Beloit Memorial Hospital

All Charges

Charge

Type

Setting

Price

LEVEL II HEMATOLOGY TESTS

Facility

$22.28

Service Code	EAPG 00409
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$22.28
Rate for Payer: Anthem Medicaid	$21.42
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$21.42
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$21.42
Rate for Payer: Dean Health Medicaid	$21.42
Rate for Payer: Independent Care Health Plan Medicaid	$21.42
Rate for Payer: Managed Health Services Medicaid	$22.28
Rate for Payer: Molina Healthcare Medicaid	$21.42
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$21.42
Rate for Payer: United Healthcare Medicaid	$21.42

LEVEL II HEPATOBILIARY AND PANCREAS PROCEDURES

Facility

$1,641.81

Service Code	EAPG 00152
Min. Negotiated Rate	$1,578.65
Max. Negotiated Rate	$1,641.81
Rate for Payer: Anthem Medicaid	$1,578.65
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,578.65
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,578.65
Rate for Payer: Dean Health Medicaid	$1,578.65
Rate for Payer: Independent Care Health Plan Medicaid	$1,578.65
Rate for Payer: Managed Health Services Medicaid	$1,641.81
Rate for Payer: Molina Healthcare Medicaid	$1,578.65
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,578.65
Rate for Payer: United Healthcare Medicaid	$1,578.65

LEVEL II HIP AND FEMUR PROCEDURES

Facility

$1,567.12

Service Code	EAPG 00055
Min. Negotiated Rate	$1,506.84
Max. Negotiated Rate	$1,567.12
Rate for Payer: Anthem Medicaid	$1,506.84
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,506.84
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,506.84
Rate for Payer: Dean Health Medicaid	$1,506.84
Rate for Payer: Independent Care Health Plan Medicaid	$1,506.84
Rate for Payer: Managed Health Services Medicaid	$1,567.12
Rate for Payer: Molina Healthcare Medicaid	$1,506.84
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,506.84
Rate for Payer: United Healthcare Medicaid	$1,506.84

LEVEL II HYSTERECTOMY AND MYOMECTOMY PROCEDURES

Facility

$1,468.85

Service Code	EAPG 00206
Min. Negotiated Rate	$1,412.35
Max. Negotiated Rate	$1,468.85
Rate for Payer: Anthem Medicaid	$1,412.35
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,412.35
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,412.35
Rate for Payer: Dean Health Medicaid	$1,412.35
Rate for Payer: Independent Care Health Plan Medicaid	$1,412.35
Rate for Payer: Managed Health Services Medicaid	$1,468.85
Rate for Payer: Molina Healthcare Medicaid	$1,412.35
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,412.35
Rate for Payer: United Healthcare Medicaid	$1,412.35

Level III

Facility

$2,005.00

Hospital Charge Code	5104609
Hospital Revenue Code	450
Min. Negotiated Rate	$313.04
Max. Negotiated Rate	$1,918.38
Rate for Payer: Aetna Commercial	$1,876.68
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper	$1,793.27
Rate for Payer: Aetna Managed Medicare	$583.86
Rate for Payer: Anthem Blue Access PPO/Blue Traditional	$1,355.38
Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus	$1,042.60
Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI	$1,000.90
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO	$1,105.16
Rate for Payer: Cash Price	$601.50
Rate for Payer: Cash Price	$601.50
Rate for Payer: Cigna Commercial	$1,918.38
Rate for Payer: Dean Health DHI/DHP/ASO	$1,166.91
Rate for Payer: Health EOS Commercial	$1,855.83
Rate for Payer: HFN Commercial	$1,918.38
Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO	$1,563.90
Rate for Payer: Multiplan Commercial	$1,668.16
Rate for Payer: NAPHCARE Commercial	$1,251.12
Rate for Payer: Preferred Network Access Commercial	$1,918.38
Rate for Payer: Quartz Beloit One Network	$1,021.75
Rate for Payer: Quartz Commercial	$1,355.38
Rate for Payer: Quartz Medicare Advantage	$1,251.12
Rate for Payer: The Alliance Commercial	$1,042.60
Rate for Payer: United Healthcare PPO	$313.04
Rate for Payer: WEA Trust Commercial	$1,146.86
Rate for Payer: WPS Commercial	$1,544.45

Level III

Facility

$2,005.00

Hospital Charge Code	5104609
Hospital Revenue Code	450
Min. Negotiated Rate	$1,021.75
Max. Negotiated Rate	$1,918.38
Rate for Payer: Aetna Commercial	$1,876.68
Rate for Payer: Aetna Gatekeeper/Not Gatekeeper	$1,793.27
Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO	$1,105.16
Rate for Payer: Cash Price	$601.50
Rate for Payer: Cigna Commercial	$1,918.38
Rate for Payer: Health EOS Commercial	$1,855.83
Rate for Payer: HFN Commercial	$1,918.38
Rate for Payer: Multiplan Commercial	$1,668.16
Rate for Payer: Preferred Network Access Commercial	$1,918.38
Rate for Payer: Quartz Beloit One Network	$1,021.75
Rate for Payer: Quartz Commercial	$1,251.12
Rate for Payer: WEA Trust Commercial	$1,146.86
Rate for Payer: WPS Commercial	$1,544.45

LEVEL III ANTERIOR SEGMENT EYE PROCEDURES

Facility

$2,260.27

Service Code	EAPG 00236
Min. Negotiated Rate	$2,173.33
Max. Negotiated Rate	$2,260.27
Rate for Payer: Anthem Medicaid	$2,173.33
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,173.33
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,173.33
Rate for Payer: Dean Health Medicaid	$2,173.33
Rate for Payer: Independent Care Health Plan Medicaid	$2,173.33
Rate for Payer: Managed Health Services Medicaid	$2,260.27
Rate for Payer: Molina Healthcare Medicaid	$2,173.33
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,173.33
Rate for Payer: United Healthcare Medicaid	$2,173.33

LEVEL III BLOOD AND TISSUE TYPING TESTS

Facility

$34.07

Service Code	EAPG 02043
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 III BLOOD PRODUCT EXCHANGE SERVICES

Facility

$1,460.98

Service Code	EAPG 00155
Min. Negotiated Rate	$1,404.79
Max. Negotiated Rate	$1,460.98
Rate for Payer: Anthem Medicaid	$1,404.79
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,404.79
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,404.79
Rate for Payer: Dean Health Medicaid	$1,404.79
Rate for Payer: Independent Care Health Plan Medicaid	$1,404.79
Rate for Payer: Managed Health Services Medicaid	$1,460.98
Rate for Payer: Molina Healthcare Medicaid	$1,404.79
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,404.79
Rate for Payer: United Healthcare Medicaid	$1,404.79

LEVEL III BRACHYTHERAPY SOURCES

Facility

$10,285.85

Service Code	EAPG 00337
Min. Negotiated Rate	$9,890.22
Max. Negotiated Rate	$10,285.85
Rate for Payer: Anthem Medicaid	$9,890.22
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$9,890.22
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$9,890.22
Rate for Payer: Dean Health Medicaid	$9,890.22
Rate for Payer: Independent Care Health Plan Medicaid	$9,890.22
Rate for Payer: Managed Health Services Medicaid	$10,285.85
Rate for Payer: Molina Healthcare Medicaid	$9,890.22
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$9,890.22
Rate for Payer: United Healthcare Medicaid	$9,890.22

LEVEL III BREAST PROCEDURES

Facility

$2,272.06

Service Code	EAPG 00022
Min. Negotiated Rate	$2,184.67
Max. Negotiated Rate	$2,272.06
Rate for Payer: Anthem Medicaid	$2,184.67
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,184.67
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,184.67
Rate for Payer: Dean Health Medicaid	$2,184.67
Rate for Payer: Independent Care Health Plan Medicaid	$2,184.67
Rate for Payer: Managed Health Services Medicaid	$2,272.06
Rate for Payer: Molina Healthcare Medicaid	$2,184.67
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,184.67
Rate for Payer: United Healthcare Medicaid	$2,184.67

LEVEL III CHEMISTRY TESTS

Facility

$38.00

Service Code	EAPG 00384
Min. Negotiated Rate	$36.54
Max. Negotiated Rate	$38.00
Rate for Payer: Anthem Medicaid	$36.54
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$36.54
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$36.54
Rate for Payer: Dean Health Medicaid	$36.54
Rate for Payer: Independent Care Health Plan Medicaid	$36.54
Rate for Payer: Managed Health Services Medicaid	$38.00
Rate for Payer: Molina Healthcare Medicaid	$36.54
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$36.54
Rate for Payer: United Healthcare Medicaid	$36.54

LEVEL III DENTAL RESTORATIONS

Facility

$307.92

Service Code	EAPG 00363
Min. Negotiated Rate	$296.08
Max. Negotiated Rate	$307.92
Rate for Payer: Anthem Medicaid	$296.08
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$296.08
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$296.08
Rate for Payer: Dean Health Medicaid	$296.08
Rate for Payer: Independent Care Health Plan Medicaid	$296.08
Rate for Payer: Managed Health Services Medicaid	$307.92
Rate for Payer: Molina Healthcare Medicaid	$296.08
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$296.08
Rate for Payer: United Healthcare Medicaid	$296.08

LEVEL III DEVICE PLACEMENT FOR RADIATION THERAPY

Facility

$1,301.13

Service Code	EAPG 00339
Min. Negotiated Rate	$1,251.08
Max. Negotiated Rate	$1,301.13
Rate for Payer: Anthem Medicaid	$1,251.08
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,251.08
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,251.08
Rate for Payer: Dean Health Medicaid	$1,251.08
Rate for Payer: Independent Care Health Plan Medicaid	$1,251.08
Rate for Payer: Managed Health Services Medicaid	$1,301.13
Rate for Payer: Molina Healthcare Medicaid	$1,251.08
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,251.08
Rate for Payer: United Healthcare Medicaid	$1,251.08

LEVEL III EAR, NOSE, MOUTH AND THROAT PROCEDURES

Facility

$1,698.15

Service Code	EAPG 00254
Min. Negotiated Rate	$1,632.83
Max. Negotiated Rate	$1,698.15
Rate for Payer: Anthem Medicaid	$1,632.83
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,632.83
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,632.83
Rate for Payer: Dean Health Medicaid	$1,632.83
Rate for Payer: Independent Care Health Plan Medicaid	$1,632.83
Rate for Payer: Managed Health Services Medicaid	$1,698.15
Rate for Payer: Molina Healthcare Medicaid	$1,632.83
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,632.83
Rate for Payer: United Healthcare Medicaid	$1,632.83

LEVEL III ENDODONTICS

Facility

$148.06

Service Code	EAPG 00366
Min. Negotiated Rate	$142.37
Max. Negotiated Rate	$148.06
Rate for Payer: Anthem Medicaid	$142.37
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$142.37
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$142.37
Rate for Payer: Dean Health Medicaid	$142.37
Rate for Payer: Independent Care Health Plan Medicaid	$142.37
Rate for Payer: Managed Health Services Medicaid	$148.06
Rate for Payer: Molina Healthcare Medicaid	$142.37
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$142.37
Rate for Payer: United Healthcare Medicaid	$142.37

LEVEL III KIDNEY AND URETERAL PROCEDURES

Facility

$1,402.02

Service Code	EAPG 00172
Min. Negotiated Rate	$1,348.09
Max. Negotiated Rate	$1,402.02
Rate for Payer: Anthem Medicaid	$1,348.09
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,348.09
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,348.09
Rate for Payer: Dean Health Medicaid	$1,348.09
Rate for Payer: Independent Care Health Plan Medicaid	$1,348.09
Rate for Payer: Managed Health Services Medicaid	$1,402.02
Rate for Payer: Molina Healthcare Medicaid	$1,348.09
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,348.09
Rate for Payer: United Healthcare Medicaid	$1,348.09

LEVEL III LAPAROSCOPY

Facility

$2,306.13

Service Code	EAPG 00148
Min. Negotiated Rate	$2,217.42
Max. Negotiated Rate	$2,306.13
Rate for Payer: Anthem Medicaid	$2,217.42
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,217.42
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,217.42
Rate for Payer: Dean Health Medicaid	$2,217.42
Rate for Payer: Independent Care Health Plan Medicaid	$2,217.42
Rate for Payer: Managed Health Services Medicaid	$2,306.13
Rate for Payer: Molina Healthcare Medicaid	$2,217.42
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,217.42
Rate for Payer: United Healthcare Medicaid	$2,217.42

LEVEL III MICROBIOLOGY TESTS

Facility

$43.24

Service Code	EAPG 00388
Min. Negotiated Rate	$41.58
Max. Negotiated Rate	$43.24
Rate for Payer: Anthem Medicaid	$41.58
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$41.58
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$41.58
Rate for Payer: Dean Health Medicaid	$41.58
Rate for Payer: Independent Care Health Plan Medicaid	$41.58
Rate for Payer: Managed Health Services Medicaid	$43.24
Rate for Payer: Molina Healthcare Medicaid	$41.58
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$41.58
Rate for Payer: United Healthcare Medicaid	$41.58

LEVEL II IMMUNIZATION

Facility

$48.48

Service Code	EAPG 00415
Min. Negotiated Rate	$46.62
Max. Negotiated Rate	$48.48
Rate for Payer: Anthem Medicaid	$46.62
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$46.62
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$46.62
Rate for Payer: Dean Health Medicaid	$46.62
Rate for Payer: Independent Care Health Plan Medicaid	$46.62
Rate for Payer: Managed Health Services Medicaid	$48.48
Rate for Payer: Molina Healthcare Medicaid	$46.62
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$46.62
Rate for Payer: United Healthcare Medicaid	$46.62

LEVEL II IMMUNOLOGY TESTS

Facility

$30.14

Service Code	EAPG 00395
Min. Negotiated Rate	$28.98
Max. Negotiated Rate	$30.14
Rate for Payer: Anthem Medicaid	$28.98
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$28.98
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$28.98
Rate for Payer: Dean Health Medicaid	$28.98
Rate for Payer: Independent Care Health Plan Medicaid	$28.98
Rate for Payer: Managed Health Services Medicaid	$30.14
Rate for Payer: Molina Healthcare Medicaid	$28.98
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$28.98
Rate for Payer: United Healthcare Medicaid	$28.98

LEVEL III NERVE PROCEDURE W OR W/O NEUROLOGICAL DEVICE

Facility

$10,144.34

Service Code	EAPG 00223
Min. Negotiated Rate	$9,754.15
Max. Negotiated Rate	$10,144.34
Rate for Payer: Anthem Medicaid	$9,754.15
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$9,754.15
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$9,754.15
Rate for Payer: Dean Health Medicaid	$9,754.15
Rate for Payer: Independent Care Health Plan Medicaid	$9,754.15
Rate for Payer: Managed Health Services Medicaid	$10,144.34
Rate for Payer: Molina Healthcare Medicaid	$9,754.15
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$9,754.15
Rate for Payer: United Healthcare Medicaid	$9,754.15

LEVEL III ORAL AND MAXILLOFACIAL PROCEDURES

Facility

$272.54

Service Code	EAPG 00369
Min. Negotiated Rate	$262.06
Max. Negotiated Rate	$272.54
Rate for Payer: Anthem Medicaid	$262.06
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$262.06
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$262.06
Rate for Payer: Dean Health Medicaid	$262.06
Rate for Payer: Independent Care Health Plan Medicaid	$262.06
Rate for Payer: Managed Health Services Medicaid	$272.54
Rate for Payer: Molina Healthcare Medicaid	$262.06
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$262.06
Rate for Payer: United Healthcare Medicaid	$262.06

LEVEL III PATHOLOGY TESTS

Facility

$61.58

Service Code	EAPG 00308
Min. Negotiated Rate	$59.22
Max. Negotiated Rate	$61.58
Rate for Payer: Anthem Medicaid	$59.22
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$59.22
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$59.22
Rate for Payer: Dean Health Medicaid	$59.22
Rate for Payer: Independent Care Health Plan Medicaid	$59.22
Rate for Payer: Managed Health Services Medicaid	$61.58
Rate for Payer: Molina Healthcare Medicaid	$59.22
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$59.22
Rate for Payer: United Healthcare Medicaid	$59.22

LEVEL III PERIPHERAL ENDOVASCULAR AND TRANSCATHETER PROCEDURES

Facility

$1,909.11

Service Code	EAPG 00085
Min. Negotiated Rate	$1,835.67
Max. Negotiated Rate	$1,909.11
Rate for Payer: Anthem Medicaid	$1,835.67
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,835.67
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,835.67
Rate for Payer: Dean Health Medicaid	$1,835.67
Rate for Payer: Independent Care Health Plan Medicaid	$1,835.67
Rate for Payer: Managed Health Services Medicaid	$1,909.11
Rate for Payer: Molina Healthcare Medicaid	$1,835.67
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,835.67
Rate for Payer: United Healthcare Medicaid	$1,835.67

Know your out-of-pocket cost for care.

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