Xyz Hospital, City: Special Discounted Rates For State Life Health Ins. Co. LTD

XYZ HOSPITAL , CITY
SPECIAL DISCOUNTED RATES FOR STATE LIFE HEALTH INS. CO. LTD.
Coverage Line of Treatment Treatment Rate
TERTIARY DENTAL Closed Redution of Mandible ###
TERTIARY DENTAL Closed Redution of Maxilla ###
TERTIARY DENTAL Facial Soft Tissue Repair ###
SECONDARY DENTAL Fistulectomy ###
Fixation of fracture of jaw with

TERTIARY DENTAL ###
Implant
Fixation of fracture of jaw with K

TERTIARY DENTAL ###
wire
TERTIARY DENTAL ORIF - Leforte (Level I) ###
TERTIARY DENTAL ORIF - Leforte (Level II) ###
TERTIARY DENTAL ORIF - Leforte (Level III) ###
ORIF - Orbital Floor with

TERTIARY DENTAL ###
reconstruction
TERTIARY DENTAL ORIF Mandible ###
TERTIARY DENTAL ORIF Mandible - Bilateral ###
TERTIARY DENTAL ORIF Mandible and Maxilla ###
TERTIARY DENTAL ORIF Maxilla ###
TERTIARY DENTAL ORIF Maxilla - Bilateral ###
ORIF Zygomatic fracture with

TERTIARY DENTAL ###
Implant
BOTH DENTAL Osteotomy - Unimax ###
TERTIARY DENTAL Sequestrectomy ###
TERTIARY DENTAL Splint Fracture - Alveolar ###
TERTIARY DENTAL TMJ Ankolysis - Bilateral ###
TERTIARY DENTAL TMJ Ankolysis - Unilateral ###
TERTIARY DENTAL Tumour excision - Benign ###
TERTIARY DENTAL Tumour excision - Malignant ###
BOTH THROAT Parotidectomy - Radical Total ###
BOTH GENERAL SURGERY Abdominoperineal Resection ###
Abscess drainage under General

BOTH GENERAL SURGERY ###
Anesthesia (GA)
Abscess drainage under Local

Anesthesia (LA)
TERTIARY GENERAL SURGERY Anterior Resection for CA ###
SECONDARY GENERAL SURGERY Appendicectomy ###
Appendicectomy + Appendicular
SECONDARY GENERAL SURGERY ###
Abscess
SECONDARY GENERAL SURGERY Bakers Cyst - Excision ###
SECONDARY GENERAL SURGERY Branchial Fistula ###
Breast Lump - Excision -

Bilateral
Breast Lump - Excision -

Unilateral
SECONDARY GENERAL SURGERY Bursa - Excision ###
BOTH GENERAL SURGERY Carbuncle back ###
Chest Intubation under

Waterseal
SECONDARY GENERAL SURGERY Cholecystectomy (Open) ###
Cholecystectomy (Open) &

Exploration of CBD
SECONDARY GENERAL SURGERY Choledochojejunostomy ###
BOTH GENERAL SURGERY Colectomy - Total ###
BOTH GENERAL SURGERY Colostomy ###
BOTH GENERAL SURGERY Colostomy Reversal ###
SECONDARY GENERAL SURGERY Cyst over Scrotum - Excision ###
SECONDARY GENERAL SURGERY Debulking of Tumor under GA ###
SECONDARY GENERAL SURGERY Dermoid Cyst - Large - Excision###
SECONDARY GENERAL SURGERY Dermoid Cyst - Small - Excision###
BOTH GENERAL SURGERY Diverticulectomy ###
Dorsal Slit and Reduction of

Paraphimosis
Drainage Pericardial Effusion

(Pericardiocentesis)
Drainage of Ischio Rectal

Abscess
SECONDARY GENERAL SURGERY Drainage of Psoas Abscess ###

Drainage of Subdiaphragmatic
Abscess
SECONDARY GENERAL SURGERY Duodenectomy ###
SECONDARY GENERAL SURGERY Duodenojejunostomy ###
BOTH GENERAL SURGERY Endoscopic band ligation ###
SECONDARY GENERAL SURGERY Epididymal Swelling -Excision ###
SECONDARY GENERAL SURGERY Epididymectomy ###
SECONDARY GENERAL SURGERY Evacuation of Scrotal Hematoma###
Excision Benign Tumor -

BOTH GENERAL SURGERY Gastrointestinal tract (with ###
Biopsy)
BOTH GENERAL SURGERY Excision Biopsy under GA ###
Excision Biopsy under local

anaesthesia
Excision Pilonidal Sinus

(Karydikays procedure)
SECONDARY GENERAL SURGERY Excision of Neurofibroma ###
Excision of Parathyroid
TERTIARY GENERAL SURGERY ###
Adenoma/Carcinoma
SECONDARY GENERAL SURGERY Excision of Sebaceous Cysts ###
Exploratory Laparotomy (Tumors

resection)
BOTH GENERAL SURGERY Exploratory Thorocotomy ###
Fibroadenoma - Bilateral (With

Biopsy)
Fibroadenoma - Unilateral (With

Biopsy)
BOTH GENERAL SURGERY Fibroma - Excision ###
SECONDARY GENERAL SURGERY Fissurectomy ###
Fissurectomy and
Haemorrhoidectomy
Fissurectomy with Eversion of

Sac - Bilateral
Fissurectomy with
Sphincterotomy
SECONDARY GENERAL SURGERY Fistulectomy (Peri Anal) ###
SECONDARY GENERAL SURGERY Ganglion - Small - Excision ###
SECONDARY GENERAL SURGERY Ganglion - large - Excision ###
SECONDARY GENERAL SURGERY Gastric Perforation ###
BOTH GENERAL SURGERY Gastrojejunostomy CA ###
SECONDARY GENERAL SURGERY Haemangioma - Excision ###
SECONDARY GENERAL SURGERY Haemorrhoidectomy ###
Haemorrhoidectomy +
Fistulectomy
BOTH GENERAL SURGERY Hemicolectomy ###
BOTH GENERAL SURGERY Hemithyroidectomy ###
BOTH GENERAL SURGERY Hepatic Resection (lobectomy) ###
SECONDARY GENERAL SURGERY Hernia - Epigastric ###
SECONDARY GENERAL SURGERY Hernia - Femoral ###

Hernia - Hiatus (Stomach
Prolapse)
SECONDARY GENERAL SURGERY Hernia - Incisional ###
SECONDARY GENERAL SURGERY Hernia - Repair ###
SECONDARY GENERAL SURGERY Hernia - Umbilical ###
SECONDARY GENERAL SURGERY Hernia Repair - Bilateral ###
SECONDARY GENERAL SURGERY Hernioplasty (mesh repair) ###
Herniorraphy and
Hydrocelectomy Sac Excision
BOTH GENERAL SURGERY Hydrocele - Excision ###
BOTH GENERAL SURGERY Hydrocelectomy + Orchidectomy###
Hydrocelectomy+ Hernioplasty
(With Mesh)
BOTH GENERAL SURGERY Incision & Drainage - Major (GA)###
BOTH GENERAL SURGERY Incision & Drainage - Minor (LA)###
Intestinal Perforation (Resection

Anastomosis)
Lap. Cholecystectomy & CBD

exploration
SECONDARY GENERAL SURGERY Laparoscopic Adhesiolysis ###
BOTH GENERAL SURGERY Laparoscopic Adrenalectomy ###
SECONDARY GENERAL SURGERY Laparoscopic Appendicectomy ###
SECONDARY GENERAL SURGERY Laparoscopic Cholecystectomy ###

SECONDARY GENERAL SURGERY Laparoscopic Cystectomy ###
SECONDARY GENERAL SURGERY Laparoscopic Hernia Repair ###
SECONDARY GENERAL SURGERY Laparoscopic Thyroidectomy ###
Laparoscopic umbilical hernia

repair
BOTH GENERAL SURGERY Laparotomy ###
SECONDARY GENERAL SURGERY Lipoma ###
Lymphnode - Excision with

Biopsy
Mastectomy / (Complete Breast

Excision)
Oeshophagoscopy for foreign

body removal
SECONDARY GENERAL SURGERY Oesophagectomy ###
BOTH GENERAL SURGERY Orchidectomy ###
SECONDARY GENERAL SURGERY Orchidectomy + Herniorraphy ###
SECONDARY GENERAL SURGERY Orchidopexy ###
SECONDARY GENERAL SURGERY Pelvic Abscess - Open Drainage###
SECONDARY GENERAL SURGERY PeriAnal Fistula with Seton ###
BOTH GENERAL SURGERY Pyeloroplasty ###
TERTIARY GENERAL SURGERY Radical Mastectomy ###
Rectal Benign Tumour (Incl.

Histopath)
SECONDARY GENERAL SURGERY Rectal Dilation ###
SECONDARY GENERAL SURGERY Rectal polyp ###
Removal of Foreign Body from

Trachea
BOTH GENERAL SURGERY Reversal of Ileostomy ###
Rubber band ligation -

Hemorrhoid
TERTIARY GENERAL SURGERY Segmental Resection of Breast ###
BOTH GENERAL SURGERY Sigmoid Diverticulum ###
BOTH GENERAL SURGERY Splenectomy ###
Suturing of wounds with local

anesthesia
Thorachostomy (Under Water

Seal)
BOTH GENERAL SURGERY Thoracoplasty ###
Total Thyroidectomy and Block

Dissection
Varicose Veins - Excision and

Ligation
SECONDARY GENERAL SURGERY Vasectomy ###
Anterior Posterior (Cystocele +

SECONDARY GYNAECOLOGY ###
Rectocele) - AP Repair
SECONDARY GYNAECOLOGY Anterior Repair (Cystocele) ###
SECONDARY GYNAECOLOGY Bartholin abscess I & D ###
SECONDARY GYNAECOLOGY Bartholin cyst removal ###

SECONDARY GYNAECOLOGY Cervical Cerclage ###
SECONDARY GYNAECOLOGY Cervical Polypectomy ###
SECONDARY GYNAECOLOGY Cesarean Hysterectomy ###
SECONDARY GYNAECOLOGY Cesarean delivery ###
SECONDARY GYNAECOLOGY Cyst - Labial ###
D&C ( Dilatation & curetage ) >

12 wks with prior IA approval
D&C ( Dilatation &

curretage)upto 8 wks
D&C ( dilatation & Curretage)

upto 12 wks
SECONDARY GYNAECOLOGY Diagnostic D&C with Biopsy ###
SECONDARY GYNAECOLOGY E&C ###
SECONDARY GYNAECOLOGY Hymenectomy ###
SECONDARY GYNAECOLOGY Hysterectomy - Vaginal ###
SECONDARY GYNAECOLOGY Hysterectomy - abdominal ###
SECONDARY GYNAECOLOGY Hysterotomy -Tumors removal ###
Laparotomy -failed laproscopy to

explore
BOTH GYNAECOLOGY Laparotomy for ectopic repture ###
SECONDARY GYNAECOLOGY Laproscopy Hysterectomy ###
SECONDARY GYNAECOLOGY Low Forceps/Vaccum Delivery ###

SECONDARY GYNAECOLOGY Manual removel of Plecenta ###
Myomectomy - Abdominal
BOTH GYNAECOLOGY ###
(including Biopsy)
SECONDARY GYNAECOLOGY Normal Delivery ###
Normal delivery with episiosty

and P repair
SECONDARY GYNAECOLOGY Ovarectomy/Oophrectomy ###
SECONDARY GYNAECOLOGY Ovarian Cystectomy ###
SECONDARY GYNAECOLOGY Perineal Tear Repair (Trauma) ###
SECONDARY GYNAECOLOGY Posterior Repair (Rectocele) ###
SECONDARY GYNAECOLOGY Recto Vaginal Fistula -Repair ###
Repair of post coital tear,

perineal injury
Rupture Uterus , closer and

repair with tubal ligation
SECONDARY GYNAECOLOGY Salphingo-oophorectomy ###
Termination of Pregnancy more

than 24 weeks
SECONDARY GYNAECOLOGY Vaginal Tear Repair (Trauma) ###
SECONDARY GYNAECOLOGY Vaginal Vault Prolapse ###
BOTH GYNAECOLOGY Vesico Vaginal Fistula repair ###
BOTH GYNAECOLOGY Vulvectomy - Radical ###
ENDOSCOPIC
BOTH Colonoscopy ###
PROCEDURES
ENDOSCOPIC
BOTH Upper GI endoscopy ###
PROCEDURES
ENDOSCOPIC
BOTH Upper GI endoscopy with biopsy###
PROCEDURES
Anterior Cervical Discectomy

TERTIARY NEUROSURGERY ###
and Fusion (ACDF)
TERTIARY NEUROSURGERY Brachial Plexus – Repair ###
TERTIARY NEUROSURGERY Brain Biopsy ###
Burr hole with Sub Dural

TERTIARY NEUROSURGERY Haematoma / Intracerebral ###
Haematoma
Burr hole with abscess/extra

dural haematoma
Carpal Tunnel Release including

SECONDARY NEUROSURGERY ###
NCS
Cerebrospinal Fluid (CSF)

BOTH NEUROSURGERY ###
Rhinorrohea - Endoscopic
Cerebrospinal Fluid (CSF)

Rhinorrohea - Repair
SECONDARY NEUROSURGERY Cervical Ribs - Bilateral ###
SECONDARY NEUROSURGERY Cervical Ribs - Unilateral ###
TERTIARY NEUROSURGERY CranioPlasty - Endogenous graft###
TERTIARY NEUROSURGERY CranioPlasty - Exogenous graft ###
TERTIARY NEUROSURGERY Craniostenosis ###
Craniotomy for Hematoma

(Extradural)
Craniotomy for Hematoma

(Subdural)
Craniotomy for Tumours –

Infratentorial
Craniotomy for Tumours –
Supratentorial
TERTIARY NEUROSURGERY Depressed Fracture ###
TERTIARY NEUROSURGERY Drainage of Spinal Abcsess ###
TERTIARY NEUROSURGERY Duroplasty - Endogenous ###
TERTIARY NEUROSURGERY Duroplasty - Exogenous ###
TERTIARY NEUROSURGERY EVD ( External Venticular Drian ###

)
TERTIARY NEUROSURGERY Encephalocele ###
Endoscopic Third
Ventriculostomy (ETV)
TERTIARY NEUROSURGERY Excision of Brain Abscess ###
TERTIARY NEUROSURGERY Laminectomy Level 2 or more ###
TERTIARY NEUROSURGERY Laminectomy with Fixation ###
Laminectomy with Fixation Level

2 or more
TERTIARY NEUROSURGERY Laminectomy with Fusion ###
BOTH NEUROSURGERY Local Neurectomy ###
BOTH NEUROSURGERY Meningocele - Anterior ###
BOTH NEUROSURGERY Meningocele - Lumbar ###
TERTIARY NEUROSURGERY Meningomyelocele ###
Micro discectomy – Cervical

(Anterior)
(Posterior) 1 Level

(Posterior) 2 Levels
Micro discectomy – Lumbar 1-

Level
Micro discectomy – Lumbar

2+Levels
R.F. Lesion for Trigeminal

Neuralgia
TERTIARY NEUROSURGERY Removal of Spinal Implant ###
TERTIARY NEUROSURGERY Revision of VP Shunt ###
TERTIARY NEUROSURGERY Spina Bifida Occulta ###
TERTIARY NEUROSURGERY Spine - Extradural Tumour ###
TERTIARY NEUROSURGERY Spine - Intradural Tumour ###
TERTIARY NEUROSURGERY Spine - Intramedullar Tumour ###
TransNasal, TransSphenoidal -
Excision of Tumor
TERTIARY NEUROSURGERY TransPedicular Fixation (TPF) ###
TransPedicular Fixation (TPF) -

more than 4 screws
TERTIARY NEUROSURGERY Twist Drill Craniostomy ###
TERTIARY ORTHOPAEDIC Above Knee Amputation ###
TERTIARY ORTHOPAEDIC Amputation (One or Two) Digit ###
BOTH ORTHOPAEDIC Amputation (One or Two) Toe ###

BOTH ORTHOPAEDIC Amputation Three or More Digits###
TERTIARY ORTHOPAEDIC Amputation Three or More Toes###
BOTH ORTHOPAEDIC Below Knee Amputation ###
Wound debridement under

BOTH ORTHOPAEDIC ###
General Anaesthesia
Wound debridement under Local

BOTH ORTHOPAEDIC ###
Anaesthesia
BOTH UROLOGY Cysto-Urethroscopy and proceed

###
BOTH UROLOGY Cystolitholapaxy ###
BOTH UROLOGY Cystolithotomy ###
Cystoscopy with Bilateral DJ

BOTH UROLOGY ###
Stent
Cystoscopy with Unilateral DJ

BOTH UROLOGY ###
Stent
BOTH UROLOGY Lithotripsy (each session) ###
BOTH UROLOGY Lithotripsy with DJ Stenting ###
BOTH UROLOGY Nephrectomy ###
TURBT (Transurethral Resection

BOTH UROLOGY of the Bladder Tumor) with ###
Histopathology
BOTH UROLOGY URS with DJ Stenting ###
BOTH UROLOGY Ureteral Stents Removal ###
Ureteric Catheterization -
BOTH UROLOGY ###
Cystoscopy
VIU (Visual Internal

BOTH UROLOGY ###
Urethrotomy )
BOTH UROLOGY Vesicolithotomy ###
TERTIARY ONCOLOGY Chemotherapy - Per sitting ###
Chemotherapy - per siting plus

cost of injections subject to
TERTIARY ONCOLOGY ###
approval for Insurance
administrator
Gamma Knife Radio Surgery
(GKRS)
TERTIARY ONCOLOGY Oncology - Medical ###
Radionuclide Therapies - I-131

Therapy for Thyrotoxicosis
TERTIARY ONCOLOGY Radiotherapy - Per Fraction - 3D###
TERTIARY ONCOLOGY Radiotherapy - Per sitting ###
SECONDARY Medical Cases AFI (Acute febrile illness) ###
BOTH Medical Cases Acute Asthmatic Attack ###
SECONDARY Medical Cases Acute Cholecystitis ###
BOTH Medical Cases Acute Gastritis ###
BOTH Medical Cases Acute Gastroentritis ###
BOTH Medical Cases Acute Suppurative Otitis Media ###
BOTH Medical Cases Acute Transverse Myelitis ###
BOTH Medical Cases Acute Viral Hepatitis ###
BOTH Medical Cases Acute and chronic meningitis ###
BOTH Medical Cases Acute and chronic pancreatitis ###

BOTH Medical Cases Acute and subacute endocarditis###
BOTH Medical Cases Acute bronchitis ###
Acute inflammatory
BOTH Medical Cases ###
demyelinating polyneuropathy
Acute organophosphorus
poisoning
BOTH Medical Cases Acute renal failure ###
BOTH Medical Cases Acute/ Chronic diarrohea ###
BOTH Medical Cases Acutre excaberation of COPD ###
SECONDARY Medical Cases Amoebiasis ###
BOTH Medical Cases Amyloidosis ###
BOTH Medical Cases Anhydramnios Pregnancy ###
BOTH Medical Cases Ascites Workup ###
BOTH Medical Cases Biliary Colic / Choledocholithiasis

###
BOTH Medical Cases Birth Asphysia ###
BOTH Medical Cases Bleeding Disorder ###
BOTH Medical Cases Bronchiatasis ###
BOTH Medical Cases CKD Conservative Rx ###
BOTH Medical Cases Celiac Disease ###
BOTH Medical Cases Cellulitis ###

Cerebral infarction
(Ischaemic/hemorrhagic stroke)
BOTH Medical Cases Cholangitis ###
BOTH Medical Cases Chronic Liver Disease (CLD) ###
BOTH Medical Cases Chronic viral hepatitis ###
BOTH Medical Cases Complications of Cerebral Palsy###
BOTH Medical Cases Coronary Care Unit (CCU) ###
BOTH Medical Cases Crohn's Disease ###
BOTH Medical Cases DVT (Deep Vein Thrombosis) ###
SECONDARY Medical Cases Dengue fever [classical dengue]###
SECONDARY Medical Cases Dengue haemorrhagic fever ###
BOTH Medical Cases Diabetic Complication ###
BOTH Medical Cases Diabetic ketoacidosis ###
BOTH Medical Cases Drug Reaction ###
Dysfunctional Uterine Bleeding

SECONDARY Medical Cases ###
(DUB)
BOTH Medical Cases Eclampsia ###
BOTH Medical Cases Emphysema ###
BOTH Medical Cases Enteric Fever (Typhiod) ###
BOTH Medical Cases Epididymitis / Epididymo-orchitis###

BOTH Medical Cases Esophagitis ###
SECONDARY Medical Cases GBS (Guillian Barre Syndrome) ###
BOTH Medical Cases Gestational Diabetes ###
Gestational [pregnancy-induced]
SECONDARY Medical Cases hypertension with significant ###
proteinuria
Gestational [pregnancy-induced]
SECONDARY Medical Cases hypertension without significant ###
proteinuria
BOTH Medical Cases Glomerulonephritis ###
BOTH Medical Cases Gullian bar syndrome ###
BOTH Medical Cases HIV with complications ###
BOTH Medical Cases Head Injury ###
BOTH Medical Cases Heart Failure ###
BOTH Medical Cases Heat stroke ###
BOTH Medical Cases Hepatic Encephalopathy ###
BOTH Medical Cases High Dependency Units (HDU) ###
High Risk Pregnancy -

Conservative Management
BOTH Medical Cases Hydrocephalus ###
BOTH Medical Cases Hyperosmolar Non-Ketotic coma###
BOTH Medical Cases Hypertension Emergencies ###
BOTH Medical Cases Hypokalemic Periodic Paralysis ###

Hypothyroidism Severe /
Myxedema
BOTH Medical Cases Intensive Care Unit - ICU ###
BOTH Medical Cases Intestinal Obstruction ###
BOTH Medical Cases Intracerebral haemorrhage ###
BOTH Medical Cases Ischemic Heart Disease ###
BOTH Medical Cases Liver abscess ###
BOTH Medical Cases Lung abscess/ Empyema ###
BOTH Medical Cases Malabsorption syndrome ###
BOTH Medical Cases Malaria (severe/cerebral) ###
BOTH Medical Cases Mesenteric Lymphadenitis ###
BOTH Medical Cases Metabolic Encephalopathy ###
Neo Natal Care (Birth

Complications exchange NEC)
BOTH Medical Cases Nephrotic syndrome ###
BOTH Medical Cases Obstructive Jaundice ###
Other bacterial foodborne

SECONDARY Medical Cases intoxications, not elsewhere ###
classified
Other bacterial intestinal

infections
BOTH Medical Cases Pancytopenia Workup ###
Pelvic inflammatory disease

(PID)
BOTH Medical Cases Peptic Ulcer Disease ###
BOTH Medical Cases Pericardial/ Pleural tuberculosis ###
BOTH Medical Cases Peripheral Vascular Disease ###
BOTH Medical Cases Plasmodium Vivax malaria ###
SECONDARY Medical Cases Plasmodium falciparum malaria ###
BOTH Medical Cases Pleural Effusion Workup ###
SECONDARY Medical Cases Pneumonia / LRTI ###
Pneumonia due to Haemophilus

influenzae
Pneumonia due to Streptococcus

pneumoniae
SECONDARY Medical Cases Pneumothorax ###
BOTH Medical Cases Pulmonary Embolism ###
BOTH Medical Cases Pyrexia of unknown origin ###
BOTH Medical Cases Renal colic ###
BOTH Medical Cases Renal encephalopathy ###

Respiratory failure due to any
cause (pneumonia, asthma,
BOTH Medical Cases COPD, ARDS, foreign body, ###
poisoning, head injury etc.)
SPO2 < 70
Respiratory tuberculosis,
SECONDARY Medical Cases bacteriologically and ###
histologically confirmed
BOTH Medical Cases Rheumatic Heart Disease ###
BOTH Medical Cases Seizures ###

BOTH Medical Cases Septic Wound Infection ###
BOTH Medical Cases Severe anemia HB < 6.0 ###
BOTH Medical Cases Severe sepsis/Septic shock ###
Sheehan Syndrome
Conservative Rx
BOTH Medical Cases Sickle cell Anemia ###
Simple and mucopurulent

chronic bronchitis
BOTH Medical Cases Snake bite ###
BOTH Medical Cases Subarachnoid haemorrhage ###
BOTH Medical Cases Systematic lupus erythematosus###
BOTH Medical Cases Tetanus ###
BOTH Medical Cases Traumatic Optic Neuropathy ###
Type 1/2 respiratory failure

SPO2<70
BOTH Medical Cases UTI (Urinary Tract Infection) ###
SECONDARY Medical Cases Ulcerative Colitis (UC) ###
Uncontrolled Diabetes Mellitus

(Greater 300)
BOTH Medical Cases Upper GI bleeding (conservative)

###
BOTH Medical Cases Urosepsis ###
BOTH Medical Cases Vasculitis ###

BOTH Medical Cases Ventilator ###
BOTH Medical Cases Viral encephalitis ###
BOTH Medical Cases Visceral leishmaniasis ###
BOTH Medical Cases Workup For Malignancy ###
BOTH Medical Cases Workup for Splenomegaly ###
BOTH Tertiary/Priority Arteriovenous (AV) Fistula ###
TERTIARY Tertiary/Priority Dialysis ###
BOTH Tertiary/Priority Double Lumen Catheter ###
Trans Arterial Chemo

TERTIARY Tertiary/Priority ###
Embolization (TACE)
Angioplasty - 1 DEB (Drug

TERTIARY Cardiology ###
Eluted Balloon)

Eluted Balloon)

Eluted Balloon)
Angioplasty - four Stents (Drug

Eluted)
Angioplasty - single Stent (Drug

Eluted)
Angioplasty - three Stents (Drug

Eluted)
Angioplasty - two Stents (Drug

Eluted)
TERTIARY Cardiology Aortic Balloon Valvuloplasty ###
TERTIARY Cardiology Cardiac Cath ###

TERTIARY Cardiology Chest Intubation ###
TERTIARY Cardiology Coronary Angiography ###
DDDR PACEMAKER (PPM) -

MRI safe
TERTIARY Cardiology Failure to Proceed to Angioplasty

###
TERTIARY Cardiology PTMC - New Balloon ###
TERTIARY Cardiology PTMC - Used Balloon ###
TERTIARY Cardiology Pericardiocentesis ###
Permanent Pace Maker - VVIR

(Single Chamber)
Pulmonary Balloon Valvuloplasty

BOTH Cardiology ###
(Closed)
Pulmonary Balloon Valvuloplasty

(Open)
TERTIARY Cardiology Temporary Pace Maker ###
Total anomalous pulmonary

venous return (TAPVC)
TERTIARY Cardiology VSD with Pulmonary Stenosis ###
BOTH Interventional Radiology Central Venous Catheter ###
TERTIARY Interventional Radiology Perma Cath Insertion ###
Advanced
BOTH CT - Brain ###
Add.Procedures
Advanced
BOTH CT - Contrast ###
Add.Procedures
Advanced
BOTH CT - Plain ###
Add.Procedures
Advanced
BOTH CT - Triphasic (Plain) ###
Add.Procedures
Advanced
BOTH CT Abdomen Pelvis Contrast ###
Add.Procedures
Advanced
BOTH CT Abdomen Pelvis Plain ###
Add.Procedures
Advanced
BOTH CT Chest Contrast ###
Add.Procedures
Advanced
BOTH CT Chest plain ###
Add.Procedures
Advanced
BOTH Histopathology (Post-Op) - Large
###
Add.Procedures
Advanced
BOTH Histopathology (Post-Op) - Small###
Add.Procedures
Advanced
BOTH MRCP ###
Add.Procedures
Advanced
BOTH MRI (Contrast) ###
Add.Procedures
Advanced
BOTH MRI (Plain) ###
Add.Procedures
Advanced
BOTH MRI Brain ###
Add.Procedures
Advanced
BOTH MRI Neck ###
Add.Procedures
BOTH Pulmonology Bronchoscopy (Diagnostic) ###
BOTH Gastroentrology PEG ###
TERTIARY Paeds Cardiology ASD - Device Occluder ###
Atrial Septal Defect (ASD) -

TERTIARY Paeds Cardiology ###
Repair
AtrioVentricular Septal Defect

(AVSD) - Repair
TERTIARY Paeds Cardiology Blalock-Taussig (BT) Shunt ###

TERTIARY Paeds Cardiology Coarctation Of Aorta - Repair ###
TERTIARY Paeds Cardiology PDA Device Closure ###
TERTIARY Paeds Cardiology PDA Ligation ###
TERTIARY Paeds Cardiology RVOT/PDA Stening ###
Tetralogy of Fallot (TOF) - Total

Correction
TERTIARY Paeds Cardiology VSD - Device Closure ###
Ventricular Septal Defect (VSD) -

Repair
TERTIARY Cardiac Surgery ASD Repair ###
TERTIARY Cardiac Surgery Aortic Valve Replacement (AVR)###
TERTIARY Cardiac Surgery CABG ###
TERTIARY Cardiac Surgery CABG + AVR ###
TERTIARY Cardiac Surgery CABG + DVR ###
TERTIARY Cardiac Surgery CABG + IABP ###
TERTIARY Cardiac Surgery CABG + MVR ###
Double Valve Replacement

TERTIARY Cardiac Surgery ###
(DVR)
TERTIARY Cardiac Surgery MVR + TV Repair ###
TERTIARY Cardiac Surgery MVR+ Aortic Valve Repair ###
TERTIARY Cardiac Surgery Mitral Valve Replacement (MVR)###

Partial Anamulous Venous
TERTIARY Cardiac Surgery ###
Drainage Repair (PAPVD)
TERTIARY Cardiac Surgery Pericardecetomy with CBP ###
TERTIARY Cardiac Surgery Pulmonary Artery (PA) Banding ###
Subaortic Membrane Resection

BOTH Cardiac Surgery ###
(SAM)

Xyz Hospital, City: Special Discounted Rates For State Life Health Ins. Co. LTD

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XYZ HOSPITAL , CITY

Coverage Line of Treatment Treatment Rate

TERTIARY DENTAL Closed Redution of Mandible ###

TERTIARY DENTAL Closed Redution of Maxilla ###

TERTIARY DENTAL Facial Soft Tissue Repair ###

SECONDARY DENTAL Fistulectomy ###

Fixation of fracture of jaw with

Fixation of fracture of jaw with K

TERTIARY DENTAL ORIF - Leforte (Level I) ###

TERTIARY DENTAL ORIF - Leforte (Level II) ###

TERTIARY DENTAL ORIF - Leforte (Level III) ###

ORIF - Orbital Floor with

TERTIARY DENTAL ORIF Mandible ###

TERTIARY DENTAL ORIF Mandible - Bilateral ###

TERTIARY DENTAL ORIF Mandible and Maxilla ###

TERTIARY DENTAL ORIF Maxilla ###

TERTIARY DENTAL ORIF Maxilla - Bilateral ###

ORIF Zygomatic fracture with

TERTIARY DENTAL Sequestrectomy ###

TERTIARY DENTAL Splint Fracture - Alveolar ###

TERTIARY DENTAL TMJ Ankolysis - Bilateral ###

TERTIARY DENTAL TMJ Ankolysis - Unilateral ###

TERTIARY DENTAL Tumour excision - Benign ###

TERTIARY DENTAL Tumour excision - Malignant ###

BOTH THROAT Parotidectomy - Radical Total ###

BOTH GENERAL SURGERY Abdominoperineal Resection ###

Abscess drainage under General

Abscess drainage under Local

TERTIARY GENERAL SURGERY Anterior Resection for CA ###

SECONDARY GENERAL SURGERY Appendicectomy ###

SECONDARY GENERAL SURGERY Bakers Cyst - Excision ###

SECONDARY GENERAL SURGERY Branchial Fistula ###

Breast Lump - Excision -

Breast Lump - Excision -

BOTH GENERAL SURGERY Carbuncle back ###

Chest Intubation under

SECONDARY GENERAL SURGERY Cholecystectomy (Open) ###

Cholecystectomy (Open) &

SECONDARY GENERAL SURGERY Choledochojejunostomy ###

BOTH GENERAL SURGERY Colectomy - Total ###

BOTH GENERAL SURGERY Colostomy ###

BOTH GENERAL SURGERY Colostomy Reversal ###

SECONDARY GENERAL SURGERY Cyst over Scrotum - Excision ###

SECONDARY GENERAL SURGERY Debulking of Tumor under GA ###

SECONDARY GENERAL SURGERY Dermoid Cyst - Large - Excision###

SECONDARY GENERAL SURGERY Dermoid Cyst - Small - Excision###

BOTH GENERAL SURGERY Diverticulectomy ###

Dorsal Slit and Reduction of

Drainage Pericardial Effusion

Drainage of Ischio Rectal

SECONDARY GENERAL SURGERY Drainage of Psoas Abscess ###

SECONDARY GENERAL SURGERY Duodenectomy ###

SECONDARY GENERAL SURGERY Duodenojejunostomy ###

BOTH GENERAL SURGERY Endoscopic band ligation ###

SECONDARY GENERAL SURGERY Epididymal Swelling -Excision ###

SECONDARY GENERAL SURGERY Epididymectomy ###

SECONDARY GENERAL SURGERY Evacuation of Scrotal Hematoma###

Excision Benign Tumor -

BOTH GENERAL SURGERY Excision Biopsy under GA ###

Excision Biopsy under local

Excision Pilonidal Sinus

SECONDARY GENERAL SURGERY Excision of Neurofibroma ###