Exhibit_14j_Annual_Financial_Summary_4.4.6.2.xlsx

XLSX spreadsheet 93 KB Posted

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

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Written by GovTribe AI ·

This document provides details of a presolicitation notice for the Reserve Health Readiness Program III (RHRP-3) contract. The U.S. Army Contracting Command - New Jersey, on behalf of the Defense Health Agency, intends to issue a solicitation on September 30, 2017 for health readiness services to support the Army Reserve, Army National Guard, Air Force Reserve, Air Force National Guard, Navy Reserve, Marine Forces Reserves, and Coast Guard Reserve. Services will include immunizations, physical examinations, pre-deployment health assessments, post-deployment health reassessments, mental health assessments, dental examinations and x-rays, dental treatment, laboratory services, and occupational health services. The government intends to award a single-award, firm-fixed-price and cost reimbursement, indefinite delivery indefinite quantity contract with a period of performance of five years. Interested parties should monitor the Federal Business Opportunities website for release of the solicitation.

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Exhibit 14j

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Other files for this federal contract opportunity

Other files attached to Special Notice-Amendment 0009, newest first.
File Type Posted
RHRP-3_Attachment_0007_Technical_Scenarios_Rev_2_May_2018.pdf PDF
W15QKN-18-R-1000_Conformed_V05-29-18.pdf PDF
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Industry_Questions_2-15-2018.pdf PDF
Conform_-_W15QKN-18-R-1000.docx DOCX document
Attachment_0007_Technical_Scenarios_24_Jan_2018.pdf PDF
Attch_0011_Quality_Assurance_Surveillance_Plan_1-24-18.pdf PDF
RHRP-3_Amend_0004_Attachments.zip ZIP file
W15QKN-18-R-1000-0004_(Released).pdf PDF
RHRP-3_Amend_0004_Exhibits_7-11.zip ZIP file
RHRP-3_Amend_0004_Exhibits_14.zip ZIP file
W15QKN-18-R-1000-0002_(Released).pdf PDF
RHRP-3_Preproposal_Conference_Attendee_List.pdf PDF
RHRP-3_PWS_-_7_Dec_clean.pdf PDF
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Exhibit_14d_RHRP-3_Post_Event_Report_4.4.2.3.xls XLS spreadsheet
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Attachment_-0004_Price_Matrix_Cost-Price_Vol_III-9-30-17-dl.xlsx XLSX spreadsheet
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Exhibit_14q_Dental_Report_Card_4.4.5.1.xls XLS spreadsheet
Attachment_0006_basis_of_award-9-30-17-draft.docx DOCX document
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Exhibit_14l_HIV_Specimen_Stats__4.4.4.6.xlsx XLSX spreadsheet
Attch_0011_Quality_Assurance_Surveillance_Plan.doc DOC document
Attachment_9-SFFL_4_Short_Term_EAL_Form_2017.pdf PDF
Exhibit_13_Checklist_and_Certification_for_Safeguarding_Unclassified_DoD_Info_Nov_2014.docx DOCX document
Attachment_0005_Proposal_Submission.docx DOCX document
Exhibit_14_-_Report__Matrix.xlsx XLSX spreadsheet
PWS_-_22_Nov_2017.pdf PDF
Attachment 0004 Price Matrix Cost-Price Vol III 9-30-17-dl.xlsx XLSX spreadsheet
Exhibit 14g PDHRA and MHA Monthly Activity Management Report 4_4_4_22.xlsx XLSX spreadsheet
Exhibit 14h RHRP_Event Planning and Forecast 4.4.3.4.xlsx XLSX spreadsheet
Exhibit 14b Invoice Reports 4_4_4_2.xlsx XLSX spreadsheet
Attachment 0007 Technical Scenarios.docx DOCX document
Exhibit 13 Checklist and Certification for Safeguarding Unclassified DoD.docx DOCX document
D001 Quality Assurance Plan.pdf PDF
Exhibit 14e InClinic Services By Service Date 4_4_4_18.xlsx XLSX spreadsheet
Attachment 0001 PWS List of Exhibits 09-20-17.doc DOC document
Attachment 0006 Basis of Award 9-30-17.docx DOCX document
W15QKN-18-R-1000_Draft.docx DOCX document
B002 Financial Reports.pdf PDF
Exhibit 14i Speed of Data Entry into SC Database 4_4_4_3.xlsx XLSX spreadsheet
B005 Group Events.pdf PDF
Attachment 0010 Pre Award Survey of Prospective Contractor Accounting Systems Checklist.pdf PDF
D003 Transition Plan Phase Out.pdf PDF
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INVOICE SUMMARY FY2016

RHRP LISTING OF ISSUED INVOICE FY 2016Total per issued invoicesTotal per FY2016 Service Summary
Inv. DateInvoice#BillGrpDollarsTASK ORDERCLINCompoTask OrderCLINTotal FY2016GroupCall-CenterIn-ClinicTravelShippingVariance
03/15/161164897AC ARMY TPR96.61HT0011-13-D-0001-0025CLIN 1001AC ARMY TPRHT0011-13-D-0001-0025CLIN 1001
03/15/161163974AC ARMY TPR86.27HT0011-13-D-0001-0025CLIN 1004HT0011-13-D-0001-0025CLIN 1004
10/15/151127493AC ARMY TPR67,025.34HT0011-13-D-0001-0034CLIN 1001HT0011-13-D-0001-0025TOTAL
11/01/151129841AC ARMY TPR124,485.26HT0011-13-D-0001-0034CLIN 1001HT0011-13-D-0001-0034CLIN 1001
11/15/151132446AC ARMY TPR62,556.80HT0011-13-D-0001-0034CLIN 1001HT0011-13-D-0001-0034CLIN 1002
12/01/151134413AC ARMY TPR117,838.42HT0011-13-D-0001-0034CLIN 1001HT0011-13-D-0001-0034CLIN 1004
12/15/151136928AC ARMY TPR164,143.97HT0011-13-D-0001-0034CLIN 1001HT0011-13-D-0001-0034TOTAL
01/01/161140035AC ARMY TPR84,400.39HT0011-13-D-0001-0034CLIN 1001HT0011-13-D-0001-0044CLIN 2001
01/15/161142751AC ARMY TPR66,762.34HT0011-13-D-0001-0034CLIN 1001HT0011-13-D-0001-0044CLIN 2002
02/01/161145254AC ARMY TPR101,137.84HT0011-13-D-0001-0034CLIN 1001HT0011-13-D-0001-0044CLIN 2004
02/15/161147313AC ARMY TPR68,290.54HT0011-13-D-0001-0034CLIN 1001HT0011-13-D-0001-0044TOTAL$0.00
03/01/161162737AC ARMY TPR116,471.69HT0011-13-D-0001-0034CLIN 1001ANGHT0011-13-D-0001-0023CLIN 1001
03/15/161164895AC ARMY TPR110,117.33HT0011-13-D-0001-0034CLIN 1001HT0011-13-D-0001-0023CLIN 1004
04/01/161166524AC ARMY TPR80,735.30HT0011-13-D-0001-0034CLIN 1001HT0011-13-D-0001-0023TOTAL
04/15/161169327AC ARMY TPR76,467.12HT0011-13-D-0001-0034CLIN 1001HT0011-13-D-0001-0038CLIN 2001
06/01/161176747AC ARMY TPR235.68HT0011-13-D-0001-0034CLIN 1001HT0011-13-D-0001-0038CLIN 2001
08/01/161188365AC ARMY TPR(163.88)HT0011-13-D-0001-0034CLIN 1001HT0011-13-D-0001-0038CLIN 2001
11/15/151132452AC ARMY TPR652.00HT0011-13-D-0001-0034CLIN 1002HT0011-13-D-0001-0038TOTAL
12/01/151135725AC ARMY TPR876.98HT0011-13-D-0001-0034CLIN 1002HT0011-13-D-0001-0050CLIN 3001
12/15/151136919AC ARMY TPR2,729.85HT0011-13-D-0001-0034CLIN 1002HT0011-13-D-0001-0050CLIN 3002
01/01/161140048AC ARMY TPR30.35HT0011-13-D-0001-0034CLIN 1002HT0011-13-D-0001-0050CLIN 3004
02/15/161147306AC ARMY TPR307.62HT0011-13-D-0001-0034CLIN 1002HT0011-13-D-0001-0050TOTAL$0.00
03/01/161162728AC ARMY TPR2,137.15HT0011-13-D-0001-0034CLIN 1002ARNGHT0011-13-D-0001-0008CLIN 0001
03/15/161163976AC ARMY TPR845.90HT0011-13-D-0001-0034CLIN 1002HT0011-13-D-0001-0008CLIN 0002
04/01/161166723AC ARMY TPR1,269.82HT0011-13-D-0001-0034CLIN 1002HT0011-13-D-0001-0008CLIN 0004
04/01/161166732AC ARMY TPR175.77HT0011-13-D-0001-0034CLIN 1002HT0011-13-D-0001-0008TOTAL
10/15/151127485AC ARMY TPR3,424.78HT0011-13-D-0001-0034CLIN 1004HT0011-13-D-0001-0022CLIN 1001
11/01/151129836AC ARMY TPR4,590.75HT0011-13-D-0001-0034CLIN 1004HT0011-13-D-0001-0022CLIN 1002
11/15/151132279AC ARMY TPR2,708.45HT0011-13-D-0001-0034CLIN 1004HT0011-13-D-0001-0022CLIN 1004
12/01/151134407AC ARMY TPR4,511.01HT0011-13-D-0001-0034CLIN 1004HT0011-13-D-0001-0022TOTAL
12/15/151136905AC ARMY TPR8,219.25HT0011-13-D-0001-0034CLIN 1004HT0011-13-D-0001-0027CLIN 1001
01/01/161140025AC ARMY TPR4,059.59HT0011-13-D-0001-0034CLIN 1004HT0011-13-D-0001-0027CLIN 1002
01/15/161142594AC ARMY TPR2,650.48HT0011-13-D-0001-0034CLIN 1004HT0011-13-D-0001-0027CLIN 1004
02/01/161145234AC ARMY TPR4,720.02HT0011-13-D-0001-0034CLIN 1004HT0011-13-D-0001-0027TOTAL
02/15/161147293AC ARMY TPR3,071.79HT0011-13-D-0001-0034CLIN 1004HT0011-13-D-0001-0040CLIN 2001
03/01/161162716AC ARMY TPR4,425.91HT0011-13-D-0001-0034CLIN 1004HT0011-13-D-0001-0040CLIN 2002
03/15/161163966AC ARMY TPR5,386.48HT0011-13-D-0001-0034CLIN 1004HT0011-13-D-0001-0040CLIN 2004
04/01/161166715AC ARMY TPR3,782.38HT0011-13-D-0001-0034CLIN 1004HT0011-13-D-0001-0040TOTAL
04/15/161169316AC ARMY TPR3,220.79HT0011-13-D-0001-0034CLIN 1004HT0011-13-D-0001-0045CLIN 2001
06/01/161176751AC ARMY TPR153.09HT0011-13-D-0001-0034CLIN 1004HT0011-13-D-0001-0045CLIN 2002
05/01/161171348AC ARMY TPR89,202.05HT0011-13-D-0001-0044CLIN 2001HT0011-13-D-0001-0045CLIN 2004
05/15/161174525AC ARMY TPR114,094.70HT0011-13-D-0001-0044CLIN 2001HT0011-13-D-0001-0045TOTAL$0.00
06/01/161176744AC ARMY TPR101,735.12HT0011-13-D-0001-0044CLIN 2001INSCOMHT0011-13-D-0001-0031CLIN 1001
06/15/161179817/1179843AC ARMY TPR42,295.71HT0011-13-D-0001-0044CLIN 2001HT0011-13-D-0001-0031TOTAL$0.00
07/01/161182660AC ARMY TPR103,559.90HT0011-13-D-0001-0044CLIN 2001MARFORRESHT0011-13-D-0001-0019CLIN 1001
07/15/161185528AC ARMY TPR53,953.89HT0011-13-D-0001-0044CLIN 2001HT0011-13-D-0001-0019CLIN 1004
08/01/161188372AC ARMY TPR105,334.72HT0011-13-D-0001-0044CLIN 2001HT0011-13-D-0001-0019TOTAL
08/15/161191239AC ARMY TPR85,909.73HT0011-13-D-0001-0044CLIN 2001HT0011-13-D-0001-0035CLIN 1001
09/01/161194895AC ARMY TPR103,095.21HT0011-13-D-0001-0044CLIN 2001HT0011-13-D-0001-0035CLIN 1002
09/15/161196140AC ARMY TPR58,604.37HT0011-13-D-0001-0044CLIN 2001HT0011-13-D-0001-0035CLIN 1004
10/01/161198781AC ARMY TPR97,479.27HT0011-13-D-0001-0044CLIN 2001HT0011-13-D-0001-0035TOTAL
08/01/161188391AC ARMY TPR486.90HT0011-13-D-0001-0044CLIN 2002HT0011-13-D-0001-0042CLIN 2001
08/15/161191129AC ARMY TPR2,809.05HT0011-13-D-0001-0044CLIN 2002HT0011-13-D-0001-0042CLIN 2002
09/01/161194896AC ARMY TPR7,379.80HT0011-13-D-0001-0044CLIN 2002HT0011-13-D-0001-0042CLIN 2004
09/15/161196135AC ARMY TPR844.75HT0011-13-D-0001-0044CLIN 2002HT0011-13-D-0001-0042TOTAL$0.00
05/01/161171340AC ARMY TPR3,299.13HT0011-13-D-0001-0044CLIN 2004MHAHT0011-13-D-0001-0026CLIN 1001
05/15/161174424AC ARMY TPR4,465.56HT0011-13-D-0001-0044CLIN 2004HT0011-13-D-0001-0026TOTAL
06/01/161176754AC ARMY TPR4,104.01HT0011-13-D-0001-0044CLIN 2004HT0011-13-D-0001-0033CLIN 1001
06/15/161179809AC ARMY TPR1,949.60HT0011-13-D-0001-0044CLIN 2004HT0011-13-D-0001-0033TOTAL
07/01/161182664AC ARMY TPR4,245.65HT0011-13-D-0001-0044CLIN 2004HT0011-13-D-0001-0049CLIN 2001
07/15/161185347AC ARMY TPR2,251.63HT0011-13-D-0001-0044CLIN 2004HT0011-13-D-0001-0049TOTAL$0.00
08/01/161188361AC ARMY TPR3,754.21HT0011-13-D-0001-0044CLIN 2004PDHRAHT0011-13-D-0001-0012CLIN 0001
08/15/161191229AC ARMY TPR3,433.78HT0011-13-D-0001-0044CLIN 2004HT0011-13-D-0001-0012TOTAL
09/01/161194872AC ARMY TPR4,408.38HT0011-13-D-0001-0044CLIN 2004HT0011-13-D-0001-0029CLIN 1001
09/15/161196114AC ARMY TPR2,322.02HT0011-13-D-0001-0044CLIN 2004HT0011-13-D-0001-0029CLIN 1002
10/01/161198762AC ARMY TPR4,155.73HT0011-13-D-0001-0044CLIN 2004HT0011-13-D-0001-0029CLIN 1003
07/01/161183565ANG(127.85)HT0011-13-D-0001-0023CLIN 1001HT0011-13-D-0001-0029TOTAL
01/15/161142753ANG412.30HT0011-13-D-0001-0023CLIN 1004HT0011-13-D-0001-0041CLIN 2001
02/15/161148098ANG(4.60)HT0011-13-D-0001-0023CLIN 1004HT0011-13-D-0001-0041CLIN 2002
10/15/151127488ANG7,583.67HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0041CLIN 2003
11/01/151129843ANG49,045.56HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0041TOTAL$0.00
11/15/151132445ANG21,734.61HT0011-13-D-0001-0038CLIN 2001USACEHT0011-13-D-0001-0039CLIN 1001
12/01/151134417ANG11,712.87HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0031TOTAL$0.00
12/15/151136927ANG9,220.20HT0011-13-D-0001-0038CLIN 2001USAFRHT0011-13-D-0001-0048CLIN 2001
01/01/161140040ANG37,338.25HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0048CLIN 2004
01/15/161142746ANG2,918.27HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0048TOTAL$0.00
02/01/161145256ANG68,134.60HT0011-13-D-0001-0038CLIN 2001USARHT0011-13-D-0001-0002CLIN 0001
02/15/161147312ANG16,194.71HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0002CLIN 0002
03/01/161162736ANG17,444.19HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0002CLIN 0004
03/15/161164899ANG58,852.80HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0002TOTAL
04/01/161166526ANG15,639.44HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0011CLIN 0001
04/15/161169326ANG6,442.52HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0011CLIN 0002
05/01/161171351ANG3,195.33HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0011CLIN 0004
05/15/161174523ANG13,729.09HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0011TOTAL
06/01/161176749ANG72,681.39HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0018CLIN 1001
06/15/161179813ANG923.72HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0018CLIN 1002
07/01/161182658ANG4,224.92HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0018CLIN 1004
07/15/161185526ANG7,236.77HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0018TOTAL
08/01/161188363ANG2,292.85HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0037CLIN 2001
08/15/161191241ANG2,401.88HT0011-13-D-0001-0038CLIN 2001HT0011-13-D-0001-0037CLIN 2002
10/15/151127480ANG1,087.40HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0037CLIN 2004
11/01/151129863ANG2,594.91HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0037TOTAL
11/15/151132449ANG4,365.25HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0046CLIN 2001
12/01/151135731ANG1,031.14HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0046CLIN 2002
12/01/151135724ANG2,437.35HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0046CLIN 2004
12/15/151136923ANG1,752.17HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0046TOTAL$0.00
01/15/161142754ANG3,969.62HT0011-13-D-0001-0038CLIN 2002USCGHT0011-13-D-0001-0020CLIN 1001
01/15/161142755ANG4,177.29HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0020TOTAL
02/15/161147288ANG1,223.34HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0036CLIN 1001
02/15/161147289ANG12,336.11HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0036CLIN 1002
03/01/161162731ANG8,450.74HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0036CLIN 1004
03/15/161163978ANG2,341.48HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0036TOTAL
04/01/161166724ANG3,748.47HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0043CLIN 2001
04/01/161166733ANG11,005.70HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0043CLIN 2002
04/15/161169127ANG3,673.50HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0043CLIN 2004
05/01/161172973ANG1,120.38HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0043TOTAL
05/01/161172976ANG129.60HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0053CLIN 3001
06/01/161177845ANG1,180.03HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0053TOTAL$0.00
06/15/161179818ANG6,011.47HT0011-13-D-0001-0038CLIN 2002USNRHT0011-13-D-0001-0021CLIN 1001
07/01/161182666ANG780.72HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0021CLIN 1004
07/01/161182667ANG3,430.15HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0021TOTAL
07/15/161185546ANG1,511.99HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0032CLIN 1001
08/15/161191122ANG494.99HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0032CLIN 1002
08/15/161191123ANG1,313.72HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0032CLIN 1004
09/01/161194888ANG789.56HT0011-13-D-0001-0038CLIN 2002HT0011-13-D-0001-0032TOTAL
10/15/151127481ANG1,188.11HT0011-13-D-0001-0038CLIN 2004HT0011-13-D-0001-0047CLIN 2001
11/01/151129834ANG1,185.14HT0011-13-D-0001-0038CLIN 2004HT0011-13-D-0001-0047CLIN 2002
12/01/151134405ANG4,750.07HT0011-13-D-0001-0038CLIN 2004HT0011-13-D-0001-0047CLIN 2004
12/15/151136914ANG865.48HT0011-13-D-0001-0038CLIN 2004HT0011-13-D-0001-0047TOTAL$0.00
01/01/161139912ANG5,021.80HT0011-13-D-0001-0038CLIN 2004$0.00
01/15/161142748ANG2,867.18HT0011-13-D-0001-0038CLIN 2004
02/01/161145235ANG2,894.65HT0011-13-D-0001-0038CLIN 2004
03/01/161162713ANG3,234.16HT0011-13-D-0001-0038CLIN 2004
03/15/161163965ANG7,112.62HT0011-13-D-0001-0038CLIN 2004
04/01/161166714ANG2,745.16HT0011-13-D-0001-0038CLIN 2004
05/15/161174423ANG1,156.45HT0011-13-D-0001-0038CLIN 2004
06/01/161176742ANG1,762.80HT0011-13-D-0001-0038CLIN 2004
08/01/161188386ANG1,518.72HT0011-13-D-0001-0038CLIN 2004
10/01/161198776ANG111.57HT0011-13-D-0001-0038CLIN 2004
09/01/161194891ANG33,986.81HT0011-13-D-0001-0050CLIN 3001

&"+,Bold Italic"&14SUMMARY OF RHRPII BILLED SERVICES FY2015

Page &P

FY16 AC ARMY

RHRP II - Deliverable 6 FY16 Annual Summary Report - Active Component Army TRICARE Prime Remote (AC Army) 10/01/2015 to 09/30/2016

Procedure NumberElementService
ModalityQuantityDollar

Amount

B1ARNG / USAR, PHA, in-clinic, price per completed PHAIC
C2USAR, PHA, group event, TIER 2 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 41 to 80)GE
C3USAR, PHA, group event, TIER 3 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 81 or more)GE
Subtotal Periodic Health Assessments
E1PHA Behavioral Health Specialist, call center, price per callCC
Subtotal Behavioral Health Assessment
H1MHA, call center, price per completed MHA when positive screenCC
H2MHA, call center, price per completed MHA when negative screenCC
I2MHA, group event, TIER 2 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 41 to 80)GE
I3MHA, group event, TIER 3 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 81 or more)GE
Subtotal Mental Health Assessment
J1Annual Audiometric Screen with MEDPROS UpdateIC
JJ2Audio Hearing Test - pure tone airIC
JJ3Audiometry - pure tone air and bone conduction testingIC
JJ5DOHERS entryIC
JJJ1Annual Audiometric Screen with MEDPROS Update (minimum 50 screens per day to schedule; price per completed screen)GE
JJJ3DOHERS entryGE
Subtotal Audio Services
K4Vision Screen with color and with & without correctionIC
KK1Comprehensive eye examIC
KK5Vision Screen with color and with & without correctionIC
KKK4Vision 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)GE
KKK5Vision 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)GE
Subtotal Vision Services
L1Hepatitis AIC
L2Hepatitis BIC
L3Influenza - InjectableIC
L6TdapIC
L9VaricellaIC
L10Varicella titerIC
L11Measles, Mumps, Rubella (MMR)IC
L13Pediatric dose Hep BIC
L15MMR titerIC
LL1Hepatitis AIC
LL2Hepatitis BIC
LL3Influenza - InjectableIC
LL6PolioIC
LL10TdapIC
LL14VaricellaIC
LL15Varicella titerIC
LL17Measles, Mumps, Rubella (MMR)IC
LL20MMR titerIC
LLL1Administration 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)GE
LLL2Administration 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)GE
LLL3Administration 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)GE
LLL6Hepatitis A (2 shot series)GE
LLL7Hepatitis B (3 shot series)GE
LLL8Inactivated Polio Vaccine (IPV)GE
LLL9InfluenzaGE
LLL11Measles, Mumps, Rubella (MMR)GE
LLL17TdapGE
LLL20VaricellaGE
LLL21Varicella titerGE
Subtotal Immunizations
M6CVSPIC
M10HIV testIC
M20Phlebotomy (blood draw)IC
MM4CVSPIC
MM8HIV testIC
MM9Phlebotomy (blood draw)IC
MMM3CVSPGE
MMM7HIV testing, group event, TIER 1 (minimum 50 tests to schedule; price per completed test when total tests completed at group event equal 40 or less)GE
MMM8HIV testing, group event, TIER 2 (minimum 50 tests to schedule; price per completed test when total tests completed at group event equal 41 to 80)GE
MMM11Phlebotomy (CVSP, DNA, G6PD,HIV, Rabies Titer, Varicella Titer) (minimum 30 draws per day to schedule; price per completed draw)GE
Subtotal Laboratory service
N3EKG, restingIC
NN4EKG, restingIC
NNN2EKG, resting (minimum 20 EKGs per day to schedule; price per completed EKG)GE
Subtotal Misc Medical Service
Q7Historical Update - MedicalIC
Subtotal Record Review-Maintenance
S1Cancellation fee, in-clinic service (price per visit)IC
S2Cancellation fee, group event, assessment service including MHA, PDHRA, PHA, PHA lite (price per individual service)GE
S4Cancellation fee, group event, audio or vision service (price per individual service)GE
S5Cancellation fee, group event, immunization, laboratory, or miscellaneous medical service (price per individual service)GE
Subtotal Administrative Fees-Cancel
T1No show fee, in-clinic service (price per visit)IC
T2No show fee, group event, assessment service including MHA, PDHRA, PHA, PHA lite (price per individual service)GE
T4No show fee, group event, audio or vision service (price per individual service)GE
T5No show fee, group event, immunization, laboratory, or miscellaneous medical service (price per individual service)GE
Subtotal Administrative Fees-No Show
Total Procedures CLIN
Subtotal Procedures CLIN, Call Center
Subtotal Procedures CLIN, In-Clinic
Subtotal Procedures CLIN, Group Event
Total Travel CLIN
Total Shipping GFE CLIN
Total Shipping Other CLIN
Total Transition CLIN
TOTAL AMOUNT

FY16 ANG

RHRP II - Deliverable 6 FY16 Annual Summary Report - Air National Guard (ANG) 10/01/2015 to 09/30/2016

Procedure NumberElementService
ModalityQuantityDollar

Amount

C6MARFORRES / USCG / USNR, PHA, group event, TIER 3 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 81 or more)GE
Subtotal Periodic Health Assessments
JJJ1Annual Audiometric Screen with MEDPROS Update (minimum 50 screens per day to schedule; price per completed screen)GE
JJJ3DOHERS entryGE
Subtotal Audio Services
KKK5Vision 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)GE
Subtotal Vision Services
M20Phlebotomy (blood draw)IC
Subtotal Laboratory service
O2Annual Dental Exam (Comprehensive Oral Examination)IC
O4Dental bitewing, set of two filmsIC
O6Dental bitewing, set of four films as indicatedIC
O10Intraoral periapical x-rayIC
O11Panographic x-rayIC
OO2Dental 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)GE
OO3Dental 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)GE
OO4Dental 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)GE
OO5Dental 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)GE
OO6Dental 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)GE
OO7Panographic radiograph, group event, TIER 1 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 40 or less)GE
OO8Panographic radiograph, group event, TIER 2 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 41 to 80)GE
OO9Panographic radiograph, group event, TIER 3 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 81 or more)GE
Subtotal Dental Service
R2Scheduling without QA (price per SM)CC
S1Cancellation fee, in-clinic service (price per visit)IC
Subtotal Administrative Fees-Cancel
T1No show fee, in-clinic service (price per visit)IC
T2No show fee, group event, assessment service including MHA, PDHRA, PHA, PHA lite (price per individual service)GE
T3No show fee, group event, dental service (price per individual service)GE
T4No show fee, group event, audio or vision service (price per individual service)GE
T5No show fee, group event, immunization, laboratory, or miscellaneous medical service (price per individual service)GE
Subtotal Administrative Fees-No Show
Total Procedures CLIN
Subtotal Procedures CLIN, Call Center
Subtotal Procedures CLIN, In-Clinic
Subtotal Procedures CLIN, Group Event
Total Travel CLIN
Total Shipping GFE CLIN
Total Shipping Other CLIN
Total Transition CLIN
TOTAL AMOUNT

FY16 ARNG

RHRP II - Deliverable 6 FY16 Annual Summary Report - Army Reserve National Guard (ARNG) 10/01/2015 to 09/30/2016

Procedure NumberElementService
ModalityQuantityDollar

Amount

A1Retention exam, younger than 39, maleIC
A2Retention exam, younger than 39, femaleIC
A3Retention exam, 39 and older, maleIC
A5Airborne examIC
A6Accession exam, maleIC
A13Firefighter / CBRN exam, younger than 39, maleIC
A14Firefighter / CBRN exam, younger than 39, femaleIC
A15Firefighter / CBRN exam, 39 and older, maleIC
Subtotal Physical Exams
B1ARNG / USAR, PHA, in-clinic, price per completed PHAIC
C2USAR, PHA, group event, TIER 2 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 41 to 80)GE
C3USAR, PHA, group event, TIER 3 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 81 or more)GE
D1PHA lite, group event, TIER 1 (minimum 30 PHA lites to schedule; price per PHA lite when total PHA lites completed at group event equal 40 or less)GE
D2PHA lite, group event, TIER 2 (minimum 30 PHA lites to schedule; price per PHA lite when total PHA lites completed at group event equal 41 to 80)GE
D3PHA lite, group event, TIER 3 (minimum 30 PHA lites to schedule; price per PHA lite when total PHA lites completed at group event equal 81 or more)GE
Subtotal Periodic Health Assessments
H1MHA, call center, price per completed MHA when positive screenCC
H2MHA, call center, price per completed MHA when negative screenCC
I1MHA, group event, TIER 1 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 40 or less)GE
I2MHA, group event, TIER 2 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 41 to 80)GE
I3MHA, group event, TIER 3 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 81 or more)GE
Subtotal Mental Health Assessment
J1Annual Audiometric Screen with MEDPROS UpdateIC
J3SPRINT (Speech Recognition in Noise Test)IC
JJ1Acoustic reflex testing thresholdIC
JJ2Audio Hearing Test - pure tone airIC
JJ3Audiometry - pure tone air and bone conduction testingIC
JJ5DOHERS entryIC
JJ7Speech audiometry threshold; w/ speech recognitionIC
JJ8SprintIC
JJ9TympanometryIC
JJJ1Annual Audiometric Screen with MEDPROS Update (minimum 50 screens per day to schedule; price per completed screen)GE
JJJ2Comprehensive audio exam / pure tone air and bone conduction testing (minimum 25 tests per day to schedule; price per completed test)GE
JJJ3DOHERS entryGE
Subtotal Audio Services
K3TonometryIC
K4Vision Screen with color and with & without correctionIC
KK2Eye examination with refraction and prescriptionIC
KK5Vision Screen with color and with & without correctionIC
KKK2Eye exam with refraction and prescription, group event (minimum 50 exams per day to schedule; price per completed exam)GE
KKK3Vision 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)GE
KKK4Vision 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)GE
KKK5Vision 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)GE
Subtotal Vision Services
L1Hepatitis AIC
L3Influenza - InjectableIC
L10Varicella titerIC
L11Measles, Mumps, Rubella (MMR)IC
LL1Hepatitis AIC
LL2Hepatitis BIC
LL3Influenza - InjectableIC
LL6PolioIC
LL9PPDIC
LL10TdapIC
LL13TwinrixIC
LL14VaricellaIC
LL15Varicella titerIC
LL17Measles, Mumps, Rubella (MMR)IC
LL19Pediatric dose Hep BIC
LL20MMR titerIC
LLL1Administration 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)GE
LLL2Administration 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)GE
LLL3Administration 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)GE
LLL4Anthrax (6 shot series) (Government will provide vaccine)GE
LLL6Hepatitis A (2 shot series)GE
LLL7Hepatitis B (3 shot series)GE
LLL8Inactivated Polio Vaccine (IPV)GE
LLL11Measles, Mumps, Rubella (MMR)GE
LLL12MenactraGE
LLL13PPDGE
LLL14Rabies (3 shot series)GE
LLL17TdapGE
LLL19Typhoid (injectable or oral)GE
LLL20VaricellaGE
LLL21Varicella titerGE
LLL22Yellow feverGE
Subtotal Immunizations
M6CVSPIC
M9G6PDIC
M10HIV testIC
M11Pregnancy, urineIC
M14Rectal exam with stool for guaiacIC
M19Thin prep w/ preventive exam (pelvic) to collect specimenIC
M20Phlebotomy (blood draw)IC
MM4CVSPIC
MM7G6PDIC
MM8HIV testIC
MM9Phlebotomy (blood draw)IC
MM11PSAIC
MM13Rectal exam w/ stool for guaiacIC
MM18Thin prep w/ preventive exam (pelvic) to collect specimenIC
MMM1Blood type and determination of Rh factor w/ venipunctureGE
MMM3CVSPGE
MMM4CVSP (Cholestech) (minimum 25 screens per day to schedule; price per completed screen)GE
MMM6G6PD TestingGE
MMM7HIV testing, group event, TIER 1 (minimum 50 tests to schedule; price per completed test when total tests completed at group event equal 40 or less)GE
MMM8HIV testing, group event, TIER 2 (minimum 50 tests to schedule; price per completed test when total tests completed at group event equal 41 to 80)GE
MMM9HIV testing, group event, TIER 3 (minimum 50 tests to schedule; price per completed test when total tests completed at group event equal 81 or more)GE
MMM11Phlebotomy (CVSP, DNA, G6PD,HIV, Rabies Titer, Varicella Titer) (minimum 30 draws per day to schedule; price per completed draw)GE
MMM12Pregnancy Test (minimum 30 tests per day to schedule; price per completed test)GE
MMM15Status hCG Strip (Kit Only)GE
Subtotal Laboratory service
N3EKG, restingIC
NN3Chest x-ray, posterior-anterior viewIC
NN4EKG, restingIC
NNN2EKG, resting (minimum 20 EKGs per day to schedule; price per completed EKG)GE
Subtotal Misc Medical Service
O1Annual Dental Exam (Periodic Oral Examination)IC
O2Annual Dental Exam (Comprehensive Oral Examination)IC
O3Dental bitewing, single filmIC
O4Dental bitewing, set of two filmsIC
O5Dental bitewing, set of three filmsIC
O6Dental bitewing, set of four films as indicatedIC
O10Intraoral periapical x-rayIC
O11Panographic x-rayIC
OO1Dental 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)GE
OO2Dental 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)GE
OO3Dental 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)GE
OO4Dental 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)GE
OO5Dental 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)GE
OO6Dental 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)GE
OO7Panographic radiograph, group event, TIER 1 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 40 or less)GE
OO8Panographic radiograph, group event, TIER 2 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 41 to 80)GE
OO9Panographic radiograph, group event, TIER 3 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 81 or more)GE
Subtotal Dental Service
P1Consultation Dental ExamIC
P4Detailed and extensive oral evaluationIC
P6Amalgam, One Surface, PermanentIC
P7Amalgam, Two Surfaces, PermanentIC
P8Amalgam, Three Surfaces, PermanentIC
P9Amalgam, Four or More Surfaces, PermanentIC
P10Apicoectomy - AnteriorIC
P11Apicoectomy - BicuspidIC
P13Apicoectomy - Molar - each add'l rootIC
P14Resin Based Composite, one surfaceIC
P15Resin Based Composite, two surfacesIC
P16Resin Based Composite, three surfacesIC
P17Resin Based Composite, four surfaceIC
P18Resin (1) one surface posteriorIC
P19Resin (2) two surface posteriorIC
P20Resin (3) three surface posteriorIC
P21Resin (4) four or more posteriorIC
P22Anterior (excluding final restoration)IC
P23Bicuspid (excluding final restoration)IC
P24Molar (excluding final restoration)IC
P25Core build up including pinsIC
P26Prefab post & coreIC
P27Extraction, single toothIC
P29Extraction deciduous toothIC
P31Surgical removal of erupted toothIC
P32Removal of impacted tooth-completely bonyIC
P33Removal of impacted tooth soft tissueIC
P34Removal of impacted tooth partial bonyIC
P35Analgesic NitrousIC
P36IV anesthesia first 30 minutesIC
P37IV anesthesia each additional 15 minutesIC
P40Deep Sedation / general anesthesia first 30 minutesIC
P41Deep Sedation / general anesthesia each additional 15 minutesIC
P42Non-intravenous conscious sedationIC
P43Therapeutic drug injection - includes antibiotic/injection of sedativeIC
P44Palliative treatment of dental painIC
P46Periodontal scaling and root planingIC
P47Perio scaling and root planing per quadrantIC
P48Full mouth debridementIC
P51Sedative fillingIC
P52Pin retention in addition to fillingIC
P53Retrograde fillingIC
P57Pulpal debridementIC
P58Pulp vitality testsIC
P59Incomplete endo therapyIC
P60Retreatment of molar endoIC
P61Immediate denture maxillaryIC
P62Immediate denture mandibularIC
P63Partial denture maxillary (resin base)IC
P64Partial denture mandibular (resin base)IC
P66Add tooth to existing partial dentureIC
P68Add clasp to existing partial dentureIC
P70Reline complete maxillary denture (laboratory)IC
P72Reline complete maxillary denture (chair side)IC
P73Reline complete mandibular denture (chair side)IC
P75Interim partial denture (maxillary)IC
P76Interim partial denture (mandibular)IC
P77Recement fixed partial dentureIC
P83Reline complete mandibular denture (laboratory)IC
P85Complete denture maxillaryIC
P86Complete denture mandibularIC
P94Fixed partial denture sectioningIC
P96Surgical removal of residual root tipsIC
P97Primary closure of sinus perforationIC
P98Biopsy of oral tissue (soft)IC
P99Biopsy of oral tissue - hardIC
P100Alveoloplasty in conjunction with extractionsIC
P101Alveoloplasty in conjunction with extractions per quadIC
P102Alveoloplasty not in conjunction with extractionsIC
P108Excision of benign lesion - lesion diameter less than 1.25 cmIC
P112Excision of benign lesion greater than 1.25 cmIC
P114Removal of odontogenic cyst / tumor - lesion diameter up to 1.25cmIC
P117Removal of benign odontogenic cyst or tumor-diameter more than 1.25 cmIC
P118Removal of lateral exostosis (maxilla or mandible)IC
P129Recement crownIC
P130Stainless steel crownIC
P132Post removalIC
P135Prefabricated resin crownIC
P136Prefabricated stainless steel crown, primary toothIC
P138Retreatment of previous RCT - anteriorIC
P139Retreatment of previous RCT - bicuspidIC
P143Internal root repair of perforation defectsIC
P146Treatment of complications (post surgical)IC
P147Treatment of root canal obstruction - non surgicalIC
P152Incision and drainage of abscess-soft tissueIC
P154Removal of reaction producing foreign bodies, musculoskeletalIC
P155Removal of loose or sloughed-off dead bone caused by infection or reduced blood supplyIC
PP1Mobile vehicle, dental treatment (limited to dental treatment services listed in Attachment 1; price per vehicle per day)GE
PP2Mobile vehicle, dental bitewings, set of 4 films as indicated (price per set)GE
PP3Prescription Authorization for Dental Restorative ServicesGE
PP4Mobile Dental Treatment team (minimum amount to be billed for treatment services; services beyond minimum amount to be billed per individual service; services limited to dental treatment services listed in Attachment 1; price per team per day)GE
PP5Portable Dental Treatment team (minimum amount to be billed for treatment services; services beyond minimum amount to be billed per individual service; services limited to dental treatment services listed in Attachment 1; price per team per day)GE
Subtotal Dental Treatment Services
Q7Historical Update - MedicalIC
Subtotal Record Review-Maintenance
S1Cancellation fee, in-clinic service (price per visit)IC
S2Cancellation fee, group event, assessment service including MHA, PDHRA, PHA, PHA lite (price per individual service)GE
S3Cancellation fee, group event, dental service (price per individual service)GE
S4Cancellation fee, group event, audio or vision service (price per individual service)GE
S5Cancellation fee, group event, immunization, laboratory, or miscellaneous medical service (price per individual service)GE
Subtotal Administrative Fees-Cancel
T1No show fee, in-clinic service (price per visit)IC
T2No show fee, group event, assessment service including MHA, PDHRA, PHA, PHA lite (price per individual service)GE
T3No show fee, group event, dental service (price per individual service)GE
T4No show fee, group event, audio or vision service (price per individual service)GE
T5No show fee, group event, immunization, laboratory, or miscellaneous medical service (price per individual service)GE
T6No show fee, group event, mobile dental treatment (price per team, per day)GE
Subtotal Administrative Fees-No Show
Total Procedures CLIN
Subtotal Procedures CLIN, Call Center
Subtotal Procedures CLIN, In-Clinic
Subtotal Procedures CLIN, Group Event
Total Travel CLIN
Total Shipping GFE CLIN
Total Shipping Other CLIN
Total Transition CLIN
TOTAL AMOUNT

FY16 INSCOM

RHRP II - Deliverable 6 FY16 Annual Summary Report - US Army Intelligence and Security Command (INSCOM) 10/01/2015 to 09/30/2016

Procedure NumberElementService
ModalityQuantityDollar

Amount

F1PDHRA, call center, price per completed DD Form 2900CC
Subtotal PDHRA
Total Procedures CLIN
Subtotal Procedures CLIN, Call Center
Subtotal Procedures CLIN, In-Clinic
Subtotal Procedures CLIN, Group Event
Total Travel CLIN
Total Shipping GFE CLIN
Total Shipping Other CLIN
Total Transition CLIN
TOTAL AMOUNT

FY16 MFR

RHRP II - Deliverable 6 FY16 Annual Summary Report - Marine Forces Reserve (MARFORRES) 10/01/2015 to 09/30/2016

Procedure NumberElementService
ModalityQuantityDollar

Amount

B2MARFORRES / USCG / USNR, PHA, in-clinic, price per completed PHAIC
C4MARFORRES / USCG / USNR, PHA, group event, TIER 1 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 40 or less)GE
C5MARFORRES / USCG / USNR, PHA, group event, TIER 2 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 41 to 80)GE
C6MARFORRES / USCG / USNR, PHA, group event, TIER 3 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 81 or more)GE
Subtotal Periodic Health Assessments
G4MARFORRES Pre-DHA Group Event (minimum 30 PHAs to schedule; price per Pre-DHA )GE
Subtotal PDHRA
H1MHA, call center, price per completed MHA when positive screenCC
H2MHA, call center, price per completed MHA when negative screenCC
I1MHA, group event, TIER 1 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 40 or less)GE
I2MHA, group event, TIER 2 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 41 to 80)GE
I3MHA, group event, TIER 3 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 81 or more)GE
Subtotal Mental Health Assessment
J1Annual Audiometric Screen with MEDPROS UpdateIC
JJ2Audio Hearing Test - pure tone airIC
JJ5DOHERS entryIC
JJJ1Annual Audiometric Screen with MEDPROS Update (minimum 50 screens per day to schedule; price per completed screen)GE
JJJ3DOHERS entryGE
Subtotal Audio Services
KK1Comprehensive eye examIC
Subtotal Vision Services
L1Hepatitis AIC
L2Hepatitis BIC
L3Influenza - InjectableIC
L5PPDIC
L8TwinrixIC
LL1Hepatitis AIC
LL2Hepatitis BIC
LL13TwinrixIC
LLL1Administration 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)GE
LLL2Administration 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)GE
LLL3Administration 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)GE
LLL6Hepatitis A (2 shot series)GE
LLL7Hepatitis B (3 shot series)GE
LLL9InfluenzaGE
LLL12MenactraGE
LLL17TdapGE
LLL22Yellow feverGE
Subtotal Immunizations
M19Thin prep w/ preventive exam (pelvic) to collect specimenIC
M20Phlebotomy (blood draw)IC
MM4CVSPIC
MM7G6PDIC
MM9Phlebotomy (blood draw)IC
MM14Sickle cell screening test w/ confirmation by reflex to hemoglobulinopathyIC
Subtotal Laboratory service
O2Annual Dental Exam (Comprehensive Oral Examination)IC
O4Dental bitewing, set of two filmsIC
O6Dental bitewing, set of four films as indicatedIC
O10Intraoral periapical x-rayIC
O11Panographic x-rayIC
OO1Dental 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)GE
OO2Dental 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)GE
OO3Dental 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)GE
OO4Dental 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)GE
OO5Dental 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)GE
OO6Dental 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)GE
OO7Panographic radiograph, group event, TIER 1 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 40 or less)GE
OO8Panographic radiograph, group event, TIER 2 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 41 to 80)GE
OO9Panographic radiograph, group event, TIER 3 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 81 or more)GE
Subtotal Dental Service
R2Scheduling without QA (price per SM)IC
Subtotal Miscellaneous Fees
S1Cancellation fee, in-clinic service (price per visit)IC
S2Cancellation fee, group event, assessment service including MHA, PDHRA, PHA, PHA lite (price per individual service)GE
Subtotal Administrative Fees-Cancel
T1No show fee, in-clinic service (price per visit)IC
T2No show fee, group event, assessment service including MHA, PDHRA, PHA, PHA lite (price per individual service)GE
T3No show fee, group event, dental service (price per individual service)GE
T4No show fee, group event, audio or vision service (price per individual service)GE
T5No show fee, group event, immunization, laboratory, or miscellaneous medical service (price per individual service)GE
Subtotal Administrative Fees-No Show
Total Procedures CLIN
Subtotal Procedures CLIN, Call Center
Subtotal Procedures CLIN, In-Clinic
Subtotal Procedures CLIN, Group Event
Total Travel CLIN
Total Shipping GFE CLIN
Total Shipping Other CLIN
Total Transition CLIN
TOTAL AMOUNT

FY16 MHA

RHRP II - Deliverable 6 FY16 Annual Summary Report - Mental Health Assessments for Air Force Reserve Command and Air National Guard MHA (AFRC, ANG) 10/01/2015 to 09/30/2016

Procedure NumberElementService
ModalityQuantityDollar

Amount

H1MHA, call center, price per completed MHA when positive screenCC
H2MHA, call center, price per completed MHA when negative screenCC
Subtotal Mental Health Assessment
R2Scheduling without QA (price per SM)CC
Subtotal Miscellaneous Fees
Total Procedures CLIN
Subtotal Procedures CLIN, Call Center
Subtotal Procedures CLIN, In-Clinic
Subtotal Procedures CLIN, Group Event
Total Travel CLIN
Total Shipping GFE CLIN
Total Shipping Other CLIN
Total Transition CLIN
TOTAL AMOUNT

FY16 PDHRA

RHRP II - Deliverable 6 FY16 Annual Summary Report - Post-Deployment Health Reassessments for Reserve Components

(PDHRA RC)

10/01/2015 to 09/30/2016

Procedure NumberElementService
ModalityQuantityDollar

Amount

F1PDHRA, call center, price per completed DD Form 2900CC
G1PDHRA, group event, TIER 1 (minimum 30 PDHRAs to schedule; price per PDHRA when total PDHRAs completed at group event equal 40 or less)GE
G2PDHRA, group event, TIER 2 (minimum 30 PDHRAs to schedule; price per PDHRA when total PDHRAs completed at group event equal 41 to 80)GE
G3PDHRA, group event, TIER 3 (minimum 30 PDHRAs to schedule; price per PDHRA when total PDHRAs completed at group event equal 81 or more)GE
Subtotal PDHRA
R2Scheduling without QA (price per SM)CC
Subtotal Miscellaneous Fees
S2Cancellation fee, group event, assessment service including MHA, PDHRA, PHA, PHA lite (price per individual service)GE
Subtotal Administrative Fees-Cancel
T2No show fee, group event, assessment service including MHA, PDHRA, PHA, PHA lite (price per individual service)GE
Subtotal Administrative Fees-No Show
Total Procedures CLIN
Subtotal Procedures CLIN, Call Center
Subtotal Procedures CLIN, In-Clinic
Subtotal Procedures CLIN, Group Event
Total Travel CLIN
Total Shipping GFE CLIN
Total Shipping Other CLIN
Total Transition CLIN
TOTAL AMOUNT

FY16 USACE

RHRP II - Deliverable 6 FY16 Annual Summary Report - US Army Corps of Engineers (USACE) 10/01/2015 to 09/30/2016

Procedure NumberElementService
ModalityQuantityDollar

Amount

F1PDHRA, call center, price per completed DD Form 2900CC
Subtotal PDHRA
Total Procedures CLIN
Subtotal Procedures CLIN, Call Center
Subtotal Procedures CLIN, In-Clinic
Subtotal Procedures CLIN, Group Event
Total Travel CLIN
Total Shipping GFE CLIN
Total Shipping Other CLIN
Total Transition CLIN
TOTAL AMOUNT

FY16 USAFR

RHRP II - Deliverable 6 FY16 Annual Summary Report - US Air Force Reserve Command (AFRC) 10/01/2015 to 09/30/2016

Procedure NumberElementService
ModalityQuantityDollar

Amount

A12Air Force retention examIC
Subtotal Physical Exams
O2Annual Dental Exam (Comprehensive Oral Examination)IC
O6Dental bitewing, set of four films as indicatedIC
O10Intraoral periapical x-rayIC
O11Panographic x-rayIC
OO3Dental 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)GE
OO6Dental 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)GE
OO8Panographic radiograph, group event, TIER 2 (minimum 20 radiographs to schedule; price per radiograph when total radiographs completed at group event equal 41 to 80)GE
Subtotal Dental Service
S1Cancellation fee, in-clinic service (price per visit)IC
Subtotal Administrative Fees-Cancel
T1No show fee, in-clinic service (price per visit)IC
T3No show fee, group event, dental service (price per individual service)GE
Subtotal Administrative Fees-No Show
Total Procedures CLIN
Subtotal Procedures CLIN, Call Center
Subtotal Procedures CLIN, In-Clinic
Subtotal Procedures CLIN, Group Event
Total Travel CLIN
Total Shipping GFE CLIN
Total Shipping Other CLIN
Total Transition CLIN
TOTAL AMOUNT

USAFR GROUP EVENT ANALYSIS

RHRP II - Deliverable 6 FY16 Annual Summary Report - US Air Force Reserve

10/01/2015 TO 09/30/2016
GROUP EVENT ANALYSIS

Administrator: Administrator:

Late receipt of funding resulted in group being billed in FY2015

GE IdEvent DateDescription/LocationQTYEXT PRICE
59190Dental Exam
59190Dental X-Ray 4 Bite
59190Dental X-Ray Panorex
59190Dental No-Show Fee
TOTAL09/11/16DOBBIN AFB
FY 2016 GE TOTAL

&F Page 2

FY16 USAR

RHRP II - Deliverable 6 FY16 Annual Summary Report - US Army Reserve (USAR) 10/01/2015 to 09/30/2016

Procedure NumberElementService
ModalityQuantityDollar

Amount

A1Retention exam, younger than 39, maleIC
A2Retention exam, younger than 39, femaleIC
A3Retention exam, 39 and older, maleIC
A4Retention exam, 39 and older, femaleIC
A5Airborne examIC
A6Accession exam, maleIC
A7Accession exam, femaleIC
A8Physical exam, Chapter 3, AGR, younger than 39, maleIC
A9Physical exam, Chapter 3, AGR, younger than 39, femaleIC
A10Physical exam, Chapter 3, AGR, 39 and older, maleIC
A11Physical exam, Chapter 3, AGR, 39 and older, femaleIC
A13Firefighter / CBRN exam, younger than 39, maleIC
A14Firefighter / CBRN exam, younger than 39, femaleIC
A16Firefighter / CBRN exam, 39 and older, femaleIC
Subtotal Physical Exams
B1ARNG / USAR, PHA, in-clinic, price per completed PHAIC
C1USAR, PHA, group event, TIER 1 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 40 or less)GE
C2USAR, PHA, group event, TIER 2 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 41 to 80)GE
C3USAR, PHA, group event, TIER 3 (minimum 30 PHAs to schedule; price per PHA when total PHAs completed at group event equal 81 or more)GE
D1PHA lite, group event, TIER 1 (minimum 30 PHA lites to schedule; price per PHA lite when total PHA lites completed at group event equal 40 or less)GE
Subtotal Periodic Health Assessments
E1PHA Behavioral Health Specialist, call center, price per callCC
E2PHA Behavioral Health Specialist, group event (minimum 60 scheduled PHAs; price for up to 60 PHAs)GE
Subtotal Behavioral Health Assessment
H1MHA, call center, price per completed MHA when positive screenCC
H2MHA, call center, price per completed MHA when negative screenCC
I1MHA, group event, TIER 1 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 40 or less)GE
I2MHA, group event, TIER 2 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 41 to 80)GE
I3MHA, group event, TIER 3 (minimum 30 MHAs to schedule; price per MHA when total MHAs completed at group event equal 81 or more)GE
Subtotal Mental Health Assessment
J1Annual Audiometric Screen with MEDPROS UpdateIC
J3SPRINT (Speech Recognition in Noise Test)IC
JJ1Acoustic reflex testing thresholdIC
JJ2Audio Hearing Test - pure tone airIC
JJ3Audiometry - pure tone air and bone conduction testingIC
JJ5DOHERS entryIC
JJ7Speech audiometry threshold; w/ speech recognitionIC
JJ8SprintIC
JJ9TympanometryIC
JJJ1Annual Audiometric Screen with MEDPROS Update (minimum 50 screens per day to schedule; price per completed screen)GE
JJJ2Comprehensive audio exam / pure tone air and bone conduction testing (minimum 25 tests per day to schedule; price per completed test)GE
JJJ3DOHERS entryGE
Subtotal Audio Services
K3TonometryIC
K4Vision Screen with color and with & without correctionIC
KK1Comprehensive eye examIC
KK3TonometryIC

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