Hysteroscopy with surgical procedure, moderate
What goes into a price?
Negotiated prices across insurers
Self pay or cash prices vary by facility when paying out of pocket without insurance benefits. The chart shows you how the lowest and highest amounts facilities charge for this service if you were paying without insurance benefits. If you're uninsured or not submitting a claim to insurance, you also have the right to a Good Faith Estimate under federal law. Contact the provider for a copy of your Good Faith Estimate or to better understand payment options available to you.
Procedures included in this package
This list includes the services and fees bundled into the Hysteroscopy with surgical procedure, moderate Standard Service Package (SSP RE002). The final price for the procedure will depend on which services your provider ultimately performs, your insurance plan and your medical benefits.
| Code | Code Type | Description |
|---|---|---|
| HCPCS J7030 | Facility Fee | Intravenous infusion of 1000cc of normal saline |
| HCPCS J1100 | Facility Fee | Intramuscular injection of 1mg dexamethasone sodium phosphate |
| HCPCS J1885 | Facility Fee | Intramuscular injection of 15mg ketorolac tromethamine |
| HCPCS J3010 | Facility Fee | Intramuscular injection of fentanyl citrate, 0.1mg |
| HCPCS J2704 | Facility Fee | Intramuscular injection of 10mg propofol |
| HCPCS J2405 | Facility Fee | Intramuscular injection of ondansetron hydrochloride, 1mg |
| HCPCS J2250 | Facility Fee | Intramuscular injection of 1mg midazolam hydrochloride |
| HCPCS 58558 | Facility Fee | Surgical Hysteroscopy with Biopsy, Polypectomy, and D&c |
| HCPCS 58558 | Professional Fee | Surgical Hysteroscopy with Biopsy, Polypectomy, and D&c |
| Revenue Code 250 | Facility Fee | Pharmacy (Also see 063X, an extension of 250X) - General |
| HCPCS J2001 | Facility Fee | Injection of 10mg Lidocaine Hcl via IV Infusion |