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Washington rates for HCPCS G0384

Level 5 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
$3,850.98 / $3,850.98 / $5,068.37
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$195.58 / $291.48 / $488.43
Asuris Northwest Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$132.88 / $985.16 / $985.16
Kaiser Permanente
Facility/Professional
Facility
Modifier
Low / Median / High Price
$325.47 / $997.33 / $1,853.80
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $50.00 / $75.00
Pacific Source
Facility/Professional
Facility
Modifier
Low / Median / High Price
$576.00 / $922.00 / $79,999.20
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$250.00 / $250.00 / $250.00
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,148.14 / $1,400.16 / $1,914.94
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$148.79 / $148.79 / $148.79