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INDIAN RIVER COUNTY HEALTH DEPARTMENT <br /> FEE SCHEDULE --Effective Oct 1, 2005 <br /> VISIT DESCRIPTION E/M CODES 0%-A 17%-B 33%-C 50%-D 67% -E 83% - F 100%-G COST <br /> Medical Visit-New Patient <br /> 99201 Level One $0.00 $9.35 $19.80 $27.50 $36.85 $45.65 $55.00 $55.00 <br /> 99202 Level Two $0.00 $9.35 $19.80 $30.00 $40.20 $49.80 $60.00 $60.00 <br /> 99203 Level Three $0.00 $11.05 $21.45 $32.50 $43.55 $53.95 $65.00 $65.00 <br /> 99204 Level Four $0.00 $11.90 $23.10 $35.00 $43.55 $58.10 $70.00 $70.00 <br /> Nurse Protocol $0.00 $9.35 $18.15 $27.50 $36.85 $45.65 $55.00 $55.00 <br /> Medical Visit-Established Patient <br /> 99211 Level One $0.00 $5.44 $10.56 $16.00 $21.44 $26.56 $32.00 $32.00 <br /> 99212 Level Two $0.00 $6.29 $12.21 $18.50 $24.79 $30.71 $37.00 $37.00 <br /> 99213 Level Three $0.00 $7.14 $13.86 $21.00 $28.14 $34.86 $42.00 $42.00 <br /> 99214 Level Four $0.00 $7.99 $15.51 $23.50 $31.49 $39.01 $47.00 $47.00 <br /> Nurse Protocol $0.00 $5.44 $10:56 $16.00 $21.44 $26.56 $32.00 $32.00 <br /> School/Work Physicial (CHCU)* $0.00 $5.44 $10.56 $16.00 $21.44 $26.56 $32.00 $32.00 <br /> REFUGEE Physical** $0.00 $10.20 $19.80 $30.00 $40.20 $49.80 $60.00 $60.00 <br /> *Medicaid"Child Health Check-Up"and routine physical do not include applicable in-house laboratory services. <br /> Must be established primary care patient to receive physical on sliding fee scale. <br /> **Does not include immunizations or laboratory services <br /> Out of County Primary Care Fee* $0.00 $30.00 $30.00 $30.00 $30.00 $30.00 $55.00 $55.00 <br /> *Deposit for services. Must be paid prior to clinic visit with balance due at completion of visit. <br /> Family Planning <br /> Initial/Annual Family Planning Visit* $0.00 $14.45 $28.05 $42.50 $56.95 $70.55 $85.00 $85.00 <br /> Subsequent Family Planning Visit(s) $0.00 $5.44 $10.56 $16.00 $21.44 $26.56 $32.00 $32.00 <br /> *Includes all applicable laboratory services <br /> A' <br /> EA1 a IBI <br /> 9/12/2005CLFEE2005-06 Page 1 of 8 <br />