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: 6/22/23)

Behavioral Health

CPT	Description	Cost
90834	PSYCHOTHERAPY 45 MINUTES	$184.37,
90832	psycotherapy, 30 minutes with patient/family member	$160.33
90837	psychotherapy, 60 minutes with patient and or family	$252.33
H0004	Behavioral Health Counseling & Therapy 15Min	$55.68
G0470	FQHC Behavioral Health Established Patient	$162.86
H0004	Integrated BH visit	$0.00
9100T	Intergrated BH phone visit	$0.00
90791	initial evaluation intake - Established	$314.00
G2025	FQHC telehealth services	$99.45
9100R	INH Referral	$0.00
NC	no charge encounter	$0.00
99443	telephonic visit 21-30 minutes	$40.00
910FT	Family Tree Grant	$0.00
H0031	Mental Health Assessment	$103.33
98968	telephonic mental health 30 minutes	$132.35
910ME	Medicaid expansion code	$0.00
90853	GROUP COUNSELING 1 HOUR	$84.00
91CDP	mental health court diversion	$0.00
G0071	communication technology-based services FQHC	$30.00
91SUP	mental health step up	$0.00

Dental

CPT	Description	Cost
D0220	INTRA ORAL PERI 1ST	$29.56
D0140	ORAL EXAM(EMERGENCY/LIMITED	$85.77
D7210	FLAP-DONE OR SECTION	$260.92
D0330	PANORAMIC FILM	$115.29
D0150	ORAL EXAM (COMPLETE)	$90.28
D0120	Periodic Oral Exam	$55.00
D1110	PROPHYLAXIS ADULT 13-20	$92.27
D0274	XRAY BITEWINGS 4 FILMS	$66.51
D1208	topical application of flouride	$34.86
D1120	PROPHYLAXIS 01-12	$63.68
D1206	topical applicatiom of flouride varnish	$52.29
D0230	INTRA ORAL PERI EA ADD	$26.60
D0272	BITEWINGS2 FILMS	$47.29
D2392	RESIN 2 SURFACE POST	$241.90
D1351	SEALANTS PER TOOTH	$51.41
D7140	EXT TOOTH OR ROOT	$165.31
D2150	AMAL 2 SURFACE	$179.41
D2391	RESIN 1 SURFACE POST	$184.81
D4341	P SCAL RP/QUAD	$241.70
D2393	RESIN 3 SURFACE POST	$300.50

Medical

CPT	Description	Cost
99213	OFFICE VISIT EXPANDED	$150.00
99214	OFFICE VISIT DETAILED	$266.00
G0467	FQHC Visit Established Patient	$162.86
99212	OFFICE VISIT FOCUSED	$90.00
83036	HGB A1C	$82.00
91000	Integrated BH visit	$0.00
99211,X0	Nurse visit only (no chg)	$0.00
0241U	SARS-Cov-2/ Flu/ RSV	$142.63
81002	URINALYSYS NON-AUTOMATED W/O MICROSCOPY	$18.00
G0511	CHRONIC CARE MANAGEMENT	$126.01
96160	behavior health screening	$25.00
MAT01	Medical assisted treatment (MAT)	$0.00
90471	IMMUNIZATION	$51.00
99203	OFFICE/OUTPATIENT VISIT, NEW, DETAILED	$224.00
NC	no charge encounter	$0.00
J1100	DECADRON 4 MG/per 1ml	$15.00
99202	OFFICE/OUTPATIENT VISIT, NEW, EXPANDED PROBLEM	$175.00
80305	urine drug screen	$60.66
9100T	Intergrated BH phone visit	$0.00
0013A	Moderna Covid-19 vaccine third dose- Booster	$40.00

Optical

CPT	Description	Cost
99213	OFFICE VISIT EXPANDED	$150.00
V2100	SPHERE, SINGLE VISION, PLANO TO +/- 4.00 PER LENS	$47.97
V2020	Frames Slideable	$67.20
92015	refraction	$39.77
G0467	FQHC Visit Established Patient	$165.33
V2784	POLYCARB	$47.63
99214	OFFICE VISIT DETAILED	$266.00
1036F	pt screened for tobacco use & identified as tobacco non-user	$0.01
V2300	SPHERE, TRIFOCAL, PLANO TO +/- 4.00D, PER LENS	$77.17
92014	exam comp., established	$252.75
92310	contact lens service	$193.04
G9903	pt screened for tobacco use/ tobacco non-user	$0.01
92340	Fitting of Spectacles	$82.43
V2760	SCRATCH 1 YR WARRANTY	$17.69
V2744	Transitions/TINT GRADE	$39.00
99212	OFFICE VISIT FOCUSED	$90.00
V2200	SPHERE, BIFOCAL PLANO TO +/- 4.00D, PER LENS	$59.09
99203	OFFICE/OUTPATIENT VISIT, NEW, DETAILED	$224.00
92004	exam comp, new	$304.50
V2750	Anti Reflective High	$25.40

Outpatient Services

CPT	Description	Cost
COPAY	COPAY FOR THE OAKS	$4.00
H2017	psychosocial rehab services per 15 minutes	$24.48
H0004	Behavioral Health Counseling & Therapy 15Min	$55.68
H2015	Comprehensive Community Support Services 15min	$9.75
H0002	BH Screen / Eligibility for Admission	$25.00
OFCRAS	OFFENDER SCREENING ASSESSMENT	$117.21
H0001	Alcohol and \ drug assessment	$5.00
T1012	alcohol / substance abuse services skills development	$4.50
OFSCRC	OFFENDER SCREENING RECORDS CLOSED	$13.75
H0031	Mental Health Assessment	$103.33
H0032	Activity Therapy 15min	$135.08
OUTRE	Community Outreach thru Oaks	$20.00
90834	PSYCHOTHERAPY 45 MINUTES	$184.37
90832	psycotherapy, 30 minutes with patient/family member	$160.33
90791	initial evaluation intake - Established	$314.00
90837	psychotherapy, 60 minutes with patient and or family	$252.33
H2011	Crisis intervention	$50.00
81001	URINALYSIS AUTOMATED WITH MICROSCOPY	$29.00
87480	CANDIDA SPECIES DIRECT PROBE TECHNIQUE	$92.00
87491	CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECH	$162.00

Psychiatry

CPT	Description	Cost
99213	OFFICE VISIT EXPANDED	$150.00
99214	OFFICE VISIT DETAILED	$266.00
99212	OFFICE VISIT FOCUSED	$90.00
G0467	FQHC Visit Established Patient	$165.33
G2025	FQHC telehealth services	$99.45
80305	urine drug screen	$60.66
99203	OFFICE/OUTPATIENT VISIT, NEW, DETAILED	$224.00
83036	HGB A1C	$82.00
99441	telephonic visit 5-10 minutes	$15.00
G0071	communication technology-based services FQHC	$30.00
99215	OFFICE VISIT COMPREHENSIVE	$376.80
99204	OFFICE/OUTPATIENT VISIT, NEW, MOD COMPLEX	$334.50
G0466	FQHC Visit New Patient	$221.81
99202	OFFICE/OUTPATIENT VISIT, NEW, EXPANDED PROBLEM	$175.00
G0511	CHRONIC CARE MANAGEMENT	$126.01
84146	PROLACTIN LEVEL	$167.00
99442	telephonic visit 11-20 minutes	$30.00
81025	URINE PREGNANCY TEST	$56.00
80061-90	LIPID PANEL	$91.00
84443-90	TSH	$110.00

Residential Services

CPT	Description	Cost
H0019	BH Long-Term Residential w/o R&B Per Diem	$95.00
COPAY	COPAY FOR THE OAKS	$4.00
H0018	BH short-term residential services	$400.00
H2034	Alcohol/Drug Use Half-Way House Per Diem	$63.00
HANDB	OAKS HANDBOOK	$5.00
H0003	Alcohol and/or drug screening;laboratory analysis of spec	$0.00
NCOI	NO CHARGE OAKS INTAKE	$0.00
NC	no charge encounter	$0.00

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