Beloit Memorial Hospital

All Charges

Charge

Type

Setting

Price

LEVEL II CHEMISTRY TESTS

Facility

$4.99

Service Code	EAPG 00401
Min. Negotiated Rate	$4.79
Max. Negotiated Rate	$4.99
Rate for Payer: Anthem Medicaid	$4.79
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$4.79
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$4.79
Rate for Payer: Dean Health Medicaid	$4.79
Rate for Payer: Independent Care Health Plan Medicaid	$4.79
Rate for Payer: Managed Health Services Medicaid	$4.99
Rate for Payer: Molina Healthcare Medicaid	$4.79
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$4.79
Rate for Payer: United Healthcare Medicaid	$4.79

LEVEL II CLOTTING TESTS

Facility

$4.56

Service Code	EAPG 00407
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$4.56
Rate for Payer: Anthem Medicaid	$4.39
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$4.39
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$4.39
Rate for Payer: Dean Health Medicaid	$4.39
Rate for Payer: Independent Care Health Plan Medicaid	$4.39
Rate for Payer: Managed Health Services Medicaid	$4.56
Rate for Payer: Molina Healthcare Medicaid	$4.39
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$4.39
Rate for Payer: United Healthcare Medicaid	$4.39

LEVEL II COMPUTED TOMOGRAPHY

Facility

$69.16

Service Code	EAPG 00300
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$69.16
Rate for Payer: Anthem Medicaid	$66.50
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$66.50
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$66.50
Rate for Payer: Dean Health Medicaid	$66.50
Rate for Payer: Independent Care Health Plan Medicaid	$66.50
Rate for Payer: Managed Health Services Medicaid	$69.16
Rate for Payer: Molina Healthcare Medicaid	$66.50
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$66.50
Rate for Payer: United Healthcare Medicaid	$66.50

LEVEL II CONVENTIONAL RADIOLOGY

Facility

$25.06

Service Code	EAPG 00389
Min. Negotiated Rate	$24.10
Max. Negotiated Rate	$25.06
Rate for Payer: Anthem Medicaid	$24.10
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$24.10
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$24.10
Rate for Payer: Dean Health Medicaid	$24.10
Rate for Payer: Independent Care Health Plan Medicaid	$24.10
Rate for Payer: Managed Health Services Medicaid	$25.06
Rate for Payer: Molina Healthcare Medicaid	$24.10
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$24.10
Rate for Payer: United Healthcare Medicaid	$24.10

LEVEL II CORNEAL AND OTHER ANTERIOR SURFACE EYE PROCEDURES

Facility

$706.20

Service Code	EAPG 00248
Min. Negotiated Rate	$679.04
Max. Negotiated Rate	$706.20
Rate for Payer: Anthem Medicaid	$679.04
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$679.04
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$679.04
Rate for Payer: Dean Health Medicaid	$679.04
Rate for Payer: Independent Care Health Plan Medicaid	$679.04
Rate for Payer: Managed Health Services Medicaid	$706.20
Rate for Payer: Molina Healthcare Medicaid	$679.04
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$679.04
Rate for Payer: United Healthcare Medicaid	$679.04

LEVEL II CRANIOFACIAL BONE PROCEDURES

Facility

$1,079.31

Service Code	EAPG 00228
Min. Negotiated Rate	$1,037.79
Max. Negotiated Rate	$1,079.31
Rate for Payer: Anthem Medicaid	$1,037.79
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,037.79
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,037.79
Rate for Payer: Dean Health Medicaid	$1,037.79
Rate for Payer: Independent Care Health Plan Medicaid	$1,037.79
Rate for Payer: Managed Health Services Medicaid	$1,079.31
Rate for Payer: Molina Healthcare Medicaid	$1,037.79
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,037.79
Rate for Payer: United Healthcare Medicaid	$1,037.79

LEVEL II DENTAL FILM

Facility

$31.13

Service Code	EAPG 00374
Min. Negotiated Rate	$29.94
Max. Negotiated Rate	$31.13
Rate for Payer: Anthem Medicaid	$29.94
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$29.94
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$29.94
Rate for Payer: Dean Health Medicaid	$29.94
Rate for Payer: Independent Care Health Plan Medicaid	$29.94
Rate for Payer: Managed Health Services Medicaid	$31.13
Rate for Payer: Molina Healthcare Medicaid	$29.94
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$29.94
Rate for Payer: United Healthcare Medicaid	$29.94

LEVEL II DENTAL RESTORATIONS

Facility

$632.06

Service Code	EAPG 00362
Min. Negotiated Rate	$607.75
Max. Negotiated Rate	$632.06
Rate for Payer: Anthem Medicaid	$607.75
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$607.75
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$607.75
Rate for Payer: Dean Health Medicaid	$607.75
Rate for Payer: Independent Care Health Plan Medicaid	$607.75
Rate for Payer: Managed Health Services Medicaid	$632.06
Rate for Payer: Molina Healthcare Medicaid	$607.75
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$607.75
Rate for Payer: United Healthcare Medicaid	$607.75

LEVEL II DIAGNOSTIC NUCLEAR MEDICINE

Facility

$196.18

Service Code	EAPG 00332
Min. Negotiated Rate	$188.63
Max. Negotiated Rate	$196.18
Rate for Payer: Anthem Medicaid	$188.63
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$188.63
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$188.63
Rate for Payer: Dean Health Medicaid	$188.63
Rate for Payer: Independent Care Health Plan Medicaid	$188.63
Rate for Payer: Managed Health Services Medicaid	$196.18
Rate for Payer: Molina Healthcare Medicaid	$188.63
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$188.63
Rate for Payer: United Healthcare Medicaid	$188.63

LEVEL II DIAGNOSTIC ULTRASOUND

Facility

$35.62

Service Code	EAPG 00289
Min. Negotiated Rate	$34.25
Max. Negotiated Rate	$35.62
Rate for Payer: Anthem Medicaid	$34.25
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$34.25
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$34.25
Rate for Payer: Dean Health Medicaid	$34.25
Rate for Payer: Independent Care Health Plan Medicaid	$34.25
Rate for Payer: Managed Health Services Medicaid	$35.62
Rate for Payer: Molina Healthcare Medicaid	$34.25
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$34.25
Rate for Payer: United Healthcare Medicaid	$34.25

LEVEL II EAR, NOSE, MOUTH AND THROAT PROCEDURES

Facility

$583.71

Service Code	EAPG 00253
Min. Negotiated Rate	$561.26
Max. Negotiated Rate	$583.71
Rate for Payer: Anthem Medicaid	$561.26
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$561.26
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$561.26
Rate for Payer: Dean Health Medicaid	$561.26
Rate for Payer: Independent Care Health Plan Medicaid	$561.26
Rate for Payer: Managed Health Services Medicaid	$583.71
Rate for Payer: Molina Healthcare Medicaid	$561.26
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$561.26
Rate for Payer: United Healthcare Medicaid	$561.26

LEVEL II ENDOCRINOLOGY TESTS

Facility

$6.19

Service Code	EAPG 00399
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.19
Rate for Payer: Anthem Medicaid	$5.95
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$5.95
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$5.95
Rate for Payer: Dean Health Medicaid	$5.95
Rate for Payer: Independent Care Health Plan Medicaid	$5.95
Rate for Payer: Managed Health Services Medicaid	$6.19
Rate for Payer: Molina Healthcare Medicaid	$5.95
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$5.95
Rate for Payer: United Healthcare Medicaid	$5.95

LEVEL II ENDODONTICS

Facility

$55.81

Service Code	EAPG 00365
Min. Negotiated Rate	$53.66
Max. Negotiated Rate	$55.81
Rate for Payer: Anthem Medicaid	$53.66
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$53.66
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$53.66
Rate for Payer: Dean Health Medicaid	$53.66
Rate for Payer: Independent Care Health Plan Medicaid	$53.66
Rate for Payer: Managed Health Services Medicaid	$55.81
Rate for Payer: Molina Healthcare Medicaid	$53.66
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$53.66
Rate for Payer: United Healthcare Medicaid	$53.66

LEVEL II ENDOSCOPY OF THE UPPER AIRWAY

Facility

$412.17

Service Code	EAPG 00063
Min. Negotiated Rate	$396.31
Max. Negotiated Rate	$412.17
Rate for Payer: Anthem Medicaid	$396.31
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$396.31
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$396.31
Rate for Payer: Dean Health Medicaid	$396.31
Rate for Payer: Independent Care Health Plan Medicaid	$396.31
Rate for Payer: Managed Health Services Medicaid	$412.17
Rate for Payer: Molina Healthcare Medicaid	$396.31
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$396.31
Rate for Payer: United Healthcare Medicaid	$396.31

LEVEL II ERCP AND RELATED ENDOSCOPIC PROCEDURES

Facility

$971.13

Service Code	EAPG 00153
Min. Negotiated Rate	$933.77
Max. Negotiated Rate	$971.13
Rate for Payer: Anthem Medicaid	$933.77
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$933.77
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$933.77
Rate for Payer: Dean Health Medicaid	$933.77
Rate for Payer: Independent Care Health Plan Medicaid	$933.77
Rate for Payer: Managed Health Services Medicaid	$971.13
Rate for Payer: Molina Healthcare Medicaid	$933.77
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$933.77
Rate for Payer: United Healthcare Medicaid	$933.77

LEVEL II ESOPHAGEAL AND GASTRIC SURGICAL PROCEDURES

Facility

$801.98

Service Code	EAPG 00126
Min. Negotiated Rate	$771.13
Max. Negotiated Rate	$801.98
Rate for Payer: Anthem Medicaid	$771.13
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$771.13
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$771.13
Rate for Payer: Dean Health Medicaid	$771.13
Rate for Payer: Independent Care Health Plan Medicaid	$771.13
Rate for Payer: Managed Health Services Medicaid	$801.98
Rate for Payer: Molina Healthcare Medicaid	$771.13
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$771.13
Rate for Payer: United Healthcare Medicaid	$771.13

LEVEL II EYELID, LACRIMAL AND CONJUNCTIVAL PROCEDURES

Facility

$372.79

Service Code	EAPG 00259
Min. Negotiated Rate	$358.45
Max. Negotiated Rate	$372.79
Rate for Payer: Anthem Medicaid	$358.45
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$358.45
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$358.45
Rate for Payer: Dean Health Medicaid	$358.45
Rate for Payer: Independent Care Health Plan Medicaid	$358.45
Rate for Payer: Managed Health Services Medicaid	$372.79
Rate for Payer: Molina Healthcare Medicaid	$358.45
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$358.45
Rate for Payer: United Healthcare Medicaid	$358.45

LEVEL II FETAL PROCEDURES

Facility

$220.33

Service Code	EAPG 00192
Min. Negotiated Rate	$211.85
Max. Negotiated Rate	$220.33
Rate for Payer: Anthem Medicaid	$211.85
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$211.85
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$211.85
Rate for Payer: Dean Health Medicaid	$211.85
Rate for Payer: Independent Care Health Plan Medicaid	$211.85
Rate for Payer: Managed Health Services Medicaid	$220.33
Rate for Payer: Molina Healthcare Medicaid	$211.85
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$211.85
Rate for Payer: United Healthcare Medicaid	$211.85

LEVEL II FOOT PROCEDURES

Facility

$1,248.65

Service Code	EAPG 00036
Min. Negotiated Rate	$1,200.62
Max. Negotiated Rate	$1,248.65
Rate for Payer: Anthem Medicaid	$1,200.62
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,200.62
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,200.62
Rate for Payer: Dean Health Medicaid	$1,200.62
Rate for Payer: Independent Care Health Plan Medicaid	$1,200.62
Rate for Payer: Managed Health Services Medicaid	$1,248.65
Rate for Payer: Molina Healthcare Medicaid	$1,200.62
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,200.62
Rate for Payer: United Healthcare Medicaid	$1,200.62

LEVEL II FOREARM AND WRIST PROCEDURES

Facility

$1,198.40

Service Code	EAPG 00024
Min. Negotiated Rate	$1,152.30
Max. Negotiated Rate	$1,198.40
Rate for Payer: Anthem Medicaid	$1,152.30
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,152.30
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,152.30
Rate for Payer: Dean Health Medicaid	$1,152.30
Rate for Payer: Independent Care Health Plan Medicaid	$1,152.30
Rate for Payer: Managed Health Services Medicaid	$1,198.40
Rate for Payer: Molina Healthcare Medicaid	$1,152.30
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,152.30
Rate for Payer: United Healthcare Medicaid	$1,152.30

LEVEL II HAND PROCEDURES

Facility

$469.56

Service Code	EAPG 00034
Min. Negotiated Rate	$451.50
Max. Negotiated Rate	$469.56
Rate for Payer: Anthem Medicaid	$451.50
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$451.50
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$451.50
Rate for Payer: Dean Health Medicaid	$451.50
Rate for Payer: Independent Care Health Plan Medicaid	$451.50
Rate for Payer: Managed Health Services Medicaid	$469.56
Rate for Payer: Molina Healthcare Medicaid	$451.50
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$451.50
Rate for Payer: United Healthcare Medicaid	$451.50

LEVEL II HEPATOBILIARY AND PANCREAS PROCEDURES

Facility

$1,227.39

Service Code	EAPG 00152
Min. Negotiated Rate	$1,180.17
Max. Negotiated Rate	$1,227.39
Rate for Payer: Anthem Medicaid	$1,180.17
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,180.17
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,180.17
Rate for Payer: Dean Health Medicaid	$1,180.17
Rate for Payer: Independent Care Health Plan Medicaid	$1,180.17
Rate for Payer: Managed Health Services Medicaid	$1,227.39
Rate for Payer: Molina Healthcare Medicaid	$1,180.17
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,180.17
Rate for Payer: United Healthcare Medicaid	$1,180.17

LEVEL II HIP AND FEMUR PROCEDURES

Facility

$2,433.86

Service Code	EAPG 00055
Min. Negotiated Rate	$2,340.25
Max. Negotiated Rate	$2,433.86
Rate for Payer: Anthem Medicaid	$2,340.25
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,340.25
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,340.25
Rate for Payer: Dean Health Medicaid	$2,340.25
Rate for Payer: Independent Care Health Plan Medicaid	$2,340.25
Rate for Payer: Managed Health Services Medicaid	$2,433.86
Rate for Payer: Molina Healthcare Medicaid	$2,340.25
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,340.25
Rate for Payer: United Healthcare Medicaid	$2,340.25

LEVEL II HYSTERECTOMY AND MYOMECTOMY PROCEDURES

Facility

$1,262.13

Service Code	EAPG 00206
Min. Negotiated Rate	$1,213.59
Max. Negotiated Rate	$1,262.13
Rate for Payer: Anthem Medicaid	$1,213.59
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,213.59
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,213.59
Rate for Payer: Dean Health Medicaid	$1,213.59
Rate for Payer: Independent Care Health Plan Medicaid	$1,213.59
Rate for Payer: Managed Health Services Medicaid	$1,262.13
Rate for Payer: Molina Healthcare Medicaid	$1,213.59
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,213.59
Rate for Payer: United Healthcare Medicaid	$1,213.59

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

Know your out-of-pocket cost for care.

All Charges