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 Premera 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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90 hospital rates
| # | Plans | |||
|---|---|---|---|---|
| 1 | COMMONSPIRIT OREGON Roseburg, OR fee schedule · inpatient | 1 | $410.71 | $257.40 – $606.06 |
| 2 | COMMONSPIRIT OREGON Roseburg, OR fee schedule · outpatient | 1 | $437.04 | $273.90 – $644.91 |
| 3 | Catholic Health Initiatives-Iowa Corp Des Moines, IA facility · fee schedule · both | 1 | $136.02 | $136.02 – $136.02 |
| 4 | Catholic Health Initiatives-Iowa Corp Des Moines, IA facility · fee schedule · outpatient | 1 | $136.02 | $136.02 – $136.02 |
| 5 | Catholic Health Initiatives-Iowa Corp West Des Moines, IA facility · fee schedule · both | 1 | $136.02 | $136.02 – $136.02 |
| 6 | Catholic Health Initiatives-Iowa Corp West Des Moines, IA facility · fee schedule · outpatient | 1 | $136.02 | $136.02 – $136.02 |
| 7 | Central Washington Health Services Association Wenatchee, WA other · both | 1 | $262.38 | $262.38 – $262.38 |
| 8 | Central Washington Health Services Association Wenatchee, WA percent of total billed charges · bothfrom % of charges | 3 | $178.17 | $166.75 – $183.13 |
| 9 | Clallam County Public Hospital District 2 DBA Olympic Medical Center Port Angeles, WA percent of total billed charges · outpatientfrom % of charges | 1 | $155.59 | $155.59 – $155.59 |
| 10 | Covenant Medical Center Inc Waterloo, IA facility · fee schedule · both | 1 | $136.02 | $136.02 – $136.02 |
| 11 | Covenant Medical Center Inc Waterloo, IA facility · fee schedule · outpatient | 1 | $136.02 | $136.02 – $136.02 |
| 12 | Diley Ridge Medical Center Canal Winchester, OH facility · other · both | 1 | $478.85 | $478.85 – $478.85 |
| 13 | Holy Cross Germantown Hospital Germantown, MD facility · percent of total billed charges · bothfrom % of charges | 1 | $217.11 | $117.45 – $293.62 |
| 14 | Holy Cross Hospital-Ft. Lauderdale Ft. Lauderdale, FL facility · case rate · outpatient | 1 | $3,407 | $764.00 – $4,068 |
| 15 | Holy Cross Hospital-Ft. Lauderdale Ft. Lauderdale, FL facility · per diem · both | 1 | $763.00 | $763.00 – $763.00 |
| 16 | Holy Cross Hospital-Ft. Lauderdale Ft. Lauderdale, FL facility · per diem · outpatient | 1 | $763.00 | $763.00 – $763.00 |
| 17 | Holy Cross Hospital-Silver Spring Silver Spring, MD facility · percent of total billed charges · bothfrom % of charges | 1 | $224.62 | $57.28 – $343.70 |
| 18 | Johnson Memorial Hospital Stafford Springs, CT facility · percent of total billed charges · bothfrom % of charges | 1 | $639.10 | $223.00 – $3,000 |
| 19 | Mercy Fitzgerald Hospital Darby, PA facility · percent of total billed charges · bothfrom % of charges | 1 | $554.36 | $220.00 – $2,240 |
| 20 | Mercy Health Hackley Campus Muskogen, MI facility · fee schedule · both | 1 | $690.23 | $690.23 – $690.23 |
| 21 | Mercy Health Hackley Campus Muskogen, MI facility · fee schedule · outpatient | 1 | $690.23 | $690.23 – $690.23 |
| 22 | Mercy Health Hackley Campus Muskogen, MI facility · percent of total billed charges · bothfrom % of charges | 1 | $120.49 | $120.49 – $120.49 |
| 23 | Mercy Health Lakeshore Campus Shelby, MI facility · percent of total billed charges · bothfrom % of charges | 1 | $168.38 | $117.95 – $275.21 |
| 24 | Mercy Health Saint Marys Rockford, MI facility · fee schedule · both | 1 | $311.63 | $311.63 – $311.63 |
| 25 | Mercy Health Saint Marys Rockford, MI facility · fee schedule · outpatient | 1 | $311.63 | $311.63 – $311.63 |
← Payers reporting HCPCS G0463 · Snapshot 20261108T203506Z-bb90dbab