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MRI Breast Without contrast bilateral

DETAIL FOR SERVICES: Study Radiologist reading (interpretation)
2020 CPT/HCPCS Primary Code 77047 Not provided by Hospital (may be billed separately)
Negotiated Private Fee $750.00 Not provided by Hospital (may be billed separately)
Prossam $250.00 Not provided by Hospital (may be billed separately)
Champva $239.78 Not provided by Hospital (may be billed separately)
First Medical $312.50 Not provided by Hospital (may be billed separately)
First Medical Vital $125.24 Not provided by Hospital (may be billed separately)
Plan de Salud Menonita $276.00 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 $375.00 Not provided by Hospital (may be billed separately)
Mapfre $325.00 Not provided by Hospital (may be billed separately)
Mcsclassicare $145.60 Not provided by Hospital (may be billed separately)
MCS Life $145.60 Not provided by Hospital (may be billed separately)
Medicare Ambulatory Payment classification (APC) Not provided by Hospital (may be billed separately)
MMM $239.78 Not provided by Hospital (may be billed separately)
MMM Vital $125.24 Not provided by Hospital (may be billed separately)
Panamerican Life $387.50 Not provided by Hospital (may be billed separately)
PMC $239.78 Not provided by Hospital (may be billed separately)
Tricare $239.83 Not provided by Hospital (may be billed separately)
Triple S Salud $325.00 Not provided by Hospital (may be billed separately)
Triple S Vital $332.71 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 $125.24 Not provided by Hospital (may be billed separately)
Negotiated Maximum Charge $375.00 Not provided by Hospital (may be billed separately)
Discounted Cash Price $600.00 Not provided by Hospital (may be billed separately)

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