Good Faith Estimate
No Surprises Act Notice for Uninsured and Self-Pay Patients
Under the No Surprises Act, healthcare providers are required to provide uninsured and self-pay patients with a Good Faith Estimate of expected healthcare costs.
This page provides estimated pricing for commonly offered psychiatric and mental health services at Therapy & Mind. Actual treatment recommendations, frequency of care, and total costs may vary based on individual clinical needs.
Provider Information
Practice Name: Therapy & Mind
Provider: David Irias, PMHNP-C
Service Model: Telehealth & Appointment-Based Services
States Served: California & Washington
Email: info@therapyandmind.com
Phone: (213) 860-4491
Estimated Service Fees
| Service | Description | Duration | Estimated Fee |
|---|---|---|---|
| 90791 | ADHD Evaluation | 55 Minutes | $350 |
| 90792 | Psychiatric Diagnostic Evaluation with Medical Services | 60 Minutes | $350 |
| +90785 | Interactive Complexity Add-On | As Needed | $75 |
| 99215 | Follow-Up Visit – Complex Medication Management | 50 Minutes | $325 |
| 99204 | Level 4 New Patient Office Visit | 45 Minutes | $300 |
| 99213 | Medication Management – Low Complexity | 15 Minutes | $150 |
| 99214 | Medication Management – Moderate Complexity | 25 Minutes | $250 |
| +90836 | Psychotherapy Add-On / EMDR | 45 Minutes | $250 |
| 90853 | Group Therapy | 60 Minutes | $100 |
| 96136 | Psychological Testing Administration & Scoring | First 30 Minutes | $150 |
| +96137 | Additional Psychological Testing Time | Additional 30 Minutes | $125 |
| 90887 | Collateral Visit / Interpretation of Results | 50 Minutes | $250 |
| 90889 | Preparation of Psychiatric Report or Clinical Summary | Varies | $250 |
Important Disclosures
- This Good Faith Estimate is not a bill.
- Actual services and costs may vary depending on clinical presentation, treatment needs, session frequency, duration, and medical necessity.
- Additional services, forms, letters, testing, or coordination of care may result in additional charges.
- Payment is generally due at the time services are rendered unless otherwise arranged.
- Therapy & Mind may operate as an out-of-network or self-pay psychiatric practice.
Your Rights Under the No Surprises Act
You have the right to receive a Good Faith Estimate explaining how much your medical and mental health care may cost.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you may dispute the bill.
For more information about your rights under the No Surprises Act, visit:
Phone: 1-800-985-3059
Questions
If you have questions regarding this Good Faith Estimate or would like additional information regarding fees, scheduling, or services, please contact Therapy & Mind directly.
Therapy & Mind
Email: info@therapyandmind.com
Phone: (213) 860-4491