Good Faith Estimate Table of Services and Fees



Service code (CPT Code)  DescriptionFee for Service (Number of Sessions Will Be Determined as We Progress)
90791Initial Diagnostic Evaluation$220
90834Psychotherapy, 38-52 minutes$140
90837Psychotherapy ≥ 53 minutes (This fee is my hourly rate & used for all prorated calculations as indicated)$185
90839Psychotherapy for a Crisis (30-74 minutes)$190
+90840Psychotherapy for a Crisis (Add on code for each additional 30 mins)$75
90846Family Psychotherapy without Patient Present, 50 minutes$185
90847Family Psychotherapy with Patient Present, 50 minutes$185
90853Group Psychotherapy$100
Case managementLetters, reports, consultations (These are not covered by insurance)Prorated based on the amount of time spent at hourly rate
98966-98968Telephone Assessment & Management  Prorated based on the amount of time spent at hourly rate
98970-98972Online Digital Evaluation & Mgt (Responding to Email & Text Messages)Prorated based on the amount of time spent at hourly rate
Cancelation FeeYour Therapist Requires a 24-Hour Cancelation FeeYou are Responsible for the Fee of the Appointment Missed $145
Production of RecordsWill require 30 days to complete after written authorization$50
Legal FeesSubpoenas, legal consultations, depositions. These will include travel times to and from venues if necessary. $300/hr and can be prorated based on time spent
Total Estimate:This Good Faith Estimate explains your therapist’s rate for each service provided. Your therapist will collaborate with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your diagnosis(es)/presenting clinical concerns.

Please note that Place of Service (in office vs. telemental health) is not delineated above since the charges are identical