Good Faith Estimate

Good Faith Estimate


Provider Name: Sweetgrass Pediatrics    NPI: 1437168135

Locations: 2713 Dantzler Drive, North Charleston, SC 29406

    748 Orangeburg Road, Summerville, SC 29483

     401 N.Live Oak Drive, Moncks Corner, SC 29461

     12 Farmfield Drive, Charleston, SC 29407

    2016 1st Avenue, Summerville, SC 29486

    1115 Professional Lane, Mt Pleasant, SC 29466

The following is a detailed list of expected charges for all scheduled services/visits based on what type of services you are scheduled for and is good for 12 months from the date of the GFE. This GFE shows the cost of items and services that are reasonably expected for your healthcare needs. If you are billed for more than this GFE you have the right to dispute the bill.

  • Sick Office/Virtual problems New Patient (includes exam, labs, test, and medications) -$130
  • Sick in Office/Virtual problems Established (includes exam, labs, test, and medications)- $100
  • Well Child Visit New Patient (includes exam, screenings, vaccines/admin, and testing)- $150
  • Well Child Visit Established (includes exam, screenings, vaccines/admin, and testing)- $120
  • Sports Physicals (includes exam and forms filled out)- $35
  • All vaccine/medication administration regardless of the number of vaccines/medications- $20
  • Depo Provera Visit- $75
  • Circumcision- $150
  • Bexerso Vaccine (Men-B) *** UNDERINSURED ONLY***- $140
  • Behavioral Health Service with Licensed Counselor- $110

**** exclusion is COVID-19 Vaccines and Administration- no charge****

A sick visit may be billed with a well child visit if additional problems are managed during the well visit

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