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INDIAN RIVER COUNTY HEALTH DEPARTMENT <br /> FEE SCHEDULE -- Effective Oct 1 , 2003 <br /> Procedures not included in office visit 0% = A 17% - B 33% - C 50% - D 67% - E 83% - F 100% - <br /> G COST <br /> IUD Insertion $0 . 00 $4 . 25 $8 .25 $ 12 . 50 $ 16. 75 $20 . 75 $25 . 00 $25 .00 <br /> IUD Removal $0 .00 $2 . 04 $3. 96 $6 . 00 $8 . 04 $9. 96 $ 12 . 00 $ 12 . 00 <br /> Norplant Removal (medical necessity) $0 . 00 $ 17.00 $33 . 00 $50 . 00 $67. 00 $83 .00 $ 100 . 00 $ 100 . 00 <br /> Ingrown Toenail Treatment $0 . 00 $ 1 . 02 $ 1 . 98 $3. 00 $4 . 02 $4. 98 $6 . 00 $6 . 00 <br /> Wart Treatment $0 .00 $ 1 . 70 $3. 30 $5 . 00 $6 . 70 $8 . 30 $ 10 .00 $ 10 . 00 <br /> Wart Treatment with Nitrogen Freeze $0 . 00 $3 .40 $6 . 60 $ 10 .00 $ 13.40 $ 16 . 60 $20 . 00 $20 . 00 <br /> Incision and Drainage $0 . 00 $4 . 25 $8 .25 $ 12 . 50 $ 16 . 75 $20 . 75 $25 . 00 $25 . 00 <br /> Respiratory Treatment $0 .00 $4 .25 $8 . 25 $ 12 . 50 $ 16 . 75 $20 . 75 $25 . 00 $25 . 00 <br /> Diaphragm Fitting $0 . 00 $4 . 25 $8 .25 $ 12 . 50 $ 16 . 75 $20 . 75 $25 . 00 $25 . 00 <br /> Colposcopy (with biopsy) $0 . 00 $5. 95 $ 11 . 55 $ 17 . 50 $23 .45 $29 . 05 $35 . 00 $35 . 00 <br /> Colposcopy (without biopsy) $0 . 00 $2 . 55 $4 . 95 $7.50 $ 10 .05 $ 12 .45 $ 15 . 00 $ 15 . 00 <br /> Procedures with set charges 0% = A 17% - B 33% - C 50% - D 67% - E 83% - F 100% - G COST <br /> Chest X-Ray $0 . 00 $5 .44 $ 10 . 56 $ 16 . 00 $21 .44 $26 . 56 $32 . 00 $32 . 00 <br /> HIV ( Includes Pre/Post Counseling ) $0 .00 $4 .25 $8 . 25 $ 12 . 50 $ 16 . 75 $20 . 75 $25 . 00 $25 . 00 <br /> Tubal Ligation <br /> Surgical $ 1 ,000 . 00 $ 19000 . 00 $ 19000 . 00 $ 1 , 000 .00 $ 1 ,000 . 00 $ 1 ,000 .00 $ 19000 . 00 $ 19000 <br />.00 <br /> Band or Clip $ 19000 . 00 $ 10000 .00 $ 19000 . 00 $ 1 ,000 . 00 $ 1 ,000 . 00 $ 1 ,000 . 00 $ 1 ,000 .00 $ 19000 <br />. 00 <br /> Postpartum $ 1 , 000 . 00 $ 19000 . 00 $ 19000 . 00 $ 1 ,000 . 00 $ 19000 .00 $ 11000 .00 $ 1 ,000 . 00 $ 19000 <br />.00 <br /> Post Cesarean $ 1 ,000 . 00 $ 19000 . 00 $ 1 ,000 . 00 $ 1 , 000 . 00 $ 1 ,000 . 00 $ 19000 . 00 $ 19000 . 00 $ <br />19000 . 00 <br /> Inpatient Per Diem $ 1 , 000 . 00 $ 19000 .00 $ 19000 . 00 $ 19000 . 00 $ 19000 . 00 $ 1 ,000 . 00 $ 19000 . 00 $ <br />19000 . 00 <br /> Outpatient Fee $ 1 ,000 . 00 $ 1 ,000 . 00 $ 19000 . 00 $ 19000 .00 $ 1 ,000 .00 $ 11000 .00 $ 19000 .00 $ 19000 <br />. 00 <br /> Vasectomy $450 . 00 $450 . 00 $450 . 00 $450 . 00 $450 . 00 $450 . 00 $450 . 00 $450 . 00 <br /> Nutritional Counseling - per hour $0 . 00 $4 . 25 $8 . 25 $ 12 . 50 $ 16 . 75 $20 . 75 $25 . 00 $25 . 00 <br /> PPD TB Test $0 .00 $ 1 . 70 $3 . 30 $5.00 $6 . 70 $8 . 30 $ 10 .00 $ 10 . 00 <br /> Immunizations 0% - A 17% - B 33% - C 50% - D 67% - E 83% - F 100% - G COST <br /> Influenza $0 .00 $3 . 06 $5 . 94 $9 . 00 $ 12 . 06 $ 14 . 94 $ 18 . 00 $ 18 . 00 <br /> Pneumococcal Pneumonia $0 .00 $3 .40 $6. 60 $ 10 . 00 $ 13 .40 $ 16 .60 $20 . 00 $20 . 00 <br /> Measles/Mumps/Rubella $0 . 00 $6 . 80 $ 13 . 20 $20 .00 $26.80 $33 . 20 $40 . 00 $40 .00 <br /> Tetanus $0 . 00 $2 . 55 $4 . 95 $7 . 50 $ 10 . 05 $ 12 .45 $ 15 . 00 $ 15 . 00 <br /> Injected Polio Vaccine $0 . 00 $5 . 10 $9. 90 $ 15 . 00 $20 . 10 $24 . 90 $30 . 00 $30 . 00 <br /> Varivax (Chicken Pox) $0 .00 $ 10 .20 $ 19 . 80 $30 .00 $40 .20 $49 . 80 $60 . 00 $60 . 00 <br /> Meningococcal $0 . 00 $ 11 . 05 $21 .45 $32 . 50 $43 . 55 $53 . 95 $65. 00 $65 . 00 <br /> 9/9/2003CLFEE2003-04 Page 2 of 7 <br />