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J <br />ATTACHMENT II <br />- <br />Fee <br />Schedule <br />INDIAN <br />RIVER CDUNTY 9LIC HEkTH UNIT <br />CLINICAL <br />FEE bDEDIA.E <br />SERV. DATE ....................... <br />SSI) <br />DIAGNOSIS <br />CLIENT <br />__________________ <br />D.O.B. --------------------- <br />- - - --- - - <br />-------------- <br />NEXT AFPT. <br />ADD.(Mai1) _______________________ <br />PROVIDER <br />---------------------- <br />---------------------- <br />CLINIC <br />CITY ---------------- <br />-------- <br />CLINIC <br />---------------------- <br />---------------------- <br />MD <br />-- -----_"_---"- <br />CA NP C)N <br />SEX ______ RACE ______ <br />CATEGORY <br />A B C 0 E F G H <br />SERVICES/PROCEDURES <br />CHA6*9E <br />PM. -CODE SERVICES/PROLEDUR�5 <br />- - - <br />CKIRGE <br />FROr, CODE <br />ffFICE VISIT (NEN PATIENT) <br />----_- (All Iyoes)-------- <br />Fluooen (A11 T oesl <br />- --- - <br />5.00 <br />------------ <br />- 90702 <br />90702 <br />Brief <br />30.00 <br />WAX") <br />HIB <br />5.00 <br />Limited <br />30.(10 <br />90010 <br />Henatitus A <br />10.00 <br />Intermediate <br />35,W <br />90015 <br />HeDatitUS B (Heptavax) <br />70.00 (cc) <br />Extended <br />44.50 <br />90017 <br />Heoatitus B (Iem. Glob.) <br />70.00 (cc) <br />Comprehensive <br />50.00 <br />90020 <br />Rabies Vaccine <br />50.W (Vial) <br />OFFICE VISIT (ESTABLISHED PATIENT) <br />MSEAS <br />Minimal <br />12.00 <br />96010 <br />Cholera <br />15.00 <br />Brief <br />21.50 <br />90040 <br />Typhoid <br />10,00 <br />Limited <br />21,50 <br />W.50 <br />Intermediate <br />25,00 <br />90060 <br />LABORATORY <br />Extended <br />30.00 <br />91A)7o <br />Blood Sugar Screening <br />5.00 <br />Comprehensive <br />45.00 <br />9006o <br />Blood Sugar Fasting (SGOT) <br />5.00 <br />84450 <br />OFi;„t Vlaii ,_....., -„„xis <br />{U PATIENT) <br />Culture/Skin <br />Culture/Throat <br />5.W <br />5.00 <br />87070 <br />Minimal <br />10.00 <br />Hematocrit ()ICT) <br />5.00 <br />87060 <br />8r.A18 <br />Brief <br />17.00 <br />Hemoglobin (HGB) <br />5.00 <br />8`.A18 <br />Limited <br />17,00 <br />Lead Blood <br />10,00 <br />Intermediate <br />20.001 <br />O'Sullivan <br />10,00 <br />Extended <br />24. (K) <br />Pregnancy Testing <br />5.00 <br />86006 <br />Comprehensive <br />36.00 <br />RH Factoring 9 <br />12.00 <br />86105 <br />EPSDT <br />Sickle Cell <br />10.00 <br />85660 <br />School Physical (MOI <br />20.00 <br />W9881 <br />Urine (Dip Stid) <br />3.00 <br />81000 <br />School Physical (CA) <br />16.00 <br />W9801 <br />VDRL <br />8.00 <br />86592 <br />School Physical (NP) <br />16.40 <br />W9001 <br />PHARMACY CHARGE <br />12.00 <br />School Physical (CHN) <br />10.00 <br />W9881 <br />COPIES <br />PAF SMEAR <br />10.00 <br />08150 <br />Medical Records (1-3 Pgs) <br />2,00 <br />MATERNITY <br />Medical Records (4-7 Pas) <br />3.00 <br />Ante Partum Care (Lox Risk) <br />800.00 <br />Medical Legal Records <br />15.00 <br />Ante Pattum Care (High Ftisk) <br />1200./10 <br />Physicals <br />Immunizations <br />1,00 <br />1,00 <br />New Pt. Comprehensive Vst. <br />50,00 <br />Established Pt. Limited Vst. <br />21.50 <br />MISCELLANEOUS <br />FAMILY PLANNING <br />Speciality Referral <br />45.00 <br />Initial/Post Partum Exam <br />60.00 <br />W9759 <br />Nutrition <br />Health Education <br />20.00 <br />110,00 <br />Medical <br />39,00 <br />Annual Exam <br />52,00 <br />Suoply/Counsel <br />14.00 <br />SEE ATTACHMENT A <br />Tubal Ligation <br />625.00 <br />Vasectomy <br />200,00 <br />INJECTIONS <br />TOTAL f _„ <br />Oral Polio <br />No Chrg, <br />90712 <br />DPT <br />No Chro. <br />90701 <br />SLIDING SCALE Z - <br />No Chrg. <br />09707 <br />" <br />TO Tine <br />5.00 <br />06585 <br />PPD <br />5.00 <br />86580 <br />-- <br />Pneumonococcal Vaccine <br />5.00 <br />01246 <br />OT (Adult) <br />10.00 <br />90702 <br />NMI` DUE S <br />