Beloit Memorial Hospital

All Charges

Charge

Type

Setting

Price

EAPG 289: LEVEL II DIAGNOSTIC ULTRASOUND

Facility

$158.22

Service Code	EAPG 00289
Min. Negotiated Rate	$69.96
Max. Negotiated Rate	$158.22
Rate for Payer: Anthem Medicaid	$69.96
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$158.22
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$69.96
Rate for Payer: Dean Health Medicaid	$69.96
Rate for Payer: Independent Care Health Plan Medicaid	$69.96
Rate for Payer: Managed Health Services Medicaid	$72.76
Rate for Payer: Molina Healthcare Medicaid	$158.22
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$69.96
Rate for Payer: United Healthcare Medicaid	$69.96
Rate for Payer: WMAP Medicaid	$69.96

EAPG 28: LEVEL I SPINE PROCEDURES

Facility

$2,132.37

Service Code	EAPG 00028
Min. Negotiated Rate	$2,050.36
Max. Negotiated Rate	$2,132.37
Rate for Payer: Anthem Medicaid	$2,050.36
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,050.36
Rate for Payer: Dean Health Medicaid	$2,050.36
Rate for Payer: Independent Care Health Plan Medicaid	$2,050.36
Rate for Payer: Managed Health Services Medicaid	$2,132.37
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,050.36
Rate for Payer: United Healthcare Medicaid	$2,050.36
Rate for Payer: WMAP Medicaid	$2,050.36

EAPG 290: PET SCANS

Facility

$966.98

Service Code	EAPG 00290
Min. Negotiated Rate	$554.37
Max. Negotiated Rate	$966.98
Rate for Payer: Anthem Medicaid	$554.37
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$966.98
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$554.37
Rate for Payer: Dean Health Medicaid	$554.37
Rate for Payer: Independent Care Health Plan Medicaid	$554.37
Rate for Payer: Managed Health Services Medicaid	$576.54
Rate for Payer: Molina Healthcare Medicaid	$966.98
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$554.37
Rate for Payer: United Healthcare Medicaid	$554.37
Rate for Payer: WMAP Medicaid	$554.37

EAPG 291: BONE DENSITY AND RELATED PROCEDURES

Facility

$69.47

Service Code	EAPG 00291
Min. Negotiated Rate	$32.77
Max. Negotiated Rate	$69.47
Rate for Payer: Anthem Medicaid	$32.77
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$69.47
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$32.77
Rate for Payer: Dean Health Medicaid	$32.77
Rate for Payer: Independent Care Health Plan Medicaid	$32.77
Rate for Payer: Managed Health Services Medicaid	$34.08
Rate for Payer: Molina Healthcare Medicaid	$69.47
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$32.77
Rate for Payer: United Healthcare Medicaid	$32.77
Rate for Payer: WMAP Medicaid	$32.77

EAPG 293: MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST

Facility

$184.79

Service Code	EAPG 00293
Min. Negotiated Rate	$100.26
Max. Negotiated Rate	$184.79
Rate for Payer: Anthem Medicaid	$100.26
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$184.79
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$100.26
Rate for Payer: Dean Health Medicaid	$100.26
Rate for Payer: Independent Care Health Plan Medicaid	$100.26
Rate for Payer: Managed Health Services Medicaid	$104.27
Rate for Payer: Molina Healthcare Medicaid	$184.79
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$100.26
Rate for Payer: United Healthcare Medicaid	$100.26
Rate for Payer: WMAP Medicaid	$100.26

EAPG 295: MAGNETIC RESONANCE IMAGING WITH CONTRAST

Facility

$376.37

Service Code	EAPG 00295
Min. Negotiated Rate	$169.14
Max. Negotiated Rate	$376.37
Rate for Payer: Anthem Medicaid	$169.14
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$376.37
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$169.14
Rate for Payer: Dean Health Medicaid	$169.14
Rate for Payer: Independent Care Health Plan Medicaid	$169.14
Rate for Payer: Managed Health Services Medicaid	$175.91
Rate for Payer: Molina Healthcare Medicaid	$376.37
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$169.14
Rate for Payer: United Healthcare Medicaid	$169.14
Rate for Payer: WMAP Medicaid	$169.14

EAPG 297: MAGNETOCEPHALOGRAPHY

Facility

$1,005.37

Service Code	EAPG 00297
Min. Negotiated Rate	$306.75
Max. Negotiated Rate	$1,005.37
Rate for Payer: Anthem Medicaid	$966.70
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$306.75
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$966.70
Rate for Payer: Dean Health Medicaid	$966.70
Rate for Payer: Independent Care Health Plan Medicaid	$966.70
Rate for Payer: Managed Health Services Medicaid	$1,005.37
Rate for Payer: Molina Healthcare Medicaid	$306.75
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$966.70
Rate for Payer: United Healthcare Medicaid	$966.70
Rate for Payer: WMAP Medicaid	$966.70

EAPG 299: LEVEL I COMPUTED TOMOGRAPHY

Facility

$225.83

Service Code	EAPG 00299
Min. Negotiated Rate	$44.34
Max. Negotiated Rate	$225.83
Rate for Payer: Anthem Medicaid	$44.34
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$225.83
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$44.34
Rate for Payer: Dean Health Medicaid	$44.34
Rate for Payer: Independent Care Health Plan Medicaid	$44.34
Rate for Payer: Managed Health Services Medicaid	$46.11
Rate for Payer: Molina Healthcare Medicaid	$225.83
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$44.34
Rate for Payer: United Healthcare Medicaid	$44.34
Rate for Payer: WMAP Medicaid	$44.34

EAPG 29: LEVEL II SPINE PROCEDURES

Facility

$4,965.36

Service Code	EAPG 00029
Min. Negotiated Rate	$4,774.38
Max. Negotiated Rate	$4,965.36
Rate for Payer: Anthem Medicaid	$4,774.38
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$4,774.38
Rate for Payer: Dean Health Medicaid	$4,774.38
Rate for Payer: Independent Care Health Plan Medicaid	$4,774.38
Rate for Payer: Managed Health Services Medicaid	$4,965.36
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$4,774.38
Rate for Payer: United Healthcare Medicaid	$4,774.38
Rate for Payer: WMAP Medicaid	$4,774.38

EAPG 2: SUPERFICIAL NEEDLE BIOPSY AND ASPIRATION

Facility

$480.73

Service Code	EAPG 00002
Min. Negotiated Rate	$283.75
Max. Negotiated Rate	$480.73
Rate for Payer: Anthem Medicaid	$283.75
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$480.73
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$283.75
Rate for Payer: Dean Health Medicaid	$283.75
Rate for Payer: Independent Care Health Plan Medicaid	$283.75
Rate for Payer: Managed Health Services Medicaid	$295.10
Rate for Payer: Molina Healthcare Medicaid	$480.73
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$283.75
Rate for Payer: United Healthcare Medicaid	$283.75
Rate for Payer: WMAP Medicaid	$283.75

EAPG 300: LEVEL II COMPUTED TOMOGRAPHY

Facility

$248.24

Service Code	EAPG 00300
Min. Negotiated Rate	$126.32
Max. Negotiated Rate	$248.24
Rate for Payer: Anthem Medicaid	$126.32
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$248.24
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$126.32
Rate for Payer: Dean Health Medicaid	$126.32
Rate for Payer: Independent Care Health Plan Medicaid	$126.32
Rate for Payer: Managed Health Services Medicaid	$131.37
Rate for Payer: Molina Healthcare Medicaid	$248.24
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$126.32
Rate for Payer: United Healthcare Medicaid	$126.32
Rate for Payer: WMAP Medicaid	$126.32

EAPG 3011: BONE CONDUCTION HEARING DEVICE IMPLANTATION

Facility

$3,616.25

Service Code	EAPG 03011
Min. Negotiated Rate	$3,477.16
Max. Negotiated Rate	$3,616.25
Rate for Payer: Anthem Medicaid	$3,477.16
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$3,477.16
Rate for Payer: Dean Health Medicaid	$3,477.16
Rate for Payer: Independent Care Health Plan Medicaid	$3,477.16
Rate for Payer: Managed Health Services Medicaid	$3,616.25
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$3,477.16
Rate for Payer: United Healthcare Medicaid	$3,477.16
Rate for Payer: WMAP Medicaid	$3,477.16

EAPG 301: COMPUTED TOMOGRAPHY- OTHER

Facility

$111.56

Service Code	EAPG 00301
Min. Negotiated Rate	$107.27
Max. Negotiated Rate	$111.56
Rate for Payer: Anthem Medicaid	$107.27
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$109.74
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$107.27
Rate for Payer: Dean Health Medicaid	$107.27
Rate for Payer: Independent Care Health Plan Medicaid	$107.27
Rate for Payer: Managed Health Services Medicaid	$111.56
Rate for Payer: Molina Healthcare Medicaid	$109.74
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$107.27
Rate for Payer: United Healthcare Medicaid	$107.27
Rate for Payer: WMAP Medicaid	$107.27

EAPG 302: COMPUTED TOMOGRAPHIC ANGIOGRAPHY

Facility

$248.00

Service Code	EAPG 00302
Min. Negotiated Rate	$154.34
Max. Negotiated Rate	$248.00
Rate for Payer: Anthem Medicaid	$154.34
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$248.00
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$154.34
Rate for Payer: Dean Health Medicaid	$154.34
Rate for Payer: Independent Care Health Plan Medicaid	$154.34
Rate for Payer: Managed Health Services Medicaid	$160.51
Rate for Payer: Molina Healthcare Medicaid	$248.00
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$154.34
Rate for Payer: United Healthcare Medicaid	$154.34
Rate for Payer: WMAP Medicaid	$154.34

EAPG 3030: SPINAL IMPLANTATION OF DRUG INFUSION DEVICE

Facility

$5,157.53

Service Code	EAPG 03030
Min. Negotiated Rate	$4,959.16
Max. Negotiated Rate	$5,157.53
Rate for Payer: Anthem Medicaid	$4,959.16
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$4,959.16
Rate for Payer: Dean Health Medicaid	$4,959.16
Rate for Payer: Independent Care Health Plan Medicaid	$4,959.16
Rate for Payer: Managed Health Services Medicaid	$5,157.53
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$4,959.16
Rate for Payer: United Healthcare Medicaid	$4,959.16
Rate for Payer: WMAP Medicaid	$4,959.16

EAPG 3033: INGUINAL, FEMORAL AND UMBILICAL HERNIA REPAIR

Facility

$1,522.68

Service Code	EAPG 03033
Min. Negotiated Rate	$1,464.12
Max. Negotiated Rate	$1,522.68
Rate for Payer: Anthem Medicaid	$1,464.12
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,464.12
Rate for Payer: Dean Health Medicaid	$1,464.12
Rate for Payer: Independent Care Health Plan Medicaid	$1,464.12
Rate for Payer: Managed Health Services Medicaid	$1,522.68
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,464.12
Rate for Payer: United Healthcare Medicaid	$1,464.12
Rate for Payer: WMAP Medicaid	$1,464.12

EAPG 3035: ABDOMINAL HERNIA REPAIR

Facility

$1,864.38

Service Code	EAPG 03035
Min. Negotiated Rate	$1,792.67
Max. Negotiated Rate	$1,864.38
Rate for Payer: Anthem Medicaid	$1,792.67
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,792.67
Rate for Payer: Dean Health Medicaid	$1,792.67
Rate for Payer: Independent Care Health Plan Medicaid	$1,792.67
Rate for Payer: Managed Health Services Medicaid	$1,864.38
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,792.67
Rate for Payer: United Healthcare Medicaid	$1,792.67
Rate for Payer: WMAP Medicaid	$1,792.67

EAPG 304: MINOR SPECIMEN COLLECTION SERVICES

Facility

$1.16

Service Code	EAPG 00304
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$1.16
Rate for Payer: Anthem Medicaid	$1.12
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1.12
Rate for Payer: Dean Health Medicaid	$1.12
Rate for Payer: Independent Care Health Plan Medicaid	$1.12
Rate for Payer: Managed Health Services Medicaid	$1.16
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1.12
Rate for Payer: United Healthcare Medicaid	$1.12
Rate for Payer: WMAP Medicaid	$1.12

EAPG 3050: OTHER TRANSPLANT PROCEDURES

Facility

$2,106.51

Service Code	EAPG 03050
Min. Negotiated Rate	$2,025.49
Max. Negotiated Rate	$2,106.51
Rate for Payer: Anthem Medicaid	$2,025.49
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,025.49
Rate for Payer: Dean Health Medicaid	$2,025.49
Rate for Payer: Independent Care Health Plan Medicaid	$2,025.49
Rate for Payer: Managed Health Services Medicaid	$2,106.51
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,025.49
Rate for Payer: United Healthcare Medicaid	$2,025.49
Rate for Payer: WMAP Medicaid	$2,025.49

EAPG 3051: HEART AND/OR LUNG TRANSPLANT

Facility

$5,440.02

Service Code	EAPG 03051
Min. Negotiated Rate	$5,230.79
Max. Negotiated Rate	$5,440.02
Rate for Payer: Anthem Medicaid	$5,230.79
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$5,230.79
Rate for Payer: Dean Health Medicaid	$5,230.79
Rate for Payer: Independent Care Health Plan Medicaid	$5,230.79
Rate for Payer: Managed Health Services Medicaid	$5,440.02
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$5,230.79
Rate for Payer: United Healthcare Medicaid	$5,230.79
Rate for Payer: WMAP Medicaid	$5,230.79

EAPG 3052: KIDNEY TRANSPLANT

Facility

$3,730.29

Service Code	EAPG 03052
Min. Negotiated Rate	$3,586.82
Max. Negotiated Rate	$3,730.29
Rate for Payer: Anthem Medicaid	$3,586.82
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$3,586.82
Rate for Payer: Dean Health Medicaid	$3,586.82
Rate for Payer: Independent Care Health Plan Medicaid	$3,586.82
Rate for Payer: Managed Health Services Medicaid	$3,730.29
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$3,586.82
Rate for Payer: United Healthcare Medicaid	$3,586.82
Rate for Payer: WMAP Medicaid	$3,586.82

EAPG 305: LEVEL I SURGICAL PATHOLOGY TESTS

Facility

$13.93

Service Code	EAPG 00305
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$13.93
Rate for Payer: Anthem Medicaid	$13.39
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$13.39
Rate for Payer: Dean Health Medicaid	$13.39
Rate for Payer: Independent Care Health Plan Medicaid	$13.39
Rate for Payer: Managed Health Services Medicaid	$13.93
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$13.39
Rate for Payer: United Healthcare Medicaid	$13.39
Rate for Payer: WMAP Medicaid	$13.39

EAPG 3060: VENTRICULAR ASSIST DEVICE PROCEDURES

Facility

$12,750.02

Service Code	EAPG 03060
Min. Negotiated Rate	$12,259.63
Max. Negotiated Rate	$12,750.02
Rate for Payer: Anthem Medicaid	$12,259.63
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$12,259.63
Rate for Payer: Dean Health Medicaid	$12,259.63
Rate for Payer: Independent Care Health Plan Medicaid	$12,259.63
Rate for Payer: Managed Health Services Medicaid	$12,750.02
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$12,259.63
Rate for Payer: United Healthcare Medicaid	$12,259.63
Rate for Payer: WMAP Medicaid	$12,259.63

EAPG 306: LEVEL II SURGICAL PATHOLOGY TESTS

Facility

$56.86

Service Code	EAPG 00306
Min. Negotiated Rate	$54.67
Max. Negotiated Rate	$56.86
Rate for Payer: Anthem Medicaid	$54.67
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$54.67
Rate for Payer: Dean Health Medicaid	$54.67
Rate for Payer: Independent Care Health Plan Medicaid	$54.67
Rate for Payer: Managed Health Services Medicaid	$56.86
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$54.67
Rate for Payer: United Healthcare Medicaid	$54.67
Rate for Payer: WMAP Medicaid	$54.67

EAPG 3070: EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) PROCEDURES

Facility

$2,999.93

Service Code	EAPG 03070
Min. Negotiated Rate	$2,884.55
Max. Negotiated Rate	$2,999.93
Rate for Payer: Anthem Medicaid	$2,884.55
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,884.55
Rate for Payer: Dean Health Medicaid	$2,884.55
Rate for Payer: Independent Care Health Plan Medicaid	$2,884.55
Rate for Payer: Managed Health Services Medicaid	$2,999.93
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,884.55
Rate for Payer: United Healthcare Medicaid	$2,884.55
Rate for Payer: WMAP Medicaid	$2,884.55

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