Pet Scan Chest, Head or Neck
| DETAIL FOR SERVICES: | Study | Radiologist reading (interpretation) | Radiopharmaceuticals |
| 2020 CPT/HCPCS Primary Code | 78814 | Not provided by Hospital (may be billed separately) | A9552 |
| Negotiated Private Fee | $945.00 | Not provided by Hospital (may be billed separately) | $689.00 |
| Prossam | $975.00 | Not provided by Hospital (may be billed separately) | As Cost By Supplier |
| Champva | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Ambulatory Payment classification (APC) |
| First Medical | Not Covered | Not provided by Hospital (may be billed separately) | Not Covered |
| First Medical Vital | $1044.65 | Not provided by Hospital (may be billed separately) | $515.00 |
| Plan de Salud Menonita | $803.25 | Not provided by Hospital (may be billed separately) | As Cost By Supplier + 3% |
| Menonita Vital | $900.00 | Not provided by Hospital (may be billed separately) | $500.00 |
| Humana Gold Plus / Gold Choice | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Ambulatory Payment classification (APC) |
| Humana | $1,000.00 | Not provided by Hospital (may be billed separately) | $500.00 |
| Mapfre | Not Covered | Not provided by Hospital (may be billed separately) | Not Covered |
| Mcsclassicare | $903.26 | Not provided by Hospital (may be billed separately) | $500.00 |
| MCS Life | $903.26 | Not provided by Hospital (may be billed separately) | $500.00 |
| Medicare | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Ambulatory Payment classification (APC) |
| MMM | $717.43 | Not provided by Hospital (may be billed separately) | $500.00 |
| MMM Vital | $970.89 | Not provided by Hospital (may be billed separately) | $500.00 |
| Panamerican Life | $1,500.00 | Not provided by Hospital (may be billed separately) | Not contracted |
| PMC | $717.43 | Not provided by Hospital (may be billed separately) | $500.00 |
| Tricare | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Ambulatory Payment classification (APC) |
| Triple S Salud | $945.00 | Not provided by Hospital (may be billed separately) | $515.00 |
| Triple S Vital | $666.75 | Not provided by Hospital (may be billed separately) | $515.00 |
| Triple S Advantage | Ambulatory Payment classification (APC) | Not provided by Hospital (may be billed separately) | Ambulatory Payment classification (APC) |
| Negotiated Minimum Charge | $666.75 | Not provided by Hospital (may be billed separately) | $500.00 |
| Negotiated Maximum Charge | $1,500.00 | Not provided by Hospital (may be billed separately) | $515.00 |
| Discounted Cash Price | $756.00 | Not provided by Hospital (may be billed separately) | $551.20 |
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