Beloit Memorial Hospital

All Charges

Charge

Type

Price

EAPG 428: PATIENT EDUCATION, INDIVIDUAL

Facility OP

$31.04

Service Code	EAPG 00428
Min. Negotiated Rate	$28.52
Max. Negotiated Rate	$31.04
Rate for Payer: Anthem Medicaid	$29.85
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$28.52
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$29.85
Rate for Payer: Dean Health Medicaid	$29.85
Rate for Payer: Independent Care Health Plan Medicaid	$29.85
Rate for Payer: Managed Health Services Medicaid	$31.04
Rate for Payer: Molina Healthcare Medicaid	$28.52
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$29.85
Rate for Payer: United Healthcare Medicaid	$29.85
Rate for Payer: WMAP Medicaid	$29.85

EAPG 429: PATIENT EDUCATION, GROUP

Facility OP

$36.35

Service Code	EAPG 00429
Min. Negotiated Rate	$15.65
Max. Negotiated Rate	$36.35
Rate for Payer: Anthem Medicaid	$15.65
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$36.35
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$15.65
Rate for Payer: Dean Health Medicaid	$15.65
Rate for Payer: Independent Care Health Plan Medicaid	$15.65
Rate for Payer: Managed Health Services Medicaid	$16.28
Rate for Payer: Molina Healthcare Medicaid	$36.35
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$15.65
Rate for Payer: United Healthcare Medicaid	$15.65
Rate for Payer: WMAP Medicaid	$15.65

EAPG 431: CLASS II CHEMOTHERAPY DRUGS

Facility OP

$107.88

Service Code	EAPG 00431
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$107.88
Rate for Payer: Anthem Medicaid	$14.91
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$107.88
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$14.91
Rate for Payer: Dean Health Medicaid	$14.91
Rate for Payer: Independent Care Health Plan Medicaid	$14.91
Rate for Payer: Managed Health Services Medicaid	$15.51
Rate for Payer: Molina Healthcare Medicaid	$107.88
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$14.91
Rate for Payer: United Healthcare Medicaid	$14.91
Rate for Payer: WMAP Medicaid	$14.91

EAPG 432: CLASS III CHEMOTHERAPY DRUGS

Facility OP

$139.58

Service Code	EAPG 00432
Min. Negotiated Rate	$51.63
Max. Negotiated Rate	$139.58
Rate for Payer: Anthem Medicaid	$51.63
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$139.58
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$51.63
Rate for Payer: Dean Health Medicaid	$51.63
Rate for Payer: Independent Care Health Plan Medicaid	$51.63
Rate for Payer: Managed Health Services Medicaid	$53.70
Rate for Payer: Molina Healthcare Medicaid	$139.58
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$51.63
Rate for Payer: United Healthcare Medicaid	$51.63
Rate for Payer: WMAP Medicaid	$51.63

EAPG 433: CLASS IV CHEMOTHERAPY DRUGS

Facility OP

$262.87

Service Code	EAPG 00433
Min. Negotiated Rate	$121.74
Max. Negotiated Rate	$262.87
Rate for Payer: Anthem Medicaid	$121.74
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$262.87
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$121.74
Rate for Payer: Dean Health Medicaid	$121.74
Rate for Payer: Independent Care Health Plan Medicaid	$121.74
Rate for Payer: Managed Health Services Medicaid	$126.61
Rate for Payer: Molina Healthcare Medicaid	$262.87
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$121.74
Rate for Payer: United Healthcare Medicaid	$121.74
Rate for Payer: WMAP Medicaid	$121.74

EAPG 434: CLASS V CHEMOTHERAPY DRUGS

Facility OP

$323.29

Service Code	EAPG 00434
Min. Negotiated Rate	$132.44
Max. Negotiated Rate	$323.29
Rate for Payer: Anthem Medicaid	$132.44
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$323.29
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$132.44
Rate for Payer: Dean Health Medicaid	$132.44
Rate for Payer: Independent Care Health Plan Medicaid	$132.44
Rate for Payer: Managed Health Services Medicaid	$137.74
Rate for Payer: Molina Healthcare Medicaid	$323.29
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$132.44
Rate for Payer: United Healthcare Medicaid	$132.44
Rate for Payer: WMAP Medicaid	$132.44

EAPG 436: CLASS II PHARMACOTHERAPY

Facility OP

$63.36

Service Code	EAPG 00436
Min. Negotiated Rate	$40.29
Max. Negotiated Rate	$63.36
Rate for Payer: Anthem Medicaid	$40.29
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$63.36
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$40.29
Rate for Payer: Dean Health Medicaid	$40.29
Rate for Payer: Independent Care Health Plan Medicaid	$40.29
Rate for Payer: Managed Health Services Medicaid	$41.90
Rate for Payer: Molina Healthcare Medicaid	$63.36
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$40.29
Rate for Payer: United Healthcare Medicaid	$40.29
Rate for Payer: WMAP Medicaid	$40.29

EAPG 437: CLASS III PHARMACOTHERAPY

Facility OP

$137.82

Service Code	EAPG 00437
Min. Negotiated Rate	$48.14
Max. Negotiated Rate	$137.82
Rate for Payer: Anthem Medicaid	$48.14
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$137.82
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$48.14
Rate for Payer: Dean Health Medicaid	$48.14
Rate for Payer: Independent Care Health Plan Medicaid	$48.14
Rate for Payer: Managed Health Services Medicaid	$50.07
Rate for Payer: Molina Healthcare Medicaid	$137.82
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$48.14
Rate for Payer: United Healthcare Medicaid	$48.14
Rate for Payer: WMAP Medicaid	$48.14

EAPG 438: CLASS IV PHARMACOTHERAPY

Facility OP

$252.40

Service Code	EAPG 00438
Min. Negotiated Rate	$78.21
Max. Negotiated Rate	$252.40
Rate for Payer: Anthem Medicaid	$78.21
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$252.40
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$78.21
Rate for Payer: Dean Health Medicaid	$78.21
Rate for Payer: Independent Care Health Plan Medicaid	$78.21
Rate for Payer: Managed Health Services Medicaid	$81.34
Rate for Payer: Molina Healthcare Medicaid	$252.40
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$78.21
Rate for Payer: United Healthcare Medicaid	$78.21
Rate for Payer: WMAP Medicaid	$78.21

EAPG 439: CLASS V PHARMACOTHERAPY

Facility OP

$265.07

Service Code	EAPG 00439
Min. Negotiated Rate	$188.76
Max. Negotiated Rate	$265.07
Rate for Payer: Anthem Medicaid	$188.76
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$265.07
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$188.76
Rate for Payer: Dean Health Medicaid	$188.76
Rate for Payer: Independent Care Health Plan Medicaid	$188.76
Rate for Payer: Managed Health Services Medicaid	$196.31
Rate for Payer: Molina Healthcare Medicaid	$265.07
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$188.76
Rate for Payer: United Healthcare Medicaid	$188.76
Rate for Payer: WMAP Medicaid	$188.76

EAPG 43: OPEN OR PERCUTANEOUS TREATMENT OF FRACTURES

Facility OP

$3,542.29

Service Code	EAPG 00043
Min. Negotiated Rate	$2,191.85
Max. Negotiated Rate	$3,542.29
Rate for Payer: Anthem Medicaid	$2,191.85
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$3,542.29
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,191.85
Rate for Payer: Dean Health Medicaid	$2,191.85
Rate for Payer: Independent Care Health Plan Medicaid	$2,191.85
Rate for Payer: Managed Health Services Medicaid	$2,279.52
Rate for Payer: Molina Healthcare Medicaid	$3,542.29
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,191.85
Rate for Payer: United Healthcare Medicaid	$2,191.85
Rate for Payer: WMAP Medicaid	$2,191.85

EAPG 440: CLASS VI PHARMACOTHERAPY

Facility OP

$532.34

Service Code	EAPG 00440
Min. Negotiated Rate	$230.00
Max. Negotiated Rate	$532.34
Rate for Payer: Anthem Medicaid	$230.00
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$532.34
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$230.00
Rate for Payer: Dean Health Medicaid	$230.00
Rate for Payer: Independent Care Health Plan Medicaid	$230.00
Rate for Payer: Managed Health Services Medicaid	$239.20
Rate for Payer: Molina Healthcare Medicaid	$532.34
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$230.00
Rate for Payer: United Healthcare Medicaid	$230.00
Rate for Payer: WMAP Medicaid	$230.00

EAPG 441: CLASS VI CHEMOTHERAPY DRUGS

Facility OP

$339.39

Service Code	EAPG 00441
Min. Negotiated Rate	$241.46
Max. Negotiated Rate	$339.39
Rate for Payer: Anthem Medicaid	$241.46
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$339.39
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$241.46
Rate for Payer: Dean Health Medicaid	$241.46
Rate for Payer: Independent Care Health Plan Medicaid	$241.46
Rate for Payer: Managed Health Services Medicaid	$251.12
Rate for Payer: Molina Healthcare Medicaid	$339.39
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$241.46
Rate for Payer: United Healthcare Medicaid	$241.46
Rate for Payer: WMAP Medicaid	$241.46

EAPG 443: CLASS VII CHEMOTHERAPY DRUGS

Facility OP

$719.23

Service Code	EAPG 00443
Min. Negotiated Rate	$383.74
Max. Negotiated Rate	$719.23
Rate for Payer: Anthem Medicaid	$383.74
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$719.23
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$383.74
Rate for Payer: Dean Health Medicaid	$383.74
Rate for Payer: Independent Care Health Plan Medicaid	$383.74
Rate for Payer: Managed Health Services Medicaid	$399.09
Rate for Payer: Molina Healthcare Medicaid	$719.23
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$383.74
Rate for Payer: United Healthcare Medicaid	$383.74
Rate for Payer: WMAP Medicaid	$383.74

EAPG 444: CLASS VII PHARMACOTHERAPY

Facility OP

$1,128.58

Service Code	EAPG 00444
Min. Negotiated Rate	$401.84
Max. Negotiated Rate	$1,128.58
Rate for Payer: Anthem Medicaid	$401.84
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,128.58
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$401.84
Rate for Payer: Dean Health Medicaid	$401.84
Rate for Payer: Independent Care Health Plan Medicaid	$401.84
Rate for Payer: Managed Health Services Medicaid	$417.91
Rate for Payer: Molina Healthcare Medicaid	$1,128.58
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$401.84
Rate for Payer: United Healthcare Medicaid	$401.84
Rate for Payer: WMAP Medicaid	$401.84

EAPG 448: EXPANDED HOURS ACCESS

Facility OP

$36.30

Service Code	EAPG 00448
Min. Negotiated Rate	$11.68
Max. Negotiated Rate	$36.30
Rate for Payer: Anthem Medicaid	$11.68
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$36.30
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$11.68
Rate for Payer: Dean Health Medicaid	$11.68
Rate for Payer: Independent Care Health Plan Medicaid	$11.68
Rate for Payer: Managed Health Services Medicaid	$12.15
Rate for Payer: Molina Healthcare Medicaid	$36.30
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$11.68
Rate for Payer: United Healthcare Medicaid	$11.68
Rate for Payer: WMAP Medicaid	$11.68

EAPG 44: BONE OR JOINT MANIPULATION UNDER ANESTHESIA

Facility OP

$801.96

Service Code	EAPG 00044
Min. Negotiated Rate	$401.03
Max. Negotiated Rate	$801.96
Rate for Payer: Anthem Medicaid	$401.03
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$801.96
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$401.03
Rate for Payer: Dean Health Medicaid	$401.03
Rate for Payer: Independent Care Health Plan Medicaid	$401.03
Rate for Payer: Managed Health Services Medicaid	$417.07
Rate for Payer: Molina Healthcare Medicaid	$801.96
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$401.03
Rate for Payer: United Healthcare Medicaid	$401.03
Rate for Payer: WMAP Medicaid	$401.03

EAPG 450: OBSERVATION

Facility OP

$902.50

Service Code	EAPG 00450
Min. Negotiated Rate	$290.78
Max. Negotiated Rate	$902.50
Rate for Payer: Anthem Medicaid	$290.78
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$902.50
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$290.78
Rate for Payer: Dean Health Medicaid	$290.78
Rate for Payer: Independent Care Health Plan Medicaid	$290.78
Rate for Payer: Managed Health Services Medicaid	$302.41
Rate for Payer: Molina Healthcare Medicaid	$902.50
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$290.78
Rate for Payer: United Healthcare Medicaid	$290.78
Rate for Payer: WMAP Medicaid	$290.78

EAPG 455: INCIDENTAL BIOLOGICAL AND SYNTHETIC APPLICATION PRODUCTS

Facility OP

$365.17

Service Code	EAPG 00455
Min. Negotiated Rate	$365.17
Max. Negotiated Rate	$365.17
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$365.17
Rate for Payer: Molina Healthcare Medicaid	$365.17

EAPG 458: ALLERGY THERAPY

Facility OP

$19.42

Service Code	EAPG 00458
Min. Negotiated Rate	$10.42
Max. Negotiated Rate	$19.42
Rate for Payer: Anthem Medicaid	$10.42
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$19.42
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$10.42
Rate for Payer: Dean Health Medicaid	$10.42
Rate for Payer: Independent Care Health Plan Medicaid	$10.42
Rate for Payer: Managed Health Services Medicaid	$10.84
Rate for Payer: Molina Healthcare Medicaid	$19.42
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$10.42
Rate for Payer: United Healthcare Medicaid	$10.42
Rate for Payer: WMAP Medicaid	$10.42

EAPG 459: VACCINE ADMINISTRATION

Facility OP

$32.24

Service Code	EAPG 00459
Min. Negotiated Rate	$16.14
Max. Negotiated Rate	$32.24
Rate for Payer: Anthem Medicaid	$16.14
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$32.24
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$16.14
Rate for Payer: Dean Health Medicaid	$16.14
Rate for Payer: Independent Care Health Plan Medicaid	$16.14
Rate for Payer: Managed Health Services Medicaid	$16.79
Rate for Payer: Molina Healthcare Medicaid	$32.24
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$16.14
Rate for Payer: United Healthcare Medicaid	$16.14
Rate for Payer: WMAP Medicaid	$16.14

EAPG 460: CLASS VIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

Facility OP

$1,185.04

Service Code	EAPG 00460
Min. Negotiated Rate	$523.94
Max. Negotiated Rate	$1,185.04
Rate for Payer: Anthem Medicaid	$523.94
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,185.04
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$523.94
Rate for Payer: Dean Health Medicaid	$523.94
Rate for Payer: Independent Care Health Plan Medicaid	$523.94
Rate for Payer: Managed Health Services Medicaid	$544.90
Rate for Payer: Molina Healthcare Medicaid	$1,185.04
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$523.94
Rate for Payer: United Healthcare Medicaid	$523.94
Rate for Payer: WMAP Medicaid	$523.94

EAPG 461: CLASS IX COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

Facility OP

$1,713.42

Service Code	EAPG 00461
Min. Negotiated Rate	$743.99
Max. Negotiated Rate	$1,713.42
Rate for Payer: Anthem Medicaid	$743.99
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,713.42
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$743.99
Rate for Payer: Dean Health Medicaid	$743.99
Rate for Payer: Independent Care Health Plan Medicaid	$743.99
Rate for Payer: Managed Health Services Medicaid	$773.75
Rate for Payer: Molina Healthcare Medicaid	$1,713.42
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$743.99
Rate for Payer: United Healthcare Medicaid	$743.99
Rate for Payer: WMAP Medicaid	$743.99

EAPG 462: CLASS X COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

Facility OP

$2,544.59

Service Code	EAPG 00462
Min. Negotiated Rate	$1,479.48
Max. Negotiated Rate	$2,544.59
Rate for Payer: Anthem Medicaid	$1,479.48
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,544.59
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,479.48
Rate for Payer: Dean Health Medicaid	$1,479.48
Rate for Payer: Independent Care Health Plan Medicaid	$1,479.48
Rate for Payer: Managed Health Services Medicaid	$1,538.66
Rate for Payer: Molina Healthcare Medicaid	$2,544.59
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,479.48
Rate for Payer: United Healthcare Medicaid	$1,479.48
Rate for Payer: WMAP Medicaid	$1,479.48

EAPG 463: CLASS XI COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

Facility OP

$3,504.18

Service Code	EAPG 00463
Min. Negotiated Rate	$1,841.97
Max. Negotiated Rate	$3,504.18
Rate for Payer: Anthem Medicaid	$1,841.97
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$3,504.18
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,841.97
Rate for Payer: Dean Health Medicaid	$1,841.97
Rate for Payer: Independent Care Health Plan Medicaid	$1,841.97
Rate for Payer: Managed Health Services Medicaid	$1,915.65
Rate for Payer: Molina Healthcare Medicaid	$3,504.18
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,841.97
Rate for Payer: United Healthcare Medicaid	$1,841.97
Rate for Payer: WMAP Medicaid	$1,841.97

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