Attachment C - Price Sheet - Pages 1-3.xlsx

XLSX spreadsheet 15 KB Posted

Attached to
Referral Lab Testing for CLSH-LDH
Solicitation number
3000026810
Issued by
East Baton Rouge Parish, Baton Rouge City, Louisiana

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Attachment C - Price Sheet for Referral Lab Testing for CLSH-LDH

This is a price sheet for referral laboratory testing services related to CLSH-LDH (Collaborative Laboratory for State Health-Laboratory Development and Health) in Louisiana. The document establishes pricing for laboratory testing services that will be provided to the state under the contract opportunity. The price sheet outlines the cost structure for various laboratory tests and services that the selected vendor will deliver as part of the referral lab testing program. The document serves as the financial component of the bid submission, requiring vendors to populate pricing information according to specified line items and testing categories detailed in the sheet.

The price sheet format allows vendors to propose their costs for the defined scope of laboratory testing services. Pricing terms would establish the financial obligations and payment structure between the state of Louisiana and the awarded vendor. This attachment is essential for evaluating vendor proposals on a cost basis and comparing the financial competitiveness of different bidders submitting responses to the referral lab testing opportunity.

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Table 1 Attachment C - Price Sheet RFx # 3000026810 - Referral Lab Testing for CLSH-LDH

line #Test NameUOMCPT CodeTest CodePriceTurn Around Time
1Comprehensive Metabolic Panel
to include the following tests: Albumin, Calcium, Carbon Dioxide, Chloride, ALT, AST, BUN:Creatinine Ratio, Creatinine with GFR Estimated, Globulin, Glucose, Potassium, Sodium, Total Protein, Urea Nitrogen, Alkaline Phosphatase, Albumin:Globulin Ratio, Total BilirubinEA800539179
2Basic Metabolic Panel
to include the following tests: BUN, Calcium, BUN:Creatinine Ratio, Creatinine with GFR Estimated, Glucose, Potassium, Sodium, Chloride, Carbon DioxideEA80048142
3Hepatic Function Panel
to include the following tests: Total Protein, Albumin, Globulin, Total Bilirubin, Direct Bilirubin, Indirect Bilirubin, Albumin: Globulin Ratio, Alkaline Phosphatase, AST, ALTEA800769175
4Valproic Acid (Depakote®), serumEA801643094
5Lithium (Eskalith®), serumEA801782128
6Rapid Plasma Reagin (RPR), Qualitative Test or VDRLEA865923500
7ProlactinEA841462800
8Thyroid‐Stimulating Hormone (TSH)EA844432835
9Thyroxine (T4), Free, DirectEA844392823
10Urinalysis, Routine (random)EA810031501
11Carbamazepine, serumEA801563025
12HIV‐1/O/2 Antibodies, Preliminary Test with ConfirmationEA867033540
13Triiodothyronine (T3), FreeEA844814273
14Lipid Panel
to include the following tests: Total Cholesterol, HDL Cholesterol, Triglycerides, LDL Cholesterol (calculated)EA80061173
15Thyroid Panel with TSH
to include the following tests: T3 uptake (THBR), Free Thyroxine Index, Thyroxine (T4), Thyroid‐ Stimulating Hormone (TSH)EA84436,

8444,

84479119
16Thyroxine(T4)EA844362819
17Hemoglobin (Hb) A1CEA830362708
18Pregnancy Test UrineEA810251540
19Complete Blood Count (CBC) with Differential and Platelet CountEA850251000
20Vitamin B12 and FolateEA82607,
827462955
21T3 Uptake (THBR)EA844792817
22Lipase, serumEA836902124
23Triiodothyronine (T3)EA844802818
24Testosterone, Total, serumEA844032830
25Amylase, serumEA821502025
26Folate (Folic Acid), serumEA827462695
27Urine Culture, RoutineEA870866049
28Sedimentation Rate, Modified WestergrenEA856521055
29Prothrombin Time (PT) with INREA856101425
30Ferritin, serumEA827282090
31Vitamin B12EA826072840
32Carcinoembryonic Antigen (CEA)EA823782645
33Prostate‐Specific Antigen (PSA), Serial MonitorEA841532606
34Hepatitis B Surface Antibodies, QualitativeEA867062737
35Ammonia, plasmaEA821402020
36Phenytoin (Dilantin®), serumEA801853064
37Clozapine (Clozaril®), serumEA801595825
38OxcarbazepineEA801835239
39Vitamin D, 25‐HydroxyEA823064958
40Prothrombin Time and Partial Thromboplastin Time (PT
& PTT)EA85610,
857301401
41Acute Hepatitis Panel, to include the following tests: Hepatitis B Core Antibody, IgM; Hepatitis B Surface Antigen, Hepatitis C Antibody; Hepatitis A Antibody, IgMEA800749325
42Testosterone, Free, Direct with Total TestosteroneEA84402,
844034937
43Thyroid‐stimulating Hormone (TSH) and Free T4EA84439,
844432836
44Carcinoembryonic Antigen (CEA), Serial MonitorEA823782645
45Phenytoin (Dilantin®), Free and Total, serumEA80185,
801865940
46Blood Culture, RoutineEA870406013
47Glucose, plasma serumEA829472217
48Hep B Virus (HBV)*EA875174286
49Hep B Core Antibody, IgM*EA867054644
50HGB, serum (Sickle Cell Screen)EA856603520
51CBC w/Diff (no Platelet)EA85004,

85014, 85018, 85041,

850481000
52ManganeseEA837854243
53Varicella IggEA867874665
54ANA with reflex titerEA860383550
55ANA w/Reflex if Positive (reflex to mult cpt)EA860383550
56Hepatitis Panel, to include the following tests: HBcAb, HBsAb, Ag, HCVAbEA800749325
57Chain‐of‐Custody Protocol, SpecimenEA99199
58Stat Testing ‐ As needed/requested ‐ Vendor must contact Agency by telephone upon completion of request within 3 hours of receiving testEA923
59Draw Fee (Venipuncture) ‐ As needed/requestedEA

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