Gastroesophageal Reflux
| DETAIL FOR SERVICES: | Study | Radiopharmaceuticals | Radiologist reading (interpretation) |
| 2020 CPT/HCPCS Primary Code | 78262 | A9541 | Not provided by Hospital (may be billed separately) |
| Negotiated Private Fee | $95.00 | $89.00 | Not provided by Hospital (may be billed separately) |
| Prossam | $95.00 | 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 | $95.00 | As Cost By Supplier | Not provided by Hospital (may be billed separately) |
| First Medical Vital | $151.89 | $26.46 | Not provided by Hospital (may be billed separately) |
| Plan de Salud Menonita | $85.50 | As Cost By Supplier + 3% | Not provided by Hospital (may be billed separately) |
| Menonita Vital | $164.86 | $62.00 | 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 | $90.00 | $54.50 | Not provided by Hospital (may be billed separately) |
| Mapfre | Not contracted | Not provided by Hospital (may be billed separately) | |
| Mcsclassicare | $95.00 | $70 | Not provided by Hospital (may be billed separately) |
| MCS Life | $95.00 | $70 | Not provided by Hospital (may be billed separately) |
| Medicare | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | |
| MMM | $152.90 | Not provided by Hospital (may be billed separately) | |
| MMM Vital | $155.54 | $20.00 | Not provided by Hospital (may be billed separately) |
| Panamerican Life | Not contracted | Not provided by Hospital (may be billed separately) | |
| PMC | $152.90 | Not provided by Hospital (may be billed separately) | |
| Tricare | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | |
| Triple S Salud | $95.00 | $75.22 | Not provided by Hospital (may be billed separately) |
| Triple S Vital | $91.62 | $26.46 | 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 | $85.50 | $20.00 | Not provided by Hospital (may be billed separately) |
| Negotiated Maximum Charge | $164.86 | $75.22 | Not provided by Hospital (may be billed separately) |
| Discounted Cash Price | $76.00 | $71.20 | Not provided by Hospital (may be billed separately) |
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