Beloit Memorial Hospital

All Charges

Charge

Type

Setting

Price

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 BLOOD AND TISSUE TYPING TESTS

Facility

$29.17

Service Code	EAPG 02043
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$29.17
Rate for Payer: Anthem Medicaid	$28.05
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$28.05
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$28.05
Rate for Payer: Dean Health Medicaid	$28.05
Rate for Payer: Independent Care Health Plan Medicaid	$28.05
Rate for Payer: Managed Health Services Medicaid	$29.17
Rate for Payer: Molina Healthcare Medicaid	$28.05
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$28.05
Rate for Payer: United Healthcare Medicaid	$28.05

LEVEL III BLOOD PRODUCT EXCHANGE SERVICES

Facility

$901.10

Service Code	EAPG 00155
Min. Negotiated Rate	$866.44
Max. Negotiated Rate	$901.10
Rate for Payer: Anthem Medicaid	$866.44
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$866.44
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$866.44
Rate for Payer: Dean Health Medicaid	$866.44
Rate for Payer: Independent Care Health Plan Medicaid	$866.44
Rate for Payer: Managed Health Services Medicaid	$901.10
Rate for Payer: Molina Healthcare Medicaid	$866.44
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$866.44
Rate for Payer: United Healthcare Medicaid	$866.44

LEVEL III BRACHYTHERAPY SOURCES

Facility

$2,613.49

Service Code	EAPG 00337
Min. Negotiated Rate	$2,512.97
Max. Negotiated Rate	$2,613.49
Rate for Payer: Anthem Medicaid	$2,512.97
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,512.97
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,512.97
Rate for Payer: Dean Health Medicaid	$2,512.97
Rate for Payer: Independent Care Health Plan Medicaid	$2,512.97
Rate for Payer: Managed Health Services Medicaid	$2,613.49
Rate for Payer: Molina Healthcare Medicaid	$2,512.97
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,512.97
Rate for Payer: United Healthcare Medicaid	$2,512.97

LEVEL III BREAST PROCEDURES

Facility

$1,608.23

Service Code	EAPG 00022
Min. Negotiated Rate	$1,546.37
Max. Negotiated Rate	$1,608.23
Rate for Payer: Anthem Medicaid	$1,546.37
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,546.37
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,546.37
Rate for Payer: Dean Health Medicaid	$1,546.37
Rate for Payer: Independent Care Health Plan Medicaid	$1,546.37
Rate for Payer: Managed Health Services Medicaid	$1,608.23
Rate for Payer: Molina Healthcare Medicaid	$1,546.37
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,546.37
Rate for Payer: United Healthcare Medicaid	$1,546.37

LEVEL III CHEMISTRY TESTS

Facility

$12.07

Service Code	EAPG 00384
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$12.07
Rate for Payer: Anthem Medicaid	$11.61
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$11.61
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$11.61
Rate for Payer: Dean Health Medicaid	$11.61
Rate for Payer: Independent Care Health Plan Medicaid	$11.61
Rate for Payer: Managed Health Services Medicaid	$12.07
Rate for Payer: Molina Healthcare Medicaid	$11.61
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$11.61
Rate for Payer: United Healthcare Medicaid	$11.61

LEVEL III DENTAL RESTORATIONS

Facility

$603.29

Service Code	EAPG 00363
Min. Negotiated Rate	$580.08
Max. Negotiated Rate	$603.29
Rate for Payer: Anthem Medicaid	$580.08
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$580.08
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$580.08
Rate for Payer: Dean Health Medicaid	$580.08
Rate for Payer: Independent Care Health Plan Medicaid	$580.08
Rate for Payer: Managed Health Services Medicaid	$603.29
Rate for Payer: Molina Healthcare Medicaid	$580.08
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$580.08
Rate for Payer: United Healthcare Medicaid	$580.08

LEVEL III EAR, NOSE, MOUTH AND THROAT PROCEDURES

Facility

$748.01

Service Code	EAPG 00254
Min. Negotiated Rate	$719.24
Max. Negotiated Rate	$748.01
Rate for Payer: Anthem Medicaid	$719.24
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$719.24
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$719.24
Rate for Payer: Dean Health Medicaid	$719.24
Rate for Payer: Independent Care Health Plan Medicaid	$719.24
Rate for Payer: Managed Health Services Medicaid	$748.01
Rate for Payer: Molina Healthcare Medicaid	$719.24
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$719.24
Rate for Payer: United Healthcare Medicaid	$719.24

LEVEL III ENDODONTICS

Facility

$66.48

Service Code	EAPG 00366
Min. Negotiated Rate	$63.93
Max. Negotiated Rate	$66.48
Rate for Payer: Anthem Medicaid	$63.93
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$63.93
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$63.93
Rate for Payer: Dean Health Medicaid	$63.93
Rate for Payer: Independent Care Health Plan Medicaid	$63.93
Rate for Payer: Managed Health Services Medicaid	$66.48
Rate for Payer: Molina Healthcare Medicaid	$63.93
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$63.93
Rate for Payer: United Healthcare Medicaid	$63.93

LEVEL III KIDNEY AND URETERAL PROCEDURES

Facility

$1,504.02

Service Code	EAPG 00172
Min. Negotiated Rate	$1,446.17
Max. Negotiated Rate	$1,504.02
Rate for Payer: Anthem Medicaid	$1,446.17
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,446.17
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,446.17
Rate for Payer: Dean Health Medicaid	$1,446.17
Rate for Payer: Independent Care Health Plan Medicaid	$1,446.17
Rate for Payer: Managed Health Services Medicaid	$1,504.02
Rate for Payer: Molina Healthcare Medicaid	$1,446.17
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,446.17
Rate for Payer: United Healthcare Medicaid	$1,446.17

LEVEL III MICROBIOLOGY TESTS

Facility

$32.01

Service Code	EAPG 00388
Min. Negotiated Rate	$30.78
Max. Negotiated Rate	$32.01
Rate for Payer: Anthem Medicaid	$30.78
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$30.78
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$30.78
Rate for Payer: Dean Health Medicaid	$30.78
Rate for Payer: Independent Care Health Plan Medicaid	$30.78
Rate for Payer: Managed Health Services Medicaid	$32.01
Rate for Payer: Molina Healthcare Medicaid	$30.78
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$30.78
Rate for Payer: United Healthcare Medicaid	$30.78

LEVEL II IMMUNIZATION

Facility

$26.51

Service Code	EAPG 00415
Min. Negotiated Rate	$25.49
Max. Negotiated Rate	$26.51
Rate for Payer: Anthem Medicaid	$25.49
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$25.49
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$25.49
Rate for Payer: Dean Health Medicaid	$25.49
Rate for Payer: Independent Care Health Plan Medicaid	$25.49
Rate for Payer: Managed Health Services Medicaid	$26.51
Rate for Payer: Molina Healthcare Medicaid	$25.49
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$25.49
Rate for Payer: United Healthcare Medicaid	$25.49

LEVEL II IMMUNOLOGY TESTS

Facility

$7.24

Service Code	EAPG 00395
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$7.24
Rate for Payer: Anthem Medicaid	$6.97
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$6.97
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$6.97
Rate for Payer: Dean Health Medicaid	$6.97
Rate for Payer: Independent Care Health Plan Medicaid	$6.97
Rate for Payer: Managed Health Services Medicaid	$7.24
Rate for Payer: Molina Healthcare Medicaid	$6.97
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$6.97
Rate for Payer: United Healthcare Medicaid	$6.97

LEVEL III NERVE PROCEDURE W OR W/O NEUROLOGICAL DEVICE

Facility

$1,344.32

Service Code	EAPG 00223
Min. Negotiated Rate	$1,292.61
Max. Negotiated Rate	$1,344.32
Rate for Payer: Anthem Medicaid	$1,292.61
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,292.61
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,292.61
Rate for Payer: Dean Health Medicaid	$1,292.61
Rate for Payer: Independent Care Health Plan Medicaid	$1,292.61
Rate for Payer: Managed Health Services Medicaid	$1,344.32
Rate for Payer: Molina Healthcare Medicaid	$1,292.61
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,292.61
Rate for Payer: United Healthcare Medicaid	$1,292.61

LEVEL III ORAL AND MAXILLOFACIAL PROCEDURES

Facility

$629.61

Service Code	EAPG 00369
Min. Negotiated Rate	$605.39
Max. Negotiated Rate	$629.61
Rate for Payer: Anthem Medicaid	$605.39
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$605.39
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$605.39
Rate for Payer: Dean Health Medicaid	$605.39
Rate for Payer: Independent Care Health Plan Medicaid	$605.39
Rate for Payer: Managed Health Services Medicaid	$629.61
Rate for Payer: Molina Healthcare Medicaid	$605.39
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$605.39
Rate for Payer: United Healthcare Medicaid	$605.39

LEVEL III PATHOLOGY TESTS

Facility

$35.90

Service Code	EAPG 00308
Min. Negotiated Rate	$34.52
Max. Negotiated Rate	$35.90
Rate for Payer: Anthem Medicaid	$34.52
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$34.52
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$34.52
Rate for Payer: Dean Health Medicaid	$34.52
Rate for Payer: Independent Care Health Plan Medicaid	$34.52
Rate for Payer: Managed Health Services Medicaid	$35.90
Rate for Payer: Molina Healthcare Medicaid	$34.52
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$34.52
Rate for Payer: United Healthcare Medicaid	$34.52

LEVEL III PERIPHERAL ENDOVASCULAR AND TRANSCATHETER PROCEDURES

Facility

$2,367.64

Service Code	EAPG 00085
Min. Negotiated Rate	$2,276.57
Max. Negotiated Rate	$2,367.64
Rate for Payer: Anthem Medicaid	$2,276.57
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,276.57
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,276.57
Rate for Payer: Dean Health Medicaid	$2,276.57
Rate for Payer: Independent Care Health Plan Medicaid	$2,276.57
Rate for Payer: Managed Health Services Medicaid	$2,367.64
Rate for Payer: Molina Healthcare Medicaid	$2,276.57
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,276.57
Rate for Payer: United Healthcare Medicaid	$2,276.57

LEVEL III PROSTHODONTICS, FIXED

Facility

$104.54

Service Code	EAPG 00355
Min. Negotiated Rate	$100.51
Max. Negotiated Rate	$104.54
Rate for Payer: Anthem Medicaid	$100.51
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$100.51
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$100.51
Rate for Payer: Dean Health Medicaid	$100.51
Rate for Payer: Independent Care Health Plan Medicaid	$100.51
Rate for Payer: Managed Health Services Medicaid	$104.54
Rate for Payer: Molina Healthcare Medicaid	$100.51
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$100.51
Rate for Payer: United Healthcare Medicaid	$100.51

LEVEL III PROSTHODONTICS, REMOVABLE

Facility

$67.41

Service Code	EAPG 00358
Min. Negotiated Rate	$64.82
Max. Negotiated Rate	$67.41
Rate for Payer: Anthem Medicaid	$64.82
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$64.82
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$64.82
Rate for Payer: Dean Health Medicaid	$64.82
Rate for Payer: Independent Care Health Plan Medicaid	$64.82
Rate for Payer: Managed Health Services Medicaid	$67.41
Rate for Payer: Molina Healthcare Medicaid	$64.82
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$64.82
Rate for Payer: United Healthcare Medicaid	$64.82

LEVEL III RADIATION THERAPY

Facility

$301.14

Service Code	EAPG 00348
Min. Negotiated Rate	$289.56
Max. Negotiated Rate	$301.14
Rate for Payer: Anthem Medicaid	$289.56
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$289.56
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$289.56
Rate for Payer: Dean Health Medicaid	$289.56
Rate for Payer: Independent Care Health Plan Medicaid	$289.56
Rate for Payer: Managed Health Services Medicaid	$301.14
Rate for Payer: Molina Healthcare Medicaid	$289.56
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$289.56
Rate for Payer: United Healthcare Medicaid	$289.56

LEVEL III RADIATION TREATMENT PREPARATION & PLANNING

Facility

$228.19

Service Code	EAPG 00478
Min. Negotiated Rate	$219.41
Max. Negotiated Rate	$228.19
Rate for Payer: Anthem Medicaid	$219.41
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$219.41
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$219.41
Rate for Payer: Dean Health Medicaid	$219.41
Rate for Payer: Independent Care Health Plan Medicaid	$219.41
Rate for Payer: Managed Health Services Medicaid	$228.19
Rate for Payer: Molina Healthcare Medicaid	$219.41
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$219.41
Rate for Payer: United Healthcare Medicaid	$219.41

LEVEL III SKIN EXCISIONS, BIOPSIES, AND REPAIRS

Facility

$387.86

Service Code	EAPG 00011
Min. Negotiated Rate	$372.94
Max. Negotiated Rate	$387.86
Rate for Payer: Anthem Medicaid	$372.94
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$372.94
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$372.94
Rate for Payer: Dean Health Medicaid	$372.94
Rate for Payer: Independent Care Health Plan Medicaid	$372.94
Rate for Payer: Managed Health Services Medicaid	$387.86
Rate for Payer: Molina Healthcare Medicaid	$372.94
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$372.94
Rate for Payer: United Healthcare Medicaid	$372.94

LEVEL III SPINE PROCEDURES

Facility

$3,551.47

Service Code	EAPG 00057
Min. Negotiated Rate	$3,414.86
Max. Negotiated Rate	$3,551.47
Rate for Payer: Anthem Medicaid	$3,414.86
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$3,414.86
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$3,414.86
Rate for Payer: Dean Health Medicaid	$3,414.86
Rate for Payer: Independent Care Health Plan Medicaid	$3,414.86
Rate for Payer: Managed Health Services Medicaid	$3,551.47
Rate for Payer: Molina Healthcare Medicaid	$3,414.86
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$3,414.86
Rate for Payer: United Healthcare Medicaid	$3,414.86

LEVEL III UPPER GI ENDOSCOPY

Facility

$884.80

Service Code	EAPG 00154
Min. Negotiated Rate	$850.76
Max. Negotiated Rate	$884.80
Rate for Payer: Anthem Medicaid	$850.76
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$850.76
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$850.76
Rate for Payer: Dean Health Medicaid	$850.76
Rate for Payer: Independent Care Health Plan Medicaid	$850.76
Rate for Payer: Managed Health Services Medicaid	$884.80
Rate for Payer: Molina Healthcare Medicaid	$850.76
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$850.76
Rate for Payer: United Healthcare Medicaid	$850.76

LEVEL III VASCULAR RADIOLOGICAL PROCEDURES

Facility

$1,003.91

Service Code	EAPG 00280
Min. Negotiated Rate	$965.30
Max. Negotiated Rate	$1,003.91
Rate for Payer: Anthem Medicaid	$965.30
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$965.30
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$965.30
Rate for Payer: Dean Health Medicaid	$965.30
Rate for Payer: Independent Care Health Plan Medicaid	$965.30
Rate for Payer: Managed Health Services Medicaid	$1,003.91
Rate for Payer: Molina Healthcare Medicaid	$965.30
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$965.30
Rate for Payer: United Healthcare Medicaid	$965.30

Know your out-of-pocket cost for care.

All Charges