ATTACHMENT 01 PALO ALTO ITEM SCHEDULE.pdf

Palo Alto Pricing Sheet

ITEM# ITEM NAME HCPCS ITEM DESCRIPTION UNIT UNIT

CODE PRICE (Where just number, unit is "Month.")

1 Rental of Contractor E1392 Concentrator, Colored Tubing, Adapter EACH

Owned Concentrator Humidifier (when required), Cannulas or

System 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.

1a Rental of Contractor E1390 To include all supplies, equipment EACH

Owned Low Decibel maintenance and 90 calendar day visit as

Concentrator System described in Item 1

Priced Per Month

1b Rental of Contractor E1390 To include all supplies, equipment EACH

Owned Home Fill maintenance and 90 calendar day visit as

Oxygen System described in Item 1

Priced Per Month

1c Rental of Contractor E1390 To include all supplies, equipment EACH

Owned Hi Flow maintenance and 90 calendar day visit as

Concentrator System described in Item 1

Priced Per Month

Palo Alto Page 1 O2 Line Items

Amendment #1

CODE PRICE (Where just number, unit is "Month.")

2 Rental of Contractor E0431 Portable System, Regulator, EACH

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

3 Rental of Contractor E0439 Resevoir, Regulator, Flowmeter, EACH

Owned Stationary Humidifier, Cannulas or Masks, and

Liquid O2 System Colored Tubing (priced per month)

4 Rental of Contractor E0434 Portable Container, Refill Adapter EACH

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.

5 Continuous Positive E0601 Delivery, Set-up & Training of EACH

Airway Device Government Owned CPAP in

(CPAP) Set-up Patient's Home to include mask and all required supplies (priced per each)

6 CPAP Maintenance E0601 Maintenance of Government Owned EACH

As Requested CPAP, to include maintenance in accordance with Manufacturer

Priced Per Each recommendation, replacement of

Mask, Headgear, Chinstraps, Tubing

& Filters Disposible/Non-Disposible in Patients Home

6a Pressure Support E0463 Pressure Support Ventilator with Volume EACH

Ventilator Control Mode, may include pressure control mod, used with invasive interface (e.g., tracheostomy tube)

6b Pressure Support E0464 Pressure Support Ventilator with Volume EACH

Ventilator Control Mode, may include pressure control mod, used w/non-invasive interface (e.g., mask)

Palo Alto Page 2

CODE PRICE (Where just number, unit is "Month.")

7 Continuous Positive E0601 Delivery, Set-up & Training of EACH

Airway Device Government Owned CPAP at the

(CPAP) Set-up Contractors Facility to include mask and all supplies

Priced Per Each

8 Bilevel Positive Airway E0470 Delivery, Set-up & Training of EACH

Pressure Device Government Owned BiLevel in

Set-up Patient's Home to include mask and all supplies

Priced Per Each

9 BiLevel Maintenance E0470 Maintenance of Government Owned EACH

As Requested BiLevel, to include maintenance in accordance with Manufacturer recommendation, replacement of

Priced Per Each Mask, Headgear, Chinstraps, Tubing

& Filters Disposible/Non-Disposible in Patients Home

10 BiLevel Set-up E0470 Delivery, Set-up & Training of EACH

Government Owned BiLevel at the

Contractors Facility to include mask

Priced Per Each and all supplies

11 Nebulizers E0570 Delivery, Set-up and Training of EACH

Government Owned Nebulizer, Compressor or Battery Powered as

Priced Per Each ordered

Palo Alto Page 3

CODE PRICE (Where just number, unit is "Month.")

12 Suction Pump E0600 Purchase, Delivery, Set-up and EACH

Training of Contractor Home Model

Respiratory Suction Pump, portable

Priced Per Each or stationary electric to include all supplies

13 Suction Pump Rental E0600 Delivery, Set-up, and Training of EACH

Contractor Owned Suction Pump to

Include all supplies

Priced Per Each

14 Rental of Contractor E0450 Delivery, Set-up, Training, and EACH

Owned Volume Maintenance of Contractor Owned

Ventilator Stationary or Portable Ventilator, to include back up Ventilator and all supplies

Priced Per Month

15 Government Owned E0450 Delivery, Set-up, and Training of a EACH

Ventilator Set-up Government Owned Ventilator to include all necessary supplies

Priced Per Each

16 Ventilator E0450 Maintenance of Government Owned EACH

Maintenance Ventilator Systems, to include all supplies

Priced Per Month

Palo Alto Page 4

CODE PRICE (Where just number, unit is "Month.")

17 Air Compressor E0565 Rental of Contractor Owned and EACH

Maintained continuous or intermittent air compressor for use with equipment not self contained or

Priced Per Month cylinder driven, to include all associated supplies

18 Full Face Masks A7030 CPAP/Bilevel Full Face Masks EACH

Including Headgear

Priced Per Each

19 Nasal Interface Mask A7034 CPAP/Bilevel Masks, Nasal EACH or Cannula Type Interface, Nasal Pillows & Nasal

Cushions (Mask or Cannula Type)

Priced Per Each Including Headgear

20 Delivery Charge A9901 Deliveries not made under all other EACH line items

Priced Per Each

21 Respiratory Therapist VA120 Government requested Respiratory EACH

Visit Therapist visit not covered by other

Line Items

Priced Per Each

Palo Alto specific pricing instructions

Line Items 1-1c Require Quarterly Maintenance Visits

Palo Alto Page 5

REFILLS - ALL QUANTITIES ARE MONTHLYUNIT

ITEM# ITEM NAME HCPCS ITEM DESCRIPTION CYLINDER UNIT

CODE PRICE

R1 E Cylinder E0443 E Cylinder Refill Cylinder

R2 D Cylinder E0443 D Cylinder Refill Cylinder

R3 C Cylinder E0443 C Cylinder Refill Cylinder

R4 M-6 Cylinder E0443 M-6 Cylinder Refill Cylinder

R5 H Tank E0443 H Tank Refill Cylinder

UNIT PER LB

PRICE

R6 Liquide Oxygen E0444 Liquide Oxygen LBS

Refill

Palo Alto Page 6

Palo Alto Page 7