Good Faith Estimate –

For patients who don’t have insurance or who are not using insurance

First visit: exam and if needed x-rays. Estimated cost: $165 – $450* **

Following Visit(s): $55-100**

Primary Service/Item

• New Patient Consultation and Examination – $165-265 **
• X-ray $80-150 **
• Corrective/Wellness Care Visit (includes adjustment) – $55-100**

Additional Items/Services **
Additional Items/Services that may be added with the primary service/item as part of care if patient agrees to the charges.

*The actual fee depends upon the unique clinical finding revealed throughout the examination.
** If any additional items/services that are needed which will be revealed through the examination please add the charges to the total estimated cost.

Disclaimer

This good faith estimate is not a contract and does not require you to obtain the items or services from any of the providers or facilities identified in the good faith estimate. There may be additional items or services that we recommend as part of the course of care that must be scheduled or requested separately and are not reflected in this good faith estimate. The information provided in this good faith estimate is only an estimate of items or services reasonably expected to be furnished at the time this good faith estimate was and actual items, services, or charges may differ from the good faith estimate.

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.

The estimated costs are valid till end of the year. At the beginning of each year, the price is calculated and may be adjusted to account for inflation and expenses.

Your Rights
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost
Under the law, health care providers need to give patients who don’t have insurance or who are not
using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any nonemergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1
  business day before your medical service or item. You can also ask your health care provider,
  and any other provider you choose, for a Good Faith Estimate before you schedule an item or
  service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute
  the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

Version 2023-04-25