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INDIAN RIVER COUNTY HEALTH DEPARTMENT ' FEE SCHEDULE 1 N 1 STD SC PT ONS ee 1 ES 171% g• S% a �. . .. Medical Visit = New Patient 99201 Level One $0. 00 $6.97 $13.53 $20.50 $27.47 $34.03 $36. 90 $38. 95 $41 . 00 $41 .00 99202 Level Two $ 1 .00 $7. 31 $14. 19 $21 . 50 $28.81 $35.69 $38. 70 $40. 85 $43.00 $43. 00 99203 Level Three $2 .00 $ 10.88 $21 . 12 $32 .00 $42 . 88 $53 . 12 $57.60 $60.80 $64. 00 $64. 00 99204 Level Four $3.00 $ 15.30 $29. 70 $45.00 $60. 30 $74.70 $81 .00 $85.50 $90. 00 $90.00 99201 TD Nurse Protocol $4.00 $4. 25 $8.25 $ 12.50 $ 16. 75 $20.75 $22 . 50 $23. 75 $25.00 $25. 00 Medical Visit - Established Patient 99211 Level One $0.00 $2 . 89 $5.61 $8 . 50 $ 11 . 39 $14. 11 $ 15.30 $16. 15 $17.00 $ 17.00 99212 Level Two $0.00 $4.93 $9. 57 $14. 50 $ 19.43 $24.07 $26. 10 $27.55 $29.00 $29. 00 99213 Level Three $0. 00 $5.95 $11 . 55 $ 17.50 $23.45 $29. 05 $31 . 50 $33.25 $35. 00 $35.00 99214 Level Four $0.00 $9. 18 $17.82 $27.00 $36. 18 $44.82 $48.60 $51 . 30 $54.00 $54.00 99211 TD Nurse Protocol $0.00 $2.89 $5.61 $8.50 $ 11 . 39 $14. 11 $ 15. 30 $16. 15 $ 17. 00 $17.00 Family Planning InitiaVAnnual Family Planning Visit* $0.00 $ 15. 30 $29. 70 $45.00 $60.30 $74. 70 $81 .00 $85. 50 $90.00 $90.00 Subsequent Family Planning Visit(s) $0.00 $6.29 $12 .21 $ 18.50 $24. 79 $30. 71 $33. 30 $35. 15 $37.00 $37.00 *Includes all applicable in-house laboratory services. All contracted Labs will be charged as per sliding fee scale ($35.00). All Lab fees will be charged in addition to office visits on a sliding fee scale. Insurance will not be billed for Lab services. Any additional Gl*nlc fees 1 medisal preeedums will be shaFged at Med*Gald rates plams 0 Procedures not included in office visit 58301 IUD Removal $0.00 $104201 $19,801 $30.00 $40.20 $49.80 $54.00 $57.0 $60. 00 Page 2 of 9