Request An Estimate

To request an estimate for an upcoming outpatient medical imaging exam, please complete the form below. A representative from our billing office will contact you within the next 24 hours.

Please note: The estimate provided is based on the information submitted in this form. If deemed necessary, additional procedures may be added at the time of your exam by your healthcare provider or radiologist.  

If you have any questions, please call 952.837.9700 Monday-Friday from 7:30am-4:00pm and ask to speak to a billing specialist.

First Name: *

Last Name: *

Phone: *

If additional information is needed, what is the best time to reach you?

 8am-12pm

 12pm-5pm

 5pm-9pm

Email: *

Which Suburban Imaging location do you prefer for your exam? *

 SI-Blaine

 SI-Burnsville

 SI-Coon Rapids

 SI-Maple Grove

 SI-Northwest

 SI-Southdale

 The Breast Center of Suburban Imaging

Exam: *Please select examMRICTPET/CTUltrasoundSpinal or Joint InjectionNuclear MedicineX-rayMammographyBone DensityBreast Diagnostic Services

Which body part is your exam for? *Please select body partAbdomenBrain/HeadBreastChestElbow/ForearmFoot/AnkleHipKneeLegNeckPelvisShoulderSinusesSpineToesWrist/Hand/Finger/Thumb

Does your exam require contrast?

 Unknown

 Yes

 No

Insurance Provider: *Please select insurance providerAetnaBlue CrossCIGNAHealthPartnersHumanaMedicaMedicarePreferred OneSelect CareUcareUnited Health CareOtherUninsured/Self Pay

If your insurance provider is not listed, please type it here:

Have you met your deductible? *

 Unknown

 Yes

 No

Ordering Clinic: *

Ordering Provider:

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