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Pricing Schedule
SECTION I – FIRST ORDERING PERIOD: June 1, 2019 – May 31, 2020
| CLIN |
| VA Procedure Description |
| Estimated Number of Monitored Patients |
| Cost per Patient Monitored |
| Total Estimated Period Cost |
| 1001 |
| Up to 30-day memory loop monitor (standard event) |
| 360 |
| 1002 |
| Up to 14-day ambulatory cardiac telemetry monitor (ACT/telemetry) |
| 36 |
SECTION II – SECOND ORDERING PERIOD: June 1, 2020 – May 31, 2021
| CLIN |
| VA Procedure Description |
| Estimated Number of Monitored Patients |
| Cost per Patient Monitored |
| Total Estimated Period Cost |
| 2001 |
| Up to 30-day memory loop monitor (standard event) |
| 360 |
| 2002 |
| Up to 14-day ambulatory cardiac telemetry monitor (ACT/telemetry) |
| 36 |
SECTION III – THIRD ORDERING PERIOD: June 1, 2021 – May 31, 2022
| CLIN |
| VA Procedure Description |
| Estimated Number of Monitored Patients |
| Cost per Patient Monitored |
| Total Estimated Period Cost |
| 3001 |
| Up to 30-day memory loop monitor (standard event) |
| 360 |
| 3002 |
| Up to 14-day ambulatory cardiac telemetry monitor (ACT/telemetry) |
| 36 |
SECTION IV – FOURTH ORDERING PERIOD: June 1, 2022 – May 31, 2023
| CLIN |
| VA Procedure Description |
| Estimated Number of Monitored Patients |
| Cost per Patient Monitored |
| Total Estimated Period Cost |
| 4001 |
| Up to 30-day memory loop monitor (standard event) |
| 360 |
| 4002 |
| Up to 14-day ambulatory cardiac telemetry monitor (ACT/telemetry) |
| 36 |
SECTION V – FIFTH ORDERING PERIOD: June 1, 2023 – May 31, 2024
| CLIN |
| VA Procedure Description |
| Estimated Number of Monitored Patients |
| Monthly Cost per Patient Monitored |
| Total Estimated Period Cost |
| 5001 |
| Up to 30-day memory loop monitor (standard event) |
| 360 |
| 5002 |
| Up to 14-day ambulatory cardiac telemetry monitor (ACT/telemetry) |
| 36 |
| Total estimated price with all five ordering periods |
| Sum for all five ordering periods |
| $ |
END SCHEDULE OF SERVICES
