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Wisconsin rates for HCPCS G0381

Level 2 hospital emergency department visit provided in a type B emergency department; (the ED must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$127.22 / $127.22 / $127.22
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$127.22 / $127.22 / $145.00
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$26.70 / $38.72 / $44.10
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.00 / $64.00 / $64.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$36.70 / $36.70 / $150.02
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$127.22 / $127.22 / $240.69
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$127.22 / $127.22 / $240.69
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $65.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$127.22 / $127.22 / $240.69
Quartz
Facility/Professional
Professional
Modifier
Low / Median / High Price
$36.70 / $36.70 / $36.70