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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.

AgeCPT CodesPriceSelf-Pay $
12-17 Years99384$439.00$351.20
18-39 Years99385$425.00$340.00
40-64 Years99386$493.00$394.40
65+99387$534.00$427.20
Breast & PelvicG0101$126.00$126.00
Pap Smear88175$88.00$58.48
HPV87624$117.00$71.46

Established Patient Annuals

Labs and problems outside of an annual exam will be billed separately.

AgeCPT CodesPriceSelf-Pay $
12-17 Years99394$376.00$300.80
18-39 Years99395$384.00$307.20
40-64 Years99396$409.00$327.20
65+99397$439.00$351.20
Breast & PelvicG0101$126.00$126.00
Pap Smear88175$88.00$58.48
HPV87624$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.

TypeCPT CodesPriceSelf-Pay $
Level 2 Office Visit99202$246.00$196.80
Level 3 Office Visit99203$348.00$278.40
Level 4 Office Visit99204$528.00$422.40
Level 5 Office Visit99205$664.00$531.20
Prolonged Services (each 15 minutes) Use w/ 9920599417$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.

TypeCPT CodesPriceSelf-Pay $
Level 2 Office Visit99212$145.00$116.00
Level 3 Office Visit99213$239.00$191.20
Level 4 Office Visit99214$349.00$279.20
Level 5 Office Visit99215$468.00$374.40
Prolonged Services (each 15 minutes) Use w/ 9921599417$400.00$320.00

GYN Ultrasounds

TypeCPT CodesPriceSelf-Pay $
Transvaginal, Complete76830$395.00$316.00
Pelvic, Complete76856$356.00$284.80
Pelvic, Limited/Follow-up76857$296.00$236.80

OB Ultrasounds

TypeCPT CodesPriceSelf-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 Limited76815$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/ NST76818$401.00$320.80
BPP w/o NST76819$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.

TypeCPT CodesPriceSelf-Pay $
IUD Insert58300$260.00$208.00
IUD Removal58301$308.00$246.40
ParagardJ7300$1,800.00$1,440.00
MirenaJ7298$1,900.00$1,520.00
KyleenaJ7296$1,600.00$1,280.00
SkylaJ7301$1,600.00$1,280.00
Nexplanon Insert11981$462.00$369.60
Nexplanon Removal11982$516.00$412.80
Nexplanon Removal & Insert11983$748.00$598.40
NexplanonJ7307$1,800.00$1,440.00
Urine Pregnancy Test81025$19.00$15.20

Mammograms

TypeCPT CodesPriceSelf-Pay $
Screening Mammo, including CAD77067$403.02$322.42
Screening Digital Breast Tomosynthesis77063$166.44$133.15
Bill 77067 & 77063 for all mammograms$569.46$455.57

Office Procedures

TypeCPT CodesPriceSelf-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.