A	B	C	D
1	Attachment A – Pricing Table
2	Proposers shall complete the table below. All rates must be all-inclusive, covering labor, materials,
3	equipment, travel, licenses, pharmaceuticals, administrative or collection fees, subcontracted
4	laboratory/radiology costs, and any other associated expenses.
5	If a service is not offered, indicate “N/A.”
7	Service	Unit of Measure	Proposed Rate ($)	Notes / Comments / Includes
8	I. Pre-Employment and Job-Related Physical Exams
9	Pre-Employment / Non-DOT Physical	Per exam
10	DOT Physical (FMCSA Compliant)	Per exam
11	Return-to-Duty / HAZWOPER Physical	Per exam
12	Fit-for-Duty Physical / Re-Evaluation
13	Police POST Physical
14	Fire NFPA 1582 Physical
16	II. Drug and Alcohol Testing Services
17	5-Panel Urine Drug Test (Non-DOT)	Per test
18	10-Panel Urine Drug Test (Non-DOT)	Per test
19	12-Panel Urine Drug Test (Non-DOT)	Per test
20	DOT Urine Drug Test	Per test
21	Oral Fluid Drug Test (Non-Federal)	Per test
22	Hair Follicle Drug Test	Per test
23	Breath Alcohol Test (DOT and Non-DOT)	Per test
24	Confirmation / GC-MS Testing	Per test
25	Random Selection Administration	Per draw / selection
26	Recollection / Retest Fee	Per test
27	After-Hours or Emergency Testing	Per test
28	No-Show / Late Cancellation Fee	Per incident
29	Other Drug/Alcohol Testing Fees (list individually)	Specify
33	III. Labortory Tests
34	CBC (Complete Blood Count)	Per test
35	CMP (Comprehensive Metabolic Panel)	Per test
36	Hemoglobin A1c	Per test
37	Lipid Panel	Per test
38	Quantiferon Gold (TB Blood Test)	Per test
39	Titers – Hep B, MMR, Varicella	Per test
40	Urinalysis	Per test
41	Blood Draw Fee	Per draw
42	Other Laboratory Fees (list individually)	Specify
46	IV. Immunizations and Vaccines
47	MMR (Measles, Mumps, Rubella)	Per injection
48	Varicella	Per injection
49	Hepatitis A	Per injection
50	Hepatitis B	Per injection
51	Twinrix (Hep A/B Combination)	Per injection
52	Tdap / Td (Tetanus, Diphtheria, Pertussis)	Per injection
53	Influenza	Per injection
54	Administration Fee (per injection visit)	Per visit
55	Other Immunization Fees (list individually)	Specify
59	V. Screenings and Functional Evaluations
60	TB Test (1-step / 2-step)	Per test
61	Audiogram (Pure Tone)	Per test

62	ECG (12-lead)	Per test
63	Chest X-ray (1 or 2 view)	Per test
64	Pulmonary Function Test (PFT)	Per test
65	Vision Exam (Snellen, Titmus, Ishihara)	Per test
66	N95 Respirator Clearance + Fit Test	Per test
67	Ergonomic Evaluation	Per hour / evaluation
68	Lifting Evaluation
69	- 20-50 pound loads
70	- 75-pound loads
71	- 100-pound loads
72	Functional Capacity Evaluation (FCE) - Comprehensive assessment for return-to-duty or fit-for-duty determination. Conducted by licensed PT/OT, includes detailed report.
73	Other Functional Fees (list individually)	Specify
77	VI. Administrative and Optional Services
78	Consortium Enrollment Fee	Per participant
79	Consortium Annual Fee	Per participant
80	MRO Administrative Fee (if billed separately)	Per test reviewed
81	Record Copy / Administrative Report	Per request
82	Wellness Screenings	Per event / person
83	Immunization Clinic	Per shot
84	Other Optional Services (list individually)	Specify
88	Certification: I hereby certify that the prices quoted above are complete and inclusive of all costs necessary to perform
89	the required services as specified in the RFP.
90	Authorized Representative Name: ____________________________
91	Title: ____________________________
92	Signature: ____________________________			Date: ____________________