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INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Nov.01,2006 VISIT DESCRIPTION E/M CODES 0%-A 17%-B 33% -C 50%-D 67%-E 83%- F 100% -G COST Medical Visit-New Patient 99201 Level One $0.00 $9.35 $19.80 $27.50 $36.85 $45.65 $55.00 $55.00 99202 Level Two $0.00 $9.35 $19.80 $30.00 $40.20 $49.80 $60.00 $60.00 99203 Level Three $0.00 $11.05 $21.45 $32.50 $43.55 $53.95 $65.00 $65.00 99204 Level Four $0.00 $11.90 $23.10 $35.00 $43.55 $58.10 $70.00 $70.00- 99201 TD Nurse Protocol $0.00 $9.35 $18.15 $27.50 $36.85 $45.65 $55.00 $55.00 Medical Visit-Established Patient 99211 Level One $0.00 $5.44 $10.56 $16.00 $21.44 $26.56 $32.00 $32.00 99212 Level Two $0.00 $6.29 $12.21 $18.50 $24.79 $30.71 $37.00 $37.00 99213 Level Three $0.00 $7.14 $13.86 $21.00 $28.14 $34.86 $42.00 $42.00 99214 Level Four $0.00 $7.99 $15.51 $23.50 $31.49 $39.01 $47.00 $47.00 99211 TD Nurse Protocol $0.00 $5.44 $10.56 $16.00 $21.44 $26.56 $32.00 $32.00 School/Work Physical(CHCU)* $0.00 $5.44 $10.56 $16.00 $21.44 $26.56 . $32.00 $32.00 *Medicaid"Child Health Check-Up"and routine physical do not include applicable in-house laboratory services. Must be established primary care patient to receive physical on sliding fee scale. Out of County Primary Care Fee* $0.00 1 $30.00 1 $30.00 $30.00 $30.00 $30.00 $55.00 $55.00 *Deposit for services. Must be paid prior to clinic visit with balance due at completion of visit. Family Planning Initial/Annual Family Planning Visit* $0.00 $14.45 $28.05 $42.50 $56.95 $70.55 $85.00 $85.00 Subsequent Family Planning Visit(s) $0.00 $5.44 $10.56 $16.00 $21.44 $26.56 $32.00 $32.00 *Includes all applicable in-house laboratory services. EXHIBIT "A" 10/23/2006CLFEE2006-07 Page 1 of 11