1. One-time costs before you see a patient
These are the costs that land once, before any revenue exists. The exact figures below are published by the organisation that charges them and were checked in August 2026. The ranges are ranges because they genuinely vary by state, specialty and carrier — quote them locally rather than trusting anyone’s average, including ours.
| Item | Cost | Notes |
|---|---|---|
| NPI number | Free | Issued by CMS through NPPES. There is no fee and never has been. Services charging to “obtain” one are charging for a form you can submit yourself. |
| EIN | Free | Direct from the IRS, issued immediately online. Same caveat as above. |
| LLC / PC formation | $50 – $800 | State filing fee. Several states also require a professional entity (PC/PLLC) rather than a plain LLC for clinical practice — check before you file, because refiling costs more than filing correctly. |
| State license | Varies widely | Per state, per licence type. Multi-state telehealth multiplies this line; compacts reduce the paperwork, not always the fee. |
| DEA registration | $888 / 3 years | Published DEA practitioner fee, retrieved August 2026. Only needed if you prescribe controlled substances — which for TRT you do. |
| LegitScript application | $975 per website | Non-refundable, regardless of outcome. Required before most high-risk processors will board a practice selling prescription products online. Expedited review is an additional $2,500 per application. |
| Malpractice insurance | Quote locally | Varies by state, specialty and limits more than any other line here. Telehealth across state lines changes the quote; ask specifically. |
| EHR onboarding | $0 – $2,000+ | A one-time implementation fee is normal. Aminova’s is $500 on the solo plan, published. Some incumbents charge nothing and some charge four figures; ask what it includes, because “onboarding” sometimes means a login and a PDF. |
2. The monthly stack once you are open
The recurring costs are where a clinic quietly becomes unprofitable, because each one is individually small. Written down together they are not.
| Item | Typical monthly | Notes |
|---|---|---|
| EHR / practice platform | $199 – $600+ | Per-provider pricing is the industry norm and the thing to model carefully — a platform that charges per seat costs a multiple of its headline price once you add a front desk. Aminova publishes $199/mo for one prescriber with unlimited staff. |
| LegitScript annual certification | $2,150 / website / year | Roughly $179 a month, per domain. Merchants placed on probationary monitoring pay $3,995 per website per year. Retrieved August 2026. |
| Payment processing | 2.6% – 4%+ of revenue | The single largest variable cost in a cash-pay practice, and the one most often quoted as a flat rate when interchange-plus would be cheaper. High-risk processing costs more than standard, and standard processors terminate practices selling prescription products. |
| AI scribe | $0 – $150 | Standalone scribes are typically $99–$150. Some platforms include it; Aminova charges $100/mo on the solo plan and includes it from the two-provider plan up. |
| Fax number | ~$2 + usage | A HIPAA-capable fax API runs about $2 per number per month plus roughly $0.07 a page. Legacy eFax plans cost considerably more for the same thing. |
| Website hosting | $0 – $300 | Wide range because it depends whether you are paying a designer a retainer. Static hosting itself is close to free. |
| Phone / messaging | $25 – $100 | A HIPAA-capable line with a BAA, not a personal mobile. |
| Business insurance | Quote locally | General liability and, increasingly, cyber liability. Cyber cover is now commonly a condition of doing business rather than an option. |
3. What is free and gets sold to you anyway
Three things new clinics regularly pay for that cost nothing.
Your NPI. Free from NPPES, and the application is short. Any service quoting a fee to obtain one is charging for the typing.
Your EIN. Free and instant from the IRS website. Third parties charge upwards of $200 to submit the same form.
Your data, on the way out of an EHR. Certified EHRs are required to give you an electronic export of your patient data without charging for it. If a vendor quotes a four-figure “extraction fee” to leave, ask whether they are certified — and if they are, ask them to point to where that fee is permitted. This is the single most expensive assumption a clinic makes at switching time.
4. The three line items that vary the most
Malpractice. Nobody can quote this for you generically and anyone who does is guessing. It moves with state, specialty, claims history, limits, and whether you practise across state lines. Get two quotes before you model anything.
Payment processing. A flat 2.5%–2.9% rate sounds simpler than interchange-plus and is usually more expensive, because a flat rate has to price in the worst card you might take. If a meaningful share of your revenue is premium credit cards — and in concierge medicine it is — the flat rate is where the margin goes. Ask for interchange-plus and compare on your actual mix, not on the headline.
LegitScript, if you sell prescription products online. It is charged per website domain, not per practice, so a second brand site doubles it. Year one is $975 plus $2,150, so $3,125 per domain. On a practice doing $30,000 a month in medication revenue that is noise. On one doing $4,000 a month it is a real share of margin, and it is due before the first dollar is processed. Our full breakdown is in what LegitScript certification actually costs.
5. A worked example: solo telehealth prescriber
One nurse practitioner, no premises, hormones and weight management, prescribing controlled substances, selling prescription products online. Published figures only; the ranged items are excluded because including a guess would make the total fiction.
Before opening: NPI free, EIN free, entity filing at state rate, DEA registration $888 for three years, LegitScript application $975, EHR onboarding $500. The published, knowable portion comes to roughly $2,363, plus your state filing fee and your malpractice premium.
Every month after: EHR $199, LegitScript amortised about $179, fax about $2 plus pages, phone about $30. That is roughly $410 a month in fixed platform cost before processing fees, insurance and anything you choose to add.
The number that actually decides profitability is not on either list. It is processing: at 3% of revenue, a practice billing $20,000 a month pays $600 — more than the entire fixed stack above. Model that line before you model any other.
6. Frequently asked questions
How much does it cost to start a cash-pay clinic?
The published, knowable one-time costs for a solo telehealth prescriber come to roughly $2,400 — DEA registration at $888 for three years, LegitScript application at $975 per website, and EHR onboarding around $500, with NPI and EIN free. On top of that sit your state entity filing, state licensing and malpractice premium, all of which vary too much to quote generically. Figures retrieved August 2026.
Do I need LegitScript certification?
If you sell prescription products online, most high-risk payment processors will not board you without it. It is $975 as a non-refundable application fee per website plus $2,150 per website per year. It is charged per domain, so a second brand site is a second full fee.
What is the DEA registration fee in 2026?
$888 for a three-year term for most individual practitioners, including physicians, nurse practitioners and physician assistants. You need it only if you prescribe controlled substances, which includes testosterone.
Is an EHR the biggest cost?
Almost never. Payment processing usually is. At 3% of revenue a practice billing $20,000 a month pays $600 in processing — more than a typical entire monthly software stack. Clinics spend weeks comparing EHR prices and minutes on their merchant agreement, and the ratio should be the other way round.
Do I have to pay to get an NPI or EIN?
No. Both are free — the NPI from NPPES and the EIN directly from the IRS, issued immediately online. Services that charge for either are charging you to fill in a form you can submit yourself in about ten minutes.