Beloit Memorial Hospital

All Charges

Charge

Type

Price

EAPG 106: MAJOR OPEN ABDOMINAL AND THORACIC VASCULAR PROCEDURES

Facility OP

$4,117.12

Service Code	EAPG 00106
Min. Negotiated Rate	$3,958.77
Max. Negotiated Rate	$4,117.12
Rate for Payer: Anthem Medicaid	$3,958.77
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$3,958.77
Rate for Payer: Dean Health Medicaid	$3,958.77
Rate for Payer: Independent Care Health Plan Medicaid	$3,958.77
Rate for Payer: Managed Health Services Medicaid	$4,117.12
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$3,958.77
Rate for Payer: United Healthcare Medicaid	$3,958.77
Rate for Payer: WMAP Medicaid	$3,958.77

EAPG 107: CHOLECYSTECTOMY AND RELATED BILIARY PROCEDURES

Facility OP

$1,483.68

Service Code	EAPG 00107
Min. Negotiated Rate	$1,426.62
Max. Negotiated Rate	$1,483.68
Rate for Payer: Anthem Medicaid	$1,426.62
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,426.62
Rate for Payer: Dean Health Medicaid	$1,426.62
Rate for Payer: Independent Care Health Plan Medicaid	$1,426.62
Rate for Payer: Managed Health Services Medicaid	$1,483.68
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,426.62
Rate for Payer: United Healthcare Medicaid	$1,426.62
Rate for Payer: WMAP Medicaid	$1,426.62

EAPG 108: OTHER INTRA-ABDOMINAL AND INTRAPERITONEAL SURGICAL PROCEDURES

Facility OP

$1,579.51

Service Code	EAPG 00108
Min. Negotiated Rate	$1,518.76
Max. Negotiated Rate	$1,579.51
Rate for Payer: Anthem Medicaid	$1,518.76
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,518.76
Rate for Payer: Dean Health Medicaid	$1,518.76
Rate for Payer: Independent Care Health Plan Medicaid	$1,518.76
Rate for Payer: Managed Health Services Medicaid	$1,579.51
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,518.76
Rate for Payer: United Healthcare Medicaid	$1,518.76
Rate for Payer: WMAP Medicaid	$1,518.76

EAPG 109: ANCILLARY DRUG ADMINISTRATION

Facility OP

$20.01

Service Code	EAPG 00109
Min. Negotiated Rate	$19.24
Max. Negotiated Rate	$20.01
Rate for Payer: Anthem Medicaid	$19.24
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$19.24
Rate for Payer: Dean Health Medicaid	$19.24
Rate for Payer: Independent Care Health Plan Medicaid	$19.24
Rate for Payer: Managed Health Services Medicaid	$20.01
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$19.24
Rate for Payer: United Healthcare Medicaid	$19.24
Rate for Payer: WMAP Medicaid	$19.24

EAPG 10: LEVEL II SKIN EXCISIONS, BIOPSIES, AND REPAIRS

Facility OP

$1,018.60

Service Code	EAPG 00010
Min. Negotiated Rate	$502.50
Max. Negotiated Rate	$1,018.60
Rate for Payer: Anthem Medicaid	$502.50
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,018.60
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$502.50
Rate for Payer: Dean Health Medicaid	$502.50
Rate for Payer: Independent Care Health Plan Medicaid	$502.50
Rate for Payer: Managed Health Services Medicaid	$522.60
Rate for Payer: Molina Healthcare Medicaid	$1,018.60
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$502.50
Rate for Payer: United Healthcare Medicaid	$502.50
Rate for Payer: WMAP Medicaid	$502.50

EAPG 110: PHARMACOTHERAPY BY EXTENDED INFUSION

Facility OP

$386.55

Service Code	EAPG 00110
Min. Negotiated Rate	$191.73
Max. Negotiated Rate	$386.55
Rate for Payer: Anthem Medicaid	$191.73
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$386.55
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$191.73
Rate for Payer: Dean Health Medicaid	$191.73
Rate for Payer: Independent Care Health Plan Medicaid	$191.73
Rate for Payer: Managed Health Services Medicaid	$199.40
Rate for Payer: Molina Healthcare Medicaid	$386.55
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$191.73
Rate for Payer: United Healthcare Medicaid	$191.73
Rate for Payer: WMAP Medicaid	$191.73

EAPG 111: PHARMACOTHERAPY EXCEPT BY EXTENDED INFUSION

Facility OP

$247.26

Service Code	EAPG 00111
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$247.26
Rate for Payer: Anthem Medicaid	$122.40
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$247.26
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$122.40
Rate for Payer: Dean Health Medicaid	$122.40
Rate for Payer: Independent Care Health Plan Medicaid	$122.40
Rate for Payer: Managed Health Services Medicaid	$127.30
Rate for Payer: Molina Healthcare Medicaid	$247.26
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$122.40
Rate for Payer: United Healthcare Medicaid	$122.40
Rate for Payer: WMAP Medicaid	$122.40

EAPG 113: LEVEL I BLOOD PRODUCT EXCHANGE SERVICES

Facility OP

$524.61

Service Code	EAPG 00113
Min. Negotiated Rate	$167.79
Max. Negotiated Rate	$524.61
Rate for Payer: Anthem Medicaid	$167.79
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$524.61
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$167.79
Rate for Payer: Dean Health Medicaid	$167.79
Rate for Payer: Independent Care Health Plan Medicaid	$167.79
Rate for Payer: Managed Health Services Medicaid	$174.50
Rate for Payer: Molina Healthcare Medicaid	$524.61
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$167.79
Rate for Payer: United Healthcare Medicaid	$167.79
Rate for Payer: WMAP Medicaid	$167.79

EAPG 114: LEVEL II BLOOD PRODUCT EXCHANGE SERVICES

Facility OP

$2,043.75

Service Code	EAPG 00114
Min. Negotiated Rate	$679.51
Max. Negotiated Rate	$2,043.75
Rate for Payer: Anthem Medicaid	$679.51
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,043.75
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$679.51
Rate for Payer: Dean Health Medicaid	$679.51
Rate for Payer: Independent Care Health Plan Medicaid	$679.51
Rate for Payer: Managed Health Services Medicaid	$706.69
Rate for Payer: Molina Healthcare Medicaid	$2,043.75
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$679.51
Rate for Payer: United Healthcare Medicaid	$679.51
Rate for Payer: WMAP Medicaid	$679.51

EAPG 115: DEEP LYMPH STRUCTURE PROCEDURES

Facility OP

$1,912.68

Service Code	EAPG 00115
Min. Negotiated Rate	$1,320.44
Max. Negotiated Rate	$1,912.68
Rate for Payer: Anthem Medicaid	$1,320.44
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,912.68
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,320.44
Rate for Payer: Dean Health Medicaid	$1,320.44
Rate for Payer: Independent Care Health Plan Medicaid	$1,320.44
Rate for Payer: Managed Health Services Medicaid	$1,373.26
Rate for Payer: Molina Healthcare Medicaid	$1,912.68
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,320.44
Rate for Payer: United Healthcare Medicaid	$1,320.44
Rate for Payer: WMAP Medicaid	$1,320.44

EAPG 116: LEVEL I ALLERGY TESTS

Facility OP

$31.16

Service Code	EAPG 00116
Min. Negotiated Rate	$14.46
Max. Negotiated Rate	$31.16
Rate for Payer: Anthem Medicaid	$14.46
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$31.16
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$14.46
Rate for Payer: Dean Health Medicaid	$14.46
Rate for Payer: Independent Care Health Plan Medicaid	$14.46
Rate for Payer: Managed Health Services Medicaid	$15.04
Rate for Payer: Molina Healthcare Medicaid	$31.16
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$14.46
Rate for Payer: United Healthcare Medicaid	$14.46
Rate for Payer: WMAP Medicaid	$14.46

EAPG 118: NUTRITION THERAPY

Facility OP

$138.80

Service Code	EAPG 00118
Min. Negotiated Rate	$68.98
Max. Negotiated Rate	$138.80
Rate for Payer: Anthem Medicaid	$68.98
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$138.80
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$68.98
Rate for Payer: Dean Health Medicaid	$68.98
Rate for Payer: Independent Care Health Plan Medicaid	$68.98
Rate for Payer: Managed Health Services Medicaid	$71.74
Rate for Payer: Molina Healthcare Medicaid	$138.80
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$68.98
Rate for Payer: United Healthcare Medicaid	$68.98
Rate for Payer: WMAP Medicaid	$68.98

EAPG 119: CAR T-CELL IMMUNOTHERAPY PREPARATION SERVICES

Facility OP

$258.87

Service Code	EAPG 00119
Min. Negotiated Rate	$248.91
Max. Negotiated Rate	$258.87
Rate for Payer: Anthem Medicaid	$248.91
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$248.91
Rate for Payer: Dean Health Medicaid	$248.91
Rate for Payer: Independent Care Health Plan Medicaid	$248.91
Rate for Payer: Managed Health Services Medicaid	$258.87
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$248.91
Rate for Payer: United Healthcare Medicaid	$248.91
Rate for Payer: WMAP Medicaid	$248.91

EAPG 11: LEVEL III SKIN EXCISIONS, BIOPSIES, AND REPAIRS

Facility OP

$2,484.70

Service Code	EAPG 00011
Min. Negotiated Rate	$742.79
Max. Negotiated Rate	$2,484.70
Rate for Payer: Anthem Medicaid	$742.79
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,484.70
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$742.79
Rate for Payer: Dean Health Medicaid	$742.79
Rate for Payer: Independent Care Health Plan Medicaid	$742.79
Rate for Payer: Managed Health Services Medicaid	$772.50
Rate for Payer: Molina Healthcare Medicaid	$2,484.70
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$742.79
Rate for Payer: United Healthcare Medicaid	$742.79
Rate for Payer: WMAP Medicaid	$742.79

EAPG 120: CAR T-CELL IMMUNOTHERAPY

Facility OP

$19,377.73

Service Code	EAPG 00120
Min. Negotiated Rate	$18,632.43
Max. Negotiated Rate	$19,377.73
Rate for Payer: Anthem Medicaid	$18,632.43
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$18,632.43
Rate for Payer: Dean Health Medicaid	$18,632.43
Rate for Payer: Independent Care Health Plan Medicaid	$18,632.43
Rate for Payer: Managed Health Services Medicaid	$19,377.73
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$18,632.43
Rate for Payer: United Healthcare Medicaid	$18,632.43
Rate for Payer: WMAP Medicaid	$18,632.43

EAPG 121: LEVEL II PERCUTANEOUS CORONARY AND INTRACARDIAC INTERVENTIONAL PROCEDURES

Facility OP

$6,234.55

Service Code	EAPG 00121
Min. Negotiated Rate	$5,994.76
Max. Negotiated Rate	$6,234.55
Rate for Payer: Anthem Medicaid	$5,994.76
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$5,994.76
Rate for Payer: Dean Health Medicaid	$5,994.76
Rate for Payer: Independent Care Health Plan Medicaid	$5,994.76
Rate for Payer: Managed Health Services Medicaid	$6,234.55
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$5,994.76
Rate for Payer: United Healthcare Medicaid	$5,994.76
Rate for Payer: WMAP Medicaid	$5,994.76

EAPG 122: PERCUTANEOUS INTRA-ABDOMINAL OR INTRATHORACIC VASCULAR PROCEDURES

Facility OP

$7,093.61

Service Code	EAPG 00122
Min. Negotiated Rate	$6,820.78
Max. Negotiated Rate	$7,093.61
Rate for Payer: Anthem Medicaid	$6,820.78
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$6,820.78
Rate for Payer: Dean Health Medicaid	$6,820.78
Rate for Payer: Independent Care Health Plan Medicaid	$6,820.78
Rate for Payer: Managed Health Services Medicaid	$7,093.61
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$6,820.78
Rate for Payer: United Healthcare Medicaid	$6,820.78
Rate for Payer: WMAP Medicaid	$6,820.78

EAPG 123: PERIPHERAL VASCULAR BYPASS PROCEDURES

Facility OP

$2,390.63

Service Code	EAPG 00123
Min. Negotiated Rate	$2,298.68
Max. Negotiated Rate	$2,390.63
Rate for Payer: Anthem Medicaid	$2,298.68
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,298.68
Rate for Payer: Dean Health Medicaid	$2,298.68
Rate for Payer: Independent Care Health Plan Medicaid	$2,298.68
Rate for Payer: Managed Health Services Medicaid	$2,390.63
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,298.68
Rate for Payer: United Healthcare Medicaid	$2,298.68
Rate for Payer: WMAP Medicaid	$2,298.68

EAPG 124: BONE MARROW BIOPSIES

Facility OP

$715.88

Service Code	EAPG 00124
Min. Negotiated Rate	$688.35
Max. Negotiated Rate	$715.88
Rate for Payer: Anthem Medicaid	$688.35
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$688.35
Rate for Payer: Dean Health Medicaid	$688.35
Rate for Payer: Independent Care Health Plan Medicaid	$688.35
Rate for Payer: Managed Health Services Medicaid	$715.88
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$688.35
Rate for Payer: United Healthcare Medicaid	$688.35
Rate for Payer: WMAP Medicaid	$688.35

EAPG 125: LEVEL I ESOPHAGEAL AND GASTRIC SURGICAL PROCEDURES

Facility OP

$1,403.72

Service Code	EAPG 00125
Min. Negotiated Rate	$1,349.73
Max. Negotiated Rate	$1,403.72
Rate for Payer: Anthem Medicaid	$1,349.73
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,349.73
Rate for Payer: Dean Health Medicaid	$1,349.73
Rate for Payer: Independent Care Health Plan Medicaid	$1,349.73
Rate for Payer: Managed Health Services Medicaid	$1,403.72
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,349.73
Rate for Payer: United Healthcare Medicaid	$1,349.73
Rate for Payer: WMAP Medicaid	$1,349.73

EAPG 126: LEVEL II ESOPHAGEAL AND GASTRIC SURGICAL PROCEDURES

Facility OP

$1,531.28

Service Code	EAPG 00126
Min. Negotiated Rate	$1,472.38
Max. Negotiated Rate	$1,531.28
Rate for Payer: Anthem Medicaid	$1,472.38
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,472.38
Rate for Payer: Dean Health Medicaid	$1,472.38
Rate for Payer: Independent Care Health Plan Medicaid	$1,472.38
Rate for Payer: Managed Health Services Medicaid	$1,531.28
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,472.38
Rate for Payer: United Healthcare Medicaid	$1,472.38
Rate for Payer: WMAP Medicaid	$1,472.38

EAPG 127: LEVEL I SMALL AND LARGE INTESTINE SURGICAL PROCEDURES

Facility OP

$890.72

Service Code	EAPG 00127
Min. Negotiated Rate	$856.46
Max. Negotiated Rate	$890.72
Rate for Payer: Anthem Medicaid	$856.46
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$856.46
Rate for Payer: Dean Health Medicaid	$856.46
Rate for Payer: Independent Care Health Plan Medicaid	$856.46
Rate for Payer: Managed Health Services Medicaid	$890.72
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$856.46
Rate for Payer: United Healthcare Medicaid	$856.46
Rate for Payer: WMAP Medicaid	$856.46

EAPG 128: LEVEL II SMALL AND LARGE INTESTINE SURGICAL PROCEDURES

Facility OP

$1,649.43

Service Code	EAPG 00128
Min. Negotiated Rate	$1,585.99
Max. Negotiated Rate	$1,649.43
Rate for Payer: Anthem Medicaid	$1,585.99
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,585.99
Rate for Payer: Dean Health Medicaid	$1,585.99
Rate for Payer: Independent Care Health Plan Medicaid	$1,585.99
Rate for Payer: Managed Health Services Medicaid	$1,649.43
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,585.99
Rate for Payer: United Healthcare Medicaid	$1,585.99
Rate for Payer: WMAP Medicaid	$1,585.99

EAPG 129: ESOPHAGOGASTRIC RESTRICTIVE PROCEDURES AND GASTRIC FUNDOPLICATION

Facility OP

$2,172.28

Service Code	EAPG 00129
Min. Negotiated Rate	$2,088.73
Max. Negotiated Rate	$2,172.28
Rate for Payer: Anthem Medicaid	$2,088.73
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,088.73
Rate for Payer: Dean Health Medicaid	$2,088.73
Rate for Payer: Independent Care Health Plan Medicaid	$2,088.73
Rate for Payer: Managed Health Services Medicaid	$2,172.28
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,088.73
Rate for Payer: United Healthcare Medicaid	$2,088.73
Rate for Payer: WMAP Medicaid	$2,088.73

EAPG 130: MINOR GASTROINTESTINAL PROCEDURES INCLUDING TUBE INSERTION OR PLACEMENT

Facility OP

$475.88

Service Code	EAPG 00130
Min. Negotiated Rate	$161.62
Max. Negotiated Rate	$475.88
Rate for Payer: Anthem Medicaid	$161.62
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$475.88
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$161.62
Rate for Payer: Dean Health Medicaid	$161.62
Rate for Payer: Independent Care Health Plan Medicaid	$161.62
Rate for Payer: Managed Health Services Medicaid	$168.08
Rate for Payer: Molina Healthcare Medicaid	$475.88
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$161.62
Rate for Payer: United Healthcare Medicaid	$161.62
Rate for Payer: WMAP Medicaid	$161.62

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