36C25821Q0037 0002.docx

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

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) 01-29-2021

NONE

Department of Veterans Affairs NCO22-Gilbert Network Contracting 3601 S. 6th Avenue Tucson AZ 85723 Department of Veterans Affairs NCO22-Gilbert Network Contracting 3601 S. 6th Avenue Tucson AZ 85723 To all Offerors/Bidders

36C25821Q0037 01-29-2021

X X

X The purpose of this Amendment is to:

A. PWS Paragraph 3.0 (e), solicitation page 24 of 100 revised From : The contractor agrees to be reimbursed for services in relation to current Medicare rates applicable to the appropriate CPT codes (Listed in Schedule) under Medicare Locality Fee Schedule-Arizona Locality 01.

TO: The contractor agrees to be reimbursed for services based on current Medicare rates applicable to the appropriate CPT codes (listed in Schedule) under Medicare Locality Fee Schedule-Arizona Locality 01.

B. B.3 Price/Cost Schedule CLINS 0001, 1001, 2001, 3001, 4001 Revised From: CPT CODE: 95941 Intra-operative Monitoring (per hour).

TO: CPT CODE: G0453 Intra-operative Monitoring (per 15 minutes).

A.1 PRICE/COST SCHEDULE

ITEM INFORMATION

CPT CODE: G0453 Intra-operative Monitoring (per 15 minutes) Contract Period: Base POP Begin: 04-01-2021 POP End: 03-31-2022

CPT CODE: 95860 Needle EMG - 1 Extremity

CPT CODE: 95861 Needle EMG - 2 Extremities

CPT CODE: 95864 Needle EMG - 4 Extremities

CPT CODE: 95867 Needle EMG - Cranial, Unilateral

CCPT CODE: 51785 Needle EMG - Anal/Urethral/Sphincter

CPT CODE: 92585 ABR (Auditory Evoked Potential; Comprehensive)

CPT CODE: 95930 VER (Visual Evoked Potential, VEP; Checkerboard or Flash

CPT CODE: 95925 SSEP Upper Limbs

CPT CODE: 95926 SSEP Lower Limbs

CPT CODE: 95928 Trans-cranial Motor Stimulation – Uppers

CPT CODE: 95929 Trans-cranial Motor Stimulation – Lowers

CPT CODE: G0453 Intra-operative Monitoring (per 15 minutes) Contract Period: Option 1 POP Begin: 04-01-2022 POP End: 03-31-2023

CPT CODE: 95860 Needle EMG - 1 Extremity

CPT CODE: 95861 Needle EMG - 2 Extremities

CPT CODE: 95864 Needle EMG - 4 Extremities

CPT CODE: 95867 Needle EMG - Cranial, Unilateral

CCPT CODE: 51785 Needle EMG - Anal/Urethral/Sphincter

CPT CODE: 92585 ABR (Auditory Evoked Potential; Comprehensive)

CPT CODE: 95930 VER (Visual Evoked Potential, VEP; Checkerboard or Flash

CPT CODE: 95925 SSEP Upper Limbs

CPT CODE: 95926 SSEP Lower Limbs

CPT CODE: 95928 Trans-cranial Motor Stimulation – Uppers

CPT CODE: 95929 Trans-cranial Motor Stimulation – Lowers

CPT CODE: G0453 Intra-operative Monitoring (per 15 minutes) Contract Period: Option 2 POP Begin: 04-01-2023 POP End: 03-31-2024

CPT CODE: 95860 Needle EMG - 1 Extremity

CPT CODE: 95861 Needle EMG - 2 Extremities

CPT CODE: 95864 Needle EMG - 4 Extremities

CPT CODE: 95867 Needle EMG - Cranial, Unilateral

CCPT CODE: 51785 Needle EMG - Anal/Urethral/Sphincter

CPT CODE: 92585 ABR (Auditory Evoked Potential; Comprehensive)

CPT CODE: 95930 VER (Visual Evoked Potential, VEP; Checkerboard or Flash

CPT CODE: 95925 SSEP Upper Limbs

CPT CODE: 95926 SSEP Lower Limbs

CPT CODE: 95928 Trans-cranial Motor Stimulation – Uppers

CPT CODE: 95929 Trans-cranial Motor Stimulation – Lowers

CPT CODE: G0453 Intra-operative Monitoring (per 15 minutes) Contract Period: Option 3 POP Begin: 04-01-2024 POP End: 03-31-2025

CPT CODE: 95860 Needle EMG - 1 Extremity

CPT CODE: 95861 Needle EMG - 2 Extremities

CPT CODE: 95864 Needle EMG - 4 Extremities

CPT CODE: 95867 Needle EMG - Cranial, Unilateral

CCPT CODE: 51785 Needle EMG - Anal/Urethral/Sphincter

CPT CODE: 92585 ABR (Auditory Evoked Potential; Comprehensive)

CPT CODE: 95930 VER (Visual Evoked Potential, VEP; Checkerboard or Flash

CPT CODE: 95925 SSEP Upper Limbs

CPT CODE: 95926 SSEP Lower Limbs

CPT CODE: 95928 Trans-cranial Motor Stimulation – Uppers

CPT CODE: 95929 Trans-cranial Motor Stimulation – Lowers

CPT CODE: G0453 Intra-operative Monitoring (per 15 minutes) Contract Period: Option 4 POP Begin: 04-01-2025 POP End: 03-31-2026

CPT CODE: 95860 Needle EMG - 1 Extremity

CPT CODE: 95861 Needle EMG - 2 Extremities

CPT CODE: 95864 Needle EMG - 4 Extremities

CPT CODE: 95867 Needle EMG - Cranial, Unilateral

CCPT CODE: 51785 Needle EMG - Anal/Urethral/Sphincter

CPT CODE: 92585 ABR (Auditory Evoked Potential; Comprehensive)

CPT CODE: 95930 VER (Visual Evoked Potential, VEP; Checkerboard or Flash

CPT CODE: 95925 SSEP Upper Limbs

CPT CODE: 95926 SSEP Lower Limbs

CPT CODE: 95928 Trans-cranial Motor Stimulation – Uppers

CPT CODE: 95929 Trans-cranial Motor Stimulation – Lowers