Good Faith Estimate Table of Services and Fees

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