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Date: <br />Treatment <br />Recommendation Therapy <br />Estimated <br />Charge Per <br />Session or <br />Service <br />(No Print) <br />Insurance <br />Allowed <br />Amount <br />(No Print) <br />Expanded <br />Estimated <br />Total <br />Charges <br />Patient Co- <br />pay <br />Patient Co- <br />insurance <br />Estimated Patient <br />Responsibility <br />1 99212 - Office/Outpatient (Established) 15-29 Minutes - Patient $68.00 $68.00 $68.00 <br />1 99213 - Office/Outpatient (Established) 30-44 Minutes - Patient $112.20 $112.20 $112.20 <br />1 97139 - PRP - Platelet Rich Plasma - Patient - 1 Series $800.00 $800.00 $800.00 <br />12 NeoGen - Electrostimulation (unattended) - Patient $118.00 $1,416.00 $1,416.00 <br />12 1010T Pressure Wave Therapy $120.00 $1,440.00 $1,440.00 <br /> Estimated Pat Portion $4,084.40 <br />NeoGen, Pressure Wave, and PRP Treatment Plan Projections for:7/29/2025