Appendix_M_-_Pricing_Spreadsheet.pdf

Appendix M -- PRICING SPREADSHEET

PRICING SPREADSHEET

ID07160027

DESCRIPTION BASE OPTION

YEAR 1

OPTION

YEAR 2

OPTION

YEAR 3

OPTION

YEAR 4

BASE PLUS

OPTIONS

IME Completed Medical Examination Report

IME Partial Optometric Medical Examination Report (Partial Physical Exam)

IME Partial Clinical Medical Examination Report (Partial Physical Exam)

IME/AMI Failure to Appear

IME/AMI

Reassignment

CPT Codes

TOTAL PRICE

BASE PERIOD

CLIN Description Estimated Quantity

Unit of

Issue Price per Unit Total

Price

0001 IME Completed Medical Examination Report 26,500

EA

IME Partial Optometric Medical Examination Report (Partial Physical Exam) 1,200

IME Partial Clinical Medical Examination Report (Partial Physical Exam) 950

0004 IME/AMI Failure to Appear 450 EA

0005 IME/AMI Reassignment 1,800 EA 0006 CPT Codes 1 LOT

CPT

Codes

Estimated Quantity

Unit of

Issue Price per Unit Total

Price

70220 X-ray - Obtain radiologic exam of sinuses, complete 30 EA

70450 X-ray - Computed Tomography (CT) scan, head or brain;

without contrast material

30 EA

70486 X-ray - Obtain computerized axial tomography, sinuses 30 EA

70551 X-ray - Obtain a magnetic resonance imaging, brain 30 EA

71020 X-ray, chest, two views - frontal & lateral 30 EA

71250 X-ray, CT thorax 30 EA

71550 X-ray - MRI thorax 30 EA

72040 X-ray of spine, cervical 30 EA

72069 X-ray spine, thoracolumbar, standing (scoliosis) 250 EA

72070 X-ray exam, spine, thoracic, two views 55 EA

72100 X-ray exam, spine, lumbosacral, four views 55 EA

72125 X-ray - CT of cervical spine 30 EA

72128 X-ray - CT of thoracic spine 30 EA

72131 X-ray - CT of lumbar spine 30 EA

72141 X-ray - MRI of spinal canal and contents, cervical 30 EA

72146 X-ray - MRI of spinal canal and contents, thoracic 30 EA

72148 X-ray - Magnetic Resonance Imaging (MRI) of spinal canal and contents, lumbar

72190 X-ray - pelvis; complete, minimum of three views 30 EA

72220 X-ray of sacrum and coccyx 30 EA

73000 X-ray of clavicle, complete 30 EA

73030 X-ray exam, shoulder, two views 200 EA

73050 X-ray of acromioclavicular joints 30 EA

73060 X-ray of humerus 30 EA

73080 X-ray of elbow, complete 30 EA

73090 X-ray of forearm 30 EA

73110 X-ray exam, wrist, three views 150 EA

73120 X-ray of hand 30 EA

73140 X-ray of finger(s) 30 EA

73510 X-ray of hip - unilateral, complete 30 EA

73520 X-ray of hips, bilateral 30 EA

73550 X-ray of femur (thigh) 30 EA

73560 X-ray of knee, anteroposterior and lateral views 30 EA

73590 X-ray of tibia and fibula 30 EA

73610 X-ray of ankle, complete 30 EA

73630 X-ray of foot, complete 30 EA

73700 X-ray - CT of lower extremity 30 EA

73721 X-ray - MRI without contrast material of lower extremity 30 EA

74150 X-ray - Obtain a CT scan -abdomen; without contrast material

74230 X-ray - Obtain a swallowing function study 5 EA

74240 X-ray - Upper Gastrointestinal (GI) radiologic exam 30 EA

74280 X-ray - Barium enema 30 EA

74290 X-ray - Cholecystography, oral contrast 30 EA

74400 X-ray - Intravenous urography (pyelography) 30 EA

74420 X-ray - Urography, retrograde, with or without Kidney, Ureter & Bladder (KUB)

76020 X-ray - Bone age study 30 EA

76040 X-ray - Bone length study 30 EA

76075 X-ray - Dual Energy X-ray Abosrptiometry (DEXA), bone density study

76092 X-ray - Screening mammography, bilateral 10 EA

76536

X-ray - Echography, B-scan and/or real time soft tissues of head/neck (thyroid, parathyroid, parotid)

76705 X-ray - Echography, abdominal, B-scan and/or real time 30 EA

76770 X-ray - Echography, retroperitoneal, B-scan and/or real time

76775 Obtain an echography, retroperitoineal 30 EA

76856 X-ray - Echography, pelvic 30 EA

76870 X-ray - Echography, scrotum and contents 30 EA

78010 X-ray - Thyroid imaging, only 30 EA

78300 X-ray - Bone and/or joint imaging; limited area 30 EA

80048 Lab test - Basic metabolic panel 202 EA

80061 Lab test - Lipid panel 30 EA

80074 Lab test - Acute Hepatitis Panel 30 EA

80076 Lab test - Hepatic function panel 250 EA

81001 Lab test - Urinalysis with microscopy 500 EA

81003 Lab test - Urinalysis without microscopy 350 EA

81015 Lab test - Urinalysis, microscopy only 250 EA

81769

Please obtain a urine calcium/creatinine ratio (calcium), via routine urine collection

20 EA

82042 Lab test - 24-hour urinary protein and volume level test 25 EA

82570 Please obtain a UP/C ratio (reatinine), via routine urin collection (add R263.07)

100 EA

82575 Lab test - Creatinine clearance 30 EA

82947 Please obtain a fasting glucose blood test 100 EA

83020 Lab test - Hemoglobin electrophoresis 20 EA

83036 Hemoglobin HbA1c (HPLC) 30 EA

84156 24-hour Urine collection 30 EA

84436 Lab test - Thyroxin, total 30 EA

84443 Lab test - Thyroid stimulating hormone (TSH)

85027 Lab test - Blood count, hemogram and platelet count, automated

86003 Lab test - Allergen specific lgE;

quantitative or semicuantitative 250 EA

90801

Office consultation with a mental health provider certified in drug/alcohol counseling or addiction medicine

50 EA

90801 Psychiatric diagnostic interview examination 80 EA

92002

Optometric/Ophthalmogical consultation that does not require a dilated examination.

Elements in a DoDMERB eye exam would qualify for this code - new patient intermediate exam

92004 comprehensive consultation requiring a dilated fundus exam

- new patient complex exam

92012 consultation that does not require a dilated examination -established patient intermediate

250 EA

92014 comprehensive consultation requiring a dilated fundus exam

- established patient comprehensive exam

92015 exam - manifest refraction (new or repeat)

40 EA

92025 Computetized Corneal Topography with interpretation (Color)

92060

Optometric/Ophthalmogical -senorimotor evaluation;

comprehensive strabismus evaluation with multiple measurements of ocular deviation to include a report

200 EA

92083 exam - extended visual field examination with automated perimetry

92506 Office - Consult - Evaluation by speech therapist/speech pathologist

51 EA

92552 Audiogram - Pure tone audiometry (threshold); air only 51 EA

92557 Obtain a comprehensive audiometry threshold evaluation 30 EA

92567 Obtain a Tympanometry 30 EA

93000 Electrocardiogram, 12-lead, with interpretation & report 30 EA

93015 Cardiovascular stress test 30 EA

93230 24-hour holter monitor study 30 EA

93306

X-ray - Echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode recording;

complete

93325 X-ray - Echocardiogram - Doppler color flow velocity mapping

94010 Spirometry, with or without maximal voluntary ventilation

(PFT)

94060 Spirometry, before and after bronchodilator (aerosol) 30 EA

94070 Bronchoprovocation pulmonary function test 30 EA

94620 Complete Excersize spirometry 30 EA

95010 Skin allergy testing 30 EA

95070 Bronchial allergy test 30 EA

95816 Electroencephalogram (EEG) 30 EA

96100 Psychological testing 30 EA

96117 Neuropsychological testing battery 30 EA

99172 visual function screening -visual acuity measurements, red lens test, cover test, near point of convergence, horizontal & vertical phorias, depth perception and color vision to include PIP, Vivid Red-Green, or FALANT

1,000 EA

99242 AMI Medical Consultation (CPT 99242) Report 1,000 EA

99243 AMI Medical Consultation (CPT 99243) Report 300 EA

99244 AMI Medical Consultation (CPT 99244) Report 250 EA

99245 AMI Medical Consultation (CPT 99245) Report 175 EA

J7674 Methacholine Chloride, NEB 30 EA

TOTAL CPT CODES*

*The total for all the CPT codes shall be entered under CLIN 0006 in the Base Period pricing chart above.

OPTION YEAR 1

Unit of

Issue Price per Unit Total

Price

1001 IME Completed Medical Examination Report 27,500

Examination Report (Partial Physical Exam) 1,300

Examination Report (Partial Physical Exam) 1,000

1004 IME/AMI Failure to Appear 500 EA

1005 IME/AMI Reassignment 1,850 EA 1006 CPT Codes 1 LOT

Estimated Quantity

Unit of

Issue Price per Unit Total

Price

(CT) scan, head or brain;

72040 X-ray of spine, cervical 30 EA

72131 X-ray - CT of lumbar spine 30 EA

Imaging (MRI) of spinal canal

73120 X-ray of hand 30 EA

73140 X-ray of finger(s) 30 EA

73630 X-ray of foot, complete 30 EA

73700 X-ray - CT of lower extremity 30 EA abdomen; without contrast with or without Kidney, Ureter

Abosrptiometry (DEXA), bone and/or real time soft tissues of head/neck (thyroid, parathyroid, retroperitoneal, B-scan and/or calcium/creatinine ratio (calcium), via routine urine

(reatinine), via routine urin

82947 Obtain a fasting glucose blood test 100 EA

84443 Lab test - Thyroid stimulating hormone (TSH) 30 EA hemogram and platelet count, mental health provider certified in drug/alcohol counseling or consultation that does not require a dilated examination.

Elements in a DoDMERB eye exam would qualify for this code - new patient intermediate comprehensive consultation requiring a dilated fundus exam consultation that does not require a dilated examination -established patient intermediate comprehensive consultation requiring a dilated fundus exam

- established patient exam - manifest refraction (new

Topography with interpretation senorimotor evaluation;

comprehensive strabismus evaluation with multiple measurements of ocular exam - extended visual field examination with automated speech therapist/speech transthoracic, real-time with image documentation (2D) with or without M-mode recording;

Doppler color flow velocity maximal voluntary ventilation

95070 Bronchial allergy test 30 EA

95816 Electroencephalogram (EEG) 30 EA

96100 Psychological testing 30 EA visual function screening -visual acuity measurements, red lens test, cover test, near point of convergence, horizontal & vertical phorias, depth perception and color vision to include PIP, Vivid Red-Green, *The total for all the CPT codes shall be entered under CLIN 1006 in the Option Year 1 pricing chart above.

OPTION YEAR 2

Unit of

Issue Price per Unit Total

Price

2001 IME Completed Medical Examination Report 28,800

Examination Report (Partial Physical Exam) 1,350

Examination Report (Partial Physical Exam) 1,100

2004 IME/AMI Failure to Appear 600 EA

2005 IME/AMI Reassignment 1,900 EA 2006 CPT Codes 1 LOT

Estimated Quantity

Unit of

Issue Price per Unit Total

Price

(CT) scan, head or brain;

72040 X-ray of spine, cervical 30 EA

72131 X-ray - CT of lumbar spine 30 EA

Imaging (MRI) of spinal canal

73120 X-ray of hand 30 EA

73140 X-ray of finger(s) 30 EA

73630 X-ray of foot, complete 30 EA

73700 X-ray - CT of lower extremity 30 EA abdomen; without contrast with or without Kidney, Ureter

Abosrptiometry (DEXA), bone and/or real time soft tissues of head/neck (thyroid, parathyroid, retroperitoneal, B-scan and/or calcium/creatinine ratio (calcium), via routine urine

(reatinine), via routine urin hemogram and platelet count, mental health provider certified in drug/alcohol counseling or consultation that does not require a dilated examination.

Elements in a DoDMERB eye exam would qualify for this code - new patient intermediate comprehensive consultation requiring a dilated fundus exam consultation that does not require a dilated examination -established patient intermediate comprehensive consultation requiring a dilated fundus exam

- established patient exam - manifest refraction (new

Topography with interpretation senorimotor evaluation;

comprehensive strabismus evaluation with multiple measurements of ocular exam - extended visual field examination with automated speech therapist/speech transthoracic, real-time with image documentation (2D) with or without M-mode recording;

Doppler color flow velocity maximal voluntary ventilation

95070 Bronchial allergy test 30 EA

95816 Electroencephalogram (EEG) 30 EA

96100 Psychological testing 30 EA visual function screening -visual acuity measurements, red lens test, cover test, near point of convergence, horizontal & vertical phorias, depth perception and color vision to include PIP, Vivid Red-Green, *The total for all the CPT codes shall be entered under CLIN 2006 in the Option Year 2 pricing

OPTION YEAR 3

Unit of

Issue Price per Unit Total

Price

3001 IME Completed Medical Examination Report 29,000

Examination Report (Partial

Examination Report (Partial

3004 IME/AMI Failure to Appear 450 EA

3005 IME/AMI Reassignment 1,800 EA 3006 CPT Codes 1 LOT

Estimated Quantity

Unit of

Issue Price per Unit Total

Price

(CT) scan, head or brain;

72040 X-ray of spine, cervical 30 EA

72131 X-ray - CT of lumbar spine 30 EA

Imaging (MRI) of spinal canal

73120 X-ray of hand 30 EA

73140 X-ray of finger(s) 30 EA

73630 X-ray of foot, complete 30 EA

73700 X-ray - CT of lower extremity 30 EA abdomen; without contrast with or without Kidney, Ureter

Abosrptiometry (DEXA), bone and/or real time soft tissues of head/neck (thyroid, parathyroid, retroperitoneal, B-scan and/or calcium/creatinine ratio (calcium), via routine urine

(reatinine), via routine urin hemogram and platelet count, mental health provider certified in drug/alcohol counseling or consultation that does not require a dilated examination.

Elements in a DoDMERB eye exam would qualify for this code - new patient intermediate comprehensive consultation requiring a dilated fundus exam consultation that does not require a dilated examination -established patient intermediate comprehensive consultation requiring a dilated fundus exam

- established patient exam - manifest refraction (new

Topography with interpretation senorimotor evaluation;

comprehensive strabismus evaluation with multiple measurements of ocular exam - extended visual field examination with automated speech therapist/speech transthoracic, real-time with image documentation (2D) with or without M-mode recording;

Doppler color flow velocity maximal voluntary ventilation

95070 Bronchial allergy test 30 EA

95816 Electroencephalogram (EEG) 30 EA

96100 Psychological testing 30 EA visual function screening -visual acuity measurements, red lens test, cover test, near point of convergence, horizontal & vertical phorias, depth perception and color vision to include PIP, Vivid Red-Green, *The total for all the CPT codes shall be entered under CLIN 3006 in the Option Year 3 pricing

OPTION YEAR 4

Unit of

Issue Price per Unit Total

Price

4001 IME Completed Medical Examination Report 30,000

Examination Report (Partial

Examination Report (Partial

4004 IME/AMI Failure to Appear 450 EA

4005 IME/AMI Reassignment 1,800 EA 4006 CPT Codes 1 LOT

Estimated Quantity

Unit of

Issue Price per Unit Total

Price

(CT) scan, head or brain;

72040 X-ray of spine, cervical 30 EA

72131 X-ray - CT of lumbar spine 30 EA

Imaging (MRI) of spinal canal

73120 X-ray of hand 30 EA

73140 X-ray of finger(s) 30 EA

73630 X-ray of foot, complete 30 EA

73700 X-ray - CT of lower extremity 30 EA abdomen; without contrast with or without Kidney, Ureter

Abosrptiometry (DEXA), bone and/or real time soft tissues of head/neck (thyroid, parathyroid, retroperitoneal, B-scan and/or calcium/creatinine ratio (calcium), via routine urine

(reatinine), via routine urin hemogram and platelet count, mental health provider certified in drug/alcohol counseling or consultation that does not require a dilated examination.

Elements in a DoDMERB eye exam would qualify for this code - new patient intermediate comprehensive consultation requiring a dilated fundus exam consultation that does not require a dilated examination -established patient intermediate comprehensive consultation requiring a dilated fundus exam

- established patient exam - manifest refraction (new

Topography with interpretation senorimotor evaluation;

comprehensive strabismus evaluation with multiple measurements of ocular exam - extended visual field examination with automated speech therapist/speech transthoracic, real-time with image documentation (2D) with or without M-mode recording;

Doppler color flow velocity maximal voluntary ventilation

95070 Bronchial allergy test 30 EA

95816 Electroencephalogram (EEG) 30 EA

96100 Psychological testing 30 EA visual function screening -visual acuity measurements, red lens test, cover test, near point of convergence, horizontal & vertical phorias, depth perception and color vision to include PIP, Vivid Red-Green, *The total for all the CPT codes shall be entered under CLIN 4006 in the Option Year 4 pricing