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PROCEDURE <br /> CODE <br /> <br />Y2011 <br />Y2033 <br />Y2032 <br />Y2135 <br />W8204 <br />W8201 <br />W8202 <br />Y2044 <br />W8203 <br />Y2045 <br />W8205 <br />J2790 <br />82951 <br />84703 <br />Y2046 <br />Y2049 <br />Y2041 <br />W8010 <br />Y2023 <br />Y2005 <br />Y2026 <br />Y2016 <br />Y2031 <br />Y2025 <br />Y2014 <br />Y2030 <br />Y2134 <br />Y2155 <br />Y2035 <br />W8012 <br />Y2047 <br />Y2048 <br />Y2001 <br />Y2002 <br />Y2003 <br />Y2004 <br />W5131 <br />W5132 <br />W5133 <br />W5141 <br />Y2012 <br />Y2013 <br />Y2225 <br />90726 <br />Y2039 <br />Y2040 <br />Y2038 <br />Y2027 <br />Y2034 <br /> <br />SERVICE LOCAL 100% <br /> RATE <br /> <br />MATERNAL HEALTH (PRENATAL) 79.20 79.20 <br />NON STRESS 40.05 40.05 <br />INTRAPARTUM CARE (VAGINAL DELIVERY) 738.50 738.50 <br />ULTRASOUND 38.14 38.14 <br />MATERNITY HOME VISIT 141.82 141.82 <br />MATERNAL CARE COORD-INT 86.06 86.06 <br />MATERNAL CARE COORD-SU~ 43.52 43.52 <br />MATERNITY CARE COORD HOME VISIT 46.98 46.98 <br />CHILDBIRTH CLASS 87.00 87.00 <br />REFRESHER CHILDBIRTH CLASSES 30.00 30.00 <br />PARENTING CLASS 92.38 92.38 <br />P, HO D IMMUNE GLOBULIN 46.38 46.38 <br />ORAL GLUCOSE TOLERANCE TEST 19.65 19.65 <br />PREGNANCY TEST 10.51 10.51 <br />POSTPARTUM/NEWBORN HOME VST:MAT 36.92 36.92 <br />ENHANCED-PSYCHOSOCIAL COUNSELING 43.22 43.22 <br />EHHANCED NUTRITION COUNSELING 33.89 33.89 <br />CHILD SCREENING (EPSDT) 82.85 82.85 <br />CHILD TREATMENT 52.69 52.69 <br />DENTAL HEALTH CARE 95.36 95.36 <br />CARDIOLOGY DIAG/EVAL 133.48 133.48 <br />ORTHOPEDIC DIAG/EVAL 68.76 68.76 <br />PHYSICAL THERAPY 33.91 33.91 <br />NEUROLOGY & SENSORY 93.76 93.76 <br />SPEECH & HEARING DIAG/EVAL 94.87 94.87 <br />SPEECH THERAPY 50.24 50.24 <br />NEUROMUSCULAR DIAG/EVAL 136.61 136.61 <br />CHILD SERVICE COORDINATION 80.00 <br />MYELODYSPLA$IA CLINIC 199.36 199.36 <br />IMMUNIZATION UPDATE 16.48 <br />POSTPARTUM/NEWBORN HOME VISIT 36.92 36.92 <br />POSTPARTUM/NEWBORN HOME VST EPSDT 54.76 54.76 <br />FAMILY PLANNING INITIAL 136.38 136.38 <br />FAMILY PLANNING LIMITED 43.28 43.28 <br />FAMILY PLANNING EXTENDED 74.14 74.14 <br />FAMILY PLANNING ANNUAL 87.80 87.80 <br />NORPLANT INSERTION 555.80 555.80 <br />NORPLANT REMOVAL 232.47 232.47 <br />NORPLANT REMOVAL/REINSERTION 703.11 703.11 <br />DEPO PROVERA INJECTION 26.35 26.35 <br />TB CONTROL/TREATMENT 83.75 <br />STD CONTROL TREATMENT 87.06 <br />RABIES IMMUNE GLOBULIN (RIG)/UNIT 42.00 42.00 <br />RABIES VACCINE/UNIT 90.00 90.00 <br />COMPREHENSIVE ADULT HLT ASSESS. 128.57 128.57 <br />LIMITED ADULT HEALTH ASSESSMENT 20.61 20.61 <br />CHRONIC DISEASE MONITORING 28.13 28.13 <br />ADULT TREATMENT 99.54 99.54 <br />REFUGEE HEALTH ASSESSMENT 140.40 140.40 <br /> <br />CHARGE SCHEDULE <br />JULY 1, 1993 <br /> <br /> 8O% <br />SF ADJ CHRG SF ADJ <br /> <br />15.84 63.36 <br />8.01 32.04 <br />147.70 590.80 <br />7.63 30.51 <br />28.36 113.46 <br />17.21 68.85 <br />8.70 34.82 <br />9.40 37.58 <br />17.40 69.60 <br />6.00 24.00 <br />18.48 73.90 <br />9.28 37.10 <br />3.93 15.72 <br />2.10 8.41 <br />7.38 29 54 <br />8.64 34 58 <br />6.78 27 11 <br />16.57 66 28 <br />10.54 42 15 <br />19.07 76 29 <br />26.70 106.78 <br />13.75 55.01 <br />6.78 27.13 <br />18.75 75.01 <br />18.97 75.90 <br />10.05 40.19 <br />27.32 109.29 <br /> <br />39.87 159.49 <br /> <br />7.38 29.54 <br />10.95 43.81 <br />27.28 109.10 <br />8.66 34.62 <br />14.83 59.31 <br />17.56 70.24 <br />111.16 444.64 <br />46.49 185.98 <br />140.62 562.49 <br />5.27 21.08 <br /> <br />8.40 33.60 <br />18.00 72.00 <br />25.71 102.86 <br />4.12 16.49 <br />5.63 22.50 <br />19.91 79.63 <br />28.08 112.32 <br /> <br />31.68 <br />16.02 <br />295.40 <br />15.26 <br />56.73 <br />34.42 <br />17.41 <br />18.79 <br />34.80 <br />12.00 <br />36.95 <br />18.55 <br />7.86 <br />4.20 <br />14.77 <br />17.29 <br />13.56 <br />33.14 <br />21.08 <br />38.14 <br />53.39 <br />27.50 <br />13.56 <br />37.50 <br />37.95 <br />20.10 <br />54.64 <br /> <br />79.74 <br /> <br />14.77 <br />21.90 <br />54.55 <br />17.31 <br />29.66 <br />35.12 <br />222.32 <br />92.99 <br />281.24 <br />10.54 <br /> <br />16.80 <br />36.00 <br />51.43 <br /> 8.24 <br />11.25 <br />39.82 <br />56.16 <br /> <br />60% <br /> CHRG <br /> <br />47.52 <br />24.03 <br />443.10 <br />22.88 <br />85.09 <br />51.64 <br />26.11 <br />28.19 <br />52.20 <br />18.00 <br />55.43 <br />27.83 <br />11.79 <br />6.31 <br />22.15 <br />25.93 <br />20.33 <br />49.71 <br />31.61 <br />57.22 <br />80.09 <br />41.26 <br />20.35 <br />56.26 <br />56.92 <br />30.14 <br />81.97 <br /> <br />119.62 <br /> <br />22.15 <br />32.86 <br />81.83 <br />25.97 <br />44.48 <br />52.68 <br />333.48 <br />139.48 <br />421.87 <br />15.81 <br /> <br />25.20 <br />54.00 <br />77.14 <br />12.37 <br />16.88 <br />59.72 <br />84.24 <br /> <br />SF ADJ <br /> <br />47.52 <br />24.03 <br />443.10 <br />22.88 <br />85.09 <br />51.64 <br />26.11 <br />28.19 <br />52.20 <br />18.00 <br />55.43 <br />27.83 <br />11.79 <br />6.31 <br />22.15 <br />25.93 <br />20.33 <br />49.71 <br />31.61 <br />57.22 <br />80.09 <br />41.26 <br />20.35 <br />56.26 <br />56.92 <br />30.14 <br />81.97 <br /> <br />119.62 <br /> <br />22.15 <br />32.86 <br />81.83 <br />25.97 <br />44.48 <br />52.68 <br />333.48 <br />139.48 <br />421.87 <br />15.81 <br /> <br />25.20 <br />54.00 <br />77.14 <br />12.37 <br />16.88 <br />59.72 <br />84.24 <br /> <br />40% <br /> CHRG <br /> <br />31.68 <br />16.02 <br />295.40 <br />15.26 <br />56.73 <br />34.42 <br />17.41 <br />18.79 <br />34.80 <br />12.00 <br />36.95 <br />18.55 <br />7.86 <br />4.20 <br />14.77 <br />17.29 <br />13.56 <br />33.14 <br />21.08 <br />38.14 <br />53 39 <br />27 50 <br />13 56 <br />37 50 <br />37 95 <br />20 10 <br />54 64 <br /> <br />79.74 <br /> <br />14.77 <br />21.90 <br />54.55 <br />17.31 <br />29.66 <br />35.12 <br />222.32 <br />92.99 <br />281.24 <br />10.54 <br /> <br />16.80 <br />36.00 <br />51.43 <br /> 8.24 <br />11.25 <br />39.82 <br />56.16 <br /> <br /> 20% <br />SF ADJ CHRG <br /> <br />63.36 15.84 <br />32.04 8.01 <br />590.80 147.70 <br />30.51 7.63 <br />113.46 28.36 <br />68.85 17.21 <br />34.82 8.70 <br />37.58 9.40 <br />69,60 17,40 <br />24.00 6.00 <br />73.90 18.48 <br />37.10 9.28 <br />15.72 3.93 <br />8.41 2.10 <br />29.54 7.38 <br />34.58 8.64 <br />27.11 6.78 <br />66.28 16.57 <br />42.15 10.54 <br />76.29 19,07 <br />106.78 26.70 <br />55.01 13.75 <br />27.13 6.78 <br />75,01 18.75 <br />75.90 18.97 <br />40.19 10.05 <br />109.29 27.32 <br /> <br /> 159.49 39.87 <br /> <br /> 29.54 7.38 <br /> 43.81 10.95 <br /> 109.10 27.28 <br /> 34.62 8.66 <br /> 59.31 14.83 <br /> 70.24 17.56 <br /> 444.64 111.16 <br /> 185.98 46.49 <br /> 562.49 140.62 <br /> 21.08 5.27 <br /> <br />33.60 8.40 <br />72.00 18.00 <br />102.86 25.71 <br />16.49 4.12 <br />22.50 5.63 <br />79.63 19.91 <br />112.32 28.08 <br /> <br /> <br />