Good Faith Estimate for cash payment
Type of Service: Outpatient Physical Therapy
Initial Evaluation:
- 97161 Physical Therapy Evaluation – Low Complexity
- 97162 Physical Therapy Evaluation – Medium Complexity
- 97163 Physical Therapy Evaluation – High Complexity
- 97164 Physical Therapy Re-Evaluation
Type of interventions: Sessions may consist of any combination of the following
- 97032 Electrical Stimulation
- 97035 Ultrasound
- 97110: Therapeutic Exercise
- 97112: Neuromuscular Re-education
- 97116: Gait Training
- 97140: Manual Therapy
- 97530: Therapeutic Activities
- 97535: Self-Care/Home Management Training
Frequency/Duration:
- Up to 3 sessions weekly for up to 90 days
- OR specific frequency/duration on script
- OR number of sessions requested by patient/client
- OR not yet scheduled
Fees: Please contact the physical therapy office at (607)-708-1110 for an estimate that is specific to your situation.
A Good Faith Estimate (GFE) is only an ESTIMATE based on usual, customary, and reasonable charges and the needs of the patient/client at the time of the original GFE. The final charge may differ. However, the final charge cannot be $400.00 or more over the original estimate. If the final charge does exceed $400.00 or more over the original estimate then the patient/client has a right to dispute the final charge with the Department of Health and Human Services within 120 days of the date on the original bill. Choosing to resolve a dispute will not affect quality of care from the provider or prevent care in the future. For more information go to https://www.cms.gov/nosurprises or call 1-800-985-3059.
If the appointment is scheduled 3 business days in advance of the appointment, then the GFE must be presented to the patient/client no later than one business day after the day of scheduling.
If the appointment is scheduled 10 business days in advance of the appointment, then the GFE must be presented to the patient/client no later than three business days after the day of scheduling.
The GFE is not a contract, therefore signing the GFE does not obligate the patient/client to obtain services from the physical therapist. The patient/client is able to decline services prior to payment.
GFE is valid for 12 months from date of signing. There may be services recommended in the future by the physical therapist that are not reflected in the original GFE. Patient/client must be notified of any changes to the original GFE and a new GFE must be issued to reflect the new changes.
Last updated: January 5, 2026