Beloit Memorial Hospital

All Charges

Charge

Type

Setting

Price

LEVEL III PROSTHODONTICS, FIXED

Facility

$276.47

Service Code	EAPG 00355
Min. Negotiated Rate	$265.84
Max. Negotiated Rate	$276.47
Rate for Payer: Anthem Medicaid	$265.84
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$265.84
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$265.84
Rate for Payer: Dean Health Medicaid	$265.84
Rate for Payer: Independent Care Health Plan Medicaid	$265.84
Rate for Payer: Managed Health Services Medicaid	$276.47
Rate for Payer: Molina Healthcare Medicaid	$265.84
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$265.84
Rate for Payer: United Healthcare Medicaid	$265.84

LEVEL III PROSTHODONTICS, REMOVABLE

Facility

$178.20

Service Code	EAPG 00358
Min. Negotiated Rate	$171.35
Max. Negotiated Rate	$178.20
Rate for Payer: Anthem Medicaid	$171.35
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$171.35
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$171.35
Rate for Payer: Dean Health Medicaid	$171.35
Rate for Payer: Independent Care Health Plan Medicaid	$171.35
Rate for Payer: Managed Health Services Medicaid	$178.20
Rate for Payer: Molina Healthcare Medicaid	$171.35
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$171.35
Rate for Payer: United Healthcare Medicaid	$171.35

LEVEL III RADIATION THERAPY

Facility

$551.64

Service Code	EAPG 00348
Min. Negotiated Rate	$530.42
Max. Negotiated Rate	$551.64
Rate for Payer: Anthem Medicaid	$530.42
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$530.42
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$530.42
Rate for Payer: Dean Health Medicaid	$530.42
Rate for Payer: Independent Care Health Plan Medicaid	$530.42
Rate for Payer: Managed Health Services Medicaid	$551.64
Rate for Payer: Molina Healthcare Medicaid	$530.42
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$530.42
Rate for Payer: United Healthcare Medicaid	$530.42

LEVEL III RADIATION TREATMENT PREPARATION & PLANNING

Facility

$120.55

Service Code	EAPG 00478
Min. Negotiated Rate	$115.91
Max. Negotiated Rate	$120.55
Rate for Payer: Anthem Medicaid	$115.91
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$115.91
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$115.91
Rate for Payer: Dean Health Medicaid	$115.91
Rate for Payer: Independent Care Health Plan Medicaid	$115.91
Rate for Payer: Managed Health Services Medicaid	$120.55
Rate for Payer: Molina Healthcare Medicaid	$115.91
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$115.91
Rate for Payer: United Healthcare Medicaid	$115.91

LEVEL III SKIN EXCISIONS, BIOPSIES, AND REPAIRS

Facility

$1,481.95

Service Code	EAPG 00011
Min. Negotiated Rate	$1,424.95
Max. Negotiated Rate	$1,481.95
Rate for Payer: Anthem Medicaid	$1,424.95
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,424.95
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,424.95
Rate for Payer: Dean Health Medicaid	$1,424.95
Rate for Payer: Independent Care Health Plan Medicaid	$1,424.95
Rate for Payer: Managed Health Services Medicaid	$1,481.95
Rate for Payer: Molina Healthcare Medicaid	$1,424.95
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,424.95
Rate for Payer: United Healthcare Medicaid	$1,424.95

LEVEL III SPINE PROCEDURES

Facility

$2,798.80

Service Code	EAPG 00057
Min. Negotiated Rate	$2,691.15
Max. Negotiated Rate	$2,798.80
Rate for Payer: Anthem Medicaid	$2,691.15
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,691.15
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,691.15
Rate for Payer: Dean Health Medicaid	$2,691.15
Rate for Payer: Independent Care Health Plan Medicaid	$2,691.15
Rate for Payer: Managed Health Services Medicaid	$2,798.80
Rate for Payer: Molina Healthcare Medicaid	$2,691.15
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,691.15
Rate for Payer: United Healthcare Medicaid	$2,691.15

LEVEL III UPPER GI ENDOSCOPY

Facility

$698.39

Service Code	EAPG 00154
Min. Negotiated Rate	$671.53
Max. Negotiated Rate	$698.39
Rate for Payer: Anthem Medicaid	$671.53
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$671.53
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$671.53
Rate for Payer: Dean Health Medicaid	$671.53
Rate for Payer: Independent Care Health Plan Medicaid	$671.53
Rate for Payer: Managed Health Services Medicaid	$698.39
Rate for Payer: Molina Healthcare Medicaid	$671.53
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$671.53
Rate for Payer: United Healthcare Medicaid	$671.53

LEVEL III VASCULAR RADIOLOGICAL PROCEDURES

Facility

$661.70

Service Code	EAPG 00280
Min. Negotiated Rate	$636.25
Max. Negotiated Rate	$661.70
Rate for Payer: Anthem Medicaid	$636.25
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$636.25
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$636.25
Rate for Payer: Dean Health Medicaid	$636.25
Rate for Payer: Independent Care Health Plan Medicaid	$636.25
Rate for Payer: Managed Health Services Medicaid	$661.70
Rate for Payer: Molina Healthcare Medicaid	$636.25
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$636.25
Rate for Payer: United Healthcare Medicaid	$636.25

LEVEL II JOINT, TENDON, OR LIGAMENT INJECTION PROCEDURES

Facility

$379.99

Service Code	EAPG 00050
Min. Negotiated Rate	$365.37
Max. Negotiated Rate	$379.99
Rate for Payer: Anthem Medicaid	$365.37
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$365.37
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$365.37
Rate for Payer: Dean Health Medicaid	$365.37
Rate for Payer: Independent Care Health Plan Medicaid	$365.37
Rate for Payer: Managed Health Services Medicaid	$379.99
Rate for Payer: Molina Healthcare Medicaid	$365.37
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$365.37
Rate for Payer: United Healthcare Medicaid	$365.37

LEVEL II KIDNEY AND URETERAL PROCEDURES

Facility

$1,033.83

Service Code	EAPG 00171
Min. Negotiated Rate	$994.06
Max. Negotiated Rate	$1,033.83
Rate for Payer: Anthem Medicaid	$994.06
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$994.06
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$994.06
Rate for Payer: Dean Health Medicaid	$994.06
Rate for Payer: Independent Care Health Plan Medicaid	$994.06
Rate for Payer: Managed Health Services Medicaid	$1,033.83
Rate for Payer: Molina Healthcare Medicaid	$994.06
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$994.06
Rate for Payer: United Healthcare Medicaid	$994.06

LEVEL II KNEE AND LOWER LEG PROCEDURES

Facility

$1,430.85

Service Code	EAPG 00052
Min. Negotiated Rate	$1,375.81
Max. Negotiated Rate	$1,430.85
Rate for Payer: Anthem Medicaid	$1,375.81
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,375.81
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,375.81
Rate for Payer: Dean Health Medicaid	$1,375.81
Rate for Payer: Independent Care Health Plan Medicaid	$1,375.81
Rate for Payer: Managed Health Services Medicaid	$1,430.85
Rate for Payer: Molina Healthcare Medicaid	$1,375.81
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,375.81
Rate for Payer: United Healthcare Medicaid	$1,375.81

LEVEL II LAPAROSCOPY

Facility

$1,801.66

Service Code	EAPG 00146
Min. Negotiated Rate	$1,732.36
Max. Negotiated Rate	$1,801.66
Rate for Payer: Anthem Medicaid	$1,732.36
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,732.36
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,732.36
Rate for Payer: Dean Health Medicaid	$1,732.36
Rate for Payer: Independent Care Health Plan Medicaid	$1,732.36
Rate for Payer: Managed Health Services Medicaid	$1,801.66
Rate for Payer: Molina Healthcare Medicaid	$1,732.36
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,732.36
Rate for Payer: United Healthcare Medicaid	$1,732.36

LEVEL II LOWER AIRWAY ENDOSCOPY

Facility

$921.14

Service Code	EAPG 00071
Min. Negotiated Rate	$885.71
Max. Negotiated Rate	$921.14
Rate for Payer: Anthem Medicaid	$885.71
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$885.71
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$885.71
Rate for Payer: Dean Health Medicaid	$885.71
Rate for Payer: Independent Care Health Plan Medicaid	$885.71
Rate for Payer: Managed Health Services Medicaid	$921.14
Rate for Payer: Molina Healthcare Medicaid	$885.71
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$885.71
Rate for Payer: United Healthcare Medicaid	$885.71

LEVEL II LOWER GI ENDOSCOPY

Facility

$626.32

Service Code	EAPG 00137
Min. Negotiated Rate	$602.23
Max. Negotiated Rate	$626.32
Rate for Payer: Anthem Medicaid	$602.23
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$602.23
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$602.23
Rate for Payer: Dean Health Medicaid	$602.23
Rate for Payer: Independent Care Health Plan Medicaid	$602.23
Rate for Payer: Managed Health Services Medicaid	$626.32
Rate for Payer: Molina Healthcare Medicaid	$602.23
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$602.23
Rate for Payer: United Healthcare Medicaid	$602.23

LEVEL II MAXILLOFACIAL PROSTHETICS

Facility

$175.58

Service Code	EAPG 00360
Min. Negotiated Rate	$168.83
Max. Negotiated Rate	$175.58
Rate for Payer: Anthem Medicaid	$168.83
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$168.83
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$168.83
Rate for Payer: Dean Health Medicaid	$168.83
Rate for Payer: Independent Care Health Plan Medicaid	$168.83
Rate for Payer: Managed Health Services Medicaid	$175.58
Rate for Payer: Molina Healthcare Medicaid	$168.83
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$168.83
Rate for Payer: United Healthcare Medicaid	$168.83

LEVEL II MICROBIOLOGY TESTS

Facility

$31.45

Service Code	EAPG 00397
Min. Negotiated Rate	$30.24
Max. Negotiated Rate	$31.45
Rate for Payer: Anthem Medicaid	$30.24
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$30.24
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$30.24
Rate for Payer: Dean Health Medicaid	$30.24
Rate for Payer: Independent Care Health Plan Medicaid	$30.24
Rate for Payer: Managed Health Services Medicaid	$31.45
Rate for Payer: Molina Healthcare Medicaid	$30.24
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$30.24
Rate for Payer: United Healthcare Medicaid	$30.24

LEVEL I IMMUNIZATION

Facility

$23.59

Service Code	EAPG 00414
Min. Negotiated Rate	$22.68
Max. Negotiated Rate	$23.59
Rate for Payer: Anthem Medicaid	$22.68
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$22.68
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$22.68
Rate for Payer: Dean Health Medicaid	$22.68
Rate for Payer: Independent Care Health Plan Medicaid	$22.68
Rate for Payer: Managed Health Services Medicaid	$23.59
Rate for Payer: Molina Healthcare Medicaid	$22.68
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$22.68
Rate for Payer: United Healthcare Medicaid	$22.68

LEVEL I IMMUNOLOGY TESTS

Facility

$9.17

Service Code	EAPG 00394
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 II NERVE PROCEDURE W OR W/O NEUROLOGICAL DEVICE

Facility

$2,534.12

Service Code	EAPG 00218
Min. Negotiated Rate	$2,436.65
Max. Negotiated Rate	$2,534.12
Rate for Payer: Anthem Medicaid	$2,436.65
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,436.65
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,436.65
Rate for Payer: Dean Health Medicaid	$2,436.65
Rate for Payer: Independent Care Health Plan Medicaid	$2,436.65
Rate for Payer: Managed Health Services Medicaid	$2,534.12
Rate for Payer: Molina Healthcare Medicaid	$2,436.65
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,436.65
Rate for Payer: United Healthcare Medicaid	$2,436.65

LEVEL II NERVOUS SYSTEM INJECTIONS INCLUDING CRANIAL TAP

Facility

$398.33

Service Code	EAPG 00220
Min. Negotiated Rate	$383.01
Max. Negotiated Rate	$398.33
Rate for Payer: Anthem Medicaid	$383.01
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$383.01
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$383.01
Rate for Payer: Dean Health Medicaid	$383.01
Rate for Payer: Independent Care Health Plan Medicaid	$383.01
Rate for Payer: Managed Health Services Medicaid	$398.33
Rate for Payer: Molina Healthcare Medicaid	$383.01
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$383.01
Rate for Payer: United Healthcare Medicaid	$383.01

LEVEL II ORAL AND MAXILLOFACIAL PROCEDURES

Facility

$272.54

Service Code	EAPG 00368
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 II OTHER UTERINE AND ADNEXA GYNECOLOGICAL PROCEDURES

Facility

$1,234.30

Service Code	EAPG 00208
Min. Negotiated Rate	$1,186.83
Max. Negotiated Rate	$1,234.30
Rate for Payer: Anthem Medicaid	$1,186.83
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,186.83
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,186.83
Rate for Payer: Dean Health Medicaid	$1,186.83
Rate for Payer: Independent Care Health Plan Medicaid	$1,186.83
Rate for Payer: Managed Health Services Medicaid	$1,234.30
Rate for Payer: Molina Healthcare Medicaid	$1,186.83
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,186.83
Rate for Payer: United Healthcare Medicaid	$1,186.83

LEVEL II PATHOLOGY TESTS

Facility

$56.34

Service Code	EAPG 00391
Min. Negotiated Rate	$54.18
Max. Negotiated Rate	$56.34
Rate for Payer: Anthem Medicaid	$54.18
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$54.18
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$54.18
Rate for Payer: Dean Health Medicaid	$54.18
Rate for Payer: Independent Care Health Plan Medicaid	$54.18
Rate for Payer: Managed Health Services Medicaid	$56.34
Rate for Payer: Molina Healthcare Medicaid	$54.18
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$54.18
Rate for Payer: United Healthcare Medicaid	$54.18

LEVEL II PENILE PROCEDURES

Facility

$708.87

Service Code	EAPG 00187
Min. Negotiated Rate	$681.61
Max. Negotiated Rate	$708.87
Rate for Payer: Anthem Medicaid	$681.61
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$681.61
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$681.61
Rate for Payer: Dean Health Medicaid	$681.61
Rate for Payer: Independent Care Health Plan Medicaid	$681.61
Rate for Payer: Managed Health Services Medicaid	$708.87
Rate for Payer: Molina Healthcare Medicaid	$681.61
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$681.61
Rate for Payer: United Healthcare Medicaid	$681.61

LEVEL II PERCUTANEOUS CORONARY AND INTRACARDIAC INTERVENTIONAL PROCEDURES

Facility

$1,961.52

Service Code	EAPG 00121
Min. Negotiated Rate	$1,886.07
Max. Negotiated Rate	$1,961.52
Rate for Payer: Anthem Medicaid	$1,886.07
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,886.07
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,886.07
Rate for Payer: Dean Health Medicaid	$1,886.07
Rate for Payer: Independent Care Health Plan Medicaid	$1,886.07
Rate for Payer: Managed Health Services Medicaid	$1,961.52
Rate for Payer: Molina Healthcare Medicaid	$1,886.07
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,886.07
Rate for Payer: United Healthcare Medicaid	$1,886.07

Know your out-of-pocket cost for care.

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