Beloit Memorial Hospital

All Charges

Charge

Type

Price

EAPG 400: LEVEL I CHEMISTRY TESTS

Facility OP

$8.90

Service Code	EAPG 00400
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$8.90
Rate for Payer: Anthem Medicaid	$4.04
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$8.90
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$4.04
Rate for Payer: Dean Health Medicaid	$4.04
Rate for Payer: Independent Care Health Plan Medicaid	$4.04
Rate for Payer: Managed Health Services Medicaid	$4.20
Rate for Payer: Molina Healthcare Medicaid	$8.90
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$4.04
Rate for Payer: United Healthcare Medicaid	$4.04
Rate for Payer: WMAP Medicaid	$4.04

EAPG 4010: LEVEL I OPIOID TREATMENT PROGRAM SERVICES

Facility OP

$72.78

Service Code	EAPG 04010
Min. Negotiated Rate	$69.98
Max. Negotiated Rate	$72.78
Rate for Payer: Anthem Medicaid	$69.98
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$69.98
Rate for Payer: Dean Health Medicaid	$69.98
Rate for Payer: Independent Care Health Plan Medicaid	$69.98
Rate for Payer: Managed Health Services Medicaid	$72.78
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$69.98
Rate for Payer: United Healthcare Medicaid	$69.98
Rate for Payer: WMAP Medicaid	$69.98

EAPG 4011: LEVEL II OPIOID TREATMENT PROGRAM SERVICES

Facility OP

$161.23

Service Code	EAPG 04011
Min. Negotiated Rate	$155.03
Max. Negotiated Rate	$161.23
Rate for Payer: Anthem Medicaid	$155.03
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$155.03
Rate for Payer: Dean Health Medicaid	$155.03
Rate for Payer: Independent Care Health Plan Medicaid	$155.03
Rate for Payer: Managed Health Services Medicaid	$161.23
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$155.03
Rate for Payer: United Healthcare Medicaid	$155.03
Rate for Payer: WMAP Medicaid	$155.03

EAPG 401: LEVEL II CHEMISTRY TESTS

Facility OP

$23.97

Service Code	EAPG 00401
Min. Negotiated Rate	$9.48
Max. Negotiated Rate	$23.97
Rate for Payer: Anthem Medicaid	$9.48
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$23.97
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$9.48
Rate for Payer: Dean Health Medicaid	$9.48
Rate for Payer: Independent Care Health Plan Medicaid	$9.48
Rate for Payer: Managed Health Services Medicaid	$9.86
Rate for Payer: Molina Healthcare Medicaid	$23.97
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$9.48
Rate for Payer: United Healthcare Medicaid	$9.48
Rate for Payer: WMAP Medicaid	$9.48

EAPG 402: BASIC CHEMISTRY TESTS

Facility OP

$3.96

Service Code	EAPG 00402
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$3.96
Rate for Payer: Anthem Medicaid	$1.83
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$3.96
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1.83
Rate for Payer: Dean Health Medicaid	$1.83
Rate for Payer: Independent Care Health Plan Medicaid	$1.83
Rate for Payer: Managed Health Services Medicaid	$1.90
Rate for Payer: Molina Healthcare Medicaid	$3.96
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1.83
Rate for Payer: United Healthcare Medicaid	$1.83
Rate for Payer: WMAP Medicaid	$1.83

EAPG 403: ORGAN OR DISEASE ORIENTED PANELS

Facility OP

$8.12

Service Code	EAPG 00403
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$8.12
Rate for Payer: Anthem Medicaid	$3.05
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$8.12
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$3.05
Rate for Payer: Dean Health Medicaid	$3.05
Rate for Payer: Independent Care Health Plan Medicaid	$3.05
Rate for Payer: Managed Health Services Medicaid	$3.17
Rate for Payer: Molina Healthcare Medicaid	$8.12
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$3.05
Rate for Payer: United Healthcare Medicaid	$3.05
Rate for Payer: WMAP Medicaid	$3.05

EAPG 404: TOXICOLOGY TESTS

Facility OP

$10.86

Service Code	EAPG 00404
Min. Negotiated Rate	$4.14
Max. Negotiated Rate	$10.86
Rate for Payer: Anthem Medicaid	$4.14
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$10.86
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$4.14
Rate for Payer: Dean Health Medicaid	$4.14
Rate for Payer: Independent Care Health Plan Medicaid	$4.14
Rate for Payer: Managed Health Services Medicaid	$4.31
Rate for Payer: Molina Healthcare Medicaid	$10.86
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$4.14
Rate for Payer: United Healthcare Medicaid	$4.14
Rate for Payer: WMAP Medicaid	$4.14

EAPG 405: THERAPEUTIC DRUG MONITORING

Facility OP

$10.23

Service Code	EAPG 00405
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$10.23
Rate for Payer: Anthem Medicaid	$4.08
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$10.23
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$4.08
Rate for Payer: Dean Health Medicaid	$4.08
Rate for Payer: Independent Care Health Plan Medicaid	$4.08
Rate for Payer: Managed Health Services Medicaid	$4.24
Rate for Payer: Molina Healthcare Medicaid	$10.23
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$4.08
Rate for Payer: United Healthcare Medicaid	$4.08
Rate for Payer: WMAP Medicaid	$4.08

EAPG 406: LEVEL I CLOTTING TESTS

Facility OP

$3.23

Service Code	EAPG 00406
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$3.23
Rate for Payer: Anthem Medicaid	$1.49
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$3.23
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1.49
Rate for Payer: Dean Health Medicaid	$1.49
Rate for Payer: Independent Care Health Plan Medicaid	$1.49
Rate for Payer: Managed Health Services Medicaid	$1.55
Rate for Payer: Molina Healthcare Medicaid	$3.23
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1.49
Rate for Payer: United Healthcare Medicaid	$1.49
Rate for Payer: WMAP Medicaid	$1.49

EAPG 407: LEVEL II CLOTTING TESTS

Facility OP

$9.59

Service Code	EAPG 00407
Min. Negotiated Rate	$8.56
Max. Negotiated Rate	$9.59
Rate for Payer: Anthem Medicaid	$8.56
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$9.59
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$8.56
Rate for Payer: Dean Health Medicaid	$8.56
Rate for Payer: Independent Care Health Plan Medicaid	$8.56
Rate for Payer: Managed Health Services Medicaid	$8.90
Rate for Payer: Molina Healthcare Medicaid	$9.59
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$8.56
Rate for Payer: United Healthcare Medicaid	$8.56
Rate for Payer: WMAP Medicaid	$8.56

EAPG 408: LEVEL I HEMATOLOGY TESTS

Facility OP

$5.53

Service Code	EAPG 00408
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$5.53
Rate for Payer: Anthem Medicaid	$2.00
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$5.53
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2.00
Rate for Payer: Dean Health Medicaid	$2.00
Rate for Payer: Independent Care Health Plan Medicaid	$2.00
Rate for Payer: Managed Health Services Medicaid	$2.08
Rate for Payer: Molina Healthcare Medicaid	$5.53
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2.00
Rate for Payer: United Healthcare Medicaid	$2.00
Rate for Payer: WMAP Medicaid	$2.00

EAPG 409: LEVEL II HEMATOLOGY TESTS

Facility OP

$8.41

Service Code	EAPG 00409
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$8.41
Rate for Payer: Anthem Medicaid	$5.00
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$8.41
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$5.00
Rate for Payer: Dean Health Medicaid	$5.00
Rate for Payer: Independent Care Health Plan Medicaid	$5.00
Rate for Payer: Managed Health Services Medicaid	$5.20
Rate for Payer: Molina Healthcare Medicaid	$8.41
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$5.00
Rate for Payer: United Healthcare Medicaid	$5.00
Rate for Payer: WMAP Medicaid	$5.00

EAPG 40: MINOR SPLINT AND STRAPPING APPLICATION

Facility OP

$199.17

Service Code	EAPG 00040
Min. Negotiated Rate	$31.46
Max. Negotiated Rate	$199.17
Rate for Payer: Anthem Medicaid	$31.46
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$199.17
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$31.46
Rate for Payer: Dean Health Medicaid	$31.46
Rate for Payer: Independent Care Health Plan Medicaid	$31.46
Rate for Payer: Managed Health Services Medicaid	$32.72
Rate for Payer: Molina Healthcare Medicaid	$199.17
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$31.46
Rate for Payer: United Healthcare Medicaid	$31.46
Rate for Payer: WMAP Medicaid	$31.46

EAPG 410: URINALYSIS

Facility OP

$3.18

Service Code	EAPG 00410
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$3.18
Rate for Payer: Anthem Medicaid	$1.00
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$3.18
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1.00
Rate for Payer: Dean Health Medicaid	$1.00
Rate for Payer: Independent Care Health Plan Medicaid	$1.00
Rate for Payer: Managed Health Services Medicaid	$1.04
Rate for Payer: Molina Healthcare Medicaid	$3.18
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1.00
Rate for Payer: United Healthcare Medicaid	$1.00
Rate for Payer: WMAP Medicaid	$1.00

EAPG 412: ANCILLARY RESPIRATORY THERAPY AND OTHER PULMONARY TESTS AND SERVICES

Facility OP

$59.10

Service Code	EAPG 00412
Min. Negotiated Rate	$23.95
Max. Negotiated Rate	$59.10
Rate for Payer: Anthem Medicaid	$23.95
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$59.10
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$23.95
Rate for Payer: Dean Health Medicaid	$23.95
Rate for Payer: Independent Care Health Plan Medicaid	$23.95
Rate for Payer: Managed Health Services Medicaid	$24.91
Rate for Payer: Molina Healthcare Medicaid	$59.10
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$23.95
Rate for Payer: United Healthcare Medicaid	$23.95
Rate for Payer: WMAP Medicaid	$23.95

EAPG 413: CARDIOGRAM

Facility OP

$20.35

Service Code	EAPG 00413
Min. Negotiated Rate	$10.68
Max. Negotiated Rate	$20.35
Rate for Payer: Anthem Medicaid	$10.68
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$20.35
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$10.68
Rate for Payer: Dean Health Medicaid	$10.68
Rate for Payer: Independent Care Health Plan Medicaid	$10.68
Rate for Payer: Managed Health Services Medicaid	$11.11
Rate for Payer: Molina Healthcare Medicaid	$20.35
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$10.68
Rate for Payer: United Healthcare Medicaid	$10.68
Rate for Payer: WMAP Medicaid	$10.68

EAPG 414: LEVEL I IMMUNIZATION

Facility OP

$17.37

Service Code	EAPG 00414
Min. Negotiated Rate	$8.85
Max. Negotiated Rate	$17.37
Rate for Payer: Anthem Medicaid	$8.85
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$17.37
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$8.85
Rate for Payer: Dean Health Medicaid	$8.85
Rate for Payer: Independent Care Health Plan Medicaid	$8.85
Rate for Payer: Managed Health Services Medicaid	$9.20
Rate for Payer: Molina Healthcare Medicaid	$17.37
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$8.85
Rate for Payer: United Healthcare Medicaid	$8.85
Rate for Payer: WMAP Medicaid	$8.85

EAPG 415: LEVEL II IMMUNIZATION

Facility OP

$73.14

Service Code	EAPG 00415
Min. Negotiated Rate	$46.77
Max. Negotiated Rate	$73.14
Rate for Payer: Anthem Medicaid	$46.77
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$73.14
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$46.77
Rate for Payer: Dean Health Medicaid	$46.77
Rate for Payer: Independent Care Health Plan Medicaid	$46.77
Rate for Payer: Managed Health Services Medicaid	$48.64
Rate for Payer: Molina Healthcare Medicaid	$73.14
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$46.77
Rate for Payer: United Healthcare Medicaid	$46.77
Rate for Payer: WMAP Medicaid	$46.77

EAPG 417: MINOR FEMALE REPRODUCTIVE PROCEDURES

Facility OP

$141.83

Service Code	EAPG 00417
Min. Negotiated Rate	$87.78
Max. Negotiated Rate	$141.83
Rate for Payer: Anthem Medicaid	$87.78
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$141.83
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$87.78
Rate for Payer: Dean Health Medicaid	$87.78
Rate for Payer: Independent Care Health Plan Medicaid	$87.78
Rate for Payer: Managed Health Services Medicaid	$91.29
Rate for Payer: Molina Healthcare Medicaid	$141.83
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$87.78
Rate for Payer: United Healthcare Medicaid	$87.78
Rate for Payer: WMAP Medicaid	$87.78

EAPG 418: AMBULATORY PATIENT MONITORING AND RELATED ASSESSMENTS

Facility OP

$112.08

Service Code	EAPG 00418
Min. Negotiated Rate	$25.66
Max. Negotiated Rate	$112.08
Rate for Payer: Dean Health Medicaid	$25.66
Rate for Payer: Anthem Medicaid	$25.66
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$112.08
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$25.66
Rate for Payer: Independent Care Health Plan Medicaid	$25.66
Rate for Payer: Managed Health Services Medicaid	$26.69
Rate for Payer: Molina Healthcare Medicaid	$112.08
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$25.66
Rate for Payer: United Healthcare Medicaid	$25.66
Rate for Payer: WMAP Medicaid	$25.66

EAPG 419: ANCILLARY OPHTHALMOLOGY OR OPTOMETRY SERVICES

Facility OP

$37.92

Service Code	EAPG 00419
Min. Negotiated Rate	$31.30
Max. Negotiated Rate	$37.92
Rate for Payer: Anthem Medicaid	$31.30
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$37.92
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$31.30
Rate for Payer: Dean Health Medicaid	$31.30
Rate for Payer: Independent Care Health Plan Medicaid	$31.30
Rate for Payer: Managed Health Services Medicaid	$32.55
Rate for Payer: Molina Healthcare Medicaid	$37.92
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$31.30
Rate for Payer: United Healthcare Medicaid	$31.30
Rate for Payer: WMAP Medicaid	$31.30

EAPG 41: CLOSED TREATMENT FX AND DISLOCATION

Facility OP

$448.73

Service Code	EAPG 00041
Min. Negotiated Rate	$191.13
Max. Negotiated Rate	$448.73
Rate for Payer: Anthem Medicaid	$191.13
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$448.73
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$191.13
Rate for Payer: Dean Health Medicaid	$191.13
Rate for Payer: Independent Care Health Plan Medicaid	$191.13
Rate for Payer: Managed Health Services Medicaid	$198.78
Rate for Payer: Molina Healthcare Medicaid	$448.73
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$191.13
Rate for Payer: United Healthcare Medicaid	$191.13
Rate for Payer: WMAP Medicaid	$191.13

EAPG 420: ELECTRONIC ANALYSIS FOR CARDIAC, NEUROLOGICAL AND OTHER DEVICES

Facility OP

$200.20

Service Code	EAPG 00420
Min. Negotiated Rate	$59.18
Max. Negotiated Rate	$200.20
Rate for Payer: Anthem Medicaid	$59.18
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$200.20
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$59.18
Rate for Payer: Dean Health Medicaid	$59.18
Rate for Payer: Independent Care Health Plan Medicaid	$59.18
Rate for Payer: Managed Health Services Medicaid	$61.55
Rate for Payer: Molina Healthcare Medicaid	$200.20
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$59.18
Rate for Payer: United Healthcare Medicaid	$59.18
Rate for Payer: WMAP Medicaid	$59.18

EAPG 423: VASCULAR ACCESS BY NEEDLE OR CATHETER

Facility OP

$295.52

Service Code	EAPG 00423
Min. Negotiated Rate	$220.45
Max. Negotiated Rate	$295.52
Rate for Payer: Anthem Medicaid	$284.15
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$220.45
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$284.15
Rate for Payer: Dean Health Medicaid	$284.15
Rate for Payer: Independent Care Health Plan Medicaid	$284.15
Rate for Payer: Managed Health Services Medicaid	$295.52
Rate for Payer: Molina Healthcare Medicaid	$220.45
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$284.15
Rate for Payer: United Healthcare Medicaid	$284.15
Rate for Payer: WMAP Medicaid	$284.15

EAPG 427: BIOFEEDBACK AND OTHER TRAINING

Facility OP

$171.19

Service Code	EAPG 00427
Min. Negotiated Rate	$36.61
Max. Negotiated Rate	$171.19
Rate for Payer: Anthem Medicaid	$36.61
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$171.19
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$36.61
Rate for Payer: Dean Health Medicaid	$36.61
Rate for Payer: Independent Care Health Plan Medicaid	$36.61
Rate for Payer: Managed Health Services Medicaid	$38.07
Rate for Payer: Molina Healthcare Medicaid	$171.19
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$36.61
Rate for Payer: United Healthcare Medicaid	$36.61
Rate for Payer: WMAP Medicaid	$36.61

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