Optional_Pricing_Sheet.docx

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Statewide Dental Services
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W912JF18R0005
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Optional Use Pricing Sheet

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CLIN 0001

0001 – Exams at Medcom, Base on 250 per year $ Each ___________________

0002 – Treatments, From 1-40, Base on 3 separate events$ Each____________________
120 per month total of three events.
0003 – Treatments, 41-up, Base on 3 separate events$ Each____________________
120 per month total of three months
0004 – Exams at other than Medcom, Base on Maximum of$ Each ____________________
250 per year.

0005 – Continuity of Care $ Each ____________________

0006 – ManPower Reporting (1 Report per Year) $ Year ____________________

1001 – Exams at Medcom, Base on 250 per year $ Each ___________________

1002 – Treatments, From 1-40, Base on 3 separate events$ Each____________________
120 per month total of three events.
1003 – Treatments, 41-up, Base on 3 separate events$ Each____________________
120 per month total of three months
1004 – Exams at other than Medcom, Base on Maximum of$ Each ____________________
250 per year.

1005 – Continuity of Care $ Each ____________________

1006 – ManPower Reporting (1 Report per Year) $ Year ____________________

2001 – Exams at Medcom, Base on 250 per year $ Each ___________________

2002 – Treatments, From 1-40, Base on 3 separate events$ Each____________________
120 per month total of three events.
2003 – Treatments, 41-up, Base on 3 separate events$ Each____________________
120 per month total of three months
2004 – Exams at other than Medcom, Base on Maximum of$ Each ____________________
250 per year.

2005 – Continuity of Care $ Each ____________________

2006 – ManPower Reporting (1 Report per Year) $ Year ____________________

3001 – Exams at Medcom, Base on 250 per year $ Each ___________________

3002 – Treatments, From 1-40, Base on 3 separate events$ Each____________________
120 per month total of three events.
3003 – Treatments, 41-up, Base on 3 separate events$ Each____________________
120 per month total of three months
3004 – Exams at other than Medcom, Base on Maximum of$ Each ____________________
250 per year.

3005 – Continuity of Care $ Each ____________________

3006 – ManPower Reporting (1 Report per Year) $ Year ____________________

4001 – Exams at Medcom, Base on 250 per year $ Each ___________________

4002 – Treatments, From 1-40, Base on 3 separate events$ Each____________________
120 per month total of three events.
4003 – Treatments, 41-up, Base on 3 separate events$ Each____________________
120 per month total of three months
4004 – Exams at other than Medcom, Base on Maximum of$ Each ____________________
250 per year.

4005 – Continuity of Care $ Each ____________________

4006 – ManPower Reporting (1 Report per Year) $ Year ____________________

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