Beloit Memorial Hospital

All Charges

Charge

Type

Price

EAPG 464: CLASS XII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

Facility OP

$5,581.45

Service Code	EAPG 00464
Min. Negotiated Rate	$2,936.34
Max. Negotiated Rate	$5,581.45
Rate for Payer: Anthem Medicaid	$2,936.34
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$5,581.45
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,936.34
Rate for Payer: Dean Health Medicaid	$2,936.34
Rate for Payer: Independent Care Health Plan Medicaid	$2,936.34
Rate for Payer: Managed Health Services Medicaid	$3,053.79
Rate for Payer: Molina Healthcare Medicaid	$5,581.45
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,936.34
Rate for Payer: United Healthcare Medicaid	$2,936.34
Rate for Payer: WMAP Medicaid	$2,936.34

EAPG 465: CLASS XIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

Facility OP

$14,922.60

Service Code	EAPG 00465
Min. Negotiated Rate	$6,552.07
Max. Negotiated Rate	$14,922.60
Rate for Payer: Anthem Medicaid	$6,552.07
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$14,922.60
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$6,552.07
Rate for Payer: Dean Health Medicaid	$6,552.07
Rate for Payer: Independent Care Health Plan Medicaid	$6,552.07
Rate for Payer: Managed Health Services Medicaid	$6,814.15
Rate for Payer: Molina Healthcare Medicaid	$14,922.60
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$6,552.07
Rate for Payer: United Healthcare Medicaid	$6,552.07
Rate for Payer: WMAP Medicaid	$6,552.07

EAPG 466: CLASS XIV COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

Facility OP

$9,279.30

Service Code	EAPG 00466
Min. Negotiated Rate	$8,922.40
Max. Negotiated Rate	$9,279.30
Rate for Payer: Anthem Medicaid	$8,922.40
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$8,922.40
Rate for Payer: Dean Health Medicaid	$8,922.40
Rate for Payer: Independent Care Health Plan Medicaid	$8,922.40
Rate for Payer: Managed Health Services Medicaid	$9,279.30
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$8,922.40
Rate for Payer: United Healthcare Medicaid	$8,922.40
Rate for Payer: WMAP Medicaid	$8,922.40

EAPG 46: LEVEL I ARTHROPLASTY

Facility OP

$1,954.91

Service Code	EAPG 00046
Min. Negotiated Rate	$1,407.15
Max. Negotiated Rate	$1,954.91
Rate for Payer: Anthem Medicaid	$1,407.15
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,954.91
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,407.15
Rate for Payer: Dean Health Medicaid	$1,407.15
Rate for Payer: Independent Care Health Plan Medicaid	$1,407.15
Rate for Payer: Managed Health Services Medicaid	$1,463.44
Rate for Payer: Molina Healthcare Medicaid	$1,954.91
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,407.15
Rate for Payer: United Healthcare Medicaid	$1,407.15
Rate for Payer: WMAP Medicaid	$1,407.15

EAPG 470: OBSTETRICAL ULTRASOUND

Facility OP

$77.79

Service Code	EAPG 00470
Min. Negotiated Rate	$41.84
Max. Negotiated Rate	$77.79
Rate for Payer: Anthem Medicaid	$41.84
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$77.79
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$41.84
Rate for Payer: Dean Health Medicaid	$41.84
Rate for Payer: Independent Care Health Plan Medicaid	$41.84
Rate for Payer: Managed Health Services Medicaid	$43.51
Rate for Payer: Molina Healthcare Medicaid	$77.79
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$41.84
Rate for Payer: United Healthcare Medicaid	$41.84
Rate for Payer: WMAP Medicaid	$41.84

EAPG 471: LEVEL I CONVENTIONAL RADIOLOGY

Facility OP

$43.98

Service Code	EAPG 00471
Min. Negotiated Rate	$23.33
Max. Negotiated Rate	$43.98
Rate for Payer: Anthem Medicaid	$23.33
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$43.98
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$23.33
Rate for Payer: Dean Health Medicaid	$23.33
Rate for Payer: Independent Care Health Plan Medicaid	$23.33
Rate for Payer: Managed Health Services Medicaid	$24.26
Rate for Payer: Molina Healthcare Medicaid	$43.98
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$23.33
Rate for Payer: United Healthcare Medicaid	$23.33
Rate for Payer: WMAP Medicaid	$23.33

EAPG 472: ULTRASOUND GUIDANCE

Facility OP

$87.72

Service Code	EAPG 00472
Min. Negotiated Rate	$46.71
Max. Negotiated Rate	$87.72
Rate for Payer: Anthem Medicaid	$46.71
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$87.72
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$46.71
Rate for Payer: Dean Health Medicaid	$46.71
Rate for Payer: Independent Care Health Plan Medicaid	$46.71
Rate for Payer: Managed Health Services Medicaid	$48.58
Rate for Payer: Molina Healthcare Medicaid	$87.72
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$46.71
Rate for Payer: United Healthcare Medicaid	$46.71
Rate for Payer: WMAP Medicaid	$46.71

EAPG 473: CT GUIDANCE

Facility OP

$84.64

Service Code	EAPG 00473
Min. Negotiated Rate	$34.21
Max. Negotiated Rate	$84.64
Rate for Payer: Anthem Medicaid	$34.21
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$84.64
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$34.21
Rate for Payer: Dean Health Medicaid	$34.21
Rate for Payer: Independent Care Health Plan Medicaid	$34.21
Rate for Payer: Managed Health Services Medicaid	$35.58
Rate for Payer: Molina Healthcare Medicaid	$84.64
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$34.21
Rate for Payer: United Healthcare Medicaid	$34.21
Rate for Payer: WMAP Medicaid	$34.21

EAPG 474: RADIOLOGICAL GUIDANCE FOR THERAPEUTIC OR DIAGNOSTIC PROCEDURES

Facility OP

$250.64

Service Code	EAPG 00474
Min. Negotiated Rate	$84.01
Max. Negotiated Rate	$250.64
Rate for Payer: Anthem Medicaid	$84.01
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$250.64
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$84.01
Rate for Payer: Dean Health Medicaid	$84.01
Rate for Payer: Independent Care Health Plan Medicaid	$84.01
Rate for Payer: Managed Health Services Medicaid	$87.37
Rate for Payer: Molina Healthcare Medicaid	$250.64
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$84.01
Rate for Payer: United Healthcare Medicaid	$84.01
Rate for Payer: WMAP Medicaid	$84.01

EAPG 475: MRI GUIDANCE

Facility OP

$149.85

Service Code	EAPG 00475
Min. Negotiated Rate	$90.64
Max. Negotiated Rate	$149.85
Rate for Payer: Anthem Medicaid	$90.64
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$149.85
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$90.64
Rate for Payer: Dean Health Medicaid	$90.64
Rate for Payer: Independent Care Health Plan Medicaid	$90.64
Rate for Payer: Managed Health Services Medicaid	$94.27
Rate for Payer: Molina Healthcare Medicaid	$149.85
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$90.64
Rate for Payer: United Healthcare Medicaid	$90.64
Rate for Payer: WMAP Medicaid	$90.64

EAPG 476: LEVEL I RADIATION TREATMENT PREPARATION AND PLANNING

Facility OP

$269.96

Service Code	EAPG 00476
Min. Negotiated Rate	$49.91
Max. Negotiated Rate	$269.96
Rate for Payer: Anthem Medicaid	$49.91
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$269.96
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$49.91
Rate for Payer: Dean Health Medicaid	$49.91
Rate for Payer: Independent Care Health Plan Medicaid	$49.91
Rate for Payer: Managed Health Services Medicaid	$51.91
Rate for Payer: Molina Healthcare Medicaid	$269.96
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$49.91
Rate for Payer: United Healthcare Medicaid	$49.91
Rate for Payer: WMAP Medicaid	$49.91

EAPG 477: LEVEL II RADIATION TREATMENT PREPARATION AND PLANNING

Facility OP

$601.72

Service Code	EAPG 00477
Min. Negotiated Rate	$77.50
Max. Negotiated Rate	$601.72
Rate for Payer: Anthem Medicaid	$77.50
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$601.72
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$77.50
Rate for Payer: Dean Health Medicaid	$77.50
Rate for Payer: Independent Care Health Plan Medicaid	$77.50
Rate for Payer: Managed Health Services Medicaid	$80.60
Rate for Payer: Molina Healthcare Medicaid	$601.72
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$77.50
Rate for Payer: United Healthcare Medicaid	$77.50
Rate for Payer: WMAP Medicaid	$77.50

EAPG 478: LEVEL III RADIATION TREATMENT PREPARATION AND PLANNING

Facility OP

$459.94

Service Code	EAPG 00478
Min. Negotiated Rate	$94.86
Max. Negotiated Rate	$459.94
Rate for Payer: Anthem Medicaid	$442.25
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$94.86
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$442.25
Rate for Payer: Dean Health Medicaid	$442.25
Rate for Payer: Independent Care Health Plan Medicaid	$442.25
Rate for Payer: Managed Health Services Medicaid	$459.94
Rate for Payer: Molina Healthcare Medicaid	$94.86
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$442.25
Rate for Payer: United Healthcare Medicaid	$442.25
Rate for Payer: WMAP Medicaid	$442.25

EAPG 47: LEVEL II ARTHROPLASTY

Facility OP

$6,899.46

Service Code	EAPG 00047
Min. Negotiated Rate	$3,942.17
Max. Negotiated Rate	$6,899.46
Rate for Payer: Anthem Medicaid	$3,942.17
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$6,899.46
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$3,942.17
Rate for Payer: Dean Health Medicaid	$3,942.17
Rate for Payer: Independent Care Health Plan Medicaid	$3,942.17
Rate for Payer: Managed Health Services Medicaid	$4,099.86
Rate for Payer: Molina Healthcare Medicaid	$6,899.46
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$3,942.17
Rate for Payer: United Healthcare Medicaid	$3,942.17
Rate for Payer: WMAP Medicaid	$3,942.17

EAPG 483: RADIATION THERAPY MANAGEMENT

Facility OP

$173.80

Service Code	EAPG 00483
Min. Negotiated Rate	$97.36
Max. Negotiated Rate	$173.80
Rate for Payer: Anthem Medicaid	$167.12
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$97.36
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$167.12
Rate for Payer: Dean Health Medicaid	$167.12
Rate for Payer: Independent Care Health Plan Medicaid	$167.12
Rate for Payer: Managed Health Services Medicaid	$173.80
Rate for Payer: Molina Healthcare Medicaid	$97.36
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$167.12
Rate for Payer: United Healthcare Medicaid	$167.12
Rate for Payer: WMAP Medicaid	$167.12

EAPG 485: CORNEAL TISSUE PROCESSING

Facility OP

$1,927.65

Service Code	EAPG 00485
Min. Negotiated Rate	$1,026.31
Max. Negotiated Rate	$1,927.65
Rate for Payer: Anthem Medicaid	$1,026.31
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,927.65
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,026.31
Rate for Payer: Dean Health Medicaid	$1,026.31
Rate for Payer: Independent Care Health Plan Medicaid	$1,026.31
Rate for Payer: Managed Health Services Medicaid	$1,067.36
Rate for Payer: Molina Healthcare Medicaid	$1,927.65
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,026.31
Rate for Payer: United Healthcare Medicaid	$1,026.31
Rate for Payer: WMAP Medicaid	$1,026.31

EAPG 486: LEVEL I BLOOD AND TISSUE TYPING TESTS

Facility OP

$4.94

Service Code	EAPG 00486
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$4.94
Rate for Payer: Anthem Medicaid	$1.49
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$4.94
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	$4.94
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 488: MINOR DEVICE EVALUATION AND INTERROGATION

Facility OP

$33.42

Service Code	EAPG 00488
Min. Negotiated Rate	$15.03
Max. Negotiated Rate	$33.42
Rate for Payer: Anthem Medicaid	$15.03
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$33.42
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$15.03
Rate for Payer: Dean Health Medicaid	$15.03
Rate for Payer: Independent Care Health Plan Medicaid	$15.03
Rate for Payer: Managed Health Services Medicaid	$15.63
Rate for Payer: Molina Healthcare Medicaid	$33.42
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$15.03
Rate for Payer: United Healthcare Medicaid	$15.03
Rate for Payer: WMAP Medicaid	$15.03

EAPG 493: LEVEL I ANCILLARY THERAPEUTIC SERVICES

Facility OP

$21.82

Service Code	EAPG 00493
Min. Negotiated Rate	$12.58
Max. Negotiated Rate	$21.82
Rate for Payer: Anthem Medicaid	$12.58
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$21.82
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$12.58
Rate for Payer: Dean Health Medicaid	$12.58
Rate for Payer: Independent Care Health Plan Medicaid	$12.58
Rate for Payer: Managed Health Services Medicaid	$13.08
Rate for Payer: Molina Healthcare Medicaid	$21.82
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$12.58
Rate for Payer: United Healthcare Medicaid	$12.58
Rate for Payer: WMAP Medicaid	$12.58

EAPG 494: COMPLEX BLOOD COLLECTION SERVICES

Facility OP

$32.47

Service Code	EAPG 00494
Min. Negotiated Rate	$31.22
Max. Negotiated Rate	$32.47
Rate for Payer: Anthem Medicaid	$31.22
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$31.22
Rate for Payer: Dean Health Medicaid	$31.22
Rate for Payer: Independent Care Health Plan Medicaid	$31.22
Rate for Payer: Managed Health Services Medicaid	$32.47
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$31.22
Rate for Payer: United Healthcare Medicaid	$31.22
Rate for Payer: WMAP Medicaid	$31.22

EAPG 497: TELEHEALTH FACILITATION

Facility OP

$11.55

Service Code	EAPG 00497
Min. Negotiated Rate	$5.85
Max. Negotiated Rate	$11.55
Rate for Payer: Anthem Medicaid	$5.85
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$11.55
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$5.85
Rate for Payer: Dean Health Medicaid	$5.85
Rate for Payer: Independent Care Health Plan Medicaid	$5.85
Rate for Payer: Managed Health Services Medicaid	$6.08
Rate for Payer: Molina Healthcare Medicaid	$11.55
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$5.85
Rate for Payer: United Healthcare Medicaid	$5.85
Rate for Payer: WMAP Medicaid	$5.85

EAPG 499: BLOOD PROCESSING, STORAGE AND RELATED SERVICES

Facility OP

$36.60

Service Code	EAPG 00499
Min. Negotiated Rate	$35.19
Max. Negotiated Rate	$36.60
Rate for Payer: Anthem Medicaid	$35.19
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$35.19
Rate for Payer: Dean Health Medicaid	$35.19
Rate for Payer: Independent Care Health Plan Medicaid	$35.19
Rate for Payer: Managed Health Services Medicaid	$36.60
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$35.19
Rate for Payer: United Healthcare Medicaid	$35.19
Rate for Payer: WMAP Medicaid	$35.19

EAPG 49: LEVEL I JOINT, TENDON, OR LIGAMENT INJECTION PROCEDURES

Facility OP

$255.82

Service Code	EAPG 00049
Min. Negotiated Rate	$102.28
Max. Negotiated Rate	$255.82
Rate for Payer: Anthem Medicaid	$102.28
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$255.82
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$102.28
Rate for Payer: Dean Health Medicaid	$102.28
Rate for Payer: Independent Care Health Plan Medicaid	$102.28
Rate for Payer: Managed Health Services Medicaid	$106.37
Rate for Payer: Molina Healthcare Medicaid	$255.82
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$102.28
Rate for Payer: United Healthcare Medicaid	$102.28
Rate for Payer: WMAP Medicaid	$102.28

EAPG 4: LEVEL II SKIN INCISION AND DRAINAGE, DEBRIDEMENT, DESTRUCTION, OTHER RELATED PX

Facility OP

$828.28

Service Code	EAPG 00004
Min. Negotiated Rate	$445.72
Max. Negotiated Rate	$828.28
Rate for Payer: Anthem Medicaid	$445.72
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$828.28
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$445.72
Rate for Payer: Dean Health Medicaid	$445.72
Rate for Payer: Independent Care Health Plan Medicaid	$445.72
Rate for Payer: Managed Health Services Medicaid	$463.55
Rate for Payer: Molina Healthcare Medicaid	$828.28
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$445.72
Rate for Payer: United Healthcare Medicaid	$445.72
Rate for Payer: WMAP Medicaid	$445.72

EAPG 50: LEVEL II JOINT, TENDON, OR LIGAMENT INJECTION PROCEDURES

Facility OP

$198.28

Service Code	EAPG 00050
Min. Negotiated Rate	$190.65
Max. Negotiated Rate	$198.28
Rate for Payer: Anthem Medicaid	$190.65
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$190.65
Rate for Payer: Dean Health Medicaid	$190.65
Rate for Payer: Independent Care Health Plan Medicaid	$190.65
Rate for Payer: Managed Health Services Medicaid	$198.28
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$190.65
Rate for Payer: United Healthcare Medicaid	$190.65
Rate for Payer: WMAP Medicaid	$190.65

Price Transparency.

All Charges