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INDIAN RIVER COUNTY HEALTH DEPARTMENT <br /> FEE SCHEDULE <br /> Fees shall be no less than the Medicaid Fee-forService reimbursement and no greater than the Medicare reimbursement rate plus fift <br /> percent, <br /> in effect at the time of service, or comparable reimbursement rates if no such rates are availble. <br /> EST <br /> Fee <br /> Medical Visit - New Patient <br /> 99201 Level One $0. 00 $6.97 $13. 53 $20.50 $27.47 $34.03 $41 .00 $41000 <br /> 99202 Level Two $0.00 $7.31 $14. 19 $21 . 50 $28.81 $35.69 $43.00 $43.00 <br /> 99203 Level Three $0. 00 $10. 88 $21 . 12 $32. 00 $42.88 $53. 12 $64. 00 $64.00 <br /> 99204 Level Four $0.00 $15. 30 $29.70 $45.00 $60.30 $74.70 $90. 00 $90.00 <br /> 99201 TD Nurse Protocol $0.00 $6. 97 $ 13. 53 $20. 50 $27.47 $34 .03 $41 .00 $41 .00 <br /> Medical Visit - Established Patient <br /> 99211 Level One $0.00 $2.89 $5.61 $8.50 $ 11 .39 $14. 11 $17.00 $ 17.00 <br /> 99212 Level Two $0.00 $4.93 $9.57 $14.50 $19.43 $24.07 $29.00 $29.00 <br /> 99213 Level Three $0. 00 $5.95 $11 .55 $ 17. 50 $23.45 $29.05 $35.00 $35.00 <br /> 99214 Level Four $0. 00 $9. 18 $17. 82 $27.00 $36. 18 $44.82 $54.00 $54. 00 <br /> 99211 TD Nurse Protocol $0.00 $2.89 $5.61 $8. 50 $11 .39 $ 14. 11 $ 17.00 $17.00 <br /> All Lab fees will be charged in addition to office visits on a sliding fee scale. <br /> School f Sports I Work Physical NOS 1 N $25.00 $25.00. <br /> Physical (CHCU)* 1 $0.00 $15.30 $29. 70 $45.00 $60.30 $74. 70 $90.00 $90. 00 <br /> *Medicaid "Child Health Check-Up" and routine physical includes applicable in-house laborato services. <br /> Must be established primary care patient to receive physical on sliding fee scale. <br /> Other Services <br /> Smoking Cessation Intermediate 3 - 10 minutes $0.00 $2. 19 $4.25 $6.45 $8.64 $10.70 $12 . 89 $ 12.89 <br /> Smoking Cessation Intensive > 10 minutes $0.00 $4.32 $8.38 $ 12.70 $17. 01 $21 .07 $25.39 $25. 39 <br /> 99499 - Flouride Varnish - 521 .01 $0. 00 $4.25 $8.25 $ 12.50 $16. 75 $20. 75 $25.00 $25.00 <br /> HIV Pre-Test Counseling $0. 00 $4.25 $8.25 $ 12.50 $16.75 $20. 75 $25. 00 $25.00 <br /> HIV Post-Test Counseling+ $0.00 $0. 00 $0.00 $0. 00 $0. 00 WOO $0.00 $0. 00 <br /> + included in pre-test counseling <br /> Any additional GIInIG fees 1 medisal pFoGedures will be charged at MedlGaid Fates p1m or, 26% <br /> Out of County Patient Fees* Patients will be assessed at 100% of Sliding Fee Scale <br /> EXHIBIT "A" <br /> Page 1 of 9 <br />