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N.C.Department of Environment,Health,and Natural Resources Page—of 11 <br /> Division of General Services FY 97-98 <br /> CONTRACT ADDENDUM <br /> DMCHIWHSIMaternal Health 98 51010 068 <br /> Office,Section,or Branch Contract Number <br /> Orange Maternal Health <br /> Contractor Activity <br /> SECTION B: NON-MEDICAID SERVICE DELIVERABLES <br /> Instructions: In the ESTIMATED NUMBER column, enter the projected number of non-Medicaid reimbursable <br /> services that the local agency plans to provide during the contract period. Multiply the ESTIAMATED NUMBER for <br /> each service by the reimbursement rate for that service and enter the amount in the ESTIMATED COST column. If <br /> the projected number for a service type is zero, enter"0" in both ESTIMATED NUMBER and ESTIMATED COST <br /> columns. <br /> ESTIMATED ESTIMATED <br /> SERVICE TYPE - NUMBER X RATE = COST <br /> Maternal Health (Pre,Perinatal) 195 X $129.94= $25,338-30 <br /> Non-Stress Test 0 X $ 59.60 = $ 0 <br /> Ultrasound _ 0 X $ 38.14 = $ 0 <br /> Maternity Home Visit(Prenatal) 0 X $ 108.05= $ 0 <br /> Parenting Class 0 X $ 92.38 = $ 0 <br /> Childbirth Class �— X $ 87.00 = $ 0 <br /> Maternal Care(Initial) 0 X $ 105.39 = $ n <br /> Maternal Care (Subsequent) 0 X S 56.70 = $ 0 <br /> Medical Nutrition Therapy 4 X S 40.61 = $ 162.44 <br /> Pregnancy Test 0 X S 10.51 = $ 0 <br /> RHO D Immune Globulin 0 X $ 46.11 = $ 0 <br /> Mat Care Coor Home Visit _-_ X $ 84.74= $ 0 <br /> Refresher Childbirth Class 0 X $ 69.18 = $ 0 <br /> Post Home Visit Mat Assess 9 X $ 85.90 = $ 773.10 <br /> Intensive Psych Counsel 0 X $ 63.59 = $ 0 <br /> Oral Glucose Tolerance �— X $ 45.98 = $ 0 <br /> MOW Brief 0 X $ 30.10 = $ 0 <br /> MOW Standard 0 X $ 54.66= $ 0 <br /> MOW Extended 0 X $ 123.12 = $ 0 <br /> Colposcopy without Biopsy 0 X $ 48.85= $ 0 <br /> TOTAL ESTIMATED COST OF SECTION B SERVICE DELIVERABLES $ 26,273.84 <br /> Instruction: If the TOTAL ESTIMATED COST OF SECTION B SERVICE DELIVERABLES is equal to or greater <br /> than the total amount of DEBM funds budgeted in the ACTIVITY BUDGET for this program,then skip to <br /> SECTION D. If less than the total amount of DEHNR funds budgeted,then continue on to SECTION C. <br /> Reviewed by <br /> DEHNR 3300(Revised 2/90) <br />