Beloit Memorial Hospital

All Charges

Charge

Type

Setting

Price

EAPG 33: LEVEL I HAND PROCEDURES

Facility

$916.20

Service Code	EAPG 00033
Min. Negotiated Rate	$542.06
Max. Negotiated Rate	$916.20
Rate for Payer: Anthem Medicaid	$542.06
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$916.20
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$542.06
Rate for Payer: Dean Health Medicaid	$542.06
Rate for Payer: Independent Care Health Plan Medicaid	$542.06
Rate for Payer: Managed Health Services Medicaid	$563.74
Rate for Payer: Molina Healthcare Medicaid	$916.20
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$542.06
Rate for Payer: United Healthcare Medicaid	$542.06
Rate for Payer: WMAP Medicaid	$542.06

EAPG 340: THERAPEUTIC NUCLEAR MEDICINE

Facility

$241.54

Service Code	EAPG 00340
Min. Negotiated Rate	$112.93
Max. Negotiated Rate	$241.54
Rate for Payer: Anthem Medicaid	$112.93
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$241.54
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$112.93
Rate for Payer: Dean Health Medicaid	$112.93
Rate for Payer: Independent Care Health Plan Medicaid	$112.93
Rate for Payer: Managed Health Services Medicaid	$117.45
Rate for Payer: Molina Healthcare Medicaid	$241.54
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$112.93
Rate for Payer: United Healthcare Medicaid	$112.93
Rate for Payer: WMAP Medicaid	$112.93

EAPG 343: LEVEL I RADIATION THERAPY

Facility

$651.08

Service Code	EAPG 00343
Min. Negotiated Rate	$74.71
Max. Negotiated Rate	$651.08
Rate for Payer: Anthem Medicaid	$74.71
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$651.08
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	$651.08
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 346: RADIOSURGERY

Facility

$3,593.17

Service Code	EAPG 00346
Min. Negotiated Rate	$2,258.49
Max. Negotiated Rate	$3,593.17
Rate for Payer: Anthem Medicaid	$2,258.49
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$3,593.17
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,258.49
Rate for Payer: Dean Health Medicaid	$2,258.49
Rate for Payer: Independent Care Health Plan Medicaid	$2,258.49
Rate for Payer: Managed Health Services Medicaid	$2,348.83
Rate for Payer: Molina Healthcare Medicaid	$3,593.17
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,258.49
Rate for Payer: United Healthcare Medicaid	$2,258.49
Rate for Payer: WMAP Medicaid	$2,258.49

EAPG 347: LEVEL II RADIATION THERAPY

Facility

$387.77

Service Code	EAPG 00347
Min. Negotiated Rate	$196.41
Max. Negotiated Rate	$387.77
Rate for Payer: Anthem Medicaid	$196.41
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$387.77
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$196.41
Rate for Payer: Dean Health Medicaid	$196.41
Rate for Payer: Independent Care Health Plan Medicaid	$196.41
Rate for Payer: Managed Health Services Medicaid	$204.27
Rate for Payer: Molina Healthcare Medicaid	$387.77
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$196.41
Rate for Payer: United Healthcare Medicaid	$196.41
Rate for Payer: WMAP Medicaid	$196.41

EAPG 348: LEVEL III RADIATION THERAPY

Facility

$2,255.93

Service Code	EAPG 00348
Min. Negotiated Rate	$591.18
Max. Negotiated Rate	$2,255.93
Rate for Payer: Anthem Medicaid	$591.18
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,255.93
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$591.18
Rate for Payer: Dean Health Medicaid	$591.18
Rate for Payer: Independent Care Health Plan Medicaid	$591.18
Rate for Payer: Managed Health Services Medicaid	$614.83
Rate for Payer: Molina Healthcare Medicaid	$2,255.93
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$591.18
Rate for Payer: United Healthcare Medicaid	$591.18
Rate for Payer: WMAP Medicaid	$591.18

EAPG 34: LEVEL II HAND PROCEDURES

Facility

$1,504.41

Service Code	EAPG 00034
Min. Negotiated Rate	$893.94
Max. Negotiated Rate	$1,504.41
Rate for Payer: Anthem Medicaid	$893.94
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,504.41
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$893.94
Rate for Payer: Dean Health Medicaid	$893.94
Rate for Payer: Independent Care Health Plan Medicaid	$893.94
Rate for Payer: Managed Health Services Medicaid	$929.70
Rate for Payer: Molina Healthcare Medicaid	$1,504.41
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$893.94
Rate for Payer: United Healthcare Medicaid	$893.94
Rate for Payer: WMAP Medicaid	$893.94

EAPG 350: ADJUNCTIVE DENTAL SERVICES

Facility

$189.19

Service Code	EAPG 00350
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$189.19
Rate for Payer: Anthem Medicaid	$96.25
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$189.19
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$96.25
Rate for Payer: Dean Health Medicaid	$96.25
Rate for Payer: Independent Care Health Plan Medicaid	$96.25
Rate for Payer: Managed Health Services Medicaid	$100.10
Rate for Payer: Molina Healthcare Medicaid	$189.19
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$96.25
Rate for Payer: United Healthcare Medicaid	$96.25
Rate for Payer: WMAP Medicaid	$96.25

EAPG 352: LEVEL I PERIODONTICS

Facility

$778.77

Service Code	EAPG 00352
Min. Negotiated Rate	$438.91
Max. Negotiated Rate	$778.77
Rate for Payer: Anthem Medicaid	$438.91
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$778.77
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$438.91
Rate for Payer: Dean Health Medicaid	$438.91
Rate for Payer: Independent Care Health Plan Medicaid	$438.91
Rate for Payer: Managed Health Services Medicaid	$456.47
Rate for Payer: Molina Healthcare Medicaid	$778.77
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$438.91
Rate for Payer: United Healthcare Medicaid	$438.91
Rate for Payer: WMAP Medicaid	$438.91

EAPG 353: LEVEL I PROSTHODONTICS, FIXED

Facility

$75.34

Service Code	EAPG 00353
Min. Negotiated Rate	$42.47
Max. Negotiated Rate	$75.34
Rate for Payer: Anthem Medicaid	$42.47
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$75.34
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$42.47
Rate for Payer: Dean Health Medicaid	$42.47
Rate for Payer: Independent Care Health Plan Medicaid	$42.47
Rate for Payer: Managed Health Services Medicaid	$44.17
Rate for Payer: Molina Healthcare Medicaid	$75.34
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$42.47
Rate for Payer: United Healthcare Medicaid	$42.47
Rate for Payer: WMAP Medicaid	$42.47

EAPG 354: LEVEL II PROSTHODONTICS, FIXED

Facility

$281.85

Service Code	EAPG 00354
Min. Negotiated Rate	$158.87
Max. Negotiated Rate	$281.85
Rate for Payer: Anthem Medicaid	$158.87
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$281.85
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$158.87
Rate for Payer: Dean Health Medicaid	$158.87
Rate for Payer: Independent Care Health Plan Medicaid	$158.87
Rate for Payer: Managed Health Services Medicaid	$165.22
Rate for Payer: Molina Healthcare Medicaid	$281.85
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$158.87
Rate for Payer: United Healthcare Medicaid	$158.87
Rate for Payer: WMAP Medicaid	$158.87

EAPG 355: LEVEL III PROSTHODONTICS, FIXED

Facility

$348.68

Service Code	EAPG 00355
Min. Negotiated Rate	$196.54
Max. Negotiated Rate	$348.68
Rate for Payer: Anthem Medicaid	$196.54
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$348.68
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$196.54
Rate for Payer: Dean Health Medicaid	$196.54
Rate for Payer: Independent Care Health Plan Medicaid	$196.54
Rate for Payer: Managed Health Services Medicaid	$204.40
Rate for Payer: Molina Healthcare Medicaid	$348.68
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$196.54
Rate for Payer: United Healthcare Medicaid	$196.54
Rate for Payer: WMAP Medicaid	$196.54

EAPG 356: LEVEL I PROSTHODONTICS, REMOVABLE

Facility

$152.74

Service Code	EAPG 00356
Min. Negotiated Rate	$86.07
Max. Negotiated Rate	$152.74
Rate for Payer: Anthem Medicaid	$86.07
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$152.74
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$86.07
Rate for Payer: Dean Health Medicaid	$86.07
Rate for Payer: Independent Care Health Plan Medicaid	$86.07
Rate for Payer: Managed Health Services Medicaid	$89.51
Rate for Payer: Molina Healthcare Medicaid	$152.74
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$86.07
Rate for Payer: United Healthcare Medicaid	$86.07
Rate for Payer: WMAP Medicaid	$86.07

EAPG 357: LEVEL II PROSTHODONTICS, REMOVABLE

Facility

$188.80

Service Code	EAPG 00357
Min. Negotiated Rate	$106.43
Max. Negotiated Rate	$188.80
Rate for Payer: Anthem Medicaid	$106.43
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$188.80
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$106.43
Rate for Payer: Dean Health Medicaid	$106.43
Rate for Payer: Independent Care Health Plan Medicaid	$106.43
Rate for Payer: Managed Health Services Medicaid	$110.69
Rate for Payer: Molina Healthcare Medicaid	$188.80
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$106.43
Rate for Payer: United Healthcare Medicaid	$106.43
Rate for Payer: WMAP Medicaid	$106.43

EAPG 358: LEVEL III PROSTHODONTICS, REMOVABLE

Facility

$224.85

Service Code	EAPG 00358
Min. Negotiated Rate	$126.75
Max. Negotiated Rate	$224.85
Rate for Payer: Anthem Medicaid	$126.75
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$224.85
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$126.75
Rate for Payer: Dean Health Medicaid	$126.75
Rate for Payer: Independent Care Health Plan Medicaid	$126.75
Rate for Payer: Managed Health Services Medicaid	$131.82
Rate for Payer: Molina Healthcare Medicaid	$224.85
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$126.75
Rate for Payer: United Healthcare Medicaid	$126.75
Rate for Payer: WMAP Medicaid	$126.75

EAPG 359: LEVEL I MAXILLOFACIAL PROSTHETICS

Facility

$659.06

Service Code	EAPG 00359
Min. Negotiated Rate	$42.42
Max. Negotiated Rate	$659.06
Rate for Payer: Anthem Medicaid	$633.71
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$42.42
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$633.71
Rate for Payer: Dean Health Medicaid	$633.71
Rate for Payer: Independent Care Health Plan Medicaid	$633.71
Rate for Payer: Managed Health Services Medicaid	$659.06
Rate for Payer: Molina Healthcare Medicaid	$42.42
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$633.71
Rate for Payer: United Healthcare Medicaid	$633.71
Rate for Payer: WMAP Medicaid	$633.71

EAPG 35: LEVEL I FOOT PROCEDURES

Facility

$1,491.40

Service Code	EAPG 00035
Min. Negotiated Rate	$888.02
Max. Negotiated Rate	$1,491.40
Rate for Payer: Anthem Medicaid	$888.02
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,491.40
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$888.02
Rate for Payer: Dean Health Medicaid	$888.02
Rate for Payer: Independent Care Health Plan Medicaid	$888.02
Rate for Payer: Managed Health Services Medicaid	$923.54
Rate for Payer: Molina Healthcare Medicaid	$1,491.40
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$888.02
Rate for Payer: United Healthcare Medicaid	$888.02
Rate for Payer: WMAP Medicaid	$888.02

EAPG 360: LEVEL II MAXILLOFACIAL PROSTHETICS

Facility

$1,483.19

Service Code	EAPG 00360
Min. Negotiated Rate	$221.58
Max. Negotiated Rate	$1,483.19
Rate for Payer: Anthem Medicaid	$1,426.14
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$221.58
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,426.14
Rate for Payer: Dean Health Medicaid	$1,426.14
Rate for Payer: Independent Care Health Plan Medicaid	$1,426.14
Rate for Payer: Managed Health Services Medicaid	$1,483.19
Rate for Payer: Molina Healthcare Medicaid	$221.58
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,426.14
Rate for Payer: United Healthcare Medicaid	$1,426.14
Rate for Payer: WMAP Medicaid	$1,426.14

EAPG 361: LEVEL I DENTAL RESTORATIONS

Facility

$1,298.10

Service Code	EAPG 00361
Min. Negotiated Rate	$833.09
Max. Negotiated Rate	$1,298.10
Rate for Payer: Anthem Medicaid	$833.09
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,298.10
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$833.09
Rate for Payer: Dean Health Medicaid	$833.09
Rate for Payer: Independent Care Health Plan Medicaid	$833.09
Rate for Payer: Managed Health Services Medicaid	$866.41
Rate for Payer: Molina Healthcare Medicaid	$1,298.10
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$833.09
Rate for Payer: United Healthcare Medicaid	$833.09
Rate for Payer: WMAP Medicaid	$833.09

EAPG 362: LEVEL II DENTAL RESTORATIONS

Facility

$1,405.98

Service Code	EAPG 00362
Min. Negotiated Rate	$1,031.13
Max. Negotiated Rate	$1,405.98
Rate for Payer: Anthem Medicaid	$1,031.13
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,405.98
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,031.13
Rate for Payer: Dean Health Medicaid	$1,031.13
Rate for Payer: Independent Care Health Plan Medicaid	$1,031.13
Rate for Payer: Managed Health Services Medicaid	$1,072.38
Rate for Payer: Molina Healthcare Medicaid	$1,405.98
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,031.13
Rate for Payer: United Healthcare Medicaid	$1,031.13
Rate for Payer: WMAP Medicaid	$1,031.13

EAPG 363: LEVEL III DENTAL RESTORATIONS

Facility

$1,546.59

Service Code	EAPG 00363
Min. Negotiated Rate	$1,134.25
Max. Negotiated Rate	$1,546.59
Rate for Payer: Anthem Medicaid	$1,134.25
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,546.59
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,134.25
Rate for Payer: Dean Health Medicaid	$1,134.25
Rate for Payer: Independent Care Health Plan Medicaid	$1,134.25
Rate for Payer: Managed Health Services Medicaid	$1,179.62
Rate for Payer: Molina Healthcare Medicaid	$1,546.59
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,134.25
Rate for Payer: United Healthcare Medicaid	$1,134.25
Rate for Payer: WMAP Medicaid	$1,134.25

EAPG 364: LEVEL I ENDODONTICS

Facility

$103.52

Service Code	EAPG 00364
Min. Negotiated Rate	$58.34
Max. Negotiated Rate	$103.52
Rate for Payer: Anthem Medicaid	$58.34
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$103.52
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$58.34
Rate for Payer: Dean Health Medicaid	$58.34
Rate for Payer: Independent Care Health Plan Medicaid	$58.34
Rate for Payer: Managed Health Services Medicaid	$60.67
Rate for Payer: Molina Healthcare Medicaid	$103.52
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$58.34
Rate for Payer: United Healthcare Medicaid	$58.34
Rate for Payer: WMAP Medicaid	$58.34

EAPG 365: LEVEL II ENDODONTICS

Facility

$186.16

Service Code	EAPG 00365
Min. Negotiated Rate	$104.92
Max. Negotiated Rate	$186.16
Rate for Payer: Anthem Medicaid	$104.92
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$186.16
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$104.92
Rate for Payer: Dean Health Medicaid	$104.92
Rate for Payer: Independent Care Health Plan Medicaid	$104.92
Rate for Payer: Managed Health Services Medicaid	$109.12
Rate for Payer: Molina Healthcare Medicaid	$186.16
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$104.92
Rate for Payer: United Healthcare Medicaid	$104.92
Rate for Payer: WMAP Medicaid	$104.92

EAPG 366: LEVEL III ENDODONTICS

Facility

$187.53

Service Code	EAPG 00366
Min. Negotiated Rate	$125.00
Max. Negotiated Rate	$187.53
Rate for Payer: Anthem Medicaid	$125.00
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$187.53
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$125.00
Rate for Payer: Dean Health Medicaid	$125.00
Rate for Payer: Independent Care Health Plan Medicaid	$125.00
Rate for Payer: Managed Health Services Medicaid	$130.00
Rate for Payer: Molina Healthcare Medicaid	$187.53
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$125.00
Rate for Payer: United Healthcare Medicaid	$125.00
Rate for Payer: WMAP Medicaid	$125.00

EAPG 367: LEVEL I ORAL SURGERY PROCEDURES

Facility

$546.77

Service Code	EAPG 00367
Min. Negotiated Rate	$497.13
Max. Negotiated Rate	$546.77
Rate for Payer: Anthem Medicaid	$497.13
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$546.77
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$497.13
Rate for Payer: Dean Health Medicaid	$497.13
Rate for Payer: Independent Care Health Plan Medicaid	$497.13
Rate for Payer: Managed Health Services Medicaid	$517.02
Rate for Payer: Molina Healthcare Medicaid	$546.77
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$497.13
Rate for Payer: United Healthcare Medicaid	$497.13
Rate for Payer: WMAP Medicaid	$497.13

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