Dental offices should provide uninsured/self-pay patients an estimate of their bill for dental items and services before those items or services are provided. This estimate is not a contract and does not require that you obtain these services at this office. This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service; it may not include additional items that may be recommended for post-treatment care or rehab services. Please note that the estimate is based on information known at the time the estimate was created.

You have the right to receive a Good Faith Estimate for the total expected cost of any dental services upon request or when scheduling services.

Please note: 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.

You can also ask your dental care office for a Good Faith Estimate before you schedule a service. If you do, make sure the dental office gives you a Good Faith Estimate in writing within 3 business days after you ask.

You can dispute the bill if you receive at least $400 more for a single procedure than your Good Faith Estimate amounts, not including any fees from complications/emergencies.

If the charges are higher than the Good Faith Estimate, you may contact K&E Advanced Dentistry at (855) 912-7677 and resolve the issue, or you may 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) of 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 or facility, you will have to pay the higher amount.

Make sure to save a copy or picture of your Good Faith Estimate and the bill.

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