J-6 Pricing Worksheet.pdf

National Responder Health Program Pricing Worksheet

Please provide all-inclusive pricing for the following procedures in the locations shown in the table. The prices should reflect the rates that have been negotiated by the offeror with their provider network.

ICD9

Code

CPT

Procedure Code

Procedure Description

Tampa, FL, 33614

Mooresville, NC, 28117

Las Vegas, NV, 89128

Columbus, OH, 43214

530.81

00740

Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proxmial duodenum

473.9 31231 Nasal Endoscopy 473.9

31267 Nasal Endoscopy w/ polypectomy

31575

Diagnostic laryngoscopy-1

530.81

43239

Upper Gastrointestinal endoscopy w/ Bx

473.2 70486

CT maxillofacial w/o dye

515 71010 EEG

786.2 71020 Chest x-ray 516.3

71250 CT Chest w/out contrast

493.90

86003

Nasal Endoscopy, surgical, with maxillary antrostomy

88305

Tissue exam by pathologist-2

530.81 88312 Special stains

493.90 90732 Nebulizer Treatment 309.81

90801

Initial Intake/psychiatric diagnostic

296.30

90805

Individual psychotherapy, ~20- 30 min w/ medical evaluation

309.81

90806

Individual psychotherapy (45-50 minutes)

ICD9

Code

CPT

Procedure Code

Procedure Description

309.81 90847

Comp Metabolic Panel

309.81 90862

Medication management

472.0 92567

Family therapy with patient

493.90 93000

Electrocardiogram, complete

476.0 94010 Spirometry 496 94060 Bronchodilation (PFT) 794.2

94240 Residual lung capacity

473.0

94260

Laboratory (Billed on an inpatient or outpatient hospital bill)

491.0 94360

Measure a/irflow resistance

515 94720 CO Diffusing (PFT)

95810 Polysomnography;

sleep staging

95811

Diagnostic Xray/Chest (Billed on an inpatient or

473.8 99203

New patient, low complexity 30 min

516.3

99204

New patient, mod.

complexity 45 min, office/outpatient

493.9 99205 AMBUL SURG

493.0

99213

Estab. Patient, low complexity 15 min.

Office/ outpatient

473.9

99214

Estab.Patient, mod.

Complexity 25 min.

Office/ outpatient

493.9 99243

Office consult, low complexity 40 min.

99244

Office consult, mod.

complexity 60 min

99245

Office consult, high complexity, 80 min.

ICD9

Code

CPT

Procedure Code

Procedure Description

473.9 A7030

Pulmonary Stress Test

A7035

Headgear used with positive airway pressure device

530.10

R0272

Polysomnography;

sleep staging with CPAP or BIPAP

496 R0300 Thoracic gas volume

R0301

Laboratory/Chemistry (Billed on an inpatient or

516.3 R0320

Venipuncture (Blood draw) - Treatment

491 R0352 CT SCAN/BODY

496 R0460 Pulmonary Function 516.3

R0636

New patient, high complexity 60 min, office/outpatient

Please provide all-inclusive pricing for the following medications in the locations shown in the table. The prices should reflect any discounts or rebates that will be given to the government.

Medication Tampa, Mooresville, NC, 28117

Las Vegas, NV, 89128

Columbus, OH, 43214

Nexium 30 day supply

Advair

Singular

Cymbalta

Prevacid

Spiriva

Seroquel

Vfend

Effexor XR

Pantoprazole

Symbicort

Zyprexa

Pulmicort

Abilify

Aciphex

Combivent

Nasonex

Lexapro

Astelin NASA

Proair HFA