GUAM H02 CLINS PRICING.xlsx
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YEAR 1
| ITEM | ITEM NAME | HCPCS CODE | ITEM DESCRIPTION | ORDERING PERIOD 1 | EST QTY | |
| PER YEAR | UNIT PRICE | TOTAL EST COST |
(Year)
| 1 | Home Oxygen Concentrators | Cost of Maintaining VA Provided Concentrators | |
| 1a | 90 Day Maintenance Check of VA Owned Low Decibel | ||
| Concentrator | E1390 | Perform Equipment Maintenance in accordance with manufacturer standards. At a minimum of once every 90 Calendar days, visit and assess patient to assure equipment compliance, change filters and provide disposable supplies. To include all supplies, equipment maintenance and 90 calendar | |
| day visit | 180 | $ |
| 1b | 90 Day Maintenance Check of VA Owned Hi Flow Concentrators | E1390 | Perform Equipment Maintenance in accordance with manufacturer standards. At a minimum of once every 90 Calendar days, visit and assess patient to assure equipment compliance, change filters and provide disposable supplies. To include all supplies, equipment maintenance and 90 calendar | |
| day visit | 60 | $ |
| 1c | Issue of Concentrator Supplies for VA-owned | ||
| Concentrator | E1390 | Cannulas or Masks and other required supplies and | |
| equipment, including supplies for back up systems. | 240 | $ |
| 2 | Rental of Contractor Owned Portable O2 Gaseous System for Use with or without Stationary | ||
| System | E0431 | Portable System includes the following: Portable wheeled cart, Regulator, Cannulas, or Masks, Tubing, Oxygen Conserving Device if requested, 12 Cylinders, and O2 Tank Cylinder Stands capable of holding 12 Cylinders, Sizes are | |
| E, D, C, B & M-6 | 300 | $ |
| 3 | Rental of Contractor Owned Stationary Liquid O2 System | E0439 | Resevoir, Regulator, Flowmeter, Humidifier, Cannulas or Masks, and Colored | |
| Tubing. | 12 | $ |
4 Rental of Contractor Owned Portable Liquid O2 System E0434 Portable Container, Refill Adapter, Flowmeter, Cannulas or Masks, and Colored Tubing. 12 $
5 Continuous Positive Airway Device (CPAP) Set-Up E0601 Delivery, Set-up & Training of Government Owned CPAP equipment and supplies in Patient's Home. Mask will be provided by VA. 60 $
| 6 | CPAP | |||
| Troubleshooti ng as requested by the COR in Patient's home | E0601 | Troubleshoot and repair of Government-owned CPAP device to be billed in 15 minute increments. | 12 | $ |
| 7 | Bilevel Positive Airway Pressure Device Set-up in Patient's Home | E0470 | Delivery, Set-up & Training of Government Owned BiLevel in Patient's Home to include all supplies. Mask will be provided | |
| by the VA. | 12 | $ |
9 BiLevel Troubleshooti ng as requested by the COR in Patient's home E0470 Troubleshoot and repair of Government-owned BiLevel device to be billed in 15 minute increments. 12 $
| 10 | BiLevel Positive Airway Pressure Device Set-up at Contractor's Facility | E0470 | Delivery, Set-up & Training of Government Owned BiLevel at the Contractors Facility to | |
| include all supplies. Mask will be provided by the VA. | 12 | $ |
11 Nebulizers E0570 Delivery, Set-up and Training of Government Owned Nebulizer, Compressor or Battery Powered as ordered 12 $
| 12 | Suction Pump Purchase and Set-up | E0600 | Purchase, Delivery, Set-up and Training of Contractor Home Model Respiratory Suction Pump, portable or stationary | |
| electric to include all supplies | 12 | $ |
| 13 | Suction Pump Rental and | ||
| Set-up | E0600 | Delivery, Set-up, and Training of Contractor Owned Suction | |
| Pump to Include all supplies | 12 | $ |
| 14 | Rental of Contractor Owned Volume Ventilator | E0450 | Delivery, Set-up, Training, and Maintenance of Contractor Owned Stationary or Portable Ventilator, to include back up | |
| Ventilator | 12 | $ |
| 15 | Rental of Air Compressor | E0565 | Rental of Contractor Owned and Maintained continuous or intermittent air compressor for use with equipment not self contained or cylinder driven, to | |
| include all associated supplies | 12 | $ |
16 Contractor issued Full Face Masks A7030 CPAP/Bilevel Full Face Masks Including Headgear 12 $
17 Contractor issued Nasal Interface Mask or Cannula Type A7034 CPAP/Bilevel Masks, Nasal Interface, Nasal Pillows & Nasal Cushions (Mask or Cannula Type) Including Headgear 12 $
| 18 | Delivery / Attempted | |||
| Delivery | A9901 | Deliveries not made Under all other line items | 12 | $ |
19 Respiratory Therapist Visit VA120 Government requested Respiratory Therapist visit not covered by other line items 12 $
| ITEM | ITEM NAME | HCPCS CODE | ITEM DESCRIPTION | CONT PERIOD | |
| (Year) | EST QTY (Year) | UNIT PRICE | TOTAL ESTIMATED COST |
(Year) R1 E Cylinder E0431 E Cylinder Refill 5760 $
| Guam only | |||||
| R2 | D Cylinder | E0443 | D Cylinder Refill | 1320 | $ |
R3 C Cylinder E0443 C Cylinder Refill 12 $
R4 M-6 Cylinder E0443 M-6 Cylinder Refill 480 $
AMS only as no Etank is available R5 H Tank E0443 H Tank Refill 0 $
R6 Liquid Oxygen E0444 Liquid Oxygen Refill 12 $
| LINE ITEMS 1- 19 | |
| TOTAL ESTIMATED PRICE - BASE PERIOD | $ |
LINE ITEMS
R1-R6
| TOTAL ESTIMATED PRICE - BASE | ||
| PERIOD | $ |
GRAND TOTAL $
YEAR 2
| ITEM | ITEM NAME | HCPCS CODE | ITEM DESCRIPTION | ORDERING PERIOD 2 | EST QTY | |
| PER YEAR | UNIT PRICE | TOTAL EST COST |
(Year)
| 1 | Home Oxygen Concentrators | Cost of Maintaining VA Provided Concentrators | ||
| 1a | 90 Day Maintenance Check of VA Owned Low Decibel Concentrator | E1390 | Perform Equipment Maintenance in accordance with manufacturer standards. At a minimum of once every 90 Calendar days, visit and assess patient to assure equipment compliance, change filters and provide disposable supplies. To include all supplies, equipment maintenance and 90 calendar | |
| day visit | 180 | $ |
| 1b | 90 Day Maintenance Check of VA Owned Hi Flow Concentrators | E1390 | Perform Equipment Maintenance in accordance with manufacturer standards. At a minimum of once every 90 Calendar days, visit and assess patient to assure equipment compliance, change filters and provide disposable supplies. To include all supplies, equipment maintenance and 90 calendar | |
| day visit | 60 | $ |
| 1c | Issue of Concentrator Supplies for VA-owned | ||
| Concentrator | E1390 | Cannulas or Masks and other required supplies and | |
| equipment, including supplies for back up systems. | 240 | $ |
| 2 | Rental of Contractor Owned Portable O2 Gaseous System for Use with or without Stationary | ||
| System | E0431 | Portable System includes the following: Portable wheeled cart, Regulator, Cannulas, or Masks, Tubing, Oxygen Conserving Device if requested, 12 Cylinders, and O2 Tank Cylinder Stands capable of holding 12 Cylinders, Sizes are | |
| E, D, C, B & M-6 | 300 | $ |
| 3 | Rental of Contractor Owned Stationary Liquid O2 | ||
| System | E0439 | Resevoir, Regulator, Flowmeter, Humidifier, Cannulas or Masks, and Colored | |
| Tubing. | 12 | $ |
4 Rental of Contractor Owned Portable Liquid O2 System E0434 Portable Container, Refill Adapter, Flowmeter, Cannulas or Masks, and Colored Tubing. 12 $
5 Continuous Positive Airway Device (CPAP) Set-Up E0601 Delivery, Set-up & Training of Government Owned CPAP equipment and supplies in Patient's Home. Mask will be provided by VA. 60 $
| 6 | CPAP | |||
| Troubleshooti ng as requested by the COR in Patient's home | E0601 | Troubleshoot and repair of Government-owned CPAP device to be billed in 15 minute increments. | 12 | $ |
| 7 | Bilevel Positive Airway Pressure Device Set-up in Patient's Home | E0470 | Delivery, Set-up & Training of Government Owned BiLevel in Patient's Home to include all supplies. Mask will be provided | |
| by the VA. | 12 | $ |
9 BiLevel Troubleshooti ng as requested by the COR in Patient's home E0470 Troubleshoot and repair of Government-owned BiLevel device to be billed in 15 minute increments. 12 $
| 10 | BiLevel Positive Airway Pressure Device Set-up at Contractor's Facility | E0470 | Delivery, Set-up & Training of Government Owned BiLevel at the Contractors Facility to | |
| include all supplies. Mask will be provided by the VA. | 12 | $ |
11 Nebulizers E0570 Delivery, Set-up and Training of Government Owned Nebulizer, Compressor or Battery Powered as ordered 12 $
| 12 | Suction Pump Purchase and Set-up | E0600 | Purchase, Delivery, Set-up and Training of Contractor Home Model Respiratory Suction Pump, portable or stationary | |
| electric to include all supplies | 12 | $ |
| 13 | Suction Pump Rental and | ||
| Set-up | E0600 | Delivery, Set-up, and Training of Contractor Owned Suction | |
| Pump to Include all supplies | 12 | $ |
| 14 | Rental of Contractor Owned Volume Ventilator | E0450 | Delivery, Set-up, Training, and Maintenance of Contractor Owned Stationary or Portable Ventilator, to include back up | |
| Ventilator | 12 | $ |
| 15 | Rental of Air Compressor | E0565 | Rental of Contractor Owned and Maintained continuous or intermittent air compressor for use with equipment not self contained or cylinder driven, to | |
| include all associated supplies | 12 | $ |
16 Contractor issued Full Face Masks A7030 CPAP/Bilevel Full Face Masks Including Headgear 12 $
17 Contractor issued Nasal Interface Mask or Cannula Type A7034 CPAP/Bilevel Masks, Nasal Interface, Nasal Pillows & Nasal Cushions (Mask or Cannula Type) Including Headgear 12 $
| 18 | Delivery / Attempted | |||
| Delivery | A9901 | Deliveries not made Under all other line items | 12 | $ |
19 Respiratory Therapist Visit VA120 Government requested Respiratory Therapist visit not covered by other line items 12 $
| ITEM | ITEM NAME | HCPCS CODE | ITEM DESCRIPTION | CONT PERIOD | |
| (Year) | EST QTY (Year) | UNIT PRICE | TOTAL ESTIMATED COST |
(Year) R1 E Cylinder E0431 E Cylinder Refill 5760 $
| Guam only | |||||
| R2 | D Cylinder | E0443 | D Cylinder Refill | 1320 | $ |
R3 C Cylinder E0443 C Cylinder Refill 12 $
R4 M-6 Cylinder E0443 M-6 Cylinder Refill 480 $
AMS only as no Etank is
R5 H Tank E0443 H Tank Refill 0 $
R6 Liquid Oxygen E0444 Liquid Oxygen Refill 12 $
| LINE ITEMS 1- 19 | |
| TOTAL ESTIMATED PRICE - BASE PERIOD | $ |
LINE ITEMS
| TOTAL ESTIMATED PRICE - BASE | ||
| PERIOD | $ |
GRAND TOTAL $
YEAR 3
| ITEM | ITEM NAME | HCPCS CODE | ITEM DESCRIPTION | ORDERING PERIOD 3 | EST QTY | |
| PER YEAR | UNIT PRICE | TOTAL EST COST |
(Year)
| 1 | Home Oxygen Concentrators | Cost of Maintaining VA Provided Concentrators | ||
| 1a | 90 Day Maintenance Check of VA Owned Low Decibel Concentrator | E1390 | Perform Equipment Maintenance in accordance with manufacturer standards. At a minimum of once every 90 Calendar days, visit and assess patient to assure equipment compliance, change filters and provide disposable supplies. To include all supplies, equipment maintenance and 90 calendar | |
| day visit | 180 | $ |
| 1b | 90 Day Maintenance Check of VA Owned Hi Flow Concentrators | E1390 | Perform Equipment Maintenance in accordance with manufacturer standards. At a minimum of once every 90 Calendar days, visit and assess patient to assure equipment compliance, change filters and provide disposable supplies. To include all supplies, equipment maintenance and 90 calendar | |
| day visit | 60 | $ |
| 1c | Issue of Concentrator Supplies for VA-owned | ||
| Concentrator | E1390 | Cannulas or Masks and other required supplies and | |
| equipment, including supplies for back up systems. | 240 | $ |
| 2 | Rental of Contractor Owned Portable O2 Gaseous System for Use with or without Stationary | ||
| System | E0431 | Portable System includes the following: Portable wheeled cart, Regulator, Cannulas, or Masks, Tubing, Oxygen Conserving Device if requested, 12 Cylinders, and O2 Tank Cylinder Stands capable of holding 12 Cylinders, Sizes are | |
| E, D, C, B & M-6 | 300 | $ |
| 3 | Rental of Contractor Owned Stationary Liquid O2 | ||
| System | E0439 | Resevoir, Regulator, Flowmeter, Humidifier, Cannulas or Masks, and Colored | |
| Tubing. | 12 | $ |
4 Rental of Contractor Owned Portable Liquid O2 System E0434 Portable Container, Refill Adapter, Flowmeter, Cannulas or Masks, and Colored Tubing. 12 $
5 Continuous Positive Airway Device (CPAP) Set-Up E0601 Delivery, Set-up & Training of Government Owned CPAP equipment and supplies in Patient's Home. Mask will be provided by VA. 60 $
| 6 | CPAP | |||
| Troubleshooti ng as requested by the COR in Patient's home | E0601 | Troubleshoot and repair of Government-owned CPAP device to be billed in 15 minute increments. | 12 | $ |
| 7 | Bilevel Positive Airway Pressure Device Set-up in Patient's Home | E0470 | Delivery, Set-up & Training of Government Owned BiLevel in Patient's Home to include all supplies. Mask will be provided | |
| by the VA. | 12 | $ |
9 BiLevel Troubleshooti ng as requested by the COR in Patient's home E0470 Troubleshoot and repair of Government-owned BiLevel device to be billed in 15 minute increments. 12 $
| 10 | BiLevel Positive Airway Pressure Device Set-up at Contractor's Facility | E0470 | Delivery, Set-up & Training of Government Owned BiLevel at the Contractors Facility to | |
| include all supplies. Mask will be provided by the VA. | 12 | $ |
11 Nebulizers E0570 Delivery, Set-up and Training of Government Owned Nebulizer, Compressor or Battery Powered as ordered 12 $
| 12 | Suction Pump Purchase and Set-up | E0600 | Purchase, Delivery, Set-up and Training of Contractor Home Model Respiratory Suction Pump, portable or stationary | |
| electric to include all supplies | 12 | $ |
| 13 | Suction Pump Rental and | ||
| Set-up | E0600 | Delivery, Set-up, and Training of Contractor Owned Suction | |
| Pump to Include all supplies | 12 | $ |
| 14 | Rental of Contractor Owned Volume Ventilator | E0450 | Delivery, Set-up, Training, and Maintenance of Contractor Owned Stationary or Portable Ventilator, to include back up | |
| Ventilator | 12 | $ |
| 15 | Rental of Air Compressor | E0565 | Rental of Contractor Owned and Maintained continuous or intermittent air compressor for use with equipment not self contained or cylinder driven, to | |
| include all associated supplies | 12 | $ |
16 Contractor issued Full Face Masks A7030 CPAP/Bilevel Full Face Masks Including Headgear 12 $
17 Contractor issued Nasal Interface Mask or Cannula Type A7034 CPAP/Bilevel Masks, Nasal Interface, Nasal Pillows & Nasal Cushions (Mask or Cannula Type) Including Headgear 12 $
| 18 | Delivery / Attempted | |||
| Delivery | A9901 | Deliveries not made Under all other line items | 12 | $ |
19 Respiratory Therapist Visit VA120 Government requested Respiratory Therapist visit not covered by other line items 12 $
| ITEM | ITEM NAME | HCPCS CODE | ITEM DESCRIPTION | CONT PERIOD | |
| (Year) | EST QTY (Year) | UNIT PRICE | TOTAL ESTIMATED COST |
(Year) R1 E Cylinder E0431 E Cylinder Refill 5760 $
| Guam only | |||||
| R2 | D Cylinder | E0443 | D Cylinder Refill | 1320 | $ |
R3 C Cylinder E0443 C Cylinder Refill 12 $
R4 M-6 Cylinder E0443 M-6 Cylinder Refill 480 $
AMS only as no Etank is
R5 H Tank E0443 H Tank Refill 0 $
R6 Liquid Oxygen E0444 Liquid Oxygen Refill 12 $
| LINE ITEMS 1- 19 | |
| TOTAL ESTIMATED PRICE - BASE PERIOD | $ |
LINE ITEMS
| TOTAL ESTIMATED PRICE - BASE | ||
| PERIOD | $ |
GRAND TOTAL $
YEAR 4
| ITEM | ITEM NAME | HCPCS CODE | ITEM DESCRIPTION | ORDERING PERIOD 4 | EST QTY | |
| PER YEAR | UNIT PRICE | TOTAL EST COST |
(Year)
| 1 | Home Oxygen Concentrators | Cost of Maintaining VA Provided Concentrators | |
| 1a | 90 Day Maintenance Check of VA Owned Low Decibel | ||
| Concentrator | E1390 | Perform Equipment Maintenance in accordance with manufacturer standards. At a minimum of once every 90 Calendar days, visit and assess patient to assure equipment compliance, change filters and provide disposable supplies. To include all supplies, equipment maintenance and 90 calendar | |
| day visit | 180 | $ |
| 1b | 90 Day Maintenance Check of VA Owned Hi Flow Concentrators | E1390 | Perform Equipment Maintenance in accordance with manufacturer standards. At a minimum of once every 90 Calendar days, visit and assess patient to assure equipment compliance, change filters and provide disposable supplies. To include all supplies, equipment maintenance and 90 calendar | |
| day visit | 60 | $ |
| 1c | Issue of Concentrator Supplies for VA-owned | ||
| Concentrator | E1390 | Cannulas or Masks and other required supplies and | |
| equipment, including supplies for back up systems. | 240 | $ |
| 2 | Rental of Contractor Owned Portable O2 Gaseous System for Use with or without Stationary | ||
| System | E0431 | Portable System includes the following: Portable wheeled cart, Regulator, Cannulas, or Masks, Tubing, Oxygen Conserving Device if requested, 12 Cylinders, and O2 Tank Cylinder Stands capable of holding 12 Cylinders, Sizes are | |
| E, D, C, B & M-6 | 300 | $ |
| 3 | Rental of Contractor Owned Stationary Liquid O2 System | E0439 | Resevoir, Regulator, Flowmeter, Humidifier, Cannulas or Masks, and Colored | |
| Tubing. | 12 | $ |
4 Rental of Contractor Owned Portable Liquid O2 System E0434 Portable Container, Refill Adapter, Flowmeter, Cannulas or Masks, and Colored Tubing. 12 $
5 Continuous Positive Airway Device (CPAP) Set-Up E0601 Delivery, Set-up & Training of Government Owned CPAP equipment and supplies in Patient's Home. Mask will be provided by VA. 60 $
| 6 | CPAP | |||
| Troubleshooti ng as requested by the COR in Patient's home | E0601 | Troubleshoot and repair of Government-owned CPAP device to be billed in 15 minute increments. | 12 | $ |
| 7 | Bilevel Positive Airway Pressure Device Set-up in Patient's Home | E0470 | Delivery, Set-up & Training of Government Owned BiLevel in Patient's Home to include all supplies. Mask will be provided | |
| by the VA. | 12 | $ |
9 BiLevel Troubleshooti ng as requested by the COR in Patient's home E0470 Troubleshoot and repair of Government-owned BiLevel device to be billed in 15 minute increments. 12 $
| 10 | BiLevel Positive Airway Pressure Device Set-up at Contractor's Facility | E0470 | Delivery, Set-up & Training of Government Owned BiLevel at the Contractors Facility to | |
| include all supplies. Mask will be provided by the VA. | 12 | $ |
11 Nebulizers E0570 Delivery, Set-up and Training of Government Owned Nebulizer, Compressor or Battery Powered as ordered 12 $
| 12 | Suction Pump Purchase and Set-up | E0600 | Purchase, Delivery, Set-up and Training of Contractor Home Model Respiratory Suction Pump, portable or stationary | |
| electric to include all supplies | 12 | $ |
| 13 | Suction Pump Rental and | ||
| Set-up | E0600 | Delivery, Set-up, and Training of Contractor Owned Suction | |
| Pump to Include all supplies | 12 | $ |
| 14 | Rental of Contractor Owned Volume Ventilator | E0450 | Delivery, Set-up, Training, and Maintenance of Contractor Owned Stationary or Portable Ventilator, to include back up | |
| Ventilator | 12 | $ |
| 15 | Rental of Air Compressor | E0565 | Rental of Contractor Owned and Maintained continuous or intermittent air compressor for use with equipment not self contained or cylinder driven, to | |
| include all associated supplies | 12 | $ |
16 Contractor issued Full Face Masks A7030 CPAP/Bilevel Full Face Masks Including Headgear 12 $
17 Contractor issued Nasal Interface Mask or Cannula Type A7034 CPAP/Bilevel Masks, Nasal Interface, Nasal Pillows & Nasal Cushions (Mask or Cannula Type) Including Headgear 12 $
| 18 | Delivery / Attempted | |||
| Delivery | A9901 | Deliveries not made Under all other line items | 12 | $ |
19 Respiratory Therapist Visit VA120 Government requested Respiratory Therapist visit not covered by other line items 12 $
| ITEM | ITEM NAME | HCPCS CODE | ITEM DESCRIPTION | CONT PERIOD | |
| (Year) | EST QTY (Year) | UNIT PRICE | TOTAL ESTIMATED COST |
(Year) R1 E Cylinder E0431 E Cylinder Refill 5760 $
| Guam only | |||||
| R2 | D Cylinder | E0443 | D Cylinder Refill | 1320 | $ |
R3 C Cylinder E0443 C Cylinder Refill 12 $
R4 M-6 Cylinder E0443 M-6 Cylinder Refill 480 $
AMS only as no Etank is
R5 H Tank E0443 H Tank Refill 0 $
R6 Liquid Oxygen E0444 Liquid Oxygen Refill 12 $
| LINE ITEMS 1- 19 | |
| TOTAL ESTIMATED PRICE - BASE PERIOD | $ |
LINE ITEMS
| TOTAL ESTIMATED PRICE - BASE | ||
| PERIOD | $ |
GRAND TOTAL $
YEAR 5
| ITEM | ITEM NAME | HCPCS CODE | ITEM DESCRIPTION | ORDERING PERIOD 5 | EST QTY | |
| PER YEAR | UNIT PRICE | TOTAL EST COST |
(Year)
| 1 | Home Oxygen Concentrators | Cost of Maintaining VA Provided Concentrators | |
| 1a | 90 Day Maintenance Check of VA Owned Low Decibel | ||
| Concentrator | E1390 | Perform Equipment Maintenance in accordance with manufacturer standards. At a minimum of once every 90 Calendar days, visit and assess patient to assure equipment compliance, change filters and provide disposable supplies. To include all supplies, equipment maintenance and 90 calendar | |
| day visit | 180 | $ |
| 1b | 90 Day Maintenance Check of VA Owned Hi Flow Concentrators | E1390 | Perform Equipment Maintenance in accordance with manufacturer standards. At a minimum of once every 90 Calendar days, visit and assess patient to assure equipment compliance, change filters and provide disposable supplies. To include all supplies, equipment maintenance and 90 calendar | |
| day visit | 60 | $ |
| 1c | Issue of Concentrator Supplies for VA-owned | ||
| Concentrator | E1390 | Cannulas or Masks and other required supplies and | |
| equipment, including supplies for back up systems. | 240 | $ |
| 2 | Rental of Contractor Owned Portable O2 Gaseous System for Use with or without Stationary | ||
| System | E0431 | Portable System includes the following: Portable wheeled cart, Regulator, Cannulas, or Masks, Tubing, Oxygen Conserving Device if requested, 12 Cylinders, and O2 Tank Cylinder Stands capable of holding 12 Cylinders, Sizes are | |
| E, D, C, B & M-6 | 300 | $ |
| 3 | Rental of Contractor Owned Stationary Liquid O2 System | E0439 | Resevoir, Regulator, Flowmeter, Humidifier, Cannulas or Masks, and Colored | |
| Tubing. | 12 | $ |
4 Rental of Contractor Owned Portable Liquid O2 System E0434 Portable Container, Refill Adapter, Flowmeter, Cannulas or Masks, and Colored Tubing. 12 $
5 Continuous Positive Airway Device (CPAP) Set-Up E0601 Delivery, Set-up & Training of Government Owned CPAP equipment and supplies in Patient's Home. Mask will be provided by VA. 60 $
6 CPAP
Troubleshooti ng as requested by the COR in Patient's home E0601 Troubleshoot and repair of Government-owned CPAP device to be billed in 15 minute increments. 12 $
| 7 | Bilevel Positive Airway Pressure Device Set-up in Patient's Home | E0470 | Delivery, Set-up & Training of Government Owned BiLevel in Patient's Home to include all supplies. Mask will be provided | |
| by the VA. | 12 | $ |
9 BiLevel Troubleshooti ng as requested by the COR in Patient's home E0470 Troubleshoot and repair of Government-owned BiLevel device to be billed in 15 minute increments. 12 $
| 10 | BiLevel Positive Airway Pressure Device Set-up at Contractor's Facility | E0470 | Delivery, Set-up & Training of Government Owned BiLevel at the Contractors Facility to | |
| include all supplies. Mask will be provided by the VA. | 12 | $ |
11 Nebulizers E0570 Delivery, Set-up and Training of Government Owned Nebulizer, Compressor or Battery Powered as ordered 12 $
| 12 | Suction Pump Purchase and Set-up | E0600 | Purchase, Delivery, Set-up and Training of Contractor Home Model Respiratory Suction Pump, portable or stationary | |
| electric to include all supplies | 12 | $ |
| 13 | Suction Pump Rental and | ||
| Set-up | E0600 | Delivery, Set-up, and Training of Contractor Owned Suction | |
| Pump to Include all supplies | 12 | $ |
| 14 | Rental of Contractor Owned Volume Ventilator | E0450 | Delivery, Set-up, Training, and Maintenance of Contractor Owned Stationary or Portable Ventilator, to include back up | |
| Ventilator | 12 | $ |
| 15 | Rental of Air Compressor | E0565 | Rental of Contractor Owned and Maintained continuous or intermittent air compressor for use with equipment not self contained or cylinder driven, to | |
| include all associated supplies | 12 | $ |
16 Contractor issued Full Face Masks A7030 CPAP/Bilevel Full Face Masks Including Headgear 12 $
17 Contractor issued Nasal Interface Mask or Cannula Type A7034 CPAP/Bilevel Masks, Nasal Interface, Nasal Pillows & Nasal Cushions (Mask or Cannula Type) Including Headgear 12 $
| 18 | Delivery / Attempted | |||
| Delivery | A9901 | Deliveries not made Under all other line items | 12 | $ |
19 Respiratory Therapist Visit VA120 Government requested Respiratory Therapist visit not covered by other line items 12 $
| ITEM | ITEM NAME | HCPCS CODE | ITEM DESCRIPTION | CONT PERIOD | |
| (Year) | EST QTY (Year) | UNIT PRICE | TOTAL ESTIMATED COST |
(Year) R1 E Cylinder E0431 E Cylinder Refill 5760 $
| Guam only | |||||
| R2 | D Cylinder | E0443 | D Cylinder Refill | 1320 | $ |
R3 C Cylinder E0443 C Cylinder Refill 12 $
R4 M-6 Cylinder E0443 M-6 Cylinder Refill 480 $
AMS only as no Etank is
R5 H Tank E0443 H Tank Refill 0 $
R6 Liquid Oxygen E0444 Liquid Oxygen Refill 12 $
| LINE ITEMS 1- 19 | |
| TOTAL ESTIMATED PRICE - BASE PERIOD | $ |
LINE ITEMS
| TOTAL ESTIMATED PRICE - BASE | ||
| PERIOD | $ |
GRAND TOTAL $
File details come from the government source that posted it. Updated .