Emergency visit, high (level 4) at Gundersen TriCounty Hospital and Clinics. CPT 99284.
What Gundersen TriCounty Hospital and Clinics publishes for this service, straight from its standard-charges file, last updated June 27, 2026.
Outpatient / ER
$717cash price (self-pay)
$1,131list price
$478–$4,286range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Quartz | All Products | $478 |
| Quartz | All Other Self Funded | $498 |
| Quartz | Self Funded | $532 |
| Quartz | Level Funded | $549 |
| UCARE | Non-Dually Eligible | $588 |
| UCARE | MSHO/Minnesota Special Needs | $588 |
| UCARE | Dually Eligible | $588 |
| Quartz | Fully Insured | $616 |
| Anthem | Medicare HMO/PPO | $667 |
| Humana | Medicare Advantage | $667 |
| Quartz | Medicare Advantage | $667 |
| UHC | Medicare Advantage | $667 |
| UHC | All Payer Appendix | $814 |
| Cigna | All Products | $872 |
| Alliance | Premier/All Products | $884 |
| Alliance | Comprehensive/All Products | $888 |
| Group Health of South Central | All Products | $905 |
| Trilogy | All Products | $905 |
| UCARE | Qualified Health Plan | $905 |
| Aspirus Arise Health | All Products | $939 |
| Allied National | Core Value Programs | $961 |
| Sana | All Products | $973 |
| Group Health Eau Claire | All Products | $1,018 |
| Coventry Health Care | All Products | $1,074 |
| WPS | All Products | $1,074 |
| WPS - ARISE | All Products | $1,074 |
| Anthem | State Specific | $3,490 |
| Anthem | HMO/POS | $3,490 |
| Anthem | PPO | $4,286 |
Inpatient
$717cash price (self-pay)
$1,131list price
$478–$1,074range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Quartz | All Other Self Funded | $666 |
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All common services at Gundersen TriCounty Hospital and Clinics