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Right to Receive a Good Faith Estimate of Expected Charges

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost

Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
    • If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling.
    • If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling.
    • You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
  • If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

 

CPT CPT Description Cash Pay Rate TOS Discount Rate
Office Visit      
99202 Office visit, new patient, level 2 (15-29 Minutes) $69 $55
99203 Office visit, new patient, level 3 (30-44 Minutes) $107 $86
99204 Office visit, new patient, level 4 (45-59 Minutes) $158 $126
99205 Office visit, new patient, level 5 (60-74 Minutes) $209 $167
99211 Office Visit (Non-Physician Nurse Visit) $23 $18
99212 Office visit, established patient, level 2 (10-19 Minutes) $55 $44
99213 Office visit, established patient, level 3 (20-29 Minutes) $88 $70
99214 Office visit, established patient, level 4 (30-39 Minutes) $125 $100
99215 Office visit, established patient, level 5 (40-54 Minutes) $175 $140
Preventitive Visit      
99385 Preventive visits, new patient, ages 18-39 $130 $104
99386 Preventive visits, new patient, ages 40-64 $150 $120
99387 Preventive visits, new patient, ages 65 and over $162 $130
99391 Preventive visits, established patient, ages less than 1 year $99 $79
99395 Preventive visits, established patient, ages 18-39 $117 $94
99396 Preventive visits, established patient, ages 40-64 $125 $100
99397 Preventive visits, established patient, ages 65 and over $134 $107
Common Lab Charges      
36415 Blood Draw (Venipuncture) $3 $2
80061 Blood Test - Lipid Panel $13 $10
80048 Blood Test - Basic Metobolic Panel $8 $6
83036 Hemoglobin A1C $10 $8
Medicare Physicals/Annual Wellness Visits      
G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment. $166 $133
G0438 Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit. $158 $126
G0439 Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit. $124 $99
99497 Advance Care Planning $81 $65

 

The health care price for any given health care service is an estimate. The actual charges for health care services are dependent on the circumstances at the time the service is rendered. Prices may be different between Colorado and Texas locations.

If you are covered by health insurance, you are strongly encouraged to consult with your health insurer to determine accurate information about your financial responsibility for a particular health service provided by a health care provider at this office. If you are not covered by health insurance, you are strongly encouraged to contact our billing office to discuss payment options prior to receiving a health care service from a health care provider at this office since posted health care prices may not reflect the actual amount of your financial responsibility.