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Lymph System Imaging

DETAIL FOR SERVICES: Study Radiopharmaceuticals  Radiologist reading (interpretation)
2020 CPT/HCPCS Primary Code 78195 A9541 Not provided by Hospital (may be billed separately)
Negotiated Private Fee $88.00 $89.00 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 $87.50 As Cost By Supplier $Not provided by Hospital (may be billed separately)
First Medical Vital $216.43 $26.46 Not provided by Hospital (may be billed separately)
Plan de Salud Menonita $79.00 As Cost By Supplier + 3% Not provided by Hospital (may be billed separately)
Menonita Vital $252.24 $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 $82.50 $54.50 Not provided by Hospital (may be billed separately)
Mapfre Not contracted Not provided by Hospital (may be billed separately)
Mcsclassicare $87.50 $70 Not provided by Hospital (may be billed separately)
MCS Life $87.50 $70 Not provided by Hospital (may be billed separately)
Medicare Ambulatory Payment classification (APC) Not provided by Hospital (may be billed separately)
MMM $190.33 Not provided by Hospital (may be billed separately)
MMM Vital $222.53 $20.00 Not provided by Hospital (may be billed separately)
Panamerican Life Not contracted Not provided by Hospital (may be billed separately)
PMC $190.33 Not provided by Hospital (may be billed separately)
Tricare Ambulatory Payment classification (APC) Not provided by Hospital (may be billed separately)
Triple S Salud $87.50 $75.22 Not provided by Hospital (may be billed separately)
Triple S Vital $135.54 $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 $79.00 $20.00 Not provided by Hospital (may be billed separately)
Negotiated Maximum Charge $252.24 $75.22 Not provided by Hospital (may be billed separately)
Discounted Cash Price $70.40 $71.20 Not provided by Hospital (may be billed separately)

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