Attachment_-0004_Price_Matrix_Cost-Price_Vol_III-9-30-17-dl.xlsx

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Special Notice-Amendment 0009
Solicitation number
W15QKN-17-R-1042
Issued by

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Written by GovTribe AI ·

This document is a presolicitation notice for a Reserve Health Readiness Program III contract to provide health readiness services to Reserve and National Guard components. Key details include:

  • The Army Contracting Command will issue a solicitation on behalf of the Defense Health Agency for health readiness services including immunizations, physicals, assessments, dental services, and laboratory services. Services will be provided through a contractor's call center, clinic network, and at group events for reserve components across the U.S., territories, and Germany.

  • The solicitation will use full and open competition and award a single-award, firm-fixed-price and cost reimbursement contract without fee for an indefinite delivery/indefinite quantity contract with task orders over five years.

  • The North American Industry Classification code is 621112 for physicians and mental health specialists with a size standard of $11 million. The service code is Q201 for general healthcare. Interested parties should monitor the Federal Business Opportunities website for release of the solicitation anticipated on September 30, 2017 and ensure registration in the System for Award Management database.

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Summary

Offeror:= Offeror fill-in required
Solicitation No. W15QKN-18-R-1000
SUMMARY
DESCRIPTIONPRICE
Procedures$0.00
Transition In$0.00
Transition Out$0.00
Contract Manpower Reporting (CMP)NSP
Shipping$34,877,907.00
Travel$58,917,121.00
ODCs$7,649,989.00
TOTAL$101,445,017.00
Instructions:
1. Type Offeror Name in cell B1 ONLY. No other input is required to this worksheet as it contains formulas which link with other worksheets.
2. CMP Price: See instructions on CMP worksheet. Cell C14 will populate automatically with NSP or dollar amount.

&"Times New Roman,Italic"SOURCE SELECTION INFORMATION - SEE FAR 2.101 AND 3.104

Procedures

Offeror:0= Offeror fill-in required
Solicitation No. W15QKN-18-R-1000
PROCEDURES PRICING
ProcedureProcedure NumberSub-ElementCPT / CDT CodeGenderGovernment Estimated QuantityBase PeriodOption Period 1Option Period 2Option Period 3Option Period 4
Fixed Unit PriceExtended AmountFixed Unit PriceExtended AmountFixed Unit PriceExtended AmountFixed Unit PriceExtended AmountFixed Unit PriceExtended Amount
A. PHYSICAL EXAMS - IN-CLINIC
Retention exam, younger than 39, maleA1Includes sub-elements: a-i.Male230$0.00$0.00$0.00$0.00$0.00
Retention exam, younger than 39, femaleA2Includes sub-elements: a-j.Female60$0.00$0.00$0.00$0.00$0.00
a.Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
b.HIV Test
c.HGB
d.HCT
e.Urinalysis, complete w/ reflex microscope (p.r.n.)
f.Total Cholesterol
g.Audiogram
h.Vision
i.Rectal
j.Pelvic / PAP - Cytopathology, cervical or vaginal.
Forms: Exam Checklist, Voucher, DD2807-1, DD2808, SF 507, Customer Satisfaction Survey, Lab Requisition, PAP Requisition, PAP Instructions, HIV Transmittal Request Form, HIV Screening Test Results Card, HIV Instructions.
Retention exam, 39 and older, maleA3Includes sub-elements: a-n.Male160$0.00$0.00$0.00$0.00$0.00
Retention exam, 39 and older, femaleA4Includes sub-elements: a-m & o.Female25$0.00$0.00$0.00$0.00$0.00
a.Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
b.HIV Test
c.HGB
d.HCT
e.Urinalysis, complete w/ reflex microscope (p.r.n.)
f.Lipid Panel
g.Audiogram
h.Vision
i.Rectal
j.Tonometry
k.Stool Occult
l.Glucose
m.EKG, 12 Lead
n.PSA Test– PSA Laboratory
o.Pelvic / PAP - Cytopathology, cervical or vaginal.
Forms: Exam Checklist, Voucher, DD2807-1, DD2808, SF 507, Customer Satisfaction Survey, Lab Requisition, PAP Requisition, PAP Instructions, HIV Transmittal Request Form, HIV Screening Test Results Card, HIV Instructions.
Airborne examA5Includes sub-elements: a-h.Both1,850$0.00$0.00$0.00$0.00$0.00
a.Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
b.HIV Test
c.Urinalysis, complete w/ reflex microscope (p.r.n.)
d.Audiogram
e.Vision
f.Color Vision
g.Rectal
h.Valsalva
Forms: Exam Checklist, Voucher, DD2807-1, DD2808, SF 507, Customer Satisfaction Survey, Lab Requisition, HIV Transmittal Request Form, HIV Screening Test Results Card, HIV Instructions.
Accession exam, maleA6Includes sub-elements: a-i.Male275$0.00$0.00$0.00$0.00$0.00
Accession exam, femaleA7Includes sub-elements: a-j.Female90$0.00$0.00$0.00$0.00$0.00
a.Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
b.HIV Test
c.Urinalysis, complete w/ reflex microscope (p.r.n.)
d.Drug Screen
e.ETOH Screen
f.Audiogram
g.Vision
h.Color Vision
i.Rectal
j.Pregnancy Test
Forms: Exam Checklist, Voucher, DD2807-1, DD2808, SF 507, Customer Satisfaction Survey, Lab Requisition, HIV Transmittal Request Form, HIV Screening Test Results Card, HIV Instructions.
Physical exam, Chapter 3, AGR, younger than 39, maleA8Includes sub-elements: a-k.Male95$0.00$0.00$0.00$0.00$0.00
Physical exam, Chapter 3, AGR, younger than 39, femaleA9Includes sub-elements: a-m.Female60$0.00$0.00$0.00$0.00$0.00
a.Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
b.Audiogram
c.Vision
d.HGB
e.HCT
f.HIV Test
g.Total Cholesterol
h.Urinalysis, complete w/ reflex microscope (p.r.n.)
i.Drug Screen
j.ETOH Screen
k.Rectal
l.Pelvic / PAP - Cytopathology, cervical or vaginal.
m.Pregnancy Test
Forms: Exam Checklist, Voucher, DD2807-1, DD2808, SF 507, Customer Satisfaction Survey, Lab Requisition, PAP Requisition, PAP Instructions, HIV Transmittal Request Form, HIV Screening Test Results Card, HIV Instructions.
Physical exam, Chapter 3, AGR, 39 and older, maleA10Includes sub-elements: a-q.Male20$0.00$0.00$0.00$0.00$0.00
Physical exam, Chapter 3, AGR, 39 and older, femaleA11Includes sub-elements: a-n & p-s.Female3$0.00$0.00$0.00$0.00$0.00
a.Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
b.Audiogram
c.Stool Occult
d.Rectal
e.Vision
f.HGB
g.HCT
h.HIV Test
i.Total Cholesterol
j.Urinalysis, complete w/ reflex microscope (p.r.n.)
k.Lipid Panel
l.Glucose
m.Drug Screen
n.ETOH Screen
o.PSA Test– PSA Laboratory
p.Tonometry
q.EKG, 12 Lead
r.Pelvic / PAP - Cytopathology, cervical or vaginal.
s.Pregnancy Test
Forms: Exam Checklist, Voucher, DD2807-1, DD2808, SF 507, Customer Satisfaction Survey, Lab Requisition, PAP Requisition, PAP Instructions, HIV Transmittal Request Form, HIV Screening Test Results Card, HIV Instructions.
Air Force retention examA12Includes sub-elements: a-e.Both15$0.00$0.00$0.00$0.00$0.00
a.Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
b.HIV draw
c.Audiogram
d.Vision
e.Rectal
Forms: Exam Checklist, Voucher, DD 2808, Customer Satisfaction Survey, RCHRA, AF1762 Specimen Transmittal.
Firefighter / CBRN exam, younger than 39, maleA13Includes sub-elements: a-v.Male35$0.00$0.00$0.00$0.00$0.00
Firefighter / CBRN exam, younger than 39, femaleA14Includes sub-elements: a-x.Female3$0.00$0.00$0.00$0.00$0.00
a.Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
b.Audiogram
c.Vision
d.Color Vision
e.Peripheral Vision
f.Depth Perception
g.HGB
h.HCT
i.HIV Test
j.Lipid Panel
k.Cholesterol
l.Glucose
m.CBC with Differential
n.Chemistry Profile
o.Lead
p.ZPP
q.Urinalysis, complete w/ reflex microscope (p.r.n.)
r.Spirometry
s.Chest X-ray
t.B-read
u.EKG, 12 Lead
v.Rectal
w.Pelvic / PAP - Cytopathology, cervical or vaginal.
x.Pregnancy Test
Forms: Exam Checklist, DD2807-1, DD2808, SF 507, RHRPII-5, RHRPII-5C, RHRPII-22, Respirator Clearance Certification, DD Form 2015, DD Form 2005, RHRPII-6, Customer Satisfaction Survey, RHRPII-14A, Lab Requisition, USACHPPM Lab Requisition.
Firefighter / CBRN exam, 39 and older, maleA15Includes sub-elements: a-z.Male2$0.00$0.00$0.00$0.00$0.00
Firefighter / CBRN exam, 39 and older, femaleA16Includes sub-elements: a-w & y-bb.Female1$0.00$0.00$0.00$0.00$0.00
a.Physical Exam - Includes: Smoking History, Occupational History, Height & Weight, Vital Signs, Respiratory Rate
b.Audiogram
c.Vision
d.Color Vision
e.Peripheral Vision
f.Depth Perception
g.HGB
h.HCT
i.HIV Test
j.Lipid Panel
k.Cholesterol
l.Glucose
m.CBC with Differential
n.Chemistry Profile
o.Lead
p.ZPP
q.Urinalysis, complete w/ reflex microscope (p.r.n.)
r.Spirometry
s.Chest X-ray
t.B-read
u.EKG, 12 Lead
v.Stress EKG
w.Rectal
x.PSA Test– PSA Laboratory
y.Tonometry
z.Stool Occult
aa.Pelvic / PAP - Cytopathology, cervical or vaginal.
bb.Pregnancy Test
Forms: Exam Checklist, DD2807-1, DD2808, SF 507, RHRPII-5,RHRPII-5C, RHRPII-22, Respirator Clearance Certification, DD Form 2015, DD Form 2005, FOH-6, Customer Satisfaction Survey, RHRPII-14A, Lab Requisition, USACHPPM Lab Requisition.
Separation History and Physical Exam (SHPE)A17Both11,225$0.00$0.00$0.00$0.00$0.00
DD Form 2697 in lieu of SHPEA18Both3,200$0.00$0.00$0.00$0.00$0.00
Occupational Medicine Examination, Basic, Baseline (Labs and tests will be determined by exposure concerns and ordered individually)A19Both250$0.00$0.00$0.00$0.00$0.00
Occupational Medicine Examination, Basic, Periodic (Labs and tests will be determined by exposure concerns and ordered individually)A20Both250$0.00$0.00$0.00$0.00$0.00
Occupational Medicine Examination, Expanded, Baseline (Labs and tests will be determined by exposure concerns and ordered individually)A21Both250$0.00$0.00$0.00$0.00$0.00
AA. PHYSICAL EXAMS GROUP EVENT
Separation History and Physical Exam (SHPE) (minimum 15 SHPEs per day to schedule; price per SHPE)AA1Both8,000$0.00$0.00$0.00$0.00$0.00
DD Form 2697 in lieu of SHPE (minimum 15 individual services per day to schedule; price per individual service)AA2Both3,000$0.00$0.00$0.00$0.00$0.00
B. IN-CLINIC PERIODIC HEALTH ASSESSMENT (PHA)(DD Form 3024) & FOCUSED EXAM (PHA price does not include vision sc reen or record review)
DoD PHA, Provider Portion without MHA portion, in-clinic, price per completed DoD PHA with data exchangeB1Both68,000$0.00$0.00$0.00$0.00$0.00
DoD PHA, Provider Portion with MHA portion, in-clinic, price per completed DoD PHA, with data exchangeB2Both5,000$0.00$0.00$0.00$0.00$0.00
DoD PHA, Provider Portion without MHA portion, in-clinic, price per completed DoD PHA without data exchangeB3Both14,000$0.00$0.00$0.00$0.00$0.00
DoD PHA, Provider Portion with MHA portion, in-clinic, price per completed DoD PHA, without data exchangeB4Both900$0.00$0.00$0.00$0.00$0.00
DoD PHA Lite, Provider Portion without MHA portion, in-clinic, price per completed DoD PHA, with data exchangeB5Both75$0.00$0.00$0.00$0.00$0.00
DoD PHA Lite, Provider Portion with MHA portion, in-clinic, price per completed DoD PHA with data exchangeB6Both75$0.00$0.00$0.00$0.00$0.00
BB. CALL CENTER PERIODIC HEALTH ASSESSMENT (DD Form 3024). PHA Provider Portion price does not include vision screen or record review)
DoD PHA, Provider Portion with MHA portion, call center, price per completed DoD PHA, with data exchangeBB1Both2,000$0.00$0.00$0.00$0.00$0.00
DoD PHA Record Review, call center, previous five yearsBB2Both10,000$0.00$0.00$0.00$0.00$0.00
DoD PHA Record Review, call center, since most recent PHA or last yearBB3Both60,000$0.00$0.00$0.00$0.00$0.00
DoD PHA, Provider Portion with MHA portion, call center, price per completed DoD PHA, without data exchangeBB4Both1,000$0.00$0.00$0.00$0.00$0.00
C. PHA & FOCUSED EXAM - GROUP EVENT
DoD PHA with MHA, group event, with data exchange TIER 1 (minimum 30 DoD PHAs to schedule; price per DoD PHA when total DoD PHAs completed at group event equal 40 or less)C1Both10,000$0.00$0.00
10,500$0.00
10,450$0.00$0.00
DoD PHA with MHA, group event, with data exchange, TIER 2 (minimum 30 DoD PHAs to schedule; price per DoD PHA when total DoD PHAs completed at group event equal 41 to 80)C2Both11,000$0.00$0.00
11,100$0.00
11,085$0.00$0.00
DoD PHA with MHA, group event, with data exchange, TIER 3 (minimum 30 DoD PHAs to schedule; price per DoD PHA when total DoD PHAs completed at group event equal 81 or more)C3Both30,000$0.00$0.00
30,365$0.00$0.00
30,320$0.00
DoD PHA without MHA, group event, with data exchange, TIER 1 (minimum 30 DoD PHAs to schedule; price per DoD PHA when total DoD PHAs completed at group event equal 40 or less)C4Both1,000$0.00$0.00$0.00$0.00
900$0.00
DoD PHA without MHA, group event, with data exchange, TIER 2 (minimum 30 DoD PHAs to schedule; price per DoD PHA when total DoD PHAs completed at group event equal 41 to 80)C5Both5,000$0.00$0.00$0.00$0.00
4,500$0.00
DoD PHA without MHA, group event, with data exchange, TIER 3 (minimum 30 DoD PHAs to schedule; price per DoD PHA when total DoD PHAs completed at group event equal 81 or more)C6Both18,500$0.00$0.00$0.00$0.00$0.00
DoD PHA with MHA, group event, without data exchange TIER 1 (minimum 30 DoD PHAs to schedule; price per DoD PHA when total DoD PHAs completed at group event equal 40 or less)C7Both6,600$0.00$0.00$0.00$0.00
6,585$0.00
DoD PHA with MHA, group event, without data exchange, TIER 2 (minimum 30 DoD PHAs to schedule; price per DoD PHA when total DoD PHAs completed at group event equal 41 to 80)C8Both7,000$0.00$0.00$0.00$0.00$0.00
DoD PHA with MHA, group event, without data exchange, TIER 3 (minimum 30 DoD PHAs to schedule; price per DoD PHA when total DoD PHAs completed at group event equal 81 or more)C9Both8,000$0.00$0.00$0.00$0.00$0.00
DoD PHA without MHA, group event, without data exchange, TIER 1 (minimum 30 DoD PHAs to schedule; price per DoD PHA when total DoD PHAs completed at group event equal 40 or less)C10Both200$0.00$0.00$0.00$0.00$0.00
DoD PHA without MHA, group event, without data exchange, TIER 2 (minimum 30 DoD PHAs to schedule; price per DoD PHA when total DoD PHAs completed at group event equal 41 to 80)C11Both2,000$0.00$0.00$0.00$0.00$0.00
DoD PHA without MHA, group event, without data exchange, TIER 3 (minimum 30 DoD PHAs to schedule; price per DoD PHA when total DoD PHAs completed at group event equal 81 or more)C12Both10,000$0.00$0.00$0.00$0.00$0.00
DoD PHA Lite, Provider Portion with MHA portion, with data exchange, price per completed DoD PHAC13Both22,500$0.00$0.00$0.00$0.00$0.00
DoD PHA Lite, Provider Portion without MHA portion, with data exchange, price per completed DoD PHAC14Both1,290$0.00$0.00$0.00$0.00$0.00
DoD PHA Record Review, previous five yearsC15Both300$0.00$0.00$0.00$0.00$0.00
DoD PHA Record Review, since most recent PHA or last yearC16Both65,000$0.00$0.00$0.00$0.00$0.00
Note: If the Contractor receives a SC-approved Group Event request for urgent services (e.g. deployments, special assignments) that do not meet the minimum to schedule and the Contractor accepts the request, the Government will be charged the minimum number to schedule multiplied by the associated Group Event TIER 1 or per day unit price.Forms: Exam Checklist, DD2807-1, DD2808, SF 507, RHRPII-5,RHRPII-5C, RHRPII-22, Respirator Clearance Certification, DD Form 2015, DD Form 2005, FOH-6, Customer Satisfaction Survey, RHRPII-14A, Lab Requisition, USACHPPM Lab Requisition.
D. RESERVED
E. PHA BEHAVIORAL HEALTH SPECIALIST STAND ALONE - CALL CENTER / GROUP EVENT
PHA Behavioral Health Specialist, call center, price per callE1Both10$0.00$0.00$0.00$0.00$0.00
PHA Behavioral Health Specialist, group event (minimum 60 scheduled PHAs; price for up to 60 PHAs)E2Both1,000$0.00$0.00$0.00$0.00$0.00
F. POST DEPLOYMENT HEALTH RE-ASSESSMENT (PDHRA) - CALL CENTER
PDHRA, call center, price per completed DD Form 2900F1Both19,455$0.00$0.00$0.00$0.00$0.00
G. PDHRA & PRE-DEPLOYMENT HEALTH ASSESSMENT (PRE-DHA) - GROUP EVENT
PDHRA, group event, TIER 1 (minimum 30 PDHRAs to schedule; price per PDHRA when total PDHRAs completed at group event equal 40 or less)G1Both305$0.00$0.00$0.00$0.00$0.00
PDHRA, group event, TIER 2 (minimum 30 PDHRAs to schedule; price per PDHRA when total PDHRAs completed at group event equal 41 to 80)G2Both650$0.00$0.00$0.00$0.00$0.00
PDHRA, group event, TIER 3 (minimum 30 PDHRAs to schedule; price per PDHRA when total PDHRAs completed at group event equal 81 or more)G3Both2,760$0.00$0.00$0.00$0.00$0.00
MARFORRES, Pre-DHA, group event (minimum 30 Pre-DHAs to schedule; price per Pre-DHA)G4Both350$0.00$0.00$0.00$0.00$0.00
AC Army TPR / ARNG / USAR, Pre-DHA, group event (minimum 30 Pre-DHAs to schedule; price per Pre-DHA)G5Both2,000$0.00$0.00$0.00$0.00$0.00
H. MENTAL HEALTH ASSESSMENT (MHA) - CALL CENTER
MHA, call center, price per completed MHA when positive screenH1Both25,000$0.00$0.00$0.00$0.00$0.00
MHA, call center, price per completed MHA when negative screenH2Both226,000$0.00$0.00$0.00$0.00$0.00
I. MHA - GROUP EVENT
MHA, group event, TIER 1 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 40 or less)I1Both7,500$0.00$0.00$0.00$0.00$0.00
MHA, group event, TIER 2 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 41 to 80)I2Both28,000$0.00$0.00$0.00$0.00$0.00
MHA, group event, TIER 3 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 81 or more)I3Both94,000$0.00$0.00$0.00$0.00$0.00
J. AUDIO w/ Exam (PHA / Physical Exam) - IN-CLINIC
Annual Audiometric Screen with MEDPROS UpdateJ192551Both63,737$0.00$0.00$0.00$0.00$0.00
Comprehensive audio exam / pure tone air and bone conduction testingJ292557Both15,000$0.00$0.00$0.00$0.00$0.00
SPRINT (Speech Recognition in Noise Test)J392506Both195$0.00$0.00$0.00$0.00$0.00
JJ. AUDIO STAND ALONE - IN-CLINIC
Acoustic reflex testing thresholdJJ192568Both3,060$0.00$0.00$0.00$0.00$0.00
Audio hearing test - pure tone airJJ292551Both2,960$0.00$0.00$0.00$0.00$0.00
Audiometry - pure tone air and bone conduction testingJJ392553Both6,935$0.00$0.00$0.00$0.00$0.00
Consultation w/ OtolaryngologistJJ499243Both100$0.00$0.00$0.00$0.00$0.00
DOHERS entryJJ5Both112,345$0.00$0.00$0.00$0.00$0.00
Evoked acoustic emission, limited (single stimulus level, either transient or distortion products)JJ692587Both6,935$0.00$0.00$0.00$0.00$0.00
Speech audiometry threshold w/ speech recognitionJJ792556Both4,110$0.00$0.00$0.00$0.00$0.00
SPRINTJJ892571Both1,320$0.00$0.00$0.00$0.00$0.00
TympanometryJJ992567Both4,095
Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions)JJ1092558Both6,935$0.00$0.00$0.00$0.00$0.00
Distortion product evoked otoacoustic emissions, comprehensive diagnostic evaluationJJ1192588Both6,935$0.00$0.00$0.00$0.00$0.00
JJJ. AUDIO - GROUP EVENT
Annual Audiometric Screen with MEDPROS Update (minimum 50 screens per day to schedule; price per completed screen)JJJ192522Both172,000$0.00$0.00$0.00$0.00$0.00
Comprehensive audio exam / pure tone air and bone conduction testing (minimum 25 tests per day to schedule; price per completed test)JJJ292557Both850$0.00$0.00$0.00$0.00$0.00
DOHERS entryJJJ3Both170,000$0.00$0.00$0.00$0.00$0.00
K. VISION w/ Exam (PHA / Physical Exam) - IN-CLINIC
Comprehensive eye examK192004Both10,000$0.00$0.00$0.00$0.00$0.00
Eye examination with refraction and prescriptionK292002Both2,500$0.00$0.00$0.00$0.00$0.00
TonometryK392100Both3$0.00$0.00$0.00$0.00$0.00
Vision Screen with color and with & without correctionK499172Both75,000$0.00$0.00$0.00$0.00$0.00
KK. VISION STAND ALONE - IN-CLINIC
Comprehensive eye examKK192004Both15,500$0.00$0.00$0.00$0.00$0.00
Eye examination with refraction and prescriptionKK292002Both6$0.00$0.00$0.00$0.00$0.00
TonometryKK392100Both13$0.00$0.00$0.00$0.00$0.00
Vision - MonocularKK499173Both1,600$0.00$0.00$0.00$0.00$0.00
Vision Screen with color and with & without correctionKK599172Both2,400$0.00$0.00$0.00$0.00$0.00
KKK. VISION - GROUP EVENT
Comprehensive eye exam (minimum 25 exams per day to schedule; price per completed exam)KKK1Both875$0.00$0.00$0.00$0.00$0.00
Eye exam with refraction and prescription, group event (minimum 50 exams per day to schedule; price per completed exam)KKK2Both1,125$0.00$0.00$0.00$0.00$0.00
Vision screen, group event, TIER 1 (minimum 30 screens to schedule; price per completed screen when total screens completed at group event equal 40 or less)KKK3Both6,150$0.00$0.00$0.00$0.00$0.00
Vision screen, group event, TIER 2 (minimum 30 screens to schedule; price per completed screen when total screens completed at group event equal 41 to 80)KKK4Both27,175$0.00$0.00$0.00$0.00$0.00
Vision screen, group event, TIER 3 (minimum 30 screens to schedule; price per completed screen when total screens completed at group event equal 81 or more)KKK5Both83,700$0.00$0.00$0.00$0.00$0.00
L. VACCINE AND TITER WITH EXAM - IN-CLINIC
Hepatitis AL190632Both2,175$0.00$0.00$0.00$0.00$0.00
Hepatitis BL290746Both2,350$0.00$0.00$0.00$0.00$0.00
Influenza - Injectable (ODC Cost)L390658Both14,900DO NOT PRICE. QUANTITY PROVIDED FOR INFORMATIONAL PURPOSES. COST WILL BE CAPTURED UNDER ODCs
Rabies TiterL486382Both2,000$0.00$0.00$0.00$0.00$0.00
PPDL586580Both14$0.00$0.00$0.00$0.00$0.00
TdapL690715Both880$0.00$0.00$0.00$0.00$0.00
Tetanus and DiphtheriaL790718Both900$0.00$0.00$0.00$0.00$0.00
TwinrixL890636Both80$0.00$0.00$0.00$0.00$0.00
VaricellaL990716Both2,650$0.00$0.00$0.00$0.00$0.00
Varicella titerL1086787Both1,585$0.00$0.00$0.00$0.00$0.00
Measles, Mumps, Rubella (MMR)L1190707Both7,450$0.00$0.00$0.00$0.00$0.00
Pediatric dose Hep AL1290633Both170$0.00$0.00$0.00$0.00$0.00
Pediatric dose Hep BL1390744Both1,033$0.00$0.00$0.00$0.00$0.00
PolioL1490713Both700$0.00$0.00$0.00$0.00$0.00
MMR titerL1586765

+86735

+86762Both2,365$0.00$0.00$0.00$0.00$0.00
ReservedL16
Measles, Rubella TiterL1786765 + 86762Both1,000$0.00$0.00$0.00$0.00$0.00
LL. VACCINE AND TITER STAND ALONE - IN-CLINIC
Hepatitis ALL190632Both1,750$0.00$0.00$0.00$0.00$0.00
Hepatitis BLL290746Both2,430$0.00$0.00$0.00$0.00$0.00
Influenza - Injectable (ODC Cost)LL390658Both27,500DO NOT PRICE. QUANTITY PROVIDED FOR INFORMATIONAL PURPOSES. COST WILL BE CAPTURED UNDER ODCs
Japanese encephalitisLL490735Both6$0.00$0.00$0.00$0.00$0.00
MeningococcusLL590733Both45$0.00
46$0.00$0.00$0.00$0.00
PolioLL690713Both675$0.00
681$0.00$0.00$0.00$0.00
RabiesLL790675Both25$0.00$0.00$0.00$0.00$0.00
Rabies TiterLL886382Both2,000$0.00$0.00$0.00$0.00$0.00
PPDLL986580Both415$0.00$0.00$0.00$0.00$0.00
TdapLL1090715Both450$0.00$0.00$0.00$0.00$0.00
Tetanus and DiphtheriaLL1190718Both1,000$0.00$0.00$0.00$0.00$0.00
TyphoidLL1290691Both450$0.00$0.00$0.00$0.00$0.00
TwinrixLL1390636Both80$0.00$0.00$0.00$0.00$0.00
VaricellaLL1490716Both2,500$0.00$0.00$0.00$0.00$0.00
Varicella titerLL1586787Both1,200$0.00$0.00$0.00$0.00$0.00
Yellow feverLL1690717Both50$0.00$0.00$0.00$0.00$0.00
Measles, Mumps, Rubella (MMR)LL1790707Both5,200$0.00$0.00$0.00$0.00$0.00
Pediatric dose Hep ALL1890633Both180$0.00$0.00$0.00$0.00$0.00
Pediatric dose Hep BLL1990744Both1,375$0.00$0.00$0.00$0.00$0.00
MMR titerLL2086765 + 86735
+86762Both1,900$0.00$0.00$0.00$0.00$0.00
ReservedLL21
Measles, Rubella TiterLL2286765 + 86762Both1,000$0.00$0.00$0.00$0.00$0.00
LLL. VACCINE AND TITERS - GROUP EVENT
Administration of vaccine, group event, TIER 1 (minimum 60 administrations to schedule; price per completed administration when total administrations completed at group event equal 60 or less)LLL190741Both11,150$0.00$0.00$0.00$0.00$0.00
Administration of vaccine, group event, TIER 2 (minimum 60 administrations to schedule; price per completed administration when total administrations completed at group event equal 61 to 120)LLL290741Both36,000$0.00$0.00$0.00$0.00$0.00
Administration of vaccine, group event, TIER 3 (minimum 60 administrations to schedule; price per completed administration when total administrations completed at group event equal 121 or more)LLL390742Both116,000$0.00$0.00$0.00$0.00$0.00
Anthrax (6 shot series) (Government will provide vaccine)LLL490581Both7,600$0.00$0.00$0.00$0.00$0.00
Globulin, ImmuneLLL590281Both500$0.00$0.00$0.00$0.00$0.00
Hepatitis A (2 shot series)LLL690632Both5,198$0.00$0.00$0.00$0.00$0.00
Hepatitis B (3 shot series)LLL790746Both6,128$0.00$0.00$0.00$0.00$0.00
Inactivated Polio Vaccine (IPV)LLL890713Both2,829$0.00$0.00$0.00$0.00$0.00
InfluenzaLLL990658Both28,000DO NOT PRICE. QUANTITY PROVIDED FOR INFORMATIONAL PURPOSES. COST WILL BE CAPTURED UNDER ODCs
Japanese EncephalitisLLL1090735Both50$0.00$0.00$0.00$0.00$0.00
Measles, Mumps, Rubella (MMR)LLL1190707Both18,450$0.00$0.00$0.00$0.00$0.00
MenactraLLL1290734Both34$0.00$0.00$0.00$0.00$0.00
PPDLLL1386580Both250$0.00$0.00$0.00$0.00$0.00
Rabies (3 shot series)LLL1490675Both110$0.00$0.00$0.00$0.00$0.00
Rabies TiterLLL1586382Both57$0.00$0.00$0.00$0.00$0.00
ReservedLLL16
TdapLLL1790715Both1,169$0.00$0.00$0.00$0.00$0.00
Tetanus and DiphtheriaLLL1890718Both1,000$0.00$0.00$0.00$0.00
950$0.00
Typhoid (injectable or oral)LLL1990691Both7,750$0.00$0.00$0.00$0.00$0.00
VaricellaLLL2090716Both7,000$0.00$0.00$0.00$0.00$0.00
Varicella titerLLL2186787Both4,050$0.00$0.00$0.00$0.00$0.00
Yellow feverLLL2290717Both200$0.00$0.00$0.00$0.00$0.00
MMR titerLLL2386765 + 86735
+86762Both2,100$0.00$0.00$0.00$0.00$0.00
ReservedLLL24
Measles, Rubella TiterLLL2586765 + 86762Both500$0.00$0.00$0.00$0.00$0.00
M. LABORATORY SERVICE w/ Exam (PHA / Physical Exam) - IN-CLINIC
AGR labsM1Services Include: 1) Drug Screen, 2) ETOH Screen, 3) Pregnancy Test, 4) Forms: Voucher, Customer Satisfaction Survey, Lab Requisition80100 + 82055 + 84702Both500$0.00$0.00$0.00$0.00$0.00
Blood type and determination of Rh factor w/ venipunctureM286901 + 36415Both1,250$0.00$0.00$0.00$0.00$0.00
Chlamydia, DNA by SDA (urine)M387491Both150$0.00$0.00$0.00$0.00$0.00
Chlamydia / Gonorrhea (by swab)M487491 + 87591Both65$0.00$0.00$0.00$0.00$0.00
Chlamydia / Gonorrhea (reflex from swab)M587490 + 87590Both45$0.00$0.00$0.00$0.00$0.00
CVSPM6Service includes: 1) Blood pressure, 2) Fasting lipid profile, including total cholesterol, LDL, HDL, and triglycerides, 3) Electrocardiogram (ECG) / EKG (Invoiced Separately), 4) Fasting blood glucose, 5) Height and weight93000 + 80061 + 82947Both13,200$0.00$0.00$0.00$0.00$0.00
DNA testM783912Both490$0.00$0.00$0.00$0.00$0.00
Gonorrhea, DNA by SDA (urine)M887951Both4$0.00$0.00$0.00$0.00$0.00
G6PDM982960Both5,600$0.00$0.00$0.00$0.00$0.00
HIV test (phlebotomy only)M1086701Both31,000$0.00$0.00$0.00$0.00$0.00
Pregnancy, urineM1184703Female17$0.00$0.00$0.00$0.00$0.00
PSAM1284153 + 36415 + 99381Male100$0.00$0.00$0.00$0.00$0.00
PSA w/ rectal examM1384153 + 361415 + 99368Male100$0.00$0.00$0.00$0.00$0.00
Rectal exam with stool for guaiacM14G0102 + 82270Both275$0.00$0.00$0.00
270$0.00$0.00
Sickle cell screening test w/ confirmation by reflex to hemoglobulinopathyM1585660 + 83021Both1$0.00$0.00$0.00$0.00$0.00
Stool occult for blood (1 slide)M1682270Both25$0.00$0.00$0.00$0.00$0.00
Stool occult for blood (2 slide)M1782270Both25$0.00$0.00$0.00$0.00$0.00
Stool occult for blood (3 slide)M1882270Both25$0.00$0.00$0.00$0.00$0.00
Thin prep w/ preventive exam (pelvic) to collect specimenM1988147 + 99385Female220$0.00$0.00$0.00$0.00$0.00
Phlebotomy (blood draw)M2036415Both61,000$0.00$0.00$0.00$0.00$0.00
Complete Blood Count (CBC) w/ differentialM2185025Both50$0.00$0.00$0.00$0.00$0.00
LDHM2283615
+83625Both50$0.00$0.00$0.00$0.00$0.00
Comprehensive Metabolic PanelM2380053Both50$0.00$0.00$0.00$0.00$0.00
Cholinesterase (plasma and RBC)M2482480
+82482Both50$0.00$0.00$0.00$0.00$0.00
Complete Blood Count (CBC), differential and platelets with smear reviewM2585007
+85027Both50$0.00$0.00$0.00$0.00$0.00
Blood leadM2683655Both50$0.00$0.00$0.00$0.00$0.00
Zinc protoporphyrinM2784202Both50$0.00$0.00$0.00$0.00$0.00
Urinalysis, complete with reflex microscope (prn)M2881001
+99000Both50$0.00$0.00$0.00$0.00$0.00
Hepatitis C antibodyM2986803Both50$0.00$0.00$0.00$0.00$0.00
MM. LABORATORY SERVICE STAND ALONE - IN-CLINIC
AGR labsMM1Services Include: 1) Drug Screen, 2) ETOH Screen, 3) Pregnancy Test, 4) Forms: Voucher, Customer Satisfaction Survey, Lab Requisition80100 + 82055 + 84702Both210$0.00$0.00$0.00$0.00$0.00
Blood type and determination of Rh factor w/ venipunctureMM286901 + 36415Both330$0.00$0.00$0.00$0.00$0.00
Chlamydia, DNA by SDA (urine)MM387491Both11$0.00$0.00$0.00$0.00$0.00
CVSPMM4Service includes: 1) Blood pressure, 2) Fasting lipid profile, including total cholesterol, LDL, HDL, and triglycerides, 3) Electrocardiogram (ECG) / EKG (Invoiced Separately), 4) Fasting blood glucose, 5) Height and weight93000 + 80061 + 82947Both1,000$0.00$0.00$0.00$0.00$0.00
DNA test (no lab) - use military labor and DNA cardMM583912Both230$0.00$0.00$0.00$0.00$0.00
Gonorrhea, DNA by SDA (urine)MM687951Both10$0.00$0.00$0.00$0.00$0.00
G6PDMM782960Both2,100$0.00$0.00$0.00$0.00$0.00
HIV test (phlebotomy only)MM886701Both23,000$0.00$0.00$0.00$0.00$0.00
Phlebotomy (blood draw)MM936415Both30,000$0.00$0.00$0.00$0.00$0.00
Pregnancy, urineMM1084703Female85$0.00$0.00$0.00$0.00$0.00
PSAMM1184153 + 36415 + 99381Male44$0.00$0.00$0.00$0.00$0.00
PSA w/ rectal examMM1284153 + 361415 + 99368Male25$0.00$0.00$0.00$0.00$0.00
Rectal exam w/ stool for guaiacMM13G0102 + 82270Both18$0.00$0.00$0.00$0.00$0.00
Sickle cell screening test w/ confirmation by reflex to hemoglobulinopathyMM1485660 + 83021Both20$0.00$0.00$0.00$0.00$0.00
Stool occult for blood (1 slide)MM1582270Both50$0.00$0.00$0.00$0.00$0.00
Stool occult for blood (2 slide)MM1682270Both50$0.00$0.00$0.00$0.00$0.00
Stool occult for blood (3 slide)MM1782270Both50$0.00$0.00$0.00$0.00$0.00
Thin prep w/ preventive exam (pelvic) to collect specimenMM1888147 + 99385Female100$0.00$0.00$0.00$0.00$0.00
Complete Blood Count (CBC) w/ differentialMM1985025Both50$0.00$0.00$0.00$0.00$0.00
Cholinesterase (plasma & RBC)MM2082480
+82482Both50$0.00$0.00$0.00$0.00$0.00
Hazardous WasteMM21NoneBoth500$0.00$0.00$0.00$0.00$0.00
LeadMM22NoneBoth100$0.00$0.00$0.00$0.00$0.00
BenzeneMM2385020
+94010Both50$0.00$0.00$0.00$0.00$0.00
Urinalysis, complete w/ reflex microscope (p.r.n.)MM2481001
+99000Both50$0.00$0.00$0.00$0.00$0.00
Rapid Plasma Reagin (RPR)MM2586592Both50$0.00$0.00$0.00$0.00$0.00
LDHMM2683615
+83625Both50$0.00$0.00$0.00$0.00$0.00
Comprehensive Metabolic PanelMM2780053Both50$0.00$0.00$0.00$0.00$0.00
Complete Blood Count (CBC), differential and platelets with smear reviewMM2885007
+85027Both50$0.00$0.00$0.00$0.00$0.00
Zinc protoporphyrinMM2982374Both50$0.00$0.00$0.00$0.00$0.00
Blood leadMM3083655Both50$0.00$0.00$0.00$0.00$0.00
Hepatitis C AntibodyMM3186803Both50$0.00$0.00$0.00$0.00$0.00
MMM. LABORATORY SERVICE - GROUP EVENT
Blood type and determination of Rh factor w/ venipunctureMMM186901 + 36415Both1,000$0.00$0.00$0.00$0.00
1,078$0.00
Chlamydia, DNA by SDA (urine)MMM287491Both10$0.00$0.00$0.00$0.00$0.00
CVSPMMM3Service includes: 1) Blood pressure, 2) Fasting lipid profile, including total cholesterol, LDL, HDL, and triglycerides, 3) Electrocardiogram (ECG) / EKG (Invoiced Separately), 4) Fasting blood glucose, 5) Height and weight93000 + 80061 + 82947Both6,800$0.00$0.00$0.00$0.00$0.00
CVSP (Cholestech) (minimum 25 screens per day to schedule; price per completed screen)MMM4Service includes: 1) Blood pressure, 2) Fasting lipid profile, including total cholesterol, LDL, HDL, and triglycerides, 3) Electrocardiogram (ECG) / EKG (Invoiced Separately), 4) Fasting blood glucose, 5) Height and weight93000 + 80061 + 82947Both805$0.00$0.00$0.00$0.00$0.00
Gonorrhea, DNA by SDA (urine)MMM587951Both10$0.00$0.00$0.00$0.00$0.00
G6PD TestingMMM682960Both12,500$0.00$0.00$0.00$0.00$0.00
HIV testing (phlebotomy only), group event, TIER 1 (minimum 50 tests to schedule; price per completed test when total tests completed at group event equal 40 or less)MMM736415Both17,000$0.00$0.00$0.00$0.00$0.00
HIV testing (phlebotomy only), group event, TIER 2 (minimum 50 tests to schedule; price per completed test when total tests completed at group event equal 41 to 80)MMM836415Both16,500$0.00$0.00$0.00$0.00$0.00
HIV testing (phlebotomy only), group event, TIER 3 (minimum 50 tests to schedule; price per completed test when total tests completed at group event equal 81 or more)MMM936415Both24,000$0.00$0.00$0.00$0.00$0.00
HPV labMMM1087621Both100$0.00$0.00$0.00$0.00$0.00
Phlebotomy (CVSP, DNA, G6PD,HIV, Rabies Titer, Varicella Titer) (minimum 30 draws per day to schedule; price per completed draw)MMM1136415Both85,000$0.00$0.00$0.00$0.00$0.00
Pregnancy Test (minimum 30 tests per day to schedule; price per completed test)MMM1284703Female900$0.00$0.00$0.00$0.00$0.00
PSAMMM1384153 + 36415 + 99381Male25$0.00$0.00$0.00$0.00$0.00
PSA w/ rectal examMMM1484153 + 361415 + 99368Male25$0.00$0.00$0.00$0.00$0.00
Status hCG Strip (Kit Only)MMM15Both1,200$0.00$0.00$0.00$0.00$0.00
Stool occult for blood (1 slide)MMM1682272Both25$0.00$0.00$0.00$0.00$0.00
Stool occult for blood (2 slide)MMM1782272Both25$0.00$0.00$0.00$0.00$0.00
Stool occult for blood (3 slide)MMM1882272Both25$0.00$0.00$0.00$0.00$0.00
Thin prep w/ preventive exam (pelvic) to collect specimenMMM1988147 + 99385Female25$0.00$0.00$0.00$0.00$0.00
Hepatitis C AntibodyMMM2086803Both100$0.00$0.00$0.00$0.00$0.00
N. MISCELLANEOUS MEDICAL SERVICE w/ Exam (PHA / Physical Exam) - IN-CLINIC
Breast examN199386Female25$0.00$0.00$0.00$0.00$0.00
Chest x-ray, posterior-anterior viewN271010Both25$0.00$0.00$0.00$0.00$0.00
EKG, restingN393000Both10,600$0.00$0.00$0.00$0.00$0.00
MammographyN477057Female10$0.00$0.00$0.00$0.00$0.00
Chest x-ray, posterior-anterior and lateral views with interpretationN571030Both100$0.00$0.00$0.00$0.00$0.00
Spirometry - Pulmonary Function Test (PFT)N694010Both100$0.00$0.00$0.00$0.00$0.00
Administer TB Risk Assessment ToolN7Both5,000$0.00$0.00$0.00$0.00$0.00
NN. MISCELLANEOUS MEDICAL SERVICE STAND ALONE - IN-CLINIC
Breast examNN199386Female1$0.00$0.00$0.00$0.00$0.00
B-readNN2Both25$0.00$0.00$0.00$0.00$0.00
Chest x-ray, posterior-anterior viewNN371010Both50$0.00$0.00$0.00$0.00$0.00
EKG, restingNN493000Both1,175$0.00$0.00$0.00$0.00$0.00
MammographyNN577057Female14$0.00$0.00$0.00$0.00$0.00
Spirometry - Pulmonary Function Test (PFT)NN694010Both5,000$0.00$0.00$0.00$0.00$0.00
NNN. MISCELLANEOUS MEDICAL SERVICE - GROUP EVENT
Breast examNNN199386Female25$0.00$0.00$0.00$0.00$0.00
EKG, resting (minimum 20 EKGs per day to schedule; price per completed EKG)NNN293000Both7,600$0.00$0.00$0.00$0.00$0.00
Administer TB Risk Assessment ToolNNN3Both23,000$0.00$0.00$0.00$0.00$0.00
O. DENTAL SERVICE w/ EXAM - IN-CLINIC
Annual Dental Exam (Periodic Oral Examination)O1D0120Both80$0.00$0.00$0.00
85$0.00
Annual Dental Exam (Comprehensive Oral Examination)O2D0150Both100,500$0.00$0.00$0.00$0.00$0.00
Dental bitewing, single filmO3D0270Both900$0.00$0.00$0.00$0.00$0.00
Dental bitewing, set of two filmsO4D0272Both390$0.00$0.00$0.00$0.00$0.00
Dental bitewing, set of three filmsO5D0273Both14$0.00$0.00$0.00$0.00$0.00
Dental bitewing, set of four films as indicatedO6D0274Both99,500$0.00$0.00$0.00$0.00$0.00
Complete series x-rayO7D0210Both1,000$0.00$0.00$0.00$0.00$0.00
Cone beam – 2 dimensional image reconstructionO8D0362Both20$0.00$0.00$0.00$0.00$0.00
Cone beam – 3 dimensional image reconstructionO9D0363Both20$0.00$0.00$0.00$0.00$0.00
Intraoral periapical x-rayO10D0220Both34,300$0.00$0.00$0.00$0.00$0.00
Panographic x-rayO11D0330Both9,800$0.00$0.00$0.00$0.00$0.00
OO. DENTAL SERVICE - GROUP EVENT
Dental exam, comprehensive oral evaluation, group event, TIER 1 (minimum 50 exams to schedule; price per exam when total exams completed at group event equal 40 or less)OO1D0150Both7,300$0.00$0.00$0.00$0.00$0.00
Dental exam, comprehensive oral evaluation, group event, TIER 2 (minimum 50 exams to schedule; price per exam when total exams completed at group event equal 41 to 80)OO2D0150Both37,000$0.00$0.00$0.00$0.00$0.00
Dental exam, comprehensive oral evaluation, group event, TIER 3 (minimum 50 exams to schedule; price per exam when total exams completed at group event equal 81 or more)OO3D0150Both104,300$0.00$0.00$0.00$0.00$0.00
Dental bitewings, set of 4 films, group event, TIER 1 (minimum 20 sets to schedule; price per set when total sets completed at group event equal 40 or less)OO4D0274Both6,200$0.00$0.00$0.00$0.00$0.00
Dental bitewings, set of 4 films, group event, TIER 2 (minimum 20 sets to schedule; price per set when total sets completed at group event equal 41 to 80)OO5D274Both38,000$0.00$0.00$0.00$0.00$0.00
Dental bitewings, set of 4 films, group event, TIER 3 (minimum 20 sets to schedule; price per set when total sets completed at group event equal 81 or more)OO6D274Both105,000$0.00$0.00$0.00$0.00$0.00
Panographic radiograph, group event, TIER 1 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 40 or less)OO7D0330Both900$0.00$0.00$0.00$0.00$0.00
Panographic radiograph, group event, TIER 2 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 41 to 80)OO8D0330Both1,880$0.00$0.00$0.00$0.00$0.00
Panographic radiograph, group event, TIER 3 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 81 or more)OO9D0330Both1,300$0.00$0.00$0.00$0.00$0.00
Dental exam, comprehensive oral evaluation, group in-clinic (minimum 15 exams to schedule; price per completed exam; transportation of Service Members is responsibility of Service Component)OO10D0150Both4,800$0.00$0.00$0.00$0.00$0.00
P. DENTAL TREATMENT SERVICE - IN-CLINIC
Consultation Dental ExamP1D0140Both13,700$0.00$0.00$0.00$0.00$0.00
Office visit after hoursP2D9440Both25$0.00$0.00$0.00$0.00$0.00
Hospital callP3D9420Both25$0.00$0.00$0.00$0.00$0.00
Detailed and extensive oral evaluationP4D9310Both1$0.00$0.00$0.00$0.00$0.00
Comprehensive periodontal evaluationP5D150Both100$0.00$0.00$0.00$0.00$0.00
Amalgam, One Surface, PermanentP6D2140Both2,400$0.00$0.00$0.00$0.00$0.00
Amalgam, Two Surfaces, PermanentP7D2150Both5,500$0.00$0.00$0.00$0.00$0.00
Amalgam, Three Surfaces, PermanentP8D2160Both3,100$0.00$0.00$0.00$0.00$0.00
Amalgam, Four or More Surfaces, PermanentP9D2162Both1,000$0.00$0.00$0.00$0.00$0.00
Apicoectomy - AnteriorP10D3410Both41$0.00$0.00$0.00$0.00$0.00
Apicoectomy - BicuspidP11D3421Both10$0.00$0.00$0.00$0.00$0.00
Apicoectomy - Molar - first rootP12D3425Both12$0.00$0.00$0.00$0.00$0.00
Apicoectomy - Molar - each add'l rootP13D3426Both7$0.00$0.00$0.00$0.00$0.00
Resin Based Composite, one surfaceP14D2330Both1,400$0.00$0.00$0.00$0.00$0.00
Resin Based Composite, two surfacesP15D2331Both1,500$0.00$0.00$0.00$0.00
1,400$0.00
Resin Based Composite, three surfacesP16D2332Both1,700$0.00$0.00$0.00$0.00$0.00
Resin Based Composite, four surfaceP17D2335Both1,300$0.00$0.00$0.00$0.00$0.00
Resin (1) one surface posteriorP18D2391Both1,350$0.00$0.00$0.00$0.00$0.00
Resin (2) two surface posteriorP19D2392Both3,000$0.00$0.00$0.00$0.00$0.00
Resin (3) three surface posteriorP20D2393Both2,100$0.00$0.00$0.00$0.00$0.00
Resin (4) four or more posteriorP21D2394Both905$0.00$0.00$0.00$0.00$0.00
Anterior (excluding final restoration)P22D3310Both750$0.00$0.00$0.00$0.00$0.00
Bicuspid (excluding final restoration)P23D3320Both1,100$0.00$0.00$0.00$0.00$0.00
Molar (excluding final restoration)P24D3330Both2,500$0.00$0.00$0.00$0.00$0.00
Core build up including pinsP25D2950Both6,100$0.00$0.00$0.00$0.00$0.00
Prefab post & coreP26D2954Both630$0.00$0.00$0.00$0.00$0.00
Extraction, single toothP27D7140Both2,300$0.00$0.00$0.00$0.00$0.00
Extraction, each additional toothP28D7140Both1,000$0.00$0.00$0.00$0.00$0.00
Extraction deciduous toothP29D7111Both5$0.00$0.00$0.00$0.00$0.00
Complete bony extractionP30D7240Both10$0.00$0.00$0.00$0.00$0.00
Surgical removal of erupted toothP31D7210Both6,000$0.00$0.00$0.00$0.00$0.00
Removal of impacted tooth-completely bonyP32D7240Both3,000$0.00$0.00$0.00$0.00$0.00
Removal of impacted tooth soft tissueP33D7220Both1,000$0.00$0.00$0.00$0.00$0.00
Removal of impacted tooth partial bonyP34D7230Both3,500$0.00$0.00$0.00$0.00$0.00
Analgesic NitrousP35D9230Both589$0.00$0.00$0.00$0.00$0.00
IV anesthesia first 30 minutesP36D9241Both163$0.00$0.00$0.00$0.00$0.00
IV anesthesia each additional 15 minutesP37D9242Both74$0.00$0.00$0.00$0.00$0.00
Local anesthesiaP38D9215Both1$0.00$0.00$0.00$0.00$0.00
Regional block anesthesiaP39D9211Both100$0.00$0.00$0.00$0.00$0.00
Deep Sedation / general anesthesia first 30 minutesP40D9220Both850$0.00$0.00$0.00$0.00$0.00
Deep Sedation / general anesthesia each additional 15 minutesP41D9221Both450$0.00$0.00$0.00$0.00$0.00
Non-intravenous conscious sedationP42D9248Both3$0.00$0.00$0.00$0.00$0.00
Therapeutic drug injection - includes antibiotic or injection of sedativeP43D9610Both1,100$0.00$0.00$0.00$0.00$0.00
Palliative treatment of dental painP44D9110Both49$0.00$0.00$0.00$0.00
50
Oral antibiotics (given at the office)P45D9630Both7$0.00$0.00$0.00$0.00$0.00
Periodontal scaling and root planingP46D4341Both28$0.00$0.00$0.00$0.00$0.00
Perio scaling and root planing per quadrantP47D4341Both99$0.00$0.00$0.00$0.00$0.00
Full mouth debridementP48D4355Both1,350$0.00$0.00$0.00$0.00$0.00
Gingivectomy, 1-3 teethP49D4211Both4$0.00$0.00$0.00$0.00$0.00
Gingivectomy, 4 or more teethP50D4210Both25$0.00$0.00$0.00$0.00$0.00
Sedative fillingP51D3940Both350$0.00$0.00$0.00$0.00$0.00
Pin retention in addition to fillingP52D2951Both19$0.00$0.00$0.00$0.00$0.00
Retrograde fillingP53D3430Both63$0.00$0.00$0.00$0.00$0.00
ReservedP54
ReservedP55
PulpotomyP56D3220Both25$0.00$0.00$0.00$0.00$0.00
Pulpal debridementP57D3221Both17$0.00$0.00$0.00$0.00$0.00
Pulp vitality testsP58D460Both1,250$0.00$0.00$0.00$0.00$0.00
Incomplete endo therapyP59D3332Both80$0.00$0.00$0.00$0.00$0.00
Retreatment of molar endoP60D3348Both325$0.00$0.00$0.00$0.00$0.00
Immediate denture maxillaryP61D5130Both40$0.00$0.00$0.00$0.00$0.00
Immediate denture mandibularP62D5140Both25$0.00$0.00$0.00$0.00$0.00
Partial denture maxillary (resin base)P63D5211Both110$0.00$0.00$0.00$0.00$0.00
Partial denture mandibular (resin base)P64D5212Both95$0.00$0.00$0.00$0.00$0.00
Adjust maxillary dentureP65D5410Both25$0.00$0.00$0.00$0.00$0.00
Add tooth to existing partial dentureP66D5650Both47$0.00$0.00$0.00$0.00$0.00
Mandibular partial denture flexible baseP67D5226Both10$0.00$0.00$0.00$0.00$0.00
Add clasp to existing partial dentureP68D5660Both9$0.00$0.00$0.00$0.00$0.00
Reline mandibular partial denture (chair side)P69D5741Both10$0.00$0.00$0.00$0.00$0.00
Reline complete maxillary denture (laboratory)P70D5750Both3$0.00$0.00$0.00$0.00$0.00
Reline mandibular partial denture (laboratory)P71D5761Both10$0.00$0.00$0.00$0.00$0.00
Reline complete maxillary denture (chair side)P72D5730Both9$0.00$0.00$0.00$0.00$0.00
Reline complete mandibular denture (chair side)P73D5731Both5$0.00$0.00$0.00$0.00$0.00
Reline maxillary partial denture (chair side)P74D5740Both1$0.00$0.00$0.00$0.00$0.00
Interim partial denture (maxillary)P75D5820Both210$0.00$0.00$0.00$0.00$0.00
Interim partial denture (mandibular)P76D5821Both19$0.00$0.00$0.00$0.00$0.00
Recement fixed partial dentureP77D6930Both5$0.00$0.00$0.00$0.00$0.00
Adjust complete denture - mandibularP78D5411Both10$0.00$0.00$0.00$0.00$0.00
Adjust partial denture - maxillaryP79D5421Both10$0.00$0.00$0.00$0.00$0.00
Adjust partial denture - mandibularP80D5422Both1$0.00$0.00$0.00$0.00$0.00
Repair broken complete denture baseP81D5510Both1$0.00$0.00$0.00$0.00$0.00
Replace missing or broken teeth - complete denture (each tooth)P82D5520Both2$0.00$0.00$0.00$0.00$0.00
Reline complete mandibular denture (laboratory)P83D5751Both2$0.00$0.00$0.00$0.00$0.00
Reline maxillary partial denture (laboratory)P84D5760Both1$0.00$0.00$0.00$0.00$0.00
Complete denture maxillaryP85D5110Both25$0.00$0.00$0.00$0.00$0.00
Complete denture mandibularP86D5120Both18$0.00$0.00$0.00$0.00$0.00
Maxillary partial denture - cast metalP87D5213Both10$0.00$0.00$0.00$0.00$0.00
Mandibular partial denture - cast metalP88D5214Both10$0.00$0.00$0.00$0.00$0.00
Repair resin denture baseP89D5610Both10$0.00$0.00$0.00$0.00$0.00
Repair or replace broken clasp - partial dentureP90D5630Both1$0.00$0.00$0.00$0.00$0.00
Replace missing or broken teeth (partial)P91D5640Both3$0.00$0.00$0.00$0.00$0.00
Rebase complete maxillary dentureP92D5710Both10$0.00$0.00$0.00$0.00$0.00
Rebase complete mandibular dentureP93D5711Both10$0.00$0.00$0.00$0.00$0.00

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