Copy_of_Attachment_-0004_Price_Matrix_Cost-Price_Vol_III-1-24-18.xlsx

XLSX spreadsheet 121 KB Posted Feb 15, 2018

Attached to: Special Notice-Amendment 0009
Solicitation number: W15QKN-17-R-1042
Issued by: Department of the Army Materiel Command Contracting Command Picatinny Arsenal

About this file

Written by GovTribe AI · Dec 30, 2023

This notice provides details regarding a forthcoming solicitation for Reserve Health Readiness Program III health readiness services. The U.S. Army Contracting Command - New Jersey will issue the solicitation on behalf of the Defense Health Agency to procure health readiness services for Service Components of the Reserve Components and Active Components throughout the U.S., its territories, Germany, and at group event gatherings. Services will include immunizations, physical examinations, pre-deployment health assessments, post-deployment health reassessments, mental health assessments, dental examinations and treatment, laboratory services, occupational health services, and Periodic Health Assessments. The government intends to award a single-award, five-year Indefinite Delivery Indefinite Quantity contract with both Firm-Fixed-Price and Cost Reimbursement task orders. The anticipated solicitation number is W15QKN-17-R-1042 and is expected to be issued on or around September 30, 2017. Interested parties should monitor the Federal Business Opportunities website.

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W15QKN-18-R-1000_Amendment_0009.docx	DOCX document	Jun 18, 2019
RHRP-3_Attachment_0005_Proposal_Submission__18_June_2019.pdf	PDF	Jun 18, 2019
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RHRP-3_Attachment_0007_Technical_Scenarios_Rev_2_May_2018.pdf	PDF	May 29, 2018
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w15qkn-18-r-1000-0006.pdf	PDF	May 29, 2018
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W15QKN-18-R-1000_Amendment_0005.docx	DOCX document	Feb 15, 2018
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W15QKN-18-R-1000-0004_(Released).pdf	PDF	Jan 30, 2018
RHRP-3_Amend_0004_Exhibits_2-6.zip	ZIP file	Jan 30, 2018
RHRP-3_Amend_0004_PWS_and_QA.zip	ZIP file	Jan 30, 2018
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RHRP-3_Amend_0004_Exhibits_7-11.zip	ZIP file	Jan 30, 2018
RHRP-3_Amend_0004_Attachments.zip	ZIP file	Jan 30, 2018
RHRP-3_Amend_0004_Exhibits_14.zip	ZIP file	Jan 30, 2018
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W15QKN-18-R-1000-0002_(Released).pdf	PDF	Dec 14, 2017
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Summary

Offeror:	= Offeror fill-in required
Solicitation No. W15QKN-18-R-1000
SUMMARY

DESCRIPTION	PRICE
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
Influenza Vaccines	$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

Procedure

Procedure Number

Sub-Element

CPT / CDT Code

Gender

Government Estimated Quantity

Base Period

Option Period 1

Option Period 2

Option Period 3

Option Period 4

Fixed Unit Price

Extended Amount

Fixed Unit Price

Extended Amount

Fixed Unit Price

Extended Amount

Fixed Unit Price

Extended Amount

Fixed Unit Price

Extended Amount

A. PHYSICAL EXAMS - IN-CLINIC
Retention exam, younger than 39, male	A1	Includes sub-elements: a-i.			Male	230		$0.00	$0.00	$0.00	$0.00	$0.00
Retention exam, younger than 39, female	A2	Includes sub-elements: a-j.			Female	60		$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, male	A3	Includes sub-elements: a-n.			Male	160		$0.00	$0.00	$0.00	$0.00	$0.00
Retention exam, 39 and older, female	A4	Includes sub-elements: a-m & o.			Female	25		$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 exam	A5	Includes sub-elements: a-h.			Both	1,850		$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, male	A6	Includes sub-elements: a-i.			Male	275		$0.00	$0.00	$0.00	$0.00	$0.00
Accession exam, female	A7	Includes sub-elements: a-j.			Female	90		$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, male	A8	Includes sub-elements: a-k.			Male	95		$0.00	$0.00	$0.00	$0.00	$0.00
Physical exam, Chapter 3, AGR, younger than 39, female	A9	Includes sub-elements: a-m.			Female	60		$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, male	A10	Includes sub-elements: a-q.			Male	20		$0.00	$0.00	$0.00	$0.00	$0.00
Physical exam, Chapter 3, AGR, 39 and older, female	A11	Includes sub-elements: a-n & p-s.			Female	3		$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 exam	A12	Includes sub-elements: a-e.			Both	15		$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, male	A13	Includes sub-elements: a-v.			Male	35		$0.00	$0.00	$0.00	$0.00	$0.00
Firefighter / CBRN exam, younger than 39, female	A14	Includes sub-elements: a-x.			Female	3		$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, male	A15	Includes sub-elements: a-z.			Male	2		$0.00	$0.00	$0.00	$0.00	$0.00
Firefighter / CBRN exam, 39 and older, female	A16	Includes sub-elements: a-w & y-bb.			Female	1		$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)	A17				Both	11,225		$0.00	$0.00	$0.00	$0.00	$0.00
DD Form 2697 in lieu of SHPE	A18				Both	3,200		$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)	A19				Both	250		$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)	A20				Both	250		$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)	A21				Both	250		$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)	AA1				Both	8,000		$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)	AA2				Both	3,000		$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 exchange	B1				Both	68,000		$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 exchange	B2				Both	5,000		$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 exchange	B3				Both	14,000		$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 exchange	B4				Both	900		$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 exchange	B5				Both	75		$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 exchange	B6				Both	75		$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 exchange	BB1				Both	2,000		$0.00	$0.00	$0.00	$0.00	$0.00
DoD PHA Record Review, call center, previous five years	BB2				Both	10,000		$0.00	$0.00	$0.00	$0.00	$0.00
DoD PHA Record Review, call center, since most recent PHA or last year	BB3				Both	60,000		$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 exchange	BB4				Both	1,000		$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)	C1				Both	10,000		$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)	C2				Both	11,000		$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)	C3				Both	30,000		$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)	C4				Both	1,000		$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)	C5				Both	5,000		$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)	C6				Both	18,500		$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)	C7				Both	6,600		$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)	C8				Both	7,000		$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)	C9				Both	8,000		$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)	C10				Both	200		$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)	C11				Both	2,000		$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)	C12				Both	10,000		$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 PHA	C13				Both	22,500		$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 PHA	C14				Both	1,290		$0.00	$0.00	$0.00	$0.00	$0.00
DoD PHA Record Review, previous five years	C15				Both	300		$0.00	$0.00	$0.00	$0.00	$0.00
DoD PHA Record Review, since most recent PHA or last year	C16				Both	65,000		$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 call	E1				Both	10		$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)	E2				Both	1,000		$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 2900	F1				Both	19,455		$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)	G1				Both	305		$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)	G2				Both	650		$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)	G3				Both	2,760		$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)	G4				Both	350		$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)	G5				Both	2,000		$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 screen	H1				Both	25,000		$0.00	$0.00	$0.00	$0.00	$0.00
MHA, call center, price per completed MHA when negative screen	H2				Both	226,000		$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)	I1				Both	7,500		$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)	I2				Both	28,000		$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)	I3				Both	94,000		$0.00	$0.00	$0.00	$0.00	$0.00
J. AUDIO w/ Exam (PHA / Physical Exam) - IN-CLINIC
Annual Audiometric Screen with MEDPROS Update	J1			92551	Both	63,737		$0.00	$0.00	$0.00	$0.00	$0.00
Comprehensive audio exam / pure tone air and bone conduction testing	J2			92557	Both	15,000		$0.00	$0.00	$0.00	$0.00	$0.00
SPRINT (Speech Recognition in Noise Test)	J3			92571	Both	195		$0.00	$0.00	$0.00	$0.00	$0.00
JJ. AUDIO STAND ALONE - IN-CLINIC
Acoustic reflex testing threshold	JJ1			92568	Both	3,060		$0.00	$0.00	$0.00	$0.00	$0.00
Audio hearing test - pure tone air	JJ2			92551	Both	2,960		$0.00	$0.00	$0.00	$0.00	$0.00
Audiometry - pure tone air and bone conduction testing	JJ3			92553	Both	6,935		$0.00	$0.00	$0.00	$0.00	$0.00
Consultation w/ Otolaryngologist	JJ4			99243	Both	100		$0.00	$0.00	$0.00	$0.00	$0.00
DOHERS entry	JJ5				Both	112,345		$0.00	$0.00	$0.00	$0.00	$0.00
Evoked acoustic emission, limited (single stimulus level, either transient or distortion products)	JJ6			92587	Both	6,935		$0.00	$0.00	$0.00	$0.00	$0.00
Speech audiometry threshold w/ speech recognition	JJ7			92556	Both	4,110		$0.00	$0.00	$0.00	$0.00	$0.00
SPRINT	JJ8			92571	Both	1,320		$0.00	$0.00	$0.00	$0.00	$0.00
Tympanometry	JJ9			92567	Both	4,095		$0.00	$0.00	$0.00	$0.00	$0.00
Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions)	JJ10			92558	Both	6,935		$0.00	$0.00	$0.00	$0.00	$0.00
Distortion product evoked otoacoustic emissions, comprehensive diagnostic evaluation	JJ11			92588	Both	6,935		$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)	JJJ1			92522	Both	172,000		$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)	JJJ2			92557	Both	850		$0.00	$0.00	$0.00	$0.00	$0.00
DOHERS entry	JJJ3				Both	170,000		$0.00	$0.00	$0.00	$0.00	$0.00
K. VISION w/ Exam (PHA / Physical Exam) - IN-CLINIC
Comprehensive eye exam	K1			92004	Both	10,000		$0.00	$0.00	$0.00	$0.00	$0.00
Eye examination with refraction and prescription	K2			92002	Both	2,500		$0.00	$0.00	$0.00	$0.00	$0.00
Tonometry	K3			92100	Both	3		$0.00	$0.00	$0.00	$0.00	$0.00
Vision Screen with color and with & without correction	K4			99172	Both	75,000		$0.00	$0.00	$0.00	$0.00	$0.00
KK. VISION STAND ALONE - IN-CLINIC
Comprehensive eye exam	KK1			92004	Both	15,500		$0.00	$0.00	$0.00	$0.00	$0.00
Eye examination with refraction and prescription	KK2			92002	Both	6		$0.00	$0.00	$0.00	$0.00	$0.00
Tonometry	KK3			92100	Both	13		$0.00	$0.00	$0.00	$0.00	$0.00
Vision - Monocular	KK4			99173	Both	1,600		$0.00	$0.00	$0.00	$0.00	$0.00
Vision Screen with color and with & without correction	KK5			99172	Both	2,400		$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)	KKK1				Both	875		$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)	KKK2				Both	1,125		$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)	KKK3				Both	6,150		$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)	KKK4				Both	27,175		$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)	KKK5				Both	83,700		$0.00	$0.00	$0.00	$0.00	$0.00
L. VACCINE AND TITER WITH EXAM - IN-CLINIC
Hepatitis A	L1			90632	Both	2,175		$0.00	$0.00	$0.00	$0.00	$0.00
Hepatitis B	L2			90746	Both	2,350		$0.00	$0.00	$0.00	$0.00	$0.00
Influenza - Injectable (ODC Cost)	L3			90688	Both	14,900	DO NOT PRICE. QUANTITY PROVIDED FOR INFORMATIONAL PURPOSES. COST WILL BE CAPTURED UNDER ODCs
Rabies Titer	L4			86382	Both	2,000		$0.00	$0.00	$0.00	$0.00	$0.00
PPD	L5			86580	Both	14		$0.00	$0.00	$0.00	$0.00	$0.00
Tdap	L6			90715	Both	880		$0.00	$0.00	$0.00	$0.00	$0.00
Tetanus and Diphtheria	L7			90718	Both	900		$0.00	$0.00	$0.00	$0.00	$0.00
Twinrix	L8			90636	Both	80		$0.00	$0.00	$0.00	$0.00	$0.00
Varicella	L9			90716	Both	2,650		$0.00	$0.00	$0.00	$0.00	$0.00
Varicella titer	L10			86787	Both	1,585		$0.00	$0.00	$0.00	$0.00	$0.00
Measles, Mumps, Rubella (MMR)	L11			90707	Both	7,450		$0.00	$0.00	$0.00	$0.00	$0.00
Pediatric dose Hep A	L12			90633	Both	170		$0.00	$0.00	$0.00	$0.00	$0.00
Pediatric dose Hep B	L13			90744	Both	1,033		$0.00	$0.00	$0.00	$0.00	$0.00
Polio	L14			90713	Both	700		$0.00	$0.00	$0.00	$0.00	$0.00
MMR titer	L15			86765

+86735

+86762	Both	2,365		$0.00		$0.00		$0.00		$0.00		$0.00
	Reserved	L16
	Measles, Rubella Titer	L17			86765 + 86762	Both	1,000		$0.00		$0.00		$0.00	$0.00	$0.00
	LL. VACCINE AND TITER STAND ALONE - IN-CLINIC
	Hepatitis A	LL1			90632	Both	1,750		$0.00		$0.00		$0.00	$0.00	$0.00
	Hepatitis B	LL2			90746	Both	2,430		$0.00		$0.00		$0.00	$0.00	$0.00
	Influenza - Injectable (ODC Cost)	LL3			90688	Both	27,500	DO NOT PRICE. QUANTITY PROVIDED FOR INFORMATIONAL PURPOSES. COST WILL BE CAPTURED UNDER ODCs
	Japanese encephalitis	LL4			90735	Both	6		$0.00		$0.00		$0.00	$0.00	$0.00
	Meningococcus	LL5			90733	Both	45		$0.00
							46				$0.00		$0.00	$0.00	$0.00
	Polio	LL6			90713	Both	675		$0.00
							681				$0.00		$0.00	$0.00	$0.00
	Rabies	LL7			90714	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Rabies Titer	LL8			86382	Both	2,000		$0.00		$0.00		$0.00	$0.00	$0.00
	PPD	LL9			86580	Both	415		$0.00		$0.00		$0.00	$0.00	$0.00
	Tdap	LL10			90715	Both	450		$0.00		$0.00		$0.00	$0.00	$0.00
	Tetanus and Diphtheria	LL11			90714	Both	1,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Typhoid	LL12			90691	Both	450		$0.00		$0.00		$0.00	$0.00	$0.00
	Twinrix	LL13			90636	Both	80		$0.00		$0.00		$0.00	$0.00	$0.00
	Varicella	LL14			90716	Both	2,500		$0.00		$0.00		$0.00	$0.00	$0.00
	Varicella titer	LL15			86787	Both	1,200		$0.00		$0.00		$0.00	$0.00	$0.00
	Yellow fever	LL16			90717	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	Measles, Mumps, Rubella (MMR)	LL17			90707	Both	5,200		$0.00		$0.00		$0.00	$0.00	$0.00
	Pediatric dose Hep A	LL18			90633	Both	180		$0.00		$0.00		$0.00	$0.00	$0.00
	Pediatric dose Hep B	LL19			90744	Both	1,375		$0.00		$0.00		$0.00	$0.00	$0.00
	MMR titer	LL20			86765 + 86735
+86762	Both	1,900		$0.00		$0.00		$0.00		$0.00		$0.00
	Reserved	LL21
	Measles, Rubella Titer	LL22			86765 + 86762	Both	1,000		$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)	LLL1			90471	Both	11,150		$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)	LLL2			90471	Both	36,000		$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)	LLL3			90472	Both	116,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Anthrax (6 shot series) (Government will provide vaccine)	LLL4			90581	Both	7,600		$0.00		$0.00		$0.00	$0.00	$0.00
	Globulin, Immune	LLL5			90281	Both	500		$0.00		$0.00		$0.00	$0.00	$0.00
	Hepatitis A (2 shot series)	LLL6			90632	Both	5,198		$0.00		$0.00		$0.00	$0.00	$0.00
	Hepatitis B (3 shot series)	LLL7			90746	Both	6,128		$0.00		$0.00		$0.00	$0.00	$0.00
	Inactivated Polio Vaccine (IPV)	LLL8			90713	Both	2,829		$0.00		$0.00		$0.00	$0.00	$0.00
	Influenza	LLL9			90658	Both	28,000	DO NOT PRICE. QUANTITY PROVIDED FOR INFORMATIONAL PURPOSES. COST WILL BE CAPTURED UNDER Line Item -Influenza Vaccines
	Japanese Encephalitis	LLL10			90735	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	Measles, Mumps, Rubella (MMR)	LLL11			90707	Both	18,450		$0.00		$0.00		$0.00	$0.00	$0.00
	Menactra	LLL12			90734	Both	34		$0.00		$0.00		$0.00	$0.00	$0.00
	PPD	LLL13			86580	Both	250		$0.00		$0.00		$0.00	$0.00	$0.00
	Rabies (3 shot series)	LLL14			90675	Both	110		$0.00		$0.00		$0.00	$0.00	$0.00
	Rabies Titer	LLL15			86382	Both	57		$0.00		$0.00		$0.00	$0.00	$0.00
	Reserved	LLL16
	Tdap	LLL17			90715	Both	1,169		$0.00		$0.00		$0.00	$0.00	$0.00
	Tetanus and Diphtheria	LLL18			90714	Both	1,000		$0.00		$0.00		$0.00		$0.00
							950							$0.00
	Typhoid (injectable or oral)	LLL19			90688	Both	7,750		$0.00		$0.00		$0.00	$0.00	$0.00
	Varicella	LLL20			90716	Both	7,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Varicella titer	LLL21			86787	Both	4,050		$0.00		$0.00		$0.00	$0.00	$0.00
	Yellow fever	LLL22			90717	Both	200		$0.00		$0.00		$0.00	$0.00	$0.00
	MMR titer	LLL23			86765 + 86735
+86762	Both	2,100		$0.00		$0.00		$0.00		$0.00		$0.00
	Reserved	LLL24
	Measles, Rubella Titer	LLL25			86765 + 86762	Both	500		$0.00		$0.00		$0.00	$0.00	$0.00
	M. LABORATORY SERVICE w/ Exam (PHA / Physical Exam) - IN-CLINIC
	AGR labs	M1	Services Include: 1) Drug Screen, 2) ETOH Screen, 3) Pregnancy Test, 4) Forms: Voucher, Customer Satisfaction Survey, Lab Requisition		80305 + 82055 + 84702	Both	500		$0.00		$0.00		$0.00	$0.00	$0.00
	Blood type and determination of Rh factor w/ venipuncture	M2			86901 + 36415	Both	1,250		$0.00		$0.00		$0.00	$0.00	$0.00
	Chlamydia, DNA by SDA (urine)	M3			87491	Both	150		$0.00		$0.00		$0.00	$0.00	$0.00
	Chlamydia / Gonorrhea (by swab)	M4			87491 + 87591	Both	65		$0.00		$0.00		$0.00	$0.00	$0.00
	Chlamydia / Gonorrhea (reflex from swab)	M5			87490 + 87590	Both	45		$0.00		$0.00		$0.00	$0.00	$0.00
	CVSP	M6	Service 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 weight		93000 + 80061 + 82947	Both	13,200		$0.00		$0.00		$0.00	$0.00	$0.00
	DNA test	M7			99000	Both	490		$0.00		$0.00		$0.00	$0.00	$0.00
	Gonorrhea, DNA by SDA (urine)	M8			87591	Both	4		$0.00		$0.00		$0.00	$0.00	$0.00
	G6PD	M9			82960	Both	5,600		$0.00		$0.00		$0.00	$0.00	$0.00
	HIV test (phlebotomy only)	M10			86701	Both	31,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Pregnancy, urine	M11			84703	Female	17		$0.00		$0.00		$0.00	$0.00	$0.00
	PSA	M12			84153 + 36415 + 99381	Male	100		$0.00		$0.00		$0.00	$0.00	$0.00
	PSA w/ rectal exam	M13			84153 + 36415 + 99368	Male	100		$0.00		$0.00		$0.00	$0.00	$0.00
	Rectal exam with stool for guaiac	M14			G0102 + 82270	Both	275		$0.00		$0.00		$0.00
							270							$0.00	$0.00
	Sickle cell screening test w/ confirmation by reflex to hemoglobulinopathy	M15			85660 + 83021	Both	1		$0.00		$0.00		$0.00	$0.00	$0.00
	Stool occult for blood (1 slide)	M16			82270	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Stool occult for blood (2 slide)	M17			82270	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Stool occult for blood (3 slide)	M18			82270	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Thin prep w/ preventive exam (pelvic) to collect specimen	M19			88147 + 99385	Female	220		$0.00		$0.00		$0.00	$0.00	$0.00
	Phlebotomy (blood draw)	M20			36415	Both	61,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Complete Blood Count (CBC) w/ differential	M21			85025	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	LDH	M22			83615
+83625	Both	50		$0.00		$0.00		$0.00		$0.00		$0.00
	Comprehensive Metabolic Panel	M23			80053	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	Cholinesterase (plasma and RBC)	M24			82480
+82482	Both	50		$0.00		$0.00		$0.00		$0.00		$0.00
	Complete Blood Count (CBC), differential and platelets with smear review	M25			85007
+85027	Both	50		$0.00		$0.00		$0.00		$0.00		$0.00
	Blood lead	M26			83655	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	Zinc protoporphyrin	M27			84202	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	Urinalysis, complete with reflex microscope (prn)	M28			81001
+99000	Both	50		$0.00		$0.00		$0.00		$0.00		$0.00
	Hepatitis C antibody	M29			86803	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	MM. LABORATORY SERVICE STAND ALONE - IN-CLINIC
	AGR labs	MM1	Services Include: 1) Drug Screen, 2) ETOH Screen, 3) Pregnancy Test, 4) Forms: Voucher, Customer Satisfaction Survey, Lab Requisition		80305 + 82055 + 84702	Both	210		$0.00		$0.00		$0.00	$0.00	$0.00
	Blood type and determination of Rh factor w/ venipuncture	MM2			86901 + 36415	Both	330		$0.00		$0.00		$0.00	$0.00	$0.00
	Chlamydia, DNA by SDA (urine)	MM3			87491	Both	11		$0.00		$0.00		$0.00	$0.00	$0.00
	CVSP	MM4	Service 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 weight		93000 + 80061 + 82947	Both	1,000		$0.00		$0.00		$0.00	$0.00	$0.00
	DNA test (no lab) - use military labor and DNA card	MM5			99000	Both	230		$0.00		$0.00		$0.00	$0.00	$0.00
	Gonorrhea, DNA by SDA (urine)	MM6			87591	Both	10		$0.00		$0.00		$0.00	$0.00	$0.00
	G6PD	MM7			82960	Both	2,100		$0.00		$0.00		$0.00	$0.00	$0.00
	HIV test (phlebotomy only)	MM8			86701	Both	23,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Phlebotomy (blood draw)	MM9			36415	Both	30,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Pregnancy, urine	MM10			84703	Female	85		$0.00		$0.00		$0.00	$0.00	$0.00
	PSA	MM11			84153 + 36415 + 99381	Male	44		$0.00		$0.00		$0.00	$0.00	$0.00
	PSA w/ rectal exam	MM12			84153 + 36415 + 99368	Male	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Rectal exam w/ stool for guaiac	MM13			G0102 + 82270	Both	18		$0.00		$0.00		$0.00	$0.00	$0.00
	Sickle cell screening test w/ confirmation by reflex to hemoglobulinopathy	MM14			85660 + 83021	Both	20		$0.00		$0.00		$0.00	$0.00	$0.00
	Stool occult for blood (1 slide)	MM15			82270	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	Stool occult for blood (2 slide)	MM16			82270	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	Stool occult for blood (3 slide)	MM17			82270	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	Thin prep w/ preventive exam (pelvic) to collect specimen	MM18			88147 + 99385	Female	100		$0.00		$0.00		$0.00	$0.00	$0.00
	Complete Blood Count (CBC) w/ differential	MM19			85025	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	Cholinesterase (plasma & RBC)	MM20			82480
+82482	Both	50		$0.00		$0.00		$0.00		$0.00		$0.00
	Hazardous Waste	MM21			None	Both	500		$0.00		$0.00		$0.00	$0.00	$0.00
	Lead	MM22			None	Both	100		$0.00		$0.00		$0.00	$0.00	$0.00
	Benzene	MM23			85020
+94010	Both	50		$0.00		$0.00		$0.00		$0.00		$0.00
	Urinalysis, complete w/ reflex microscope (p.r.n.)	MM24			81001
+99000	Both	50		$0.00		$0.00		$0.00		$0.00		$0.00
	Rapid Plasma Reagin (RPR)	MM25			86592	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	LDH	MM26			83615
+83625	Both	50		$0.00		$0.00		$0.00		$0.00		$0.00
	Comprehensive Metabolic Panel	MM27			80053	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	Complete Blood Count (CBC), differential and platelets with smear review	MM28			85007
+85027	Both	50		$0.00		$0.00		$0.00		$0.00		$0.00
	Zinc protoporphyrin	MM29			82374	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	Blood lead	MM30			83655	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	Hepatitis C Antibody	MM31			86803	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	MMM. LABORATORY SERVICE - GROUP EVENT
	Blood type and determination of Rh factor w/ venipuncture	MMM1			86901 + 36415	Both	1,000		$0.00				$0.00	$0.00	$0.00
							1,078				$0.00
	Chlamydia, DNA by SDA (urine)	MMM2			87491	Both	10		$0.00		$0.00		$0.00	$0.00	$0.00
	CVSP	MMM3	Service 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 weight		93000 + 80061 + 82947	Both	6,800		$0.00		$0.00		$0.00	$0.00	$0.00
	CVSP (Cholestech) (minimum 25 screens per day to schedule; price per completed screen)	MMM4	Service 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 weight		93000 + 80061 + 82947	Both	805		$0.00		$0.00		$0.00	$0.00	$0.00
	Gonorrhea, DNA by SDA (urine)	MMM5			87591	Both	10		$0.00		$0.00		$0.00	$0.00	$0.00
	G6PD Testing	MMM6			82960	Both	12,500		$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)	MMM7			36415	Both	17,000		$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)	MMM8			36415	Both	16,500		$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)	MMM9			36415	Both	24,000		$0.00		$0.00		$0.00	$0.00	$0.00
	HPV lab	MMM10			87621	Both	100		$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)	MMM11			36415	Both	85,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Pregnancy Test (minimum 30 tests per day to schedule; price per completed test)	MMM12			84703	Female	900		$0.00		$0.00		$0.00	$0.00	$0.00
	PSA	MMM13			84153 + 36415 + 99381	Male	25		$0.00		$0.00		$0.00	$0.00	$0.00
	PSA w/ rectal exam	MMM14			84153 + 36415 + 99368	Male	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Status hCG Strip (Kit Only)	MMM15				Both	1,200		$0.00		$0.00		$0.00	$0.00	$0.00
	Stool occult for blood (1 slide)	MMM16			82272	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Stool occult for blood (2 slide)	MMM17			82272	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Stool occult for blood (3 slide)	MMM18			82272	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Thin prep w/ preventive exam (pelvic) to collect specimen	MMM19			88147 + 99385	Female	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Hepatitis C Antibody	MMM20			86803	Both	100		$0.00		$0.00		$0.00	$0.00	$0.00
	N. MISCELLANEOUS MEDICAL SERVICE w/ Exam (PHA / Physical Exam) - IN-CLINIC
	Breast exam	N1			99386	Female	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Chest x-ray, posterior-anterior view	N2			71010	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	EKG, resting	N3			93000	Both	10,600		$0.00		$0.00		$0.00	$0.00	$0.00
	Mammography	N4			77057	Female	10		$0.00		$0.00		$0.00	$0.00	$0.00
	Chest x-ray, posterior-anterior and lateral views with interpretation	N5			71030	Both	100		$0.00		$0.00		$0.00	$0.00	$0.00
	Spirometry - Pulmonary Function Test (PFT)	N6			94010	Both	100		$0.00		$0.00		$0.00	$0.00	$0.00
	Administer TB Risk Assessment Tool	N7				Both	5,000		$0.00		$0.00		$0.00	$0.00	$0.00
	NN. MISCELLANEOUS MEDICAL SERVICE STAND ALONE - IN-CLINIC
	Breast exam	NN1			99386	Female	1		$0.00		$0.00		$0.00	$0.00	$0.00
	B-read	NN2				Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Chest x-ray, posterior-anterior view	NN3			71010	Both	50		$0.00		$0.00		$0.00	$0.00	$0.00
	EKG, resting	NN4			93000	Both	1,175		$0.00		$0.00		$0.00	$0.00	$0.00
	Mammography	NN5			77057	Female	14		$0.00		$0.00		$0.00	$0.00	$0.00
	Spirometry - Pulmonary Function Test (PFT)	NN6			94010	Both	5,000		$0.00		$0.00		$0.00	$0.00	$0.00
	NNN. MISCELLANEOUS MEDICAL SERVICE - GROUP EVENT
	Breast exam	NNN1			99386	Female	25		$0.00		$0.00		$0.00	$0.00	$0.00
	EKG, resting (minimum 20 EKGs per day to schedule; price per completed EKG)	NNN2			93000	Both	7,600		$0.00		$0.00		$0.00	$0.00	$0.00
	Administer TB Risk Assessment Tool	NNN3				Both	23,000		$0.00		$0.00		$0.00	$0.00	$0.00
	O. DENTAL SERVICE w/ EXAM - IN-CLINIC
	Annual Dental Exam (Periodic Oral Examination)	O1			D0120	Both	80		$0.00					$0.00	$0.00
							85				$0.00		$0.00
	Annual Dental Exam (Comprehensive Oral Examination)	O2			D0150	Both	100,500		$0.00		$0.00		$0.00	$0.00	$0.00
	Dental bitewing, single film	O3			D0270	Both	900		$0.00		$0.00		$0.00	$0.00	$0.00
	Dental bitewing, set of two films	O4			D0272	Both	390		$0.00		$0.00		$0.00	$0.00	$0.00
	Dental bitewing, set of three films	O5			D0273	Both	14		$0.00		$0.00		$0.00	$0.00	$0.00
	Dental bitewing, set of four films as indicated	O6			D0274	Both	99,500		$0.00		$0.00		$0.00	$0.00	$0.00
	Complete series x-ray	O7			D0210	Both	1,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Cone beam – 2 dimensional image reconstruction	O8			D0362	Both	20		$0.00		$0.00		$0.00	$0.00	$0.00
	Cone beam – 3 dimensional image reconstruction	O9			D0363	Both	20		$0.00		$0.00		$0.00	$0.00	$0.00
	Intraoral periapical x-ray	O10			D0220	Both	34,300		$0.00		$0.00		$0.00	$0.00	$0.00
	Panographic x-ray	O11			D0330	Both	9,800		$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)	OO1			D0150	Both	7,300		$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)	OO2			D0150	Both	37,000		$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)	OO3			D0150	Both	104,300		$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)	OO4			D0274	Both	6,200		$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)	OO5			D0274	Both	38,000		$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)	OO6			D0274	Both	105,000		$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)	OO7			D0330	Both	900		$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)	OO8			D0330	Both	1,880		$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)	OO9			D0330	Both	1,300		$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)	OO10			D0150	Both	4,800		$0.00		$0.00		$0.00	$0.00	$0.00
	P. DENTAL TREATMENT SERVICE - IN-CLINIC
	Consultation Dental Exam	P1			D0140	Both	13,700		$0.00		$0.00		$0.00	$0.00	$0.00
	Office visit after hours	P2			D9440	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Hospital call	P3			D9420	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Detailed and extensive oral evaluation	P4			D9310	Both	1		$0.00		$0.00		$0.00	$0.00	$0.00
	Comprehensive periodontal evaluation	P5			D0150	Both	100		$0.00		$0.00		$0.00	$0.00	$0.00
	Amalgam, One Surface, Permanent	P6			D2140	Both	2,400		$0.00		$0.00		$0.00	$0.00	$0.00
	Amalgam, Two Surfaces, Permanent	P7			D2150	Both	5,500		$0.00		$0.00		$0.00	$0.00	$0.00
	Amalgam, Three Surfaces, Permanent	P8			D2160	Both	3,100		$0.00		$0.00		$0.00	$0.00	$0.00
	Amalgam, Four or More Surfaces, Permanent	P9			D2162	Both	1,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Apicoectomy - Anterior	P10			D3410	Both	41		$0.00		$0.00		$0.00	$0.00	$0.00
	Apicoectomy - Bicuspid	P11			D3421	Both	10		$0.00		$0.00		$0.00	$0.00	$0.00
	Apicoectomy - Molar - first root	P12			D3425	Both	12		$0.00		$0.00		$0.00	$0.00	$0.00
	Apicoectomy - Molar - each add'l root	P13			D3426	Both	7		$0.00		$0.00		$0.00	$0.00	$0.00
	Resin Based Composite, one surface	P14			D2330	Both	1,400		$0.00		$0.00		$0.00	$0.00	$0.00
	Resin Based Composite, two surfaces	P15			D2331	Both	1,500		$0.00		$0.00		$0.00	$0.00
							1,400								$0.00
	Resin Based Composite, three surfaces	P16			D2332	Both	1,700		$0.00		$0.00		$0.00	$0.00	$0.00
	Resin Based Composite, four surface	P17			D2335	Both	1,300		$0.00		$0.00		$0.00	$0.00	$0.00
	Resin (1) one surface posterior	P18			D2391	Both	1,350		$0.00		$0.00		$0.00	$0.00	$0.00
	Resin (2) two surface posterior	P19			D2392	Both	3,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Resin (3) three surface posterior	P20			D2393	Both	2,100		$0.00		$0.00		$0.00	$0.00	$0.00
	Resin (4) four or more posterior	P21			D2394	Both	905		$0.00		$0.00		$0.00	$0.00	$0.00
	Anterior (excluding final restoration)	P22			D3310	Both	750		$0.00		$0.00		$0.00	$0.00	$0.00
	Bicuspid (excluding final restoration)	P23			D3320	Both	1,100		$0.00		$0.00		$0.00	$0.00	$0.00
	Molar (excluding final restoration)	P24			D3330	Both	2,500		$0.00		$0.00		$0.00	$0.00	$0.00
	Core build up including pins	P25			D2950	Both	6,100		$0.00		$0.00		$0.00	$0.00	$0.00
	Prefab post & core	P26			D2954	Both	630		$0.00		$0.00		$0.00	$0.00	$0.00
	Extraction, single tooth	P27			D7140	Both	2,300		$0.00		$0.00		$0.00	$0.00	$0.00
	Extraction, each additional tooth	P28			D7140	Both	1,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Extraction deciduous tooth	P29			D7111	Both	5		$0.00		$0.00		$0.00	$0.00	$0.00
	Complete bony extraction	P30			D7240	Both	10		$0.00		$0.00		$0.00	$0.00	$0.00
	Surgical removal of erupted tooth	P31			D7210	Both	6,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Removal of impacted tooth-completely bony	P32			D7240	Both	3,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Removal of impacted tooth soft tissue	P33			D7220	Both	1,000		$0.00		$0.00		$0.00	$0.00	$0.00
	Removal of impacted tooth partial bony	P34			D7230	Both	3,500		$0.00		$0.00		$0.00	$0.00	$0.00
	Analgesic Nitrous	P35			D9230	Both	589		$0.00		$0.00		$0.00	$0.00	$0.00
	IV anesthesia first 30 minutes	P36			D9239	Both	163		$0.00		$0.00		$0.00	$0.00	$0.00
	IV anesthesia each additional 15 minutes	P37			D9243	Both	74		$0.00		$0.00		$0.00	$0.00	$0.00
	Local anesthesia	P38			D9215	Both	1		$0.00		$0.00		$0.00	$0.00	$0.00
	Regional block anesthesia	P39			D9221	Both	100		$0.00		$0.00		$0.00	$0.00	$0.00
	Deep Sedation / general anesthesia first 30 minutes	P40			D9222	Both	850		$0.00		$0.00		$0.00	$0.00	$0.00
	Deep Sedation / general anesthesia each additional 15 minutes	P41			D9223	Both	450		$0.00		$0.00		$0.00	$0.00	$0.00
	Non-intravenous conscious sedation	P42			D9248	Both	3		$0.00		$0.00		$0.00	$0.00	$0.00
	Therapeutic drug injection - includes antibiotic or injection of sedative	P43			D9610	Both	1,100		$0.00		$0.00		$0.00	$0.00	$0.00
	Palliative treatment of dental pain	P44			D9110	Both	49		$0.00		$0.00			$0.00	$0.00
							50						$0.00
	Oral antibiotics (given at the office)	P45			D9630	Both	7		$0.00		$0.00		$0.00	$0.00	$0.00
	Periodontal scaling and root planing	P46			D4341	Both	28		$0.00		$0.00		$0.00	$0.00	$0.00
	Perio scaling and root planing per quadrant	P47			D4341	Both	99		$0.00		$0.00		$0.00	$0.00	$0.00
	Full mouth debridement	P48			D4355	Both	1,350		$0.00		$0.00		$0.00	$0.00	$0.00
	Gingivectomy, 1-3 teeth	P49			D4211	Both	4		$0.00		$0.00		$0.00	$0.00	$0.00
	Gingivectomy, 4 or more teeth	P50			D4210	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Sedative filling	P51			D3940	Both	350		$0.00		$0.00		$0.00	$0.00	$0.00
	Pin retention in addition to filling	P52			D2951	Both	19		$0.00		$0.00		$0.00	$0.00	$0.00
	Retrograde filling	P53			D3430	Both	63		$0.00		$0.00		$0.00	$0.00	$0.00
	Reserved	P54
	Reserved	P55
	Pulpotomy	P56			D3220	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Pulpal debridement	P57			D3221	Both	17		$0.00		$0.00		$0.00	$0.00	$0.00
	Pulp vitality tests	P58			D0460	Both	1,250		$0.00		$0.00		$0.00	$0.00	$0.00
	Incomplete endo therapy	P59			D3332	Both	80		$0.00		$0.00		$0.00	$0.00	$0.00
	Retreatment of molar endo	P60			D3348	Both	325		$0.00		$0.00		$0.00	$0.00	$0.00
	Immediate denture maxillary	P61			D5130	Both	40		$0.00		$0.00		$0.00	$0.00	$0.00
	Immediate denture mandibular	P62			D5140	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Partial denture maxillary (resin base)	P63			D5211	Both	110		$0.00		$0.00		$0.00	$0.00	$0.00
	Partial denture mandibular (resin base)	P64			D5212	Both	95		$0.00		$0.00		$0.00	$0.00	$0.00
	Adjust maxillary denture	P65			D5410	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Add tooth to existing partial denture	P66			D5650	Both	47		$0.00		$0.00		$0.00	$0.00	$0.00
	Mandibular partial denture flexible base	P67			D5226	Both	10		$0.00		$0.00		$0.00	$0.00	$0.00
	Add clasp to existing partial denture	P68			D5660	Both	9		$0.00		$0.00		$0.00	$0.00	$0.00
	Reline mandibular partial denture (chair side)	P69			D5741	Both	10		$0.00		$0.00		$0.00	$0.00	$0.00
	Reline complete maxillary denture (laboratory)	P70			D5750	Both	3		$0.00		$0.00		$0.00	$0.00	$0.00
	Reline mandibular partial denture (laboratory)	P71			D5761	Both	10		$0.00		$0.00		$0.00	$0.00	$0.00
	Reline complete maxillary denture (chair side)	P72			D5730	Both	9		$0.00		$0.00		$0.00	$0.00	$0.00
	Reline complete mandibular denture (chair side)	P73			D5731	Both	5		$0.00		$0.00		$0.00	$0.00	$0.00
	Reline maxillary partial denture (chair side)	P74			D5740	Both	1		$0.00		$0.00		$0.00	$0.00	$0.00
	Interim partial denture (maxillary)	P75			D5820	Both	210		$0.00		$0.00		$0.00	$0.00	$0.00
	Interim partial denture (mandibular)	P76			D5821	Both	19		$0.00		$0.00		$0.00	$0.00	$0.00
	Recement fixed partial denture	P77			D6930	Both	5		$0.00		$0.00		$0.00	$0.00	$0.00
	Adjust complete denture - mandibular	P78			D5411	Both	10		$0.00		$0.00		$0.00	$0.00	$0.00
	Adjust partial denture - maxillary	P79			D5421	Both	10		$0.00		$0.00		$0.00	$0.00	$0.00
	Adjust partial denture - mandibular	P80			D5422	Both	1		$0.00		$0.00		$0.00	$0.00	$0.00
	Repair broken complete denture base	P81			D5510	Both	1		$0.00		$0.00		$0.00	$0.00	$0.00
	Replace missing or broken teeth - complete denture (each tooth)	P82			D5520	Both	2		$0.00		$0.00		$0.00	$0.00	$0.00
	Reline complete mandibular denture (laboratory)	P83			D5751	Both	2		$0.00		$0.00		$0.00	$0.00	$0.00
	Reline maxillary partial denture (laboratory)	P84			D5760	Both	1		$0.00		$0.00		$0.00	$0.00	$0.00
	Complete denture maxillary	P85			D5110	Both	25		$0.00		$0.00		$0.00	$0.00	$0.00
	Complete denture mandibular	P86			D5120	Both	18		$0.00		$0.00		$0.00	$0.00	$0.00
	Maxillary partial denture - cast metal	P87			D5213	Both	10		$0.00		$0.00		$0.00	$0.00	$0.00
	Mandibular partial denture - cast metal	P88			D5214	Both	10		$0.00		$0.00		$0.00	$0.00	$0.00
	Repair resin denture base	P89			D5610	Both	10		$0.00		$0.00		$0.00	$0.00	$0.00
	Repair or replace broken clasp - partial denture	P90			D5630	Both	1		$0.00		$0.00		$0.00	$0.00	$0.00
	Replace missing or broken teeth (partial)	P91			D5640	Both	3		$0.00		$0.00		$0.00	$0.00	$0.00
	Rebase complete maxillary denture	P92			D5710	Both	10		$0.00		$0.00		$0.00	$0.00	$0.00

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Dec 30, 2023.