Kaiser Permanente 2011 Sample Fee List Members in any deductible plan can use the sample fee list to estimate charges.

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1 Kaiser Permanente 2011 Sample Fee List Members in any deductible plan can use the sample fee list to estimate charges. Colorado AREA As your partner in health, we want to help you better manage your care. Staying on top of your finances, like how much you spend on health care, helps give you peace of mind so you can concentrate on the things in life you enjoy. This Sample Fee List shows estimated member charges for some commonly used medical services such as office visits, lab tests, and X-rays when provided at Kaiser Permanente medical offices. The charges for services may be different when you receive care or services from a provider at a non Kaiser Permanente medical office, even if the provider is under contract to provide services for Kaiser Permanente members. Note that these estimated member charges are based on typical encounters. Your actual charge may vary based on the length, severity, diagnosis type, and your deductible and out-of-pocket maximum status at the time of your visit. As a Kaiser Permanente member, the amount of charges you pay out of your own pocket will depend on your plan coverage and on factors such as whether or not your provider is a Kaiser Permanente practitioner. Additionally, your benefit plan may cover services at different levels of copayment or coinsurance. Use this list to help you: Estimate your out-of-pocket medical spending for the coming year, based on how much care and services from our medical offices you expect to use. Manage the balance on your Kaiser Permanente Deductible Plan with Health Savings Account (HSA) Option or Kaiser Permanente PPO Plan with HSA Option if you re enrolled in an HSA-qualified plan. Plan for health care costs. Review your options during open enrollment. You may choose another Kaiser Permanente benefit option that better fits your needs. Estimate the funds you may need for your health savings account or flexible spending account. For more information about our charges or if you have questions about a service that s not listed, please call Member Services at and follow the prompts.

2 Office Visits New patient visit, level 1 (low severity) $84 New patient visit, level 2 $105 New patient visit, level 3 $137 New patient visit, level 4 $196 New patient visit, level 5 (high severity) $264 Established patient visit, level 1 (low severity) $44 Established patient visit, level 2 $63 Established patient visit, level 3 $80 Established patient visit, level 4 $116 Established patient visit, level 5 (high severity) $186 Office Visits (Preventive) Well-baby office visit, new patient (under 1 year)* $148 Well-child office visit, new patient (1 4 years)* $160 Well-child office visit, new patient (5 11 years)* $171 Well-child office visit, new patient (12 17 years)* $183 Well-adult office visit, new patient (18 39 years)* $247 Well-adult office visit, new patient (40 64 years)* $270 Well-adult office visit, new patient (65 and older)* $304 Well-baby office visit, established patient (under 1 year)* $122 Well-child office visit, established patient (1 4 years)* $129 Well-child office visit, established patient (5 11 years)* $141 Well-child office visit, established patient (12 17 years)* $152 Well-adult office visit, established patient (18 39 years)* $205 Well-adult office visit, established patient (40 64 years)* $224 Well-adult office visit, established (65 and older)* $225 Specialist Consultations Office consultation $153 Specialist visit, low $326 Specialist visit, moderate $195 Specialist visit, extended $249 2

3 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) $98 Emergency care by a physician, level 2 $148 Emergency care by a physician, level 3 $221 Emergency care by a physician, level 4 (high severity) $330 Psychotherapy Visits Group psychological therapy $71 Individual therapy (after diagnostic interview) $81 Managing mental health drugs $181 Psychiatric diagnostic interview exam $121 Eye Examinations Eye exam, routine visit, new patient $140 Eye exam and treatment, new patient $185 Eye exam, routine visit, established patient $133 Eye exam and treatment, established patient $164 Intermediate eye exam/established patient & refraction $170 Intermediate eye exam/new patient & refraction $163 Vision screening test $30 Hearing Services Comprehensive audiometry evaluation $88 Ear cleaning $95 Eardrum test $43 Hearing screening test (pure tone, air only) $22 Physical Therapy Services Electric stimulation therapy, treatment only $17 Physical therapy, evaluation $52 Physical therapy, exercises, treatment only $46 Physical therapy, hot and cold application, treatment only $15 Physical therapy, ultrasound, treatment only $15 Vaccines and Other Injections (vaccine charges include costs of administration and vaccine product) Allergy shot $24 Chickenpox vaccine* $105 (continues) 3

4 Vaccines and Other Injections (continued) (vaccine charges include costs of administration and vaccine product) Diphtheria, tetanus, booster vaccine* $26 Diphtheria, tetanus, pertussis vaccine* $57 Flu shot, children (3 years and older) $19 Flu shot, infants $19 Hepatitis B vaccine* $85 Intravenous push, single or initial substance/drug $111 Measles, mumps, and rubella vaccine* $69 Pneumococcal vaccine* $109 Polio vaccine* $39 Respiratory syncoval virus $25 Rubella vaccine* $26 Therapeutic injection (administration only, does not include medication) $32 Therapeutic IV injection (administration only, does not include medication) $41 Vaccine administration Adult $27 Zoster $257 Tests and Procedures Breathing capacity test $70 Breathing treatment $29 Colonoscopy and removal of abnormal tissue using cautery $1,433 Colonoscopy and removal of abnormal tissue using snare technique $1,433 Colonoscopy and removal of colon tissue for examination $1,113 Diagnostic colonoscopy $1,110 Diagnostic proctosigmoidoscopy $115 Diagnostic sigmoidoscopy $223 Draining fluid from around swollen joint $125 Electrocardiogram (EKG) $50 Electromylogram (EMG), one extremity $217 Fetal monitoring $160 LEEP procedure $951 Removal of abnormal areas of skin $19 Sigmoidoscopy and removal of tissue for examination $324 Skin biopsy $123 Skin biopsy (each additional lesion within same visit) $90 (continues) 4

5 Tests and Procedures (continued) Stress test $258 Surgically destroying an abnormal area of skin $54 Ultrasound test of heart $380 Vasectomy $604 X-rays, CT Scans, and Other Imaging Studies CT scan of chest, including dye $704 CT scan of pelvis, including dye $603 CT scan of pelvis, without dye $525 CT scan of sinus and nasal passages $749 CT scan of stomach area, with dye $704 CT scan of stomach area, without dye $599 DXA bone density, peripheral $95 DXA bone density, vert fx $82 Mammogram $230 Mammogram (one side) $176 Mammogram (screening) $178 MRI of any joint of the lower extreme, without dye $922 MRI of any joint of the upper extreme, without dye $972 MRI of brain including dye $1,669 MRI of brain without dye $1,147 MRI of brain without dye, followed by further sequences including dye $1,675 MRI, Abdomen, with contrast $1,352 MRI, Abdomen, without contrast $1,162 MRI, Abdomen, without contrast, followed by with contrast $1,627 MRI, Angiogram, pelvis $1,081 MRI, Cervical spine, with contrast $1,206 MRI, Cervical spine, without contrast $1,075 MRI, Cervical spine, without dye, followed by further consequences including dye $1,521 MRI, Head, with contrast $1,172 MRI, Head, without contrast $1,055 MRI, Lower extremity $1,328 MRI, Lumbar spine, with contrast $1,246 MRI, Lumbar spine, without contrast $1,082 MRI, Lumbar spine without dye, followed by further consequences including dye $1,576 MRI, Neck, with contrast $1,187 (continues) 5

6 X-rays, CT Scans, and Other Imaging Studies (continued) MRI, Neck, without contrast $1,038 MRI, Thoracic spine, with contrast $1,598 MRI, Thoracic spine, without contrast $1,141 MRI, Thoracic spine without dye, followed by further consequences including dye $1,574 MRI, Upper extremity $1,251 Pregnancy ultrasound $221 Review of CT scan of head or brain $504 Ultrasound of breast $150 Ultrasound of pelvis $218 Ultrasound of stomach area $263 Vaginal ultrasound $250 X-ray for osteoporosis $294 X-ray of abdomen (complete) $92 X-ray of ankle $56 X-ray of ankle (complete) $64 X-ray of both knees $59 X-ray of chest $78 X-ray of chest (one view interpretation) $60 X-ray of finger $46 X-ray of foot $55 X-ray of foot (complete) $62 X-ray of hand $53 X-ray of hand (complete) $62 X-ray of hip $72 X-ray of knee $61 X-ray of knee (complete) $81 X-ray of lower back bones $81 X-ray of neck $111 X-ray of neck bones $79 X-ray of shoulder $74 X-ray of stomach area (one view) $68 X-ray of wrist (complete) $62 X-ray of wrist (two views) $54 6

7 Laboratory Tests Albumin test $7 Alkaline phosphatase test $6 Allergy test $7 ALT test $6 Amylase test $10 AST test $6 Bilirubin test (total) $7 Blood antibody test $9 Blood clotting test $5 Blood-sugar test, diagnostic* $8 Blood-sugar test, monitoring $16 Calcium test (total) $7 Cholesterol, serum or whole blood* $7 Complete blood count $9 Creatinine test $7 Hepatitis B surface antigen test $31 Hepatitis C test $32 Kidney function test $5 Laboratory chemistry test for creatine kinase $8 Lipid panel test $16 Magnesium test $9 Pap test, cervical cancer screening* $49 Phosphorus test $6 Potassium test $6 Pregnancy test $10 Prostate test* $22 Sodium test $6 Strep A Swab test $39 Test for blood in stool* $6 Test for genital warts $78 Thyroid stimulating hormone test $20 Urine bacteria colony count $24 Urine test (complete) $5 Urine test (dip stick only) $5 Urine test (microanalysis only) $4 Please recycle January