Aetna "Select Provider" Listing - High-Tech Radiology Houston - January, PET Imaging of Sugar Land

Transcription

1 Aetna "Select Provider" Listing - High-Tech Radiology TEXAS BRAZORIA COUNTY Angleton Brazoria County CT, Inc , Brazos Pkwy., Suite C Angleton, TX Phone: / Fax: Svcs: CT Brazoria County Imaging Center, LLC 700 North Front Street, Suite B Angleton, TX Phone: / Fax: , Brazoria County Imaging on Brazos 2760 Brazos Pkwy., Suite B Angleton, TX Phone: / Fax: , Lake Jackson Lake Jackson Imaging Center, L.P. 217 Oak Drive South, Suite A Lake Jackson, TX Phone: / Fax: , Pearland Pearland MRI Pearland and Imaging Center , Broadway Street, Suite 109 Pearland, TX Phone: / Fax: CHAMBERS COUNTY Anahuac Bayside Community Hospital & Clinic , Bayside Community Hospital 200 Hospital Drive Anahuac, TX Phone: FORT BEND COUNTY Sugar Land Fort Bend Imaging, Inc , Southwest Frwy. Phone: / Fax: , OMR, CNM, CT, PET Global Imaging, LP Hwy. 6 South, Suite B Phone: / Fax: , PET Imaging of Sugar Land West Grand Pkwy. South, Suite A Sugar Land, TX Phone: / Fax: Svcs: CT, PET , Upright MRI of Sugar Land, LLP 2655 Cordes Drive, Suite 150 Sugar Land, TX Phone: / Fax: , GALVESTON COUNTY Dickinson Fairmont Diagnostic Center & Open MRI , FM 646 West Dickinson, TX Phone: / Fax: Texas City A1 Imaging of Texas City 9300 East Emmett Lowery Expwy., Suite 148 Texas City, TX Phone: / Fax: , HARRIS COUNTY Baytown Baytown Imaging and Diagnostic Center , A Garth Road Baytown, TX Phone: / Fax: Jacinto MRI and Diagnostic Center 2800 Garth Road Baytown, TX Phone: , CNM, CT , Pars MRI, P.A West Baker Road, Suite 101 Baytown, TX Phone: / Fax: , Bellaire Nuclear Imaging of Texas Nuclear Imaging of Texas 5420 West Loop South, Suite 1700 Bellaire, TX Svcs: CNM , Houston A1 Imaging of Houston Northwest Frwy. Houston, TX Phone: / Fax: , Advanced Diagnostic 8305 Knight Road Phone: / Fax: , CNM, CT , Bellaire Diagnostic Imaging, LLC 9440 Bellaire Blvd., Suite 100 Houston, TX Phone: / Fax: , OMR, CNM, CT , Champions MRI and Diagnostic Center Walters Road, Suite A Houston, TX Phone: / Fax: , Cypress-Fairbanks Medical Center Steepletop Drive Phone: , CNM, CT, PET , Clarus Imaging Center , Clairus Imaging Center 9901 Town Park Drive Houston, TX Phone: / Fax: Diagnostic MRI West Sam Houston Pkwy., Suite 150 Houston, TX Phone: / Fax: , Diagnostic MRI Central 2256 West Holcombe Blvd. Phone: / Fax: , Diagnostic Radiology of Houston , Gessner Drive, Suite 150 Houston, TX Phone: / Fax: , OMR , East Sam Houston Pkwy. North Houston, TX Phone: / Fax: MR - Closed MRI OMR - Open MRI CNM - Cardio Nuclear Medicine CT - CAT Scan PET - Positron Emission Tomography 1 of 4

2 Aetna "Select Provider" Listing - High-Tech Radiology East Side Imaging, Inc East Frwy. Houston, TX Phone: / Fax: , CNM, CT, PET , Excel Diagnostics, LTD 9701 Richmond Avenue, Suite 122 Houston, TX Svcs: CNM, PET , Gulf Coast MRI and Diagnostics 1051 Pineloch Drive, Suite 175 Houston, TX Phone: , CNM, CT, PET , Heights Diagnostic Imaging Center, Inc 427 West 20th Street, Suite 401 Houston, TX Phone: / Fax: , Houston Medical Imaging , Audley Street Houston, TX Phone: / Fax: , CNM, CT, PET , Richmond Avenue Houston, TX Phone: / Fax: , OMR, CNM, CT, PET , Katy Freeway, Suite 100 Phone: / Fax: , CNM, CT, PET Houston MRI & Diagnostic Center Gulf Frwy. Houston, TX Phone: / Fax: , Houston Northwest Medical Center 710 FM 1960 West Phone: , CNM, CT, PET , I. Imaging, P.A , FM 1960 West, Suite 108 Phone: / Fax: Main Imaging Center, Inc South Main Street, Suite B5 Phone: / Fax: , Memorial MRI and Diagnostic, LLC , Campbell Road Phone: / Fax: , CNM, CT , Campbell Road Phone: / Fax: , CNM, CT MRI Central Houston 3301 South Shepherd Drive Houston, TX Phone: / Fax: , Normandy MRI & Diagnostic Center East Frwy. Houston, TX Phone: / Fax: , North Houston Xray, Inc. 411 West Parker Road, Suite A Houston, TX Phone: / Fax: , NWDC Diagnostic Imaging 1140 Cypress Station Drive Phone: / Fax: , CNM, CT , One Step Diagnostic II Inc Fannin Street, Suite 102 Phone: / Fax: , One Step Diagnostic, Inc Red Oak Drive, Suite 100 Phone: / Fax: , OMR, CNM, CT , Park Plaza Hospital and Medical Center , Hermann Drive Houston, TX Phone: , CNM, CT, PET PET Imaging of Houston LLC , , South Braeswood Blvd., Suite A Phone: / Fax: Svcs: PET PET Imaging of Willowbrook Hargrave Road, Suite 130 Houston, TX Phone: / Fax: Svcs: CT, PET , Rice Nuclear Diagnostics, LP 1414 South Loop West, Suite 120 Phone: / Fax: , PET , Scarsdale Imaging, Inc Scarsdale Blvd., Suite A Houston, TX Phone: / Fax: , South Loop MRI, LP , South Loop West, Suite 170A Phone: / Fax: , Steeplechase Diagnostic, Inc Jones Road, Suite 150 Phone: / Fax: , OMR, CNM, CT, PET , Town & Country Open MRI Katy Frwy. Houston, TX Phone: / Fax: , OMR , Unicare MRI & Diagnostic Center, LLC 7007 North Frwy., Suite 110 Houston, TX Phone: / Fax: , Westchase Imaging, LTD 9701 Richmond Avenue, Suite 124 Houston, TX , Woodlake Imaging, L.L.C Gessner Drive, Suite 100 Phone: / Fax: , Humble Deerbrook Diagnostic Imaging Center, 8901 FM 1960 Bypass Road West, Suite 104 Humble, TX Phone: / Fax: Humble MRI and Diagnostic Center Hwy. 59, Suite 100 Humble, TX Phone: / Fax: , MR - Closed MRI OMR - Open MRI CNM - Cardio Nuclear Medicine CT - CAT Scan PET - Positron Emission Tomography 2 of 4

3 Aetna "Select Provider" Listing - High-Tech Radiology Katy Katy Open MRI 954 South Fry Road Katy, TX Phone: / Fax: , OMR, CNM, CT, PET , Nassau Bay Upright MRI of Clear Lake, LLC 1202 Nasa Pkwy. Nassau Bay, TX Phone: / Fax: , Pasadena Gulf Coast MRI and Diagnostics 5233 Fairmont Pkwy., Suite A Pasadena, TX Phone: / Fax: , OMR, CNM, CT, PET , Spring 2920 Open MRI & Digital Imaging, L.P FM 2920, Suite 170 Spring, TX Phone: / Fax: , Webster Lakeside Open MRI and Diagnostic Center , Hwy. 3 Webster, TX Phone: / Fax: Pulse Imaging, Inc. 202 Texas Avenue, Suite 500 Webster, TX Phone: / Fax: , JEFFERSON COUNTY Beaumont Beaumont MRI, Inc , College Avenue Phone: / Fax: Diagnostic Health Beaumont 3220 Medical Center Drive Phone: / Fax: , OMR, CNM, CT, PET , HealthSouth Imaging of Beaumont Joint Venture , Medical Center Drive, Suite 100 Center , Phone: / Fax: The MRI Center, L.L.C Dowlen Road Beaumont, TX Phone: / Fax: , Port Arthur Diagnostic Health Port Arthur 3445 Regional Drive Port Arthur, TX Phone: / Fax: , Gulf Coast Open MRI Unit, Ltd Memorial Blvd. Port Arthur, TX Phone: / Fax: , LIBERTY COUNTY Liberty Liberty Dayton Regional Medical Center , North Travis Street Liberty, TX Phone: / Fax: MATAGORDA COUNTY Palacios Palacios Community Medical Center , Green Avenue Palacios, TX Phone: Svcs: CT MONTGOMERY COUNTY Conroe Aurum Diagnostic Imaging, LLP , River Pointe Drive, Suite 180 Phone: / Fax: Conroe MRI - Diagnostic LTD 200 River Pointe Drive, Suite 130 Phone: / Fax: , OMR , Spring The Woodlands Open MRI and Imaging 4800 West Panther Creek Drive, Suite 150 Spring, TX Phone: The Woodlands I. Imaging, P.A , , Six Pines Drive, Suite 190 The Woodlands, TX Phone: / Fax: PET Imaging of The Woodlands 3091 College Park Drive, Suite 340 The Woodlands, TX Phone: / Fax: Svcs: PET , Woodstead MRI, Inc Woodstead Court, Suite 100 The Woodlands, TX Phone: / Fax: , WHARTON COUNTY El Campo El Campo Memorial Hospital , Sandy Corner Road El Campo, TX Phone: , CNM, CT, PET Wharton Open MRI of Wharton 1307 Hospital Drive Wharton, TX Phone: / Fax: , OMR , Note(s): These procedures may require preauthorization. Aetna's radiology management vendors may have more current information that will replace the information contained within this List. MR - Closed MRI OMR - Open MRI CNM - Cardio Nuclear Medicine CT - CAT Scan PET - Positron Emission Tomography 3 of 4

4 Aetna "Select Provider" Listing - High-Tech Radiology Effective January 1, 2012, Aetna requires all providers administering high-tech radiology services to be accredited by the American College of Radiology and/or the Intersocietal Accreditation Commission. Any provider who performs these services but is not accredited at the time of service may not be eligible for payment. Aetna s radiology management vendors will offer alternative accredited providers in accordance with these standards. MR - Closed MRI OMR - Open MRI CNM - Cardio Nuclear Medicine CT - CAT Scan PET - Positron Emission Tomography 4 of 4

5 Aetna "Select Provider" Listing - Low-Tech Radiology TEXAS BRAZORIA COUNTY Angleton Brazoria County CT, Inc , Brazos Pkwy., Suite C Angleton, TX Phone: / Fax: Svcs: X Lake Jackson Lake Jackson Imaging Center, L.P. 217 Oak Drive South, Suite A Lake Jackson, TX Phone: / Fax: , Pearland Pearland MRI Pearland and Imaging Center , Broadway Street, Suite 109 Pearland, TX Phone: / Fax: Sound Choices, LLC 3901 East Pear Street Pearland, TX Phone: / Fax: Svcs: US , CHAMBERS COUNTY Winnie Winnie Community Hospital , Broadway Avenue Winnie, TX Phone: / Fax: Svcs: X FORT BEND COUNTY Sugar Land Fort Bend Imaging, Inc , Southwest Frwy. Phone: / Fax: , S, M Global Imaging, LP Hwy. 6 South, Suite B Phone: / Fax: , M , Mammography and Ultrasound Specialists , Hwy. 6, Suite 700 Phone: , M GALVESTON COUNTY Dickinson Fairmont Diagnostic Center & Open MRI , FM 646 West Dickinson, TX Phone: / Fax: HARRIS COUNTY Baytown Baytown Imaging and Diagnostic Center , A Garth Road Baytown, TX Phone: / Fax: Jacinto MRI and Diagnostic Center 2800 Garth Road Baytown, TX Phone: , M , Pars MRI, P.A West Baker Road, Suite 101 Baytown, TX Phone: / Fax: , Bellaire Nuclear Imaging of Texas Nuclear Imaging of Texas 5420 West Loop South, Suite 1700 Bellaire, TX , The Rose Diagnostic Center 5420 West Loop South, Suite 3300 Bellaire, TX Phone: / Fax: , M , Houston Advanced Diagnostic 8305 Knight Road Phone: / Fax: , Bellaire Diagnostic Imaging, LLC 9440 Bellaire Blvd., Suite 100 Houston, TX Phone: / Fax: , BD , Champions MRI and Diagnostic Center Walters Road, Suite A Houston, TX Phone: / Fax: , Cypress-Fairbanks Medical Center Steepletop Drive Phone: , M , Diagnos PET CT Imaging 2000 North Loop West, Suite 100 Houston, TX Phone: / Fax: , Diagnostic MRI West Sam Houston Pkwy., Suite 150 Houston, TX Phone: / Fax: , Diagnostic MRI Central 2256 West Holcombe Blvd. Phone: / Fax: Svcs: X, FL , Diagnostic Radiology of Houston , Gessner Drive, Suite 150 Houston, TX Phone: / Fax: , East Sam Houston Pkwy. North Houston, TX Phone: / Fax: East Side Imaging, Inc East Frwy. Houston, TX Phone: / Fax: , S, M , Excel Diagnostics, LTD 9701 Richmond Avenue, Suite 122 Houston, TX , Gulf Coast MRI and Diagnostics 1051 Pineloch Drive, Suite 175 Houston, TX Phone: , Heights Diagnostic Imaging Center, Inc 427 West 20th Street, Suite 401 Houston, TX Phone: / Fax: , M , Houston Medical Imaging 3303 Audley Street Houston, TX Phone: / Fax: , S, M , X - X-Ray FL - Fluoroscopy US - Ultrasound S - Sonogram BD - Bone Density M - Mammography 1 of 3

6 Aetna "Select Provider" Listing - Low-Tech Radiology , Richmond Avenue Houston, TX Phone: / Fax: , S, BD, M , Katy Freeway, Suite 100 Phone: / Fax: , M Houston MRI & Diagnostic Center Gulf Frwy. Houston, TX Phone: / Fax: , Houston Northwest Medical Center 710 FM 1960 West Phone: , M , I. Imaging, P.A. 837 FM 1960 West, Suite 108 Phone: / Fax: Svcs: X, FL , Main Imaging Center, Inc South Main Street, Suite B5 Phone: / Fax: , Memorial MRI and Diagnostic, LLC , Campbell Road Phone: / Fax: , M , Campbell Road Phone: / Fax: , M MRI Central Houston 3301 South Shepherd Drive Houston, TX Phone: / Fax: Svcs: X, FL , Normandy MRI & Diagnostic Center East Frwy. Houston, TX Phone: / Fax: , North Houston Xray, Inc. 411 West Parker Road, Suite A Houston, TX Phone: / Fax: , NWDC Diagnostic Imaging 1140 Cypress Station Drive Phone: / Fax: , BD , One Step Diagnostic II Inc Fannin Street, Suite 102 Phone: / Fax: , One Step Diagnostic Inc Red Oak Drive, Suite 100 Phone: / Fax: , Park Plaza Hospital and Medical Center 1313 Hermann Drive Houston, TX Phone: , M , Physician Care & Diagnostic Center, LLC , Bellaire Blvd., Suite 134 Houston, TX Phone: / Fax: R.I.T.A. Foundation , Richmond Avenue, Suite 120 Houston, TX Rice Nuclear Diagnostics, LP , South Loop West, Suite 120 Phone: / Fax: Scarsdale Imaging, Inc , Scarsdale Blvd., Suite A Houston, TX Phone: / Fax: Shriners Hospital for Children-Houston TX , Main Street Phone: / Fax: Svcs: X South Loop MRI, LP , , South Loop West, Suite 170A Phone: / Fax: Steeplechase Diagnostic, Inc , Jones Road, Suite 150 Phone: / Fax: , S, M Texas Mobile Health , Glenshannon Drive Houston, TX Phone: The Breast Center , Fannin Street Phone: / Fax: , Fannin Street Phone: , M The Rose Diagnostic Center , North Featherwood Drive, Suite 260 Houston, TX Phone: / Fax: , M Town & Country Open MRI Katy Frwy. Houston, TX Phone: / Fax: Unicare MRI & Diagnostic Center, LLC 7007 North Frwy., Suite 110 Houston, TX Phone: / Fax: , S, M Westchase Imaging, LTD 9701 Richmond Avenue, Suite 124 Houston, TX 77042, M Woman's Imaging Center 7900 Fannin Street Phone: / Fax: , M Woodlake Imaging, L.L.C Gessner Drive, Suite 100 Phone: / Fax: , , , , , Humble Deerbrook Diagnostic Imaging Center, LLC , FM 1960 Bypass Road West, Suite 104 Humble, TX Phone: / Fax: Humble MRI and Diagnostic Center , Hwy. 59, Suite 100 Humble, TX Phone: / Fax: X - X-Ray FL - Fluoroscopy US - Ultrasound S - Sonogram BD - Bone Density M - Mammography 2 of 3

7 Aetna "Select Provider" Listing - Low-Tech Radiology Katy Katy Open MRI 954 South Fry Road Katy, TX Phone: / Fax: , Texas Mobile Health 701 South Fry Road, Suite 105 Katy, TX Phone: , Nassau Bay Upright MRI of Clear Lake, LLC 1202 Nasa Pkwy. Nassau Bay, TX Phone: / Fax: Svcs: X , Pasadena Gulf Coast MRI and Diagnostics 5233 Fairmont Pkwy., Suite A Pasadena, TX Phone: / Fax: , Spring 2920 Open MRI & Digital Imaging, L.P FM 2920, Suite 170 Spring, TX Phone: / Fax: , Webster Lakeside Open MRI and Diagnostic Center , Hwy. 3 Webster, TX Phone: / Fax: , BD Pulse Imaging, Inc. 202 Texas Avenue, Suite 500 Webster, TX Phone: / Fax: , JEFFERSON COUNTY Beaumont Beaumont Bone & Joint Institute , Laurel Street Beaumont, TX Phone: Beaumont MRI, Inc College Avenue Phone: / Fax: , Diagnostic Health Beaumont 3220 Medical Center Drive Phone: / Fax: , M , HealthSouth Imaging of Beaumont Joint Venture , Medical Center Drive, Suite 100 Phone: / Fax: , M The MRI Center, L.L.C Dowlen Road Beaumont, TX Phone: / Fax: Svcs: X, S , Port Arthur Diagnostic Health Port Arthur 3445 Regional Drive Port Arthur, TX Phone: / Fax: , M , Gulf Coast Open MRI Unit, Ltd Memorial Blvd. Port Arthur, TX Phone: / Fax: , BD , LIBERTY COUNTY Cleveland Cleveland Regional Medical Center, L.P , East Crockett Street Cleveland, TX Phone: , M Liberty Liberty Dayton Regional Medical Center 1353 North Travis Street Liberty, TX Phone: / Fax: , MONTGOMERY COUNTY Conroe Aurum Diagnostic Imaging, LLP , River Pointe Drive, Suite 180 Phone: / Fax: Conroe MRI - Diagnostic LTD 200 River Pointe Drive, Suite 130 Phone: / Fax: , M , Spring The Woodlands Open MRI and Imaging Center , West Panther Creek Drive, Suite 150 Spring, TX Phone: The Woodlands I. Imaging, P.A , Six Pines Drive, Suite 190 The Woodlands, TX Phone: / Fax: , Woodstead MRI, Inc Woodstead Court, Suite 100 The Woodlands, TX Phone: / Fax: Svcs: X, FL , X - X-Ray FL - Fluoroscopy US - Ultrasound S - Sonogram BD - Bone Density M - Mammography 3 of 3

8 Aetna "Select Provider" Listing - Ambulatory Surgery TEXAS BRAZORIA COUNTY Angleton Angleton Danbury Medical Center , Hospital Drive Angleton, TX Phone: / Fax: Brazoria County Surgery Center 2760 Brazos Pkwy. Angleton, TX Phone: / Fax: , Lake Jackson Brazosport Eye Institute 103 Parking Way Lake Jackson, TX Phone: / Fax: , Houston VAMC 208 South Oak Drive, Suite 700 Lake Jackson, TX Phone: , The Endoscopy Center 109 Parking Way Street Lake Jackson, TX Phone: / Fax: , Pearland St. Luke's Episcopal Hospital SLC ER Center - Pearland Shadow Creek Pkwy. Pearland, TX Phone: / Fax: , Sweeny Sweeny Community Hospital 305 North McKinney Street Sweeny, TX Phone: , CHAMBERS COUNTY Anahuac Bayside Community Hospital & Clinic , Bayside Community Hospital 200 Hospital Drive Anahuac, TX Phone: Winnie Winnie Community Hospital 538 Broadway Avenue Winnie, TX Phone: / Fax: , COLORADO COUNTY Columbus Columbus Community Hospital , Shult Drive Columbus, TX Phone: / Fax: Eagle Lake Rice Medical Center 600 South Austin Road Eagle Lake, TX Phone: , FORT BEND COUNTY Richmond Houston VAMC , Southwest Frwy., Suite 200 Richmond, TX Phone: Sugar Land St. Luke's Sugar Land Hospital 1317 Lake Pointe Pkwy. Phone: / Fax: , Sugar Land Ambulatory Surgery Cntr - HCA Affiliate , Southwest Frwy., Suite 100 Phone: / Fax: Sugar Land Surgical Hospital 1211 Hwy. 6, Suite 70 Phone: , GALVESTON COUNTY Galveston Houston VAMC , Avenue North Galveston, TX Phone: Shriners Hospital for Children- Galveston TX , Market Street Galveston, TX Phone: / Fax: University of Texas Medical Branch at Galveston , University Blvd. Galveston, TX Phone: GRIMES COUNTY Navasota Grimes St. Joseph Health Center , South Judson Street Navasota, TX Phone: HARRIS COUNTY Houston Advanced Laser Vision & Surgical Institute , Fuqua Street, Suite 250 Houston, TX Phone: / Fax: Bay Area Endoscopy Center, LC 444 FM 1959 Road, Suite B Houston, TX Phone: / Fax: , Baylor College of Medicine Ambulatory Surgery Center , Cambridge Street, BLDG. B, Suite 1 Phone: / Fax: Ben Taub General Hospital 1504 Taub Loop Phone: / Fax: , Caplan Surgery Center 3100 Weslayan Street, Suite 400 Houston, TX Phone: / Fax: , Children's Memorial Hermann Hospital 6411 Fannin Street Phone: , Cypress-Fairbanks Medical Center Steepletop Drive Phone: , Doctors Hospital - Tidwell 510 West Tidwell Road Houston, TX Phone: , East Houston Surgery Center East Frwy., Suite 100 Houston, TX Phone: , Fannin Surgicare - HCA Affiliate 7700 Fannin Street Phone: / Fax: , of 3

9 Aetna "Select Provider" Listing - Ambulatory Surgery Gramercy Outpatient Surgery Center - HCA Affiliate , Gramercy Street Phone: HEA Surgery Center 2855 Gramercy Street, Suite 100 Phone: / Fax: , Heights Surgery Center, Inc. 427 West 20th Street, Suite 102 Houston, TX Phone: / Fax: , Houston Northwest Medical Center 710 FM 1960 West Phone: , Houston VAMC , Preston Street Houston, TX Phone: , Holcombe Blvd. Phone: Lyndon B. Johnson General Hospital 5656 Kelley Street Houston, TX Phone: / Fax: , Mann Cataract Surgery Center 5115 Main Street Houston, TX Phone: / Fax: , MEC Endoscopy, LLC 1233 Campbell Road Phone: / Fax: , Quentin Mease Community Hospital 3601 North MacGregor Way Houston, TX Phone: / Fax: Medical Center Cath Lab , Fannin Street, Suite 333 Texas International Endoscopy Center, Phone: / Fax: L.P , Main Street, Suite 1500 Medical Center Endoscopy, LLP , Fannin Street, Suite 600 Phone: / Fax: Phone: / Fax: The Diagnostic Heart Center of St. Luke's , Park Plaza Hospital and Medical Center , Main Street, Suite Hermann Drive Houston, TX Phone: / Fax: Phone: TOPS Surgical Specialty Hospital , Physicians Endoscopy Center , Red Oak Drive 3030 South Gessner Road, Suite 150 Houston, TX Phone: Phone: / Fax: , SCA Houston Hospital for Specialized Surgery , LaBranch Street Houston, TX Phone: / Fax: Shriners Hospital for Children-Houston TX , Main Street Phone: / Fax: St. Joseph Medical Center 1401 St. Joseph Pkwy. Houston, TX Phone: / Fax: , St. Luke's Episcopal Hospital , SL Diag & Treat Cnter - Kirby Glen 2457 South Braeswood Blvd. Phone: / Fax: , SLC ER Center - Holcombe 2727 West Holcombe Blvd. Phone: / Fax: , SLC ER Center - San Felipe 5749 San Felipe Street Houston, TX Phone: / Fax: , Bertner Street Phone: / Fax: St. Luke's Hospital at The Vintage Chasewood Park Drive Houston, TX Phone: / Fax: , Town Park Surgery 9901 Town Park Drive Houston, TX Phone: / Fax: , United Surgery Center Southeast North Featherwood Drive, Suite 100 Houston, TX Phone: , Woman's Hospital of Texas - HCA Affiliate , Fannin Street Phone: / Fax: Wortham Surgery Center FM 1960 Road West, Suite 118 Phone: / Fax: , Humble Humble Kingwood Endoscopy Center Mckay Drive, Suite 101 Humble, TX Phone: / Fax: , Mann Cataract Surgery Center South Memorial Drive Humble, TX Phone: / Fax: , Pasadena St. Luke's Patients Medical Center 4600 East Sam Houston Pkwy. South Pasadena, TX Phone: / Fax: , Tomball Tomball Regional Hospital Authority 605 Holderrieth Blvd. Tomball, TX Phone: / Fax: , Webster Bay Area Houston Endoscopy Center 1015 Medical Center Blvd., Suite 1200 Webster, TX Phone: / Fax: , Bay Area Surgicare Center - HCA Affiliate , Medical Center Blvd. Webster, TX Phone: / Fax: JEFFERSON COUNTY Beaumont Beaumont Bone & Joint Institute , Laurel Street Beaumont, TX Phone: of 3

10 Aetna "Select Provider" Listing - Ambulatory Surgery Beaumont Surgical Affiliates, LLC 3560 North College Phone: / Fax: , CHRISTUS St. Elizabeth Hospital 2830 Calder Avenue Beaumont, TX Phone: / Fax: , Christus St. Elizabeth Outpatient Surg 3050 Liberty Street Beaumont, TX Phone: / Fax: , Houston VAMC 3420 Veterans Circle Beaumont, TX Phone: , The Endoscopy Center of Southeast Texas, LP , North 14th Street, Suite 200 Beaumont, TX Phone: Groves Renaissance Hospital - Groves th Street Groves, TX Phone: , LIBERTY COUNTY Cleveland Cleveland Regional Medical Center, L.P , East Crockett Street Cleveland, TX Phone: MATAGORDA COUNTY Bay City Matagorda Regional Medical Center , th Street Bay City, TX Phone: MONTGOMERY COUNTY Conroe Conroe Surgery Center , River Pointe Drive, Suite 200 Phone: / Fax: Houston VAMC 800 Riverwood Court Phone: , River Oaks Endoscopy 1501 River Pointe Drive, Suite 260 Phone: / Fax: , Shenandoah Woodlands Endoscopy Center 111 Vision Park Blvd., Suite 160 Shenandoah, TX Phone: / Fax: , The Woodlands St. Luke's Lakeside Hospital, LLC St. Lukes Way The Woodlands, TX Phone: / Fax: , St. Luke's The Woodlands Hospital St. Luke's Way The Woodlands, TX Phone: / Fax: , WHARTON COUNTY El Campo El Campo Memorial Hospital , Sandy Corner Road El Campo, TX Phone: Note(s): Some ambulatory procedures require the physician to notify Aetna prior to performing services (e.g., colonoscopy and other scope procedures). These procedures were not used to determine this listing. 3 of 3

11 TEXAS BRAZORIA COUNTY Pearland Pearland Premier Sleep Study Pearland Premier Sleep Study , Sunrise Blvd., Suite 103 Pearland, TX Phone: / Fax: COLORADO COUNTY Columbus Columbus Community Hospital , Shult Drive Columbus, TX Phone: / Fax: FORT BEND COUNTY Stafford Rest Technologies, Inc , South Kirkwood Road, Suite 200 Stafford, TX Phone: / Fax: HARRIS COUNTY Houston Apnix , Bellaire Blvd., Suite F Phone: / Fax: , Bellaire Blvd., Suite B Phone: / Fax: Conroe Premier Sleep Center Memorial Drive, Suite 1125 Houston, TX Phone: / Fax: , Aetna "Select Provider" Listing - Sleep Studies Cypress-Fairbanks Medical Center Steepletop Drive Phone: , HMS Diagnostics, Inc Fannin Street, Suite 420 Phone: , Houston Northwest Medical Center 710 FM 1960 West Phone: , I Sleep Diagnostics, L.P , FM 1960 West, Suite 100 Phone: / Fax: , Southwest Freeway, Suite 170 Houston, TX Phone: Park Plaza Hospital and Medical Center 1313 Hermann Drive Houston, TX L.P , Phone: Rest Technologies, Inc , Sugar Land 2201 West Holcombe Blvd., Suite 325 Sugar Land Cancer Center , Phone: / Fax: Southwest Frwy. The Houston Sleep Center , Phone: / Fax: San Felipe Street, Suite 550 Houston, TX Sugar Land Premier Sleep Center Sugar Phone: / Fax: Land Premier Sleep Center , Sweetwater Blvd., Suite 210 The Sleep Well Center, Inc , Sugar Land, TX Mitchelldale Street, Suite E16 Phone: / Fax: Houston, TX Phone: / Fax: , Katy The Houston Sleep Center Kingsland Blvd., Suite 101 Katy, TX Phone: / Fax: Pasadena The Sleep Well Center, Inc , Vista Road Baylor College of Medicine - Department Pasadena, TX of Interna l Medicine Phone: / Fax: , South Main Street, Suite A Spring Phone: / Fax: Northwest Premier Sleep Center , , Spring Cypress Road, Suite E Spring, TX Phone: / Fax: JEFFERSON COUNTY Beaumont Elite Sleep Solutions , Eastex Freeway, Suite C Beaumont, TX Phone: / Fax: , Sleep Labs of Texas, Inc. 42 North 11th Street Beaumont, TX Phone: , Nederland Southeast Texas Sleep Diagnostics, LLC 1112 North Hwy. 69, Suite A Nederland, TX Phone: / Fax: , LIBERTY COUNTY Liberty Liberty - Dayton Community Hospital, 1353 North Travis Street Liberty, TX Phone: / Fax: MATAGORDA COUNTY Bay City Matagorda Regional Medical Center , th Street Bay City, TX Phone: MONTGOMERY COUNTY Conroe Conroe Premier Sleep Center , North Loop 336 West, Suite B Phone: / Fax: Montgomery Montgomery Sleep Diagnostic Center, LLC , Hwy. 105 West, Suite 133 Montgomery, TX Phone: / Fax: Shenandoah Woodlands Premiere Sleep Center 114 Vision Park, Suite 100 Shenandoah, TX Phone: / Fax: , of 2

12 Aetna "Select Provider" Listing - Sleep Studies The Woodlands Sleep Diagnostics of Texas, Inc West Panther Creek Drive, Suite 101 The Woodlands, TX Phone: / Fax: , WALKER COUNTY Huntsville Huntsville Sleep Center, LLC , Medical Park Lane, Suite B Huntsville, TX Phone: / Fax: WHARTON COUNTY Wharton Gulf Coast Medical Center , US 59 Road Wharton, TX Phone: of 2