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LITHOTRIPSY

 

SERVICE FEE MEMORANDUM

MS-91-92-2

DATE: November 1, 1991

RE: Lithotripsy Services, ACT, Inc., Louisville, KY

Lithotripsy services are now available through ACT, Inc. in Louisville, Effective November 1, 1991, the following DVR maximum allowable fees cover all technical charges for lithotripsy services. Physician (Urology and Anesthesia) charges are not included in ACT's charges.

PROCEDURE

DVR ALLOWABLE FEE

TREATMENT: Outpatient Hospitalization

  

Extracorporeal Shock Wave Lithotripsy

$3,900

Extracorporeal Shock Wave Lithotripsy

with Cystoscopy and Stents Involved

4,575
   

AUTHORIZATION

  

VENDOR NUMBER:

V01029061

VENDOR NAME & ADDRESS:

ACT INC

221 E CHESTNUT ST

LOUISVILLE KY 40202

EXPENDITURE CATEGORY CODE:

SUBCATEGORY CODE:

LETTER:

2

3

C

 

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