Who is Eligible for a Good Faith Estimate?
What is a good faith estimate?
A Good Faith Estimate explains the expected costs for your care at One Community Health. It is based on what we know when the estimate is created. It does not include charges from other providers or unexpected costs that may come up during your visit.
Under federal law, patients without insurance or not using insurance have the right to receive a written Good Faith Estimate before non-emergency services are scheduled. This estimate shows the total expected cost of your care.
You can ask for a Good Faith Estimate at any time before scheduling. If your final bill is $400 or more above the estimate, you can dispute it. Be sure to keep a copy or photo of your estimate. For questions or more information, visit cms.gov/nosurprises or call 206-615-2010.
If your insurance is helping pay for the cost of care, please contact your insurance company to ask what you will have to pay for your care.
If you are on the OCH Sliding Scale Program, the cost for patients on the sliding scale is between $0 and $35. If you are receiving family planning or root canal services, please contact the clinic directly for an estimate at 541-386-6380. You can learn more HERE.
What is my estimate?
Medical Services
Recently, a federal law was passed requiring medical facilities to provide self-pay patients with an estimate for the cost of services. This is an estimate only and no payment is required at this time. You have scheduled an appointment at One Community Health and our records indicate that you have no insurance. If our records are incorrect, please call us at 541.386.6380 x11598 with your insurance information and we will update our records. For our uninsured patients, we offer an approximate cost for the services you can expect to receive at your healthcare appointment. Due to a wide range of service options, the cost of an office visit at One Community Health varies. Your office visit level will vary depending on the length of your visit and complexity of your care. Please find below the price range of each type of healthcare visit available at OCH.
| Type of Care | Price Range | CPT Code |
|---|---|---|
| Office Visit (Exam Only) | $137 – $536 |
99202 – 99205 55212 – 99215 |
| Acupuncture | $96 – $169 | 97810 – 97811 |
| Adult Preventative (Exam Only) | $285 – $367 | 99385 – 99396 |
There may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate. We look forward to greeting you at your visit to One Community Health. Please do not hesitate to contact us with any questions or concerns at (541)386-6380.
Disclaimers: The information provided in the good faith estimate is only an estimate regarding items or services reasonably expected to be furnished at the time the good faith estimate is issued to the uninsured (or self-pay) individual and that actual items, services, or charges may differ from the good faith estimate. This does not include other providers’ charges, or any other services billed outside of OCH or any unknown or unexpected costs that may arise during your visit.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. The uninsured (or self-pay) individual has the right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in the good faith estimate, as specified in § 149.620; if you receive a bill that is at least $400 more than a Good Faith Estimate, or if you just want to discuss your bill, give us a call at 541-386-6380 and enter extension 11598. We’ll do our best to make things right and share other ways you might be able to save on your healthcare bills. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to an uninsured (or self-pay) individual by a provider or facility. The good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate. For additional information about the No Surprise Act, please visit www.cms.gov/nosurprises.
Well Child Check
Recently, a federal law was passed requiring medical facilities to provide self-pay patients with an estimate for the cost of services. This is an estimate only and no payment is required at this time. You have scheduled an appointment at One Community Health and our records indicate that you have no insurance. If our records are incorrect, please call us at 541.386.6380 x11598 with your insurance information and we will update our records. For our uninsured patients, we offer an approximate cost for the services you can expect to receive at your healthcare appointment. Due to a wide range of service options, the cost of an office visit at One Community Health varies. Your office visit level will vary depending on the length of your visit and complexity of your care. Please find below the price range of each type of healthcare visit available at OCH.
| Type of Care | Price Range | CPT Code |
|---|---|---|
| Well Child Check | $268 – $332 |
99381 – 99384 99391 – 99394 |
| Immunizations (0-17 years old) | $21.96 / Vaccine | 90471 – 90474 |
| Circumcision | $465 | 54150 |
There may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate. We look forward to greeting you at your visit to One Community Health. Please do not hesitate to contact us with any questions or concerns at (541)386-6380.
Disclaimers: The information provided in the good faith estimate is only an estimate regarding items or services reasonably expected to be furnished at the time the good faith estimate is issued to the uninsured (or self-pay) individual and that actual items, services, or charges may differ from the good faith estimate. This does not include other providers’ charges, or any other services billed outside of OCH or any unknown or unexpected costs that may arise during your visit.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. The uninsured (or self-pay) individual has the right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in the good faith estimate, as specified in § 149.620; if you receive a bill that is at least $400 more than a Good Faith Estimate, or if you just want to discuss your bill, give us a call at 541-386-6380 and enter extension 11598. We’ll do our best to make things right and share other ways you might be able to save on your healthcare bills. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to an uninsured (or self-pay) individual by a provider or facility. The good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate. For additional information about the No Surprise Act, please visit www.cms.gov/nosurprises.
Dental Maintenance
Recently, a federal law was passed requiring medical facilities to provide self-pay patients with an estimate for the cost of services. This is an estimate only and no payment is required at this time. You have scheduled an appointment at One Community Health and our records indicate that you have no insurance. If our records are incorrect, please call us at 541.386.6380 x11598 with your insurance information and we will update our records. For our uninsured patients, we offer an approximate cost for the services you can expect to receive at your healthcare appointment. Due to a wide range of service options, the cost of an office visit at One Community Health varies. Your office visit level will vary depending on the length of your visit and complexity of your care. Please find below the price range of each type of healthcare visit available at OCH.
| Type of Care | Price Range | CPT Code |
|---|---|---|
| Exam | $58 – $114 | D0120 – D0180 |
| Imaging | $30 – $180 | D0220 – D0368 |
| Cleaning | $93 – $152 | D1110 – D4910 |
| Fluoride | $41 – $58 | D1206 – D1208 |
| Sealants | $52 – $59 (per tooth) | D1351 – D1354 |
| Space Maintainer | $323 – $432 | D1510 – D1517 |
| Night Guard | $110 | D9945 |
There may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate. We look forward to greeting you at your visit to One Community Health. Please do not hesitate to contact us with any questions or concerns at (541)386-6380.
Disclaimers: The information provided in the good faith estimate is only an estimate regarding items or services reasonably expected to be furnished at the time the good faith estimate is issued to the uninsured (or self-pay) individual and that actual items, services, or charges may differ from the good faith estimate. This does not include other providers’ charges, or any other services billed outside of OCH or any unknown or unexpected costs that may arise during your visit.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. The uninsured (or self-pay) individual has the right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in the good faith estimate, as specified in § 149.620; if you receive a bill that is at least $400 more than a Good Faith Estimate, or if you just want to discuss your bill, give us a call at 541-386-6380 and enter extension 11598. We’ll do our best to make things right and share other ways you might be able to save on your healthcare bills. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to an uninsured (or self-pay) individual by a provider or facility. The good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate. For additional information about the No Surprise Act, please visit www.cms.gov/nosurprises.
Dental Procedures
Recently, a federal law was passed requiring medical facilities to provide self-pay patients with an estimate for the cost of services. This is an estimate only and no payment is required at this time. You have scheduled an appointment at One Community Health and our records indicate that you have no insurance. If our records are incorrect, please call us at 541.386.6380 x11598 with your insurance information and we will update our records. For our uninsured patients, we offer an approximate cost for the services you can expect to receive at your healthcare appointment. Due to a wide range of service options, the cost of an office visit at One Community Health varies. Your office visit level will vary depending on the length of your visit and complexity of your care. Please find below the price range of each type of healthcare visit available at OCH.
| Type of Care | Price Range | CPT Code |
|---|---|---|
| Amalgam Fillings | $146 – $258 (per tooth) | D2140 – D2161 |
| Composite Fillings | $142 – $306 (per tooth) | D2330 – D2394 |
| Extractions | $150 – $473 (per tooth) | D7140 – D7240 |
| Scaling and Root Planing | $180 – $306 (per quadrant) | D4341 – D4346 |
| Emergency* | $92 – $937 | D0140, D0220 – D0364 |
* Cost includes initial exam and imaging. Additional treatment recommended by the provider as a result of this exam may not be included in this estimate.
There may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate. We look forward to greeting you at your visit to One Community Health. Please do not hesitate to contact us with any questions or concerns at (541)386-6380.
Disclaimers: The information provided in the good faith estimate is only an estimate regarding items or services reasonably expected to be furnished at the time the good faith estimate is issued to the uninsured (or self-pay) individual and that actual items, services, or charges may differ from the good faith estimate. This does not include other providers’ charges, or any other services billed outside of OCH or any unknown or unexpected costs that may arise during your visit.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. The uninsured (or self-pay) individual has the right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in the good faith estimate, as specified in § 149.620; if you receive a bill that is at least $400 more than a Good Faith Estimate, or if you just want to discuss your bill, give us a call at 541-386-6380 and enter extension 11598. We’ll do our best to make things right and share other ways you might be able to save on your healthcare bills. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to an uninsured (or self-pay) individual by a provider or facility. The good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate. For additional information about the No Surprise Act, please visit www.cms.gov/nosurprises.
Virtual Visit
Recently, a federal law was passed requiring medical facilities to provide self-pay patients with an estimate for the cost of services. This is an estimate only and no payment is required at this time. You have scheduled an appointment at One Community Health and our records indicate that you have no insurance. If our records are incorrect, please call us at 541.386.6380 x11598 with your insurance information and we will update our records. For our uninsured patients, we offer an approximate cost for the services you can expect to receive at your healthcare appointment. Due to a wide range of service options, the cost of an office visit at One Community Health varies. Your office visit level will vary depending on the length of your visit and complexity of your care. Please find below the price range of each type of healthcare visit available at OCH.
| Type of Care | Price Range | CPT Code |
|---|---|---|
| Virtual / Phone Visit, Behavioral Health Evaluation | $367 | 90791 |
| Virtual / Phone Visit, Behavioral Health Therapy | $159 – $309 | 90832 – 90839 |
| Virtual / Phone Visit, Medical Office Visit | $137 – $439 | 99212 – 99215 |
There may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate. We look forward to greeting you at your visit to One Community Health. Please do not hesitate to contact us with any questions or concerns at (541)386-6380.
Disclaimers: The information provided in the good faith estimate is only an estimate regarding items or services reasonably expected to be furnished at the time the good faith estimate is issued to the uninsured (or self-pay) individual and that actual items, services, or charges may differ from the good faith estimate. This does not include other providers’ charges, or any other services billed outside of OCH or any unknown or unexpected costs that may arise during your visit.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. The uninsured (or self-pay) individual has the right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in the good faith estimate, as specified in § 149.620; if you receive a bill that is at least $400 more than a Good Faith Estimate, or if you just want to discuss your bill, give us a call at 541-386-6380 and enter extension 11598. We’ll do our best to make things right and share other ways you might be able to save on your healthcare bills. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to an uninsured (or self-pay) individual by a provider or facility. The good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate. For additional information about the No Surprise Act, please visit www.cms.gov/nosurprises.
Behavioral Health & Counseling
Recently, a federal law was passed requiring medical facilities to provide self-pay patients with an estimate for the cost of services. This is an estimate only and no payment is required at this time. You have scheduled an appointment at One Community Health and our records indicate that you have no insurance. If our records are incorrect, please call us at 541.386.6380 x11598 with your insurance information and we will update our records. For our uninsured patients, we offer an approximate cost for the services you can expect to receive at your healthcare appointment. Due to a wide range of service options, the cost of an office visit at One Community Health varies. Your office visit level will vary depending on the length of your visit and complexity of your care. Please find below the price range of each type of healthcare visit available at OCH.
| Type of Care | Price Range | CPT Code |
|---|---|---|
| Psychotherapy | $159 – $309 | 90832 – 90837 |
| Evaluation | $199 – $367 | 90791 – 96156 |
| Counseling | $31 – $139 | 99406 – 99409 |
There may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate. We look forward to greeting you at your visit to One Community Health. Please do not hesitate to contact us with any questions or concerns at (541)386-6380.
Disclaimers: The information provided in the good faith estimate is only an estimate regarding items or services reasonably expected to be furnished at the time the good faith estimate is issued to the uninsured (or self-pay) individual and that actual items, services, or charges may differ from the good faith estimate. This does not include other providers’ charges, or any other services billed outside of OCH or any unknown or unexpected costs that may arise during your visit.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. The uninsured (or self-pay) individual has the right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in the good faith estimate, as specified in § 149.620; if you receive a bill that is at least $400 more than a Good Faith Estimate, or if you just want to discuss your bill, give us a call at 541-386-6380 and enter extension 11598. We’ll do our best to make things right and share other ways you might be able to save on your healthcare bills. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to an uninsured (or self-pay) individual by a provider or facility. The good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate. For additional information about the No Surprise Act, please visit www.cms.gov/nosurprises.
Frequently Asked Questions
Other assistance types or estimate questions?
No! This is an estimate of what your care may cost at your next visit.
You received this estimate because your insurance isn’t listed in your chart or you don’t have a discount plan active.
Your bill may not match this estimate exactly. If it’s off by $400 or more, contact our billing team so we can review it with you.
Have more questions? Call us at 541-386-6380 and we will be happy to assist you.