Price list.pdf

0001 Base Ordering Period-Period of Performance: 10/01/2022-09/30/2023

CPT Code Description Estimated Quantity

Unit Price Extended Amount

95940 Intraoperative Neuromonitoring 295 92585 Auditory evoked potentials (Auditor evoke potential) 4 95860 EMG, one extremity (muscle test 1 limb) 4 95861 EMG, two extremities (muscle test 2 limbs) 65 95863 EMG, three extremities (muscle test 3 limbs) 1 95864 EMG four extremities (muscle test 4 limbs) 4 95867 EMG, Cranial nerve supplied muscles, unilateral (muscle test cran nerv unilat) 10 95868 EMG, Cranial nerve supplied muscles, bilateral (muscle test cran nerv bilat) 1 95870 EMG, one extremity (limited study) (muscle test nonparaspinal) 1 95930 Visual evoked potentials 1 95933 Orbicularis oculi blink reflex (blink reflex test) 1 95938 Somatosensory evoke potentials, upper and lower (somatosensory testing) 40 95939 Transcranial elicited motor evoked potentials, upper and lower (Cmotor evloked upr&lwr limbs) 75 95955 Electroencephalography (EEG during surgery) 7 95961 Funtional cortical/subcortical mapping (electrode stimulation brain-1st hour) 4 95925 Somatosensory evoked potentials, upper only 45 95926 Somatosensory evoked potentials, lower only 1 95928 Motor evoked potentials, upper only 1 95929 Motor evoked potentials, lower only 1 95829 Electrocorticography-Includes Grid Electrodes 1 95961 Funtional cortical/subcortical mapping (electrode stimulation brain each additional hour) 4 95865 EMG, larynx 1 95870 EMG, anal/urinary sphincter 1 51792 Bulbocavernosus 1

1001 Ordering Period One-Period of Performance: 10/01/2023-09/30/2024

CPT Code Description Estimated Quantity

Unit Price Extended Amount

95940 Intraoperative Neuromonitoring 295 92585 Auditory evoked potentials (Auditor evoke potential) 4 95860 EMG, one extremity (muscle test 1 limb) 4 95861 EMG, two extremities (muscle test 2 limbs) 65 95863 EMG, three extremities (muscle test 3 limbs) 1 95864 EMG four extremities (muscle test 4 limbs) 4 95867 EMG, Cranial nerve supplied muscles, unilateral (muscle test cran nerv unilat) 10 95868 EMG, Cranial nerve supplied muscles, bilateral (muscle test cran nerv bilat) 1

Base Year Total

95870 EMG, one extremity (limited study) (muscle test nonparaspinal) 1 95930 Visual evoked potentials 1 95933 Orbicularis oculi blink reflex (blink reflex test) 1 95938 Somatosensory evoke potentials, upper and lower (somatosensory testing) 40 95939 Transcranial elicited motor evoked potentials, upper and lower (Cmotor evloked upr&lwr limbs) 75 95955 Electroencephalography (EEG during surgery) 7 95961 Funtional cortical/subcortical mapping (electrode stimulation brain-1st hour) 4 95925 Somatosensory evoked potentials, upper only 45 95926 Somatosensory evoked potentials, lower only 1 95928 Motor evoked potentials, upper only 1 95929 Motor evoked potentials, lower only 1 95829 Electrocorticography-Includes Grid Electrodes 1 95961 Funtional cortical/subcortical mapping (electrode stimulation brain each additional hour) 4 95865 EMG, larynx 1 95870 EMG, anal/urinary sphincter 1 51792 Bulbocavernosus 1

2001 Ordering Period Two-Period of Performance: 10/01/2024-09/30/2025

CPT Code Description Estimated Quantity

Unit Price Extended Amount

95940 Intraoperative Neuromonitoring 295 92585 Auditory evoked potentials (Auditor evoke potential) 4 95860 EMG, one extremity (muscle test 1 limb) 4 95861 EMG, two extremities (muscle test 2 limbs) 65 95863 EMG, three extremities (muscle test 3 limbs) 1 95864 EMG four extremities (muscle test 4 limbs) 4 95867 EMG, Cranial nerve supplied muscles, unilateral (muscle test cran nerv unilat) 10 95868 EMG, Cranial nerve supplied muscles, bilateral (muscle test cran nerv bilat) 1 95870 EMG, one extremity (limited study) (muscle test nonparaspinal) 1 95930 Visual evoked potentials 1 95933 Orbicularis oculi blink reflex (blink reflex test) 1 95938 Somatosensory evoke potentials, upper and lower (somatosensory testing) 40 95939 Transcranial elicited motor evoked potentials, upper and lower (Cmotor evloked upr&lwr limbs) 75 95955 Electroencephalography (EEG during surgery) 7 95961 Funtional cortical/subcortical mapping (electrode stimulation brain-1st hour) 4 95925 Somatosensory evoked potentials, upper only 45 95926 Somatosensory evoked potentials, lower only 1 95928 Motor evoked potentials, upper only 1 95929 Motor evoked potentials, lower only 1 95829 Electrocorticography-Includes Grid Electrodes 1

Ordering Period One Total

95961 Funtional cortical/subcortical mapping (electrode stimulation brain each additional hour) 4 95865 EMG, larynx 1 95870 EMG, anal/urinary sphincter 1 51792 Bulbocavernosus 1

3001 Ordering Period Three-Period of Performance: 10/01/2025-09/30/2026

CPT Code Description Estimated Quantity

Unit Price Extended Amount

95940 Intraoperative Neuromonitoring 295 92585 Auditory evoked potentials (Auditor evoke potential) 4 95860 EMG, one extremity (muscle test 1 limb) 4 95861 EMG, two extremities (muscle test 2 limbs) 65 95863 EMG, three extremities (muscle test 3 limbs) 1 95864 EMG four extremities (muscle test 4 limbs) 4 95867 EMG, Cranial nerve supplied muscles, unilateral (muscle test cran nerv unilat) 10 95868 EMG, Cranial nerve supplied muscles, bilateral (muscle test cran nerv bilat) 1 95870 EMG, one extremity (limited study) (muscle test nonparaspinal) 1 95930 Visual evoked potentials 1 95933 Orbicularis oculi blink reflex (blink reflex test) 1 95938 Somatosensory evoke potentials, upper and lower (somatosensory testing) 40 95939 Transcranial elicited motor evoked potentials, upper and lower (Cmotor evloked upr&lwr limbs) 75 95955 Electroencephalography (EEG during surgery) 7 95961 Funtional cortical/subcortical mapping (electrode stimulation brain-1st hour) 4 95925 Somatosensory evoked potentials, upper only 45 95926 Somatosensory evoked potentials, lower only 1 95928 Motor evoked potentials, upper only 1 95929 Motor evoked potentials, lower only 1 95829 Electrocorticography-Includes Grid Electrodes 1 95961 Funtional cortical/subcortical mapping (electrode stimulation brain each additional hour) 4 95865 EMG, larynx 1 95870 EMG, anal/urinary sphincter 1 51792 Bulbocavernosus 1

4001 Ordering Period Four-Period of Performance: 10/01/2026-09/30/2027

CPT Code Description Estimated Quantity

Unit Price Extended Amount

95940 Intraoperative Neuromonitoring 295 92585 Auditory evoked potentials (Auditor evoke potential) 4 95860 EMG, one extremity (muscle test 1 limb) 4

Ordering Period Two Total

Ordering Period Three Total

95861 EMG, two extremities (muscle test 2 limbs) 65 95863 EMG, three extremities (muscle test 3 limbs) 1 95864 EMG four extremities (muscle test 4 limbs) 4 95867 EMG, Cranial nerve supplied muscles, unilateral (muscle test cran nerv unilat) 10 95868 EMG, Cranial nerve supplied muscles, bilateral (muscle test cran nerv bilat) 1 95870 EMG, one extremity (limited study) (muscle test nonparaspinal) 1 95930 Visual evoked potentials 1 95933 Orbicularis oculi blink reflex (blink reflex test) 1 95938 Somatosensory evoke potentials, upper and lower (somatosensory testing) 40 95939 Transcranial elicited motor evoked potentials, upper and lower (Cmotor evloked upr&lwr limbs) 75 95955 Electroencephalography (EEG during surgery) 7 95961 Funtional cortical/subcortical mapping (electrode stimulation brain-1st hour) 4 95925 Somatosensory evoked potentials, upper only 45 95926 Somatosensory evoked potentials, lower only 1 95928 Motor evoked potentials, upper only 1 95929 Motor evoked potentials, lower only 1 95829 Electrocorticography-Includes Grid Electrodes 1 95961 Funtional cortical/subcortical mapping (electrode stimulation brain each additional hour) 4 95865 EMG, larynx 1 95870 EMG, anal/urinary sphincter 1 51792 Bulbocavernosus 1

Ordering Period Four Total

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