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 Tricare 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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224 hospital rates
| # | Plans | |||
|---|---|---|---|---|
| 1 | Affinity Hospital LLC Birmingham, AL facility · fee schedule · outpatient | 1 | $115.69 | $115.69 – $115.69 |
| 2 | Armstrong County Memorial Hospital Kittanning, PA facility · fee schedule · outpatient | 1 | $129.68 | $129.68 – $129.68 |
| 3 | Ascension Seton Austin, TX fee schedule · outpatient | 1 | $98.67 | $98.67 – $98.67 |
| 4 | Ascension Seton Austin, TX fee schedule · outpatient | 1 | $98.67 | $98.67 – $98.67 |
| 5 | Ascension Seton Austin, TX fee schedule · outpatient | 1 | $98.67 | $98.67 – $98.67 |
| 6 | Ascension Seton Luling, TX fee schedule · outpatient | 1 | $98.67 | $98.67 – $98.67 |
| 7 | Ascension Seton Burnet, TX fee schedule · outpatient | 1 | $98.67 | $98.67 – $98.67 |
| 8 | Ascension Seton Smithville, TX fee schedule · outpatient | 1 | $98.67 | $98.67 – $98.67 |
| 9 | Ascension Seton Bastrop, TX fee schedule · outpatient | 1 | $98.67 | $98.67 – $98.67 |
| 10 | Ascension Seton Austin, TX fee schedule · outpatient | 1 | $98.67 | $98.67 – $98.67 |
| 11 | Beaufort Memorial Hospital Beaufort, SC facility · case rate · outpatient | 1 | $126.98 | $126.98 – $126.98 |
| 12 | Benefis Community Hospitals, Inc Choteau, MT other · both | 1 | $0.01 | $0.01 – $0.01 |
| 13 | Benefis Hospitals Inc Helena, MT other · outpatient | 1 | $128.87 | $128.87 – $128.87 |
| 14 | Bluffton Health System LLC Bluffton, IN facility · fee schedule · outpatient | 1 | $133.82 | $133.82 – $133.82 |
| 15 | Brandon HMA LLC Brandon, MS facility · fee schedule · outpatient | 1 | $114.19 | $114.19 – $114.19 |
| 16 | Bullhead City Hospital Corporation City, AZ facility · fee schedule · outpatient | 1 | $142.07 | $142.07 – $142.07 |
| 17 | Butler Healthcare Providers_ DBA Butler Memorial Hospital Butler, PA facility · case rate · outpatient | 1 | $123.97 | $123.97 – $123.97 |
| 18 | CLAIBORNE MEDICAL CENTER Tazewell, TN fee schedule · outpatient | 1 | $129.37 | $129.37 – $129.37 |
| 19 | CORNING HOSPITAL Corning, NY facility · fee schedule · outpatient | 1 | $74.49 | $34.12 – $129.53 |
| 20 | CORNING HOSPITAL Corning, NY facility · other · outpatient | 2 | $154.61 | $152.50 – $156.21 |
| 21 | CUMBERLAND MEDICAL CENTER, INC. Crossville, TN fee schedule · both | 1 | $129.37 | $129.37 – $129.37 |
| 22 | Campbell County HMA, LLC LaFollette, TN facility · fee schedule · outpatient | 1 | $117.99 | $117.99 – $117.99 |
| 23 | Carlsbad Medical Center LLC Carlsbad, NM facility · fee schedule · outpatient | 1 | $131.80 | $131.80 – $131.80 |
| 24 | Cary Medical Center Caribou, ME case rate · outpatient | 1 | $124.59 | $124.59 – $124.59 |
| 25 | Centinela Hospital Medical Center Inglewood, CA fee schedule · outpatient | 1 | $161.78 | $84.25 – $170.39 |
← Payers reporting HCPCS G0463 · Snapshot 20261108T203506Z-bb90dbab