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Exhibit 4 Edward Hines, Jr. VA Hospital – Station 578 5000 South 5th Avenue Hines, IL 60141 Base Year – February 1, 2019 through January 31, 2020
| CLIN |
| Description |
| Est Qty |
| Unit of Issue |
| Rate |
| Est Total |
| 0001 |
| 24- to 48-hour Holter (Continuous Rhythm) |
| 20 |
| ea |
| $ |
| $ |
| 0002 |
| 30-day Event |
| 0 |
| ea |
| $ |
| $ |
| 0003 |
| 14-day (or less) Telemetry |
| 165 |
| ea |
| $ |
| $ |
| 0004 |
| 30-day (or less but >14 days) Telemetry |
| 280 |
| ea |
| $ |
| $ |
| Estimated Total – Base Year: $______________ |
| Option Year 1 – February 1, 2020 through January 31, 2021 | |
| CLIN |
| Description |
| Est Qty |
| Unit of Issue |
| Rate |
| Est Total |
| 1001 |
| 24- to 48-hour Holter (Continuous Rhythm) |
| 20 |
| ea |
| $ |
| $ |
| 1002 |
| 30-day Event |
| 0 |
| ea |
| $ |
| $ |
| 1003 |
| 14-day (or less) Telemetry |
| 165 |
| ea |
| $ |
| $ |
| 1004 |
| 30-day (or less but >14 days) Telemetry |
| 280 |
| ea |
| $ |
| $ |
| Estimated Total – Option Year 1: $______________ |
| Option Year 2 – February 1, 2021 through January 31, 2022 | |
| CLIN |
| Description |
| Est Qty |
| Unit of Issue |
| Rate |
| Est Total |
| 2001 |
| 24- to 48-hour Holter (Continuous Rhythm) |
| 20 |
| ea |
| $ |
| $ |
| 2002 |
| 30-day Event |
| 0 |
| ea |
| $ |
| $ |
| 2003 |
| 14-day (or less) Telemetry |
| 165 |
| ea |
| $ |
| $ |
| 2004 |
| 30-day (or less but >14 days) Telemetry |
| 280 |
| ea |
| $ |
| $ |
| Estimated Total – Option Year 2: $______________ |
| Option Year 3 – February 1, 2022 through January 31, 2023 | |
| CLIN |
| Description |
| Est Qty |
| Unit of Issue |
| Rate |
| Est Total |
| 3001 |
| 24- to 48-hour Holter (Continuous Rhythm) |
| 20 |
| ea |
| $ |
| $ |
| 3002 |
| 30-day Event |
| 0 |
| ea |
| $ |
| $ |
| 3003 |
| 14-day (or less) Telemetry |
| 165 |
| ea |
| $ |
| $ |
| 3004 |
| 30-day (or less but >14 days) Telemetry |
| 280 |
| ea |
| $ |
| $ |
| Estimated Total – Option Year 3: $______________ |
| Option Year 4 – February 1, 2023 through January 31, 2024 | |
| CLIN |
| Description |
| Est Qty |
| Unit of Issue |
| Rate |
| Est Total |
| 4001 |
| 24- to 48-hour Holter (Continuous Rhythm) |
| 20 |
| ea |
| $ |
| $ |
| 4002 |
| 30-day Event |
| 0 |
| ea |
| $ |
| $ |
| 4003 |
| 14-day (or less) Telemetry |
| 165 |
| ea |
| $ |
| $ |
| 4004 |
| 30-day (or less but >14 days) Telemetry |
| 280 |
| ea |
| $ |
| $ |
| | Estimated Total – Option Year 4: $______________ |
| Estimated Grand Total – 5 Years (Base plus 4 Option Years) | $________________ | |
