Tarif RSCA Medan Apr 2022

RSCA MEDAN
BUKU TARIF INSURANCE 2022

TARIF INSURANCE
NO. KODE KETERANGAN SATUAN 01 APR 2022
TARIF ADMINISTRASI
1 ACCAGOLD KARTU MEMBERSHIP CA GOLD PIECE 50,000
2 ACKIDS BIAYA PENDAFTARAN KARTU CA KIDS PIECE 50,000
3 ACLAUNDRY ADMIN CHARGES - LAUNDRY PIECE Variabel
4 ACPCOR1 ADMIN CHARGES - RAWAT INAP CORPORATE (1-5 HARI) PASIEN 165,375
5 ACPCOR20 ADMIN CHARGES - RAWAT INAP CORPORATE (>20 HARI) PASIEN 496,125
6 ACPCOR6 ADMIN CHARGES - RAWAT INAP CORPORATE (6-20 HARI) PASIEN 275,100
7 ACRFOP ADMIN CHARGES - RAWAT JALAN ASURANSI PASIEN 66,150
8 ACRGF ADMIN CHARGES - PENDAFTARAN RAWAT INAP PASIEN 181,125
9 ACRGFC ADMIN CHARGES - PENDAFTARAN KUNJUNGAN PERTAMA PASIEN 47,250
10 ACRGOPD BIAYA ADMINISTRASI RAWAT JALAN KUNJUNGAN 52,500
11 ACSENAM BIAYA SENAM HAMIL KUNJUNGAN 31,500
12 ACSINS ADMIN CHARGES - RAWAT INAP ASURANSI PASIEN Variabel
13 ACREGIP2 BIAYA ADMIN – RAWAT INAP ASURANSI PASIEN 1,050,000
14 ACAMBHOMECARE ADMIN CHARGES - AMBULANCE HOMECARE PASIEN 603,750
15 ACHOMESWAB ADMIN PELAYANAN HOMECARE SWAB KUNJUNGAN 210,000
16 ACRGOTC ADMIN CHARGES - PENDAFTARAN OTC PASIEN 10,500
17 ACSTAMP BIAYA ADMIN - MATERAI PIECE 10,500
18 ACVENUS BIAYA PENDAFTARAN VENUS CARD PIECE 50,000
TARIF AMBULANCE
19 ACAMB ADMIN CHARGES - AMBULANCE < 7 KM % 380,846
20 ACAMB7 ADMIN CHARGES - AMBULANCE 7-15 KM % 830,760
21 ACAMB15 ADMIN CHARGES - AMBULANCE > 15 KM % Variabel
TARIF KAMAR BEDAH & GAS MEDIK

22 ORCAROXY CARBON DIOXIDE CO2 ADULT LITER 174,631
23 ORCAROXY-KID CARBON DIOXIDE CO2 KID LITER 122,262
24 ORITROG NITROGEN GAS-N2 LITER 75,059
25 ORITROXY NITRO OXYGEN N2O ADULT LITER 279,227
26 ORITROXY-KID NITRO OXYGEN N20 KID LITER 227,005
27 ORMSR1 BIAYA KAMAR OPERASI MINOR INPATIENT JAM 866,502
28 ORMSR2 BIAYA KAMAR OPERASI MINOR DAYCARE JAM 565,110
29 ORO2CITY O2 PORTABLE WITHIN CITY TABUNG 261,870
30 ORO2PORT OXYGEN PORTABLE WITH REGULATOR TABUNG 1,429,932
31 OROXY1 OXYGEN LITER/MENIT 358
32 ORRADD OT ADDITIONAL 1/2 HR 1/2 JAM 502,320
33 ORRECV BIAYA KAMAR RECOVERY/HOUR JAM 175,812
34 ORRUTAMA BIAYA KAMAR OPERASI UTAMA JAM 1,670,214
35 ORRUTAMACITO OPERATING ROOM 1st HOUR (CITO) JAM 1,996,722
TARIF KAMAR
36 RCDECHAIR BIAYA KAMAR - DECK CHAIR PIECE 107,640
37 RCDR BIAYA KAMAR BERSALIN HARI 908,500
38 RCER1TO3 BED ANE < 3 HOURS HARI 95,920
39 RCER3TO6 BED ANE 3 - 6 HOURS HARI 167,860
40 RCLODGER BIAYA KAMAR - LODGER PIECE 263,120
41 RCMORTU MORTUARY ROOM (KAMAR MAYAT) % 203,320
42 RCNC BIAYA KAMAR BOKS BAYI HARI 180,000
43 RDAYCARE BIAYA KAMAR DAY CARE PROSEDUR 402,500
44 RCBD6 BIAYA KAMAR 6 TEMPAT TIDUR HARI 250,000
48 RCBS1 BIAYA KAMAR SUPERIOR HARI 960,000
49 RCBD1 BIAYA KAMAR DELUXE HARI 1,430,000
50 RCPRE BIAYA KAMAR PREMIER HARI 2,150,000
51 RCBDC BIAYA KAMAR DELUXE CLUB HARI 2,150,000
52 RCBFC BIAYA KAMAR FAMILY CLUB HARI 3,000,000
53 RCBDISO BIAYA KAMAR ISOLASI HARI 1,200,000
54 RCBDISOICU BIAYA KAMAR ICU ISOLASI HARI 1,500,000
55 RCBDNICU BIAYA KAMAR NICU HARI 830,000
56 RCBDSBW BIAYA KAMAR BAYI SAKIT HARI 370,000
57 RCBDHDU BIAYA KAMAR HDU HARI 720,000
58 RCBDICU BIAYA KAMAR ICU HARI 940,000
59 RCMATTRESS BIAYA KAMAR - MATRAS SET 29,900
60 RCOTH BIAYA KAMAR LAINNYA % Variabel
TARIF KONSULTASI DOKTER

61 SCOPDGP KONSULTASI GP VISITING OP KUNJUNGAN 242,550
62 SCVGP4N6 KONSULTASI GP VISIT RUANGAN 4 DAN 6 BED KUNJUNGAN 242,550
63 SCVGP1N2 KONSULTASI GP VISIT RUANGAN SVIP,VIP,DELUXE,SUPERIOR,2BED KUNJUNGAN 291,060
64 SCGPFC KONSULTASI GP VISIT RUANGAN FAMILY CLUB KUNJUNGAN 305,613
65 SCGPGC KONSULTASI GP GENERAL CLINIC KUNJUNGAN 173,250
66 SCOPDSP1 KONSULTASI SPESIALIS OP 1 KUNJUNGAN 181,913

67 SCAIP4N6 KONSULTASI SPESIALIS 1 VISIT RUANGAN 4 DAN 6 BED KUNJUNGAN 181,913
68 SCAIPVIP KONSULTASI SPESIALIS 1 VISIT RUANGAN VIP,DELUXE,SUPERIOR,2BEDDED KUNJUNGAN 200,162
69 SCAIPICU KONSULTASI SPESIALIS 1 VISIT RUANGAN DC,SVIP, ICU/HDU/SBW/NICU KUNJUNGAN 240,125
70 SCAIPFC KONSULTASI SPESIALIS 1 VISIT RUANGAN FAMILY CLUB KUNJUNGAN 253,050
71 SCAIPISO DOCTOR VISIT RUANGAN ISOLATION 1 KUNJUNGAN 519,750
72 SCAOL1 KONSULTASI SPESIALIS ONLINE 1 KUNJUNGAN 196,350
73 SCAHOMECARE VISIT DOCTOR SPESIALIS HOMECARE KUNJUNGAN 483,000

75 SCBIP4N6 KONSULTASI SPESIALIS 2 VISIT RUANGAN 4 DAN 6 BED KUNJUNGAN 242,550
76 SCBIPVIP KONSULTASI SPESIALIS 2 VISIT RUANGAN VIP,DELUXE,SUPERIOR,2BEDDED KUNJUNGAN 266,805
77 SCBIPICU KONSULTASI SPESIALIS 2 VISIT RUANGAN DC/SVIP, ICU/HDU/SBW/NICU KUNJUNGAN 320,166
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TARIF INSURANCE
78 SCBIPFC KONSULTASI SPESIALIS 2 VISIT RUANGAN FAMILY CLUB KUNJUNGAN 338,100

79 SCBIPISO DOCTOR VISIT RUANGAN ISOLATION 2 KUNJUNGAN 519,750
80 SCBOL1 KONSULTASI SPESIALIS ONLINE 1 KUNJUNGAN 196,350
81 SCBHOMECARE VISIT DOCTOR SPESIALIS HOMECARE KUNJUNGAN 483,000

83 SCCIP4N6 KONSULTASI SPESIALIS 3 VISIT RUANGAN 4 DAN 6 BED KUNJUNGAN 303,188
84 SCCIPVIP KONSULTASI SPESIALIS 3 VISIT RUANGAN VIP,DELUXE,SUPERIOR,2BEDDED KUNJUNGAN 333,564
85 SCCIPICU KONSULTASI SPESIALIS 3 VISIT RUANGAN SVIP, ICU/HDU/SBW/NICU KUNJUNGAN 400,208
86 SCCIPFC KONSULTASI SPESIALIS 3 VISIT RUANGAN FAMILY CLUB KUNJUNGAN 422,100
87 SCCIPISO DOCTOR VISIT RUANGAN ISOLATION 3 KUNJUNGAN 519,750
88 SCCOL1 KONSULTASI SPESIALIS ONLINE 1 KUNJUNGAN 196,350
89 SCCOL2SS KONSULTASI SUB-SPESIALIS ONLINE KUNJUNGAN 288,750
90 SCCHOMECARE VISIT DOCTOR SPESIALIS HOMECARE KUNJUNGAN 483,000

92 SCDIP4N6 KONSULTASI SPESIALIS 4 VISIT RUANGAN 4 DAN 6 BED KUNJUNGAN 485,100
93 SCDIPVIP KONSULTASI SPESIALIS 4 VISIT RUANGAN VIP,DELUXE,SUPERIOR,2BEDDED KUNJUNGAN 533,610
94 SCDIPICU KONSULTASI SPESIALIS 4 VISIT RUANGAN SVIP, ICU/HDU/SBW/NICU KUNJUNGAN 640,332
95 SCDIPISO DOCTOR VISIT RUANGAN ISOLATION 4 KUNJUNGAN 519,750
96 SCDOL2SS KONSULTASI SUB-SPESIALIS ONLINE KUNJUNGAN 288,750

98 SCEIP4N6 KONSULTASI SPESIALIS 5 VISIT RUANGAN 4 DAN 6 BED KUNJUNGAN 727,650
99 SCEIPVIP KONSULTASI SPESIALIS 5 VISIT RUANGAN VIP,DELUXE,SUPERIOR,2BEDDED KUNJUNGAN 727,650
100 SCEIPICU KONSULTASI SPESIALIS 5 VISIT RUANGAN SVIP, ICU/HDU/SBW/NICU KUNJUNGAN 727,650
101 SCEIPISO DOCTOR VISIT RUANGAN ISOLATION 5 KUNJUNGAN 519,750
102 SCEOL2SS KONSULTASI SUB-SPESIALIS ONLINE KUNJUNGAN 288,750
TARIF KONSULTASI MO
103 MCDURMOV PRIVATE DUTY RMO (PERJALANAN DENGAN PESAWAT) PASIEN 10,117,800
104 MCDURMOVA PRIVATE DUTY RMO LUAR KOTA PER JAM JAM 830,760
105 MCMOIP3 KONSULTASI MO VISIT RUANGAN 4 DAN 6 BED KUNJUNGAN 164,824
106 MCMOIP4 KONSULTASI MO VISIT RUANGAN VIP,DELUXE,SUPERIOR,2BEDDED KUNJUNGAN 197,789
107 MCMOMCU PEMERIKSAAN DAN KOSULTASI RMO KUNJUNGAN 138,500
108 MCRMO1 RMO FEE (07.00 - 21.00) OP KUNJUNGAN 110,849
109 MCRMO2 RMO FEE (21.00 - 07.00) OP KUNJUNGAN 166,152
110 MCRMOFEE PRIVATE DUTY RMO (DALAM KOTA) PASIEN 242,466
111 MCRMOIP RMO FEE (07.00-21.00) IP KUNJUNGAN 138,500
112 MCRMOIP2 RMO FEE (21.00-07.00) IP KUNJUNGAN 166,152
113 MCIPISO DOCTOR VISIT RUANGAN ISOLATION KUNJUNGAN 313,950
114 MCOL1 KONSULTASI MO ONLINE 1 KUNJUNGAN 75,348
115 MCHOMECARE VISIT DOCTOR MO HOMECARE KUNJUNGAN 241,500
TARIF LABORATORIUM
116 LAAGD ANALISA GAS DARAH TEST 621,013
117 LAALB ALBUMIN TEST 181,196
118 LAALK ALKOHOL DALAM DARAH TEST 1,083,180
119 LAALP FOSFATASE ALKALI (ALP) TEST 179,592
120 LAAMYL AMILASE TEST 515,352
121 LAAPHOS ACID PHOSPHATASE TEST 1,418,550
122 LAAPOA APO - A1 TEST 832,650
123 LAAPOB APO - B TEST 597,450
124 LABICAR BICARBONAT (BICARB) TEST 554,400
125 LABILD BILIRUBIN DIRECT TEST 143,172
126 LABILIND BILIRUBIN INDIRECT TEST 139,608
127 LABILT BILIRUBIN TOTAL TEST 139,608
128 LABTEM ANALISA BATU EMPEDU TEST 270,443
129 LACA CALCIUM TEST 219,851
130 LACALION CALCIUM ION TEST 578,925
131 LACARB CARBAMAZEPIN TEST 3,435,600
132 LACHOL CHOLESTEROL TOTAL TEST 121,800
133 LACHOLIN CHOLINESTERASE TEST 452,550
134 LACKMB CK-MB TEST 845,544
135 LACL CHLORIDA (CL) TEST 260,463
136 LACPEP C-PEPTIDE TEST 1,215,900
137 LACPK CPK/CK TEST 401,016
138 LACREAT KREATININ TEST 175,560
139 LACTH ACTH TEST 5,515,650
140 LACTX CTX (BETA CROSLAPS) TEST 1,383,900
141 LACYCLO CYCLOSPORIN TEST 3,958,500
142 LACYSTC CYSTATIN C TEST 914,550
143 LADIPON ADIPONEKTIN TEST 1,139,639
144 LAEGFR EGFR (ESTIMATED GLOMEROLUS FILTRATE RATE) TEST 166,597
145 LAELEKT PAKET NATRIUM, KALIUM, CHLORIDA TEST 604,440
146 LAG2PP GLUKOSA 2 JAM PP TEST 69,888
147 LAGDN GLUKOSA PUASA TEST 81,984
148 LAGDNHBA PANEL GLUKOSA PUASA DAN HBA 1C TEST 477,344
149 LAGDS GLUKOSA SEWAKTU (GLUCOSE RANDOM) TEST 81,984
150 LAGDSHBA PANEL GLUKOSA SEWAKTU DAN HBA 1C TEST 477,344
151 LAGDSTIK GLUCOTEST STRIP TEST 69,888
152 LAGENE GENE EXPERT TEST 199,710
153 LAGGT GAMMA GT (GGT) TEST 207,480
154 LAGKH GLUCOTEST STRIP KURVA HARIAN 3X TEST 209,496
155 LAGLOB GLOBULIN TEST 180,399
156 LAGRAT PAKET TOTAL PROTEIN, ALBUMIN, GLOBULIN, A/G RATIO TEST 403,137
157 LAGTT5 TES TOLERANSI GLUKOSA (GTT) TEST 438,816
158 LAHBA HBA 1C TEST 394,800
159 LAHDL HDL - CHOLESTEROL TEST 153,552
160 LAHSCRP HSCRP TEST 699,300
161 LAINS INSULIN TEST 979,729
162 LAKAL KALIUM (K) TEST 249,480
163 LAKRECLE KREATININ CLEARANCE TEST 355,950
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TARIF INSURANCE
164 LALAC LACTATE TEST 554,400

165 LALDH LDH TEST 273,320
166 LALDL LDL - CHOLESTEROL TEST 189,672
167 LALDLD LDL - CHOLESTEROL DIRECT TEST 212,352
168 LALIP LIPASE TEST 561,704
169 LALIPOA LIPOPROTEIN (A) TEST 1,124,550
170 LAMAG MAGNESIUM TEST 246,030
171 LAMAKUAL MIKRO ALBUMIN KUALITATIF TEST 370,235
172 LAMON AMONIAK TEST 1,384,530
173 LAMYOGL MYOGLOBIN TEST 1,151,420
174 LANAT NATRIUM (NA) TEST 249,480
175 LAOSMOS OSMOLARITAS SERUM TEST 1,202,875
176 LAOSMOU OSMOLARITAS URIN TEST 506,730
177 LAPCRERT PROTEIN CREATININ RATIO TEST 449,411
178 LAPDL1 PDL 1 TEST 4,053,357
179 LAPHEN PHENYTOIN TEST 2,699,550
180 LAPHENO PHENOBARBITAL TEST 5,492,550
181 LAPHOS FOSFOR ANORGANIK (IN. PHOS) TEST 215,376
182 LAPHOSU PHOSPOR URINE TEST 354,816
183 LAPIVKA PIVKA TEST TEST 1,329,216
184 LAPLU PLUMBUM TEST 663,894
185 LAPORAT APO A1 / APO B RATIO TEST 1,221,413
186 LAPROTC PROTEIN C TEST 1,723,145
187 LAPROTS PROTEIN S TEST 1,723,145
188 LASGOT SGOT TEST 129,528
189 LASGPT SGPT TEST 129,528
190 LATP TOTAL PROTEIN TEST 169,680
191 LATPELEK PROTEIN ELEKTROFORESIS (SPE) TEST 779,940
192 LATRIG TRIGLISERIDA (TG) TEST 123,816
193 LAUA URIC ACID TEST 123,816
194 LAUBT UBT (URE BREATH TEST) TEST 3,512,250
195 LAUCRT ASAM URAT CREATININ RATIO TEST 449,411
196 LAUREUM UREA (BUN) TEST 136,080
197 LB6PD G-6PD (SCREENING) TEST 268,061
198 LB6PDQ G 6 PD (QUANTITATIVE) TEST 1,017,030
199 LBACT ACT-ACTIVATE CLOTING TIME TEST 398,832
200 LBAGTROM AGREGASI THROMBOSIT TEST 1,066,800
201 LBAPTT APTT (ACTIVATED PTT) TEST 425,301
202 LBASFOL ASAM FOLATE TEST 1,827,630
203 LBATIII AT III TEST 1,261,260
204 LBATPO ANTI TPO TEST 2,583,000
205 LBBT WAKTU PERDARAHAN (BT) TEST 95,592
206 LBCD4 CD 4 TEST 726,495
207 LBCD8 CD 8 TEST 597,660
208 LBCLTR COULTER TEST 987,005
209 LBCOLDAG COLD AGLUTININ TEST 236,486
210 LBCT WAKTU PEMBEKUAN (CT) TEST 95,592
211 LBDIM D-DIMER TEST 1,605,033
212 LBDL01 DARAH LENGKAP (DARAH RUTIN,LED,RETIKULOSIT,IPF) TEST 434,448
213 LBDLGOL DARAH LENGKAP DAN GOL DARAH TEST 438,816
214 LBDR01 ROUTINE BLOOD (HB,WBC,RBC,HCT,PLT,NER,HITUNG JENIS) TEST 197,568
215 LBEPINE EPINEPHRINE TEST 709,459
216 LBFACT11 FACTOR XI TEST 4,626,815
217 LBFACT8 FACTOR VIII TEST 2,668,050
218 LBFACT9 FACTOR IX TEST 3,057,810
219 LBFE FE SERUM (SERUM IRON) TEST 325,248
220 LBFER FERRITIN TEST 608,160
221 LBFERUR FERRITIN URINE TEST 966,389
222 LBFIBRIN FIBRINOGEN TEST 633,672
223 LBGOL GOL. DARAH A B O/RHESUS TEST 180,880
224 LBHBH BADAN INKLUSI HBH TEST 269,577
225 LBHELEK HB ELEKTROFORESIS TEST 1,461,600
226 LBHHPLC ANALISA HB (HPLC) TEST 1,169,595
227 LBHOM HOMOCYSTEIN TEST 1,882,650
228 LBLE SEL LE TEST 276,334
229 LBLED LED (LAJU ENDAP DARAH) TEST 137,697
230 LBMALARI MALARIA TEST 199,584
231 LBMALICT ICT MALARIA PV/PF (PLASMODIUM VIVAX/FALCIPARUM TEST 958,487
232 LBMAPTT MIXED APTT TEST 382,872
233 LBMDT GAMBARAN SED. DARAH TEPI (PBF) TEST 347,088
234 LBMICROF MICROFILARIA TEST 199,584
235 LBPT PT/INR TEST 569,501
236 LBRCF RED CELL FOLATE TEST 2,035,514
237 LBRET RETIKULOSIT (RETIC) TEST 363,321
238 LBRISTO RISTOCETINE TEST 827,789
239 LBTIBC TIBC TEST 339,192
240 LBTRANS TRANSFERIN TEST 1,336,650
241 LBTT THROMBIN TIME (TT) TEST 643,228
242 LBUFFY BUFFY COAT STAINING TEST 897,456
243 LBVIRAL VIRAL LOAD HIV TEST 3,713,441
244 LBVISCD VISCOSITAS DARAH TEST 681,219
245 LBVIT VIT. B12 TEST 1,825,530
246 LBVITD25 VIT D 25-OH TEST 904,176
247 LBVWB VWF TEST 3,882,706
248 LBWB WESTERN BLOT TEST 3,459,456
249 LCADA ADA TEST 922,530
250 LCFLUIDS FLUIDS (SPUTUM,URINE,WASHING,ETC) TEST 499,442
251 LCFNA01A FINE NEEDLE ASPIRATION TEST 878,772
252 LCHPV HPV- DNA TEST 1,663,200
253 LCLIQ ANALISA CAIRAN LCS TEST 1,141,541
254 LCPAPLIQA PAP SMEAR TEST 259,783
255 LCSENDI ANALISA CAIRAN SENDI TEST 1,046,472
256 LCSPERM ANALISA SPERMA TEST 813,624
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TARIF INSURANCE
257 LDAMPHE SCREENING AMPHETAMIN TEST 219,408

258 LDBARBIT BARBITURAT TEST 361,200
259 LDBENZO SCREENING BENZOADIAZEPIN TEST 229,320
260 LDCOCA SCREENING COCAINE TEST 229,320
261 LDCOTINUR COTININ URINE TEST 1,072,418
262 LDDIG DIGOXIN TEST 3,277,050
263 LDHLA HLA-B27 TEST 4,731,284
264 LDMET SCREENING MET (SHABU-SHABU) TEST 229,320
265 LDMETADH SCREENING METADHONE TEST 226,265
266 LDOPIAT SCREENING OPIATE (MORPHINE) TEST 229,320
267 LDPHENCY SCREENING PHENCYCLIDINE TEST 225,398
268 LDPHENI PHENITOID TEST 2,159,561
269 LDPROPOXY SCREENING PROPOXYPHENE TEST 225,398
270 LDTACRO TACROLIMUS TEST 1,787,415
271 LDTHC SCREENING THC / CANNABINOID (MARIJUANA) TEST 229,320
272 LDTHEO THEOPHYLLIN TEST 4,952,850
273 LDVALAC VALPORIC ACID TEST 2,919,782
274 LEALDOS ALDOSTERON TEST 3,524,598
275 LEAMH AMH (ANTI MULLERIAN HORMONE) TEST 5,512,642
276 LEANTHYRO ANTI THYROGLOBULIN TEST 1,295,390
277 LEATSHR ANTI TSH RECEPTOR TEST 2,194,211
278 LEBHCG B-HCG QUANTITATIVE TEST 1,148,616
279 LECALCI CALCITONIN TEST 3,713,441
280 LECORT CORTISOL TEST 1,297,800
281 LECORUR CORTISOL URINE TEST 8,017,144
282 LEDHEAS DHEAS TEST 1,984,500
283 LEESTRA ESTRADIOL TEST 1,245,300
284 LEFRTESTO FREE TESTOSTERON TEST 3,787,418
285 LEFRUKTO FRUKTOSAMIN TEST 2,208,245
286 LEFSH FSH TEST 809,760
287 LEFT3 FT3 TEST 895,440
288 LEFT4 FT 4 TEST 743,904
289 LEFT4TSH PANEL ENDOCRINE (FT4, TSH) TEST 1,326,024
290 LEGLYALB GLYCATED ALBUMIN TEST 510,300
291 LEGROW GROWTH HORMON TEST 1,196,811
292 LEI5HIAA 5-HIAA TEST 294,698
293 LEIGF IGF-1 TEST 2,824,500
294 LELH LH TEST 799,680
295 LEPROCAL PRO CALCITONIN TEST 2,037,700
296 LEPROG PROGESTERON TEST 1,165,290
297 LEPROL PROLACTIN TEST 775,656
298 LEPTHIN PTH INTACT TEST 2,189,250
299 LESTRI ESTRIOL TEST 917,532
300 LET3 T3 TEST 570,360
301 LET4 T4 TEST 570,360
302 LETEST TESTOSTERON TEST 1,051,365
303 LETHYRO THYROGLOBULIN TEST 1,379,700
304 LETRAB TRAB * 1,237,530
305 LETSH TSH-S (THYROID STIMUL. HORMONE) TEST 582,456
306 LETTG ANTI TTG TEST 1,371,447
307 LFABOGR ABO/RH GROUPING TEST 93,581
308 LFABOKELL ABO/RH, KELL GROUPING TEST 233,756
309 LFABSID ANTIBODIES IDENTIFICATION TEST 701,138
310 LFABSS ANTIBODIES SCREENING TEST 93,581
311 LFBATYP RHESUS TYPING TEST 93,581
312 LFCOMBTEST COOMBS TEST DIRECT/INDIRECT TEST 1,034,544
313 LFCRMNR CROSS MATCH MINOR TEST 78,094
314 LFCRMYR CROSS MATCH MAYOR TEST 78,094
315 LFGOLN GOLONGAN DARAH NEONATUS TEST 134,138
316 LFNAT NAT (NUCLEIC ACID TEST) TEST 1,357,067
317 LFPLAGEL PLATELET GEL TEST 1,432,200
318 LFPRECRYO PRE TRANSFUSION TESTING CRYO TEST 389,550
319 LFPREFFP PRE TRANSFUSION TESTING FFP TEST 389,550
320 LFPREFWB PRE TRANSFUSION TESTING FWB TEST 545,213
321 LFPREPRC PRE TRANSFUSION TESTING PRC PROSEDUR 545,213
322 LFPRETC PRE TRANSFUSION TESTING TC TEST 389,550
323 LFTEG THROMBOELASTOGRAPH TEST 1,495,331
324 LFTEGHPRN THROMBOELASTOGRAPH HEPARINASE TEST 1,884,881
325 LFWRCNAT WRC NAT TEST 1,562,715
326 LHCD 3W CD 3 TEST 798,875
327 LHCD117 CD 117 TEST 1,857,413
328 LHCD20 CD 20 TEST 798,875
329 LHE125 HE4+CA 125 (ROMA) TEST 2,460,465
330 LHER ER (ESTROGEN RECEPTOR 301C) TEST 797,496
331 LHFROZEN FROZEN SECTION TEST 2,910,749
332 LHHER HER-2 TEST 797,496
333 LHKI67 KI 67 TEST 1,196,328
334 LHLARGEA LARGE SPECIMEN TEST 1,802,205
335 LHMEDIUMA MEDIUM SPECIMEN TEST 1,017,631
336 LHPANCYT CYTOKERATIN 20 TEST 1,198,313
337 LHPR PR (PROGESTERON RECEPTOR 302C) TEST 797,496
338 LHSMALLA SMALL SPECIMEN TEST 659,220
339 LHSTI hs-TROPONIN I TEST 1,694,602
340 LHVIMEN VIMENTIN TEST 987,005
341 LIACAIGG ACA IGG TEST 1,747,935
342 LIACAIGM ACA IGM TEST 1,747,935
343 LIACCP ANTI CCP IgG TEST 2,048,550
344 LIADP ADENOSINE DISPHOSPHATE (ADP) TEST 616,943
345 LIADSDNA ANTI DS DNA TEST 1,507,800
346 LIAFP AFP TEST 743,904
347 LIAHAVG ANTI HAV IgG TEST 1,086,792
348 LIAHAVM IGM ANTI HAV TEST 997,474
349 LIAHBCG ANTI HBC IGG TEST 753,816
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TARIF INSURANCE
350 LIAHBCM ANTI HBC IGM TEST 1,266,048

351 LIAHBE ANTI HBE TEST 1,294,104
352 LIAHBS ANTI HBS TEST 697,872
353 LIAHCV ANTI HCV TEST 1,019,439
354 LIAHCVM IGM ANTI HCV TEST 1,649,550
355 LIAMIKO ANTI MIKOPLASMA IgM TEST 2,918,055
356 LIAMIKOG ANTI MIKOPLASMA IgG TEST 2,842,166
357 LIANA ANA TEST 1,487,115
358 LIANAIF ANA IF TEST 1,547,175
359 LIANCA ANCA TEST 1,899,975
360 LIANMCV ANTI MCV TEST 695,079
361 LIANPRO ANA PROFILE TEST 1,967,308
362 LIANTIJO ANTI JO-1 TEST 1,480,421
363 LIANTISCL ANTI SCL-70 TEST 1,184,510
364 LIANTISM ANTI SM TEST 1,048,682
365 LIANTISSA ANTI SS-A (RO) TEST 987,005
366 LIANTISSB ANTI SS-B (LA) TEST 987,005
367 LIASTO ASTO (KUANTITATIF) TEST 624,120
368 LIATOPY IGE ATOPY TEST 3,381,357
369 LIB2GPIG B2GPI IGG TEST 1,840,020
370 LIB2GPIM B2GPI IGM TEST 1,840,020
371 LIB2MIC BETA2 MICROGLOBULIN TEST 2,588,040
372 LIBCRABL BCR-ABL TEST 2,216,655
373 LIC3 C-3 KOMPLEMEN TEST 1,595,265
374 LIC4 C-4 KOMPLEMEN TEST 1,508,010
375 LICA12 CA 125 TEST 1,391,712
376 LICA15 CA 15-3 TEST 1,373,904
377 LICA19 CA 19-9 TEST 1,434,786
378 LICA72 CA 72-4 TEST 2,368,800
379 LICEA CEA TEST 697,872
380 LICGA CgA (CHROMOGRANIN A) TEST 8,692,992
381 LICHIKM ANTI CHIKUNGUNYA IGM TEST 697,872
382 LICHLAG CHLAMYDIA IGG TEST 1,935,150
383 LICHLAM CHLAMYDIA IGM TEST 1,935,150
384 LICHROM ANALISA CHROMOSOM TEST 5,202,005
385 LICIFRA CYFRA 21-1 TEST 1,966,650
386 LICLOSD CLOSTRIDIUM DIFFICILE TEST 1,371,447
387 LICMVG ANTI CMV IGG TEST 715,512
388 LICMVGAV AV. ANTI CMV IGG TEST 1,000,944
389 LICMVM ANTI CMV IGM TEST 990,696
390 LICMVPCR CMV PCR TEST 2,508,487
391 LICOMPACT TOTAL COMPLEMENT ACTIVITY TEST 1,579,694
392 LICRP CRP (KUANTITATIF) TEST 660,240
393 LIDHF ANTI DENGUE IGG/IGM TEST 1,076,712
394 LIEBVEA ANTI EBV EA IGA TEST 2,689,360
395 LIEBVVCA ANTI EBV VCA IGA TEST 2,282,222
396 LIFPSA FREE PSA TEST 2,097,365
397 LIGA IGA TEST 1,196,811
398 LIGG IGG TEST 1,408,050
399 LIGLIAD IgA ANTI GLIADIN TEST 1,192,653
400 LIGM IGM TEST 1,248,613
401 LIHANTA HANTA VIRUS TEST 1,820,684
402 LIHBE HBE AG TEST 1,034,880
403 LIHBS HBS AG TEST 353,136
404 LIHBSAG HBS AG KUANTITATIF TEST 841,129
405 LIHBSAGK HBS AG KONFIRMASI TEST 1,883,616
406 LIHBVDNA HBV-DNA TEST 4,559,730
407 LIHCVGEN HCV RNA GENOTYPE TEST 9,457,718
408 LIHCVKT HCV RNA (KUANTITATIF) TEST 5,832,225
409 LIHE4 HE4 TEST 1,634,850
410 LIHIV ANTI HIV TEST 943,152
411 LIHIV1 HIV RNA KUANTITATIF TEST 2,881,321
412 LIHIVKF HIV KONFIRMASI TEST 1,421,616
413 LIHPILO ANTI HELICOBACTER IGG (H.PILORY) TEST 1,329,888
414 LIHPILOM ANTI HELICOBACTER IGM (H. PILORY) TEST 1,136,283
415 LIHPSA HPSA TEST 513,167
416 LIHPVGEN HPV - GENOTYPE TEST 2,673,074
417 LIHSV1G ANTI HSV 1 IGG TEST 969,360
418 LIHSV1M ANTI HSV 1 IGM TEST 973,560
419 LIHSV2G ANTI HSV 2 IGG TEST 848,820
420 LIHSV2M ANTI HSV 2 IGM TEST 848,820
421 LIIGE IGE TOTAL TEST 833,616
422 LIIGRA IGRA TEST 2,282,700
423 LILCA LCA TEST 1,637,386
424 LILEPTGM LEPTOSPIRA IGM TEST 2,418,050
425 LILETEST LE TEST TEST 945,945
426 LINFLUA INFLU A TEST 1,064,102
427 LINS1 NS 1 ANTIGEN TEST 833,616
428 LINSE NSE TEST 1,739,603
429 LINTPRO NT-PRO BNP TEST 1,933,050
430 LIOSTEO N MID OSTEOCALCIN TEST 1,371,447
431 LIP1NP AMYLASE TEST 477,593
432 LIPAP PAP TEST 839,050
433 LIPSA PSA TEST 969,192
434 LIRF RF (REMATIC FACTOR) TEST 624,120
435 LIRHEUM RHEUMACHEC TEST 2,317,392
436 LIROTA ROTAVIRUS TEST 615,025
437 LIRUBG ANTI RUBELLA IGG TEST 697,872
438 LIRUBM ANTI RUBELLA IGM TEST 883,512
439 LISALMOM SALMONELLA TYPHI IGM TEST 717,864
440 LISCC SCC TEST 1,690,500
441 LISERAM ANTI AMOEBA TEST 891,545
442 LISLA SLA TEST 874,046
Page 5
TARIF INSURANCE
443 LISTREPA STREPTO A TEST 1,466,042

444 LITBA TB ANTIGEN TEST 468,552
445 LITBICT ANTI M TBC TEST 468,552
446 LITBPCR PCR-TB TEST 1,794,555
447 LITEO TOTAL EOSINOFIL TEST 179,592
448 LITOXG ANTI TOXO IGG TEST 654,192
449 LITOXGAV AV. ANTI TOXO IGG TEST 1,346,100
450 LITOXM ANTI TOXO IGM TEST 654,192
451 LITPHA TPHA TEST 339,192
452 LITSHN TSH NEONATUS TEST 364,300
453 LIVDRL VDRL TEST 239,400
454 LIWIDAL WIDAL TEST 349,104
455 LIZIKA VIRUS ZIKA TEST 4,835,754
456 LJACBAL ANALISA CAIRAN BAL TEST 1,774,584
457 LJASCI ANALISA CAIRAN ASCITES TEST 1,046,472
458 LJDIFF JML SEL/HITUNG JENIS (CELL COUNT) TEST 199,584
459 LJGLUK GLUKOSA (GLUCOSE) TEST 78,222
460 LJNON NONNE TEST 99,960
461 LJPAN PANDY TEST 99,960
462 LJPROT PROTEIN CAIRAN TEST 370,235
463 LKCD10 CD 10 TEST 1,418,918
464 LKCD14 CD 14 TEST 3,546,947
465 LKCD30 CD 30 TEST 1,198,313
466 LKCD33 CD 33 TEST 1,196,328
467 LKCD34 CD 34 TEST 1,557,171
468 LKCD41 CD 41 TEST 3,546,947
469 LKCD5 CD 5 TEST 1,418,918
470 LKPHCTLK PAKET IHC TUMOR LYMPHOMA (CD 30, CD 20) TEST 1,794,576
471 LKPHCTM PAKET IHC TUMOR MEDIASTINUM (CYTOKERATIN, VIMENTIN, CD 30) TEST 3,189,984
472 LKPHCTP PAKET IHC TUMOR PAYUDARA (ER, PR, HER2, Ki67) TEST 3,123,665
473 LMANSWAB KULTUR ANAL SWAB TEST 997,080
474 LMJAR KULTUR & RESISTENSI JARINGAN TEST 1,113,836
475 LMKAN KULTUR ANAEROB TEST 1,878,135
476 LMKBTA KULTUR BTA (AFB CULTURE) TEST 1,627,500
477 LMKCAND KULTUR CANDIDA TEST 1,056,888
478 LMKFSS KULTUR FAECES (SALMONELLA-SHIGELLA) TEST 1,058,657
479 LMKFVC KULTUR FAECES (VIBRIO CHOLERA) TEST 1,056,888
480 LMKGALL GALL KULTUR (BILE CULTURE) TEST 1,056,888
481 LMKKAT KULTUR KATETER TEST 1,234,262
482 LMKNS KULTUR & RESISTENSI DIPHTERI (NOSE S) TEST 1,056,888
483 LMKRBRON KULTUR & RESISTENSI BRONCHIAL WASHING TEST 1,153,984
484 LMKRC KULTUR & RESISTENSI CAIRAN TEST 1,058,657
485 LMKRCSF KULTUR & RESISTENSI CSF (CSF CULT.) TEST 1,244,284
486 LMKRD KULTUR & RESISTENSI DARAH (BLD CULT) TEST 1,148,957
487 LMKRF KULTUR & RESISTENSI FAECES(STL CULT) TEST 1,046,016
488 LMKRGO KULTUR & RESISTENSI GO (GO CULT.) TEST 1,089,916
489 LMKRJAM KULTUR & RESISTENSI JAMUR TEST 1,058,657
490 LMKRPUS KULTUR & RESISTENSI PUS TEST 1,088,752
491 LMKRSKR KULTUR & RESISTENSI SEKRET(FLD.CULT) TEST 1,058,657
492 LMKRSPT KULTUR & RESISTENSI SPUTUM (SPT CULT) TEST 1,164,021
493 LMKRTE KULTUR & RESISTENSI TRANSUDAT / EKSUDA TEST 1,056,888
494 LMKRTGG KULTUR & RESISTENSI USAP TENGGOROK (THROAT SWAB) TEST 1,058,657
495 LMKRU KULTUR & RESISTENSI URINE (UR. CULT) TEST 998,684
496 LMPBTA01 PENGECATAN BTA (SPUTUM 3X) TEST 419,544
497 LMPBTA02 PENGECATAN MYCOBACTERIUM LEPRAE TEST 133,749
498 LMPBTA03 PENGECATAN BTA TEST 139,854
499 LMPCAND CANDIDA TEST 159,779
500 LMPDIPH PENGECATAN DIPHTERI TEST 129,696
501 LMPGLG PGL 1 IGG TEST 867,300
502 LMPGLM PGL 1 IGM TEST 867,300
503 LMPGO GO (G.C.) TEST 159,779
504 LMPGRAM PENGECATAN GRAM (GRAMS STAIN) TEST 159,779
505 LMPJAM JAMUR / FUNGI TEST 169,931
506 LMPTRICH TRICHOMONAS TEST 159,779
507 LMRECSWAB KULTUR RECTAL SWAB TEST 997,080
508 LOAINAB ANTI INSULIN ANTIBODI TEST 2,394,488
509 LOAINFR ANTI INTRINSIK FAKTOR TEST 2,758,140
510 LOALKSALV ALKOHOL SALIVA TEST 411,296
511 LOAMA AMA TEST 2,916,165
512 LOANDROS ANDROSTENEDION TEST 3,287,765
513 LOBCAIRANT BTA CAIRAN/SPUTUM TEST 455,175
514 LOBMP BONE MARROW PUNCTION (BMP) TEST 520,926
515 LOBORGM BORRELIA IGG & IGM TEST 6,021,650
516 LOC1Q ANTI C1Q TEST 2,051,453
517 LOCRYPPO CRYPTOSPORIDIA TEST 1,418,918
518 LOCYTOG CYTOLOGY GIEMSA TEST 827,789
519 LOEPO EPO TEST 2,731,633
520 LOGAST GASTRIN TEST 2,650,032
521 LOGBM ANTI GBM TEST 1,418,918
522 LOGIEMSA GIEMSA TEST 472,973
523 LOGRAM GRAM TEST 485,625
524 LOHBHK HBH KLEHAWER TEST 945,945
525 LOHEBO HEINZ BODIES TEST 709,459
526 LOHTLOV HTLV I/II TEST 3,791,403
527 LOIGER IGE SPESIFIK TEST 3,986,850
528 LOIL1 IL-1 TEST 2,908,348
529 LOIL6 IL-6 TEST 2,985,990
530 LOJAK2 JAK2 TEST 3,289,671
531 LOLKM ANTI LKM-1 TEST 1,371,447
532 LOLOEGIO U.LEGIONELLA TEST 898,648
533 LOMJOF MORFOLOGI/JUMLAH SEL TEST 851,351
534 LOMYOGUR MYOGLOBIN URINE TEST 1,151,420
535 LOMYOSP MYOSITIS PANEL TEST 3,045,562
Page 6
TARIF INSURANCE
536 LONGAL NGAL TEST 1,579,694

537 LOPAS PAS TEST 827,789
538 LOSHBG SHBG TEST 3,824,100
539 LOSTEO OSTEOCALCIN TEST 1,324,150
540 LOSUGWAT SUGAR WATER TEST TEST 205,821
541 LOTNFA TNF ALPHA TEST 2,955,645
542 LOTRFUR TRANSFERIN URINE TEST 1,336,624
543 LOUPE UPE TEST 750,540
544 LOVMAU VMA URINE TEST 242,550
545 LPDHF1 PANEL DEMAM DENGUE (DARAH LENGKAP, DENGUE IGE & IGM, DENGUE NS1 AG) TEST 1,885,420
546 LPDIAB2 PANEL DIABETES 2 (GDP, GD 2 JAM, HBA1C) TEST 555,234
PAKET NARKOBA 5 TEST
547 LPDRUG (AMPHETAMIN,MORPHIN,CANABIS/THC/MARIJUANA,METHAMPHETAMIN,BENZODIAZE TEST 1,033,657
PIN)
548 LPDRUG03 PAKET NARKOBA 3 TEST (AMPHETAMIN,MORPHIN,CANABIS/THC/MARIJUANA) TEST 638,064
549 LPGIN1 PANEL GINJAL 1 (UREUM, KREATININ, URIC ACID) TEST 359,016
550 LPGIN3 PANEL GINJAL 3 (UREUM, KREATININ, URIC ACID, CYSTATIN C) TEST 1,285,360
551 LPLIP PANEL LIPID (CHOLESTEROL, HDL, LDL, TRIGLISERIDA) TEST 544,320
552 LPLIV3 PANEL LIVER 3 (SGOT, SGPT, GGT, ALP, BILIRUBIN) TEST 817,656
553 LPPOSTHD PAKET POST HD (UREUM CREATININ) TEST 239,676
554 LPPREHD PAKET PRE HD (UREUM CREATININ) TEST 239,676
555 LRATIO RATIO CHOLESTEROL * 119,784
556 LRCDIFF C.DIFFICILE TEST 1,192,653
557 LRDS DARAH SAMAR/BENZIDIN (O.B) TEST 243,907
558 LRFAECES FAECES LENGKAP (FAEC TEST 141,845
559 LRFECAL FECAL CALPROTECTIN TEST 1,648,500
560 LSDL SMALL DENSE LDL TEST 708,766
561 LSPLEU ANALISA CAIRAN PLEURA TEST 1,046,472
562 LTTO THROMBOTEST OWREN TEST 483,194
563 LUACR RATIO URINE ALBUMIN CREATININ TEST 553,350
564 LUBAGIN ANALISA BATU GINJAL TEST 771,136
565 LUBENCE PROTEIN BENCE JONES TEST 308,558
566 LUCA CALSIUM URINE (URINE CA) TEST 235,100
567 LUCL CHLORIDA URINE (URINE CL) TEST 262,994
568 LUCREAT CREATININ URINE 24 JAM (UR. CREAT TEST 180,600
569 LUESBA PROTEIN 24 JAM TEST 428,715
570 LUHCG TEST PACK HCG TEST 215,376
571 LUKUR KALIUM URINE (URINE KA) TEST 262,994
572 LUMIKROO MIKRO ALBUMIN KUANTITATIF TEST 411,296
573 LUNA NATRIUM URINE (URINE NA) TEST 309,750
574 LUPROUR TOTAL PROTEIN URINE TEST 172,904
575 LUUA ASAM URAT URINE 24 JAM TEST 180,600
576 LUUL URINE LENGKAP (URINE FEME/URINE PANEL) TEST 165,984
577 LUUR URINE RUTIN TEST 119,784
578 LUUREUM UREUM URINE 24 JAM (URINE UREA) TEST 139,440
579 LASD LUPUS ANTICOAGULANT (SCT & dRVVT) TEST 5,037,816
580 LHCELLB CELL BLOCK TEST 1,336,650
581 LIVZVG ANTI VZV IgG TEST 1,593,900
582 LIVZVM ANTI VZV IgM TEST 1,793,400
583 LOIMUN IMMUNOTYPING TEST 1,911,814
584 LOTH LABORATORIUM LAINNYA PROSEDUR Variabel
585 LOVITB1B6 VITAMIN B1 & B6 TEST 1,081,080
586 LLEUPHE LEUKEMIA PHENOTYPING TEST 3,998,400
587 LOCOV RAPID TEST COVID 19 IGG IGM TEST 150,000
588 LOCOVPCR SARS COV-2 REAL TIME PCR TEST 26,000
589 LOANTIGEN RAPID ANTIGEN SARS COV-2 TEST 109,000
590 LOCOVID SARS-COV-2 IGG & IGM (CMIA) TEST 400,000
591 LOCOVRNA2 SARS COV-2 RNA (INHOUSE) TEST 4,200,000
592 LOCOVRNA3 SARS COV-2 RNA SAME DAY TEST 1,325,000
593 LOCOVRNA4 SARS COV-2 RNA NEXT DAY TEST 300,000
594 LOCOVRNA5 SARS COV-2 RNA THREE DAY TEST 900,000
595 LOCOVRNA6 RESPIRATORY PANEL INCLUDE SARS COV-2 TEST 3,000,000
596 LOSABKU SARS-COV-2 ANTIBODI KUANTITATIF S (RBD) TEST 288,750
597 LACOVPCR SWAB PCR CEPAT TEST 750,000
598 LOITRATIO IT RATIO TEST 156,450
599 LOLSCPER ANALISA CAIRAN PERIKAD TEST 1,005,900
600 LHPROCORE PROSTATE & CORE BIOPSY SPECIMENT TEST 4,252,500
601 LHSPECSP SPECIFIC SPECIMENT (MASTECTOMY, HEMICOLECTOMY) TEST 3,236,100
602 LAATHALAB ANALISA THALASEMIA ALFA & BETHA TEST 6,375,600
603 LOANTIPP PENDAMPING PASIEN RAPID ANTIGEN SARS COV-2 TEST 109,000
TARIF BDRS
604 LBCRYO30 CRYOPRECIPITATE 30 CC * 541,800
605 LBDKPRC PRC DONOR KELUARGA * 812,700
606 LBDKWB WB DONOR KELUARGA * 812,700
607 LBFILPLAT FILTER PLATELET * 620,025
608 LBFILREDC FILTER RED CELL * 620,025
609 LBFP150 FRESH FROZEN PLASMA (FFP) 150CC * 602,044
610 LBFP300 FRESH FROZEN PLASMA (FFP) 300CC BAG 2,558,456
611 LBFPA700 FRESH FROZEN PLASMA (FFP) APHERESIS 700CC * 4,020,319
612 LBFWB350 FWB 350CC - V * 677,250
613 LBGC GRANULOCYTE COLLECTION * 8,126,606
614 LBLMC LYMPHO MONO COLLECTION * 8,126,606
615 LBPLABO BLOOD BAG/PLEBOTOMY * 150,544
616 LBPRC175 PACKED RED CELLS (PRC) 175CC * 737,494
617 LBSTEM STEM CELL COLLECTION * 8,126,606
618 LBTC50 THROMBOCYTE CONCENTRATE (TC) 50 CC * 541,800
619 LBTGR THERAPEUTIC GRANULOCYTE REDUCTION * 8,126,606
620 LBTHROM1 THROMBOCYTE CONCENTRATE (TC) * 5,492,944
621 LBTLMR THERAPEUTIC LYMPHO/MONO REDUCTION * 8,126,606
622 LBTPE TPE (TERAPEUTIC PLASMA EXCHANGE) * 8,126,606
623 LBTPR THERAPEUTIC PLATELET REDUCTION * 8,126,606
624 LBVITAPH VIT. APHERESIS * 602,044
Page 7
TARIF INSURANCE
625 LBWPRC WASHING PACKED RED CELLS * 225,750
TARIF FISIOTERAPI
626 RHOTGYMEQUIP PHYSIO TREADMILL PROSEDUR 118,157
627 RHOTQDB QUADRICEPS BENCH PROSEDUR 118,157
628 RHOTSTABIC STATIC BICYCLE PROSEDUR 118,157
629 RHPTAKMOV ACTIVE MOVEMENT/LATIHAN-LATIHAN AKTIF PROSEDUR 118,157
630 RHPTBALEXER BALANCE EXERCISES/LATIHAN KESEIMBANGAN PROSEDUR 118,157
631 RHPTBOEX BOBATH EXERCISES PROSEDUR 118,157
632 RHPTCABG EXERCISE FOR POST OP CABG PROSEDUR 214,484
633 RHPTCP BREATHING EXERSICES/LATIHAN PERNAFASAN PROSEDUR 118,157
634 RHPTCPMH CPM (CONTINOUS PASSIVE MOVEMENTS) PER JAM PROSEDUR 235,967
635 RHPTCPT CHEST PHYSIOTHERAPY PROSEDUR 160,949
636 RHPTELESTIMF ELECTRICAL SIMULATION - FARADIC PROSEDUR 118,157
637 RHPTELESTIMG ELECTRICAL SIMUL - GALVANIC PROSEDUR 118,157
638 RHPTGENEXC GYMNASIUM EXERCISES PROSEDUR 171,518
639 RHPTIFT INTERFERENTIAL THERAPY PROSEDUR 118,157
640 RHPTIHSI INHALASI / NEBULIZER PROSEDUR 118,157
641 RHPTIRR SINAR INFRA MERAH PROSEDUR 128,725
642 RHPTKD ICE PACK / KOMPRES DINGIN PROSEDUR 118,157
643 RHPTKP CORRECTION POSTURE/KOREKSI SIKAP TUBUH PROSEDUR 118,157
644 RHPTKPNS HOT PACK / KOMPRES PANAS PROSEDUR 118,157
645 RHPTKTP KINESIOTAPPING PROSEDUR 118,157
646 RHPTLATJAL WALKING EXERCISE/LATIHAN BERJALAN PROSEDUR 128,725
647 RHPTLATKOOR COORDINATION EXERCISES/LAT. KOORDINASI PROSEDUR 118,157
648 RHPTMASS MASSAGE PROSEDUR 118,157
649 RHPTMMT MUSCLE TEST/EVALUASI KEKUATAN OTOT PROSEDUR 118,157
650 RHPTMNLDV MANUAL LUMPH DRAINASE VOLDER PROSEDUR 235,967
651 RHPTMT15 PASSIVE JOINT MOBILIZATION/MANUAL THERAP PROSEDUR 118,157
652 RHPTPASMOV PASSIVE MOVEMENT/LATIHAN PASIF PROSEDUR 118,157
653 RHPTPBATH PARAFFIN BATH PROSEDUR 118,157
654 RHPTPEKE PENINGKATAN KEKUATAN GERAKAN SENDI PROSEDUR 118,157
655 RHPTPNF P.N.F (PROPIOCAPTURE NERO NUSCULAR FAC.) PROSEDUR 118,157
656 RHPTPNMF PROPRIOCEPTOR NEURO MUSCULAR FASILITATIO PROSEDUR 118,157
657 RHPTPODR POSTURAL DRAINAGE PROSEDUR 118,157
658 RHPTRLT RED LASER THERAPY PROSEDUR 118,157
659 RHPTSTRENG STRENGTHENING EXERCISES/PENGUATAN OTOT PROSEDUR 133,679
660 RHPTSWD SHORTWAVE DIATHERMY PROSEDUR 118,157
661 RHPTSWT SHOCK WAVE THERAPY PROSEDUR 321,725
662 RHPTTC STATIC/INTERMITTEN CARVICAL TRACTION PROSEDUR 118,157
663 RHPTTENS TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR) PROSEDUR 118,157
664 RHPTTL STATIC/INTERMITTEN LUMBAR TRACTION PROSEDUR 118,157
665 RHPTUST ULTRASOUND THERAPY PROSEDUR 128,725
666 RHPTRT ROMBERG TEST PROSEDUR 173,250
667 RHPTTFSSM TERAPI FISIK STIMULASI SENSORIK DAN MOTORIK PROSEDUR 259,875
668 RHPTTWP TERAPI WICARA PSIKOLOGIS PROSEDUR 259,875
669 RHPTSEN SENSORIS INTEGRITAS PROSEDUR 259,875
670 RHPTOTH REHABILITASI LAINNYA PROSEDUR Variabel
TARIF RADIOLOGI
671 RCARM C-ARM % 2,078,664
672 RCCAD CT HEAD EXAMINATION WITH CONTRAST % 1,870,848
673 RCCARD CTA CORONARY % 7,898,520
674 RCCBRA CT SCAN ROUTINE BRAIN + IV CONTRAST % 3,872,272
675 RCCBTH CT SCAN THORAX HRCT + IV CONTRAST % 5,820,024
676 RCCFBS CT BODY EXAM WC % 2,510,465
677 RCCLOW CT SCAN LOWER ABDOMEN + IV CONTRAST % 5,230,130
678 RCCNAS CT SCAN NASOPHARYNX + IV CONTRAST % 3,325,728
679 RCCNEC CT SCAN NECK + IV CONTRAST % 3,949,344
680 RCCSEL CT SCAN SELLA TURSICA + IV CONTRAST % 3,949,344
681 RCCULO CT SCAN ABDOMEN + IV CONTRAST % 7,586,880
682 RCCUPP CT SCAN UPPER ABDOMEN + IV CONTRAST % 5,404,392
683 RCOAOR CT ANGIO AORTA % 8,314,320
684 RCOCER CT ANGIO CERVICAL % 7,482,888
685 RCOCRA CT ANGIO CRANIAL % 7,898,520
686 RCOLEX CT ANGIO LOWER EXTREMITY % 8,314,320
687 RCOLOW CT ANGIO LOWER ABDOMEN % 7,898,520
688 RCOTHO CT ANGIO THORAX % 7,898,520
689 RCOUEX CT ANGIO UPPER EXTREMITY % 8,314,320
690 RCOUPP CT ANGIO UPPER ABDOMEN % 9,524,751
691 RCTALS CT CALCIUM SCORING * 3,741,528
692 RCTANK CT SCAN ANKLE JOINT % 2,078,664
693 RCTANK3D CT SCAN ANKLE JOINT 3D % 3,741,528
694 RCTARS CT CARDIAC ANGIO CORONER + CALCIUM SCORING * 8,314,320
695 RCTBIOP CT BIOPSY % 3,582,146
696 RCTBMD CT BONE MINERAL DENSITY (BMD) OSTEO % 1,662,864
697 RCTBPERC CT SCAN BRAIN PERFUSION % 4,157,160
698 RCTBRA CT SCAN ROUTINE BRAIN % 1,796,088
699 RCTBRA3D CT SCAN ROUTINE BRAIN 3D % 3,533,712
700 RCTBTH CT SCAN THORAX % 3,429,720
701 RCTBTH3D CT SCAN THORAX 3D % 6,235,824
702 RCTCER CT SCAN CERVICAL % 2,390,472
703 RCTCER3D CT SCAN CERVICAL SPINE 3D % 4,572,960
704 RCTCUB CT SCAN CUBITI % 1,974,840
705 RCTCUB3D CT SCAN CUBITI/ELBOW JOINT 3D % 3,741,528
706 RCTDPE CT SCAN DIGITAL PELVIMETRY % 1,870,848
707 RCTEXT CT SCAN EXTREMITAS LONG BONE % 2,494,296
708 RCTEXT3D CT SCAN EXTREMITAS 3D % 4,988,592
709 RCTFAB CT FACIAL BONE % 2,078,664
710 RCTFAB3D CT FACIAL BONE 3D % 3,949,344
711 RCTGEN CT SCAN GENU % 1,974,840
712 RCTGEN3D CT SCAN GENU/KNEE 3D % 3,741,528
713 RCTHIP CT SCAN HIP JOINT % 2,078,664
Page 8
TARIF INSURANCE
714 RCTHIP3D CT SCAN HIP JOINT 3D % 3,949,344

715 RCTINAC CT SCAN INNER AUDITORY CANAL % 2,078,664
716 RCTL3PH CT SCAN LIVER 3 PHASE % 7,959,650
717 RCTLOW CT SCAN LOWER ABDOMEN % 3,014,088
718 RCTLOW3D CT SCAN LOWER ABDOMEN 3D % 5,612,208
719 RCTLUM CT SCAN LUMBAL % 2,390,472
720 RCTLUM3D CT SCAN LUMBAR SPINE 3D % 4,572,960
721 RCTMAN CT MANDIBULA % 1,974,840
722 RCTMAN3D CT MANDIBULA 3D % 3,741,528
723 RCTMNS CT SCAN MANUS % 1,974,840
724 RCTMNS3D CT SCAN MANUS 3D % 3,741,528
725 RCTNAS CT SCAN NASOPHARYNX % 1,767,024
726 RCTNAS3D CT SCAN NASOPHARYNX 3D % 3,325,728
727 RCTNEC CT SCAN NECK % 2,078,664
728 RCTNEC3D CT SCAN NECK 3D % 3,741,528
729 RCTORB CT SCAN ORBITA % 1,767,024
730 RCTORB3D CT SCAN ORBITA 3D % 3,325,728
731 RCTPANO CT SCAN PANORAMIK (CBCT) % 765,072
732 RCTPAR CT SCAN PARANASAL SINUS % 1,870,848
733 RCTPAR3D CT SCAN PARANASAL SINUS 3D % 3,325,728
734 RCTPEL3D CT SCAN PELVIS 3D % 5,968,269
735 RCTPELV CT SCAN PELVIS % 3,014,088
736 RCTSEL CT SCAN SELLA TURSICA % 1,767,024
737 RCTSEL3D CT SCAN SELLA TURSICA 3D % 2,910,096
738 RCTSHD CT SCAN SHOULDER JOINT % 1,870,848
739 RCTSHD3D CT SCAN SHOULDER JOINT 3D % 3,741,528
740 RCTTEM CT SCAN TEMPORAL BONE % 2,078,664
741 RCTTEM3D CT SCAN TEMPORAL BONE 3D % 3,741,528
742 RCTTHO CT SCAN THORACIC SPINE % 2,598,288
743 RCTTHO3D CT SCAN THORACAL SPINE 3D % 4,988,592
744 RCTULO CT SCAN UPPER + LOWER ABDOMEN % 5,196,408
745 RCTULO3D CT SCAN UPPER + LOWER ABDOMEN 3D % 9,353,568
746 RCTUPP CT SCAN UPPER ABDOMEN % 2,910,096
747 RCTUPP3D CT SCAN UPPER ABDOMEN 3D % 5,196,408
748 RCTWJN CT SCAN WRIST JOINT % 1,974,840
749 RCTWJN3D CT SCAN WRIST JOINT 3D % 3,741,528
750 RMAAOR MRA AORTA WITH CONTRAST % 6,235,824
751 RMAARV MRA + MRV LOWER EXTREMITAS % 6,235,824
752 RMABRA MRA BRAIN % 4,157,160
753 RMABRAC MRA BRAIN WITH CONTRAST * 7,578,744
754 RMABRAMS MRI + MRA/MRV BRAIN + SPECTROSCOPY % 7,275,072
755 RMANEC MRA NECK % 5,404,392
756 RMAPEL MRA PELVIS % 5,612,208
757 RMAREN MRA RENAL % 5,612,208
758 RMASUB MRA SUBCLAUIAN % 5,612,208
759 RMCBRACS MRI BRAIN + IV CONTRAST + SPECTROSCOPY % 7,898,520
760 RMCBRE MRI BREAST + IV CONTRAST % 6,651,456
761 RMCCERC MRI CERVICAL SPINE + IV CONTRAST % 5,820,024
762 RMCEXAM MRI ADDITIONAL EXAMINATION WITH CONTRAST % 2,494,296
763 RMCLUMC MRI LUMBAR SPINE + IV CONTRAST % 5,820,024
764 RMCTHSC MRI THORARIC SPINE + IV CONTRAST % 6,131,832
765 RMCUABC MRI UPPER ABDOMEN + IV CONTRAST % 6,027,840
766 RMMMUS MAMMOGRAPHY + USG BREAST % 1,662,864
767 RMRANK MRI ANKLE JOINT % 4,572,960
768 RMRBRA MRI BRAIN % 4,572,960
769 RMRBRAM MRI BRAIN + MRA/MRV % 6,235,824
770 RMRCER MRI CERVICAL SPINE % 4,572,960
771 RMRCERMY MRI CERVICAL SPINE + MYELO % 5,404,392
772 RMRCUB MRI CUBITI % 4,572,960
773 RMREXT MRI EXTREMITIES LONG BONE % 4,988,592
774 RMRGEN MRI GENU % 4,572,960
775 RMRHIP MRI HIP JOINT % 4,572,960
776 RMRLAB MRI LOWER ABDOMEN % 4,572,960
777 RMRLMY MRI LUMBAL + MYELOGRAPHY % 5,404,392
778 RMRLUM MRI LUMBAR SPINE % 4,572,960
779 RMRMNS MRI MANUS % 4,572,960
780 RMRMRCP MRI MRCP % 4,906,443
781 RMRNAS MRI NASOPHARYNX % 4,572,960
782 RMRNEC MRI NECK % 4,572,960
783 RMRORB MRI ORBITA % 4,572,960
784 RMRPAR MRI PARANASAL SINUS % 4,572,960
785 RMRRU MRU / UROLOGI % 4,780,776
786 RMRSEL MRI SELLA TURSICA % 6,443,640
787 RMRSHD MRI SHOULDER JOINT % 4,572,960
788 RMRSP MRI SPINE + SAGITAL VIEW % 5,820,024
789 RMRSPEC MRI SPECTROSCOPY % 4,157,160
790 RMRTEM MRI TEMPORAL BONE % 4,572,960
791 RMRTHO MRI THORAX % 4,364,976
792 RMRTHS MRI THORARIC SPINE % 4,572,960
793 RMRTMJ MRI TEMPORO MANDIBULAR JOINT % 4,988,592
794 RMRUAB MRI UPPER ABDOMEN % 4,780,776
795 RMRULA MRI UPPER LOWER ABDOMEN % 8,729,952
796 RMRWJN MRI WRIST JOINT % 4,572,960
797 ROMBCCT KONSUL BACA FOTO CT-SCAN % 139,104
798 ROMBCMR KONSUL BACA FOTO MRI % 173,397
799 ROMBCUS KONSUL BACA FOTO USG % 80,782
800 ROMBCXR KONSUL BACA FOTO X-RAY % 80,782
801 ROMCD CETAK CD % 62,496
802 ROMCONION CONTRAST NON IONIC WATER SOLUBLE BOTOL 1,351,224
803 ROMENG REPORT IN ENGLISH % 224,233
804 ROMFFB CHARGE X-RAY FILM % 312,423
805 ROMFUS CETAK FILM USG (1 LEMBAR) % 21,000
806 ROMRAD PRINT ULANG HASIL RADIOLOGI % 41,664
Page 9
TARIF INSURANCE
807 RUSAPP USG APPENDIX % 1,039,416

808 RUSBRS USG BREAST % 935,592
809 RUSDOP USG DOPLER % 3,741,528
810 RUSG-URO USG UROLOGY ITEM % 364,532
811 RUSKID USG KIDNEY + BLADDER % 1,122,576
812 RUSPEL USG PELVIS (LOWER ABDOMEN) % 1,039,416
813 RUSSUP USG SUPERFICIAL % 1,039,416
814 RUSTES USG TESTIS % 1,351,224
815 RUSTHY USG THYROID % 1,039,416
816 RUSULO USG UPPER & LOWER ABDOMEN % 1,455,048
817 RUSVPP USG UPPER ABDOMEN (LIVER,GB,PANCREAS,KID % 1,143,408
818 RXCAFOL X-RAY BA FOLLOW THROUGH % 2,757,175
819 RXCAPP X-RAY APPENDIX % 1,662,864
820 RXCB2V X-RAY BNO + IVP % 2,078,664
821 RXCCOLO X-RAY COLON % 2,261,616
822 RXCCYS X-RAY CYSTOGRAPHY (BLASS CONTRAST) % 2,510,234
823 RXCESOF X-RAY ESOFAGOGRAM % 835,800
824 RXCFIS X-RAY FISTULOGRAPHY % 2,666,974
825 RXCGAL X-RAY GALACTOGRAPHY % 2,078,664
826 RXCHYS X-RAY HYSTEROSALPINGOGRAPH (HSG) % 2,548,838
827 RXCLOPO X-RAY LOPOGRAFI % 1,846,200
828 RXCOMD X-RAY OMD % 2,358,400
829 RXCONION X-RAY CONTRAST NON IONIC WATER SOLBLE % 1,351,224
830 RXCRPG X-RAY RETROGRADE PYELOGRAPHY % 2,510,234
831 RXCSOX X-RAY BA ESHOPHAGUS % 1,979,600
832 RXCTUBE X-RAY T-TUBE CHOLANGIOGRAPHY % 2,825,002
833 RXCURC X-RAY URETHROCYSTOGRAPHY % 2,510,234
834 RXR3POS X-RAY ABDOMEN 3 POSISI % 1,046,033
835 RXRABD X-RAY ANTEBRACHII DEXTRA % 385,253
836 RXRABDPX X-RAY ANTEBRACHII DEXTRA MOBILE % 665,280
837 RXRABS X-RAY ANTEBRACHII SINISTRA % 385,253
838 RXRABSPX X-RAY ANTEBRACHII SINISTRA MOBILE % 665,280
839 RXRAKD X-RAY ANKLE JOINT DEXTRA % 385,253
840 RXRAKDPX X-RAY ANKLE JOINT DEXTRA MOBILE % 665,280
841 RXRAKS X-RAY ANKLE JOINT SINISTRA % 385,253
842 RXRAKSPX X-RAY ANKLE JOINT SINISTRA MOBILE % 665,280
843 RXRATR X-RAY ATRISIANI (KNEE CHEST) % 519,792
844 RXRATRPX X-RAY ATRISIANI (KNEE CHEST) MOBILE % 1,039,416
845 RXRBABY X-RAY BABYGRAM FOTO % 623,616
846 RXRBABYPX X-RAY BABYGRAM FOTO MOBILE % 1,039,416
847 RXRBAGE X-RAY BONE AGE * 520,644
848 RXRBNO X-RAY BNO % 416,443
849 RXRBNOPX X-RAY BNO MOBILE % 748,440
850 RXRCAD X-RAY CALCANEUS DEXTRA % 385,253
851 RXRCAS X-RAY CALCANEUS SINISTRA % 385,253
852 RXRCER X-RAY CERVICAL (AP+LATERAL) % 520,644
853 RXRCERPX X-RAY CERVICAL (AP+LATERAL) MOBILE % 914,592
854 RXRCLA X-RAY CLAVICULA % 395,705
855 RXRCLAPX X-RAY CLAVICULA MOBILE % 665,280
856 RXRCOB X-RAY CERVICAL (AP+LAT+OBLIQUE) % 727,608
857 RXRCOBPX X-RAY CERVICAL (AP+LAT+OBLIQUE) MOBILE % 1,143,408
858 RXRCRD X-RAY CRURIS DEXTRA % 458,084
859 RXRCRDPX X-RAY CRURIS DEXTRA MOBILE % 831,432
860 RXRCRS X-RAY CRURIS SINISTRA % 458,084
861 RXRCRSPX X-RAY CRURIS SINISTRA (AP+LATERAL) MOBILE % 831,432
862 RXRCUD X-RAY CUBITI DEXTRA % 385,253
863 RXRCUDPX X-RAY CUBITI DEXTRA MOBILE % 665,280
864 RXRCUS X-RAY CUBITI SINISTRA % 385,253
865 RXRCUSPX X-RAY CUBITI SINISTRA MOBILE % 665,280
866 RXRFED X-RAY FEMUR DEXTRA % 458,084
867 RXRFEDPX X-RAY FEMUR DEXTRA MOBILE % 831,432
868 RXRFES X-RAY FEMUR SINISTRA % 458,084
869 RXRFESPX X-RAY FEMUR SINISTRA MOBILE % 831,432
870 RXRGND X-RAY GENU DEXTRA % 385,253
871 RXRGNDPX X-RAY GENU DEXTRA MOBILE % 665,280
872 RXRGNS X-RAY GENU SINISTRA % 385,253
873 RXRGNSPX X-RAY GENU SINISTRA MOBILE % 665,280
874 RXRGSD X-RAY GENU DEXTRA + SKY LINE % 520,644
875 RXRGSS X-RAY GENU SINISTRA + SKY LINE % 520,644
876 RXRHUD X-RAY HUMERUS DEXTRA % 458,084
877 RXRHUDPX X-RAY HUMERUS DEXTRA MOBILE % 831,432
878 RXRHUS X-RAY HUMERUS SINISTRA % 458,084
879 RXRHUSPX X-RAY HUMERUS SINISTRA MOBILE % 831,432
880 RXRLOB X-RAY LUMBOSACRAL (AP+LAT+OBLIQUE) % 727,608
881 RXRLOBPX X-RAY LUMBOSACRAL (AP+LATERAL+OBLIQUE) MOBILE % 1,143,408
882 RXRLUM X-RAY LUMBOSACRAL (AP+LATERAL) % 520,644
883 RXRLUMPX X-RAY LUMBOSACRAL (AP+LATERAL) MOBILE % 935,592
884 RXRMAD X-RAY MASTOID DEXTRA % 519,792
885 RXRMAN X-RAY MANDIBULA % 519,792
886 RXRMANPX X-RAY MANDIBULA MOBILE % 1,039,416
887 RXRMAS X-RAY MASTOID SINISTRA % 519,792
888 RXRMND X-RAY MANUS DEXTRA % 385,253
889 RXRMNDPX X-RAY MANUS DEXTRA MOBILE % 665,280
890 RXRMNS X-RAY MANUS SINISTRA % 385,253
891 RXRMNSPX X-RAY MANUS SINISTRA MOBILE % 665,280
892 RXRNSL X-RAY OS. NASAL % 384,720
893 RXRPAB X-RAY POLOS ABDOMEN % 416,443
894 RXRPABPX X-RAY POLOS ABDOMEN MOBILE % 866,828
895 RXRPDD X-RAY PEDIS DEXTRA % 385,253
896 RXRPDDPX X-RAY PEDIS DEXTRA MOBILE % 665,280
897 RXRPDS X-RAY PEDIS SINISTRA % 385,253
898 RXRPDSPX X-RAY PEDIS SINISTRA MOBILE % 665,280
899 RXRPEL X-RAY PELVIS % 416,443
Page 10
TARIF INSURANCE
900 RXRPELPX X-RAY PELVIS MOBILE % 748,440

901 RXRSCH X-RAY SKULL (SCHEDEL) % 623,616
902 RXRSCHPX X-RAY SKULL (SCHEDEL) MOBILE % 1,039,416
903 RXRSCOL X-RAY SCOLIOSIS PROGRAM % 1,559,040
904 RXRSHD X-RAY SHOULDER JOINT % 437,362
905 RXRSHYV X-RAY SHOULDER JOINT + Y VIEW % 551,833
906 RXRSIN X-RAY SINUS SERIES (WATERS+LATERAL) % 520,644
907 RXRSINPX X-RAY SINUS SERIES (WATERS+LATERAL) MOBILE % 1,039,416
908 RXRTAP X-RAY THORACIC SPINE % 623,616
909 RXRTAPPX X-RAY THORACAL (AP+LATERAL) MOBILE % 914,592
910 RXRTLA X-RAY THORAX (PA + LAT) % 623,616
911 RXRTLAPX X-RAY THORAX (PA+LATERAL) MOBILE % 1,194,048
912 RXRTMJ X-RAY TEMPORO MANDIBULAR JOINT % 727,608
913 RXRTPA X-RAY THORAX % 417,816
914 RXRTPAB X-RAY THORAX PHOTO BESAR % 415,800
915 RXRTPAPX X-RAY THORAX (PA) MOBILE % 659,154
916 RXRWRD X-RAY WRIST JOINT DEXTRA % 385,253
917 RXRWRDPX X-RAY WRIST DEXTRA MOBILE % 665,280
918 RXRWRS X-RAY WRIST JOINT SINISTRA % 385,253
919 RXRWRSPX X-RAY WRIST SINISTRA MOBILE % 665,280
920 RXPHLEB X-RAY PHLEBOGRAPHY PEMAKAIAN 6,720,000
921 RCTLUNG CT SCAN LUNG LOW DOSE PEMAKAIAN 1,197,000
922 RMBRAC MRI BRAIN + IV CONTRAST * 5,820,150
923 ROMNUCL NUCLEAR GAMMA CAMERA % Variabel
924 ROMRADIOI RADIOTERAPI I (15X) % Variabel
925 ROMRADIOII RADIOTERAPI II (30X) % Variabel
926 ROMSIM SIMULATOR (PERSIAPAN RADIOTERAPI) % Variabel
927 ROMOTH RADIOLOGI LAINNYA % Variabel
TARIF PROSEDUR PERAWAT

928 NAFFCATH AFF CATHETER PROSEDUR 62,935
929 NAFFHECT AFF HECTING NURSING PROSEDUR 62,935
930 NAFFNGT AFF NGT PROSEDUR 62,935
931 NAPRON1 PENGURUSAN APRON (ANTAR) PROSEDUR 3,255,525
932 NAPRON2 PENGURUSAN APRON (JEMPUT) PROSEDUR 3,052,004
933 NBLADWASH BLADDER WASHOUT (IRIGASI BLADDER) PROSEDUR 121,895
934 NBLTRAN BLOOD TRANSFUSION PROSEDUR 108,722
935 NCATH CATHETERIZATION PROSEDUR 108,722
936 NCBLUE CODE BLUE PROSEDUR 393,387
937 NCDRECORDING CD RECORDING PROCDR FOR PTCA % 112,067
938 NCENVEN PROSEDUR CENTRAL VENOUS LINE PROSEDUR 159,472
939 NCHEM<10 CHEMOTHERAPHY PROCEDURE > 5 HOURS PROSEDUR 699,341
940 NCHEM<5 CHEMOTHERAPHY PROCEDURE 1-5 HOUR PROSEDUR 525,000
941 NCHEPORT PROSEDUR CHEMOPORT PROSEDUR 108,722
942 NCITY PRIVATE NURSE FEE (DALAM KOTA) PASIEN 168,118
943 NDAYVERB GANTI VERBAND - PERAWAT PROSEDUR 65,495
944 NECG ECG NURSING PROSEDUR 65,336
945 NECP ECP NURSING PROSEDUR 101,283
946 NEEG EEG NURSING PROSEDUR 108,722
947 NENDINTU NURSING ENOTRACHEAL INTUBATATION PROSEDUR 217,430
948 NFLI PRIVATE DUTY NURSING (PERJALANAN DENGAN PESAWAT) PASIEN 9,390,654
949 NFLIPLUS PRIVATE DUTY NURSE LUAR KOTA (PER ADDTIONAL DAY) HARI 420,287
950 NHAIR CUCI RAMBUT PROSEDUR 84,066
951 NINJEC INJECTION MEDICATION PROSEDUR 81,822
952 NIVCAN I.V. CANNULATION - PERAWAT PROSEDUR 145,059
953 NLEPGIS PROSEDUR BUKA GIPS PROSEDUR 108,722
954 NMEDROP EYE DROP PROCEDURE PROSEDUR 26,754
955 NNASOINS NASO-GASTRIC TUBE INSERTION PROSEDUR 130,817
956 NNEBUL NEBULIZER NURSING PROCEDURE PROSEDUR 21,779
957 NORESUSC NURSE RESUSCITATION PROSEDUR 217,430
958 NOTH KEPERAWATAN LAINNYA PROSEDUR Variabel
959 NOTVERB GANTI VERBAND OR PROSEDUR 157,228
960 NOXYTHE OXYGEN THERAPY PROSEDUR 101,829
961 NPASGIPS PROSEDUR PASANG GIPS PROSEDUR 101,283
962 NPNGT PROSEDUR PASANG NGT PROSEDUR 70,127
963 NRECTWASH RECTAL/COLONIC WASHOUT PROSEDUR 81,822
964 NROOM1 PRIVATE NURSE FEE DI ROOM (SHIFT I) SHIFT 504,338
965 NROOM2 PRIVATE NURSE FEE DI ROOM (SHIFT II) SHIFT 504,338
966 NROOM3 PRIVATE NURSE FEE DI ROOM (SHIFT III) SHIFT 626,126
967 NSPIRO NURSING PROCEDURE SPIROMETRI PROSEDUR 21,779
968 NSTOMWASH STOMACH WASHOUT/KUMBAH LAMBUNG PROSEDUR 320,229
969 NSUCTION SUCTIONING CONTINUOUS PROSEDUR 114,476
970 NSUCTION1 SUCTIONING IN ANE PROSEDUR 62,935
971 NSURSTEP HEMOGLUCOTEST PROSEDUR 8,861
972 NTREADMILL PROSEDUR PERAWAT TREADMILL PROSEDUR 108,722
973 NWOUND WOUND CARE - PERAWAT PROSEDUR 81,822
974 NVITAL NURSING CARE GENERAL PROSEDUR 188,370
975 NVITAL-ANG FONDS NURSING ANGIO PROSEDUR 693,840
976 NVITALANGCIT NVITAL NURSING ANGIO CITO PROSEDUR 1,159,515
977 NVITAL-BABY NURSING CARE BABY PROSEDUR 185,850
978 NVITAL-ICU NURSING CARE HDU/ICU/SBW/NICU PROSEDUR 346,500
979 NVITAL-OT FONDS OT - INPATIENT PROSEDUR 371,700
980 NVITALOTIP NVITAL OPERATING ROOM IP PRIVATE PROSEDUR 724,645
981 NVITALOTOP NVITAL OPERATING ROOM OP PRIVATE PROSEDUR 362,330
982 NVITAL-OTOUT FONDS OT - OUTPATIENT PROSEDUR 185,850
983 NVITALISO NURSING CARE ISOLATION ROOM PROSEDUR 458,640
984 NVITALISOICU NURSING CARE ISOLATION ICU ROOM PROSEDUR 709,275
985 NVITALDAYCARE NURSING CARE DAYCARE PROSEDUR 147,420
TARIF PERALATAN MEDIK

986 EQAQUATERM AQUATERM III EXTERNAL PEMAKAIAN 244,806
987 EQARTHROSCOPY ARTHROSCOPY DIAGNOSTIC PEMAKAIAN 21,031,290
988 EQAUDIO EHS-AUDIOMETRI PEMAKAIAN 187,819
Page 11
TARIF INSURANCE
989 EQAUTOREF AUTOREFRAKSI EYE EQP PEMAKAIAN 40,889

990 EQBASIC BASIC EMERGENCY KIT (PORT RESUSCITATOR) PEMAKAIAN 1,504,913
991 EQBIOMET BIOMETRI EYE CHECK PEMAKAIAN 113,006
992 EQBIOPROST INSTRUMENT BIOPSY PEMAKAIAN 678,615
993 EQBLWARM BLOOD WARMER PEMAKAIAN 173,250
994 EQBRONCHOS PERALATAN MEDIK BRONCHOSCOPY SET 1,053,544
995 EQCABGEQP CABG EQUIPMENT USE PEMAKAIAN 22,573,688
996 EQCATHLAB-ANG CATH LAB-ANGIO EQUIPMENT USE PEMAKAIAN 6,094,988
997 EQCPAP-DAY NCPAP EQUIPMENT USE PEMAKAIAN 587,536
998 EQCTG CTG MONITORING - 1 HOUR PEMAKAIAN 571,211
999 EQCTGOUTP CTG OUTPATIENT PEMAKAIAN 244,806
1000 EQDECUBIBED TRIPLE BED/DECUBITUS BED PEMAKAIAN 204,084
1001 EQDEFIBR DEFIBRILATOR PEMAKAIAN 326,404
1002 EQDIATHERMY DIATHERMY - MONO/BI POLAR (W CABLE ONLY) PEMAKAIAN 489,613
1003 EQDIAVALLAB DIATHERMY MACHINE VALLEYLAB PROSEDUR 571,211
1004 EQDOPPL DOPPLER PEMAKAIAN 408,015
1005 EQDRILL DRILL OTRHO PEMAKAIAN 1,632,020
1006 EQECG12 12-LEAD ECG PEMAKAIAN 171,448
1007 EQECGMON ECG/CARDIAC MONITORING (CONTINOUS) PEMAKAIAN 1,468,825
1008 EQECHOCARD ECHO CARDIOGRAPHY (DIAGNOSTIC ULTRASOUND) PEMAKAIAN 1,187,654
1009 EQEEGMON EEG-ELECTRO ENCEPHALO GRAPH PEMAKAIAN 1,354,577
1010 EQEMERESCBOX EMERGENCY&RESCUE BOX PEMAKAIAN 3,762,281
1011 EQENDOS EQP ENDOSCOPY PROSEDUR Variabel
1012 EQENTCO2 ENDTIDAL CO2 (MONITORING) PEMAKAIAN 150,544
1013 EQFORCDEL FORCEPS DELIVER PEMAKAIAN 203,306
1014 EQGOMPUMP GOMCO PUMP PEMAKAIAN 138,812
1015 EQHAEMO HAEMOTERM EQUIPMENT PEMAKAIAN 816,017
1016 EQHARGENSYS HARMONIC GENERATOR SYSTEM PEMAKAIAN 571,211
1017 EQHEADLI HEAD LIGHT PEMAKAIAN 326,404
1018 EQHEAR EQUIPMENT HEARING IMPLANT CENTER (HOSPITAL) PROSEDUR Variabel
1019 EQKHEAR1 EQP HEARING IMPLANT CENTER (MEDEL) PROSEDUR Variabel
1020 EQKHEARH EQP HEARING IMPLANT CENTER (HOSPITAL) PROSEDUR Variabel
1021 EQKMETLASER LASER METABOLIC SET (INTRA VENA, MULTI CHANNEL & OXYPEN) PROSEDUR Variabel
1022 EQINFTRESU INFANT BLENDING / T- PIECE RESUSITATOR (FA:10H/5F/5493) PEMAKAIAN 233,146
1023 EQINFUSPUMP INFUSION PUMP PEMAKAIAN 204,084
1024 EQINSEMINATOR INSEMINATOR PEMAKAIAN 329,306
1025 EQKECP EQP ECP (EXTERNAL COUNTER PULSATION) PT. SIMAK PROSEDUR 500,588
1026 EQLASBIO LASER BIOLITEC LEONARDO DUAL 45 PEMAKAIAN 3,672,055
1027 EQMICENT MICROSCOPE ENT PEMAKAIAN 376,294
1028 EQMICEYE MICROSCOPE EYE PEMAKAIAN 408,015
1029 EQMICOPMI MICROSCOPE OPMI VARIO 700 ZEISS PEMAKAIAN 3,753,652
1030 EQNEBULI NEBULIZER PEMAKAIAN 163,209
1031 EQO2SAT SATURASI OXYGEN PEMAKAIAN 110,212
1032 EQOTH PERALATAN RS LAINNYA PEMAKAIAN Variabel
1033 EQOXYCHK OXYMETRI CHECK PEMAKAIAN 179,534
1034 EQPACE PACE MAKER MACHINE PEMAKAIAN 2,031,750
1035 EQPACER PACER (EXTERNAL) PEMAKAIAN 2,031,750
1036 EQPBDRILL PNEUMATIC BONE DRILL PEMAKAIAN 8,901,291
1037 EQPCNLSET PERCUTANEOUS NEPHROLITHOTOMY (PCNL) SET PROSEDUR 5,664,204
1038 EQPHACO PHACO MACHINE PEMAKAIAN 2,448,036
1039 EQPHOTO1 PHOTOTHERAPY SINGLE LIGHT PEMAKAIAN 179,534
1040 EQPHOTO2 PHOTOTHERAPY-DOUBLE LIGHT PEMAKAIAN 326,404
1041 EQPORTINC PORTABLE INCUBATOR PEMAKAIAN 326,404
1042 EQSACHE SACHE (UROLOGY) PEMAKAIAN 3,160,369
1043 EQSCOPE SCOPE LAPARASCOPY PEMAKAIAN 816,017
1044 EQSETBASIC SET BASIC INSTRUMENT PEMAKAIAN 420,525
1045 EQSETHYSTERE HYSTEROSCOPY SET 10K FLUID SYSTEM PEMAKAIAN 3,264,039
1046 EQSETLAPARA LAPARASCOPIC SET PEMAKAIAN 3,264,039
1047 EQSETLAPARMIS MIS LAPARASCOPY SET PEMAKAIAN 4,855,631
1048 EQSETMAJOR SET MAJOR INSTRUMENT PEMAKAIAN 225,750
1049 EQSETMINI SET MINI INSTRUMENT PEMAKAIAN 219,188
1050 EQSISTOCOPY SISTOCOPY(UROLOGY) PEMAKAIAN 3,264,039
1051 EQSPIRO SPIROMETRY PROSEDUR 146,883
1052 EQSYRIPUMP SYRINGE PUMP PEMAKAIAN 204,084
1053 EQTHERBLAN THERMAL BLANKET PEMAKAIAN 326,404
1054 EQTONOME TONOMETER EYE EQP PEMAKAIAN 40,889
1055 EQTOURNIQUET TOURNIQUET MACHINE PEMAKAIAN 326,404
1056 EQTRDMILL TREADMILL PROSEDUR 1,142,421
1057 EQTURP TUR (UROLOGY) PEMAKAIAN 4,288,652
1058 EQURFLOW UROFLOWMETRY PORTABLE PROSEDUR 846,838
1059 EQURS URS EQUIPMENT PEMAKAIAN 2,937,635
1060 EQURSLASER URS LASER EQUIPMENT PEMAKAIAN 5,394,680
1061 EQUSG4DGY USG 4D COLOR - GYNECOLOGY PEMAKAIAN 816,017
1062 EQUSG4DGY1 USG 4 D COLOUR PEMAKAIAN 416,339
1063 EQUSGBW-G USG B/W - GYNECOLOGY - EQUSGBW-G PEMAKAIAN 542,931
1064 EQUSGBWGY USG B/W - GYNECOLOGY PEMAKAIAN 489,613
1065 EQUSGBWGY1 USG BLACK / WHITE - GYNECOLOGY PEMAKAIAN 277,555
1066 EQUSGEYE USG EYE PEMAKAIAN 341,513
1067 EQUSGOTH BIAYA USG PEMAKAIAN 244,806
1068 EQUSGTVBW USG TRANSVAGINAL BW - EQUSGTVBW PEMAKAIAN 571,211
1069 EQUSGTVGBW USG TRANSVAGINAL BW PEMAKAIAN 489,613
1070 EQUSGTVGC USG TRANSVAGINAL COLOR PEMAKAIAN 602,044
1071 EQUSGURO ULTRASONOGRAPHY / USG UROLOGY TP PROSEDUR 285,682
1072 EQUSGURO1 ULTRASONOGRAPHY / USG UROLOGY P PROSEDUR 408,015
1073 EQUSG4D BIAYA USG 4D PEMAKAIAN Variabel
1074 EQVACEXT VACCUM EXTRACTION PEMAKAIAN 244,806
1075 EQVACUUM VACCUM MACHINE FOR TOP PEMAKAIAN 244,806
1076 EQVENDAY VENTILATOR - 1 DAY PEMAKAIAN 1,413,825
1077 EQHFNC HIGH FLOW NASAL CANNULA PEMAKAIAN 962,850
1078 EQBIA BIO-ELECTRICAL IMPEDANCE ANALYSIS (BIA) - BODY MASS ANALYSIS PROSEDUR 426,563
TARIF PERALATAN DOKTER

1079 EQDCBIOE PERALATAN DOKTER - THERAPY BIO E PROSEDUR 657,956
Page 12
TARIF INSURANCE
1080 EQDCECG003 ECG DR. MASRUL LUBIS PROSEDUR 229,908

1081 EQDCEYE004 LASER YAG CAPSULOTOMY UNILATERAL PROSEDUR 2,361,387
1082 EQDCEYE005 LASER YAG CAPSULOTOMY BILATERAL ( 2 EYES) PROSEDUR 4,719,755
1083 EQDCGLUC001 GLUCOTEST PROSEDUR 31,878
1084 EQDCHOLTER001 HOLTER MONITORING PROCEDURE PROSEDUR 3,146,504
1085 EQDCLASE001 LASER DR. M FAUZI NASUTION PROSEDUR 15,666,588
1086 EQDCNASO001 NASO ENDOSCOPY THT PROSEDUR 158,424
1087 EQDCSLIM001 SLIMMING MASTER DR. M FAUZI NASUTION PROSEDUR 949,578
1088 EQDCSPIR002 SPIROMETRI PROF TAMSIL PROSEDUR 316,607
1089 EQDCTHT001 ELECTRIC SUCTION TELINGA THT PROSEDUR 79,333
1090 EQDCTHT002 EXTRACTIE CRUSTA THT PROSEDUR 158,424
1091 EQDCTHT003 KAUSTIC STOMATITIS + BIOPSI THT PROSEDUR 237,515
1092 EQDCTHT004 TEST ALERGI PROSEDUR 554,001
1093 EQDCUSG005 USD 2D DR. M FAUZI NASUTION PROSEDUR 474,910
1094 EQDCUSG006 USD 3D DR. M FAUZI NASUTION PROSEDUR 791,396
1095 EQDCUSG007 USD 4D DR. M FAUZI NASUTION PROSEDUR 1,266,185
1096 EQDCUSGSP DIAGNOSTIC ULTRASOUND SUPERFICIAL PROSEDUR 767,970
1097 EQDCVASC001 VASCULAR ENDOSCOPY DR. M FAUZI NASUTION PROSEDUR 3,165,099
1098 EQDMICLAR MICROLARINGOSCOPY PROF ABDUL RACHMAN PROSEDUR 3,968,087
TARIF BIAYA ANESTESI

1099 SA0066A PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) - SA PROSEDUR 2,561,591
1100 SA0066B PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) (1 VESSEL) - SA PROSEDUR 4,562,297
1101 SA0066C PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) (2 VESSELS) - SA PROSEDUR 5,131,634
1102 SA0066D PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) (>2 VESSELS) - SA PROSEDUR 5,703,264
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) (DES/BMS 1
1103 SA0066E PROSEDUR 6,842,178
STENT) - SA
1104 SA0066F PROSEDUR 7,983,628
STENT) - SA
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) (DES/BMS >2
1105 SA0066G PROSEDUR 8,563,832
STENT) - SA
1106 SA0066H PERCUTANEOUS TRANSLUMINAL COR ANGIOGRAPHY (F) - SA PROSEDUR 1,737,472
REVISION OF HIP REPLACEMENT, BOTH ACETABULAR AND FEMORAL COMPONENTS -
1107 SA0070 PROSEDUR 6,327,421
SA
1108 SA0102 VENTRICULOPUNCTURE THROUGH PREVIOUSLY IMPLANTED CATHETER - SA PROSEDUR 1,441,634
1109 SA0109 OTHER CRANIAL PUNCTURE - SA PROSEDUR 1,330,907
1110 SA0113A CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF BRAIN (STEREOTIC) - SA PROSEDUR 5,752,651
1111 SA0113B CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF BRAIN (DIAGNOSTIC) - SA PROSEDUR 2,561,591
CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF BRAIN (EXPLORATORY BURRHOLE) -
1112 SA0113C PROSEDUR 3,063,307
SA
1113 SA0114 OPEN BIOPSY OF BRAIN - SA PROSEDUR 4,851,373
1114 SA0121 INCISION AND DRAINAGE OF CRANIAL SINUS - SA PROSEDUR 1,946,007
1115 SA0122A REMOVAL OF INTRACRANIAL NEUROSTIMULATOR LEAD(S) (BRAIN) - SA PROSEDUR 3,118,973
1116 SA0122B REMOVAL OF INTRACRANIAL NEUROSTIMULATOR LEAD(S) (CARNIAL NERVE) - SA PROSEDUR 2,744,527
1117 SA0124A OTHER CRANIOTOMY (EXPLORATORY OPEN CRANIOTOMY) - SA PROSEDUR 6,480,290
1118 SA0124B OTHER CRANIOTOMY (EVACUATION OF EXTRADURAL HAEMATOMA) - SA PROSEDUR 6,703,557
1119 SA0124C OTHER CRANIOTOMY (DECOMPRESSION OF CRANIAL NERVE (CRANIOTOMY)) - SA PROSEDUR 9,863,585
1120 SA0124D OTHER CRANIOTOMY (CRANIOTOMY-POSTOPERATIVE HAEMORRHAGE) - SA PROSEDUR 4,664,331
1121 SA0124E OTHER CRANIOTOMY (BURRHOLE FOR INTRACRANIAL INFECTION) - SA PROSEDUR 5,811,335
1122 SA0131 INCISION OF CEREBRAL MENINGES - SA PROSEDUR 7,376,135
1123 SA0151 EXCISION OF LESION OR TISSUE OF CEREBRAL MENINGES - SA PROSEDUR 6,902,674
1124 SA0152 HEMISPHERECTOMY - SA PROSEDUR 11,989,751
1125 SA0159A OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF BRAIN - SA PROSEDUR 9,222,523
1126 SA0159B OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF BRAIN (ABCESS) - SA PROSEDUR 6,168,272
OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF BRAIN
1127 SA0159C PROSEDUR 9,863,585
(CEREBELLOPONTINE ANGLE TUMOUR) - SA
OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF BRAIN (THERAPEUTIC
1128 SA0159D PROSEDUR 3,734,073
ENDOSCOPIC OP ON VENTRICLE OF BRAIN) - SA
1129 SA016 EXCISION OF LESION OF SKULL - SA PROSEDUR 3,118,973
1130 SA0201 OPENING OF CRANIAL SUTURE - SA PROSEDUR 6,045,349
ELEVATION OF SKULL FRACTURE FRAGMENTS (FORAMEN MAGNUM DECOMPRESSION)
1131 SA0202A PROSEDUR 6,327,421
- SA
1132 SA0202B ELEVATION OF SKULL FRACTURE FRAGMENTS - SA PROSEDUR 6,194,596
1133 SA0206A OTHER CRANIAL OSTEOPLASTY (PLASTIC REPAIR CRANIUM) - SA PROSEDUR 6,881,180
1134 SA0206B OTHER CRANIAL OSTEOPLASTY (REPAIR OF SKULL) - SA PROSEDUR 5,239,584
1135 SA0206C OTHER CRANIAL OSTEOPLASTY (RECONSTRUCTIVE CRANIOPLASTY) - SA PROSEDUR 3,934,156
1136 SA0212 OTHER REPAIR OF CEREBRAL MENINGES - SA PROSEDUR 3,337,651
1137 SA0212A OTHER REPAIR OF CEREBRAL MENINGES (REPAIR OF DURA) - SA PROSEDUR 6,703,557
1138 SA022A VENTRICULOSTOMY (CREATION OF VENTRICULOVASCULAR ANASTOMOSIS) - SA PROSEDUR 3,118,973
1139 SA022B VENTRICULOSTOMY (VENTRICULOCISTERNAL INTUBATION) - SA PROSEDUR 4,851,373
1140 SA0234 VENTRICULAR SHUNT TO ABDOMINAL CAVITY AND ORGANS - SA PROSEDUR 6,114,418
1141 SA0241 IRRIGATION AND EXPLORATION OF VENTRICULAR SHUNT - SA PROSEDUR 1,355,057
REPLACEMENT OF VENTRICULAR SHUNT (REVISION OF VENTRICULOPERITONEAL
1142 SA0242 PROSEDUR 2,744,527
SHUNT AT VENTRICULAR SITE) - SA
1143 SA0243 REMOVAL OF VENTRICULAR SHUNT - SA PROSEDUR 2,495,299
IMPLANTATION OR REPLACEMENT OF INTRACRANIAL NEUROSTIMULATOR LEAD(S) -
1144 SA0293 PROSEDUR 3,118,973
SA
1145 SA0309 OTHER EXPLORATION AND DECOMPRESSION OF SPINAL CANAL - SA PROSEDUR 5,754,462
1146 SA031 DIVISION OF INTRASPINAL NERVE ROOT - SA PROSEDUR 4,720,480
1147 SA0331 SPINAL TAP - SA PROSEDUR 702,765
OTHER DIAGNOSTIC PROCEDURES ON SPINAL CORD AND SPINAL CANAL
1148 SA0339 PROSEDUR 3,293,336
STRUCTURES - SA
1149 SA034 EXCISION OR DESTRUCTION OF LESION OF SPINAL CORD OR SPINAL MENINGES - SA PROSEDUR 6,902,674
1150 SA0352 REPAIR OF SPINAL MYELOMENINGOCELE - SA PROSEDUR 5,231,132
Page 13
TARIF INSURANCE
INSERTION OF CATHETER INTO SPINAL CANAL FOR INFUSION OF THERAPEUTIC OR

1151 SA0390 PROSEDUR 3,934,156
PALLIATIVE SUBSTANCES - SA
INJECTION OF ANESTHETIC INTO SPINAL CANAL FOR ANALGESIA
1152 SA0391A PROSEDUR 880,268
(CERVICAL/THORACIC) - SA
1153 SA0391B INJECTION OF ANESTHETIC INTO SPINAL CANAL FOR ANALGESIA (LUMBAL) - SA PROSEDUR 699,988
1154 SA0396 PERCUTANEOUS DENERVATION OF FACET - SA PROSEDUR 1,946,007
1155 SA0401 EXCISION OF ACOUSTIC NEUROMA - SA PROSEDUR 9,863,585
1156 SA0404 BILATERAL POSTERIOR NASAL NEURECTOMY - SA PROSEDUR 3,316,640
OTHER EXCISION OR AVULSION OF CRANIAL AND PERIPHERAL NERVE
1157 SA0407A PROSEDUR 7,235,340
(INTRACRANIAL TRANSECTION OF CRANIAL NERVE) - SA
OTHER EXCISION OR AVULSION OF CRANIAL AND PERIPHERAL NERVE (INCLUDE
1158 SA0407B PROSEDUR 8,517,705
EXCISION OF LESION ON CRANIAL NERVE) - SA
OTHER EXCISION OR AVULSION OF CRANIAL AND PERIPHERAL NERVES (MAJOR
1159 SA0407C PROSEDUR 1,946,007
NERVE) - SA
OTHER EXCISION OR AVULSION OF CRANIAL AND PERIPHERAL NERVES (EXCISION
1160 SA0407D PROSEDUR 1,577,116
OF LESION) - SA
OTHER EXCISION OR AVULSION OF CRANIAL AND PERIPHERAL NERVES
1161 SA0407E PROSEDUR 1,255,921
(TRANSECTION/EXCISION) - SA
CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF CRANIAL OR PERIPHERAL NERVE OR
1162 SA0411 PROSEDUR 1,255,921
GANGLION - SA
OTHER DIAGNOSTIC PROCEDURES ON CRANIAL AND PERIPHERAL NERVES AND
1163 SA0419A PROSEDUR 3,351,658
GANGLIA-EXPLORATION OF NERVE - SA
1164 SA042 DESTRUCTION OF CRANIAL AND PERIPHERAL NERVES - SA PROSEDUR 7,235,340
1165 SA042A DESTRUCTION OF CRANIAL AND PERIPHERAL NERVES (INJ) - SA PROSEDUR 1,407,100
1166 SA042B DESTRUCTION OF CRANIAL AND PERIPHERAL NERVES (RF) - SA PROSEDUR 2,598,782
1167 SA043 SUTURE OF CRANIAL AND PERIPHERAL NERVES - SA PROSEDUR 3,354,314
1168 SA0443A RELEASE OF CARPAL TUNNEL SYNDROME (ENDOSCOPIC) - SA PROSEDUR 1,360,370
1169 SA0443B RELEASE OF CARPAL TUNNEL SYNDROME (ENDOSCOPIC BILATERAL) - SA PROSEDUR 2,278,794
1170 SA0444 RELEASE OF TARSAL TUNNEL - SA PROSEDUR 2,278,794
OTHER PERIPHERAL NERVE OR GANGLION DECOMPRESSION OR LYSIS OF
1171 SA0449 PROSEDUR 1,255,921
ADHESIONS - SA
1172 SA0449A PROSEDUR 1,255,921
ADHESIONS-DEEP - SA
1173 SA045 CRANIAL OR PERIPHERAL NERVE GRAFT - SA PROSEDUR 1,577,116
1174 SA045A CRANIAL OR PERIPHERAL NERVE GRAFT (PRIMARY & 2ND) - SA PROSEDUR 3,765,951
1175 SA045B CRANIAL OR PERIPHERAL NERVE GRAFT-COMPLEX - SA PROSEDUR 5,666,918
1176 SA046A TRANSPOSITION OF CRANIAL AND PERIPHERAL NERVES (NEUROLYSIS) - SA PROSEDUR 1,577,116
1177 SA046B TRANSPOSITION OF CRANIAL AND PERIPHERAL NERVES (SUBMUSCULAR) - SA PROSEDUR 2,744,527
REVISION OF PREVIOUS REPAIR OF CRANIAL AND PERIPHERAL NERVES
1178 SA0475A PROSEDUR 3,378,585
(MICROSURGERY) - SA
REVISION OF PREVIOUS REPAIR OF CRANIAL AND PERIPHERAL NERVES (NON
1179 SA0475B PROSEDUR 1,688,206
MICROSURGERY) - SA
REVISION OF PREVIOUS REPAIR OF CRANIAL AND PERIPHERAL NERVES (RELEASE
1180 SA0475C PROSEDUR 2,468,734
PERIPHERAL NERVES) - SA
REVISION OF PREVIOUS REPAIR OF CRANIAL AND PERIPHERAL NERVES (2ND REPAIR
1181 SA0475D PROSEDUR 2,184,126
NERVE TRUNK) - SA
1182 SA0479A OTHER NEUROPLASTY REPAIR OF CRANIAL NERVE (INTRACRANIAL) - SA PROSEDUR 4,208,500
1183 SA0479B OTHER NEUROPLASTY PRIMARY REPAIR PERIPHERAL NERVE W MICROSURGERY - SA PROSEDUR 2,969,122
1184 SA0479C OTHER NEUROPLASTY PRIMARY REPAIR PERIPHERAL NERVE - SA PROSEDUR 1,360,370
1185 SA0479D OTHER NEUROPLASTY PRIMARY REPAIR NERVE TRUNK - SA PROSEDUR 1,577,116
1186 SA0481 INJECTION OF ANESTHETIC INTO PERIPHERAL NERVE FOR ANALGESIA - SA PROSEDUR 540,839
1187 SA0492 IMPLANTATION OR REPLACEMENT OF PERIPHERAL NEUROSTIMULATOR LEAD(S) - SA PROSEDUR 2,969,122
1188 SA0523 LUMBAR SYMPATHECTOMY - SA PROSEDUR 1,577,116
1189 SA0523A LUMBAR SYMPATHECTOMY (LAPAROSCOPIC) - SA PROSEDUR 2,973,227
1190 SA0524 PRESACRAL SYMPATHECTOMY - SA PROSEDUR 2,468,734
1191 SA052A THORASCOPIC SYMPATHECTOMY - SA PROSEDUR 3,910,368
1192 SA052B THORACIC SYMPATHECTOMY : DIAG.(LA UNDER X-RAY CTRL) - SA PROSEDUR 1,577,116
1193 SA052C THORACIC SYMPATHECTOMY : THERAPEUTIC (NEUROLYTIC UNDER X-RAY CTRL) - SA PROSEDUR 2,278,794
1194 SA0532 INJECTION OF NEUROLYTIC AGENT INTO SYMPATHETIC NERVE - SA PROSEDUR 2,108,295
1195 SA0609 OTHER INCISION OF THYROID FIELD - SA PROSEDUR 1,120,560
1196 SA0611A CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF THYROID GLAND (FNAB) - SA PROSEDUR 457,401
CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF THYROID GLAND (NEEDLE BIOPSY) -
1197 SA0611B PROSEDUR 839,937
SA
1198 SA062A UNILATERAL THYROID LOBECTOMY (HEMI-THYROIDECTOMY) - SA PROSEDUR 3,216,659
UNILATERAL THYROID LOBECTOMY (ISTHMULOBECTOMY WITH FROZEN SECTION
1199 SA062B PROSEDUR 7,712,906
EXCISION) - SA
1200 SA0631 EXCISION OF LESION OF THYROID - SA PROSEDUR 1,865,346
1201 SA0639 OTHER PARTIAL THYROIDECTOMY - SA PROSEDUR 3,216,659
1202 SA064A COMPLETE THYROIDECTOMY (TOTAL) - SA PROSEDUR 3,216,659
1203 SA064B COMPLETE THYROIDECTOMY (BILATERAL SUBTOTAL) - SA PROSEDUR 3,216,659
1204 SA064C COMPLETE THYROIDECTOMY + BERRYPICKING (LIFADENECTOMY) - SA PROSEDUR 10,190,093
1205 SA067A EXCISION OF THYROGLOSSAL DUCT OR TRACT (THYROGLOSSAL CYST) - SA PROSEDUR 1,455,521
1206 SA067B EXCISION OF THYROGLOSSAL DUCT OR TRACT (THYROGLOSSAL TRACT) - SA PROSEDUR 1,865,346
EXCISION OF THYROGLOSSAL DUCT OR TRACT (THYROGLOSSAL CYST ONCOLOGY) -
1207 SA067C PROSEDUR 7,712,906
SA
1208 SA0681 COMPLETE PARATHYROIDECTOMY - SA PROSEDUR 3,934,156
1209 SA0689 OTHER PARATHYROIDECTOMY - SA PROSEDUR 3,934,156
1210 SA0695 PARATHYROID TISSUE REIMPLANTATION - SA PROSEDUR 2,561,591
OTHER OPERATIONS ON THYROID (REGION) AND PARATHYROID - THYROID
1211 SA0698 PROSEDUR 3,609,459
ABERRANT - SA
1212 SA0698A OTHER OPERATIONS ON THYROID (REGION) AND PARATHYROID - ENDOSCOPIC - SA PROSEDUR 10,190,093
1213 SA0729 OTHER PARTIAL ADRENALECTOMY - SA PROSEDUR 2,598,782
1214 SA073 BILATERAL ADRENALECTOMY - SA PROSEDUR 2,793,068
1215 SA0753 PARTIAL EXCISION OF PINEAL GLAND - SA PROSEDUR 8,517,705
1216 SA0754 TOTAL EXCISION OF PINEAL GLAND - SA PROSEDUR 8,517,705
1217 SA0761 PARTIAL EXCISION OF PITUITARY GLAND, TRANSFRONTAL APPROACH - SA PROSEDUR 7,235,340
TOTAL EXCISION OF PITUITARY GLAND, UNSPECIFIED APPROACH -
1218 SA0769 PROSEDUR 7,235,340
HYPOPHYSECTOMY NOS - SA
1219 SA0780 THYMECTOMY, NOT OTHERWISE SPECIFIED - SA PROSEDUR 3,378,585
Page 14
TARIF INSURANCE
1220 SA0811 BIOPSY OF EYELID - SA PROSEDUR 669,438

1221 SA0822A EXCISION OF OTHER MINOR LESION OF EYEBROW - SA PROSEDUR 699,988
1222 SA0822B EXCISION OF OTHER MINOR LESION OF CANTHUS - SA PROSEDUR 1,455,521
1223 SA0825 DESTRUCTION OF LESION OF EYELID - SA PROSEDUR 585,638
1224 SA0836 REPAIR OF BLEPHAROPTOSIS BY OTHER TECHNIQUES - SA PROSEDUR 2,561,591
1225 SA0849 OTHER REPAIR OF ENTROPION OR ECTROPION - SA PROSEDUR 1,688,206
1226 SA0851 CANTHOTOMY - SA PROSEDUR 910,334
1227 SA0852A BLEPHARORRHAPHY (TARSORRHAPHY) - SA PROSEDUR 1,255,921
1228 SA0852B BLEPHARORRHAPHY (TARSOMULLERECTOMY) - SA PROSEDUR 2,561,591
1229 SA0859 CANTHOPLASTY / REPAIR OF EPICANTHAL / TELECANTHAL FOLD - SA PROSEDUR 1,407,100
1230 SA0861 RECONSTRUCTION OF EYELID WITH SKIN FLAP OR GRAFT - SA PROSEDUR 1,455,521
1231 SA0869A OTHER RECONSTRUCTION OF EYELID WITH FLAPS OR GRAFTS (TOTAL) - SA PROSEDUR 2,630,177
1232 SA0869B OTHER RECONSTRUCTION OF EYELID WITH FLAPS OR GRAFTS (BILATERAL) - SA PROSEDUR 4,208,500
LINEAR REPAIR OF LACERATION OF EYELID OR EYEBROW (SUTURE OF EYEBROW) -
1233 SA0881A PROSEDUR 457,401
SA
LINEAR REPAIR OF LACERATION OF EYELID OR EYEBROW (SUTURE OF EYELID
1234 SA0881B PROSEDUR 590,588
(LACERATION)) - SA
1235 SA0893 OTHER EPILATION OF EYELID - SA PROSEDUR 639,975
1236 SA090A INCISION OF LACRIMAL GLAND (EYELID LESSION) - SA PROSEDUR 540,839
1237 SA090B INCISION OF LACRIMAL GLAND (CONJUNCTIVAL CYST) - SA PROSEDUR 495,558
1238 SA0912 BIOPSY OF LACRIMAL SAC - SA PROSEDUR 540,839
1239 SA0943 PROBING OF NASOLACRIMAL DUCT (UNDER GA) - SA PROSEDUR 457,401
1240 SA0944 INTUBATION OF NASOLACRIMAL DUCT - SA PROSEDUR 3,216,659
1241 SA0949 OTHER MANIPULATION OF LACRIMAL PASSAGE - THAT WITH DILATION - SA PROSEDUR 457,401
1242 SA0953 INCISION OF LACRIMAL SAC - SA PROSEDUR 540,839
1243 SA096 EXCISION OF LACRIMAL SAC AND PASSAGE - SA PROSEDUR 1,455,521
1244 SA0973 REPAIR OF CANALICULUS - SA PROSEDUR 1,455,521
1245 SA0982 CONJUNCTIVOCYSTORHINOSTOMY - SA PROSEDUR 3,476,272
1246 SA0983 CONJUNCTIVORHINOSTOMY WITH INSERTION OF TUBE OR STENT - SA PROSEDUR 2,969,122
1247 SA100 REMOVAL OF EMBEDDED FOREIGN BODY FROM CONJUNCTIVA BY INCISION - SA PROSEDUR 540,839
1248 SA1021 BIOPSY OF CONJUNCTIVA - SA PROSEDUR 495,558
1249 SA1031 EXCISION OF LESION OR TISSUE OF CONJUNCTIVA - SA PROSEDUR 698,780
1250 SA1032 DESTRUCTION OF LESION OF CONJUNCTIVA - SA PROSEDUR 495,558
1251 SA1033 OTHER DESTRUCTIVE PROCEDURES ON CONJUNCTIVA - SA PROSEDUR 839,937
1252 SA1044 OTHER FREE GRAFT TO CONJUNCTIVA - SA PROSEDUR 1,407,100
1253 SA105 LYSIS OF ADHESIONS OF CONJUNCTIVA AND EYELID - SA PROSEDUR 495,558
1254 SA106A REPAIR OF LACERATION OF CONJUNCTIVA (SUTURE) - SA PROSEDUR 698,780
1255 SA106B REPAIR OF LACERATION OF CONJUNCTIVA (REMOVAL OF SUTURE) - SA PROSEDUR 495,558
1256 SA1091 SUBCONJUNCTIVAL INJECTION - SA PROSEDUR 495,558
1257 SA110 MAGNETIC REMOVAL OF EMBEDDED FOREIGN BODY FROM CORNEA - SA PROSEDUR 590,588
1258 SA111 INCISION OF CORNEA - SA PROSEDUR 590,588
1259 SA1121 SCRAPING OF CORNEA FOR SMEAR OR CULTURE - SA PROSEDUR 590,588
1260 SA1143 CRYOTHERAPY OF CORNEAL LESION - SA PROSEDUR 495,558
OTHER REMOVAL OR DESTRUCTION OF CORNEAL LESION - EXCISION OF CORNEA
1261 SA1149 PROSEDUR 698,780
NOS - SA
1262 SA1149A OTHER REMOVAL OR DESTRUCTION OF CORNEAL LESION-CHELATION - SA PROSEDUR 880,268
1263 SA1151 SUTURE OF CORNEAL LACERATION - SA PROSEDUR 1,621,914
1264 SA1152 REPAIR OF POSTOPERATIVE WOUND DEHISCENCE OF CORNEA - SA PROSEDUR 839,937
1265 SA1159 OTHER REPAIR OF CORNEA (REMOVAL OF CORNEAL SUTURE) - SA PROSEDUR 495,558
1266 SA1161 LAMELLAR KERATOPLASTY WITH AUTOGRAFT - SA PROSEDUR 2,896,913
1267 SA1163 PENETRATING KERATOPLASTY WITH AUTOGRAFT - SA PROSEDUR 2,896,913
1268 SA1191 TATTOOING OF CORNEA - SA PROSEDUR 880,268
REMOVAL OF INTRAOCULAR FOREIGN BODY FROM ANTERIOR SEGMENT OF EYE -
1269 SA1200A PROSEDUR 2,287,247
IRIS - SA
1270 SA1200B PROSEDUR 1,407,100
ANTERIOR CHAMBER - SA
1271 SA1212 OTHER IRIDOTOMY - IRIDOCYCLECTOMY - SA PROSEDUR 2,896,913
1272 SA1212A OTHER IRIDOTOMY (LASER IRIDOTOMY) - SA PROSEDUR 1,407,100
1273 SA1213 EXCISION OF PROLAPSED IRIS - SA PROSEDUR 2,744,527
1274 SA1214 OTHER IRIDECTOMY - SA PROSEDUR 1,407,100
1275 SA1242 EXCISION OF LESION OF IRIS - SA PROSEDUR 2,287,247
1276 SA1252 GONIOTOMY WITHOUT GONIOPUNCTURE - SA PROSEDUR 2,744,527
1277 SA1253 GONIOTOMY WITH GONIOPUNCTURE - SA PROSEDUR 2,744,527
1278 SA1254 TRABECULOTOMY AB EXTERNO - SA PROSEDUR 1,407,100
1279 SA1255 CYCLODIALYSIS - SA PROSEDUR 2,134,860
1280 SA1264A TRABECULECTOMY AB EXTERNO (SURGICAL TRABECULECTOMY) - SA PROSEDUR 2,474,288
1281 SA1264B TRABECULECTOMY AB EXTERNO (LASER TRABECULOPLASTY) - SA PROSEDUR 1,455,521
1282 SA1272 CYCLOCRYOTHERAPY - SA PROSEDUR 1,407,100
1283 SA1281 SUTURE OF LACERATION OF SCLERA - SA PROSEDUR 1,056,442
1284 SA1284 EXCISION OR DESTRUCTION OF LESION OF SCLERA - SA PROSEDUR 880,268
1285 SA1287 SCLERAL REINFORCEMENT WITH GRAFT - SA PROSEDUR 2,184,126
1286 SA1291 THERAPEUTIC EVACUATION OF ANTERIOR CHAMBER - SA PROSEDUR 1,455,521
1287 SA1292 INJECTION INTO ANTERIOR CHAMBER (IRRIGATION) - SA PROSEDUR 698,780
1288 SA1299 OTHER OPERATIONS ON ANTERIOR CHAMBER - SA PROSEDUR 2,184,126
1289 SA1370 INSERTION OF PSEUDOPHAKOS, NOT OTHERWISE SPECIFIED - SA PROSEDUR 2,134,860
INSERTION OF INTRAOCULAR LENS PROSTHESIS AT TIME OF CATARACT
1290 SA1371 PROSEDUR 2,134,860
EXTRACTION, ONE-STAGE - SA
1291 SA138 REMOVAL OF IMPLANTED LENS - SA PROSEDUR 1,621,914
REMOVAL OF FOREIGN BODY FROM POSTERIOR SEGMENT OF EYE WITHOUT USE OF
1292 SA1402 PROSEDUR 1,255,921
MAGNET - SA
OTHER DIAGNOSTIC PROCEDURES ON RETINA, CHOROID, VITREOUS, AND
1293 SA1419 PROSEDUR 2,598,782
POSTERIOR CHAMBER - SA
1294 SA1422 DESTRUCTION OF CHORIORETINAL LESION BY CRYOTHERAPY - SA PROSEDUR 1,455,521
DESTRUCTION OF CHORIORETINAL LESION BY PHOTOCOAGULATION OF
1295 SA1425 PROSEDUR 1,455,521
UNSPECIFIED TYPE - SA
1296 SA1426 DESTRUCTION OF CHORIORETINAL LESION BY RADIATION THERAPY - SA PROSEDUR 1,455,521
OTHER DESTRUCTION OF CHORIORETINAL LESION - DESTRUCTION OF LESION OF
1297 SA1429 PROSEDUR 2,598,782
RETINA AND CHOROID NOS - SA
1298 SA1441 SCLERAL BUCKLING WITH IMPLANT - SA PROSEDUR 2,910,920
1299 SA1471 REMOVAL OF VITREOUS, ANTERIOR APPROACH - SA PROSEDUR 2,134,860
REMOVAL OF VITREOUS, ANTERIOR APPROACH (VITRECTOMY PARS PLANA
1300 SA1471A PROSEDUR 3,111,728
APPROACH W INSERTION OF INT.TAMPONADE) - SA
1301 SA1479 OTHER OPERATIONS ON VITREOUS - SA PROSEDUR 4,359,558
Page 15
TARIF INSURANCE
1302 SA1521 LENGTHENING PROCEDURE ON ONE EXTRAOCULAR MUSCLE - SA PROSEDUR 1,621,914

OTHER OPERATIONS ON TWO OR MORE EXTRAOCULAR MUSCLES, ONE OR BOTH
1303 SA154A PROSEDUR 2,630,177
EYES (SQUINT) - SA
1304 SA154B PROSEDUR 3,609,459
EYES (SQUINT W ADJUSTABLE SUTURES) - SA
1305 SA155 TRANSPOSITION OF EXTRAOCULAR MUSCLES - SA PROSEDUR 2,561,591
1306 SA156A REVISION OF EXTRAOCULAR MUSCLE SURGERY (REVISION OF SQUINT) - SA PROSEDUR 3,351,658
REVISION OF EXTRAOCULAR MUSCLE SURGERY (REVISION OF SQUINT W
1307 SA156B PROSEDUR 4,208,500
ADJUSTABLE SUTURES) - SA
1308 SA1609 OTHER ORBITOTOMY - SA PROSEDUR 1,621,914
1309 SA1609A OTHER ORBITOTOMY (EXPLORATION/REMOVAL OF FOREIGN BODY) - SA PROSEDUR 2,287,247
1310 SA1623 BIOPSY OF EYEBALL AND ORBIT - SA PROSEDUR 1,407,100
1311 SA1649 OTHER ENUCLEATION OF EYEBALL - SA PROSEDUR 2,845,353
1312 SA1652 EXENTERATION OF ORBIT WITH THERAPEUTIC REMOVAL OF ORBITAL BONE - SA PROSEDUR 2,793,068
1313 SA1659 OTHER EXENTERATION OF ORBIT / EVISCERATION OF ORBIT NOS - SA PROSEDUR 2,845,353
1314 SA1666 OTHER REVISION OF EXENTERATION CAVITY - SA PROSEDUR 2,793,068
1315 SA1691 RETROBULBAR INJECTION OF THERAPEUTIC AGENT - SA PROSEDUR 495,558
1316 SA1692 EXCISION OF LESION OF ORBIT - SA PROSEDUR 2,287,247
LAPAROSCOPIC REPAIR OF INGUINAL HERNIA WITH GRAFT OR PROSTHESIS, NOT
1317 SA1713 PROSEDUR 2,453,640
OTHERWISE SPECIFIED - SA
1318 SA1736 LAPAROSCOPIC SIGMOIDECTOMY - SA PROSEDUR 3,091,200
1319 SA1739 OTHER LAPAROSCOPIC PARTIAL EXCISION OF LARGE INTESTINE - SA PROSEDUR 4,657,328
1320 SA1762A LASER ASSISTED UVULOPALATOPLASTY - SA PROSEDUR 4,663,969
1321 SA1762C LASER ASSISTED HEMICORDECTOMY - SA PROSEDUR 6,218,625
1322 SA1762D LASER ASSISTED ARYTENOIDECTOMY - SA PROSEDUR 4,663,969
1323 SA1762E LASER ASSISTED VOCAL CORD SURGERY - SA PROSEDUR 4,663,969
1324 SA182 EXCISION OR DESTRUCTION OF LESION OF EXTERNAL EAR - SA PROSEDUR 831,847
1325 SA1821 EXCISION OF PREAURICULAR SINUS - SA PROSEDUR 1,514,205
1326 SA1829A EXCISION OR DESTRUCTION OF OTHER LESION OF EXTERNAL EAR (GRANULASI) - SA PROSEDUR 880,268
EXCISION OR DESTRUCTION OF OTHER LESION OF EXTERNAL EAR (REMOVAL OF
1327 SA1829B PROSEDUR 2,134,860
EXOSTOSES FROM EAC) - SA
1328 SA1839 AMPUTATION OF EXTERNAL EAR - SA PROSEDUR 1,899,035
1329 SA184 SUTURE OF LACERATION OF EXTERNAL EAR - SA PROSEDUR 590,588
1330 SA185 SURGICAL CORRECTION OF PROMINENT EAR - SA PROSEDUR 590,588
1331 SA186 RECONSTRUCTION OF EXTERNAL AUDITORY CANAL - SA PROSEDUR 3,278,121
1332 SA186A RECONSTRUCTION OF EXTERNAL AUDITORY CANAL (GRAFT) - SA PROSEDUR 4,208,500
1333 SA186B RECONSTRUCTION OF EXTERNAL AUDITORY CANAL (EAR) SA PROSEDUR 2,599,385
1334 SA186C RECONSTRUCTION OF EXTERNAL AUDITORY CANAL - MEATOPLASTY SA PROSEDUR 1,899,398
1335 SA1919 OTHER STAPEDECTOMY - SA PROSEDUR 2,969,122
OTHER OPERATIONS ON OSSICULAR CHAIN - OSSICULOPLASTY WITH/WITHOUT
1336 SA193 PROSEDUR 3,278,604
TYMPANOPLASTY - SA
1337 SA194 MYRINGOPLASTY (TYMPANOPLASTY) SA PROSEDUR 3,326,421
1338 SA194A MYRINGOPLASTY SA PROSEDUR 2,474,651
1339 SA200 MYRINGOTOMY - SA PROSEDUR 450,760
1340 SA2001 MYRINGOTOMY WITH INSERTION OF TUBE - SA PROSEDUR 1,255,921
1341 SA2031 ELECTROCOCHLEOGRAPHY - TRANS TYMPANIC - SA PROSEDUR 1,601,266
1342 SA2032 BIOPSY OF MIDDLE AND INNER EAR - SA PROSEDUR 2,134,860
1343 SA2041 SIMPLE MASTOIDECTOMY - SA PROSEDUR 3,351,658
1344 SA2042 RADICAL MASTOIDECTOMY - SA PROSEDUR 4,324,541
1345 SA2049A OTHER MASTOIDECTOMY - PETROSECTOMY - SA PROSEDUR 4,359,558
1346 SA2049B OTHER MASTOIDECTOMY - MODIFIED RADICAL MASTOIDECTOMY - SA PROSEDUR 3,991,874
1347 SA2049C OTHER MASTOIDECTOMY - PETROSECTOMY (COMPLEX) - SA PROSEDUR 5,231,132
1348 SA2051A EXCISION OF LESION OF MIDDLE EAR - POLYPECTOMY - SA PROSEDUR 910,334
1349 SA2051B EXCISION OF LESION OF MIDDLE EAR -TUMOUR - SA PROSEDUR 2,969,122
1350 SA2079 INCISION OF ENDOLYMPHATIC SAC - OPERATION(S) ENDOLYMPHATIC SAC - SA PROSEDUR 2,599,385
1351 SA2079A LABYRINTHECTOMY (TRANSTYMPANIC) - MEMBRANOUS - SA PROSEDUR 2,897,517
1352 SA2079B LABYRINTHECTOMY (TRANSTYMPANIC) - OSSEUS - SA PROSEDUR 3,008,245
1353 SA2092 REVISION OF MASTOIDECTOMY - SA PROSEDUR 2,474,651
IMPLANTATION OR REPLACEMENT OF COCHLEAR PROSTHETIC DEVICE, SINGLE
1354 SA2097 PROSEDUR 5,828,844
CHANNEL - SA
IMPLANTATION OR REPLACEMENT OF COCHLEAR PROSTHETIC DEVICE, MULTIPLE
1355 SA2098 PROSEDUR 8,294,801
CHANNEL - SA
1356 SA2101 CONTROL OF EPISTAXIS BY ANTERIOR NASAL PACKING - SA PROSEDUR 457,401
1357 SA2102 CONTROL OF EPISTAXIS BY POSTERIOR (AND ANTERIOR) PACKING - SA PROSEDUR 762,295
1358 SA2103 CONTROL OF EPISTAXIS BY CAUTERIZATION (AND PACKING) - SA PROSEDUR 457,401
1359 SA2104 CONTROL OF EPISTAXIS BY LIGATION OF ETHMOIDAL ARTERIES - SA PROSEDUR 1,621,914
1360 SA211 INCISION OF NOSE - SA PROSEDUR 590,588
1361 SA211A INCISION OF NOSE (LATERAL RHINOTOMY INTO SINUS FOR MALIGNANCY) - SA PROSEDUR 2,774,956
1362 SA2122 BIOPSY OF NOSE - SA PROSEDUR 540,839
1363 SA2123 BIOPSY OF LESION OF TURBINATE OF NOSE - SA PROSEDUR 540,839
1364 SA2129 OTHER DIAGNOSTIC PROCEDURE ON NOSE - VOCAL CORD (SLEEP ENDOSCOPY) PROSEDUR 672,578
1365 SA213 LOCAL EXCISION OR DESTRUCTION OF LESION OF NOSE - SA PROSEDUR 492,419
1366 SA2130 EXCISION OR DESTRUCTION OF LESION OF NOSE, NOT OTHERWISE SPECIFIED - SA PROSEDUR 699,988
1367 SA2131A LOCAL EXCISION OR DESTRUCTION OF INTRANASAL LESION - POLYPECTOMY - SA PROSEDUR 831,847
1368 SA2132 LOCAL EXCISION OR DESTRUCTION OF OTHER LESION OF NOSE - SA PROSEDUR 457,401
1369 SA2132B LOCAL EXCISION OR DESTRUCTION OF OTHER LESION OF NOSE (INTERNAL) - SA PROSEDUR 590,588
1370 SA214 RESECTION OF NOSE - AMPUTATION OF NOSE - SA PROSEDUR 1,899,035
1371 SA215 SUBMUCOUS RESECTION OF NASAL SEPTUM - SA PROSEDUR 1,760,414
1372 SA216 TURBINECTOMY - SA PROSEDUR 880,268
1373 SA2161A TURBINECTOMY BY DIATHERMY OR CRYOSURGERY (DIATHERMY) - SA PROSEDUR 590,588
1374 SA2161B TURBINECTOMY BY DIATHERMY OR CRYOSURGERY (CAUTERISATION) - SA PROSEDUR 540,839
1375 SA2169 OTHER TURBINECTOMY - SA PROSEDUR 1,899,035
1376 SA2169A QUILTING SUTURE OF NASAL SEPTUM - SA PROSEDUR 2,072,915
1377 SA2169B BILATERAL TURBINOPLASTY - SA PROSEDUR 3,316,640
1378 SA2169C REMOVAL OF BILATERAL TURBINATE BONE - SA PROSEDUR 2,072,915
1379 SA2172A OPEN REDUCTION OF NASAL FRACTURE - OPEN FRACTURE - SA PROSEDUR 3,766,313
1380 SA2172B OPEN REDUCTION OF NASAL FRACTURE - CLOSED FRACTURE - SA PROSEDUR 3,421,210
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1381 SA2184 REVISION RHINOPLASTY - RHINOSEPTOPLASTY - SA PROSEDUR 3,118,973

1382 SA2184A REVISION OF RHINOSEPTOPLASTY - SEPTOPLASTY OF NOSE - SA PROSEDUR 1,760,777
1383 SA2187 OTHER RHINOPLASTY, NOS - SA PROSEDUR 2,474,288
1384 SA2188 OTHER SEPTOPLASTY - SA PROSEDUR 1,621,914
1385 SA219 OTHER OPERATION ON NOSE - INTRANASAL ANTROSTOMY INCL.ENDOSCOPIC - SA PROSEDUR 1,047,023
1386 SA2191 LYSIS OF ADHESIONS OF NOSE - SA PROSEDUR 540,839
1387 SA2201 PUNCTURE OF NASAL SINUS FOR ASPIRATION OR LAVAGE - SA PROSEDUR 669,438
1388 SA2219A OTHER DIAGNOSTIC PROCEDURES ON NASAL SINUSES - MINI FESS - SA PROSEDUR 2,690,189
1389 SA2219B OTHER DIAGNOSTIC PROCEDURES ON NASAL SINUSES - ADVANCED FESS - SA PROSEDUR 6,263,786
1390 SA2219C OTHER DIAGNOSTIC PROCEDURES ON NASAL SINUSES - SA PROSEDUR 381,691
1391 SA222 INTRANASAL ANTROTOMY - SA PROSEDUR 2,134,860
1392 SA2239 OTHER EXTERNAL MAXILLARY ANTROTOMY - SA PROSEDUR 5,051,818
1393 SA2241 FRONTAL SINUSOTOMY - SA PROSEDUR 839,937
1394 SA2261 EXCISION OF LESION OF MAXILLARY SINUS WITH CALDWELL-LUC APPROACH - SA PROSEDUR 1,513,722
1395 SA2263 EXT FRONTOETHMOIDECTOMY - SA PROSEDUR 2,599,385
1396 SA2263A INTRANASAL ETHMOIDECTOMY - SA PROSEDUR 1,407,100
1397 SA2263B EXT ETHMOIDECTOMY INCLUDING ENDOSCOPIC - SA PROSEDUR 2,037,898
1398 SA2263C TRANSANTRAL ETHMOIDECTOMY - SA PROSEDUR 1,899,398
1399 SA2263D RADICAL FRONTOETHMOIDECTOMY - SA PROSEDUR 3,174,518
1400 SA2271 CLOSURE OF NASAL SINUS FISTULA - SA PROSEDUR 1,946,007
1401 SA2279 OTHER REPAIR OF NASAL SINUS - REPAIR OF BONE OF ACCESSORY SINUS - SA PROSEDUR 3,459,246
OTHER OPERATION ON NASAL SINUSES - ANTERIOR AND POSTERIOR OPENING INTO
1402 SA229 PROSEDUR 2,412,344
FESS - SA
1403 SA229A OTHER OPERATION ON NASAL SINUSES - SPHENOID SINUS - SA PROSEDUR 1,047,023
1404 SA229B OTHER OPERATION ON NASAL SINUSES - UNSPECIFIED - SA PROSEDUR 1,047,023
1405 SA2319 OTHER SURGICAL EXTRACTION OF TOOTH - SA PROSEDUR 1,756,792
1406 SA235 IMPLANTATION OF TOOTH - SA PROSEDUR 2,411,861
1407 SA2373 APICOECTOMY - SA PROSEDUR 1,389,108
1408 SA244A EXCISION OF DENTAL LESION OF JAW - SA PROSEDUR 1,688,206
1409 SA244B EXCISION OF DENTAL LESION OF JAW - CYST - SA PROSEDUR 1,255,921
1410 SA245 ALVEOLOPLASTY - SA PROSEDUR 1,865,346
1411 SA245A ALVEOLECTOMY - SA PROSEDUR 1,859,067
1412 SA246 EXPOSURE OF TOOTH - SA PROSEDUR 1,946,007
1413 SA2501 OPEN/CLOSED [NEEDLE] BIOPSY OF TONGUE - SA PROSEDUR 495,558
1414 SA251 EXCISION OR DESTRUCTION OF LESION OR TISSUE OF TONGUE - SA PROSEDUR 1,255,921
1415 SA251A INSICION/EXCISION OF PAPILLOMA/FIBROMA - SA PROSEDUR 2,481,292
1416 SA252 PARTIAL GLOSSECTOMY - SA PROSEDUR 3,118,973
1417 SA252A PARTIAL GLOSSECTOMY (HEMIGLOSECTOMY) - SA PROSEDUR 5,051,818
1418 SA253 COMPLETE GLOSSECTOMY - SA PROSEDUR 3,609,459
1419 SA253A COMPLETE GLOSSECTOMY (COMPLEX) - SA PROSEDUR 7,712,906
OTHER REPAIR AND PLASTIC OPERATIONS ON TONGUE (GLOSSOPLASTY/TONGUE
1420 SA2559A PROSEDUR 2,561,591
FLAP 1ST STAGE) - SA
1421 SA2559B PROSEDUR 1,455,521
FLAP 2ND STAGE) - SA
OTHER REPAIR AND PLASTIC OPERATIONS ON TONGUE (FUSION OF TONGUE TO LIP)
1422 SA2559C PROSEDUR 3,118,973
- SA
1423 SA2591 LINGUAL FRENOTOMY - SA PROSEDUR 698,780
1424 SA2592 LINGUAL FRENECTOMY - SA PROSEDUR 698,780
1425 SA2593 LYSIS OF ADHESIONS OF TONGUE - SA PROSEDUR 495,558
1426 SA260 INCISION OF SALIVARY GLAND OR DUCT - SA PROSEDUR 590,588
1427 SA2611 CLOSED [NEEDLE] BIOPSY OF SALIVARY GLAND OR DUCT - SA PROSEDUR 839,937
1428 SA2621 MARSUPIALIZATION OF SALIVARY GLAND CYST - SA PROSEDUR 2,578,375
OTHER EXCISION OF SALIVARY GLAND LESION - SIALOLITHIASIS PAROTID (OPEN) -
1429 SA2629A PROSEDUR 1,255,921
SA
OTHER EXCISION OF SALIVARY GLAND LESION - SIALOLITHIASIS SUBMANDIBULAR -
1430 SA2629B PROSEDUR 1,056,442
SA
OTHER EXCISION OF SALIVARY GLAND LESION - SIALOLITHIASIS PAROTID
1431 SA2629C PROSEDUR 1,056,442
(MANIPULATIVE) - SA
1432 SA2629D EXCISION OF LESION OF SALIVARY GLAND - PAROTID/SUBMANDIBULAR - SA PROSEDUR 1,688,206
1433 SA2629E EXCISION OF LESION OF SALIVARY GLAND - SUBLINGUAL - SA PROSEDUR 590,588
OTHER EXCISION OF SALIVARY GLAND LESION-STONE EXTRACTION WITH IMAGING -
1434 SA2629F PROSEDUR 1,144,348
SA
1435 SA2630 SIALOADENECTOMY, NOT OTHERWISE SPECIFIED - SA PROSEDUR 5,051,818
1436 SA2630A SIALOADENECTOMY, NOT OTHERWISE SPECIFIED - PAROTID - SA PROSEDUR 2,744,527
1437 SA2631 PARTIAL SIALOADENECTOMY - SA PROSEDUR 4,208,500
1438 SA2631B SIALOADENECTOMY, NOT OTHERWISE SPECIFIED - SUBMANDIBULAR - SA PROSEDUR 1,865,346
1439 SA2631C SIALOADENECTOMY, NOT OTHERWISE SPECIFIED - SUBLINGUAL - SA PROSEDUR 1,455,521
1440 SA2632 COMPLETE SIALOADENECTOMY - SA PROSEDUR 5,231,132
1441 SA2632A COMPLETE SIALOADENECTOMY (PAROTIDECTOMY) - SA PROSEDUR 8,895,653
1442 SA2642 CLOSURE OF SALIVARY FISTULA - SA PROSEDUR 1,255,921
OTHER REPAIR AND PLASTIC OPERATIONS ON SALIVARY GLAND OR DUCT -
1443 SA2649 PROSEDUR 1,688,206
TRANSPOSITION OF PAROTID/SUBMANDIBULAR DUCT - SA
1444 SA2699 OTHER OPERATIONS ON SALIVARY GLAND OR DUCT - SA PROSEDUR 590,588
1445 SA2699LP OTHER OPERATIONS ON SALIVARY GLAND OR DUCT-LIGATION OF PAROTID - SA PROSEDUR 698,780
OTHER OPERATIONS ON SALIVARY GLAND OR DUCT-LIGATION OF SUBMANDIBULAR -
1446 SA2699LS PROSEDUR 698,780
SA
1447 SA2699M OTHER OPERATIONS ON SALIVARY GLAND OR DUCT-SUBMANDIBULAR - SA PROSEDUR 698,780
1448 SA270 INCISION ABSCESS AND DRAINAGE (ORAL SURGERY) - SA PROSEDUR 1,859,067
1449 SA271 INCISION OF PALATE - SA PROSEDUR 756,982
1450 SA2721 BIOPSY OF BONY PALATE - SA PROSEDUR 698,780
1451 SA2722 BIOPSY OF UVULA AND SOFT PALATE - SA PROSEDUR 698,780
1452 SA2723 BIOPSY OF LIP - SA PROSEDUR 756,982
1453 SA2724 BIOPSY OF MOUTH, UNSPECIFIED STRUCTURE - SA PROSEDUR 585,638
LOCAL EXCISION OR DESTRUCTION OF LESION OR TISSUE OF BONY PALATE
1454 SA2731 PROSEDUR 910,334
(MOUTH) - SA
1455 SA2731A PROSEDUR 1,255,921
(PALATE) - SA
1456 SA2731B PROSEDUR 7,712,906
(UNROOFING MAXILLA) - SA
1457 SA2742 WIDE EXCISION OF LESION OF LIP - SA PROSEDUR 1,255,921
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1458 SA2743 OTHER EXCISION OF LESION OR TISSUE OF LIP - SA PROSEDUR 1,455,521

1459 SA2749 OTHER EXCISION OF MOUTH (EXCEPT TOUNGUE, UVULA, AND PALATE) - SA PROSEDUR 839,937
1460 SA2749A OTHER EXCISION OF MOUTH (REMOVAL OF EXCESS MUCOSA) - SA PROSEDUR 1,255,921
1461 SA2749B FRENULECTOMY - SA PROSEDUR 1,859,067
1462 SA2751 SUTURE OF LACERATION OF LIP - SA PROSEDUR 756,982
1463 SA2752 SUTURE OF LACERATION OF OTHER PART OF MOUTH - SA PROSEDUR 910,334
1464 SA2754A REPAIR OF CLEFT LIP - PRIMARY - SA PROSEDUR 2,561,591
1465 SA2754B REPAIR OF CLEFT LIP - REVISION - SA PROSEDUR 3,118,973
1466 SA2755 FULL-THICKNESS SKIN GRAFT TO LIP AND MOUTH - SA PROSEDUR 1,455,521
1467 SA2755A FULL-THICKNESS SKIN GRAFT TO LIP AND MOUTH - MOUTH - SA PROSEDUR 1,455,521
1468 SA2757A ATTACHMENT OF PEDICLE OR FLAP GRAFT TO LIP AND MOUTH (MOUTH) - SA PROSEDUR 2,598,782
1469 SA2757B ATTACHMENT OF PEDICLE OR FLAP GRAFT TO LIP AND MOUTH (LIP) - SA PROSEDUR 2,969,122
1470 SA2759 OTHER PLASTIC REPAIR OF MOUTH - SA PROSEDUR 1,688,206
1471 SA2759A OTHER PLASTIC REPAIR OF MOUTH - GRAFT MUCOSA TO MOUTH - SA PROSEDUR 1,255,921
1472 SA2761 SUTURE OF LACERATION OF PALATE - SA PROSEDUR 910,334
1473 SA2762 CORRECTION OF CLEFT PALATE - SA PROSEDUR 3,351,658
1474 SA2763 REVISION OF CLEFT PALATE REPAIR - SA PROSEDUR 2,278,794
1475 SA2769A OTHER PLASTIC REPAIR OF PALATE - FLAP OF PALATE - SA PROSEDUR 1,946,007
1476 SA2769B OTHER PLASTIC REPAIR OF PALATE - FLAP OF SKIN - SA PROSEDUR 2,744,527
1477 SA2779 OTHER OPERATIONS ON UVULA - SA PROSEDUR 1,056,442
1478 SA2779A UVULOPALATOPLASTY - SA PROSEDUR 1,793,621
1479 SA2792 INCISION/EXCISION OF PHLEGMON - SA PROSEDUR 2,481,292
1480 SA2799 EXOSTOSIS (ORAL SURGERY) - SA PROSEDUR 2,481,292
1481 SA280 INCISION AND DRAINAGE OF TONSIL AND PERITONSILLAR STRUCTURES - SA PROSEDUR 457,401
1482 SA282 TONSILLECTOMY WITHOUT ADENOIDECTOMY - SA PROSEDUR 1,455,521
1483 SA282A TONSILLECTOMY WITHOUT ADENOIDECTOMY - LINGUAL TONSIL - SA PROSEDUR 1,255,921
1484 SA282B TONSILLECTOMY WITHOUT ADENOIDECTOMY - WITH COMPLICATION - SA PROSEDUR 4,448,068
1485 SA282C TONSILLECTOMY WITHOUT ADENOIDECTOMY - COBLATION - SA PROSEDUR 4,102,602
1486 SA282D TONSILLECTOMY WITHOUT ADENOIDECTOMY - THERMAL WELDING - SA PROSEDUR 3,766,313
1487 SA283 TONSILLECTOMY WITH ADENOIDECTOMY - SA PROSEDUR 1,594,504
1488 SA285 EXCISION (REDUCTION) OF LINGUAL TONSIL - SA PROSEDUR 1,345,155
1489 SA286 ADENOIDECTOMY WITHOUT TONSILLECTOMY - SA PROSEDUR 756,982
1490 SA2911 PHARYNGOSCOPY - THERAPEUTIC ENDOSCOPIC OPERATION ON PHARYNX - SA PROSEDUR 700,471
1491 SA2912 PHARYNGEAL BIOPSY - DIAG.ENDOSCOPIC EXAM OF PHARYNX - SA PROSEDUR 700,471
1492 SA292 EXCISION OF BRANCHIAL CLEFT CYST OR VESTIGE - SA PROSEDUR 1,622,276
1493 SA2932 PHARYNGEAL DIVERTICULECTOMY - SA PROSEDUR 2,287,247
1494 SA2933 PHARYNGECTOMY (PARTIAL) - SA PROSEDUR 3,351,658
OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF PHARYNX - TOTAL
1495 SA2939A PROSEDUR 7,235,340
PHARYNGECTOMY - SA
OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF PHARYNX -
1496 SA2939B PROSEDUR 2,287,247
PHARYNGEAL POUCH - SA
OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF PHARYNX - OPEN
1497 SA2939C PROSEDUR 880,268
EXCISION - SA
1498 SA295 OTHER REPAIR OF PHARYNX - SA PROSEDUR 2,599,385
1499 SA2952 CLOSURE OF BRANCHIAL CLEFT FISTULA - SA PROSEDUR 2,474,651
1500 SA3009 OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF LARYNX - SA PROSEDUR 1,829,000
1501 SA301 HEMILARYNGECTOMY - SA PROSEDUR 3,118,973
1502 SA3022 VOCAL CORDECTOMY - SA PROSEDUR 2,774,956
1503 SA303 COMPLETE LARYNGECTOMY - SA PROSEDUR 3,734,073
1504 SA304 RADICAL LARYNGECTOMY - SA PROSEDUR 4,359,558
1505 SA304A RADICAL LARYNGECTOMY (THYROIDECTOMY+RND) - SA PROSEDUR 10,190,093
1506 SA310 INJECTION OF LARYNX - SA PROSEDUR 1,519,639
1507 SA310A MEDIALIZATION OF VOCAL CORD WITH INJECTION FAT/OTHER MATERIAL - SA PROSEDUR 4,145,831
1508 SA311 TEMPORARY TRACHEOSTOMY (MINI TRACHEOSTOMY) - SA PROSEDUR 839,937
1509 SA311A TEMPORARY TRACHEOSTOMY-CITO - SA PROSEDUR 5,051,818
1510 SA311B TEMPORARY TRACHEOSTOMY (ELECTIVE TRACHEOSTOMY) - SA PROSEDUR 1,971,968
1511 SA3129 OTHER PERMANENT TRACHEOSTOMY - SA PROSEDUR 1,513,722
1512 SA3143 CLOSED [ENDOSCOPIC] BIOPSY OF LARYNX - SA PROSEDUR 910,334
1513 SA3144 CLOSED [ENDOSCOPIC] BIOPSY OF TRACHEA - SA PROSEDUR 1,056,442
1514 SA3169 OTHER REPAIR OF LARYNX - SA PROSEDUR 4,359,558
1515 SA3169B OPEN MEDIALIZATION OF VOCAL CORD - SA PROSEDUR 6,218,625
1516 SA3169C OPEN MEDIALIZATION/LATERIZATION OF VOCAL CORD - SA PROSEDUR 6,218,625
RECONSTRUCTION OF TRACHEA AND CONSTRUCTION OF ARTIFICIAL LARYNX-
1517 SA3175A PROSEDUR 4,359,558
EXCISION+RECONSTRUCTION - SA
1518 SA3175B PROSEDUR 2,774,956
TRACHEOPLASTY - SA
1519 SA3175C PROSEDUR 5,231,132
EXCISION+RECONSTRUCTION (COMPLEX) - SA
1520 SA3179 OTHER REPAIR AND PLASTIC OPERATIONS ON TRACHEA - SA PROSEDUR 2,561,591
1521 SA3193 REPLACEMENT OF LARYNGEAL OR TRACHEAL STENT - SA PROSEDUR 1,255,921
1522 SA321 OTHER EXCISION OF BRONCHUS - SA PROSEDUR 7,712,906
1523 SA3228 ENDOSCOPIC EXCISION OR DESTRUCTION OF LESION OR TISSUE OF LUNG - SA PROSEDUR 1,455,521
1524 SA3229 OTHER LOCAL EXCISION OR DESTRUCTION OF LESION OR TISSUE OF LUNG - SA PROSEDUR 4,208,500
1525 SA3239 OTHER AND UNSPECIFIED SEGMENTAL RESECTION OF LUNG - SA PROSEDUR 7,959,116
1526 SA324 LOBECTOMY OF LUNG - SA PROSEDUR 5,231,132
1527 SA3241 THORACOSCOPIC LOBECTOMY OF LUNG - SA PROSEDUR 2,744,527
1528 SA3250 THORACOSCOPIC PNEUMONECTOMY - SA PROSEDUR 2,744,527
1529 SA3259 OTHER AND UNSPECIFIED PNEUMONECTOMY - SA PROSEDUR 5,231,132
1530 SA3320 THORACOSCOPIC LUNG BIOPSY - SA PROSEDUR 839,937
1531 SA3323 OTHER BRONCHOSCOPY SA PROSEDUR 384,830
1532 SA3324 CLOSED [ENDOSCOPIC] BIOPSY OF BRONCHUS - SA PROSEDUR 1,455,521
1533 SA3324BL CLOSED [ENDOSCOPIC] BIOPSY OF BRONCHUS (BRONCHIAL LAVAGE) - SA PROSEDUR 1,255,921
1534 SA3326 CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF LUNG - SA PROSEDUR 698,780
1535 SA3326A CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF LUNG (CORE BIOPSY) - SA PROSEDUR 1,120,560
1536 SA3327 CLOSED ENDOSCOPIC BIOPSY OF LUNG - SA PROSEDUR 1,455,521
1537 SA3334 THORACOPLASTY - SA PROSEDUR 3,934,156
1538 SA3391 BRONCHIAL DILATION - SA PROSEDUR 1,455,521
1539 SA3402 EXPLORATORY THORACOTOMY - SA PROSEDUR 2,661,692
1540 SA3402A EXPLORATORY THORACOTOMY (MEDIAN STERNOTOMY) - SA PROSEDUR 1,688,206
1541 SA3404 INSERTION OF INTERCOSTAL CATHETER FOR DRAINAGE - SA PROSEDUR 839,937
INSERTION OF INTERCOSTAL CATHETER FOR DRAINAGE (INSERTION TUBE DRAIN
1542 SA3404A PROSEDUR 1,164,513
PLEURAL CAVITY) - SA
Page 18
TARIF INSURANCE
1543 SA3404C INSERTION OF INTERCOSTAL CATHETER FOR DRAINAGE - COMPLEX - SA PROSEDUR 1,971,968
1544 SA3409 OTHER INCISION OF PLEURA - OPEN CHEST DRAINAGE - SA PROSEDUR 2,278,794
1545 SA3422 MEDIASTINOSCOPY - SA PROSEDUR 1,946,007
1546 SA3423 BIOPSY OF CHEST WALL - SA PROSEDUR 839,937
1547 SA3424 OTHER PLEURAL BIOPSY - SA PROSEDUR 3,934,156
1548 SA343 EXCISION OR DESTRUCTION OF LESION OR TISSUE OF MEDIASTINUM - SA PROSEDUR 1,946,007
1549 SA344 EXCISION OR DESTRUCTION OF LESION OF CHEST WALL - SA PROSEDUR 3,476,272
1550 SA3451 DECORTICATION OF LUNG - SA PROSEDUR 4,208,500
1551 SA3459 OTHER EXCISION OF PLEURA - SA PROSEDUR 3,609,459
1552 SA3474 REPAIR OF PECTUS DEFORMITY - SA PROSEDUR 4,208,500
1553 SA3484 OTHER REPAIR OF DIAPHRAGM - SA PROSEDUR 4,208,500
1554 SA3492 INJECTION INTO THORACIC CAVITY - INTRODUCTION - SA PROSEDUR 630,919
1555 SA3492A INJECTION INTO THORACIC CAVITY - PLEURODESIS - SA PROSEDUR 1,120,560
1556 SA3501 CLOSED HEART VALVOTOMY, AORTIC VALVE - SA PROSEDUR 6,327,421
1557 SA3502 CLOSED HEART VALVOTOMY, MITRAL VALVE - SA PROSEDUR 6,327,421
1558 SA3510 OPEN HEART VALVULOPLASTY WITHOUT REPLACEMENT, UNSPECIFIED VALVE - SA PROSEDUR 9,369,596
1559 SA3520 OPEN AND OTHER REPLACEMENT OF UNSPECIFIED HEART VALVE - SA PROSEDUR 9,369,596
1560 SA3521 OPEN AND OTHER REPLACEMENT OF AORTIC VALVE WITH TISSUE GRAFT - SA PROSEDUR 9,369,596
1561 SA3522 OPEN AND OTHER REPLACEMENT OF AORTIC VALVE - SA PROSEDUR 25,661,790
1562 SA3523 OPEN AND OTHER REPLACEMENT OF MITRAL VALVE WITH TISSUE GRAFT - SA PROSEDUR 9,369,596
1563 SA3524 OPEN AND OTHER REPLACEMENT OF MITRAL VALVE - SA PROSEDUR 9,369,596
1564 SA3525 OPEN AND OTHER REPLACEMENT OF PULMONARY VALVE WITH TISSUE GRAFT - SA PROSEDUR 9,369,596
1565 SA3527 OPEN AND OTHER REPLACEMENT OF TRICUSPID VALVE WITH TISSUE GRAFT - SA PROSEDUR 9,369,596
1566 SA3539 OPERATIONS ON OTHER STRUCTURES ADJACENT TO VALVES OF HEART - SA PROSEDUR 9,369,596
1567 SA3551 REPAIR OF ATRIAL SEPTAL DEFECT WITH PROSTHESIS, OPEN TECHNIQUE - SA PROSEDUR 5,231,132
1568 SA3552 REPAIR OF ATRIAL SEPTAL DEFECT WITH PROSTHESIS, CLOSED TECHNIQUE - SA PROSEDUR 4,208,500
1569 SA3554 REPAIR OF ENDOCARDIAL CUSHION DEFECT WITH PROSTHESIS - SA PROSEDUR 9,369,596
1570 SA3571 OTHER AND UNSPECIFIED REPAIR OF ATRIAL SEPTAL DEFECT - SA PROSEDUR 9,369,596
1571 SA3572 OTHER AND UNSPECIFIED REPAIR OF VENTRICULAR SEPTAL DEFECT - SA PROSEDUR 9,369,596
1572 SA3573 OTHER AND UNSPECIFIED REPAIR OF ENDOCARDIAL CUSHION DEFECT - SA PROSEDUR 9,369,596
1573 SA3581 TOTAL REPAIR OF TETRALOGY OF FALLOT - SA PROSEDUR 9,369,596
1574 SA3582 TOTAL REPAIR OF TOTAL ANOMALOUS PULMONARY VENOUS CONNECTION - SA PROSEDUR 9,369,596
1575 SA3583 LIGATION OF CONNECTIONS BETWEEN AORTA AND PULMONARY ARTERY - SA PROSEDUR 7,227,008
1576 SA3583A TOTAL REPAIR OF TRUNCUS ARTERIOSUS (CORRECTION) - SA PROSEDUR 6,327,421
TOTAL REPAIR OF TRUNCUS ARTERIOSUS (CONNECTION TO PULMONARY ARTERY
1577 SA3583B PROSEDUR 7,959,116
FROM AORTA) - SA
TOTAL CORRECTION OF TRANSPOSITION OF GREAT VESSELS, NOT ELSEWHERE
1578 SA3584A PROSEDUR 9,979,867
CLASSIFIED - ARTERIAL SWITCH OPERATION [JATENE] - SA
1579 SA3584B PROSEDUR 9,369,596
CLASSIFIED - SA
1580 SA3592 CREATION OF CONDUIT BETWEEN RIGHT VENTRICLE AND PULMONARY ARTERY - SA PROSEDUR 7,959,116
CREATION OF CONDUIT BETWEEN RIGHT VENTRICLE AND PULMONARY ARTERY -
1581 SA3592A PROSEDUR 9,369,596
CREATION VALVED CARDIAC CONDUIT - SA
1582 SA3593 CREATION OF CONDUIT BETWEEN LEFT VENTRICLE AND AORTA - SA PROSEDUR 9,369,596
1583 SA3594 CREATION OF CONDUIT BETWEEN ATRIUM AND PULMONARY ARTERY - SA PROSEDUR 9,369,596
REVISION OF CORRECTIVE PROCEDURE ON HEART / REPAIR OF PULMONARY ARTERY
1584 SA3595 PROSEDUR 10,701,952
- SA
REVISION OF CORRECTIVE PROCEDURE ON HEART / OPEN OPERATION ON
1585 SA3595A PROSEDUR 5,975,072
PULMONARY ARTERY - SA
1586 SA3595B REVISION OF CORRECTIVE PROCEDURE ON HEART - SA PROSEDUR 7,227,008
PERCUTANEOUS VALVULOPLASTY (THERAPEUTIC TRANSLUMINAL OPERATIONS
1587 SA3596A PROSEDUR 4,208,500
SEPTUM HEART) - SA
PERCUTANEOUS VALVULOPLASTY (PERCUTANEOUS TRANSLUMINAL MITRAL
1588 SA3596B PROSEDUR 9,979,867
VALVULOTOMY) - SA
1589 SA3599 OTHER OPERATIONS ON VALVES OF HEART - SA PROSEDUR 3,934,156
1590 SA3603 OPEN CHEST CORONARY ARTERY ANGIOPLASTY - SA PROSEDUR 9,369,596
1591 SA3611 (AORTO)CORONARY BYPASS OF ONE CORONARY ARTERY - SA PROSEDUR 9,369,596
1592 SA3699 OTHER OPERATIONS ON VESSELS OF HEART - SA PROSEDUR 9,369,596
1593 SA370 PERICARDIOCENTESIS - SA PROSEDUR 1,946,007
1594 SA370A PERICARDIOCENTESIS (DECOMPRESSION FO CARDIAC TAMPONADE) - SA PROSEDUR 3,351,658
1595 SA3712 PERICARDIOTOMY - SA PROSEDUR 1,946,007
1596 SA3723A COMBINED RIGHT AND LEFT HEART CARDIAC CATHETERIZATION (ADULT) - SA PROSEDUR 1,946,007
1597 SA3723B COMBINED RIGHT AND LEFT HEART CARDIAC CATHETERIZATION (PAEDIATRIC) - SA PROSEDUR 2,278,794
1598 SA3727 CARDIAC MAPPING - SA PROSEDUR 2,278,794
CARDIAC MAPPING - MAP GUIDED SURG FOR VENTRICULAR ARRHYTHMIAS (W
1599 SA3727A PROSEDUR 3,934,156
MAPPING) - SA
1600 SA3731 PERICARDIECTOMY - SA PROSEDUR 5,231,132
1601 SA3732 EXCISION OF ANEURYSM OF HEART - SA PROSEDUR 7,235,340
EXCISION OR DESTRUCTION OF OTHER LESION OR TISSUE OF HEART, OPEN
1602 SA3733 PROSEDUR 9,369,596
APPROACH - SA
EXCISION OR DESTRUCTION OF OTHER LESION OR TISSUE OF HEART, OTHER
1603 SA3734 PROSEDUR 6,327,421
APPROACH - TRANSLUMINAL - SA
EXCISION OR DESTRUCTION OF OTHER LESION OR TISSUE OF HEART,OTHER
1604 SA3734A PROSEDUR 3,476,272
APPROACH-ABLATION AV NODE - SA
1605 SA3749 OTHER REPAIR OF HEART AND PERICARDIUM - SA PROSEDUR 9,369,596
REVISION OR RELOCATION OF CARDIAC DEVICE POCKET (RESITTING OF IV CARDIAC
1606 SA3779A PROSEDUR 1,946,007
PACEMAKER SYSTEM) - SA
REVISION OR RELOCATION OF CARDIAC DEVICE POCKET (REMOVAL OF PACING
1607 SA3779B PROSEDUR 6,327,421
SYSTEM WITH BYPASS) - SA
1608 SA3779C PROSEDUR 839,937
SYSTEM W/O BYPASS) - SA
INSERTION, REVISION, REPLACEMENT, AND REMOVAL OF LEADS; INSERTION OF
1609 SA377A TEMPORARY PACEMAKER SYSTEM; OR REVISION OF CARDIAC DEVICE POCKET PROSEDUR 2,278,794
(SINGLE CHAMBER) - SA
1610 SA377B TEMPORARY PACEMAKER SYSTEM; OR REVISION OF CARDIAC DEVICE POCKET (DUAL PROSEDUR 3,118,973
CHAMBER) - SA
Page 19
TARIF INSURANCE
REPLACEMENT OF ANY TYPE PACEMAKER DEVICE WITH SINGLE-CHAMBER DEVICE,

1611 SA3785 NOT SPECIFIED AS RATE RES / REPLACEMENT OF ANY TYPE PACEMAKER DEVICE PROSEDUR 2,561,591
WITH DUAL-CHAMBER DEVICE - SA
1612 SA3787 REPLACEMENT OF ANY TYPE PACEMAKER DEVICE WITH DUAL-CHAMBER DEVICE - SA PROSEDUR 2,561,591
IMPLANTATION OR REPLACEMENT OF AUTOMATIC CARDIOVERTER/DEFIBRILLATOR,
1613 SA3794 PROSEDUR 5,231,132
TOTAL SYSTEM [AICD] - SA
1614 SA3800 INCISION OF VESSEL - THROMBECTOMY - SA PROSEDUR 2,598,782
1615 SA3800A INCISION OF VESSEL - THROMBECTOMY (OPEN) - SA PROSEDUR 3,734,073
1616 SA3805 INCISION OF VESSEL (PULMONARY EMBOLECTOMY) - SA PROSEDUR 7,959,116
1617 SA3810 ENDARTERECTOMY WITH GRAFT - UNSPESIFIED - SA PROSEDUR 3,747,839
1618 SA3811 ENDARTERECTOMY (INTRACRANIAL VESSEL) - SA PROSEDUR 7,959,116
1619 SA3812 ENDARTERECTOMY CAROTID - SA PROSEDUR 6,327,421
1620 SA3814 ENDARTERECTOMY AORTA INCLUDE PATCH GRAFT - SA PROSEDUR 7,959,116
1621 SA3815 ENDARTERECTOMY WITH GRAFT - SUBCLAVIA - SA PROSEDUR 6,327,421
1622 SA3816 ENDARTERECTOMY ILIAC ARTERY INCLUDE PATCH GRAFT - SA PROSEDUR 5,231,132
1623 SA3817 ENDARTERECTOMY RENAL ARTERY - SA PROSEDUR 6,327,421
1624 SA3819 ENDARTERECTOMY FEMORAL ARTERY - SA PROSEDUR 4,208,500
1625 SA3821 BIOPSY OF BLOOD VESSEL - SA PROSEDUR 839,937
RESECTION OF VESSEL WITH ANASTOMOSIS - EXCISION OF ARETRIOVENOUS
1626 SA3830 PROSEDUR 9,369,596
MALFORMATION - SA
1627 SA3841 RESECTION OF VESSEL WITH REPLACEMENT (INTRACRANIAL VESSEL) - SA PROSEDUR 8,517,705
RESECTION OF VESSEL WITH REPLACEMENT (AORTA) (REVISION OF PROSTHESIS
1628 SA3844A PROSEDUR 6,327,421
ABDOMINAL AORTA) - SA
RESECTION OF VESSEL WITH REPLACEMENT (AORTA) (OTHER OPEN OP VISCERAL
1629 SA3844B PROSEDUR 7,959,116
BRANCH ABDOMINAL AORTA) - SA
RESECTION OF VESSEL WITH REPLACEMENT (AORTA) (INFRARENAL ABDOMINAL
1630 SA3844C PROSEDUR 6,327,421
AORTIC ANEURYSM TUBE GRAFT) - SA
1631 SA3844D PROSEDUR 7,959,116
AORTIC ANEURYSM BIFURCATION GRAFT) - SA
1632 SA3845 RESECTION OF VESSEL WITH REPLACEMENT (OTHER THORACIC VESSELS) - SA PROSEDUR 9,369,596
RESECTION OF VESSEL WITH REPLACEMENT - EMERGENCY REPLACE OF
1633 SA3845A PROSEDUR 9,369,596
ANEURYSMAL SEGMENT ARCH OF AORTA (ARCHUS/ASCENDING) - SA
RESECTION OF VESSEL WITH REPLACEMENT - PLAN REPLACE ANEURYSMAL SEGMENT
1634 SA3845B PROSEDUR 9,369,596
THORACIC AORTA - SA
RESECTION OF VESSEL WITH REPLACEMENT - PLAN REPLACE OF ANEURYSMAL
1635 SA3845C PROSEDUR 6,327,421
SEGMENT ASCENDING AORTA - SA
1636 SA3845D PROSEDUR 9,369,596
SEGMENT ARCH AORTA - SA
1637 SA3850A LIGATION AND STRIPPING OF VARICOSE VEINS - RECURRENT - SA PROSEDUR 3,118,973
LIGATION AND STRIPPING OF VARICOSE VEINS - RECURRENT BILATERAL / MULTI
1638 SA3850B PROSEDUR 5,231,132
PHLEBECTOMY - SA
1639 SA3859 LIGATION AND STRIPPING OF VARICOSE VEINS - SAPHENOUS VEINS - SA PROSEDUR 3,118,973
1640 SA3859A LIGATION AND STRIPPING OF VARICOSE VEIN - SAPHENOUS VEINS UNILATERAL - SA PROSEDUR 1,946,007
1641 SA3859B LIGATION AND STRIPPING OF VARICOSE VEIN - SAPHENOUS VEINS BILATERAL - SA PROSEDUR 3,118,973
1642 SA3859C LIGATION AND STRIPPING OF VARICOSE VEINS - SAPHENOUS VEINS (COMPLEX) - SA PROSEDUR 5,231,132
1643 SA3866 OTHER EXCISION OF VESSEL - ILLIAC ARTERY - SA PROSEDUR 5,231,132
1644 SA3868 OTHER EXCISION OF VESSEL - VARICOSE VEIN LEG - SA PROSEDUR 1,056,442
1645 SA387A INTERRUPTION OF THE VENA CAVA (PLICATION OF VENA CAVA) - SA PROSEDUR 3,351,658
INTERRUPTION OF THE VENA CAVA (REPAIR OF WOUND OF MAJOR ARTERY/VEIN OF
1646 SA387B PROSEDUR 3,118,973
ABDOMEN) - SA
1647 SA3893 VENOUS CATHETERIZATION, NOT ELSEWHERE CLASSIFIED - SA PROSEDUR 1,056,442
1648 SA3893A VENOUS CATHETERIZATION, NON TUNNELLED - SA PROSEDUR 880,751
1649 SA3893B VENOUS CATHETERIZATION, TUNNELLED - SA PROSEDUR 1,407,100
1650 SA3893C VENOUS CATHETERIZATION - INSERTION OF VENA CAVA FILTER - SA PROSEDUR 1,622,276
1651 SA3893D VENOUS CATHETERIZATION, NOT ELSEWHERE CLASSIFIED / CVC - SA PROSEDUR 2,374,187
1652 SA3893E VENOUS CATHETERIZATION, NOT ELSEWHERE CLASSIFIED / CHEMOPOT - SA PROSEDUR 4,746,924
VENOUS CATHETERIZATION FOR RENAL DIALYSIS / DOUBLE OR TRIPLE LUMEN HD -
1653 SA3895B PROSEDUR 2,374,187
SA
1654 SA3895C VENOUS CATHERIZATION FOR RENAL DIALYSIS / TUNELLING - SA PROSEDUR 1,318,711
SYSTEMIC TO PULMONARY ARTERY SHUNT (CREATION OF SHUNT TO PULMONARY
1655 SA390A PROSEDUR 6,327,421
ARTERY FR SUBCLAVIA ARTERY BY INTERPOS.TUBE PROS.) - SA
SYSTEMIC TO PULMONARY ARTERY SHUNT (CONNECTION TO PULMONARY ARTERY
1656 SA390B PROSEDUR 7,959,116
FR SUBCLAVIA ARTERY) - SA
1657 SA390C SYSTEMIC TO PULMONARY ARTERY SHUNT (REPAIR OF PULMONARY ARTERY) - SA PROSEDUR 9,369,596
SYSTEMIC TO PULMONARY ARTERY SHUNT (OPEN OPERATION ON PULMONARY
1658 SA390D PROSEDUR 5,231,132
ARTERY) - SA
SYSTEMIC TO PULMONARY ARTERY SHUNT (TRANSLUMINAL OPERATION ON
1659 SA390E PROSEDUR 3,934,156
PULMONARY ARTERY) - SA
1660 SA390F PROSEDUR 7,959,116
FROM AORTA) - SA
1661 SA391 INTRA-ABDOMINAL VENOUS SHUNT - SA PROSEDUR 6,327,421
INTRA ABDOMINAL VENOUS SHUNT (TRANSJUGULAR INTRAHEPATIC
1662 SA391A PROSEDUR 3,507,184
PORTOSYSTEMIC SHUNT) - SA
1663 SA3922 AORTA-SUBCLAVIAN-CAROTID BYPASS - SA PROSEDUR 4,208,500
AORTA-SUBCLAVIAN-CAROTID BYPASS (EXCISION OF INFECTED AORTIC GRAFT W
1664 SA3922A PROSEDUR 9,369,596
BYPASS) - SA
1665 SA3922B AORTA-SUBCLAVIAN-CAROTID BYPASS (BYPASS CAROTID ARTERY FR ARCH) - SA PROSEDUR 6,327,421
1666 SA3925 AORTA-ILIAC-FEMORAL BYPASS - SA PROSEDUR 6,327,421
AORTA-ILIAC-FEMORAL BYPASS (AORTO-ILIAC,AORTO-FEMORAL,ILEO-FEMORAL
1667 SA3925A PROSEDUR 6,327,421
BYPASS) - SA
1668 SA3925B AORTA-ILIAC-FEMORAL BYPASS (OPEN OPERATION ILIAC ARTERY) - SA PROSEDUR 5,231,132
1669 SA3926 OTHER INTRA-ABDOMINAL VASCULAR SHUNT OR BYPASS - SA PROSEDUR 3,118,973
1670 SA3927 ARTERIOVENOSTOMY FOR RENAL DIALYSIS - SA PROSEDUR 1,946,007
1671 SA3929 OTHER (PERIPHERAL) VASCULAR SHUNT OR BYPASS - SA PROSEDUR 4,208,500
OTHER (PERIPHERAL) VASCULAR SHUNT OR BYPASS - FEMORO-FEMORAL BYPASS -
1672 SA3929A PROSEDUR 4,208,500
SA
Page 20
TARIF INSURANCE
OTHER (PERIPHERAL) VASCULAR SHUNT OR BYPASS - FEMORO-POPLITEAL BYPASS

1673 SA3929B PROSEDUR 5,231,132
USING PROSTHESIS &/VEIN&/CUFF/PATCH - SA
OTHER (PERIPHERAL) VASCULAR SHUNT OR BYPASS - FEMORO-DISTAL CALF BYPASS
1674 SA3929C PROSEDUR 5,231,132
USING PROSTHESIS&/VEIN&/VEIN CUFF/PATCH - SA
OTHER (PERIPHERAL) VASCULAR SHUNT OR BYPASS -REVISION FEMORAL BYPASS
1675 SA3929D PROSEDUR 3,934,156
GRAFT - SA
1676 SA3930 SUTURE OF UNSPECIFIED BLOOD VESSEL - SA PROSEDUR 3,118,973
1677 SA3949 OTHER REVISION OF VASCULAR PROCEDURE - SA PROSEDUR 5,231,132
ANGIOPLASTY OR ATHERECTOMY OF OTHER NON CORONARY VESSEL(S) - INCLUDE
1678 SA3950A PROSEDUR 1,946,007
PTA NON CORONARY VESSEL - SA
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY (PTA) OF NON- CORONARY VESSELS -
1679 SA3950B PROSEDUR 2,278,794
FEMORAL ARTERY - SA
1680 SA3950C PROSEDUR 1,946,007
ILLIAC ARTERY - SA
1681 SA3950D PROSEDUR 2,278,794
RENAL ARTERY - SA
ANGIOPLASTY OR ATHERECTOMY OF OTHER NON CORONARY VESSEL(S) -
1682 SA3950E PROSEDUR 6,327,421
RECONSTRUCTION OF RENAL ARTERY - SA
1683 SA3951 CLIPPING OF ANEURYSM - SA PROSEDUR 7,959,116
1684 SA3952 OTHER REPAIR OF ANEURYSM - POPLITEAL - SA PROSEDUR 5,231,132
OTHER REPAIR OF ANEURYSM - REINFORCEMENT OF ANEURYSM OF CEREBRAL
1685 SA3952A PROSEDUR 7,959,116
ARTERY - SA
1686 SA3953 REPAIR OF ARTERIOVENOUS FISTULA - SA PROSEDUR 4,208,500
REPAIR OF ARTERIOVENOUS FISTULA (CREATION ARTERIOVENOUS FISTULA
1687 SA3953A PROSEDUR 1,946,007
(INCLUDE SUBSEQUENT CLOSURE) - SA
REPAIR OF ARTERIOVENOUS FISTULA - OCCLUSION OF FISTULA UNDER IMAGING
1688 SA3953B PROSEDUR 2,599,385
CONTROL - SA
REPAIR OF BLOOD VESSEL WITH TISSUE PATCH GRAFT (MICRO-ARTERIAL/MICRO-
1689 SA3956A PROSEDUR 6,327,421
VENOUS GRAFT) - SA
REPAIR OF BLOOD VESSEL WITH TISSUE PATCH GRAFT (REPAIR ARTERY USE VEIN
1690 SA3956B PROSEDUR 3,934,156
GRAFT) - SA
REPAIR OF BLOOD VESSEL WITH UNSPECIFIED TYPE OF PATCH GRAFT - AORTA
1691 SA3958 PROSEDUR 3,118,973
ABDOMINALIS - SA
REPAIR OF BLOOD VESSEL WITH UNSPECIFIED TYPE OF PATCH GRAFT-AORTA
1692 SA3958A PROSEDUR 6,327,421
REPAIR - SA
1693 SA3959 OTHER REPAIR OF VESSEL - SA PROSEDUR 5,231,132
1694 SA3959A OTHER REPAIR OF VESSEL -MICROSURGERY - SA PROSEDUR 3,934,156
1695 SA3959B OTHER REPAIR OF VESSEL - ARTERIOPLASTY - SA PROSEDUR 3,351,658
ENDOVASCULLAR PROSEDURE ON VESSELS - EMBOLISATION OF ARTERY OF
1696 SA397 PROSEDUR 1,622,276
INTERNAL NOSE - SA
OTHER ENDOVASCULAR PROCEDURES ON OTHER VESSELS (REPLACE THORACIC-
1697 SA3979C PROSEDUR 9,369,596
ABDOMINAL ANEURYSM) - SA
1698 SA3992 INJECTION OF SCLEROSING AGENT INTO VEIN - SA PROSEDUR 474,065
1699 SA3997 OTHER PERFUSION - SA PROSEDUR 3,934,156
1700 SA4011A BIOPSY OF LYMPHATIC STRUCTURE (CERVICAL, INGUINAL, AXILLARY) - SA PROSEDUR 639,975
1701 SA4011B BIOPSY OF LYMPHATIC STRUCTURE (EXCISION BIOPSY LYMPH NODE) - SA PROSEDUR 968,174
1702 SA4011C BIOPSY OF LYMPHATIC STRUCTURE - CERVICAL LYMPH NODE - SA PROSEDUR 492,419
1703 SA4011D BIOPSY OF LYMPHATIC STRUCTURE - AXILLARY LYMPH NODE - SA PROSEDUR 679,340
1704 SA4011E BIOPSY OF LYMPHATIC STRUCTURE - MAMMARY LYMPH NODE - SA PROSEDUR 1,109,451
1705 SA402 SIMPLE EXCISION OF LYMPHATIC STRUCTURE - SA PROSEDUR 2,578,375
1706 SA4021 EXCISION OF DEEP CERVICAL LYMPH NODE - SA PROSEDUR 4,208,500
1707 SA4023 EXCISION OF AXILLARY LYMPH NODE - SA PROSEDUR 2,561,591
1708 SA4024 EXCISION OF INGUINAL LYMPH NODE - SA PROSEDUR 2,561,591
1709 SA4024A EXCISION OF INGUINAL LYMPH NODE (COMPLEX) - SA PROSEDUR 8,895,653
1710 SA4029 SIMPLE EXCISION OF OTHER LYMPHATIC STRUCTURE - SA PROSEDUR 3,573,596
SIMPLE EXCISION OF OTHER LYMPHATIC STRUCTURE (BLOK DISSECTION OF PELVIC
1711 SA4029A PROSEDUR 2,969,122
LYMPH NODES) - SA
SIMPLE EXCISION OF OTHER LYMPHATIC STRUCTURE (EXCISION CYSTIC HYGROMA) -
1712 SA4029B PROSEDUR 2,278,794
SA
1713 SA4029C SIMPLE EXCISION OF OTHER LYMPHATIC STRUCTURE (COMPLEX) - SA PROSEDUR 7,712,906
1714 SA403 REGIONAL LYMPH NODE EXCISION - SA PROSEDUR 698,780
1715 SA404 RADICAL EXCISION OF CERVICAL LYMPH NODES - CLYMPH NODE - SA PROSEDUR 3,507,184
1716 SA4040 RADICAL NECK DISSECTION, NOT OTHERWISE SPECIFIED - SA PROSEDUR 8,895,653
1717 SA4051 RADICAL EXCISION OF AXILLARY LYMPH NODES - SA PROSEDUR 8,895,653
1718 SA4051A RADICAL EXCISION OF AXILLARY LYMPH NODES - AXILLARY LYMPH NODE - SA PROSEDUR 2,134,860
1719 SA4052 RADICAL EXCISION OF PERIAORTIC LYMPH NODES - SA PROSEDUR 3,734,073
1720 SA409 OTHER OPERATIONS ON LYMPHATIC STRUCTURES - SA PROSEDUR 3,351,658
1721 SA409A RECONSTRUCTION LYMPH OEDEM WITH MIROSURGERY OPERATION - SA PROSEDUR 29,020,331
1722 SA4131 BIOPSY OF BONE MARROW - SA PROSEDUR 910,334
1723 SA415A SPLEENECTOMY-LAPAROSCOPIC - SA PROSEDUR 3,353,348
1724 SA415B SPLEENECTOMY-OPEN - SA PROSEDUR 2,661,692
1725 SA4219 OTHER EXTERNAL FISTULIZATION OF ESOPHAGUS - SA PROSEDUR 6,327,421
1726 SA4232 LOCAL EXCISION OF OTHER LESION OR TISSUE OF ESOPHAGUS - SA PROSEDUR 2,744,527
ENDOSCOPIC EXCISION OR DESTRUCTION OF LESION OR TISSUE OF ESOPHAGUS -
1727 SA4233 PROSEDUR 1,455,521
INJECTION SCLEROTHERAPY - SA
1728 SA4242 TOTAL ESOPHAGECTOMY - SA PROSEDUR 7,235,340
1729 SA4242A TOTAL ESOPHAGECTOMY (COMPLEX) - SA PROSEDUR 9,369,596
1730 SA4251 INTRATHORACIC ESOPHAGOESOPHAGOSTOMY - SA PROSEDUR 5,752,651
1731 SA427 ESOPHAGOMYOTOMY - SA PROSEDUR 3,216,659
1732 SA427A ESOPHAGOMYOTOMY (BYPASS OESOPHAGUS) - SA PROSEDUR 3,609,459
1733 SA427B ESOPHAGOMYOTOMY (THORASCOPIC OESOPHAGOGASTRIC MYOTOMY) - SA PROSEDUR 3,378,585
1734 SA4281 INSERTION OF PERMANENT TUBE INTO ESOPHAGUS - SA PROSEDUR 1,899,398
1735 SA4283 CLOSURE OF ESOPHAGOSTOMY - SA PROSEDUR 3,118,973
1736 SA4284 REPAIR OF ESOPHAGEAL FISTULA, NOT ELSEWHERE CLASSIFIED - SA PROSEDUR 5,051,818
1737 SA4289 OTHER REPAIR OF ESOPHAGUS - SA PROSEDUR 3,934,156
1738 SA4289A OTHER REPAIR OF ESOPHAGUS-TRANSTHORACIC - SA PROSEDUR 4,359,558
1739 SA4289B OTHER REPAIR OF ESOPHAGUS-THORACOSCOPIC - SA PROSEDUR 3,742,646
1740 SA4289C OTHER REPAIR OF ESOPHAGUS-TRANSABDOMINAL ANTI REFLUX - SA PROSEDUR 3,506,822
1741 SA4289D OTHER REPAIR OF ESOPHAGUS-REVISION ANTI REFLUX OP - SA PROSEDUR 4,707,922
1742 SA4289E OTHER REPAIR OF ESOPHAGUS-TRANSTHORACIC (COMPLEX) - SA PROSEDUR 5,231,132
1743 SA4289F OTHER REPAIR OF ESOPHAGUS-THORACOSCOPIC EXTRA - SA PROSEDUR 4,208,500
1744 SA4311 PERCUTANEOUS [ENDOSCOPIC] GASTROSTOMY - SA PROSEDUR 2,134,860
1745 SA4319 OTHER GASTROSTOMY - SA PROSEDUR 2,561,591
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TARIF INSURANCE
1746 SA4319C OTHER GASTROSTOMY (COMPLEX) - SA PROSEDUR 3,573,596

1747 SA433 PYLOROMYOTOMY - SA PROSEDUR 2,630,177
1748 SA435 PARTIAL GASTRECTOMY WITH ANASTOMOSIS TO ESOPHAGUS - SA PROSEDUR 2,793,068
1749 SA436 PARTIAL GASTRECTOMY WITH ANASTOMOSIS TO DUODENUM - SA PROSEDUR 2,793,068
1750 SA437 PARTIAL GASTRECTOMY WITH ANASTOMOSIS TO JEJUNUM - SA PROSEDUR 2,793,068
1751 SA438 OTHER PARTIAL GASTRECTOMY - SA PROSEDUR 2,793,068
1752 SA4381 PARTIAL GASTRECTOMY WITH JEJUNAL TRANSPOSITION - SA PROSEDUR 2,793,068
1753 SA4389 OPEN AND OTHER PARTIAL GASTRECTOMY - SA PROSEDUR 2,793,068
1754 SA4399 OTHER TOTAL GASTRECTOMY - SA PROSEDUR 4,208,500
1755 SA4399A OTHER TOTAL GASTRECTOMY-OESOPHAGOGASTRECTOMY - SA PROSEDUR 7,235,340
1756 SA4399C OTHER TOTAL GASTRECTOMY-OESOPHAGOGASTRECTOMY (COMPLEX) - SA PROSEDUR 7,959,116
1757 SA4400 VAGOTOMY, NOT OTHERWISE SPECIFIED - SA PROSEDUR 2,969,122
1758 SA4400L VAGOTOMY, NOS - LAPAROSCOPIC - SA PROSEDUR 3,326,421
1759 SA4401 TRUNCAL VAGOTOMY - SA PROSEDUR 2,474,288
1760 SA4402 HIGHLY SELECTIVE VAGOTOMY - SA PROSEDUR 2,969,122
1761 SA4403 OTHER SELECTIVE VAGOTOMY - SA PROSEDUR 3,326,421
1762 SA4403P OTHER SELECTIVE VAGOTOMY-WITH PYLOROPLASTY - SA PROSEDUR 2,598,782
1763 SA4413 OTHER GASTROSCOPY A PROSEDUR 384,830
1764 SA4413B GASTROSCOPY BIOPSY A PROSEDUR 384,830
1765 SA4413L GASTROSCOPY LIGATIE VEG A PROSEDUR 384,830
1766 SA4413S GASTROSCOPY SCLEROTHERAPY A PROSEDUR 384,830
1767 SA442 PYLOROPLASTY - SA PROSEDUR 2,630,177
1768 SA4429 OTHER PYLOROPLASTY - SA PROSEDUR 3,118,973
PERCUTANEOUS [ENDOSCOPIC] GASTROJEJUNOSTOMY (BYPASS OF
1769 SA4432 PROSEDUR 2,630,177
DUODENUM/JEJUNUM) - SA
1770 SA4432A PERCUTANEOUS [ENDOSCOPIC] GASTROJEJUNOSTOMY - SA PROSEDUR 2,599,385
1771 SA4438A LAPAROSCOPIC GASTROENTEROSTOMY - GASTRO-JEJUNOSTOMY - SA PROSEDUR 3,506,822
1772 SA4438B LAPAROSCOPIC GASTROENTEROSTOMY -GASTROSTOMY/JEJUNOSTOMY - SA PROSEDUR 3,307,705
1773 SA4439 OTHER GASTROENTEROSTOMY - SA PROSEDUR 2,598,782
1774 SA4441 SUTURE OF GASTRIC ULCER SITE - SA PROSEDUR 2,630,177
1775 SA4442 SUTURE OF DUODENAL ULCER SITE - SA PROSEDUR 2,630,177
1776 SA4443 ENDOSCOPIC CONTROL OF GASTRIC OR DUODENAL BLEEDING - SA PROSEDUR 3,091,200
1777 SA445 REVISION OF GASTRIC ANASTOMOSIS - SA PROSEDUR 2,793,068
1778 SA4462 CLOSURE OF GASTROSTOMY - SA PROSEDUR 2,278,794
1779 SA4465 ESOPHAGOGASTROPLASTY-HELLER"S OP - SA PROSEDUR 2,772,420
1780 SA4468 LAPAROSCOPIC GASTROPLASTY - SA PROSEDUR 2,793,068
1781 SA4469 OTHER REPAIR OF STOMACH - GASTROPLASTY - SA PROSEDUR 2,744,527
1782 SA4499 GASTRIC OPERATION NEC - SA PROSEDUR 2,630,177
1783 SA4512 ENDOSCOPY OF SMALL INTESTINE THROUGH ARTIFICIAL STOMA - SA PROSEDUR 699,988
1784 SA4523 COLONOSCOPY A PROSEDUR 384,830
1785 SA4523B COLONOSCOPY BIOPSY A PROSEDUR 384,830
1786 SA4523P COLONOSCOPY POLIPECTOMY A PROSEDUR 384,830
1787 SA4524 FLEXIBLE SIGMOIDOSCOPY A PROSEDUR 384,830
1788 SA4531 OTHER LOCAL EXCISION OF LESION OF DUODENUM - SA PROSEDUR 2,793,068
LOCAL EXCISION OF LESION OR TISSUE OF SMALL INTESTINE, EXCEPT DUODENUM -
1789 SA4533A PROSEDUR 2,598,782
EXCISION OF JEJUNUM - SA
1790 SA4533B PROSEDUR 3,007,762
EXCISION OF LESION OF JEJUNUM - SA
OTHER DESTRUCTION OF LESION OF SMALL INTESTINE, EXCEPT DUODENUM-
1791 SA4534 PROSEDUR 3,091,200
LAPAROSCOPIC RESECTION OF SMALL INTESTINE - SA
1792 SA4541 EXCISION OF LESION OR TISSUE OF LARGE INTESTINE - SA PROSEDUR 2,561,591
1793 SA4573 OPEN AND OTHER RIGHT HEMICOLECTOMY - SA PROSEDUR 2,896,913
1794 SA4574 OPEN AND OTHER RESECTION OF TRANSVERSE COLON - SA PROSEDUR 2,896,913
1795 SA4575 OPEN AND OTHER LEFT HEMICOLECTOMY - SA PROSEDUR 2,896,913
OPEN AND OTHER LEFT HEMICOLECTOMY (REVERSAL OF HARTMANN"S PROCEDURE) -
1796 SA4575A PROSEDUR 4,707,922
SA
1797 SA4576 OPEN AND OTHER SIGMOIDECTOMY - SA PROSEDUR 2,896,913
1798 SA4579 OTHER AND UNSPECIFIED PARTIAL EXCISION OF LARGE INTESTINE - SA PROSEDUR 2,770,971
1799 SA4594 LARGE-TO-LARGE INTESTINAL ANASTOMOSIS - SA PROSEDUR 5,683,099
1800 SA4595 ANASTOMOSIS TO ANUS - SA PROSEDUR 5,752,651
1801 SA4603 EXTERIORIZATION OF LARGE INTESTINE - SA PROSEDUR 2,561,591
1802 SA4610 COLOSTOMY, NOT OTHERWISE SPECIFIED - SA PROSEDUR 2,969,122
1803 SA4610L COLOSTOMY, NOT OTHERWISE SPECIFIED -- LAPAROSCOPIC - SA PROSEDUR 3,326,421
1804 SA4620 ILEOSTOMY, BYPASS OF IELUM - SA PROSEDUR 2,630,177
1805 SA4620A ILEOSTOMY, NOT OTHERWISE SPECIFIED - SA PROSEDUR 2,630,177
1806 SA4620B ILEOSTOMY, ATTENTION - SA PROSEDUR 1,899,035
1807 SA4639 ENTEROSTOMY NEC - SA PROSEDUR 2,134,860
1808 SA4651 CLOSURE OF STOMA OF SMALL INTESTINE - SA PROSEDUR 2,519,932
1809 SA4652E CLOSURE OF STOMA OF LARGE INTESTINE-EXTRA PERITONEAL - SA PROSEDUR 1,865,346
1810 SA4652I CLOSURE OF STOMA OF LARGE INTESTINE-INTRA PERITONEAL - SA PROSEDUR 2,287,247
1811 SA4680 INTRA-ABDOMINAL MANIPULATION OF INTESTINE, NOT OTHERWISE SPECIFIED - SA PROSEDUR 2,630,177
1812 SA4682 INTRA-ABDOMINAL MANIPULATION OF LARGE INTESTINE - SA PROSEDUR 2,969,122
1813 SA4701 LAPAROSCOPIC APPENDECTOMY - SA PROSEDUR 2,564,368
1814 SA4709 OTHER APPENDECTOMY - SA PROSEDUR 1,899,035
1815 SA4709A OTHER APPENDECTOMY-COMPLICATION - SA PROSEDUR 2,994,238
1816 SA472 DRAINAGE OF APPENDICEAL ABSCESS - SA PROSEDUR 1,899,035
1817 SA480 PROCTOTOMY - SA PROSEDUR 5,752,651
1818 SA4823 RIGID PROCTOSIGMOIDOSCOPY - SA PROSEDUR 474,065
1819 SA4825 OPEN BIOPSY OF RECTUM - SA PROSEDUR 590,588
1820 SA4835 LOCAL EXCISION OF RECTAL LESION OR TISSUE - SA PROSEDUR 1,784,202
1821 SA4835A LOCAL EXCISION OF RECTAL LESION OR TISSUE (OPEN) - SA PROSEDUR 2,598,782
1822 SA4842 LAPAROSCOPIC PULL-THROUGH RESECTION OF RECTUM - SA PROSEDUR 6,237,704
1823 SA4849 OTHER PULL-THROUGH RESECTION OF RECTUM - SA PROSEDUR 5,752,651
1824 SA4850 ABDOMINOPERINEAL RESECTION OF THE RECTUM, NOT OTHERWISE SPECIFIED - SA PROSEDUR 5,752,651
1825 SA4861 TRANSSACRAL RECTOSIGMOIDECTOMY - SA PROSEDUR 2,474,288
1826 SA4862 ANTERIOR RESECTION OF RECTUM WITH SYNCHRONOUS COLOSTOMY - SA PROSEDUR 5,752,651
1827 SA4869 RECTAL RESECTION NEC - SA PROSEDUR 3,278,121
1828 SA4876 OTHER PROCTOPEXY - SA PROSEDUR 2,630,177
1829 SA4892 ANORECTAL MYECTOMY - SA PROSEDUR 540,839
1830 SA4901 INCISION OF PERIANAL ABSCESS - SA PROSEDUR 699,988
1831 SA4904 OTHER EXCISION OF PERIANAL TISSUE - SA PROSEDUR 590,588
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TARIF INSURANCE
1832 SA4911 ANAL FISTULOTOMY - SA PROSEDUR 1,255,921

1833 SA4912B ANAL FISTULECTOMY-LAY OPEN HIGH FISTULA - SA PROSEDUR 1,899,035
1834 SA493 LOCAL EXCISION OR DESTRUCTION OF OTHER LESION OR TISSUE OF ANUS - SA PROSEDUR 540,839
1835 SA4939 OTHER LOCAL EXCISION OR DESTRUCTION OF LESION OR TISSUE OF ANUS - SA PROSEDUR 540,839
1836 SA4941 REDUCTION OF HEMORRHOIDS - SA PROSEDUR 474,065
1837 SA4942 INJECTION OF HEMORRHOIDS - SA PROSEDUR 474,065
1838 SA4946S EXCISION OF HEMORRHOIDS-STAPPLER - SA PROSEDUR 1,912,801
1839 SA4951 LEFT LATERAL ANAL SPHINCTEROTOMY - SA PROSEDUR 590,588
1840 SA4971 SUTURE OF LACERATION OF ANUS - SA PROSEDUR 1,865,346
1841 SA4973 CLOSURE OF ANAL FISTULA - SA PROSEDUR 1,255,921
1842 SA4979 OTHER REPAIR OF ANAL SPHINCTER - SA PROSEDUR 1,899,035
1843 SA5011 CLOSED (PERCUTANEOUS) [NEEDLE] BIOPSY OF LIVER - SA PROSEDUR 669,438
1844 SA5012 OPEN BIOPSY OF LIVER - SA PROSEDUR 2,278,794
1845 SA5014 LAPAROSCOPIC LIVER BIOPSY - SA PROSEDUR 1,865,346
1846 SA5021 MARSUPIALIZATION OF LESION OF LIVER - SA PROSEDUR 1,575,667
1847 SA5022 PARTIAL HEPATECTOMY - SA PROSEDUR 4,707,922
1848 SA5022A PARTIAL HEPATECTOMY - HEMIHEPATECTOMY - SA PROSEDUR 7,235,340
1849 SA5025 LAPAROSCOPIC ABLATION OF LIVER LESION OR TISSUE - SA PROSEDUR 2,661,692
1850 SA5029 OTHER DESTRUCTION OF LESION OF LIVER - SA PROSEDUR 4,208,500
1851 SA5069 OTHER REPAIR OF LIVER - SA PROSEDUR 3,609,459
1852 SA510 CHOLECYSTOTOMY AND CHOLECYSTOSTOMY - SA PROSEDUR 2,287,247
1853 SA5110 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY [ERCP] A PROSEDUR 1,922,219
1854 SA5112 PERCUTANEOUS BIOPSY OF GALLBLADDER OR BILE DUCTS - SA PROSEDUR 1,455,521
1855 SA5122 CHOLECYSTECTOMY - SA PROSEDUR 3,379,320
1856 SA5123 LAPAROSCOPIC CHOLECYSTECTOMY - SA PROSEDUR 3,308,550
1857 SA5123A LAPAROSCOPIC CHOLECYSTECTOMY-WITH CHOLANGIOGRAM - SA PROSEDUR 3,278,121
1858 SA5135 OTHER GALLBLADDER ANASTOMOSIS - SA PROSEDUR 3,351,658
1859 SA5136 CHOLEDOCHOENTEROSTOMY - SA PROSEDUR 3,118,973
1860 SA5137 ANASTOMOSIS OF HEPATIC DUCT TO GASTROINTESTINAL TRACT - SA PROSEDUR 4,208,500
1861 SA5139 OTHER BILE DUCT ANASTOMOSIS - SA PROSEDUR 3,476,272
1862 SA5149 INCISION OF OTHER BILE DUCTS FOR RELIEF OF OBSTRUCTION - SA PROSEDUR 3,118,973
1863 SA5151 EXPLORATION OF COMMON DUCT - SA PROSEDUR 2,969,122
1864 SA5169 EXCISION OF OTHER BILE DUCT - SA PROSEDUR 3,118,973
1865 SA5179 REPAIR OF OTHER BILE DUCTS - SA PROSEDUR 3,476,272
1866 SA5182 PANCREATIC SPHINCTEROTOMY - SA PROSEDUR 3,118,973
1867 SA5198 OTHER PERCUTANEOUS PROCEDURES ON BILIARY TRACT - SA PROSEDUR 1,829,000
1868 SA5198A OTHER PERCUTANEOUS PROCEDURES ON BILIARY TRACT (DILATATION) - SA PROSEDUR 3,351,658
1869 SA5199 BILIARY TRACT OP NEC - SA PROSEDUR 3,118,973
OTHER. INSERTION OR REPLACEMENT OF BILLIARY TRACT PROSTHESIS (PLASTIC) -
1870 SA5199A PROSEDUR 2,287,247
SA
OTHER. INSERTION OR REPLACEMENT OF BILLIARY TRACT PROSTHESIS (METALLIC) -
1871 SA5199B PROSEDUR 2,897,517
SA
1872 SA5201 DRAINAGE OF PANCREATIC CYST BY CATHETER - SA PROSEDUR 2,969,122
1873 SA5211 CLOSED [ASPIRATION] [NEEDLE] [PERCUTANEOUS] BIOPSY OF PANCREAS - SA PROSEDUR 2,278,794
1874 SA5212 OPEN BIOPSY OF PANCREAS - SA PROSEDUR 2,969,122
1875 SA522 LOCAL EXCISION OR DESTRUCTION OF PANCREAS AND PANCREATIC DUCT - SA PROSEDUR 2,969,122
OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF PANCREAS OR
1876 SA5222 PROSEDUR 2,969,122
PANCREATIC DUCT - SA
1877 SA523 MARSUPIALIZATION OF PANCREATIC CYST - SA PROSEDUR 2,969,122
1878 SA5252 DISTAL PANCREATECTOMY - SA PROSEDUR 3,934,156
1879 SA526 TOTAL PANCREATECTOMY - SA PROSEDUR 6,327,421
1880 SA526A TOTAL PANCREATECTOMY A - SA PROSEDUR 5,752,651
1881 SA527 RADICAL PANCREATICODUODENECTOMY - SA PROSEDUR 6,327,421
1882 SA5296 ANASTOMOSIS OF PANCREAS - SA PROSEDUR 3,934,156
1883 SA5300 UNILATERAL REPAIR OF INGUINAL HERNIA, NOT OTHERWISE SPECIFIED - SA PROSEDUR 2,744,527
UNILATERAL REPAIR OF INGUINAL HERNIA, NOT OTHERWISE SPECIFIED-PRIMARY -
1884 SA5300P PROSEDUR 1,688,206
SA
UNILATERAL REPAIR OF INGUINAL HERNIA, NOT OTHERWISE SPECIFIED-RECURRENT
1885 SA5300R PROSEDUR 2,744,527
- SA
1886 SA5310 BILATERAL REPAIR OF INGUINAL HERNIA, NOT OTHERWISE SPECIFIED - SA PROSEDUR 2,744,527
BILATERAL REPAIR OF INGUINAL HERNIA, NOT OTHERWISE SPECIFIED - RECURRENT
1887 SA5310R PROSEDUR 4,208,500
HERNIA - SA
1888 SA5321 UNILATERAL REPAIR OF FEMORAL HERNIA WITH GRAFT OR PROSTHESIS - SA PROSEDUR 1,455,521
UNILATERAL REPAIR OF FEMORAL HERNIA WITH GRAFT OR PROSTHESIS-RECURRENT
1889 SA5321R PROSEDUR 2,278,794
- SA
1890 SA5329 OTHER UNILATERAL FEMORAL HERNIORRHAPHY - SA PROSEDUR 2,744,527
1891 SA5341 OTHER AND OPEN REPAIR OF UMBILICAL HERNIA WITH GRAFT OR PROSTHESIS - SA PROSEDUR 1,455,521
1892 SA5351 INCISIONAL HERNIA REPAIR - SA PROSEDUR 1,946,007
1893 SA5361 OTHER OPEN INCISIONAL HERNIA REPAIR WITH GRAFT OR PROSTHESIS - SA PROSEDUR 2,744,527
OTHER AND OPEN REPAIR OF OTHER HERNIA OF ANTERIOR ABDOMINAL WALL WITH
1894 SA5369 PROSEDUR 1,946,007
GRAFT OR PROSTHESIS - SA
1895 SA5371 LAPAROSCOPIC REPAIR OF DIAPHRAGMATIC HERNIA, ABDOMINAL APPROACH - SA PROSEDUR 3,506,822
LAPAROSCOPIC REPAIR OF DIAPHRAGMATIC HERNIA, ABDOMINAL APPROACH
1896 SA5371R PROSEDUR 4,208,500
(REPAIR) - SA
1897 SA5372 OTHER AND OPEN REPAIR OF DIAPHRAGMATIC HERNIA, ABDOMINAL APPROACH - SA PROSEDUR 3,506,822
OTHER AND OPEN REPAIR OF DIAPHRAGMATIC HERNIA, ABDOMINAL APPROACH -
1898 SA5372A PROSEDUR 3,934,156
CONGENITAL - SA
OTHER AND OPEN REPAIR OF DIAPHRAGMATIC HERNIA, ABDOMINAL APPROACH
1899 SA5372C PROSEDUR 4,208,500
(COMPLEX) - SA
REPAIR OF DIAPHRAGMATIC HERNIA, ABDOMINAL APPROACH, NOT OTHERWISE
1900 SA5375 PROSEDUR 2,598,782
SPECIFIED - SA
1901 SA5375A PROSEDUR 3,118,973
SPECIFIED (COMPLEX) - SA
REPAIR OF DIAPHRAGMATIC HERNIA WITH THORACIC APPROACH, NOT OTHERWISE
1902 SA5380 PROSEDUR 3,351,658
SPECIFIED - SA
1903 SA5381 PLICATION OF THE DIAPHRAGM - SA PROSEDUR 3,476,272
1904 SA5381A PLICATION OF THE DIAPHRAGM (TRANSABDOMINAL ANTI-REFLUX OP) - SA PROSEDUR 4,208,500
1905 SA5381R PLICATION OF THE DIAPHRAGM-REVISION - SA PROSEDUR 5,231,132
1906 SA5411 EXPLORATORY LAPAROTOMY - SA PROSEDUR 5,231,132
1907 SA5412 REOPENING OF RECENT LAPAROTOMY SITE - SA PROSEDUR 2,561,591
Page 23
TARIF INSURANCE
1908 SA5419 OTHER LAPAROTOMY - SA PROSEDUR 2,561,591

1909 SA544A EXCISION OR DESTRUCTION OF PERITONEAL TISSUE - OMENTUM - SA PROSEDUR 2,744,527
1910 SA544B EXCISION OR DESTRUCTION OF PERITONEAL TISSUE - PRESACRAL TUMOUR - SA PROSEDUR 2,578,133
1911 SA5451 LAPAROSCOPIC LYSIS OF PERITONEAL ADHESIONS - SA PROSEDUR 1,829,000
1912 SA5459 OTHER LYSIS OF PERITONEAL ADHESIONS - SA PROSEDUR 2,278,794
1913 SA5461 RECLOSURE OF POSTOPERATIVE DISRUPTION OF ABDOMINAL WALL - SA PROSEDUR 1,865,346
1914 SA5491 PERCUTANEOUS ABDOMINAL DRAINAGE - SA PROSEDUR 457,401
1915 SA5494 CREATION OF PERITONEOVASCULAR SHUNT - SA PROSEDUR 1,946,007
1916 SA5494A CREATION OF PERITONEOVASCULAR SHUNT (COMPLEX) - SA PROSEDUR 2,495,299
1917 SA5495 INCISION OF PERITONEUM - SA PROSEDUR 1,688,206
1918 SA5496 INJECTION OF AIR INTO PERITONEAL CAVITY - SA PROSEDUR 1,688,206
1919 SA5501 NEPHROTOMY - SA PROSEDUR 3,476,272
1920 SA5501A NEPHROTOMY. NEPHROLITHOTOMY - SA PROSEDUR 4,359,558
1921 SA5502 NEPHROSTOMY (PERCUTANEOUS INSERTION OF NEPHROSTOMY TUBE) SA PROSEDUR 2,561,591
1922 SA5502A NEPHROSTOMY SA PROSEDUR 1,622,276
1923 SA5503 PERCUTANEOUS NEPHROSTOMY WITHOUT FRAGMENTATION - SA PROSEDUR 8,553,930
1924 SA5504 PERCUTANEOUS NEPHROSTOMY WITH FRAGMENTATION - SA PROSEDUR 4,989,994
1925 SA5512 PYELOSTOMY (DRAINAGE OF PYONEPHROSIS/PERINEPHRIC ABSCESS) - SA PROSEDUR 2,910,920
1926 SA5512A PYELOSTOMY (PERCUTANEOUS PYELYSIS) - SA PROSEDUR 3,278,604
1927 SA5523 CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF KIDNEY - SA PROSEDUR 1,351,555
CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF KIDNEY (DIAGNOSTIC ENDOSCOPIC
1928 SA5523A PROSEDUR 2,969,122
EXAM) - SA
1929 SA554 PARTIAL NEPHRECTOMY - SA PROSEDUR 3,576,253
1930 SA5551 NEPHROURETERECTOMY - SA PROSEDUR 3,825,602
1931 SA5551A NEPHROURETERECTOMY - NEPHRECTOMY + PERIRENAL TISSUE - SA PROSEDUR 4,989,994
1932 SA5551B NEPHROURETERECTOMY - LAPAROSCOPIC NEPHRECTOMY - SA PROSEDUR 4,989,994
1933 SA5553 REMOVAL OF TRANSPLANTED OR REJECTED KIDNEY - SA PROSEDUR 3,825,602
1934 SA5554 BILATERAL NEPHRECTOMY - SA PROSEDUR 6,503,354
1935 SA5569 OTHER KIDNEY TRANSPLANTATION - SA PROSEDUR 7,852,252
1936 SA5581 SUTURE OF LACERATION OF KIDNEY - SA PROSEDUR 4,075,313
1937 SA5589 RENAL REPAIR NEC - SA PROSEDUR 3,576,253
1938 SA5599 RENAL OPERATION NEC - SA PROSEDUR 3,576,253
1939 SA560 TRANSURETHRAL REMOVAL OF OBSTRUCTION FROM URETER AND RENAL PELVIS - SA PROSEDUR 3,278,604
1940 SA561 URETERAL MEATOTOMY - SA PROSEDUR 1,912,801
1941 SA562 URETEROTOMY - SA PROSEDUR 3,576,253
1942 SA5631 URETEROSCOPY - SA PROSEDUR 1,580,255
1943 SA564 URETERECTOMY - SA PROSEDUR 3,077,193
1944 SA5651 FORMATION OF CUTANEOUS URETERO-ILEOSTOMY - ILEAL CONDUIT - SA PROSEDUR 5,239,584
1945 SA5651A FORMATION OF CUTANEOUS URETERO-ILEOSTOMY - SA PROSEDUR 3,908,919
1946 SA5671 URINARY DIVERSION TO INTESTINE - SA PROSEDUR 4,740,645
1947 SA5674 URETERONEOCYSTOSTOMY - SA PROSEDUR 4,407,979
1948 SA5679 URETERAL ANASTOMOSIS NEC - SA PROSEDUR 3,118,973
1949 SA5683 CLOSURE OF URETEROSTOMY - SA PROSEDUR 3,118,973
1950 SA5684 CLOSURE OF OTHER FISTULA OF URETER - SA PROSEDUR 3,825,602
1951 SA5689 OTHER REPAIR OF URETER - SA PROSEDUR 4,208,500
1952 SA570 TRANSURETHRAL CLEARANCE OF BLADDER - SA PROSEDUR 2,910,920
1953 SA5717 PERCUTANEOUS CYSTOSTOMY - SA PROSEDUR 762,295
1954 SA5718 OTHER SUPRAPUBIC CYSTOSTOMY - SA PROSEDUR 1,663,573
1955 SA5718A PERCUTANEOUS CYSTOSTOMY + SUPRAPUBIC TUBE - SA PROSEDUR 1,144,348
1956 SA5719 OTHER CYSTOTOMY - SA PROSEDUR 2,910,920
1957 SA5719E TRANSURETHRAL CLEARANCE OF BLADDER-ENDOSCOPIC VESICO-LITHOTRIPSY - SA PROSEDUR 3,118,973
1958 SA5731 CYSTOSCOPY THROUGH ARTIFICIAL STOMA - SA PROSEDUR 990,995
1959 SA5733 CLOSED [TRANSURETHRAL] BIOPSY OF BLADDER - SA PROSEDUR 1,455,521
OTHER TRANSURETHRAL EXCISION OR DESTRUCTION OF LESION OR TISSUE OF
1960 SA5749 PROSEDUR 3,576,253
BLADDER - SA
1961 SA5749A PROSEDUR 3,077,193
BLADDER - DIVERTICULECTOMY - SA
1962 SA5749B PROSEDUR 3,576,253
BLADDER - RESECTION - SA
1963 SA5749C PROSEDUR 1,846,509
BLADDER - DESTRUCTION - SA
1964 SA5749F PROSEDUR 1,144,348
BLADDER - FEMALE - SA
1965 SA5749M PROSEDUR 2,910,920
BLADDER - MALE - SA
1966 SA5759 OPEN EXCISION OR DESTRUCTION OF OTHER LESION OR TISSUE OF BLADDER - SA PROSEDUR 2,744,527
1967 SA576 PARTIAL CYSTECTOMY - SA PROSEDUR 2,969,122
1968 SA577 TOTAL CYSTECTOMY - SA PROSEDUR 6,327,421
1969 SA5782 CLOSURE OF CYSTOSTOMY - SA PROSEDUR 1,360,370
1970 SA5783 REPAIR OF FISTULA INVOLVING BLADDER AND INTESTINE - SA PROSEDUR 3,905,417
1971 SA5784 REPAIR OF OTHER FISTULA OF BLADDER - SA PROSEDUR 3,243,587
1972 SA5784A REPAIR OF OTHER FISTULA OF BLADDER - CUTANEOUS VESICAL FISTULA - SA PROSEDUR 3,077,193
1973 SA5784B REPAIR OF OTHER FISTULA OF BLADDER - URETHRORECTAL FISTULA - SA PROSEDUR 2,561,591
1974 SA5785 CYSTOURETHROPLASTY AND PLASTIC REPAIR OF BLADDER NECK - SA PROSEDUR 2,561,591
1975 SA5787 RECONSTRUCTION OF URINARY BLADDER - UNILATERAL - SA PROSEDUR 4,208,500
1976 SA5787A RECONSTRUCTION OF URINARY BLADDER - BILATERAL - SA PROSEDUR 5,231,132
1977 SA5787B RECONSTRUCTION OF URINARY BLADDER (CONTINENT POUCH/NEO BLADDER) - SA PROSEDUR 6,327,421
1978 SA5789 OTHER REPAIR OF BLADDER - SA PROSEDUR 2,973,227
OTHER REPAIR OF BLADDER - ENDOSCOPIC ANTI-REFLUX PROCEDURE (AND
1979 SA5789A PROSEDUR 1,946,007
BILATERAL) - SA
1980 SA5789B OTHER REPAIR OF BLADDER - VAGINAL OPERATION FOR BLADDER - SA PROSEDUR 3,077,193
1981 SA5789C OTHER REPAIR OF BLADDER (COMPLEX) - SA PROSEDUR 3,908,919
1982 SA5791 SPHINCTEROTOMY OF BLADDER - SA PROSEDUR 1,688,206
1983 SA5791A SPHINCTEROTOMY OF BLADDER (RESECTION OF BLADDER NECK) - SA PROSEDUR 2,578,133
1984 SA5792 DILATION OF BLADDER NECK - SA PROSEDUR 1,171,154
1985 SA580 URETHROTOMY - SA PROSEDUR 623,795
1986 SA580A URETHROTOMY - INCLUDE CYSTOSCOPY - SA PROSEDUR 2,278,794
1987 SA581 URETHRAL MEATOTOMY - SA PROSEDUR 699,988
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1988 SA581E URETHRAL MEATOTOMY - ENDOSCOPIC - SA PROSEDUR 1,688,206

1989 SA5822 OTHER URETHROSCOPY - SA PROSEDUR 590,588
1990 SA5831 ENDOSCOPIC EXCISION OR DESTRUCTION OF LESION OR TISSUE OF URETHRA - SA PROSEDUR 2,910,920
1991 SA5839 OTHER LOCAL EXCISION OR DESTRUCTION OF LESION OR TISSUE OF URETHRA - SA PROSEDUR 831,847
OTHER LOCAL EXCISION OR DESTRUCTION OF LESION OR TISSUE OF URETHRA -
1992 SA5839A PROSEDUR 3,118,973
URETHRECTOMY - SA
1993 SA5839B PROSEDUR 2,278,794
VALVE RESECTION - SA
1994 SA5839C PROSEDUR 1,688,206
DIVERTICULECTOMY - SA
1995 SA5839D PROSEDUR 669,438
PROLAPSE URETHRA - SA
1996 SA5843 CLOSURE OF OTHER FISTULA OF URETHRA - SA PROSEDUR 1,580,255
CLOSURE OF OTHER FISTULA OF URETHRA - REPAIR OF URETHRO-VAGINAL FISTULA -
1997 SA5843A PROSEDUR 2,994,238
SA
1998 SA5845 REPAIR OF HYPOSPADIAS OR EPISPADIAS - SA PROSEDUR 3,609,459
1999 SA5845EA REPAIR OF HYPOSPADIAS OR EPISPADIAS - GLANDULAR HYPOSPADIA - SA PROSEDUR 2,411,861
2000 SA5845EB REPAIR OF HYPOSPADIAS OR EPISPADIAS - CORPORAL HYPOSPADIA - SA PROSEDUR 2,744,527
2001 SA5845EC REPAIR OF HYPOSPADIAS OR EPISPADIAS - PERINEAL HYPOSPADIA - SA PROSEDUR 3,077,193
2002 SA5846 OTHER RECONSTRUCTION OF URETHRA - SA PROSEDUR 3,118,973
2003 SA5846A OTHER RECONSTRUCTION OF URETHRA-URETHROCELE - SA PROSEDUR 2,561,591
2004 SA5846B OTHER RECONSTRUCTION OF URETHRA (COMPLEX) - SA PROSEDUR 3,576,253
2005 SA5847 URETHRAL MEATOPLASTY - SA PROSEDUR 2,079,194
2006 SA586 DILATION OF URETHRA - SA PROSEDUR 457,401
2007 SA5900 RETROPERITONEAL DISSECTION, NOT OTHERWISE SPECIFIED - SA PROSEDUR 3,934,156
2008 SA5902 OTHER LYSIS OF PERIRENAL OR PERIURETERAL ADHESIONS - SA PROSEDUR 3,118,973
2009 SA5902B OTHER LYSIS OF PERIRENAL OR PERIURETERAL ADHESIONS - BILATERAL - SA PROSEDUR 3,734,073
2010 SA594 SUPRAPUBIC SLING OPERATION - SA PROSEDUR 3,077,193
2011 SA595 RETROPUBIC URETHRAL SUSPENSION - SA PROSEDUR 3,077,193
2012 SA598 URETERAL CATHETERIZATION - SA PROSEDUR 1,455,521
2013 SA598A URETERAL CATHETERIZATION - DRAINAGE OF KIDNEY - SA PROSEDUR 2,910,920
2014 SA600 INCISION OF PROSTATE - SA PROSEDUR 1,946,007
2015 SA6011 CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF PROSTATE - SA PROSEDUR 590,588
2016 SA6012 OPEN BIOPSY OF PROSTATE - SA PROSEDUR 1,360,370
2017 SA6018 OTHER DIAGNOSTIC PROCEDURES ON PROSTATE AND PERIPROSTATIC TISSUE - SA PROSEDUR 1,360,370
2018 SA6029 OTHER TRANSURETHRAL PROSTATECTOMY - SA PROSEDUR 2,969,122
2019 SA605 RADICAL PROSTATECTOMY - SA PROSEDUR 4,407,979
2020 SA6061 LOCAL EXCISION OF LESION OF PROSTATE - SA PROSEDUR 2,969,122
2021 SA6079 OTHER OPERATIONS ON SEMINAL VESICLES - SA PROSEDUR 2,278,794
2022 SA6095 TRANSURETHRAL BALLOON DILATION OF THE PROSTATIC URETHRA - SA PROSEDUR 2,744,527
TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE BY MICROWAVE
2023 SA6096 PROSEDUR 2,278,794
THERMOTHERAPY - SA
OTHER TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE BY OTHER
2024 SA6097 PROSEDUR 2,278,794
THERMOTHERAPY - SA
2025 SA612 EXCISION OF HYDROCELE (OF TUNICA VAGINALIS) - SA PROSEDUR 2,245,588
2026 SA6212 OPEN BIOPSY OF TESTIS - SA PROSEDUR 699,988
2027 SA6219 OTHER DIAGNOSTIC PROCEDURES ON TESTES - SA PROSEDUR 1,688,206
2028 SA622 EXCISION OR DESTRUCTION OF TESTICULAR LESION - SA PROSEDUR 880,268
2029 SA623 UNILATERAL ORCHIECTOMY - SA PROSEDUR 1,946,007
2030 SA623L UNILATERAL ORCHIECTOMY - LAPAROSCOPIC - SA PROSEDUR 4,225,043
2031 SA6241 REMOVAL OF BOTH TESTES AT SAME OPERATIVE EPISODE - SA PROSEDUR 3,118,973
2032 SA625 ORCHIOPEXY - SA PROSEDUR 1,455,521
2033 SA625A ORCHIOPEXY - MICROVASCULAR TRANSFER OF TESTIS TO SCROTUM - SA PROSEDUR 4,075,313
2034 SA625B ORCHIOPEXY - BILATERAL FIXATION OF TESTIS - SA PROSEDUR 2,561,591
2035 SA625C ORCHIOPEXY - ABDOMINAL UNDESCENDED TESTIS - SA PROSEDUR 2,278,794
2036 SA625D ORCHIOPEXY - FIXATION OF TESTIS - SA PROSEDUR 2,661,692
2037 SA627 INSERTION OF TESTICULAR PROSTHESIS - SA PROSEDUR 2,910,920
2038 SA631 EXCISION OF VARICOCELE AND HYDROCELE OF SPERMATIC CORD - SA PROSEDUR 1,360,370
2039 SA632 EXCISION OF CYST OF EPIDIDYMIS - SA PROSEDUR 1,946,007
2040 SA634 EPIDIDYMECTOMY - SA PROSEDUR 2,561,591
2041 SA634B EPIDIDYMECTOMY-BILATERAL - SA PROSEDUR 1,946,007
2042 SA640 CIRCUMCISION - SA PROSEDUR 1,056,442
2043 SA6411 BIOPSY OF PENIS - SA PROSEDUR 590,588
2044 SA643 AMPUTATION OF PENIS - SA PROSEDUR 3,118,973
2045 SA643P AMPUTATION OF PENIS-PARTIAL - SA PROSEDUR 2,278,794
2046 SA6444 RECONSTRUCTION OF PENIS - SA PROSEDUR 2,561,591
2047 SA6445 REPLANTATION OF PENIS - SA PROSEDUR 3,118,973
2048 SA6449 OTHER REPAIR OF PENIS - SA PROSEDUR 2,278,794
2049 SA6493 DIVISION OF PENILE ADHESIONS - SA PROSEDUR 590,588
2050 SA6493P DIVISION OF PENILE ADHESIONS-PEYRONIE"S - SA PROSEDUR 2,910,920
2051 SA6521 MARSUPIALIZATION OF OVARIAN CYST - SA PROSEDUR 2,564,368
2052 SA6523 LAPAROSCOPIC MARSUPIALIZATION OF OVARIAN CYST - SA PROSEDUR 2,278,794
2053 SA6525 OTHER LAPAROSCOPIC LOCAL EXCISION OR DESTRUCTION OF OVARY - SA PROSEDUR 2,744,527
2054 SA6549 OTHER UNILATERAL SALPINGO-OOPHORECTOMY - SA PROSEDUR 2,278,794
2055 SA6561 OTHER REMOVAL OF BOTH OVARIES AND TUBES AT SAME OPERATIVE EPISODE - SA PROSEDUR 2,969,122
2056 SA6622A BILATERAL ENDOSCOPIC LIGATION AND DIVISION OF FALLOPIAN TUBES - SA PROSEDUR 1,546,928
OTHER BILATERAL LIGATION AND CRUSHING OF FALLOPIAN TUBES / STERILIZATION
2057 SA6631 PROSEDUR 1,546,928
- SA
OTHER BILATERAL LIGATION AND DIVISION OF FALLOPIAN TUBES. POMEROY
2058 SA6632A PROSEDUR 1,546,928
OPERATION - SA
2059 SA6711 ENDOCERVICAL BIOPSY - SA PROSEDUR 540,839
2060 SA6712 OTHER CERVICAL BIOPSY - SA PROSEDUR 831,847
2061 SA6712C OTHER CERVICAL BIOPSY (COMPLEX) - SA PROSEDUR 1,120,560
2062 SA672 CONIZATION OF CERVIX - SA PROSEDUR 1,514,205
2063 SA6732 DESTRUCTION OF LESION OF CERVIX BY CAUTERIZATION - SA PROSEDUR 1,164,513
2064 SA674 AMPUTATION OF CERVIX - SA PROSEDUR 2,278,794
2065 SA6812 HYSTEROSCOPY - SA PROSEDUR 1,360,370
2066 SA6813 OPEN BIOPSY OF UTERUS - SA PROSEDUR 590,588
2067 SA6823 ENDOMETRIAL ABLATION - SA PROSEDUR 2,578,133
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2068 SA6829 OTHER EXCISION OR DESTRUCTION OF LESION OF UTERUS - SA PROSEDUR 2,969,122

2069 SA6839 OTHER AND UNSPECIFIED SUBTOTAL ABDOMINAL HYSTERECTOMY - SA PROSEDUR 3,243,587
2070 SA6849 OTHER AND UNSPECIFIED TOTAL ABDOMINAL HYSTERECTOMY - SA PROSEDUR 3,243,587
OTHER AND UNSPECIFIED TOTAL ABDOMINAL HYSTERECTOMY + REMOVAL OF
2071 SA6849A PROSEDUR 3,243,587
ADNEXA - SA
2072 SA6849B PROSEDUR 4,208,500
ADNEXA (OVARIAN) - SA
2073 SA6851 LAPAROSCOPICALLY ASSISTED VAGINAL HYSTERECTOMY (LAVH) - SA PROSEDUR 3,576,253
2074 SA6859 OTHER AND UNSPECIFIED VAGINAL HYSTERECTOMY - SA PROSEDUR 3,576,253
2075 SA6869 OTHER AND UNSPECIFIED RADICAL ABDOMINAL HYSTERECTOMY - SA PROSEDUR 6,327,421
2076 SA688 PELVIC EVISCERATION - SA PROSEDUR 5,752,651
2077 SA688A PELVIC EVISCERATION - ANTERIOR/POSTERIOR - SA PROSEDUR 7,235,340
2078 SA689 OTHER AND UNSPECIFIED HYSTERECTOMY - SA PROSEDUR 3,642,665
2079 SA6902 DILATION AND CURETTAGE FOLLOWING DELIVERY OR ABORTION - SA PROSEDUR 1,580,255
2080 SA6909 OTHER DILATION AND CURETTAGE - SA PROSEDUR 756,982
2081 SA6922 OTHER UTERINE SUSPENSION - SA PROSEDUR 1,946,007
2082 SA6923 VAGINAL REPAIR OF CHRONIC INVERSION OF UTERUS - SA PROSEDUR 1,580,255
2083 SA6929 OTHER REPAIR OF UTERUS AND SUPPORTING STRUCTURES - SA PROSEDUR 1,946,007
2084 SA6949 OTHER REPAIR OF UTERUS - SA PROSEDUR 2,578,133
2085 SA7013 LYSIS OF INTRALUMINAL ADHESIONS OF VAGINA - SA PROSEDUR 970,347
2086 SA7014 OTHER VAGINOTOMY - SA PROSEDUR 1,247,468
2087 SA7033 EXCISION OR DESTRUCTION OF LESION OF VAGINA - SA PROSEDUR 1,513,722
2088 SA7051 REPAIR OF CYSTOCELE - SA PROSEDUR 2,910,920
2089 SA7051A REPAIR OF CYSTOCELE-CERVIX UTERI - SA PROSEDUR 3,492,815
2090 SA7051B REPAIR OF CYSTOCELE-VAGINAL HYSTERECTOMY - SA PROSEDUR 3,609,459
2091 SA7052 REPAIR OF RECTOCELE - SA PROSEDUR 2,561,591
2092 SA7062 VAGINAL RECONSTRUCTION - SA PROSEDUR 4,324,541
2093 SA7073 REPAIR OF RECTOVAGINAL FISTULA - SA PROSEDUR 3,825,602
2094 SA708 OBLITERATION OF VAGINAL VAULT - SA PROSEDUR 2,744,527
2095 SA7123 MARSUPIALIZATION OF BARTHOLIN"S GLAND (CYST) - SA PROSEDUR 1,514,205
2096 SA7124 EXCISION OR OTHER DESTRUCTION OF BARTHOLIN"S GLAND (CYST) - SA PROSEDUR 1,514,205
2097 SA713 OTHER LOCAL EXCISION OR DESTRUCTION OF VULVA AND PERINEUM - SA PROSEDUR 784,271
2098 SA715 RADICAL VULVECTOMY - SA PROSEDUR 4,208,500
2099 SA7161 UNILATERAL VULVECTOMY - SA PROSEDUR 2,598,782
2100 SA7179 OTHER REPAIR OF VULVA AND PERINEUM - SA PROSEDUR 1,164,513
2101 SA718 OTHER OPERATIONS ON VULVA - SA PROSEDUR 880,268
2102 SA7279 OTHER VACUUM EXTRACTION - SA PROSEDUR 2,495,299
2103 SA7359 OTHER MANUALLY ASSISTED DELIVERY - SA PROSEDUR 2,278,794
2104 SA740 CLASSICAL CESAREAN SECTION - SA PROSEDUR 2,789,929
2105 SA741 LOW CERVICAL CESAREAN SECTION - SA PROSEDUR 2,789,929
2106 SA7411 LOW CERVICAL CESAREAN SECTION -OPERATOR KE-2 - SA PROSEDUR 2,789,929
2107 SA741A LOW CERVICAL CESAREAN SECTION (2-4BED) - SA PROSEDUR 2,789,929
2108 SA742 EXTRAPERITONEAL CESAREAN SECTION - SA PROSEDUR 2,789,929
2109 SA743 REMOVAL OF EXTRATUBAL ECTOPIC PREGNANCY - SA PROSEDUR 2,744,527
2110 SA744 CESAREAN SECTION OF OTHER SPECIFIED TYPE - SA PROSEDUR 2,789,929
2111 SA744LC CESAREAN SECTION OF OTHER SPECIFIED TYPE - GEMILI - SA PROSEDUR 2,789,929
2112 SA7491 HYSTEROTOMY TO TERMINATE PREGNANCY - SA PROSEDUR 2,789,929
2113 SA7499 OTHER CESAREAN SECTION OF UNSPECIFIED TYPE - SA PROSEDUR 2,789,929
2114 SA752 INTRAUTERINE TRANSFUSION - SA PROSEDUR 1,580,255
2115 SA7562 REPAIR OF CURRENT OBSTETRIC LACERATION OF RECTUM AND SPHINCTER ANI - SA PROSEDUR 3,160,631
2116 SA7569 REPAIR OF OTHER CURRENT OBSTETRIC LACERATION - SA PROSEDUR 2,774,956
2117 SA7611 BIOPSY OF FACIAL BONE - SA PROSEDUR 639,975
LOCAL EXCISION OR DESTRUCTION OF LESION OF FACIAL BONE (EXCISION OF
2118 SA762 PROSEDUR 2,474,288
MAXILLA) - SA
LOCAL EXCISION OR DESTRUCTION OF LESION OF FACIAL BONE-EXTENSIVE
2119 SA762A PROSEDUR 3,476,272
EXCISION MANDIBLE - SA
LOCAL EXCISION OR DESTRUCTION OF LESION OF FACIAL BONE - FACIAL BONE
2120 SA762B PROSEDUR 3,934,156
TUMOUR - SA
2121 SA762C LOCAL EXCISION OR DESTRUCTION OF LESION OF FACIAL BONE-TUMOUR - SA PROSEDUR 7,712,906
2122 SA762D PROSEDUR 1,688,206
LESION OF JAW) - SA
2123 SA7631 PARTIAL MANDIBULECTOMY - SA PROSEDUR 8,895,653
2124 SA7631A PARTIAL MANDIBULECTOMY-SEGMENTAL/MARGINAL - SA PROSEDUR 7,712,906
2125 SA7631B PARTIAL MANDIBULECTOMY-WITH RECONSTRUCTION - SA PROSEDUR 10,190,093
2126 SA7639 PARTIAL OSTECTOMY OF OTHER FACIAL BONE - SA PROSEDUR 1,395,025
2127 SA7639A PARTIAL OSTECTOMY OF OTHER FACIAL BONE-HEMIMAXILLECTOMY - SA PROSEDUR 3,734,073
2128 SA7639C PARTIAL OSTECTOMY OF OTHER FACIAL BONE-MAXILLECTOMY - SA PROSEDUR 8,895,653
2129 SA7641 TOTAL MANDIBULECTOMY WITH SYNCHRONOUS RECONSTRUCTION - SA PROSEDUR 10,190,093
2130 SA7642 OTHER TOTAL MANDIBULECTOMY - SA PROSEDUR 5,051,818
2131 SA7643 OTHER RECONSTRUCTION OF MANDIBLE - SA PROSEDUR 8,895,653
TOTAL OSTECTOMY OF OTHER FACIAL BONE WITH SYNCHRONOUS
2132 SA7644 PROSEDUR 3,934,156
RECONSTRUCTION - SA
2133 SA765 TEMPOROMANDIBULAR ARTHROPLASTY - SA PROSEDUR 2,973,227
2134 SA7661 CLOSED OSTEOPLASTY [OSTEOTOMY] OF MANDIBULAR RAMUS - SA PROSEDUR 1,829,000
2135 SA767 REDUCTION OF FACIAL FRACTURE. INCLUDES INTERNAL FIXATION - SA PROSEDUR 1,351,917
2136 SA7670 REDUCTION OF FACIAL FRACTURE, NOT OTHERWISE SPECIFIED - SA PROSEDUR 1,247,468
REDUCTION OF FACIAL FRACTURE, NOT OTHERWISE SPECIFIED- TRANS ORAL
2137 SA7670A PROSEDUR 8,682,650
SURGERY WITH POST. FIXATION - SA
2138 SA7671 CLOSED REDUCTION OF MALAR AND ZYGOMATIC FRACTURE - SA PROSEDUR 1,577,116
2139 SA7672 OPEN REDUCTION OF MALAR AND ZYGOMATIC FRACTURE - SA PROSEDUR 2,468,734
2140 SA7673 CLOSED REDUCTION OF MAXILLARY FRACTURE - SA PROSEDUR 1,351,555
2141 SA7674 OPEN REDUCTION OF MAXILLARY FRACTURE - SA PROSEDUR 1,971,968
2142 SA7675 CLOSED REDUCTION OF MANDIBULAR FRACTURE - SA PROSEDUR 1,171,154
2143 SA7675A CLOSED REDUCTION OF MANDIBULAR FRACTURE (EXTRA) - SA PROSEDUR 1,577,116
2144 SA7676 OPEN REDUCTION OF MANDIBULAR FRACTURE - SA PROSEDUR 1,688,206
OPEN REDUCTION OF MANDIBULAR FRACTURE (RAISED WIRING MANDIBLE /
2145 SA7676A PROSEDUR 1,971,968
MAXILLA) - SA
2146 SA7677 OPEN REDUCTION OF ALVEOLAR FRACTURE - SA PROSEDUR 1,144,348
2147 SA7679 OTHER OPEN REDUCTION OF FACIAL FRACTURE - SA PROSEDUR 1,946,007
2148 SA7691 BONE GRAFT TO FACIAL BONE - SA PROSEDUR 1,946,007
2149 SA7692 INSERTION OF SYNTHETIC IMPLANT IN FACIAL BONE - SA PROSEDUR 3,351,658
2150 SA7693 CLOSED REDUCTION OF TEMPOROMANDIBULAR DISLOCATION - SA PROSEDUR 1,144,348
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2151 SA7695 OTHER MANIPULATION OF TEMPOROMANDIBULAR JOINT - SA PROSEDUR 639,975

2152 SA7696 INJECTION OF THERAPEUTIC SUBSTANCE INTO TEMPOROMANDIBULAR JOINT - SA PROSEDUR 582,136
REMOVAL OF INTERNAL FIXATION DEVICE FROM FACIAL BONE (FIXATOR MAXILLA) -
2153 SA7697 PROSEDUR 910,334
SA
2154 SA7700 SEQUESTRECTOMY UNSPECIFIED SITE - SA PROSEDUR 2,108,295
2155 SA7720 WEDGE OSTEOTOMY-UNSPECIFIED SITE - SA PROSEDUR 3,216,659
2156 SA7728 WEDGE OSTEOTOMY - TARSAL/METATARSAL - SA PROSEDUR 1,255,921
2157 SA7728A WEDGE OSTEOTOMY - TARSAL/METATARSAL (CLOSING) - SA PROSEDUR 2,561,591
2158 SA7740 BIOPSY OF BONE, UNSPECIFIED SITE - SA PROSEDUR 1,056,442
BUNIONECTOMY WITH SOFT TISSUE CORRECTION AND OSTEOTOMY OF THE FIRST
2159 SA7751 PROSEDUR 2,973,227
METATARSAL - SA
2160 SA7751A PROSEDUR 2,278,794
METATARSAL (CORRECTION MINOR) - SA
2161 SA7751B PROSEDUR 4,208,500
METATARSAL - BILATERAL - SA
2162 SA7752 BUNIONECTOMY WITH SOFT TISSUE CORRECTION AND ARTHRODESIS - SA PROSEDUR 1,829,000
2163 SA7753 OTHER BUNIONECTOMY WITH SOFT TISSUE CORRECTION - SA PROSEDUR 2,108,295
2164 SA7753B OTHER BUNIONECTOMY WITH SOFT TISSUE CORRECTION - BILATERAL - SA PROSEDUR 3,118,973
2165 SA7754 EXCISION OR CORRECTION OF BUNIONETTE - SA PROSEDUR 1,144,348
2166 SA7754A EXCISION OR CORRECTION OF BUNIONETTE-SIMPLE BILATERAL - SA PROSEDUR 1,688,206
2167 SA7754B EXCISION OR CORRECTION OF BUNIONETTE-BILATERAL - SA PROSEDUR 3,609,459
2168 SA7757 REPAIR OF CLAW TOE - SA PROSEDUR 1,946,007
2169 SA7759 OTHER BUNIONECTOMY - SA PROSEDUR 2,774,956
2170 SA7759A OTHER BUNIONECTOMY-KELLER"S UNILATERAL - SA PROSEDUR 1,829,000
2171 SA7759B OTHER BUNIONECTOMY-KELLER"S BILATERAL - SA PROSEDUR 2,744,527
2172 SA776 LOCAL EXCISION OF LESION OR TISSUE OF BONE - SA PROSEDUR 1,395,025
2173 SA7761 LOCAL EXCISION OF LESION OR TISSUE OF BONE-CLAVICLE - SA PROSEDUR 2,278,794
2174 SA7769 LOCAL EXCISION OF LESION OR TISSUE OF BONE-PELVIS - SA PROSEDUR 2,278,794
2175 SA7788 OTHER PARTIAL OSTECTOMY-TARSAL - SA PROSEDUR 2,744,527
2176 SA7790 TOTAL OSTECTOMY-UNSPECIFIED SITE - SA PROSEDUR 3,910,368
2177 SA7800 BONE GRAFT-UNSPECIFIED SITE - SA PROSEDUR 2,468,734
2178 SA7800A BONE GRAFT-UNSPECIFIED SITE (COMPLEX) - SA PROSEDUR 10,190,093
2179 SA7801 BONE GRAFT-CLAVICLE, SCAPULA - SA PROSEDUR 2,278,794
2180 SA7804 BONE GRAFT-CARPAL - SA PROSEDUR 2,973,227
2181 SA781 APPLICATION OF EXTERNAL FIXATOR DEVICE - SA PROSEDUR 880,751
2182 SA7810 APPLICATION OF EXTERNAL FIXATOR DEVICE-UNSPECIFIED SITE - SA PROSEDUR 2,774,956
2183 SA7820E LIMB SHORTENING PROCEDURES-UNSPECIFIED SITE, EPIPHYSIS - SA PROSEDUR 1,829,000
2184 SA7829 LIMB SHORTENING PROCEDURES-PELVIC - SA PROSEDUR 5,231,132
2185 SA7829H LIMB SHORTENING PROCEDURES-HIP - SA PROSEDUR 3,631,073
2186 SA7850 INTERNAL FIXATION OF BONE WITHOUT FRACTURE REDUCTION-NAILLING - SA PROSEDUR 910,334
INTERNAL FIXATION OF BONE WITHOUT FRACTURE REDUCTION-LOCKED
2187 SA7850A PROSEDUR 2,770,971
INTRAMEDULLARY NAILING - SA
INTERNAL FIXATION OF BONE WITHOUT FRACTURE REDUCTION-NAILLING
2188 SA7850B PROSEDUR 3,351,658
(MULTIPLE FRACTURE FIXATION) - SA
REMOVAL OF EXTERNAL IMMOBILIZATION DEVICE (EXTERNAL FIXATION FROM
2189 SA7860F PROSEDUR 910,334
BONE) - SA
2190 SA7860K REMOVAL OF IMPLANTED DEVICES FROM BONE-K-WIRE, UNSPECIFIED SITE - SA PROSEDUR 2,108,295
REMOVAL OF EXTERNAL IMMOBILIZATION DEVICE (SKELETAL TRACTION FROM
2191 SA7860T PROSEDUR 639,975
BONE) - SA
CLOSED REDUCTION OF FRACTURE WITHOUT INTERNAL FIXATION-UNSPECIFIED
2192 SA7900 PROSEDUR 1,144,348
SITE - SA
2193 SA791 CLOSED REDUCTION OF FRACTURE WITH INTERNAL FIXATION - SA PROSEDUR 2,108,295
2194 SA7930 OPEN REDUCTION OF FRACTURE WITH INTERNAL FIXATION-UNSPECIFIED SITE - SA PROSEDUR 3,216,659
OPEN REDUCTION OF FRACTURE WITH INTERNAL FIXATION HUMERUS - SMALL BONE
2195 SA7931 PROSEDUR 2,108,295
- SA
OPEN REDUCTION OF FRACTURE WITH INTERNAL FIXATION HUMERUS - LONG BONE -
2196 SA7931A PROSEDUR 2,973,227
SA
OPEN REDUCTION OF FRACTURE WITH INTERNAL FIXATION HUMERUS (COMPLEX) -
2197 SA7931C PROSEDUR 4,208,500
SA
2198 SA7935 OPEN REDUCTION OF FRACTURE WITH INTERNAL FIXATION-FEMUR - SA PROSEDUR 3,631,073
OPEN REDUCTION OF FRACTURE WITH INTERNAL FIXATION OTHER SPECIFIED BONE
2199 SA7939 PROSEDUR 2,108,295
- SA
2200 SA7939C PROSEDUR 4,208,500
(COMPLEX) - SA
2201 SA7980 OPEN REDUCTION OF DISLOCATION OF UNSPECIFIED SITE - SA PROSEDUR 2,973,227
2202 SA7987 OPEN REDUCTION OF DISLOCATION OF ANKLE - SA PROSEDUR 2,744,527
ARTHROTOMY FOR REMOVAL OF PROSTHESIS WITHOUT REPLACEMENT-UNSPECIFIED
2203 SA8000 PROSEDUR 1,829,000
SITE - SA
2204 SA8009 ARTHROTOMY FOR REMOVAL OF PROSTHESIS WITHOUT REPLACEMENT-SPINE - SA PROSEDUR 2,962,481
2205 SA8020 ARTHROSCOPY - UNSPECIFIED SITE - SA PROSEDUR 1,255,921
2206 SA8020A ARTHROSCOPY - UNSPECIFIED CAVITY UNILATERAL - SA PROSEDUR 2,973,227
2207 SA8020B ARTHROSCOPY - UNSPECIFIED CAVITY BILATERAL - SA PROSEDUR 4,559,158
2208 SA8020C ARTHROSCOPY - UNSPECIFIED CAVITY UNILATERAL (ARTICULAR CARTILAGE) - SA PROSEDUR 1,829,000
2209 SA8021 ARTHROSCOPY - SHOULDER - SA PROSEDUR 2,973,227
2210 SA8021R ARTHROSCOPY - REVISION SHOULDER - SA PROSEDUR 3,765,951
2211 SA8026 ARTHROSCOPY - KNEE - SA PROSEDUR 1,144,348
2212 SA8026A ARTHROSCOPY - KNEE EXTENSIVE - SA PROSEDUR 3,118,973
2213 SA8026B ARTHROSCOPY - KNEE SEMILUNAR CARTILAGE - SA PROSEDUR 2,973,227
2214 SA8026C ARTHROSCOPY - KNEE SEMILUNAR CARTILAGE BILATERAL - SA PROSEDUR 4,208,500
2215 SA8030 BIOPSY OF JOINT STRUCTURE-UNSPECIFIED - SA PROSEDUR 1,255,921
2216 SA8051 EXCISION OF INTERVERTEBRAL DISC - SA PROSEDUR 3,118,973
EXCISION OF INTERVERTEBRAL DISC-POSTERIOR DECOMPRESSION W INSTRUMENT -
2217 SA8051A PROSEDUR 5,050,007
SA
2218 SA8051C EXCISION OF INTERVERTEBRAL DISC-CERVICAL - SA PROSEDUR 4,208,500
2219 SA8051D EXCISION OF INTERVERTEBRAL DISC-CERVICAL WITH FUSION - SA PROSEDUR 5,231,132
2220 SA8051E EXCISION OF INTERVERTEBRAL DISC-DISCECTOMY LASER - SA PROSEDUR 4,559,158
EXCISION OF INTERVERTEBRAL DISC-ANTERIOR & POSTERIOR DECOMPRESSION W
2221 SA8051F PROSEDUR 7,593,122
INSTRUMENT - SA
Page 27
TARIF INSURANCE
EXCISION OF INTERVERTEBRAL DISC-OPEN DOOR LAMINOPLASTY CERVICAL REGION

2222 SA8051G PROSEDUR 5,754,462
(HIROBYASHI) - SA
2223 SA8052 INTERVERTEBRAL CHEMONUCLEOLYSIS - SA PROSEDUR 2,194,873
2224 SA8054 OTHER AND UNSPECIFIED REPAIR OF THE ANULUS FIBROSUS - SA PROSEDUR 4,171,671
2225 SA8054A OTHER AND UNSPECIFIED REPAIR OF THE ANULUS FIBROSUS (REVISION) - SA PROSEDUR 4,839,781
2226 SA8059 OTHER DESTRUCTION OF INTERVERTEBRAL DISC - SA PROSEDUR 3,742,646
2227 SA807 SYNOVECTOMY - SA PROSEDUR 2,278,794
2228 SA8074 SYNOVECTOMY-HAND - SA PROSEDUR 3,476,272
2229 SA8100 SPINAL FUSION, NOT OTHERWISE SPECIFIED - SA PROSEDUR 4,208,500
2230 SA8100A SPINAL FUSION, NOS (PRIMARY POST/ANT DECOMPRESSION W FUSION) - SA PROSEDUR 5,231,132
SPINAL FUSION, NOS (PRIMARY POST/ANT DECOMPRESSION W FUSION &
2231 SA8100B PROSEDUR 5,754,462
INSTRUMENT) - SA
SPINAL FUSION, NOS (PRIMARY POST/ANT. EXCISION DISC W FUSION AND OR
2232 SA8100C PROSEDUR 5,231,132
INSTRUMENT) - SA
SPINAL FUSION, NOS (COMBINED ANT. & POST. FUSION CERVICAL SPINE, W
2233 SA8100D PROSEDUR 8,682,650
INSTRUMENT) - SA
SPINAL FUSION, NOS (PRIMARY TRANSTHORACIC/POST./ANT.-LAT.EX. VERTEBRAL
2234 SA8100E PROSEDUR 4,839,781
DISC W FUSION) - SA
SPINAL FUSION, NOS (COMBINED ANT. & POST. DECOMPRESSION, W FUSION &
2235 SA8100F PROSEDUR 9,550,721
INSTRUMENT) - SA
2236 SA8100G SPINAL FUSION, NOS (REVISION POST. / ANT. DECOMPRESSION W FUSION) - SA PROSEDUR 7,593,122
SPINAL FUSION, NOS (REVISION POST/ANT EXCISION INTERVERTEBRAL DISC W
2237 SA8100H PROSEDUR 6,902,674
FUSION AND/OR W INSTRUMENT) - SA
SPINAL FUSION, NOS (PRIMARY POST/ANT TRANSTHORACIC DECOMPRESSION W
2238 SA8100I PROSEDUR 6,902,674
FUSION AND/OR W INSTRUMENT) - SA
LUMBAR AND LUMBOSACRAL FUSION OF THE ANTERIOR COLUMN, POSTERIOR
2239 SA8108 PROSEDUR 4,171,671
TECHNIQUE - SA
2240 SA8115 TARSOMETATARSAL FUSION - SA PROSEDUR 1,395,025
2241 SA8115B TARSOMETATARSAL FUSION-BILATERAL - SA PROSEDUR 2,561,591
2242 SA8116 METATARSOPHALANGEAL FUSION - SA PROSEDUR 2,278,794
2243 SA8120 ARTHRODESIS OF UNSPECIFIED JOINT - SA PROSEDUR 1,829,000
2244 SA8126 METACARPOCARPAL FUSION - SA PROSEDUR 1,395,025
2245 SA8128 INTERPHALANGEAL FUSION - SA PROSEDUR 1,395,025
2246 SA8128B INTERPHALANGEAL FUSION-BILATERAL - SA PROSEDUR 2,561,591
2247 SA8129 ARTHRODESIS OF OTHER SPECIFIED JOINTS - SA PROSEDUR 2,774,956
2248 SA8129A ARTHRODESIS OF OTHER SPECIFIED JOINTS-TRIPLE FUSION - SA PROSEDUR 2,744,527
2249 SA8144 PATELLAR STABILIZATION - SA PROSEDUR 3,609,459
2250 SA8145 OTHER REPAIR OF THE CRUCIATE LIGAMENTS - SA PROSEDUR 4,045,246
2251 SA8147 OTHER REPAIR OF KNEE - SA PROSEDUR 1,577,116
2252 SA8149 OTHER REPAIR OF ANKLE - SA PROSEDUR 3,476,272
2253 SA8149B OTHER REPAIR OF ANKLE-BILATERAL - SA PROSEDUR 5,231,132
2254 SA8151 TOTAL HIP REPLACEMENT - SA PROSEDUR 5,666,918
2255 SA8151A TOTAL HIP REPLACEMENT-BILATERAL - SA PROSEDUR 6,327,421
2256 SA8153 REVISION OF HIP REPLACEMENT, NOT OTHERWISE SPECIFIED - SA PROSEDUR 4,261,751
2257 SA8154 TOTAL KNEE REPLACEMENT - SA PROSEDUR 5,666,918
2258 SA8154B TOTAL KNEE REPLACEMENT-BILATERAL - SA PROSEDUR 6,327,421
2259 SA8154C TOTAL KNEE REPLACEMENT-UNICOMPARTMENTAL - SA PROSEDUR 4,261,751
2260 SA8155 REVISION OF KNEE REPLACEMENT,NOT OTHERWISE SPECIFIED - SA PROSEDUR 6,327,421
2261 SA8156 TOTAL ANKLE REPLACEMENT - SA PROSEDUR 5,231,132
2262 SA8157 REPLACEMENT OF JOINT OF FOOT AND TOE - SA PROSEDUR 3,476,272
REVISION OF JOINT REPLACEMENT OF LOWER EXTREMITY, NOT ELSEWHERE
2263 SA8159 PROSEDUR 6,327,421
CLASSIFIED - SA
2264 SA8165A PERCUTANEOUS VERTEBROPLASTY-CT GUIDE - SA PROSEDUR 4,559,158
2265 SA8165B PERCUTANEOUS VERTEBROPLASTY-FLUOROSCOPICALLY GUIDE - SA PROSEDUR 3,378,585
2266 SA8166A PERCUTANEOUS VERTEBRAL AUGMENTATION-POSTERIOR - SA PROSEDUR 8,682,650
2267 SA8166B PERCUTANEOUS VERTEBRAL AUGMENTATION-ANTERIOR - SA PROSEDUR 10,221,005
2268 SA8173 TOTAL WRIST REPLACEMENT - SA PROSEDUR 6,861,498
2269 SA8179 OTHER REPAIR OF HAND, FINGERS AND WRIST - SA PROSEDUR 2,969,122
2270 SA8180 OTHER TOTAL SHOULDER REPLACEMENT - SA PROSEDUR 5,231,132
2271 SA8180R TOTAL SHOULDER REPLACEMENT-REVISION - SA PROSEDUR 6,327,421
2272 SA8181 PARTIAL SHOULDER REPLACEMENT - SA PROSEDUR 3,631,073
2273 SA8181R PARTIAL SHOULDER REPLACEMENT-REVISION - SA PROSEDUR 4,045,246
2274 SA8184 TOTAL ELBOW REPLACEMENT - SA PROSEDUR 5,231,132
2275 SA8184R TOTAL ELBOW REPLACEMENT-REVISION - SA PROSEDUR 6,327,421
2276 SA8190S OTHER REPAIR OF JOINT-STABILIZATION - SA PROSEDUR 2,468,734
2277 SA8191 ARTHROCENTESIS - SA PROSEDUR 474,065
2278 SA8192 INJECTION OF THERAPEUTIC SUBSTANCE INTO JOINT OR LIGAMENT - SA PROSEDUR 910,334
2279 SA8192A INJECTION OF THERAPEUTIC SUBSTANCE INTO JOINT OR LIGAMENT-FACET - SA PROSEDUR 474,065
2280 SA8192X INJECTION OF THERAPEUTIC SUBSTANCE INTO JOINT OR LIGAMENT-XRAY - SA PROSEDUR 551,103
2281 SA8193 SUTURE OF CAPSULE OR LIGAMENT OF UPPER EXTREMITY (ARCOMIOPLASTY) - SA PROSEDUR 2,468,734
SUTURE OF CAPSULE OR LIGAMENT OF UPPER EXTREMITY (PRIMARY / SECONDARY) -
2282 SA8193A PROSEDUR 3,934,156
SA
2283 SA8196 OTHER REPAIR OF JOINT - SA PROSEDUR 2,468,734
2284 SA8196A OTHER REPAIR OF JOINT (RECONSTRUCTION) - SA PROSEDUR 4,261,751
2285 SA8201 EXPLORATION OF TENDON SHEATH OF HAND - SA PROSEDUR 1,395,025
2286 SA8211 TENOTOMY OF HAND - SA PROSEDUR 551,103
2287 SA8221 EXCISION OF LESION OF TENDON SHEATH OF HAND - SA PROSEDUR 1,056,442
2288 SA8229 EXCISION OF OTHER LESION OF SOFT TISSUE OF HAND (FASCIA) - SA PROSEDUR 582,136
2289 SA8229A EXCISION OF OTHER LESION OF SOFT TISSUE OF HAND (TENDON) - SA PROSEDUR 1,056,442
2290 SA8233 OTHER TENONECTOMY OF HAND - SA PROSEDUR 1,255,921
2291 SA8235 OTHER FASCIECTOMY OF HAND - SA PROSEDUR 1,829,000
2292 SA8235A OTHER FASCIECTOMY OF HAND-DERMOFASCIECTOMY - SA PROSEDUR 3,118,973
2293 SA8235B OTHER FASCIECTOMY OF HAND-MULTIPLE - SA PROSEDUR 2,774,956
2294 SA8256 OTHER HAND TENDON TRANSFER OR TRANSPLANTATION - SA PROSEDUR 2,774,956
2295 SA8261 POLLICIZATION OPERATION CARRYING OVER NERVES AND BLOOD SUPPLY - SA PROSEDUR 4,359,558
2296 SA8279 PLASTIC OPERATION ON HAND WITH OTHER GRAFT OR IMPLANT - SA PROSEDUR 2,108,295
2297 SA8279E PLASTIC OPERATION ON HAND WITH OTHER GRAFT OR IMPLANT-EXTENSOR - SA PROSEDUR 1,255,921
2298 SA8279F PLASTIC OPERATION ON HAND WITH OTHER GRAFT OR IMPLANT-FLEXOR - SA PROSEDUR 2,774,956
2299 SA8285 OTHER TENODESIS OF HAND - SA PROSEDUR 2,468,734
2300 SA8286A OTHER TENOPLASTY OF HAND - WITH IMPLANT - SA PROSEDUR 2,973,227
Page 28
TARIF INSURANCE
2301 SA8286C OTHER TENOPLASTY OF HAND - EXCLUDE FLEXOR - SA PROSEDUR 1,577,116

2302 SA8302S MYOTOMY-SHOULDER - SA PROSEDUR 3,118,973
2303 SA8303 BURSOTOMY - SA PROSEDUR 1,056,442
2304 SA8313 OTHER TENOTOMY - SA PROSEDUR 1,829,000
2305 SA8314 DUPUYTREN"S SUBCUTANEOUS FASCIOTOMY - SA PROSEDUR 910,334
2306 SA8314A RELEASE FASCIOTOMY OF ANT./POST. COMPARTMENT OF LEG - SA PROSEDUR 2,561,591
2307 SA8319 OTHER DIVISION OF SOFT TISSUE - SA PROSEDUR 2,108,295
2308 SA8321 OPEN BIOPSY OF SOFT TISSUE - SA PROSEDUR 699,988
2309 SA8321A OPEN BIOPSY OF SOFT TISSUE (ONCOLOGY) - SA PROSEDUR 1,120,560
2310 SA8331 EXCISION OF LESION OF TENDON SHEATH - SA PROSEDUR 1,395,025
2311 SA8343 EXCISION OF MUSCLE OR FASCIA FOR GRAFT - SA PROSEDUR 1,395,025
2312 SA8344 OTHER FASCIECTOMY - SA PROSEDUR 1,056,442
2313 SA835 BURSECTOMY - SA PROSEDUR 1,056,442
2314 SA8363 ROTATOR CUFF REPAIR - SA PROSEDUR 3,118,973
2315 SA8364A OTHER SUTURE OF TENDON-ACHILLORAPHY - SA PROSEDUR 1,247,468
2316 SA8364B OTHER SUTURE OF TENDON-ACHILLORAPHY 2ND - SA PROSEDUR 2,744,527
2317 SA837 RECONSTRUCTION OF MUSCLE AND TENDON - SA PROSEDUR 2,774,956
2318 SA8375 TENDON TRANSFER OR TRANSPLANTATION - SA PROSEDUR 1,395,025
2319 SA8375M TENDON TRANSFER OR TRANSPLANTATION-MULTIPLE - SA PROSEDUR 2,278,794
2320 SA8388 OTHER PLASTIC OPERATIONS ON TENDON - SA PROSEDUR 2,744,527
INJECTION OF LOCALLY-ACTING THERAPEUTIC SUBSTANCE INTO OTHER SOFT
2321 SA8398 PROSEDUR 474,065
TISSUE - SA
2322 SA8399 OTHER OPERATIONS ON MUSCLE, TENDON, FASCIA, AND BURSA - SA PROSEDUR 699,988
2323 SA8400 UPPER LIMB AMPUTATION, NOT OTHERWISE SPECIFIED - SA PROSEDUR 7,712,906
2324 SA8401 AMPUTATION AND DISARTICULATION OF FINGER - SA PROSEDUR 1,577,116
2325 SA8403 AMPUTATION THROUGH HAND - SA PROSEDUR 1,577,116
2326 SA8405 AMPUTATION THROUGH FOREARM - SA PROSEDUR 2,468,734
2327 SA8409 INTERTHORACOSCAPULAR AMPUTATION - SA PROSEDUR 10,190,093
2328 SA8411 AMPUTATION OF TOE - SA PROSEDUR 1,395,025
2329 SA8412 AMPUTATION THROUGH FOOT - SA PROSEDUR 3,216,659
2330 SA8418 DISARTICULATION OF HIP - SA PROSEDUR 8,895,653
2331 SA8419 ABDOMINOPELVIC AMPUTATION - SA PROSEDUR 10,190,093
2332 SA8422 FINGER REATTACHMENT - SA PROSEDUR 1,395,025
2333 SA844 IMPLANTATION OR FITTING OF PROSTHETIC LIMB DEVICE - SA PROSEDUR 6,327,421
IMPLANTATION OR FITTING OF PROSTHETIC LIMB DEVICE, NOT OTHERWISE
2334 SA8440 PROSEDUR 3,378,585
SPECIFIED - SA
2335 SA8440A PROSEDUR 3,631,073
SPECIFIED - ARTHROPLASTY - SA
2336 SA8459 INSERTION OF OTHER SPINAL DEVICES - SA PROSEDUR 6,902,674
2337 SA8460 INSERTION OF SPINAL DISC PROSTHESIS, NOT OTHERWISE SPECIFIED - SA PROSEDUR 3,378,585
2338 SA8472 APPLICATION OF EXTERNAL FIXATOR DEVICE, RING SYSTEM - SA PROSEDUR 6,327,421
2339 SA8472A APPLICATION OF EXTERNAL FIXATOR DEVICE, RING SYSTEM -- ADJUSTMENT - SA PROSEDUR 2,561,591
2340 SA8481B REVISION OF INTERSPINOUS PROCESS DEVICE(S) - SA PROSEDUR 7,593,122
REVISION OF INTERSPINOUS PROCESS DEVICE(S) (REVISION POST. AND OR ANT.
2341 SA8481C PROSEDUR 7,593,122
DECOMPRESSION + FUSION WITH / WITHOUT INSTRUMENT) - SA
2342 SA8491 AMPUTATION, NOT OTHERWISE SPECIFIED - SA PROSEDUR 5,051,818
2343 SA8511 CLOSED (PERCUTANEOUS NEEDLE) BIOPSY OF BREAST - SA PROSEDUR 450,760
2344 SA8512 OPEN BIOPSY OF BREAST - SA PROSEDUR 1,121,043
2345 SA8521 LOCAL EXCISION OF LESION OF BREAST - WIDE LOCAL EXCISION - SA PROSEDUR 1,971,968
LOCAL EXCISION OF LESION OF BREAST (MULTIPLE TUMOUR MAMMAE / BILATERAL) -
2346 SA8521A PROSEDUR 5,051,818
SA
2347 SA8521B LOCAL EXCISION OF LESION OF BREAST - SA PROSEDUR 1,351,917
LOCAL EXCISION OF LESION OF BREAST - STEREOTACTIC/GUIDE WIRE EXCISION -
2348 SA8521D PROSEDUR 2,218,178
SA
2349 SA8521P LOCAL EXCISION OF LESION OF BREAST-PAPILOMA INTRADUCTAL - SA PROSEDUR 5,051,818
2350 SA8522 RESECTION OF QUADRANT OF BREAST - SA PROSEDUR 1,802,073
2351 SA8524 EXCISION OF ECTOPIC BREAST TISSUE - SA PROSEDUR 5,051,818
2352 SA8525 EXCISION OF NIPPLE - SA PROSEDUR 1,109,451
2353 SA8525A EXCISION OF NIPPLE - MICRODOCHOTOMY - SA PROSEDUR 1,351,917
UNILATERAL SUBCUTANEOUS MAMMECTOMY WITH SYNCHRONOUS IMPLANT
2354 SA8533 PROSEDUR 5,051,818
(MAJOR) - SA
2355 SA8533A UNILATERAL SUBCUTANEOUS MAMMECTOMY WITH SYNCHRONOUS IMPLANT - SA PROSEDUR 2,703,351
2356 SA8534 OTHER UNILATERAL SUBCUTANEOUS MAMMECTOMY - SA PROSEDUR 8,895,653
2357 SA8541 UNILATERAL SIMPLE MASTECTOMY - SA PROSEDUR 5,051,818
2358 SA8541A UNILATERAL SIMPLE MASTECTOMY (INCLUDE AXILLARY NODE BIOPSY) - SA PROSEDUR 2,218,178
2359 SA8543 UNILATERAL EXTENDED SIMPLE MASTECTOMY - SA PROSEDUR 8,895,653
UNILATERAL EXTENDED SIMPLE MASTECTOMY, MODIFIED RADICAL MASTECTOMY -
2360 SA8543A PROSEDUR 2,703,351
SA
2361 SA8545 UNILATERAL RADICAL MASTECTOMY - SA PROSEDUR 2,924,807
2362 SA8553 UNILATERAL BREAST IMPLANT - SA PROSEDUR 1,802,073
2363 SA8570 TOTAL RECONSTRUCTION OF BREAST, NOT OTHERWISE SPECIFIED - SA PROSEDUR 10,190,093
2364 SA8570A TOTAL RECONSTRUCTION OF BREAST, USING LOCAL FLAP - SA PROSEDUR 2,931,931
2365 SA8571 LATISSIMUS DORSI MYOCUTANEOUS FLAP (RECONSTRUCTION OF BREAST) - SA PROSEDUR 3,604,146
2366 SA8572 TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS (TRAM) FLAP - SA PROSEDUR 5,752,651
2367 SA8589 OTHER MAMMOPLASTY - SA PROSEDUR 8,895,653
2368 SA8594 REMOVAL OF IMPLANT OF BREAST - SA PROSEDUR 1,247,831
2369 SA8601A ASPIRATION OF SKIN AND SUBCUTANEOUS TISSUE - SA PROSEDUR 474,065
2370 SA8601B ASPIRATION OF SKIN AND SUBCUTANEOUS TISSUE-DRAINAGE OF LESION - SA PROSEDUR 540,839
ASPIRATION OF SKIN AND SUBCUTANEOUS TISSUE-DRAINAGE OF SUBCUTANEOUS
2371 SA8601C PROSEDUR 910,334
ABSCESS - SA
2372 SA8602 INJECTION OR TATTOOING OF SKIN LESION OR DEFECT - SA PROSEDUR 474,065
2373 SA8603 INCISION OF PILONIDAL SINUS OR CYST - SA PROSEDUR 1,575,667
2374 SA8604 OTHER INCISION WITH DRAINAGE OF SKIN AND SUBCUTANEOUS TISSUE - SA PROSEDUR 474,065
OTHER INCISION WITH DRAINAGE OF SKIN AND SUBCUTANEOUS TISSUE (BREAST
2375 SA8604A PROSEDUR 1,109,451
ABSCESS) - SA
INCISION WITH REMOVAL OF FOREIGN BODY OR DEVICE FROM SKIN AND
2376 SA8605 PROSEDUR 1,056,442
SUBCUTANEOUS TISSUE - SA
2377 SA8607 INSERTION OF TOTALLY IMPLANTABLE VASCULAR ACCESS DEVICE [VAD] - SA PROSEDUR 1,455,521
2378 SA8609A OTHER INCISION OF SKIN AND SUBCUTANEOUS TISSUE-ESCHAROTOMY <10% - SA PROSEDUR 1,865,346
Page 29
TARIF INSURANCE
2379 SA8609B OTHER INCISION OF SKIN AND SUBCUTANEOUS TISSUE-ESCHAROTOMY >10% - SA PROSEDUR 2,561,591
2380 SA8611 CLOSED BIOPSY OF SKIN AND SUBCUTANEOUS TISSUE - SA PROSEDUR 474,065
2381 SA8619 OTHER DIAGNOSTIC PROCEDURES ON SKIN AND SUBCUTANEOUS TISSUE - SA PROSEDUR 1,971,968
EXCISION OR DESTRUCTION OF LESION OR TISSUE OF SKIN AND SUBCUTANEOUS
2382 SA862 PROSEDUR 2,578,375
TISSUE - SA
2383 SA8621 EXCISION OF PILONIDAL CYST OR SINUS - SA PROSEDUR 699,988
2384 SA8622 EXCISIONAL DEBRIDEMENT OF WOUND, INFECTION, OR BURN - SA PROSEDUR 756,982
2385 SA8622A EXCISIONAL DEBRIDEMENT OF WOUND, INFECTION, OR BURN-<3 - SA PROSEDUR 590,588
2386 SA8622B EXCISIONAL DEBRIDEMENT OF WOUND, INFECTION, OR BURN->3 - SA PROSEDUR 1,455,521
EXCISIONAL DEBRIDEMENT OF WOUND, INFECTION, OR BURN (COCCYGEAL
2387 SA8622C PROSEDUR 1,255,921
PRESSURE ULCER EXCISION) - SA
2388 SA8622GA EXCISIONAL DEBRIDEMENT OF WOUND, INFECTION, OR BURN-GA - SA PROSEDUR 1,056,442
2389 SA8623 REMOVAL OF NAIL, NAIL BED, OR NAIL FOLD - SA PROSEDUR 1,056,442
2390 SA8624 CHEMOSURGERY OF SKIN - SA PROSEDUR 3,609,459
2391 SA8625 DERMABRASION - SA PROSEDUR 910,334
2392 SA8625A DERMABRASION-EXTENSIVE - SA PROSEDUR 1,455,521
2393 SA8627 DEBRIDEMENT OF NAIL, NAIL BED, OR NAIL FOLD - SA PROSEDUR 756,982
OTHER LOCAL EXCISION OR DESTRUCTION OF LESION OR TISSUE OF SKIN AND
2394 SA863 PROSEDUR 474,065
SUBCUTANEOUS TISSUE - SA
2395 SA863A PROSEDUR 1,455,521
SUBCUTANEOUS TISSUE - >4 LESSION - SA
2396 SA863B PROSEDUR 5,051,818
SUBCUTANEOUS TISSUE (EXCISION OF HEMANGIOMA) - SA
2397 SA863L PROSEDUR 1,164,513
SUBCUTANEOUS TISSUE - LASER - SA
2398 SA863M PROSEDUR 7,712,906
SUBCUTANEOUS TISSUE-MULTIPLE - SA
2399 SA864 RADICAL EXCISION OF SKIN LESION - SA PROSEDUR 1,455,521
2400 SA864A RADICAL EXCISION OF SKIN LESION (COMPLEX) - SA PROSEDUR 8,895,653
RADICAL EXCISION OF SKIN LESION (MALIGNANT MELANOMA EXCISION INCL
2401 SA864B PROSEDUR 3,118,973
GRAFTING) - SA
2402 SA865 SUTURE OR OTHER CLOSURE OF SKIN AND SUBCUTANEOUS TISSUE - SA PROSEDUR 1,865,346
SUTURE OR OTHER CLOSURE OF SKIN AND SUBCUTANEOUS TISSUE (MALIGNANT
2403 SA865A PROSEDUR 2,598,782
MELANOMA) - SA
SUTURE OR OTHER CLOSURE OF SKIN AND SUBCUTANEOUS TISSUE-SECONDARY
2404 SA865S PROSEDUR 540,839
SUTURE - SA
2405 SA8660 FREE SKIN GRAFT, NOT OTHERWISE SPECIFIED - SA PROSEDUR 4,882,285
2406 SA8662L OTHER SKIN GRAFT TO HAND-LARGE - SA PROSEDUR 2,474,288
2407 SA8662S OTHER SKIN GRAFT TO HAND-SMALL - SA PROSEDUR 1,395,025
2408 SA8663 FULL-THICKNESS SKIN GRAFT TO OTHER SITES - SA PROSEDUR 1,688,206
2409 SA8663A FULL-THICKNESS SKIN GRAFT TO OTHER SITES (SPLIT THICKNESS) - SA PROSEDUR 7,712,906
2410 SA8663C FULL-THICKNESS SKIN GRAFT TO OTHER SITES (BUTTOCECTOMY) - SA PROSEDUR 8,895,653
2411 SA8669 OTHER SKIN GRAFT TO OTHER SITES - SA PROSEDUR 10,190,093
2412 SA8670 PEDICLE OR FLAP GRAFT, NOT OTHERWISE SPECIFIED - SA PROSEDUR 1,971,968
2413 SA8670D PEDICLE OR FLAP GRAFT, NOT OTHERWISE SPECIFIED - DISTANT FLAP - SA PROSEDUR 2,630,177
2414 SA8670L PEDICLE OR FLAP GRAFT, NOT OTHERWISE SPECIFIED - LARGE FOCAL FLAP - SA PROSEDUR 2,561,591
PEDICLE OR FLAP GRAFT, NOT OTHERWISE SPECIFIED - NEUROVASCULAR ISLAND
2415 SA8670N PROSEDUR 3,476,272
FLAP - SA
2416 SA8670S PEDICLE OR FLAP GRAFT, NOT OTHERWISE SPECIFIED - SMALL LOCAL FLAP - SA PROSEDUR 2,561,591
2417 SA8689 OTHER REPAIR AND RECONSTRUCTION OF SKIN AND SUBCUTANEOUS TISSUE - SA PROSEDUR 10,190,093
2418 SA8693 INSERTION OF TISSUE EXPANDER - SA PROSEDUR 1,865,346
2419 SA8774 RETROGRADE PYELOGRAM - SA PROSEDUR 1,688,206
2420 SA8794 CONTRAST VASOGRAM - SA PROSEDUR 990,995
2421 SA8860 PHLEBOGRAPHY USING CONTRAST MATERIAL, UNSPECIFIED SITE - SA PROSEDUR 639,975
2422 SA8929 OTHER NONOPERATIVE GENITOURINARY SYSTEM MEASUREMENTS - SA PROSEDUR 699,988
2423 SA9315 MOBILIZATION OF SPINE - SA PROSEDUR 1,091,942
2424 SA9325 FORCED EXTENSION OF LIMB - SA PROSEDUR 756,982
2425 SA9344 OTHER SKELETAL TRACTION - SA PROSEDUR 1,180,211
2426 SA9351 APPLICATION OF PLASTER JACKET - SA PROSEDUR 590,588
2427 SA9354 APPLICATION OF SPLINT - SA PROSEDUR 474,065
2428 SA9354P APPLICATION OF SPLINT - PLASTER HIP - SA PROSEDUR 910,334
APPLICATION OF OTHER WOUND DRESSING (EXTENSIVE DRESSING OF BURN OF
2429 SA9357 PROSEDUR 756,982
SKIN OR SUBCUTANEOUS TISSUE) - SA
2430 SA9512 FLUORESCEIN ANGIOGRAPHY OR ANGIOSCOPY OF EYE - SA PROSEDUR 457,401
2431 SA9604 INSERTION OF ENDOTRACHEAL TUBE / INTUBASI - SA PROSEDUR 2,374,187
2432 SA9604A RE - INSERTION OF ENDOTRACHEAL TUBE / RE-INTUBASI - SA PROSEDUR 2,374,187
2433 SA9605 OTHER INTUBATION OF RESPIRATORY TRACT - SA PROSEDUR 2,134,860
2434 SA9607 INSERTION OF OTHER (NASO-)GASTRIC TUBE - SA PROSEDUR 2,630,177
2435 SA9607A INSERTION NASO GASTRIC TUBE - SA PROSEDUR 1,581,946
2436 SA9622 DILATION OF RECTUM - SA PROSEDUR 540,839
2437 SA9625 THERAPEUTIC DISTENTION OF BLADDER - SA PROSEDUR 1,171,154
2438 SA9629 REDUCTION OF INTUSSUSCEPTION OF ALIMENTARY TRACT - SA PROSEDUR 699,988
2439 SA9652 IRRIGATION OF EAR - SA PROSEDUR 450,760
2440 SA967 OTHER CONTINUOUS INVASIVE MECHANICAL VENTILATION - SA PROSEDUR 791,033
2441 SA9736 REMOVAL OF OTHER EXTERNAL MANDIBULAR FIXATION DEVICE - SA PROSEDUR 910,334
2442 SA9762 REMOVAL OF URETEROSTOMY TUBE AND URETERAL CATHETER - SA PROSEDUR 1,580,255
2443 SA9771 REMOVAL OF INTRAUTERINE CONTRACEPTIVE DEVICE - SA PROSEDUR 183,661
2444 SA9788 REMOVAL OF EXTERNAL IMMOBILIZATION DEVICE - SA PROSEDUR 1,056,442
2445 SA9811 REMOVAL OF INTRALUMINAL FOREIGN BODY FROM EAR WITHOUT INCISION - SA PROSEDUR 623,795
2446 SA9812 REMOVAL OF INTRALUMINAL FOREIGN BODY FROM NOSE WITHOUT INCISION - SA PROSEDUR 381,691
2447 SA9813 REMOVAL OF FOREIGN BODY OF PHARYNX - SA PROSEDUR 621,863
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY [ESWL] OF THE KIDNEY, URETER
2448 SA9851 PROSEDUR 3,243,587
AND/OR BLADDER - SA
2449 SA9851K PROSEDUR 2,561,591
AND/OR BLADDER - KIDNEY - SA
2450 SA9851U PROSEDUR 1,688,206
AND/OR BLADDER - URETER - SA
2451 SA9910 INJECTION OR INFUSION OF THROMBOLYTIC AGENT - SA PROSEDUR 2,108,295
2452 SA9925 INJECTION OR INFUSION OF CANCER CHEMOTHERAPEUTIC SUBSTANCE - SA PROSEDUR 1,120,560
Page 30
TARIF INSURANCE
INJECTION OR INFUSION OF OTHER THERAPEUTIC OR PROPHYLACTIC SUBSTANCE -

2453 SA9929 PROSEDUR 1,455,521
SA
CARDIOPULMONARY RESUSCITATION, NOT OTHERWISE SPECIFIED& RJPO /
2454 SA9960 PROSEDUR 791,033
DEFIBRILASI - SA
2455 SA1762B LASER ASSISTED TONSILECTOMY - SA PROSEDUR 4,663,969
2456 SA3500 BALOON VALVULATION - SA PROSEDUR 9,576,683
2457 SA3734B LASER VASCULAR THERAPY - SA PROSEDUR 4,650,807
REDUCTION OF FRACTURE AND DISLOCATION APPLICATION OF CAST (GIPS < 2
2458 SA4131A PROSEDUR 527,315
SENDI) - SA
2459 SA6631A PROSEDUR 3,093,736
(PDP COVID) - SA
2460 SA6902A DILATION AND CURETTAGE FOLLOWING DELIVERY OR ABORTION (PDP COVID) - SA PROSEDUR 3,160,148
2461 SA7279A OTHER VACUUM EXTRACTION (PDP COVID) - SA PROSEDUR 4,990,356
2462 SA7359A OTHER MANUALLY ASSISTED DELIVERY (PDP COVID) - SA PROSEDUR 4,557,226
2463 SA741B CESAREAN SECTION WITH COMPLICATION - SA PROSEDUR 5,579,495
2464 SA741C CESAREAN SECTION OF OTHER UNSPECIFIED TYPE - SA PROSEDUR 4,557,226
2465 SA743A REMOVAL OF EXTRATUBAL ECTOPIC PREGNANCY (PDP COVID) - SA PROSEDUR 5,488,933
2466 SA744A CESAREAN SECTION OF OTHER SPECIFIED TYPE (PDP COVID) - SA PROSEDUR 5,579,495
2467 SA8191A MILD ARTHROCENTESIS FOR THERAPEUTIC - SA PROSEDUR 829,190
2468 SA8191B MODERATE ARTHROCENTESIS FOR THERAPEUTIC - SA PROSEDUR 1,243,725
2469 SA8191C SEVERE ARTHROCENTESIS FOR THERAPEUTIC - SA PROSEDUR 1,658,381
2470 SA8152 PARTIAL HIP REPLACEMENT - SA PROSEDUR 4,261,751
2471 SA3009A ENDOSCOPIC VOCAL CORD SURGERY - SA PROSEDUR 4,609,500
2472 SA5498A PERITONEAL DIALYSIS / INSERTION OF PERITONEAL DIALYSIS - SA PROSEDUR 1,582,350
2473 SA7021 VAGINOSCOPY / VAGINAL EXAMINATION - SA PROSEDUR 105,000
2474 SA743B LAPAROSCOPIC ECTOPIC PREGNANCY - SA PROSEDUR 3,018,750
2475 SA295A OSA SURGERY - SA PROSEDUR 5,120,850
TARIF BIAYA BEDAH

2476 SG0051 IMPLANTATION OF CARDIAC RESYNCHRONIZATION DEFIBRILLATOR PROSEDUR 31,648,696
2477 SG0066B PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) (1 VESSEL) PROSEDUR 13,686,409
2478 SG0066C PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) (2 VESSELS) PROSEDUR 15,394,659
2479 SG0066D PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) (>2 VESSELS) PROSEDUR 17,109,551
2480 SG0066E PROSEDUR 20,526,172
STENT)
2481 SG0066F PROSEDUR 23,950,763
STENT)
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) (DES/BMS >2
2482 SG0066G PROSEDUR 25,691,253
STENT)
2483 SG0066H PERCUTANEOUS TRANSLUMINAL COR ANGIOGRAPHY (F) PROSEDUR 5,212,415
2484 SG0066I PERCUTANEOUS TRANSLUMINAL COR ANGIOGRAPHY (R) PROSEDUR 5,876,661
2485 SG0070 REVISION OF HIP REPLACEMENT, BOTH ACETABULAR AND FEMORAL COMPONENTS PROSEDUR 18,982,021
2486 SG0102 VENTRICULOPUNCTURE THROUGH PREVIOUSLY IMPLANTED CATHETER PROSEDUR 4,324,541
2487 SG0109 OTHER CRANIAL PUNCTURE PROSEDUR 3,992,357
2488 SG0113A CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF BRAIN (STEREOTIC) PROSEDUR 17,257,590
2489 SG0113B CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF BRAIN (DIAGNOSTIC) PROSEDUR 7,684,530
2490 SG0113C CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF BRAIN (EXPLORATORY BURRHOLE) PROSEDUR 9,189,800
2491 SG0114 OPEN BIOPSY OF BRAIN PROSEDUR 14,553,877
2492 SG0121 INCISION AND DRAINAGE OF CRANIAL SINUS PROSEDUR 5,837,780
2493 SG0122A REMOVAL OF INTRACRANIAL NEUROSTIMULATOR LEAD(S) (BRAIN) PROSEDUR 9,356,555
2494 SG0122B REMOVAL OF INTRACRANIAL NEUROSTIMULATOR LEAD(S) (CARNIAL NERVE) PROSEDUR 8,233,460
2495 SG0124A OTHER CRANIOTOMY (EXPLORATORY OPEN CRANIOTOMY) PROSEDUR 19,440,629
2496 SG0124B OTHER CRANIOTOMY (EVACUATION OF EXTRADURAL HAEMATOMA) PROSEDUR 20,110,550
2497 SG0124C OTHER CRANIOTOMY (DECOMPRESSION OF CRANIAL NERVE (CRANIOTOMY)) PROSEDUR 29,590,754
2498 SG0124D OTHER CRANIOTOMY (CRANIOTOMY-POSTOPERATIVE HAEMORRHAGE) PROSEDUR 13,992,993
2499 SG0124E OTHER CRANIOTOMY (BURRHOLE FOR INTRACRANIAL INFECTION) PROSEDUR 17,433,885
2500 SG0131 INCISION OF CEREBRAL MENINGES PROSEDUR 22,128,162
2501 SG0151 EXCISION OF LESION OR TISSUE OF CEREBRAL MENINGES PROSEDUR 20,707,780
2502 SG0152 HEMISPHERECTOMY PROSEDUR 35,969,131
2503 SG0159A OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF BRAIN PROSEDUR 27,667,206
2504 SG0159B OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF BRAIN (ABCESS) PROSEDUR 18,504,575
OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF BRAIN
2505 SG0159C PROSEDUR 29,590,754
(CEREBELLOPONTINE ANGLE TUMOUR)
OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF BRAIN (THERAPEUTIC
2506 SG0159D PROSEDUR 11,201,978
ENDOSCOPIC OP ON VENTRICLE OF BRAIN)
2507 SG016 EXCISION OF LESION OF SKULL PROSEDUR 9,356,555
2508 SG0201 OPENING OF CRANIAL SUTURE PROSEDUR 18,135,926
2509 SG0202A ELEVATION OF SKULL FRACTURE FRAGMENTS (FORAMEN MAGNUM DECOMPRESSION) PROSEDUR 18,982,021
2510 SG0202B ELEVATION OF SKULL FRACTURE FRAGMENTS PROSEDUR 18,583,787
2511 SG0206A OTHER CRANIAL OSTEOPLASTY (PLASTIC REPAIR CRANIUM) PROSEDUR 20,643,299
2512 SG0206B OTHER CRANIAL OSTEOPLASTY (REPAIR OF SKULL) PROSEDUR 15,718,752
2513 SG0206C OTHER CRANIAL OSTEOPLASTY (RECONSTRUCTIVE CRANIOPLASTY) PROSEDUR 11,801,984
2514 SG0212 OTHER REPAIR OF CEREBRAL MENINGES PROSEDUR 10,012,952
2515 SG0212A OTHER REPAIR OF CEREBRAL MENINGES (REPAIR OF DURA) PROSEDUR 20,110,550
2516 SG022A VENTRICULOSTOMY (CREATION OF VENTRICULOVASCULAR ANASTOMOSIS) PROSEDUR 9,356,555
2517 SG022B VENTRICULOSTOMY (VENTRICULOCISTERNAL INTUBATION) PROSEDUR 14,553,877
2518 SG0234 VENTRICULAR SHUNT TO ABDOMINAL CAVITY AND ORGANS PROSEDUR 18,343,133
2519 SG0241 IRRIGATION AND EXPLORATION OF VENTRICULAR SHUNT PROSEDUR 4,064,928
REPLACEMENT OF VENTRICULAR SHUNT (REVISION OF VENTRICULOPERITONEAL
2520 SG0242 PROSEDUR 8,233,460
SHUNT AT VENTRICULAR SITE)
2521 SG0243 REMOVAL OF VENTRICULAR SHUNT PROSEDUR 7,485,534
2522 SG0293 IMPLANTATION OR REPLACEMENT OF INTRACRANIAL NEUROSTIMULATOR LEAD(S) PROSEDUR 9,356,555
2523 SG0309 OTHER EXPLORATION AND DECOMPRESSION OF SPINAL CANAL PROSEDUR 17,263,024
2524 SG031 DIVISION OF INTRASPINAL NERVE ROOT PROSEDUR 14,161,198
2525 SG0331 SPINAL TAP PROSEDUR 2,107,933
2526 SG0331A SPINAL TAP / LUMBAL PUNCTURE PROSEDUR 949,699
Page 31
TARIF INSURANCE
OTHER DIAGNOSTIC PROCEDURES ON SPINAL CORD AND SPINAL CANAL

2527 SG0339 PROSEDUR 9,879,765
STRUCTURES
2528 SG034 EXCISION OR DESTRUCTION OF LESION OF SPINAL CORD OR SPINAL MENINGES PROSEDUR 20,707,780
2529 SG0352 REPAIR OF SPINAL MYELOMENINGOCELE PROSEDUR 15,693,274
INSERTION OF CATHETER INTO SPINAL CANAL FOR INFUSION OF THERAPEUTIC OR
2530 SG0390 PROSEDUR 11,801,984
PALLIATIVE SUBSTANCES
INJECTION OF ANESTHETIC INTO SPINAL CANAL FOR ANALGESIA
2531 SG0391A PROSEDUR 2,640,440
(CERVICAL/THORACIC)
2532 SG0391B INJECTION OF ANESTHETIC INTO SPINAL CANAL FOR ANALGESIA (LUMBAL) PROSEDUR 2,099,843
2533 SG0396 PERCUTANEOUS DENERVATION OF FACET PROSEDUR 5,837,780
2534 SG0401 EXCISION OF ACOUSTIC NEUROMA PROSEDUR 29,590,754
OTHER EXCISION OR AVULSION OF CRANIAL AND PERIPHERAL NERVE
2535 SG0407A PROSEDUR 21,705,899
(INTRACRANIAL TRANSECTION OF CRANIAL NERVE)
OTHER EXCISION OR AVULSION OF CRANIAL AND PERIPHERAL NERVE (INCLUDE
2536 SG0407B PROSEDUR 25,552,874
EXCISION OF LESION ON CRANIAL NERVE)
OTHER EXCISION OR AVULSION OF CRANIAL AND PERIPHERAL NERVES (MAJOR
2537 SG0407C PROSEDUR 5,837,780
NERVE)
OTHER EXCISION OR AVULSION OF CRANIAL AND PERIPHERAL NERVES (EXCISION
2538 SG0407D PROSEDUR 4,730,864
OF LESION)
OTHER EXCISION OR AVULSION OF CRANIAL AND PERIPHERAL NERVES
2539 SG0407E PROSEDUR 3,767,762
(TRANSECTION/EXCISION)
CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF CRANIAL OR PERIPHERAL NERVE OR
2540 SG0411 PROSEDUR 3,767,762
GANGLION
OTHER DIAGNOSTIC PROCEDURES ON CRANIAL AND PERIPHERAL NERVES AND
2541 SG0419A PROSEDUR 10,054,611
GANGLIA-EXPLORATION OF NERVE
2542 SG042 DESTRUCTION OF CRANIAL AND PERIPHERAL NERVES PROSEDUR 21,705,899
2543 SG042A DESTRUCTION OF CRANIAL AND PERIPHERAL NERVES (INJ) PROSEDUR 4,221,058
2544 SG042B DESTRUCTION OF CRANIAL AND PERIPHERAL NERVES (RF) PROSEDUR 7,796,224
2545 SG043 SUTURE OF CRANIAL AND PERIPHERAL NERVES PROSEDUR 10,062,701
2546 SG0443A RELEASE OF CARPAL TUNNEL SYNDROME (ENDOSCOPIC) PROSEDUR 4,081,109
2547 SG0443B RELEASE OF CARPAL TUNNEL SYNDROME (ENDOSCOPIC BILATERAL) PROSEDUR 6,835,899
2548 SG0444 RELEASE OF TARSAL TUNNEL PROSEDUR 6,835,899
2549 SG0449 PROSEDUR 3,767,762
ADHESIONS
2550 SG0449A PROSEDUR 3,767,762
ADHESIONS-DEEP
2551 SG045 CRANIAL OR PERIPHERAL NERVE GRAFT PROSEDUR 4,730,864
2552 SG045A CRANIAL OR PERIPHERAL NERVE GRAFT (PRIMARY & 2ND) PROSEDUR 11,297,491
2553 SG045B CRANIAL OR PERIPHERAL NERVE GRAFT-COMPLEX PROSEDUR 17,000,634
2554 SG046A TRANSPOSITION OF CRANIAL AND PERIPHERAL NERVES (NEUROLYSIS) PROSEDUR 4,730,864
2555 SG046B TRANSPOSITION OF CRANIAL AND PERIPHERAL NERVES (SUBMUSCULAR) PROSEDUR 8,233,460
REVISION OF PREVIOUS REPAIR OF CRANIAL AND PERIPHERAL NERVES
2556 SG0475A PROSEDUR 10,135,393
(MICROSURGERY)
REVISION OF PREVIOUS REPAIR OF CRANIAL AND PERIPHERAL NERVES (NON
2557 SG0475B PROSEDUR 5,064,376
MICROSURGERY)
REVISION OF PREVIOUS REPAIR OF CRANIAL AND PERIPHERAL NERVES (RELEASE
2558 SG0475C PROSEDUR 7,406,201
PERIPHERAL NERVES)
REVISION OF PREVIOUS REPAIR OF CRANIAL AND PERIPHERAL NERVES (2ND REPAIR
2559 SG0475D PROSEDUR 6,552,137
NERVE TRUNK)
2560 SG0479A OTHER NEUROPLASTY REPAIR OF CRANIAL NERVE (INTRACRANIAL) PROSEDUR 12,625,137
2561 SG0479B OTHER NEUROPLASTY PRIMARY REPAIR PERIPHERAL NERVE W MICROSURGERY PROSEDUR 8,907,245
2562 SG0479C OTHER NEUROPLASTY PRIMARY REPAIR PERIPHERAL NERVE PROSEDUR 4,081,109
2563 SG0479D OTHER NEUROPLASTY PRIMARY REPAIR NERVE TRUNK PROSEDUR 4,730,864
2564 SG0481 INJECTION OF ANESTHETIC INTO PERIPHERAL NERVE FOR ANALGESIA PROSEDUR 1,622,276
2565 SG0492 IMPLANTATION OR REPLACEMENT OF PERIPHERAL NEUROSTIMULATOR LEAD(S) PROSEDUR 8,907,245
2566 SG0523 LUMBAR SYMPATHECTOMY PROSEDUR 4,730,864
2567 SG0523A LUMBAR SYMPATHECTOMY (LAPAROSCOPIC) PROSEDUR 8,919,440
2568 SG0524 PRESACRAL SYMPATHECTOMY PROSEDUR 7,406,201
2569 SG052A THORASCOPIC SYMPATHECTOMY PROSEDUR 11,730,621
2570 SG052B THORACIC SYMPATHECTOMY : DIAG.(LA UNDER X-RAY CTRL) PROSEDUR 4,730,864
2571 SG052C THORACIC SYMPATHECTOMY : THERAPEUTIC (NEUROLYTIC UNDER X-RAY CTRL) PROSEDUR 6,835,899
2572 SG0532 INJECTION OF NEUROLYTIC AGENT INTO SYMPATHETIC NERVE PROSEDUR 6,324,764
2573 SG0609 OTHER INCISION OF THYROID FIELD PROSEDUR 3,361,439
2574 SG0611A CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF THYROID GLAND (FNAB) PROSEDUR 1,372,082
2575 SG0611B CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF THYROID GLAND (NEEDLE BIOPSY) PROSEDUR 2,519,449
2576 SG062A UNILATERAL THYROID LOBECTOMY (HEMI-THYROIDECTOMY) PROSEDUR 9,649,857
UNILATERAL THYROID LOBECTOMY (ISTHMULOBECTOMY WITH FROZEN SECTION
2577 SG062B PROSEDUR 23,138,357
EXCISION)
2578 SG0631 EXCISION OF LESION OF THYROID PROSEDUR 5,595,676
2579 SG0639 OTHER PARTIAL THYROIDECTOMY PROSEDUR 9,649,857
2580 SG064A COMPLETE THYROIDECTOMY (TOTAL) PROSEDUR 9,649,857
2581 SG064B COMPLETE THYROIDECTOMY (BILATERAL SUBTOTAL) PROSEDUR 9,649,857
2582 SG064C COMPLETE THYROIDECTOMY + BERRYPICKING (LIFADENECTOMY) PROSEDUR 30,570,036
2583 SG067A EXCISION OF THYROGLOSSAL DUCT OR TRACT (THYROGLOSSAL CYST) PROSEDUR 4,366,199
2584 SG067B EXCISION OF THYROGLOSSAL DUCT OR TRACT (THYROGLOSSAL TRACT) PROSEDUR 5,595,676
2585 SG067C EXCISION OF THYROGLOSSAL DUCT OR TRACT (THYROGLOSSAL CYST ONCOLOGY) PROSEDUR 23,138,357
2586 SG0681 COMPLETE PARATHYROIDECTOMY PROSEDUR 11,801,984
2587 SG0689 OTHER PARATHYROIDECTOMY PROSEDUR 11,801,984
2588 SG0695 PARATHYROID TISSUE REIMPLANTATION PROSEDUR 7,684,530
OTHER OPERATIONS ON THYROID (REGION) AND PARATHYROID - THYROID
2589 SG0698 PROSEDUR 10,828,015
ABERRANT
2590 SG0698A OTHER OPERATIONS ON THYROID (REGION) AND PARATHYROID - ENDOSCOPIC PROSEDUR 30,570,036
2591 SG0729 OTHER PARTIAL ADRENALECTOMY PROSEDUR 7,796,224
2592 SG073 BILATERAL ADRENALECTOMY PROSEDUR 8,378,601
2593 SG0753 PARTIAL EXCISION OF PINEAL GLAND PROSEDUR 25,552,874
2594 SG0754 TOTAL EXCISION OF PINEAL GLAND PROSEDUR 25,552,874
2595 SG0761 PARTIAL EXCISION OF PITUITARY GLAND, TRANSFRONTAL APPROACH PROSEDUR 21,705,899
TOTAL EXCISION OF PITUITARY GLAND, UNSPECIFIED APPROACH -
2596 SG0769 PROSEDUR 21,705,899
HYPOPHYSECTOMY NOS
2597 SG0780 THYMECTOMY, NOT OTHERWISE SPECIFIED PROSEDUR 10,135,393
2598 SG0811 BIOPSY OF EYELID PROSEDUR 2,008,314
Page 32
TARIF INSURANCE
2599 SG0821 EXCISION OF CHALAZION PROSEDUR 3,956,012

2600 SG0822A EXCISION OF OTHER MINOR LESION OF EYEBROW PROSEDUR 2,099,843
2601 SG0822B EXCISION OF OTHER MINOR LESION OF CANTHUS PROSEDUR 4,366,199
2602 SG0825 DESTRUCTION OF LESION OF EYELID PROSEDUR 1,756,792
2603 SG0836 REPAIR OF BLEPHAROPTOSIS BY OTHER TECHNIQUES PROSEDUR 7,684,530
2604 SG0849 OTHER REPAIR OF ENTROPION OR ECTROPION PROSEDUR 5,064,376
2605 SG0851 CANTHOTOMY PROSEDUR 2,730,641
2606 SG0852A BLEPHARORRHAPHY (TARSORRHAPHY) PROSEDUR 3,767,762
2607 SG0852B BLEPHARORRHAPHY (TARSOMULLERECTOMY) PROSEDUR 7,684,530
2608 SG0859 CANTHOPLASTY / REPAIR OF EPICANTHAL / TELECANTHAL FOLD PROSEDUR 4,221,058
2609 SG0861 RECONSTRUCTION OF EYELID WITH SKIN FLAP OR GRAFT PROSEDUR 4,366,199
2610 SG0869A OTHER RECONSTRUCTION OF EYELID WITH FLAPS OR GRAFTS (TOTAL) PROSEDUR 7,890,409
2611 SG0869B OTHER RECONSTRUCTION OF EYELID WITH FLAPS OR GRAFTS (BILATERAL) PROSEDUR 12,625,137
2612 SG0881A LINEAR REPAIR OF LACERATION OF EYELID OR EYEBROW (SUTURE OF EYEBROW) PROSEDUR 1,372,082
LINEAR REPAIR OF LACERATION OF EYELID OR EYEBROW (SUTURE OF EYELID
2613 SG0881B PROSEDUR 1,771,644
(LACERATION))
2614 SG0893 OTHER EPILATION OF EYELID PROSEDUR 1,919,563
2615 SG090A INCISION OF LACRIMAL GLAND (EYELID LESSION) PROSEDUR 1,622,276
2616 SG090B INCISION OF LACRIMAL GLAND (CONJUNCTIVAL CYST) PROSEDUR 1,486,433
2617 SG0912 BIOPSY OF LACRIMAL SAC PROSEDUR 1,622,276
2618 SG0943 PROBING OF NASOLACRIMAL DUCT (UNDER GA) PROSEDUR 1,372,082
2619 SG0944 INTUBATION OF NASOLACRIMAL DUCT PROSEDUR 9,649,857
2620 SG0949 OTHER MANIPULATION OF LACRIMAL PASSAGE - THAT WITH DILATION PROSEDUR 1,372,082
2621 SG0953 INCISION OF LACRIMAL SAC PROSEDUR 1,622,276
2622 SG096 EXCISION OF LACRIMAL SAC AND PASSAGE PROSEDUR 4,366,199
2623 SG0973 REPAIR OF CANALICULUS PROSEDUR 4,366,199
2624 SG0982 CONJUNCTIVOCYSTORHINOSTOMY PROSEDUR 10,428,574
2625 SG0983 CONJUNCTIVORHINOSTOMY WITH INSERTION OF TUBE OR STENT PROSEDUR 8,907,245
2626 SG100 REMOVAL OF EMBEDDED FOREIGN BODY FROM CONJUNCTIVA BY INCISION PROSEDUR 1,622,276
2627 SG1021 BIOPSY OF CONJUNCTIVA PROSEDUR 1,486,433
2628 SG1031 EXCISION OF LESION OR TISSUE OF CONJUNCTIVA PROSEDUR 2,095,737
2629 SG1032 DESTRUCTION OF LESION OF CONJUNCTIVA PROSEDUR 1,486,433
2630 SG1033 OTHER DESTRUCTIVE PROCEDURES ON CONJUNCTIVA PROSEDUR 2,519,449
2631 SG1044 OTHER FREE GRAFT TO CONJUNCTIVA PROSEDUR 4,221,058
2632 SG105 LYSIS OF ADHESIONS OF CONJUNCTIVA AND EYELID PROSEDUR 1,486,433
2633 SG106A REPAIR OF LACERATION OF CONJUNCTIVA (SUTURE) PROSEDUR 2,095,737
2634 SG106B REPAIR OF LACERATION OF CONJUNCTIVA (REMOVAL OF SUTURE) PROSEDUR 1,486,433
2635 SG1091 SUBCONJUNCTIVAL INJECTION PROSEDUR 1,486,433
2636 SG110 MAGNETIC REMOVAL OF EMBEDDED FOREIGN BODY FROM CORNEA PROSEDUR 1,771,644
2637 SG111 INCISION OF CORNEA PROSEDUR 1,771,644
2638 SG1121 SCRAPING OF CORNEA FOR SMEAR OR CULTURE PROSEDUR 1,771,644
2639 SG1143 CRYOTHERAPY OF CORNEAL LESION PROSEDUR 1,486,433
OTHER REMOVAL OR DESTRUCTION OF CORNEAL LESION - EXCISION OF CORNEA
2640 SG1149 PROSEDUR 2,095,737
NOS
2641 SG1149A OTHER REMOVAL OR DESTRUCTION OF CORNEAL LESION-CHELATION PROSEDUR 2,640,440
2642 SG1151 SUTURE OF CORNEAL LACERATION PROSEDUR 4,865,380
2643 SG1152 REPAIR OF POSTOPERATIVE WOUND DEHISCENCE OF CORNEA PROSEDUR 2,519,449
2644 SG1159 OTHER REPAIR OF CORNEA (REMOVAL OF CORNEAL SUTURE) PROSEDUR 1,486,433
2645 SG1161 LAMELLAR KERATOPLASTY WITH AUTOGRAFT PROSEDUR 8,690,740
2646 SG1163 PENETRATING KERATOPLASTY WITH AUTOGRAFT PROSEDUR 8,690,740
2647 SG117 LASIK / OTHER RECONSTRUCTIVE AND REFRACTIVE SURGERY ON CORNEA * 36,709,208
2648 SG1191 TATTOOING OF CORNEA PROSEDUR 2,640,440
2649 SG1200A PROSEDUR 6,861,498
IRIS
2650 SG1200B PROSEDUR 4,221,058
ANTERIOR CHAMBER
2651 SG1212 OTHER IRIDOTOMY - IRIDOCYCLECTOMY PROSEDUR 8,690,740
2652 SG1212A OTHER IRIDOTOMY (LASER IRIDOTOMY) PROSEDUR 4,221,058
2653 SG1213 EXCISION OF PROLAPSED IRIS PROSEDUR 8,233,460
2654 SG1214 OTHER IRIDECTOMY PROSEDUR 4,221,058
2655 SG1242 EXCISION OF LESION OF IRIS PROSEDUR 6,861,498
2656 SG1252 GONIOTOMY WITHOUT GONIOPUNCTURE PROSEDUR 8,233,460
2657 SG1253 GONIOTOMY WITH GONIOPUNCTURE PROSEDUR 8,233,460
2658 SG1254 TRABECULOTOMY AB EXTERNO PROSEDUR 4,221,058
2659 SG1255 CYCLODIALYSIS PROSEDUR 6,404,097
2660 SG1264A TRABECULECTOMY AB EXTERNO (SURGICAL TRABECULECTOMY) PROSEDUR 7,422,382
2661 SG1264B TRABECULECTOMY AB EXTERNO (LASER TRABECULOPLASTY) PROSEDUR 4,366,199
2662 SG1272 CYCLOCRYOTHERAPY PROSEDUR 4,221,058
2663 SG1281 SUTURE OF LACERATION OF SCLERA PROSEDUR 3,169,084
2664 SG1284 EXCISION OR DESTRUCTION OF LESION OF SCLERA PROSEDUR 2,640,440
2665 SG1287 SCLERAL REINFORCEMENT WITH GRAFT PROSEDUR 6,552,137
2666 SG1291 THERAPEUTIC EVACUATION OF ANTERIOR CHAMBER PROSEDUR 4,366,199
2667 SG1292 INJECTION INTO ANTERIOR CHAMBER (IRRIGATION) PROSEDUR 2,095,737
2668 SG1299 OTHER OPERATIONS ON ANTERIOR CHAMBER PROSEDUR 6,552,137
2669 SG1370 INSERTION OF PSEUDOPHAKOS, NOT OTHERWISE SPECIFIED PROSEDUR 6,404,097
INSERTION OF INTRAOCULAR LENS PROSTHESIS AT TIME OF CATARACT
2670 SG1371 PROSEDUR 6,404,097
EXTRACTION, ONE-STAGE
2671 SG138 REMOVAL OF IMPLANTED LENS PROSEDUR 4,865,380
REMOVAL OF FOREIGN BODY FROM POSTERIOR SEGMENT OF EYE WITHOUT USE OF
2672 SG1402 PROSEDUR 3,767,762
MAGNET
OTHER DIAGNOSTIC PROCEDURES ON RETINA, CHOROID, VITREOUS, AND
2673 SG1419 PROSEDUR 7,796,224
POSTERIOR CHAMBER
2674 SG1422 DESTRUCTION OF CHORIORETINAL LESION BY CRYOTHERAPY PROSEDUR 4,366,199
DESTRUCTION OF CHORIORETINAL LESION BY PHOTOCOAGULATION OF
2675 SG1425 PROSEDUR 4,366,199
UNSPECIFIED TYPE
2676 SG1426 DESTRUCTION OF CHORIORETINAL LESION BY RADIATION THERAPY PROSEDUR 4,366,199
OTHER DESTRUCTION OF CHORIORETINAL LESION - DESTRUCTION OF LESION OF
2677 SG1429 PROSEDUR 7,796,224
RETINA AND CHOROID NOS
2678 SG1441 SCLERAL BUCKLING WITH IMPLANT PROSEDUR 8,732,399
2679 SG1471 REMOVAL OF VITREOUS, ANTERIOR APPROACH PROSEDUR 6,404,097
REMOVAL OF VITREOUS, ANTERIOR APPROACH (VITRECTOMY PARS PLANA
2680 SG1471A PROSEDUR 9,334,941
APPROACH W INSERTION OF INT.TAMPONADE)
Page 33
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2681 SG1479 OTHER OPERATIONS ON VITREOUS PROSEDUR 13,078,312

2682 SG1521 LENGTHENING PROCEDURE ON ONE EXTRAOCULAR MUSCLE PROSEDUR 4,865,380
2683 SG154A PROSEDUR 7,890,409
EYES (SQUINT)
2684 SG154B PROSEDUR 10,828,015
EYES (SQUINT W ADJUSTABLE SUTURES)
2685 SG155 TRANSPOSITION OF EXTRAOCULAR MUSCLES PROSEDUR 7,684,530
2686 SG156A REVISION OF EXTRAOCULAR MUSCLE SURGERY (REVISION OF SQUINT) PROSEDUR 10,054,611
REVISION OF EXTRAOCULAR MUSCLE SURGERY (REVISION OF SQUINT W
2687 SG156B PROSEDUR 12,625,137
ADJUSTABLE SUTURES)
2688 SG1609 OTHER ORBITOTOMY PROSEDUR 4,865,380
2689 SG1609A OTHER ORBITOTOMY (EXPLORATION/REMOVAL OF FOREIGN BODY) PROSEDUR 6,861,498
2690 SG1623 BIOPSY OF EYEBALL AND ORBIT PROSEDUR 4,221,058
2691 SG1649 OTHER ENUCLEATION OF EYEBALL PROSEDUR 8,536,059
2692 SG1652 EXENTERATION OF ORBIT WITH THERAPEUTIC REMOVAL OF ORBITAL BONE PROSEDUR 8,378,601
2693 SG1659 OTHER EXENTERATION OF ORBIT / EVISCERATION OF ORBIT NOS PROSEDUR 8,536,059
2694 SG1666 OTHER REVISION OF EXENTERATION CAVITY PROSEDUR 8,378,601
2695 SG1691 RETROBULBAR INJECTION OF THERAPEUTIC AGENT PROSEDUR 1,486,433
2696 SG1692 EXCISION OF LESION OF ORBIT PROSEDUR 6,861,498
LAPAROSCOPIC REPAIR OF INGUINAL HERNIA WITH GRAFT OR PROSTHESIS, NOT
2697 SG1713 PROSEDUR 7,360,437
OTHERWISE SPECIFIED
2698 SG1736 LAPAROSCOPIC SIGMOIDECTOMY PROSEDUR 9,273,238
2699 SG1739 OTHER LAPAROSCOPIC PARTIAL EXCISION OF LARGE INTESTINE PROSEDUR 13,971,620
2700 SG182 EXCISION OR DESTRUCTION OF LESION OF EXTERNAL EAR PROSEDUR 2,495,299
2701 SG1821 EXCISION OF PREAURICULAR SINUS PROSEDUR 4,542,494
2702 SG1829A EXCISION OR DESTRUCTION OF OTHER LESION OF EXTERNAL EAR (GRANULASI) PROSEDUR 2,640,440
EXCISION OR DESTRUCTION OF OTHER LESION OF EXTERNAL EAR (REMOVAL OF
2703 SG1829B PROSEDUR 6,404,097
EXOSTOSES FROM EAC)
2704 SG1839 AMPUTATION OF EXTERNAL EAR PROSEDUR 5,696,623
2705 SG184 SUTURE OF LACERATION OF EXTERNAL EAR PROSEDUR 1,771,644
2706 SG185 SURGICAL CORRECTION OF PROMINENT EAR PROSEDUR 1,771,644
2707 SG186 RECONSTRUCTION OF EXTERNAL AUDITORY CANAL PROSEDUR 9,834,122
2708 SG186A RECONSTRUCTION OF EXTERNAL AUDITORY CANAL (GRAFT) PROSEDUR 12,625,137
2709 SG186B RECONSTRUCTION OF EXTERNAL AUDITORY CANAL (EAR) PROSEDUR 7,797,673
2710 SG186C RECONSTRUCTION OF EXTERNAL AUDITORY CANAL - MEATOPLASTY PROSEDUR 5,697,830
2711 SG1919 OTHER STAPEDECTOMY PROSEDUR 8,907,245
OTHER OPERATIONS ON OSSICULAR CHAIN - OSSICULOPLASTY WITH/WITHOUT
2712 SG193 PROSEDUR 9,835,450
TYMPANOPLASTY
2713 SG194 MYRINGOPLASTY (TYMPANOPLASTY) PROSEDUR 9,979,263
2714 SG194A MYRINGOPLASTY PROSEDUR 7,423,589
2715 SG200 MYRINGOTOMY PROSEDUR 1,351,917
2716 SG2001 MYRINGOTOMY WITH INSERTION OF TUBE PROSEDUR 3,767,762
2717 SG2031 ELECTROCOCHLEOGRAPHY - TRANS TYMPANIC PROSEDUR 4,803,435
2718 SG2032 BIOPSY OF MIDDLE AND INNER EAR PROSEDUR 6,404,097
2719 SG2041 SIMPLE MASTOIDECTOMY PROSEDUR 10,054,611
2720 SG2042 RADICAL MASTOIDECTOMY PROSEDUR 12,973,501
2721 SG2049A OTHER MASTOIDECTOMY - PETROSECTOMY PROSEDUR 13,078,312
2722 SG2049B OTHER MASTOIDECTOMY - MODIFIED RADICAL MASTOIDECTOMY PROSEDUR 11,975,381
2723 SG2049C OTHER MASTOIDECTOMY - PETROSECTOMY (COMPLEX) PROSEDUR 15,693,274
2724 SG2051A EXCISION OF LESION OF MIDDLE EAR - POLYPECTOMY PROSEDUR 2,730,641
2725 SG2051B EXCISION OF LESION OF MIDDLE EAR -TUMOUR PROSEDUR 8,907,245
2726 SG2079 INCISION OF ENDOLYMPHATIC SAC - OPERATION(S) ENDOLYMPHATIC SAC PROSEDUR 7,797,673
2727 SG2079A LABYRINTHECTOMY (TRANSTYMPANIC) - MEMBRANOUS PROSEDUR 8,692,068
2728 SG2079B LABYRINTHECTOMY (TRANSTYMPANIC) - OSSEUS PROSEDUR 9,024,251
2729 SG2092 REVISION OF MASTOIDECTOMY PROSEDUR 7,423,589
IMPLANTATION OR REPLACEMENT OF COCHLEAR PROSTHETIC DEVICE, SINGLE
2730 SG2097 PROSEDUR 17,486,170
CHANNEL
IMPLANTATION OR REPLACEMENT OF COCHLEAR PROSTHETIC DEVICE, MULTIPLE
2731 SG2098 PROSEDUR 24,884,160
CHANNEL
2732 SG2101 CONTROL OF EPISTAXIS BY ANTERIOR NASAL PACKING PROSEDUR 1,372,082
2733 SG2102 CONTROL OF EPISTAXIS BY POSTERIOR (AND ANTERIOR) PACKING PROSEDUR 2,286,764
2734 SG2103 CONTROL OF EPISTAXIS BY CAUTERIZATION (AND PACKING) PROSEDUR 1,372,082
2735 SG2104 CONTROL OF EPISTAXIS BY LIGATION OF ETHMOIDAL ARTERIES PROSEDUR 4,865,380
2736 SG211 INCISION OF NOSE PROSEDUR 1,771,644
2737 SG211A INCISION OF NOSE (LATERAL RHINOTOMY INTO SINUS FOR MALIGNANCY) PROSEDUR 8,324,867
2738 SG2121 RHINOSCOPY / NASOENDOSCOPY PROSEDUR 232,082
2739 SG2122 BIOPSY OF NOSE PROSEDUR 1,622,276
2740 SG2123 BIOPSY OF LESION OF TURBINATE OF NOSE PROSEDUR 1,622,276
2741 SG2129 OTHER DIAGNOSTIC PROCEDURE ON NOSE - VOCAL CORD (SLEEP ENDOSCOPY) PROSEDUR 2,017,733
2742 SG213 LOCAL EXCISION OR DESTRUCTION OF LESION OF NOSE PROSEDUR 1,477,014
2743 SG2130 EXCISION OR DESTRUCTION OF LESION OF NOSE, NOT OTHERWISE SPECIFIED PROSEDUR 2,099,843
2744 SG2131A LOCAL EXCISION OR DESTRUCTION OF INTRANASAL LESION - POLYPECTOMY PROSEDUR 2,495,299
2745 SG2132 LOCAL EXCISION OR DESTRUCTION OF OTHER LESION OF NOSE PROSEDUR 1,372,082
2746 SG2132A ENDOSCOPIC TUMOR RESSECTION OF SINUS OR PARANASAL * 15,364,109
2747 SG2132B LOCAL EXCISION OR DESTRUCTION OF OTHER LESION OF NOSE (INTERNAL) PROSEDUR 1,771,644
2748 SG214 RESECTION OF NOSE - AMPUTATION OF NOSE PROSEDUR 5,696,623
2749 SG215 SUBMUCOUS RESECTION OF NASAL SEPTUM PROSEDUR 5,280,881
2750 SG216 TURBINECTOMY PROSEDUR 2,640,440
2751 SG2161A TURBINECTOMY BY DIATHERMY OR CRYOSURGERY (DIATHERMY) PROSEDUR 1,771,644
2752 SG2161B TURBINECTOMY BY DIATHERMY OR CRYOSURGERY (CAUTERISATION) PROSEDUR 1,622,276
2753 SG2169 OTHER TURBINECTOMY PROSEDUR 5,696,623
2754 SG2172A OPEN REDUCTION OF NASAL FRACTURE - OPEN FRACTURE PROSEDUR 11,298,819
2755 SG2172B OPEN REDUCTION OF NASAL FRACTURE - CLOSED FRACTURE PROSEDUR 8,955,786
2756 SG2184 REVISION RHINOPLASTY - RHINOSEPTOPLASTY PROSEDUR 9,356,555
2757 SG2184A REVISION OF RHINOSEPTOPLASTY - SEPTOPLASTY OF NOSE PROSEDUR 5,282,330
2758 SG2187 OTHER RHINOPLASTY, NOS PROSEDUR 7,422,382
2759 SG2188 OTHER SEPTOPLASTY PROSEDUR 4,865,380
2760 SG219 OTHER OPERATION ON NOSE - INTRANASAL ANTROSTOMY INCL.ENDOSCOPIC PROSEDUR 3,140,949
2761 SG2191 LYSIS OF ADHESIONS OF NOSE PROSEDUR 1,622,276
2762 SG2201 PUNCTURE OF NASAL SINUS FOR ASPIRATION OR LAVAGE PROSEDUR 2,008,314
2763 SG2219A OTHER DIAGNOSTIC PROCEDURES ON NASAL SINUSES - MINI FESS PROSEDUR 8,070,568
2764 SG2219B OTHER DIAGNOSTIC PROCEDURES ON NASAL SINUSES - ADVANCED FESS PROSEDUR 18,790,994
2765 SG2219C OTHER DIAGNOSTIC PROCEDURES ON NASAL SINUSES PROSEDUR 1,144,831
Page 34
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2766 SG222 INTRANASAL ANTROTOMY PROSEDUR 6,404,097

2767 SG2239 OTHER EXTERNAL MAXILLARY ANTROTOMY PROSEDUR 15,155,333
2768 SG2241 FRONTAL SINUSOTOMY PROSEDUR 2,519,449
2769 SG2261 EXCISION OF LESION OF MAXILLARY SINUS WITH CALDWELL-LUC APPROACH PROSEDUR 4,541,045
2770 SG2263 EXT FRONTOETHMOIDECTOMY PROSEDUR 7,797,673
2771 SG2263A INTRANASAL ETHMOIDECTOMY PROSEDUR 4,221,058
2772 SG2263B EXT ETHMOIDECTOMY INCLUDING ENDOSCOPIC PROSEDUR 6,113,573
2773 SG2263C TRANSANTRAL ETHMOIDECTOMY PROSEDUR 5,697,830
2774 SG2263D RADICAL FRONTOETHMOIDECTOMY PROSEDUR 9,523,311
2775 SG2271 CLOSURE OF NASAL SINUS FISTULA PROSEDUR 5,837,780
2776 SG2279 OTHER REPAIR OF NASAL SINUS - REPAIR OF BONE OF ACCESSORY SINUS PROSEDUR 10,377,497
OTHER OPERATION ON NASAL SINUSES - ANTERIOR AND POSTERIOR OPENING INTO
2777 SG229 PROSEDUR 7,236,668
FESS
2778 SG229A OTHER OPERATION ON NASAL SINUSES - SPHENOID SINUS PROSEDUR 3,140,949
2779 SG229B OTHER OPERATION ON NASAL SINUSES - UNSPECIFIED PROSEDUR 3,140,949
2780 SG2319 OTHER SURGICAL EXTRACTION OF TOOTH PROSEDUR 5,270,255
2781 SG235 IMPLANTATION OF TOOTH PROSEDUR 7,235,340
2782 SG2373 APICOECTOMY PROSEDUR 4,167,203
2783 SG244A EXCISION OF DENTAL LESION OF JAW PROSEDUR 5,064,376
2784 SG244B EXCISION OF DENTAL LESION OF JAW - CYST PROSEDUR 3,767,762
2785 SG245 ALVEOLOPLASTY PROSEDUR 5,595,676
2786 SG245A ALVEOLECTOMY PROSEDUR 5,577,201
2787 SG246 EXPOSURE OF TOOTH PROSEDUR 5,837,780
2788 SG2501 OPEN/CLOSED [NEEDLE] BIOPSY OF TONGUE PROSEDUR 1,486,433
2789 SG251 EXCISION OR DESTRUCTION OF LESION OR TISSUE OF TONGUE PROSEDUR 3,767,762
2790 SG251A INSICION/EXCISION OF PAPILLOMA/FIBROMA PROSEDUR 7,443,755
2791 SG252 PARTIAL GLOSSECTOMY PROSEDUR 9,356,555
2792 SG252A PARTIAL GLOSSECTOMY (HEMIGLOSECTOMY) PROSEDUR 15,155,333
2793 SG253 COMPLETE GLOSSECTOMY PROSEDUR 10,828,015
2794 SG253A COMPLETE GLOSSECTOMY (COMPLEX) PROSEDUR 23,138,357
2795 SG2559A PROSEDUR 7,684,530
FLAP 1ST STAGE)
2796 SG2559B PROSEDUR 4,366,199
FLAP 2ND STAGE)
2797 SG2559C OTHER REPAIR AND PLASTIC OPERATIONS ON TONGUE (FUSION OF TONGUE TO LIP) PROSEDUR 9,356,555
2798 SG2591 LINGUAL FRENOTOMY PROSEDUR 2,095,737
2799 SG2592 LINGUAL FRENECTOMY PROSEDUR 2,095,737
2800 SG2592A LINGUAL FRENECTOMY DI OPD PROSEDUR 791,033
2801 SG2593 LYSIS OF ADHESIONS OF TONGUE PROSEDUR 1,486,433
2802 SG260 INCISION OF SALIVARY GLAND OR DUCT PROSEDUR 1,771,644
2803 SG2611 CLOSED [NEEDLE] BIOPSY OF SALIVARY GLAND OR DUCT PROSEDUR 2,519,449
2804 SG2621 MARSUPIALIZATION OF SALIVARY GLAND CYST PROSEDUR 7,734,279
2805 SG2629A OTHER EXCISION OF SALIVARY GLAND LESION - SIALOLITHIASIS PAROTID (OPEN) PROSEDUR 3,767,762
2806 SG2629B OTHER EXCISION OF SALIVARY GLAND LESION - SIALOLITHIASIS SUBMANDIBULAR PROSEDUR 3,169,084
OTHER EXCISION OF SALIVARY GLAND LESION - SIALOLITHIASIS PAROTID
2807 SG2629C PROSEDUR 3,169,084
(MANIPULATIVE)
2808 SG2629D EXCISION OF LESION OF SALIVARY GLAND - PAROTID/SUBMANDIBULAR PROSEDUR 5,064,376
2809 SG2629E EXCISION OF LESION OF SALIVARY GLAND - SUBLINGUAL PROSEDUR 1,771,644
2810 SG2629F OTHER EXCISION OF SALIVARY GLAND LESION-STONE EXTRACTION WITH IMAGING PROSEDUR 3,432,802
2811 SG2630 SIALOADENECTOMY, NOT OTHERWISE SPECIFIED PROSEDUR 15,155,333
2812 SG2630A SIALOADENECTOMY, NOT OTHERWISE SPECIFIED - PAROTID PROSEDUR 8,233,460
2813 SG2631 PARTIAL SIALOADENECTOMY PROSEDUR 12,625,137
2814 SG2631B SIALOADENECTOMY, NOT OTHERWISE SPECIFIED - SUBMANDIBULAR PROSEDUR 5,595,676
2815 SG2631C SIALOADENECTOMY, NOT OTHERWISE SPECIFIED - SUBLINGUAL PROSEDUR 4,366,199
2816 SG2632 COMPLETE SIALOADENECTOMY PROSEDUR 15,693,274
2817 SG2632A COMPLETE SIALOADENECTOMY (PAROTIDECTOMY) PROSEDUR 26,686,595
2818 SG2642 CLOSURE OF SALIVARY FISTULA PROSEDUR 3,767,762
OTHER REPAIR AND PLASTIC OPERATIONS ON SALIVARY GLAND OR DUCT -
2819 SG2649 PROSEDUR 5,064,376
TRANSPOSITION OF PAROTID/SUBMANDIBULAR DUCT
2820 SG2699 OTHER OPERATIONS ON SALIVARY GLAND OR DUCT PROSEDUR 1,771,644
2821 SG2699LP OTHER OPERATIONS ON SALIVARY GLAND OR DUCT-LIGATION OF PAROTID PROSEDUR 2,095,737
2822 SG2699LS OTHER OPERATIONS ON SALIVARY GLAND OR DUCT-LIGATION OF SUBMANDIBULAR PROSEDUR 2,095,737
2823 SG2699M OTHER OPERATIONS ON SALIVARY GLAND OR DUCT-SUBMANDIBULAR PROSEDUR 2,095,737
2824 SG270 INCISION ABSCESS AND DRAINAGE (ORAL SURGERY) PROSEDUR 5,577,201
2825 SG271 INCISION OF PALATE PROSEDUR 2,270,704
2826 SG2721 BIOPSY OF BONY PALATE PROSEDUR 2,095,737
2827 SG2722 BIOPSY OF UVULA AND SOFT PALATE PROSEDUR 2,095,737
2828 SG2723 BIOPSY OF LIP PROSEDUR 2,270,704
2829 SG2724 BIOPSY OF MOUTH, UNSPECIFIED STRUCTURE PROSEDUR 1,756,792
2830 SG2731 PROSEDUR 2,730,641
(MOUTH)
2831 SG2731A PROSEDUR 3,767,762
(PALATE)
2832 SG2731B PROSEDUR 23,138,357
(UNROOFING MAXILLA)
2833 SG2742 WIDE EXCISION OF LESION OF LIP PROSEDUR 3,767,762
2834 SG2743 OTHER EXCISION OF LESION OR TISSUE OF LIP PROSEDUR 4,366,199
2835 SG2749 OTHER EXCISION OF MOUTH (EXCEPT TOUNGUE, UVULA, AND PALATE) PROSEDUR 2,519,449
2836 SG2749A OTHER EXCISION OF MOUTH (REMOVAL OF EXCESS MUCOSA) PROSEDUR 3,767,762
2837 SG2749B FRENULECTOMY PROSEDUR 5,577,201
2838 SG2751 SUTURE OF LACERATION OF LIP PROSEDUR 2,270,704
2839 SG2752 SUTURE OF LACERATION OF OTHER PART OF MOUTH PROSEDUR 2,730,641
2840 SG2754A REPAIR OF CLEFT LIP - PRIMARY PROSEDUR 7,684,530
2841 SG2754B REPAIR OF CLEFT LIP - REVISION PROSEDUR 9,356,555
2842 SG2755 FULL-THICKNESS SKIN GRAFT TO LIP AND MOUTH PROSEDUR 4,366,199
2843 SG2755A FULL-THICKNESS SKIN GRAFT TO LIP AND MOUTH - MOUTH PROSEDUR 4,366,199
2844 SG2757A ATTACHMENT OF PEDICLE OR FLAP GRAFT TO LIP AND MOUTH (MOUTH) PROSEDUR 7,796,224
2845 SG2757B ATTACHMENT OF PEDICLE OR FLAP GRAFT TO LIP AND MOUTH (LIP) PROSEDUR 8,907,245
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TARIF INSURANCE
2846 SG2759 OTHER PLASTIC REPAIR OF MOUTH PROSEDUR 5,064,376

2847 SG2759A OTHER PLASTIC REPAIR OF MOUTH - GRAFT MUCOSA TO MOUTH PROSEDUR 3,767,762
2848 SG2761 SUTURE OF LACERATION OF PALATE PROSEDUR 2,730,641
2849 SG2762 CORRECTION OF CLEFT PALATE PROSEDUR 10,054,611
2850 SG2763 REVISION OF CLEFT PALATE REPAIR PROSEDUR 6,835,899
2851 SG2769A OTHER PLASTIC REPAIR OF PALATE - FLAP OF PALATE PROSEDUR 5,837,780
2852 SG2769B OTHER PLASTIC REPAIR OF PALATE - FLAP OF SKIN PROSEDUR 8,233,460
2853 SG2779 OTHER OPERATIONS ON UVULA PROSEDUR 3,169,084
2854 SG2779A UVULOPALATOPLASTY PROSEDUR 5,380,379
2855 SG2792 INCISION/EXCISION OF PHLEGMON PROSEDUR 7,443,755
2856 SG2799 EXOSTOSIS (ORAL SURGERY) PROSEDUR 7,443,755
2857 SG280 INCISION AND DRAINAGE OF TONSIL AND PERITONSILLAR STRUCTURES PROSEDUR 1,372,082
2858 SG282 TONSILLECTOMY WITHOUT ADENOIDECTOMY PROSEDUR 4,366,199
2859 SG282A TONSILLECTOMY WITHOUT ADENOIDECTOMY - LINGUAL TONSIL PROSEDUR 3,767,762
2860 SG282B TONSILLECTOMY WITHOUT ADENOIDECTOMY - WITH COMPLICATION PROSEDUR 13,344,083
2861 SG282C TONSILLECTOMY WITHOUT ADENOIDECTOMY - COBLATION PROSEDUR 12,307,565
2862 SG282D TONSILLECTOMY WITHOUT ADENOIDECTOMY - THERMAL WELDING PROSEDUR 11,298,819
2863 SG283 TONSILLECTOMY WITH ADENOIDECTOMY PROSEDUR 4,783,270
2864 SG285 EXCISION (REDUCTION) OF LINGUAL TONSIL PROSEDUR 4,035,344
2865 SG286 ADENOIDECTOMY WITHOUT TONSILLECTOMY PROSEDUR 2,270,704
2866 SG2911 PHARYNGOSCOPY - THERAPEUTIC ENDOSCOPIC OPERATION ON PHARYNX PROSEDUR 2,101,171
2867 SG2912 PHARYNGEAL BIOPSY - DIAG.ENDOSCOPIC EXAM OF PHARYNX PROSEDUR 2,101,171
2868 SG292 EXCISION OF BRANCHIAL CLEFT CYST OR VESTIGE PROSEDUR 4,866,708
2869 SG2932 PHARYNGEAL DIVERTICULECTOMY PROSEDUR 6,861,498
2870 SG2933 PHARYNGECTOMY (PARTIAL) PROSEDUR 10,054,611
OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF PHARYNX - TOTAL
2871 SG2939A PROSEDUR 21,705,899
PHARYNGECTOMY
OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF PHARYNX -
2872 SG2939B PROSEDUR 6,861,498
PHARYNGEAL POUCH
OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF PHARYNX - OPEN
2873 SG2939C PROSEDUR 2,640,440
EXCISION
2874 SG295 OTHER REPAIR OF PHARYNX PROSEDUR 7,797,673
2875 SG2952 CLOSURE OF BRANCHIAL CLEFT FISTULA PROSEDUR 7,423,589
2876 SG295A OSA SURGERY * 15,364,109
2877 SG3009 OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF LARYNX PROSEDUR 5,486,759
2878 SG3009A ENDOSCOPIC VOCAL CORD SURGERY * 13,828,411
2879 SG3009B LASER PHONOSURGERY * 15,364,109
2880 SG301 HEMILARYNGECTOMY PROSEDUR 9,356,555
2881 SG3022 VOCAL CORDECTOMY PROSEDUR 8,324,867
2882 SG3022A HEMICORDECTOMY * 15,364,109
2883 SG303 COMPLETE LARYNGECTOMY PROSEDUR 11,201,978
2884 SG304 RADICAL LARYNGECTOMY PROSEDUR 13,078,312
2885 SG304A RADICAL LARYNGECTOMY (THYROIDECTOMY+RND) PROSEDUR 30,570,036
2886 SG31 TYPE 1 TYROPLASTY * 15,364,109
2887 SG310 INJECTION OF LARYNX PROSEDUR 4,558,554
2888 SG311 TEMPORARY TRACHEOSTOMY (MINI TRACHEOSTOMY) PROSEDUR 2,519,449
2889 SG311A TEMPORARY TRACHEOSTOMY-CITO PROSEDUR 15,155,333
2890 SG311B TEMPORARY TRACHEOSTOMY (ELECTIVE TRACHEOSTOMY) PROSEDUR 5,915,784
2891 SG3129 OTHER PERMANENT TRACHEOSTOMY PROSEDUR 4,541,045
2892 SG3142 LARYNGOSCOPY AND OTHER TRACHEOSCOPY PROSEDUR 474,910
2893 SG3142A LARYNGOSCOPE FLEXIBLE * 846,337
2894 SG3143 CLOSED [ENDOSCOPIC] BIOPSY OF LARYNX PROSEDUR 2,730,641
2895 SG3144 CLOSED [ENDOSCOPIC] BIOPSY OF TRACHEA PROSEDUR 3,169,084
2896 SG3169 OTHER REPAIR OF LARYNX PROSEDUR 13,078,312
2897 SG3169A ARITENOIDECTOMY/EPIGLOTOPEXY * 15,364,109
2898 SG3175A PROSEDUR 13,078,312
EXCISION+RECONSTRUCTION
2899 SG3175B PROSEDUR 8,324,867
TRACHEOPLASTY
2900 SG3175C PROSEDUR 15,693,274
EXCISION+RECONSTRUCTION (COMPLEX)
2901 SG3179 OTHER REPAIR AND PLASTIC OPERATIONS ON TRACHEA PROSEDUR 7,684,530
2902 SG3193 REPLACEMENT OF LARYNGEAL OR TRACHEAL STENT PROSEDUR 3,767,762
2903 SG321 OTHER EXCISION OF BRONCHUS PROSEDUR 23,138,357
2904 SG3228 ENDOSCOPIC EXCISION OR DESTRUCTION OF LESION OR TISSUE OF LUNG PROSEDUR 4,366,199
2905 SG3229 OTHER LOCAL EXCISION OR DESTRUCTION OF LESION OR TISSUE OF LUNG PROSEDUR 12,625,137
2906 SG3239 OTHER AND UNSPECIFIED SEGMENTAL RESECTION OF LUNG PROSEDUR 23,876,864
2907 SG324 LOBECTOMY OF LUNG PROSEDUR 15,693,274
2908 SG3241 THORACOSCOPIC LOBECTOMY OF LUNG PROSEDUR 8,233,460
2909 SG3250 THORACOSCOPIC PNEUMONECTOMY PROSEDUR 8,233,460
2910 SG3259 OTHER AND UNSPECIFIED PNEUMONECTOMY PROSEDUR 15,693,274
2911 SG3320 THORACOSCOPIC LUNG BIOPSY PROSEDUR 2,519,449
2912 SG3323 OTHER BRONCHOSCOPY PROSEDUR 1,729,865
2913 SG3324 CLOSED [ENDOSCOPIC] BIOPSY OF BRONCHUS PROSEDUR 4,366,199
2914 SG3324BL CLOSED [ENDOSCOPIC] BIOPSY OF BRONCHUS (BRONCHIAL LAVAGE) PROSEDUR 3,767,762
2915 SG3326 CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF LUNG PROSEDUR 2,095,737
2916 SG3326A CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF LUNG (CORE BIOPSY) PROSEDUR 3,361,439
2917 SG3327 CLOSED ENDOSCOPIC BIOPSY OF LUNG PROSEDUR 4,366,199
2918 SG3334 THORACOPLASTY PROSEDUR 11,801,984
2919 SG3391 BRONCHIAL DILATION PROSEDUR 4,366,199
2920 SG3402 EXPLORATORY THORACOTOMY PROSEDUR 7,984,473
2921 SG3402A EXPLORATORY THORACOTOMY (MEDIAN STERNOTOMY) PROSEDUR 5,064,376
2922 SG3404 INSERTION OF INTERCOSTAL CATHETER FOR DRAINAGE PROSEDUR 2,519,449
INSERTION OF INTERCOSTAL CATHETER FOR DRAINAGE (INSERTION TUBE DRAIN
2923 SG3404A PROSEDUR 3,493,418
PLEURAL CAVITY)
2924 SG3404B INSERTION OF INTERCOSTAL CATHETER FOR DRAINAGE / PLEURA FLUID PROSEDUR 1,581,946
2925 SG3404C INSERTION OF INTERCOSTAL CATHETER FOR DRAINAGE - COMPLEX PROSEDUR 5,915,784
2926 SG3409 OTHER INCISION OF PLEURA - OPEN CHEST DRAINAGE PROSEDUR 6,835,899
2927 SG3422 MEDIASTINOSCOPY PROSEDUR 5,837,780
2928 SG3423 BIOPSY OF CHEST WALL PROSEDUR 2,519,449
2929 SG3424 OTHER PLEURAL BIOPSY PROSEDUR 11,801,984
2930 SG343 EXCISION OR DESTRUCTION OF LESION OR TISSUE OF MEDIASTINUM PROSEDUR 5,837,780
2931 SG344 EXCISION OR DESTRUCTION OF LESION OF CHEST WALL PROSEDUR 10,428,574
Page 36
TARIF INSURANCE
2932 SG3451 DECORTICATION OF LUNG PROSEDUR 12,625,137

2933 SG3459 OTHER EXCISION OF PLEURA PROSEDUR 10,828,015
2934 SG3474 REPAIR OF PECTUS DEFORMITY PROSEDUR 12,625,137
2935 SG3484 OTHER REPAIR OF DIAPHRAGM PROSEDUR 12,625,137
2936 SG3485 IMPLANTATION OF DIAPHRAGMATIC PACEMAKER PROSEDUR 14,603,747
2937 SG3492 INJECTION INTO THORACIC CAVITY - INTRODUCTION PROSEDUR 1,892,756
2938 SG3492A INJECTION INTO THORACIC CAVITY - PLEURODESIS PROSEDUR 3,361,439
2939 SG3500 BALOON VALVULATION PROSEDUR 28,730,048
2940 SG3501 CLOSED HEART VALVOTOMY, AORTIC VALVE PROSEDUR 18,982,021
2941 SG3502 CLOSED HEART VALVOTOMY, MITRAL VALVE PROSEDUR 18,982,021
2942 SG3510 OPEN HEART VALVULOPLASTY WITHOUT REPLACEMENT, UNSPECIFIED VALVE PROSEDUR 28,108,547
2943 SG3520 OPEN AND OTHER REPLACEMENT OF UNSPECIFIED HEART VALVE PROSEDUR 28,108,547
2944 SG3521 OPEN AND OTHER REPLACEMENT OF AORTIC VALVE WITH TISSUE GRAFT PROSEDUR 28,108,547
2945 SG3522 OPEN AND OTHER REPLACEMENT OF AORTIC VALVE PROSEDUR 76,985,008
2946 SG3523 OPEN AND OTHER REPLACEMENT OF MITRAL VALVE WITH TISSUE GRAFT PROSEDUR 28,108,547
2947 SG3524 OPEN AND OTHER REPLACEMENT OF MITRAL VALVE PROSEDUR 28,108,547
2948 SG3525 OPEN AND OTHER REPLACEMENT OF PULMONARY VALVE WITH TISSUE GRAFT PROSEDUR 28,108,547
2949 SG3527 OPEN AND OTHER REPLACEMENT OF TRICUSPID VALVE WITH TISSUE GRAFT PROSEDUR 28,108,547
2950 SG3539 OPERATIONS ON OTHER STRUCTURES ADJACENT TO VALVES OF HEART PROSEDUR 28,108,547
2951 SG3551 REPAIR OF ATRIAL SEPTAL DEFECT WITH PROSTHESIS, OPEN TECHNIQUE PROSEDUR 15,693,274
2952 SG3552 REPAIR OF ATRIAL SEPTAL DEFECT WITH PROSTHESIS, CLOSED TECHNIQUE PROSEDUR 12,625,137
2953 SG3554 REPAIR OF ENDOCARDIAL CUSHION DEFECT WITH PROSTHESIS PROSEDUR 28,108,547
2954 SG3571 OTHER AND UNSPECIFIED REPAIR OF ATRIAL SEPTAL DEFECT PROSEDUR 28,108,547
2955 SG3572 OTHER AND UNSPECIFIED REPAIR OF VENTRICULAR SEPTAL DEFECT PROSEDUR 28,108,547
2956 SG3573 OTHER AND UNSPECIFIED REPAIR OF ENDOCARDIAL CUSHION DEFECT PROSEDUR 28,108,547
2957 SG3581 TOTAL REPAIR OF TETRALOGY OF FALLOT PROSEDUR 28,108,547
2958 SG3582 TOTAL REPAIR OF TOTAL ANOMALOUS PULMONARY VENOUS CONNECTION PROSEDUR 28,108,547
2959 SG3583 LIGATION OF CONNECTIONS BETWEEN AORTA AND PULMONARY ARTERY PROSEDUR 22,331,264
2960 SG3583A TOTAL REPAIR OF TRUNCUS ARTERIOSUS (CORRECTION) PROSEDUR 18,982,021
TOTAL REPAIR OF TRUNCUS ARTERIOSUS (CONNECTION TO PULMONARY ARTERY
2961 SG3583B PROSEDUR 23,876,864
FROM AORTA)
2962 SG3584A PROSEDUR 29,939,117
CLASSIFIED - ARTERIAL SWITCH OPERATION [JATENE]
2963 SG3584B PROSEDUR 28,108,547
CLASSIFIED
2964 SG3592 CREATION OF CONDUIT BETWEEN RIGHT VENTRICLE AND PULMONARY ARTERY PROSEDUR 23,876,864
CREATION OF CONDUIT BETWEEN RIGHT VENTRICLE AND PULMONARY ARTERY -
2965 SG3592A PROSEDUR 28,108,547
CREATION VALVED CARDIAC CONDUIT
2966 SG3593 CREATION OF CONDUIT BETWEEN LEFT VENTRICLE AND AORTA PROSEDUR 28,108,547
2967 SG3594 CREATION OF CONDUIT BETWEEN ATRIUM AND PULMONARY ARTERY PROSEDUR 28,108,547
2968 SG3595 REVISION OF CORRECTIVE PROCEDURE ON HEART / REPAIR OF PULMONARY ARTERY PROSEDUR 33,069,078
REVISION OF CORRECTIVE PROCEDURE ON HEART / OPEN OPERATION ON
2969 SG3595A PROSEDUR 18,462,796
PULMONARY ARTERY
2970 SG3595B REVISION OF CORRECTIVE PROCEDURE ON HEART PROSEDUR 22,331,264
PERCUTANEOUS VALVULOPLASTY (THERAPEUTIC TRANSLUMINAL OPERATIONS
2971 SG3596A PROSEDUR 12,625,137
SEPTUM HEART)
PERCUTANEOUS VALVULOPLASTY (PERCUTANEOUS TRANSLUMINAL MITRAL
2972 SG3596B PROSEDUR 29,939,117
VALVULOTOMY)
2973 SG3599 OTHER OPERATIONS ON VALVES OF HEART PROSEDUR 11,801,984
2974 SG3603 OPEN CHEST CORONARY ARTERY ANGIOPLASTY PROSEDUR 28,108,547
2975 SG3611 (AORTO)CORONARY BYPASS OF ONE CORONARY ARTERY PROSEDUR 28,108,547
2976 SG3699 OTHER OPERATIONS ON VESSELS OF HEART PROSEDUR 28,108,547
2977 SG370 PERICARDIOCENTESIS PROSEDUR 5,837,780
2978 SG370A PERICARDIOCENTESIS (DECOMPRESSION FO CARDIAC TAMPONADE) PROSEDUR 10,054,611
2979 SG370B PERICARDIAL PUNCTURE /TAP PROSEDUR 5,876,661
2980 SG3712 PERICARDIOTOMY PROSEDUR 5,837,780
LEFT/RIGHT HEART CARDIAC CATHETERIZATION / ADULT CARDIAC
2981 SG3721 PROSEDUR 6,868,139
CATHETERIZATION
LEFT/RIGHT HEART CARDIAC CATHETERIZATION/ PAEDIATRIC CARDIAC
2982 SG3722 PROSEDUR 6,868,139
CATHETERIZATION
2983 SG3723A COMBINED RIGHT AND LEFT HEART CARDIAC CATHETERIZATION (ADULT) PROSEDUR 5,837,780
2984 SG3723B COMBINED RIGHT AND LEFT HEART CARDIAC CATHETERIZATION (PAEDIATRIC) PROSEDUR 6,835,899
2985 SG3726 ELECTRO PHYSIOLOGY STUDY PROSEDUR 20,924,647
2986 SG3726A ELECTRO PHYSIOLOGY STUDY & ABLATIO PROSEDUR 26,190,071
2987 SG3727 CARDIAC MAPPING PROSEDUR 6,835,899
CARDIAC MAPPING - MAP GUIDED SURG FOR VENTRICULAR ARRHYTHMIAS (W
2988 SG3727A PROSEDUR 11,801,984
MAPPING)
2989 SG3731 PERICARDIECTOMY PROSEDUR 15,693,274
2990 SG3732 EXCISION OF ANEURYSM OF HEART PROSEDUR 21,705,899
EXCISION OR DESTRUCTION OF OTHER LESION OR TISSUE OF HEART, OPEN
2991 SG3733 PROSEDUR 28,108,547
APPROACH
EXCISION OR DESTRUCTION OF OTHER LESION OR TISSUE OF HEART, OTHER
2992 SG3734 PROSEDUR 18,982,021
APPROACH - TRANSLUMINAL
EXCISION OR DESTRUCTION OF OTHER LESION OR TISSUE OF HEART,OTHER
2993 SG3734A PROSEDUR 10,428,574
APPROACH-ABLATION AV NODE
2994 SG3734B LASER VASCULAR THERAPY PROSEDUR 13,952,180
2995 SG3749 OTHER REPAIR OF HEART AND PERICARDIUM PROSEDUR 28,108,547
2996 SG3778 INSERTION OF TEMPORARY TRANSVENOUS PACEMAKER SYSTEM PROSEDUR 3,843,110
REVISION OR RELOCATION OF CARDIAC DEVICE POCKET (RESITTING OF IV CARDIAC
2997 SG3779A PROSEDUR 5,837,780
PACEMAKER SYSTEM)
2998 SG3779B PROSEDUR 18,982,021
SYSTEM WITH BYPASS)
2999 SG3779C PROSEDUR 2,519,449
SYSTEM W/O BYPASS)
3000 SG3779D REPOSITION TEMPORARY PACEMAKER PROSEDUR 4,570,750
3001 SG377A TEMPORARY PACEMAKER SYSTEM; OR REVISION OF CARDIAC DEVICE POCKET PROSEDUR 6,835,899
(SINGLE CHAMBER)
3002 SG377B TEMPORARY PACEMAKER SYSTEM; OR REVISION OF CARDIAC DEVICE POCKET (DUAL PROSEDUR 9,356,555
CHAMBER)
Page 37
TARIF INSURANCE
REPLACEMENT OF ANY TYPE PACEMAKER DEVICE WITH SINGLE-CHAMBER DEVICE,

3003 SG3785 NOT SPECIFIED AS RATE RES / REPLACEMENT OF ANY TYPE PACEMAKER DEVICE PROSEDUR 7,684,530
WITH DUAL-CHAMBER DEVICE
3004 SG3787 REPLACEMENT OF ANY TYPE PACEMAKER DEVICE WITH DUAL-CHAMBER DEVICE PROSEDUR 7,684,530
IMPLANTATION OR REPLACEMENT OF AUTOMATIC CARDIOVERTER/DEFIBRILLATOR,
3005 SG3794 PROSEDUR 15,693,274
TOTAL SYSTEM [AICD]
3006 SG3800 INCISION OF VESSEL - THROMBECTOMY PROSEDUR 7,796,224
3007 SG3800A INCISION OF VESSEL - THROMBECTOMY (OPEN) PROSEDUR 11,201,978
3008 SG3805 INCISION OF VESSEL (PULMONARY EMBOLECTOMY) PROSEDUR 23,876,864
3009 SG3810 ENDARTERECTOMY WITH GRAFT - UNSPESIFIED PROSEDUR 11,243,395
3010 SG3811 ENDARTERECTOMY (INTRACRANIAL VESSEL) PROSEDUR 23,876,864
3011 SG3812 ENDARTERECTOMY CAROTID PROSEDUR 18,982,021
3012 SG3814 ENDARTERECTOMY AORTA INCLUDE PATCH GRAFT PROSEDUR 23,876,864
3013 SG3815 ENDARTERECTOMY WITH GRAFT - SUBCLAVIA PROSEDUR 18,982,021
3014 SG3816 ENDARTERECTOMY ILIAC ARTERY INCLUDE PATCH GRAFT PROSEDUR 15,693,274
3015 SG3817 ENDARTERECTOMY RENAL ARTERY PROSEDUR 18,982,021
3016 SG3819 ENDARTERECTOMY FEMORAL ARTERY PROSEDUR 12,625,137
3017 SG3821 BIOPSY OF BLOOD VESSEL PROSEDUR 2,519,449
RESECTION OF VESSEL WITH ANASTOMOSIS - EXCISION OF ARETRIOVENOUS
3018 SG3830 PROSEDUR 28,108,547
MALFORMATION
3019 SG3841 RESECTION OF VESSEL WITH REPLACEMENT (INTRACRANIAL VESSEL) PROSEDUR 25,552,874
RESECTION OF VESSEL WITH REPLACEMENT (AORTA) (REVISION OF PROSTHESIS
3020 SG3844A PROSEDUR 18,982,021
ABDOMINAL AORTA)
RESECTION OF VESSEL WITH REPLACEMENT (AORTA) (OTHER OPEN OP VISCERAL
3021 SG3844B PROSEDUR 23,876,864
BRANCH ABDOMINAL AORTA)
3022 SG3844C PROSEDUR 18,982,021
AORTIC ANEURYSM TUBE GRAFT)
3023 SG3844D PROSEDUR 23,876,864
AORTIC ANEURYSM BIFURCATION GRAFT)
3024 SG3845 RESECTION OF VESSEL WITH REPLACEMENT (OTHER THORACIC VESSELS) PROSEDUR 28,108,547
RESECTION OF VESSEL WITH REPLACEMENT - EMERGENCY REPLACE OF
3025 SG3845A PROSEDUR 28,108,547
ANEURYSMAL SEGMENT ARCH OF AORTA (ARCHUS/ASCENDING)
RESECTION OF VESSEL WITH REPLACEMENT - PLAN REPLACE ANEURYSMAL SEGMENT
3026 SG3845B PROSEDUR 28,108,547
THORACIC AORTA
3027 SG3845C PROSEDUR 18,982,021
SEGMENT ASCENDING AORTA
3028 SG3845D PROSEDUR 28,108,547
SEGMENT ARCH AORTA
3029 SG3850A LIGATION AND STRIPPING OF VARICOSE VEINS - RECURRENT PROSEDUR 9,356,555
LIGATION AND STRIPPING OF VARICOSE VEINS - RECURRENT BILATERAL / MULTI
3030 SG3850B PROSEDUR 15,693,274
PHLEBECTOMY
3031 SG3859 LIGATION AND STRIPPING OF VARICOSE VEINS - SAPHENOUS VEINS PROSEDUR 9,356,555
3032 SG3859A LIGATION AND STRIPPING OF VARICOSE VEIN - SAPHENOUS VEINS UNILATERAL PROSEDUR 5,837,780
3033 SG3859B LIGATION AND STRIPPING OF VARICOSE VEIN - SAPHENOUS VEINS BILATERAL PROSEDUR 9,356,555
3034 SG3859C LIGATION AND STRIPPING OF VARICOSE VEINS - SAPHENOUS VEINS (COMPLEX) PROSEDUR 15,693,274
3035 SG3866 OTHER EXCISION OF VESSEL - ILLIAC ARTERY PROSEDUR 15,693,274
3036 SG3868 OTHER EXCISION OF VESSEL - VARICOSE VEIN LEG PROSEDUR 3,169,084
3037 SG387A INTERRUPTION OF THE VENA CAVA (PLICATION OF VENA CAVA) PROSEDUR 10,054,611
INTERRUPTION OF THE VENA CAVA (REPAIR OF WOUND OF MAJOR ARTERY/VEIN OF
3038 SG387B PROSEDUR 9,356,555
ABDOMEN)
3039 SG3893 VENOUS CATHETERIZATION, NOT ELSEWHERE CLASSIFIED PROSEDUR 3,169,084
3040 SG3893A VENOUS CATHETERIZATION, NON TUNNELLED PROSEDUR 2,641,889
3041 SG3893B VENOUS CATHETERIZATION, TUNNELLED PROSEDUR 4,221,058
3042 SG3893C VENOUS CATHETERIZATION - INSERTION OF VENA CAVA FILTER PROSEDUR 4,866,708
3043 SG3895C VENOUS CATHERIZATION FOR RENAL DIALYSIS / TUNELLING PROSEDUR 3,956,012
SUBCLAVIAN- PULMONARY ANASTOMOSIS (GRAFT) / CREATION OF SHUNT TO
3044 SG390 PROSEDUR 22,331,264
PULMONARY ARTERY FR SUBCLAVIA ARTERY BY INTERPOS.TUBE PROS.
SYSTEMIC TO PULMONARY ARTERY SHUNT (CREATION OF SHUNT TO PULMONARY
3045 SG390A PROSEDUR 18,982,021
ARTERY FR SUBCLAVIA ARTERY BY INTERPOS.TUBE PROS.)
3046 SG390B PROSEDUR 23,876,864
FR SUBCLAVIA ARTERY)
3047 SG390C SYSTEMIC TO PULMONARY ARTERY SHUNT (REPAIR OF PULMONARY ARTERY) PROSEDUR 28,108,547
SYSTEMIC TO PULMONARY ARTERY SHUNT (OPEN OPERATION ON PULMONARY
3048 SG390D PROSEDUR 15,693,274
ARTERY)
SYSTEMIC TO PULMONARY ARTERY SHUNT (TRANSLUMINAL OPERATION ON
3049 SG390E PROSEDUR 11,801,984
PULMONARY ARTERY)
3050 SG390F PROSEDUR 23,876,864
FROM AORTA)
3051 SG391 INTRA-ABDOMINAL VENOUS SHUNT PROSEDUR 18,982,021
INTRA ABDOMINAL VENOUS SHUNT (TRANSJUGULAR INTRAHEPATIC
3052 SG391A PROSEDUR 10,521,431
PORTOSYSTEMIC SHUNT)
3053 SG3922 AORTA-SUBCLAVIAN-CAROTID BYPASS PROSEDUR 12,625,137
AORTA-SUBCLAVIAN-CAROTID BYPASS (EXCISION OF INFECTED AORTIC GRAFT W
3054 SG3922A PROSEDUR 28,108,547
BYPASS)
3055 SG3922B AORTA-SUBCLAVIAN-CAROTID BYPASS (BYPASS CAROTID ARTERY FR ARCH) PROSEDUR 18,982,021
3056 SG3925 AORTA-ILIAC-FEMORAL BYPASS PROSEDUR 18,982,021
AORTA-ILIAC-FEMORAL BYPASS (AORTO-ILIAC,AORTO-FEMORAL,ILEO-FEMORAL
3057 SG3925A PROSEDUR 18,982,021
BYPASS)
3058 SG3925B AORTA-ILIAC-FEMORAL BYPASS (OPEN OPERATION ILIAC ARTERY) PROSEDUR 15,693,274
3059 SG3926 OTHER INTRA-ABDOMINAL VASCULAR SHUNT OR BYPASS PROSEDUR 9,356,555
3060 SG3927 ARTERIOVENOSTOMY FOR RENAL DIALYSIS PROSEDUR 5,837,780
3061 SG3929 OTHER (PERIPHERAL) VASCULAR SHUNT OR BYPASS PROSEDUR 12,625,137
3062 SG3929A OTHER (PERIPHERAL) VASCULAR SHUNT OR BYPASS - FEMORO-FEMORAL BYPASS PROSEDUR 12,625,137
OTHER (PERIPHERAL) VASCULAR SHUNT OR BYPASS - FEMORO-POPLITEAL BYPASS
3063 SG3929B PROSEDUR 15,693,274
USING PROSTHESIS &/VEIN&/CUFF/PATCH
OTHER (PERIPHERAL) VASCULAR SHUNT OR BYPASS - FEMORO-DISTAL CALF BYPASS
3064 SG3929C PROSEDUR 15,693,274
USING PROSTHESIS&/VEIN&/VEIN CUFF/PATCH
OTHER (PERIPHERAL) VASCULAR SHUNT OR BYPASS -REVISION FEMORAL BYPASS
3065 SG3929D PROSEDUR 11,801,984
GRAFT
3066 SG3930 SUTURE OF UNSPECIFIED BLOOD VESSEL PROSEDUR 9,356,555
3067 SG3949 OTHER REVISION OF VASCULAR PROCEDURE PROSEDUR 15,693,274
Page 38
TARIF INSURANCE
3068 SG395 OTHER REPAIR OF VESSELS / TRANSLUMINAL OPERATION ON PULMONARY ARTERY PROSEDUR 13,884,077
ANGIOPLASTY OR ATHERECTOMY OF OTHER NON CORONARY VESSEL(S) - INCLUDE
3069 SG3950A PROSEDUR 5,837,780
PTA NON CORONARY VESSEL
3070 SG3950B PROSEDUR 6,835,899
FEMORAL ARTERY
3071 SG3950C PROSEDUR 5,837,780
ILLIAC ARTERY
3072 SG3950D PROSEDUR 6,835,899
RENAL ARTERY
ANGIOPLASTY OR ATHERECTOMY OF OTHER NON CORONARY VESSEL(S) -
3073 SG3950E PROSEDUR 18,982,021
RECONSTRUCTION OF RENAL ARTERY
3074 SG3951 CLIPPING OF ANEURYSM PROSEDUR 23,876,864
3075 SG3952 OTHER REPAIR OF ANEURYSM - POPLITEAL PROSEDUR 15,693,274
OTHER REPAIR OF ANEURYSM - REINFORCEMENT OF ANEURYSM OF CEREBRAL
3076 SG3952A PROSEDUR 23,876,864
ARTERY
3077 SG3953 REPAIR OF ARTERIOVENOUS FISTULA PROSEDUR 12,625,137
REPAIR OF ARTERIOVENOUS FISTULA (CREATION ARTERIOVENOUS FISTULA
3078 SG3953A PROSEDUR 5,837,780
(INCLUDE SUBSEQUENT CLOSURE)
REPAIR OF ARTERIOVENOUS FISTULA - OCCLUSION OF FISTULA UNDER IMAGING
3079 SG3953B PROSEDUR 7,797,673
CONTROL
REPAIR OF BLOOD VESSEL WITH TISSUE PATCH GRAFT (MICRO-ARTERIAL/MICRO-
3080 SG3956A PROSEDUR 18,982,021
VENOUS GRAFT)
REPAIR OF BLOOD VESSEL WITH TISSUE PATCH GRAFT (REPAIR ARTERY USE VEIN
3081 SG3956B PROSEDUR 11,801,984
GRAFT)
REPAIR OF BLOOD VESSEL WITH UNSPECIFIED TYPE OF PATCH GRAFT - AORTA
3082 SG3958 PROSEDUR 9,356,555
ABDOMINALIS
REPAIR OF BLOOD VESSEL WITH UNSPECIFIED TYPE OF PATCH GRAFT-AORTA
3083 SG3958A PROSEDUR 18,982,021
REPAIR
3084 SG3959 OTHER REPAIR OF VESSEL PROSEDUR 15,693,274
3085 SG3959A OTHER REPAIR OF VESSEL -MICROSURGERY PROSEDUR 11,801,984
3086 SG3959B OTHER REPAIR OF VESSEL - ARTERIOPLASTY PROSEDUR 10,054,611
REVISION OR RELOCATION OF PACEMAKER POCKET / REMOVAL OF PACING SYSTEM
3087 SG3966 PROSEDUR 6,128,304
WITHOUT BYPASS
ENDOVASCULLAR PROSEDURE ON VESSELS - EMBOLISATION OF ARTERY OF
3088 SG397 PROSEDUR 4,866,708
INTERNAL NOSE
OTHER ENDOVASCULAR PROCEDURES ON OTHER VESSELS (REPLACE THORACIC-
3089 SG3979C PROSEDUR 28,108,547
ABDOMINAL ANEURYSM)
3090 SG3992 INJECTION OF SCLEROSING AGENT INTO VEIN PROSEDUR 1,421,952
3091 SG3995 HEMODILUTION / HEMODIAFILTRATION PROSEDUR 791,033
3092 SG3997 OTHER PERFUSION PROSEDUR 11,801,984
3093 SG4011A BIOPSY OF LYMPHATIC STRUCTURE (CERVICAL, INGUINAL, AXILLARY) PROSEDUR 1,919,563
3094 SG4011B BIOPSY OF LYMPHATIC STRUCTURE (EXCISION BIOPSY LYMPH NODE) PROSEDUR 2,904,158
3095 SG4011C BIOPSY OF LYMPHATIC STRUCTURE - CERVICAL LYMPH NODE PROSEDUR 1,477,014
3096 SG4011D BIOPSY OF LYMPHATIC STRUCTURE - AXILLARY LYMPH NODE PROSEDUR 2,037,898
3097 SG4011E BIOPSY OF LYMPHATIC STRUCTURE - MAMMARY LYMPH NODE PROSEDUR 3,327,870
3098 SG402 SIMPLE EXCISION OF LYMPHATIC STRUCTURE PROSEDUR 7,734,279
3099 SG4021 EXCISION OF DEEP CERVICAL LYMPH NODE PROSEDUR 12,625,137
3100 SG4023 EXCISION OF AXILLARY LYMPH NODE PROSEDUR 7,684,530
3101 SG4024 EXCISION OF INGUINAL LYMPH NODE PROSEDUR 7,684,530
3102 SG4024A EXCISION OF INGUINAL LYMPH NODE (COMPLEX) PROSEDUR 26,686,595
3103 SG4029 SIMPLE EXCISION OF OTHER LYMPHATIC STRUCTURE PROSEDUR 10,720,427
SIMPLE EXCISION OF OTHER LYMPHATIC STRUCTURE (BLOK DISSECTION OF PELVIC
3104 SG4029A PROSEDUR 8,907,245
LYMPH NODES)
3105 SG4029B SIMPLE EXCISION OF OTHER LYMPHATIC STRUCTURE (EXCISION CYSTIC HYGROMA) PROSEDUR 6,835,899
3106 SG4029C SIMPLE EXCISION OF OTHER LYMPHATIC STRUCTURE (COMPLEX) PROSEDUR 23,138,357
3107 SG403 REGIONAL LYMPH NODE EXCISION PROSEDUR 2,095,737
3108 SG404 RADICAL EXCISION OF CERVICAL LYMPH NODES - CLYMPH NODE PROSEDUR 10,521,431
3109 SG4040 RADICAL NECK DISSECTION, NOT OTHERWISE SPECIFIED PROSEDUR 26,686,595
3110 SG4051 RADICAL EXCISION OF AXILLARY LYMPH NODES PROSEDUR 26,686,595
3111 SG4051A RADICAL EXCISION OF AXILLARY LYMPH NODES - AXILLARY LYMPH NODE PROSEDUR 6,404,097
3112 SG4052 RADICAL EXCISION OF PERIAORTIC LYMPH NODES PROSEDUR 11,201,978
3113 SG409 OTHER OPERATIONS ON LYMPHATIC STRUCTURES PROSEDUR 10,054,611
REDUCTION OF FRACTURE AND DISLOCATION. APPLICATION OF CAST ( GIPS >
3114 SG4131 PROSEDUR 2,730,641
SENDI )
REDUCTION OF FRACTURE AND DISLOCATION. APPLICATION OF CAST ( GIPS < 2
3115 SG4131A PROSEDUR 1,581,946
SENDI )
3116 SG4131B BONE MARROW PUNCTION * 1,921,012
3117 SG415A SPLEENECTOMY-LAPAROSCOPIC PROSEDUR 10,060,045
3118 SG415B SPLEENECTOMY-OPEN PROSEDUR 7,984,473
3119 SG4219 OTHER EXTERNAL FISTULIZATION OF ESOPHAGUS PROSEDUR 18,982,021
3120 SG4224 FEES (FIBREOPTIC ENDOSCOPIC EVALUATION OF SWALLOWING) * 1,153,163
3121 SG4232 LOCAL EXCISION OF OTHER LESION OR TISSUE OF ESOPHAGUS PROSEDUR 8,233,460
ENDOSCOPIC EXCISION OR DESTRUCTION OF LESION OR TISSUE OF ESOPHAGUS -
3122 SG4233 PROSEDUR 4,366,199
INJECTION SCLEROTHERAPY
3123 SG4242 TOTAL ESOPHAGECTOMY PROSEDUR 21,705,899
3124 SG4242A TOTAL ESOPHAGECTOMY (COMPLEX) PROSEDUR 28,108,547
3125 SG4251 INTRATHORACIC ESOPHAGOESOPHAGOSTOMY PROSEDUR 17,257,590
3126 SG427 ESOPHAGOMYOTOMY PROSEDUR 9,649,857
3127 SG427A ESOPHAGOMYOTOMY (BYPASS OESOPHAGUS) PROSEDUR 10,828,015
3128 SG427B ESOPHAGOMYOTOMY (THORASCOPIC OESOPHAGOGASTRIC MYOTOMY) PROSEDUR 10,135,393
3129 SG4281 INSERTION OF PERMANENT TUBE INTO ESOPHAGUS PROSEDUR 5,697,830
3130 SG4283 CLOSURE OF ESOPHAGOSTOMY PROSEDUR 9,356,555
3131 SG4284 REPAIR OF ESOPHAGEAL FISTULA, NOT ELSEWHERE CLASSIFIED PROSEDUR 15,155,333
3132 SG4289 OTHER REPAIR OF ESOPHAGUS PROSEDUR 11,801,984
3133 SG4289A OTHER REPAIR OF ESOPHAGUS-TRANSTHORACIC PROSEDUR 13,078,312
3134 SG4289B OTHER REPAIR OF ESOPHAGUS-THORACOSCOPIC PROSEDUR 11,227,577
3135 SG4289C OTHER REPAIR OF ESOPHAGUS-TRANSABDOMINAL ANTI REFLUX PROSEDUR 10,520,102
3136 SG4289D OTHER REPAIR OF ESOPHAGUS-REVISION ANTI REFLUX OP PROSEDUR 14,123,524
3137 SG4289E OTHER REPAIR OF ESOPHAGUS-TRANSTHORACIC (COMPLEX) PROSEDUR 15,693,274
3138 SG4289F OTHER REPAIR OF ESOPHAGUS-THORACOSCOPIC EXTRA PROSEDUR 12,625,137
3139 SG4311 PERCUTANEOUS [ENDOSCOPIC] GASTROSTOMY PROSEDUR 6,404,097
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TARIF INSURANCE
3140 SG4319 OTHER GASTROSTOMY PROSEDUR 7,684,530

3141 SG4319C OTHER GASTROSTOMY (COMPLEX) PROSEDUR 10,720,427
3142 SG433 PYLOROMYOTOMY PROSEDUR 7,890,409
3143 SG435 PARTIAL GASTRECTOMY WITH ANASTOMOSIS TO ESOPHAGUS PROSEDUR 8,378,601
3144 SG436 PARTIAL GASTRECTOMY WITH ANASTOMOSIS TO DUODENUM PROSEDUR 8,378,601
3145 SG437 PARTIAL GASTRECTOMY WITH ANASTOMOSIS TO JEJUNUM PROSEDUR 8,378,601
3146 SG438 OTHER PARTIAL GASTRECTOMY PROSEDUR 8,378,601
3147 SG4381 PARTIAL GASTRECTOMY WITH JEJUNAL TRANSPOSITION PROSEDUR 8,378,601
3148 SG4389 OPEN AND OTHER PARTIAL GASTRECTOMY PROSEDUR 8,378,601
3149 SG4399 OTHER TOTAL GASTRECTOMY PROSEDUR 12,625,137
3150 SG4399A OTHER TOTAL GASTRECTOMY-OESOPHAGOGASTRECTOMY PROSEDUR 21,705,899
3151 SG4399C OTHER TOTAL GASTRECTOMY-OESOPHAGOGASTRECTOMY (COMPLEX) PROSEDUR 23,876,864
3152 SG4400 VAGOTOMY, NOT OTHERWISE SPECIFIED PROSEDUR 8,907,245
3153 SG4400L VAGOTOMY, NOS - LAPAROSCOPIC PROSEDUR 9,979,263
3154 SG4401 TRUNCAL VAGOTOMY PROSEDUR 7,422,382
3155 SG4402 HIGHLY SELECTIVE VAGOTOMY PROSEDUR 8,907,245
3156 SG4403 OTHER SELECTIVE VAGOTOMY PROSEDUR 9,979,263
3157 SG4403P OTHER SELECTIVE VAGOTOMY-WITH PYLOROPLASTY PROSEDUR 7,796,224
3158 SG4413 OTHER GASTROSCOPY PROSEDUR 1,537,510
3159 SG4413B GASTROSCOPY BIOPSY PROSEDUR 1,602,111
3160 SG4413L GASTROSCOPY LIGATIE VEG PROSEDUR 1,440,789
3161 SG4413S GASTROSCOPY SCLEROTHERAPY PROSEDUR 1,729,865
3162 SG442 PYLOROPLASTY PROSEDUR 7,890,409
3163 SG4429 OTHER PYLOROPLASTY PROSEDUR 9,356,555
PERCUTANEOUS [ENDOSCOPIC] GASTROJEJUNOSTOMY (BYPASS OF
3164 SG4432 PROSEDUR 7,890,409
DUODENUM/JEJUNUM)
3165 SG4432A PERCUTANEOUS [ENDOSCOPIC] GASTROJEJUNOSTOMY PROSEDUR 7,797,673
3166 SG4438A LAPAROSCOPIC GASTROENTEROSTOMY - GASTRO-JEJUNOSTOMY PROSEDUR 10,520,102
3167 SG4438B LAPAROSCOPIC GASTROENTEROSTOMY -GASTROSTOMY/JEJUNOSTOMY PROSEDUR 9,922,873
3168 SG4439 OTHER GASTROENTEROSTOMY PROSEDUR 7,796,224
3169 SG4441 SUTURE OF GASTRIC ULCER SITE PROSEDUR 7,890,409
3170 SG4442 SUTURE OF DUODENAL ULCER SITE PROSEDUR 7,890,409
3171 SG4443 ENDOSCOPIC CONTROL OF GASTRIC OR DUODENAL BLEEDING PROSEDUR 9,273,238
3172 SG445 REVISION OF GASTRIC ANASTOMOSIS PROSEDUR 8,378,601
3173 SG4462 CLOSURE OF GASTROSTOMY PROSEDUR 6,835,899
3174 SG4465 ESOPHAGOGASTROPLASTY-HELLER"S OP PROSEDUR 8,316,777
3175 SG4468 LAPAROSCOPIC GASTROPLASTY PROSEDUR 8,378,601
3176 SG4469 OTHER REPAIR OF STOMACH - GASTROPLASTY PROSEDUR 8,233,460
3177 SG4499 GASTRIC OPERATION NEC PROSEDUR 7,890,409
3178 SG4512 ENDOSCOPY OF SMALL INTESTINE THROUGH ARTIFICIAL STOMA PROSEDUR 2,099,843
3179 SG4523 COLONOSCOPY PROSEDUR 2,305,601
3180 SG4523B COLONOSCOPY BIOPSY PROSEDUR 2,467,043
3181 SG4523P COLONOSCOPY POLIPECTOMY PROSEDUR 2,017,733
3182 SG4524 FLEXIBLE SIGMOIDOSCOPY PROSEDUR 960,566
3183 SG4531 OTHER LOCAL EXCISION OF LESION OF DUODENUM PROSEDUR 8,378,601
3184 SG4533A PROSEDUR 7,796,224
EXCISION OF JEJUNUM
3185 SG4533B PROSEDUR 9,023,044
EXCISION OF LESION OF JEJUNUM
OTHER DESTRUCTION OF LESION OF SMALL INTESTINE, EXCEPT DUODENUM-
3186 SG4534 PROSEDUR 9,273,238
LAPAROSCOPIC RESECTION OF SMALL INTESTINE
3187 SG4541 EXCISION OF LESION OR TISSUE OF LARGE INTESTINE PROSEDUR 7,684,530
3188 SG4573 OPEN AND OTHER RIGHT HEMICOLECTOMY PROSEDUR 8,690,740
3189 SG4574 OPEN AND OTHER RESECTION OF TRANSVERSE COLON PROSEDUR 8,690,740
3190 SG4575 OPEN AND OTHER LEFT HEMICOLECTOMY PROSEDUR 8,690,740
3191 SG4575A OPEN AND OTHER LEFT HEMICOLECTOMY (REVERSAL OF HARTMANN"S PROCEDURE) PROSEDUR 14,123,524
3192 SG4576 OPEN AND OTHER SIGMOIDECTOMY PROSEDUR 8,690,740
3193 SG4579 OTHER AND UNSPECIFIED PARTIAL EXCISION OF LARGE INTESTINE PROSEDUR 8,312,672
3194 SG4594 LARGE-TO-LARGE INTESTINAL ANASTOMOSIS PROSEDUR 17,049,176
3195 SG4595 ANASTOMOSIS TO ANUS PROSEDUR 17,257,590
3196 SG4603 EXTERIORIZATION OF LARGE INTESTINE PROSEDUR 7,684,530
3197 SG4610 COLOSTOMY, NOT OTHERWISE SPECIFIED PROSEDUR 8,907,245
3198 SG4610L COLOSTOMY, NOT OTHERWISE SPECIFIED -- LAPAROSCOPIC PROSEDUR 9,979,263
3199 SG4620 ILEOSTOMY, BYPASS OF IELUM PROSEDUR 7,890,409
3200 SG4620A ILEOSTOMY, NOT OTHERWISE SPECIFIED PROSEDUR 7,890,409
3201 SG4620B ILEOSTOMY, ATTENTION PROSEDUR 5,696,623
3202 SG4639 ENTEROSTOMY NEC PROSEDUR 6,404,097
3203 SG4651 CLOSURE OF STOMA OF SMALL INTESTINE PROSEDUR 7,559,433
3204 SG4652E CLOSURE OF STOMA OF LARGE INTESTINE-EXTRA PERITONEAL PROSEDUR 5,595,676
3205 SG4652I CLOSURE OF STOMA OF LARGE INTESTINE-INTRA PERITONEAL PROSEDUR 6,861,498
3206 SG4680 INTRA-ABDOMINAL MANIPULATION OF INTESTINE, NOT OTHERWISE SPECIFIED PROSEDUR 7,890,409
3207 SG4682 INTRA-ABDOMINAL MANIPULATION OF LARGE INTESTINE PROSEDUR 8,907,245
3208 SG4701 LAPAROSCOPIC APPENDECTOMY PROSEDUR 7,692,620
3209 SG4709 OTHER APPENDECTOMY PROSEDUR 5,696,623
3210 SG4709A OTHER APPENDECTOMY-COMPLICATION PROSEDUR 8,982,593
3211 SG472 DRAINAGE OF APPENDICEAL ABSCESS PROSEDUR 5,696,623
3212 SG480 PROCTOTOMY PROSEDUR 17,257,590
3213 SG4823 RIGID PROCTOSIGMOIDOSCOPY PROSEDUR 1,421,952
3214 SG4825 OPEN BIOPSY OF RECTUM PROSEDUR 1,771,644
3215 SG4835 LOCAL EXCISION OF RECTAL LESION OR TISSUE PROSEDUR 5,352,244
3216 SG4835A LOCAL EXCISION OF RECTAL LESION OR TISSUE (OPEN) PROSEDUR 7,796,224
3217 SG4842 LAPAROSCOPIC PULL-THROUGH RESECTION OF RECTUM PROSEDUR 18,712,990
3218 SG4849 OTHER PULL-THROUGH RESECTION OF RECTUM PROSEDUR 17,257,590
3219 SG4850 ABDOMINOPERINEAL RESECTION OF THE RECTUM, NOT OTHERWISE SPECIFIED PROSEDUR 17,257,590
3220 SG4861 TRANSSACRAL RECTOSIGMOIDECTOMY PROSEDUR 7,422,382
3221 SG4862 ANTERIOR RESECTION OF RECTUM WITH SYNCHRONOUS COLOSTOMY PROSEDUR 17,257,590
3222 SG4869 RECTAL RESECTION NEC PROSEDUR 9,834,122
3223 SG4876 OTHER PROCTOPEXY PROSEDUR 7,890,409
3224 SG4892 ANORECTAL MYECTOMY PROSEDUR 1,622,276
3225 SG4901 INCISION OF PERIANAL ABSCESS PROSEDUR 2,099,843
3226 SG4904 OTHER EXCISION OF PERIANAL TISSUE PROSEDUR 1,771,644
3227 SG4911 ANAL FISTULOTOMY PROSEDUR 3,767,762
Page 40
TARIF INSURANCE
3228 SG4912B ANAL FISTULECTOMY-LAY OPEN HIGH FISTULA PROSEDUR 5,696,623

3229 SG493 LOCAL EXCISION OR DESTRUCTION OF OTHER LESION OR TISSUE OF ANUS PROSEDUR 1,622,276
3230 SG4939 OTHER LOCAL EXCISION OR DESTRUCTION OF LESION OR TISSUE OF ANUS PROSEDUR 1,622,276
3231 SG4941 REDUCTION OF HEMORRHOIDS PROSEDUR 1,421,952
3232 SG4942 INJECTION OF HEMORRHOIDS PROSEDUR 1,421,952
3233 SG4946S EXCISION OF HEMORRHOIDS-STAPPLER PROSEDUR 5,738,282
3234 SG4951 LEFT LATERAL ANAL SPHINCTEROTOMY PROSEDUR 1,771,644
3235 SG4971 SUTURE OF LACERATION OF ANUS PROSEDUR 5,595,676
3236 SG4973 CLOSURE OF ANAL FISTULA PROSEDUR 3,767,762
3237 SG4979 OTHER REPAIR OF ANAL SPHINCTER PROSEDUR 5,696,623
3238 SG5011 CLOSED (PERCUTANEOUS) [NEEDLE] BIOPSY OF LIVER PROSEDUR 2,008,314
3239 SG5012 OPEN BIOPSY OF LIVER PROSEDUR 6,835,899
3240 SG5014 LAPAROSCOPIC LIVER BIOPSY PROSEDUR 5,595,676
3241 SG5021 MARSUPIALIZATION OF LESION OF LIVER PROSEDUR 4,726,759
3242 SG5022 PARTIAL HEPATECTOMY PROSEDUR 14,123,524
3243 SG5022A PARTIAL HEPATECTOMY - HEMIHEPATECTOMY PROSEDUR 21,705,899
3244 SG5025 LAPAROSCOPIC ABLATION OF LIVER LESION OR TISSUE PROSEDUR 7,984,473
3245 SG5029 OTHER DESTRUCTION OF LESION OF LIVER PROSEDUR 12,625,137
3246 SG5069 OTHER REPAIR OF LIVER PROSEDUR 10,828,015
3247 SG510 CHOLECYSTOTOMY AND CHOLECYSTOSTOMY PROSEDUR 6,861,498
3248 SG5110 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY [ERCP] PROSEDUR 6,725,534
3249 SG5112 PERCUTANEOUS BIOPSY OF GALLBLADDER OR BILE DUCTS PROSEDUR 4,366,199
3250 SG5122 CHOLECYSTECTOMY PROSEDUR 10,134,558
3251 SG5123 LAPAROSCOPIC CHOLECYSTECTOMY PROSEDUR 9,925,529
3252 SG5123A LAPAROSCOPIC CHOLECYSTECTOMY-WITH CHOLANGIOGRAM PROSEDUR 9,834,122
3253 SG5135 OTHER GALLBLADDER ANASTOMOSIS PROSEDUR 10,054,611
3254 SG5136 CHOLEDOCHOENTEROSTOMY PROSEDUR 9,356,555
3255 SG5137 ANASTOMOSIS OF HEPATIC DUCT TO GASTROINTESTINAL TRACT PROSEDUR 12,625,137
3256 SG5139 OTHER BILE DUCT ANASTOMOSIS PROSEDUR 10,428,574
3257 SG5149 INCISION OF OTHER BILE DUCTS FOR RELIEF OF OBSTRUCTION PROSEDUR 9,356,555
3258 SG5151 EXPLORATION OF COMMON DUCT PROSEDUR 8,907,245
3259 SG5169 EXCISION OF OTHER BILE DUCT PROSEDUR 9,356,555
3260 SG5179 REPAIR OF OTHER BILE DUCTS PROSEDUR 10,428,574
3261 SG5182 PANCREATIC SPHINCTEROTOMY PROSEDUR 9,356,555
3262 SG5198 OTHER PERCUTANEOUS PROCEDURES ON BILIARY TRACT PROSEDUR 5,486,759
3263 SG5198A OTHER PERCUTANEOUS PROCEDURES ON BILIARY TRACT (DILATATION) PROSEDUR 10,054,611
3264 SG5199 BILIARY TRACT OP NEC PROSEDUR 9,356,555
3265 SG5199A OTHER. INSERTION OR REPLACEMENT OF BILLIARY TRACT PROSTHESIS (PLASTIC) PROSEDUR 6,861,498
3266 SG5199B OTHER. INSERTION OR REPLACEMENT OF BILLIARY TRACT PROSTHESIS (METALLIC) PROSEDUR 8,692,068
3267 SG5201 DRAINAGE OF PANCREATIC CYST BY CATHETER PROSEDUR 8,907,245
3268 SG5211 CLOSED [ASPIRATION] [NEEDLE] [PERCUTANEOUS] BIOPSY OF PANCREAS PROSEDUR 6,835,899
3269 SG5212 OPEN BIOPSY OF PANCREAS PROSEDUR 8,907,245
3270 SG522 LOCAL EXCISION OR DESTRUCTION OF PANCREAS AND PANCREATIC DUCT PROSEDUR 8,907,245
OTHER EXCISION OR DESTRUCTION OF LESION OR TISSUE OF PANCREAS OR
3271 SG5222 PROSEDUR 8,907,245
PANCREATIC DUCT
3272 SG523 MARSUPIALIZATION OF PANCREATIC CYST PROSEDUR 8,907,245
3273 SG5252 DISTAL PANCREATECTOMY PROSEDUR 11,801,984
3274 SG526 TOTAL PANCREATECTOMY PROSEDUR 18,982,021
3275 SG526A TOTAL PANCREATECTOMY A PROSEDUR 17,257,590
3276 SG527 RADICAL PANCREATICODUODENECTOMY PROSEDUR 18,982,021
3277 SG5296 ANASTOMOSIS OF PANCREAS PROSEDUR 11,801,984
3278 SG5300 UNILATERAL REPAIR OF INGUINAL HERNIA, NOT OTHERWISE SPECIFIED PROSEDUR 8,233,460
3279 SG5300P UNILATERAL REPAIR OF INGUINAL HERNIA, NOT OTHERWISE SPECIFIED-PRIMARY PROSEDUR 5,064,376
3280 SG5300R UNILATERAL REPAIR OF INGUINAL HERNIA, NOT OTHERWISE SPECIFIED-RECURRENT PROSEDUR 8,233,460
3281 SG5310 BILATERAL REPAIR OF INGUINAL HERNIA, NOT OTHERWISE SPECIFIED PROSEDUR 8,233,460
BILATERAL REPAIR OF INGUINAL HERNIA, NOT OTHERWISE SPECIFIED - RECURRENT
3282 SG5310R PROSEDUR 12,625,137
HERNIA
3283 SG5321 UNILATERAL REPAIR OF FEMORAL HERNIA WITH GRAFT OR PROSTHESIS PROSEDUR 4,366,199
3284 SG5321R UNILATERAL REPAIR OF FEMORAL HERNIA WITH GRAFT OR PROSTHESIS-RECURRENT PROSEDUR 6,835,899
3285 SG5329 OTHER UNILATERAL FEMORAL HERNIORRHAPHY PROSEDUR 8,233,460
3286 SG5341 OTHER AND OPEN REPAIR OF UMBILICAL HERNIA WITH GRAFT OR PROSTHESIS PROSEDUR 4,366,199
3287 SG5351 INCISIONAL HERNIA REPAIR PROSEDUR 5,837,780
3288 SG5361 OTHER OPEN INCISIONAL HERNIA REPAIR WITH GRAFT OR PROSTHESIS PROSEDUR 8,233,460
OTHER AND OPEN REPAIR OF OTHER HERNIA OF ANTERIOR ABDOMINAL WALL WITH
3289 SG5369 PROSEDUR 5,837,780
GRAFT OR PROSTHESIS
3290 SG5371 LAPAROSCOPIC REPAIR OF DIAPHRAGMATIC HERNIA, ABDOMINAL APPROACH PROSEDUR 10,520,102
LAPAROSCOPIC REPAIR OF DIAPHRAGMATIC HERNIA, ABDOMINAL APPROACH
3291 SG5371R PROSEDUR 12,625,137
(REPAIR)
3292 SG5372 OTHER AND OPEN REPAIR OF DIAPHRAGMATIC HERNIA, ABDOMINAL APPROACH PROSEDUR 10,520,102
OTHER AND OPEN REPAIR OF DIAPHRAGMATIC HERNIA, ABDOMINAL APPROACH -
3293 SG5372A PROSEDUR 11,801,984
CONGENITAL
OTHER AND OPEN REPAIR OF DIAPHRAGMATIC HERNIA, ABDOMINAL APPROACH
3294 SG5372C PROSEDUR 12,625,137
(COMPLEX)
3295 SG5375 PROSEDUR 7,796,224
SPECIFIED
3296 SG5375A PROSEDUR 9,356,555
SPECIFIED (COMPLEX)
REPAIR OF DIAPHRAGMATIC HERNIA WITH THORACIC APPROACH, NOT OTHERWISE
3297 SG5380 PROSEDUR 10,054,611
SPECIFIED
3298 SG5381 PLICATION OF THE DIAPHRAGM PROSEDUR 10,428,574
3299 SG5381A PLICATION OF THE DIAPHRAGM (TRANSABDOMINAL ANTI-REFLUX OP) PROSEDUR 12,625,137
3300 SG5381R PLICATION OF THE DIAPHRAGM-REVISION PROSEDUR 15,693,274
3301 SG5411 EXPLORATORY LAPAROTOMY PROSEDUR 15,693,274
3302 SG5412 REOPENING OF RECENT LAPAROTOMY SITE PROSEDUR 7,684,530
3303 SG5419 OTHER LAPAROTOMY PROSEDUR 7,684,530
3304 SG544A EXCISION OR DESTRUCTION OF PERITONEAL TISSUE - OMENTUM PROSEDUR 8,233,460
3305 SG544B EXCISION OR DESTRUCTION OF PERITONEAL TISSUE - PRESACRAL TUMOUR PROSEDUR 7,734,279
3306 SG5451 LAPAROSCOPIC LYSIS OF PERITONEAL ADHESIONS PROSEDUR 5,486,759
Page 41
TARIF INSURANCE
3307 SG5459 OTHER LYSIS OF PERITONEAL ADHESIONS PROSEDUR 6,835,899

3308 SG5461 RECLOSURE OF POSTOPERATIVE DISRUPTION OF ABDOMINAL WALL PROSEDUR 5,595,676
3309 SG5491 PERCUTANEOUS ABDOMINAL DRAINAGE PROSEDUR 1,372,082
3310 SG5494 CREATION OF PERITONEOVASCULAR SHUNT PROSEDUR 5,837,780
3311 SG5494A CREATION OF PERITONEOVASCULAR SHUNT (COMPLEX) PROSEDUR 7,485,534
3312 SG5495 INCISION OF PERITONEUM PROSEDUR 5,064,376
3313 SG5496 INJECTION OF AIR INTO PERITONEAL CAVITY PROSEDUR 5,064,376
3314 SG5498A PERITONEAL DIALYSIS / INSERTION OF PERITONEAL DIALYSIS PROSEDUR 4,746,924
3315 SG5501 NEPHROTOMY PROSEDUR 10,428,574
3316 SG5501A NEPHROTOMY. NEPHROLITHOTOMY PROSEDUR 13,078,312
3317 SG5502 NEPHROSTOMY (PERCUTANEOUS INSERTION OF NEPHROSTOMY TUBE) PROSEDUR 7,684,530
3318 SG5502A NEPHROSTOMY PROSEDUR 4,866,708
3319 SG5503 PERCUTANEOUS NEPHROSTOMY WITHOUT FRAGMENTATION PROSEDUR 25,661,549
3320 SG5504 PERCUTANEOUS NEPHROSTOMY WITH FRAGMENTATION PROSEDUR 14,969,619
3321 SG5512 PYELOSTOMY (DRAINAGE OF PYONEPHROSIS/PERINEPHRIC ABSCESS) PROSEDUR 8,732,399
3322 SG5512A PYELOSTOMY (PERCUTANEOUS PYELYSIS) PROSEDUR 9,835,450
3323 SG5523 CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF KIDNEY PROSEDUR 4,054,302
CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF KIDNEY (DIAGNOSTIC ENDOSCOPIC
3324 SG5523A PROSEDUR 8,907,245
EXAM)
3325 SG554 PARTIAL NEPHRECTOMY PROSEDUR 10,728,517
3326 SG5551 NEPHROURETERECTOMY PROSEDUR 11,476,442
3327 SG5551A NEPHROURETERECTOMY - NEPHRECTOMY + PERIRENAL TISSUE PROSEDUR 14,969,619
3328 SG5551B NEPHROURETERECTOMY - LAPAROSCOPIC NEPHRECTOMY PROSEDUR 14,969,619
3329 SG5553 REMOVAL OF TRANSPLANTED OR REJECTED KIDNEY PROSEDUR 11,476,442
3330 SG5554 BILATERAL NEPHRECTOMY PROSEDUR 19,509,819
3331 SG5569 OTHER KIDNEY TRANSPLANTATION PROSEDUR 23,556,635
3332 SG5581 SUTURE OF LACERATION OF KIDNEY PROSEDUR 12,225,575
3333 SG5589 RENAL REPAIR NEC PROSEDUR 10,728,517
3334 SG5599 RENAL OPERATION NEC PROSEDUR 10,728,517
3335 SG560 TRANSURETHRAL REMOVAL OF OBSTRUCTION FROM URETER AND RENAL PELVIS PROSEDUR 9,835,450
3336 SG561 URETERAL MEATOTOMY PROSEDUR 5,738,282
3337 SG5612A PHARYNGEAL BIOPSY PROSEDUR 1,186,490
3338 SG562 URETEROTOMY PROSEDUR 10,728,517
3339 SG5631 URETEROSCOPY PROSEDUR 4,740,283
3340 SG564 URETERECTOMY PROSEDUR 9,231,458
3341 SG5651 FORMATION OF CUTANEOUS URETERO-ILEOSTOMY - ILEAL CONDUIT PROSEDUR 15,718,752
3342 SG5651A FORMATION OF CUTANEOUS URETERO-ILEOSTOMY PROSEDUR 11,726,636
3343 SG5671 URINARY DIVERSION TO INTESTINE PROSEDUR 14,221,694
3344 SG5674 URETERONEOCYSTOSTOMY PROSEDUR 13,223,695
3345 SG5679 URETERAL ANASTOMOSIS NEC PROSEDUR 9,356,555
3346 SG5683 CLOSURE OF URETEROSTOMY PROSEDUR 9,356,555
3347 SG5684 CLOSURE OF OTHER FISTULA OF URETER PROSEDUR 11,476,442
3348 SG5689 OTHER REPAIR OF URETER PROSEDUR 12,625,137
3349 SG570 TRANSURETHRAL CLEARANCE OF BLADDER PROSEDUR 8,732,399
3350 SG5717 PERCUTANEOUS CYSTOSTOMY PROSEDUR 2,286,764
3351 SG5718 OTHER SUPRAPUBIC CYSTOSTOMY PROSEDUR 4,990,356
3352 SG5718A PERCUTANEOUS CYSTOSTOMY + SUPRAPUBIC TUBE PROSEDUR 3,432,802
3353 SG5719 OTHER CYSTOTOMY PROSEDUR 8,732,399
3354 SG5719E TRANSURETHRAL CLEARANCE OF BLADDER-ENDOSCOPIC VESICO-LITHOTRIPSY PROSEDUR 9,356,555
3355 SG5731 CYSTOSCOPY THROUGH ARTIFICIAL STOMA PROSEDUR 2,972,744
3356 SG5733 CLOSED [TRANSURETHRAL] BIOPSY OF BLADDER PROSEDUR 4,366,199
3357 SG5749 PROSEDUR 10,728,517
BLADDER
3358 SG5749A PROSEDUR 9,231,458
BLADDER - DIVERTICULECTOMY
3359 SG5749B PROSEDUR 10,728,517
BLADDER - RESECTION
3360 SG5749C PROSEDUR 5,539,165
BLADDER - DESTRUCTION
3361 SG5749F PROSEDUR 3,432,802
BLADDER - FEMALE
3362 SG5749M PROSEDUR 8,732,399
BLADDER - MALE
3363 SG5759 OPEN EXCISION OR DESTRUCTION OF OTHER LESION OR TISSUE OF BLADDER PROSEDUR 8,233,460
3364 SG576 PARTIAL CYSTECTOMY PROSEDUR 8,907,245
3365 SG577 TOTAL CYSTECTOMY PROSEDUR 18,982,021
3366 SG5782 CLOSURE OF CYSTOSTOMY PROSEDUR 4,081,109
3367 SG5783 REPAIR OF FISTULA INVOLVING BLADDER AND INTESTINE PROSEDUR 11,715,769
3368 SG5784 REPAIR OF OTHER FISTULA OF BLADDER PROSEDUR 9,730,518
3369 SG5784A REPAIR OF OTHER FISTULA OF BLADDER - CUTANEOUS VESICAL FISTULA PROSEDUR 9,231,458
3370 SG5784B REPAIR OF OTHER FISTULA OF BLADDER - URETHRORECTAL FISTULA PROSEDUR 7,684,530
3371 SG5785 CYSTOURETHROPLASTY AND PLASTIC REPAIR OF BLADDER NECK PROSEDUR 7,684,530
3372 SG5787 RECONSTRUCTION OF URINARY BLADDER - UNILATERAL PROSEDUR 12,625,137
3373 SG5787A RECONSTRUCTION OF URINARY BLADDER - BILATERAL PROSEDUR 15,693,274
3374 SG5787B RECONSTRUCTION OF URINARY BLADDER (CONTINENT POUCH/NEO BLADDER) PROSEDUR 18,982,021
3375 SG5789 OTHER REPAIR OF BLADDER PROSEDUR 8,919,440
OTHER REPAIR OF BLADDER - ENDOSCOPIC ANTI-REFLUX PROCEDURE (AND
3376 SG5789A PROSEDUR 5,837,780
BILATERAL)
3377 SG5789B OTHER REPAIR OF BLADDER - VAGINAL OPERATION FOR BLADDER PROSEDUR 9,231,458
3378 SG5789C OTHER REPAIR OF BLADDER (COMPLEX) PROSEDUR 11,726,636
3379 SG5791 SPHINCTEROTOMY OF BLADDER PROSEDUR 5,064,376
3380 SG5791A SPHINCTEROTOMY OF BLADDER (RESECTION OF BLADDER NECK) PROSEDUR 7,734,279
3381 SG5792 DILATION OF BLADDER NECK PROSEDUR 3,513,463
3382 SG5794 INSERTION OF INDWELLING URINARY CATHETER PROSEDUR 791,033
3383 SG580 URETHROTOMY PROSEDUR 1,871,142
3384 SG580A URETHROTOMY - INCLUDE CYSTOSCOPY PROSEDUR 6,835,899
3385 SG581 URETHRAL MEATOTOMY PROSEDUR 2,099,843
3386 SG581E URETHRAL MEATOTOMY - ENDOSCOPIC PROSEDUR 5,064,376
3387 SG5822 OTHER URETHROSCOPY PROSEDUR 1,771,644
3388 SG5831 ENDOSCOPIC EXCISION OR DESTRUCTION OF LESION OR TISSUE OF URETHRA PROSEDUR 8,732,399
3389 SG5839 OTHER LOCAL EXCISION OR DESTRUCTION OF LESION OR TISSUE OF URETHRA PROSEDUR 2,495,299
Page 42
TARIF INSURANCE

3390 SG5839A PROSEDUR 9,356,555
URETHRECTOMY
3391 SG5839B PROSEDUR 6,835,899
VALVE RESECTION
3392 SG5839C PROSEDUR 5,064,376
DIVERTICULECTOMY
3393 SG5839D PROSEDUR 2,008,314
PROLAPSE URETHRA
3394 SG5843 CLOSURE OF OTHER FISTULA OF URETHRA PROSEDUR 4,740,283
3395 SG5843A CLOSURE OF OTHER FISTULA OF URETHRA - REPAIR OF URETHRO-VAGINAL FISTULA PROSEDUR 8,982,593
3396 SG5845 REPAIR OF HYPOSPADIAS OR EPISPADIAS PROSEDUR 10,828,015
3397 SG5845EA REPAIR OF HYPOSPADIAS OR EPISPADIAS - GLANDULAR HYPOSPADIA PROSEDUR 7,235,340
3398 SG5845EB REPAIR OF HYPOSPADIAS OR EPISPADIAS - CORPORAL HYPOSPADIA PROSEDUR 8,233,460
3399 SG5845EC REPAIR OF HYPOSPADIAS OR EPISPADIAS - PERINEAL HYPOSPADIA PROSEDUR 9,231,458
3400 SG5846 OTHER RECONSTRUCTION OF URETHRA PROSEDUR 9,356,555
3401 SG5846A OTHER RECONSTRUCTION OF URETHRA-URETHROCELE PROSEDUR 7,684,530
3402 SG5846B OTHER RECONSTRUCTION OF URETHRA (COMPLEX) PROSEDUR 10,728,517
3403 SG5847 URETHRAL MEATOPLASTY PROSEDUR 6,237,341
3404 SG586 DILATION OF URETHRA PROSEDUR 1,372,082
3405 SG5900 RETROPERITONEAL DISSECTION, NOT OTHERWISE SPECIFIED PROSEDUR 11,801,984
3406 SG5902 OTHER LYSIS OF PERIRENAL OR PERIURETERAL ADHESIONS PROSEDUR 9,356,555
3407 SG5902B OTHER LYSIS OF PERIRENAL OR PERIURETERAL ADHESIONS - BILATERAL PROSEDUR 11,201,978
3408 SG594 SUPRAPUBIC SLING OPERATION PROSEDUR 9,231,458
3409 SG595 RETROPUBIC URETHRAL SUSPENSION PROSEDUR 9,231,458
3410 SG598 URETERAL CATHETERIZATION PROSEDUR 4,366,199
3411 SG598A URETERAL CATHETERIZATION - DRAINAGE OF KIDNEY PROSEDUR 8,732,399
3412 SG600 INCISION OF PROSTATE PROSEDUR 5,837,780
3413 SG6011 CLOSED [PERCUTANEOUS] [NEEDLE] BIOPSY OF PROSTATE PROSEDUR 1,771,644
3414 SG6012 OPEN BIOPSY OF PROSTATE PROSEDUR 4,081,109
3415 SG6018 OTHER DIAGNOSTIC PROCEDURES ON PROSTATE AND PERIPROSTATIC TISSUE PROSEDUR 4,081,109
3416 SG6029 OTHER TRANSURETHRAL PROSTATECTOMY PROSEDUR 8,907,245
3417 SG605 RADICAL PROSTATECTOMY PROSEDUR 13,223,695
3418 SG6061 LOCAL EXCISION OF LESION OF PROSTATE PROSEDUR 8,907,245
3419 SG6079 OTHER OPERATIONS ON SEMINAL VESICLES PROSEDUR 6,835,899
3420 SG6095 TRANSURETHRAL BALLOON DILATION OF THE PROSTATIC URETHRA PROSEDUR 8,233,460
TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE BY MICROWAVE
3421 SG6096 PROSEDUR 6,835,899
THERMOTHERAPY
OTHER TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE BY OTHER
3422 SG6097 PROSEDUR 6,835,899
THERMOTHERAPY
3423 SG612 EXCISION OF HYDROCELE (OF TUNICA VAGINALIS) PROSEDUR 6,736,401
3424 SG6212 OPEN BIOPSY OF TESTIS PROSEDUR 2,099,843
3425 SG6219 OTHER DIAGNOSTIC PROCEDURES ON TESTES PROSEDUR 5,064,376
3426 SG622 EXCISION OR DESTRUCTION OF TESTICULAR LESION PROSEDUR 2,640,440
3427 SG623 UNILATERAL ORCHIECTOMY PROSEDUR 5,837,780
3428 SG623L UNILATERAL ORCHIECTOMY - LAPAROSCOPIC PROSEDUR 12,674,886
3429 SG6241 REMOVAL OF BOTH TESTES AT SAME OPERATIVE EPISODE PROSEDUR 9,356,555
3430 SG625 ORCHIOPEXY PROSEDUR 4,366,199
3431 SG625A ORCHIOPEXY - MICROVASCULAR TRANSFER OF TESTIS TO SCROTUM PROSEDUR 12,225,575
3432 SG625B ORCHIOPEXY - BILATERAL FIXATION OF TESTIS PROSEDUR 7,684,530
3433 SG625C ORCHIOPEXY - ABDOMINAL UNDESCENDED TESTIS PROSEDUR 6,835,899
3434 SG625D ORCHIOPEXY - FIXATION OF TESTIS PROSEDUR 7,984,473
3435 SG627 INSERTION OF TESTICULAR PROSTHESIS PROSEDUR 8,732,399
3436 SG631 EXCISION OF VARICOCELE AND HYDROCELE OF SPERMATIC CORD PROSEDUR 4,081,109
3437 SG632 EXCISION OF CYST OF EPIDIDYMIS PROSEDUR 5,837,780
3438 SG634 EPIDIDYMECTOMY PROSEDUR 7,684,530
3439 SG634B EPIDIDYMECTOMY-BILATERAL PROSEDUR 5,837,780
3440 SG640 CIRCUMCISION PROSEDUR 3,169,084
3441 SG6411 BIOPSY OF PENIS PROSEDUR 1,771,644
3442 SG643 AMPUTATION OF PENIS PROSEDUR 9,356,555
3443 SG643P AMPUTATION OF PENIS-PARTIAL PROSEDUR 6,835,899
3444 SG6444 RECONSTRUCTION OF PENIS PROSEDUR 7,684,530
3445 SG6445 REPLANTATION OF PENIS PROSEDUR 9,356,555
3446 SG6449 OTHER REPAIR OF PENIS PROSEDUR 6,835,899
3447 SG6493 DIVISION OF PENILE ADHESIONS PROSEDUR 1,771,644
3448 SG6493P DIVISION OF PENILE ADHESIONS-PEYRONIE"S PROSEDUR 8,732,399
3449 SG6521 MARSUPIALIZATION OF OVARIAN CYST PROSEDUR 7,692,620
3450 SG6523 LAPAROSCOPIC MARSUPIALIZATION OF OVARIAN CYST PROSEDUR 6,835,899
3451 SG6525 OTHER LAPAROSCOPIC LOCAL EXCISION OR DESTRUCTION OF OVARY PROSEDUR 8,233,460
3452 SG6549 OTHER UNILATERAL SALPINGO-OOPHORECTOMY PROSEDUR 6,835,899
3453 SG6561 OTHER REMOVAL OF BOTH OVARIES AND TUBES AT SAME OPERATIVE EPISODE PROSEDUR 8,907,245
3454 SG6622 BILATERAL ENDOSCOPIC LIGATION AND DIVISION OF FALLOPIAN TUBES PROSEDUR 5,447,636
3455 SG6631 OTHER BILATERAL LIGATION AND CRUSHING OF FALLOPIAN TUBES / STERILIZATION PROSEDUR 4,640,664
OTHER BILATERAL LIGATION AND DIVISION OF FALLOPIAN TUBES. POMEROY
3456 SG6632 PROSEDUR 4,640,664
OPERATION
3457 SG6711 ENDOCERVICAL BIOPSY PROSEDUR 1,622,276
3458 SG6712 OTHER CERVICAL BIOPSY PROSEDUR 2,495,299
3459 SG6712C OTHER CERVICAL BIOPSY (COMPLEX) PROSEDUR 3,361,439
3460 SG672 CONIZATION OF CERVIX PROSEDUR 4,542,494
3461 SG6732 DESTRUCTION OF LESION OF CERVIX BY CAUTERIZATION PROSEDUR 3,493,418
3462 SG674 AMPUTATION OF CERVIX PROSEDUR 6,835,899
3463 SG6812 HYSTEROSCOPY PROSEDUR 4,081,109
3464 SG6813 OPEN BIOPSY OF UTERUS PROSEDUR 1,771,644
3465 SG6823 ENDOMETRIAL ABLATION PROSEDUR 7,734,279
3466 SG6829 OTHER EXCISION OR DESTRUCTION OF LESION OF UTERUS PROSEDUR 8,907,245
3467 SG6839 OTHER AND UNSPECIFIED SUBTOTAL ABDOMINAL HYSTERECTOMY PROSEDUR 9,730,518
3468 SG6849 OTHER AND UNSPECIFIED TOTAL ABDOMINAL HYSTERECTOMY PROSEDUR 9,730,518
3469 SG6849A PROSEDUR 9,730,518
ADNEXA
3470 SG6849B PROSEDUR 12,625,137
ADNEXA (OVARIAN)
3471 SG6851 LAPAROSCOPICALLY ASSISTED VAGINAL HYSTERECTOMY (LAVH) PROSEDUR 10,728,517
Page 43
TARIF INSURANCE
3472 SG6859 OTHER AND UNSPECIFIED VAGINAL HYSTERECTOMY PROSEDUR 10,728,517

3473 SG6869 OTHER AND UNSPECIFIED RADICAL ABDOMINAL HYSTERECTOMY PROSEDUR 18,982,021
3474 SG688 PELVIC EVISCERATION PROSEDUR 17,257,590
3475 SG688A PELVIC EVISCERATION - ANTERIOR/POSTERIOR PROSEDUR 21,705,899
3476 SG689 OTHER AND UNSPECIFIED HYSTERECTOMY PROSEDUR 10,927,634
3477 SG6902 DILATION AND CURETTAGE FOLLOWING DELIVERY OR ABORTION PROSEDUR 4,740,283
3478 SG6909 OTHER DILATION AND CURETTAGE PROSEDUR 2,270,704
3479 SG6922 OTHER UTERINE SUSPENSION PROSEDUR 5,837,780
3480 SG6923 VAGINAL REPAIR OF CHRONIC INVERSION OF UTERUS PROSEDUR 4,740,283
3481 SG6929 OTHER REPAIR OF UTERUS AND SUPPORTING STRUCTURES PROSEDUR 5,837,780
3482 SG6949 OTHER REPAIR OF UTERUS PROSEDUR 7,734,279
3483 SG697 INSERTION OF INTRAUTERINE CONTRACEPTIVE DEVICE PROSEDUR 550,862
3484 SG6993 INSERTION OF LAMINARIA PROSEDUR 791,758
3485 SG7013 LYSIS OF INTRALUMINAL ADHESIONS OF VAGINA PROSEDUR 2,910,920
3486 SG7014 OTHER VAGINOTOMY PROSEDUR 3,742,163
3487 SG7021 VAGINOSCOPY / VAGINAL EXAMINATION PROSEDUR 316,244
3488 SG7033 EXCISION OR DESTRUCTION OF LESION OF VAGINA PROSEDUR 4,541,045
3489 SG7051 REPAIR OF CYSTOCELE PROSEDUR 8,732,399
3490 SG7051A REPAIR OF CYSTOCELE-CERVIX UTERI PROSEDUR 10,478,323
3491 SG7051B REPAIR OF CYSTOCELE-VAGINAL HYSTERECTOMY PROSEDUR 10,828,015
3492 SG7052 COLPORRHAPHY/REPAIR OF RECTOCELE PROSEDUR 7,684,530
3493 SG7062 VAGINAL RECONSTRUCTION PROSEDUR 12,973,501
3494 SG7073 REPAIR OF RECTOVAGINAL FISTULA PROSEDUR 11,476,442
3495 SG708 OBLITERATION OF VAGINAL VAULT PROSEDUR 8,233,460
3496 SG7123 MARSUPIALIZATION OF BARTHOLIN"S GLAND (CYST) PROSEDUR 4,542,494
3497 SG7124 EXCISION OR OTHER DESTRUCTION OF BARTHOLIN"S GLAND (CYST) PROSEDUR 4,542,494
3498 SG713 OTHER LOCAL EXCISION OR DESTRUCTION OF VULVA AND PERINEUM PROSEDUR 2,352,693
3499 SG715 RADICAL VULVECTOMY PROSEDUR 12,625,137
3500 SG7161 UNILATERAL VULVECTOMY PROSEDUR 7,796,224
3501 SG7179 OTHER REPAIR OF VULVA AND PERINEUM PROSEDUR 3,493,418
3502 SG718 OTHER OPERATIONS ON VULVA PROSEDUR 2,640,440
3503 SG7279 OTHER VACUUM EXTRACTION PROSEDUR 7,485,534
3504 SG7359 OTHER MANUALLY ASSISTED DELIVERY PROSEDUR 6,835,899
3505 SG740 CLASSICAL CESAREAN SECTION PROSEDUR 8,369,303
3506 SG741 LOW CERVICAL CESAREAN SECTION PROSEDUR 8,369,303
3507 SG7411 LOW CERVICAL CESAREAN SECTION -OPERATOR KE-2 PROSEDUR 8,369,303
3508 SG741A LOW CERVICAL CESAREAN SECTION (2-4BED) PROSEDUR 8,369,303
3509 SG742 EXTRAPERITONEAL CESAREAN SECTION PROSEDUR 8,369,303
3510 SG743 REMOVAL OF EXTRATUBAL ECTOPIC PREGNANCY PROSEDUR 8,233,460
3511 SG744 CESAREAN SECTION OF OTHER SPECIFIED TYPE PROSEDUR 8,369,303
3512 SG744LC CESAREAN SECTION OF OTHER SPECIFIED TYPE - GEMILI PROSEDUR 8,369,303
3513 SG7491 HYSTEROTOMY TO TERMINATE PREGNANCY PROSEDUR 8,369,303
3514 SG7499 OTHER CESAREAN SECTION OF UNSPECIFIED TYPE PROSEDUR 8,369,303
3515 SG752 INTRAUTERINE TRANSFUSION PROSEDUR 4,740,283
3516 SG7562 REPAIR OF CURRENT OBSTETRIC LACERATION OF RECTUM AND SPHINCTER ANI PROSEDUR 9,481,652
3517 SG7569 REPAIR OF OTHER CURRENT OBSTETRIC LACERATION PROSEDUR 8,324,867
3518 SG7611 BIOPSY OF FACIAL BONE PROSEDUR 1,919,563
3519 SG762 PROSEDUR 7,422,382
MAXILLA)
LOCAL EXCISION OR DESTRUCTION OF LESION OF FACIAL BONE-EXTENSIVE
3520 SG762A PROSEDUR 10,428,574
EXCISION MANDIBLE
LOCAL EXCISION OR DESTRUCTION OF LESION OF FACIAL BONE - FACIAL BONE
3521 SG762B PROSEDUR 11,801,984
TUMOUR
3522 SG762C LOCAL EXCISION OR DESTRUCTION OF LESION OF FACIAL BONE-TUMOUR PROSEDUR 23,138,357
3523 SG762D PROSEDUR 5,064,376
LESION OF JAW)
3524 SG7631 PARTIAL MANDIBULECTOMY PROSEDUR 26,686,595
3525 SG7631A PARTIAL MANDIBULECTOMY-SEGMENTAL/MARGINAL PROSEDUR 23,138,357
3526 SG7631B PARTIAL MANDIBULECTOMY-WITH RECONSTRUCTION PROSEDUR 30,570,036
3527 SG7639 PARTIAL OSTECTOMY OF OTHER FACIAL BONE PROSEDUR 4,184,712
3528 SG7639A PARTIAL OSTECTOMY OF OTHER FACIAL BONE-HEMIMAXILLECTOMY PROSEDUR 11,201,978
3529 SG7639C PARTIAL OSTECTOMY OF OTHER FACIAL BONE-MAXILLECTOMY PROSEDUR 26,686,595
3530 SG7641 TOTAL MANDIBULECTOMY WITH SYNCHRONOUS RECONSTRUCTION PROSEDUR 30,570,036
3531 SG7642 OTHER TOTAL MANDIBULECTOMY PROSEDUR 15,155,333
3532 SG7643 OTHER RECONSTRUCTION OF MANDIBLE PROSEDUR 26,686,595
TOTAL OSTECTOMY OF OTHER FACIAL BONE WITH SYNCHRONOUS
3533 SG7644 PROSEDUR 11,801,984
RECONSTRUCTION
3534 SG765 TEMPOROMANDIBULAR ARTHROPLASTY PROSEDUR 8,919,440
3535 SG7661 CLOSED OSTEOPLASTY [OSTEOTOMY] OF MANDIBULAR RAMUS PROSEDUR 5,486,759
3536 SG767 REDUCTION OF FACIAL FRACTURE. INCLUDES INTERNAL FIXATION PROSEDUR 4,055,510
3537 SG7670 REDUCTION OF FACIAL FRACTURE, NOT OTHERWISE SPECIFIED PROSEDUR 3,742,163
REDUCTION OF FACIAL FRACTURE, NOT OTHERWISE SPECIFIED- TRANS ORAL
3538 SG7670A PROSEDUR 26,047,707
SURGERY WITH POST. FIXATION
3539 SG7671 CLOSED REDUCTION OF MALAR AND ZYGOMATIC FRACTURE PROSEDUR 4,730,864
3540 SG7672 OPEN REDUCTION OF MALAR AND ZYGOMATIC FRACTURE PROSEDUR 7,406,201
3541 SG7673 CLOSED REDUCTION OF MAXILLARY FRACTURE PROSEDUR 4,054,302
3542 SG7674 OPEN REDUCTION OF MAXILLARY FRACTURE PROSEDUR 5,915,784
3543 SG7675 CLOSED REDUCTION OF MANDIBULAR FRACTURE PROSEDUR 3,513,463
3544 SG7675A CLOSED REDUCTION OF MANDIBULAR FRACTURE (EXTRA) PROSEDUR 4,730,864
3545 SG7676 OPEN REDUCTION OF MANDIBULAR FRACTURE PROSEDUR 5,064,376
OPEN REDUCTION OF MANDIBULAR FRACTURE (RAISED WIRING MANDIBLE /
3546 SG7676A PROSEDUR 5,915,784
MAXILLA)
3547 SG7677 OPEN REDUCTION OF ALVEOLAR FRACTURE PROSEDUR 3,432,802
3548 SG7679 OTHER OPEN REDUCTION OF FACIAL FRACTURE PROSEDUR 5,837,780
3549 SG7691 BONE GRAFT TO FACIAL BONE PROSEDUR 5,837,780
3550 SG7692 INSERTION OF SYNTHETIC IMPLANT IN FACIAL BONE PROSEDUR 10,054,611
3551 SG7693 CLOSED REDUCTION OF TEMPOROMANDIBULAR DISLOCATION PROSEDUR 3,432,802
3552 SG7695 OTHER MANIPULATION OF TEMPOROMANDIBULAR JOINT PROSEDUR 1,919,563
3553 SG7696 INJECTION OF THERAPEUTIC SUBSTANCE INTO TEMPOROMANDIBULAR JOINT PROSEDUR 1,746,045
3554 SG7697 REMOVAL OF INTERNAL FIXATION DEVICE FROM FACIAL BONE (FIXATOR MAXILLA) PROSEDUR 2,730,641
3555 SG7700 SEQUESTRECTOMY UNSPECIFIED SITE PROSEDUR 6,324,764
3556 SG7720 WEDGE OSTEOTOMY-UNSPECIFIED SITE PROSEDUR 9,649,857
Page 44
TARIF INSURANCE
3557 SG7728 WEDGE OSTEOTOMY - TARSAL/METATARSAL PROSEDUR 3,767,762

3558 SG7728A WEDGE OSTEOTOMY - TARSAL/METATARSAL (CLOSING) PROSEDUR 7,684,530
3559 SG7740 BIOPSY OF BONE, UNSPECIFIED SITE PROSEDUR 3,169,084
3560 SG7751 PROSEDUR 8,919,440
METATARSAL
3561 SG7751A PROSEDUR 6,835,899
METATARSAL (CORRECTION MINOR)
3562 SG7751B PROSEDUR 12,625,137
METATARSAL - BILATERAL
3563 SG7752 BUNIONECTOMY WITH SOFT TISSUE CORRECTION AND ARTHRODESIS PROSEDUR 5,486,759
3564 SG7753 OTHER BUNIONECTOMY WITH SOFT TISSUE CORRECTION PROSEDUR 6,324,764
3565 SG7753B OTHER BUNIONECTOMY WITH SOFT TISSUE CORRECTION - BILATERAL PROSEDUR 9,356,555
3566 SG7754 EXCISION OR CORRECTION OF BUNIONETTE PROSEDUR 3,432,802
3567 SG7754A EXCISION OR CORRECTION OF BUNIONETTE-SIMPLE BILATERAL PROSEDUR 5,064,376
3568 SG7754B EXCISION OR CORRECTION OF BUNIONETTE-BILATERAL PROSEDUR 10,828,015
3569 SG7757 REPAIR OF CLAW TOE PROSEDUR 5,837,780
3570 SG7759 OTHER BUNIONECTOMY PROSEDUR 8,324,867
3571 SG7759A OTHER BUNIONECTOMY-KELLER"S UNILATERAL PROSEDUR 5,486,759
3572 SG7759B OTHER BUNIONECTOMY-KELLER"S BILATERAL PROSEDUR 8,233,460
3573 SG776 LOCAL EXCISION OF LESION OR TISSUE OF BONE PROSEDUR 4,184,712
3574 SG7761 LOCAL EXCISION OF LESION OR TISSUE OF BONE-CLAVICLE PROSEDUR 6,835,899
3575 SG7769 LOCAL EXCISION OF LESION OR TISSUE OF BONE-PELVIS PROSEDUR 6,835,899
3576 SG7788 OTHER PARTIAL OSTECTOMY-TARSAL PROSEDUR 8,233,460
3577 SG7790 TOTAL OSTECTOMY-UNSPECIFIED SITE PROSEDUR 11,730,621
3578 SG7800 BONE GRAFT-UNSPECIFIED SITE PROSEDUR 7,406,201
3579 SG7800A BONE GRAFT-UNSPECIFIED SITE (COMPLEX) PROSEDUR 30,570,036
3580 SG7801 BONE GRAFT-CLAVICLE, SCAPULA PROSEDUR 6,835,899
3581 SG7804 BONE GRAFT-CARPAL PROSEDUR 8,919,440
3582 SG781 APPLICATION OF EXTERNAL FIXATOR DEVICE PROSEDUR 2,641,889
3583 SG7810 APPLICATION OF EXTERNAL FIXATOR DEVICE-UNSPECIFIED SITE PROSEDUR 8,324,867
3584 SG7820E LIMB SHORTENING PROCEDURES-UNSPECIFIED SITE, EPIPHYSIS PROSEDUR 5,486,759
3585 SG7829 LIMB SHORTENING PROCEDURES-PELVIC PROSEDUR 15,693,274
3586 SG7829H LIMB SHORTENING PROCEDURES-HIP PROSEDUR 10,892,616
3587 SG7850 INTERNAL FIXATION OF BONE WITHOUT FRACTURE REDUCTION-NAILLING PROSEDUR 2,730,641
INTERNAL FIXATION OF BONE WITHOUT FRACTURE REDUCTION-LOCKED
3588 SG7850A PROSEDUR 8,312,672
INTRAMEDULLARY NAILING
INTERNAL FIXATION OF BONE WITHOUT FRACTURE REDUCTION-NAILLING
3589 SG7850B PROSEDUR 10,054,611
(MULTIPLE FRACTURE FIXATION)
REMOVAL OF EXTERNAL IMMOBILIZATION DEVICE (EXTERNAL FIXATION FROM
3590 SG7860F PROSEDUR 2,730,641
BONE)
3591 SG7860K REMOVAL OF IMPLANTED DEVICES FROM BONE-K-WIRE, UNSPECIFIED SITE PROSEDUR 6,324,764
REMOVAL OF EXTERNAL IMMOBILIZATION DEVICE (SKELETAL TRACTION FROM
3592 SG7860T PROSEDUR 1,919,563
BONE)
CLOSED REDUCTION OF FRACTURE WITHOUT INTERNAL FIXATION-UNSPECIFIED
3593 SG7900 PROSEDUR 3,432,802
SITE
3594 SG791 CLOSED REDUCTION OF FRACTURE WITH INTERNAL FIXATION PROSEDUR 6,324,764
3595 SG7930 OPEN REDUCTION OF FRACTURE WITH INTERNAL FIXATION-UNSPECIFIED SITE PROSEDUR 9,649,857
3596 SG7931 OPEN REDUCTION OF FRACTURE WITH INTERNAL FIXATION HUMERUS - SMALL BONE PROSEDUR 6,324,764
3597 SG7931A OPEN REDUCTION OF FRACTURE WITH INTERNAL FIXATION HUMERUS - LONG BONE PROSEDUR 8,919,440
3598 SG7931C OPEN REDUCTION OF FRACTURE WITH INTERNAL FIXATION HUMERUS (COMPLEX) PROSEDUR 12,625,137
3599 SG7935 OPEN REDUCTION OF FRACTURE WITH INTERNAL FIXATION-FEMUR PROSEDUR 10,892,616
3600 SG7939 OPEN REDUCTION OF FRACTURE WITH INTERNAL FIXATION OTHER SPECIFIED BONE PROSEDUR 6,324,764
3601 SG7939C PROSEDUR 12,625,137
(COMPLEX)
3602 SG7980 OPEN REDUCTION OF DISLOCATION OF UNSPECIFIED SITE PROSEDUR 8,919,440
3603 SG7987 OPEN REDUCTION OF DISLOCATION OF ANKLE PROSEDUR 8,233,460
ARTHROTOMY FOR REMOVAL OF PROSTHESIS WITHOUT REPLACEMENT-UNSPECIFIED
3604 SG8000 PROSEDUR 5,486,759
SITE
3605 SG8009 ARTHROTOMY FOR REMOVAL OF PROSTHESIS WITHOUT REPLACEMENT-SPINE PROSEDUR 8,887,200
3606 SG8020 ARTHROSCOPY - UNSPECIFIED SITE PROSEDUR 3,767,762
3607 SG8020A ARTHROSCOPY - UNSPECIFIED CAVITY UNILATERAL PROSEDUR 8,919,440
3608 SG8020B ARTHROSCOPY - UNSPECIFIED CAVITY BILATERAL PROSEDUR 13,676,990
3609 SG8020C ARTHROSCOPY - UNSPECIFIED CAVITY UNILATERAL (ARTICULAR CARTILAGE) PROSEDUR 5,486,759
3610 SG8021 ARTHROSCOPY - SHOULDER PROSEDUR 8,919,440
3611 SG8021R ARTHROSCOPY - REVISION SHOULDER PROSEDUR 11,297,491
3612 SG8026 ARTHROSCOPY - KNEE PROSEDUR 3,432,802
3613 SG8026A ARTHROSCOPY - KNEE EXTENSIVE PROSEDUR 9,356,555
3614 SG8026B ARTHROSCOPY - KNEE SEMILUNAR CARTILAGE PROSEDUR 8,919,440
3615 SG8026C ARTHROSCOPY - KNEE SEMILUNAR CARTILAGE BILATERAL PROSEDUR 12,625,137
3616 SG8030 BIOPSY OF JOINT STRUCTURE-UNSPECIFIED PROSEDUR 3,767,762
3617 SG8051 EXCISION OF INTERVERTEBRAL DISC PROSEDUR 9,356,555
3618 SG8051A EXCISION OF INTERVERTEBRAL DISC-POSTERIOR DECOMPRESSION W INSTRUMENT PROSEDUR 15,149,778
3619 SG8051C EXCISION OF INTERVERTEBRAL DISC-CERVICAL PROSEDUR 12,625,137
3620 SG8051D EXCISION OF INTERVERTEBRAL DISC-CERVICAL WITH FUSION PROSEDUR 15,693,274
3621 SG8051E EXCISION OF INTERVERTEBRAL DISC-DISCECTOMY LASER PROSEDUR 13,676,990
EXCISION OF INTERVERTEBRAL DISC-ANTERIOR & POSTERIOR DECOMPRESSION W
3622 SG8051F PROSEDUR 22,779,246
INSTRUMENT
EXCISION OF INTERVERTEBRAL DISC-OPEN DOOR LAMINOPLASTY CERVICAL REGION
3623 SG8051G PROSEDUR 17,263,024
(HIROBYASHI)
3624 SG8052 INTERVERTEBRAL CHEMONUCLEOLYSIS PROSEDUR 6,584,377
3625 SG8054 OTHER AND UNSPECIFIED REPAIR OF THE ANULUS FIBROSUS PROSEDUR 12,514,892
3626 SG8054A OTHER AND UNSPECIFIED REPAIR OF THE ANULUS FIBROSUS (REVISION) PROSEDUR 14,519,101
3627 SG8059 OTHER DESTRUCTION OF INTERVERTEBRAL DISC PROSEDUR 11,227,577
3628 SG807 SYNOVECTOMY PROSEDUR 6,835,899
3629 SG8074 SYNOVECTOMY-HAND PROSEDUR 10,428,574
3630 SG8100 SPINAL FUSION, NOT OTHERWISE SPECIFIED PROSEDUR 12,625,137
3631 SG8100A SPINAL FUSION, NOS (PRIMARY POST/ANT DECOMPRESSION W FUSION) PROSEDUR 15,693,274
Page 45
TARIF INSURANCE
SPINAL FUSION, NOS (PRIMARY POST/ANT DECOMPRESSION W FUSION &

3632 SG8100B PROSEDUR 17,263,024
INSTRUMENT)
SPINAL FUSION, NOS (PRIMARY POST/ANT. EXCISION DISC W FUSION AND OR
3633 SG8100C PROSEDUR 15,693,274
INSTRUMENT)
SPINAL FUSION, NOS (COMBINED ANT. & POST. FUSION CERVICAL SPINE, W
3634 SG8100D PROSEDUR 26,047,707
INSTRUMENT)
SPINAL FUSION, NOS (PRIMARY TRANSTHORACIC/POST./ANT.-LAT.EX. VERTEBRAL
3635 SG8100E PROSEDUR 14,519,101
DISC W FUSION)
SPINAL FUSION, NOS (COMBINED ANT. & POST. DECOMPRESSION, W FUSION &
3636 SG8100F PROSEDUR 28,651,922
INSTRUMENT)
3637 SG8100G SPINAL FUSION, NOS (REVISION POST. / ANT. DECOMPRESSION W FUSION) PROSEDUR 22,779,246
SPINAL FUSION, NOS (REVISION POST/ANT EXCISION INTERVERTEBRAL DISC W
3638 SG8100H PROSEDUR 20,707,780
FUSION AND/OR W INSTRUMENT)
SPINAL FUSION, NOS (PRIMARY POST/ANT TRANSTHORACIC DECOMPRESSION W
3639 SG8100I PROSEDUR 20,707,780
FUSION AND/OR W INSTRUMENT)
LUMBAR AND LUMBOSACRAL FUSION OF THE ANTERIOR COLUMN, POSTERIOR
3640 SG8108 PROSEDUR 12,514,892
TECHNIQUE
3641 SG8115 TARSOMETATARSAL FUSION PROSEDUR 4,184,712
3642 SG8115B TARSOMETATARSAL FUSION-BILATERAL PROSEDUR 7,684,530
3643 SG8116 METATARSOPHALANGEAL FUSION PROSEDUR 6,835,899
3644 SG8120 ARTHRODESIS OF UNSPECIFIED JOINT PROSEDUR 5,486,759
3645 SG8126 METACARPOCARPAL FUSION PROSEDUR 4,184,712
3646 SG8128 INTERPHALANGEAL FUSION PROSEDUR 4,184,712
3647 SG8128B INTERPHALANGEAL FUSION-BILATERAL PROSEDUR 7,684,530
3648 SG8129 ARTHRODESIS OF OTHER SPECIFIED JOINTS PROSEDUR 8,324,867
3649 SG8129A ARTHRODESIS OF OTHER SPECIFIED JOINTS-TRIPLE FUSION PROSEDUR 8,233,460
3650 SG8144 PATELLAR STABILIZATION PROSEDUR 10,828,015
3651 SG8145 OTHER REPAIR OF THE CRUCIATE LIGAMENTS PROSEDUR 12,135,496
3652 SG8147 OTHER REPAIR OF KNEE PROSEDUR 4,730,864
3653 SG8149 OTHER REPAIR OF ANKLE PROSEDUR 10,428,574
3654 SG8149B OTHER REPAIR OF ANKLE-BILATERAL PROSEDUR 15,693,274
3655 SG8151 TOTAL HIP REPLACEMENT PROSEDUR 17,000,634
3656 SG8151A TOTAL HIP REPLACEMENT-BILATERAL PROSEDUR 18,982,021
3657 SG8153 REVISION OF HIP REPLACEMENT, NOT OTHERWISE SPECIFIED PROSEDUR 12,785,252
3658 SG8154 TOTAL KNEE REPLACEMENT PROSEDUR 17,000,634
3659 SG8154B TOTAL KNEE REPLACEMENT-BILATERAL PROSEDUR 18,982,021
3660 SG8154C TOTAL KNEE REPLACEMENT-UNICOMPARTMENTAL PROSEDUR 12,785,252
3661 SG8155 REVISION OF KNEE REPLACEMENT,NOT OTHERWISE SPECIFIED PROSEDUR 18,982,021
3662 SG8156 TOTAL ANKLE REPLACEMENT PROSEDUR 15,693,274
3663 SG8157 REPLACEMENT OF JOINT OF FOOT AND TOE PROSEDUR 10,428,574
REVISION OF JOINT REPLACEMENT OF LOWER EXTREMITY, NOT ELSEWHERE
3664 SG8159 PROSEDUR 18,982,021
CLASSIFIED
3665 SG8165A PERCUTANEOUS VERTEBROPLASTY-CT GUIDE PROSEDUR 13,676,990
3666 SG8165B PERCUTANEOUS VERTEBROPLASTY-FLUOROSCOPICALLY GUIDE PROSEDUR 10,135,393
3667 SG8166A PERCUTANEOUS VERTEBRAL AUGMENTATION-POSTERIOR PROSEDUR 26,047,707
3668 SG8166B PERCUTANEOUS VERTEBRAL AUGMENTATION-ANTERIOR PROSEDUR 30,662,772
3669 SG8173 TOTAL WRIST REPLACEMENT PROSEDUR 20,584,011
3670 SG8179 OTHER REPAIR OF HAND, FINGERS AND WRIST PROSEDUR 8,907,245
3671 SG8180 OTHER TOTAL SHOULDER REPLACEMENT PROSEDUR 15,693,274
3672 SG8180R TOTAL SHOULDER REPLACEMENT-REVISION PROSEDUR 18,982,021
3673 SG8181 PARTIAL SHOULDER REPLACEMENT PROSEDUR 10,892,616
3674 SG8181R PARTIAL SHOULDER REPLACEMENT-REVISION PROSEDUR 12,135,496
3675 SG8184 TOTAL ELBOW REPLACEMENT PROSEDUR 15,693,274
3676 SG8184R TOTAL ELBOW REPLACEMENT-REVISION PROSEDUR 18,982,021
3677 SG8190S OTHER REPAIR OF JOINT-STABILIZATION PROSEDUR 7,406,201
3678 SG8191 ARTHROCENTESIS PROSEDUR 1,421,952
3679 SG8192 INJECTION OF THERAPEUTIC SUBSTANCE INTO JOINT OR LIGAMENT PROSEDUR 2,730,641
3680 SG8192A INJECTION OF THERAPEUTIC SUBSTANCE INTO JOINT OR LIGAMENT-FACET PROSEDUR 1,421,952
3681 SG8192B INJEKSI INTRAARTIKULAR * 769,298
3682 SG8192X INJECTION OF THERAPEUTIC SUBSTANCE INTO JOINT OR LIGAMENT-XRAY PROSEDUR 1,653,188
3683 SG8193 SUTURE OF CAPSULE OR LIGAMENT OF UPPER EXTREMITY (ARCOMIOPLASTY) PROSEDUR 7,406,201
3684 SG8193A SUTURE OF CAPSULE OR LIGAMENT OF UPPER EXTREMITY (PRIMARY / SECONDARY) PROSEDUR 11,801,984
3685 SG8196 OTHER REPAIR OF JOINT PROSEDUR 7,406,201
3686 SG8196A OTHER REPAIR OF JOINT (RECONSTRUCTION) PROSEDUR 12,785,252
3687 SG8201 EXPLORATION OF TENDON SHEATH OF HAND PROSEDUR 4,184,712
3688 SG8211 TENOTOMY OF HAND PROSEDUR 1,653,188
3689 SG8221 EXCISION OF LESION OF TENDON SHEATH OF HAND PROSEDUR 3,169,084
3690 SG8229 EXCISION OF OTHER LESION OF SOFT TISSUE OF HAND (FASCIA) PROSEDUR 1,746,045
3691 SG8229A EXCISION OF OTHER LESION OF SOFT TISSUE OF HAND (TENDON) PROSEDUR 3,169,084
3692 SG8233 OTHER TENONECTOMY OF HAND PROSEDUR 3,767,762
3693 SG8235 OTHER FASCIECTOMY OF HAND PROSEDUR 5,486,759
3694 SG8235A OTHER FASCIECTOMY OF HAND-DERMOFASCIECTOMY PROSEDUR 9,356,555
3695 SG8235B OTHER FASCIECTOMY OF HAND-MULTIPLE PROSEDUR 8,324,867
3696 SG8256 OTHER HAND TENDON TRANSFER OR TRANSPLANTATION PROSEDUR 8,324,867
3697 SG8261 POLLICIZATION OPERATION CARRYING OVER NERVES AND BLOOD SUPPLY PROSEDUR 13,078,312
3698 SG8279 PLASTIC OPERATION ON HAND WITH OTHER GRAFT OR IMPLANT PROSEDUR 6,324,764
3699 SG8279E PLASTIC OPERATION ON HAND WITH OTHER GRAFT OR IMPLANT-EXTENSOR PROSEDUR 3,767,762
3700 SG8279F PLASTIC OPERATION ON HAND WITH OTHER GRAFT OR IMPLANT-FLEXOR PROSEDUR 8,324,867
3701 SG8285 OTHER TENODESIS OF HAND PROSEDUR 7,406,201
3702 SG8286A OTHER TENOPLASTY OF HAND - WITH IMPLANT PROSEDUR 8,919,440
3703 SG8286C OTHER TENOPLASTY OF HAND - EXCLUDE FLEXOR PROSEDUR 4,730,864
3704 SG8302S MYOTOMY-SHOULDER PROSEDUR 9,356,555
3705 SG8303 BURSOTOMY PROSEDUR 3,169,084
3706 SG8313 OTHER TENOTOMY PROSEDUR 5,486,759
3707 SG8314 DUPUYTREN"S SUBCUTANEOUS FASCIOTOMY PROSEDUR 2,730,641
3708 SG8314A RELEASE FASCIOTOMY OF ANT./POST. COMPARTMENT OF LEG PROSEDUR 7,684,530
3709 SG8319 OTHER DIVISION OF SOFT TISSUE PROSEDUR 6,324,764
3710 SG8321 OPEN BIOPSY OF SOFT TISSUE PROSEDUR 2,099,843
3711 SG8321A OPEN BIOPSY OF SOFT TISSUE (ONCOLOGY) PROSEDUR 3,361,439
3712 SG8331 EXCISION OF LESION OF TENDON SHEATH PROSEDUR 4,184,712
3713 SG8343 EXCISION OF MUSCLE OR FASCIA FOR GRAFT PROSEDUR 4,184,712
3714 SG8344 OTHER FASCIECTOMY PROSEDUR 3,169,084
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TARIF INSURANCE
3715 SG835 BURSECTOMY PROSEDUR 3,169,084

3716 SG8363 ROTATOR CUFF REPAIR PROSEDUR 9,356,555
3717 SG8364A OTHER SUTURE OF TENDON-ACHILLORAPHY PROSEDUR 3,742,163
3718 SG8364B OTHER SUTURE OF TENDON-ACHILLORAPHY 2ND PROSEDUR 8,233,460
3719 SG837 RECONSTRUCTION OF MUSCLE AND TENDON PROSEDUR 8,324,867
3720 SG8375 TENDON TRANSFER OR TRANSPLANTATION PROSEDUR 4,184,712
3721 SG8375M TENDON TRANSFER OR TRANSPLANTATION-MULTIPLE PROSEDUR 6,835,899
3722 SG8388 OTHER PLASTIC OPERATIONS ON TENDON PROSEDUR 8,233,460
INJECTION OF LOCALLY-ACTING THERAPEUTIC SUBSTANCE INTO OTHER SOFT
3723 SG8398 PROSEDUR 1,421,952
TISSUE
3724 SG8398A INJEKSI SOFT TISSUE * 615,101
3725 SG8399 OTHER OPERATIONS ON MUSCLE, TENDON, FASCIA, AND BURSA PROSEDUR 2,099,843
3726 SG8400 UPPER LIMB AMPUTATION, NOT OTHERWISE SPECIFIED PROSEDUR 23,138,357
3727 SG8401 AMPUTATION AND DISARTICULATION OF FINGER PROSEDUR 4,730,864
3728 SG8403 AMPUTATION THROUGH HAND PROSEDUR 4,730,864
3729 SG8405 AMPUTATION THROUGH FOREARM PROSEDUR 7,406,201
3730 SG8409 INTERTHORACOSCAPULAR AMPUTATION PROSEDUR 30,570,036
3731 SG8411 AMPUTATION OF TOE PROSEDUR 4,184,712
3732 SG8412 AMPUTATION THROUGH FOOT PROSEDUR 9,649,857
3733 SG8418 DISARTICULATION OF HIP PROSEDUR 26,686,595
3734 SG8419 ABDOMINOPELVIC AMPUTATION PROSEDUR 30,570,036
3735 SG8422 FINGER REATTACHMENT PROSEDUR 4,184,712
3736 SG844 IMPLANTATION OR FITTING OF PROSTHETIC LIMB DEVICE PROSEDUR 18,982,021
3737 SG8440 PROSEDUR 10,135,393
SPECIFIED
3738 SG8440A PROSEDUR 10,892,616
SPECIFIED - ARTHROPLASTY
3739 SG8459 INSERTION OF OTHER SPINAL DEVICES PROSEDUR 20,707,780
3740 SG8460 INSERTION OF SPINAL DISC PROSTHESIS, NOT OTHERWISE SPECIFIED PROSEDUR 10,135,393
3741 SG8472 APPLICATION OF EXTERNAL FIXATOR DEVICE, RING SYSTEM PROSEDUR 18,982,021
3742 SG8472A APPLICATION OF EXTERNAL FIXATOR DEVICE, RING SYSTEM -- ADJUSTMENT PROSEDUR 7,684,530
3743 SG8481B REVISION OF INTERSPINOUS PROCESS DEVICE(S) PROSEDUR 22,779,246
REVISION OF INTERSPINOUS PROCESS DEVICE(S) (REVISION POST. AND OR ANT.
3744 SG8481C PROSEDUR 22,779,246
DECOMPRESSION + FUSION WITH / WITHOUT INSTRUMENT)
3745 SG8491 AMPUTATION, NOT OTHERWISE SPECIFIED PROSEDUR 15,155,333
3746 SG8511 CLOSED (PERCUTANEOUS NEEDLE) BIOPSY OF BREAST PROSEDUR 1,351,917
3747 SG8512 OPEN BIOPSY OF BREAST PROSEDUR 3,362,767
3748 SG8521 LOCAL EXCISION OF LESION OF BREAST - WIDE LOCAL EXCISION PROSEDUR 5,915,784
3749 SG8521A LOCAL EXCISION OF LESION OF BREAST (MULTIPLE TUMOUR MAMMAE / BILATERAL) PROSEDUR 15,155,333
3750 SG8521B LOCAL EXCISION OF LESION OF BREAST PROSEDUR 4,055,510
3751 SG8521D LOCAL EXCISION OF LESION OF BREAST - STEREOTACTIC/GUIDE WIRE EXCISION PROSEDUR 6,654,291
3752 SG8521P LOCAL EXCISION OF LESION OF BREAST-PAPILOMA INTRADUCTAL PROSEDUR 15,155,333
3753 SG8522 RESECTION OF QUADRANT OF BREAST PROSEDUR 5,405,978
3754 SG8524 EXCISION OF ECTOPIC BREAST TISSUE PROSEDUR 15,155,333
3755 SG8525 EXCISION OF NIPPLE PROSEDUR 3,327,870
3756 SG8525A EXCISION OF NIPPLE - MICRODOCHOTOMY PROSEDUR 4,055,510
UNILATERAL SUBCUTANEOUS MAMMECTOMY WITH SYNCHRONOUS IMPLANT
3757 SG8533 PROSEDUR 15,155,333
(MAJOR)
3758 SG8533A UNILATERAL SUBCUTANEOUS MAMMECTOMY WITH SYNCHRONOUS IMPLANT PROSEDUR 8,109,691
3759 SG8534 OTHER UNILATERAL SUBCUTANEOUS MAMMECTOMY PROSEDUR 26,686,595
3760 SG8541 UNILATERAL SIMPLE MASTECTOMY PROSEDUR 15,155,333
3761 SG8541A UNILATERAL SIMPLE MASTECTOMY (INCLUDE AXILLARY NODE BIOPSY) PROSEDUR 6,654,291
3762 SG8543 UNILATERAL EXTENDED SIMPLE MASTECTOMY PROSEDUR 26,686,595
3763 SG8543A UNILATERAL EXTENDED SIMPLE MASTECTOMY, MODIFIED RADICAL MASTECTOMY PROSEDUR 8,109,691
3764 SG8545 UNILATERAL RADICAL MASTECTOMY PROSEDUR 8,774,057
3765 SG8553 UNILATERAL BREAST IMPLANT PROSEDUR 5,405,978
3766 SG8570 TOTAL RECONSTRUCTION OF BREAST, NOT OTHERWISE SPECIFIED PROSEDUR 30,570,036
3767 SG8570A TOTAL RECONSTRUCTION OF BREAST, USING LOCAL FLAP PROSEDUR 8,795,672
3768 SG8571 LATISSIMUS DORSI MYOCUTANEOUS FLAP (RECONSTRUCTION OF BREAST) PROSEDUR 10,811,955
3769 SG8572 TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS (TRAM) FLAP PROSEDUR 17,257,590
3770 SG8589 OTHER MAMMOPLASTY PROSEDUR 26,686,595
3771 SG8594 REMOVAL OF IMPLANT OF BREAST PROSEDUR 3,743,492
3772 SG8601A ASPIRATION OF SKIN AND SUBCUTANEOUS TISSUE PROSEDUR 1,421,952
3773 SG8601B ASPIRATION OF SKIN AND SUBCUTANEOUS TISSUE-DRAINAGE OF LESION PROSEDUR 1,622,276
ASPIRATION OF SKIN AND SUBCUTANEOUS TISSUE-DRAINAGE OF SUBCUTANEOUS
3774 SG8601C PROSEDUR 2,730,641
ABSCESS
3775 SG8602 INJECTION OR TATTOOING OF SKIN LESION OR DEFECT PROSEDUR 1,421,952
3776 SG8603 INCISION OF PILONIDAL SINUS OR CYST PROSEDUR 4,726,759
3777 SG8604 OTHER INCISION WITH DRAINAGE OF SKIN AND SUBCUTANEOUS TISSUE PROSEDUR 1,421,952
OTHER INCISION WITH DRAINAGE OF SKIN AND SUBCUTANEOUS TISSUE (BREAST
3778 SG8604A PROSEDUR 3,327,870
ABSCESS)
INCISION WITH REMOVAL OF FOREIGN BODY OR DEVICE FROM SKIN AND
3779 SG8605 PROSEDUR 3,169,084
SUBCUTANEOUS TISSUE
3780 SG8605A INCISION WITH REMOVAL OF FOREIGN BODY OR DEVICE / AFF IMPLANT PROSEDUR 791,033
3781 SG8605B INCISION OF SKIN AND SUBCUTANEOUS TISSUE / PASANG IMPLANT PROSEDUR 554,243
3782 SG8607 INSERTION OF TOTALLY IMPLANTABLE VASCULAR ACCESS DEVICE [VAD] PROSEDUR 4,366,199
3783 SG8609A OTHER INCISION OF SKIN AND SUBCUTANEOUS TISSUE-ESCHAROTOMY <10% PROSEDUR 5,595,676
3784 SG8609B OTHER INCISION OF SKIN AND SUBCUTANEOUS TISSUE-ESCHAROTOMY >10% PROSEDUR 7,684,530
3785 SG8611 CLOSED BIOPSY OF SKIN AND SUBCUTANEOUS TISSUE PROSEDUR 1,421,952
3786 SG8619 OTHER DIAGNOSTIC PROCEDURES ON SKIN AND SUBCUTANEOUS TISSUE PROSEDUR 5,915,784
EXCISION OR DESTRUCTION OF LESION OR TISSUE OF SKIN AND SUBCUTANEOUS
3787 SG862 PROSEDUR 7,734,279
TISSUE
3788 SG8621 EXCISION OF PILONIDAL CYST OR SINUS PROSEDUR 2,099,843
3789 SG8622 EXCISIONAL DEBRIDEMENT OF WOUND, INFECTION, OR BURN PROSEDUR 2,270,704
3790 SG8622A EXCISIONAL DEBRIDEMENT OF WOUND, INFECTION, OR BURN-<3 PROSEDUR 1,771,644
3791 SG8622B EXCISIONAL DEBRIDEMENT OF WOUND, INFECTION, OR BURN->3 PROSEDUR 4,366,199
EXCISIONAL DEBRIDEMENT OF WOUND, INFECTION, OR BURN (COCCYGEAL
3792 SG8622C PROSEDUR 3,767,762
PRESSURE ULCER EXCISION)
3793 SG8622GA EXCISIONAL DEBRIDEMENT OF WOUND, INFECTION, OR BURN-GA PROSEDUR 3,169,084
3794 SG8623 REMOVAL OF NAIL, NAIL BED, OR NAIL FOLD PROSEDUR 3,169,084
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TARIF INSURANCE
3795 SG8624 CHEMOSURGERY OF SKIN PROSEDUR 10,828,015

3796 SG8625 DERMABRASION PROSEDUR 2,730,641
3797 SG8625A DERMABRASION-EXTENSIVE PROSEDUR 4,366,199
3798 SG8625C MICRO DERMABRASION DIAMOND PROSEDUR 470,804
3799 SG8627 DEBRIDEMENT OF NAIL, NAIL BED, OR NAIL FOLD PROSEDUR 2,270,704
3800 SG863 PROSEDUR 1,421,952
SUBCUTANEOUS TISSUE
3801 SG863A PROSEDUR 4,366,199
SUBCUTANEOUS TISSUE - >4 LESSION
3802 SG863B PROSEDUR 15,155,333
SUBCUTANEOUS TISSUE (EXCISION OF HEMANGIOMA)
3803 SG863L PROSEDUR 3,493,418
SUBCUTANEOUS TISSUE - LASER
3804 SG863M PROSEDUR 23,138,357
SUBCUTANEOUS TISSUE-MULTIPLE
3805 SG864 RADICAL EXCISION OF SKIN LESION PROSEDUR 4,366,199
3806 SG864A RADICAL EXCISION OF SKIN LESION (COMPLEX) PROSEDUR 26,686,595
RADICAL EXCISION OF SKIN LESION (MALIGNANT MELANOMA EXCISION INCL
3807 SG864B PROSEDUR 9,356,555
GRAFTING)
3808 SG865 SUTURE OR OTHER CLOSURE OF SKIN AND SUBCUTANEOUS TISSUE PROSEDUR 5,595,676
SUTURE OR OTHER CLOSURE OF SKIN AND SUBCUTANEOUS TISSUE (MALIGNANT
3809 SG865A PROSEDUR 7,796,224
MELANOMA)
SUTURE OR OTHER CLOSURE OF SKIN AND SUBCUTANEOUS TISSUE-SECONDARY
3810 SG865S PROSEDUR 1,622,276
SUTURE
3811 SG8660 FREE SKIN GRAFT, NOT OTHERWISE SPECIFIED PROSEDUR 14,646,734
3812 SG8662L OTHER SKIN GRAFT TO HAND-LARGE PROSEDUR 7,422,382
3813 SG8662S OTHER SKIN GRAFT TO HAND-SMALL PROSEDUR 4,184,712
3814 SG8663 FULL-THICKNESS SKIN GRAFT TO OTHER SITES PROSEDUR 5,064,376
3815 SG8663A FULL-THICKNESS SKIN GRAFT TO OTHER SITES (SPLIT THICKNESS) PROSEDUR 23,138,357
3816 SG8663C FULL-THICKNESS SKIN GRAFT TO OTHER SITES (BUTTOCECTOMY) PROSEDUR 26,686,595
3817 SG8669 OTHER SKIN GRAFT TO OTHER SITES PROSEDUR 30,570,036
3818 SG8670 PEDICLE OR FLAP GRAFT, NOT OTHERWISE SPECIFIED PROSEDUR 5,915,784
3819 SG8670D PEDICLE OR FLAP GRAFT, NOT OTHERWISE SPECIFIED - DISTANT FLAP PROSEDUR 7,890,409
3820 SG8670L PEDICLE OR FLAP GRAFT, NOT OTHERWISE SPECIFIED - LARGE FOCAL FLAP PROSEDUR 7,684,530
PEDICLE OR FLAP GRAFT, NOT OTHERWISE SPECIFIED - NEUROVASCULAR ISLAND
3821 SG8670N PROSEDUR 10,428,574
FLAP
3822 SG8670S PEDICLE OR FLAP GRAFT, NOT OTHERWISE SPECIFIED - SMALL LOCAL FLAP PROSEDUR 7,684,530
3823 SG8683 LIPOSUCTION / TAMITA * 4,664,090
3824 SG8689 OTHER REPAIR AND RECONSTRUCTION OF SKIN AND SUBCUTANEOUS TISSUE PROSEDUR 30,570,036
3825 SG8693 INSERTION OF TISSUE EXPANDER PROSEDUR 5,595,676
3826 SG8774 RETROGRADE PYELOGRAM PROSEDUR 5,064,376
3827 SG8794 CONTRAST VASOGRAM PROSEDUR 2,972,744
3828 SG8840 PERIPHERAL (EXTREMITY) ARTERIOGRAPHY PROSEDUR 5,876,661
3829 SG8842A AORTOGRAPHY PROSEDUR 3,567,800
3830 SG8856 CORONARY ARTERIOGRAPHY USING TWO CATHETERS PROSEDUR 1,729,865
3831 SG8860 PHLEBOGRAPHY USING CONTRAST MATERIAL, UNSPECIFIED SITE PROSEDUR 1,919,563
3832 SG8872 DIAGNOSTIC ULTRASOUND OF HEART PROSEDUR 316,244
3833 SG8872A ADVANCED ECHOCARDIOGRAPHY PROSEDUR 1,958,927
3834 SG8872C TRANSOESOPHAGEAL ECHO EXAM PROSEDUR 2,742,474
3835 SG8873 DIAGNOSTIC ULTRASOUND OF OTHER SITES OF THORAX PROSEDUR 791,033
3836 SG8876 DIAGNOSTIC ULTRA SOUND OF ABDOMINAL AND RETROPERITONEUM PROSEDUR 1,076,124
DIAGNOSTIC ULTRASOUND OF PERIPHERAL VASCULAR SYSTEM / MAPPING VASCULAR
3837 SG8877 PROSEDUR 791,033
PERIFER
3838 SG8878 DIAGNOSTIC ULTRASOUND OF GRAVID UTERUS PROSEDUR 395,577
3839 SG8878A DIAGNOSTIC ULTRASOUND OBGYN PROSEDUR 434,070
3840 SG8879 USG MUSCULOSKELETAL DIAGNOSTIC PROSEDUR 538,062
3841 SG8929 OTHER NONOPERATIVE GENITOURINARY SYSTEM MEASUREMENTS PROSEDUR 2,099,843
3842 SG8941 CARDIOVASCULAR STRESS TEST USING TREADMILL PROSEDUR 316,244
3843 SG8945 ARTIFICIAL PACEMAKER RATE CHECK PROSEDUR 13,884,077
3844 SG8950 AMBULATORY CARDIAC MONITORING. ANALOG DEVICES [HOLTER- TYPE] PROSEDUR 474,910
3845 SG8950A HOLTER READING PROSEDUR 653,016
3846 SG8952 ELECTROCARDIOGRAPHY PROSEDUR 316,244
3847 SG90 MICROSCOPIC EXAMINATION. CELL BLOCK AND PAPANICOLOU SMEAR PROSEDUR 316,244
3848 SG9315 MOBILIZATION OF SPINE PROSEDUR 3,275,465
3849 SG9325 FORCED EXTENSION OF LIMB PROSEDUR 2,270,704
3850 SG9344 OTHER SKELETAL TRACTION PROSEDUR 3,540,390
3851 SG9351 APPLICATION OF PLASTER JACKET PROSEDUR 1,771,644
3852 SG9354 APPLICATION OF SPLINT PROSEDUR 1,421,952
3853 SG9354P APPLICATION OF SPLINT - PLASTER HIP PROSEDUR 2,730,641
APPLICATION OF OTHER WOUND DRESSING (EXTENSIVE DRESSING OF BURN OF
3854 SG9357 PROSEDUR 2,270,704
SKIN OR SUBCUTANEOUS TISSUE)
3855 SG9357A APPLICATION OF OTHER WOUND DRESSING MINOR PROSEDUR 158,907
3856 SG9357B APPLICATION OF OTHER WOUND DRESSING MAYOR PROSEDUR 316,244
3857 SG9433 BEHAVIOR THERAPY, DESENSITIZATION THERAPY PROSEDUR 791,033
3858 SG9511 FUNDUS PHOTOGRAPHY PROSEDUR 618,844
3859 SG9512 FLUORESCEIN ANGIOGRAPHY OR ANGIOSCOPY OF EYE PROSEDUR 1,372,082
3860 SG9605 OTHER INTUBATION OF RESPIRATORY TRACT PROSEDUR 6,404,097
3861 SG9607 INSERTION OF OTHER (NASO-)GASTRIC TUBE PROSEDUR 7,890,409
3862 SG9622 DILATION OF RECTUM PROSEDUR 1,622,276
3863 SG9625 THERAPEUTIC DISTENTION OF BLADDER PROSEDUR 3,513,463
3864 SG9629 REDUCTION OF INTUSSUSCEPTION OF ALIMENTARY TRACT PROSEDUR 2,099,843
3865 SG9652 IRRIGATION OF EAR PROSEDUR 1,351,917
3866 SG9653A IRRIGATION OF NASAL PASSAGES PROSEDUR 949,578
3867 SG9736 REMOVAL OF OTHER EXTERNAL MANDIBULAR FIXATION DEVICE PROSEDUR 2,730,641
NON OPERATIVE REMOVAL OF HEART ASSIST SYSTEMINTRA- AORTIC BALLOON PUMP
3868 SG9744 PROSEDUR 9,040,553
(IABP) / PERCUTANEOUS TRANSLUMINAL BALLOON OPERATION AORTA
3869 SG9744A INSERTION OF IABP PROSEDUR 3,567,800
3870 SG9762 REMOVAL OF URETEROSTOMY TUBE AND URETERAL CATHETER PROSEDUR 4,740,283
3871 SG9764 REMOVAL OF OTHER URINARY DRAINAGE DEVICE. (URINARY CATHETER) PROSEDUR 316,244
3872 SG9771 REMOVAL OF INTRAUTERINE CONTRACEPTIVE DEVICE PROSEDUR 550,862
3873 SG9779 REMOVAL OF SUTURES / AFF HECTING PROSEDUR 316,244
3874 SG9788 REMOVAL OF EXTERNAL IMMOBILIZATION DEVICE PROSEDUR 3,169,084
3875 SG9788A REMOVAL OF EXTERNAL IMMOBILIZATION DEVICE / BUKA GIPS < 2 SENDI PROSEDUR 791,033
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TARIF INSURANCE
3876 SG9788B REMOVAL OF EXTERNAL IMMOBILIZATION DEVICE / BUKA GIPS > 2 SENDI PROSEDUR 1,186,490
3877 SG9811 REMOVAL OF INTRALUMINAL FOREIGN BODY FROM EAR WITHOUT INCISION PROSEDUR 1,871,142
3878 SG9812 REMOVAL OF INTRALUMINAL FOREIGN BODY FROM NOSE WITHOUT INCISION PROSEDUR 1,144,831
3879 SG9851 PROSEDUR 9,730,518
AND/OR BLADDER
3880 SG9851K PROSEDUR 7,684,530
AND/OR BLADDER - KIDNEY
3881 SG9851U PROSEDUR 5,064,376
AND/OR BLADDER - URETER
3882 SG9901 EXCHANGE TRANSFUSION PROSEDUR 7,911,902
3883 SG9910 INJECTION OR INFUSION OF THROMBOLYTIC AGENT PROSEDUR 6,324,764
3884 SG9925 INJECTION OR INFUSION OF CANCER CHEMOTHERAPEUTIC SUBSTANCE PROSEDUR 3,361,439
3885 SG9929 INJECTION OR INFUSION OF OTHER THERAPEUTIC OR PROPHYLACTIC SUBSTANCE PROSEDUR 4,366,199
INJECTION OR INFUSION OF OTHER THERAPEUTIC OR PROPHYLACTIC SUBSTANCE
3886 SG992A PROSEDUR 624,278
(VIT C)
3887 SG992B INJECTION OR INFUSION (VIT C) 10 X PROSEDUR 4,747,407
PROPHYLACTIC VACCINATION AND INOCULATION AGAINST CERTAIN BACTERIAL
3888 SG993 PROSEDUR 236,791
DISEASES
3889 SG9962 OTHER ELECTRIC COUNTERSHOCK OF HEART (ECP) PROSEDUR 189,819
3890 SG9962B DIRECT CURRENT SHOCK / CARDIOVERSION PROSEDUR 1,958,927
3891 SG9979 OTHER. APHERESIS (HARVEST) OF STEM CELLS PROSEDUR 7,911,902
3892 SG9992 OTHER ACUPUNCTURE PROSEDUR 295,958
3893 SG4131C BONE MARROW PUNCTION (INTERPRETATION) PROSEDUR 1,166,083
3894 SG0404 BILATERAL POSTERIOR NASAL NEURECTOMY PROSEDUR 9,949,800
3895 SG1762A LASER ASSISTED UVULOPALATOPLASTY PROSEDUR 13,991,906
3896 SG1762B LASER ASSISTED TONSILECTOMY PROSEDUR 13,991,906
3897 SG1762C LASER ASSISTED HEMICORDECTOMY PROSEDUR 18,655,875
3898 SG1762D LASER ASSISTED ARYTENOIDECTOMY PROSEDUR 13,991,906
3899 SG1762E LASER ASSISTED VOCAL CORD SURGERY PROSEDUR 13,991,906
3900 SG2169A QUILTING SUTURE OF NASAL SEPTUM PROSEDUR 6,218,625
3901 SG2169B BILATERAL TURBINOPLASTY PROSEDUR 9,949,800
3902 SG2169C REMOVAL OF BILATERAL TURBINATE BONE PROSEDUR 6,218,625
3903 SG310A MEDIALIZATION OF VOCAL CORD WITH INJECTION FAT/OTHER MATERIAL PROSEDUR 12,437,250
3904 SG3169B OPEN MEDIALIZATION OF VOCAL CORD PROSEDUR 18,655,875
3905 SG3169C OPEN MEDIALIZATION/LATERIZATION OF VOCAL CORD PROSEDUR 18,655,875
3906 SG409A RECONSTRUCTION LYMPH OEDEM WITH MIROSURGERY OPERATION PROSEDUR 87,060,750
3907 SG9813 REMOVAL OF FOREIGN BODY OF PHARYNX PROSEDUR 1,865,588
3908 SG2919 NASOPHARYNX AND THROAT SWAB PROSEDUR 932,794
3909 SG6631A PROSEDUR 9,281,207
(PDP COVID)
3910 SG6902A DILATION AND CURETTAGE FOLLOWING DELIVERY OR ABORTION (PDP COVID) PROSEDUR 9,480,445
3911 SG7279A OTHER VACUUM EXTRACTION (PDP COVID) PROSEDUR 14,971,068
3912 SG7359A OTHER MANUALLY ASSISTED DELIVERY (PDP COVID) PROSEDUR 13,671,677
3913 SG741B CESAREAN SECTION WITH COMPLICATION PROSEDUR 16,738,486
3914 SG741C CESAREAN SECTION OF OTHER UNSPECIFIED TYPE PROSEDUR 13,671,677
3915 SG743A REMOVAL OF EXTRATUBAL ECTOPIC PREGNANCY (PDP COVID) PROSEDUR 16,466,798
3916 SG744A CESAREAN SECTION OF OTHER SPECIFIED TYPE (PDP COVID) PROSEDUR 16,738,486
3917 SG8948 INTERROGATION OF REPROGRAM PACEMAKER PROSEDUR 1,492,470
3918 SG8191A MILD ARTHROCENTESIS FOR THERAPEUTIC PROSEDUR 2,487,450
3919 SG8191B MODERATE ARTHROCENTESIS FOR THERAPEUTIC PROSEDUR 3,731,175
3920 SG8191C SEVERE ARTHROCENTESIS FOR THERAPEUTIC PROSEDUR 4,974,900
3921 SG743B LAPAROSCOPIC ECTOPIC PREGNANCY PROSEDUR 9,056,250
3922 SG8152 PARTIAL HIP REPLACEMENT PROSEDUR 12,785,252
TARIF PROSEDUR RMO/MO

3923 MOAFFHECT AFF HECTING - MO PROSEDUR 58,695
3924 MODAYBIG EXTERPATIE BESAR (DAY SURGERY) - MO PROSEDUR 480,207
3925 MODAYBUGIPS BUKA GIPS - MO PROSEDUR 167,486
3926 MODAYCORP CORPUS ALENEUM - MO PROSEDUR 320,229
3927 MODAYMED EXTERPATIE SEDANG (DAY SURGERY) - MO PROSEDUR 407,453
3928 MODAYSML EXTERPATIE KECIL (DAY SURGERY) - MO PROSEDUR 320,229
3929 MODAYVERBA GANTI VERBAND - MO PROSEDUR 61,016
3930 MOOTH MO PROSEDUR LAINNYA - MO PROSEDUR Variabel
3931 MOSUT15 TOILET&SUTURES<15MIN - MO PROSEDUR 121,895
3932 MOSUT30 TOILET&SUTURES>15MIN - MO PROSEDUR 121,895
3933 MOSUTURE10 6-10 SUTURE/WOUND - MO PROSEDUR 370,461
3934 MOSUTURE5 1-5 SUTURE/WOUND - MO PROSEDUR 211,712
3935 MOWOUND WOUND CARE/WOUND TOILET WITHOUT SUTURE - MO PROSEDUR 76,304
TARIF PROSEDUR SPESIALIS

3936 SCP HIFU TREATMENT PROCEDUR PROSEDUR 1,114,386
3937 SCPABDTAP ABDOMINAL TAPPING PROSEDUR 118,346
3938 SCPAFFHECT2 AFF HECTING SPESIALIS PROSEDUR 68,250
3939 SCPAN0001 PENDAMPINGAN CT-SCAN PROSEDUR 894,212
3940 SCPAN0002 PENDAMPINGAN CT-SCAN PASIEN HIGH RISK PROSEDUR 1,788,287
3941 SCPAN0003 PENDAMPINGAN MRI PROSEDUR 894,212
3942 SCPAN0004 PENDAMPINGAN MRI PASIEN HIGH RISK PROSEDUR 1,788,287
3943 SCPAN0005 PENDAMPINGAN ESCORT PASIEN DALAM KOTA PROSEDUR 1,788,287
3944 SCPAN0006 PENDAMPINGAN ESCORT PASIEN LUAR KOTA / NEGARA PROSEDUR Variabel
3945 SCPARTLINE ARTERIAL LINE PROSEDUR 118,346
3946 SCPARTPUNC ARTERIAL PUNCTURE PROSEDUR 118,346
3947 SCPBONEXT BONE MARROW EXTRACTION PROSEDUR 118,346
3948 SCPCATHROMBUS CORONARY SUCTION THROMBUS PROSEDUR 3,801,389
3949 SCPCENVEN CENTRAL VENOUS LINE PROSEDUR 118,346
3950 SCPCESARPAE1 HONOR DOKTER ANAK DI PROSEDUR CAESERIAN (KAMAR 2 DAN 4) PROSEDUR 456,183
3951 SCPCESARPAE2 HONOR DOKTER ANAK DI PROSEDUR CAESERIAN (KAMAR 1 DAN VIP) PROSEDUR 608,244
3952 SCPCESARPAEC1 HONOR DOKTER ANAK (CITO) DI PROSEDUR CAESERIAN (KAMAR 2 DAN 4) PROSEDUR 912,366
3953 SCPCESARPAEC2 HONOR DOKTER ANAK (CITO) DI PROSEDUR CAESERIAN (KAMAR 1 DAN VIP) PROSEDUR 1,064,427
3954 SCPCHEM CHEMOTHERAPHY PROCEDURE PROSEDUR 2,280,915
3955 SCPCHESTTASP CHEST TUBE INSERTION SET PROSEDUR 118,346
3956 SCPCURETTE KURET PROSEDUR 311,084
3957 SCPCYSTABLAT CYST ABLATION UNDER IMAGING CONTROL PROSEDUR 4,113,428
Page 49
TARIF INSURANCE
3958 SCPDAYADEN ADENOID PROSEDUR 311,084

3959 SCPDAYBIG EXTERPATIE BESAR (DAY SURGERY) PROSEDUR 559,923
3960 SCPDAYBUGIPS BUKA GIPS PROSEDUR 195,195
3961 SCPDAYCORP CORPUS ALENEUM PROSEDUR 373,328
3962 SCPDAYENDO D&C/ENDOMETRIUM BIOPSI PROSEDUR 466,557
3963 SCPDAYMED EXTERPATIE SEDANG (DAY SURGERY) PROSEDUR 475,020
3964 SCPDAYREP REPOSISI TERTUTUP/PASANG GIPS PROSEDUR 254,573
3965 SCPDAYSIRC SIRCUMSISI PROSEDUR 311,084
3966 SCPDAYSML EXTERPATIE KECIL (DAY SURGERY) PROSEDUR 373,328
3967 SCPDAYTAMP PASAN TAMPON & CABUT PROSEDUR 59,241
3968 SCPDAYTONSIL LOKAL TONSILECTOMIE PROSEDUR 466,557
3969 SCPDAYVERBB GANTI VERBAND PROSEDUR 71,117
3970 SCPDAYVERBC GANTI VERBAND MAJOR PROSEDUR 228,228
3971 SCPDEN001 PEDIATRIC DENTAL - TREPANASI PROSEDUR 304,122
3972 SCPDEN002 PEDIATRIC DENTAL - PEMERIKSAAN RA/RB PROSEDUR 304,122
3973 SCPDEN003 PEDIATRIC DENTAL - PENAMBALAN GIC PROSEDUR 380,153
3974 SCPDEN004 PEDIATRIC DENTAL - PENAMBALAN RESIT KOMPOSIT PROSEDUR 532,214
3975 SCPDEN005 PEDIATRIC DENTAL - PERAWATAN SALURAN AKAR DEVIT PROSEDUR 304,122
3976 SCPDEN006 PEDIATRIC DENTAL - PERAWATAN SALURAN AKAR GANTI OBAT PROSEDUR 304,122
3977 SCPDEN007 PEDIATRIC DENTAL - PERAWATAN SALURAN AKAR PENGISIAN PROSEDUR 380,153
3978 SCPDEN008 PEDIATRIC DENTAL - PENCABUTAN/EXODONTI GIGI PERISTENSI PROSEDUR 380,153
3979 SCPDEN009 PEDIATRIC DENTAL - PENCABUTAN/EXODONTI GIGI DECIDUI+INJEKSI PROSEDUR 456,183
3980 SCPDEN010 PEDIATRIC DENTAL - PENCABUTAN/EXODONTI GIGI DECIDUI+CLORETYL PROSEDUR 380,153
3981 SCPDEN011 PEDIATRIC DENTAL - PENCABUTAN/EXODONTI SISA AKAR PROSEDUR 380,153
3982 SCPDEN012 PEDIATRIC DENTAL - SKALING/TAF/POLISH PROSEDUR 532,214
3983 SCPDEN013 BUKA ATAP PULP PROSEDUR 154,791
3984 SCPDEN014 PERAWATAN ALAT MYOFUNCTIONL (QUAD HELIX) PROSEDUR 4,625,985
3985 SCPDEN015 KONTROL RA/ RB + GANTI PROSEDUR 462,872
3986 SCPDEN016 GANTI NITI / SS PROSEDUR 385,476
3987 SCPDEN017 BLUSHING PROSEDUR 230,822
3988 SCPDEN018 PASANG BRACKET LEPAS PROSEDUR 154,791
3989 SCPDEN019 RETAINER 1 RAHANG PROSEDUR 1,541,768
3990 SCPDEN020 BAND AND LOOP PROSEDUR 1,541,768
3991 SCPDEN021 FINER REINFORCE PROSEDUR 1,541,768
3992 SCPDEN022 REMOVABLE SM PROSEDUR 3,084,491
3993 SCPDEN023 FISSURE SEALENT PROSEDUR 385,476
3994 SCPDEN024 PREVENTIVE RESIN PROSEDUR 770,952
3995 SCPDOAP DOCTOR FEE DONOR APHERESIS PROSEDUR 684,275
3996 SCPDR0001 HIFU TREATMENT (PAKET 3X) PROSEDUR 3,041,084
3997 SCPDR0002 RADIO FREKWENSI / TREATMENT PROSEDUR 1,292,519
3998 SCPDR0003 ULTRASOUND CAVITASI PROSEDUR 304,122
3999 SCPDR0004 AKUPUNTUR KESEHATAN (PAKET 10 X TREATMENT) PROSEDUR 3,041,084
4000 SCPDR0005 ACNE PEELING PROSEDUR 684,275
4001 SCPDR0006 GLOWING PEEL PROSEDUR 532,214
4002 SCPDR0007 DERMAROLLER PROSEDUR 1,520,610
4003 SCPDR0008 P R P ( PLATELET RICH PLASMA ) PROSEDUR 2,280,915
4004 SCPDR0009 TANAM BENANG / TANPA BENANG PROSEDUR 3,041,084
4005 SCPDR0010 FILLER (TANPA FILLER SERUM) PROSEDUR 3,041,084
4006 SCPDR0011 IPL/LASER PROSEDUR 912,366
4007 SCPDR0012 INJEKSI ACNE PER AREA PROSEDUR 456,183
4008 SCPDR0013 HAIRLOSS TREATMENT + AKUPUNTUR (16 X TREATMENT) PROSEDUR 6,082,167
4009 SCPDR0014 HIFU TREATMENT 1 X PROSEDUR PROSEDUR 1,292,519
4010 SCPDR0015 RADIO FREKWENSI / TREATMENT (PAKET 3 X) PROSEDUR 3,041,084
4011 SCPDR0016 AKUPUNTUR KESEHATAN (PAKET 10 X TREATMENT) PROSEDUR 288,561
4012 SCPDR0017 FCL NANO BIOLIGHT 1 X PROCEDUR PROSEDUR 458,913
4013 SCPDR0018 FCL NANO BB GLOW 1 X PROSEDUR PROSEDUR 1,573,163
4014 SCPDR0019 FCL NANO BB GLOW (PAKET 3 X) PROSEDUR 3,932,429
4015 SCPDR0020 BASIC FACIAL TREATMENT PROSEDUR 247,202
4016 SCPDR0021 WHITENING INJECTION PROSEDUR 556,101
4017 SCPDR0022 WHITENING INJECTION PACKAGE (10 X) PROSEDUR 5,189,457
4018 SCPEARSYR EARSYRINGING PROSEDUR 73,983
4019 SCPENDINT ENOTRACHEAL INTUBATION PROSEDUR 118,346
4020 SCPENT001 ADVANCE THERAPY BIO E ALERGY PROSEDUR 771,225
4021 SCPEPIANE EPIDURAL ANESTHESIA PROSEDUR 118,346
4022 SCPEYEFUNDUS INDIRECT FUNDUSCOPY PROSEDUR 444,717
4023 SCPFINENEEDLE PROSEDUR FINE NEEDLE ASPIRATION PROSEDUR 532,214
4024 SCPFNCYTO FINE NEEDLE ASPIRATION CYTOLOGY PROSEDUR 1,115,615
4025 SCPFOREIGNBODY RETRIEVAL OF FOREIGN BODY UNDER X-RAY GUIDANCE PROSEDUR 5,552,684
4026 SCPHCG UJI HCG PROSEDUR 268,496
4027 SCPINJARTC INJEKSI INTRAARTICULER PROSEDUR 536,855
4028 SCPINTRAMUS INJEKSI INTRAMUSCULARE PROSEDUR 179,088
4029 SCPINTRAVENA INJEKSI INTRAVENA PROSEDUR 269,315
4030 SCPINTUBASI TINDAKAN INTUBASI PROSEDUR 2,313,402
4031 SCPIUDIN INSERTION IUD PROSEDUR 327,737
4032 SCPIUDOUT PROSEDUR REMOVAL IUD PROSEDUR 262,353
4033 SCPIVCAN I.V. CANNULATION PROSEDUR 88,725
4034 SCPLCMASS PERCUTANEOUS LASER COAGULATION OF MASS PROSEDUR 12,745,142
4035 SCPLUMBP LUMBAR PUNCTURE PROSEDUR 118,346
4036 SCPMANTOUX MANTOUX TEST PROSEDUR 536,855
4037 SCPNURSERY HONOR DOKTER ANAK VISIT NURSERY KUNJUNGAN 131,313
4038 SCPON0001 MYELOPEROXIDASE STAIN PROSEDUR 395,577
4039 SCPON0002 NITROBLUE TETRAZOLIUM STAIN PROSEDUR 447,174
4040 SCPON0003 PERIODIC ACID SCHIFF STRAIN PROSEDUR 447,174
4041 SCPON0004 SUDDEN BLACK PROSEDUR 447,311
4042 SCPPA001 PROSEDUR FROZEN SECTION OPERATING ROOM PROSEDUR 1,788,287
4043 SCPPAED0001 DEVELOPMENT TEST PROSEDUR 797,297
4044 SCPPAPS PROSEDUR PAP SMEAR PROSEDUR 327,737
4045 SCPPERDIAL PERITONEAL DIALYSIS PROSEDUR 73,983
4046 SCPPIERC EAR PIERCING PROCEDURE PACKAGE PROSEDUR 197,789
4047 SCPPK001 PROSEDURE THROMBOCYTE CONCENTRATE (TC) PROSEDUR 716,352
4048 SCPPK002 PROSEDURE FRESH FROZEN PLASMA (FFP) 700 CC PROSEDUR 716,352
4049 SCPPK003 PROCEDURE THERAPEUTIC PLATELET REDUCTION PROSEDUR 8,943,890
4050 SCPPK004 PROCEDURE THERAPEUTIC LYMPHO/MONO REDUCTION PROSEDUR 716,352
Page 50
TARIF INSURANCE
4051 SCPPK005 PROSEDUR THERAPEUTIC GRANULOCYTE REDUCTION PROSEDUR 8,943,890

4052 SCPPK006 PROSEDUR LYMPHO MONO COLLECTION PROSEDUR 8,943,890
4053 SCPPK007 PROSEDUR GRANULOCYTE COLLECTION PROSEDUR 8,943,890
4054 SCPPK008 PROSEDUR PLATELET GEL PROSEDUR 536,855
4055 SCPPPARIS PLASTER OF PARIS PROSEDUR 118,346
4056 SCPPSY001 PEMERIKSAAN INTELEGENSI I (KLIEN TYPICAL) PROSEDUR 133,907
4057 SCPPSY002 PEMERIKSAAN INTELEGENSI II (KLIEN TYPICAL/SN) PROSEDUR 267,677
4058 SCPPSY003 DETEKSI PERKEMBANGAN PROSEDUR 89,817
4059 SCPPSY004 LAPORAN HASIL PEMERIKSAAN I (BRIEF, MAX 3 HALAMAN) PROSEDUR 179,634
4060 SCPPSY005 LAPORAN HASIL PEMERIKSAAN I (BRIEF, LEBIH DARI 3 HALAMAN) PROSEDUR 447,174
4061 SCPSHAVPREP SHAVING/SKIN PREP PROSEDUR 73,983
4062 SCPSUT15 TOILET&SUTURES<15MIN PROSEDUR 141,960
4063 SCPSUT30 TOILET&SUTURES>15MIN PROSEDUR 141,960
4064 SCPSUTURE10 6-10 SUTURE/WOUND PROSEDUR 431,886
4065 SCPSUTURE5 1-5 SUTURE/WOUND PROSEDUR 246,929
4066 SCPTHAP DOCTOR FEE THERAPEUTIC APHERESIS PROSEDUR 7,710,749
4067 SCPUR0001 POST PCNL PROSEDUR 447,174
4068 SCPVAGEXAM VAGINAL EXAMINATION PROSEDUR 118,346
4069 SCPVAGWASH PROSEDUR VAGINAL WASHING PROSEDUR 262,353
4070 SCPVAKSIN PROSEDUR INJEKSI PROSEDUR 228,092
4071 SCPWOUND WOUND CARE PROSEDUR 88,725
4072 SCPWOUNDH WOUND HEALING PROSEDUR 231,504
4073 SCPCP0001 ANA IF (INTERPRETATION) PROSEDUR 439,394
4074 SCPNEU0001 EEG INTERPRETATION PROSEDUR 379,607
4075 SCPDENPED0001 PEMASANGAN BRACKET PERTAMA PROSEDUR 7,029,750
4076 SCPDENPED0002 PEMASANGAN BRACKET KEDUA PROSEDUR 14,059,500
4077 SCPLAC001 EKSTRAKSI NIPPLE CORE PROSEDUR 177,450
4078 SCPLAC002 TRAINING PEMBERIAN ASI DENGAN CUP FEEDING PROSEDUR 106,050
4079 SCPLAC003 TRAINING PERAH ASI PROSEDUR 106,050
4080 SCPLAC004 TBML (THERAPEUTIC BREAST MASSAGE FOR LACTATION) PROSEDUR 106,050
4081 SCPLAC005 TRAINING SUPLEMENTASI PROSEDUR 130,200
4082 SCPLAC006 PIJAT OXITOCIN PROSEDUR 106,050
4083 SCPLAC007 TRAINING RELAKTASI PROSEDUR 106,050
4084 SCPDC0001 DIABETIC FOOD SCREENING PROCEDURES - SPECIALIST 117,600
4085 SCPHV HOME VISIT SPECIALIST KUNJUNGAN 424,242
4086 SCPINT0001 USG KIDNEY-BLADDER NEPHROLOGY PROSEDUR 208,950
4087 SCPBIA BIA PROCEDURE PROSEDUR 121,212
4088 SCPPED001 INJEKSI TESTOSTERON ESTER PROSEDUR 294,000
4089 SCPPED002 INJEKSI GNRH AGONIST (LEUPRORELIN ACETATE) PROSEDUR 323,400
4090 SCPPED003 UJI STIMULASI HORMON PERTUMBUHAN PROSEDUR 883,050
4091 SCPPED004 UJI STIMULASI HCG PROSEDUR 323,400
4092 SCPPED005 UJI HAUS (WATER DESMOPRESSIN TEST)/ UJI DESMOPRESSIN (DDAVP) PROSEDUR 588,000
4093 SCPPED006 TERAPI ZOLEDRONIC ACID PADA OSTEOGENESIS IMPERFECTA PROSEDUR 588,000
4094 SCPPED007 INISIASI TERAPI INSULIN PADA PASIEN BARU DM PROSEDUR 411,600
HONOR DOKTER ANAK CITO DI PROSEDUR DELIVERY DENGAN RESIKO (KAMAR 2
4095 SCPDELPAEC1 PROSEDUR 899,000
DAN 4)
HONOR DOKTER ANAK CITO DI PROSEDUR DELIVERY DENGAN RESIKO (KAMAR 1
4096 SCPDELPAEC2 PROSEDUR 1,136,000
DAN VIP)
4097 SCPINT0002 USG WHOLE ABDOMEN PROSEDUR 352,800
TARIF DENTAL
4098 DENJL11 KONSULTASI DRG PROSEDUR 203,826
4099 DENJL12 IMPRESSION MODEL RA DAN RB (STUDY MODEL) PROSEDUR 407,531
4100 DENJL21 PENAMBALAN SEMENTARA PROSEDUR Variabel
4101 DENJL22 PENAMBALAN RESIN COMPOSITE (UMUM) PROSEDUR 475,393
4102 DENJL221 PENAMBALAN RESIN COMPOSITE (CLASS 1, 2, 3 SMALL <1/2 MAHKOTA GIGI) PROSEDUR 475,393
4103 DENJL222 PENAMBALAN RESIN COMPOSITE (CLASS 1, 2, 3 LARGE) PROSEDUR 679,098
PENAMBALAN RESIN COMPOSITE (CLASS 4 ANTERIOR COMPOSITE, CLOSED
4104 DENJL223 PROSEDUR 1,018,647
DIASTEMA)
4105 DENJL224 PENAMBALAN RESIN COMPOSITE (POSTERIOR MOD) PROSEDUR 1,018,647
4106 DENJL225 PENAMBALAN RESIN COMPOSITE (INLAY / OVERLAY COMPOSITE (DIRECT)) PROSEDUR Variabel
4107 DENJL23 POST REINFORCEMENT FIBER / LOGAM PROSEDUR 1,018,647
4108 DENJL24 BUILD UP COMPOSITE FX > 1/2 MAHKOTA GIGI PROSEDUR 1,018,647
PERAWATAN SALURAN AKAR (OPEN ACCESS, GLIDE PATH, PULP REMOVAL,
PENGISIAN SALURAN AKAR (NORMAL CANAL))
PERAWATAN SALURAN AKAR (OPEN ACCESS, GLIDE PATH, PULP REMOVAL,
PENGISIAN SALURAN AKAR (CURVED CANAL, S CANAL, C SHAPE CANAL))
4111 DENJL253 PENAMBALAN PERMANEN PSA PROSEDUR 2,037,294
4112 DENJL31 PENCABUTAN GIGI SUSU PROSEDUR 284,981
4113 DENJL32 PENCABUTAN GIGI TETAP PROSEDUR 475,393
4114 DENJL33 PENCABUTAN GIGI TETAP DENGAN KOMPLIKASI (FX TERBUKA DAN FX TERTUTUP) PROSEDUR 679,098
4115 DENJL34 INSISI ABSES/ FISTEL PROSEDUR 339,549
4116 DENJL35 DRY SOCKET PROSEDUR 271,688
4117 DENJL36 CURRETAGE PER GIGI PROSEDUR 135,844
4118 DENJL37 ALVEOLEKTOMI PER KUADRAN PROSEDUR 2,037,294
4119 DENJL38 OPERASI GIGI MIRING / TERPENDAM PROSEDUR 5,093,114
4120 DENJL39 HECTING PROSEDUR 135,844
4121 DENJL41 PEMBERSIHAN KARANG GIGI + FLUORIDASI TIAP RAHANG RA DAN RB (GINGIVITIS) PROSEDUR 475,393
PEMBERSIHAN KARANG GIGI + FLUORIDASI TIAP RAHANG RA DAN RB
4122 DENJL42 PROSEDUR 679,098
(PERIODONTITIS)
4123 DENJL43 FIBER SPLINT UNTUK GIGI MOBILITY PER RAHANG PROSEDUR Variabel
4124 DENJL511 GIGI TIRUAN PENUH AKRILIK 1 RAHANG PROSEDUR 6,790,739
4125 DENJL512 GIGI TIRUAN PENUH AKRILIK 2 RAHANG PROSEDUR 13,581,477
4126 DENJL513 GIGI TIRUAN PENUH VALPLAST 1 RAHANG PROSEDUR 6,790,739
4127 DENJL514 GIGI TIRUAN PENUH VALPLAST 2 RAHANG PROSEDUR 13,581,477
4128 DENJL515 GIGI TIRUAN PENUH KERANGKA LOGAM VITALIUM 1 RAHANG PROSEDUR 7,469,837
4129 DENJL516 GIGI TIRUAN PENUH KERANGKA LOGAM VITALIUM 2 RAHANG PROSEDUR 14,939,673
4130 DENJL521 GIGI TIRUAN SEBAGIAN LEPASAN AKRILIK PROSEDUR 4,753,565
4131 DENJL522 GIGI TIRUAN SEBAGIAN LEPASAN VALPLAST PROSEDUR 5,432,663
4132 DENJL523 GIGI TIRUAN SEBAGIAN LEPASAN LOGAM VITALIUM PROSEDUR 6,790,739
4133 DENJL524 GIGI TIRUAN SEBAGIAN SADDLE VALPLAST PROSEDUR 4,074,467
Page 51
TARIF INSURANCE
4134 DENJL525 GIGI TIRUAN SEBAGIAN SADDLE LOGAM PROSEDUR 4,074,467

4135 DENJL531 GIGI TIRUAN CEKAT MARYLAND PROSEDUR 4,753,565
4136 DENJL532 GIGI TIRUAN CEKAT PFM PROSEDUR 4,753,565
4137 DENJL533 GIGI TIRUAN CEKAT ALL CERAMIC PROSEDUR Variabel
4138 DENJL534 GIGI TIRUAN INLAY/ OVERLAY LOGAM PROSEDUR 3,395,369
4139 DENJL535 GIGI TIRUAN INLAY/ OVERLAY COMPOSITE (INDIRECT) PROSEDUR 2,716,392
4140 DENJL541 DENTURE REPAIR RELINING PROSEDUR 814,942
4141 DENJL542 DENTURE REPAIR REBASING PROSEDUR 814,942
4142 DENJL543 REPARASI PREOTESA RETAK PROSEDUR 679,098
4143 DENJL544 DENTURE REPAIR PENAMBAHAN GIGI AKRILIK PROSEDUR 679,098
4144 DENJL545 DENTURE REPAIR PENAMBAHAN GIGI AKRILIK + METAL SUPPORT PROSEDUR 950,786
4145 DENJL551 TMD PROBLEM SPLINT REPOSISI PROSEDUR 5,432,663
4146 DENJL552 TMD PROBLEM SPLINT STABILISASI PROSEDUR 5,432,663
4147 DENJL553 TMD PROBLEM MOUTH GUARD ( BRUXISM) PROSEDUR 2,037,294
4148 DENJL554 TMD PROBLEM NTSS PROSEDUR 1,358,196
4149 DENJL61 INTRAORAL PROSEDUR 271,688
4150 DENJL62 DIGITAL PANORAMIK PROSEDUR 475,393
TARIF CSSD
4151 CSA00001 CATHERIZATION SET SET 104,748
4152 CSA00002 CHEST TUBE INSERTION SET/ WSD SET SET 174,631
4153 CSA00003 DELIVERY SET SET 174,631
4154 CSA00004 DRESSING SET SET 104,748
4155 CSA00005 AFF HECTING SET SET 104,748
4156 CSA00006 CIRCUMCISION SET SET 174,631
4157 CSA00007 EPIDURAL SET SET 104,748
4158 CSA00008 LUMBAR PUNCTURE SET SET 174,631
4159 CSA00009 STITCHING SET SET 174,631
4160 CSA00010 STOMACH WASHOUT SET/ KUMBAH LAMBUNG SET 174,631
4161 CSA00011 SUPPLEMENTARY UTENSIL SINGLE SET 131,087
4162 CSA00012 GALIPOT PIECE 69,883
4163 CSA00013 VULVA SWABBING SET SET 104,748
4164 CSA00014 TRACHEOSTOMIE SET SET 261,870
4165 CSA00015 SUCTION TUBING PIECE 139,766
4166 CSA00016 SILICONE MASK PIECE 178,133
4167 CSA00017 HARMONIC SCAPLE PIECE 174,631
4168 CSA00018 TISSUE FORCEPS PIECE 139,766
4169 CSA00019 SINGLE INSTRUMENT - SUCTION TUBE PIECE 139,766
4170 CSA00020 SCISSORS CURVE PIECE 139,766
4171 CSA00021 SINGLE INSTRUMENT - ORTHOPEDICS PIECE 139,766
4172 CSA00022 VASCULAR INSTRUMENT PIECE 139,766
4173 CSA00023 DISSECTING FORCEPS PIECE 139,766
4174 CSA00024 INSTRUMENT FOR PROCEDURE ASSISTANT PIECE 139,766
4175 CSA00025 NEEDLE HOLDER PIECE 139,766
4176 CSA00026 ARTHERY FORCEPS PIECE 139,766
4177 CSA00027 RETRACTOR PIECE 139,766
4178 CSA00028 RIGHT ANGLE FORCEPS PIECE 139,766
4179 CSA00029 BIAYA STERILISASI PERALATAN DOKTER PIECE 174,631
4180 CSA00030 INSTRUMENT STERRAD FOR LARGE SET SET 523,740
4181 CSA00031 OTHER SINGLE INSTRUMENT PIECE 139,766
4182 CSA00032 UROLOGY INSTRUMENT SET SET 174,631
4183 CSA00033 PCNL SET 174,631
4184 CSA00034 D & C DELIVERY SET SET 506,384
4185 CSA00035 HAAK SPOELLING SET SET 218,327
4186 CSA00036 CERVICAL CONE BIOPSY SET SET 497,705
4187 CSA00037 CVP SET SET 174,631
4188 CSA00038 LINEN X4 SET 87,392
4189 CSA00039 LINEN X2 SET 87,392
4190 CSA00040 DRESSING TRACHEOSTOMY SET SET 104,748
4191 CSD00001 COTTON TAPE SET 8,831
4192 CSD00002 KASA DEPPER 20 X 20 SET 52,374
4193 CSD00003 VAGINAL ROLL SET 69,883
4194 CSD00004 TAMPON VAGINAL SET 69,883
4195 CSD00005 PLAIN GAUZE 10 X 10 SET 122,257
4196 CSD00006 PLAIN GAUZE 7.5 X 7.5 SET 87,392
4197 CSD00007 RYTEX GAUZE 10 X 10 SET 139,766
4198 CSD00008 RYTEX LAPARASCOPY 10 X 10 SET 122,257
4199 CSD00009 RYTEX LAPARASCOPY 5 X 5 SET 35,018
4200 CSD00010 STICK RYTEX SET 139,766
4201 CSD00011 PEANUT LARGE SET 26,339
4202 CSD00012 PENNY TOWEL SET 174,631
4203 CSD00013 PEANUT SMALL SET 52,374
4204 CSD00014 SWAB STICK LARGE SET 26,339
4205 CSD00015 SWAB STICK SMALL SET 21,011
4206 CSD00016 EYE SPONGE SET 17,509
4207 CSD00017 PLAIN GAUZE 5 X 5 SET 52,374
4208 CSD00018 SPALK PAEDIATRIC SET 35,018
4209 CSD00019 TAMPON HIDUNG SET 69,883
4210 CSD00020 PLAIN GAUZE 2 X 2 CM SET 35,018
4211 CSD00021 GLOVE STERILE SET 21,011
4212 CSD00022 COTTON BUD L SET 17,509
4213 CSD00023 PLAIN GAUZE 5 X 5 CM (OBSOLETE) SET 15,073
4214 CSD00024 COTTON SWABS SMALL SET 21,011
4215 CSL00001 ADULT VENTILATOR+TUBING+CONNECTOR(150CM) SET 488,875
4216 CSL00002 INFANT VENTILATOR+TUBING+CONNECTOR(150CM SET 488,875
4217 CSN00001 BASIC SET SET 174,631
4218 CSN00002 MINI SET SET 174,631
4219 CSN00003 MINI SURGERY SET SET 174,631
4220 CSN00004 LAPARATOMY SET SET 174,631
4221 CSN00005 MINI DELIVERY SET SET 174,631
4222 CSN00006 PLASTIC SET SET 174,631
4223 CSN00007 PREPARATION SET SET 174,631
4224 CSN00008 GASTRO INTESTINAL SET 174,631
Page 52
TARIF INSURANCE
4225 CSN00009 THIROID SET SET 174,631

4226 CSN00010 GALL BLADDER SET SET 174,631
4227 CSN00011 PAEDIATRIC SET SET 174,631
4228 CSN00012 PROSTATECTOMY SET SET 174,631
4229 CSN00013 AV FISTULA SET SET 174,631
4230 CSN00014 CRANIOTOMY SET SET 174,631
4231 CSN00015 BOR CRANIOTOMY ( AESCULAP) SET 174,631
4232 CSN00016 CERVIX SET SET 174,631
4233 CSN00017 D & C SET OT SET 174,631
4234 CSN00018 LSCS SET SET 174,631
4235 CSN00019 HYSTERECTOMIE SET SET 174,631
4236 CSN00020 HYSTERESCOPY SET SET 174,631
4237 CSN00021 VAGINAL HYSTERCTOMIE SET SET 174,631
4238 CSN00022 PPH SET SET 174,631
4239 CSN00023 LAPARASCOPY SET SET 174,631
4240 CSN00024 LAPARASCOPY (OLYMPUS) SET 174,631
4241 CSN00025 KUSHNER NAIL SET SET 174,631
4242 CSN00026 MENISECTOMY SET SET 174,631
4243 CSN00027 AO DHS/DCS INSTRUMENT SET SET 174,631
4244 CSN00028 STAPPLING SET SET 174,631
4245 CSN00029 CERVICAL FUSION SET SET 174,631
4246 CSN00030 BONE REDUCTION SET SET 174,631
4247 CSN00031 HAND SET SET 174,631
4248 CSN00032 LAMINECTOMY SET SET 174,631
4249 CSN00033 LARGE ORTHOPEDIC SET (BASIC ORTHO SET) SET 261,870
4250 CSN00034 SMALL ORTHOPEDIC SET (BASIC ORTHO SET) SET 261,870
4251 CSN00035 BOR TULANG ( BOJIN/AESCULAP) SET 261,870
4252 CSN00036 DHS SET SET 261,870
4253 CSN00037 MOORES THOMSON ARTOPLASTY SET 174,631
4254 CSN00038 BASIC NASAL PROSEDUR SET SET 174,631
4255 CSN00039 SET FESS INSTRUMENT SET 174,631
4256 CSN00040 TONSILECTOMY SET SET 174,631
4257 CSN00041 EUM MYRENGOTOMY SET SET 174,631
4258 CSN00042 CATARAC EXTRACTION SET SET 174,631
4259 CSN00043 PHACO SET SET 174,631
4260 CSN00044 PTERYGIUM SET 174,631
4261 CSN00045 LASIC SET SET 174,631
4262 CSN00046 EYE MUSCLE SET SET 174,631
4263 CSN00047 BASIN SET SET 174,631
4264 CSN00048 HEAD PACK SET 139,766
4265 CSN00049 GOWN SET 139,766
4266 CSN00050 LINEN ORTHO SET 174,631
4267 CSN00051 ABDOMINAL PACK SET 139,766
4268 CSN00052 LINEN JANTUNG SET 174,631
4269 CSN00053 LITHOTOMY PACK SET 139,766
4270 CSN00054 LINEN KATARAK SET 139,766
4271 CSN00055 MEDIUM ROUND HOLE SET 104,748
4272 CSN00056 TUR SET SET 174,631
4273 CSN00057 SACHE SET (UROLOGY) SET 174,631
4274 CSN00058 CYTOSCOPY SET SET 174,631
4275 CSN00059 LITHOTRIPSI SET 174,631
4276 CSN00060 ANGIO INSTRUMENT SET SET 174,631
4277 CSN00061 PPM SET SET 174,631
4278 CSN00062 TPM SET SET 174,631
4279 CSN00063 TEST LUNG SET 174,631
4280 CSN00064 BASIN CARDIAC SET SET 174,631
4281 CSN00065 BASIC INFANT CARDIAC SET SET 174,631
4282 CSN00066 CABG SET SET 174,631
4283 CSN00067 BASIN ADULT SET SET 174,631
4284 CSN00068 CORONARY SET SET 174,631
4285 CSN00069 VALVES SURGERY SET SET 174,631
4286 CSN00070 BASIC ARTHROSCOPY SET SET 174,631
4287 CSN00071 RE OPENING SET SET 174,631
4288 CSSA0041 INSTRUMENT STERRAD FOR SINGLE SET SET 174,631
4289 CSS000072 KASA LUKA BAKAR SET 184,984
TARIF LAIN-LAIN
4290 PMU1 BIAYA RACIKAN 1-30 PACK % 16,459
4291 PMU2 BIAYA RACIKAN 30-60 PACK % 27,431
4292 PMU3 BIAYA RACIKAN >60 PACKS % 38,259
4293 MSMAPD2 MEDICAL SUPPLIES APD LEVEL 2 * 196,560
4294 MSMAPD3 MEDICAL SUPPLIES APD LEVEL 3 * 262,080
4295 MSMHOMECARE MEDICAL SUPPLIES HOMECARE * 627,900
4296 MSMJEN1 PETI JENAZAH * 1,569,750
4297 MSMJEN2 WRAPPING JENAZAH * 608,265
4298 MSMISO MEDICAL SUPPLIES ISOLATION * 491,400
4299 MSMISOER MEDICAL SUPPLIES ISOLATION EMERGENCY ROOM * 577,500
4300 MSMORPPI MEDICAL SUPPLIES OPERATING ROOM PPI * 491,400
Page 53

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RSCA MEDAN

BUKU TARIF INSURANCE 2022

TARIF KAMAR BEDAH & GAS MEDIK

TARIF KONSULTASI DOKTER

66 SCOPDSP1 KONSULTASI SPESIALIS OP 1 KUNJUNGAN 181,913

74 SCOPDSP2 KONSULTASI SPESIALIS OP 2 KUNJUNGAN 242,550

78 SCBIPFC KONSULTASI SPESIALIS 2 VISIT RUANGAN FAMILY CLUB KUNJUNGAN 338,100

82 SCOPDSP3 KONSULTASI SPESIALIS OP 3 KUNJUNGAN 303,188

91 SCOPDSP4 KONSULTASI SPESIALIS OP 4 KUNJUNGAN 485,100

97 SCOPDSP5 KONSULTASI SPESIALIS OP 5 KUNJUNGAN 727,650

164 LALAC LACTATE TEST 554,400

257 LDAMPHE SCREENING AMPHETAMIN TEST 219,408

350 LIAHBCM ANTI HBC IGM TEST 1,266,048

443 LISTREPA STREPTO A TEST 1,466,042

536 LONGAL NGAL TEST 1,579,694

625 LBWPRC WASHING PACKED RED CELLS * 225,750

714 RCTHIP3D CT SCAN HIP JOINT 3D % 3,949,344

807 RUSAPP USG APPENDIX % 1,039,416

900 RXRPELPX X-RAY PELVIS MOBILE % 748,440

TARIF PROSEDUR PERAWAT

TARIF PERALATAN MEDIK

989 EQAUTOREF AUTOREFRAKSI EYE EQP PEMAKAIAN 40,889

TARIF PERALATAN DOKTER

1080 EQDCECG003 ECG DR. MASRUL LUBIS PROSEDUR 229,908

TARIF BIAYA ANESTESI

INSERTION OF CATHETER INTO SPINAL CANAL FOR INFUSION OF THERAPEUTIC OR

1220 SA0811 BIOPSY OF EYELID - SA PROSEDUR 669,438

1302 SA1521 LENGTHENING PROCEDURE ON ONE EXTRAOCULAR MUSCLE - SA PROSEDUR 1,621,914

1381 SA2184 REVISION RHINOPLASTY - RHINOSEPTOPLASTY - SA PROSEDUR 3,118,973

1458 SA2743 OTHER EXCISION OF LESION OR TISSUE OF LIP - SA PROSEDUR 1,455,521

REPLACEMENT OF ANY TYPE PACEMAKER DEVICE WITH SINGLE-CHAMBER DEVICE,

OTHER (PERIPHERAL) VASCULAR SHUNT OR BYPASS - FEMORO-POPLITEAL BYPASS

1746 SA4319C OTHER GASTROSTOMY (COMPLEX) - SA PROSEDUR 3,573,596

1832 SA4911 ANAL FISTULOTOMY - SA PROSEDUR 1,255,921

1908 SA5419 OTHER LAPAROTOMY - SA PROSEDUR 2,561,591

1988 SA581E URETHRAL MEATOTOMY - ENDOSCOPIC - SA PROSEDUR 1,688,206

2068 SA6829 OTHER EXCISION OR DESTRUCTION OF LESION OF UTERUS - SA PROSEDUR 2,969,122

2151 SA7695 OTHER MANIPULATION OF TEMPOROMANDIBULAR JOINT - SA PROSEDUR 639,975

EXCISION OF INTERVERTEBRAL DISC-OPEN DOOR LAMINOPLASTY CERVICAL REGION

2301 SA8286C OTHER TENOPLASTY OF HAND - EXCLUDE FLEXOR - SA PROSEDUR 1,577,116

INJECTION OR INFUSION OF OTHER THERAPEUTIC OR PROPHYLACTIC SUBSTANCE -

TARIF BIAYA BEDAH

OTHER DIAGNOSTIC PROCEDURES ON SPINAL CORD AND SPINAL CANAL

2599 SG0821 EXCISION OF CHALAZION PROSEDUR 3,956,012

2681 SG1479 OTHER OPERATIONS ON VITREOUS PROSEDUR 13,078,312

2766 SG222 INTRANASAL ANTROTOMY PROSEDUR 6,404,097

2846 SG2759 OTHER PLASTIC REPAIR OF MOUTH PROSEDUR 5,064,376

2932 SG3451 DECORTICATION OF LUNG PROSEDUR 12,625,137

REPLACEMENT OF ANY TYPE PACEMAKER DEVICE WITH SINGLE-CHAMBER DEVICE,

3140 SG4319 OTHER GASTROSTOMY PROSEDUR 7,684,530

3228 SG4912B ANAL FISTULECTOMY-LAY OPEN HIGH FISTULA PROSEDUR 5,696,623

3307 SG5459 OTHER LYSIS OF PERITONEAL ADHESIONS PROSEDUR 6,835,899

OTHER LOCAL EXCISION OR DESTRUCTION OF LESION OR TISSUE OF URETHRA -

3472 SG6859 OTHER AND UNSPECIFIED VAGINAL HYSTERECTOMY PROSEDUR 10,728,517

3557 SG7728 WEDGE OSTEOTOMY - TARSAL/METATARSAL PROSEDUR 3,767,762

SPINAL FUSION, NOS (PRIMARY POST/ANT DECOMPRESSION W FUSION &

3715 SG835 BURSECTOMY PROSEDUR 3,169,084

3795 SG8624 CHEMOSURGERY OF SKIN PROSEDUR 10,828,015

TARIF PROSEDUR RMO/MO

TARIF PROSEDUR SPESIALIS

3958 SCPDAYADEN ADENOID PROSEDUR 311,084

4051 SCPPK005 PROSEDUR THERAPEUTIC GRANULOCYTE REDUCTION PROSEDUR 8,943,890

4134 DENJL525 GIGI TIRUAN SEBAGIAN SADDLE LOGAM PROSEDUR 4,074,467

4225 CSN00009 THIROID SET SET 174,631