Health & Wellness Center
Costs of Most Common Services

Transparency in Health Care Prices Act

Community health centers offer service to all individuals regardless of insurance status or ability to pay. Qualified patients in households with incomes below 200% of the Federal Poverty Level (FPL) receive discounts on a sliding fee scale. Qualified patients with incomes less than 100% FPL pay a nominal fee. If a patient has insurance, the carrier will be billed. Copays and denied services will be transferred to the guarantor. All patients may apply for the Sliding Fee scale. Below are some of the most common services provided. The costs below represent the cost of services for self-pay patients and do not take into account any coverage from Medicaid, Medicare, or private health insurance. Contact us if you would like help enrolling in health insurance coverage.

(Information Publishing Date: 3/9/26)

Behavioral Health

CPT	Description	Cost
90832	PSYCHOTHERAPY W/PATIENT 30 MINUTES	$239.76
90837	PSYCHOTHERAPY W/PATIENT 60 MINUTES	$469.53
90834	PSYCHOTHERAPY W/PATIENT 45 MINUTES	$201.29
H0004	BEHAVIORAL HEALTH COUNSELING AND THERAPY, PER 15 MINUTES	$55.68
90791	PSYCHIATRIC DIAGNOSTIC EVALUATION	$314.00
G0470	FQHC VISIT, MH ESTAB PT	$192.31
H0031	MH HEALTH ASSESS BY NON-MD	$103.33
90847	FAMILY PSYCHOTHERAPY W/PATIENT PRESENT 50 MINS	$319.68
G2025	DIS SITE TELE SVCS RHC/FQHC	$168.72
90839	PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES	$450.00

Dental

CPT	Description	Cost
D0220	INTRAORAL - PERIAPICAL FIRST RADIOGRAPHIC IMAGE	$37.81
D1110	PROPHYLAXIS - ADULT	$116.30
D0274	BITEWINGS - FOUR RADIOGRAPHIC IMAGES	$82.30
D0120	PERIODIC ORAL EVALUATION ESTABLISHED PATIENT	$67.03
D0330	PANORAMIC RADIOGRAPHIC IMAGE	$145.86
D0140	LIMITED ORAL EVALUATION - PROBLEM FOCUSED	$112.38
D0150	COMP ORAL EVALUATION - NEW/ESTABLISHED PATIENT	$118.30
D1208	TOPICAL APPLICATION OF FLUORIDE	$43.39
D7140	EXTRACTION ERUPTED TOOTH OR EXPOSED ROOT	$223.17
D1120	PROPHYLAXIS - CHILD	$80.26

Medical

CPT	Description	Cost
99213	OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN	$275.28
99214	OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN	$391.83
36416	COLLECTION CAPILLARY BLOOD SPECIMEN	$17.03
83036	HEMOGLOBIN GLYCOSYLATED A1C	$82.00
96372	THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM	$49.31
80305	DRUG TEST PRSMV READ DIRECT OPTICAL OBS PR DATE	$60.66
81003	URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY	$29.00
99212	OFFICE/OUTPATIENT ESTABLISHED SF MDM 10 MIN	$167.61
99203	OFFICE/OUTPATIENT NEW LOW MDM 30 MINUTES	$338.55
90460	IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT VAC/TOX	$56.11

Optical

CPT	Description	Cost
99213	OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN	$275.28
92015	DETERMINATION REFRACTIVE STATE	$61.05
92014	OPH SVCS MEDICAL XM&EVAL COMPRE EST PT 1/>VST	$378.51
V2100	LENS SPHER SINGLE PLANO 4.00	$56.35
V2020	VISION SVCS FRAMES PURCHASES	$90.00
V2784	LENS POLYCARB OR EQUAL	$32.50
V2781	PROGRESSIVE LENS PER LENS	$90.63
V2020	VISION SVCS FRAMES PURCHASES	$0.00
V2744	TINT PHOTOCHROMATIC LENS/ES	$39.00
99212	OFFICE/OUTPATIENT ESTABLISHED SF MDM 10 MIN	$167.61

Outpatient Services

CPT	Description	Cost
99213	OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN	$275.28
87804	IAADIADOO INFLUENZA	$50.32
87880	IAADIADOO STREPTOCOCCUS GROUP A	$40.96
87426	IAAD IA SEVERE AQT RESPIR SYND CORONAVIRUS	$126.25
99203	OFFICE/OUTPATIENT NEW LOW MDM 30 MINUTES	$338.55
99212	OFFICE/OUTPATIENT ESTABLISHED SF MDM 10 MIN	$167.61
99214	OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN	$391.83
81003	URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY	$29.00
96372	THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM	$49.31
87428	IAAD IA SARSCOV & INFLUENZA VIRUS TYPES A&B	$115.23

Psychiatry

CPT	Description	Cost
99213	OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN	$275.28
99214	OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN	$391.83
80305	DRUG TEST PRSMV READ DIRECT OPTICAL OBS PR DATE	$60.66
99212	OFFICE/OUTPATIENT ESTABLISHED SF MDM 10 MIN	$167.61
99203	OFFICE/OUTPATIENT NEW LOW MDM 30 MINUTES	$338.55
99204	OFFICE/OUTPATIENT NEW MODERATE MDM 45 MINUTES	$508.38
G0467	FQHC VISIT, ESTAB PT	$192.31
36416	COLLECTION CAPILLARY BLOOD SPECIMEN	$17.03
83036	HEMOGLOBIN GLYCOSYLATED A1C	$82.00
99215	OFFICE/OUTPATIENT ESTABLISHED HIGH MDM 40 MIN	$548.34

Recovery Housing

CPT	Description	Cost
H0019	LONG-TERM RESIDENTIAL (WHERE STAY IS TYPICALLY LONGER THAN 30 DAYS), NO ROOM AND BOARD, PER DIEM	$160.00
H0019	LONG-TERM RESIDENTIAL (WHERE STAY IS TYPICALLY LONGER THAN 30 DAYS), NO ROOM AND BOARD, PER DIEM	$95.00
80305	DRUG TEST PRSMV READ DIRECT OPTICAL OBS PR DATE	$60.66
H0019	LONG-TERM RESIDENTIAL (WHERE STAY IS TYPICALLY LONGER THAN 30 DAYS), NO ROOM AND BOARD, PER DIEM	$140.00
H0032	MH SVC PLAN DEV BY NON-MD	$0.00
H0019	LONG-TERM RESIDENTIAL (WHERE STAY IS TYPICALLY LONGER THAN 30 DAYS), NO ROOM AND BOARD, PER DIEM	$326.00
96372	THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM	$49.31
TC241	HOUSING	$28.57
90832	PSYCHOTHERAPY W/PATIENT 30 MINUTES	$239.76
90791	PSYCHIATRIC DIAGNOSTIC EVALUATION	$314.00

Residential Services

CPT	Description	Cost
TC241	HOUSING	$28.57
H0019	LONG-TERM RESIDENTIAL (WHERE STAY IS TYPICALLY LONGER THAN 30 DAYS), NO ROOM AND BOARD, PER DIEM	$95.00

COVID Specific

CPT	Description	Cost
99201	OFFICE/OUTPATIENT VISIT, NEW, PROBLEM FOCUSED	$88.00
99202	OFFICE/OUTPATIENT VISIT, NEW, EXPANDED PROBLEM	$163.00
99203	OFFICE/OUTPATIENT VISIT, NEW, DETAILED	$224.00
99204	OFFICE/OUTPATIENT VISIT, NEW, MOD COMPLEX	$334.50
99205	OFFICE/OUTPATIENT VISIT, NEW, HIGH COMPLEX	$433.00
99211	OFFICE/OUTPATIENT VISIT, EST, MIN	$50.00
99212	OFFICE/OUTPATIENT VISIT, EST, FOCUSED	$89.00
99213	OFFICE/OUTPATIENT VISIT, EST, EXPANDED	$150.00
99214	OFFICE/OUTPATIENT VISIT, EST, DETAILED	$248.00
99215	OFFICE VISIT COMPREHENSIVE	$376.80
87635	SARS COV W/COV 2 RNA (COVID19 Test)	$100.00
0241U	SARS-Cov-2/ Flu/ RSV (COVID19 Rapid Test)	$142.63
86769	SARS-CoV2-Antibody IGG Immunology	$100.00
0011A	Adm. Sarscov2 100mcg/0.5ml 1st dose	$40.00
0012A	Adm Sarscov2 100mcg/0.5ml 2nd dose	$40.00
0031A	Adm J&J SARSCOV2 Single Dose	$28.39

We can help you determine whether you qualify for sliding fee scale discounts or if you are eligible for health care coverage to help cover the cost of care.

This document will be updated annually by Stephanie Long and will be displayed on the Health & Wellness Center website.

Please contact 1 (800) 640-9741 or [email protected] with any questions.

The Health & Center offers a sliding fee program for qualified patients. This program is based on a combination of the patients documented income and the federal poverty guidelines.

If a patient has insurance, the carrier will be billed. Copays and denied services will be transferred to the guarantor.

Many insurance plans are waiving copays on COVID19 related visits. Please check with your plan for specifics.
Prices valid as of 4/20/2020.

CPT Code	Description	Cost
99201	OFFICE/OUTPATIENT VISIT, NEW, PROBLEM FOCUSED	$88.00
99202	OFFICE/OUTPATIENT VISIT, NEW, EXPANDED PROBLEM	$163.00
99203	OFFICE/OUTPATIENT VISIT, NEW, DETAILED	$224.00
99204	OFFICE/OUTPATIENT VISIT, NEW, MOD COMPLEX	$334.00
99205	OFFICE/OUTPATIENT VISIT, NEW, HIGH COMPLEX	$443.00
99211	OFFICE/OUTPATIENT VISIT, EST, MIN	$50.00
99212	OFFICE/OUTPATIENT VISIT, EST, FOCUSED	$89.00
99213	OFFICE/OUTPATIENT VISIT, EST, EXPANDED	$150.00
99214	OFFICE/OUTPATIENT VISIT, EST, DETAILED	$248.00
99215	OFFICE VISIT COMPREHENSIVE	$376.00
87635	SARS COV W/COV 2 RNA (COVID19 Test)	$100.00
0241U	SARS-Cov-2/ Flu/ RSV (COVID 19 Rapid Test)	$142.00

CPT	Description	Cost
99201	OFFICE/OUTPATIENT VISIT, NEW, PROBLEM FOCUSED	$88.00
99202	OFFICE/OUTPATIENT VISIT, NEW, EXPANDED PROBLEM	$163.00
99203	OFFICE/OUTPATIENT VISIT, NEW, DETAILED	$224.00
99204	OFFICE/OUTPATIENT VISIT, NEW, MOD COMPLEX	$334.50
99205	OFFICE/OUTPATIENT VISIT, NEW, HIGH COMPLEX	$433.00
99211	OFFICE/OUTPATIENT VISIT, EST, MIN	$50.00
99212	OFFICE/OUTPATIENT VISIT, EST, FOCUSED	$89.00
99213	OFFICE/OUTPATIENT VISIT, EST, EXPANDED	$150.00
99214	OFFICE/OUTPATIENT VISIT, EST, DETAILED	$248.00
99215	OFFICE VISIT COMPREHENSIVE	$376.80
87635	SARS COV W/COV 2 RNA (COVID19 Test)	$100.00
0241U	SARS-Cov-2/ Flu/ RSV (COVID19 Rapid Test)	$142.63
86769	SARS-CoV2-Antibody IGG Immunology	$100.00
0011A	Adm. Sarscov2 100mcg/0.5ml 1st dose	$40.00
0012A	Adm Sarscov2 100mcg/0.5ml 2nd dose	$40.00
0031A	Adm J&J SARSCOV2 Single Dose	$28.39