36C79119R0009-0014002.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 a future request for proposal for Positive Airway Pressure devices and associated accessories/replacement parts to be issued by the Department of Veterans Affairs. The solicitation will seek to award multiple indefinite delivery indefinite quantity contracts with a total maximum value of $450 million over five years. The contracts will have a one year base period and four one-year option periods. The solicitation is set aside as a tiered small business opportunity for Service Disabled Veteran Owned Small Businesses first, then Veteran Owned Small Businesses, and Small Businesses. Interested offerors should register on beta.SAM.gov and Vendor Information Pages if applicable. The request for proposal is expected to be released on July 12, 2019, with proposals accepted for 30 days. It will provide instructions for proposal submission. Offerors should contact the listed contracting officials with any questions.
36C79119R0009 0014 ATTACHMENT E PRICE SHEDULE_Amendment 14.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 9 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 | 22,767 | $450.00 | $10,245,339.35 | 25,075 | $475.00 | $11,910,805.04 | 27,617 | $425.00 | $11,737,351.45 | 30,417 | $450.00 | $13,687,601.88 | 33,500 | $475.00 | $15,912,636.16 | $63,493,733.87 | $500.00 |
0001AA 22,767 $0.00 $0.00 25,075 $0.00 $0.00 27,617 $0.00 $0.00 30,417 $0.00 $0.00 33,500 $0.00 $0.00 $0.00 $0.00
0001AB 22,767 $0.00 $0.00 25,075 $0.00 $0.00 27,617 $0.00 $0.00 30,417 $0.00 $0.00 33,500 $0.00 $0.00 $0.00 $0.00
0001AC 22,767 $0.00 $0.00 25,075 $0.00 $0.00 27,617 $0.00 $0.00 30,417 $0.00 $0.00 33,500 $0.00 $0.00 $0.00 $0.00
0001AD 22,767 $0.00 $0.00 25,075 $0.00 $0.00 27,617 $0.00 $0.00 30,417 $0.00 $0.00 33,500 $0.00 $0.00 $0.00 $0.00
0001AE 22,767 $0.00 $0.00 25,075 $0.00 $0.00 27,617 $0.00 $0.00 30,417 $0.00 $0.00 33,500 $0.00 $0.00 $0.00 $0.00
0001AF 22,767 $0.00 $0.00 25,075 $0.00 $0.00 27,617 $0.00 $0.00 30,417 $0.00 $0.00 33,500 $0.00 $0.00 $0.00 $0.00
0001AG 22,767 $0.00 $0.00 25,075 $0.00 $0.00 27,617 $0.00 $0.00 30,417 $0.00 $0.00 33,500 $0.00 $0.00 $0.00 $0.00
0001AH 22,767 $0.00 $0.00 25,075 $0.00 $0.00 27,617 $0.00 $0.00 30,417 $0.00 $0.00 33,500 $0.00 $0.00 $0.00 $0.00
0001AI 22,767 $0.00 $0.00 25,075 $0.00 $0.00 27,617 $0.00 $0.00 30,417 $0.00 $0.00 33,500 $0.00 $0.00 $0.00 $0.00
0001AJ 22,767 $0.00 $0.00 25,075 $0.00 $0.00 27,617 $0.00 $0.00 30,417 $0.00 $0.00 33,500 $0.00 $0.00 $0.00 $0.00
0001AK 22,767 $0.00 $0.00 25,075 $0.00 $0.00 27,617 $0.00 $0.00 30,417 $0.00 $0.00 33,500 $0.00 $0.00 $0.00 $0.00
0001AL 22,767 $0.00 $0.00 25,075 $0.00 $0.00 27,617 $0.00 $0.00 30,417 $0.00 $0.00 33,500 $0.00 $0.00 $0.00 $0.00
| 0001AM | 22,767 | $0.00 | $0.00 | 25,075 | $0.00 | $0.00 | 27,617 | $0.00 | $0.00 | 30,417 | $0.00 | $0.00 | 33,500 | $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 9 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 | 427 | $1,700.00 | $725,101.27 | 446 | $1,750.00 | $779,691.33 | 465 | $1,650.00 | $767,897.96 | 486 | $1,750.00 | $850,731.53 | 508 | $1,700.00 | $863,253.43 | $3,986,675.53 | $1,800.00 |
0002AA 427 $0.00 $0.00 446 $0.00 $0.00 465 $0.00 $0.00 486 $0.00 $0.00 508 $0.00 $0.00 $0.00 $0.00
0002AB 427 $0.00 $0.00 446 $0.00 $0.00 465 $0.00 $0.00 486 $0.00 $0.00 508 $0.00 $0.00 $0.00 $0.00
0002AC 427 $0.00 $0.00 446 $0.00 $0.00 465 $0.00 $0.00 486 $0.00 $0.00 508 $0.00 $0.00 $0.00 $0.00
0002AD 427 $0.00 $0.00 446 $0.00 $0.00 465 $0.00 $0.00 486 $0.00 $0.00 508 $0.00 $0.00 $0.00 $0.00
0002AE 427 $0.00 $0.00 446 $0.00 $0.00 465 $0.00 $0.00 486 $0.00 $0.00 508 $0.00 $0.00 $0.00 $0.00
0002AF 427 $0.00 $0.00 446 $0.00 $0.00 465 $0.00 $0.00 486 $0.00 $0.00 508 $0.00 $0.00 $0.00 $0.00
0002AG 427 $0.00 $0.00 446 $0.00 $0.00 465 $0.00 $0.00 486 $0.00 $0.00 508 $0.00 $0.00 $0.00 $0.00
0002AH 427 $0.00 $0.00 446 $0.00 $0.00 465 $0.00 $0.00 486 $0.00 $0.00 508 $0.00 $0.00 $0.00 $0.00
0002AI 427 $0.00 $0.00 446 $0.00 $0.00 465 $0.00 $0.00 486 $0.00 $0.00 508 $0.00 $0.00 $0.00 $0.00
0002AJ 427 $0.00 $0.00 446 $0.00 $0.00 465 $0.00 $0.00 486 $0.00 $0.00 508 $0.00 $0.00 $0.00 $0.00
0002AK 427 $0.00 $0.00 446 $0.00 $0.00 465 $0.00 $0.00 486 $0.00 $0.00 508 $0.00 $0.00 $0.00 $0.00
0002AL 427 $0.00 $0.00 446 $0.00 $0.00 465 $0.00 $0.00 486 $0.00 $0.00 508 $0.00 $0.00 $0.00 $0.00
| 0002AM | 427 | $0.00 | $0.00 | 446 | $0.00 | $0.00 | 465 | $0.00 | $0.00 | 486 | $0.00 | $0.00 | 508 | $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 |
| 0002A1 | 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 | |||||
| 0002A2 | 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 | |||||
| 0002A3 | 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 | |||||
| 0002A4 | 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 | |||||
| 0002A5 | 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 | |||||
| 0002A6 | 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 |
| 0002B1 | 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 | ||||
| 0002B2 | 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 | ||||
| 0002B3 | 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 | ||||
| 0002B4 | 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 |
| 0002B5 | 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 |
| 0002B6 | 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 |
| 0002B7 | 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 |
| 0002B8 | 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 |
| 0002C1 | 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 |
0002C2 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
0002C3 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
| 0002C4 | 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 |
| 0002D1 | 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 |
0002D2 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
0002D3 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
0002D4 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
| 0002D5 | 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 |
| 0002E1 | 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 |
0002E2 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
0002E3 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
0002E4 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
| 0002E5 | 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 |
| 0002F1 | 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 |
0002F2 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
0002F3 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
0002F4 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
| 0002F5 | 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 |
| 0002G1 | 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 |
0002G2 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
0002G3 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
0002G4 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
| 0002G5 | 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 9 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 | 834 | $1,000.00 | $833,657.10 | 866 | $900.00 | $779,799.72 | 901 | $950.00 | $855,494.99 | 936 | $1,050.00 | $982,735.53 | 973 | $1,000.00 | $972,749.56 | $4,424,436.91 | $1,100.00 |
0003AA 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003AB 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003AC 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003AD 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003AE 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003AF 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003AG 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003AH 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003AI 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003AJ 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003AK 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003AL 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
| 0003AM | 834 | $0.00 | $0.00 | 866 | $0.00 | $0.00 | 901 | $0.00 | $0.00 | 936 | $0.00 | $0.00 | 973 | $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 |
| 0003A1 | 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 | |||||
| 0003A2 | 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 | |||||
| 0003A3 | 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 | |||||
| 0003A4 | 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 | |||||
| 0003A5 | 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 | |||||
| 0003A6 | 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 |
| 0003B1 | 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 | ||||
| 0003B2 | 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 | ||||
| 0003B3 | 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 | ||||
| 0003B4 | 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 |
| 0003B5 | 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 |
| 0003B6 | 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 |
| 0003B7 | 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 |
| 0003B8 | 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 |
| 0003C1 | 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 |
0003C2 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
0003C3 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
| 0003C4 | 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 |
| 0003D1 | 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 |
0003D2 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
0003D3 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
0003D4 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
| 0003D5 | 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 |
| 0003E1 | 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 |
0003E2 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
0003E3 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
0003E4 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
| 0003E5 | 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 |
| 0003F1 | 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 |
0003F2 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
0003F3 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
0003F4 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
| 0003F5 | 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 |
| 0003G1 | 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 |
0003G2 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
0003G3 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
0003G4 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
| 0003G5 | 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 9 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 0003B | 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 | 834 | $1,000.00 | $833,657.10 | 866 | $900.00 | $779,799.72 | 901 | $950.00 | $855,494.99 | 936 | $1,050.00 | $982,735.53 | 973 | $1,000.00 | $972,749.56 | $4,424,436.91 | $1,100.00 |
0003BA 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003BB 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003BC 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003BD 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003BE 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003BF 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003BG 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003BH 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003BI 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003BJ 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003BK 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
0003BL 834 $0.00 $0.00 866 $0.00 $0.00 901 $0.00 $0.00 936 $0.00 $0.00 973 $0.00 $0.00 $0.00 $0.00
| 0003BM | 834 | $0.00 | $0.00 | 866 | $0.00 | $0.00 | 901 | $0.00 | $0.00 | 936 | $0.00 | $0.00 | 973 | $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) |
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