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IGCE
| PRICING | 1. ORIGINATING OFFICE: | 2. DATE SUBMITTED: | 3. PROJECT NO. | 4. CONTRACT NO. (For Mods) |
| OWCP/DEEOIC | | | |
| 5. PROJECT AND CITY: | | 6. PURPOSE (Project Name): | |
| WORKSHEET | CMC Contract | | Contract Medical Consultant Services- DEEOIC | |
| 200 Constitution Ave NW | | 7. ITEM | |
| Washington DC 20201 | | | |
| 8. ESTIMATE VALID TO: | 9. ESTIMATED BY: | 10. DATE: | 11. Page 1 OF 1 | |
| Base Period (BP) | QUANTITY | | | | | | |
| DESCRIPTION OF WORK | NO. UNITS | UNIT MEASURE | ESTIMATED MAX QUANTITIES | PER UNIT | SUBTOTALS | PER UNIT | SUBTOTALS |
| CLIN 0001 Causation | 1 | ea. | 2500 | $0.00 |
| CLIN 0002 Impairment | 1 | ea. | 2000 | $0.00 |
| CLIN 0003 Diagnosis Clarification | 1 | ea. | 500 | $0.00 |
| CLIN 0004 Wage Loss | 1 | ea. | 50 | $0.00 |
| CLIN 0005 Supplemental | 1 | ea. | 250 | $0.00 |
| CLIN 0006 Appointment Cancelation | 1 | ea. | 15 | $0.00 |
| CLIN 0007 Second Opinion | 1 | ea. | 200 | $0.00 |
| CLIN 0008 Referee File Review | 1 | ea. | 25 | $0.00 |
| CLIN 0009 Referee Physical Examination | 1 | ea. | 10 | $0.00 |
| CLIN 0010 Referee Impairment File Review | 1 | ea. | 100 | $0.00 |
| CLIN 0011 Expedite/Terminal | 1 | ea. | 100 | $0.00 |
| CLIN 0012 Diagnostic Testing | 1 | ea. | 80 | $0.00 |
| CLIN 0013 Interpreter Services | 1 | ea. | 100 | $0.00 |
| CLIN 0014 Medical Records Translation Services | 1 | ea. | 100 | $0.00 |
| Base Period Totals NTE | | |
| BP Quantity Sub-Total Base CLINS | 6030 | $0.00 |
| Option Period 1 (OP1) | QUANTITY | | | LABOR | | | |
| DESCRIPTION OF WORK | NO. UNITS | UNIT MEASURE | ESTIMATED MAX QUANTITIES | PER UNIT | SUBTOTALS | PER UNIT | SUBTOTALS |
| CLIN 1001 Causation | 1 | ea. | 2500 | $0.00 |
| CLIN 1002 Impairment | 1 | ea. | 2000 | $0.00 |
| CLIN 1003 Diagnosis Clarification | 1 | ea. | 500 | $0.00 |
| CLIN 1004 Wage Loss | 1 | ea. | 50 | $0.00 |
| CLIN 1005 Supplemental | 1 | ea. | 250 | $0.00 |
| CLIN 1006 Appointment Cancelation | 1 | ea. | 15 | $0.00 |
| CLIN 1007 Second Opinion | 1 | ea. | 200 | $0.00 |
| CLIN 1008 Referee File Review | 1 | ea. | 25 | $0.00 |
| CLIN 1009 Referee Physical Examination | 1 | ea. | 10 | $0.00 |
| CLIN 1010 Referee Impairment File Review | 1 | ea. | 100 | $0.00 |
| CLIN 1011 Expedite/Terminal | 1 | ea. | 100 | $0.00 |
| CLIN 1012 Diagnostic Testing | 1 | ea. | 80 | $0.00 |
| CLIN 1013 Interpreter Services | 1 | ea. | 100 | $0.00 |
| CLIN 1014 Medical Records Translation Services | 1 | ea. | 100 | $0.00 |
| OP1 Totals NTE | | |
| OP1 Quantity Sub-Total Base CLINS | 6030 | $0.00 |
| Option Period 2 (OP2) | QUANTITY | | | LABOR | | | |
| DESCRIPTION OF WORK | NO. UNITS | UNIT MEASURE | ESTIMATED MAX QUANTITIES | PER UNIT | SUBTOTALS | PER UNIT | SUBTOTALS |
| CLIN 2001 Causation | 1 | ea. | 2500 | $0.00 |
| CLIN 2002 Impairment | 1 | ea. | 2000 | $0.00 |
| CLIN 2003 Diagnosis Clarification | 1 | ea. | 500 | $0.00 |
| CLIN 2004 Wage Loss | 1 | ea. | 50 | $0.00 |
| CLIN 2005 Supplemental | 1 | ea. | 250 | $0.00 |
| CLIN 2006 Appointment Cancelation | 1 | ea. | 15 | $0.00 |
| CLIN 2007 Second Opinion | 1 | ea. | 200 | $0.00 |
| CLIN 2008 Referee File Review | 1 | ea. | 25 | $0.00 |
| CLIN 2009 Referee Physical Examination | 1 | ea. | 10 | $0.00 |
| CLIN 2010 Referee Impairment File Review | 1 | ea. | 100 | $0.00 |
| CLIN 2011 Expedite/Terminal | 1 | ea. | 100 | $0.00 |
| CLIN 2012 Diagnostic Testing | 1 | ea. | 80 | $0.00 |
| CLIN 2013 Interpreter Services | 1 | ea. | 100 | $0.00 |
| CLIN 2014 Medical Records Translation Services | 1 | ea. | 100 | $0.00 |
| OP2 Totals NTE | | |
| OP2 Quantity Sub-Total Base CLINS | 6030 | $0.00 |
| Option Period 3 (OP3) | QUANTITY | | | LABOR | | | |
| DESCRIPTION OF WORK | NO. UNITS | UNIT MEASURE | ESTIMATED MAX QUANTITIES | PER UNIT | SUBTOTALS | PER UNIT | SUBTOTALS |
| CLIN 3001 Causation | 1 | ea. | 2500 | $0.00 |
| CLIN 3002 Impairment | 1 | ea. | 2000 | $0.00 |
| CLIN 3003 Diagnosis Clarification | 1 | ea. | 500 | $0.00 |
| CLIN 3004 Wage Loss | 1 | ea. | 50 | $0.00 |
| CLIN 3005 Supplemental | 1 | ea. | 250 | $0.00 |
| CLIN 3006 Appointment Cancelation | 1 | ea. | 15 | $0.00 |
| CLIN 3007 Second Opinion | 1 | ea. | 200 | $0.00 |
| CLIN 3008 Referee File Review | 1 | ea. | 25 | $0.00 |
| CLIN 3009 Referee Physical Examination | 1 | ea. | 10 | $0.00 |
| CLIN 3010 Referee Impairment File Review | 1 | ea. | 100 | $0.00 |
| CLIN 3011 Expedite/Terminal | 1 | ea. | 100 | $0.00 |
| CLIN 3012 Diagnostic Testing | 1 | ea. | 80 | $0.00 |
| CLIN 3013 Interpreter Services | 1 | ea. | 100 | $0.00 |
| CLIN 3014 Medical Records Translation Services | 1 | ea. | 100 | $0.00 |
| OP3 Totals NTE | | |
| OP3 Quantity Sub-Total Base CLINS | 6030 | $0.00 |
| Option Period 4 (OP4) | QUANTITY | | | LABOR | | | |
| DESCRIPTION OF WORK | NO. UNITS | UNIT MEASURE | ESTIMATED MAX QUANTITIES | PER UNIT | SUBTOTALS | PER UNIT | SUBTOTALS |
| CLIN 4001 Causation | 1 | ea. | 2500 | $0.00 |
| CLIN 4002 Impairment | 1 | ea. | 2000 | $0.00 |
| CLIN 4003 Diagnosis Clarification | 1 | ea. | 500 | $0.00 |
| CLIN 4004 Wage Loss | 1 | ea. | 50 | $0.00 |
| CLIN 4005 Supplemental | 1 | ea. | 250 | $0.00 |
| CLIN 4006 Appointment Cancelation | 1 | ea. | 15 | $0.00 |
| CLIN 4007 Second Opinion | 1 | ea. | 200 | $0.00 |
| CLIN 4008 Referee File Review | 1 | ea. | 25 | $0.00 |
| CLIN 4009 Referee Physical Examination | 1 | ea. | 10 | $0.00 |
| CLIN 4010 Referee Impairment File Review | 1 | ea. | 100 | $0.00 |
| CLIN 4011 Expedite/Terminal | 1 | ea. | 100 | $0.00 |
| CLIN 4012 Diagnostic Testing | 1 | ea. | 80 | $0.00 |
| CLIN 4013 Interpreter Services | 1 | ea. | 100 | $0.00 |
| CLIN 4014 Medical Records Translation Services | 1 | ea. | 100 | $0.00 |
| OP4 Totals NTE | | |
| OP4 Quantity Sub-Total Base CLINS | 6030 | $0.00 |
Grand Total - Base period and all option years NTE $0.00
| Base Period | 01 NOV 2022 - 31 OCT 2023 | $0.00 |
| Option Period 1 | 01 NOV 2023 - 31 OCT 2024 | $0.00 |
| Option Period 2 | 01 NOV 2024 - 31 OCT 2025 | $0.00 |
| Option Period 3 | 01 NOV 2025 - 31 OCT 2026 | $0.00 |
| Option Period 4 | 01 NOV 2026 - 31 OCT 2027 | $0.00 |
| Grand Total NTE | 01 NOV 2022- 31 OCT 2027 | $0.00 |