A.09.02_W81K02-17-T-0032-0002.pdf

W40M PACIFIC RGNL CNTRG OFC

US MEDCOM HCAA

POC: CHARIS K. NAITO

160 KRUKOWSKI RD BLDG 160

HONOLULU HI 96819-1552

0010861788-0003

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

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 (Type or print)

30-105-04EXCEPTION TO SF 30

APPROVED BY OIRM 11-84

STANDARD FORM 30 (Rev. 10-83)

Prescribed by GSA

FAR (48 CFR) 53.243

1. This amendment is hereby issued to add the follow ing additional CPT Codes to ATTACHMENT 2, NEUROINTERVENTIONAL PROCEDURES, FEE SCHEDULE, as show n at the end of the table in the Summary of Changes:

36012 Place cath in vein

36222 Place cath intracranial carotid

36223 Place cath carotid/inom art

36224 Place cath carotid art

36225 Unilat vert circulation arch

36226 Place cath unilat vertebral

75860-26 Vein x-ray neck

1. CONTRACT ID CODE PAGE OF PAGES

J 1 3

16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)

16C. DATE SIGNED

BY 06-Jan-2017

16B. UNITED STATES OF AMERICA15C. DATE SIGNED15B. CONTRACTOR/OFFEROR

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

8. NAME AND ADDRESS OF CONTRACTOR (No., Street, County, State and Zip Code) X W81K02-17-T-0032

X 9B. DATED (SEE ITEM 11)

20-Dec-2016

10B. DATED (SEE ITEM 13)

9A. AMENDMENT OF SOLICITATION NO.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

X The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offer is extended, X is not extended.

Offer 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:

(a) By completing Items 8 and 15, and returning 1 copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted;

or (c) By separate letter or telegram 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 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 telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

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

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

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.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(B).

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

D. OTHER (Specify type of modification and authority)

E. IMPORTANT: Contractor is not, is required to sign this document and return copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

10A. MOD. OF CONTRACT/ORDER NO.

2. AMENDMENT/MODIFICATION NO. 5. PROJECT NO.(If applicable)

6. ISSUED BY

3. EFFECTIVE DATE

06-Jan-2017

CODE

W40M PACIFIC RGNL CNTRG OFC

USA MEDCOM HCAA

160 KRUKOWSKI RD BLDG 160

HONOLULU HI 96819-1552

W81K02 7. ADMINISTERED BY (If other than item 6)

4. REQUISITION/PURCHASE REQ. NO.

CODE W81K02

FACILITY CODECODE

EMAIL:TEL:

W81K02-17-T-0032

SECTION SF 30 BLOCK 14 CONTINUATION PAGE

SUMMARY OF CHANGES

SECTION SF 1449 - CONTINUATION SHEET

The following have been modified:

ATTACHMENT 2 - FEE SCHEDULE

ATTACHMENT 2

NEUROINTERVENTIONAL PROCEDURES

FEE SCHEDULE

CPT

CODE

DESCRIPTION

BASE

8 FEB 17 -

30 SEPT 17

OPTION I

1 OCT 17 -

30 SEPT 18

OPTION II

1 OCT 18 -

30 SEPT 19

OPTION III

1 OCT 19 -

30 SEPT 20

OPTION IV

1 OCT 20 -

30 SEPT 21

35475 Brachiocephalic-each vessel

36010 Intro cath venous

36200 Intro cath aorta

36215 Select cath place, 1st order

36216 Select cath place, 2nd order

36217 Select cath place, 3rd order

36218 Select cath place, additional

36245 Select cath place abd 1st order

36246 Select cath place abd 2nd order

36247 Select cath place abd 3rd order

36248 Select cath place abd add

37201 Trans cath inf thrombolysis

37202 Inf nonthrombolytic

37203 Trans cath retrieval foreign

37204 Trans cath occ or emb

37205 Trans cath place intravascular stent

37206 Trans cath place intravascular stent, add vess

37215 Cervical Carotid Stent

61623 Endo vas temp balloon art occ

61624 Trans cath emb

61626 Trans cath emb head

61635 Intracranial Stent (left ICA-global)

61640 Intracranial angioplasty-vasospasm

(global)

61641 Intracranial angioplasty-vasospasm, diff fam

61642 Intracranial angioplasty-vasospasm add ves

61708 Surg aneurysm electrothrombosis

W81K02-17-T-0032

61710 Surg aneurysm emb

75605-26 Thoracic aortogram

75625-26 Abdominal aortogram

75650-26 Angio cervicocerebral

75660-26 Angio ext carotid

75662-26 Angio ext carotid

75665-26 Angio carotid cerebral

75671-26 Angio carotid cerebral

75676-26 Angio carotid cervical

75680-26 Angio carotic cervical

75685-26 Angio vertebral cervical

75705-26 Angio spinal

75710-26 Angio ext uni

75716-26 Angio ext

75774-26 Angio each additional

75894-26 Transcath emb

75896-26 Transcath infusion

75898-26 Angio exist cath

75960-26 Trans cath place intravascular stent

75961-26 Trans cath retrieval foreign

75962-26 Trans balloon angioplasty

75964-26 Trans balloon angioplasty

99141 IV Sedation

99144 Mod sedation 1st 30 min

99145 Mod sedation add 15 min

36012 Place cath in vein

36222 Place cath intracranial carotid

36223 Place cath carotid/inom art

36224 Place cath carotid art

36225 Unilat vert circulation arch

36226 Place cath unilat vertebral

75860-26 Vein x-ray neck

(End of Summary of Changes)