DETAIL FOR SERVICES: | Facility Fee | Physician Services |
2020 CPT/HCPCS Primary Code | 97597 | Not provided by Hospital (may be billed separately) |
Negotiated Private Fee | $350.00 | Not provided by Hospital (may be billed separately) |
Prossam | $200.00 | Not provided by Hospital (may be billed separately) |
Champva | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) |
First Medical | $200.00 | 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 | $350.00 | Not provided by Hospital (may be billed separately) |
Menonita Vital | $183.00 | 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 | $225.00 | Not provided by Hospital (may be billed separately) |
MCS Life | $225.00 | 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 | $350.00 | Not provided by Hospital (may be billed separately) |
Discounted Cash Price | $280.00 | Not provided by Hospital (may be billed separately) |
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