Beloit Memorial Hospital

All Charges

Charge

Type

Price

EAPG 173: LEVEL I BLADDER AND URETERAL PROCEDURES

Facility OP

$672.84

Service Code	EAPG 00173
Min. Negotiated Rate	$646.96
Max. Negotiated Rate	$672.84
Rate for Payer: Anthem Medicaid	$646.96
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$646.96
Rate for Payer: Dean Health Medicaid	$646.96
Rate for Payer: Independent Care Health Plan Medicaid	$646.96
Rate for Payer: Managed Health Services Medicaid	$672.84
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$646.96
Rate for Payer: United Healthcare Medicaid	$646.96
Rate for Payer: WMAP Medicaid	$646.96

EAPG 174: LEVEL II BLADDER AND URETERAL PROCEDURES

Facility OP

$1,752.05

Service Code	EAPG 00174
Min. Negotiated Rate	$1,684.66
Max. Negotiated Rate	$1,752.05
Rate for Payer: Anthem Medicaid	$1,684.66
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,684.66
Rate for Payer: Dean Health Medicaid	$1,684.66
Rate for Payer: Independent Care Health Plan Medicaid	$1,684.66
Rate for Payer: Managed Health Services Medicaid	$1,752.05
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,684.66
Rate for Payer: United Healthcare Medicaid	$1,684.66
Rate for Payer: WMAP Medicaid	$1,684.66

EAPG 175: LEVEL III BLADDER AND URETERAL PROCEDURES

Facility OP

$2,112.58

Service Code	EAPG 00175
Min. Negotiated Rate	$2,031.33
Max. Negotiated Rate	$2,112.58
Rate for Payer: Anthem Medicaid	$2,031.33
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,031.33
Rate for Payer: Dean Health Medicaid	$2,031.33
Rate for Payer: Independent Care Health Plan Medicaid	$2,031.33
Rate for Payer: Managed Health Services Medicaid	$2,112.58
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,031.33
Rate for Payer: United Healthcare Medicaid	$2,031.33
Rate for Payer: WMAP Medicaid	$2,031.33

EAPG 176: LEVEL I PROSTATE PROCEDURES

Facility OP

$735.65

Service Code	EAPG 00176
Min. Negotiated Rate	$707.36
Max. Negotiated Rate	$735.65
Rate for Payer: Anthem Medicaid	$707.36
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$707.36
Rate for Payer: Dean Health Medicaid	$707.36
Rate for Payer: Independent Care Health Plan Medicaid	$707.36
Rate for Payer: Managed Health Services Medicaid	$735.65
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$707.36
Rate for Payer: United Healthcare Medicaid	$707.36
Rate for Payer: WMAP Medicaid	$707.36

EAPG 177: MINOR DERMATOLOGY SERVICES

Facility OP

$12.16

Service Code	EAPG 00177
Min. Negotiated Rate	$11.69
Max. Negotiated Rate	$12.16
Rate for Payer: Anthem Medicaid	$11.69
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$11.69
Rate for Payer: Dean Health Medicaid	$11.69
Rate for Payer: Independent Care Health Plan Medicaid	$11.69
Rate for Payer: Managed Health Services Medicaid	$12.16
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$11.69
Rate for Payer: United Healthcare Medicaid	$11.69
Rate for Payer: WMAP Medicaid	$11.69

EAPG 178: ANTEPARTUM PROCEDURES

Facility OP

$249.30

Service Code	EAPG 00178
Min. Negotiated Rate	$239.71
Max. Negotiated Rate	$249.30
Rate for Payer: Anthem Medicaid	$239.71
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$239.71
Rate for Payer: Dean Health Medicaid	$239.71
Rate for Payer: Independent Care Health Plan Medicaid	$239.71
Rate for Payer: Managed Health Services Medicaid	$249.30
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$239.71
Rate for Payer: United Healthcare Medicaid	$239.71
Rate for Payer: WMAP Medicaid	$239.71

EAPG 179: ECTOPIC PREGNANCY PROCEDURES

Facility OP

$1,558.24

Service Code	EAPG 00179
Min. Negotiated Rate	$1,498.31
Max. Negotiated Rate	$1,558.24
Rate for Payer: Anthem Medicaid	$1,498.31
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,498.31
Rate for Payer: Dean Health Medicaid	$1,498.31
Rate for Payer: Independent Care Health Plan Medicaid	$1,498.31
Rate for Payer: Managed Health Services Medicaid	$1,558.24
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,498.31
Rate for Payer: United Healthcare Medicaid	$1,498.31
Rate for Payer: WMAP Medicaid	$1,498.31

EAPG 17: INTERMEDIATE WOUND REPAIR AND TREATMENT

Facility OP

$164.96

Service Code	EAPG 00017
Min. Negotiated Rate	$158.62
Max. Negotiated Rate	$164.96
Rate for Payer: Anthem Medicaid	$158.62
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$158.62
Rate for Payer: Dean Health Medicaid	$158.62
Rate for Payer: Independent Care Health Plan Medicaid	$158.62
Rate for Payer: Managed Health Services Medicaid	$164.96
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$158.62
Rate for Payer: United Healthcare Medicaid	$158.62
Rate for Payer: WMAP Medicaid	$158.62

EAPG 180: TESTICULAR AND EPIDIDYMAL PROCEDURES

Facility OP

$1,355.10

Service Code	EAPG 00180
Min. Negotiated Rate	$983.19
Max. Negotiated Rate	$1,355.10
Rate for Payer: Anthem Medicaid	$983.19
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,355.10
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$983.19
Rate for Payer: Dean Health Medicaid	$983.19
Rate for Payer: Independent Care Health Plan Medicaid	$983.19
Rate for Payer: Managed Health Services Medicaid	$1,022.52
Rate for Payer: Molina Healthcare Medicaid	$1,355.10
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$983.19
Rate for Payer: United Healthcare Medicaid	$983.19
Rate for Payer: WMAP Medicaid	$983.19

EAPG 182: INSERTION OF PENILE PROSTHESIS

Facility OP

$9,585.88

Service Code	EAPG 00182
Min. Negotiated Rate	$5,494.89
Max. Negotiated Rate	$9,585.88
Rate for Payer: Anthem Medicaid	$5,494.89
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$9,585.88
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$5,494.89
Rate for Payer: Dean Health Medicaid	$5,494.89
Rate for Payer: Independent Care Health Plan Medicaid	$5,494.89
Rate for Payer: Managed Health Services Medicaid	$5,714.69
Rate for Payer: Molina Healthcare Medicaid	$9,585.88
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$5,494.89
Rate for Payer: United Healthcare Medicaid	$5,494.89
Rate for Payer: WMAP Medicaid	$5,494.89

EAPG 183: LEVEL I PENILE PROCEDURES

Facility OP

$1,890.67

Service Code	EAPG 00183
Min. Negotiated Rate	$818.90
Max. Negotiated Rate	$1,890.67
Rate for Payer: Anthem Medicaid	$818.90
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,890.67
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$818.90
Rate for Payer: Dean Health Medicaid	$818.90
Rate for Payer: Independent Care Health Plan Medicaid	$818.90
Rate for Payer: Managed Health Services Medicaid	$851.66
Rate for Payer: Molina Healthcare Medicaid	$1,890.67
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$818.90
Rate for Payer: United Healthcare Medicaid	$818.90
Rate for Payer: WMAP Medicaid	$818.90

EAPG 184: LEVEL II PROSTATE PROCEDURES

Facility OP

$2,318.36

Service Code	EAPG 00184
Min. Negotiated Rate	$1,828.51
Max. Negotiated Rate	$2,318.36
Rate for Payer: Anthem Medicaid	$1,828.51
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,318.36
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,828.51
Rate for Payer: Dean Health Medicaid	$1,828.51
Rate for Payer: Independent Care Health Plan Medicaid	$1,828.51
Rate for Payer: Managed Health Services Medicaid	$1,901.65
Rate for Payer: Molina Healthcare Medicaid	$2,318.36
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,828.51
Rate for Payer: United Healthcare Medicaid	$1,828.51
Rate for Payer: WMAP Medicaid	$1,828.51

EAPG 187: LEVEL II PENILE PROCEDURES

Facility OP

$1,318.95

Service Code	EAPG 00187
Min. Negotiated Rate	$1,268.22
Max. Negotiated Rate	$1,318.95
Rate for Payer: Anthem Medicaid	$1,268.22
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,268.22
Rate for Payer: Dean Health Medicaid	$1,268.22
Rate for Payer: Independent Care Health Plan Medicaid	$1,268.22
Rate for Payer: Managed Health Services Medicaid	$1,318.95
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,268.22
Rate for Payer: United Healthcare Medicaid	$1,268.22
Rate for Payer: WMAP Medicaid	$1,268.22

EAPG 188: LEVEL I PERINEAL AND VAGINAL GYNECOLOGICAL PROCEDURES

Facility OP

$1,052.68

Service Code	EAPG 00188
Min. Negotiated Rate	$1,012.19
Max. Negotiated Rate	$1,052.68
Rate for Payer: Anthem Medicaid	$1,012.19
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,012.19
Rate for Payer: Dean Health Medicaid	$1,012.19
Rate for Payer: Independent Care Health Plan Medicaid	$1,012.19
Rate for Payer: Managed Health Services Medicaid	$1,052.68
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,012.19
Rate for Payer: United Healthcare Medicaid	$1,012.19
Rate for Payer: WMAP Medicaid	$1,012.19

EAPG 189: LEVEL II PERINEAL AND VAGINAL GYNECOLOGICAL PROCEDURES

Facility OP

$2,394.20

Service Code	EAPG 00189
Min. Negotiated Rate	$2,302.12
Max. Negotiated Rate	$2,394.20
Rate for Payer: Anthem Medicaid	$2,302.12
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,302.12
Rate for Payer: Dean Health Medicaid	$2,302.12
Rate for Payer: Independent Care Health Plan Medicaid	$2,302.12
Rate for Payer: Managed Health Services Medicaid	$2,394.20
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,302.12
Rate for Payer: United Healthcare Medicaid	$2,302.12
Rate for Payer: WMAP Medicaid	$2,302.12

EAPG 18: COMPLEX WOUND REPAIR AND TREATMENT

Facility OP

$438.85

Service Code	EAPG 00018
Min. Negotiated Rate	$421.97
Max. Negotiated Rate	$438.85
Rate for Payer: Anthem Medicaid	$421.97
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$421.97
Rate for Payer: Dean Health Medicaid	$421.97
Rate for Payer: Independent Care Health Plan Medicaid	$421.97
Rate for Payer: Managed Health Services Medicaid	$438.85
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$421.97
Rate for Payer: United Healthcare Medicaid	$421.97
Rate for Payer: WMAP Medicaid	$421.97

EAPG 190: ARTIFICIAL FERTILIZATION

Facility OP

$242.66

Service Code	EAPG 00190
Min. Negotiated Rate	$169.74
Max. Negotiated Rate	$242.66
Rate for Payer: Anthem Medicaid	$169.74
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$242.66
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$169.74
Rate for Payer: Dean Health Medicaid	$169.74
Rate for Payer: Independent Care Health Plan Medicaid	$169.74
Rate for Payer: Managed Health Services Medicaid	$176.53
Rate for Payer: Molina Healthcare Medicaid	$242.66
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$169.74
Rate for Payer: United Healthcare Medicaid	$169.74
Rate for Payer: WMAP Medicaid	$169.74

EAPG 191: LEVEL I FETAL PROCEDURES

Facility OP

$193.45

Service Code	EAPG 00191
Min. Negotiated Rate	$80.42
Max. Negotiated Rate	$193.45
Rate for Payer: Anthem Medicaid	$80.42
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$193.45
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$80.42
Rate for Payer: Dean Health Medicaid	$80.42
Rate for Payer: Independent Care Health Plan Medicaid	$80.42
Rate for Payer: Managed Health Services Medicaid	$83.64
Rate for Payer: Molina Healthcare Medicaid	$193.45
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$80.42
Rate for Payer: United Healthcare Medicaid	$80.42
Rate for Payer: WMAP Medicaid	$80.42

EAPG 192: LEVEL II FETAL PROCEDURES

Facility OP

$668.11

Service Code	EAPG 00192
Min. Negotiated Rate	$414.23
Max. Negotiated Rate	$668.11
Rate for Payer: Anthem Medicaid	$414.23
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$668.11
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$414.23
Rate for Payer: Dean Health Medicaid	$414.23
Rate for Payer: Independent Care Health Plan Medicaid	$414.23
Rate for Payer: Managed Health Services Medicaid	$430.80
Rate for Payer: Molina Healthcare Medicaid	$668.11
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$414.23
Rate for Payer: United Healthcare Medicaid	$414.23
Rate for Payer: WMAP Medicaid	$414.23

EAPG 194: ABORTION AND MISCARRIAGE TREATMENT AND PROCEDURES

Facility OP

$1,363.27

Service Code	EAPG 00194
Min. Negotiated Rate	$718.51
Max. Negotiated Rate	$1,363.27
Rate for Payer: Anthem Medicaid	$718.51
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,363.27
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$718.51
Rate for Payer: Dean Health Medicaid	$718.51
Rate for Payer: Independent Care Health Plan Medicaid	$718.51
Rate for Payer: Managed Health Services Medicaid	$747.25
Rate for Payer: Molina Healthcare Medicaid	$1,363.27
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$718.51
Rate for Payer: United Healthcare Medicaid	$718.51
Rate for Payer: WMAP Medicaid	$718.51

EAPG 195: VAGINAL DELIVERY PROCEDURES

Facility OP

$1,490.13

Service Code	EAPG 00195
Min. Negotiated Rate	$894.88
Max. Negotiated Rate	$1,490.13
Rate for Payer: Anthem Medicaid	$894.88
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,490.13
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$894.88
Rate for Payer: Dean Health Medicaid	$894.88
Rate for Payer: Independent Care Health Plan Medicaid	$894.88
Rate for Payer: Managed Health Services Medicaid	$930.68
Rate for Payer: Molina Healthcare Medicaid	$1,490.13
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$894.88
Rate for Payer: United Healthcare Medicaid	$894.88
Rate for Payer: WMAP Medicaid	$894.88

EAPG 19: MOHS MICROGRAPHIC SURGERY

Facility OP

$407.69

Service Code	EAPG 00019
Min. Negotiated Rate	$392.01
Max. Negotiated Rate	$407.69
Rate for Payer: Anthem Medicaid	$392.01
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$392.01
Rate for Payer: Dean Health Medicaid	$392.01
Rate for Payer: Independent Care Health Plan Medicaid	$392.01
Rate for Payer: Managed Health Services Medicaid	$407.69
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$392.01
Rate for Payer: United Healthcare Medicaid	$392.01
Rate for Payer: WMAP Medicaid	$392.01

EAPG 2016: LEVEL II ALLERGY TESTS

Facility OP

$20.07

Service Code	EAPG 02016
Min. Negotiated Rate	$19.30
Max. Negotiated Rate	$20.07
Rate for Payer: Anthem Medicaid	$19.30
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$19.30
Rate for Payer: Dean Health Medicaid	$19.30
Rate for Payer: Independent Care Health Plan Medicaid	$19.30
Rate for Payer: Managed Health Services Medicaid	$20.07
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$19.30
Rate for Payer: United Healthcare Medicaid	$19.30
Rate for Payer: WMAP Medicaid	$19.30

EAPG 2020: NONINVASIVE VENTILATION SUPPORT

Facility OP

$57.46

Service Code	EAPG 02020
Min. Negotiated Rate	$55.25
Max. Negotiated Rate	$57.46
Rate for Payer: Anthem Medicaid	$55.25
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$55.25
Rate for Payer: Dean Health Medicaid	$55.25
Rate for Payer: Independent Care Health Plan Medicaid	$55.25
Rate for Payer: Managed Health Services Medicaid	$57.46
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$55.25
Rate for Payer: United Healthcare Medicaid	$55.25
Rate for Payer: WMAP Medicaid	$55.25

EAPG 202: CESAREAN DELIVERY PROCEDURES

Facility OP

$1,117.81

Service Code	EAPG 00202
Min. Negotiated Rate	$1,074.82
Max. Negotiated Rate	$1,117.81
Rate for Payer: Anthem Medicaid	$1,074.82
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,074.82
Rate for Payer: Dean Health Medicaid	$1,074.82
Rate for Payer: Independent Care Health Plan Medicaid	$1,074.82
Rate for Payer: Managed Health Services Medicaid	$1,117.81
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,074.82
Rate for Payer: United Healthcare Medicaid	$1,074.82
Rate for Payer: WMAP Medicaid	$1,074.82

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