Attachment_C_-_Price_Proposal_Form.xlsx

XLSX spreadsheet 60 KB Posted Sep 14, 2015

Attached to: Nationwide Cardiac Testing Services Federal contract opportunity
Solicitation number: 15-233-SOL-00286
Issued by: Department of Health and Human Services Program Support Center

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From the source

Attachment C Price Proposal Form

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Other files for this federal contract opportunity

Other files attached to Nationwide Cardiac Testing Services, newest first.
File	Type	Posted
Questions_and_Answers_-_FOH_Cardiac_Testing_Services(2015-09-27).pdf	PDF	Sep 27, 2015
15-233-SOL-00286_SOLICITATION_IDIQ_-_REVISED_(2015-09-27).pdf	PDF	Sep 27, 2015
Attachment_B_-_Non-Disclosure_Agreement.pdf	PDF	Sep 14, 2015
Attachment_G_-_OMB_Standard_Form_LLL_-_Lobbying_Activities.pdf	PDF	Sep 14, 2015
Attachment_A_-_Past_Performance_Questionnaire.pdf	PDF	Sep 14, 2015
15-233-SOL-00286_Nationwide_Cardiac_Testing_Services.pdf	PDF	Sep 14, 2015
Attachment_E_-_FOH-74_Referral_Ticket_(M.89).pdf	PDF	Sep 14, 2015
Attachment_D_-_List_of_Cities.xlsx	XLSX spreadsheet	Sep 14, 2015
Attachment_F_-_FBI_Security_Forms.pdf	PDF	Sep 14, 2015

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Data Entry

			Instructions
	Quantities by City to attain Price per Test		Assign each city to a pricing level by entering the Quantity for each Test from column F to the Price Level either in G, H or I. This will autopopulate the quantities to the next tabs. Fill in the price for each CLIN on each of the following tabs.
				Low Cost of Living	Medium Cost of Living	High Cost of Living
State	City	TEST	TOTAL PROJECTED for PRICING	Level 1	Level 2	Level 3
AK	Anchorage	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	40
	Anchorage	Non-Stress Echocardiogram	1
	Anchorage	Exercise Treadmill ECG with Nuclear Imaging	1
	Anchorage	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Anchorage	Missed Appointment	4
AK	Fairbanks	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	3
	Fairbanks	Non-Stress Echocardiogram	1
	Fairbanks	Exercise Treadmill ECG with Nuclear Imaging	1
	Fairbanks	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Fairbanks	Missed Appointment	1
AL	Birmingham	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	80
	Birmingham	Non-Stress Echocardiogram	1
	Birmingham	Exercise Treadmill ECG with Nuclear Imaging	1
	Birmingham	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Birmingham	Missed Appointment	8
AL	Mobile	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	30
	Mobile	Non-Stress Echocardiogram	1
	Mobile	Exercise Treadmill ECG with Nuclear Imaging	1
	Mobile	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Mobile	Missed Appointment	3
AR	Little Rock	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	80
	Little Rock	Non-Stress Echocardiogram	1
	Little Rock	Exercise Treadmill ECG with Nuclear Imaging	1
	Little Rock	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Little Rock	Missed Appointment	8
AZ	Phoenix	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	120
	Phoenix	Non-Stress Echocardiogram	1
	Phoenix	Exercise Treadmill ECG with Nuclear Imaging	1
	Phoenix	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Phoenix	Missed Appointment	12
CA	Diamond Bar	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	6
	Diamond Bar	Non-Stress Echocardiogram	1
	Diamond Bar	Exercise Treadmill ECG with Nuclear Imaging	1
	Diamond Bar	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Diamond Bar	Missed Appointment	1
CA	Fresno	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	18
	Fresno	Non-Stress Echocardiogram	1
	Fresno	Exercise Treadmill ECG with Nuclear Imaging	1
	Fresno	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Fresno	Missed Appointment	2
CA	Long Beach	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	14
	Long Beach	Non-Stress Echocardiogram	1
	Long Beach	Exercise Treadmill ECG with Nuclear Imaging	1
	Long Beach	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Long Beach	Missed Appointment	1
CA	Los Angeles	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	200
	Los Angeles	Non-Stress Echocardiogram	1
	Los Angeles	Exercise Treadmill ECG with Nuclear Imaging	1
	Los Angeles	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Los Angeles	Missed Appointment	20
CA	Riverside	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	30
	Riverside	Non-Stress Echocardiogram	1
	Riverside	Exercise Treadmill ECG with Nuclear Imaging	1
	Riverside	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Riverside	Missed Appointment	3
CA	Sacramento	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	100
	Sacramento	Non-Stress Echocardiogram	1
	Sacramento	Exercise Treadmill ECG with Nuclear Imaging	1
	Sacramento	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Sacramento	Missed Appointment	10
CA	San Diego	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	25
	San Diego	Non-Stress Echocardiogram	1
	San Diego	Exercise Treadmill ECG with Nuclear Imaging	1
	San Diego	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	San Diego	Missed Appointment	2
CA	San Francisco	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	160
	San Francisco	Non-Stress Echocardiogram	1
	San Francisco	Exercise Treadmill ECG with Nuclear Imaging	1
	San Francisco	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	San Francisco	Missed Appointment	16
CA	San Jose	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	25
	San Jose	Non-Stress Echocardiogram	1
	San Jose	Exercise Treadmill ECG with Nuclear Imaging	1
	San Jose	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	San Jose	Missed Appointment	2
CA	Santa Ana	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	10
	Santa Ana	Non-Stress Echocardiogram	1
	Santa Ana	Exercise Treadmill ECG with Nuclear Imaging	1
	Santa Ana	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Santa Ana	Missed Appointment	1
CA	Van Nuys	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	15
	Van Nuys	Non-Stress Echocardiogram	1
	Van Nuys	Exercise Treadmill ECG with Nuclear Imaging	1
	Van Nuys	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Van Nuys	Missed Appointment	1
CO	Denver	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	140
	Denver	Non-Stress Echocardiogram	1
	Denver	Exercise Treadmill ECG with Nuclear Imaging	1
	Denver	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Denver	Missed Appointment	14
CT	Hartford	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	110
	Hartford	Non-Stress Echocardiogram	1
	Hartford	Exercise Treadmill ECG with Nuclear Imaging	1
	Hartford	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Hartford	Missed Appointment	11
DC	Washington	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	700
	Washington	Non-Stress Echocardiogram	1
	Washington	Exercise Treadmill ECG with Nuclear Imaging	1
	Washington	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Washington	Missed Appointment	25
FL	Ft. Lauderdale	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	5
	Ft. Lauderdale	Non-Stress Echocardiogram	1
	Ft. Lauderdale	Exercise Treadmill ECG with Nuclear Imaging	1
	Ft. Lauderdale	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Ft. Lauderdale	Missed Appointment	1
FL	Jacksonville	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	10
	Jacksonville	Non-Stress Echocardiogram	1
	Jacksonville	Exercise Treadmill ECG with Nuclear Imaging	1
	Jacksonville	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Jacksonville	Missed Appointment	1
FL	Miami	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	300
	Miami	Non-Stress Echocardiogram	1
	Miami	Exercise Treadmill ECG with Nuclear Imaging	1
	Miami	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Miami	Missed Appointment	15
FL	Orlando	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	40
	Orlando	Non-Stress Echocardiogram	1
	Orlando	Exercise Treadmill ECG with Nuclear Imaging	1
	Orlando	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Orlando	Missed Appointment	4
FL	Tampa	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	100
	Tampa	Non-Stress Echocardiogram	1
	Tampa	Exercise Treadmill ECG with Nuclear Imaging	1
	Tampa	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Tampa	Missed Appointment	10
GA	Atlanta	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	150
	Atlanta	Non-Stress Echocardiogram	1
	Atlanta	Exercise Treadmill ECG with Nuclear Imaging	1
	Atlanta	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Atlanta	Missed Appointment	10
HI	Honolulu	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	80
	Honolulu	Non-Stress Echocardiogram	1
	Honolulu	Exercise Treadmill ECG with Nuclear Imaging	1
	Honolulu	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Honolulu	Missed Appointment	8
IA	Des Moines	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	15
	Des Moines	Non-Stress Echocardiogram	1
	Des Moines	Exercise Treadmill ECG with Nuclear Imaging	1
	Des Moines	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Des Moines	Missed Appointment	1
ID	Boise	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	40
	Boise	Non-Stress Echocardiogram	1
	Boise	Exercise Treadmill ECG with Nuclear Imaging	1
	Boise	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Boise	Missed Appointment	4
IL	Chicago	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	30
	Chicago	Non-Stress Echocardiogram	1
	Chicago	Exercise Treadmill ECG with Nuclear Imaging	1
	Chicago	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Chicago	Missed Appointment	3
IN	Indianapolis	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	120
	Indianapolis	Non-Stress Echocardiogram	1
	Indianapolis	Exercise Treadmill ECG with Nuclear Imaging	1
	Indianapolis	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Indianapolis	Missed Appointment	12
KY	Lexington	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	6
	Lexington	Non-Stress Echocardiogram	1
	Lexington	Exercise Treadmill ECG with Nuclear Imaging	1
	Lexington	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Lexington	Missed Appointment	1
KY	Louisville	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	40
	Louisville	Non-Stress Echocardiogram	1
	Louisville	Exercise Treadmill ECG with Nuclear Imaging	1
	Louisville	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Louisville	Missed Appointment	4
LA	New Orleans	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	90
	New Orleans	Non-Stress Echocardiogram	1
	New Orleans	Exercise Treadmill ECG with Nuclear Imaging	1
	New Orleans	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	New Orleans	Missed Appointment	9
MA	Boston	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	130
	Boston	Non-Stress Echocardiogram	1
	Boston	Exercise Treadmill ECG with Nuclear Imaging	1
	Boston	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Boston	Missed Appointment	13
MA	Concord	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	10
	Concord	Non-Stress Echocardiogram	1
	Concord	Exercise Treadmill ECG with Nuclear Imaging	1
	Concord	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Concord	Missed Appointment	1
MD	Baltimore	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	150
	Baltimore	Non-Stress Echocardiogram	1
	Baltimore	Exercise Treadmill ECG with Nuclear Imaging	1
	Baltimore	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	2
	Baltimore	Missed Appointment	15
MD	Greenbelt	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	20
	Greenbelt	Non-Stress Echocardiogram	1
	Greenbelt	Exercise Treadmill ECG with Nuclear Imaging	1
	Greenbelt	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Greenbelt	Missed Appointment	2
MI	Detroit	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	250
	Detroit	Non-Stress Echocardiogram	1
	Detroit	Exercise Treadmill ECG with Nuclear Imaging	1
	Detroit	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Detroit	Missed Appointment	20
MN	Minneapolis	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	225
	Minneapolis	Non-Stress Echocardiogram	1
	Minneapolis	Exercise Treadmill ECG with Nuclear Imaging	1
	Minneapolis	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Minneapolis	Missed Appointment	20
MN	St. Paul	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	6
	St. Paul	Non-Stress Echocardiogram	1
	St. Paul	Exercise Treadmill ECG with Nuclear Imaging	1
	St. Paul	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	St. Paul	Missed Appointment	1
MO	Kansas City	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	50
	Kansas City	Non-Stress Echocardiogram	1
	Kansas City	Exercise Treadmill ECG with Nuclear Imaging	1
	Kansas City	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Kansas City	Missed Appointment	5
MO	Springfield	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	5
	Springfield	Non-Stress Echocardiogram	1
	Springfield	Exercise Treadmill ECG with Nuclear Imaging	1
	Springfield	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Springfield	Missed Appointment	1
MO	St. Louis	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	10
	St. Louis	Non-Stress Echocardiogram	1
	St. Louis	Exercise Treadmill ECG with Nuclear Imaging	1
	St. Louis	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	St. Louis	Missed Appointment	1
MS	Jackson	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	60
	Jackson	Non-Stress Echocardiogram	1
	Jackson	Exercise Treadmill ECG with Nuclear Imaging	1
	Jackson	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Jackson	Missed Appointment	6
NC	Raleigh	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	30
	Raleigh	Non-Stress Echocardiogram	1
	Raleigh	Exercise Treadmill ECG with Nuclear Imaging	1
	Raleigh	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Raleigh	Missed Appointment	3
NC	Research Triangle Park	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	30
	Research Triangle Park	Non-Stress Echocardiogram	1
	Research Triangle Park	Exercise Treadmill ECG with Nuclear Imaging	1
	Research Triangle Park	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Research Triangle Park	Missed Appointment	3
NE	Omaha	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	100
	Omaha	Non-Stress Echocardiogram	1
	Omaha	Exercise Treadmill ECG with Nuclear Imaging	1
	Omaha	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Omaha	Missed Appointment	10
NJ	Atlantic City	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	15
	Atlantic City	Non-Stress Echocardiogram	1
	Atlantic City	Exercise Treadmill ECG with Nuclear Imaging	1
	Atlantic City	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Atlantic City	Missed Appointment	1
NJ	Edison	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	5
	Edison	Non-Stress Echocardiogram	1
	Edison	Exercise Treadmill ECG with Nuclear Imaging	1
	Edison	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Edison	Missed Appointment	1
NJ	Newark	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	180
	Newark	Non-Stress Echocardiogram	1
	Newark	Exercise Treadmill ECG with Nuclear Imaging	1
	Newark	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Newark	Missed Appointment	15
NM	Albuquerque	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	200
	Albuquerque	Non-Stress Echocardiogram	1
	Albuquerque	Exercise Treadmill ECG with Nuclear Imaging	1
	Albuquerque	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Albuquerque	Missed Appointment	15
NV	Las Vegas	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	100
	Las Vegas	Non-Stress Echocardiogram	1
	Las Vegas	Exercise Treadmill ECG with Nuclear Imaging	1
	Las Vegas	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Las Vegas	Missed Appointment	10
NY	Albany	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	15
	Albany	Non-Stress Echocardiogram	1
	Albany	Exercise Treadmill ECG with Nuclear Imaging	1
	Albany	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Albany	Missed Appointment	1
NY	Buffalo	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	35
	Buffalo	Non-Stress Echocardiogram	1
	Buffalo	Exercise Treadmill ECG with Nuclear Imaging	1
	Buffalo	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Buffalo	Missed Appointment	3
NY	Greenport	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	30
	Greenport	Non-Stress Echocardiogram	1
	Greenport	Exercise Treadmill ECG with Nuclear Imaging	1
	Greenport	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Greenport	Missed Appointment	3
NY	Hudson Valley area	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	15
	Hudson Valley area	Non-Stress Echocardiogram	1
	Hudson Valley area	Exercise Treadmill ECG with Nuclear Imaging	1
	Hudson Valley area	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Hudson Valley area	Missed Appointment	1
NY	Long Island area	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	25
	Long Island area	Non-Stress Echocardiogram	1
	Long Island area	Exercise Treadmill ECG with Nuclear Imaging	1
	Long Island area	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Long Island area	Missed Appointment	2
NY	New York	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	550
	New York	Non-Stress Echocardiogram	1
	New York	Exercise Treadmill ECG with Nuclear Imaging	1
	New York	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	New York	Missed Appointment	30
NY	Syracuse	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	10
	Syracuse	Non-Stress Echocardiogram	1
	Syracuse	Exercise Treadmill ECG with Nuclear Imaging	1
	Syracuse	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Syracuse	Missed Appointment	1
NY	White Plains	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	5
	White Plains	Non-Stress Echocardiogram	1
	White Plains	Exercise Treadmill ECG with Nuclear Imaging	1
	White Plains	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	White Plains	Missed Appointment	1
OH	Akron	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	5
	Akron	Non-Stress Echocardiogram	1
	Akron	Exercise Treadmill ECG with Nuclear Imaging	1
	Akron	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Akron	Missed Appointment	1
OH	Cincinnati	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	70
	Cincinnati	Non-Stress Echocardiogram	1
	Cincinnati	Exercise Treadmill ECG with Nuclear Imaging	1
	Cincinnati	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Cincinnati	Missed Appointment	7
OH	Cleveland	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	5
	Cleveland	Non-Stress Echocardiogram	1
	Cleveland	Exercise Treadmill ECG with Nuclear Imaging	1
	Cleveland	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Cleveland	Missed Appointment	1
OH	Columbus	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	60
	Columbus	Non-Stress Echocardiogram	1
	Columbus	Exercise Treadmill ECG with Nuclear Imaging	1
	Columbus	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Columbus	Missed Appointment	6
OK	Oklahoma City	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	15
	Oklahoma City	Non-Stress Echocardiogram	1
	Oklahoma City	Exercise Treadmill ECG with Nuclear Imaging	1
	Oklahoma City	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Oklahoma City	Missed Appointment	1
OR	Portland	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	60
	Portland	Non-Stress Echocardiogram	1
	Portland	Exercise Treadmill ECG with Nuclear Imaging	1
	Portland	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Portland	Missed Appointment	6
PA	Harrisburg	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	5
	Harrisburg	Non-Stress Echocardiogram	1
	Harrisburg	Exercise Treadmill ECG with Nuclear Imaging	1
	Harrisburg	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Harrisburg	Missed Appointment	1
PA	Philadelphia	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	160
	Philadelphia	Non-Stress Echocardiogram	1
	Philadelphia	Exercise Treadmill ECG with Nuclear Imaging	1
	Philadelphia	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Philadelphia	Missed Appointment	16
PA	Pittsburgh	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	35
	Pittsburgh	Non-Stress Echocardiogram	1
	Pittsburgh	Exercise Treadmill ECG with Nuclear Imaging	1
	Pittsburgh	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Pittsburgh	Missed Appointment	3
PR	Hato Rey	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	90
	Hato Rey	Non-Stress Echocardiogram	1
	Hato Rey	Exercise Treadmill ECG with Nuclear Imaging	1
	Hato Rey	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Hato Rey	Missed Appointment	9
SC	Charleston	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	15
	Charleston	Non-Stress Echocardiogram	1
	Charleston	Exercise Treadmill ECG with Nuclear Imaging	1
	Charleston	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Charleston	Missed Appointment	1
SC	Columbia	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	35
	Columbia	Non-Stress Echocardiogram	1
	Columbia	Exercise Treadmill ECG with Nuclear Imaging	1
	Columbia	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Columbia	Missed Appointment	3
SD	Rapid City	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	25
	Rapid City	Non-Stress Echocardiogram	1
	Rapid City	Exercise Treadmill ECG with Nuclear Imaging	1
	Rapid City	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Rapid City	Missed Appointment	2
TN	Knoxville	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	110
	Knoxville	Non-Stress Echocardiogram	1
	Knoxville	Exercise Treadmill ECG with Nuclear Imaging	1
	Knoxville	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Knoxville	Missed Appointment	11
TN	Memphis	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	5
	Memphis	Non-Stress Echocardiogram	1
	Memphis	Exercise Treadmill ECG with Nuclear Imaging	1
	Memphis	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Memphis	Missed Appointment	1
TN	Nashville	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	25
	Nashville	Non-Stress Echocardiogram	1
	Nashville	Exercise Treadmill ECG with Nuclear Imaging	1
	Nashville	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Nashville	Missed Appointment	2
TX	Austin	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	64
	Austin	Non-Stress Echocardiogram	1
	Austin	Exercise Treadmill ECG with Nuclear Imaging	1
	Austin	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Austin	Missed Appointment	1
TX	Brownsville	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	10
	Brownsville	Non-Stress Echocardiogram	1
	Brownsville	Exercise Treadmill ECG with Nuclear Imaging	1
	Brownsville	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Brownsville	Missed Appointment	1
TX	Dallas	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	20
	Dallas	Non-Stress Echocardiogram	1
	Dallas	Exercise Treadmill ECG with Nuclear Imaging	1
	Dallas	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Dallas	Missed Appointment	2
TX	El Paso	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	20
	El Paso	Non-Stress Echocardiogram	1
	El Paso	Exercise Treadmill ECG with Nuclear Imaging	1
	El Paso	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	El Paso	Missed Appointment	2
TX	Fort Worth	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	4
	Fort Worth	Non-Stress Echocardiogram	1
	Fort Worth	Exercise Treadmill ECG with Nuclear Imaging	1
	Fort Worth	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Fort Worth	Missed Appointment	1
TX	Houston	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	150
	Houston	Non-Stress Echocardiogram	1
	Houston	Exercise Treadmill ECG with Nuclear Imaging	1
	Houston	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Houston	Missed Appointment	7
TX	San Antonio	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	15
	San Antonio	Non-Stress Echocardiogram	1
	San Antonio	Exercise Treadmill ECG with Nuclear Imaging	1
	San Antonio	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	San Antonio	Missed Appointment	1
UT	Salt Lake City	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	60
	Salt Lake City	Non-Stress Echocardiogram	1
	Salt Lake City	Exercise Treadmill ECG with Nuclear Imaging	1
	Salt Lake City	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Salt Lake City	Missed Appointment	6
VA	Arlington	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	25
	Arlington	Non-Stress Echocardiogram	1
	Arlington	Exercise Treadmill ECG with Nuclear Imaging	1
	Arlington	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Arlington	Missed Appointment	2
VA	Norfolk	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	35
	Norfolk	Non-Stress Echocardiogram	1
	Norfolk	Exercise Treadmill ECG with Nuclear Imaging	1
	Norfolk	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Norfolk	Missed Appointment	3
VA	Quantico	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	5
	Quantico	Non-Stress Echocardiogram	1
	Quantico	Exercise Treadmill ECG with Nuclear Imaging	1
	Quantico	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Quantico	Missed Appointment	1
VA	Reston	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	100
	Reston	Non-Stress Echocardiogram	1
	Reston	Exercise Treadmill ECG with Nuclear Imaging	1
	Reston	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Reston	Missed Appointment	10
VA	Richmond	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	70
	Richmond	Non-Stress Echocardiogram	1
	Richmond	Exercise Treadmill ECG with Nuclear Imaging	1
	Richmond	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Richmond	Missed Appointment	7
WA	Pasco	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	15
	Pasco	Non-Stress Echocardiogram	1
	Pasco	Exercise Treadmill ECG with Nuclear Imaging	1
	Pasco	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Pasco	Missed Appointment	1
WA	Seattle	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	135
	Seattle	Non-Stress Echocardiogram	1
	Seattle	Exercise Treadmill ECG with Nuclear Imaging	1
	Seattle	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Seattle	Missed Appointment	13
WI	Milwaukee	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	50
	Milwaukee	Non-Stress Echocardiogram	1
	Milwaukee	Exercise Treadmill ECG with Nuclear Imaging	1
	Milwaukee	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Milwaukee	Missed Appointment	5
WV	Clarksburg	Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	25
	Clarksburg	Non-Stress Echocardiogram	1
	Clarksburg	Exercise Treadmill ECG with Nuclear Imaging	1
	Clarksburg	Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	1
	Clarksburg	Missed Appointment	2

TOTAL: Cardiovascular Stress Test, Maximum (EST) – Bruce or Blake Protocol	0	0	0
TOTAL: Non-Stress Echocardiogram	0	0	0
TOTAL: Exercise Treadmill ECG with Nuclear Imaging	0	0	0
TOTAL: Cardiac Stress Test - Treadmill Echo (aka Stress Echocardiogram	0	0	0
TOTAL: Missed Appointment	0	0	0

Summary of Options Cardiac Test Services Pricing Sheet Summary

Base Year: 12 months	$ - 0
Option Year 1: 12 months	$ - 0
Option Year 2: 12 months	$ - 0
Option Year 3: 12 months	$ - 0
Option Year 4: 12 months	$ - 0
Total	$ - 0

Base year

Base Year: 12 months	Base Year: 12 months
			Enter quantity based on cities in this level	Lowest		Enter quantity based on cities in this level	Medium		Enter quantity based on cities in this level	Highest
Description	CPT Code	Definition	Quantity	Level 1 (Pricing)	Level 1 Total Cost	Quantity	Level 2 (Pricing)	Level 2 Total Cost	Quantity	Level 3 (Pricing)	Level 3 Total Cost	Base Year Grand Total
EXERCISE STRESS TEST - BRUCE OR BALKE PROTOCOL	93105	BRUCE OR BALKE PROTOCOL	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Non-Stress Test Echocardiogram	93350	ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Cardiac Stress Test - Thallium/Cardiolyte	78464	Exercise myocardial perfusion imaging, Stress Thallium, Chemical, drug (pharmacologic) stressing	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Cardiac Stress Test – Treadmill Echo aka Stress Echocardiogram	93351	ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Missed Appt/Late Cancellation Fee	99199		- 0		$ - 0	- 0		$ - 0	- 0		$ - 0
Total Cost					$ - 0			$ - 0			$ - 0	$ - 0

Option Year 1

Option Year 1: 12 months
			Enter quantity based on cities in this level	Lowest		Enter quantity based on cities in this level	Medium		Enter quantity based on cities in this level	Highest
Description	CPT Code	Definition	Quantity	Level 1 (Pricing)	Level 1 Total Cost	Quantity	Level 2 (Pricing)	Level 2 Total Cost	Quantity	Level 3 (Pricing)	Level 3 Total Cost	Option Year 1 Grand Total
EXERCISE STRESS TEST - BRUCE OR BALKE PROTOCOL	93105		- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Non-Stress Test Echocardiogram	93350	ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Cardiac Stress Test - Thallium/Cardiolyte	78464	Exercise myocardial perfusion imaging, Stress Thallium, Chemical, drug (pharmacologic) stressing	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Cardiac Stress Test – Treadmill Echo aka Stress Echocardiogram	93351	ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Missed Appt/Late Cancellation Fee	99199		- 0		$ - 0	- 0		$ - 0	- 0		$ - 0
Total Cost					$ - 0			$ - 0			$ - 0	$ - 0

Option Year 2

Option Year 2: 12 months
			Enter quantity based on cities in this level	Lowest		Enter quantity based on cities in this level	Medium		Enter quantity based on cities in this level	Highest
Description	CPT Code	Definition	Quantity	Level 1 (Pricing)	Level 1 Total Cost	Quantity	Level 2 (Pricing)	Level 2 Total Cost	Quantity	Level 3 (Pricing)	Level 3 Total Cost	Option Year 2 Grand Total
EXERCISE STRESS TEST - BRUCE OR BALKE PROTOCOL	93105		- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Non-Stress Test Echocardiogram	93350	ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Cardiac Stress Test - Thallium/Cardiolyte	78464	Exercise myocardial perfusion imaging, Stress Thallium, Chemical, drug (pharmacologic) stressing	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Cardiac Stress Test – Treadmill Echo aka Stress Echocardiogram	93351	ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Missed Appt/Late Cancellation Fee	99199		- 0		$ - 0	- 0		$ - 0	- 0		$ - 0
Total Cost					$ - 0			$ - 0			$ - 0	$ - 0

Option Year 3

Option Year 3: 12 months							106%
			Enter quantity based on cities in this level	Lowest		Enter quantity based on cities in this level	Medium		Enter quantity based on cities in this level	Highest
Description	CPT Code	Definition	Quantity	Level 1 (Pricing)	Level 1 Total Cost	Quantity	Level 2 (Pricing)	Level 2 Total Cost	Quantity	Level 3 (Pricing)	Level 3 Total Cost	Option Year 3 Grand Total
EXERCISE STRESS TEST - BRUCE OR BALKE PROTOCOL	93105		- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Non-Stress Test Echocardiogram	93350	ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Cardiac Stress Test - Thallium/Cardiolyte	78464	Exercise myocardial perfusion imaging, Stress Thallium, Chemical, drug (pharmacologic) stressing	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Cardiac Stress Test – Treadmill Echo aka Stress Echocardiogram	93351	ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Missed Appt/Late Cancellation Fee	99199		- 0		$ - 0	- 0		$ - 0	- 0		$ - 0
Total Cost					$ - 0			$ - 0			$ - 0	$ - 0

Option Year 4

Option Year 4: 12 months
			Enter quantity based on cities in this level	Lowest		Enter quantity based on cities in this level	Medium		Enter quantity based on cities in this level	Highest
Description	CPT Code	Definition	Quantity	Level 1 (Pricing)	Level 1 Total Cost	Quantity	Level 2 (Pricing)	Level 2 Total Cost	Quantity	Level 3 (Pricing)	Level 3 Total Cost	Option Year 4 Grand Total
EXERCISE STRESS TEST - BRUCE OR BALKE PROTOCOL	93105		- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Non-Stress Test Echocardiogram	93350	ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Cardiac Stress Test - Thallium/Cardiolyte	78464	Exercise myocardial perfusion imaging, Stress Thallium, Chemical, drug (pharmacologic) stressing	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Cardiac Stress Test – Treadmill Echo aka Stress Echocardiogram	93351	ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION	- 0		$ - 0	- 0		$ - 0	- 0		$ - 0	- 0
Missed Appt/Late Cancellation Fee	99199		- 0		$ - 0	- 0		$ - 0	- 0		$ - 0
Total Cost					$ - 0			$ - 0			$ - 0	$ - 0

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File details come from the government source that posted it. Updated Nov 14, 2017.