Beloit Memorial Hospital

All Charges

Charge

Type

Price

EAPG 134: LEVEL I UPPER GI ENDOSCOPY

Facility OP

$618.55

Service Code	EAPG 00134
Min. Negotiated Rate	$400.73
Max. Negotiated Rate	$618.55
Rate for Payer: Anthem Medicaid	$400.73
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$618.55
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$400.73
Rate for Payer: Dean Health Medicaid	$400.73
Rate for Payer: Independent Care Health Plan Medicaid	$400.73
Rate for Payer: Managed Health Services Medicaid	$416.76
Rate for Payer: Molina Healthcare Medicaid	$618.55
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$400.73
Rate for Payer: United Healthcare Medicaid	$400.73
Rate for Payer: WMAP Medicaid	$400.73

EAPG 135: LEVEL II UPPER GI ENDOSCOPY

Facility OP

$866.50

Service Code	EAPG 00135
Min. Negotiated Rate	$833.17
Max. Negotiated Rate	$866.50
Rate for Payer: Anthem Medicaid	$833.17
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$853.77
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$833.17
Rate for Payer: Dean Health Medicaid	$833.17
Rate for Payer: Independent Care Health Plan Medicaid	$833.17
Rate for Payer: Managed Health Services Medicaid	$866.50
Rate for Payer: Molina Healthcare Medicaid	$853.77
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$833.17
Rate for Payer: United Healthcare Medicaid	$833.17
Rate for Payer: WMAP Medicaid	$833.17

EAPG 136: LEVEL I LOWER GI ENDOSCOPY

Facility OP

$592.96

Service Code	EAPG 00136
Min. Negotiated Rate	$409.48
Max. Negotiated Rate	$592.96
Rate for Payer: Anthem Medicaid	$409.48
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$592.96
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$409.48
Rate for Payer: Dean Health Medicaid	$409.48
Rate for Payer: Independent Care Health Plan Medicaid	$409.48
Rate for Payer: Managed Health Services Medicaid	$425.86
Rate for Payer: Molina Healthcare Medicaid	$592.96
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$409.48
Rate for Payer: United Healthcare Medicaid	$409.48
Rate for Payer: WMAP Medicaid	$409.48

EAPG 137: LEVEL II LOWER GI ENDOSCOPY

Facility OP

$875.48

Service Code	EAPG 00137
Min. Negotiated Rate	$659.89
Max. Negotiated Rate	$875.48
Rate for Payer: Anthem Medicaid	$841.81
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$659.89
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$841.81
Rate for Payer: Dean Health Medicaid	$841.81
Rate for Payer: Independent Care Health Plan Medicaid	$841.81
Rate for Payer: Managed Health Services Medicaid	$875.48
Rate for Payer: Molina Healthcare Medicaid	$659.89
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$841.81
Rate for Payer: United Healthcare Medicaid	$841.81
Rate for Payer: WMAP Medicaid	$841.81

EAPG 138: LEVEL I ERCP AND RELATED ENDOSCOPIC PROCEDURES

Facility OP

$1,805.44

Service Code	EAPG 00138
Min. Negotiated Rate	$1,064.14
Max. Negotiated Rate	$1,805.44
Rate for Payer: Anthem Medicaid	$1,064.14
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,805.44
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,064.14
Rate for Payer: Dean Health Medicaid	$1,064.14
Rate for Payer: Independent Care Health Plan Medicaid	$1,064.14
Rate for Payer: Managed Health Services Medicaid	$1,106.71
Rate for Payer: Molina Healthcare Medicaid	$1,805.44
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,064.14
Rate for Payer: United Healthcare Medicaid	$1,064.14
Rate for Payer: WMAP Medicaid	$1,064.14

EAPG 141: LEVEL I ANAL AND RECTAL PROCEDURES

Facility OP

$1,107.15

Service Code	EAPG 00141
Min. Negotiated Rate	$597.55
Max. Negotiated Rate	$1,107.15
Rate for Payer: Anthem Medicaid	$597.55
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,107.15
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$597.55
Rate for Payer: Dean Health Medicaid	$597.55
Rate for Payer: Independent Care Health Plan Medicaid	$597.55
Rate for Payer: Managed Health Services Medicaid	$621.45
Rate for Payer: Molina Healthcare Medicaid	$1,107.15
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$597.55
Rate for Payer: United Healthcare Medicaid	$597.55
Rate for Payer: WMAP Medicaid	$597.55

EAPG 142: LEVEL II ANAL AND RECTAL PROCEDURES

Facility OP

$1,565.81

Service Code	EAPG 00142
Min. Negotiated Rate	$934.71
Max. Negotiated Rate	$1,565.81
Rate for Payer: Anthem Medicaid	$934.71
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,565.81
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$934.71
Rate for Payer: Dean Health Medicaid	$934.71
Rate for Payer: Independent Care Health Plan Medicaid	$934.71
Rate for Payer: Managed Health Services Medicaid	$972.10
Rate for Payer: Molina Healthcare Medicaid	$1,565.81
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$934.71
Rate for Payer: United Healthcare Medicaid	$934.71
Rate for Payer: WMAP Medicaid	$934.71

EAPG 150: ABDOMINAL PARACENTESIS AND RELATED PERITONEAL DRAINAGE PROCEDURES

Facility OP

$311.78

Service Code	EAPG 00150
Min. Negotiated Rate	$299.79
Max. Negotiated Rate	$311.78
Rate for Payer: Anthem Medicaid	$299.79
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$299.79
Rate for Payer: Dean Health Medicaid	$299.79
Rate for Payer: Independent Care Health Plan Medicaid	$299.79
Rate for Payer: Managed Health Services Medicaid	$311.78
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$299.79
Rate for Payer: United Healthcare Medicaid	$299.79
Rate for Payer: WMAP Medicaid	$299.79

EAPG 151: LEVEL I HEPATOBILIARY AND PANCREAS PROCEDURES

Facility OP

$957.21

Service Code	EAPG 00151
Min. Negotiated Rate	$920.39
Max. Negotiated Rate	$957.21
Rate for Payer: Anthem Medicaid	$920.39
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$920.39
Rate for Payer: Dean Health Medicaid	$920.39
Rate for Payer: Independent Care Health Plan Medicaid	$920.39
Rate for Payer: Managed Health Services Medicaid	$957.21
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$920.39
Rate for Payer: United Healthcare Medicaid	$920.39
Rate for Payer: WMAP Medicaid	$920.39

EAPG 152: LEVEL II HEPATOBILIARY AND PANCREAS PROCEDURES

Facility OP

$2,342.89

Service Code	EAPG 00152
Min. Negotiated Rate	$2,252.78
Max. Negotiated Rate	$2,342.89
Rate for Payer: Anthem Medicaid	$2,252.78
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,252.78
Rate for Payer: Dean Health Medicaid	$2,252.78
Rate for Payer: Independent Care Health Plan Medicaid	$2,252.78
Rate for Payer: Managed Health Services Medicaid	$2,342.89
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,252.78
Rate for Payer: United Healthcare Medicaid	$2,252.78
Rate for Payer: WMAP Medicaid	$2,252.78

EAPG 153: LEVEL II ERCP AND RELATED ENDOSCOPIC PROCEDURES

Facility OP

$1,841.00

Service Code	EAPG 00153
Min. Negotiated Rate	$1,770.19
Max. Negotiated Rate	$1,841.00
Rate for Payer: Anthem Medicaid	$1,770.19
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,770.19
Rate for Payer: Dean Health Medicaid	$1,770.19
Rate for Payer: Independent Care Health Plan Medicaid	$1,770.19
Rate for Payer: Managed Health Services Medicaid	$1,841.00
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,770.19
Rate for Payer: United Healthcare Medicaid	$1,770.19
Rate for Payer: WMAP Medicaid	$1,770.19

EAPG 154: LEVEL III UPPER GI ENDOSCOPY

Facility OP

$1,621.58

Service Code	EAPG 00154
Min. Negotiated Rate	$1,559.21
Max. Negotiated Rate	$1,621.58
Rate for Payer: Anthem Medicaid	$1,559.21
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,559.21
Rate for Payer: Dean Health Medicaid	$1,559.21
Rate for Payer: Independent Care Health Plan Medicaid	$1,559.21
Rate for Payer: Managed Health Services Medicaid	$1,621.58
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,559.21
Rate for Payer: United Healthcare Medicaid	$1,559.21
Rate for Payer: WMAP Medicaid	$1,559.21

EAPG 155: LEVEL III BLOOD PRODUCT EXCHANGE SERVICES

Facility OP

$1,917.36

Service Code	EAPG 00155
Min. Negotiated Rate	$1,843.62
Max. Negotiated Rate	$1,917.36
Rate for Payer: Anthem Medicaid	$1,843.62
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,843.62
Rate for Payer: Dean Health Medicaid	$1,843.62
Rate for Payer: Independent Care Health Plan Medicaid	$1,843.62
Rate for Payer: Managed Health Services Medicaid	$1,917.36
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,843.62
Rate for Payer: United Healthcare Medicaid	$1,843.62
Rate for Payer: WMAP Medicaid	$1,843.62

EAPG 156: OCULAR IMAGING AND RELATED SERVICES

Facility OP

$24.19

Service Code	EAPG 00156
Min. Negotiated Rate	$23.26
Max. Negotiated Rate	$24.19
Rate for Payer: Anthem Medicaid	$23.26
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$23.26
Rate for Payer: Dean Health Medicaid	$23.26
Rate for Payer: Independent Care Health Plan Medicaid	$23.26
Rate for Payer: Managed Health Services Medicaid	$24.19
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$23.26
Rate for Payer: United Healthcare Medicaid	$23.26
Rate for Payer: WMAP Medicaid	$23.26

EAPG 157: REPRODUCTIVE PATHOLOGY TESTS

Facility OP

$42.08

Service Code	EAPG 00157
Min. Negotiated Rate	$40.46
Max. Negotiated Rate	$42.08
Rate for Payer: Anthem Medicaid	$40.46
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$40.46
Rate for Payer: Dean Health Medicaid	$40.46
Rate for Payer: Independent Care Health Plan Medicaid	$40.46
Rate for Payer: Managed Health Services Medicaid	$42.08
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$40.46
Rate for Payer: United Healthcare Medicaid	$40.46
Rate for Payer: WMAP Medicaid	$40.46

EAPG 158: PATHOLOGY CONSULTATION AND INTERPRETATION

Facility OP

$36.10

Service Code	EAPG 00158
Min. Negotiated Rate	$34.71
Max. Negotiated Rate	$36.10
Rate for Payer: Anthem Medicaid	$34.71
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$34.71
Rate for Payer: Dean Health Medicaid	$34.71
Rate for Payer: Independent Care Health Plan Medicaid	$34.71
Rate for Payer: Managed Health Services Medicaid	$36.10
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$34.71
Rate for Payer: United Healthcare Medicaid	$34.71
Rate for Payer: WMAP Medicaid	$34.71

EAPG 159: MINOR UROLOGY SERVICES

Facility OP

$37.21

Service Code	EAPG 00159
Min. Negotiated Rate	$35.78
Max. Negotiated Rate	$37.21
Rate for Payer: Anthem Medicaid	$35.78
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$35.78
Rate for Payer: Dean Health Medicaid	$35.78
Rate for Payer: Independent Care Health Plan Medicaid	$35.78
Rate for Payer: Managed Health Services Medicaid	$37.21
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$35.78
Rate for Payer: United Healthcare Medicaid	$35.78
Rate for Payer: WMAP Medicaid	$35.78

EAPG 161: URINARY STUDIES AND PROCEDURES

Facility OP

$327.79

Service Code	EAPG 00161
Min. Negotiated Rate	$167.66
Max. Negotiated Rate	$327.79
Rate for Payer: Anthem Medicaid	$167.66
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$327.79
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$167.66
Rate for Payer: Dean Health Medicaid	$167.66
Rate for Payer: Independent Care Health Plan Medicaid	$167.66
Rate for Payer: Managed Health Services Medicaid	$174.37
Rate for Payer: Molina Healthcare Medicaid	$327.79
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$167.66
Rate for Payer: United Healthcare Medicaid	$167.66
Rate for Payer: WMAP Medicaid	$167.66

EAPG 166: LEVEL I URETHRAL PROCEDURES

Facility OP

$1,238.05

Service Code	EAPG 00166
Min. Negotiated Rate	$1,156.03
Max. Negotiated Rate	$1,238.05
Rate for Payer: Anthem Medicaid	$1,190.43
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,156.03
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,190.43
Rate for Payer: Dean Health Medicaid	$1,190.43
Rate for Payer: Independent Care Health Plan Medicaid	$1,190.43
Rate for Payer: Managed Health Services Medicaid	$1,238.05
Rate for Payer: Molina Healthcare Medicaid	$1,156.03
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,190.43
Rate for Payer: United Healthcare Medicaid	$1,190.43
Rate for Payer: WMAP Medicaid	$1,190.43

EAPG 167: LEVEL II URETHRAL PROCEDURES

Facility OP

$3,761.77

Service Code	EAPG 00167
Min. Negotiated Rate	$2,375.53
Max. Negotiated Rate	$3,761.77
Rate for Payer: Anthem Medicaid	$2,375.53
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$3,761.77
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,375.53
Rate for Payer: Dean Health Medicaid	$2,375.53
Rate for Payer: Independent Care Health Plan Medicaid	$2,375.53
Rate for Payer: Managed Health Services Medicaid	$2,470.55
Rate for Payer: Molina Healthcare Medicaid	$3,761.77
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,375.53
Rate for Payer: United Healthcare Medicaid	$2,375.53
Rate for Payer: WMAP Medicaid	$2,375.53

EAPG 168: DIALYSIS PROCEDURES

Facility OP

$749.71

Service Code	EAPG 00168
Min. Negotiated Rate	$322.88
Max. Negotiated Rate	$749.71
Rate for Payer: Anthem Medicaid	$322.88
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$749.71
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$322.88
Rate for Payer: Dean Health Medicaid	$322.88
Rate for Payer: Independent Care Health Plan Medicaid	$322.88
Rate for Payer: Managed Health Services Medicaid	$335.80
Rate for Payer: Molina Healthcare Medicaid	$749.71
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$322.88
Rate for Payer: United Healthcare Medicaid	$322.88
Rate for Payer: WMAP Medicaid	$322.88

EAPG 16: SIMPLE WOUND REPAIR AND TREATMENT

Facility OP

$78.76

Service Code	EAPG 00016
Min. Negotiated Rate	$75.73
Max. Negotiated Rate	$78.76
Rate for Payer: Anthem Medicaid	$75.73
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$75.73
Rate for Payer: Dean Health Medicaid	$75.73
Rate for Payer: Independent Care Health Plan Medicaid	$75.73
Rate for Payer: Managed Health Services Medicaid	$78.76
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$75.73
Rate for Payer: United Healthcare Medicaid	$75.73
Rate for Payer: WMAP Medicaid	$75.73

EAPG 170: LEVEL I KIDNEY AND URETERAL PROCEDURES

Facility OP

$632.70

Service Code	EAPG 00170
Min. Negotiated Rate	$608.37
Max. Negotiated Rate	$632.70
Rate for Payer: Anthem Medicaid	$608.37
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$608.37
Rate for Payer: Dean Health Medicaid	$608.37
Rate for Payer: Independent Care Health Plan Medicaid	$608.37
Rate for Payer: Managed Health Services Medicaid	$632.70
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$608.37
Rate for Payer: United Healthcare Medicaid	$608.37
Rate for Payer: WMAP Medicaid	$608.37

EAPG 171: LEVEL II KIDNEY AND URETERAL PROCEDURES

Facility OP

$1,251.04

Service Code	EAPG 00171
Min. Negotiated Rate	$1,202.92
Max. Negotiated Rate	$1,251.04
Rate for Payer: Anthem Medicaid	$1,202.92
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,202.92
Rate for Payer: Dean Health Medicaid	$1,202.92
Rate for Payer: Independent Care Health Plan Medicaid	$1,202.92
Rate for Payer: Managed Health Services Medicaid	$1,251.04
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,202.92
Rate for Payer: United Healthcare Medicaid	$1,202.92
Rate for Payer: WMAP Medicaid	$1,202.92

EAPG 172: LEVEL III KIDNEY AND URETERAL PROCEDURES

Facility OP

$2,944.46

Service Code	EAPG 00172
Min. Negotiated Rate	$2,831.21
Max. Negotiated Rate	$2,944.46
Rate for Payer: Anthem Medicaid	$2,831.21
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,831.21
Rate for Payer: Dean Health Medicaid	$2,831.21
Rate for Payer: Independent Care Health Plan Medicaid	$2,831.21
Rate for Payer: Managed Health Services Medicaid	$2,944.46
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,831.21
Rate for Payer: United Healthcare Medicaid	$2,831.21
Rate for Payer: WMAP Medicaid	$2,831.21

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