Beloit Memorial Hospital

All Charges

Charge

Type

Price

EAPG 548: PERIPHERAL AND OTHER VASCULAR RELATED INJURIES

Facility OP

$93.17

Service Code	EAPG 00548
Min. Negotiated Rate	$89.59
Max. Negotiated Rate	$93.17
Rate for Payer: Anthem Medicaid	$89.59
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$89.59
Rate for Payer: Dean Health Medicaid	$89.59
Rate for Payer: Independent Care Health Plan Medicaid	$89.59
Rate for Payer: Managed Health Services Medicaid	$93.17
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$89.59
Rate for Payer: United Healthcare Medicaid	$89.59
Rate for Payer: WMAP Medicaid	$89.59

EAPG 54: FIXATION DEVICE INSERTION OR REPLACEMENT PROCEDURES

Facility OP

$1,000.39

Service Code	EAPG 00054
Min. Negotiated Rate	$961.91
Max. Negotiated Rate	$1,000.39
Rate for Payer: Dean Health Medicaid	$961.91
Rate for Payer: Anthem Medicaid	$961.91
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$961.91
Rate for Payer: Independent Care Health Plan Medicaid	$961.91
Rate for Payer: Managed Health Services Medicaid	$1,000.39
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$961.91
Rate for Payer: United Healthcare Medicaid	$961.91
Rate for Payer: WMAP Medicaid	$961.91

EAPG 550: ACUTE MAJOR EYE INFECTIONS

Facility OP

$89.68

Service Code	EAPG 00550
Min. Negotiated Rate	$57.92
Max. Negotiated Rate	$89.68
Rate for Payer: Anthem Medicaid	$57.92
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$89.68
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$57.92
Rate for Payer: Dean Health Medicaid	$57.92
Rate for Payer: Independent Care Health Plan Medicaid	$57.92
Rate for Payer: Managed Health Services Medicaid	$60.24
Rate for Payer: Molina Healthcare Medicaid	$89.68
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$57.92
Rate for Payer: United Healthcare Medicaid	$57.92
Rate for Payer: WMAP Medicaid	$57.92

EAPG 551: CATARACTS

Facility OP

$77.06

Service Code	EAPG 00551
Min. Negotiated Rate	$46.69
Max. Negotiated Rate	$77.06
Rate for Payer: Anthem Medicaid	$46.69
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$77.06
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$46.69
Rate for Payer: Dean Health Medicaid	$46.69
Rate for Payer: Independent Care Health Plan Medicaid	$46.69
Rate for Payer: Managed Health Services Medicaid	$48.56
Rate for Payer: Molina Healthcare Medicaid	$77.06
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$46.69
Rate for Payer: United Healthcare Medicaid	$46.69
Rate for Payer: WMAP Medicaid	$46.69

EAPG 552: GLAUCOMA

Facility OP

$96.28

Service Code	EAPG 00552
Min. Negotiated Rate	$55.85
Max. Negotiated Rate	$96.28
Rate for Payer: Anthem Medicaid	$55.85
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$96.28
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$55.85
Rate for Payer: Dean Health Medicaid	$55.85
Rate for Payer: Independent Care Health Plan Medicaid	$55.85
Rate for Payer: Managed Health Services Medicaid	$58.08
Rate for Payer: Molina Healthcare Medicaid	$96.28
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$55.85
Rate for Payer: United Healthcare Medicaid	$55.85
Rate for Payer: WMAP Medicaid	$55.85

EAPG 553: OTHER OPHTHALMIC SYSTEM DIAGNOSES

Facility OP

$89.58

Service Code	EAPG 00553
Min. Negotiated Rate	$63.28
Max. Negotiated Rate	$89.58
Rate for Payer: Anthem Medicaid	$63.28
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$89.58
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$63.28
Rate for Payer: Dean Health Medicaid	$63.28
Rate for Payer: Independent Care Health Plan Medicaid	$63.28
Rate for Payer: Managed Health Services Medicaid	$65.81
Rate for Payer: Molina Healthcare Medicaid	$89.58
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$63.28
Rate for Payer: United Healthcare Medicaid	$63.28
Rate for Payer: WMAP Medicaid	$63.28

EAPG 555: CONJUNCTIVITIS

Facility OP

$91.88

Service Code	EAPG 00555
Min. Negotiated Rate	$49.39
Max. Negotiated Rate	$91.88
Rate for Payer: Anthem Medicaid	$49.39
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$91.88
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$49.39
Rate for Payer: Dean Health Medicaid	$49.39
Rate for Payer: Independent Care Health Plan Medicaid	$49.39
Rate for Payer: Managed Health Services Medicaid	$51.37
Rate for Payer: Molina Healthcare Medicaid	$91.88
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$49.39
Rate for Payer: United Healthcare Medicaid	$49.39
Rate for Payer: WMAP Medicaid	$49.39

EAPG 556: OCULAR AND PERIOCULAR MALIGNANCY

Facility OP

$70.47

Service Code	EAPG 00556
Min. Negotiated Rate	$67.76
Max. Negotiated Rate	$70.47
Rate for Payer: Anthem Medicaid	$67.76
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$67.76
Rate for Payer: Dean Health Medicaid	$67.76
Rate for Payer: Independent Care Health Plan Medicaid	$67.76
Rate for Payer: Managed Health Services Medicaid	$70.47
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$67.76
Rate for Payer: United Healthcare Medicaid	$67.76
Rate for Payer: WMAP Medicaid	$67.76

EAPG 557: OTHER EYE INFECTION DIAGNOSES

Facility OP

$44.70

Service Code	EAPG 00557
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$44.70
Rate for Payer: Anthem Medicaid	$42.98
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$42.98
Rate for Payer: Dean Health Medicaid	$42.98
Rate for Payer: Independent Care Health Plan Medicaid	$42.98
Rate for Payer: Managed Health Services Medicaid	$44.70
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$42.98
Rate for Payer: United Healthcare Medicaid	$42.98
Rate for Payer: WMAP Medicaid	$42.98

EAPG 558: MALFUNCTION, REACTION, OR COMPLICATION OF OCULAR DEVICE OR PROCEDURE

Facility OP

$58.10

Service Code	EAPG 00558
Min. Negotiated Rate	$55.87
Max. Negotiated Rate	$58.10
Rate for Payer: Anthem Medicaid	$55.87
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$55.87
Rate for Payer: Dean Health Medicaid	$55.87
Rate for Payer: Independent Care Health Plan Medicaid	$55.87
Rate for Payer: Managed Health Services Medicaid	$58.10
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$55.87
Rate for Payer: United Healthcare Medicaid	$55.87
Rate for Payer: WMAP Medicaid	$55.87

EAPG 55: LEVEL II HIP AND FEMUR PROCEDURES

Facility OP

$5,057.74

Service Code	EAPG 00055
Min. Negotiated Rate	$4,863.21
Max. Negotiated Rate	$5,057.74
Rate for Payer: Anthem Medicaid	$4,863.21
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$4,863.21
Rate for Payer: Dean Health Medicaid	$4,863.21
Rate for Payer: Independent Care Health Plan Medicaid	$4,863.21
Rate for Payer: Managed Health Services Medicaid	$5,057.74
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$4,863.21
Rate for Payer: United Healthcare Medicaid	$4,863.21
Rate for Payer: WMAP Medicaid	$4,863.21

EAPG 560: EAR, NOSE, MOUTH, THROAT, CRANIAL AND FACIAL MALIGNANCIES

Facility OP

$110.03

Service Code	EAPG 00560
Min. Negotiated Rate	$69.84
Max. Negotiated Rate	$110.03
Rate for Payer: Anthem Medicaid	$69.84
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$110.03
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$69.84
Rate for Payer: Dean Health Medicaid	$69.84
Rate for Payer: Independent Care Health Plan Medicaid	$69.84
Rate for Payer: Managed Health Services Medicaid	$72.63
Rate for Payer: Molina Healthcare Medicaid	$110.03
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$69.84
Rate for Payer: United Healthcare Medicaid	$69.84
Rate for Payer: WMAP Medicaid	$69.84

EAPG 561: VERTIGO AND OTHER LABYRINTH DISORDERS

Facility OP

$139.78

Service Code	EAPG 00561
Min. Negotiated Rate	$94.86
Max. Negotiated Rate	$139.78
Rate for Payer: Anthem Medicaid	$94.86
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$139.78
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$94.86
Rate for Payer: Dean Health Medicaid	$94.86
Rate for Payer: Independent Care Health Plan Medicaid	$94.86
Rate for Payer: Managed Health Services Medicaid	$98.65
Rate for Payer: Molina Healthcare Medicaid	$139.78
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$94.86
Rate for Payer: United Healthcare Medicaid	$94.86
Rate for Payer: WMAP Medicaid	$94.86

EAPG 562: INFECTIONS OF UPPER RESPIRATORY TRACT AND OTITIS MEDIA

Facility OP

$94.91

Service Code	EAPG 00562
Min. Negotiated Rate	$65.71
Max. Negotiated Rate	$94.91
Rate for Payer: Anthem Medicaid	$65.71
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$94.91
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$65.71
Rate for Payer: Dean Health Medicaid	$65.71
Rate for Payer: Independent Care Health Plan Medicaid	$65.71
Rate for Payer: Managed Health Services Medicaid	$68.34
Rate for Payer: Molina Healthcare Medicaid	$94.91
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$65.71
Rate for Payer: United Healthcare Medicaid	$65.71
Rate for Payer: WMAP Medicaid	$65.71

EAPG 563: DENTAL AND ORAL DIAGNOSES AND INJURIES

Facility OP

$96.58

Service Code	EAPG 00563
Min. Negotiated Rate	$53.43
Max. Negotiated Rate	$96.58
Rate for Payer: Anthem Medicaid	$53.43
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$96.58
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$53.43
Rate for Payer: Dean Health Medicaid	$53.43
Rate for Payer: Independent Care Health Plan Medicaid	$53.43
Rate for Payer: Managed Health Services Medicaid	$55.57
Rate for Payer: Molina Healthcare Medicaid	$96.58
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$53.43
Rate for Payer: United Healthcare Medicaid	$53.43
Rate for Payer: WMAP Medicaid	$53.43

EAPG 564: OTHER EAR, NOSE, MOUTH, THROAT AND CRANIOFACIAL DIAGNOSES

Facility OP

$100.15

Service Code	EAPG 00564
Min. Negotiated Rate	$64.72
Max. Negotiated Rate	$100.15
Rate for Payer: Anthem Medicaid	$64.72
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$100.15
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$64.72
Rate for Payer: Dean Health Medicaid	$64.72
Rate for Payer: Independent Care Health Plan Medicaid	$64.72
Rate for Payer: Managed Health Services Medicaid	$67.31
Rate for Payer: Molina Healthcare Medicaid	$100.15
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$64.72
Rate for Payer: United Healthcare Medicaid	$64.72
Rate for Payer: WMAP Medicaid	$64.72

EAPG 566: MALFUNCTION, REACTION, OR COMPLICATION OF OTOLARYNGOLOGIC DEVICE OR PROCEDURE

Facility OP

$62.51

Service Code	EAPG 00566
Min. Negotiated Rate	$60.11
Max. Negotiated Rate	$62.51
Rate for Payer: Anthem Medicaid	$60.11
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$60.11
Rate for Payer: Dean Health Medicaid	$60.11
Rate for Payer: Independent Care Health Plan Medicaid	$60.11
Rate for Payer: Managed Health Services Medicaid	$62.51
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$60.11
Rate for Payer: United Healthcare Medicaid	$60.11
Rate for Payer: WMAP Medicaid	$60.11

EAPG 56: SKIN AND CONNECTIVE TISSUE GRAFTING AND FLAP PROCEDURES

Facility OP

$839.03

Service Code	EAPG 00056
Min. Negotiated Rate	$806.76
Max. Negotiated Rate	$839.03
Rate for Payer: Anthem Medicaid	$806.76
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$806.76
Rate for Payer: Dean Health Medicaid	$806.76
Rate for Payer: Independent Care Health Plan Medicaid	$806.76
Rate for Payer: Managed Health Services Medicaid	$839.03
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$806.76
Rate for Payer: United Healthcare Medicaid	$806.76
Rate for Payer: WMAP Medicaid	$806.76

EAPG 570: CYSTIC FIBROSIS - PULMONARY DISEASE

Facility OP

$204.01

Service Code	EAPG 00570
Min. Negotiated Rate	$122.31
Max. Negotiated Rate	$204.01
Rate for Payer: Anthem Medicaid	$122.31
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$204.01
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$122.31
Rate for Payer: Dean Health Medicaid	$122.31
Rate for Payer: Independent Care Health Plan Medicaid	$122.31
Rate for Payer: Managed Health Services Medicaid	$127.20
Rate for Payer: Molina Healthcare Medicaid	$204.01
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$122.31
Rate for Payer: United Healthcare Medicaid	$122.31
Rate for Payer: WMAP Medicaid	$122.31

EAPG 571: RESPIRATORY MALIGNANCY

Facility OP

$121.97

Service Code	EAPG 00571
Min. Negotiated Rate	$63.31
Max. Negotiated Rate	$121.97
Rate for Payer: Anthem Medicaid	$63.31
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$121.97
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$63.31
Rate for Payer: Dean Health Medicaid	$63.31
Rate for Payer: Independent Care Health Plan Medicaid	$63.31
Rate for Payer: Managed Health Services Medicaid	$65.84
Rate for Payer: Molina Healthcare Medicaid	$121.97
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$63.31
Rate for Payer: United Healthcare Medicaid	$63.31
Rate for Payer: WMAP Medicaid	$63.31

EAPG 572: BRONCHIOLITIS AND RSV PNEUMONIA

Facility OP

$142.42

Service Code	EAPG 00572
Min. Negotiated Rate	$136.94
Max. Negotiated Rate	$142.42
Rate for Payer: Anthem Medicaid	$136.94
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$140.75
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$136.94
Rate for Payer: Dean Health Medicaid	$136.94
Rate for Payer: Independent Care Health Plan Medicaid	$136.94
Rate for Payer: Managed Health Services Medicaid	$142.42
Rate for Payer: Molina Healthcare Medicaid	$140.75
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$136.94
Rate for Payer: United Healthcare Medicaid	$136.94
Rate for Payer: WMAP Medicaid	$136.94

EAPG 574: CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility OP

$126.03

Service Code	EAPG 00574
Min. Negotiated Rate	$102.19
Max. Negotiated Rate	$126.03
Rate for Payer: Anthem Medicaid	$102.19
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$126.03
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$102.19
Rate for Payer: Dean Health Medicaid	$102.19
Rate for Payer: Independent Care Health Plan Medicaid	$102.19
Rate for Payer: Managed Health Services Medicaid	$106.28
Rate for Payer: Molina Healthcare Medicaid	$126.03
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$102.19
Rate for Payer: United Healthcare Medicaid	$102.19
Rate for Payer: WMAP Medicaid	$102.19

EAPG 575: ASTHMA

Facility OP

$117.03

Service Code	EAPG 00575
Min. Negotiated Rate	$86.25
Max. Negotiated Rate	$117.03
Rate for Payer: Anthem Medicaid	$86.25
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$117.03
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$86.25
Rate for Payer: Dean Health Medicaid	$86.25
Rate for Payer: Independent Care Health Plan Medicaid	$86.25
Rate for Payer: Managed Health Services Medicaid	$89.70
Rate for Payer: Molina Healthcare Medicaid	$117.03
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$86.25
Rate for Payer: United Healthcare Medicaid	$86.25
Rate for Payer: WMAP Medicaid	$86.25

EAPG 576: OTHER RESPIRATORY SYSTEM DIAGNOSES

Facility OP

$136.64

Service Code	EAPG 00576
Min. Negotiated Rate	$83.67
Max. Negotiated Rate	$136.64
Rate for Payer: Anthem Medicaid	$83.67
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$136.64
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$83.67
Rate for Payer: Dean Health Medicaid	$83.67
Rate for Payer: Independent Care Health Plan Medicaid	$83.67
Rate for Payer: Managed Health Services Medicaid	$87.02
Rate for Payer: Molina Healthcare Medicaid	$136.64
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$83.67
Rate for Payer: United Healthcare Medicaid	$83.67
Rate for Payer: WMAP Medicaid	$83.67

EAPG 579: STATUS ASTHMATICUS

Facility OP

$135.00

Service Code	EAPG 00579
Min. Negotiated Rate	$119.13
Max. Negotiated Rate	$135.00
Rate for Payer: Anthem Medicaid	$129.81
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$119.13
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$129.81
Rate for Payer: Dean Health Medicaid	$129.81
Rate for Payer: Independent Care Health Plan Medicaid	$129.81
Rate for Payer: Managed Health Services Medicaid	$135.00
Rate for Payer: Molina Healthcare Medicaid	$119.13
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$129.81
Rate for Payer: United Healthcare Medicaid	$129.81
Rate for Payer: WMAP Medicaid	$129.81

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