1 TRIDENT-8057-ATTACH A-PRICE SHT-rebid.pdf
PDF 541 KB Posted
- Attached to
- Mobile Diagnostic Imaging Services
- Contract number
- 410008-M23-BAD8057-RFB-01
- Issued by
- Wisconsin
About this file
This is a Bid Price Response Sheet for Mobile Diagnostic Imaging Services under RFB# BAD-8057, submitted by TridentCare to the Wisconsin Department of Corrections (DOC). The document serves as a pricing proposal where the bidder accepts 60.00% of Medicare allowable rates for various diagnostic imaging services. The bid covers 119 different CPT codes ranging from basic X-ray examinations to ultrasound procedures and electrocardiogram services.
The contract encompasses a comprehensive range of medical imaging services including X-rays of various body parts (jaw, chest, spine, extremities), ultrasound examinations (abdominal, pelvic, breast, vascular), echocardiograms, and portable equipment setup and transportation services. TridentCare's pricing is structured as a percentage of Medicare allowable rates, with the bidder accepting 60% of those rates across all service lines. The total annual cost for all services is $601,378.68, calculated based on average annual usage volumes multiplied by the discounted Medicare rates. The document includes specific CPT codes, usage projections, Medicare allowable costs per unit, and the bidder's discounted pricing for each service, with transportation codes (R0070, R0075 with various modifiers) representing significant cost components for portable imaging equipment delivery and setup.
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| File | Type | Posted |
|---|---|---|
| 8057 Contract Announcement.doc | DOC document |
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TOTAL COST: $ 601,378.68
60.00%
COLUMN A COLUMN B COLUMN C COLUMN D COLUMN E COLUMN F COLUMN G COLUMN H COLUMN I
LINE REF CPT CODE SHORT DESCRIPTION MODIFIER
AVERAGE
ANNUAL USAGE
MEDICARE ALLOWABLE
WISCONSIN PER UNIT COST
MEDICARE ALLOWABLE TOTAL
ANNUAL COST
BIDDER'S PERCENTAGE OF
MEDICARE ACCEPTED
BIDDER TOTAL ANNUAL COST PER
LINE ITEM
*Table Column E Multiplied by Column F *Bidder Provided Percentage *Table Column G Multiplied by Column H
1 70100 X-ray exam of jaw <4views NULL 3 37.40$ 112.20$ 60.00% 67.32$
2 70110 X-ray exam of jaw 4/> views NULL 12 42.76$ 513.12$ 60.00% 307.87$
3 70140 X-ray exam of facial bones NULL 17 31.23$ 530.91$ 60.00% 318.55$
4 70150 X-ray exam of facial bones NULL 13 46.37$ 602.81$ 60.00% 361.69$
5 70160 X-ray exam of nasal bones NULL 21 37.06$ 778.26$ 60.00% 466.96$
6 70190 X-ray exam of eye sockets NULL 1 37.14$ 37.14$ 60.00% 22.28$
7 70200 X-ray exam of eye sockets NULL 37 47.38$ 1,753.06$ 60.00% 1,051.84$
8 70210 X-ray exam of sinuses NULL 18 31.52$ 567.36$ 60.00% 340.42$
9 70220 X-ray exam of sinuses NULL 14 36.83$ 515.62$ 60.00% 309.37$
10 70250 X-ray exam of skull NULL 8 34.80$ 278.40$ 60.00% 167.04$
11 70260 X-ray exam of skull NULL 6 43.80$ 262.80$ 60.00% 157.68$
12 70328 X-ray exam of jaw joint NULL 1 33.82$ 33.82$ 60.00% 20.29$
13 70360 X-ray exam of neck NULL 21 30.56$ 641.76$ 60.00% 385.06$
14 71045 X-ray exam chest 1 view NULL 83 25.02$ 2,076.66$ 60.00% 1,246.00$
15 71046 X-ray exam chest 2 views NULL 1077 32.59$ 35,099.43$ 60.00% 21,059.66$
16 71046 X-ray exam chest 2 views NULL 1 32.59$ 32.59$ 60.00% 19.55$
17 71047 X-ray exam chest 3 views NULL 69 41.17$ 2,840.73$ 60.00% 1,704.44$
18 71048 X-ray exam chest 4+ views NULL 19 45.16$ 858.04$ 60.00% 514.82$
19 71100 X-ray exam ribs uni 2 views NULL 27 35.85$ 967.95$ 60.00% 580.77$
20 71101 X-ray exam unilat ribs/chest NULL 14 41.17$ 576.38$ 60.00% 345.83$
21 71110 X-ray exam ribs bil 3 views NULL 6 42.84$ 257.04$ 60.00% 154.22$
22 71111 X-ray exam ribs/chest4/> vws NULL 2 51.38$ 102.76$ 60.00% 61.66$
23 71120 X-ray exam breastbone 2/>vws NULL 4 32.88$ 131.52$ 60.00% 78.91$ eSUPPLIER SUBMITTAL: The Bid Price Response Sheet (Attachment A) shall be uploaded with the Bidder's responses into eSupplier..
Attachment A: Bid Price Response Sheet
MOBILE DIAGNOSTIC IMAGING SERVICES RFB#: BAD-8057
INSTRUCTIONS:
See RFB Section 5.0, Pricing Structure and Bid Price Response Sheet Instructions.
1 The Bidder shall enter their BIDDER'S COMPANY NAME in the associated space provided below.
2 The Bidder shall enter their BIDDER'S PERCENTAGE OF MEDICARE ACCEPTED in the associated space provided below and save.
• If the BIDDER'S PERCENTAGE OF MEDICARE ACCEPTED space is "0%" or "left empty", then DOC shall only accept your services at no cost.
• Only 2 (two) decimal points shall be provided by the bidder and accepted by DOC for the BIDDER'S PERCENTAGE OF MEDICARE ACCEPTED and also as listed in each line item under TABLE COLUMN H below.
• Prices listed on the Bid Price Response Sheet are in U.S. Dollars.
*Bidder shall not alter the Bid Price Response Sheet in any manner, any alteration may be the basis for rejecting your Bid response.
*Failure to follow any RFB#: BAD-8057 and/or Bid Price Response Sheet instructions may be the basis for rejecting your Bid response.
*SAVE and SUBMIT only one final version of your completed Attachment A: Bid Price Response Sheet.
HARD COPY SUBMITTAL: The Bid Price Response Sheet (Attachment A) shall be organized under a separate cover, see RFB Section 6.5.2.
1 BIDDER'S COMPANY NAME: > TridentCare
2 BIDDER'S PERCENTAGE OF MEDICARE ACCEPTED:
For information on CPT codes please reference the following link: https://www.cms.gov/regulations-and-guidance/administrative-simplification/code-sets
24 71130 X-ray strenoclavic jt 3/>vws NULL 4 40.42$ 161.68$ 60.00% 97.01$
25 72020 X-ray exam of spine 1 view NULL 2 23.67$ 47.34$ 60.00% 28.40$
26 72040 X-ray exam neck spine 2-3 vw NULL 191 38.46$ 7,345.86$ 60.00% 4,407.52$
27 72050 X-ray exam neck spine 4/5vws NULL 56 51.93$ 2,908.08$ 60.00% 1,744.85$
28 72070 X-ray exam thorac spine 2vws NULL 80 31.90$ 2,552.00$ 60.00% 1,531.20$
29 72072 X-ray exam thorac spine 3vws NULL 36 38.16$ 1,373.76$ 60.00% 824.26$
30 72082 X-ray exam entire spi 2/3 vw NULL 1 68.41$ 68.41$ 60.00% 41.05$
31 72083 X-ray exam entire spi 4/5 vw NULL 2 76.86$ 153.72$ 60.00% 92.23$
32 72100 X-ray exam l-s spine 2/3 vws NULL 427 38.79$ 16,563.33$ 60.00% 9,938.00$
33 72110 X-ray exam l-2 spine 4/>vws NULL 93 49.95$ 4,645.35$ 60.00% 2,787.21$
34 72114 X-ray exam l-s spine bending NULL 16 60.46$ 967.36$ 60.00% 580.42$
35 72120 X-ray bend only l-s spine NULL 16 39.77$ 636.32$ 60.00% 381.79$
36 72170 X-ray exam of pelvis NULL 34 26.95$ 916.30$ 60.00% 549.78$
37 72190 X-ray exam of pelvis NULL 14 41.13$ 575.82$ 60.00% 345.49$
38 72200 X-ray exam si joints NULL 5 31.84$ 159.20$ 60.00% 95.52$
39 72202 X-ray exam si joints 3/> vws NULL 8 38.16$ 305.28$ 60.00% 183.17$
40 72220 X-ray exam sacrum tailbone NULL 18 31.52$ 567.36$ 60.00% 340.42$
41 73000 X-ray exam of collar bone NULL 38 31.17$ 1,184.46$ 60.00% 710.68$
42 73010 X-ray exam of shoulder blade NULL 8 23.04$ 184.32$ 60.00% 110.59$
43 73020 X-ray exam of shoulder NULL 13 20.72$ 269.36$ 60.00% 161.62$
44 73030 X-ray exam of shoulder NULL 531 33.49$ 17,783.19$ 60.00% 10,669.91$
45 73050 X-ray exam of shoulders NULL 21 27.62$ 580.02$ 60.00% 348.01$
46 73060 X-ray exam of humerus NULL 14 30.84$ 431.76$ 60.00% 259.06$
47 73070 X-ray exam of elbow NULL 46 28.24$ 1,299.04$ 60.00% 779.42$
48 73080 X-ray exam of elbow NULL 74 31.52$ 2,332.48$ 60.00% 1,399.49$
49 73090 X-ray exam of forearm NULL 51 28.24$ 1,440.24$ 60.00% 864.14$
50 73100 X-ray exam of wrist NULL 38 32.80$ 1,246.40$ 60.00% 747.84$
51 73100 X-ray exam of wrist NULL 44 32.80$ 1,443.20$ 60.00% 865.92$
52 73110 X-ray exam of wrist NULL 167 39.66$ 6,623.22$ 60.00% 3,973.93$
53 73120 X-ray exam of hand NULL 161 30.19$ 4,860.59$ 60.00% 2,916.35$
54 73130 X-ray exam of hand NULL 404 35.43$ 14,313.72$ 60.00% 8,588.23$
55 73140 X-ray exam of finger(s) NULL 267 36.32$ 9,697.44$ 60.00% 5,818.46$
56 73501 X-ray exam hip uni 1 view NULL 38 31.54$ 1,198.52$ 60.00% 719.11$
57 73502 X-ray exam hip uni 2-3 views NULL 236 45.63$ 10,768.68$ 60.00% 6,461.21$
58 73503 X-ray exam hip uni 4/> views NULL 38 57.47$ 2,183.86$ 60.00% 1,310.32$
59 73521 X-ray exam hips bi 2 views NULL 16 40.09$ 641.44$ 60.00% 384.86$
60 73522 X-ray exam hips bi 3-4 views NULL 22 52.29$ 1,150.38$ 60.00% 690.23$
61 73523 X-ray exam hips bi 5/> views NULL 4 59.83$ 239.32$ 60.00% 143.59$
62 73551 X-ray exam of femur 1 NULL 4 28.24$ 112.96$ 60.00% 67.78$
63 73552 X-ray exam of femur 2/> NULL 31 34.14$ 1,058.34$ 60.00% 635.00$
64 73560 X-ray exam of knee 1 or 2 NULL 229 33.13$ 7,586.77$ 60.00% 4,552.06$
65 73562 X-ray exam of knee 3 NULL 558 39.69$ 22,147.02$ 60.00% 13,288.21$
66 73564 X-ray exam knee 4 or more NULL 216 44.98$ 9,715.68$ 60.00% 5,829.41$
67 73565 X-ray exam of knees NULL 2 39.32$ 78.64$ 60.00% 47.18$
68 73590 X-ray exam of lower leg NULL 64 30.52$ 1,953.28$ 60.00% 1,171.97$
69 73600 X-ray exam of ankle NULL 165 31.17$ 5,143.05$ 60.00% 3,085.83$
70 73610 X-ray exam of ankle NULL 252 35.75$ 9,009.00$ 60.00% 5,405.40$
71 73620 X-ray exam of foot NULL 197 27.26$ 5,370.22$ 60.00% 3,222.13$
72 73630 X-ray exam of foot NULL 363 33.47$ 12,149.61$ 60.00% 7,289.77$
73 73650 X-ray exam of heel NULL 17 27.91$ 474.47$ 60.00% 284.68$
74 73660 X-ray exam of toe(s) NULL 69 28.17$ 1,943.73$ 60.00% 1,166.24$
75 74018 X-ray exam abdomen 1 view NULL 394 29.25$ 11,524.50$ 60.00% 6,914.70$
76 74019 X-ray exam abdomen 2 views NULL 44 35.87$ 1,578.28$ 60.00% 946.97$
77 74021 X-ray exam abdomen 3+ views NULL 1 42.15$ 42.15$ 60.00% 25.29$
78 74022 X-ray exam complete abdomen NULL 32 48.77$ 1,560.64$ 60.00% 936.38$
79 76536 Us exam of head and neck NULL 237 109.86$ 26,036.82$ 60.00% 15,622.09$
80 76604 Us exam chest NULL 21 56.79$ 1,192.59$ 60.00% 715.55$
81 76641 Ultrasound breast complete NULL 22 101.40$ 2,230.80$ 60.00% 1,338.48$
82 76642 Ultrasound breast limited NULL 54 83.05$ 4,484.70$ 60.00% 2,690.82$
83 76700 Us exam abdom complete NULL 212 115.58$ 24,502.96$ 60.00% 14,701.78$
84 76705 Echo exam of abdomen NULL 623 86.13$ 53,658.99$ 60.00% 32,195.39$
85 76770 Us exam abdo back wall comp NULL 298 106.97$ 31,877.06$ 60.00% 19,126.24$
86 76775 Us exam abdo back wall lim NULL 42 56.44$ 2,370.48$ 60.00% 1,422.29$
87 76805 Ob us >= 14 wks sngl fetus NULL 1 132.90$ 132.90$ 60.00% 79.74$
88 76817 Transvaginal us obstetric NULL 2 91.34$ 182.68$ 60.00% 109.61$
89 76830 Transvaginal us non-ob NULL 49 117.95$ 5,779.55$ 60.00% 3,467.73$
90 76856 Us exam pelvic complete NULL 117 104.26$ 12,198.42$ 60.00% 7,319.05$
91 76857 Us exam pelvic limited NULL 177 46.62$ 8,251.74$ 60.00% 4,951.04$
92 76870 Us exam scrotum NULL 135 99.27$ 13,401.45$ 60.00% 8,040.87$
93 76881 Us compl joint r-t w/img NULL 24 57.32$ 1,375.68$ 60.00% 825.41$
94 76882 Us lmtd jt/nonvasc xtr strux NULL 161 54.75$ 8,814.75$ 60.00% 5,288.85$
95 93000 Electrocardiogram complete NULL 96 13.59$ 1,304.64$ 60.00% 782.78$
96 93010 Electrocardiogram report NULL 2 7.94$ 15.88$ 60.00% 9.53$
97 93306 Tte w/doppler complete NULL 333 194.35$ 64,718.55$ 60.00% 38,831.13$
98 93308 Tte f-up or lmtd NULL 12 96.23$ 1,154.76$ 60.00% 692.86$
99 93880 Extracranial bilat study NULL 66 187.14$ 12,351.24$ 60.00% 7,410.74$
100 93882 Extracranial uni/ltd study NULL 1 121.67$ 121.67$ 60.00% 73.00$
101 93925 Lower extremity study NULL 46 236.79$ 10,892.34$ 60.00% 6,535.40$
102 93926 Lower extremity study NULL 14 22.05$ 308.70$ 60.00% 185.22$
103 93930 Upper extremity study NULL 2 191.36$ 382.72$ 60.00% 229.63$
104 93931 Upper extremity study NULL 3 121.36$ 364.08$ 60.00% 218.45$
105 93970 Extremity study NULL 40 183.90$ 7,356.00$ 60.00% 4,413.60$
106 93971 Extremity study NULL 91 116.59$ 10,609.69$ 60.00% 6,365.81$
107 93975 Vascular study NULL 155 260.21$ 40,332.55$ 60.00% 24,199.53$
108 93976 Vascular study NULL 9 37.22$ 334.98$ 60.00% 200.99$
109 93978 Vascular study NULL 21 176.14$ 3,698.94$ 60.00% 2,219.36$
110 93979 Vascular study NULL 2 114.51$ 229.02$ 60.00% 137.41$
111 93990 Doppler flow testing NULL 1 21.81$ 21.81$ 60.00% 13.09$
112 Q0092 Set up port xray equipment NULL 6849 22.27$ 152,527.23$ 60.00% 91,516.34$
113 R0070 Transport portable x-ray NULL 540 135.94$ 73,407.60$ 60.00% 44,044.56$
114 R0075 Transport port x-ray multipl UN 516 67.97$ 35,072.52$ 60.00% 21,043.51$
115 R0075 Transport port x-ray multipl UP 560 45.31$ 25,375.47$ 60.00% 15,225.28$
116 R0075 Transport port x-ray multipl UQ 582 33.99$ 19,779.27$ 60.00% 11,867.56$
117 R0075 Transport port x-ray multipl UR 612 27.19$ 16,639.06$ 60.00% 9,983.43$
118 R0075 Transport port x-ray multipl US 3000 22.66$ 67,970.00$ 60.00% 40,782.00$
119 601,378.68$ TOTAL COST :
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