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 Medicaid 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 | ACADIAN MEDICAL CENTER EUNICE, LA percent of total billed charges · bothfrom % of charges | 6 | $287.97 | $28.44 – $926.00 |
| 2 | Brookings Health System Brookings, SD fee schedule · outpatient | 1 | $150.00 | $150.00 – $150.00 |
| 3 | Bullhead City Hospital Corporation City, AZ facility · percent of total billed charges · outpatientfrom % of charges | 1 | $94.27 | $68.40 – $115.52 |
| 4 | CATHOLIC HEALTH INITIATIVES COLORADO Salt Lake City, UT fee schedule · outpatient | 1 | $136.02 | $136.02 – $136.02 |
| 5 | CentraState Medical Center Freehold Township, NJ per diem · outpatient | 1 | $79.31 | $79.31 – $79.31 |
| 6 | Chilton Medical Center Pompton Plains, NJ per diem · outpatient | 1 | $79.31 | $79.31 – $79.31 |
| 7 | Dupont Hospital LLC Wayne, IN facility · other · outpatient | 1 | $165.95 | $159.12 – $295.62 |
| 8 | Eisenhower Medical Center Rancho Mirage, CA fee schedule · both | 3 | $34.10 | $34.10 – $34.10 |
| 9 | Granbury Hospital Corporation Granbury, TX facility · fee schedule · outpatient | 1 | $266.13 | $45.02 – $463.35 |
| 10 | HMA Santa Rosa Medical Center LLC Milton, FL facility · fee schedule · outpatient | 1 | $115.26 | $115.26 – $115.26 |
| 11 | Hackettstown Medical Center Hackettstown, NJ per diem · outpatient | 1 | $79.31 | $79.31 – $79.31 |
| 12 | Hospital Authority of Colquitt County Moultrie, GA fee schedule · both | 1 | $220.86 | $160.00 – $307.00 |
| 13 | IOM Health System LP Fort Wayne, IN facility · other · outpatient | 1 | $165.05 | $159.12 – $295.62 |
| 14 | Kirksville Missouri Hospital Co LLC PO Box C8502 Kirksville, MO facility · fee schedule · outpatient | 1 | $109.86 | $109.86 – $109.86 |
| 15 | Laredo Texas Hospital Company LP Laredo, TX facility · fee schedule · outpatient | 1 | $45.95 | $23.50 – $74.31 |
| 16 | Longview Medical Center LP Longview, TX facility · fee schedule · outpatient | 1 | $26.07 | $9.30 – $57.59 |
| 17 | Lowell General Hospital Lowell, MA percent of total billed charges · bothfrom % of charges | 1 | $459.00 | $459.00 – $459.00 |
| 18 | Lutheran Musculoskeletal Center LLC Fort Wayne, IN facility · other · outpatient | 1 | $159.12 | $159.12 – $159.12 |
| 19 | Lutheran Musculoskeletal Center LLC Fort Wayne, IN facility · per diem · outpatient | 1 | $122.40 | $122.40 – $122.40 |
| 20 | MELROSEWAKEFIELD HEALTHCARE Medford, MA percent of total billed charges · bothfrom % of charges | 1 | $573.75 | $459.00 – $688.50 |
| 21 | MINDEN MEDICAL CENTER MINDEN, LA percent of total billed charges · bothfrom % of charges | 16 | $30.10 | $13.89 – $46.31 |
| 22 | Maple Grove Hospital Corporation Grove, MN facility · other · both | 1 | $112.81 | $112.81 – $112.81 |
| 23 | Mercy Hospital South Louis, MO facility · fee schedule · outpatient | 1 | $109.86 | $109.86 – $109.86 |
| 24 | Mercy Hospital South Louis, MO facility · percent of total billed charges · outpatientfrom % of charges | 1 | $42.75 | $42.75 – $42.75 |
| 25 | Morristown Medical Center Morristown, NJ per diem · outpatient | 1 | $79.31 | $79.31 – $79.31 |
← Payers reporting HCPCS G0463 · Snapshot 20261108T203506Z-bb90dbab