Kaiser Permanente 2015 Sample Fee List 1 Members in any deductible plan can use this list to help estimate their charges.

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1 Kaiser Permanente 2015 Sample Fee List 1 Members in any deductible plan 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 shows you estimated charges 2 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 (FSA), 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 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, 2015, 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.

2 Office Visits New patient visit, level 1 (low severity) - Primary Care $59 New patient visit, level 1 (low severity) - Specialty Care $65 New patient visit, level 2 - Primary Care $101 New patient visit, level 2 - Specialty Care $111 New patient visit, level 3 - Primary Care $147 New patient visit, level 3 - Specialty Care $161 New patient visit, level 4 - Primary Care $225 New patient visit, level 4 - Specialty Care $247 New patient visit, level 5 (high severity) - Primary Care $280 New patient visit, level 5 (high severity) - Specialty Care $308 Established patient visit, level 1 (low severity) - Primary Care $27 Established patient visit, level 1 (low severity) - Specialty Care $30 Established patient visit, level 2 - Primary Care $59 Established patient visit, level 2 - Specialty Care $65 Established patient visit, level 3 - Primary Care $99 Established patient visit, level 3 - Specialty Care $109 Established patient visit, level 4 - Primary Care $146 Established patient visit, level 4 - Specialty Care $161 Established patient visit, level 5 (high severity) - Primary Care $195 Established patient visit, level 5 (high severity) - Specialty Care $215 Office Visits (Preventive) Well-baby office visit, new patient (under 1 year)* $150 Well-child office visit, new patient (1 4 years)* $157 Well-child office visit, new patient (5 11 years)* $163 Well-child office visit, new patient (12 17 years)* $185 Well-adult office visit, new patient (18 39 years)* $179 Well-adult office visit, new patient (40 64 years)* $207 Well-adult office visit, new patient (65 and older)* $225 Well-baby office visit, established patient (under 1 year)* $135 Well-child office visit, established patient (1 4 years)* $145 Well-child office visit, established patient (5 11 years)* $144 Well-child office visit, established patient (12 17 years)* $158 Well-adult office visit, established patient (18 39 years)* $161 Well-adult office visit, established patient (40 64 years)* $172 Well-adult office visit, established patient (65 and older)* $185 These estimated member charges are valid as of January 1, 2015, and may change without notice. 2

3 Specialist Consultations Office consultation $66 Specialist visit, long $252 Specialist visit, short $125 Specialist visit, typical $170 Emergency Visits Emergency care by physician, level 1 (low severity) $93 Emergency care by physician, level 2 $141 Emergency care by physician, level 3 $235 Emergency care by physician, level 4 (high severity) $350 Psychotherapy Visits Group psychological therapy $42 Psychiatric diagnostic interview exam $215 Therapy $138 Eye Examinations Eye exam, routine visit, new patient $116 Eye exam and treatment, new patient $210 Eye exam, routine visit, established patient $121 Eye exam and treatment, established patient $175 Intermediate eye exam, new patient and refraction $144 Intermediate eye exam, established patient and refraction $149 Vision screening test $5 Hearing Services Comprehensive audiometry evaluation $61 Ear cleaning $78 Eardrum test $24 Hearing screening test (pure tone, air only) $19 Physical Therapy Services Electric stimulation therapy, treatment only $29 Physical therapy evaluation $137 Physical therapy, exercises, treatment only $58 Physical therapy, hot and cold application, treatment only $10 Physical therapy, ultrasound, treatment only $21 These estimated member charges are valid as of January 1, 2015, and may change without notice. 3

4 Vaccines and Other Injections Allergy shot $14 Chickenpox vaccine* $120 Diphtheria, tetanus booster vaccine* $34 Diphtheria, tetanus, pertussis vaccine* $41 Flu shot, children (3 years and older)* $25 Flu shot, infants* $10 Hepatitis B vaccine* $96 Intravenous push, single or initial substance/drug $91 Measles, mumps, and rubella vaccine* $81 Pneumococcal vaccine* $129 Polio vaccine* $46 Respiratory syncytial virus* $255 Rubella vaccine* $43 Therapeutic injection (administration only, does not include medication) $40 Therapeutic intravenous injection (administration only, does not include medication) $31 Vaccine administration, adult $40 Zoster vaccine* $261 Tests and Procedures Breathing capacity test $58 Breathing treatment $29 Colonoscopy and removal of abnormal tissue using cautery* $732 Colonoscopy and removal of abnormal tissue using snare technique* $826 Colonoscopy and removal of colon tissue for examination* $732 Diagnostic colonoscopy* $615 Diagnostic proctosigmoidoscopy $194 Diagnostic sigmoidoscopy $215 Draining fluid from around swollen joint $95 Electrocardiogram (EKG) $27 Electromyogram (EMG), one extremity $196 Fetal monitoring $78 Loop electrosurgical excision procedure (LEEP) $464 Removal of abnormal areas of skin $10 Sigmoidoscopy and removal of tissue for examination $258 Skin biopsy $160 (continues) These estimated member charges are valid as of January 1, 2015, and may change without notice. 4

5 Tests and Procedures (continued) Skin biopsy (each additional lesion within same visit) $51 Stress test $122 Surgically destroying an abnormal area of skin $35 Ultrasound test of heart $213 Vasectomy $599 X-rays, CT Scans, and Other Imaging Studies CT scan of chest, including dye $681 CT scan of pelvis, including dye $670 CT scan of pelvis, without dye $430 CT scan of sinus and nasal passages $578 CT scan of stomach area, with dye $683 CT scan of stomach area, without dye $440 DXA bone density scan, peripheral $44 DXA bone density scan, vertebral fracture $14 Mammogram $184 Mammogram (one side) $143 Mammogram (screening) $131 MRI of any joint of the lower extremity, without dye $726 MRI of any joint of the upper extremity, without dye $725 MRI of brain, including dye $949 MRI of brain, without dye $697 MRI of brain, without dye, followed by further sequences including dye $1,119 MRI, abdomen, with contrast $1,322 MRI, abdomen, without contrast $959 MRI, abdomen, without contrast, followed by with contrast $1,479 MRI, angiogram, pelvis $1,196 MRI, cervical spine, with contrast $952 MRI, cervical spine, without contrast $692 MRI, cervical spine, without dye, followed by further sequences including dye $1,120 MRI, head, with contrast $1,137 MRI, head, without contrast $1,004 MRI, lower extremity $1,467 MRI, lumbar spine, with contrast $940 MRI, lumbar spine, without contrast $693 (continues) These estimated member charges are valid as of January 1, 2015, and may change without notice. 5

6 X-rays, CT Scans, and Other Imaging Studies (continued) MRI, lumbar spine, without dye, followed by further sequences including dye $1,117 MRI, neck, with contrast $1,214 MRI, neck, without contrast $1,004 MRI, thoracic spine, with contrast $943 MRI, thoracic spine, without contrast $692 MRI, thoracic spine, without dye, followed by further sequences including dye $1,121 MRI, upper extremity $1,459 Pregnancy ultrasound $235 Review of CT scan of head or brain $352 Ultrasound of breast $44 Ultrasound of pelvis $200 Ultrasound of stomach area $227 Vaginal ultrasound $203 X-ray for osteoporosis* $79 X-ray of abdomen (complete) $80 X-ray of ankle $47 X-ray of ankle (complete) $57 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 $44 X-ray of foot (complete) $54 X-ray of hand $45 X-ray of hand (complete) $54 X-ray of hip $64 X-ray of knee $53 X-ray of knee (complete) $71 X-ray of lower back bones $59 X-ray of neck $79 X-ray of neck bones $59 X-ray of shoulder $53 X-ray of stomach area (one view) $40 X-ray of wrist (complete) $62 X-ray of wrist (two views) $51 These estimated member charges are valid as of January 1, 2015, and may change without notice. 6

7 Laboratory Tests Albumin test $11 Alkaline phosphatase test $11 Allergy test $10 ALT liver function test $12 Amylase test $14 AST liver function test $11 Bilirubin test (total) $11 Blood antibody test $9 Blood clotting test $9 Blood sugar test, diagnostic $9 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 $23 Hepatitis C test* $31 Kidney function test $9 Laboratory chemistry test for creatine kinase $14 Lipid panel test* $29 Magnesium test $15 Pap test, cervical cancer screening* $23 Phosphorus test $10 Potassium test $10 Pregnancy test $15 Prostate test* $40 Sodium test $11 Strep-A-Swab test $44 Test for blood in stool* $7 Test for genital warts $0 Thyroid stimulating hormone test $37 Urine bacteria colony count $18 Urine test (complete) $7 Urine test (dipstick only) $5 Urine test (microanalysis only) $7 These estimated member charges are valid as of January 1, 2015, and may change without notice. 7 Please recycle January 2015