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.

CPTDescription Cost
90834PSYCHOTHERAPY 45 MINUTES $184.37
90837psychotherapy, 60 minutes with patient and or family $252.33
90832psycotherapy, 30 minutes with patient/family member $160.33
G0470FQHC Behavioral Health Established Patient $165.33
H0004Behavioral Health Counseling & Therapy 15Min $55.68
90791initial evaluation intake - Established $314.00
G2025FQHC telehealth services $99.45
99443telephonic visit 21-30 minutes $40.00
H0031Mental Health Assessment $103.33
90834,NPsychotherapy 45 Minutes - New Patient $184.37
98968telephonic mental health 30 minutes $132.35
90839Crisis Intervention 60 Minutes $450.00
G0071communication technology-based services FQHC $30.00
99442telephonic visit 11-20 minutes $30.00
90847COUNSELING FAMILY W/PATIENT $296.00
90853GROUP COUNSELING 1 HOUR $84.00
96113develop/behavioral testing ser-woodcock johnson add'l 30 min $258.82
G0469FQHC Behavioral Health New Patient $221.81
96112develop/behavior testing/ woodcock johnson $150.00
90791,NInitial Evaluation Intake - New Patient $314.00
CPTDescription Cost
D0220INTRA ORAL PERI 1ST $29.56
D0140ORAL EXAM(EMERGENCY/LIMITED $85.77
D7210FLAP-DONE OR SECTION $260.92
D0330PANORAMIC FILM $115.29
D0150ORAL EXAM (COMPLETE) $90.28
D0120Periodic Oral Exam $55.00
D1110PROPHYLAXIS ADULT 13-20 $92.27
D0274XRAY BITEWINGS 4 FILMS $66.51
D1208topical application of flouride $34.86
D1120PROPHYLAXIS 01-12 $63.68
D1206topical applicatiom of flouride varnish $52.29
D0230INTRA ORAL PERI EA ADD $26.60
D0272BITEWINGS2 FILMS $47.29
D2392RESIN 2 SURFACE POST $241.90
D1351SEALANTS PER TOOTH $51.41
D7140EXT TOOTH OR ROOT $165.31
D2150AMAL 2 SURFACE $179.41
D2391RESIN 1 SURFACE POST $184.81
D4341P SCAL RP/QUAD $241.70
D2393RESIN 3 SURFACE POST $300.50
CPTDescription Cost
99213OFFICE VISIT EXPANDED $150.00
99214OFFICE VISIT DETAILED $266.00
G0467FQHC Visit Established Patient $165.33
99212OFFICE VISIT FOCUSED $90.00
83036HGB A1C $82.00
0011AAdm. Sarscov2 100mcg/0.5ml 1st dose $40.00
0012AAdm Sarscov2 100mcg/0.5ml 2nd dose $40.00
81002URINALYSYS NON-AUTOMATED W/O MICROSCOPY $18.00
96160behavior health screening $25.00
G0511CHRONIC CARE MANAGEMENT $126.01
0241USARS-Cov-2/ Flu/ RSV $142.63
99202OFFICE/OUTPATIENT VISIT, NEW, EXPANDED PROBLEM $175.00
90471IMMUNIZATION $51.00
99203OFFICE/OUTPATIENT VISIT, NEW, DETAILED $224.00
J1100DECADRON 4 MG/per 1ml $15.00
90472IMMUNIZATION ADDITIONAL $40.00
81025URINE PREGNANCY TEST $56.00
80305urine drug screen $60.66
J3301KENALOG 200/5ml $15.00
90686flu vaccine .5ml $20.00
CPTDescription Cost
99213OFFICE VISIT EXPANDED $150.00
V2100SPHERE, SINGLE VISION, PLANO TO +/- 4.00 PER LENS $47.97
V2020Frames Slideable $67.20
92015refraction $39.77
G0467FQHC Visit Established Patient $165.33
V2784POLYCARB $47.63
99214OFFICE VISIT DETAILED $266.00
1036Fpt screened for tobacco use & identified as tobacco non-user $0.01
V2300SPHERE, TRIFOCAL, PLANO TO +/- 4.00D, PER LENS $77.17
92014exam comp., established $252.75
92310contact lens service $193.04
G9903pt screened for tobacco use/ tobacco non-user $0.01
92340Fitting of Spectacles $82.43
V2760SCRATCH 1 YR WARRANTY $17.69
V2744Transitions/TINT GRADE $39.00
99212OFFICE VISIT FOCUSED $90.00
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
CPTDescription Cost
COPAYCOPAY FOR THE OAKS $4.00
H2017psychosocial rehab services per 15 minutes $24.48
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 $252.33
H2011Crisis intervention $50.00
81001URINALYSIS AUTOMATED WITH MICROSCOPY $29.00
87480CANDIDA SPECIES DIRECT PROBE TECHNIQUE $92.00
87491CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECH $162.00
CPTDescription Cost
99213OFFICE VISIT EXPANDED $150.00
99214OFFICE VISIT DETAILED $266.00
99212OFFICE VISIT FOCUSED $90.00
G0467FQHC Visit Established Patient $165.33
G2025FQHC telehealth services $99.45
80305urine drug screen $60.66
99203OFFICE/OUTPATIENT VISIT, NEW, DETAILED $224.00
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 $334.50
G0466FQHC Visit New Patient $221.81
99202OFFICE/OUTPATIENT VISIT, NEW, EXPANDED PROBLEM $175.00
G0511CHRONIC CARE MANAGEMENT $126.01
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
CPTDescription Cost
H0019BH Long-Term Residential w/o R&B Per Diem $95.00
COPAYCOPAY FOR THE OAKS $4.00
HANDBOAKS HANDBOOK $5.00
H2034Alcohol/Drug Use Half-Way House Per Diem $63.00
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