Colorado
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.
We’re here to help.
Do you have questions about
your costs? Or need help paying
for care? Call 303-338-3025
or 1-877-803-1929 (TTY 711)
Monday through Friday, 8:00 a.m.
to 6:00 p.m. Or chat live online
with a financial counselor at kp.org.
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
• 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)
• Identify preventive care services, most of which are covered at no cost (visit kp.org/prevention for a full list)
What happens after I reach my deductible?
You 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
out-of-pocket maximum
X-ray of both knees $94
Copay or coinsurance
(e.g., $10 or 20%)
$0
Ultrasound of pelvis $247
Copay or coinsurance
(e.g., $10 or 20%)
$0
Stress test $186
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/org.
2023 Kaiser Permanente estimated fees Colorado
SERVICE ESTIMATED FEES
Of
fice visits
New patient visit, level 2 - Primary Care* $102
New patient visit, level 2 - Specialty Care* $122
New patient visit, level 3 - Primary Care* $157
New patient visit, level 3 - Specialty Care* $188
New patient visit, level 4 - Primary Care* $233
New patient visit, level 4 - Specialty Care* $280
New patient visit, level 5 (high severity) - Primary Care* $308
New patient visit, level 5 (high severity) - Specialty Care* $370
Established patient visit, level 1 (low severity) - Primary Care* $33
Established patient visit, level 1 (low severity) - Specialty Care* $40
Established patient visit, level 2 - Primary Care* $80
Established patient visit, level 2 - Specialty Care* $96
Established patient visit, level 3 - Primary Care* $127
Established patient visit, level 3 - Specialty Care* $152
Established patient visit, level 4 - Primary Care* $179
Established patient visit, level 4 - Specialty Care* $215
Established patient visit, level 5 (high severity) - Primary Care* $252
Established patient visit, level 5 (high severity) - Specialty Care* $302
Office visits (preventive)
Well-baby office visit, new patient (under 1 year)* $222
Well-child office visit, new patient (1 to 4 years)* $232
Well-child office visit, new patient (5 to 11 years)* $241
Well-child office visit, new patient (12 to 17 years)* $273
Well-adult office visit, new patient (18 to 39 years)* $265
Well-adult office visit, new patient (40 to 64 years)* $306
Well-adult office visit, new patient (65 and older)* $331
Well-baby office visit, established patient (under 1 year)* $201
Well-child office visit, established patient (1 to 4 years)* $213
Well-child office visit, established patient (5 to 11 years)* $212
Well-child office visit, established patient (12 to 17 years)* $232
Well-adult office visit, established patient (18 to 39 years)* $237
Well-adult office visit, established patient (40 to 64 years)* $254
Well-adult office visit, established patient (65 and older)* $274
3
SERVICE ESTIMATED FEES
Specialist consultations
Specialist visit, long $359
Specialist visit, short $176
Specialist visit, typical $242
Psychotherapy visits
Group psychological therapy $32
Psychiatric diagnostic interview exam $209
Therapy $120
Eye examinations
Eye exam, refraction $30
Eye exam, routine visit, established patient $137
Eye exam, routine visit, new patient $133
Eye exam and treatment, established patient $194
Eye exam and treatment, new patient $230
Intermediate eye exam, established patient and refraction $167
Intermediate eye exam, new patient and refraction $163
Vision screening test* $8
Hearing services
Comprehensive audiometry evaluation $98
Ear cleaning $105
Eardrum test $44
Hearing screening test (pure tone, air only)* $31
Physical therapy services
Electric stimulation therapy, treatment only $27
Physical therapy evaluation* $219
Physical therapy, exercises, treatment only $64
Physical therapy, hot and cold application, treatment only $13
Physical therapy, ultrasound, treatment only $31
*
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/org.
2023 Kaiser Permanente estimated fees Colorado
4
SERVICE ESTIMATED FEES
Vaccines and other injections
Allergy shot $25
Chicken pox vaccine* $113
Diphtheria, tetanus booster vaccine* $31
Diphtheria, tetanus, pertussis vaccine* $39
Flu shot, adults (18 to 64)* $38
Flu shot, children (3 years and older)* $24
Flu shot, infants* $24
Hepatitis B vaccine* $130
Intravenous push, single or initial substance/drug $104
Measles, mumps, and rubella vaccine* $78
Polio vaccine* $44
Respiratory syncytial virus $102
Therapeutic injection (administration only, does not include medication) $37
Therapeutic intravenous injection (administration only, does not include medication) $47
Vaccine administration, adult $32
Zoster vaccine* $248
Tests and procedures
Breathing capacity test $71
Breathing treatment $30
Colonoscopy and removal of abnormal tissue using cautery* $1,142
Colonoscopy and removal of abnormal tissue using snare technique* $1,052
Colonoscopy and removal of colon tissue for examination* $1,017
Diagnostic colonoscopy* $786
Diagnostic proctosigmoidoscopy $299
Diagnostic sigmoidoscopy $437
Draining fluid from around swollen joint $145
Electrocardiogram (EKG) $37
Electromyogram (EMG), one extremity $303
Fetal monitoring $91
Incisional biopsy of skin (e.g., wedge), single lesion $360
Incisional biopsy of skin, each additional lesion within same visit $16
Loop electrosurgical excision procedure (LEEP) $621
Punch biopsy of skin, single lesion $291
Punch biopsy of skin, each additional lesion within same visit $136
(continues)
*
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/org.
2023 Kaiser Permanente estimated fees Colorado
5
SERVICE ESTIMATED FEES
Tests and procedures (continued)
Removal of abnormal areas of skin $15
Sigmoidoscopy and removal of tissue for examination* $683
Stress test $186
Surgically destroying an abnormal area of skin $60
Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette), single lesion $234
Tangential biopsy of skin, each additional lesion within same visit $116
Ultrasound test of heart $372
Vasectomy $761
X-rays, CT scans, and other imaging studies
CT scan of chest, including dye $657
CT scan of pelvis, including dye $879
CT scan of pelvis, without dye $522
CT scan of sinus and nasal passages $686
CT scan of stomach area, with dye $900
CT scan of stomach area, without dye $537
DXA bone density scan, peripheral $71
Mammogram, diagnostic (one view) $291
Mammogram, diagnostic (two views) $368
Mammogram (screening)* $297
MRI brain stem with contrast $1,077
MRI cardiac with, without contrast with stress $1,726
MRI neck with contrast $980
MRI of any joint of the lower extremity, without dye $803
MRI of any joint of the upper extremity, without dye $805
MRI of brain, including dye $1,077
MRI of brain, without dye $777
MRI of brain, without dye, followed by further sequences including dye $1,270
MRI, abdomen, with contrast $1,218
MRI, abdomen, without contrast $780
MRI, abdomen, without contrast, followed by with contrast $1,360
(continues)
*
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/org.
2023 Kaiser Permanente estimated fees Colorado
6
SERVICE ESTIMATED FEES
X-rays, CT scans, and other imaging studies (continued)
MRI, angiogram, pelvis $1,348
MRI, cervical spine, with contrast $1,103
MRI, cervical spine, without contrast $759
MRI, cervical spine, without dye, followed by further sequences including dye $1,278
MRI, head, with contrast $906
MRI, head, without contrast $859
MRI, lower extremity $1,357
MRI, lumbar spine, with contrast $1,082
MRI, lumbar spine, without contrast $760
MRI, lumbar spine, without dye, followed by further sequences including dye $1,274
MRI, neck, with contrast $980
MRI, neck, without contrast $861
MRI, thoracic spine, with contrast $1,091
MRI, thoracic spine, without contrast $759
MRI, thoracic spine, without dye, followed by further sequences including dye $1,280
MRI, upper extremity $1,664
Pregnancy ultrasound $341
Review of CT scan of head or brain $414
Ultrasound of pelvis $247
Ultrasound of stomach area $273
Vaginal ultrasound $273
X-ray for osteoporosis* $85
X-ray of ankle $74
X-ray of ankle (complete) $85
X-ray of both knees $94
X-ray of chest (one view) $59
X-ray of chest (two views) $77
X-ray of finger $87
X-ray of foot (complete) $80
X-ray of hand (complete) $84
X-ray of knee (complete) $107
X-ray of stomach area (complete) $115
X-ray of wrist (complete) $95
*
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/org.
2023 Kaiser Permanente estimated fees Colorado
7
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SERVICE ESTIMATED FEES
Laboratory tests
Albumin test $10
Alkaline phosphatase test $11
Allergy test $11
ALT liver function test $11
Amylase test $14
AST liver function test $11
Bilirubin test (total) $10
Blood antibody test $9
Blood clotting test $9
Blood sugar test, diagnostic $8
Blood sugar test, monitoring* $20
Calcium test (total) $11
Cholesterol level test $9
Complete blood count $16
Creatinine test $11
Hepatitis B surface antigen test* $22
Hepatitis C test* $30
Kidney function test $8
Laboratory chemistry test for creatine kinase $14
Lipid panel test* $28
Magnesium test $14
Pap test, cervical cancer screening* $50
Phosphorus test $10
Your actual costs may vary
These are just sample fees. Members can get an estimate based on their plan details at kp.org/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 Colorado
