36C79119R0009-0001001.xlsx
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- PAP New Issue TIERED EVALUATIONS Federal contract opportunity
- Solicitation number
- 36C79119R0009
About this file
This pre-solicitation announcement provides notice for an upcoming request for proposal for Positive Airway Pressure devices and associated accessories, replacement parts, facial interfaces, and mask liners. The Department of Veterans Affairs intends to award multiple indefinite delivery/indefinite quantity contracts with a total maximum value of $250 million over five years. Awards will be set aside for Service-Disabled Veteran-Owned Small Businesses, with a cascading order of precedence for Veteran-Owned Small Businesses and small businesses. The solicitation will be issued on July 12, 2019 and proposals will be accepted for 30 days. Interested parties should register on FedBizOpps to receive notification of the solicitation and any amendments. Registration in the System for Award Management is required to be eligible for award. The announcement instructs interested parties to direct any questions to the named Contracting Officer or Contract Specialist.
36C79119R0009 0001 ATTACHMENT E PRICE SHEDULE.xlsx
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Master Product List
| MASTER SUMMARY OF ITEM SUBMISSIONS | ||||
| **All items submitted within the offer shall be identified on this sheet.** | ||||
| CLIN | SUB-CLIN | HCPCS/L-CODE | Make | Model |
CLIN 01 APAP
Instructions/Examples: Each sheet within this workbook shall be used per CLIN. All Sub-CLINS shall be under the appropriate CLIN in order to be considered.
Please fill out the Unit Price for the Base Year and all Option Years for each item on your bid along with your commercially published list price.
These estimated quantities are estimates only and are not commitments. Additional sub-CLINs (0001AI-0001AL) have been added if an offeror wishes to bid more than 8 models. Note the quantities of the additional sub-CLINs are not included in the estimated annual quantity, however they are used for the purpose of calculating a total evaluated price.
See Row 14 for an example calculation and cell T14 for the total price that will be evaluated in consideration for award. Note each model offered must include the unit price for the base and options years to be considered for award.
| OFFEROR NAME (MANDATORY) : ___________________________________________________________________________________________ | ||||||||||||||||||||
| HCPCS/L Code: E0601 | Suggested HCPCS/L Code (if different): ________________ Pre-Approved Items for this CLIN are listed in Attachment F | |||||||||||||||||||
| CLIN 0001 | CATEGORY I-Auto-Titrating Continuous Positive Airway Pressure (APAP) Device/(See attachment D for Minimum Technical Requirements and Attachment F for Pre-Approved items) | |||||||||||||||||||
| SUBCLINS for each PAP Model Offered | MODEL/BRAND | ITEM DESCRIPTION | PLACE OF MANUFACTURE | Est. QTY* BASE YEAR | UNIT PRICE BASE YEAR | TOTAL PRICE BASE YEAR | Est. QTY* OPTION PERIOD I | UNIT PRICE OPTION PERIOD I | TOTAL PRICE OPTION PERIOD I | Est. QTY* OPTION PERIOD II | UNIT PRICE OPTION PERIOD II | TOTAL PRICE OPTION PERIOD II | Est. QTY* OPTION PERIOD III | UNIT PRICE OPTION PERIOD III | TOTAL PRICE OPTION PERIOD III | Est. QTY* OPTION PERIOD IV | UNIT PRICE OPTION PERIOD IV | TOTAL PRICE OPTION PERIOD IV | BASE YEAR AND 4 YEAR OPTION PERIODS -TOTAL PRICE FOR PRODUCT | Published List Price |
| 0001-Sample | 25,613 | $450.00 | $11,526,006.77 | 28,210 | $475.00 | $13,399,655.67 | 31,069 | $425.00 | $13,204,520.38 | 34,219 | $450.00 | $15,398,552.11 | 37,688 | $0.00 | $475.00 | $53,529,209.93 | $500.00 |
0001AA 25,613 $0.00 $0.00 28,210 $0.00 $0.00 31,069 $0.00 $0.00 34,219 $0.00 $0.00 37,688 $0.00 $0.00 $0.00 $0.00
0001AB 25,613 $0.00 $0.00 28,210 $0.00 $0.00 31,069 $0.00 $0.00 34,219 $0.00 $0.00 37,688 $0.00 $0.00 $0.00 $0.00
0001AC 25,613 $0.00 $0.00 28,210 $0.00 $0.00 31,069 $0.00 $0.00 34,219 $0.00 $0.00 37,688 $0.00 $0.00 $0.00 $0.00
0001AD 25,613 $0.00 $0.00 28,210 $0.00 $0.00 31,069 $0.00 $0.00 34,219 $0.00 $0.00 37,688 $0.00 $0.00 $0.00 $0.00
0001AE 25,613 $0.00 $0.00 28,210 $0.00 $0.00 31,069 $0.00 $0.00 34,219 $0.00 $0.00 37,688 $0.00 $0.00 $0.00 $0.00
0001AF 25,613 $0.00 $0.00 28,210 $0.00 $0.00 31,069 $0.00 $0.00 34,219 $0.00 $0.00 37,688 $0.00 $0.00 $0.00 $0.00
0001AG 25,613 $0.00 $0.00 28,210 $0.00 $0.00 31,069 $0.00 $0.00 34,219 $0.00 $0.00 37,688 $0.00 $0.00 $0.00 $0.00
0001AH 25,613 $0.00 $0.00 28,210 $0.00 $0.00 31,069 $0.00 $0.00 34,219 $0.00 $0.00 37,688 $0.00 $0.00 $0.00 $0.00
0001AI 25,613 $0.00 $0.00 28,210 $0.00 $0.00 31,069 $0.00 $0.00 34,219 $0.00 $0.00 37,688 $0.00 $0.00 $0.00 $0.00
0001AJ 25,613 $0.00 $0.00 28,210 $0.00 $0.00 31,069 $0.00 $0.00 34,219 $0.00 $0.00 37,688 $0.00 $0.00 $0.00 $0.00
0001AK 25,613 $0.00 $0.00 28,210 $0.00 $0.00 31,069 $0.00 $0.00 34,219 $0.00 $0.00 37,688 $0.00 $0.00 $0.00 $0.00
| 0001AL | 25,613 | $0.00 | $0.00 | 28,210 | $0.00 | $0.00 | 31,069 | $0.00 | $0.00 | 34,219 | $0.00 | $0.00 | 37,688 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| 204,907 | $0.00 | 225,678 | $0.00 | 248,556 | $0.00 | 273,752 | $0.00 | 301,503 | $0.00 | ||||||||||
| TOTAL PRICE FOR BASE AND ALL OPTION PERIODS | $0.00 | ||||||||||||||||||
| ACCESSORIES |
| CHIN STRAPS | |||||||||||
| CHIN STRAPS **Estimated quantity: 99,387 Base Year, 120,155 Option Period 1, 145,263 Option Period 2,175,618 Option Period 3, 212,315 Option Period 4 . Estimated quantities for Chin Straps comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A 7036 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION CHIN STRAPS | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0001A1 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A2 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A3 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A4 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A5 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A6 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| FILTERS | |||||||||||
| Filters **Estimated quantity: 1,289,558 Base Year, 1,554,131 Option Period 1, 1,873,938 Option Period 2, 2,260,673 Option Period 3, 2,728,527Option Period 4. Estimated quantities for Filters comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A 7038 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0001B1 | Filters (Disposalble)-1 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0001B2 | Filters (Disposalble)-2 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0001B3 | Filters (Disposalble)-4 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0001B4 | Filters (Disposalble)-6 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B5 | Filters (Non Disposalble)-1 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B6 | Filters (Non Disposalble)-2 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B7 | Filters (Non Disposalble)-4 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B8 | Filters (Non Disposalble)-6 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tubing | |||||||||||
| **Estimated quantity: 828,324 Base Year, 1,112,930 Option Period 1, 1,527,325 Option Period 2, 2,147,325 Option Period 3, 3,099,542 Option Period 4. Estimated quantities for Tubing comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A7037 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0001C1 | Tubing (Standard) 6 Feet | 6 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0001C2 | Tubing (Standard) 10 Feet | 10 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0001C3 | Tubing (Heated/Climate) 6 Feet | 6 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0001C4 | Tubing (Heated/Climate) 10Feet | 10 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
REPLACEMENT PARTS
| HUMIDIFIER WATER CHAMBER | ||||||||||
| Estimated quantity 222,460 Base Year, 329,774 Option Period 1, 492,910 Option Period 2, 740,753 Option Period 3, 1,117,133 Option Period 4. Estimated quantities for Humidifier Water Chamber comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | ||||||||||
| HCPCS/LCODE A7046 Suggested HCPCS/LCODE __________________ (if different) | ||||||||||
| Sub CLIN for Corresponding Replacement Parts | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0001D1 | Humidifier Water Chamber | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| SECURE DIGITAL CARDS (SD) CARDS | ||||||||||
| Estimated Quantity: 922 | ||||||||||
| HCPCS/LCODE A9279 Suggested HCPCS/LCODE __________________ (if different) | ||||||||||
| Sub CLIN for Corresponding Replacement Parts | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0001E1 | SECURE DIGITAL CARDS (SD) CARDS 10 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Estimate 1,205 | POWER CHORD | |||||||||
| *CORRESPONDING CLIN FOR PAP DEVICE | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0001F1 | POWER CHORD | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Estimate 1,205 | POWER SUPPLY | |||||||||
| *CORRESPONDING CLIN FOR PAP DEVICE | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0001G1 | POWER SUPPLY | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
CLIN 02 ASV
Instructions/Examples: Each sheet within this workbook shall be used per CLIN. All Sub-CLINS shall be under the appropriate CLIN in order to be considered.
Please fill out the Unit Price for the Base Year and all Option Years for each item on your bid along with your commercially published list price.
These estimated quantities are estimates only and are not commitments. Additional sub-CLINs (0002AI-0002AL) have been added if an offeror wishes to bid more than 8 models. Note the quantities of the additional sub-CLINs are not included in the estimated annual quantity, however they are used for the purpose of calculating a total evaluated price.
See Row 14 for an example calculation and cell T14 for the total price that will be evaluated in consideration for award. Note each model offered must include the unit price for the base and options years to be considered for award.
| OFFEROR NAME (MANDATORY) : ___________________________________________________________________________________________ | ||||||||||||||||||||
| HCPCS/L Code: E0471 | Suggested HCPCS/L Code (if different): ________________ Pre-Approved Items for this CLIN are listed in Attachment F | |||||||||||||||||||
| CLIN 0002 | CATEGORY II-Adaptive Servo-Ventilation (ASV) Device/(See attachment D for Minimum Technical Requirements and Attachment F for Pre-Approved items) | |||||||||||||||||||
| SUBCLINS | MODEL/BRAND | ITEM DESCRIPTION | PLACE OF MANUFACTURE | Est. QTY* BASE YEAR | UNIT PRICE BASE YEAR | TOTAL PRICE BASE YEAR | Est. QTY* OPTION PERIOD I | UNIT PRICE OPTION PERIOD I | TOTAL PRICE OPTION PERIOD I | Est. QTY* OPTION PERIOD II | UNIT PRICE OPTION PERIOD II | TOTAL PRICE OPTION PERIOD II | Est. QTY* OPTION PERIOD III | UNIT PRICE OPTION PERIOD III | TOTAL PRICE OPTION PERIOD III | Est. QTY* OPTION PERIOD IV | UNIT PRICE OPTION PERIOD IV | TOTAL PRICE OPTION PERIOD IV | BASE YEAR AND 4 YEAR OPTION PERIODS -TOTAL PRICE FOR PRODUCT | Published Price |
| 0002-Sample | 480 | $1,700.00 | $815,738.93 | 501 | $1,750.00 | $877,152.75 | 524 | $1,650.00 | $863,885.20 | 547 | $1,750.00 | $957,072.97 | 571 | $1,700.00 | $971,160.11 | $4,485,009.97 | $1,800.00 |
0002AA 480 $0.00 $0.00 501 $0.00 $0.00 524 $0.00 $0.00 547 $0.00 $0.00 571 $0.00 $0.00 $0.00 $0.00
0002AB 480 $0.00 $0.00 501 $0.00 $0.00 524 $0.00 $0.00 547 $0.00 $0.00 571 $0.00 $0.00 $0.00 $0.00
0002AC 480 $0.00 $0.00 501 $0.00 $0.00 524 $0.00 $0.00 547 $0.00 $0.00 571 $0.00 $0.00 $0.00 $0.00
0002AD 480 $0.00 $0.00 501 $0.00 $0.00 524 $0.00 $0.00 547 $0.00 $0.00 571 $0.00 $0.00 $0.00 $0.00
0002AE 480 $0.00 $0.00 501 $0.00 $0.00 524 $0.00 $0.00 547 $0.00 $0.00 571 $0.00 $0.00 $0.00 $0.00
0002AF 480 $0.00 $0.00 501 $0.00 $0.00 524 $0.00 $0.00 547 $0.00 $0.00 571 $0.00 $0.00 $0.00 $0.00
0002AG 480 $0.00 $0.00 501 $0.00 $0.00 524 $0.00 $0.00 547 $0.00 $0.00 571 $0.00 $0.00 $0.00 $0.00
0002AH 480 $0.00 $0.00 501 $0.00 $0.00 524 $0.00 $0.00 547 $0.00 $0.00 571 $0.00 $0.00 $0.00 $0.00
0002AI 480 $0.00 $0.00 501 $0.00 $0.00 524 $0.00 $0.00 547 $0.00 $0.00 571 $0.00 $0.00 $0.00 $0.00
0002AJ 480 $0.00 $0.00 501 $0.00 $0.00 524 $0.00 $0.00 547 $0.00 $0.00 571 $0.00 $0.00 $0.00 $0.00
0002AK 480 $0.00 $0.00 501 $0.00 $0.00 524 $0.00 $0.00 547 $0.00 $0.00 571 $0.00 $0.00 $0.00 $0.00
| 0002AL | 480 | $0.00 | $0.00 | 501 | $0.00 | $0.00 | 524 | $0.00 | $0.00 | 547 | $0.00 | $0.00 | 571 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| 3,839 | $0.00 | 4,010 | $0.00 | 4,189 | $0.00 | 4,375 | $0.00 | 4,570 | $0.00 | ||||||||||
| TOTAL PRICE FOR BASE AND ALL OPTION PERIODS | $0.00 | ||||||||||||||||||
| ACCESSORIES |
| CHIN STRAPS | |||||||||||
| CHIN STRAPS **Estimated quantity: 99,387 Base Year, 120,155 Option Period 1, 145,263 Option Period 2,175,618 Option Period 3, 212,315 Option Period 4 . Estimated quantities for Chin Straps comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A 7036 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION CHIN STRAPS | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0002A1 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0002A2 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0002A3 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0002A4 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0002A5 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0002A6 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| FILTERS | |||||||||||
| Filters **Estimated quantity: 1,289,558 Base Year, 1,554,131 Option Period 1, 1,873,938 Option Period 2, 2,260,673 Option Period 3, 2,728,527Option Period 4. Estimated quantities for Filters comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A 7038 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0002B1 | Filters (Disposalble)-1 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0002B2 | Filters (Disposalble)-2 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0002B3 | Filters (Disposalble)-4 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0002B4 | Filters (Disposalble)-6 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0002B5 | Filters (Non Disposalble)-1 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0002B6 | Filters (Non Disposalble)-2 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0002B7 | Filters (Non Disposalble)-4 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0002B8 | Filters (Non Disposalble)-6 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tubing | |||||||||||
| **Estimated quantity: 828,324 Base Year, 1,112,930 Option Period 1, 1,527,325 Option Period 2, 2,147,325 Option Period 3, 3,099,542 Option Period 4. Estimated quantities for Tubing comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A7037 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0002C1 | Tubing (Standard) 6 Feet | 6 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0002C2 | Tubing (Standard) 10 Feet | 10 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0002C3 | Tubing (Heated/Climate) 6 Feet | 6 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0002C4 | Tubing (Heated/Climate) 10Feet | 10 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
REPLACEMENT PARTS
| HUMIDIFIER WATER CHAMBER | ||||||||||
| Estimated quantity 222,460 Base Year, 329,774 Option Period 1, 492,910 Option Period 2, 740,753 Option Period 3, 1,117,133 Option Period 4. Estimated quantities for Humidifier Water Chamber comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | ||||||||||
| HCPCS/LCODE A7046 Suggested HCPCS/LCODE __________________ (if different) | ||||||||||
| Sub CLIN for Corresponding Replacement Parts | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0002D1 | Humidifier Water Chamber | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| SECURE DIGITAL CARDS (SD) CARDS | ||||||||||
| Estimated Quantity: 922 | ||||||||||
| HCPCS/LCODE A9279 Suggested HCPCS/LCODE __________________ (if different) | ||||||||||
| Sub CLIN for Corresponding Replacement Parts | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0002E1 | SECURE DIGITAL CARDS (SD) CARDS 10 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Estimate 1,205 | POWER CHORD | |||||||||
| *CORRESPONDING CLIN FOR PAP DEVICE | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0002F1 | Power Chord | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Estimate 1,205 | POWER SUPPLY | |||||||||
| *CORRESPONDING CLIN FOR PAP DEVICE | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0002G1 | POWER SUPPLY | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
CLIN 03A BPAP
Instructions/Examples: Each sheet within this workbook shall be used per CLIN. All Sub-CLINS shall be under the appropriate CLIN in order to be considered.
Please fill out the Unit Price for the Base Year and all Option Years for each item on your bid along with your commercially published list price.
These estimated quantities are estimates only and are not commitments. Additional sub-CLINs (0003AI-0003AL) have been added if an offeror wishes to bid more than 8 models. Note the quantities of the additional sub-CLINs are not included in the estimated annual quantity, however they are used for the purpose of calculating a total evaluated price.
See Row 14 for an example calculation and cell T14 for the total price that will be evaluated in consideration for award. Note each model offered must include the unit price for the base and options years to be considered for award.
| OFFEROR NAME (MANDATORY) : ___________________________________________________________________________________________ | ||||||||||||||||||||
| HCPCS/L Code: E0470 | Suggested HCPCS/L Code (if different): ________________ Pre-Approved Items for this CLIN are listed in Attachment F | |||||||||||||||||||
| CLIN 0003A | CATEGORY III-Bi-level Positive Airway Pressure (BPAP) Machines Without Spontaneous-Timed(S/T) Capabilities/(See attachment D for Minimum Technical Requirements and Attachment F for Pre-Approved items) | |||||||||||||||||||
| SUBCLINS | MODEL/BRAND | ITEM DESCRIPTION | PLACE OF MANUFACTURE | Est. QTY* BASE YEAR | UNIT PRICE BASE YEAR | TOTAL PRICE BASE YEAR | Est. QTY* OPTION PERIOD I | UNIT PRICE OPTION PERIOD I | TOTAL PRICE OPTION PERIOD I | Est. QTY* OPTION PERIOD II | UNIT PRICE OPTION PERIOD II | TOTAL PRICE OPTION PERIOD II | Est. QTY* OPTION PERIOD III | UNIT PRICE OPTION PERIOD III | TOTAL PRICE OPTION PERIOD III | Est. QTY* OPTION PERIOD IV | UNIT PRICE OPTION PERIOD IV | TOTAL PRICE OPTION PERIOD IV | BASE YEAR AND 4 YEAR OPTION PERIODS -TOTAL PRICE FOR PRODUCT | Published List Price |
| 0003-Sample | 938 | $1,000.00 | $937,864.24 | 975 | $900.00 | $877,274.69 | 1,013 | $950.00 | $962,431.87 | 1,053 | $1,050.00 | $1,105,577.47 | 1,094 | $1,000.00 | $1,094,343.26 | $4,977,491.52 | $1,100.00 |
0003AA 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003AB 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003AC 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003AD 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003AE 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003AF 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003AG 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003AH 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003AI 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003AJ 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003AK 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
| 0003AL | 938 | $0.00 | $0.00 | 975 | $0.00 | $0.00 | 1,013 | $0.00 | $0.00 | 1,053 | $0.00 | $0.00 | 1,094 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| 7,503 | $0.00 | 7,798 | $0.00 | 8,105 | $0.00 | 8,423 | $0.00 | 8,755 | $0.00 | ||||||||||
| TOTAL PRICE FOR BASE AND ALL OPTION PERIODS | $0.00 | ||||||||||||||||||
| ACCESSORIES |
| CHIN STRAPS | |||||||||||
| CHIN STRAPS **Estimated quantity: 99,387 Base Year, 120,155 Option Period 1, 145,263 Option Period 2,175,618 Option Period 3, 212,315 Option Period 4 . Estimated quantities for Chin Straps comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A 7036 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION CHIN STRAPS | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003A1 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A2 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A3 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A4 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A5 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A6 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| FILTERS | |||||||||||
| Filters **Estimated quantity: 1,289,558 Base Year, 1,554,131 Option Period 1, 1,873,938 Option Period 2, 2,260,673 Option Period 3, 2,728,527Option Period 4. Estimated quantities for Filters comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A 7038 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003B1 | Filters (Disposalble)-1 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0003B2 | Filters (Disposalble)-2 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0003B3 | Filters (Disposalble)-4 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0003B4 | Filters (Disposalble)-6 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0003B5 | Filters (Non Disposalble)-1 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0003B6 | Filters (Non Disposalble)-2 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0003B7 | Filters (Non Disposalble)-4 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0003B8 | Filters (Non Disposalble)-6 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tubing | |||||||||||
| **Estimated quantity: 828,324 Base Year, 1,112,930 Option Period 1, 1,527,325 Option Period 2, 2,147,325 Option Period 3, 3,099,542 Option Period 4. Estimated quantities for Tubing comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A7037 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003C1 | Tubing (Standard) 6 Feet | 6 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0003C2 | Tubing (Standard) 10 Feet | 10 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0003C3 | Tubing (Heated/Climate) 6 Feet | 6 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0003C4 | Tubing (Heated/Climate) 10Feet | 10 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
REPLACEMENT PARTS
| HUMIDIFIER WATER CHAMBER | ||||||||||
| Estimated quantity 222,460 Base Year, 329,774 Option Period 1, 492,910 Option Period 2, 740,753 Option Period 3, 1,117,133 Option Period 4. Estimated quantities for Humidifier Water Chamber comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | ||||||||||
| HCPCS/LCODE A7046 Suggested HCPCS/LCODE __________________ (if different) | ||||||||||
| Sub CLIN for Corresponding Replacement Parts | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003D1 | Humidifier Water Chamber | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| SECURE DIGITAL CARDS (SD) CARDS | ||||||||||
| Estimated Quantity: 922 | ||||||||||
| HCPCS/LCODE A9279 Suggested HCPCS/LCODE __________________ (if different) | ||||||||||
| Sub CLIN for Corresponding Replacement Parts | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003E1 | SECURE DIGITAL CARDS (SD) CARDS 10 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Estimate 1,205 | POWER CHORD | |||||||||
| *CORRESPONDING CLIN FOR PAP DEVICE | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003F1 | POWER CHORD | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Estimate 1,205 | POWER SUPPLY | |||||||||
| *CORRESPONDING CLIN FOR PAP DEVICE | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003G1 | POWER SUPPLY | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
CLIN 03B BPAP
Instructions/Examples: Each sheet within this workbook shall be used per CLIN. All Sub-CLINS shall be under the appropriate CLIN in order to be considered.
Please fill out the Unit Price for the Base Year and all Option Years for each item on your bid along with your commercially published list price.
These estimated quantities are estimates only and are not commitments. Additional sub-CLINs (0003BI-0003BL) have been added if an offeror wishes to bid more than 8 models. Note the quantities of the additional sub-CLINs are not included in the estimated annual quantity, however they are used for the purpose of calculating a total evaluated price.
See Row 14 for an example calculation and cell T14 for the total price that will be evaluated in consideration for award. Note each model offered must include the unit price for the base and options years to be considered for award.
| OFFEROR NAME (MANDATORY) : ___________________________________________________________________________________________ | ||||||||||||||||||||
| HCPCS/L Code: E0470 | Suggested HCPCS/L Code (if different): ________________ Pre-Approved Items for this CLIN are listed in Attachment F | |||||||||||||||||||
| CLIN 0003 | CATEGORY III-Bi-level Positive Airway Pressure (BPAP) Machines With Spontaneous-Timed (S/T) Capabilities/(See attachment D for Minimum Technical Requirements and Attachment F for Pre-Approved items) | |||||||||||||||||||
| SUBCLINS | MODEL/BRAND | ITEM DESCRIPTION | PLACE OF MANUFACTURE | Est. QTY* BASE YEAR | UNIT PRICE BASE YEAR | TOTAL PRICE BASE YEAR | Est. QTY* OPTION PERIOD I | UNIT PRICE OPTION PERIOD I | TOTAL PRICE OPTION PERIOD I | Est. QTY* OPTION PERIOD II | UNIT PRICE OPTION PERIOD II | TOTAL PRICE OPTION PERIOD II | Est. QTY* OPTION PERIOD III | UNIT PRICE OPTION PERIOD III | TOTAL PRICE OPTION PERIOD III | Est. QTY* OPTION PERIOD IV | UNIT PRICE OPTION PERIOD IV | TOTAL PRICE OPTION PERIOD IV | BASE YEAR AND 4 YEAR OPTION PERIODS -TOTAL PRICE FOR PRODUCT | Published List Price |
| 0003-Sample | 938 | $1,000.00 | $937,864.24 | 975 | $900.00 | $877,274.69 | 1,013 | $950.00 | $962,431.87 | 1,053 | $1,050.00 | $1,105,577.47 | 1,094 | $1,000.00 | $1,094,343.26 | $4,977,491.52 | $1,100.00 |
0003BA 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003BB 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003BC 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003BD 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003BE 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003BF 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003BG 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003BH 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003BI 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003BJ 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003BK 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
| 0003BL | 938 | $0.00 | $0.00 | 975 | $0.00 | $0.00 | 1,013 | $0.00 | $0.00 | 1,053 | $0.00 | $0.00 | 1,094 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| 7,503 | $0.00 | 7,798 | $0.00 | 8,105 | $0.00 | 8,423 | $0.00 | 8,755 | $0.00 | ||||||||||
| TOTAL PRICE FOR BASE AND ALL OPTION PERIODS | $0.00 | ||||||||||||||||||
| ACCESSORIES |
| CHIN STRAPS | |||||||||||
| CHIN STRAPS **Estimated quantity: 99,387 Base Year, 120,155 Option Period 1, 145,263 Option Period 2,175,618 Option Period 3, 212,315 Option Period 4 . Estimated quantities for Chin Straps comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A 7036 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION CHIN STRAPS | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003A1 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A2 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A3 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A4 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A5 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A6 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| FILTERS | |||||||||||
| Filters **Estimated quantity: 1,289,558 Base Year, 1,554,131 Option Period 1, 1,873,938 Option Period 2, 2,260,673 Option Period 3, 2,728,527Option Period 4. Estimated quantities for Filters comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A 7038 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003B1 | Filters (Disposalble)-1 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0003B2 | Filters (Disposalble)-2 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0003B3 | Filters (Disposalble)-4 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0003B4 | Filters (Disposalble)-6 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0003B5 | Filters (Non Disposalble)-1 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0003B6 | Filters (Non Disposalble)-2 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0003B7 | Filters (Non Disposalble)-4 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0003B8 | Filters (Non Disposalble)-6 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tubing | |||||||||||
| **Estimated quantity: 828,324 Base Year, 1,112,930 Option Period 1, 1,527,325 Option Period 2, 2,147,325 Option Period 3, 3,099,542 Option Period 4. Estimated quantities for Tubing comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A7037 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003C1 | Tubing (Standard) 6 Feet | 6 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0003C2 | Tubing (Standard) 10 Feet | 10 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0003C3 | Tubing (Heated/Climate) 6 Feet | 6 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0003C4 | Tubing (Heated/Climate) 10Feet | 10 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
REPLACEMENT PARTS
| HUMIDIFIER WATER CHAMBER | ||||||||||
| Estimated quantity 222,460 Base Year, 329,774 Option Period 1, 492,910 Option Period 2, 740,753 Option Period 3, 1,117,133 Option Period 4. Estimated quantities for Humidifier Water Chamber comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | ||||||||||
| HCPCS/LCODE A7046 Suggested HCPCS/LCODE __________________ (if different) | ||||||||||
| Sub CLIN for Corresponding Replacement Parts | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003D1 | Humidifier Water Chamber | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| SECURE DIGITAL CARDS (SD) CARDS | ||||||||||
| Estimated Quantity: 922 | ||||||||||
| HCPCS/LCODE A9279 Suggested HCPCS/LCODE __________________ (if different) | ||||||||||
| Sub CLIN for Corresponding Replacement Parts | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003E1 | SECURE DIGITAL CARDS (SD) CARDS 10 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Estimate 1,205 | POWER CHORD | |||||||||
| *CORRESPONDING CLIN FOR PAP DEVICE | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003F1 | POWER CHORD | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Estimate 1,205 | POWER SUPPLY | |||||||||
| *CORRESPONDING CLIN FOR PAP DEVICE | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003G1 | POWER SUPPLY | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
CLIN 03C BPAP
Instructions/Examples: Each sheet within this workbook shall be used per CLIN. All Sub-CLINS shall be under the appropriate CLIN in order to be considered.
Please fill out the Unit Price for the Base Year and all Option Years for each item on your bid along with your commercially published list price.
These estimated quantities are estimates only and are not commitments. Additional sub-CLINs (0003CI-0003CL) have been added if an offeror wishes to bid more than 8 models. Note the quantities of the additional sub-CLINs are not included in the estimated annual quantity, however they are used for the purpose of calculating a total evaluated price.
See Row 14 for an example calculation and cell T14 for the total price that will be evaluated in consideration for award. Note each model offered must include the unit price for the base and options years to be considered for award.
| OFFEROR NAME (MANDATORY) : ___________________________________________________________________________________________ | ||||||||||||||||||||
| HCPCS/L Code: E0470 | Suggested HCPCS/L Code (if different): ________________ Pre-Approved Items for this CLIN are listed in Attachment F | |||||||||||||||||||
| CLIN 0003 | CATEGORY III-Auto-Titrating Bilevel Positive Airway Pressure (BPAP) Machines/(See attachment D for Minimum Technical Requirements and Attachment F for Pre-Approved items) | |||||||||||||||||||
| SUBCLINS | MODEL/BRAND | ITEM DESCRIPTION | PLACE OF MANUFACTURE | Est. QTY* BASE YEAR | UNIT PRICE BASE YEAR | TOTAL PRICE BASE YEAR | Est. QTY* OPTION PERIOD I | UNIT PRICE OPTION PERIOD I | TOTAL PRICE OPTION PERIOD I | Est. QTY* OPTION PERIOD II | UNIT PRICE OPTION PERIOD II | TOTAL PRICE OPTION PERIOD II | Est. QTY* OPTION PERIOD III | UNIT PRICE OPTION PERIOD III | TOTAL PRICE OPTION PERIOD III | Est. QTY* OPTION PERIOD IV | UNIT PRICE OPTION PERIOD IV | TOTAL PRICE OPTION PERIOD IV | BASE YEAR AND 4 YEAR OPTION PERIODS -TOTAL PRICE FOR PRODUCT | Published List Price |
| 0003-Sample | 938 | $1,000.00 | $937,864.24 | 975 | $900.00 | $877,274.69 | 1,013 | $950.00 | $962,431.87 | 1,053 | $1,050.00 | $1,105,577.47 | 1,094 | $1,000.00 | $1,094,343.26 | $4,977,491.52 | $1,100.00 |
0003CA 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003CB 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003CC 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003CD 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003CE 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003CF 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003CG 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003CH 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003CI 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003CJ 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
0003CK 938 $0.00 $0.00 975 $0.00 $0.00 1,013 $0.00 $0.00 1,053 $0.00 $0.00 1,094 $0.00 $0.00 $0.00 $0.00
| 0003CL | 938 | $0.00 | $0.00 | 975 | $0.00 | $0.00 | 1,013 | $0.00 | $0.00 | 1,053 | $0.00 | $0.00 | 1,094 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| 7,503 | $0.00 | 7,798 | $0.00 | 8,105 | $0.00 | 8,423 | $0.00 | 8,755 | $0.00 | ||||||||||
| TOTAL PRICE FOR BASE AND ALL OPTION PERIODS | $0.00 | ||||||||||||||||||
| ACCESSORIES |
| CHIN STRAPS | |||||||||||
| CHIN STRAPS **Estimated quantity: 99,387 Base Year, 120,155 Option Period 1, 145,263 Option Period 2,175,618 Option Period 3, 212,315 Option Period 4 . Estimated quantities for Chin Straps comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A 7036 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION CHIN STRAPS | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003A1 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A2 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A3 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A4 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A5 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0003A6 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| FILTERS | |||||||||||
| Filters **Estimated quantity: 1,289,558 Base Year, 1,554,131 Option Period 1, 1,873,938 Option Period 2, 2,260,673 Option Period 3, 2,728,527Option Period 4. Estimated quantities for Filters comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A 7038 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003B1 | Filters (Disposalble)-1 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0003B2 | Filters (Disposalble)-2 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0003B3 | Filters (Disposalble)-4 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0003B4 | Filters (Disposalble)-6 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0003B5 | Filters (Non Disposalble)-1 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0003B6 | Filters (Non Disposalble)-2 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0003B7 | Filters (Non Disposalble)-4 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0003B8 | Filters (Non Disposalble)-6 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tubing | |||||||||||
| **Estimated quantity: 828,324 Base Year, 1,112,930 Option Period 1, 1,527,325 Option Period 2, 2,147,325 Option Period 3, 3,099,542 Option Period 4. Estimated quantities for Tubing comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | |||||||||||
| HCPCS/LCODE A7037 Suggested HCPCS/LCODE __________________ (if different) | |||||||||||
| Sub CLIN for Corresponding Accessories | MODEL/BRAND | ITEM DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | SIZE | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003C1 | Tubing (Standard) 6 Feet | 6 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0003C2 | Tubing (Standard) 10 Feet | 10 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0003C3 | Tubing (Heated/Climate) 6 Feet | 6 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||
| 0003C4 | Tubing (Heated/Climate) 10Feet | 10 Feet | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
REPLACEMENT PARTS
| HUMIDIFIER WATER CHAMBER | ||||||||||
| Estimated quantity 222,460 Base Year, 329,774 Option Period 1, 492,910 Option Period 2, 740,753 Option Period 3, 1,117,133 Option Period 4. Estimated quantities for Humidifier Water Chamber comprise of various models, sizes and features. These estimated quantities are estimates only and are not commitments. | ||||||||||
| HCPCS/LCODE A7046 Suggested HCPCS/LCODE __________________ (if different) | ||||||||||
| Sub CLIN for Corresponding Replacement Parts | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003D1 | Humidifier Water Chamber | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| SECURE DIGITAL CARDS (SD) CARDS | ||||||||||
| Estimated Quantity: 922 | ||||||||||
| HCPCS/LCODE A9279 Suggested HCPCS/LCODE __________________ (if different) | ||||||||||
| Sub CLIN for Corresponding Replacement Parts | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003E1 | SECURE DIGITAL CARDS (SD) CARDS 10 Pack | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Estimate 1,205 | POWER CHORD | |||||||||
| *CORRESPONDING CLIN FOR PAP DEVICE | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003F1 | POWER CHORD | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Estimate 1,205 | POWER SUPPLY | |||||||||
| *CORRESPONDING CLIN FOR PAP DEVICE | REPLACEMENT PART DESCRIPTION | DETAILED DESCRIPTION OF ITEM OFFERED | PLACE OF MANUFACTURE | DESCRIPTION AND PAP MODEL FOR THIS REPLACEMENT PART BEING OFFERED | UNIT PRICE BASE YEAR | UNIT PRICE OPTION PERIOD I | UNIT PRICE OPTION PERIOD II | UNIT PRICE OPTION PERIOD III | UNIT PRICE OPTION PERIOD IV | Published List Price |
| 0003G1 | POWER SUPPLY | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
CLIN 04 VAPS
Instructions/Examples: Each sheet within this workbook shall be used per CLIN. All Sub-CLINS shall be under the appropriate CLIN in order to be considered.
Please fill out the Unit…
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