Exhibit B1_RHRP Services.xlsx

XLSX spreadsheet 49 KB Posted Feb 20, 2025

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

About this file

Written by GovTribe AI · Feb 20, 2025

This file is an Excel spreadsheet that details the medical and dental procedures required under the Remote Health Readiness Program 4th Generation (RHRP-4) contract. The document provides comprehensive coding and billing information using CPT, CDT, ICD-10, and HCPCS codes for various medical services across multiple categories: physical exams, occupational health services, assessments, audiology, optometry, immunizations, laboratory services, dental readiness, and dental treatment.

The services are organized by delivery modality (in-clinic, virtual, or group event) with minimum quantity requirements specified for certain procedures. Key service categories include retention exams, accession exams, deployment health assessments, periodic health assessments, immunizations (both routine and deployment-related), comprehensive laboratory testing panels, dental examinations and treatments, and various specialty medical services like audiometry and vision screening. The document serves as a technical requirements matrix for healthcare providers to deliver military medical readiness services under the RHRP-4 contract.

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Other files for this federal contract opportunity

Other files attached to Remote Health Readiness Program 4 (RHRP-4), newest first.
File	Type	Posted
SF-30 Amendment 0008 HT001125R0020.pdf	PDF	Apr 30, 2025
SF-30 Amendment 0007 HT001125R0020.pdf	PDF	Apr 24, 2025
Attachment E_Pricing Sheet_RHRP Services_4.21.25.xlsx	XLSX spreadsheet	Apr 22, 2025
Attachment E_Pricing Sheet_RHRP Services_4.17.25.xlsx	XLSX spreadsheet	Apr 17, 2025
SF-30 Amendment 0004 HT001125R0020.pdf	PDF	Apr 11, 2025
52.212-1_2.28.25_v3.docx	DOCX document	Apr 11, 2025
SF-30 Amendment 0003 HT001125R0020.pdf	PDF	Apr 11, 2025
Attachment G_RFP Proposal Worksheetv3.xlsx	XLSX spreadsheet	Apr 11, 2025
A010_Data_Infringement_Notification.pdf	PDF	Apr 9, 2025
A050_Credential_Audit_Corrective_Action_Plan.pdf	PDF	Apr 9, 2025
A110_Appointment_Cancellation_Notice.pdf	PDF	Apr 9, 2025
A090_Call_and_Chat_Data_Report.pdf	PDF	Apr 9, 2025
Exhibit H_Service Appointment RequestV2.docx	DOCX document	Apr 9, 2025
Exhibit F1_ SM location by ZipCode 20250304.xlsx	XLSX spreadsheet	Apr 9, 2025
Attachment E_Pricing Sheet_RHRP Services_3.7.25.xlsx	XLSX spreadsheet	Apr 9, 2025
Exhibit Q_DRC Data Flow 2024.pdf	PDF	Apr 9, 2025
Exhibit R_Call Data.pdf	PDF	Apr 9, 2025
Exhibit S_RHRP Customer Concern Form (2025).docx	DOCX document	Apr 9, 2025
A070_DEERS_SM_Eligibility_Checks.pdf	PDF	Apr 9, 2025
Exhibit E2_Emergency Notification FlowV2.pdf	PDF	Apr 9, 2025
Exhibit T_RHRP-DP_Services_Supplement 2025V2.docx	DOCX document	Apr 9, 2025
SF-30 Amendment 0002 HT0011-25-R-0020.pdf	PDF	Apr 9, 2025
A040_Vendor_Network_Provider_Directory.pdf	PDF	Apr 9, 2025
A120_Abnormal_Diagnostic_Procedure_Result_Notice.pdf	PDF	Apr 9, 2025
A100_Readiness_Service_Results_by_SM.pdf	PDF	Apr 9, 2025
Attachment F_RFP_RHRP4_QA form_Responses_4.2.25.pdf	PDF	Apr 2, 2025
Attachment A_Performance Based Milestone Payment.pdf	PDF	Feb 20, 2025
Attachment B_RHRP-4 Group Event Weekend Scenario.xlsx	XLSX spreadsheet	Feb 20, 2025
Attachment C_Small Business Commitment RHRP4.docx	DOCX document	Feb 20, 2025
Attachment D_HT0011-R-25-0020 RHRP4 PPQ.docx	DOCX document	Feb 20, 2025
Attachment E_Pricing Sheet_RHRP Services.xlsx	XLSX spreadsheet	Feb 20, 2025
Exhibit A_RHRP-3 Systems Map.pdf	PDF	Feb 20, 2025
Exhibit C1_Group Event Location Data.xlsx	XLSX spreadsheet	Feb 20, 2025
Exhibit H_Service Appointment Request.docx	DOCX document	Feb 20, 2025
Exhibit I_GE Planning Template.pdf	PDF	Feb 20, 2025
Exhibit K_DA Form 3024 - PHA.pdf	PDF	Feb 20, 2025
ATTACHMENT G_SCA_Wage-Determination.pdf	PDF	Feb 20, 2025
Exhibit G_User Roles.pdf	PDF	Feb 20, 2025
Exhibit N_DNA Collection Instructions.pdf	PDF	Feb 20, 2025
Exhibit P_Optometry Data Flow.pptx	PPTX presentation	Feb 20, 2025
Exhibit S_RHRP Customer Concern Form (5-2023).pdf	PDF	Feb 20, 2025
HT001125R0020 RHRP4 RFP.pdf	PDF	Feb 20, 2025
Attachment F_RFP_RHRP4_QA form.xlsx	XLSX spreadsheet	Feb 20, 2025
Exhibit E1_Incident Report.docx	DOCX document	Feb 20, 2025
Exhibit E2_Emergency Notification Flow.pdf	PDF	Feb 20, 2025
Exhibit F3_RHRP-2 FY22 Services by Modality State Zip.xlsx	XLSX spreadsheet	Feb 20, 2025
Exhibit J_PHA Flow.pdf	PDF	Feb 20, 2025
Exhibit M_HIV Provider Testing Key Resources.pdf	PDF	Feb 20, 2025
Exhibit T_RHRP-DP_Services_Supplement 2025.docx	DOCX document	Feb 20, 2025
Exhibit XX_DHA CAC Request Process.pdf	PDF	Feb 20, 2025

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Procedures

	Remote Health Readiness Program 4th Generation (RHRP-4)	Legend:	Current Procedural Terminology (CPT) &
Current Dental Terminology (CDT) Codes	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

	X = Procedure/Modality Needed
Readiness Services Required - as of 21 January 2025	Modality Not Needed for this Procedure/Not Applicable
Procedure	Modality			Min Qty Required		Notes and Additional Instructions
	In-clinic	Virtual	Group Event	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				99204	Evaluation and Management (E/M), Office/outpatient, new, 45-59 minutes
Accession Exam (Army)	X				99204	see 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		X	15	99420	DOD0222 (I/CD-10)
Cardiovascular Screening Program (CVSP) - (Blood Pressure, Fasting Lipid Profile, EKG, Fasting Glucose, Height and Weight)	X		X	25		see elements below - with PHA or DRHA
OCCUPATIONAL
Airborne exam	X				99204	see above
Occupational Health Examination (Labs and tests will be determined by exposure concerns and ordered individually)	X		X	15	99499
- Baseline					DOD0214	ICD-10 code
- Periodic					DOD0215	ICD-10 code
- Termination					DOD0216	ICD-10 code
Firefighter / CBRN exam	X				99204	see above
MISCELLANEOUS EXAMS & PROCEDURES
Clinical breast exam	X				99211	G0101 (w/ pelvic exam)
12-lead Electrocardiogram (ECG), resting	X				93010
Preventive exam (pelvic)/vaginal exam	X				99459
Rectal exam	X				G0102	HCPCS code
Spirometry	X				94010
Valsalva test (part of Airborne exam)	X				95921
Chest x-ray, B-read	X					provider service to read the xray
Chest x-ray, posterior-anterior and lateral views	X				71046
Mammography	X				77067
ASSESSMENTS
Periodic Health Assessment (PHA) DD Form 3024
DoD PHA (Part C1) Mental Health Portion Only	X	X	X	30	90792
DoD PHA (Part C2) Provider Portion w/o Mental Health Only	X	X	X	30	99202	CPT E/M, Office/outpatient, New, 15-29 min
DoD PHA (Parts C1, C2) Provider Portion Complete	X	X	X	30	90203	above 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 Health	X	X	X	30	99202
DoD PHA (Parts B, C1, C2) Complete PHA	X	X	X	30	DOD0225	ICD-10 code
DEPLOYMENT RELATED HEALTH ASSESSMENTS (DRHA)
Pre-Deployment Health Assessment (Pre-DHA) DD Form 2795	X	X	X	30	DOD0211	ICD-10 code
Post-Deployment Health Assessment (PDHA) DD Form 2796	X	X	X	30	DOD0212	ICD-10 code
Post-Deployment Health Re-Assessment (PDHRA) DD Form 2900	X	X	X	30	DOD0213	ICD-10 code
Mental Health Assessment (MHA) DD Form 2978	X	X	X	30	90792	same as PHA, Part C1 above
Miscellaneous Assessments
Tuberculosis (TB) Risk Assessment Tool, Administration	X	X	X		96127	simple questionaire review - NAVMED 6224/7, Army MEDCOM Form 831
Neuropsychological Assessments	X		X		96132
AUDIOLOGY
Annual Hearing Test (Includes Tympanic Visualization and Cerumen Removal as required)	X		X	50	92552
Comprehensive Audiometric Evaluation (CAE) (Includes pure tone air and bone conduction testing as required)	X		X	25	92557
Military Operational Hearing Test (MOHT)	X		X		92700	unlisted otorhinolaryngological procedure
Speech Recognition in Noise Test (SPRINT) being deprecated, replaced by MOHT	X				92700	unlisted otorhinolaryngological procedure
Cerumen impaction removal	X		X		69210 or 69209	instruments or lavage
Consultation w/ Otolaryngologist	X				99203
OPTOMETRY
Vision Screen (with Color Vision Deficiency screening as required)	X		X	30	99173
Comprehensive Eye Exam with Refraction and Prescription	X		X	50	92004
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		X		92283
Tonometry	X					Provided 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 vaccine	X		X	60	96372
Phlebotomy and sample submission	X		X	30	36415	see 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 hours	X		X	60	86580/ 99499	placement/read
Urine Pregnancy (inclusive of any vaccination that requires it)					81025	Not priced separately - but included in cost of vaccinations, needed as part of the vaccinations that require it.
Routine Adult
COVID-19	X		X		90480
Hepatitis A (2 dose series)	X		X		90632	priced per dose
Hepatitis B (1 or 2 doses)	X		X		G0010	priced per dose, mutiple options
Hepatitis A & B Combination - TWINRIX (3 dose series)	X		X		90636	priced per dose
Influenza, Northern Hemisphere	X		X		multiple
Measles, Mumps, Rubella (MMR)	X		X		90707
MMR titer - lab	X		X		multiple	86735; 86762; 86765
Measles, Rubella titer - lab	X		X		see above
Meningococcal	X		X		multiple
Pneumococcal	X		X		multiple
Polio	X		X		90713
Tetanus, Diphtheria and Pertussis (Tdap)	X		X		90715
Tetanus and Diphtheria (Td)	X		X		90714
Varicella (chickenpox)	X		X		90716
Varicella-zoster virus (VZV) titer - lab	X		X		86787
Deployment Related
Anthrax (6 shot series) (Government provided)	X		X		90581
Influenza, Southern Hemisphere	X		X		multiple
Japanese Encephalitis (JEV)	X		X		90738
Rabies (3 dose series)	X		X		90471	per dose
Rabies titer - lab	X		X		86382
Tick-Borne Encephalitis	X		X		90626/90627	dose dependant (0.25ml/0.5ml)
Typhoid	X		X		multiple
Yellow Fever (Government provided)	X		X		90717
LABORATORY SERVICES
Procedures
Phlebotomy (blood draw) and sample submission	X		X	30	36415
Stool collection	X					considered integral to any stool test
Urine collection	X		X	15	P9615	HCPCS code
Readiness/Deployment Support
ABO Grouping and Rho(D) Typing (Blood type), blood	X		X		86900
Sexually Transmitted Infections (STI) Profile w/ Chlamydia, Gonorrhea, serum and swab or urine	X				multiple	87491, 87591-3, 87801
DNA test, blood - (Government collection card)	X		X
Glucose, blood, fasting	X		X		82947
Glucose-6-phosphate dehydrogenase (G6PD), blood	X		X		82955
Human immuno virus (HIV), blood (Government testing)	X		X
Human immuno virus (HIV), blood (Commercial testing)	X		X		multiple
Lipid panel, blood, fasting	X		X		80061
Cholesterol, total, blood	X		X		82465	only billable if Lipid panel is not performed
High-density lipoprotein (HDL) cholesterol, blood
Low-density lipoprotein (LDL) cholesterol, blood
Very low-density lipoprotein (VLDL) cholesterol, blood
Triglycerides, blood
Pregnancy (hCG), urine	X		X		81025	see same test in Immunizations - not chargable above
Prostate-specific antigen (PSA), blood	X		X		84153
Sickle cell screen w/ reflex to hemoglobinopathy evaluation	X		X		85660
Physical Exam Support
Complete Blood Count (CBC), blood	X		X		85027
Red blood cell (RBC), blood
Hemoglobin (Hb), blood	X		X		85018	only billable if CBC is not performed
Hematocrit (Hct), blood	X		X		85014	only billable if CBC is not performed
White blood cell (WBC), blood
Platelets, blood
Complete Blood Count (CBC) w/ differential, reflex to peripheral smear review, blood	X		X		85025
Comprehensive Metabolic Panel (CMP), 14 tests, blood	X		X		80053
Glucose, blood, non-fasting
Calcium, blood
Sodium, potassium, bicarbonate and chloride, blood
Albumin, blood	X				82040	only billable if CMP is not performed
Total protein, blood
Alkaline phosphate (ALP), Alanine transaminase (ALT), and Aspartate aminotransferase (AST), blood
Bilirubin, blood
Blood Urea Nitrogen (BUN)	X				84520	only billable if CMP is not performed
Creatinine, blood	X				82565	only billable if CMP is not performed
Drug Screen, urine (13-drug)	X		X		80306
Alcohol test, urine	X		X		80307
Neisseria Gonorrhoeae (NG), NAA urine	X		X		87591
Hepatitis C Virus (HCV) antibody w/ reflex to quantitative real-time PCR, blood	X		X		86803 (86804)
Fecal-occult blood test (e.g., guiac), feces	X		X		82270
Fecal-occult blood test (Colorectal cander Screening), feces	X		X		82274
Rapid Plasma Reagin (RPR), blood	X		X		86592
Pap smear,	X		X		88164 or 88142	conventional or liquid base
Urinalysis, complete with reflex microscope as required	X		X		81001
Toxicology (Occupational Health)
Benzene, blood	X				84600
Beta-2 microglobulin (B2M), urine	X				82232
Cadmium, blood or urine	X				82300	same code for blood or urine
Cholinesterase, plasma/serum	X				82480
Gamma-glutamyl transferase (GGT), blood	X				82977
Lactate dehydrogenase (LDH), blood	X				83615
Lead, blood	X				83655
Bilirubin, total, blood	X				82247
Aromatic Solvents, blood	X				84600
Zinc Protoporphyrin (ZPP), blood	X				84202
DENTAL READINESS
Comprehensive oral evaluation [Annual Dental Exam]	X		X	50	D0150
Dental Radiology, Standard
Bitewing, single radiographic image	X		X	20*	D0270	*Minimum quantity is an aggregate amount of all bitewings. (20 bitewings total minimum)
Bitewing, two radiographic images	X		X	20*	D0272	*Minimum quantity is an aggregate amount of all bitewings. (20 bitewings total minimum)
Bitewing, three radiographic images	X		X	20*	D0273	*Minimum quantity is an aggregate amount of all bitewings. (20 bitewings total minimum)
Bitewing, four radiographic images	X		X	20*	D0274	*Minimum quantity is an aggregate amount of all bitewings. (20 bitewings total minimum)
Panographic radiographic image	X		X	20	D0330
DENTAL TREATMENT
Diagnostic Services
Limited oral evaluation - problem focused	X		X		D0140
Intraoral - comprehensive series of radiographic images	X		X		D0210
Intraoral - periabical first radiolgraphic image	X		X		D0220
Intraoral - periapical each additional radiographic image	X		X		D0230
Cone beam CT image capture with limited field of view - less than one whole jaw	X				D0380
Cone beam CT image capture with field of view of one full dental arch - mandible	X				D0381
Cone beam CT image capture with field of view of one full dental arch - maxilla with or without cranium	X				D0382
Restorative Services
Amalgam - one surface, primary or permanent	X		X		D2140
Amalgam - two surfaces, primary or permanent	X		X		D2150
Amalgam - three surfaces, primary or permanent	X		X		D2160
Amalgam - four or more surfaces, primary or permanent	X		X		D2161
Resin-based composite, one surface, anterior	X		X		D2330
Resin-based composite, two surfaces, anterior	X		X		D2331
Resin-based composite, three surfaces, anterior	X		X		D2332
Resin-based composite, four or more surfaces or involving incisal angle (anterior)	X		X		D2335
Resin-based composite, one surface, posterior	X		X		D2391
Resin-based composite, two surfaces, posterior	X		X		D2392
Resin-based composite, three surfaces, posterior	X		X		D2393
Pin retention - per tooth, in addtion to restoration	X		X		D2951
Recement or rebond inlay, onlay, veneer or partial coverage restoration	X		X		D2910
Recement or rebond indirectly fabricated or prefabricated post and core	X		X		D2915
Recement or rebond crown	X		X		D2920
Core build up, including any pins when required	X		X		D2950
Prefabricated post and core for crowns	X		X		D2954
Endodontic Services
Pulp cap - indirect (excluding final restoration)	X		X		D3120
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament	X		X		D3220
Pulpal debridement - primary and permanent teeth	X				D3221
Endodontic therapy, anterior tooth (excluding final restoration)	X		X		D3310
Endodontic therapy, premolar tooth (excluding final restoration)	X		X		D3320
Endodontic therapy, molar tooth (excluding final restoration)	X		X		D3330
Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth	X		X		D3332
Retreatment of previous root canal therapy - anterior	X		X		D3346
Retreatment of previous root canal therapy - premolar	X		X		D3347
Retreatment of previous root canal therapy - molar	X		X		D3348
Apicoectomy - anterior	X				D3410
Apicoectomy - premolar (first root)	X				D3421
Apicoectomy - molar (first root)	X				D3425
Apicoectomy - molar (each additional root)	X				D3426
Bone graft in conjunction with periadicular surgery - per tooth, single site	X				D3428
Retrograde filling - per root	X				D3430
Decoronation or submergence of an erupted tooth - Intentional removal of coronal tooth structure for preservation of the root and surrounding bone	X				D3921
Periodontal Services
Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit	X		X		D4355
Prosthedontic Services
Complete denture - maxillary	X				D5110
Complete denture - mandibular	X				D5120
Immediate denture - maxillary	X				D5130
Immediate denture- mandibular	X				D5140
Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth)	X				D5211
Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth)	X				D5212
Maxillary partial denture - cast metal framework with resin denture base (including retentive/clasping materials, rests and teeth)	X				D5213
Mandibular partial denture - cast metal framework with resin denture base (including retentive/clasping materials, rests and teeth)	X				D5214
Maxillary partial denture - flexible base (including retentative/clasping materials, rests, and teeth)	X				D5225
Mandibular partial denture - flexible base (including retentative/clasping materials, rests, and teeth)	X				D5226
Adjust complete denture - maxillary	X				D5410
Adjust complete denture - mandibular	X				D5411
Adjust partial denture - maxillary	X				D5421
Adjust partial denture - mandibular	X				D5422
Repair broken complete denture base, mandibular	X				D5511
Repair broken complete denture base, maxillary	X				D5512
Replace missing or broken teeth - complete denture (each tooth)	X				D5520
Repair resin partial denture base, mandibular	X				D5611
Repair resin partial denture base, maxillary	X				D5612
Repair cast partial denture base, mandibular	X				D5621
Repair cast partial denture base, maxillary	X				D5622
Repair or replace broken retentive clasping materials - per tooth	X				D5630
Rebase complete maxillary denture	X				D5710
Rebase complete mandibular denture	X				D5711
Rebase maxillary partial denture	X				D5720
Rebase mandibular partial denture	X				D5721
Rebase hybrid prosthesis - replacing the base material connect to the framework	X				D5725
Reline complete maxillary denture (direct) [chair side]	X				D5730
Reline complete mandibular denture (direct) [chair side]	X				D5731
Reline maxillary partial denture (direct) [chair side]	X				D5740
Reline mandibular partial denture (direct) [chair side]	X				D5741
Reline complete maxillary denture (indirect) [laboratory]	X				D5750
Reline complete mandibular denture (indirect) [laboratory]	X				D5751
Reline maxillary partial denture (indirect) [laboratory]	X				D5760
Reline mandibular partial denture (indirect) [laboratory]	X				D5761
Soft liner for complete or partial removable denture - indirect - a dscrete procedure provided when the dentist determines placement of the soft liner is clinically indicated	X				D5765
Interim partial denture (including retentive/clasping materials, rests and teeth), maxillary	X				D5820
Interim partial denture (including retentive/clasping materials, rests and teeth), mandibular	X				D5821
Recement or rebond fixed partial denture	X				D6930
Implant Services
Recement or rebond implant/abutment supported crown	X		X		D6092
Recement or rebond implant/abutment supported fixed partial denture	X		X		D6093
Oral Surgery Services
Extraction coronal remnants – primary tooth	X		X		D7111
Extraction, erupted tooth or exposed root (elevation and/or forceps removal)	X		X		D7140
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated	X		X		D7210
Removal of impacted tooth - soft tissue	X		X		D7220
Removal of impacted tooth - partial bony	X		X		D7230
Removal of impacted tooth - completely bony	X		X		D7240
Removal of impacted tooth - completely bony, with unusual surgical complications	X				D7241
Removal of residual tooth roots (cutting procedure)	X		X		D7250
Coronectomy - intentional partial tooth removal, impacted teeth only	X				D7251
Oroantral fistula closure	X				D7260
Primary closure of a sinus perforation	X		X		D7261
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth	X				D7270
Exposure of an unerupted tooth	X				D7280
Incisional biopsy of oral tissue - hard (bone, tooth)	X				D7285
Incisional biopsy of oral tissue - soft	X				D7286
Brush biopsy - transepithelial sample collection	X				D7288
Alveoloplasty in conjunction with extractions - for or more teeth or tooth spaces, per quadrant	X		X		D7310
Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant	X				D7320
Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant	X				D7321
Excision of benign lesion - lesion diameter less than 1.25 cm	X				D7410
Excision of benign lesion - greater than 1.25 cm	X				D7411
Excision of benign lesion, complicated	X				D7412
Removal of benign odontogenic cyst or tumor with lesion diameter up to 1.25 cm	X				D7450
Removal of benign odontogenic cyst or tumor with lesion diameter greater than 1.25 cm	X				D7451
Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm	X				D7460
Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm	X				D7461
Removal of lateral exostosis (maxilla or mandible)	X				D7471
Removal of lateral exostosis - (maxilla or mandible)	X				D7471
Removal of torus palatinus	X				D7472
Removal of torus mandibularis	X				D7473
Reduction of osseous tuberosity	X				D7485
Incision and drainage of abscess - intraoral soft tissue	X				D7510
Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial spaces)	X				D7511
Suture of recent small wounds - up to 5 cm	X				D7910
Complicated suture - up to 5 cm	X				D7911
Complicated suture - greater than 5 cm	X				D7912
Bone replacement graft for ridge preservation-per site.	X				D7953
Excision of pericoronal gingiva	X				D7971
Surgical reduction of fibrous tuberosity	X				D7972
Removal of foreign body from mucosa, skin or subcutaneous alveolar tissue	X				D7530
Removal of reaction producing foreign bodies, musculoskeletal system	X				D7540
Maxillary sinusotomy for removal of tooth fragment or foreign body	X				D7560
General Services
Palliative treatment of dental pain - per visit	X		X		D9110
Deep sedation/general anesthesia - first 15 minutes	X				D9222
Deep sedation/general anesthesia - each subsequent 15 minute increment	X				D9223
Intravenous moderate (conscious) sedation/anesthesia - first 15 minutes	X				D9239
Intravenous moderate (conscious) sedation/anesthesia - each subsequent 15 minute increment	X				D9243
Consultation - diagnositic service provided by dentist or physician other than requesting dentist or physician	X				D9310
Office visit - after regularly scheduled hours	X				D9440
Therapeutic parenteral drug, single adminitration	X		X		D9610
Therapeutic parenteral drug, two or more administrations, different medications	X		X		D9612
Treatment of complications (post-surgical) unusual circumstances, by report	X				D9930
Occlusal guard - hard appliance, full arch	X				D9944
Inhalation of Nitrous Oxide/Analgesia, Anxiolysis	X				D9230
MISCELLANEOUS FEE
SC-Requested Direct Outreach (price per SM)
VA disability rating admin (price per individual service)
Summary of care profile
Legacy transcription of profile with PHA
DD Form 2697 in lieu of SHPE
Individual Item Medical Record Update
Bulk Medical Record Update
CANCELLATION ADMIN FEE (late cancellations, within 72 hours of scheduled appointment)	X	X	X
NO SHOW ADMIN FEE	X	X	X

RHRP-4 PWS Exhibit A_RHRP4 Services

Exam Elements

	This worksheet describes the elements to each Physical Exam, and annotates to which demographic each applies.
	PHYSICAL EXAMS
		Procedure	Retention Exam	Accession Exam	Airborne Exam	Firefighter / CBRN Exam	SHA/SHPE
(ICD-10 DOD0222)	Occupational Health Exam,

Basic, Baseline (ICD-10 DOD0214) Occupational Health Exam, Basic, Periodic (ICD-10 DOD0215) Occupational Health Exam, Personnel Reliability Program (PRP)

(ICD-10 DOD0224)

see: https://www.med.navy.mil/Portals/62/Documents/NMFA/NMCPHC/root/Occupational%20and%20Environmental%20Medicine/32OccMedCodingGuide2017.pdf

Gender

Male

Female

Male

Female

Both

Male

Female

Both

https://www.med.navy.mil/Portals/62/Documents/NMFA/NMCPHC/root/Occupational%20and%20Environmental%20Medicine/33OEM_Orange_Manual_ICD-10Final.pdf?ver=2SOvLQI7cVP9wFiOGzH3cw%3D%3D

Age

<39 y/o

≥39 y/o

<39 y/o

≥39 y/o

<39 y/o

≥39 y/o

<39 y/o

≥39 y/o

This provides ICD-10 for PHA (DOD0225) and DRHAs (DOD0211-DOD0213)

Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate

(Exam Requirements based on exam form, labs and tests determined by exposure concerns and ordered individually)

note: changes to Occ Health Exams to align with DOD ICD-10 codes

Valsalva

Rectal

Stool Occult Guiac

Pelvic / PAP - Cytopathology, cervical or vaginal.

HIV Test (Civilian lab/not CDS)

HIV Test (Government CDS)

Complete Blood Count (CBC) w/ Differential

HGB

HCT

Urinalysis, complete w/ reflex microscope (p.r.n.)

Lipid Panel

Total Cholesterol

Comprehensive Metabolic Panel (CMP)

Glucose

HCV antibody test (Hepatitis C)

X (optional, SM choice)

PSA Test - lab

Drug Screen

*AGR only

ETOH Screen

*AGR only

Pregnancy Test

*AGR only

Lead

ZPP

Audiogram

Vision (Comprehensive Eye Exam)

Tonometry

Color Vision

Peripheral Vision & Depth Perception

Chest X-Ray

B-Read

EKG, 12 Lead

EKG, Stress

Spirometry

Forms

Exam Checklist

X Exam specific forms

DD Form 2015

DD Form 2807-1

DD Form 2808

SF 507

HHS Form FOH-6

RHRP 5

RHRP 5C

RHRP 14A

RHRP 22

Respirator Clearance Certification

Lab Requisition

Lab Requisition (USA CHPPM Lab)

HIV Transmittal Request Form, HIV Screening Test Results Card, HIV Instructions

PAP Requisition, PAP Instructions

Sub test not explicitly required but done

X = Explicitly required test

&"Times New Roman,Italic"SOURCE SELECTION INFORMATION - SEE FAR 2.101 AND 3.104

Sheet2

File details come from the government source that posted it. Updated Jul 23, 2025.