Fee Schedule and Service Costs

Fee Schedule and Service Costs

(Good Faith Estimate)
Federal law requires providers to provide a Good Faith Estimate of costs to the client’s not using insurance benefits. If you are using insurance, the following will not be an accurate reflection of your costs.

The frequency and duration of counseling and psychiatric services will vary by client and cannot be predicted in advance. Often, clients will start at a higher frequency of visit and over time decrease how often they are coming in, but time frames for this will be different based on the individual. There is no requirement for the number of sessions or duration of therapy. Every client is free to choose their own schedule and to discontinue treatment at any time.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Counselor
Private Pay/Out-of-Network cost per session:*
Annual Cost for sessions on a weekly basis (50 Sessions):
Annual Cost for bi-weekly sessions (24 Sessions):Calculation
Annual cost for meeting Monthly (12 Sessions):
The Current Procedural Terminology (CPT) codes for the above services may vary but are generally as follows:
Counseling Sessions code: 90837
Initial Psychiatric Session codes: 99204 & 90936
Follow-up Psychiatric Session codes: 99213 or 99214 & 90833
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