SNO | Package Name | Category | A1 | A2 | A3 | A4 | A5 | A6 | S1 | S2 |
---|---|---|---|---|---|---|---|---|---|---|
2362 | 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 |
2363 | 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 |
2364 | 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 |
2365 | 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 |
2366 | 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 |
2367 | 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 |
2368 | 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 |
2369 | 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 |
2370 | 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 |
2372 | 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 |
2373 | 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 |
2374 | 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 |
2375 | 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 |
2376 | 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 |
2377 | 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 |
2378 | 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 |
2379 | 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 |
2380 | 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 |
2381 | 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 |
2382 | 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 |
2383 | 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 |
2384 | 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 |
2385 | 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 |
2386 | 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 |
2387 | CMU0841 -IV : CUSTOM MADE PROSTHESIS (EXTERNAL) (FINGERS, TOES AND SMALL JOINTS) | PMR | 52500 | 52500 | 52500 | 52500 | 52500 | 52500 | 52500 | 52500 |