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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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