GOOD FAITH ESTIMATE TABLE OF SERVICES AND FEES
*The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover. This means that the final cost of services may be different than this estimate.
Contact your health plan to find out how much, if any, your plan will pay and how much you may have to pay.
| Provider | Service Code (CPT Code) | Description | Fee for Service (Number of Sessions Will Be Determined as We Progress) |
|---|---|---|---|
| Courtney Hicks, LMFT-S, DBT-LBC | 90791 | Psychotherapy, Intake | $265 |
| 90834 | Psychotherapy, 45 minutes | $200 | |
| 90837 | Psychotherapy, 60 minutes | $265 | |
| 90846 | Family Psychotherapy without patient present, 45 minutes | $200 | |
| 90847 | Family Psychotherapy with patient present, 45 minutes | $200 | |
| n/a | DBT Consultation for Providers, 45 minutes | $200 | |
| Leigh Mann, LMFT | 90791 | Psychotherapy, Intake | $220 |
| 90834 | Psychotherapy, 45 minutes | $165 | |
| 90837 | Psychotherapy, 60 minutes | $220 | |
| 90846 | Family Psychotherapy without patient present, 45 minutes | $165 | |
| 90847 | Family Psychotherapy with patient present, 45 minutes | $165 | |
| Whitney Lee, LMFT | 90791 | Psychotherapy, Intake | $200 |
| 90834 | Psychotherapy, 45 minutes | $150 | |
| 90837 | Psychotherapy, 60 minutes | $200 | |
| 90846 | Family Psychotherapy without patient present, 45 minutes | $150 | |
| 90847 | Family Psychotherapy with patient present, 45 minutes | $150 | |
| Kimberly Berry, LPC | 90834 | Psychotherapy, 45 minutes | $150 |
| 90837 | Psychotherapy, 60 minutes | $200 | |
| 90846 | Family Psychotherapy without patient present, 45 minutes | $150 | |
| 90847 | Family Psychotherapy with patient present, 45 minutes | $150 | |
| Payton Landrum | 90834 | Psychotherapy, 45 minutes | $125 |
| 90837 | Psychotherapy, 60 minutes | $165 | |
| 90846 | Family Psychotherapy without patient present, 45 minutes | $125 | |
| 90847 | Family Psychotherapy with patient present, 45 minutes | $125 | |
| Nancy Davila-Slentz, LPC | 90791 | Psychotherapy, Intake | $215 |
| 90834 | Psychotherapy, 45 minutes | $160 | |
| 90837 | Psychotherapy, 60 minutes | $215 | |
| 90846 | Family Psychotherapy without patient present, 45 minutes | $160 | |
| 90847 | Family Psychotherapy with patient present, 45 minutes | $160 | |
| DBT Groups (Various Providers) | 90853 | Group Therapy (Adult DBT Skills Group) | $75 |
| 90849 | Adolescent Multifamily Skills Group (with one parent present) | $150 | |
| 90849 | Adolescent Multifamily Skills Group (with two parents present) | $225 |
| Total Estimate: | This Good Faith Estimate explains your therapist’s rate for each service provided. *Comprehensive DBT for Adults consists of weekly individual and group sessions. One round of treatment lasts 12 months. *Comprehensive DBT for Adolescents consists of weekly individual and multifamily group sessions, as well as an estimated 5-10 parent sessions and 5-10 family sessions. The exact number of parent and family sessions are not guaranteed and are dependent upon the needs of each client and family. One round of treatment lasts 12 months. *The addition of DBT Prolonged Exposure Protocol for PTSD as formal trauma treatment will add an estimated 16 weeks of 60-minute (rather than 45-minute) sessions. This is not a guarantee, the actual total number of sessions is highly individualized and dependent upon client progress through treatment. *These fees are accurate for the calendar year of 2023 and are subject to change thereafter. *Please note that you pay a set weekly rate to be in the program rather than for individual sessions; your weekly rate will be the total combined cost of individual and group sessions for your assigned provider. Additional weekly sessions can be requested and will be billed at the rate of your assigned provider’s individual session fee. If you opt to cancel your weekly session and your therapist is unable to accommodate a change in schedule, you will still be charged your weekly rate for the program. *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
North Texas DBT Associates/LCL Mental Health Services Practice Information:
ADDRESS: 5600 W. Lovers Ln, Ste 307; Dallas, Texas 75209
CONTACT PERSON: Courtney Hicks, LMFT-Supervisor, DBT-LBC; courtneyh@ntxdbt.com
FEDERAL TAX ID: 83-0556095
GROUP NPI#: 1487105680
Disclaimer
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. 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, federal law allows you to dispute (appeal) the bill.
If you are billed for more than this Good Faith Estimate, you 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.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency 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
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises.
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.
- You can 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.