RHRP-II Attachment 1 - Procedures Fixed Unit Prices - B.xlsx

XLSX spreadsheet 54 KB Posted Apr 13, 2012

Attached to: Reserve Health Readiness Program (RHRP) II Federal contract opportunity
Solicitation number: HT0011-12-R-0009
Issued by: Defense Health Agency

About this file

From the source

HT0011-12-R-0009 Attachment 1 - Procedures Fixed Unit Prices

View the file

Other files for this federal contract opportunity

Other files attached to Reserve Health Readiness Program (RHRP) II, newest first.
File	Type	Posted
HT0011-12-R-0009-0004.pdf	PDF	May 10, 2012
HT0011-12-R-0009-0003.pdf	PDF	May 9, 2012
RHRP-II Attachment 28 - AI No. 042 - Security of Unclassified Department of Defense Information on Non-TMA Information Systems.pdf	PDF	May 8, 2012
HT0011-12-R-0009-0002.doc	DOC document	May 8, 2012
RHRP-II Attachment 1 - Procedures Fixed Unit Prices.xlsx	XLSX spreadsheet	May 8, 2012
RHRP-II Attachment 26 - Past Performance Questionnaire v2.docx	DOCX document	May 8, 2012
RHRP-II Attachment 27 - Army PDHRA Referral Form	—	May 8, 2012
RHRP-II Industry Questions and Answers.xls	XLS spreadsheet	May 8, 2012
RHRP-II_Attachment_22_-_RHRPII-_5C_Occ_Health_Form2.pdf	PDF	Apr 18, 2012
HT0011-12-R-0009 Amendment.doc	DOC document	Apr 18, 2012
RHRP-II_Attachment_11_-_Service_Component_IT_Specs_OTSG.doc	DOC document	Apr 18, 2012
RHRP-II_Attachment_26_-_Past Performance Questionnaire.doc	DOC document	Apr 18, 2012
RHRP-II Attachment 14 -Reports Schedule 6 Jan 2012.xlsx	XLSX spreadsheet	Apr 13, 2012
RHRP-II Attachment 22 - RHRPII- 5C Occ Health Form.pdf	PDF	Apr 13, 2012
RHRP-II Attachment 21 - RHRPII-5 Occ Health Form.pdf	PDF	Apr 13, 2012
RHRP-II Attachment 24 - RHRPII-22 Occ Health.pdf	PDF	Apr 13, 2012
RHRP-II Attachment 15 - Functional Capacity Certificate SF 507 .pdf	PDF	Apr 13, 2012
RHRP-II Attachment 3 - Non-Disclosure AgreementL.doc	DOC document	Apr 13, 2012
RHRP-II Attachment 10 - Service Component IT Specs_USCG.doc	DOC document	Apr 13, 2012
RHRP-II Attachment 8 - Service Component IT Specs_USAR .doc	DOC document	Apr 13, 2012
RHRP-II Attachment 7 - Service Component IT Specs_USAFR-ANG.doc	DOC document	Apr 13, 2012
RHRP-II Attachment 16 - ARMY PHA Form.pdf	PDF	Apr 13, 2012
RHRP-II Attachment 23 - RHRPII -6 Occ Health Form.pdf	PDF	Apr 13, 2012
RHRP-II Attachment 25 - RHRP Health Questionaire.pdf	PDF	Apr 13, 2012
RHRP-II Attachment 20 - USAFR RCHRA Form.pdf	PDF	Apr 13, 2012
RHRP-II Attachment 9 ver1 - Service Component IT Specs_ARNG.doc	DOC document	Apr 13, 2012
RHRP-II Attachment 2 - USPSTF.xls	XLS spreadsheet	Apr 13, 2012
RHRP-II Attachment 11 - Service Component IT Specs_OTSG.doc	DOC document	Apr 13, 2012
RHRP-II Attachment 12 - Performance Requirements Summary Jan6 2012.doc	DOC document	Apr 13, 2012
RHRP-II Attachment 6 - Service Component IT Specs_USNR-MARFORRES.doc	DOC document	Apr 13, 2012
RHRP-II Attachment 17 - USNR-MFR PHA Form.pdf	PDF	Apr 13, 2012
RHRP-II Attachment 5 - GFE.xlsx	XLSX spreadsheet	Apr 13, 2012
HT0011-12-R-0009.doc	DOC document	Apr 13, 2012
RHRP-II Attachment 19 - USAFR PHA Form - 2808.pdf	PDF	Apr 13, 2012
RHRP-II Attachment 1A.docx	DOCX document	Apr 13, 2012
RHRP-II Attachment 4 - PULHES PHYSICAL PROFILE SERIAL.doc	DOC document	Apr 13, 2012
RHRP-II Attachment 18 - USCGR PHA Form.pdf	PDF	Apr 13, 2012

Show all 37

On GovTribe

Work with this file on GovTribe

Download the original file
Contacts named in this file
Similar government files
Ask GovTribe AI about this file

Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

Attachment 1 - Master Element New Procedure Number Sub-Element Gender Historic Quantity Fixed Unit Price Extended Amount

A. PHYSICAL EXAMS - IN-CLINIC
Retention exam, younger than 39, male	A1	Includes sub-elements: a-i.		Male	329
Retention exam, younger than 39, female	A2	Includes sub-elements: a-j.		Female	123
		a.	Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
		b.	HIV Test
		c.	HGB
		d.	HCT
		e.	Urinalysis, complete w/ reflex microscope (p.r.n.)
		f.	Total Cholesterol
		g.	Audiogram
		h.	Vision
		i.	Rectal
		j.	Pelvic / PAP - Cytopathology, cervical or vaginal.
		Forms: Exam Checklist, Voucher, DD2807-1, DD2808, SF 507, Customer Satisfaction Survey, Lab Requisition, PAP Requisition, PAP Instructions, HIV Transmittal Request Form, HIV Screening Test Results Card, HIV Instructions.

Retention exam, 39 and older, male	A3	Includes sub-elements: a-n.		Male	323
Retention exam, 39 and older, female	A4	Includes sub-elements: a-m & o.		Female	50
		a.	Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
		b.	HIV Test
		c.	HGB
		d.	HCT
		e.	Urinalysis, complete w/ reflex microscope (p.r.n.)
		f.	Lipid Panel
		g.	Audiogram
		h.	Vision
		i.	Rectal
		j.	Tonometry
		k.	Stool Occult
		l.	Glucose
		m.	EKG, 12 Lead
		n.	PSA Test– PSA Laboratory
		o.	Pelvic / PAP - Cytopathology, cervical or vaginal.
		Forms: Exam Checklist, Voucher, DD2807-1, DD2808, SF 507, Customer Satisfaction Survey, Lab Requisition, PAP Requisition, PAP Instructions, HIV Transmittal Request Form, HIV Screening Test Results Card, HIV Instructions.

Airborne exam	A5	Includes sub-elements: a-h.		Both	640
		a.	Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
		b.	HIV Test
		c.	Urinalysis, complete w/ reflex microscope (p.r.n.)
		d.	Audiogram
		e.	Vision
		f.	Color Vision
		g.	Rectal
		h.	Valsalva
		Forms: Exam Checklist, Voucher, DD2807-1, DD2808, SF 507, Customer Satisfaction Survey, Lab Requisition, HIV Transmittal Request Form, HIV Screening Test Results Card, HIV Instructions.

Accession exam, male	A6	Includes sub-elements: a-i.		Male	5
Accession exam, female	A7	Includes sub-elements: a-j.		Female	5
		a.	Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
		b.	HIV Test
		c.	Urinalysis, complete w/ reflex microscope (p.r.n.)
		d.	Drug Screen
		e.	ETOH Screen
		f.	Audiogram
		g.	Vision
		h.	Color Vision
		i.	Rectal
		j.	Pregnancy Test
		Forms: Exam Checklist, Voucher, DD2807-1, DD2808, SF 507, Customer Satisfaction Survey, Lab Requisition, HIV Transmittal Request Form, HIV Screening Test Results Card, HIV Instructions.

Physical exam, Chapter 3, AGR, younger than 39, male	A8	Includes sub-elements: a-k.		Male	11
Physical exam, Chapter 3, AGR, younger than 39, female	A9	Includes sub-elements: a-m.		Female	6
		a.	Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
		b.	Audiogram
		c.	Vision
		d.	HGB
		e.	HCT
		f.	HIV Test
		g.	Total Cholesterol
		h.	Urinalysis, complete w/ reflex microscope (p.r.n.)
		i.	Drug Screen
		j.	ETOH Screen
		k.	Rectal
		l.	Pelvic / PAP - Cytopathology, cervical or vaginal.
		m.	Pregnancy Test
		Forms: Exam Checklist, Voucher, DD2807-1, DD2808, SF 507, Customer Satisfaction Survey, Lab Requisition, PAP Requisition, PAP Instructions, HIV Transmittal Request Form, HIV Screening Test Results Card, HIV Instructions.

Physical exam, Chapter 3, AGR, 39 and older, male	A10	Includes sub-elements: a-q.		Male	3
Physical exam, Chapter 3, AGR, 39 and older, female	A11	Includes sub-elements: a-n & q-s.		Female	1
		a.	Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
		b.	Audiogram
		c.	Stool Occult
		d.	Rectal
		e.	Vision
		f.	HGB
		g.	HCT
		h.	HIV Test
		i.	Total Cholesterol
		j.	Urinalysis, complete w/ reflex microscope (p.r.n.)
		k.	Lipid Panel
		l.	Glucose
		m.	Drug Screen
		n.	ETOH Screen
		o.	PSA Test– PSA Laboratory
		p.	Tonometry
		q.	EKG, 12 Lead
		r.	Pelvic / PAP - Cytopathology, cervical or vaginal.
		s.	Pregnancy Test
		Forms: Exam Checklist, Voucher, DD2807-1, DD2808, SF 507, Customer Satisfaction Survey, Lab Requisition, PAP Requisition, PAP Instructions, HIV Transmittal Request Form, HIV Screening Test Results Card, HIV Instructions.

Air Force retention exam	A12	Includes sub-elements: a-e.		Both	205
		a.	Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
		b.	HIV draw
		c.	Audiogram
		d.	Vision
		e.	Rectal
		Forms: Exam Checklist, Voucher, DD 2808, Customer Satisfaction Survey, RCHRA, AF1762 Specimen Transmittal.

Firefighter / CBRN exam, younger than 39, male	A13	Includes sub-elements: a-v.		Male	119
Firefighter / CBRN exam, younger than 39, female	A14	Includes sub-elements: a-x.		Female	10
		a.	Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
		b.	Audiogram
		c.	Vision
		d.	Color Vision
		e.	Peripheral Vision
		f.	Depth Perception
		g.	HGB
		h.	HCT
		i.	HIV Test
		j.	Lipid Panel
		k.	Cholesterol
		l.	Glucose
		m.	CBC with Differential
		n.	Chemistry Profile
		o.	Lead
		p.	ZPP
		q.	Urinalysis, complete w/ reflex microscope (p.r.n.)
		r.	Spirometry
		s.	Chest X-ray
		t.	B-read
		u.	EKG, 12 Lead
		v.	Rectal
		w.	Pelvic / PAP - Cytopathology, cervical or vaginal.
		x.	Pregnancy Test
		Forms: Exam Checklist, DD2807-1, DD2808, SF 507, RHRPII-5, RHRPII-5C, RHRPII-22, Respirator Clearance Certification, DD Form 2015, DD Form 2005, RHRPII-6, Customer Satisfaction Survey, RHRPII-14A, Lab Requisition, USACHPPM Lab Requisition.

Firefighter / CBRN exam, 39 and older, male	A15	Includes sub-elements: a-z.		Male	12
Firefighter / CBRN exam, 39 and older, female	A16	Includes sub-elements: a-w & y-bb.		Female	5
		a.	Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
		b.	Audiogram
		c.	Vision
		d.	Color Vision
		e.	Peripheral Vision
		f.	Depth Perception
		g.	HGB
		h.	HCT
		i.	HIV Test
		j.	Lipid Panel
		k.	Cholesterol
		l.	Glucose
		m.	CBC with Differential
		n.	Chemistry Profile
		o.	Lead
		p.	ZPP
		q.	Urinalysis, complete w/ reflex microscope (p.r.n.)
		r.	Spirometry
		s.	Chest X-ray
		t.	B-read
		u.	EKG, 12 Lead
		v.	Stress EKG
		w.	Rectal
		x.	PSA Test– PSA Laboratory
		y.	Tonometry
		z.	Stool Occult
		aa.	Pelvic / PAP - Cytopathology, cervical or vaginal.
		bb.	Pregnancy Test
		Forms: Exam Checklist, DD2807-1, DD2808, SF 507, RHRPII-5,RHRPII-5C, RHRPII-22, Respirator Clearance Certification, DD Form 2015, DD Form 2005, FOH-6, Customer Satisfaction Survey, RHRPII-14A, Lab Requisition, USACHPPM Lab Requisition.
B. PERIODIC HEALTH ASSESSMENT (PHA) & FOCUSED EXAM - IN-CLINIC
ARNG / USAR
ARNG / USAR, PHA, in-clinic, price per completed PHA	B1			Both	65,952
MARFORRES / USCG / USNR
MARFORRES / USCG / USNR, PHA, in-clinic, price per completed PHA	B2			Both	9,510
C. PHA & FOCUSED EXAM - GROUP EVENT
USAR
USAR, PHA, group event, TIER 1 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 40 or less)	C1			Both	35,160
USAR, PHA, group event, TIER 2 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 41 to 80)	C2			Both	21,604
USAR, PHA, group event, TIER 3 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 81 or more)	C3			Both	25,867
MARFORRES / USCG / USNR
MARFORRES / USCG / USNR, PHA, group event, TIER 1 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 40 or less)	C4			Both	6,360
MARFORRES / USCG / USNR, PHA, group event, TIER 2 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 41 to 80)	C5			Both	5,070
MARFORRES / USCG / USNR, PHA, group event, TIER 3 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 81 or more)	C6			Both	6,666
ARNG
ARNG, PHA point of service, group event, TIER 1 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 40 or less)	C7			Both	12,990
ARNG, PHA point of service, group event, TIER 2 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 41 to 80)	C8			Both	11,635
ARNG, PHA point of service, group event, TIER 3 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 81 or more)	C9			Both	40,213
D. PHA LITE & FOCUSED EXAM - GROUP EVENT
PHA lite, group event, TIER 1 (minimum 30 PHA lites to schedule; price per PHA lite when total PHA lites completed at group event equal 40 or less)	D1			Both	3,360
PHA lite, group event, TIER 2 (minimum 30 PHA lites to schedule; price per PHA lite when total PHA lites completed at group event equal 41 to 80)	D2			Both	3,217
PHA lite, group event, TIER 3 (minimum 30 PHA lites to schedule; price per PHA lite when total PHA lites completed at group event equal 81 or more)	D3			Both	12,657
E. PHA BEHAVIORAL HEALTH SPECIALIST STAND ALONE - CALL CENTER / GROUP EVENT
PHA Behavioral Health Specialist, call center, price per call	E1			Both	1
PHA Behavioral Health Specialist, group event (minimum 60 scheduled PHAs; price for up to 60 PHAs)	E2			Both	1
F. POST DEPLOYMENT HEALTH RE-ASSESSMENT (PDHRA) - CALL CENTER
PDHRA, call center, price per completed DD Form 2900	F1			Both	61,939
G. PDHRA - GROUP EVENT
PDHRA, group event, TIER 1 (minimum 30 PDHRAs to schedule; price per PDHRA when total PDHRAs completed at group event equal 40 or less)	G1			Both	9,960
PDHRA, group event, TIER 2 (minimum 30 PDHRAs to schedule; price per PDHRA when total PDHRAs completed at group event equal 41 to 80)	G2			Both	7,422
PDHRA, group event, TIER 3 (minimum 30 PDHRAs to schedule; price per PDHRA when total PDHRAs completed at group event equal 81 or more)	G3			Both	16,745
H. MENTAL HEALTH ASSESSMENT (MHA) - CALL CENTER
MHA, call center, price per completed MHA when positive screen	H1			Both	30
MHA, call center, price per completed MHA when negative screen	H2			Both	10,013
I. MHA - GROUP EVENT
MHA, group event, TIER 1 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 40 or less)	I1			Both	3,000
MHA, group event, TIER 2 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 41 to 80)	I2			Both	3,000
MHA, group event, TIER 3 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 81 or more)	I3			Both	3,000
J. AUDIO w/ Exam (PHA / Physical Exam) - IN-CLINIC
Annual Audiometric Screen with MEDPROS Update	J1			Both	26,611
Comprehensive audio exam / pure tone air and bone conduction testing	J2			Both	2,706
SPRINT (Speech Recognition in Noise Test)	J3			Both	1,181
JJ. AUDIO STAND ALONE - IN-CLINIC
Acoustic reflex testing threshold	JJ1			Both	1,444
Audio Hearing Test - pure tone air	JJ2			Both	5,416
Audiometry - pure tone air and bone conduction testing	JJ3			Both	5,106
Consultation w/ Otolaryngologist	JJ4			Both	5
DOHERS entry	JJ5			Both	34,453
Evoked acoustic emission; limited (single stimulus level, either transient or distortion products)	JJ6			Both	5
Speech audiometry threshold; w/ speech recognition	JJ7			Both	3,220
Sprint	JJ8			Both	1,430
Tympanometry	JJ9			Both	3,156
JJJ. AUDIO - GROUP EVENT
Annual Audiometric Screen with MEDPROS Update (minimum 50 screens per day to schedule; price per completed screen)	JJJ1			Both	137,133
Comprehensive audio exam / pure tone air and bone conduction testing (minimum 25 tests per day to schedule; price per completed test)	JJJ2			Both	4,534
DOHERS entry	JJJ3			Both	134,023
K. VISION w/ Exam (PHA / Physical Exam) - IN-CLINIC
Comprehensive eye exam	K1			Both	5
Eye examination with refraction and prescription	K2			Both	367
Tonometry	K3			Both	11
Vision Screen with color and with & without correction	K4			Both	51,178
KK. VISION STAND ALONE - IN-CLINIC
Comprehensive eye exam	KK1			Both	6,395
Eye examination with refraction and prescription	KK2			Both	16,769
Tonometry	KK3			Both	11
Vision - Monocular	KK4			Both	11
Vision Screen with color and with & without correction	KK5			Both	944
KKK. VISION - GROUP EVENT
Comprehensive eye exam (minimum 25 exams per day to schedule; price per completed exam)	KKK1			Both	5,986
Eye exam with refraction and prescription, group event (minimum 50 exams per day to schedule; price per completed exam)	KKK2			Both	20,328
Vision screen, group event, TIER 1 (minimum 30 screens to schedule; price per completed screen when total screens completed at group event equal 40 or less)	KKK3			Both	2,059
Vision screen, group event, TIER 2 (minimum 30 screens to schedule; price per completed screen when total screens completed at group event equal 41 to 80)	KKK4			Both	88,900
Vision screen, group event, TIER 3 (minimum 30 screens to schedule; price per completed screen when total screens completed at group event equal 81 or more)	KKK5			Both	98,355
L. IMMUNIZATION w/ Exam (PHA / Physical Exam) - IN-CLINIC
Hepatitis A	L1			Both	3,270
Hepatitis B	L2			Both	2,576
Influenza - Injectable	L3			Both	8,353
Rabies Titer	L4			Both	5
PPD	L5			Both	98
Tdap	L6			Both	1,535
Tetanus and Diphtheria	L7			Both	41
Twinrix	L8			Both	326
Varicella	L9			Both	5
Varicella titer	L10			Both	5
LL. IMMUNIZATION STAND ALONE - IN-CLINIC
Hepatitis A	LL1			Both	3,075
Hepatitis B	LL2			Both	3,657
Influenza - Injectable	LL3			Both	9,105
Japanese encephalitis	LL4			Both	45
Meningococcus	LL5			Both	18
Polio	LL6			Both	5
Rabies	LL7			Both	20
Rabies Titer	LL8			Both	5
PPD	LL9			Both	1,086
Tdap	LL10			Both	2,227
Tetanus and Diphtheria	LL11			Both	129
Typhoid	LL12			Both	130
Twinrix	LL13			Both	314
Varicella	LL14			Both	305
Varicella titer	LL15			Both	1,612
Yellow fever	LL16			Both	52
LLL. IMMUNIZATION - GROUP EVENT
Administration of vaccine, group event, TIER 1 (minimum 60 administrations to schedule; price per completed administration when total administrations completed at group event equal 60 or less)	LLL1			Both	149,275
Administration of vaccine, group event, TIER 2 (minimum 60 administrations to schedule; price per completed administration when total administrations completed at group event equal 61 to 120)	LLL2			Both	84,508
Administration of vaccine, group event, TIER 3 (minimum 60 administrations to schedule; price per completed administration when total administrations completed at group event equal 121 or more)	LLL3			Both	104,252
Anthrax (6 shot series) (Government will provide vaccine)	LLL4			Both	22,137
Globulin, Immune	LLL5			Both	5
Hepatitis A (2 shot series)	LLL6			Both	23,924
Hepatitis B (3 shot series)	LLL7			Both	24,089
Inactivated Polio Vaccine (IPV)	LLL8			Both	75
Influenza	LLL9			Both	6,964
Japanese Encephalitis	LLL10			Both	337
Measles, Mumps, Rubella (MMR)	LLL11			Both	159
Menactra	LLL12			Both	2,048
PPD	LLL13			Both	6,765
Rabies (3 shot series)	LLL14			Both	154
Rabies Titer	LLL15			Both	5
Storage of DoD Vaccine	LLL16			Both	137,981
Tdap	LLL17			Both	43,879
Tetanus and Diphtheria	LLL18			Both	1,718
Typhoid (injectable or oral)	LLL19			Both	25,036
Varicella	LLL20			Both	167
Varicella titer	LLL21			Both	1,612
Yellow fever	LLL22			Both	1,297
M. LABORATORY SERVICE w/ Exam (PHA / Physical Exam) - IN-CLINIC
AGR labs	M1	Services Include: 1) Drug Screen, 2) ETOH Screen, 3) Pregnancy Test, 4) Forms: Voucher, Customer Satisfaction Survey, Lab Requisition		Both	17
Blood type and determination of Rh factor w/ venipuncture	M2			Both	152
Chlamydia, DNA by SDA (urine)	M3			Both	26
Chlamydia / Gonorrhea (by swab)	M4			Both	555
Chlamydia / Gonorrhea (reflex from swab)	M5			Both	1
CVSP	M6	Service includes: 1) Blood pressure, 2) Fasting lipid profile, including total cholesterol, LDL, HDL, and triglycerides, 3) Electrocardiogram (ECG) / EKG (Invoiced Separately), 4) Fasting blood glucose, 5) Height and weight		Both	19,619
DNA test	M7			Both	2,517
Gonorrhea, DNA by SDA (urine)	M8			Both	5
G6PD	M9			Both	1,972
HIV test	M10			Both	3,569
Pregnancy, urine	M11			Female	356
PSA	M12			Male	69
PSA w/ rectal exam	M13			Male	5
Rectal exam with stool for guaiac	M14			Both	291
Sickle cell screening test w/ confirmation by reflex to hemoglobulinopathy	M15			Both	56
Stool occult for blood (1 slide)	M16			Both	5
Stool occult for blood (2 slide)	M17			Both	5
Stool occult for blood (3 slide)	M18			Both	5
Thin prep w/ preventive exam (pelvic) to collect specimen	M19			Female	851
Phlebotomy (blood draw)	M20			Both	5,146
MM. LABORATORY SERVICE STAND ALONE - IN-CLINIC
AGR labs	MM1	Services Include: 1) Drug Screen, 2) ETOH Screen, 3) Pregnancy Test, 4) Forms: Voucher, Customer Satisfaction Survey, Lab Requisition		Both	17
Blood type and determination of Rh factor w/ venipuncture	MM2			Both	58
Chlamydia, DNA by SDA (urine)	MM3			Both	122
CVSP	MM4	Service includes: 1) Blood pressure, 2) Fasting lipid profile, including total cholesterol, LDL, HDL, and triglycerides, 3) Electrocardiogram (ECG) / EKG (Invoiced Separately), 4) Fasting blood glucose, 5) Height and weight		Both	433
DNA test (no lab) - use military labor and DNA card	MM5			Both	315
Gonorrhea, DNA by SDA (urine)	MM6			Both	24
G6PD	MM7			Both	1,558
HIV test	MM8			Both	9,945
Phlebotomy (blood draw)	MM9			Both	78
Pregnancy, urine	MM10			Female	419
PSA	MM11			Male	1
PSA w/ rectal exam	MM12			Male	5
Rectal exam w/ stool for guaiac	MM13			Both	45
Sickle cell screening test w/ confirmation by reflex to hemoglobulinopathy	MM14			Both	47
Stool occult for blood (1 slide)	MM15			Both	5
Stool occult for blood (2 slide)	MM16			Both	5
Stool occult for blood (3 slide)	MM17			Both	5
Thin prep w/ preventive exam (pelvic) to collect specimen	MM18			Female	2,526
MMM. LABORATORY SERVICE - GROUP EVENT
Blood type and determination of Rh factor w/ venipuncture	MMM1			Both	1,721
Chlamydia, DNA by SDA (urine)	MMM2			Both	621
CVSP	MMM3	Service includes: 1) Blood pressure, 2) Fasting lipid profile, including total cholesterol, LDL, HDL, and triglycerides, 3) Electrocardiogram (ECG) / EKG (Invoiced Separately), 4) Fasting blood glucose, 5) Height and weight		Both	17,580
CVSP (Cholestech) (minimum 25 screens per day to schedule; price per completed screen)	MMM4			Both	1,412
Gonorrhea, DNA by SDA (urine)	MMM5			Both	98
G6PD Testing	MMM6			Both	33,085
HIV testing, group event, TIER 1 (minimum 50 tests to schedule; price per completed test when total tests completed at group event equal 40 or less)	MMM7			Both	19,845
HIV testing, group event, TIER 2 (minimum 50 tests to schedule; price per completed test when total tests completed at group event equal 41 to 80)	MMM8			Both	12,287
HIV testing, group event, TIER 3 (minimum 50 tests to schedule; price per completed test when total tests completed at group event equal 81 or more)	MMM9			Both	10,000
HPV lab	MMM10			Both	1
Phlebotomy (CVSP, DNA, G6PD,HIV, Rabies Titer, Varicella Titer) (minimum 30 draws per day to schedule; price per completed draw)	MMM11			Both	21,288
Pregnancy Test (minimum 30 tests per day to schedule; price per completed test)	MMM12			Female	6,735
PSA	MMM13			Male	14
PSA w/ rectal exam	MMM14			Male	5
Status hCG Strip (Kit Only)	MMM15			Both	3,985
Stool occult for blood (1 slide)	MMM16			Both	5
Stool occult for blood (2 slide)	MMM17			Both	5
Stool occult for blood (3 slide)	MMM18			Both	5
Thin prep w/ preventive exam (pelvic) to collect specimen	MMM19			Female	107
N. MISCELLANEOUS MEDICAL SERVICE w/ Exam (PHA / Physical Exam) - IN-CLINIC
Breast exam	N1			Both	5
Chest x-ray, posterior-anterior view	N2			Both	1
EKG, resting	N3			Both	17,935
Mammography	N4			Female	156
Chest x-ray, posterior-anterior and lateral views with interpretation	N5			Both	20
NN. MISCELLANEOUS MEDICAL SERVICE STAND ALONE - IN-CLINIC
Breast exam	NN1			Both	5
B-read	NN2			Both	24
Chest x-ray, posterior-anterior view	NN3			Both	149
EKG, resting	NN4			Both	671
Mammography	NN5			Female	380
NNN. MISCELLANEOUS MEDICAL SERVICE - GROUP EVENT
Breast exam	NNN1			Both	5
EKG, resting (minimum 20 EKGs per day to schedule; price per completed EKG)	NNN2			Both	26,053
O. DENTAL SERVICE - IN-CLINIC
Annual Dental Exam (Periodic Oral Examination)	O1			Both	494
Annual Dental Exam (Comprehensive Oral Examination)	O2			Both	57,076
Dental bitewing, single film	O3			Both	1,121
Dental bitewing, set of two films	O4			Both	964
Dental bitewing, set of three films	O5			Both	15
Dental bitewing, set of four films as indicated	O6			Both	57,566
Complete series x-ray	O7			Both	4
Cone beam – 2 dimensional image reconstruction	O8			Both	2
Cone beam – 3 dimensional image reconstruction	O9			Both	2
Intraoral periapical x-ray	O10			Both	40,653
Panographic x-ray	O11			Both	24,710
OO. DENTAL SERVICE - GROUP EVENT
Dental exam, comprehensive oral evaluation, group event, TIER 1 (minimum 50 exams to schedule; price per exam when total exams completed at group event equal 40 or less)	OO1			Both	189,680
Dental exam, comprehensive oral evaluation, group event, TIER 2 (minimum 50 exams to schedule; price per exam when total exams completed at group event equal 41 to 80)	OO2			Both	12,165
Dental exam, comprehensive oral evaluation, group event, TIER 3 (minimum 50 exams to schedule; price per exam when total exams completed at group event equal 81 or more)	OO3			Both	10,000
Dental bitewings, set of 4 films, group event, TIER 1 (minimum 20 sets to schedule; price per set when total sets completed at group event equal 40 or less)	OO4			Both	39,706
Dental bitewings, set of 4 films, group event, TIER 2 (minimum 20 sets to schedule; price per set when total sets completed at group event equal 41 to 80)	OO5			Both	86,646
Dental bitewings, set of 4 films, group event, TIER 3 (minimum 20 sets to schedule; price per set when total sets completed at group event equal 81 or more)	OO6			Both	50,000
Panographic radiograph, group event, TIER 1 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 40 or less)	OO7			Both	22,100
Panographic radiograph, group event, TIER 2 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 41 to 80)	OO8			Both	10,000
Panographic radiograph, group event, TIER 3 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 81 or more)	OO9			Both	5,459
Dental exam, comprehensive oral evaluation, group in-clinic (minimum 15 exams to schedule; price per completed exam; transportation of Service Members is responsibility of Service Component)	OO10			Both	83
P. DENTAL TREATMENT SERVICE - IN-CLINIC
Consultation Dental Exam	P1			Both	18,501
Office visit after hours	P2			Both	2
Hospital call	P3			Both	1
Detailed and extensive oral evaluation	P4			Both	20
Comprehensive periodontal evaluation	P5			Both	5
Amalgam, One Surface, Permanent	P6			Both	5,734
Amalgam, Two Surfaces, Permanent	P7			Both	10,960
Amalgam, Three Surfaces, Permanent	P8			Both	6,002
Amalgam, Four or More Surfaces, Permanent	P9			Both	1,809
Apicoectomy - Anterior	P10			Both	25
Apicoectomy - Bicuspid	P11			Both	7
Apicoectomy - Molar - first root	P12			Both	10
Apicoectomy - Molar - each add'l root	P13			Both	5
Resin Based Composite, one surface	P14			Both	2,241
Resin Based Composite, two surfaces	P15			Both	2,405
Resin Based Composite, three surfaces	P16			Both	2,546
Resin Based Composite, four surface	P17			Both	1,529
Resin (1) one surface posterior	P18			Both	2,265
Resin (2) two surface posterior	P19			Both	3,581
Resin (3) three surface posterior	P20			Both	2,409
Resin (4) four or more posterior	P21			Both	1,045
Anterior (excluding final restoration)	P22			Both	1,053
Bicuspid (excluding final restoration)	P23			Both	1,930
Molar (excluding final restoration)	P24			Both	3,796
Core build up including pins	P25			Both	8,957
Prefab post & core	P26			Both	836
Extraction, single tooth	P27			Both	5,371
Extraction, each additional tooth	P28			Both	1
Extraction deciduous tooth	P29			Both	3
Complete bony extraction	P30			Both	226
Surgical removal of erupted tooth	P31			Both	8,642
Removal of impacted tooth-completely bony	P32			Both	3,017
Removal of impacted tooth soft tissue	P33			Both	1,065
Removal of impacted tooth partial bony	P34			Both	4,070
Analgesic Nitrous	P35			Both	1,034
IV anesthesia first 30 minutes	P36			Both	1,472
IV anesthesia each additional 15 minutes	P37			Both	663
Local anesthesia	P38			Both	7
Regional block anesthesia	P39			Both	1
Deep Sedation / general anesthesia first 30 minutes	P40			Both	3,656
Deep Sedation / general anesthesia each additional 15 minutes	P41			Both	1,695
Non-intravenous conscious sedation	P42			Both	62
Therapeutic drug injection - includes antibiotic or injection of sedative	P43			Both	732
Palliative treatment of dental pain	P44			Both	112
Oral antibiotics (given at the office)	P45			Both	11
Periodontal scaling and root planing	P46			Both	7
Perio scaling and root planing per quadrant	P47			Both	177
Full mouth debridement	P48			Both	1,228
Gingivectomy, 1-3 teeth	P49			Both	5
Gingivectomy, 4 or more teeth	P50			Both	5
Sedative filling	P51			Both	369
Pin retention in addition to filling	P52			Both	63
Retrograde filling	P53			Both	31
Pulp cap (indirect)	P54			Both	393
Pulp cap (direct)	P55			Both	95
Pulpotomy	P56			Both	32
Pulpal debridement	P57			Both	42
Pulp vitality tests	P58			Both	306
Incomplete endo therapy	P59			Both	58
Retreatment of molar endo	P60			Both	332
Immediate denture maxillary	P61			Both	146
Immediate denture mandibular	P62			Both	89
Partial denture maxillary (resin base)	P63			Both	229
Partial denture mandibular (resin base)	P64			Both	180
Adjust maxillary denture	P65			Both	1
Add tooth to existing partial denture	P66			Both	67
Mandibular partial denture flexible base	P67			Both	1
Add clasp to existing partial denture	P68			Both	4
Reline mandibular partial denture (chair side)	P69			Both	1
Reline complete maxillary denture (laboratory)	P70			Both	3
Reline mandibular partial denture (laboratory)	P71			Both	1
Reline complete maxillary denture (chair side)	P72			Both	1
Reline complete mandibular denture (chair side)	P73			Both	1
Reline maxillary partial denture (chair side)	P74			Both	1
Interim partial denture (maxillary)	P75			Both	424
Interim partial denture (mandibular)	P76			Both	54
Recement fixed partial denture	P77			Both	10
Adjust complete denture - mandibular	P78			Both	1
Adjust partial denture - maxillary	P79			Both	1
Adjust partial denture - mandibular	P80			Both	1
Repair broken complete denture base	P81			Both	2
Replace missing or broken teeth - complete denture (each tooth)	P82			Both	4
Reline complete mandibular denture (laboratory)	P83			Both	4
Reline maxillary partial denture (laboratory)	P84			Both	1
Complete denture maxillary	P85			Both	9
Complete denture mandibular	P86			Both	4
Maxillary partial denture - cast metal	P87			Both	1
Mandibular partial denture - cast metal	P88			Both	1
Repair resin denture base	P89			Both	1
Repair or replace broken clasp - partial denture	P90			Both	1
Replace missing or broken teeth (partial)	P91			Both	1
Rebase complete maxillary denture	P92			Both	1
Rebase complete mandibular denture	P93			Both	1
Fixed partial denture sectioning	P94			Both	30
Fixed partial denture repair, by report	P95			Both	1
Surgical removal of residual root tips	P96			Both	1,098
Primary closure of sinus perforation	P97			Both	19
Biopsy of oral tissue (soft)	P98			Both	143
Biopsy of oral tissue - hard	P99			Both	23
Alveoloplasty in conjunction with extractions	P100			Both	4
Alveoloplasty in conjunction with extractions per quad	P101			Both	9
Alveoloplasty not in conjunction with extractions	P102			Both	32
Complicated suture	P103			Both	1
Complicated suture - greater than 5 cm	P104			Both	1
Repair of maxillofacial hard or softer tissue defect	P105			Both	1
Excision of malignant tumor (lesion diameter greater than 1.25 cm)	P106			Both	1
Excision of malignant tumor - lesion diameter up to 1.25 cm	P107			Both	1
Excision of benign lesion - lesion diameter less than 1.25 cm	P108			Both	14
Excision of malignant lesion up to 1.25 cm	P109			Both	1
Excision of malignant lesion greater than 1.25 cm	P110			Both	1
Excision of malignant lesion, complicated	P111			Both	1
Excision of benign lesion greater than 1.25 cm	P112			Both	7
Excision of benign lesion, complicated	P113			Both	1
Removal of odontogenic cyst / tumor - lesion diameter up to 1.25cm	P114			Both	39
Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm	P115			Both	12
Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm	P116			Both	2
Removal of benign odontogenic cyst or tumor (lesion diameter greater than 1.25 cm)	P117			Both	20
Removal of lateral exostosis (maxilla or mandible)	P118			Both	11
Removal of torus mandibularis	P119			Both	8
Removal of torus palatinus	P120			Both	4
Brush biopsy - transepithelial sample collection	P121			Both	1
Destruction of lesion by physical / chemical	P122			Both	1
Crown - porcelain fused to high noble metal	P123			Both	1
Crown - porcelain fused to noble metal	P124			Both	5
Crown - full cast high noble metal	P125			Both	4
Crown - full cast noble metal	P126			Both	1
Temporary crown (fractured tooth)	P127			Both	4
Crown repair, by report	P128			Both	5
Recement crown	P129			Both	54
Stainless steel crown	P130			Both	650
Resin based composite crown, anterior	P131			Both	282
Post removal	P132			Both	2
Cast post and core in addition to crown	P133			Both	3
Provisional crown	P134			Both	15
Prefabricated resin crown	P135			Both	81
Prefabricated stainless steel crown, primary tooth	P136			Both	38
Diagnostic casts	P137			Both	1
Retreatment of previous RCT - anterior	P138			Both	92
Retreatment of previous RCT - bicuspid	P139			Both	91
Oroantral fistula closure	P140			Both	34
Osseous surgery (four or more teeth)	P141			Both	1
Distal or proximal wedge procedure	P142			Both	1
Internal root repair of perforation defects	P143			Both	34
Osseous surgery (including flap entry & closure) - one to three contiguous teeth or bounded teeth spaces per quadrant	P144			Both	1
Free soft tissue graft procedure (including donor site surgery)	P145			Both	1
Treatment of complications (post surgical)	P146			Both	8
Treatment of root canal obstruction - non surgical	P147			Both	2
Apexification / recalcification - initial visit	P148			Both	1
Gingival flap procedure and root planing - 4 or more teeth per quadrant	P149			Both	1
Bone replacement graft - first site in quadrant	P150			Both	1
Biologic material to aid in soft and osseous tissue regeneration	P151			Both	2
Incision and drainage of abscess-soft tissue	P152			Both	37
Removal of foreign body from mucosa, skin or subcutaneous alveolar tissue	P153			Both	15
Removal of reaction producing foreign bodies, musculoskeletal	P154			Both	5
Removal of loose or sloughed-off dead bone caused by infection or reduced blood supply	P155			Both	6
Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bone - autogenous or nonautogenous	P156			Both	3
Frenulectomy (frenum are muscle fibers covered by a mucous membrane that attaches the cheek, lips, and / or tongue to associated dental mucosa)	P157			Both	2
Appliance removal (not by dentist who placed it) includes removal of archbar	P158			Both	1
Removable appliance therapy an example would be for treating tongue thrusting	P159			Both	1
Occlusal guard - removable dental appliance, designed to minimize the effects of grinding and other occlusal factors	P160			Both	4
Occlusal adjustment	P161			Both	6
Repair of orthodontic appliance	P162			Both	7
Replacement of lost or broken retainer	P163			Both	1
PP. DENTAL TREATMENT SERVICE - GROUP EVENT
Mobile vehicle, dental treatment (limited to dental treatment services listed in Attachment 1; price per vehicle per day)	PP1			Both	1,811
Mobile vehicle, dental bitewings, set of 4 films as indicated (price per set)	PP2			Both	3,684
Prescription Authorization for Dental Restorative Services	PP3			Both	8,456
Q. MEDICAL AND DENTAL RECORD PROCESSING - CONTRACTOR LOCATION
Record Maintenance - Medical	Q1			Both	2,045
Record Maintenance - Dental	Q2			Both	358
Record Review - Medical	Q3			Both	10,080
Record Review - Dental	Q4			Both	39
Digitization of Medical Records (includes x-rays)	Q5			Both	100
Digitization of Dental Records (includes x-rays)	Q6			Both	728
Historical Update - Medical	Q7			Both	8,000
Historical Update - Dental	Q8			Both	12,291
R. MISCELLANEOUS FEE
Vaccine Destruction (per 1 lb.)	R1			N/A	1,235
S. CANCELLATION FEE
Cancellation fee, in-clinic service (price per visit)	S1			Both	71,226
Cancellation fee, group event, assessment service including MHA, PDHRA, PHA, PHA lite (price per individual service)	S2			Both	11,396
Cancellation fee, group event, dental service (price per individual service)	S3			Both	21,717
Cancellation fee, group event, audio or vision service (price per individual service)	S4			Both	17,865
Cancellation fee, group event, immunization, laboratory, or miscellaneous medical service (price per individual service)	S5			Both	24,644
T. NO SHOW FEE
No show fee, in-clinic service (price per visit)	T1			Both	24,034
No show fee, group event, assessment service including MHA, PDHRA, PHA, PHA lite (price per individual service)	T2			Both	5,698
No show fee, group event, dental service (price per individual service)	T3			Both	10,858
No show fee, group event, audio or vision service (price per individual service)	T4			Both	8,932
No show fee, group event, immunization, laboratory, or miscellaneous medical service (price per individual service)	T5			Both	12,322
						Total	$0.00

ATTACHMENT 1 - PROCEDURES AND FIXED UNIT PRICES

OPTION YEAR 1 - CLIN 1001 NEW CONTRACT #

&P 19-May-11

File details come from the government source that posted it. Updated Nov 14, 2017.