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 |
|---|---|---|---|---|---|---|---|
| IMMUNIZATIONS | 90707 | MMR II – ADULT-S | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| IMMUNIZATIONS | 90713 | POLIO (IPV) – PEDIATRIC | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| IMMUNIZATIONS | 90713 | POLIOVIRUS VACCINE (IPV) | $53.04 | $42.43 | $31.82 | $21.22 | $10.61 |
| IMMUNIZATIONS | 91322 | SARSCOV2 VAC 50 MCG/0.5ML IM | $279.34 | $223.47 | $167.60 | $111.74 | $55.87 |
| IMMUNIZATIONS | 91322 | SPIKEVAX COVID-19 (MRNA, 2025-2026 FORMULA) | $279.34 | $223.47 | $167.60 | $111.74 | $55.87 |
| IMMUNIZATIONS | 90715 | TDAP (ADACEL) – ADULT-S | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| IMMUNIZATIONS | 90715 | TDAP (ADACEL) – PEDIATRIC/VFC | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| IMMUNIZATIONS | 90715 | TDAP (BOOSTRIX) – ADULT-S | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| IMMUNIZATIONS | 90715 | TDAP(ADACEL) – ADULT-DISTRICT | $68.94 | $55.15 | $41.36 | $27.58 | $13.79 |
| IMMUNIZATIONS | 90716 | VARICELLA – ADULT-D | $154.66 | $123.73 | $92.80 | $61.86 | $30.93 |
| IMMUNIZATIONS | 90716 | VARICELLA – ADULT-S | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| IMMUNIZATIONS | 90716 | VARICELLA – PEDIATRIC | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| IMMUNIZATIONS | 90472 | VFC ADMIN FEE, EACH ADDTL DOSE | $20.13 | $16.10 | $12.08 | $8.05 | $4.03 |
| IMMUNIZATIONS | 90471 | VFC IMM. ADMIN. FEE, 1ST DOSE | $20.13 | $16.10 | $12.08 | $8.05 | $4.03 |
| LAB | 87491 | CHLAMYDIA (CT) URINE/VAGINAL | $63.16 | $50.53 | $37.90 | $25.26 | $12.63 |
| LAB | 87591 | GONORRHEA (GC) URINE/VAGINAL | $63.16 | $50.53 | $37.90 | $25.26 | $12.63 |
| MISC | MISC29 | CHLAMYDIA TEST | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| MISC | MISC08 | EXTREMITIES | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| MISC | MISC28 | GONORRHEA TEST | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| OFFICE PROCEDURE | 36415 | BLOOD DRAW | $15.90 | $12.72 | $9.54 | $6.36 | $3.18 |
| OFFICE PROCEDURE | 96372 | INJECTION SC/IM | $30.90 | $24.72 | $18.54 | $12.36 | $6.18 |