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INDIAN RIVER COUNTY HEALTH DEPARTMENT <br /> FEE SCHF IE <br /> y 12-13 <br /> RTR'T�0'A1101, <br /> C Fee <br /> rvrr a oo ° �° ° 0"A.3:.�. 6. 4 . l? r�Qi�" 4,. 95a° r a. . . <br /> 3 I� <br /> 8 -St !iw - ,8,..., ..., .,,. <br /> Medical Visit-New Patient <br /> 99201 Level One $0.00 $6.97 $13.53 $20.50 $27.47 $34.03 $36.90 $38.95 $41.00 $41.00 <br /> 99202 Level Two $1.00 $7.31 $14.19 $21.50 $28.81 $35.69 $38.70 $40.85 $43.00 $43.00 <br /> 99203 Level Three $2.00 $10.88 $21.12 $32.00 $42.88 $53.12 $57.60 $60.80 $64.00 $64.00 <br /> 99204 Level Four $3.00 $15.30 $29.70 $45.00 $60.30 $74.70 $81.00 $85.50 $90.00 $90.00 <br /> 99201 TD Nurse Protocol $4.00 $4.25 $8.25 $12.50 $16.75 $20.75 $22.50 $23.75 $25.00 $25.00 <br /> Medical Visit-Established Patient <br /> 99211 Level One $0.00 $2.89 $5.61 $8.50 $11.39 $14.11 $15.30 $16.15 $17.00 $17.00 <br /> 99212 Level Two $0.00 $4.93 $9.57 $14.50 $19.43 $24.07 $26.10 $27.55 $29.00 $29.00 <br /> 99213 Level Three $0.00 $5.95 $11.55 $17.50 $23.45 $29.05 $31.50 $33.25 $35.00 $35.00 <br /> 99214 Level Four $0.00 $9.18 $17.82 $27.00 $36.18 $44.82 $48.60 $51.30 $54.00 $54.00 <br /> 99211 TD Nurse Protocol $0.00 $2.89 $5.61 $8.50 $11.39 $14.11 $15.30 $16.15 $17.00 $17.00 <br /> Family Planning <br /> Initial/AnnualmlFamily Planning Visit $15.30 $29.70 $45.00 $60.30 $74.70 $81.00 $85.50 $90.00 $90.00 <br /> Subsequent Family Planning Visit(s) $0.00 $6.29 $12.211 $18.50 $24.79 $30.71 $33.30 $35.15 $37.00 $37.00 <br /> *Includes all applicable in-house laboratory services.All contracted Labs will be charged as per sliding fee scale($35.00). <br /> All Lab fees will be charged in addition to office visits on a sliding fee scale. Insurance will not be billed for Lab services. <br /> -An"dditie recederes will he shairged at M ° <br /> Procedures not included in office visit <br /> 58301 IUD Removal $0.00 $10.20 $19.80 $30.00 $40.20 $49.80 $54.00 $57.0 $60.00 $60.0 <br /> Page 2 of 9 <br /> SO <br />