47QFWA22R0008 Appendix M - Pricing Spreadsheet.xlsx

XLSX spreadsheet 44 KB Posted Mar 29, 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 is a combined synopsis/solicitation for medical services to support the Department of Defense Medical Examination Review Board (DoDMERB). Services include providing a subcontracted network of medical providers to conduct Initial Medical Examinations and Additional Medical Services for civilian and military applicants to the five Service Academies, Reserve Officers' Training Corps programs, and other programs as required. The solicitation includes pricing tables for various medical services across a one-year base period and four one-year option periods. Offerors must submit proposals through the GSA ASSIST system by April 29, 2022 at 10:00 AM Central Time and register for a pre-proposal conference on April 5, 2022. Technical approach, previous experience, past performance, and small business participation will be evaluated, followed by price. The General Services Administration will award a contract on behalf of the Defense Health Agency to provide the required DoDMERB medical services.

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Other files for this federal contract opportunity

Other files attached to DoDMERB Medical Services, newest first.
File	Type	Posted
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 Questions and Answers 4.18.2022.xlsx	XLSX spreadsheet	Apr 19, 2022
47QFWA22R0008 Revised Appendix M - Pricing Spreadsheet 4.18.2022.xlsx	XLSX spreadsheet	Apr 19, 2022
47QFWA22R0008 Revised Solicitation Sections B-J 4.4.2022.pdf	PDF	Apr 12, 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 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
TOTAL PRICE

Base

CLIN	Description	Estimated Quantity	Unit of Issue	Price per Unit	Total Price
0001	IME Completed Medical Examination Report	26000	EA
0002	IME Partial Optometric Medical Examination Report (Partial Physical Exam)	1200	EA
0003	IME Partial Clinical Medical Examination Report (Partial Physical Exam)	950	EA
0004	IME/AMS Failure to Appear	450	EA
0005	IME/AMS Reassignment	1800	EA
0006	CPT Codes	1	LOT	N/A

	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
	71020	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
	96101	Psychological testing	10	EA
	96117	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
	99521	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
1001	IME Completed Medical Examination Report	26000	EA
1002	IME Partial Optometric Medical Examination Report (Partial Physical Exam)	1200	EA
1003	IME Partial Clinical Medical Examination Report (Partial Physical Exam)	950	EA
1004	IME/AMS Failure to Appear	450	EA
1005	IME/AMS Reassignment	1800	EA
1006	CPT Codes	1	LOT	N/A

	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
	71020	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
	96101	Psychological testing	10	EA
	96117	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
	99521	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
2001	IME Completed Medical Examination Report	26000	EA
2002	IME Partial Optometric Medical Examination Report (Partial Physical Exam)	1200	EA
2003	IME Partial Clinical Medical Examination Report (Partial Physical Exam)	950	EA
2004	IME/AMS Failure to Appear	450	EA
2005	IME/AMS Reassignment	1800	EA
2006	CPT Codes	1	LOT	N/A

	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
	71020	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
	96101	Psychological testing	10	EA
	96117	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
	99521	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
3001	IME Completed Medical Examination Report	26000	EA
3002	IME Partial Optometric Medical Examination Report (Partial Physical Exam)	1200	EA
3003	IME Partial Clinical Medical Examination Report (Partial Physical Exam)	950	EA
3004	IME/AMS Failure to Appear	450	EA
3005	IME/AMS Reassignment	1800	EA
3006	CPT Codes	1	LOT	N/A

	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
	71020	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
	96101	Psychological testing	10	EA
	96117	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
	99521	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
4001	IME Completed Medical Examination Report	26000	EA
4002	IME Partial Optometric Medical Examination Report (Partial Physical Exam)	1200	EA
4003	IME Partial Clinical Medical Examination Report (Partial Physical Exam)	950	EA
4004	IME/AMS Failure to Appear	450	EA
4005	IME/AMS Reassignment	1800	EA
4006	CPT Codes	1	LOT	N/A

	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
	71020	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
	96101	Psychological testing	10	EA
	96117	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
	99521	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 Mar 29, 2022.