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

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

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HT0011-12-R-0009 Attachment 1 - Procedures Fixed Unit Prices v2

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

ElementProcedure NumberSub-ElementCPT / CDT CodeGenderHistoric QuantityBase PeriodOption Period 1Option Period 2Option Period 3Option Period 4
Fixed Unit PriceExtended AmountFixed Unit PriceExtended AmountFixed Unit PriceExtended AmountFixed Unit PriceExtended AmountFixed Unit PriceExtended Amount
A. PHYSICAL EXAMS - IN-CLINIC
Retention exam, younger than 39, maleA1Includes sub-elements: a-i.Male329
Retention exam, younger than 39, femaleA2Includes sub-elements: a-j.Female123
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, maleA3Includes sub-elements: a-n.Male323
Retention exam, 39 and older, femaleA4Includes sub-elements: a-m & o.Female50
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 examA5Includes sub-elements: a-h.Both640
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, maleA6Includes sub-elements: a-i.Male5
Accession exam, femaleA7Includes sub-elements: a-j.Female5
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, maleA8Includes sub-elements: a-k.Male11
Physical exam, Chapter 3, AGR, younger than 39, femaleA9Includes sub-elements: a-m.Female6
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, maleA10Includes sub-elements: a-q.Male3
Physical exam, Chapter 3, AGR, 39 and older, femaleA11Includes sub-elements: a-n & q-s.Female1
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 examA12Includes sub-elements: a-e.Both205
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, maleA13Includes sub-elements: a-v.Male119
Firefighter / CBRN exam, younger than 39, femaleA14Includes sub-elements: a-x.Female10
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, maleA15Includes sub-elements: a-z.Male12
Firefighter / CBRN exam, 39 and older, femaleA16Includes sub-elements: a-w & y-bb.Female5
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 PHAB1Both65,952
MARFORRES / USCG / USNR
MARFORRES / USCG / USNR, PHA, in-clinic, price per completed PHAB2Both9,510
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)C1Both35,160
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)C2Both21,604
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)C3Both25,867
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)C4Both6,360
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)C5Both5,070
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)C6Both6,666
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)C7Both12,990
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)C8Both11,635
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)C9Both40,213
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)D1Both3,360
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)D2Both3,217
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)D3Both12,657
E. PHA BEHAVIORAL HEALTH SPECIALIST STAND ALONE - CALL CENTER / GROUP EVENT
PHA Behavioral Health Specialist, call center, price per callE1Both1
PHA Behavioral Health Specialist, group event (minimum 60 scheduled PHAs; price for up to 60 PHAs)E2Both1
F. POST DEPLOYMENT HEALTH RE-ASSESSMENT (PDHRA) - CALL CENTER
PDHRA, call center, price per completed DD Form 2900F1Both61,939
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)G1Both9,960
PDHRA, group event, TIER 2 (minimum 30 PDHRAs to schedule; price per PDHRA when total PDHRAs completed at group event equal 41 to 80)G2Both7,422
PDHRA, group event, TIER 3 (minimum 30 PDHRAs to schedule; price per PDHRA when total PDHRAs completed at group event equal 81 or more)G3Both16,745
H. MENTAL HEALTH ASSESSMENT (MHA) - CALL CENTER
MHA, call center, price per completed MHA when positive screenH1Both30
MHA, call center, price per completed MHA when negative screenH2Both10,013
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)I1Both3,000
MHA, group event, TIER 2 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 41 to 80)I2Both3,000
MHA, group event, TIER 3 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 81 or more)I3Both3,000
J. AUDIO w/ Exam (PHA / Physical Exam) - IN-CLINIC
Annual Audiometric Screen with MEDPROS UpdateJ192551Both26,611
Comprehensive audio exam / pure tone air and bone conduction testingJ292557Both2,706
SPRINT (Speech Recognition in Noise Test)J392506Both1,181
JJ. AUDIO STAND ALONE - IN-CLINIC
Acoustic reflex testing thresholdJJ192568Both1,444
Audio Hearing Test - pure tone airJJ292551Both5,416
Audiometry - pure tone air and bone conduction testingJJ392553Both5,106
Consultation w/ OtolaryngologistJJ499243Both5
DOHERS entryJJ5Both34,453
Evoked acoustic emission; limited (single stimulus level, either transient or distortion products)JJ692587Both5
Speech audiometry threshold; w/ speech recognitionJJ792556Both3,220
SprintJJ892571Both1,430
TympanometryJJ992567Both3,156
JJJ. AUDIO - GROUP EVENT
Annual Audiometric Screen with MEDPROS Update (minimum 50 screens per day to schedule; price per completed screen)JJJ192522Both137,133
Comprehensive audio exam / pure tone air and bone conduction testing (minimum 25 tests per day to schedule; price per completed test)JJJ292557Both4,534
DOHERS entryJJJ3Both134,023
K. VISION w/ Exam (PHA / Physical Exam) - IN-CLINIC
Comprehensive eye examK192004Both5
Eye examination with refraction and prescriptionK292002Both367
TonometryK392100Both11
Vision Screen with color and with & without correctionK499172Both51,178
KK. VISION STAND ALONE - IN-CLINIC
Comprehensive eye examKK192004Both6,395
Eye examination with refraction and prescriptionKK292002Both16,769
TonometryKK392100Both11
Vision - MonocularKK499173Both11
Vision Screen with color and with & without correctionKK599172Both944
KKK. VISION - GROUP EVENT
Comprehensive eye exam (minimum 25 exams per day to schedule; price per completed exam)KKK1Both5,986
Eye exam with refraction and prescription, group event (minimum 50 exams per day to schedule; price per completed exam)KKK2Both20,328
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)KKK3Both2,059
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)KKK4Both88,900
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)KKK5Both98,355
L. IMMUNIZATION w/ Exam (PHA / Physical Exam) - IN-CLINIC
Hepatitis AL190632Both3,270
Hepatitis BL290746Both2,576
Influenza - InjectableL390658Both8,353
Rabies TiterL490658Both5
PPDL586580Both98
TdapL690715Both1,535
Tetanus and DiphtheriaL790718Both41
TwinrixL890636Both326
VaricellaL990716Both5
Varicella titerL1086787Both5
LL. IMMUNIZATION STAND ALONE - IN-CLINIC
Hepatitis ALL190632Both3,075
Hepatitis BLL290746Both3,657
Influenza - InjectableLL390658Both9,105
Japanese encephalitisLL490735Both45
MeningococcusLL590733Both18
PolioLL690713Both5
RabiesLL790675Both20
Rabies TiterLL886382Both5
PPDLL986580Both1,086
TdapLL1090715Both2,227
Tetanus and DiphtheriaLL1190718Both129
TyphoidLL1290691Both130
TwinrixLL1390636Both314
VaricellaLL1490716Both305
Varicella titerLL1586787Both1,612
Yellow feverLL1690717Both52
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)LLL190741Both149,275
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)LLL290741Both84,508
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)LLL390742Both104,252
Anthrax (6 shot series) (Government will provide vaccine)LLL490581Both22,137
Globulin, ImmuneLLL590281Both5
Hepatitis A (2 shot series)LLL690632Both23,924
Hepatitis B (3 shot series)LLL790746Both24,089
Inactivated Polio Vaccine (IPV)LLL890713Both75
InfluenzaLLL990658Both6,964
Japanese EncephalitisLLL1090735Both337
Measles, Mumps, Rubella (MMR)LLL1190707Both159
MenactraLLL1290734Both2,048
PPDLLL1386580Both6,765
Rabies (3 shot series)LLL1490675Both154
Rabies TiterLLL1586382Both5
Storage of DoD VaccineLLL16Both137,981
TdapLLL1790715Both43,879
Tetanus and DiphtheriaLLL1890718Both1,718
Typhoid (injectable or oral)LLL1990691Both25,036
VaricellaLLL2090716Both167
Varicella titerLLL2186787Both1,612
Yellow feverLLL2290717Both1,297
M. LABORATORY SERVICE w/ Exam (PHA / Physical Exam) - IN-CLINIC
AGR labsM1Services Include: 1) Drug Screen, 2) ETOH Screen, 3) Pregnancy Test, 4) Forms: Voucher, Customer Satisfaction Survey, Lab Requisition80100 + 82055 + 84702Both17
Blood type and determination of Rh factor w/ venipunctureM286901 + 36415Both152
Chlamydia, DNA by SDA (urine)M387491Both26
Chlamydia / Gonorrhea (by swab)M487491 + 87591Both555
Chlamydia / Gonorrhea (reflex from swab)M587490 + 87590Both1
CVSPM6Service 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 weight93000 + 80061 + 82947Both19,619
DNA testM783912Both2,517
Gonorrhea, DNA by SDA (urine)M887951Both5
G6PDM982960Both1,972
HIV test (phlebotomy only)M1086701Both3,569
Pregnancy, urineM1184703Female356
PSAM1284153 + 36415 + 99381Male69
PSA w/ rectal examM1384153 + 361415 + 99368Male5
Rectal exam with stool for guaiacM14G0102 + 82270Both291
Sickle cell screening test w/ confirmation by reflex to hemoglobulinopathyM1585660 + 83021Both56
Stool occult for blood (1 slide)M1682270Both5
Stool occult for blood (2 slide)M1782270Both5
Stool occult for blood (3 slide)M1882270Both5
Thin prep w/ preventive exam (pelvic) to collect specimenM1988147 + 99385Female851
Phlebotomy (blood draw)M2036415Both5,146
MM. LABORATORY SERVICE STAND ALONE - IN-CLINIC
AGR labsMM1Services Include: 1) Drug Screen, 2) ETOH Screen, 3) Pregnancy Test, 4) Forms: Voucher, Customer Satisfaction Survey, Lab Requisition80100 + 82055 + 84702Both17
Blood type and determination of Rh factor w/ venipunctureMM286901 + 36415Both58
Chlamydia, DNA by SDA (urine)MM387491Both122
CVSPMM4Service 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 weight93000 + 80061 + 82947Both433
DNA test (no lab) - use military labor and DNA cardMM583912Both315
Gonorrhea, DNA by SDA (urine)MM687951Both24
G6PDMM782960Both1,558
HIV test (phlebotomy only)MM886701Both9,945
Phlebotomy (blood draw)MM936415Both78
Pregnancy, urineMM1084703Female419
PSAMM1184153 + 36415 + 99381Male1
PSA w/ rectal examMM1284153 + 361415 + 99368Male5
Rectal exam w/ stool for guaiacMM13G0102 + 82270Both45
Sickle cell screening test w/ confirmation by reflex to hemoglobulinopathyMM1485660 + 83021Both47
Stool occult for blood (1 slide)MM1582270Both5
Stool occult for blood (2 slide)MM1682270Both5
Stool occult for blood (3 slide)MM1782270Both5
Thin prep w/ preventive exam (pelvic) to collect specimenMM1888147 + 99385Female2,526
MMM. LABORATORY SERVICE - GROUP EVENT
Blood type and determination of Rh factor w/ venipunctureMMM186901 + 36415Both1,721
Chlamydia, DNA by SDA (urine)MMM287491Both621
CVSPMMM3Service 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 weight93000 + 80061 + 82947Both17,580
CVSP (Cholestech) (minimum 25 screens per day to schedule; price per completed screen)MMM493000 + 80061 + 82947Both1,412
Gonorrhea, DNA by SDA (urine)MMM587951Both98
G6PD TestingMMM682960Both33,085
HIV testing (phlebotomy only), group event, TIER 1 (minimum 50 tests to schedule; price per completed test when total tests completed at group event equal 40 or less)MMM786701Both19,845
HIV testing (phlebotomy only), group event, TIER 2 (minimum 50 tests to schedule; price per completed test when total tests completed at group event equal 41 to 80)MMM886701Both12,287
HIV testing (phlebotomy only), group event, TIER 3 (minimum 50 tests to schedule; price per completed test when total tests completed at group event equal 81 or more)MMM986701Both10,000
HPV labMMM1087621Both1
Phlebotomy (CVSP, DNA, G6PD,HIV, Rabies Titer, Varicella Titer) (minimum 30 draws per day to schedule; price per completed draw)MMM1136415Both21,288
Pregnancy Test (minimum 30 tests per day to schedule; price per completed test)MMM1284703Female6,735
PSAMMM1384153 + 36415 + 99381Male14
PSA w/ rectal examMMM1484153 + 361415 + 99368Male5
Status hCG Strip (Kit Only)MMM15Both3,985
Stool occult for blood (1 slide)MMM1682272Both5
Stool occult for blood (2 slide)MMM1782272Both5
Stool occult for blood (3 slide)MMM1882272Both5
Thin prep w/ preventive exam (pelvic) to collect specimenMMM1988147 + 99385Female107
N. MISCELLANEOUS MEDICAL SERVICE w/ Exam (PHA / Physical Exam) - IN-CLINIC
Breast examN199386Both5
Chest x-ray, posterior-anterior viewN271010Both1
EKG, restingN393000Both17,935
MammographyN477057Female156
Chest x-ray, posterior-anterior and lateral views with interpretationN571030Both20
NN. MISCELLANEOUS MEDICAL SERVICE STAND ALONE - IN-CLINIC
Breast examNN199386Both5
B-readNN2Both24
Chest x-ray, posterior-anterior viewNN371010Both149
EKG, restingNN493000Both671
MammographyNN577057Female380
NNN. MISCELLANEOUS MEDICAL SERVICE - GROUP EVENT
Breast examNNN199386Both5
EKG, resting (minimum 20 EKGs per day to schedule; price per completed EKG)NNN293000Both26,053
O. DENTAL SERVICE - IN-CLINIC
Annual Dental Exam (Periodic Oral Examination)O1D0120Both494
Annual Dental Exam (Comprehensive Oral Examination)O2D0150Both57,076
Dental bitewing, single filmO3D0270Both1,121
Dental bitewing, set of two filmsO4D0272Both964
Dental bitewing, set of three filmsO5D0274Both15
Dental bitewing, set of four films as indicatedO6D0330Both57,566
Complete series x-rayO7D0210Both4
Cone beam – 2 dimensional image reconstructionO8D0362Both2
Cone beam – 3 dimensional image reconstructionO9D0363Both2
Intraoral periapical x-rayO10D0220Both40,653
Panographic x-rayO11D0330Both24,710
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)OO1D0150Both189,680
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)OO2D0150Both12,165
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)OO3D0150Both10,000
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)OO4D0274Both39,706
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)OO5D274Both86,646
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)OO6D274Both50,000
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)OO7D0330Both22,100
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)OO8D0330Both10,000
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)OO9D0330Both5,459
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)OO10D0150Both83
P. DENTAL TREATMENT SERVICE - IN-CLINIC
Consultation Dental ExamP1D0140Both18,501
Office visit after hoursP2D9440Both2
Hospital callP3D9420Both1
Detailed and extensive oral evaluationP4D9310Both20
Comprehensive periodontal evaluationP5D150Both5
Amalgam, One Surface, PermanentP6D2140Both5,734
Amalgam, Two Surfaces, PermanentP7D2150Both10,960
Amalgam, Three Surfaces, PermanentP8D2160Both6,002
Amalgam, Four or More Surfaces, PermanentP9D2162Both1,809
Apicoectomy - AnteriorP10D3410Both25
Apicoectomy - BicuspidP11D3421Both7
Apicoectomy - Molar - first rootP12D3425Both10
Apicoectomy - Molar - each add'l rootP13D3426Both5
Resin Based Composite, one surfaceP14D2330Both2,241
Resin Based Composite, two surfacesP15D2331Both2,405
Resin Based Composite, three surfacesP16D2332Both2,546
Resin Based Composite, four surfaceP17D2335Both1,529
Resin (1) one surface posteriorP18D2391Both2,265
Resin (2) two surface posteriorP19D2392Both3,581
Resin (3) three surface posteriorP20D2393Both2,409
Resin (4) four or more posteriorP21D2394Both1,045
Anterior (excluding final restoration)P22D3310Both1,053
Bicuspid (excluding final restoration)P23D3320Both1,930
Molar (excluding final restoration)P24D3330Both3,796
Core build up including pinsP25D2950Both8,957
Prefab post & coreP26D2954Both836
Extraction, single toothP27D7140Both5,371
Extraction, each additional toothP28D7140Both1
Extraction deciduous toothP29D7111Both3
Complete bony extractionP30D7240Both226
Surgical removal of erupted toothP31D7210Both8,642
Removal of impacted tooth-completely bonyP32D7240Both3,017
Removal of impacted tooth soft tissueP33D7220Both1,065
Removal of impacted tooth partial bonyP34D7230Both4,070
Analgesic NitrousP35D9230Both1,034
IV anesthesia first 30 minutesP36D9241Both1,472
IV anesthesia each additional 15 minutesP37D9242Both663
Local anesthesiaP38D9215Both7
Regional block anesthesiaP39D9211Both1
Deep Sedation / general anesthesia first 30 minutesP40D9220Both3,656
Deep Sedation / general anesthesia each additional 15 minutesP41D9221Both1,695
Non-intravenous conscious sedationP42D9248Both62
Therapeutic drug injection - includes antibiotic or injection of sedativeP43D9610Both732
Palliative treatment of dental painP44D9110Both112
Oral antibiotics (given at the office)P45D9630Both11
Periodontal scaling and root planingP46D4341Both7
Perio scaling and root planing per quadrantP47D4341Both177
Full mouth debridementP48D4355Both1,228
Gingivectomy, 1-3 teethP49D4211Both5
Gingivectomy, 4 or more teethP50D4210Both5
Sedative fillingP51D3940Both369
Pin retention in addition to fillingP52D2951Both63
Retrograde fillingP53D3430Both31
Pulp cap (indirect)P54D3120Both393
Pulp cap (direct)P55D3110Both95
PulpotomyP56D3220Both32
Pulpal debridementP57D3221Both42
Pulp vitality testsP58D460Both306
Incomplete endo therapyP59D3332Both58
Retreatment of molar endoP60D3348Both332
Immediate denture maxillaryP61D5130Both146
Immediate denture mandibularP62D5140Both89
Partial denture maxillary (resin base)P63D5211Both229
Partial denture mandibular (resin base)P64D5212Both180
Adjust maxillary dentureP65D5410Both1
Add tooth to existing partial dentureP66D5650Both67
Mandibular partial denture flexible baseP67D5226Both1
Add clasp to existing partial dentureP68D5660Both4
Reline mandibular partial denture (chair side)P69D5741Both1
Reline complete maxillary denture (laboratory)P70D5750Both3
Reline mandibular partial denture (laboratory)P71D5761Both1
Reline complete maxillary denture (chair side)P72D5730Both1
Reline complete mandibular denture (chair side)P73D5731Both1
Reline maxillary partial denture (chair side)P74D5740Both1
Interim partial denture (maxillary)P75D5820Both424
Interim partial denture (mandibular)P76D5821Both54
Recement fixed partial dentureP77D6930Both10
Adjust complete denture - mandibularP78D5411Both1
Adjust partial denture - maxillaryP79D5421Both1
Adjust partial denture - mandibularP80D5422Both1
Repair broken complete denture baseP81D5510Both2
Replace missing or broken teeth - complete denture (each tooth)P82D5520Both4
Reline complete mandibular denture (laboratory)P83D5751Both4
Reline maxillary partial denture (laboratory)P84D5760Both1
Complete denture maxillaryP85D5110Both9
Complete denture mandibularP86D5120Both4
Maxillary partial denture - cast metalP87D5213Both1
Mandibular partial denture - cast metalP88D5214Both1
Repair resin denture baseP89D5610Both1
Repair or replace broken clasp - partial dentureP90D5630Both1
Replace missing or broken teeth (partial)P91D5640Both1
Rebase complete maxillary dentureP92D5710Both1
Rebase complete mandibular dentureP93D5711Both1
Fixed partial denture sectioningP94D9120Both30
Fixed partial denture repair, by reportP95D6980Both1
Surgical removal of residual root tipsP96D7250Both1,098
Primary closure of sinus perforationP97D7261Both19
Biopsy of oral tissue (soft)P98D7286Both143
Biopsy of oral tissue - hardP99D7285Both23
Alveoloplasty in conjunction with extractionsP100D7311Both4
Alveoloplasty in conjunction with extractions per quadP101D7310Both9
Alveoloplasty not in conjunction with extractionsP102D7320Both32
Complicated sutureP103D7911Both1
Complicated suture - greater than 5 cmP104D7912Both1
Repair of maxillofacial hard or softer tissue defectP105D7955Both1
Excision of malignant tumor (lesion diameter greater than 1.25 cm)P106D7441Both1
Excision of malignant tumor - lesion diameter up to 1.25 cmP107D7440Both1
Excision of benign lesion - lesion diameter less than 1.25 cmP108D7411Both14
Excision of malignant lesion up to 1.25 cmP109D7413Both1
Excision of malignant lesion greater than 1.25 cmP110D7414Both1
Excision of malignant lesion, complicatedP111D7415Both1
Excision of benign lesion greater than 1.25 cmP112D7411Both7
Excision of benign lesion, complicatedP113D7412Both1
Removal of odontogenic cyst / tumor - lesion diameter up to 1.25cmP114D7450Both39
Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cmP115D7460Both12
Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cmP116D7461Both2
Removal of benign odontogenic cyst or tumor (lesion diameter greater than 1.25 cm)P117D7451Both20
Removal of lateral exostosis (maxilla or mandible)P118D7471Both11
Removal of torus mandibularisP119D7473Both8
Removal of torus palatinusP120D7472Both4
Brush biopsy - transepithelial sample collectionP121D7288Both1
Destruction of lesion by physical / chemicalP122D7465Both1
Crown - porcelain fused to high noble metalP123D2750Both1
Crown - porcelain fused to noble metalP124D2752Both5
Crown - full cast high noble metalP125D2790Both4
Crown - full cast noble metalP126D2792Both1
Temporary crown (fractured tooth)P127D2970Both4
Crown repair, by reportP128D2980Both5
Recement crownP129D2920Both54
Stainless steel crownP130D2931Both650
Resin based composite crown, anteriorP131D2390Both282
Post removalP132D2955Both2
Cast post and core in addition to crownP133D2952Both3
Provisional crownP134D2799Both15
Prefabricated resin crownP135D2932Both81
Prefabricated stainless steel crown, primary toothP136D2934Both38
Diagnostic castsP137D470Both1
Retreatment of previous RCT - anteriorP138D3346Both92
Retreatment of previous RCT - bicuspidP139D3347Both91
Oroantral fistula closureP140D7260Both34
Osseous surgery (four or more teeth)P141D4260Both1
Distal or proximal wedge procedureP142D4274Both1
Internal root repair of perforation defectsP143D3333Both34
Osseous surgery (including flap entry & closure) - one to three contiguous teeth or bounded teeth spaces per quadrantP144D4261Both1
Free soft tissue graft procedure (including donor site surgery)P145D4271Both1
Treatment of complications (post surgical)P146D9930Both8
Treatment of root canal obstruction - non surgicalP147D3331Both2
Apexification / recalcification - initial visitP148D3351Both1
Gingival flap procedure and root planing - 4 or more teeth per quadrantP149D4240Both1
Bone replacement graft - first site in quadrantP150D4263Both1
Biologic material to aid in soft and osseous tissue regenerationP151D4265Both2
Incision and drainage of abscess-soft tissueP152D7510Both37
Removal of foreign body from mucosa, skin or subcutaneous alveolar tissueP153D7530Both15
Removal of reaction producing foreign bodies, musculoskeletalP154D7540Both5
Removal of loose or sloughed-off dead bone caused by infection or reduced blood supplyP155D7550Both6
Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bone - autogenous or nonautogenousP156D7950Both3
Frenulectomy (frenum are muscle fibers covered by a mucous membrane that attaches the cheek, lips, and / or tongue to associated dental mucosa)P157D7960Both2
Appliance removal (not by dentist who placed it) includes removal of archbarP158D7997Both1
Removable appliance therapy an example would be for treating tongue thrustingP159D8210Both1
Occlusal guard - removable dental appliance, designed to minimize the effects of grinding and other occlusal factorsP160D9940Both4
Occlusal adjustmentP161D9952Both6
Repair of orthodontic applianceP162D8691Both7
Replacement of lost or broken retainerP163D8692Both1
PP. DENTAL TREATMENT SERVICE - GROUP EVENT
Mobile vehicle, dental treatment (limited to dental treatment services listed in Attachment 1; price per vehicle per day)PP1Both1,811
Mobile vehicle, dental bitewings, set of 4 films as indicated (price per set)PP2Both3,684
Prescription Authorization for Dental Restorative ServicesPP3Both8,456
Q. MEDICAL AND DENTAL RECORD PROCESSING - CONTRACTOR LOCATION
Record Maintenance - MedicalQ1Both2,045
Record Maintenance - DentalQ2Both358
Record Review - MedicalQ3Both10,080
Record Review - DentalQ4Both39
Digitization of Medical Records (includes x-rays)Q5Both100
Digitization of Dental Records (includes x-rays)Q6Both728
Historical Update - MedicalQ7Both8,000
Historical Update - DentalQ8Both12,291
R. MISCELLANEOUS FEE
Vaccine Destruction (per 1 lb.)R1N/A1,235
S. CANCELLATION FEE
Cancellation fee, in-clinic service (price per visit)S1Both71,226
Cancellation fee, group event, assessment service including MHA, PDHRA, PHA, PHA lite (price per individual service)S2Both11,396
Cancellation fee, group event, dental service (price per individual service)S3Both21,717
Cancellation fee, group event, audio or vision service (price per individual service)S4Both17,865
Cancellation fee, group event, immunization, laboratory, or miscellaneous medical service (price per individual service)S5Both24,644
T. NO SHOW FEE
No show fee, in-clinic service (price per visit)T1Both24,034
No show fee, group event, assessment service including MHA, PDHRA, PHA, PHA lite (price per individual service)T2Both5,698
No show fee, group event, dental service (price per individual service)T3Both10,858
No show fee, group event, audio or vision service (price per individual service)T4Both8,932
No show fee, group event, immunization, laboratory, or miscellaneous medical service (price per individual service)T5Both12,322
Total$0.00$0.00$0.00$0.00$0.00

ATTACHMENT 1 - PROCEDURES AND FIXED UNIT PRICES

OPTION YEAR 1 - CLIN 1001 NEW CONTRACT #

&P 19-May-11

Tab B -Detail

ElementProcedure NumberSub-ElementCPT / CDT CodeGenderHistoric QuantityBase PeriodOption Period 1Option Period 2Option Period 3Option Period 4
MaterialsDirect LaborFringeG&AOverheadProfitFixed Unit PriceExtended AmountMaterialsDirect LaborFringeG&AOverheadProfitFixed Unit PriceExtended AmountMaterialsDirect LaborFringeG&AOverheadProfitFixed Unit PriceExtended AmountMaterialsDirect LaborFringeG&AOverheadProfitFixed Unit PriceExtended AmountMaterialsDirect LaborFringeG&AOverheadProfitFixed Unit PriceExtended Amount
A. PHYSICAL EXAMS - IN-CLINIC
Retention exam, younger than 39, maleA1Includes sub-elements: a-i.Male329
Retention exam, younger than 39, femaleA2Includes sub-elements: a-j.Female123
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, maleA3Includes sub-elements: a-n.Male323
Retention exam, 39 and older, femaleA4Includes sub-elements: a-m & o.Female50
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 examA5Includes sub-elements: a-h.Both640
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, maleA6Includes sub-elements: a-i.Male5
Accession exam, femaleA7Includes sub-elements: a-j.Female5
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, maleA8Includes sub-elements: a-k.Male11
Physical exam, Chapter 3, AGR, younger than 39, femaleA9Includes sub-elements: a-m.Female6
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, maleA10Includes sub-elements: a-q.Male3
Physical exam, Chapter 3, AGR, 39 and older, femaleA11Includes sub-elements: a-n & q-s.Female1
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 examA12Includes sub-elements: a-e.Both205
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, maleA13Includes sub-elements: a-v.Male119
Firefighter / CBRN exam, younger than 39, femaleA14Includes sub-elements: a-x.Female10
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, maleA15Includes sub-elements: a-z.Male12
Firefighter / CBRN exam, 39 and older, femaleA16Includes sub-elements: a-w & y-bb.Female5
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 PHAB1Both65,952
MARFORRES / USCG / USNR
MARFORRES / USCG / USNR, PHA, in-clinic, price per completed PHAB2Both9,510
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)C1Both35,160
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)C2Both21,604
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)C3Both25,867
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)C4Both6,360
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)C5Both5,070
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)C6Both6,666
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)C7Both12,990
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)C8Both11,635
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)C9Both40,213
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)D1Both3,360
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)D2Both3,217
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)D3Both12,657
E. PHA BEHAVIORAL HEALTH SPECIALIST STAND ALONE - CALL CENTER / GROUP EVENT
PHA Behavioral Health Specialist, call center, price per callE1Both1
PHA Behavioral Health Specialist, group event (minimum 60 scheduled PHAs; price for up to 60 PHAs)E2Both1
F. POST DEPLOYMENT HEALTH RE-ASSESSMENT (PDHRA) - CALL CENTER
PDHRA, call center, price per completed DD Form 2900F1Both61,939
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)G1Both9,960
PDHRA, group event, TIER 2 (minimum 30 PDHRAs to schedule; price per PDHRA when total PDHRAs completed at group event equal 41 to 80)G2Both7,422

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