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 Medical Mutual 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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105 hospital rates
| # | Plans | |||
|---|---|---|---|---|
| 1 | ALLE-KISKI MEDICAL CENTER NATRONA HEIGHTS, PA fee schedule · outpatient | 1 | $353.01 | $353.01 – $353.01 |
| 2 | Adena Health System Chillicothe, OH facility · fee schedule · outpatient | 1 | $127.12 | $127.12 – $127.12 |
| 3 | Barnesville Hospital Association, Inc. Barnesville, OH facility · percent of total billed charges · outpatientfrom % of charges | 1 | $107.07 | $107.07 – $107.07 |
| 4 | Benefis Hospitals Inc Helena, MT percent of total billed charges · bothfrom % of charges | 1 | $200.25 | $160.20 – $240.30 |
| 5 | Bethesda Hospital Inc. Lebanon, OH facility · fee schedule · outpatient | 1 | $132.34 | $132.34 – $132.34 |
| 6 | CANONSBURG GENERAL HOSPITAL CANONSBURG, PA fee schedule · outpatient | 1 | $353.01 | $353.01 – $353.01 |
| 7 | Catholic Health Initiatives-Iowa Corp Des Moines, IA facility · percent of total billed charges · bothfrom % of charges | 1 | $103.19 | $51.01 – $291.48 |
| 8 | Catholic Health Initiatives-Iowa Corp West Des Moines, IA facility · percent of total billed charges · bothfrom % of charges | 1 | $101.74 | $51.01 – $291.48 |
| 9 | Central Community Hospital Elkader, IA facility · percent of total billed charges · bothfrom % of charges | 1 | $220.27 | $95.68 – $376.10 |
| 10 | Coshocton Regional Medical Center Coshocton, OH fee schedule · outpatient | 1 | $127.84 | $127.84 – $127.84 |
| 11 | Coshocton Regional Medical Center Coshocton, OH percent of total billed charges · outpatientfrom % of charges | 1 | $418.36 | $418.36 – $418.36 |
| 12 | Covenant Medical Center Inc Waterloo, IA facility · fee schedule · outpatient | 1 | $122.98 | $122.98 – $122.98 |
| 13 | Covenant Medical Center Inc Waterloo, IA facility · percent of total billed charges · bothfrom % of charges | 1 | $314.82 | $141.09 – $1,122 |
| 14 | Diley Ridge Medical Center Canal Winchester, OH facility · other · both | 1 | $128.37 | $128.37 – $128.37 |
| 15 | Diley Ridge Medical Center Canal Winchester, OH facility · percent of total billed charges · bothfrom % of charges | 1 | $241.24 | $125.57 – $448.99 |
| 16 | Dupont Hospital LLC Wayne, IN facility · percent of total billed charges · inpatientfrom % of charges | 1 | $608.97 | $129.32 – $2,696 |
| 17 | Dupont Hospital LLC Wayne, IN facility · percent of total billed charges · outpatientfrom % of charges | 1 | $608.97 | $129.32 – $2,696 |
| 18 | East Liverpool City Hospital Liverpool, OH fee schedule · outpatient | 1 | $125.33 | $125.33 – $125.33 |
| 19 | East Liverpool City Hospital Liverpool, OH percent of total billed charges · outpatientfrom % of charges | 1 | $119.07 | $119.07 – $119.07 |
| 20 | Fisher-Titus Medical Center Norwalk, OH facility · case rate · outpatient | 1 | $120.88 | $120.88 – $120.88 |
| 21 | GROVE CITY MEDICAL CENTER GROVE CITY, PA fee schedule · outpatient | 1 | $353.01 | $353.01 – $353.01 |
| 22 | Highland District Hospital Hillsboro, OH percent of total billed charges · outpatientfrom % of charges | 2 | $179.90 | $57.12 – $359.45 |
| 23 | JEFFERSON REGIONAL MEDICAL CENTER JEFFERSON HILLS, PA fee schedule · outpatient | 1 | $304.94 | $304.94 – $304.94 |
| 24 | Mayo Clinic Rochester, MN facility · percent of total billed charges · bothfrom % of charges | 2 | $157.07 | $67.45 – $303.05 |
| 25 | Mayo Clinic Arizona Phoenix, AZ facility · percent of total billed charges · bothfrom % of charges | 4 | $197.40 | $165.60 – $228.00 |
← Payers reporting HCPCS G0463 · Snapshot 20261108T203506Z-bb90dbab