United Summit Center Fee Schedule
| STANDARD FEE | UNIT OF SERVICE | CODE DESCRIPTION |
| $75.00 | :30 | ASSESSMENTS |
| $20.00 | :15 | CASE MANAGEMENT |
| $60.00 | :15 | TREATMENT PLAN/REVIEW by MD/LP |
| $15.00 | :15 | TREATMENT PLAN/REVIEW by NON MD |
| $210.00 | EVENT | PSYCH-EVAL/EXTERNAL CASE CONSULTATION WITH REPORT |
| $150.00 | :60 | NEUROPSYCHOLOGICAL TESTING |
| $30.00 | :15 | INTERNAL AGENCY CASE CONSULTATION |
| $75.00 | :30 | EVALUATION/ASSESSMENTS (WVFAI, Clinical, Acuity/Activity, etc) |
| $30.00 | :15 | STANDARDIZED TESTING (Project#s for each testing) |
| $75.00 | :30 | INITIAL CLINICAL ASSESSMENT/REASSESSMENT |
| $125.00 | EVENT | EVALUATION INTERVIEW WITH REPORT w/o TESTING |
| $50.00 | :30 | EMERGENCY WALK IN |
| $50.00 | :15 | MEDICAL OFFICE VISIT |
| $100.00 | DAY | ASSERTIVE COMMUNITY TREATMENT |
| $50.00 | EVENT | MEDICATION EVALUATION MANAGEMENT |
| $30.00 | EVENT | HALDOL INJECTION |
| $70.00 | EVENT | CLOZAPHINE INJECTION |
| $40.00 | EVENT | PROLIXIN INJECTION |
| $30.00 | :15 | MEDICAL SERVICES BY RN |
| $150.00-$230.00 | EVENT | INPATIENT MEDICAL EVALUATION/HOSPITAL ADMISSION(Depending on Level) |
| $65.00-$85.00 | EVENT | INPATIENT PSYCHIATRIC FOLLOW UP VISIT(Depending on Level) |
| $50.00 | :30 | INTENSIVE INDIVIDUAL THERAPY by LP/MA/BA |
| $20.00 | :15 | GROUP THERAPY |
| $15.00 | :15 | SUPPORTIVE GROUP THERAPY |
| $175.00 | EVENT | INPATIENT CONSULTATION |
| $25.00 | :60 | DAY TREATMENT |
| $30.00 | :60 | DAY HABILITATION 1:1 |
| $25.00 | :60 | DAY HABILITATION 1:2 |
| $20.00 | :60 | DAY HABILITATION 1:4 |
| $15.00 | :60 | DAY HABILITATION 1:6+ |
| $15.00 | :60 | COMMUNITY FOCUS |
| $20.00 | :60 | RES. HABILITATION 1:1 |
| $16.00 | :60 | RES. HABILITATION 1:2 |
| $12.00 | :60 | RES. HABILITATION 1:3 |
| $10.00 | :60 | RES. HABILITATION 1:4 |
| $12.00 | :60 | RESPITE LEVEL I |
| $20.00 | :60 | RESPITE LEVEL II |
| $12.00 | :60 | ADULT COMPANION - LEVEL I |
| $20.00 | :60 | ADULT COMPANION - LEVEL II |
| $12.00 | :60 | COMMUNITY RES.HABILITATION |
| $7.00 | EVENT | CLIENT TRANSPORTATION |
| $0.49 | :01 | STAFF TRANSPORTATION by mileage |
| $100.00 | :60 | BILLABLE COURT TESTIMONY |
| $75.00 | EVENT | PROBABLE CAUSE |
| $35.00 | :60 | SUPPORTIVE EMPLOYMENT |
| $17.00 | :15 | CRISIS STABLIZATION |
| $25.00 | :60 | SOCIALIZATION SUPPORT |
| $20.00 | :60 | GENERAL SUPPORT |
| $20.00 | :60 | SUPPORTIVE RESIDENTIAL |
The above Fee Schedule has been reviewed with me and I have been provided the opportunity to ask questions relating to the Fee Schedule. I understand the fees charged to me and parties financially responsible for services rendered to me by United Summit Center (USC) shall be in accordance with this Fee Schedule. Any revisions shall be presented for my review. If I wish to continue receiving treatment, I must sign this Fee Schedule. USC is not obligated to provide services at fees set forth in any Fee Schedule which has been superceded beyond the effective date of any revised Fee Schedule.
