HBP-2 1

2.
Specialty Code Package Code AB PM - JAY Procedure Code AB PM - JAY

HBP 2.0 Specialty HBP 2.1 Package Name HBP 2.1 Procedure Name Procedure Price Stratification Implant Total Package Price
% Total Body Surface Area

Burns (TBSA) - any %
BM Burns Management BM001 Thermal burns BM001A 7,000 NA NA 7,000
(not requiring admission).
Needs at least 5-6 dressing

Burns (TBSA): Upto 40 %;
Includes % TBSA skin grafted,
flap cover, follow-up dressings
BM Burns Management BM001 Thermal burns BM001B etc. as deemed necessary; 40,000 NA NA 40,000
Surgical procedures are
required for deep burns that
are not amenable to heal with
dressings alone.

Burns (TBSA): 40% - 60 %;
BM Burns Management BM001 Thermal burns BM001C etc. as deemed necessary; 50,000 NA NA 50,000
dressings alone.

Burns (TBSA): > 60 %;
BM Burns Management BM001 Thermal burns BM001D etc. as deemed necessary; 80,000 NA NA 80,000
dressings alone.

BM Burns Management BM002 Scald burns BM002A 7,000 NA NA 7,000
Page 1
2.1


BM Burns Management BM002 Scald burns BM002B etc. as deemed necessary; 40,000 NA NA 40,000
dressings alone.

Burns (TBSA): 40% - 60 %;
BM Burns Management BM002 Scald burns BM002C etc. as deemed necessary; 50,000 NA NA 50,000
dressings alone.

BM Burns Management BM002 Scald burns BM002D etc. as deemed necessary; 80,000 NA NA 80,000
dressings alone.

BM Burns Management BM003 Flame burns BM003A 7,000 NA NA 7,000

BM Burns Management BM003 Flame burns BM003B etc. as deemed necessary; 40,000 NA NA 40,000
dressings alone.
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Burns (TBSA): 40 % - 60 %;
BM Burns Management BM003 Flame burns BM003C etc. as deemed necessary; 50,000 NA NA 50,000
dressings alone.

BM Burns Management BM003 Flame burns BM003D etc. as deemed necessary; 80,000 NA NA 80,000
dressings alone.
Electrical contact burns: Low

voltage - without part of limb /
limb loss; Includes % TBSA
skin grafted, flap cover, follow-
up dressings etc. as deemed
BM Burns Management BM004 Electrical contact burns BM004A 30,000 NA NA 30,000
necessary; Surgical
procedures are required for
deep burns that are not
amenable to heal with
dressings alone.
Electrical contact burns: Low

voltage - with part of limb /
BM Burns Management BM004 Electrical contact burns BM004B 40,000 NA NA 40,000
necessary; Surgical
dressings alone.
Electrical contact burns: High

voltage - with part of limb /
BM Burns Management BM004 Electrical contact burns BM004C 60,000 NA NA 60,000
necessary; Surgical
dressings alone.
Page 3
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Electrical contact burns: High

voltage - without part of limb /
BM Burns Management BM004 Electrical contact burns BM004D 50,000 NA NA 50,000
necessary; Surgical
dressings alone.
Chemical burns: Without

significant facial scarring
and/or loss of function;
BM Burns Management BM005 Chemical burns BM005A 40,000 NA NA 40,000
etc. as deemed necessary;
dressings alone.
Chemical burns: With

significant facial scarring
and/or loss of function;
BM Burns Management BM005 Chemical burns BM005B 60,000 NA NA 60,000
etc. as deemed necessary;
dressings alone.
Post Burn Contracture

surgeries for Functional
Improvement (Package
including splints, pressure
garments, silicone - gel sheet
and physiotherapy): Excluding
Neck contracture; Contracture
BM Burns Management BM006 surgeries for Functional BM006A 50,000 NA NA 50,000
release with - Split thickness
Improvement
Skin Graft (STSG) / Full
Thickness Skin Graft (FTSG) /
Flap cover is done for each
joint with post - operative
regular dressings for STSG /
FTSG / Flap cover.
surgeries for Functional
Improvement (Package
including splints, pressure
garments, silicone - gel sheet
and physiotherapy): Neck
contracture; Contracture
BM Burns Management BM006 surgeries for Functional BM006B 50,000 NA NA 50,000
release with - Split thickness
Improvement
Skin Graft (STSG) /
Full Thickness Skin Graft
(FTSG) / Flap cover is done
for each joint with post-
operative regular dressings for
STSG / FTSG / Flap cover.
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Laceration - Suturing / Laceration - Suturing /

ER Emergency ER001 ER001A 2,000 NA NA 2,000
Dressing Dressing
Emergency with stable

ER Emergency ER002 Cardiopulmonary emergency ER002A 2,000 NA NA 2,000
cardiopulmonary status
Emergency with unstable

ER Emergency ER002 Cardiopulmonary emergency ER002B cardiopulmonary status with 10,000 NA NA 10,000
resuccitation
Animal bites (Excluding Snake Animal bites (Excluding Snake

ER Emergency ER003 ER003A 1,700 NA NA 1,700
Bite) Bite)
Laboratory Tests for COVID- Laboratory Tests for COVID-

19 Infection (PCR) 19 Infection (PCR)
(Reimbursement level for this (Reimbursement level for this
ID Infectious Diseases ID001 ID001A 1500 NA NA 1500
package will be as per the package will be as per the
ICMR guidelines, issued from ICMR guidelines, issued from
time to time) time to time)
Page 5
2.1

Laboratory Tests for COVID- Laboratory Tests for COVID-

19 Infection (PCR) 19 Infection (PCR)
(Reimbursement level for this (Reimbursement level for this
ID Infectious Diseases ID001 ID001B 3000 NA NA 3000
package will be as per the package will be as per the
ICMR guidelines, issued from ICMR guidelines, issued from
time to time) time to time)
Routine Ward - 1800 Routine Ward - 1800

Treatment of COVID-19 Treatment of COVID-19 HDU - 2700 HDU - 2700
ID Infectious Diseases ID003 ID003A 1,800 NA
Infection Infection ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
ICU (with Ventilator) - 4500 ICU (with Ventilator) - 4500
Dural AVMs (per sitting) with

IN Interventional Neuroradiology IN001 Dural AVMs / AVFs IN001A 70,000 NA NA 70,000
glue
Dural AVFs (per sitting) with

IN Interventional Neuroradiology IN001 Dural AVMs / AVFs IN001B 70,000 NA NA 70,000
glue
Dural AVMs (per sitting) with

IN Interventional Neuroradiology IN001 Dural AVMs / AVFs IN001C 150,000 NA NA 150,000
onyx
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2.1

Dural AVFs (per sitting) with

IN Interventional Neuroradiology IN001 Dural AVMs / AVFs IN001D 150,000 NA NA 150,000
onyx
Cerebral & Spinal AVM Cerebral AVM embolization -

IN Interventional Neuroradiology IN002 embolization - Using IN002A Using Histoacryl 100,000 NA NA 100,000
Histoacryl (per sitting) (per sitting)
Cerebral & Spinal AVM Spinal AVM embolization -

IN Interventional Neuroradiology IN002 embolization - Using IN002B Using Histoacryl 100,000 NA NA 100,000
Histoacryl (per sitting) (per sitting)
Coil embolization for Coil embolization for

aneurysms aneurysms
IN Interventional Neuroradiology IN003 IN003A 100,000 NA 408,000 100000 - 500000
(includes cost of first 3 coils + (includes cost of first 3 coils +
balloon and / or stent if used) balloon and / or stent if used)
Carotico-cavernous Fistula
(CCF) embolization with coils.
Carotico-cavernous Fistula
IN Interventional Neuroradiology IN004 IN004A [includes 5 coils, guide 30,000 NA 120,000 150,000
(CCF) embolization
catheter, micro-catheter, micro-
guidewire, general items]
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Carotid-cavernous Fistula
(CCF) embolization with
Carotico-cavernous Fistula balloon
IN Interventional Neuroradiology IN004 IN004B 64,000 NA 11,000 75,000
(CCF) embolization (includes one balloon, guide
catheter, micro-catheter, micro-
guidewire, general items)
Pre-operative tumour Pre-operative tumour

IN Interventional Neuroradiology IN005 embolization IN005A embolization 40,000 NA NA 40,000
(per session) (per session)
Intracranial balloon Intracranial balloon

IN Interventional Neuroradiology IN006 IN006A 160,000 NA NA 160,000
angioplasty with stenting angioplasty with stenting
Intracranial thrombolysis / clot Intracranial thrombolysis / clot

retrieval retrieval
IN Interventional Neuroradiology IN008 Balloon test occlusion IN008A Balloon test occlusion 70,000 NA NA 70,000
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Parent vessel occlusion - Parent vessel occlusion -

Basic Basic
IN Interventional Neuroradiology IN010 Vertebroplasty IN010A Vertebroplasty 40,000 NA NA 40,000
Right / Left Heart

MC Cardiology MC001 MC001A Right Heart Catheterization 5,000 NA NA 5,000
Catheterization
Right / Left Heart

MC Cardiology MC001 MC001B Left Heart Catheterization 5,000 NA NA 5,000
Catheterization
Cardiology, Interventional Catheter directed For Deep vein thrombosis

MC MC002 MC002A 30,800 NA NA 30,800
Neuroradiology Thrombolysis (DVT)
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Cardiology, Interventional Catheter directed

MC MC002 MC002B For Mesenteric Thrombosis 30,800 NA NA 30,800
Neuroradiology Thrombolysis
Cardiology, Interventional Catheter directed

MC MC002 MC002C For Peripheral vessels 30,800 NA NA 30,800
Neuroradiology Thrombolysis
Cardiac Balloon - Adult -

14000 Adult - 52600
MC Cardiology MC003 Balloon Dilatation MC003A Coarctation of Aorta 38,600 NA
Cardiac Balloon - Pediatric - Pediatric - 71600
33000

14000 Adult - 52600
MC Cardiology MC003 Balloon Dilatation MC003B Pulmonary Artrey Stenosis 38,600 NA
Cardiac Balloon - Pediatric - Pediatric - 71600
33000

Balloon Pulmonary / Aortic 14000 Adult - 37400
MC Cardiology MC004 MC004A Balloon Pulmonary Valvotomy 23,400 NA
Valvotomy Cardiac Balloon - Pediatric - Pediatric - 56400
33000
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Balloon Pulmonary / Aortic 14000 Adult - 37400
MC Cardiology MC004 MC004B Balloon Aortic Valvotomy 23,400 NA
Valvotomy Cardiac Balloon - Pediatric - Pediatric - 56400
33000
MC Cardiology MC005 Balloon Mitral Valvotomy MC005A Balloon Mitral Valvotomy 35,700 NA Balloon & Accessories - 55000 90,700
MC Cardiology MC006 Balloon Atrial Septostomy MC006A Balloon Atrial Septostomy 24,400 NA NA 24,400
MC Cardiology MC007 ASD Device Closure MC007A ASD Device Closure 36,900 NA ASD Device - 62000 98,900
MC Cardiology MC008 VSD Device Closure MC008A VSD Device Closure 37,900 NA VSD Device - 72000 109,900
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2.1

MC Cardiology MC009 PDA Device Closure MC009A PDA Device Closure 25,000 NA PDA Device - 30000 55,000
Coronary Stent for PDA

stenting - Bare Metal - 8700 Bare Metal Stent - 48960
MC Cardiology MC010 PDA stenting MC010A PDA stenting 40,260 NA
Coronary Stent for PDA Drug Eluting Stent - 71860
stenting - Drug Eluting - 31600
Bare Metal Stent (1) - 49300

Bare Metal Stent (2) - 58000
Coronary Stent for PTCA - Bare Metal Stent (3) - 66700
PTCA, inclusive of diagnostic PTCA, inclusive of diagnostic Bare Metal - 8700 Drug Eluting Stent (1) - 72200
MC Cardiology MC011 MC011A 40,600 NA
angiogram angiogram Coronary Stent for PTCA - Drug Eluting Stent (2) -
Drug Eluting - 31600 103800
Drug Eluting Stent (3) -
135400
Implant for
"Electrophysiological Study"
MC Cardiology MC012 Electrophysiological Study MC012A Electrophysiological Study 20,000 NA includes - Steerable decapolar 66,000
catheter, Quadripolar Catheter
- 46000
Implant for
"Electrophysiological Study
with Radio Frequency
Electrophysiological Study
MC Cardiology MC012 Electrophysiological Study MC012B 20,000 NA Ablation" includes includes - 96,000
with Radio Frequency Ablation
Steerable decapolar catheter,
Quadripolar Catheter, Radio
Frequency Catheter - 76000
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Percutaneous Transluminal Percutaneous Transluminal

MC Cardiology MC013 MC013A 34,000 NA NA 34,000
Septal Myocardial Ablation Septal Myocardial Ablation
Temporary Pacemaker Temporary Pacemaker

MC Cardiology, CTVS MC014 MC014A 19,200 NA NA 19,200
implantation implantation
Permanent Pacemaker
Single Chamber Permanent Single Chamber Pacemaker -
MC Cardiology, CTVS MC015 MC015A Implantation - 24,500 NA 69,500
Pacemaker Implantation Rate Responsive - 45000
Single Chamber
Permanent Pacemaker
Double Chamber Permanent Double Chamber Pacemaker -
MC Cardiology, CTVS MC016 MC016A Implantation - 33,000 NA 108,000
Pacemaker Implantation Rate Responsive - 75000
Double Chamber
Peripheral Stent - Bare Metal -

MC Cardiology MC017 Peripheral Angioplasty MC017A Peripheral Angioplasty 34,500 NA 55,500
21000
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2.1

Bronchial artery Embolisation Bronchial artery Embolisation

(for Haemoptysis) (for Haemoptysis)
Cardiology,
MC MC019 Pericardiocentesis MC019A Pericardiocentesis 12,100 NA NA 12,100
General Surgery
Systemic Thrombolysis (for Systemic Thrombolysis (for

MI) MI)
Arteriovenous Malformation
MC Cardiology MC021 Embolization MC021A 40,600 TBF TBF TBF
(AVM) in the Limbs

General Medicine, Pediatric HDU - 2700 HDU - 2700
MG MG001 Acute febrile illness MG001A Acute febrile illness 1,800 NA
Medical Management ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
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MG MG002 Severe sepsis MG002A Severe sepsis 1,800 NA

MG MG002 Severe sepsis MG002B Septic shock 1,800 NA

MG MG003 Malaria MG003A Malaria 1,800 NA

MG MG003 Malaria MG003B Complicated malaria 1,800 NA

MG MG004 Dengue fever MG004A Dengue fever 1,800 NA
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2.1


MG MG004 Dengue fever MG004B Dengue hemorrhagic fever 1,800 NA

MG MG004 Dengue fever MG004C Dengue shock syndrome 1,800 NA

MG MG005 Chikungunya fever MG005A Chikungunya fever 1,800 NA

MG MG006 Enteric fever MG006A Enteric fever 1,800 NA

MG MG007 HIV with complications MG007A HIV with complications 1,800 NA
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MG MG008 Leptospirosis MG008A Leptospirosis 1,800 NA

General Medicine, Pediatric Acute gastroenteritis with Acute gastroenteritis with HDU - 2700 HDU - 2700
MG MG009 MG009A 1,800 NA
Medical Management dehydration moderate dehydration ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

General Medicine, Pediatric Acute gastroenteritis with Acute gastroenteritis with HDU - 2700 HDU - 2700
MG MG009 MG009B 1,800 NA
Medical Management dehydration severe dehydration ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

MG MG010 Diarrohea MG010A Chronic diarrohea 1,800 NA

MG MG010 Diarrohea MG010B Persistent diarrohea 1,800 NA
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MG MG011 Dysentery MG011A Dysentery 1,800 NA

MG MG012 Acute viral hepatitis MG012A Acute viral hepatitis 1,800 NA

MG MG013 Chronic Hepatitis MG013A Chronic Hepatitis 1,800 NA

MG MG014 Liver abscess MG014A Liver abscess 1,800 NA

MG MG015 Visceral leishmaniasis MG015A Visceral leishmaniasis 1,800 NA
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MG MG016 Pneumonia MG016A Pneumonia 1,800 NA

MG MG017 Severe pneumonia MG017A Severe pneumonia 1,800 NA

MG MG018 Empyema MG018A Empyema 1,800 NA

MG MG019 Lung abscess MG019A Lung abscess 1,800 NA

General Medicine, Pediatric Pericardial / Pleural HDU - 2700 HDU - 2700
MG MG020 MG020A Pericardial tuberculosis 1,800 NA
Medical Management tuberculosis ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Page 19
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General Medicine, Pediatric Pericardial / Pleural HDU - 2700 HDU - 2700
MG MG020 MG020B Pleural tuberculosis 1,800 NA
Medical Management tuberculosis ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

MG MG021 Urinary Tract Infection MG021A Urinary Tract Infection 1,800 NA

MG MG022 Viral encephalitis MG022A Viral encephalitis 1,800 NA

MG MG023 Septic Arthritis MG023A Septic Arthritis 1,800 NA

MG MG024 Skin and soft tissue infections MG024A Skin and soft tissue infections 1,800 NA
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General Medicine, Pediatric Recurrent vomiting with Recurrent vomiting with HDU - 2700 HDU - 2700
MG MG025 MG025A 1,800 NA
Medical Management dehydration dehydration ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

MG MG026 Pyrexia of unknown origin MG026A Pyrexia of unknown origin 1,800 NA

HDU - 2700 HDU - 2700
MG General Medicine MG027 Bronchiectasis MG027A Bronchiectasis 1,800 NA
ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

MG MG028 Acute bronchitis MG028A Acute bronchitis 1,800 NA

HDU - 2700 HDU - 2700
MG General Medicine MG029 Acute excaberation of COPD MG029A Acute excaberation of COPD 1,800 NA
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General Medicine, Pediatric Acute excaberation of Acute excaberation of HDU - 2700 HDU - 2700
MG MG030 MG030A 1,800 NA
Medical Management Interstitial Lung Disease Interstitial Lung Disease ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

MG MG031 Endocarditis MG031A Bacterial Endocarditis 1,800 NA

MG MG031 Endocarditis MG031B Fungal Endocarditis 1,800 NA

MG MG032 Vasculitis MG032A Vasculitis 1,800 NA

MG MG033 Pancreatitis MG033A Acute pancreatitis 1,800 NA
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MG MG033 Pancreatitis MG033B Chronic pancreatitis 1,800 NA

MG MG034 Ascites MG034A Ascites 1,800 NA

MG MG035 Acute transverse myelitis MG035A Acute transverse myelitis 1,800 NA

MG MG036 Atrial Fibrillation MG036A Atrial Fibrillation 1,800 NA

HDU - 2700 HDU - 2700
MG General Medicine MG037 Cardiac Tamponade MG037A Cardiac Tamponade 1,800 NA
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MG MG038 Congestive heart failure MG038A Congestive heart failure 1,800 NA

MG MG039 Asthma MG039A Acute asthmatic attack 1,800 NA

MG MG039 Asthma MG039B Status asthmaticus 1,800 NA

MG MG040 Respiratory failure MG040A Type 1 respiratory failure 1,800 NA

MG MG040 Respiratory failure MG040B Type 2 respiratory failure 1,800 NA
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2.1

Due to any cause (pneumonia, Routine Ward - 1800 Routine Ward - 1800
General Medicine, Pediatric asthma, COPD, ARDS, foreign HDU - 2700 HDU - 2700
MG MG040 Respiratory failure MG040C 1,800 NA
Medical Management body, poisoning, head injury ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
etc.) ICU (with Ventilator) - 4500 ICU (with Ventilator) - 4500

General Medicine, Pediatric Upper GI bleeding HDU - 2700 HDU - 2700
MG MG041 Upper GI bleeding MG041A 1,800 NA
Medical Management (conservative) ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

General Medicine, Pediatric Upper GI bleeding HDU - 2700 HDU - 2700
MG MG041 Upper GI bleeding MG041B 1,800 NA
Medical Management (endoscopic) ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

MG MG042 Lower GI hemorrhage MG042A Lower GI hemorrhage 1,800 NA

MG MG043 Addison’s disease MG043A Addison’s disease 1,800 NA
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2.1


HDU - 2700 HDU - 2700
MG General Medicine MG044 Renal colic MG044A Renal colic 1,800 NA

MG MG045 AKI / Renal failure MG045A AKI / Renal failure 1,800 NA

MG MG046 Seizures MG046A Seizures 1,800 NA

MG MG047 Status epilepticus MG047A Status epilepticus 1,800 NA

HDU - 2700 HDU - 2700
MG General Medicine MG048 Cerebrovascular accident MG048A Cerebrovascular accident 1,800 NA
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2.1


Cerebral sino-venous Cerebral sino-venous HDU - 2700 HDU - 2700
MG General Medicine MG049 MG049A 1,800 NA
thrombosis / Stroke thrombosis ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

Cerebral sino-venous HDU - 2700 HDU - 2700
MG General Medicine MG049 MG049B Acute stroke 1,800 NA
thrombosis / Stroke ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

MG General Medicine MG049 MG049C Acute ischemic stroke 1,800 NA

MG General Medicine MG049 MG049D Acute heamorrhagic stroke 1,800 NA

General Medicine, Pediatric Immune mediated CNS Immune mediated CNS HDU - 2700 HDU - 2700
MG MG050 MG050A 1,800 NA
Medical Management disorders disorders ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
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2.1


MG MG051 Hydrocephalus MG051A Hydrocephalus 1,800 NA

MG MG052 Myxedema coma MG052A Myxedema coma 1,800 NA

MG MG053 Thyrotoxic crisis MG053A Thyrotoxic crisis 1,800 NA

HDU - 2700 HDU - 2700
MG General Medicine MG054 Gout MG054A Gout 1,800 NA

MG MG055 Pneumothroax MG055A Pneumothroax 1,800 NA
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2.1


MG MG056 Neuromuscular disorders MG056A Neuromuscular disorders 1,800 NA

MG MG057 Hypoglycemia MG057A Hypoglycemia 1,800 NA

HDU - 2700 HDU - 2700
MG General Medicine MG058 Diabetic Foot MG058A Diabetic Foot 1,800 NA

MG MG059 Diabetic ketoacidosis MG059A Diabetic ketoacidosis 1,800 NA

MG MG060 Electrolyte Imbalance MG060A Hypercalcemia 1,800 NA
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2.1


MG MG060 Electrolyte Imbalance MG060B Hypocalcemia 1,800 NA

MG MG060 Electrolyte Imbalance MG060C Hyponatremia 1,800 NA

MG MG060 Electrolyte Imbalance MG060D Hypernatremia 1,800 NA
MG General Medicine MG060 Electrolyte Imbalance MG060E Hyperkalaemia - TBF TBF TBF
MG General Medicine MG060 Electrolyte Imbalance MG060F Hypokalaemia - TBF TBF TBF
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General Medicine, Pediatric Hyperosmolar Non-Ketotic Hyperosmolar Non-Ketotic HDU - 2700 HDU - 2700
MG MG061 MG061A 1,800 NA
Medical Management coma coma ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

MG MG062 Accelerated hypertension MG062A Accelerated hypertension 1,800 NA

MG MG063 Hypertensive emergencies MG063A Hypertensive emergencies 1,800 NA

MG MG064 Severe anemia MG064A Severe anemia 1,800 NA

MG MG065 Sickle cell Anemia MG065A Sickle cell Anemia 1,800 NA
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MG MG066 Anaphylaxis MG066A Anaphylaxis 1,800 NA

MG MG067 Heat stroke MG067A Heat stroke 1,800 NA

General Medicine, Pediatric Systematic lupus Systematic lupus HDU - 2700 HDU - 2700
MG MG068 MG068A 1,800 NA
Medical Management erythematosus erythematosus ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

MG MG069 Guillian Barre Syndrome MG069A Guillian Barre Syndrome 1,800 NA

MG MG070 Snake bite MG070A Snake bite 1,800 NA
Page 32
2.1


General Medicine, Pediatric Acute organophosphorus HDU - 2700 HDU - 2700
MG MG071 Poisoning MG071A 1,800 NA
Medical Management poisoning ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

MG MG071 Poisoning MG071B Other poisonings 1,800 NA
Haemodialysis / Peritoneal
MG General Medicine MG072 MG072A Haemodialysis 1,500 NA NA 1,500
Dialysis
Haemodialysis / Peritoneal
MG General Medicine MG072 MG072B Peritoneal Dialysis 1,500 NA NA 1,500
Dialysis
General Medicine, Pediatric

MG MG073 Plasmapheresis MG073A Plasmapheresis 2,000 NA NA 2,000
Medical Management
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2.1


MG MG074 Blood transfusion MG074A Whole Blood transfusion 2,000 NA NA 2,000
Medical Management
Blood component including

MG MG074 Blood transfusion MG074B platelet transfusion (RDP, PC, 2,000 NA NA 2,000
Medical Management
SDP)
High end radiological High end radiological

diagnostic diagnostic
MG Medical Management, MG075 MG075A 5,000 NA NA 5,000
(CT, MRI, Imaging including (CT, MRI, Imaging including
Cardiology
nuclear imaging) nuclear imaging)
General Medicine, Pediatric High end histopathology High end histopathology

MG Medical Management, MG076 (Biopsies) and advanced MG076A (Biopsies) and advanced 5,000 NA NA 5,000
Cardiology serology investigations serology investigations
MG General Medicine MG077 CRRTCVVHDF MG077A Initiation cost for disposable 35,000 TBF TBF TBF
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2.1

MG General Medicine MG078 Alcoholic Liver Disease MG078A Alcoholic Liver Disease - TBF TBF TBF
MG General Medicine MG079 Peripheral Arterial Thrombosis MG079A Peripheral Arterial Thrombosis - TBF TBF TBF
MG General Medicine MG081 IHD / CAD / Arrhythmia MG081A Arrhythmia - TBF TBF TBF
MG General Medicine MG081 IHD / CAD / Arrhythmia MG081B CAD - TBF TBF TBF

MM Mental Disorders MM001 Mental Retardation MM001A Mental Retardation 1,500 NA
HDU - 2500 HDU - 2500
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2.1

Mental disorders - Organic, Mental disorders - Organic, Routine Ward - 1500 Routine Ward - 1500
MM Mental Disorders MM002 MM002A 1,500 NA
including symptomatic including symptomatic HDU - 2500 HDU - 2500
Schizophrenia, schizotypal Schizophrenia, schizotypal Routine Ward - 1500 Routine Ward - 1500
and delusional disorders and delusional disorders HDU - 2500 HDU - 2500
Neurotic, stress-related and Neurotic, stress-related and Routine Ward - 1500 Routine Ward - 1500
somatoform disorders somatoform disorders HDU - 2500 HDU - 2500

MM Mental Disorders MM005 Mood (affective) disorders MM005A Mood (affective) disorders 1,500 NA
HDU - 2500 HDU - 2500
Behavioural syndromes Behavioural syndromes

associated with physiological associated with physiological Routine Ward - 1500 Routine Ward - 1500
disturbances and physical disturbances and physical HDU - 2500 HDU - 2500
factors factors
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2.1

Mental and Behavioural Mental and Behavioural

MM Mental Disorders MM007 disorders due to psychoactive MM007A disorders due to psychoactive 1,500 NA
HDU - 2500 HDU - 2500
substance use substance use
Pre - Electro Convulsive Pre - Electro Convulsive

Therapy (ECT) and Pre - Therapy (ECT) and Pre -
Transcranial Magnetic Transcranial Magnetic
Stimulation (TMS) Package Stimulation (TMS) Package
(Cognitive Tests, Complete (Cognitive Tests, Complete
Haemogram, Liver Function Haemogram, Liver Function
Test, Renal Function Test, Test, Renal Function Test,
MM Mental Disorders MM008 MM008A 10,000 NA NA 10,000
Serum Electrolytes, Electro Serum Electrolytes, Electro
Cardiogram (ECG), CT / MRI Cardiogram (ECG), CT / MRI
Brain, Electroencephalogram, Brain, Electroencephalogram,
Thyroid Function Test, VDRL, Thyroid Function Test, VDRL,
HIV Test, Vitamin B12 levels, HIV Test, Vitamin B12 levels,
Folate levels, Lipid Profile, Folate levels, Lipid Profile,
Homocysteine levels) Homocysteine levels)
Electro Convulsive Therapy Electro Convulsive Therapy

MM Mental Disorders MM009 MM009A 3,000 NA NA 3,000
(ECT) - per session (ECT) - per session
Transcranial Magnetic Transcranial Magnetic

MM Mental Disorders MM010 Stimulation (TMS) - per MM010A Stimulation (TMS) - per 1,000 NA NA 1,000
session session
Basic neonatal care package: Basic neonatal care package:

Babies that can be managed Babies that can be managed
by side of mother in postnatal by side of mother in postnatal
ward without requiring ward without requiring
admission in SNCU/NICU: admission in SNCU/NICU:
• Any newborn needing • Any newborn needing
feeding support feeding support
MN Neo - natal Care MN001 • Babies requiring closer MN001A • Babies requiring closer 500 Routine Ward - 500 NA Routine Ward - 500
monitoring or short-term care monitoring or short-term care
for conditions like: for conditions like:
o Birth asphyxia (need for o Birth asphyxia (need for
positive pressure ventilation; positive pressure ventilation;
no HIE) no HIE)
o Moderate jaundice requiring o Moderate jaundice requiring
phototherapy phototherapy
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2.1

Special Neonatal Care Special Neonatal Care
Package: Babies that required Package: Babies that required
admission to SNCU or NICU: admission to SNCU or NICU:
Babies admitted for short term Babies admitted for short term
care for conditions like: care for conditions like:
• Mild Respiratory • Mild Respiratory
Distress/tachypnea Distress/tachypnea
MN Neo - natal Care MN002 • Mild encephalopathy MN002A • Mild encephalopathy 3,000 SNCU / NICU - 3000 NA SNCU / NICU - 3000
• Severe jaundice requiring • Severe jaundice requiring
intensive phototherapy intensive phototherapy
• Haemorrhagic disease of • Haemorrhagic disease of
newborn newborn
• Unwell baby requiring • Unwell baby requiring
monitoring monitoring
• Some dehydration • Some dehydration
Intensive Neonatal Care Intensive Neonatal Care
Package Package
Babies with birthweight 1500- Babies with birthweight 1500-
1799 g 1799 g
or or
Babies of any birthweight and Babies of any birthweight and
at least one of the following at least one of the following
MN Neo - natal Care MN003 conditions: MN003A conditions: 5,000 SNCU / NICU - 5000 NA SNCU / NICU - 5000
• Need for mechanical • Need for mechanical
ventilation for less than 24 ventilation for less than 24
hours or non-invasive hours or non-invasive
respiratory support (CPAP, respiratory support (CPAP,
HFFNC) HFFNC)
• Sepsis / pneumonia without • Sepsis / pneumonia without
complications complications
Advanced Neonatal Care Advanced Neonatal Care
Package: Package:
Babies with birthweight of Babies with birthweight of
1200-1499 g 1200-1499 g
or or
Babies of any birthweight with Babies of any birthweight with
• Any condition requiring • Any condition requiring
invasive ventilation longer invasive ventilation longer
than 24 hours than 24 hours
• Hypoxic Ischemic • Hypoxic Ischemic
encephalopathy requiring encephalopathy requiring
Therapeutic Hypothermia Therapeutic Hypothermia
• Cardiac rhythm disorders • Cardiac rhythm disorders
Critical Care Neonatal Critical Care Neonatal
Package: Package:
Babies with birthweight of Babies with birthweight of
<1200 g <1200 g
or or
Babies of any birthweight with Babies of any birthweight with
• Severe Respiratory Failure • Severe Respiratory Failure
requiring High Frequency requiring High Frequency
Ventilation or inhaled Nitric Ventilation or inhaled Nitric
Oxide (iNO) Oxide (iNO)
• Multisystem failure requiring • Multisystem failure requiring
multiple organ support multiple organ support
including mechanical including mechanical
Chronic Care Package: If the Chronic Care Package: If the

baby requires stay beyond the baby requires stay beyond the
upper limit of usual stay in upper limit of usual stay in
Package no MN004A or Package no MN004A or
MN Neo - natal Care MN006 MN005A for conditions like MN006A MN005A for conditions like 3,000 SNCU / NICU - 3000 NA SNCU / NICU - 3000
severe BPD requiring severe BPD requiring
respiratory support, severe respiratory support, severe
NEC requiring prolonged TPN NEC requiring prolonged TPN
support support
Page 38
2.1

High Risk Newborn Post High Risk Newborn Post

MN Neo - natal Care MN007 Discharge Care Package MN007A Discharge Care Package 2,400 NA NA 2,400
(Protocol Driven) (Protocol Driven)
Laser Therapy for Retinopathy Laser Therapy for Retinopathy

of Prematurity (Irrespective of of Prematurity
MN Neo - natal Care MN008 MN008A 1,500 NA NA 1,500
no. of eyes affected) - per (Irrespective of no. of eyes
session affected) - per session
Advanced Surgery for Advanced Surgery for

Retinopathy of Prematurity Retinopathy of Prematurity
Ventriculoperitoneal Shunt Ventriculoperitoneal Shunt

Surgery (VP) or Omaya Surgery (VP) or Omaya
Reservoir or External Drainage Reservoir or External Drainage
for Hydrocephalus for Hydrocephalus
Cyclophosphamide +
Epirubcin
Cyclophosphamide - 830 mg
MO Medical Oncology MO001 CT for CA Breast MO001A 7,200 NA NA 7,200
/m2 D1
Epirubicin -100mg/m2 D1
every 21 days
Page 39
2.1

Weekly Paclitaxel for Adjuvant

Therapy
MO Medical Oncology MO001 CT for CA Breast MO001B 5,800 NA NA 5,800
Paclitaxel 80mg/m2 every
week
Weekly Paclitaxel in
metastatic setting
MO Medical Oncology MO001 CT for CA Breast MO001C 5,800 NA NA 5,800
Paclitaxel 80mg/m2 every
week
Cyclophosphamide +
Methotrexate + 5 - FU
Cyclophosphamide -
MO Medical Oncology MO001 CT for CA Breast MO001D 100mg/m2 orally D1-D14 3,200 NA NA 3,200
Methotrexate 40mg/m2 IV D1
D8 5FU 600 mg/m2 D1, D8
every 28 days
Docetaxel +
Cyclophosphamide
MO Medical Oncology MO001 CT for CA Breast MO001E Docetaxel 75mg/m2 D1 19,800 NA NA 19,800
Cyclophosphamide 600
mg/m2 D1 every 21 days
Trastuzumab
Trastuzumab 8 mg/Kg in Cycle
MO Medical Oncology MO001 CT for CA Breast MO001F 1 D1 21,200 NA NA 21,200
Trastuzumab 6 mg/kg D1 from
C2 every 21 days
Page 40
2.1

Tamoxifen
MO Medical Oncology MO001 CT for CA Breast MO001G 1,200 NA NA 1,200
Tamoxifem 20 mg orally daily
Letrozole
MO Medical Oncology MO001 CT for CA Breast MO001H 3,900 NA NA 3,900
Letrozole 2.5 mg orally daily
Carboplatin + Paclitaxel
Paclitaxel 175mg/m2 D1
MO Medical Oncology MO001 CT for CA Breast MO001I 14,900 NA NA 14,900
Carboplatin AUC 5-6 D1 every
21 days
Capecitabine
Capecitabine - 1000mg/m2
MO Medical Oncology MO001 CT for CA Breast MO001J 7,400 NA NA 7,400
orally twice daily D1-D14
every 21 days
Carboplatin + Gemcitabine
Gemcitabine - 1000mg/m2 D1
D8
MO Medical Oncology MO001 CT for CA Breast MO001K Carboplatin AUC 2 D1 D8 13,900 NA NA 13,900
D8
Carboplatin AUC 5-6 D1 only
Page 41
2.1

Cyclophosphamide +
Adriamycin
Cyclophosphamide - 600 mg
MO Medical Oncology MO001 CT for CA Breast MO001L 4,500 NA NA 4,500
/m2 D1
Adriamycin - 60mg/m2 D1
every 21 days
Fulvestrant
MO Medical Oncology MO001 CT for CA Breast MO001M Fulvestrant 500 mg D1 D15 11,000 NA NA 11,000
D28 then every 28 days
Paclitaxel
MO Medical Oncology MO001 CT for CA Breast MO001N Paclitaxel 175 mg/m2 D1 11,800 NA NA 11,800
every 21 days
Exemestane
MO Medical Oncology MO001 CT for CA Breast MO001O 10,400 NA NA 10,400
Exemestane 25 mg orally daily
CT for Metastatic bone Zoledronic Acid

MO Medical Oncology MO002 malignancy and multiple MO002A Zoledronic acid 4 mg IV 4,500 NA NA 4,500
myeloma Monthly
Page 42
2.1

Cisplatin + Irinotecan
Cisplatin 60mg/m2 D1
MO Medical Oncology MO003 CT for CA Ovary MO003A 10,200 NA NA 10,200
Irinotecan 60 mg/m2 D1 D8
D15 every 28 days
Lipodox + Carboplatin
Lipopdox 30 mg/m2 D1
MO Medical Oncology MO003 CT for CA Ovary MO003B 17,200 NA NA 17,200
28 days
Etoposide
MO Medical Oncology MO003 CT for CA Ovary MO003C Etoposide 50 mg/m2 OD D1- 3,400 NA NA 3,400
D14 every 21 days
Irinotecan
MO Medical Oncology MO003 CT for CA Ovary MO003D Irinotecan 60 -90 mg/m2 D1 8,400 NA NA 8,400
D8 every 21 days
Lipodox
MO Medical Oncology MO003 CT for CA Ovary MO003E Lipodox 40 mg/m2 IV every 28 14,800 NA NA 14,800
days
Page 43
2.1

D8
MO Medical Oncology MO003 CT for CA Ovary MO003F Carboplatin AUC 2 D1 D8 13,900 NA NA 13,900
D8
Carboplatin AUC 5-6 D1 only
MO Medical Oncology MO003 CT for CA Ovary MO003G 14,700 NA NA 14,700
21 days
Carboplatin (AUC 7)
MO Medical Oncology MO004 CT for Germ Cell Tumor MO004A Carboplatin AUC 7 every 21 5,800 NA NA 5,800
days
Bleomycin + Etoposide +
Cisplatin
Bleomycin 30 units D1 D8 D15
MO Medical Oncology MO004 CT for Germ Cell Tumor MO004B 11,600 NA NA 11,600
Cisplatin 20 mg/m2 IV D1-D5
Etoposide 100mg/m2 D1-D5
every 21 days
Etoposide + Cisplatin
Cisplatin 20 mg/m2 IV D1-D5
MO Medical Oncology MO004 CT for Germ Cell Tumor MO004C 10,000 NA NA 10,000
Etoposide 100mg/m2 D1-D5
every 21 days
Page 44
2.1

Gemcitabine + Oxaliplatin
Gemcitabine 1000mg/m2 D1
MO Medical Oncology MO004 CT for Germ Cell Tumor MO004D D8 17,500 NA NA 17,500
Oxaiplatin 130mg/m2 D1
every 21 days
Gemcitabine + Paclitaxel
MO Medical Oncology MO004 CT for Germ Cell Tumor MO004E D8 D15 17,500 NA NA 17,500
Paclitaxel 100 mg/m2 D1 D8
D15 every 28 days
Paclitaxel + Ifosfamide +
Cisplatin
Paclitaxel 240 mg/m2 D1
Ifosfamide 1500mg/m2 D2-D5
MO Medical Oncology MO004 CT for Germ Cell Tumor MO004F 24,400 NA NA 24,400
Mesna 300 mg/m2 0h 4h 8h
D2-D5
Cisplatin 25mg/m2 D2-D5
every 21 days
Vinblastin + Ifosfamide +
Cisplatin
Vinblastine 0.11 mg/kg IV D1-
D2
MO Medical Oncology MO004 CT for Germ Cell Tumor MO004G Mesna 240mg/m2 0h 4h 8h 12,600 NA NA 12,600
D1-D5
Ifosfamide 1200mg/m2 D1-D5
Cisplatin 20 mg/m2 D1-D5
every 21 days
Etoposide + Methotrexate +
Dactinomycin-
Cyclophosphamide +
Vincristine
Etoposide 100mg/m2 IV D1
D2
Dactinomycin 0.5 mg IV push
CT for Gestational
MO Medical Oncology MO005 MO005A D1 D2 11,400 NA NA 11,400
Trophoblastic Neoplasia
Methotrexate 300 mg /m2 D1
Leucovorin 15 mg PO every
12 hrs for 4 doses
Cyclophosphamide 600mg/m2
D8
Vincrstine 1 mg/m2 D8 every 2
weeks
Page 45
2.1

Etoposide + Methotrexate +
Dactinomycin + Cisplatin
Etoposide 100mg/m2 IV D1
D2 D8
CT for Gestational Dactinomycin 0.5 mg IV push
MO Medical Oncology MO005 MO005B 12,200 NA NA 12,200
Trophoblastic Neoplasia D1 D2 Methotrexate 300 mg
/m2 D1
Leucovorin 15 mg PO every
12 hrs for 4 doses Cisplatin
75mg/m2 D8 every 2 weeks
Methotrexate
Methotrexate 1/mg/kg IM
every other day x 4 days D1 3
CT for Gestational D5 D7
MO Medical Oncology MO005 MO005C 1,100 NA NA 1,100
Trophoblastic Neoplasia Alternating every other day
with
Leucovorin 15 mg PO repeat
every 14 days
MO Medical Oncology MO006 CT for Cervical Cancer MO006A 14,900 NA NA 14,900
21 days
Cisplatin
MO Medical Oncology MO006 CT for Cervical Cancer MO006B Cisplatin 40 mg/m2 every 2,200 NA NA 2,200
week
MO Medical Oncology MO007 CT for Endometrial Cancer MO007A 14,900 NA NA 14,900
21 days
Page 46
2.1

Cisplatin + Doxorubicin
Doxorubicin 60 mg/m2 D1
MO Medical Oncology MO007 CT for Endometrial Cancer MO007B 4,200 NA NA 4,200
Cisplatin 50mg/m2 every 3
weeks
Cisplatin + 5 FU
5 FU 1000mg/m2 D1-D4
MO Medical Oncology MO008 CT for Vulvar Cancer MO008A 7,600 NA NA 7,600
Cisplatin 75mg/m2 D1 every 4
weeks
Cisplatin
MO Medical Oncology MO008 CT for Vulvar Cancer MO008B Cisplatin 40 mg/m2 every 2,200 NA NA 2,200
week
Vincristine + Topotecan +
Cyclophosphamide +
Irinotecan + Temozolamide
Vincristine 1.5mg/m2( day 1)
Topotecan 1.5mg/m2 (day 1-
5)
MO Medical Oncology MO009 CT for Ewing Sarcoma MO009A 22,400 NA NA 22,400
(days 1-5)
Given every 3 weeks
Irinotecan 10-50 mg/sqM days
1-5 and days 8-12
Temozolamide 100mg/m2
days 1-5 of each cycle every
3 weeks
Vincristine + Ifosfamide +
Etoposide
Vincristine + Doxorubicin +
Cyclophosphamide
Vincristine +
Cyclophosphamide +
Dactinomycin.
MO Medical Oncology MO009 CT for Ewing Sarcoma MO009B 4 cycles VIE, 6 cycles VAC, 4 9,700 NA NA 9,700
cycles VCD
Vincristine 1.5mg/m2 (day 1, 8
and 15)
Ifosfamide: 1800mg/m2
(days1-5)
Etposide: 100mg/sq.m (days 1-
5)
Page 47
2.1

Vincristine + Adriamycin +
Cyclophosphamide
Ifosfamide + Etoposide
Ifosfamide: 1800mg/m2
(days1-5)
Etposide: 100mg/sq.m (days 1-
5)
MO Medical Oncology MO009 CT for Ewing Sarcoma MO009C 12,500 NA NA 12,500
Given every 2-3 weekly
Vincristine 1.5mg/m2 (day 1
and 8)
Adriamyicn: 75mg/m2 (day 1)
Cyclophosphamide
1200mg/m2 (day 1)
Given 2-3 weekly
Doxorubicin + Cisplatin
Cisplatin 100mg/m2
MO Medical Oncology MO010 CT for Osteogenic Sarcoma MO010A 21,800 NA NA 21,800
Doxorubicin 75mg/m2 given
every 3 weeks
Methotrexate + Doxorubicin +
Cisplatin for Relapsed
Osteogenic Sarcoma
MO Medical Oncology MO010 CT for Osteogenic Sarcoma MO010B Cisplatin 120mg/sq.m 27,000 NA NA 27,000
Doxorubicin 75mg/m2
Methotrexate 8-12 gram/m2
Each cycle for 5 weeks
OGS - 12
Ifosfamide 1800 mg/m2 D1-
D5
Mesna 600mg/m2 0h 3h 6h 9h
MO Medical Oncology MO010 CT for Osteogenic Sarcoma MO010C 29,600 NA NA 29,600
D1-D5
Adriamycin 25mg/m2 D1- D3
every 21 days
OGS - 12
Ifosfamide 1800 mg/m2 D1-
D5
MO Medical Oncology MO010 CT for Osteogenic Sarcoma MO010D Mesna 600mg/m2 0h 3h 6h 9h 36,200 NA NA 36,200
D1-D5
every 21 days
Page 48
2.1

Gemcitabine + Docetaxel
Gemcitabine 900 mg/m2 D1
MO Medical Oncology MO011 CT for Soft Tissue Sarcoma MO011A D8 30,900 NA NA 30,900
Docetaxel 100 mg/m2 D8
every 21 days
Ifosfamide + Adriamycin
Doxorubicin 30mg/m2 D1 D2
Ifosfamide 2000 to
MO Medical Oncology MO011 CT for Soft Tissue Sarcoma MO011B 3000mg/m2 13,700 NA NA 13,700
Mesna 400 to 600 mg/m2 0h
4h 8h D1 - D3
Every 21 days
Dacarbazine + Cisplatin
Dacarbazine 250mg/m2 D1-
MO Medical Oncology MO012 CT for Metastatic Melanoma MO012A D5 7,100 NA NA 7,100
Cisplatin 75 mg/m2 Every 21
days
Temozolamide
MO Medical Oncology MO012 CT for Metastatic Melanoma MO012B Temozolamide 200mg/m2 D1- 23,100 NA NA 23,100
D5 every 28 days
5 FU + Mitomycin C
5 FU 1000mg/m2 D1-D4 D29-
MO Medical Oncology MO013 CT for Anal Cancer MO013A 10,500 NA NA 10,500
D32
Mitomycin 10mg/m2 D1
Page 49
2.1

Capecitabine + Mitomycin C
Capecitabine 825mg/m2 PO
MO Medical Oncology MO013 CT for Anal Cancer MO013B twice daily till completion of 13,800 NA NA 13,800
RT
Mitomycin 10mg/2 D1
Cisplatin + 5 FU
5 FU 1000mg/m2 D1-D4
MO Medical Oncology MO013 CT for Anal Cancer MO013C 7,600 NA NA 7,600
weeks
MO Medical Oncology MO013 CT for Anal Cancer MO013D 14,900 NA NA 14,900
21 days
Cisplatin + Paclitaxel
MO Medical Oncology MO013 CT for Anal Cancer MO013E 13,300 NA NA 13,300
Cisplatin 75mg/m2 D1 every
21 days
5 FU + Leucovorin
5 FU 1200mg/m2 D1 D2
MO Medical Oncology MO014 CT for Colorectal Cancer MO014A 4,700 NA NA 4,700
Leucovorin 400mg/m2 D1
every 14 days
Page 50
2.1

Capecitabine + Irinotecan
Capecitabine 1000mg/m2 D1-
MO Medical Oncology MO014 CT for Colorectal Cancer MO014B D14 12,500 NA NA 12,500
Irinotecan 200 mg/m2 D1
every 21 days
5 FU + Leucovorin +
Oxaliplatin
5 FU 1200mg/m2 D1 D2
MO Medical Oncology MO014 CT for Colorectal Cancer MO014C 11,100 NA NA 11,100
Leucovorin 400mg/m2 D1
Oxaliplatin 85 mg/m2 D1 every
14 days
5FU + Leucovorin + Irinotecan

5 FU 1200mg/m2 D1 D2
MO Medical Oncology MO014 CT for Colorectal Cancer MO014D Leucovorin 400mg/m2 D1 8,700 NA NA 8,700
Irinotecan 180mg/m2 85
Capecitabine + Oxaliplatin
MO Medical Oncology MO014 CT for Colorectal Cancer MO014E D14 16,500 NA NA 16,500
Oxaliplatin 130 mg/m2 D1
every 21 days
Capecitabine along with RT

MO Medical Oncology MO014 CT for Colorectal Cancer MO014F Capecitabine 825 mg/m2 7,200 NA NA 7,200
twice daily
Page 51
2.1

Capecitabine
MO Medical Oncology MO014 CT for Colorectal Cancer MO014G Capecitabine 1000mg/m2 D1- 7,300 NA NA 7,300
D14 every 21 days
5FU + Leucovorin +
Oxaliplatin + Irinotecan
5 FU 1200mg/m2 D1 D2
MO Medical Oncology MO014 CT for Colorectal Cancer MO014H Leucovorin 400mg/m2 D1 15,100 NA NA 15,100
Irinotecan 180mg/m2 every 14
days
MO Medical Oncology MO015 CT for Esophageal Cancer MO015A 14,900 NA NA 14,900
21 days
Cisplatin + 5 FU
5 FU 1000mg/m2 D1-D4
MO Medical Oncology MO015 CT for Esophageal Cancer MO015B 9,600 NA NA 9,600
weeks
Cisplatin + 5 FU
Cisplatin 75mg/m2 D1 D29
MO Medical Oncology MO015 CT for Esophageal Cancer MO015C 9,600 NA NA 9,600
5FU 100mg/m2 D1-D4 D29
D32 every 35 days
Page 52
2.1

Paclitaxel + Carboplatin
MO Medical Oncology MO015 CT for Esophageal Cancer MO015D 25,100 NA NA 25,100
Carboplatin AUC 2 D1 every
week
MO Medical Oncology MO015 CT for Esophageal Cancer MO015E 25,100 NA NA 25,100
week
Cisplatin + Docetaxel
Docetaxel 40mg/m2 D1
CT for Esophageal / Stomach Cisplatin 40 mg/m2 D1
MO Medical Oncology MO016 MO016A 12,100 NA NA 12,100
Cancer Leucovorin 400mg/m2 D1
5FU 1000mg/m2 D1 D2 every
14 days
Irinotecan
CT for Esophageal / Stomach
MO Medical Oncology MO016 MO016B Irinotecan 60- 90 mg/m2 D1 8,300 NA NA 8,300
Cancer
D8 every 21 days
5 FU
MO Medical Oncology MO016 MO016C 5 FU 250 mg/m2 D1-D5 over 8,000 NA NA 8,000
Cancer
24 hrs every week
Page 53
2.1

Capecitabine
MO Medical Oncology MO016 MO016D Capecitabine 825 mg/m2 7,200 NA NA 7,200
Cancer
twice daily
Capecitabine + Oxaliplatin
MO Medical Oncology MO016 MO016E D14 16,500 NA NA 16,500
Cancer
every 21 days
Docetaxel + Cisplatin + 5 FU
CT for Esophageal / Stomach Cisplatin 40 mg/m2 D1
MO Medical Oncology MO016 MO016F 16,400 NA NA 16,400
14 days
Docetaxel + Cisplatin + Xeloda

MO Medical Oncology MO016 MO016G Cisplatin 40 mg/m2 D1 19,700 NA NA 19,700
Cancer
Capecitabine 825mg/m2 twice
daily every 14 days
Docetaxel + Oxaliplatin + 5 FU
CT for Esophageal / Stomach Oxaliplatin 85 mg/m2 D1
MO Medical Oncology MO016 MO016H 20,400 NA NA 20,400
14 days
Page 54
2.1

Docetaxel + Oxaliplatin +
Xeloda
CT for Esophageal / Stomach Docetaxel 50mg/m2 D1
MO Medical Oncology MO016 MO016I 24,900 NA NA 24,900
Cancer Oxaliplatin 85 mg/m2 D1
Capecitabine 825 mg/m2
Twice daily every 14 days

5 FU 1200mg/m2 D1 D2
MO Medical Oncology MO016 MO016J Leucovorin 400mg/m2 D1 8,700 NA NA 8,700
Cancer
5FU + Leucovorin +
Oxaliplatin
CT for Esophageal / Stomach 5 FU 1200mg/m2 D1 D2
MO Medical Oncology MO016 MO016K 11,100 NA NA 11,100
14 days
Paclitaxel
MO Medical Oncology MO016 MO016L Paclitaxel 80mg/m2 every 5,800 NA NA 5,800
Cancer
week
Doxorubicin
CT for Hepatocellular
MO Medical Oncology MO017 MO017A Doxorubicin 30-75 mg/m2 one 10,000 NA NA 10,000
Carcinoma
course
Page 55
2.1

Sorafenib
CT for Hepatocellular
MO Medical Oncology MO017 MO017B Sorafenib 400mg PO twice 7,400 NA NA 7,400
Carcinoma
daily
Gemcitabine + Nanopaclitaxel
D8 D16
MO Medical Oncology MO018 CT for Panceratic Cancer MO018A 23,500 NA NA 23,500
Albumin bound Paclitaxel
125mg/m2 D1 D8 D15 every
28 days
Gemcitabine
MO Medical Oncology MO018 CT for Panceratic Cancer MO018B Gemcitabine 1000mg /m2 D1 9,000 NA NA 9,000
D8 every 21 days
Gemcitabine
MO Medical Oncology MO018 CT for Panceratic Cancer MO018C Gemcitabine 300mg/m2 9,000 NA NA 9,000
weekly
5FU + Leucovorin +
Oxaliplatin + Irinotecan
5 FU 1200mg/m2 D1 D2
MO Medical Oncology MO018 CT for Panceratic Cancer MO018D Leucovorin 400mg/m2 D1 15,500 NA NA 15,500
Irinotecan 180mg/m2 every 14
days
Page 56
2.1

Capecitabine
MO Medical Oncology MO018 CT for Panceratic Cancer MO018E Capecitabine 825 mg/m2 7,400 NA NA 7,400
twice daily
Capecitabine + Gemcitabine
MO Medical Oncology MO018 CT for Panceratic Cancer MO018F D8 D15 31,500 NA NA 31,500
Capecitabine 830mg/m2 twice
daily D1-D21 every 28 days
Capecitabine
CT for Gall Bladder Cancer / Capecitabine 1000 - 1250
Cholangiocarcinoma mg/m2 twice daily D1 -D14
every 21 days
Cisplatin + Gemcitabine
CT for Gall Bladder Cancer /
MO Medical Oncology MO019 MO019B D8 10,900 NA NA 10,900
Cholangiocarcinoma
Cisplatin 25 mg/m2 D1 D8
every 21 days

5 FU 1200mg/m2 D1 D2
MO Medical Oncology MO019 MO019C Leucovorin 400mg/m2 D1 8,900 NA NA 8,900
Cholangiocarcinoma
Page 57
2.1

Gemcitabine
MO Medical Oncology MO019 MO019D Gemcitabine 300 mg/m2 D1 9,000 NA NA 9,000
Cholangiocarcinoma
every week
Gemcitabine
MO Medical Oncology MO019 MO019E Gemcitabine 1000mg /m2 D1 8,900 NA NA 8,900
Cholangiocarcinoma
D8 every 21 days
Oxaliplatin + Gemcitabine
CT for Gall Bladder Cancer / Gemcitabine 1000 mg/m2 D1
MO Medical Oncology MO019 MO019F 17,100 NA NA 17,100
Cholangiocarcinoma Oxaliplatin 100 mg/m2 D1
every 14 days
Capecitabine + Irinotecan
MO Medical Oncology MO019 MO019G D14 12,600 NA NA 12,600
Cholangiocarcinoma
Irinotecan 200 mg/m2 D1
every 21 days
5FU + Leucovorin +
Oxaliplatin
CT for Gall Bladder Cancer / 5 FU 1200mg/m2 D1 D2
MO Medical Oncology MO019 MO019H 11,300 NA NA 11,300
Cholangiocarcinoma Leucovorin 400mg/m2 D1
14 days
Page 58
2.1

CT for Gastointestinal stromal Imatinib

tumor Imatinib 400 mg once daily
CT for Gastointestinal stromal Sunitinib

tumor Sunitinb 37.5 mg once daily
Temozolamide
MO Medical Oncology MO021 CT for CA Brain MO021A Temozolomide 150 - 200 13,000 NA NA 13,000
mg/m2 D1-D5 every 28 days
Temozolamide
MO Medical Oncology MO021 CT for CA Brain MO021B Temozolomide 75mg/m2 once 67,600 NA NA 67,600
daily
Gemcitabine + Cisplatin
MO Medical Oncology MO022 CT for Mesothelioma MO022A D8 11,100 NA NA 11,100
Cisplatin 75 mg/m2 D1 every
21 days
Page 59
2.1

Pemetrexed + Cisplatin
Pemetrexed 500mg/m2 D1
MO Medical Oncology MO022 CT for Mesothelioma MO022B 9,200 NA NA 9,200
21 days
Pemetrexed + Carboplatin
MO Medical Oncology MO022 CT for Mesothelioma MO022C 10,000 NA NA 10,000
21 days
Cisplatin + Etoposide
Etoposide 100mg/m2 D1 - D3
MO Medical Oncology MO023 CT for Thymic Carcinoma MO023A 5,300 NA NA 5,300
Cisplatin 75-100 mg/m2 D1
every 21 days
Cisplatin + Adriamycin +
Cyclophosphamide
Cisplatin 50 mg/m2 D1
MO Medical Oncology MO023 CT for Thymic Carcinoma MO023B 5,000 NA NA 5,000
Cisplatin + Docetaxel
MO Medical Oncology MO024 CT for CA Head & Neck MO024A 12,400 NA NA 12,400
21 days
Page 60
2.1

Cisplatin
MO Medical Oncology MO024 CT for CA Head & Neck MO024B Cisplatin 100mg/m2 every 21 9,800 NA NA 9,800
days
MO Medical Oncology MO024 CT for CA Head & Neck MO024C D8 14,300 NA NA 14,300
21 days
Docetaxel + Cisplatin + 5 FU
MO Medical Oncology MO024 CT for CA Head & Neck MO024D Cisplatin 75 mg/m2 D1 16,500 NA NA 16,500
5 FU 750 mg/m2 D1- D5 every
21 days
Docetaxel
MO Medical Oncology MO024 CT for CA Head & Neck MO024E Docetaxel 20mg/m2 every 15,000 NA NA 15,000
week
Docetaxel
MO Medical Oncology MO024 CT for CA Head & Neck MO024F Docetaxel 75 mg/m2 D1 every 14,400 NA NA 14,400
21 days
Page 61
2.1

Etoposide + Carboplatin
MO Medical Oncology MO024 CT for CA Head & Neck MO024G 7,100 NA NA 7,100
21 days
MO Medical Oncology MO024 CT for CA Head & Neck MO024H 9,200 NA NA 9,200
every 21 days
Gemcitabine
MO Medical Oncology MO024 CT for CA Head & Neck MO024I Gemcitabine 1000 mg/m2 D1 9,200 NA NA 9,200
D8 every 21 days
MO Medical Oncology MO024 CT for CA Head & Neck MO024J D8 11,100 NA NA 11,100
21 days
MO Medical Oncology MO024 CT for CA Head & Neck MO024K 7,700 NA NA 7,700
week
Page 62
2.1

MO Medical Oncology MO024 CT for CA Head & Neck MO024L Paclitaxel 175mg/m2 every 21 15,100 NA NA 15,100
days
Paclitaxel
MO Medical Oncology MO024 CT for CA Head & Neck MO024M Paclitaxel 80mg/m2 every 5,700 NA NA 5,700
week
Paclitaxel
MO Medical Oncology MO024 CT for CA Head & Neck MO024N Paclitaxel 175mg/m2 every 21 12,200 NA NA 12,200
days
Carboplatin
MO Medical Oncology MO024 CT for CA Head & Neck MO024O 2,400 NA NA 2,400
Carboplatin AUC 2 every week
Cisplatin
MO Medical Oncology MO024 CT for CA Head & Neck MO024P 2,200 NA NA 2,200
Cisplatin 40mg/m2 every week
Page 63
2.1

Sunitinib
MO Medical Oncology MO025 CT for Renal Cell Cancer MO025A 50 mg once daily 4 weeks on 26,400 NA NA 26,400
2 weeks off
Cisplatin + Methotrexate +
Vinblastin
Methotrexate 30mg/m2 D1 D8
CT for Ureter / Bladder / Vinblastine 4 mg/m2 D1 D8
Urethra Doxorubicin 30 mg/m2 D2
Cuisplatin 100 mg/m2 D2
Leucovorin 15 mg PO D2 D9
every 21 days
CT for Ureter / Bladder /
MO Medical Oncology MO026 MO026B D8 14,300 NA NA 14,300
Urethra
21 days
Cisplatin + Gemcitabine
MO Medical Oncology MO026 MO026C D8 11,100 NA NA 11,100
Urethra
21 days
Cisplatin + 5 FU
CT for Ureter / Bladder / 5 FU 1000mg/m2 D1-D4
MO Medical Oncology MO026 MO026D 7,800 NA NA 7,800
Urethra Cisplatin 75mg/m2 D1 every 4
weeks
Page 64
2.1

CT for Ureter / Bladder / Paclitaxel 175 mg /m2 D1
MO Medical Oncology MO026 MO026E 13,500 NA NA 13,500
Urethra Cisplatin 75 mg /m2 D1 every
21 days
Docetaxel
MO Medical Oncology MO026 MO026F Docetaxel 75 mg/m2 D1 every 14,400 NA NA 14,400
Urethra
21 days
Gemcitabine + Paclitaxel
CT for Ureter / Bladder / Gemcitabine 2500 mg/m2 D1
MO Medical Oncology MO026 MO026G 17,500 NA NA 17,500
Urethra Paclitaxel 150 mg/m2 D1
every 14 days
Gemcitabine
MO Medical Oncology MO026 MO026H Gemcitabine 1000mg /m2 D1 9,200 NA NA 9,200
Urethra
D8 every 21 days
Methotrexate + Vinblastin +
Doxorubicin + Cisplatin
Methotrexate 30mg/m2 D1
MO Medical Oncology MO026 MO026I Vinblastine 3 mg/m2 D2 6,600 NA NA 6,600
Urethra
Cuisplatin 70 mg/m2 D2 every
14 days
Page 65
2.1

CT for Ureter / Bladder / Paclitaxel 175mg/m2 D1
MO Medical Oncology MO026 MO026J 15,100 NA NA 15,100
Urethra Carboplatin AUC 5-6 D1 every
21 days
Paclitaxel
MO Medical Oncology MO026 MO026K Paclitaxel 80 mg/m2 D1 every 5,700 NA NA 5,700
Urethra
week
MO Medical Oncology MO027 CT for CA Penis MO027A 13,500 NA NA 13,500
21 days
5 FU + Cisplatin
5 FU 1000mg/m2 D1-D4
MO Medical Oncology MO027 CT for CA Penis MO027B 7,800 NA NA 7,800
weeks
Capecitabine
Capecitabine 1000-1250
MO Medical Oncology MO027 CT for CA Penis MO027C 7,400 NA NA 7,400
mg/m2 PO twice daily D1 -
D14 every 21 days
Page 66
2.1

MO Medical Oncology MO027 CT for CA Penis MO027D 15,100 NA NA 15,100
21 days
Paclitaxel
MO Medical Oncology MO027 CT for CA Penis MO027E Paclitaxel 80 mg/m2 D1 every 5,700 NA NA 5,700
week
Paclitaxel
MO Medical Oncology MO027 CT for CA Penis MO027F Paclitaxel 175 mg/m2 D1 12,200 NA NA 12,200
every 21 days
MO Medical Oncology MO027 CT for CA Penis MO027G 7,900 NA NA 7,900
week
Docetaxel
MO Medical Oncology MO028 CT for CA Prostate MO028A Docetaxel 60 mg/m2 D1 every 11,700 NA NA 11,700
14 days
Page 67
2.1

Docetaxel
MO Medical Oncology MO028 CT for CA Prostate MO028B Docetaxel 75 mg/m2 D1 every 14,100 NA NA 14,100
21 days
MO Medical Oncology MO028 CT for CA Prostate MO028C 7,100 NA NA 7,100
21 days
LHRH Agonist
MO Medical Oncology MO028 CT for CA Prostate MO028D Leuprolide 22.5 ug every 3 15,300 NA NA 15,300
months
Mitoxantrone + Prednisolone
Mitoxantrone 12mg/m2 every
MO Medical Oncology MO028 CT for CA Prostate MO028E 4,200 NA NA 4,200
3 weeks
Prednsiolone 10 mg daily
MO Medical Oncology MO028 CT for CA Prostate MO028F 7,700 NA NA 7,700
week
Page 68
2.1

MO Medical Oncology MO028 CT for CA Prostate MO028G 15,100 NA NA 15,100
21 days
Docetaxel
MO Medical Oncology MO028 CT for CA Prostate MO028H Docetaxel 20mg/m2 D1 every 14,700 NA NA 14,700
week
Rituximab +
Cyclophosphamide +
Etoposide + Prednsiolone
Rituximab 375mg/m2
CT for B - Cell NHL - High
mg/m2
MO Medical Oncology MO029 Grade MO029A 26,200 NA NA 26,200
Vincristine 1.4 mg/m2, on
(Except Burkitt's & PCNSL)
Day1
Etoposide 65mg/m2 Day 1 to
3
Prednisolone 100 mg Day 1-5
Total 6 cycles, repeat 21 days
Rituximab +
Cyclophosphamide +
Doxorubicin + Prednsiolone
Rituximab 375mg/m2
CT for B - Cell NHL - High
MO Medical Oncology MO029 Grade MO029B 27,000 NA NA 27,000
mg/m2
Doxorubicin 50mg/m2
Vincristine 1.4 mg/m2 on Day1
Prednisolone 100 mg Day 1-5
Total 6 cycles, repeat 21 days
Rituxmab + Dexamethasone +
High Dose Cytarabine +
Cisplatin
Rituximab 375mg/m2 Day 1
Cytarabine 2g/m2 BD on day 2
CT for High - Grade NHL - B
MO Medical Oncology MO030 MO030A Dexamethasone 40 mg Day 1 - 34,900 NA NA 34,900
Cell
4
Cisplatin 75mg/m2 or
Carboplatin AUC-5 on day 1
Cycle to be repeated every
21days
Page 69
2.1

GDP - R
Gemcitabine 1000mg/m2 on
day 1 and 8
CT for Relapsed B - Cell NHL -
Dexamethasone 40 mg Day 1 -
MO Medical Oncology MO031 High Grade MO031A 35,300 NA NA 35,300
4
Cisplatin 75mg/m2 on day 1
Cycle to be repeated every
21days
Total- 6 cycles
ICE - R
Rituximab 375mg/m2
Ifosfamide 1.66g/m2 on day 1 -
3
CT for Relapsed B - Cell NHL -
Mesna 1.66g/m2 day 1 - 3
MO Medical Oncology MO031 High Grade MO031B 31,900 NA NA 31,900
Carboplatin AUC 5 on day 1
Etoposide 100mg/m2 on day 1
-3
Cycle every 21days for 6
cycles
Etoposide + Prednsiolone +
Vincristine +
Cyclophosphamide +
Doxorubicin
Etoposide 50mg/m2
CT for PMBCL / Burkitt's VCR 0.4mg/m2
MO Medical Oncology MO032 Lymphoma / Seropositive MO032A Doxorubicin 10mg/m2 Day1 - 31,700 NA NA 31,700
B - Cell NHLR 4
on day 5 Prednisolone 100 mg
day 1-5
Every 21 days
Dose adjustment each cycle
depending on nadir counts
Codox - M - IVAC / GMALL /

MO Medical Oncology MO033 CT for Burkitt's NHL MO033A 34,500 NA NA 34,500
BFM / Hyper CVAD
Bendamustine + Rituximab
Bendamustine 90mg/m2 on
CT for Low Grade B - Cell day 1, 2
NHL Rituximab 375mg/m2 on day 1
Repeat every 28 days, Total 6
cycles
Page 70
2.1

Lenalidomide + Rituximab
CT for Low Grade B - Cell Rituximab 375mg/m2 Day 1
NHL Lenlidomide 25 mg D1-28, for
8 cycles
Rituximab
MO Medical Oncology MO035 CT for Low Grade NHL MO035A Rituximab 375mg/m2 per 24,800 NA NA 24,800
week for 6 weeks
Rituximab +
Cyclophosphamide +
Vincristine + Prednisolone
Rituximab 375 mg/m2
MO Medical Oncology MO035 CT for Low Grade NHL MO035B 25,800 NA NA 25,800
Vincristine 1.4mg/m2 Day 1
Prednisolone 100 mg Day 1 -
5
Repeat every 21days. Total 6
cycles
Fludarabine +
Cyclophosphamide
CT for Chronic Lymphocytic Fludarabine 25mg/m2 D1-3
Leukemia Cyclophosphamide 250
mg/m2 D1-3 every 28 days for
6 cycles
Rituxmab + Chlorambucil
CT for Chronic Lymphocytic
MO Medical Oncology MO036 MO036B Chlorambucil 10 mg/m2 D1-7 24,900 NA NA 24,900
Leukemia
Repeat every 28 days for 12
cycles
Page 71
2.1

Rituximab + Fludarabine +
Cyclophosphamide
Rituximab 375mg/m2 on day 1
MO Medical Oncology MO036 MO036C Fludarabine 25mg/m2 D1 - 3 40,700 NA NA 40,700
Leukemia
mg/m2 D1 - 3
Every 28 days for 6 cycles
Lenalidomide
MO Medical Oncology MO036 MO036D lenalidomide-10-25 mg/day 4,800 NA NA 4,800
Leukemia
day 1 to 21 every 28 days
CHOEP
D1
CT for Peripheral T - Cell Vincristine 1.4mg/m2 D1
Lymphoma Adriamycin 50 mg/m2 D1
Etoposide 100mg/m2 D1-3
Prednisolone 100 mg D1-5
Every 21days. Total 6 cycles
CHOP
D1
CT for Peripheral T - Cell
MO Medical Oncology MO037 MO037B Vincristine 1.4mg/m2 D1 4,000 NA NA 4,000
Lymphoma
Adriamycin 50 mg/m2 D1
Prednisolone 100 mg D1-5
Every 21days. Total 6 cycles
SMILE
Methotrexate 2gm/m2 D1
Ifosfamide 1500mg/m2 D2-4
CT for Peripheral T - Cell Etoposide 100mg/m2 D2-4
Lymphoma L-asparginase 6000U/m2
D8,10,12,14,16,18,20
Dexamethasone 40mg D1-4
every 28 days
Page 72
2.1

GELOX
and D8
MO Medical Oncology MO038 CT for NK - T Cell Lymphoma MO038A Oxaliplatin 130mg/m2 D1 18,900 NA NA 18,900
L- asparginase 6000 U/m2 D1-
7
Repeat every 21 days
LVP
L-asparginase 6000U/m2 D1-5
MO Medical Oncology MO038 CT for NK - T Cell Lymphoma MO038B Vincristine 1.4mg/m2 D1 7,600 NA NA 7,600
Prednisolone 100mg D1-5
COPP
D1, 8
Vincristine 1.4mg/m2 D1, 8
MO Medical Oncology MO039 CT for Hodgkin's Lymphoma MO039A Procarbazine 100 mg/m2 D1- 3,600 NA NA 3,600
14
Prednisolone 40mg/m2 D1-14
Every 28days. Total 6 - 8
cycles
ABVD
Adriamycin 25mg/m2
Bleomycin 10unit/m2
MO Medical Oncology MO039 CT for Hodgkin's Lymphoma MO039B Vinblastine 6mg/m2 10,200 NA NA 10,200
Dacarbazine 375 mg/m2 Day
1,15
AEVD
Adriamycin 25mg/m2
Vinblastine 6mg/m2
Dacarbazine 375 mg/m2 Day
MO Medical Oncology MO039 CT for Hodgkin's Lymphoma MO039C 10,200 NA NA 10,200
1,15
Etoposide 65mg/m2 Day 1-3,
15-17
Page 73
2.1

ICE
Ifosfamide 1.5 mg/m2 D1-3
CT for Relapsed Hodgkin
MO Medical Oncology MO040 MO040A Carboplatin AUC5 D2 9,700 NA NA 9,700
Lymphoma
Every 3 weeks
MINE
Ifosfamide 4 gm/m2 over
CT for Relapsed Hodgkin 3days (D1-3)
Lymphoma Mitoxantrone 8mg/m2
Every 3 weeks
PTCL - GDP
and D8
CT for Relapsed Hodgkin
MO Medical Oncology MO040 MO040C Dexamethasone 40mg D1-4 12,500 NA NA 12,500
Lymphoma
Cisplatin 75mg/m2 D1 or
Cacrboplatin AUC-5
Every 3 weeks
DHAP
Dexamethasone 40mg D1-4
Cisplatin 100mg/m2 or
MO Medical Oncology MO041 CT for Relapsed NHL & HL MO041A 11,500 NA NA 11,500
Carboplatin AUC-5D1
Cytarabine 2 gm/m2 BD D2
Lenalidomide +
Dexamethasone
Lenalidomide 25 mg daily
CT for MM / Amyloidosis /
MO Medical Oncology MO042 MO042A Day1-21 6,000 NA NA 6,000
POEMS
Dexamethasone 40mg Day 1,
8, 15, 22
Every 28days
Page 74
2.1

Pomalidomide +
Dexamethasone
Pomalidomide 4 mg daily Day
CT for MM / Amyloidosis /
MO Medical Oncology MO042 MO042B 1-21 6,800 NA NA 6,800
POEMS
8, 15, 22
Every 28 days
Cyclophosphamide +
Thalidomide +
Dexamethasone
Cyclophosphamide 100mg D1-
D14
MO Medical Oncology MO043 CT for MM / Amyloidosis MO043A 4,000 NA NA 4,000
Thalidomide 100-200 mg daily
Day 1-28
8, 15, 22
Every 28 days
Melphalan + Thalidomide +
Prednisolone
Melphalan 9mg/m2 D1-D4
MO Medical Oncology MO043 CT for MM / Amyloidosis MO043B 4,100 NA NA 4,100
Thalidomide 100mg D1-28
Prednisolone 100mg Day1-4
Every 28days
Bortezomib +
Cyclophosphamide +
Dexamethasone
Cyclophosphamide - 300
mg/m2 day 1, 8, 15, 22
MO Medical Oncology MO043 CT for MM / Amyloidosis MO043C 14,600 NA NA 14,600
8, 15, 22
Bortezomib 1.3 mg/m2 Day1,
8, 15, 22
Every 28 days
Bortezomib + Dexamethasone
Bortezomib 1.3 mg/m2 Day1,
8, 15, 22
MO Medical Oncology MO043 CT for MM / Amyloidosis MO043D 13,300 NA NA 13,300
Dexamethasone 40mg Day1,
8, 15, 22
Every 28 day
Page 75
2.1

Bortezomib + Melphalan +
Prednsiolone
Melphalan 9mg/m2 D1-D4
MO Medical Oncology MO043 CT for MM / Amyloidosis MO043E Prednisolone 100mg Day 1-4 12,600 NA NA 12,600
Bortezomib 1.3 mg/m2 Day 1,
8, 15, 22
Every 28 days
Bortezomib + Lenalidomide +
Dexamethasone
Lenalidomide 25 mg daily Day
1 - 21
MO Medical Oncology MO043 CT for MM / Amyloidosis MO043F Dexamethasone 40mg Day 1, 17,800 NA NA 17,800
8, 15, 22
8, 15, 22
Every 28 days
Bortezomib + Thalidomide +
Dexamethasone
Thalidomide 100 mg daily Day
1 - 28 Dexamethasone 40 mg
MO Medical Oncology MO043 CT for MM / Amyloidosis MO043G 15,000 NA NA 15,000
Day 1, 8, 15, 22
8, 15, 22
Every 28 days
Imatinib
CT for Chronic Myeloid Imatinib 400 mg, 600 mg, 800
Leukemia mg
(per month X 5 years)
Hydroxurea
CT for Myeloproliferative Hydroxurea daily
Neoplasm (Dose will be based on blood
counts)
Page 76
2.1

Cytarabine 2 gm / M2 BD for 3
CT for Acute Myeloid
MO Medical Oncology MO046 MO046A days 60,000 NA NA 60,000
Leukemia
Cytarabine 100 mg / M2 7
CT for Acute Myeloid days
Leukemia Daunomycin 60 mg / M2 3
days
BFM-90
BFM-95
CT for Acute Lymphoblastic BFM-2000
Leukemia HyperCVAD
UKALL
GMALL
BFM-90
BFM-95
CT for Acute Lymphoblastic BFM-2000
Leukemia HyperCVAD
UKALL
GMALL
6 Mercaptopurine 50 mg / M2
CT for Acute Lymphoblastic daily
Leukemia Methotrexate 25 mg / M2
Weekly for 2 years
Page 77
2.1

BFM-90
BFM-95
CT for Lymphoblastic BFM-2000
Lymphoma HyperCVAD
UKALL
GMALL
BFM-90
BFM-95
CT for Lymphoblastic BFM-2000
Lymphoma HyperCVAD
UKALL
GMALL
6 Mercaptopurine 50 mg/M2
CT for Lymphoblastic daily and
Lymphoma Methotrexate 25 mg/M2
Weekly for 2 Years
Arsenic trioxide
CT for Acute Promyelocytic ATRA
MO Medical Oncology MO049 Leukemia MO049A Daunomycin or Idarubcin 32,000 NA NA 32,000
(High Risk) Cytarabine - multiagent - vary
in each protocol
Arsenic trioxide
CT for Acute Promyelocytic ATRA
MO Medical Oncology MO049 Leukemia MO049B Daunomycin or Idarubcin 96,000 NA NA 96,000
(High Risk) Cytarabine - multiagent - vary
on protocol
Page 78
2.1

6 MP 50 mg / day daily
CT for Acute Promyelocytic Methotrexate 15 mg Weekly
MO Medical Oncology MO049 Leukemia MO049C ATRA 45 mg / M2 for 14 days 8,000 NA NA 8,000
(High Risk) Every three months for 18
Months
ATO 0.15 mg / kg Five days a

CT for Acute Promyelocytic
week for 16 Weeks
MO Medical Oncology MO050 Leukemia MO050A 12,000 NA NA 12,000
ATRA 45 mg / M2 Two Weeks
(Low Risk)
a Month for 7 Months
CT for Acute Promyelocytic

ATO 0.15 mg / kg
MO Medical Oncology MO050 Leukemia MO050B 80,000 NA NA 80,000
ATRA 45 mg / M2
(Low Risk)
Cefoperazone + Sulbactum
Piperalicillin + Tazobactum
Cefoperazone
Piperacillin
Amikacin
MO Medical Oncology MO051 Febrile Neutopenia MO051A Gentamicin 28,000 NA NA 28,000
Cefipime
Levofloxacin
Amoxycillin and clavulanate
Teicoplanin
Vancomycin
Meropenem
Imipenem
Colistin
Tigecyclin
MO Medical Oncology MO051 Febrile Neutopenia MO051B 60,000 NA NA 60,000
Linezolid
Voriconazole
Caspfungin
Amphotericin - B
Page 79
2.1

Rasburicase
Chemotherapy Complications - Febuxostat
Tumor Lysis Syndrome Allopurinol
Sevelamer
5 microgram / kg / day
(max 300 microgram per day)
Granulocyte Colony
MO Medical Oncology MO053 MO053A for 7 days or 12,800 NA NA 12,800
Stimulating Factor Use
PEG - GCSF 6mg one single
dose per chemotherapy cycle
Langerhans Cell Histiocytosis

CT for Langerhans Cell
MO Medical Oncology MO054 MO054A (Histiocytosis Protocol - 22,400 NA NA 22,400
Histiocytosis
Induction)
Langerhans Cell Histiocytosis

CT for Langerhans Cell
MO Medical Oncology MO054 MO054B (Histiocytosis Protocol - 17,000 NA NA 17,000
Histiocytosis
Maintenance)
Vincristine + Carboplatin
and 15 for first 4 cycles and
MO Medical Oncology MO055 CT for Low Grade Glioma MO055A then only day 1 from cycle 5 to 5,600 NA NA 5,600
17)
Carboplatin 550mg/m2 every
3 weeks (all cycles)
Page 80
2.1

Vinblastin
MO Medical Oncology MO055 CT for Low Grade Glioma MO055B Vinblastine 6 mg/m2 every 1,900 NA NA 1,900
week
CT for Medulloblastoma /
MO Medical Oncology MO056 MO056A PACKER 4,900 NA NA 4,900
Brain PNET
Cisplatin + Cyclophosphamide
+ Vincristine
Cyclophosphamide
1000mg/m2 (2 days every
CT for Medulloblastoma / CNS cycles)
PNET Vincristine 1.5mg/m2 (days 1
and 8)
Cisplatin 100mg/m2 (1 day per
cycle)
Cycles given every 3 weekly
Cabroplatin + Etoposide +
Cyclophosphamide +
Doxorubicin
Carboplatin 600mg/m2
MO Medical Oncology MO057 CT for Neuroblastoma MO057A 7,900 NA NA 7,900
Etoposide 100mg/m2 (days 1-
5)
Cyclophosphamide
Doxorubicin
Carboplatin + Cisplatin +
MO Medical Oncology MO057 CT for Neuroblastoma MO057B Cyclophosphamide + 6,800 NA NA 6,800
Vincristine + Etoposide
Page 81
2.1

13-cis retinoic acid 160mg/m2

MO Medical Oncology MO057 CT for Neuroblastoma MO057C per day for 2 weeks 2,000 NA NA 2,000
Each cycle given 4 weekly
Vincristine + Carboplatin +
Etoposide
MO Medical Oncology MO058 CT for Retinoblastoma MO058A Carboplatin 600mg/m2 day 1 7,100 NA NA 7,100
Etoposide 150mg/m2 days 1-3
Vincristine1.5mg/m2 day 1
Vincristine +
Cyclophosphamide +
Dactinomycin
and 15)
MO Medical Oncology MO059 CT for Rhabdomyosarcoma MO059A 4,800 NA NA 4,800
Cyclophosphamie 1200 - 2200
mg/m2 (day 1)
Dactinomycin 1.5mg / m2 (day
1)
3 weekly cycle
Vincristine + Ifosfamide +
Etoposide
Vincristine 1.5mg/m2 (days 1,
8 and 15)
MO Medical Oncology MO059 CT for Rhabdomyosarcoma MO059B Ifosfamide 1.8gm/m2 (days 1- 16,200 NA NA 16,200
5)
Etoposide 100mg/m2 (days 1-
5)
Each cycle every 3 weeks
Vincristine + Topotecan +
Cyclophosphamide and
Vincristine + Adriamycin +
Cyclophosphamide
Vincristine 1.5mg/m2 (day 1)
Topotecan 1.5mg/m2 (day 1-
5)
CT for Relapse
MO Medical Oncology MO060 MO060A Cyclophosphamide 250mg/m2 12,200 NA NA 12,200
Rhabdomyosarcoma
(days 1-5)
3 - weekly
Vincristine 1.5mg/m2
Adriamyicn 60mg/m2
(all Day 1)
Every 3 weeks. Cycles given
Page 82
2.1

Vincristine + Actinomycin D
Vincristine 1.5 mg/m2 weekly
for 12 weeks and then 3
MO Medical Oncology MO061 CT for Wilms Tumor MO061A 3,000 NA NA 3,000
weekly
Actinomycin D 45 microgram /
kg 3 weekly for 24 weeks
Vincristine + Actinomycin D +
Doxorubicin
Vincristine 1.5 mg/m2 weekly
for 12 weeks and then 3
MO Medical Oncology MO061 CT for Wilms Tumor MO061B weekly 4,200 NA NA 4,200
Actinomycin D 45
microgram/kg 3 weekly
Doxorubicin 60mg/m2 for 24
weeks
Cyclophosphamide +
Doxorubicin + Etoposide +
Vincristine + Dactinomycin
Vincristine 1.5 mg/m2
Dactinomycin 45
MO Medical Oncology MO061 CT for Wilms Tumor MO061C microgram/kg 12,300 NA NA 12,300
Adriamyicn 60mg/m2
Cyclophosphamide
Etoposide
Weekly chemotherapy -
varying hybrid regimen
Consolidation
CT for Pediatric Acute
MO Medical Oncology MO062 MO062A (Phase II, CNS Therapy 208,600 NA NA 208,600
Lymphoblastic Leukemia
Reinduction)
ICICLE
CT for Pediatric Acute BFM
Lymphoblastic Leukemia KLALL
MCP:841
Page 83
2.1

6 - Mercaptopurine 75mg/m2
daily
CT for Pediatric Acute Methotrexate 20mg/m2 weekly
Lymphoblastic Leukemia Vincristine 1.5mg/m2 monthly
Intrathecal methotrexate 12
mg 3 monthly
Consolidation
CT for Pediatric Lymphoblastic
MO Medical Oncology MO063 MO063A (Phase II, CNS Therapy 208,600 NA NA 208,600
Lymphoma
Reinduction)
ICICLE
CT for Pediatric Lymphoblastic BFM
Lymphoma KLALL
MCP:841
6 - Mercaptopurine 75mg/m2
daily
CT for Pediatric Lymphoblastic Methotrexate 20mg/m2 weekly
Lymphoma Vincristine 1.5mg/m2 monthly
Intrathecal methotrexate 12
mg 3 monthly
Cytrabine 3 gram/m2 twice a

CT for Pediatric Acute Myeloid
MO Medical Oncology MO064 MO064A day 57,600 NA NA 57,600
Leukemia
Days 1, 3 and 5
Page 84
2.1

Cytrabine 200mg/m2/day days

1-10 and
MO Medical Oncology MO064 MO064B Daunorubicin 50mg/m2 days 94,400 NA NA 94,400
Leukemia
1, 3 and 5
Etposide 100mg/m2 days 1-5
Cytrabine 100-200mg/m2/day
MO Medical Oncology MO064 MO064C days 1-7 and Daunorubicin 92,800 NA NA 92,800
Leukemia
50mg/m2 days 1, 3 and 5

MO Medical Oncology MO065 MO065A Consolidation 36,800 NA NA 36,800
Promyelocytic Leukemia

MO Medical Oncology MO065 MO065B Induction 97,600 NA NA 97,600

MO Medical Oncology MO065 MO065C Maintenance 39,300 NA NA 39,300
Page 85
2.1

CT for Pediatric Hodgkins

MO Medical Oncology MO066 MO066A COPDAC 7,800 NA NA 7,800
Lymphoma

MO Medical Oncology MO066 MO066B OPEA 13,000 NA NA 13,000
Lymphoma

MO Medical Oncology MO067 MO067A ICE 21,500 NA NA 21,500
Lymphoma Relapse

MO Medical Oncology MO067 MO067B DECA 17,800 NA NA 17,800
Lymphoma Relapse

MO Medical Oncology MO067 MO067C IGVD 34,000 NA NA 34,000
Lymphoma Relapse
Page 86
2.1

CT for Pediatric Non Hodgkins

MO Medical Oncology MO068 MO068A LMB 89 - 96 - Consolidation 33,500 NA NA 33,500
Lymphoma
CT for Pediatric Non Hodgkins LMB 89 - 96 - Induction -

Lymphoma COPADAM

MO Medical Oncology MO068 MO068C LMB 89 - 96 - Maintenance 15,400 NA NA 15,400
Lymphoma

MO Medical Oncology MO068 MO068D MCP - 842 13,200 NA NA 13,200
Lymphoma
Pediatric - Germ Cell Tumor /

MO Medical Oncology MO069 PEDIATRIC-GCT/JEB MO069A 10,000 NA NA 10,000
JEB
Page 87
2.1

CT for Pediatric Carboplatin + Cisplatin +

Hepatoblastoma Doxorubicin
CT for Pediatric
MO Medical Oncology MO070 MO070B Cisplatin 5,600 NA NA 5,600
Hepatoblastoma
Docetaxel
MO Medical Oncology MO071 CT for CA Lung MO071A Docetaxel 75 mg/m2 D1 every 16,200 NA NA 16,200
21 days
Erlotinib
MO Medical Oncology MO071 CT for CA Lung MO071B 13,000 NA NA 13,000
Erlotinib 150 mg once daily
Gefitnib
MO Medical Oncology MO071 CT for CA Lung MO071C 11,000 NA NA 11,000
Gefitinib 250 mg once daily
Page 88
2.1

MO Medical Oncology MO071 CT for CA Lung MO071D 15,100 NA NA 15,100
21 days
Pemetrexed + Carboplatin
MO Medical Oncology MO071 CT for CA Lung MO071E 10,000 NA NA 10,000
21 days
Topotecan
MO Medical Oncology MO071 CT for CA Lung MO071F Topotecan 1.5 mg/m2 D1-D5 24,600 NA NA 24,600
every 21 days
Docetaxel
MO Medical Oncology MO071 CT for CA Lung MO071G Docetaxel 20 mg/m2 D1 every 14,600 NA NA 14,600
week
MO Medical Oncology MO071 CT for CA Lung MO071H 7,100 NA NA 7,100
21 days
Page 89
2.1

MO Medical Oncology MO071 CT for CA Lung MO071I 5,500 NA NA 5,500
every 21 days
Gemcitabine
MO Medical Oncology MO071 CT for CA Lung MO071J Gemcitabine 1000mg /m2 D1 8,900 NA NA 8,900
D8 every 21 days
Gemcitabine + Carboplatin
MO Medical Oncology MO071 CT for CA Lung MO071K D8 14,300 NA NA 14,300
21 days
MO Medical Oncology MO071 CT for CA Lung MO071L D8 11,100 NA NA 11,100
Cisplatin 75 mg/m2 D1 D8
every 21 days
Paclitaxel
MO Medical Oncology MO071 CT for CA Lung MO071M Paclitaxel 80mg/m2 every 5,800 NA NA 5,800
week
Page 90
2.1

Paclitaxel
MO Medical Oncology MO071 CT for CA Lung MO071N Paclitaxel 175mg/m2 every 21 12,000 NA NA 12,000
days
MO Medical Oncology MO071 CT for CA Lung MO071O 7,900 NA NA 7,900
week
Paclitaxel + Cisplatin
MO Medical Oncology MO071 CT for CA Lung MO071P 13,500 NA NA 13,500
21 days
Pemetrexed + Cisplatin
MO Medical Oncology MO071 CT for CA Lung MO071Q 9,200 NA NA 9,200
21 days
Pemetrexed
MO Medical Oncology MO071 CT for CA Lung MO071R Pemetrexed 500mg/m2 D1 7,600 NA NA 7,600
every 21 days
Page 91
2.1

Vinorelbine + Carboplatin
Vinorelbine 25mg/m2 D1 D8
MO Medical Oncology MO071 CT for CA Lung MO071S 22,800 NA NA 22,800
CarboplatinAUC 5-6 D1 every
21 days
Vinorelbine + Cisplatin
Vinorelbine 25mg/m2 D1 D8
MO Medical Oncology MO071 CT for CA Lung MO071T 20,600 NA NA 20,600
21 days
Carboplatin Carboplatin AUC

MO Medical Oncology MO072 CT for CA Cervix MO072A 2,400 TBF TBF TBF
2 every week

Pediatric Medical Febrile seizures / other HDU - 2700 HDU - 2700
MP MP001 MP001A Febrile seizures 1,800 NA
Management seizures ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

MP MP001 MP001B Flury of seizures 1,800 NA
Page 92
2.1


Pediatric Medical
Febrile seizures / other HDU - 2700 HDU - 2700
MP Management, General MP001 MP001C Neurocysticercosis 1,800 NA
seizures ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medicine

MP MP001 MP001D Epilepsy 1,800 NA

Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP002 Epileptic encephalopathy MP002A Epileptic encephalopathy 1,800 NA
Medicine

Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP003 Acute encephalitis MP003A Infectious - uncomplicated 1,800 NA
Medicine

Pediatric Medical
Immune-mediated - HDU - 2700 HDU - 2700
MP Management, General MP003 Acute encephalitis MP003B 1,800 NA
uncomplicated ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medicine
Page 93
2.1


Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP004 Acute encephalitis syndrome MP004A Acute encephalitis syndrome 1,800 NA
Medicine
Acute meningo encephalitis /

aseptic meningitis / febrile Routine Ward - 1800 Routine Ward - 1800
Pediatric Medical
encephalopathy / hypertensive HDU - 2700 HDU - 2700
MP Management, General MP005 MP005A Acute meningo encephalitis 1,800 NA
encehalopathy / metabolic ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medicine
encephalopathy / hepatic ICU (with Ventilator) - 4500 ICU (with Ventilator) - 4500
encephalopathy / brain abcess

Pediatric Medical encephalopathy / hypertensive HDU - 2700 HDU - 2700
MP MP005 MP005B Aseptic meningitis 1,800 NA
Management encehalopathy / metabolic ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

Pediatric Medical
MP Management, General MP005 MP005C Febrile encephalopathy 1,800 NA
Medicine

MP MP005 MP005D Hypertensive encehalopathy 1,800 NA
Page 94
2.1


Pediatric Medical
MP Management, General MP005 MP005E Metabolic encephalopathy 1,800 NA
Medicine

Pediatric Medical
MP Management, General MP005 MP005F Hepatic encephalopathy 1,800 NA
Medicine

MP MP005 MP005G Brain abscess 1,800 NA

Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP006 Meningitis MP006A Chronic meningitis 1,800 NA
Medicine

Pediatric Medical
Partially treated pyogenic HDU - 2700 HDU - 2700
MP Management, General MP006 Meningitis MP006B 1,800 NA
meningitis ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medicine
Page 95
2.1


Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP006 Meningitis MP006C Neuro tuberculosis 1,800 NA
Medicine

Pediatric Medical
Complicated bacterial HDU - 2700 HDU - 2700
MP Management, General MP006 Meningitis MP006D 1,800 NA
meningitis ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medicine

Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP006 Meningitis MP006E Acute meningitis 1,800 NA
Medicine

Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP007 Optic neuritis MP007A Optic neuritis 1,800 NA
Medicine
After Decompressive
craniotomy / Routine Ward - 1800 Routine Ward - 1800
Pediatric Medical Medical Management for After Shunt procedure / HDU - 2700 HDU - 2700
MP MP008 MP008A 1,800 NA
Management Raised intracranial pressure After other emergency neuro ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
surgical procedures / ICU (with Ventilator) - 4500 ICU (with Ventilator) - 4500
For ICP monitoring
Page 96
2.1


Pediatric Medical HDU - 2700 HDU - 2700
MP MP009 Intracranial hemorrhage MP009A Intracranial hemorrhage 1,800 NA
Management ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

Pediatric Medical
Intracranial space occupying Intracranial space occupying HDU - 2700 HDU - 2700
MP Management, General MP010 MP010A 1,800 NA
lesion lesion ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medicine

Pediatric Medical Intracranial ring enhancing Intracranial ring enhancing
HDU - 2700 HDU - 2700
MP Management, General MP011 lesion with complication MP011A lesion with complication 1,800 NA
Medicine (tuberculoma) (tuberculoma)

Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP012 Cerebral herniation MP012A Cerebral herniation 1,800 NA
Medicine
Acute neuroregression / Acute Acute neuroregression / Acute Routine Ward - 1800 Routine Ward - 1800
Pediatric Medical
worsening in neuro metabolic worsening in neuro metabolic HDU - 2700 HDU - 2700
and neurodegenerative and neurodegenerative ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medicine
conditions conditions ICU (with Ventilator) - 4500 ICU (with Ventilator) - 4500
Page 97
2.1


Pediatric Medical
Acute demyelinating Acute demyelinating HDU - 2700 HDU - 2700
myelopathy myelopathy ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medicine

MP MP015 Juvenile myasthenia MP015A Juvenile myasthenia 1,800 NA

MP MP016 Acute ataxia MP016A Acute ataxia 1,800 NA

Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP017 Acute ischemic stroke MP017A Acute ischemic stroke 1,800 NA
Medicine

MP MP018 Wheezing MP018A Wheezing 1,800 NA
Page 98
2.1


MP MP019 Chronic cough MP019A Chronic cough 1,800 NA

Pediatric Medical
Acute urticaria / Anaphylaxis HDU - 2700 HDU - 2700
MP Management, General MP020 MP020A Acute urticaria 1,800 NA
acute asthma ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medicine

Pediatric Medical
Acute urticaria / Anaphylaxis HDU - 2700 HDU - 2700
MP Management, General MP020 MP020B Anaphylaxis acute asthma 1,800 NA
acute asthma ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medicine

MP MP021 Acute abdomen MP021A Acute abdomen 1,800 NA

Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP022 Celiac disease MP022A Celiac disease 1,800 NA
Medicine
Page 99
2.1


Pediatric Medical
Unexplained Unexplained HDU - 2700 HDU - 2700
hepatosplenomegaly hepatosplenomegaly ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medicine

MP MP024 Infantile cholestasis MP024A Infantile cholestasis 1,800 NA

Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP025 Acute glomerulonephritis MP025A Acute glomerulonephritis 1,800 NA
Medicine

Pediatric Medical
Nephrotic syndrome with Nephrotic syndrome with HDU - 2700 HDU - 2700
peritonitis peritonitis ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medicine

Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP027 Haemolytic uremic syndrome MP027A Haemolytic uremic syndrome 1,800 NA
Medicine
Page 100
2.1

Pediatric Medical
MP MP028 CRRT MP028A CRRT 8,000 NA NA 8,000
Management

Global developmental delay /
MP MP029 Intellectual disability of MP029A Global developmental delay 1,800 NA
unknown etiology

Global developmental delay /
Pediatric Medical Intellectual disability of HDU - 2700 HDU - 2700
MP MP029 Intellectual disability of MP029B 1,800 NA
Management unknown etiology ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
unknown etiology

Pediatric Medical Rickets - requiring admission Rickets - requiring admission HDU - 2700 HDU - 2700
MP MP030 MP030A 1,800 NA
Management for Work Up for Work Up ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

MP MP031 Acute severe malnutrition MP031A Acute severe malnutrition 1,800 NA
Page 101
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Pediatric Medical Developmental and behavioral Developmental and behavioral HDU - 2700 HDU - 2700
MP MP032 MP032A 1,800 NA
Management disorders disorders ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

MP MP033 Short stature MP033A Short stature 1,800 NA

MP MP034 Dysmorphic children MP034A Dysmorphic children 1,800 NA

MP MP035 Floppy infant MP035A Floppy infant 1,800 NA

MP MP036 Inborn errors of metabolism MP036A Inborn errors of metabolism 1,800 NA
Page 102
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MP MP037 Wilson’s disease MP037A Wilson’s disease 1,800 NA

Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP038 Rheumatoid arthritis MP038A Rheumatoid arthritis 1,800 NA
Medicine

Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP039 Rheumatic fever MP039A Rheumatic fever 1,800 NA
Medicine

MP MP040 Cyanotic spells MP040A Cyanotic spells 1,800 NA

MP MP040 Cyanotic spells MP040B Cyanotic spells with CHD 1,800 NA
Page 103
2.1


Pediatric Medical Cyanotic spells with Chest HDU - 2700 HDU - 2700
MP MP040 Cyanotic spells MP040C 1,800 NA
Management infection ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600

MP MP040 Cyanotic spells MP040D Cyanotic spells with Sepsis 1,800 NA

MP MP041 Immune haemolytic anemia MP041A Immune haemolytic anemia 1,800 NA

Pediatric Medical
Idiopathic Thrombocytopenic Idiopathic Thrombocytopenic HDU - 2700 HDU - 2700
Purpura Purpura ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medicine

MP MP043 Kawasaki Disease MP043A Kawasaki Disease 1,800 NA
Page 104
2.1


Pediatric Medical
HDU - 2700 HDU - 2700
MP Management, General MP044 Steven Johnson syndrome MP044A Steven Johnson syndrome 1,800 NA
Medicine

MP MP045 Trauma MP045A Trauma 1,800 NA

Pediatric Medical
Ketogenic diet initiation in Ketogenic diet initiation in HDU - 2700 HDU - 2700
refractory epilepsy refractory epilepsy ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medicine
Pediatric Medical Severe Acute Laryngitis

MP MP047 Acute Laryngitis MP047A - TBF TBF TBF
Management requiring hospitalization
Pediatric Medical
MP MP048 Hemostatic Disorders MP048A Platelet function disorders - TBF TBF TBF
Management
Page 105
2.1

2D External Beam
Radiotherapy (6 Fractions)
MR Radiation Oncology MR001 MR001A Radical 11,000 NA NA 11,000
(Inclusive of Simulation &
Planning Cost)
2D External Beam
MR Radiation Oncology MR001 MR001B Adjuvant 11,000 NA NA 11,000
Planning Cost)
2D External Beam
MR Radiation Oncology MR001 MR001C Neoadjuvant 11,000 NA NA 11,000
Planning Cost)
2D External Beam
MR Radiation Oncology MR001 MR001D Additional fractions - 1 - NA 500 (18) 9,000
Planning Cost)
2D External Beam
Radiotherapy - Palliative
MR Radiation Oncology MR002 (Upto 10 Fractions) MR002A Palliative 10,000 NA NA 10,000
Planning Cost)
Page 106
2.1

2D External Beam
MR Radiation Oncology MR003 MR003A Radical 20,000 NA NA 20,000
Planning Cost)
2D External Beam
MR Radiation Oncology MR003 MR003B Adjuvant 20,000 NA NA 20,000
Planning Cost)
2D External Beam
MR Radiation Oncology MR003 MR003C Neoadjuvant 20,000 NA NA 20,000
Planning Cost)
2D External Beam
MR Radiation Oncology MR003 MR003D Additional fractions - 2 - NA 500 (10) 5,000
Planning Cost)
Linear Accelerator, External

Beam Radiotherapy 3D CRT
MR Radiation Oncology MR004 (6 Fractions) MR004A Radical 21,000 NA NA 21,000
Planning Cost)
Page 107
2.1


MR Radiation Oncology MR004 (6 Fractions) MR004B Adjuvant 21,000 NA NA 21,000
Planning Cost)

MR Radiation Oncology MR004 (6 Fractions) MR004C Neoadjuvant 21,000 NA NA 21,000
Planning Cost)

MR Radiation Oncology MR004 (6 Fractions) MR004D Additional fractions - 3 - NA 1000 (18) 18,000
Planning Cost)

MR Radiation Oncology MR005 (25 Fractions) MR005A Radical 40,000 NA NA 40,000
Planning Cost)

MR Radiation Oncology MR005 (25 Fractions) MR005B Adjuvant 40,000 NA NA 40,000
Planning Cost)
Page 108
2.1


MR Radiation Oncology MR005 (25 Fractions) MR005C Neoadjuvant 40,000 NA NA 40,000
Planning Cost)

MR Radiation Oncology MR005 (25 Fractions) MR005D Additional fractions - 4 - NA 1000 (10) 10,000
Planning Cost)

Beam Radiotherapy IMRT
(Intensity Modulated
MR Radiation Oncology MR006 Radiotherapy) MR006A Radical 70,000 NA NA 70,000
(20 Fractions)
Planning Cost)

MR Radiation Oncology MR006 Radiotherapy) MR006B Adjuvant 70,000 NA NA 70,000
(20 Fractions)
Planning Cost)

MR Radiation Oncology MR006 Radiotherapy) MR006C Neoadjuvant 70,000 NA NA 70,000
(20 Fractions)
Planning Cost)
Page 109
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MR Radiation Oncology MR006 Radiotherapy) MR006D Additional fractions - 5 - NA 2000 (15) 30,000
(20 Fractions)
Planning Cost)

MR Radiation Oncology MR007 Radiotherapy) MR007A Radical 42,000 NA NA 42,000
(6 Fractions)
Planning Cost)

MR Radiation Oncology MR007 Radiotherapy) MR007B Adjuvant 42,000 NA NA 42,000
(6 Fractions)
Planning Cost)

MR Radiation Oncology MR007 Radiotherapy) MR007C Neoadjuvant 42,000 NA NA 42,000
(6 Fractions)
Planning Cost)

MR Radiation Oncology MR007 Radiotherapy) MR007D Additional fractions - 6 - NA 2000 (18) 36,000
(6 Fractions)
Planning Cost)
Page 110
2.1

Linear Accelerator External

Beam Radiotherapy IGRT
(Image Guided radiotherapy)
MR Radiation Oncology MR008 with 3D CRT or IMRT MR008A Radical 90,000 NA NA 90,000
(20 Fractions)
Planning Cost)

MR Radiation Oncology MR008 with 3D CRT or IMRT MR008B Adjuvant 90,000 NA NA 90,000
(20 Fractions)
Planning Cost)

MR Radiation Oncology MR008 with 3D CRT or IMRT MR008C Neoadjuvant 90,000 NA NA 90,000
(20 Fractions)
Planning Cost)

MR Radiation Oncology MR008 with 3D CRT or IMRT MR008D Additional fractions - 7 - NA 2500 (15) 37,500
(20 Fractions)
Planning Cost)

MR Radiation Oncology MR009 with 3D CRT or IMRT MR009A Radical 55,000 NA NA 55,000
(6 Fractions)
Planning Cost)
Page 111
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MR Radiation Oncology MR009 with 3D CRT or IMRT MR009B Adjuvant 55,000 NA NA 55,000
(6 Fractions)
Planning Cost)

MR Radiation Oncology MR009 with 3D CRT or IMRT MR009C Neoadjuvant 55,000 NA NA 55,000
(6 Fractions)
Planning Cost)

MR Radiation Oncology MR009 with 3D CRT or IMRT MR009D Additional fractions - 8 - NA 2500 (18) 45,000
(6 Fractions)
Planning Cost)
SRT / SBRT with IGRT

(Stereotacatic radiotherapy)
MR Radiation Oncology MR010 (4 Fractions) MR010A 82,000 NA NA 82,000
Planning Cost)

MR Radiation Oncology MR010 (4 Fractions) MR010B Additional fractions - 9 - NA 11000 (4) 44,000
Planning Cost)
Page 112
2.1

SRS with IGRT (Stereotacatic

radiotherapy) SRS with IGRT (Stereotacatic
MR Radiation Oncology MR011 MR011A 70,000 NA NA 70,000
(Inclusive of Simulation & radiotherapy)
Planning Cost)
Respiratory Gating along with

Linear Accelerator planning (5
MR Radiation Oncology MR012 Fractions) MR012A 65,000 NA NA 65,000
Linear Accelerator planning
Planning Cost)

Linear Accelerator planning (5
MR Radiation Oncology MR012 Fractions) MR012B Additional fractions - 10 - NA 3500 (10) 35,000
Planning Cost)
Brachytherapy High Dose

MR Radiation Oncology MR013 MR013A Intracavitory 3,500 NA NA 3,500
Radiation

MR Radiation Oncology MR013 MR013B Intraluminal 3,500 NA NA 3,500
Radiation
Page 113
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MR Radiation Oncology MR013 MR013C Endobiliary 3,500 NA NA 3,500
Radiation

MR Radiation Oncology MR013 MR013D Endobronchial 3,500 NA NA 3,500
Radiation

MR Radiation Oncology MR013 MR013E CVS 3,500 NA NA 3,500
Radiation

Radiation (5 doses)
MR Radiation Oncology MR014 (Inclusive of Simulation, MR014A Interstitial 42,000 NA NA 42,000
Planning Cost, OT & other
charges )

Radiation (5 doses)
MR Radiation Oncology MR014 (Inclusive of Simulation, MR014B Surface Mould 42,000 NA NA 42,000
charges )
Page 114
2.1


Radiation (5 doses)
MR Radiation Oncology MR014 (Inclusive of Simulation, MR014C Additional fractions - 11 - NA 1250 (15) 18,750
charges )
Transplant surgery, including

OT Organ and Tissue Transplant OT001 Renal Transplant OT001A 215,595 TBF TBF TBF
donor nephrectomy
OT Organ and Tissue Transplant OT001 Renal Transplant OT001B Induction 39,526 TBF TBF TBF
OT Organ and Tissue Transplant OT001 Renal Transplant OT001C Intervention for acute rejection 107,797 TBF TBF TBF
Post-Transplant Medication –
OT Organ and Tissue Transplant OT001 Renal Transplant OT001D 50,000 TBF TBF TBF
Month 1-3
Page 115
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OT Organ and Tissue Transplant OT001 Renal Transplant OT001E 50,000 TBF TBF TBF
Month 3-6
OT Organ and Tissue Transplant OT001 Renal Transplant OT001F 40,000 TBF TBF TBF
Month 6-12
Fracture - Conservative Fracture - Conservative

Orthopedics, Emergency
SB SB001 Management - SB001A Management - 2,000 NA NA 2,000
Room Packages
Without plaster Without plaster
SB Orthopedics SB002 Application of Traction SB002A Skeletal Tractions with pin 2,000 NA NA 2,000
SB Orthopedics SB002 Application of Traction SB002B Skin Traction 700 NA NA 700
Page 116
2.1

SB Orthopedics SB003 Application of P.O.P. casts SB003A Upper Limbs 3,000 NA NA 3,000
SB Orthopedics SB003 Application of P.O.P. casts SB003B Lower Limbs 3,000 NA NA 3,000
Application of P.O.P. Spikas &

SB Orthopedics SB004 SB004A Spikas 3,500 NA NA 3,500
Jackets
Application of P.O.P. Spikas &

SB Orthopedics SB004 SB004B Jackets 3,500 NA NA 3,500
Jackets
SB Orthopedics SB005 External fixation of Fracture SB005A Long bone 14,000 NA External Fixator - 5000 19,000
Page 117
2.1

SB Orthopedics SB005 External fixation of Fracture SB005B Small bone 9,500 NA External Fixator - 5000 14,500
SB Orthopedics SB005 External fixation of Fracture SB005C Pelvis 14,000 NA External Fixator - 5000 19,000
SB Orthopedics SB005 External fixation of Fracture SB005D Both bones - forearms 15,000 NA External Fixator - 5000 20,000
Implant for Percutaneous -

Percutaneous - Fixation of Percutaneous - Fixation of LA - 3000 LA - 5000
SB Orthopedics SB006 SB006A 3,000 Fixation of Fracture
Fracture Fracture GA - 8000 GA - 10000
(K - Wire / Screw) - 2000
Implant for Elastic Nailing of

Elastic nailing for fracture
SB Orthopedics SB007 SB007A Femur 11,000 NA Femur / Humerus / Forearm 16,000
fixation
(Elastic Nail) - 5000
Page 118
2.1


SB Orthopedics SB007 SB007B Humerus 11,000 NA Femur / Humerus / Forearm 16,000
fixation

SB Orthopedics SB007 SB007C Forearm 11,000 NA Femur / Humerus / Forearm 16,000
fixation
Internal Fixation of Small Internal Fixation of Small Implant for Internal Fixation of
SB Orthopedics SB008 SB008A 8,500 NA 10,000
Bones Bones Small Bones - 1500
Locking Plate for Metaphyseal

Fracture - Long Bones - Fracture - Long Bones -
SB Orthopedics SB009 SB009A 12,700 NA fracture - Long Bone (2) - 26,700
Metaphyseal - ORIF Metaphyseal - ORIF
7000
Fixation of Diaphyseal Open Reduction Internal Plate for ORIF - Diaphyseal

Fracture - Long Bone Fixation fracture - Long Bone - 6000
Page 119
2.1

Fixation of Diaphyseal IM Nail for CR&F - Diaphyseal

SB Orthopedics SB010 SB010B Closed Reduction & Fixation 18,000 NA 25,000
Fracture - Long Bone fracture - Long Bone - 7000
Plate for Comminuted

Surgery for Comminuted
SB Orthopedics SB011 SB011A Plating 11,800 NA Fracture - Olecranon of Ulna - 19,800
Fracture - Olecranon of Ulna
8000
Implant for Fracture Head

SB Orthopedics SB012 Fracture Head radius SB012A Fixation 10,000 NA 15,000
radius (Plate / Screw) - 5000
SB Orthopedics SB012 Fracture Head radius SB012B Excision 9,200 NA NA 9,200
Fracture - Single Bone - Fracture - Single Bone - Implant for Fracture - Single
SB Orthopedics SB013 Forearm - ORIF - Plating / SB013A Forearm - ORIF - Plating / 8,900 NA Bones - Forearm - ORIF 12,400
Nailing Nailing (Plate / Nail) - 3500
Page 120
2.1

Fracture - Both Bones - Fracture - Both Bones - Implants for Fracture - Both
SB Orthopedics SB014 Forearm - ORIF - Plating / SB014A Forearm - ORIF - Plating / 12,700 NA Bones - Forearm - ORIF 19,700
Nailing Nailing (Plates & / or Nails) - 7000
Fracture Condyle - Humerus - Implant for Fracture Condyle -

SB Orthopedics SB015 SB015A Lateral Condyle 8,500 NA 10,000
ORIF Humerus - ORIF - 1500
Fracture Condyle - Humerus - Implant for Fracture Condyle -

SB Orthopedics SB015 SB015B Medial Condyle 8,500 NA 10,000
ORIF Humerus - ORIF - 1500
Implant for Fracture

Fracture intercondylar Fracture intercondylar
intercondylar Humerus +
SB Orthopedics SB016 Humerus + olecranon SB016A Humerus + olecranon 15,100 NA 26,100
olecranon osteotomy (TBW +
osteotomy osteotomy
2 Plates) - 11000
Open Reduction Internal Implant for Displaced Clavicle

SB Orthopedics SB017 Displaced Clavicle Fracture SB017A 17,000 NA 20,000
Fixation Fracture (Plate) - 3000
Page 121
2.1

Implant for "Fracture -

Acetabulum - Single
SB Orthopedics SB018 Fracture - Acetabulum SB018A Single Approach 28,000 NA 38,000
Approach" - Recon Plate (2) -
10000
Implant for "Fracture -

Acetabulum - Combined
SB Orthopedics SB018 Fracture - Acetabulum SB018B Combined Approach 33,500 NA 48,500
Approach" - Recon Plate (3) -
15000
Cannulated Screws for Closed

Closed Reduction and Reduction and Percutaneous
SB Orthopedics SB019 Fracture - Neck Femur SB019A 10,000 NA 15,000
Percutaneous Screw Fixation Screw Fixation (neck femur) -
5000
Dynamic Hip Screw for

Intertrochanteric Fracture with
SB Orthopedics SB019 Fracture - Neck Femur SB019B 15,800 NA Intertrochanteric Fracture - 20,800
Dynamic Hip Screw
5000
Intertrochanteric Fracture with

SB Orthopedics SB019 Fracture - Neck Femur SB019C 16,100 NA Proximal Femoral Nail - 8000 24,100
Proximal Femoral Nail
Page 122
2.1

Implant for Ankle Fracture

Open Reduction Internal ORIF
SB Orthopedics SB020 Ankle Fractures SB020A 14,000 NA 19,000
Fixation (Tension Band Wire + Plate) -
5000
Implant for Cervical spine

fixation including odontoid
(Screw) - 5000
Cervical spine fixation Cervical spine fixation
SB Orthopedics SB021 SB021A 20,000 NA fixation including odontoid 55,000
including odontoid including odontoid
(Odontoid Screw) - 20000
fixation including odontoid
(Cage) - 10000
Implant for Dorsal and lumber

spine fixation
(Plate including screw) (6) - 70000
Dorsal and lumber spine
SB Orthopedics SB022 SB022A Anterior 40,000 NA 5000 or
fixation
or 50000
spine fixation (Cage) - 10000

spine fixation
(Plate including screw) (6) - 60000
Dorsal and lumber spine
SB Orthopedics SB022 SB022B Posterior 30,000 NA 5000 or
fixation
or 40000
spine fixation (Cage) - 10000
SB Orthopedics SB023 Bone grafting for Non union SB023A Bone grafting for Non union 10,000 NA NA 10,000
Page 123
2.1

SB Orthopedics SB024 Arthorotomy of any joint SB024A Arthorotomy of any joint 14,000 NA NA 14,000
SB Orthopedics SB025 Arthrolysis of joint SB025A Elbow 15,000 NA NA 15,000
SB Orthopedics SB025 Arthrolysis of joint SB025B Knee 15,000 NA NA 15,000
SB Orthopedics SB025 Arthrolysis of joint SB025C Ankle 15,000 NA NA 15,000
SB Orthopedics SB026 Arthrodesis SB026A Ankle / Triple with implant 15,000 NA NA 15,000
Page 124
2.1

Implant for Arthrodesis of

SB Orthopedics SB026 Arthrodesis SB026B Shoulder 15,000 NA Shoulder (Screw / Plate) - 20,000
5000

SB Orthopedics SB026 Arthrodesis SB026C Wrist 15,000 NA 20,000
Wrist (Plate) - 5000

Knee
SB Orthopedics SB026 Arthrodesis SB026D Knee 15,000 NA 25,000
(Compression Assembly /
Ilizarov) - 10000
Orthopedics, Surgical
SB SB026 Arthrodesis SB026E Hand 27,000 NA NA 27,000
Oncology
Orthopedics, Surgical
SB SB026 Arthrodesis SB026F Foot 27,000 NA NA 27,000
Oncology
Page 125
2.1

SB Orthopedics SB026 Arthrodesis SB026G Ankle / Triple without implant 15,000 NA NA 15,000
SB Orthopedics SB027 Disarticulation SB027A Hind quarter 25,000 NA NA 25,000
SB Orthopedics SB027 Disarticulation SB027B Fore quarter 25,000 NA NA 25,000
Closed reduction of joint

SB Orthopedics SB028 SB028A Hip 7,400 NA NA 7,400
dislocation

SB Orthopedics SB028 SB028B Shoulder 5,500 NA NA 5,500
dislocation
Page 126
2.1


SB Orthopedics SB028 SB028C Elbow 5,500 NA NA 5,500
dislocation

SB Orthopedics SB028 SB028D Knee 5,500 NA NA 5,500
dislocation
Implant for Open Reduction of

SB Orthopedics SB029 Open Reduction of Small Joint SB029A Open Reduction of Small Joint 8,500 NA Small joints 10,000
(K - Wire) - 1500
Implant for Tension Band

SB Orthopedics SB030 Tension Band Wiring SB030A Tension Band Wiring 13,000 NA 15,000
Wiring (Wire) - 2000
Implant for Unipolar

SB Orthopedics SB031 Hemiarthroplasty SB031A Unipolar 15,000 NA 18,000
Hemiarthroplasty - 3000
Page 127
2.1

Non - Modular - Non -

Cemented - 7000 22000
SB Orthopedics SB031 Hemiarthroplasty SB031B Bipolar (Non - Modular) 15,000 NA or 0r
Non - Modular - Cemented - 25000
10000
SB Orthopedics SB031 Hemiarthroplasty SB031C Bipolar (Modular) 15,000 NA Modular - Cemented - 20000 35,000
Implant for AC Joint

reconstruction / Stabilization
AC Joint reconstruction /
SB Orthopedics SB032 SB032A Rockwood Type - I 20,500 NA (Plate/ screw / Fibre wire / 30,500
Stabilization
reconstruction by tendon etc) -
10000

SB Orthopedics SB032 SB032B Rockwood Type - II 20,500 NA (Plate/ screw / Fibre wire / 30,500
Stabilization
10000

SB Orthopedics SB032 SB032C Rockwood Type - III 20,500 NA (Plate/ screw / Fibre wire / 30,500
Stabilization
10000
Page 128
2.1


SB Orthopedics SB032 SB032D Rockwood Type - IV 20,500 NA (Plate/ screw / Fibre wire / 30,500
Stabilization
10000

SB Orthopedics SB032 SB032E Rockwood Type - V 20,500 NA (Plate/ screw / Fibre wire / 30,500
Stabilization
10000

SB Orthopedics SB032 SB032F Rockwood Type - VI 20,500 NA (Plate/ screw / Fibre wire / 30,500
Stabilization
10000
Excision Arthoplasty of Femur Excision Arthoplasty of Femur

SB Orthopedics SB033 SB033A 17,500 NA NA 17,500
head head
SB Orthopedics SB034 Open Reduction of CDH SB034A Open Reduction of CDH 20,000 NA NA 20,000
Page 129
2.1

SB Orthopedics SB035 Patellectomy SB035A Patellectomy 11,000 NA NA 11,000
Arthroscopic Meniscus Repair Arthroscopic Meniscus Repair

/ Meniscectomy / Meniscectomy
Implant for Elbow

SB Orthopedics SB037 Elbow replacement SB037A Elbow replacement 14,100 NA 45,100
Replacement - 31000
Implant for Total Hip

SB Orthopedics SB038 Total Hip Replacement SB038A Cemented 35,000 NA Replacement - Cemented - 70,000
35000

SB Orthopedics SB038 Total Hip Replacement SB038B Cementless 37,000 NA Replacement - Cementless - 97,000
60000
Page 130
2.1


SB Orthopedics SB038 Total Hip Replacement SB038C Hybrid 32,000 NA 77,000
Replacement - Hybrid - 45000
Revision - Total Hip Implant for Revision Total Hip

SB Orthopedics SB038 Total Hip Replacement SB038D 40,000 NA 140,000
Replacement Replacement - 100000
Primary - Total Knee Implant for Total Knee

SB Orthopedics SB039 Total Knee Replacement SB039A 25,000 NA 80,000
Replacement Replacement - 55000
Revision - Total Knee Implant for Revision Total

SB Orthopedics SB039 Total Knee Replacement SB039B 30,000 NA 130,000
Replacement Knee Replacement - 100000
Bone Tumour Excision Bone Tumour Excision

Modular Custom Prosthesis
(malignant) including GCT + (malignant) including GCT +
for Bone Tumour Excision -
SB Orthopedics SB040 Joint replacement SB040A Joint replacement 57,000 NA 177,000
malignant including GCT +
(depending upon type of joint (depending upon type of joint
Joint replacement - 120000
and implant) and implant)
Page 131
2.1

Implant for Bone Tumour

Orthopedics, Surgical Bone Tumour Excision + Bone Tumour Excision +
SB SB041 SB041A 30,000 NA Excision + reconstruction 40,000
Oncology reconstruction reconstruction
(Plate) - 10000
Bone Tumour (benign) Bone Tumour (benign)

SB Orthopedics SB042 curettage / Excision SB042A curettage / Excision and bone 20,000 NA NA 20,000
and bone grafting grafting
SB Orthopedics SB043 Single Stage Amputation SB043A Above Elbow 15,000 NA NA 15,000
SB Orthopedics SB043 Single Stage Amputation SB043B Below Elbow 15,000 NA NA 15,000
SB Orthopedics SB043 Single Stage Amputation SB043C Above Knee 15,000 NA NA 15,000
Page 132
2.1

SB Orthopedics SB043 Single Stage Amputation SB043D Below Knee 15,000 NA NA 15,000
SB Orthopedics SB043 Single Stage Amputation SB043E Foot 15,000 NA NA 15,000
SB Orthopedics SB043 Single Stage Amputation SB043F Hand 15,000 NA NA 15,000
SB Orthopedics SB043 Single Stage Amputation SB043G Wrist 15,000 NA NA 15,000
SB Orthopedics SB044 Two Stage Amputation SB044A Above Elbow 23,200 NA NA 23,200
Page 133
2.1

SB Orthopedics SB044 Two Stage Amputation SB044B Below Elbow 23,200 NA NA 23,200
SB Orthopedics SB044 Two Stage Amputation SB044C Above Knee 23,200 NA NA 23,200
SB Orthopedics SB044 Two Stage Amputation SB044D Below Knee 23,200 NA NA 23,200
SB Orthopedics SB044 Two Stage Amputation SB044E Foot 23,200 NA NA 23,200
SB Orthopedics SB044 Two Stage Amputation SB044F Hand 23,200 NA NA 23,200
Page 134
2.1

SB Orthopedics SB044 Two Stage Amputation SB044G Wrist 23,200 NA NA 23,200
SB Orthopedics SB045 Amputation - Fingers / Toes SB045A Finger(s) 10,400 NA NA 10,400
SB Orthopedics SB045 Amputation - Fingers / Toes SB045B Toe(s) 10,400 NA NA 10,400
SB Orthopedics SB046 Tendon Grafting / Repair SB046A Tendon Grafting 15,000 NA NA 15,000
SB Orthopedics SB046 Tendon Grafting / Repair SB046B Tendon Repair 15,000 NA NA 15,000
Page 135
2.1

SB Orthopedics SB047 Tendon Release / Tenotomy SB047A Tendon Release / Tenotomy 5,000 NA NA 5,000
SB Orthopedics SB048 Tenolysis SB048A Tenolysis 5,000 NA NA 5,000
Implant & brace for

Reconstruction of Cruciate Reconstruction of ACL / PCL
SB Orthopedics SB049 Ligament with implant and SB049A Anterior 25,700 NA (Bio screw / Endobutton / 42,700
brace Suture disc + Ethibond) -
17000
Implant & brace for

Reconstruction of Cruciate Reconstruction of ACL / PCL
SB Orthopedics SB049 Ligament with implant and SB049B Posterior 25,700 NA (Bio screw / Endobutton / 42,700
brace Suture disc + Ethibond) -
17000
SB Orthopedics SB050 Fasciotomy SB050A Fasciotomy 10,500 NA NA 10,500
Page 136
2.1

Duputryen’s Contracture Duputryen’s Contracture

release + rehabilitation release + rehabilitation
Debridement & Closure of

Anti-biotic + dressing -
SB Orthopedics SB052 injuries - contused lacerated SB052A 10,900 NA NA 10,900
minimum of 5 sessions
wounds
Debridement & Closure of

Anti-biotic + dressing -
SB Orthopedics SB052 injuries - contused lacerated SB052B 3,000 NA NA 3,000
minimum of 2 sessions
wounds
SB Orthopedics SB053 Sequestectomy / Curettage SB053A Sequestectomy / Curettage 10,000 NA NA 10,000
Implant for Spine deformity

correction
(Plate including screw) (6) -
SB Orthopedics SB054 Spine deformity correction SB054A Spine deformity correction 40,000 NA 5000 80,000
Implant for Spine deformity
correction
(Cage) - 10000
Page 137
2.1

Implant for Osteotomy - Long

SB Orthopedics SB055 Osteotomy SB055A Long Bone 18,000 NA 23,000
Bone (Screw) - 5000
SB Orthopedics SB055 Osteotomy SB055B Small Bone 10,000 NA NA 10,000
SB Orthopedics SB056 Pelvic Osteotomy and fixation SB056A Pelvic Osteotomy and fixation 20,000 NA NA 20,000
Plate for High Tibial

SB Orthopedics SB057 High Tibial Osteotomy SB057A High Tibial Osteotomy 16,000 NA 23,000
Osteotomy - 7000
Implant for Ilizarov fixation -

SB Orthopedics SB058 Ilizarov Fixation SB058A Ilizarov Fixation 15,000 NA 25,000
10000
Page 138
2.1

Implant for Limb Lengthening /

Limb Lengthening / Bone Limb Lengthening / Bone
SB Orthopedics SB059 SB059A 23,700 NA Bone Transport by Ilizarov - 35,700
Transport by Ilizarov Transport by Ilizarov
12000
Growth Modulation and Growth Modulation and Implant for Growth Modulation
fixation fixation & Fixation (Plate) (6) - 5000
Corrective Surgery for foot

SB Orthopedics SB061 SB061A Vertical Talus 15,000 NA NA 15,000
deformities
Corrective Surgery for foot

SB Orthopedics SB061 SB061B Other foot deformities 15,000 NA NA 15,000
deformities
Correction of club foot per Correction of club foot per

cast cast
Page 139
2.1

Corrective Surgery in Club Corrective Surgery in Club

SB Orthopedics SB063 SB063A 12,000 NA JESS Fixator - 8000 20,000
Foot / JESS Fixator Foot / JESS Fixator
Excision of Osteochondroma /
SB Orthopedics SB064 SB064A Osteochondroma 10,000 NA NA 10,000
Exostosis
Excision of Osteochondroma /
SB Orthopedics SB064 SB064B Exostosis 10,000 NA NA 10,000
Exostosis
Orthopedics,
SB SB065 Excision of Bursa SB065A Excision of Bursa 3,000 NA NA 3,000
General Surgery
Nerve Transposition / Release

SB Orthopedics SB066 SB066A Nerve Transposition 13,000 NA NA 13,000
/ Neurolysis
Page 140
2.1


SB Orthopedics SB066 SB066B Nerve Release 13,000 NA NA 13,000
/ Neurolysis

SB Orthopedics SB066 SB066C Nerve Neurolysis 13,000 NA NA 13,000
/ Neurolysis
SB Orthopedics SB067 Nerve Repair Surgery SB067A Nerve Repair Surgery 13,800 NA NA 13,800
SB Orthopedics, Neurosurgery SB068 Nerve root block SB068A Nerve root block 3,000 NA NA 3,000
Exploration and Ulnar nerve Exploration and Ulnar nerve

Repair Repair
Page 141
2.1

SB Orthopedics SB070 Implant Removal under LA SB070A K - Wire 5,000 NA NA 5,000
SB Orthopedics SB070 Implant Removal under LA SB070B Screw 5,000 NA NA 5,000
Implant Removal under RA /

SB Orthopedics SB071 SB071A Nail 15,000 NA NA 15,000
GA
Implant Removal under RA /

SB Orthopedics SB071 SB071B Plate 15,000 NA NA 15,000
GA
SB Orthopedics SB072 Core Decompression SB072A Core Decompression 10,000 TBF TBF TBF
Page 142
2.1

Arthroscopy / open - Arthroscopy / open -

SB Orthopedics SB074 SB074A 10,000 TBF TBF TBF
synovectomy synovectomy
SC Surgical Oncology SC001 Glossectomy SC001A Hemiglossectomy 24,000 NA NA 24,000
SC Surgical Oncology SC001 Glossectomy SC001B Total Glossectomy 30,000 NA NA 30,000
SC Surgical Oncology, ENT SC002 Palatectomy SC002A Soft palate 20,000 NA NA 20,000
SC Surgical Oncology, ENT SC002 Palatectomy SC002B Hard palate 20,000 NA NA 20,000
Page 143
2.1

SC Surgical Oncology SC003 Maxillectomy SC003A Partial 27,000 NA NA 27,000
SC Surgical Oncology SC003 Maxillectomy SC003B Radical 33,000 NA NA 33,000
SC Surgical Oncology SC003 Maxillectomy SC003C Total 30,000 NA NA 30,000
Composite resection (Oral Composite resection (Oral

SC Surgical Oncology SC004 SC004A 40,000 NA NA 40,000
Cavity) Cavity)
Oesophageal / Tracheal
SC Surgical Oncology SC005 SC005A Oesophageal stenting 45,000 NA Oesophageal stent 45,000
stenting
Page 144
2.1

Oesophageal / Tracheal
SC Surgical Oncology SC005 SC005B Tracheal stenting 45,000 NA Tracheal stent 45,000
stenting
Transthoracic esophagectomy:
SC Surgical Oncology SC006 SC006A Open 60,000 NA NA 60,000
2F / 3F
Transthoracic esophagectomy:
SC Surgical Oncology SC006 SC006B MIS 60,000 NA NA 60,000
2F / 3F
SC Surgical Oncology SC007 Gastric pull-up / Jejunal Graft SC007A Gastric pull-up / Jejunal Graft 36,000 NA NA 36,000
Radical Small Bowel

SC Surgical Oncology SC008 SC008A Open 33,000 NA NA 33,000
Resection
Page 145
2.1

Radical Small Bowel

SC Surgical Oncology SC008 SC008B Lap. 33,000 NA NA 33,000
Resection
SC Surgical Oncology SC009 Intersphincteric resection SC009A Open 40,200 NA NA 40,200
SC Surgical Oncology SC009 Intersphincteric resection SC009B Lap. 40,200 NA NA 40,200
Surgery for Abdominal wall Abdominal wall tumour

tumour resection
Surgery for Abdominal wall Abdominal wall tumour

SC Surgical Oncology SC010 SC010B 39,000 NA NA 39,000
tumour resection with reconstruction
Page 146
2.1

Exploratory laparotomy f / b Exploratory laparotomy f / b

diversion stoma / bypass diversion stoma
Exploratory laparotomy f / b Exploratory laparotomy f / b

diversion stoma / bypass diversion bypass
SC Surgical Oncology SC012 Abdominoperineal resection SC012A Open 39,600 NA NA 39,600
SC Surgical Oncology SC012 Abdominoperineal resection SC012B Lap. 39,600 NA NA 39,600
SC Surgical Oncology SC013 Omentectomy SC013A Omentectomy 21,000 NA NA 21,000
Page 147
2.1

Procedures Requiring Bypass Procedures Requiring Bypass

Techniques Techniques
Segmentectomy - Segmentectomy -
hepatobiliary system hepatobiliary system
Radical / Revision
SC Surgical Oncology SC016 SC016A Radical 39,600 NA NA 39,600
Cholecystectomy
Radical / Revision
SC Surgical Oncology SC016 SC016B Revision 39,600 NA NA 39,600
Cholecystectomy
Enucleation of pancreatic Enucleation of pancreatic

neoplasm neoplasm
Page 148
2.1

Surgical Oncology, Pediatric

SC SC018 Hepatoblastoma Excision SC018A Hepatoblastoma Excision 52,200 NA NA 52,200
Surgery
SC Surgical Oncology SC019 Hemipelvectomy - Internal SC019A Hemipelvectomy - Internal 54,000 NA NA 54,000
SC Surgical Oncology SC020 Pelvic Exenteration SC020A Anterior - Open 58,800 NA NA 58,800
SC Surgical Oncology SC020 Pelvic Exenteration SC020B Anterior - Lap. 58,800 NA NA 58,800
SC Surgical Oncology SC020 Pelvic Exenteration SC020C Total - Open 58,800 NA NA 58,800
Page 149
2.1

SC Surgical Oncology SC020 Pelvic Exenteration SC020D Total - Lap. 58,800 NA NA 58,800
Surgical Oncology, Pediatric

SC SC021 Wilms tumors: surgery SC021A Wilms tumors: surgery 33,000 NA NA 33,000
Surgery
Ureteric end to end Ureteric end to end

anastomosis anastomosis
Distal ureterectomy with Distal ureterectomy with

SC Surgical Oncology, Urology SC023 SC023A 30,000 NA NA 30,000
reimplantation reimplantation
With continent diversion -

SC Surgical Oncology, Urology SC024 Radical cystectomy SC024A 98,000 NA NA 98,000
Open
Page 150
2.1

SC Surgical Oncology, Urology SC024 Radical cystectomy SC024B With Ileal Conduit - Open 88,000 NA NA 88,000
SC Surgical Oncology, Urology SC024 Radical cystectomy SC024C With Ileal Conduit - Lap. 88,000 NA NA 88,000
SC Surgical Oncology, Urology SC024 Radical cystectomy SC024D With neobladder - Open 98,000 NA NA 98,000
SC Surgical Oncology, Urology SC024 Radical cystectomy SC024E With neobladder - Lap 98,000 NA NA 98,000
With ureterosigmoidostomy -
SC Surgical Oncology, Urology SC024 Radical cystectomy SC024F 75,000 NA NA 75,000
Open
Page 151
2.1

With ureterosigmoidostomy -
SC Surgical Oncology, Urology SC024 Radical cystectomy SC024G 75,000 NA NA 75,000
Lap
SC Surgical Oncology, Urology SC024 Radical cystectomy SC024H With ureterostomy -Open 70,000 NA NA 70,000
SC Surgical Oncology, Urology SC024 Radical cystectomy SC024I With ureterostomy -Lap. 70,000 NA NA 70,000
SC Surgical Oncology SC025 Channel TURP SC025A Channel TURP 22,800 NA NA 22,800
SC Surgical Oncology, Urology SC026 Radical Urethrectomy SC026A Radical Urethrectomy 30,000 NA NA 30,000
Page 152
2.1

Penile preserving surgery Penile preserving surgery

SC Surgical Oncology, Urology SC027 SC027A 25,000 NA NA 25,000
(WLE, Glansectomy, Laser) (WLE, Glansectomy, Laser)
Excision of undescended Excision of undescended

testicular mass testicular mass
SC Surgical Oncology SC029 Germ Cell Tumour Excision SC029A Germ Cell Tumour Excision 30,000 NA NA 30,000
Surgical Oncology, Obstetrics

SC SC030 Bilateral salpingoophorectomy SC030A Open 21,000 NA NA 21,000
& Gynecology

SC SC030 Bilateral salpingoophorectomy SC030B Lap. 21,000 NA NA 21,000
& Gynecology
Page 153
2.1

SC Surgical Oncology SC031 Leiomyoma excision SC031A Open 42,000 NA NA 42,000
SC Surgical Oncology SC031 Leiomyoma excision SC031B MIS 42,000 NA NA 42,000
Class I radical hysterectomy +

SC SC032 Radical Hysterectomy SC032A bilateral salpingoophorectomy 27,000 NA NA 27,000
& Gynecology
+ BPLND - Lap.
Class I radical hysterectomy +

SC SC032 Radical Hysterectomy SC032B bilateral salpingoophorectomy 27,000 NA NA 27,000
& Gynecology
+ BPLND - Open
Class I radical Hysterectomy

SC SC032 Radical Hysterectomy SC032C +/- bilateral 27,000 NA NA 27,000
& Gynecology
salpingoophorectomy - Lap.
Page 154
2.1

Class I radical Hysterectomy

SC SC032 Radical Hysterectomy SC032D +/- bilateral 27,000 NA NA 27,000
& Gynecology
salpingoophorectomy - Open
Surgical Oncology, Obstetrics Class II radical hysterctomy +

SC SC032 Radical Hysterectomy SC032E 27,000 NA NA 27,000
& Gynecology BPLND
Surgical Oncology, Obstetrics Class III radical hysterctomy +

SC SC032 Radical Hysterectomy SC032F 27,000 NA NA 27,000
& Gynecology BPLND
Hysterectomy + bilateral
Surgical Oncology, Obstetrics salpingoophorectomy +
SC SC032 Radical Hysterectomy SC032G 34,000 NA NA 34,000
& Gynecology omentectomy + peritonectomy
and organ resections
SC Surgical Oncology SC033 Radical vaginectomy SC033A Radical vaginectomy 30,000 NA NA 30,000
Page 155
2.1

Surgical Oncology, Obstetrics Vulvectomy + reconstruction Vulvectomy + reconstruction

SC SC034 SC034A 36,000 NA NA 36,000
& Gynecology procedures procedures
SC Surgical Oncology SC035 Radical Trachelectomy SC035A Radical Trachelectomy 40,000 NA NA 40,000
SC Surgical Oncology SC036 Sacral Tumour Excision SC036A Anterior + Posterior approach 60,000 NA NA 60,000
SC Surgical Oncology SC036 Sacral Tumour Excision SC036B Posterior approach 54,000 NA NA 54,000
Resection of nasopharyngeal Resection of nasopharyngeal

tumour tumour
Page 156
2.1

SC Surgical Oncology SC038 Total Pharyngectomy SC038A Total Pharyngectomy 36,000 NA NA 36,000
Parapharyngeal Tumour Parapharyngeal Tumour

Excision Excision
Partial laryngectomy (voice

SC Surgical Oncology SC040 Laryngectomy SC040A 39,000 NA Voice prosthesis - 30000 69,000
preserving)
SC Surgical Oncology SC040 Laryngectomy SC040B Total Laryngectomy 36,000 NA NA 36,000
SC Surgical Oncology SC041 Tracheal resection SC041A Tracheal resection 36,000 NA NA 36,000
Page 157
2.1

SC Surgical Oncology SC042 Tracheal / Carinal resection SC042A Tracheal / Carinal resection 58,800 NA NA 58,800
Tracheal Stenosis (End to end Tracheal Stenosis (End to end

Anastamosis) (Throat) Anastamosis) (Throat)
Central airway tumour Central airway tumour

debulking debulking
SC Surgical Oncology SC045 Diagnostic thoracoscopy SC045A Diagnostic thoracoscopy 15,000 NA NA 15,000
Sleeve resection of lung Sleeve resection of lung

cancer cancer
Page 158
2.1

SC Surgical Oncology SC047 Mediastinoscopy SC047A Diagnostic 22,200 NA NA 22,200
SC Surgical Oncology SC047 Mediastinoscopy SC047B Staging 22,200 NA NA 22,200
Removal of Chest Wall

SC Surgical Oncology SC048 SC048A Chest Wall Tumour Excision 36,000 NA NA 36,000
Tumour
Removal of Chest Wall Removal of chest wall tumour

Tumour with reconstruction
SC Surgical Oncology SC049 Pleurectomy Decortication SC049A Pleurectomy Decortication 39,000 NA NA 39,000
Page 159
2.1

SC Surgical Oncology SC050 Chamberlain procedure SC050A Chamberlain procedure 22,200 NA NA 22,200
SC Surgical Oncology SC051 Extrapleural pneumonectomy SC051A Extrapleural pneumonectomy 66,000 NA NA 66,000
SC Surgical Oncology SC052 Pneumonectomy SC052A Pneumonectomy 54,000 NA NA 54,000
SC Surgical Oncology SC053 Lung metastectomy SC053A Open 30,000 NA NA 30,000
SC Surgical Oncology SC053 Lung metastectomy SC053B VATS 30,000 NA NA 30,000
Page 160
2.1

SC Surgical Oncology SC054 Thoracostomy SC054A Thoracostomy 19,800 NA NA 19,800
SC Surgical Oncology SC055 Mediastinal lymphadenectomy SC055A Open 36,000 NA NA 36,000
SC Surgical Oncology SC055 Mediastinal lymphadenectomy SC055B Video - assisted 36,000 NA NA 36,000
Mediastinal mass excision with Mediastinal mass excision with

lung resection lung resection
SC Surgical Oncology SC057 Segmental resection of lung SC057A Open 42,000 NA NA 42,000
Page 161
2.1

SC Surgical Oncology SC057 Segmental resection of lung SC057B Thoracoscopic 42,000 NA NA 42,000
SC Surgical Oncology SC058 Wedge resection lung SC058A Open 36,000 NA NA 36,000
SC Surgical Oncology SC058 Wedge resection lung SC058B Thoracoscopic 36,000 NA NA 36,000
Breast conserving surgery

SC Surgical Oncology SC059 Breast conserving surgery SC059A (lumpectomy + axillary 22,800 NA NA 22,800
surgery)
Breast conserving surgery with

SC Surgical Oncology SC059 Breast conserving surgery SC059B 24,600 NA NA 24,600
Oncoplasty
Page 162
2.1

Axillary Sampling / Sentinel Axillary Sampling / Sentinel

Node Biopsy Node Biopsy
SC Surgical Oncology SC061 Axillary dissection SC061A Axillary dissection 19,800 NA NA 19,800
Scalp tumour excision with Scalp tumour excision with

skull bone excision skull bone excision
SC Surgical Oncology SC063 Neuroblastoma Excision SC063A Neuroblastoma Excision 60,000 NA NA 60,000
Excision of Pinna for Growths

/ Injuries - Total Amputation &
SC Surgical Oncology, ENT SC064 SC064A Growth - Squamous 21,600 NA NA 21,600
Excision of External Auditory
Meatus
Page 163
2.1


SC Surgical Oncology, ENT SC064 SC064B Growth - Basal 21,600 NA NA 21,600
Meatus

SC Surgical Oncology, ENT SC064 SC064C Injury 21,600 NA NA 21,600
Meatus
Neck dissection - Neck dissection -

comprehensive comprehensive
Benign Soft Tissue Tumour - Benign Soft Tissue Tumour -

Excision Excision
Malignant Soft Tissue Tumour - Malignant Soft Tissue Tumour -

Excision Excision
Page 164
2.1

Surgical Oncology, Plastic &

SC SC068 Regional flap SC068A Myocutaneous flap 30,600 NA NA 30,600
Reconstructive Surgery
Surgical Oncology, Plastic &

SC SC068 Regional flap SC068B Fasciocutaneous flap 30,600 NA NA 30,600
SC Surgical Oncology SC069 Rotationplasty SC069A Rotationplasty 45,000 NA NA 45,000
Surgical Oncology, Bone tumors / soft tissue Bone tumors / soft tissue
SC SC070 SC070A 30,000 NA NA 30,000
Orthopedics sarcomas: surgery sarcomas: surgery
SC Surgical Oncology SC071 Endoprosthesis Revision SC071A Complete 39,000 NA NA 39,000
Page 165
2.1

SC Surgical Oncology SC071 Endoprosthesis Revision SC071B Partial 24,000 NA NA 24,000
Vertebral Tumour Excision Vertebral Tumour Excision

and Reconstruction and Reconstruction
Surgical Oncology, Plastic & Microvascular reconstruction Microvascular reconstruction Implant for Microvascular
SC SC073 SC073A 45,000 NA 60,000
Reconstructive Surgery (free flaps) (free flaps) reconstruction - 15000
Surgical Oncology, CTVS,

SC Plastic & Reconstructive SC074 Vascular reconstruction SC074A Vascular reconstruction 57,600 NA NA 57,600
Surgery
SC Surgical Oncology SC075 Curopsy / Sclerotherapy SC075A Curopsy / Sclerotherapy 19,200 NA NA 19,200
Page 166
2.1

Chemo Port - Adult - 15000

33000
SC Surgical Oncology SC076 Chemo Port Insertion SC076A Chemo Port Insertion 18,000 NA Chemo Port - Pediatric -
43000
25000
Posterior Exenteration Posterior Exenteration

SC Surgical Oncology SC077 SC077A 70,000 TBF TBF TBF
(Gynaec) (Gynaec)
Bilateral pelvic lymph Node Bilateral pelvic lymph Node

Dissection (BPLND) Dissection (BPLND)
Head & Neck Flap Cutting any

SC Surgical Oncology SC079 Plastic surgery flap division SC079A 5,000 TBF TBF TBF
type
Resuturing of Any Wound gap Resuturing of Any Wound gap

BM Burns Management SC080 SC080A 3,000 TBF TBF TBF
Surgeries Surgeries
Page 167
2.1

Cytoreductive surgery for Cytoreductive surgery for

ovarian cancer ovarian cancer
SE Ophthalmology SE001 Ptosis Surgery SE001A Ptosis Surgery 8,000 NA NA 8,000
SE Ophthalmology SE002 Entropion correction SE002A Entropion correction 6,600 NA NA 6,600
SE Ophthalmology SE003 Ectropion correction SE003A Ectropion correction 6,500 NA NA 6,500
SE Ophthalmology SE004 Lid Tear Repair SE004A Lid Tear Repair 5,000 NA NA 5,000
Page 168
2.1

SE Ophthalmology SE005 Lid Abscess Drainage SE005A Lid Abscess Drainage 3,000 NA NA 3,000
Lid Tumor excision + Lid Lid Tumor excision + Lid

SE Ophthalmology SE006 SE006A 10,000 NA NA 10,000
Reconstruction Reconstruction
SE Ophthalmology SE007 Chalazion Removal SE007A Chalazion Removal 2,000 NA NA 2,000
SE Ophthalmology SE008 Squint correction SE008A Minor - upto 2 muscles 4,000 NA NA 4,000
Major - 3 or more muscles

(complex surgery involving
SE Ophthalmology SE008 Squint correction SE008B 14,000 NA NA 14,000
four muscles or oblique
muscles)
Page 169
2.1

Conjunctival tumour excision Conjunctival tumour excision

Tissue graft- amniotic
SE Ophthalmology SE009 including Amniotic Membrane SE009A including Amniotic Membrane 7,000 NA 7,000
membrane
Graft Graft
Canaliculo
Silicon Tube / Silicon stent -
SE Ophthalmology SE010 Dacryocystorhinostomy SE010A Dacryocystorhinostomy with 8,000 NA 10,000
2000
Silicon Tube / Stent
Canaliculo
SE Ophthalmology SE010 Dacryocystorhinostomy SE010B Dacryocystorhinostomy 8,000 NA NA 8,000
without Silicon Tube / Stent
Dacryocystorhinostomy with Silicon Tube / Silicon stent -

SE Ophthalmology SE010 Dacryocystorhinostomy SE010C 8,000 NA 10,000
Silicon Tube / Stent 2000
Dacryocystorhinostomy
SE Ophthalmology SE010 Dacryocystorhinostomy SE010D 8,000 NA NA 8,000
without Silicon Tube / Stent
Page 170
2.1

SE Ophthalmology SE011 Corneal Ulcer Management SE011A Corneal Ulcer Management 4,000 NA NA 4,000
SE Ophthalmology SE012 Corneal Grafting SE012A Corneal Grafting 8,500 NA NA 8,500
SE Ophthalmology SE012 Corneal Grafting SE012B Corneal Graft - Follow Up 2,000 NA NA 2,000
SE Ophthalmology SE012 Corneal Grafting SE012C Lamellar Keratoplasty 13,750 NA NA 13,750
SE Ophthalmology SE013 Corneal Collagen Crosslinking SE013A Corneal Collagen Crosslinking 9,000 NA NA 9,000
Page 171
2.1

Pterygium + Conjunctival Pterygium + Conjunctival

Autograft Autograft
Corneo / Scleral / Corneo Corneo / Scleral / Corneo

scleral tear repair scleral tear repair
SE Ophthalmology SE016 Corneal / Scleral Patch Graft SE016A Corneal / Scleral Patch Graft 3,000 NA NA 3,000
SE Ophthalmology SE017 Scleral buckling surgery SE017A Scleral buckling surgery 15,000 NA NA 15,000
SE Ophthalmology SE018 Scleral Buckle Removal SE018A Scleral Buckle Removal 5,500 NA NA 5,500
Page 172
2.1

Tissue graft - Cornea / Sclera -

SE Ophthalmology SE019 Limbal Dermoid Removal SE019A Limbal Dermoid Removal 1,000 NA 4,000
3000
Phaco emulsification with

Foldable Hydrophobic
SE Ophthalmology SE020 Cataract surgery SE020A foldable hydrophobic acrylic 4,500 NA 7,500
intraocular lens - 3000
IOL
SE Ophthalmology SE020 Cataract surgery SE020B SICS with non-foldable IOL 4,000 NA Non foldable IOL - 1000 5,000
SE Ophthalmology SE021 Surgery for Pediatric Cataract SE021A Paediatric lensectomy 9,200 NA 12,200
Pediatric lens aspiration with

SE Ophthalmology SE021 Surgery for Pediatric Cataract SE021B posterior capsulotomy & 9,200 NA 12,200
anterior vitrectomy
Page 173
2.1

Paediatric Membranectomy & Foldable Hydrophobic

SE Ophthalmology SE021 Surgery for Pediatric Cataract SE021C 9,200 NA 12,200
anterior vitrectomy intraocular lens - 3000
SE Ophthalmology SE022 Capsulotomy (YAG) SE022A Capsulotomy (YAG) 1,500 NA NA 1,500
SFIOL (inclusive of SFIOL (inclusive of Glue for Scleral fixated IOL -

SE Ophthalmology SE023 SE023A 15,000 NA 18,000
Vitrectomy) Vitrectomy) 3000
Secondary IOL / IOL Secondary IOL / IOL

SE Ophthalmology SE024 SE024A 2,000 NA IOL - 3000 5,000
Exchange / Explant Exchange / Explant
SE Ophthalmology SE025 IRIS Prolapse – Repair SE025A IRIS Prolapse – Repair 4,000 NA NA 4,000
Page 174
2.1

SE Ophthalmology SE026 Iridectomy SE026A Iridectomy 2,000 NA NA 2,000
Cyclocryotherapy /
SE Ophthalmology SE027 Glaucoma Surgery SE027A 3,700 NA NA 3,700
Cyclophotocoagulation
Glaucoma Surgery
(Trabeculectomy only) with or
without Mitomycin C, including
postoperative medications for
12 weeks
SE Ophthalmology SE027 Glaucoma Surgery SE027B 11,000 NA NA 11,000
(and wherever surgical or
laser procedures required for
bleb augmentation and
anterior chamber
maintenance)
Valved / Non Valved

SE Ophthalmology SE027 Glaucoma Surgery SE027C Glaucoma Shunt Surgery 13,000 NA 20,000
Glaucoma tube - shunt - 7000
SE Ophthalmology SE027 Glaucoma Surgery SE027D Pediatric Glaucoma Surgery 15,000 NA NA 15,000
Page 175
2.1

EUA for Confirmation of EUA for Confirmation of

Pediatric Glaucoma Pediatric Glaucoma
Retinal Laser For retinal tear repair Per Eye

Photocoagulation Per Sitting
Pan Retinal Photocoagulation

(PRP) - Retinal Laser
including 3 sittings / package
Retinal Laser
SE Ophthalmology SE029 SE029B of retino laser 8,500 NA NA 8,500
Photocoagulation
photocoagulation
(3 sittings per eye for both
eyes)
SE Ophthalmology SE030 ROP Laser - Per Eye SE030A ROP Laser - Per Eye 5,000 NA NA 5,000
SE Ophthalmology SE031 Retinal Cryopexy SE031A Retinal Cryopexy 3,800 NA NA 3,800
Page 176
2.1

Vitreoretinal Surgery (with Vitreoretinal Surgery (with

SE Ophthalmology SE032 SE032A 17,900 NA 23,900
Silicon Oil Insertion) Silicon Oil Insertion)
Implant for "Vitreoretinal

Surgery" (IOL & Per flouro
carbon liquid) - 6000
SE Ophthalmology SE033 SOR (Silicon Oil Removal) SE033A SOR (Silicon Oil Removal) 9,300 NA NA 9,300
Endophthalmitis (excluding Endophthalmitis (excluding

Vitrectomy) Vitrectomy)
SE Ophthalmology SE035 Enucleation SE035A Without implant 8,400 NA NA 8,400
Implant for "Enucleation"

SE Ophthalmology SE035 Enucleation SE035B With implant 8,400 NA (Conformers + Plastic / silicon 9,400
ball type implant) - 1000
Page 177
2.1

Implant for "Evisceration"

SE Ophthalmology SE036 Evisceration SE036A Evisceration 3,800 NA (Conformers + Plastic / silicon 4,800
ball type implant) - 1000
Ophthalmology, Surgical
SE SE037 Exenteration SE037A Exenteration 15,000 NA NA 15,000
Oncology
Socket Reconstruction Socket Reconstruction

SE Ophthalmology SE038 including Amniotic Membrane SE038A including Amniotic Membrane 11,200 NA NA 11,200
Graft Graft
SE Ophthalmology SE039 Orbitotomy SE039A Orbitotomy 14,000 NA NA 14,000
Ophthalmology, ENT, General GA / EUA separate add on GA / EUA separate add on

SE SE040 SE040A 3,000 NA NA 3,000
Surgery, Radiation Oncology package package
Page 178
2.1

Orbital fracture repair under

SE Ophthalmology SE041 Orbital fracture repair SE041A 10,500 TBF TBF TBF
GA
General Surgery, Surgical

SG SG001 Oesophagectomy SG001A Oesophagectomy 28,300 NA NA 28,300
Oncology
General Surgery, Pediatric Operations for Replacement Operations for Replacement

SG SG002 SG002A 30,500 NA NA 30,500
Surgery of Oesophagus by Colon of Oesophagus by Colon
Bleeding Ulcer - Partial

SG General Surgery SG003 Gastrectomy SG003A Gastrectomy without 25,000 NA NA 25,000
Vagotomy
Bleeding Ulcer - Partial

SG General Surgery SG003 Gastrectomy SG003B 25,000 NA NA 25,000
Gastrectomy with Vagotomy
Page 179
2.1

General Surgery, Surgical Partial Gastrectomy for

SG SG003 Gastrectomy SG003C 27,800 NA NA 27,800
Oncology Carcinoma
General Surgery, Surgical Subtotal Gastrectomy for

SG SG003 Gastrectomy SG003D 27,800 NA NA 27,800
Oncology Carcinoma

SG SG003 Gastrectomy SG003E Total Gastrectomy - Lap. 51,600 NA NA 51,600
Oncology

SG SG003 Gastrectomy SG003F Total Gastrectomy - Open 51,600 NA NA 51,600
Oncology
General Surgery, Pediatric

SG SG004 Operative Gastrostomy SG004A Operative Gastrostomy 15,000 NA NA 15,000
Surgery
Page 180
2.1

SG General Surgery SG005 Vagotomy SG005A G J Vagotomy 23,500 NA NA 23,500
SG General Surgery SG005 Vagotomy SG005B Vagotomy + Pyloroplasty 23,500 NA NA 23,500
Operation for Bleeding Peptic Operation for Bleeding Peptic

SG General Surgery SG006 SG006A 22,500 NA NA 22,500
Ulcer Ulcer
Operation for Gastric /

SG General Surgery SG007 SG007A Gastric Perforation 18,500 NA NA 18,500
Duodenal Perforation
Operation for Gastric /

SG General Surgery SG007 SG007B Duodenal Perforation 18,500 NA NA 18,500
Duodenal Perforation
Page 181
2.1


SG SG008 Pyloroplasty SG008A Pyloroplasty 14,000 NA NA 14,000
Surgery

SG SG009 Pyloromyotomy SG009A Pyloromyotomy 15,000 NA NA 15,000
Surgery

SG SG010 Gastrojejunostomy SG010A Gastrojejunostomy 18,500 NA NA 18,500
Oncology
General Surgery, Pediatric CystoJejunostomy /

SG SG011 SG011A CystoJejunostomy - Open 20,000 NA NA 20,000
Surgery Cystogastrostomy

SG SG011 SG011B CystoJejunostomy - Lap. 20,000 NA NA 20,000
Page 182
2.1


SG SG011 SG011C Cystogastrostomy - Open 20,000 NA NA 20,000

SG SG011 SG011D Cystogastrostomy - Lap. 20,000 NA NA 20,000

SG SG012 Feeding Jejunostomy SG012A Feeding Jejunostomy 10,000 NA NA 10,000
Oncology, Pediatric Surgery

SG SG013 Ileostomy SG013A Ileostomy 14,000 NA NA 14,000
Surgery
General Surgery, Pediatric Congenital Atresia & Stenosis Congenital Atresia & Stenosis
SG SG014 SG014A 23,000 NA NA 23,000
Surgery of Small Intestine of Small Intestine
Page 183
2.1

General Surgery, Pediatric Operation for Duplication of Operation for Duplication of

SG SG015 SG015A 18,000 NA NA 18,000
Surgery Intestine Intestine
Excision Duodenal
SG General Surgery SG016 Diverticulectomy SG016A 20,000 NA NA 20,000
Diverticulum

SG SG016 Diverticulectomy SG016B Excision Meckel's Diverticulum 15,000 NA NA 15,000
Surgery

SG SG017 Appendicectomy SG017A Open 11,000 NA NA 11,000
Surgery

SG SG017 Appendicectomy SG017B Lap. 11,000 NA NA 11,000
Surgery
Page 184
2.1


SG SG018 Appendicular Perforation SG018A Appendicular Perforation 17,500 NA NA 17,500
Surgery
General Surgery, Pediatric Operative drainage of Operative drainage of

SG SG019 SG019A 12,000 NA NA 12,000
Surgery Appendicular Abscess Appendicular Abscess

SG SG020 Total Colectomy SG020A Open 23,000 NA NA 23,000
Oncology

SG SG020 Total Colectomy SG020B Lap. 23,000 NA NA 23,000
Oncology

SG SG021 Hemi colectomy SG021A Right - Open 25,000 NA NA 25,000
Oncology
Page 185
2.1


SG SG021 Hemi colectomy SG021B Right - Lap. 25,000 NA NA 25,000
Oncology

SG SG021 Hemi colectomy SG021C Left - Open 25,000 NA NA 25,000
Oncology

SG SG021 Hemi colectomy SG021D Left - Lap. 25,000 NA NA 25,000
Oncology
General Surgery, Pediatric Operative Management of Operative Management of

SG SG022 SG022A 25,000 NA NA 25,000
Surgery Volvulus of Large Bowel Volvulus of Large Bowel

SG SG023 Colostomy SG023A Colostomy 14,000 NA NA 14,000
Page 186
2.1


SG SG024 Closure of stoma SG024A Closure of stoma 14,500 NA NA 14,500
SG General Surgery SG025 Sigmoid Resection SG025A Sigmoid Resection 21,500 NA NA 21,500
Perineal Procedure for Rectal Perineal Procedure for Rectal

Prolapse Prolapse
Abdominal Procedure for

SG General Surgery SG027 SG027A Open 19,000 NA NA 19,000
Rectal Prolapse
Abdominal Procedure for

SG General Surgery SG027 SG027B Lap. 19,000 NA NA 19,000
Rectal Prolapse
Page 187
2.1


SG SG028 Rectal Polyp Excision SG028A Rectal Polyp Excision 9,600 NA NA 9,600
Oncology

SG SG029 Anterior Resection of rectum SG029A Open 28,500 NA NA 28,500
Oncology

SG SG029 Anterior Resection of rectum SG029B Lap. 28,500 NA NA 28,500
Oncology

SG SG030 Resection Anastomosis SG030A Open 25,000 NA NA 25,000
Surgery

SG SG030 Resection Anastomosis SG030B Lap. 25,000 NA NA 25,000
Surgery
Page 188
2.1

SG General Surgery SG031 Procedure for Fissure in Ano SG031A Procedure for Fissure in Ano 8,000 NA NA 8,000
SG General Surgery SG032 Haemorroidectomy SG032A without Stapler 15,000 NA NA 15,000
SG General Surgery SG032 Haemorroidectomy SG032B with Stapler 15,000 NA Haemorroid Stapler - 17000 32,000
Management of Pilonidal Management of Pilonidal LA - 5000 LA - 5000

SG General Surgery SG033 SG033A 5,000 NA
Sinus Sinus GA - 13500 GA - 13500
Exicision of Sinus and Exicision of Sinus and

Curettage Curettage
Page 189
2.1


SG SG035 Exploratory Laparotomy SG035A Exploratory Laparotomy 10,000 NA NA 10,000
Surgery

SG Surgery, Obstetrics & SG036 Closure of Burst Abdomen SG036A Closure of Burst Abdomen 15,000 NA NA 15,000
Gynecology

SG SG037 Hepatic Resection SG037A Open 20,000 NA NA 20,000

SG SG037 Hepatic Resection SG037B Lap. 20,000 NA NA 20,000
General Surgery, Pediatric Abdominal Hydatid Cyst Abdominal Hydatid Cyst

SG SG038 SG038A 15,800 NA NA 15,800
Surgery (Single Organ) (Single Organ)
Page 190
2.1

General Surgery, Pediatric Without Exploration of CBD -

SG SG039 Cholecystectomy SG039A 22,800 NA NA 22,800
Surgery Open
General Surgery, Pediatric With Exploration of CBD -

SG SG039 Cholecystectomy SG039B 22,800 NA NA 22,800
Surgery Open
General Surgery, Pediatric Without Exploration of CBD -

SG SG039 Cholecystectomy SG039C 22,800 NA NA 22,800
Surgery Lap.

SG SG039 Cholecystectomy SG039D With Exploration of CBD - Lap. 22,800 NA NA 22,800
Surgery

SG SG040 Operative Cholecystostomy SG040A Open 10,000 NA NA 10,000
Surgery
Page 191
2.1


SG SG040 Operative Cholecystostomy SG040B Lap. 10,000 NA NA 10,000
Surgery

SG SG041 Operation of Choledochal Cyst SG041A Operation of Choledochal Cyst 24,500 NA NA 24,500
Surgery

SG SG042 Splenectomy SG042A Open 25,000 NA NA 25,000
Surgery

SG SG042 Splenectomy SG042B Lap. 25,000 NA NA 25,000
Surgery

SG SG043 Bypass - Inoperable Pancreas SG043A Bypass - Inoperable Pancreas 23,500 NA NA 23,500
Oncology
Page 192
2.1

General Surgery, Surgical Distal Pancreatectomy with Distal Pancreatectomy with

SG SG044 SG044A 25,000 NA NA 25,000
Oncology, Pediatric Surgery Pancreatico Jejunostomy Pancreatico Jejunostomy
General Surgery, Surgical PancreaticoDuodenectomy PancreaticoDuodenectomy

SG SG045 SG045A 30,000 NA NA 30,000
Oncology (Whipple's) (Whipple's)
SG General Surgery SG046 Porto Caval Anastomosis SG046A Porto Caval Anastomosis 31,500 NA NA 31,500
Mesenteric Caval Mesenteric Caval

Anastomosis Anastomosis

SG SG048 Mesenteric Cyst – Excision SG048A Mesenteric Cyst – Excision 15,000 NA NA 15,000
Surgery
Page 193
2.1

General Surgery, Surgical Retroperitoneal Tumor – Retroperitoneal Tumor –

SG SG049 SG049A 23,000 NA NA 23,000
Oncology, Pediatric Surgery Excision Excision
Mesh - 6 X 3 - Polypropylene -
SG General Surgery SG050 Groin Hernia Repair SG050A Inguinal - Open 14,200 NA 16,200
2000
SG General Surgery SG050 Groin Hernia Repair SG050B Inguinal - Lap. 14,200 NA 16,200
2000
SG General Surgery SG050 Groin Hernia Repair SG050C Femoral - Open 14,200 NA 16,200
2000
SG General Surgery SG050 Groin Hernia Repair SG050D Femoral - Lap 14,200 NA 16,200
2000
Page 194
2.1

General Surgery, Pediatric Tackers - 15000

SG SG050 Groin Hernia Repair SG050E Obturator - Lap. 20,000 NA 40,000
Surgery Mesh - 15 X 15 - 5000

SG SG051 Hernia - Ventral SG051A Epigastric 17,400 NA Mesh - 15 X 15 - 5000 22,400
Surgery

SG SG051 Hernia - Ventral SG051B Umbilical 17,400 NA Mesh - 15 X 15 - 5000 22,400
Surgery

SG SG051 Hernia - Ventral SG051C Paraumbilical 17,400 NA Mesh - 15 X 15 - 5000 22,400
Surgery

SG SG051 Hernia - Ventral SG051D Spigelian 17,400 NA Mesh - 15 X 15 - 5000 22,400
Surgery
Page 195
2.1

Mesh - 30 X 30 - 15000 35000

SG SG052 Repair of Incisional Hernia SG052A Repair of Incisional Hernia 20,000 NA or or
Surgery
Mesh - 15 X 15 - 5000 25000
General Surgery, Pediatric Hiatus Hernia Repair /

SG SG053 SG053A Hiatus Hernia Repair - Open 23,500 NA NA 23,500
Surgery Fundoplication

SG SG053 SG053B Hiatus Hernia Repair - Lap. 23,500 NA NA 23,500

SG SG053 SG053C Fundoplication - Open 23,500 NA NA 23,500

SG SG053 SG053D Fundoplication - Lap. 23,500 NA NA 23,500
Page 196
2.1

Excision of cyst / Sebaceous

SG General Surgery SG054 SG054A Single Cyst 2,000 NA NA 2,000
Cysts over scrotum
Excision of cyst / Sebaceous

SG General Surgery SG054 SG054B Multiple Cysts 7,000 NA NA 7,000
Cysts over scrotum
SG General Surgery SG055 Excision Filarial Scrotum SG055A Excision Filarial Scrotum 6,500 NA NA 6,500

SG SG056 Operation for Hydrocele (U/L) SG056A Operation for Hydrocele (U/L) 5,000 NA NA 5,000
Surgery
General Surgery, Pediatric Epididymal Cyst / Nodule

SG SG057 SG057A Epididymal Cyst exision 4,600 NA NA 4,600
Surgery Excision
Page 197
2.1

General Surgery, Pediatric Epididymal Cyst / Nodule

SG SG057 SG057B Epididymal Nodule excision 4,600 NA NA 4,600
Surgery Excision
SG General Surgery, Urology SG058 Vasovasostomy SG058A Vasovasostomy 12,000 NA NA 12,000

SG SG059 Orchidectomy SG059A Orchidectomy 11,200 NA NA 11,200
General Surgery, Pediatric Inguinal Node (dissection) - Inguinal Node (dissection) -

SG SG060 SG060A 16,000 NA NA 16,000
Surgery U/L U/L

SG SG061 Estlander Operation (lip) SG061A Estlander Operation (lip) 9,300 NA NA 9,300
Oncology
Page 198
2.1


SG SG062 Operation for Carcinoma Lip SG062A Wedge Excision 19,000 NA NA 19,000
Oncology
General Surgery, Surgical Wedge Excision and

SG SG062 Operation for Carcinoma Lip SG062B 23,800 NA NA 23,800
Oncology Vermilionectomy

SG SG062 Operation for Carcinoma Lip SG062C Cheek advancement 26,800 NA NA 26,800
Oncology
Complete Excision of Growth Complete Excision of Growth

SG SG063 from Tongue only (inclusive of SG063A from Tongue only 9,400 NA NA 9,400
Histopathology) (inclusive of Histopathology)
Excision of Growth from Excision of Growth from

SG SG064 Tongue with neck node SG064A Tongue with neck node 23,500 NA NA 23,500
Oncology
dissection dissection
Page 199
2.1

SG General Surgery SG065 Microlaryngoscopic Surgery SG065A Microlaryngoscopic Surgery 18,500 NA NA 18,500

SG SG066 Submandibular Mass Excision SG066A Submandibular Mass Excision 15,000 NA NA 15,000
Oncology

SG SG067 Radical Neck Dissection SG067A Radical Neck Dissection 15,000 NA NA 15,000
Oncology, ENT
Surgical removal of Branchial Surgical removal of Branchial

SG General Surgery, ENT SG068 SG068A 15,000 NA NA 15,000
Cyst Cyst
General Surgery, Surgical Carotid Body tumour - Carotid Body tumour -

SG SG069 SG069A 20,000 NA NA 20,000
Oncology, CTVS Excision Excision
Page 200
2.1


SG Oncology, Pediatric Surgery, SG070 Thyroidectomy SG070A Hemi thyroidectomy 17,000 NA NA 17,000
ENT

SG Oncology, Pediatric Surgery, SG070 Thyroidectomy SG070B Total thyroidectomy 20,000 NA NA 20,000
ENT

Total Thyroidectomy with
SG Oncology, Pediatric Surgery, SG070 Thyroidectomy SG070C 28,000 NA NA 28,000
Block Dissection
ENT
General Surgery, Surgical Excision of Parathyroid Excision of Parathyroid

SG SG071 SG071A 20,400 NA NA 20,400
Oncology, Pediatric Surgery Adenoma / Carcinoma Adenoma
General Surgery, Surgical Excision of Parathyroid Excision of Parathyroid

SG SG071 SG071B 20,400 NA NA 20,400
Oncology, Pediatric Surgery Adenoma / Carcinoma Carcinoma
Page 201
2.1


SG SG072 Thymectomy SG072A Thymectomy 28,000 NA NA 28,000
Surgery

SG SG073 Sympathectomy SG073A Sympathectomy 15,000 NA NA 15,000
Surgery
General Surgery, Surgical Breast Lump Excision Breast Lump Excision LA - 6000 LA - 6000
SG SG074 SG074A 6,000 NA
Oncology (Benign) (Benign) GA - 12000 GA - 12000

SG SG075 Mastectomy SG075A Simple Mastectomy 20,000 NA NA 20,000
Oncology
General Surgery, Surgical Radical / Modified Radical

SG SG075 Mastectomy SG075B 25,000 NA NA 25,000
Oncology Mastectomy
Page 202
2.1

SG General Surgery SG076 Excision Mammary Fistula SG076A Excision Mammary Fistula 14,500 NA NA 14,500

SG SG077 Intercostal drainage Only SG077A Intercostal drainage Only 4,800 NA NA 4,800
Surgery, CTVS

SG SG078 Rib Resection & Drainage SG078A Rib Resection & Drainage 14,000 NA NA 14,000
Surgery

SG SG079 Thoracoplasty SG079A Thoracoplasty 20,000 NA NA 20,000
Surgery

SG SG080 Decortication (Pleurectomy) SG080A Decortication (Pleurectomy) 28,000 NA NA 28,000
Surgery
Page 203
2.1


SG SG081 Lobectomy SG081A Thoracoscopic 27,500 NA NA 27,500
Surgery, Surgical Oncology

SG SG081 Lobectomy SG081B Open 27,500 NA NA 27,500
General Surgery, Pediatric Thoracoscopic Segmental Thoracoscopic Segmental

SG SG082 SG082A 25,000 NA NA 25,000
Surgery Resection Resection

SG SG083 Lung Hydatid Cyst removal SG083A Lung Hydatid Cyst removal 20,000 NA NA 20,000
Surgery
General Surgery, Pediatric Incision & Drainage of Incision & Drainage of LA - 5000 LA - 5000
SG SG084 SG084A 5,000 NA
Surgery Abscess Abscess GA - 10000 GA - 10000
Page 204
2.1

Lipoma / Cyst / other LA - 5000 LA - 5000

SG General Surgery SG085 SG085A Lipoma Excision 5,000 NA
cutaneous swellings Excision GA - 10000 GA - 10000
Lipoma / Cyst / other LA - 5000 LA - 5000

SG General Surgery SG085 SG085B Cyst Excision 5,000 NA
cutaneous swellings Excision GA - 10000 GA - 10000
Lipoma / Cyst / other Other cutaneous swellings LA - 5000 LA - 5000

SG General Surgery SG085 SG085C 5,000 NA
cutaneous swellings Excision Excision GA - 10000 GA - 10000
LA - 5000 LA - 5000
SG General Surgery SG086 Debridement of Ulcer SG086A Debridement of Ulcer 5,000 NA
GA - 10000 GA - 10000

SG SG087 Flap Reconstructive Surgery SG087A Flap Reconstructive Surgery 20,000 NA NA 20,000
Oncology
Page 205
2.1

General Surgery, Plastic &

SG SG088 Free Grafts - Wolfe Grafts SG088A Free Grafts - Wolfe Grafts 14,000 NA NA 14,000
SG General Surgery SG089 Tissue Reconstruction Flap SG089A Tissue Reconstruction Flap 25,000 NA NA 25,000

SG Reconstructive Surgery, SG090 Split thickness skin grafts SG090A Small (< 4% TBSA) 13,500 NA NA 13,500
Pediatric Surgery

SG Reconstructive Surgery, SG090 Split thickness skin grafts SG090B Medium (4 - 8% TBSA) 13,500 NA NA 13,500
Pediatric Surgery

SG Reconstructive Surgery, SG090 Split thickness skin grafts SG090C Large (> 8% TBSA) 13,500 NA NA 13,500
Pediatric Surgery
Page 206
2.1


SG Oncology, Plastic & SG091 Skin Flaps - Rotation Flaps SG091A Skin Flaps - Rotation Flaps 11,400 NA NA 11,400
SG General Surgery, Orthopedics SG092 Tendon Transfer SG092A Tendon Transfer 15,000 NA NA 15,000
Lymphatics Excision of Lymphatics Excision of

SG General Surgery SG093 Subcutaneous Tissues In SG093A Subcutaneous Tissues In 10,000 NA NA 10,000
Lymphoedema Lymphoedema
SG General Surgery SG094 AV Fistula without prosthesis SG094A AV Fistula without prosthesis 6,000 NA NA 6,000
Management of Varicose Management of Varicose

Veins Veins
Page 207
2.1


SG Surgery, Obstetrics & SG096 Biopsy SG096A Lymph Node 5,000 NA NA 5,000
Gynecology

SG Surgery, Obstetrics & SG096 Biopsy SG096B Endometrial Aspiration 2,000 NA NA 2,000
Gynecology

Cervix Cancer screening (PAP
SG Surgery, Obstetrics & SG096 Biopsy SG096C 1,000 NA NA 1,000
+ Colposcopy)
Gynecology

SG Surgery, Obstetrics & SG096 Biopsy SG096D Cervical (Neck) 1,500 NA NA 1,500
Gynecology

SG Surgery, Obstetrics & SG096 Biopsy SG096E Vulval 1,500 NA NA 1,500
Gynecology
Page 208
2.1

Stoma Management follow up

SG General Surgery SG097 Stoma Management SG097A 4,500 NA NA 4,500
of Ileostomy
Stoma Management follow up

SG General Surgery SG097 Stoma Management SG097B 4,500 NA NA 4,500
of Colostomy
General Surgery, Pediatric LA - 5000 LA - 5000

SG SG098 Foreign Body Removal SG098A Foreign Body Removal 5,000 NA
Surgery, ENT GA - 8000 GA - 8000
Necrotising fasciitis / Fournier Necrotising fasciitis / Fournier

SG General Surgery SG099 SG099A 10,000 TBF TBF TBF
Gangrene Gangrene
Surgical management of Surgical management of

Lower GI bleed (inclusive of Lower GI bleed (inclusive of
SG General Surgery SG100 sigmoidoscopy / colonoscopy) - SG100A sigmoidoscopy / colonoscopy) - 18,000 TBF TBF TBF
excluding local perineal excluding local perineal
conditions conditions
Page 209
2.1

SG General Surgery SG101 Caecopexy SG101A Caecopexy 30,000 TBF TBF TBF
Repair of Renal Artery Repair of Renal Artery

Stenosis Stenosis
SG General Surgery SG103 ERCP + Stenting SG103A ERCP + Stenting 15,000 TBF TBF TBF
Circumcision - Phimosis /
SG General Surgery SG104 Circumcision SG104A Paraphimosis or any other 7,000 TBF TBF TBF
clinical condition
Percutaneous Transhepatic Percutaneous Transhepatic

Biliary Drainage (PTBD) Biliary Drainage (PTBD)
Page 210
2.1

Pinna surgery for tumour /

SL ENT, Surgical Oncology SL001 SL001A Pinna surgery for tumour 8,600 NA NA 8,600
trauma
Pinna surgery for tumour /

SL ENT SL001 SL001B Pinna surgery for trauma 8,600 NA NA 8,600
trauma
Partial Ossicular Replacement

Prosthesis - Indian Titanium -
7000 19900
SL ENT SL002 Tympanoplasty SL002A Tympanoplasty 12,900 NA or or
Total Ossicular Replacement 19900
Prosthesis - Indian Titanium -
7000
Piston for Stapedectomy /

SL ENT SL003 Stapedectomy / tympanotomy SL003A Stapedectomy 13,000 NA 18,000
Tympanotomy - 5000
Piston for Stapedectomy /

SL ENT SL003 Stapedectomy / tympanotomy SL003B Tympanotomy 13,000 NA 18,000
Tympanotomy - 5000
Page 211
2.1

SL ENT, Surgical Oncology SL004 Mastoidectomy SL004A Simple 28,000 NA NA 28,000
SL ENT, Surgical Oncology SL004 Mastoidectomy SL004B Radical 28,000 NA NA 28,000
Myringotomy with or without LA - 5000 LA - 5000

SL ENT, Surgical Oncology SL005 SL005A Unilateral 5,000 NA
Grommet GA - 10000 GA - 10000
Myringotomy with or without LA - 5000 LA - 5000

SL ENT, Surgical Oncology SL005 SL005B Bilateral 5,000 NA
Grommet GA - 10000 GA - 10000
SL ENT SL006 Endoscopic DCR SL006A Endoscopic DCR 19,300 NA NA 19,300
Page 212
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HDU - 2700 HDU - 2700
SL ENT SL007 Epistaxis treatment - packing SL007A Epistaxis treatment - packing 1,800 NA
SL ENT SL008 Functional septo rhinoplasty SL008A Functional septo rhinoplasty 21,800 NA NA 21,800
LA - 12000 LA - 12000
SL ENT SL009 Septoplasty SL009A Septoplasty 12,000 NA
GA - 18000 GA - 18000
LA - 8000 LA - 8000
SL ENT SL010 Fracture - setting nasal bone SL010A Fracture - setting nasal bone 8,000 NA
GA - 12000 GA - 12000
Inferior turbinate reduction Inferior turbinate reduction

SL ENT SL011 SL011A 5,700 NA NA 5,700
under GA under GA
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SL ENT SL012 Open sinus surgery SL012A Open sinus surgery 15,000 NA NA 15,000
Functional Endoscopic Sinus Functional Endoscopic Sinus

SL ENT SL013 SL013A 11,000 NA NA 11,000
(FESS) (FESS)
Ant. Ethmoidal / Ant. Ethmoidal artery ligation -

SL ENT SL014 SL014A 15,000 NA NA 15,000
sphenopalatine artery ligation Open
Ant. Ethmoidal / Ant. Ethmoidal artery ligation -

SL ENT SL014 SL014B 15,000 NA NA 15,000
sphenopalatine artery ligation Endoscopic
Ant. Ethmoidal / Sphenopalatine artery ligation -

SL ENT SL014 SL014C 15,000 NA NA 15,000
sphenopalatine artery ligation Open
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Ant. Ethmoidal / Sphenopalatine artery ligation -

SL ENT SL014 SL014D 15,000 NA NA 15,000
sphenopalatine artery ligation Endoscopic
SL ENT SL015 Adenoidectomy SL015A Adenoidectomy 5,000 NA NA 5,000
SL ENT SL016 Tonsillectomy SL016A Tonsillectomy - U/L 7,500 NA NA 7,500
SL ENT SL016 Tonsillectomy SL016B Tonsillectomy - B/L 7,500 NA NA 7,500
Peritonsillar abscess drainage

SL ENT, Pediatric Surgery SL017 SL017A Peritonsillar abscess drainage 5,800 NA NA 5,800
/ intraoral calculus removal
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Peritonsillar abscess drainage

SL ENT, Pediatric Surgery SL017 SL017B Intraoral calculus removal 5,800 NA NA 5,800
/ intraoral calculus removal
Thyroglossal / Branchial cyst /

SL ENT SL018 SL018A Thyroglossal cyst excision 15,300 NA NA 15,300
sinus / fistula excision

SL ENT SL018 SL018B Thyroglossal sinus excision 15,300 NA NA 15,300

SL ENT SL018 SL018C Thyroglossal fistula excision 15,300 NA NA 15,300

SL ENT SL018 SL018D Branchial sinus excision 15,300 NA NA 15,300
Page 216
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SL ENT SL018 SL018E Branchial fistula excision 15,300 NA NA 15,300
Uvulopalatopharyngoplasty Uvulopalatopharyngoplasty
SL ENT SL019 SL019A 18,600 NA NA 18,600
(UPPP) (UPPP)
Excision of tumour of oral Excision of tumour of oral

Implant for Excision of tumour
cavity / paranasal sinus / cavity / paranasal sinus /
SL ENT, Surgical Oncology SL020 SL020A 10,000 NA of oral cavity / paranasal sinus 30,000
laryngopharynx with or without laryngopharynx without
/ laryngopharynx - 20000
reconstruction reconstruction

SL ENT, Surgical Oncology SL020 SL020B 36,500 NA NA 36,500
laryngopharynx with or without laryngopharynx with pedicled
reconstruction flap reconstruction

Implant for Excision of tumour
SL ENT, Surgical Oncology SL020 SL020C 25,000 NA of oral cavity / paranasal sinus 45,000
laryngopharynx with or without laryngopharynx with free flap
/ laryngopharynx - 20000
reconstruction reconstruction
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ENT, Surgical Oncology,

SL SL021 Parotidectomy SL021A Total Parotidectomy 28,200 NA NA 28,200
General Surgery
ENT, Surgical Oncology,

SL SL021 Parotidectomy SL021B Superficial Parotidectomy 23,800 NA NA 23,800
General Surgery
Removal of Submandibular Removal of Submandibular LA - 9000 LA - 9000

SL ENT SL022 SL022A 9,000 NA
Salivary gland Salivary gland GA - 15000 GA - 15000
Removal of Submandibular LA - 9000 LA - 9000

SL ENT SL022 SL022B Removal of Ranula 9,000 NA
Salivary gland GA - 15000 GA - 15000
Removal of Submandibular Removal of Submandibular LA - 9000 LA - 9000

SL ENT SL022 SL022C 9,000 NA
Salivary gland Lymph node GA - 15000 GA - 15000
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Rigid laryngoscopy /
bronchoscopy / Rigid laryngoscopy - LA - 7000 LA - 7000
SL ENT, Pediatric Surgery SL023 SL023A 7,000 NA
oesophagoscopy - Diagnostic Diagnostic + / - biopsy GA - 12000 GA - 12000
+ / - biopsy
bronchoscopy / Rigid bronchoscopy - LA - 7000 LA - 7000
SL ENT, Pediatric Surgery SL023 SL023B 7,000 NA
+ / - biopsy
bronchoscopy / Rigid oesophagoscopy - LA - 7000 LA - 7000
SL ENT, Pediatric Surgery SL023 SL023C 7,000 NA
+ / - biopsy
Microlaryngeal surgery with or Microlaryngeal surgery with or

SL ENT SL024 SL024A 17,000 NA NA 17,000
without laser without laser
Implant for Open laryngeal

Open laryngeal framework Open laryngeal framework framework surgery /
SL ENT, Surgical Oncology SL025 SL025A 5,000 NA 20,000
surgery / Thyroplasty surgery / Thyroplasty Thyroplasty (Keel / Stent) -
15000
Page 219
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ENT, Cardiology, CTVS,

LA - 6000 LA - 6000
SL General Surgery, Pediatric SL026 Tracheostomy / Tracheotomy SL026A Tracheostomy 6,000 NA
GA - 10000 GA - 10000
ENT, Cardiology, CTVS,

LA - 6000 LA - 6000
SL General Surgery, Pediatric SL026 Tracheostomy / Tracheotomy SL026B Tracheotomy 6,000 NA
GA - 10000 GA - 10000
ENT, Surgical Oncology, Selective Benign neck tumour

SL SL027 Neck dissection SL027A 18,800 NA NA 18,800
General Surgery excision
ENT, Surgical Oncology, Comprehensive Benign neck

SL SL027 Neck dissection SL027B 18,800 NA NA 18,800
General Surgery tumour excision
ENT, Surgical Oncology, Selective Pharyngeal

SL SL027 Neck dissection SL027C 18,800 NA NA 18,800
General Surgery diverticulum excision
Page 220
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ENT, Surgical Oncology, Comprehensive Pharyngeal

SL SL027 Neck dissection SL027D 18,800 NA NA 18,800
General Surgery diverticulum excision
ENT, General Surgery, Deep neck abscess drainage/

SL SL028 SL028A Deep neck abscess drainage 16,800 NA NA 16,800
Pediatric Surgery Post trauma neck exploration
ENT, General Surgery, Deep neck abscess drainage/

SL SL028 SL028B Post trauma neck exploration 16,800 NA NA 16,800
Pediatric Surgery Post trauma neck exploration
ENT, Surgical Oncology, Endoscopic CSF Rhinorrhea

SL SL029 Anterior skull base surgery SL029A 26,000 NA Fibrin Glue - 9000 35,000
Neurosurgery Repair
SL ENT, Surgical Oncology SL029 Anterior skull base surgery SL029B Optic nerve decompression 25,500 NA Fibrin Glue - 9000 34,500
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SL ENT, Surgical Oncology SL029 Anterior skull base surgery SL029C Orbital decompression 25,500 NA Fibrin Glue - 9000 34,500
SL ENT, Surgical Oncology SL029 Anterior skull base surgery SL029D Craniofacial resection 25,500 NA Fibrin Glue - 9000 34,500
SL ENT, Surgical Oncology SL029 Anterior skull base surgery SL029E Maxillary swing 25,500 NA Fibrin Glue - 9000 34,500
Advanced anterior skull base

SL ENT, Surgical Oncology SL030 SL030A Endoscopic Hypophysectomy 39,800 NA Fibrin Glue - 9000 48,800
surgery
Advanced anterior skull base

SL ENT, Surgical Oncology SL030 SL030B Clival tumour excision 39,800 NA Fibrin Glue - 9000 48,800
surgery
Page 222
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SL ENT, Surgical Oncology SL031 Lateral skull base procedures SL031A Subtotal petrosectomy 24,700 NA Fibrin Glue - 9000 33,700
Post-traumatic facial nerve

SL ENT, Surgical Oncology SL031 Lateral skull base procedures SL031B 24,700 NA Fibrin Glue - 9000 33,700
decompression
SL ENT, Surgical Oncology SL031 Lateral skull base procedures SL031C CSF Otorrhoea repair 24,700 NA Fibrin Glue - 9000 33,700
Advanced lateral skull base

SL ENT, Surgical Oncology SL032 SL032A Fisch approach 39,900 NA Fibrin Glue - 9000 48,900
surgery

SL ENT, Surgical Oncology SL032 SL032B Translabyrinthine approach 39,900 NA Fibrin Glue - 9000 48,900
surgery
Page 223
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SL ENT, Surgical Oncology SL032 SL032C Transcochlear approach 39,900 NA Fibrin Glue - 9000 48,900
surgery

SL ENT, Surgical Oncology SL032 SL032D Temporal Bone resection 39,900 NA Fibrin Glue - 9000 48,900
surgery
Closed reduction /
intermaxillary fixation for Closed reduction for fracture
SL ENT SL033 SL033A 9,200 NA NA 9,200
fracture of maxilla / mandible / of maxilla
zygoma
Closed reduction /
SL ENT SL033 SL033B 9,200 NA NA 9,200
fracture of maxilla / mandible / of mandible
zygoma
Closed reduction /
SL ENT SL033 SL033C 9,200 NA NA 9,200
fracture of maxilla / mandible / of zygoma
zygoma
Page 224
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Closed reduction /
Closed reduction and
intermaxillary fixation for
SL ENT SL033 SL033D Intermaxillary fixation for 9,200 NA NA 9,200
fracture of maxilla / mandible /
fracture of mandible
zygoma
Implant for Open reduction

Open reduction and internal
ENT, Oral & Maxillofacial Open reduction and internal Single - 14000 and internal fixation of maxilla Single - 18000
SL SL034 fixation of maxilla / mandible / SL034A 14,000
Surgery, Plastic Surgery fixation of maxilla Multiple - 21000 / mandible / zygoma Multiple - 25000
zygoma
(Plates / Screws) - 4000

SL SL034 fixation of maxilla / mandible / SL034B 14,000
Surgery, Plastic Surgery fixation of mandible Multiple - 21000 / mandible / zygoma Multiple - 25000
zygoma

SL SL034 fixation of maxilla / mandible / SL034C 14,000
Surgery, Plastic Surgery fixation of zygoma Multiple - 21000 / mandible / zygoma Multiple - 25000
zygoma
Clinic based therapeutic

SL ENT SL035 SL035A Turbinate reduction 1,200 NA NA 1,200
interventions of ENT
Page 225
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SL ENT SL035 SL035B Biopsy 1,200 NA NA 1,200

SL ENT SL035 SL035C Intratympanic injections 1,200 NA NA 1,200

SL ENT SL035 SL035D Wide bore aspiration 1,200 NA NA 1,200

SL ENT SL035 SL035E Biopsy 2,000 TBF TBF TBF
Extraction of impacted tooth Extraction of impacted tooth

SM Oral & Maxillofacial Surgery SM001 SM001A 500 NA NA 500
under LA under LA
Page 226
2.1

SM Oral & Maxillofacial Surgery SM002 Sequestrectomy SM002A Sequestrectomy 1,500 NA NA 1,500
TM joint ankylosis of both jaws TM joint ankylosis of both jaws

SM Oral & Maxillofacial Surgery SM003 SM003A 15,000 NA NA 15,000
- under GA - under GA
Closed reduction (1 jaw) using

SM Oral & Maxillofacial Surgery SM004 Fixation of fracture of jaw SM004A 5,000 NA NA 5,000
wires - under LA
Open reduction (1 jaw) and

SM Oral & Maxillofacial Surgery SM004 Fixation of fracture of jaw SM004B fixing of plates / wire – under 12,000 NA NA 12,000
GA
Enucleation / excision /
Surgery for Cyst & tumour of
SM Oral & Maxillofacial Surgery SM005 SM005A marsupialization for cyst & 2,500 NA NA 2,500
Maxilla / Mandible
tumour of Maxilla under LA
Page 227
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Enucleation / excision /
Surgery for Cyst & tumour of
SM Oral & Maxillofacial Surgery SM005 SM005B marsupialization for cyst & 2,500 NA NA 2,500
Maxilla / Mandible
tumour of Mandible under LA
Mandible Tumour Resection Mandible Tumour Resection

SM Oral & Maxillofacial Surgery SM006 and reconstruction / Cancer SM006A and reconstruction / Cancer 6,000 NA NA 6,000
surgery surgery
Release of fibrous bands & Release of fibrous bands &

SM Oral & Maxillofacial Surgery SM007 grafting - in (OSMF) treatment SM007A grafting - in (OSMF) treatment 3,000 NA NA 3,000
under GA under GA
SM Oral & Maxillofacial Surgery SM008 Apicoectomy (A) Tooth SM008A Apicoectomy (A) Tooth 1,500 TBF TBF TBF
Correction of oro-antral Correction of oro-antral

SM Oral & Maxillofacial Surgery SM009 SM009A 7,000 TBF TBF TBF
communication communication
Page 228
2.1

Intraoral submandibular
SM Oral & Maxillofacial Surgery SM010 Submandibular sialolithotomy SM010A 6,000 TBF TBF TBF
sialolithotomy Soft Tissue
Intraoral submandibular
SM Oral & Maxillofacial Surgery SM010 Submandibular sialolithotomy SM010B 6,000 TBF TBF TBF
sialolithotomy Hard Tissue
Extra oral submandibular

SM Oral & Maxillofacial Surgery SM010 Submandibular sialolithotomy SM010C 9,000 TBF TBF TBF
sialolithotomy under GA
SM Oral & Maxillofacial Surgery SM011 Dentoalveolar trauma - wiring SM011A Dentoalveolar trauma - wiring 3,000 TBF TBF TBF
Extraoral parotid sialolithotomy

SM Oral & Maxillofacial Surgery SM012 Parotid sialolithotomy SM012A 11,000 TBF TBF TBF
under GA
Page 229
2.1

SM Oral & Maxillofacial Surgery SM012 Parotid sialolithotomy SM012B Intraoral parotid sialolithotomy 6,000 TBF TBF TBF
Re-implantation of Avulsed Re-implantation of Avulsed

tooth with wiring tooth with wiring
Osteoradionecrosis Osteoradionecrosis
management by excision management by excision
SN Neurosurgery SN001 Depressed Fracture SN001A Depressed Fracture 40,000 NA NA 40,000
CranioPlasty with Endogenous

SN Neurosurgery SN002 CranioPlasty SN002A 20,000 NA NA 20,000
graft
Page 230
2.1

Implant for "CranioPlasty with

CranioPlasty with Exogenous
SN Neurosurgery SN002 CranioPlasty SN002B 20,000 NA Exogenous graft" - To be 20000 + Implant Price
graft
decided by SHA
SN Neurosurgery SN003 Twist Drill Craniostomy SN003A Twist Drill Craniostomy 15,000 NA NA 15,000
SN Neurosurgery SN004 Craniostenosis SN004A Craniostenosis 28,000 NA NA 28,000
SN Neurosurgery SN005 Meningocele SN005A Anterior 36,000 NA NA 36,000
SN Neurosurgery SN005 Meningocele SN005B Lumbar 36,000 NA NA 36,000
Page 231
2.1

SN Neurosurgery SN005 Meningocele SN005C Occipital 50,000 NA NA 50,000
SN Neurosurgery SN006 Surgery for tumour meninges SN006A Gocussa 50,000 NA NA 50,000
SN Neurosurgery SN006 Surgery for tumour meninges SN006B Posterior 50,000 NA NA 50,000
Duroplasty with Endogenous

SN Neurosurgery SN007 Duroplasty SN007A 12,500 NA NA 12,500
graft
Implant for "Duroplasty -

Duroplasty with Exogenous
SN Neurosurgery SN007 Duroplasty SN007B 12,500 NA Exogenous" - To be decided 12500 + Implant Price
graft
by SHA
Page 232
2.1

SN Neurosurgery SN008 Burr hole surgery SN008A Burr hole 7,000 NA NA 7,000
Burr hole surgery with chronic

SN Neurosurgery SN008 Burr hole surgery SN008B 20,000 NA NA 20,000
Sub Dural Haematoma
Surgery for Haematoma -

SN Neurosurgery SN009 SN009A Head injuries 55,000 NA NA 55,000
Intracranial

SN Neurosurgery SN009 SN009B Hypertensive 50,000 NA NA 50,000
Intracranial

SN Neurosurgery SN009 SN009C Child - subdural 50,000 NA NA 50,000
Intracranial
Page 233
2.1

SN Neurosurgery SN010 Excision of Brain Abscess SN010A Excision of Brain Abscess 36,000 NA NA 36,000
Single - 20000 Single - 20000

SN Neurosurgery SN011 Abscess Tapping SN011A Abscess Tapping 20,000 NA
Multiple - 30000 Multiple - 30000
SN Neurosurgery SN012 Epilepsy Surgery SN012A Epilepsy Surgery 50,000 NA NA 50,000
SN Neurosurgery SN013 Brain Biopsy SN013A Brain Biopsy 15,000 NA NA 15,000
SN Neurosurgery SN014 Excision of Orbital Tumour SN014A Excision of Orbital Tumour 40,000 NA NA 40,000
Page 234
2.1

Excision of Brain Tumor

SN Neurosurgery SN015 SN015A Parasagital 50,000 NA NA 50,000
Supratentorial

SN Neurosurgery SN015 SN015B Basal 50,000 NA NA 50,000
Supratentorial

SN Neurosurgery SN015 SN015C Brainstem 50,000 NA NA 50,000
Supratentorial

SN Neurosurgery SN015 SN015D C P Angle 50,000 NA NA 50,000
Supratentorial

SN Neurosurgery SN015 SN015E Supratentorial & others 55,000 NA NA 55,000
Supratentorial
Page 235
2.1

SN Neurosurgery SN016 Stereotactic Lesioning SN016A Stereotactic Lesioning 60,000 NA NA 60,000
SN Neurosurgery SN017 Trans Sphenoidal Surgery SN017A Trans Sphenoidal Surgery 50,000 NA NA 50,000
SN Neurosurgery SN018 Trans oral Surgery SN018A Trans oral Surgery 40,000 NA NA 40,000
Implant for "Transoral surgery

Transoral surgery (Anterior) Transoral surgery (Anterior)
(Anterior) and CV Junction
SN Neurosurgery SN019 and CV Junction (Posterior SN019A and CV Junction (Posterior 55,000 NA 55000 + Implant Price
(Posterior Sterlization)" - To be
Sterilisation) Sterilisation)
decided by SHA
External Ventricular Drainage External Ventricular Drainage

SN Neurosurgery SN020 (EVD) SN020A (EVD) 30,000 NA NA 30,000
including antibiotics including antibiotics
Page 236
2.1

SN Neurosurgery SN021 Ventricular Puncture SN021A Ventricular Puncture 15,000 NA NA 15,000
SN Neurosurgery SN022 Shunt Surgery SN022A Ventriculo - peritoneal 30,000 NA NA 30,000
SN Neurosurgery SN022 Shunt Surgery SN022B Ventriculo - pleural 30,000 NA NA 30,000
SN Neurosurgery SN022 Shunt Surgery SN022C Ventriculo - atrial 30,000 NA NA 30,000
SN Neurosurgery SN022 Shunt Surgery SN022D Theco - peritoneal 30,000 NA NA 30,000
Page 237
2.1

Aneurysm Clipping including Aneurysm Clipping including

SN Neurosurgery SN023 SN023A 50,000 NA Clip for Aneurysm (3) - 15000 95,000
angiogram angiogram
Superficial Temporal Artery Superficial Temporal Artery

(STA): middle cerebral artery (STA): middle cerebral artery
SN Neurosurgery SN024 SN024A 60,000 NA NA 60,000
(MCA) or (other EC - IC) (MCA) or (other EC - IC)
Bypass procedure Bypass procedure
Arterio venous malformation

SN Neurosurgery SN025 SN025A Intracranial 50,000 NA NA 50,000
(AVM) excision

SN Neurosurgery SN025 SN025B Intraspinal 50,000 NA NA 50,000
(AVM) excision

SN Neurosurgery SN025 SN025C Scalp 25,000 NA NA 25,000
(AVM) excision
Page 238
2.1

Foramen Magnum Foramen Magnum

Decompression Decompression
SN Neurosurgery SN027 Skull Traction SN027A Skull Traction 8,000 NA NA 8,000
Posterior Cervical Discetomy Posterior Cervical Discetomy

without implant without implant
Posterior Cervical Fusion with Posterior Cervical Fusion with Implant for "Posterior Cervical
SN Neurosurgery SN029 implant SN029A implant 50,000 NA Fusion with implant (Lateral 50,000
(Lateral mass fixation) (Lateral mass fixation) mass fixation)"
Cervical Disc Multiple level Cervical Disc Multiple level

without Fusion without Fusion
Page 239
2.1

Single - 20000 Single - 20000

SN Neurosurgery SN031 Excision of Cervical Ribs SN031A Excision of Cervical Ribs 20,000 NA
Multiple - 30000 Multiple - 30000
Thoracic / Lumbar Thoracic Corpectomy with Implant for "Thoracic

SN Neurosurgery, Orthopedics SN032 SN032A 60,000 NA 60,000
Corpectomy with fusion fusion Corpectomy with fusion"
Thoracic / Lumbar Lumbar Corpectomy with Implant for "Lumbar

SN Neurosurgery, Orthopedics SN032 SN032B 60,000 NA 60,000
Corpectomy with fusion fusion Corpectomy with fusion"
SN Neurosurgery SN033 Lumbar Discectomy SN033A Lumbar Discectomy 30,000 NA NA 30,000
SN Neurosurgery, Orthopedics SN034 Laminectomy SN034A Laminectomy with Fusion 40,000 NA NA 40,000
Page 240
2.1

Laminectomy with Fusion and Implant for Laminectomy with

SN Neurosurgery, Orthopedics SN034 Laminectomy SN034B 40,000 NA 50,000
fixation Fusion and fixation - 10000
SN Neurosurgery SN035 Neurectomy SN035A Neurectomy 16,000 NA NA 16,000
Neurosurgery, ENT, Oral &

SN SN035 Neurectomy SN035B Neurectomy - Trigeminal 16,500 NA NA 16,500
Maxillofacial Surgery
SN Neurosurgery SN036 Micro discectomy SN036A Cervical 40,000 NA NA 40,000
SN Neurosurgery SN036 Micro discectomy SN036B Lumbar 40,000 NA NA 40,000
Page 241
2.1

Surgery for Spinal Canal Surgery for Spinal Canal

Stenosis Stenosis
Spine - Decompression & Spine - Decompression &

SN Neurosurgery, Orthopedics SN038 SN038A 40,000 NA NA 40,000
Fusion Fusion
Implant for Spine -

Spine - Decompression & Spine - Decompression &
SN Neurosurgery, Orthopedics SN038 SN038B 40,000 NA Decompression & Fusion with 50,000
Fusion Fusion with fixation
fixation - 10000
Spine - Extradural Spine - Extradural

Haematoma Haematoma
Implant for Spine - Extradural

Spine - Extradural Spine - Extradural
SN Neurosurgery SN039 SN039B 30,000 NA Haematoma with fixation - 40,000
Haematoma Haematoma with fixation
10000
Page 242
2.1

Spine - Intradural Spine - Intradural

Haematoma Haematoma
Implant for Spine - Intradural

Spine - Intradural Spine - Intradural
SN Neurosurgery SN040 SN040B 40,000 NA Haematoma with fixation - 50,000
Haematoma Haematoma with fixation
10000
SN Neurosurgery SN041 Spine - Extradural Tumour SN041A Spine - Extradural Tumour 30,000 NA NA 30,000
Spine - Extradural Tumour Implant for Spine - Extradural

SN Neurosurgery SN041 Spine - Extradural Tumour SN041B 30,000 NA 40,000
with fixation Tumour with fixation - 10000
SN Neurosurgery SN042 Spine - Intradural Tumour SN042A Spine - Intradural Tumour 40,000 NA NA 40,000
Page 243
2.1

Spine - Intradural Tumour with Implant for Spine - Intradural

SN Neurosurgery SN042 Spine - Intradural Tumour SN042B 40,000 NA 50,000
fixation Tumour with fixation - 10000
SN Neurosurgery SN043 Spine - Intramedullar Tumour SN043A Spine - Intramedullar Tumour 50,000 NA NA 50,000
Implant for Spine -

Spine - Intramedullar Tumour
SN Neurosurgery SN043 Spine - Intramedullar Tumour SN043B 50,000 NA Intramedullar Tumour with 60,000
with fixation
fixation - 10000
R. F. Lesioning for Trigeminal R. F. Lesioning for Trigeminal

Neuralgia Neuralgia
SN Neurosurgery SN045 Brachial Plexus – Repair SN045A Brachial Plexus – Repair 27,000 NA NA 27,000
Page 244
2.1

SN Neurosurgery, Orthopedics SN046 Carpal Tunnel Release SN046A Carpal Tunnel Release 10,000 NA NA 10,000
SN Neurosurgery SN047 Nerve Decompression SN047A Nerve Decompression 16,000 NA NA 16,000
SN Neurosurgery SN048 Cranial Nerve Anastomosis SN048A Cranial Nerve Anastomosis 32,000 NA NA 32,000
SN Neurosurgery SN049 Peripheral Nerve Surgery SN049A Minor 15,000 NA NA 15,000
SN Neurosurgery SN049 Peripheral Nerve Surgery SN049B Major 30,000 NA NA 30,000
Page 245
2.1

Nerve Biopsy excluding Nerve Biopsy excluding

Hensens Hensens
SN Neurosurgery SN051 Muscle Biopsy with report SN051A Muscle Biopsy with report 7,000 NA NA 7,000
SN Neurosurgery SN052 Anterior Encephalocele SN052A Anterior Encephalocele 50,000 NA NA 50,000
SN Neurosurgery SN053 Spina Bifida Surgery SN053A Spina Bifida Surgery 36,000 NA NA 36,000
Gamma Knife radiosurgery Gamma Knife radiosurgery

(GKRS) / SRS for tumours / (GKRS) / SRS for tumours /
Arteriovenous malformation Arteriovenous malformation
(AVM) (AVM)
Page 246
2.1

SN Neurosurgery SN056 Chronic SDH / EDH SN056A Craniotomy 80,000 TBF TBF TBF
Endoscopic Third Endoscopic Third

SN Neurosurgery SN057 SN057A 20,000 TBF TBF TBF
Ventriculostomy Ventriculostomy
SN Neurosurgery SN059 R. F. Lesioning SN059A For Sacrolitis 5,000 TBF TBF TBF
SN Neurosurgery SN059 R. F. Lesioning SN059B For Spine spondolosis 5,000 TBF TBF TBF
SN Neurosurgery SN059 R. F. Lesioning SN059C For Tendinitis 5,000 TBF TBF TBF
Page 247
2.1

For Degeneration of joints on

SN Neurosurgery SN059 R. F. Lesioning SN059D 5,000 TBF TBF TBF
arthritis
SN Neurosurgery SN060 Discectomy - Dorsal SN060A Discectomy - Dorsal 30,000 TBF TBF TBF
Diagnostic Cerebral / Spinal Diagnostic Cerebral / Spinal

SN Neurosurgery SN061 Angiography (DSA - Digital SN061A Angiography (DSA - Digital 12,000 TBF TBF TBF
Substraction Angiography) Substraction Angiography)
Reexploration for Cranial / Reexploration for Cranial /

SN Neurosurgery SN062 SN062A 25,000 TBF TBF TBF
Spinal surgeries Spinal surgeries
Conservative management of
SN Neurosurgery SN063 SN063A Complex spine injury - TBF TBF TBF
high cervical injury
Page 248
2.1

ST Polytrauma SN063 SN063B Moderate head injury - TBF TBF TBF
SN Neurosurgery SN063 SN063C Severe head injury - TBF TBF TBF
ST Polytrauma SN063 SN063D Simple head injury - TBF TBF TBF
SN Neurosurgery SN063 SN063E Simple spine injury - TBF TBF TBF
SO Obstetrics & Gynecology SO001 Lap. Salpingo-oophrectomy SO001A Lap. Salpingo-oophrectomy 14,000 NA NA 14,000
Page 249
2.1

Laparotomy and proceed for Laparotomy and proceed for

Obstetrics & Gynecology,
Ovarian Cancers. Omentomy Ovarian Cancers. Omentomy
SO Surgical Oncology, Pediatric SO002 SO002A 38,000 NA NA 38,000
with Bilateral Salpingo- with Bilateral Salpingo-
Surgery
oophorectomy oophorectomy
Laparoscopic tubal surgeries Laparoscopic tubal surgeries

SO Obstetrics & Gynecology SO003 (for any indication including SO003A (for any indication including 13,900 NA NA 13,900
ectopic pregnancy) ectopic pregnancy)
Procedure on Fallopian Tube Procedure on Fallopian Tube

SO Obstetrics & Gynecology SO004 SO004A 11,600 NA NA 11,600
for establishing Tubal Patency for establishing Tubal Patency
Laparotomy for broad Laparotomy for broad

ligament haematoma ligament haematoma
SO Obstetrics & Gynecology SO006 Abdominal Myomectomy SO006A Abdominal Myomectomy 20,000 NA NA 20,000
Page 250
2.1

SO Obstetrics & Gynecology SO007 Hysteroscopic myomectomies SO007A Hysteroscopic myomectomies 9,900 NA NA 9,900
SO Obstetrics & Gynecology SO008 Polypectomy SO008A Polypectomy 1,500 NA NA 1,500
SO Obstetrics & Gynecology SO009 Hysteroscopic polypectomy SO009A Hysteroscopic polypectomy 7,200 NA NA 7,200

SO SO010 Hysterectomy SO010A Abdominal Hysterectomy 20,000 NA NA 20,000
Surgical Oncology
Obstetrics & Gynecology, Abdominal Hysterectomy +

SO SO010 Hysterectomy SO010B 20,000 NA NA 20,000
Surgical Oncology Salpingo-oophorectomy
Page 251
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Non descent vaginal

SO Obstetrics & Gynecology SO010 Hysterectomy SO010C 20,000 NA NA 20,000
hysterectomy
Vaginal hysterectomy with

SO Obstetrics & Gynecology SO010 Hysterectomy SO010D anterior and posterior 20,000 NA NA 20,000
colpoperineorrhaphy
Obstetrics & Gynecology, Laparoscopic hysterectomy

SO SO010 Hysterectomy SO010E 20,000 NA NA 20,000
Pediatric Surgery (TLH)
Obstetrics & Gynecology, Laparoscopically assisted

SO SO010 Hysterectomy SO010F 20,000 NA NA 20,000
Pediatric Surgery vaginal hysterectomy (LAVH)
SO Obstetrics & Gynecology SO011 Caesarean hysterectomy SO011A Caesarean hysterectomy 20,000 NA NA 20,000
Page 252
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SO Obstetrics & Gynecology SO012 Manchester Repair SO012A Manchester Repair 15,000 NA NA 15,000
Surgeries for Prolapse - Sling Surgeries for Prolapse - Sling

SO Obstetrics & Gynecology SO013 SO013A 28,900 NA Sling - 5000 33,900
Surgeries Surgeries
SO Obstetrics & Gynecology SO014 Hysterotomy SO014A Hysterotomy 5,000 NA NA 5,000
Lap. Surgery for Lap. Surgery for

SO Obstetrics & Gynecology SO015 Endometriosis SO015A Endometriosis 11,200 NA NA 11,200
(Other than Hysterectomy) (Other than Hysterectomy)
SO Obstetrics & Gynecology SO016 Diagnostic hysteroscopy SO016A With biopsy 6,000 NA NA 6,000
Page 253
2.1

SO Obstetrics & Gynecology SO016 Diagnostic hysteroscopy SO016B Without biopsy 6,000 NA NA 6,000
SO Obstetrics & Gynecology SO017 Hysteroscopic IUCD removal SO017A Hysteroscopic IUCD removal 4,700 NA NA 4,700
SO Obstetrics & Gynecology SO018 D&C (Dilatation&curretage) SO018A D&C (Dilatation&curretage) 3,000 NA NA 3,000
SO Obstetrics & Gynecology SO019 Dilation and Evacuation (D&E) SO019A Dilation and Evacuation (D&E) 5,000 NA NA 5,000
SO Obstetrics & Gynecology SO020 Pyometra drainage SO020A Pyometra drainage 5,000 NA NA 5,000
Page 254
2.1

SO Obstetrics & Gynecology SO021 Intrauterine transfusions SO021A Intrauterine transfusions 11,000 NA NA 11,000
SO Obstetrics & Gynecology SO022 Hysteroscopic adhesiolysis SO022A Hysteroscopic adhesiolysis 6,900 NA NA 6,900
SO Obstetrics & Gynecology SO023 Laparoscopic adhesiolysis SO023A Laparoscopic adhesiolysis 6,000 NA NA 6,000
Trans - vaginal tape / Trans-

SO Obstetrics & Gynecology SO024 SO024A Trans-vaginal tape 15,200 NA Tension free Vaginal Tape 15,200
obturator tape
Trans - vaginal tape / Trans-

SO Obstetrics & Gynecology SO024 SO024B Trans-obturator tape 15,200 NA Trans Obturator Tape 15,200
obturator tape
Page 255
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SO SO025 Sacrocolpopexy (Abdominal) SO025A Open 23,900 NA Mesh - 15 X 15 - 5000 28,900
Urology

SO SO025 Sacrocolpopexy (Abdominal) SO025B Lap. 23,900 NA Mesh - 15 X 15 - 5000 28,900
Urology
LLETZ (including PAP smear LLETZ (including PAP smear

and colposcopy) and colposcopy)
Vaginal Sacrospinus fixation Vaginal Sacrospinus fixation

with repair with repair
Excision of Vaginal Septum Excision of Vaginal Septum

(vaginal route) (vaginal route)
Page 256
2.1

Obstetrics & Gynecology, Hymenectomy for imperforate Hymenectomy for imperforate

SO SO029 SO029A 3,000 NA NA 3,000
Pediatric Surgery hymen hymen
Anterior & Posterior Anterior & Posterior

Colpoperineorrhapy Colpoperineorrhapy
Vaginoplasty (McIndoe Vaginoplasty (McIndoe

procedure) procedure)
Obstetrics & Gynecology, Vaginal repair for vesico- Vaginal repair for vesico-
SO SO032 SO032A 34,000 NA NA 34,000
Urology vaginal fistula vaginal fistula

SO SO033 Rectovaginal fistula repair SO033A Rectovaginal fistula repair 24,000 NA NA 24,000
Pediatric Surgery
Page 257
2.1

SO Obstetrics & Gynecology SO034 Vulval Hamatoma drainage SO034A Vulval Hamatoma drainage 3,000 NA NA 3,000

SO SO035 Vulvectomy simple SO035A Vulvectomy simple 15,000 NA NA 15,000
Surgical Oncology
Radical Vulvectomy with Radical Vulvectomy with

SO SO036 Inguinal and Pelvic lymph SO036A Inguinal and Pelvic lymph 38,500 NA NA 38,500
Surgical Oncology
node disection node disection
Abdomino Perineal repair for Abdomino Perineal repair for

Mullerian Anomaly Mullerian Anomaly
Pelvic Abscess Management Pelvic Abscess Management

including Colpotomy including Colpotomy
Page 258
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Diagnostic / Staging Diagnostic / Staging
SO Pediatric Surgery, Surgical SO039 SO039A 9,700 NA NA 9,700
laparoscopy laparoscopy
Oncology
Laparotomy for benign

SO Obstetrics & Gynecology SO040 SO040A Ectopic 14,000 NA NA 14,000
disorders
Laparotomy for benign

SO Obstetrics & Gynecology SO040 SO040B PID 14,000 NA NA 14,000
disorders
SO Obstetrics & Gynecology SO041 Laparoscopic cystectomy SO041A Laparoscopic cystectomy 15,000 NA NA 15,000
SO Obstetrics & Gynecology SO042 Cystocele - Anterior repair SO042A Cystocele - Anterior repair 6,000 NA NA 6,000
Page 259
2.1

SO Obstetrics & Gynecology SO043 Burch SO043A Abdominal 30,000 NA NA 30,000
SO Obstetrics & Gynecology SO043 Burch SO043B Laparoscopic 30,000 NA NA 30,000
Electro Cauterisation / Cryo Electro Cauterisation / Cryo

Surgery Surgery
EUA for (minor girls / EUA for (minor girls /

SO Obstetrics & Gynecology SO045 unmarried sexually inactive / SO045A unmarried sexually inactive / 2,000 NA NA 2,000
victims of sexual abuse) victims of sexual abuse)

Hospitalisation for Antenatal Hospitalisation for Antenatal HDU - 2700 HDU - 2700
SO Obstetrics & Gynecology SO046 SO046A 1,800 NA
Complications Complications ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Page 260
2.1

SO Obstetrics & Gynecology SO047 Amniocentesis SO047A Amniocentesis 14,500 NA NA 14,500
SO Obstetrics & Gynecology SO048 Chorionic villus sampling SO048A Chorionic villus sampling 14,500 NA NA 14,500
SO Obstetrics & Gynecology SO049 Cordocentesis SO049A Cordocentesis 14,500 NA NA 14,500
SO Obstetrics & Gynecology SO050 McDonald's stitch SO050A McDonald's stitch 4,000 NA NA 4,000
SO Obstetrics & Gynecology SO051 Shirodkar's stitch SO051A Shirodkar's stitch 4,000 NA NA 4,000
Page 261
2.1


Medical management of Medical management of HDU - 2700 HDU - 2700
SO Obstetrics & Gynecology SO052 SO052A 1,800 NA
ectopic pregnancy ectopic pregnancy ICU (without Ventilator) - 3600 ICU (without Ventilator) - 3600
Medical Termination of
SO Obstetrics & Gynecology SO053 SO053A MTP upto 8 weeks 3,500 NA NA 3,500
Pregnancy
SO Obstetrics & Gynecology SO053 SO053B MTP 8 to 12 weeks 5,000 NA NA 5,000
Pregnancy
SO Obstetrics & Gynecology SO053 SO053C MTP > 12 weeks 6,500 NA NA 6,500
Pregnancy
SO Obstetrics & Gynecology SO054 High risk delivery SO054A Pre-mature delivery 11,500 NA NA 11,500
Page 262
2.1

Mothers with eclampsia /

SO Obstetrics & Gynecology SO054 High risk delivery SO054B imminent eclampsia / severe 11,500 NA NA 11,500
pre-eclampsia
Major Fetal malformation

SO Obstetrics & Gynecology SO054 High risk delivery SO054C requiring intervention 11,500 NA NA 11,500
immediately after birth
Mothers with severe anaemia

SO Obstetrics & Gynecology SO054 High risk delivery SO054D 11,500 NA NA 11,500
(<7 g/dL)
Other maternal and fetal

conditions as per guidelines-
eg previous caesarean
SO Obstetrics & Gynecology SO054 High risk delivery SO054E 11,500 NA NA 11,500
section, diabetes, severe
growth retardation, etc that
qualify for high risk delivery.
SO Obstetrics & Gynecology SO055 Manual removal of placenta SO055A Manual removal of placenta 8,500 NA NA 8,500
Page 263
2.1

Secondary suturing of Secondary suturing of

episiotomy episiotomy
SO Obstetrics & Gynecology SO057 Caesarean Delivery SO057A Caesarean Delivery 11,500 NA NA 11,500
Re exploration after
SO Obstetrics & Gynecology SO058 laparotomy / Caesarean SO058A 14,000 NA NA 14,000
Caesarean Section
Section
SO Obstetrics & Gynecology SO058 laparotomy / Caesarean SO058B 14,000 NA NA 14,000
laparotomy
Section
Vulvo vaginal cyst enucleation

SO Obstetrics & Gynecology SO059 SO059A Vulvo vaginal cyst enucleation 4,700 NA NA 4,700
/ drainage
Page 264
2.1

Vulvo vaginal cyst enucleation

SO Obstetrics & Gynecology SO059 SO059B Vulvo vaginal cyst drainage 4,700 NA NA 4,700
/ drainage
SO Obstetrics & Gynecology SO060 Ovariotomy - Lap / Open SO060A Open 10,000 TBF TBF TBF
SO Obstetrics & Gynecology SO060 Ovariotomy - Lap / Open SO060B Laparoscopic 10,000 TBF TBF TBF
Plastic & Reconstructive

SP SP001 Pressure Sore – Surgery SP001A Pressure Sore – Surgery 30,000 NA NA 30,000
Surgery

SP SP002 Diabetic Foot – Surgery SP002A Diabetic Foot – Surgery 30,000 NA NA 30,000
Surgery
Page 265
2.1

Plastic & Reconstructive Revascularization of limb / Revascularization of limb /

SP SP003 SP003A 25,000 NA NA 25,000
Surgery digit digit
Ear Pinna Reconstruction with Ear Pinna Reconstruction with

Plastic & Reconstructive costal cartilage / Prosthesis costal cartilage / Prosthesis Prosthesis for Ear Pinna
SP SP004 SP004A 30,000 NA 30,000
Surgery (including the cost of (including the cost of Reconstruction
prosthesis / implants) prosthesis / implants)

SP SP005 Scalp avulsion reconstruction SP005A Scalp avulsion reconstruction 50,000 NA NA 50,000
Surgery
Tissue Expander for

disfigurement following burns / Tissue Expander / Implant for
Plastic & Reconstructive Tissue Expander for
SP SP006 trauma / congenital deformity SP006A 50,000 NA disfigurement following burns / 50,000
Surgery disfigurement following burns
(including cost of expander / trauma / congenital deformity
implant)
Tissue Expander for

disfigurement following burns / Tissue Expander for Tissue Expander / Implant for
SP SP006 trauma / congenital deformity SP006B disfigurement following 50,000 NA disfigurement following burns / 50,000
Surgery
(including cost of expander / trauma trauma / congenital deformity
implant)
Page 266
2.1

Tissue Expander for

disfigurement following burns / Tissue Expander for Tissue Expander / Implant for
SP SP006 trauma / congenital deformity SP006C disfigurement following 50,000 NA disfigurement following burns / 50,000
Surgery
(including cost of expander / congenital deformity trauma / congenital deformity
implant)

SP SP007 Hemangioma SP007A Sclerotherapy under GA 35,000 NA NA 35,000
Surgery

SP SP007 Hemangioma SP007B Debulking 35,000 NA NA 35,000
Surgery

SP SP007 Hemangioma SP007C Excision 35,000 NA NA 35,000
Surgery

SP SP008 NPWT SP008A NPWT 2,000 NA NA 2,000
Surgery
Page 267
2.1

Pediatric Surgery, Oral &

Cleft Lip and Palate Surgery Cleft Lip and Palate Surgery
SS Maxillofacial Surgery, Plastic SS001 SS001A 15,000 NA NA 15,000
(per stage) (per stage)
& Reconstructive Surgery
SS Pediatric Surgery SS002 Ankyloglossia SS002A Ankyloglossia Minor 5,000 NA NA 5,000
SS Pediatric Surgery SS002 Ankyloglossia SS002B Ankyloglossia Major 15,000 NA NA 15,000
SS Pediatric Surgery SS003 Anti GERD Surgery SS003A Anti GERD Surgery 10,000 NA NA 10,000
Gastrostomy + Gastrostomy +
SS Pediatric Surgery SS004 SS004A 20,000 NA NA 20,000
Esophagoscopy + Threading Esophagoscopy + Threading
Page 268
2.1

SS Pediatric Surgery SS005 Ladds Procedure SS005A Ladds Procedure 30,000 NA NA 30,000
SS Pediatric Surgery SS006 Duplication Cyst Excision SS006A Duplication Cyst Excision 20,000 NA NA 20,000
Non – Operative Reduction in

SS Pediatric Surgery SS007 Intussusception SS007A 20,000 NA NA 20,000
infants
SS Pediatric Surgery SS007 Intussusception SS007B Operative in infants 25,000 NA NA 25,000
Surgery for Hirschsprung’s

SS Pediatric Surgery SS008 SS008A Myectomy 25,000 NA NA 25,000
Disease
Page 269
2.1


SS Pediatric Surgery SS008 SS008B Pull Through 20,000 NA NA 20,000
Disease

SS Pediatric Surgery SS008 SS008C Rectal Biopsy - Punch 10,000 NA NA 10,000
Disease

SS Pediatric Surgery SS008 SS008D Rectal Biopsy – Open 10,000 NA NA 10,000
Disease

SS Pediatric Surgery SS008 SS008E Sphinecterotomy 15,000 NA NA 15,000
Disease
Rectal Polypectomy - Rectal Polypectomy -

Sigmoiescopic Under GA Sigmoiescopic Under GA
Page 270
2.1

SS Pediatric Surgery SS010 Ano Rectal Malformation SS010A Abd - Perineal PSARP 20,000 NA NA 20,000
SS Pediatric Surgery SS010 Ano Rectal Malformation SS010B Anoplasty 20,000 NA NA 20,000
SS Pediatric Surgery SS010 Ano Rectal Malformation SS010C Cutback 20,000 NA NA 20,000
SS Pediatric Surgery SS010 Ano Rectal Malformation SS010D PSARP 20,000 NA NA 20,000
SS Pediatric Surgery SS010 Ano Rectal Malformation SS010E Redo - Pullthrough 15,000 NA NA 15,000
Page 271
2.1

SS Pediatric Surgery SS010 Ano Rectal Malformation SS010F Transposition 15,000 NA NA 15,000
SS Pediatric Surgery SS011 Fecal Fistula Closure SS011A Fecal Fistula Closure 25,000 NA NA 25,000
SS Pediatric Surgery SS012 GI Tumor Excision SS012A GI Tumor Excision 30,000 NA NA 30,000
Congenital Diaphragmatic Congenital Diaphragmatic

Hernia Hernia
SS Pediatric Surgery SS014 Exomphalos / Gastroschisis SS014A Exomphalos 25,000 NA NA 25,000
Page 272
2.1

SS Pediatric Surgery SS014 Exomphalos / Gastroschisis SS014B Gastroschisis 25,000 NA NA 25,000
SS Pediatric Surgery SS015 Hernia & Hydrocele SS015A Hernia & Hydrocele 20,000 NA NA 20,000
Retro - Peritoneal Retro - Peritoneal

Lymphangioma Excision Lymphangioma Excision
Surgery for Sacrococcygeal Surgery for Sacrococcygeal

Teratoma Teratoma
Surgery for Congenital Lobar Surgery for Congenital Lobar

Emphysema Emphysema
Page 273
2.1

Bilateral - Palpable +
SS Pediatric Surgery SS019 Undescended Testis SS019A 15,000 NA NA 15,000
Nonpalpable
SS Pediatric Surgery SS019 Undescended Testis SS019B Bilateral Palpable 15,000 NA NA 15,000
SS Pediatric Surgery SS019 Undescended Testis SS019C Bilateral Non - Palpable 20,000 NA NA 20,000
SS Pediatric Surgery SS019 Undescended Testis SS019D Unilateral - Palpable 15,000 NA NA 15,000
SS Pediatric Surgery SS019 Undescended Testis SS019E Reexploration / Second Stage 20,000 NA NA 20,000
Page 274
2.1

Polytrauma, Orthopedics,
Conservative Management of
ST Neurosurgery, General ST001 ST001A Severe 1,000 Routine Ward - 1000 NA Routine Ward - 1000
Head Injury
Surgery
Conservative Management of
ST Neurosurgery, General ST001 ST001B Depressed Fracture 5,000 Routine Ward - 5000 NA Routine Ward - 5000
Head Injury
Surgery
Polytrauma, Orthopedics, Implant for Open reduction

Head injury with repair of Head injury with repair of
Neurosurgery, General and internal fixation of maxilla
ST ST002 Facio-Maxillary Injury & ST002A Facio-Maxillary Injury & 31,000 NA 35,000
Surgery, Oral & Maxillofacial / mandible / zygoma
fixations (including implants) fixations (including implants)
Surgery (Plates / Screws) - 4000
Polytrauma, Orthopedics, Craniotomy and evacuation of Subdural hematoma along

ST Neurosurgery, General ST003 Haematoma with fixation of ST003A with fixation of fracture of 60,000 NA NA 60,000
Surgery fracture of long bone single long bone
Polytrauma, Orthopedics, Craniotomy and evacuation of Extradural hematoma along

ST Neurosurgery, General ST003 Haematoma with fixation of ST003B with fixation of fracture of 60,000 NA NA 60,000
Surgery fracture of long bone single long bone
Page 275
2.1

Polytrauma, Orthopedics, Craniotomy and evacuation of Subdural hematoma along

ST Neurosurgery, General ST003 Haematoma with fixation of ST003C with fixation of fracture of 2 or 75,000 NA NA 75,000
Surgery fracture of long bone more long bone.
Polytrauma, Orthopedics, Craniotomy and evacuation of Extradural hematoma along

ST Neurosurgery, General ST003 Haematoma with fixation of ST003D with fixation of fracture of 2 or 75,000 NA NA 75,000
Surgery fracture of long bone more long bone.
Polytrauma, Orthopedics, Management of Chest injury Implant for "One fracture of

Management of Chest injury
ST Neurosurgery, General ST004 ST004A with fixation of Single Long 30,000 NA long bone (with implants)" - 35,000
with fracture of Long bone
Surgery bone 5000
Polytrauma, Orthopedics, Management of Chest injury

Management of Chest injury
ST Neurosurgery, General ST004 ST004B with fixation of 2 or more Long 45,000 NA NA 45,000
with fracture of Long bone
Surgery bones
Polytrauma, Orthopedics, Surgical intervention for

Management of Visceral injury
ST Neurosurgery, General ST005 ST005A Visceral injury and fixation of 30,000 NA NA 30,000
and fracture long bone
Surgery fracture of single long bone
Page 276
2.1

Surgical intervention for

Management of Visceral injury Visceral injury and fixation of
ST Neurosurgery, General ST005 ST005B 45,000 NA NA 45,000
and fracture long bone fracture of 2 or more long
Surgery
bones
Internal fixation of Internal fixation of
ST Neurosurgery, General ST006 ST006A 40,000 NA NA 40,000
Pelviacetabular fracture Pelviacetabular fracture
Surgery
Polytrauma, Orthopedics, Internal fixation with Flap Internal fixation with Flap
ST Neurosurgery, General ST007 cover Surgery for wound in ST007A cover Surgery for wound in 40,000 NA NA 40,000
Surgery compound fracture compound fracture
Polytrauma, Orthopedics, Emergency tendons repair ± Emergency tendons repair ±

ST Neurosurgery, General ST008 Peripheral Nerve repair/ ST008A Peripheral Nerve repair/ 30,000 NA NA 30,000
Surgery reconstructive surgery reconstructive surgery
Management of Nerve Plexus
ST Neurosurgery, General ST009 ST009A Nerve Plexus injury repair 50,000 NA NA 50,000
/ Tendon injuries
Surgery
Page 277
2.1

Management of Nerve Plexus Nerve Plexus injury
/ Tendon injuries reconstruction
Surgery
ST Neurosurgery, General ST009 ST009C Tendon injury repair 50,000 NA NA 50,000
/ Tendon injuries
Surgery
ST Neurosurgery, General ST009 ST009D Tendon injury reconstruction 50,000 NA NA 50,000
/ Tendon injuries
Surgery
ST Neurosurgery, General ST009 ST009E Tendon Transfer 50,000 NA NA 50,000
/ Tendon injuries
Surgery
Plexus injury along with Plexus injury along with
ST Neurosurgery, General ST010 ST010A 60,000 NA NA 60,000
Vascular injury repair / graft Vascular injury repair
Surgery
Page 278
2.1

Plexus injury along with Plexus injury along with
Vascular injury repair / graft Vascular injury graft
Surgery
U/L - 27500 U/L - 27500

SU Urology & Pediatric Surgery SU001 Adrenalectomy SU001A Open 27,500 NA
B/L - 32500 B/L - 32500
U/L - 27500 U/L - 27500

SU Urology & Pediatric Surgery SU001 Adrenalectomy SU001B Lap. 27,500 NA
B/L - 32500 B/L - 32500
Renal Cyst deroofing or

SU Urology, Pediatric Surgery SU002 SU002A Open 25,000 NA NA 25,000
Marsupialization
Renal Cyst deroofing or

SU Urology, Pediatric Surgery SU002 SU002B Lap. 25,000 NA NA 25,000
Marsupialization
Page 279
2.1

Urology, Pediatric Surgery,

SU SU003 Nephrectomy SU003A For Benign pathology - Open 27,500 NA NA 27,500
Surgical Oncology

SU SU003 Nephrectomy SU003B For Benign pathology - Lap. 27,500 NA NA 27,500
Surgical Oncology

SU SU003 Nephrectomy SU003C Radical (Renal tumor) - Open 27,500 NA NA 27,500
Surgical Oncology

SU SU003 Nephrectomy SU003D Radical (Renal tumor) - Lap. 27,500 NA NA 27,500
Surgical Oncology

SU SU004 Nephrectomy - Partial or Hemi SU004A Open 42,000 NA NA 42,000
Surgical Oncology
Page 280
2.1


SU SU004 Nephrectomy - Partial or Hemi SU004B Lap. 42,000 NA NA 42,000
Surgical Oncology
SU Urology SU005 Nephrolithotomy SU005A Open 30,000 NA NA 30,000
SU Urology SU005 Nephrolithotomy SU005B Anatrophic 30,000 NA NA 30,000
Open Nephrolithotomy - Open Nephrolithotomy -

SU Urology SU006 SU006A 1,000 NA NA 1,000
Follow Up Follow Up
PCNL (Percutaneous PCNL (Percutaneous U/L - 35000 U/L - 35000

SU Urology SU007 SU007A 35,000 NA
Nephrolithotomy) Nephrolithotomy) B/L - 40000 B/L - 40000
Page 281
2.1

Urology, Pediatric Surgery, Nephrostomy - Percutaneous Nephrostomy - Percutaneous

SU SU008 SU008A 14,000 NA NA 14,000
Interventional Neuroradiology ultrasound guided ultrasound guided
Nephrostomy (PCN) - Follow Nephrostomy (PCN) - Follow

Up Up

SU SU010 Nephro ureterectomy (Benign) SU010A Open 27,500 NA NA 27,500
Surgical Oncology

SU SU010 Nephro ureterectomy (Benign) SU010B Lap. 27,500 NA NA 27,500
Surgical Oncology
Urology, Pediatric Surgery, Nephro ureterectomy with cuff

SU SU011 SU011A Open 27,500 NA NA 27,500
Surgical Oncology of bladder
Page 282
2.1

Urology, Pediatric Surgery, Nephro ureterectomy with cuff

SU SU011 SU011B Lap. 27,500 NA NA 27,500
Surgical Oncology of bladder
SU Urology SU013 Perinephric Abscess drainage SU013A Open 14,000 NA NA 14,000
SU Urology SU013 Perinephric Abscess drainage SU013B Percutaneous 14,000 NA NA 14,000
Ureteroscopy + Stone removal U/L - 28000 U/L - 28000

SU Urology SU014 SU014A Lower Ureter 28,000 NA
with lithotripsy B/L - 43000 B/L - 43000
Ureteroscopy + Stone removal U/L - 28000 U/L - 28000

SU Urology SU014 SU014B Upper Ureter 28,000 NA
with lithotripsy B/L - 43000 B/L - 43000
Page 283
2.1

URSL / URSL - Laser - Follow URSL / URSL - Laser - Follow

Up Up
Extracoporeal shock - wave

Extracoporeal shock - wave
SU Urology SU016 SU016A Lithotripsy (ESWL) stone, with 18,500 NA DJ Stent - 200 18,700
Lithotripsy (ESWL)
or without stent (one side)
SU Urology SU017 ESWL - Follow Up SU017A ESWL - Follow Up 1,000 NA NA 1,000
SU Urology, Pediatric Surgery SU018 Ureterolithotomy SU018A Open 20,000 NA NA 20,000
SU Urology, Pediatric Surgery SU018 Ureterolithotomy SU018B Lap. 20,000 NA NA 20,000
Page 284
2.1

Lap Ureterolithotomy - Follow Lap Ureterolithotomy - Follow

Up Up
Open Ureterolithotomy - Open Ureterolithotomy -

Follow Up Follow Up
Pyeloplasty /
SU Urology, Pediatric Surgery SU021 Pyeloureterostomy / SU021A Pyeloplasty - Open 27,500 NA NA 27,500
Pyelopyelostomy
Pyeloplasty /
SU Urology, Pediatric Surgery SU021 Pyeloureterostomy / SU021B Pyeloplasty - Laparoscopic 27,500 NA NA 27,500
Pyelopyelostomy
Pyeloplasty /
SU Urology, Pediatric Surgery SU021 Pyeloureterostomy / SU021C Pyeloureterostomy - Open 27,500 NA NA 27,500
Pyelopyelostomy
Page 285
2.1

Pyeloplasty /
Pyeloureterostomy -
SU Urology, Pediatric Surgery SU021 Pyeloureterostomy / SU021D 27,500 NA NA 27,500
Laparoscopic
Pyelopyelostomy
Pyeloplasty /
SU Urology, Pediatric Surgery SU021 Pyeloureterostomy / SU021E Pyelopyelostomy - Open 27,500 NA NA 27,500
Pyelopyelostomy
Pyeloplasty /
Pyelopyelostomy -
SU Urology, Pediatric Surgery SU021 Pyeloureterostomy / SU021F 27,500 NA NA 27,500
Laparoscopic
Pyelopyelostomy
SU Urology SU022 Pyeloplasty SU022A Pyeloplasty - Follow Up 1,500 NA NA 1,500
SU Urology, Pediatric Surgery SU023 Ureterocalycostomy SU023A Ureterocalycostomy - Open 25,000 NA NA 25,000
Page 286
2.1

Ureterocalycostomy -
SU Urology, Pediatric Surgery SU023 Ureterocalycostomy SU023B 25,000 NA NA 25,000
Laparoscopic
SU Urology, Pediatric Surgery SU024 Pyelolithotomy SU024A Open 28,000 NA NA 28,000
SU Urology, Pediatric Surgery SU024 Pyelolithotomy SU024B Lap. 28,000 NA NA 28,000
Internal Ureterotomy including Internal Ureterotomy including

SU Urology SU025 cystoscopy as an independent SU025A cystoscopy as an independent 10,000 NA NA 10,000
procedure procedure
Ureterolysis for retroperitoneal

fibrosis
SU Urology SU026 SU026A Open 28,000 NA NA 28,000
(with or without omental
wrapping)
Page 287
2.1

Ureterolysis for retroperitoneal

fibrosis
SU Urology SU026 SU026B Lap. 28,000 NA NA 28,000
(with or without omental
wrapping)
SU Urology, Pediatric Surgery SU027 Ureterostomy SU027A Ureterostomy (Cutaneous) 20,000 NA NA 20,000
SU Urology, Pediatric Surgery SU028 Uretero-ureterostomy SU028A Open 25,000 NA NA 25,000
SU Urology, Pediatric Surgery SU028 Uretero-ureterostomy SU028B Lap. 25,000 NA NA 25,000
Urology , Obstetrics & Uretero-vaginal / Uterine Uretero - vaginal fistula repair -

SU SU029 SU029A 25,000 NA NA 25,000
Gynecology fistula repair Open
Page 288
2.1

Urology , Obstetrics & Uretero-vaginal / Uterine Uretero - Uterine fistula repair -

SU SU029 SU029B 25,000 NA NA 25,000
Gynecology fistula repair Open
Urology , Obstetrics & Uretero-vaginal / Uterine Uretero - vaginal fistula repair -

SU SU029 SU029C 25,000 NA NA 25,000
Gynecology fistula repair Laparoscopic
Urology , Obstetrics & Uretero-vaginal / Uterine Uretero - Uterine fistula repair -

SU SU029 SU029D 25,000 NA NA 25,000
Gynecology fistula repair Laparoscopic
U/L - 23000 U/L - 23000

SU Urology, Pediatric Surgery SU030 Ureteric reimplantation SU030A Open 23,000 NA
B/L - 33000 B/L - 33000
U/L - 23000 U/L - 23000

SU Urology, Pediatric Surgery SU030 Ureteric reimplantation SU030B Lap. 23,000 NA
B/L - 33000 B/L - 33000
Page 289
2.1

SU Urology SU031 Boari flap for ureteric stricture SU031A Open 30,000 NA NA 30,000
SU Urology SU031 Boari flap for ureteric stricture SU031B Lap. 30,000 NA NA 30,000
Ileal replacement for ureteric Ileal replacement for ureteric

stricture stricture
DJ stenting including DJ stenting including

cystoscopy, ureteric cystoscopy, ureteric
SU Urology, Pediatric Surgery SU033 SU033A 9,800 NA DJ Stent - 200 10,000
catheterization, retrograde catheterization, retrograde
pyelogram pyelogram
SU Urology SU034 DJ Stent Removal SU034A DJ Stent Removal 5,000 NA NA 5,000
Page 290
2.1

Ureterocele incision including Ureterocele incision including

pyelogram pyelogram
Ureteric sampling including Ureteric sampling including

pyelogram pyelogram
Acute management of upper Acute management of upper

SU Urology, Pediatric Surgery SU037 urinary tract trauma – SU037A urinary tract trauma – 2,000 Routine Ward - 2000 NA Routine Ward - 2000
conservative conservative
Retrograde with laser /

SU Urology SU038 Endopyelotomy SU038A 25,000 NA NA 25,000
bugbee
SU Urology SU038 Endopyelotomy SU038B Antegrade with laser / bugbee 25,000 NA NA 25,000
Page 291
2.1

Open Pyelolithotomy - Follow Open Pyelolithotomy - Follow

Up Up
Cystolithotomy - Open,
SU Urology, Pediatric Surgery SU040 SU040A Open - including cystoscopy 18,500 NA NA 18,500
including cystoscopy
Cystolithotripsy / Urethral
Cystolithotripsy endoscopic,
SU Urology, Pediatric Surgery SU041 Stone endoscopic, including SU041A 18,500 NA NA 18,500
including cystoscopy
cystoscopy
Cystolithotripsy / Urethral Urethral Stone removal

SU Urology, Pediatric Surgery SU041 Stone endoscopic, including SU041B endoscopic, including 18,500 NA NA 18,500
cystoscopy cystoscopy
SU Urology, Pediatric Surgery SU042 Diagnostic Cystoscopy SU042A Diagnostic Cystoscopy 6,500 NA NA 6,500
Page 292
2.1

Urology, Surgical Oncology,

SU SU043 Partial Cystectomy SU043A Open 23,000 NA NA 23,000
Pediatric Surgery

SU SU043 Partial Cystectomy SU043B Lap. 23,000 NA NA 23,000
Pediatric Surgery
SU Urology SU044 Partial Cystectomy - Follow Up SU044A Partial Cystectomy - Follow Up 1,000 NA NA 1,000
SU Urology, Pediatric Surgery SU045 Augmentation cystoplasty SU045A Open 30,000 NA NA 30,000
SU Urology, Pediatric Surgery SU045 Augmentation cystoplasty SU045B Lap. 30,000 NA NA 30,000
Page 293
2.1

SU Urology SU046 Deflux for VUR SU046A Deflux for VUR 1,200 NA NA 1,200
Bladder Diverticulectomy -
SU Urology SU047 Bladder Diverticulectomy SU047A 1,000 NA NA 1,000
Follow Up
Open bladder diverticulectomy Open bladder diverticulectomy

SU Urology, Pediatric Surgery SU048 with / without ureteric re- SU048A with / without ureteric re- 25,000 NA NA 25,000
implantation implantation
Bladder injury repair Bladder injury repair

SU Urology, Pediatric Surgery SU049 SU049A 23,000 NA NA 23,000
(with or without urethral injury) (with or without urethral injury)
Bladder injury repair with Bladder injury repair with

SU Urology, Pediatric Surgery SU050 colostomy SU050A colostomy 27,500 NA NA 27,500
(with or without urethral injury) (with or without urethral injury)
Page 294
2.1

Extrophy Bladder repair Extrophy Bladder repair

including osteotomy if needed including osteotomy if needed
+ epispadias repair + ureteric + epispadias repair + ureteric
reimplant reimplant
Neurogenic bladder - Package Neurogenic bladder - Package

for evaluation / investigation for evaluation / investigation
SU Urology, Pediatric Surgery SU052 (catheter + ultrasound + SU052A (catheter + ultrasound + 14,300 NA NA 14,300
culture + RGU/ MCU) for 1 culture + RGU/ MCU) for 1
month (medicines - antibiotics) month (medicines - antibiotics)
Y V Plasty of Bladder Neck / Y V Plasty of Bladder Neck /

Bladder Neck Reconstruction Bladder Neck Reconstruction
Bladder Neck incision - Bladder Neck incision -

Endoscopic Endoscopic
TURBT TURBT
SU Urology, Surgical Oncology SU055 (Transurethral Resection of SU055A (Transurethral Resection of 27,500 NA NA 27,500
the Bladder Tumor) the Bladder Tumor)
Page 295
2.1

SU Urology, Surgical Oncology SU056 TURBT - Restage SU056A TURBT - Restage 18,000 NA NA 18,000
Post TURBT - Check Post TURBT - Check

SU Urology SU057 Cystoscopy (Per sitting) with SU057A Cystoscopy (Per sitting) with 10,000 NA NA 10,000
cold-cup biopsy cold-cup biopsy
SU Urology SU058 Urachal Cyst excision SU058A Urachal Cyst excision - Open 18,500 NA NA 18,500
Urachal Cyst excision -

SU Urology SU058 Urachal Cyst excision SU058B 18,500 NA NA 18,500
Laparoscopic
SU Urology SU059 VVF Repair - Follow Up SU059A VVF Repair - Follow Up 1,500 NA NA 1,500
Page 296
2.1

SU Urology, Medical Oncology SU060 Intravesical BCG / Mitomycin SU060A Induction cycles 15,000 NA NA 15,000
SU Urology, Medical Oncology SU060 Intravesical BCG / Mitomycin SU060B Maintenance 30,000 NA NA 30,000
Suprapubic Drainage - Closed Suprapubic Drainage - Closed

/ Trocar / Trocar
Stress incontinence surgery - BIS standard sling for women -

SU Urology, Surgical Oncology SU062 Stress incontinence surgery SU062A 23,000 NA 28,000
Open 5000
Repair of stress incontinence - Repair of stress incontinence -

Follow Up Follow Up
Page 297
2.1

Emergency management of Emergency management of

SU Urology, Pediatric Surgery SU064 SU064A 2,000 Routine Ward - 2000 NA Routine Ward - 2000
Acute retention of Urine Acute retention of Urine
SU Urology, Pediatric Surgery SU065 Meatotomy / Meatoplasty SU065A Meatotomy 3,500 NA NA 3,500
SU Urology, Pediatric Surgery SU065 Meatotomy / Meatoplasty SU065B Meatoplasty 3,500 NA NA 3,500
SU Urology, Pediatric Surgery SU066 Urethroplasty SU066A Urethroplasty - End to end 28,000 NA NA 28,000
Urethroplasty - Substitution -
SU Urology, Pediatric Surgery SU066 Urethroplasty SU066B 28,000 NA NA 28,000
single stage
Page 298
2.1

Urethroplasty - Substitution -
SU Urology, Pediatric Surgery SU066 Urethroplasty SU066C 41,500 NA NA 41,500
two stage
SU Urology, Pediatric Surgery SU066 Urethroplasty SU066D Urethroplasty - Transpubic 32,000 NA NA 32,000
SU Urology SU067 Urethroplasty Follow Up SU067A Urethroplasty Follow Up 1,000 NA NA 1,000
Non endocopic as an
SU Urology, Pediatric Surgery SU068 Urethral Dilatation SU068A 2,000 NA NA 2,000
independent procedure
Endocopic as an independent
SU Urology, Pediatric Surgery SU068 Urethral Dilatation SU068B 5,000 NA NA 5,000
procedure
Page 299
2.1

Perineal Urethrostomy without Perineal Urethrostomy without

closure closure
Post. Urethral Valve Post. Urethral Valve

fulguration fulguration

SU Plastic & Reconstructive SU071 Hypospadias repair SU071A Single stage 28,000 NA NA 28,000
Surgery

Two or more stage (First
SU Plastic & Reconstructive SU071 Hypospadias repair SU071B 12,000 NA NA 12,000
Stage)
Surgery

Two or more stage
SU Plastic & Reconstructive SU071 Hypospadias repair SU071C 2 NA NA 2
(Intermediate Stage)
Surgery
Page 300
2.1


Two or more stage (Final
SU Plastic & Reconstructive SU071 Hypospadias repair SU071D 30,000 NA NA 30,000
Stage)
Surgery
Hypospadias Repair - Follow Hypospadias Repair - Follow

Up Up
Urology, Pediatric Surgery, Emergency management of Emergency management of

SU SU073 SU073A 2,000 Routine Ward - 2000 NA Routine Ward - 2000
Emergency Hematuria Hematuria
SU Urology SU074 Excision of Urethral Caruncle SU074A Excision of Urethral Caruncle 5,000 NA NA 5,000
Urology, Obstetrics &

SU SU075 Urethrovaginal fistula repair SU075A Urethrovaginal fistula repair 30,000 NA NA 30,000
Gynecology, Pediatric Surgery
Page 301
2.1

SU Urology, Pediatric Surgery SU076 Urethrorectal fistula repair SU076A Urethrorectal fistula repair 40,000 NA NA 40,000
Open simple prostatetctomy Open simple prostatetctomy

for BPH for BPH
SU Urology SU078 Radical prostatectomy SU078A Open 50,000 NA NA 50,000
SU Urology SU078 Radical prostatectomy SU078B Lap. 50,000 NA NA 50,000
SU Urology SU079 Holmium Laser Prostatectomy SU079A Holmium Laser Prostatectomy 40,000 NA NA 40,000
Page 302
2.1

TURP-Transurethral Resection
SU Urology SU080 SU080A Monopolar 27,500 NA NA 27,500
of the Prostate, BPH
TURP-Transurethral Resection
SU Urology SU080 SU080B Bipolar 27,500 NA NA 27,500
of the Prostate, BPH
Transrectal Ultrasound guided Transrectal Ultrasound guided

SU Urology SU081 prostate biopsy (minimum 12 SU081A prostate biopsy (minimum 12 10,000 NA NA 10,000
core) core)
SU Urology, Surgical Oncology SU082 Penectomy SU082A Partial Penectomy 15,000 NA NA 15,000
Total Penectomy + Perineal

SU Urology, Surgical Oncology SU082 Penectomy SU082B 25,000 NA NA 25,000
Urethrostomy
Page 303
2.1

SU Urology SU083 Surgery for Priapism SU083A Aspiration 15,000 NA NA 15,000
SU Urology SU083 Surgery for Priapism SU083B Shunt 15,000 NA NA 15,000
Surgery for Priaprism - Follow Surgery for Priaprism - Follow

Up Up
Penile Prosthesis - Malleable -

SU Urology SU085 Penile prosthesis insertion SU085A Penile prosthesis insertion 35,000 NA 35,000
Indian Implant

SU SU086 Orchiectomy SU086A High inguinal 13,800 NA NA 13,800
Pediatric Surgery
Page 304
2.1


SU SU086 Orchiectomy SU086B Simple 10,000 NA NA 10,000
Pediatric Surgery
Bilateral Orchidectomy for Bilateral Orchidectomy for

SU Urology, Surgical Oncology SU087 SU087A 10,000 NA NA 10,000
hormone ablation hormone ablation
U/L - 30000 U/L - 30000

SU Urology, Pediatric Surgery SU088 Orchiopexy SU088A Orchiopexy with laparoscopy 30,000 NA
B/L - 35000 B/L - 35000
Orchiopexy without
SU Urology, Pediatric Surgery SU088 Orchiopexy SU088B 15,000 NA NA 15,000
laparoscopy - U/L
Orchiopexy without
SU Urology, Pediatric Surgery SU088 Orchiopexy SU088C 15,000 NA NA 15,000
laparoscopy - B/L
Page 305
2.1

Surgical Correction of U/L - 10000 U/L - 10000

SU Urology SU089 SU089A Non Microsurgical 10,000 NA
Varicocele B/L - 15000 B/L - 15000
Surgical Correction of U/L - 15000 U/L - 15000

SU Urology SU089 SU089B Microsurgical 15,000 NA
Varicocele B/L - 20000 B/L - 20000
Urology, Surgical Oncology, Radical Retroperitoneal lymph

SU SU090 SU090A Open 36,500 NA NA 36,500
Obstetrics & Gynecology node dissection
Urology, Surgical Oncology, Radical Retroperitoneal lymph

SU SU090 SU090B Lap. 36,500 NA NA 36,500
Obstetrics & Gynecology node dissection
U/L - 18500 U/L - 18500

SU Urology, Surgical Oncology SU091 Ilio-Inguinal lymphadenectomy SU091A Ilio-Inguinal lymphadenectomy 18,500 NA
B/L - 23500 B/L - 23500
Page 306
2.1

Urology, Obstetrics & Hysterectomy as part of VVF / Hysterectomy as part of VVF /

SU SU092 SU092A 5,000 NA NA 5,000
Gynecology uterovaginal fistula repair uterovaginal fistula repair
SU Urology SU093 PCNL - Follow Up SU093A PCNL - Follow Up 1,200 NA NA 1,200
Emergency management of Emergency management of

Ureteric stone - Package for Ureteric stone - Package for
SU Urology, Pediatric Surgery SU094 evaluation / investigation SU094A evaluation / investigation 3,500 NA NA 3,500
(ultrasound + culture) for 3 (ultrasound + culture) for 3
weeks (medicines). weeks (medicines).
Retrograde Intrarenal Surgery Retrograde Intrarenal Surgery

SU Urology SU095 SU095A 30,000 TBF TBF TBF
with Laser Lithotripsy with Laser Lithotripsy
SO Obstetrics & Gynecology SU096 Repair for VVF SU096A Open / Vaginal 34,000 TBF TBF TBF
Page 307
2.1

SU Urology SU096 Repair for VVF SU096B Laparoscopic 34,000 TBF TBF TBF
Permanent tunnelled catheter Permanent tunnelled catheter

SU Urology SU097 placement as substitute for AV SU097A placement as substitute for AV 30,000 TBF TBF TBF
fistula in long term dialysis fistula in long term dialysis
Pelvic lymphadenectomy, after

SC Surgical Oncology SU098 SU098A Open 25,000 TBF TBF TBF
prior cancer surgery
Pelvic lymphadenectomy, after

SU Urology SU098 SU098B Laparoscopic 30,000 TBF TBF TBF
prior cancer surgery
Surgical Correction of
SV CTVS SV001 Category - I Congenital Heart SV001A Unifocalization of MAPCA 100,000 NA NA 100,000
Disease
Page 308
2.1

Isolated Secundum Atrial
SV CTVS SV001 Category - I Congenital Heart SV001B 100,000 NA NA 100,000
Septal Defect (ASD) Repair
Disease
SV CTVS SV001 Category - I Congenital Heart SV001C Glenn procedure 100,000 NA NA 100,000
Disease
SV CTVS SV001 Category - I Congenital Heart SV001D Pulmonary Artery Banding 100,000 NA NA 100,000
Disease
Systemic - Pulmonary Artery
SV CTVS SV001 Category - I Congenital Heart SV001E 100,000 NA PTFE Patch - Thin - 30000 130,000
shunt
Disease
SV CTVS SV001 Category - I Congenital Heart SV001F Vascular Ring division 100,000 NA NA 100,000
Disease
Page 309
2.1

Dacron Graft - Straight -
SV CTVS SV001 Category - I Congenital Heart SV001G Coarctation repair 100,000 NA 130,000
30000
Disease
SV CTVS SV001 Category - I Congenital Heart SV001H BT Shunt (inclusives of grafts) 150,000 TBF TBF TBF
Disease
PTFE Patch - Thin - 150000

Mechanical Valve - Bileaflet -
160000
40000
Mechanical Valve - Tilting Disc
Surgical Correction of ASD closure + Partial Mechanical Valve - Tilting Disc
- 148000
SV CTVS SV002 Category - II Congenital Heart SV002A Anomalous Venous Drainage 120,000 NA - 28000
Pericardial Patch - 138000
Disease Repair Pericardial Patch - 18000
Tissue Valve - 190000
Valve Ring - Mitral - 155000
Valve Ring - Tricuspid -
Valve Ring - Tricuspid - 35000
155000

160000
40000
Surgical Correction of Mechanical Valve - Tilting Disc
ASD Closure + Mitral - 148000
SV CTVS SV002 Category - II Congenital Heart SV002B 120,000 NA - 28000
procedure Pericardial Patch - 138000
Disease Pericardial Patch - 18000
155000

160000
40000
ASD Closure + Tricuspid - 148000
SV CTVS SV002 Category - II Congenital Heart SV002C 120,000 NA - 28000
155000
Page 310
2.1


160000
40000
ASD Closure + Pulmonary - 148000
SV CTVS SV002 Category - II Congenital Heart SV002D 120,000 NA - 28000
155000

160000
40000
ASD Closure + Infundibular - 148000
SV CTVS SV002 Category - II Congenital Heart SV002E 120,000 NA - 28000
155000

160000
40000
- 148000
SV CTVS SV002 Category - II Congenital Heart SV002F VSD closure 120,000 NA - 28000
155000

160000
40000
- 148000
SV CTVS SV002 Category - II Congenital Heart SV002G Infundibular PS repair 120,000 NA - 28000
155000

160000
40000
- 148000
SV CTVS SV002 Category - II Congenital Heart SV002H Valvular PS / PR repair 120,000 NA - 28000
155000
Page 311
2.1


160000
40000
- 148000
SV CTVS SV002 Category - II Congenital Heart SV002I Partial AV canal repair 120,000 NA - 28000
155000

160000
40000
- 148000
SV CTVS SV002 Category - II Congenital Heart SV002J Intermediate AV canal repair 120,000 NA - 28000
155000

160000
40000
- 148000
SV CTVS SV002 Category - II Congenital Heart SV002K Atrial septectomy + Glenn 120,000 NA - 28000
155000

160000
40000
- 148000
SV CTVS SV002 Category - II Congenital Heart SV002L Atrial septectomy + PA Band 120,000 NA - 28000
155000

160000
40000
Surgical Correction of Sinus of Valsalva aneurysm Mechanical Valve - Tilting Disc
- 148000
SV CTVS SV002 Category - II Congenital Heart SV002M repair with aortic valve 120,000 NA - 28000
Disease procedure Pericardial Patch - 18000
155000
Page 312
2.1


160000
40000
Surgical Correction of Sinus of Valsalva aneurysm Mechanical Valve - Tilting Disc
- 148000
SV CTVS SV002 Category - II Congenital Heart SV002N repair without aortic valve 120,000 NA - 28000
Disease procedure Pericardial Patch - 18000
155000

160000
40000
Sub-aortic membrane - 148000
SV CTVS SV002 Category - II Congenital Heart SV002O 120,000 NA - 28000
resection Pericardial Patch - 138000
155000

190000
40000
Surgical Correction of - 168000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003A Ebstien repair 150,000 NA Pericardial Patch - 138000
Disease RV - PA Conduit - 270000
RV - PA Conduit - 120000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003B Double switch operation 150,000 NA Pericardial Patch - 138000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003C Rastelli Procedure 150,000 NA Pericardial Patch - 138000
185000
Page 313
2.1

PTFE Patch - Thin - 30000 Mechanical Valve - Bileaflet -
Mechanical Valve - Bileaflet - 190000
40000 Mechanical Valve - Tilting Disc
Mechanical Valve - Tilting Disc - 168000
- 28000 Pericardial Patch - 138000
Pericardial Patch - 18000 RV - PA Conduit - 270000
SV CTVS SV003 Category - III Congenital Heart SV003D Fontan procedure 150,000 NA
RV - PA Conduit - 120000 Tissue Valve - 220000
Disease
Tissue Valve - 70000 Valve Ring - Mitral - 185000
Valve Ring - Mitral - 35000 Valve Ring - Tricuspid -
Valve Ring - Tricuspid - 35000 185000
Dacron Graft Straight - 30000 Dacron Graft Straight -
PTFE Graft Straight - 50000 180000
PTFE Graft Straight - 200000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003E AP window repair 150,000 NA Pericardial Patch - 138000
185000

190000
40000
Arch interruption Repair - 28000
SV CTVS SV003 Category - III Congenital Heart SV003F 150,000 NA Pericardial Patch - 138000
without VSD closure Pericardial Patch - 18000
185000

190000
40000
Arch interruption Repair with - 28000
SV CTVS SV003 Category - III Congenital Heart SV003G 150,000 NA Pericardial Patch - 138000
VSD closure Pericardial Patch - 18000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003H DORV Repair 150,000 NA Pericardial Patch - 138000
185000
Page 314
2.1


190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003I Supravalvular AS repair 150,000 NA Pericardial Patch - 138000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003J Konno procedure 150,000 NA Pericardial Patch - 138000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003K Norwood procedure 150,000 NA Pericardial Patch - 138000
185000

190000
40000
VSD closure + RV - PA - 28000
SV CTVS SV003 Category - III Congenital Heart SV003L 150,000 NA Pericardial Patch - 138000
conduit Pericardial Patch - 18000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003M VSD + Aortic procedure 150,000 NA Pericardial Patch - 138000
185000
Page 315
2.1


190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003N VSD + Mitral procedure 150,000 NA Pericardial Patch - 138000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003O VSD + Tricuspid procedure 150,000 NA Pericardial Patch - 138000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003P VSD + Pulmonary procedure 150,000 NA Pericardial Patch - 138000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003Q VSD + Infundibular procedure 150,000 NA Pericardial Patch - 138000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003R VSD + Coarctation repair 150,000 NA Pericardial Patch - 138000
185000
Page 316
2.1


190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003S TAPVC Repair 150,000 NA Pericardial Patch - 138000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003T Truncus arteriosus repair 150,000 NA Pericardial Patch - 138000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003U Tetralogy of Fallot Repair 150,000 NA Pericardial Patch - 138000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003V Complete AV canal repair 150,000 NA Pericardial Patch - 138000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003W Arterial switch operation 150,000 NA Pericardial Patch - 138000
185000
Page 317
2.1


190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003X Senning Operation 150,000 NA Pericardial Patch - 138000
185000

190000
40000
- 28000
SV CTVS SV003 Category - III Congenital Heart SV003Y Mustard Operation 150,000 NA Pericardial Patch - 138000
185000
SV CTVS SV003 Category - III Congenital Heart SV003Z ALCAPA 200,000 TBF TBF TBF
Disease
Coronary artery bypass Coronary artery bypass

grafting (CABG), grafting (CABG),
SV CTVS SV004 SV004A 118,100 NA NA 118,100
including intra operative including intra operative
balloon pump (if required) balloon pump (if required)
Mechanical Valve - Bileaflet - Mechanical Valve - Bileaflet -

40000 159000
SV CTVS SV005 Single Valve Procedure SV005A Aortic Valve 119,000 NA Mechanical Valve - Tilting Disc Mechanical Valve - Tilting Disc
- 28000 - 147000
Tissue Valve - 70000 Tissue Valve - 189000
Page 318
2.1


40000 159000
Mechanical Valve - Tilting Disc Mechanical Valve - Tilting Disc
SV CTVS SV005 Single Valve Procedure SV005B Mitral Valve 119,000 NA
- 28000 - 147000
Valve Ring - Mitral - 35000 Valve Ring - Mitral - 154000

159000
40000
SV CTVS SV005 Single Valve Procedure SV005C Tricuspid Valve 119,000 NA - 147000
- 28000
154000
Aortic Valve - Repair -

142000
Aortic Valve - Relacement - Mechanical Valve - Bileaflet -
182000
142000 40000
Mitral Valve - Repair - 142000 Mechanical Valve - Tilting Disc
- 170000
SV CTVS SV006 Double Valve Procedure SV006A Double Valve Procedure 142,000 Mitral Valve - Replacement - - 28000
142000 Tissue Valve - 70000
Tricuspid Valve - Repair - Valve Ring - Mitral - 35000
142000 Valve Ring - Tricuspid - 35000
177000
Tricuspid Valve - Replacement
- 142000
Aortic Valve - Repair -

170000
210000
170000 40000
- 198000
SV CTVS SV007 Triple valve procedure SV007A Triple valve procedure 170,000 Mitral Valve - Replacement - - 28000
170000 Tissue Valve - 70000
170000 Valve Ring - Tricuspid - 35000
205000
Tricuspid Valve - Replacement
- 170000
Closed Mitral Valvotomy Closed Mitral Valvotomy

including thoracotomy including thoracotomy
Page 319
2.1

SV CTVS SV009 Ross Procedure SV009A Ross Procedure 150,000 NA RV - PA Conduit - 120000 270,000
Surgery for Hypertrophic Surgery for Hypertrophic

SV CTVS SV010 Obstructive Cardiomyopathy SV010A Obstructive Cardiomyopathy 111,000 NA NA 111,000
(HOCM) (HOCM)
Pericardial window (via Pericardial window (via

thoracotomy) thoracotomy)
SV CTVS SV012 Pericardiectomy SV012A Pericardiectomy 67,000 NA NA 67,000
Patent Ductus Arteriosus Patent Ductus Arteriosus

SV CTVS SV013 (PDA) Closure via SV013A (PDA) Closure via 57,000 NA NA 57,000
thoracotomy thoracotomy
Page 320
2.1

Composite Aortic Valved Composite Aortic Valved

conduit - Mechanical - 100000 conduit - Mechanical - 250000
Dacron Graft - Straight - Dacron Graft - Straight -
30000 180000
Aortic Root Replacement
SV CTVS SV014 SV014A Bental Procedure 150,000 NA Mechanical Valve - Bileaflet - Mechanical Valve - Bileaflet -
Surgery
40000 190000
- 28000 - 178000

30000 180000
SV CTVS SV014 SV014B Aortic Dissection 150,000 NA Mechanical Valve - Bileaflet - Mechanical Valve - Bileaflet -
Surgery
40000 190000
- 28000 - 178000

30000 180000
SV CTVS SV014 SV014C Aortic Aneurysm 150,000 NA Mechanical Valve - Bileaflet - Mechanical Valve - Bileaflet -
Surgery
40000 190000
- 28000 - 178000

30000 180000
Aortic Root Replacement Valve sparing root
SV CTVS SV014 SV014D 150,000 NA Mechanical Valve - Bileaflet - Mechanical Valve - Bileaflet -
Surgery replacement
40000 190000
- 28000 - 178000

30000 180000
SV CTVS SV014 SV014E AVR + Root enlargement 150,000 NA Mechanical Valve - Bileaflet - Mechanical Valve - Bileaflet -
Surgery
40000 190000
- 28000 - 178000
Page 321
2.1

Arch Graft - 85000 Arch Graft - 235000

Aortic Arch Replacement / Coselli Graft - 85000 Coselli Graft - 235000
Aortic Arch Replacement
SV CTVS, General Surgery SV015 Thoracoabdominal aneurysm SV015A 150,000 NA Complex grafts other than Complex grafts other than
using bypass
Repair using bypass Arch Graft & Coseli Graft - Arch Graft & Coseli Graft -
85000 235000
Arch Graft - 85000 Arch Graft - 235000

Aortic Arch Replacement / Coselli Graft - 85000 Coselli Graft - 235000
Thoracoabdominal aneurysm
SV CTVS, General Surgery SV015 Thoracoabdominal aneurysm SV015B 150,000 NA Complex grafts other than Complex grafts other than
Repair using bypass
Repair using bypass Arch Graft & Coseli Graft - Arch Graft & Coseli Graft -
85000 235000
Aortic Aneurysm Repair using

SV CTVS, General Surgery SV016 Aortic Aneurysm Repair SV016A Cardiopulmonary bypass 120,000 NA 150,000
30000
(CPB)
Aortic Aneurysm Repair using Dacron Graft - Straight -

SV CTVS, General Surgery SV016 Aortic Aneurysm Repair SV016B 120,000 NA 150,000
Left Heart Bypass 30000
Aortic Aneurysm Repair

without using Dacron Graft - Straight -
SV CTVS, General Surgery SV016 Aortic Aneurysm Repair SV016C 65,500 NA 95,500
Cardiopulmonary bypass 30000
(CPB)
Page 322
2.1

Aortic Aneurysm Repair

SV CTVS, General Surgery SV016 Aortic Aneurysm Repair SV016D without using Left Heart 65,500 NA 95,500
30000
Bypass
Aorto Iliac / Aorto femoral Dacron Graft - Bifurcated -

SV CTVS SV017 SV017A Aorto Iliac bypass - U/L 64,500 NA 99,500
bypass (Uni and Bi) 35000

SV CTVS SV017 SV017B Aorto femoral bypass - U/L 64,500 NA 99,500

SV CTVS SV017 SV017C Aorto Iliac bypass - B/L 64,500 NA 99,500

SV CTVS SV017 SV017D Aorto femoral bypass - B/L 64,500 NA 99,500
Page 323
2.1

Pulmonary Embolectomy /
SV CTVS SV018 SV018A Pulmonary Embolectomy 141,000 NA NA 141,000
Thromboendarterectomy
Pulmonary Embolectomy /
SV CTVS SV018 SV018B Thromboendarterectomy 141,000 NA NA 141,000
Thromboendarterectomy

SV CTVS SV019 Peripheral Arterial Surgeries SV019A Femoro - Femoral Bypass 50,000 NA 30000 80000
PTFE Graft - Straight - 50000 PTFE Graft - Straight - 100000

SV CTVS SV019 Peripheral Arterial Surgeries SV019B Carotid - endearterectomy 50,000 NA 30000 80000

SV CTVS SV019 Peripheral Arterial Surgeries SV019C Carotid Body Tumor Excision 50,000 NA 30000 80000
Page 324
2.1


Thoracic Outlet syndrome
SV CTVS SV019 Peripheral Arterial Surgeries SV019D 50,000 NA 30000 80000
Repair

SV CTVS SV019 Peripheral Arterial Surgeries SV019E Carotid aneurysm repair 50,000 NA 30000 80000

SV CTVS SV019 Peripheral Arterial Surgeries SV019F Subclavian aneurysm repair 50,000 NA 30000 80000

SV CTVS SV019 Peripheral Arterial Surgeries SV019G Axillary aneurysm repair 50,000 NA 30000 80000

SV CTVS SV019 Peripheral Arterial Surgeries SV019H Brachial aneurysm repair 50,000 NA 30000 80000
Page 325
2.1


SV CTVS SV019 Peripheral Arterial Surgeries SV019I Femoral aneurysm repair 50,000 NA 30000 80000

SV CTVS SV019 Peripheral Arterial Surgeries SV019J Popliteal aneurysm repair 50,000 NA 30000 80000

SV CTVS SV019 Peripheral Arterial Surgeries SV019K Femoral - popliteal Bypass 50,000 NA 30000 80000

SV CTVS SV019 Peripheral Arterial Surgeries SV019L Axillo - Brachial Bypass 50,000 NA 30000 80000

SV CTVS SV019 Peripheral Arterial Surgeries SV019M Carotio - carotid Bypass 50,000 NA 30000 80000
Page 326
2.1


SV CTVS SV019 Peripheral Arterial Surgeries SV019N Carotido - subclavian bypass 50,000 NA 30000 80000

SV CTVS SV019 Peripheral Arterial Surgeries SV019O Carotido - axillary bypass 50,000 NA 30000 80000

SV CTVS SV019 Peripheral Arterial Surgeries SV019P Axillo - femoral bypass - U/L 50,000 NA 30000 80000

SV CTVS SV019 Peripheral Arterial Surgeries SV019Q Axillo - femoral bypass - B/L 50,000 NA 30000 80000

SV CTVS SV019 Peripheral Arterial Surgeries SV019R Aorto - carotid bypass 50,000 NA 30000 80000
Page 327
2.1


SV CTVS SV019 Peripheral Arterial Surgeries SV019S Aorto - subclavian bypass 50,000 NA 30000 80000
SV CTVS SV019 Peripheral Arterial Surgeries SV019T Patch Graft Angioplasty 70,000 TBF TBF TBF
Small Arterial Aneurysms –

SV CTVS SV019 Peripheral Arterial Surgeries SV019U 70,000 TBF TBF TBF
Repair
Medium size arterial

SV CTVS SV019 Peripheral Arterial Surgeries SV019V 70,000 TBF TBF TBF
aneurysms with synthetic graft
Surgery for Arterial Aneursysm

SV CTVS SV019 Peripheral Arterial Surgeries SV019W 70,000 TBF TBF TBF
–Vertebral
Page 328
2.1

Surgery for Arterial Aneurysm

SV CTVS SV019 Peripheral Arterial Surgeries SV019X 70,000 TBF TBF TBF
Renal Artery
Operations for Acquired

SV CTVS SV019 Peripheral Arterial Surgeries SV019Y 70,000 TBF TBF TBF
Arteriovenous Fistual
Congenital Arterio Venous

SV CTVS SV019 Peripheral Arterial Surgeries SV019Z 70,000 TBF TBF TBF
Fistula
CTVS, General Surgery,

SV SV020 Thromboembolectomy SV020A Thromboembolectomy 28,000 NA NA 28,000
Pediatric Surgery
Peripheral arterial injury repair Peripheral arterial injury repair

(without bypass) (without bypass)
Page 329
2.1

Thoracotomy, Thoraco Thoracotomy, Thoraco

SV CTVS, Pediatric Surgery SV022 SV022A 30,000 NA NA 30,000
Abdominal Approach Abdominal Approach
Lung surgery including

SV CTVS, Pediatric Surgery SV023 SV023A Lung cyst exision 45,000 NA NA 45,000
Thoracotomy

SV CTVS, Pediatric Surgery SV023 SV023B Decortication 45,000 NA NA 45,000
Thoracotomy

SV CTVS, Pediatric Surgery SV023 SV023C Hydatid cyst 45,000 NA NA 45,000
Thoracotomy
Lung surgery including Other simple lung procedure

SV CTVS, Pediatric Surgery SV023 SV023D 45,000 NA NA 45,000
Thoracotomy excluding lung resection
Page 330
2.1

Lung surgery including Bronchial Repair Surgery for

SV CTVS SV023 SV023E 45,000 TBF TBF TBF
Thoracotomy Injuries due to FB
Non infective - 70000 Non infective - 70000

SV CTVS SV024 Pulmonary Resection SV024A Pulmonary Resection 70,000 NA
Infective - 90000 Infective - 90000
CTVS, General Surgery, Foreign Body Removal with Foreign Body Removal with
SV SV025 SV025A 20,000 NA NA 20,000
Pediatric Surgery scope scope
CTVS, Surgical Oncology, Surgical Correction of Surgical Correction of

SV SV026 SV026A 65,000 NA NA 65,000
Pediatric Surgery Bronchopleural Fistula Bronchopleural Fistula
CTVS, General Surgery, Space - Occupying Lesion Space - Occupying Lesion

SV SV027 SV027A 65,500 NA NA 65,500
Pediatric Surgery (SOL) mediastinum (SOL) mediastinum
Page 331
2.1

Isolated Intercostal Drainage Isolated Intercostal Drainage

CTVS, General Surgery, and Management of ICD, and Management of ICD,
SV SV028 SV028A 10,000 NA NA 10,000
Pediatric Surgery Intercostal Block, Antibiotics & Intercostal Block, Antibiotics &
Physiotherapy Physiotherapy
SV CTVS, Pediatric Surgery SV029 Diaphragmatic Repair SV029A Diaphragmatic Repair 30,000 NA 32,000
2000
SV CTVS, Surgical Oncology SV030 Surgery for Cardiac Tumour SV030A Surgery for Cardiac Tumour 95,000 NA NA 95,000

115000
40000
- 103000
Immediate reoperation (within - 28000
SV CTVS SV031 SV031A Tetralogy of Fallot Repair 75,000 NA Pericardial Patch - 93000
5 days) Pericardial Patch - 18000
110000

40000 99500
Immediate reoperation (within
SV CTVS SV031 SV031B Aortic Valve 59,500 NA Mechanical Valve - Tilting Disc Mechanical Valve - Tilting Disc
5 days)
- 28000 - 87500
Page 332
2.1


40000 99500
Immediate reoperation (within Mechanical Valve - Tilting Disc Mechanical Valve - Tilting Disc
SV CTVS SV031 SV031C Mitral Valve 59,500 NA
5 days) - 28000 - 87500
Valve Ring - Mitral - 35000 Valve Ring - Mitral - 94500

40000 99500
Immediate reoperation (within Mechanical Valve - Tilting Disc Mechanical Valve - Tilting Disc
SV CTVS SV031 SV031D Tricuspid Valve 59,500 NA
5 days) - 28000 - 87500
Valve Ring - Tricuspid - 35000 Valve Ring - Tricuspid - 94500
Aortic Valve - Repair - 71000

71000 111000
40000
Immediate reoperation (within Mitral Valve - Replacement - - 99000
SV CTVS SV031 SV031E Double Valve Procedure 71,000 - 28000
5 days) 71000 Tissue Valve - 141000
71000 Valve Ring - Tricuspid -
Tricuspid Valve - Replacement 106000
- 71000
Aortic Valve - Repair - 85000

85000 125000
40000
Immediate reoperation (within Mitral Valve - Replacement - - 113000
SV CTVS SV031 SV031F Triple valve procedure 85,000 - 28000
5 days) 85000 Tissue Valve - 155000
85000 Valve Ring - Tricuspid -
Tricuspid Valve - Replacement 120000
- 85000
Low Cardiac Output syndrome Low Cardiac Output syndrome

SV CTVS SV032 requiring IABP insertion post - SV032A requiring IABP insertion post - 50,000 NA NA 50,000
operatively operatively
Page 333
2.1

SV CTVS SV033 Re-do sternotomy SV033A Re-do sternotomy 20,000 NA NA 20,000
CTVS, General Surgery,

Pediatric Surgery, Surgical Excessive bleeding requiring Excessive bleeding requiring
SV SV034 SV034A 10,000 NA NA 10,000
Oncology, Obstetrics & re-exploration re-exploration
Gynecology
SV CTVS SV035 Mediastinotomy SV035A Mediastinotomy 28,750 TBF TBF TBF
US Unspecified Surgical Package US001 Unspecified Surgical Package US001A Unspecified Surgical Package Upto 1 lakh NA NA Upto 1 lakh
Page 334

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2.

Specialty Code Package Code AB PM - JAY Procedure Code AB PM - JAY

% Total Body Surface Area

% Total Body Surface Area

% Total Body Surface Area

% Total Body Surface Area

% Total Body Surface Area

Specialty Code Package Code AB PM - JAY Procedure Code AB PM - JAY

% Total Body Surface Area

% Total Body Surface Area

% Total Body Surface Area

% Total Body Surface Area

% Total Body Surface Area

Specialty Code Package Code AB PM - JAY Procedure Code AB PM - JAY

% Total Body Surface Area

% Total Body Surface Area

Electrical contact burns: Low

Electrical contact burns: Low

Electrical contact burns: High

Specialty Code Package Code AB PM - JAY Procedure Code AB PM - JAY

Electrical contact burns: High

Chemical burns: Without

Chemical burns: With

Post Burn Contracture

Specialty Code Package Code AB PM - JAY Procedure Code AB PM - JAY

Laceration - Suturing / Laceration - Suturing /

Emergency with stable

Emergency with unstable

Animal bites (Excluding Snake Animal bites (Excluding Snake

Laboratory Tests for COVID- Laboratory Tests for COVID-

Specialty Code Package Code AB PM - JAY Procedure Code AB PM - JAY

Laboratory Tests for COVID- Laboratory Tests for COVID-

Routine Ward - 1800 Routine Ward - 1800

Dural AVMs (per sitting) with

Dural AVFs (per sitting) with

Dural AVMs (per sitting) with

Specialty Code Package Code AB PM - JAY Procedure Code AB PM - JAY

Dural AVFs (per sitting) with

Cerebral & Spinal AVM Cerebral AVM embolization -

Cerebral & Spinal AVM Spinal AVM embolization -

Coil embolization for Coil embolization for

Specialty Code Package Code AB PM - JAY Procedure Code AB PM - JAY

Pre-operative tumour Pre-operative tumour

Intracranial balloon Intracranial balloon

Intracranial thrombolysis / clot Intracranial thrombolysis / clot

Specialty Code Package Code AB PM - JAY Procedure Code AB PM - JAY

Parent vessel occlusion - Parent vessel occlusion -

IN Interventional Neuroradiology IN010 Vertebroplasty IN010A Vertebroplasty 40,000 NA NA 40,000

Right / Left Heart

Right / Left Heart

Cardiology, Interventional Catheter directed For Deep vein thrombosis

Specialty Code Package Code AB PM - JAY Procedure Code AB PM - JAY

Cardiology, Interventional Catheter directed

Cardiology, Interventional Catheter directed

Cardiac Balloon - Adult -

Cardiac Balloon - Adult -

Cardiac Balloon - Adult -

Specialty Code Package Code AB PM - JAY Procedure Code AB PM - JAY

Cardiac Balloon - Adult -

Specialty Code Package Code AB PM - JAY Procedure Code AB PM - JAY

Coronary Stent for PDA

Bare Metal Stent (1) - 49300