Fees:                                                                   

Initial Diagnostic Consultation Exam or Initial Neurobehavioral Status Exam....................................	$225   (CPT 90791 or 96116)
Neuropsychological and/or Psychological Testing...............................................................................	$300  (CPT 96132 or 96133)

      Note: CPT 96138 or 96139 = $75.00 per half hour

A complete neuropsychological evaluation may vary with the client’s condition and referral question(s). A complete battery typically involves a review of all available accident, incident, and/or clinical reports, family history, educational history, school transcripts, job history, work evaluations, medical records, and medical history, a formal clinical diagnostic interview/neurobehavioral status exam, and informal self-report measures, surveys, and questionnaires, the administration of formal tests, scoring and of all tests and measures, professional interpretation of the results, diagnostic formulation, recommendations for referrals, treatment and/or other recommendations, specialized addenda, a formal results and information feedback session for the patient/family, and preparation of an extensive diagnostic report. 

 

Effective April 1, 2023, all fees not covered by an insurance carrier, that is, the difference between the amount charged and the amount paid or allowed by the insurance company, whether in-network or out, is the responsibility of the client. Currently, the Center is in-network with BCBS PPO of IL, Aetna PPO and HMO, and some, but not all therapists are in-network with Cigna.  The estimated cost of a full neuropsychological evaluation is between $2000 and $3000. Payment plans may be requested as needed.

 Fee Schedule:                                                                   

CPT #	Description		Cost
90791	Initial Diagnostic Consultation Exam		$225
96130	Psychological testing evaluation services including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback; first hour		$300
96131 +	Each additional hour		$300
96132	Neuropsychological testing evaluation services including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback; first hour		$300
96133 +	Each additional hour		$300
96136	Psychological/neuropsychological test administration and scoring by clinician; first 30 minutes		$150
96137	Each additional 30 minutes		$150
96138	Psychological/neuropsychological test administration and scoring by diagnostic technician; first 30 minutes		$150
96139	Each additional 30 minutes		$150

      

Attestations of Self-pay Clients:

I understand that if Central DuPage Pastoral Counseling Center does not accept my insurance and/or I have opted to self-pay, I will be responsible for paying the assessment fees according to the fee schedule contained herein. I also agree to provide a credit or debit card to be kept on file for this purpose prior to the beginning of the assessment process. I understand that I will be responsible for payment of at least 50% at the time services are rendered. The remaining 50% will be due at the feedback session and must be paid prior to the release of the final report. Further, I accept all responsibility for any reasonable expenses, including attorney fees and costs, incurred in collecting the same.

Insured Clients - Payment for Services Rendered and Assignment of Benefits

It is understood that I, the undersigned, shall have the primary duty and obligation to pay Central DuPage Pastoral Counseling Center for all services notwithstanding any contractual arrangements which the undersigned may have with any third party (be it an insurance company, employer, union or the like).  As such, Central DuPage Pastoral Counseling Center may, at their discretion, accept the assignment of insurance benefits, but an assignment of benefits will not release the undersigned from responsibility for payment of services that are rendered.  It is further understood that the undersigned accepts all responsibility for any reasonable expenses, including attorney fees and costs, incurred in collecting the same.

I also authorize Central DuPage Pastoral Counseling Center to submit a claim to my insurance carrier, or its intermediaries, for all covered services rendered and authorize and direct my insurance carrier, or its intermediaries, to issue payment directly to Central DuPage Pastoral Counseling Center. I further authorize complete information to my insurance carrier, or its intermediaries, regarding services rendered.

Payment Guarantor - complete only if someone other than the client is responsible for payment

I, the undersigned, unconditionally guarantee to pay for any and all services rendered by Central DuPage Pastoral Counseling Center to the above-named client (guarantors can be spouses, family members, friends, significant others, etc.).