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Kr-ULANu5 CHRISTIAN MIGRANTS ASSOCIATION <br /> Services Agreement February 01, 2006 -January 31, 2007 <br /> RCMA CURRENT SFS - <br /> Health and Disabilities 0%-A 17%-B 33%-C 50%-D 67%-E 83%- F 100%-G COST COST <br /> Physical Exam $0.00 $4.08 $7.92 $12.00 $16.08 $19.92 $24.00 $24.00 $32.00 <br /> Hemoglobin/Hematocrit $0.00 $1.28 $2.48 $3.75 $5.03 $6.23 $7.50 $7.50 $10.00 <br /> TB Screening $0.00 $1.28 $2.48 $3.75 $5.03 $6.231 $7.50 $7.50 $10.00 <br /> Lead Screening $0.00 $1.28 $2.48 $3.75 $5.03 $6.23 $7.50 $7.50 $10.00 <br /> Vision Screening $0.00 $1.28 $2.48 $3.75 $5.03 $6.23 $7.50 $7.50 $10.00 <br /> Hearing Screening $0.00 $1.28 $2.48 $3.75 $5.03 $6.23 $7.50 $7.50 $10.00 <br /> Dental Screening N/A <br /> Dental Exam&Treatment N/A <br /> NOTE: <br /> Lead,Vision and Hearing screening is included in Physical Exam. <br /> Dental Screening, Dental Exam and Treatment is covered under a separate agreement. <br /> Hepatitis B Vaccine/Blood Exposure RCMA CURRENT SFS <br /> Agreement 0%-A 17%-B 33%-C 50%-D 67%-E 83%- F 100%-G COST COST <br /> Office Visit for Hep B Vaccine $0.00 $7.01 $13.61 $20.63 $27.64 $34.24 $41.25 $41.25 $55.00 <br /> Hep Vaccine per shot $0.00 $4.46 $8.66 $13.13 $17.59 $21.79 $26.25 $26.25 $35.00 <br /> Hepatitis B antibody Testing $0.001 $2.551 $4.951 $7.501 $10.051 $12.451 $15.001 $1.9001 $20.00 <br /> Exposure incident Evaluation,Testing,and <br /> Counseling N/A <br /> NOTE: Exposure incident Evaluation and Counseling included in cost of Office Visit. Lab fees are charged separately. <br /> RCMA CURRENT SFS <br /> Dental Services 0%-A 17%-B 33%-C 50%-D 67%-E 83%- F 100%-G COST COST <br /> D0150 Oral Examination <br /> $8.00 $16.00 <br /> D1120 Prophylaxis-Child $7.00 $14.00 <br /> D1203 Topical Fluoride-Child 1 $5.50 $11.00 <br /> D 0272 Bitewing-Two Films $4.50 $9.00 <br /> D7111 Single Tooth Extraction $13.50 <br /> $27.00 <br /> D3220 Therapeutic Pulpotomy $25.00 $50.00 <br /> D2140 Amalgam-One Surface $15.50 $31.00 <br /> D2150 Amalgam-Two Surface $20.501 $41.00 <br /> D2160 Amalgam-Three Surface $25.50 $51.00 <br /> D2330 Resin-One Surface Anterior Primary $17.00 $34.00 <br /> D2331 Resin-Two Surface Anterior Primary $19.50 $39.00 <br /> D2332 Resin-Three Surface Anterior Primary $22.00 $44.00 <br /> D2930 Prefabricated Steel Crown Primary $34.00 $68.00 <br /> Missed Appointment <br /> $8.00 $16.00 <br /> NOTE: No Sliding Fee Scale for Dental Services. <br /> J:\KLINE\Core Contract 06-07\CLFEE2006-07, RCMA 10/23/2006 <br />