Attachment E_Pricing Sheet_RHRP Services.xlsx

XLSX spreadsheet 306 KB Posted

Attached to
Remote Health Readiness Program 4 (RHRP-4) Federal contract opportunity
Solicitation number
HT001125R0020
Issued by
Defense Health Agency

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Written by GovTribe AI ·

This is a pricing spreadsheet template for the Remote Health Readiness Program 4th Generation (RHRP-4) contract, detailing all medical and dental procedures, laboratory services, immunizations, and other health services to be provided. The spreadsheet breaks down pricing across three delivery modalities - in-clinic, virtual, and group events - with projected annual quantities for each service. Services include physical exams, occupational health screenings, assessments, audiology, optometry, immunizations, laboratory work, dental procedures, and miscellaneous fees like cancellations and no-shows.

The template includes tabs for base period and nine option years, plus tabs for shipping/travel costs (with not-to-exceed amounts ranging from $12.3M for base period to $31.3M for option year 9) and transition-in CLIN pricing. For group events, the template allows for tiered volume discounts based on number of personnel (Tier I: 1-100, Tier II: 101-250, Tier III: 251-500, Tier IV: 501+). Each medical service is identified with its corresponding CPT, ICD-10, HCPCS or CDT code, with minimum quantity requirements specified for certain procedures. The pricing structure requires offerors to provide all-inclusive/fully-loaded firm-fixed unit prices for each procedure across all delivery modalities.

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Other files attached to Remote Health Readiness Program 4 (RHRP-4), newest first.
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SF-30 Amendment 0008 HT001125R0020.pdf PDF
SF-30 Amendment 0007 HT001125R0020.pdf PDF
Attachment E_Pricing Sheet_RHRP Services_4.21.25.xlsx XLSX spreadsheet
Attachment E_Pricing Sheet_RHRP Services_4.17.25.xlsx XLSX spreadsheet
SF-30 Amendment 0004 HT001125R0020.pdf PDF
52.212-1_2.28.25_v3.docx DOCX document
SF-30 Amendment 0003 HT001125R0020.pdf PDF
Attachment G_RFP Proposal Worksheetv3.xlsx XLSX spreadsheet
A010_Data_Infringement_Notification.pdf PDF
A050_Credential_Audit_Corrective_Action_Plan.pdf PDF
A110_Appointment_Cancellation_Notice.pdf PDF
A090_Call_and_Chat_Data_Report.pdf PDF
Exhibit H_Service Appointment RequestV2.docx DOCX document
Exhibit F1_ SM location by ZipCode 20250304.xlsx XLSX spreadsheet
Attachment E_Pricing Sheet_RHRP Services_3.7.25.xlsx XLSX spreadsheet
Exhibit Q_DRC Data Flow 2024.pdf PDF
Exhibit R_Call Data.pdf PDF
Exhibit S_RHRP Customer Concern Form (2025).docx DOCX document
A070_DEERS_SM_Eligibility_Checks.pdf PDF
Exhibit E2_Emergency Notification FlowV2.pdf PDF
Exhibit T_RHRP-DP_Services_Supplement 2025V2.docx DOCX document
SF-30 Amendment 0002 HT0011-25-R-0020.pdf PDF
A040_Vendor_Network_Provider_Directory.pdf PDF
A120_Abnormal_Diagnostic_Procedure_Result_Notice.pdf PDF
A100_Readiness_Service_Results_by_SM.pdf PDF
Attachment F_RFP_RHRP4_QA form_Responses_4.2.25.pdf PDF
Attachment A_Performance Based Milestone Payment.pdf PDF
Attachment B_RHRP-4 Group Event Weekend Scenario.xlsx XLSX spreadsheet
Attachment C_Small Business Commitment RHRP4.docx DOCX document
Attachment D_HT0011-R-25-0020 RHRP4 PPQ.docx DOCX document
Exhibit A_RHRP-3 Systems Map.pdf PDF
Exhibit B1_RHRP Services.xlsx XLSX spreadsheet
Exhibit C1_Group Event Location Data.xlsx XLSX spreadsheet
Exhibit H_Service Appointment Request.docx DOCX document
Exhibit I_GE Planning Template.pdf PDF
Exhibit K_DA Form 3024 - PHA.pdf PDF
ATTACHMENT G_SCA_Wage-Determination.pdf PDF
Exhibit G_User Roles.pdf PDF
Exhibit N_DNA Collection Instructions.pdf PDF
Exhibit P_Optometry Data Flow.pptx PPTX presentation
Exhibit S_RHRP Customer Concern Form (5-2023).pdf PDF
HT001125R0020 RHRP4 RFP.pdf PDF
Attachment F_RFP_RHRP4_QA form.xlsx XLSX spreadsheet
Exhibit E1_Incident Report.docx DOCX document
Exhibit E2_Emergency Notification Flow.pdf PDF
Exhibit F3_RHRP-2 FY22 Services by Modality State Zip.xlsx XLSX spreadsheet
Exhibit J_PHA Flow.pdf PDF
Exhibit M_HIV Provider Testing Key Resources.pdf PDF
Exhibit T_RHRP-DP_Services_Supplement 2025.docx DOCX document
Exhibit XX_DHA CAC Request Process.pdf PDF
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Pricing Instructions

The Contractor shall input information into the yellow colored cells on each Tab. See special instructions for Shipping and Travel Tab below.
Price Per Procedure (in the Services tabs): For the In-clinic, Virtual, and Group Event modalities, the Offeror shall provide all-inclusive/fully-loaded firm-fixed unit prices, for each identified procedure, in the appropriate cells in each of the Services Tabs (e.g., Services_BasePd, Services_OptYr1, etc.). See the Addendum to FAR 52.212-1, Volume 5 - Price instructions for further information about the meaning of all-inclusive/fully-loaded procedure pricing. The Government has provided estimated quantities for each procedure at all of the Services Tabs. The estimated quantities for the base year (Services_BasePd Tab) assume a 6 month base period of performance (to ensure consistency in evaluation).
Group Event Tiers: For the purpose of potentially applying volume discount pricing to procedures delivered at Group Events, the Group Events will be organized into Tiers based on the size of the Group Event (# of Service Members who receive services at the Event--see Descriptions below) as follows: Tier I, Tier II, Tier III, and Tier IV. Offerors may propose, in the identified cells at the Services BasePd Tab, discount percentages applicable to Tiers II, III, and IV. Any discount proposed for a specified Tier will apply to all procedures delivered at Group Events in that TIER--except the discount will not apply to No-Show Fees, Cancellation Fees, and Swap-out Fees. Although the Offeror will enter any discounts on the Services_BasePd Tab, the discounts proposed will apply to the entire period of performance of the contract and its task orders. (As noted elsewhere, shipping and travel will be paid under the Shipping and Travel CLIN on a cost reimbursable basis. Any Tier-based pricing discounts will not apply to shipping and travel.) The Offeror's proposed volume discounts, if any, will not be factored into the Offeror's proposed price (total evaluated price) for evaluation purposes. See the Addendum to FAR 52.212-1, Volume 5 - Price instructions for explanation on how the Government will evaluate any offered discounts.
TIERGROUP EVENT DESCRIPTION
Tier I1-100 Personnel
Tier IITier II, 101-250 Personnel
Tier IIITier III, 251-500 Personnel
Tier IVTier IV, 501+ Personnel

Shipping and Travel Tab: NTE amounts listed in column B are for the COST CLINs only and do not require offeror input. (Note that the base year Shipping and Travel NTE amount assumes a 6 month base year period of performance.)

Transition In CLIN Tab - Pricing: The Offeror shall enter its proposed overall FFP transition-in price for CLIN 0001 in the appropriate cell. Upon entering its overall proposed Transition-In price, the SLIN prices (by identified percentages) will automatically populate in the other column F cells. The SLINs align with the milestone activities outlined in Attachment A_ Performance Based Milestone Payment Schedule.

Services_BasePd Remote Health Readiness Program 4th Generation (RHRP-4) Legend: ICD-10 code: Patient diagnosis or medical condition CPT code: medical services or procedures performed HCPCS (Healthcare Common Procedure Coding System) Code: broader Medicare/Medicaid billing for CPT and specific supplies and services not covered by CPT Current Procedural Terminology (CPT) & Current Dental Terminology (CDT) Codes

X = Procedure/Modality Needed
Readiness Services Pricing Sheet - as of 31 January 2025Modality Not Needed for this Procedure/Not Applicable
ProcedureModalityMin Qty RequiredTotal Cost: Multiply Qty Times Rate
(Columns C, E, G)Notes and Additional Instructions
In-clinicIn-clinic Price Per ServiceProjected QTY/Year (In-Clinic)VirtualVirtual Price Per ServiceProjected QTY/Year (Virtual)Group EventGroup Event Price Per ServiceProjected QTY/Year (GE)Group Event Tier Discount %per scheduled Group Event (per day)
PHYSICAL EXAM (Includes Labs, Immunizations, and Focused Exams (Audiology, Cardiology) as Required)
Retention Exam (Army and Air Force)X$ - 07.00Tier I _____%$ - 099204Evaluation and Management (E/M), Office/outpatient, new, 45-59 minutes
Accession Exam (Army)X$ - 0406.00Tier II _____%$ - 099204see above
Separation Health Assessment (SHA) DD Form 3146 formerly Separation History and Physical Exam (SHPE) DD Form 2870 (w/ Hep C antigens and Annual Hearing Test)X$ - 0414.00X$ - 01,771.00Tier III _____%15$ - 099420DOD0222 (I/CD-10)
Cardiovascular Screening Program (CVSP) - (Blood Pressure, Fasting Lipid Profile, EKG, Fasting Glucose, Height and Weight)X$ - 0448.00X$ - 01,299.00Tier IV _____%25$ - 0see elements below - with PHA or DRHA
OCCUPATIONAL
Airborne examX$ - 0174.00$ - 099204see above
Occupational Health Examination (Labs and tests will be determined by exposure concerns and ordered individually)X$ - 0123.00X$ - 08.0015$ - 099499
- Baseline$ - 0DOD0214ICD-10 code
- Periodic$ - 0DOD0215ICD-10 code
- Termination$ - 0DOD0216ICD-10 code
Firefighter / CBRN examX$ - 03.00$ - 099204see above
MISCELLANEOUS EXAMS & PROCEDURES
Clinical breast examX$ - 01.00$ - 099211G0101 (w/ pelvic exam)
12-lead Electrocardiogram (ECG), restingX$ - 0257.00$ - 093010
Preventive exam (pelvic)/vaginal examX$ - 01.00$ - 099459
Rectal examX$ - 01.00$ - 0G0102HCPCS code
SpirometryX$ - 012.00$ - 094010
Valsalva test (part of Airborne exam)X$ - 01.00$ - 095921
Chest x-ray, B-readX$ - 01.00$ - 0provider service to read the xray
Chest x-ray, posterior-anterior and lateral viewsX$ - 033.00$ - 071046
MammographyX$ - 02.00$ - 077067
ASSESSMENTS
Periodic Health Assessment (PHA) DD Form 3024
DoD PHA (Part C1) Mental Health Portion OnlyX$ - 01.00X$ - 014,339.00X$ - 015.0030$ - 090792
DoD PHA (Part C2) Provider Portion w/o Mental Health OnlyX$ - 01.00X$ - 01.00X$ - 015.0030$ - 099202CPT E/M, Office/outpatient, New, 15-29 min
DoD PHA (Parts C1, C2) Provider Portion CompleteX$ - 01.00X$ - 01.00X$ - 015.0030$ - 090203above codes (90792/99202) cannot be combined, 90203 represents 30-45 min exam to accomodate the BH time.
DoD PHA (Parts B, C2) Record Review and Provider w/o Mental HealthX$ - 079.00X$ - 091,361.00X$ - 015.0030$ - 099202
DoD PHA (Parts B, C1, C2) Complete PHAX$ - 041,899.00X$ - 06,693.00X$ - 043,578.0030$ - 0DOD0225ICD-10 code
DEPLOYMENT RELATED HEALTH ASSESSMENTS (DRHA)
Pre-Deployment Health Assessment (Pre-DHA) DD Form 2795X$ - 01.00X$ - 01.00X$ - 021.0030$ - 0DOD0211ICD-10 code
Post-Deployment Health Assessment (PDHA) DD Form 2796X$ - 01.00X$ - 01.00X$ - 015.0030$ - 0DOD0212ICD-10 code
Post-Deployment Health Re-Assessment (PDHRA) DD Form 2900X$ - 01.00X$ - 09,447.00X$ - 0497.0030$ - 0DOD0213ICD-10 code
Mental Health Assessment (MHA) DD Form 2978X$ - 01.00X$ - 01.00X$ - 015.0030$ - 090792same as PHA, Part C1 above
Miscellaneous Assessments
Tuberculosis (TB) Risk Assessment Tool, AdministrationX$ - 01.00X$ - 01.00X$ - 01,764.00$ - 096127simple questionaire review - NAVMED 6224/7, Army MEDCOM Form 831
Neuropsychological AssessmentsX$ - 01.00X$ - 01.00$ - 096132
AUDIOLOGY
Annual Hearing Test (Includes Tympanic Visualization and Cerumen Removal as required)X$ - 02,365.00X$ - 07,241.0050$ - 092552
Comprehensive Audiometric Evaluation (CAE) (Includes pure tone air and bone conduction testing as required)X$ - 01,720.00X$ - 01,080.0025$ - 092557
Military Operational Hearing Test (MOHT)X$ - 01.00X$ - 01.00$ - 092700unlisted otorhinolaryngological procedure
Speech Recognition in Noise Test (SPRINT) being deprecated, replaced by MOHTX$ - 02,062.00$ - 092700unlisted otorhinolaryngological procedure
Cerumen impaction removalX$ - 01.00X$ - 01.00$ - 069210 or 69209instruments or lavage
Consultation w/ OtolaryngologistX$ - 01.00$ - 099203
OPTOMETRY
Vision Screen (with Color Vision Deficiency screening as required)X$ - 07,691.00X$ - 02,132.0030$ - 099173
Comprehensive Eye Exam with Refraction and PrescriptionX$ - 0880.00X$ - 017.0050$ - 092004
Color Vision Deficiency (CVD) screening (Red-green); Army (Titmus V4 or Pseudoisochromatic Plates #2 (PIP#2)), Maritime (PIP#2 or Cone Contrast Test (CCT)), Air Force (PIP#2 or CCT).X$ - 04,120.00X$ - 06,139.00$ - 092283
TonometryX$ - 01.00$ - 0Provided within the CEE, consider deleting - change the PE to require a CEE
IMMUNIZATIONS (Age Appropriate and Related Labs) - not to exceed CHAMPUS Maximum Allowable Charge acceptable rate
Procedures
Administration of vaccineX$ - 01.00X$ - 07,289.0060$ - 096372
Phlebotomy and sample submissionX$ - 01.00X$ - 015.0030$ - 036415see lab below for duplicate - 2nd to having titers (labs) in the IMMs group for clarity.
Purified Protein Derivative (PPD) Test for Tuberculosis (TB), administration and read at 48-72 hoursX$ - 06.00X$ - 0236.0060$ - 086580/ 99499placement/read
Urine Pregnancy (inclusive of any vaccination that requires it)$ - 081025Not priced separately - but included in cost of vaccinations, needed as part of the vaccinations that require it.
Routine Adult
COVID-19X$ - 01.00X$ - 01.00$ - 090480
Hepatitis A (2 dose series)X$ - 02,089.00X$ - 013.00$ - 090632priced per dose
Hepatitis B (1 or 2 doses)X$ - 02,124.00X$ - 01,749.00$ - 0G0010priced per dose, mutiple options
Hepatitis A & B Combination - TWINRIX (3 dose series)X$ - 07.00X$ - 01.00$ - 090636priced per dose
Influenza, Northern HemisphereX$ - 029,768.00X$ - 0899.00$ - 0multiple
Measles, Mumps, Rubella (MMR)X$ - 0220.00X$ - 0998.00$ - 090707
MMR titer - labX$ - 08.00X$ - 028.00$ - 0multiple86735; 86762; 86765
Measles, Rubella titer - labX$ - 01.00X$ - 01.00$ - 0see above
MeningococcalX$ - 049.00X$ - 01.00$ - 0multiple
PneumococcalX$ - 01.00X$ - 01.00$ - 0multiple
PolioX$ - 0292.00X$ - 0133.00$ - 090713
Tetanus, Diphtheria and Pertussis (Tdap)X$ - 0597.00X$ - 0388.00$ - 090715
Tetanus and Diphtheria (Td)X$ - 02,686.00X$ - 0285.00$ - 090714
Varicella (chickenpox)X$ - 01,176.00X$ - 077.00$ - 090716
Varicella-zoster virus (VZV) titer - labX$ - 05.00X$ - 01.00$ - 086787
Deployment Related
Anthrax (6 shot series) (Government provided)X$ - 01.00X$ - 02,335.00$ - 090581
Influenza, Southern HemisphereX$ - 01.00X$ - 01.00$ - 0multiple
Japanese Encephalitis (JEV)X$ - 046.00X$ - 01.00$ - 090738
Rabies (3 dose series)X$ - 067.00X$ - 015.00$ - 090471per dose
Rabies titer - labX$ - 01.00X$ - 01.00$ - 086382
Tick-Borne EncephalitisX$ - 01.00X$ - 01.00$ - 090626/90627dose dependant (0.25ml/0.5ml)
TyphoidX$ - 0222.00X$ - 0283.00$ - 0multiple
Yellow Fever (Government provided)X$ - 01.00X$ - 01.00$ - 090717
LABORATORY SERVICES
Procedures
Phlebotomy (blood draw) and sample submissionX$ - 059,411.00X$ - 04,721.0030$ - 036415
Stool collectionX$ - 01.00$ - 0considered integral to any stool test
Urine collectionX$ - 01.00X$ - 08.0015$ - 0P9615HCPCS code
Readiness/Deployment Support
ABO Grouping and Rho(D) Typing (Blood type), bloodX$ - 0572.00X$ - 027.00$ - 086900
Sexually Transmitted Infections (STI) Profile w/ Chlamydia, Gonorrhea, serum and swab or urineX$ - 01.00$ - 0multiple87491, 87591-3, 87801
DNA test, blood - (Government collection card)X$ - 0246.00X$ - 01.00$ - 0
Glucose, blood, fastingX$ - 01.00X$ - 01.00$ - 082947
Glucose-6-phosphate dehydrogenase (G6PD), bloodX$ - 03,275.00X$ - 04,349.00$ - 082955
Human immuno virus (HIV), blood (Government testing)X$ - 028,055.00X$ - 01.00$ - 0
Human immuno virus (HIV), blood (Commercial testing)X$ - 01.00X$ - 01.00$ - 0multiple
Lipid panel, blood, fastingX$ - 01.00X$ - 01.00$ - 080061
Cholesterol, total, bloodX$ - 01.00X$ - 01.00$ - 082465only billable if Lipid panel is not performed
High-density lipoprotein (HDL) cholesterol, blood$ - 0
Low-density lipoprotein (LDL) cholesterol, blood$ - 0
Very low-density lipoprotein (VLDL) cholesterol, blood$ - 0
Triglycerides, blood$ - 0
Pregnancy (hCG), urineX$ - 03.00X$ - 04,771.00$ - 081025see same test in Immunizations - not chargable above
Prostate-specific antigen (PSA), bloodX$ - 01.00X$ - 01.00$ - 084153
Sickle cell screen w/ reflex to hemoglobinopathy evaluationX$ - 023,019.00X$ - 038.00$ - 085660
Physical Exam Support
Complete Blood Count (CBC), bloodX$ - 086.00X$ - 01.00$ - 085027
Red blood cell (RBC), blood$ - 0
Hemoglobin (Hb), bloodX$ - 01.00X$ - 01.00$ - 085018only billable if CBC is not performed
Hematocrit (Hct), bloodX$ - 01.00X$ - 01.00$ - 085014only billable if CBC is not performed
White blood cell (WBC), blood$ - 0
Platelets, blood$ - 0
Complete Blood Count (CBC) w/ differential, reflex to peripheral smear review, bloodX$ - 032.00X$ - 01.00$ - 085025
Comprehensive Metabolic Panel (CMP), 14 tests, bloodX$ - 0119.00X$ - 01.00$ - 080053
Glucose, blood, non-fasting$ - 0
Calcium, blood$ - 0
Sodium, potassium, bicarbonate and chloride, blood$ - 0
Albumin, bloodX$ - 01.00$ - 082040only billable if CMP is not performed
Total protein, blood$ - 0
Alkaline phosphate (ALP), Alanine transaminase (ALT), and Aspartate aminotransferase (AST), blood$ - 0
Bilirubin, blood$ - 0
Blood Urea Nitrogen (BUN)X$ - 01.00$ - 084520only billable if CMP is not performed
Creatinine, bloodX$ - 01.00$ - 082565only billable if CMP is not performed
Drug Screen, urine (13-drug)X$ - 01.00X$ - 01.00$ - 080306
Alcohol test, urineX$ - 01.00X$ - 01.00$ - 080307
Neisseria Gonorrhoeae (NG), NAA urineX$ - 01.00X$ - 01.00$ - 087591
Hepatitis C Virus (HCV) antibody w/ reflex to quantitative real-time PCR, bloodX$ - 0228.00X$ - 01.00$ - 086803 (86804)
Fecal-occult blood test (e.g., guiac), fecesX$ - 01.00X$ - 01.00$ - 082270
Fecal-occult blood test (Colorectal cander Screening), fecesX$ - 01.00X$ - 01.00$ - 082274
Rapid Plasma Reagin (RPR), bloodX$ - 01.00X$ - 01.00$ - 086592
Pap smear,X$ - 011.00X$ - 01.00$ - 088164 or 88142conventional or liquid base
Urinalysis, complete with reflex microscope as requiredX$ - 0118.00X$ - 01.00$ - 081001
Toxicology (Occupational Health)
Benzene, bloodX$ - 01.00$ - 084600
Beta-2 microglobulin (B2M), urineX$ - 01.00$ - 082232
Cadmium, blood or urineX$ - 01.00$ - 082300same code for blood or urine
Cholinesterase, plasma/serumX$ - 01.00$ - 082480
Gamma-glutamyl transferase (GGT), bloodX$ - 01.00$ - 082977
Lactate dehydrogenase (LDH), bloodX$ - 01.00$ - 083615
Lead, bloodX$ - 033.00$ - 083655
Bilirubin, total, bloodX$ - 01.00$ - 082247
Aromatic Solvents, bloodX$ - 01.00$ - 084600
Zinc Protoporphyrin (ZPP), bloodX$ - 034.00$ - 084202
DENTAL READINESS
Comprehensive oral evaluation [Annual Dental Exam]X$ - 044,315.00X$ - 096,457.0050$ - 0D0150
Dental Radiology, Standard
Bitewing, single radiographic imageX$ - 09.00X$ - 010.0020*$ - 0D0270*Minimum quantity is an aggregate amount of all bitewings. (20 bitewings total minimum)
Bitewing, two radiographic imagesX$ - 0186.00X$ - 010.0020*$ - 0D0272*Minimum quantity is an aggregate amount of all bitewings. (20 bitewings total minimum)
Bitewing, three radiographic imagesX$ - 08.00X$ - 010.0020*$ - 0D0273*Minimum quantity is an aggregate amount of all bitewings. (20 bitewings total minimum)
Bitewing, four radiographic imagesX$ - 04,425.00X$ - 018,224.0020*$ - 0D0274*Minimum quantity is an aggregate amount of all bitewings. (20 bitewings total minimum)
Panographic radiographic imageX$ - 03,124.00X$ - 0536.0020$ - 0D0330
DENTAL TREATMENT
Diagnostic Services
Limited oral evaluation - problem focusedX$ - 01.00X$ - 01.00$ - 0D0140
Intraoral - comprehensive series of radiographic imagesX$ - 01.00X$ - 01.00$ - 0D0210
Intraoral - periabical first radiolgraphic imageX$ - 01.00X$ - 01.00$ - 0D0220
Intraoral - periapical each additional radiographic imageX$ - 03,061.00X$ - 01.00$ - 0D0230
Cone beam CT image capture with limited field of view - less than one whole jawX$ - 014.00$ - 0D0380
Cone beam CT image capture with field of view of one full dental arch - mandibleX$ - 023.00$ - 0D0381
Cone beam CT image capture with field of view of one full dental arch - maxilla with or without craniumX$ - 01.00$ - 0D0382
Restorative Services
Amalgam - one surface, primary or permanentX$ - 0232.00X$ - 01.00$ - 0D2140
Amalgam - two surfaces, primary or permanentX$ - 08.00X$ - 01.00$ - 0D2150
Amalgam - three surfaces, primary or permanentX$ - 0277.00X$ - 01.00$ - 0D2160
Amalgam - four or more surfaces, primary or permanentX$ - 072.00X$ - 01.00$ - 0D2161
Resin-based composite, one surface, anteriorX$ - 0337.00X$ - 01.00$ - 0D2330
Resin-based composite, two surfaces, anteriorX$ - 0363.00X$ - 01.00$ - 0D2331
Resin-based composite, three surfaces, anteriorX$ - 063.00X$ - 01.00$ - 0D2332
Resin-based composite, four or more surfaces or involving incisal angle (anterior)X$ - 0414.00X$ - 01.00$ - 0D2335
Resin-based composite, one surface, posteriorX$ - 082.00X$ - 01.00$ - 0D2391
Resin-based composite, two surfaces, posteriorX$ - 0200.00X$ - 01.00$ - 0D2392
Resin-based composite, three surfaces, posteriorX$ - 01,191.00X$ - 01.00$ - 0D2393
Pin retention - per tooth, in addtion to restorationX$ - 02.00X$ - 01.00$ - 0D2951
Recement or rebond inlay, onlay, veneer or partial coverage restorationX$ - 01.00X$ - 01.00$ - 0D2910
Recement or rebond indirectly fabricated or prefabricated post and coreX$ - 01.00X$ - 01.00$ - 0D2915
Recement or rebond crownX$ - 01.00X$ - 01.00$ - 0D2920
Core build up, including any pins when requiredX$ - 01,691.00X$ - 01.00$ - 0D2950
Prefabricated post and core for crownsX$ - 017.00X$ - 01.00$ - 0D2954
Endodontic Services
Pulp cap - indirect (excluding final restoration)X$ - 01.00X$ - 01.00$ - 0D3120
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicamentX$ - 01.00X$ - 01.00$ - 0D3220
Pulpal debridement - primary and permanent teethX$ - 08.00$ - 0D3221
Endodontic therapy, anterior tooth (excluding final restoration)X$ - 0198.00X$ - 01.00$ - 0D3310
Endodontic therapy, premolar tooth (excluding final restoration)X$ - 0408.00X$ - 01.00$ - 0D3320
Endodontic therapy, molar tooth (excluding final restoration)X$ - 0767.00X$ - 01.00$ - 0D3330
Incomplete endodontic therapy; inoperable, unrestorable or fractured toothX$ - 018.00X$ - 01.00$ - 0D3332
Retreatment of previous root canal therapy - anteriorX$ - 01.00X$ - 01.00$ - 0D3346
Retreatment of previous root canal therapy - premolarX$ - 01.00X$ - 01.00$ - 0D3347
Retreatment of previous root canal therapy - molarX$ - 0108.00X$ - 01.00$ - 0D3348
Apicoectomy - anteriorX$ - 011.00$ - 0D3410
Apicoectomy - premolar (first root)X$ - 01.00$ - 0D3421
Apicoectomy - molar (first root)X$ - 02.00$ - 0D3425
Apicoectomy - molar (each additional root)X$ - 02.00$ - 0D3426
Bone graft in conjunction with periadicular surgery - per tooth, single siteX$ - 01.00$ - 0D3428
Retrograde filling - per rootX$ - 018.00$ - 0D3430
Decoronation or submergence of an erupted tooth - Intentional removal of coronal tooth structure for preservation of the root and surrounding boneX$ - 01.00$ - 0D3921
Periodontal Services
Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visitX$ - 046.00X$ - 01.00$ - 0D4355
Prosthedontic Services
Complete denture - maxillaryX$ - 01.00$ - 0D5110
Complete denture - mandibularX$ - 04.00$ - 0D5120
Immediate denture - maxillaryX$ - 010.00$ - 0D5130
Immediate denture- mandibularX$ - 07.00$ - 0D5140
Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth)X$ - 029.00$ - 0D5211
Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth)X$ - 018.00$ - 0D5212
Maxillary partial denture - cast metal framework with resin denture base (including retentive/clasping materials, rests and teeth)X$ - 01.00$ - 0D5213
Mandibular partial denture - cast metal framework with resin denture base (including retentive/clasping materials, rests and teeth)X$ - 01.00$ - 0D5214
Maxillary partial denture - flexible base (including retentative/clasping materials, rests, and teeth)X$ - 01.00$ - 0D5225
Mandibular partial denture - flexible base (including retentative/clasping materials, rests, and teeth)X$ - 01.00$ - 0D5226
Adjust complete denture - maxillaryX$ - 01.00$ - 0D5410
Adjust complete denture - mandibularX$ - 01.00$ - 0D5411
Adjust partial denture - maxillaryX$ - 01.00$ - 0D5421
Adjust partial denture - mandibularX$ - 01.00$ - 0D5422
Repair broken complete denture base, mandibularX$ - 01.00$ - 0D5511
Repair broken complete denture base, maxillaryX$ - 01.00$ - 0D5512
Replace missing or broken teeth - complete denture (each tooth)X$ - 01.00$ - 0D5520
Repair resin partial denture base, mandibularX$ - 01.00$ - 0D5611
Repair resin partial denture base, maxillaryX$ - 01.00$ - 0D5612
Repair cast partial denture base, mandibularX$ - 01.00$ - 0D5621
Repair cast partial denture base, maxillaryX$ - 01.00$ - 0D5622
Repair or replace broken retentive clasping materials - per toothX$ - 01.00$ - 0D5630
Rebase complete maxillary dentureX$ - 01.00$ - 0D5710
Rebase complete mandibular dentureX$ - 01.00$ - 0D5711
Rebase maxillary partial dentureX$ - 01.00$ - 0D5720
Rebase mandibular partial dentureX$ - 01.00$ - 0D5721
Rebase hybrid prosthesis - replacing the base material connect to the frameworkX$ - 01.00$ - 0D5725
Reline complete maxillary denture (direct) [chair side]X$ - 01.00$ - 0D5730
Reline complete mandibular denture (direct) [chair side]X$ - 01.00$ - 0D5731
Reline maxillary partial denture (direct) [chair side]X$ - 01.00$ - 0D5740
Reline mandibular partial denture (direct) [chair side]X$ - 01.00$ - 0D5741
Reline complete maxillary denture (indirect) [laboratory]X$ - 01.00$ - 0D5750
Reline complete mandibular denture (indirect) [laboratory]X$ - 01.00$ - 0D5751
Reline maxillary partial denture (indirect) [laboratory]X$ - 01.00$ - 0D5760
Reline mandibular partial denture (indirect) [laboratory]X$ - 01.00$ - 0D5761
Soft liner for complete or partial removable denture - indirect - a dscrete procedure provided when the dentist determines placement of the soft liner is clinically indicatedX$ - 01.00$ - 0D5765
Interim partial denture (including retentive/clasping materials, rests and teeth), maxillaryX$ - 07.00$ - 0D5820
Interim partial denture (including retentive/clasping materials, rests and teeth), mandibularX$ - 04.00$ - 0D5821
Recement or rebond fixed partial dentureX$ - 07.00$ - 0D6930
Implant Services
Recement or rebond implant/abutment supported crownX$ - 01.00X$ - 01.00$ - 0D6092
Recement or rebond implant/abutment supported fixed partial dentureX$ - 01.00X$ - 01.00$ - 0D6093
Oral Surgery Services
Extraction coronal remnants – primary toothX$ - 0569.00X$ - 01.00$ - 0D7111
Extraction, erupted tooth or exposed root (elevation and/or forceps removal)X$ - 02.00X$ - 01.00$ - 0D7140
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicatedX$ - 01,933.00X$ - 01.00$ - 0D7210
Removal of impacted tooth - soft tissueX$ - 028.00X$ - 01.00$ - 0D7220
Removal of impacted tooth - partial bonyX$ - 0100.00X$ - 01.00$ - 0D7230
Removal of impacted tooth - completely bonyX$ - 0929.00X$ - 01.00$ - 0D7240
Removal of impacted tooth - completely bony, with unusual surgical complicationsX$ - 01.00$ - 0D7241
Removal of residual tooth roots (cutting procedure)X$ - 0106.00X$ - 01.00$ - 0D7250
Coronectomy - intentional partial tooth removal, impacted teeth onlyX$ - 016.00$ - 0D7251
Oroantral fistula closureX$ - 01.00$ - 0D7260
Primary closure of a sinus perforationX$ - 07.00X$ - 01.00$ - 0D7261
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced toothX$ - 01.00$ - 0D7270
Exposure of an unerupted toothX$ - 01.00$ - 0D7280
Incisional biopsy of oral tissue - hard (bone, tooth)X$ - 06.00$ - 0D7285
Incisional biopsy of oral tissue - softX$ - 09.00$ - 0D7286
Brush biopsy - transepithelial sample collectionX$ - 01.00$ - 0D7288
Alveoloplasty in conjunction with extractions - for or more teeth or tooth spaces, per quadrantX$ - 05.00X$ - 01.00$ - 0D7310
Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrantX$ - 02.00$ - 0D7320
Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrantX$ - 01.00$ - 0D7321
Excision of benign lesion - lesion diameter less than 1.25 cmX$ - 04.00$ - 0D7410
Excision of benign lesion - greater than 1.25 cmX$ - 01.00$ - 0D7411
Excision of benign lesion, complicatedX$ - 01.00$ - 0D7412
Removal of benign odontogenic cyst or tumor with lesion diameter up to 1.25 cmX$ - 06.00$ - 0D7450
Removal of benign odontogenic cyst or tumor with lesion diameter greater than 1.25 cmX$ - 02.00$ - 0D7451
Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cmX$ - 01.00$ - 0D7460
Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cmX$ - 01.00$ - 0D7461
Removal of lateral exostosis (maxilla or mandible)X$ - 01.00$ - 0D7471
Removal of lateral exostosis - (maxilla or mandible)X$ - 01.00$ - 0D7471
Removal of torus palatinusX$ - 01.00$ - 0D7472
Removal of torus mandibularisX$ - 01.00$ - 0D7473
Reduction of osseous tuberosityX$ - 01.00$ - 0D7485
Incision and drainage of abscess - intraoral soft tissueX$ - 05.00$ - 0D7510
Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial spaces)X$ - 01.00$ - 0D7511
Suture of recent small wounds - up to 5 cmX$ - 01.00$ - 0D7910
Complicated suture - up to 5 cmX$ - 01.00$ - 0D7911
Complicated suture - greater than 5 cmX$ - 01.00$ - 0D7912
Bone replacement graft for ridge preservation-per site.X$ - 01.00$ - 0D7953
Excision of pericoronal gingivaX$ - 01.00$ - 0D7971
Surgical reduction of fibrous tuberosityX$ - 01.00$ - 0D7972
Removal of foreign body from mucosa, skin or subcutaneous alveolar tissueX$ - 01.00$ - 0D7530
Removal of reaction producing foreign bodies, musculoskeletal systemX$ - 01.00$ - 0D7540
Maxillary sinusotomy for removal of tooth fragment or foreign bodyX$ - 01.00$ - 0D7560
General Services
Palliative treatment of dental pain - per visitX$ - 011.00X$ - 01.00$ - 0D9110
Deep sedation/general anesthesia - first 15 minutesX$ - 02,597.00$ - 0D9222
Deep sedation/general anesthesia - each subsequent 15 minute incrementX$ - 01.00$ - 0D9223
Intravenous moderate (conscious) sedation/anesthesia - first 15 minutesX$ - 01.00$ - 0D9239
Intravenous moderate (conscious) sedation/anesthesia - each subsequent 15 minute incrementX$ - 028.00$ - 0D9243
Consultation - diagnositic service provided by dentist or physician other than requesting dentist or physicianX$ - 0434.00$ - 0D9310
Office visit - after regularly scheduled hoursX$ - 01.00$ - 0D9440
Therapeutic parenteral drug, single adminitrationX$ - 0433.00X$ - 01.00$ - 0D9610
Therapeutic parenteral drug, two or more administrations, different medicationsX$ - 02.00X$ - 01.00$ - 0D9612
Treatment of complications (post-surgical) unusual circumstances, by reportX$ - 01.00$ - 0D9930
Occlusal guard - hard appliance, full archX$ - 01.00$ - 0D9944
Inhalation of Nitrous Oxide/Analgesia, AnxiolysisX$ - 0196.00$ - 0D9230
MISCELLANEOUS FEE
SC-Requested Direct Outreach (price per SM)$ - 0660.00$ - 0
VA disability rating admin (price per individual service)$ - 0
Summary of care profile$ - 0
Legacy transcription of profile with PHA$ - 0
DD Form 2697 in lieu of SHPE$ - 0
Individual Item Medical Record Update$ - 078,086.00$ - 0
Bulk Medical Record Update$ - 0
CANCELLATION ADMIN FEE (late cancellations, within 72 hours of scheduled appointment)X$ - 03,814.00X$ - 01.00X$ - 0375.00$ - 0
NO SHOW ADMIN FEEX$ - 024,196.00X$ - 01.00X$ - 063,177.00$ - 0
Swap Out FeeX$ - 01.00$ - 0
Total$ - 0

RHRP-4 PWS Exhibit A_RHRP4 Services

&P

Services_OptYr1 Remote Health Readiness Program 4th Generation (RHRP-4) Legend: ICD-10 code: Patient diagnosis or medical condition CPT code: medical services or procedures performed HCPCS (Healthcare Common Procedure Coding System) Code: broader Medicare/Medicaid billing for CPT and specific supplies and services not covered by CPT Current Procedural Terminology (CPT) & Current Dental Terminology (CDT) Codes

X = Procedure/Modality Needed
Readiness Services Pricing Sheet - as of 31 January 2025Modality Not Needed for this Procedure/Not Applicable
ProcedureModalityMin Qty RequiredTotal Cost: Multiply Qty Times Rate
(Columns C, E, G)Notes and Additional Instructions
In-clinicIn-clinic Price Per ServiceProjected QTY/Year (In-Clinic)VirtualVirtual Price Per ServiceProjected QTY/Year (Virtual)Group EventGroup Event Price Per ServiceProjected QTY/Year (GE)per scheduled Group Event (per day)
PHYSICAL EXAM (Includes Labs, Immunizations, and Focused Exams (Audiology, Cardiology) as Required)
Retention Exam (Army and Air Force)X$ - 013.00$ - 099204Evaluation and Management (E/M), Office/outpatient, new, 45-59 minutes
Accession Exam (Army)X$ - 0811.00$ - 099204see above
Separation Health Assessment (SHA) DD Form 3146 formerly Separation History and Physical Exam (SHPE) DD Form 2870 (w/ Hep C antigens and Annual Hearing Test)X$ - 0827.00X$ - 03,542.0015$ - 099420DOD0222 (I/CD-10)
Cardiovascular Screening Program (CVSP) - (Blood Pressure, Fasting Lipid Profile, EKG, Fasting Glucose, Height and Weight)X$ - 0895.00X$ - 02,597.0025$ - 0see elements below - with PHA or DRHA
OCCUPATIONAL
Airborne examX$ - 0348.00$ - 099204see above
Occupational Health Examination (Labs and tests will be determined by exposure concerns and ordered individually)X$ - 0245.00X$ - 015.0015$ - 099499
- Baseline$ - 0DOD0214ICD-10 code
- Periodic$ - 0DOD0215ICD-10 code
- Termination$ - 0DOD0216ICD-10 code
Firefighter / CBRN examX$ - 06.00$ - 099204see above
MISCELLANEOUS EXAMS & PROCEDURES
Clinical breast examX$ - 01.00$ - 099211G0101 (w/ pelvic exam)
12-lead Electrocardiogram (ECG), restingX$ - 0513.00$ - 093010
Preventive exam (pelvic)/vaginal examX$ - 01.00$ - 099459
Rectal examX$ - 01.00$ - 0G0102HCPCS code
SpirometryX$ - 024.00$ - 094010
Valsalva test (part of Airborne exam)X$ - 01.00$ - 095921
Chest x-ray, B-readX$ - 02.00$ - 0provider service to read the xray
Chest x-ray, posterior-anterior and lateral viewsX$ - 065.00$ - 071046
MammographyX$ - 04.00$ - 077067
ASSESSMENTS
Periodic Health Assessment (PHA) DD Form 3024
DoD PHA (Part C1) Mental Health Portion OnlyX$ - 01.00X$ - 028,677.00X$ - 030.0030$ - 090792
DoD PHA (Part C2) Provider Portion w/o Mental Health OnlyX$ - 01.00X$ - 01.00X$ - 030.0030$ - 099202CPT E/M, Office/outpatient, New, 15-29 min
DoD PHA (Parts C1, C2) Provider Portion CompleteX$ - 01.00X$ - 01.00X$ - 030.0030$ - 090203above codes (90792/99202) cannot be combined, 90203 represents 30-45 min exam to accomodate the BH time.
DoD PHA (Parts B, C2) Record Review and Provider w/o Mental HealthX$ - 0158.00X$ - 0182,722.00X$ - 030.0030$ - 099202
DoD PHA (Parts B, C1, C2) Complete PHAX$ - 083,798.00X$ - 013,386.00X$ - 087,156.0030$ - 0DOD0225ICD-10 code
DEPLOYMENT RELATED HEALTH ASSESSMENTS (DRHA)
Pre-Deployment Health Assessment (Pre-DHA) DD Form 2795X$ - 01.00X$ - 01.00X$ - 041.0030$ - 0DOD0211ICD-10 code
Post-Deployment Health Assessment (PDHA) DD Form 2796X$ - 01.00X$ - 01.00X$ - 030.0030$ - 0DOD0212ICD-10 code
Post-Deployment Health Re-Assessment (PDHRA) DD Form 2900X$ - 01.00X$ - 018,893.00X$ - 0993.0030$ - 0DOD0213ICD-10 code
Mental Health Assessment (MHA) DD Form 2978X$ - 01.00X$ - 01.00X$ - 030.0030$ - 090792same as PHA, Part C1 above
Miscellaneous Assessments
Tuberculosis (TB) Risk Assessment Tool, AdministrationX$ - 01.00X$ - 01.00X$ - 03,527.00$ - 096127simple questionaire review - NAVMED 6224/7, Army MEDCOM Form 831
Neuropsychological AssessmentsX$ - 01.00X$ - 01.00$ - 096132
AUDIOLOGY
Annual Hearing Test (Includes Tympanic Visualization and Cerumen Removal as required)X$ - 04,729.00X$ - 014,482.0050$ - 092552
Comprehensive Audiometric Evaluation (CAE) (Includes pure tone air and bone conduction testing as required)X$ - 03,439.00X$ - 02,159.0025$ - 092557
Military Operational Hearing Test (MOHT)X$ - 01.00X$ - 01.00$ - 092700unlisted otorhinolaryngological procedure
Speech Recognition in Noise Test (SPRINT) being deprecated, replaced by MOHTX$ - 04,123.00$ - 092700unlisted otorhinolaryngological procedure
Cerumen impaction removalX$ - 01.00X$ - 01.00$ - 069210 or 69209instruments or lavage
Consultation w/ OtolaryngologistX$ - 01.00$ - 099203
OPTOMETRY
Vision Screen (with Color Vision Deficiency screening as required)X$ - 015,382.00X$ - 04,263.0030$ - 099173
Comprehensive Eye Exam with Refraction and PrescriptionX$ - 01,760.00X$ - 034.0050$ - 092004
Color Vision Deficiency (CVD) screening (Red-green); Army (Titmus V4 or Pseudoisochromatic Plates #2 (PIP#2)), Maritime (PIP#2 or Cone Contrast Test (CCT)), Air Force (PIP#2 or CCT).X$ - 08,239.00X$ - 012,277.00$ - 092283
TonometryX$ - 01.00$ - 0Provided within the CEE, consider deleting - change the PE to require a CEE
IMMUNIZATIONS (Age Appropriate and Related Labs) - not to exceed CHAMPUS Maximum Allowable Charge acceptable rate
Procedures
Administration of vaccineX$ - 01.00X$ - 014,578.0060$ - 096372
Phlebotomy and sample submissionX$ - 01.00X$ - 030.0030$ - 036415see lab below for duplicate - 2nd to having titers (labs) in the IMMs group for clarity.
Purified Protein Derivative (PPD) Test for Tuberculosis (TB), administration and read at 48-72 hoursX$ - 011.00X$ - 0472.0060$ - 086580/ 99499placement/read
Urine Pregnancy (inclusive of any vaccination that requires it)$ - 081025Not priced separately - but included in cost of vaccinations, needed as part of the vaccinations that require it.
Routine Adult
COVID-19X$ - 01.00X$ - 01.00$ - 090480
Hepatitis A (2 dose series)X$ - 04,177.00X$ - 026.00$ - 090632priced per dose
Hepatitis B (1 or 2 doses)X$ - 04,247.00X$ - 03,497.00$ - 0G0010priced per dose, mutiple options
Hepatitis A & B Combination - TWINRIX (3 dose series)X$ - 014.00X$ - 01.00$ - 090636priced per dose
Influenza, Northern HemisphereX$ - 059,536.00X$ - 01,798.00$ - 0multiple
Measles, Mumps, Rubella (MMR)X$ - 0439.00X$ - 01,996.00$ - 090707
MMR titer - labX$ - 015.00X$ - 056.00$ - 0multiple86735; 86762; 86765
Measles, Rubella titer - labX$ - 01.00X$ - 01.00$ - 0see above
MeningococcalX$ - 097.00X$ - 01.00$ - 0multiple
PneumococcalX$ - 01.00X$ - 01.00$ - 0multiple
PolioX$ - 0585.00X$ - 0265.00$ - 090713
Tetanus, Diphtheria and Pertussis (Tdap)X$ - 01,193.00X$ - 0776.00$ - 090715
Tetanus and Diphtheria (Td)X$ - 05,371.00X$ - 0569.00$ - 090714
Varicella (chickenpox)X$ - 02,352.00X$ - 0153.00$ - 090716
Varicella-zoster virus (VZV) titer - labX$ - 010.00X$ - 01.00$ - 086787
Deployment Related
Anthrax (6 shot series) (Government provided)X$ - 01.00X$ - 04,669.00$ - 090581
Influenza, Southern HemisphereX$ - 01.00X$ - 01.00$ - 0multiple
Japanese Encephalitis (JEV)X$ - 091.00X$ - 01.00$ - 090738
Rabies (3 dose series)X$ - 0133.00X$ - 029.00$ - 090471per dose
Rabies titer - labX$ - 01.00X$ - 01.00$ - 086382
Tick-Borne EncephalitisX$ - 01.00X$ - 01.00$ - 090626/90627dose dependant (0.25ml/0.5ml)
TyphoidX$ - 0443.00X$ - 0566.00$ - 0multiple
Yellow Fever (Government provided)X$ - 01.00X$ - 01.00$ - 090717
LABORATORY SERVICES
Procedures
Phlebotomy (blood draw) and sample submissionX$ - 0118,822.00X$ - 09,441.0030$ - 036415
Stool collectionX$ - 01.00$ - 0considered integral to any stool test
Urine collectionX$ - 01.00X$ - 015.0015$ - 0P9615HCPCS code
Readiness/Deployment Support
ABO Grouping and Rho(D) Typing (Blood type), bloodX$ - 01,143.00X$ - 054.00$ - 086900
Sexually Transmitted Infections (STI) Profile w/ Chlamydia, Gonorrhea, serum and swab or urineX$ - 01.00$ - 0multiple87491, 87591-3, 87801
DNA test, blood - (Government collection card)X$ - 0491.00X$ - 01.00$ - 0
Glucose, blood, fastingX$ - 01.00X$ - 01.00$ - 082947
Glucose-6-phosphate dehydrogenase (G6PD), bloodX$ - 06,549.00X$ - 08,698.00$ - 082955
Human immuno virus (HIV), blood (Government testing)X$ - 056,109.00X$ - 01.00$ - 0
Human immuno virus (HIV), blood (Commercial testing)X$ - 01.00X$ - 01.00$ - 0multiple
Lipid panel, blood, fastingX$ - 01.00X$ - 01.00$ - 080061
Cholesterol, total, bloodX$ - 01.00X$ - 01.00$ - 082465only billable if Lipid panel is not performed
High-density lipoprotein (HDL) cholesterol, blood$ - 0
Low-density lipoprotein (LDL) cholesterol, blood$ - 0
Very low-density lipoprotein (VLDL) cholesterol, blood$ - 0
Triglycerides, blood$ - 0
Pregnancy (hCG), urineX$ - 05.00X$ - 09,541.00$ - 081025see same test in Immunizations - not chargable above
Prostate-specific antigen (PSA), bloodX$ - 01.00X$ - 01.00$ - 084153
Sickle cell screen w/ reflex to hemoglobinopathy evaluationX$ - 046,037.00X$ - 075.00$ - 085660
Physical Exam Support
Complete Blood Count (CBC), bloodX$ - 0171.00X$ - 01.00$ - 085027
Red blood cell (RBC), blood$ - 0
Hemoglobin (Hb), bloodX$ - 01.00X$ - 01.00$ - 085018only billable if CBC is not performed
Hematocrit (Hct), bloodX$ - 01.00X$ - 01.00$ - 085014only billable if CBC is not performed
White blood cell (WBC), blood$ - 0
Platelets, blood$ - 0
Complete Blood Count (CBC) w/ differential, reflex to peripheral smear review, bloodX$ - 063.00X$ - 01.00$ - 085025
Comprehensive Metabolic Panel (CMP), 14 tests, bloodX$ - 0238.00X$ - 01.00$ - 080053
Glucose, blood, non-fasting$ - 0
Calcium, blood$ - 0
Sodium, potassium, bicarbonate and chloride, blood$ - 0
Albumin, bloodX$ - 01.00$ - 082040only billable if CMP is not performed
Total protein, blood$ - 0
Alkaline phosphate (ALP), Alanine transaminase (ALT), and Aspartate aminotransferase (AST), blood$ - 0
Bilirubin, blood$ - 0
Blood Urea Nitrogen (BUN)X$ - 01.00$ - 084520only billable if CMP is not performed
Creatinine, bloodX$ - 01.00$ - 082565only billable if CMP is not performed
Drug Screen, urine (13-drug)X$ - 01.00X$ - 01.00$ - 080306
Alcohol test, urineX$ - 01.00X$ - 01.00$ - 080307
Neisseria Gonorrhoeae (NG), NAA urineX$ - 01.00X$ - 01.00$ - 087591
Hepatitis C Virus (HCV) antibody w/ reflex to quantitative real-time PCR, bloodX$ - 0455.00X$ - 01.00$ - 086803 (86804)
Fecal-occult blood test (e.g., guiac), fecesX$ - 01.00X$ - 01.00$ - 082270
Fecal-occult blood test (Colorectal cander Screening), fecesX$ - 01.00X$ - 01.00$ - 082274
Rapid Plasma Reagin (RPR), bloodX$ - 01.00X$ - 01.00$ - 086592
Pap smear,X$ - 021.00X$ - 01.00$ - 088164 or 88142conventional or liquid base
Urinalysis, complete with reflex microscope as requiredX$ - 0236.00X$ - 01.00$ - 081001
Toxicology (Occupational Health)
Benzene, bloodX$ - 01.00$ - 084600
Beta-2 microglobulin (B2M), urineX$ - 01.00$ - 082232
Cadmium, blood or urineX$ - 01.00$ - 082300same code for blood or urine
Cholinesterase, plasma/serumX$ - 01.00$ - 082480
Gamma-glutamyl transferase (GGT), bloodX$ - 01.00$ - 082977
Lactate dehydrogenase (LDH), bloodX$ - 01.00$ - 083615
Lead, bloodX$ - 065.00$ - 083655
Bilirubin, total, bloodX$ - 01.00$ - 082247
Aromatic Solvents, bloodX$ - 01.00$ - 084600
Zinc Protoporphyrin (ZPP), bloodX$ - 067.00$ - 084202
DENTAL READINESS
Comprehensive oral evaluation [Annual Dental Exam]X$ - 088,630.00X$ - 096,457.0050$ - 0D0150
Dental Radiology, Standard
Bitewing, single radiographic imageX$ - 017.00X$ - 020.0020*$ - 0D0270*Minimum quantity is an aggregate amount of all bitewings. (20 bitewings total minimum)
Bitewing, two radiographic imagesX$ - 0371.00X$ - 020.0020*$ - 0D0272*Minimum quantity is an aggregate amount of all bitewings. (20 bitewings total minimum)
Bitewing, three radiographic imagesX$ - 015.00X$ - 020.0020*$ - 0D0273*Minimum quantity is an aggregate amount of all bitewings. (20 bitewings total minimum)
Bitewing, four radiographic imagesX$ - 08,849.00X$ - 036,448.0020*$ - 0D0274*Minimum quantity is an aggregate amount of all bitewings. (20 bitewings total minimum)
Panographic radiographic imageX$ - 06,248.00X$ - 01,071.0020$ - 0D0330
DENTAL TREATMENT
Diagnostic Services
Limited oral evaluation - problem focusedX$ - 01.00X$ - 01.00$ - 0D0140
Intraoral - comprehensive series of radiographic imagesX$ - 01.00X$ - 01.00$ - 0D0210
Intraoral - periabical first radiolgraphic imageX$ - 01.00X$ - 01.00$ - 0D0220
Intraoral - periapical each additional radiographic imageX$ - 06,121.00X$ - 01.00$ - 0D0230
Cone beam CT image capture with limited field of view - less than one whole jawX$ - 027.00$ - 0D0380
Cone beam CT image capture with field of view of one full dental arch - mandibleX$ - 045.00$ - 0D0381
Cone beam CT image capture with field of view of one full dental arch - maxilla with or without craniumX$ - 01.00$ - 0D0382
Restorative Services
Amalgam - one surface, primary or permanentX$ - 0463.00X$ - 01.00$ - 0D2140
Amalgam - two surfaces, primary or permanentX$ - 016.00X$ - 01.00$ - 0D2150
Amalgam - three surfaces, primary or permanentX$ - 0554.00X$ - 01.00$ - 0D2160
Amalgam - four or more surfaces, primary or permanentX$ - 0144.00X$ - 01.00$ - 0D2161
Resin-based composite, one surface, anteriorX$ - 0674.00X$ - 01.00$ - 0D2330
Resin-based composite, two surfaces, anteriorX$ - 0725.00X$ - 01.00$ - 0D2331
Resin-based composite, three surfaces, anteriorX$ - 0126.00X$ - 01.00$ - 0D2332
Resin-based composite, four or more surfaces or involving incisal angle (anterior)X$ - 0828.00X$ - 01.00$ - 0D2335
Resin-based composite, one surface, posteriorX$ - 0163.00X$ - 01.00$ - 0D2391
Resin-based composite, two surfaces, posteriorX$ - 0399.00X$ - 01.00$ - 0D2392
Resin-based composite, three surfaces, posteriorX$ - 02,382.00X$ - 01.00$ - 0D2393
Pin retention - per tooth, in addtion to restorationX$ - 03.00X$ - 01.00$ - 0D2951
Recement or rebond inlay, onlay, veneer or partial coverage restorationX$ - 01.00X$ - 01.00$ - 0D2910
Recement or rebond indirectly fabricated or prefabricated post and coreX$ - 01.00X$ - 01.00$ - 0D2915
Recement or rebond crownX$ - 01.00X$ - 01.00$ - 0D2920
Core build up, including any pins when requiredX$ - 03,381.00X$ - 01.00$ - 0D2950
Prefabricated post and core for crownsX$ - 034.00X$ - 01.00$ - 0D2954
Endodontic Services
Pulp cap - indirect (excluding final restoration)X$ - 01.00X$ - 01.00$ - 0D3120
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicamentX$ - 01.00X$ - 01.00$ - 0D3220
Pulpal debridement - primary and permanent teethX$ - 015.00$ - 0D3221
Endodontic therapy, anterior tooth (excluding final restoration)X$ - 0395.00X$ - 01.00$ - 0D3310
Endodontic therapy, premolar tooth (excluding final restoration)X$ - 0815.00X$ - 01.00$ - 0D3320
Endodontic therapy, molar tooth (excluding final restoration)X$ - 01,534.00X$ - 01.00$ - 0D3330
Incomplete endodontic therapy; inoperable, unrestorable or fractured toothX$ - 036.00X$ - 01.00$ - 0D3332
Retreatment of previous root canal therapy - anteriorX$ - 01.00X$ - 01.00$ - 0D3346
Retreatment of previous root canal therapy - premolarX$ - 01.00X$ - 01.00$ - 0D3347
Retreatment of previous root canal therapy - molarX$ - 0216.00X$ - 01.00$ - 0D3348
Apicoectomy - anteriorX$ - 022.00$ - 0D3410
Apicoectomy - premolar (first root)X$ - 01.00$ - 0D3421
Apicoectomy - molar (first root)X$ - 04.00$ - 0D3425
Apicoectomy - molar (each additional root)X$ - 04.00$ - 0D3426
Bone graft in conjunction with periadicular surgery - per tooth, single siteX$ - 01.00$ - 0D3428
Retrograde filling - per rootX$ - 035.00$ - 0D3430
Decoronation or submergence of an erupted tooth - Intentional removal of coronal tooth structure for preservation of the root and surrounding boneX$ - 01.00$ - 0D3921

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated .