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 Wellmark 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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143 hospital rates
| # | Plans | |||
|---|---|---|---|---|
| 1 | Allen Memorial Hospital Corporation Waterloo, IA case rate · outpatient | 1 | $121.19 | $121.19 – $121.19 |
| 2 | Ann & Robert H. Lurie Children's Hospital of Chicago Chicago, IL percent of total billed charges · inpatientfrom % of charges | 1 | $230.00 | $230.00 – $230.00 |
| 3 | Ann & Robert H. Lurie Children's Hospital of Chicago Chicago, IL percent of total billed charges · outpatientfrom % of charges | 1 | $230.00 | $230.00 – $230.00 |
| 4 | Avera Behavioral Health Hospital Sioux Falls, SD case rate · outpatient | 2 | $46.00 | $46.00 – $46.00 |
| 5 | Avera Heart Hospital Sioux Falls, SD case rate · outpatient | 2 | $197.50 | $197.50 – $197.50 |
| 6 | Avera McKennan Hospital Sioux Falls, SD inpatient | 2 | $9.00 | $9.00 – $9.00 |
| 7 | Avera McKennan Hospital Sioux Falls, SD case rate · outpatient | 2 | $128.87 | $128.87 – $128.87 |
| 8 | Avera Specialty Hospital Sioux Falls, SD case rate · outpatient | 2 | $46.00 | $46.00 – $46.00 |
| 9 | Avera St. Luke's Aberdeen, SD outpatient | 1 | $154.00 | $154.00 – $154.00 |
| 10 | Avera St. Luke's Aberdeen, SD case rate · outpatient | 1 | $154.00 | $154.00 – $154.00 |
| 11 | Avera St. Mary's Hospital Pierre, SD inpatient | 1 | $27.61 | $27.61 – $27.61 |
| 12 | Avera St. Mary's Hospital Pierre, SD outpatient | 1 | $140.00 | $140.00 – $140.00 |
| 13 | Avera St. Mary's Hospital Pierre, SD case rate · inpatient | 1 | $27.61 | $27.61 – $27.61 |
| 14 | Avera St. Mary's Hospital Pierre, SD case rate · outpatient | 1 | $140.00 | $140.00 – $140.00 |
| 15 | Catholic Health Initiatives-Iowa Corp Des Moines, IA facility · fee schedule · both | 2 | $136.02 | $136.02 – $136.02 |
| 16 | Catholic Health Initiatives-Iowa Corp Des Moines, IA facility · fee schedule · outpatient | 2 | $136.02 | $136.02 – $136.02 |
| 17 | Catholic Health Initiatives-Iowa Corp Des Moines, IA facility · other · both | 1 | $127.28 | $127.28 – $127.28 |
| 18 | Catholic Health Initiatives-Iowa Corp Des Moines, IA facility · other · outpatient | 1 | $127.28 | $127.28 – $127.28 |
| 19 | Catholic Health Initiatives-Iowa Corp West Des Moines, IA facility · fee schedule · both | 2 | $136.02 | $136.02 – $136.02 |
| 20 | Catholic Health Initiatives-Iowa Corp West Des Moines, IA facility · fee schedule · outpatient | 2 | $136.02 | $136.02 – $136.02 |
| 21 | Catholic Health Initiatives-Iowa Corp West Des Moines, IA facility · other · both | 1 | $127.28 | $127.28 – $127.28 |
| 22 | Catholic Health Initiatives-Iowa Corp West Des Moines, IA facility · other · outpatient | 1 | $127.28 | $127.28 – $127.28 |
| 23 | Central Community Hospital Elkader, IA facility · percent of total billed charges · bothfrom % of charges | 1 | $154.04 | $66.91 – $263.01 |
| 24 | Central Iowa Hospital Corporation Des Moines, IA case rate · outpatient | 1 | $122.69 | $122.69 – $122.69 |
| 25 | Covenant Medical Center Inc Waterloo, IA facility · fee schedule · both | 2 | $136.02 | $136.02 – $136.02 |
← Payers reporting HCPCS G0463 · Snapshot 20261108T203506Z-bb90dbab