Beloit Memorial Hospital

All Charges

Charge

Type

Setting

Price

LEVEL II REPAIR AND PLASTIC PROCEDURES OF EYE

Facility

$655.21

Service Code	EAPG 00241
Min. Negotiated Rate	$630.01
Max. Negotiated Rate	$655.21
Rate for Payer: Anthem Medicaid	$630.01
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$630.01
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$630.01
Rate for Payer: Dean Health Medicaid	$630.01
Rate for Payer: Independent Care Health Plan Medicaid	$630.01
Rate for Payer: Managed Health Services Medicaid	$655.21
Rate for Payer: Molina Healthcare Medicaid	$630.01
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$630.01
Rate for Payer: United Healthcare Medicaid	$630.01

LEVEL II SHOULDER AND UPPER ARM PROCEDURES

Facility

$2,047.55

Service Code	EAPG 00058
Min. Negotiated Rate	$1,968.79
Max. Negotiated Rate	$2,047.55
Rate for Payer: Anthem Medicaid	$1,968.79
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,968.79
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,968.79
Rate for Payer: Dean Health Medicaid	$1,968.79
Rate for Payer: Independent Care Health Plan Medicaid	$1,968.79
Rate for Payer: Managed Health Services Medicaid	$2,047.55
Rate for Payer: Molina Healthcare Medicaid	$1,968.79
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,968.79
Rate for Payer: United Healthcare Medicaid	$1,968.79

LEVEL II SKIN EXCISIONS, BIOPSIES, AND REPAIRS

Facility

$267.43

Service Code	EAPG 00010
Min. Negotiated Rate	$257.14
Max. Negotiated Rate	$267.43
Rate for Payer: Anthem Medicaid	$257.14
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$257.14
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$257.14
Rate for Payer: Dean Health Medicaid	$257.14
Rate for Payer: Independent Care Health Plan Medicaid	$257.14
Rate for Payer: Managed Health Services Medicaid	$267.43
Rate for Payer: Molina Healthcare Medicaid	$257.14
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$257.14
Rate for Payer: United Healthcare Medicaid	$257.14

LEVEL II SKIN INCISION AND DRAINAGE, DEBRIDEMENT, DESTRUCTION, OTHER RELATED PX

Facility

$239.66

Service Code	EAPG 00004
Min. Negotiated Rate	$230.45
Max. Negotiated Rate	$239.66
Rate for Payer: Anthem Medicaid	$230.45
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$230.45
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$230.45
Rate for Payer: Dean Health Medicaid	$230.45
Rate for Payer: Independent Care Health Plan Medicaid	$230.45
Rate for Payer: Managed Health Services Medicaid	$239.66
Rate for Payer: Molina Healthcare Medicaid	$230.45
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$230.45
Rate for Payer: United Healthcare Medicaid	$230.45

LEVEL II SMALL AND LARGE INTESTINE SURGICAL PROCEDURES

Facility

$873.43

Service Code	EAPG 00128
Min. Negotiated Rate	$839.83
Max. Negotiated Rate	$873.43
Rate for Payer: Anthem Medicaid	$839.83
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$839.83
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$839.83
Rate for Payer: Dean Health Medicaid	$839.83
Rate for Payer: Independent Care Health Plan Medicaid	$839.83
Rate for Payer: Managed Health Services Medicaid	$873.43
Rate for Payer: Molina Healthcare Medicaid	$839.83
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$839.83
Rate for Payer: United Healthcare Medicaid	$839.83

LEVEL II SPINE PROCEDURES

Facility

$2,170.23

Service Code	EAPG 00029
Min. Negotiated Rate	$2,086.76
Max. Negotiated Rate	$2,170.23
Rate for Payer: Anthem Medicaid	$2,086.76
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,086.76
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,086.76
Rate for Payer: Dean Health Medicaid	$2,086.76
Rate for Payer: Independent Care Health Plan Medicaid	$2,086.76
Rate for Payer: Managed Health Services Medicaid	$2,170.23
Rate for Payer: Molina Healthcare Medicaid	$2,086.76
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,086.76
Rate for Payer: United Healthcare Medicaid	$2,086.76

LEVEL II SURGICAL PATHOLOGY TESTS

Facility

$34.62

Service Code	EAPG 00306
Min. Negotiated Rate	$33.29
Max. Negotiated Rate	$34.62
Rate for Payer: Anthem Medicaid	$33.29
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$33.29
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$33.29
Rate for Payer: Dean Health Medicaid	$33.29
Rate for Payer: Independent Care Health Plan Medicaid	$33.29
Rate for Payer: Managed Health Services Medicaid	$34.62
Rate for Payer: Molina Healthcare Medicaid	$33.29
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$33.29
Rate for Payer: United Healthcare Medicaid	$33.29

LEVEL II THORACIC AND CHEST PROCEDURES

Facility

$1,100.38

Service Code	EAPG 00070
Min. Negotiated Rate	$1,058.05
Max. Negotiated Rate	$1,100.38
Rate for Payer: Anthem Medicaid	$1,058.05
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,058.05
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,058.05
Rate for Payer: Dean Health Medicaid	$1,058.05
Rate for Payer: Independent Care Health Plan Medicaid	$1,058.05
Rate for Payer: Managed Health Services Medicaid	$1,100.38
Rate for Payer: Molina Healthcare Medicaid	$1,058.05
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,058.05
Rate for Payer: United Healthcare Medicaid	$1,058.05

LEVEL II UPPER GI ENDOSCOPY

Facility

$457.26

Service Code	EAPG 00135
Min. Negotiated Rate	$439.67
Max. Negotiated Rate	$457.26
Rate for Payer: Anthem Medicaid	$439.67
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$439.67
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$439.67
Rate for Payer: Dean Health Medicaid	$439.67
Rate for Payer: Independent Care Health Plan Medicaid	$439.67
Rate for Payer: Managed Health Services Medicaid	$457.26
Rate for Payer: Molina Healthcare Medicaid	$439.67
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$439.67
Rate for Payer: United Healthcare Medicaid	$439.67

LEVEL II URETHRAL PROCEDURES

Facility

$1,281.41

Service Code	EAPG 00167
Min. Negotiated Rate	$1,232.12
Max. Negotiated Rate	$1,281.41
Rate for Payer: Anthem Medicaid	$1,232.12
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,232.12
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,232.12
Rate for Payer: Dean Health Medicaid	$1,232.12
Rate for Payer: Independent Care Health Plan Medicaid	$1,232.12
Rate for Payer: Managed Health Services Medicaid	$1,281.41
Rate for Payer: Molina Healthcare Medicaid	$1,232.12
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,232.12
Rate for Payer: United Healthcare Medicaid	$1,232.12

LEVEL II VARICOSE VEIN AND RELATED PROCEDURES

Facility

$570.17

Service Code	EAPG 00103
Min. Negotiated Rate	$548.24
Max. Negotiated Rate	$570.17
Rate for Payer: Anthem Medicaid	$548.24
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$548.24
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$548.24
Rate for Payer: Dean Health Medicaid	$548.24
Rate for Payer: Independent Care Health Plan Medicaid	$548.24
Rate for Payer: Managed Health Services Medicaid	$570.17
Rate for Payer: Molina Healthcare Medicaid	$548.24
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$548.24
Rate for Payer: United Healthcare Medicaid	$548.24

LEVEL II VASCULAR RADIOLOGICAL PROCEDURES

Facility

$375.17

Service Code	EAPG 00279
Min. Negotiated Rate	$360.74
Max. Negotiated Rate	$375.17
Rate for Payer: Anthem Medicaid	$360.74
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$360.74
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$360.74
Rate for Payer: Dean Health Medicaid	$360.74
Rate for Payer: Independent Care Health Plan Medicaid	$360.74
Rate for Payer: Managed Health Services Medicaid	$375.17
Rate for Payer: Molina Healthcare Medicaid	$360.74
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$360.74
Rate for Payer: United Healthcare Medicaid	$360.74

LEVEL I JOINT, TENDON, OR LIGAMENT INJECTION PROCEDURES

Facility

$53.46

Service Code	EAPG 00049
Min. Negotiated Rate	$51.40
Max. Negotiated Rate	$53.46
Rate for Payer: Anthem Medicaid	$51.40
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$51.40
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$51.40
Rate for Payer: Dean Health Medicaid	$51.40
Rate for Payer: Independent Care Health Plan Medicaid	$51.40
Rate for Payer: Managed Health Services Medicaid	$53.46
Rate for Payer: Molina Healthcare Medicaid	$51.40
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$51.40
Rate for Payer: United Healthcare Medicaid	$51.40

LEVEL I KIDNEY AND URETERAL PROCEDURES

Facility

$321.25

Service Code	EAPG 00170
Min. Negotiated Rate	$308.90
Max. Negotiated Rate	$321.25
Rate for Payer: Anthem Medicaid	$308.90
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$308.90
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$308.90
Rate for Payer: Dean Health Medicaid	$308.90
Rate for Payer: Independent Care Health Plan Medicaid	$308.90
Rate for Payer: Managed Health Services Medicaid	$321.25
Rate for Payer: Molina Healthcare Medicaid	$308.90
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$308.90
Rate for Payer: United Healthcare Medicaid	$308.90

LEVEL I KNEE AND LOWER LEG PROCEDURES

Facility

$708.23

Service Code	EAPG 00026
Min. Negotiated Rate	$680.99
Max. Negotiated Rate	$708.23
Rate for Payer: Anthem Medicaid	$680.99
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$680.99
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$680.99
Rate for Payer: Dean Health Medicaid	$680.99
Rate for Payer: Independent Care Health Plan Medicaid	$680.99
Rate for Payer: Managed Health Services Medicaid	$708.23
Rate for Payer: Molina Healthcare Medicaid	$680.99
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$680.99
Rate for Payer: United Healthcare Medicaid	$680.99

LEVEL I LOWER AIRWAY ENDOSCOPY

Facility

$394.91

Service Code	EAPG 00064
Min. Negotiated Rate	$379.72
Max. Negotiated Rate	$394.91
Rate for Payer: Anthem Medicaid	$379.72
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$379.72
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$379.72
Rate for Payer: Dean Health Medicaid	$379.72
Rate for Payer: Independent Care Health Plan Medicaid	$379.72
Rate for Payer: Managed Health Services Medicaid	$394.91
Rate for Payer: Molina Healthcare Medicaid	$379.72
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$379.72
Rate for Payer: United Healthcare Medicaid	$379.72

LEVEL I LOWER GI ENDOSCOPY

Facility

$215.30

Service Code	EAPG 00136
Min. Negotiated Rate	$207.02
Max. Negotiated Rate	$215.30
Rate for Payer: Anthem Medicaid	$207.02
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$207.02
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$207.02
Rate for Payer: Dean Health Medicaid	$207.02
Rate for Payer: Independent Care Health Plan Medicaid	$207.02
Rate for Payer: Managed Health Services Medicaid	$215.30
Rate for Payer: Molina Healthcare Medicaid	$207.02
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$207.02
Rate for Payer: United Healthcare Medicaid	$207.02

LEVEL I MAXILLOFACIAL PROSTHETICS

Facility

$337.06

Service Code	EAPG 00359
Min. Negotiated Rate	$324.10
Max. Negotiated Rate	$337.06
Rate for Payer: Anthem Medicaid	$324.10
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$324.10
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$324.10
Rate for Payer: Dean Health Medicaid	$324.10
Rate for Payer: Independent Care Health Plan Medicaid	$324.10
Rate for Payer: Managed Health Services Medicaid	$337.06
Rate for Payer: Molina Healthcare Medicaid	$324.10
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$324.10
Rate for Payer: United Healthcare Medicaid	$324.10

LEVEL I MICROBIOLOGY TESTS

Facility

$1.76

Service Code	EAPG 00396
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$1.76
Rate for Payer: Anthem Medicaid	$1.69
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1.69
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1.69
Rate for Payer: Dean Health Medicaid	$1.69
Rate for Payer: Independent Care Health Plan Medicaid	$1.69
Rate for Payer: Managed Health Services Medicaid	$1.76
Rate for Payer: Molina Healthcare Medicaid	$1.69
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1.69
Rate for Payer: United Healthcare Medicaid	$1.69

LEVEL I NERVE PROCEDURE W OR W/O NEUROLOGICAL DEVICE

Facility

$293.58

Service Code	EAPG 00217
Min. Negotiated Rate	$282.29
Max. Negotiated Rate	$293.58
Rate for Payer: Anthem Medicaid	$282.29
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$282.29
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$282.29
Rate for Payer: Dean Health Medicaid	$282.29
Rate for Payer: Independent Care Health Plan Medicaid	$282.29
Rate for Payer: Managed Health Services Medicaid	$293.58
Rate for Payer: Molina Healthcare Medicaid	$282.29
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$282.29
Rate for Payer: United Healthcare Medicaid	$282.29

LEVEL I NERVOUS SYSTEM INJECTIONS INCLUDING CRANIAL TAP

Facility

$86.45

Service Code	EAPG 00214
Min. Negotiated Rate	$83.13
Max. Negotiated Rate	$86.45
Rate for Payer: Anthem Medicaid	$83.13
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$83.13
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$83.13
Rate for Payer: Dean Health Medicaid	$83.13
Rate for Payer: Independent Care Health Plan Medicaid	$83.13
Rate for Payer: Managed Health Services Medicaid	$86.45
Rate for Payer: Molina Healthcare Medicaid	$83.13
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$83.13
Rate for Payer: United Healthcare Medicaid	$83.13

LEVEL I ORAL AND MAXILLOFACIAL PROCEDURES

Facility

$270.71

Service Code	EAPG 00367
Min. Negotiated Rate	$260.29
Max. Negotiated Rate	$270.71
Rate for Payer: Anthem Medicaid	$260.29
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$260.29
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$260.29
Rate for Payer: Dean Health Medicaid	$260.29
Rate for Payer: Independent Care Health Plan Medicaid	$260.29
Rate for Payer: Managed Health Services Medicaid	$270.71
Rate for Payer: Molina Healthcare Medicaid	$260.29
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$260.29
Rate for Payer: United Healthcare Medicaid	$260.29

LEVEL I OTHER UTERINE AND ADNEXA GYNECOLOGICAL PROCEDURES

Facility

$511.34

Service Code	EAPG 00207
Min. Negotiated Rate	$491.67
Max. Negotiated Rate	$511.34
Rate for Payer: Anthem Medicaid	$491.67
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$491.67
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$491.67
Rate for Payer: Dean Health Medicaid	$491.67
Rate for Payer: Independent Care Health Plan Medicaid	$491.67
Rate for Payer: Managed Health Services Medicaid	$511.34
Rate for Payer: Molina Healthcare Medicaid	$491.67
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$491.67
Rate for Payer: United Healthcare Medicaid	$491.67

LEVEL I PATHOLOGY TESTS

Facility

$0.88

Service Code	EAPG 00390
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$0.88
Rate for Payer: Anthem Medicaid	$0.84
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$0.84
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$0.84
Rate for Payer: Dean Health Medicaid	$0.84
Rate for Payer: Independent Care Health Plan Medicaid	$0.84
Rate for Payer: Managed Health Services Medicaid	$0.88
Rate for Payer: Molina Healthcare Medicaid	$0.84
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$0.84
Rate for Payer: United Healthcare Medicaid	$0.84

LEVEL I PENILE PROCEDURES

Facility

$425.69

Service Code	EAPG 00183
Min. Negotiated Rate	$409.32
Max. Negotiated Rate	$425.69
Rate for Payer: Anthem Medicaid	$409.32
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$409.32
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$409.32
Rate for Payer: Dean Health Medicaid	$409.32
Rate for Payer: Independent Care Health Plan Medicaid	$409.32
Rate for Payer: Managed Health Services Medicaid	$425.69
Rate for Payer: Molina Healthcare Medicaid	$409.32
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$409.32
Rate for Payer: United Healthcare Medicaid	$409.32

Know your out-of-pocket cost for care.

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