If patient has a Medicaid/State Funded insurance plan, they cannot be offered self-pay as another option.

If patient is self pay, please run Simplicity to get the most up to date pricing and use the following verbiage:

"The self-pay fee will be collected at the time of service in the amount of $xxx.xx".

Self Pay Codes:

 Arizona: 

  EXA Insurance Name: Self Pay-AZ  (20962)

 Nevada:

  EXA Insurance Name: Self Pay-NV  (20966)

  Southern California:

  EXA Insurance Name: Self Pay- SoCal (26278)

ONLY TO BE USED AT THE FOLLOWING SITES:

• Beverly Hills/Beverly Hills Olympic

• Carlsbad

• Encinitas

• Irvine

• Laguna Hills

• Redlands

• Riverside

• San Bernardino

• San Vincente

• Santa Ana

• Torrance

  Northern California:

 EXA Insurance Name: Self Pay- NorCal (20968)

ONY TO BE USED AT THE FOLLOWING SITES:

• Daly City

• Los Gatos

• Monterey

• Mountain View

• Redwood

• SFAMI

• SFMRC

• San Rafael

• Santa Clara

  Florida:

  EXA Insurance Name: Self Pay- FL  (20965)

  Colorado:

  EXA Insurance Name: Self Pay- CO  (23348)

 Texas:

  EXA Insurance Name: Self Pay- TX (25197)

  Kentucky:

  EXA Insurance Name: Self Pay- KY  (120037)

  New York:

   EXA Insurance Name: Self Pay- NY  (26557)

  Illinois:

  EXA Insurance Name: Self Pay- IL  (27390)

  Wisconsin:

  EXA Insurance Name: Self Pay- WI  (HCP15546IN)

2025 Self Pay Fee Schedules  

** RATES WILL TAKE EFFECT 1.13.2025**

Self Pay Fee Schedule for AZ, SoCal, NV, FL, KY

Self Pay Fee Schedule for CO

Self Pay Fee Schedule for Midwest

Self Pay Fee Schedule for NY, NorCal

Self Pay Fee Schedule for TX