The rate for uninsured or those who are insured and do not plan on submitting their own claim to insurance are as follows, and are based on the length of time the appointment was booked for, even if the visit ends early. You may also be responsible for fees submitted to your insurance if your insurance does not pay your doctor. Estimate Of What You Could Pay: Review your detailed estimate. Call your health plan. Your plan may have better information about how much you will be asked to pay. You can also ask about what’s covered under your plan and your provider options. Questions about your rights? Call this federal phone number for information and complaints: 1-800-985-3059. You may also visit: www.cms.gov/nosurprises. Prior authorization or other care management limitations: Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage. Understanding your options: You can also get the items or services described in this notice from providers who are in-network with your health plan. For more information please call your health plan for in-network providers. More information about your rights and protections: Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law. More details about your estimate: The amount below is only an estimate; it isn’t an offer or contract for services. This is only an estimate regarding the items or services reasonable expected to be furnished and actual items, services, or charges may differ. It doesn’t include any information about what your health plan may cover. This means that the final cost of services may be different than this estimate. Contact your health plan to find out if your plan will pay any portion of these costs, and how much you may have to pay out-of-pocket. There may be additional items or services the provider recommends as part of the course of care that must be scheduled or requested separately and are not included in the GFE. Cash pay pricing: 99204 Comprehensive 60 min – new patient visit $306.9 99215 Comprehensive 60 min – established patient visit $271.77 99214 Comp, 45 min – established patient visit $202.83 99213 Detailed 30 min – established patient visit $138.54 99212 Expanded 15 min – established patient visit $84.19