M Health Fairview Masonic Childrens Hospital

Provider Information

Services

• Ankle Repair - Arthroscopic

  SSP MS009

  up to

  $3,696

• Articular Finger Fracture Repair - Surgical

  SSP MS019

  up to

  $1,483

• Breast MRI

  SSP RA011

  up to

  $983

• Breast Ultrasound

  SSP RA012

  up to

  $198

• Bronchoscopy

  SSP PU000

  up to

  $1,627

• Carpal Tunnel Repair

  SSP NU002

  up to

  $2,720

• Cataract Removal with Intraocular Lens Insertion

  SSP OP000

  up to

  $2,699

• Clavicle/Scapula Repair - Non-Surgical

  SSP MS028

  up to

  $1,890

• Colonoscopy

  SSP GA002

  up to

  $1,485

• Colonoscopy via Stoma

  SSP GA000

  up to

  $1,263

• CT

  SSP RA001

  up to

  $685

• CT of Abdomen and Pelvis

  SSP RA004

  up to

  $817

• Esophagogastroduodenoscopy, Simple

  SSP GA007

  up to

  $1,081

• Fetal MRI

  SSP RA006

  up to

  $555

• Fine Needle Aspiration Biopsy with Ultrasound Guidance

  SSP DE003

  up to

  $773

• Forearm/Wrist Repair - Non-Surgical

  SSP MS010

  up to

  $644

• Hernia Repair - Laparoscopic

  SSP GA010

  up to

  $6,589

• Hernia Repair - Non-Laparoscopic

  SSP GA011

  up to

  $3,951

• Hip Repair - Arthroscopic

  SSP MS008

  up to

  $8,170

• Hysteroscopy with Surgical Procedure

  SSP RE003

  up to

  $5,850

• Knee Repair - Arthroscopic

  SSP MS006

  up to

  $3,807

• Laparoscopic Surgery of Ovaries and/or Fallopian Tubes

  SSP RE004

  up to

  $6,786

• Mammogram

  SSP RA010

  up to

  $231

• MRI with Contrast

  SSP RA007

  up to

  $640

• MRI without Contrast

  SSP RA005

  up to

  $873

• Percutaneous Breast Biopsy

  SSP DE000

  up to

  $1,735

• Shoulder Repair, Complex - Arthroscopic

  SSP MS005

  up to

  $8,170

• Tonsil and Adenoid Removal (Child Under 12)

  SSP EN000

  up to

  $6,624

• Tonsil and/or Adenoid Removal

  SSP EN004

  up to

  $3,787

• Ultrasound

  SSP RA008

  up to

  $307

• X-Ray

  SSP RA000

  up to

  $282