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 Medica 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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167 hospital rates
| # | Plans | |||
|---|---|---|---|---|
| 1 | AHS Hillcrest Medical Center, LLC Tulsa, OK facility · percent of total billed charges · bothfrom % of charges | 1 | $812.47 | $565.73 – $1,221 |
| 2 | AHS Southcrest Hospital, LLC Tulsa, OK facility · percent of total billed charges · bothfrom % of charges | 1 | $488.52 | $353.40 – $624.34 |
| 3 | Allen Memorial Hospital Corporation Waterloo, IA percent of total billed charges · outpatientfrom % of charges | 1 | $122.21 | $27.28 – $309.52 |
| 4 | Alton Memorial Hospital Alton, IL other · both | 1 | $149.80 | $149.80 – $149.80 |
| 5 | Alton Memorial Hospital Alton, IL other · outpatient | 1 | $149.80 | $149.80 – $149.80 |
| 6 | Alton Memorial Hospital Alton, IL percent of total billed charges · bothfrom % of charges | 1 | $384.22 | $201.60 – $580.00 |
| 7 | Avera Behavioral Health Hospital Sioux Falls, SD percent of total billed charges · outpatientfrom % of charges | 2 | $80.85 | $74.68 – $87.02 |
| 8 | Avera Heart Hospital Sioux Falls, SD percent of total billed charges · inpatientfrom % of charges | 2 | $130.94 | $120.35 – $141.52 |
| 9 | Avera Heart Hospital Sioux Falls, SD percent of total billed charges · outpatientfrom % of charges | 2 | $131.66 | $120.14 – $143.18 |
| 10 | Avera McKennan Hospital Sioux Falls, SD percent of total billed charges · outpatientfrom % of charges | 2 | $80.85 | $74.68 – $87.02 |
| 11 | Avera Specialty Hospital Sioux Falls, SD percent of total billed charges · outpatientfrom % of charges | 2 | $80.85 | $74.68 – $87.02 |
| 12 | Avera St. Luke's Aberdeen, SD percent of total billed charges · inpatientfrom % of charges | 2 | $110.48 | $101.57 – $119.39 |
| 13 | Avera St. Luke's Aberdeen, SD percent of total billed charges · outpatientfrom % of charges | 2 | $111.38 | $102.06 – $120.69 |
| 14 | Avera St. Mary's Hospital Pierre, SD percent of total billed charges · inpatientfrom % of charges | 2 | $100.26 | $92.17 – $108.34 |
| 15 | Avera St. Mary's Hospital Pierre, SD percent of total billed charges · outpatientfrom % of charges | 2 | $101.07 | $92.61 – $109.52 |
| 16 | BETHESDA HOSPITAL BOYNTON BEACH, FL fee schedule · both | 1 | $111.22 | $55.61 – $139.03 |
| 17 | BSA Hospital Amarillo, TX facility · percent of total billed charges · bothfrom % of charges | 1 | $467.74 | $285.60 – $730.10 |
| 18 | Barnes Jewish Hospital St. Louis, MO other · both | 1 | $112.02 | $56.01 – $140.02 |
| 19 | Barnes Jewish Hospital St. Louis, MO other · outpatient | 1 | $136.02 | $56.01 – $140.02 |
| 20 | Barnes Jewish Hospital St. Louis, MO percent of total billed charges · bothfrom % of charges | 1 | $461.63 | $198.40 – $1,032 |
| 21 | Barnes Jewish St. Peters Hospital St. Peters, MO other · both | 1 | $140.02 | $140.02 – $140.02 |
| 22 | Barnes Jewish St. Peters Hospital St. Peters, MO other · outpatient | 1 | $140.02 | $140.02 – $140.02 |
| 23 | Barnes Jewish St. Peters Hospital St. Peters, MO percent of total billed charges · bothfrom % of charges | 1 | $372.93 | $201.60 – $580.00 |
| 24 | Barnes Jewish St. Peters Hospital St. Peters, MO percent of total billed charges · outpatientfrom % of charges | 1 | $838.40 | $838.40 – $838.40 |
| 25 | Brookings Health System Brookings, SD fee schedule · outpatient | 1 | $138.01 | $138.01 – $138.01 |
← Payers reporting HCPCS G0463 · Snapshot 20261108T203506Z-bb90dbab