Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
Est Eval Visit Level 5 - Psych|PROCEDURE PERFORMED ON INFANTS LESS THAN 4 KG
The hospitals that file a Bcbs Tx rate for this code, one row per hospital and set of terms (billing class, payment method, setting). Rates under different terms are never blended, so the terms are shown under each hospital’s name. Figures are the hospital’s averages across its plans.
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45 hospital rates
| # | Plans | |||
|---|---|---|---|---|
| 1 | CHRISTUS Good Shepherd Hospital - Northpark Longview, TX fee schedule · outpatient | 5 | $603.53 | $186.65 – $779.05 |
| 2 | CHRISTUS Health - Pine Street Texarkana, TX fee schedule · outpatient | 6 | $496.59 | $126.51 – $645.73 |
| 3 | CHRISTUS Hospital - Orange Orange, TX fee schedule · outpatient | 6 | $426.31 | $129.08 – $552.99 |
| 4 | CHRISTUS West Beaumont Beaumont, TX fee schedule · outpatient | 6 | $426.31 | $129.08 – $552.99 |
| 5 | Christus Health Southeast Texas Beaumont, TX fee schedule · outpatient | 6 | $426.31 | $129.08 – $552.99 |
| 6 | Christus Health Southeast Texas Port Arthur, TX fee schedule · outpatient | 6 | $426.31 | $129.08 – $552.99 |
| 7 | Good Shepherd Medical Center - Longview Longview, TX fee schedule · outpatient | 5 | $603.53 | $186.65 – $779.05 |
| 8 | Good Shepherd Medical Center - Marshall Marshall, TX fee schedule · outpatient | 5 | $603.53 | $186.65 – $779.05 |
| 9 | Hendrick Medical Center Abilene, TX facility · percent of total billed charges · inpatientfrom % of charges | 4 | $238.73 | $170.18 – $397.09 |
| 10 | Hendrick Medical Center Abilene, TX facility · percent of total billed charges · outpatientfrom % of charges | 4 | $234.00 | $170.18 – $397.09 |
| 11 | Hendrick Medical Center Brownwood, TX facility · percent of total billed charges · inpatientfrom % of charges | 4 | $605.13 | $556.17 – $658.01 |
| 12 | Hendrick Medical Center Brownwood, TX facility · percent of total billed charges · outpatientfrom % of charges | 4 | $605.13 | $556.17 – $658.01 |
| 13 | Hendrick Medical Center Abilene, TX facility · percent of total billed charges · inpatientfrom % of charges | 4 | $238.73 | $170.18 – $397.09 |
| 14 | Hendrick Medical Center Abilene, TX facility · percent of total billed charges · outpatientfrom % of charges | 4 | $234.00 | $170.18 – $397.09 |
| 15 | Knox County Hospital District Knox City, TX percent of total billed charges · outpatientfrom % of charges | 3 | $93.00 | $63.00 – $150.00 |
| 16 | MHHS IMAGING CENTER Houston, TX facility · case rate · outpatient | 6 | $311.08 | $244.61 – $382.57 |
| 17 | Mother Frances Hospital - Jacksonville Jacksonville, TX fee schedule · outpatient | 5 | $461.40 | $370.98 – $533.28 |
| 18 | Mother Frances Hospital - South Tyler Tyler, TX fee schedule · outpatient | 6 | $404.80 | $121.81 – $533.28 |
| 19 | Mother Frances Hospital - Sulphur Springs Sulphur Springs, TX fee schedule · outpatient | 6 | $161.82 | $132.74 – $193.60 |
| 20 | Mother Frances Hospital - Tyler Tyler, TX fee schedule · outpatient | 6 | $404.80 | $121.81 – $533.28 |
| 21 | Mother Frances Hospital - Tyler Tyler, TX fee schedule · outpatient | 6 | $404.80 | $121.81 – $533.28 |
| 22 | Mother Frances Hospital - Winnsboro Winnsboro, TX fee schedule · outpatient | 5 | $461.40 | $370.98 – $533.28 |
| 23 | Santa Rosa Emergency Center - Alon San Antonio, TX fee schedule · outpatient | 6 | $316.18 | $121.01 – $410.39 |
| 24 | Santa Rosa Emergency Center - Creekside New Braunfels, TX fee schedule · outpatient | 5 | $320.43 | $277.07 – $362.86 |
| 25 | Santa Rosa Hospital - Alamo Heights San Antonio, TX fee schedule · outpatient | 6 | $316.95 | $121.01 – $410.39 |
← Payers reporting HCPCS G0463 · Snapshot 20261108T203506Z-bb90dbab