36C26318R0477-010.xlsx

XLSX spreadsheet 30 KB Posted Jul 27, 2018

Attached to: Pathology Services Des Moines POP: PO#
Solicitation number: 36C26318R0477
Issued by: Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 23

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36C26318R0477 D.9 - Price Schedule.xlsx

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Pathology Price Schedule

	Pathology and Laboratory Testing Services Price Schedule
						103%			103%			103%			103%
			Ordering Period December 1, 2018 - November 30, 2019			Ordering Period December 1, 2019 - November 30, 2020			Ordering Period December 1, 2020 - November 30, 2021			Ordering Period December 1, 2021 - November 30, 2022			Ordering Period December 1, 2022 - November 30, 2023			Minimum	Maximum
CLIN	TESTING PROCEDURE/OFF SITE	CPT	Est Qty	CMS Rate	Extended Amount	Est Qty	CMS Rate	Extended Amount	Est Qty	CMS Rate	Extended Amount	Est Qty	CMS Rate	Extended Amount	Est Qty	CMS Rate	Extended Amount	Minimum	Maximum
0001	CALR GENE COM VARIANTS	81219	3	$	$	3	$	$	3	$	$	3	$	$	3	$	$	0	24
0002	EGFR Gene Com Variants	81235	4	$	$	4	$	$	4	$	$	4	$	$	5	$	$	1	32
0003	JAK2 Gene	81270	3	$	$	3	$	$	3	$	$	3	$	$	3	$	$	1	24
0004	PML/RARalpha	81315	2	$	$	2	$	$	2	$	$	2	$	$	2	$	$	1	16
0005	T Cell receptor rearrangement	81342	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0006	Unlisted molecular pathology procedure	81479	3	$	$	3	$	$	3	$	$	3	$	$	3	$	$	1	24
0007	Bone Marrow Interpretation	85097	41	$	$	42	$	$	43	$	$	45	$	$	46	$	$	0	327
0008	Cyto Non-Gyn Liquid Prep	88112-TC	77	$	$	79	$	$	82	$	$	84	$	$	87	$	$	1	613
0009	Fine Needle Aspirate	88173-TC	29	$	$	30	$	$	31	$	$	32	$	$	33	$	$	1	231
0010	Flow Cytometry first antibody	88184-TC	19	$	$	20	$	$	20	$	$	21	$	$	21	$	$	1	151
0011	Flow cytometry Additional antibodies	88185-TC	225	$	$	232	$	$	239	$	$	246	$	$	253	$	$	1	1792
0012	Tissue culture for neoplastic disorders;bone marrow	88237-TC	39	$	$	40	$	$	41	$	$	43	$	$	44	$	$	0	311
0013	Solid tumor	88239-TC	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0014	Chromosome analysis count 5 cells, 1 karyotype with banding	88261-TC	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0015	Chromosome analysis count 15-20 cells, 2 karyotype with banding	88262-TC	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0016	Chromosome analysis count 45 cells for masaicism,, 2 karyotype with banding	88263-TC	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0017	Chromosome analysis count 20-25 cells	88264-TC	33	$	$	34	$	$	35	$	$	36	$	$	37	$	$	0	263
0018	Cytogenetics DNA Probe	88271	4	$	$	4	$	$	4	$	$	4	$	$	5	$	$	1	32
0019	Tzank Prep	88273-TC	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0020	Cytogenetics 100-300	88275	2	$	$	2	$	$	2	$	$	2	$	$	2	$	$	1	16
0021	Chormosome Karyotype Study	88280	5	$	$	5	$	$	5	$	$	5	$	$	6	$	$	0	40
0022	Chromosome analysis additional cells counted, each study.	88285-TC	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0023	Cyto/Molecular Report	88291	36	$	$	37	$	$	38	$	$	39	$	$	41	$	$	0	287
0024	Level IV Surgical Pathology gross & Microscopic (Bone Marrow)	88305-TC	95	$	$	98	$	$	101	$	$	104	$	$	107	$	$	0	757
0025	Decalcification	88311-TC	40	$	$	41	$	$	42	$	$	44	$	$	45	$	$	0	319
0026	Special Stain Group 1	88312-TC	176	$	$	181	$	$	187	$	$	192	$	$	198	$	$	0	1402
0027	Special Stain Group 2	88313-TC	127	$	$	131	$	$	135	$	$	139	$	$	143	$	$	0	1011
0028	Enzyme Histochemistry	88319-TC	37	$	$	38	$	$	39	$	$	40	$	$	42	$	$	1	295
0029	Consultation (slides prepared elsewhere)*	88321	5	$	$	5	$	$	5	$	$	5	$	$	6	$	$	1	40
0030	Consultation (requires preparation of slides)*	88323	19	$	$	20	$	$	20	$	$	21	$	$	21	$	$	1	151
0031	Consultation, comprehensive (requires review of records and specimens*	88325	3	$	$	3	$	$	3	$	$	3	$	$	3	$	$	1	24
0032	Immunohistochemistry, per specimen, each additional single antibody stain	88341	91	$	$	94	$	$	97	$	$	99	$	$	102	$	$	1	725
0033	Immuno-Histochemistry	88364	917	$	$	945	$	$	973	$	$	1002	$	$	1032	$	$	0	7303
0034	Immunohistochemistry, per specimen, each multiplex stain	88344	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0035	Immunofluorescent Study (each antibody	88346-TC	27	$	$	28	$	$	29	$	$	30	$	$	30	$	$	1	215
0036	Electron Microscopy	88348-TC	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0037	Immunofluorescence Additional stains	88350	53	$	$	55	$	$	56	$	$	58	$	$	60	$	$	1	422
0038	Tumor Immunohistochem/Manual	88360	7	$	$	7	$	$	7	$	$	8	$	$	8	$	$	1	56
0039	Immunohistochemistry with computer assisted tech	88361-TC	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0040	In situ hybridization, per specimen, each additional probe stain	88364	8	$	$	8	$	$	8	$	$	9	$	$	9	$	$	0	64
0041	In situ Hybridization	88365-TC	28	$	$	29	$	$	30	$	$	31	$	$	32	$	$	0	223
0042	In situ hybridization, per specimen, each multiplex probe stain	88366	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0043	MDS in situ TC	88367-TC	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0044	Morphometric analysis in situ hybridization, manual, per specimen	88368	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0045	Morphometric analysis in situ hybridization, manual, per specimen, each additional single probe stain	88369	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0046	Morphometric analysis, in situ hybridization each additional	88373	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0047	Morphometric analysis, in situ hybridization	88374	20	$	$	21	$	$	21	$	$	22	$	$	23	$	$	1	159
0048	Morphometric analysis in situ hybridization, manual, per specimen, each multiplex stain	88377	4	$	$	4	$	$	4	$	$	4	$	$	5	$	$	1	32
0049	Surgical Pathology, gross and micro, prostate needle biopsy, any method	G0416	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0050	First Immuno Stain	G0461	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
0051	Subsequent immune stains	G0462	1	$	$	1	$	$	1	$	$	1	$	$	1	$	$	0	8
				Sub-total	$		Sub-total	$		Sub-total	$		Sub-total	$	Sub-total		$

	Description	Quantity	Hours		Quantity	Hours		Quantity	Hours		Quantity	Hours		Quantity	Hours
0052	Pathology Assistant	260	$	$	260	$	$	260	$	$	260	$	$	260	$	$	1	1,950

0053	Pathologist On-Site	598	$	$	598	$	$	598	$	$	598	$	$	598	$	$	1	4,485
0054	Pathologist Off-site Consulation	260	$	$	260	$	$	260	$	$	260	$	$	260	$	$	1	1,950
0055	Pathologist Administrative Meetings	12	$	$	12	$	$	12	$	$	12	$	$	12	$	$	1	90
0056	Pathologist Call-Back	160	$	$	160	$	$	160	$	$	160	$	$	160	$	$	1	1,200

0057 On-call Pathologist 8760 $ $ 8760 $ $ 8760 $ $ 8760 $ $ 8760 $ $ 1 65,700

Total $ $ $ $ $

GRAND TOTAL: $__________________________

For Official Use Only (FOUO)

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