Beloit Memorial Hospital

All Charges

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Type

Price

EAPG 637: GALLBLADDER AND BILIARY TRACT DIAGNOSES

Facility OP

$114.92

Service Code	EAPG 00637
Min. Negotiated Rate	$88.10
Max. Negotiated Rate	$114.92
Rate for Payer: Anthem Medicaid	$88.10
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$114.92
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$88.10
Rate for Payer: Dean Health Medicaid	$88.10
Rate for Payer: Independent Care Health Plan Medicaid	$88.10
Rate for Payer: Managed Health Services Medicaid	$91.62
Rate for Payer: Molina Healthcare Medicaid	$114.92
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$88.10
Rate for Payer: United Healthcare Medicaid	$88.10
Rate for Payer: WMAP Medicaid	$88.10

EAPG 638: CHOLECYSTITIS

Facility OP

$155.43

Service Code	EAPG 00638
Min. Negotiated Rate	$126.12
Max. Negotiated Rate	$155.43
Rate for Payer: Anthem Medicaid	$126.12
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$155.43
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$126.12
Rate for Payer: Dean Health Medicaid	$126.12
Rate for Payer: Independent Care Health Plan Medicaid	$126.12
Rate for Payer: Managed Health Services Medicaid	$131.16
Rate for Payer: Molina Healthcare Medicaid	$155.43
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$126.12
Rate for Payer: United Healthcare Medicaid	$126.12
Rate for Payer: WMAP Medicaid	$126.12

EAPG 639: OTHER HEPATOBILIARY SYSTEM DIAGNOSES

Facility OP

$119.23

Service Code	EAPG 00639
Min. Negotiated Rate	$73.57
Max. Negotiated Rate	$119.23
Rate for Payer: Anthem Medicaid	$73.57
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$119.23
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$73.57
Rate for Payer: Dean Health Medicaid	$73.57
Rate for Payer: Independent Care Health Plan Medicaid	$73.57
Rate for Payer: Managed Health Services Medicaid	$76.51
Rate for Payer: Molina Healthcare Medicaid	$119.23
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$73.57
Rate for Payer: United Healthcare Medicaid	$73.57
Rate for Payer: WMAP Medicaid	$73.57

EAPG 63: LEVEL II ENDOSCOPY OF THE UPPER AIRWAY

Facility OP

$2,321.00

Service Code	EAPG 00063
Min. Negotiated Rate	$782.05
Max. Negotiated Rate	$2,321.00
Rate for Payer: Anthem Medicaid	$782.05
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$2,321.00
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$782.05
Rate for Payer: Dean Health Medicaid	$782.05
Rate for Payer: Independent Care Health Plan Medicaid	$782.05
Rate for Payer: Managed Health Services Medicaid	$813.33
Rate for Payer: Molina Healthcare Medicaid	$2,321.00
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$782.05
Rate for Payer: United Healthcare Medicaid	$782.05
Rate for Payer: WMAP Medicaid	$782.05

EAPG 641: HEPATIC COMA AND MAJOR ACUTE LIVER DIAGNOSES

Facility OP

$71.76

Service Code	EAPG 00641
Min. Negotiated Rate	$69.00
Max. Negotiated Rate	$71.76
Rate for Payer: Anthem Medicaid	$69.00
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$69.00
Rate for Payer: Dean Health Medicaid	$69.00
Rate for Payer: Independent Care Health Plan Medicaid	$69.00
Rate for Payer: Managed Health Services Medicaid	$71.76
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$69.00
Rate for Payer: United Healthcare Medicaid	$69.00
Rate for Payer: WMAP Medicaid	$69.00

EAPG 642: GASTROINTESTINAL VASCULAR INSUFFICIENCY

Facility OP

$96.06

Service Code	EAPG 00642
Min. Negotiated Rate	$92.37
Max. Negotiated Rate	$96.06
Rate for Payer: Anthem Medicaid	$92.37
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$92.37
Rate for Payer: Dean Health Medicaid	$92.37
Rate for Payer: Independent Care Health Plan Medicaid	$92.37
Rate for Payer: Managed Health Services Medicaid	$96.06
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$92.37
Rate for Payer: United Healthcare Medicaid	$92.37
Rate for Payer: WMAP Medicaid	$92.37

EAPG 647: FRACTURES, DISLOCATIONS, OTHER INJURIES - UPPER EXTREMITY INCLUDING SHOULDER

Facility OP

$120.97

Service Code	EAPG 00647
Min. Negotiated Rate	$116.32
Max. Negotiated Rate	$120.97
Rate for Payer: Anthem Medicaid	$116.32
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$116.32
Rate for Payer: Dean Health Medicaid	$116.32
Rate for Payer: Independent Care Health Plan Medicaid	$116.32
Rate for Payer: Managed Health Services Medicaid	$120.97
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$116.32
Rate for Payer: United Healthcare Medicaid	$116.32
Rate for Payer: WMAP Medicaid	$116.32

EAPG 648: FRACTURES, DISLOCATIONS AND SPRAINS OF THE SKULL, CRANIUM AND FACE

Facility OP

$138.56

Service Code	EAPG 00648
Min. Negotiated Rate	$133.23
Max. Negotiated Rate	$138.56
Rate for Payer: Anthem Medicaid	$133.23
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$133.23
Rate for Payer: Dean Health Medicaid	$133.23
Rate for Payer: Independent Care Health Plan Medicaid	$133.23
Rate for Payer: Managed Health Services Medicaid	$138.56
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$133.23
Rate for Payer: United Healthcare Medicaid	$133.23
Rate for Payer: WMAP Medicaid	$133.23

EAPG 649: OTHER PATHOLOGICAL FRACTURES W/O MUSCULOSKELETAL MALIGNANCY

Facility OP

$116.04

Service Code	EAPG 00649
Min. Negotiated Rate	$111.58
Max. Negotiated Rate	$116.04
Rate for Payer: Anthem Medicaid	$111.58
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$111.58
Rate for Payer: Dean Health Medicaid	$111.58
Rate for Payer: Independent Care Health Plan Medicaid	$111.58
Rate for Payer: Managed Health Services Medicaid	$116.04
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$111.58
Rate for Payer: United Healthcare Medicaid	$111.58
Rate for Payer: WMAP Medicaid	$111.58

EAPG 64: LEVEL I LOWER AIRWAY ENDOSCOPY

Facility OP

$1,368.21

Service Code	EAPG 00064
Min. Negotiated Rate	$744.66
Max. Negotiated Rate	$1,368.21
Rate for Payer: Anthem Medicaid	$744.66
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$1,368.21
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$744.66
Rate for Payer: Dean Health Medicaid	$744.66
Rate for Payer: Independent Care Health Plan Medicaid	$744.66
Rate for Payer: Managed Health Services Medicaid	$774.45
Rate for Payer: Molina Healthcare Medicaid	$1,368.21
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$744.66
Rate for Payer: United Healthcare Medicaid	$744.66
Rate for Payer: WMAP Medicaid	$744.66

EAPG 650: FRACTURES, DISLOCATIONS, OTHER INJURIES - LOWER EXTREMITY INCLUDING FEMUR

Facility OP

$258.61

Service Code	EAPG 00650
Min. Negotiated Rate	$114.79
Max. Negotiated Rate	$258.61
Rate for Payer: Anthem Medicaid	$114.79
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$258.61
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$114.79
Rate for Payer: Dean Health Medicaid	$114.79
Rate for Payer: Independent Care Health Plan Medicaid	$114.79
Rate for Payer: Managed Health Services Medicaid	$119.38
Rate for Payer: Molina Healthcare Medicaid	$258.61
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$114.79
Rate for Payer: United Healthcare Medicaid	$114.79
Rate for Payer: WMAP Medicaid	$114.79

EAPG 651: FRACTURES, DISLOCATIONS, SPRAINS AND OTHER INJURIES OF THE PELVIS AND HIP

Facility OP

$201.96

Service Code	EAPG 00651
Min. Negotiated Rate	$145.47
Max. Negotiated Rate	$201.96
Rate for Payer: Anthem Medicaid	$145.47
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$201.96
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$145.47
Rate for Payer: Dean Health Medicaid	$145.47
Rate for Payer: Independent Care Health Plan Medicaid	$145.47
Rate for Payer: Managed Health Services Medicaid	$151.29
Rate for Payer: Molina Healthcare Medicaid	$201.96
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$145.47
Rate for Payer: United Healthcare Medicaid	$145.47
Rate for Payer: WMAP Medicaid	$145.47

EAPG 652: OTHER INJURIES AND DISORDERS OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE

Facility OP

$178.52

Service Code	EAPG 00652
Min. Negotiated Rate	$60.11
Max. Negotiated Rate	$178.52
Rate for Payer: Anthem Medicaid	$60.11
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$178.52
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: Molina Healthcare Medicaid	$178.52
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 653: MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FX DUE TO MALIGNANCY

Facility OP

$142.81

Service Code	EAPG 00653
Min. Negotiated Rate	$81.27
Max. Negotiated Rate	$142.81
Rate for Payer: Anthem Medicaid	$81.27
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$142.81
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$81.27
Rate for Payer: Dean Health Medicaid	$81.27
Rate for Payer: Independent Care Health Plan Medicaid	$81.27
Rate for Payer: Managed Health Services Medicaid	$84.52
Rate for Payer: Molina Healthcare Medicaid	$142.81
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$81.27
Rate for Payer: United Healthcare Medicaid	$81.27
Rate for Payer: WMAP Medicaid	$81.27

EAPG 654: OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS

Facility OP

$112.48

Service Code	EAPG 00654
Min. Negotiated Rate	$63.37
Max. Negotiated Rate	$112.48
Rate for Payer: Anthem Medicaid	$63.37
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$112.48
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$63.37
Rate for Payer: Dean Health Medicaid	$63.37
Rate for Payer: Independent Care Health Plan Medicaid	$63.37
Rate for Payer: Managed Health Services Medicaid	$65.90
Rate for Payer: Molina Healthcare Medicaid	$112.48
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$63.37
Rate for Payer: United Healthcare Medicaid	$63.37
Rate for Payer: WMAP Medicaid	$63.37

EAPG 655: CONNECTIVE TISSUE DIAGNOSES

Facility OP

$100.44

Service Code	EAPG 00655
Min. Negotiated Rate	$52.54
Max. Negotiated Rate	$100.44
Rate for Payer: Anthem Medicaid	$52.54
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$100.44
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$52.54
Rate for Payer: Dean Health Medicaid	$52.54
Rate for Payer: Independent Care Health Plan Medicaid	$52.54
Rate for Payer: Managed Health Services Medicaid	$54.64
Rate for Payer: Molina Healthcare Medicaid	$100.44
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$52.54
Rate for Payer: United Healthcare Medicaid	$52.54
Rate for Payer: WMAP Medicaid	$52.54

EAPG 656: FRACTURES, DISLOCATIONS, OTHER INJURIES OF THE NECK, UPPER BACK AND CHEST

Facility OP

$132.83

Service Code	EAPG 00656
Min. Negotiated Rate	$127.51
Max. Negotiated Rate	$132.83
Rate for Payer: Anthem Medicaid	$127.51
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$132.83
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$127.51
Rate for Payer: Dean Health Medicaid	$127.51
Rate for Payer: Independent Care Health Plan Medicaid	$127.51
Rate for Payer: Managed Health Services Medicaid	$132.61
Rate for Payer: Molina Healthcare Medicaid	$132.83
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$127.51
Rate for Payer: United Healthcare Medicaid	$127.51
Rate for Payer: WMAP Medicaid	$127.51

EAPG 657: FRACTURES, DISLOCATIONS, SPRAINS AND OTHER INJURIES OF THE LOWER BACK

Facility OP

$117.76

Service Code	EAPG 00657
Min. Negotiated Rate	$70.89
Max. Negotiated Rate	$117.76
Rate for Payer: Anthem Medicaid	$70.89
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$117.76
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$70.89
Rate for Payer: Dean Health Medicaid	$70.89
Rate for Payer: Independent Care Health Plan Medicaid	$70.89
Rate for Payer: Managed Health Services Medicaid	$73.73
Rate for Payer: Molina Healthcare Medicaid	$117.76
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$70.89
Rate for Payer: United Healthcare Medicaid	$70.89
Rate for Payer: WMAP Medicaid	$70.89

EAPG 658: SCIATICA AND LOW BACK PAIN

Facility OP

$130.58

Service Code	EAPG 00658
Min. Negotiated Rate	$69.04
Max. Negotiated Rate	$130.58
Rate for Payer: Anthem Medicaid	$69.04
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$130.58
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$69.04
Rate for Payer: Dean Health Medicaid	$69.04
Rate for Payer: Independent Care Health Plan Medicaid	$69.04
Rate for Payer: Managed Health Services Medicaid	$71.80
Rate for Payer: Molina Healthcare Medicaid	$130.58
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$69.04
Rate for Payer: United Healthcare Medicaid	$69.04
Rate for Payer: WMAP Medicaid	$69.04

EAPG 659: MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE

Facility OP

$123.78

Service Code	EAPG 00659
Min. Negotiated Rate	$79.75
Max. Negotiated Rate	$123.78
Rate for Payer: Anthem Medicaid	$79.75
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$123.78
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$79.75
Rate for Payer: Dean Health Medicaid	$79.75
Rate for Payer: Independent Care Health Plan Medicaid	$79.75
Rate for Payer: Managed Health Services Medicaid	$82.94
Rate for Payer: Molina Healthcare Medicaid	$123.78
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$79.75
Rate for Payer: United Healthcare Medicaid	$79.75
Rate for Payer: WMAP Medicaid	$79.75

EAPG 660: OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES

Facility OP

$124.02

Service Code	EAPG 00660
Min. Negotiated Rate	$70.92
Max. Negotiated Rate	$124.02
Rate for Payer: Anthem Medicaid	$70.92
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$124.02
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$70.92
Rate for Payer: Dean Health Medicaid	$70.92
Rate for Payer: Independent Care Health Plan Medicaid	$70.92
Rate for Payer: Managed Health Services Medicaid	$73.76
Rate for Payer: Molina Healthcare Medicaid	$124.02
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$70.92
Rate for Payer: United Healthcare Medicaid	$70.92
Rate for Payer: WMAP Medicaid	$70.92

EAPG 662: OSTEOPOROSIS

Facility OP

$89.68

Service Code	EAPG 00662
Min. Negotiated Rate	$56.57
Max. Negotiated Rate	$89.68
Rate for Payer: Anthem Medicaid	$56.57
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$89.68
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$56.57
Rate for Payer: Dean Health Medicaid	$56.57
Rate for Payer: Independent Care Health Plan Medicaid	$56.57
Rate for Payer: Managed Health Services Medicaid	$58.83
Rate for Payer: Molina Healthcare Medicaid	$89.68
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$56.57
Rate for Payer: United Healthcare Medicaid	$56.57
Rate for Payer: WMAP Medicaid	$56.57

EAPG 663: PAIN RELATED DIAGNOSES

Facility OP

$114.38

Service Code	EAPG 00663
Min. Negotiated Rate	$59.08
Max. Negotiated Rate	$114.38
Rate for Payer: Anthem Medicaid	$59.08
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$114.38
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$59.08
Rate for Payer: Dean Health Medicaid	$59.08
Rate for Payer: Independent Care Health Plan Medicaid	$59.08
Rate for Payer: Managed Health Services Medicaid	$61.44
Rate for Payer: Molina Healthcare Medicaid	$114.38
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$59.08
Rate for Payer: United Healthcare Medicaid	$59.08
Rate for Payer: WMAP Medicaid	$59.08

EAPG 66: PULMONARY REHABILITATIVE SERVICES

Facility OP

$101.32

Service Code	EAPG 00066
Min. Negotiated Rate	$14.19
Max. Negotiated Rate	$101.32
Rate for Payer: Anthem Medicaid	$14.19
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$101.32
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$14.19
Rate for Payer: Dean Health Medicaid	$14.19
Rate for Payer: Independent Care Health Plan Medicaid	$14.19
Rate for Payer: Managed Health Services Medicaid	$14.76
Rate for Payer: Molina Healthcare Medicaid	$101.32
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$14.19
Rate for Payer: United Healthcare Medicaid	$14.19
Rate for Payer: WMAP Medicaid	$14.19

EAPG 670: NON-PRESSURE CHRONIC SKIN ULCERS

Facility OP

$136.30

Service Code	EAPG 00670
Min. Negotiated Rate	$59.90
Max. Negotiated Rate	$136.30
Rate for Payer: Anthem Medicaid	$59.90
Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO	$136.30
Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid	$59.90
Rate for Payer: Dean Health Medicaid	$59.90
Rate for Payer: Independent Care Health Plan Medicaid	$59.90
Rate for Payer: Managed Health Services Medicaid	$62.30
Rate for Payer: Molina Healthcare Medicaid	$136.30
Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP	$59.90
Rate for Payer: United Healthcare Medicaid	$59.90
Rate for Payer: WMAP Medicaid	$59.90

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