SNO | Package Name | Category | A1 | A2 | A3 | A4 | A5 | A6 | S1 | S2 |
---|---|---|---|---|---|---|---|---|---|---|
2067 | CMU0841 -I-A : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSTIBIAL - MOBILITY GRADE 1 | PMR | 26800 | 26800 | 26800 | 26800 | 26800 | 26800 | 26800 | 26800 |
2068 | CMU0841 -I-B : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSTIBIAL - MOBILITY GRADE 2 | PMR | 65600 | 65600 | 65600 | 65600 | 65600 | 65600 | 65600 | 65600 |
2069 | CMU0841 -I-C : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSTIBIAL - MOBILITY GRADE 3 | PMR | 185900 | 185900 | 185900 | 185900 | 185900 | 185900 | 185900 | 185900 |
2070 | CMU0841 -I-D : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSFEMORAL - MOBILITY GRADE 1 | PMR | 72500 | 72500 | 72500 | 72500 | 72500 | 72500 | 72500 | 72500 |
2071 | CMU0841 -I-E : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSFEMORAL - MOBILITY GRADE 2 | PMR | 185300 | 185300 | 185300 | 185300 | 185300 | 185300 | 185300 | 185300 |
2072 | CMU0841 -I-F : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSFEMORAL - MOBILITY GRADE 3 | PMR | 185900 | 185900 | 185900 | 185900 | 185900 | 185900 | 185900 | 185900 |
2073 | CMU0841 -I-G : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSRADIAL - MOBILITY GRADE 1 | PMR | 41000 | 41000 | 41000 | 41000 | 41000 | 41000 | 41000 | 41000 |
2074 | CMU0841 -I-H : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSRADIAL - MOBILITY GRADE 2 | PMR | 99200 | 99200 | 99200 | 99200 | 99200 | 99200 | 99200 | 99200 |
2075 | CMU0841 -I-I : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSRADIAL - MOBILITY GRADE 3 | PMR | 192200 | 192200 | 192200 | 192200 | 192200 | 192200 | 192200 | 192200 |
2076 | CMU0841 -I-J : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSHUMERAL - MOBILITY GRADE 1 | PMR | 77700 | 77700 | 77700 | 77700 | 77700 | 77700 | 77700 | 77700 |
2077 | CMU0841 -I-K : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSHUMERAL - MOBILITY GRADE 2 | PMR | 83000 | 83000 | 83000 | 83000 | 83000 | 83000 | 83000 | 83000 |
2078 | CMU0841 -I-L : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSHUMERAL - MOBILITY GRADE 3 | PMR | 206900 | 206900 | 206900 | 206900 | 206900 | 206900 | 206900 | 206900 |
2080 | CMU0841 -II-A : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSTIBIAL - MOBILITY GRADE 1 | PMR | 26800 | 26800 | 26800 | 26800 | 26800 | 26800 | 26800 | 26800 |
2081 | CMU0841 -II-B : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSTIBIAL - MOBILITY GRADE 2 | PMR | 65600 | 65600 | 65600 | 65600 | 65600 | 65600 | 65600 | 65600 |
2082 | CMU0841 -II-C : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSTIBIAL - MOBILITY GRADE 3 | PMR | 185900 | 185900 | 185900 | 185900 | 185900 | 185900 | 185900 | 185900 |
2083 | CMU0841 -II-D : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSFEMORAL - MOBILITY GRADE 1 | PMR | 72500 | 72500 | 72500 | 72500 | 72500 | 72500 | 72500 | 72500 |
2084 | CMU0841 -II-E : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSFEMORAL - MOBILITY GRADE 2 | PMR | 185300 | 185300 | 185300 | 185300 | 185300 | 185300 | 185300 | 185300 |
2085 | CMU0841 -II-F : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSFEMORAL - MOBILITY GRADE 3 | PMR | 185900 | 185900 | 185900 | 185900 | 185900 | 185900 | 185900 | 185900 |
2086 | CMU0841 -II-G : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSRADIAL - MOBILITY GRADE 1 | PMR | 41000 | 41000 | 41000 | 41000 | 41000 | 41000 | 41000 | 41000 |
2087 | CMU0841 -II-H : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSRADIAL - MOBILITY GRADE 2 | PMR | 99200 | 99200 | 99200 | 99200 | 99200 | 99200 | 99200 | 99200 |
2088 | CMU0841 -II-I : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSRADIAL - MOBILITY GRADE 3 | PMR | 192200 | 192200 | 192200 | 192200 | 192200 | 192200 | 192200 | 192200 |
2089 | CMU0841 -II-J : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSHUMERAL - MOBILITY GRADE 1 | PMR | 77700 | 77700 | 77700 | 77700 | 77700 | 77700 | 77700 | 77700 |
2090 | CMU0841 -II-K : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSHUMERAL - MOBILITY GRADE 2 | PMR | 83000 | 83000 | 83000 | 83000 | 83000 | 83000 | 83000 | 83000 |
2091 | CMU0841 -II-L : CUSTOM MADE PROSTHESIS (EXTERNAL) (EXCEPT FINGERS, TOES AND SMALL JOINTS) - TRANSHUMERAL - MOBILITY GRADE 3 | PMR | 206900 | 206900 | 206900 | 206900 | 206900 | 206900 | 206900 | 206900 |
2093 | CMU0841 -IV : CUSTOM MADE PROSTHESIS (EXTERNAL) (FINGERS, TOES AND SMALL JOINTS) | PMR | 52500 | 52500 | 52500 | 52500 | 52500 | 52500 | 52500 | 52500 |