CGHS Approved List

. . . 7000/- 5. SACH Rs. Pylon/ tube. Trans Femoral Prosthesis ( Above Knee Prosthesis) Rs. Covering Socks.a Transtibial Prosthesis (Below Knee Prosthesis) with Rs. Pylon/tube. Trans Femoral Prosthesis ( Above Knee Prosthesis) (Its components include-S. Transtibial prosthesis (Below Knee Prosthesis) (Its components include-S. etc. Covering Socks. Socket Mounting Adaptor. Socket fabrication & fitment charges) 6.a Trans Femoral Prosthesis ( Above Knee Prosthesis) Rs. Pylon/ tube. Sleeve Suspension. SACH FOOT.S. Bonded Pylon/Pylon with 4 screw Adaptor. Rate/Price 1.) 2.20. Covering Socks. Bonded pylon / Pylon with 4 screw Adaptor ( 400mm) Polycentric Prosthetic Knee Joint. Bonded pylon / Pylon with 4 screw Adaptor ( 400mm) Single axis Prosthetic Knee Joint. Socket fabrication & fitment charges 9. Foam cover.TES Belt.45500/- silicone / PU liner with shuttle lock mechanism 3.S. Socket Adaptor .61140/- with Silicon/ PU liner 7.TES Belt. Hip Joint (basic). Trans Femoral Prosthesis ( Above Knee Prosthesis) Rs. Foot Adapter Rs. Tube (Angle tube adaptor. 37000/- silicone / PU liner 2. Covering Socks Socket charges. Socket fabrication & fitment charges. Foot Adapter .S. Pylon/tube. Bonded Pylon / Pylon with 4 Rs. 40840/- screw Adaptor ( 400mm) Polycentric Prosthetic Knee Joint. Foot Adapter. 10 degree) Short Tube.60300/- (Its components include-S.S. 51940/- (Its components include-S. Foam cover. Transtibial Prosthesis (Below Knee Prosthesis) with Rs. SACH FOOT. Socket Adaptor. etc. Foam cover. Socket Adaptor. Tube Clamp Adaptor. Knee Disarticulation Prosthesis )Rs. Foot Adapter . SACH FOOT. Socket Adaptor .000/- FOOT.40840 + with Suction Valve 3800=44640/- 7. Hip Disarticulation Prosthesis Rs. Covering Socks. 4. Name of Prosthesis Approved No. Foam Cover. Symes Prosthesis Its component includes. ANNEXURE-IA LOWER EXTREMITY PROSTHETICS (Above 12 years) Sl.19300/- Sleeve Suspension. Socket charges.) 5 . Partial Foot Prosthesis ( Shoe with filler) Rs.SYME’S FOOT. 69640/- with Silicon /PU liner with shuttle lock mechanism 8. Foot Adapter . SYME. etc. Trans Tibial Prosthesis (Below Rs. Foam cover. 35140+ Not silicone / PU liner with shuttle 8500 =43640 Applicable lock mechanism 3. Tube Clamp Adaptor.4000/. Not Knee Prosthesis) with silicone / applicable PU liner 2.) 2. SACH FOOT.TES Belt. 70280+ Not Knee Prosthesis) with Silicon/PU 8500=78780 Applicable liner with shuttle lock mechanism 8.a.980/. Covering Socks.780/. SACH FOOT.12000/- tube. Knee Disarticulation Prosthesis (Its components include-S. Rs. Socket fabrication & fitment charges) 6. 35. rate/Price rate/Price (Child 7-12 (Child 0-6 years) years) 1. Pylon/ Rs.70.5000/- tube. Foot Adapter Sleeve Suspension.18.S. Covering Socks. Socket charges.S.a Trans Tibial Prosthesis with Rs. ANNEXURE-IB LOWER EXTREMITY PROSTHETICS (CHILD UPTO THE AGE OF 12 YEARS) Sl. Sleeve Suspension.140/.19300/. Rs. Foot Adapter . Rs.S. PARTIAL FOOT PROSTHESIS Rs. Applicable Valve 7. Foot Adapter . Name of Prosthesis Approved Approved No. Trans Femoral Prosthesis (Above Rs. Bonded pylon / Pylon with 4 screw Adaptor (400mm) Polycentric Prosthetic Knee Joint. Socket Adaptor . Trans Femoral Prosthesis ( Above Rs. Pylon/ 6 . Socket Adaptor. 49. Pylon/ Rs. Trans Femoral Prosthesis ( Above Knee Prosthesis) (Its components include-S.1500/- (Shoe with filler) 5.5000/- FOOT . Symes Prosthesis Its component includes. Foam cover.49980 + Not Knee Prosthesis) with Suction 3800=53.280/.140/. Bonded pylon / Pylon with 4 screw Adaptor. Transtibial prosthesis (Below Knee Prosthesis) (Its components include-S. Covering Socks Socket charges 4. Socket mounting adaptor. Not Knee Prosthesis) with Silicon / PU Applicable liner 7. Trans Femoral Prosthesis ( Above Rs.S Rs. Rs. 12000/- Bonded pylon / Pylon with 4 screw Adaptor (400mm) Polycentric Prosthetic Knee Joint. Hip Joint (basic).980/.) NOTE: 1. Rs. Socket Adaptor . Socket Adaptor. Prescription of Trans Femoral Prosthesis may be considered as Above Knee Prosthesis. Socket fabrication & fitment charges) 9. Foot Adapter . Bonded pylon / Pylon with 4 screw Rs. Pylon/ tube. Rs. Foot Adapter . Prescription of Trans Tibial Prosthesis may be considered as Below Knee Prosthesis. tube. 49. Socket fabrication & fitment charges. Tube (Angle tube adaptor.TES Belt. Hip Disarticulation Prosthesis (Its components include-S. SACH FOOT. Foam cover.15000/- Adaptor ( 400mm) Single axis Prosthetic Knee Joint. SACH FOOT. 7 . Rs. Covering Socks. 2. Covering Socks.S. 10 degree) Short Tube. Foam cover.60300/. Foam cover. Socket fabrication & fitment charges) 5. Foam cover. Trans Femoral Rs.S. Applicable Applicable S. Not Not (Below Knee Prosthesis) Applicable Applicable with silicone / PU liner 3. Bonded pylon / Pylon with 4 screw Adaptor (400mm) Polycentric Prosthetic Knee Joint.340/. Socket Adaptor.) 2.TES Belt. Not Not Prosthesis (Above Knee Applicable Applicable Prosthesis) (Its components include- S.52200 Not Not (Below Knee Prosthesis) Applicable Applicable with silicone / PU liner with shuttle lock mechanism 4.540/. Transtibial prosthesis (Below Knee Prosthesis) Not Not (Its components include.43700/.S. Name of Prosthesis Approved Approved Approved No. Bonded pylon / Pylon with 4 screw Adaptor. Covering Socks. Rs. DYNAMIC RESPONSE FOOT. Foot Adapter. Trans tibial Prosthesis Rs. Rate/Price Rate/Price Rate/Price (Above 12 years CHILD (7.64. Not Not Prosthesis (Above Knee Applicable Applicable Prosthesis) with Silicon / PU liner 8 . Tube Clamp Adaptor. ANNEXURE-IC HIGH END LOWER EXTREMITY PROSTHETICS Sl. Socket Adaptor . Foot Adapter . Socket charges. DYNAMIC FOOT. Pylon/ tube. Covering Socks.47540 + Not Not Prosthesis (Above Knee 3800=51.Applicable Applicable Prosthesis) with Suction Valve 6. Sleeve Suspension. etc. Pylon/ tube. 47. Trans Femoral Rs.26. CHILD of age) 12 Years) (0-6) Years 1.540/. Trans Femoral Rs. Trans tibial Prosthesis Rs.700/. 3.3000/- PROSTHESIS 9c.7 Trans Femoral 64540+ Not Not Prosthesis (Above Knee 8500=73040/.9000/. commando persons / police personals sustaining amputation in saddle and likely go back to active and strenuous work.9000/. 2. Rs. Pylon/ tube. Foot Adapter . 5. GREAT TOE SILICON Rs. Silicone Prosthesis For Rs. Applicable Applicable Prosthesis) with Silicon / PU liner with shuttle lock mechanism 8.S. Rs. 9 .3000/- plate 9b. Foam cover. DYNAMIC FOOT.7500/-each Rs. State/ National or international level. Shoe filler with carbon Rs.4000/. PARTIAL FOOT PROSTHESIS 9a. commando persons / police personals sustaining amputation in saddle and likely go back to active and strenuous work. Externally Powered Prosthesis /Myoelectric Prosthesis may be prescribed for one side and body powered Prosthesis or Passive Prosthesis for the other side. Socket fabrication & fitment charges) 9. paramilitary. Rs. 4.58640/.5000/. cultural activities. In case of Bilateral Upper Limb amputation. Not Second Toe to Vth Toe Applicable RECOMMENDED CRITERIA FOR HIGH END PROSTHESIS 1. Participating in cultural activities. Knee Disarticulation Rs. Shoe filler with carbon plate can be prescribed only for Military. Dynamic foot can also be prescribed for young / children and dynamic athletes of University. paramilitary. Not Not Prosthesis Applicable Applicable (Its components include- S. Shoe filler with carbon plate can also be prescribed for young / children and dynamic athletes of University. Covering Socks. Socket Adaptor . Bonded pylon / Pylon with 4 screw Adaptor ( 400mm) Polycentric Prosthetic Knee Joint. at State / National or international level. Dynamic foot can be prescribed only for Military. Rs.TES Belt.5000/. Trans Radial or Below Elbow / Wrist Rs.2000/- Disarticulation Passive Prosthesis 2.30. Trans Humeral or Rs. Rs. Rs. Not Disarticulation body Applicable powered Prosthesis 10 .20.000/.000/.5000/. 22000/.10.000/. Shoulder Rs. Shoulder Rs.000/. Not Prosthesis (Trans Applicable Radial or Below Elbow / Wrist Disarticulation) Its components includes trans radial kit and socket 3.000/- Above Elbow / Elbow Disarticulation Passive Prosthesis 4. ANNEXURE-ID UPPER EXTREMITY PROSTHETICS Sl.20. Rate/Price Rate/Price Rate/Price (Above 12 CHILD (7-12 CHILD years of age) Years) (0-6) Years 1.10.000/.10. Rs.5. 37. Rs. Body Powered 28000/. Rs. 12000/. Not Prosthesis (Trans Applicable Humeral or Above Elbow / Elbow Disarticulation) 5. Name of Prosthesis Approved Approved Approved No.000/. Rs. Body Powered 17000/.000/- Disarticulation Passive Prosthesis 6. 28000/. 000/- Prosthesis 11 . Electrode cable. Electrodes. Applicable Applicable Elbow Disarticulation Prosthesis (It includes:. Flexible inner Liner and socket.1. Rate/Price Rate/Price rate/Price (Above 12 CHILD (7. Hand. Wrist Unit Battery Charger & Transformer. Name of Prosthesis Approved Approved Approved No. Connector block cable Silicone Glove. Electrodes.29. Lithium ion Battery (one pair) with cover. Externally Powered Not Not Trans Humeral / Rs. Flexible inner Liner and sockets. Hand.500/.10. Silicone Partial Hand Rs. etc) 3. Lithium ion Battery (one pair) with cover.8000/. ANNEXURE-IE HIGH END UPPER EXTREMITY PROSTHETICS (ADULT) Sl.5000/. Battery Charger & Transformer. Applicable Applicable radial / Wrist Disarticulation prosthesis (It includes:. CHILD years of age) 12 Years) (0-6) Years 1. Mechanical Elbow. Not Prosthesis Applicable 5. etc) 2. Electrode cable. Rs.35000/.7000/. Silicone Thumb Rs.6000/. Not Prosthesis each Applicable 4. Externally Powered Not Not below elbow or Trans Rs.25000/. Silicone Finger Rs. Rs. Connector block cable Silicone Glove.1.76. Rs. Rs. Wrist Unit.500/. Rigid TLSO / Taylor.O--. 2500/- Jacket 12 UNDER ARM BRACE 3500/.s 1500/.Anterior Spinal Hyperextension Brace 3. L. CASH-.s brace. Not Applicable Post Cervical Orthosis 5. Soft L.O / Chair 1200/. 3000/. 1000/. 1200/. Not Applicable 4.Cervical Thoraco Lumbo Sacral Orthosis 12 . TLSO BI. Rate/Price Rate/Price Rate/Price (Above 12 CHILD (7. 500/. corset / Belt 700/. 5000/. 800/- Orthosis 6. SOMI BRACE / Three 2000/. CTLSO ( MILWAUKEE 5000/.Lumbo Sacral Orthosis 2.S. Head Cervical Thoraco 1500 1500/. Not Applicable Cervical Collar 2. 200/. William.S. Not Applicable Back Orthosis 7. 1200/- Orthosis (HCTO) 11. 2000/. Not Applicable BRACE) 10.Valve / Body 3000/. Not Applicable (Boston Brace / Miami Brace / Wilmington Brace / NYOH Brace ) 13. CHILD years of age) 12 Years) (0-6) Years 1.s brace 8. Hyperextension brace / 1200/. Knight Taylor. 1000/. Four Post Cervical 1200/. Name of Prosthesis Approved Approved Approved No. ASH. 1500/.Thoraco Lumbo Sacral Orthosis 5. 1000/. Rigid L. Soft / Semi rigid 200/. 1000/- brace.S. ANNEXURE-IIA SPINAL ORTHOTICS Sl. HALO BRACE 15000/. Philadelphia or Two 1500/. 3500/.Cruciform Anterior Spinal Hyperextension 4. 1200/- post Cervical collar / Head Cervical Orthosis (Moulded collar) 3. Not Applicable ASH / CASH / JEWETT BRACE 9. Not Not Applicable Applicable Abbreviations: 1. TLSO---. CTLSO----. Soft Insole ( Plastozote) 300/. Molded Shoe ( Leather). Not Applicable One Piece 7. 700/- Pair (Leather) 14. Silicone / PU Insole 500/. 200/. 200/. 600/. Not Applicable support (One Piece) 4. 2000/. Arch Support 300/. AFO Conventional 3500/. Open toe shoes for 1500/. AFO Conventional 2500/. 1000/. Silicone / PU arch 350/. 100/- 5. 800/- Piece) 13 Flat Feet / CTEV Shoes 1200/. Not Applicable (One Piece) 11. 50 per Not Applicable inch ½ inch 17. Not Not Applicable (One Piece) Applicable 8. Molded / customized 600/. Silicone Toe separator 200/. 250/. UCBL ( Unilateral) 800/. 2700/. 100/. Not Applicable with Insole ( One Piece) 2.B. 1600/. 200/. 2000/. 800/. Not Not Applicable (One Piece) Applicable 9. -Not Not Applicable paraplegic one pair Applicable 18. Molded Shoe ( Leather). 50 per ½ Rs. SMO without shoes (One 1200/. 1500/- (One Side) 20. 200/- (Unilateral) 3. 400/- Insole (One Piece) 10. Rate/Price Rate/Price Rate/Price (Above 12 CHILD (7-12 CHILD years of age) Years) (0-6) Years 1. Pad 200/. Soft Insole cross link 100/. 500/- 12. Silicone Heel Cushion 300/. 2000/- (Bilateral) 13 . Splint with / Not Not 800/- without shoe Applicable Applicable 19. Medial / Lateral Wedge 100/. 100/. Not Applicable both side affected 16 Shoe Raise Rs. Name of Prosthesis Approved Approved Approved No. Not Applicable one side normal & one side affected 15. Soft Heel Pad / M. Not Applicable polymer (One Piece) 6. 100/. ANNEXURE-IIB LOWER EXTREMITY ORTHOTICS Sl. 500/. 3000/.T. D. 2200/. 1000/. 800/- Non weight relieving 33. immobilizer etc. 3000/- with shoes (One side) 35. 4000/. Not Applicable 28. Trilateral Orthosis 4000/. Off loader Knee 17000/. 500/. HIP Abduction Orthosis Not 1000/. 3200/.B Brace without 1800/. 1000/- (Conventional) Applicable 39.) 25.T.F. 4500/- Conventional with shoes 36. FRO (Floor Reaction 1800/. HKAFO Polyproxyline 5000/. KAFO conventional with 4000/. KAFO custom molded 4000/. Not Not Applicable Orthosis) Applicable 23. Femoral Fracture Brace 1500/. 1200/. 18000/- Applicable 42 Reciprocating Gait 32000/. P. 800/. Femoral Fracture Brace 4000/. 4000/- conventional with shoe 31. Knee Sleeve with hinge 800/. 2000/- weight relieving 34. Not Applicable hinge 27. Knee Orthosis 1500/. Not Not Applicable Applicable 24.21 Polypropylene / 1200/. 3200/. 1500/. 3200/. 2000/- shoe (One side) 30. Knee Sleeve without 500/. 1500/. Pneumatic walker 3500/. Pavlik Harness for CDH Not Not 2500/- Applicable Applicable 40. Not Applicable (Immobilizer) 41 SWASH Brace Not 18000/. Hip Bracing 2000/. 3000/- custom moulded without shoes (One side) 37. 5500/. 1200/- shoes 26. 2000/- without shoe (One side) 32. 3200/. Bilateral HKAFO 6500/. HKAFO Conventional 5000/. Bilateral KAFO 5500/. Not Not Applicable Orthosis Applicable 14 . 4500/.O without shoes 22. 4000/. 800/- Customized A. Not Not Applicable Orthosis Applicable 29. 900/- Polypropylene (Valgum /Varus. 2000/- 38. 1000/. Hand Orthosis 400/. 500/- 12. 800/. 200/- Orthosis 9. Not Not orthosis Applicable Applicable 16. 200/. 100/. Wrist Hand Orthosis 1000/. 800/- without elbow hinge and forearm support 17. Humeral fracture brace 1200/. Tennis Elbow support 200/. 350/. Knuckle bender 500/. 700/. Fracture Brace ( Below 1200/. 700/- (Immobilizer) 15. 300/. 300/. Not Applicable 6.P 7. 300/- 4. Elbow orthosis 1000/. Wrist Hand Orthosis 700/. 100/- ( One Piece) 2. Not Applicable 11. 200/- stabilizer 5. Elastic Wrist Hand 400/. Shoulder Elbow Wrist 2200/. Humeral fracture brace 1600/. 700/- Elbow) 14. 500/- (dynamic) 8. Adjustable arm sling 300/. 800/. 800/. 400/- ( Static) P. 1200/. Elbow orthosis (static) 900/. 600/- (Dynamic) 13. 500/. 1600/. Not Applicable 10. 1400/- Hand Orthosis ( Air plane splint) 15 . Gun slinger shoulder 1000/. Rate/Price Rate/Price Rate/Price (Above 12 CHILD (7-12 CHILD years of age) Years) (0-6) Years 1. shoulder brace 1000/. Thumb Spica / 300/. 300/. ANNEXURE-IIC UPPER EXTREMITY ORTHOTICS Sl. 800/. 100/. 1000/- with elbow hinge and forearm support 18. Finger orthosis static 150/. Finger orthosis 200/. Name of Prosthesis Approved Approved Approved No. 700/. 100/- dynamic ( One Piece) 3. 200/. 650/. 350/. Not Not driven) Applicable Applicable Tricycle Hand Propelled 6000/. 7000/- 6.000/. (i) Quadriplegic wheel Not 1. Wheel Chair Folding 7000/.Stand Not applicable 7300/. Not crutch (Aluminum) Applicable Adjustable 4. Walker/Rollator 1500/. Walking Stick 350/. Commode Chair 2500/. CHILD years of age) 12 Years) (0-6) Years 1. Not ( Chrome Plated) Applicable Motorized Wheel chair 8. NAME OF ORTHOSIS Approved Approved Approved Rate/Price Rate/Price Rate/Price (Above 12 CHILD (7.P. Applicable Applicable --------- 16 . Not Applicable 7.Chair / C. 900/- (Aluminium) 5.P.000/.000/. Auxillary Crutch / Elbow 850/. Not chair with Chin Applicable Applicable and Head Control (ii) Quadriplegic wheel 60.10. Not (Adjustable) Aluminium Applicable 2. 4000/. C. Not Not 9. Tripod / Quadripod 750/.N0. Not Not walking stick Aluminium Applicable Applicable 3. ANNEXURE-III MOBILITY AIDS S. 1200/. 2500/. Not chair with joy stick Not Applicable Applicable (iii) Motorized wheel chair (Handle 35.