Good Faith Estimate Form
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.
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Annual Physical: New Patient
Adult Annual Physical: New Patient | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee Annual Physical | 99387 | 25.00 | 50.56 | 75.84 | 170.64 | 233.84 | 316.00 Comprehensive Metabolic Panel | 10 | 0.00 | 0.21 | 0.31 | 0.70 | 0.96 | 1.30 CBC | 1000 | 0.00 | 0.18 | 0.26 | 0.59 | 0.81 | 1.10 TSH | 808 | 0.00 | 0.24 | 0.36 | 0.81 | 1.11 | 1.50 Lipid Panel | 14 | 0.00 | 0.32 | 0.48 | 1.08 | 1.48 | 2.00 Occult Blood IFA | 2949 | 0.00 | 1.77 | 2.65 | 5.97 | 8.18 | 11.05 Vitamin D - 25-Hydroxy | 915 | 0.00 | 3.68 | 5.52 | 12.42 | 17.02 | 23.00 EKG with Interpretation | 93000 | 10.00 | 14.56 | 21.84 | 49.14 | 67.34 | 91.00 Urinalysis | 81002 | 0.00 | 2.24 | 3.36 | 7.56 | 10.36 | 14.00 Hemoglobin A1C | 317 | 0.00 | 0.42 | 0.63 | 1.43 | 1.95 | 2.64 Total | | 35.00 | 74.17 | 111.26 | 250.34 | 343.06 | 463.59
Annual Physical: Current Patient
Adult Annual Physical: Current Patient | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee Annual Physical | 99397 | 25.00 | 42.24 | 63.36 | 142.56 | 195.36 | 264.00 Comprehensive Metabolic Panel | 10 | 0.00 | 0.21 | 0.31 | 0.70 | 0.96 | 1.30 CBC | 1000 | 0.00 | 0.18 | 0.26 | 0.59 | 0.81 | 1.10 TSH | 808 | 0.00 | 0.24 | 0.36 | 0.81 | 1.11 | 1.50 Lipid Panel | 14 | 0.00 | 0.32 | 0.48 | 1.08 | 1.48 | 2.00 Occult Blood IFA | 2949 | 0.00 | 1.77 | 2.65 | 5.97 | 8.18 | 11.05 Vitamin D - 25-Hydroxy | 915 | 0.00 | 3.68 | 5.52 | 12.42 | 17.02 | 23.00 EKG with Interpretation | 93000 | 10.00 | 14.56 | 21.84 | 49.14 | 67.34 | 91.00 Urinalysis | 81002 | 0.00 | 2.24 | 3.36 | 7.56 | 10.36 | 14.00 Hemoglobin A1C | 317 | 0.00 | 0.42 | 0.63 | 1.43 | 1.95 | 2.64 Total | | 35.00 | 65.85 | 98.78 | 222.26 | 304.58 | 411.59
Adult Sick: New Patient
Adult Sick: New Patient | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee New Patient Sick Visit | 99204 | 25.00 | 55.68 | 83.52 | 187.92 | 257.52 | 348.00 Chest X-Ray | 71046 | 10.00 | 13.60 | 20.40 | 45.90 | 62.90 | 85.00 Comprehensive Metabolic Panel | 10 | 0.00 | 0.21 | 0.31 | 0.70 | 0.96 | 1.30 CBC | 1000 | 0.00 | 0.18 | 0.26 | 0.59 | 0.81 | 1.10 TSH | 808 | 0.00 | 0.24 | 0.36 | 0.81 | 1.11 | 1.50 Lipid Panel | 14 | 0.00 | 0.32 | 0.48 | 1.08 | 1.48 | 2.00 Urine Culture | 1406 | 0.00 | 0.80 | 1.20 | 2.70 | 3.70 | 5.00 Hemoglobin A1C | 317 | 0.00 | 0.42 | 0.63 | 1.43 | 1.95 | 2.64 Microalbumin | 853 | 0.00 | 0.80 | 1.20 | 2.70 | 3.70 | 5.00 Total | | 35.00 | 72.25 | 108.37 | 243.83 | 334.14 | 451.54
Adult Sick: Current Patient
Adult Sick: Current Patient | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee Current Patient Sick Visit | 99214 | 25.00 | 36.64 | 54.96 | 123.66 | 169.46 | 229.00 Chest X-Ray | 71046 | 10.00 | 13.60 | 20.40 | 45.90 | 62.90 | 85.00 Comprehensive Metabolic Panel | 10 | 0.00 | 0.21 | 0.31 | 0.70 | 0.96 | 1.30 CBC | 1000 | 0.00 | 0.18 | 0.26 | 0.59 | 0.81 | 1.10 TSH | 808 | 0.00 | 0.24 | 0.36 | 0.81 | 1.11 | 1.50 Lipid Panel | 14 | 0.00 | 0.32 | 0.48 | 1.08 | 1.48 | 2.00 Hemoglobin A1C | 317 | 0.00 | 0.42 | 0.63 | 1.43 | 1.95 | 2.64 Microalbumin | 853 | 0.00 | 0.80 | 1.20 | 2.70 | 3.70 | 5.00 Total | | 35.00 | 53.21 | 79.81 | 179.57 | 246.08 | 332.54
STD Testing: New Patient
New Patient STD Testing | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee New Patient STD Check Visit | 99204 | 25.00 | 55.68 | 83.52 | 187.92 | 257.52 | 348.00 HIV-1/HIV-2 Single | 1527 | 0.00 | 0.88 | 1.32 | 2.97 | 4.07 | 5.50 RPR | 1520 | 0.00 | 0.24 | 0.36 | 0.81 | 1.11 | 1.50 Chlamydia - DNA Amplified - Urine | 57 | 0.00 | 8.48 | 12.72 | 28.62 | 39.22 | 53.00 HSV Culture | 77 | 0.00 | 3.68 | 5.52 | 12.42 | 17.02 | 23.00 Acute Hepatitis Panel | 15 | 0.00 | 3.20 | 4.80 | 10.80 | 14.80 | 20.00 Total | | 25.00 | 72.16 | 108.24 | 243.54 | 333.74 | 451.00
STD Testing: Current Patient
Current Patient STD Testing | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee Current Patient STD Check Visit | 99214 | 25.00 | 36.64 | 54.96 | 123.66 | 169.46 | 229.00 HIV-1/HIV-2 Single | 1527 | 0.00 | 0.88 | 1.32 | 2.97 | 4.07 | 5.50 RPR | 1520 | 0.00 | 0.24 | 0.36 | 0.81 | 1.11 | 1.50 Chlamydia - DNA Amplified - Urine | 57 | 0.00 | 8.48 | 12.72 | 28.62 | 39.22 | 53.00 HSV Culture | 77 | 0.00 | 3.68 | 5.52 | 12.42 | 17.02 | 23.00 Acute Hepatitis Panel | 15 | 0.00 | 3.20 | 4.80 | 10.80 | 14.80 | 20.00 Total | | 75.00 | 197.44 | 296.16 | 666.36 | 913.16 | 1,234.00
Pediatric Well Child: New Patient
Pediatric Well Child: New | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee New Well Child Check Up | 99384 | 25.00 | 40.00 | 60.00 | 135.00 | 185.00 | 250.00 Initial Immunization Administration | 90471 | 0.00 | 3.36 | 5.04 | 11.34 | 15.54 | 21.00 Immunization Admin. Each Additional | 90472 | 0.00 | 4.48 | 6.72 | 15.12 | 20.72 | 28.00 Lead Screen | 851 | 0.00 | 0.80 | 1.20 | 2.70 | 3.70 | 5.00 Hemoglobin | 85018 | 0.00 | 3.36 | 5.04 | 11.34 | 15.54 | 21.00 Umbilicus Cauterization | 17250 | 25.00 | 32.48 | 48.72 | 109.62 | 150.22 | 203.00 Total | | 50.00 | 84.48 | 126.72 | 285.12 | 390.72 | 528.00
Pediatric Well Child: Current Patient
Pediatric Well Child: Current | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee Current Well Child Check Up | 99394 | 25.00 | 34.56 | 51.84 | 116.64 | 159.84 | 216.00 Initial Immunization Administration | 90471 | 0.00 | 3.36 | 5.04 | 11.34 | 15.54 | 21.00 Immunization Admin. Each Additional | 90472 | 0.00 | 4.48 | 6.72 | 15.12 | 20.72 | 28.00 Lead Screen | 851 | 0.00 | 0.80 | 1.20 | 2.70 | 3.70 | 5.00 Hemoglobin | 85018 | 0.00 | 3.36 | 5.04 | 11.34 | 15.54 | 21.00 Umbilicus Cauterization | 17250 | 25.00 | 32.48 | 48.72 | 109.62 | 150.22 | 203.00 Total | | 50.00 | 79.04 | 118.56 | 266.76 | 365.56 | 494.00
Pediatric Sick Visit: New Patient
Pediatric Sick Visit: New Patient | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee New Sick Visit | 99204 | 25.00 | 55.68 | 83.52 | 187.92 | 257.52 | 348.00 Respiratory Treatment | 94640 | 0.00 | 10.24 | 15.36 | 34.56 | 47.36 | 64.00 Albuterol | J7613 | 0.00 | 1.76 | 2.64 | 5.94 | 8.14 | 11.00 Chest X-Ray | 71046 | 10.00 | 13.60 | 20.40 | 45.90 | 62.90 | 85.00 Rapid Strep | 87880 | 0.00 | 3.04 | 4.56 | 10.26 | 14.06 | 19.00 Rapid Flu | 87804 | 0.00 | 9.44 | 14.16 | 31.86 | 43.66 | 59.00 Urinalysis | 81002 | 0.00 | 2.24 | 3.36 | 7.56 | 10.36 | 14.00 Urine Culture | 1406 | 0.00 | 0.80 | 1.20 | 2.70 | 3.70 | 5.00 Cerumen Removal - Lavage/Irrigation | 69209 | 25.00 | 26.00 | 27.00 | 28.00 | 30.34 | 41.00 Cerumen Removal - Instrumentation | 69210 | 25.00 | 30.00 | 35.00 | 40.00 | 56.24 | 76.00 Total | | 85.00 | 152.80 | 207.20 | 394.70 | 534.28 | 722.00
Pediatric Sick Visit: Current Patient
Pediatric Sick Visit: Current Patient | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee Current Sick Visit | 99214 | 25.00 | 36.64 | 54.96 | 123.66 | 169.46 | 229.00 Respiratory Treatment | 94640 | 0.00 | 10.24 | 15.36 | 34.56 | 47.36 | 64.00 Albuterol | J7613 | 0.00 | 1.76 | 2.64 | 5.94 | 8.14 | 11.00 Chest X-Ray | 71046 | 10.00 | 13.60 | 20.40 | 45.90 | 62.90 | 85.00 Rapid Strep | 87880 | 0.00 | 3.04 | 4.56 | 10.26 | 14.06 | 19.00 Rapid Flu | 87804 | 0.00 | 9.44 | 14.16 | 31.86 | 43.66 | 59.00 Urinalysis | 81002 | 0.00 | 2.24 | 3.36 | 7.56 | 10.36 | 14.00 Urine Culture | 1406 | 0.00 | 0.80 | 1.20 | 2.70 | 3.70 | 5.00 Cerumen Removal - Lavage/Irrigation | 69209 | 25.00 | 26.00 | 27.00 | 28.00 | 30.34 | 41.00 Cerumen Removal - Instrumentation | 69210 | 25.00 | 30.00 | 35.00 | 40.00 | 56.24 | 76.00 Total | | 85.00 | 133.76 | 178.64 | 330.44 | 446.22 | 603.00
Annual Well Woman: New Patient
Annual Well Woman: New Patient | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee New Well Woman Exam | 99386 | 25.00 | 49.76 | 74.64 | 167.94 | 230.14 | 311.00 Pap Smear - Thin Prep + HPV | 75 | 0.00 | 8.16 | 12.24 | 27.54 | 37.74 | 51.00 Comprehensive Metabolic Panel | 10 | 0.00 | 0.21 | 0.31 | 0.70 | 0.96 | 1.30 CBC | 1000 | 0.00 | 0.18 | 0.26 | 0.59 | 0.81 | 1.10 Lipid Panel | 14 | 0.00 | 0.32 | 0.48 | 1.08 | 1.48 | 2.00 TSH | 808 | 0.00 | 0.24 | 0.36 | 0.81 | 1.11 | 1.50 HIV-1/HIV-2 Single | 1527 | 0.00 | 0.88 | 1.32 | 2.97 | 4.07 | 5.50 Chlamydia - DNA Amplified - Urine | 57 | 0.00 | 8.48 | 12.72 | 28.62 | 39.22 | 53.00 Total | | 25.00 | 68.22 | 102.34 | 230.26 | 315.54 | 426.40
Annual Well Woman: Current Patient
Annual Well Woman: Current Patient | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee Current Well Woman Exam | 99396 | 25.00 | 40.80 | 61.20 | 137.70 | 188.70 | 255.00 Pap Smear - Thin Prep + HPV | 75 | 0.00 | 8.16 | 12.24 | 27.54 | 37.74 | 51.00 Comprehensive Metabolic Panel | 10 | 0.00 | 0.21 | 0.31 | 0.70 | 0.96 | 1.30 CBC | 1000 | 0.00 | 0.18 | 0.26 | 0.59 | 0.81 | 1.10 Lipid Panel | 14 | 0.00 | 0.32 | 0.48 | 1.08 | 1.48 | 2.00 TSH | 808 | 0.00 | 0.24 | 0.36 | 0.81 | 1.11 | 1.50 HIV-1/HIV-2 Single | 1527 | 0.00 | 0.88 | 1.32 | 2.97 | 4.07 | 5.50 Chlamydia - DNA Amplified - Urine | 57 | 0.00 | 8.48 | 12.72 | 28.62 | 39.22 | 53.00 Total | | 25.00 | 59.26 | 88.90 | 200.02 | 274.10 | 370.40
Birth Control
Birth Control | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee IUD Insertion | 58300 | 25.00 | 41.28 | 61.92 | 139.32 | 190.92 | 258.00 IUD Cost | J7298 | 325.00 | 325.00 | 325.00 | 325.00 | 325.00 | 325.00 Depo Provera Injection | 96372 | 10.00 | 10.00 | 10.00 | 10.00 | 10.00 | 10.00 Depo Provera Medication | J1050 | - | 4.80 | 7.20 | 16.20 | 22.20 | 30.00 Urine Pregnancy Test | 81025 | 0.00 | 4.32 | 6.48 | 14.58 | 19.98 | 27.00 Beta HCG Blood Test | 823 | 0.00 | 0.48 | 0.72 | 1.62 | 2.22 | 3.00 Total | | 360.00 | 385.88 | 411.32 | 506.72 | 570.32 | 653.00
GYN Procedures
GYN Procedures | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee Colposcopy with Biopsy | 57454 | 25.00 | 73.60 | 110.40 | 248.40 | 340.40 | 460.00 Pathology - One Biopsy | 73 | 0.00 | 6.08 | 9.12 | 20.52 | 28.12 | 38.00 Conization with Scope - LEEP | 57461 | 25.00 | 154.40 | 231.60 | 521.10 | 714.10 | 965.00 Total | | 50.00 | 234.08 | 351.12 | 790.02 | 1,082.62| 1,463.00
Eye Exam: New Patient
Eye Exam: New Patient | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee New Comprehensive Eye Exam | 92004 | 40.00 | 45.00 | 50.00 | 60.00 | 70.00 | 75.00 Refraction | 92015 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 Fundus Photo | 92250 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 Visual Field | 92083 | 10.00 | 20.00 | 25.00 | 35.00 | 40.00 | 50.00 OCT | 92134 | 10.00 | 10.00 | 10.00 | 10.00 | 10.00 | 10.00 Total | | 60.00 | 75.00 | 85.00 | 105.00 | 120.00 | 135.00
Eye Exam: Current Patient
Eye Exam: Current Patient | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee Established Comprehensive Exam | 92014 | 40.00 | 45.00 | 50.00 | 60.00 | 70.00 | 75.00 Refraction | 92015 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 Fundus Photo | 92250 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 Visual Field | 92083 | 10.00 | 20.00 | 25.00 | 35.00 | 40.00 | 50.00 OCT | 92134 | 10.00 | 10.00 | 10.00 | 10.00 | 10.00 | 10.00 Total | | 60.00 | 75.00 | 85.00 | 105.00 | 120.00 | 135.00
Frames and Lenses
Frames and Lenses | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee Basic Frames | V2020 | 20.00 | 25.00 | 30.00 | 35.00 | 39.00 | 44.00 Basic Lenses | V2200 | 35.00 | 40.00 | 45.00 | 50.00 | 55.00 | 60.00 Total | | 55.00 | 65.00 | 75.00 | 85.00 | 94.00 | 104.00
Psychotherapy
Psychotherapy | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee Initial Psych Diagnostic Interview | 90791 | 25.00 | 44.80 | 67.20 | 151.20 | 207.20 | 280.00 Psychotherapy - 45 Min (38-52 Min) | 90834 | 25.00 | 27.04 | 40.56 | 91.26 | 125.06 | 169.00 Total | | 50.00 | 71.84 | 107.76 | 242.46 | 332.26 | 449.00
Psychiatry: Med Management
Psychiatry: Med Management | Code | Slide A | Slide B | Slide C | Slide D | Slide E | Full Fee Psych Eval w/ Med Services | 90792 | 25.00 | 50.56 | 75.84 | 170.64 | 233.84 | 316.00 New Patient | 99204 | 25.00 | 55.68 | 83.52 | 187.92 | 257.52 | 348.00 Current Patient | 99214 | 25.00 | 36.64 | 54.96 | 123.66 | 169.46 | 229.00 EKG with Interpretation | 93000 | 10.00 | 14.56 | 21.84 | 49.14 | 67.34 | 91.00 Lithium Level | 345 | 0.00 | 0.72 | 1.08 | 2.43 | 3.33 | 4.50 Valproic Acid | 714 | 0.00 | 0.88 | 1.32 | 2.97 | 4.07 | 5.50 Total | | 85.00 | 159.04 | 238.56 | 536.76 | 735.56 | 994.00
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Annual Physical: New Patient
Annual Physical: Current Patient
Adult Sick: New Patient
Adult Sick: Current Patient
STD Testing: New Patient
STD Testing: Current Patient
Pediatric Well Child: New Patient
Pediatric Well Child: Current Patient
Pediatric Sick Visit: New Patient
Pediatric Sick Visit: Current Patient
Annual Well Woman: New Patient
Annual Well Woman: Current Patient
Birth Control
GYN Procedures
Eye Exam: New Patient
Eye Exam: Current Patient
Frames and Lenses
Psychotherapy
Psychiatry: Med Management
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