Year 1 (6/25/25 – 6/30/25) O2Safe Tank ($____ * 1 ea. * 12mos) = $_______________ *Liquid Oxygen – ($____ * 3,500lbs * 12 mos) = $_______________ Liquid Oxygen Reservoirs – ($____* 3ea * 12mos) = $_______________ Liquid Oxygen Portable – ($___ * 30ea * 12mos) = $_______________ E-Tank contents – ($___* 8ea * 12 mos) = $_______________ E-Tank rental – ($___ * 12ea * 12 mos) = $_______________ Approximate use of Respiratory Therapist = $_______________ ($____ * 24hrs per yr) Delivery Charge – ($____ * 12 mos) = $_______________ BiPAP rental ($____ * 3ea * 12 mos) = $_______________ C-PAP rental ($____ * 2ea * 12 mos) = $_______________ Concentrator, Standard 5LPM – ($____ * 30ea * 12 mos) = $_______________ Concentrator, Hi-flow 10LPM – ($____ * 1 ea. * 12 mos) = $_______________ VPAP Servo BIPAP – ($____ * 1 ea. * 12 mos) = $_______________ BiPAP Auto – ($____ * 1 ea. * 12 mos) = $_______________ BiPAP ST – ($____ * 1 ea. * 12 mos) = $_______________ CPAP Auto Smart – ($____ * 3 ea. * 12 mos) = $_______________ Heaters – ($____ * 9 ea. * 12 mos) = $_______________ Airvo – ( $____ * 1 ea. * 12 mos) Dr Rx Only = $_______________ Cough Assist – ($____ * 1 ea. * 12 mos) Dr Rx Only = $_______________ Small Cylinder cart – ($____ * 2 ea. * 12 mos) = $_______________ Misc disposables BIPAP/CPAP – ($____ * 12 mos)
