ADVANCE BENEFICIARY NOTICE (ABN)

In some cases the physician may order specific tests to determine a diagnosis, or detect presymptomatic diseases or treatments. In the case that insurance is not billed, you are responsible for the balance. Be aware that no services will be rendered without your consent.

• Acupuncture

  $50 – $80
• **MRI / MRA

  $350- $450
• **Medicine

  $5 – $15
• **Injection

  $30 – $950
• **Nerve Conduction Study (NCV/EMG)

  $380- $480
• **EEG

  $440

**These prices are subject to change depending upon services rendered and / or units of medication administered.

I have been notified that in my case, my insurance may deny payment of these services listed above due to frequency, type of test performed, medical necessity or documentation. If my insurance denies payment, I agree to be personally and fully responsible for payment.