36C79119R0009-0005001.xlsx
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- PAP New Issue TIERED EVALUATIONS Federal contract opportunity
- Solicitation number
- 36C79119R0009
About this file
This pre-solicitation announcement provides advance notice of an upcoming request for proposal from the Department of Veterans Affairs for Positive Airway Pressure devices and associated accessories, replacement parts, and supplies. The VA intends to award multiple firm fixed price IDIQ contracts for a base period of one year plus four one-year options. The solicitation seeks to obtain PAP technologies and secure a continuous supply of products to support clinical programs for veterans. Interested offerors must register in the System for Award Management and Vendor Information Pages databases. The anticipated solicitation will be issued on or around July 12, 2019 and proposals will be accepted for 30 days. Questions should be directed to the specified contracting officer and contract specialist.
36C79119R0009 0005 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 | |||||||||||||||||||
| **Estimated quantity: 1,254,395. These estimated quantities are estimates only and are not commitments. | ||||||||||||||||||||
| 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 | $475.00 | $17,901,715.67 | $71,430,450.61 | $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: 16,564 Base Year, 20,026 Option Period 1, 24,210 Option Period 2, 29,270 Option Period 3, 35,386 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 | 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 |
| 0001A1 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A2 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A3 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A4 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A5 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A6 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 16,564 | 20,026 | 24,210 | 29,270 | 35,386 |
| FILTERS | ||||||||||||||||||||||
| Filters **Estimated quantity: 214,928 Base Year, 259,024 Option Period 1, 312,328 Option Period 2, 376,784 Option Period 3, 454,760 Option 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 | 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 |
| 0001B1 | Filters (Disposalble)-1 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0001B2 | Filters (Disposalble)-2 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0001B3 | Filters (Disposalble)-4 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0001B4 | Filters (Disposalble)-6 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B5 | Filters (Non Disposalble)-1 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B6 | Filters (Non Disposalble)-2 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B7 | Filters (Non Disposalble)-4 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B8 | Filters (Non Disposalble)-6 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 214,928 | 259,024 | 312,328 | 376,784 | 454,760 |
| Tubing | ||||||||||||||||||||||
| **Estimated quantity: 138,056 Base Year, 185,492 Option Period 1, 254,556 Option Period 2, 357,888 Option Period 3, 516,592 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 | 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 |
| 0001C1 | Tubing (Standard) 6 Feet | 6 Feet | 34,514 | $0.00 | $0.00 | 46,373 | $0.00 | $0.00 | 63,639 | $0.00 | $0.00 | 89,472 | $0.00 | $0.00 | 129,148 | $0.00 | $0.00 | $0.00 | $0.00 |
0001C2 Tubing (Standard) 10 Feet 10 Feet 34,514 $0.00 $0.00 46,373 $0.00 $0.00 63,639 $0.00 $0.00 89,472 $0.00 $0.00 129,148 $0.00 $0.00 $0.00 $0.00
0001C3 Tubing (Heated/Climate) 6 Feet 6 Feet 34,514 $0.00 $0.00 46,373 $0.00 $0.00 63,639 $0.00 $0.00 89,472 $0.00 $0.00 129,148 $0.00 $0.00 $0.00 $0.00
| 0001C4 | Tubing (Heated/Climate) 10Feet | 10 Feet | 34,514 | $0.00 | $0.00 | 46,373 | $0.00 | $0.00 | 63,639 | $0.00 | $0.00 | 89,472 | $0.00 | $0.00 | 129,148 | $0.00 | $0.00 | $0.00 | $0.00 |
| 138,056 | 185,492 | 254,556 | 357,888 | 516,592 |
REPLACEMENT PARTS
| HUMIDIFIER WATER CHAMBER | |||||||||||||||||||||
| Estimated quantity 37,080 Base Year, 54,965 Option Period 1, 82,155 Option Period 2, 123,460 Option Period 3, 186,190 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 | 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 |
| 0001D1 | Humidifier Water Chamber | 7,416 | $0.00 | $0.00 | 10,993 | $0.00 | $0.00 | 16,431 | $0.00 | $0.00 | 24,692 | $0.00 | $0.00 | 37,238 | $0.00 | $0.00 | $0.00 | $0.00 |
0001D2 7,416 $0.00 $0.00 10,993 $0.00 $0.00 16,431 $0.00 $0.00 24,692 $0.00 $0.00 37,238 $0.00 $0.00 $0.00 $0.00
0001D3 7,416 $0.00 $0.00 10,993 $0.00 $0.00 16,431 $0.00 $0.00 24,692 $0.00 $0.00 37,238 $0.00 $0.00 $0.00 $0.00
0001D4 7,416 $0.00 $0.00 10,993 $0.00 $0.00 16,431 $0.00 $0.00 24,692 $0.00 $0.00 37,238 $0.00 $0.00 $0.00 $0.00
| 0001D5 | 7,416 | $0.00 | $0.00 | 10,993 | $0.00 | $0.00 | 16,431 | $0.00 | $0.00 | 24,692 | $0.00 | $0.00 | 37,238 | $0.00 | $0.00 | $0.00 | $0.00 |
| 37,080 | 54,965 | 82,155 | 123,460 | 186,190 |
| SECURE DIGITAL CARDS (SD) CARDS | |||||||||||||||||||||
| Estimated Quantity: 154 | |||||||||||||||||||||
| 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 | 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 |
| 0001E1 | SECURE DIGITAL CARDS (SD) CARDS 10 Pack | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | $0.00 | $0.00 |
0001E2 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 $0.00 $0.00
0001E3 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 $0.00 $0.00
0001E4 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 $0.00 $0.00
| 0001E5 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | $0.00 | $0.00 |
| 31 | 31 | 31 | 31 | 31 |
| Estimate 201 | 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 | 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 |
| 0001F1 | POWER CHORD | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | $0.00 | $0.00 |
0001F2 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
0001F3 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
0001F4 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
| 0001F5 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | $0.00 | $0.00 |
| 40 | 40 | 40 | 40 | 40 |
| Estimate 201 | 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 | 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 |
| 0001G1 | POWER Supply | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | $0.00 | $0.00 |
0001G2 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
0001G3 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
0001G4 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
| 0001G5 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | $0.00 | $0.00 |
| 40 | 40 | 40 | 40 | 40 |
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 | |||||||||||||||||||
| **Estimated quantity: 20,983. These estimated quantities are estimates only and are not commitments. | ||||||||||||||||||||
| 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: 16,564 Base Year, 20,026 Option Period 1, 24,210 Option Period 2, 29,270 Option Period 3, 35,386 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 | 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 |
| 0001A1 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A2 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A3 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A4 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A5 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A6 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 16,564 | 20,026 | 24,210 | 29,270 | 35,386 |
| FILTERS | ||||||||||||||||||||||
| Filters **Estimated quantity: 214,928 Base Year, 259,024 Option Period 1, 312,328 Option Period 2, 376,784 Option Period 3, 454,760 Option 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 | 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 |
| 0001B1 | Filters (Disposalble)-1 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0001B2 | Filters (Disposalble)-2 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0001B3 | Filters (Disposalble)-4 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0001B4 | Filters (Disposalble)-6 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B5 | Filters (Non Disposalble)-1 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B6 | Filters (Non Disposalble)-2 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B7 | Filters (Non Disposalble)-4 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B8 | Filters (Non Disposalble)-6 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 214,928 | 259,024 | 312,328 | 376,784 | 454,760 |
| Tubing | ||||||||||||||||||||||
| **Estimated quantity: 138,056 Base Year, 185,492 Option Period 1, 254,556 Option Period 2, 357,888 Option Period 3, 516,592 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 | 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 |
| 0001C1 | Tubing (Standard) 6 Feet | 6 Feet | 34,514 | $0.00 | $0.00 | 46,373 | $0.00 | $0.00 | 63,639 | $0.00 | $0.00 | 89,472 | $0.00 | $0.00 | 129,148 | $0.00 | $0.00 | $0.00 | $0.00 |
0001C2 Tubing (Standard) 10 Feet 10 Feet 34,514 $0.00 $0.00 46,373 $0.00 $0.00 63,639 $0.00 $0.00 89,472 $0.00 $0.00 129,148 $0.00 $0.00 $0.00 $0.00
0001C3 Tubing (Heated/Climate) 6 Feet 6 Feet 34,514 $0.00 $0.00 46,373 $0.00 $0.00 63,639 $0.00 $0.00 89,472 $0.00 $0.00 129,148 $0.00 $0.00 $0.00 $0.00
| 0001C4 | Tubing (Heated/Climate) 10Feet | 10 Feet | 34,514 | $0.00 | $0.00 | 46,373 | $0.00 | $0.00 | 63,639 | $0.00 | $0.00 | 89,472 | $0.00 | $0.00 | 129,148 | $0.00 | $0.00 | $0.00 | $0.00 |
| 138,056 | 185,492 | 254,556 | 357,888 | 516,592 |
REPLACEMENT PARTS
| HUMIDIFIER WATER CHAMBER | |||||||||||||||||||||
| Estimated quantity 37,080 Base Year, 54,965 Option Period 1, 82,155 Option Period 2, 123,460 Option Period 3, 186,190 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 | 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 |
| 0001D1 | Humidifier Water Chamber | 7,416 | $0.00 | $0.00 | 10,993 | $0.00 | $0.00 | 16,431 | $0.00 | $0.00 | 24,692 | $0.00 | $0.00 | 37,238 | $0.00 | $0.00 | $0.00 | $0.00 |
0001D2 7,416 $0.00 $0.00 10,993 $0.00 $0.00 16,431 $0.00 $0.00 24,692 $0.00 $0.00 37,238 $0.00 $0.00 $0.00 $0.00
0001D3 7,416 $0.00 $0.00 10,993 $0.00 $0.00 16,431 $0.00 $0.00 24,692 $0.00 $0.00 37,238 $0.00 $0.00 $0.00 $0.00
0001D4 7,416 $0.00 $0.00 10,993 $0.00 $0.00 16,431 $0.00 $0.00 24,692 $0.00 $0.00 37,238 $0.00 $0.00 $0.00 $0.00
| 0001D5 | 7,416 | $0.00 | $0.00 | 10,993 | $0.00 | $0.00 | 16,431 | $0.00 | $0.00 | 24,692 | $0.00 | $0.00 | 37,238 | $0.00 | $0.00 | $0.00 | $0.00 |
| 37,080 | 54,965 | 82,155 | 123,460 | 186,190 |
| SECURE DIGITAL CARDS (SD) CARDS | |||||||||||||||||||||
| Estimated Quantity: 154 | |||||||||||||||||||||
| 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 | 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 |
| 0001E1 | SECURE DIGITAL CARDS (SD) CARDS 10 Pack | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | $0.00 | $0.00 |
0001E2 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 $0.00 $0.00
0001E3 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 $0.00 $0.00
0001E4 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 $0.00 $0.00
| 0001E5 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | $0.00 | $0.00 |
| 31 | 31 | 31 | 31 | 31 |
| Estimate 201 | 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 | 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 |
| 0001F1 | POWER CHORD | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | $0.00 | $0.00 |
0001F2 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
0001F3 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
0001F4 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
| 0001F5 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | $0.00 | $0.00 |
| 40 | 40 | 40 | 40 | 40 |
| Estimate 201 | 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 | 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 |
| 0001G1 | POWER Supply | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | $0.00 | $0.00 |
0001G2 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
0001G3 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
0001G4 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
| 0001G5 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | $0.00 | $0.00 |
| 40 | 40 | 40 | 40 | 40 |
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 | |||||||||||||||||||
| **Estimated quantity: 40,854. These estimated quantities are estimates only and are not commitments. | ||||||||||||||||||||
| 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: 16,564 Base Year, 20,026 Option Period 1, 24,210 Option Period 2, 29,270 Option Period 3, 35,386 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 | 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 |
| 0001A1 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A2 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A3 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A4 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A5 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 0001A6 | 2,761 | $0.00 | $0.00 | 3,338 | $0.00 | $0.00 | 4,035 | $0.00 | $0.00 | 4,878 | $0.00 | $0.00 | 5,898 | $0.00 | $0.00 | $0.00 | $0.00 | |||||
| 16,564 | 20,026 | 24,210 | 29,270 | 35,386 |
| FILTERS | ||||||||||||||||||||||
| Filters **Estimated quantity: 214,928 Base Year, 259,024 Option Period 1, 312,328 Option Period 2, 376,784 Option Period 3, 454,760 Option 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 | 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 |
| 0001B1 | Filters (Disposalble)-1 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0001B2 | Filters (Disposalble)-2 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0001B3 | Filters (Disposalble)-4 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| 0001B4 | Filters (Disposalble)-6 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B5 | Filters (Non Disposalble)-1 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B6 | Filters (Non Disposalble)-2 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B7 | Filters (Non Disposalble)-4 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 0001B8 | Filters (Non Disposalble)-6 Pack | 26,866 | $0.00 | $0.00 | 32,378 | $0.00 | $0.00 | 39,041 | $0.00 | $0.00 | 47,098 | $0.00 | $0.00 | 56,845 | $0.00 | $0.00 | $0.00 | $0.00 |
| 214,928 | 259,024 | 312,328 | 376,784 | 454,760 |
| Tubing | ||||||||||||||||||||||
| **Estimated quantity: 138,056 Base Year, 185,492 Option Period 1, 254,556 Option Period 2, 357,888 Option Period 3, 516,592 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 | 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 |
| 0001C1 | Tubing (Standard) 6 Feet | 6 Feet | 34,514 | $0.00 | $0.00 | 46,373 | $0.00 | $0.00 | 63,639 | $0.00 | $0.00 | 89,472 | $0.00 | $0.00 | 129,148 | $0.00 | $0.00 | $0.00 | $0.00 |
0001C2 Tubing (Standard) 10 Feet 10 Feet 34,514 $0.00 $0.00 46,373 $0.00 $0.00 63,639 $0.00 $0.00 89,472 $0.00 $0.00 129,148 $0.00 $0.00 $0.00 $0.00
0001C3 Tubing (Heated/Climate) 6 Feet 6 Feet 34,514 $0.00 $0.00 46,373 $0.00 $0.00 63,639 $0.00 $0.00 89,472 $0.00 $0.00 129,148 $0.00 $0.00 $0.00 $0.00
| 0001C4 | Tubing (Heated/Climate) 10Feet | 10 Feet | 34,514 | $0.00 | $0.00 | 46,373 | $0.00 | $0.00 | 63,639 | $0.00 | $0.00 | 89,472 | $0.00 | $0.00 | 129,148 | $0.00 | $0.00 | $0.00 | $0.00 |
| 138,056 | 185,492 | 254,556 | 357,888 | 516,592 |
REPLACEMENT PARTS
| HUMIDIFIER WATER CHAMBER | |||||||||||||||||||||
| Estimated quantity 37,080 Base Year, 54,965 Option Period 1, 82,155 Option Period 2, 123,460 Option Period 3, 186,190 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 | 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 |
| 0001D1 | Humidifier Water Chamber | 7,416 | $0.00 | $0.00 | 10,993 | $0.00 | $0.00 | 16,431 | $0.00 | $0.00 | 24,692 | $0.00 | $0.00 | 37,238 | $0.00 | $0.00 | $0.00 | $0.00 |
0001D2 7,416 $0.00 $0.00 10,993 $0.00 $0.00 16,431 $0.00 $0.00 24,692 $0.00 $0.00 37,238 $0.00 $0.00 $0.00 $0.00
0001D3 7,416 $0.00 $0.00 10,993 $0.00 $0.00 16,431 $0.00 $0.00 24,692 $0.00 $0.00 37,238 $0.00 $0.00 $0.00 $0.00
0001D4 7,416 $0.00 $0.00 10,993 $0.00 $0.00 16,431 $0.00 $0.00 24,692 $0.00 $0.00 37,238 $0.00 $0.00 $0.00 $0.00
| 0001D5 | 7,416 | $0.00 | $0.00 | 10,993 | $0.00 | $0.00 | 16,431 | $0.00 | $0.00 | 24,692 | $0.00 | $0.00 | 37,238 | $0.00 | $0.00 | $0.00 | $0.00 |
| 37,080 | 54,965 | 82,155 | 123,460 | 186,190 |
| SECURE DIGITAL CARDS (SD) CARDS | |||||||||||||||||||||
| Estimated Quantity: 154 | |||||||||||||||||||||
| 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 | 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 |
| 0001E1 | SECURE DIGITAL CARDS (SD) CARDS 10 Pack | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | $0.00 | $0.00 |
0001E2 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 $0.00 $0.00
0001E3 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 $0.00 $0.00
0001E4 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 6 $0.00 $0.00 $0.00 $0.00
| 0001E5 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | 6 | $0.00 | $0.00 | $0.00 | $0.00 |
| 31 | 31 | 31 | 31 | 31 |
| Estimate 201 | 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 | 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 |
| 0001F1 | POWER CHORD | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | $0.00 | $0.00 |
0001F2 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
0001F3 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
0001F4 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
| 0001F5 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | $0.00 | $0.00 |
| 40 | 40 | 40 | 40 | 40 |
| Estimate 201 | 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 | 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 |
| 0001G1 | POWER Supply | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | $0.00 | $0.00 |
0001G2 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
0001G3 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
0001G4 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 8 $0.00 $0.00 $0.00 $0.00
| 0001G5 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | 8 | $0.00 | $0.00 | $0.00 | $0.00 |
| 40 | 40 | 40 | 40 | 40 |
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 | |||||||||||||||||||
| **Estimated quantity: 40,854. These estimated quantities are estimates only and are not commitments. | ||||||||||||||||||||
| 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: 16,564 Base Year, 20,026 Option Period 1, 24,210 Option Period 2, 29,270 Option Period 3, 35,386 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 | 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 |
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