3rd Qtr. 2014 Fee Schedule Worksheet.xlsx

Clinic
Vaccine
Laboratory
Counseling
Dental
SUMMIT COUNTY PUBLIC HEALTH
CLINIC FEE SCHEDULE1,2
SERVICE TYPE
CLINIC SERVICES
Blood Pressure
Hearing Screening
Vision Screening
Mantoux (TB Skin Test)
Two step Mantoux (TB Skin Test)
Non-Contractual Professional Consulting Services
Court Ordered STD Testing
Documentation HIV Testing
OFFICE VISITS - PHYSICIAN / NURSE PRACTITIONER
New Patient Office Visit brief
New Patient Office Visit limited (10 min)
New Patient Office Visit medium (20 min)
New Patient Office Visit moderate (30 min)
New Patient Office Visit comprehensive-moderate(45min)
New Patient Office Visit comprehensive-detailed (60 min)
Established Patient Office Visit limited (10 min)
Established Patient Office Visit medium (15 min)
Established Patient Office Visit moderate (25 min)
Established Patient Office Visit high (40 min)
FEES EFFECTIVE
JULY 1, 2014
$15.00
$25.00
$25.00
$20.00
$35.00
$50.00
$95.00
$20.00
$30.00
$40.00
$55.00
$85.00
$105.00
$110.00
$35.00
$45.00
$65.00
$85.00
OFFICE VISITS - NURSE
Office Consultation Fee -Travel3
$60.00
3
Brief Office Consultation Fee-Travel
$35.00
Brief Assessment
$20.00
REFUGEE HEALTH SERVICES
Refugee navigator service for new arrivals as per ODJFS contract
Examinations and testing as per ODJFS contract
Completion of immunization section of I-693 form
Replacement of I- 693
$50.00
$765.00
$40.00
$20.00
1
Contractual charges are based on fee schedule in effect at the time contract was signed.
2
Summit County Public Health reserves the right to reduce or waive fees based on sliding fee scale (ability to pay) parameters
and/or other state/federal programs. Sliding fee scale does not apply to international travel vaccines and/or travel consultation
fees.
3
International Travel Counseling: Consultation fee applies regardless of the number of vaccines or prescriptions provided.
Administration fee for vaccine applies in addition to consultation fee.
SUMMIT COUNTY PUBLIC HEALTH
IMMUNIZATION FEE SCHEDULE1,2,3,6
FEES EFFECTIVE
JULY 1, 2014
SERVICE TYPE
VACCINE
Vaccines marked with the VFC symbol are available to VFC eligible children at no cost.
See VFC Eligibility Criteria below4. Vaccine administration fees still apply.
Vaccine Administration Fee (per vaccine)
Comvax Vaccine - HIB/Hep B (Pediatric) VFC
Gardasil
VFC
$21.00
$39.00
$174.00
Hepatitis A Vaccine (Adult)
$54.00
Hepatitis A Vaccine (Pediatric) VFC
$29.00
Hepatitis B Vaccine (Adult)
$59.00
Hepatitis B Vaccine (Pediatric) VFC
$19.00
Hepatitis A/B Combined Vaccine
HIB Vaccine VFC
$79.00
$24.00
Trivalent Influenza Vaccine (includes vaccine administration fee)
5 VFC
Quadrivalent Influenza Vaccine (includes vaccine administration fee)5 VFC
Fluzone High Dose (includes vaccine administration fee)
Ixiaro (Japanese Encephalitis)
No Longer Provided
$45.00
No Longer Provided
$299.00
Meningococcal Conjugate Menactra VFC
$134.00
Meningococcal Polysaccharide Menomune
VFC
$154.00
MMR Vaccine VFC
$74.00
Pneumococcal Vaccine (Adult)
Polio VFC
$89.00
Rabies Vaccine
Rotarix VFC
$334.00
$139.00
Rotateq VFC
$94.00
Td - Decavac or Tenivac VFC
$29.00
Tdap-Adacel or Boostrix VFC
$49.00
Typhoid
Varicella (Chicken
Pox)) VFC
(
$119.00
Yellow Fever
$139.00
Zostavax
Pentacel (Dtap & Polio) (Pediatric) VFC
$224.00
Prevnar (Pediatric) VFC
$179.00
Daptacel (Dtap) (Pediatric) VFC
$29.00
$29.00
$69.00
$79.00
Kinrix (Dtap & Polio ages 4 -6 yrs) (Pediatric) VFC
Pediarix (Dtap, Polio, Hep B) (Pediatric)
VFC
$64.00
$89.00
Vaccination Site Fee (for off-site clinics)
$50.00
Yellow travel book replacement and documentation
$10.00
1
Contractual charges are based on fee schedule in effect at the time contract was signed.
2
Summit County Public Health reserves the right to reduce or waive fees based on sliding fee scale (ability to pay) parameters
and/or other state/federal programs. Sliding fee scale does not apply to international travel vaccines and/or travel consultation
fees.
3
International Travel Counseling: Consultation fee applies regardless of the number of vaccines or prescriptions provided.
Administration fee for vaccine applies in addition to consultation fee.
4
VFC (Vaccines for Children Program) Eligibility Criteria- Children through 18 years of age who meet at least one of the
following criteria are eligible to receive VFC vaccine:
• Medicaid eligible: A child who is eligible for the Medicaid program.
• Uninsured: A child who has no health insurance coverage.
• American Indian or Alaskan Native
• Underinsured: A child who has commercial (private) health insurance but the coverage does not include vaccines, a
child whose insurance covers only selected vaccines (VFC-eligible for non-covered vaccines only), or a child whose insurance
caps vaccine coverage at a certain amount. Once that coverage amount is reached, the child is categorized as underinsured.
5
Influenza vaccine fees are waived for Board of Health members and Township Association members.
Feesmaybewaivedinresponsetoacommunicablediseaseoutbreak.
6
SUMMIT COUNTY PUBLIC HEALTH
LABORATORY FEE SCHEDULE1,2,3,4
SERVICE TYPE
LABORATORY SERVICES
Specimen Collection Venous
Specimen Collection Capillary
Glucose Blood Stick
LABORATORY TESTS
Strep Culture
Gonorrhea
RPR
Blood Lead
Chlamydia - antigen detection by DFA
Pregnancy Test
Wet Mount
Herpes Type 1
Herpes Type 2
Urine Dipstick
Urine Dipstick/Micro
Glucose Serum
Hepatitis B (HBSAg)
Hepatitis B (HBcAb)
Hepatitis B (HBSAb)
HIV 1&2 Antibody
Hemoglobin
Gram Stain
Varicella Titer
Urine Drug Screen
Quantiferon Gold TB
Chlamydia, amplified probe technique (Urine or Swab)
Gonorrhoeae, amplified probe technique (Urine or Swab)
1
FEES EFFECTIVE
JULY 1, 2014
$10.00
$10.00
$10.00
$9.00
$12.00
$7.00
$18.00
$18.00
$10.00
$7.00
$18.00
$18.00
$4.00
$5.00
$6.00
$14.00
$18.00
$16.00
$19.00
$4.00
$7.00
$18.00
$22.49
$86.00
$15.00
$15.00
Contractual charges are based on fee schedule in effect at the time contract was signed.
2'
Other laboratory tests (send outs) are charged according to current fee schedule from laboratory performing the tests.
3
Summit County Public Health reserves the right to reduce or waive fees based on sliding fee scale (ability to pay) parameters
and/or other state/federal programs.
4
Laboratory tests are only performed on patients receiving other health district services.
SUMMIT COUNTY PUBLIC HEALTH
COUNSELING FEE SCHEDULE1
SERVICE TYPE
COUNSELING
Assessment (hourly)
Case Management (hourly)
Group Counseling (15 min)
Individual Counseling (15 min)
Intensive Outpatient
Intervention (Community Services)
Community-Based Process (Prevention)
Education (Prevention)
Information Dissemination (Prevention)
Recovery Coach
FEES EFFECTIVE
JULY 1, 2014
$96.24
$92.85
$9.52
$23.21
$136.90
$73.13
$78.84
$80.74
$80.33
$25.00
1
Summit County Public Health reserves the right to reduce or waive fees based on sliding fee scale (ability to pay) parameters
and/or other state/federal programs.
SUMMIT COUNTY PUBLIC HEALTH
DENTAL FEE SCHEDULE1
SERVICE TYPE
DENTAL SERVICES
Periodic Oral Exam
Limited Oral Exam
Comprehensive Oral Evaluation
Periapical X-ray
Additional Periapical X-ray
Two Bitewing X-rays
Four Bitewing X-rays
Prophylaxis – age 14 through Adult
Prophylaxis – age 13 and Younger
Flouride Treatment only-14 through Adult
Topical application of fluoride-Child
Sealant (per tooth)
Resin-based Composite Restoration,One Surface
Resin-based Composite Restoration, Two Surface, Anterior
Resin-based Composite Restoration,Three Surface, Anterior
Resin-based Composite Restoration, involving the Incisal Angle 3 or 4 or more S
Resin-based Composite Restoration, One Surface, Posterior
Resin-based Composite Restoration, Two Surface, Posterior
Resin-based Composite Restoration, Three Surface, Posterior
Resin-based Composite Restoration, Four Surface, Posterior
Prefab Stainless Steel Crown-Primary Tooth
Prefab Stainless Steel Crown-Permanent Tooth
Dental Sedative Filling
Pulpotomy
Periodontal Scaling and Root Planing- 4 or more teeth
Periodontal Scaling and Root Planing - 1 to 3 teeth
Full Mouth Debridement
Basic Extraction (per tooth)
Surgical Extraction (per tooth)
Soft Tissue Extraction (per tooth)
Part Bony Impact w/remov bone, tooth sect
MI Paste Treatment
FEES EFFECTIVE
JULY 1, 2014
$25.00
$25.00
$30.00
$10.00
$10.00
$25.00
$30.00
$40.00
$25.00
$20.00
$20.00
$25.00
$55.00
$70.00
$80.00
$100.00
$55.00
$70.00
$80.00
$100.00
$110.00
$120.00
$55.00
$105.00
$130.00
$115.00
$125.00
$65.00
$105.00
$215.00
$255.00
$20.00
1
Summit County Public Health reserves the right to reduce or waive fees based on sliding fee scale (ability to pay) parameters
and/or other state/federal programs.

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