Beloit Memorial Hospital

All Charges

Charge

Type

Setting

Price

LEVEL I ADJUNCTIVE GENERAL DENTAL SERVICES

Facility

$51.19

Service Code	EAPG 00350
Min. Negotiated Rate	$49.22
Max. Negotiated Rate	$51.19
Rate for Payer: Anthem Medicaid	$49.22
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$49.22
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$49.22
Rate for Payer: Dean Health Medicaid	$49.22
Rate for Payer: Independent Care Health Plan Medicaid	$49.22
Rate for Payer: Managed Health Services Medicaid	$51.19
Rate for Payer: Molina Healthcare Medicaid	$49.22
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$49.22
Rate for Payer: United Healthcare Medicaid	$49.22

LEVEL I ANAL AND RECTAL PROCEDURES

Facility

$317.27

Service Code	EAPG 00141
Min. Negotiated Rate	$305.06
Max. Negotiated Rate	$317.27
Rate for Payer: Anthem Medicaid	$305.06
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$305.06
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$305.06
Rate for Payer: Dean Health Medicaid	$305.06
Rate for Payer: Independent Care Health Plan Medicaid	$305.06
Rate for Payer: Managed Health Services Medicaid	$317.27
Rate for Payer: Molina Healthcare Medicaid	$305.06
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$305.06
Rate for Payer: United Healthcare Medicaid	$305.06

LEVEL I ANCILLARY THERAPEUTIC SERVICES

Facility

$23.62

Service Code	EAPG 00493
Min. Negotiated Rate	$22.71
Max. Negotiated Rate	$23.62
Rate for Payer: Anthem Medicaid	$22.71
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$22.71
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$22.71
Rate for Payer: Dean Health Medicaid	$22.71
Rate for Payer: Independent Care Health Plan Medicaid	$22.71
Rate for Payer: Managed Health Services Medicaid	$23.62
Rate for Payer: Molina Healthcare Medicaid	$22.71
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$22.71
Rate for Payer: United Healthcare Medicaid	$22.71

LEVEL I ANTERIOR SEGMENT EYE PROCEDURES

Facility

$227.64

Service Code	EAPG 00234
Min. Negotiated Rate	$218.88
Max. Negotiated Rate	$227.64
Rate for Payer: Anthem Medicaid	$218.88
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$218.88
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$218.88
Rate for Payer: Dean Health Medicaid	$218.88
Rate for Payer: Independent Care Health Plan Medicaid	$218.88
Rate for Payer: Managed Health Services Medicaid	$227.64
Rate for Payer: Molina Healthcare Medicaid	$218.88
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$218.88
Rate for Payer: United Healthcare Medicaid	$218.88

LEVEL I ARTHROPLASTY

Facility

$764.45

Service Code	EAPG 00046
Min. Negotiated Rate	$735.04
Max. Negotiated Rate	$764.45
Rate for Payer: Anthem Medicaid	$735.04
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$735.04
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$735.04
Rate for Payer: Dean Health Medicaid	$735.04
Rate for Payer: Independent Care Health Plan Medicaid	$735.04
Rate for Payer: Managed Health Services Medicaid	$764.45
Rate for Payer: Molina Healthcare Medicaid	$735.04
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$735.04
Rate for Payer: United Healthcare Medicaid	$735.04

LEVEL I ARTHROSCOPY

Facility

$468.17

Service Code	EAPG 00037
Min. Negotiated Rate	$450.16
Max. Negotiated Rate	$468.17
Rate for Payer: Anthem Medicaid	$450.16
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$450.16
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$450.16
Rate for Payer: Dean Health Medicaid	$450.16
Rate for Payer: Independent Care Health Plan Medicaid	$450.16
Rate for Payer: Managed Health Services Medicaid	$468.17
Rate for Payer: Molina Healthcare Medicaid	$450.16
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$450.16
Rate for Payer: United Healthcare Medicaid	$450.16

LEVEL I BLADDER AND URETERAL PROCEDURES

Facility

$339.01

Service Code	EAPG 00173
Min. Negotiated Rate	$325.97
Max. Negotiated Rate	$339.01
Rate for Payer: Anthem Medicaid	$325.97
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$325.97
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$325.97
Rate for Payer: Dean Health Medicaid	$325.97
Rate for Payer: Independent Care Health Plan Medicaid	$325.97
Rate for Payer: Managed Health Services Medicaid	$339.01
Rate for Payer: Molina Healthcare Medicaid	$325.97
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$325.97
Rate for Payer: United Healthcare Medicaid	$325.97

LEVEL I BLOOD AND BLOOD PRODUCT EXCHANGE

Facility

$93.69

Service Code	EAPG 00113
Min. Negotiated Rate	$90.09
Max. Negotiated Rate	$93.69
Rate for Payer: Anthem Medicaid	$90.09
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$90.09
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$90.09
Rate for Payer: Dean Health Medicaid	$90.09
Rate for Payer: Independent Care Health Plan Medicaid	$90.09
Rate for Payer: Managed Health Services Medicaid	$93.69
Rate for Payer: Molina Healthcare Medicaid	$90.09
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$90.09
Rate for Payer: United Healthcare Medicaid	$90.09

LEVEL I BLOOD AND TISSUE TYPING TESTS

Facility

$0.78

Service Code	EAPG 00486
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.78
Rate for Payer: Anthem Medicaid	$0.75
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$0.75
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$0.75
Rate for Payer: Dean Health Medicaid	$0.75
Rate for Payer: Independent Care Health Plan Medicaid	$0.75
Rate for Payer: Managed Health Services Medicaid	$0.78
Rate for Payer: Molina Healthcare Medicaid	$0.75
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$0.75
Rate for Payer: United Healthcare Medicaid	$0.75

LEVEL I BLOOD PRODUCTS

Facility

$29.38

Service Code	EAPG 02061
Min. Negotiated Rate	$28.25
Max. Negotiated Rate	$29.38
Rate for Payer: Anthem Medicaid	$28.25
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$28.25
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$28.25
Rate for Payer: Dean Health Medicaid	$28.25
Rate for Payer: Independent Care Health Plan Medicaid	$28.25
Rate for Payer: Managed Health Services Medicaid	$29.38
Rate for Payer: Molina Healthcare Medicaid	$28.25
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$28.25
Rate for Payer: United Healthcare Medicaid	$28.25

LEVEL I BRACHYTHERAPY SOURCES

Facility

$55.96

Service Code	EAPG 00335
Min. Negotiated Rate	$53.81
Max. Negotiated Rate	$55.96
Rate for Payer: Anthem Medicaid	$53.81
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$53.81
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$53.81
Rate for Payer: Dean Health Medicaid	$53.81
Rate for Payer: Independent Care Health Plan Medicaid	$53.81
Rate for Payer: Managed Health Services Medicaid	$55.96
Rate for Payer: Molina Healthcare Medicaid	$53.81
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$53.81
Rate for Payer: United Healthcare Medicaid	$53.81

LEVEL I BREAST PROCEDURES

Facility

$286.09

Service Code	EAPG 00020
Min. Negotiated Rate	$275.08
Max. Negotiated Rate	$286.09
Rate for Payer: Anthem Medicaid	$275.08
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$275.08
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$275.08
Rate for Payer: Dean Health Medicaid	$275.08
Rate for Payer: Independent Care Health Plan Medicaid	$275.08
Rate for Payer: Managed Health Services Medicaid	$286.09
Rate for Payer: Molina Healthcare Medicaid	$275.08
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$275.08
Rate for Payer: United Healthcare Medicaid	$275.08

LEVEL I CENTRAL VENOUS ACCESS PROCEDURES

Facility

$253.88

Service Code	EAPG 00075
Min. Negotiated Rate	$244.12
Max. Negotiated Rate	$253.88
Rate for Payer: Anthem Medicaid	$244.12
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$244.12
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$244.12
Rate for Payer: Dean Health Medicaid	$244.12
Rate for Payer: Independent Care Health Plan Medicaid	$244.12
Rate for Payer: Managed Health Services Medicaid	$253.88
Rate for Payer: Molina Healthcare Medicaid	$244.12
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$244.12
Rate for Payer: United Healthcare Medicaid	$244.12

LEVEL I CHEMISTRY TESTS

Facility

$2.14

Service Code	EAPG 00400
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$2.14
Rate for Payer: Anthem Medicaid	$2.06
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2.06
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2.06
Rate for Payer: Dean Health Medicaid	$2.06
Rate for Payer: Independent Care Health Plan Medicaid	$2.06
Rate for Payer: Managed Health Services Medicaid	$2.14
Rate for Payer: Molina Healthcare Medicaid	$2.06
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2.06
Rate for Payer: United Healthcare Medicaid	$2.06

LEVEL I CLOTTING TESTS

Facility

$0.79

Service Code	EAPG 00406
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$0.79
Rate for Payer: Anthem Medicaid	$0.76
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$0.76
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$0.76
Rate for Payer: Dean Health Medicaid	$0.76
Rate for Payer: Independent Care Health Plan Medicaid	$0.76
Rate for Payer: Managed Health Services Medicaid	$0.79
Rate for Payer: Molina Healthcare Medicaid	$0.76
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$0.76
Rate for Payer: United Healthcare Medicaid	$0.76

LEVEL I COMPUTED TOMOGRAPHY

Facility

$22.96

Service Code	EAPG 00299
Min. Negotiated Rate	$22.07
Max. Negotiated Rate	$22.96
Rate for Payer: Anthem Medicaid	$22.07
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$22.07
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$22.07
Rate for Payer: Dean Health Medicaid	$22.07
Rate for Payer: Independent Care Health Plan Medicaid	$22.07
Rate for Payer: Managed Health Services Medicaid	$22.96
Rate for Payer: Molina Healthcare Medicaid	$22.07
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$22.07
Rate for Payer: United Healthcare Medicaid	$22.07

LEVEL I CONVENTIONAL RADIOLOGY

Facility

$11.99

Service Code	EAPG 00471
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$11.99
Rate for Payer: Anthem Medicaid	$11.53
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$11.53
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$11.53
Rate for Payer: Dean Health Medicaid	$11.53
Rate for Payer: Independent Care Health Plan Medicaid	$11.53
Rate for Payer: Managed Health Services Medicaid	$11.99
Rate for Payer: Molina Healthcare Medicaid	$11.53
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$11.53
Rate for Payer: United Healthcare Medicaid	$11.53

LEVEL I CORNEAL AND OTHER ANTERIOR SURFACE EYE PROCEDURES

Facility

$124.06

Service Code	EAPG 00247
Min. Negotiated Rate	$119.29
Max. Negotiated Rate	$124.06
Rate for Payer: Anthem Medicaid	$119.29
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$119.29
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$119.29
Rate for Payer: Dean Health Medicaid	$119.29
Rate for Payer: Independent Care Health Plan Medicaid	$119.29
Rate for Payer: Managed Health Services Medicaid	$124.06
Rate for Payer: Molina Healthcare Medicaid	$119.29
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$119.29
Rate for Payer: United Healthcare Medicaid	$119.29

LEVEL I CRANIOFACIAL BONE PROCEDURES

Facility

$571.48

Service Code	EAPG 00227
Min. Negotiated Rate	$549.50
Max. Negotiated Rate	$571.48
Rate for Payer: Anthem Medicaid	$549.50
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$549.50
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$549.50
Rate for Payer: Dean Health Medicaid	$549.50
Rate for Payer: Independent Care Health Plan Medicaid	$549.50
Rate for Payer: Managed Health Services Medicaid	$571.48
Rate for Payer: Molina Healthcare Medicaid	$549.50
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$549.50
Rate for Payer: United Healthcare Medicaid	$549.50

LEVEL I DENTAL FILM

Facility

$8.15

Service Code	EAPG 00373
Min. Negotiated Rate	$7.84
Max. Negotiated Rate	$8.15
Rate for Payer: Anthem Medicaid	$7.84
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$7.84
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$7.84
Rate for Payer: Dean Health Medicaid	$7.84
Rate for Payer: Independent Care Health Plan Medicaid	$7.84
Rate for Payer: Managed Health Services Medicaid	$8.15
Rate for Payer: Molina Healthcare Medicaid	$7.84
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$7.84
Rate for Payer: United Healthcare Medicaid	$7.84

LEVEL I DENTAL RESTORATIONS

Facility

$473.66

Service Code	EAPG 00361
Min. Negotiated Rate	$455.44
Max. Negotiated Rate	$473.66
Rate for Payer: Anthem Medicaid	$455.44
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$455.44
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$455.44
Rate for Payer: Dean Health Medicaid	$455.44
Rate for Payer: Independent Care Health Plan Medicaid	$455.44
Rate for Payer: Managed Health Services Medicaid	$473.66
Rate for Payer: Molina Healthcare Medicaid	$455.44
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$455.44
Rate for Payer: United Healthcare Medicaid	$455.44

LEVEL I DIAGNOSTIC NUCLEAR MEDICINE

Facility

$79.60

Service Code	EAPG 00331
Min. Negotiated Rate	$76.54
Max. Negotiated Rate	$79.60
Rate for Payer: Anthem Medicaid	$76.54
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$76.54
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$76.54
Rate for Payer: Dean Health Medicaid	$76.54
Rate for Payer: Independent Care Health Plan Medicaid	$76.54
Rate for Payer: Managed Health Services Medicaid	$79.60
Rate for Payer: Molina Healthcare Medicaid	$76.54
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$76.54
Rate for Payer: United Healthcare Medicaid	$76.54

LEVEL I DIAGNOSTIC ULTRASOUND

Facility

$23.51

Service Code	EAPG 00288
Min. Negotiated Rate	$22.61
Max. Negotiated Rate	$23.51
Rate for Payer: Anthem Medicaid	$22.61
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$22.61
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$22.61
Rate for Payer: Dean Health Medicaid	$22.61
Rate for Payer: Independent Care Health Plan Medicaid	$22.61
Rate for Payer: Managed Health Services Medicaid	$23.51
Rate for Payer: Molina Healthcare Medicaid	$22.61
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$22.61
Rate for Payer: United Healthcare Medicaid	$22.61

LEVEL I EAR, NOSE, MOUTH AND THROAT PROCEDURES

Facility

$306.73

Service Code	EAPG 00252
Min. Negotiated Rate	$294.93
Max. Negotiated Rate	$306.73
Rate for Payer: Anthem Medicaid	$294.93
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$294.93
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$294.93
Rate for Payer: Dean Health Medicaid	$294.93
Rate for Payer: Independent Care Health Plan Medicaid	$294.93
Rate for Payer: Managed Health Services Medicaid	$306.73
Rate for Payer: Molina Healthcare Medicaid	$294.93
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$294.93
Rate for Payer: United Healthcare Medicaid	$294.93

LEVEL I ENDOCRINOLOGY TESTS

Facility

$2.36

Service Code	EAPG 00398
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$2.36
Rate for Payer: Anthem Medicaid	$2.27
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2.27
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2.27
Rate for Payer: Dean Health Medicaid	$2.27
Rate for Payer: Independent Care Health Plan Medicaid	$2.27
Rate for Payer: Managed Health Services Medicaid	$2.36
Rate for Payer: Molina Healthcare Medicaid	$2.27
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2.27
Rate for Payer: United Healthcare Medicaid	$2.27

Know your out-of-pocket cost for care.

All Charges