Patient Estimates
Disclaimer
I understand this estimate is based on the information provided at the time it was created and the actual amount may be higher or lower. The estimated costs identified above may not include any diagnostic or ancillary services. If additional services are medically necessary beyond the scope outlined in the estimate, I understand that I will be billed for these services. If your actual patient liability amount is less than the amount that appears on this estimate, any overpayment will be applied to existing self-pay balances prior to a refund being issued.