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HomeMy WebLinkAboutMINUTES - 11062001 - C.165 r TO: BOARD OF SUPERVISORS 100 Apr.FROM: . William Walker, M.D. , Health Services Director ' By: Ginger Marieiro, Contracts Administrator Contra Costa DATE: October 24, 2001C Ol.11lty SUBJECT: Approval of Amendment to Sharing Agreement #26-346 (Modification #3 V612S-6162) with the U. S. Department of Veterans Affairs SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDED ACTION: Approve and authorize the Health Services Director, or his designee (Frank Puglisi, Jr. ) , to execute on behalf of the County, Amendment/Modification #3 (County #26-346-3) , with the U. S . Department of Veterans Affairs, Northern California Health Care System (VANCHCS) , effective August 1, 2001, to amend Contract #26-346, to extend the term of the agreement through July 31, 2003 . FINANCIAL IMPACT: This Contract is funded in the Health Services Department ' s Enterprise I Budget . Under the term of the agreement VANCHCS will continue to be paid a fee for each service in accordance with the attached fee schedule, which is incorporated in the Contract . The services provided for the County' s patients under this Contract are billable to patients and third party payors . REASONS FOR RECOMMENDATIONS/BACKGROUND: For many years the County and U. S. Department of Veterans Affairs has maintained a mutual sharing agreement which has made available to the County specialized medical services not otherwise available due to lack of resources, equipment, and personnel . These services included specialized laboratory testing, radiology services, nuclear medicine studies, CT scans, MRI ' s, dermatology, gastroenterology, urology, audiology and speech, and ophthalmology services . The County provided Emergency Room treatment and inpatient care, including certain ancillary services, for VA-referred patients . On September 1, 1998 , the Board of Supervisors approved Sharing Agreement #26- 346 (as amended by Contract Modifications #26-346-1 and #26-346-2) with VANCHCS (under the auspices of the VANCHCS Nuclear Regulatory Commission License) to provide a full range of Nuclear Medicine Services to County' s patients at the VA Outpatient Clinic in Martinez and/or the Contra Costa Regional Medical Center' s Nuclear Medicine Department, through July 31, 2001 . Approval of Modification #3 (County #26-346-3) will allow VANCHCS to continue providing nuclear medicine services through July 31, 2003 . The Contract documents have always been prepared by the Veterans Administration. ATTACHMENT: A YES SIGNATURE: _RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE /APPROVE _OTHER SIGNATURE(S : Q��Z, ACTION OF BOARD O APPROVED AS RECOMMENDED X OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS (ABSENT4 AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. ATTESTED { )LOWj u Y 1 h 0 U ,(9n JOHN SWEETEN,CLERK OF THE BOARD O Frank Puglisi, Jr. (313-5100) SUPERVISORS AND COUNTY ADMINISTRATOR Contact Person: CC: Health Services Dept. (Contracts) Auditor-Controller IA // - � J(� " Risk Management BY DEPUTY Contractor PAGE 1 of 8 .Nuclear Medicine Services FEE SCHEDULE OPTION 3: 8/1/01 -7/31/02 Item# PROCEDURES Services provided at VAOPC Services provided at CCRMC Est. Est. 1 CPT Code Description Qty. Unit Price Total Price Qty. Unit Price Total Price 2 76075 Bone Density 130 $190 $24,742 0 $0 $0 3 78006 Thyroid U&S 1-131 1 $165 $165 0 $208 $0 4 78007 Thyroid U&S 1-123 38 $177 $6,718 1 $223 $223 5 78011 Thyroid Scan Tc99m Flow 10 $1641 $1,643 0 $207 $0 6 78018 Cancer Survey 3 $365 $1,095 0 $460 $0 7 78018 WB Thyroid Scan(MIBI) 0 $365 $0 0 $460 $0 8 78070 Parathyroid Scan 2 $150 $300 0 . $189 $0 9 78122 RBC Mass 1 $284 $284 0 $358 $0 10 78195 Lymph Scan 2 $295 $591 10 $3721 $3,720 11 78205 Hemangioma Scan SPECT(w/78202) 1 $375 $375 0 $473 $0 12 78205 Liver/Spleen Scan SPECT 0 $375 $0 0 $473 $0 13 78215 Liver/Spleen Scan Planar 15 $196 $2,933 0 $246 $0 14 78220 HIDA 35 $239 $8,372 28 $301 $8,436 15 78223 HIDA w/EF 5 $261 $1,305 3 $329 $986 16 78258 Esoph. Motility 0 $211 $0 0 $266 $0 17 78262 Gastric Reflex 0 $282 $0 1 $355 $355 18 78264 lGastric Empty 25 $282 $7,046 3 $355 $1,065 19 78267 C14 breath test 25 $108 $2,704 0 $136 $0 20 78270 Schillings, Stage 1 5 $100. $499 5 $126 $629 21 78271 Schillings, Stage II and III 5 $105 $525 5 $132 $662 22 78278 GI Bleed 0 $338 $0 2 $426 $852 23 78290 Meckels 3 $215 $646 1 $271 $271 24 78305 Bone, Ltd 15 $215 $3,229 1 $271 $271 25 78306 Bone,WB 96 $295 $28,355 49 $372 $18,230 26 78315 Bone, Ltd w/Flow 24 $334 $8,012 23 $421 $9,672 27 78315 Bone,WB w/Flow 5 $334 $1,669 1 $421 $421 28 78320 Bone Spect 3 $397 $1,192 0 $500 $0 29 78460 Persantine Myov Planar" 0 $266 $0 1 $335 $335 30 78460 ITreadmill Myov Planar' 0 $266 $0 0 $335 $0 31 78460 1 Dobutamine TI-201 Planar" 0 $266 $0 0 $335 $0 32 78460 24 hr TI-201 Planar(Addit.) 0 $191 $0 0 $241 $0 33 78461 Planar Persantine TI-201" 0 $420 $0 0 $529 $0 34 78461 Planar Myov Rest 0 $345 $0 0 $435 $0 35 78464 SPECT addit.TL-201 0 $465 $0 0 $586 $0 36 78464 Treadmill Myov SPECT" 7 $540 $3,778 0 $680 $0 37 78464 IRest Myov SPECT' 50 $540 $0 15 $680 $0 38 78464 Persantine Myov SPECT" 47 $540 $25,369 13 $680 $8,839 39 78464 24 hr TL-201 SPECT 0 $465 $0 0 $586 $0 40 78465 Thallium or Myoview Treadmill Test" 1 $825 $825 9 $1,039 $9,349 41 78465 SPECT Rest TL-201 0 $750 $0 0 $945 $0 42 78465 SPECT Dobutamine TL-201 or Myoview" 0 $825 $0 8 $1,039 $8,311 SPECT Persantine,Adenenosine or Myoview 43 78465 w/TL-201' 120 $825 $98,966 78 $1,039 $81,029 44 78466 PYP Myocardial Infarction Planar 0 $193 $0 0 $244 $0 45 78469 PYP Myocardial Infarction Scan 0 $352 $0 0 $443 $0 46 78472 GWMS 12 $372 $4,468 3 $469 $1,407 47 78473 Exercise GWMS' 0 $631 $0 0 $795 $0 48 78478 Myocardial Perfusion Study w/Wall Motion 118 $130 $15,340 108 $1641 $17,685 49 78481 GWMS w/ 1st Pass 0 $357 $0 0 $449 $0 50 78483 Ex GWMS w/1st Pass" 0 $610 $0 0 $769 $0 51 78580 Lung Perfusion 1 0 $241 $01 0 $304 $0 C. OPTION 3: 8!1/01 -7/31/02 V261S-6162,Modification$13, 5/31/01 Nuc Fees Mod 3 As 1 1 Nuclear Medicine Services FEE SCHEDULE PAGE 2 of 8 Item# PROCEDURES Services provided at VAOPC Services provided at CCRMC CPT Est. Est. Code Description Qty. Unit Price Total Price Qty. Unit Price Total Price 52 78580 Lung Quantification 2 $241 $483 0 $304 $0 53 78585 Lung V/Q 55 $386 $21,221 91 $486 $44,227 54 78594 Lung Vent(addit.) 0 $312 $0 0 $393 $0 55 78606 Cerebral Flow and Scan 0 $258 $0 0 $325 $0 56 78630 Cisternogram 1 $324 $324 1 $409 $409 57 78650 CSF Leak Study 0 $297 $0 0 $375 $0 58 78707 Renal Scan-Baseline 27 $312 $8,424 3 $393 $1,179 59 78707 Lasix Renal(Incl Lasix) 2 $333 $666 0 $419 $0 60 78709 Captopril Renal(inc Captopril) 13 $333 $4,326 0 $419 $0 61 78800 Octreoscan Ltd 2 view 0 $233 $0 0 $293 $0 62 78800 Oncoscint Ltd 2 view 0 $288 $0 0 $363 $0 63 78801 Ga-67 Ltd 1 $288 $288 1 $363 $363 64 78802 Ga-67 WB 20 $365 $7,301 1 $460 $460 65 78802 Octreoscan WB 1 $365 $365 0 $460 $0 66 78802 Oncoscint WB 0 $365 $0 0 $460 $0 67 78803 Ga-67 SPECT 2 $436 $872 0 $549 $0 68 78803 Octreoscan SPECT 0 $436 $0 0 $549 $0 69 78803 Oncoscint SPECT 0 $436 $0 0 $549 $0 70 78805 In-111 WBC Ltd 2 $238 $476 8 $300 $2,400 71 78806 In-111 WBC WB 12 $414 $4,967 2 $521 $1,043 72 78806 In-111 WBC SPECT(addit) 0 $426 $0 0 $521 $0 73 79000 Hyperthyroid Therapy Initial 20 $2801 $5,607 0 $343 $0 74 79001 Hyperthyroid Therapy Additional 3 $150 $449 0 $183 $0 75 79030 Thyroid Therapy-Ablation 2 $302 $603 0 $369 $0 76 79035 Thyroid Therapy Cancer 2 $333 $666 0 $407 $0 77 79100 P-32 Therapy 0 $244 $0 0 $299 $0 78 79401 Sr-89 Therapy 0 $246 $0 0 $250 $0 79 78890 lComputer Processing(<30 min) 0 $0 $0 0 $0 $0 80 78891 Computer Processing(>30 min) 0 $0 $0 0 $0 $0 81 99241 Office Consultation-15 minutes 5 $68 $342 0 $84 $0 82 99242 Office Consultation-30 minutes 2 $105 $210 0 $128 $0 83 99243 Office Consultation-40 minutes 2 $137 $274 0 $168 $0 "Includes 93016&93018 Item# ISOTOPES/SUPPLIES Est. Ref# Description(CPT/HCPCS) Qty. Unit Price Total Price 84 00001 78990 A4641 Tc99m MAG3 40 $185 $7,400 85 00002 78990 A4641 Tc99m MAA 57 $30 $1,710 86 00003 178990 A4641 Tc99m SC 16 $38 $608 87 00004 78990 A4641 Tc99m DTPA 2 $55 $110 88 00005 78990 A4641 Tc99m Choletec 40 $55 $2,200 89 00006 78990 A4641 1-123 200 uCi 38 $100 $3,800 90 00007 78990 A4641 1-131(1-10 mCi) 20 $200 $4,000 91 00008 78990 A4641 1-131(ea addl mCi) 20 $15 $300 92 00009 78990 A4641 IN-111 DTPA(1vi) 0 $769 $0 93 00010 78990 A4641 IN-111 WBC (per labeling) 0 $508 $0 94 00011 78990 A4641 Xenon(10mCi/vi) 55 $30 $1,650 95 00012 78990 A4641 Ga67 (6 mCi) 1 21 $125 $2,6251 1 V261S-6162,Modification#3, 5/31/01 Nuc Fees Mod 3.xls PAGE 3 of 8 .Nuclear Medicine Services FEE SCHEDULE Item# ISOTOPES/SUPPLIES Est. Ref# Description(CPT/HCPCS) Qty. Unit Price Total Price 96 00013 78990 A4641 DICOPAC(1 kt) 0 $264 $0 97 00014 78990 A4641 Ultratag(1 kt) 10 $71 $710 98 00015 78990 A4641 Otreoscan/dose 0 $1,224 $0 99 00016 78990 A4641 Tc04(30 mCi) 10 $12 $120 100 00017 78990 A4641 Bulk Tc04 4 $24 $96 101 00018 78990 A4641 Prostascint 0 $1,535 $0 102 00019 78990 A4641 Tc99m CEA 0 $1,422 $0 103 00020 78990 A4642 Oncoscint 0 $1,352 $0 104 00021 78990 A9502 Tc99m Myoview 97 $106 $10,282 105 00022 78990 A9503 Tc99m MDP 140 $38 $5,320 106 00023 78990 A9505 TL-201 (3 mCi) 120 $85 $10,200 107 00024 78990 A9600 S-89 Chloride(4 mCi) 0 $3,135 $0 108 00025 JO 150 Adenosine(per 6 mg) 0 $26 $0 109 00026 J0280 Aminophylline(to 250 mg) 400 $2 $800 110 00027 J1245 Persantine(10 mg)(Per) 400 $24 $9,600 111 00028 J1550 Dobutamine(per 250 mg) 0 $26 $0 112 00029 Dobutamine Pack 0 $71 $0 113 00030 CCK/Morphine 0 $65 $0 114 00031 78990 A464lChromium 51/Ascorbic Acid 1 $1,005 $1,005 MRI SERVICES AT VAOPC Services provided at VAOPC `New Services priced at current CPT CODE Champus Maximum Allowable Cost. Unit Price 115 70541 MRA Head&Neck w&w/o contrast $1,592.92 116 70551 Brain w/o contrast $617.29 117 70553 Brain w&w/o contrast $1,315.93 118 72141 C-Spine w/o contrast $623.79 119 72146 T-Spine w/o contrast $681.99 120 72148 L-Spine w/o contrast $675.50 121 72156 C-Spine w&w/o contrast $1,328.03 122 72157 T-Spine w&w/o contrast $1,328.03 123 72158 L-Spine w&w/o contrast $1,316.19 124 73221 Upper Extremity Joint 1 $583.50 125 73721 Lower Extremity Joint $583.50 Supply of paramagnetic Contrast materiel 126 A4647 e.g. Gadolinium) lat Cost ADDITIONAL Item# PROCEDURES/MISCELLANEOUS Services provided at VAOPC Services provided at CCRMC CPT/HCPCS Est. Est. Code Description Qty. Unit Price Total Price Qty. Unit Price Total Price 127 78701 Renal Imaging, statics w/vasc flow 0 $230 $0 2 $250 $500 128 78185 Spleen Imaging w/flow 1 $156 $156 1 $172 $172 129 78195 Lymphatic&Lymph Node Imaging 0 1 $300 $0 5 $327 $1,635 130 78206 Liver SPECT w/flow(Hemangioma) 4 $377 $1,508 1 $376 $376 131 78305 Bone Imaging Mult.Areas 20 $258 $5,160 20 $281 $5,620 132 78456 Acute Venous Throm. Imaging, Peptide 1 $282 $282 5 $307 $1,535 133 78480 Wall motion w/Ejection Fraction 50 $129 $6,450 50 $141 $7,050 134 78596 Pulmonary Quantitative/Diff. Function 1 $477 $477 1 $518 $518 135 78710 Kidney Spect 2 $172 $344 2 1 $404 $808 136 78715 Kidney, Vascular Flow Only 0 $108 $0 1 $118 $118 137 78740 Ureteral Reflux(Voiding Cystogram) 0 $155 $0 1 $169 $169 138 78760 Testicular imaging w/o Vascular Flow 0 $193 $0 1 $210 $210 139 78761 Testicular Imaging w[Vascular Flow 0 $226 $0 1 $245 $245 V261S-6162,Modification 03, 5/31/01 Nuc Fees Mod 3.xls PAGE 4 of 8 Nuclear Medicine Services FEE SCHEDULE 140 1 A4641 199mTc Glucoheptanate 2 1 $75 $150 11 141 A4641 99mTc DMSA 2 $136 $272 142 A9502 99mTc Sestamibi 10 $125 $1,250 143 A9504 99m Tc Apcitude ACUTECT 6 $385 $2,310 TECHNICAUPROFESSIONAL SUPPORT Professional Fee for Radiation Safety Officer 144 (RSO)(per hour) $98 Nuclear Medicine Technical Support/After 145 Hours Support Fee(per hour) $48 146 Medical Physicist Support Fee(per hour) $103 Medical Physics Technician Support Fee(per 147 hour) $57 Facility Use Fee(to be paid to CCRMC by VA for use of CCRMC space and equipment)(per 148 1 1procedure) $135 V261S-6162,Modification 03, 5131101 Nuc Fees Mod 3.xls •Nuclear Medicine Services FEE SCHEDULE PAGE 5 of 8 OPTION 4+C52: 8/1/02 -7/31/03 Item# PROCEDURES Services provided at VAOPC Services provided at CCRMC Est. Est. 1 CPTCode Description Qty. Unit Price Total Price Qty. Unit Price Total Price 2 76075 Bone Density 130 $198 $25,693 0 $0 $0 3 78006 Thyroid U&S I-131 1 $172 $172 0 $208 $0 4 78007 Thyroid U&S 1-123 38 $184 $6,977 1 $223 $223 5 78011 Thyroid Scan Tc99m Flow 10 $1711 $1,706 0 $207 $0 6 78018 Cancer Survey 3 $379 $1,137 0 $460 $0 7 78018 WB Thyroid Scan(MIBI) 0 $379 sol 0 $460. $0 8 78070 Parathyroid Scan 2 $156 $311 0 $189 $0 9 78122 RBC Mass 1 $295 $295 0 $358 $0 10 78195 Lymph Scan 2 $307 $613 10 $372 $3,720 11 78205 Hemangioma Scan SPECT(w/78202) 1 $390 $390 0 $473 $0 12 78205 Liver/Spleen Scan SPECT 0 $390 $0 0 $473 $0 13 78215 Liver/Spleen Scan Planar 15 $203 $3,046 0 $246 $0 14 78220 HIDA 35 $248 $8,694 28 $301 $8,436 15 78223 HIDA w/EF 5 $271 $1,355 3 $329 $986 16 78258 Esoph. Motility 0 $219 $0 0 $266 $0 17 78262 Gastric Reflex 0 $293 $0 1 $355 $355 18 78264 Gastric Empty 25 $293 $7,317 3 $355 $1,065 19 78267 C14 breath test 25 $112 $2,808 0 $136 $0 20 78270 Schillings, Stage F 5 $104 $518 5 $126 $629 21 78271 Schillings, Stage IT and III 5 $109 $545 5 $132 $662 22 78278 GI Bleed 0 $351 $0 2 $426 $852 23 78290 Meckels 3 $224 $671 1 $271 $271 24 78305 Bone, Ltd 15 .$224 $3,353 1 $271 $271 25 78306 Bone,WB 96 $307 $29,445 49 $372 $18,230 26 78315 Bone, Ltd w/Flow 24 $347 $8,320 23 $421 $9,672 27 78315 Bone,WB w/Flow 5 $347 $1,733 1 $421 $421 28 78320 Bone Spect 3 $4131 $1,238 0 $500 $0 29 78460 Persantine Myov Planar" 0 $276 $0 1 $335 $335 30 78460 Treadmill Myov Planar' 0 $276 $0 0 $335 $0 31 78460 Dobutamine TI-201 Planar" 0 $276 $0 0 $335 $0 32 1 78460 24 hr TI-201 Planar(Addit.) 0 $199 $0 0 $241 $0 33 78461 Planar Persantine TI-201 0 $436 $0 0 $529 $0 34 78461 Planar Myov Rest 0 $359 $0 0 $435 $0 35 78464 SPECT addit.TL-201 0 $483 $0 0 $586 $0 36 78464 Treadmill Myov SPECT' 7 $561 $3,924 0 $680 $0 37 78464 Rest Myov SPECT" 50 $561 $0 15 $680 $0 38 78464 Persantine Myov SPECT` 47 $561 $26,344 13 $680 $8,839 39 78464 24 hr TL-201 SPECT 0 $483 $0 0 $586 $0 40 78465 Thallium or Myoview Treadmill Test" 1 $856 $856 9 $1,039 $9,349 41 78465 SPECT Rest TL-201 0 $779 $0 0 $945 $0 42 78465 SPECT Dobutamine TL-201 or Myoview" 0 $856 $0 8 $1,039 $8,311 SPECT Persantine,Adenenosine or Myoview 43 78465 w/TL-201" 120 $856 $102,773 78 $1,039 $81,029 44 78466 PYP Myocardial Infarction Planar 0 $201 $0 0 $244 $0 45 78469 PYP Myocardial Infarction Scan 0 $365 $0 0 $443 $0 46 78472 GWMS 12 $387 $4,640 3 $4691 $1,407 47 78473 Exercise GWMS' 0 $656 $0 0 $795 $0 48 78478 Myocardial Perfusion Study w/Wall Motion 118 $135 $15,930 108 $164 $17,685 49 78481 GWMS w/ 1st Pass 0 $370 $0 0 $449 $0 50 78483 Ex GWMS w/1st Pass" 0 $634 $0 0 $769 $0 51 78580 jLung Perfusion 0 $251 $0 0 $304 $0 C. JOPTION 4: 8/1/02 -7/31/03 V261 S-6162,Modification#3, 5/31/01 Nuc Fees Mod 3.As PAGE 6 of B ,Nuclear Medicine Services FEE SCHEDULE Item# PROCEDURES Services provided at VAOPC Services provided at CCRMC CPT Est. Est. Code Description Qty. Unit Price Total Price Qty. Unit Price Total Price 52 78580 Lung Quantification 2 $251 $501 0 $304 $0 53 78585 Lung V/Q 55 $401 $22,037 91 $486 $44,227 54 78594 Lung Vent(addit.) 0 $324 $0 0 $393 $0 55 78606 Cerebral Flow and Scan 0 $268 $0 0 $325 . $0 56 78630 Cisternogram 1 $337 $337 1 $409 $409 57 78650 CSF Leak Study 0 $309 $0 0 $375 $0 58 78707 Renal Scan-Baseline 27 $324 $8,748 3 $393 $1,179 59 78707 1 Lasix Renal(Incl Lasix) 2 $346 $691 0 $419 $0 60 78709 Captopril Renal(inc Captopril) 13 $346 $4,493 0 $419 $0 61 78800 Octreoscan Ltd 2 view 0 $242 $0 0 $293 $0 62 78800 Oncoscint Ltd 2 view 0 $299 $0 0 $363 $0 63 78801 Ga-67 Ltd 1 $299 $299 1 $363 $363 64 78802 Ga-67 WB 20 $379 $7,582 1 $460 $460 65 78802 Octreoscan WB 1 $379 $379 0 $460 $0 66 78802 Oncoscint WB 0 $379 $0 0 $460 $0 67 78803 Ga-67 SPECT 2 $453 $905 0 $549 $0 68 78803 Octreoscan SPECT 0 $453 $0 0 $549 $0 69 78803 Oncoscint SPECT 0 $453 $0 0 $549 $0 70 78805 In-111 WBC Ltd 2 $247 $495 8 $300 $2,400 71 78806 In-111 WBC WB 12 $430 $5,158 2 $521 $1,043 72 78806 In-111 WBC SPECT(addit) 0 $430 $0 0 $521 $0 73 79000 lHyperthyroid Therapy Initial 20 $2831 $5,659 0 $343 $0 74 79001 Hyperthyroid Therapy Additional 3 $151 $454 0 $183 $0 75 79030 Thyroid Therapy-Ablation 2 $305 $609 0 $369 $0 76 79035 Thyroid Therapy Cancer 2 $336 $672 0 $407 $0 77 79100 P-32 Therapy 0 $246 $0 0 $299 $0 78 79401 Sr-89 Therapy 0 $248 $0 0 $250 $0 79 78890 lCornputer Processing(<30 min) 0 $0 $0 0 $0 $0 80 78891 lCornputer Processing(>30 min) 0 $0 $0 0 $0 $0 81 99241 lOffice Consultation- 15 minutes 5 $69 $346 0 $84 $0 82 99242 lOffice Consultation-30 minutes 2 $106 $212 0 $128 $0 83 99243 101fice Consultation-40 minutes 2 $138 $276 0 $168 $0 "Includes 93016 &93018 Item# ISOTOPES/SUPPLIES Est. Ref# Description(CPT/HCPCS) Qty. Unit Price Total Price 84 00001 178990 A4641 Tc99m MAG3 40 $192 $7,696 85 00002 178990 A4641 Tc99m MAA 57 $311 $1,778 86 00003 78990 A4641 Tc99m SC 16 $40 $632 87 00004 78990 A4641 Tc99m DTPA 2 $57 $114 88 00005 78990 A4641 Tc99m Choletec 40 $57 $2,288 89 00006 78990 A4641 1-123 200 uCi 38 $104 $3,952 90 00007 78990 A4641 1-131(1-10 mCi) 20 $208 $4,160 91 00008 78990 A4641 1-131(ea add)mCi) 20 $16 $312 92 00009 78990 A4641 IN-111 DTPA(1vi) 0 $800 $0 93 00010 78990 A4641 IN-111 WBC(per labeling) 0 $528 $0 94 00011 78990 A4641 Xenon(10mCi/vi) 55 $31 $1,716 95 00012 78990 A4641 Ga67(6 mCi) 21 $130 $2,730 V261S-6162,Modification 93, 5/31I01 Nuc Fees Mod 3.xls Nuclear Medicine Services FEE SCHEDULE PAGE 7 Of 8 Item# ISOTOPES/SUPPLIES Est. Ref# Description(CPT/HCPCS) Qty. Unit Price Total Price 96 00013 78990 A4641 DICOPAC(1 kt) 0 $275 $0 97 00014 78990 A4641 Ultratag(1 kt) 10 $74 $738 98 00015 78990 A4641 Otreoscan/dose 0 $1,273 $0 99 00016 78990 A4641 Tc04(30 mCi) 10 $12 $125 100 00017 78990 A4641 Bulk Tc04 4 $25 $100 101 00018 78990 A4641 Prostascint 0 $1,596 $0 102 00019 78990 A4641 Tc99m CEA 0 $1,479 $0 103 00020 78990 A4642 Oncoscint 0 $1,406 $0 104 00021 78990 A9502 Tc99m Myoview 97 $110 $10,693 105 00022 78990 A9503 Tc99m MDP 140 $40 $5,533 106 00023 78990 A9505 TL-201 (3 mCi) 120 $88 $10,608 107 00024 78990 A9600 S-89 Chloride(4 mCi) 0 $3,260 $0 108 00025 J0150 Adenosine(per 6 mg) 0 $27 $0 109 00026 J0280 Aminophylline(to 250 mg) 400 $2 $832 110 00027 J1245 Persantine(10 mg)(Per) 400 $25 $9,984 111 00028 J1550 Dobutamine(per 250 mg) 0 $27 $0 112 00029 Dobutamine Pack 0 $74 $0 113 00030 CCK/Morphine 0 $68 $0 114 00031 78990 A4641 Chromium 51/Ascorbic Acid 1 $1,045 $1,045 MRI SERVICES AT VAOPC Services provided at VAOPC "New Services priced at current CPT CODE Champus Maximum Allowable Cost. Unit Price 115 70541 MRA Head& Neck w&w/o contrast $1,657 116 70551 Brain w/o contrast $642 117 70553 Brain w&w/o contrast $1,369 118 72141 C-Spine w/o contrast $649 119 72146 T-Spine w/o contrast $709 120 72148 L-Spine w/o contrast $703 121 72156 C-Spine w&w/o contrast $1,381 122 1 72157 T-Spine w&w/o contrast $1,381 123 72158 L-Spine w&w/o contrast $1,369 124 73221 Upper Extremity Joint $607 125 73721 Lower Extremity Joint $607 Supply of paramagnetic Contrast materiel 126 A4647 e.g. Gadolinium) at Cost ADDITIONAL Item# PROCEDURES/MISCELLANEOUS Services provided at VAOPC Services provided at CCRMC CPT/HCPCS Est. Est. Code Description Qty. Unit Price I Total Price Qty. Unit Price Total Price 127 78701 Renal Imaging,statics w/vasc flow 0 $239 $0 2 $250 $500 128 78185 Spleen Imaging w/flow 1 $162 $162 1 $172 $172 129 78195 Lymphatic&Lymph Node Imaging 0 $312 $0 5 $327 $1,635 130 78206 Liver SPECT w/flow(Hemangioma) 4 $392 $1,568 1 $376 $376 131 78305 Bone Imaging Mult.Areas 20 $268 $5,366 20 $281 $5,620 132 78456 Acute Venous Throm. Imaging, Peptide 1 $293 $293 5 $307 $1,535 133 78480 Wall motion w/Ejection Fraction 50 $134 $6,708 50 $141 $7,050 134 78596 jPulmonary Quantitative/Diff. Function 1 $496 $496 1 $518 $518 135 78710 Kidney Spect 2 $179 $358 2 $404 $808 136 78715 Kidney, Vascular Flow Only 0 $112 $0 1 $118 $118 137 78740 Ureteral Reflux(Voiding Cystogram) 0 $161 $0 1 $169 $169 138 78760 Testicular imaging w/o Vascular Flow 0 $201 $0 1 $210 $210 139 78761 Testicular Imaging wNascular Flow 0 $235 $0 1 $245 $245 V261S-6162,Modification#3, 5/31/01 Nuc Fees Mod 3.x1s • PAGE 8 of 8 Nuclear Medicine Services FEE SCHEDULE 140 A4641 99mTc Glucoheptanate 2 $78 $156 141 A4641 99mTc DMSA 2 $141 $283 142 A9502 99mTc Sestamibi 10 $130 $1,300 143 A9504 99m Tc Apcitude ACUTECT 6 $400 $2,402 TECHNICAUPROFESSIONAL SUPPORT Professional Fee for Radiation Safety Officer 144 (RSO)(per hour) $102 Nuclear Medicine Technical Support/After 145 Hours Support Fee(per hour) $52 146 Medical Physicist Support Fee(per hour) $105 Medical Physics Technician Support Fee(per 147 hour) $61 Facility Use Fee(to be paid to CCRMC by VA for use of CCRMC space and equipment)(per 148 1 1procedure) $141 V261 S-6162,Modification#3, 5/31101 Nuc Fees Mod 3.xls