Beloit Memorial Hospital

All Charges

Charge

Type

Price

EAPG 26: LEVEL I KNEE AND LOWER LEG PROCEDURES

Facility OP

$1,351.79

Service Code	EAPG 00026
Min. Negotiated Rate	$1,299.80
Max. Negotiated Rate	$1,351.79
Rate for Payer: Anthem Medicaid	$1,299.80
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,299.80
Rate for Payer: Dean Health Medicaid	$1,299.80
Rate for Payer: Independent Care Health Plan Medicaid	$1,299.80
Rate for Payer: Managed Health Services Medicaid	$1,351.79
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,299.80
Rate for Payer: United Healthcare Medicaid	$1,299.80
Rate for Payer: WMAP Medicaid	$1,299.80

EAPG 270: OCCUPATIONAL THERAPY

Facility OP

$424.86

Service Code	EAPG 00270
Min. Negotiated Rate	$86.26
Max. Negotiated Rate	$424.86
Rate for Payer: Anthem Medicaid	$86.26
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$424.86
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$86.26
Rate for Payer: Dean Health Medicaid	$86.26
Rate for Payer: Independent Care Health Plan Medicaid	$86.26
Rate for Payer: Managed Health Services Medicaid	$89.71
Rate for Payer: Molina Healthcare Medicaid	$424.86
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$86.26
Rate for Payer: United Healthcare Medicaid	$86.26
Rate for Payer: WMAP Medicaid	$86.26

EAPG 271: PHYSICAL THERAPY

Facility OP

$267.08

Service Code	EAPG 00271
Min. Negotiated Rate	$78.73
Max. Negotiated Rate	$267.08
Rate for Payer: Anthem Medicaid	$78.73
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$267.08
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$78.73
Rate for Payer: Dean Health Medicaid	$78.73
Rate for Payer: Independent Care Health Plan Medicaid	$78.73
Rate for Payer: Managed Health Services Medicaid	$81.88
Rate for Payer: Molina Healthcare Medicaid	$267.08
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$78.73
Rate for Payer: United Healthcare Medicaid	$78.73
Rate for Payer: WMAP Medicaid	$78.73

EAPG 272: SPEECH THERAPY AND EVALUATION

Facility OP

$197.41

Service Code	EAPG 00272
Min. Negotiated Rate	$94.65
Max. Negotiated Rate	$197.41
Rate for Payer: Anthem Medicaid	$94.65
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$197.41
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$94.65
Rate for Payer: Dean Health Medicaid	$94.65
Rate for Payer: Independent Care Health Plan Medicaid	$94.65
Rate for Payer: Managed Health Services Medicaid	$98.44
Rate for Payer: Molina Healthcare Medicaid	$197.41
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$94.65
Rate for Payer: United Healthcare Medicaid	$94.65
Rate for Payer: WMAP Medicaid	$94.65

EAPG 276: PROCEDURES FOR REVISION OR REMOVAL OF NEUROSTIMULATOR DEVICES

Facility OP

$1,442.03

Service Code	EAPG 00276
Min. Negotiated Rate	$1,386.57
Max. Negotiated Rate	$1,442.03
Rate for Payer: Anthem Medicaid	$1,386.57
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,386.57
Rate for Payer: Dean Health Medicaid	$1,386.57
Rate for Payer: Independent Care Health Plan Medicaid	$1,386.57
Rate for Payer: Managed Health Services Medicaid	$1,442.03
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,386.57
Rate for Payer: United Healthcare Medicaid	$1,386.57
Rate for Payer: WMAP Medicaid	$1,386.57

EAPG 277: LEVEL I VASCULAR RADIOLOGICAL PROCEDURES

Facility OP

$464.16

Service Code	EAPG 00277
Min. Negotiated Rate	$446.31
Max. Negotiated Rate	$464.16
Rate for Payer: Anthem Medicaid	$446.31
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$446.31
Rate for Payer: Dean Health Medicaid	$446.31
Rate for Payer: Independent Care Health Plan Medicaid	$446.31
Rate for Payer: Managed Health Services Medicaid	$464.16
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$446.31
Rate for Payer: United Healthcare Medicaid	$446.31
Rate for Payer: WMAP Medicaid	$446.31

EAPG 278: INJECTION(S) FOR RADIOLOGICAL IMAGING

Facility OP

$141.54

Service Code	EAPG 00278
Min. Negotiated Rate	$136.10
Max. Negotiated Rate	$141.54
Rate for Payer: Anthem Medicaid	$136.10
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$136.10
Rate for Payer: Dean Health Medicaid	$136.10
Rate for Payer: Independent Care Health Plan Medicaid	$136.10
Rate for Payer: Managed Health Services Medicaid	$141.54
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$136.10
Rate for Payer: United Healthcare Medicaid	$136.10
Rate for Payer: WMAP Medicaid	$136.10

EAPG 279: LEVEL II VASCULAR RADIOLOGICAL PROCEDURES

Facility OP

$731.47

Service Code	EAPG 00279
Min. Negotiated Rate	$703.34
Max. Negotiated Rate	$731.47
Rate for Payer: Anthem Medicaid	$703.34
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$703.34
Rate for Payer: Dean Health Medicaid	$703.34
Rate for Payer: Independent Care Health Plan Medicaid	$703.34
Rate for Payer: Managed Health Services Medicaid	$731.47
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$703.34
Rate for Payer: United Healthcare Medicaid	$703.34
Rate for Payer: WMAP Medicaid	$703.34

EAPG 27: LEVEL I HIP AND FEMUR PROCEDURES

Facility OP

$1,796.38

Service Code	EAPG 00027
Min. Negotiated Rate	$1,727.29
Max. Negotiated Rate	$1,796.38
Rate for Payer: Anthem Medicaid	$1,727.29
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,727.29
Rate for Payer: Dean Health Medicaid	$1,727.29
Rate for Payer: Independent Care Health Plan Medicaid	$1,727.29
Rate for Payer: Managed Health Services Medicaid	$1,796.38
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,727.29
Rate for Payer: United Healthcare Medicaid	$1,727.29
Rate for Payer: WMAP Medicaid	$1,727.29

EAPG 280: LEVEL III VASCULAR RADIOLOGICAL PROCEDURES

Facility OP

$2,114.74

Service Code	EAPG 00280
Min. Negotiated Rate	$1,836.55
Max. Negotiated Rate	$2,114.74
Rate for Payer: Anthem Medicaid	$1,836.55
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,114.74
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,836.55
Rate for Payer: Dean Health Medicaid	$1,836.55
Rate for Payer: Independent Care Health Plan Medicaid	$1,836.55
Rate for Payer: Managed Health Services Medicaid	$1,910.01
Rate for Payer: Molina Healthcare Medicaid	$2,114.74
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,836.55
Rate for Payer: United Healthcare Medicaid	$1,836.55
Rate for Payer: WMAP Medicaid	$1,836.55

EAPG 282: MAGNETIC RESONANCE ANGIOGRAPHY

Facility OP

$311.40

Service Code	EAPG 00282
Min. Negotiated Rate	$204.30
Max. Negotiated Rate	$311.40
Rate for Payer: Anthem Medicaid	$204.30
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$311.40
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$204.30
Rate for Payer: Dean Health Medicaid	$204.30
Rate for Payer: Independent Care Health Plan Medicaid	$204.30
Rate for Payer: Managed Health Services Medicaid	$212.47
Rate for Payer: Molina Healthcare Medicaid	$311.40
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$204.30
Rate for Payer: United Healthcare Medicaid	$204.30
Rate for Payer: WMAP Medicaid	$204.30

EAPG 284: MYELOGRAPHY AND DISCOGRAPHY IMAGING PROCEDURES

Facility OP

$478.62

Service Code	EAPG 00284
Min. Negotiated Rate	$232.33
Max. Negotiated Rate	$478.62
Rate for Payer: Anthem Medicaid	$232.33
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$478.62
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$232.33
Rate for Payer: Dean Health Medicaid	$232.33
Rate for Payer: Independent Care Health Plan Medicaid	$232.33
Rate for Payer: Managed Health Services Medicaid	$241.62
Rate for Payer: Molina Healthcare Medicaid	$478.62
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$232.33
Rate for Payer: United Healthcare Medicaid	$232.33
Rate for Payer: WMAP Medicaid	$232.33

EAPG 286: MAMMOGRAPHY AND OTHER RELATED PROCEDURES

Facility OP

$54.60

Service Code	EAPG 00286
Min. Negotiated Rate	$19.82
Max. Negotiated Rate	$54.60
Rate for Payer: Anthem Medicaid	$19.82
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$54.60
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$19.82
Rate for Payer: Dean Health Medicaid	$19.82
Rate for Payer: Independent Care Health Plan Medicaid	$19.82
Rate for Payer: Managed Health Services Medicaid	$20.61
Rate for Payer: Molina Healthcare Medicaid	$54.60
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$19.82
Rate for Payer: United Healthcare Medicaid	$19.82
Rate for Payer: WMAP Medicaid	$19.82

EAPG 288: LEVEL I DIAGNOSTIC ULTRASOUND

Facility OP

$120.21

Service Code	EAPG 00288
Min. Negotiated Rate	$45.41
Max. Negotiated Rate	$120.21
Rate for Payer: Anthem Medicaid	$45.41
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$120.21
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$45.41
Rate for Payer: Dean Health Medicaid	$45.41
Rate for Payer: Independent Care Health Plan Medicaid	$45.41
Rate for Payer: Managed Health Services Medicaid	$47.23
Rate for Payer: Molina Healthcare Medicaid	$120.21
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$45.41
Rate for Payer: United Healthcare Medicaid	$45.41
Rate for Payer: WMAP Medicaid	$45.41

EAPG 289: LEVEL II DIAGNOSTIC ULTRASOUND

Facility OP

$158.22

Service Code	EAPG 00289
Min. Negotiated Rate	$69.96
Max. Negotiated Rate	$158.22
Rate for Payer: Anthem Medicaid	$69.96
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$158.22
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$69.96
Rate for Payer: Dean Health Medicaid	$69.96
Rate for Payer: Independent Care Health Plan Medicaid	$69.96
Rate for Payer: Managed Health Services Medicaid	$72.76
Rate for Payer: Molina Healthcare Medicaid	$158.22
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$69.96
Rate for Payer: United Healthcare Medicaid	$69.96
Rate for Payer: WMAP Medicaid	$69.96

EAPG 28: LEVEL I SPINE PROCEDURES

Facility OP

$2,132.37

Service Code	EAPG 00028
Min. Negotiated Rate	$2,050.36
Max. Negotiated Rate	$2,132.37
Rate for Payer: Anthem Medicaid	$2,050.36
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,050.36
Rate for Payer: Dean Health Medicaid	$2,050.36
Rate for Payer: Independent Care Health Plan Medicaid	$2,050.36
Rate for Payer: Managed Health Services Medicaid	$2,132.37
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,050.36
Rate for Payer: United Healthcare Medicaid	$2,050.36
Rate for Payer: WMAP Medicaid	$2,050.36

EAPG 290: PET SCANS

Facility OP

$966.98

Service Code	EAPG 00290
Min. Negotiated Rate	$554.37
Max. Negotiated Rate	$966.98
Rate for Payer: Anthem Medicaid	$554.37
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$966.98
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$554.37
Rate for Payer: Dean Health Medicaid	$554.37
Rate for Payer: Independent Care Health Plan Medicaid	$554.37
Rate for Payer: Managed Health Services Medicaid	$576.54
Rate for Payer: Molina Healthcare Medicaid	$966.98
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$554.37
Rate for Payer: United Healthcare Medicaid	$554.37
Rate for Payer: WMAP Medicaid	$554.37

EAPG 291: BONE DENSITY AND RELATED PROCEDURES

Facility OP

$69.47

Service Code	EAPG 00291
Min. Negotiated Rate	$32.77
Max. Negotiated Rate	$69.47
Rate for Payer: Anthem Medicaid	$32.77
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$69.47
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$32.77
Rate for Payer: Dean Health Medicaid	$32.77
Rate for Payer: Independent Care Health Plan Medicaid	$32.77
Rate for Payer: Managed Health Services Medicaid	$34.08
Rate for Payer: Molina Healthcare Medicaid	$69.47
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$32.77
Rate for Payer: United Healthcare Medicaid	$32.77
Rate for Payer: WMAP Medicaid	$32.77

EAPG 293: MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST

Facility OP

$184.79

Service Code	EAPG 00293
Min. Negotiated Rate	$100.26
Max. Negotiated Rate	$184.79
Rate for Payer: Anthem Medicaid	$100.26
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$184.79
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$100.26
Rate for Payer: Dean Health Medicaid	$100.26
Rate for Payer: Independent Care Health Plan Medicaid	$100.26
Rate for Payer: Managed Health Services Medicaid	$104.27
Rate for Payer: Molina Healthcare Medicaid	$184.79
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$100.26
Rate for Payer: United Healthcare Medicaid	$100.26
Rate for Payer: WMAP Medicaid	$100.26

EAPG 295: MAGNETIC RESONANCE IMAGING WITH CONTRAST

Facility OP

$376.37

Service Code	EAPG 00295
Min. Negotiated Rate	$169.14
Max. Negotiated Rate	$376.37
Rate for Payer: Anthem Medicaid	$169.14
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$376.37
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$169.14
Rate for Payer: Dean Health Medicaid	$169.14
Rate for Payer: Independent Care Health Plan Medicaid	$169.14
Rate for Payer: Managed Health Services Medicaid	$175.91
Rate for Payer: Molina Healthcare Medicaid	$376.37
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$169.14
Rate for Payer: United Healthcare Medicaid	$169.14
Rate for Payer: WMAP Medicaid	$169.14

EAPG 297: MAGNETOCEPHALOGRAPHY

Facility OP

$1,005.37

Service Code	EAPG 00297
Min. Negotiated Rate	$306.75
Max. Negotiated Rate	$1,005.37
Rate for Payer: Anthem Medicaid	$966.70
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$306.75
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$966.70
Rate for Payer: Dean Health Medicaid	$966.70
Rate for Payer: Independent Care Health Plan Medicaid	$966.70
Rate for Payer: Managed Health Services Medicaid	$1,005.37
Rate for Payer: Molina Healthcare Medicaid	$306.75
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$966.70
Rate for Payer: United Healthcare Medicaid	$966.70
Rate for Payer: WMAP Medicaid	$966.70

EAPG 299: LEVEL I COMPUTED TOMOGRAPHY

Facility OP

$225.83

Service Code	EAPG 00299
Min. Negotiated Rate	$44.34
Max. Negotiated Rate	$225.83
Rate for Payer: Anthem Medicaid	$44.34
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$225.83
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$44.34
Rate for Payer: Dean Health Medicaid	$44.34
Rate for Payer: Independent Care Health Plan Medicaid	$44.34
Rate for Payer: Managed Health Services Medicaid	$46.11
Rate for Payer: Molina Healthcare Medicaid	$225.83
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$44.34
Rate for Payer: United Healthcare Medicaid	$44.34
Rate for Payer: WMAP Medicaid	$44.34

EAPG 29: LEVEL II SPINE PROCEDURES

Facility OP

$4,965.36

Service Code	EAPG 00029
Min. Negotiated Rate	$4,774.38
Max. Negotiated Rate	$4,965.36
Rate for Payer: Anthem Medicaid	$4,774.38
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$4,774.38
Rate for Payer: Dean Health Medicaid	$4,774.38
Rate for Payer: Independent Care Health Plan Medicaid	$4,774.38
Rate for Payer: Managed Health Services Medicaid	$4,965.36
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$4,774.38
Rate for Payer: United Healthcare Medicaid	$4,774.38
Rate for Payer: WMAP Medicaid	$4,774.38

EAPG 2: SUPERFICIAL NEEDLE BIOPSY AND ASPIRATION

Facility OP

$480.73

Service Code	EAPG 00002
Min. Negotiated Rate	$283.75
Max. Negotiated Rate	$480.73
Rate for Payer: Anthem Medicaid	$283.75
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$480.73
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$283.75
Rate for Payer: Dean Health Medicaid	$283.75
Rate for Payer: Independent Care Health Plan Medicaid	$283.75
Rate for Payer: Managed Health Services Medicaid	$295.10
Rate for Payer: Molina Healthcare Medicaid	$480.73
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$283.75
Rate for Payer: United Healthcare Medicaid	$283.75
Rate for Payer: WMAP Medicaid	$283.75

EAPG 300: LEVEL II COMPUTED TOMOGRAPHY

Facility OP

$248.24

Service Code	EAPG 00300
Min. Negotiated Rate	$126.32
Max. Negotiated Rate	$248.24
Rate for Payer: Anthem Medicaid	$126.32
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$248.24
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$126.32
Rate for Payer: Dean Health Medicaid	$126.32
Rate for Payer: Independent Care Health Plan Medicaid	$126.32
Rate for Payer: Managed Health Services Medicaid	$131.37
Rate for Payer: Molina Healthcare Medicaid	$248.24
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$126.32
Rate for Payer: United Healthcare Medicaid	$126.32
Rate for Payer: WMAP Medicaid	$126.32

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