Northwest
2023
Kaiser Permanente 2023 sample fee list
1
What’s a sample fee list?
A sample fee list can help you understand your health care costs by
showing the estimated amount you may pay for certain services.
2
Keep in mind that this list doesn’t include costs for hospital services,
and the amount you’re ultimately charged may vary based on the
care you receive, the type of facility you visit, your plan details, and
whether you’ve reached your deductible.
Get a cost estimate
If you’re a member, it’s easy
to get a sense of costs before
you get care. Visit kp.org to get
a personalized estimate based
on your plan benefits.
How can I use the list?
The sample fee list can help you:
• Choose the right Kaiser Permanente deductible HMO plan during open enrollment
• Estimate what you’ll pay for services before you reach your deductible
• Identify preventive care services, most of which are covered at no cost (visit kp.org/prevention for a full list)
• Estimate your spending on upcoming medical services if your plan comes with a flexible spending account
(FSA), health incentive account (HIA), health reimbursement arrangement (HRA), or health savings account (HSA)
What happens after I reach my deductible?
As a deductible plan member, you’ll typically pay the full charge for covered services until you reach a set
amount known as a deductible. Then you’ll start paying less — a copay or a percentage of the charges (called
a coinsurance) for the rest of the year. (Depending on your plan, you may pay copays or coinsurance for some
services without having to reach your deductible.)
This means that for some services, you may pay less than the estimated fees shown on the sample fee list after you
reach your deductible. Here are some examples:
Service
What you pay before
reaching deductible
What you pay after
reaching deductible
What you pay after
reaching out-of-pocket
maximum
X-ray of both knees $123
Copay or coinsurance
(e.g., $10 or 20%)
$0
Ultrasound of pelvis $323
Copay or coinsurance
(e.g., $10 or 20%)
$0
Stress test $190
Copay or coinsurance
(e.g., $10 or 20%)
$0
Have questions?
If you want more information or have questions about a service that’s not listed, please call the number on your
Kaiser Permanente ID card.
1. The estimated fees in this sample fee list are valid as of January 1, 2023, and may change without notice. This sample fee list only applies to
members who get medical services from Kaiser Permanente facilities. 2. Professional services are usually received at a medical office, including
doctor’s office visits, lab tests, and X-rays. They may also include physician-related services provided in a hospital.
The amount you’re actually charged may be different depending on the care you get, the type of facility you visit, your plan details, and whether
you’ve reached your deductible.
If 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
*
Depending on your plan, these services may be preventive and covered at no cost or at a copay. For more information, see your Evidence of
Coverage or Summary Plan Description.
These estimated fees are valid starting January 1, 2023, and may change without notice.
The fees shown are for professional services only and do not include fees for facility or other services. The amount you’re actually charged
may be different depending on the care you get, the type of facility you visit, your plan details, and whether you’ve reached your deductible.
Your actual costs may vary
These are just sample fees. Members can get an estimate based on their plan details at kp.org.
2023 Kaiser Permanente estimated fees Northwest
SERVICE ESTIMATED FEES
Office visits
New patient visit, level 2 $167
New patient visit, level 3 $255
New patient visit, level 4 $380
New patient visit, level 5 (high severity) $502
Established patient visit, level 1 (low severity) $54
Established patient visit, level 2 $130
Established patient visit, level 3 $208
Established patient visit, level 4 $293
Established patient visit, level 5 (high severity) $412
Office visits (preventive)
Well-baby office visit, new patient (under 1 year)* $251
Well-child office visit, new patient (1 to 4 years)* $262
Well-child office visit, new patient (5 to 11 years)* $272
Well-child office visit, new patient (12 to 17 years)* $308
Well-adult office visit, new patient (18 to 39 years)* $299
Well-adult office visit, new patient (40 to 64 years)* $345
Well-adult office visit, new patient (65 and older)* $373
Well-baby office visit, established patient (under 1 year)* $227
Well-child office visit, established patient (1 to 4 years)* $241
Well-child office visit, established patient (5 to 11 years)* $240
Well-child office visit, established patient (12 to 17 years)* $262
Well-adult office visit, established patient (18 to 39 years)* $268
Well-adult office visit, established patient (40 to 64 years)* $287
Well-adult office visit, established patient (65 and older)* $309
Specialist consultations
Specialist visit, long $405
Specialist visit, short $198
Specialist visit, typical $272
3
Your actual costs may vary
These are just sample fees. Members can get an estimate based on their plan details at kp.org.
*
Depending on your plan, these services may be preventive and covered at no cost or at a copay. For more information, see your Evidence of
Coverage or Summary Plan Description.
These estimated fees are valid starting January 1, 2023, and may change without notice.
The fees shown are for professional services only and do not include fees for facility or other services. The amount you’re actually charged
may be different depending on the care you get, the type of facility you visit, your plan details, and whether you’ve reached your deductible.
SERVICE ESTIMATED FEES
Psychotherapy visits
Group psychological therapy $45
Psychiatric diagnostic interview exam $297
Therapy $170
Eye examinations
Eye exam, routine visit, new patient $183
Eye exam and treatment, new patient $317
Eye exam, routine visit, established patient $189
Eye exam and treatment, established patient $268
Eye exam, refraction $40
Vision screening test* $8
Hearing services
Comprehensive audiometry evaluation $100
Ear cleaning $297
Eardrum test $45
Hearing screening test (pure tone, air only)* $31
Physical therapy services
Electric stimulation therapy, treatment only $39
Physical therapy, evaluation* $315
Physical therapy, exercises, treatment only $92
Physical therapy, hot and cold application, treatment only $19
Physical therapy, ultrasound, treatment only $45
Vaccines and other injections
Allergy shot
$26
Chicken pox vaccine*
$122
Diphtheria, tetanus booster vaccine*
$34
Diphtheria, tetanus, pertussis vaccine*
$42
Flu shot, adults (18 to 64 years)*
$40
(continues)
2023 Kaiser Permanente estimated fees Northwest
4
*
Depending on your plan, these services may be preventive and covered at no cost or at a copay. For more information, see your Evidence of
Coverage or Summary Plan Description.
These estimated fees are valid starting January 1, 2023, and may change without notice.
The fees shown are for professional services only and do not include fees for facility or other services. The amount you’re actually charged
may be different depending on the care you get, the type of facility you visit, your plan details, and whether you’ve reached your deductible.
Your actual costs may vary
These are just sample fees. Members can get an estimate based on their plan details at kp.org.
SERVICE ESTIMATED FEES
Vaccines and other injections (continued)
Flu shot, children (3 years and older)* $26
Flu shot, infants* $26
Hepatitis B vaccine* $138
Intravenous push, single or initial substance/drug $107
Measles, mumps, and rubella vaccine* $83
Polio vaccine* $47
Therapeutic injection (administration only, does not include medication) $38
Therapeutic IV injection (administration only, does not include medication) $48
Tests and procedures
Breathing capacity test $72
Breathing treatment $30
Colonoscopy and removal of abnormal tissue using cautery* $1,620
Colonoscopy and removal of abnormal tissue using snare technique* $1,494
Colonoscopy and removal of colon tissue for examination* $1,494
Diagnostic colonoscopy $1,115
Diagnostic proctosigmoidoscopy $425
Diagnostic sigmoidoscopy $623
Draining fluid from around swollen joint $204
Electrocardiogram (EKG) $38
Fetal monitoring* $132
Incisional biopsy of skin (e.g., wedge), single lesion $513
Punch biopsy of skin, single lesion $414
Removal of abnormal areas of skin $22
Sigmoidoscopy and removal of tissue for examination* $975
Stress test $190
Surgically destroying an abnormal area of skin $216
Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette), single lesion $334
Ultrasound test of heart $381
2023 Kaiser Permanente estimated fees Northwest
5
*
Depending on your plan, these services may be preventive and covered at no cost or at a copay. For more information, see your Evidence of
Coverage or Summary Plan Description.
These estimated fees are valid starting January 1, 2023, and may change without notice.
The fees shown are for professional services only and do not include fees for facility or other services. The amount you’re actually charged
may be different depending on the care you get, the type of facility you visit, your plan details, and whether you’ve reached your deductible.
Your actual costs may vary
These are just sample fees. Members can get an estimate based on their plan details at kp.org.
SERVICE ESTIMATED FEES
X-rays, CT scans, and other imaging studies
CT scan of chest, including dye $766
CT scan of pelvis, including dye $1,026
CT scan of pelvis, without dye $609
CT scan of sinus and nasal passages $800
CT scan of stomach area, with dye $1,050
CT scan of stomach area, without dye $626
Mammogram, diagnostic (one view) $382
Mammogram, diagnostic (two views) $482
Mammogram (screening)* $389
MRI brain stem with contrast $1,256
MRI cardiac with, without contrast with stress $2,015
MRI neck with contrast $1,143
Pregnancy ultrasound $348
Review of CT scan of the head or brain $483
Ultrasound of pelvis $323
Ultrasound of stomach area $258
Vaginal ultrasound $367
X-ray for osteoporosis $112
X-ray of ankle $97
X-ray of ankle (complete) $112
X-ray of both knees $123
X-ray of chest (one view) $78
X-ray of chest (two views) $101
X-ray of finger $114
X-ray of foot (complete) $104
X-ray of hand (complete) $111
X-ray of knee (complete) $140
X-ray of stomach area (complete) $151
X-ray of wrist (complete) $124
2023 Kaiser Permanente estimated fees Northwest
6
SERVICE ESTIMATED FEES
Laboratory tests
Albumin test $13
Alkaline phosphatase test $14
Allergy test $14
ALT test $14
Amylase test $18
AST test $14
Bilirubin test (total) $14
Blood antibody test $12
Blood clotting test $12
Blood sugar test, diagnostic $11
Blood sugar test, monitoring* $26
Calcium test (total) $14
Cholesterol level test $12
Complete blood count $21
Creatinine test $14
Hepatitis B surface antigen test* $28
Hepatitis C test* $39
Kidney function test $11
Laboratory chemistry test for creatine kinase $18
Lipid panel test* $36
Magnesium test $18
Pap test, cervical cancer screening* $56
Please recycle. 1049714689 March 2023
Your actual costs may vary
These are just sample fees. Members can get an estimate based on their plan details at kp.org.
*Depending on your plan, these services may be preventive and covered at no cost or at a copay. For more information, see your Evidence of
Coverage or Summary Plan Description.
These estimated fees are valid starting January 1, 2023, and may change without notice.
The fees shown are for professional services only and do not include fees for facility or other services. The amount you’re actually charged
may be different depending on the care you get, the type of facility you visit, your plan details, and whether you’ve reached your deductible.
2023 Kaiser Permanente estimated fees Northwest
