Cost of Care Estimate

To help us provide you with the most accurate price estimate, please be ready to provide as much information as possible about the specific medical services described by your physician. For surgical price estimates, you may be asked to provide us with a specific CPT Procedure code, a five-digit numerical procedure code that can be obtained from your physician. This code will help determine the procedure being performed and the estimated financial responsibility.

No Surprises Act

Call Today!

Learn more by contacting our dedicated estimation phone line.

The information provided is a Good Faith Estimate and does not include any unknown or unexpected costs that may arise during treatment. This estimate will be based on the information you have provided and the most current benefits available from your insurance company. Benefits and eligibility are subject to change and are not a guarantee of payment. Final billed charges may vary for many reasons, among them are the patient’s medical condition, unknown circumstances or complications, final diagnosis and recommended treatment ordered by the physician.

In addition, this estimate does not include any durable medical equipment, anesthesiologist, pathologist, hospital facility charges, laboratory, or radiology fees. Those fees are billed separately by their respective billing companies and are not included in this estimate.

You have a right to dispute (appeal) your bill if it is higher than your Good Faith Estimate.

You may also start a dispute resolution process with the U.S Department of Health and Human Services. If you chose this process, you must pay a $25 fee and start the dispute within 120 calendar days (about 4 months) of the date on the original bill. If the agency reviewing your dispute agrees with you, you will have to pay the Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount on your bill.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-877-696-6775

The estimate is valid for 30 days.

Indiana Urgent Care Facilities

Top 15 most common Urgent Care services:

Code for Service Description of Service Charge Total Units Billed Self Pay No Discount Self pay w/30% Discount IN Medicare and Managed Care Plans Non-government/

In-network

IN Medicaid and Managed Care Plans
87804 DETECT AGENT,IMMUN,DIR OBS,INFLUENZA $26.00 4625 $26.00 $18.20 $0.00 $16.62 $16.32
99213 OFFICE OUTPATIENT VISIT $119.00 3507 $119.00 $83.30 $86.24 $96.74 $51.99
99203 OFFICE OUTPATIENT NEW $173.00 2186 $173.00 $121.10 $105.68 $142.68 $76.71
99214 OFFICE OUTPATIENT VISIT $173.00 2110 $173.00 $121.10 $122.65 $143.16 $76.88
87880 STREP A ASSAY W/OPTIC $26.00 1825 $26.00 $18.20 $0.00 $13.76 $16.32
73630 X-RAY FOOT 3+ VW $46.00 807 $46.00 $32.20 $23.72 $31.90 $16.27
71046 RADIOLOGIC EXAM CHEST 2 VIEWS $50.00 541 $50.00 $35.00 $20.89 $24.85 $13.54
81003 URINALYSIS, AUTO, W/O SCOPE $6.00 532 $6.00 $4.20 $0.00 $2.21 $2.25
99202 OFFICE OUTPATIENT NEW $120.00 511 $120.00 $84.00 $68.46 $99.00 $52.90
S9088 SERVICES PROVIDED IN URGENT $65.00 370 $65.00 $45.50 $0.00 $27.21 $0.00
99051 MEDICAL SERVICES, EVE/WKEND/HOLIDAY $34.00 342 $34.00 $23.80 $0.00 $23.84 $0.00
96372 INJECTION,THERAP/PROPH/DIAGNOST, IM OR SUBCUT $50.00 309 $50.00 $35.00 $13.32 $31.34 $17.61
93000 ELECTROCARDIOGRAM, COMPLETE $40.00 201 $40.00 $28.00 $13.79 $26.66 $11.83
81002 URINALYSIS NONAUTO W/O SCOPE $6.00 134 $6.00 $4.20 $0.00 $3.80 $3.48
94640 PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT $36.00 64 $36.00 $25.20 $12.72 $24.94 $12.80

Special Note to Indiana Patients:

A patient treated at our Indiana locations may at any time ask a health care provider for an estimate of the price the health care providers and health facility will charge for providing a non-emergency medical service. Indiana law requires that the estimate be provided within five business days of the request. Call our dedicated estimation phone line.

Call (859) 344-5555