Beloit Memorial Hospital

All Charges

Charge

Type

Setting

Price

EAPG 444: CLASS VII PHARMACOTHERAPY

Facility

$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

$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

$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

$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

$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

$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

$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

$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

$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

$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

$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

EAPG 464: CLASS XII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

Facility

$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

$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

$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

$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

$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

$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

$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

$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

$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

$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

$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

$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

$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

$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

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