Good Faith Estimate For Cash Services

Restore Pelvic Health Physical Therapy

1314 Westgate Pkwy Suite 7

Dothan, AL 36303

Phone: (334) 268-5880

Fax: (334) 268-5865

Email: Kelli@restoreptwiregrass.com

Purpose

This Good Faith Estimate is intended to provide you with an estimate of the charges you'll incur at Restore Pelvic Health Physical Therapy. Uninsured and self-pay clients, even if seeking reimbursement from their insurance company, are entitled to Good Faith Estimates as of January 1st, 2022, under the No Surprises Act.

Clinic Fee Structure

Your physical therapy treatment will include an initial evaluation and a combination of treatments that may include manual therapy, exercise, neuromuscular retraining, and more. The total cost of your care will include the initial visit, plus any follow-up visits, and will be paid as you go. Your first session will be an evaluation (along with any treatment provided). Follow-up visits are based on a plan determined at your initial evaluation. The number of visits will vary based on your particular symptoms and goals, which we will discuss during your evaluation. At your request, you can be provided with a superbill for each session that you can submit to your insurance company for reimbursement. We cannot guarantee reimbursement from your insurance company, and you are responsible for seeking reimbursement from your insurance company.

Disclaimer

This Good Faith Estimate shows the costs of items and services that are reasonably expected based on your health care needs. The estimate is based on information known at the time the estimate was created. It 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.

This Good Faith Estimate is not a contract and does not require you to obtain the services or items from the providers or facility identified in it. You have the right to request another Good Faith Estimate at any time during your course of care.

If the actual billed service charges exceed this estimate by $400 or more, then you (the patient) have the right to dispute the bill via the patient-provider dispute resolution process with the U.S. Department of Health and Human Services (HHS). If at any point during your care, you wish to dispute or have questions about a charge, we request that you contact us first so that we may attempt to resolve the matter.

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 $35 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.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059.

EstimatedTotal Cost: (all prices include dry needling and most other modalities, when appropriate)

Evaluation (50-60 minutes):  $150.00

Follow ups 50-60 minutes: (recommended): $135.00 or 30 minutes $75.00

Careplans: Can include ANY treatments performed during that 30 min (except shockwave)

30 min

3 sessions $195 (65 ea)

4 sessions $ 252 (63 ea)

6 sessions $ 360 (60 ea)

1 Hour

3 sessions $375 (125 ea)

4 sessions $ 492 (123 ea)

6 sessions $ 720 ($120 ea)

Prices ONLY when performed during a traditional PT Session with use of insurance

Dry Needling $50/body part/region 

EMTT $25/body part/region

Cold Laser (LLLT). $25/body part/region

Combined EMTT & LLLT. $45/body part/region

SoftWave care plans

Evaluation and credit

Self-pay evaluation: $150. For ED and peripheral neuropathy, the $150 self-pay evaluation is credited toward a purchased care plan. . Insurance-billed evaluation amounts are not credited toward a self-pay care plan as these cannot be waived by law.

Erectile Dysfunction (ED) Treatments

PACKAGES:  No per session rate until after 6 sessions

6 initial sessions:   

Pay in full: $1,200  (200 ea)

2 Payment Plan: $675 × 2= 1,350 total (225/visit)

(ONLY) After 6 initial sessions:

Pay in full: 3 additional sessions) $525 (175 ea)

22 Payment Plan: 270 x 2 = 540    (180/visit)

Per Visit: $185

Maintenance visits: $99

Peripheral Neuropathy: Includes shockwave, EMTT, & LLLT

Neuropathy one extremity
30 min INITIAL 6 visits

Pay in full: $750 (125/visit)

2 Payment plan: 450 × 2 = 900 total (150/visit)

Per Visit: $175

Neuropathy one extremity
30 min second 6 visits (after initial 6)

Pay in Full: 660 (110/visit)

2 Payment Plan: 360 × 2= 720 total (120/visit)

Per Visit: $150

Neuropathy two extremities
60 min INITIAL  6 visits

Pay in Full: $1,200 (200/visit)

2 Payment Plan: $675 × 2= 1,350 total (225/visit)

Per Visit: $250

Neuropathy two extremities
60 min second 6 visits (after initial 6)

Pau in Full: $1,020 (170/visit)

2 Payment Plan: $540 x 2= 1.080 total (180/visit)

Per Visit: $185

*The 185 ED and two-extremity neuropathy rates apply only after the first six visits are completed.

Maintenance: $99 for a 30-minute self-pay visit.

ED may include other treatment as needed. Neuropathy may include EMTT and LLLT as appropriate. The selected course and frequency are documented on the estimate.

Other conditions (anything besides ED & peripheral neuropathy)

Tendinopathies, pain, carpal tunnel, incontinence, pelvic pain, dyspareunia, whiplash, tennis or golfers elbow, TMD, etc

Trial Session $99 (allowed 1 time per lifetime)

*Pricing subject to change

Individual visit

$150; up to 1,500 shocks

$200; up to 2,500 shocks

Additional shocks

$15 per additional 500

$15 per additional 500

30 min visits:

6 visits paid in full: $600 ($100/visit)

6 visits in two payments. $375 × 2 = $750 total ($125/visit)

60 min visits (softwave + other treatments

6 visits Pay in full : $900

2 payment plan: $525 × 2 = $1,050 total ($175/visit)

The 60-minute option is determined by staff and may include EMTT and LLLT and/or other traditional PT treatments.

SoftWave added to an insurance PT visit: $0.10 per shock, $40 minimum, or a purchased care plan. Insurance patient responsibility is separate and added to this cost when applicable.