Quotation Estimate Radiologist in United States Chicago –Free Word Template Download with AI
Professional Radiologist Diagnostic Imaging Services
United States Chicago, Illinois
Document No. QE-CHI-2025-04782Provider Information
Dr. Margaret L. Whitfield, MD, FACR
Board-Certified Radiologist
Lakeview Diagnostic Imaging Center
2155 N. Lake Shore Drive, Suite 400
Chicago, Illinois 60614, United States
Phone: (312) 555-0187
Email: [email protected]
IL Medical License: 231.004872
Client / Referred By
Northshore Medical Group
Attn: Dr. James R. Callahan, MD
1400 N. Lakeview Avenue
Evanston, Illinois 60201, United States
Phone: (847) 555-0342
Referral Date: June 12, 2025
Insurance Provider: Blue Cross Blue Shield of Illinois
Policy Reference: BCBS-IL-8829104
Quotation Estimate Details
Quotation Estimate Date: June 14, 2025
Valid Until: July 14, 2025
Service Location: Chicago, Illinois, United States
Estimated Service Date: June 28, 2025
Payment Terms
Method: Insurance billing with patient co-pay
Co-Pay Amount: $75.00 (due at time of service)
Balance Due: 30 days from date of service
Currency: United States Dollars (USD)
This Quotation Estimate is issued by Dr. Margaret L. Whitfield, a board-certified Radiologist practicing in the United States Chicago metropolitan area, in response to the referral from Northshore Medical Group. The following diagnostic imaging and radiological interpretation services are included in this Quotation Estimate. All procedures will be performed in compliance with the Illinois Department of Public Health regulations and the American College of Radiology (ACR) standards of practice.
| # | Service Description | CPT Code | Quantity | Unit Price (USD) | Subtotal (USD) |
|---|---|---|---|---|---|
| 1 | Comprehensive MRI of the Brain with and without contrast (Radiologist interpretation and report) | 70553 | 1 | $1,240.00 | $1,240.00 |
| 2 | CT Scan of the Chest with IV contrast (Radiologist read and detailed report) | 71260 | 1 | $890.00 | $890.00 |
| 3 | Ultrasound of the Abdomen, Complete (Radiologist supervision and interpretation) | 76700 | 1 | $425.00 | $425.00 |
| 4 | Digital Mammography, Bilateral, Diagnostic (Radiologist interpretation) | 77067 | 1 | $380.00 | $380.00 |
| 5 | Consultation and follow-up review of imaging findings by the Radiologist | 99245 | 1 | $210.00 | $210.00 |
| 6 | Written Radiologist report with comparative analysis to prior imaging studies | 99241 | 1 | $95.00 | $95.00 |
| 7 | Facility fee for imaging equipment usage at Chicago, IL location | N/A | 1 | $350.00 | $350.00 |
| TOTAL ESTIMATED CHARGE | $3,590.00 | ||||
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date of July 14, 2025, a new Quotation Estimate must be requested, as Radiologist service fees in the United States Chicago area are subject to periodic adjustment.
- All Radiologist services described in this Quotation Estimate will be performed at the Lakeview Diagnostic Imaging Center facility located in Chicago, Illinois, United States. The facility is accredited by the American College of Radiology and the Joint Commission.
- The Radiologist, Dr. Margaret L. Whitfield, is board-certified by the American Board of Radiology and maintains active malpractice insurance coverage in the state of Illinois. All imaging interpretations will be conducted in accordance with the ACR Practice Parameter for the Performance of Diagnostic Imaging Services.
- Pre-authorization from the patient's insurance carrier (Blue Cross Blue Shield of Illinois) is required prior to the scheduled service date. The referring physician's office is responsible for obtaining this authorization. This Quotation Estimate does not constitute a guarantee of insurance reimbursement.
- The patient's co-pay of $75.00 is due at the time of the imaging appointment. The remaining balance, less any applicable insurance adjustments, will be billed to the insurance carrier and the patient as determined by the plan's benefit structure.
- All medical imaging records, Radiologist reports, and diagnostic findings generated from services covered by this Quotation Estimate will be maintained in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and the Illinois Personal Information Protection Act.
- Should the patient require a second opinion or additional Radiologist consultation beyond the scope of this Quotation Estimate, a separate Quotation Estimate will be issued at the standard consultation rate of $210.00 per session.
- This Quotation Estimate is non-transferable and applies solely to the patient identified in the referral documentation from Northshore Medical Group, Evanston, Illinois, United States.
- Any disputes regarding charges or services rendered under this Quotation Estimate shall be resolved in accordance with the Illinois Medical Practice Act and applicable federal healthcare regulations governing the United States Chicago metropolitan region.
By signing below, the referring physician or authorized representative acknowledges receipt of this Quotation Estimate for Radiologist services in Chicago, Illinois, United States, and authorizes the scheduling of the described diagnostic imaging procedures. The patient's written consent for the specific imaging procedures will be obtained separately at the time of the appointment in compliance with Illinois informed consent statutes.
Referring Physician / Authorized Representative
Name: ______________________________
Title: ______________________________
Signature: ______________________________
Date: ______________________________
Radiologist / Service Provider
Name: Dr. Margaret L. Whitfield, MD, FACR
Title: Board-Certified Radiologist
Signature: ______________________________
Date: ______________________________
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