DETAIL FOR SERVICES: | Surgery Procedure | Anesthesia | Physician Services |
2020 CPT/HCPCS Primary Code | 52240 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Negotiated Private Fee | $4,504.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Prossam | $1,300.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Champva | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
First Medical | $728.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
First Medical Vital | $677.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Plan de Salud Menonita | $1,100.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Menonita Vital | $704.00 | Not provided by Hospital (may be billed separately) | 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) | Not provided by Hospital (may be billed separately) |
Humana | $725.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Mapfre | $781.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Mcsclassicare | $890.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
MCS Life | $896.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Medicare | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
MMM | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
MMM Vital | $677.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Panamerican Life | $734.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
PMC | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Tricare | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Triple S Salud | $900.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Triple S Vital | $704.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Triple S Advantage | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Negotiated Minimum Charge | $677.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Negotiated Maximum Charge | $1,300.00 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
Discounted Cash Price | $3,603.20 | Not provided by Hospital (may be billed separately) | Not provided by Hospital (may be billed separately) |
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