STEP 1 -- Choose Your Service

Diagnostic Tests (such as blood test or x-ray)

Surgeries, Procedures and Medical Condition (such as knee replacement or pneumonia)

STEP 2 -- Choose Your Insurance

Medicare

All Other Insurance

No Insurance

STEP 3 -- Read Disclaimer and Check Box

The estimated patient cost is based on the information entered. If you have requested an estimate for a surgical procedure, this estimate does not include:

• pre-procedure office visits
• post-procedure office visits
• diagnostic testing

If you have met all or part of your deductible or maximum out-of-pocket expenses, the actual amount you owe may be different.

Note: The estimated cost is not a guarantee of insurance coverage. Please check with your insurance company if you need help understanding your benefits for the service chosen.

I HAVE READ THE DISCLAIMER AND UNDERSTAND THIS IS AN ESTIMATE ONLY. MY ACTUAL BALANCE MAY BE DIFFERENT.

STEP 4 -- Contact Information

First Name:

Daytime Phone:

Additional information that you feel would be beneficial to our customer service group:

STEP 5 -- Click Button To Receive Estimate

Within 48 hours you will receive a call from our Customer Service department giving you an estimated cost.