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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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