Diabetic Shoes Pricing Schedule.docx
DOCX document 17 KB Posted
- Attached to
- Therapeutic Diabetic Shoe Program
- Solicitation number
- 246-26-Q0039
About this file
This is a Pricing Schedule for diabetic foot supplies and services to be provided to the Lawton Indian Hospital under solicitation number 246-26-Q0039. The schedule lists line items with corresponding HCPCS codes for a comprehensive therapeutic shoe program serving eligible American Indian and Alaska Native patients through the Indian Health Service Lawton Service Unit.
The pricing schedule encompasses a comprehensive range of diabetic foot care products and services organized into several categories: diabetic shoes (off-the-shelf and custom options with various modifications), women's and men's extra depth shoes and boots, custom molded footwear, diabetic inserts and orthotics, shoe modifications (heel lifts, wedges, rockers, reinforcements, and other alterations), compression knee sleeves at varying pressure levels, and lower extremity orthoses including cervical collars, thoracic-lumbar-sacral orthoses (TLSO), lumbar-sacral orthoses (LSO), knee orthoses (KO), ankle-foot orthoses (AFO), and upper extremity bracing. Labor is priced per 15-minute increment. The document does not include specific pricing information, as the actual prices are blank and must be filled in by vendors. Units of measure vary by product type, with most items priced per each (EA) and certain items priced per pair (PAIR).
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Text version
Diabetic Foot Supplies and Services Pricing Schedule Lawton Indian Hospital
| CODE |
| DESCRIPTION |
| PRICE |
| UNIT |
| A5500 |
| Diabetic OTS Shoe |
EA
| A5501 |
| Diabetic Custom Shoe |
EA
| A5503 |
| Diabetic – Shoe Mod Rocker Bottom |
EA
| A5504 |
| Diabetic – Shoe Mod Wedge, Addition |
EA
| A5505 |
| Diabetic – Shoe Mod Metatarsal Bar |
EA
| A5506 |
| Diabetic – Shoe Mod Off-set heels |
EA
| A5507 |
| Diabetic – Shoe Mod Unspecified |
EA
| L3216 |
| Women’s Extra Depth Shoe |
EA
| L3217 |
| Women’s Extra Depth Boot |
EA
| L3221 |
| Men’s Extra Depth Shoe |
EA
| L3222 |
| Men’s Extra Depth Boot |
EA
| L3230 |
| Custom Molded Shoes |
EA
| L3230 |
| Custom Molded Boots |
EA
| L3257 |
| Split Shoe Size |
PAIR
| A5512 |
| Diabetic – OTC Multi-density Insert |
EA
| A5513 |
| Diabetic – Custom Multi-density Orthotic |
EA
| L3000 |
| UCB Type Orthotic |
EA
| L3010 |
| Custom Foot Orthotic |
EA
| L3020 |
| Custom Foot Orthotic with Metatarsal Pad |
EA
| L3031 |
| Carbon Foot Plate |
EA
| L3040 |
| OTC Full Length Orthotic |
EA
| L3050 |
| OTC Metatarsal Length Orthotic |
EA
| L3060 |
| OTC Full Length with Met Pad Orthotic |
EA
| L5000 |
| Toe Filler Orthotic |
EA
| E0951 |
| Shoe Mod – Loop to Back of Shoes Addition |
EA
| L3300 |
| Shoe Mod – 1” Heel Lift, Tapered, Outside Shoe |
EA
| L3310 |
| Shoe Mod – 1” Elevation, Inside Shoe |
EA
| L3332 |
| Shoe Mod – ½” Heel Lift, Inside Shoe |
EA
| L3334 |
| Shoe mod – 1” Elevation, Outside Shoe |
EA
| L3340 |
| Shoe mod – Heel Wedge, Sach |
EA
| L3360 |
| Shoe Mod – Sole Wedge |
EA
| L3390 |
| Shoe Mod – Outflare Wedge |
EA
| L3340 |
| Shoe Mod – Metatrasla Bar Wedge Rocker |
EA
| L3410 |
| Shoe Mod – Metatarsal Bar |
EA
| L3430 |
| Shoe Mod – Heel Counter Reinforcement Any |
EA
| L3540 |
| Shoe Mod – Shoe Sole |
EA
| L3570 |
| Shoe Mod – Instep Exten/Velcro Extension |
EA
| L3580 |
| Shoe Mod – Lace to Velcro |
EA
| L3649 |
| Shoe Mod – Heel to Toe Rocker |
EA
| L3649 |
| Shoe Mod – Double Rocker |
EA
| L3649 |
| Shoe Mod – Zipper Added |
EA
| L4002 |
| Strap Replacement |
EA
| L4205 |
| Labor – Per 15 min |
EA
| A6530 |
| Knee Comp. 18-30mmHG |
PAIR
| A6549 |
| Knee Comp. 20-30mmHG |
PAIR
| A6531 |
| Knee Comp. 30-40mmHG |
PAIR
| L0174 |
| CO-Aspen TX/Miami J |
EA
| L0190 |
| TLSO – Minerva Lehrman |
EA
| L0472 |
| TLSO – CASH, Jewette |
EA
| L0484 |
| TLSO – Bivalve |
EA
| L0631 |
| LSO – Sagittal Control |
EA
| L0637 |
| LSO – Sagittal – Coronal Control |
EA
| L1832 |
| KO – Post Op |
EA
| L1940 |
| AFO – Leather or Plastic Material, Custom |
EA
| L1951 |
| AFO – Carbon Fiber |
EA
| L1960 |
| AFO – Solid, Boot |
EA
| L1970 |
| Plastic AFO with Joints |
EA
| L2210 |
| AFO – Add On, Dorsi Assist, Plantar Stop |
EA
| L2275 |
| AFO – Varus/Valgus Correction |
EA
| L2280 |
| AFO – Inner Boot |
EA
| L2330 |
| AFO – Lacer |
EA
| L2340 |
| AFO – Add On, pretib shell |
EA
| L2820 |
| AFO – Soft Interface, Leather |
EA
| L2840 |
| Addition to Lower Extermity orthosis Tibial Length sock |
EA
| L3981 |
| UE – Humeral Fx Brace, shoulder cap included |
EA
| L4631 |
| CROW |
EA
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