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Home My WebLink About2006-176 1 1/7/0 6 RESOLUTION NO. 2006- 176 A RESOLUTION OF INDIAN RIVER COUNTY, FLORIDA, TO, ADOPT - A 2006/2007 FEE SCHEDULE FOR THE INDIAN RIVER COUNTY HEALTH DEPARTMENT. WHEREAS, the Indian River County Health Department has proposed a fee schedule for November 1 , 2006, through September 30, 2007, 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 November 7, 2006, 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 November 1 , 2006, through and including September 30, 2007, and, thereafter, shall continue to be in full force and effect from November 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 Lowther , and the motion was seconded by Commissioner Davi s , and, upon being put to a vote, the vote was as follows: RESOLUTION NO. 2006- 176 Chairman Arthur R. Neuberger Aye Vice Chairman Gary C. Wheeler Aye Commissioner Sandra L. Bowden Aye Commissioner Wesley S. Davis Aye Commissioner Thomas S. Lowther Aye The Chairman thereupon declared the resolution duly passed and adopted this stn day of November , 2006. INDIAN RIVER COUNTY, FLORIDA Attest: J. K. Barton, Clerk Board ofz-County Commissioners By By Arthur R-.--Ne --.r.ger, man Deputy Clerk APPROVED AS TO FORM YSSISTANT EGAL SUFFICIENCY Attachment- Exhibit "A" ,MARIA EL COUNTY ATTORNEY Effective Date: November 7, 2006, nuns pro tunc to November 1 , 2006. INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Nov.01,2006 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- 99201 TD 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 99211 TD Nurse Protocol $0.00 $5.44 $10.56 $16.00 $21.44 $26.56 $32.00 $32.00 School/Work Physical(CHCU)* $0.00 $5.44 $10.56 $16.00 $21.44 $26.56 . $32.00 $32.00 *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. Out of County Primary Care Fee* $0.00 1 $30.00 1 $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 in-house laboratory services. EXHIBIT "A" 10/23/2006CLFEE2006-07 Page 1 of 11 INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Nov.01,2006 Procedures not included in office visit 0%-A 17% -B 33%-C 50%-D 67%-E 83% - F 100% -G COST 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 REMOVAUINSERTION $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 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 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 $300.00 $300.00 $300.00 $300.00 $300.00 $30.00 $300.00 $300.00 Nutritional Counseling-per hour $0.00 $5.95 $11.55 $17.50 $23.45 $29.05 $35.00 $35.00 TST Eval and placement if req $0.00 $1.70 $3.30 $5.00 $6.70 $8.30 $10.00 $10.00 10/23/2006CLFEE2006-07 Page 2 of 11 INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Nov.01,2006 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 $10.20 $19.80 $30.00 $40.20 $49.80 $60.00 $60.00 Tetanus $0.00 $4.25 $8.25 $12.50 $16.75 $20.75 $25.00 $25.00 Tdap $0.00 $5.95 $11.55 $17.50 $23.45 $29.05 $35.00 $35.00 Injected Polio Vaccine $0.00 $6.80 $13.20 $20.00 $26.80 $33.20 $40.00 $40.00 Varivax(Chicken Pox) $0.00 $15.30 $29.70 $45.00 $60.30 $74.70 $90.00 $90.00 Meningococcal $0.00 $17.85 $34.65 $52.50 $70.35 $87.15 $105.00 $105.00 Rabies Vaccine(per injection) $165.00 $165.00 $165.00 $165.00 $165.00 $165.00 $165.00 $165.00 RIG - Per 2cc Vial $150.00 $150.00 $150.00 $150.00 $150.00 $150.00 $165.00 $165.00 Hepatitis A Vaccine(per injection) $0.00 $6.80 $13.20 $20.00 $26.80 $33.20 $40.00 $40.00 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 Shingles Vaccine $170.00 $170.00 $170.00 $170.00 $170.00 $170.00 $170.00 $170.00 Cervical Cancer Vaccine $0.00 $22.95 $44.55 $67.50 $90.45 $112.05 $135.00 $135.00 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.Tetanus availability may be limited due to supply. Travel Immunizations(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 $40.00 Hepatitis A Vaccine-Children $40.00 Hep A Immune Globulin* $55.00 Per 2 ml dose Twinrix(Hep A&B) $60.00 Meningococcal $105.00 Tetanus $25.00 Tdap* $35.00 Typhoid $65.00 Yellow Fever $95.00 *As available 10/23/2006CLFEE2006-07 Page 3 of 11 INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Nov.01, 2006 Laboratory Services 0%-A 17% -B 33% -C 50%-D 67% -E 83%- F 100%-G COST IN-HOUSE LAB LAB $0.00 $2.55 $4.95 $7.50 $10.05 $12.45 $15.00 $15.00 Contracted Laboratory Services LAB $0.00 $4.25 $8.25 $12.50 $16.75 $20.75 $25.00 $25.00 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. 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. 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 Overnight 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. 10/23/2006CLFEE2006-07 Page 4 of 11 INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Nov.01, 2006 Environmental Health County Fees Well Permit(Potable) $75.00 Quarterly Sample Collection Fee and Analysis $250.00 Well Permit(Irrigation) $50.00 Grease Trap Construction Permit(Sewer) $75.00 Well Permit(2 Sites or more) $100.00 Grease Trap Annual Operating Permit $50.00 Well Abandonment $25.00 Haz Waste Assessment/Inspection (Small Quantity Generators) $50.00 Well Permit Construction Variance $100.00 OSTDS Permits After Construction Begins Double Fees Public Supply Well Permit $250.00 Annual Child Care Inspection Fee 1 $100.00 Demolition Permit:5 3000 sq ft $50.00 Annual Residential Facility Inspection Fee $50.00 Demolition Permit>3000 sq It $100.00 Sanitation Certification Inspection upon Request $50.00 Demolition Reinspection $25.00 Administrative Site Plan-OSTDS $50.00 Environmental Assessment $150.00 Administrative Site Plan-Sewer $25.00 Indoor Air Quality Assessment $50.00/hr Site Plan Review-OSTDS $75.00 Plan Review Regulated Facilities $75.00 Site Plan Review-Sewer $25.00 Laboratory Fees Range$5.00-$25.00 Revised Site Plan -OSTDS $50.00 Bacteriological Drinking Water Test $25.00 Revised Site Plan-Sewer I $25.00 Sample Collection Fee $50.00 Subdiv Plan Review OSTDS 0-100=$100$1 for ea over 100: $100 and UP Sharps Containers: Subdivision Plan Review Sewer $25.00 1 Gal Size $3.00 2 Gal Size $4.00 NOTE: Clients shall not be denied Sharps Containers for failure or inability to pay. Environmental Health State Fees Please see Attachment IV 10/23/2006CLFEE2006-07 Page 5 of 11 INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Nov.01, 2006 Dental Services(Sliding Fee Scale does not apply) D0120 Periodic Oral Exam $15.00 D5130 Immediate Denture- Max $310.00 D0140 Emergency Examination $15.00 D5140 Immediate Denture- Man $310.00 D0150 Oral Examination $16.00 D5211 Acrylic Partial (Upper) $285.00 D0210 Intra Oral Complete Sen (inc BW) $32.00 D5212 Acrylic Partial (Lower) $285.00 D0220 Periapical First Film $4.00 D5213 Cast Metal Partial (Upper) $425.00 D0230 Periapical Addt'l Film $3.00 D5214Cast Metal Partial (Lower) $425.00 D0240 Intra Oral-Occlusal $8.00 D5255 Maxillary flex partiall $560.00 D0270 Bitewing-Single Film $6.00 D5256 Mandibular flex partial $560.00 D 0272 Bitewing-Two Films $9.00 D5281 Partial Denture $249.25 D0274 Bitewing- Four Films $11.00 D5410 Adj Denture Max $14.00 D0330 Panoramic film $30.00 D5411 Adj Denture Man $14.00 D0350 Oral/Facial photo image $7.00 D5421 Adj Partial Denture Max $14.00 DD0470 Diagnostic Casts $22.00 D5422 Adj Partial Denture Man $14.00 D1110 Prophylaxis-Adult $36.00 D5510 Repair Complete Denture Base+ LAB $45.00 D1120 Prophylaxis-Child $14.00 D5520 Replace Teeth Complete Denture+ LAB $75.00 D12037opical Fluoride-Child $11.00 D5640 Replace Teeth Partial Denture+ LAB $30.00 D1204 Topical Fluoride-Adult $16.00 D5650 Add Tooth Partial Existing Denture+ LAB $30.00 D1330 Oral Hygiene Instructions $6.00 D5660 Add Clasp Partial Denture+ LAB $45.00 D1351 Sealant-Per Tooth $13.00 D5710 Rebase Maxillary denture $201.25 D1510 Space Maintainer- Fixed Unilateral $72.00 D5711 Rebase Mandibular denture $201.25 D1515 Space Maintainer- Fixed Bilateral $117.00 D5730 Reline Complete Max-Chair side $63.00 D1550 Recement Space Maintainer $17.00 D5731 Reline Complete Man-Chair side $63.00 D2140 Amalgam -One Surface D or P $31.00 D5750 Reline Complete Max+ LAB $100.00 D2150 Amalgam -Two Surface D or P $41.00 D5751 Reline Complete Man + LAB $100.00 D2160 Amalgam-Three Surface D or P $51.00 D5820 Acrylic Flipper- Upper $175.00 D2161 Amalgam-Four or more D or P $61.00 D5821 Acrylic Flipper-Lower $175.00 D2330 Resin-One Surface Anterior Primary $34.00 D5899 Unspec removable prosthodontic+ LAB $425.00 D2331 Resin-Two Surface Anterior Primary $39.00 D7111 Single Tooth Extraction(Child) $27.00 D2332 Resin-Three Surface Anterior Primary $44.00 D7140 Single Tooth Extraction(Adult) $35.00 D2335 Resin-Four or more Anterior Primary $72.00 D7210 Surgical Removal of Tooth $75.00 D2390 Anterior Composite Resin Crown $72.00 D7220 Removal of Impacted Tooth (Soft Tissue) $62.00 D2391 Resin-One Surface Post Primary $31.00 D7230 Removal of Impacted Tooth (Partially Bony) $85.00 D2392 Resin-Two Surface Post Primary $41.00 D7240 Removal of Impacted Tooth (Completely Bony) $79.00 D2393 Resin-Three Surface Post Primary $51.00 D7241 Removal of Impacted Tooth (Completely Bony unusual) $82.00 D2394 Resin- Four or more $84.75 D7250 Root Recovery-Surgical 1 $65.00 D2740 Crown/Porcelain/Ceramic Substrate $396.00 D7270 Tooth Reimplant/Stabilization Child Only $27.00 D2752 Permanent Crown $246.00 D7281 Surgical Exposure to Aid Eruption $45.00 D2792 Gold Crown (Posterior)+ LAB $150.00 D7285 Biopsy- Hard Tissue $118.75 D2799 Provisional single crown $75.00 D7286 Biopsy-Soft Tissuel $81.25 D2920 Recement Crown $17.00 D7310 Alveoplasty With Extraction $45.00 D2930 Prefabricated Steel Crown Primary $68.00 D7320 Alveoplasty No Extract 1-quadrant) $85.00 10/23/2006CLFEE2006-07 Page 6 of 11 INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Nov.01, 2006 Dental Services(Sliding Fee Scale does not apply)CONTINUED D2931 Prefabricated Steel Crown Permanent $68.00 D7450 Cyst Removal $156.75 D2940 Sedative Filling $18.00 D7471 Removal of Exostosis $187.50 D2950 Crown Build-Up $75.00 D7510 I&D- Intraoral (Drainage Abscess) $47.00 D2951 Pin Retention-Per Tooth $2.00 D7960 Frenectomy $113.75 D2954 Prefab Post/Core in Add Crown $53.00 D9230 Analgesia(Nitrous) $35.20 D2960 Labial Veneer Chair side $169.75 D9310 Consultation $18.00 D2961 Labial Veneer+ LAB $227.50 D9630 Drugsl $19.50 D2970 Temp Crown $75.00 D9920 Behavior Management $24.00 D2971 Add procedure under partial $50.00 D9930 Unsched Post Op-Surgery $37.50 D3110 Pulp Cap Direct $13.00 D9940 Occlusal Guard- Hard $156.25 D3120 Pulp Cap Indirect $11.00 D9941 Occlusal Guard-Soft $125.00 D3220 Therapeutic Pulpotomy $50.00 D9951 Occlusal Adjustment-Limited $50.00 D3310 Root Canal (Anterior) $148.00 D9972 External Bleaching 1 $140.00 D3320 Root Canal (Bicuspid) $190.00 D9974 Internal Bleaching Per tooth $66.20 D3330 Root Canal (Molar) $235.00 Bleach Material Refill: per box D4240 Periodontal Surgery $190.50 From Patterson $25.00 D4341 Root Planning per Quadrant $40.00 From Perfecta $60.00 D4355 Full Mouth Debridement $47.50 DNLAB Dental Lab Charges $25.00 D5110 Upper Denture(Full) $390.00 D5120 Lower Denture(Full) $390.00 10/23/2006CLFEE2006-07 Page 7 of 11 INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Nov.01, 2006 Florida Administrative Code,Chapter 10D-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. 10/23/2006CLFEE2006-07 Page 8 of 11 INDIAN RIVER COUNTY HEALTH DEPARTMENT FEE SCHEDULE --Effective Nov.01,2006 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) 10/23/2006CLFEE2006-07 Page 9 of 11 I INDIAN RIVER COUNTY HEALTH DEPARTMENT FORMULARY PRICE LIST Efffective Nov. 01, 2006 Cost Cost Unit per Unit per Product Name Issue UI Product Name Issue UI Acetaminophen suppositories 120 mg Each $0.23 Hydrocortisone 1% cream Tube $1.49 Acetasol HC Bottle $13.00 Ibuprofen 400 mg Each $0.02 Actifed tabs Box $2.50 Kenaloq 40, in' 1 cc in' $6.00 Albuterol .083% Each $0.12 Labetalol 100mg Each $0.10 Aldactone 50 m (Spironolactone) Each $0.29 Labetalol 2TOmg Each $0.13 Amitriptyline HCL 25 mg Each $0.03 Lisinopril 20 mg Each $0.06 Amitriptyline HCL 100 mg Each $0.11 Lisinopril 5 mg Each $0.03 Amoxicillin/Pot C lavulanate Strawberry Bottle $22.83 Medroxyprogesterone Acetate(Depo-Provera)tabs 10 Mg. Each $0.13 Amoxicillin 250 mg susp Bottle $1.82 Metformin hcl 500 mg (Glucophage) Each $0.04 Aspirin EC 325 mg Each $0.02 Metformin hcl 1000 mg (Glucophage) Each $0.07 Aspirin EC 81 mg Each $0.01 Motrin, childrens berry Bottle $4.86 Atenolol 50 mg Each $0.03 Mupirocin Ointment 2% Tube $9.78 Atenolol 100 mg Each $0.06 Nadolol 20mg Each $0.18 Aurodex ear drops Bottle $1.09 Nadolol 40mg Each $0.21 Bacitracin Tube $1.47 Na roxin 500 mg Each $0.06 Benzoin Comp Tincture Bottle 1 $3.22 Neomycin/Polymyxin Gramicidin o thalmic solution Bottle $16.01 Captopril 50 mg Each $0.02 Neomycin/Polymyxin HC otic solution Bottle $13.99 Captopril 100 mg Each $0.05 Nifedi in ER 60mg Each $0.58 Cephalexin 250 mg Each $0.07 Nitrotab sub lingual 3mg Each 1 $0.03 Cephalexin 500 m Each $0.12 Nix Bottle $5.78 Cephalexin suspension 250 mg Bottle $14.41 Norvasc 5mg Each $1.41 Ci rofloxin hcl 500 mg Each $0.09 Pen VK suspension 250 mg Bottle $2.74 Cleocin Palmitate 75m /5ml Bottle $24.20 Pen VK tabs 500 mg Each $0.14 Clindamycin HCL 150mg Each $0.16 Phen le hrin 2.5% optic solution Bottle $1.21 Clonidine .1 mg Each $0.07 Phene ran suppositories 12.5 mg Each $0.87 Clonidine .2 mg Each $0.09 Pink bismuth Each $0.04 Clotrimazole cream 1% Tube $2.18 Polymyxin B/Trimetho rim 10 mU-.1% Pol rim Bottle $1.24 Coreg 3.12 m Carvedilol Each $1.58 Prednisone 10 mg Each $0.02 Coreg 6.25 m Carvedilol Each $1.58 Prednisolone 15 mg/5 ml Bottle $8.74 Cyanocobalamin 1000mcg 1 cc in' $1.44 Pro aracaine .5 O/S Bottle $1.93 Depo-Medrol 80 mg 1 cc in' $8.71 Proventil syrup 2 mg/5 cc Albuterol sulfate Bottle $15.64 Dexamethone Sod Phos 4 mg 1-2c in' $0.30 Q-Tussin Bottle $0.82 Diabetic tussin Bottle $4.87 Ranitidine 150 m Zantac Each $0.02 Di oxin .25 mg Each $0.11 Silvadene cream 1% Tube $5.29 Elimite Tube $17.77 Sodium Chloride .9% Bottle $0.93 Erythromycin e e ointment 5m / m Tube $1.21 Sodium Soulam d Sulfacetamide Sodium 10% Bottle $2.05 Erythromycin Stearate 500 mg Each $0.15 Sulfamethoxazole/Trimetho rim Cher 200-40m /5ml Bottle $17.22 E hrom cin/sulfisoxazole(berry) Pedia;Bottle $4.94 Triam/HCTZ 37.5/25 Each $0.05 Ethyl Chloride Fine 103.05 ml Each $15.81 Triamcinolone 0.1% Cream Tube $2.23 Fluor-I-Strips Each $0.16 Triple anitbiotic ointment Tube $2.82 Furosemide 20 m Lasix Each $0.23 Tropicamide 1%optic solution Bottle $3.56 Furosemide 40 m Lasix Each $0.28 Tylenol Infant 80 mg/.8 ml Bottle $26.98 3enahist allergy 25 Mg Box $0.90 Tylenol Liquid Susp 160 mg/5 ml cherry Bottle $5.69 :;enapap caplet 500 Mg Each $2.86 Verapamil 240 mg Each $0.19 3enapap infant drops Bottle $1.55 Warfarin 2 m Coumadin Each $0.13 31 buride 5 mg Each $0.10 Warfarin 5 m Coumadin Each $0.13 3riseofulvin 125 mg/ml Bottle $34.77 Xylocaine 1% Vile $2.66 3rifulvin tabs 250 mg Each $2.22 Xylocaine 2% Vile $3.68 -1drochlorothiazide 25 mg Each $0.03 Jote:A$1.50 per bottle repack fee will be added to all dipensed medications under the repackaging pro ram. 'harmac ems received from the State Pharmacy are in-kind donation at no cost to IRCHD will not be charged to the patient. CLFEE2006-07 3:38 PM 10/23/2006 Kr-ULANu5 CHRISTIAN MIGRANTS ASSOCIATION Services Agreement February 01, 2006 -January 31, 2007 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 $5.03 $6.231 $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 33%-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 $41.25 $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 $4.951 $7.501 $10.051 $12.451 $15.001 $1.9001 $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 1 $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 $20.501 $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 $22.00 $44.00 D2930 Prefabricated Steel Crown Primary $34.00 $68.00 Missed Appointment $8.00 $16.00 NOTE: No Sliding Fee Scale for Dental Services. J:\KLINE\Core Contract 06-07\CLFEE2006-07, RCMA 10/23/2006