Attachment_A_-_Service_Price_List_v2.xlsx
XLSX spreadsheet 38 KB Posted
- Attached to
- FOH Private Provider Network (PPN)
- Solicitation number
- 18-233-SOL-00494
About this file
This document includes an attachment to a solicitation for a Federal Occupational Health Private Provider Network. The solicitation seeks multiple award indefinite-delivery, indefinite-quantity contracts to provide nationwide private provider network services in two regions - East and West - in support of the Department of Health and Human Services Program Support Center's Federal Occupational Health. The attachment lists service prices for general medical services, dental services, vaccines and medications, independent medical examinations, and various fees across a five year base period and four option periods. It does not specify quantities, but provides unit prices that would be applied to future delivery orders. There is no set-aside specified. Questions are due by the deadline stated in Section L.3 of the solicitation, with proposals to follow thereafter. Award dates are not mentioned.
Revised n Attachment A Price List
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Attachment A FOHNet East
| Attachment A - Service List |
| East Region |
| 18-233-SOL-00494-000001 |
| General Services | BASE PERIOD | OPTION PERIOD 1 | OPTION PERIOD 2 | OPTION PERIOD 3 | OPTION PERIOD 4 | ||||||||||
| Service Title | Price Per Service | Estimated Quantity | Extended Price | Price Per Service | Estimated Quantity | Extended Price | Price Per Service | Estimated Quantity | Extended Price | Price Per Service | Estimated Quantity | Extended Price | Price Per Service | Estimated Quantity | Extended Price |
| Acoustic Reflex (Stand Alone) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Acoustic Reflex (w/Exam) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Audiometry (Stand Alone) | 2620 | 2620 | 2620 | 2620 | 2620 | ||||||||||
| Audiometry (w/Exam) | 5720 | 5720 | 5720 | 5720 | 5720 | ||||||||||
| Audiometry with CAOHC-Certified Technician (Add-on) | 40 | 40 | 40 | 40 | 40 | ||||||||||
| Best Vision Screening (Stand Alone) | 15 | 15 | 15 | 15 | 15 | ||||||||||
| Best Vision Screening (w/Exam) | 1360 | 1360 | 1360 | 1360 | 1360 | ||||||||||
| Bone Density Screening | 40 | 40 | 40 | 40 | 40 | ||||||||||
| B-Reading | 380 | 380 | 380 | 380 | 380 | ||||||||||
| Bronchodilation Responsiveness | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Bronchospasm Provocation Evaluation | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Color Doppler | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Colorectal Cancer Screening - EZ Detect | 20 | 20 | 20 | 20 | 20 | ||||||||||
| Colorectal Cancer Screening - EZ Detect (Stand Alone) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Colorectal Cancer Screening - Hemoccult | 80 | 80 | 80 | 80 | 80 | ||||||||||
| Colorectal Cancer Screening - Hemoccult (Stand Alone) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Commercial Driver's License (CDL) Examination (Stand Alone) | 200 | 200 | 200 | 200 | 200 | ||||||||||
| Commercial Driver's License (CDL) Examination (w/Exam) | 520 | 520 | 520 | 520 | 520 | ||||||||||
| Comprehensive Audiometry | 20 | 20 | 20 | 20 | 20 | ||||||||||
| Comprehensive Eye Exam | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Comprehensive Vision Screening (Stand Alone) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Comprehensive Vision Screening (w/Exam) | 4400 | 4400 | 4400 | 4400 | 4400 | ||||||||||
| CT Chest (w/Contrast) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| CT Chest (w/out Contrast) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| CT Maxillo-Facial Area (w/Contrast) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| CT Maxillo-Facial Area (w/out Contrast) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Dermatology Screening | 60 | 60 | 60 | 60 | 60 | ||||||||||
| Diffusing Capacity | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Doppler | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Echocardiography | 5 | 5 | 5 | 5 | 5 | ||||||||||
| EKG Overread | 1180 | 1180 | 1180 | 1180 | 1180 | ||||||||||
| EKG Overread - Same Day | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Electrocardiogram (EKG) | 4500 | 4500 | 4500 | 4500 | 4500 | ||||||||||
| Examination - Brief | 60 | 60 | 60 | 60 | 60 | ||||||||||
| Examination - Intermediate | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Examination - Comprehensive (Moderate Complexity) | 5680 | 5680 | 5680 | 5680 | 5680 | ||||||||||
| Examination - Comprehensive (High Complexity) | 300 | 300 | 300 | 300 | 300 | ||||||||||
| Exercise Stress Test (EST) | 280 | 280 | 280 | 280 | 280 | ||||||||||
| Exercise Stress Test (EST) - Thallium/Cardiolyte | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Federal Aviation Administration (FAA) Examination | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Flexible Sigmoidoscopy | 5 | 5 | 5 | 5 | 5 | ||||||||||
| FOH PPN Consultation | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Functional Capacity Evaluation | 10 | 10 | 10 | 10 | 10 | ||||||||||
| Fundus (Retina) Photography | 20 | 20 | 20 | 20 | 20 | ||||||||||
| Hearing Aid, Binaural | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Hearing Aid, Monaural | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Immunization Administration (Injection) - Government Provided Vaccine | 140 | 140 | 140 | 140 | 140 | ||||||||||
| Immunization Administration (Intranasal/Oral) - Government Provided Vaccine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Independent Medical Review (up to 1/2 inch or 125 pages) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Ishihara Color Vision - 14 Plate | 1140 | 1140 | 1140 | 1140 | 1140 | ||||||||||
| Ishihara Color Vision - 24 Plate | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Mammography (Stand Alone) | 60 | 60 | 60 | 60 | 60 | ||||||||||
| Mammography (w/Exam) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Medical Record Review | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Myocardial Perfusion | 5 | 5 | 5 | 5 | 5 | ||||||||||
| NMP22 Bladdercheck Test | 40 | 40 | 40 | 40 | 40 | ||||||||||
| Venipuncture / Specimen Collection / Lab Handling | 660 | 660 | 660 | 660 | 660 | ||||||||||
| Pulmonary Compliance Study | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Pulmonary Stress Testing | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Puretone Audiometry | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Respirator Fit Test | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Respirator Medical Clearance (Stand Alone) | 60 | 60 | 60 | 60 | 60 | ||||||||||
| Respirator Medical Clearance (w/Exam) | 440 | 440 | 440 | 440 | 440 | ||||||||||
| Speech Audiometry | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Spirometry (Stand Alone) | 860 | 860 | 860 | 860 | 860 | ||||||||||
| Spirometry (w/Exam) | 20 | 20 | 20 | 20 | 20 | ||||||||||
| Stress Echocardiogram | 10 | 10 | 10 | 10 | 10 | ||||||||||
| Tonometry | 480 | 480 | 480 | 480 | 480 | ||||||||||
| Tuberculosis Skin Test and Reading (Stand Alone) | 1940 | 1940 | 1940 | 1940 | 1940 | ||||||||||
| Tuberculosis Skin Test and Reading (w/Exam) | 140 | 140 | 140 | 140 | 140 | ||||||||||
| Vital Signs/Body Height and Weight (Stand Alone) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Wellness Screening | 260 | 260 | 260 | 260 | 260 | ||||||||||
| Wellness Screening - Prostate Cancer | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Wellness Screening - Prostate Cancer with PSA | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Wellness Vision Screening | 560 | 560 | 560 | 560 | 560 | ||||||||||
| X-Ray - Chest (PA & LAT Views) | 100 | 100 | 100 | 100 | 100 | ||||||||||
| X-Ray - Chest (PA View) | 640 | 640 | 640 | 640 | 640 | ||||||||||
| X-Ray - Hip (Bilateral, 3-4 View) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Hip (Unilateral, 2 View) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Knee (Unilateral, 1-2 View) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Knee (Unilateral, Femur 2 View) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Knee (Unilateral, Femur 3 View) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Knee (Unilateral, Tib/Fib 2 View) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Shoulder (Unilateral, 2 View) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Sinus | 5 | 5 | 5 | 5 | 5 | ||||||||||
| TOTAL GENERAL SERVICES | $ - 0 | TOTAL GENERAL SERVICES | $ - 0 | TOTAL GENERAL SERVICES | $ - 0 | TOTAL GENERAL SERVICES | $ - 0 | TOTAL GENERAL SERVICES | $ - 0 | ||||||
| Dental Services | |||||||||||||||
| Service Title | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price |
| Oral Examination - Comprehensive | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Oral Examination - Periodic | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Dental Bitewing (Single Film) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Dental Bitewing (Two Films) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Dental Bitewing (Three Films) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Dental Bitewing (Four Films) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Complete Series | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Intraoral | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Panographic | 5 | 5 | 5 | 5 | 5 | ||||||||||
| TOTAL DENTAL SERVICES | $ - 0 | TOTAL DENTAL SERVICES | $ - 0 | TOTAL DENTAL SERVICES | $ - 0 | TOTAL DENTAL SERVICES | $ - 0 | TOTAL DENTAL SERVICES | $ - 0 | ||||||
| Vaccines & Medications | |||||||||||||||
| Service Title | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price |
| Anthrax Vaccine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Antiviral - Relenza | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Antiviral - Tamiflu | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Bay Gam (Immune Serum Globulin) (Gamma Globulin) - 2 ml vial | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Bay Gam (Immune Serum Globulin) (Gamma Globulin) - 10 ml vial | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Hepatitis A / Hepatitis B Combination Vaccine | 10 | 10 | 10 | 10 | 10 | ||||||||||
| Hepatitis A Vaccine | 40 | 40 | 40 | 40 | 40 | ||||||||||
| Hepatitis B Vaccine | 100 | 100 | 100 | 100 | 100 | ||||||||||
| Influenza Virus Vaccine - Trivalent | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Influenza Virus Vaccine - Quadrivalent | 880 | 880 | 880 | 880 | 880 | ||||||||||
| Influenza Virus Vaccination - Voucher Program | 15 | 15 | 15 | 15 | 15 | ||||||||||
| Japanese Encephalitis Vaccine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Measles, Mumps, and Rubella (MMR) Vaccine | 20 | 20 | 20 | 20 | 20 | ||||||||||
| Meningococcal Vaccine | 10 | 10 | 10 | 10 | 10 | ||||||||||
| Pneumococcal Vaccine - 13-Valent | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Pneumococcal Vaccine - 23-Valent | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Polio Vaccine | 10 | 10 | 10 | 10 | 10 | ||||||||||
| Rabies Vaccine - Booster | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Rabies Vaccine (Intramuscular) | 10 | 10 | 10 | 10 | 10 | ||||||||||
| Stamaril Vaccine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Tetanus , Diphtheria, and Acellular Pertussis (Tdap) Vaccine | 100 | 100 | 100 | 100 | 100 | ||||||||||
| Tetanus and Diphtheria (Td) Vaccine | 20 | 20 | 20 | 20 | 20 | ||||||||||
| Travel Medication - Acetazolamide | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Travel Medication - Chloroquine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Travel Medication - Ciprofloxacin | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Travel Medication - Doxycycline | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Travel Medication - Loperamide | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Travel Medication - Malarone | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Travel Medication - Mefloquine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Typhoid Vaccine (Injection) | 40 | 40 | 40 | 40 | 40 | ||||||||||
| Typhoid Vaccine (Oral) | 20 | 20 | 20 | 20 | 20 | ||||||||||
| Varicella Vaccine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Written Prescription - Ciprofloxacin | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Written Prescription - Doxycycline | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Yellow Fever Vaccine | 40 | 40 | 40 | 40 | 40 | ||||||||||
| TOTAL VACCINES & MEDICATIONS | $ - 0 | TOTAL VACCINES & MEDICATIONS | $ - 0 | TOTAL VACCINES & MEDICATIONS | $ - 0 | TOTAL VACCINES & MEDICATIONS | $ - 0 | TOTAL VACCINES & MEDICATIONS | $ - 0 | ||||||
| Independent Medical Examination (IME) | |||||||||||||||
| Service Title | Price Per Report | Estimated Quantity | Extended Price | Price Per Report | Estimated Quantity | Extended Price | Price Per Report | Estimated Quantity | Extended Price | Price Per Report | Estimated Quantity | Extended Price | Price Per Report | Estimated Quantity | Extended Price |
| Allergist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Audiologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Cardiologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Clarification | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Dermatologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Endocrinologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Family Practice | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Gastroenterologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Hematologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Infectious Disease | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Internist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Nephrologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Neurologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Neuropsychiatrist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Oncologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Ophthalmologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Orthopedist | 10 | 10 | 10 | 10 | 10 | ||||||||||
| Otolaryngologist (E.N.T.) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Physical Medicine & Rehabilitation | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Psychiatrist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Psychologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Pulmonologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Rheumatologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Supplemental Request IME | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Urologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| TOTAL IME | $ - 0 | TOTAL IME | $ - 0 | TOTAL IME | $ - 0 | TOTAL IME | $ - 0 | TOTAL IME | $ - 0 | ||||||
| Fees | |||||||||||||||
| Service Title | Price per Incident | Estimated Quantity | Extended Price | Price per Incident | Estimated Quantity | Extended Price | Price per Incident | Estimated Quantity | Extended Price | Price per Incident | Estimated Quantity | Extended Price | Price per Incident | Estimated Quantity | Extended Price |
| Expedited Service Fee | 1900 | 1900 | 1900 | 1900 | 1900 | ||||||||||
| FBI Security Fee | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Forms Completion Fee | 140 | 140 | 140 | 140 | 140 | ||||||||||
| Missed Appointment (No-Show) / Late Cancellation Fee | 1000 | 1000 | 1000 | 1000 | 1000 | ||||||||||
| Mobile Outreach Fee | 10 | 10 | 10 | 10 | 10 | ||||||||||
| Mobile Outreach Late Cancellation Fee | 5 | 5 | 5 | 5 | 5 | ||||||||||
| OCONUS Fee | 120 | 120 | 120 | 120 | 120 | ||||||||||
| Out of Network Fee | 5 | 5 | 5 | 5 | 5 | ||||||||||
| TOTAL FEES | $ - 0 | TOTAL FEES | $ - 0 | TOTAL FEES | $ - 0 | TOTAL FEES | $ - 0 | TOTAL FEES | $ - 0 | ||||||
| TOTAL BASE YEAR | $ - 0 | TOTAL BASE YEAR | $ - 0 | TOTAL BASE YEAR | $ - 0 | TOTAL BASE YEAR | $ - 0 | TOTAL BASE YEAR | $ - 0 | ||||||
| TOTAL EVALUATED PRICE | $ - 0 |
&P
Attachment A FOHNet West
| Attachment A - Service List |
| West Region |
| General Services | BASE PERIOD | OPTION PERIOD 1 | OPTION PERIOD 2 | OPTION PERIOD 3 | OPTION PERIOD 4 | ||||||||||
| Service Title | Price Per Service | Estimated Quantity | Extended Price | Price Per Service | Estimated Quantity | Extended Price | Price Per Service | Estimated Quantity | Extended Price | Price Per Service | Estimated Quantity | Extended Price | Price Per Service | Estimated Quantity | Extended Price |
| Acoustic Reflex (Stand Alone) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Acoustic Reflex (w/Exam) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Audiometry (Stand Alone) | 2840 | 2840 | 2840 | 2840 | 2840 | ||||||||||
| Audiometry (w/Exam) | 3280 | 3280 | 3280 | 3280 | 3280 | ||||||||||
| Audiometry with CAOHC-Certified Technician (Add-on) | 80 | 80 | 80 | 80 | 80 | ||||||||||
| Best Vision Screening (Stand Alone) | 10 | 10 | 10 | 10 | 10 | ||||||||||
| Best Vision Screening (w/Exam) | 1000 | 1000 | 1000 | 1000 | 1000 | ||||||||||
| Bone Density Screening | 5 | 5 | 5 | 5 | 5 | ||||||||||
| B-Reading | 380 | 380 | 380 | 380 | 380 | ||||||||||
| Bronchodilation Responsiveness | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Bronchospasm Provocation Evaluation | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Color Doppler | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Colorectal Cancer Screening - EZ Detect | 10 | 10 | 10 | 10 | 10 | ||||||||||
| Colorectal Cancer Screening - EZ Detect (Stand Alone) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Colorectal Cancer Screening - Hemoccult | 20 | 20 | 20 | 20 | 20 | ||||||||||
| Colorectal Cancer Screening - Hemoccult (Stand Alone) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Commercial Driver's License (CDL) Examination (Stand Alone) | 140 | 140 | 140 | 140 | 140 | ||||||||||
| Commercial Driver's License (CDL) Examination (w/Exam) | 400 | 400 | 400 | 400 | 400 | ||||||||||
| Comprehensive Audiometry | 15 | 15 | 15 | 15 | 15 | ||||||||||
| Comprehensive Eye Exam | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Comprehensive Vision Screening (Stand Alone) | 10 | 10 | 10 | 10 | 10 | ||||||||||
| Comprehensive Vision Screening (w/Exam) | 2140 | 2140 | 2140 | 2140 | 2140 | ||||||||||
| CT Chest (w/Contrast) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| CT Chest (w/out Contrast) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| CT Maxillo-Facial Area (w/Contrast) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| CT Maxillo-Facial Area (w/out Contrast) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Dermatology Screening | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Diffusing Capacity | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Doppler | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Echocardiography | 5 | 5 | 5 | 5 | 5 | ||||||||||
| EKG Overread | 1180 | 1180 | 1180 | 1180 | 1180 | ||||||||||
| EKG Overread - Same Day | |||||||||||||||
| Electrocardiogram (EKG) | 2200 | 2200 | 2200 | 2200 | 2200 | ||||||||||
| Examination - Brief | 50 | 50 | 50 | 50 | 50 | ||||||||||
| Examination - Intermediate | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Examination - Comprehensive (Moderate Complexity) | 3160 | 3160 | 3160 | 3160 | 3160 | ||||||||||
| Examination - Comprehensive (High Complexity) | 160 | 160 | 160 | 160 | 160 | ||||||||||
| Exercise Stress Test (EST) | 160 | 160 | 160 | 160 | 160 | ||||||||||
| Exercise Stress Test (EST) - Thallium/Cardiolyte | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Federal Aviation Administration (FAA) Examination | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Flexible Sigmoidoscopy | 5 | 5 | 5 | 5 | 5 | ||||||||||
| FOH PPN Consultation | |||||||||||||||
| Functional Capacity Evaluation | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Fundus (Retina) Photography | 20 | 20 | 20 | 20 | 20 | ||||||||||
| Hearing Aid, Binaural | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Hearing Aid, Monaural | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Immunization Administration (Injection) - Government Provided Vaccine | 225 | 225 | 225 | 225 | 225 | ||||||||||
| Immunization Administration (Intranasal/Oral) - Government Provided Vaccine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Independent Medical Review (up to 1/2 inch or 125 pages) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Ishihara Color Vision - 14 Plate | 660 | 660 | 660 | 660 | 660 | ||||||||||
| Ishihara Color Vision - 24 Plate | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Mammography (Stand Alone) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Mammography (w/Exam) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Medical Record Review | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Myocardial Perfusion | 5 | 5 | 5 | 5 | 5 | ||||||||||
| NMP22 Bladdercheck Test | 20 | 20 | 20 | 20 | 20 | ||||||||||
| Venipuncture / Specimen Collection / Lab Handling | 1260 | 1260 | 1260 | 1260 | 1260 | ||||||||||
| Pulmonary Compliance Study | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Pulmonary Stress Testing | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Puretone Audiometry | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Respirator Fit Test | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Respirator Medical Clearance (Stand Alone) | 60 | 60 | 60 | 60 | 60 | ||||||||||
| Respirator Medical Clearance (w/Exam) | 200 | 200 | 200 | 200 | 200 | ||||||||||
| Speech Audiometry | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Spirometry (Stand Alone) | 1900 | 1900 | 1900 | 1900 | 1900 | ||||||||||
| Spirometry (w/Exam) | 80 | 80 | 80 | 80 | 80 | ||||||||||
| Stress Echocardiogram | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Tonometry | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Tuberculosis Skin Test and Reading (Stand Alone) | 1080 | 1080 | 1080 | 1080 | 1080 | ||||||||||
| Tuberculosis Skin Test and Reading (w/Exam) | 580 | 580 | 580 | 580 | 580 | ||||||||||
| Vital Signs/Body Height and Weight (Stand Alone) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Wellness Screening | 160 | 160 | 160 | 160 | 160 | ||||||||||
| Wellness Screening - Prostate Cancer | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Wellness Screening - Prostate Cancer with PSA | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Wellness Vision Screening | 540 | 540 | 540 | 540 | 540 | ||||||||||
| X-Ray - Chest (PA & LAT Views) | 15 | 15 | 15 | 15 | 15 | ||||||||||
| X-Ray - Chest (PA View) | 460 | 460 | 460 | 460 | 460 | ||||||||||
| X-Ray - Hip (Bilateral, 3-4 View) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Hip (Unilateral, 2 View) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Knee (Unilateral, 1-2 View) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Knee (Unilateral, Femur 2 View) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Knee (Unilateral, Femur 3 View) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Knee (Unilateral, Tib/Fib 2 View) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Shoulder (Unilateral, 2 View) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Sinus | 5 | 5 | 5 | 5 | 5 | ||||||||||
| TOTAL GENERAL SERVICES | $ - 0 | TOTAL GENERAL SERVICES | $ - 0 | TOTAL GENERAL SERVICES | $ - 0 | TOTAL GENERAL SERVICES | $ - 0 | TOTAL GENERAL SERVICES | $ - 0 | ||||||
| Dental Services | |||||||||||||||
| Service Title | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price |
| Oral Examination - Comprehensive | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Oral Examination - Periodic | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Dental Bitewing (Single Film) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Dental Bitewing (Two Films) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Dental Bitewing (Three Films) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Dental Bitewing (Four Films) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Complete Series | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Intraoral | 5 | 5 | 5 | 5 | 5 | ||||||||||
| X-Ray - Panographic | 5 | 5 | 5 | 5 | 5 | ||||||||||
| TOTAL DENTAL SERVICES | $ - 0 | TOTAL DENTAL SERVICES | $ - 0 | TOTAL DENTAL SERVICES | $ - 0 | TOTAL DENTAL SERVICES | $ - 0 | TOTAL DENTAL SERVICES | $ - 0 | ||||||
| Vaccines & Medications | |||||||||||||||
| Service Title | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price | Price | Estimated Quantity | Extended Price |
| Anthrax Vaccine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Antiviral - Relenza | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Antiviral - Tamiflu | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Bay Gam (Immune Serum Globulin) (Gamma Globulin) - 2 ml vial | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Bay Gam (Immune Serum Globulin) (Gamma Globulin) - 10 ml vial | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Hepatitis A / Hepatitis B Combination Vaccine | 40 | 40 | 40 | 40 | 40 | ||||||||||
| Hepatitis A Vaccine | 1120 | 1120 | 1120 | 1120 | 1120 | ||||||||||
| Hepatitis B Vaccine | 1400 | 1400 | 1400 | 1400 | 1400 | ||||||||||
| Influenza Virus Vaccine - Trivalent | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Influenza Virus Vaccine - Quadrivalent | 180 | 180 | 180 | 180 | 180 | ||||||||||
| Influenza Virus Vaccination - Voucher Program | 1040 | 1040 | 1040 | 1040 | 1040 | ||||||||||
| Japanese Encephalitis Vaccine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Measles, Mumps, and Rubella (MMR) Vaccine | 400 | 400 | 400 | 400 | 400 | ||||||||||
| Meningococcal Vaccine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Pneumococcal Vaccine - 13-Valent | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Pneumococcal Vaccine - 23-Valent | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Polio Vaccine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Rabies Vaccine - Booster | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Rabies Vaccine (Intramuscular) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Stamaril Vaccine | |||||||||||||||
| Tetanus , Diphtheria, and Acellular Pertussis (Tdap) Vaccine | 920 | 920 | 920 | 920 | 920 | ||||||||||
| Tetanus and Diphtheria (Td) Vaccine | 40 | 40 | 40 | 40 | 40 | ||||||||||
| Travel Medication - Acetazolamide | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Travel Medication - Chloroquine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Travel Medication - Ciprofloxacin | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Travel Medication - Doxycycline | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Travel Medication - Loperamide | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Travel Medication - Malarone | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Travel Medication - Mefloquine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Typhoid Vaccine (Injection) | 20 | 20 | 20 | 20 | 20 | ||||||||||
| Typhoid Vaccine (Oral) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Varicella Vaccine | 360 | 360 | 360 | 360 | 360 | ||||||||||
| Written Prescription - Ciprofloxacin | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Written Prescription - Doxycycline | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Yellow Fever Vaccine | 5 | 5 | 5 | 5 | 5 | ||||||||||
| TOTAL VACCINES & MEDICATIONS | $ - 0 | TOTAL VACCINES & MEDICATIONS | $ - 0 | TOTAL VACCINES & MEDICATIONS | $ - 0 | TOTAL VACCINES & MEDICATIONS | $ - 0 | TOTAL VACCINES & MEDICATIONS | $ - 0 | ||||||
| Independent Medical Examination (IME) | |||||||||||||||
| Service Title | Price Per Report | Estimated Quantity | Extended Price | Price Per Report | Estimated Quantity | Extended Price | Price Per Report | Estimated Quantity | Extended Price | Price Per Report | Estimated Quantity | Extended Price | Price Per Report | Estimated Quantity | Extended Price |
| Allergist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Audiologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Cardiologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Clarification | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Dermatologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Endocrinologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Family Practice | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Gastroenterologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Hematologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Infectious Disease | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Internist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Nephrologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Neurologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Neuropsychiatrist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Oncologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Ophthalmologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Orthopedist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Otolaryngologist (E.N.T.) | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Physical Medicine & Rehabilitation | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Psychiatrist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Psychologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Pulmonologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Rheumatologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Supplemental Request IME | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Urologist | 5 | 5 | 5 | 5 | 5 | ||||||||||
| TOTAL IME | $ - 0 | TOTAL IME | $ - 0 | TOTAL IME | $ - 0 | TOTAL IME | $ - 0 | TOTAL IME | $ - 0 | ||||||
| Fees | |||||||||||||||
| Service Title | Price per Incident | Estimated Quantity | Extended Price | Price per Incident | Estimated Quantity | Extended Price | Price per Incident | Estimated Quantity | Extended Price | Price per Incident | Estimated Quantity | Extended Price | Price per Incident | Estimated Quantity | Extended Price |
| Expedited Service Fee | 1100 | 1100 | 1100 | 1100 | 1100 | ||||||||||
| FBI Security Fee | 5 | 5 | 5 | 5 | 5 | ||||||||||
| Forms Completion Fee | 100 | 100 | 100 | 100 | 100 | ||||||||||
| Missed Appointment (No-Show) / Late Cancellation Fee | 820 | 820 | 820 | 820 | 820 | ||||||||||
| Mobile Outreach Fee | 40 | 40 | 40 | 40 | 40 | ||||||||||
| Mobile Outreach Late Cancellation Fee | |||||||||||||||
| OCONUS Fee | 220 | 220 | 220 | 220 | 220 | ||||||||||
| Out of Network Fee | 5 | 5 | 5 | 5 | 5 | ||||||||||
| TOTAL FEES | $ - 0 | TOTAL FEES | $ - 0 | TOTAL FEES | $ - 0 | TOTAL FEES | $ - 0 | TOTAL FEES | $ - 0 | ||||||
| TOTAL BASE YEAR | $ - 0 | TOTAL BASE YEAR | $ - 0 | TOTAL BASE YEAR | $ - 0 | TOTAL BASE YEAR | $ - 0 | TOTAL BASE YEAR | $ - 0 | ||||||
| TOTAL EVALUATED PRICE | $ - 0 |
&P
File details come from the government source that posted it. Updated .