Schedule 5 - Appendix A - Surgically Implanted Prostheses

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ORTHOPAEDIC Billing Code Product Further Size Notations SN661 Compass PIP Kit assembly includes 0.45 x 5" K Single sterile PIP Hinge Kit Wires, 1 Small Pin Support Block, 1 Hexdriver, 1 Compass PIP (Packed Sterile) Prostheses, Joint, Hip SN003 Hydroxylapatite coated Primary Image Hip Stem, Titanium, left and Sizes 9 - 18 Femoral Stems right SN019 Low Profile Classic Compression Hip 130 - 150 deg Hot forged stainless 5 - 6 holes Screw System SN020 Osteotomy Plates Blade, 130 deg Adult osteotomy 50 - 110mm SN021 Osteotomy Plates Blade, 95 deg Adult osteotomy 50 - 80mm SN022 Osteotomy Plates Blade, Adult osteotomy 4 hole 40 - 80mm SN023 Osteotomy Plates Blade, 90 deg adolescent osteotomy 40 - 60mm 3 hole SN024 Osteotomy Plates Blade, 130 deg Angled Blade Plate shaft 60 - 152mm Small Stature 50 - 80mm SN025 Osteotomy Plates Blade, 95 deg Condylar Blade 40 - Shaft 92 - 156mm SN027 Osteotomy Plates Blade, 115 deg Bifurcated Infant 30 - 35mm SN036 Osteotomy Plates Blade, Child Osteotomy 80 -100 deg 35 - 45mm SN139 Osteotomy Plates Blade, 90 deg Infant Osteotomy 25 - 32mm SN140 Low Profile Classic Compression Hip 130 - 150 deg Hot forged stainless 3 - 4 holes Screw System SN663 35deg Reflection Liner UHMWPE 50 - 60mm SN678 Echelon with HA Cobalt Chromium with 11-20 Hyrdoxyapetite Coating SN687 Femoral Head 12/14 Taper 22 - 36mm, +0 - +16mm SN689 Reflection Constrained Acetabular Liner - 22 - 32mm, 42 - 76mm UHMWPE Page 324 of 638
ORTHOPAEDIC Billing Code Product Further Size Notations SN692 Spectrum EF Tantalum marked high offset and Size 1 - 8 standard stems SN693 Hip Component Femoral or acetabular Size 0 - 20 SN695 Opera Acetabular Cup Flanged - XLPE 22-36mm, 42-76mm SN696 Reflection Acetabular Cup - XLPE 22-36mm,40-61mm SN698 Reflection Acetabular liner - XLPE (0 & 20 22-36mm, 42-76mm degrees) SN702 Collarless Polished Cemented Stem Tantalum marked high offset and Size 0 to 5 standard offset stems Prostheses, Joint, Hip, Acetabular Component SN278 Femoral Head Ceramic AlO3 14/16 taper, 28 and 32mm, Std - Xlong SN285 Reflection Acetabular Cup Dual Geometry 42 - 76mm Porous Titanium Alloy, No Hole, Three Hole, Multi-Hole SN290 Reflection Acetabular Shell Ceramic, Porous 46-66mm OD Titanium Alloy SN297 Reflection Acetabular Liner Ceramic, AlO3 28 - 32mm, 46 - 66mm OD SN298 Reflection Acetabular Shell Porous HA Coated 42 - 76mm Titanium Alloy SN299 Reflection Head Ceramic, AlO3 28-32mm SN688 Reflection HA Coated acetabular ceramic cup Sizes 45 - 66 SN701 Reflection Constrained acetabular liner - 42 - 76mm adaptor ring Prostheses, Joint, Hip, Femoral Component SN010 Basis Femoral Component Hip stem, Cobalt Chromium Length 115 - 135mm SN127 Marathon Femoral Component Hip stem, Cobalt Chrome Lengths 115 - 135mm Page 325 of 638
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Schedule 5 - Appendix A - Surgicall
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CARDIO-THORACIC Billing Code Produc
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EAR, NOSE & THROAT Billing Code Pro
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ENDOSCOPIC PRODUCTS Billing Code Pr
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GENERAL/MISCELLANEOUS Billing Code
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MECHANICAL INTERNAL WOUND CLOSURE B
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NEUROSURGICAL Billing Code Product
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OPHTHALMIC Billing Code Product Fur
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ORTHOPAEDIC Billing Code Product Fu
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PLASTIC AND RECONSTRUCTIVE Billing
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UROGENITAL Billing Code Product Fur
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VASCULAR Billing Code Product Furth
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Schedule 5 - Appendix A - Surgically Implanted Prostheses

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