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Wisconsin rates for HCPCS E0300

Pediatric Crib Hospital Grade Fully Enclosed With Or Without Top Enclosure (Revised 01/01/13)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,110.85 / $2,110.85 / $2,110.85
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,326.64 / $1,899.77 / $2,490.12
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,115.00 / $3,426.50 / $5,669.30
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,636.06 / $2,896.95 / $3,831.45
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$219.61 / $666.61 / $666.61
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,950.00 / $8,326.35 / $12,931.97
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,657.50 / $3,611.25 / $4,514.06
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$358.23 / $1,930.26 / $3,577.22
DeanCare
Facility/Professional
Professional
Modifier
Low / Median / High Price
$373.80 / $2,270.90 / $2,270.90
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$358.23 / $2,981.02 / $17,045.09
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,136.76 / $1,589.39 / $2,981.02
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6.22 / $58.40 / $2,554.30
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$358.23 / $2,110.85 / $3,799.53
Prevea360
Facility/Professional
Professional
Modifier
Low / Median / High Price
$373.80 / $2,270.90 / $2,270.90
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$347.79 / $759.61 / $986.30
Quartz
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,950.00 / $3,737.96 / $17,045.09
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$244.82 / $1,950.00 / $1,950.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,027.16 / $1,585.86 / $2,924.34