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S.No Procedure NameGeneral Ward /

Sharingsingle Room Deluxe Room/Ac Room

E.N.T

1 Adenoidectomy

2 Antral Wash/Puncture3 DNS Pepair

4 FESS

5 Mastoidectomy

6 Tympanoplasty

7 Tympanoplasty + Mastoidectomy

8 Septoplasty

9 Tonsillectomy

10 Tonsillectomy & Adenoidectomy

GENERAL SURGERY

11 Amputation Minor (Toes, Digits,Ray)12 Amputation above knee

13 Amputation below knee

14 Amputation above Elbow

15 Amputation below Elbow

16 Appendicectomy - open

17 Appendicectomy - Leparoscopic

18 Cholecystecomy - Open

19 Cholecystecomy - Leparoscopic

20 Circumcision

21 Fissure-Dialtion

22 Fistulectomy - Low

23 fistulectomy - High

24 Fissurectomy Sphincterotomy

25 Haemorrhoidectomy

26 Hernia - Simple

27 Hernia - Femoral / Inguinal Unilateral

28 Hernia - Femoral / Inguinal Bilateral

29 Hernia - Complicated

30 Herniorraphy

31 Incisional Hernia -Mesh Repair

32 Hernia - Laparoscopic

33 Laprotomy Emergency

34 Laprotomy Routine35 Lymph Node Biopsy -LA

36 Lymph Node Biopsy -GA

37 Lipoma LA

38 Lipoma GA

39 Perianal Abcess

40 Pilonidal Sinus

41 Radical Mastectomy Modified

TARIFF STATEMENT (PACKAGES

Name of the Hospital City

Provider Code State

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S.No Procedure NameGeneral Ward /

Sharingsingle Room Deluxe Room/Ac Room

42 Breast Lumpectomy

43 Simple Mastectomy

44 Thyroidectomy - Hemi45 Thyroidectomy - Total

46 Varicose Veins Stripping - Unilateral

47 Varicose Veins Stripping - Bilateral

OBSTETRICS & GYNECOLOGY

48 Caesarean Section

49 Delivery - Normal

50 Delivery - Forceps

51 Hysterectomy + BSO - Open

52 Hysterectomy + BSO - Laparoscopic

53 Hysterectomy - Vaginal54 Hysterectomy - LAVH / TLH

55 D & C

56 D & C with Hysteroscopy

OPTHALMOLOGY

57 Cataract - Phaco

58 Cataract Mulitifocal IOL

59 Cataract Unifocal

60 Cataract - Foldable Cataract Acrylic

ORTHOPAEDICS

61 Arthroscopy

62 Arthroscopic Surgery

63 Carpel Tunnel Release

64 Closed Reduction - Dislocation - Minor

65 Closed Reduction - Dislocation - Major

66 Implant Removal - Minor

67 Implant Removal - Major

68 Open Reduction - dislocation - Minor

69 Open Reduction - dislocation - Major

70 Internal Fixation of Fracture - Minor

71 Internal Fixation of Fracture - Major

72 Knee Ligament Reconstruction73 Laminectomy

74 Laminectomy & Discectomy

75 ORIF

TARIFF STATEMENT (PACKAGES

Name of the Hospital City

Provider Code State

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S.No Procedure NameGeneral Ward /

Sharingsingle Room Deluxe Room/Ac Room

76 Reduction of Fracture Under GA

77 Total Knee Replacement

78 Total Hip Replacement

UROLOGY & NEPHROLOGY

79 A V Fistula

80 A V Graft

81 Removal of Calculi

82 TURP

83 Hydrocelectomy Unilateral

84 Hydrocelectomy Bilateral

85 Vaticocelectomy

86 Lithotripsy - PCNL + Stenting

87 Lithotripsy - ESWL + Stenting

CARDIOLOGY

88 asd Closure

89 VSD Closure

90 CABG

91 Caoronary Angiogram

92 Angioplasty - PTCA

93 Permanent Pacemaker Implantaion

94 Heart Surgery - Open

95 Heart Surgery - Closed

2

3 For any other services no mentioned in this list, please attach additional sheets.

Name of the Designated Offical Signature & Seal of Designated Offical

Date :

Provider Code State

1. Please mention the tariff only for the services available in your hispotal.

The package charges are inclusive of Bed / Nursing/Hospital charges, Doctor's / Surgeion's Charges,

investigations, medicines & Consumables

Name of the Hospital City

TARIFF STATEMENT (PACKAGES

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S.No Service Name Rate S.No Service Name Rate

E. LAB CHARGES

1 General Ward 38 Complete Blood Picture

2 Semi Private Room 39 ESR

3 Single room 40 LFT4 AC Room 41 Thyroid Profile

5 Deluxe Room 42 Widal

6 ICU/ICCU/NICU/MICU per day 43 Malarial Parasites

7 NEONATAL ICU per day 44 Lipid Profile

8 Monitor charges 45 Cgrouping And Typing

9 Pluse Oxymeter charges 46 CUE

10 Syringe pump charges 47 Stool Examination

11 Infusiuon pump charges 48 Culture & Sensitivity

12 Nebuliser charges 49 Electrolytes

13 Nursing charges per day 50 ABG

14 Ventilator charges per hour / day 51 RBS

15 Consultant fee / Visit (specialist) 52 HIV I & II

16 Consultant fee / visit (Super specialist) 53 HBSAG

54 Urea Creatinine

17 Surgeon Charges for Major operation 55 CT/BT

18 Surgeon Charges for Minor operation 56 Montaux

19 Assistant Surgeon Fees 57 Blood Screening & Cross Matching

20 Anesthethist Surgeon fees G. OTHERS

21 Resident Doctor Charges/DMO 58 Endoscopy

22 Physiotherapy 59 Colonoscopy

23 First Consultation 60 ECG

24 subsequent Consultation 61 ECHO

25 Dressing Minor 62 TMT

26 Dressing Major 63 Dialysis

64 Blood Transfusion charges

27 OT Charges / Hour 65 Registration charges

28 N2O2 Charges / Hour 66 Ambulance

29 Anesthesia Charges

30 C Arm Charges

31 Microscope charge

32 Laproscope charge

33 CT Scan

34 USG

35 Mammography

36 MRI

37 X-Ray

B. Professional Charges

C. ot & RELATED CHARGES

D. RADIOLOGY CHARGES

TARIFF STATEMENT (PACKAGES

Name of the Hospital City

Provider Code State

A. Room/ICU/E Equipment/Nursing Charges