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1992-226-Authorizing The Town Manager To Sign A Agreement With Los Gatos MRI For Workers' Compensation MRI ServicesRESOLUTION 1992 -226 RESOLUTION OF THE TOWN OF LOS GATOS AUTHORIZING THE TOWN MANAGER TO SIGN A AGREEMENT WITH LOS GATOS MRI FOR WORKERS' COMPENSATION MRI SERVICES RESOLVED, by the Town Council of the Town of Los Gatos, County of Santa Clara, State of California, that the Town of Los Gatos enter into an agreement with Los Gatos MRI for Workers' Compensation MRI Services on the terms and conditions outlined in attached Exhibit A, and that the Town Manager is authorized, and is hereby directed, to execute said agreement in the name and on behalf of the Town of Los Gatos. PASSED AND ADOPTED at a regular meeting of the Town Council of the Town of Los Gatos, California, held on the 7th day of December, 1992. the following vote: COUNCIL MEMBERS: AYES: Randy Attaway, Steven Blanton, Linda Lubeck,Patrick O'Laughlin, Mayor Joanne Benjamin NAYES: None ABSENT: None ABSTAIN: None SIGNED: �`� M OR OF THE TOW F LOS GATOS LOS GATOS, CALIFORNIA ATTEST: CLERK OF THE TOWN OF LOS GATOS LOS GATOS, CALIFORNIA Los Gatos MRI A\ ~till Poll'o RJ. U( c' B —(QI • 10' vJ 110" 10,) November 11, 1992 Ms. Carla Turner Town of Los Gatos 110 E. Main Street Los Gatos, Ca. 95032 Re: Provision of MRI Services Dear Ms. Turner, TME, Inc. ( "TME ") is pleased to present the following terms and conditions concerning the provision of MRI services to patients of Town of Los Gatos ( "TLG "). The MRI services will be available at the diagnostic imaging center known as Los Gatos MRI, located at 800 Pollard Road, Suite B -101, Los Gatos, California ( "Center "). PROVISION OF SERVICES: MRI services, including professional interpretation, will be provided to patients referred to Center from TLG. Scans and written interpretations will be delivered to TLG physicians within 48 hours from the provision of services, and a telephone report will be available for hospital inpatients. FINANCIAL ARRANGEMENTS: TLG will reimburse Center for the MRI services provided according to the fee schedule attached as Exhibit "A," which represents a global charge. TLG will reimburse the Center within sixty (60) days of the receipt of invoice for services. Invoices not paid within sixty (60) days will be subjected to customary late charge. A copy of the medical report will be included with each invoice. MARKETING: TLG may advertise and market the availability of MRI services at the Center to its referring physicians and patient population. Center reserves the right to control the marketing or advertising of MRI services at the Center. TERMlTERMINATION: This Agreement shall become effective upon execution by both parties and shall continue in effect for as long as MRI services are provided at the Center. Center may amend the fee schedule attached upon thirty (30) days prior written notice to TLG. Moreover, the Center underrstands that TLG is under no obligation to refer any specified number of patients, of any patients whatsoever, to the Center. This agreement may be terminated without cause by either party by giving the other party ninety (90) days written notice of termination. NON - EXCLUSIVITY: This Agreement is not an exclusive arrangement. TLG may refer patients for MRI services to any diagnostic center deemed appropriate by the referring physician, and Center may provide services to any patient referred by TLG or any other physician. No employment, independent contractor, or agency relationship is created by this Agreement. I� A 1 TM El Center Ms. Carla Turner Nov. 11, 1992 Page 2 CONFIDENTIALITY: TLG, TME, and their respective agents , employees, representatives, and shareholders will deep the terms of this agreement confidential for as long as Center providing MRI services to TLG patients and for five (5) years after Center ceases providing MRI services to TLG patients. This proposal will expire thirty (60) days after your receipt unless an executed original is received by us prior to that date. If the foregoing accurately sets forth the terms of out understanding, please acknowledge in the space provided below and return one original to the undersigned. \Very tru urs, V David Hokeness Director of Professional Relations AGREED AND ACCEPTED: APPROVED AS TO FORM: TOWN OF LOS GATOS cc: Shelly Schulzt KATHERINE ANDERTON, TOWN ATTORNEY ATTEST: MARIAN V. COSGROVE, TOWN CLERK h A 1741 Center ATTACHMENT 1 Payments due within ninety (60) days of invoice. Invoices not paid within ninety (60) days will be subject to customary late charges. I A �TMEI Center EXHIBIT "A" FEE SCHEDULE - LOS GATOS, TOWN OF CPT-4 Codes Description Fee 70336 MRI of TMJ Bilateral $750.00 70540 MRI of Orbit, Face and Neck $750.00 70551 MRI of Brain / Brain Stem $750.00 71550 MRI of Chest / Mediastinum $750.00 72141 MRI of Cervical Spine $750.00 72146 MRI of Thoracic Spine $750.00 72148 MRI of Lumbar Spine $750.00 72196 MRI of Pelvis / Hips $750.00 73220 MRI of Upper Extremity $750.00 73221 MRI of Lower Extremity Joint $750.00 73720 MRI of Lower Extremity $750.00 73721 MRI of Lower Extremity Joint $750.00 74181 MRI of Abdomen $750.00 75552 MRI of Myocardium $750.00 99070M Gadolinium $125.00 Sedation Fee $50.00 Injection Fee $25,00 22 Modifier Additional Sequences $125.00 Payments due within ninety (60) days of invoice. Invoices not paid within ninety (60) days will be subject to customary late charges. I A �TMEI Center ATTACHMENT 2 -� LOS GATOS MRI FEE SCHEDULE NON - DISCOUNTED - j ` P -T -4 Code. _ —..... Body Payt. + _- Price 70336 _ Bilateral TMJ 70336 -52 Unilateral TMJ 1,000.(10 70540 Orbit, Face & Neck 500.00 70540 -22 Orbit, Face & Neck, Add'l Seq. 1,000.00 70540 -52 Orbit, Face & Neck, Ltd. Stud X 1,250.00 70540 -76 Orbit, Face & Neck, Repeat 250.00 70551 Brain, Stem w/o contrast 600.00 70551 -22 70551 Brain, Stem w/o contrast, Add'1 Se 990.00 1,230.00 -52 70551 -76 Brain, Stem w/o contrast, Ltd. Stud Y Brain, Stem w/o contrast, 330.00 * 70552 Repeat Brain, Stem with contrast 590.00 * 70552 -22 Brain, Stem with contrast, Add'1 Seq. 1,115.00 * 70552 -52 Brain, Stem with contrast, Ltd. Study 1,230.00 * 70552 -76 * 70553 Brain, Stem with contrast, Repeat 330.00 590.00 71550 MRI Brain with and without contrast Chest, Mediastinum 1,355.00 — 71550 -22 Chest, Mediastinum, Add'1 Se Seq. 1,000.00 71550 -52 Chest, Mediastinum, Ltd. Seq 1,300.00 71550 -76 Chest, Mediastinum, Repeat 300.00 72141 Cervical Spine w/o contrast 600.00 72141 -22 72141 -52 Cervical Spine w/o contrast, Adcd'1 Seq. Cervical Spine 1,200.00 72141 -76 w/o contrast, Ltd. Seq. Cervical Spine w/o contrast, Repeat 300.00 * 72142 Cervical Spine with contrast 540.00 * 72142 -22 * Cervical Spine with contrast; Add'1 Seq. 1,025.00 1,200.00 72142 -52 * Cervical Spine with contrast, Ltd. Seq. 300.00 72142 -76 * Cervical Spine with contrast, Repeat 540.00 72156 72146 MRI Cervical Spine with and without contrast 1,325.00 72146 -22 Thoracic Spine w/o contrast Thoracic Spine w/o 72146 -52 contrast, Add'l Seq. Thoracic Spine w/o contrast, Ltd. 1,200.00 72146 -76 Seq. Thoracic Spine w/o contrast, Repeat 300.00 72147 Thoracic Spine with contrast 540.00 72147 -22 72147 -52 Thoracic Spine with contrast, Add'l Se Thoracic Spine 1,025.00 1 72147 -76 with contrast, Ltd. Seq. Thoracic Spine with contrast, Repeat 300.00 * 72157 72148 MRI Thoracic Spine with and without contrast 540.00 1,325.00 Lumbar Spine w/o contrast 72148 -22 72148 Lumbar Spine w/o contrast, Add'1 Seq. 900.00 1,200.00 -52 Lumbar Spine w/o contrast, Ltd. Seq. 72148 -76 Lumbar Spine w/o contrast, Repeat 300.00 * 72149 Lumbar Spine with contrast 540.00 t 72149-22 * Lumbar Spine with contrast, Add'1 Seq. 1,025.00 1,200.00 72149 -52 * Lumbar Spine with contrast, Ltd. Seq. 72149 -76 Lumbar Spine with contrast, Repeat 300.00 * 72158 MRI Lumbar Spine with and without contrast 1,325.00 11(1112- C �-Ite Sl10 - -10 >> 3/ rtL 11 G- `��d L=: Ec�? v;. � i i Two CPT -4 Code Body Part Price 72196 -22 Pelvis, Hips 1,000.00 72196 Pelvis, Hips, Add'1 Seq. 1,300.00 72196 -52 Pelvis, Hips, Ltd. Seq. 300.00 72196 -76 Pelvis, Hips, Repeat 600.00 73220 Upper Extremity 800.00 73220 -22 Upper Extremity, Add'1 Seq. 1,070.00 73220 -52 Upper Extremity, Ltd. Seq. 270.00 73220 -76 Upper Extremity, Repeat .480.00 73221 Upper Extremity, Joint 800.00 73221 -22 Upper Extremity, Joint, Add'l Seq. 1,070.00 73221 -52 Upper Extremity, Joint, Ltd. Seq. 270.00 73221 -76 Upper Extremity, Joint, Repeat 480.00 73720 Lower Extremity 800.00 73720 -22 Lower Extremity, Add'1 Seq. 1,070.00 73720 -52 Lower Extremity, Ltd. Seq. 270.00 73720 -76 Lower Extremity, Repeat 480.00 73721 Lower Extremity, Joint 800.00 73721 -22 Lower Extremity, Joint, Add'1 Seq. 1,070.00 73721 -52 Lower Extremity, Joint, Ltd. Seq. 270.00 73721 -76 Lower Extremity, Joint, Repeat 480.00 74181 Abdomen 1,000.00 74181 -22 Abdomen, Add'1 Seq. 11300.00 74181 -52 Abdomen, Ltd. Seq. 300.00 74181 -76 Abdomen, Repeat 600.00 75552 Myocardium 1,000.00 75552 -22 Myocardium, Add'1 Seq. 1,300.00 75552 -52 Myocardium, Ltd. Seq. 300.00 75552 -76 Myocardium, Repeat 600.00 99058 Charge for Emergency Service 50.00 9907OC Sedation - Chloral Hydrate 10.00 9907OG Glucagon 20.00 99070M Magnevist - Contrast Agent Only 125.00 99070V Sedation - Valium 50.00 'j'I�,0 L\/ 1.V rR4 YE Np4s Su , c , Y.�G c. ) ZUDES COST OF CONTRAST AGENT _eesch4.LOS - ") //� /I9z W.jUV,