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INDIAN RIVER COUNTY HEALTH DEPARTMENT <br /> FEE SCHEDULE -- Effective Oct 1 , 2003 <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 $7 . 65 $ 16. 50 $22 . 50 $30 . 15 $37 . 35 $45 . 00 $45 . 00 <br /> 99202 Level Two $0 . 00 $7 . 65 $ 16 . 50 $25 . 00 $33 . 50 $41 . 50 $50 .00 $50 . 00 <br /> 99203 Level Three $0 . 00 $9 . 35 $ 18 . 15 $27 . 50 $36. 85 $45. 65 $55 . 00 $55 . 00 <br /> 99204 Level Four $0 . 00 $ 10 .20 $ 19 . 80 $30 .00 $36 . 85 $49 . 80 $60 .00 $60 . 00 <br /> 99205 Level Five $0 .00 $ 11 . 05 $ 18. 15 $32 .50 $43 . 55 $53 . 95 $65.00 $65 . 00 <br /> Nurse Protocol $0 . 00 $7 . 65 $ 14 . 85 $22 . 50 $30 . 15 $37 .35 $45 . 00 $45. 00 <br /> Medical Visit - Established Patient <br /> 99211 Level One $0 . 00 $5. 10 $9 . 90 $ 15 .00 $20 . 10 $24 . 90 $30 . 00 $30 . 00 <br /> 99212 Level Two $0 . 00 $5 . 95 $ 11 . 55 $ 17 . 50 $23 .45 $29 . 05 $35 . 00 $35 . 00 <br /> 99213 Level Three $0 . 00 $6 . 80 $ 13 . 20 $20 . 00 $26 . 80 $33 . 20 $40 . 00 $40 . 00 <br /> 99214 Level Four $0 . 00 $7 . 65 $ 14 . 85 $22 . 50 $30 . 15 $37 . 35 $45 . 00 $45 . 00 <br /> 99215 Level Five $0 . 00 $8. 50 $ 16 . 50 $25 .00 $33 . 50 $41 . 50 $50 . 00 $50 . 00 <br /> Nurse Protocol $0 .00 $5 . 10 $9 . 90 $ 15 . 00 $20 . 10 $24 . 90 $30 . 00 $30 . 00 <br /> School/Work Physicial (CHCU )* $0 . 00 $5. 10 $9. 90 $ 15 . 00 $20 . 10 $24 . 90 $30 . 00 $30 . 00 <br /> Immigration Physical** $0 .00 $8 . 50 $ 16 . 50 $25 . 00 $33 . 50 $41 . 50 $50 . 00 $50 . 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 /> **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 $30 . 00 $30 . 00 <br /> *Deposit for services . Must be paid prior to clinic visit with balance due at completion of visit. <br /> Family Planning <br /> Initial/Annual Family Planning Visit* $0 . 00 $ 13. 60 $26 .40 $40 . 00 $53 .60 $66 .40 $80 . 00 $80 . 00 <br /> Subsequent Family Planning Visit(s ) $0 . 00 $3 .40 $6 . 60 $ 10 . 00 $ 13 .40 $ 16 . 60 $20 . 00 $20 . 00 <br /> * Includes all applicable laboratory services <br /> 9/9/2003CLFEE2003-04 Page 1 of 7 <br />