ESBD_538769_1784205454286_Exhibit_C_Pricing Sheet.xlsm

This is an Exhibit C Pricing Sheet for a Request for Proposal issued by the Texas Health and Human Services Commission (HHS) on behalf of the San Angelo State Supported Living Center (SSLC) for dental anesthesia services. The solicitation, identified as HHSTX-HHS0017648 (PCS 137), was posted on July 16, 2026, with a submission deadline of July 30, 2026, at 10:30 AM CST. The scope of work requires bidders to provide dental anesthesia services for residents at the San Angelo SSLC, including services related to intraoral procedures and procedures on facial bones or skull. Bidders must hold a valid DDS or DMD license and possess a Texas State Board of Dental Examiners anesthesia permit. The solicitation also requires successful completion of a mandatory two-week training course. Inquiries should be directed to Michael McKelvy at HHS Purchasing.

Bidders must submit pricing for three primary cost categories: all-inclusive pricing per fifteen-minute increment for CDT code 00170 (intraoral anesthesia procedures), all-inclusive pricing per fifteen-minute increment for CDT code 00190 (anesthesia for facial bones or skull procedures), and a trip fee per clinic visit. Acceptable pricing ranges from $0.00 to $200,000.00 for each category. All bid responses must include required documentation: a copy of the DDS or DMD license, Texas State Board of Dental Examiners anesthesia permit, completed Exhibit A HHS Solicitation Affirmations (Pages 1-13), completed Exhibit C Pricing Sheet, completed Exhibit D Bidder Reference Form, evidence of financial capability and solvency, and signed Addendum Acknowledgement Form(s) if applicable. Failure to submit the Exhibit A Affirmations and Exhibit C Pricing Sheet will result in bid disqualification. Bidders may optionally complete Form 4109 TIN application and submit Public Information Act copies if applicable.