Fees

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.

ProviderService Code (CPT Code)DescriptionFee for Service (Number of Sessions Will Be Determined as We Progress)
Courtney Hicks,
LMFT-S, DBT-LBC
90791Psychotherapy, Intake$245
90834Psychotherapy,
45 minutes
$185
90837Psychotherapy,
60 minutes
$245
90846Family Psychotherapy without patient present,
45 minutes
$185
90847Family Psychotherapy with patient present,
45 minutes
$185
n/aDBT Consultation for Providers,
45 minutes
$200
Leigh Mann,
LMFT
90791Psychotherapy, Intake$220
90834Psychotherapy,
45 minutes
$165
90837Psychotherapy,
60 minutes
$220
90846Family Psychotherapy without patient present,
45 minutes
$165
90847Family Psychotherapy with patient present,
45 minutes
$165
Nancy Davila,
LPC
90791Psychotherapy, Intake$215
90834Psychotherapy,
45 minutes
$160
90837Psychotherapy,
60 minutes
$215
90846Family Psychotherapy without patient present,
45 minutes
$160
90847Family Psychotherapy with patient present,
45 minutes
$160
Whitney Lee,
LMFT
90791Psychotherapy, Intake$200
90834Psychotherapy,
45 minutes
$150
90837Psychotherapy,
60 minutes
$200
90846Family Psychotherapy without patient present,
45 minutes
$150
90847Family Psychotherapy with patient present,
45 minutes
$150
DBT Groups
(Various Providers)
90853Group Therapy (Adult DBT Skills Group)$75
90849Adolescent Multifamily Skills Group (with one parent present)$150
90849Adolescent 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 or EMDR as formal trauma treatment will add an estimated 16 60-minute sessions. This is not a guarantee, the actual total number sessions is highly individualized and dependent upon client progress through treatment.
*These fees are accurate for the calendar year of 2022 and are subject to change thereafter.
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.