Gastric Mucosa Imaging
| DETAIL FOR SERVICES: | Study | Radiopharmaceuticals | Radiologist reading (interpretation) |
| 2020 CPT/HCPCS Primary Code | 78261 | A9512 | Not provided by Hospital (may be billed separately) |
| Negotiated Private Fee | $80.00 | $37.00 | Not provided by Hospital (may be billed separately) |
| Prossam | $60.00 | 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 | Not Covered | Not Covered | Not provided by Hospital (may be billed separately) |
| First Medical Vital | $128.25 | Not Covered | Not provided by Hospital (may be billed separately) |
| Plan de Salud Menonita | $85.00 | As Cost By Supplier + 3% | Not provided by Hospital (may be billed separately) |
| Menonita Vital | $146.53 | $12.50 | 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 | $95.00 | $12.00 | Not provided by Hospital (may be billed separately) |
| Mapfre | Not contracted | Not provided by Hospital (may be billed separately) | |
| Mcsclassicare | $65.00 | As Cost By Supplier | Not provided by Hospital (may be billed separately) |
| MCS Life | $65.00 | As Cost By Supplier | Not provided by Hospital (may be billed separately) |
| Medicare | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | |
| MMM | $153.94 | Not provided by Hospital (may be billed separately) | |
| MMM Vital | $129.15 | $12.00 | Not provided by Hospital (may be billed separately) |
| Panamerican Life | Not contracted | Not provided by Hospital (may be billed separately) | |
| PMC | $153.94 | Not provided by Hospital (may be billed separately) | |
| Tricare | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | |
| Triple S Salud | $80.00 | Not Covered | Not provided by Hospital (may be billed separately) |
| Triple S Vital | $77.98 | Not Covered | 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 | $60.00 | $12.00 | Not provided by Hospital (may be billed separately) |
| Negotiated Maximum Charge | $146.53 | $12.50 | Not provided by Hospital (may be billed separately) |
| Discounted Cash Price | $64.00 | $29.60 | Not provided by Hospital (may be billed separately) |
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