The State of Minnesota requires our clinic to post provider charges for common services, and the average payments or reimbursements received for those services from government and commercial insurance.
New Patient Annuals
A patient that has not been seen at any Premier clinic within the last 3 years. Labs and problems outside of an annual exam will be billed separately.
| Age | CPT Codes | Price | Self-Pay $ |
|---|---|---|---|
| 12-17 Years | 99384 | $439.00 | $351.20 |
| 18-39 Years | 99385 | $425.00 | $340.00 |
| 40-64 Years | 99386 | $493.00 | $394.40 |
| 65+ | 99387 | $534.00 | $427.20 |
| Breast & Pelvic | G0101 | $126.00 | $126.00 |
| Pap Smear | 88175 | $88.00 | $58.48 |
| HPV | 87624 | $117.00 | $71.46 |
Established Patient Annuals
Labs and problems outside of an annual exam will be billed separately.
| Age | CPT Codes | Price | Self-Pay $ |
|---|---|---|---|
| 12-17 Years | 99394 | $376.00 | $300.80 |
| 18-39 Years | 99395 | $384.00 | $307.20 |
| 40-64 Years | 99396 | $409.00 | $327.20 |
| 65+ | 99397 | $439.00 | $351.20 |
| Breast & Pelvic | G0101 | $126.00 | $126.00 |
| Pap Smear | 88175 | $88.00 | $58.48 |
| HPV | 87624 | $117.00 | $71.46 |
New Patient E&M Visits
A patient that has not been seen at any Premier clinic within the last 3 years.
| Type | CPT Codes | Price | Self-Pay $ |
|---|---|---|---|
| Level 2 Office Visit | 99202 | $246.00 | $196.80 |
| Level 3 Office Visit | 99203 | $348.00 | $278.40 |
| Level 4 Office Visit | 99204 | $528.00 | $422.40 |
| Level 5 Office Visit | 99205 | $664.00 | $531.20 |
| Prolonged Services (each 15 minutes) Use w/ 99205 | 99417 | $400.00 | $320.00 |
Established Patient E&M Visits
A patient that has not been seen at any Premier clinic within the last 3 years.
| Type | CPT Codes | Price | Self-Pay $ |
|---|---|---|---|
| Level 2 Office Visit | 99212 | $145.00 | $116.00 |
| Level 3 Office Visit | 99213 | $239.00 | $191.20 |
| Level 4 Office Visit | 99214 | $349.00 | $279.20 |
| Level 5 Office Visit | 99215 | $468.00 | $374.40 |
| Prolonged Services (each 15 minutes) Use w/ 99215 | 99417 | $400.00 | $320.00 |
GYN Ultrasounds
| Type | CPT Codes | Price | Self-Pay $ |
|---|---|---|---|
| Transvaginal, Complete | 76830 | $395.00 | $316.00 |
| Pelvic, Complete | 76856 | $356.00 | $284.80 |
| Pelvic, Limited/Follow-up | 76857 | $296.00 | $236.80 |
OB Ultrasounds
| Type | CPT Codes | Price | Self-Pay $ |
|---|---|---|---|
| 20-Week (transabdominal) | 76805 | $461.00 | $368.80 |
| 1st Trimester/Pregnancy Confirmation (transabdominal) | 76801 | $400.00 | $320.00 |
| Nuchal (NT Scan) | 76813 | $396.00 | $316.80 |
| Pregnant Uterus Limited | 76815 | $275.00 | $220.00 |
| Pregnant Uterus Repeat (transabdominal) | 76816 | $376.00 | $300.80 |
| Early OB, Complete (transvaginal) | 76817 | $316.00 | $252.80 |
| Non-Stress Test (NST) | 59025 | $157.00 | $125.60 |
| BPP w/ NST | 76818 | $401.00 | $320.80 |
| BPP w/o NST | 76819 | $293.00 | $234.40 |
IUD/Nexplanon
Quotefor insertion (and removal if needed) in addition to IUD/Device itself. There is also a chance a urine pregnancy test will be run.
| Type | CPT Codes | Price | Self-Pay $ |
|---|---|---|---|
| IUD Insert | 58300 | $260.00 | $208.00 |
| IUD Removal | 58301 | $308.00 | $246.40 |
| Paragard | J7300 | $1,800.00 | $1,440.00 |
| Mirena | J7298 | $1,900.00 | $1,520.00 |
| Kyleena | J7296 | $1,600.00 | $1,280.00 |
| Skyla | J7301 | $1,600.00 | $1,280.00 |
| Nexplanon Insert | 11981 | $462.00 | $369.60 |
| Nexplanon Removal | 11982 | $516.00 | $412.80 |
| Nexplanon Removal & Insert | 11983 | $748.00 | $598.40 |
| Nexplanon | J7307 | $1,800.00 | $1,440.00 |
| Urine Pregnancy Test | 81025 | $19.00 | $15.20 |
Mammograms
| Type | CPT Codes | Price | Self-Pay $ |
|---|---|---|---|
| Screening Mammo, including CAD | 77067 | $403.02 | $322.42 |
| Screening Digital Breast Tomosynthesis | 77063 | $166.44 | $133.15 |
| Bill 77067 & 77063 for all mammograms | $569.46 | $455.57 |
Office Procedures
| Type | CPT Codes | Price | Self-Pay $ |
|---|---|---|---|
| Artificial Insemination (AI/IUI) | 58322 | $261.00 | $208.80 |
| Sperm Washing Southdale, Oakdale, & MetroPartners Only | 58323 | $135.00 | $108.00 |
| Circumcision West Only | 54150 | $433.55 | $376.80 |
| Mona Lisa Touch (Initial Treatment) | MONA1 | $2,500.00 | $2,500.00 |
| Mona Lisa Touch (Follow-up Treatment) | MONAM | $850.00 | $850.00 |
| Cosmetic Botox Patient ($11.03/unit + $0.22 tax) West Only | BOTOX | $11.25/unit | $11.25/unit |
| Dry Needling (1 or 2 muscle(s)) Oakdale Only | MISCDRYNEEDLE1 | $35.00 | $35.00 |
| Dry Needling (3 or more muscles) Oakdale Only | MISCDRYNEEDLE2 | $50.00 | $50.00 |
| Semen Analysis Kit West Only | MISCSPERMKIT | $189.00 | $189.00 |
| Surgical Prep Kit ($8.32 + $0.68 tax) West Only | SURPREP | $9.00 | $9.00 |
Coding standards and associated charge and reimbursement values may vary based on complexity of a visit and whether a patient is a new or existing patient. A New Patient has not received professional services from Premier Women’s Health of Minnesota within the previous three years. An established patient has received professional services from Premier Women’s Health of Minnesota with the previous years.
This is not a comprehensive list of services provided by our clinic. These charges are meant to be informative and do not reflect the amount you may owe for your care. Individual health plans have negotiated rates with the clinic.