Cardiac Blood Pool Image Gasted Heart Planar Single at rest or stress
| DETAIL FOR SERVICES: | Study | Radiopharmaceuticals | Radiologist reading (interpretation) |
| 2020 CPT/HCPCS Primary Code | 78472 | A9538 | Not provided by Hospital (may be billed separately) |
| Negotiated Private Fee | $125.00 | $163.00 | Not provided by Hospital (may be billed separately) |
| Prossam | $125.00 | As Cost By Supplier | Not provided by Hospital (may be billed separately) |
| Champva | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | |
| First Medical | $125.00 | As Cost By Supplier | Not provided by Hospital (may be billed separately) |
| First Medical Vital | $131.70 | $35.00 | Not provided by Hospital (may be billed separately) |
| Plan de Salud Menonita | $112.50 | As Cost By Supplier + 3% | Not provided by Hospital (may be billed separately) |
| Menonita Vital | $239.01 | $80.00 | 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 | $112.5 | $41.00 | Not provided by Hospital (may be billed separately) |
| Mapfre | Not contracted | Not provided by Hospital (may be billed separately) | |
| Mcsclassicare | $125.00 | $55 | Not provided by Hospital (may be billed separately) |
| MCS Life | $125.00 | $55 | Not provided by Hospital (may be billed separately) |
| Medicare | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | |
| MMM | $130.66 | Not provided by Hospital (may be billed separately) | |
| MMM Vital | $135.50 | $30.00 | Not provided by Hospital (may be billed separately) |
| Panamerican Life | Not contracted | Not provided by Hospital (may be billed separately) | |
| PMC | $130.66 | Not provided by Hospital (may be billed separately) | |
| Tricare | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | |
| Triple S Salud | $125.00 | $35.00 | Not provided by Hospital (may be billed separately) |
| Triple S Vital | $111.56 | $35.00 | 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 | $111.56 | $30.00 | Not provided by Hospital (may be billed separately) |
| Negotiated Maximum Charge | $239.01 | $80.00 | Not provided by Hospital (may be billed separately) |
| Discounted Cash Price | $100.00 | $130.40 | Not provided by Hospital (may be billed separately) |
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