I'm planning [procedure, CPT code if known] with [surgeon], and I'll be paying as a self-pay patient. Before I schedule, please send me, in writing: (1) one all-inclusive price covering the surgeon, anesthesia, the facility, [implants,] [pathology,] and follow-up visits for [number] days; (2) what the price excludes, and what a complication or an overnight stay would cost; (3) when payment is due, and whether it's refundable if the procedure is cancelled; and (4) the good-faith estimates for each provider that the law requires for self-pay patients. I'm comparing this with [other facility / my plan's allowed amount] before I decide. [Name, phone.]