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Sheet1
| ITEM# | ITEM NAME | HCPCS | ITEM DESCRIPTION | UNIT | UNIT |
| | CODE | | PRICE | OF |
| | | | | MEASURE |
| 1 | Rental of Contractor | E1392 | Concentrator, Colored Tubing, Adapter | | EA |
| Owned Portable Concentrator | | Humidifier (when required), Cannulas or | | |
| System (Freestyle) | | Masks and other required supplies and | | |
| | | equipment, including back up systems. | | |
| Priced Per Month | | Perform Equipment Maintenance in | | |
| | | accordance with manufacturer standards. | | |
| | | At a minimum of once every 90 calendar | | |
| | | days, visit and assess patient to assure | | |
| | | equipment complinace, change filters and | | |
| | | provide disposable supplies. | | |
| 2 | Rental of Contractor | E1392 | Concentrator, Colored Tubing, Adapter | EA |
| Owned Portable Concentrator | | Humidifier (when required), Cannulas or | |
| System (Oxlife or IGO) | | Masks and other required supplies and | |
| | | equipment, including back up systems. | |
| Priced Per Month | | Perform Equipment Maintenance in | |
| | | accordance with manufacturer standards. | |
| | | At a minimum of once every 90 calendar | |
| | | days, visit and assess patient to assure | |
| | | equipment complinace, change filters and | |
| | | provide disposable supplies. | |
| 3 | Rental of Contractor | E1390 | | EA |
| Owned Low Decibel | | To include all supplies, equipment | |
| Concentrator System | | maintenance and 90 calendar day visit as | |
| | | described in Item 1 | |
| Priced Per Month | | | |
| 4 | Rental of Contractor | E1390 | | EA |
| Owned Hi Flow | | To include all supplies, equipment | |
| Concentrator System | | maintenance and 90 calendar day visit as | |
| | | described in Item 1 | |
| Priced Per Month | | | |
| 5 | Rental of Contractor | E0431 | Portable System, Regulator, | EA |
| Owned Portable O2 | | Flowmeter, Humidifier, Cannulas, | |
| Gaseous System for | | or Masks, Tubing, | |
| use with or without | | Conserving Device and O2 Tank | |
| Stationary System | | Cylinder Stands capable of holding | |
| Priced Per Month | | 12 cylinders, sizes E, D, C & M-6 | |
| 6 | Rental of Contractor | E0439 | Resevoir, Regulator, Flowmeter, | EA |
| Owned Stationary | | Humidifier, Cannulas or Masks, and | |
| Liquid O2 System | | Colored Tubing. | |
Priced Per Month
| 7 | Rental of Contractor | E0434 | Portable Container, Refill Adapter | EA |
| Owned Portable | | Flowmeter, Cannulas or Masks, and | |
| Liquid O2 System | | Colored Tubing. Resevoir will be provided | |
| | | if another Stationary System (e.g. | |
| Priced Per Month | | Concentrator) is rented. | |
| 8 | Suction Pump Rental | E0600 | Delivery, Set-up, and Training of | EA |
| | | Contractor Owned Suction Pump to | |
| | | Include all supplies | |
| Priced Per month | | | |
| 9 | Rental of Contractor | E0465 | Delivery, Set-up, Training, and | EA |
| Owned Volume | | Maintenance of Contractor Owned | |
| Ventilator | | Stationary or Portable Ventilator, to | |
| | | include back up Ventilator and all supplies | |
| Priced Per Month | | | |
| 10 | Air Compressor | E0570 | Rental of Contractor Owned and | EA |
| | | Maintained continuous or intermittent | |
| | | air compressor for use with | |
| | | equipment not self contained or | |
| Priced Per Month | | cylinder driven, to include all | |
| | | associated supplies | |
| 11 | Delivery Charge | A9901 | Deliveries not made under all other | EA |
| | | line items | |
12 Delivery Charge A9901 Delivery out of catchment area, per mile. Mile
Priced Per Each
| 13 | Fire Safe | VA186 | Delivery, Set-up | Each |
| Cannula Valve | | of FSCV. | |
Priced Per Each
| | | REFILLS - ALL QUANTITIES ARE MONTHLY | UNIT | |
| ITEM# | ITEM NAME | HCPCS | ITEM DESCRIPTION | CYLINDER | UNIT |
| | CODE | | PRICE | |
| R1 | E Cylinder | E0443 | E Cylinder Refill | | EA |
R2 D Cylinder E0443 D Cylinder Refill EA
R3 C Cylinder E0443 C Cylinder Refill EA
R4 M-6 Cylinder E0443 M-6 Cylinder Refill EA
R5 M-90 Tank E0443 M-90 Tank Refill EA
| R6 | Liquid Oxygen | E0444 | Liquid Oxygen | Pounds |
| | | Refill | |
Section D 01/24/2010 Price Schedule Attachment DA&P