Name of the Hospital Provider Code S.No 1 2 3 4 5 6 7 8 9 10 Procedure Name E.N.

T Adenoidectomy Antral Wash/Puncture DNS Pepair FESS Mastoidectomy Tympanoplasty Tympanoplasty + Mastoidectomy Septoplasty Tonsillectomy Tonsillectomy & Adenoidectomy GENERAL SURGERY Amputation Minor (Toes, Digits,Ray) Amputation above knee Amputation below knee Amputation above Elbow Amputation below Elbow Appendicectomy - open Appendicectomy - Leparoscopic Cholecystecomy - Open Cholecystecomy - Leparoscopic Circumcision Fissure-Dialtion Fistulectomy - Low fistulectomy - High Fissurectomy Sphincterotomy Haemorrhoidectomy Hernia - Simple Hernia - Femoral / Inguinal Unilateral Hernia - Femoral / Inguinal Bilateral Hernia - Complicated Herniorraphy Incisional Hernia -Mesh Repair Hernia - Laparoscopic Laprotomy Emergency Laprotomy Routine Lymph Node Biopsy -LA Lymph Node Biopsy -GA Lipoma LA Lipoma GA Perianal Abcess Pilonidal Sinus Radical Mastectomy Modified

TARIFF STATEMENT (PACKAGES City State General Ward / single Room Sharing

Deluxe Room/Ac Room

11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41

Name of the Hospital Provider Code S.No 42 43 44 45 46 47 Procedure Name Breast Lumpectomy Simple Mastectomy Thyroidectomy - Hemi Thyroidectomy - Total Varicose Veins Stripping - Unilateral Varicose Veins Stripping - Bilateral OBSTETRICS & GYNECOLOGY Caesarean Section Delivery - Normal Delivery - Forceps Hysterectomy + BSO - Open Hysterectomy + BSO - Laparoscopic Hysterectomy - Vaginal Hysterectomy - LAVH / TLH D&C D & C with Hysteroscopy OPTHALMOLOGY Cataract - Phaco Cataract Mulitifocal IOL Cataract Unifocal Cataract - Foldable Cataract Acrylic

TARIFF STATEMENT (PACKAGES City State General Ward / single Room Sharing

Deluxe Room/Ac Room

48 49 50 51 52 53 54 55 56

57 58 59 60

61 62 63 64 65 66 67 68 69 70 71 72 73 74 75

ORTHOPAEDICS Arthroscopy Arthroscopic Surgery Carpel Tunnel Release Closed Reduction - Dislocation - Minor Closed Reduction - Dislocation - Major Implant Removal - Minor Implant Removal - Major Open Reduction - dislocation - Minor Open Reduction - dislocation - Major Internal Fixation of Fracture - Minor Internal Fixation of Fracture - Major Knee Ligament Reconstruction Laminectomy Laminectomy & Discectomy ORIF

Name of the Hospital Provider Code S.No Procedure Name

TARIFF STATEMENT (PACKAGES City State General Ward / single Room Sharing

Deluxe Room/Ac Room

76 Reduction of Fracture Under GA 77 Total Knee Replacement 78 Total Hip Replacement UROLOGY & NEPHROLOGY A V Fistula A V Graft Removal of Calculi TURP Hydrocelectomy Unilateral Hydrocelectomy Bilateral Vaticocelectomy Lithotripsy - PCNL + Stenting Lithotripsy - ESWL + Stenting CARDIOLOGY asd Closure VSD Closure CABG Caoronary Angiogram Angioplasty - PTCA Permanent Pacemaker Implantaion Heart Surgery - Open Heart Surgery - Closed Please mention the tariff only for the services available in your hispotal. The package charges are inclusive of Bed / Nursing/Hospital charges, Doctor's / Surgeion's Charges, investigations, medicines & Consumables For any other services no mentioned in this list, please attach additional sheets.

79 80 81 82 83 84 85 86 87

88 89 90 91 92 93 94 95 1. 2

Name of the Designated Offical Date :

Signature & Seal of Designated Offical

Name of the Hospital Provider Code S.No Service Name A. Room/ICU/E Equipment/Nursing Charges 1 General Ward 2 Semi Private Room 3 Single room 4 AC Room 5 Deluxe Room 6 ICU/ICCU/NICU/MICU per day 7 NEONATAL ICU per day 8 Monitor charges 9 Pluse Oxymeter charges 10 Syringe pump charges 11 Infusiuon pump charges 12 Nebuliser charges 13 Nursing charges per day 14 Ventilator charges per hour / day 15 Consultant fee / Visit (specialist) 16 Consultant fee / visit (Super specialist) B. Professional Charges 17 Surgeon Charges for Major operation 18 Surgeon Charges for Minor operation 19 Assistant Surgeon Fees 20 Anesthethist Surgeon fees 21 Resident Doctor Charges/DMO 22 Physiotherapy 23 First Consultation 24 subsequent Consultation 25 Dressing Minor 26 Dressing Major C. ot & RELATED CHARGES 27 OT Charges / Hour 28 N2O2 Charges / Hour 29 Anesthesia Charges 30 C Arm Charges 31 Microscope charge 32 Laproscope charge D. RADIOLOGY CHARGES 33 CT Scan 34 USG 35 Mammography 36 MRI 37 X-Ray Rate

TARIFF STATEMENT (PACKAGES City State S.No Service Name E. LAB CHARGES 38 Complete Blood Picture 39 ESR 40 LFT 41 Thyroid Profile 42 Widal 43 Malarial Parasites 44 Lipid Profile 45 Cgrouping And Typing 46 CUE 47 Stool Examination 48 Culture & Sensitivity 49 Electrolytes 50 ABG 51 RBS 52 HIV I & II 53 HBSAG 54 Urea Creatinine 55 CT/BT 56 Montaux 57 Blood Screening & Cross Matching G. OTHERS 58 Endoscopy 59 Colonoscopy 60 ECG 61 ECHO 62 TMT 63 Dialysis 64 Blood Transfusion charges 65 Registration charges 66 Ambulance Rate