Clinic Fee Schedule Test
Note: Self-pay fees include the standard 20% self-pay adjustment. Sliding fee amounts shown also include the 20% self-pay adjustment.*
| Service Type | CPT | Description (click for details) | Fee | Self-Pay | 75% Slide | 50% Slide | 25% Slide |
|---|---|---|---|---|---|---|---|
| BEHAVIORAL HEALTH | 90834 | INDIVIDUAL THERAPY, 38-52 MIN | $89.00 | $71.20 | $53.40 | $35.60 | $17.80 |
| BEHAVIORAL HEALTH | 90837 | INDIVIDUAL THERAPY, 60 MIN | $105.00 | $84.00 | $63.00 | $42.00 | $21.00 |
| BIRTH CONTROL | J1050 | MEDROXYPROGESTERONE INJECTION | $153.00 | $122.40 | $91.80 | $61.20 | $30.60 |
| E&M ESTABLISHED | 99211 | ESTABLISHED BRIEF EXAM | $50.30 | $40.24 | $30.18 | $20.12 | $10.06 |
| E&M ESTABLISHED | 99215 | ESTABLISHED COMPREHENSIVE EXAM | $390.15 | $312.12 | $234.09 | $156.06 | $78.03 |
| E&M ESTABLISHED | 99214 | ESTABLISHED DETAILED EXAM | $278.06 | $222.45 | $166.84 | $111.22 | $55.61 |
| E&M ESTABLISHED | 99213 | ESTABLISHED EXPANDED EXAM | $197.59 | $158.07 | $118.55 | $79.04 | $39.52 |
| E&M ESTABLISHED | 99212 | ESTABLISHED PROBLEM EXAM | $122.15 | $97.72 | $73.29 | $48.86 | $24.43 |
| E&M NEW | 99204 | NEW COMPREHENSIVE EXAM | $362.84 | $290.27 | $217.70 | $145.14 | $72.57 |
| E&M NEW | 99205 | NEW COMPREHENSIVE EXAM | $479.24 | $383.39 | $287.54 | $191.70 | $95.85 |
| E&M NEW | 99203 | NEW DETAILED EXAM | $242.13 | $193.70 | $145.28 | $96.85 | $48.43 |
| E&M NEW | 99202 | NEW EXPANDED EXAM | $155.20 | $124.16 | $93.12 | $62.08 | $31.04 |
| E&M NEW | 99201 | NEW PROBLEM VISIT | $85.00 | $68.00 | $51.00 | $34.00 | $17.00 |
| IMMUNIZATIONS | 90471 | ADULT ADMIN FEE 1ST DOSE | $44.55 | $35.64 | $26.73 | $17.82 | $8.91 |
| IMMUNIZATIONS | 90472 | ADULT IMM. ADMIN FEE, EACH ADDTL DOSE | $31.61 | $25.29 | $18.97 | $12.64 | $6.32 |
| IMMUNIZATIONS | 90480 | COVID-19 VACCINE ADMINISTRATION (2025-2026) – DISTRICT | $80.00 | $64.00 | $48.00 | $32.00 | $16.00 |
| IMMUNIZATIONS | 90480 | COVID-19 VACCINE ADMINISTRATION (2025-2026) VFC | $20.13 | $16.10 | $12.08 | $8.05 | $4.03 |
| IMMUNIZATIONS | 90633 | HEP A – PEDIATRIC | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| IMMUNIZATIONS | 90651 | HPV 9 – PEDIATRIC | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| IMMUNIZATIONS | 90651 | HPV GARDASIL 9 (PF) – ADULT-D | $433.62 | $346.90 | $260.17 | $173.45 | $86.72 |
| IMMUNIZATIONS | 90472 | IMM. ADMIN FEE, EACH ADDTL DOSE | $31.61 | $25.29 | $18.97 | $12.64 | $6.32 |
| IMMUNIZATIONS | 90471 | IMM. ADMIN. FEE, 1ST DOSE | $20.13 | $16.10 | $12.08 | $8.05 | $4.03 |
| IMMUNIZATIONS | 90619 | MENINGOCOCCAL (GROUPS A, C, Y, W) CONJUGATE VACCINE (MENQUADFI) – 0.5ML STATE SUPPLIED | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| IMMUNIZATIONS | 90707 | MMR – ADULT-D | $140.38 | $112.30 | $84.23 | $56.15 | $28.08 |
| IMMUNIZATIONS | 90707 | MMR – PEDIATRIC | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |