Entity Name (required) Contact Name (required) Telephone Number (required) Fax Number (required) Contact Email (required) Corporate Address (required) Number of Locations: Specialty: ---RadiologySurgical CenterHospitalPain ManagementSpine SurgeonASCChiropracticPhysical TherapyOther Billable Charge for Cervical MRI w/o. Billable Charge for MRI w/o Lumbar. Billable Charge for Upper Extremity MRI w/o. Billable Charge for Lower Extremity MRI w/o.