Office Visit Plastic Surgery
| DETAIL FOR SERVICES: | Facility Fee | Physician Services |
| 2020 CPT/HCPCS Primary Code | G0463 | Not provided by Hospital (may be billed separately) |
| Negotiated Private Fee | $40.00 | Not provided by Hospital (may be billed separately) |
| Prossam | $25.00 | Not provided by Hospital (may be billed separately) |
| Champva | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) |
| First Medical | $40.00 | Not provided by Hospital (may be billed separately) |
| First Medical Vital | $54.60 | Not provided by Hospital (may be billed separately) |
| Plan de Salud Menonita | $30.00 | Not provided by Hospital (may be billed separately) |
| Menonita Vital | $54.00 | Not provided by Hospital (may be billed separately) |
| Humana Gold Plus / Gold Choice | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) |
| Humana | $25.00 | Not provided by Hospital (may be billed separately) |
| Mapfre | $15.00 | Not provided by Hospital (may be billed separately) |
| Mcsclassicare | $35.00 | Not provided by Hospital (may be billed separately) |
| MCS Life | $35.00 | Not provided by Hospital (may be billed separately) |
| Medicare | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) |
| MMM | $25.00 | Not provided by Hospital (may be billed separately) |
| MMM Vital | $54.60 | Not provided by Hospital (may be billed separately) |
| Panamerican Life | $25.00 | Not provided by Hospital (may be billed separately) |
| PMC | $25.00 | Not provided by Hospital (may be billed separately) |
| Tricare | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) |
| Triple S Salud | $70.00 | Not provided by Hospital (may be billed separately) |
| Triple S Vital | $55.00 | Not provided by Hospital (may be billed separately) |
| Triple S Advantage | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) |
| Negotiated Minimum Charge | $15.00 | Not provided by Hospital (may be billed separately) |
| Negotiated Maximum Charge | $70.00 | Not provided by Hospital (may be billed separately) |
| Discounted Cash Price | $32.00 | Not provided by Hospital (may be billed separately) |
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