Limb Prostheses (Externally Powered)
Product Manual
Effective Date : February 01, 2012
Assistive Devices ProgramMinistry of Health and Long-Term Care
Printed Date: Oct 5, 2015 Page: 1 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Externally Powered Wrist Disarticulation Definitive Prostheses
1/2 And 1/2 Silastic-Acrylic Socket PRE19A104 2 $1,088.00
Adult Wrist Disarticulation Externally Powered Prosthesis
PRD192ADL 2 $9,522.00
Child Wrist Disarticulation Externally Powered Prosthesis
PRD191CHD 2 $9,522.00
Lightweight Carbon-Acrylic Exo-Lam
PRE19A112 2 $131.00
Molded Socket, Fitting, Location Of Control And Alignment
PRE190100 2 $2,046.00
Multi-Layer Socket-Growth Allowance PRE19A105 2 $348.00
Obturator Self-Suspending PRE19A107 2 $218.00
One-Piece Forearm To Socket Exo-Lam
PRE19A111 2 $479.00
Silastic Insert PRE19A103 2 $1,001.00
Suction Suspension PRE19A106 2 $261.00
Supracondylar (Northwestern) Socket PRE19A108 2 $218.00
Test Socket PRE19A101 10 $174.00
Thermoplastic Insert PRE19A102 2 $261.00
Two-Piece Forearm To Socket Exo-Lam Ob
PRE19A110 2 $392.00
Externally Powered Wrist Disarticulation Replacement Sockets
1/2 And 1/2 Silastic-Acrylic Socket
PRE44A104 2 $1,088.00
Adult Wrist Disarticulation Definitive Socket Replacement
PRD442ADL 2 $2,062.00
Child Wrist Disarticulation Definitive Socket Replacement
PRD441CHD 2 $2,062.00
Lightweight Carbon-Acrylic Exo-Lam PRE44A112 2 $131.00
Molded Socket, Fitting, Location Of Control, Fitted To Present Definitive Unit
PRE440100 2 $2,177.00
Multilayer Socket - Growth Allowance
PRE44A105 2 $348.00
Obturator Selfsuspending PRE44A107 2 $218.00
One-Piece Forearm To Socket Exo-Lam PRE44A111 2 $479.00
Silastic Insert PRE44A103 2 $1,001.00
Suction Suspension PRE44A106 2 $261.00
Page: 2 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Externally Powered Wrist Disarticulation Replacement Sockets
Supracondylar (Northwestern) PRE44A108 2 $218.00
Test Socket PRE44A101 10 $174.00
Thermoplastic Insert PRE44A102 2 $261.00
Two-Piece Forearm To Socket Exo-Lam Ob
PRE44A110 2 $392.00
Externally Powered Trans-Radial Definitive Prostheses
1/2 And 1/2 Silastic-Acrylic Socket PRE20A204 2 $1,045.00
Adult Trans-Radial Externally Powered Prosthesis
PRD202ADL 2 $10,208.00
Child Trans-Radial Externally Powered Prosthesis
PRD201CHD 2 $10,208.00
Custom Made Pull-In-Tube PRE20A213 2 $109.00
Elbow Obturator (3/4 Socket) PRE20A207 2 $131.00
Lightweight Carbon-Acrylic Exo-Lam
PRE20A212 2 $131.00
Molded Socket, Fitting, Location Of Control And Alignment
PRE200200 2 $2,220.00
Multi-Layer Socket-Growth Allowance PRE20A205 2 $305.00
One-Piece Forearm To Socket Exo-Lam
PRE20A211 2 $435.00
Primary Paediatric Active Trans-Radial Prosthesis
PRD200INF 2 $8,825.00
Silastic Insert PRE20A203 2 $958.00
Split-Socket For Step-Up Hinge PRE20A209 2 $435.00
Suction Suspension PRE20A206 2 $261.00
Supracondylar Socket (Muenster Or Northwestern)
PRE20A208 2 $218.00
Test Socket PRE20A201 10 $218.00
Thermoplastic Insert PRE20A202 2 $218.00
Two-Piece Forearm To Socket Exo-Lam Ob
PRE20A210 2 $392.00
Externally Powered Trans-Radial Replacement Sockets
1/2 And 1/2 Silastic-Acrylic Socket PRE45A204 2 $1,045.00
Adult Trans-Radial Definitive Socket Replacement
PRD452ADL 2 $2,188.00
Child Trans-Radial Definitive Socket Replacement
PRD451CHD 2 $2,188.00
Page: 3 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Externally Powered Trans-Radial Replacement Sockets
Elbow Obturator (3/4 Socket) PRE45A207 2 $131.00
Lightweight Carbon-Acrylic Exo-Lam
PRE45A212 2 $131.00
Molded Socket, Fitting, Location Of Control, Fitted To Present Definitive Unit
PRE450200 2 $2,351.00
Multi-Layer Socket-Growth Allowance
PRE45A205 2 $305.00
One-Piece Forearm To Socket Exo-Lam PRE45A211 2 $435.00
Primary Paediatric Active Trans-Radial Definitive Socket Replacement
PRD450INF 2 $2,188.00
Silastic Insert PRE45A203 2 $958.00
Split-Socket For Step-Up Hinge PRE45A209 2 $435.00
Suction Suspension PRE45A206 2 $261.00
Supracondylar Socket (Muenster Or Northwestern)
PRE45A208 2 $218.00
Test Socket PRE45A201 10 $218.00
Thermoplastic Insert PRE45A202 2 $218.00
Two-Piece Forearm To Socket Exo-Lam Ob
PRE45A210 2 $392.00
Externally Powered Elbow Disarticulation Definitive Prostheses
1/2 And 1/2 Silastic-Acrylic Socket PRE21A304 2 $1,132.00
Adult Elbow Disarticulation Externally Powered Prosthesis
PRD212ADL 2 $15,899.00
Carbon Frame Outer Socket PRE21A308 2 $348.00
Child Elbow Disarticulation Externally Powered Prosthesis
PRD211CHD 2 $15,899.00
Cosmetic Endofoam Cover And Finish PRE21A314 2 $479.00
Endo Forearm Ob Or Equal PRE21A313 2 $0.00
Lightweight Carbon-Acrylic Exo-Lam
PRE21A312 2 $196.00
Molded Socket, Fitting, Location Of Control And Alignment
PRE210300 2 $2,481.00
Multi-Layer Socket-Growth Allowance PRE21A305 2 $392.00
Obturator Selfsuspending PRE21A307 2 $305.00
Silastic Insert PRE21A303 2 $1,045.00
Page: 4 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Externally Powered Elbow Disarticulation Definitive Prostheses
Standard Forearm Exo-Lam PRE21A311 2 $827.00
Suction Suspension PRE21A306 2 $261.00
Test Socket PRE21A301 10 $261.00
Thermoplastic Insert PRE21A302 2 $305.00
Externally Powered Elbow Disarticulation Replacement Sockets
1/2 And 1/2 Silastic-Acrylic Socket PRE46A304 2 $1,132.00
Adult Elbow Disarticulation Definitive Socket Replacement
PRD462ADL 2 $2,093.00
Carbon Frame Outer Socket PRE46A308 2 $348.00
Child Elbow Disarticulation Definitive Socket Replacement
PRD461CHD 2 $2,093.00
Cosmetic Endofoam Cover And Finish PRE46A314 2 $479.00
Molded Socket, Fitting, Location Of Control, Fitted To Present Definitive Unit
PRE460300 2 $2,612.00
Multi-Layer Socket-Growth Allowance PRE46A305 2 $392.00
Obturator Selfsuspending PRE46A307 2 $305.00
Silastic Insert PRE46A303 2 $1,045.00
Suction Suspension PRE46A306 2 $261.00
Test Socket PRE46A301 10 $261.00
Thermoplastic Insert PRE46A302 2 $305.00
Externally Powered Trans-Humeral Definitive Prostheses
1/2 And 1/2 Silastic-Acrylic Socket PRE22A404 2 $1,088.00
1/2 And 1/2 Silastic-Acrylic Socket (Replacement) PRE47A404 2 $1,088.00
Adult Trans-Humeral Externally Powered Prosthesis
PRD222ADL 2 $16,957.00
Carbon Frame Outer Socket PRE22A408 2 $348.00
Carbon Frame Outer Socket (Replacement) PRE47A408 2 $348.00
Child Trans-Humeral Externally Powered Prosthesis
PRD221CHD 2 $16,957.00
Cosmetic Endofoam Cover And Finish PRE22A414 2 $609.00
Cosmetic Endofoam Cover And Finish (Replacement) PRE47A414 2 $609.00
Custom Made Pull-In-Tube PRE22A415 2 $109.00
Endo Forearm Ob Or Equal PRE22A413 2 $0.00
Lightweight Carbon-Acrylic Exo-Lam
PRE22A412 2 $196.00
Page: 5 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Externally Powered Trans-Humeral Definitive Prostheses
Molded Socket, Fitting, Location Of Control And Alignment
PRE220400 2 $2,394.00
Molded Socket, Fitting, Location Of Control, Fitted To Present Definitive Unit
PRE470400 2 $2,525.00
Primary Paediatric Active Trans-Humeral Prosthesis
PRD220INF 2 $10,652.00
Silastic Insert PRE22A403 2 $1,001.00
Silastic Insert (Replacement) PRE47A403 2 $1,001.00
Standard Forearm Exo-Lam PRE22A411 2 $566.00
Suction Suspension PRE22A406 2 $261.00
Suction Suspension (Replacement) PRE47A406 2 $261.00
Test Socket PRE22A401 10 $261.00
Test Socket (Replacement) PRE47A401 10 $261.00
Thermoplastic Insert PRE22A402 2 $348.00
Thermoplastic Insert (Replacement) PRE47A402 2 $348.00
Two-Piece Humeral Section To Socket Exo-Lam
PRE22A410 2 $392.00
Externally Powered Trans-Humeral Replacement Sockets
Adult Trans-Humeral Definitive Socket Replacement
PRD472ADL 2 $2,029.00
Child Trans-Humeral Definitive Socket Replacement
PRD471CHD 2 $2,029.00
Primary Paediatric Active Trans-Humeral Definitive Socket Replacement
PRD470INF 2 $2,029.00
Externally Powered Shoulder Disarticulation Definitive Prostheses
Adult Shoulder Disarticulation Externally Powered Prosthesis
PRD232ADL 2 $14,514.00
Carbon Frame Outer Socket PRE23A508 2 $522.00
Child Shoulder Disarticulation Externally Powered Prosthesis
PRD231CHD 2 $14,514.00
Cosmetic Endofoam Cover And Finish PRE23A514 2 $827.00
Endo Forearm And Humeral Section Ob Or Equal
PRE23A513 2 $0.00
Frame Style Socket, Fitting, Location Of Control And Alignment
PRE230550 2 $3,395.00
Lightweight Carbon-Acrylic Forearm And Humeral Section Exo-Lam
PRE23A512 2 $261.00
Page: 6 of 22
Ministry of Health and Long-Term Care
Assistive DevicesProgram
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Externally Powered Shoulder Disarticulation Definitive Prostheses
Molded Socket, Fitting, Location Of Control And Alignment
PRE230500 2 $3,134.00
Ob Shoulder Joint 12s4, 12s5 PRE23A518 1 $0.00
Ob Shoulder Joint 12s7 PRE23A517 2 $0.00
Shoulder Bulkhead Fs-75 PRE23A515 2 $0.00
Shoulder Flex/Abd Joint Faj-100 Or Equal
PRE23A516 2 $0.00
Silastic Insert PRE23A503 2 $1,001.00
Standard Forearm And Humeral Section Exo-Lam
PRE23A511 2 $1,088.00
Test Socket PRE23A501 10 $305.00
Thermoplastic Insert PRE23A502 2 $392.00
Externally Powered Shoulder Disarticulation Replacement Sockets
Adult Shoulder Disarticulation Frame Type Socket Replacement
PRD484ADL 2 $2,821.00
Adult Shoulder Disarticulation, Molded Definitive Socket Replacement
PRD482ADL 2 $2,757.00
Carbon Frame Outer Socket PRE48A508 2 $522.00
Child Shoulder Disarticulation Frame Type Socket Replacement
PRD483CHD 2 $2,821.00
Child Shoulder Disarticulation, Molded Definitive Socket Replacement
PRD481CHD 2 $2,757.00
Cosmetic Endofoam Cover And Finish PRE48A514 2 $827.00
Frame Style Socket, Fitting, Location Of Control, Fitted To Present Definitive Unit
PRE480550 2 $3,570.00
Molded Socket, Fitting, Location Of Control, Fitted To Present Definitive Unit
PRE480500 2 $3,483.00
Silastic Insert PRE48A503 2 $1,001.00
Test Socket PRE48A501 10 $305.00
Thermoplastic Insert PRE48A502 2 $392.00
Externally Powered Forequarter Definitive Prostheses
Adult Fore Quarter Externally Powered Prosthesis
PRD242ADL 2 $17,690.00
Page: 7 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Externally Powered Forequarter Definitive Prostheses Carbon Frame Outer Socket PRE24A608 2 $522.00
Child Fore Quarter Externally Powered Prosthesis
PRD241CHD 2 $17,690.00
Cosmetic Endofoam Cover And Finish PRE24A614 2 $827.00
Endo Forearm, Humeral Section, Ob Or Equal
PRE24A613 2 $0.00
Frame Style Socket, Fitting, Location Of Control And Alignment
PRE240650 2 $3,918.00
Lightweight Carbon-Acrylic Forearm Humeral And Shoulder Restoration Exo-Lam
PRE24A612 2 $261.00
Molded Socket, Fitting, Location Of Control And Alignment
PRE240600 2 $3,657.00
Ob Shoulder Joint 12s4, 12s5 PRE24A618 2 $0.00
Ob Shoulder Joint 12s7 PRE24A617 2 $0.00
Shoulder Bulkhead Fs-75 PRE24A615 2 $0.00
Shoulder Flex/Abd Joint Faj-100 Or Equal
PRE24A616 2 $0.00
Silastic Insert PRE24A603 2 $1,001.00
Standard Forearm, Humeral Section, And Shoulder Restoration Exo-Lam
PRE24A611 2 $1,175.00
Test Socket PRE24A601 10 $305.00
Thermoplastic Insert PRE24A602 2 $392.00
Externally Powered Forequarter Replacement Sockets
Adult Fore Quarter Definitive Frame Type Socket Replacement
PRD494ADL 2 $3,201.00
Adult Fore Quarter Definitive, Molded Socket Replacement
PRD492ADL 2 $3,139.00
Carbon Frame Outer Socket PRE49A608 2 $522.00
Child Fore Quarter Definitive PRD493CHD 2 $3,201.00
Page: 8 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Externally Powered Forequarter Replacement Sockets
Frame Type Socket Replacement
Child Fore Quarter Definitive, Molded Socket Replacement
PRD491CHD 2 $3,139.00
Cosmetic Endofoam Cover And Finish PRE49A614 2 $827.00
Frame Style Socket, Fitting, Location Of Control, Fitted To Present Definitive Unit
PRE490650 2 $4,092.00
Molded Socket, Fitting, Location Of Control, Fitted To Present Definitive Unit
PRE490600 2 $4,005.00
Silastic Insert PRE49A603 2 $1,001.00
Test Socket PRE49A601 10 $305.00
Thermoplastic Insert PRE49A602 2 $392.00
Externally Powered Electric Hand Replacement
Adult Electric Hand Replacement All Amputation Levels
PRD822ADL 2 $4,514.00
Child Electric Hand Replacement All Amputation Levels
PRD821CHD 2 $4,514.00
Primary Paediatric Electro- Mechanical Hand Replacement, All Amputation Levels
PRD820INF 2 $4,445.00
Externally Powered Electric Elbow Replacement
Adult Electric Elbow Replacement, All Amputation Levels
PRD842ADL 2 $3,861.00
Child Electric Elbow Replacement, All Amputation Levels
PRD841CHD 2 $3,861.00
Other Externally Powered Components, Accessories & Control Systems
Chest Strap PRE350006 4 $0.00
Figure-8 Or Ring Type Harness PRE350001 2 $0.00
Figure-9 Harness PRE350004 4 $0.00
Flexible Dacron Hinge PRE32C116 4 $0.00
Hdc Alternative Lock PRE32C105 4 $0.00
Hdc Battery Charger 54726, 56993 PRE34E105 2 $0.00
Hdc Battery Modular 56776 PRE34E104 2 $0.00
Hdc Battery Pack 5v 54729 PRE34E101 2 $0.00
Hdc Battery Remote 56356 PRE34E103 2 $0.00
Hdc Battery Remote 56891 PRE34E102 2 $0.00
Hdc Becker Lock Grip Blg 100, 101 PRE30C124 2 $0.00
Page: 9 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Other Externally Powered Components, Accessories & Control Systems
Hdc Becker Lock Grip Blg 200, 201 PRE30C125 2 $0.00
Hdc Becker Plylite Bp 100, 101 PRE30C126 2 $0.00
Hdc Becker Plylite Bp 200, 201 PRE30C127 2 $0.00
Hdc Capp Friction Wrist 1412, 1413, 1414
PRE31C108 2 $0.00
Hdc Capp Preflexed Wrist PRE31C109 2 $0.00
Hdc Elbow E200, E400 PRE32C101 4 $0.00
Hdc Elbow E400hd PRE32C102 4 $0.00
Hdc Elbow E50 PRE32C103 4 $0.00
Hdc Electric Hand PRE30E102 2 $0.00
Hdc Extra Insert For Wd400 PRE31C114 2 $0.00
Hdc Extra Insert For Wd400s PRE31C115 2 $0.00
Hdc Flexible Metal Hinge 2", 4", 6"
PRE32C113 4 $0.00
Hdc Flexion Wrist Aprl PRE31C111 2 $0.00
Hdc Flexion Wrist Fw200, 300, 500
PRE31C110 2 $0.00
Hdc Flexion Wrist Sierra PRE31C112 2 $0.00
Hdc Friction Wrist We500, 200n, 300n, 500n
PRE31C106 2 $0.00
Hdc Hosmer-Nyu Electric Elbow Large 56884, 56885
PRE32E102 2 $0.00
Hdc Hosmer-Nyu Electric Elbow Medium 70415, 71982
PRE32E101 2 $0.00
Hdc Hosmer-Nyu Electric Elbow With Forearm Free Swing Large 57432, 57443
PRE32E104 2 $0.00
Hdc Hosmer-Nyu Electric Elbow With Forearm Free Swing Medium 57431, 57442
PRE32E103 2 $0.00
Hdc Lift Assist PRE32C104 4 $0.00
Hdc Manual Lock PRE32C106 4 $0.00
Hdc Michigan Electric Hook #70790-93
PRE30E101 2 $0.00
Hdc Model "2" Load Aprl Vo PRE30C116 2 $0.00
Page: 10 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Other Externally Powered Components, Accessories & Control Systems
Hdc Model #10p PRE30C113 2 $0.00
Hdc Model #10x PRE30C114 2 $0.00
Hdc Model #3 PRE30C101 2 $0.00
Hdc Model #5 PRE30C102 2 $0.00
Hdc Model #555 PRE30C105 2 $0.00
Hdc Model #5x PRE30C103 2 $0.00
Hdc Model #5xa PRE30C104 2 $0.00
Hdc Model #6 PRE30C107 2 $0.00
Hdc Model #7 PRE30C108 2 $0.00
Hdc Model #7lo PRE30C109 2 $0.00
Hdc Model #8 PRE30C110 2 $0.00
Hdc Model #88x PRE30C112 2 $0.00
Hdc Model #8x PRE30C111 2 $0.00
Hdc Model #99x PRE30C115 2 $0.00
Hdc Model #Ss555 PRE30C106 2 $0.00
Hdc Model Aprl Vc PRE30C117 2 $0.00
Hdc Model Aprl Vc PRE30C121 2 $0.00
Hdc Model Becker Imperial PRE30C123 2 $0.00
Hdc Model Capp Td #1 PRE30C119 2 $0.00
Hdc Model Dorrance Vo PRE30C120 2 $0.00
Hdc Model Hosmer New Concept PRE30C118 2 $0.00
Hdc Model Robin-Aids Vo PRE30C128 2 $0.00
Hdc Model Robin-Aids Vo Soft PRE30C129 2 $0.00
Hdc Model Sierra Vo PRE30C122 2 $0.00
Hdc Outside Locking Hinges E500, E2500
PRE32C107 1 $0.00
Hdc Outside Locking Hinges E5500hd
PRE32C108 1 $0.00
Hdc Oval Friction Wrist Ow100, 75n, 100n
PRE31C107 2 $0.00
Hdc Polycentric Hinge Pc100 PRE32C110 1 $0.00
Hdc Polycentric Hinge Pc50 PRE32C111 1 $0.00
Hdc Prehension Actuator #59163-68 PRE30E103 2 $0.00
Page: 11 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Other Externally Powered Components, Accessories & Control Systems
Hdc Quick Change Wrist Fm100 Or Equal
PRE31C104 2 $0.00
Hdc Quick Change Wrist Fm100s Or Equal
PRE31C105 2 $0.00
Hdc Quick Change Wrist Wd400ss Or Equal
PRE31C103 2 $0.00
Hdc Quick Change Wrist Wd400 Or Equal
PRE31C101 2 $0.00
Hdc Quick Change Wrist Wd400s Or Equal PRE31C102 2 $0.00
Hdc Single-Axis Hinge Sp100l PRE32C115 1 $0.00
Hdc Single-Axis Hinge Sp75, 100 PRE32C114 1 $0.00
Hdc Step-Up Hinge Ma50, 75, 100 PRE32C112 1 $0.00
Hdc Stump Activated Locking Hinges E600, E1600
PRE32C109 1 $0.00
Hdc Switch, 2 Position Pull 1/2" 57412
PRE33E104 2 $0.00
Hdc Switch, 3 Position Pull 1" 71977
PRE33E105 2 $0.00
Hdc Switch, Double Push 56277 PRE33E102 2 $0.00
Hdc Switch, Single Pull 1/2" 57405
PRE33E103 2 $0.00
Hdc Switch, Single Push 53036 PRE33E101 2 $0.00
Hdc Wrist Disarticulation Friction Wa600
PRE31C113 2 $0.00
Heavy Duty Control Cable PRE350008 2 $0.00
Hook-To-Hand Cable Adaptor PRE350010 2 $0.00
Ipo 2 1/4", 2 1/2", 2 3/4", 3 1/4" Steeper Myo Hand
PRE30E402 2 $0.00
Ipo 2 1/4", 2 1/2", 2 3/4", 3 1/4" Steeper Servo Hand
PRE30E403 2 $0.00
Ipo 2" System Teknik Myo Hand PRE30E401 2 $0.00
Ipo 3-State Myocontrol, External Battery M101
PRE33E402 2 $0.00
Ipo 3-State Myocontrol, PRE33E401 2 $0.00
Page: 12 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Other Externally Powered Components, Accessories & Control Systems
Internal Battery M111
Ipo 3-State Myocontrol, Em03/04 PRE33E403 2 $0.00
Ipo Adaptor For Steeper Lamination Ring St266
PRE31E402 2 $0.00
Ipo Boston Elbow Myo Control Bes-100
PRE32E401 2 $0.00
Ipo Boston Elbow Switch Control Bes-150
PRE32E402 2 $0.00
Ipo Cable Ec01 PRE33E404 2 $0.00
Ipo Electrode 84e1 PRE33E417 2 $0.00
Ipo Extra Inserts Rd 2409-I PRE31C402 2 $0.00
Ipo Friction Wrist Rd 2409 PRE31C401 2 $0.00
Ipo Hand Adaptor Cable Mc13 PRE30E404 2 $0.00
Ipo Hand Adaptor Cable Mc14 PRE30E405 2 $0.00
Ipo Hand Adaptor Cable Mc15 PRE30E406 2 $0.00
Ipo Hand Adaptor Cable Mc16 PRE30E407 2 $0.00
Ipo Hand Adaptor Cable Mc17 PRE30E408 2 $0.00
Ipo Hand Adaptor Cable Mc18 PRE30E409 2 $0.00
Ipo Hand Adaptor Cable Mc19 PRE30E410 2 $0.00
Ipo In-Line Control Switch Ah3913 PRE33E418 2 $0.00
Ipo Mounting Kit PRE33E419 2 $0.00
Ipo Pl01 Voluntary Opening Plug PRE33E416 2 $0.00
Ipo Slow Battery Charger Bc01, 40ma For M111
PRE34E401 2 $0.00
Ipo Steeper 6v Electric Gripper Pg101, Pg102 With Friction Wrist
PRE30E412 2 $0.00
Ipo Steeper 6v Electric Gripper Pg105, Pg106 With Ob Disconnect
PRE30E413 2 $0.00
Ipo Steeper Adaptor Plug, Ob To Steeper Ah3925
PRE33E413 2 $0.00
Ipo Steeper Amplifier Cable Ah3905
PRE33E407 2 $0.00
Ipo Steeper Amplifier Electrode Ah3901
PRE33E405 2 $0.00
Ipo Steeper Battery 6v Ah3902 PRE34E402 2 $0.00
Page: 13 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Other Externally Powered Components, Accessories & Control Systems
Ipo Steeper Battery Charger Ah3909 PRE34E405 2 $0.00
Ipo Steeper Battery Clip And Cable Ah3912
PRE34E404 2 $0.00
Ipo Steeper Battery Mount System Ah3903
PRE34E403 2 $0.00
Ipo Steeper Car Adaptor For Charger Ah3910
PRE34E407 2 $0.00
Ipo Steeper Carbon Fibre Gripper Cfg With Hand Plate
PRE30C401 2 $0.00
Ipo Steeper Connector Block Ah3904
PRE33E406 2 $0.00
Ipo Steeper Connector Block Cambion Cable Ah3908
PRE33E409 2 $0.00
Ipo Steeper Hand Connector Cable Ah3907
PRE33E408 2 $0.00
Ipo Steeper Lamination Ring Ap610, 611, 612
PRE31E403 2 $0.00
Ipo Steeper Mechanical Elbow Mk14 Forearm Extension
PRE32C401 1 $0.00
Ipo Steeper Servo Transducer St-11
PRE33E414 2 $0.00
Ipo Steeper Servo Transducer St-12
PRE33E415 2 $0.00
Ipo Steeper Servo Cable With Transducer Ah3911
PRE33E411 2 $0.00
Ipo Steeper Single Site Vo Cable Ah3918
PRE33E410 2 $0.00
Ipo Steeper Touch Switch Ah3916 PRE33E412 2 $0.00
Ipo Steeper Transformer For Charger Ah3926
PRE34E406 2 $0.00
Ipo System Teknik Lamination Ring St265
PRE31E401 2 $0.00
Ob Battery Charger 757l11 PRE34E208 2 $0.00
Ob Battery Connection Cable 13e51-1
PRE34E203 4 $0.00
Ob Battery Connection Cable 13e51-2
PRE34E204 2 $0.00
Ob Battery Connection Cable PRE34E205 2 $0.00
Page: 14 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Other Externally Powered Components, Accessories & Control Systems
13e51-3
Ob Battery Connection Cable 13e52-1
PRE34E206 2 $0.00
Ob Battery Connection Cable 13e52-2
PRE34E207 2 $0.00
Ob Battery Interchangeable 757b8 PRE34E201 2 $0.00
Ob Battery Mount Set 757z103 PRE34E202 2 $0.00
Ob Coaxial Plug 9e169 PRE31E203 2 $0.00
Ob Connection Cable Digital Qd 13e99.eq.120 PRE33E218 4 $0.00
Ob Connection Cable Switch Control Wd 13e98
PRE33E217 2 $0.00
Ob Connection Cable With On/Off Switch 13e97 For 10s12
PRE33E216 2 $0.00
Ob Coupling Piece 10s4 PRE31E202 2 $0.00
Ob Electric Wrist Rotator 10s12-6 PRE31E205 2 $0.00
Ob Electrode 6v Analog 13e68.eq.60
PRE33E203 2 $0.00
Ob Electrode 6v Analog Exchange 13c4
PRE33E204 2 $0.00
Ob Electrode 6v Analog Exchange 13e125.eq.60
PRE33E205 2 $0.00
Ob Electrode 6v Digital 13e67 PRE33E201 2 $0.00
Ob Electrode 6v Digital Exchange 13c3
PRE33E202 2 $0.00
Ob Electrode Cable 13e129 PRE33E208 2 $0.00
Ob Electrode Cable 13e48 PRE33E207 2 $0.00
Ob Electrode Mount Set Flexible 13e84
PRE33E209 2 $0.00
Ob Electrode Mount Set Rigid 13e109
PRE33E210 4 $0.00
Ob Endo Wrist 10r1, 10r2 PRE31C201 2 $0.00
Ob Endo Wrist 10r3 PRE31C202 2 $0.00
Ob Four Channel Control 13e103 PRE33E206 2 $0.00
Ob Lamination Collar 10s1 PRE31E201 2 $0.00
Ob Lamination Ring 9e94.eq.44 PRE31E206 2 $0.00
Page: 15 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Other Externally Powered Components, Accessories & Control Systems
For 7 1/4, 7 3/4, 8
Ob Lamination Ring 9e94.eq.50 For 6 3/4 PRE31E207 2 $0.00
Ob Mechanical Hand Vc 8k25, 8k27 PRE30C204 2 $0.00
Ob Mechanical Hand Vo 8k21, 8k23 PRE30C203 2 $0.00
Ob Passive Hand Cosmetic Or Equal 8k3, 8k4
PRE30C201 2 $0.00
Ob Passive Hand Mechanical 8k12 PRE30C202 2 $0.00
Ob Switch, Cable 13e50, For 10s12 PRE33E215 2 $0.00
Ob Switch, Cable Pull 9x18 PRE33E213 2 $0.00
Ob Switch, Harness Pull 9x14 PRE33E212 2 $0.00
Ob Switch, Rocker Type 9x25 PRE33E211 2 $0.00
Ob Switch, Wrist Rotation Control 10s13
PRE33E214 2 $0.00
Ob System Electric Greifer, Qd 8e26.eq. 6-G
PRE30E250 2 $0.00
Ob System Electric Greifer, Qd 8e28.eq. G
PRE30E252 2 $0.00
Ob System Electric Greifer, Qd 8e30.eq. 6
PRE30E254 2 $0.00
Ob System Electric Greifer, Qd 8e30.eq. 6-G
PRE30E255 2 $0.00
Ob System Electric Greifer, Qd 8e32.eq. 6-G
PRE30E258 2 $0.00
Ob System Electric Greifer, Qd 8e33.eq. 1-G
PRE30E259 2 $0.00
Ob System Electric Greifer, Wd 8e27.eq. 6-G
PRE30E251 2 $0.00
Ob System Electric Greifer, Wd 8e29.eq. G
PRE30E253 2 $0.00
Ob System Electric Greifer, Wd 8e31.eq. 6
PRE30E256 2 $0.00
Ob System Electric Greifer, Wd 8e31.eq. 6-G
PRE30E257 2 $0.00
Ob System Electric Greifer, Wd 8e34.eq. 1-G
PRE30E260 2 $0.00
Ob System Electric Hand 8e21.eq. 7 3/4
PRE30E228 2 $0.00
Page: 16 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Other Externally Powered Components, Accessories & Control Systems
Ob System Electric Hand, Double Channel, Qd 8e25.eq. 7 1/4
PRE30E238 2 $0.00
Ob System Electric Hand, Double Channel, Qd 8e25.eq. 7 3/4
PRE30E239 2 $0.00
Ob System Electric Hand, Double Channel, Qd 8e25.eq. 8
PRE30E240 2 $0.00
Ob System Electric Hand, Double Channel, Wd 8e24.eq. 7 1/4
PRE30E235 2 $0.00
Ob System Electric Hand, Double Channel, Wd 8e24.eq. 7 3/4
PRE30E236 2 $0.00
Ob System Electric Hand, Double Channel, Wd 8e24.eq. 8
PRE30E237 2 $0.00
Ob System Electric Hand, Energy Saving, Qd 8e38.eq.1 6 3/4
PRE30E242 2 $0.00
Ob System Electric Hand, Energy Saving, Qd 8e38.eq.1 7 1/4
PRE30E243 2 $0.00
Ob System Electric Hand, Energy Saving, Qd 8e38.eq.1 7 3/4
PRE30E244 2 $0.00
Ob System Electric Hand, Energy Saving, Qd 8e38.eq.1-8 1/4
PRE30E245 2 $0.00
Ob System Electric Hand, Energy Saving, Wd 8e39.eq.1 6 3/4
PRE30E246 2 $0.00
Ob System Electric Hand, Energy Saving, Wd 8e39.eq.1 7 1/4
PRE30E247 2 $0.00
Ob System Electric Hand, Energy Saving, Wd 8e39.eq.1 7 3/4
PRE30E248 2 $0.00
Ob System Electric Hand, Energy Saving, Wd 8e39.eq.1 8
PRE30E249 2 $0.00
Ob System Electric Hand, Grip Force, Qd 8e23.eq. 7 1/4
PRE30E232 2 $0.00
Ob System Electric Hand, Grip Force, Qd 8e23.eq. 7 3/4
PRE30E233 2 $0.00
Ob System Electric Hand, Grip Force, Qd 8e23.eq. 8
PRE30E234 2 $0.00
Ob System Electric Hand, Grip Force, Wd 8e22.eq. 7 1/4
PRE30E229 2 $0.00
Ob System Electric Hand, Grip Force, Wd 8e22.eq. 7 3/4
PRE30E230 2 $0.00
Page: 17 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Other Externally Powered Components, Accessories & Control Systems
Ob System Electric Hand, Grip Force, Wd 8e22.eq. 8
PRE30E231 2 $0.00
Ob System Electric Hand, M12x1.5 8e12.eq. 6 3/4
PRE30E201 2 $0.00
Ob System Electric Hand, M12x1.5 8e12.eq. 7 1/4
PRE30E202 2 $0.00
Ob System Electric Hand, M12x1.5 8e12.eq. 7 3/4
PRE30E203 2 $0.00
Ob System Electric Hand, M12x1.5 8e14.eq. 6 3/4
PRE30E206 2 $0.00
Ob System Electric Hand, M12x1.5 8e14.eq. 7 1/4
PRE30E207 2 $0.00
Ob System Electric Hand, M12x1.5 8e14.eq. 7 3/4
PRE30E208 2 $0.00
Ob System Electric Hand, M12x1.5 8e14.eq. 8
PRE30E209 2 $0.00
Ob System Electric Hand, Qd 8e13.eq. 6 3/4
PRE30E204 2 $0.00
Ob System Electric Hand, Qd 8e13.eq. 7 1/4
PRE30E205 2 $0.00
Ob System Electric Hand, Qd 8e17.eq. 6 3/4
PRE30E221 2 $0.00
Ob System Electric Hand, Qd 8e17.eq. 7 1/4
PRE30E222 2 $0.00
Ob System Electric Hand, Qd 8e17.eq. 7 1/4 S
PRE30E223 2 $0.00
Ob System Electric Hand, Qd 8e17.eq. 7 3/4
PRE30E224 2 $0.00
Ob System Electric Hand, Qd 8e17.eq. 7 3/4 S
PRE30E225 2 $0.00
Ob System Electric Hand, Qd 8e17.eq. 8
PRE30E226 2 $0.00
Ob System Electric Hand, Qd 8e17.eq. 8 S
PRE30E227 2 $0.00
Ob System Electric Hand, Switch Control, Qd 8e37.eq. 7 3/4
PRE30E241 2 $0.00
Ob System Electric Hand, Wd 8e15.eq. 6 3/4
PRE30E210 2 $0.00
Page: 18 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Other Externally Powered Components, Accessories & Control Systems
Ob System Electric Hand, Wd 8e15.eq. 7 1/4 S
PRE30E211 2 $0.00
Ob System Electric Hand, Wd 8e15.eq. 7 3/4 S
PRE30E212 2 $0.00
Ob System Electric Hand, Wd 8e15.eq. 8 S
PRE30E213 2 $0.00
Ob System Electric Hand, Wd 8e16.eq. 6 3/4
PRE30E214 2 $0.00
Ob System Electric Hand, Wd 8e16.eq. 7 1/4
PRE30E215 2 $0.00
Ob System Electric Hand, Wd 8e16.eq. 7 1/4 S
PRE30E216 2 $0.00
Ob System Electric Hand, Wd 8e16.eq. 7 3/4
PRE30E217 2 $0.00
Ob System Electric Hand, Wd 8e16.eq. 7 3/4 S
PRE30E218 2 $0.00
Ob System Electric Hand, Wd 8e16.eq. 8
PRE30E219 2 $0.00
Ob System Electric Hand, Wd 8e16.eq. 8 S
PRE30E220 2 $0.00
Ob Wrist Rotation Unit 10s14 PRE31E204 2 $0.00
Production Gloves PRE30C100 2 $0.00
Remote Battery Mount Procedure On Triceps Cuff
PRE340070 2 $0.00
Remote Battery Mount Procedure On Waist Belt
PRE340071 2 $0.00
Shoulder Saddle PRE350005 2 $0.00
Standard Control Cable PRE350007 2 $0.00
Teflon Or Equal Cable Insert PRE350009 2 $0.00
Triceps Cuff Leather Non-Molded PRE350002 2 $0.00
Triceps Cuff Molded; Thermo, Leather Or Lamination
PRE350003 3 $0.00
Ual Alt-Seq Module PRE33E503 2 $0.00
Ual Cable Actuator PRE33E504 2 $0.00
Ual Mini Bridge PRE33E506 2 $0.00
Ual Pressure Pad Actuator PRE33E505 4 $0.00
Page: 19 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Other Externally Powered Components, Accessories & Control Systems
Ual Sd 1728-A Constant Speed Control System
PRE33E501 2 $0.00
Ual Variable Speed Control System Per Function
PRE33E502 2 $0.00
Vas Battery 12v, 220ma 99-01, 99-04, 99-05
PRE34E306 2 $0.00
Vas Battery 12v, 500ma 101-01 101-04, 101-05
PRE34E307 2 $0.00
Vas Battery 6v, 225ma 99-06 PRE34E301 2 $0.00
Vas Battery 6v, 225ma 99-07 PRE34E302 2 $0.00
Vas Battery 6v, 225ma 99-08 PRE34E303 2 $0.00
Vas Battery 6v, 450ma 99-09 PRE34E304 2 $0.00
Vas Battery 7.2v, 500ma 101-06, 101-07
PRE34E305 2 $0.00
Vas Battery Charger, Adjustable 99-10
PRE34E308 2 $0.00
Vas Electric Elbow 62 PRE32E312 2 $0.00
Vas Electric Elbow Model 62 PRE32E304 2 $0.00
Vas Lam Collar Short Vv 205-431a PRE31E304 2 $0.00
Vas Lam Collar Straight Vv 205-430 Small PRE31E302 2 $0.00
Vas Lam Collar Taper Vv 205-431 Large PRE31E303 2 $0.00
Vas Lamination Forearm Saddle 62-48
PRE32E306 2 $0.00
Vas Large Wrist Adaptor #205-431a PRE31E301 2 $0.00
Vas Modular Forearm Saddle 62-68
PRE32E307 2 $0.00
Vas Modular Forearm Saddle 62-69
PRE32E308 2 $0.00
Vas Myoelectric Control System 79vv81a
PRE33E301 2 $0.00
Vas Myoelectric Control System 79vv81ab
PRE33E302 2 $0.00
Vas Myoelectric Elbow 8-12a PRE32E301 2 $0.00
Vas Myoelectric Elbow 8-12b PRE32E302 2 $0.00
Vas Myoelectric Elbow 8-12c PRE32E303 2 $0.00
Page: 20 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Other Externally Powered Components, Accessories & Control Systems
Vas Myoelectric Elbow Vv 3-8a PRE32E309 2 $0.00
Vas Myoelectric Elbow Vv 3-8b PRE32E310 2 $0.00
Vas Myoelectric Elbow Vv 3-8c PRE32E311 2 $0.00
Vas Myoelectric Hand Avv03 PRE30E301 2 $0.00
Vas Myoelectric Hand Avv26 PRE30E302 2 $0.00
Vas Myoelectric Hand Avv59 PRE30E303 2 $0.00
Vas Myoelectric Hand Bvv03 PRE30E304 2 $0.00
Vas Myoelectric Hand Bvv26 PRE30E305 2 $0.00
Vas Myoelectric Hand Bvv59 PRE30E306 2 $0.00
Vas Myoelectric Hand Cvv03 PRE30E307 2 $0.00
Vas Myoelectric Hand Cvv26 PRE30E308 2 $0.00
Vas Myoelectric Hand Cvv59 PRE30E309 2 $0.00
Vas Myoelectric Hand Vv 0-3 A 1000 PRE30E311 2 $0.00
Vas Myoelectric Hand Vv 2-6 A 1000 PRE30E312 2 $0.00
Vas Myoelectric Hand Vv 5-9 A 1000 PRE30E313 2 $0.00
Vas Sm2-Sh Winchester Charger Connector PRE34E309 2 $0.00
Vas Swed Adaptor Vv 205-514 PRE31E307 2 $0.00
Vas Switch, 3-State Pull Control 127-00
PRE33E309 2 $0.00
Vas Switch, 3-State Push Button 190-00
PRE33E306 2 $0.00
Vas Switch, 3-State Push Button For Elbow 62-71
PRE33E308 2 $0.00
Vas Switch, 3-State Push Button With Cable 192-00
PRE33E307 2 $0.00
Vas Switch, Dual Push Button For Elbow 62-67
PRE33E305 2 $0.00
Vas Switch, Dual Push Button 117-00 PRE33E304 2 $0.00
Vas Switch, Single Push Button 42-00
PRE33E303 2 $0.00
Vas Turntable For Elbow 62-46 PRE32E305 2 $0.00
Vas V120 Adaptor Bock 9x18 Pull Switch / Elbow
PRE33E321 2 $0.00
Vas V121 Electrode Bock To PRE33E322 2 $0.00
Page: 21 of 22
Ministry of Health and Long-Term Care
Assistive Devices Program
Product Manual
Limb Prostheses (Externally Powered)
Effective Date: February 01, 2012
Externally Power Upper ExtremityDevice Type Device Device Code Max
Allowed Qty
Approved Price
Other Externally Powered Components, Accessories & Control Systems
Hand Control
Vas V124 Adaptor To Bock Qd PRE33E323 2 $0.00
Vas V131 Battery Mount, Ob Type PRE33E324 2 $0.00
Vas V620 Adaptor Bock-Bock Cable Converter
PRE33E310 2 $0.00
Vas V622 Vas-Bock Cable Converter PRE33E311 2 $0.00
Vas V812107 External Cable PRE33E312 2 $0.00
Vas V812108 External Cable 3" PRE33E313 2 $0.00
Vas V812110 External Cable 5" PRE33E314 2 $0.00
Vas V812112 Battery Cable Assembly PRE33E315 2 $0.00
Vas V812113 Battery Mount Assembly PRE33E316 2 $0.00
Vas V812118 Adaptor Cable For Electrodes / Elbow
PRE33E317 2 $0.00
Vas V812136 Motor Power Cable PRE33E318 2 $0.00
Vas V812141 On/Off Switch Connector PRE33E320 2 $0.00
Vas V812146 Y Cable PRE33E319 2 $0.00
Vas Wrist Assembly Vv 205-508 PRE31E305 2 $0.00
Vas Wrist Assembly Vv 205-509 PRE31E306 2 $0.00
Vas Wrist Disarticulation Vv 205-601 PRE31E308 2 $0.00
Vas/Unb Wrist Vv 205-602 PRE31E309 2 $0.00
Page: 22 of 22
