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Home My WebLink About2005-167 /0 O 5� 'rr RESOLUTION NO. 2005- 167 A RESOLUTION OF INDIAN RIVER COUNTY, FLORIDA, TO ADOPT A 2005/2006 FEE SCHEDULE FOR THE INDIAN RIVER COUNTY HEALTH DEPARTMENT. WHEREAS, the Indian River County Health Department has proposed a fee schedule for October 1 , 2005, through September 30, 2006, as more specifically set forth in Exhibit "A" attached hereto and made a part hereof; and WHEREAS, Florida Statutes section 154.06(1 ) provides that the Indian River County Board of County Commissioners must approve the fee schedule by resolution, NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF COUNTY COMMISSIONERS OF INDIAN RIVER COUNTY, FLORIDA, that: 1 . Effective October 1 , 2005, all of the fees set forth on Exhibit "A" are hereby approved for use by the Indian River County Health Department, pursuant to Florida law. 2. The fees set forth on Exhibit "A" are in effect from October 1 , 2005, through and including September 30, 2006, and, thereafter, shall continue to be in full force and effect from October 1 , 2006, and continuing until such time as the Indian River County Health Department requests that the Indian River County Board of County Commissioners adopt a new resolution that supersedes this Resolution in whole or in part. This Resolution was moved for adoption by Commissioner Davis and the motion was seconded by Commissioner Wheel er , and, upon being put to a vote, the vote was as follows: i i RESOLUTION NO. 2005- 167 Chairman Thomas S. Lowther Aye Vice Chairman Arthur R. Neuberger Aye Commissioner Wesley S. Davis Aye Commissioner Gary C. Wheeler Aye Commissioner Sandra L. Bowden Aye The Chairman thereupon declared the resolution duly passed and adopted this 4th day of October 12005. INDIAN RIVER COUNTY, FLORIDA I Attest: J. K. Barton, Clerk Board of County Commissioners ~ - By By gyp . Thomas S. Lowther, Chairman Deputy Cle APPROVED AS TO FORM Attachment: �EXhlbit-"A" ANS GAL SUFFICIENCY /4SS ANT To Y Effective Date: October 4, 2005, nunc pro tunc to October 1 , 2005. INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Oct 1, 2005 VISIT DESCRIPTION E/M CODES 0%-A 17%-B 33%-C 50%-D 67% -E 83% - F 100%-G COST Medical Visit-New Patient 99201 Level One $0.00 $9.35 $19.80 $27.50 $36.85 $45.65 $55.00 $55.00 99202 Level Two $0.00 $9.35 $19.80 $30.00 $40.20 $49.80 $60.00 $60.00 99203 Level Three $0.00 $11.05 $21.45 $32.50 $43.55 $53.95 $65.00 $65.00 99204 Level Four $0.00 $11.90 $23.10 $35.00 $43.55 $58.10 $70.00 $70.00 Nurse Protocol $0.00 $9.35 $18.15 $27.50 $36.85 $45.65 $55.00 $55.00 Medical Visit-Established Patient 99211 Level One $0.00 $5.44 $10.56 $16.00 $21.44 $26.56 $32.00 $32.00 99212 Level Two $0.00 $6.29 $12.21 $18.50 $24.79 $30.71 $37.00 $37.00 99213 Level Three $0.00 $7.14 $13.86 $21.00 $28.14 $34.86 $42.00 $42.00 99214 Level Four $0.00 $7.99 $15.51 $23.50 $31.49 $39.01 $47.00 $47.00 Nurse Protocol $0.00 $5.44 $10:56 $16.00 $21.44 $26.56 $32.00 $32.00 School/Work Physicial (CHCU)* $0.00 $5.44 $10.56 $16.00 $21.44 $26.56 $32.00 $32.00 REFUGEE Physical** $0.00 $10.20 $19.80 $30.00 $40.20 $49.80 $60.00 $60.00 *Medicaid"Child Health Check-Up"and routine physical do not include applicable in-house laboratory services. Must be established primary care patient to receive physical on sliding fee scale. **Does not include immunizations or laboratory services Out of County Primary Care Fee* $0.00 $30.00 $30.00 $30.00 $30.00 $30.00 $55.00 $55.00 *Deposit for services. Must be paid prior to clinic visit with balance due at completion of visit. Family Planning Initial/Annual Family Planning Visit* $0.00 $14.45 $28.05 $42.50 $56.95 $70.55 $85.00 $85.00 Subsequent Family Planning Visit(s) $0.00 $5.44 $10.56 $16.00 $21.44 $26.56 $32.00 $32.00 *Includes all applicable laboratory services A' EA1 a IBI 9/12/2005CLFEE2005-06 Page 1 of 8 INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Oct 1,2005 Procedures not included in office visit 0% -A 17%-B 33%-C 50%-D. 67%-E 83%- F 100%-G COST 57454 Colposcopy(with biopsy) $0.00 $8.50 $16.50 $25.00 $33.50 $41.50 $50.00 $50.00 57452 Colposcopy(without biopsy) $0.00 $6.80 $13.20 $20.00 $26.80 $33.20 $40.00 $40.00 58300 IUD Insertion $0.00 $9.35 $18.15 $27.50 $36.85 $45.65 $55.00 $55.00 58301 IUD Removal $0.00 $10.20 $19.80 $30.00 $40.20 $49.80 $60.00 $60.00 11975 IMPLANTABLE CONTRA INSERTION $0.00 $21.25 $41.25 $62.50 $83.75 $103.75 $125.00 $125.00 11976 IMPLANTABLE CONTRA REMOVAL $0.00 $21.25 $41.25 $62.50 $83.75 $103.75 $125.00 $125.00 11977 REMOVALIINSERTION $0.00 $32.30 $62.70 $95.00 $127.30 $157.70 $190.00 $190.00 11765 Ingrown Toenail Treatment $0.00 $6.80 $13.20 $20.00 $26.80 $33.20 $40.00 $40.00 17000 Wart Treatment-First $0.00 $5.95 $11.55 $17.50 $23.45 $29.05 $35.00 $35.00 17003 Wart Treatment-Second- 14 $0.00 $1.02 $1.98 $3.00 $4.02 $4.98 $6.00 $6.00 10060 Incision and Drainage $0.00 $9.35 $18.15 $27.50 $36.85 $45.65 $55.00 $55.00 94640 Respiratory Treatment $0.00 $1.36 $2.64 $4.00 $5.36 $6.64 $8.00 $8.00 57170 Diaphragm Fitting $0.00 $9.35 $18.15 $27.50 $36.85 $45.65 $55.00 $55.00 93000 EKG $0.00 $5.10 $9.90 $15.00 $20.10 $24.90 $30.00 30.00 Procedures with set charges 0%-A 17%-B 33%-C 50%-D 67%-E 83%- F 100% -G COST 71020 Chest X-Ray $0.00 $9.35 $18.15 $27.50 $36.85 $45.65 $55.00 $55.00 Tubal Ligation Surgical $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 Band or Clip $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 Postpartum $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 Post Cesarean $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 Inpatient Per Diem $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 Outpatient Fee $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 $1,000.00 Vasectomy $450.00 $450.00 $450.00 $450.00 $450.00 $450.00 $450.00 $450.00 Nutritional Counseling-per hour $0.00 $5.95 $11.55 $17.50 $23.45 $29.05 $35.00 $35.00 PPD TB Evaluation $0.00 $1.70 $3.30 $5.00 $6.70 $8.30 $10.00 $10.00 9/12/2005CLFEE2005-06 Page 2 of 8 INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Oct 1, 2005 Immunizations 0%-A 17%-B 33%-C 50%-,D 67% -E 83%- F 100%-G COST . Influenza $0.00 $4.76 $9.24 $14.00 $18.76 $23.24 $28.00 $28.00 Pneumococcal Pneumonia $0.00 $5.95 $11.55 $17.50 $23:45 $29.05 $35.00 $35.00 Measles/Mumps/Rubella $0.00 $9.35 $18.15 $27.50 $36.85 $45.65 $55.00 $55.00 Tetanus $0.00 $4.25 $8.25 $12.50 $16.75 $20.75 $25.00 $25.00 Injected Polio Vaccine $0.00 $5.95 $11.55 $17.50 $23.45 $29.05 $35.00 $35.00 Varivax(Chicken Pox) $0.00 $13.60 $26.40 $40.00 $53.60 $66.40 $80.00 $80.00 Meningococcal $0.00 $16.15 $31.35 $47.50 $63.65 $78.85 $95.00 $95.00 Rabies Vaccine(per injection) $125.00 $125.00 $125.00 $125.00 $125.00 $125.00 $165.00 $165.00 RIG - Per 2cc Vial $150.00 $150.00 $150.00 $150.00 $150.00 $150.00 $150.00 $150.00 Hepatitis A Vaccine(per injection) $0.00 $5.95 $11.55 $17.50 $23.45 $29.05 $35.00 $35.00 Hepatitis B Vaccine(per injection) $0.00 $7.65 $14.85 $22.50 $30.15 $37.35 $45.00 $45.00 Twinrix-Hep A,&B(per injection) $0.00 $10.20 $19.80 $30.00 $40.20 $49.80 $60.00 $60.00 Per CDC guidelines, vaccine for childhood immunizations are covered under the Vaccine for Children Program and are provided at no cost to children age 0-18. Charges for communicable disease control issues will be waived with authorization. Travel'lmmunizations(Sliding Fee Scale does not apply--Per Injection) Travel Immunization Consult Visit $32.00 Hepatitis B Vaccine $45.00 Hep B Immune Globulin* $550.00 Hepatitis A Vaccine $35.00 Hepatitis A Vaccine-Children $35.00 Twinrix(Hep A&B) $60.00 Hep A Immune Globulin* $45.00 Per 2 ml dose Meningococcal $95.00 Tetanus $25.00 Typhoid $65.00 Yellow Fever $95.00 *As available 9112/2005CLFEE2005-06 Page 3 of 8 INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Oct 1,2005 Dental Services(Sliding Fee Scale does not apply) , D0120 Periodic OralExam $15.00 15211 Acrylic Partial(Upper) $285.00 D0140 Emergency Examination $15.00 D5212 Acrylic Partial (Lower) $285.00 D0150 Oral Examination $16.00 D5213 Cast Metal Partial(Upper) $425.00 D0210 Intra Oral Complete Sen (inc BW) $32.00 D5214Cast Metal Partial(Lower) $425.00 D0220 Periapical First Film $4.00 D5281 Partial Denture $243.75 D0230.Pedapical Addfl Film $3.00 D5410 Adj Denture Max $14.00 D0240 Intra Oral-Occlusal $8.00 D5411 Adj Denture Man $14.00 D0270 Bitewing-Single Film $6.00 D5421 Adj Partial Denture Max $14.00 D 0272 Bitewing-Two Films $9.00 D5422 Adj Partial Denture Man $14.00 10274 Bitewing-Four Films $11.00 D5510 Repair Complete Denture Base $90.00 DD0470 Diagnostic Casts $22.00 D5520 Replace Teeth Complete Denture $90.00 D1110 Prophylaxis`Adult $34.00 D5640 Replace Teeth Partial Denture $90.00 D1120 Prophylaxis-Child $14.00 D5650 Add Tooth Partial Existing Denture $100.00 D1203 Topical Fluoride-Child $11.00 D5660 Add Clasp Partial Denture $150.00 D1204 Topical Fluoride Adult $16.00 D5730 Reline Complete Max-Chairside $63.00 D1330 Oral Hygiene Instructions $6.00 D5731 Reline Complete Man-Chairside $63.00 D1351 Sealant-Per Tooth $13.00 - D5750 Reline Complete Max-Lab $180.00 D1510 Space Maintainer-Fixed Unilateral $72.00 D5751 Reline Complete Man-Lab $180.00 D1515 Space Maintainer-Fixed Bilateral $117.00 D5820 Acrylic Flipper-Upper $150.00 D1550 Recement Space Mait $17.00 D5820 Acrylic Flipper-Lower $150.00 D2140 Amalgam-One Surface D or P $31.00 D6242 Pontic Porcelain Fused to Gold $232.25 D2150 Amalgam-Two Surface D or P $41.00 16752 Crown Porcelain Fused to Gold $237.50 D2160 Amalgam-Three Surface D or P $51.00 D7111 Single Tooth Extraction (Child) $27.00 D2161 Amalgam-Four or more D or P $61.00 D7140 Single Tooth Extraction (Adult) $35.00 D2330 Resin-One Surface Anterior Primary $34.00 D7210 Surgical Removal of Tooth $55.00 D2331 Resin-Two Surface Anterior Primary $39.00 D7220 Removal of Impacted Tooth(Soft Tissue) $62.00 D2332 Resin-Three Surface Anterior Primary $44.00 D7230 Removal of Impacted Tooth(Partially Bony) $77.00 D2335 Resin-Four or more Anterior Primary $72.00 D7240 Removal of Impacted Tooth(Completely Bony) $79.00 D2390 Anterior Composite Resin Crown $72.00 D7241 Removal of Impacted Tooth (Completely Bony unusual) $82.00 D2391 Resin-One Surface Post Primary $31.00 D7250 Root Recovery-Sergical $54.00 D2392 Resin-Two Surface Post Primary $41.00 D7270 Tooth.Reimplant/Stabilization $27.00 D2393 Resin-Three Surface Post Primary. $51.00 D7281 Surgical Exposure to Aid Eruption $38.00 D2394 Resin-Four or more $78.00 D7285 Biopsy-Hard Tissue $110.00 D2752 Permanent Crown $231.25 D7286 Biopsy-Soft Tissuel $77.00 D2792 Gold Crown (Posterior) $228.25 17310 Alveolectomy With Extraction $45.00 D2920 Recement Crown $17.00 D7320 Alveolectomy No Extraction $56.00 12930 Prefabricated Steel Crown Primary $68.00 D7410 Surgical Excision<1.25cm $110.75 D2931 Prefabricated Steel Crown Permanent $68.00 D7411 Surgical Excision>1.25cm $167.25 D2940 Sedative Filling $18.00 D7450 Cyst Removal 1 $125.25 D2950 Crown Build-Up $65.00 D7471 Removal of Exotosis $170.25 9/12/2005CLFEE2005-06 Page 4 of 8 i INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Oct 1, 2005 Dental Services(Sliding Fee Scale does not apply)CONTINUED D2951 Pin Retention-Per Tooth $2.00 D7510 1&D-Intraoral (Dranage Abcess) $47.00 D2954 Prefab Post/Core in Add Crown $53.00 D7960 Frenulectomy $106.75 D2970 Temp Crown $42.00 D9110 Palliative Services $13.00 D3110 Pulp Cap Direct $13.00 D9230 Analgesia(Nitrous) $28.00 D3120 Pulp Cap Indirect $11.00 D9310 Consultation $18.00 D3220 Therapeutic Pulpotomy $50.00 D9630 Drugsj $19.25 D3310 Root Canal(Anterior) $148.00 D9920 Behavior Management $24.00 D3320 Root Canal(Bicuspid) $190.00 D9930 Unsched Post Op-Surgery $33.75 D3330 Root Canal(Molar) $235.00 D9940 Occlusal Guard-Hard $153.00 D4240 Periodontal Surgery $184.00 D9941 Occlusal Guard-Soft $125.00 D4341 Root Planning per Quadrant $40.00 D9951 Occlusal Adjustment-Limited $49.00 D4355 Full Mouth Debridement $46.25 D9972 External Bleaching 1 $139.30 D5110 Upper Denture(Full) $325.00 Resin Elected-One Surface** $55.00 D5120 Lower Denture(Full) $325.00 Resin Elected-Two Surface** $65.00 D5130 Immediate Denture-Max $418.00 Resin Elected-Three Surface** $80.00 D5140 Immediate Denture-Man $412.50 Resin Elected-Four or more** $105.00 **If client requests Resin fillings. Laboratory Services 0%-A 17%-B 33%-C 50%-D 67% -E 83%- F 100%-G COST IN-HOUSE LAB LAB $0.00 $1.70 $3.30 $5.00 $6.70 $8.30 $10.00 $10.00 Contracted Laboratory Services LAB $0.00 $3.40 $6.60 $10.00 $13.40 $16.60 $20.00 $20.00 NOTE: Tests which exceed a charge of$100.00 will be billed individually on sliding fee scale percentage based on IRCHD cost of lab service. IN-HOUSE and CONTRACTED LAB Fee is for all labs performed at the time of service. Pharmacy 4 Pharmaceutical items will be billed on a per pill basis at IRCHD cost. Attached to this fee schedule is a current listing of prices. An itemized pharmaceutical listing is updated weekly and is available by contacting the cashier. Items received from the State Pharmacy as in-kind donation at no cost to IRCHD will not'be charged to the patient. Medical Records Fees Copy of Medical Record/per page $1.00 per page for the first 25 pages; $.25 each additional page thereafter. NOTE: Florida Statutes regarding release of medical records must be met prior to release of medical records to any source. No fees are charged to physician offices/other medical agents with the understanding that IRCHD will also be exempt from such payment. 9/12/2005CLFEE2005-06 Page 5 of 8 INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Oct 1, 2005 Vital Statistics Fees Birth Certificates(computer) $12.00 Birth Certificates(book) $15.00 Additional Copies(computer) $8.00 Additional Copies(book) $8.00 Death Certificates $10.00 Research Fee(per year) $3.00 Expedite Fee $5.00 Overnite Shipment $10.00 Birth Certificates are provided free of charge to the following only: Children&Families Case Workers who are involved in a custody case. Case Worker must present proper ID, completed application request and copy of the signed court petition. Only one certified copy will be provided per six(6) month period. Environmental Health County Fees Well Permit(Potable) $75.00 Environmental Health Plan Review $75.00 Well Permit(Irrigation) $50.00 Environmental Assessment $150.00 Well Permit(2 Sites or more) $100.00 Grease Trap Construction Permit $75.00 Well Abandoment $0.00 Grease Trap Annual Operating Permit $50.00 Well Permit Construction Variance $100.00 Hazardous Waste Verification/Assessment/Inspection $50.00 Public Supply Well Permit $250.00 "After the Fact"OSTDS New System $400.00 Demolition Permit $50.00 "After the Fact"OSTDS Repair Permit $230.00 Demolition Permit $100.00 Bacteriological Water Sample(Drinking Water) $20.00 Reinspection for Demolition Permit $25.00 Chemical Water Sample 1 $5.00-$25.00 Environmental Health Misc. Lab $20.00 Indoor Air Quality Assessment $50.00 Site Plan Review-OSTDS $75.00 Administrative Site Plan-OSTDS $50.00 Site Plan Review-Sewer $20.00 Administrative Site Plan-Sewer $20.00 Site Plan Amended-OSTDS $50.00 Subdivision Plan Review OSTDS 0-100=$100$1 for ea over 100: $100 and UP Site Plan Amended-Sewer $10.00 Subdivision.Plan.Review Sewer $20.00 Environmental Health State Fees Please see Attachment Vl 9/12/2005CLFEE2005-06 Page 6 of 8 INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Oct 1,2005 Florida Administrative Code,Chapter 1013-121 For the purpose of family planning, sexually transmitted disease, or HIV/AIDS services only, minors seeking those services shall be considered a separate family for income eligibility determination purposes and shall be assessed.fees for those services based upon their own personal gross income. Any client who elects to waive the eligibility determination process shall be assigned to the full fee category. If there is no fee for a service, income eligibility does not need to be determined, except for WIC. The self-declaration statement shall include a signed acknowledgment that the statement is true at the time it is made, and that the person making the statement understands that the provider shall attempt to verify the statement. Verification can be secured by telephone, in written form, or by face-to-face contact, verification does not require a written document to confirm an applicant's or client's statement. If the provider is unable to verify wages paid or an employer will not verify wages paid, the self-declaratory statement provided by the applicant must be accepted as accurate. Clients served by CHD's and their subcontractors shall not be denied services for tuberculosis, sexually transmitted disease, or HIV/AIDS communicable disease control because of failure or inability to pay a prescribed fee, regardless of their income. Clients interviewed, examined, or tested at IRCHD's initiative because they are a contact to a case of communicable disease or because they are a member of a group at risk that is being investigated by the IRCHD shall not be charged a fee for the interview, examination, or testing; these clients may be charged on a sliding fee scale for any treatment indicated, but they cannot be denied services based on inability to pay. Clients served by IRCHD and their subcontractors shall not be denied family planning services for failure or inability to pay a prescribed fee, regardless of their income; however, the family planning services of inserting Norplant, and male and female sterilization, shall be limited depending on the availability of funds to pay for these services. Clients shall not be denied pregnancy testing for failure or inability to pay. Clients may request a review of their fee charge on the basis that they have severe, unusual, and unavoidable expenses or obligations that substantially reduce their ability to pay and which warrant special consideration. 9/12/2005CLFEE2005-06 Page 7 of 8 INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Oct 1, 2005 IRCHD POLICIES School Year Policy Regarding Physicals: If a patient is already established at IRCHD as a primary care patient, physicals will be given based on sliding fee scale; however, if they are new to the clinic for medical care, they must pay the advance fee of$32.00 unless they register as a primary care patient and transfer all current medical records to the health department. County of Residence: (Primary Care) If a patient has Medicaid, other confirmed medical coverage, or prepays out of county charge,we will see them in the clinic and bill for service. However, all sliding fee or zero pay patients must be seen at the health department in the county of their residence. Failure to show confirmation of county residence will result in payment of 100%until such confirmation is obtained. (Exception to this rule will be for treatment of communicable diseases and family planning services. Insurance will not be billed for family planning services. Employee medical care will be provided based on approved policy and procedure. Hepatitis A&B vaccines are provided free of charge to ages 0-18 per CDC Vaccine for Children guidelines. If a patient has Medicaid coverage. Medicaid will cover Hep A&B to age 21. Vaccines will not be provided on a sliding fee scale for non-established patients over the age of 18. EXCEPTION: Vaccine will be provided free of charge or on reduced fee if vaccine is treatment for communicable disease. Anonymous HIV Testing: $25.00 fee applies to all patients who request HIV test. However, test will be given regardless of ability to pay. Reduced fee will be accepted for hardship cases. Per agreement with Partners in Women's Health, a reduced fee of$10.00 will be billed to those patients who are pregnant and referred to IRCHD for HIV testing. Access to dental services will be limited to those patients who make 200%or less of the Federal Poverty Level. (Effective May 8, 2002) 9/12/2005CLFEE2005-06 Page 8 of 8 INDIAN RIVER COUNTY HEALTH DEPARTMENT FORMULARY PRICE LIST Cost Cost Unit per Unit per Product Name Issue UI Product Name Issue UI Acetaminophen suppositories 120 mg Each $0.14 Havrix Adult Hep-A prefilled Each Actifed tabs Box $2.45 Havrix Pediatrics He -A prefilled Each Albuterol inhaler Kit $2.78 Hepatitis A Immune globulin 2ml Each Albuterol.083% Each $0.10 Hepatitis B Immune globulin 5ml Each Aldactone 50 mg(Spironolactone) Each '$0.68 Hydrochlorothiazide 25 mg Each $0.02 Amitriptyline HCL 25 mg Each $0.02 Hydrocortisone 1%cream Tube $0.82 Amoxicillin 250 mg susp Bottle $2.03 lbu rofen 400 mg Each $0.02 Aspirin EC 325 mg Each 0.01,Kenalog 40,in' 1 cc in' $5.77 Aspirin EC 81 mg Each $0.02 Lisinopril 20 mg Each $0.07 Atenolol 50 mg Each $0.03 Lisino ril 5 mg Each $0.05 Atenolol 100 mg Each $0.06 Medrox pro esterone Acetate(Depo-Provera)tabs 10 mg. Each $0.10 Aurodex ear drops Bottle $0.89 Metformin hcl 500 m (Glucophage) Each $0.05 Bacitracin Tube $1.11 Metformin hcl 1000 m (Glucophage) Each $0.08 Benzoin Comp Tincture Bottle $17.65 Motrin,childrens berry Bottle $4.21 Captopril 50 mg Each $0.02 MMR Vacine Each Captopril 100 mg Each $0.06 Naproxin 500 mg Each $0.07 Cephalexin 250 mg Each $0.05 Neomvcin/Polymyxin Gramicidin opthalmic solution Bottle $16.02 Cephalexin 500 mg Each $0.09 Neomycin/Polymyxin HC opthalmic solution Bottle $8.89 Cephaiexin suspension 125 mg Bottle $6.78 Nitrotab sub lingual 3mg Each $0.03 Cephalexin suspension 250 mg Bottle $9.69 Nix Bottle $7.76 Ciprofloxin hcl 500 mg Each $0.09 Pen VK suspension 250 mg Bottle $2.74 Clonidine.1 mg Each $0.05 Pen VK tabs 500 mg Each $0.15 Clonidine.2 mg Each $0.07 Phen le hrin 2.5%optic solution Bottle $1.49 Clotrimazole cream 1% Tube $1.20 Phene ran suppositories 12.5 mg Each $3.46 Coreg 3.12 mg(Carvedilol) Each $1.51 Pneumovax 1 cc in' Coreg 6.25 m (Carvedilol) Each $1.51 Pink bismuth Each $0.06 Cyanocobalamin 1000mcg 1 cc in' $0.54 Prednisone 10 mg Each $0.02 Depo-Medrol 80 mg 1 cc in' $8.24 Proparacaine.5 O/S Bottle $1.88 Dexamethone Sod Phos 4 mg 1 cc in' $0.31 Q-Tussin Bottle $0.76 Diabetic tussin Bottle $4.20 Ranitidine 150 m (Zantac) Each $0.03 Digoxin.25 mg Each $0.07 Silvadene cream 1% Tube $5.34 Elimite Tube $32.77 Sodium Chloride.9% Bottle $7.67 Engerix-B adult 20mcg Each Triam/HCTZ 37.5/25 Each $0.05 Engerix-B pediatric 10 mcg .5 cc in' Triamcinolone 0.1%Cream Tube $1.23 Erythromycin e e ointment 5m / m Tube $0.59 Triple anitbiotic ointment Tube $1.96 Erythromycin Stearate 500 mg Each $0.13 Tropicamide I%optic solution Bottle $2.43 Ethyl Chloride Fine 103.05 ml Each $14.64 TwinRix 1 cc in' Fluor-I-Strips Each $0.16 T phim VI prefilled syringe .5 cc in' Furosemide 20 m (Lasix) Each $0.19 Vera amil 240 mg Each $0.19 Furosemide 40 m (Lasix) Each $0.21 Warfarin 2 m (Coumadin) Each $0.12 Genahist allergy 25 mg Box $0.90 Warfarin 5 m Coumadin Each $0.12 Genapap caplet 500 mg Each $1.67 Xylocaine 1% Vile $2.58 Genapap infant drops Bottle $1.13 X locaine 2% Vile $3.57 Glyburide 5 mg Each $0.07 Note:A$1.50 per bottle repack fee will be added to all dipensed medications under the repackaging program. Blank fees are covered under the fee schedule. CLFEE2005-06 10:00 AM 9/9/2005 REDLANDS CHRISTIAN MIGRANTS ASSOCIATION Services Agreement February 01, 2005 -January 31, 2006 RCMA CURRENT SFS Health and Disabilities 0%-A 17%-B 33%-C 50%-D 67%-E 83%- F 100%-G COST COST Physical Exam ` $0.00 $4.08 $7.92 $12.00 $16.08 $19:92 $24.00 $24.00 $32.00 Hemoglobin/Hematocrit $0.00 $1.28 $2.48 $3.75 $5.03 $6.23 $7.50 $7.50 $10.00 TB Screening $0.00 $1.28 . $2.48 $3.75 $5.031 $6.23 $7.50 $7.50 $10.00 Lead Screening $0.00 $1.28 $2.48 $3.75 $5.03 $6.23 $7.50 $7.50 $10.00 Vision Screening $0.00 $1.28 $2.48 $3.75 $5.03 $6.23 $7.50 $7.50 $10.00 Hearing Screening $0.00 $1.28 $2.48 $3.75 $5.03 $6.23 $7.50 $7.50 $10.00 Dental Screening N/A Dental Exam&Treatment N/A NOTE: Lead,Vision and Hearing screening is included in Physical Exam. Dental Screening, Dental Exam and Treatment is covered under a separate agreement. Hepatitis B Vaccine/Blood Exposure RCMA CURRENT SFS Agreement 0%-A 17%-B 330/6-C 50%-D 67%-E 83%- F 100%-G COST COST Office Visit for Hep B Vaccine $0.00 $7:01 $13.61 $20.63 $27.64 $34.24 $4.1.25 $41.25 $55.00 Hep Vaccine per shot $0.00 $4.46 $8.66 $13.13 $17.59 $21.79 $26.25 $26.25 $35.00 Hepatitis B antibody Testing $0.001 $2.551 $4.95 $7.50 $10.051 $12.451 $15.001 $15.001 $20.00 Exposure incident Evaluation,Testing, and - Counseling N/A NOTE: Exposure incident Evaluation and Counseling included in cost of Office Visit. Lab fees are charged separately. RCMA CURRENT SFS Dental Services 0%-A . 17%-B 33%-C 50%-D 67%-E 83% F 100%-G COST COST D0150 Oral Examination $8.00 $16.00 D1120 Prophylaxis-Child $7.00 $14.00 D1203 Topical Fluoride-Child $5.50 $11.00 D 0272 Bitewing-Two Films $4.50 $9.00 D7111 Single Tooth Extraction $13.50 $27.00 D3220 Therapeutic Pulpotomy $25.00. $50.00 D2140 Amalgam-One Surface $15.50 $31.00 D2150 Amalgam-Two Surface $20.50 $41.00 D2160 Amalgam-Three Surface $25.50 $51.00 D2330 Resin-One Surface Anterior Primary $17.00 $34.00 D2331 Resin-Two Surface Anterior Primary $19.50 $39.00 D2332 Resin-Three Surface Anterior Primary 1 $22.001 $44.00 D2930 Prefabricated Steel Crown Primary 1 $34.001 $68.00 Missed Appointment. $8.001 $16.00 NOTE: No Sliding Fee Scale for Dental Services. JAKLINE\Core Contract 05-06\CLFEE2005-06, RCMA 9/8/2005