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INDIAN RIVER COUNTY HEALTH DEPARTMENT <br /> FEE SCHEDULE -- Effective Oct 1 , 2004 <br /> VISIT DESCRIPTION E/M CODES 0% - A 17% - B 33% - C 50% - D 67% - E 83% - F 100% - G COST <br /> Medical Visit - New Patient <br /> 99201 Level One �- $0 . 00 $9. 35 $ 19 .80 $27 . 50 $36 . 85 $45.65 $55.00 $55.00 <br /> 99202 Level Two $0.00 $9 .35 $ 19 . 80 $30 . 00 $40 .20 $49 .80 $60 . 00 $60 . 00 <br /> 99203 Level Three $0 .00 $ 11 . 05 $21 .45 $32 .50 $43 . 55 $53 . 95 $65. 00 $65.00 <br /> 99204 Level Four $0 . 00 $ 11 .90 $23 . 10 $35 .00 $43 . 55 _ $58 . 10 $70 .00 $70 .00 <br /> Nurse Protocol $0 . 00 $9 . 35 $ 18 . 15 $27 . 50 $36.85 $45 . 65 $55 00 $55 . 00 <br /> Medical Visit - Established Patient - <br /> 99211 Level One $0 .00 $5 .44 $ 10 . 56 $ 16.00 $21 .44 $26 .56 $32 .00 $32 .00 <br /> 99212 Level Two _ $0 .00 $6 .29 $ 12 .21 _ $ 18 . 50 $24 . 79 $30 . 71 $37 . 00 $37 . 00 <br /> 99213 Level Three $0 .00 __$77 -_14 $ 13 . 86 <br /> �- _ - _ $21_. 00 - $28 . 14 1 $34 .86 1 $42 . 00 $42 .00 <br /> 99214 Level Four 1 $0.00 $7 . 99 $ 15 . 51 1 $23. 50 $31 .49 $39 .01 $47 .00 $47 . 00 <br /> Nurse Protocol $0 .00 $5 .44 $ 10 .6 $ 16 $21 .44 $26 . 56 ! - $32 . 00 $32 .00 <br /> School/Work Physicial (CHCU )* $0.00 $5 .44 $ 10 . 56 $ 16 .001 $21 .44 $26 . 56 $32 .00 $32 .00 <br /> Immigration Physical** $0 .00 $ 10 .20 $ 19.80 1 $30 . 00 ; $40 .20 $49 .80 $60 . 00 $60 . 00 <br /> *Medicaid "Child Health Check-Up" and routine physical do not include applicable in-house laboratory services . <br /> Must be established primary care patient to receive physical on sliding fee scale . <br /> **Does not include immunizations or contracted laboratory services <br /> Out of County Primary Care Fee* $0 . 00 $30 .00 $30 . 00 $30 .00 $30 .00 $30 . 00 $55 .00 $55 . 00 <br /> *Deposit for services. Must be paid prior to clinic visit with balance due at completion of visit. ; <br /> Family Planning I - <br /> Initial/Annual Family Planning Visit* $0 . 00 $ 14.45 $28 .05 $42 .50 $56 .95 $70 .55 $85 . 00 $85. 00 <br /> Subsequent Family Planning Visit(s ) 1 $0 . 00 $5 .44 $ 10 . 5_6 $ 16 . 00 $21 .44 _ $26 .56 $32 . 00 1 $32 .00 <br /> *Includes all applicable laboratory services <br /> 11 /2/2004CLFEE2004-05 Page 1 of 7 <br />