HomeMy WebLinkAbout2018-066RESOLUTION NO. 2018-066
A RESOLUTION OF INDIAN RIVER COUNTY, FLORIDA,
TO ADOPT A 2018/2019 FEE SCHEDULE FOR THE
FLORIDA DEPARTMENT OF HEALTH IN INDIAN RIVER.
WHEREAS, the Indian River County Health Department has proposed a new fee
schedule to become effective July 17, 2018, as set forth more fully in Exhibit "A"
attached hereto; and
WHEREAS, section 154.06(1), Florida Statutes, provides that the Indian River
County Board of County Commissioners must establish the fee schedule by resolution ,
NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF COUNTY
COMMISSIONERS OF INDIAN RIVER COUNTY, FLORIDA, that:
1. Effective July 17, 2018, all fees set forth on Exhibit "A" are established for use
by the Florida Department of Health in Indian River. Such fees shall remain in effect
until further resolution of this Board.
This Resolution was moved for adoption by Commissioner Simi ari
and the motion was seconded by Commissioner Zorc and, upon being put
to a vote, the vote was as follows:
Chairman Peter D. O'Bryan
Vice Chairman Bob Solari
Commissioner Susan Adams
Commissioner Joseph E. Flescher
Commissioner Tim Zorc
AYE
AYE
The Chairman thereupon declared the resolution duly passed and adopted this
17th day of July , 2018.
Attest: Jeffrey R. Smith
Cler f Court and
/Comptroller
B
Y
Deputy Clerk
Attachment: Exhibit "A"
INDIAN RIVER COUNTY, FLORIDA
BOARD OF COUNTY COMMISSIONERS
BY
Peter D. O'Bryan, Chairman
APPROVED AS TO FORM
AND LEGAL SUFFICIENCY
BY
UNTY ATTORNEY
•'` vFACOUNN• ''
INDIAN RNER COUNTY HEALTH DEPARTMENT
FEE SCHEDULE -
Fen shall be no lees then the Medklad Fee4w -8ervice reimbursement and no BrNbrtim the Medkan reimbursement rate plus fill
In effect at the time of service, comparable reimbursement rates If no such rates are available.
n..* .,f r -...h, Patient Fees- Patients will he assessed at inn-/. of Siidinn Fee Scala
VISIT DESCRIPTION E/M CODES
0% -A
17% - B
33% - C 50% - D
67% - E
83%- F
100%- G
Cy 18-19 Fee
$0.00
$20.86
Medical Visit
- New Patient
$82.22
$101.85
$122.71 .NO
CHANGE
99201 Level One
$0.00
$8.37
$16.26
$24.63
$33.00
$40.89
$49.26
NO CHANGE
99202 Level Two
$0.00
$14.191
$27.54 i
$41.731
$55.91 '
$69.26
$83.45
JiO CHANGE
99203 Level Three
$0.00
$20.73
$40.24
$60.971
$81.70
$101.21
$121.94
00CHANGE
99204 Level Four
$0.00
$31.65
$61.44
$93.10
$124.75
$154.54
$186.19
O CHANGE
99201 TD Nurse Protocol
$0.00
$3.86
$7.49
$11.361
$15,22
$18.85
$22.71
O CHANGE
$0.001
$28.59
Medical Visit - Established Patient
$84.09
$112.67
$139.58
$168.17
V O CHANGE
99211 Level One
$0.00
$3.86
$7.49
$11.36
$15.22
$18.85
$22.71
NO CHANGE
_ _
99212 Level Two
$0.001
$8.37
$16.26
$24.63
$33.00
$40.89
$49.26
NO CHANGE
99213 Level Three
$0.001
$13.79
$26.76
$40.55
$54.34
$67.31
$81.10
O CHANGE
99214 Level Four
$0.00
$20.22
$39.24
$59.46
$79.68
$98.70
$118.92
O CHANGE
99211 TD Nurse Protocol
$0.00
_
$3.86
$7.49
$11.36
$15.22 I
$18.8sl
$22.71 IND
CHANGE
Lab fees will be charged in addition to office visits on a sliding fee scale.
Well Child Visit 0-1
- Well Chid Visit 1-4
- Well Child Visits 5-11
-
Well Child Visit 12-17
EP - Well Child Visit 1840
- Adult Scr 21-39 yrs
Adult Scr 40-64 yrs
- Adult Scr 65> yrs
Well Child Vbk 0-1
- Well Chid Visit 1-4
1- Well Child Visits 5-11
I - Well Child Visit 12-17
i EP - Well Child Visit 18-20
i - Adult Scr 21-39 yrs
i - Adult Scr 40-64 yrs
F - Adult Scr 65> yrs
icaid "Child Health Check -Up" and routine physical Includes applicable In-house laboratory services.
be established Primary arc Patient to receive Physical on sliding fee sale.
Palle 1 of 7 7/11/2018
Physicals - New Patient
$0.00
$20.86
$40.49
$61.36
$82.22
$101.85
$122.71 .NO
CHANGE
$0.00
$21.61
$41.94
$63.55
$85.16
$105.49
$127.10
O CHANGE
$0.00
$22.53
$43.73
$66.27
$88.80
$110.00
$132.53
NO CHANGE
$0.00
$25.50
$49.49
$74.99
$100.49
$124.48
$149.98
NO CHANGE
$0.00
$24.82
$48.17
$72.99
$97.81
$121.16
$145.98
NO CHANGE
$0.00
$24.82
$48.17
$72.99
$97.81
$121.16
$145.98
O CHANGE
$0.001
$28.59
$55.50
$84.09
$112.67
$139.58
$168.17
V O CHANGE
$0.00
$31.161
$60.48
$91.64
$122.80
$1S2.121
$183.28
%0 CHANGE
Physicals - Established Patient
$0.00
$_18.72
$36.34
$55.07_
$73.79
$91.41
$110.13
NO CHANGE
$0.00
$19.96
$38.74
$58.70
$78.66
$97.44
$117.40
NO CHANGE
$0.00
$19.89
$38.62
$58.51
$78.40
$97.13
$117.02
NO CHANGE
$0.00
$21.69
$42.11
$63.81
$85.50
$105.92
$127.61
NO CHANGE
$0.00
$22.13
$42.95
$65.08
$87.21
$108.03
$130.16
O CHANGE
$0.00
$22.13
$42.95
$65.08
$87.21
$108.03
$130.16
NO CHANGE
$0.00
$23.67
$45.95
$69.62
$93.29
$115.57
$139.24
NO CHANGE
$0.00
$2S.S6
$49.62
$75.18
$100.74
$124.80
$150.36
O CHANGE
icaid "Child Health Check -Up" and routine physical Includes applicable In-house laboratory services.
be established Primary arc Patient to receive Physical on sliding fee sale.
Palle 1 of 7 7/11/2018
INDIAN RIVER COUNTY HEALTH DEPARTMENT
FEE SCHEDULE -
Page 2 of 7 7/11/2018
FAMILY
PLANNING VISIT
DESCRIPTION
E/M CODES
0%-A
17%-B
33%-C
50%-D
67%-E
83%- F
90%- G
95%- H
100%-I CY18-19 Fee
Medical Visit
- New Patient
99201 Level One
$0.00
$8.37
$16.26
$24.63
$33.00
$40.89
$44.33
$46.80
$49.26 NO CHANGE
99202 Level Two
$0.001
$14.1911
$27.S41
$41.73
$55.91
$69.26
$75.11
$79.28
$83.45 NO CHANGE
99203 Level Three
$0.00
$20.73
$40.24
$60.97
$81.70
$101.21
$109.75
$115.84
$121.94 NO CHANGE
99204 Level Four
$0.001
$31.65
$61.44 1
$93.10
$124.75
$154.54
$167.57
$176.88
$186.19 NO CHANGE
99201 TD Nurse Protocol
$0.001
$8.37
$16.26
$24.63
$33.00
$40.89
$44.33
$46.80
$49.26 NO CHANGE
Medical Visit - Established Patient
99211 Level One
$0.00
$3.86
$7A9
$11.361
$1S.221
$18.85
$20.44
$21.57
$22.7100 CHANGE
99212 Level TWo
$0.00
$8.37
$16.26
$24.63
$33.00
$40.89
$44.33
$46.80
$49.26 O CHANGE
99213 Level Three
$0.00
$13.79
$26.76
$40.SS
$54.34
$67.31
$72.99
$77.05
$81.10 NO CHANGE
99214 Level Four
$0.00
$20.22
$39.24
$59.46
$79.68
$98.70
$107.03
$112.97
$118.92 O CHANGE
99211 TD Nurse Protocol
$0.00
$3.86
$7.49
$11.36
$15.22
$18.85
$20.44
$21.57
$22.71 ' O CHANGE
Family Planning
Initial/Annual Family Planning Visit*
$0.001
$15.30
$29.70
$45.00
$60.30
$74.70
$81.00
$85.50
$90.00 NO CHANGE
Subsequent Family Planning Visit(s)
$0.001
$3.86
$7.49
$11.36
$15.22
WAS
$20.44
$21.57
$22.71 NO CHANGE
*Includes all applicable In-house laboratory services. All contracted Labs wUl be charged as per sliding fee sale ($35.00).
All Lab fees Will be charged in addition to office visits on a sliding fee sale. Insurance Will not be billed for lab services.
Procedures not Included in office visit
58301 IUD Removal
$0.00
$10.20
$19.80
$30.00
$40.20
$49.80
$54.00
$57.001
$60.00 NO CHANGE
Other Services
0%-A
17%-B
33%-C
50%-D
67%-E
83%- F
100%-G
CY18-19 Fee
Smoking Cessation Intermediate 3 - 10 minutes
$0.00
$2.19
$4.25
$6.45
$8.64
$10.70
$12.89
NO CHANGE
Smoking Cessation Intensive i 10 minutes_
$0.00
$4.32
$8381
$12.70
$17.01
$21.07
$25.39
NO CHANGE
99499 - Flouride Varnish - 521.01
$0.00
$4.25
$8.25
$12.50
$16.75
$20.751
$25.00
NO CHANGE
HIV Pre -Test Counseling
$0.00
$3.86
$7.49
$11.36
$15.22
$18.85
$22.71
NO CHANGE
HIV Post -Test Counseling+
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
NO CHANGE
-
-
+ included in pre-test counseling
Procedures not included in office visit
0%-A
17%-B
33% - C
50% - D
67% - E
83% - F
100% - G
CY 18-19 In
58301 IUD Removal
$0.00
$10.20
$19.80
$30.00
$40.20
$49.80
$60.00NO CHANGE
11765 Ingrown Toenail Treatment
$0.00
$8.50
$16.50
$25.00
$33.50
$41.50
$50.00
O CHANGE
17000 Wart Treatment - First
$0.00
$5.95
$11.55
$17.50
$23.45
$29.05
$35.00
,� OCHANGE
17003 Wart Treatment - Each additional wart
$0.00
$1.02
$1.98
$3.00
$4.02
$4.98
$6.00
NO CHANGE
100601ndsion and Drainage
$0.00
$9.35
$18.15
$27.50
$36.85
$45.65
$55.00
NO CHANGE
94640 Respiratory Treatment •
$0.00
$1.70
$3.30
$5.00
$6.70
$8.30
$10.00 0 CHANGE
93000 EKG
$0.00
$S.101
$9.90
$15.00
$20.10
$24.90
$30.00
NO CHANGE
• There Is an additional charge for mediation
Page 2 of 7 7/11/2018
INDIAN RR/ER COUNTY HEALTH DEPARTMENT
FEE SCHEDULE -
Procedures with set charges
0%-A 17%- B 33%- C 50%- D 67%- E 83%- F
100%- G
CY 18-19 Fee
71020 Chest X -Ray
$0.00 $9.35 $18.15 $27.50 $36.85 $45.65
$55.00
NO CHANGE
Tubal Ugation
Current contracted rate
17%-B
NO CHANGE
Vasectomy
Current contracted rate
83%- F
NO CHANGE
Nutritional Counseling - per hour
$0.00 $5.95 $11.55 $17.50 $23.45 529.05
$35.00
NO CHANGE
TO Quantfferon-GOLD Test
NO SLIDING FEE
$40.00
NO CHANGE
TST Evaluation • (Prepayment)
NO SLIDING FEE
$5.00
CHANGE
placement 0
NO SLIDING FEE
$15 00
CO
CHANGE
• Unless included in Physical or Office Visit. if it is part of an EPI investigation, there will be no charge and should be indicated as such on the Client encounter fora:
Insurance will be billed If insurance information is available.
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.
CY 18-19 Fee
IMMUNIZATIONS
Travel Immunizations (Sliding Fee Scale does not apply -- Per Injection)
Travel Immunization Consult Visit
$40.00
UPDATE old ($35.00)
4dministration Fee - 90471 1st shot
0%-A
17%-B
33%-C
50%-D
,,67%-E
83%- F
100%-G
CY 18-19 Fee
renza
$0.00
$4.25
$8.25
$12.50
$16.75
$20.75
$25.00
NO CHANGE
umococcal Pneumonia
$0.00
$15.76
$30.60
$46.37
$62.13
$76.97
$92.73
NO CHANGE
vac (Tetanus -Td)
$0.00
$8.58
$16.65
$25.23
$33.30
$41.87
$50.45
O CHANGE
cel (Tdap)
$0.00
$8.92
$17.31
$26.23
$35.14
$43.53
$52.45
O CHANGE
cted Polio Vaccine
$0.00
$7.72
$14.99
$22.71
$30.43
$37.70
$45.42
O CHANGE
tingotoccal
$0.00
$21.02
$40.80
$6182
$8Z.83
$102.61
$123.63
O CHANGE
fes Vaccine (per injection)
$0.00
$S1A7
$99.91
$151.38
$202.84
$251.28
$302.75
O CHANGE
Rabies Imm Globulin - Per 2cc Mal
$0.00
$106.78
$207.29
$314.07
$420.35
$521.36
$628.14
O CHANGE
atitis A Vaccine (per Injection)
$0.00
$3.65
$16.80
$25.46
$34.11
$42.26
$50.91
O CHANGE
atitis B Vaccine (per in)ection)
$0.00
$9.53
$18.50
$23.04
$3757
$46.54
$56.07
O CHANGE
nrbt -Hep A & B (per injection)
$0.00
$13A7
$26.14
$39.61
$53.08
$65.75
$79.22
O CHANGE
igles Vaccine-2ostavax
$205.22
O CHANGE
Basil (Cervical Cancer Vaccine)
$0.00
$30.69
$59.53
$90.27
$120.96
$149.35
$180.54
O CHANGE
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.
Paye 3 of 7 711111=18
CY 18-19 Fee
Travel Immunizations (Sliding Fee Scale does not apply -- Per Injection)
Travel Immunization Consult Visit
$40.00
UPDATE old ($35.00)
4dministration Fee - 90471 1st shot
$20.00
NO CHANGE
1ldministration Fee, additional shot - 90472
$5.00
NO CHANGE
Hepatitis B Vaccine
$56.07
NO CHANGE
Hepatitis B Vaccine - Children
$35.72
NO CHANGE All vaccines eq cost
Hep B Immune Globulin* per ml
$163.20
NO CHANGE plus $20.00 (as sbn leftt will
Hepatitis A Vaccine
$50.91
NO CHANGE ter
Hepatitis A Vaccine - Children
$40.45
NO CHANGE
Hep A Immune Globulin* per 2 ml dose
$88.88
NO CHANGE
rwinrix (HepA & B)
$79.22
NO CHANGE
Meningococcal
123.63
NO CHANGE
rinivac (Tetanus -Td)
$50.45
NO CHANGE
Measles/Mumps/Rubella
$78.21
NO CHANGE
Varivax (Chicken Pox)
121.ZZ
NO CHANGE
Itdacel (Tdap)•
52.45
NO CHANGE
ryphoid (injection)
$77.34
NO CHANGE (oral is also available - check for pricing)
fellow Few
5138.39
NO CHANGE
4CTHIB (Tetanus Toxoid Conjugate)
$41.10
_
NO CHANGE
PREVNAR (Pneumococcal 13 VALCor+DIP)
$174.82
NO CHANGE
Recombivax HB (Hep B - HI Dose)
$176.06
NO CHANGE
'As available
Paye 3 of 7 711111=18
INDIAN RK/ER COUNTY HEALTH DEPARTMENT
FEE SCHEDULE —
IN-HOUSE LAB
LAB $0.00 $4.251 $8.25 1 $12.01 $16.75 $20.75
$25.00 NO CHANGE
Contracted Laboratory Services
LAB $0.00 $5.95 $11 -SSI $17.S01 $23.45 I $29.05
$35.00 NO CHANGE
NOTE: Tests which exceed a charge of $100.00 will be billed individually on a 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.
All Lab fees will be charged in addition to office visits on a sliding fee scale as above.
Miscellaneous Fees
General Health Consultation - private facilities and agencies
$SS.00 NO CHANGE
Smoking Cessation - group setting
$25.00 per client NO CHANGE
Notary Public Fee
$15.00 NO CHANGE
Return Check Service Charge $15.00 or 5% of the face amount of the check, draft or order, whichever is greater not to
exceed $150.00. (S. 215.34(2), F.S.) I (DOHP 56-66-08 - AR Policy)
Special reports (Physician's narrative, insurance forms, or review of medical records by physician)
$25.00 CHA
Records Fees
7
Copy of Medical Record/per page $0.15 per page and an additional $.05 for double sided copies plus cost of postage N mailed.
Large scale copying requets requiring extensive clerical assistance will be subject to an $10.00 administration fee In addition to the above stated fee
per FL Statute 119.07.
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.
680 School Form / Copy of immunization on Record Knot processed at the same time of immunization
Pharmaceutical Services
The charges to clients for all items purchased by and under the purview of the Health Department shall be predicated upon the basis of actual costs
plus $10.00 fee for each Item purchased on a sliding fee basis. Insulin and Epilepsy medications an be provided at no charge if residents
meet financial screening eligibility criteria.
Vital Statistics Fees CY 18-19 Fee
Birth Certificates (computer) $12.00 NO CHANGE
Additional Copies (computer) $10.00 NO CHANGE
Death Certificates $12.00 NO CHANGE
Plastic Sleeve $5.00 NO CHANGE
Research Fee (per year) $3.00 NO CHANGE
Expedite Fee $5.00 NO CHANGE
Overnight Shipment $15.00 NO CHANGE
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.
Paye 4 of 7 7/11/2018
INDIAN RIVER COUNTY HEALTH DEPARTMENT
FEE SCHEDULE —
CY 18-19 Fee SEE ATTACHED FOR NEW FEES CY 18-19 Fee
Environmental Health County Fees
X00
�i0.G0 "GA0
Well ftFmilljf00+00�
j3i.00 ii0A0
>ji00.00 aCYWf•FNi
>jii0.00 j100A0
X00
"0AO
ji00A0 u0.00
t60.00 $7640
"6040 j3i.00
><i0.00
$3640 wff u
"040
$KAO
Oram" $740 Rep4empua0winspedlens "040
T6aai-e — — 64.00 $MOM
NOTE: Clients shall not be denied Sharps Containers for failure or inability to pay.
Environmental Health State Fees
Page 5 of 7 7/11/2018
INDIAN RIVER COUNTY HEALTH DEPARTMENT
FEE SCHEDULE -
D0120 Periodic Oral Exam (Medicaid Return)
DO140 Umked Oral Exam (EMER)
D0150 Comprehensive Exam (Medicaid)
CY 18-19 Fee NO CHANGE
Dental Services (Sliding Fee Scale does not apply)
22.50 D5110 Complete Denture - Max _
12.00 D5120 Complete Denture - Mand
24.00 05211 Upper Partial - Resin Base
CY 18-19 Fee
461.00
461.00
400.00
D0210 Intra Oral Complete Sen (inc BW)
48.00
D5212 Lower Partial - Resin Base
$400.
D0220 PA Single -First
6.00
D5213 Maxillary Partial Denture (Cast Metal)
$S50.04
D0230 PA -Each Additional
4S0
DS214 Mandibular Partial Denture (Cast Metal)
$550.
D0270 Bitewings -Single L or R
9.00
D5410 Adjust Complete Denture - Max
$21.
D0272 Bkewings-Two
13.50
D5411 Adjust Complete Denture - Mand
$21.
D0274 Bkewings-Four
1650
05421 Adjust Partial Denture - Max
$21.
D0330 Panoramic Film
45.00
D5422 Adjust Partial Denture - Mand
$21.
D0470 Diagnostic Cast
33.00
05510 Repair Complete Denture - Base + LAB
$65.50+ lob
D1110 Prophylaxis - Adult 14+
27.00
D5S20 Replace Teeth Complete Denture + LAB
$S8 + lab
D1120 Prophylaxis - Child <14
21.00
DS640 Replace Teeth - Partial Denture + LAB
$S8 + lab
D1203 Topical Fluoride - Child <14
11.00
D56S0 Add Tooth to Existing Denture + LAB
$62.50 + lab
D1204 Topical Fluoride - Aduk 14+
11.00
D5660 Add gasp to Partial Denture + LAB
$77.50 + lab
D1206 Fluoride Varnish
17.00
D5730 Reline Complete Max - Chairside
$94.00
D1208 Topcal application of fluoride
17.00
01330 Oral Hygiene Instruction
9.00
DS731 Reline Complete Mand - Chairside
$94.00
D33S1 Sealant - Per Tooth 3, 14, 19, 30
1950
DS7S0 Reline Complete Max + LAB
$168 + lab
D1510 Space Main-Fha!d-Unilat (includes lab fee)
150.00
D57S1 Reline Complete Mand + LAB
$168 + lab
D1515 Space Main-Fixed-Bilat (includes lab fee)
175.00
DS820 Interim Partial Denture (Upper Flipper)
$163.50 + lab
D15S0 Recement Space Maint
25.00
DS821 Interim Partial Denture (Lower Flipper)
$163.50+lob
02140 AM 1 Surf -
46.50
D7211 N Coron Remnants -Deciduous
$40.
DZ150 AM 2 Surf -
61.00
D7140 Ext. Erupted Tooth or
$40
02160 AM 3 Surf -
76.00
D7160 Schad Surg Post Op
$40.
D2161 AM 4 Surf -
91.00
D7210 Surgical Erupted
$70.0101
D2330 Comp Resin -One Surface -Ant
51.00
D7220 Surg Ext -Soft Tissue Impact
$92.
DZ331 Comp Two Surface Ant
58.00
D7230 Surg Ext -Part. Bony Impact
$114.
02332 Comp Three Surface Ant
6SS0
D7240 Surg Ext -Part. Bony Impact
$114.
DZ390 Resin based composke,crown anterior
107.50
D233S Corn Incisal Angle + 4 Surf
10750
D7250 Root Recovery -Surgery
$90.
D2391 Comp Resin 1 Surf Post
55.00
D7280 Surg Exposure to Aid Eruption
$202.
D2392 Comp Resin 2 Surf Post
65.00
D7285 Biopsy - Hard Tissue + LAB
$100 + lab
D2393 Comp Resin 3 Surf Post
76.00
D7286 Biopsy - Soft Tissue + LAB
$85 + lab
D2394 Comp Resin 4 > Surf Post
85.00
D7288 Brush Biopsy + LAB 1$40
+ lab
DZ920 Recement Crown
25.50
D7310 Alveoloplasty w/Extraction
$70.04
D2930 Stainless Steel - Primary
101.50
D7320 Alveoloplasty No Extraction
$83
DZ931 Stainless Steel Crown - Perm
101.50
D7S10 I & D - Intreoral (Drainage Abcess)
$70.04
D2940 Sedative Filling
27.00
09110 Palliative Services 1
$20.001
D2951 Pin Retention - Per Tooth
7.00
D9230 Analgesia (Nitrous)
$41.
D2970 Temporary Crown
70.00
09310 Consukation
$Z0.001
D3110 Pulp Cap - Direct
20.00
D9630 Drugs
$25.
D3120 Pulp Cap - Indirect
20.00
D9930 Treatment Complication (Post Surgery)
$40.
D3220 Vital Pulpotomy
75.00
D9940 Occlusal Guard 1
$100+lob
D3310 Endodontic therapy anterior w/o final restoration
220.00
D9951 Occlusal Adjustment - Umked
$50.
D3320 Endodontic therapy bicuspid w/o final restoration
282.50
D9972 External Bleaching (Upper & Lower Arch)
$100.
D3330 Endodontic therapy molar w/o final restoration
349.50
D4341 Periodontal Scaling/Root Planning Quad N
50.00
04342 Periodontal 1-3 Teeth 50.00
D43S5 Full Mouth Debridement 7750
rry other service provided not listed will be at Medicaid rate plus $15.00
Pape 6 of 7 7M 1/2018
INDIAN RIVER COUNTY HEALTH DEPARTMENT
FEE SCHEDULE —
Florida Administrative Code, Chapter 1OD-121 i I I I j
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 shag be assessfees for those ed e services based upon their
own personal gross income.
AM client who elects to waive the eligibility determination process shall be assigned to the full fee category. N 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 IRCHO'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.
1 7-
Cllents 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.
IRCHD POum
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 $25.00 unless they
register as a primary care patient and transfer all current medical records to the health department
County of Residence: (PrimaryCare) If a patient has Medicaid, other confirmed medical coverage, or prepays out of county charge, we will
see them in the clink 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.)
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. H 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.
Access to dental services will be limited to those patients who make less than 300% of the current Federal Poverty Level.
Access to eye clink services will be limited to those patients who make less than 200% of the current Federal Povertv Level.
Pape 7 of 7 7/11/2018
Florida Department of Health in Indian River County
Environmental Health Fee Schedule FY 2018/2019
Well Permit - Irrigation
50
75
Well Permit -Drinking Residential
75
110
Well Permit - Drinking Public
250
250
Monitoring Wells
100
100
Well Abandonment
25
25
Well Site Visit/Locating
75
Well Reinspection
50
Well Variance Private/Public
100
100
No Well Application Double Permit Fee
Double Fee
Double Fee
Additional County Fee Sample Collection
50
50
Water System Review/Si n-off/Letter
20
Additional County Fee Limited Use Initial and Annual
50
Limited Use Annual Water Collection and Lab
250
290
Addition Limited Use Reinspection Fee
50
50
Limited Use Late Fee
25
50
Limited Use Well Sanitary Surve /Environmental Assessment
150
150
Additional County Fee Swimming Pools up to 25,000
50
Additional County Fee Swimming Pools over 25,000
50
Exempted Swimming Pools
50
Pool Reinspection Fee per reinspection
50
50
Bathing Lake Fee Collection Plus Lab
30
Swimming Pool Late Fee
25
50
New OSTDS County Fee
60
Modification OSTDS County Fee
60
Repair OSTDS
50
Additional Reinspection Fee OSTDS/Mound Inspection
25
Additional Abandonment Fee
30
Additional Variance Fee Residential or Commercial
75
Plan Review Fee /Stamp Plans
35
Timed Inspection OSTDS
150
100
Existing System County
35
OSTDS Managed System Fee/Annual Operating
50
OSTDS Septic Disposal/Portable Toilet Service
50
OSTDS Work without permit or after construction begins)
Double Fee
Double Fee
Plan Review Fee Minor
25
35
Plan Review Fee Major Per Hr.
75
75
Major Site Plan Amendment/Revised
25
35
Additional Late Food
25
Food Reinspection First Inspection/Inspection Request
50
50
Additional ALF/Residential Food
45
Additional School Food
45
Additional Civic Food
45
Additional Detention
45
Additional Bars
45
Additional Food Plan Review
75
75
Tanning Facility Plan Reviews
75
75
Tanning Reinspection Fee
50
50
Tanning Late Fee
50
Body Piercing Reinspection Fee
50
50
Tattoo Reinspection
50
50
Group Care Plan Reviews
75
75
Group Care Voluntary
50
75
Group Care ALF/Residential
50
100
Group Care Reinspection
50
50
Group Care Schools Public, Private or Charter
75
Group Care Late Fee
25
50
Housing and Public Buildings/Any Inspection /Sanitation
50
50
Indoor Air Quality Residential/Commercial Per Hr.
150
150
Haz. Waste Assessment/Inspection Small Quantity Generator
50
50
Environmental Assessment
150
150
Additional Migrant Housing 5-50
50
Additional Migrant Housing 51-100
75
Additional Migrant Housing > 101
100
Migrant Reinspection
50
50
Migrant Plan Review
75
75
Migrant Late Fee
25
50
Additional Mobile Home Park Fee up to 25
50
Additional Mobile Home Park Fee up to 25 -149
50
Additional Mobile Home Park Fee over 150
50
Mobile Home Park Late Fee
25
50
Temporary Campground Plan Review/MHP Plan Review
75
75
Demolitions Single Family
75
75
Demolitions Commercial <3000 sq. ft./>3000 sq. ft.
100/150
100/150
Demolition Reinspection
50
50
Grease Trap Construction
75
75
Grease Trap Annual Operating
50
50
Laboratory Fees 5-25
25
35
Double Fees (operating without a permit all programs)
Double Fee
Reinspection/Non-Compliance Inspection
50
50
Research/Report/Plus Staff Cost Per Hr.
10
10
Training Fee Per Hr.
25
Rabies Low Risk or Request for Testing
110
Child Care Inspections
100
0
Sharps Disposal Containers
3.00/4.00
0