36C24919Q0175-002.docx

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VA249-18-AP-3931 Radiopharmaceuticals Replaces 621-19-1-029-0001
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36C24919Q0175
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36C24919Q0175 P09-621 Radiopharmaceuticals Supply List.docx

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B.4 Price/Cost Schedule:

Base Year Period of Performance: April 01, 2019 to March 31, 2020

CLIN
CLIN Supplies
EST QTY
UNIT COST
TOTAL COST
0001
Sodium Pertechnetate Tc99M, U.D.
20
0002
Sodium Pertechnetate Tc99M per mCI
865
0003
Sodium Pertechnetate Tc99M Flood
56
0004
HDP/MDP Tc99M
378
0005
PYP Vial
1
0006
MAA Tc99M
60
0007
Sulfur Colloid Tc99M
101
0008
Sulfur Colloid Tc99M, Filtered
17
0009
DTPA Tc99M
55
0010
MAG 3 Tc99M
12
0011
Choletec Tc99M
115
0012
Ceretec Tc99M WBC
10
0013
Co-57 Flood 15 mCi
1
0014
Cardiolote Tc99M
4225
0015
Thallous Chloride T1-201/mCi
110
0016
Sodium Iodide, 1-123, 200uCi
50
0017
Sodium Iodide, 1-131, 1 mCi
10
0018
Sodioum Iodide, I-131, 1 mCi, Each additional mCi
575
0019
Gallium Citrate GS-67/mCi
5
0020
Gallium Citrate, Ga-67 source
1
0021
In-111 Octreoscan
10
0022
Hepatolite-TC99m
0-1
0023
*Quadramet 153 Sa
0-1
0024
I-123 MIBG
0-1
0025
14 Carbon
0-1
0026
111 In-WBC
0-1

PET Radioisotopes:

0027
F18-Vizamyl (dementia)
0028
Ga68-NETSPOT (neuroendocrine tumor)
0029
N13-Ammonia (cardiac)

Non-radioactive products:

0030
Ultratag Kits
18
0031
Venti-Scan IV & vent Kit
42
0032
Kinevac up to 0.8 micrograms (unit dose)
75
0033
Kinevac, Each additional 0.1 microgram
875

ESTIMATED FOR BASE YEAR

OPTION YEAR ONE (1)

Option Year One Period of Performance: April 01, 2020 to March 31, 2021

CLIN
CLIN Supplies
EST QTY
UNIT COST
TOTAL COST
1001
Sodium Pertechnetate Tc99M, U.D.
20
1002
Sodium Pertechnetate Tc99M per mCI
865
1003
Sodium Pertechnetate Tc99M Flood
56
1004
HDP/MDP Tc99M
378
1005
PYP Vial
1
1006
MAA Tc99M
60
1007
Sulfur Colloid Tc99M
101
1008
Sulfur Colloid Tc99M, Filtered
17
1009
DTPA Tc99M
55
1010
MAG 3 Tc99M
12
1011
Choletec Tc99M
115
1012
Ceretec Tc99M WBC
10
1013
Co-57 Flood 15 mCi
1
1014
Cardiolote Tc99M
4225
1015
Thallous Chloride T1-201/mCi
110
1016
Sodium Iodide, 1-123, 200uCi
50
1017
Sodium Iodide, 1-131, 1 mCi
10
1018
Sodioum Iodide, I-131, 1 mCi, Each additional mCi
575
1019
Gallium Citrate GS-67/mCi
5
1020
Gallium Citrate, Ga-67 source
1
1021
In-111 Octreoscan
10
1022
Hepatolite-TC99m
0-1
1023
*Quadramet 153 Sa
0-1
1024
I-123 MIBG
0-1
1025
14 Carbon
0-1
1026
111 In-WBC
0-1

PET Radioisotopes:

1027
F18-Vizamyl (dementia)
1028
Ga68-NETSPOT (neuroendocrine tumor)
1029
N13-Ammonia (cardiac)

Non-radioactive products:

1030
Ultratag Kits
18
1031
Venti-Scan IV & vent Kit
42
1032
Kinevac up to 0.8 micrograms (unit dose)
75
1033
Kinevac, Each additional 0.1 microgram
875

ESTIMATED TOTAL OPTION YEAR 1

OPTION YEAR TWO (2)

Option Year Two Period of Performance: April 01, 2021 to March 31, 2022

CLIN
CLIN Supplies
EST QTY
UNIT COST
TOTAL COST
2001
Sodium Pertechnetate Tc99M, U.D.
20
2002
Sodium Pertechnetate Tc99M per mCI
865
2003
Sodium Pertechnetate Tc99M Flood
56
2004
HDP/MDP Tc99M
378
2005
PYP Vial
1
2006
MAA Tc99M
60
2007
Sulfur Colloid Tc99M
101
2008
Sulfur Colloid Tc99M, Filtered
17
2009
DTPA Tc99M
55
2010
MAG 3 Tc99M
12
2011
Choletec Tc99M
115
2012
Ceretec Tc99M WBC
10
2013
Co-57 Flood 15 mCi
1
2014
Cardiolote Tc99M
4225
2015
Thallous Chloride T1-201/mCi
110
2016
Sodium Iodide, 1-123, 200uCi
50
2017
Sodium Iodide, 1-131, 1 mCi
10
2018
Sodioum Iodide, I-131, 1 mCi, Each additional mCi
575
2019
Gallium Citrate GS-67/mCi
5
2020
Gallium Citrate, Ga-67 source
1
2021
In-111 Octreoscan
10
2022
Hepatolite-TC99m
0-1
2023
*Quadramet 153 Sa
0-1
2024
I-123 MIBG
0-1
2025
14 Carbon
0-1
2026
111 In-WBC
0-1

PET Radioisotopes:

2027
F18-Vizamyl (dementia)
2028
Ga68-NETSPOT (neuroendocrine tumor)
2029
N13-Ammonia (cardiac)

Non-radioactive products:

2030
Ultratag Kits
18
2031
Venti-Scan IV & vent Kit
42
2032
Kinevac up to 0.8 micrograms (unit dose)
75
2033
Kinevac, Each additional 0.1 microgram
875

ESTIMATED TOTAL OPTION YEAR 2

OPTION YEAR THREE (3)

Option Year Three Period of Performance: April 01, 2022 to March 31, 2023

CLIN
CLIN Supplies
EST QTY
UNIT COST
TOTAL COST
3001
Sodium Pertechnetate Tc99M, U.D.
20
3002
Sodium Pertechnetate Tc99M per mCI
865
3003
Sodium Pertechnetate Tc99M Flood
56
3004
HDP/MDP Tc99M
378
3005
PYP Vial
1
3006
MAA Tc99M
60
3007
Sulfur Colloid Tc99M
101
3008
Sulfur Colloid Tc99M, Filtered
17
3009
DTPA Tc99M
55
3010
MAG 3 Tc99M
12
3011
Choletec Tc99M
115
3012
Ceretec Tc99M WBC
10
3013
Co-57 Flood 15 mCi
1
3014
Cardiolote Tc99M
4225
3015
Thallous Chloride T1-201/mCi
110
3016
Sodium Iodide, 1-123, 200uCi
50
3017
Sodium Iodide, 1-131, 1 mCi
10
3018
Sodioum Iodide, I-131, 1 mCi, Each additional mCi
575
3019
Gallium Citrate GS-67/mCi
5
3020
Gallium Citrate, Ga-67 source
1
3021
In-111 Octreoscan
10
3022
Hepatolite-TC99m
0-1
3023
*Quadramet 153 Sa
0-1
3024
I-123 MIBG
0-1
3025
14 Carbon
0-1
3026
111 In-WBC
0-1

PET Radioisotopes:

3027
F18-Vizamyl (dementia)
3028
Ga68-NETSPOT (neuroendocrine tumor)
3029
N13-Ammonia (cardiac)

Non-radioactive products:

3030
Ultratag Kits
18
3031
Venti-Scan IV & vent Kit
42
3032
Kinevac up to 0.8 micrograms (unit dose)
75
3033
Kinevac, Each additional 0.1 microgram
875

ESTIMATED TOTAL OPTION YEAR 3

OPTION YEAR FOUR (4)

Option Year Four Period of Performance: April 01, 2023 to March 31, 2024

CLIN
CLIN Supplies
EST QTY
UNIT COST
TOTAL COST
4001
Sodium Pertechnetate Tc99M, U.D.
20
4002
Sodium Pertechnetate Tc99M per mCI
865
4003
Sodium Pertechnetate Tc99M Flood
56
4004
HDP/MDP Tc99M
378
4005
PYP Vial
1
4006
MAA Tc99M
60
4007
Sulfur Colloid Tc99M
101
4008
Sulfur Colloid Tc99M, Filtered
17
4009
DTPA Tc99M
55
4010
MAG 3 Tc99M
12
4011
Choletec Tc99M
115
4012
Ceretec Tc99M WBC
10
4013
Co-57 Flood 15 mCi
1
4014
Cardiolote Tc99M
4225
4015
Thallous Chloride T1-201/mCi
110
4016
Sodium Iodide, 1-123, 200uCi
50
4017
Sodium Iodide, 1-131, 1 mCi
10
4018
Sodioum Iodide, I-131, 1 mCi, Each additional mCi
575
4019
Gallium Citrate GS-67/mCi
5
4020
Gallium Citrate, Ga-67 source
1
4021
In-111 Octreoscan
10
4022
Hepatolite-TC99m
0-1
4023
*Quadramet 153 Sa
0-1
4024
I-123 MIBG
0-1
4025
14 Carbon
0-1
4026
111 In-WBC
0-1

PET Radioisotopes:

4027
F18-Vizamyl (dementia)
4028
Ga68-NETSPOT (neuroendocrine tumor)
4029
N13-Ammonia (cardiac)

Non-radioactive products:

4030
Ultratag Kits
18
4031
Venti-Scan IV & vent Kit
42
4032
Kinevac up to 0.8 micrograms (unit dose)
75
4033
Kinevac, Each additional 0.1 microgram
875

ESTIMATED TOTAL OPTION YEAR 4

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