47QFWA22R0008 Revised Appendix M - Pricing Spreadsheet.xlsx
XLSX spreadsheet 45 KB Posted
- Attached to
- DoDMERB Medical Services Federal contract opportunity
- Solicitation number
- 47QFWA22R0008
About this file
This solicitation requests proposals for Department of Defense Medical Examination Review Board medical services. The General Services Administration will award a one-year base contract with four one-year options to provide initial medical examinations, additional medical services, and connectivity between DoDMERB, applicants, and medical providers. Services support applicant qualification determinations for military and government programs. Offerors must register in GSA ASSIST and submit pricing, technical approach, experience, past performance, and small business participation plans by April 29 for evaluation. The solicitation involves over 30 clinical procedure codes and estimated quantities. It advises of pre-proposal and question deadlines and requires electronic payment and security safeguards.
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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 | 26000 | EA | July 1, 2022 - May 16, 2023 | ||
| 0002 | IME Partial Optometric Medical Examination Report (Partial Physical Exam) | 1200 | EA | July 1, 2022 - May 16, 2023 | ||
| 0003 | IME Partial Clinical Medical Examination Report (Partial Physical Exam) | 950 | EA | July 1, 2022 - May 16, 2023 | ||
| 0004 | IME/AMS Failure to Appear | 450 | EA | July 1, 2022 - May 16, 2023 | ||
| 0005 | IME/AMS Reassignment | 1800 | EA | July 1, 2022 - May 16, 2023 | ||
| 0006 | CPT Codes | 1 | LOT | N/A | July 1, 2022 - May 16, 2023 | |
| 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 | 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 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 | May 17, 2023 – May 16, 2024 | ||
| 1002 | IME Partial Optometric Medical Examination Report (Partial Physical Exam) | 1200 | EA | May 17, 2023 – May 16, 2024 | ||
| 1003 | IME Partial Clinical Medical Examination Report (Partial Physical Exam) | 950 | EA | May 17, 2023 – May 16, 2024 | ||
| 1004 | IME/AMS Failure to Appear | 450 | EA | May 17, 2023 – May 16, 2024 | ||
| 1005 | IME/AMS Reassignment | 1800 | EA | May 17, 2023 – May 16, 2024 | ||
| 1006 | CPT Codes | 1 | LOT | N/A | May 17, 2023 – May 16, 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 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 | May 17, 2024 – May 16, 2025 | ||
| 2002 | IME Partial Optometric Medical Examination Report (Partial Physical Exam) | 1200 | EA | May 17, 2024 – May 16, 2025 | ||
| 2003 | IME Partial Clinical Medical Examination Report (Partial Physical Exam) | 950 | EA | May 17, 2024 – May 16, 2025 | ||
| 2004 | IME/AMS Failure to Appear | 450 | EA | May 17, 2024 – May 16, 2025 | ||
| 2005 | IME/AMS Reassignment | 1800 | EA | May 17, 2024 – May 16, 2025 | ||
| 2006 | CPT Codes | 1 | LOT | N/A | May 17, 2024 – May 16, 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 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 | May 17, 2025 – May 16, 2026 | ||
| 3002 | IME Partial Optometric Medical Examination Report (Partial Physical Exam) | 1200 | EA | May 17, 2025 – May 16, 2026 | ||
| 3003 | IME Partial Clinical Medical Examination Report (Partial Physical Exam) | 950 | EA | May 17, 2025 – May 16, 2026 | ||
| 3004 | IME/AMS Failure to Appear | 450 | EA | May 17, 2025 – May 16, 2026 | ||
| 3005 | IME/AMS Reassignment | 1800 | EA | May 17, 2025 – May 16, 2026 | ||
| 3006 | CPT Codes | 1 | LOT | N/A | May 17, 2025 – May 16, 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 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 | May 17, 2026 – May 16, 2027 | ||
| 4002 | IME Partial Optometric Medical Examination Report (Partial Physical Exam) | 1200 | EA | May 17, 2026 – May 16, 2027 | ||
| 4003 | IME Partial Clinical Medical Examination Report (Partial Physical Exam) | 950 | EA | May 17, 2026 – May 16, 2027 | ||
| 4004 | IME/AMS Failure to Appear | 450 | EA | May 17, 2026 – May 16, 2027 | ||
| 4005 | IME/AMS Reassignment | 1800 | EA | May 17, 2026 – May 16, 2027 | ||
| 4006 | CPT Codes | 1 | LOT | N/A | May 17, 2026 – May 16, 2027 |
| 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 .