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Attachment C 36C24818Q0809
PRICE/COST SCHEDULE
ITEM INFORMATION (Estimated Quantities) Base Year October 1, 2018 to September 30, 2019
| ITEM NUMBER |
| DESCRIPTION OF SUPPLIES/SERVICES |
| QUANTITY |
| UNIT |
| UNIT PRICE |
| AMOUNT |
| 0001 |
| Leukocyte Reduced RBC (Zika Tested) |
| 2,000.00 |
| EA |
| ___________ |
| ___________ |
| 0002 |
| Plateletpheresis (Leukoreduced/Bacterial tested/ ZIKA tested) |
| 350.00 |
| EA |
| ___________ |
| ___________ |
| 0003 |
| Fresh Frozen Plasma- FFP (Type AB) |
| 40.00 |
| EA |
| ___________ |
| ___________ |
| 0004 |
| Fresh Frozen Plasma- FFP (Type non-AB) |
| 150.00 |
| EA |
| ___________ |
| ___________ |
| 0005 |
| Pooled Cryoprecipitate |
| 20.00 |
| EA |
| ___________ |
| ___________ |
| 0006 |
| Special Tests: ABO Typing |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 0007 |
| Rh Typing |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 0008 |
| Compatibility Testing |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 0009 |
| Compatibility Testing (AGT Phase) |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 0010 |
| DAT |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 0011 |
| Antibody Identification (Each Panel) |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 0012 |
| Antibody Identification (Enzyme Treated) Each Panel |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 0013 |
| Sickle Cell Screen |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 0014 |
| CMV (Donor Unit or Patient) |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 0015 |
| Irradiation Fee (Blood/Blood Component) |
| 300.00 |
| EA |
| ___________ |
| ___________ |
| 0016 |
| Washing |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 0017 |
| Deglycerolyzing Fee |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 0018 |
| FREEZING |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 0019 |
| LIQUID PLASMA (LP) |
| 25.00 |
| EA |
| ___________ |
| ___________ |
| 0020 |
| Differential Adsorption |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 0021 |
| Rare Unit Fee |
| 6.00 |
| EA |
| ___________ |
| ___________ |
| 0022 |
| Unit Search for Rare Unit |
| 6.00 |
| EA |
| ___________ |
| ___________ |
| 0023 |
| Elution |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 0024 |
| Autologous Donation Fee |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 0025 |
| Directed Donation Fee |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 0026 |
| Plateletpheresis Crossmatch/HLA Crossmatch |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 0027 |
| Auto Adsorption |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 0028 |
| Antibody Titration |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 0029 |
| ABO Discrepancy/Resolution |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 0030 |
| Special Antigen Testing: Each antigen Screened per Unit Group 1 Unit RBC each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 0031 |
| Group 2: Unit RBC Each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 0032 |
| Group 3: Unit RBC Each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 0033 |
| Group 4: Unit Each RBC Antigen Tested |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 0034 |
| Genetic RBC Phenotypes |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 0035 |
| Antibody Screen |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 0036 |
| Antibody ID, Selected Cells Panel |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 0037 |
| Special Delivery Fee |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 0038 |
| Long Distance Courier |
| 1.00 |
| UN |
| ___________ |
| ___________ |
| 0039 |
| Delivery Charges: A flat rate per month will be charged for all special deliveries of blood and/or blood components to this VA facility up to 4 deliveries per day. |
| 12.00 |
| MO |
| ___________ |
| ___________ |
| 0040 |
| Plasma Exchange: Cost of each process to include albumin 500mL/unit |
| 15.00 |
| UN |
| ___________ |
| ___________ |
| 0041 |
| Plasma Exchange: Cost of each process to include saline 500mL/Unit |
| 15.00 |
| UN |
| ___________ |
| ___________ |
| 0042 |
| Plasma Exchange: Cost of each process to include Saline 1000mL/Unit |
| 20.00 |
| UN |
| ___________ |
| ___________ |
| 0043 |
| Machine Transport |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 0044 |
| Theraputic Plasma Exchange (Theraputic Phlebotomy) |
| 35.00 |
| EA |
| ___________ |
| ___________ |
| 0045 |
| Red Cell Exchange |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 0046 |
| White Cell Depletion |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 0047 |
| Platelet Depletion |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 0048 |
| Red Cell Depletion/Exchange |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 0049 |
| Nursing Services |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 0050 |
| After Hours Fee (Weekends & Holidays included) |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 0051 |
| Procedure Cancelation Fee |
| 1.00 |
| EA |
| ___________ |
| ___________ |
Option Year One (1) October 1, 2019 to September 30, 2020
| ITEM NUMBER |
| DESCRIPTION OF SUPPLIES/SERVICES |
| QUANTITY |
| UNIT |
| UNIT PRICE |
| AMOUNT |
| 1001 |
| Leukocyte Reduced RBC (Zika Tested) |
| 2,000.00 |
| EA |
| ___________ |
| ___________ |
| 1002 |
| Plateletpheresis (Leukoreduced/Bacterial tested/ ZIKA tested) |
| 350.00 |
| EA |
| ___________ |
| ___________ |
| 1003 |
| Fresh Frozen Plasma- FFP (Type AB) |
| 40.00 |
| EA |
| ___________ |
| ___________ |
| 1004 |
| Fresh Frozen Plasma- FFP (Type non-AB) |
| 150.00 |
| EA |
| ___________ |
| ___________ |
| 1005 |
| Pooled Cryoprecipitate |
| 20.00 |
| EA |
| ___________ |
| ___________ |
| 1006 |
| Special Tests: ABO Typing |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 1007 |
| Rh Typing |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 1008 |
| Compatibility Testing |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 1009 |
| Compatibility Testing (AGT Phase) |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 1010 |
| DAT |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 1011 |
| Antibody Identification (Each Panel) |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 1012 |
| Antibody Identification (Enzyme Treated) Each Panel |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 1013 |
| Sickle Cell Screen |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 1014 |
| CMV (Donor Unit or Patient) |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 1015 |
| Irradiation Fee (Blood/Blood Component) |
| 300.00 |
| EA |
| ___________ |
| ___________ |
| 1016 |
| Washing |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 1017 |
| Deglycerolyzing Fee |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 1018 |
| FREEZING |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 1019 |
| LIQUID PLASMA (LP) |
| 25.00 |
| EA |
| ___________ |
| ___________ |
| 1020 |
| Differential Adsorption |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 1021 |
| Rare Unit Fee |
| 6.00 |
| EA |
| ___________ |
| ___________ |
| 1022 |
| Unit Search for Rare Unit |
| 6.00 |
| EA |
| ___________ |
| ___________ |
| 1023 |
| Elution |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 1024 |
| Autologous Donation Fee |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 1025 |
| Directed Donation Fee |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 1026 |
| Plateletpheresis Crossmatch/HLA Crossmatch |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 1027 |
| Auto Adsorption |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 1028 |
| Antibody Titration |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 1029 |
| ABO Discrepancy/Resolution |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 1030 |
| Special Antigen Testing: Each antigen Screened per Unit Group 1 Unit RBC each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 1031 |
| Group 2: Unit RBC Each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 1032 |
| Group 3: Unit RBC Each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 1033 |
| Group 4: Unit Each RBC Antigen Tested |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 1034 |
| Genetic RBC Phenotypes |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 1035 |
| Antibody Screen |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 1036 |
| Antibody ID, Selected Cells Panel |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 1037 |
| Special Delivery Fee |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 1038 |
| Long Distance Courier |
| 1.00 |
| UN |
| ___________ |
| ___________ |
| 1039 |
| Delivery Charges: A flat rate per month will be charged for all special deliveries of blood and/or blood components to this VA facility up to 4 deliveries per day. |
| 12.00 |
| MO |
| ___________ |
| ___________ |
| 1040 |
| Plasma Exchange: Cost of each process to include albumin 500mL/unit |
| 15.00 |
| UN |
| ___________ |
| ___________ |
| 1041 |
| Plasma Exchange: Cost of each process to include saline 500mL/Unit |
| 15.00 |
| UN |
| ___________ |
| ___________ |
| 1042 |
| Plasma Exchange: Cost of each process to include Saline 1000mL/Unit |
| 20.00 |
| UN |
| ___________ |
| ___________ |
| 1043 |
| Machine Transport |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 1044 |
| Theraputic Plasma Exchange (Theraputic Phlebotomy) |
| 35.00 |
| EA |
| ___________ |
| ___________ |
| 1045 |
| Red Cell Exchange |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 1046 |
| White Cell Depletion |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 1047 |
| Platelet Depletion |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 1048 |
| Red Cell Depletion/Exchange |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 1049 |
| Nursing Services |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 1050 |
| After Hours Fee (Weekends and Holidays Included) |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 1051 |
| Procedure Cancelation Fee |
| 1.00 |
| EA |
| ___________ |
| ___________ |
Option Year Two (2) October 1, 2020 to September 30, 2021
| ITEM NUMBER |
| DESCRIPTION OF SUPPLIES/SERVICES |
| QUANTITY |
| UNIT |
| UNIT PRICE |
| AMOUNT |
| 2001 |
| Leukocyte Reduced RBC (Zika Tested) |
| 2,000.00 |
| EA |
| ___________ |
| ___________ |
| 2002 |
| Plateletpheresis (Leukoreduced/Bacterial tested/ ZIKA tested) |
| 350.00 |
| EA |
| ___________ |
| ___________ |
| 2003 |
| Fresh Frozen Plasma- FFP (Type AB) |
| 40.00 |
| EA |
| ___________ |
| ___________ |
| 2004 |
| Fresh Frozen Plasma- FFP (Type non-AB) |
| 150.00 |
| EA |
| ___________ |
| ___________ |
| 2005 |
| Pooled Cryoprecipitate |
| 20.00 |
| EA |
| ___________ |
| ___________ |
| 2006 |
| Special Tests: ABO Typing |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 2007 |
| Rh Typing |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 2008 |
| Compatibility Testing |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 2009 |
| Compatibility Testing (AGT Phase) |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 2010 |
| DAT |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 2011 |
| Antibody Identification (Each Panel) |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 2012 |
| Antibody Identification (Enzyme Treated) Each Panel |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 2013 |
| Sickle Cell Screen |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 2014 |
| CMV (Donor Unit or Patient) |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 2015 |
| Irradiation Fee (Blood/Blood Component) |
| 300.00 |
| EA |
| ___________ |
| ___________ |
| 2016 |
| Washing |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 2017 |
| Deglycerolyzing Fee |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 2018 |
| FREEZING |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 2019 |
| LIQUID PLASMA (LP) |
| 25.00 |
| EA |
| ___________ |
| ___________ |
| 2020 |
| Differential Adsorption |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 2021 |
| Rare Unit Fee |
| 6.00 |
| EA |
| ___________ |
| ___________ |
| 2022 |
| Unit Search for Rare Unit |
| 6.00 |
| EA |
| ___________ |
| ___________ |
| 2023 |
| Elution |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 2024 |
| Autologous Donation Fee |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 2025 |
| Directed Donation Fee |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 2026 |
| Plateletpheresis Crossmatch/HLA Crossmatch |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 2027 |
| Auto Adsorption |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 2028 |
| Antibody Titration |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 2029 |
| ABO Discrepancy/Resolution |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 2030 |
| Special Antigen Testing: Each antigen Screened per Unit Group 1 Unit RBC each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 2031 |
| Group 2: Unit RBC Each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 2032 |
| Group 3: Unit RBC Each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 2033 |
| Group 4: Unit Each RBC Antigen Tested |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 2034 |
| Genetic RBC Phenotypes |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 2035 |
| Antibody Screen |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 2036 |
| Antibody ID, Selected Cells Panel |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 2037 |
| Special Delivery Fee |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 2038 |
| Long Distance Courier |
| 1.00 |
| UN |
| ___________ |
| ___________ |
| 2039 |
| Delivery Charges: A flat rate per month will be charged for all special deliveries of blood and/or blood components to this VA facility up to 4 deliveries per day. |
| 12.00 |
| MO |
| ___________ |
| ___________ |
| 2040 |
| Plasma Exchange: Cost of each process to include albumin 500mL/unit |
| 15.00 |
| UN |
| ___________ |
| ___________ |
| 2041 |
| Plasma Exchange: Cost of each process to include saline 500mL/Unit |
| 15.00 |
| UN |
| ___________ |
| ___________ |
| 2042 |
| Plasma Exchange: Cost of each process to include Saline 1000mL/Unit |
| 20.00 |
| UN |
| ___________ |
| ___________ |
| 2043 |
| Machine Transport |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 2044 |
| Theraputic Plasma Exchange (Theraputic Phlebotomy) |
| 35.00 |
| EA |
| ___________ |
| ___________ |
| 2045 |
| Red Cell Exchange |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 2046 |
| White Cell Depletion |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 2047 |
| Platelet Depletion |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 2048 |
| Red Cell Depletion/Exchange |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 2049 |
| Nursing Services |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 2050 |
| After Hours Fee (Weekends and Holidays Included) |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 2051 |
| Procedure Cancelation Fee |
| 1.00 |
| EA |
| ___________ |
| ___________ |
Option Year three (3) October 1, 2021 to September 30, 2022
| ITEM NUMBER |
| DESCRIPTION OF SUPPLIES/SERVICES |
| QUANTITY |
| UNIT |
| UNIT PRICE |
| AMOUNT |
| 3001 |
| Leukocyte Reduced RBC (Zika Tested) |
| 2,000.00 |
| EA |
| ___________ |
| ___________ |
| 3002 |
| Plateletpheresis (Leukoreduced/Bacterial tested/ ZIKA tested) |
| 350.00 |
| EA |
| ___________ |
| ___________ |
| 3003 |
| Fresh Frozen Plasma- FFP (Type AB) |
| 40.00 |
| EA |
| ___________ |
| ___________ |
| 3004 |
| Fresh Frozen Plasma- FFP (Type non-AB) |
| 150.00 |
| EA |
| ___________ |
| ___________ |
| 3005 |
| Pooled Cryoprecipitate |
| 20.00 |
| EA |
| ___________ |
| ___________ |
| 3006 |
| Special Tests: ABO Typing |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 3007 |
| Rh Typing |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 3008 |
| Compatibility Testing |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 3009 |
| Compatibility Testing (AGT Phase) |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 3010 |
| DAT |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 3011 |
| Antibody Identification (Each Panel) |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 3012 |
| Antibody Identification (Enzyme Treated) Each Panel |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 3013 |
| Sickle Cell Screen |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 3014 |
| CMV (Donor Unit or Patient) |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 3015 |
| Irradiation Fee (Blood/Blood Component) |
| 300.00 |
| EA |
| ___________ |
| ___________ |
| 3016 |
| Washing |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 3018 |
| FREEZING |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 3019 |
| LIQUID PLASMA (LP) |
| 25.00 |
| EA |
| ___________ |
| ___________ |
| 3020 |
| Differential Adsorption |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 3021 |
| Rare Unit Fee |
| 6.00 |
| EA |
| ___________ |
| ___________ |
| 3022 |
| Unit Search for Rare Unit |
| 6.00 |
| EA |
| ___________ |
| ___________ |
| 3023 |
| Elution |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 3024 |
| Autologous Donation Fee |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 3025 |
| Directed Donation Fee |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 3026 |
| Plateletpheresis Crossmatch/HLA Crossmatch |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 3027 |
| Auto Adsorption |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 3028 |
| Antibody Titration |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 3029 |
| ABO Discrepancy/Resolution |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 3030 |
| Special Antigen Testing: Each antigen Screened per Unit Group 1 Unit RBC each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 3031 |
| Group 2: Unit RBC Each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 3032 |
| Group 3: Unit RBC Each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 3033 |
| Group 4: Unit Each RBC Antigen Tested |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 3034 |
| Genetic RBC Phenotypes |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 3035 |
| Antibody Screen |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 3036 |
| Antibody ID, Selected Cells Panel |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 3037 |
| Special Delivery Fee |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 3038 |
| Long Distance Courier |
| 1.00 |
| UN |
| ___________ |
| ___________ |
| 3039 |
| Delivery Charges: A flat rate per month will be charged for all special deliveries of blood and/or blood components to this VA facility up to 4 deliveries per day. |
| 12.00 |
| MO |
| ___________ |
| ___________ |
| 3040 |
| Plasma Exchange: Cost of each process to include albumin 500mL/unit |
| 15.00 |
| UN |
| ___________ |
| ___________ |
| 3041 |
| Plasma Exchange: Cost of each process to include saline 500mL/Unit |
| 15.00 |
| UN |
| ___________ |
| ___________ |
| 3042 |
| Plasma Exchange: Cost of each process to include Saline 1000mL/Unit |
| 20.00 |
| UN |
| ___________ |
| ___________ |
| 3043 |
| Machine Transport |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 3044 |
| Theraputic Plasma Exchange (Theraputic Phlebotomy) |
| 35.00 |
| EA |
| ___________ |
| ___________ |
| 3045 |
| Red Cell Exchange |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 3046 |
| White Cell Depletion |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 3047 |
| Platelet Depletion |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 3048 |
| Red Cell Depletion/Exchange |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 3049 |
| Nursing Services |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 3050 |
| After Hours Fee (Weekends and Holidays Included) |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 3051 |
| Procedure Cancelation Fee |
| 1.00 |
| EA |
| ___________ |
| ___________ |
Option Year Four (4) October 1, 2022 to September 30, 2023
| ITEM NUMBER |
| DESCRIPTION OF SUPPLIES/SERVICES |
| QUANTITY |
| UNIT |
| UNIT PRICE |
| AMOUNT |
| 4001 |
| Leukocyte Reduced RBC (Zika Tested) |
| 2,000.00 |
| EA |
| ___________ |
| ___________ |
| 4002 |
| Plateletpheresis (Leukoreduced/Bacterial tested/ ZIKA tested) |
| 350.00 |
| EA |
| ___________ |
| ___________ |
| 4003 |
| Fresh Frozen Plasma- FFP (Type AB) |
| 40.00 |
| EA |
| ___________ |
| ___________ |
| 4004 |
| Fresh Frozen Plasma- FFP (Type non-AB) |
| 150.00 |
| EA |
| ___________ |
| ___________ |
| 4005 |
| Pooled Cryoprecipitate |
| 20.00 |
| EA |
| ___________ |
| ___________ |
| 4006 |
| Special Tests: ABO Typing |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 4007 |
| Rh Typing |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 4008 |
| Compatibility Testing |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 4009 |
| Compatibility Testing (AGT Phase) |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 4010 |
| DAT |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 4011 |
| Antibody Identification (Each Panel) |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 4012 |
| Antibody Identification (Enzyme Treated) Each Panel |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 4013 |
| Sickle Cell Screen |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 4014 |
| CMV (Donor Unit or Patient) |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 4015 |
| Irradiation Fee (Blood/Blood Component) |
| 300.00 |
| EA |
| ___________ |
| ___________ |
| 4016 |
| Washing |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 4017 |
| Deglycerolyzing Fee |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 4018 |
| FREEZING |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 4019 |
| LIQUID PLASMA (LP) |
| 25.00 |
| EA |
| ___________ |
| ___________ |
| 4020 |
| Differential Adsorption |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 4021 |
| Rare Unit Fee |
| 6.00 |
| EA |
| ___________ |
| ___________ |
| 4022 |
| Unit Search for Rare Unit |
| 6.00 |
| EA |
| ___________ |
| ___________ |
| 4023 |
| Elution |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 4024 |
| Autologous Donation Fee |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 4025 |
| Directed Donation Fee |
| 2.00 |
| EA |
| ___________ |
| ___________ |
| 4026 |
| Plateletpheresis Crossmatch/HLA Crossmatch |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 4027 |
| Auto Adsorption |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 4028 |
| Antibody Titration |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 4029 |
| ABO Discrepancy/Resolution |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 4030 |
| Special Antigen Testing: Each antigen Screened per Unit Group 1 Unit RBC each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 4031 |
| Group 2: Unit RBC Each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 4032 |
| Group 3: Unit RBC Each Antigen Tested |
| 15.00 |
| EA |
| ___________ |
| ___________ |
| 4033 |
| Group 4: Unit Each RBC Antigen Tested |
| 10.00 |
| EA |
| ___________ |
| ___________ |
| 4034 |
| Genetic RBC Phenotypes |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 4035 |
| Antibody Screen |
| 30.00 |
| EA |
| ___________ |
| ___________ |
| 4036 |
| Antibody ID, Selected Cells Panel |
| 5.00 |
| EA |
| ___________ |
| ___________ |
| 4037 |
| Special Delivery Fee |
| 3.00 |
| EA |
| ___________ |
| ___________ |
| 4038 |
| Long Distance Courier |
| 1.00 |
| UN |
| ___________ |
| ___________ |
| 4039 |
| Delivery Charges: A flat rate per month will be charged for all special deliveries of blood and/or blood components to this VA facility up to 4 deliveries per day. |
| 12.00 |
| MO |
| ___________ |
| ___________ |
| 4040 |
| Plasma Exchange: Cost of each process to include albumin 500mL/unit |
| 15.00 |
| UN |
| ___________ |
| ___________ |
| 4041 |
| Plasma Exchange: Cost of each process to include saline 500mL/Unit |
| 15.00 |
| UN |
| ___________ |
| ___________ |
| 4042 |
| Plasma Exchange: Cost of each process to include Saline 1000mL/Unit |
| 20.00 |
| UN |
| ___________ |
| ___________ |
| 4043 |
| Machine Transport |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 4044 |
| Theraputic Plasma Exchange (Theraputic Phlebotomy) |
| 35.00 |
| EA |
| ___________ |
| ___________ |
| 4045 |
| Red Cell Exchange |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 4046 |
| White Cell Depletion |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 4047 |
| Platelet Depletion |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 4048 |
| Red Cell Depletion/Exchange |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 4049 |
| Nursing Services |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 4050 |
| After Hours Fee (Weekends and Holidays Included) |
| 1.00 |
| EA |
| ___________ |
| ___________ |
| 4051 |
| Procedure Cancelation Fee |
| 1.00 |
| EA |
| ___________ |
| ___________ |
GRAND TOTAL
