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INDIAN RIVER COUNTY HEALTH DEPARTMENT <br /> FEE SCH' E <br /> Fees shall be no less than the Medicaid Fee-for-Service reimbursement and no greater than the Medicare reimbursement rate plus fifty percent, <br /> in effect at the time of service,or comparable reimbursement rates if no such rates are availble. <br /> 10 .:G"' CY 12-13 <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 $41.00 <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 <br /> $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 1 Sports/Work Physical ; ;,. , ,(NOSLIDII�aFE,Gr .�t Wit"' a�, 06 <br /> " $25.00 $25.00 <br /> Physical(CHCU)* $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 laboratory 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 $Q.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 <br /> $25.39 $25.39 <br /> 99499-Flouride Varnish-521.01 $0.00 $4.25 $8.25 $12.50 $16.75 $20.75 <br /> $25.00 $25.00 <br /> HIV Pre-Test Counseling $0.00 $4.25 $8,25 <br /> $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 $0.00 <br /> $0.00 $0.00 <br /> +included in pre-test counseling <br /> ,4f#"dditional rlint6-fees-1 FnediGat-pFeGedWes will-fie GhaF ed at Meth_'.'Fates plus 260/; <br /> Out of County Patient Fees* Patients will be assessed at 100%of Sliding Fee Scale <br /> EXHIBIT "A" <br /> iV Page 1 of 9 <br /> 00 <br />