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Attachment 3 <br />87880 Strep A (UNC Lab)$20.00 $15.71 2017 <br />88175 Pap Thin Prep (Wake Med)$26.50 $40.00 2016 <br />New 2019 90750 Shingrix Vaccine $0.00 $138.60 New <br />99080 Screening Form Completion $25.00 $0.00 2016 <br />Medicaid only 90750SL Shingrix Vaccine $0.00 2018 <br />Dental D1354 Silver Diamine Fluoride $49.00 2018 <br />Dental D4320 Provisional Splinting, intracoronal $115.00 2018 <br />Dental D4321 Provisional Splinting, extracoronal $115.00 2018 <br />J7297 Liletta IUD $47.04 $47.04 2016 <br />Medicaid only J7297ud Liletta IUD $47.04 $47.04 2016 <br />87389 HIV (State Lab)$0.00 <br />87800 Chlamydia & Gonorrhea/Vaginal NAAT (State Lab $0.00 <br />86803 Hep C Antibody (State Lab)$0.00 <br />87273 Herpes Simplex Culture (State Lab)$0.00 <br />86592 RPR with Reflex TREP sure (State Lab)$0.00 <br />86762 Rubella Titer (State Lab)$0.00 <br />93870 Zika (State Lab)$0.00 <br />87798 Pertussis PCR (State Lab)$0.00 <br />15