| Procedure Code | Description | Cost per Unit | # of Sessions per Week Unless Otherwise Identified or Units for Non-Sessions | Expected Cost |
|---|---|---|---|---|
| 90791 - GT | Diagnostic Evaluation - virtual | $275 | 1-2 sessions (only once) | $275-$550 |
| 90837 - GT | Treatment with patient 60 minutes - virtual | $225 | 1-2 | $225-$450 |
| 90834 - GT | Treatment with patient 45 minutes - virtual | $200 | 1-2 | $200-$400 |
| 90832 - GT | Treatment with patient 30 minutes - virtual | $175 | 1-2 | $175-$350 |
| Disability Form Completion/Letter Writing | Initial Documentation for Accommodations Requests | $50 per form/letter | 1 | $50 |
| Follow Up Disability Documentation | Any follow-up documentation for accommodations requests | $25 per form/letter | 1-2 | $25-$50 |
| Reduced Rate for 90837-GT | Reduced Rate for Uninsured Clients, per Approval of Therapist | $50 | 1-2 | $50-$100 |
| Reduced Rate for 90834-GT | Reduced Rate for Uninsured Clients, per Approval of Therapist | $50 | 1-2 | $50-$100 |
| Reduced Rate for 90832-GT | Reduced Rate for Uninsured Clients, per Approval of Therapist | $50 | 1-2 | $50-$100 |
| No Show | The client did not show for the session. | $100 | 1 | $100 |
| Late Cancellation | The client late canceled the session with less than 24 hours notice | $100 | 1 | $100 |
| Expenses Related to Any Legal Process | including attorneys fees, documentation, travel time, time spent at depositions or trials | $400 per hour | as needed | $400 per hour |
Good Faith Estimate Pursuant to the No Surprises Act
Agency Name: True Self in Progress, P.C.
Agency NPI 2: 140-755-2573
Revision Date: 7/1/26
The fees identified below are estimated to be the maximum out of pocket fees to be incurred for the following services. If you have insurance or other third-party payors or have entered into an agreement with the Practice to deviate from their ordinary out of pocket fees, then, your expected obligations will be less than identified herein.
Disclaimer
This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The estimate is based on the information known to us when we did the estimate.
If you are using insurance or other third-party payor, and you receive service that are deemed by the insurance company or third-party payor to be not reimbursable under your policy, you will be responsible for the payment of any such services as identified hereinabove. 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 contact listed above if billed charges are higher than the Good Faith Estimate. You can request an update to 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 or call CMS at 1-800-985-3059.
This Good Faith Estimate is not a contract.