COST PROPOSAL

ATTACHMENT B

RFP #5864 Z1

BIDDER NAME: ______

DESCRIPTION / Initial Contract Period Year One / Initial Contract Period Year Two / Initial Contract Period Year Three / Initial Contract Period Year Four / Initial Contract Period Year Five / Initial Contract Period Year Six
Set-up fee Matrix Design, and Benefit System load
Monthly Administrative Fee
Total
COST
Procedural Code / Description / QTY / Initial Contract Period Year One / Initial Contract Period Year Two / Initial Contract Period Year Three / Initial Contract Period Year Four / Initial Contract Period Year Five / Initial Contract Period Year Six
99213 / Established Patient Office or Other Outpatient Services / 118
36415 / Venous Procedures / 71
99214 / Established Patient Office or Other Outpatient Services / 62
81001 / Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents / 61
99283 / New or Established Patient Emergency Department Services / 59
99284 / New or Established Patient Emergency Department Services / 56
71010 / Code Deleted Was **Radiologic examination, chest; single view, frontal**Use 71045 Instead / 54
85025 / Blood Count / 53
97140 / Physical Medicine and Rehabilitation Therapeutic Procedures / 50
99202 / New Patient Office or Other Outpatient Services / 46
99203 / New Patient Office or Other Outpatient Services / 45
99232 / Subsequent Hospital Care / 45
97110 / Therapeutic procedure, 1 or more areas, each 15 minutes / 43
87086 / Culture, bacterial / 39
99285 / New or Established Patient Emergency Department Services / 38
99212 / Established Patient Office or Other Outpatient Services / 36
70450 / Computed tomography, head or brain / 35
80048 / Organ or Disease Oriented Panels / 32
80053 / Organ or Disease Oriented Panels / 27
88305 / Surgical pathology, gross and microscopic examination / 27
99053 / Miscellaneous Medicine Services / 27
Percent Discount off all other Procedure Codes / % / % / % / % / % / %

OPTIONAL RENEWALS

DESCRIPTION / First Optional Renewal Period Year One / First Optional Renewal Period Year Two
Monthly Administrative Fee
Total
COST
Procedural Code / Description / QTY / First Optional Renewal Period Year One / First Optional Renewal Period Year Two
99213 / Established Patient Office or Other Outpatient Services / 118
36415 / Venous Procedures / 71
99214 / Established Patient Office or Other Outpatient Services / 62
81001 / Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents / 61
99283 / New or Established Patient Emergency Department Services / 59
99284 / New or Established Patient Emergency Department Services / 56
71010 / Code Deleted Was **Radiologic examination, chest; single view, frontal**Use 71045 Instead / 54
85025 / Blood Count / 53
97140 / Physical Medicine and Rehabilitation Therapeutic Procedures / 50
99202 / New Patient Office or Other Outpatient Services / 46
99203 / New Patient Office or Other Outpatient Services / 45
99232 / Subsequent Hospital Care / 45
97110 / Therapeutic procedure, 1 or more areas, each 15 minutes / 43
87086 / Culture, bacterial / 39
99285 / New or Established Patient Emergency Department Services / 38
99212 / Established Patient Office or Other Outpatient Services / 36
70450 / Computed tomography, head or brain / 35
80048 / Organ or Disease Oriented Panels / 32
80053 / Organ or Disease Oriented Panels / 27
88305 / Surgical pathology, gross and microscopic examination / 27
99053 / Miscellaneous Medicine Services / 27
Percent Discount off all other Procedure Codes / % / %