Quotation Estimate Radiologist in United States Houston –Free Word Template Download with AI
Professional Radiologist Services
United States Houston, Texas 77002
Document Reference: QTE-HOU-RAD-2025-0417
Service Provider
Dr. Margaret L. Chen, MD, FACR
Board-Certified Radiologist
Houston Advanced Imaging Center
1200 Medical Center Drive, Suite 450
United States Houston, TX 77030
Phone: (713) 555-0187
Email: [email protected]
NPI: 1497823651
Client / Receiving Facility
Bayshore Medical Group
Attn: Dr. Robert A. Williams, Chief of Medicine
4500 Gulf Freeway, Building C
United States Houston, TX 77023
Phone: (713) 555-0342
Email: [email protected]
Tax ID: 74-2839105
This Quotation Estimate is issued by Dr. Margaret L. Chen, a board-certified Radiologist practicing in United States Houston, to provide comprehensive diagnostic imaging interpretation services for Bayshore Medical Group. The following services are included in this estimate, reflecting the standard scope of a practicing Radiologist in the Houston, Texas metropolitan area:
| # | Service Description | CPT Code | Quantity | Unit Rate (USD) | Total (USD) |
|---|---|---|---|---|---|
| 1 | Interpretation of CT scans (head, chest, abdomen, pelvis) – monthly retainer for up to 120 studies | 70450 / 71250 / 74176 / 74177 | 120 | $185.00 | $22,200.00 |
| 2 | MRI interpretation services (brain, spine, joints) – up to 60 studies per month | 70551 / 72148 / 73221 | 60 | $245.00 | $14,700.00 |
| 3 | Ultrasound interpretation (abdominal, pelvic, vascular) – up to 80 studies per month | 76700 / 76856 / 93306 | 80 | $145.00 | $11,600.00 |
| 4 | Digital mammography and breast imaging interpretation – up to 50 studies per month | 77067 / 77065 | 50 | $195.00 | $9,750.00 |
| 5 | Interventional radiology consultation and procedural reporting – up to 20 cases per month | 77012 / 77021 | 20 | $425.00 | $8,500.00 |
| 6 | Emergency and after-hours Radiologist on-call coverage (24/7 availability, up to 15 urgent reads per month) | Various (as applicable) | 15 | $310.00 | $4,650.00 |
| 7 | PACS integration, report generation, and electronic medical record (EMR) interface management | N/A (Administrative) | 1 | $1,200.00 | $1,200.00 |
| 8 | Monthly quality assurance review, peer consultation, and regulatory compliance reporting for United States Houston health department | N/A (Administrative) | 1 | $850.00 | $850.00 |
| Subtotal (Monthly Services) | $73,450.00 |
| Applicable Texas Sales Tax (6.25%) | $4,590.63 |
| Administrative & Licensing Fee (State of Texas) | $350.00 |
| Grand Total (Monthly) | $78,390.63 |
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, pricing may be subject to revision based on current market rates for Radiologist services in the United States Houston area.
- All services described herein shall be performed by Dr. Margaret L. Chen, MD, FACR, or by a credentialed associate Radiologist under her direct supervision and quality assurance oversight, in full compliance with the Texas Medical Board and the American College of Radiology (ACR) accreditation standards.
- Payment terms: Net 30 days from the date of invoice issuance. Invoices will be submitted on the first business day of each calendar month for services rendered in the preceding month. Late payments shall accrue interest at 1.5% per month.
- This Quotation Estimate assumes a minimum monthly engagement of twelve (12) months. Early termination prior to the twelve-month period will require a 60-day written notice and a termination fee equal to two months of the contracted service rate.
- The Radiologist shall maintain full malpractice and professional liability insurance with a minimum coverage of $5,000,000 per occurrence and $10,000,000 aggregate, as required by the State of Texas and the facility's risk management policies.
- All diagnostic reports generated under this agreement shall be delivered electronically via the client's EMR system within four (4) hours for routine studies and within one (1) hour for STAT or emergency reads, consistent with the standard of care expected of a Radiologist in United States Houston.
- Confidentiality: All patient data and imaging studies shall be handled in strict accordance with the Health Insurance Portability and Accountability Act (HIPAA) and the Texas Medical Records Act. The Radiologist and all associated personnel shall sign individual HIPAA Business Associate Agreements prior to commencing services.
- Any services exceeding the monthly quantities specified in this Quotation Estimate will be billed at the per-study unit rates listed in Section 2, with a 10% surcharge for volumes exceeding 150% of the stated monthly cap.
- This Quotation Estimate does not constitute a binding contract until executed in writing by both parties. The final service agreement will incorporate all terms herein along with additional provisions regarding indemnification, dispute resolution, and governing law (State of Texas, United States Houston jurisdiction).
- The Radiologist reserves the right to decline any imaging study that falls outside the scope of her board certification or that presents ethical or clinical concerns, in accordance with the ACR Code of Ethics.
By signing below, both parties acknowledge that they have read, understood, and agree to the terms set forth in this Quotation Estimate for Radiologist services to be rendered in United States Houston, Texas.
Service Provider (Radiologist)
Dr. Margaret L. Chen, MD, FACR
Signature: ___________________________
Date: ___________________________
Client / Receiving Facility
Bayshore Medical Group
Signature: ___________________________
Name / Title: ___________________________
Date: ___________________________
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