ESBD_360308_1716395716946_HHS0014562_V2_Exhibit C - Pricing Sheet -.xlsx
XLSX spreadsheet 24 KB Posted
- Attached to
- HHS0014562_V2 Provide Orthosis insoles and shoes
- Solicitation number
- HHS0014562V2
- Issued by
- Lampasas County, Texas
About this file
This document is an Exhibit D Pricing Sheet for a formal Invitation for Bid (IFB) solicitation numbered HHS0014562_V1 issued by the Texas Health and Human Services Commission (HHSC) to provide orthosis insoles and shoes for residents of the Mexia State Supported Living Center. The solicitation is seeking bids for a variety of orthopedic items including insoles, shoes, lifts, and socks in various sizes, quantities, and configurations. Responses are due on June 6, 2024 by 10:30AM, with delivery to the Mexia facility. The contract term and renewal options are not specified.
The pricing sheet provides detailed line items and unit prices for the requested products, which must include fitting and follow-up services. Applicable HCPCS codes are included. Pricing is requested for both closed-toe and open-toe styles in beige and black colors, in a range of compression levels and sizes. Freight costs are to be included, with an estimated delivery time noted. Pricing is to be quoted FOB destination with freight prepaid.
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Text version
Exhibit
| EXHIBIT D | |||||||
| PRICING SHEET | |||||||
| Formal IFB - Solicitation No:HHS0014562_V1 | Response Due Date: 06-06-2024 @ 10:30AM | ||||||
| Ship To: | |||||||
| Mexia State Supported Living Center | |||||||
| 424 Mesquite Dr. | |||||||
| Mexia, TX 76667 | |||||||
| Line No. | Class-Item | Description | Qty | UOM | Unit Price | Extension | |
| 1 | 520/70 | Orthosis insoles and shoes | 1 | EA | $ - 0 | $ - 0 | |
| 2 | L3010 | Foot, insert, removable, molded to patient model, longitudinal arch support | 1 | EA | $ - 0 | $ - 0 | |
| 3 | L3020 | Foot, insert, removable, molded to patient model, longitudinal/ metatarsal support | 1 | EA | $ - 0 | $ - 0 | |
| 4 | L3030 | Foot, insert, removable | 1 | EA | $ - 0 | $ - 0 | |
| 5 | L3310 | Lift, elevation, heel and sole, neoprene | 1 | EA | $ - 0 | $ - 0 | |
| 6 | L3332 | Lift, elevation, inside shoe, tapered, up to one-half inch | 1 | EA | $ - 0 | $ - 0 | |
| 7 | L3216 | Orthopedic footwear, ladies shoe, depth inlay | 1 | EA | $ - 0 | $ - 0 | |
| 8 | L3221 | Orthopedic footwear, men’s shoe, depth inlay | 1 | EA | $ - 0 | $ - 0 | |
| 9 | L3300 | Lift, elevation, heel, tapered to metatarsals | 1 | EA | $ - 0 | $ - 0 | |
| 10 | L3230 | Custom shoe, orthopedic footwear, depth inlay | 1 | EA | $ - 0 | $ - 0 | |
| 11 | L2360 | Addition to lower extremity, extended steel shank | 1 | EA | $ - 0 | $ - 0 | |
| 12 | L5000 | Partial foot, shoe insert with longitudinal arch, toe filler | 1 | EA | $ - 0 | $ - 0 | |
| 13 | L3580 | Orthopedic shoe addition, convert instep to velcro closure | 1 | EA | $ - 0 | $ - 0 | |
| 14 | L1930 | Ankle foot orthosis, plastic or other material | 1 | EA | $ - 0 | $ - 0 | |
| 15 | L1940 | Ankle foot orthosis, plastic or other material | 1 | EA | $ - 0 | $ - 0 | |
| 16 | L1960 | Ankle foot orthosis, posterior solid ankle, plastic | 1 | EA | $ - 0 | $ - 0 | |
| 17 | L1970 | Foot orthosis, plastic with ankle joint | 1 | EA | $ - 0 | $ - 0 | |
| 18 | L1820 | Knee orthosis, elastic with condylar pads and joints, with or without patellar control | 1 | EA | $ - 0 | $ - 0 | |
| 19 | Anke Socks | 1 | EA | $ - 0 | $ - 0 | ||
| 20 | creq Socks | 1 | EA | $ - 0 | $ - 0 | ||
| 21 | Over the calf Socks | 1 | EA | $ - 0 | $ - 0 | ||
| $ - 0 | |||||||
| Fitting and Follow up fitting must be included | $ - 0 | ||||||
| $ - 0 | |||||||
| A5500 | Custom preparation and supply of off-the-shelf depth- inlay shoe manufactured to accommodate multi- density insert(s), | EA | $ - 0 | ||||
| A5501 | Custom preparation and supply of shoe molded from | ||||||
| cast(s) of patients foot (custom molded shoe), | EA | $ - 0 | |||||
| A5512 | Multiple density insert, direct formed, molded to foot after external heat source of 230 degrees fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 | ||||||
| durometer (or higher), prefabricated, | EA | $ - 0 | |||||
| A5513 | Multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer or higher, includes arch filler and other shaping material, custom fabricated | EA | $ - 0 | ||||
| A5503 | Modification of off-the-shelf depth-inlay shoe or custom- molded shoe with roller or rigid rocker bottom | EA | $ - 0 | ||||
| $ - 0 | |||||||
| Beige w/ closed toe (sizes available) | $ - 0 | ||||||
| Price Per Pair | 15-20 mmHg | 20-30 mmHg | 30-40 |
mmHg
| Knee High (S, M, L, XL) | $ - 0 | ||||
| Knee High w/ silicone band | |||||
| (M, L, XL) | $ - 0 | ||||
| Thigh High (S, M, L, XL) | $ - 0 | ||||
| Thigh high w/ silicone band (S, M, L, XL) | $ - 0 | ||||
| Beige w/ Open toe (sizes available) | $ - 0 | ||||
| $ - 0 | |||||
| Price Per Pair | 15-20 mmHg | 20-30 mmHg | 30-40 |
mmHg
| Knee High (S, M, L, XL) | $ - 0 | ||||
| Knee High w/ silicone band | |||||
| (M, L, XL) | $ - 0 | ||||
| Thigh High (S, M, L, XL) | $ - 0 | ||||
| Thigh high w/ silicone band (S, M, L, XL) | $ - 0 | ||||
| $ - 0 | |||||
| Black w/ closed toe (sizes available) | $ - 0 | ||||
| $ - 0 | |||||
| Price Per Pair | 15-20 mmHg | 20-30 mmHg | 30-40 |
mmHg
| Knee High (S, M, L, XL) | $ - 0 | ||||||
| Knee High w/ silicone band (M, L, XL) | $ - 0 | ||||||
| Thigh High (S, M, L, XL) | $ - 0 | ||||||
| Thigh high w/ silicone band | |||||||
| (S, M, L, XL) | $ - 0 | ||||||
| $ - 0 | |||||||
| $ - 0 | |||||||
| 22 | 1 | EA | $ - 0 | $ - 0 | |||
| 23 | 1 | EA | $ - 0 | ||||
| 24 | 2 | EA | $ - 0 | $ - 0 | |||
| 25 | 3 | EA | $ - 0 | $ - 0 | |||
| Freight | 1 | EA | $ - 0 | $ - 0 | |||
| Estimated Delivery Time: | Total | $ - 0 | |||||
| NOTE: Quote F.O.B. Destination Freight Prepaid & Included, otherwise show exact delivery cost and terms. Unless stated otherwise, delivery is considered to be 14 days after receipt of order |
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