36C25618R0296-00003001.pdf

5. PROJECT NUMBER (if applicable)

CODE 7. ADMINISTERED BY

2. AMENDMENT/MODIFICATION NUMBER

CODE

6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NUMBER 3. EFFECTIVE DATE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED

PAGE OF PAGES

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED

BPA NO. 1. CONTRACT ID CODE

FACILITY CODE CODE

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR

ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV. 11/2016)

is required to sign this document and return ___________ copies to the issuing office. is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES

SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER

BY

Contractor

16C. DATE SIGNED

14. DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED STATES OF AMERICA

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER 16A. NAME AND TITLE OF CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

STANDARD FORM 30 PREVIOUS EDITION NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.243

(Type or print) (Type or print)

(Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

(Number, street, county, State and ZIP Code)

(If other than Item 6)

(Specify type of modification and authority)

(such as changes in paying office, appropriation date, etc.)

(If required)

(SEE ITEM 11)

(SEE ITEM 13)

(X)

CHECK

ONE

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

(Signature of person authorized to sign) (Signature of Contracting Officer)

1 34

00003 04-12-2018

None

00502

ALEXANDRIA VA HEALTH CARE SYSTEM

NETWORK CONTRACTING OFFICE 16

ALEXANDRIA VA HEALTH CARE SYSTEM

PO BOX 69004

ALEXANDRIA LA 71306-9004

00502

DEPARTMENT OF VETERANS AFFAIRS

NETWORK CONTRACTING OFFICE 16

ALEXANDRIA VA HEALTH CARE SYSTEM

2495 SHREVEPORT HIGHWAY

PINEVILLE LA 71360-4004

To all Offerors/Bidders

36C25618R0296

03-23-2018

X

X X

X 1

The purpose of this amendment is provide a revised Pricing Schedule and revise language in the Price Schedule instructions.

Ensure all amendments are signed and returned with the proposal by the closing date and time of

24 April 2018 at 4:00PM CDT per guidance in Amendment 00002

All other terms and conditions of the solicitation remain the same.

Martin Priest

Contracting Officer

NCO1616l2-68195

CONTINUATION PAGE

A.1 SCHEDULE OF SERVICES

SCHEDULE OF SERVICES

1. The Contractor shall furnish all personnel to provide services necessary to perform onsite

General Surgery Physician Services to eligible beneficiaries of the Department of Veterans Affairs

Medical Center, Fayetteville, AR, (hereinafter referred to as VAMC). The contractor’s physician

(s)’ care shall cover the range of General Surgery services as would be provided in a state-of-the-art civilian medical treatment facility and the standard of care shall be of a quality, meeting or exceeding currently recognized national standards http://www.absurgery.org/default.jsp?policyhomegs as established by the American Board of

General Surgery http://www.absurgery.org/.

2. Place of Performance: Services shall be provided on site, VAMC, 1100 N. College Ave., Fayetteville, AR 72703

3. Pricing Instructions:

The offeror is instructed to include all other than price and cost information supporting the proposed price as directed in Instructions to Offerors addendum to 52.212-1 and/or Section D-

Contract Documents, Exhibits, or attachments, VA Directive 1663.

4. Pricing Instructions:

Offerors must fill out the cells in the following columns in the Price Schedule for EA Contract Line

Item Number (CLIN). For pricing and evaluation purposes, the current CMS rates should be used in completing EA CLIN for the base year and option years.

4.1 Throughout the life of the contract the VA will pay the awarded firm fixed percentage of the

Medicare rate effective at the time the service is provided by the Contractor.

4.2 This basis of the contractor’s proposed fixed percentage of Medicare rate will be used by the

Government for future pricing of additional codes/procedures and for reimbursement under the contract. The basis of estimate used for your fixed price, i.e. the way that your price is calculated, shall remain the same throughout the life of the contract and may be validated by post award audits.

4.3 If post-operative aftercare will be provided at the VAMC facility (as indicated in the PWS), the contractor shall reduce their proposed price per code by the percentage indicated on the

CMS website (10%) assigned to post-operative part of the procedure.

http://www.absurgery.org/default.jsp?policyhomegs http://www.absurgery.org/

36C25618R0296A00003

4.4 The Offeror shall complete the attached price schedule for the performance location proposed. No CLINS or codes should be left blank. If for some reason a code on the schedule has expired or is for any other reason unusable, offerors shall annotate the Price per Code block with “N/A” or otherwise notate the replacement code.

4.5 The Offeror shall base pricing on the application of Medicare reimbursement rules. For routine care, it is expected that VAMC patients will have prescriptions filled at VA pharmacies. All spreadsheets must be submitted in Microsoft Excel and without protected/locked portions or other methods which prevent or do not facilitate expeditious pricing validation. PDF files and similarly constructed files are not acceptable.

5. Ordering Procedures: Task orders will be issued by the Contracting Officer to fund services provided against the contract. These task orders will be issued for no more than a 12-month period.

5.1 The minimum quantity that the Government will order under this IDC Contract is $10,000.00 and the maximum amount for the contract base and all option periods will not exceed $5,000,000.000.

6. Completing the Schedule of Services:

6.1 % of CMS UNIT COST: Place the percentage of the CMS Unit Cost that the offeror is willing to accept. This percentage should be a value below 100%.

6.2 Proposed Fixed Price EA: This is the Proposed FIXED PRICE for each of the identified HCPC by CLIN. It is computed by multiplying the CMS UNIT COST times the Proposed % of CMS

UNIT COST. This will establish the proposed Fixed Price of each HCPC for this contract.

6.3 Estimated Total Annual Cost: This this cost of the Proposed FIXED PRICE x the EST. QTY

6.4 The CMS UNIT COST is already included. Offeror will only need to include the % of CMS Unit

Cost they are willing to accept. Note that since the work is being accomplished ON-SITE at the VHSO facility that only the Professional Element Modifier 26 is priced or if no Professional

Element Modifier 26, the Participating Provider cost is used “When performed in a facility setting”.

7. Options: “For the purposes of the award of this Contract, the Government intends to evaluate the option to extend services under FAR 52.217-8 as follows:

7.1 The evaluation will consider the possibility that the option can be exercised at any time, and can be exercised in increments of one to six months, but not for more than a total of six months during the life of the contract. The evaluation will assume that the prices for any option exercised under FAR 52.217-8 will be at the same rates as those in effect under the contract at the time the option is exercised. The evaluation will therefore assume that the addition of the price or prices of any possible extension or extensions under FAR 52.217-8 to the total price for the basic requirement and the total price for the priced options has the same effect on the total price of all proposals relative to each other, and will not affect the ranking of proposals based on price, unless, after reviewing the proposals, the Government determines that there is a basis for finding otherwise. This evaluation will not obligate the

Government to exercise any option under FAR 52.217-8.

Period of Performance: BASE: 01 June 2018 to 31 May 2019

CLIN HCPCS Short Description

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

0001 10060 Drainage of skin abscess 2 EA $ 91.82 %

0002 10061 Drainage of skin abscess 4 EA $ 169.55

0003 10081 Drainage Pilonidal Cyst 5 EA $ 160.77

0004 10120 Remove foreign body 4 EA $ 97.36

0005 10121 Remove foreign body 1 EA $ 175.16

0006 10140 Drainage hematoma 1 EA $ 111.88

0007 10180 Complex Drainage Wound 3 EA $ 166.31

0008 11008 Remove mesh from abd wall 3 EA $ 260.88

0009 11042 Debride SubQ Tissue 2 EA $ 59.25

0010 11043 Deb musc/fascia 20 sq cm/< 1 EA $ 148.71

0011 11044 Deb Bone 20 sq cm/< 3 EA $ 220.20

0012 11100 Biopsy Skin Lesion 2 EA $ 46.82

0013 11400 Exc tr-ext b9+marg< 0.5 cm 4 EA $ 75.59

0014 11403 Exc tr-ext b9+marg 2.1 - 3 cm 4 EA $ 138.28

0015 11404 Exc tr-ext b9+marg 3.1 - 4 cm 4 EA $ 151.96

0016 11406 Exc tr-ext b9+marg >4.0 cm 5 EA $ 231.96

0017 11420 Exc h-f-nk-sp b9+marg < 0.5 6 EA $ 76.61

0018 11421 Exc h-f-nk-sp b9+marg 0.6 - 1 5 EA $ 103.53

0019 11422 Exc h-f-nk-sp b9+marg 1.1 - 2 5 EA $ 128.03

0020 11423 Exc h-f-nk-sp b9+marg 2.1-3 2 EA $ 147.03

0021 11424 Exc h-f-nk-sp b9+marg 3.1 - 4 1 EA $ 169.04

0022 11426 Exc h-f-nk-sp b9+marg >4 2 EA $ 259.90

0023 11441 Exc Face-MM 3 EA $ 123.05

0024 11442 Exc Face-MM 3 EA $ 135.87

0025 11444 Exc Face-MM 1 EA $ 213.73

0026 11601 Exc TR-Ext Mal 3 EA $ 140.70

0027 11602 Exc TR-Ext Mal 3 EA $ 154.80

0028 11603 Exc TR-Ext Mal 2 EA $ 185.67

0029 11606 Exc TR-Ext Mal 1 EA $ 303.71

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

0030 11620 Exc h-f-nk-sp Mal 4 EA $ 114.14

0031 11621 Exc h-f-nk-sp Mal 2 EA $ 141.58

0032 11622 Exc h-f-nk-sp Mal 4 EA $ 162.03

0033 11624 Exc h-f-nk-sp Mal 1 EA $ 227.94

0034 11640 Exc h-f-nk-sp Mal 4 EA $ 118.04

0035 11641 Exc h-f-nk-sp Mal 2 EA $ 147.54

0036 11642 Exc h-f-nk-sp Mal 6 EA $ 173.87

0037 11643 Exc h-f-nk-sp Mal 1 EA $ 218.24

0038 11771 Remove pilonidal cyst exten 6 EA $ 407.01

0039 12001 Repair Superficial Wound 1 EA $ 42.57

0040 12004 Repair Superficial Wound 1 EA $ 70.22

0041 12011 Repair Superficial Wound 1 EA $ 53.04

0042 12013 Repair Superficial Wound 1 EA $ 55.92

0043 15120 Skn Splt A-Grft 2 EA $ 651.47

0044 15734 Muscle Skin Grft Trunk 3 EA $ 1,424.92

0045 17000 Destruction Premalig Lesion 3 EA $ 49.36

0046 17003 Destruction Premalig Lesion 2-14 3 EA $ 2.28

0047 17282 Destruction Skin Lesion 1 EA $ 136.19

0048 19120 Removal of breast lesion 2 EA $ 386.03

0049 19300 Removal of breast tissue 3 EA $ 385.98

0050 21552 Exc Face Less SBQ 3 cm /> 2 EA $ 418.47

0051 21554 Exc Face Less SBQ 5 cm /> 2 EA $ 687.25

0052 21555 Exc Neck Less SC < 3 cm 1 EA $ 285.34

0053 21920 Biopsy Soft Tissue Back 1 EA $ 150.51

0054 21931 Exc back les sc 3 cm/> 1 EA $ 440.75

0055 21933 Exc back tum deep 5 cm/> 1 EA $ 683.30

0056 22900 Exc Abdl Tum Deep 2 EA $ 529.68

0057 22903 Exc Abd less SC 3 cm /> 2 EA $ 411.41

0058 27590 Amputate leg at thigh 3 EA $ 753.78

0059 27880 Amputation of lower leg 4 EA $ 865.12

0060 28805 Amputation thru metatarsal 5 EA $ 699.25

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

0061 28810 Amputation toe & metatarsal 6 EA $ 408.03

0062 28820 Amputation toe 3 EA $ 375.75

0063 36556 Insert non-tunnel cv cath 4 EA $ 94.46

0064 36561 Insert tunneled cv cath 7 EA $ 323.77

0065 36590 Removal tunneled cv cath 5 EA $ 193.26

0066 38500 Biopsy/removal lymph nodes 2 EA $ 238.61

0067 38510 Biopsy/removal lymph nodes 3 EA $ 395.47

0068 43235 Egd diagnostic brush wash 200 EA $ 119.86

0069 43236 Upper GI Scope W/Submuc Inj 1 EA $ 135.47

0070 43239 Egd biopsy single/multiple 300 EA $ 135.16

0071 43245 Upper GI Scope Dilate Strictr 3 EA $ 171.48

0072 43246 Place gastrostomy tube 20 EA $ 195.13

0073 43247 Operative Upper GI Endoscopy 10 EA $ 173.51

0074 43248 Uppr GI Endoscopy/Guide Wire 10 EA $ 162.66

0075 43249 Esoph egd dilation <30 mm 30 EA $ 149.84

0076 43250 Dilate Esophagus 20 EA $ 165.95

0077 43251 Operative Upper GI Endoscopy 19 EA $ 192.43

0078 43255 Operative Upper GI Endoscopy 1 EA $ 197.03

0079 43280 Laparoscopy fundoplasty 3 EA $ 1,021.31

0080 43450 Dilate Esophagus 30 EA $ 77.23

0081 43633 Removal of stomach partial 3 EA $ 1,817.70

0082 43760 Change gastrostomy tube 20 EA $ 45.45

0083 43800 Reconsstruction Pylorus 1 EA $ 877.18

0084 43830 Place gastrostomy tube 8 EA $ 658.94

0085 44050 Reduce bowel obstruction 3 EA $ 882.83

0086 44120 Removal Small Intestine 5 EA $ 1,158.68

0087 44139 Mobilization of colon 5 EA $ 115.76

0088 44140 Partial removal of colon 10 EA $ 1,270.05

0089 44141 Partial removal of colon 3 EA $ 1,727.56

0090 44145 Partial removal of colon 10 EA $ 1,575.39

0091 44147 Partial removal of colon 10 EA $ 1,842.80

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

0092 44160 Removal of colon 5 EA $ 1,176.29

0093 44188 Lap Colostomy 3 EA $ 1,160.61

0094 44204 Laparo partial colectomy 10 EA $ 1,462.25

0095 44205 Lap colectomy part w/ileum 10 EA $ 1,272.08

0096 44207 L colectomy/coloproctostomy 8 EA $ 1,736.07

0097 44213 Lap mobil splenic fl add-on 3 EA $ 180.27

0098 44300 Open Bowel to Skin 1 EA $ 785.14

0099 44320 Colostomy 5 EA $ 1,137.92

0100 44380 Small Bowel Endoscopy 1 EA $ 54.95

0101 44388 Colonoscopy thru stoma spx 5 EA $ 152.25

0102 44389 Colonoscopy with Biopsy 1 EA $ 168.07

0103 44602 Suture small intestine 1 EA $ 1,338.26

0104 44604 Suture large intestine 1 EA $ 989.85

0105 44625 Repair bowel opening 1 EA $ 967.77

0106 44626 Repair bowel opening 6 EA $ 1,521.50

0107 44640 Repair bowel-skin fistula 2 EA $ 1,329.96

0108 44650 Repair bowel fistula 2 EA $ 1,374.17

0109 44661 Repair Bowel-Bladder Fistula 2 EA $ 1,479.11

0110 44900 Drain App Abscess Open 2 EA $ 730.48

0111 44960 Appendectomy 3 EA $ 825.11

0112 44970 Laparoscopy appendectomy 18 EA $ 566.21

0113 45100 Biopsy Rectum 1 EA $ 282.26

0114 45112 Removal Rectum 1 EA $ 1,793.14

0115 45171 Exc Tect Tum Transanal Part 2 EA $ 567.15

0116 45172 Exc rect tum transanal full 2 EA $ 771.37

0117 45300 Proscosigmoidoscopy 2 EA $ 51.59

0118 45330 Diagnostic Sigmoidoscopy 15 EA $ 54.07

0119 45331 Sigmoidoscopy and Biopsy 8 EA $ 69.58

0120 45333 Sigmoidoscopy and Polypectomy 5 EA $ 90.91

0121 45335 Sigmoidoscopy W/Submuc Inj 2 EA $ 64.09

0122 45338 Sigmoidoscopy W/Tumr Remov 1 EA $ 117.48

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

0123 45378 Diagnostic colonoscopy 400 EA $ 180.78

0124 45380 Colonoscopy and biopsy 310 EA $ 196.81

0125 45381 Colonoscopy submucous njx 60 EA $ 196.81

0126 45382 Colonoscopy w/control bleed 2 EA $ 254.28

0127 45384 Colonoscopy w/ Lesion Removal 250 EA $ 225.30

0128 45385 Colonoscopy w/lesion removal 150 EA $ 249.37

0129 45386 Colonoscopy Dilate Stricture 4 EA $ 207.40

0130 45990 Surg dx exam anorectal 2 EA $ 102.20

0131 46040 Incision of rectal abscess 8 EA $ 389.20

0132 46200 Removal Anal Fissure 3 EA $ 304.91

0133 46250 Remove Ext Hem Groups 2+ 2 EA $ 296.50

0134 46260 Remove in/ex hem groups 2+ 9 EA $ 441.61

0135 46270 Removal Anal Fissure SubQ 6 EA $ 367.05

0136 46600 Diagnostic Anoscopy 3 EA $ 38.93

0137 46604 Anoscopy and dilation 6 EA $ 63.31

0138 46922 Excision of anal lesion(s) 3 EA $ 127.71

0139 46947 Hemorrhoidopexy by stapling 5 EA $ 359.86

0140 47100 Wedge biopsy of liver 5 EA $ 794.32

0141 47562 Laparoscopic cholecystectomy 45 EA $ 619.84

0142 47563 Laparo cholecystectomy/graph 50 EA $ 673.05

0143 47600 Removal of gallbladder 4 EA $ 1,006.97

0144 47605 Removal Gallbladder 4 EA $ 1,060.19

0145 49000 Exploration of abdomen 2 EA $ 727.15

0146 49002 Reopening of abdomen 3 EA $ 977.42

0147 49020 Drainage abdom abscess open 3 EA $ 1,504.56

0148 49320 Diag Laparo Separate Proc 2 EA $ 308.52

0149 49322 Laparoscopy Aspiration 2 EA $ 350.70

0150 49402 Remove foreign body Abdomen 2 EA $ 808.92

0151 49505 Prp i/hern init reduc >5 yr 100 EA $ 488.89

0152 49520 Rerepair ing hernia reduce 11 EA $ 594.42

0153 49521 Rerepair ing hernia blocked 11 EA $ 674.57

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

0154 49550 Rpr Rem Hernia Init Reduce 2 EA $ 541.30

0155 49555 Rerepair fem hernia reduce 1 EA $ 563.43

0156 49560 Rpr ventral hern init reduc 16 EA $ 695.31

0157 49561 Rpr ventral hern init block 25 EA $ 877.06

0158 49565 Rerepair ventrl hern reduce 6 EA $ 723.85

0159 49566 Rerepair ventrl hern block 9 EA $ 885.07

0160 49568 Hernia repair w/mesh 49 EA $ 254.04

0161 49582 Rpr Umb Hern Block 1 EA $ 452.44

0162 49585 Rpr umbil hern reduc > 5 yr 19 EA $ 417.76

0163 49587 Rpr umbil hern block > 5 yr 41 EA $ 446.26

0164 99203 Office/outpatient visit new 1,225 EA $ 73.06

0165 99204 Office/outpatient visit new 45 EA $ 123.75

SUB-TOTAL

Total Estimate for BASE YEAR: $________________________________

Period of Performance: OPTION 1: June 01, 2019 to May 31, 2020

CLIN HCPCS Short Description

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

1001 10060 Drainage of skin abscess 2 EA $ 91.82 % $ $

1002 10061 Drainage of skin abscess 4 EA $ 169.55 % $ $

1003 10081 Drainage Pilonidal Cyst 5 EA $ 160.77 % $ $

1004 10120 Remove foreign body 4 EA $ 97.36 % $ $

1005 10121 Remove foreign body 1 EA $ 175.16 % $ $

1006 10140 Drainage hematoma 1 EA $ 111.88 % $ $

1007 10180 Complex Drainage Wound 3 EA $ 166.31 % $ $

1008 11008 Remove mesh from abd wall 3 EA $ 260.88 % $ $

1009 11042 Debride SubQ Tissue 2 EA $ 59.25 % $ $

1010 11043 Deb musc/fascia 20 sq cm/< 1 EA $ 148.71 % $ $

1011 11044 Deb Bone 20 sq cm/< 3 EA $ 220.20 % $ $

1012 11100 Biopsy Skin Lesion 2 EA $ 46.82 % $ $

1013 11400 Exc tr-ext b9+marg< 0.5 cm 4 EA $ 75.59 % $ $

1014 11403 Exc tr-ext b9+marg 2.1 - 3 cm 4 EA $ 138.28 % $ $

1015 11404 Exc tr-ext b9+marg 3.1 - 4 cm 4 EA $ 151.96 % $ $

1016 11406 Exc tr-ext b9+marg >4.0 cm 5 EA $ 231.96 % $ $

1017 11420 Exc h-f-nk-sp b9+marg < 0.5 6 EA $ 76.61 % $ $

1018 11421 Exc h-f-nk-sp b9+marg 0.6 - 1 5 EA $ 103.53 % $ $

1019 11422 Exc h-f-nk-sp b9+marg 1.1 - 2 5 EA $ 128.03 % $ $

1020 11423 Exc h-f-nk-sp b9+marg 2.1-3 2 EA $ 147.03 % $ $

1021 11424 Exc h-f-nk-sp b9+marg 3.1 - 4 1 EA $ 169.04 % $ $

1022 11426 Exc h-f-nk-sp b9+marg >4 2 EA $ 259.90 % $ $

1023 11441 Exc Face-MM 3 EA $ 123.05 % $ $

1024 11442 Exc Face-MM 3 EA $ 135.87 % $ $

1025 11444 Exc Face-MM 1 EA $ 213.73 % $ $

1026 11601 Exc TR-Ext Mal 3 EA $ 140.70 % $ $

1027 11602 Exc TR-Ext Mal 3 EA $ 154.80 % $ $

1028 11603 Exc TR-Ext Mal 2 EA $ 185.67 % $ $

1029 11606 Exc TR-Ext Mal 1 EA $ 303.71 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

1030 11620 Exc h-f-nk-sp Mal 4 EA $ 114.14 % $ $

1031 11621 Exc h-f-nk-sp Mal 2 EA $ 141.58 % $ $

1032 11622 Exc h-f-nk-sp Mal 4 EA $ 162.03 % $ $

1033 11624 Exc h-f-nk-sp Mal 1 EA $ 227.94 % $ $

1034 11640 Exc h-f-nk-sp Mal 4 EA $ 118.04 % $ $

1035 11641 Exc h-f-nk-sp Mal 2 EA $ 147.54 % $ $

1036 11642 Exc h-f-nk-sp Mal 6 EA $ 173.87 % $ $

1037 11643 Exc h-f-nk-sp Mal 1 EA $ 218.24 % $ $

1038 11771 Remove pilonidal cyst exten 6 EA $ 407.01 % $ $

1039 12001 Repair Superficial Wound 1 EA $ 42.57 % $ $

1040 12004 Repair Superficial Wound 1 EA $ 70.22 % $ $

1041 12011 Repair Superficial Wound 1 EA $ 53.04 % $ $

1042 12013 Repair Superficial Wound 1 EA $ 55.92 % $ $

1043 15120 Skn Splt A-Grft 2 EA $ 651.47 % $ $

1044 15734 Muscle Skin Grft Trunk 3 EA $ 1,424.92 % $ $

1045 17100 Destruction Premalig Lesion 3 EA $ 49.36 % $ $

1046 17003 Destruction Premalig Lesion 2-14 3 EA $ 2.28 % $ $

1047 17282 Destruction Skin Lesion 1 EA $ 136.19 % $ $

1048 19120 Removal of breast lesion 2 EA $ 386.03 % $ $

1049 19300 Removal of breast tissue 3 EA $ 385.98 % $ $

1050 21552 Exc Face Less SBQ 3 cm /> 2 EA $ 418.47 % $ $

1051 21554 Exc Face Less SBQ 5 cm /> 2 EA $ 687.25 % $ $

1052 21555 Exc Neck Less SC < 3 cm 1 EA $ 285.34 % $ $

1053 21920 Biopsy Soft Tissue Back 1 EA $ 150.51 % $ $

1054 21931 Exc back les sc 3 cm/> 1 EA $ 440.75 % $ $

1055 21933 Exc back tum deep 5 cm/> 1 EA $ 683.30 % $ $

1056 22900 Exc Abdl Tum Deep 2 EA $ 529.68 % $ $

1057 22903 Exc Abd less SC 3 cm /> 2 EA $ 411.41 % $ $

1058 27590 Amputate leg at thigh 3 EA $ 753.78 % $ $

1059 27880 Amputation of lower leg 4 EA $ 865.12 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

1060 28805 Amputation thru metatarsal 5 EA $ 699.25 % $ $

1061 28810 Amputation toe & metatarsal 6 EA $ 408.03 % $ $

1062 28820 Amputation toe 3 EA $ 375.75 % $ $

1063 36556 Insert non-tunnel cv cath 4 EA $ 94.46 % $ $

1064 36561 Insert tunneled cv cath 7 EA $ 323.77 % $ $

1065 36590 Removal tunneled cv cath 5 EA $ 193.26 % $ $

1066 38500 Biopsy/removal lymph nodes 2 EA $ 238.61 % $ $

1067 38510 Biopsy/removal lymph nodes 3 EA $ 395.47 % $ $

1068 43235 Egd diagnostic brush wash 200 EA $ 119.86 % $ $

1069 43236 Upper GI Scope W/Submuc Inj 1 EA $ 135.47 % $ $

1070 43239 Egd biopsy single/multiple 300 EA $ 135.16 % $ $

1071 43245 Upper GI Scope Dilate Strictr 3 EA $ 171.48 % $ $

1072 43246 Place gastrostomy tube 20 EA $ 195.13 % $ $

1073 43247 Operative Upper GI Endoscopy 10 EA $ 173.51 % $ $

1074 43248 Uppr GI Endoscopy/Guide Wire 10 EA $ 162.66 % $ $

1075 43249 Esoph egd dilation <30 mm 30 EA $ 149.84 % $ $

1076 43250 Dilate Esophagus 20 EA $ 165.95 % $ $

1077 43251 Operative Upper GI Endoscopy 19 EA $ 192.43 % $ $

1078 43255 Operative Upper GI Endoscopy 1 EA $ 197.03 % $ $

1079 43280 Laparoscopy fundoplasty 3 EA $ 1,021.31 % $ $

1080 43450 Dilate Esophagus 30 EA $ 77.23 % $ $

1081 43633 Removal of stomach partial 3 EA $ 1,817.70 % $ $

1082 43760 Change gastrostomy tube 20 EA $ 45.45 % $ $

1083 43800 Reconsstruction Pylorus 1 EA $ 877.18 % $ $

1084 43830 Place gastrostomy tube 8 EA $ 658.94 % $ $

1085 44050 Reduce bowel obstruction 3 EA $ 882.83 % $ $

1086 44120 Removal Small Intestine 5 EA $ 1,158.68 % $ $

1087 44139 Mobilization of colon 5 EA $ 115.76 % $ $

1088 44140 Partial removal of colon 10 EA $ 1,270.05 % $ $

1089 44141 Partial removal of colon 3 EA $ 1,727.56 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

1090 44145 Partial removal of colon 10 EA $ 1,575.39 % $ $

1091 44147 Partial removal of colon 10 EA $ 1,842.80 % $ $

1092 44160 Removal of colon 5 EA $ 1,176.29 % $ $

1093 44188 Lap Colostomy 3 EA $ 1,160.61 % $ $

1094 44204 Laparo partial colectomy 10 EA $ 1,462.25 % $ $

1095 44205 Lap colectomy part w/ileum 10 EA $ 1,272.08 % $ $

1096 44207 L colectomy/coloproctostomy 8 EA $ 1,736.07 % $ $

1097 44213 Lap mobil splenic fl add-on 3 EA $ 180.27 % $ $

1098 44300 Open Bowel to Skin 1 EA $ 785.14 % $ $

1099 44320 Colostomy 5 EA $ 1,137.92 % $ $

1100 44380 Small Bowel Endoscopy 1 EA $ 54.95 % $ $

1101 44388 Colonoscopy thru stoma spx 5 EA $ 152.25 % $ $

1102 44389 Colonoscopy with Biopsy 1 EA $ 168.07 % $ $

1103 44602 Suture small intestine 1 EA $ 1,338.26 % $ $

1104 44604 Suture large intestine 1 EA $ 989.85 % $ $

1105 44625 Repair bowel opening 1 EA $ 967.77 % $ $

1106 44626 Repair bowel opening 6 EA $ 1,521.50 % $ $

1107 44640 Repair bowel-skin fistula 2 EA $ 1,329.96 % $ $

1108 44650 Repair bowel fistula 2 EA $ 1,374.17 % $ $

1109 44661 Repair Bowel-Bladder Fistula 2 EA $ 1,479.11 % $ $

1110 44900 Drain App Abscess Open 2 EA $ 730.48 % $ $

1111 44960 Appendectomy 3 EA $ 825.11 % $ $

1112 44970 Laparoscopy appendectomy 18 EA $ 566.21 % $ $

1113 45100 Biopsy Rectum 1 EA $ 282.26 % $ $

1114 45112 Removal Rectum 1 EA $ 1,793.14 % $ $

1115 45171 Exc Tect Tum Transanal Part 2 EA $ 567.15 % $ $

1116 45172 Exc rect tum transanal full 2 EA $ 771.37 % $ $

1117 45300 Proscosigmoidoscopy 2 EA $ 51.59 % $ $

1118 45330 Diagnostic Sigmoidoscopy 15 EA $ 54.07 % $ $

1119 45331 Sigmoidoscopy and Biopsy 8 EA $ 69.58 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

1120 45333 Sigmoidoscopy and Polypectomy 5 EA $ 90.91 % $ $

1121 45335 Sigmoidoscopy W/Submuc Inj 2 EA $ 64.09 % $ $

1122 45338 Sigmoidoscopy W/Tumr Remov 1 EA $ 117.48 % $ $

1123 45378 Diagnostic colonoscopy 400 EA $ 180.78 % $ $

1124 45380 Colonoscopy and biopsy 310 EA $ 196.81 % $ $

1125 45381 Colonoscopy submucous njx 60 EA $ 196.81 % $ $

1126 45382 Colonoscopy w/control bleed 2 EA $ 254.28 % $ $

1127 45384 Colonoscopy w/ Lesion Removal 250 EA $ 225.30 % $ $

1128 45385 Colonoscopy w/lesion removal 150 EA $ 249.37 % $ $

1129 45386 Colonoscopy Dilate Stricture 4 EA $ 207.40 % $ $

1130 45990 Surg dx exam anorectal 2 EA $ 102.20 % $ $

1131 46040 Incision of rectal abscess 8 EA $ 389.20 % $ $

1132 46200 Removal Anal Fissure 3 EA $ 304.91 % $ $

1133 46250 Remove Ext Hem Groups 2+ 2 EA $ 296.50 % $ $

1134 46260 Remove in/ex hem groups 2+ 9 EA $ 441.61 % $ $

1135 46270 Removal Anal Fissure SubQ 6 EA $ 367.05 % $ $

1136 46600 Diagnostic Anoscopy 3 EA $ 38.93 % $ $

1137 46604 Anoscopy and dilation 6 EA $ 63.31 % $ $

1138 46922 Excision of anal lesion(s) 3 EA $ 127.71 % $ $

1139 46947 Hemorrhoidopexy by stapling 5 EA $ 359.86 % $ $

1140 47100 Wedge biopsy of liver 5 EA $ 794.32 % $ $

1141 47562 Laparoscopic cholecystectomy 45 EA $ 619.84 % $ $

1142 47563 Laparo cholecystectomy/graph 50 EA $ 673.05 % $ $

1143 47600 Removal of gallbladder 4 EA $ 1,006.97 % $ $

1144 47605 Removal Gallbladder 4 EA $ 1,060.19 % $ $

1145 49100 Exploration of abdomen 2 EA $ 727.15 % $ $

1146 49002 Reopening of abdomen 3 EA $ 977.42 % $ $

1147 49020 Drainage abdom abscess open 3 EA $ 1,504.56 % $ $

1148 49320 Diag Laparo Separate Proc 2 EA $ 308.52 % $ $

1149 49322 Laparoscopy Aspiration 2 EA $ 350.70 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

1150 49402 Remove foreign body Abdomen 2 EA $ 808.92 % $ $

1151 49505 Prp i/hern init reduc >5 yr 100 EA $ 488.89 % $ $

1152 49520 Rerepair ing hernia reduce 11 EA $ 594.42 % $ $

1153 49521 Rerepair ing hernia blocked 11 EA $ 674.57 % $ $

1154 49550 Rpr Rem Hernia Init Reduce 2 EA $ 541.30 % $ $

1155 49555 Rerepair fem hernia reduce 1 EA $ 563.43 % $ $

1156 49560 Rpr ventral hern init reduc 16 EA $ 695.31 % $ $

1157 49561 Rpr ventral hern init block 25 EA $ 877.06 % $ $

1158 49565 Rerepair ventrl hern reduce 6 EA $ 723.85 % $ $

1159 49566 Rerepair ventrl hern block 9 EA $ 885.07 % $ $

1160 49568 Hernia repair w/mesh 49 EA $ 254.04 % $ $

1161 49582 Rpr Umb Hern Block 1 EA $ 452.44 % $ $

1162 49585 Rpr umbil hern reduc > 5 yr 19 EA $ 417.76 % $ $

1163 49587 Rpr umbil hern block > 5 yr 41 EA $ 446.26 % $ $

1164 99203 Office/outpatient visit new 1,225 EA $ 73.06 % $ $

1165 99204 Office/outpatient visit new 45 EA $ 123.75 % $ $

Total Estimate for Option Year 1: $________________________________

Period of Performance: OPTION 2: June 01, 2020 to 31 May 2021

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

2001 10060 Drainage of skin abscess 2 EA $ 91.82 % $ $

2002 10061 Drainage of skin abscess 4 EA $ 169.55 % $ $

2003 10081 Drainage Pilonidal Cyst 5 EA $ 160.77 % $ $

2004 10120 Remove foreign body 4 EA $ 97.36 % $ $

2005 10121 Remove foreign body 1 EA $ 175.16 % $ $

2006 10140 Drainage hematoma 1 EA $ 111.88 % $ $

2007 10180 Complex Drainage Wound 3 EA $ 166.31 % $ $

2008 11008 Remove mesh from abd wall 3 EA $ 260.88 % $ $

2009 11042 Debride SubQ Tissue 2 EA $ 59.25 % $ $

2020 11043 Deb musc/fascia 20 sq cm/< 1 EA $ 148.71 % $ $

2011 11044 Deb Bone 20 sq cm/< 3 EA $ 220.20 % $ $

2012 11100 Biopsy Skin Lesion 2 EA $ 46.82 % $ $

2013 11400 Exc tr-ext b9+marg< 0.5 cm 4 EA $ 75.59 % $ $

2014 11403 Exc tr-ext b9+marg 2.1 - 3 cm 4 EA $ 138.28 % $ $

2015 11404 Exc tr-ext b9+marg 3.1 - 4 cm 4 EA $ 151.96 % $ $

2016 11406 Exc tr-ext b9+marg >4.0 cm 5 EA $ 231.96 % $ $

2017 11420 Exc h-f-nk-sp b9+marg < 0.5 6 EA $ 76.61 % $ $

2018 11421 Exc h-f-nk-sp b9+marg 0.6 - 1 5 EA $ 103.53 % $ $

2019 11422 Exc h-f-nk-sp b9+marg 1.1 - 2 5 EA $ 128.03 % $ $

2020 11423 Exc h-f-nk-sp b9+marg 2.1-3 2 EA $ 147.03 % $ $

2021 11424 Exc h-f-nk-sp b9+marg 3.1 - 4 1 EA $ 169.04 % $ $

2022 11426 Exc h-f-nk-sp b9+marg >4 2 EA $ 259.90 % $ $

2023 11441 Exc Face-MM 3 EA $ 123.05 % $ $

2024 11442 Exc Face-MM 3 EA $ 135.87 % $ $

2025 11444 Exc Face-MM 1 EA $ 213.73 % $ $

2026 11601 Exc TR-Ext Mal 3 EA $ 140.70 % $ $

2027 11602 Exc TR-Ext Mal 3 EA $ 154.80 % $ $

2028 11603 Exc TR-Ext Mal 2 EA $ 185.67 % $ $

2029 11606 Exc TR-Ext Mal 1 EA $ 303.71 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

2030 11620 Exc h-f-nk-sp Mal 4 EA $ 114.14 % $ $

2031 11621 Exc h-f-nk-sp Mal 2 EA $ 141.58 % $ $

2032 11622 Exc h-f-nk-sp Mal 4 EA $ 162.03 % $ $

2033 11624 Exc h-f-nk-sp Mal 1 EA $ 227.94 % $ $

2034 11640 Exc h-f-nk-sp Mal 4 EA $ 118.04 % $ $

2035 11641 Exc h-f-nk-sp Mal 2 EA $ 147.54 % $ $

2036 11642 Exc h-f-nk-sp Mal 6 EA $ 173.87 % $ $

2037 11643 Exc h-f-nk-sp Mal 1 EA $ 218.24 % $ $

2038 11771 Remove pilonidal cyst exten 6 EA $ 407.01 % $ $

2039 12001 Repair Superficial Wound 1 EA $ 42.57 % $ $

2040 12004 Repair Superficial Wound 1 EA $ 70.22 % $ $

2041 12011 Repair Superficial Wound 1 EA $ 53.04 % $ $

2042 12013 Repair Superficial Wound 1 EA $ 55.92 % $ $

2043 15120 Skn Splt A-Grft 2 EA $ 651.47 % $ $

2044 15734 Muscle Skin Grft Trunk 3 EA $ 1,424.92 % $ $

2045 17100 Destruction Premalig Lesion 3 EA $ 49.36 % $ $

2046 17003 Destruction Premalig Lesion 2-14 3 EA $ 2.28 % $ $

2047 17282 Destruction Skin Lesion 1 EA $ 136.19 % $ $

2048 19120 Removal of breast lesion 2 EA $ 386.03 % $ $

2049 19300 Removal of breast tissue 3 EA $ 385.98 % $ $

2050 21552 Exc Face Less SBQ 3 cm /> 2 EA $ 418.47 % $ $

2051 21554 Exc Face Less SBQ 5 cm /> 2 EA $ 687.25 % $ $

2052 21555 Exc Neck Less SC < 3 cm 1 EA $ 285.34 % $ $

2053 21920 Biopsy Soft Tissue Back 1 EA $ 150.51 % $ $

2054 21931 Exc back les sc 3 cm/> 1 EA $ 440.75 % $ $

2055 21933 Exc back tum deep 5 cm/> 1 EA $ 683.30 % $ $

2056 22900 Exc Abdl Tum Deep 2 EA $ 529.68 % $ $

2057 22903 Exc Abd less SC 3 cm /> 2 EA $ 411.41 % $ $

2058 27590 Amputate leg at thigh 3 EA $ 753.78 % $ $

2059 27880 Amputation of lower leg 4 EA $ 865.12 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

2060 28805 Amputation thru metatarsal 5 EA $ 699.25 % $ $

2061 28810 Amputation toe & metatarsal 6 EA $ 408.03 % $ $

2062 28820 Amputation toe 3 EA $ 375.75 % $ $

2063 36556 Insert non-tunnel cv cath 4 EA $ 94.46 % $ $

2064 36561 Insert tunneled cv cath 7 EA $ 323.77 % $ $

2065 36590 Removal tunneled cv cath 5 EA $ 193.26 % $ $

2066 38500 Biopsy/removal lymph nodes 2 EA $ 238.61 % $ $

2067 38510 Biopsy/removal lymph nodes 3 EA $ 395.47 % $ $

2068 43235 Egd diagnostic brush wash 200 EA $ 119.86 % $ $

2069 43236 Upper GI Scope W/Submuc Inj 1 EA $ 135.47 % $ $

2070 43239 Egd biopsy single/multiple 300 EA $ 135.16 % $ $

2071 43245 Upper GI Scope Dilate Strictr 3 EA $ 171.48 % $ $

2072 43246 Place gastrostomy tube 20 EA $ 195.13 % $ $

2073 43247 Operative Upper GI Endoscopy 10 EA $ 173.51 % $ $

2074 43248 Uppr GI Endoscopy/Guide Wire 10 EA $ 162.66 % $ $

2075 43249 Esoph egd dilation <30 mm 30 EA $ 149.84 % $ $

2076 43250 Dilate Esophagus 20 EA $ 165.95 % $ $

2077 43251 Operative Upper GI Endoscopy 19 EA $ 192.43 % $ $

2078 43255 Operative Upper GI Endoscopy 1 EA $ 197.03 % $ $

2079 43280 Laparoscopy fundoplasty 3 EA $ 1,021.31 % $ $

2080 43450 Dilate Esophagus 30 EA $ 77.23 % $ $

2081 43633 Removal of stomach partial 3 EA $ 1,817.70 % $ $

2082 43760 Change gastrostomy tube 20 EA $ 45.45 % $ $

2083 43800 Reconsstruction Pylorus 1 EA $ 877.18 % $ $

2084 43830 Place gastrostomy tube 8 EA $ 658.94 % $ $

2085 44050 Reduce bowel obstruction 3 EA $ 882.83 % $ $

2086 44120 Removal Small Intestine 5 EA $ 1,158.68 % $ $

2087 44139 Mobilization of colon 5 EA $ 115.76 % $ $

2088 44140 Partial removal of colon 10 EA $ 1,270.05 % $ $

2089 44141 Partial removal of colon 3 EA $ 1,727.56 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

2090 44145 Partial removal of colon 10 EA $ 1,575.39 % $ $

2091 44147 Partial removal of colon 10 EA $ 1,842.80 % $ $

2092 44160 Removal of colon 5 EA $ 1,176.29 % $ $

2093 44188 Lap Colostomy 3 EA $ 1,160.61 % $ $

2094 44204 Laparo partial colectomy 10 EA $ 1,462.25 % $ $

2095 44205 Lap colectomy part w/ileum 10 EA $ 1,272.08 % $ $

2096 44207 L colectomy/coloproctostomy 8 EA $ 1,736.07 % $ $

2097 44213 Lap mobil splenic fl add-on 3 EA $ 180.27 % $ $

2098 44300 Open Bowel to Skin 1 EA $ 785.14 % $ $

2099 44320 Colostomy 5 EA $ 1,137.92 % $ $

2100 44380 Small Bowel Endoscopy 1 EA $ 54.95 % $ $

2101 44388 Colonoscopy thru stoma spx 5 EA $ 152.25 % $ $

2102 44389 Colonoscopy with Biopsy 1 EA $ 168.07 % $ $

2103 44602 Suture small intestine 1 EA $ 1,338.26 % $ $

2104 44604 Suture large intestine 1 EA $ 989.85 % $ $

2105 44625 Repair bowel opening 1 EA $ 967.77 % $ $

2106 44626 Repair bowel opening 6 EA $ 1,521.50 % $ $

2107 44640 Repair bowel-skin fistula 2 EA $ 1,329.96 % $ $

2108 44650 Repair bowel fistula 2 EA $ 1,374.17 % $ $

2109 44661 Repair Bowel-Bladder Fistula 2 EA $ 1,479.11 % $ $

2110 44900 Drain App Abscess Open 2 EA $ 730.48 % $ $

2111 44960 Appendectomy 3 EA $ 825.11 % $ $

2112 44970 Laparoscopy appendectomy 18 EA $ 566.21 % $ $

2113 45100 Biopsy Rectum 1 EA $ 282.26 % $ $

2114 45112 Removal Rectum 1 EA $ 1,793.14 % $ $

2115 45171 Exc Tect Tum Transanal Part 2 EA $ 567.15 % $ $

2116 45172 Exc rect tum transanal full 2 EA $ 771.37 % $ $

2117 45300 Proscosigmoidoscopy 2 EA $ 51.59 % $ $

2118 45330 Diagnostic Sigmoidoscopy 15 EA $ 54.07 % $ $

2119 45331 Sigmoidoscopy and Biopsy 8 EA $ 69.58 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

2120 45333 Sigmoidoscopy and Polypectomy 5 EA $ 90.91 % $ $

2121 45335 Sigmoidoscopy W/Submuc Inj 2 EA $ 64.09 % $ $

2122 45338 Sigmoidoscopy W/Tumr Remov 1 EA $ 117.48 % $ $

2123 45378 Diagnostic colonoscopy 400 EA $ 180.78 % $ $

2124 45380 Colonoscopy and biopsy 310 EA $ 196.81 % $ $

2125 45381 Colonoscopy submucous njx 60 EA $ 196.81 % $ $

2126 45382 Colonoscopy w/control bleed 2 EA $ 254.28 % $ $

2127 45384 Colonoscopy w/ Lesion Removal 250 EA $ 225.30 % $ $

2128 45385 Colonoscopy w/lesion removal 150 EA $ 249.37 % $ $

2129 45386 Colonoscopy Dilate Stricture 4 EA $ 207.40 % $ $

2130 45990 Surg dx exam anorectal 2 EA $ 102.20 % $ $

2131 46040 Incision of rectal abscess 8 EA $ 389.20 % $ $

2132 46200 Removal Anal Fissure 3 EA $ 304.91 % $ $

2133 46250 Remove Ext Hem Groups 2+ 2 EA $ 296.50 % $ $

2134 46260 Remove in/ex hem groups 2+ 9 EA $ 441.61 % $ $

2135 46270 Removal Anal Fissure SubQ 6 EA $ 367.05 % $ $

2136 46600 Diagnostic Anoscopy 3 EA $ 38.93 % $ $

2137 46604 Anoscopy and dilation 6 EA $ 63.31 % $ $

2138 46922 Excision of anal lesion(s) 3 EA $ 127.71 % $ $

2139 46947 Hemorrhoidopexy by stapling 5 EA $ 359.86 % $ $

2140 47100 Wedge biopsy of liver 5 EA $ 794.32 % $ $

2141 47562 Laparoscopic cholecystectomy 45 EA $ 619.84 % $ $

2142 47563 Laparo cholecystectomy/graph 50 EA $ 673.05 % $ $

2143 47600 Removal of gallbladder 4 EA $ 1,006.97 % $ $

2144 47605 Removal Gallbladder 4 EA $ 1,060.19 % $ $

2145 49100 Exploration of abdomen 2 EA $ 727.15 % $ $

2146 49002 Reopening of abdomen 3 EA $ 977.42 % $ $

2147 49020 Drainage abdom abscess open 3 EA $ 1,504.56 % $ $

2148 49320 Diag Laparo Separate Proc 2 EA $ 308.52 % $ $

2149 49322 Laparoscopy Aspiration 2 EA $ 350.70 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

2150 49402 Remove foreign body Abdomen 2 EA $ 808.92 % $ $

2151 49505 Prp i/hern init reduc >5 yr 100 EA $ 488.89 % $ $

2152 49520 Rerepair ing hernia reduce 11 EA $ 594.42 % $ $

2153 49521 Rerepair ing hernia blocked 11 EA $ 674.57 % $ $

2154 49550 Rpr Rem Hernia Init Reduce 2 EA $ 541.30 % $ $

2155 49555 Rerepair fem hernia reduce 1 EA $ 563.43 % $ $

2156 49560 Rpr ventral hern init reduc 16 EA $ 695.31 % $ $

2157 49561 Rpr ventral hern init block 25 EA $ 877.06 % $ $

2158 49565 Rerepair ventrl hern reduce 6 EA $ 723.85 % $ $

2159 49566 Rerepair ventrl hern block 9 EA $ 885.07 % $ $

2160 49568 Hernia repair w/mesh 49 EA $ 254.04 % $ $

2161 49582 Rpr Umb Hern Block 1 EA $ 452.44 % $ $

2162 49585 Rpr umbil hern reduc > 5 yr 19 EA $ 417.76 % $ $

2163 49587 Rpr umbil hern block > 5 yr 41 EA $ 446.26 % $ $

2164 99203 Office/outpatient visit new 1,225 EA $ 73.06 % $ $

2165 99204 Office/outpatient visit new 45 EA $ 123.75 % $ $

Total Estimate for Option Year 2: $________________________________

Period of Performance: OPTION 3: June 01, 2021 to May 31, 2022

CLIN HCPCS Short Description

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

3001 10060 Drainage of skin abscess 2 EA $ 91.82 % $ $

3002 10061 Drainage of skin abscess 4 EA $ 169.55 % $ $

3003 10081 Drainage Pilonidal Cyst 5 EA $ 160.77 % $ $

3004 10120 Remove foreign body 4 EA $ 97.36 % $ $

3005 10121 Remove foreign body 1 EA $ 175.16 % $ $

3006 10140 Drainage hematoma 1 EA $ 111.88 % $ $

3007 10180 Complex Drainage Wound 3 EA $ 166.31 % $ $

3008 11008 Remove mesh from abd wall 3 EA $ 260.88 % $ $

3009 11042 Debride SubQ Tissue 2 EA $ 59.25 % $ $

3010 11043 Deb musc/fascia 20 sq cm/< 1 EA $ 148.71 % $ $

3011 11044 Deb Bone 20 sq cm/< 3 EA $ 220.20 % $ $

3012 11100 Biopsy Skin Lesion 2 EA $ 46.82 % $ $

3013 11400 Exc tr-ext b9+marg< 0.5 cm 4 EA $ 75.59 % $ $

3014 11403 Exc tr-ext b9+marg 2.1 - 3 cm 4 EA $ 138.28 % $ $

3015 11404 Exc tr-ext b9+marg 3.1 - 4 cm 4 EA $ 151.96 % $ $

3016 11406 Exc tr-ext b9+marg >4.0 cm 5 EA $ 231.96 % $ $

3017 11420 Exc h-f-nk-sp b9+marg < 0.5 6 EA $ 76.61 % $ $

3018 11421 Exc h-f-nk-sp b9+marg 0.6 - 1 5 EA $ 103.53 % $ $

3019 11422 Exc h-f-nk-sp b9+marg 1.1 - 2 5 EA $ 128.03 % $ $

3020 11423 Exc h-f-nk-sp b9+marg 2.1-3 2 EA $ 147.03 % $ $

3021 11424 Exc h-f-nk-sp b9+marg 3.1 - 4 1 EA $ 169.04 % $ $

3022 11426 Exc h-f-nk-sp b9+marg >4 2 EA $ 259.90 % $ $

3023 11441 Exc Face-MM 3 EA $ 123.05 % $ $

3024 11442 Exc Face-MM 3 EA $ 135.87 % $ $

3025 11444 Exc Face-MM 1 EA $ 213.73 % $ $

3026 11601 Exc TR-Ext Mal 3 EA $ 140.70 % $ $

3027 11602 Exc TR-Ext Mal 3 EA $ 154.80 % $ $

3028 11603 Exc TR-Ext Mal 2 EA $ 185.67 % $ $

3029 11606 Exc TR-Ext Mal 1 EA $ 303.71 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

3030 11620 Exc h-f-nk-sp Mal 4 EA $ 114.14 % $ $

3031 11621 Exc h-f-nk-sp Mal 2 EA $ 141.58 % $ $

3032 11622 Exc h-f-nk-sp Mal 4 EA $ 162.03 % $ $

3033 11624 Exc h-f-nk-sp Mal 1 EA $ 227.94 % $ $

3034 11640 Exc h-f-nk-sp Mal 4 EA $ 118.04 % $ $

3035 11641 Exc h-f-nk-sp Mal 2 EA $ 147.54 % $ $

3036 11642 Exc h-f-nk-sp Mal 6 EA $ 173.87 % $ $

3037 11643 Exc h-f-nk-sp Mal 1 EA $ 218.24 % $ $

3038 11771 Remove pilonidal cyst exten 6 EA $ 407.01 % $ $

3039 12001 Repair Superficial Wound 1 EA $ 42.57 % $ $

3040 12004 Repair Superficial Wound 1 EA $ 70.22 % $ $

3041 12011 Repair Superficial Wound 1 EA $ 53.04 % $ $

3042 12013 Repair Superficial Wound 1 EA $ 55.92 % $ $

3043 15120 Skn Splt A-Grft 2 EA $ 651.47 % $ $

3044 15734 Muscle Skin Grft Trunk 3 EA $ 1,424.92 % $ $

3045 17100 Destruction Premalig Lesion 3 EA $ 49.36 % $ $

3046 17003 Destruction Premalig Lesion 2-14 3 EA $ 2.28 % $ $

3047 17282 Destruction Skin Lesion 1 EA $ 136.19 % $ $

3048 19120 Removal of breast lesion 2 EA $ 386.03 % $ $

3049 19300 Removal of breast tissue 3 EA $ 385.98 % $ $

3050 21552 Exc Face Less SBQ 3 cm /> 2 EA $ 418.47 % $ $

3051 21554 Exc Face Less SBQ 5 cm /> 2 EA $ 687.25 % $ $

3052 21555 Exc Neck Less SC < 3 cm 1 EA $ 285.34 % $ $

3053 21920 Biopsy Soft Tissue Back 1 EA $ 150.51 % $ $

3054 21931 Exc back les sc 3 cm/> 1 EA $ 440.75 % $ $

3055 21933 Exc back tum deep 5 cm/> 1 EA $ 683.30 % $ $

3056 22900 Exc Abdl Tum Deep 2 EA $ 529.68 % $ $

3057 22903 Exc Abd less SC 3 cm /> 2 EA $ 411.41 % $ $

3058 27590 Amputate leg at thigh 3 EA $ 753.78 % $ $

3059 27880 Amputation of lower leg 4 EA $ 865.12 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

3060 28805 Amputation thru metatarsal 5 EA $ 699.25 % $ $

3061 28810 Amputation toe & metatarsal 6 EA $ 408.03 % $ $

3062 28820 Amputation toe 3 EA $ 375.75 % $ $

3063 36556 Insert non-tunnel cv cath 4 EA $ 94.46 % $ $

3064 36561 Insert tunneled cv cath 7 EA $ 323.77 % $ $

3065 36590 Removal tunneled cv cath 5 EA $ 193.26 % $ $

3066 38500 Biopsy/removal lymph nodes 2 EA $ 238.61 % $ $

3067 38510 Biopsy/removal lymph nodes 3 EA $ 395.47 % $ $

3068 43235 Egd diagnostic brush wash 200 EA $ 119.86 % $ $

3069 43236 Upper GI Scope W/Submuc Inj 1 EA $ 135.47 % $ $

3070 43239 Egd biopsy single/multiple 300 EA $ 135.16 % $ $

3071 43245 Upper GI Scope Dilate Strictr 3 EA $ 171.48 % $ $

3072 43246 Place gastrostomy tube 20 EA $ 195.13 % $ $

3073 43247 Operative Upper GI Endoscopy 10 EA $ 173.51 % $ $

3074 43248 Uppr GI Endoscopy/Guide Wire 10 EA $ 162.66 % $ $

3075 43249 Esoph egd dilation <30 mm 30 EA $ 149.84 % $ $

3076 43250 Dilate Esophagus 20 EA $ 165.95 % $ $

3077 43251 Operative Upper GI Endoscopy 19 EA $ 192.43 % $ $

3078 43255 Operative Upper GI Endoscopy 1 EA $ 197.03 % $ $

3079 43280 Laparoscopy fundoplasty 3 EA $ 1,021.31 % $ $

3080 43450 Dilate Esophagus 30 EA $ 77.23 % $ $

3081 43633 Removal of stomach partial 3 EA $ 1,817.70 % $ $

3082 43760 Change gastrostomy tube 20 EA $ 45.45 % $ $

3083 43800 Reconsstruction Pylorus 1 EA $ 877.18 % $ $

3084 43830 Place gastrostomy tube 8 EA $ 658.94 % $ $

3085 44050 Reduce bowel obstruction 3 EA $ 882.83 % $ $

3086 44120 Removal Small Intestine 5 EA $ 1,158.68 % $ $

3087 44139 Mobilization of colon 5 EA $ 115.76 % $ $

3088 44140 Partial removal of colon 10 EA $ 1,270.05 % $ $

3089 44141 Partial removal of colon 3 EA $ 1,727.56 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

3090 44145 Partial removal of colon 10 EA $ 1,575.39 % $ $

3091 44147 Partial removal of colon 10 EA $ 1,842.80 % $ $

3092 44160 Removal of colon 5 EA $ 1,176.29 % $ $

3093 44188 Lap Colostomy 3 EA $ 1,160.61 % $ $

3094 44204 Laparo partial colectomy 10 EA $ 1,462.25 % $ $

3095 44205 Lap colectomy part w/ileum 10 EA $ 1,272.08 % $ $

3096 44207 L colectomy/coloproctostomy 8 EA $ 1,736.07 % $ $

3097 44213 Lap mobil splenic fl add-on 3 EA $ 180.27 % $ $

3098 44300 Open Bowel to Skin 1 EA $ 785.14 % $ $

3099 44320 Colostomy 5 EA $ 1,137.92 % $ $

3100 44380 Small Bowel Endoscopy 1 EA $ 54.95 % $ $

3101 44388 Colonoscopy thru stoma spx 5 EA $ 152.25 % $ $

3102 44389 Colonoscopy with Biopsy 1 EA $ 168.07 % $ $

3103 44602 Suture small intestine 1 EA $ 1,338.26 % $ $

3104 44604 Suture large intestine 1 EA $ 989.85 % $ $

3105 44625 Repair bowel opening 1 EA $ 967.77 % $ $

3106 44626 Repair bowel opening 6 EA $ 1,521.50 % $ $

3107 44640 Repair bowel-skin fistula 2 EA $ 1,329.96 % $ $

3108 44650 Repair bowel fistula 2 EA $ 1,374.17 % $ $

3109 44661 Repair Bowel-Bladder Fistula 2 EA $ 1,479.11 % $ $

3110 44900 Drain App Abscess Open 2 EA $ 730.48 % $ $

3111 44960 Appendectomy 3 EA $ 825.11 % $ $

3112 44970 Laparoscopy appendectomy 18 EA $ 566.21 % $ $

3113 45100 Biopsy Rectum 1 EA $ 282.26 % $ $

3114 45112 Removal Rectum 1 EA $ 1,793.14 % $ $

3115 45171 Exc Tect Tum Transanal Part 2 EA $ 567.15 % $ $

3116 45172 Exc rect tum transanal full 2 EA $ 771.37 % $ $

3117 45300 Proscosigmoidoscopy 2 EA $ 51.59 % $ $

3118 45330 Diagnostic Sigmoidoscopy 15 EA $ 54.07 % $ $

3119 45331 Sigmoidoscopy and Biopsy 8 EA $ 69.58 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

3120 45333 Sigmoidoscopy and Polypectomy 5 EA $ 90.91 % $ $

3121 45335 Sigmoidoscopy W/Submuc Inj 2 EA $ 64.09 % $ $

3122 45338 Sigmoidoscopy W/Tumr Remov 1 EA $ 117.48 % $ $

3123 45378 Diagnostic colonoscopy 400 EA $ 180.78 % $ $

3124 45380 Colonoscopy and biopsy 310 EA $ 196.81 % $ $

3125 45381 Colonoscopy submucous njx 60 EA $ 196.81 % $ $

3126 45382 Colonoscopy w/control bleed 2 EA $ 254.28 % $ $

3127 45384 Colonoscopy w/ Lesion Removal 250 EA $ 225.30 % $ $

3128 45385 Colonoscopy w/lesion removal 150 EA $ 249.37 % $ $

3129 45386 Colonoscopy Dilate Stricture 4 EA $ 207.40 % $ $

3130 45990 Surg dx exam anorectal 2 EA $ 102.20 % $ $

3131 46040 Incision of rectal abscess 8 EA $ 389.20 % $ $

3132 46200 Removal Anal Fissure 3 EA $ 304.91 % $ $

3133 46250 Remove Ext Hem Groups 2+ 2 EA $ 296.50 % $ $

3134 46260 Remove in/ex hem groups 2+ 9 EA $ 441.61 % $ $

3135 46270 Removal Anal Fissure SubQ 6 EA $ 367.05 % $ $

3136 46600 Diagnostic Anoscopy 3 EA $ 38.93 % $ $

3137 46604 Anoscopy and dilation 6 EA $ 63.31 % $ $

3138 46922 Excision of anal lesion(s) 3 EA $ 127.71 % $ $

3139 46947 Hemorrhoidopexy by stapling 5 EA $ 359.86 % $ $

3140 47100 Wedge biopsy of liver 5 EA $ 794.32 % $ $

3141 47562 Laparoscopic cholecystectomy 45 EA $ 619.84 % $ $

3142 47563 Laparo cholecystectomy/graph 50 EA $ 673.05 % $ $

3143 47600 Removal of gallbladder 4 EA $ 1,006.97 % $ $

3144 47605 Removal Gallbladder 4 EA $ 1,060.19 % $ $

3145 49100 Exploration of abdomen 2 EA $ 727.15 % $ $

3146 49002 Reopening of abdomen 3 EA $ 977.42 % $ $

3147 49020 Drainage abdom abscess open 3 EA $ 1,504.56 % $ $

3148 49320 Diag Laparo Separate Proc 2 EA $ 308.52 % $ $

3149 49322 Laparoscopy Aspiration 2 EA $ 350.70 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

3150 49402 Remove foreign body Abdomen 2 EA $ 808.92 % $ $

3151 49505 Prp i/hern init reduc >5 yr 100 EA $ 488.89 % $ $

3152 49520 Rerepair ing hernia reduce 11 EA $ 594.42 % $ $

3153 49521 Rerepair ing hernia blocked 11 EA $ 674.57 % $ $

3154 49550 Rpr Rem Hernia Init Reduce 2 EA $ 541.30 % $ $

3155 49555 Rerepair fem hernia reduce 1 EA $ 563.43 % $ $

3156 49560 Rpr ventral hern init reduc 16 EA $ 695.31 % $ $

3157 49561 Rpr ventral hern init block 25 EA $ 877.06 % $ $

3158 49565 Rerepair ventrl hern reduce 6 EA $ 723.85 % $ $

3159 49566 Rerepair ventrl hern block 9 EA $ 885.07 % $ $

3160 49568 Hernia repair w/mesh 49 EA $ 254.04 % $ $

3161 49582 Rpr Umb Hern Block 1 EA $ 452.44 % $ $

3162 49585 Rpr umbil hern reduc > 5 yr 19 EA $ 417.76 % $ $

3163 49587 Rpr umbil hern block > 5 yr 41 EA $ 446.26 % $ $

3164 99203 Office/outpatient visit new 1,225 EA $ 73.06 % $ $

3165 99204 Office/outpatient visit new 45 EA $ 123.75 % $ $

Total Estimate for Option Year 3: $________________________________

Period of Performance: OPTION 4: June 01, 2022 to May 31, 2023

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

4001 10060 Drainage of skin abscess 2 EA $ 91.82 % $ $

4002 10061 Drainage of skin abscess 4 EA $ 169.55 % $ $

4003 10081 Drainage Pilonidal Cyst 5 EA $ 160.77 % $ $

4004 10120 Remove foreign body 4 EA $ 97.36 % $ $

4005 10121 Remove foreign body 1 EA $ 175.16 % $ $

4006 10140 Drainage hematoma 1 EA $ 111.88 % $ $

4007 10180 Complex Drainage Wound 3 EA $ 166.31 % $ $

4008 11008 Remove mesh from abd wall 3 EA $ 260.88 % $ $

4009 11042 Debride SubQ Tissue 2 EA $ 59.25 % $ $

4010 11043 Deb musc/fascia 20 sq cm/< 1 EA $ 148.71 % $ $

4011 11044 Deb Bone 20 sq cm/< 3 EA $ 220.20 % $ $

4012 11100 Biopsy Skin Lesion 2 EA $ 46.82 % $ $

4013 11400 Exc tr-ext b9+marg< 0.5 cm 4 EA $ 75.59 % $ $

4014 11403 Exc tr-ext b9+marg 2.1 - 3 cm 4 EA $ 138.28 % $ $

4015 11404 Exc tr-ext b9+marg 3.1 - 4 cm 4 EA $ 151.96 % $ $

4016 11406 Exc tr-ext b9+marg >4.0 cm 5 EA $ 231.96 % $ $

4017 11420 Exc h-f-nk-sp b9+marg < 0.5 6 EA $ 76.61 % $ $

4018 11421 Exc h-f-nk-sp b9+marg 0.6 - 1 5 EA $ 103.53 % $ $

4019 11422 Exc h-f-nk-sp b9+marg 1.1 - 2 5 EA $ 128.03 % $ $

4020 11423 Exc h-f-nk-sp b9+marg 2.1-3 2 EA $ 147.03 % $ $

4021 11424 Exc h-f-nk-sp b9+marg 3.1 - 4 1 EA $ 169.04 % $ $

4022 11426 Exc h-f-nk-sp b9+marg >4 2 EA $ 259.90 % $ $

4023 11441 Exc Face-MM 3 EA $ 123.05 % $ $

4024 11442 Exc Face-MM 3 EA $ 135.87 % $ $

4025 11444 Exc Face-MM 1 EA $ 213.73 % $ $

4026 11601 Exc TR-Ext Mal 3 EA $ 140.70 % $ $

4027 11602 Exc TR-Ext Mal 3 EA $ 154.80 % $ $

4028 11603 Exc TR-Ext Mal 2 EA $ 185.67 % $ $

4029 11606 Exc TR-Ext Mal 1 EA $ 303.71 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total Fee Per

Year

4030 11620 Exc h-f-nk-sp Mal 4 EA $ 114.14 % $ $

4031 11621 Exc h-f-nk-sp Mal 2 EA $ 141.58 % $ $

4032 11622 Exc h-f-nk-sp Mal 4 EA $ 162.03 % $ $

4033 11624 Exc h-f-nk-sp Mal 1 EA $ 227.94 % $ $

4034 11640 Exc h-f-nk-sp Mal 4 EA $ 118.04 % $ $

4035 11641 Exc h-f-nk-sp Mal 2 EA $ 147.54 % $ $

4036 11642 Exc h-f-nk-sp Mal 6 EA $ 173.87 % $ $

4037 11643 Exc h-f-nk-sp Mal 1 EA $ 218.24 % $ $

4038 11771 Remove pilonidal cyst exten 6 EA $ 407.01 % $ $

4039 12001 Repair Superficial Wound 1 EA $ 42.57 % $ $

4040 12004 Repair Superficial Wound 1 EA $ 70.22 % $ $

4041 12011 Repair Superficial Wound 1 EA $ 53.04 % $ $

4042 12013 Repair Superficial Wound 1 EA $ 55.92 % $ $

4043 15120 Skn Splt A-Grft 2 EA $ 651.47 % $ $

4044 15734 Muscle Skin Grft Trunk 3 EA $ 1,424.92 % $ $

4045 17100 Destruction Premalig Lesion 3 EA $ 49.36 % $ $

4046 17003 Destruction Premalig Lesion 2-14 3 EA $ 2.28 % $ $

4047 17282 Destruction Skin Lesion 1 EA $ 136.19 % $ $

4048 19120 Removal of breast lesion 2 EA $ 386.03 % $ $

4049 19300 Removal of breast tissue 3 EA $ 385.98 % $ $

4050 21552 Exc Face Less SBQ 3 cm /> 2 EA $ 418.47 % $ $

4051 21554 Exc Face Less SBQ 5 cm /> 2 EA $ 687.25 % $ $

4052 21555 Exc Neck Less SC < 3 cm 1 EA $ 285.34 % $ $

4053 21920 Biopsy Soft Tissue Back 1 EA $ 150.51 % $ $

4054 21931 Exc back les sc 3 cm/> 1 EA $ 440.75 % $ $

4055 21933 Exc back tum deep 5 cm/> 1 EA $ 683.30 % $ $

4056 22900 Exc Abdl Tum Deep 2 EA $ 529.68 % $ $

4057 22903 Exc Abd less SC 3 cm /> 2 EA $ 411.41 % $ $

4058 27590 Amputate leg at thigh 3 EA $ 753.78 % $ $

4059 27880 Amputation of lower leg 4 EA $ 865.12 % $ $

EST

QTY U/I

CMS UNIT

COST

% of CMS

UNIT

COST

FIXED

PRICE EA

Estimated Total…