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Attachment A: Contract Pricing
| Line Item |
| Unit |
| Page Reference |
Base Year:
See pages 2 - 5
| Provide Medical Services |
| July 18, 2015 to July 17, 2016 |
Option Year 1:
See pages 6 - 9
| Provide Medical Services |
| July 18, 2016 to July 17, 2017 |
Option Year 2:
See pages 10 - 13
| Provide Medical Services |
| July 18, 2017 to July 17, 2018 |
Option Year 3:
See pages 14 - 17
| Provide Medical Services |
| July 18, 2018 to July 17, 2019 |
Option Year 4:
See pages 18 - 21
| Provide Medical Services |
| July 18, 2019 to July 17, 2020 |
Base Year
| Item |
| PWS Reference |
| Price |
| Notes |
| Applicant Pre-Placement Examination (including vitals) |
| 4.4 |
| Pre-Placement Exercise Stress Test |
| 4.4 |
| Pre-Placement Thyroid Panel |
| 4.4 |
| Pre-Placement Vision (including Ishihara, depth perception, peripheral and acuity) |
| 4.4 |
| Pre-Placement Health History Questionnaire |
| 4.4 |
| Pre-Placement Physical Examination (including vitals) |
| 4.4 |
| Pre-Placement Spirometry |
| 4.4 |
| Pre-Placement Resting EKG |
| 4.4 |
| Pre-Placement OSHA Audiogram |
| 4.4 |
| Pre-Placement Specimen Collection – Blood |
| 4.4 |
| Pre-Placement Specimen Collection – Urine |
| 4.4 |
| Pre-Placement Chemistry Panel w/Lipids |
| 4.4 |
| Pre-Placement CBC w/Diff. |
| 4.4 |
| Pre-Placement Blood Lead (includes ZPP) |
| 4.4 |
| Pre-Placement QuantiFERON-TB-Gold |
| 4.4 |
| Pre-Placement Urinalysis |
| 4.4 |
| Purified Protein Derivative (PPD) – Tuberculosis Skin Test |
| 4.4 |
| Biennial Physical Fitness Screening (includes vitals), HHQ, Blood Pressure, Height & Weight, Lipid Panel, glucose Specimen Collection –Blood, Blood Lead, and ZPP) |
| 4.5, 4.6 |
| Biennial Physical Fitness Examination |
| 4.5, 4.6 |
| Biennial Physical Fitness Screening – Health History Questionnaire |
| 4.5, 4.6 |
Biennial Vision (including Ishihara, depth perception, and peripheral and acuity)
| Biennial Urinalysis |
| 4.5, 4.6 |
Biennial PPD
| Biennial QuantiFERON-TB-Gold |
| 4.4 |
| Biennial Physical Fitness Resting EKG |
| 4.5, 4.6 |
| Biennial Physical Fitness Exercise Stress Test |
| 4.5, 4.6 |
| Biennial Physical Fitness Specimen Collection –Blood |
| 4.5, 4.6 |
| Biennial Physical Fitness Thyroid Panel |
| 4.5, 4.6 |
| Biennial Physical Fitness Glucose |
| 4.5, 4.6 |
| Biennial Physical Fitness Lipid Panel |
| 4.5, 4.6 |
| Administrative - Contractor Review of all Medical Screenings |
| 4.5 |
| Biennial Physical Fitness Screening and Lead and ZPP test |
| 4.6, 4.8 |
| Hearing Conservation Program Audiogram (Incl. hearing questionnaire) |
| 4.9 |
| Hearing Conservation Program Follow Up Audiogram |
| 4.9 |
| Additional – Administrative time to update clearance ratings for all active agents |
| 4.5 |
| Biennial Physical Fitness Screening - Repeat Blood Lead (includes repeat ZPP) |
| 4.6 |
| Biennial Physical Fitness Screening - Specimen Collection (Blood) |
| 4.6 |
| Fitness for Duty Examination (including HHQ, PE, Blood Pressure, Height & Weight) |
| 4.10 |
| Fitness for Duty OSHA Audiogram (including Hearing History) |
| 4.10 |
| Fitness for Duty Resting EKG |
| 4.10 |
| Fitness for Duty Exercise Stress Test |
| 4.10 |
| Fitness for Duty Spirometry |
| 4.10 |
| Fitness for Duty Vision |
| 4.10 |
| Fitness for Duty Vision (including color, Farnsworth) |
| 4.10 |
| Fitness for Duty Lipid Panel |
| 4.10 |
| Fitness for Duty Glucose |
| 4.10 |
| Fitness for Duty Blood Lead (including ZPP) |
| 4.10 |
| Fitness for Duty Blood Chemistry w/Lipids |
| 4.10 |
| Fitness for Duty Thyroid Panel (TSH w/free T4 RFX) |
| 4.10 |
| Fitness for Duty CBC |
| 4.10 |
| Fitness for Duty Routine Urinalysis |
| 4.10 |
| Fitness for Duty PPD |
| 4.10 |
| Fitness for Duty QuantiFERON-TB-Gold |
| 4.10 |
| Fitness for Duty Specimen Collection (Urine) |
| 4.10 |
| Fitness for Duty Specimen Collection (Blood) |
| 4.10 |
| Fitness for Duty Blood Group & Type |
| 4.10 |
| Fitness for Duty HIV test |
| 4.10 |
| Fitness for Duty Hepatitis C Antibody |
| 4.10 |
| Fitness for Duty Hepatitis B Antigen |
| 4.10 |
| Fitness for Duty Psychological Consultation (per hour) |
| 4.10 |
| Fitness for Duty Psychiatric Consult (per hour) |
| 4.10 |
| Independent Medical Examination (IME) |
| 4.10 |
Scheduling Fee
Rescheduling Fee
| Temporary Restricted Duty; Return to Duty; Post Refractive Surgery Evaluation; Report of Medical & Psychological Conditions & Medications; Additional Advisory Services -- MRO Consultation (per hour) |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.10, 4.11, 4.12, 4.13, 4.14, 4.15 |
| Immunizations Administration Fee |
| 4.15 |
| Immunizations Hepatitis A (2 shot series) |
| 4.15 |
| Immunizations Hepatitis B (3 shot series) |
| 4.15 |
| Hepatitis B Antibody (Titer) |
| 4.15 |
| Immunizations Twinrix |
| 4.15 |
| Immunizations Tetanus (diphtheria) |
| 4.15 |
| Immunizations Typhoid (injectable or oral) |
| 4.15 |
| Immunizations Japanese Encephalitis |
| 4.15 |
| Immunizations Yellow Fever |
| 4.15 |
| Immunizations Pneumococcal |
| 4.15 |
| Immunizations Globulin, immune |
| 4.15 |
| Immunizations MMR (Mumps, Measles, Rubella) |
| 4.15 |
| Immunizations Rabies (3 shot series) |
| 4.15 |
| Medical Advisory Review Officer Meeting -- per meeting (to include all necessary staff to attend and be prepared to discuss relevant medical cases and issues in detail) |
| 4.7 |
| Medical Advisory Review Officer Meeting -- travel |
| 4.7 |
| Critical Incident Stress, Debriefing/Counseling-- per hour psychiatrist |
| 4.16 |
| --No show – billable if less than 24 hours’ notice |
| 4.17 |
| Contract Psychologist – Travel |
| 4.17 |
| Breath Alcohol Testing – at clinic |
| 4.17 |
| Breath Alcohol Testing (blood) – confirmation |
| 4.17 |
| Breath Alcohol Testing – onsite |
| 4.17 |
| Breath Alcohol Testing (breath) – confirmation |
| 4.17 |
| No show fee |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.15 |
| Failure to cancel Fitness Clearance Examination appointment w/in 48 hours of examination |
| 4.5, 4.6 |
| Failure to cancel Physical Examination appointment w/in 48 hours of examination |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.15 |
| Medical Record Copy Fee |
| 4.3, 4.4, 4.5, 4.6, , 4.8, 4.9, 4.10, 4.11, 4.12, 4.13, 4.15 |
Option Year 1
| Item |
| PWS Reference |
| Price |
| Notes |
| Applicant Pre-Placement Examination (including vitals) |
| 4.4 |
| Pre-Placement Exercise Stress Test |
| 4.4 |
| Pre-Placement Thyroid Panel |
| 4.4 |
| Pre-Placement Vision (including Ishihara, depth perception, peripheral and acuity) |
| 4.4 |
| Pre-Placement Health History Questionnaire |
| 4.4 |
| Pre-Placement Physical Examination (including vitals) |
| 4.4 |
| Pre-Placement Spirometry |
| 4.4 |
| Pre-Placement Resting EKG |
| 4.4 |
| Pre-Placement OSHA Audiogram |
| 4.4 |
| Pre-Placement Specimen Collection – Blood |
| 4.4 |
| Pre-Placement Specimen Collection – Urine |
| 4.4 |
| Pre-Placement Chemistry Panel w/Lipids |
| 4.4 |
| Pre-Placement CBC w/Diff. |
| 4.4 |
| Pre-Placement Blood Lead (includes ZPP) |
| 4.4 |
| Pre-Placement QuantiFERON-TB-Gold |
| 4.4 |
| Pre-Placement Urinalysis |
| 4.4 |
| Purified Protein Derivative (PPD) – Tuberculosis Skin Test |
| 4.4 |
| Biennial Physical Fitness Screening (includes vitals), HHQ, Blood Pressure, Height & Weight, Lipid Panel, glucose Specimen Collection –Blood, Blood Lead, and ZPP) |
| 4.5, 4.6 |
| Biennial Physical Fitness Examination |
| 4.5, 4.6 |
| Biennial Physical Fitness Screening – Health History Questionnaire |
| 4.5, 4.6 |
Biennial Vision (including Ishihara, depth perception, and peripheral and acuity)
| Biennial Urinalysis |
| 4.5, 4.6 |
| Biennial QuantiFERON-TB-Gold |
| 4.4 |
| Biennial Physical Fitness Resting EKG |
| 4.5, 4.6 |
| Biennial Physical Fitness Exercise Stress Test |
| 4.5, 4.6 |
| Biennial Physical Fitness Specimen Collection –Blood |
| 4.5, 4.6 |
| Biennial Physical Fitness Thyroid Panel |
| 4.5, 4.6 |
| Biennial Physical Fitness Glucose |
| 4.5, 4.6 |
| Biennial Physical Fitness Lipid Panel |
| 4.5, 4.6 |
| Biennial Physical Fitness Screening and Lead and ZPP test |
| 4.6, 4.8 |
| Hearing Conservation Program Audiogram (Incl. hearing questionnaire) |
| 4.9 |
| Hearing Conservation Program Follow Up Audiogram |
| 4.9 |
| Biennial Physical Fitness Screening - Repeat Blood Lead (includes repeat ZPP) |
| 4.6 |
| Biennial Physical Fitness Screening - Specimen Collection (Blood) |
| 4.6 |
| Fitness for Duty Examination (including HHQ, PE, Blood Pressure, Height & Weight) |
| 4.10 |
| Fitness for Duty OSHA Audiogram (including Hearing History) |
| 4.10 |
| Fitness for Duty Resting EKG |
| 4.10 |
| Fitness for Duty Exercise Stress Test |
| 4.10 |
| Fitness for Duty Spirometry |
| 4.10 |
| Fitness for Duty Vision |
| 4.10 |
| Fitness for Duty Vision (including color, Farnsworth) |
| 4.10 |
| Fitness for Duty Lipid Panel |
| 4.10 |
| Fitness for Duty Glucose |
| 4.10 |
| Fitness for Duty Blood Lead (including ZPP) |
| 4.10 |
| Fitness for Duty Blood Chemistry w/Lipids |
| 4.10 |
| Fitness for Duty Thyroid Panel (TSH w/free T4 RFX) |
| 4.10 |
| Fitness for Duty CBC |
| 4.10 |
| Fitness for Duty Routine Urinalysis |
| 4.10 |
| Fitness for Duty PPD |
| 4.10 |
| Fitness for Duty QuantiFERON-TB-Gold |
| 4.10 |
| Fitness for Duty Specimen Collection (Urine) |
| 4.10 |
| Fitness for Duty Specimen Collection (Blood) |
| 4.10 |
| Fitness for Duty Blood Group & Type |
| 4.10 |
| Fitness for Duty HIV test |
| 4.10 |
| Fitness for Duty Hepatitis C Antibody |
| 4.10 |
| Fitness for Duty Hepatitis B Antigen |
| 4.10 |
| Fitness for Duty Psychological Consultation (per hour) |
| 4.10 |
| Fitness for Duty Psychiatric Consult (per hour) |
| 4.10 |
| Independent Medical Examination (IME) |
| 4.10 |
Scheduling Fee
Rescheduling Fee
| Temporary Restricted Duty; Return to Duty; Post Refractive Surgery Evaluation; Report of Medical & Psychological Conditions & Medications; Additional Advisory Services -- MRO Consultation (per hour) |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.10, 4.11, 4.12, 4.13, 4.14, 4.15 |
| Immunizations Administration Fee |
| 4.15 |
| Immunizations Hepatitis A (2 shot series) |
| 4.15 |
| Immunizations Hepatitis B (3 shot series) |
| 4.15 |
| Hepatitis B Antibody (Titer) |
| 4.15 |
| Immunizations Twinrix |
| 4.15 |
| Immunizations Tetanus (diphtheria) |
| 4.15 |
| Immunizations Typhoid (injectable or oral) |
| 4.15 |
| Immunizations Japanese Encephalitis |
| 4.15 |
| Immunizations Yellow Fever |
| 4.15 |
| Immunizations Pneumococcal |
| 4.15 |
| Immunizations Globulin, immune |
| 4.15 |
| Immunizations MMR (Mumps, Measles, Rubella) |
| 4.15 |
| Immunizations Rabies (3 shot series) |
| 4.15 |
| Medical Advisory Review Officer Meeting -- per meeting (to include all necessary staff to attend and be prepared to discuss relevant medical cases and issues in detail) |
| 4.7 |
| Medical Advisory Review Officer Meeting -- travel |
| 4.7 |
| Critical Incident Stress, Debriefing/Counseling-- per hour psychiatrist |
| 4.16 |
| --No show – billable if less than 24 hours’ notice |
| 4.17 |
| Contract Psychologist – Travel |
| 4.17 |
| Breath Alcohol Testing – at clinic |
| 4.17 |
| Breath Alcohol Testing (blood) – confirmation |
| 4.17 |
| Breath Alcohol Testing – onsite |
| 4.17 |
| Breath Alcohol Testing (breath) – confirmation |
| 4.17 |
| No show fee |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.15 |
| Failure to cancel Fitness Clearance Examination appointment w/in 48 hours of examination |
| 4.5, 4.6 |
| Failure to cancel Physical Examination appointment w/in 48 hours of examination |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.15 |
| Medical Record Copy Fee |
| 4.3, 4.4, 4.5, 4.6, , 4.8, 4.9, 4.10, 4.11, 4.12, 4.13, 4.15 |
Option Year 2
| Item |
| PWS Reference |
| Price |
| Notes |
| Applicant Pre-Placement Examination (including vitals) |
| 4.4 |
| Pre-Placement Exercise Stress Test |
| 4.4 |
| Pre-Placement Thyroid Panel |
| 4.4 |
| Pre-Placement Vision (including Ishihara, depth perception, peripheral and acuity) |
| 4.4 |
| Pre-Placement Health History Questionnaire |
| 4.4 |
| Pre-Placement Physical Examination (including vitals) |
| 4.4 |
| Pre-Placement Spirometry |
| 4.4 |
| Pre-Placement Resting EKG |
| 4.4 |
| Pre-Placement OSHA Audiogram |
| 4.4 |
| Pre-Placement Specimen Collection – Blood |
| 4.4 |
| Pre-Placement Specimen Collection – Urine |
| 4.4 |
| Pre-Placement Chemistry Panel w/Lipids |
| 4.4 |
| Pre-Placement CBC w/Diff. |
| 4.4 |
| Pre-Placement Blood Lead (includes ZPP) |
| 4.4 |
| Pre-Placement QuantiFERON-TB-Gold |
| 4.4 |
| Pre-Placement Urinalysis |
| 4.4 |
| Purified Protein Derivative (PPD) – Tuberculosis Skin Test |
| 4.4 |
| Biennial Physical Fitness Screening (includes vitals), HHQ, Blood Pressure, Height & Weight, Lipid Panel, glucose Specimen Collection –Blood, Blood Lead, and ZPP) |
| 4.5, 4.6 |
| Biennial Physical Fitness Examination |
| 4.5, 4.6 |
| Biennial Physical Fitness Screening – Health History Questionnaire |
| 4.5, 4.6 |
Biennial Vision (including Ishihara, depth perception, and peripheral and acuity)
| Biennial Urinalysis |
| 4.5, 4.6 |
| Biennial - Specimen Collection – Routine Urine |
| 4.6 |
| Biennial - CBC w/Differential/Platelet |
| 4.6 |
| Biennial QuantiFERON-TB-Gold |
| 4.4 |
| Biennial Physical Fitness Resting EKG |
| 4.5, 4.6 |
| Biennial Physical Fitness Exercise Stress Test |
| 4.5, 4.6 |
| Biennial Physical Fitness Specimen Collection –Blood |
| 4.5, 4.6 |
| Biennial Physical Fitness Thyroid Panel |
| 4.5, 4.6 |
| Biennial Physical Fitness Glucose |
| 4.5, 4.6 |
| Biennial Physical Fitness Lipid Panel |
| 4.5, 4.6 |
| Biennial Physical Fitness Screening and Lead and ZPP test |
| 4.6, 4.8 |
| Hearing Conservation Program Audiogram (Incl. hearing questionnaire) |
| 4.9 |
| Hearing Conservation Program Follow Up Audiogram |
| 4.9 |
| Biennial Physical Fitness Screening - Repeat Blood Lead (includes repeat ZPP) |
| 4.6 |
| Biennial Physical Fitness Screening - Specimen Collection (Blood) |
| 4.6 |
| Fitness for Duty Examination (including HHQ, PE, Blood Pressure, Height & Weight) |
| 4.10 |
| Fitness for Duty OSHA Audiogram (including Hearing History) |
| 4.10 |
| Fitness for Duty Resting EKG |
| 4.10 |
| Fitness for Duty Exercise Stress Test |
| 4.10 |
| Fitness for Duty Spirometry |
| 4.10 |
| Fitness for Duty Vision |
| 4.10 |
| Fitness for Duty Vision (including color, Farnsworth) |
| 4.10 |
| Fitness for Duty Lipid Panel |
| 4.10 |
| Fitness for Duty Glucose |
| 4.10 |
| Fitness for Duty Blood Lead (including ZPP) |
| 4.10 |
| Fitness for Duty Blood Chemistry w/Lipids |
| 4.10 |
| Fitness for Duty Thyroid Panel (TSH w/free T4 RFX) |
| 4.10 |
| Fitness for Duty CBC |
| 4.10 |
| Fitness for Duty Routine Urinalysis |
| 4.10 |
| Fitness for Duty PPD |
| 4.10 |
| Fitness for Duty QuantiFERON-TB-Gold |
| 4.10 |
| Fitness for Duty Specimen Collection (Urine) |
| 4.10 |
| Fitness for Duty Specimen Collection (Blood) |
| 4.10 |
| Fitness for Duty Blood Group & Type |
| 4.10 |
| Fitness for Duty HIV test |
| 4.10 |
| Fitness for Duty Hepatitis C Antibody |
| 4.10 |
| Fitness for Duty Hepatitis B Antigen |
| 4.10 |
| Fitness for Duty Psychological Consultation (per hour) |
| 4.10 |
| Fitness for Duty Psychiatric Consult (per hour) |
| 4.10 |
| Independent Medical Examination (IME) |
| 4.10 |
Scheduling Fee
Rescheduling Fee
| Temporary Restricted Duty; Return to Duty; Post Refractive Surgery Evaluation; Report of Medical & Psychological Conditions & Medications; Additional Advisory Services -- MRO Consultation (per hour) |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.10, 4.11, 4.12, 4.13, 4.14, 4.15 |
| Immunizations Administration Fee |
| 4.15 |
| Immunizations Hepatitis A (2 shot series) |
| 4.15 |
| Immunizations Hepatitis B (3 shot series) |
| 4.15 |
| Hepatitis B Antibody (Titer) |
| 4.15 |
| Immunizations Twinrix |
| 4.15 |
| Immunizations Tetanus (diphtheria) |
| 4.15 |
| Immunizations Typhoid (injectable or oral) |
| 4.15 |
| Immunizations Japanese Encephalitis |
| 4.15 |
| Immunizations Yellow Fever |
| 4.15 |
| Immunizations Pneumococcal |
| 4.15 |
| Immunizations Globulin, immune |
| 4.15 |
| Immunizations MMR (Mumps, Measles, Rubella) |
| 4.15 |
| Immunizations Rabies (3 shot series) |
| 4.15 |
| Medical Advisory Review Officer Meeting -- per meeting (to include all necessary staff to attend and be prepared to discuss relevant medical cases and issues in detail) |
| 4.7 |
| Medical Advisory Review Officer Meeting -- travel |
| 4.7 |
| Critical Incident Stress, Debriefing/Counseling-- per hour psychiatrist |
| 4.16 |
| --No show – billable if less than 24 hours’ notice |
| 4.17 |
| Contract Psychologist – Travel |
| 4.17 |
| Breath Alcohol Testing – at clinic |
| 4.17 |
| Breath Alcohol Testing (blood) – confirmation |
| 4.17 |
| Breath Alcohol Testing – onsite |
| 4.17 |
| Breath Alcohol Testing (breath) – confirmation |
| 4.17 |
| No show fee |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.15 |
| Failure to cancel Fitness Clearance Examination appointment w/in 48 hours of examination |
| 4.5, 4.6 |
| Failure to cancel Physical Examination appointment w/in 48 hours of examination |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.15 |
| Medical Record Copy Fee |
| 4.3, 4.4, 4.5, 4.6, , 4.8, 4.9, 4.10, 4.11, 4.12, 4.13, 4.15 |
Option Year 3
| Item |
| PWS Reference |
| Price |
| Notes |
| Applicant Pre-Placement Examination (including vitals) |
| 4.4 |
| Pre-Placement Exercise Stress Test |
| 4.4 |
| Pre-Placement Thyroid Panel |
| 4.4 |
| Pre-Placement Vision (including Ishihara, depth perception, peripheral and acuity) |
| 4.4 |
| Pre-Placement Health History Questionnaire |
| 4.4 |
| Pre-Placement Physical Examination (including vitals) |
| 4.4 |
| Pre-Placement Spirometry |
| 4.4 |
| Pre-Placement Resting EKG |
| 4.4 |
| Pre-Placement OSHA Audiogram |
| 4.4 |
| Pre-Placement Specimen Collection – Blood |
| 4.4 |
| Pre-Placement Specimen Collection – Urine |
| 4.4 |
| Pre-Placement Chemistry Panel w/Lipids |
| 4.4 |
| Pre-Placement CBC w/Diff. |
| 4.4 |
| Pre-Placement Blood Lead (includes ZPP) |
| 4.4 |
| Pre-Placement QuantiFERON-TB-Gold |
| 4.4 |
| Pre-Placement Urinalysis |
| 4.4 |
| Purified Protein Derivative (PPD) – Tuberculosis Skin Test |
| 4.4 |
| Biennial Physical Fitness Screening (includes vitals), HHQ, Blood Pressure, Height & Weight, Lipid Panel, glucose Specimen Collection –Blood, Blood Lead, and ZPP) |
| 4.5, 4.6 |
| Biennial Physical Fitness Examination |
| 4.5, 4.6 |
| Biennial Physical Fitness Screening – Health History Questionnaire |
| 4.5, 4.6 |
Biennial Vision (including Ishihara, depth perception, and peripheral and acuity)
| Biennial Urinalysis |
| 4.5, 4.6 |
| Biennial QuantiFERON-TB-Gold |
| 4.4 |
| Biennial Physical Fitness Resting EKG |
| 4.5, 4.6 |
| Biennial Physical Fitness Exercise Stress Test |
| 4.5, 4.6 |
| Biennial Physical Fitness Specimen Collection –Blood |
| 4.5, 4.6 |
| Biennial Physical Fitness Thyroid Panel |
| 4.5, 4.6 |
| Biennial Physical Fitness Glucose |
| 4.5, 4.6 |
| Biennial Physical Fitness Lipid Panel |
| 4.5, 4.6 |
| Biennial Physical Fitness Screening and Lead and ZPP test |
| 4.6, 4.8 |
| Hearing Conservation Program Audiogram (Incl. hearing questionnaire) |
| 4.9 |
| Hearing Conservation Program Follow Up Audiogram |
| 4.9 |
| Biennial Physical Fitness Screening - Repeat Blood Lead (includes repeat ZPP) |
| 4.6 |
| Biennial Physical Fitness Screening - Specimen Collection (Blood) |
| 4.6 |
| Fitness for Duty Examination (including HHQ, PE, Blood Pressure, Height & Weight) |
| 4.10 |
| Fitness for Duty OSHA Audiogram (including Hearing History) |
| 4.10 |
| Fitness for Duty Resting EKG |
| 4.10 |
| Fitness for Duty Exercise Stress Test |
| 4.10 |
| Fitness for Duty Spirometry |
| 4.10 |
| Fitness for Duty Vision |
| 4.10 |
| Fitness for Duty Vision (including color, Farnsworth) |
| 4.10 |
| Fitness for Duty Lipid Panel |
| 4.10 |
| Fitness for Duty Glucose |
| 4.10 |
| Fitness for Duty Blood Lead (including ZPP) |
| 4.10 |
| Fitness for Duty Blood Chemistry w/Lipids |
| 4.10 |
| Fitness for Duty Thyroid Panel (TSH w/free T4 RFX) |
| 4.10 |
| Fitness for Duty CBC |
| 4.10 |
| Fitness for Duty Routine Urinalysis |
| 4.10 |
| Fitness for Duty PPD |
| 4.10 |
| Fitness for Duty QuantiFERON-TB-Gold |
| 4.10 |
| Fitness for Duty Specimen Collection (Urine) |
| 4.10 |
| Fitness for Duty Specimen Collection (Blood) |
| 4.10 |
| Fitness for Duty Blood Group & Type |
| 4.10 |
| Fitness for Duty HIV test |
| 4.10 |
| Fitness for Duty Hepatitis C Antibody |
| 4.10 |
| Fitness for Duty Hepatitis B Antigen |
| 4.10 |
| Fitness for Duty Psychological Consultation (per hour) |
| 4.10 |
| Fitness for Duty Psychiatric Consult (per hour) |
| 4.10 |
| Independent Medical Examination (IME) |
| 4.10 |
Scheduling Fee
Rescheduling Fee
| Temporary Restricted Duty; Return to Duty; Post Refractive Surgery Evaluation; Report of Medical & Psychological Conditions & Medications; Additional Advisory Services -- MRO Consultation (per hour) |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.10, 4.11, 4.12, 4.13, 4.14, 4.15 |
| Immunizations Administration Fee |
| 4.15 |
| Immunizations Hepatitis A (2 shot series) |
| 4.15 |
| Immunizations Hepatitis B (3 shot series) |
| 4.15 |
| Hepatitis B Antibody (Titer) |
| 4.15 |
| Immunizations Twinrix |
| 4.15 |
| Immunizations Tetanus (diphtheria) |
| 4.15 |
| Immunizations Typhoid (injectable or oral) |
| 4.15 |
| Immunizations Japanese Encephalitis |
| 4.15 |
| Immunizations Yellow Fever |
| 4.15 |
| Immunizations Pneumococcal |
| 4.15 |
| Immunizations Globulin, immune |
| 4.15 |
| Immunizations MMR (Mumps, Measles, Rubella) |
| 4.15 |
| Immunizations Rabies (3 shot series) |
| 4.15 |
| Medical Advisory Review Officer Meeting -- per meeting (to include all necessary staff to attend and be prepared to discuss relevant medical cases and issues in detail) |
| 4.7 |
| Medical Advisory Review Officer Meeting -- travel |
| 4.7 |
| Critical Incident Stress, Debriefing/Counseling-- per hour psychiatrist |
| 4.16 |
| --No show – billable if less than 24 hours’ notice |
| 4.17 |
| Contract Psychologist – Travel |
| 4.17 |
| Breath Alcohol Testing – at clinic |
| 4.17 |
| Breath Alcohol Testing (blood) – confirmation |
| 4.17 |
| Breath Alcohol Testing – onsite |
| 4.17 |
| Breath Alcohol Testing (breath) – confirmation |
| 4.17 |
| No show fee |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.15 |
| Failure to cancel Fitness Clearance Examination appointment w/in 48 hours of examination |
| 4.5, 4.6 |
| Failure to cancel Physical Examination appointment w/in 48 hours of examination |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.15 |
| Medical Record Copy Fee |
| 4.3, 4.4, 4.5, 4.6, , 4.8, 4.9, 4.10, 4.11, 4.12, 4.13, 4.15 |
Option Year 4
| Item |
| PWS Reference |
| Price |
| Notes |
| Applicant Pre-Placement Examination (including vitals) |
| 4.4 |
| Pre-Placement Exercise Stress Test |
| 4.4 |
| Pre-Placement Thyroid Panel |
| 4.4 |
| Pre-Placement Vision (including Ishihara, depth perception, peripheral and acuity) |
| 4.4 |
| Pre-Placement Health History Questionnaire |
| 4.4 |
| Pre-Placement Physical Examination (including vitals) |
| 4.4 |
| Pre-Placement Spirometry |
| 4.4 |
| Pre-Placement Resting EKG |
| 4.4 |
| Pre-Placement OSHA Audiogram |
| 4.4 |
| Pre-Placement Specimen Collection – Blood |
| 4.4 |
| Pre-Placement Specimen Collection – Urine |
| 4.4 |
| Pre-Placement Chemistry Panel w/Lipids |
| 4.4 |
| Pre-Placement CBC w/Diff. |
| 4.4 |
| Pre-Placement Blood Lead (includes ZPP) |
| 4.4 |
| Pre-Placement QuantiFERON-TB-Gold |
| 4.4 |
| Pre-Placement Urinalysis |
| 4.4 |
| Purified Protein Derivative (PPD) – Tuberculosis Skin Test |
| 4.4 |
| Biennial Physical Fitness Screening (includes vitals), HHQ, Blood Pressure, Height & Weight, Lipid Panel, glucose Specimen Collection –Blood, Blood Lead, and ZPP) |
| 4.5, 4.6 |
| Biennial Physical Fitness Examination |
| 4.5, 4.6 |
| Biennial Physical Fitness Screening – Health History Questionnaire |
| 4.5, 4.6 |
Biennial Vision (including Ishihara, depth perception, and peripheral and acuity)
| Biennial Urinalysis |
| 4.5, 4.6 |
| Biennial QuantiFERON-TB-Gold |
| 4.4 |
| Biennial Physical Fitness Resting EKG |
| 4.5, 4.6 |
| Biennial Physical Fitness Exercise Stress Test |
| 4.5, 4.6 |
| Biennial Physical Fitness Specimen Collection –Blood |
| 4.5, 4.6 |
| Biennial Physical Fitness Thyroid Panel |
| 4.5, 4.6 |
| Biennial Physical Fitness Glucose |
| 4.5, 4.6 |
| Biennial Physical Fitness Lipid Panel |
| 4.5, 4.6 |
| Biennial Physical Fitness Screening and Lead and ZPP test |
| 4.6, 4.8 |
| Hearing Conservation Program Audiogram (Incl. hearing questionnaire) |
| 4.9 |
| Hearing Conservation Program Follow Up Audiogram |
| 4.9 |
| Biennial Physical Fitness Screening - Repeat Blood Lead (includes repeat ZPP) |
| 4.6 |
| Biennial Physical Fitness Screening - Specimen Collection (Blood) |
| 4.6 |
| Fitness for Duty Examination (including HHQ, PE, Blood Pressure, Height & Weight) |
| 4.10 |
| Fitness for Duty OSHA Audiogram (including Hearing History) |
| 4.10 |
| Fitness for Duty Resting EKG |
| 4.10 |
| Fitness for Duty Exercise Stress Test |
| 4.10 |
| Fitness for Duty Spirometry |
| 4.10 |
| Fitness for Duty Vision |
| 4.10 |
| Fitness for Duty Vision (including color, Farnsworth) |
| 4.10 |
| Fitness for Duty Lipid Panel |
| 4.10 |
| Fitness for Duty Glucose |
| 4.10 |
| Fitness for Duty Blood Lead (including ZPP) |
| 4.10 |
| Fitness for Duty Blood Chemistry w/Lipids |
| 4.10 |
| Fitness for Duty Thyroid Panel (TSH w/free T4 RFX) |
| 4.10 |
| Fitness for Duty CBC |
| 4.10 |
| Fitness for Duty Routine Urinalysis |
| 4.10 |
| Fitness for Duty PPD |
| 4.10 |
| Fitness for Duty QuantiFERON-TB-Gold |
| 4.10 |
| Fitness for Duty Specimen Collection (Urine) |
| 4.10 |
| Fitness for Duty Specimen Collection (Blood) |
| 4.10 |
| Fitness for Duty Blood Group & Type |
| 4.10 |
| Fitness for Duty HIV test |
| 4.10 |
| Fitness for Duty Hepatitis C Antibody |
| 4.10 |
| Fitness for Duty Hepatitis B Antigen |
| 4.10 |
| Fitness for Duty Psychological Consultation (per hour) |
| 4.10 |
| Fitness for Duty Psychiatric Consult (per hour) |
| 4.10 |
| Independent Medical Examination (IME) |
| 4.10 |
Scheduling Fee
Rescheduling Fee
| Temporary Restricted Duty; Return to Duty; Post Refractive Surgery Evaluation; Report of Medical & Psychological Conditions & Medications; Additional Advisory Services -- MRO Consultation (per hour) |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.10, 4.11, 4.12, 4.13, 4.14, 4.15 |
| Immunizations Administration Fee |
| 4.15 |
| Immunizations Hepatitis A (2 shot series) |
| 4.15 |
| Immunizations Hepatitis B (3 shot series) |
| 4.15 |
| Hepatitis B Antibody (Titer) |
| 4.15 |
| Immunizations Twinrix |
| 4.15 |
| Immunizations Tetanus (diphtheria) |
| 4.15 |
| Immunizations Typhoid (injectable or oral) |
| 4.15 |
| Immunizations Japanese Encephalitis |
| 4.15 |
| Immunizations Yellow Fever |
| 4.15 |
| Immunizations Pneumococcal |
| 4.15 |
| Immunizations Globulin, immune |
| 4.15 |
| Immunizations MMR (Mumps, Measles, Rubella) |
| 4.15 |
| Immunizations Rabies (3 shot series) |
| 4.15 |
| Medical Advisory Review Officer Meeting -- per meeting (to include all necessary staff to attend and be prepared to discuss relevant medical cases and issues in detail) |
| 4.7 |
| Medical Advisory Review Officer Meeting -- travel |
| 4.7 |
| Critical Incident Stress, Debriefing/Counseling-- per hour psychiatrist |
| 4.16 |
| --No show – billable if less than 24 hours’ notice |
| 4.17 |
| Contract Psychologist – Travel |
| 4.17 |
| Breath Alcohol Testing – at clinic |
| 4.17 |
| Breath Alcohol Testing (blood) – confirmation |
| 4.17 |
| Breath Alcohol Testing – onsite |
| 4.17 |
| Breath Alcohol Testing (breath) – confirmation |
| 4.17 |
| No show fee |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.15 |
| Failure to cancel Fitness Clearance Examination appointment w/in 48 hours of examination |
| 4.5, 4.6 |
| Failure to cancel Physical Examination appointment w/in 48 hours of examination |
| 4.3, 4.4, 4.5, 4.6, 4.8, 4.9, 4.15 |
| Medical Record Copy Fee |
| 4.3, 4.4, 4.5, 4.6, , 4.8, 4.9, 4.10, 4.11, 4.12, 4.13, 4.15 |
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