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: 1/6/25)

CPT

Description Cost

90834

PSYCHOTHERAPY 45 MINUTES

$201.29

90834,N

Psychotherapy 45 Minutes - New Patient

$318.57

90832

psychotherapy, 30 minutes with patient/family member

$239.76

90837

psychotherapy, 60 minutes with patient and or family

$469.53

H0004

Behavioral Health Counseling & Therapy 15Min$55.68

G0470

FQHC Behavioral Health Established Patient

$178.15

9100T

Integrated BH phone visit

$0.00

9200T

PRSS non-billable phone charges

$0.00

920FT

PRSS charges Family Tree

$0.00

90791

initial evaluation intake - Established$314.00

G2025

FQHC telehealth services

$168.72

9100R

INH Referral$0.00

NC

no charge encounter$0.00

NCBH

Behavioral Health No Charge services

$0.00

PCC01

PCC visit

$0.00

EAPCH

EAP patient charge

$0.00

99443

telephonic visit 21-30 minutes$40.00

910FT

Family Tree Grant$0.00

H0003

Alcohol and/or drug screening; laboratory analysis of spec

$0.00

H0031

Mental Health Assessment$103.33

H0032

Activity Therapy 15 minutes

$135.08

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

G0511

CHRONIC CARE MANAGEMENT

$195.36

91000

Integrated BH visit

$0.00

CPT

Description Cost

D0001

Dental Treatment Plan Completed

$0.00

D0220INTRA ORAL PERI 1ST

$37.81

D0140

ORAL EXAM(EMERGENCY/LIMITED)

$112.38

D7210FLAP-DONE OR SECTION $260.92
D0330PANORAMIC FILM

$145.86

D0150ORAL EXAM (COMPLETE)

$118.30

D0120Periodic Oral Exam

$67.03

D1110PROPHYLAXIS ADULT 13-20

$116.30

D0274XRAY BITEWINGS 4 FILMS

$82.30

D1208

topical application of fluoride

$43.39

D1120PROPHYLAXIS 01-12

$80.26

D1206

topical application of fluoride varnish

$65.09

D0230INTRA ORAL PERI EA ADD

$34.03

D0272BITEWINGS2 FILMS

$58.52

D2392RESIN 2 SURFACE POST

$296.57

D1351SEALANTS PER TOOTH

$75.56

D7140EXT TOOTH OR ROOT

$223.17

D2150AMAL 2 SURFACE $179.41
D2391RESIN 1 SURFACE POST $184.81
D4341P SCAL RP/QUAD

$329.59

D2393RESIN 3 SURFACE POST $300.50

D0603

Dental caries assessment high risk

$90.42

D0601

Dental caries assessment low

$90.42

D0180

PERIO CHART

$128.15

CPT

Description Cost
99213OFFICE VISIT EXPANDED

$275.28

99214OFFICE VISIT DETAILED

$391.83

G0467FQHC Visit Established Patient

$178.15

99212OFFICE VISIT FOCUSED

$167.61

83036HGB A1C$82.00
91000Integrated BH visit$0.00
99211,X0Nurse visit only (no chg)$0.00
0241USARS-Cov-2/ Flu/ RSV$142.63
81002URINALYSYS NON-AUTOMATED W/O MICROSCOPY$18.00
G0511CHRONIC CARE MANAGEMENT

$195.36

96160behavior health screening$25.00
MAT01Medical assisted treatment (MAT)$0.00
90471IMMUNIZATION$51.00
99203OFFICE/OUTPATIENT VISIT, NEW, DETAILED

$338.55

NCno charge encounter$0.00
J1100DECADRON 4 MG/per 1ml$15.00

J3301

KENALOG 40 MG/ML

$15.00

J0696

ROCEPHIN 500 mg per mil

$15.00

99202OFFICE/OUTPATIENT VISIT, NEW, EXPANDED PROBLEM$175.00
80305urine drug screen$60.66
9100TIntergrated BH phone visit$0.00
0013AModerna Covid-19 vaccine third dose- Booster$40.00

36415

venipuncture blood draw

$17.03

87880

STREP SCREEN

$40.96

CPT

Description Cost
99213OFFICE VISIT EXPANDED

$275.28

V2100SPHERE, SINGLE VISION, PLANO TO +/- 4.00 PER LENS

$56.35

V2020Frames Slideable

$70.76

92015refraction

$61.05

G0467FQHC Visit Established Patient

$178.15

V2784POLYCARB

$65.00

99214OFFICE VISIT DETAILED

$391.83

1036Fpt screened for tobacco use & identified as tobacco non-user $0.01
V2300SPHERE, TRIFOCAL, PLANO TO +/- 4.00D, PER LENS

$90.63

92014exam comp., established

$378.51

92310contact lens service

$308.58

G9903pt screened for tobacco use/ tobacco non-user $0.01
92340Fitting of Spectacles

$104.34

V2760SCRATCH 1 YR WARRANTY $17.69
V2744Transitions/TINT GRADE

$39.00

99212OFFICE VISIT FOCUSED

$167.61

V2200SPHERE, BIFOCAL PLANO TO +/- 4.00D, PER LENS $59.09
99203OFFICE/OUTPATIENT VISIT, NEW, DETAILED $224.00
92004exam comp, new $304.50
V2750Anti Reflective High $25.40

BSV01

Bundle single vision with frame and lens

$40.00

PREV

Prepayment for Vision Services

$0.00

92134

scanning imaging retina

$122.10

V2520

CONTACT LENS, HYDROPHILIC SPHERICAL, PER LENS

$147.98

92250

photography, fundus w/ interpretation

$143.88

CPT

Description Cost
COPAYCOPAY FOR THE OAKS $4.00

NCOI

NO CHARGE OAKS INTAKE

$0.00

92000

PRSS non-billable charges

$0.00

9200T

PRSS non-billable phone charges

$0.00

H2017psychosocial rehab services per 15 minutes $24.48

H0003

Alcohol and/or drug screening; laboratory analysis of spec

$0.00

H0004Behavioral Health Counseling & Therapy 15Min $55.68
H2015Comprehensive Community Support Services 15min $9.75
H0002BH Screen / Eligibility for Admission $25.00
OFCRASOFFENDER SCREENING ASSESSMENT $117.21
H0001Alcohol and \ drug assessment $5.00
T1012alcohol / substance abuse services skills development $4.50
OFSCRCOFFENDER SCREENING RECORDS CLOSED $13.75
H0031Mental Health Assessment $103.33
H0032Activity Therapy 15min $135.08
OUTRECommunity Outreach thru Oaks $20.00
90834PSYCHOTHERAPY 45 MINUTES $184.37
90832psycotherapy, 30 minutes with patient/family member $160.33
90791initial evaluation intake - Established $314.00
90837psychotherapy, 60 minutes with patient and or family

$469.53

H2011Crisis intervention $50.00
81001URINALYSIS AUTOMATED WITH MICROSCOPY $29.00
87480CANDIDA SPECIES DIRECT PROBE TECHNIQUE $92.00
87491CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECH $162.00

1010

UA COLLECTING

$22.00

H0019

BH Long-Term Residential w/o R&B Per Diem

$95.00

2010

SA INDIVIDUAL COUNSELING

$40.00

2011

SUBSTANCE ABUSE ASSESSMENT

$232.00

NCADI

NO CHARGE 6MO ASI UPDATE

$0.00

NC

no charge encounter

$0.00

REENT

Re-Entry Code

$0.00

CPT

Description Cost
99213OFFICE VISIT EXPANDED

$275.28

99214OFFICE VISIT DETAILED

$391.83

99212OFFICE VISIT FOCUSED

$167.61

G0467FQHC Visit Established Patient

$178.15

G2025FQHC telehealth services

$168.72

80305urine drug screen $60.66
99203OFFICE/OUTPATIENT VISIT, NEW, DETAILED

$338.55

91000

Integrated BH visit

$0.00

83036HGB A1C $82.00
99441telephonic visit 5-10 minutes $15.00
G0071communication technology-based services FQHC $30.00
99215OFFICE VISIT COMPREHENSIVE $376.80
99204OFFICE/OUTPATIENT VISIT, NEW, MOD COMPLEX

$508.38

G0466FQHC Visit New Patient

$239.01

99202OFFICE/OUTPATIENT VISIT, NEW, EXPANDED PROBLEM

$218.67

G0511CHRONIC CARE MANAGEMENT

$195.36

84146PROLACTIN LEVEL $167.00
99442telephonic visit 11-20 minutes $30.00
81025URINE PREGNANCY TEST $56.00
80061-90LIPID PANEL $91.00
84443-90TSH $110.00

96372

Injection Administration

$49.31

36415

venipuncture blood draw

$17.03

85025

CBC

$46.02

MAT01

Medical assisted treatment (MAT)

$0.00

99211

OFFICE/OUTPATIENT VISIT, EST, MIN

$0.00

NC

no charge encounter

$0.00

CPT

Description Cost

RHDAY

Recovery Housing Daily Rate

$28.57

RHMEA

Recovery Housing Meal

$3.00

H0019BH Long-Term Residential w/o R&B Per Diem$95.00
H0003Alcohol and/or drug screening;laboratory analysis of spec$0.00

CPT

Description Cost
H0019BH Long-Term Residential w/o R&B Per Diem$95.00
COPAYCOPAY FOR THE OAKS$4.00
H0018BH short-term residential services$400.00
H2034Alcohol/Drug Use Half-Way House Per Diem$63.00
HANDBOAKS HANDBOOK$5.00
H0003Alcohol and/or drug screening;laboratory analysis of spec$0.00
NCOINO CHARGE OAKS INTAKE$0.00
NCno charge encounter$0.00

80305

urine drug screen

$60.66

RHDAY

Recovery Housing Daily Rate

$28.57

99211

OFFICE/OUTPATIENT VISIT, EST, MIN

$66.60

87798

infectious agent detection, each organism amplified probe

$650.00

87661

trichomonas RNA qualitative

$173.69

87591

neisseria gonorrhoeae, amplified probe

$162.00

87563

Genitalium SureSwab

$190.00

87529

herpes simplex virus, amplified probe

$500.00

87511

gardnerella vaginalis, amplified

$130.00

87491

CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECH

$162.00

91000

Integrated BH visit

$0.00

99211

OFFICE/OUTPATIENT VISIT, EST, MIN

$0.00

PRESR

Prepayment for Residential Services

$0.00

REENT

Re-Entry Code

$0.00

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