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MRI Breast Without and With contrast bilateral

DETAIL FOR SERVICES: Study Radiologist reading (interpretation)
2020 CPT/HCPCS Primary Code 77049 Not provided by Hospital (may be billed separately)
Negotiated Private Fee $830.00 Not provided by Hospital (may be billed separately)
Prossam $375.00 Not provided by Hospital (may be billed separately)
Champva $378.85 Not provided by Hospital (may be billed separately)
First Medical $312.50 Not provided by Hospital (may be billed separately)
First Medical Vital $206.53 Not provided by Hospital (may be billed separately)
Plan de Salud Menonita $276.25 Not provided by Hospital (may be billed separately)
Menonita Vital $276.25 Not provided by Hospital (may be billed separately)
Humana Gold Plus / Gold Choice Ambulatory Payment classification (APC) Not provided by Hospital (may be billed separately)
Humana $412.50 Not provided by Hospital (may be billed separately)
Mapfre $325.00 Not provided by Hospital (may be billed separately)
Mcsclassicare $206.00 Not provided by Hospital (may be billed separately)
MCS Life $206.00 Not provided by Hospital (may be billed separately)
Medicare Ambulatory Payment classification (APC) Not provided by Hospital (may be billed separately)
MMM $378.85 Not provided by Hospital (may be billed separately)
MMM Vital $206.53 Not provided by Hospital (may be billed separately)
Panamerican Life $387.50 Not provided by Hospital (may be billed separately)
PMC $378.85 Not provided by Hospital (may be billed separately)
Tricare $377.40 Not provided by Hospital (may be billed separately)
Triple S Salud $342.00 Not provided by Hospital (may be billed separately)
Triple S Vital $191.00 Not provided by Hospital (may be billed separately)
Triple S Advantage Ambulatory Payment classification (APC) Not provided by Hospital (may be billed separately)
Negotiated Minimum Charge $191.00 Not provided by Hospital (may be billed separately)
Negotiated Maximum Charge $412.50 Not provided by Hospital (may be billed separately)
Discounted Cash Price $664.00 Not provided by Hospital (may be billed separately)

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