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S.

No Procedure Name
General Ward /
Sharing
single Room Deluxe Room/Ac Room
E.N.T
1 Adenoidectomy
2 Antral Wash/Puncture
3 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 Routine
35 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
S.No Procedure Name
General Ward /
Sharing
single Room Deluxe Room/Ac Room
42 Breast Lumpectomy
43 Simple Mastectomy
44 Thyroidectomy - Hemi
45 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 - Vaginal
54 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 Reconstruction
73 Laminectomy
74 Laminectomy & Discectomy
75 ORIF
TARIFF STATEMENT (PACKAGES
Name of the Hospital City
Provider Code State
S.No Procedure Name
General Ward /
Sharing
single 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
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 LFT
4 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