Beloit Memorial Hospital

All Charges

Charge

Type

Price

EAPG 379: LEVEL II ORTHODONTICS

Facility OP

$641.28

Service Code	EAPG 00379
Min. Negotiated Rate	$270.31
Max. Negotiated Rate	$641.28
Rate for Payer: Anthem Medicaid	$616.62
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$270.31
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$616.62
Rate for Payer: Dean Health Medicaid	$616.62
Rate for Payer: Independent Care Health Plan Medicaid	$616.62
Rate for Payer: Managed Health Services Medicaid	$641.28
Rate for Payer: Molina Healthcare Medicaid	$270.31
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$616.62
Rate for Payer: United Healthcare Medicaid	$616.62
Rate for Payer: WMAP Medicaid	$616.62

EAPG 37: LEVEL I ARTHROSCOPY

Facility OP

$1,622.61

Service Code	EAPG 00037
Min. Negotiated Rate	$888.79
Max. Negotiated Rate	$1,622.61
Rate for Payer: Anthem Medicaid	$888.79
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,622.61
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$888.79
Rate for Payer: Dean Health Medicaid	$888.79
Rate for Payer: Independent Care Health Plan Medicaid	$888.79
Rate for Payer: Managed Health Services Medicaid	$924.34
Rate for Payer: Molina Healthcare Medicaid	$1,622.61
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$888.79
Rate for Payer: United Healthcare Medicaid	$888.79
Rate for Payer: WMAP Medicaid	$888.79

EAPG 380: ANESTHESIA

Facility OP

$18.64

Service Code	EAPG 00380
Min. Negotiated Rate	$9.45
Max. Negotiated Rate	$18.64
Rate for Payer: Anthem Medicaid	$9.45
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$18.64
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$9.45
Rate for Payer: Dean Health Medicaid	$9.45
Rate for Payer: Independent Care Health Plan Medicaid	$9.45
Rate for Payer: Managed Health Services Medicaid	$9.83
Rate for Payer: Molina Healthcare Medicaid	$18.64
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$9.45
Rate for Payer: United Healthcare Medicaid	$9.45
Rate for Payer: WMAP Medicaid	$9.45

EAPG 381: LEVEL I DENTAL IMPLANTS

Facility OP

$954.56

Service Code	EAPG 00381
Min. Negotiated Rate	$538.00
Max. Negotiated Rate	$954.56
Rate for Payer: Anthem Medicaid	$538.00
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$954.56
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$538.00
Rate for Payer: Dean Health Medicaid	$538.00
Rate for Payer: Independent Care Health Plan Medicaid	$538.00
Rate for Payer: Managed Health Services Medicaid	$559.52
Rate for Payer: Molina Healthcare Medicaid	$954.56
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$538.00
Rate for Payer: United Healthcare Medicaid	$538.00
Rate for Payer: WMAP Medicaid	$538.00

EAPG 382: LEVEL II DENTAL IMPLANTS

Facility OP

$1,050.01

Service Code	EAPG 00382
Min. Negotiated Rate	$591.80
Max. Negotiated Rate	$1,050.01
Rate for Payer: Anthem Medicaid	$591.80
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,050.01
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$591.80
Rate for Payer: Dean Health Medicaid	$591.80
Rate for Payer: Independent Care Health Plan Medicaid	$591.80
Rate for Payer: Managed Health Services Medicaid	$615.47
Rate for Payer: Molina Healthcare Medicaid	$1,050.01
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$591.80
Rate for Payer: United Healthcare Medicaid	$591.80
Rate for Payer: WMAP Medicaid	$591.80

EAPG 384: LEVEL III CHEMISTRY TESTS

Facility OP

$23.88

Service Code	EAPG 00384
Min. Negotiated Rate	$22.96
Max. Negotiated Rate	$23.88
Rate for Payer: Anthem Medicaid	$22.96
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$22.96
Rate for Payer: Dean Health Medicaid	$22.96
Rate for Payer: Independent Care Health Plan Medicaid	$22.96
Rate for Payer: Managed Health Services Medicaid	$23.88
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$22.96
Rate for Payer: United Healthcare Medicaid	$22.96
Rate for Payer: WMAP Medicaid	$22.96

EAPG 385: LEVEL I COMPLEX LABORATORY, MOLECULAR PATHOLOGY AND GENETIC TESTS

Facility OP

$31.60

Service Code	EAPG 00385
Min. Negotiated Rate	$15.70
Max. Negotiated Rate	$31.60
Rate for Payer: Anthem Medicaid	$15.70
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$31.60
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$15.70
Rate for Payer: Dean Health Medicaid	$15.70
Rate for Payer: Independent Care Health Plan Medicaid	$15.70
Rate for Payer: Managed Health Services Medicaid	$16.33
Rate for Payer: Molina Healthcare Medicaid	$31.60
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$15.70
Rate for Payer: United Healthcare Medicaid	$15.70
Rate for Payer: WMAP Medicaid	$15.70

EAPG 386: LEVEL II COMPLEX LABORATORY, MOLECULAR PATHOLOGY AND GENETIC TESTS

Facility OP

$102.89

Service Code	EAPG 00386
Min. Negotiated Rate	$55.49
Max. Negotiated Rate	$102.89
Rate for Payer: Anthem Medicaid	$55.49
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$102.89
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$55.49
Rate for Payer: Dean Health Medicaid	$55.49
Rate for Payer: Independent Care Health Plan Medicaid	$55.49
Rate for Payer: Managed Health Services Medicaid	$57.71
Rate for Payer: Molina Healthcare Medicaid	$102.89
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$55.49
Rate for Payer: United Healthcare Medicaid	$55.49
Rate for Payer: WMAP Medicaid	$55.49

EAPG 387: LEVEL III COMPLEX LABORATORY, MOLECULAR PATHOLOGY AND GENETIC TESTS

Facility OP

$291.98

Service Code	EAPG 00387
Min. Negotiated Rate	$121.08
Max. Negotiated Rate	$291.98
Rate for Payer: Anthem Medicaid	$121.08
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$291.98
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$121.08
Rate for Payer: Dean Health Medicaid	$121.08
Rate for Payer: Independent Care Health Plan Medicaid	$121.08
Rate for Payer: Managed Health Services Medicaid	$125.92
Rate for Payer: Molina Healthcare Medicaid	$291.98
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$121.08
Rate for Payer: United Healthcare Medicaid	$121.08
Rate for Payer: WMAP Medicaid	$121.08

EAPG 388: LEVEL III MICROBIOLOGY TESTS

Facility OP

$71.49

Service Code	EAPG 00388
Min. Negotiated Rate	$68.74
Max. Negotiated Rate	$71.49
Rate for Payer: Anthem Medicaid	$68.74
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$68.74
Rate for Payer: Dean Health Medicaid	$68.74
Rate for Payer: Independent Care Health Plan Medicaid	$68.74
Rate for Payer: Managed Health Services Medicaid	$71.49
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$68.74
Rate for Payer: United Healthcare Medicaid	$68.74
Rate for Payer: WMAP Medicaid	$68.74

EAPG 389: LEVEL II CONVENTIONAL RADIOLOGY

Facility OP

$51.14

Service Code	EAPG 00389
Min. Negotiated Rate	$49.17
Max. Negotiated Rate	$51.14
Rate for Payer: Anthem Medicaid	$49.17
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$49.17
Rate for Payer: Dean Health Medicaid	$49.17
Rate for Payer: Independent Care Health Plan Medicaid	$49.17
Rate for Payer: Managed Health Services Medicaid	$51.14
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$49.17
Rate for Payer: United Healthcare Medicaid	$49.17
Rate for Payer: WMAP Medicaid	$49.17

EAPG 38: LEVEL II ARTHROSCOPY

Facility OP

$3,871.99

Service Code	EAPG 00038
Min. Negotiated Rate	$2,241.51
Max. Negotiated Rate	$3,871.99
Rate for Payer: Anthem Medicaid	$2,241.51
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$3,871.99
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,241.51
Rate for Payer: Dean Health Medicaid	$2,241.51
Rate for Payer: Independent Care Health Plan Medicaid	$2,241.51
Rate for Payer: Managed Health Services Medicaid	$2,331.17
Rate for Payer: Molina Healthcare Medicaid	$3,871.99
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,241.51
Rate for Payer: United Healthcare Medicaid	$2,241.51
Rate for Payer: WMAP Medicaid	$2,241.51

EAPG 390: LEVEL I PATHOLOGY TESTS

Facility OP

$25.44

Service Code	EAPG 00390
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$25.44
Rate for Payer: Anthem Medicaid	$1.67
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$25.44
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1.67
Rate for Payer: Dean Health Medicaid	$1.67
Rate for Payer: Independent Care Health Plan Medicaid	$1.67
Rate for Payer: Managed Health Services Medicaid	$1.74
Rate for Payer: Molina Healthcare Medicaid	$25.44
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1.67
Rate for Payer: United Healthcare Medicaid	$1.67
Rate for Payer: WMAP Medicaid	$1.67

EAPG 391: LEVEL II PATHOLOGY TESTS

Facility OP

$27.98

Service Code	EAPG 00391
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$27.98
Rate for Payer: Anthem Medicaid	$11.05
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$27.98
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$11.05
Rate for Payer: Dean Health Medicaid	$11.05
Rate for Payer: Independent Care Health Plan Medicaid	$11.05
Rate for Payer: Managed Health Services Medicaid	$11.49
Rate for Payer: Molina Healthcare Medicaid	$27.98
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$11.05
Rate for Payer: United Healthcare Medicaid	$11.05
Rate for Payer: WMAP Medicaid	$11.05

EAPG 392: PAP SMEARS

Facility OP

$18.44

Service Code	EAPG 00392
Min. Negotiated Rate	$6.89
Max. Negotiated Rate	$18.44
Rate for Payer: Anthem Medicaid	$6.89
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$18.44
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$6.89
Rate for Payer: Dean Health Medicaid	$6.89
Rate for Payer: Independent Care Health Plan Medicaid	$6.89
Rate for Payer: Managed Health Services Medicaid	$7.17
Rate for Payer: Molina Healthcare Medicaid	$18.44
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$6.89
Rate for Payer: United Healthcare Medicaid	$6.89
Rate for Payer: WMAP Medicaid	$6.89

EAPG 393: LEVEL II BLOOD AND TISSUE TYPING TESTS

Facility OP

$32.19

Service Code	EAPG 00393
Min. Negotiated Rate	$21.04
Max. Negotiated Rate	$32.19
Rate for Payer: Anthem Medicaid	$21.04
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$32.19
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$21.04
Rate for Payer: Dean Health Medicaid	$21.04
Rate for Payer: Independent Care Health Plan Medicaid	$21.04
Rate for Payer: Managed Health Services Medicaid	$21.88
Rate for Payer: Molina Healthcare Medicaid	$32.19
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$21.04
Rate for Payer: United Healthcare Medicaid	$21.04
Rate for Payer: WMAP Medicaid	$21.04

EAPG 394: LEVEL I IMMUNOLOGY TESTS

Facility OP

$7.97

Service Code	EAPG 00394
Min. Negotiated Rate	$3.89
Max. Negotiated Rate	$7.97
Rate for Payer: Anthem Medicaid	$3.89
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$7.97
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$3.89
Rate for Payer: Dean Health Medicaid	$3.89
Rate for Payer: Independent Care Health Plan Medicaid	$3.89
Rate for Payer: Managed Health Services Medicaid	$4.05
Rate for Payer: Molina Healthcare Medicaid	$7.97
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$3.89
Rate for Payer: United Healthcare Medicaid	$3.89
Rate for Payer: WMAP Medicaid	$3.89

EAPG 395: LEVEL II IMMUNOLOGY TESTS

Facility OP

$14.30

Service Code	EAPG 00395
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$14.30
Rate for Payer: Anthem Medicaid	$13.75
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$13.75
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$13.75
Rate for Payer: Dean Health Medicaid	$13.75
Rate for Payer: Independent Care Health Plan Medicaid	$13.75
Rate for Payer: Managed Health Services Medicaid	$14.30
Rate for Payer: Molina Healthcare Medicaid	$13.75
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$13.75
Rate for Payer: United Healthcare Medicaid	$13.75
Rate for Payer: WMAP Medicaid	$13.75

EAPG 396: LEVEL I MICROBIOLOGY TESTS

Facility OP

$6.36

Service Code	EAPG 00396
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$6.36
Rate for Payer: Anthem Medicaid	$3.56
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$6.36
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$3.56
Rate for Payer: Dean Health Medicaid	$3.56
Rate for Payer: Independent Care Health Plan Medicaid	$3.56
Rate for Payer: Managed Health Services Medicaid	$3.70
Rate for Payer: Molina Healthcare Medicaid	$6.36
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$3.56
Rate for Payer: United Healthcare Medicaid	$3.56
Rate for Payer: WMAP Medicaid	$3.56

EAPG 397: LEVEL II MICROBIOLOGY TESTS

Facility OP

$21.14

Service Code	EAPG 00397
Min. Negotiated Rate	$14.44
Max. Negotiated Rate	$21.14
Rate for Payer: Anthem Medicaid	$14.44
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$21.14
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$14.44
Rate for Payer: Dean Health Medicaid	$14.44
Rate for Payer: Independent Care Health Plan Medicaid	$14.44
Rate for Payer: Managed Health Services Medicaid	$15.02
Rate for Payer: Molina Healthcare Medicaid	$21.14
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$14.44
Rate for Payer: United Healthcare Medicaid	$14.44
Rate for Payer: WMAP Medicaid	$14.44

EAPG 398: LEVEL I ENDOCRINOLOGY TESTS

Facility OP

$11.99

Service Code	EAPG 00398
Min. Negotiated Rate	$4.47
Max. Negotiated Rate	$11.99
Rate for Payer: Anthem Medicaid	$4.47
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$11.99
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$4.47
Rate for Payer: Dean Health Medicaid	$4.47
Rate for Payer: Independent Care Health Plan Medicaid	$4.47
Rate for Payer: Managed Health Services Medicaid	$4.65
Rate for Payer: Molina Healthcare Medicaid	$11.99
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$4.47
Rate for Payer: United Healthcare Medicaid	$4.47
Rate for Payer: WMAP Medicaid	$4.47

EAPG 399: LEVEL II ENDOCRINOLOGY TESTS

Facility OP

$20.84

Service Code	EAPG 00399
Min. Negotiated Rate	$11.78
Max. Negotiated Rate	$20.84
Rate for Payer: Anthem Medicaid	$11.78
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$20.84
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$11.78
Rate for Payer: Dean Health Medicaid	$11.78
Rate for Payer: Independent Care Health Plan Medicaid	$11.78
Rate for Payer: Managed Health Services Medicaid	$12.25
Rate for Payer: Molina Healthcare Medicaid	$20.84
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$11.78
Rate for Payer: United Healthcare Medicaid	$11.78
Rate for Payer: WMAP Medicaid	$11.78

EAPG 39: CAST APPLICATION OR REPLACEMENT

Facility OP

$256.95

Service Code	EAPG 00039
Min. Negotiated Rate	$74.71
Max. Negotiated Rate	$256.95
Rate for Payer: Anthem Medicaid	$74.71
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$256.95
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	$256.95
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 3: LEVEL I SKIN INCISION AND DRAINAGE, DEBRIDEMENT, DESTRUCTION, OTHER RELATED PX

Facility OP

$237.48

Service Code	EAPG 00003
Min. Negotiated Rate	$68.59
Max. Negotiated Rate	$237.48
Rate for Payer: Anthem Medicaid	$68.59
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$237.48
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$68.59
Rate for Payer: Dean Health Medicaid	$68.59
Rate for Payer: Independent Care Health Plan Medicaid	$68.59
Rate for Payer: Managed Health Services Medicaid	$71.33
Rate for Payer: Molina Healthcare Medicaid	$237.48
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$68.59
Rate for Payer: United Healthcare Medicaid	$68.59
Rate for Payer: WMAP Medicaid	$68.59

EAPG 4001: EMERGING TECHNOLOGY PROCEDURES

Facility OP

$295.94

Service Code	EAPG 04001
Min. Negotiated Rate	$284.56
Max. Negotiated Rate	$295.94
Rate for Payer: Anthem Medicaid	$284.56
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$284.56
Rate for Payer: Dean Health Medicaid	$284.56
Rate for Payer: Independent Care Health Plan Medicaid	$284.56
Rate for Payer: Managed Health Services Medicaid	$295.94
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$284.56
Rate for Payer: United Healthcare Medicaid	$284.56
Rate for Payer: WMAP Medicaid	$284.56

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