Attachment_A_-_Service_Price_List_v3.xlsx
XLSX spreadsheet 36 KB Posted
- Attached to
- FOH Private Provider Network (PPN)
- Solicitation number
- 18-233-SOL-00494
About this file
This document package includes an attachment to a federal contract solicitation for private provider network services. The solicitation seeks proposals for nationwide commercial services to establish a Private Provider Network on a multiple award IDIQ contract basis to support the Department of Health and Human Services Program Support Center Federal Occupational Health. The attachment provides a price list for medical, dental and other services across five option periods to be delivered in two regions, estimating quantities for pricing purposes. It also includes independent medical examination fees and various other fees. No set-aside is specified and proposals are due on dates referenced in the solicitation.
The related federal contract opportunity provides additional context, with the solicitation number and name identifying it as the FOH Private Provider Network solicitation from the Department of Health and Human Services Program Support Center. The opportunity type is listed as a solicitation, and it describes the requirement as anticipated multiple award FFP IDIQ contracts for nationwide private provider network services in two regions to support the named federal agency. It notes parts of the package use FBO enhanced security controls and provides contact information for any issues accessing the secure content.
FOHNet Attachment A Service Price List
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Attachment A FOHNet East
| Attachment A - Service List |
| East 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) | 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 | ||||||||||
| 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 | ||||||||||
| 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 | ||||||||||
| 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 | ||||||||||
| 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 | ||||||||||
| 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 | ||||||||||
| 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 | ||||||||||
| 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 | ||||||||||
| 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 .