Beloit Memorial Hospital

All Charges

Charge

Type

Price

EAPG 321: CRISIS INTERVENTION

Facility OP

$188.06

Service Code	EAPG 00321
Min. Negotiated Rate	$76.58
Max. Negotiated Rate	$188.06
Rate for Payer: Anthem Medicaid	$76.58
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$188.06
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$76.58
Rate for Payer: Dean Health Medicaid	$76.58
Rate for Payer: Independent Care Health Plan Medicaid	$76.58
Rate for Payer: Managed Health Services Medicaid	$79.64
Rate for Payer: Molina Healthcare Medicaid	$188.06
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$76.58
Rate for Payer: United Healthcare Medicaid	$76.58
Rate for Payer: WMAP Medicaid	$76.58

EAPG 322: MEDICATION ADMINISTRATION AND OBSERVATION

Facility OP

$111.06

Service Code	EAPG 00322
Min. Negotiated Rate	$18.03
Max. Negotiated Rate	$111.06
Rate for Payer: Anthem Medicaid	$18.03
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$111.06
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$18.03
Rate for Payer: Dean Health Medicaid	$18.03
Rate for Payer: Independent Care Health Plan Medicaid	$18.03
Rate for Payer: Managed Health Services Medicaid	$18.75
Rate for Payer: Molina Healthcare Medicaid	$111.06
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$18.03
Rate for Payer: United Healthcare Medicaid	$18.03
Rate for Payer: WMAP Medicaid	$18.03

EAPG 323: BEHAVIORAL HEALTH ASSESSMENT

Facility OP

$217.42

Service Code	EAPG 00323
Min. Negotiated Rate	$103.19
Max. Negotiated Rate	$217.42
Rate for Payer: Anthem Medicaid	$103.19
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$217.42
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$103.19
Rate for Payer: Dean Health Medicaid	$103.19
Rate for Payer: Independent Care Health Plan Medicaid	$103.19
Rate for Payer: Managed Health Services Medicaid	$107.32
Rate for Payer: Molina Healthcare Medicaid	$217.42
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$103.19
Rate for Payer: United Healthcare Medicaid	$103.19
Rate for Payer: WMAP Medicaid	$103.19

EAPG 324: SCREENING FOR BEHAVIORAL CHANGE OR RISK ASSESSMENT

Facility OP

$97.26

Service Code	EAPG 00324
Min. Negotiated Rate	$9.59
Max. Negotiated Rate	$97.26
Rate for Payer: Anthem Medicaid	$9.59
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$97.26
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$9.59
Rate for Payer: Dean Health Medicaid	$9.59
Rate for Payer: Independent Care Health Plan Medicaid	$9.59
Rate for Payer: Managed Health Services Medicaid	$9.97
Rate for Payer: Molina Healthcare Medicaid	$97.26
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$9.59
Rate for Payer: United Healthcare Medicaid	$9.59
Rate for Payer: WMAP Medicaid	$9.59

EAPG 325: PREVENTION COUNSELING

Facility OP

$31.21

Service Code	EAPG 00325
Min. Negotiated Rate	$30.01
Max. Negotiated Rate	$31.21
Rate for Payer: Anthem Medicaid	$30.01
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$30.01
Rate for Payer: Dean Health Medicaid	$30.01
Rate for Payer: Independent Care Health Plan Medicaid	$30.01
Rate for Payer: Managed Health Services Medicaid	$31.21
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$30.01
Rate for Payer: United Healthcare Medicaid	$30.01
Rate for Payer: WMAP Medicaid	$30.01

EAPG 327: INTENSIVE OUTPATIENT PSYCHIATRIC TREATMENT

Facility OP

$471.04

Service Code	EAPG 00327
Min. Negotiated Rate	$144.09
Max. Negotiated Rate	$471.04
Rate for Payer: Anthem Medicaid	$144.09
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$471.04
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$144.09
Rate for Payer: Dean Health Medicaid	$144.09
Rate for Payer: Independent Care Health Plan Medicaid	$144.09
Rate for Payer: Managed Health Services Medicaid	$149.85
Rate for Payer: Molina Healthcare Medicaid	$471.04
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$144.09
Rate for Payer: United Healthcare Medicaid	$144.09
Rate for Payer: WMAP Medicaid	$144.09

EAPG 328: DAY REHABILITATION, HALF DAY

Facility OP

$231.36

Service Code	EAPG 00328
Min. Negotiated Rate	$130.39
Max. Negotiated Rate	$231.36
Rate for Payer: Anthem Medicaid	$130.39
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$231.36
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$130.39
Rate for Payer: Dean Health Medicaid	$130.39
Rate for Payer: Independent Care Health Plan Medicaid	$130.39
Rate for Payer: Managed Health Services Medicaid	$135.61
Rate for Payer: Molina Healthcare Medicaid	$231.36
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$130.39
Rate for Payer: United Healthcare Medicaid	$130.39
Rate for Payer: WMAP Medicaid	$130.39

EAPG 329: DAY REHABILITATION, FULL DAY

Facility OP

$382.98

Service Code	EAPG 00329
Min. Negotiated Rate	$194.27
Max. Negotiated Rate	$382.98
Rate for Payer: Anthem Medicaid	$194.27
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$382.98
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$194.27
Rate for Payer: Dean Health Medicaid	$194.27
Rate for Payer: Independent Care Health Plan Medicaid	$194.27
Rate for Payer: Managed Health Services Medicaid	$202.04
Rate for Payer: Molina Healthcare Medicaid	$382.98
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$194.27
Rate for Payer: United Healthcare Medicaid	$194.27
Rate for Payer: WMAP Medicaid	$194.27

EAPG 331: LEVEL I DIAGNOSTIC NUCLEAR MEDICINE

Facility OP

$332.59

Service Code	EAPG 00331
Min. Negotiated Rate	$152.70
Max. Negotiated Rate	$332.59
Rate for Payer: Anthem Medicaid	$152.70
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$332.59
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$152.70
Rate for Payer: Dean Health Medicaid	$152.70
Rate for Payer: Independent Care Health Plan Medicaid	$152.70
Rate for Payer: Managed Health Services Medicaid	$158.81
Rate for Payer: Molina Healthcare Medicaid	$332.59
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$152.70
Rate for Payer: United Healthcare Medicaid	$152.70
Rate for Payer: WMAP Medicaid	$152.70

EAPG 332: LEVEL II DIAGNOSTIC NUCLEAR MEDICINE

Facility OP

$728.18

Service Code	EAPG 00332
Min. Negotiated Rate	$365.71
Max. Negotiated Rate	$728.18
Rate for Payer: Anthem Medicaid	$365.71
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$728.18
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$365.71
Rate for Payer: Dean Health Medicaid	$365.71
Rate for Payer: Independent Care Health Plan Medicaid	$365.71
Rate for Payer: Managed Health Services Medicaid	$380.34
Rate for Payer: Molina Healthcare Medicaid	$728.18
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$365.71
Rate for Payer: United Healthcare Medicaid	$365.71
Rate for Payer: WMAP Medicaid	$365.71

EAPG 333: BEHAVIORAL HEALTH RESIDENTIAL TREATMENT

Facility OP

$224.48

Service Code	EAPG 00333
Min. Negotiated Rate	$215.85
Max. Negotiated Rate	$224.48
Rate for Payer: Anthem Medicaid	$215.85
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$215.85
Rate for Payer: Dean Health Medicaid	$215.85
Rate for Payer: Independent Care Health Plan Medicaid	$215.85
Rate for Payer: Managed Health Services Medicaid	$224.48
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$215.85
Rate for Payer: United Healthcare Medicaid	$215.85
Rate for Payer: WMAP Medicaid	$215.85

EAPG 335: CLASS I BRACHYTHERAPY SOURCES

Facility OP

$110.52

Service Code	EAPG 00335
Min. Negotiated Rate	$106.27
Max. Negotiated Rate	$110.52
Rate for Payer: Anthem Medicaid	$106.27
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$106.27
Rate for Payer: Dean Health Medicaid	$106.27
Rate for Payer: Independent Care Health Plan Medicaid	$106.27
Rate for Payer: Managed Health Services Medicaid	$110.52
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$106.27
Rate for Payer: United Healthcare Medicaid	$106.27
Rate for Payer: WMAP Medicaid	$106.27

EAPG 336: CLASS II BRACHYTHERAPY SOURCES

Facility OP

$1,458.40

Service Code	EAPG 00336
Min. Negotiated Rate	$1,402.31
Max. Negotiated Rate	$1,458.40
Rate for Payer: Anthem Medicaid	$1,402.31
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,402.31
Rate for Payer: Dean Health Medicaid	$1,402.31
Rate for Payer: Independent Care Health Plan Medicaid	$1,402.31
Rate for Payer: Managed Health Services Medicaid	$1,458.40
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,402.31
Rate for Payer: United Healthcare Medicaid	$1,402.31
Rate for Payer: WMAP Medicaid	$1,402.31

EAPG 337: CLASS III BRACHYTHERAPY SOURCES

Facility OP

$4,841.37

Service Code	EAPG 00337
Min. Negotiated Rate	$4,655.16
Max. Negotiated Rate	$4,841.37
Rate for Payer: Anthem Medicaid	$4,655.16
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$4,655.16
Rate for Payer: Dean Health Medicaid	$4,655.16
Rate for Payer: Independent Care Health Plan Medicaid	$4,655.16
Rate for Payer: Managed Health Services Medicaid	$4,841.37
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$4,655.16
Rate for Payer: United Healthcare Medicaid	$4,655.16
Rate for Payer: WMAP Medicaid	$4,655.16

EAPG 33: LEVEL I HAND PROCEDURES

Facility OP

$916.20

Service Code	EAPG 00033
Min. Negotiated Rate	$542.06
Max. Negotiated Rate	$916.20
Rate for Payer: Anthem Medicaid	$542.06
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$916.20
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$542.06
Rate for Payer: Dean Health Medicaid	$542.06
Rate for Payer: Independent Care Health Plan Medicaid	$542.06
Rate for Payer: Managed Health Services Medicaid	$563.74
Rate for Payer: Molina Healthcare Medicaid	$916.20
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$542.06
Rate for Payer: United Healthcare Medicaid	$542.06
Rate for Payer: WMAP Medicaid	$542.06

EAPG 340: THERAPEUTIC NUCLEAR MEDICINE

Facility OP

$241.54

Service Code	EAPG 00340
Min. Negotiated Rate	$112.93
Max. Negotiated Rate	$241.54
Rate for Payer: Anthem Medicaid	$112.93
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$241.54
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$112.93
Rate for Payer: Dean Health Medicaid	$112.93
Rate for Payer: Independent Care Health Plan Medicaid	$112.93
Rate for Payer: Managed Health Services Medicaid	$117.45
Rate for Payer: Molina Healthcare Medicaid	$241.54
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$112.93
Rate for Payer: United Healthcare Medicaid	$112.93
Rate for Payer: WMAP Medicaid	$112.93

EAPG 343: LEVEL I RADIATION THERAPY

Facility OP

$651.08

Service Code	EAPG 00343
Min. Negotiated Rate	$74.71
Max. Negotiated Rate	$651.08
Rate for Payer: Anthem Medicaid	$74.71
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$651.08
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$74.71
Rate for Payer: Dean Health Medicaid	$74.71
Rate for Payer: Independent Care Health Plan Medicaid	$74.71
Rate for Payer: Managed Health Services Medicaid	$77.70
Rate for Payer: Molina Healthcare Medicaid	$651.08
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$74.71
Rate for Payer: United Healthcare Medicaid	$74.71
Rate for Payer: WMAP Medicaid	$74.71

EAPG 346: RADIOSURGERY

Facility OP

$3,593.17

Service Code	EAPG 00346
Min. Negotiated Rate	$2,258.49
Max. Negotiated Rate	$3,593.17
Rate for Payer: Anthem Medicaid	$2,258.49
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$3,593.17
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,258.49
Rate for Payer: Dean Health Medicaid	$2,258.49
Rate for Payer: Independent Care Health Plan Medicaid	$2,258.49
Rate for Payer: Managed Health Services Medicaid	$2,348.83
Rate for Payer: Molina Healthcare Medicaid	$3,593.17
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,258.49
Rate for Payer: United Healthcare Medicaid	$2,258.49
Rate for Payer: WMAP Medicaid	$2,258.49

EAPG 347: LEVEL II RADIATION THERAPY

Facility OP

$387.77

Service Code	EAPG 00347
Min. Negotiated Rate	$196.41
Max. Negotiated Rate	$387.77
Rate for Payer: Anthem Medicaid	$196.41
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$387.77
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$196.41
Rate for Payer: Dean Health Medicaid	$196.41
Rate for Payer: Independent Care Health Plan Medicaid	$196.41
Rate for Payer: Managed Health Services Medicaid	$204.27
Rate for Payer: Molina Healthcare Medicaid	$387.77
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$196.41
Rate for Payer: United Healthcare Medicaid	$196.41
Rate for Payer: WMAP Medicaid	$196.41

EAPG 348: LEVEL III RADIATION THERAPY

Facility OP

$2,255.93

Service Code	EAPG 00348
Min. Negotiated Rate	$591.18
Max. Negotiated Rate	$2,255.93
Rate for Payer: Anthem Medicaid	$591.18
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,255.93
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$591.18
Rate for Payer: Dean Health Medicaid	$591.18
Rate for Payer: Independent Care Health Plan Medicaid	$591.18
Rate for Payer: Managed Health Services Medicaid	$614.83
Rate for Payer: Molina Healthcare Medicaid	$2,255.93
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$591.18
Rate for Payer: United Healthcare Medicaid	$591.18
Rate for Payer: WMAP Medicaid	$591.18

EAPG 34: LEVEL II HAND PROCEDURES

Facility OP

$1,504.41

Service Code	EAPG 00034
Min. Negotiated Rate	$893.94
Max. Negotiated Rate	$1,504.41
Rate for Payer: Anthem Medicaid	$893.94
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,504.41
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$893.94
Rate for Payer: Dean Health Medicaid	$893.94
Rate for Payer: Independent Care Health Plan Medicaid	$893.94
Rate for Payer: Managed Health Services Medicaid	$929.70
Rate for Payer: Molina Healthcare Medicaid	$1,504.41
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$893.94
Rate for Payer: United Healthcare Medicaid	$893.94
Rate for Payer: WMAP Medicaid	$893.94

EAPG 350: ADJUNCTIVE DENTAL SERVICES

Facility OP

$189.19

Service Code	EAPG 00350
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$189.19
Rate for Payer: Anthem Medicaid	$96.25
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$189.19
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$96.25
Rate for Payer: Dean Health Medicaid	$96.25
Rate for Payer: Independent Care Health Plan Medicaid	$96.25
Rate for Payer: Managed Health Services Medicaid	$100.10
Rate for Payer: Molina Healthcare Medicaid	$189.19
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$96.25
Rate for Payer: United Healthcare Medicaid	$96.25
Rate for Payer: WMAP Medicaid	$96.25

EAPG 352: LEVEL I PERIODONTICS

Facility OP

$778.77

Service Code	EAPG 00352
Min. Negotiated Rate	$438.91
Max. Negotiated Rate	$778.77
Rate for Payer: Anthem Medicaid	$438.91
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$778.77
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$438.91
Rate for Payer: Dean Health Medicaid	$438.91
Rate for Payer: Independent Care Health Plan Medicaid	$438.91
Rate for Payer: Managed Health Services Medicaid	$456.47
Rate for Payer: Molina Healthcare Medicaid	$778.77
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$438.91
Rate for Payer: United Healthcare Medicaid	$438.91
Rate for Payer: WMAP Medicaid	$438.91

EAPG 353: LEVEL I PROSTHODONTICS, FIXED

Facility OP

$75.34

Service Code	EAPG 00353
Min. Negotiated Rate	$42.47
Max. Negotiated Rate	$75.34
Rate for Payer: Anthem Medicaid	$42.47
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$75.34
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$42.47
Rate for Payer: Dean Health Medicaid	$42.47
Rate for Payer: Independent Care Health Plan Medicaid	$42.47
Rate for Payer: Managed Health Services Medicaid	$44.17
Rate for Payer: Molina Healthcare Medicaid	$75.34
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$42.47
Rate for Payer: United Healthcare Medicaid	$42.47
Rate for Payer: WMAP Medicaid	$42.47

EAPG 354: LEVEL II PROSTHODONTICS, FIXED

Facility OP

$281.85

Service Code	EAPG 00354
Min. Negotiated Rate	$158.87
Max. Negotiated Rate	$281.85
Rate for Payer: Anthem Medicaid	$158.87
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$281.85
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$158.87
Rate for Payer: Dean Health Medicaid	$158.87
Rate for Payer: Independent Care Health Plan Medicaid	$158.87
Rate for Payer: Managed Health Services Medicaid	$165.22
Rate for Payer: Molina Healthcare Medicaid	$281.85
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$158.87
Rate for Payer: United Healthcare Medicaid	$158.87
Rate for Payer: WMAP Medicaid	$158.87

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