<p>FY 2015 KWCSP RATE SHEET</p><p>Contracted Provider Name______Local Health Dept. Name______KENTUCKY WOMEN’S CANCER SCREENING PROGRAM NEGOTIATED RATES SHEET</p><p>The list below includes the CPT code and negotiated rates for this specific KWCSP provider contract with the Local Health Department. Enter the technical and professional rates for CPT codes where it is applicable. </p><p>This list should only include the CPT codes that will be reimbursed to this contracted provider by the LHD. Use multiple copies of this form for additional codes.</p><p>The link below will take you to the current version of the Core Clinical Service Guide (CCSG). The Cancer Screening/Follow-Up Section, found in the CCSG, is to be utilized by the provider when providing services to cancer screening patients referred by the health department. http://chfs.ky.gov/dph/CCSG.htm</p><p>CPT CODE GLOBAL RATE TECHNICAL ONLY PROFESSIONAL ONLY</p><p>IF APPLICABLE, THE TOTAL NUMBER OF MAMMOGRAMS PERFORMED UNDER THE TERMS OF THIS CONTRACT SHALL NOT EXCEED ______UNLESS AUTHORIZED BY THE HEALTH DEPARTMENT IN WRITING.</p>