Beloit Memorial Hospital

All Charges

Charge

Type

Price

EAPG 3011: BONE CONDUCTION HEARING DEVICE IMPLANTATION

Facility OP

$3,616.25

Service Code	EAPG 03011
Min. Negotiated Rate	$3,477.16
Max. Negotiated Rate	$3,616.25
Rate for Payer: Anthem Medicaid	$3,477.16
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$3,477.16
Rate for Payer: Dean Health Medicaid	$3,477.16
Rate for Payer: Independent Care Health Plan Medicaid	$3,477.16
Rate for Payer: Managed Health Services Medicaid	$3,616.25
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$3,477.16
Rate for Payer: United Healthcare Medicaid	$3,477.16
Rate for Payer: WMAP Medicaid	$3,477.16

EAPG 301: COMPUTED TOMOGRAPHY- OTHER

Facility OP

$111.56

Service Code	EAPG 00301
Min. Negotiated Rate	$107.27
Max. Negotiated Rate	$111.56
Rate for Payer: Anthem Medicaid	$107.27
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$109.74
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$107.27
Rate for Payer: Dean Health Medicaid	$107.27
Rate for Payer: Independent Care Health Plan Medicaid	$107.27
Rate for Payer: Managed Health Services Medicaid	$111.56
Rate for Payer: Molina Healthcare Medicaid	$109.74
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$107.27
Rate for Payer: United Healthcare Medicaid	$107.27
Rate for Payer: WMAP Medicaid	$107.27

EAPG 302: COMPUTED TOMOGRAPHIC ANGIOGRAPHY

Facility OP

$248.00

Service Code	EAPG 00302
Min. Negotiated Rate	$154.34
Max. Negotiated Rate	$248.00
Rate for Payer: Anthem Medicaid	$154.34
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$248.00
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$154.34
Rate for Payer: Dean Health Medicaid	$154.34
Rate for Payer: Independent Care Health Plan Medicaid	$154.34
Rate for Payer: Managed Health Services Medicaid	$160.51
Rate for Payer: Molina Healthcare Medicaid	$248.00
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$154.34
Rate for Payer: United Healthcare Medicaid	$154.34
Rate for Payer: WMAP Medicaid	$154.34

EAPG 3030: SPINAL IMPLANTATION OF DRUG INFUSION DEVICE

Facility OP

$5,157.53

Service Code	EAPG 03030
Min. Negotiated Rate	$4,959.16
Max. Negotiated Rate	$5,157.53
Rate for Payer: Anthem Medicaid	$4,959.16
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$4,959.16
Rate for Payer: Dean Health Medicaid	$4,959.16
Rate for Payer: Independent Care Health Plan Medicaid	$4,959.16
Rate for Payer: Managed Health Services Medicaid	$5,157.53
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$4,959.16
Rate for Payer: United Healthcare Medicaid	$4,959.16
Rate for Payer: WMAP Medicaid	$4,959.16

EAPG 3033: INGUINAL, FEMORAL AND UMBILICAL HERNIA REPAIR

Facility OP

$1,522.68

Service Code	EAPG 03033
Min. Negotiated Rate	$1,464.12
Max. Negotiated Rate	$1,522.68
Rate for Payer: Anthem Medicaid	$1,464.12
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,464.12
Rate for Payer: Dean Health Medicaid	$1,464.12
Rate for Payer: Independent Care Health Plan Medicaid	$1,464.12
Rate for Payer: Managed Health Services Medicaid	$1,522.68
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,464.12
Rate for Payer: United Healthcare Medicaid	$1,464.12
Rate for Payer: WMAP Medicaid	$1,464.12

EAPG 3035: ABDOMINAL HERNIA REPAIR

Facility OP

$1,864.38

Service Code	EAPG 03035
Min. Negotiated Rate	$1,792.67
Max. Negotiated Rate	$1,864.38
Rate for Payer: Anthem Medicaid	$1,792.67
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,792.67
Rate for Payer: Dean Health Medicaid	$1,792.67
Rate for Payer: Independent Care Health Plan Medicaid	$1,792.67
Rate for Payer: Managed Health Services Medicaid	$1,864.38
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,792.67
Rate for Payer: United Healthcare Medicaid	$1,792.67
Rate for Payer: WMAP Medicaid	$1,792.67

EAPG 304: MINOR SPECIMEN COLLECTION SERVICES

Facility OP

$1.16

Service Code	EAPG 00304
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$1.16
Rate for Payer: Anthem Medicaid	$1.12
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1.12
Rate for Payer: Dean Health Medicaid	$1.12
Rate for Payer: Independent Care Health Plan Medicaid	$1.12
Rate for Payer: Managed Health Services Medicaid	$1.16
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1.12
Rate for Payer: United Healthcare Medicaid	$1.12
Rate for Payer: WMAP Medicaid	$1.12

EAPG 3050: OTHER TRANSPLANT PROCEDURES

Facility OP

$2,106.51

Service Code	EAPG 03050
Min. Negotiated Rate	$2,025.49
Max. Negotiated Rate	$2,106.51
Rate for Payer: Anthem Medicaid	$2,025.49
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,025.49
Rate for Payer: Dean Health Medicaid	$2,025.49
Rate for Payer: Independent Care Health Plan Medicaid	$2,025.49
Rate for Payer: Managed Health Services Medicaid	$2,106.51
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,025.49
Rate for Payer: United Healthcare Medicaid	$2,025.49
Rate for Payer: WMAP Medicaid	$2,025.49

EAPG 3051: HEART AND/OR LUNG TRANSPLANT

Facility OP

$5,440.02

Service Code	EAPG 03051
Min. Negotiated Rate	$5,230.79
Max. Negotiated Rate	$5,440.02
Rate for Payer: Anthem Medicaid	$5,230.79
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$5,230.79
Rate for Payer: Dean Health Medicaid	$5,230.79
Rate for Payer: Independent Care Health Plan Medicaid	$5,230.79
Rate for Payer: Managed Health Services Medicaid	$5,440.02
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$5,230.79
Rate for Payer: United Healthcare Medicaid	$5,230.79
Rate for Payer: WMAP Medicaid	$5,230.79

EAPG 3052: KIDNEY TRANSPLANT

Facility OP

$3,730.29

Service Code	EAPG 03052
Min. Negotiated Rate	$3,586.82
Max. Negotiated Rate	$3,730.29
Rate for Payer: Anthem Medicaid	$3,586.82
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$3,586.82
Rate for Payer: Dean Health Medicaid	$3,586.82
Rate for Payer: Independent Care Health Plan Medicaid	$3,586.82
Rate for Payer: Managed Health Services Medicaid	$3,730.29
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$3,586.82
Rate for Payer: United Healthcare Medicaid	$3,586.82
Rate for Payer: WMAP Medicaid	$3,586.82

EAPG 305: LEVEL I SURGICAL PATHOLOGY TESTS

Facility OP

$13.93

Service Code	EAPG 00305
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$13.93
Rate for Payer: Anthem Medicaid	$13.39
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$13.39
Rate for Payer: Dean Health Medicaid	$13.39
Rate for Payer: Independent Care Health Plan Medicaid	$13.39
Rate for Payer: Managed Health Services Medicaid	$13.93
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$13.39
Rate for Payer: United Healthcare Medicaid	$13.39
Rate for Payer: WMAP Medicaid	$13.39

EAPG 3060: VENTRICULAR ASSIST DEVICE PROCEDURES

Facility OP

$12,750.02

Service Code	EAPG 03060
Min. Negotiated Rate	$12,259.63
Max. Negotiated Rate	$12,750.02
Rate for Payer: Anthem Medicaid	$12,259.63
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$12,259.63
Rate for Payer: Dean Health Medicaid	$12,259.63
Rate for Payer: Independent Care Health Plan Medicaid	$12,259.63
Rate for Payer: Managed Health Services Medicaid	$12,750.02
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$12,259.63
Rate for Payer: United Healthcare Medicaid	$12,259.63
Rate for Payer: WMAP Medicaid	$12,259.63

EAPG 306: LEVEL II SURGICAL PATHOLOGY TESTS

Facility OP

$56.86

Service Code	EAPG 00306
Min. Negotiated Rate	$54.67
Max. Negotiated Rate	$56.86
Rate for Payer: Anthem Medicaid	$54.67
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$54.67
Rate for Payer: Dean Health Medicaid	$54.67
Rate for Payer: Independent Care Health Plan Medicaid	$54.67
Rate for Payer: Managed Health Services Medicaid	$56.86
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$54.67
Rate for Payer: United Healthcare Medicaid	$54.67
Rate for Payer: WMAP Medicaid	$54.67

EAPG 3070: EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) PROCEDURES

Facility OP

$2,999.93

Service Code	EAPG 03070
Min. Negotiated Rate	$2,884.55
Max. Negotiated Rate	$2,999.93
Rate for Payer: Anthem Medicaid	$2,884.55
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,884.55
Rate for Payer: Dean Health Medicaid	$2,884.55
Rate for Payer: Independent Care Health Plan Medicaid	$2,884.55
Rate for Payer: Managed Health Services Medicaid	$2,999.93
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,884.55
Rate for Payer: United Healthcare Medicaid	$2,884.55
Rate for Payer: WMAP Medicaid	$2,884.55

EAPG 307: INSERTION OR REMOVAL OF DRUG DELIVERY DEVICE

Facility OP

$138.35

Service Code	EAPG 00307
Min. Negotiated Rate	$133.03
Max. Negotiated Rate	$138.35
Rate for Payer: Anthem Medicaid	$133.03
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$133.03
Rate for Payer: Dean Health Medicaid	$133.03
Rate for Payer: Independent Care Health Plan Medicaid	$133.03
Rate for Payer: Managed Health Services Medicaid	$138.35
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$133.03
Rate for Payer: United Healthcare Medicaid	$133.03
Rate for Payer: WMAP Medicaid	$133.03

EAPG 308: LEVEL III PATHOLOGY TESTS

Facility OP

$63.87

Service Code	EAPG 00308
Min. Negotiated Rate	$61.41
Max. Negotiated Rate	$63.87
Rate for Payer: Anthem Medicaid	$61.41
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$61.41
Rate for Payer: Dean Health Medicaid	$61.41
Rate for Payer: Independent Care Health Plan Medicaid	$61.41
Rate for Payer: Managed Health Services Medicaid	$63.87
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$61.41
Rate for Payer: United Healthcare Medicaid	$61.41
Rate for Payer: WMAP Medicaid	$61.41

EAPG 309: ADAPTIVE BEHAVIORAL HEALTH TREATMENT SERVICES

Facility OP

$18.78

Service Code	EAPG 00309
Min. Negotiated Rate	$18.06
Max. Negotiated Rate	$18.78
Rate for Payer: Anthem Medicaid	$18.06
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$18.06
Rate for Payer: Dean Health Medicaid	$18.06
Rate for Payer: Independent Care Health Plan Medicaid	$18.06
Rate for Payer: Managed Health Services Medicaid	$18.78
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$18.06
Rate for Payer: United Healthcare Medicaid	$18.06
Rate for Payer: WMAP Medicaid	$18.06

EAPG 310: DEVELOPMENTAL AND NEUROPSYCHOLOGICAL TESTING

Facility OP

$635.03

Service Code	EAPG 00310
Min. Negotiated Rate	$242.61
Max. Negotiated Rate	$635.03
Rate for Payer: Anthem Medicaid	$242.61
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$635.03
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$242.61
Rate for Payer: Dean Health Medicaid	$242.61
Rate for Payer: Independent Care Health Plan Medicaid	$242.61
Rate for Payer: Managed Health Services Medicaid	$252.31
Rate for Payer: Molina Healthcare Medicaid	$635.03
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$242.61
Rate for Payer: United Healthcare Medicaid	$242.61
Rate for Payer: WMAP Medicaid	$242.61

EAPG 312: BEHAVIORAL AND SUBSTANCE ABUSE PARTIAL HOSPITALIZATION PROGRAM

Facility OP

$305.73

Service Code	EAPG 00312
Min. Negotiated Rate	$147.73
Max. Negotiated Rate	$305.73
Rate for Payer: Anthem Medicaid	$147.73
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$305.73
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$147.73
Rate for Payer: Dean Health Medicaid	$147.73
Rate for Payer: Independent Care Health Plan Medicaid	$147.73
Rate for Payer: Managed Health Services Medicaid	$153.64
Rate for Payer: Molina Healthcare Medicaid	$305.73
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$147.73
Rate for Payer: United Healthcare Medicaid	$147.73
Rate for Payer: WMAP Medicaid	$147.73

EAPG 315: COUNSELING OR INDIVIDUAL BRIEF PSYCHOTHERAPY

Facility OP

$116.98

Service Code	EAPG 00315
Min. Negotiated Rate	$53.74
Max. Negotiated Rate	$116.98
Rate for Payer: Anthem Medicaid	$53.74
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$116.98
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$53.74
Rate for Payer: Dean Health Medicaid	$53.74
Rate for Payer: Independent Care Health Plan Medicaid	$53.74
Rate for Payer: Managed Health Services Medicaid	$55.89
Rate for Payer: Molina Healthcare Medicaid	$116.98
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$53.74
Rate for Payer: United Healthcare Medicaid	$53.74
Rate for Payer: WMAP Medicaid	$53.74

EAPG 316: INDIVIDUAL COMPREHENSIVE PSYCHOTHERAPY

Facility OP

$117.17

Service Code	EAPG 00316
Min. Negotiated Rate	$64.21
Max. Negotiated Rate	$117.17
Rate for Payer: Anthem Medicaid	$64.21
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$117.17
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$64.21
Rate for Payer: Dean Health Medicaid	$64.21
Rate for Payer: Independent Care Health Plan Medicaid	$64.21
Rate for Payer: Managed Health Services Medicaid	$66.78
Rate for Payer: Molina Healthcare Medicaid	$117.17
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$64.21
Rate for Payer: United Healthcare Medicaid	$64.21
Rate for Payer: WMAP Medicaid	$64.21

EAPG 317: FAMILY PSYCHOTHERAPY

Facility OP

$123.53

Service Code	EAPG 00317
Min. Negotiated Rate	$70.03
Max. Negotiated Rate	$123.53
Rate for Payer: Anthem Medicaid	$70.03
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$123.53
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$70.03
Rate for Payer: Dean Health Medicaid	$70.03
Rate for Payer: Independent Care Health Plan Medicaid	$70.03
Rate for Payer: Managed Health Services Medicaid	$72.83
Rate for Payer: Molina Healthcare Medicaid	$123.53
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$70.03
Rate for Payer: United Healthcare Medicaid	$70.03
Rate for Payer: WMAP Medicaid	$70.03

EAPG 318: GROUP PSYCHOTHERAPY

Facility OP

$166.15

Service Code	EAPG 00318
Min. Negotiated Rate	$97.88
Max. Negotiated Rate	$166.15
Rate for Payer: Anthem Medicaid	$97.88
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$166.15
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$97.88
Rate for Payer: Dean Health Medicaid	$97.88
Rate for Payer: Independent Care Health Plan Medicaid	$97.88
Rate for Payer: Managed Health Services Medicaid	$101.80
Rate for Payer: Molina Healthcare Medicaid	$166.15
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$97.88
Rate for Payer: United Healthcare Medicaid	$97.88
Rate for Payer: WMAP Medicaid	$97.88

EAPG 319: ACTIVITY THERAPY

Facility OP

$66.73

Service Code	EAPG 00319
Min. Negotiated Rate	$64.03
Max. Negotiated Rate	$66.73
Rate for Payer: Anthem Medicaid	$64.03
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$66.73
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$64.03
Rate for Payer: Dean Health Medicaid	$64.03
Rate for Payer: Independent Care Health Plan Medicaid	$64.03
Rate for Payer: Managed Health Services Medicaid	$66.59
Rate for Payer: Molina Healthcare Medicaid	$66.73
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$64.03
Rate for Payer: United Healthcare Medicaid	$64.03
Rate for Payer: WMAP Medicaid	$64.03

EAPG 320: BEHAVIORAL HEALTH - CASE MANAGEMENT AND TREATMENT PLAN DEVELOPMENT

Facility OP

$130.92

Service Code	EAPG 00320
Min. Negotiated Rate	$41.15
Max. Negotiated Rate	$130.92
Rate for Payer: Anthem Medicaid	$41.15
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$130.92
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$41.15
Rate for Payer: Dean Health Medicaid	$41.15
Rate for Payer: Independent Care Health Plan Medicaid	$41.15
Rate for Payer: Managed Health Services Medicaid	$42.80
Rate for Payer: Molina Healthcare Medicaid	$130.92
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$41.15
Rate for Payer: United Healthcare Medicaid	$41.15
Rate for Payer: WMAP Medicaid	$41.15

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