Endoscospy
| DETAIL FOR SERVICES: | Facility Fee | Sedation Drugs | Physician Services | Pathology/Interpretation of results | Disposable Products (ej. Tweezer, endoclip) |
| 2020 CPT/HCPCS Primary Code | 43191 | Not provided by Hospital (may be billed separately) | 88305 | Provided as required by necessity | |
| Negotiated Private Fee | $350.00 | $15.00 | Not provided by Hospital (may be billed separately) | $90.00 | Provided as required by necessity |
| Prossam | $200.00 | Not Covered | Not provided by Hospital (may be billed separately) | $75.00 | Provided as required by necessity |
| Champva | Ambulatory Payment classification (APC) | Not Covered | Not provided by Hospital (may be billed separately) | Ambulatory Payment classification (APC) | Provided as required by necessity |
| First Medical | $158.00 | Not Covered | Not provided by Hospital (may be billed separately) | $35.00 | Provided as required by necessity |
| First Medical Vital | $127.05 | Not Covered | Not provided by Hospital (may be billed separately) | $35.00 | Provided as required by necessity |
| Plan de Salud Menonita | $150.00 | Not Covered | Not provided by Hospital (may be billed separately) | $50.00 | Provided as required by necessity |
| Menonita Vital | $127.00 | Not Covered | Not provided by Hospital (may be billed separately) | $50.00 | Provided as required by necessity |
| Humana Gold Plus / Gold Choice | Ambulatory Payment classification (APC) | Not Covered | Not provided by Hospital (may be billed separately) | Ambulatory Payment classification (APC) | Provided as required by necessity |
| Humana | $350.00 | Not Covered | Not provided by Hospital (may be billed separately) | $37.00 | Provided as required by necessity |
| Mapfre | $162.00 | Not Covered | Not provided by Hospital (may be billed separately) | $70.00 | Provided as required by necessity |
| Mcsclassicare | $150.00 | Not Covered | Not provided by Hospital (may be billed separately) | $59.73 | Provided as required by necessity |
| MCS Life | $155.00 | Not Covered | Not provided by Hospital (may be billed separately) | $59.73 | Provided as required by necessity |
| Medicare | Ambulatory Payment classification (APC) | Not Covered | Not provided by Hospital (may be billed separately) | Ambulatory Payment classification (APC) | Provided as required by necessity |
| MMM | Ambulatory Payment classification (APC) | Not Covered | Not provided by Hospital (may be billed separately) | Ambulatory Payment classification (APC) | Provided as required by necessity |
| MMM Vital | $127.05 | Not Covered | Not provided by Hospital (may be billed separately) | $16.86 | Provided as required by necessity |
| Panamerican Life | $123.00 | Not Covered | Not provided by Hospital (may be billed separately) | Not Contracted | Provided as required by necessity |
| PMC | Ambulatory Payment classification (APC) | Not Covered | Not provided by Hospital (may be billed separately) | Ambulatory Payment classification (APC) | Provided as required by necessity |
| Tricare | Ambulatory Payment classification (APC) | Not Covered | Not provided by Hospital (may be billed separately) | Ambulatory Payment classification (APC) | Provided as required by necessity |
| Triple S Salud | $105.00 | Not Covered | Not provided by Hospital (may be billed separately) | $58.00 | Provided as required by necessity |
| Triple S Vital | $127.00 | Not Covered | Not provided by Hospital (may be billed separately) | $53.63 | Provided as required by necessity |
| Triple S Advantage | Ambulatory Payment classification (APC) | Not Covered | Not provided by Hospital (may be billed separately) | Ambulatory Payment classification (APC) | Provided as required by necessity |
| Negotiated Minimum Charge | $105.00 | Not Covered | Not provided by Hospital (may be billed separately) | $16.86 | Provided as required by necessity |
| Negotiated Maximum Charge | $350.00 | Not Covered | Not provided by Hospital (may be billed separately) | $70.00 | Provided as required by necessity |
| Discounted Cash Price | $280.00 | $12.00 | Not provided by Hospital (may be billed separately) | $72.00 | Provided as required by necessity |
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