Provider / NPIDr. Sarah Kim, MD — NPI 1234567890
Procedure date4/10/2026
Lakewood Family Medicine
3200 Lakewood Blvd
Suite 110, Dallas, TX 75214
billing@lakewoodfm.com
+1 (214) 555-0478
Suite 110, Dallas, TX 75214
billing@lakewoodfm.com
+1 (214) 555-0478
This is a good faith estimate per the No Surprises Act. The actual charges may differ from the amounts listed. You have the right to dispute a bill that exceeds this estimate by $400 or more.
Provider:
Lakewood Family Medicine
3200 Lakewood Blvd
Suite 110, Dallas, TX 75214
Suite 110, Dallas, TX 75214
billing@lakewoodfm.com
+1 (214) 555-0478
+1 (214) 555-0478
Patient
Emily Rodriguez
8901 Swiss Ave
Dallas, TX 75218
Dallas, TX 75218
emily.rodriguez@email.com
| Description | Rate | Qty | Amount | |
|---|---|---|---|---|
| Office visit — new patient | CPT 99203 — Level 3 evaluation and management | 1 | $225.00 | $225.00 |
| Comprehensive metabolic panel | CPT 80053 — Blood work, lab processing | 1 | $95.00 | $95.00 |
| Electrocardiogram (EKG) | CPT 93000 — 12-lead EKG with interpretation | 1 | $150.00 | $150.00 |
Notes & Terms
This Good Faith Estimate is provided in compliance with the No Surprises Act (effective January 1, 2022). This estimate shows the expected charges for scheduled healthcare services. Actual charges may differ if additional services are needed. You have the right to dispute a bill that exceeds this estimate by $400 or more.
Subtotal$470.00
Discount$0.00
Tax$0.00
Estimated Cost$470.00
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