You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.
Our published rates
Below is the schedule of cash rates for the most common services. A personalized written Good Faith Estimate, including any anticipated ancillary services, will be provided before your first visit.
| Service | CPT | Length | Cash rate |
|---|---|---|---|
Initial evaluation with medical decision-making Comprehensive psychiatric eval including medication review and prescribing decisions | 90792 | 60–90 min | $400 |
Med management — moderate complexity Standard medication management — most common follow-up Most common follow-up | 99214 | 25 min | $250 |
Med management — high complexity Complex medication management with significant clinical decision-making | 99215 | 40 min | $285 |
Med management — low complexity Brief medication management visit | 99213 | 15 min | $200 |
Psychotherapy add-on (30 min) Therapy combined with medication management | 90833 | +30 min | $100 |
Psychotherapy add-on (45 min) | 90836 | +45 min | $135 |
Psychotherapy add-on (60 min) | 90838 | +60 min | $175 |
Extended intake For complex trauma, multi-system cases, or culturally specific intake | Cash service | 90 min | $500 |
Additional service fees
| Service | Fee |
|---|---|
Emotional Support Animal (ESA) letter — established patient | $200 |
Workplace ADA accommodation letter | $250 |
Academic / DSPS accommodation letter | $200 |
FMLA initial certification | $300 |
Long-term disability paperwork | $500 |
Court letter (non-testimony) | $500 |
Controlled medication refill outside scheduled visit | $50 |
Prior authorization (medication) | $75 |
Care coordination (per 10 minutes) First 5 minutes per encounter is free. | $35 |
Brief emotional/behavioral assessment | $25 |
Disclaimer
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs. The estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.
If you are billed for more than this Good Faith Estimate, you may have the right to dispute the bill
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
If you dispute your bill, the provider or facility cannot move the bill for the disputed item or service into collection or threaten to do so. The provider or facility must also suspend the accrual of any late fees on unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility cannot take or threaten to take any retributive action against you for disputing your bill.
There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate, reduced by the $25 fee. If the SDR entity disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059.
Keep a copy of your Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
Texas balance-billing protections
Texas patients are also protected under Tex. Ins. Code §1467 (state balance-billing law). For additional information, see the Texas Department of Insurance: tdi.texas.gov.