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 Molina 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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677 hospital rates
| # | Plans | |||
|---|---|---|---|---|
| 1 | AKRON GENERAL MEDICAL CENTER Akron, OH facility · case rate · outpatient | 1 | $60.30 | $60.30 – $60.30 |
| 2 | ALLE-KISKI MEDICAL CENTER NATRONA HEIGHTS, PA fee schedule · outpatient | 1 | $135.13 | $135.13 – $135.13 |
| 3 | AMH Cath Labs LLC Arlington, TX case rate · outpatient | 1 | $140.66 | $140.66 – $140.66 |
| 4 | ARH Mary Breckinridge Health Services, Inc Barbourville, KY percent of total billed charges · outpatientfrom % of charges | 1 | $44.74 | $44.74 – $44.74 |
| 5 | ARH Mary Breckinridge Health Services, Inc Hayden, KY percent of total billed charges · outpatientfrom % of charges | 1 | $39.47 | $39.47 – $39.47 |
| 6 | ARH Mary Breckinridge Health Services, Inc Martin, KY percent of total billed charges · outpatientfrom % of charges | 1 | $52.63 | $52.63 – $52.63 |
| 7 | Adena Fayette Medical Center Washington Court House, OH facility · case rate · outpatient | 1 | $278.84 | $278.84 – $278.84 |
| 8 | Adena Health System Chillicothe, OH facility · fee schedule · outpatient | 2 | $193.86 | $127.12 – $260.60 |
| 9 | Advocate Childrens Hospital Oak Lawn Oak Lawn, IL facility · case rate · outpatient | 1 | $194.79 | $194.79 – $194.79 |
| 10 | Advocate Childrens Hospital Park Ridge Park Ridge, IL facility · case rate · outpatient | 1 | $194.79 | $194.79 – $194.79 |
| 11 | Advocate Christ Medical Center Oak Lawn, IL facility · case rate · outpatient | 1 | $194.79 | $194.79 – $194.79 |
| 12 | Advocate Condell Medical Center Libertyville, IL case rate · outpatient | 1 | $194.79 | $194.79 – $194.79 |
| 13 | Advocate Good Samaritan Hospital Downers Grove, IL case rate · outpatient | 1 | $194.79 | $194.79 – $194.79 |
| 14 | Advocate Good Shepherd Hospital Barrington, IL case rate · outpatient | 1 | $194.79 | $194.79 – $194.79 |
| 15 | Advocate Illinois Masonic Medical Center Chicago, IL case rate · outpatient | 1 | $194.79 | $194.79 – $194.79 |
| 16 | Advocate Lutheran General Hospital Park Ridge, IL case rate · outpatient | 1 | $194.79 | $194.79 – $194.79 |
| 17 | Advocate Sherman Hospital Elgin, IL case rate · outpatient | 1 | $194.79 | $194.79 – $194.79 |
| 18 | Advocate South Suburban Hospital Hazel Crest, IL case rate · outpatient | 1 | $194.79 | $194.79 – $194.79 |
| 19 | Advocate Trinity Hospital Chicago, IL case rate · outpatient | 1 | $194.79 | $194.79 – $194.79 |
| 20 | Agnesian Healthcare Inc. Fond Du Lac, WI fee schedule · outpatient | 1 | $98.76 | $98.76 – $98.76 |
| 21 | Allen Memorial Hospital Corporation Waterloo, IA case rate · outpatient | 1 | $121.19 | $121.19 – $121.19 |
| 22 | Appalachian Regional Healthcare, Inc. Liberty, KY percent of total billed charges · outpatientfrom % of charges | 1 | $55.26 | $55.26 – $55.26 |
| 23 | Appalachian Regional Healthcare, Inc. McDowell, KY percent of total billed charges · outpatientfrom % of charges | 1 | $44.74 | $44.74 – $44.74 |
| 24 | BAPTIST HEALTHCARE SYSTEM INC Elizabethtown, KY percent of total billed charges · bothfrom % of charges | 1 | $43.69 | $43.69 – $43.69 |
| 25 | BAPTIST HEALTHCARE SYSTEM INC Elizabethtown, KY percent of total billed charges · outpatientfrom % of charges | 1 | $38.33 | $1.67 – $71.19 |
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