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N.C.Department of Environment,Health,and Natural Resources Page 2 of 2 <br /> Division of General Services <br /> FY 1997-98 <br /> CONTRACT ADDENDUM , <br /> Women's Preventive Health 98 51510 068 <br /> Office, Section, or Branch Contract Number <br /> Orange Family Planninlz <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 ESTIMATED 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 /> FP Initial Visit 245 x $190.24 = $46,608.8 <br /> FP Complete Physical/Annual Exam 620 x $149.63 = $92,770.6 <br /> FP Limited Revisit 775 x $63.68 = $49,352.00 <br /> FP Extended Revisit 22 x $106.90 = $ 20-351 .8 <br /> Depo Injection 475 x $23.74 = $11 <br /> Norplant Insertion 0 x $504.90 = $ 0 <br /> Norplant Removal 6 x $197.11 $ 1,182.66 <br /> Norplant Removal and Reinsertion 0 x $645.91 — $ - '0 <br /> IUD Device and Insertion 0 x $177.35 = $ 0 <br /> IUD Removal 0 x $89.71 = $ 0 <br /> Pregnancy Test(not associated with a <br /> family planning visit) 0 x $10.51 = $ 0 <br /> Psychosocial Counseling 0 x $63.59 — $ 0 <br /> Medical Nutrition Therapy 0 x $56.97 — $ 0 ' <br /> Colposcopy without Biopsy 0 x $48.85 = $ 0 <br /> Colposcopy with Biopsy 0 x $73.37 = $ 0 _ <br /> Cryosurgery 0 x $78.90 = $ 0 <br /> TOTAL ESTIMATED COST OF SECTION B SERVICE DELIVERABLES $203,542-36 <br /> Instruction: If the TOTAL ESTIMATED COST OF SECTION B SERVICE DELIVERABLES is equal to or greater <br /> than the total amount of DEHNR funds budgeted in the ACTIVITY BUDGET for this program, then skip to <br /> SECTION D. If lest than the total amount of DEHNR funds budgeted, then continue on to SECTION C. <br /> Reviewed by <br /> DEHNR 3300(Revised 2/97) <br /> General Services Division(Review 1798) <br /> Initials Date <br />