Your Right to a Good Faith Estimate

Under federal law, you have the right to receive a “Good Faith Estimate” (GFE) explaining how much your medical care will cost. This applies if you are uninsured or if you choose to pay out-of-pocket (self-pay).

The GFE is based on the information we know at the time and reflects your expected treatment plan. Actual charges may differ if your care needs change. If this happens, we will provide you with an updated estimate.

If your bill is $400 or more above the estimate, you may dispute the charges through the federal dispute resolution process. For more information, visit www.cms.gov/nosurprises or call 1-800-985-3059.

 

Estimated Costs

1. Tinnitus Treatment (Telehealth)

• Comprehensive Hearing Evaluation with Speech Recognition (CPT 92557) — $150

• Tinnitus Consultation (CPT 99203) — $300

• Estimated Total: $450

2. In-Person Tinnitus Treatment

• Comprehensive Hearing Evaluation with Speech Recognition — $150

• Tinnitus Consultation, New Patient — $300

• Estimated Total: $450

3. In-Person Hearing Test (Adults under 65 without Medicare)

• Comprehensive Hearing Test with Speech Recognition — $150

• Additional follow-up or device-related services may apply.

4. Pediatric Auditory Processing Disorder (APD) Evaluation

• Auditory Processing Evaluation — $1,200

• Additional testing or therapy may be recommended.

Important Notes

• This estimate is not a contract or guarantee of costs.

• Additional services, tests, or treatments may result in charges not listed here.

• You are not required to accept or continue treatment based on this estimate.

• Keep a copy of this Good Faith Estimate for your records.

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