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Wisconsin 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
$291.48 / $291.48 / $340.12
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$195.58 / $291.48 / $294.39
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.97 / $146.88 / $164.92
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64.00 / $64.00 / $64.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$419.40 / $419.40 / $419.40
DeanCare
Facility/Professional
Facility
Modifier
Low / Median / High Price
$241.29 / $291.48 / $699.55
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$210.46 / $291.48 / $699.55
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$50.00 / $65.00 / $85.00
Prevea360
Facility/Professional
Facility
Modifier
Low / Median / High Price
$241.29 / $291.48 / $699.55