LITTLEROCK.PRICING.AMEND4.xls
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- FITNESS FOR DUTY PHYSICAL EXAMS
- Solicitation number
- RFQ-OSCU-FFDPE2011
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LITTLE ROCK PRICE MATRIX - AMENDMENT 4
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Sheet1
| RFP-OSCU-FFDPE2011 PRICING MATRIX | ||||||||||||||
| **revised per amendment 4** | ||||||||||||||
| SECTION A | ||||||||||||||
| LOCATION: | LITTLE ROCK, ARKANSAS | ****INSTRUCTIONS**** | ||||||||||||
| VENDOR NAME: | ||||||||||||||
| Point of Contact: | Phone : | 1) Proposed pricing shall be submitted utilizing this form. | ||||||||||||
| Below is the estimated number of each exam per category per year | 2) No other pricing format, form, or notations will be accepted. | |||||||||||||
| 1. | Pre-Employment (Applicant) Physical Examinations | 25 | 3) Any line item that is left blank may be viewed as Non-Responsive. If a particular | |||||||||||
| 2. | Fitness for Duty (FFD) Periodic Examinations (On-Board) | 45 | service is not available, please indicate as N/A. If a line item is included in the price of | |||||||||||
| 3. | Cardiovascular (Stress) Tests - Bruce or Balke Protocols | 20 | another line item, please explain. | |||||||||||
| 4. | Department of State/Embassy Personnel (LEGAT) Physical Examinations | 5 | 4) Offerors shall complete and submit one pricing matrix for each proposed location. | |||||||||||
| 5. | Hazardous Materials Response Unit (HMRU) Examinations | 2 | 5) Please provide a price for all exams, including those estimated at zero (0), if available. | |||||||||||
| 6. | Department of Transportation Physical Exams for Commercial Drivers | 1 | 6) Items marked with "***" are not required services; however, if pricing is service is available, please indicate pricing | |||||||||||
| 7. | Respiratory Protection Examinations | 30 | ||||||||||||
| 8. | Hazardous Device School Examinations | 1 | ||||||||||||
| 9. | Diver Examinations - Navy Dive (NOAA) Standards | 1 | ||||||||||||
| 10. | Language Specialists - Audiometric Surveillance | 1 | ||||||||||||
| 11. | Federal Aviation Administration (FAA) Pilot Examinations*** | 1 | ||||||||||||
| SECTION B | VENDOR MUST COMPLETE ALL OPEN CELLS | |||||||||||||
| 1. | Pre-Employment (Applicant) Physical Examination | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | ||||||||
| Enter unit price for performing one of this exam type refer to FD 945 | ||||||||||||||
| Pricing should reflect REQUIRED components only - No Special Circumstance Components | ||||||||||||||
| Multiply unit price by number of pre-employment physicals in Section A above | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 2. | Fitness for Duty (FFD) Periodic Examinations (On-Board) | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | ||||||||
| Enter unit price for performing this exam, Refer to FD 943 | ||||||||||||||
| Pricing should reflect REQUIRED components only - No Special Circumstance Components | ||||||||||||||
| Multiply unit price by number of Fitness for duty Periodic Exams in Section A above | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 3. | Cardiovascular (Stress) Tests - Brucs/Balke protocol | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | ||||||||
| Enter unit price for performing one of this exam type refer to FD 943 | ||||||||||||||
| Multiply unit price by number of cardiovascular stress tests in Section A above | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 4. | Department of State/Embassy Personnel (LEGAT) Physical Examinations | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | ||||||||
| Enter unit price for performing this exam, Refer to FD 949 | ||||||||||||||
| Pricing should reflect REQUIRED components only - No Special Circumstance Components | ||||||||||||||
| Multiply unit price by number of Department of State examinations in Section A above | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 5. | Hazardous Materials Response Unit (HMRU) Examination - Initial | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | ||||||||
| Enter unit price for performing one of this exam type refer to FD 944 | ||||||||||||||
| Pricing should reflect REQUIRED components only - No Special Circumstance Components | ||||||||||||||
| Multiply unit price by number of HMRU exams in Section A above | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 6. | Department of Transportation Physical Exams for Commercial Drivers | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | ||||||||
| Enter total price for perfroming one of this exam type refer to FD-964 | ||||||||||||||
| Multiply unit price by number of Department of Transportation Exams in Section A above | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 7. | Respiratory Protection Exam - Initial | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | ||||||||
| Enter unit price for perfominig one of this exam type, refer to FD-946, 900 and 899 | ||||||||||||||
| Multiply unit price by numbr of Respiratory Protection Exams in Section A above | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 8. | Hazardous Device School | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | ||||||||
| Enter unit price for performing one of this exam type, refer to FD 965 | ||||||||||||||
| Multiply unit price by number of Hazardous Device School Exams in Section A above | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 9. | FBI Dive Examinations - Navy Dive (NOAA) Standards | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | ||||||||
| Enter unit price for performing one of this exam type , refer to FD 966 | ||||||||||||||
| Multiply unit price by number of FBI Dive Exams in Section A above | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 10. | Language Specialists - Audiometric Surveillance Examinations | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | ||||||||
| Enter unit price for performing one of this exam type, refer to section III.14.1 | ||||||||||||||
| Multiply unit price by number of Language Specialist Exams in Section A above | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 11. | Federal Aviation Administration (FAA) Class 1 Examinations*** | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | ||||||||
| Enter unit price for performing one of this exam type, refer to FD 963 | ||||||||||||||
| Multiply unit price by number of FAA examiniations in Section A above | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| ***NOT REQUIRED; HOWEVER, IF SERVICE IS AVAILABLE, PLEASE PROVIDE PRICING*** | ||||||||||||||
| TOTAL LINES 24, 29, 33, 38, 43, 47, 51, 55, 59, and 63 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 12. | Immunizations | - FBI SUPPLIED | CPT Code | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | ||||||
| Enter unit price for each injection listed below with FBI Supplied Serum | ||||||||||||||
| **ASSUME A QUANTITY OF ONE** | ||||||||||||||
| Standard | a. Polio (IPV) | i. w/FBI supplied serum | 90471 | |||||||||||
| b. MMR booster (born 1957 +) | ||||||||||||||
| i. w/FBI supplied serum | 90471 | |||||||||||||
| c. Tetanus/Diptheria booster (every 10 years) | ||||||||||||||
| i. w/FBI supplied serum | 90471 | |||||||||||||
| d. Tdap tetanus/Diptheria/Pertussis | ||||||||||||||
| i. w/FBI supplied serum | 90471 | |||||||||||||
| e. Hepatitis A (per shot) | i. w/FBI supplied serum | 90471 | ||||||||||||
| f. Hepatitis B (per shot) | i. w/FBI supplied serum | 90471 | ||||||||||||
| g. Typhoid - Oral | i. FBI supplied | 90473 | ||||||||||||
| h. Typhoid - IM | i. w/FBI supplied serum | 90471 | ||||||||||||
| i. Influenza - IM | i. w/FBI supplied serum | 90471 | ||||||||||||
| j. Influenza - Intranasal | i. w/FBI supplied serum | 90471 | ||||||||||||
| k. Twinvax (Twinrix) | i. w/FBI supplied serum | 90471 | ||||||||||||
| Special Use | a. Meningococcal Vaccine | i. w/FBI supplied serum | 90471 | |||||||||||
| b. Yellow Fever | i. w/FBI supplied serum | 90471 | ||||||||||||
| c. Rabies Vaccine (per shot) | i. w/FBI supplied serum | 90471 | ||||||||||||
| d. Japanese B Encephalitis | i. w/FBI supplied serum | 90471 | ||||||||||||
| d. Anthrax Vaccine | i. w/FBI supplied serum | 90471 | ||||||||||||
| e. Botulinum Toxin Vaccine | i. w/FBI supplied serum | 90471 | ||||||||||||
| TOTAL LINES 75 - 94 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 13 | Immunizations - VENDOR SUPPLIED | CPT Code | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | |||||||
| Enter unit price for each injection listed below with Vendor Supplied Serum if available. | ||||||||||||||
| **ASSUME A QUANTITY OF ONE** | ||||||||||||||
| Standard | a. Polio (IPV) | i. vendor supplied serum | 90471/90713 | |||||||||||
| b. MMR booster (born 1957 +) | ||||||||||||||
| i. vendor supplied serum | 90471/90707 | |||||||||||||
| c. Tetanus/Diptheria booster (every 10 years) | ||||||||||||||
| i. vendor supplied serum | 90471/90718 | |||||||||||||
| d. Tdap tetanus/Diptheria/Pertussis | ||||||||||||||
| i. vendor supplied serum | 90471/90715 | |||||||||||||
| e. Hepatitis A (per shot) | i. vendor supplied serum | 90471/90632 | ||||||||||||
| f. Hepatitis B (per shot) | i. vendor supplied serum | 90471/90746 | ||||||||||||
| g. Typhoid - Oral | i. vendor supplied | 90473/90690 | ||||||||||||
| h. Typhoid - IM | i. vendor supplied serum | 90471/90691 | ||||||||||||
| i. Influenza - IM | i. vendor supplied serum | 90471/90658 | ||||||||||||
| j. Influenza - Intranasal | i. vendor supplied serum | 90471 | ||||||||||||
| k. Twinvax (Twinrix)/shot | i. vendor supplied serum | 90471/90636 | ||||||||||||
| Special Use | a. Meningococcal Vaccine | i. vendor supplied serum | 90471/90733-4 | |||||||||||
| b. Yellow Fever | i. vendor supplied serum | 90471/90717 | ||||||||||||
| c. Rabies Vaccine (per shot) | i. vendor supplied serum | 90471/90675 | ||||||||||||
| d. Japanese B Encephalitis | N/A - FBI Supplied | |||||||||||||
| d. Anthrax Vaccine per shot | N/A - FBI Supplied | |||||||||||||
| e. Botulinum Toxin Vaccine | N/A - FBI Supplied | |||||||||||||
| TOTAL LINES 100-116 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 13a | Travel Medicines | |||||||||||||
| **ASSUME A QUANTITY OF ONE** | ||||||||||||||
| Enter unit price of travel medicines below - Vendor Supplied Medications or Prescriptions | ||||||||||||||
| Malaria | i. Malarone | |||||||||||||
| Consult/Prescription | 4120F | |||||||||||||
| Consult/Medications | 4120F | |||||||||||||
| ii. Doxycycline | ||||||||||||||
| Consult/Prescription | 4120F | |||||||||||||
| Consult/Medications | 4120F | |||||||||||||
| iii. Mefloquine | ||||||||||||||
| Consult/Prescription | 4120F | |||||||||||||
| Consult/Medications | 4120F | |||||||||||||
| Antibiotics forTravelers' Diarrhea | Consult/Prescription | 4120F | ||||||||||||
| Consult/Medications | 4120F | |||||||||||||
| Sleep Aid Medications | Consult/Prescription | 4120F | ||||||||||||
| Consult/Medications | 4120F | |||||||||||||
| TOTAL LINES 126-137 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 14. | Additional Individual Testing as Requested | CPT Code | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | |||||||
| **ASSUME A QUANTITY OF ONE** | ||||||||||||||
| a. ALT | 84460 | |||||||||||||
| b. Audiometry | 92551 | |||||||||||||
| c. Blood group and type | 86900, 01 | |||||||||||||
| d. Blood Lead-age 9 mos. through 6 years | 83655 | |||||||||||||
| e. Blood Lead & ZPP - Adult - (if authorized by HCPU) | 84202/83655 | |||||||||||||
| f. Blood renal and metabolic panels | 80053 | |||||||||||||
| g. Chest X-ray, PA/LAT | 71020 | |||||||||||||
| h. Colonoscopy - per approval *** | 45378 | |||||||||||||
| i. Complete GYN Exam w/ PAP as indicated | 88141 | |||||||||||||
| j. Completion of Respiratory Questionnaire | FD-900 | |||||||||||||
| k. Creatinine | 82565 | |||||||||||||
| l. Digital Rectal Exam, Male > 40- offer | 45999 | |||||||||||||
| m. Distant and Near Visual Acuity, w & w/o correction | 99172 | |||||||||||||
| n. Electrocardiogram w/interpretation | 93000 | |||||||||||||
| o. Fasting Blood Glucose | 82947 | |||||||||||||
| p. Complete blood count with diff | 85025 | |||||||||||||
| q. CXR - P/A and lateral | 71020 | |||||||||||||
| r. Mantoux skin test & interruptation | 86580 | |||||||||||||
| s. Flexible Sigmoidoscopy - per approval*** | 45330 | |||||||||||||
| t. G6PD, if not previously done | 82955 | |||||||||||||
| u. GGT & Uric Acid | 82977/84550 | |||||||||||||
| s. HbA1C | 83036 | a. Urinalysis | 81001 | |||||||||||
| t. Hepatitis B Antibody and Antigen | 87340/86706 | b. Stool for occult blood X 3 - offer | 82270 | |||||||||||
| v. Hepatitis C antibody | 86803 | |||||||||||||
| w. History, physical exam, vitals, written summary | 99395,96,97 | |||||||||||||
| x. HIV, I & II Elisa | 87390/87391 | |||||||||||||
| y. Intraocular Tension (IOT) > 40 years of age | 92120 | |||||||||||||
| z. Lipid panel | 80061 | |||||||||||||
| aa. Mammogram (as indicated) | 77057 | |||||||||||||
| bb. Prostate specific antigen (PSA) | 84153 | |||||||||||||
| cc. Pulmonary function test | 94010 | |||||||||||||
| dd. RBC Cholinesterase x 1 draw and Plasma Cholinesterase x 1 draw | 82482/82480 | |||||||||||||
| ee. Serology, RPR | 86592 | |||||||||||||
| ff. Sickle Cell-Mediterranean or Black only | 85660 | |||||||||||||
| gg. Stool for occult blood x's 3 | 82270 | |||||||||||||
| hh. Stool for Ova & Parasites (as indicated) | 87177 | |||||||||||||
| ii. UA and micro. | 81001 | |||||||||||||
| jj. Visual fields Strabismus, Color Vision | 99172 | |||||||||||||
| kk. cardiologist over read of EKG | 99499 | |||||||||||||
| ll. Chest x-ray over read by radiologist | 76499 | |||||||||||||
| mm. IGRA as alternative to tubercullin skin tests*** | 86480 | |||||||||||||
| nn. Thallium/Nuclear SPECT Stress Test | 93015 | , 78451, 78452 | ||||||||||||
| nn. Cont'd | A9505, A9502 | |||||||||||||
| oo. Stress Echocardiogram | 93350, 93018 | |||||||||||||
| pp. FAA Class II Examination*** | FD-963 | |||||||||||||
| qq. FAA Class III Examination*** | FD-963 | |||||||||||||
| rr. Opthalmology/Optometry Examination*** | FD-943 | |||||||||||||
| TOTAL LINES 141-184 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||
| 15. | Hourly Rate for Expert Testimony | CPT Code | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | |||||||
| 99075 | ||||||||||||||
| 16. | Hourly Rate for Medical Consultation and Training | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | ||||||||
| 99078 | ||||||||||||||
| *Total Pricing Per Year - sum of lines 71,95,138,188,191, & 194* | Base Year | YEAR 1 | YEAR 2 | YEAR 3 | YEAR 4 | |||||||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||||||
| *GRAND TOTAL FOR ALL FIVE YEARS* - | $0.00 |
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