36C24818Q0683-0002001.pdf

D.1 DETAILED PRICE/COST SCHEDULE (Amended)

Item

BASE YEAR

10/1/2018 Thru 9/30/2019

Estimated M Yearly

Quantity

Unit of Issue

Unit Price

Total Price

0001. Initial set-ups of equipment that consists of various cylinders with regulator, handcart, pouch, backpack, proper storage and disposable supplies

EACH

0002. Stationary Concentrator 1-5 LPM with Back-up M-60, regulator, stand, nasal cannula or mask and humidifier when specified.

9,312

0003. Stationary Concentrator 5-10 LPM with Back-up M-60, regulator, 0004. Portable System Rental for patients’ home

10,524

0005. Cylinder, Aluminum, E-tank, Refill

0006. Cylinder, Aluminum, D-tank, 0007. Cylinder, Aluminum, C-tank, 0008. Cylinder, Aluminum, M-6, 0009. Cylinder, Aluminum, H or K-tank Refill

0010. Cylinder, Aluminum, B or BB-tank Refill

0011. Demand Nasal Cannula (e.g.

Oximyzer) Reservoir or Pendand/equivalent

0012. Oxysafe Fire Safety Thermal Fuses (2 thermal fuse kits per oxygen source i.e concentrator, portables (# of portables)

0013. Pneumatic Demand/Conserving Regulators

0014. Cylinder, Aluminum, E-tank Rental, complete portable system (e.g. tank, regulator, etc) for each Medical Center for availability to issue home oxygen beneficiaries who deplete their portable units during appointments or to send home with new start-up (e.g. discharged from inpatient).

0015. Ventilator, Volume ventilator, alternated current with battery back up, alarms, disposable circuits with oxygen cumulator capabilities; back up ventilator; ambu bag; suction machine with three (3) disposables per beneficiary to include connecting tubing, suction catheter, tubing, bacterial humidifier filters, Closed System Suction Catheter w/ Swivel Adapter with a MeterDose Inhaler (MDI) port, Resuscitation Bag w/ Mask and oxygen tubing and Yankauer suction and tips instrument where applicable

36 EACH

0016. Portable Concentrator w/two batteries. For travel not to exceed 30 days.

200 EACH

0017. 5-7Ft Cannulas w/oxygen tubing changed weekly (4) per patient monthly

40,000 EACH

0018. 14-25Ft Cannulas w/oxygen

30,000 EACH

0019. 50Ft Cannulas w/oxygen

30,000 EACH

0020. Rental liquid oxygen system (90 – 100 lbs) stationary reservoir per beneficiary.

400 EACH

0021. Rental portable liquid oxygen system with reservoir per beneficiary with carrying bag

400 EACH

0022. Liquid oxygen per pound 200,000 LB

0023. High volume air compressor capable of producing 8 to 15 lpm. Cost of monthly rental to include disposable supplies to be changed/washed weekly. Disposable shall include: (A) Mask, T-piece or trach collar; 2 on hand at all times.

(B) Aerosol corrugated hose, 6 ft., 2 on hand at all times. (C) Nebulizer adapter. 4 on hand at all times. (D) Large aerosol nebulizer bottle; 2 on hand at all times.

200 EACH

0024. Heated humidifier to be used in conjunction with volume ventilator

36 EACH

0025. Heated system for humidified compressed air with disposable to include a temperature sensor.

Disposables shall include: (A) Mask, T-piece or trach collar; 2 on hand at all times. (B) Aerosol corrugated hose, 6 ft., 2 on hand at all times. (C) Nebulizer adapter. 4 on hand at all times. (D) Large aerosol nebulizer bottle; 2 on hand at all times.

72 EACH

0026. Emergency service to check out situations other than equipment failures

20 EACH

0027. Delivery for re-supply and/or relocation of equipment due to change in beneficiary’s residence.

8 EACH

0028. Maintenance of VA purchased portable oxygen concentrators, when appropriately prescribed

220 EACH $_____

Total Base Year $ __________________

OPTION YEAR 1

10/1/2019 Thru 9/30/2020

Quantity

Unit of Issue

Unit Price

Total Price

1001. Initial set-ups of equipment that consists of various cylinders with regulator, handcart, pouch, backpack, 1002. Stationary Concentrator 1-5

10,616

1003. Stationary Concentrator 5-10 LPM with Back-up M-60, regulator, 1004. Portable System Rental for

11,997

1005. Cylinder, Aluminum, E-tank, 1006. Cylinder, Aluminum, D-tank, 1007. Cylinder, Aluminum, C-tank, 1008. Cylinder, Aluminum, M-6, 1009. Cylinder, Aluminum, H or K-

1,000

1010. Cylinder, Aluminum, B or

1011. Demand Nasal Cannula (e.g.

1012. Oxysafe Fire Safety Thermal Fuses (2 thermal fuse kits per

1013. Pneumatic

1014. Cylinder, Aluminum, E-tank Rental, complete portable system (e.g. tank, regulator, etc) for each Medical Center for availability to issue home oxygen beneficiaries who deplete their portable units during appointments or to send home

1015. Ventilator, Volume ventilator, alternated current with battery back up, alarms, disposable circuits with oxygen cumulator capabilities; back up ventilator; ambu bag; suction machine with three (3) disposables per beneficiary to include connecting tubing, suction catheter, tubing, bacterial humidifier filters, Closed System Suction Catheter w/ Swivel Adapter with a MeterDose Inhaler (MDI) port, Resuscitation Bag w/ Mask and oxygen tubing and

41 EACH

1016. Portable Concentrator w/two

228 EACH

1017. 5-7Ft Cannulas w/oxygen

45,600 EACH

1018. 14-25Ft Cannulas w/oxygen

34,200 EACH

1019. 50Ft Cannulas w/oxygen

34,200 EACH

1020. Rental liquid oxygen system

456 EACH

1021. Rental portable liquid oxygen

456 EACH

1022. Liquid oxygen per pound 228,000 LB

1023. High volume air compressor lpm. Cost of monthly rental to include disposable supplies to be changed/washed weekly. Disposable shall include: (A) Mask, T-piece or trach collar; 2 on hand at all times.

(B) Aerosol corrugated hose, 6 ft., 2 on hand at all times. (C) Nebulizer adapter. 4 on hand at all times. (D)

228 EACH

1024. Heated humidifier to be used

41 EACH

1025. Heated system for humidified include a temperature sensor.

Disposables shall include: (A) Mask, T-piece or trach collar; 2 on hand at all times. (B) Aerosol corrugated hose, 6 ft., 2 on hand at all times. (C) Nebulizer adapter. 4 on hand at all

82 EACH

1026. Emergency service to check

23 EACH

1027. Delivery for re-supply and/or

9 EACH

1028. Maintenance of VA purchased

251 EACH $_____

Total Option Year 1 $ __________________

OPTION YEAR 2

10/1/2020 Thru 9/30/2021

Quantity

Unit of Issue

Unit Price

Total Price

2001. Initial set-ups of equipment that consists of various cylinders with regulator, handcart, pouch, backpack, 2002. Stationary Concentrator 1-5

12,102

2003. Stationary Concentrator 5-10 LPM with Back-up M-60, regulator, 2004. Portable System Rental for

13,677

2005. Cylinder, Aluminum, E-tank, 2006. Cylinder, Aluminum, D-tank, 2007. Cylinder, Aluminum, C-tank, 2008. Cylinder, Aluminum, M-6, 2009. Cylinder, Aluminum, H or K-

2010. Cylinder, Aluminum, B or

2011. Demand Nasal Cannula (e.g.

2012. Oxysafe Fire Safety Thermal Fuses (2 thermal fuse kits per

10397

2013. Pneumatic

2014. Cylinder, Aluminum, E-tank Rental, complete portable system (e.g. tank, regulator, etc) for each Medical Center for availability to issue home oxygen beneficiaries who deplete their portable units during appointments or to send home

2015. Ventilator, Volume ventilator, alternated current with battery back up, alarms, disposable circuits with oxygen cumulator capabilities; back up ventilator; ambu bag; suction machine with three (3) disposables per beneficiary to include connecting tubing, suction catheter, tubing, bacterial humidifier filters, Closed System Suction Catheter w/ Swivel Adapter with a MeterDose Inhaler (MDI) port, Resuscitation Bag w/ Mask and oxygen tubing and

47 EACH

2016. Portable Concentrator w/two

260 EACH

2017. 5-7Ft Cannulas w/oxygen

51,984 EACH

2018. 14-25Ft Cannulas w/oxygen

38,988 EACH

2019. 50Ft Cannulas w/oxygen

38,988 EACH

2020. Rental liquid oxygen system

520 EACH

2021. Rental portable liquid oxygen

520 EACH

2022. Liquid oxygen per pound 259,920 LB

2023. High volume air compressor lpm. Cost of monthly rental to include disposable supplies to be changed/washed weekly. Disposable shall include: (A) Mask, T-piece or trach collar; 2 on hand at all times.

(B) Aerosol corrugated hose, 6 ft., 2 on hand at all times. (C) Nebulizer adapter. 4 on hand at all times. (D)

260 EACH

2024. Heated humidifier to be used

47 EACH

2025. Heated system for humidified include a temperature sensor.

Disposables shall include: (A) Mask, T-piece or trach collar; 2 on hand at all times. (B) Aerosol corrugated hose, 6 ft., 2 on hand at all times. (C) Nebulizer adapter. 4 on hand at all

93 EACH

2026. Emergency service to check

26 EACH

2027. Delivery for re-supply and/or

10 EACH

2028. Maintenance of VA purchased

286 EACH $_____

Total Option Year 2 $ __________________

OPTION YEAR 3

10/1/2021 Thru 9/30/2022

Quantity

Unit of Issue

Unit Price

Total Price

3001. Initial set-ups of equipment that consists of various cylinders with regulator, handcart, pouch, backpack, 3002. Stationary Concentrator 1-5

13,796

3003. Stationary Concentrator 5-10 LPM with Back-up M-60, regulator, 3004. Portable System Rental for

15,592

3005. Cylinder, Aluminum, E-tank, 3006. Cylinder, Aluminum, D-tank, 3007. Cylinder, Aluminum, C-tank, 3008. Cylinder, Aluminum, M-6, 3009. Cylinder, Aluminum, H or K-

3010. Cylinder, Aluminum, B or

3011. Demand Nasal Cannula (e.g.

3012. Oxysafe Fire Safety Thermal Fuses (2 thermal fuse kits per

11853

3013. Pneumatic

3014. Cylinder, Aluminum, E-tank Rental, complete portable system (e.g. tank, regulator, etc) for each Medical Center for availability to issue home oxygen beneficiaries who deplete their portable units during appointments or to send home

3015. Ventilator, Volume ventilator, alternated current with battery back up, alarms, disposable circuits with oxygen cumulator capabilities; back up ventilator; ambu bag; suction machine with three (3) disposables per beneficiary to include connecting tubing, suction catheter, tubing, bacterial humidifier filters, Closed System Suction Catheter w/ Swivel Adapter with a MeterDose Inhaler (MDI) port, Resuscitation Bag w/ Mask and oxygen tubing and

54 EACH

3016. Portable Concentrator w/two

296 EACH

3017. 5-7Ft Cannulas w/oxygen

59,262 EACH

3018. 14-25Ft Cannulas w/oxygen

44,446 EACH

3019. 50Ft Cannulas w/oxygen

44,446 EACH

3020. Rental liquid oxygen system

593 EACH

3021. Rental portable liquid oxygen

593 EACH

3022. Liquid oxygen per pound 296,309 LB

3023. High volume air compressor lpm. Cost of monthly rental to include disposable supplies to be changed/washed weekly. Disposable shall include: (A) Mask, T-piece or trach collar; 2 on hand at all times.

(B) Aerosol corrugated hose, 6 ft., 2 on hand at all times. (C) Nebulizer adapter. 4 on hand at all times. (D)

296 EACH

3024. Heated humidifier to be used

54 EACH

3025. Heated system for humidified include a temperature sensor.

Disposables shall include: (A) Mask, T-piece or trach collar; 2 on hand at all times. (B) Aerosol corrugated hose, 6 ft., 2 on hand at all times. (C) Nebulizer adapter. 4 on hand at all

106 EACH

3026. Emergency service to check

30 EACH

3027. Delivery for re-supply and/or

11 EACH

3028. Maintenance of VA purchased

326 EACH $_____

Total Option Year 3 $ __________________

OPTION YEAR 4

10/1/2022 Thru 9/30/2023

Quantity

Unit of Issue

Unit Price

Total Price

4001. Initial set-ups of equipment that consists of various cylinders with regulator, handcart, pouch, backpack, 4002. Stationary Concentrator 1-5

15,727

4003. Stationary Concentrator 5-10 LPM with Back-up M-60, regulator, 4004. Portable System Rental for

17,775

4005. Cylinder, Aluminum, E-tank, 4006. Cylinder, Aluminum, D-tank, 4007. Cylinder, Aluminum, C-tank, 4008. Cylinder, Aluminum, M-6, 4009. Cylinder, Aluminum, H or K-

4010. Cylinder, Aluminum, B or

4011. Demand Nasal Cannula (e.g.

4012. Oxysafe Fire Safety Thermal Fuses (2 thermal fuse kits per

13512

4013. Pneumatic

4014. Cylinder, Aluminum, E-tank Rental, complete portable system (e.g. tank, regulator, etc) for each Medical Center for availability to issue home oxygen beneficiaries who deplete their portable units during appointments or to send home

4015. Ventilator, Volume ventilator, alternated current with battery back up, alarms, disposable circuits with oxygen cumulator capabilities; back up ventilator; ambu bag; suction machine with three (3) disposables per beneficiary to include connecting tubing, suction catheter, tubing, bacterial humidifier filters, Closed System Suction Catheter w/ Swivel Adapter with a MeterDose Inhaler (MDI) port, Resuscitation Bag w/ Mask and oxygen tubing and

62 EACH

4016. Portable Concentrator w/two

337 EACH

4017. 5-7Ft Cannulas w/oxygen

67,559 EACH

4018. 14-25Ft Cannulas w/oxygen

50,668 EACH

4019. 50Ft Cannulas w/oxygen

50,668 EACH

4020. Rental liquid oxygen system

676 EACH

4021. Rental portable liquid oxygen

676 EACH

4022. Liquid oxygen per pound 337,792 LB

4023. High volume air compressor lpm. Cost of monthly rental to include disposable supplies to be changed/washed weekly. Disposable shall include: (A) Mask, T-piece or trach collar; 2 on hand at all times.

(B) Aerosol corrugated hose, 6 ft., 2 on hand at all times. (C) Nebulizer adapter. 4 on hand at all times. (D)

337 EACH

4024. Heated humidifier to be used

62 EACH

4025. Heated system for humidified include a temperature sensor.

Disposables shall include: (A) Mask, T-piece or trach collar; 2 on hand at all times. (B) Aerosol corrugated hose, 6 ft., 2 on hand at all times. (C) Nebulizer adapter. 4 on hand at all

121 EACH

4026. Emergency service to check

34 EACH

4027. Delivery for re-supply and/or

13 EACH

4028. Maintenance of VA purchased

372 EACH $_____

Total Option Year 4 $ __________________

Grand Total $ __________________