAR MEDICINE

Facility

$243.72

Service Code	EAPG 00331
Min. Negotiated Rate	$234.34
Max. Negotiated Rate	$243.72
Rate for Payer: Anthem Medicaid	$234.34
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$234.34
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$234.34
Rate for Payer: Dean Health Medicaid	$234.34
Rate for Payer: Independent Care Health Plan Medicaid	$234.34
Rate for Payer: Managed Health Services Medicaid	$243.72
Rate for Payer: Molina Healthcare Medicaid	$234.34
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$234.34
Rate for Payer: United Healthcare Medicaid	$234.34

LEVEL I DIAGNOSTIC ULTRASOUND

Facility

$106.13

Service Code	EAPG 00288
Min. Negotiated Rate	$102.05
Max. Negotiated Rate	$106.13
Rate for Payer: Anthem Medicaid	$102.05
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$102.05
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$102.05
Rate for Payer: Dean Health Medicaid	$102.05
Rate for Payer: Independent Care Health Plan Medicaid	$102.05
Rate for Payer: Managed Health Services Medicaid	$106.13
Rate for Payer: Molina Healthcare Medicaid	$102.05
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$102.05
Rate for Payer: United Healthcare Medicaid	$102.05

LEVEL I EAR, NOSE, MOUTH AND THROAT PROCEDURES

Facility

$891.00

Service Code	EAPG 00252
Min. Negotiated Rate	$856.73
Max. Negotiated Rate	$891.00
Rate for Payer: Anthem Medicaid	$856.73
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$856.73
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$856.73
Rate for Payer: Dean Health Medicaid	$856.73
Rate for Payer: Independent Care Health Plan Medicaid	$856.73
Rate for Payer: Managed Health Services Medicaid	$891.00
Rate for Payer: Molina Healthcare Medicaid	$856.73
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$856.73
Rate for Payer: United Healthcare Medicaid	$856.73

LEVEL I ENDOCRINOLOGY TESTS

Facility

$20.96

Service Code	EAPG 00398
Min. Negotiated Rate	$20.16
Max. Negotiated Rate	$20.96
Rate for Payer: Anthem Medicaid	$20.16
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$20.16
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$20.16
Rate for Payer: Dean Health Medicaid	$20.16
Rate for Payer: Independent Care Health Plan Medicaid	$20.16
Rate for Payer: Managed Health Services Medicaid	$20.96
Rate for Payer: Molina Healthcare Medicaid	$20.16
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$20.16
Rate for Payer: United Healthcare Medicaid	$20.16

Know your out-of-pocket cost for care.

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