509-662-6000
Sliding Fee Scale
What is a Sliding Fee Scale?
A sliding fee scale is a program offered by CVCH to make healthcare services more affordable for our patients. This program adjusts the cost of care based on a patient’s gross family income and number of household members, allowing those with lower incomes to pay reduced fees.
By using a sliding scale, CVCH ensures that essential healthcare services remain accessible to all members of the community, regardless of their financial situation. CVCH will not deny services based on a patient’s inability to pay, even if that means reducing or waiving costs.
The Sliding Fee Scale is revised annually based on the published Federal Poverty guidelines.
How to Apply for the Sliding Fee Discount Program
- Make an appointment with Member Services who will assist you in reviewing your insurance options.
- Complete the Sliding Fee application.
- Provide CVCH proof of your estimated current annual income:
- Tax return, proof of income for the last 60 days, self-employment bookkeeping records, SSI, Unemployment benefits, recent tax return, or
- Letter of financial support (unhoused only)
- Proof of income is required every 6-12 months to continue to qualify for the Sliding Fee Discount Program. You are encouraged to complete a new sliding fee application if your household size or monthly income changes.
Need Help?
Our Member Services Specialists can guide you through the enrollment process of our in-clinic Slide Fee and Washington Apple Health.
Call (509) 662-6000 or email our Member Services team at [email protected]
today and ask to speak with an Enrollment Specialist to see if you qualify!
You will be required to present documentation to determine eligibility for the Sliding Fee Program. These documents include proof of income for the last 60 days (paycheck stub or letter from employer) or your most recent tax return. Click here to view the list of required documents in English or click here to view the list of required documents in Spanish. Please bring these documents with you when you meet with your Member Services representative.
Other Financial Resources
- Poverty Scale
- Sliding Fee Scale
- Medical Services
- Dental Services
- Behavioral Services
Poverty Scale
Percent of Poverty Based on Family Size and Family Income Per Year
| Family Size | PLAN A: < 101% | PLAN B: 101 - 133% | PLAN C: 134 - 167% | PLAN D: 168 - 200% | NOT ELIGIBLE: >200% |
|---|---|---|---|---|---|
| 1 | $0 to $15,960 | $15,961 to $21,227 | $21,228 to $26,777 | $26,778 to $31,920 | $31,921 |
| 2 | $0 to $21,640 | $21,641 to $28,781 | $28,782 to $36,307 | $36,308 to $43,280 | $43,281 |
| 3 | $0 to $27,320 | $27,321 to $36,336 | $36,337 to $45,837 | $45,838 to $54,640 | $54,641 |
| 4 | $0 to $33,000 | $33,001 to $43,890 | $43,891 to $55,367 | $55,368 to $66,000 | $66,001 |
| 5 | $0 to $38,680 | $38,681 to $51,444 | $51,445 to $64,896 | $64,894 to $77,360 | $77,361 |
| 6 | $0 to $44,360 | $44,361 to $58,999 | $59,000 to $74,426 | $74,427 to $88,720 | $88,721 |
| 7 | $0 to $50,040 | $50,041 to $66,553 | $66,554 to $83,956 | $83,957 to $100,080 | $100,081 |
| 8 | $0 to $55,720 | $55,721 to $74,108 | $74,109 to $93,486 | $93,487 to $111,440 | $111,441 |
| 9 | $0 to $61,400 | $61,401 to $81,662 | $81,663 to $103,016 | $103,017 to $122,800 | $122,801 |
| 10 | $0 to $67,080 | $67,081 to $89,216 | $89,217 to $112,545 | $112,546 to $134,160 | $134,161 |
| 11 | $0 to $72,760 | $72,761 to $96,771 | $96,772 to $122,075 | $122,076 to $145,520 | $145,521 |
| 12 | $0 to $78,440 | $78,441 to $104,325 | $104,326 to $131,605 | $131,606 to $156,880 | $156,881 |
Percent of Poverty Based on Family Size and Family Income Per Month
| Family Size | PLAN A: < 101% | PLAN B: 101 - 133% | PLAN C: 134 - 167% | PLAN D: 168 - 200% | NOT ELIGIBLE: >200% |
|---|---|---|---|---|---|
| 1 | $0 to $1,330 | $1,331 to $1,769 | $1,770 to $2,231 | $2,232 to $2,660 | >$2,661 |
| 2 | $0 to $1,803 | $1,804 to $2,398 | $2,399 to $3,026 | $3,027 to $3,607 | >$3,608 |
| 3 | $0 to $2,277 | $2,278 to $3,028 | $3,029 to $3,820 | $3,821 to $4,553 | >$4,554 |
| 4 | $0 to $2,750 | $2,751 to $3,658 | $3,659 to $4,614 | $4,615 to $5,500 | >$5,501 |
| 5 | $0 to $3,223 | $3,224 to $4,287 | $4,288 to $5,408 | $5,409 to $6,447 | >$6,448 |
| 6 | $0 to $3,697 | $3,698 to 4,917 | $4,918 to $6,202 | $6,203 to $7,393 | >$7,394 |
| 7 | $0 to $4,170 | $4,171 to $5,546 | $5,547 to $6,996 | $6,997 to $8,340 | >$8,341 |
| 8 | $0 to $4,643 | $4,644 to $6,176 | $6,177 to $7,791 | $7,792 to $9,287 | >$9,288 |
| 9 | $0 to $5,117 | $5,118 to $6,805 | $6,806 to $8,585 | $8,586 to $10,233 | >$10,234 |
| 10 | $0 to $5,590 | $5,591 to $7,435 | $7,436 to $9,379 | $9,380 to $11,180 | >$11,181 |
| 11 | $0 to $6,063 | $6,064 to $8,064 | $8,065 to $10,173 | $10,174 to $12,127 | >$12,128 |
| 12 | $0 to $6,537 | $6,538 to $8,694 | $8,695 to $10,967 | $10,968 to $13,07 | >$13,074 |
Sliding Fee Scale
Sliding Fee Scale 2025
| Service | Plan A | Plan B | Plan C | Plan D | Not Eligible |
|---|---|---|---|---|---|
| Medical* | $40 | 75% Slide | 50% Slide | 25% Slide | not applicable |
| Medical Tier 2 | $150 | 75% Slide | 50% Slide | 25% Slide | not applicable |
| Dental* | $65 | 75% Slide | 50% Slide | 25% Slide | not applicable |
| Dental Tier 2** | $300 | 75% Slide | 50% Slide | 25% Slide | not applicable |
| Behavioral | $15 | 75% Slide | 50% Slide | 25% Slide | not applicable |
| SUD | $15 | 75% Slide | 50% Slide | 25% Slide | not applicable |
| Diabetes and Nutrition | $15 | 75% Slide | 50% Slide | 25% Slide | not applicable |
| Outreach | $0 | $0 | $0 | $0 | not applicable |
| Laboratory | 100% Slide | 75% Slide | 50% Slide | 25% Slide | not applicable |
| Vaccines Tier 3*** | $100 | $120 | $140 | $160 | not applicable |
| Pharmacy <30-day supply** | Acquisition + $5 | Acquisition + $6 | Acquisition + $7 | Acquisition + $8 | not applicable |
| Pharmacy>30-Day supply*** | Acquisition + $10 | Acquisition + $12 | Acquisition + $14 | Acquisition + $16 | not applicable |
Any sliding fee scale within tier B, C, or D will be at least the nominal charge listed in slide A plus a dollar.
If you have questions regarding these slides or the cost of services, please speak with any Member Services Representative for further information.
* Sliding Fee charges will not exceed the billed charge. Certain services may include an additional lab fee.
** Dental procedures may include a lab fee in addition to fee shown in the schedule above. You will be provided a cost estimate prior to scheduling these appointments.
*** Services where the purchasing cost of a prescription, equipment or item plus a flat fee will be charged.
Medical Services
Medical Services - Diabetes & Nutrition
| Service | Code | Slide A | Slide B | Slide C | Slide D | NO Slide |
|---|---|---|---|---|---|---|
| Program or Service | 97802 | $15 | $24 | $48 | $72 | $96 |
| Medical* | 97803 | $15 | $22 | $43 | $65 | $86 |
| Medical Tier 2 | G0108 | $15 | $23 | $46 | $69 | $92 |
Medical Services - Annual Preventative
| Service | Code | Slide A | Slide B | Slide C | Slide D | NO Slide |
|---|---|---|---|---|---|---|
| Established Patient Preventative Visit - Infant | 99391 | $40 | $61 | $121 | $182 | $242 |
| Established Patient Preventative Visit - Age 1-17 | 99392-99394 | $40 | $64 | $129 | $193 | $257 |
| Established Patient Preventative Visit - Age 18-65+ | 99395-99397 | $40 | $82 | $163 | $245 | $326 |
| New Patient Preventative - Infant | 99381-99382 | $40 | $61 | $123 | $184 | $245 |
| New Patient Preventative - Age 5-17 | 99383-99384 | $40 | $69 | $138 | $207 | $276 |
| New Patient Preventative - Age 18-65+ | 99385-99387 | $40 | $97 | $194 | $290 | $387 |
Medical Services - General
| Service | Code | Slide A | Slide B | Slide C | Slide D | NO Slide |
|---|---|---|---|---|---|---|
| Office Visit | 99211-99215 | $40 | $98 | $197 | $295 | $393 |
| New Patient Visit | 99201-99205 | $40 | $145 | $290 | $435 | $580 |
| New Patient Visit - Age 0-4 | 99381-99382 | $40 | $61 | $123 | $184 | $245 |
Medical Services - Medication Management with Psychiatric Nurse Practitioner
| Service | Code | Slide A | Slide B | Slide C | Slide D | NO Slide |
|---|---|---|---|---|---|---|
| Office/Outpatient Visit - Estimated 10-29 Minutes | 99212-99213 | $40 | $48 | $95 | $143 | $190 |
| Office/Outpatient Visit - Estimated 30-54 Minutes | 99214-99215 | $40 | $98 | $197 | $295 | $393 |
| Telehealth Visit - Estimated 10-29 Minutes | 98012-98014 | $40 | $52 | $104 | $156 | $208 |
Medica Medical Services - Contraceptive
| Contraceptive Devices Tier 2 < 30 Day Supply (Device cost + Insertion cost) | Code | Slide A | Slide B | Slide C | Slide D | Self Pay NO Slide |
|---|---|---|---|---|---|---|
| LEVONORGESTREL IUD (MIRENA) + Insertion | J7298 | $317 | $395 | $509 | $623 | $2,298 |
| INTRAUT COPPER CONTRACEPTIVE (PARAGUARD) + Insertion | J7300 | $349 | $427 | $541 | $655 | $2,175 |
| ETONOGESTREL IMPLANT SYSTEM (NEXPLANON) + Insertion | J7307 | $603 | $695 | $823 | $950 | $2,303 |
| SKYLA + Insertion | J7301 | $659 | $737 | $851 | $965 | $1,992 |
| KYLEENA + Insertion | J7296 | $795 | $873 | $987 | $1,101 | $2,298 |
| LILETTA + Insertion | J7297 | $175 | $253 | $367 | $481 | $1,808 |
| Remove Intrauterine Device | 58301 | $40 | $69 | $138 | $206 | $275 |
Dental Services
Dental Services Tiers
| Sliding Fee Discount Category | Tier 1 - Basic Dental Services (Dental Exams, Imaging, Basic Cleanings, Fluoride and Periodontal Maintenance) | Tier 2 - Restorative and Periodontal Services (Crown, Inlays and Onlays, Endodontics, Extractions, Occlusal Guards, Etc.) |
|---|---|---|
| A <101% | $65 Nominal Fee | $300 Nominal Fee |
| B 101-133% | 75% Discount | 75% Discount |
| C 134-167% | 50% Discount | 50% Discount |
| D 168-200% | 25% Discount | 25% Discount |
| >200% | No Discount | No Discount |
*Dental Procedures may include a lab fee in addition to the fee shown in the schedule. You will be provided a cost estimate prior to scheduling these appointments.
Basic Dental Services
| Service | Code | Slide A | Slide B | Slide C | Slide D | NO Slide |
|---|---|---|---|---|---|---|
| Adult Exam/Dual Hygiene Visit | D0120, D0220, D0230, D0272, D1110, D1206, D0330 | $65 | $147 | $293 | $440 | $586 |
| New Patient Exam | D0150, D0220, D0230, D0274, D0330 | $65 | $119 | $238 | $357 | $476 |
| Child Exam | D0120, D0220, D0230, D0272, D1120, D1206 | $65 | $96 | $192 | $288 | $384 |
| Dental Restorative - Two Surface | D2392 | $65 | $85 | $170 | $255 | $340 |
| Dental Restorative - Three Surface | D2393 | $65 | $103 | $207 | $310 | $413 |
| Dental Restorative - Four or More Surfaces | D2394 | $65 | $123 | $246 | $368 | $491 |
| Dental Extraction per tooth | D7210 | $65 | $207 | $207 | $310 | $413 |
| Dental Perio Maintenance | D4910, D1206 | $65 | $66 | $189 | $189 | $252 |
| Dental SRP | D4341 | $65 | $92 | $183 | $275 | $366 |
| Prophylaxis | D1110, D1206 | $65 | $66 | $97 | $145 | $193 |
Tier 2 Dental Services
| Service | Code | Slide A | Slide B | Slide C | Slide D | Lab Fee (at cost) | Self Pay-No Slide* (Lab Fee Not Included) |
|---|---|---|---|---|---|---|---|
| Crown-porcelain/ceramic | D2740 | $300 | $395 | $790 | $1,184 | $215 | $1.580 |
| Crown-porcelain/high noble metal | D2750 | $300 | $402 | $803 | $1,205 | $215 | $1,606 |
| Crown-porcelain/noble metal | D2752 | $300 | $382 | $764 | $1,145 | $215 | $1,527 |
| Crown full cast noble metal | D2792 | $300 | $390 | $780 | $1,169 | $215 | $1,559 |
| RCT, Anterior | D3310 | $300 | $301 | $542 | $813 | $0 | $1,084 |
| RCT, Bicuspid | D3320 | $300 | $310 | $619 | $928 | $0 | $1,237 |
| RCT, Molar | D3330 | $300 | $373 | $746 | $1,118 | $0 | $1,491 |
| Retreat Previous Rcnl Therap-a | D3346 | $300 | $314 | $628 | $941 | $0 | $1,255 |
| Retreat Previous Rcnl Therap-b | D3347 | $300 | $349 | $698 | $1,046 | $0 | $1,395 |
| Retreat Previous Rcnl Therap-m | D3348 | $300 | $414 | $827 | $1,241 | $0 | $1,654 |
| Complete Denture Maxillary | D5110 | $300 | $650 | $1,300 | $1,950 | Market Price** | $2,600 |
| Complete Denture Mandibular | D5120 | $300 | $652 | $1,303 | $1,955 | Market Price** | $2,606 |
| Immediate denture maxillary | D5130 | $300 | $687 | $1,374 | $2,060 | Market Price** | $2,747 |
| Dentures immediate mandible | D5140 | $300 | $687 | $1,375 | $2,062 | Market Price** | $2,749 |
| Maxillary partial dent-resin B | D5211 | $300 | $500 | $1,000 | $1,500 | Market Price** | $2,000 |
| Mandibular partial dent-resin | D5212 | $300 | $505 | $1,010 | $1,514 | Market Price** | $2,019 |
| Pontic Cast High Noble Metal | D6210 | $300 | $393 | $787 | $1,180 | Market Price** | $1,573 |
| Pontic Cast Predom Base Metal | D6211 | $300 | $369 | $739 | $1,108 | $215 | $1,477 |
| Pontic Cast Predom Base Metal | D6212 | $300 | $373 | $746 | $1,118 | $215 | $1,491 |
| Pontic Titanium | D6214 | $300 | $387 | $773 | $1,160 | $215 | $1,546 |
| Pontic Porc Fused High Noble Metal | D6240 | $300 | $398 | $796 | $1,194 | $215 | $1,592 |
| Pontic Porc Fused Predom Base | D6241 | $300 | $373 | $746 | $1,118 | $215 | $1,491 |
| Pontic Porc Fused Noble Metal | D6242 | $300 | $382 | $764 | $1,146 | $215 | $1,528 |
| Pontic Porcelain/Ceramic | D6245 | $300 | $323 | $645 | $968 | $215 | $1,290 |
| FPD retainer crown porcelain | D6740 | $300 | $398 | $797 | $1,195 | $215 | $1,593 |
| Crown porc fused high noble metal | D6750 | $300 | $401 | $801 | $1,202 | $215 | $1,602 |
| Crown full cast high noble metal | D6790 | $300 | $398 | $796 | $1,194 | Market Price* | $1,592 |
Behavioral Services
Behavioral Health Services - Individual
| Service | Code | Slide A | Slide B | Slide C | Slide D | NO Slide |
|---|---|---|---|---|---|---|
| Psychotherapy Diagnostic Evaluation | 90791 | $15 | $78 | $157 | $235 | $313 |
| Psychotherapy Diagnostic Evaluation With Medication Services | 90792 | $15 | $92 | $184 | $276 | $368 |
| Psychotherapy - 30-60 Minutes | 90832, 90834, 90837 | $15 | $53 | $105 | $158 | $210 |
Behavioral Health Services - Group
| Service | Code | Slide A | Slide B | Slide C | Slide D | Self Pay-No Slide* (Lab Fee Not Included) | |
|---|---|---|---|---|---|---|---|
| Family Psychotherapy | 90846-90847 | $15 | $54 | $109 | $163 | $217 | |
| Multiple Family Group Psychotherapy | 90849 | $15 | $34 | $69 | $103 | $137 | |
| Group Psychotherapy | 90853 | $15 | $24 | $48 | $71 | $95 | |
| Health Behavior Intervention - Individual Face to Face (Initial 30 Minutes) | 96158 | $15 | $49 | $98 | $147 | $196 | |
| Health Behavior Assessment (Or Re-Assessment) | 96156 | $15 | $68 | $136 | $203 | $271 |
Behavioral Health Services - Testing
| Service | Code | Slide A | Slide B | Slide C | Slide D | Self Pay-No Slide* (Lab Fee Not Included) |
|---|---|---|---|---|---|---|
| Psychotherapy Testing - First Hour | 96130 | $15 | $68 | $136 | $203 | $271 |
| Psychotherapy Testing - Each Additional Hour | 96131 | $15 | $54 | $109 | $163 | $217 |
| Neuro Psychotherapy Testing - First Hour | 96132 | $15 | $85 | $169 | $254 | $338 |
| Neuro Psychotherapy Testing - Each Additional Hour | 96133 | $15 | $78 | $157 | $235 | $313 |
| Psychotherapy or Neuro Test Administration & Scoring - First 30 Minutes | 96136 | $15 | $34 | $68 | $102 | $136 |
| Psychotherapy or Neuro Test Administration & Scoring - Each Additional 30 Minutes | 96137 | $15 | $34 | $68 | $102 | $136 |
Behavioral Health Services - New Path (Substance Use Disorder)
| Service | Code | Slide A | Slide B | Slide C | Slide D | Self Pay-No Slide* (Lab Fee Not Included) |
|---|---|---|---|---|---|---|
| Alcohol and/or Drug Assessment (New Patient) | H0001 | $15 | $50 | $100 | $150 | $200 |
| Behavioral Health Counseling (Per 15 Minutes) | H0004 | $15 | $16 | $25 | $37.50 | $50 |
| 30 Minute Group Intervention Services - 2+ Individuals | 96164 | $15 | $16 | $18 | $27 | $36 |
| Adult Group (Face to Face) - Per 15 Minutes | 96165 | $15 | $16 | $17 | $18 | $18 |
*Actual prices may be less than maximum price, but will not exceed the maximum for the codes listed. The prices listed are for the visit itself, and does not include the cost of vaccinations, tests, or other procedures that may be preformed.
Disclaimer:
***These fees are estimates showing the maximum expected charges for the visit or service listed. The process listed applies to the visit only and do not include the cost of vaccinations, tests, or other procedures that may be performed. If your final billed charges are $400 or more above this estimate, you have the right to dispute the bill. Patients will be asked to pay towards their visit at the time of service.***
***These fees are estimates showing the maximum expected charges for the visit or service listed. The process listed applies to the visit only and do not include the cost of vaccinations, tests, or other procedures that may be performed. If your final billed charges are $400 or more above this estimate, you have the right to dispute the bill. Patients will be asked to pay towards their visit at the time of service.***