Beloit Memorial Hospital

All Charges

Charge

Type

Price

EAPG 247: LEVEL I CORNEAL AND OTHER ANTERIOR SURFACE EYE PROCEDURES

Facility OP

$245.90

Service Code	EAPG 00247
Min. Negotiated Rate	$236.44
Max. Negotiated Rate	$245.90
Rate for Payer: Anthem Medicaid	$236.44
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$236.44
Rate for Payer: Dean Health Medicaid	$236.44
Rate for Payer: Independent Care Health Plan Medicaid	$236.44
Rate for Payer: Managed Health Services Medicaid	$245.90
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$236.44
Rate for Payer: United Healthcare Medicaid	$236.44
Rate for Payer: WMAP Medicaid	$236.44

EAPG 248: LEVEL II CORNEAL AND OTHER ANTERIOR SURFACE EYE PROCEDURES

Facility OP

$1,372.40

Service Code	EAPG 00248
Min. Negotiated Rate	$1,319.62
Max. Negotiated Rate	$1,372.40
Rate for Payer: Anthem Medicaid	$1,319.62
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,319.62
Rate for Payer: Dean Health Medicaid	$1,319.62
Rate for Payer: Independent Care Health Plan Medicaid	$1,319.62
Rate for Payer: Managed Health Services Medicaid	$1,372.40
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,319.62
Rate for Payer: United Healthcare Medicaid	$1,319.62
Rate for Payer: WMAP Medicaid	$1,319.62

EAPG 249: MINOR EAR, NOSE, MOUTH AND THROAT PROCEDURES

Facility OP

$73.20

Service Code	EAPG 00249
Min. Negotiated Rate	$70.38
Max. Negotiated Rate	$73.20
Rate for Payer: Anthem Medicaid	$70.38
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$70.38
Rate for Payer: Dean Health Medicaid	$70.38
Rate for Payer: Independent Care Health Plan Medicaid	$70.38
Rate for Payer: Managed Health Services Medicaid	$73.20
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$70.38
Rate for Payer: United Healthcare Medicaid	$70.38
Rate for Payer: WMAP Medicaid	$70.38

EAPG 24: LEVEL II FOREARM AND WRIST PROCEDURES

Facility OP

$2,368.17

Service Code	EAPG 00024
Min. Negotiated Rate	$2,277.09
Max. Negotiated Rate	$2,368.17
Rate for Payer: Anthem Medicaid	$2,277.09
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,277.09
Rate for Payer: Dean Health Medicaid	$2,277.09
Rate for Payer: Independent Care Health Plan Medicaid	$2,277.09
Rate for Payer: Managed Health Services Medicaid	$2,368.17
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,277.09
Rate for Payer: United Healthcare Medicaid	$2,277.09
Rate for Payer: WMAP Medicaid	$2,277.09

EAPG 250: COCHLEAR DEVICE IMPLANTATION

Facility OP

$21,522.50

Service Code	EAPG 00250
Min. Negotiated Rate	$9,884.63
Max. Negotiated Rate	$21,522.50
Rate for Payer: Anthem Medicaid	$9,884.63
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$21,522.50
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$9,884.63
Rate for Payer: Dean Health Medicaid	$9,884.63
Rate for Payer: Independent Care Health Plan Medicaid	$9,884.63
Rate for Payer: Managed Health Services Medicaid	$10,280.02
Rate for Payer: Molina Healthcare Medicaid	$21,522.50
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$9,884.63
Rate for Payer: United Healthcare Medicaid	$9,884.63
Rate for Payer: WMAP Medicaid	$9,884.63

EAPG 251: OTORHINOLARYNGOLOGIC FUNCTION TESTS

Facility OP

$172.36

Service Code	EAPG 00251
Min. Negotiated Rate	$57.21
Max. Negotiated Rate	$172.36
Rate for Payer: Anthem Medicaid	$57.21
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$172.36
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$57.21
Rate for Payer: Dean Health Medicaid	$57.21
Rate for Payer: Independent Care Health Plan Medicaid	$57.21
Rate for Payer: Managed Health Services Medicaid	$59.50
Rate for Payer: Molina Healthcare Medicaid	$172.36
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$57.21
Rate for Payer: United Healthcare Medicaid	$57.21
Rate for Payer: WMAP Medicaid	$57.21

EAPG 252: LEVEL I EAR, NOSE, MOUTH AND THROAT PROCEDURES

Facility OP

$1,011.41

Service Code	EAPG 00252
Min. Negotiated Rate	$581.20
Max. Negotiated Rate	$1,011.41
Rate for Payer: Anthem Medicaid	$581.20
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,011.41
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$581.20
Rate for Payer: Dean Health Medicaid	$581.20
Rate for Payer: Independent Care Health Plan Medicaid	$581.20
Rate for Payer: Managed Health Services Medicaid	$604.45
Rate for Payer: Molina Healthcare Medicaid	$1,011.41
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$581.20
Rate for Payer: United Healthcare Medicaid	$581.20
Rate for Payer: WMAP Medicaid	$581.20

EAPG 253: LEVEL II EAR, NOSE, MOUTH AND THROAT PROCEDURES

Facility OP

$1,778.49

Service Code	EAPG 00253
Min. Negotiated Rate	$1,052.77
Max. Negotiated Rate	$1,778.49
Rate for Payer: Anthem Medicaid	$1,052.77
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,778.49
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,052.77
Rate for Payer: Dean Health Medicaid	$1,052.77
Rate for Payer: Independent Care Health Plan Medicaid	$1,052.77
Rate for Payer: Managed Health Services Medicaid	$1,094.88
Rate for Payer: Molina Healthcare Medicaid	$1,778.49
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,052.77
Rate for Payer: United Healthcare Medicaid	$1,052.77
Rate for Payer: WMAP Medicaid	$1,052.77

EAPG 254: LEVEL III EAR, NOSE, MOUTH AND THROAT PROCEDURES

Facility OP

$2,107.55

Service Code	EAPG 00254
Min. Negotiated Rate	$1,376.17
Max. Negotiated Rate	$2,107.55
Rate for Payer: Anthem Medicaid	$1,376.17
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,107.55
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,376.17
Rate for Payer: Dean Health Medicaid	$1,376.17
Rate for Payer: Independent Care Health Plan Medicaid	$1,376.17
Rate for Payer: Managed Health Services Medicaid	$1,431.22
Rate for Payer: Molina Healthcare Medicaid	$2,107.55
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,376.17
Rate for Payer: United Healthcare Medicaid	$1,376.17
Rate for Payer: WMAP Medicaid	$1,376.17

EAPG 255: LEVEL IV EAR, NOSE, MOUTH AND THROAT PROCEDURES

Facility OP

$3,106.53

Service Code	EAPG 00255
Min. Negotiated Rate	$1,824.70
Max. Negotiated Rate	$3,106.53
Rate for Payer: Anthem Medicaid	$1,824.70
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$3,106.53
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,824.70
Rate for Payer: Dean Health Medicaid	$1,824.70
Rate for Payer: Independent Care Health Plan Medicaid	$1,824.70
Rate for Payer: Managed Health Services Medicaid	$1,897.69
Rate for Payer: Molina Healthcare Medicaid	$3,106.53
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,824.70
Rate for Payer: United Healthcare Medicaid	$1,824.70
Rate for Payer: WMAP Medicaid	$1,824.70

EAPG 256: TONSIL AND ADENOID PROCEDURES

Facility OP

$1,424.28

Service Code	EAPG 00256
Min. Negotiated Rate	$824.68
Max. Negotiated Rate	$1,424.28
Rate for Payer: Anthem Medicaid	$824.68
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,424.28
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$824.68
Rate for Payer: Dean Health Medicaid	$824.68
Rate for Payer: Independent Care Health Plan Medicaid	$824.68
Rate for Payer: Managed Health Services Medicaid	$857.67
Rate for Payer: Molina Healthcare Medicaid	$1,424.28
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$824.68
Rate for Payer: United Healthcare Medicaid	$824.68
Rate for Payer: WMAP Medicaid	$824.68

EAPG 257: AUDIOMETRY

Facility OP

$109.10

Service Code	EAPG 00257
Min. Negotiated Rate	$33.19
Max. Negotiated Rate	$109.10
Rate for Payer: Anthem Medicaid	$33.19
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$109.10
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$33.19
Rate for Payer: Dean Health Medicaid	$33.19
Rate for Payer: Independent Care Health Plan Medicaid	$33.19
Rate for Payer: Managed Health Services Medicaid	$34.52
Rate for Payer: Molina Healthcare Medicaid	$109.10
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$33.19
Rate for Payer: United Healthcare Medicaid	$33.19
Rate for Payer: WMAP Medicaid	$33.19

EAPG 258: LEVEL I EYELID, LACRIMAL AND CONJUNCTIVAL PROCEDURES

Facility OP

$571.51

Service Code	EAPG 00258
Min. Negotiated Rate	$549.53
Max. Negotiated Rate	$571.51
Rate for Payer: Anthem Medicaid	$549.53
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$549.53
Rate for Payer: Dean Health Medicaid	$549.53
Rate for Payer: Independent Care Health Plan Medicaid	$549.53
Rate for Payer: Managed Health Services Medicaid	$571.51
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$549.53
Rate for Payer: United Healthcare Medicaid	$549.53
Rate for Payer: WMAP Medicaid	$549.53

EAPG 259: LEVEL II EYELID, LACRIMAL AND CONJUNCTIVAL PROCEDURES

Facility OP

$740.62

Service Code	EAPG 00259
Min. Negotiated Rate	$712.13
Max. Negotiated Rate	$740.62
Rate for Payer: Anthem Medicaid	$712.13
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$712.13
Rate for Payer: Dean Health Medicaid	$712.13
Rate for Payer: Independent Care Health Plan Medicaid	$712.13
Rate for Payer: Managed Health Services Medicaid	$740.62
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$712.13
Rate for Payer: United Healthcare Medicaid	$712.13
Rate for Payer: WMAP Medicaid	$712.13

EAPG 25: LEVEL I SHOULDER AND UPPER ARM PROCEDURES

Facility OP

$2,028.58

Service Code	EAPG 00025
Min. Negotiated Rate	$1,950.56
Max. Negotiated Rate	$2,028.58
Rate for Payer: Anthem Medicaid	$1,950.56
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,950.56
Rate for Payer: Dean Health Medicaid	$1,950.56
Rate for Payer: Independent Care Health Plan Medicaid	$1,950.56
Rate for Payer: Managed Health Services Medicaid	$2,028.58
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,950.56
Rate for Payer: United Healthcare Medicaid	$1,950.56
Rate for Payer: WMAP Medicaid	$1,950.56

EAPG 260: CASE MANAGEMENT AND CARE PLANNING SERVICES

Facility OP

$96.14

Service Code	EAPG 00260
Min. Negotiated Rate	$45.19
Max. Negotiated Rate	$96.14
Rate for Payer: Anthem Medicaid	$45.19
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$96.14
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$45.19
Rate for Payer: Dean Health Medicaid	$45.19
Rate for Payer: Independent Care Health Plan Medicaid	$45.19
Rate for Payer: Managed Health Services Medicaid	$47.00
Rate for Payer: Molina Healthcare Medicaid	$96.14
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$45.19
Rate for Payer: United Healthcare Medicaid	$45.19
Rate for Payer: WMAP Medicaid	$45.19

EAPG 261: ESRD MONTHLY CASE MANAGEMENT

Facility OP

$257.50

Service Code	EAPG 00261
Min. Negotiated Rate	$247.60
Max. Negotiated Rate	$257.50
Rate for Payer: Anthem Medicaid	$247.60
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$247.60
Rate for Payer: Dean Health Medicaid	$247.60
Rate for Payer: Independent Care Health Plan Medicaid	$247.60
Rate for Payer: Managed Health Services Medicaid	$257.50
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$247.60
Rate for Payer: United Healthcare Medicaid	$247.60
Rate for Payer: WMAP Medicaid	$247.60

EAPG 262: CLEFT LIP AND PALATE REPAIR

Facility OP

$1,153.15

Service Code	EAPG 00262
Min. Negotiated Rate	$1,108.80
Max. Negotiated Rate	$1,153.15
Rate for Payer: Anthem Medicaid	$1,108.80
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,108.80
Rate for Payer: Dean Health Medicaid	$1,108.80
Rate for Payer: Independent Care Health Plan Medicaid	$1,108.80
Rate for Payer: Managed Health Services Medicaid	$1,153.15
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,108.80
Rate for Payer: United Healthcare Medicaid	$1,108.80
Rate for Payer: WMAP Medicaid	$1,108.80

EAPG 263: THYROID AND PARATHYROID PROCEDURES

Facility OP

$1,866.26

Service Code	EAPG 00263
Min. Negotiated Rate	$1,794.48
Max. Negotiated Rate	$1,866.26
Rate for Payer: Anthem Medicaid	$1,794.48
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,794.48
Rate for Payer: Dean Health Medicaid	$1,794.48
Rate for Payer: Independent Care Health Plan Medicaid	$1,794.48
Rate for Payer: Managed Health Services Medicaid	$1,866.26
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,794.48
Rate for Payer: United Healthcare Medicaid	$1,794.48
Rate for Payer: WMAP Medicaid	$1,794.48

EAPG 264: MAJOR CRANIOTOMY AND CRANIECTOMY SURGICAL PROCEDURES

Facility OP

$1,616.70

Service Code	EAPG 00264
Min. Negotiated Rate	$1,554.52
Max. Negotiated Rate	$1,616.70
Rate for Payer: Anthem Medicaid	$1,554.52
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,554.52
Rate for Payer: Dean Health Medicaid	$1,554.52
Rate for Payer: Independent Care Health Plan Medicaid	$1,554.52
Rate for Payer: Managed Health Services Medicaid	$1,616.70
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,554.52
Rate for Payer: United Healthcare Medicaid	$1,554.52
Rate for Payer: WMAP Medicaid	$1,554.52

EAPG 265: PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES

Facility OP

$6,075.42

Service Code	EAPG 00265
Min. Negotiated Rate	$5,841.75
Max. Negotiated Rate	$6,075.42
Rate for Payer: Anthem Medicaid	$5,841.75
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$5,841.75
Rate for Payer: Dean Health Medicaid	$5,841.75
Rate for Payer: Independent Care Health Plan Medicaid	$5,841.75
Rate for Payer: Managed Health Services Medicaid	$6,075.42
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$5,841.75
Rate for Payer: United Healthcare Medicaid	$5,841.75
Rate for Payer: WMAP Medicaid	$5,841.75

EAPG 266: OPEN INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES

Facility OP

$1,795.58

Service Code	EAPG 00266
Min. Negotiated Rate	$1,726.52
Max. Negotiated Rate	$1,795.58
Rate for Payer: Anthem Medicaid	$1,726.52
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$1,726.52
Rate for Payer: Dean Health Medicaid	$1,726.52
Rate for Payer: Independent Care Health Plan Medicaid	$1,726.52
Rate for Payer: Managed Health Services Medicaid	$1,795.58
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$1,726.52
Rate for Payer: United Healthcare Medicaid	$1,726.52
Rate for Payer: WMAP Medicaid	$1,726.52

EAPG 267: OTHER CRANIOTOMY PROCEDURES INCLUDING CRANIOPLASTY

Facility OP

$2,304.71

Service Code	EAPG 00267
Min. Negotiated Rate	$2,216.07
Max. Negotiated Rate	$2,304.71
Rate for Payer: Anthem Medicaid	$2,216.07
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,216.07
Rate for Payer: Dean Health Medicaid	$2,216.07
Rate for Payer: Independent Care Health Plan Medicaid	$2,216.07
Rate for Payer: Managed Health Services Medicaid	$2,304.71
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,216.07
Rate for Payer: United Healthcare Medicaid	$2,216.07
Rate for Payer: WMAP Medicaid	$2,216.07

EAPG 268: CRANIAL AND SPINAL SHUNT PROCEDURES

Facility OP

$2,486.85

Service Code	EAPG 00268
Min. Negotiated Rate	$2,391.20
Max. Negotiated Rate	$2,486.85
Rate for Payer: Anthem Medicaid	$2,391.20
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$2,391.20
Rate for Payer: Dean Health Medicaid	$2,391.20
Rate for Payer: Independent Care Health Plan Medicaid	$2,391.20
Rate for Payer: Managed Health Services Medicaid	$2,486.85
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$2,391.20
Rate for Payer: United Healthcare Medicaid	$2,391.20
Rate for Payer: WMAP Medicaid	$2,391.20

EAPG 269: LEVEL II ANCILLARY THERAPEUTIC SERVICES

Facility OP

$15.57

Service Code	EAPG 00269
Min. Negotiated Rate	$14.97
Max. Negotiated Rate	$15.57
Rate for Payer: Anthem Medicaid	$14.97
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$14.97
Rate for Payer: Dean Health Medicaid	$14.97
Rate for Payer: Independent Care Health Plan Medicaid	$14.97
Rate for Payer: Managed Health Services Medicaid	$15.57
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$14.97
Rate for Payer: United Healthcare Medicaid	$14.97
Rate for Payer: WMAP Medicaid	$14.97

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