47QFWA22R0008 Revised Appendix M - Pricing Spreadsheet 4.18.2022.xlsx

XLSX spreadsheet 45 KB Posted Apr 19, 2022

Attached to: DoDMERB Medical Services Federal contract opportunity
Solicitation number: 47QFWA22R0008
Issued by: General Services Administration Federal Acquisition Service Assisted Acquisition Services Region 7

About this file

Written by GovTribe AI · Dec 28, 2023

This solicitation requests proposals for Department of Defense Medical Examination Review Board medical services. The General Services Administration will acquire these services on behalf of the Defense Health Agency. Services include initial medical examinations, additional medical services, and associated CPT medical codes. The base period of performance is from May 2022 to September 2022, with four one-year option periods. Evaluation factors are technical approach, previous experience, past performance, small business participation plan, and price. Price is less important than the non-price factors. The solicitation identifies required services and estimated quantities by contract line item number for the base period and each option year. Offerors must register in GSA ASSIST and provide registration details to the contracting officer by April 22nd to receive the RFP and submit a proposal, which are due April 29th. A pre-proposal conference is scheduled for April 5th.

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Other files for this federal contract opportunity

Other files attached to DoDMERB Medical Services, newest first.
File	Type	Posted
47QFWA22R0008 Questions and Answers 4.18.2022.xlsx	XLSX spreadsheet	Apr 19, 2022
47QFWA22R0008 Revised Solicitation Sections K-M 4.18.2022.pdf	PDF	Apr 19, 2022
47QFWA22R0008 Revised Solicitation Sections B-J 4.18.2022.pdf	PDF	Apr 19, 2022
47QFWA22R0008 Revised Appendix M - Pricing Spreadsheet.xlsx	XLSX spreadsheet	Apr 12, 2022
47QFWA22R0008 Appendix K - Historical Data - AMS by Month 2019 - 2022.xlsx	XLSX spreadsheet	Apr 12, 2022
47QFWA22R0008 Revised Appendix D - DD Form 2807-2.pdf	PDF	Apr 12, 2022
47QFWA22R0008 Questions and Answers 4.11.2022.xlsx	XLSX spreadsheet	Apr 12, 2022
47QFWA22R0008 Appendix I - Historica Data - Exams by Month 2019 - 2022.xlsx	XLSX spreadsheet	Apr 12, 2022
47QFWA22R0008 Revised Solicitation Sections K-M 4.4.2022.pdf	PDF	Apr 12, 2022
47QFWA22R0008 Revised Solicitation Sections B-J 4.4.2022.pdf	PDF	Apr 12, 2022
47QFWA22R0008 Appendix M - Pricing Spreadsheet.xlsx	XLSX spreadsheet	Mar 29, 2022
47QFWA22R0008 Solicitation Sections B-J 12.29.2021.pdf	PDF	Mar 29, 2022
47QFWA22R0008 Appendix L - QASP.pdf	PDF	Mar 29, 2022
47QFWA22R0008 Appendix C - DD Form 2808.pdf	PDF	Mar 29, 2022
47QFWA22R0008 Solicitation Sections K-M 2.24.2022.pdf	PDF	Mar 29, 2022
47QFWA22R0008 Appendix J - Subcontracting Plan.docx	DOCX document	Mar 29, 2022
47QFWA22R0008 Appendix H - Historical Data - Exams by Zip Code.xlsx	XLSX spreadsheet	Mar 29, 2022

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Total Pricing

DESCRIPTION	BASE	OPTION YEAR 1	OPTION YEAR 2	OPTION YEAR 3	OPTION YEAR 4	BASE PLUS OPTIONS
IME Completed Medical Examination Report
IME Partial Optometric Medical Examination Report (Partial Physical Exam)
IME Partial Clinical Medical Examination Report (Partial Physical Exam)
IME/AMS Failure to Appear
IME/AMS Reassignment
CPT Codes
Transition Period		N/A	N/A	N/A	N/A
TOTAL PRICE

Base

CLIN	Description	Estimated Quantity	Unit of Issue	Price per Unit	Total Price	Period of Performance
0001	IME Completed Medical Examination Report	7000	EA			July 1, 2022 - September 30, 2022
0002	IME Partial Optometric Medical Examination Report (Partial Physical Exam)	300	EA			July 1, 2022 - September 30, 2022
0003	IME Partial Clinical Medical Examination Report (Partial Physical Exam)	240	EA			July 1, 2022 - September 30, 2022
0004	IME/AMS Failure to Appear	115	EA			July 1, 2022 - September 30, 2022
0005	IME/AMS Reassignment	300	EA			July 1, 2022 - September 30, 2022
0006	CPT Codes	1	LOT	N/A		July 1, 2022 - September 30, 2022
0007	Transition Period	1	EA			May 17, 2022 - June 30, 2022

	CPT Codes		Estimated Quantity	Unit of Issue	Price Per Unit	Total Price
	70450	X-ray - Computed Tomography (CT) scan, head or brain; without contrast material	3	EA
	70486	X-ray - Obtain computerized axial tomography, sinuses	5	EA
	70551	Magnetic resonance imaging, brain	5	EA
	71046	Forward a radiologist's report of NEW x-ray films of chest	3	EA
	71250	CT thorax	2	EA
	71550	Obtain a new MRI of the thorax without contrast material for $ and forward a Board Certified Radiologist's interpretation of the MRI	2	EA
	72040	X-ray of spine, cervical	3	EA
	72070	X-ray exam, spine, thoracic, two views	3	EA
	72082	X-ray spine, thoracolumbar, standing (scoliosis)	5	EA
	72100	X-ray exam, spine, lumbosacral, four views	10	EA
	72125	X-ray - CT of cervical spine	2	EA
	72128	X-ray - CT of thoracic spine	2	EA
	72131	X-ray - CT of lumbar spine	4	EA
	72141	X-ray - MRI of spinal canal and contents, cervical	2	EA
	72146	X-ray - MRI of spinal canal and contents, thoracic	2	EA
	72148	X-ray - Magnetic Resonance Imaging (MRI) of spinal canal and contents, lumbar	5	EA
	72220	X-ray of sacrum and coccyx	2	EA
	73000	X-ray of clavicle, complete	2	EA
	73030	X-ray exam, shoulder, two views	3	EA
	73050	X-ray of acromioclavicular joints	2	EA
	73060	X-ray of humerus	2	EA
	73080	X-ray of elbow, complete	4	EA
	73090	X-ray of forearm	2	EA
	73110	X-ray exam, wrist, three views	3	EA
	73120	X-ray of hand	2	EA
	73140	X-ray of finger(s)	2	EA
	73502	X-ray of hip - unilateral, complete	10	EA
	73521	X-ray of hips, bilateral	3	EA
	73551	X-ray of femur (thigh)	2	EA
	73560	X-ray of knee, anteroposterior and lateral views	10	EA
	73590	X-ray of tibia and fibula	10	EA
	73610	X-ray of ankle, complete	5	EA
	73630	X-ray of foot, complete	5	EA
	73700	X-ray - CT of lower extremity	2	EA
	73721	X-ray - MRI without contrast material of lower extremity	10	EA
	74150	X-ray - Obtain a CT scan - abdomen; without contrast material	3	EA
	76536	X-ray - Echography, B-scan and/or real time soft tissues of head/neck (thyroid, parathyroid,
parotid)	3	EA
	76705	X-ray - Echography, abdominal, B-scan and/or real time	3	EA
	76770	X-ray - Echography, retroperitoneal, B-scan and/or real time	3	EA
	76775	Obtain an echography, retroperitoineal	10	EA
	76856	X-ray - Echography, pelvic	5	EA
	76870	X-ray - Echography, scrotum and contents	3	EA
	77081	X-ray - Dual Energy X-ray Absorptiometry (DEXA), bone density study	2	EA
	80048	Lab test - Basic metabolic panel	10	EA
	80061	Lab test - Lipid panel	25	EA
	80074	Lab test - Acute Hepatitis Panel	30	EA
	80076	Lab test - Hepatic function panel	10	EA
	81001	Lab test - Urinalysis with microscopy	50	EA
	81003	Lab test - Urinalysis without microscopy	5	EA
	81015	Lab test - Urinalysis, microscopy only	3	EA
	82340	Please obtain a urine calcium/creatinine ratio (calcium), via routine urine collection	5	EA
	82570	Please obtain a UP/C ratio (reatinine), via routine urin collection (add R263.07)	4	EA
	82575	Lab test - Creatinine clearance	2	EA
	82947	Please obtain a fasting glucose blood test	25	EA
	83020	Lab test - Hemoglobin electrophoresis	2	EA
	83036	Hemoglobin HbA1c (HPLC)	20	EA
	84133	Lab test - 24-hour urinary protein and volume level test	5	EA
	84156	24-hour Urine collection	5	EA
	84436	Lab test - Thyroxin, total	3	EA
	84443	Lab test - Thyroid stimulating hormone (TSH)	50	EA
	85025	Lab test - REPEAT complete blood count, automated	5	EA
	85027	Lab test - Blood count, hemogram and platelet count, automated	100	EA
	86003	Lab test - Allergen specific lgE; quantitative or semicuantitative	65	EA
	86480	Lab test - QuantiFERON - TB Gold (QFT-Gold) blood test	50	EA
	90791	Psychiatric diagnostic interview examination	125	EA
	90792	Office consultation with a mental health provider certified in drug/alcohol counseling or addiction medicine	20	EA
	92002	Optometric/Ophthalmogical consultation that does not require a dilated examination. Elements in a DoDMERB eye exam would qualify for this code - new patient ntermediate exam	2	EA
	92004	Optometric/Ophthalmogical comprehensive consultation requiring a dilated fundus exam - new patient complex exam	90	EA
	92004	Optometric/Ophthalmogical exam - manifest refraction (new or repeat)	40	EA
	92012	Optometric/Ophthalmogical consultation that does not require a dilated examination - established patient intermediate exam	90	EA
	92025	Computetized Corneal Topography with interpretation (Color)	100	EA
	92060	Optometric/Ophthalmogical - senorimotor evaluation; comprehensive strabismus evaluation with multiple measurements of ocular deviation to include a report	2	EA
	92083	Optometric/Ophthalmogical exam - extended visual field examination with automated perimetry	2	EA
	92552	Audiogram - Pure tone audiometry (threshold); air only	10	EA
	92557	Obtain a comprehensive audiometry threshold evaluation	150	EA
	92567	Obtain a Tympanometry	2	EA
	93000	Electrocardiogram, 12-lead, with interpretation & report	50	EA
	93015	Cardiovascular stress test	5	EA
	93228	24-hour holter monitor study	5	EA
	93303	Obtain transthoracic echocardiography for congenital anomalies	2	EA
	93306	Obtain echocardiogram and color flow doppler for evaluation of murmur	100	EA
	93320	Obtain echocardiography, pulsed wave and/or continuous wave	2	EA
	93325	X-ray - Echocardiogram - Doppler color flow velocity mapping	50	EA
	93350	Obtain transthoracic echocardiography, real-time with image documentation (2D), rest/stress	2	EA
	94010	Spirometry, with or without maximal voluntary ventilation (PFT)	15	EA
	94010	Complete Exercise spirometry	15	EA
	94060	Spirometry, before and after bronchodilator (aerosol)	150	EA
	94070	Bronchoprovocation pulmonary function test	50	EA
	95004	Skin allergy testing	40	EA
	95017	Obtain skin allergy testing (intracutaneous/intradermal tests)	5	EA
	95070	Bronchial allergy test	50	EA
	95079	Obtain ingestion challenge test	40	EA
	95816	Electroencephalogram (EEG)	15	EA
	96130	Psychological testing	10	EA
	96132	Neuropsychological testing battery	10	EA
	99172	Optometric/Ophthalmogical - visual function screening - visual acuity measurements, red lens test, cover test, near point of convergence, horizontal & vertical phorias, depth perception and color vision to include PIP, Vivid Red-Green, or FALANT	200	EA
	99242	AMS Medical Consultation (CPT 99242) Report	750	EA
	99244	AMS Medical Consultation (CPT 99244) Report	15	EA
	99245	AMS Medical Consultation (CPT 99245) Report	25	EA
	92521	Office - Consult - Evaluation by speech therapist/speech pathologist	5	EA
	J7674	Methacholine Chloride, NEB	50	EA
	TOTAL CPT CODES*

*The total for all the CPT codes shall be entered under CLIN 0006 in the Base Period pricing chart above.

Option Year 1

CLIN	Description	Estimated Quantity	Unit of Issue	Price per Unit	Total Price	Period of Performance
1001	IME Completed Medical Examination Report	26000	EA			October 1, 2022 – September 30, 2023
1002	IME Partial Optometric Medical Examination Report (Partial Physical Exam)	1200	EA			October 1, 2022 – September 30, 2023
1003	IME Partial Clinical Medical Examination Report (Partial Physical Exam)	950	EA			October 1, 2022 – September 30, 2023
1004	IME/AMS Failure to Appear	450	EA			October 1, 2022 – September 30, 2023
1005	IME/AMS Reassignment	1800	EA			October 1, 2022 – September 30, 2023
1006	CPT Codes	1	LOT	N/A		October 1, 2022 – September 30, 2023

	CPT Codes		Estimated Quantity	Unit of Issue	Price Per Unit	Total Price
	70450	X-ray - Computed Tomography (CT) scan, head or brain; without contrast material	10	EA
	70486	X-ray - Obtain computerized axial tomography, sinuses	10	EA
	70551	Magnetic resonance imaging, brain	25	EA
	71046	Forward a radiologist's report of NEW x-ray films of chest	10	EA
	71250	CT thorax	5	EA
	71550	Obtain a new MRI of the thorax without contrast material for $ and forward a Board Certified Radiologist's interpretation of the MRI	5	EA
	72040	X-ray of spine, cervical	10	EA
	72070	X-ray exam, spine, thoracic, two views	10	EA
	72082	X-ray spine, thoracolumbar, standing (scoliosis)	25	EA
	72100	X-ray exam, spine, lumbosacral, four views	40	EA
	72125	X-ray - CT of cervical spine	5	EA
	72128	X-ray - CT of thoracic spine	5	EA
	72131	X-ray - CT of lumbar spine	10	EA
	72141	X-ray - MRI of spinal canal and contents, cervical	5	EA
	72146	X-ray - MRI of spinal canal and contents, thoracic	5	EA
	72148	X-ray - Magnetic Resonance Imaging (MRI) of spinal canal and contents, lumbar	20	EA
	72220	X-ray of sacrum and coccyx	5	EA
	73000	X-ray of clavicle, complete	5	EA
	73030	X-ray exam, shoulder, two views	10	EA
	73050	X-ray of acromioclavicular joints	5	EA
	73060	X-ray of humerus	5	EA
	73080	X-ray of elbow, complete	15	EA
	73090	X-ray of forearm	5	EA
	73110	X-ray exam, wrist, three views	10	EA
	73120	X-ray of hand	5	EA
	73140	X-ray of finger(s)	5	EA
	73502	X-ray of hip - unilateral, complete	30	EA
	73521	X-ray of hips, bilateral	10	EA
	73551	X-ray of femur (thigh)	5	EA
	73560	X-ray of knee, anteroposterior and lateral views	35	EA
	73590	X-ray of tibia and fibula	30	EA
	73610	X-ray of ankle, complete	15	EA
	73630	X-ray of foot, complete	15	EA
	73700	X-ray - CT of lower extremity	5	EA
	73721	X-ray - MRI without contrast material of lower extremity	50	EA
	74150	X-ray - Obtain a CT scan - abdomen; without contrast material	10	EA
	76536	X-ray - Echography, B-scan and/or real time soft tissues of head/neck (thyroid, parathyroid,
parotid)	10	EA
	76705	X-ray - Echography, abdominal, B-scan and/or real time	10	EA
	76770	X-ray - Echography, retroperitoneal, B-scan and/or real time	10	EA
	76775	Obtain an echography, retroperitoineal	30	EA
	76856	X-ray - Echography, pelvic	20	EA
	76870	X-ray - Echography, scrotum and contents	10	EA
	77081	X-ray - Dual Energy X-ray Absorptiometry (DEXA), bone density study	5	EA
	80048	Lab test - Basic metabolic panel	50	EA
	80061	Lab test - Lipid panel	100	EA
	80074	Lab test - Acute Hepatitis Panel	120	EA
	80076	Lab test - Hepatic function panel	40	EA
	81001	Lab test - Urinalysis with microscopy	200	EA
	81003	Lab test - Urinalysis without microscopy	15	EA
	81015	Lab test - Urinalysis, microscopy only	10	EA
	82340	Please obtain a urine calcium/creatinine ratio (calcium), via routine urine collection	20	EA
	82570	Please obtain a UP/C ratio (reatinine), via routine urin collection (add R263.07)	15	EA
	82575	Lab test - Creatinine clearance	5	EA
	82947	Please obtain a fasting glucose blood test	75	EA
	83020	Lab test - Hemoglobin electrophoresis	5	EA
	83036	Hemoglobin HbA1c (HPLC)	60	EA
	84133	Lab test - 24-hour urinary protein and volume level test	25	EA
	84156	24-hour Urine collection	15	EA
	84436	Lab test - Thyroxin, total	10	EA
	84443	Lab test - Thyroid stimulating hormone (TSH)	150	EA
	85025	Lab test - REPEAT complete blood count, automated	15	EA
	85027	Lab test - Blood count, hemogram and platelet count, automated	400	EA
	86003	Lab test - Allergen specific lgE; quantitative or semicuantitative	250	EA
	86480	Lab test - QuantiFERON - TB Gold (QFT-Gold) blood test	200	EA
	90791	Psychiatric diagnostic interview examination	550	EA
	90792	Office consultation with a mental health provider certified in drug/alcohol counseling or addiction medicine	80	EA
	92002	Optometric/Ophthalmogical consultation that does not require a dilated examination. Elements in a DoDMERB eye exam would qualify for this code - new patient ntermediate exam	10	EA
	92004	Optometric/Ophthalmogical comprehensive consultation requiring a dilated fundus exam - new patient complex exam	325	EA
	92004	Optometric/Ophthalmogical exam - manifest refraction (new or repeat)	150	EA
	92012	Optometric/Ophthalmogical consultation that does not require a dilated examination - established patient intermediate exam	250	EA
	92025	Computetized Corneal Topography with interpretation (Color)	300	EA
	92060	Optometric/Ophthalmogical - senorimotor evaluation; comprehensive strabismus evaluation with multiple measurements of ocular deviation to include a report	10	EA
	92083	Optometric/Ophthalmogical exam - extended visual field examination with automated perimetry	10	EA
	92552	Audiogram - Pure tone audiometry (threshold); air only	40	EA
	92557	Obtain a comprehensive audiometry threshold evaluation	600	EA
	92567	Obtain a Tympanometry	10	EA
	93000	Electrocardiogram, 12-lead, with interpretation & report	150	EA
	93015	Cardiovascular stress test	20	EA
	93228	24-hour holter monitor study	15	EA
	93303	Obtain transthoracic echocardiography for congenital anomalies	10	EA
	93306	Obtain echocardiogram and color flow doppler for evaluation of murmur	350	EA
	93320	Obtain echocardiography, pulsed wave and/or continuous wave	10	EA
	93325	X-ray - Echocardiogram - Doppler color flow velocity mapping	200	EA
	93350	Obtain transthoracic echocardiography, real-time with image documentation (2D), rest/stress	5	EA
	94010	Spirometry, with or without maximal voluntary ventilation (PFT)	50	EA
	94010	Complete Exercise spirometry	50	EA
	94060	Spirometry, before and after bronchodilator (aerosol)	550	EA
	94070	Bronchoprovocation pulmonary function test	150	EA
	95004	Skin allergy testing	125	EA
	95017	Obtain skin allergy testing (intracutaneous/intradermal tests)	10	EA
	95070	Bronchial allergy test	150	EA
	95079	Obtain ingestion challenge test	125	EA
	95816	Electroencephalogram (EEG)	50	EA
	96130	Psychological testing	10	EA
	96132	Neuropsychological testing battery	10	EA
	99172	Optometric/Ophthalmogical - visual function screening - visual acuity measurements, red lens test, cover test, near point of convergence, horizontal & vertical phorias, depth perception and color vision to include PIP, Vivid Red-Green, or FALANT	700	EA
	99242	AMS Medical Consultation (CPT 99242) Report	2350	EA
	99244	AMS Medical Consultation (CPT 99244) Report	150	EA
	99245	AMS Medical Consultation (CPT 99245) Report	100	EA
	92521	Office - Consult - Evaluation by speech therapist/speech pathologist	15	EA
	J7674	Methacholine Chloride, NEB	150	EA
	TOTAL CPT CODES*

*The total for all the CPT codes shall be entered under CLIN 1006 in the Option Year 1 pricing chart above.

Option Year 2

CLIN	Description	Estimated Quantity	Unit of Issue	Price per Unit	Total Price	Period of Performance
2001	IME Completed Medical Examination Report	26000	EA			October 1, 2023 – September 30, 2024
2002	IME Partial Optometric Medical Examination Report (Partial Physical Exam)	1200	EA			October 1, 2023 – September 30, 2024
2003	IME Partial Clinical Medical Examination Report (Partial Physical Exam)	950	EA			October 1, 2023 – September 30, 2024
2004	IME/AMS Failure to Appear	450	EA			October 1, 2023 – September 30, 2024
2005	IME/AMS Reassignment	1800	EA			October 1, 2023 – September 30, 2024
2006	CPT Codes	1	LOT	N/A		October 1, 2023 – September 30, 2024

	CPT Codes		Estimated Quantity	Unit of Issue	Price Per Unit	Total Price
	70450	X-ray - Computed Tomography (CT) scan, head or brain; without contrast material	10	EA
	70486	X-ray - Obtain computerized axial tomography, sinuses	10	EA
	70551	Magnetic resonance imaging, brain	25	EA
	71046	Forward a radiologist's report of NEW x-ray films of chest	10	EA
	71250	CT thorax	5	EA
	71550	Obtain a new MRI of the thorax without contrast material for $ and forward a Board Certified Radiologist's interpretation of the MRI	5	EA
	72040	X-ray of spine, cervical	10	EA
	72070	X-ray exam, spine, thoracic, two views	10	EA
	72082	X-ray spine, thoracolumbar, standing (scoliosis)	25	EA
	72100	X-ray exam, spine, lumbosacral, four views	40	EA
	72125	X-ray - CT of cervical spine	5	EA
	72128	X-ray - CT of thoracic spine	5	EA
	72131	X-ray - CT of lumbar spine	10	EA
	72141	X-ray - MRI of spinal canal and contents, cervical	5	EA
	72146	X-ray - MRI of spinal canal and contents, thoracic	5	EA
	72148	X-ray - Magnetic Resonance Imaging (MRI) of spinal canal and contents, lumbar	20	EA
	72220	X-ray of sacrum and coccyx	5	EA
	73000	X-ray of clavicle, complete	5	EA
	73030	X-ray exam, shoulder, two views	10	EA
	73050	X-ray of acromioclavicular joints	5	EA
	73060	X-ray of humerus	5	EA
	73080	X-ray of elbow, complete	15	EA
	73090	X-ray of forearm	5	EA
	73110	X-ray exam, wrist, three views	10	EA
	73120	X-ray of hand	5	EA
	73140	X-ray of finger(s)	5	EA
	73502	X-ray of hip - unilateral, complete	30	EA
	73521	X-ray of hips, bilateral	10	EA
	73551	X-ray of femur (thigh)	5	EA
	73560	X-ray of knee, anteroposterior and lateral views	35	EA
	73590	X-ray of tibia and fibula	30	EA
	73610	X-ray of ankle, complete	15	EA
	73630	X-ray of foot, complete	15	EA
	73700	X-ray - CT of lower extremity	5	EA
	73721	X-ray - MRI without contrast material of lower extremity	50	EA
	74150	X-ray - Obtain a CT scan - abdomen; without contrast material	10	EA
	76536	X-ray - Echography, B-scan and/or real time soft tissues of head/neck (thyroid, parathyroid,
parotid)	10	EA
	76705	X-ray - Echography, abdominal, B-scan and/or real time	10	EA
	76770	X-ray - Echography, retroperitoneal, B-scan and/or real time	10	EA
	76775	Obtain an echography, retroperitoineal	30	EA
	76856	X-ray - Echography, pelvic	20	EA
	76870	X-ray - Echography, scrotum and contents	10	EA
	77081	X-ray - Dual Energy X-ray Absorptiometry (DEXA), bone density study	5	EA
	80048	Lab test - Basic metabolic panel	50	EA
	80061	Lab test - Lipid panel	100	EA
	80074	Lab test - Acute Hepatitis Panel	120	EA
	80076	Lab test - Hepatic function panel	40	EA
	81001	Lab test - Urinalysis with microscopy	200	EA
	81003	Lab test - Urinalysis without microscopy	15	EA
	81015	Lab test - Urinalysis, microscopy only	10	EA
	82340	Please obtain a urine calcium/creatinine ratio (calcium), via routine urine collection	20	EA
	82570	Please obtain a UP/C ratio (reatinine), via routine urin collection (add R263.07)	15	EA
	82575	Lab test - Creatinine clearance	5	EA
	82947	Please obtain a fasting glucose blood test	75	EA
	83020	Lab test - Hemoglobin electrophoresis	5	EA
	83036	Hemoglobin HbA1c (HPLC)	60	EA
	84133	Lab test - 24-hour urinary protein and volume level test	25	EA
	84156	24-hour Urine collection	15	EA
	84436	Lab test - Thyroxin, total	10	EA
	84443	Lab test - Thyroid stimulating hormone (TSH)	150	EA
	85025	Lab test - REPEAT complete blood count, automated	15	EA
	85027	Lab test - Blood count, hemogram and platelet count, automated	400	EA
	86003	Lab test - Allergen specific lgE; quantitative or semicuantitative	250	EA
	86480	Lab test - QuantiFERON - TB Gold (QFT-Gold) blood test	200	EA
	90791	Psychiatric diagnostic interview examination	550	EA
	90792	Office consultation with a mental health provider certified in drug/alcohol counseling or addiction medicine	80	EA
	92002	Optometric/Ophthalmogical consultation that does not require a dilated examination. Elements in a DoDMERB eye exam would qualify for this code - new patient ntermediate exam	10	EA
	92004	Optometric/Ophthalmogical comprehensive consultation requiring a dilated fundus exam - new patient complex exam	325	EA
	92004	Optometric/Ophthalmogical exam - manifest refraction (new or repeat)	150	EA
	92012	Optometric/Ophthalmogical consultation that does not require a dilated examination - established patient intermediate exam	250	EA
	92025	Computetized Corneal Topography with interpretation (Color)	300	EA
	92060	Optometric/Ophthalmogical - senorimotor evaluation; comprehensive strabismus evaluation with multiple measurements of ocular deviation to include a report	10	EA
	92083	Optometric/Ophthalmogical exam - extended visual field examination with automated perimetry	10	EA
	92552	Audiogram - Pure tone audiometry (threshold); air only	40	EA
	92557	Obtain a comprehensive audiometry threshold evaluation	600	EA
	92567	Obtain a Tympanometry	10	EA
	93000	Electrocardiogram, 12-lead, with interpretation & report	150	EA
	93015	Cardiovascular stress test	20	EA
	93228	24-hour holter monitor study	15	EA
	93303	Obtain transthoracic echocardiography for congenital anomalies	10	EA
	93306	Obtain echocardiogram and color flow doppler for evaluation of murmur	350	EA
	93320	Obtain echocardiography, pulsed wave and/or continuous wave	10	EA
	93325	X-ray - Echocardiogram - Doppler color flow velocity mapping	200	EA
	93350	Obtain transthoracic echocardiography, real-time with image documentation (2D), rest/stress	5	EA
	94010	Spirometry, with or without maximal voluntary ventilation (PFT)	50	EA
	94010	Complete Exercise spirometry	50	EA
	94060	Spirometry, before and after bronchodilator (aerosol)	550	EA
	94070	Bronchoprovocation pulmonary function test	150	EA
	95004	Skin allergy testing	125	EA
	95017	Obtain skin allergy testing (intracutaneous/intradermal tests)	10	EA
	95070	Bronchial allergy test	150	EA
	95079	Obtain ingestion challenge test	125	EA
	95816	Electroencephalogram (EEG)	50	EA
	96130	Psychological testing	10	EA
	96132	Neuropsychological testing battery	10	EA
	99172	Optometric/Ophthalmogical - visual function screening - visual acuity measurements, red lens test, cover test, near point of convergence, horizontal & vertical phorias, depth perception and color vision to include PIP, Vivid Red-Green, or FALANT	700	EA
	99242	AMS Medical Consultation (CPT 99242) Report	2350	EA
	99244	AMS Medical Consultation (CPT 99244) Report	150	EA
	99245	AMS Medical Consultation (CPT 99245) Report	100	EA
	92521	Office - Consult - Evaluation by speech therapist/speech pathologist	15	EA
	J7674	Methacholine Chloride, NEB	150	EA
	TOTAL CPT CODES*

*The total for all the CPT codes shall be entered under CLIN 2006 in the Option Year 2 pricing chart above.

Option Year 3

CLIN	Description	Estimated Quantity	Unit of Issue	Price per Unit	Total Price	Period of Perforamance
3001	IME Completed Medical Examination Report	26000	EA			October 1, 2024 – September 30, 2025
3002	IME Partial Optometric Medical Examination Report (Partial Physical Exam)	1200	EA			October 1, 2024 – September 30, 2025
3003	IME Partial Clinical Medical Examination Report (Partial Physical Exam)	950	EA			October 1, 2024 – September 30, 2025
3004	IME/AMS Failure to Appear	450	EA			October 1, 2024 – September 30, 2025
3005	IME/AMS Reassignment	1800	EA			October 1, 2024 – September 30, 2025
3006	CPT Codes	1	LOT	N/A		October 1, 2024 – September 30, 2025

	CPT Codes		Estimated Quantity	Unit of Issue	Price Per Unit	Total Price
	70450	X-ray - Computed Tomography (CT) scan, head or brain; without contrast material	10	EA
	70486	X-ray - Obtain computerized axial tomography, sinuses	10	EA
	70551	Magnetic resonance imaging, brain	25	EA
	71046	Forward a radiologist's report of NEW x-ray films of chest	10	EA
	71250	CT thorax	5	EA
	71550	Obtain a new MRI of the thorax without contrast material for $ and forward a Board Certified Radiologist's interpretation of the MRI	5	EA
	72040	X-ray of spine, cervical	10	EA
	72070	X-ray exam, spine, thoracic, two views	10	EA
	72082	X-ray spine, thoracolumbar, standing (scoliosis)	25	EA
	72100	X-ray exam, spine, lumbosacral, four views	40	EA
	72125	X-ray - CT of cervical spine	5	EA
	72128	X-ray - CT of thoracic spine	5	EA
	72131	X-ray - CT of lumbar spine	10	EA
	72141	X-ray - MRI of spinal canal and contents, cervical	5	EA
	72146	X-ray - MRI of spinal canal and contents, thoracic	5	EA
	72148	X-ray - Magnetic Resonance Imaging (MRI) of spinal canal and contents, lumbar	20	EA
	72220	X-ray of sacrum and coccyx	5	EA
	73000	X-ray of clavicle, complete	5	EA
	73030	X-ray exam, shoulder, two views	10	EA
	73050	X-ray of acromioclavicular joints	5	EA
	73060	X-ray of humerus	5	EA
	73080	X-ray of elbow, complete	15	EA
	73090	X-ray of forearm	5	EA
	73110	X-ray exam, wrist, three views	10	EA
	73120	X-ray of hand	5	EA
	73140	X-ray of finger(s)	5	EA
	73502	X-ray of hip - unilateral, complete	30	EA
	73521	X-ray of hips, bilateral	10	EA
	73551	X-ray of femur (thigh)	5	EA
	73560	X-ray of knee, anteroposterior and lateral views	35	EA
	73590	X-ray of tibia and fibula	30	EA
	73610	X-ray of ankle, complete	15	EA
	73630	X-ray of foot, complete	15	EA
	73700	X-ray - CT of lower extremity	5	EA
	73721	X-ray - MRI without contrast material of lower extremity	50	EA
	74150	X-ray - Obtain a CT scan - abdomen; without contrast material	10	EA
	76536	X-ray - Echography, B-scan and/or real time soft tissues of head/neck (thyroid, parathyroid,
parotid)	10	EA
	76705	X-ray - Echography, abdominal, B-scan and/or real time	10	EA
	76770	X-ray - Echography, retroperitoneal, B-scan and/or real time	10	EA
	76775	Obtain an echography, retroperitoineal	30	EA
	76856	X-ray - Echography, pelvic	20	EA
	76870	X-ray - Echography, scrotum and contents	10	EA
	77081	X-ray - Dual Energy X-ray Absorptiometry (DEXA), bone density study	5	EA
	80048	Lab test - Basic metabolic panel	50	EA
	80061	Lab test - Lipid panel	100	EA
	80074	Lab test - Acute Hepatitis Panel	120	EA
	80076	Lab test - Hepatic function panel	40	EA
	81001	Lab test - Urinalysis with microscopy	200	EA
	81003	Lab test - Urinalysis without microscopy	15	EA
	81015	Lab test - Urinalysis, microscopy only	10	EA
	82340	Please obtain a urine calcium/creatinine ratio (calcium), via routine urine collection	20	EA
	82570	Please obtain a UP/C ratio (reatinine), via routine urin collection (add R263.07)	15	EA
	82575	Lab test - Creatinine clearance	5	EA
	82947	Please obtain a fasting glucose blood test	75	EA
	83020	Lab test - Hemoglobin electrophoresis	5	EA
	83036	Hemoglobin HbA1c (HPLC)	60	EA
	84133	Lab test - 24-hour urinary protein and volume level test	25	EA
	84156	24-hour Urine collection	15	EA
	84436	Lab test - Thyroxin, total	10	EA
	84443	Lab test - Thyroid stimulating hormone (TSH)	150	EA
	85025	Lab test - REPEAT complete blood count, automated	15	EA
	85027	Lab test - Blood count, hemogram and platelet count, automated	400	EA
	86003	Lab test - Allergen specific lgE; quantitative or semicuantitative	250	EA
	86480	Lab test - QuantiFERON - TB Gold (QFT-Gold) blood test	200	EA
	90791	Psychiatric diagnostic interview examination	550	EA
	90792	Office consultation with a mental health provider certified in drug/alcohol counseling or addiction medicine	80	EA
	92002	Optometric/Ophthalmogical consultation that does not require a dilated examination. Elements in a DoDMERB eye exam would qualify for this code - new patient ntermediate exam	10	EA
	92004	Optometric/Ophthalmogical comprehensive consultation requiring a dilated fundus exam - new patient complex exam	325	EA
	92004	Optometric/Ophthalmogical exam - manifest refraction (new or repeat)	150	EA
	92012	Optometric/Ophthalmogical consultation that does not require a dilated examination - established patient intermediate exam	250	EA
	92025	Computetized Corneal Topography with interpretation (Color)	300	EA
	92060	Optometric/Ophthalmogical - senorimotor evaluation; comprehensive strabismus evaluation with multiple measurements of ocular deviation to include a report	10	EA
	92083	Optometric/Ophthalmogical exam - extended visual field examination with automated perimetry	10	EA
	92552	Audiogram - Pure tone audiometry (threshold); air only	40	EA
	92557	Obtain a comprehensive audiometry threshold evaluation	600	EA
	92567	Obtain a Tympanometry	10	EA
	93000	Electrocardiogram, 12-lead, with interpretation & report	150	EA
	93015	Cardiovascular stress test	20	EA
	93228	24-hour holter monitor study	15	EA
	93303	Obtain transthoracic echocardiography for congenital anomalies	10	EA
	93306	Obtain echocardiogram and color flow doppler for evaluation of murmur	350	EA
	93320	Obtain echocardiography, pulsed wave and/or continuous wave	10	EA
	93325	X-ray - Echocardiogram - Doppler color flow velocity mapping	200	EA
	93350	Obtain transthoracic echocardiography, real-time with image documentation (2D), rest/stress	5	EA
	94010	Spirometry, with or without maximal voluntary ventilation (PFT)	50	EA
	94010	Complete Exercise spirometry	50	EA
	94060	Spirometry, before and after bronchodilator (aerosol)	550	EA
	94070	Bronchoprovocation pulmonary function test	150	EA
	95004	Skin allergy testing	125	EA
	95017	Obtain skin allergy testing (intracutaneous/intradermal tests)	10	EA
	95070	Bronchial allergy test	150	EA
	95079	Obtain ingestion challenge test	125	EA
	95816	Electroencephalogram (EEG)	50	EA
	96130	Psychological testing	10	EA
	96132	Neuropsychological testing battery	10	EA
	99172	Optometric/Ophthalmogical - visual function screening - visual acuity measurements, red lens test, cover test, near point of convergence, horizontal & vertical phorias, depth perception and color vision to include PIP, Vivid Red-Green, or FALANT	700	EA
	99242	AMS Medical Consultation (CPT 99242) Report	2350	EA
	99244	AMS Medical Consultation (CPT 99244) Report	150	EA
	99245	AMS Medical Consultation (CPT 99245) Report	100	EA
	92521	Office - Consult - Evaluation by speech therapist/speech pathologist	15	EA
	J7674	Methacholine Chloride, NEB	150	EA
	TOTAL CPT CODES*

*The total for all the CPT codes shall be entered under CLIN 3006 in the Option Year 3 pricing chart above.

Option Year 4

CLIN	Description	Estimated Quantity	Unit of Issue	Price per Unit	Total Price	Period of Performance
4001	IME Completed Medical Examination Report	26000	EA			October 1, 2025 – September 30, 2026
4002	IME Partial Optometric Medical Examination Report (Partial Physical Exam)	1200	EA			October 1, 2025 – September 30, 2026
4003	IME Partial Clinical Medical Examination Report (Partial Physical Exam)	950	EA			October 1, 2025 – September 30, 2026
4004	IME/AMS Failure to Appear	450	EA			October 1, 2025 – September 30, 2026
4005	IME/AMS Reassignment	1800	EA			October 1, 2025 – September 30, 2026
4006	CPT Codes	1	LOT	N/A		October 1, 2025 – September 30, 2026

	CPT Codes		Estimated Quantity	Unit of Issue	Price Per Unit	Total Price
	70450	X-ray - Computed Tomography (CT) scan, head or brain; without contrast material	10	EA
	70486	X-ray - Obtain computerized axial tomography, sinuses	10	EA
	70551	Magnetic resonance imaging, brain	25	EA
	71046	Forward a radiologist's report of NEW x-ray films of chest	10	EA
	71250	CT thorax	5	EA
	71550	Obtain a new MRI of the thorax without contrast material for $ and forward a Board Certified Radiologist's interpretation of the MRI	5	EA
	72040	X-ray of spine, cervical	10	EA
	72070	X-ray exam, spine, thoracic, two views	10	EA
	72082	X-ray spine, thoracolumbar, standing (scoliosis)	25	EA
	72100	X-ray exam, spine, lumbosacral, four views	40	EA
	72125	X-ray - CT of cervical spine	5	EA
	72128	X-ray - CT of thoracic spine	5	EA
	72131	X-ray - CT of lumbar spine	10	EA
	72141	X-ray - MRI of spinal canal and contents, cervical	5	EA
	72146	X-ray - MRI of spinal canal and contents, thoracic	5	EA
	72148	X-ray - Magnetic Resonance Imaging (MRI) of spinal canal and contents, lumbar	20	EA
	72220	X-ray of sacrum and coccyx	5	EA
	73000	X-ray of clavicle, complete	5	EA
	73030	X-ray exam, shoulder, two views	10	EA
	73050	X-ray of acromioclavicular joints	5	EA
	73060	X-ray of humerus	5	EA
	73080	X-ray of elbow, complete	15	EA
	73090	X-ray of forearm	5	EA
	73110	X-ray exam, wrist, three views	10	EA
	73120	X-ray of hand	5	EA
	73140	X-ray of finger(s)	5	EA
	73502	X-ray of hip - unilateral, complete	30	EA
	73521	X-ray of hips, bilateral	10	EA
	73551	X-ray of femur (thigh)	5	EA
	73560	X-ray of knee, anteroposterior and lateral views	35	EA
	73590	X-ray of tibia and fibula	30	EA
	73610	X-ray of ankle, complete	15	EA
	73630	X-ray of foot, complete	15	EA
	73700	X-ray - CT of lower extremity	5	EA
	73721	X-ray - MRI without contrast material of lower extremity	50	EA
	74150	X-ray - Obtain a CT scan - abdomen; without contrast material	10	EA
	76536	X-ray - Echography, B-scan and/or real time soft tissues of head/neck (thyroid, parathyroid,
parotid)	10	EA
	76705	X-ray - Echography, abdominal, B-scan and/or real time	10	EA
	76770	X-ray - Echography, retroperitoneal, B-scan and/or real time	10	EA
	76775	Obtain an echography, retroperitoineal	30	EA
	76856	X-ray - Echography, pelvic	20	EA
	76870	X-ray - Echography, scrotum and contents	10	EA
	77081	X-ray - Dual Energy X-ray Absorptiometry (DEXA), bone density study	5	EA
	80048	Lab test - Basic metabolic panel	50	EA
	80061	Lab test - Lipid panel	100	EA
	80074	Lab test - Acute Hepatitis Panel	120	EA
	80076	Lab test - Hepatic function panel	40	EA
	81001	Lab test - Urinalysis with microscopy	200	EA
	81003	Lab test - Urinalysis without microscopy	15	EA
	81015	Lab test - Urinalysis, microscopy only	10	EA
	82340	Please obtain a urine calcium/creatinine ratio (calcium), via routine urine collection	20	EA
	82570	Please obtain a UP/C ratio (reatinine), via routine urin collection (add R263.07)	15	EA
	82575	Lab test - Creatinine clearance	5	EA
	82947	Please obtain a fasting glucose blood test	75	EA
	83020	Lab test - Hemoglobin electrophoresis	5	EA
	83036	Hemoglobin HbA1c (HPLC)	60	EA
	84133	Lab test - 24-hour urinary protein and volume level test	25	EA
	84156	24-hour Urine collection	15	EA
	84436	Lab test - Thyroxin, total	10	EA
	84443	Lab test - Thyroid stimulating hormone (TSH)	150	EA
	85025	Lab test - REPEAT complete blood count, automated	15	EA
	85027	Lab test - Blood count, hemogram and platelet count, automated	400	EA
	86003	Lab test - Allergen specific lgE; quantitative or semicuantitative	250	EA
	86480	Lab test - QuantiFERON - TB Gold (QFT-Gold) blood test	200	EA
	90791	Psychiatric diagnostic interview examination	550	EA
	90792	Office consultation with a mental health provider certified in drug/alcohol counseling or addiction medicine	80	EA
	92002	Optometric/Ophthalmogical consultation that does not require a dilated examination. Elements in a DoDMERB eye exam would qualify for this code - new patient ntermediate exam	10	EA
	92004	Optometric/Ophthalmogical comprehensive consultation requiring a dilated fundus exam - new patient complex exam	325	EA
	92004	Optometric/Ophthalmogical exam - manifest refraction (new or repeat)	150	EA
	92012	Optometric/Ophthalmogical consultation that does not require a dilated examination - established patient intermediate exam	250	EA
	92025	Computetized Corneal Topography with interpretation (Color)	300	EA
	92060	Optometric/Ophthalmogical - senorimotor evaluation; comprehensive strabismus evaluation with multiple measurements of ocular deviation to include a report	10	EA
	92083	Optometric/Ophthalmogical exam - extended visual field examination with automated perimetry	10	EA
	92552	Audiogram - Pure tone audiometry (threshold); air only	40	EA
	92557	Obtain a comprehensive audiometry threshold evaluation	600	EA
	92567	Obtain a Tympanometry	10	EA
	93000	Electrocardiogram, 12-lead, with interpretation & report	150	EA
	93015	Cardiovascular stress test	20	EA
	93228	24-hour holter monitor study	15	EA
	93303	Obtain transthoracic echocardiography for congenital anomalies	10	EA
	93306	Obtain echocardiogram and color flow doppler for evaluation of murmur	350	EA
	93320	Obtain echocardiography, pulsed wave and/or continuous wave	10	EA
	93325	X-ray - Echocardiogram - Doppler color flow velocity mapping	200	EA
	93350	Obtain transthoracic echocardiography, real-time with image documentation (2D), rest/stress	5	EA
	94010	Spirometry, with or without maximal voluntary ventilation (PFT)	50	EA
	94010	Complete Exercise spirometry	50	EA
	94060	Spirometry, before and after bronchodilator (aerosol)	550	EA
	94070	Bronchoprovocation pulmonary function test	150	EA
	95004	Skin allergy testing	125	EA
	95017	Obtain skin allergy testing (intracutaneous/intradermal tests)	10	EA
	95070	Bronchial allergy test	150	EA
	95079	Obtain ingestion challenge test	125	EA
	95816	Electroencephalogram (EEG)	50	EA
	96130	Psychological testing	10	EA
	96132	Neuropsychological testing battery	10	EA
	99172	Optometric/Ophthalmogical - visual function screening - visual acuity measurements, red lens test, cover test, near point of convergence, horizontal & vertical phorias, depth perception and color vision to include PIP, Vivid Red-Green, or FALANT	700	EA
	99242	AMS Medical Consultation (CPT 99242) Report	2350	EA
	99244	AMS Medical Consultation (CPT 99244) Report	150	EA
	99245	AMS Medical Consultation (CPT 99245) Report	100	EA
	92521	Office - Consult - Evaluation by speech therapist/speech pathologist	15	EA
	J7674	Methacholine Chloride, NEB	150	EA
	TOTAL CPT CODES*

*The total for all the CPT codes shall be entered under CLIN 4006 in the Option Year 4 pricing chart above.

File details come from the government source that posted it. Updated Apr 19, 2022.