Patient Billing Estimate

If you have any questions regarding pricing and would like one of our representatives to provide you with an estimate for testing services, please complete the contact form below. Please note that the estimate is dependent on accurate patient information, and is subject to your specific plan benefits. This complimentary assessment is performed using currently available information and does not guarantee final billing amounts.

The NxGen MDx Team is Here to Assist You

Monday – Friday 8:30am – 7pm (EST)

Patient First Name *

Patient Last Name *

Phone *

Email *

Preferred Method of Contact *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Date of Birth *

Gender *

Insurance Name *

Member ID *

Group ID

Relationship to Patient *

Subscriber Name *

Please input name as it appears on insurance card.

Subscriber Date of Birth *

Medical Claims Mailing Address

I Am Interested In An Estimate For... *

Test Type is required to determine a cost estimate.

Provider State

Provider Name

If available, please provide the diagnosis code(s) submitted with your test order.

Additional Comments