Good Faith Estimate 

A Good Faith Estimate is an estimate of the costs of our dermatology services based on the complexity of your office visit. Until we have seen you in-clinic, we do not know which diagnoses and procedures your skin, hair, or nail problems may require.

Below, we provide a cost estimator tool for the most common types of office visits. This tool uses a sliding scale based on Federal Poverty Guidelines from the Department of Health & Human Services (DHHS) to provide a Good Faith Estimate to qualifying individuals, explained in more depth later.


Using the tool below, select your household size and income level. From there, you will see a Good Faith Estimate for three (3) levels of office visits that correspond to the severity of your problem, the complexity of your care, and the involvement of our providers.

Use Our Estimator

Select Household Size
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Your Estimated Cost
Level 2
Level 3
Level 4
$30.00
New Patient
Level 2
Level 3
Level 4
$20.00
Existing Patient
Level 2
Level 3
Level 4
$40.00
New Patient
Level 2
Level 3
Level 4
$30.00
Existing Patient
Level 2
Level 3
Level 4
$50.00
New Patient
Level 2
Level 3
Level 4
$40.00
Existing Patient
Level 2
Level 3
Level 4
$40.00
New Patient
Level 2
Level 3
Level 4
$30.00
Existing Patient
Level 2
Level 3
Level 4
$50.00
New Patient
Level 2
Level 3
Level 4
$40.00
Existing Patient
Level 2
Level 3
Level 4
$60.00
New Patient
Level 2
Level 3
Level 4
$50.00
Existing Patient
Level 2
Level 3
Level 4
$50.00
New Patient
Level 2
Level 3
Level 4
$40.00
Existing Patient
Level 2
Level 3
Level 4
$60.00
New Patient
Level 2
Level 3
Level 4
$50.00
Existing Patient
Level 2
Level 3
Level 4
$70.00
New Patient
Level 2
Level 3
Level 4
$60.00
Existing Patient
Level 2
Level 3
Level 4
$60.00
New Patient
Level 2
Level 3
Level 4
$50.00
Existing Patient
Level 2
Level 3
Level 4
$70.00
New Patient
Level 2
Level 3
Level 4
$60.00
Existing Patient
Level 2
Level 3
Level 4
$80.00
New Patient
Level 2
Level 3
Level 4
$70.00
Existing Patient
Level 2
Level 3
Level 4
$92.25
New Patient
Level 2
Level 3
Level 4
$71.21
Existing Patient
Level 2
Level 3
Level 4
$137.02
New Patient
Level 2
Level 3
Level 4
$111.77
Existing Patient
Level 2
Level 3
Level 4
$205.64
New Patient
Level 2
Level 3
Level 4
$159.00
Existing Patient
Your office visit level will vary based on the clinical complexity of your needs

What Are Office Visit Levels & What Will My Visit Be?

Your office visit level will vary based on the clinical complexity of your needs
Level 2 Visit
Problems Addressed - One Minor Problem.

Complexity of Care - Minimal Medical Decision Making.

Provider Involvement - The Provider is Only Monitoring.
Level 3 Visit
Problems Addressed - 2 Or More Minor Problems OR 1 Stable & Chronic Problem.

Complexity of Care - Low Medical Decision Making.

Provider Involvement - The Provider is Monitoring, Referral to Outside Specialist, Advisement.
Level 4 Visit
Problems Addressed - 2 Or More Stable & Chronic Problem OR 1 Chronic Problem That Isn’t Stable.

Complexity of Care - Moderate Medical Decision Making.

Provider Involvement - Prescription Management, Surgery, Monitoring, Referral to Outside Specialist, Advisement.

How Skin Cancer & Cosmetic Dermatology Center Determines Your Estimate

Our Good Faith Estimate is based on Payment Groups for patients that decide to participate in the Sliding Scale program AND qualify for it. Payment Groups are based on the number of people in the household and total income, which you can view in the Sliding Scale Prices document below.

Sliding Scale Prices
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*This schedule is based on the Federal Poverty Guidelines from the Department of Health & Human Services (DHHS) and updated annually.



We offer this program to qualifying individuals and may adjust charges to a small fee due at the time of service, based on proven socioeconomic need. Sliding Scale status is valid for one year from the date of application and must be recertified annually on the anniversary date.


To apply, an individual must provide two pieces of information:

    1. Sliding Fee Application – Available upon request from our front desk


    2. Proof of Monthly Household Income* – Provided by the Patient



*Examples of Acceptable Monthly Household Income:
    -  Tax return from the previous year (if self-employed, tax return plus Schedule C)
    -  Most recent check stubs – 4 stubs for weekly pay or 2 stubs for bi-weekly pay
    -  Notarized letter from employer (for odd jobs, etc.)

This information must be provided to the office before an individual may be considered for Sliding Scale program. All paperwork must be turned in at once, and patients are responsible to pay in full on the date of services for all charges incurred until qualified on the Sliding Fee program.

Good Faith Estimate - Disclaimer

This Good Faith Estimate shows the cost of items and services that are reasonably expected for your health care needs.  The estimate is based on information known at the time the estimate was created.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment.  You could be charged more if complications or special circumstances occur.  If this happens, federal law allows you to dispute (appeal) the bill.  If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact the health care provider or practice listed to let them know the billed charges are higher than the Good Faith Estimate.  You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

If you are billed more than $400 above the amount on this Good Faith Estimate, you may also start a dispute resolution process with the U. S. Department of Health and Human Services (HHS).  If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) from the date on the original bill.  There is a $25 fee to use the dispute process.  If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate.  If the agency disagrees with you and agrees with the health care provider, you will have to pay the higher amount.
 

For questions, to learn more or get a form to start the dispute resolution process, go to www.cms.gov/nosurprises.