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Solicitation No. RRB13R001, Revised as of Amendment A-2 Page 1 of 15 Attachment B – Schedule of Examinations/Tests and Prices Unit Pricing Schedule / CLIN 001 / Initial Contract Term 10/01/2013 – 09/30/2014
Examination/Test Number (& Sub-CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 003 |
| Otolaryngology (ear exam) , including audiometric test with air and bone conduction pure tone studies with speech discrimination |
| 35 |
| 005 |
| Otolaryngology (ear exam), including audiometric test and an ENG or caloric test |
| 5 |
| 006 |
| Otolaryngology (ear exam), including a speech discrimination test with a hearing in noise test (HINT) |
| 5 |
| 007 |
| Ophthalmology (eye exam) |
| 60 |
| 011 |
| I. Q. Evaluation with psychometric testing |
| 40 |
| 014 |
| Minnesota Multi-phasic Personality Inventory |
| 5 |
| 017 |
| Internal Medicine Exam with orthopedic involvement |
| 950 |
| 018 |
| Internal Medicine Exam |
| 150 |
| 020 |
| Serum Protein Electrophoresis |
| 5 |
| 023 |
| Arterial Blood Gas Studies (resting) |
| 5 |
| 024 |
| PT (Prothrombin Time) and INR (International Normalized Ratio) |
| 5 |
| 026 |
| A1C ( also known as glycated hemoglobin HbA1c) test |
| 5 |
| 030 |
| Complete blood cell count (CBC) |
| 10 |
| 032 |
| Serum Creatinine; if not available, do BUN (blood urea nitrogen) or NPN (non-protein nitrogen) |
| 5 |
| 034 |
| Erythrocyte Sedimentation Rate |
| 5 |
| 036 |
| SMA Series (SMA-12, etc) |
| 10 |
| 037 |
| Anti-convulsant Serum Level |
| 5 |
| 038 |
| Liver function studies |
| 10 |
Unit Pricing Schedule / CLIN 001 / Initial Contract Term 10/01/2013 – 09/30/2014
Examination/Test Number (& Sub- CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 040 |
| Electro-encephalogram |
| 5 |
| 041 |
| Pulmonary Function Test, spirometry |
| 100 |
| 042 |
| Diffusing Capacity/Lungs (DLCO) |
| 5 |
| 043 |
| Stress (treadmill or bicycle) test with monitoring. Submit interpretation and sample tracings. |
| 5 |
| 045 |
| Electrocardiogram (EKG) with interpretation, submit tracing |
| 200 |
| 046 |
| Doppler Ultrasound Flow Detection Tech. |
| 5 |
| 048 |
| Antinuclear Antibody |
| 5 |
| 052/152 |
| Left/Right ankle joint, anteroposterior, lateral views, and oblique (x-ray) |
| 50 |
| 053/153 |
| Left/Right arm humerus, anteroposterior, lateral views, and oblique (x-ray) |
| 5 |
| 055 |
| Chest, anteroposterior and lateral (x-ray) |
| 220 |
| 058/158 |
| Left/Right elbow, anteroposterior, lateral views and oblique (x-ray) |
| 10 |
| 062/162 |
| Left/Right foot, anteroposterior, lateral views and oblique. (x-ray) |
| 50 |
| 063/163 |
| Left/Right forearm, anteroposterior, lateral views and oblique. (x-ray) |
| 5 |
| 067/167 |
| Left/Right hand, anteroposterior, lateral views and oblique. (x-ray) |
| 30 |
| 068 |
| Hip joints (right and left on one film) anteroposterior view (x-ray) |
| 60 |
| 073/173 |
| Left/Right knee joint, anteroposterior, lateral views and oblique. (x-ray) |
| 220 |
| 075/175 |
| Left/Right leg, tibia and fibular, anteroposterior, lateral views (x-ray) |
| 15 |
| 079/179 |
| Left/Right shoulder joint, anteroposterior view, internal and external rotation (x-ray) |
| 200 |
| 085 |
| Skull, anteroposterior, right and left lateral frontal and basal occipital (x-ray) |
| 5 |
| 087 |
| Spine, cervical, anteroposterior and lateral views odontoid (x-ray) |
| 200 |
| 088 |
| Spine, dorsal, anteroposterior and lateral views, 14X17 film (x-ray) |
| 10 |
Unit Pricing Schedule / CLIN 001 / Initial Contract Term 10/01/2013 – 09/30/2014
Examination/Test Number (& Sub- CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 089 |
| Spine, lumbo-sacral, anteroposterior and lateral views, 14X17 film (x-ray) |
| 400 |
| 092/192 |
| Left/Right thigh, femur, survey film (x-ray) |
| 5 |
| 094/194 |
| Left/Right wrist, anteroposterior and lateral views (x-ray) |
| 20 |
| 116 |
| Orthopedic Specialist Exam |
| 5 |
| 123 |
| Arterial Blood Gas (exercise) |
| 5 |
| 200 |
| Functional Capacity Evaluation |
| 5 |
| 300 |
| Cervical Spine CT Scan |
| 2 |
| 301 |
| Lumbar Spine CT Scan |
| 2 |
| 305 |
| Cervical Spine MRI without contrast |
| 5 |
| 306 |
| Lumbar Spine MRI without contrast |
| 5 |
| 307 |
| Shoulder MRI without contrast |
| 5 |
| 308 |
| Knee MRI without contrast |
| 2 |
| 309 |
| Hip MRI without contrast |
| 2 |
Unit Pricing Schedule / CLIN 002 / First Option Term 10/01/2014 – 09/30/2015
Examination/Test Number (& Sub- CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 003 |
| Otolaryngology (ear exam) , including audiometric test with air and bone conduction pure tone studies with speech discrimination |
| 35 |
| 005 |
| Otolaryngology (ear exam), including audiometric test and an ENG or caloric test |
| 5 |
| 006 |
| Otolaryngology (ear exam), including a speech discrimination test with a hearing in noise test (HINT) |
| 5 |
| 007 |
| Ophthalmology (eye exam) |
| 60 |
| 011 |
| I. Q. Evaluation with psychometric testing |
| 40 |
| 014 |
| Minnesota Multi-phasic Personality Inventory |
| 5 |
| 017 |
| Internal Medicine Exam with orthopedic involvement |
| 950 |
| 018 |
| Internal Medicine Exam |
| 150 |
| 020 |
| Serum Protein Electrophoresis |
| 5 |
| 023 |
| Arterial Blood Gas Studies (resting) |
| 5 |
| 024 |
| PT (Prothrombin Time) and INR (International Normalized Ratio) |
| 5 |
| 026 |
| A1C ( also known as glycated hemoglobin HbA1c) test |
| 5 |
| 030 |
| Complete blood cell count (CBC) |
| 10 |
| 032 |
| Serum Creatinine; if not available, do BUN (blood urea nitrogen) or NPN (non-protein nitrogen) |
| 5 |
| 034 |
| Erythrocyte Sedimentation Rate |
| 5 |
| 036 |
| SMA Series (SMA-12, etc) |
| 10 |
| 037 |
| Anti-convulsant Serum Level |
| 5 |
| 038 |
| Liver function studies |
| 10 |
Examination/Test Number (& Sub- CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 040 |
| Electro-encephalogram |
| 5 |
| 041 |
| Pulmonary Function Test, spirometry |
| 100 |
| 042 |
| Diffusing Capacity/Lungs (DLCO) |
| 5 |
| 043 |
| Stress (treadmill or bicycle) test with monitoring. Submit interpretation and sample tracings. |
| 5 |
| 045 |
| Electrocardiogram (EKG) with interpretation, submit tracing |
| 200 |
| 046 |
| Doppler Ultrasound Flow Detection Tech. |
| 5 |
| 048 |
| Antinuclear Antibody |
| 5 |
| 052/152 |
| Left/Right ankle joint, anteroposterior, lateral views, and oblique (x-ray) |
| 50 |
| 053/153 |
| Left/Right arm humerus, anteroposterior, lateral views, and oblique (x-ray) |
| 5 |
| 055 |
| Chest, anteroposterior and lateral (x-ray) |
| 220 |
| 058/158 |
| Left/Right elbow, anteroposterior, lateral views and oblique (x-ray) |
| 10 |
| 062/162 |
| Left/Right foot, anteroposterior, lateral views and oblique. (x-ray) |
| 50 |
| 063/163 |
| Left/Right forearm, anteroposterior, lateral views and oblique. (x-ray) |
| 5 |
| 067/167 |
| Left/Right hand, anteroposterior, lateral views and oblique. (x-ray) |
| 30 |
| 068 |
| Hip joints (right and left on one film) anteroposterior view (x-ray) |
| 60 |
| 073/173 |
| Left/Right knee joint, anteroposterior, lateral views and oblique. (x-ray) |
| 220 |
| 075/175 |
| Left/Right leg, tibia and fibular, anteroposterior, lateral views (x-ray) |
| 15 |
| 079/179 |
| Left/Right shoulder joint, anteroposterior view, internal and external rotation (x-ray) |
| 200 |
| 085 |
| Skull, anteroposterior, right and left lateral frontal and basal occipital (x-ray) |
| 5 |
| 087 |
| Spine, cervical, anteroposterior and lateral views odontoid (x-ray) |
| 200 |
| 088 |
| Spine, dorsal, anteroposterior and lateral views, 14X17 film (x-ray) |
| 10 |
Examination/Test Number (& Sub- CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 089 |
| Spine, lumbo-sacral, anteroposterior and lateral views, 14X17 film (x-ray) |
| 400 |
| 092/192 |
| Left/Right thigh, femur, survey film (x-ray) |
| 5 |
| 094/194 |
| Left/Right wrist, anteroposterior and lateral views (x-ray) |
| 20 |
| 116 |
| Orthopedic Specialist Exam |
| 5 |
| 123 |
| Arterial Blood Gas (exercise) |
| 5 |
| 200 |
| Functional Capacity Evaluation |
| 5 |
| 300 |
| Cervical Spine CT Scan |
| 2 |
| 301 |
| Lumbar Spine CT Scan |
| 2 |
| 305 |
| Cervical Spine MRI without contrast |
| 5 |
| 306 |
| Lumbar Spine MRI without contrast |
| 5 |
| 307 |
| Shoulder MRI without contrast |
| 5 |
| 308 |
| Knee MRI without contrast |
| 2 |
| 309 |
| Hip MRI without contrast |
| 2 |
Unit Pricing Schedule / CLIN 003 / Second Option Term 10/01/2054 – 09/30/2016
Examination/Test Number (& Sub- CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 003 |
| Otolaryngology (ear exam) , including audiometric test with air and bone conduction pure tone studies with speech discrimination |
| 35 |
| 005 |
| Otolaryngology (ear exam), including audiometric test and an ENG or caloric test |
| 5 |
| 006 |
| Otolaryngology (ear exam), including a speech discrimination test with a hearing in noise test (HINT) |
| 5 |
| 007 |
| Ophthalmology (eye exam) |
| 60 |
| 011 |
| I. Q. Evaluation with psychometric testing |
| 40 |
| 014 |
| Minnesota Multi-phasic Personality Inventory |
| 5 |
| 017 |
| Internal Medicine Exam with orthopedic involvement |
| 950 |
| 018 |
| Internal Medicine Exam |
| 150 |
| 020 |
| Serum Protein Electrophoresis |
| 5 |
| 023 |
| Arterial Blood Gas Studies (resting) |
| 5 |
| 024 |
| PT (Prothrombin Time) and INR (International Normalized Ratio) |
| 5 |
| 026 |
| A1C ( also known as glycated hemoglobin HbA1c) test |
| 5 |
| 030 |
| Complete blood cell count (CBC) |
| 10 |
| 032 |
| Serum Creatinine; if not available, do BUN (blood urea nitrogen) or NPN (non-protein nitrogen) |
| 5 |
| 034 |
| Erythrocyte Sedimentation Rate |
| 5 |
| 036 |
| SMA Series (SMA-12, etc) |
| 10 |
| 037 |
| Anti-convulsant Serum Level |
| 5 |
| 038 |
| Liver function studies |
| 10 |
Unit Pricing Schedule / CLIN 003 / Second Option Term 10/01/2015 – 09/30/2016
Examination/Test Number (& Sub- CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 040 |
| Electro-encephalogram |
| 5 |
| 041 |
| Pulmonary Function Test, spirometry |
| 100 |
| 042 |
| Diffusing Capacity/Lungs (DLCO) |
| 5 |
| 043 |
| Stress (treadmill or bicycle) test with monitoring. Submit interpretation and sample tracings. |
| 5 |
| 045 |
| Electrocardiogram (EKG) with interpretation, submit tracing |
| 200 |
| 046 |
| Doppler Ultrasound Flow Detection Tech. |
| 5 |
| 048 |
| Antinuclear Antibody |
| 5 |
| 052/152 |
| Left/Right ankle joint, anteroposterior, lateral views, and oblique (x-ray) |
| 50 |
| 053/153 |
| Left/Right arm humerus, anteroposterior, lateral views, and oblique (x-ray) |
| 5 |
| 055 |
| Chest, anteroposterior and lateral (x-ray) |
| 220 |
| 058/158 |
| Left/Right elbow, anteroposterior, lateral views and oblique (x-ray) |
| 10 |
| 062/162 |
| Left/Right foot, anteroposterior, lateral views and oblique. (x-ray) |
| 50 |
| 063/163 |
| Left/Right forearm, anteroposterior, lateral views and oblique. (x-ray) |
| 5 |
| 067/167 |
| Left/Right hand, anteroposterior, lateral views and oblique. (x-ray) |
| 30 |
| 068 |
| Hip joints (right and left on one film) anteroposterior view (x-ray) |
| 60 |
| 073/173 |
| Left/Right knee joint, anteroposterior, lateral views and oblique. (x-ray) |
| 220 |
| 075/175 |
| Left/Right leg, tibia and fibular, anteroposterior, lateral views (x-ray) |
| 15 |
| 079/179 |
| Left/Right shoulder joint, anteroposterior view, internal and external rotation (x-ray) |
| 200 |
| 085 |
| Skull, anteroposterior, right and left lateral frontal and basal occipital (x-ray) |
| 5 |
| 087 |
| Spine, cervical, anteroposterior and lateral views odontoid (x-ray) |
| 200 |
| 088 |
| Spine, dorsal, anteroposterior and lateral views, 14X17 film (x-ray) |
| 10 |
Unit Pricing Schedule / CLIN 003 / Second Option Term 10/01/2015 – 09/30/2016
Examination/Test Number (& Sub- CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 089 |
| Spine, lumbo-sacral, anteroposterior and lateral views, 14X17 film (x-ray) |
| 400 |
| 092/192 |
| Left/Right thigh, femur, survey film (x-ray) |
| 5 |
| 094/194 |
| Left/Right wrist, anteroposterior and lateral views (x-ray) |
| 20 |
| 116 |
| Orthopedic Specialist Exam |
| 5 |
| 123 |
| Arterial Blood Gas (exercise) |
| 5 |
| 200 |
| Functional Capacity Evaluation |
| 5 |
| 300 |
| Cervical Spine CT Scan |
| 2 |
| 301 |
| Lumbar Spine CT Scan |
| 2 |
| 305 |
| Cervical Spine MRI without contrast |
| 5 |
| 306 |
| Lumbar Spine MRI without contrast |
| 5 |
| 307 |
| Shoulder MRI without contrast |
| 5 |
| 308 |
| Knee MRI without contrast |
| 2 |
| 309 |
| Hip MRI without contrast |
| 2 |
Unit Pricing Schedule / CLIN 004 / Third Option Term 10/01/2016 – 09/30/2017
Examination/Test Number (& Sub- CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 003 |
| Otolaryngology (ear exam) , including audiometric test with air and bone conduction pure tone studies with speech discrimination |
| 35 |
| 005 |
| Otolaryngology (ear exam), including audiometric test and an ENG or caloric test |
| 5 |
| 006 |
| Otolaryngology (ear exam), including a speech discrimination test with a hearing in noise test (HINT) |
| 5 |
| 007 |
| Ophthalmology (eye exam) |
| 60 |
| 011 |
| I. Q. Evaluation with psychometric testing |
| 40 |
| 014 |
| Minnesota Multi-phasic Personality Inventory |
| 5 |
| 017 |
| Internal Medicine Exam with orthopedic involvement |
| 950 |
| 018 |
| Internal Medicine Exam |
| 150 |
| 020 |
| Serum Protein Electrophoresis |
| 5 |
| 023 |
| Arterial Blood Gas Studies (resting) |
| 5 |
| 024 |
| PT (Prothrombin Time) and INR (International Normalized Ratio) |
| 5 |
| 026 |
| A1C ( also known as glycated hemoglobin HbA1c) test |
| 5 |
| 030 |
| Complete blood cell count (CBC) |
| 10 |
| 032 |
| Serum Creatinine; if not available, do BUN (blood urea nitrogen) or NPN (non-protein nitrogen) |
| 5 |
| 034 |
| Erythrocyte Sedimentation Rate |
| 5 |
| 036 |
| SMA Series (SMA-12, etc) |
| 10 |
| 037 |
| Anti-convulsant Serum Level |
| 5 |
| 038 |
| Liver function studies |
| 10 |
Examination/Test Number (& Sub- CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 040 |
| Electro-encephalogram |
| 5 |
| 041 |
| Pulmonary Function Test, spirometry |
| 100 |
| 042 |
| Diffusing Capacity/Lungs (DLCO) |
| 5 |
| 043 |
| Stress (treadmill or bicycle) test with monitoring. Submit interpretation and sample tracings. |
| 5 |
| 045 |
| Electrocardiogram (EKG) with interpretation, submit tracing |
| 200 |
| 046 |
| Doppler Ultrasound Flow Detection Tech. |
| 5 |
| 048 |
| Antinuclear Antibody |
| 5 |
| 052/152 |
| Left/Right ankle joint, anteroposterior, lateral views, and oblique (x-ray) |
| 50 |
| 053/153 |
| Left/Right arm humerus, anteroposterior, lateral views, and oblique (x-ray) |
| 5 |
| 055 |
| Chest, anteroposterior and lateral (x-ray) |
| 220 |
| 058/158 |
| Left/Right elbow, anteroposterior, lateral views and oblique (x-ray) |
| 10 |
| 062/162 |
| Left/Right foot, anteroposterior, lateral views and oblique. (x-ray) |
| 50 |
| 063/163 |
| Left/Right forearm, anteroposterior, lateral views and oblique. (x-ray) |
| 5 |
| 067/167 |
| Left/Right hand, anteroposterior, lateral views and oblique. (x-ray) |
| 30 |
| 068 |
| Hip joints (right and left on one film) anteroposterior view (x-ray) |
| 60 |
| 073/173 |
| Left/Right knee joint, anteroposterior, lateral views and oblique. (x-ray) |
| 220 |
| 075/175 |
| Left/Right leg, tibia and fibular, anteroposterior, lateral views (x-ray) |
| 15 |
| 079/179 |
| Left/Right shoulder joint, anteroposterior view, internal and external rotation (x-ray) |
| 200 |
| 085 |
| Skull, anteroposterior, right and left lateral frontal and basal occipital (x-ray) |
| 5 |
| 087 |
| Spine, cervical, anteroposterior and lateral views odontoid (x-ray) |
| 200 |
| 088 |
| Spine, dorsal, anteroposterior and lateral views, 14X17 film (x-ray) |
| 10 |
Examination/Test Number (& Sub- CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 089 |
| Spine, lumbo-sacral, anteroposterior and lateral views, 14X17 film (x-ray) |
| 400 |
| 092/192 |
| Left/Right thigh, femur, survey film (x-ray) |
| 5 |
| 094/194 |
| Left/Right wrist, anteroposterior and lateral views (x-ray) |
| 20 |
| 116 |
| Orthopedic Specialist Exam |
| 5 |
| 123 |
| Arterial Blood Gas (exercise) |
| 5 |
| 200 |
| Functional Capacity Evaluation |
| 5 |
| 300 |
| Cervical Spine CT Scan |
| 2 |
| 301 |
| Lumbar Spine CT Scan |
| 2 |
| 305 |
| Cervical Spine MRI without contrast |
| 5 |
| 306 |
| Lumbar Spine MRI without contrast |
| 5 |
| 307 |
| Shoulder MRI without contrast |
| 5 |
| 308 |
| Knee MRI without contrast |
| 2 |
| 309 |
| Hip MRI without contrast |
| 2 |
Unit Pricing Schedule / CLIN 005 / Fourth Option Term 10/01/2017 – 09/30/2018
Examination/Test Number (& Sub- CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 003 |
| Otolaryngology (ear exam) , including audiometric test with air and bone conduction pure tone studies with speech discrimination |
| 35 |
| 005 |
| Otolaryngology (ear exam), including audiometric test and an ENG or caloric test |
| 5 |
| 006 |
| Otolaryngology (ear exam), including a speech discrimination test with a hearing in noise test (HINT) |
| 5 |
| 007 |
| Ophthalmology (eye exam) |
| 60 |
| 011 |
| I. Q. Evaluation with psychometric testing |
| 40 |
| 014 |
| Minnesota Multi-phasic Personality Inventory |
| 5 |
| 017 |
| Internal Medicine Exam with orthopedic involvement |
| 950 |
| 018 |
| Internal Medicine Exam |
| 150 |
| 020 |
| Serum Protein Electrophoresis |
| 5 |
| 023 |
| Arterial Blood Gas Studies (resting) |
| 5 |
| 024 |
| PT (Prothrombin Time) and INR (International Normalized Ratio) |
| 5 |
| 026 |
| A1C ( also known as glycated hemoglobin HbA1c) test |
| 5 |
| 030 |
| Complete blood cell count (CBC) |
| 10 |
| 032 |
| Serum Creatinine; if not available, do BUN (blood urea nitrogen) or NPN (non-protein nitrogen) |
| 5 |
| 034 |
| Erythrocyte Sedimentation Rate |
| 5 |
| 036 |
| SMA Series (SMA-12, etc) |
| 10 |
| 037 |
| Anti-convulsant Serum Level |
| 5 |
| 038 |
| Liver function studies |
| 10 |
Unit Pricing Schedule / CLIN 005 / Fourth Option Term 10/01/2017 – 09/30/2018
Examination/Test Number (& Sub- CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 040 |
| Electro-encephalogram |
| 5 |
| 041 |
| Pulmonary Function Test, spirometry |
| 100 |
| 042 |
| Diffusing Capacity/Lungs (DLCO) |
| 5 |
| 043 |
| Stress (treadmill or bicycle) test with monitoring. Submit interpretation and sample tracings. |
| 5 |
| 045 |
| Electrocardiogram (EKG) with interpretation, submit tracing |
| 200 |
| 046 |
| Doppler Ultrasound Flow Detection Tech. |
| 5 |
| 048 |
| Antinuclear Antibody |
| 5 |
| 052/152 |
| Left/Right ankle joint, anteroposterior, lateral views, and oblique (x-ray) |
| 50 |
| 053/153 |
| Left/Right arm humerus, anteroposterior, lateral views, and oblique (x-ray) |
| 5 |
| 055 |
| Chest, anteroposterior and lateral (x-ray) |
| 220 |
| 058/158 |
| Left/Right elbow, anteroposterior, lateral views and oblique (x-ray) |
| 10 |
| 062/162 |
| Left/Right foot, anteroposterior, lateral views and oblique. (x-ray) |
| 50 |
| 063/163 |
| Left/Right forearm, anteroposterior, lateral views and oblique. (x-ray) |
| 5 |
| 067/167 |
| Left/Right hand, anteroposterior, lateral views and oblique. (x-ray) |
| 30 |
| 068 |
| Hip joints (right and left on one film) anteroposterior view (x-ray) |
| 60 |
| 073/173 |
| Left/Right knee joint, anteroposterior, lateral views and oblique. (x-ray) |
| 220 |
| 075/175 |
| Left/Right leg, tibia and fibular, anteroposterior, lateral views (x-ray) |
| 15 |
| 079/179 |
| Left/Right shoulder joint, anteroposterior view, internal and external rotation (x-ray) |
| 200 |
| 085 |
| Skull, anteroposterior, right and left lateral frontal and basal occipital (x-ray) |
| 5 |
| 087 |
| Spine, cervical, anteroposterior and lateral views odontoid (x-ray) |
| 200 |
| 088 |
| Spine, dorsal, anteroposterior and lateral views, 14X17 film (x-ray) |
| 10 |
Unit Pricing Schedule / CLIN 005 / Fourth Option Term 10/01/2017 – 09/30/201
Examination/Test Number (& Sub- CLIN)
| Examination/Test Name |
| Estimated No. Ordered Annually |
Unit Price
| 089 |
| Spine, lumbo-sacral, anteroposterior and lateral views, 14X17 film (x-ray) |
| 400 |
| 092/192 |
| Left/Right thigh, femur, survey film (x-ray) |
| 5 |
| 094/194 |
| Left/Right wrist, anteroposterior and lateral views (x-ray) |
| 20 |
| 116 |
| Orthopedic Specialist Exam |
| 5 |
| 123 |
| Arterial Blood Gas (exercise) |
| 5 |
| 200 |
| Functional Capacity Evaluation |
| 5 |
| 300 |
| Cervical Spine CT Scan |
| 2 |
| 301 |
| Lumbar Spine CT Scan |
| 2 |
| 305 |
| Cervical Spine MRI without contrast |
| 5 |
| 306 |
| Lumbar Spine MRI without contrast |
| 5 |
| 307 |
| Shoulder MRI without contrast |
| 5 |
| 308 |
| Knee MRI without contrast |
| 2 |
| 309 |
| Hip MRI without contrast |
| 2 |
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