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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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