Kaiser Permanente 2013 Sample Fee List Members in any deductible plan 1 can use this list to help estimate their charges. COLORADO As your partner in health, we want to help you manage your health care spending. Knowing how much you can expect to pay for care and services can give you peace of mind so you can concentrate on the things you enjoy in life. This Sample Fee List 2 shows you estimated charges for many common medical services like office visits, lab tests, and X-rays when you receive care at Kaiser Permanente facilities. Your charges may be different if you receive care or services from a contracted provider at a non Kaiser Permanente facility. This list doesn t apply to medical services received from any network providers who aren t Kaiser Permanente providers. The amount you pay out of your own pocket for a service will depend on your plan coverage, whether you ve reached your deductible or out-of-pocket maximum, and other factors. The amount you are asked to pay may be a copay (a fixed dollar amount you pay for services) or coinsurance (a percentage of charges you pay for services). Please note that these estimated charges are based on typical visits. Your actual charges may vary depending on your diagnosis and the length of your visit. Use this Sample Fee List to help with the following: Review your benefit options during open enrollment. If you have a choice of plans, the amount you pay out of your own pocket for care may vary, so knowing how much services cost can help you choose the best Kaiser Permanente plan for you. Estimate how much you ll spend throughout the year for care and services at our facilities. Manage funds in your health savings account (HSA) or health reimbursement arrangement (HRA) to cover upcoming medical services. 3 Estimate the funds you may need for your flexible spending account, and manage them throughout the year. For more information about your benefits, please call Member Services or Customer Service at the number provided on your ID card. For cost estimates for a specific medical service or to ask about payment plans or other financial assistance, please contact Financial Counseling at 303-338-3025. 1 This Sample Fee List does not apply to medical services received from any network providers who are not Kaiser Permanente providers. 2 The estimated member charges in this Sample Fee List are valid as of January 1, 2013, and may change without notice. 3 You must be enrolled in an HSA-qualified deductible plan or a deductible plan with HRA to use this feature. If you are enrolled through a group s self-funded plan, your health benefits are self-insured by your employer, union, or Plan sponsor. Kaiser Permanente Insurance Company provides certain administrative services for the Plan and is not an insurer of the Plan or financially liable for health care benefits under the Plan.
Office Visits New patient visit, level 1 (low severity) $59 New patient visit, level 2 $100 New patient visit, level 3 $145 New patient visit, level 4 $221 New patient visit, level 5 (high severity) $274 Established patient visit, level 1 (low severity) $27 Established patient visit, level 2 $59 Established patient visit, level 3 $97 Established patient visit, level 4 $143 Established patient visit, level 5 (high severity) $193 Office Visits (Preventive) Well-baby office visit, new patient (under 1 year)* $139 Well-child office visit, new patient (1 4 years)* $146 Well-child office visit, new patient (5 11 years)* $151 Well-child office visit, new patient (12 17 years)* $170 Well-adult office visit, new patient (18 39 years)* $166 Well-adult office visit, new patient (40 64 years)* $192 Well-adult office visit, new patient (65 and older)* $208 Well-baby office visit, established patient (under 1 year)* $124 Well-child office visit, established patient (1 4 years)* $133 Well-child office visit, established patient (5 11 years)* $132 Well-child office visit, established patient (12 17 years)* $145 Well-adult office visit, established patient (18 39 years)* $148 Well-adult office visit, established patient (40 64 years)* $158 Well-adult office visit, established patient (65 and older)* $171 Specialist Consultations Office consultation $60 Specialist visit, long $228 Specialist visit, short $113 Specialist visit, typical $154 These estimated member charges are valid as of January 1, 2013, and may change without notice. 2
Emergency Care by a Physician (physician fee only, does not include other fees such as facility fees, X-rays, lab tests, or additional procedures) Emergency care by a physician, level 1 (low severity) $88 Emergency care by a physician, level 2 $133 Emergency care by a physician, level 3 $221 Emergency care by a physician, level 4 (high severity) $330 Psychotherapy Visits Group psychological therapy $80 Managing mental health drugs $150 Psychiatric diagnostic interview exam $391 Therapy $210 Eye Examinations Eye exam, routine visit, new patient $132 Eye exam and treatment, new patient $243 Eye exam, routine visit, established patient $139 Eye exam and treatment, established patient $201 Intermediate eye exam and refraction, new patient $171 Intermediate eye exam and refraction, established patient $178 Vision screening test $8 Hearing Services Comprehensive audiometry evaluation $100 Ear cleaning $77 Eardrum test $38 Hearing screening test (pure tone, air only) $31 Physical Therapy Services Electric stimulation therapy, treatment only $39 Physical therapy evaluation $189 Physical therapy exercises, treatment only $79 Physical therapy, hot and cold application, treatment only $15 Physical therapy, ultrasound, treatment only $31 Vaccines and Other Injections Allergy shot $25 Chickenpox vaccine* $132 (continues) These estimated member charges are valid as of January 1, 2013, and may change without notice. 3
Vaccines and Other Injections (continued) Diphtheria, tetanus booster vaccine* $37 Diphtheria, tetanus, pertussis vaccine* $48 Flu shot, children (3 years and older)* $28 Flu shot, infants* $17 Hepatitis B vaccine* $153 Intravenous push, single or initial substance/drug $144 Measles, mumps, and rubella vaccine* $90 Pneumococcal vaccine* $245 Polio vaccine* $51 Respiratory syncytial virus* $241 Rubella vaccine* $48 Therapeutic injection (administration only, does not include medication) $62 Therapeutic intravenous injection (administration only, does not include medication) $51 Vaccine administration, adult $62 Zoster vaccine $287 Tests and Procedures Breathing capacity test $93 Breathing treatment $46 Colonoscopy and removal of abnormal tissue using cautery* $717 Colonoscopy and removal of abnormal tissue using snare technique* $813 Colonoscopy and removal of colon tissue for examination* $723 Diagnostic colonoscopy* $606 Diagnostic proctosigmoidoscopy $183 Diagnostic sigmoidoscopy $216 Draining fluid from around swollen joint $105 Electrocardiogram (EKG) $49 Electromyogram (EMG), one extremity $247 Fetal monitoring $72 Loop electrosurgical excision procedure (LEEP) $439 Removal of abnormal areas of skin $10 Sigmoidoscopy and removal of tissue for examination $258 Skin biopsy $156 Skin biopsy (each additional lesion within same visit) $49 (continues) These estimated member charges are valid as of January 1, 2013, and may change without notice. 4
Tests and Procedures (continued) Stress test $228 Surgically destroying an abnormal area of skin $30 Ultrasound test of heart $341 Vasectomy $609 X-rays, CT Scans, and Other Imaging Studies CT scan of chest, including dye $469 CT scan of pelvis, including dye $444 CT scan of pelvis, without dye $365 CT scan of sinus and nasal passages $413 CT scan of stomach area, with dye $508 CT scan of stomach area, without dye $373 DXA bone density scan, peripheral $46 DXA bone density scan, vertebral fracture $46 Mammogram $180 Mammogram (one side) $141 Mammogram (screening) $130 MRI of any joint of the lower extremity, without dye $650 MRI of any joint of the upper extremity, without dye $650 MRI of brain, including dye $839 MRI of brain, without dye $658 MRI of brain, without dye, followed by further sequences including dye $1,041 MRI, abdomen, with contrast $835 MRI, abdomen, without contrast $657 MRI, abdomen, without contrast, followed by with contrast $1,033 MRI, angiogram, pelvis $838 MRI, cervical spine, with contrast $850 MRI, cervical spine, without contrast $668 MRI, cervical spine, without dye, followed by further sequences including dye $1,055 MRI, head, with contrast $793 MRI, head, without contrast $637 MRI, lower extremity $1,024 MRI, lumbar spine, with contrast $839 MRI, lumbar spine, without contrast $659 MRI, lumbar spine, without dye, followed by further sequences including dye $1,038 MRI, neck, with contrast $794 (continues) These estimated member charges are valid as of January 1, 2013, and may change without notice. 5
X-rays, CT Scans, and Other Imaging Studies (continued) MRI, neck, without contrast $637 MRI, thoracic spine, with contrast $788 MRI, thoracic spine, without contrast $668 MRI, thoracic spine, without dye, followed by further sequences including dye $988 MRI, upper extremity $1,025 Pregnancy ultrasound $232 Review of CT scan of head or brain $296 Ultrasound of breast $143 Ultrasound of pelvis $205 Ultrasound of stomach area $218 Vaginal ultrasound $207 X-ray for osteoporosis $91 X-ray of abdomen (complete) $79 X-ray of ankle $47 X-ray of ankle (complete) $55 X-ray of both knees $58 X-ray of chest $50 X-ray of chest (one view interpretation) $38 X-ray of finger $54 X-ray of foot $45 X-ray of foot (complete) $52 X-ray of hand $46 X-ray of hand (complete) $53 X-ray of hip $64 X-ray of knee $51 X-ray of knee (complete) $71 X-ray of lower back bones $60 X-ray of neck $87 X-ray of neck bones $65 X-ray of shoulder $51 X-ray of stomach area (one view) $40 X-ray of wrist (complete) $61 X-ray of wrist (two views) $52 These estimated member charges are valid as of January 1, 2013, and may change without notice. 6
Laboratory Tests Albumin test $11 Alkaline phosphatase test $11 Allergy test $10 ALT liver function test $11 Amylase test $14 AST liver function test $11 Bilirubin test (total) $11 Blood antibody test $9 Blood clotting test $8 Blood sugar test, diagnostic $8 Blood sugar test, monitoring $21 Calcium test (total) $11 Cholesterol level test* $9 Complete blood count $15 Creatinine test $11 Hepatitis B surface antigen test $22 Hepatitis C test $31 Kidney function test $8 Laboratory chemistry test for creatine kinase $14 Lipid panel test $29 Magnesium test $14 Pap test, cervical cancer screening* $23 Phosphorus test $10 Potassium test $10 Pregnancy test $15 Prostate test* $39 Sodium test $10 Strep A Swab test $43 Test for blood in stool* $7 Test for genital warts $75 Thyroid stimulating hormone test $36 Urine bacteria colony count $17 Urine test (complete) $7 Urine test (dipstick only) $5 Urine test (microanalysis only) $7 These estimated member charges are valid as of January 1, 2013, and may change without notice. 7 Please recycle. 84880 December 2012