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Outside State
Outside State NABH Entry Outside State

Specialt Package Procedure Non-NABH NABH Package NABH Entry Mandatory Documents - Claim
Sr No Specialty Sub-Specialty Package Name Procedure Name Hospital with >100 Level Package NABH Package Mandatory Documents - Pre Authorization
y Code Code Code Package Cost Cost Level Package Processing
Bed Cost Cost
Cost
a) Clinical notes mentioning the circumstances that a) Post treatment clinical photograph
Chemical burns: With significant facial scarring led to Chemical Burn b) Blood test (CBC, Sr. creatinine, Platelet
and/or loss of function; Includes % TBSA skin b) MLC copy with number etc.) c) X ray
grafted, flap cover,debridement,skin c) Clinical Photograph d) Detailed Discharge Summary
1 Burns Management BM Burns Management BM005 Chemical burns BM005B grafting,follow-up dressings etc. as deemed 78750 86625 94500 102375 110250 114187 d) Document showing % of burn through rule of 9 e) Detailed procedure / operative notes
necessary; Surgical procedures are required for
deep burns that are not amenable to heal with
dressings alone.
Chemical burns: Without significant facial led to Chemical Burn b) Blood test (CBC, Sr. creatinine, Platelet
scarring and/or loss of function; Includes % b) MLC copy with number etc.) c) X ray
TBSA skin grafted, flap cover, follow-up c) Clinical Photograph d) Detailed Discharge Summary
dressings etc. as deemed necessary; Surgical d) Document showing % of burn through rule of 9 e) Detailed procedure / operative notes
2 Burns Management BM Burns Management BM005 Chemical burns BM005A procedures are required for deep burns that are 52500 57750 63000 68250 73500 76125
not amenable to heal with dressings
alone.(Similar to therma burns
require more grafting, debridement,(skin
grafing/canthopexy)
Electrical contact burns: High voltage - with part led to low voltage electrical contact burns b) Blood test (CBC, Sr. creatinine, Platelet
of limb / limb loss; Includes % TBSA skin grafted, b) MLC copy with number etc.) c) X ray
flap cover,fasciotomy +/- /amputation/Central IV c) Clinical Photograph d) Detailed Discharge Summary
Line/debridement/early skin grafting pedicle or d) Document showing % of burn through rule of 9 e) Detailed procedure / operative notes
3 Burns Management BM Burns Management BM004 Electrical contact burns BM004C 78750 86625 94500 102375 110250 114187
free flap coverage,follow-up dressings etc. as
deemed necessary; Surgical procedures are
required for deep burns that are not amenable to
heal with dressings alone.
Electrical contact burns: High voltage - without led to low voltage electrical contact burns b) Blood test (CBC, Sr. creatinine, Platelet
part of limb / limb loss; Includes % TBSA skin b) MLC copy with number etc.) c) X ray
grafted, flap cover, fasciotomy +/- c) Clinical Photograph d) Detailed Discharge Summary
/debridement/early skin grafting/flap cover: d) Document showing % of burn through rule of 9 e) Detailed procedure / operative notes
4 Burns Management BM Burns Management BM004 Electrical contact burns BM004D 65625 72187 78750 85312 91875 95156
pedicle or free flap coverage,follow-up dressings
etc. as deemed necessary; Surgical procedures
are required for deep burns that are not
amenable to heal with dressings alone.
Electrical contact burns: Low voltage - with part led to low voltage electrical contact burns b) Blood test (CBC, Sr. creatinine, Platelet
of limb / limb loss; Includes % TBSA skin grafted, b) MLC copy with number etc.) c) X ray
flap cover, follow-up dressings Amputation etc. c) Clinical Photograph d) Detailed Discharge Summary
5 Burns Management BM Burns Management BM004 Electrical contact burns BM004B 52500 57750 63000 68250 73500 76125
as deemed necessary; Surgical procedures are d) Document showing % of burn through rule of 9 e) Detailed procedure / operative notes
Electrical contact burns: Low voltage - without led to low voltage electrical contact burns b) Blood test (CBC, Sr. creatinine, Platelet
part of limb / limb loss; Includes % TBSA skin b) MLC copy with number c) Clinical etc.) c) X ray
grafted, flap cover, follow-up dressings etc. as Photograph d) Document showing d) Detailed Discharge Summary
6 Burns Management BM Burns Management BM004 Electrical contact burns BM004A 39375 43312 47250 51187 55125 57093
deemed necessary; Surgical procedures are % of burn through rule of 9 e) Detailed procedure / operative notes
a) Clinical notes a) Post treatment clinical photograph
% Total Body Surface Area Burns (TBSA) - any b) MLC copy with number b) Blood test (CBC, Sr. creatinine, Platelet
% c) Clinical Photograph with due consent of patient etc.) c) X ray
7 Burns Management BM Burns Management BM003 Flame burns BM003A 7350 8085 8820 9555 10290 10657
(not requiring admission). d) Document showing % of burn through rule of 9 d) Discharge Summary e)
Needs at least 5-6 dressing Procedure/ operative notes
% Total Body Surface Area Burns (TBSA): > 60 a) Clinical notes b) MLC a) Post treatment clinical photograph
%; Includes % TBSA skin grafted, flap cover, copy with number c) Clinical b) Blood test (CBC, Sr. creatinine, Platelet
follow-up dressings etc. as deemed necessary; Photograph with due consent of patient etc.) c) X ray
8 Burns Management BM Burns Management BM003 Flame burns BM003D 105000 115500 126000 136500 147000 152250
Surgical procedures are required for deep burns d) Document showing % of burn through rule of 9 d) Discharge Summary e)
that are not amenable to heal with dressings Procedure/ operative notes
alone.
% Total Body Surface Area Burns (TBSA): 40 % - a) Clinical notes b) MLC a) Post treatment clinical photograph
60 %; Includes % TBSA skin grafted, flap cover, copy with number c) Clinical b) Blood test (CBC, Sr. creatinine, Platelet
9 Burns Management BM Burns Management BM003 Flame burns BM003C 65625 72187 78750 85312 91875 95156
alone.
% Total Body Surface Area Burns (TBSA): Upto a) Clinical notes b) MLC a) Post treatment clinical photograph
40 %; Includes % TBSA skin grafted, flap cover, copy with number c) Clinical b) Blood test (CBC, Sr. creatinine, Platelet
10 Burns Management BM Burns Management BM003 Flame burns BM003B 52500 57750 63000 68250 73500 76125
alone.
Post Burn Contracture surgeries for Functional a) Clinical history detailing the burns - etiology, a) Detailed indoor case papers
Improvement (Package including splints, treatment given, and resultant contractures left b) Detailed procedure/ Operative notes
pressure garments, silicone - gel sheet and b) Functional disability to be detailed and expected c) Post-operative clinical photograph of the
physiotherapy): Excluding Neck contracture; functional improvement to be shared. affected part
Post Burn Contracture surgeries for C) Pre-operative clinical photograph. d) Discharge summary
11 Burns Management BM Burns Management BM006 BM006A Contracture release with - Split thickness Skin 65625 72187 78750 85312 91875 95156
Functional Improvement
Graft (STSG) / Full Thickness Skin Graft (FTSG)
/ Flap cover is done for each joint with post -
operative regular dressings for STSG / FTSG /
Flap cover.
a) Clinical history detailing the burns - etiology, a) Detailed indoor case papers
Post Burn Contracture surgeries for Functional treatment given, and resultant contractures left b) Detailed procedure/ Operative notes
Improvement (Package including splints, b) Functional disability to be detailed and expected c) Post-operative clinical photograph of the
pressure garments,contracture release & split functional improvement to be shared. affected part
skin graft with or without flap C) Pre-operative clinical photograph. d) Discharge summary
Post Burn Contracture surgeries for reconstruction,silicone - gel sheet and
12 Burns Management BM Burns Management BM006 BM006B 65625 72187 78750 85312 91875 95156
Functional Improvement physiotherapy): Neck contracture; Contracture
release with - Split thickness Skin Graft (STSG) /
Full Thickness Skin Graft (FTSG) / Flap cover is
done for each joint with post-operative regular
dressings for STSG / FTSG / Flap cover.
Outside State
Bed Cost Cost
Cost
Criteria 3: % Total Body Surface Area Burns a) Clinical notes b) MLC a) Post treatment clinical photograph
(TBSA): 25-40 %; Includes % TBSA skin grafted, copy with number c) Clinical b) Blood test (CBC, Sr. creatinine, Platelet
flap cover, follow-up dressings etc. as deemed Photograph with due consent of patient etc.) c) X ray
13 Burns Management BM Burns Management BM002 Scald burns BM002C 65625 72187 78750 85312 91875 95156
necessary; Surgical procedures are required for d) Document showing % of burn through rule of 9 d) Discharge Summary e)
deep burns that are not amenable to heal with Procedure/ operative notes
dressings alone.
a) Clinical notes b) MLC a) Post treatment clinical photograph
Criteria 1: % Total Body Surface Area Burns
copy with number c) Clinical b) Blood test (CBC, Sr. creatinine, Platelet
(TBSA): less than 20% in adults and less than
14 Burns Management BM Burns Management BM002 Scald burns BM002A 7350 8085 8820 9555 10290 10657 Photograph with due consent of patient etc.) c) X ray
10% in children younger than 12 years. Dressing
d) Document showing % of burn through rule of 9 d) Discharge Summary e)
without anesthesia
Procedure/ operative notes
(TBSA): Upto 25%; Includes % TBSA skin copy with number c) Clinical b) Blood test (CBC, Sr. creatinine, Platelet
grafted, flap cover, follow-up dressings etc. as Photograph with due consent of patient etc.) c) X ray
15 Burns Management BM Burns Management BM002 Scald burns BM002B 52500 57750 63000 68250 73500 76125
deemed necessary; Surgical procedures are d) Document showing % of burn through rule of 9 d) Discharge Summary e)
required for deep burns that are not amenable to Procedure/ operative notes
(TBSA):40- 60 %; Includes % TBSA skin grafted, copy with number c) Clinical b) Blood test (CBC, Sr. creatinine, Platelet
16 Burns Management BM Burns Management BM002 Scald burns BM002D 105000 115500 126000 136500 147000 152250
dressings alone.
(TBSA):60-80 %; Includes % TBSA skin grafted, copy with number c) Clinical b) Blood test (CBC, Sr. creatinine, Platelet
17 Burns Management BM Burns Management BM002 Scald burns BM002E 105000 115500 126000 136500 147000 152250
dressings alone.
(TBSA): 25-40 %; Includes % TBSA skin grafted, copy with number c) Clinical b) Blood test (CBC, Sr. creatinine, Platelet
18 Burns Management BM Burns Management BM001 Thermal burns BM001C 65625 72187 78750 85312 91875 95156
dressings alone.
a) Clinical notes b) MLC a) Post treatment clinical photograph
Criteria 1: % Total Body Surface Area Burns
copy with number c) Clinical b) Blood test (CBC, Sr. creatinine, Platelet
(TBSA):less than 20% in adults and less than
19 Burns Management BM Burns Management BM001 Thermal burns BM001A 7350 8085 8820 9555 10290 10657 Photograph with due consent of patient etc.) c) X ray
10% in children younger than 12 years. Dressing
d) Document showing % of burn through rule of 9 d) Discharge Summary e)
without anesthesia
Procedure/ operative notes
(TBSA): Upto 25%; Includes % TBSA skin copy with number c) Clinical b) Blood test (CBC, Sr. creatinine, Platelet
grafted, flap cover, follow-up dressings etc. as Photograph with due consent of patient etc.) c) X ray
20 Burns Management BM Burns Management BM001 Thermal burns BM001B 52500 57750 63000 68250 73500 76125
deemed necessary; Surgical procedures are d) Document showing % of burn through rule of 9 d) Discharge Summary e)
required for deep burns that are not amenable to Procedure/ operative notes
(TBSA):40- 60 %; Includes % TBSA skin grafted, copy with number c) Clinical b) Blood test (CBC, Sr. creatinine, Platelet
21 Burns Management BM Burns Management BM001 Thermal burns BM001D 105000 115500 126000 136500 147000 152250
dressings alone.
(TBSA):60-80 %; Includes % TBSA skin grafted, copy with number c) Clinical b) Blood test (CBC, Sr. creatinine, Platelet
22 Burns Management BM Burns Management BM001 Thermal burns BM001E 105000 115500 126000 136500 147000 152250
dressings alone.
1. CLINICAL NOTES 2. INDICATIONS A)X Ray showing the pacemaker in situ.
3. DETAILED ECG WORK UP 4. B) GST Invoice .
CAG REPORT IF DONE. 5. C) Barcode of designated pacemaker.
ECHO REPORT WITH STILLS. 6. D)Detailed Procedure .
23 Cardiology MC Cardiology MC023 AICD IMPLANTATION MC023B AICD implantation Dual Chamber 36000 39600 43200 46800 50400 52200 CBC & SERUM ELECTROLTES REPORT E) Operative Notes.
F)detailed discharge summary.
G) CLINICAL PHOTOGRAPH OF PATIENT
POST PROCEDURE H)
ECG POST PROCEDURE
24 Cardiology MC Cardiology MC023 AICD IMPLANTATION MC023A AICD implantation Single Chamber 25875 28462 31050 33637 36225 37518 CBC & SERUM ELECTROLTES REPORT E) Operative Notes.
POST PROCEDURE H)
ECG POST PROCEDURE
a)Clinical notes b)Echo/Doppler report a)Procedure / Operative notes b) Post
procedure stills of ECHO with report
25 Cardiology MC Cardiology MC007 ASD Device Closure MC007A ASD Device Closure 75000 82500 90000 97500 105000 108750
c) Detailed Discharge Summary
d) Invoice/ barcode of blade / device used
a) Clinical notes with planned line of treatment a) Procedure / Operative notes b) Post
b) Echo report/ Doppler report with stills procedure stills of ECHO with report
26 Cardiology MC Cardiology MC006 Balloon Atrial Septostomy MC006A Balloon Atrial Septostomy 32025 35227 38430 41632 44835 46436
d) Invoice of blade/balloon used
a) Clinical notes b) a) Procedure/ Operation notes b) Post
Echo/Doppler report and Stills Procedure Echo/Angiogram with report c)
27 Cardiology MC Cardiology MC003 Balloon Dilatation MC003A Coarctation of Aorta 50715 55786 60858 65929 71001 73536
Detailed discharge summary d) Barcode of
the balloon/implant, If used
a) Clinical notes b) Echo- a) Procedure/ Operation notes b) Post
Doppler report and Stills c) Angiogram Report and Procedure Echo/Angiogram with reports and
28 Cardiology MC Cardiology MC003 Balloon Dilatation MC003B Pulmonary Artery Stenosis 50715 55786 60858 65929 71001 73536 Stills stills c) Detailed
discharge summary d) Barcode of the
balloon, If used
a) Clinical notes with planned line of treatment a) Procedure / Operative notes
b) Detailed Echo /Doppler report b) Post procedure stills of ECHO with report
29 Cardiology MC Cardiology MC005 Balloon Mitral Valvotomy MC005A Balloon Mitral Valvotomy 60000 66000 72000 78000 84000 87000 c) Detailed Discharge Summary
d) Invoice/ barcode of balloon used
Outside State
Bed Cost Cost
Cost
a) Clinical notes with planned line of treatment a) Procedure / Operative notes with
b) Detailed Echo report indication of procedure b) Post procedure
30 Cardiology MC Cardiology MC004 Balloon Pulmonary / Aortic Valvotomy MC004B Balloon Aortic Valvotomy 30765 33841 36918 39994 43071 44609 stills of ECHO with report c)
Detailed Discharge Summary
d) Invoice of balloon used
a) Clinical notes with planned line of treatment a) Procedure / Operative notes b) Post
b) Detailed Echo report procedure stills of ECHO with report
31 Cardiology MC Cardiology MC004 Balloon Pulmonary / Aortic Valvotomy MC004A Balloon Pulmonary Valvotomy 60000 66000 72000 78000 84000 87000
d) Invoice of balloon used
a) Clinical notes with planned line of treatment a) Procedure / Operative notes b) Check
Bronchial artery Embolisation Bronchial artery Embolisation b) Chest X ray c) HRCT angiography of same bronchial artery after
32 Cardiology MC Cardiology MC018 MC018A 43050 47355 51660 55965 60270 62422
(for Haemoptysis) (for Haemoptysis) Chest/ CTPA procedure c) Detailed
Discharge Summary
33 Cardiology MC Cardiology MC024 Combo device implantation MC024A Combo device implantation 40000 44000 48000 52000 56000 58000 CBC & SERUM ELECTROLTES REPORT E) Operative Notes.
POST PROCEDURE H)
ECG POST PROCEDURE
1) CLINICAL NOTES 2) ECG 1. PROCEDURAL NOTES.
3) TROP - T TEST 4) INDICATIONS 2) ANGIOGRAM REPORT
34 Cardiology MC Cardiology MC025 Coronary Angiography MC025A Coronary Angiography 8000 8800 9600 10400 11200 11600
3) ANGIOGRAM STILLS WITH NAME,
DATE & TIME
a) Clinical notes b) ECG a) Procedure / Operative notes b) EP study
with report of cardiologist report c) Detailed Discharge
35 Cardiology MC Cardiology MC012 Electrophysiological Study MC012A Electrophysiological Study 36435 40078 43722 47365 51009 52830
c) Echo/ colour doppler report with stills Summary d) Invoice/ Bar
d) Indication for procedure code of catheters
a) Clinical notes b) ECG a) Procedure / Operative notes b) EP study
Electrophysiological Study with report of cardiologist report c) Detailed Discharge
36 Cardiology MC Cardiology MC012 Electrophysiological Study MC012B 36435 40078 43722 47365 51009 52830
with Radio Frequency Ablation c) Echo/ colour doppler report with stills Summary d) Invoice/ Bar
d) Indication for procedure code of catheters
A) CLINICAL NOTES B) ECG C) A) DISCHARGE SUMMARY B)
ECHO D) PREVIOUS DISCHARGE DETAIL RELEVANT DOCUMENTS C)
CERTIFICATE IF ANY. E) PROCEDURE DETAILED NOTE. D) OT
37 Cardiology MC Cardiology MC021 Embolization MC021A Arteriovenous Malformation (AVM) in the Limbs 53340 58674 64008 69342 74676 77343 PHOTOGRAPH OF PATIENT TAKING NOTE E) PHOTOGRAPH OF PATIENT
TREATMENT F) ALL INVESTIGATIONS IN TAKING TREATMENT F) GST INVOICE OF
SUPPORT OF DIAGNOSIS SUPPLIER FOR IMPLANTS/DRUGS USED
IF ANY.
A) OPD PRESCRIPTION WITH CLINICAL A) OPD PRESCRIPTION WITH CLINICAL
NOTES INDICATING FOLLOW-UP. NOTES INDICATING FOLLOW-UP.
B) PAST HISTORY OF PATIENT C) B) PAST HISTORY OF PATIENT
INVESTIGATIONS ADV. BY TREATING DOCTOR C) INVESTIGATIONS BY TREATING
38 Cardiology MC Cardiology MC022 follow up -Cardiology MC022E FifthFollow-up - After 3 months 2310 2541 2772 3003 3234 3349 D) PREVIOUS DISCHARGE CERTIFICATE. DOCTOR D) PHOTOGRAPH OF
E) PHOTOGRAPH OF PATIENT TAKING PATIENT TREATED E) COMPLETE
TREATMENT DISCHARGE SUMMARY. F)
OUTCOME

39 Cardiology MC Cardiology MC022 follow up -Cardiology MC022D fourth Follow-up- After 3 months 2310 2541 2772 3003 3234 3349 D) PREVIOUS DISCHARGE CERTIFICATE. DOCTOR D) PHOTOGRAPH OF
OUTCOME

40 Cardiology MC Cardiology MC022 follow up -Cardiology MC022B Second Follow-up- After 3 months 4620 5082 5544 6006 6468 6699 D) PREVIOUS DISCHARGE CERTIFICATE. DOCTOR D) PHOTOGRAPH OF
OUTCOME

41 Cardiology MC Cardiology MC022 follow up -Cardiology MC022C Third Follow-up- After 3 months 2310 2541 2772 3003 3234 3349 D) PREVIOUS DISCHARGE CERTIFICATE. DOCTOR D) PHOTOGRAPH OF
OUTCOME
a) Clinical notes b) Detailed a) Procedure / Operative notes b) Post

Echo/ Doppler report Procedure Echo/Doppler c)
42 Cardiology MC Cardiology MC009 PDA Device Closure MC009A PDA Device Closure 42840 47124 51408 55692 59976 62118
a) Clinical notes a) Procedure / Operative notes
b) Echo report or Angiography Report b) Per-procedure or Post procedure stills of
angio or ECHO showing stent in place, with
43 Cardiology MC Cardiology MC010 PDA stenting MC010A PDA stenting 52920 58212 63504 68796 74088 76734 report
d) Invoice of stent used
e) Barcode of stent used
a) Clinical notes b) ECG a) Procedure / Operative notes b) Post
Percutaneous Transluminal Septal Percutaneous Transluminal Septal Myocardial with report of cardiologist procedure echo/colour Doppler report and
44 Cardiology MC Cardiology MC013 MC013A 44625 49087 53550 58012 62475 64706
Myocardial Ablation Ablation c) Echo/ color Doppler report with stills angio stills c) Detailed Discharge Summary
a) Clinical notes b) Doppler a) Procedure / Operative notes b) Post

ultrasound/ Digital subtraction angiography/ procedure stills of Angio with report
Computed tomography angiography/ magnetic c) Detailed Discharge Summary
45 Cardiology MC Cardiology MC017 Peripheral Angioplasty MC017A Peripheral Angioplasty 45360 49896 54432 58968 63504 65772
resonance angiography report with stills d) Invoice/ Barcode of stent used
c) Angiogram Report with stills
Outside State
Bed Cost Cost
Cost
a) Clinical notes b) Patient a) Still image of the patient undergoing the
Photograph c) Investigation procedure with date & time
reports b) Angiogram stills & report showing stent &
i. Electrocardiogram (ECG) post stent flow c) Serial ECGs (Post
ii. 2D ECHO Procedure) d) Cardiac
iii. Coronary Angiography stills & reports (showing enzymes (Troponins T/ I (if not available then
46 Cardiology MC Cardiology MC011 PTCA, inclusive of diagnostic angiogram MC011A PTCA, inclusive of diagnostic angiogram 92000 101200 110400 119600 128800 133400 blockage) CPK-MB) e)
iv. Cardiac enzymes (Troponins T/ I (if not available Procedure/ Operation notes
then CPK-MB) f) Detailed discharge summary
v. Routine Biochemistry (Haemogram, urea, g) Barcode of the stent(s) used (Bare metal/
creatinine, electrolytes, sugar, fasting lipids, Liver Drug eluting stent)
function test, Urinalysis)
a) Clinical Notes with planned line of treatment and a) Procedure/ Operation notes b)Detailed
47 Cardiology MC Cardiology MC001 Right / Left Heart Catheterization MC001B Left Heart Catheterization 13125 14437 15750 17062 18375 19031 indication for procedure b) discharge summary c) Invoices of catheter
ECG and other accessories used
a) Clinical Notes with planned line of treatment and a) Procedure/ Operation notes b)Detailed
indication for procedure b) discharge summary c) Invoices of catheter
48 Cardiology MC Cardiology MC001 Right / Left Heart Catheterization MC001A Right Heart Catheterization 13125 14437 15750 17062 18375 19031
ECG c) Echo and other accessories used
report with stills
A) CLINICAL NOTES B) ECG C) A) DISCHARGE SUMMARY B)
ECHO D) PREVIOUS DISCHARGE DETAIL RELEVANT DOCUMENTS C)
CERTIFICATE IF ANY. E) PROCEDURE DETAILED NOTE. D) OT
49 Cardiology MC Cardiology MC020 Systemic Thrombolysis (for MI) MC020A Systemic Thrombolysis (for MI) 23520 25872 28224 30576 32928 34104 PHOTOGRAPH OF PATIENT TAKING NOTE E) PHOTOGRAPH OF PATIENT
TREATMENT F) ALL INVESTIGATIONS IN TAKING TREATMENT F) GST INVOICE OF
SUPPORT OF DIAGNOSIS SUPPLIER FOR IMPLANTS/DRUGS USED
IF ANY.
a) Clinical notes b) a) Procedure / Operative notes b) Post
Echo/Doppler report procedure stills of ECHO with report
50 Cardiology MC Cardiology MC008 VSD Device Closure MC008A VSD Device Closure 75000 82500 90000 97500 105000 108750
a) Clinical notes b) Echo/ a) Procedure / Operative notes b) Post
Cardiology, color Doppler report with stills procedure echo/colour Doppler report
51 Cardiology MC MC019 Pericardiocentesis MC019A Pericardiocentesis 15960 17556 19152 20748 22344 23142
General Surgery c) Detailed Discharge Summary
d) Analysis of fluid removed
A)Clinical notes. A)X Ray showing the pacemaker in situ.
B) ECG. B) Invoice .
Permanent Pacemaker Implantation -
Double Chamber Permanent Pacemaker C) Report by cardiologist necessitating procedure. C) Barcode of designated pacemaker.
52 Cardiology MC Cardiology, CTVS MC016 MC016A Double Chamber (With Temporary pacemaker 43365 47701 52038 56374 60711 62879
Implantation D) Angiogram if done D)Detailed Procedure .
implantation)
E) Operative Notes.
F)detailed discharge summary
a) Clinical notes with indication for implantation a) Procedure / Operative notes b) X Ray
Permanent Pacemaker Implantation - b) ECG with report of cardiologist showing pacemaker in situ
Single Chamber Permanent Pacemaker
53 Cardiology MC Cardiology, CTVS MC015 MC015A Single Chamber (With Temporary pacemaker 32235 35458 38682 41905 45129 46740 c) Angiogram report, if done c) Detailed Discharge Summary
Implantation
implantation) d) Invoice/barcode of designated pacemaker
a) Clinical notes b) ECG a) Indoor case papers b)

with report of cardiologist Procedure / Operative notes with indication
c) ECG paced rhythm strip/ still frame of lead
in situ d) Detailed Discharge
54 Cardiology MC Cardiology, CTVS MC014 Temporary Pacemaker implantation MC014A Temporary Pacemaker implantation 25200 27720 30240 32760 35280 36540
Summary e) Invoice
& barcode of designated pacemaker pacing
lead
a) Clinical Notes with planned line of treatment a) Procedure/ Operation notes b) Post
b) Colour Doppler/ CT angio Report procedure Colour Doppler/ angio report of
Cardiology, Interventional affected limb c) Detailed
55 Cardiology MC MC002 Catheter directed Thrombolysis MC002A For Deep vein thrombosis (DVT) 40425 44467 48510 52552 56595 58616
Radiology discharge summary d) Invoices of catheter
used e) Invoice of thrombolytic drug
(tPA) used
b) Doppler Report/CT angiogram report procedure colour doppler/ CT Angiogram of
Cardiology, Interventional affected vessel c) Detailed
56 Cardiology MC MC002 Catheter directed Thrombolysis MC002B For Mesenteric Thrombosis 40425 44467 48510 52552 56595 58616
used e) Invoice of thrombolytic drug
used
b) Doppler Report/ Angiogram report procedure colour doppler/Angio report of
Cardiology, Interventional affected limb c) Detailed
57 Cardiology MC MC002 Catheter directed Thrombolysis MC002C For Peripheral vessels 40425 44467 48510 52552 56595 58616
used e) Invoice of thrombolytic drug used
a) Clinical notes with history, symptoms, a) Detailed Indoor case papers (ICPs)
58 COVID-19 CO COVID-19 CO001 Covid CO001A Covid Treatment - General Bed 1750 1925 2100 2275 2450 2537 evaluation findings, indication for procedure, b) All investigation reports c) Detailed
planned line of management Discharge Summary
59 COVID-19 CO COVID-19 CO001 Covid CO001B Covid Treatment - ICU 12000 13200 14400 15600 16800 17400 evaluation findings, indication for procedure, b) All investigation reports c) Detailed
60 COVID-19 CO COVID-19 CO001 Covid CO001C Covid Treatment - ICU with Ventilator 13000 14300 15600 16900 18200 18850 evaluation findings, indication for procedure, b) All investigation reports c) Detailed
61 COVID-19 CO COVID-19 CO002 Covid Test CO002B ANTIGEN Test 100 100 100 100 100 100 evaluation findings, indication for procedure, b) All investigation reports c) Detailed
62 COVID-19 CO COVID-19 CO002 Covid Test CO002A RTPCR Test 450 450 450 450 450 450 evaluation findings, indication for procedure, b) All investigation reports c) Detailed
a) Clinical notes including evaluation findings, a) Detailed Indoor case papers
indication of graft requirement, and planned line of b) Detailed Procedure / Operative notes
management c) Graft details - barcode/invoice (if artificial
Aortic Aneurysm Repair using Cardiopulmonary b) Electrocardiogram (ECG) c) Chest X- graft used)
63 CTVS SV CTVS SV016 Aortic Aneurysm Repair SV016A 173250 190575 207900 225225 242550 251212
bypass (CPB) ray d) Post-op investigations
d) 2D ECHO - Chest X-ray / USG Chest/Abdomen
e) CT/MRI e) Detailed Discharge Summary
Outside State
Bed Cost Cost
Cost
64 CTVS SV CTVS SV016 Aortic Aneurysm Repair SV016B Aortic Aneurysm Repair using Left Heart Bypass 173250 190575 207900 225225 242550 251212 b) Electrocardiogram (ECG) c) Chest X- graft used)
ray d) Post-op investigations
Aortic Aneurysm Repair without using b) Electrocardiogram (ECG) c) Chest X- graft used)
65 CTVS SV CTVS SV016 Aortic Aneurysm Repair SV016C 94600 104060 113520 122980 132440 137170
Cardiopulmonary bypass (CPB) ray d) Post-op investigations
Aortic Aneurysm Repair without using Left Heart b) Electrocardiogram (ECG) c) Chest X- graft used)
66 CTVS SV CTVS SV016 Aortic Aneurysm Repair SV016D 94600 104060 113520 122980 132440 137170
Bypass ray d) Post-op investigations
Aortic Arch Replacement / management c) Intraoperative neurologic monitoring if
Aortic Arch Replacement using cardiopulmonary b) CXR Chest applicable
67 CTVS SV CTVS SV015 Thoracoabdominal aneurysm Repair using SV015A 216615 238276 259938 281599 303261 314091
bypass c) ECG (Electrocardiogram) d) Graft details - barcode/invoice (if artificial
bypass
d) 2DECHO graft used) e) Detailed
e) CT/MRI Discharge Summary
management c) Clinical Evaluation of the brain function
b) Chest Xray during the procedure (Intra-operative
Aortic Arch Replacement / c) Electrocardiogram (ECG) monitoring documentation) d) Post-
Thoracoabdominal aneurysm Repair using partial
68 CTVS SV CTVS SV015 Thoracoabdominal aneurysm Repair using SV015B 216615 238276 259938 281599 303261 314091 d) 2D ECHO op investigations
cardiopulmonary bypass
bypass e) Transthoracic Echocardiogram - Chest X-ray/2DECHO
f) CT/MRI/ Angiography - CT scan (optional) e)
g) Lung function test Detailed Discharge Summary
h) Serum Urea and creatinine
indication of implant/graft requirement, and b) Detailed Procedure / Operative notes
planned line of management c) Post procedure stills of ECHO with report
69 CTVS SV CTVS SV014 Aortic Root Replacement Surgery SV014C Aortic Aneurysm ( Root Ascending ) 216615 238276 259938 281599 303261 314091 b) Chest Xray d) Implant/Graft (if artificial graft is used)
c) Echo/Doppler report details - barcode/invoice
d) CT/MRI/ Angiogram e) Detailed Discharge Summary

70 CTVS SV CTVS SV014 Aortic Root Replacement Surgery SV014B Aortic Dissection 216615 238276 259938 281599 303261 314091 b) Chest Xray d) Implant/Graft (if artificial graft is used)

71 CTVS SV CTVS SV014 Aortic Root Replacement Surgery SV014E AVR + Root enlargement 216615 238276 259938 281599 303261 314091 b) Chest Xray d) Implant/Graft (if artificial graft is used)

72 CTVS SV CTVS SV014 Aortic Root Replacement Surgery SV014A Bental Procedure 216615 238276 259938 281599 303261 314091 b) Chest Xray d) Implant/Graft (if artificial graft is used)

73 CTVS SV CTVS SV014 Aortic Root Replacement Surgery SV014D Valve sparing root replacement 216615 238276 259938 281599 303261 314091 b) Chest Xray d) Implant/Graft (if artificial graft is used)
a) Clinical notes with history, signs, symptoms, A) Detailed Indoor case papers (ICPs)
evaluation findings, indication for procedure, B) Detailed Operation & Anaesthesia notes.
planned line of management b) Magnetic C) Detailed discharge summary.
resonance Angiogram (MRA) c) Angiogram / CT D) Intra OP and Post OP photographs of
74 CTVS SV CTVS SV040 Aortic stenting SV040A Aortic stenting 65625 72187 78750 85312 91875 95156
Angiogram, ECHO , ECG patient
d) Pre-OP clinical photograph of patient

Aorto Iliac / Aorto femoral bypass (Uni and management c) Post-operative Duplex Ultrasound
75 CTVS SV CTVS SV017 SV017D Aorto femoral bypass - B/L 93135 102448 111762 121075 130389 135045
Bi) b) Duplex ultrasonography d) Graft details - barcode/invoice (if artificial
c) Ankle-brachial index (ABI) test graft used)
d) MR/CT Angiography e) Detailed Discharge Summary
76 CTVS SV CTVS SV017 SV017B Aorto femoral bypass - U/L 93135 102448 111762 121075 130389 135045
Outside State
Bed Cost Cost
Cost
77 CTVS SV CTVS SV017 SV017C Aorto Iliac bypass - B/L 93135 102448 111762 121075 130389 135045
78 CTVS SV CTVS SV017 SV017A Aorto Iliac bypass - U/L 93135 102448 111762 121075 130389 135045
a) Clinical notes A) Detailed Indoor case papers (ICPs)
b) Investigation reports B) Detailed Operation & Anaesthesia notes.
c) Electrocardiogram (ECG) C) Detailed discharge summary.
d) Chest X-ray D) Intra OP and Post OP photographs of
e) 2D ECHO patient
f) Coronary Angiography stills & reports (showing E) Post OP ECHO
blockage)
79 CTVS SV CTVS SV038 CABG + Left ventricular aneurysm repair SV038A CABG + Left ventricular aneurysm repair 236145 259759 283374 306988 330603 342410 g) Cardiac enzymes (Troponins T/ I (if not
available then CPK-MB)
h) Routine Biochemistry (Haemogram, urea,
creatinine, electrolytes, sugar, fasting lipids, Liver
i) Patient Photograph
a) Clinical notes with planned line of treatment a) Procedure / Operative notes

b) Detailed Echo /Doppler report b) Post procedure stills of ECHO with report
Closed Mitral Valvotomy including
80 CTVS SV CTVS SV008 SV008A Closed mitral valvotomy 82320 90552 98784 107016 115248 119364 c) Detailed Discharge Summary
thoracotomy

Photograph c) Investigation procedure with date & time (With pic of the
reports site of incision post procedure) b) 2D ECHO
i. Electrocardiogram (ECG) (post procedure) c) Cardiac enzymes
ii. Chest X-ray (Troponins T/ I (if not available then CPK-MB)
Coronary artery bypass grafting (CABG), iii. 2D ECHO d) Procedure/ Operation notes e) Detailed
Coronary artery bypass grafting (CABG), with or iv. Coronary Angiography stills & reports (showing discharge summary f) Post op Chest X-ray
81 CTVS SV CTVS SV004 including intra operative balloon pump (if SV004A 175000 192500 210000 227500 245000 253750
without intraoperative IABP) blockage) showing sternal sutures
required)
v. Cardiac enzymes (Troponins T/ I (if not available
then CPK-MB)
vi. Routine Biochemistry (Haemogram, urea,
creatinine, electrolytes, sugar, fasting lipids, Liver
indication of implant requirement (if applicable), b) Detailed operative / procedure notes
and planned line of management c) Post-op Xray Chest/Abdomen report
82 CTVS SV CTVS SV029 Diaphragmatic Repair SV029A Diaphragmatic Repair 43365 47701 52038 56374 60711 62879 b) Chest X ray AP/ Lateral d) Implant details (invoice/barcode) if
c) USG/ CECT Abdomen/Thorax applicable
e) FIR documentation (in case of trauma)
f) Detailed discharge summary
83 CTVS SV CTVS SV006 Double Valve Procedure SV006A Double valve replacement / repair 205065 225571 246078 266584 287091 297344
d) Barcode of implant, if used
a) Clinical notes including previous surgery details, a) Detailed Indoor case papers
evaluation findings, and planned line of b) Detailed Procedure / Operative notes
84 CTVS SV CTVS SV034 Excessive bleeding requiring re-exploration SV034A Excessive bleeding requiring re-exploration 14490 15939 17388 18837 20286 21010
management c) Blood transfusion notes (if applicable)
b) Chest X-ray d) Detailed Discharge Summary
evaluation findings, indication for procedure,CT B) Detailed Operation & Anaesthesia notes.
Scan report , Cardiac Doppler C) Detailed discharge summary.
85 CTVS SV CTVS SV041 follow up -CTVS SV041E FifthFollow-up - After 3 months 2310 2541 2772 3003 3234 3349
b) Pre-OP clinical photograph of patient D) Intra OP and Post OP photographs of
patient
86 CTVS SV CTVS SV041 follow up -CTVS SV041D fourth Follow-up- After 3 months 2310 2541 2772 3003 3234 3349
patient
87 CTVS SV CTVS SV041 follow up -CTVS SV041B Second Follow-up- After 3 months 4620 5082 5544 6006 6468 6699
patient
88 CTVS SV CTVS SV041 follow up -CTVS SV041C Third Follow-up- After 3 months 2310 2541 2772 3003 3234 3349
patient

indication b) Detailed Procedure / Operative notes
89 CTVS SV CTVS SV025 Foreign Body Removal with scope SV025A Foreign Body Removal with scope 28875 31762 34650 37537 40425 41868 for procedure, and planned line of management c) Post procedure Chest X-ray report
b) Chest X-ray report d) Photograph of removed foreign body
e) Detailed discharge Summary
a) Clinical notes b) Clinical a) Procedure / Operative notes b) Post
notes indicating need for reoperation procedure stills of ECHO with report
90 CTVS SV CTVS SV031 Immediate reoperation (within 5 days) SV031B Aortic valve replacement /repair 205900 226490 247080 267670 288260 298555
c) Echo/Doppler report c) Detailed Discharge Summary
Outside State
Bed Cost Cost
Cost
Echo/Doppler report c) Clinical procedure stills of ECHO with report
91 CTVS SV CTVS SV031 Immediate reoperation (within 5 days) SV031E Double valve replacement /repair 102585 112843 123102 133360 143619 148748
notes indicating need for reoperation c) Detailed Discharge Summary
92 CTVS SV CTVS SV031 Immediate reoperation (within 5 days) SV031C Mitral valve replacement /repair 205900 226490 247080 267670 288260 298555
a) Clinical notes b) a) Indoor case papers b)
Echo/Doppler report Procedure / Operative notes c) Post
Tetralogy of Fallot Repair (immediate re procedure stills of ECHO with report
93 CTVS SV CTVS SV031 Immediate reoperation (within 5 days) SV031A 108360 119196 130032 140868 151704 157122
operation) d) Detailed Discharge Summary
e) Detailed Operative notes indicating need
for Reoperation
94 CTVS SV CTVS SV031 Immediate reoperation (within 5 days) SV031D Tricuspid valve replacement /repair 205900 226490 247080 267670 288260 298555
Clinical notes indicating need for reoperation procedure stills of ECHO with report
95 CTVS SV CTVS SV031 Immediate reoperation (within 5 days) SV031F Triple valve replacement /repair 122745 135019 147294 159568 171843 177980
a) Clinical notes with evaluation findings, indication a) Detailed Indoor case papers
of procedure and planned line of management b) Detailed Procedure / Operative notes
Isolated Intercostal Drainage and Isolated Intercostal Drainage and Management
b) Documentation of intercostal block, antibiotics, c) Post procedure Chest X-ray with reports
96 CTVS SV CTVS SV028 Management of ICD, Intercostal Block, SV028A of ICD, Intercostal Block, Antibiotics & 14490 15939 17388 18837 20286 21010
and physiotherapy as applicable d) Detailed Discharge Summary
Antibiotics & Physiotherapy Physiotherapy
c) Chest X-Ray PA
planned line of management C) Detailed discharge summary.
b) Angiogram / CT Angiogram / Doppler D) Intra OP and Post OP photographs of
97 CTVS SV CTVS SV037 Left ventricular aneurysm repair SV037A Left ventricular aneurysm repair 170520 187572 204624 221676 238728 247254 ultrasound /Magnetic patient
resonance angiography (MRA) reports
c)Echo,Ecg, CT Scan of Heart

Photograph c) Investigation procedure with date & time b) 2D ECHO
reports (post procedure) c) Procedure/ Operation
i. Electrocardiogram (ECG) notes d) Detailed discharge summary e)
Low Cardiac Output syndrome requiring Low Cardiac Output syndrome requiring IABP ii. Chest X-ray Barcode of IABP used f) Post op Chest X-ray
98 CTVS SV CTVS SV032 SV032A 72240 79464 86688 93912 101136 104748
IABP insertion post - operatively insertion post - operatively iii. 2D ECHO showing sternal sutures g) Clinical notes /
Indoor case papers
h) showing poor hemodynamics and high
usage of inotropic agents
a) Clinical notes with history, symptoms, A) Detailed Indoor case papers (ICPs)
planned line of management , b) CT, C) Detailed discharge summary.
X-RAY Chest, ECHO,BRONCOSCOPY D) Photograph of Removed Foreign body
c) Pre-OP clinical photograph of patient E) Intra OP and Post OP photographs of
99 CTVS SV CTVS SV023 Lung surgery including Thoracotomy SV023E Bronchial Repair Surgery for Injuries due to FB 64995 71494 77994 84493 90993 94242 patient
A)Clinical notes. A)Detailed Operation notes.

100 CTVS SV CTVS SV023 Lung surgery including Thoracotomy SV023B Decortication 64995 71494 77994 84493 90993 94242 B) CT Chest B) Discharge summary

indication b) Detailed Procedure operative notes
for procedure, and planned line of management c) Intra operative or specimen Photographs.
b) CT/MRI Chest D) Histopathological
101 CTVS SV CTVS SV023 Lung surgery including Thoracotomy SV023C Hydatid cyst 64995 71494 77994 84493 90993 94242 examination
e) Postoperative
Chest X ray or CT

indication for procedure, and planned line of b) Detailed Procedureoperative notes
102 CTVS SV CTVS SV023 Lung surgery including Thoracotomy SV023A Lung cyst exision 64995 71494 77994 84493 90993 94242 management b) HRCT c) Histopathological
Chest examination
d) Detailed discharge summary
Other simple lung procedure excluding lung
103 CTVS SV CTVS SV023 Lung surgery including Thoracotomy SV023D 64995 71494 77994 84493 90993 94242 B) CT Chest B) Discharge summary
resection
a) Clinical notes with planned line of treatment and A)Detailed Operation / Procedure notes
CT Thorax. & Anaesthesia notes.
b) Biopsy c) X- B) Detailed Indoor case papers (ICPs)
Ray Chest , ECG / ECHO d) Pre- C) Post Procedure Photographs of surgical
OP clinical photograph of patient site.
D) HPE report.
104 CTVS SV CTVS SV035 Mediastinotomy SV035A Mediastinotomy 41580 45738 49896 54054 58212 60291 E) Detailed Discharge Summary
F) Intra OP and Post OP photographs of
patient
a) Clinical notes b) Detailed a) Procedure / Operative notes b) Post

Patent Ductus Arteriosus (PDA) Closure via Patent Ductus Arteriosus (PDA) Closure via
105 CTVS SV CTVS SV013 SV013A 82320 90552 98784 107016 115248 119364 Echo/ Doppler report Procedure Echo/Doppler c)
thoracotomy thoracotomy
Outside State
Bed Cost Cost
Cost
planned line of management C) Detailed discharge summary.
b) CT,ECG,ECHO c) D) Intra OP and Post OP photographs of
106 CTVS SV CTVS SV036 Pectus excavation SV036A Pectus excavation 65265 71791 78318 84844 91371 94634 Pre-OP clinical photograph of patient patient

107 CTVS SV CTVS SV011 Pericardial window (via thoracotomy) SV011A Pericardial window (via thoracotomy) 43365 47701 52038 56374 60711 62879 Echo/Doppler report procedure stills of ECHO with report
108 CTVS SV CTVS SV012 Pericardiectomy SV012A Pericardiectomy 96810 106491 116172 125853 135534 140374 Echo/Doppler report procedure stills of ECHO with report
Peripheral arterial injury repair (without a) Clinical notes a) Procedure / Operative notes
109 CTVS SV CTVS SV021 SV021A Peripheral arterial injury repair (without bypass) 43365 47701 52038 56374 60711 62879
bypass) b) Duplex USG report b) Detailed Discharge Summary
a) Clinical notes with history, signs, symptoms, a) Detailed Indoor case papers b)
evaluation findings, indication for procedure, Procedure / operation notes
planned line of management and advice c) Invoice/barcode of graft used (if artificial
for admission graft used)
110 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019R Aorto - carotid bypass 72240 79464 86688 93912 101136 104748
b) Angiogram / CT Angiogram / Doppler d) Discharge Summary
ultrasound /Magnetic
investigations confirming the diagnosis
a) Clinical notes b) a) Detailed Indoor case papers
Doppler/Angio/ CT Angio/ MRI report b) Procedure / operation notes
111 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019S Aorto - subclavian bypass 72240 79464 86688 93912 101136 104748 c) Invoice/barcode of graft used (if artificial
graft used)
d) Discharge Summary
112 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019G Axillary aneurysm repair 72240 79464 86688 93912 101136 104748 c) Invoice/barcode of graft used (if artificial
graft used)
113 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019L Axillo - Brachial Bypass 72240 79464 86688 93912 101136 104748 c) Invoice/barcode of graft used (if artificial
graft used)
a) Clinical notes with history, signs, symptoms, a) Detailed Indoor case papers
evaluation findings, indication for procedure, b) Procedure / operation notes
114 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019Q Axillo - femoral bypass - B/L 72240 79464 86688 93912 101136 104748 for admission graft used)
b) Angiogram / CT Angiogram / Doppler ultrasound d) Discharge Summary
/MRI reports
115 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019P Axillo - femoral bypass - U/L 72240 79464 86688 93912 101136 104748 for admission graft used)
/MRI reports
116 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019H Brachial artery aneurysm repair 72240 79464 86688 93912 101136 104748 c) Invoice/barcode of graft used (if artificial
graft used)
117 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019B Carotid - endearterectomy 72240 79464 86688 93912 101136 104748
118 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019E Carotid aneurysm repair 72240 79464 86688 93912 101136 104748
119 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019C Carotid Body Tumor Excision 72240 79464 86688 93912 101136 104748
120 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019O Carotido - axillary bypass 72240 79464 86688 93912 101136 104748 c) Invoice/barcode of graft used (if artificial
graft used)
121 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019N Carotido - subclavian artery bypass 72240 79464 86688 93912 101136 104748
Outside State
Bed Cost Cost
Cost
122 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019M Carotio - carotid Bypass 72240 79464 86688 93912 101136 104748
evaluation findings, indication for procedure, B) Detailed procedure/ operative &
planned line of management , Anaesthesia notes C)
b) Duplex ultrasound Barcode of the implant or graft if used
123 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019Z Congenital Arterio Venous Fistula 72240 79464 86688 93912 101136 104748 scan/Angiography/CTAngiography (CTA)/ DSA / (optional)
ECHO c) Pre-OP D) Detailed discharge summary
clinical photograph of patient E) Intra OP and Post OP photographs of
patient
124 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019K Femoral - popliteal Bypass 72240 79464 86688 93912 101136 104748 for admission graft used)
/MRI reports
125 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019I Femoral artery aneurysm repair 72240 79464 86688 93912 101136 104748 for admission graft used)
/MRI reports
126 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019A Femoro - Femoral Bypass 72240 79464 86688 93912 101136 104748
a) Clinical notes with history, signs, symptoms, A) Detailed Operation & Anaesthesia notes.
evaluation findings, indication for procedure, B) Detailed Indoor case papers (ICPs)
planned line of management C) Detailed discharge summary
Medium size arterial aneurysms with synthetic b) Angiogram / CT Angiogram / Doppler D) Intra OP and Post OP photographs of
127 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019V 72240 79464 86688 93912 101136 104748
graft ultrasound / ECG / ECHO c) patient E)
Digital Subtraction Angiography (DSA) Invoice & Barcode of graft used
evaluation findings, indication for procedure, B) Detailed procedure/ operative &
planned line of management , Anaesthesia notes C)
b) Duplex ultrasound Barcode of the implant or graft if used
128 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019Y Operations for Acquired Arteriovenous Fistual 72240 79464 86688 93912 101136 104748 scan/Angiography/CTAngiography (CTA)/ DSA (optional)
c) Pre-OP clinical photograph of patient D) Detailed discharge summary
E) Intra OP and Post OP photographs of
patient
planned line of management, C) Detailed discharge summary
129 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019T Patch Graft Angioplasty 72240 79464 86688 93912 101136 104748 b) Angiogram / CT Angiogram / Doppler D) Intra OP and Post OP photographs of
ultrasound / ECG / ECHO c) Digital patient
Subtraction Angiography d) Pre-OP
clinical photograph of patient
130 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019J Popliteal artery aneurysm repair 72240 79464 86688 93912 101136 104748 for admission graft used)
/MRI reports
planned line of management and advice C) Detailed discharge summary
for admission D) Intra OP and Post OP photographs of
131 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019U Small Arterial Aneurysms – Repair 72240 79464 86688 93912 101136 104748
b) Angiogram / CT Angiogram / Doppler patient
ultrasound / ECG /ECHO c)
Digital Subtraction Angiography (DSA)
132 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019F Subclavian aneurysm repair 72240 79464 86688 93912 101136 104748 c) Invoice/barcode of graft used (if artificial
graft used)
133 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019W Surgery for Arterial Aneursysm –Vertebral 72240 79464 86688 93912 101136 104748 b) CT-Angiography, ECG / ECHO and Digital D) Intra OP and Post OP photographs of
Subtraction Angiography (DSA) patient
c) Pre-OP clinical photograph of patient
134 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019X Surgery for Arterial Aneurysm Renal Artery 72240 79464 86688 93912 101136 104748 b) Angiogram / CT Angiogram / Doppler D) Intra OP and Post OP photographs of
ultrasound / ECG / ECHO c) Pre- patient
OP clinical photograph of patient
Outside State
Bed Cost Cost
Cost
135 CTVS SV CTVS SV019 Peripheral Arterial Surgeries SV019D Thoracic Outlet syndrome Repair 72240 79464 86688 93912 101136 104748 c) Invoice/barcode of graft used (if artificial
graft used)
Pulmonary Embolectomy / Echo/Doppler report c) CTPA report procedure stills of ECHO with report
136 CTVS SV CTVS SV018 SV018B Pulmanary Thromboendarterectomy 203595 223954 244314 264673 285033 295212
Thromboendarterectomy d) Lung perfusion scan c) Lung perfusion report d)
Pulmonary Embolectomy /
137 CTVS SV CTVS SV018 SV018A Pulmonary Embolectomy 203595 223954 244314 264673 285033 295212 Echo/Doppler report c) CT procedure stills of ECHO with report
Thromboendarterectomy
Angiography report c) Detailed Discharge Summary
of procedure, and planned line of management b) Detailed Procedure / Operative notes
b) Chest X-Ray / CT c) Post procedure serial Chest X-ray until
138 CTVS SV CTVS SV024 Pulmonary Resection SV024A Pulmonary Resection 101115 111226 121338 131449 141561 146616
chest tube removal
d) Histopathological examination
e) Detailed Discharge Summary
previous surgery details, and planned line of b) Detailed Procedure / Operative notes
139 CTVS SV CTVS SV033 Re-do sternotomy SV033A Re-do sternotomy 28875 31762 34650 37537 40425 41868
management c) Post-op Chest Xray / ECHO
b) CT/MRI Chest / 2DECHO d) Detailed Discharge Summary
a) Clinical notes b) Echo/ a) Indoor case papers b)
color Doppler report with stills Procedure / Operative notes c) Post
140 CTVS SV CTVS SV009 Ross Procedure SV009A Ross Procedure 216615 238276 259938 281599 303261 314091
procedure echo/colour Doppler report
d) Detailed Discharge Summary
141 CTVS SV CTVS SV005 Single Valve Procedure SV005A Aortic valve replacement 171885 189073 206262 223450 240639 249233
142 CTVS SV CTVS SV005 Single Valve Procedure SV005B Mitral valve replacement / Mitral valve repair 171885 189073 206262 223450 240639 249233
Tricuspid valve replacement / Tricuspid valve Echo/Doppler report procedure stills of ECHO with report
143 CTVS SV CTVS SV005 Single Valve Procedure SV005C 171885 189073 206262 223450 240639 249233
repair c) Detailed Discharge Summary
A)Clinical notes. A)Detailed discharge summary.
Space - Occupying Lesion (SOL) B) CT Chest B) Detailed Operation notes.
144 CTVS SV CTVS SV027 SV027A Space - Occupying Lesion (SOL) mediastinum 94600 104060 113520 122980 132440 137170
mediastinum C) HPE of SOL

B) ECHO report B) Discharge summary.
145 CTVS SV CTVS SV030 Surgery for Cardiac Tumour SV030A Surgery for Cardiac Tumour 137235 150958 164682 178405 192129 198990
C)HPE report of tumor.
a) Clinical notes b) ECG a) Indoor case papers b)

Surgery for Hypertrophic Obstructive Surgery for Hypertrophic Obstructive with report of cardiologist Procedure / Operative notes c) Post
146 CTVS SV CTVS SV010 SV010A 160335 176368 192402 208435 224469 232485
Cardiomyopathy (HOCM) Cardiomyopathy (HOCM) c) Echo/ color Doppler report with stills procedure echo/colour Doppler report
A)Clinical notes. A)Detailed operative notes .
147 CTVS SV CTVS SV026 Surgical Correction of Bronchopleural Fistula SV026A Surgical Correction of Bronchopleural Fistula 93870 103257 112644 122031 131418 136111 B) CT Chest B) discharge summary
a) Clinical notes b) a) Procedure/ Operation notes b) Post

Surgical Correction of Category - I Echo/Doppler report and Stills Procedure Echo/Angiogram with report c)
148 CTVS SV CTVS SV001 SV001G Coarctation repair 144375 158812 173250 187687 202125 209343
Congenital Heart Disease Detailed discharge summary d) Barcode of
the balloon/implant, If used
A)Clinical notes. A)Detailed discharge summary.
B) ECHO. B) Detailed Operative notes.
Surgical Correction of Category - I
149 CTVS SV CTVS SV001 SV001C Glenn procedure 144375 158812 173250 187687 202125 209343 C) doppler reports C) barcode of Implant,.
Congenital Heart Disease
D)if used.

Surgical Correction of Category - I Isolated Secundum Atrial Septal Defect (ASD) procedure stills of ECHO with report
150 CTVS SV CTVS SV001 SV001B 144375 158812 173250 187687 202125 209343
Congenital Heart Disease Repair c) Detailed Discharge Summary
151 CTVS SV CTVS SV001 SV001D Pulmonary Artery Banding 144375 158812 173250 187687 202125 209343 Echo/Doppler report procedure stills of ECHO with report
152 CTVS SV CTVS SV001 SV001E Systemic - Pulmonary Artery shunt 144375 158812 173250 187687 202125 209343 Echo/Doppler report procedure stills of ECHO with report c)
153 CTVS SV CTVS SV001 SV001A Unifocalization of MAPCA 144375 158812 173250 187687 202125 209343 Echo/Doppler report c) CT Angio/ procedure stills of ECHO with report
Cardiac Catheterization report c) Detailed Discharge Summary
154 CTVS SV CTVS SV001 SV001F Vascular Ring division 144375 158812 173250 187687 202125 209343 Echo/Barium swallow/CT/MRI/ Angiography report procedure stills of ECHO with report
Surgical Correction of Category - II procedure stills of ECHO with report
155 CTVS SV CTVS SV002 SV002E ASD Closure + Infundibular procedure 173250 190575 207900 225225 242550 251212
Congenital Heart Disease c) Detailed Discharge Summary
156 CTVS SV CTVS SV002 SV002B ASD Closure + Mitral procedure 173250 190575 207900 225225 242550 251212
Surgical Correction of Category - II ASD closure + Partial Anomalous Venous
157 CTVS SV CTVS SV002 SV002A 173250 190575 207900 225225 242550 251212 procedure stills of ECHO with report
Congenital Heart Disease Drainage Repair
158 CTVS SV CTVS SV002 SV002D ASD Closure + Pulmonary procedure 173250 190575 207900 225225 242550 251212
159 CTVS SV CTVS SV002 SV002C ASD Closure + Tricuspid procedure 173250 190575 207900 225225 242550 251212
Outside State
Bed Cost Cost
Cost
a) Clinical notes including clinical assessment, a) Detailed Indoor case papers
of procedure, implant requirement, and planned c) Post procedure stills of ECHO with report
Surgical Correction of Category - II line d) Implant details (barcode/invoice)
160 CTVS SV CTVS SV002 SV002K Atrial septectomy + Glenn 173250 190575 207900 225225 242550 251212
Congenital Heart Disease of management e) Detailed Discharge Summary
b) Pulse oximetry documentation
c) Echo/Doppler report
a) Clinical notes including clinical assessment, a) Detailed Indoor case papers
Surgical Correction of Category - II of procedure, implant requirement, and planned c) Post procedure stills of ECHO with report
161 CTVS SV CTVS SV002 SV002L Atrial septectomy + PA Band 173250 190575 207900 225225 242550 251212
Congenital Heart Disease line of management d) Implant details barcode/invoice
b) Pulse oximetry documentation e) Detailed Discharge Summary
c) Echo/Doppler report
Surgical Correction of Category - II
162 CTVS SV CTVS SV002 SV002G Infundibular PS repair 173250 190575 207900 225225 242550 251212 Echo/Doppler report procedure stills of ECHO with report
163 CTVS SV CTVS SV002 SV002J Intermediate AV canal repair 173250 190575 207900 225225 242550 251212 Echo/Doppler report procedure stills of ECHO with report
164 CTVS SV CTVS SV002 SV002I Partial AV canal repair 173250 190575 207900 225225 242550 251212 Echo/Doppler report procedure stills of ECHO with report
a) Clinical notes b) a) Indoor case papers b) Procedure /
Echo/Doppler report c) Cardiac Operative notes c) Post procedure stills
Surgical Correction of Category - II Sinus of Valsalva aneurysm repair with aortic
165 CTVS SV CTVS SV002 SV002M 173250 190575 207900 225225 242550 251212 CT/MRI report of ECHO with report d)
Congenital Heart Disease valve procedure
e) Barcode of implant, if used
a) Clinical notes b) a) Indoor case papers b) Procedure /
Echo/Doppler report c) Cardiac Operative notes c) Post procedure stills
Surgical Correction of Category - II Sinus of Valsalva aneurysm repair without aortic
166 CTVS SV CTVS SV002 SV002N 173250 190575 207900 225225 242550 251212 CT/MRI report of ECHO with report d)
Congenital Heart Disease valve procedure
Surgical Correction of Category - II Echo/Doppler report Procedure / Operative notes c) Post
167 CTVS SV CTVS SV002 SV002O Sub-aortic membrane resection 173250 190575 207900 225225 242550 251212
Congenital Heart Disease procedure stills of ECHO with report
168 CTVS SV CTVS SV002 SV002H Valvular PS / PR repair 173250 190575 207900 225225 242550 251212 Echo/Doppler report procedure stills of ECHO with report
Surgical Correction of Category - II Echo/Doppler report procedure stills of ECHO with report
169 CTVS SV CTVS SV002 SV002F VSD closure 173250 190575 207900 225225 242550 251212
a) Clinical notes with history, signs, symptoms,
evaluation findings, indication for procedure, A) Detailed Procedure / operation notes
planned line of management ,b) Chest X-ray c) B) Anaesthesia Notes C) Detailed Indoor
ECHO / Doppler report d) ECG e) Cardiac MRI / case papers (ICPs) D)
Surgical Correction of Category - III Cardiac Catheterisation / CT Angio f) Pre-OP Invoice/barcode of graft used(if artificial graft
170 CTVS SV CTVS SV003 SV003Z ALCAPA repair 288750 317625 346500 375375 404250 418687 clinical photograph of patient used)
E) Detailed Discharge Summary
F) Intra OP and Post OP photographs of
patient

Surgical Correction of Category - III
171 CTVS SV CTVS SV003 SV003E AP window repair 216615 238276 259938 281599 303261 314091 Echo/Doppler report procedure stills of ECHO with report
172 CTVS SV CTVS SV003 SV003G Arch interruption Repair with VSD closure 216615 238276 259938 281599 303261 314091 procedure stills of ECHO with report
173 CTVS SV CTVS SV003 SV003F Arch interruption Repair without VSD closure 216615 238276 259938 281599 303261 314091 procedure stills of ECHO with report
Surgical Correction of Category - III Echo/Doppler report Procedure / Operative notes c) Post
174 CTVS SV CTVS SV003 SV003W Arterial switch operation 216615 238276 259938 281599 303261 314091
175 CTVS SV CTVS SV003 SV003V Complete AV canal repair 216615 238276 259938 281599 303261 314091 Echo/Doppler report procedure stills of ECHO with report
176 CTVS SV CTVS SV003 SV003H DORV Repair 216615 238276 259938 281599 303261 314091
177 CTVS SV CTVS SV003 SV003B Double switch operation 216615 238276 259938 281599 303261 314091 procedure stills of ECHO with report
178 CTVS SV CTVS SV003 SV003A Ebstien anomoly repair 216615 238276 259938 281599 303261 314091 Echo/Doppler report procedure stills of ECHO with report c)
A)ECHO . A)Detailed discharge summary.
B) Doppler Report B) Detailed Operative notes.
179 CTVS SV CTVS SV003 SV003D Fontan procedure 216615 238276 259938 281599 303261 314091 C) barcode of Implant.
D)if used.
a) Clinical notes b) Echo/ a) Indoor case papers b)

Surgical Correction of Category - III color Doppler report with stills Procedure / Operative notes c) Post
180 CTVS SV CTVS SV003 SV003J Konno procedure 216615 238276 259938 281599 303261 314091
Congenital Heart Disease procedure echo/colour Doppler report
Outside State
Bed Cost Cost
Cost
181 CTVS SV CTVS SV003 SV003Y Mustard Operation 216615 238276 259938 281599 303261 314091 procedure stills of ECHO with report
A)ECHO . A)Detailed discharge summary.
B) Doppler Report B) Detailed Operative notes.
182 CTVS SV CTVS SV003 SV003K Norwood procedure 216615 238276 259938 281599 303261 314091 C) barcode of Implant.
D)if used.

183 CTVS SV CTVS SV003 SV003C Rastelli Procedure 216615 238276 259938 281599 303261 314091
184 CTVS SV CTVS SV003 SV003X Senning Operation 216615 238276 259938 281599 303261 314091 procedure stills of ECHO with report
185 CTVS SV CTVS SV003 SV003I Supravalvular AS repair 216615 238276 259938 281599 303261 314091
186 CTVS SV CTVS SV003 SV003S TAPVC Repair 216615 238276 259938 281599 303261 314091 Echo/Doppler report procedure ECHO with reports
Surgical Correction of Category - III procedure stills of ECHO with report
187 CTVS SV CTVS SV003 SV003U Tetralogy of Fallot Repair 216615 238276 259938 281599 303261 314091
Congenital Heart Disease d) Detailed Discharge Summary
e) Detailed Operative notes indicating need
for Reoperation
188 CTVS SV CTVS SV003 SV003T Truncus arteriosus repair 216615 238276 259938 281599 303261 314091
Surgical Correction of Category - III Echo/Doppler report procedure stills of ECHO with report
189 CTVS SV CTVS SV003 SV003M VSD + Aortic procedure 216615 238276 259938 281599 303261 314091
190 CTVS SV CTVS SV003 SV003R VSD + Coarctation repair 216615 238276 259938 281599 303261 314091
191 CTVS SV CTVS SV003 SV003Q VSD + Infundibular procedure 216615 238276 259938 281599 303261 314091
192 CTVS SV CTVS SV003 SV003N VSD + Mitral procedure 216615 238276 259938 281599 303261 314091
193 CTVS SV CTVS SV003 SV003P VSD + Pulmonary artery procedure 216615 238276 259938 281599 303261 314091
194 CTVS SV CTVS SV003 SV003O VSD + Tricuspid procedure 216615 238276 259938 281599 303261 314091
195 CTVS SV CTVS SV003 SV003L VSD closure + RV - PA conduit 216615 238276 259938 281599 303261 314091
a) Clinical notes with evaluation findings, indication a) Detailed Indoor case papers (ICPs) with
of procedure, treatment details
and planned line of management b) Detailed Procedure / operative notes
196 CTVS SV CTVS SV022 Thoracotomy, Thoraco Abdominal Approach SV022A Thoracotomy, Thoraco Abdominal Approach 43365 47701 52038 56374 60711 62879
b) Based on Etiology Postoperative c) Chest/Abdomen X-ray
CT Chest/Abdomen d) USG Chest/Abdomen
e) Detailed discharge summary
a) Clinical notes b) Duplex a) Procedure / Operative notes b) Detailed
197 CTVS SV CTVS SV020 Thromboembolectomy SV020A Peripheral Thromboembolectomy 40425 44467 48510 52552 56595 58616
USG report Discharge Summary
planned line of management b) Chest X-ray C) Detailed discharge summary.
c) ECHO , d) ECG D) Intra OP and Post OP photographs of
198 CTVS SV CTVS SV039 Tracheal repair SV039A Tracheal repair 65625 72187 78750 85312 91875 95156
e) BRONCOSCOPY , CT Scan patient

199 CTVS SV CTVS SV007 Triple valve procedure SV007A Triple valve replacement / repair 245490 270039 294588 319137 343686 355960
a) Clinical Notes including classification of bites, a) Detailed Indoor Case Papers
evaluation findings, indications for the procedure, b) Clinical Notes with complete treatment
and planned line of treatment details including no. of doses of vaccine with
Emergency Room Emergency Room b) Pre-clinical photograph dates (as needed)
200 ER ER003 Animal bites (Excluding Snake Bite) ER003A Animal bites (Excluding Snake Bite) 1785 1963 2142 2320 2499 2588
Packages Packages c) Invoice / bar code sticker of the vaccine (If
its applicable)
d) Discharge summary and follow-up advice
a) Clinical Notes including evaluation findings, a) Detailed Indoor Case Papers

Emergency Room Emergency Room Emergency with stable indications for the procedure, and planned line of b) Detailed Discharge summary
201 ER ER002 Cardiopulmonary emergency ER002A 2100 2310 2520 2730 2940 3045
Packages Packages cardiopulmonary status treatment
b) Electrocardiogram (ECG)report
Outside State
Bed Cost Cost
Cost
a) Clinical Notes including evaluation findings, a) Detailed Indoor Case Papers
Emergency with unstable cardiopulmonary status
Emergency Room Emergency Room indications for the procedure, and planned line of b) Detailed Discharge summary
202 ER ER002 Cardiopulmonary emergency ER002B with 11550 12705 13860 15015 16170 16747
Packages Packages treatment
resuccitation
b) Electrocardiogram (ECG)report
a) Clinical notes including evaluation findings, a) Detailed clinical notes, vitals and treatment
planned line of treatment given
Emergency Room Emergency Room b) Pre-clinical photograph b) Detailed Procedure / Operative Notes
203 ER ER001 Laceration - Suturing / Dressing ER001A Laceration - Suturing / Dressing 2100 2310 2520 2730 2940 3045
Packages Packages c) Post procedure clinical photograph of the
affected part
d) Detailed Discharge summary
a) Clinical notes (detailing signs, symptoms, a) Indoor case papers b)
examination findings, indications for doing the Procedure note/ operative note
204 ENT SL ENT SL015 Adenoidectomy SL015A Adenoidectomy 9870 10857 11844 12831 13818 14311
procedure & advise for admission) c) Detailed Discharge summary
b) X-ray of Nasopharynx (lateral view)
indication for procedure, and planned line of b) Detailed procedure/Operative notes
Ant. Ethmoidal / sphenopalatine artery management, advise for the procedure. c) Detailed discharge summary
205 ENT SL ENT SL014 SL014B Ant. Ethmoidal artery ligation - Endoscopic 17010 18711 20412 22113 23814 24664
ligation b) Contrast Enhanced Computerized Tomography
(CECT) Scan of nose and paranasal sinuses

206 ENT SL ENT SL014 SL014A Ant. Ethmoidal artery ligation - Open 17010 18711 20412 22113 23814 24664

207 ENT SL ENT SL014 SL014D Sphenopalatine artery ligation - Endoscopic 17010 18711 20412 22113 23814 24664

208 ENT SL ENT SL014 SL014C Sphenopalatine artery ligation - Open 17010 18711 20412 22113 23814 24664
a) Clinical notes including evaluation findings, a) Clinical notes detailing signs and
indication for procedure, and planned line of symptoms, treatment given
management, advise for the day care procedure. b) Procedure note/ operative note
b) Nasoendoscopy/ radiology/ audiometry findings c) Post procedure clinical picture (biopsy,
Clinic based therapeutic interventions of to justify the need for Procedure. wide bore aspiration), endoscopy picture (IT
209 ENT SL ENT SL035 SL035B Biopsy 1260 1386 1512 1638 1764 1827
ENT reduction), radiology (optional, wide bore
needle aspiration), audiology and radiology
(IT injections)
d) Discharge summary report
210 ENT SL ENT SL035 SL035C Intratympanic injections 1260 1386 1512 1638 1764 1827
(IT injections)
211 ENT SL ENT SL035 SL035A Turbinate reduction 1260 1386 1512 1638 1764 1827
(IT injections)
212 ENT SL ENT SL035 SL035D Wide bore aspiration 1260 1386 1512 1638 1764 1827
(IT injections)
a) Clinical notes (detailing signs, symptoms, a) Indoor case papers & Consent (informed
examination findings, clinical photographs (intraoral written)
& extraoral), indications for doing b) Procedure note/ operative note &
the procedure & advise for admission) Anesthesia Notes, (where applicable)
b) Document required for Investigation of fracture: c) Barcode of Implants used
• X-ray Nasal bone Lateral view (Right/Left) for d) Post-Operative X-ray of the affected part
nasal bone e) Detailed Discharge summary
fracture or
Closed reduction / intermaxillary fixation for Closed reduction and Intermaxillary fixation of • X-Ray mandible latera Oblique, PA view for
213 ENT SL ENT SL033 SL033D 5250 5775 6300 6825 7350 7612 Mandible
fracture of maxilla / mandible / zygoma mandible
Fracture or Submento vertex, CBCT/ CT/ OPG.
• OPG(Orthopantomogram) for mandible fracture
or
• X-ray Lateral oblique view (Right/Left) for
mandible or
• X-ray cranial PA view(skull) or
c) Clinical photograph of the affected part
Outside State
Bed Cost Cost
Cost
fracture or
Closed reduction / intermaxillary fixation for • X-Ray mandible latera Oblique, PA view for
214 ENT SL ENT SL033 SL033H Intermaxillary fixation for fracture of mandible 12600 13860 15120 16380 17640 18270 Mandible
fracture of maxilla / mandible / zygoma
or
mandible or
fracture or
215 ENT SL ENT SL033 SL033B Closed reduction for fracture of mandible 5250 5775 6300 6825 7350 7612 Mandible
or
mandible or
fracture or
216 ENT SL ENT SL033 SL033F fracture of mandible 12600 13860 15120 16380 17640 18270 Mandible
or
mandible or
fracture or
217 ENT SL ENT SL033 SL033A Closed reduction of maxilla 5250 5775 6300 6825 7350 7612 Mandible
or
mandible or
fracture or
218 ENT SL ENT SL033 SL033E fracture of maxilla 12600 13860 15120 16380 17640 18270 Mandible
or
mandible or
Outside State
Bed Cost Cost
Cost
fracture or
219 ENT SL ENT SL033 SL033C Closed reduction of zygoma 5250 5775 6300 6825 7350 7612 Mandible
or
mandible or
fracture or
220 ENT SL ENT SL033 SL033G fracture of zygoma 12600 13860 15120 16380 17640 18270 Mandible
or
mandible or
A)Clinical notes. A)Detailed Procedure .

B)CT /MRI. B) Operative Notes..
Cochlear Implant Surgery* Surgery(53000) C)Radiographic stills
Cochlear Implant Surgery* Surgery(53000) *pre -
*pre -op evaluation(including vaccine for D)photograph.
op evaluation(including vaccine for meningitis)-
meningitis)- 10000/- *Initial mapping and E)CT/MRI.
10000/- *Initial mapping and swithch on - 5000/-
221 ENT SL ENT SL036 swithch on - 5000/-Rehabilitation Therapy SL036A 170625 187687 204750 221812 238875 247406 G)Angio.
Rehabilitation Therapy (part- 1 for first 6 months)
(part- 1 for first 6 months) -21700 H) GST Invoice OF IMPLANT
-21700 Rehabilitation Therapy (part- 2 for
Rehabilitation Therapy (part- 2 for second 6 I) bar code of glue used.
second 6 months)-40300
months)-40300 J) Detailed Discharge Summary
a) Clinical notes (detailing signs, symptoms, a) Detailed Discharge summary

indications for doing the procedure& advise for b) Indoor case papers c)
222 ENT SL ENT SL006 Endoscopic DCR SL006A Endoscopic DCR 21000 23100 25200 27300 29400 30450 admission) b) Procedure note/ operative note
Examination/ investigation findings- Dye d) Intraoperative photograph with time and
disappearance test/ Probing & irrigation date (Optional)
a) Clinical notes clearly indicating symptoms and a) Indoor case papers available indicating
signs b) Lab investigations (Complete Blood count, i. Signs & symptoms
Haemoglobin, Coagulation profile) ii. Physical & local examination
c) Report of local examination by anterior iii. Investigations performed
rhinoscopy/ endoscopy identifying the source of iv. Screening for coagulation disorders/
bleeding available anticoagulation medications/ hematological
223 ENT SL ENT SL007 Epistaxis treatment - packing SL007A Epistaxis treatment - packing 2625 2887 3150 3412 3675 3806 malignancies
v. Appropriate treatment given based on the
cause of bleeding b) Clinical photograph of
patient and the affected part c)
Discharge Summary with appropriate
discharge advise
a) Clinical Notes, Indication for procedure, Planned a) OT Note, HPE Report, Intraoperative
224 ENT SL ENT SL037 Excision of Rhinosprodiosis SL037A Excision of Rhinosprodiosis 13225 14547 15870 17192 18515 19176 line of Management, Advice for the procedure, photograph
Rainoscopy report
a) Clinical notes (detailing signs, symptoms, a) Detailed Indoor Case Papers
examination findings, planned line of treatment & b) Detailed Procedure / Operative Notes
advise for admission) c) Post procedure X-ray
b) X-ray/CT report of the affected part d) Post procedure clinical photograph of the
225 ENT SL ENT SL010 Fracture - setting nasal bone SL010A Fracture - setting nasal bone 9135 10048 10962 11875 12789 13245
c) Medico-legal case (MLC) / First information affected part
report (FIR) for traumatic injuries and e) Detailed discharge summary
circumstances of the incident which led to fracture
(In applicable cases)
chronicity of sinusitis, examination findings, b) Indoor case papers c)
Functional Endoscopic Sinus (FESS)stratified as indications for doing the procedure& advise for Procedure note/ operative note
226 ENT SL ENT SL013 Functional Endoscopic Sinus (FESS) SL013A 15435 16978 18522 20065 21609 22380
U/L or B/L and cost adjusted admission) b) CT d) Intra procedure Still images of the affected
(PNS) report part with time and date
e) Histopathology report
a) Clinical notes (detailing signs, symptoms, a) Indoor case papers b) Operative/
examination findings, indications for doing the procedure notes c) Detailed Discharge
procedure, circumstances of the incident which led summary
to disfigurement and advise for admission)
227 ENT SL ENT SL008 Functional septo rhinoplasty SL008A Functional septo rhinoplasty 23835 26218 28602 30985 33369 34560
b) Clinical picture of the affected part along with full
face of the patient and anterior rhinoscopy/
endoscopic picture showing deviated septum
a) Clinical notes (detailing signs, symptoms, a) Indoor case papers b)

228 ENT SL ENT SL011 Inferior turbinate reduction under GA SL011A Inferior turbinate reduction under GA 6300 6930 7560 8190 8820 9135 procedure& advise for admission) c) Detailed Discharge summary
b) Nasal Endoscopic picture of the affected part, if d) Intra-operative stills of the affected part
available with time and date (optional)
Outside State
Bed Cost Cost
Cost
a) Clinical notes (detailing signs, symptoms, a) Detailed Indoor case papers
examination findings, planned line of treatment & b) Detailed Procedure/ Operative notes
advise for admission) c) Histopathology report (In all applicable
229 ENT SL ENT SL024 Microlaryngeal surgery with or without laser SL024A Microlaryngeal surgery with or without laser 17850 19635 21420 23205 24990 25882 b) laryngoscopy findings/Laryngeal cases)
electromyography confirming the diagnosis and d) Post procedure clinical/Intraprocedural
indication for surgery photograph of the affected part
e) Detailed Discharge summary
chronicity of sinusitis, examination findings, b) Indoor case papers c)
Open sinus surgery(Open Sinus Surgery
230 ENT SL ENT SL012 Open sinus surgery SL012A 17010 18711 20412 22113 23814 24664 indications for doing the procedure& advise for Procedure note/ operative note
(Single/Multiple Sinuses)
admission) b) CT d) Histopathology report
(PNS) report
a) History a) Post procedure clinical photograph of
b) Pre-op Clinical photograph affected part
b) Detailed Procedure
231 ENT SL ENT SL001 Pinna surgery for tumour / trauma SL001B Pinna surgery for trauma 10500 11550 12600 13650 14700 15225
c) Operative Notes
a) History a) Histopath report

b) Pre-op Clinical photograph b) Post procedure clinical photograph of
c) Biopsy affected part
232 ENT SL ENT SL001 Pinna surgery for tumour / trauma SL001A Pinna surgery for tumor 10500 11550 12600 13650 14700 15225 c) Detailed Procedure
d) Operative Notes
a) Clinical notes a) Histopathology report

b) Clinical photograph b) Post procedure clinical photograph of
c) MLC/FIR for traumatic injuries and affected part
233 ENT SL ENT SL022 Removal of Submandibular Salivary gland SL022B Removal of Ranula 30450 33495 36540 39585 42630 44152 circumstances of the incident which led to rupture c) Detailed Procedure
of salivary duct. d) Operative Notes
e) Detailed discharge summary.
a) Clinical notes to establish indication; Biopsy if a) Histopathology report

tumour b) Post procedure clinical photograph of
b) Clinical Photograph of affected part affected part
234 ENT SL ENT SL022 Removal of Submandibular Salivary gland SL022A Removal of Submandibular Salivary gland 30450 33495 36540 39585 42630 44152 c) Detailed Procedure
d) Operative Notes
a) Clinical notes : (detailing a) Clinical notes b) Procedure

signs, symptoms, examination findings, indications note/ operative note
for doing the procedure, circumstances of the c) Detailed Discharge summary
235 ENT SL ENT SL009 Septoplasty SL009A Septoplasty 14595 16054 17514 18973 20433 21162 incident which led to Deviated Nasal Septum&
advise for admission)
b) Anterior rhinoscopy/ endoscopic picture showing
deviated nasal septum
a) Clinical notes (detailing signs, symptoms, ear a) Indoor case papers b)
procedure& advise for admission) c) Detailed Discharge summary
236 ENT SL ENT SL003 Stapedectomy / tympanotomy SL003A Stapedectomy 18165 19981 21798 23614 25431 26339
b) Audiometry report confirming conductive d) Intra-operative photograph with time and
deafness and Tympanometry date (optional) e) Invoice of the ossicular
prosthesis/ piston used, if any
procedure& advise for admission) c) Detailed Discharge summary
237 ENT SL ENT SL003 Stapedectomy / tympanotomy SL003B Tympanotomy 15750 17325 18900 20475 22050 22837
b) Audiometry report confirming conductive d) Intra-operative photograph with time and
a) Clinical Notes, Indication for procedure, Planned a) OT Note, Intraoperative photograph
238 ENT SL ENT SL038 Surgical Treatment for preauricular sinus SL038A Surgical Treatment for preauricular sinus 18550 20405 22260 24115 25970 26897 line of Management, Advice for the procedure
a) Clinical notes with signs, symptoms, indications, a) Indoor case papers (ICPs) b) Detailed
planned line of management and advise for Procedure / operative notes
Thyroglossal / Branchial cyst / sinus / fistula admission b) Clinical c) Intra-operative photographs (optional)
239 ENT SL ENT SL018 SL018E Branchial fistula excision 17850 19635 21420 23205 24990 25882
excision Photograph c) USG Neck/ Fine d) Detailed discharge summary e)
needle aspiration cytology (FNAC) d) Histopathological examination
Optional CT/MRI
Thyroglossal / Branchial cyst / sinus / fistula admission b) Clinical c) Intra-operative photographs (optional)
240 ENT SL ENT SL018 SL018D Branchial sinus excision 17850 19635 21420 23205 24990 25882
excision Photograph c) USG Neck/ Fine d) Detailed discharge summary e)
Optional CT/MRI
examination b) Procedure note/ operative note
findings, indications for doing the procedure & c) Histopathology examination report
Thyroglossal / Branchial cyst / sinus / fistula advise for d) Photograph of the Gross specimen of the
241 ENT SL ENT SL018 SL018A Thyroglossal cyst excision 17850 19635 21420 23205 24990 25882
excision admission) tissue removed
b) Pre-operative clinical photograph of the affected e) Post procedure clinical photograph of the
part affected part
f) Detailed Discharge summary
242 ENT SL ENT SL018 SL018C Thyroglossal fistula excision 17850 19635 21420 23205 24990 25882
part affected part
243 ENT SL ENT SL018 SL018B Thyroglossal sinus excision 17850 19635 21420 23205 24990 25882
part affected part
Outside State
Bed Cost Cost
Cost
a) Clinical notes (detailing signs, symptoms, a) Indoor case papers
examination findings, indications for doing the b) Procedure note/ operative note
244 ENT SL ENT SL016 Tonsillectomy SL016B Tonsillectomy - B/L adenotonsillectomy 12810 14091 15372 16653 17934 18574
b) Throat culture report d) Histopathology report
e) Post procedure clinical photograph of the
affected part
Tonsillectomy - U/L tonsillectomy procedure & advise for admission) c) Detailed Discharge summary
245 ENT SL ENT SL016 Tonsillectomy SL016A 12810 14091 15372 16653 17934 18574
(unilateral/bilateral) b) Throat culture report d) Histopathology report
affected part
a) Clinical notes (detailing signs, symptoms, ear a) Detailed Discharge summary
examination findings, indications for doing the b) Indoor case papers c)
Tympanoplasty (can be stratified (GA/LA) and procedure & advice for admission) Procedure note/ operative note
246 ENT SL ENT SL002 Tympanoplasty SL002A 16170 17787 19404 21021 22638 23446
price adjusted accordingly ) b) Audiogram report d) Intra-operative photograph with time and
date (optional) e) Invoice of the ossicular
prosthesis used, if any
247 ENT SL ENT SL019 Uvulopalatopharyngoplasty (UPPP) SL019A Uvulopalatopharyngoplasty (UPPP) 21000 23100 25200 27300 29400 30450 procedure & advise for admission) c) Detailed Discharge summary
b) Polysomnography (sleep study) d) Post procedure clinical photograph of the
affected part
a) Clinical notes confirming the indication for the a) Scar photo
procedure with imaging (X-ray/ CT) Evidence b) Post procedure clinical photograph
b) Audiometry c) Detailed Procedure
248 ENT SL ENT, Surgical Oncology SL004 Mastoidectomy SL004B Radical 29400 32340 35280 38220 41160 42630 d) Operative Notes
f) Histopath
a) Clinical notes confirming the indication for the a) Scar photo

procedure with imaging (X-ray/ CT) Evidence b) Post procedure clinical photograph
b) Audiometry c) Detailed Procedure
249 ENT SL ENT, Surgical Oncology SL004 Mastoidectomy SL004A Simple 29400 32340 35280 38220 41160 42630 d) Operative Notes
f) Histopath
a) Clinical notes a) Photograph of patient while undergoing

b) Audiogram the procedure
justifying surgery. b) Detailed Procedure
250 ENT SL ENT, Surgical Oncology SL005 Myringotomy with or without Grommet SL005B Bilateral 7980 8778 9576 10374 11172 11571
c) Operative Notes
a) Clinical notes a) Photograph of patient while undergoing

b) Audiogram the procedure
justifying surgery. b) Detailed Procedure
251 ENT SL ENT, Surgical Oncology SL005 Myringotomy with or without Grommet SL005A Unilateral 7980 8778 9576 10374 11172 11571
c) Operative Notes
a) CT Scan a) Histopathology report

b) FNAC b) Post procedure clinical photograph of
ENT, Surgical Oncology, c) Clinical Photograph of affected part affected part
252 ENT SL General SL021 Parotidectomy SL021B Superficial Parotidectomy 25916 28507 31099 33690 36282 37578 c) Detailed Procedure
Surgery d) Operative Notes
a) CT Scan a) Histopathology report

b) FNAC b) Post procedure clinical photograph of
ENT, Surgical Oncology, c) Clinical Photograph of affected part affected part
253 ENT SL General SL021 Parotidectomy SL021A Total Parotidectomy 30708 33778 36849 39920 42991 44526 c) Detailed Procedure
Surgery d) Operative Notes
Indication for surgery with supporting investigation a) Histopathology report

reports b) Post procedure Imaging
a) X-ray c) Post procedure clinical photograph of
b) CT affected part
ENT,General Surgery, Comprehensive Benign neck tumour c) MRI d) Detailed Procedure
254 ENT SL SL027 Neck dissection SL027B 24675 27142 29610 32077 34545 35778 e) Operative Notes
Surgical Oncology excision
A. FNAC/ Biospy in case of tumours f) Detailed discharge summary
B. Clinical Photograph

b) CT affected part
ENT,General Surgery, Comprehensive Pharyngeal c) MRI d) Detailed Procedure
255 ENT SL SL027 Neck dissection SL027D 24675 27142 29610 32077 34545 35778 e) Operative Notes
Surgical Oncology diverticulum excision

b) CT affected part
ENT,General Surgery, Selective Benign neck tumour c) MRI d) Detailed Procedure
256 ENT SL SL027 Neck dissection SL027A 24675 27142 29610 32077 34545 35778 e) Operative Notes
Outside State
Bed Cost Cost
Cost
b) CT affected part
ENT,General Surgery, Selective Pharyngeal diverticulum c) MRI d) Detailed Procedure
257 ENT SL SL027 Neck dissection SL027C 24675 27142 29610 32077 34545 35778 e) Operative Notes

examination findings, indications for doing the b) Detailed Procedure note/ operative note
procedure & advice for admission) c) Post procedure clinical photograph of the
Deep neck abscess drainage/ Post trauma b) Clinical photograph of the affected part affected part
ENT,General
258 ENT SL SL028 neck SL028A Deep neck abscess drainage 17640 19404 21168 22932 24696 25578
Surgery,Peadiatric Surgery c) Contrast enhanced CT/ lateral soft tissue neck d) Culture/ sensitivity report of the pus
exploration X-ray supporting the diagnosis/ USG of neck removed

examination findings, indications for doing the b) Detailed Procedure note/ operative note
procedure & advice for admission) c) Post procedure clinical photograph of the
Deep neck abscess drainage/ Post trauma b) Clinical photograph of the affected part affected part
ENT,General
259 ENT SL SL028 neck SL028B Post trauma neck exploration 22050 24255 26460 28665 30870 31972
Surgery,Peadiatric Surgery c) Contrast enhanced CT/ lateral soft tissue neck d) Culture/ sensitivity report of the pus
exploration X-ray supporting the diagnosis/ USG of neck removed
a) Detailed Clinical notes with history, symptoms, a) Detailed indoor case papers
signs and indication for procedure b) Detailed Procedure / Operative note
c) Post procedure clinical photograph of the
ENT,General affected part
260 ENT SL SL026 Tracheostomy / Tracheotomy SL026A Tracheostomy 29400 32340 35280 38220 41160 42630
Surgery,Peadiatric Surgery d) Histopathology report (In applicable
cases)
signs and indication for procedure b) Detailed Procedure / Operative note
c) Post procedure clinical photograph of the
ENT,General affected part
261 ENT SL SL026 Tracheostomy / Tracheotomy SL026B Tracheotomy 29400 32340 35280 38220 41160 42630
Surgery,Peadiatric Surgery d) Histopathology report (In applicable
cases)
a) Clinical notes (detailing signs, symptoms, a) Indoor case papers (including Informed
examination findings, clinical photographs(intraoral written
& extraoral) indications for doing the procedure & consent)
advise for admission) Procedure / Operative b) Procedure note/ operative note &
Notes, Post Procedure Photograph of affected Anesthesia Notes
part. c) Barcode of Implants used
ENT,Oral & Maxillofacial b) X-ray of Paranasal sinus (PNS) with Water’s d) Post-operative X-Ray
Open reduction and internal fixation of
262 ENT SL Surgery,Plastic & SL034 SL034B Open reduction and internal fixation of mandible 18000 19800 21600 23400 25200 26100 view/ e) Detailed Discharge summary
maxilla / mandible / zygoma
Reconstructive Surgery mandible latera Oblique, antero- posterior for
Mandible Fracture/ mandible lateral oblique,
Submento vertex or CBCT/CT/OPG. (Xray in 2
planes).
263 ENT SL Surgery,Plastic & SL034 SL034A Open reduction and internal fixation of maxilla 18000 19800 21600 23400 25200 26100 view/ e) Detailed Discharge summary
planes).
264 ENT SL Surgery,Plastic & SL034 SL034C Open reduction and internal fixation of zygoma 18000 19800 21600 23400 25200 26100 view/ e) Detailed Discharge summary
planes).
a) Doctor's notes with presenting complaints a) C/S of pus

b) Duration and physical examination findings of b) Post procedure clinical photograph of
oral cavity and tonsils affected part
Peritonsillar abscess drainage / intraoral c) Clinical photograph if possible c) Detailed Procedure
265 ENT SL ENT,Pediatric Surgery SL017 calculus SL017B Intraoral calculus removal 6090 6699 7308 7917 8526 8830
d) Operative Notes
removal e) Detailed discharge summary

Peritonsillar abscess drainage / intraoral
266 ENT SL ENT,Pediatric Surgery SL017 calculus SL017A Peritonsillar abscess drainage 6090 6699 7308 7917 8526 8830
b) Throat culture report d) Culture/ Sensitivity report of pus
removal
affected part
Outside State
Bed Cost Cost
Cost
Clinical notes with planned line of treatment a) Procedure Notes
b) Operative Notes
Rigid laryngoscopy / bronchoscopy / Rigid bronchoscopy - Diagnostic + / c) Post Procedure Photograph of affected
267 ENT SL ENT,Pediatric Surgery SL023 SL023B 7350 8085 8820 9555 10290 10657
oesophagoscopy - Diagnostic + / - biopsy - biopsy part
d) Histopathology report

b) Operative Notes
Rigid laryngoscopy / bronchoscopy / Rigid laryngoscopy - Diagnostic + / - c) Post Procedure Photograph of affected
268 ENT SL ENT,Pediatric Surgery SL023 SL023A 7350 8085 8820 9555 10290 10657
oesophagoscopy - Diagnostic + / - biopsy biopsy part

b) Operative Notes
Rigid laryngoscopy / bronchoscopy / Rigid oesophagoscopy - Diagnostic c) Post Procedure Photograph of affected
269 ENT SL ENT,Pediatric Surgery SL023 SL023C 7350 8085 8820 9555 10290 10657
oesophagoscopy - Diagnostic + / - biopsy + / - biopsy part
Clinical notes with planned line of treatment and a) Procedure Notes

Coronal b) Operative Notes
a) CT c) Post Procedure Photograph of affected
b)MRI part.
270 ENT SL ENT,Surgical Oncology SL030 Advanced anterior skull base surgery SL030B Clival tumour excision 52290 57519 62748 67977 73206 75820
establishing diagnosis and establishing need of d) Histopathology report
surgery.
Clinical notes with planned line of treatment and a) Procedure Notes

Coronal b) Operative Notes
a) CT c) Post Procedure Photograph of affected
b)MRI part.
271 ENT SL ENT,Surgical Oncology SL030 Advanced anterior skull base surgery SL030A Endoscopic Hypophysectomy 52290 57519 62748 67977 73206 75820
establishing diagnosis and establishing need of d) Histopathology report
surgery.
a) Clinical notes including evaluation findings, a) Detailed Indoor case papers with daily
indication for procedure, and planned line of vitals and line of treatment
management, advise for the procedure b) Detailed Procedure / operative note
272 ENT SL ENT,Surgical Oncology SL032 Advanced lateral skull base surgery SL032A Fisch approach 52395 57634 62874 68113 73353 75972 b) CT/MRI/ biopsy to establish the indication and c) Histopathology report d) Post
justify the surgery procedure clinical photograph of the affected
c) Audiogram report justifying surgery (if part
applicable) e) Detailed Discharge summary
273 ENT SL ENT,Surgical Oncology SL032 Advanced lateral skull base surgery SL032D Temporal Bone resection 52395 57634 62874 68113 73353 75972 b) CT/MRI/ biopsy to establish the indication and c) Histopathology report d) Post
274 ENT SL ENT,Surgical Oncology SL032 Advanced lateral skull base surgery SL032C Transcochlear approach 52395 57634 62874 68113 73353 75972 b) CT/MRI/ biopsy to establish the indication and c) Histopathology report d) Post
275 ENT SL ENT,Surgical Oncology SL032 Advanced lateral skull base surgery SL032B Translabyrinthine approach 52395 57634 62874 68113 73353 75972 b) CT/MRI/ biopsy to establish the indication and c) Histopathology report d) Post
a) CT Scan a) Procedure
b) Biopsy b) Operative Notes
Excision of tumour of oral cavity / paranasal Excision of tumour of oral cavity / paranasal
c) Clinical Photograph of affected part c) Post Procedure Photograph of affected
276 ENT SL ENT,Surgical Oncology SL020 sinus / laryngopharynx with or without SL020B sinus / laryngopharynx 47985 52783 57582 62380 67179 69578
part
reconstruction with pedicled flap reconstruction
Excision of tumour of oral cavity / paranasal Excision of tumour of oral cavity / paranasal
c) Clinical notes with planned line of treatment c) Post Procedure Photograph of affected
277 ENT SL ENT,Surgical Oncology SL020 sinus / laryngopharynx with or without SL020A sinus / laryngopharynx 13125 14437 15750 17062 18375 19031
d) Pre operative Clinical Photograph of affected part
reconstruction without reconstruction
part. d) Histopathology report
Excision of tumour of oral cavity / paranasal Excision of tumour of oral cavity /
c) Clinical Photograph of affected part c) Post Procedure Photograph of affected
278 ENT SL ENT,Surgical Oncology SL020 sinus / laryngopharynx with or without SL020C paranasal sinus / laryngopharynx with free flap 35050 38555 42060 45565 49070 50822
part
reconstruction reconstruction
279 ENT SL ENT,Surgical Oncology SL031 Lateral skull base procedures SL031C CSF Otorrhoea repair 32445 35689 38934 42178 45423 47045 b) CT/MRI/ biopsy to establish the indication and c) Histopathology report d) Post
Post-traumatic facial nerve b) CT/MRI/ biopsy to establish the indication and c) Histopathology report d) Post
280 ENT SL ENT,Surgical Oncology SL031 Lateral skull base procedures SL031B 32445 35689 38934 42178 45423 47045
decompression justify the surgery procedure clinical photograph of the affected
Outside State
Bed Cost Cost
Cost
281 ENT SL ENT,Surgical Oncology SL031 Lateral skull base procedures SL031A Subtotal petrosectomy 32445 35689 38934 42178 45423 47045 b) CT/MRI/ biopsy to establish the indication and c) Histopathology report d) Post
Clinical notes to establish indication and a) Histopathology report in case of tumours
justification of surgery b) Post procedure clinical photograph of
Evidence through affected part
a) CT c) Detailed Procedure
Open laryngeal framework surgery / b) MRI d) Operative Notes
282 ENT SL ENT,Surgical Oncology SL025 SL025A Open laryngeal framework surgery / Thyroplasty 5250 5775 6300 6825 7350 7612
Thyroplasty c) Biopsy e) Detailed discharge summary
d) Clinical Photograph
a) Clinical notes with planned line of treatment a) Procedure Notes

detailing aetiology b) Operative Notes
ENT,Surgical
283 ENT SL SL029 Anterior skull base surgery SL029D Craniofacial resection 33495 36844 40194 43543 46893 48567 b) MLC/ FIR if traumatic c) Post Procedure Photograph of affected
Oncology,Neurosurgery
c) CT to confirm need of surgery part.

ENT,Surgical
284 ENT SL SL029 Anterior skull base surgery SL029A Endoscopic CSF Rhinorrhea Repair 34125 37537 40950 44362 47775 49481 b) MLC/ FIR if traumatic c) Post Procedure Photograph of affected

ENT,Surgical
285 ENT SL SL029 Anterior skull base surgery SL029E Maxillary swing 33495 36844 40194 43543 46893 48567 b) MLC/ FIR if traumatic c) Post Procedure Photograph of affected

ENT,Surgical
286 ENT SL SL029 Anterior skull base surgery SL029B Optic nerve decompression 33495 36844 40194 43543 46893 48567 b) MLC/ FIR if traumatic c) Post Procedure Photograph of affected

ENT,Surgical
287 ENT SL SL029 Anterior skull base surgery SL029C Orbital decompression 33495 36844 40194 43543 46893 48567 b) MLC/ FIR if traumatic c) Post Procedure Photograph of affected
a. Clinical notes (specifying history such as h/o a. Clinical Notes (specifying history such as
Fall, Clenched teeth, Kidney failure, Liver failure, h/o Fall, Clenched teeth, Kidney failure, Liver
Encephalitis, Alcohol or drug abuse, if present) failure, Encephalitis, Alcohol or drug abuse, if
General Medicine, b. CT/MRI/EEG c. present)
288 General Medicine MG neurology, pediatric MG119 Drug resistant epilepsy MG119A Drug resistant epilepsy 2200 2420 2640 2860 3080 3190 Blood tests to rule out metabolic causes of seizure b. CT/MRI/EEG
medicine – CBC, Electrolytes, ESR c. Operative/ procedures notes
d. Discharge summary
e. Any other investigation reports (specify the
investigations)
a. Clinical notes (specifying history such as h/o a. Clinical Notes (specifying history such as
Fall, Clenched teeth, Kidney failure, Liver failure, h/o Fall, Clenched teeth, Kidney failure, Liver
Encephalitis, Alcohol or drug abuse, if present) failure, Encephalitis, Alcohol or drug abuse, if
General Medicine, b. CT/MRI/EEG c. present)
Evaluation of drug resistant epilepsy-Phase- Blood tests to rule out metabolic causes of seizure b. CT/MRI/EEG
289 General Medicine MG neurology, pediatric MG118 MG118A Evaluation of drug resistant epilepsy-Phase-1 2200 2420 2640 2860 3080 3190
1 – CBC, Electrolytes, ESR c. Operative/ procedures notes
medicine
d. Discharge summary
e. Any other investigation reports (specify the
investigations)
a. Clinical Notes including evaluation findings, a. Detailed indoor case papers along with
General Medicine,
indications for the procedure, and planned line of indications
290 General Medicine MG neurology, pediatric MG069 Guillain Barre syndrome MG069A Guillain Barre syndrome (IVIG) 2200 2420 2640 2860 3080 3190
treatment b. Detailed procedure notes
medicine
c. Detailed discharge summary
General Medicine,
291 General Medicine MG neurology, pediatric MG115 Inflammatory Myopathy/ Myaesthenic Crisis MG115A Inflammatory Myopathy/ Myaesthenic Crisis 2200 2420 2640 2860 3080 3190
medicine
Comprehensive medical rehabilitation for of
General Medicine, indications for the procedure, and planned line of indications
complication secondary to specified
292 General Medicine MG neurology, pediatric MG120 Medical/ neuro rehablitation MG120B 36750 40425 44100 47775 51450 53287 treatment b. Detailed procedure notes
disanility/multiple disability including procedures,
medicine c. Detailed discharge summary
chemodenevaration with or with out orthosis
General Medicine, Comprehensive medical rehabilitation for spinal
293 General Medicine MG neurology, pediatric MG120 Medical/ neuro rehablitation MG120A injury/ traumatic brain injury, CVA, Cerebral palsy 26250 28875 31500 34125 36750 38062
medicine with or without orthosis
a) Clinical notes including history, symptoms, a) Detailed Indoor case papers (ICPs) with
signs, vitals, examination findings, planned line of treatment details b) All
treatment and advice for admission b) - IQ investigation done c)
assessment Detailed discharge summary
General Medicine, - Learning
294 General Medicine MG neurology, pediatric MG120 Medical/ neuro rehablitation MG120F Medical Rehabilitation special learning disability 7350 8085 8820 9555 10290 10657 ▪ Wide range achievement test, fifth edition
medicine (WRAT5)
▪ Grade level assessment device (GLAD)
▪ Dyslexia Screening test
▪ NIMHANS battery for learning difficulties
- Eye and hearing screening (optional)
treatment and advice for admission b) i. investigation done c)
General Medicine, Intelligence Quotient (IQ) test Detailed discharge summary
295 General Medicine MG neurology, pediatric MG120 Medical/ neuro rehablitation MG120E Medical Rehabilitation intellectual dissability 7350 8085 8820 9555 10290 10657
ii. Social maturity assessment (Vineland Social
medicine Maturity Scale - VSMS)
iii. Developmental screening test (DST)
iv. CT/MRI Brain (Optional)
Outside State
Bed Cost Cost
Cost
treatment and advice for admission b) i. investigation done c)
Observation assessment ii. ACDS (ADHD Clinical Detailed discharge summary
Diagnostic Scale) iii. DBRS (Disruptive Behavior
Disorder Rating Scale)
iv. INCLEN Diagnostic Tool for ADHD (INDT-
ADHD)
General Medicine, v. CBCL (Child Behavior Check-List)
296 General Medicine MG neurology, pediatric MG120 Medical/ neuro rehablitation MG120G Medical Rehabilitation multiple disability 7350 8085 8820 9555 10290 10657 vi. Conners abbreviated rating scale
medicine vii. Vanderbilt ADHD diagnostic parent rating scale
viii. Lab: CBC, glucose, RFT, LFT, Sr electrolytes,
TSH, lactate, ammonia, metabolic screening,
ferritin, B12, toxicology screening, ABG, urinalysis
(based on condition)
ix. EEG
x. CT/MRI (optional)
a. Clinical Notes including evaluation findings, a. Detailed Indoor case papers with
indications for the procedure, and planned line of treatment given details.
General Medicine, treatment b. Creatine b. Detailed Discharge Summary
297 General Medicine MG neurology, pediatric MG120 Medical/ neuro rehablitation MG120D Medical rehabilitation of muscular dystrophy 7350 8085 8820 9555 10290 10657 Phosphokinase (CPK), Electrolytes report
medicine c. EMG studies, Nerve conduction velocity
d. CT Angiography studies/MRI/CT for spine
General Medicine,
Single event multiple level surgery for spasticity indications for the procedure, and planned line of indications
298 General Medicine MG neurology, pediatric MG120 Medical/ neuro rehablitation MG120C 15750 17325 18900 20475 22050 22837
management in cerebral palsy treatment b. Detailed procedure notes
medicine
General Medicine,
299 General Medicine MG neurology, pediatric MG117 Moyamoya revascularization MG117A Moyamoya revascularization 2200 2420 2640 2860 3080 3190
medicine
General Medicine,
300 General Medicine MG neurology, pediatric MG116 PLASMAPHERESIS MG116A Guillain Barre syndrome (Plasmapheresis) 2200 2420 2640 2860 3080 3190
medicine
General Medicine,
301 General Medicine MG neurology, pediatric MG116 PLASMAPHERESIS MG116B Myasthenic crisis (Plasmapheresis) 2200 2420 2640 2860 3080 3190
medicine
a)Clinical notes detailing examination findings, a)Detailed Indoor case paper along with
previous surgery/procedure, follow-up visit details, treatment details
investigations, Planned line of treatment b) b) Post treatment LFT (Liver function test),
302 General Medicine MG General medicine MG110 Acute liver failure MG110A Acute liver failure 2250 2475 2700 2925 3150 3262
USG Whole Abdomen c) LFT (Liver Serum Bilirubin Reports
function test), Serum Bilirubin c) Detailed discharge summary
d) Serological test for hepatitis
303 General Medicine MG General medicine MG108 Acute liver failure/Fulminant Hepatitis MG108A Acute liver failure/Fulminant Hepatitis 52500 57750 63000 68250 73500 76125
a)Clinical Notes including evaluation findings, a)Detailed Indoor case papers with treatment
indications for the procedure, and planned line of details
304 General Medicine MG General Medicine MG060 Electrolyte Imbalance MG060E Hyperkalaemia 2250 2475 2700 2925 3150 3262 treatment b) Serum Potassium b) Post treatment serum Potassium
report c) Other Serum Electrolytes c) Post treatment serum electrolytes
305 General Medicine MG General Medicine MG060 Electrolyte Imbalance MG060F Hypokalaemia 2250 2475 2700 2925 3150 3262 treatment b) Serum Potassium b) Post treatment serum Potassium
a) Clinical Notes including evaluation findings, a) Detailed indoor case papers along with
306 General Medicine MG General Medicine MG054 Gout MG054A Gout 2250 2475 2700 2925 3150 3262
treatment b) Serum Uric acid b) Detailed procedure notes
levels. c)reactive protein level c) Detailed Discharge Summary
A) Clinical notes A) Detailed ICPs
B) detailing history B) Treatment details
High end radiological diagnostic
C) Admission notes showing vitals C) detailed discharge summary
307 General Medicine MG General Medicine MG075 (CT, MRI, Imaging including nuclear MG075C Brain & Heart FDG PET Scan 15396 16935 18475 20014 21554 22324
D) examination findings D) All investigations reports.
imaging)
E) any investigations done
F) planned line of management
308 General Medicine MG General Medicine MG075 (CT, MRI, Imaging including nuclear MG075B FDG Whole body PET Scan 21554 23709 25864 28020 30175 31253
imaging)
Gallium-68 Peptide PET imaging for C) Admission notes showing vitals C) detailed discharge summary
309 General Medicine MG General Medicine MG075 (CT, MRI, Imaging including nuclear MG075D 15750 17325 18900 20475 22050 22837
Neuroendocrine Tumor D) examination findings D) All investigations reports.
imaging)
a) Clinical Notes including evaluation findings, a) Detailed Indoor case papers
indication b) Investigations reports (if done)
310 General Medicine MG General medicine MG112 Hyberbilirubinemia MG112A Hyberbilirubinemia 2250 2475 2700 2925 3150 3262 of procedure and planned line of management c) Detailed Procedure notes and indication (if
any)
a)Clinical notes detailing history and Admission a)Detailed Indoor case papers (ICPs)
notes showing vitals and examination findings. b) Treatment details
b)Investigation reports establishing diagnosis c) Relevant Investigations report
311 General Medicine MG General Medicine MG081 IHD / CAD / Arrhythmia MG081A Arrhythmia 2350 2585 2820 3055 3290 3407
ECG/ECHO/Cardiac Enzymes/ Angiography/ ECG/ECHO/Cardiac Enzymes/ Angiography/
Holter? Holter
Outside State
Bed Cost Cost
Cost
312 General Medicine MG General Medicine MG081 IHD / CAD / Arrhythmia MG081B CAD 2350 2585 2820 3055 3290 3407
Holter? Holter
313 General Medicine MG General medicine MG114 Oesophageal Varices Banding MG114A Oesophageal Varices Banding 2250 2475 2700 2925 3150 3262
a. Clinical notes detailing history and admission a. Detailed Indoor case papers (ICPs)
notes showing vitals and examination findings. b. b. Treatment details
Investigation reports such as Blood tests & c. Relevant Investigations report Blood tests
314 General Medicine MG General Medicine MG079 Peripheral Arterial Thrombosis MG079A Peripheral Arterial Thrombosis 2350 2585 2820 3055 3290 3407
Doppler Ultrasound & Doppler Ultrasound
c. Relevant investigations MRI/CT/MRA (optional) d. Detailed discharge summary
indications for the procedure, and planned line of treatment details b.
315 General Medicine MG General medicine MG111 Pleural Effusion MG111A Pleural Effusion 2250 2475 2700 2925 3150 3262 treatment b. Erythrocyte Post treatment Chest x-ray c.
Sedimentation Rate (ESR) report Detailed discharge summary
c. X – Ray / MRI / CT scan (Chest) report
a)Admission note b) Plan of a) Detailed Indoor case papers
management c) MLC copy(if applicable) b) Detailed Procedure notes
d) C.T. / M.R.I. / X-Ray e) Any other c) All investigation reports
316 General Medicine MG General medicine MG113 POLYTRAUMA MG113A Polytrauma 2250 2475 2700 2925 3150 3262
radiological investigation supporting diagnosis d) Detailed discharge summary
f) Clinical photograph
a. Clinical Notes detailing the injury and need for a. Detailed Indoor case papers
surgery b. Medico legal case report/ FIR copy b. Detailed Procedure/Operative notes
of accident (if applicable) c. X- c. Post op X-ray film and report of the
317 General Medicine MG General medicine MG113 POLYTRAUMA MG113E Trauma Blunt injury conservative 2250 2475 2700 2925 3150 3262
ray / CT report of the affected area. affected part
d. Clinical photograph of affected part d. Invoice/Barcode of implant, if used
e. Detailed discharge summary
of accident (if applicable) c. X- c. Post op X-ray film and report of chest
318 General Medicine MG General medicine MG113 POLYTRAUMA MG113F Trauma Contusion chest injury 2250 2475 2700 2925 3150 3262
ray/ CT report of fractured limb d. Invoice/Barcode of implant, if used
d. Clinical photograph of affected part (CT chest e. Detailed discharge summary
film and report)
a)Admission note b) Plan of a) Detailed Indoor case papers
management c) MLC copy(if applicable) b) Detailed Procedure notes
d) C.T. / M.R.I. / X-Ray e) Any other c) All investigation reports
319 General Medicine MG General medicine MG113 POLYTRAUMA MG113B Trauma- FacioMaxillary 2250 2475 2700 2925 3150 3262
radiological investigation supporting diagnosis d) Detailed discharge summary
f) Clinical photograph
320 General Medicine MG General medicine MG113 POLYTRAUMA MG113C Trauma Hand injury 2250 2475 2700 2925 3150 3262 of accident (if applicable) c. X- c. Post op X-ray film and report of chest
d. Clinical photograph of affected part e. Detailed discharge summary
of accident (if applicable) c. X- c. Post op X-ray film and report of chest
321 General Medicine MG General medicine MG113 POLYTRAUMA MG113D Trauma Rib fracture conservative 2250 2475 2700 2925 3150 3262
d. Clinical photograph of affected part (CT chest e. Detailed discharge summary
film and report)
322 General Medicine MG General medicine MG109 Pulmonary thromboembolism MG109A Pulmonary thromboembolism 2250 2475 2700 2925 3150 3262
a)Clinical Notes including evaluation findings, a)Detailed indoor case papers along with
treatment b) C-reactive protein b) Biopsy report (if applicable)
General medicine /high end Diffuse alveolar Hemorrhage Associated Diffuse alveolar Hemorrhage Associated with c) Urine Routine, ESR c) Antineutrophil cytoplasmic antibodies
323 General Medicine MG MG106 MG106A 142800 157080 171360 185640 199920 207060
drugs with SLE/Vasculitis/GP Syndrome SLE/Vasculitis/GP Syndrome (ANCA) levels / The antinuclear antibody
(ANA) test
a)Clinical Notes including evaluation findings, a)Detailed Indoor case paper (ICPs)
indications for the procedure, and planned line of b) Post treatment Plain X ray erect
General medicine /high end treatment b) Serum Amylase, Abdomen/USG/CT abdomen
324 General Medicine MG MG105 Pulmonary Thromboembolism MG105A Pulmonary Thromboembolism 26250 28875 31500 34125 36750 38062
drugs Lipase, LFT, CBC reports c) Serum Amylase, Lipase, LFT, CBC
c) USG Abdomen report/CT Abdomen (Contrast) d) Detailed discharge summary
a) Clinical notes detailing history. a) Detailed ICPs.

b) Admission notes showing vitals. b) Treatment details.
c) Examination findings. c) Detailed discharge summary.
General medicine /high end d) Any investigations done. d) All investigations reports.
325 General Medicine MG MG107 Severe/Refractory Vasculitis MG107A Severe/Refractory Vasculitis 78750 86625 94500 102375 110250 114187
drugs e) Planned line of management.
a) Clinical Notes including evaluation findings, a) Detailed Indoor Case papers along with
indications for the procedure, and planned line of treatment details
General Medicine, General treatment b) Post treatment glucose level
326 General Medicine MG MG058 Diabetic Foot MG058A Diabetic Foot -- debridement 2250 2475 2700 2925 3150 3262
Surgery,Endocrinology b) Complete Blood count, Blood glucose level, c) Post treatment photograph of affected foot
HbA1C Report d) Detailed Discharge Summary
c) Photograph of affected foot
a. Clinical notes including evaluation findings and a. Detailed indoor case papers
General Medicine, planned line of treatment b) b)b. Detailed Procedure / Operative Notes
327 General Medicine MG MG037 Cardiac Tamponade MG037A Cardiac Tamponade 2250 2475 2700 2925 3150 3262
Cardiology USG/CT report confirming the diagnosis of c) Intra procedure still photograph
intercostal abscess
indications for the procedure, and planned line of b) Post treatment Plain X ray erect
General Medicine, treatment b) Serum Amylase, Abdomen/USG/CT abdomen
328 General Medicine MG MG104 Acute necrotizing severe pancreatitis MG104A Acute necrotizing severe pancreatitis 2250 2475 2700 2925 3150 3262
Gastroenterology Lipase, LFT, CBC reports c) Serum Amylase, Lipase, LFT, CBC
c) USG Abdomen report/CT Abdomen (Contrast) d) Detailed discharge summary
Outside State
Bed Cost Cost
Cost
a)Clinical Notes including evaluation findings, and a)Detailed Indoor case paper (ICPs) b)
planned line of treatment b)x-ray of treatment given c)
General Medicine, colon,colonoscopy, sigmoidoscopy. detailed discharge summary
329 General Medicine MG MG101 Acute severe ulcerative colitis MG101A Acute severe ulcerative colitis 2250 2475 2700 2925 3150 3262
Gastroenterology c)stool and CBC reports
d) USG Abdomen report/CT Abdomen(contrast)
indications for the procedure, and planned line of b) Investigation report (X- ray erect
General Medicine,
330 General Medicine MG MG103 Intestinal obstruction MG103A Intestinal obstruction 2250 2475 2700 2925 3150 3262 treatment b) Any Investigation Abdomen/USG/CT abdomen)
Gastroenterology
done (x-ray,CT,USG, barium enema) c) Detailed discharge summary
a)Clinical Notes including evaluation findings, a)Detailed Indoor case paper (ICPs) b)
indications for the procedure, and planned line of treatment given c)
General Medicine,
331 General Medicine MG MG102 Mesenteric Ischemia MG102A Mesenteric Ischemia 2250 2475 2700 2925 3150 3262 treatment detailed discharge summary
Gastroenterology
b) USG Abdomen report/CT
Abdomen/Angiography
a)Clinical notes b) a)Clinical Notes / Indoor case papers
Pathological Examination (Complete Blood count, b)Detail discharge Summary & dialysis chart
Blood urea, Serum Creatinine, GFR, serum (Only dialysis chart in chronic dialysis pts) c)
electrolytes). In chronic renal failure/ chronic All investigation reports
General Medicine, General dialysis patients investigations need to be done
332 General Medicine MG MG045 AKI / Renal failure MG045A AKI / Renal failure 2250 2475 2700 2925 3150 3262 and submitted only once. These investigations to
Surgery,Nephrology
be repeated monthly.
Quarterly- Serum Iron, ferritin, TIBC, TSAT, SGOT,
SGPT, viral markers, calcium, phosphate c)
Planned line of treatment
General Medicine, General c) Examination findings. c) Detailed discharge summary.
333 General Medicine MG MG044 Renal colic MG044A Renal colic 2250 2475 2700 2925 3150 3262
Surgery,Nephrology d) Any investigations done. d) All investigations reports.
e) Planned line of management

General Medicine, dialysis patients investigations need to be done
334 General Medicine MG MG072 Haemodialysis / Peritoneal Dialysis MG072A Peritoneal Dialysis (Pd Catheter Insertion) 1575 1732 1890 2047 2205 2283 and submitted only once. These investigations to
Nephrology
335 General Medicine MG MG072 Haemodialysis / Peritoneal Dialysis MG072B Peritoneal Dialysis (PD fluid & disposables ) 1050 1155 1260 1365 1470 1522 and submitted only once. These investigations to
Nephrology
a)clinical notes including Indications for PDC a)detailed indoor case papers( ICP)
General Medicine, b)detailed descriptionof PDC b)procedure/ OT note
336 General Medicine MG MG100 Chronic PD catheter Insertion MG100A Chronic PD catheter Insertion 4305 4735 5166 5596 6027 6242
Nephrology- Interventional c)investigations-LFT,KFT and as perrequirement c) post treatment results d)
detailed discharge summary
337 General Medicine MG Nephrology, Organ MG072 Haemodialysis / Peritoneal Dialysis MG072D Haemodialysis (For Sero +ve patient) 2500 2750 3000 3250 3500 3625 and submitted only once. These investigations to
transplantation be repeated monthly.
338 General Medicine MG Nephrology, Organ MG072 Haemodialysis / Peritoneal Dialysis MG072C Haemodialysis (For Sero -ve patient) 1575 1732 1890 2047 2205 2283 and submitted only once. These investigations to
transplantation be repeated monthly.
a) Clinical Notes including evaluation findings, a) Detailed Indoor case papers with
General Medicine, Pediatric indications for the procedure, and planned line of treatment given
339 General Medicine MG MG062 Accelerated hypertension MG062A Accelerated hypertension 2250 2475 2700 2925 3150 3262
Medical Management treatment b) Detailed procedure notes
b) Fundoscopy report c) Detailed Discharge Summary
a) Clinical notes with detailing history a) Detailed Indoor case papers, Treatment
b) CBC, ESR, Peripheral smear, LFT report details
General Medicine, Pediatric
340 General Medicine MG MG001 Acute febrile illness MG001A Acute febrile illness 2250 2475 2700 2925 3150 3262 b) Post treatment CBC, ESR, Peripheral
Medical Management
smear, LFT reports
General Medicine, Pediatric indications for the procedure, and planned line of indications
341 General Medicine MG MG035 Acute transverse myelitis MG035A Acute transverse myelitis 2250 2475 2700 2925 3150 3262
Medical Management treatment b. Detailed procedure notes
a) Clinical Notes including history (Drug Hx, IV, Sub a) Detailed Indoor case papers
cutaneous TM, Oral), b) Post treatment CBC report
physical examination,evaluation findings, c) Detailed Discharge Summary
General Medicine, Pediatric indications for the
342 General Medicine MG MG066 Anaphylaxis MG066A Anaphylaxis 2250 2475 2700 2925 3150 3262
Medical Management procedure, and planned line of treatment
b) Complete Blood Count (CBC)/ allergen-specific
immunoglobulin E (IgE)
report
Outside State
Bed Cost Cost
Cost
a) Clinical Notes including evaluation findings, a) Detailed Indoor case papers including
indications for the procedure, and planned line of treatment
treatment b) Blood grouping details
General Medicine, Pediatric Blood component including platelet transfusion (ABO and Rh) b) Post Transfusion hemogram
343 General Medicine MG MG074 Blood transfusion MG074B 2100 2310 2520 2730 2940 3045
Medical Management (RDP, PC, SDP) c) Complete hemogram c) Detailed Discharge Summary
d) Viral markers of the donor e) Screening
for Malaria, Syphilis, HIV, HBV, HCV, CMV
a) Clinical Notes including evaluation findings, a) Detailed Indoor case papers including
indications for the procedure, and planned line of treatment
treatment b) Blood grouping details
General Medicine, Pediatric (ABO and Rh) b) Post Transfusion hemogram
344 General Medicine MG MG074 Blood transfusion MG074A Whole Blood transfusion 2100 2310 2520 2730 2940 3045
Medical Management c) Complete hemogram c) Detailed Discharge Summary
d) Viral markers of the donor e) Screening
for Malaria, Syphilis, HIV, HBV, HCV, CMV

indications for the procedure, and planned line of b) Post procedure CBC report
345 General Medicine MG MG005 Chikungunya fever MG005A Chikungunya fever 2250 2475 2700 2925 3150 3262 treatment c) Detailed Discharge Summary
Medical Management
b) CBC report
c) IgM - ELISA test reports for Chikungunya
a) Clinical notes b)Complete a) Indoor case papers including monitoring of
Blood Count (CBC) c) NS1 Antigen vitals b) Complete Blood Count
346 General Medicine MG MG004 Dengue fever MG004A Dengue fever 2250 2475 2700 2925 3150 3262 d)Peripheral blood film e) Planned line (CBC) c) All other
Medical Management
of treatment investigation reports d)
Discharge Summary
347 General Medicine MG MG004 Dengue fever MG004B Dengue hemorrhagic fever 2250 2475 2700 2925 3150 3262 d)Peripheral blood film e) Planned line (CBC) c) All other
Medical Management
Discharge Summary
348 General Medicine MG MG004 Dengue fever MG004C Dengue shock syndrome 2250 2475 2700 2925 3150 3262 d)Peripheral blood film e) Planned line (CBC) c) All other
Medical Management
Discharge Summary
indications treatment details
349 General Medicine MG MG060 Electrolyte Imbalance MG060A Hypercalcemia 2250 2475 2700 2925 3150 3262 for the procedure, and planned line of treatment b) Post treatment serum calcium
Medical Management
b) Serum Calcium report d) Detailed Discharge Summary
indications treatment details b) Post treatment serum
350 General Medicine MG MG060 Electrolyte Imbalance MG060D Hypernatremia 2250 2475 2700 2925 3150 3262 for the procedure, and planned line of treatment electrolytes
Medical Management
b) Other Serum Electrolytes c) Detailed Discharge Summary
indications treatment details
351 General Medicine MG MG060 Electrolyte Imbalance MG060B Hypocalcemia 2250 2475 2700 2925 3150 3262 for the procedure, and planned line of treatment b) Post treatment serum calcium
Medical Management
b) Serum Calcium report d) Detailed Discharge Summary
indications treatment details b) Post treatment serum
352 General Medicine MG MG060 Electrolyte Imbalance MG060C Hyponatremia 2250 2475 2700 2925 3150 3262 for the procedure, and planned line of treatment electrolytes
Medical Management
b) Other Serum Electrolytes c) Detailed Discharge Summary
a) Clinical notes with detailing history a) Detailed Indoor case papers, Treatment
b) CBC, ESR, Peripheral smear, LFT report details
353 General Medicine MG MG006 Enteric fever MG006A Enteric fever 2250 2475 2700 2925 3150 3262 b) Post treatment CBC, ESR, Peripheral
Medical Management
smear, LFT reports
a) Clinical notes with detailing history and a) Detailed Indoor Case Papers (ICPs) with
Admission notes showing vitals treatment details
(Temperature, BP, Pulse) and planned line of b) Post treatment WBC, Sr. electrolytes
General Medicine, Pediatric treatment c) Detailed Discharge Summary
354 General Medicine MG MG067 Heat stroke MG067A Heat stroke 2250 2475 2700 2925 3150 3262
Medical Management b) White Blood Count, Sr. electrolytes, Blood gas,
Creatine phosphokinase,
lactate dehydrogenase
a) Clinical Notes including evaluation findings, a) Detailed indoor case papers and
indications for the procedure, and planned line of treatment given b) Detailed
355 General Medicine MG MG007 HIV with complications MG007A HIV with complications 2250 2475 2700 2925 3150 3262 treatment Discharge Summary
Medical Management
b) CD4 cell count report
c) HIV-ELISA/HIV viral load report
a) Clinical Notes including evaluation findings, a) Detailed Indoor case papers with details of
356 General Medicine MG MG051 Hydrocephalus MG051A Hydrocephalus 2250 2475 2700 2925 3150 3262
b) Neuroimaging report c) Detailed Discharge Summary
357 General Medicine MG MG061 Hyperosmolar Non-Ketotic coma MG061A Hyperosmolar Non-Ketotic coma 2350 2585 2820 3055 3290 3407
358 General Medicine MG MG063 Hypertensive emergencies MG063A Hypertensive emergencies 2250 2475 2700 2925 3150 3262
b) Fundoscopy report c) Detailed Discharge Summary
General Medicine, Pediatric c) Examination findings. c) Detailed discharge summary.
359 General Medicine MG MG050 Immune mediated CNS disorders MG050A Immune mediated CNS disorders 2250 2475 2700 2925 3150 3262
Medical Management d) Any investigations done. d) All investigations reports.
a) Clinical notes detailing examination findings, a) Detailed Indoor case papers and
investigations, Planned line of treatment treatment details
360 General Medicine MG MG008 Leptospirosis MG008A Leptospirosis 2250 2475 2700 2925 3150 3262 b) MAT (Microscopic Agglutination Test), PCR or b) Detailed discharge summary
Medical Management
IgM antibody test
c) LFT, KFT Reports
Outside State
Bed Cost Cost
Cost
a) Clinical Notes including evaluation findings, a) Detailed Indoor case paper
indications for the procedure, and planned line of
b) Post treatment Blood investigation report
361 General Medicine MG MG003 Malaria MG003B Complicated malaria 2250 2475 2700 2925 3150 3262 treatment (CBC, MP, Platelet
Medical Management
b) Peripheral smear/RMT test report etc.)
c) Blood report (CBC, MP, Platelet.) c) Detailed discharge summary
a) Clinical Notes including evaluation findings, a) Detailed Indoor case paper
indications for the procedure, and planned line of
b) Post treatment Blood investigation report
362 General Medicine MG MG003 Malaria MG003A Malaria 2250 2475 2700 2925 3150 3262 treatment (CBC, MP, Platelet
Medical Management
b) Peripheral smear/RMT test report etc.)
c) Blood report (CBC, MP, Platelet.) c) Detailed discharge summary
a) Clinical Notes including evaluation findings, a) Detailed indoor case papers along with
General Medicine, Pediatric indications for the procedure, and planned line of
indications
363 General Medicine MG MG073 Plasmapheresis MG073A Plasmapheresis 2100 2310 2520 2730 2940 3045
c) Detailed discharge summary
a)Clinical notes detailing history and admission a. Detailed indoor case papers (ICPs)
notes showing vitals and examination findings. b. Treatment details
b)Relevant investigations like CBC, Prothrombin c. Relevant investigations report - CBC/
General Medicine, Pediatric Time (PT), Partial Thromboplastin Time (PTT) and Prothrombin Time (PT)/ Partial
364 General Medicine MG MG099 Platelet pheresis MG099A Platelet pheresis 11550 12705 13860 15015 16170 16747
Medical Management Platelet Function Test Thromboplastin Time (PTT) / Platelet
Function Test
d. Detailed discharge summary
indications for the procedure, and planned line of treatment given details
General Medicine, Pediatric treatment b) Detailed discharge summary
365 General Medicine MG MG071 Poisoning MG071A Acute organophosphorus poisoning 2250 2475 2700 2925 3150 3262
Medical Management b) Red cell cholinesterase level, ECG, CBL, LFT,
KFT reports (as applicable)
c) Copy of Medico legal certificate / FIR
General Medicine, Pediatric treatment b) Detailed discharge summary
366 General Medicine MG MG071 Poisoning MG071B Other poisonings 2250 2475 2700 2925 3150 3262
Medical Management b) Red cell cholinesterase level, ECG, CBL, LFT,
KFT reports (as applicable)
c) Copy of Medico legal certificate / FIR
Clinical notes with vitals (Blood pressure, Pulse a) Indoor case papers
367 General Medicine MG MG026 Pyrexia of unknown origin MG026A Pyrexia of unknown origin 2250 2475 2700 2925 3150 3262 rate) b)CT/MRI scan report
Medical Management
Clinical notes with vitals (Blood pressure, Pulse a)Indoor case papers
368 General Medicine MG MG023 Septic Arthritis MG023A Septic Arthritis 2250 2475 2700 2925 3150 3262 rate) b)CT/MRI scan report
Medical Management
c)Discharge Summary
a) Clinical Notes including evaluation findings, a) Detailed Indoor case papers and
General Medicine, Pediatric indications for the procedure, and planned line of Treatment details
369 General Medicine MG MG064 Severe anemia MG064A Severe anemia 2250 2475 2700 2925 3150 3262
Medical Management treatment b) Post treatment CBC, Hb reports
b) CBC, Hb report c) Detailed Discharge Summary
a) Clinical notes b) Complete a) Indoor case papers b)
Blood count Culture reports- Blood & Urine
370 General Medicine MG MG002 Severe sepsis MG002B Septic shock 2250 2475 2700 2925 3150 3262 Urine Routine c) Planned c) Biochemistry- Renal Function Test &
Medical Management
line of management Liver Function Test reports d) Discharge
summary
a) Clinical notes b) Complete a) Indoor case papers b)
Blood count Culture reports- Blood & Urine
371 General Medicine MG MG002 Severe sepsis MG002A Severe sepsis 2250 2475 2700 2925 3150 3262 Urine Routine c) Planned c) Biochemistry- Renal Function Test &
Medical Management
line of management Liver Function Test reports d) Discharge
summary
indications for the procedure, and planned line of treatment chart
372 General Medicine MG MG065 Sickle cell Anemia MG065A Sickle cell Anemia 2250 2475 2700 2925 3150 3262 treatment b) High-performance liquid chromatography
Medical Management
b) Electrophoresis report (HPLC)
373 General Medicine MG MG024 Skin and soft tissue infections MG024A Skin and soft tissue infections 2250 2475 2700 2925 3150 3262 rate) b)CT/MRI scan report
Medical Management
c)Discharge Summary
a) Clinical Notes including evaluation findings, a) Detailed Indoor Case Papers with
indications for the procedure, and planned line of treatment details
374 General Medicine MG MG070 Snake bite MG070A Snake bite 2250 2475 2700 2925 3150 3262 treatment b) Details of Anti-snake venom used (If
Medical Management
b) Urine examination for albumin and blood report applicable)
indications for the procedure, advise for admission treatment details
and planned line of treatment b) Detailed Discharge Summary
General Medicine, Pediatric Systematic lupus erythematosus (SLE)/ Diffuse b) Antinuclear antibody (ANA test)
375 General Medicine MG MG068 Systematic lupus erythematosus MG068A 2250 2475 2700 2925 3150 3262
Medical Management alveolar hemmorhage associated with SLE c) Erythrocyte sedimentation rate (ESR) or C-
reactive protein (CRP) level
d) X ray report
General Medicine, Pediatric b)Investigation reports establishing diagnosis c) Relevant Investigations report
376 General Medicine MG MG021 Urinary Tract Infection MG021A Urinary Tract Infection 2250 2475 2700 2925 3150 3262
Medical Management ECG/ECHO/Cardiac Enzymes/ Angiography/ ECG/ECHO/Cardiac Enzymes/ Angiography/
Holter? Holter
a)Clinical notes b)Clinical Evaluation a)Detailed Indoor case papers (ICPs)
c)CT/MRI brain d)Cerebrospinal Fluid (CSF) b)Detailed Procedure / operative notes
General Medicine, Pediatric Analysis e)Coagulation Profile f)Planned c)Post-operative photographs (optional)
377 General Medicine MG MG032 Vasculitis MG032A Vasculitis 2250 2475 2700 2925 3150 3262
Medical Management line of treatment d)CT brain (Preop & Post
op)e)Histopathology examination f)Detailed
discharge summary
378 General Medicine MG MG022 Viral Encephalitis MG022A Viral Encephalitis 2250 2475 2700 2925 3150 3262
379 General Medicine MG Medical Management, MG036 Atrial Fibrillation MG036A Atrial Fibrillation 2250 2475 2700 2925 3150 3262
Cardiology
380 General Medicine MG Medical Management, MG038 Congestive heart failure MG038A Congestive heart failure 2250 2475 2700 2925 3150 3262
Cardiology
Outside State
Bed Cost Cost
Cost
indications for the procedure, and planned line of treatment given
treatment. b. Relevant b. Detailed Discharge Summary
381 General Medicine MG Medical Management, MG031 Endocarditis MG031A Bacterial Endocarditis 2250 2475 2700 2925 3150 3262
Investigations i. Hemogram ii.
Cardiology
Biochemistry. c. MRI/CT Spinal
cord
a. Clinical notes detailing the injury and need for a. Detailed Indoor case papers
surgery , Planned line of treatment. b. Detailed Procedure/ Operative notes
b. Medico legal case report/ FIR copy of accident c. Post op X-ray film and report of skull
382 General Medicine MG Medical Management, MG031 Endocarditis MG031B Fungal Endocarditis 2250 2475 2700 2925 3150 3262
(if applicable) c. X-ray/ CT d. Detailed discharge summary
Cardiology
report d. CT/ MRI Brain film and report

General Medicine, Pediatric indications for the procedure, and planned line of b) Post treatment Stool culture report
383 General Medicine MG Medical Management, MG009 Acute gastroenteritis with dehydration MG009A Acute gastroenteritis with moderate dehydration 2250 2475 2700 2925 3150 3262 treatment c) Post treatment Sr. Electrolyte report
Gastroenterology b) CBC report d) Detailed Discharge Summary
c) Sr. Electrolyte report
General Medicine, Pediatric indications for the procedure, and planned line of b) Post treatment Stool culture report
384 General Medicine MG Medical Management, MG009 Acute gastroenteritis with dehydration MG009B Acute gastroenteritis with severe dehydration 2250 2475 2700 2925 3150 3262 treatment c) Post treatment Sr. Electrolyte report
Gastroenterology b) CBC report d) Detailed Discharge Summary
indications for the procedure, and planned line of b) ACTH stimulation test, Contrast-Enhanced
treatment CT Abdomen report
385 General Medicine MG Medical MG043 Addison’s disease MG043A Addison’s disease 2250 2475 2700 2925 3150 3262
b) Sr. Electrolyte, Sr. Cortisol Yes c) Post treatment Blood sugar test report
Management,Endocrinology
c) Blood Sugar test d) Post treatment Sr. Cortisol level report
a) Clinical Notes including evaluation findings, a) Detailed Indoor case papers and
General Medicine, Pediatric treatment b) Post procedure blood glucose (fasting and
386 General Medicine MG Medical MG059 Diabetic ketoacidosis MG059A Diabetic ketoacidosis 2250 2475 2700 2925 3150 3262 b) Blood glucose (RBS) PP)
Management,Endocrinology c) Sr. Bicarbonate report c) Detailed Discharge summary
d) Arterial blood gas report
e) Urine Ketone report
387 General Medicine MG Medical MG057 Hypoglycemia MG057A Hypoglycemia 2250 2475 2700 2925 3150 3262
Management,Endocrinology
treatment b) Post treatment FTSH, FT3 and FT4 level
General Medicine, Pediatric b) Thyroid stimulating hormone (TSH), Free c) Detailed Discharge Summary
388 General Medicine MG Medical MG052 Myxedema coma MG052A Myxedema coma 2250 2475 2700 2925 3150 3262
Triiodothyronine (FT3) and Free Thyroxine (FT4)
Management,Endocrinology level reports
d) USG thyroid gland report
indications for the procedure, advise for admission treatment details
and planned line of treatment b) Radionuclide Iodine uptake study report
General Medicine, Pediatric b) Thyroid stimulating hormone, Free c) Post treatment Thyroid stimulating
389 General Medicine MG Medical MG053 Thyrotoxic crisis MG053A Thyrotoxic crisis 2250 2475 2700 2925 3150 3262
triiodothyonine (FT3), hormone, Free triiodothyonine
Management,Endocrinology Free Thyroxine (FT4) (FT3), Free Thyroxine (FT4)
c) Thyroid Ultrasound scan d) Detailed Discharge Summary
General Medicine, Pediatric a) Clinical Notes including evaluation findings, a) Detailed indoor case papers along with
Medical indications for the procedure, and planned line of indications
390 General Medicine MG MG012 Acute viral hepatitis MG012A Acute viral hepatitis 2250 2475 2700 2925 3150 3262
Management,Gastroenterol treatment b) Serum Uric acid b) Detailed procedure notes
ogy levels. c)reactive protein level c) Detailed Discharge Summary
a. Clinical Notes including evaluation findings, a). Detailed Indoor case papers with details
indications for the procedure, and planned line of of treatment given ( ATT if given) b) Detailed
Medical
391 General Medicine MG MG034 Ascites MG034A Ascites 2250 2475 2700 2925 3150 3262 treatment b)LP/HP report procedure notes c). Detailed
Management,Gastroenterol
c). Neuroimaging report. d). CBNAAT with Discharge Summary
ogy
DST if applicable
Medical
392 General Medicine MG MG013 Chronic Hepatitis MG013A Chronic Hepatitis 2250 2475 2700 2925 3150 3262 treatment b) Serum Potassium b) Post treatment serum Potassium
ogy
a)Clinical notes detailing examination findings, a. Detailed Indoor case papers with
General Medicine, Pediatric previous surgery/procedure, follow-up visit details, treatment details b.
Medical investigations, Planned line of treatment b) Post treatment Chest x-ray c.
393 General Medicine MG MG010 Diarrohea MG010A Chronic diarrohea 2250 2475 2700 2925 3150 3262
Management,Gastroenterol USG Whole Abdomen c) LFT (Liver Detailed discharge summary
ogy function test), Serum Bilirubin
indications for the procedure, and planned line of treatment details b.
Medical
394 General Medicine MG MG010 Diarrohea MG010B Persistent diarrohea 2250 2475 2700 2925 3150 3262 treatment b. Erythrocyte Post treatment Chest x-ray c.
Sedimentation Rate (ESR) report Detailed discharge summary
ogy
c. X – Ray / MRI / CT scan (Chest) report
General Medicine, Pediatric a. Clinical Notes including evaluation findings, a. Detailed indoor case papers along with
395 General Medicine MG MG011 Dysentery MG011A Dysentery 2250 2475 2700 2925 3150 3262
Management,Gastroenterol treatment b. Detailed procedure notes
ogy c. Detailed discharge summary
Medical
396 General Medicine MG MG014 Liver abscess MG014A Liver abscess 2250 2475 2700 2925 3150 3262 treatment b) Serum Potassium b) Post treatment serum Potassium
ogy
a) Clinical Notes including evaluation findings, a) Detailed Indoor Case Papers and
indications for the procedure, and planned line of Treatment details
Medical
397 General Medicine MG MG042 Lower GI hemorrhage MG042A Lower GI hemorrhage 2250 2475 2700 2925 3150 3262 treatment b) Detailed Discharge Summary
b) CBC, Platelets reports
ogy
c) Fecal tagging / Colonoscopy reports
398 General Medicine MG MG033 Pancreatitis MG033A Acute pancreatitis 2250 2475 2700 2925 3150 3262
Outside State
Bed Cost Cost
Cost
399 General Medicine MG MG033 Pancreatitis MG033B Chronic pancreatitis 2250 2475 2700 2925 3150 3262
General Medicine, Pediatric Clinical notes with vitals (Blood pressure, Pulse a)Indoor case papers
Medical rate) b)CT/MRI scan report
400 General Medicine MG MG025 Recurrent vomiting with dehydration MG025A Recurrent vomiting with dehydration 2250 2475 2700 2925 3150 3262
Management,Gastroenterol c)Discharge Summary
ogy
General Medicine, Pediatric indications for the procedure, and planned line of treatment given details
Medical treatment b) Detailed discharge summary
401 General Medicine MG MG041 Upper GI bleeding MG041A Upper GI bleeding (conservative) 2250 2475 2700 2925 3150 3262
Management,Gastroenterol b) Complete Blood count, platelets, Liver Function
ogy Test, Hemoglobin
c) Upper endoscopy report/CT
General Medicine, Pediatric indications for the procedure, and planned line of treatment given details
Medical treatment b) Detailed discharge summary
402 General Medicine MG MG041 Upper GI bleeding MG041B Upper GI bleeding (endoscopic) 2250 2475 2700 2925 3150 3262
Management,Gastroenterol b) Complete Blood count, platelets, Liver Function
ogy Test, Hemoglobin
c) Upper endoscopy report/CT
403 General Medicine MG MG015 Visceral leishmaniasis MG015A Visceral leishmaniasis 2250 2475 2700 2925 3150 3262
General Medicine, Pediatric indications for the procedure, and planned line of details
404 General Medicine MG Medical MG056 Neuromuscular Disorders MG056A Neuromuscular Disorders 2250 2475 2700 2925 3150 3262 treatment b) Serum Potassium b) Post treatment serum Potassium
Management,Neurology report c) Other Serum Electrolytes c) Post treatment serum electrolytes
a) Clinical notes with vitals and indications a) Indoor case papers
b) C.T./L.P. c) b)CT/LP. Report
405 General Medicine MG Medical MG028 Acute bronchitis MG028A Acute bronchitis 2250 2475 2700 2925 3150 3262
Routine Blood test(CBC) d) Plan line of c) Treatment Details d)CSF culture report
Management,Pulmonology
treatment e) Detailed Discharge Summary
a) Clinical notes with indications a)Indoor case papers
General Medicine, Pediatric b) Chest X Ray c) b) CSF examination
Acute excaberation of Interstitial Lung
406 General Medicine MG Medical MG030 MG030A Acute excaberation of Interstitial Lung Disease 2250 2475 2700 2925 3150 3262 Planned line of treatment c) CT Brain
Disease
Management,Pulmonology d) Discharge Summary
e) GST Invoice of IVIG
407 General Medicine MG Medical MG039 Asthma MG039A Acute asthmatic attack 2250 2475 2700 2925 3150 3262
408 General Medicine MG Medical MG039 Asthma MG039B Status asthmaticus 2250 2475 2700 2925 3150 3262
b) C.T./L.P. c) b)CT/LP. Report
409 General Medicine MG Medical MG027 Bronchiectasis MG027A Bronchiectasis 2250 2475 2700 2925 3150 3262
Routine Blood test(CBC) d) Plan line of c) Treatment Details d)CSF culture report
a)Clinical notes detailing history b)Notes showing a)Detailed Indoor case papers (ICPs)
General Medicine, Pediatric evidence of unstable hemodynamic status b)Any investigation done.
410 General Medicine MG Medical MG018 Empyema MG018A Empyema 2250 2475 2700 2925 3150 3262 c)Investigations done –Serum creatinine c)Treatment details
Management,Pulmonology d)Indication for CRRT e)Planned line of d)Detailed Discharge summary
treatment
a. Clinical notes detailing history of alcohol a. Detailed indoor case papers (ICPs)
consumption and admission notes showing vitals b. Treatment details
and examination findings. b. Investigation c. Investigations reports (LFT/ Prothrombin
General Medicine, Pediatric reports establishing diagnosis – LFT/ Prothrombin time/ Serum albumin/ Serum electrolytes)
411 General Medicine MG Medical MG019 Lung abscess MG019A Lung abscess 2250 2475 2700 2925 3150 3262
time/ Serum albumin/ Serum electrolytes c. d. Detailed discharge summary
Management,Pulmonology Other relevant investigations of USG/CT/MRI/Liver
Biopsy/Endoscopy (if required)

General Medicine, Pediatric dialysis patients investigations need to be done
412 General Medicine MG Medical MG016 Pneumonia MG016A Pneumonia 2250 2475 2700 2925 3150 3262 and submitted only once. These investigations to
Management,Pulmonology be repeated monthly.
General Medicine, Pediatric indications for the procedure, and planned line of details
413 General Medicine MG Medical MG055 Pneumothorax MG055A Pneumothorax 2250 2475 2700 2925 3150 3262 treatment b) Serum Potassium b) Post treatment serum Potassium
Management,Pulmonology report c) Other Serum Electrolytes c) Post treatment serum electrolytes
a) Clinical notes with APACHE a)Still photograph of the patient undergoing
score b the treatment (+/- ventilatory
)Investigations support) b) Detailed
1. CBC Indoor case papers having treatment and
2. Chest X-ray management c) Relevant
3. ABG (if investigations including serial ABGs (refer
available) para 1.5 i. b.) (ABG if
General Medicine, Pediatric Respiratory failure Due to any cause 4. ECG Available) d) Detailed
414 General Medicine MG Medical MG040 Respiratory failure MG040C (pneumonia, asthma, COPD, ARDS, foreign 2250 2475 2700 2925 3150 3262 5. NCCT Head discharge summary
Management,Pulmonology body, poisoning, head injury etc.) 6. Fundus
examination c )Clinical
photograph of the patient on
bed
Outside State
Bed Cost Cost
Cost
415 General Medicine MG Medical MG040 Respiratory failure MG040A Type 1 respiratory failure 2250 2475 2700 2925 3150 3262
a)Clinical notes detailing history and admission a. Detailed indoor case papers (ICPs)
notes showing vitals and examination findings. b. Treatment details
General Medicine, Pediatric b)Relevant investigations like CBC, Prothrombin c. Relevant investigations report - CBC/
416 General Medicine MG Medical MG040 Respiratory failure MG040B Type 2 respiratory failure 2250 2475 2700 2925 3150 3262 Time (PT), Partial Thromboplastin Time (PTT) and Prothrombin Time (PT)/ Partial
Management,Pulmonology Platelet Function Test Thromboplastin Time (PTT) / Platelet
Function Test
General Medicine, Pediatric dialysis patients investigations need to be done
417 General Medicine MG Medical MG017 Severe pneumonia MG017A Severe pneumonia 2250 2475 2700 2925 3150 3262 and submitted only once. These investigations to
Management,Pulmonology be repeated monthly.
a. Clinical notes detailing history and admission a. Detailed Indoor case papers (ICPs)
notes showing vitals and examination findings. b. b. Treatment details
Investigation reports such as Blood tests & c. Relevant Investigations report Blood tests
418 General Medicine MG Medical MG020 TUBERCULOSIS MG020A Pericardial tuberculosis 2250 2475 2700 2925 3150 3262
Doppler Ultrasound & Doppler Ultrasound
c. Relevant investigations MRI/CT/MRA (optional) d. Detailed discharge summary
419 General Medicine MG Medical MG020 TUBERCULOSIS MG020B Pleural tuberculosis 2250 2475 2700 2925 3150 3262
Holter? Holter
A) Clinical notes a). Detailed Indoor case papers with details
B) detailing history of treatment given b)
General Medicine, BRONCHOSCOPY / INTERCOSTAL C) Admission notes showing vitals Detailed procedure notes c).
420 General Medicine MG MG096 MG096A Bronchoscopy 8925 9817 10710 11602 12495 12941
Pulmonology DRAINAGE D) examination findings Detailed Discharge Summary
General Medicine, Endobronchial Ultrasound guided fine needle C) Admission notes showing vitals C) detailed discharge summary
421 General Medicine MG MG097 Endobronchial Ultrasound (EBUS) MG097A 16500 18150 19800 21450 23100 23925
Pulmonology interventional biopsy D) examination findings D) All investigations reports.
a. Clinical notes including evaluation findings and a. Detailed indoor case papers
General Medicine,
BRONCHOSCOPY / INTERCOSTAL planned line of treatment b) b)b. Detailed Procedure / Operative Notes
422 General Medicine MG Pulmonology, General MG096 MG096B Intercostal drainage 2250 2475 2700 2925 3150 3262
DRAINAGE USG/CT report confirming the diagnosis of c) Intra procedure still photograph
surgery
intercostal abscess
a. Clinical notes detailing history of alcohol a. Detailed indoor case papers (ICPs)
consumption and admission notes showing vitals b. Treatment details
and examination findings. b. Investigation c. Investigations reports (LFT/ Prothrombin
General reports establishing diagnosis – LFT/ Prothrombin time/ Serum albumin/ Serum electrolytes)
423 General Medicine MG MG078 Alcoholic Liver Disease MG078A Alcoholic Liver Disease 2350 2585 2820 3055 3290 3407
Medicine,Gastroenterology time/ Serum albumin/ Serum electrolytes c. d. Detailed discharge summary
Other relevant investigations of USG/CT/MRI/Liver
Biopsy/Endoscopy (if required)
A) Clinical notes a). Detailed Indoor case papers with details

B) detailing history of treatment given b)
General C) Admission notes showing vitals Detailed procedure notes c).
424 General Medicine MG MG095 Cholangitis MG095A Cholangitis 2250 2475 2700 2925 3150 3262
medicine,Gastroenterology D) examination findings Detailed Discharge Summary
General a)Clinical notes with vitals (Blood pressure, Pulse a)Indoor case papers b)CT/MRI scan report
425 General Medicine MG MG049 Acute hemorrhagic stroke MG049D Acute hemorrhagic stroke 2250 2475 2700 2925 3150 3262
Medicine,Neurology rate) c)Discharge Summary
a)Clinical notes b)Clinical Evaluation a)Detailed Indoor case papers (ICPs)
c)CT/MRI brain d)Cerebrospinal Fluid (CSF) b)Detailed Procedure / operative notes
General Acute hemorrhagic stroke- Extra ventricular Analysis e)Coagulation Profile f)Planned c)Post-operative photographs (optional)
426 General Medicine MG MG091 ACUTE HEMORRHAGIC STROKE MG091B 2250 2475 2700 2925 3150 3262
Medicine,Neurology drainage line of treatment d)CT brain (Preop & Post
op)e)Histopathology examination f)Detailed
discharge summary
a. Clinical notes detailing the injury and need for a. Detailed Indoor case papers
surgery , Planned line of treatment. b. Detailed Procedure/ Operative notes
General Acute hemorrhagic stroke- Hematoma b. Medico legal case report/ FIR copy of accident c. Post op X-ray film and report of skull
427 General Medicine MG MG091 ACUTE HEMORRHAGIC STROKE MG091A 2250 2475 2700 2925 3150 3262
Medicine,Neurology evacuation (if applicable) c. X-ray/ CT d. Detailed discharge summary
report d. CT/ MRI Brain film and report
General
428 General Medicine MG MG086 ACUTE ISCHEMIC STOKE MG086A Acute Ischemic Stoke 2250 2475 2700 2925 3150 3262 rate) b)CT/MRI scan report
Medicine,Neurology
c)Discharge Summary
General Acute ischemic stroke- intravenous thrombolysis -
429 General Medicine MG MG086 ACUTE ISCHEMIC STOKE MG086B 2250 2475 2700 2925 3150 3262 rate) b)CT/MRI scan report
Medicine,Neurology Recombinant tissue plasminogen activator
c)Discharge Summary
General Acute ischemic stroke- Intravenous thrombolysis-
430 General Medicine MG MG086 ACUTE ISCHEMIC STOKE MG086C 2250 2475 2700 2925 3150 3262 rate) b)CT/MRI scan report
Medicine,Neurology Tenecteplase
c)Discharge Summary
General Acute transverse myelitis/ Acute demyelinating treatment. b. Relevant b. Detailed Discharge Summary
431 General Medicine MG MG090 ENCEPHALITIS / MYELITIS MG090C 2250 2475 2700 2925 3150 3262
Medicine,Neurology encephalitis Investigations i. Hemogram ii.
Biochemistry. c. MRI/CT Spinal
cord
Outside State
Bed Cost Cost
Cost
b) Chest X Ray c) b) CSF examination
General Autoimmune encephalitis - Immunoglubulin
432 General Medicine MG MG090 ENCEPHALITIS / MYELITIS MG090B 2250 2475 2700 2925 3150 3262 Planned line of treatment c) CT Brain
Medicine,Neurology (IVIG)
e) GST Invoice of IVIG
General b) Chest X Ray c) b) CSF examination
433 General Medicine MG MG090 ENCEPHALITIS / MYELITIS MG090A Autoimmune encephalitis - Plasmapheresis 2250 2475 2700 2925 3150 3262
Medicine,Neurology Planned line of treatment c) CT Brain
General b) C.T./L.P. c) b)CT/LP. Report
434 General Medicine MG MG089 Fungal Meningitis MG089A Fungal Meningitis 2250 2475 2700 2925 3150 3262
Medicine,Neurology Routine Blood test(CBC) d) Plan line of c) Treatment Details d)CSF culture report
General
435 General Medicine MG MG092 Myasthenic crisis (IVIG) MG092B Myasthenic crisis - Immunoglobulins (IVIG) 2250 2475 2700 2925 3150 3262 treatment. b. Relevant b. Detailed Discharge Summary
Medicine,Neurology
Investigations c. MRI/CT
Spinal cord
General
436 General Medicine MG MG093 Myasthenic crisis (Plasmapheresis) MG093A Myasthenic crisis - Plasmapheresis 2250 2475 2700 2925 3150 3262 treatment. b. Relevant b. Detailed Discharge Summary
Medicine,Neurology
Spinal cord
General b) C.T./L.P. c) b)CT/LP. Report
437 General Medicine MG MG088 Pyogenic Meningitis MG088A Pyogenic Meningitis 2250 2475 2700 2925 3150 3262
Medicine,Neurology Routine Blood test(CBC) d) Plan line of c) Treatment Details d)CSF culture report
a. Clinical Notes including evaluation findings, a). Detailed Indoor case papers with details
indications for the procedure, and planned line of of treatment given ( ATT if given) b) Detailed
General Tuberculous meningitis (Hydrocephalus – Tuberculous meningitis (Hydrocephalus – VP
438 General Medicine MG MG094 MG094A 2250 2475 2700 2925 3150 3262 treatment b)LP/HP report procedure notes c). Detailed
Medicine,Neurology VP SHUNT/ EVD/Omaya) SHUNT/ EVD/Omaya)
c). Neuroimaging report. d). CBNAAT with Discharge Summary
DST if applicable
Clinical notes with vitals (Blood pressure, Pulse a) Indoor case papers
General
439 General Medicine MG MG087 Venous sinus thrombosis MG087A Venous sinus thrombosis 2250 2475 2700 2925 3150 3262 rate) b)CT/MRI scan report
Medicine,Neurology
General b) Chest X Ray c) b) CSF examination
440 General Medicine MG MG029 Acute excaberation of COPD MG029A Acute excaberation of COPD 2250 2475 2700 2925 3150 3262
Medicine,Pulmonology Planned line of treatment c) CT Brain
Interventional General
441 General Medicine MG MG082 Bone marrow aspiration of biopsy MG082A Bone marrow aspiration of biopsy 1300 1430 1560 1690 1820 1885 treatment. b. Relevant b. Detailed Discharge Summary
Medicine
Spinal cord
Interventional General DVT Pneumatic Compression Stockings DVT Pneumatic Compression Stockings (Add on
442 General Medicine MG MG085 MG085A 1000 1100 1200 1300 1400 1450 treatment. b. Relevant b. Detailed Discharge Summary
Medicine (Add on package in ICU) package in ICU)
Spinal cord
443 General Medicine MG MG084 Joint Aspiration MG084A Joint Aspiration 250 275 300 325 350 362 treatment. b. Relevant b. Detailed Discharge Summary
Medicine
Spinal cord
444 General Medicine MG MG083 Lumbar puncture MG083A Lumbar puncture 150 165 180 195 210 217 treatment. b. Relevant b. Detailed Discharge Summary
Medicine
Spinal cord
a)Clinical notes detailing history b)Notes showing a)Detailed Indoor case papers (ICPs)
Pediatric Medical Continuous renal replacement evidence of unstable hemodynamic status b)Any investigation done.
Continuous renal replacement therapy in AKI
445 General Medicine MG Management, General MG077 therapy/Continuous veno-venous MG077A 34650 38115 41580 45045 48510 50242 c)Investigations done –Serum creatinine c)Treatment details
(initiation cost for disposable)
Medicine,Nephrology hemofiltration d)Indication for CRRT e)Planned line of d)Detailed Discharge summary
treatment
a) Clinical notes and a) Histopath
b) Sr Amylase and Sr Lipase b) Intra procedure clinical photograph
c) CT/MRI c) Detailed discharge summary
d) USG d) Detailed Operative notes
446 General Surgery SG General Surgery SG121 Pancreatic Necrosectomy SG121A Pancreatic Necrosectomy 63000 69300 75600 81900 88200 91350
e) ERCP
justifying the surgery.
a) Clinical notes including evaluation findings a) Detailed Indoor case papers (ICPs) with
Lap especially per rectal examination, indication for treatment details
447 General Surgery SG General Surgery SG027 Abdominal Procedure for Rectal Prolapse SG027B 21315 23446 25578 27709 29841 30906
procedure, and planned line of management b) Detailed Procedure / operative notes
Open especially per rectal examination, indication for treatment details
448 General Surgery SG General Surgery SG027 Abdominal Procedure for Rectal Prolapse SG027A 21315 23446 25578 27709 29841 30906
Pathological Examination (Complete Blood count, b)Detail discharge Summary c) All
Blood urea, Serum Creatinine, GFR, serum investigation reports
electrolytes). In chronic renal failure/ chronic
dialysis patients investigations need to be done
449 General Surgery SG General Surgery SG094 AV Fistula without prosthesis SG094A AV Fistula without prosthesis 19320 21252 23184 25116 27048 28014 and submitted only once. These investigations to
a) Clinical notes a) Post procedure clinical photograph
b) Some imaging to show tract of sinus b) Detailed Operative notes
c)Clinical Photograph c) Detailed discharge summary
450 General Surgery SG General Surgery SG110 Brachial sinus excision SG110A Brachial sinus excision 21000 23100 25200 27300 29400 30450
confirming the diagnosis. d) Histopath of Curreted material
Outside State
Bed Cost Cost
Cost
a) Clinical notes and a) Detailed discharge summary
b) X Ray Abdomen b) X Ray Abdomen
c) CT Contrast c) Detailed Operative notes.
451 General Surgery SG General Surgery SG101 Caecopexy SG101A Caecopexy 26250 28875 31500 34125 36750 38062
confirming the diagnosis.
a) Clinical notes and a) Histopathology report

b) LFT AND Sr Amylase & Sr Lipase b) Intra procedure clinical photograph
c) CT/USG c) Detailed discharge summary
Choledochoduodenostomy Or Choledocho Choledochoduodenostomy Or Choledocho d) ERCP d) Detailed Operative notes
452 General Surgery SG General Surgery SG118 SG118A 36750 40425 44100 47775 51450 53287
Jejunostomy Jejunostomy justifying the surgery.

Circumcision - Phimosis / Paraphimosis or any b) Clinical photograph of affected part b) Detailed Operative notes
453 General Surgery SG General Surgery SG104 Circumcision SG104A 10500 11550 12600 13650 14700 15225
other clinical condition c) Detailed discharge summary
a) Clinical notes including evaluation findings, a) Detailed

indication of procedure and planned line of Indoor case papers ( with treatment details
management b) Detailed Procedure operative notes
454 General Surgery SG General Surgery SG086 Debridement of Ulcer SG086A Debridement of Ulcer 5250 5775 6300 6825 7350 7612
b) Clinical Photographs of the affected part c) Post procedure photographs
a) Clinical notes a) Detailed Operative notes

b) USG b) Histopath
c) CT Scan/MRI c) Detailed discharge summary
d) Lab investigations
455 General Surgery SG General Surgery SG122 Distal Pancreatectomy + Splenectomy SG122A Distal Pancreatectomy + Splenectomy 63000 69300 75600 81900 88200 91350
confirming the diagnosis and justifying the surgery.

indication of procedure and b) Detailed Procedure / operative notes
planned line of management c) Histopathological examination report
b) Barium X-ray / Upper GI Endoscopy /
456 General Surgery SG General Surgery SG016 Diverticulectomy SG016A Excision Duodenal Diverticulum 26250 28875 31500 34125 36750 38062
USG/CECT/MRI Abdomen / Meckel
scan (99mTcpertechnetate Scintigraphy –
gastrointestinal bleeding) / Double
balloon Enteroscopy
a) Clinical notes a) Histopath if done
b) Scrotal USG b) Intra procedure clinical photograph
confirming the diagnosis. c) Detailed Operative notes
457 General Surgery SG General Surgery SG111 Epididymal Excision under GA SG111A Epididymal Excision under GA 2100 2310 2520 2730 2940 3045
C) Clinical photos d) Detailed discharge summary
a.Clinical Notes a) Post procedure endoscopic ultrasound

b,Endoscopic ultrasound c)LFT & Pancreatic b) Detailed Operative notes
458 General Surgery SG General Surgery SG109 ERCP SG109A ERCP 15750 17325 18900 20475 22050 22837 enzymes like amylase and lipas c) Detailed discharge summary
d)Endoscopic retrograde d.Post procedure X ray
cholangiopancreatography report
a.Clinical Notes b.Endoscopic ultrasound a) Post procedure endoscopic ultrasound
c.LFT and pancreatic enzymes like amylase and b) Detailed Operative notes
459 General Surgery SG General Surgery SG103 ERCP SG103A ERCP + Stenting/Stone removal 26250 28875 31500 34125 36750 38062 lipase. c) Detailed discharge summary
d.Endoscopic retrograde d.Post procedure X ray/cholangiography
cholangiopancreatography(ERCP)
a) Clinical notes a) Detailed Indoor case papers
b) Clinical photographs b) Detailed Procedure / operative notes
460 General Surgery SG General Surgery SG055 Excision Filarial Scrotum SG055A Excision Filarial Scrotum 8400 9240 10080 10920 11760 12180
c) Peripheral blood examination c) Post-operative Photographs
d) USG Abdomen and scrotum d) Detailed discharge summary
a) Clinical notes including evaluation findings, a) Detailed Indoor case papers (ICPs) with
indication for procedure, and planned line of treatment details
461 General Surgery SG General Surgery SG076 Excision Mammary Fistula SG076A Excision Mammary Fistula 14500 15950 17400 18850 20300 21025 management b) Detailed Procedure / operative notes
b) Ultrasound of the affected site c) Histopathological examination
indication for procedure and planned line of treatment details
Excision of cyst / Sebaceous Cysts over management b) Detailed Procedure / operative notes Yes
462 General Surgery SG General Surgery SG054 SG054B Multiple Cysts 7000 7700 8400 9100 9800 10150
scrotum b) Scrotal ultrasound (not required for sebaceous c) Histopathological examination
cysts) d) Detailed discharge summary
Excision of cyst / Sebaceous Cysts over management b) Detailed Procedure / operative notes Yes
463 General Surgery SG General Surgery SG054 SG054A Single Cyst 2835 3118 3402 3685 3969 4110
scrotum b) Scrotal ultrasound (not required for sebaceous c) Histopathological examination
a) Clinical notes a) Detailed Indoor case papers (ICPs)

b) Clinical picture (private parts may be covered) b) Detailed Procedure / operative notes
c) Planned line of treatment c) Post-operative clinical photograph
464 General Surgery SG General Surgery SG034 Exicision of Sinus and Curettage SG034A Exicision of Sinus and Curettage 5250 5775 6300 6825 7350 7612
(optional)
A) Clinical notes A) Post procedure clinical photograph
B) X-ray B) Detailed Operative notes
465 General Surgery SG General Surgery SG107 Fistulectomy SG107A Fistulectomy 12000 13200 14400 15600 16800 17400 C) USG report of the affected part confirming the C) detailed discharge summary
diagnosis D) relevant imaging study for comparison
D) Still Photograph of the imaging
a) Clinical notes explaining endoscopy has failed, a) Detailed Indoor case papers (ICPs)
or other indication for proceeding with surgery b) Detailed Procedure / operative notes
Bleeding Ulcer - Partial Gastrectomy with
466 General Surgery SG General Surgery SG003 Gastrectomy SG003B 65625 72187 78750 85312 91875 95156 b) Upper GI Endoscopy with photographs c) Intra-operative photographs
Vagotomy
c) Planned line of treatment d) Histopathological examination
a) Clinical notes explaining endoscopy has failed, a) Detailed Indoor case papers (ICPs)
or other indication for proceeding with surgery b) Detailed Procedure / operative notes
Bleeding Ulcer - Partial Gastrectomy without
467 General Surgery SG General Surgery SG003 Gastrectomy SG003A 65625 72187 78750 85312 91875 95156 b) Upper GI Endoscopy with photographs c) Intra-operative photographs
Vagotomy
c) Planned line of treatment d) Histopathological examination
Outside State
Bed Cost Cost
Cost
indication for implant as applicable, and planned treatment details
line of management b) Detailed Procedure / operative notes
468 General Surgery SG General Surgery SG050 Groin Hernia Repair SG050D Femoral - Lap 21315 23446 25578 27709 29841 30906 b) Ultrasound/CT/MRI of the groin (for obturator c) Implant details – barcode/invoice (if
hernia applicable)
diagnosed preoperatively) d) Detailed discharge summary
469 General Surgery SG General Surgery SG050 Groin Hernia Repair SG050C Femoral - Open 21000 23100 25200 27300 29400 30450 b) Ultrasound/CT/MRI of the groin (for obturator c) Implant details – barcode/invoice (if
hernia applicable)
a)Clinical notes b) Photograph a)Post op clinical photograph b)Operative

showing hernia / bulge notes c)Invoice of the Mesh / tacker
470 General Surgery SG General Surgery SG050 Groin Hernia Repair SG050B Inguinal - Lap. 21000 23100 25200 27300 29400 30450 used d)Detailed
Discharge Summary e)Pre-anesthesia check-
up report
a)Clinical notes b) Photograph a)Post op clinical photograph b)Operative
showing hernia / bulge notes c)Invoice of the Mesh / tacker
471 General Surgery SG General Surgery SG050 Groin Hernia Repair SG050A Inguinal - Open 21000 23100 25200 27300 29400 30450 used d)Detailed
Discharge Summary e)Pre-anesthesia check-
up report
a) Clinical notes a) Indoor case papers (ICPs)
b) Clinical Examination b) Detailed Procedure / operative notes
472 General Surgery SG General Surgery SG032 Haemorroidectomy SG032B with Stapler 32000 35200 38400 41600 44800 46400
c) Proctoscopy c) Intra-op clinical photographs
b) Clinical Examination b) Detailed Procedure / operative notes
473 General Surgery SG General Surgery SG032 Haemorroidectomy SG032A without Stapler 15000 16500 18000 19500 21000 21750
c) Proctoscopy c) Intra-op clinical photographs
a) Clinical notes a) Endoscopic still Photograph
b) Endoscopy report b) Detailed discharge summary
confirming the diagnosis of nfantile hypertrophic c) Detailed Operative notes
474 General Surgery SG General Surgery SG123 Heller Myotomy (Lap./Open) SG123A Heller Myotomy (Lap./Open) 31500 34650 37800 40950 44100 45675
pyloric stenosis.
C.USG/MRI
a) Clinical notes and a) Histopathology report

b) Sr Amylase b) Intra procedure clinical photograph
c) CT c) Detailed discharge summary
d) USG d) Detailed Operative notes
475 General Surgery SG General Surgery SG119 Hepatico Jejunostomy for biliary stricture SG119A Hepatico Jejunostomy for biliary stricture 47250 51975 56700 61425 66150 68512
e) ERCP
a) Clinical notes a) Intra procedure clinical photograph

b) X-ray b) Detailed Operative notes &
476 General Surgery SG General Surgery SG053 Hiatus Hernia Repair / Fundoplication SG053D Fundoplication - Lap. 23500 25850 28200 30550 32900 34075 c) USG c) Discharge summary
d) UGI Endoscopy
a) Clinical notes and a) Histopathology

b) CT Scan b) Intra procedure clinical photograph
c) Colonoscopy confirming the diagnosis and need c) detailed discharge summary
I Stage- Sub Total Colectomy + Ileostomy + I Stage- Sub Total Colectomy + Ileostomy + J - of surgery d) Detailed Operative notes
J - Pouch Pouch d) Biopsy of the lsoion

c) Colonoscopy confirming the diagnosis and need c) Detailed discharge summary
478 General Surgery SG General Surgery SG124 I Stage-Sub Total Colectomy + Ileostomy SG124A I Stage-Sub Total Colectomy + Ileostomy 42000 46200 50400 54600 58800 60900 of surgery d) Detailed Operative notes
d) Biopsy of the lsoion

b) Clinical photograph of affected part b) Detailed Operative notes
479 General Surgery SG General Surgery SG115 Ingrowing Toe Nail SG115A Ingrowing Toe Nail 2100 2310 2520 2730 2940 3045

b) Clinical photographs c) Planned b) Detailed Procedure / operative notes
Lipoma / Cyst / other cutaneous swellings
480 General Surgery SG General Surgery SG085 SG085B Cyst Excision 5250 5775 6300 6825 7350 7612 line of treatment c) Post-operative photographs
Excision
481 General Surgery SG General Surgery SG085 SG085A Lipoma Excision 5250 5775 6300 6825 7350 7612 line of treatment c) Post-operative photographs
Excision
482 General Surgery SG General Surgery SG085 SG085C Other cutaneous swellings Excision 5250 5775 6300 6825 7350 7612 line of treatment c) Post-operative photographs
Excision
b) Clinical picture c) Planned b) Detailed Procedure / operative notes
Lymphatics Excision of Subcutaneous Lymphatics Excision of Subcutaneous Tissues In
483 General Surgery SG General Surgery SG093 SG093A 15750 17325 18900 20475 22050 22837 line of treatment c) Post-operative clinical photograph
Tissues In Lymphoedema Lymphoedema
management b) Detailed Procedure / operative notes
484 General Surgery SG General Surgery SG033 Management of Pilonidal Sinus SG033A Management of Pilonidal Sinus 5985 6583 7182 7780 8379 8678
c) Histopathological examination report for
chronic cases
Outside State
Bed Cost Cost
Cost
a) Clinical notes a) Detailed discharge summary
b) Duplex ultrasonography b) Post procedure clinical photograph
485 General Surgery SG General Surgery SG095 Management of Varicose Veins SG095B Laser ablation of varicose veins 17250 18975 20700 22425 24150 25012 c) Colour Doppler confirming the diagnosis c) Detailed Operative notes
d) pre-op clinical photograph
a) Clinical notes with details of clinical examination a) Indoor case papers (ICPs)
Management of Varicose Veins-Operative and planned line of treatment b) b) Detailed Procedure / operative notes
486 General Surgery SG General Surgery SG095 Management of Varicose Veins SG095A 17325 19057 20790 22522 24255 25121
management Clinical photographs c) c) Post-op clinical photographs
Duplex scan d) Detailed discharge summary
a) Clinical notes a) Detailed discharge summary
b) Duplex ultrasonography b) Post procedure clinical photograph
487 General Surgery SG General Surgery SG095 Management of Varicose Veins SG095C Minor sclerotherapy 5250 5775 6300 6825 7350 7612 c) Colour Doppler confirming the diagnosis c) Detailed Operative notes
d) Pre-op clinical photograph
indication of procedure and planned line of treatment details
488 General Surgery SG General Surgery SG047 Mesenteric Caval Anastomosis SG047A Mesenteric Caval Anastomosis 51030 56133 61236 66339 71442 73993 b) Complete blood count c) Detailed discharge summary
c) Liver function tests
d)Oesophagogastroduodenoscopy
e) USG/CT Abdomen
a) Clinical notes a) Histopath
b) USG/CT/MRI b) Intra procedure clinical photograph
confirming the diagnosis. c) Detailed Operative notes
489 General Surgery SG General Surgery SG112 Mesentric cyst excision SG112A Mesentric cyst excision 21000 23100 25200 27300 29400 30450
a) Clinical notes a) Post procedure Nasal Endoscopy

b) Nasal Endoscopy b) Post procedure clinical photograph
confirming the diagnosis for which this surgery is c) Intra procedure clinical photograph
490 General Surgery SG General Surgery SG065 Microlaryngoscopic Surgery SG065A Microlaryngoscopic Surgery 19425 21367 23310 25252 27195 28166
done. d) Detailed discharge summary
e) Detailed Operative notes

491 General Surgery SG General Surgery SG113 Mole Excision SG113A Mole Excision 2100 2310 2520 2730 2940 3045

492 General Surgery SG General Surgery SG099 Necrotising fasciitis / Fournier Gangrene SG099C Fournier Gangrene 14800 16280 17760 19240 20720 21460

493 General Surgery SG General Surgery SG099 Necrotising fasciitis / Fournier Gangrene SG099B Necrotising fasciitis 14800 16280 17760 19240 20720 21460

b) USG b) Intra procedure & Post procedure clinical
494 General Surgery SG General Surgery SG114 Neurofibroma Excision under LA SG114A Neurofibroma Excision under LA 2100 2310 2520 2730 2940 3045 report confirming the diagnosis. photograph
c)Clinical photograph to confirm diagnosis. c) Detailed Operative notes
indication of procedure, and planned line of treatment details
495 General Surgery SG General Surgery SG006 Operation for Bleeding Peptic Ulcer SG006A Operation for Bleeding Peptic Ulcer 28560 31416 34272 37128 39984 41412 management b) Detailed Procedure / operative notes
b) Confirmed case of peptic ulcer disease c) Detailed discharge summary
c) Upper endoscopy
indication of procedure and planned line of treatment details b) Detailed Procedure /
496 General Surgery SG General Surgery SG007 Operation for Gastric / Duodenal Perforation SG007B Duodenal Perforation 23730 26103 28476 30849 33222 34408
management operative notes c) Detailed
b) X-ray Chest/Abdomen / USG/CT Abdomen discharge summary
indication of procedure and planned line of treatment details b) Detailed Procedure /
497 General Surgery SG General Surgery SG007 Operation for Gastric / Duodenal Perforation SG007A Gastric Perforation 23730 26103 28476 30849 33222 34408
management operative notes c) Detailed
b) X-ray Chest/Abdomen / USG/CT Abdomen discharge summary
especially per rectal examination, indication for treatment details
498 General Surgery SG General Surgery SG026 Perineal Procedure for Rectal Prolapse SG026A Perineal Procedure for Rectal Prolapse 19740 21714 23688 25662 27636 28623
indication of procedure and planned line of treatment details
499 General Surgery SG General Surgery SG046 Porto Caval Anastomosis SG046A Porto Caval Anastomosis 52500 57750 63000 68250 73500 76125 b) Complete blood count c) Detailed discharge summary
c) Liver function tests
d)Oesophagogastroduodenoscopy
e) USG/CT Abdomen
500 General Surgery SG General Surgery SG031 Procedure for Fissure in Ano SG031A Procedure for Fissure in Ano 10500 11550 12600 13650 14700 15225 b) Anal examination findings b) Detailed Procedure / operative notes
a)Colour Doppler a)Operative notes with still images.

b)Renal artery angigram/ CT angiogram report & b) Renogram report.
501 General Surgery SG General Surgery SG102 Repair of Renal Artery Stenosis SG102A Repair of Renal Artery Stenosis 79800 87780 95760 103740 111720 115710 stills stills showing blocks & Reports c) Post procedure (Angiogram/Xray)stills
c) Clinical Notes images
d) USG Report d) Barcode of the stents used.
b) Endoscopy report b) Histopathology report
c) Biopsy c) Post procedure clinical photograph
Replacement Surgery For Corrosive Injury Replacement Surgery For Corrosive Injury d) CT Scan d) Detailed Operative notes
Stomach Stomach confirming the diagnosis for which this surgery is e) Detailed discharge summary
done.
a) Clinical notes including evaluation findings and a) Detailed Indoor case papers (ICPs) with
planned line of management treatment details
503 General Surgery SG General Surgery SG025 Sigmoid Resection SG025A Sigmoid Resection 24255 26680 29106 31531 33957 35169 b) X-ray erect Abdomen or b) Detailed Procedure / operative notes
Barium Enema or CT abdomen c) Post-operative X-ray Abdomen
Outside State
Bed Cost Cost
Cost
a) Clinical notes and a) Intra procedure clinical photograph
b) USG-doppler b) Detailed discharge summary
c) CT c) Detailed Operative notes
d) MRI
504 General Surgery SG General Surgery SG116 Splenorenal Anastomosis SG116A Splenorenal Anastomosis 73500 80850 88200 95550 102900 106575
report confirming the diagnosis for which the
surgery is done
a) Discharge summary of the last admission a) Photographic evidence of stoma

b) Clinical notes including examination findings of complication, if any
the current visit b) Invoice/receipt of consumables (optional) if
colostomy bag changed
505 General Surgery SG General Surgery SG097 Stoma Management SG097B Stoma Management follow up of Colostomy 5775 6352 6930 7507 8085 8373
c) Signed statement from pt. that s/he has
received the consumables: Ileostomy /
Colostomy - bags, adhesive, clips etc. for 2
months
a) Discharge summary of the last admission a) Photographic evidence of stoma
b) Clinical notes including examination findings of complication, if any
the current visit b) Invoice/receipt of consumables (optional) if
colostomy bag changed
506 General Surgery SG General Surgery SG097 Stoma Management SG097A Stoma Management follow up of Ileostomy 5775 6352 6930 7507 8085 8373
c) Signed statement from pt. that s/he has
received the consumables: Ileostomy /
Colostomy - bags, adhesive, clips etc. for 2
months
a) Clinical notes a) Histopathology report and
b) CT Scan b) Intra procedure Clinical photograph of
Surgical management of Lower GI bleed Surgical management of Lower GI bleed c) Colonoscopy confirming the diagnosis and need removed colon
(inclusive of sigmoidoscopy / colonoscopy) - (inclusive of sigmoidoscopy / colonoscopy) - of surgery c) Detailed discharge summary
Colonoscopic management only excluding Colonoscopic management only excluding local d) Biopsy of the lesion d) Detailed Operative notes
local perineal conditions perineal conditions
a) Clinical notes detailing original pathology a) Clinical notes detailing original pathology
b) Evidence of confirmed diagnosis of Leprosy (If b) Previous surgery report and indication of
applicable) c) Clinical current
508 General Surgery SG General Surgery SG089 Tissue Reconstruction Flap SG089A Tissue Reconstruction Flap 36960 40656 44352 48048 51744 53592
photograph. procedure c)
Clinical photograph.
a) Clinical notes b) X ray / a) Indoor case papers (ICPs) b) Treatment

CT Scan detail c) Intra operative
509 General Surgery SG General Surgery SG005 Vagotomy SG005A G J Vagotomy 33810 37191 40572 43953 47334 49024 photograph d) Discharge summary
e) Histopathological report
a) Clinical notes b) X ray / a) Indoor case papers (ICPs) b) Treatment

CT Scan detail c) Intra operative
510 General Surgery SG General Surgery SG005 Vagotomy SG005B Vagotomy + Pyloroplasty 33810 37191 40572 43953 47334 49024 photograph d) Discharge summary
e) Histopathological report
admission b) Clinical c) Intra-operative photographs (optional)
511 General Surgery SG General Surgery, ENT SG068 Surgical removal of Branchial Cyst/Sinus SG068A Surgical removal of Branchial Cyst/Sinus 21000 23100 25200 27300 29400 30450
Photograph c) USG Neck/ Fine d) Detailed discharge summary e)
Optional CT/MRI
a) Clinical notes with history, signs, symptoms, a) Detailed Indoor Case Papers
evaluation findings, indication for procedure, b) Post op clinical photograph
planned line of management and advice for c) Detailed operative note
General Surgery, admission d) Detailed Discharge Summary
512 General Surgery SG SG092 Tendon Transfer SG092A Tendon Transfer 26250 28875 31500 34125 36750 38062
Orthopedics b) Clinical photograph of affected part
c) Evidence of confirmed diagnosis of Leprosy (If
applicable)
b) USG b) Intra procedure clinical photograph of
confirming the diagnosis. removed appendix
General Surgery, Pediatric c) post procedure clinical photograph
513 General Surgery SG SG017 Appendicectomy SG017B Lap 21000 23100 25200 27300 29400 30450
Surgery d) Detailed Operative notes

b) USG b) Intra procedure clinical photograph of
confirming the diagnosis. removed appendix
General Surgery, Pediatric c) post procedure clinical photograph
514 General Surgery SG SG017 Appendicectomy SG017A Open 21000 23100 25200 27300 29400 30450
Surgery d) Detailed Operative notes

b) X Ray Abdomen Erect b) Intra procedure clinical photograph
General Surgery, Pediatric c) USG c) detailed discharge summary
515 General Surgery SG SG018 Appendicular Perforation SG018A Appendicular Perforation 21000 23100 25200 27300 29400 30450
Surgery confirming the diagnosis. d) Detailed Operative notes
a)Clinical notes b) USG a) Operative notes b)Pre-

upper abdomen c)LFT (Liver function anesthesia check-up report
test) c)Detailed Discharge Summary
General Surgery, Pediatric d)Intraoperative photograph and
516 General Surgery SG SG039 Cholecystectomy SG039D With Exploration of CBD - Lap 32655 35920 39186 42451 45717 47349
Surgery Pictures of gross specimen removed
e)Histopathology report (can be submitted
within 7 days of discharge)
517 General Surgery SG SG039 Cholecystectomy SG039B With Exploration of CBD - Open 32655 35920 39186 42451 45717 47349
Outside State
Bed Cost Cost
Cost
518 General Surgery SG SG039 Cholecystectomy SG039C Without Exploration of CBD - Lap 32655 35920 39186 42451 45717 47349
519 General Surgery SG SG039 Cholecystectomy SG039A Without Exploration of CBD - Open 32655 35920 39186 42451 45717 47349
b) Clinical Evaluation Upper / lower gastrointestinal b) Detailed Procedure / operative notes
General Surgery, Pediatric Congenital Atresia & Stenosis of Small series contrast study c) Intraoperative photos (optional)
520 General Surgery SG SG014 SG014A Congenital Atresia & Stenosis of Small Intestine 39375 43312 47250 51187 55125 57093
Surgery Intestine c) Optional d) Detailed discharge summary
d) X-ray erect/CT/MRI Abdomen
e) Planned line of treatment
a) Clinical notes a) Histopathology
b) USG b) Detailed discharge summary
General Surgery, Pediatric c) CT Scan confirming the diagnosis for which the c) Detailed Operative notes
521 General Surgery SG SG080 Decortication (Pleurectomy) SG080A Decortication (Pleurectomy) 34650 38115 41580 45045 48510 50242
Surgery surgery is done
d) Biopsy

indication of procedure and b) Detailed Procedure / operative notes
planned line of management c) Histopathological examination report
General Surgery, Pediatric b) Barium X-ray / Upper GI Endoscopy /
522 General Surgery SG SG016 Diverticulectomy SG016B Excision Meckel's Diverticulum 17745 19519 21294 23068 24843 25730
Surgery USG/CECT/MRI Abdomen / Meckel
scan (99mTcpertechnetate Scintigraphy –
gastrointestinal bleeding) / Double
balloon Enteroscopy
General Surgery, Pediatric management b) Detailed Procedure / operative notes Yes
523 General Surgery SG SG057 Epididymal Cyst / Nodule Excision SG057A Epididymal Cyst excision 5565 6121 6678 7234 7791 8069
Surgery b) Scrotal ultrasound (not required for sebaceous c) Histopathological examination
General Surgery, Pediatric management b) Detailed Procedure / operative notes Yes
524 General Surgery SG SG057 Epididymal Cyst / Nodule Excision SG057B Epididymal Nodule excision 5565 6121 6678 7234 7791 8069
Surgery b) Scrotal ultrasound (not required for sebaceous c) Histopathological examination
a) Clinical notes b) X ray a) Indoor case papers (ICPs) b) Detailed

abdomen (erect posture) operative notes c) Intra-operative clinical
General Surgery, Pediatric
525 General Surgery SG SG035 Exploratory Laparotomy SG035A Exploratory Laparotomy 13000 14300 15600 16900 18200 18850 photograph/ stills d) Detailed
Surgery
Discharge summary e)
Histopathological report
General Surgery, Pediatric b) Ultrasound/CT/MRI of the groin (for obturator c) Implant details – barcode/invoice (if
526 General Surgery SG SG050 Groin Hernia Repair SG050E Obturator - Lap. 24045 26449 28854 31258 33663 34865
Surgery hernia applicable)
a) Clinical notes and a) Post procedure clinical photograph

b) USG (specifying size of defect) b) Detailed discharge summary
527 General Surgery SG SG051 Hernia - Ventral SG051A Epigastric 21000 23100 25200 27300 29400 30450 c) Clinical photograph c) Detailed Operative notes
Surgery
d) Invoice of Mesh used

528 General Surgery SG SG051 Hernia - Ventral SG051C Paraumbilical 26250 28875 31500 34125 36750 38062 c) Clinical photograph c) Detailed Operative notes
Surgery

529 General Surgery SG SG051 Hernia - Ventral SG051D Spigelian 26250 28875 31500 34125 36750 38062 c) Clinical photograph c) Detailed Operative notes
Surgery

530 General Surgery SG SG051 Hernia - Ventral SG051B Umbilical 26250 28875 31500 34125 36750 38062 c) Clinical photograph c) Detailed Operative notes
Surgery

b) Clinical Evaluation b) Detailed Procedure / operative notes
c) Upper gastrointestinal series/barium swallow c) Detailed discharge summary
General Surgery, Pediatric d) Upper endoscopy
531 General Surgery SG SG053 Hiatus Hernia Repair / Fundoplication SG053C Fundoplication - Open(+/- Hiatus Hernia repair) 27615 30376 33138 35899 38661 40041
Surgery e) 24-hr pH-monitoring
f) Oesophageal manometry
g) Planned line of treatment
532 General Surgery SG SG053 Hiatus Hernia Repair / Fundoplication SG053B Hiatus Hernia Repair - Lap 27615 30376 33138 35899 38661 40041
Outside State
Bed Cost Cost
Cost
533 General Surgery SG SG053 Hiatus Hernia Repair / Fundoplication SG053A Hiatus Hernia Repair - Open 27615 30376 33138 35899 38661 40041
General Surgery, Pediatric abdomen (erect posture) operative notes c) Intra-operative
534 General Surgery SG SG013 Ileostomy SG013A Ileostomy 17325 19057 20790 22522 24255 25121
Surgery clinical photograph/ stills d)
Detailed Discharge summary
535 General Surgery SG SG084 Incision & Drainage of Abscess SG084A Incision & Drainage of Abscess 5250 5775 6300 6825 7350 7612 management b) Detailed Procedure / operative notes
Surgery
b) Clinical Photograph c) Culture report of wound or pus
c) Sepsis screen/blood culture d) Detailed discharge summary
b) USG b) Intra procedure clinical photograph
c) Biopsy c) Detailed discharge summary
General Surgery, Pediatric report confirming the diagnosis for which the d) Detailed Operative notes
536 General Surgery SG SG060 Inguinal Node (dissection) - U/L SG060A Inguinal Node (dissection) - U/L 20790 22869 24948 27027 29106 30145
Surgery surgery is done.
General Surgery, Pediatric management b) b) Detailed Procedure / operative notes
537 General Surgery SG SG083 Lung Hydatid Cyst removal SG083A Lung Hydatid Cyst removal 27615 30376 33138 35899 38661 40041
Surgery CT/MRI Chest c) Histopathological examination report
d) Postoperative Chest X-ray or CT
538 General Surgery SG SG048 Mesenteric Cyst – Excision SG048A Mesenteric Cyst – Excision 21735 23908 26082 28255 30429 31515 management b) Detailed Procedure / operative notes
Surgery
b) USG/CT/MRI Abdomen c) Histopathology examination
b) CT/MRI b) Detailed operative/ procedure notes
539 General Surgery SG SG015 Operation for Duplication of Intestine SG015A Operation for Duplication of Intestine 26670 29337 32004 34671 37338 38671 c) Endoscopic ultrasound ± fine needle aspiration c) Detailed discharge summary
Surgery
d) Planned line of treatment d) Histopathological examination
a) Clinical notes a) Histopath if done

General Surgery, Pediatric confirming the diagnosis. c) Detailed Operative notes
540 General Surgery SG SG056 OPERATION FOR HYDROCELE SG056B Operation for Hydrocele (B/L) 15750 17325 18900 20475 22050 22837
Surgery C) Clinical photos d) Detailed discharge summary

541 General Surgery SG SG056 OPERATION FOR HYDROCELE SG056A Operation for Hydrocele (U/L) 10500 11550 12600 13650 14700 15225 confirming the diagnosis. c) Detailed Operative notes
Surgery

General Surgery, Pediatric Operation forAbdominal Hydatid Cyst (Single Operation forAbdominal Hydatid Cyst (Single b) USG/CT/MRI Abdomen b) Detailed Procedure / operative notes
542 General Surgery SG SG038 SG038A 22050 24255 26460 28665 30870 31972
Surgery Organ) - Change in Name Organ) - Change in Name c) Detailed discharge summary
d) Intra-operative Photographs (optional)
General Surgery, Pediatric management b) Detailed Procedure / operative notes
543 General Surgery SG SG041 Operation of Choledochal Cyst SG041A Operation of Choledochal Cyst 33285 36613 39942 43270 46599 48263
Surgery b) Ultrasound Abdomen c) Detailed discharge summary
c) Magnetic Resonance
Cholangiopancreatography (MRCP)
General Surgery, Pediatric Operations for Replacement of Oesophagus Operations for Replacement of Oesophagus by b) Barium contrast swallow / Upper b) Detailed procedure/operative notes
Surgery by Colon Colon Gastrointestinal Endoscopy c) Detailed discharge summary
c) Planned line of treatment e) Barium contrast swallow
b) Clinical evaluation b) Detailed Procedure / operative notes
545 General Surgery SG SG040 Operative Cholecystostomy SG040B Lap 11865 13051 14238 15424 16611 17204 c) USG/CT Abdomen / Liver function test / White c) Operative photographs
Surgery
blood count / Hepatobiliaryiminodiacetic acid scan d) Detailed discharge summary
(HIDA scan-optional)
b) Clinical evaluation b) Detailed Procedure / operative notes
546 General Surgery SG SG040 Operative Cholecystostomy SG040A Open 11865 13051 14238 15424 16611 17204 c) USG/CT Abdomen / Liver function test / White c) Operative photographs
Surgery
blood count / Hepatobiliaryiminodiacetic acid scan d) Detailed discharge summary
(HIDA scan-optional)
a) Clinical notes a) Intra Operative clinical photograph
General Surgery, Pediatric b) USG b) Detailed Operative notes
547 General Surgery SG SG019 Operative drainage of Appendicular Abscess SG019A Operative drainage of Appendicular Abscess 15750 17325 18900 20475 22050 22837
Surgery c) discharge summary.
a) Clinical notes, specifying need for gastrostomy a) Detailed Indoor case papers (ICPs)
General Surgery, Pediatric (indication) b) Detailed Procedure / operative notes
548 General Surgery SG SG004 Operative Gastrostomy SG004A Operative Gastrostomy 26250 28875 31500 34125 36750 38062
Surgery b) Clinical Evaluation c) Intra-operative photographs (optional)
c) Planned line of treatment d) Detailed discharge summary
a) Clinical notes including evaluation findings and a) Detailed Indoor case papers (ICPs) with
planned line of management treatment details
General Surgery, Pediatric Operative Management of Volvulus of Large Operative Management of Volvulus of Large
549 General Surgery SG SG022 SG022A 34545 37999 41454 44908 48363 50090 b) X-ray erect Abdomen or b) Detailed Procedure / operative notes
Surgery Bowel Bowel
Barium Enema or CT abdomen c) Post-operative X-ray Abdomen
indication for procedure, and planned line of treatment
General Surgery, Pediatric management details
550 General Surgery SG SG009 Pyloromyotomy SG009A Pyloromyotomy 39375 43312 47250 51187 55125 57093
Surgery b) USG Abdomen/ Upper Gastrointestinal b) Detailed Procedure / operative notes
Endoscopy/ c) Detailed discharge summary
Barium meal series
Outside State
Bed Cost Cost
Cost
indication for procedure, and planned line of treatment
General Surgery, Pediatric management details
551 General Surgery SG SG008 Pyloroplasty SG008A Pyloroplasty 21735 23908 26082 28255 30429 31515
Surgery b) USG Abdomen/ Upper Gastrointestinal b) Detailed Procedure / operative notes
Endoscopy/ c) Detailed discharge summary
Barium meal series
a) Clinical notes including info about previous a) Post procedure clinical photograph
surgery in whose incision this hernia has occurred b) Detailed discharge summary
b) USG (specifying size of defect) c) Detailed Operative notes
General Surgery, Pediatric c) Clinical photograph d) Invoice of Mesh used
552 General Surgery SG SG052 Repair of Incisional Hernia SG052A Repair of Incisional Hernia Lap/Open 21315 23446 25578 27709 29841 30906
Surgery

General Surgery, Pediatric Lap
553 General Surgery SG SG030 Resection Anastomosis SG030B 28035 30838 33642 36445 39249 40650 photograph/ stills d) Detailed
Surgery
554 General Surgery SG SG030 Resection Anastomosis SG030A Open 28035 30838 33642 36445 39249 40650 photograph/ stills d) Detailed
Surgery
a) Clinical notes with evaluation findings, indication a) Detailed Indoor case papers (ICPs) with
of procedure, and planned line of management treatment
b) X-ray/CT/MRI Chest report details
General Surgery, Pediatric b) Detailed Procedure / operative notes
555 General Surgery SG SG078 Rib Resection & Drainage SG078A Rib Resection & Drainage 21000 23100 25200 27300 29400 30450
Surgery c) Pus culture report
d) Postoperative Chest X-ray
a) Clinical notes a) Detailed Operative notes
b) USG b) Histopath
c) CT Scan c) Detailed discharge summary
General Surgery, Pediatric d) Lab investigations
556 General Surgery SG SG042 Splenectomy SG042B Lap 36960 40656 44352 48048 51744 53592
Surgery confirming the diagnosis and justifying the surgery.

557 General Surgery SG SG042 Splenectomy SG042A Open 36960 40656 44352 48048 51744 53592 c) USG/CECT Abdomen c) Intra-operative photographs (optional)
Surgery
d) Planned line of treatment d) Histopathological examination
558 General Surgery SG SG011 Surgical Management of PseudoCyst SG011D Cystogastrostomy - Lap 27615 30376 33138 35899 38661 40041
Surgery b) White blood cell count, serum amylase reports c) Detailed discharge summary
c) USG/CECT/MRI Abdomen
559 General Surgery SG SG011 Surgical Management of PseudoCyst SG011C Cystogastrostomy - Open 27615 30376 33138 35899 38661 40041
560 General Surgery SG SG011 Surgical Management of PseudoCyst SG011B CystoJejunostomy - Lap 23625 25987 28350 30712 33075 34256
561 General Surgery SG SG011 Surgical Management of PseudoCyst SG011A CystoJejunostomy - Open 23625 25987 28350 30712 33075 34256

b) Supporting Evidence of need of surgery b) Detailed discharge summary
c) EMG c) Detailed Operative notes
General Surgery, Pediatric d) Nerve conduction study
562 General Surgery SG SG073 Sympathectomy SG108A Sympathectomy-Bilateral (B/L) 36750 40425 44100 47775 51450 53287
Surgery e) CT
f) MRI
g) Clinical Photograph

b) Clinical photographs c) b) Detailed Procedure / operative notes
563 General Surgery SG SG073 Sympathectomy SG073A Sympathectomy-Unilateral (U/L) 21735 23908 26082 28255 30429 31515 Investigations c) Detailed discharge summary
Surgery
1. Doppler ultrasound blood flow
d) Planned line of treatment
General Surgery, Pediatric b) Clinical Evaluation b) Detailed Procedure / operative notes
564 General Surgery SG SG079 Thoracoplasty SG079A Thoracoplasty 30000 33000 36000 39000 42000 43500
Surgery c) Chest X-ray/CT/MRI c) X-ray Chest prior to discharge
d) Planned line of treatment d) Detailed discharge summary
b) CT Thorax confirming the diagnosis b) Detailed Operative notes,
General Surgery, Pediatric c) Biopsy c) Histopath
565 General Surgery SG SG082 Thoracoscopic Segmental Resection SG082A Thoracoscopic Segmental Resection 41895 46084 50274 54463 58653 60747
Surgery d) Cytology d) Detailed discharge summary
e) Scar Photo
Outside State
Bed Cost Cost
Cost
c) Investigations (Optional – Based on Etiology) c) Histopathological examination
1. CT/MRI/PET d) Detailed discharge summary
2. Thoracoscopy
General Surgery, Pediatric 3. Biopsy
566 General Surgery SG SG072 Thymectomy SG072A Thymectomy 63000 69300 75600 81900 88200 91350 4. Pulmonary function test
Surgery
5. Thyroid profile
6. Nerve conduction studies
(EMG/ENMG)/Prostigmine/Tensilon test/
7. Ach receptor antibody testing
of procedure and planned line of management b) Detailed Procedure / Operative notes
567 General Surgery SG SG077 Intercostal drainage Only SG077A Intercostal drainage Only 5880 6468 7056 7644 8232 8526 b) Chest X-Ray PA c) Post procedure Chest X-ray with reports
Surgery, CTVS

indication for procedure, and planned line of b) Procedure note/ operative note
management, advise for the day care procedure. c) Post procedure clinical photograph/
General Surgery, Pediatric b) X-ray report/ clinical picture of the affected part relevant imaging study for pre and post
568 General Surgery SG SG098 Foreign Body Removal SG098A Foreign Body Removal 7350 8085 8820 9555 10290 10657
Surgery, ENT confirming the diagnosis and justify the procedure. procedure comparison
a) Clinical notes with supporting investigations

General Surgery, Pediatric b) Indication for procedure a) Other Investigation reports if done
569 General Surgery SG Surgery, Obstetrics & SG096 Biopsy SG096C Cervix Cancer screening (PAP + Colposcopy) 2625 2887 3150 3412 3675 3806 b) Detailed procedure notes
Gynecology c) Histopathological Examination
570 General Surgery SG Surgery, Obstetrics & SG096 Biopsy SG096B Endometrial Aspiration 2835 3118 3402 3685 3969 4110 b) Detailed procedure notes
a) Clinical notes with supporting investigations a) Detailed indoor case papers
General Surgery, Pediatric b) Clinical photograph b) Other Investigation reports if done
571 General Surgery SG Surgery, Obstetrics & SG096 Biopsy SG096A Lymph Node 5250 5775 6300 6825 7350 7612 c) Detailed procedure notes
Gynecology d) Histopathological Examination
572 General Surgery SG Surgery, Obstetrics & SG096 Biopsy SG096E Vulval 2625 2887 3150 3412 3675 3806 b) Detailed procedure notes
b) Clinical Photograph b) Procedure operative notes
573 General Surgery SG Surgery, Obstetrics & SG036 Closure of Burst Abdomen SG036A Closure of Burst Abdomen 15750 17325 18900 20475 22050 22837
c) Planned line of treatment c) Post operative photographs
Gynecology
574 General Surgery SG SG081 Lobectomy SG081B Open 34545 37999 41454 44908 48363 50090
Surgery, Surgical Oncology d) Cytology d) Detailed discharge summary
e) Scar Photo

575 General Surgery SG SG081 Lobectomy SG081A Thoracoscopic 34545 37999 41454 44908 48363 50090
Surgery, Surgical Oncology d) Cytology d) Detailed discharge summary
e) Scar Photo
a) Clinical notes detailing original pathology (In a) Detailed Indoor Case Papers
case of Split thickness b) Detailed procedure/Operative notes
General Surgery, Plastic &
576 General Surgery SG SG088 Free Grafts - Wolfe Grafts SG088A Free Grafts - Wolfe Grafts 32865 36151 39438 42724 46011 47654 skin graft time of burn) c) Post procedure clinical photograph of the
Reconstructive Surgery
b) Supporting reports and clinical photograph. affected part
d) Discharge summary
General Surgery, Plastic & case of Split thickness b) Detailed procedure/Operative notes
577 General Surgery SG Reconstructive Surgery, SG090 Split thickness skin grafts SG090C Large (> 8% TBSA) 21420 23562 25704 27846 29988 31059 skin graft time of burn) c) Post procedure clinical photograph of the
Pediatric Surgery b) Supporting reports and clinical photograph. affected part
578 General Surgery SG Reconstructive Surgery, SG090 Split thickness skin grafts SG090B Medium (4 - 8% TBSA) 19000 20900 22800 24700 26600 27550 skin graft time of burn) c) Post procedure clinical photograph of the
579 General Surgery SG Reconstructive Surgery, SG090 Split thickness skin grafts SG090A Small (< 4% TBSA) 19740 21714 23688 25662 27636 28623 skin graft time of burn) c) Post procedure clinical photograph of the
b) Biopsy b) post procedure clinical photograph
General Surgery, Surgical Lap
580 General Surgery SG SG029 Anterior Resection of rectum SG029B 52500 57750 63000 68250 73500 76125 c) Colonoscopy c) Detailed Operative notes
Oncology
d) detailed discharge summary
General Surgery, Surgical especially per rectal examination, indication for treatment details
581 General Surgery SG SG029 Anterior Resection of rectum SG029A Open 52500 57750 63000 68250 73500 76125
Oncology procedure, and planned line of management b) Detailed Procedure / operative notes
b) Sono mammogram b) Intra operative clinical photograph
General Surgery, Surgical
582 General Surgery SG SG074 Breast Lump Excision (Benign) SG074A Breast Lump Excision (Benign) 10500 11550 12600 13650 14700 15225 c) Mamography showing breast lump c) Detailed Operative notes
Oncology
d) FNAC report d) Detailed discharge summary.
Outside State
Bed Cost Cost
Cost
Clinical and radiological evidence of inoperability. a) Histopathology report
( b) Intra operative clinical photograph
a) Biopsy c) Detailed Operative notes and
b) ERCP. d) Discharge summary.
General Surgery, Surgical c) MRCP
583 General Surgery SG SG043 Bypass - Inoperable Pancreas SG043A Bypass - Inoperable Pancreas 65625 72187 78750 85312 91875 95156
Oncology )
a) Clinical notes detailing the original pathology thet a) Post procedure clinical photograph
has led to this surgery with suporting investigation b) Detailed Operative notes
General Surgery, Surgical reports. c) Detailed discharge summary
584 General Surgery SG SG061 Estlander Operation (lip) SG061A Estlander Operation (lip) 19425 21367 23310 25252 27195 28166
Oncology b) FIR/MLC in case of traumatic aetiology
c) Clinical Photograph
Photograph
b) USG b) Post procedure clinical photograph
c) CT c) Detailed Operative notes
d) MRI d) Detailed discharge summary
General Surgery, Surgical Excision of Growth from Tongue with neck Excision of Growth from Tongue with neck node e) Clinical Photograph
Oncology node dissection dissection report confirming the diagnosis
a) Clinical notes detailing the original pathology that a) Post procedure clinical photograph
has led to this surgery with supporting investigation b) Detailed Operative notes
586 General Surgery SG SG087 Flap Reconstructive Surgery SG087A Flap Reconstructive Surgery 37900 41690 45480 49270 53060 54955 reports. c) Detailed discharge summary
Oncology
b) Clinical Photograph

b) mandatory Biopsy b) Histopathology report
c) Endoscopy c) post procedure clinical photograph
General Surgery, Surgical d) CT Scan confirming the diagnosis d) Detailed Operative notes
587 General Surgery SG SG003 Gastrectomy SG003C Partial Gastrectomy for Carcinoma 45675 50242 54810 59377 63945 66228
Oncology e) Clinical photograph e) Detailed discharge summary

b) mandatory Biopsy Endoscopy b) Histopathology report
General Surgery, Surgical c) CT Scan confirming the diagnosis c) post procedure clinical photograph
588 General Surgery SG SG003 Gastrectomy SG003D Subtotal Gastrectomy for Carcinoma 45675 50242 54810 59377 63945 66228
Oncology d) Clinical photograph d) Detailed Operative notes

b) Endoscopy report Video b) Histopathology report
c) Biopsy c) post procedure clinical photograph
d) CT Scan d) Detailed Operative notes
General Surgery, Surgical confirming the diagnosis for which this surgery is e) Detailed discharge summary
589 General Surgery SG SG003 Gastrectomy SG003E Total Gastrectomy - Lap. 85365 93901 102438 110974 119511 123779
Oncology done.

b) Endoscopy report Video b) Histopathology report
c) Biopsy c) post procedure clinical photograph
General Surgery, Surgical d) CT Scan d) Detailed Operative notes
590 General Surgery SG SG003 Gastrectomy SG003F Total Gastrectomy - Open 85365 93901 102438 110974 119511 123779
Oncology confirming the diagnosis for which this surgery is e) Detailed discharge summary
done.
a) Clinical notes and Endoscopy report OR a) Intra operative photograph

b) Biopsy OR b) Detailed Operative notes
c) CT Scan c) detailed discharge summary
General Surgery, Surgical confirming the diagnosis for which this surgery is
591 General Surgery SG SG010 Gastrojejunostomy SG010A Gastrojejunostomy 31500 34650 37800 40950 44100 45675
Oncology done.
a) Clinical notes and a) Histopathology report and

c) Colonoscopy confirming the diagnosis and need removed colon
General Surgery, Surgical of surgery c) Detailed discharge summary
592 General Surgery SG SG021 Hemi colectomy SG021D Left- Lap 36960 40656 44352 48048 51744 53592
Oncology d) Biopsy of the lsoion d) Detailed Operative notes

593 General Surgery SG SG021 Hemi colectomy SG021C Left-Open 36960 40656 44352 48048 51744 53592

594 General Surgery SG SG021 Hemi colectomy SG021B Right- Lap 36960 40656 44352 48048 51744 53592

595 General Surgery SG SG021 Hemi colectomy SG021A Right-Open 36960 40656 44352 48048 51744 53592
Outside State
Bed Cost Cost
Cost
b) Mammography b) Detailed discharge summary
General Surgery, Surgical c) Biopsy c) Detailed Operative notes
596 General Surgery SG SG075 Mastectomy SG075B Radical / Modified Radical Mastectomy 34545 37999 41454 44908 48363 50090
Oncology justifying surgery.

b) Mammography b) Post procedure clinical photograph
597 General Surgery SG SG075 Mastectomy SG075A Simple Mastectomy 26250 28875 31500 34125 36750 38062 c) Biopsy confirming the diagnosis c) Detailed Operative notes
Oncology
d) Clinical Photograph d) Detailed discharge summary
Clinical notes and a) Histopath

a) USG b) Intra procedure clinical photograph
b) CT c) detailed discharge summary
General Surgery, Surgical c) MRI d) Detailed Operative notes
598 General Surgery SG SG001 Oesophagectomy SG001A Oesophagectomy 131250 144375 157500 170625 183750 190312
Oncology d) Biopsy
report confirming the diagnosis for which the
surgery is done.

b) Biopsy report b) Post procedure clinical photograph
599 General Surgery SG SG062 Operation for Carcinoma Lip SG062C Cheek advancement 39375 43312 47250 51187 55125 57093 c) Clinical Photograph c) Detailed Operative notes
Oncology

600 General Surgery SG SG062 Operation for Carcinoma Lip SG062A Wedge Excision 26355 28990 31626 34261 36897 38214 c) Clinical Photograph c) Detailed Operative notes
Oncology

601 General Surgery SG SG062 Operation for Carcinoma Lip SG062B Wedge Excision and Vermilionectomy 39375 43312 47250 51187 55125 57093 c) Clinical Photograph c) Detailed Operative notes
Oncology

General Surgery, Surgical d) USG d) Detailed Operative notes
602 General Surgery SG SG045 PancreaticoDuodenectomy (Whipple's) SG045A PancreaticoDuodenectomy (Whipple's) 131250 144375 157500 170625 183750 190312
Oncology e) ERCP
General Surgery, Surgical especially per rectal examination, indication for treatment details
603 General Surgery SG SG028 Rectal Polyp Excision SG028A Rectal Polyp Excision 10500 11550 12600 13650 14700 15225
Oncology procedure, and planned line of management b) Detailed Procedure / operative notes
b) USG b) Post procedure clinical photograph
c) CT Scan confirming the diagnosis for which the c) Detailed Operative notes
General Surgery, Surgical surgery is done d) Detailed discharge summary
604 General Surgery SG SG066 Submandibular Mass Excision SG066A Submandibular Mass Excision 26250 28875 31500 34125 36750 38062
Oncology d) Biopsy
e) FNAC
f) Clinical Photograph

General Surgery, Surgical Lap of surgery d) Detailed Operative notes
605 General Surgery SG SG106 Subtotal Colectomy SG106B 36645 40309 43974 47638 51303 53135
Oncology d) Biopsy of the lsoion

General Surgery, Surgical Open of surgery d) Detailed Operative notes
606 General Surgery SG SG106 Subtotal Colectomy SG106A 36645 40309 43974 47638 51303 53135

General Surgery, Surgical Lap of surgery d) Detailed Operative notes
607 General Surgery SG SG020 Total Colectomy SG020B 50715 55786 60858 65929 71001 73536

General Surgery, Surgical Open of surgery d) Detailed Operative notes
608 General Surgery SG SG020 Total Colectomy SG020A 50715 55786 60858 65929 71001 73536

b) USG Neck b) Detailed Operative notes
General Surgery, Surgical c) Colour Doppler c) Histopathology
609 General Surgery SG SG069 Carotid Body tumour - Excision SG069A Carotid Body tumour - Excision 39375 43312 47250 51187 55125 57093
Oncology, CTVS confirming the diagnosis. d) Detailed discharge summary

General Surgery, Surgical c) MRI Neck confirming the diagnosis c) Post procedure clinical photograph
610 General Surgery SG SG067 Radical Neck Dissection SG067A Radical Neck Dissection 35385 38923 42462 46000 49539 51308
Oncology, ENT d) Biopsy d) Detailed discharge summary
e) Clinical Photograph e) Detailed Operative notes
Clinical notes detailing why colostomy was done? a) Post procedure clinical photograph
General Surgery, Surgical Clinical photograph b) Detailed Operative notes
611 General Surgery SG SG024 Closure of stoma SG024A Closure of stoma 17535 19288 21042 22795 24549 25425
Oncology, Pediatric Surgery c) Detailed discharge summary
Outside State
Bed Cost Cost
Cost
b) CT b) Detailed Operative notes
c) MRI c) detailed surgery notes.
General Surgery, Surgical d) Colonoscopy
612 General Surgery SG SG023 Colostomy SG023A Colostomy 21000 23100 25200 27300 29400 30450
Oncology, Pediatric Surgery evidence of need of surgery.
a) Clinical notes confirming the diagnosis a) Histopath

b) Clinical Photograph b) Post procedure clinical photograph
General Surgery, Surgical Complete Excision of Growth from Tongue Complete Excision of Growth from Tongue only
613 General Surgery SG SG063 SG063A 21945 24139 26334 28528 30723 31820 c) FNAC if done c) Detailed Operative notes
Oncology, Pediatric Surgery only (inclusive of Histopathology) (inclusive of Histopathology)

General Surgery, Surgical Distal Pancreatectomy with Distal Pancreatectomy/Pancreatico Jejunostomy d) USG d) Detailed Operative notes
Oncology, Pediatric Surgery Pancreatico Jejunostomy with/without spleenlectomy e) ERCP

c) CT Scan c) Detailed discharge summary
General Surgery, Surgical Excision of Parathyroid Adenoma / d) Nuclear Imaging d) Detailed Operative notes
615 General Surgery SG SG071 SG071A Excision of Parathyroid Adenoma/Carcinoma 26250 28875 31500 34125 36750 38062
Oncology, Pediatric Surgery Carcinoma confirming the diagnosis.

b) Endoscopy report +/- Video b) detailed discharge summary
c) Biopsy c) Detailed Operative notes
General Surgery, Surgical d) CT Scan
616 General Surgery SG SG012 Feeding Jejunostomy SG012A Feeding Jejunostomy 15750 17325 18900 20475 22050 22837
Oncology, Pediatric Surgery confirming the diagnosis for which this surgery is
done.

c) CT c) detailed discharge summary
General Surgery, Surgical d) MRI d) Detailed Operative notes
617 General Surgery SG SG037 Hepatic Resection SG037B Lap 39375 43312 47250 51187 55125 57093
Oncology, Pediatric Surgery e) Biopsy
report confirming the justification of surgery.

c) CT c) detailed discharge summary
General Surgery, Surgical d) MRI d) Detailed Operative notes
618 General Surgery SG SG037 Hepatic Resection SG037A Open 39375 43312 47250 51187 55125 57093
Oncology, Pediatric Surgery e) Biopsy
report confirming the justification of surgery.

b) Describing Swelling in scrotum b) Intra operative clinical photograph
c) USG of scrotum c) Detailed Operative notes
General Surgery, Surgical d) FNAC d) Detailed discharge summary
619 General Surgery SG SG059 Orchidectomy SG059A Orchidectomy 12600 13860 15120 16380 17640 18270
Oncology, Pediatric Surgery e) Tumour markers (if cancer of prostate/testis etc.
is the indication) justification of orchidectmy.

b) X- Ray b) Intra procedure clinical photograph
c) USG c) Detailed discharge summary and
General Surgery, Surgical d) CT Abdomen d) Detailed Operative notes
620 General Surgery SG SG049 Retroperitoneal Tumor – Excision SG049A Retroperitoneal Tumor – Excision 41160 45276 49392 53508 57624 59682
Oncology, Pediatric Surgery confirming the diagnosis.
a) Clinical notes a) Histopath report

b) Thyroid Function Test b) Post procedure clinical photograph
c) FNAC c) Detailed Operative notes
General Surgery, Surgical d) USG d) Detailed discharge summary
621 General Surgery SG Oncology, Pediatric SG070 Thyroidectomy SG070A Hemi thyroidectomy 27615 30376 33138 35899 38661 40041
Surgery, ENT

b) Thyroid Function Test b) Post procedure clinical photograph
c) FNAC c) Detailed Operative notes
General Surgery, Surgical d) USG d) Detailed discharge summary
622 General Surgery SG Oncology, Pediatric SG070 Thyroidectomy SG070B Total thyroidectomy 27615 30376 33138 35899 38661 40041
Surgery, ENT

b) FNAC b) Post procedure clinical photograph
c) Biopsy c) Scar Photo
General Surgery, Surgical d) Thyroid Function Test d) Detailed discharge summary
623 General Surgery SG Oncology, Pediatric SG070 Thyroidectomy SG070C Total Thyroidectomy with Block Dissection 45780 50358 54936 59514 64092 66381
e) USG e) Detailed Operative notes
Surgery, ENT confirming the diagnosis and need for surgery
a) Clinical notes detailing original pathology a) Detailed Indoor case papers

b) Previous surgery report and indication of current b) Detailed procedure/ Operative notes
procedure c) c) Post procedure clinical photograph of the
624 General Surgery SG Oncology, Plastic & SG091 Skin Flaps - Rotation Flaps SG091A Skin Flaps - Rotation Flaps 30240 33264 36288 39312 42336 43848
Clinical photograph. affected part
Reconstructive Surgery
Outside State
Bed Cost Cost
Cost
625 General Surgery SG General Surgery, Urology SG058 Vasovasostomy SG058A Vasovasostomy 12600 13860 15120 16380 17640 18270
b) Pre-operative scrotal examination c) Detailed discharge summary
a.Clinical Notes b.Endoscopic ultrasound a) Post procedure endoscopic ultrasound
c.LFT and Pancreatic enzymes like amylase and b) Detailed Operative notes
Interventional Percutaneous transhepatic external biliary Percutaneous transhepatic external biliary
626 General Surgery SG SG105 SG105A 26460 29106 31752 34398 37044 38367 lipase c) Detailed discharge summary
Radiology/General surgery drainage (PTBD) drainage (PTBD)
d.Endoscopic retrograde d.Post procedure X ray/cholangiography
cholangiopancreatography
C. T. Chest - without contrast (for lungs) C. T. Chest - without contrast (for lungs) a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
627 HD HD016 HD016A 1760 1936 2112 2288 2464 2552
High End Diagnostics High End Diagnostics c) Films/ Images and report procedure
C. T. Scan Lower Abdomen(incl. Pelvis) C. T. Scan Lower Abdomen(incl. Pelvis) With a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
628 HD HD017 HD017A 1955 2150 2346 2541 2737 2834
High End Diagnostics High End Diagnostics With Contrast Contrast c) Films/ Images and report procedure
C. T. Spine (Cervical, Dorsal, Lumbar, C. T. Spine (Cervical, Dorsal, Lumbar, a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
629 HD HD025 HD025A 1725 1897 2070 2242 2415 2501
High End Diagnostics High End Diagnostics Sacral)–without contrast Sacral)–without contrast c) Films/ Images and report procedure
C.T SCAN ABDOMEN C. T. Scan Lower Abdomen( Incl. Pelvis) Without a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
630 HD HD018 HD018A 1725 1897 2070 2242 2415 2501
High End Diagnostics High End Diagnostics Contrast c) Films/ Images and report procedure
C.T SCAN ABDOMEN C. T. Scan Whole Abdomen With Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
631 HD HD018 HD018C 4658 5123 5589 6055 6521 6754
C.T SCAN ABDOMEN C. T. Scan Whole Abdomen Without Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
632 HD HD018 HD018B 3105 3415 3726 4036 4347 4502
C.T SCAN LIMBS C. T. Scan Limbs -With Contrast including CT a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
633 HD HD028 HD028B 2591 2850 3109 3368 3627 3756
High End Diagnostics High End Diagnostics angiography c) Films/ Images and report procedure
C.T SCAN LIMBS C. T. Scan Limbs -Without Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
634 HD HD028 HD028A 1955 2150 2346 2541 2737 2834
C.T SCAN NECK C. T. Scan Neck – With Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
635 HD HD022 HD022B 1955 2150 2346 2541 2737 2834
C.T SCAN NECK C. T. Scan Neck – Without Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
636 HD HD022 HD022A 1553 1708 1863 2018 2174 2251
C.T SCAN OF PARA NASAL SINUSES C. T. Scan of Para Nasal Sinuses - With a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
637 HD HD024 HD024B 1840 2024 2208 2392 2576 2668
C.T SCAN OF PARA NASAL SINUSES C. T. Scan of Para Nasal Sinuses- Without a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
638 HD HD024 HD024A 1035 1138 1242 1345 1449 1500
C.T SCAN ORBITS C. T. Scan Orbits - With Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
639 HD HD023 HD023B 1857 2042 2228 2414 2599 2692
C.T SCAN ORBITS C. T. Scan Orbits - Without Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
640 HD HD023 HD023A 1369 1505 1642 1779 1916 1985
CT - Dental CT - Dental a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
641 HD HD027 HD027A 1466 1612 1759 1905 2052 2125
CT angiography abdomen/ Chest CT angiography abdomen/ Chest a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
642 HD HD020 HD020A 5175 5692 6210 6727 7245 7503
CT Enteroclysis CT Enteroclysis a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
643 HD HD021 HD021A 6210 6831 7452 8073 8694 9004
CT GUIDED BIOPSY C. T. Guided intervention -percutaneous a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
644 HD HD029 HD029C 1501 1651 1801 1951 2101 2176
High End Diagnostics High End Diagnostics catheter drainage / tube placement c) Films/ Images and report procedure
CT GUIDED BIOPSY C.T. Guided intervention –FNAC a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
645 HD HD029 HD029A 1242 1366 1490 1614 1738 1800
CT GUIDED BIOPSY C.T. Guided Trucut Biopsy a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
646 HD HD029 HD029B 1380 1518 1656 1794 1932 2001
a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
647 HD HD011 CT GUIDED PERSUTANEOUS BIOPSY HD011A CT guided percutaneous biopsy 3750 4125 4500 4875 5250 5437
648 HD HD011 CT GUIDED PERSUTANEOUS BIOPSY HD011B CT guided percutaneous FNAC 3150 3465 3780 4095 4410 4567
649 HD HD011 CT GUIDED PERSUTANEOUS BIOPSY HD011C CT guided percutaneous needle aspiration 3150 3465 3780 4095 4410 4567
CT HEAD CT Head- with Contrast (+/- CT angiography) a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
650 HD HD015 HD015B 1553 1708 1863 2018 2174 2251
CT HEAD CT Head-Without Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
651 HD HD015 HD015A 978 1075 1173 1271 1369 1418
CT Temporal bone – without contrast CT Temporal bone – without contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
652 HD HD026 HD026A 1027 1129 1232 1335 1437 1489
653 HD HD007 Diagnostic venography (DVA) HD007A Diagnostic venography (DVA) 5550 6105 6660 7215 7770 8047
654 HD HD009 Diskography HD009A Diskography 5550 6105 6660 7215 7770 8047
655 HD HD012 Genetic workup HD012A Genetic workup 20100 22110 24120 26130 28140 29145
656 HD HD008 IVUS(Intravascular Ultrasound) HD008A IVUS(Intravascular Ultrasound) 16600 18260 19920 21580 23240 24070
657 HD HD006 Lymphangiography HD006A Lymphangiography 10950 12045 13140 14235 15330 15877
658 HD HD013 Metabolic work up HD013A Metabolic work up 30100 33110 36120 39130 42140 43645
MR cholecysto-pancreatography. MR cholecysto-pancreatography. a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
659 HD HD053 HD053A 5693 6262 6831 7400 7970 8254
MR Enteroclysis MR Enteroclysis a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
660 HD HD055 HD055A 2200 2420 2640 2860 3080 3190
MR for Salivary Glands with Sialography MR for Salivary Glands with Sialography a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
661 HD HD033 HD033A 3105 3415 3726 4036 4347 4502
MRI ABDOMEN MRI Abdomen – With Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
662 HD HD045 HD045B 5750 6325 6900 7475 8050 8337
MRI ABDOMEN MRI Abdomen – Without Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
663 HD HD045 HD045A 2444 2688 2932 3177 3421 3543
MRI Angiography - with contrast MRI Angiography - with contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
664 HD HD054 HD054A 5693 6262 6831 7400 7970 8254
MRI ANKLE MRI Ankle both joints - With contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
665 HD HD039 HD039C 5175 5692 6210 6727 7245 7503
MRI ANKLE MRI Ankle both joints - Without contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
666 HD HD039 HD039D 2875 3162 3450 3737 4025 4168
MRI ANKLE MRI Ankle single joint - With contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
667 HD HD039 HD039B 5750 6325 6900 7475 8050 8337
MRI ANKLE MRI Ankle Single joint - Without contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
668 HD HD039 HD039A 2444 2688 2932 3177 3421 3543
MRI BREAST MRI Breast - With Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
669 HD HD046 HD046A 4399 4838 5278 5718 6158 6378
MRI BREAST MRI Breast - Without Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
670 HD HD046 HD046B 2444 2688 2932 3177 3421 3543
Outside State
Bed Cost Cost
Cost
MRI CERVICAL/ CERVICO DORSAL MRI Cervical/ Cervico Dorsal Spine – With a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
671 HD HD049 HD049B 4600 5060 5520 5980 6440 6670
High End Diagnostics High End Diagnostics SPINE Contrast c) Films/ Images and report procedure
MRI CERVICAL/ CERVICO DORSAL MRI Cervical/Cervico Dorsal Spine – Without a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
672 HD HD049 HD049A 2200 2420 2640 2860 3080 3190
High End Diagnostics High End Diagnostics SPINE Contrast c) Films/ Images and report procedure
MRI CHEST MRI Chest – With Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
673 HD HD048 HD048B 4600 5060 5520 5980 6440 6670
MRI CHEST MRI Chest – Without Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
674 HD HD048 HD048A 2444 2688 2932 3177 3421 3543
MRI DORSAL/ DORSO LUMBAR SPINE MRI Dorsal/ Dorso Lumbar Spine – With a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
675 HD HD050 HD050B 4600 5060 5520 5980 6440 6670
MRI DORSAL/ DORSO LUMBAR SPINE MRI Dorsal/ Dorso Lumbar Spine - Without a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
676 HD HD050 HD050A 2444 2688 2932 3177 3421 3543
MRI EXTREMITIES MRI Extremities - With contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
677 HD HD042 HD042A 5175 5692 6210 6727 7245 7503
MRI EXTREMITIES MRI Extremities - Without contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
678 HD HD042 HD042B 2444 2688 2932 3177 3421 3543
MRI HEAD MRI Head – With Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
679 HD HD030 HD030B 3275 3602 3930 4257 4585 4748
MRI HEAD MRI Head – Without Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
680 HD HD030 HD030A 2298 2527 2757 2987 3217 3332
MRI HIP MRI Hip - With contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
681 HD HD040 HD040A 2875 3162 3450 3737 4025 4168
MRI HIP MRI Hip – without contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
682 HD HD040 HD040B 2444 2688 2932 3177 3421 3543
MRI KNEE MRI knee both joints - With contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
683 HD HD038 HD038D 5750 6325 6900 7475 8050 8337
MRI KNEE MRI knee both joints - Without contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
684 HD HD038 HD038C 2444 2688 2932 3177 3421 3543
MRI KNEE MRI knee Single joint - With contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
685 HD HD038 HD038B 5750 6325 6900 7475 8050 8337
MRI KNEE MRI knee Single joint - Without contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
686 HD HD038 HD038A 2444 2688 2932 3177 3421 3543
MRI LUMBAR/ LUMBO - SACRAL SPINE MRI Lumbar/ Lumbo-Sacral Spine – Without a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
687 HD HD051 HD051A 2444 2688 2932 3177 3421 3543
MRI LUMBAR/ LUMBO - SACRAL SPINE MRI Lumbar/ Lumbo-Sacral Spine – With a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
688 HD HD051 HD051B 5750 6325 6900 7475 8050 8337
MRI NASOPHARYNX AND PNS MRI Nasopharynx and PNS – With Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
689 HD HD032 HD032B 4025 4427 4830 5232 5635 5836
MRI NASOPHARYNX AND PNS MRI Nasopharynx and PNS – Without Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
690 HD HD032 HD032A 2818 3099 3381 3663 3945 4086
MRI NECK MRI Neck - Without Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
691 HD HD034 HD034A 3105 3415 3726 4036 4347 4502
MRI NECK MRI Neck- with contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
692 HD HD034 HD034B 5750 6325 6900 7475 8050 8337
MRI ORBITS MRI Orbits – With Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
693 HD HD031 HD031B 2300 2530 2760 2990 3220 3335
MRI ORBITS MRI Orbits – Without Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
694 HD HD031 HD031A 1662 1828 1994 2160 2326 2409
MRI PELVIS MRI Pelvis – with contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
695 HD HD041 HD041B 5750 6325 6900 7475 8050 8337
MRI PELVIS MRI Pelvis – Without Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
696 HD HD041 HD041A 2444 2688 2932 3177 3421 3543
MRI SHOULDER MRI Shoulder – With conntrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
697 HD HD035 HD035B 2990 3289 3588 3887 4186 4335
MRI SHOULDER MRI Shoulder – Without contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
698 HD HD035 HD035A 2300 2530 2760 2990 3220 3335
MRI SHOULDER BOTH JOINTS MRI Shoulder both joints – With contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
699 HD HD036 HD036B 4600 5060 5520 5980 6440 6670
MRI SHOULDER BOTH JOINTS MRI shoulder both Joints - Without contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
700 HD HD036 HD036A 3450 3795 4140 4485 4830 5002
MRI Spine Screening - Without Contrast MRI Spine Screening - Without Contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
701 HD HD047 HD047A 1150 1265 1380 1495 1610 1667
MRI TEMPORAL BONE / INNER EAR MR Temporal Bone/ Inner ear with contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
702 HD HD044 HD044A 4600 5060 5520 5980 6440 6670
MRI TEMPORAL BONE / INNER EAR MR Temporal Bone/ Inner ear without contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
703 HD HD044 HD044B 2875 3162 3450 3737 4025 4168
MRI TEMPOROMANDIBULAR B/L MRI Temporomandibular – B/L - With contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
704 HD HD043 HD043A 4140 4554 4968 5382 5796 6003
MRI TEMPOROMANDIBULAR B/L MRI Temporomandibular – B/L - Without a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
705 HD HD043 HD043B 2444 2688 2932 3177 3421 3543
High End Diagnostics High End Diagnostics contrast c) Films/ Images and report procedure
MRI WRIST MRI Wrist both joints - Without contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
706 HD HD037 HD037C 2444 2688 2932 3177 3421 3543
MRI WRIST MRI Wrist Both joints - With contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
707 HD HD037 HD037D 5750 6325 6900 7475 8050 8337
MRI WRIST MRI Wrist Single joint - With contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
708 HD HD037 HD037B 4600 5060 5520 5980 6440 6670
MRI WRIST MRI Wrist Single joint - Without contrast a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
709 HD HD037 HD037A 2444 2688 2932 3177 3421 3543
Triple Phase CT abdomen Triple Phase CT abdomen a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
710 HD HD019 HD019A 5175 5692 6210 6727 7245 7503
711 HD HD010 USG GUIDED BIOPSY HD010A USG guided percutaneous biopsy 2550 2805 3060 3315 3570 3697
712 HD HD010 USG GUIDED BIOPSY HD010B USG guided percutaneous FNAC 750 825 900 975 1050 1087
713 HD HD010 USG GUIDED BIOPSY HD010C USG guided percutaneous needle aspiration 750 825 900 975 1050 1087
714 HD HD014 Vedio EEG Monitoring Test (VEEG) HD014A Vedio EEG Monitoring Test (VEEG) 3650 4015 4380 4745 5110 5292
Whole body MRI (For oncological workup) Whole body MRI (For oncological workup) a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
715 HD HD052 HD052A 5865 6451 7038 7624 8211 8504
716 High end procedures HP High end procedures HP003 CEREBRAL ANGIOGRAM HP003B Cerebral angiogram under general anesthesia 18950 20845 22740 24635 26530 27477
c) Films/ Images and report procedure
717 High end procedures HP High end procedures HP003 CEREBRAL ANGIOGRAM HP003A Cerebral angiogram under local anesthesia 5850 6435 7020 7605 8190 8482
718 High end procedures HP High end procedures HP002 CT GUIDED PERCUTANEOUS HP002B CT guided percutaneous catheter drainage 5850 6435 7020 7605 8190 8482
Outside State
Bed Cost Cost
Cost
CT guided percutaneous Microwave Ablation a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
719 High end procedures HP High end procedures HP002 CT GUIDED PERCUTANEOUS HP002A 33100 36410 39720 43030 46340 47995
(MWA) c) Films/ Images and report procedure
CT guided percutaneous Radiofrequency a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
720 High end procedures HP High end procedures HP002 CT GUIDED PERCUTANEOUS HP002C 29100 32010 34920 37830 40740 42195
Ablation (RFA) c) Films/ Images and report procedure
721 High end procedures HP High end procedures HP005 HP005A 70050 77055 84060 91065 98070 101572
Plasmapheresis Plasmapheresis c) Films/ Images and report procedure
722 High end procedures HP High end procedures HP004 Spinal Angiogram under general anesthesia HP004A Spinal Angiogram under general anesthesia 18950 20845 22740 24635 26530 27477
723 High end procedures HP High end procedures HP001 USG GUIDED PERSUTANEOUS HP001C USG guided percutaneous catheter drainage 5850 6435 7020 7605 8190 8482
USG guided percutaneous Microwave Ablation a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
724 High end procedures HP High end procedures HP001 USG GUIDED PERSUTANEOUS HP001B 30700 33770 36840 39910 42980 44515
(MWA) c) Films/ Images and report procedure
USG guided percutaneous Radiofrequency a)Clinical Notes b) Investigation Report a) Clinical notes b) Indication for
725 High end procedures HP High end procedures HP001 USG GUIDED PERSUTANEOUS HP001A 26700 29370 32040 34710 37380 38715
Ablation (RFA) c) Films/ Images and report procedure
Infectious Diseases, Infectious Diseases, b) C.T./L.P. c) b)CT/LP. Report
726 ID ID005 Treatment of systemic fungal infections ID005A Treatment of systemic fungal infections 2250 2475 2700 2925 3150 3262
General Medicine General Medicine Routine Blood test(CBC) d) Plan line of c) Treatment Details d)CSF culture report
C) DSA confirming the diagnosis C)Radiographic stills
D)photograph.
E)CT/MRI.
727 Interventional radiology IN Interventional radiology IN021 Alcohol embolisation IN021A Alcohol embolisation 30870 33957 37044 40131 43218 44761 G)Angio.
H) GST Invoice OF IMPLANT
I) bar code of glue used.
J) Detailed Discharge Summary

D)photograph.
Angioplasty (IVC/central vein) with high pressure E)CT/MRI.
728 Interventional radiology IN Interventional radiology IN026 ANGIOPLASTY IN026D 61215 67336 73458 79579 85701 88761 G)Angio.
balloon

D)photograph.
E)CT/MRI.
729 Interventional radiology IN Interventional radiology IN026 ANGIOPLASTY IN026A Angioplasty (venous) 26355 28990 31626 34261 36897 38214 G)Angio.

D)photograph.
E)CT/MRI.
730 Interventional radiology IN Interventional radiology IN026 ANGIOPLASTY IN026C Angioplasty and bare metal stenting (venous) 46515 51166 55818 60469 65121 67446 G)Angio.

D)photograph.
Angioplasty and covered stent placement E)CT/MRI.
731 Interventional radiology IN Interventional radiology IN026 ANGIOPLASTY IN026E 59220 65142 71064 76986 82908 85869 G)Angio.
(venous)

D)photograph.
E)CT/MRI.
732 Interventional radiology IN Interventional radiology IN026 ANGIOPLASTY IN026B Angioplasty and stenting hepatic vein 65940 72534 79128 85722 92316 95613 G)Angio.

D)photograph.
E)CT/MRI.
733 Interventional radiology IN Interventional radiology IN023 Angioplasty (arterial) IN023A Angioplasty (arterial) 37695 41464 45234 49003 52773 54657 G)Angio.

D)photograph.
Angioplasty (arterial) using microguidewire and E)CT/MRI.
734 Interventional radiology IN Interventional radiology IN023 Angioplasty (arterial) IN023B 58485 64333 70182 76030 81879 84803 G)Angio.
guiding catheter
Outside State
Bed Cost Cost
Cost
D)photograph.
E)CT/MRI.
735 Interventional radiology IN Interventional radiology IN023 Angioplasty (arterial) IN023C Angioplasty and bare metal stenting (arterial) 50610 55671 60732 65793 70854 73384 G)Angio.

D)photograph.
Angioplasty and bare metal stenting (arterial) E)CT/MRI.
736 Interventional radiology IN Interventional radiology IN023 Angioplasty (arterial) IN023D 79905 87895 95886 103876 111867 115862 G)Angio.
CTO lesion

D)photograph.
Angioplasty and covered stent placement E)CT/MRI.
737 Interventional radiology IN Interventional radiology IN023 Angioplasty (arterial) IN023E 65835 72418 79002 85585 92169 95460 G)Angio.
(arterial)

D)photograph.
Angioplasty (central vein/ CIV ) with high E)CT/MRI.
Angioplasty (central vein/ CIV ) with high
738 Interventional radiology IN Interventional radiology IN030 pressure balloon Aand specilaised venous IN030A 218190 240009 261828 283647 305466 316375 G)Angio.
pressure balloon and specilaised venous stent
stent H) GST Invoice OF IMPLANT

D)photograph.
Angioplasty (complex): cutting balloon/drug Angioplasty (complex): cutting balloon/drug E)CT/MRI.
739 Interventional radiology IN Interventional radiology IN028 IN028A 69825 76807 83790 90772 97755 101246 G)Angio.
coated balloon coated balloon

D)photograph.
Angioplasty with medicated SFA stent Angioplasty with medicated SFA stent E)CT/MRI.
/Specialised stent (arterial) CTO lesion /Specialised stent (arterial) CTO lesion

D)photograph.
E)CT/MRI.
741 Interventional radiology IN Interventional radiology IN027 Angioplasty-Below knee angioplasty IN027A Angioplasty Below knee angioplasty 69930 76923 83916 90909 97902 101398 G)Angio.

D)photograph.
Arteriovenous fistula (AVF)/Arteriovenous E)CT/MRI.
742 Interventional radiology IN Interventional radiology IN049 IN049B AVF 136920 150612 164304 177996 191688 198534 G)Angio.
Malformation (AVM)

D)photograph.
743 Interventional radiology IN Interventional radiology IN049 IN049C AVM (nidus upto 3 cm) 164535 180988 197442 213895 230349 238575 G)Angio.
Malformation (AVM)
Outside State
Bed Cost Cost
Cost
D)photograph.
744 Interventional radiology IN Interventional radiology IN049 IN049A Pial AVF (Single hole) 126420 139062 151704 164346 176988 183309 G)Angio.
Malformation (AVM)

D)photograph.
E)CT/MRI.
745 Interventional radiology IN Interventional radiology IN004 Balloon test occlusion IN004A Balloon test occlusion 91875 101062 110250 119437 128625 133218 G)Angio.

D)photograph.
Balloon-occluded retrograde transvenous Balloon-occluded retrograde transvenous E)CT/MRI.
obliteration (BRTO) obliteration (BRTO)

Carotico-cavernous Fistula (CCF) embolization D)photograph.
with coils. E)CT/MRI.
Carotico-cavernous Fistula (CCF)
747 Interventional radiology IN Interventional radiology IN001 IN001A [includes 5 coils, guide catheter, micro-catheter, 196875 216562 236250 255937 275625 285468 G)Angio.
embolization
micro-guidewire, H) GST Invoice OF IMPLANT
general items] I) bar code of glue used.

Carotid-cavernous Fistula (CCF) embolization D)photograph.
Carotico-cavernous Fistula (CCF) with balloon (includes one balloon, guide E)CT/MRI.
748 Interventional radiology IN Interventional radiology IN001 IN001B 98490 108339 118188 128037 137886 142810 G)Angio.
embolization catheter, micro-catheter, micro-
guidewire, general items) H) GST Invoice OF IMPLANT

D)photograph.
E)CT/MRI.
749 Interventional radiology IN Interventional radiology IN050 Carotid angioplasty & stenting IN050A Carotid stenting 131250 144375 157500 170625 183750 190312 G)Angio.

D)photograph.
E)CT/MRI.
750 Interventional radiology IN Interventional radiology IN050 Carotid angioplasty & stenting IN050B Carotid stenting-membrane layered 185535 204088 222642 241195 259749 269025 G)Angio.

D)photograph.
E)CT/MRI.
751 Interventional radiology IN Interventional radiology IN053 Carotid stenting with protection device IN053A Carotid stenting with protection device 218295 240124 261954 283783 305613 316527 G)Angio.

D)photograph.
Catheter directed thrombolysis E)CT/MRI.
752 Interventional radiology IN Interventional radiology IN024 IN024A Catheter directed thrombolysis (arterial/venous) 46305 50935 55566 60196 64827 67142 G)Angio.
(arterial/venous)
Outside State
Bed Cost Cost
Cost
D)photograph.
E)CT/MRI.
753 Interventional radiology IN Interventional radiology IN012 Chemoport/implantable lines IN012A Chemoport/implantable lines 15330 16863 18396 19929 21462 22228 G)Angio.

D)photograph.
E)CT/MRI.
754 Interventional radiology IN Interventional radiology IN020 Coil embolization IN020B Coil embolization (with microcatheter) 39900 43890 47880 51870 55860 57855 G)Angio.

D)photograph.
E)CT/MRI.
755 Interventional radiology IN Interventional radiology IN020 Coil embolization IN020A Coil embolization (without microcatheter) 21000 23100 25200 27300 29400 30450 G)Angio.

D)photograph.
CT guided percutaneous ganglion/plexus CT guided percutaneous ganglion/plexus block E)CT/MRI.
block (Neuronolysis) (Neuronolysis)

D)photograph.
E)CT/MRI.
757 Interventional radiology IN Interventional radiology IN072 Diagnostic angiography (DSA) IN072A Diagnostic angiography (DSA) 9135 10048 10962 11875 12789 13245 G)Angio.

D)photograph.
E)CT/MRI.
758 Interventional radiology IN Interventional radiology IN052 Dural sinus stenting IN052A Dural sinus stenting 139545 153499 167454 181408 195363 202340 G)Angio.

D)photograph.
Endovascular therapy for intracranial E)CT/MRI.
759 Interventional radiology IN Interventional radiology IN048 IN048D 3 Coil + Balloon 161070 177177 193284 209391 225498 233551 G)Angio.
aneurysm

D)photograph.
760 Interventional radiology IN Interventional radiology IN048 IN048F 3 Coil + Balloon+Stent 232470 255717 278964 302211 325458 337081 G)Angio.
aneurysm

D)photograph.
761 Interventional radiology IN Interventional radiology IN048 IN048E 5 Coil + Balloon 362670 398937 435204 471471 507738 525871 G)Angio.
aneurysm
Outside State
Bed Cost Cost
Cost
D)photograph.
762 Interventional radiology IN Interventional radiology IN048 IN048G 5 Coil + Balloon+Stent 453915 499306 544698 590089 635481 658176 G)Angio.
aneurysm

D)photograph.
763 Interventional radiology IN Interventional radiology IN048 IN048H 7 Coil + Balloon+Stent 498015 547816 597618 647419 697221 722121 G)Angio.
aneurysm

D)photograph.
764 Interventional radiology IN Interventional radiology IN048 IN048A Aneurysm-3 Coil 144165 158581 172998 187414 201831 209039 G)Angio.
aneurysm

D)photograph.
765 Interventional radiology IN Interventional radiology IN048 IN048B Aneurysm-5 Coil 283920 312312 340704 369096 397488 411684 G)Angio.
aneurysm

D)photograph.
766 Interventional radiology IN Interventional radiology IN048 IN048C Aneurysm-7 Coil 337785 371563 405342 439120 472899 489788 G)Angio.
aneurysm

D)photograph.
E)CT/MRI.
767 Interventional radiology IN Interventional radiology IN077 EVOH Package IN077A AVM (1 vial) 140910 155001 169092 183183 197274 204319 G)Angio.

D)photograph.
E)CT/MRI.
768 Interventional radiology IN Interventional radiology IN077 EVOH Package IN077B AVM (3 vial) 140910 155001 169092 183183 197274 204319 G)Angio.

D)photograph.
E)CT/MRI.
769 Interventional radiology IN Interventional radiology IN077 EVOH Package IN077C AVM (5 vial) 140910 155001 169092 183183 197274 204319 G)Angio.

D)photograph.
Facet joint intra-articular intervention- Facet joint intra-articular intervention- E)CT/MRI.
CS/Thoracic/LS CS/Thoracic/LS
Outside State
Bed Cost Cost
Cost
D)photograph.
E)CT/MRI.
771 Interventional radiology IN Interventional radiology IN031 Fenestration of dissecting aneurysm IN031A Fenestration of dissecting aneurysm 39165 43081 46998 50914 54831 56789 G)Angio.

D)photograph.
Fistuloplasty / Thrombectomy of dialysis E)CT/MRI.
772 Interventional radiology IN Interventional radiology IN076 IN076A Fistuloplasty / Thrombectomy of dialysis fistula 42630 46893 51156 55419 59682 61813 G)Angio.
fistula

D)photograph.
E)CT/MRI.
773 Interventional radiology IN Interventional radiology IN019 Gelfoam embolization IN019B Gelfoam embolization (with microcatheter) 30870 33957 37044 40131 43218 44761 G)Angio.

D)photograph.
E)CT/MRI.
774 Interventional radiology IN Interventional radiology IN019 Gelfoam embolization IN019A Gelfoam embolization (without microcatheter) 15330 16863 18396 19929 21462 22228 G)Angio.

D)photograph.
E)CT/MRI.
775 Interventional radiology IN Interventional radiology IN018 Glue embolization IN018B Glue embolization (with microcatheter) 42525 46777 51030 55282 59535 61661 G)Angio.

D)photograph.
E)CT/MRI.
776 Interventional radiology IN Interventional radiology IN018 Glue embolization IN018A Glue embolization (without microcatheter) 26460 29106 31752 34398 37044 38367 G)Angio.

D)photograph.
Hepatic venous wedge pressure Hepatic venous wedge pressure measurement E)CT/MRI.
measurement (HVPG) (HVPG)

D)photograph.
Intervention for Acute stroke (Aspiration & Intervention for Acute stroke (Aspiration & stent E)CT/MRI.
stent retrieval) retrieval)

D)photograph.
Intracranial balloon angioplasty with E)CT/MRI.
779 Interventional radiology IN Interventional radiology IN002 Intracranial balloon angioplasty with stenting IN002A 210000 231000 252000 273000 294000 304500 G)Angio.
stenting
Outside State
Bed Cost Cost
Cost
D)photograph.
Intracranial stenting for Intracranial Intracranial stenting for Intracranial E)CT/MRI.
atheroscelorosis disease (ICAD) atheroscelorosis disease (ICAD)

D)photograph.
Intracranial thrombolysis / clot E)CT/MRI.
781 Interventional radiology IN Interventional radiology IN003 Intracranial thrombolysis / clot retrieval IN003A 210000 231000 252000 273000 294000 304500 G)Angio.
retrieval

D)photograph.
E)CT/MRI.
782 Interventional radiology IN Interventional radiology IN034 IVC FILTER IN034A IVC filter placement 20370 22407 24444 26481 28518 29536 G)Angio.

D)photograph.
IVC filter placement with Catheter directed E)CT/MRI.
783 Interventional radiology IN Interventional radiology IN034 IVC FILTER IN034B 38010 41811 45612 49413 53214 55114 G)Angio.
thrombolysis (arterial/venous)

D)photograph.
E)CT/MRI.
784 Interventional radiology IN Interventional radiology IN034 IVC FILTER IN034C IVC filter retrieval 15120 16632 18144 19656 21168 21924 G)Angio.

D)photograph.
E)CT/MRI.
785 Interventional radiology IN Interventional radiology IN036 Joint/bursa intervention IN036A Joint/bursa intervention 7245 7969 8694 9418 10143 10505 G)Angio.

D)photograph.
E)CT/MRI.
786 Interventional radiology IN Interventional radiology IN069 Kyphoplasty IN069A Kyphoplasty 41685 45853 50022 54190 58359 60443 G)Angio.

D)photograph.
E)CT/MRI.
787 Interventional radiology IN Interventional radiology IN016 Lymphatic occlusion of chylous leak IN016A Lymphatic occlusion of chylous leak 22365 24601 26838 29074 31311 32429 G)Angio.

D)photograph.
E)CT/MRI.
788 Interventional radiology IN Interventional radiology IN039 Median branch rhizotomy- CS/Thoracic/LS IN039A Median branch rhizotomy- CS/Thoracic/LS 19845 21829 23814 25798 27783 28775 G)Angio.
Outside State
Bed Cost Cost
Cost
D)photograph.
Microwave ablation of bone tumor /osteoid Microwave ablation of bone tumor /osteoid E)CT/MRI.
osteoma osteoma

D)photograph.
E)CT/MRI.
790 Interventional radiology IN Interventional radiology IN043 Neural foraminal block IN043A Neural foraminal block 7245 7969 8694 9418 10143 10505 G)Angio.

D)photograph.
Oesophageal /gastric / duodenal / colonic Oesophageal /gastric / duodenal / colonic E)CT/MRI.
stenting/balloon dilatation stenting/balloon dilatation

D)photograph.
PAIR / percutaneous sclerotherapy for PAIR / percutaneous sclerotherapy for Hydatid E)CT/MRI.
Hydatid cyst cyst

D)photograph.
E)CT/MRI.
793 Interventional radiology IN Interventional radiology IN005 Parent vessel occlusion - Basic IN005A Parent vessel occlusion - Basic 39375 43312 47250 51187 55125 57093 G)Angio.

D)photograph.
Percutaneous antegrade uretric stenting Percutaneous antegrade uretric stenting after E)CT/MRI.
after prior PCN prior PCN

D)photograph.
E)CT/MRI.
795 Interventional radiology IN Interventional radiology IN007 Percutaneous cholangioplasty IN007A Percutaneous cholangioplasty 15960 17556 19152 20748 22344 23142 G)Angio.

D)photograph.
E)CT/MRI.
796 Interventional radiology IN Interventional radiology IN056 Percutaneous cholecystostomy IN056A Percutaneous cholecystostomy 23205 25525 27846 30166 32487 33647 G)Angio.

D)photograph.
Percutaneous Discotomy/nucleotomy using Percutaneous Discotomy/nucleotomy using laser E)CT/MRI.
laser or nucleuotome or nucleuotome
Outside State
Bed Cost Cost
Cost
D)photograph.
E)CT/MRI.
798 Interventional radiology IN Interventional radiology IN060 Percutaneous gastrostomy IN060A Percutaneous gastrostomy 8295 9124 9954 10783 11613 12027 G)Angio.

D)photograph.
Percutaneous Injection sclerotherapy for low Percutaneous Injection sclerotherapy for low flow E)CT/MRI.
flow vascular malformation vascular malformation

D)photograph.
E)CT/MRI.
800 Interventional radiology IN Interventional radiology IN013 Percutaneous nephrostomy IN013A Percutaneous nephrostomy 23205 25525 27846 30166 32487 33647 G)Angio.

D)photograph.
PERCUTANEOUS TRANSHEPATIC Percutaneous transhepatic biliary stenting E)CT/MRI.
801 Interventional radiology IN Interventional radiology IN006 IN006B 37275 41002 44730 48457 52185 54048 G)Angio.
BILIARY STENTING (SEMS) (SEMS) after prior PTBD

D)photograph.
PERCUTANEOUS TRANSHEPATIC Primary percutaneous transhepatic biliary E)CT/MRI.
BILIARY STENTING (SEMS) stenting (SEMS)

D)photograph.
E)CT/MRI.
803 Interventional radiology IN Interventional radiology IN011 Peripherally inserted central catheter (PICC) IN011A Peripherally inserted central catheter (PICC) 9345 10279 11214 12148 13083 13550 G)Angio.

D)photograph.
Plug-assisted retrograde transvenous Plug-assisted retrograde transvenous obliteration E)CT/MRI.
obliteration (PARTO) (PARTO)

D)photograph.
E)CT/MRI.
805 Interventional radiology IN Interventional radiology IN033 Post EVAR endoleak management IN033A Post EVAR endoleak management 28665 31531 34398 37264 40131 41564 G)Angio.

D)photograph.
E)CT/MRI.
806 Interventional radiology IN Interventional radiology IN065 Pre-operative portal vein embolization IN065A Pre-operative portal vein embolization 35070 38577 42084 45591 49098 50851 G)Angio.
Outside State
Bed Cost Cost
Cost
D)photograph.
Primary percutaneous antegrade uretric E)CT/MRI.
807 Interventional radiology IN Interventional radiology IN014 IN014A Primary percutaneous antegrade uretric stenting 25410 27951 30492 33033 35574 36844 G)Angio.
stenting

D)photograph.
PRP -suprascapular /tennis elbow/other E)CT/MRI.
808 Interventional radiology IN Interventional radiology IN041 IN041A PRP -suprascapular /tennis elbow/other tendon 7245 7969 8694 9418 10143 10505 G)Angio.
tendon

D)photograph.
E)CT/MRI.
809 Interventional radiology IN Interventional radiology IN017 PVA embolization IN017B PVA embolization (with microcatheter) 39900 43890 47880 51870 55860 57855 G)Angio.

D)photograph.
E)CT/MRI.
810 Interventional radiology IN Interventional radiology IN017 PVA embolization IN017A PVA embolization (without microcatheter) 16590 18249 19908 21567 23226 24055 G)Angio.

D)photograph.
Radiofrequency Ablation (RFA) of bone Radiofrequency Ablation (RFA) of bone tumor E)CT/MRI.
tumor /metastases/osteoid osteoma /metastases/osteoid osteoma

D)photograph.
Radiofrequency ablation-Trigeminal Radiofrequency ablation-Trigeminal E)CT/MRI.
812 Interventional radiology IN Interventional radiology IN040 nerve/genicular nerve /celiac plexus /stellate IN040A nerve/genicular nerve /celiac plexus /stellate 19845 21829 23814 25798 27783 28775 G)Angio.
Ganglion/sympathetic nerve (any branch) Ganglion/sympathetic nerve (any branch) H) GST Invoice OF IMPLANT

D)photograph.
E)CT/MRI.
813 Interventional radiology IN Interventional radiology IN055 Retinoblastoma package IN055A Retinoblastoma under GA 94710 104181 113652 123123 132594 137329 G)Angio.

D)photograph.
E)CT/MRI.
814 Interventional radiology IN Interventional radiology IN035 Retrieval of intravascular foreign body IN035A Retrieval of intravascular foreign body 17745 19519 21294 23068 24843 25730 G)Angio.

D)photograph.
E)CT/MRI.
815 Interventional radiology IN Interventional radiology IN037 Sacroiliac joint denervation IN037A Sacroiliac joint denervation 19845 21829 23814 25798 27783 28775 G)Angio.
Outside State
Bed Cost Cost
Cost
D)photograph.
E)CT/MRI.
816 Interventional radiology IN Interventional radiology IN046 STROKE IN046B Stroke-Aspiration Catheter 325815 358396 390978 423559 456141 472431 G)Angio.

D)photograph.
E)CT/MRI.
817 Interventional radiology IN Interventional radiology IN046 STROKE IN046A Stroke-Stent Retreiver 305550 336105 366660 397215 427770 443047 G)Angio.

D)photograph.
E)CT/MRI.
818 Interventional radiology IN Interventional radiology IN032 TEVAR for aortic aneurysm/ dissection IN032A TEVAR for aortic aneurysm/ dissection 87990 96789 105588 114387 123186 127585 G)Angio.

D)photograph.
Thrombectomy followed by thrombolysis Thrombectomy followed by thrombolysis E)CT/MRI.
(arterial/venous) (arterial/venous)

D)photograph.
Transarterial chemoembolization - conventional E)CT/MRI.
820 Interventional radiology IN Interventional radiology IN061 Transarterial chemoembolization IN061A 63000 69300 75600 81900 88200 91350 G)Angio.
(cTACE)

D)photograph.
Transarterial chemoembolization - Drug eluting E)CT/MRI.
821 Interventional radiology IN Interventional radiology IN061 Transarterial chemoembolization IN061B 54075 59482 64890 70297 75705 78408 G)Angio.
beads (DEB-TACE)

D)photograph.
Transjugular intrahepatic portosystemic Transjugular intrahepatic portosystemic shunt E)CT/MRI.
822 Interventional radiology IN Interventional radiology IN062 shunt creation (TIPSS)/Direct transjugular IN062A creation (TIPSS)/Direct transjugular Intrahepatic 99435 109378 119322 129265 139209 144180 G)Angio.
Intrahepatic Portosystemic shunt(DIPSS) Portosystemic shunt(DIPSS) H) GST Invoice OF IMPLANT

D)photograph.
E)CT/MRI.
823 Interventional radiology IN Interventional radiology IN059 Transjugular Liver biopsy IN059A Transjugular Liver biopsy 18480 20328 22176 24024 25872 26796 G)Angio.

D)photograph.
E)CT/MRI.
824 Interventional radiology IN Interventional radiology IN078 Tumor Embolization IN078A Tumor Embolization 94605 104065 113526 122986 132447 137177 G)Angio.
Outside State
Bed Cost Cost
Cost
D)photograph.
Tunelled longterm indwelling catheter for Tunelled longterm indwelling catheter for E)CT/MRI.
refractory ascites/pleural effusion refractory ascites/pleural effusion

D)photograph.
E)CT/MRI.
826 Interventional radiology IN Interventional radiology IN009 Tunnelled long-term venous catheter IN009A Tunnelled long-term venous catheter 15330 16863 18396 19929 21462 22228 G)Angio.

D)photograph.
USG guided percutaneous ganglion/plexus USG guided percutaneous ganglion/plexus block E)CT/MRI.
block (Neuronolysis) (Neuronolysis)

D)photograph.
USG guided percutaneous Microwave E)CT/MRI.
USG guided percutaneous Microwave Ablation
828 Interventional radiology IN Interventional radiology IN071 Ablation (MWA)- benign breast /thyroid IN071A 38640 42504 46368 50232 54096 56028 G)Angio.
(MWA)- benign breast /thyroid tumor
tumor H) GST Invoice OF IMPLANT

D)photograph.
E)CT/MRI.
829 Interventional radiology IN Interventional radiology IN070 Vaccum assisted breast biopsy IN070A Vaccum assisted breast biopsy 11235 12358 13482 14605 15729 16290 G)Angio.

D)photograph.
E)CT/MRI.
830 Interventional radiology IN Interventional radiology IN075 Varicocele embolization IN075A Varicocele embolization 23835 26218 28602 30985 33369 34560 G)Angio.

D)photograph.
Varicose vein: endovenous treatment (for Varicose vein: endovenous treatment (for one E)CT/MRI.
one limb) limb)

D)photograph.
E)CT/MRI.
832 Interventional radiology IN Interventional radiology IN022 Vascular plug assisted embolization IN022A Vascular plug assisted embolization 51555 56710 61866 67021 72177 74754 G)Angio.

D)photograph.
Vasospasm management-post Vasospasm management-post coiling/clipping E)CT/MRI.
coiling/clipping (Cost per session) (Cost per session)
Outside State
Bed Cost Cost
Cost
D)photograph.
E)CT/MRI.
834 Interventional radiology IN Interventional radiology IN068 Vertebroplasty/Cementoplasty IN068A Vertebroplasty/Cementoplasty 28980 31878 34776 37674 40572 42021 G)Angio.
a) CBC. a) BAR CODE OF THE DRUGS.

b) LFT. b) REPORTS OF THE TESTS
c) Serum Electrolytes (PATHOLOGY, RADIOLOGY,
d) Blood Phosphate levels. MICROBIOLOGY, HEMATOLOGY,
e) Uric Acid. BIOCHEMISTRY,ETC.)
f) BUN c) DISCHARGE SUMMARY OF INPATIENT
l) Tumor board meeting report DEPARTMENT.
Rasburicase m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
Chemotherapy Complications - Tumor Lysis Febuxostat o) Govt. referral form. DEPARTMENT.
835 Medical Oncology MO Medical Oncology MO052 MO052A 27720 30492 33264 36036 38808 40194
Syndrome Allopurinol e) CHARTS OF CHEMOTHERAPY
Sevelamer REGIMEN.
f) TRANFUSION SLIPS.
Invoice of Medicinel) Tumor board meeting
report
m) Hysterectomy report
n) Papsmear Reoprt
o) Govt. referral form.
b) MDC. b) REPORTS OF THE TESTS
c) HIV. (PATHOLOGY, RADIOLOGY,
d) HBSAG. MICROBIOLOGY, HEMATOLOGY,
e) HCV. BIOCHEMISTRY,ETC.)
f) BIOCHEM. c) DISCHARGE SUMMARY OF INPATIENT
g) CSF CYTOMORPHOLOGY. DEPARTMENT.
h) FLOW CYTOMETRY. d) DISCHARGE SUMMARY OF DAY CARE
6 Mercaptopurine 50 mg / M2 daily i) BONE MARROW FLOW CYTOMETRY. DEPARTMENT.
836 Medical Oncology MO Medical Oncology MO047 CT for Acute Lymphoblastic Leukemia MO047C 4620 5082 5544 6006 6468 6699
Methotrexate 25 mg / M2 Weekly for 2 years j) CYTOGENETICS. e) CHARTS OF CHEMOTHERAPY
k) NGS. REGIMEN.
l) BIOPSY f) TRANFUSION SLIPS.
l) Tumor board meeting report Invoice of Medicinel) Tumor board meeting
m) Hysterectomy report n) Papsmear Reoprt report
o) Govt. referral form. m) Hysterectomy report
n) Papsmear Reoprt
f) 2D ECHO. c) DISCHARGE SUMMARY OF INPATIENT
BFM-90 g) NCCT CHEST. DEPARTMENT.
BFM-95 h) BONE MARROW or Peripheral bloodFLOW d) DISCHARGE SUMMARY OF DAY CARE
BFM-2000 CYTOMETRY. DEPARTMENT.
837 Medical Oncology MO Medical Oncology MO047 CT for Acute Lymphoblastic Leukemia MO047B 143010 157311 171612 185913 200214 207364 i) CYTOGENETICS. e) CHARTS OF CHEMOTHERAPY
HyperCVAD
UKALL j) Molecular. REGIMEN.
GMALL k) BIOPSY. f) TRANFUSION SLIPS.
l) PET-CT or CECT chest abdomen Invoice of Medicinel) Tumor board meeting
m) Pelvis(if LBL) report
l) Tumor board meeting report m) Hysterectomy report
m) Hysterectomy report n) Papsmear Reoprt n) Papsmear Reoprt
o) Govt. referral form. o) Govt. referral form.

838 Medical Oncology MO Medical Oncology MO047 CT for Acute Lymphoblastic Leukemia MO047A HyperCVAD 184800 203280 221760 240240 258720 267960 i) CYTOGENETICS. e) CHARTS OF CHEMOTHERAPY
GMALL ( this does not include antibiotics, k) BIOPSY. f) TRANFUSION SLIPS.
antifungals, blood and platelets transfusion) l) PET-CT or CECT chest abdomen Invoice of Medicinel) Tumor board meeting

c) RFT. (PATHOLOGY, RADIOLOGY,
d) RBS. MICROBIOLOGY, HEMATOLOGY,
e) Bone marrow aspiration. BIOCHEMISTRY,ETC.)
f) flow cytometry or Peripheral blood flow c) DISCHARGE SUMMARY OF INPATIENT
cytometry. DEPARTMENT.
Cytarabine 100 mg / M2 7 days g) cytogenetics. d) DISCHARGE SUMMARY OF DAY CARE
Daunomycin 60 mg / M2 3 days ( this does not h) Molecular DEPARTMENT.
839 Medical Oncology MO Medical Oncology MO046 CT for Acute Myeloid Leukemia MO046B 122010 134211 146412 158613 170814 176914
include antibiotics, antifungals, blood and l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
platelets transfusion) m) Hysterectomy report n) Papsmear Reoprt REGIMEN.
o) Govt. referral form. f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
g) cytogenetics. d) DISCHARGE SUMMARY OF DAY CARE
Cytarabine 2 gm / M2 BD for 3 days h) Molecular DEPARTMENT.
840 Medical Oncology MO Medical Oncology MO046 CT for Acute Myeloid Leukemia MO046A 82320 90552 98784 107016 115248 119364
Every 21 days for 3 cycles l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
m) Hysterectomy report n) Papsmear Reoprt REGIMEN.
report
n) Papsmear Reoprt
g) PT. DEPARTMENT.
6 MP 50 mg / day daily h) APTT. d) DISCHARGE SUMMARY OF DAY CARE
CT for Acute Promyelocytic Leukemia Methotrexate 15 mg Weekly i) FIBRINOGEN. DEPARTMENT.
841 Medical Oncology MO Medical Oncology MO049 MO049C 9240 10164 11088 12012 12936 13398 j) 2D ECHO. e) CHARTS OF CHEMOTHERAPY
(High Risk) ATRA 45 mg / M2 for 14 days
Every three months for 18 Months k) NCCT CHEST. REGIMEN.
l) BONE MARROW FLOW CYTOMETRY. f) TRANFUSION SLIPS.
m) CYTOGENETICS. Invoice of Medicinel) Tumor board meeting
n) RQPCR PML RARA. report
o) BIOPSY m) Hysterectomy report
l) Tumor board meeting report n) Papsmear Reoprt
m) Hysterectomy report n) Papsmear Reoprt o) Govt. referral form.
a) CBC BIOCHEM a) BAR CODE OF THE DRUGS.
b) ECG BONEMARROW b) REPORTS OF THE TESTS
c) RQPCR PML RARA (PATHOLOGY, RADIOLOGY,
l) Tumor board meeting report MICROBIOLOGY, HEMATOLOGY,
m) Hysterectomy report n) Papsmear Reoprt BIOCHEMISTRY,ETC.)
o) Govt. referral form. c) DISCHARGE SUMMARY OF INPATIENT
DEPARTMENT.
Arsenic trioxide d) DISCHARGE SUMMARY OF DAY CARE
CT for Acute Promyelocytic Leukemia ATRA DEPARTMENT.
(High Risk) Daunomycin or Idarubcin e) CHARTS OF CHEMOTHERAPY
Cytarabine - multiagent - vary in each protocol REGIMEN.
report
n) Papsmear Reoprt
g) PT. DEPARTMENT.
Arsenic trioxide h) APTT. d) DISCHARGE SUMMARY OF DAY CARE
CT for Acute Promyelocytic Leukemia ATRA i) FIBRINOGEN. DEPARTMENT.
843 Medical Oncology MO Medical Oncology MO049 MO049B 111825 123007 134190 145372 156555 162146 j) 2D ECHO. e) CHARTS OF CHEMOTHERAPY
(High Risk) Daunomycin or Idarubcin
Cytarabine - multiagent - vary on protocol k) NCCT CHEST. REGIMEN.
g) PT. DEPARTMENT.
h) APTT. d) DISCHARGE SUMMARY OF DAY CARE
CT for Acute Promyelocytic Leukemia ATO 0.15 mg / kg day 1-45 or 60 i) FIBRINOGEN. DEPARTMENT.
844 Medical Oncology MO Medical Oncology MO050 MO050B 93555 102910 112266 121621 130977 135654 j) 2D ECHO. e) CHARTS OF CHEMOTHERAPY
(Low Risk) ATRA 45 mg / M2 - day 1-45 or 60
k) NCCT CHEST. REGIMEN.
Outside State
Bed Cost Cost
Cost
g) PT. DEPARTMENT.
ATO 0.15 mg / kg day 1-Day 5, day 8-12, day 15- h) APTT. d) DISCHARGE SUMMARY OF DAY CARE
CT for Acute Promyelocytic Leukemia 19, day 22-26 every 56 days for 4 cycles i) FIBRINOGEN. DEPARTMENT.
845 Medical Oncology MO Medical Oncology MO050 MO050A 63525 69877 76230 82582 88935 92111 j) 2D ECHO. e) CHARTS OF CHEMOTHERAPY
(Low Risk) ATRA 45 mg / M2 day 1-Day 14 and Day 29-43
every 56 days for 4 cycles k) NCCT CHEST. REGIMEN.
e) CECT Thorax . BIOCHEMISTRY,ETC.)
f) abdomen . c) DISCHARGE SUMMARY OF INPATIENT
g) MRI Pelvis. DEPARTMENT.
5 FU + Mitomycin C h) CEA. d) DISCHARGE SUMMARY OF DAY CARE
846 Medical Oncology MO Medical Oncology MO013 CT for Anal Cancer MO013A 5 FU 1000mg/m2 D1-D4 D29-D32 12705 13975 15246 16516 17787 18422 i) Histopathology DEPARTMENT.
Mitomycin 10mg/m2 D1 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
g) MRI Pelvis. DEPARTMENT.
Capecitabine + Mitomycin C h) CEA. d) DISCHARGE SUMMARY OF DAY CARE
Capecitabine 825mg/m2 PO twice daily till i) Histopathology DEPARTMENT.
847 Medical Oncology MO Medical Oncology MO013 CT for Anal Cancer MO013B 19530 21483 23436 25389 27342 28318
completion of RT l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
Mitomycin 10mg/2 D1 m) Hysterectomy report n) Papsmear Reoprt REGIMEN.
report
n) Papsmear Reoprt
g) Pelvis. DEPARTMENT.
Carboplatin + Paclitaxel h) CEA. d) DISCHARGE SUMMARY OF DAY CARE
848 Medical Oncology MO Medical Oncology MO013 CT for Anal Cancer MO013D Paclitaxel 175mg/m2 D1 17220 18942 20664 22386 24108 24969 i) Histopathology DEPARTMENT.
Carboplatin AUC 5-6 D1 every 21 days l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Cisplatin + 5 FU h) CEA. d) DISCHARGE SUMMARY OF DAY CARE
849 Medical Oncology MO Medical Oncology MO013 CT for Anal Cancer MO013C 5 FU 1000mg/m2 D1-D4 9450 10395 11340 12285 13230 13702 i) Histopathology DEPARTMENT.
Cisplatin 75mg/m2 D1 every 4 weeks l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Cisplatin + Paclitaxel h) CEA. d) DISCHARGE SUMMARY OF DAY CARE
850 Medical Oncology MO Medical Oncology MO013 CT for Anal Cancer MO013E Paclitaxel 175 mg/m2 D1 15435 16978 18522 20065 21609 22380 i) Histopathology DEPARTMENT.
Cisplatin 75mg/m2 D1 every 21 days l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
b) Biochemistry. b) REPORTS OF THE TESTS
c) PET CT or CECT Chest abdomen . (PATHOLOGY, RADIOLOGY,
d) pelvis. MICROBIOLOGY, HEMATOLOGY,
e) Bone marrow studies. BIOCHEMISTRY,ETC.)
Rituximab + Cyclophosphamide + Doxorubicin + f) Biopsy or fluid flow. c) DISCHARGE SUMMARY OF INPATIENT
Prednsiolone g) PB cytometry. DEPARTMENT.
Rituximab 375mg/m2 h) ECG. d) DISCHARGE SUMMARY OF DAY CARE
CT for B - Cell NHL - High Grade Cyclophosphamide 750 mg/m2 i) 2D-ECHO DEPARTMENT.
851 Medical Oncology MO Medical Oncology MO029 MO029B 31185 34303 37422 40540 43659 45218
(Except Burkitt's & PCNSL) Doxorubicin 50mg/m2 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
Vincristine 1.4 mg/m2 on Day1 m) Hysterectomy report n) Papsmear Reoprt REGIMEN.
Prednisolone 100 mg Day 1-5 o) Govt. referral form. f) TRANFUSION SLIPS.
Total 6 cycles, repeat 21 days Invoice of Medicinel) Tumor board meeting
report
n) Papsmear Reoprt
c) PET CT or CECT Chest abdomen . (PATHOLOGY, RADIOLOGY,
Rituximab + Cyclophosphamide + Etoposide + f) Biopsy or fluid flow. c) DISCHARGE SUMMARY OF INPATIENT
Prednsiolone g) PB cytometry. DEPARTMENT.
Rituximab 375mg/m2 h) ECG. d) DISCHARGE SUMMARY OF DAY CARE
CT for B - Cell NHL - High Grade Cyclophosphamide 750 mg/m2 i) 2D-ECHO DEPARTMENT.
(Except Burkitt's & PCNSL) Vincristine 1.4 mg/m2, on Day1 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
Etoposide 65mg/m2 Day 1 to 3 m) Hysterectomy report n) Papsmear Reoprt REGIMEN.
Prednisolone 100 mg Day 1-5 o) Govt. referral form. f) TRANFUSION SLIPS.
Total 6 cycles, repeat 21 days Invoice of Medicinel) Tumor board meeting
report
n) Papsmear Reoprt
c) PET CT or CECT Chest abdomen (PATHOLOGY, RADIOLOGY,
f) Biopsy or fluid flow cytometry. c) DISCHARGE SUMMARY OF INPATIENT
g) ECG. DEPARTMENT.
h) 2D-ECHO d) DISCHARGE SUMMARY OF DAY CARE
853 Medical Oncology MO Medical Oncology MO033 CT for Burkitt's NHL MO033A Codox - M - IVAC / GMALL / BFM / Hyper CVAD 39900 43890 47880 51870 55860 57855 l) Tumor board meeting report DEPARTMENT.
m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
o) Govt. referral form. REGIMEN.
report
n) Papsmear Reoprt
e) MRI brain. BIOCHEMISTRY,ETC.)
f) Histopathology c) DISCHARGE SUMMARY OF INPATIENT
Temozolamide m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
854 Medical Oncology MO Medical Oncology MO021 CT for CA Brain MO021A Temozolomide 150 - 200 mg/m2 D1-D5 every 5775 6352 6930 7507 8085 8373 o) Govt. referral form. DEPARTMENT.
28 days e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
e) MRI brain. BIOCHEMISTRY,ETC.)
f) Histopathology c) DISCHARGE SUMMARY OF INPATIENT
m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
Temozolamide o) Govt. referral form. DEPARTMENT.
855 Medical Oncology MO Medical Oncology MO021 CT for CA Brain MO021B 34650 38115 41580 45045 48510 50242
Temozolomide 75mg/m2 once daily e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
a) BAR CODE OF THE DRUGS.
b) REPORTS OF THE TESTS
a) CBC. (PATHOLOGY, RADIOLOGY,
b) LFT. MICROBIOLOGY, HEMATOLOGY,
c) RFT. BIOCHEMISTRY,ETC.)
d) Biopsy report or surgical pathology report of c) DISCHARGE SUMMARY OF INPATIENT
Modified radical mastectomy or breast DEPARTMENT.
conservation surgery. d) DISCHARGE SUMMARY OF DAY CARE
Capecitabine e) ECG. DEPARTMENT.
856 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001J Capecitabine - 1000mg/m2 orally twice daily D1- 8610 9471 10332 11193 12054 12484 f) 2D-ECHO. e) CHARTS OF CHEMOTHERAPY
D14 every 21 days g) USG abdomen REGIMEN.
h) pelvis. f) TRANFUSION SLIPS.
i) CXR PA view or CECT chest Invoice of Medicinel) Tumor board meeting
j) abdomen report
k) pelvis in case of metastatic disease m) Hysterectomy report
Carboplatin + Gemcitabine conservation surgery. d) DISCHARGE SUMMARY OF DAY CARE
Gemcitabine - 1000mg/m2 D1 D8 e) ECG. DEPARTMENT.
857 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001K Carboplatin AUC 2 D1 D8 16065 17671 19278 20884 22491 23294 f) 2D-ECHO. e) CHARTS OF CHEMOTHERAPY
Gemcitabine - 1000mg/m2 D1 D8 g) USG abdomen REGIMEN.
Carboplatin AUC 5-6 D1 only h) pelvis. f) TRANFUSION SLIPS.
j) abdomen report
d) Biopsy report or surgical pathology report of MICROBIOLOGY, HEMATOLOGY,
Modified radical mastectomy or breast BIOCHEMISTRY,ETC.)
conservation surgery. c) DISCHARGE SUMMARY OF INPATIENT
e) ECG. DEPARTMENT.
Carboplatin + Paclitaxel f) 2D-ECHO. d) DISCHARGE SUMMARY OF DAY CARE
858 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001I Paclitaxel 175mg/m2 D1 17220 18942 20664 22386 24108 24969 g) USG abdomen DEPARTMENT.
Carboplatin AUC 5-6 D1 every 21 days h) pelvis. e) CHARTS OF CHEMOTHERAPY
i) CXR PA view or CECT chest REGIMEN.
j) abdomen f) TRANFUSION SLIPS.
k) pelvis in case of metastatic disease Invoice of Medicinel) Tumor board meeting
l) Tumor board meeting report report
m) Hysterectomy report n) Papsmear Reoprt m) Hysterectomy report
o) Govt. referral form. n) Papsmear Reoprt
e) ECG. DEPARTMENT.
Cyclophosphamide + Adriamycin f) 2D-ECHO. d) DISCHARGE SUMMARY OF DAY CARE
859 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001L Cyclophosphamide - 600 mg /m2 D1 5250 5775 6300 6825 7350 7612 g) USG abdomen DEPARTMENT.
Adriamycin - 60mg/m2 D1 every 21 days h) pelvis. e) CHARTS OF CHEMOTHERAPY
Outside State
Bed Cost Cost
Cost
e) ECG. DEPARTMENT.
f) 2D-ECHO. d) DISCHARGE SUMMARY OF DAY CARE
Cyclophosphamide + Epirubcin g) USG abdomen DEPARTMENT.
860 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001A Cyclophosphamide - 600 mg /m2 D1 8500 9350 10200 11050 11900 12325 h) pelvis. e) CHARTS OF CHEMOTHERAPY
Epirubicin -90mg/m2 D1 every 21 days i) CXR PA view or CECT chest REGIMEN.
k) pelvis in case of metastatic disease l) Tumor Invoice of Medicinel) Tumor board meeting
board meeting report m) report
Hysterectomy report n) Papsmear Reoprt o) m) Hysterectomy report
Govt. referral form. n) Papsmear Reoprt

e) ECG. DEPARTMENT.
Cyclophosphamide + Methotrexate + 5 - FU f) 2D-ECHO. d) DISCHARGE SUMMARY OF DAY CARE
Cyclophosphamide - 100mg/m2 orally D1-D14 g) USG abdomen DEPARTMENT.
861 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001D 4100 4510 4920 5330 5740 5945
Methotrexate 40mg/m2 IV D1 h) pelvis. e) CHARTS OF CHEMOTHERAPY
D8 5FU 600 mg/m2 D1, D8 every 28 days i) CXR PA view or CECT chest REGIMEN.
e) ECG. DEPARTMENT.
Docetaxel + Cyclophosphamide f) 2D-ECHO. d) DISCHARGE SUMMARY OF DAY CARE
Docetaxel 75mg/m2 D1 g) USG abdomen DEPARTMENT.
862 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001E 10710 11781 12852 13923 14994 15529
Cyclophosphamide 600 mg/m2 D1 every 21 h) pelvis. e) CHARTS OF CHEMOTHERAPY
days i) CXR PA view or CECT chest REGIMEN.
d) Biopsy report MICROBIOLOGY, HEMATOLOGY,
e) surgical pathology report of Modified radical BIOCHEMISTRY,ETC.)
mastectomy c) DISCHARGE SUMMARY OF INPATIENT
f) breast conservation surgery. DEPARTMENT.
g) ER d) DISCHARGE SUMMARY OF DAY CARE
Exemestane h) PR positive . DEPARTMENT.
863 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001O 4515 4966 5418 5869 6321 6546
Exemestane 25 mg orally daily (q 3 monthsly) i) mammography. e) CHARTS OF CHEMOTHERAPY
j) USG abdomen REGIMEN.
k) pelvis. f) TRANFUSION SLIPS.
l) CXR PA view Invoice of Medicinel) Tumor board meeting
m) CECT chest abdomen and pelvis report
e) ER or PR positive . DEPARTMENT.
Fulvestrant f) mammography. d) DISCHARGE SUMMARY OF DAY CARE
864 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001M Fulvestrant 500 mg D1 D15 D28 then every 28 41580 45738 49896 54054 58212 60291 g) USG abdomen DEPARTMENT.
days h) pelvis. e) CHARTS OF CHEMOTHERAPY
i) CXR PA view or CECT chest abdomen and REGIMEN.
pelvis f) TRANFUSION SLIPS.
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
d) Biopsy report MICROBIOLOGY, HEMATOLOGY,
e) surgical pathology report of Modified radical BIOCHEMISTRY,ETC.)
mastectomy c) DISCHARGE SUMMARY OF INPATIENT
f) breast conservation surgery. DEPARTMENT.
g) ER d) DISCHARGE SUMMARY OF DAY CARE
Lapatinib h) PR positive . DEPARTMENT.
865 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001P 17430 19173 20916 22659 24402 25273
Lapatinib 500 mg BD orally , daily i) mammography. e) CHARTS OF CHEMOTHERAPY
j) USG abdomen REGIMEN.
k) pelvis. f) TRANFUSION SLIPS.
l) CXR PA view Invoice of Medicinel) Tumor board meeting
m) CECT chest abdomen and pelvis report
e) ECG. DEPARTMENT.
Letrozole f) 2D-ECHO. e) CHARTS OF CHEMOTHERAPY
866 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001H 4515 4966 5418 5869 6321 6546
Letrozole 2.5 mg orally daily g) USG abdomen REGIMEN.
j) abdomen report

e) ER or PR positive . DEPARTMENT.
f) mammography. d) DISCHARGE SUMMARY OF DAY CARE
Paclitaxel g) USG abdomen DEPARTMENT.
867 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001N 13650 15015 16380 17745 19110 19792
Paclitaxel 175 mg/m2 D1 every 21 days h) pelvis. e) CHARTS OF CHEMOTHERAPY
i) CXR PA view or CECT chest abdomen and REGIMEN.
pelvis f) TRANFUSION SLIPS.
n) Papsmear Reoprt
e) ECG. DEPARTMENT.
Tamoxifen f) 2D-ECHO. e) CHARTS OF CHEMOTHERAPY
868 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001G 1365 1501 1638 1774 1911 1979
Tamoxifem 20 mg orally daily g) USG abdomen REGIMEN.
j) abdomen report
a) CBC. BAR CODE OF THE DRUGS, REPORTS

b) LFT. OF THE TESTS (PATHOLOGY,
c) RFT. RADIOLOGY, MICROBIOLOGY,
d) Biopsy report or surgical pathology report of HEMATOLOGY, BIOCHEMISTRY,ETC.)
Modified radical mastectomy or breast DISCHARGE SUMMARY OF INPATIENT
conservation surgery. DEPARTMENT, DISCHARGE SUMMARY
e) ECG. OF DAY CARE DEPARTMENT, CHARTS
Trastuzumab f) 2D-ECHO. OF CHEMOTHERAPY REGIMEN,
869 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001F Trastuzumab 8 mg/Kg in Cycle 1 D1 24570 27027 29484 31941 34398 35626 g) USG abdomen TRANFUSION SLIPS Invoice of Medicinel)
Trastuzumab 6 mg/kg D1 from C2 every 21 days h) pelvis. Tumor board meeting report
i) CXR PA view or CECT chest m) Hysterectomy report
j) abdomen n) Papsmear Reoprt
k) pelvis in case of metastatic disease o) Govt. referral form.
l) Tumor board meeting report
m) Hysterectomy report n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
e) ECG. DEPARTMENT.
g) USG abdomen DEPARTMENT.
Weekly Paclitaxel for Adjuvant Therapy h) pelvis. e) CHARTS OF CHEMOTHERAPY
870 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001B 6950 7645 8340 9035 9730 10077
Paclitaxel 80mg/m2 every week i) CXR PA view or CECT chest REGIMEN.
k) pelvis in case of metastatic disease l) Tumor Invoice of Medicinel) Tumor board meeting
board meeting report m) report
Hysterectomy report n) Papsmear Reoprt o) m) Hysterectomy report
Govt. referral form. n) Papsmear Reoprt

e) ECG. DEPARTMENT.
Weekly Paclitaxel in metastatic setting g) USG abdomen DEPARTMENT.
871 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001C 6950 7645 8340 9035 9730 10077
Paclitaxel 80mg/m2 every week h) pelvis. e) CHARTS OF CHEMOTHERAPY
e) CECT Thorax. BIOCHEMISTRY,ETC.)
f) Abdomen c) DISCHARGE SUMMARY OF INPATIENT
h) histopathology d) DISCHARGE SUMMARY OF DAY CARE
872 Medical Oncology MO Medical Oncology MO072 CT for CA Cervix MO072A Carboplatin Carboplatin AUC 2 every week 3150 3465 3780 4095 4410 4567 l) Tumor board meeting report DEPARTMENT.
report
n) Papsmear Reoprt
e) histopathology-squamous carcinoma. BIOCHEMISTRY,ETC.)
f) nasopharyngeal carcinoma. c) DISCHARGE SUMMARY OF INPATIENT
g) salivary gland DEPARTMENT.
Carboplatin + Gemcitabine l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
873 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024C Gemcitabine 1000 mg/m2 D1 D8 16065 17671 19278 20884 22491 23294 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Carboplatin AUC 5-6 D1 every 21 days o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
e) CECT BIOCHEMISTRY,ETC.)
f) MR Face c) DISCHARGE SUMMARY OF INPATIENT
g) neck. DEPARTMENT.
h) histopathology -squamous carcinoma. d) DISCHARGE SUMMARY OF DAY CARE
Carboplatin i) nasopharyngeal carcinoma DEPARTMENT.
874 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024O 3150 3465 3780 4095 4410 4567
Carboplatin AUC 2 every week l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Cisplatin + Docetaxel h) histopathology -squamous carcinoma. d) DISCHARGE SUMMARY OF DAY CARE
875 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024A Docetaxel 75 mg/m2 D1 14385 15823 17262 18700 20139 20858 i) Nasopharyngeal carcinoma Pure tone DEPARTMENT.
Cisplatin 75 mg/m2 D1 every 21 days audiometry e) CHARTS OF CHEMOTHERAPY
l) Tumor board meeting report REGIMEN.
m) Hysterectomy report n) Papsmear Reoprt f) TRANFUSION SLIPS.
o) Govt. referral form. Invoice of Medicinel) Tumor board meeting
report
n) Papsmear Reoprt
Cisplatin i) nasopharyngeal carcinoma. DEPARTMENT.
876 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024B 11340 12474 13608 14742 15876 16443
Cisplatin 100mg/m2 every 21 days j) Pure tone audiometry e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Cisplatin l) Tumor board meeting report DEPARTMENT.
877 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024P 2730 3003 3276 3549 3822 3958
Cisplatin 40mg/m2 every week m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Docetaxel + Cisplatin + 5 FU l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
Docetaxel 75 mg/m2 D1 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
878 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024D 16800 18480 20160 21840 23520 24360
Cisplatin 75 mg/m2 D1 o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
5 FU 750 mg/m2 D1- D5 every 21 days REGIMEN.
report
n) Papsmear Reoprt
l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
Docetaxel m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
879 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024E 3780 4158 4536 4914 5292 5481
Docetaxel 20mg/m2 every week o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
h) histopathology -squamous carcinoma d) DISCHARGE SUMMARY OF DAY CARE
Docetaxel l) Tumor board meeting report DEPARTMENT.
880 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024F 14400 15840 17280 18720 20160 20880
Docetaxel 75 mg/m2 D1 every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
e) histopathology -esthesioneuroblastoma. BIOCHEMISTRY,ETC.)
f) Neuroendocrine. c) DISCHARGE SUMMARY OF INPATIENT
Etoposide + Carboplatin m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
881 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024G Etoposide 100mg/m2 D1 - D3 8925 9817 10710 11602 12495 12941 o) Govt. referral form. DEPARTMENT.
Carboplatin AUC 5-6 D1 every 21 days e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
e) histopathology -esthesioneuroblastoma. BIOCHEMISTRY,ETC.)
f) Neuroendocrine. c) DISCHARGE SUMMARY OF INPATIENT
Etoposide + Cisplatin m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
882 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024H Etoposide 100mg/m2 D1 - D3 10710 11781 12852 13923 14994 15529 o) Govt. referral form. DEPARTMENT.
Cisplatin 75-100 mg/m2 D1 every 21 days e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Gemcitabine + Cisplatin l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
883 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024J Gemcitabine 1000 mg/m2 D1 D8 14070 15477 16884 18291 19698 20401 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Cisplatin 75 mg/m2 D1 every 21 days o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Gemcitabine m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
884 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024I 10395 11434 12474 13513 14553 15072
Gemcitabine 1000 mg/m2 D1 D8 every 21 days o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Paclitaxel + Carboplatin m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
885 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024L 16800 18480 20160 21840 23520 24360
Paclitaxel 175mg/m2 every 21 days o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Paclitaxel + Carboplatin l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
886 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024K Paclitaxel 80mg/m2 D1 8925 9817 10710 11602 12495 12941 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Carboplatin AUC 2 D1 every week o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Paclitaxel m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
887 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024N 13650 15015 16380 17745 19110 19792
Paclitaxel 175mg/m2 every 21 days o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
f) salivary gland c) DISCHARGE SUMMARY OF INPATIENT
Paclitaxel o) Govt. referral form. DEPARTMENT.
888 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024M 6930 7623 8316 9009 9702 10048
Paclitaxel 80mg/m2 every week e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
f) abdomen c) DISCHARGE SUMMARY OF INPATIENT
h) histopathology- Non Small cell Lung cancer d) DISCHARGE SUMMARY OF DAY CARE
Docetaxel l) Tumor board meeting report DEPARTMENT.
889 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071G 3675 4042 4410 4777 5145 5328
Docetaxel 20 mg/m2 D1 every week m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
g) Pelvis DEPARTMENT.
890 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071A 9870 10857 11844 12831 13818 14311
Docetaxel 75 mg/m2 D1 every 21 days o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
h) EGFR mutation positive d) DISCHARGE SUMMARY OF DAY CARE
Erlotinib l) Tumor board meeting report DEPARTMENT.
891 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071B 5250 5775 6300 6825 7350 7612
Erlotinib 150 mg once daily m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Etoposide + Carboplatin h) histopathology - Small Cell Lung Carcinoma d) DISCHARGE SUMMARY OF DAY CARE
892 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071H Etoposide 100mg/m2 D1 - D3 8925 9817 10710 11602 12495 12941 l) Tumor board meeting report DEPARTMENT.
Carboplatin AUC 5-6 D1 every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Etoposide + Cisplatin h) histopathology - Small Cell Lung Carcinoma d) DISCHARGE SUMMARY OF DAY CARE
893 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071I Etoposide 100mg/m2 D1 - D3 7875 8662 9450 10237 11025 11418 l) Tumor board meeting report DEPARTMENT.
Cisplatin 75-100 mg/m2 D1 every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
h) EGFR mutation positive d) DISCHARGE SUMMARY OF DAY CARE
Gefitnib l) Tumor board meeting report DEPARTMENT.
894 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071C 2940 3234 3528 3822 4116 4263
Gefitinib 250 mg once daily m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Gemcitabine + Carboplatin h) histopathology- Non Small cell Lung cancer d) DISCHARGE SUMMARY OF DAY CARE
895 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071K Gemcitabine 1000 mg/m2 D1 D8 16065 17671 19278 20884 22491 23294 l) Tumor board meeting report DEPARTMENT.
report
n) Papsmear Reoprt
Gemcitabine + Cisplatin h) histopathology- Non Small cell Lung cancer d) DISCHARGE SUMMARY OF DAY CARE
896 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071L Gemcitabine 1000 mg/m2 D1 D8 14070 15477 16884 18291 19698 20401 l) Tumor board meeting report DEPARTMENT.
Cisplatin 75 mg/m2 D1 D8 every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
h) histopathology (non small cell carcinoma) d) DISCHARGE SUMMARY OF DAY CARE
Gemcitabine l) Tumor board meeting report DEPARTMENT.
897 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071J 10395 11434 12474 13513 14553 15072
Gemcitabine 1000mg /m2 D1 D8 every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Paclitaxel + Carboplatin h) histopathology (non small cell carcinoma) d) DISCHARGE SUMMARY OF DAY CARE
898 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071D Paclitaxel 175mg/m2 D1 16800 18480 20160 21840 23520 24360 l) Tumor board meeting report DEPARTMENT.
report
n) Papsmear Reoprt
Paclitaxel + Carboplatin h) histopathology (non small cell carcinoma) d) DISCHARGE SUMMARY OF DAY CARE
899 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071O Paclitaxel 50mg/m2 D1 8925 9817 10710 11602 12495 12941 l) Tumor board meeting report DEPARTMENT.
Carboplatin AUC 2 D1 every week m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Paclitaxel + Cisplatin h) histopathology- Non Small cell Lung cancer d) DISCHARGE SUMMARY OF DAY CARE
900 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071P Paclitaxel 175 mg/m2 D1 15435 16978 18522 20065 21609 22380 l) Tumor board meeting report DEPARTMENT.
Cisplatin 75mg/m2 D1 every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Paclitaxel l) Tumor board meeting report DEPARTMENT.
901 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071N 13650 15015 16380 17745 19110 19792
Paclitaxel 175mg/m2 every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Paclitaxel l) Tumor board meeting report DEPARTMENT.
902 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071M 6930 7623 8316 9009 9702 10048
Paclitaxel 80mg/m2 every week m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
d) RBS. c) DISCHARGE SUMMARY OF INPATIENT
e) CECT Thorax. DEPARTMENT.
Pemetrexed + Carboplatin f) abdomen d) DISCHARGE SUMMARY OF DAY CARE
903 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071E Pemetrexed 500mg/m2 D1 11760 12936 14112 15288 16464 17052 g) Pelvis. DEPARTMENT.
Carboplatin AUC 5-6 D1 every 21 days h) histopathology (non small cell – e) CHARTS OF CHEMOTHERAPY
adenocarcinoma or adenosquamous carcinoma REGIMEN.
l) Tumor board meeting report f) TRANFUSION SLIPS.
m) Hysterectomy report n) Papsmear Reoprt Invoice of Medicinel) Tumor board meeting
o) Govt. referral form. report
n) Papsmear Reoprt
Pemetrexed + Cisplatin h) histopathology – adenocarcinoma d) DISCHARGE SUMMARY OF DAY CARE
904 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071Q Pemetrexed 500mg/m2 D1 10920 12012 13104 14196 15288 15834 i) adenosquamous carcinoma DEPARTMENT.
Cisplatin 75 mg/m2 D1 every 21 days l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
e) CECT Thorax. DEPARTMENT.
f) abdomen d) DISCHARGE SUMMARY OF DAY CARE
Pemetrexed g) Pelvis. DEPARTMENT.
905 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071R 8820 9702 10584 11466 12348 12789
Pemetrexed 500mg/m2 D1 every 21 days h) histopathology (non small cell - adenocarcinoma e) CHARTS OF CHEMOTHERAPY
or adenosquamous carcinoma) REGIMEN.
l) Tumor board meeting report f) TRANFUSION SLIPS.
n) Papsmear Reoprt
h) histopathology - Small Cell Lung Carcinoma d) DISCHARGE SUMMARY OF DAY CARE
Topotecan l) Tumor board meeting report DEPARTMENT.
906 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071F 28455 31300 34146 36991 39837 41259
Topotecan 1.5 mg/m2 D1-D5 every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Vinorelbine + Carboplatin h) histopathology- Non Small cell Lung cancer d) DISCHARGE SUMMARY OF DAY CARE
907 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071S Vinorelbine 25mg/m2 D1 D8 22800 25080 27360 29640 31920 33060 l) Tumor board meeting report DEPARTMENT.
CarboplatinAUC 5-6 D1 every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Vinorelbine + Cisplatin h) histopathology- Non Small cell Lung cancer d) DISCHARGE SUMMARY OF DAY CARE
908 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071T Vinorelbine 25mg/m2 D1 D8 20600 22660 24720 26780 28840 29870 l) Tumor board meeting report DEPARTMENT.
Cisplatin 75mg/m2 D1 every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
d) Biopsy report or surgical pathology report c) DISCHARGE SUMMARY OF INPATIENT
e) ECG. DEPARTMENT.
909 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003H Cyclophosphamide 50 mg/m2 OD D1-D21 every 3255 3580 3906 4231 4557 4719 g) USG abdomen DEPARTMENT.
28 days h) pelvis. e) CHARTS OF CHEMOTHERAPY
Outside State
Bed Cost Cost
Cost
a) CBc. a) BAR CODE OF THE DRUGS.
e) CA-125. BIOCHEMISTRY,ETC.)
f) CECT Thorax. c) DISCHARGE SUMMARY OF INPATIENT
g) abdomen DEPARTMENT.
h) Pelvis. d) DISCHARGE SUMMARY OF DAY CARE
910 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003C 3990 4389 4788 5187 5586 5785 i) HPR or cytology suggestive of ovarian DEPARTMENT.
Etoposide 50 mg/m2 OD D1-D21 every 28 days adenocarcinoma e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Carboplatin + Gemcitabine g) abdomen DEPARTMENT.
Gemcitabine - 1000mg/m2 D1 D8 h) Pelvis. d) DISCHARGE SUMMARY OF DAY CARE
911 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003F Carboplatin AUC 2 D1 D8 16065 17671 19278 20884 22491 23294 i) HPR or cytology suggestive of ovarian DEPARTMENT.
Gemcitabine - 1000mg/m2 D1 D8 adenocarcinoma e) CHARTS OF CHEMOTHERAPY
Carboplatin AUC 5-6 D1 only l) Tumor board meeting report REGIMEN.
report
n) Papsmear Reoprt
Carboplatin + Paclitaxel h) Pelvis. d) DISCHARGE SUMMARY OF DAY CARE
912 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003G Paclitaxel 175mg/m2 D1 17220 18942 20664 22386 24108 24969 i) HPR or cytology suggestive of ovarian DEPARTMENT.
Carboplatin AUC 5-6 D1 every 21 days adenocarcinoma e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Cisplatin + Irinotecan h) Pelvis. d) DISCHARGE SUMMARY OF DAY CARE
913 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003A Cisplatin 60mg/m2 D1 15120 16632 18144 19656 21168 21924 i) HPR or cytology suggestive of ovarian DEPARTMENT.
Irinotecan 60 mg/m2 D1 D8 D15 every 28 days adenocarcinoma e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
e) ECG. DEPARTMENT.
Cisplatin f) 2D-ECHO. d) DISCHARGE SUMMARY OF DAY CARE
914 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003L Cisplatin 40 mg/m2 every week (maximum- 6 4830 5313 5796 6279 6762 7003 g) USG abdomen DEPARTMENT.
cycles) h) pelvis. e) CHARTS OF CHEMOTHERAPY
Outside State
Bed Cost Cost
Cost
Irinotecan i) HPR or cytology suggestive of ovarian DEPARTMENT.
915 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003D 12705 13975 15246 16516 17787 18422
Irinotecan 60 -90 mg/m2 D1 D8 every 21 days adenocarcinoma e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
e) ECG. DEPARTMENT.
Letrozole g) USG abdomen DEPARTMENT.
916 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003J 4515 4966 5418 5869 6321 6546
Letrozole 2.5 mg orally daily (3 months) h) pelvis. e) CHARTS OF CHEMOTHERAPY
Lipodox + Carboplatin h) Pelvis. d) DISCHARGE SUMMARY OF DAY CARE
917 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003B Lipopdox 30 mg/m2 D1 19950 21945 23940 25935 27930 28927 i) HPR or cytology suggestive of ovarian DEPARTMENT.
Carboplatin AUC 5-6 D1 every 28 days adenocarcinoma e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Lipodox i) HPR or cytology suggestive of ovarian DEPARTMENT.
918 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003E 20790 22869 24948 27027 29106 30145
Lipodox 40 mg/m2 IV every 28 days adenocarcinoma e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
e) ECG. DEPARTMENT.
Single agent Carboplatin f) 2D-ECHO. d) DISCHARGE SUMMARY OF DAY CARE
919 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003K Carboplatin AUC 5-6 D1 every 21 days ( 8085 8893 9702 10510 11319 11723 g) USG abdomen DEPARTMENT.
maximum -6 cycle) h) pelvis. e) CHARTS OF CHEMOTHERAPY
Outside State
Bed Cost Cost
Cost
e) ECG. DEPARTMENT.
Tamoxifen g) USG abdomen DEPARTMENT.
920 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003I 1470 1617 1764 1911 2058 2131
Tamoxifem 20 mg orally daily (3 months) h) pelvis. e) CHARTS OF CHEMOTHERAPY
b) RFT. b) REPORTS OF THE TESTS
c) LFT. (PATHOLOGY, RADIOLOGY,
d) CECT Thorax. MICROBIOLOGY, HEMATOLOGY,
e) abdomen BIOCHEMISTRY,ETC.)
f) Pelvis. c) DISCHARGE SUMMARY OF INPATIENT
g) histopathology DEPARTMENT.
5 FU + Cisplatin l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
921 Medical Oncology MO Medical Oncology MO027 CT for CA Penis MO027B 5 FU 1000mg/m2 D1-D4 9450 10395 11340 12285 13230 13702 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Cisplatin 75mg/m2 D1 every 4 weeks o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Capecitabine l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
922 Medical Oncology MO Medical Oncology MO027 CT for CA Penis MO027C Capecitabine 1000-1250 mg/m2 PO twice daily 8500 9350 10200 11050 11900 12325 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
D1 -D14 every 21 days o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Cisplatin + Paclitaxel l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
923 Medical Oncology MO Medical Oncology MO027 CT for CA Penis MO027A Paclitaxel 175 mg/m2 D1 15435 16978 18522 20065 21609 22380 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Cisplatin 75 mg/m2 D1 every 21 days o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
924 Medical Oncology MO Medical Oncology MO027 CT for CA Penis MO027D Paclitaxel 175mg/m2 D1 16800 18480 20160 21840 23520 24360 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
925 Medical Oncology MO Medical Oncology MO027 CT for CA Penis MO027G Paclitaxel 80 mg/m2 D1 8925 9817 10710 11602 12495 12941 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Carboplatin AUC 2 D1 every week o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
926 Medical Oncology MO Medical Oncology MO027 CT for CA Penis MO027F 13650 15015 16380 17745 19110 19792
Paclitaxel 175 mg/m2 D1 every 21 days o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
927 Medical Oncology MO Medical Oncology MO027 CT for CA Penis MO027E 6930 7623 8316 9009 9702 10048
Paclitaxel 80 mg/m2 D1 every week o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
d) PSA. MICROBIOLOGY, HEMATOLOGY,
e) ECG. BIOCHEMISTRY,ETC.)
f) CECTThorax. c) DISCHARGE SUMMARY OF INPATIENT
Abiraterone 1000 mg + Prednisolone 10mg daily h) Pelvis. d) DISCHARGE SUMMARY OF DAY CARE
928 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028I 15015 16516 18018 19519 21021 21771 i) bone scan. DEPARTMENT.
Once every month
j) histopathology e) CHARTS OF CHEMOTHERAPY
n) Papsmear Reoprt
Docetaxel i) bone scan. DEPARTMENT.
929 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028H 3780 4158 4536 4914 5292 5481
Docetaxel 20mg/m2 D1 every week j) histopathology e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
930 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028A 11700 12870 14040 15210 16380 16965
Docetaxel 60 mg/m2 D1 every 14 days j) histopathology e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
931 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028B 14100 15510 16920 18330 19740 20445
Docetaxel 75 mg/m2 D1 every 21 days j) histopathology e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Etoposide + Carboplatin h) Pelvis. d) DISCHARGE SUMMARY OF DAY CARE
932 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028C Etoposide 100mg/m2 D1 - D3 8925 9817 10710 11602 12495 12941 i) bone scan. DEPARTMENT.
Carboplatin AUC 5-6 D1 every 21 days j) histopathology e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
LHRH Agonist i) bone scan. DEPARTMENT.
933 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028D 17745 19519 21294 23068 24843 25730
Leuprolide 22.5 ug every 3 months j) histopathology e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Mitoxantrone + Prednisolone h) Pelvis. d) DISCHARGE SUMMARY OF DAY CARE
934 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028E Mitoxantrone 12mg/m2 every 3 weeks 4935 5428 5922 6415 6909 7155 i) bone scan. DEPARTMENT.
Prednsiolone 10 mg daily j) histopathology e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Paclitaxel + Carboplatin h) Pelvis. d) DISCHARGE SUMMARY OF DAY CARE
935 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028G Paclitaxel 175mg/m2 D1 16800 18480 20160 21840 23520 24360 i) bone scan. DEPARTMENT.
Carboplatin AUC 5-6 D1 every 21 days j) histopathology e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Paclitaxel + Carboplatin h) Pelvis. d) DISCHARGE SUMMARY OF DAY CARE
936 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028F Paclitaxel 80mg/m2 D1 8925 9817 10710 11602 12495 12941 i) bone scan. DEPARTMENT.
Carboplatin AUC 2 D1 every week j) histopathology e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Carboplatin + Paclitaxel h) histopathology d) DISCHARGE SUMMARY OF DAY CARE
937 Medical Oncology MO Medical Oncology MO006 CT for Cervical Cancer MO006A Paclitaxel 175mg/m2 D1 17220 18942 20664 22386 24108 24969 l) Tumor board meeting report DEPARTMENT.
report
n) Papsmear Reoprt
Cisplatin l) Tumor board meeting report DEPARTMENT.
938 Medical Oncology MO Medical Oncology MO006 CT for Cervical Cancer MO006B 2730 3003 3276 3549 3822 3958
Cisplatin 40 mg/m2 every week m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
c) Chest X ay (PATHOLOGY, RADIOLOGY,
d) USG abdomen MICROBIOLOGY, HEMATOLOGY,
e) pelvis or CECT Chest abdomen BIOCHEMISTRY,ETC.)
f) pelvis. c) DISCHARGE SUMMARY OF INPATIENT
g) Bone marrow studies. DEPARTMENT.
Fludarabine + Cyclophosphamide h) Biopsy or fluid flow cytometry d) DISCHARGE SUMMARY OF DAY CARE
Fludarabine 25mg/m2 D1-3 l) Tumor board meeting report DEPARTMENT.
939 Medical Oncology MO Medical Oncology MO036 CT for Chronic Lymphocytic Leukemia MO036A 21000 23100 25200 27300 29400 30450
Cyclophosphamide 250 mg/m2 D1-3 every 28 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
days for 6 cycles o) Govt. referral form. REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Lenalidomide h) Biopsy or fluid flow cytometry d) DISCHARGE SUMMARY OF DAY CARE
940 Medical Oncology MO Medical Oncology MO036 CT for Chronic Lymphocytic Leukemia MO036D lenalidomide-10-25 mg/day day 1 to 21 every 28 5565 6121 6678 7234 7791 8069 l) Tumor board meeting report DEPARTMENT.
days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Rituximab + Fludarabine + Cyclophosphamide g) Bone marrow studies. DEPARTMENT.
Rituximab 375mg/m2 on day 1 h) Biopsy or fluid flow cytometry d) DISCHARGE SUMMARY OF DAY CARE
941 Medical Oncology MO Medical Oncology MO036 CT for Chronic Lymphocytic Leukemia MO036C Fludarabine 25mg/m2 D1 - 3 47040 51744 56448 61152 65856 68208 l) Tumor board meeting report DEPARTMENT.
Cyclophosphamide 250 mg/m2 D1 - 3 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Every 28 days for 6 cycles o) Govt. referral form. REGIMEN.
. f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
Rituxmab + Chlorambucil h) Biopsy or fluid flow cytometry d) DISCHARGE SUMMARY OF DAY CARE
Rituximab 375mg/m2 Day 1 l) Tumor board meeting report DEPARTMENT.
942 Medical Oncology MO Medical Oncology MO036 CT for Chronic Lymphocytic Leukemia MO036B 24900 27390 29880 32370 34860 36105
Chlorambucil 10 mg/m2 D1-7 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Repeat every 28 days for 12 cycles o) Govt. referral form. REGIMEN.
report
n) Papsmear Reoprt
d) MDC. MICROBIOLOGY, HEMATOLOGY,
e) BONE MARROW. BIOCHEMISTRY,ETC.)
f) BIOPSY. c) DISCHARGE SUMMARY OF INPATIENT
g) CYTOGENETICS. DEPARTMENT.
h) RQ PCR BCR ABL d) DISCHARGE SUMMARY OF DAY CARE
943 Medical Oncology MO Medical Oncology MO044 CT for Chronic Myeloid Leukemia MO044B Dasatinib 100 mg once a day 5775 6352 6930 7507 8085 8373 l) Tumor board meeting report DEPARTMENT.
report
n) Papsmear Reoprt
g) CYTOGENETICS. DEPARTMENT.
Imatinib h) RQ PCR BCR ABL d) DISCHARGE SUMMARY OF DAY CARE
944 Medical Oncology MO Medical Oncology MO044 CT for Chronic Myeloid Leukemia MO044A Imatinib 400 mg, 600 mg, 800 mg 19400 21340 23280 25220 27160 28130 l) Tumor board meeting report DEPARTMENT.
(per month X 5 years) m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
5 FU + Leucovorin + Oxaliplatin h) CEA. d) DISCHARGE SUMMARY OF DAY CARE
5 FU 1200mg/m2 D1 D2 i) Histopathology . DEPARTMENT.
945 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014C 15855 17440 19026 20611 22197 22989
Leucovorin 400mg/m2 D1 j) Colonoscopy e) CHARTS OF CHEMOTHERAPY
Oxaliplatin 85 mg/m2 D1 every 14 days l) Tumor board meeting report REGIMEN.
report
n) Papsmear Reoprt
5 FU + Leucovorin h) CEA. d) DISCHARGE SUMMARY OF DAY CARE
946 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014A 5 FU 1200mg/m2 D1 D2 6400 7040 7680 8320 8960 9280 i) Histopathology . DEPARTMENT.
Leucovorin 400mg/m2 D1 every 14 days j) Colonoscopy e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
5FU + Leucovorin + Irinotecan g) Pelvis. DEPARTMENT.
5 FU 1200mg/m2 D1 D2 h) CEA. d) DISCHARGE SUMMARY OF DAY CARE
947 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014D Leucovorin 400mg/m2 D1 11130 12243 13356 14469 15582 16138 i) Histopathology DEPARTMENT.
Irinotecan 180mg/m2 85 mg/m2 D1 every 14 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
days m) Hysterectomy report n) Papsmear Reoprt REGIMEN.
report
n) Papsmear Reoprt
5FU + Leucovorin + Oxaliplatin + Irinotecan g) Pelvis. DEPARTMENT.
5 FU 1200mg/m2 D1 D2 h) CEA. d) DISCHARGE SUMMARY OF DAY CARE
948 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014H Leucovorin 400mg/m2 D1 21735 23908 26082 28255 30429 31515 i) Histopathology . DEPARTMENT.
Oxaliplatin 85 mg/m2 D1 j) Colonoscopy e) CHARTS OF CHEMOTHERAPY
Irinotecan 180mg/m2 every 14 days l) Tumor board meeting report REGIMEN.
report
n) Papsmear Reoprt
Capecitabine + Irinotecan h) CEA. d) DISCHARGE SUMMARY OF DAY CARE
949 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014B Capecitabine 1000mg/m2 D1-D14 14490 15939 17388 18837 20286 21010 i) Histopathology DEPARTMENT.
Irinotecan 200 mg/m2 D1 every 21 days l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Capecitabine + Oxaliplatin h) CEA. d) DISCHARGE SUMMARY OF DAY CARE
950 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014E Capecitabine 1000mg/m2 D1-D14 16500 18150 19800 21450 23100 23925 i) Histopathology . DEPARTMENT.
Oxaliplatin 130 mg/m2 D1 every 21 days j) Colonoscopy e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
h) CEA. d) DISCHARGE SUMMARY OF DAY CARE
Capecitabine along with RT i) Histopathology . DEPARTMENT.
951 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014F 8400 9240 10080 10920 11760 12180
Capecitabine 825 mg/m2 twice daily j) Colonoscopy e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
h) CEA. d) DISCHARGE SUMMARY OF DAY CARE
Capecitabine i) Histopathology . DEPARTMENT.
952 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014G 8500 9350 10200 11050 11900 12325
Capecitabine 1000mg/m2 D1-D14 every 21 days j) Colonoscopy e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
g) Pelvis.histopathology . DEPARTMENT.
Anastrozole h) ECG. d) DISCHARGE SUMMARY OF DAY CARE
953 Medical Oncology MO Medical Oncology MO007 CT for Endometrial Cancer MO007E 4515 4966 5418 5869 6321 6546 i) 2D ECHO DEPARTMENT.
1 mg orally daily (for 3 months)
l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Carboplatin + Gemcitabine g) Pelvis.histopathology . DEPARTMENT.
Gemcitabine - 1000mg/m2 D1 D8 h) ECG. d) DISCHARGE SUMMARY OF DAY CARE
954 Medical Oncology MO Medical Oncology MO007 CT for Endometrial Cancer MO007D Carboplatin AUC 2 D1 D8 16065 17671 19278 20884 22491 23294 i) 2D ECHO DEPARTMENT.
Gemcitabine - 1000mg/m2 D1 D8 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
Carboplatin AUC 5-6 D1 only every 3 weeks m) Hysterectomy report n) Papsmear Reoprt REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Carboplatin + Paclitaxel h) histopathology d) DISCHARGE SUMMARY OF DAY CARE
955 Medical Oncology MO Medical Oncology MO007 CT for Endometrial Cancer MO007A Paclitaxel 175mg/m2 D1 17220 18942 20664 22386 24108 24969 l) Tumor board meeting report DEPARTMENT.
Carboplatin AUC 5 D1 every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Cisplatin + Doxorubicin h) ECG. d) DISCHARGE SUMMARY OF DAY CARE
956 Medical Oncology MO Medical Oncology MO007 CT for Endometrial Cancer MO007B Doxorubicin 60 mg/m2 D1 5145 5659 6174 6688 7203 7460 i) 2D ECHO DEPARTMENT.
Cisplatin 50mg/m2 every 3 weeks l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Lipodox + Carboplatin h) ECG. d) DISCHARGE SUMMARY OF DAY CARE
957 Medical Oncology MO Medical Oncology MO007 CT for Endometrial Cancer MO007C Lipopdox 30 mg/m2 D1 19950 21945 23940 25935 27930 28927 i) 2D ECHO DEPARTMENT.
Carboplatin AUC 5 D1 every 28 days l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
e) CECT Thorax BIOCHEMISTRY,ETC.)
h) Histopathology . d) DISCHARGE SUMMARY OF DAY CARE
5 FU i) UGI endoscospy DEPARTMENT.
958 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016C 10920 12012 13104 14196 15288 15834
5 FU 250 mg/m2 D1-D5 over 24 hrs every week l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
5 FU 1200mg/m2 D1 D2 h) Histopathology . d) DISCHARGE SUMMARY OF DAY CARE
959 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016J Leucovorin 400mg/m2 D1 11130 12243 13356 14469 15582 16138 i) UGI endoscospy DEPARTMENT.
Irinotecan 180mg/m2 85 mg/m2 D1 every 14 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
5FU + Leucovorin + Oxaliplatin h) Histopathology . d) DISCHARGE SUMMARY OF DAY CARE
5 FU 1200mg/m2 D1 D2 i) UGI endoscospy DEPARTMENT.
960 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016K 15855 17440 19026 20611 22197 22989
Leucovorin 400mg/m2 D1 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
Oxaliplatin 85 mg/m2 D1 every 14 days m) Hysterectomy report n) Papsmear Reoprt REGIMEN.
report
n) Papsmear Reoprt
Capecitabine + Oxaliplatin h) Histopathology . d) DISCHARGE SUMMARY OF DAY CARE
961 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016E Capecitabine 1000mg/m2 D1-D14 16500 18150 19800 21450 23100 23925 i) UGI endoscospy DEPARTMENT.
Oxaliplatin 130 mg/m2 D1 every 21 days l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Capecitabine i) UGI endoscospy DEPARTMENT.
962 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016D 8400 9240 10080 10920 11760 12180
Capecitabine 825 mg/m2 twice daily l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Cisplatin + Docetaxel g) Pelvis. DEPARTMENT.
Docetaxel 40mg/m2 D1 h) Histopathology . d) DISCHARGE SUMMARY OF DAY CARE
963 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016A Cisplatin 40 mg/m2 D1 16065 17671 19278 20884 22491 23294 i) UGI endoscospy DEPARTMENT.
5FU 1000mg/m2 D1 D2 every 14 days m) Hysterectomy report n) Papsmear Reoprt REGIMEN.
report
n) Papsmear Reoprt
Docetaxel + Cisplatin + 5 FU g) Pelvis. DEPARTMENT.
964 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016F Cisplatin 40 mg/m2 D1 16800 18480 20160 21840 23520 24360 i) UGI endoscospy DEPARTMENT.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Docetaxel + Cisplatin + Capecitabine g) Pelvis. DEPARTMENT.
965 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016G Cisplatin 40 mg/m2 D1 19700 21670 23640 25610 27580 28565 i) UGI endoscospy DEPARTMENT.
Capecitabine 825mg/m2 twice daily every 14 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Docetaxel + Oxaliplatin + 5 FU g) Pelvis. DEPARTMENT.
966 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016H Oxaliplatin 85 mg/m2 D1 21420 23562 25704 27846 29988 31059 i) UGI endoscospy DEPARTMENT.
report
n) Papsmear Reoprt
Docetaxel + Oxaliplatin + Capecitabine g) Pelvis. DEPARTMENT.
967 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016I Oxaliplatin 85 mg/m2 D1 24900 27390 29880 32370 34860 36105 i) UGI endoscospy DEPARTMENT.
Capecitabine 825 mg/m2 Twice daily every 14 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Irinotecan i) UGI endoscospy DEPARTMENT.
968 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016B 12700 13970 15240 16510 17780 18415
Irinotecan 60- 90 mg/m2 D1 D8 every 21 days l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Paclitaxel i) UGI endoscospy DEPARTMENT.
969 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016L 6930 7623 8316 9009 9702 10048
Paclitaxel 80mg/m2 every week l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Carboplatin + Paclitaxel h) Histopathology . d) DISCHARGE SUMMARY OF DAY CARE
970 Medical Oncology MO Medical Oncology MO015 CT for Esophageal Cancer MO015A Paclitaxel 175mg/m2 D1 17220 18942 20664 22386 24108 24969 i) UGI endoscospy DEPARTMENT.
Carboplatin AUC 5-6 D1 every 21 days l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Cisplatin + 5 FU h) Histopathology . d) DISCHARGE SUMMARY OF DAY CARE
971 Medical Oncology MO Medical Oncology MO015 CT for Esophageal Cancer MO015B 5 FU 1000mg/m2 D1-D4 11235 12358 13482 14605 15729 16290 i) UGI endoscospy DEPARTMENT.
Cisplatin 75mg/m2 D1 every 4 weeks l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Cisplatin + 5 FU h) Histopathology . d) DISCHARGE SUMMARY OF DAY CARE
972 Medical Oncology MO Medical Oncology MO015 CT for Esophageal Cancer MO015C Cisplatin 75mg/m2 D1 D29 16380 18018 19656 21294 22932 23751 i) UGI endoscospy DEPARTMENT.
5FU 1000mg/m2 D1-D4 D29 D32 every 35 days l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Paclitaxel + Carboplatin h) Histopathology . d) DISCHARGE SUMMARY OF DAY CARE
973 Medical Oncology MO Medical Oncology MO015 CT for Esophageal Cancer MO015D Paclitaxel 50mg/m2 D1 31395 34534 37674 40813 43953 45522 i) UGI endoscospy DEPARTMENT.
Carboplatin AUC 2 D1 every week l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Paclitaxel + Carboplatin h) Histopathology . d) DISCHARGE SUMMARY OF DAY CARE
974 Medical Oncology MO Medical Oncology MO015 CT for Esophageal Cancer MO015E Paclitaxel 50mg/m2 D1 31395 34534 37674 40813 43953 45522 i) UGI endoscospy DEPARTMENT.
Carboplatin AUC 2 D1 every week l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
c) PET CT (PATHOLOGY, RADIOLOGY,
d) CT CHEST MICROBIOLOGY, HEMATOLOGY,
Vincristine + Adriamycin + Cyclophosphamide e) BONE SCAN. BIOCHEMISTRY,ETC.)
Ifosfamide + Etoposide f) Bone marrow studies. c) DISCHARGE SUMMARY OF INPATIENT
Ifosfamide: 1800mg/m2 (days1-5) g) Biopsy. DEPARTMENT.
Etposide: 100mg/sq.m (days 1-5) h) ECG. d) DISCHARGE SUMMARY OF DAY CARE
975 Medical Oncology MO Medical Oncology MO009 CT for Ewing Sarcoma MO009C Given every 2-3 weekly 14700 16170 17640 19110 20580 21315 i) 2D-ECHO DEPARTMENT.
Vincristine 1.5mg/m2 (day 1 and 8) l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
Adriamyicn: 75mg/m2 (day 1) m) Hysterectomy report n) Papsmear Reoprt REGIMEN.
Cyclophosphamide 1200mg/m2 (day 1) o) Govt. referral form. f) TRANFUSION SLIPS.
Given 2-3 weekly Invoice of Medicinel) Tumor board meeting
report
n) Papsmear Reoprt
Vincristine + Ifosfamide + Etoposide b) Biochemistry. b) REPORTS OF THE TESTS
Vincristine + Doxorubicin + Cyclophosphamide c) PET CT (PATHOLOGY, RADIOLOGY,
Vincristine + Cyclophosphamide + Dactinomycin. d) CT CHEST MICROBIOLOGY, HEMATOLOGY,
4 cycles VIE, 6 cycles VAC, 4 cycles VCD e) BONE SCAN. BIOCHEMISTRY,ETC.)
Vincristine 1.5mg/m2 (day 1, 8 and 15) f) Bone marrow studies. c) DISCHARGE SUMMARY OF INPATIENT
Ifosfamide: 1800mg/m2 (days1-5) g) Biopsy. DEPARTMENT.
Etposide: 100mg/sq.m (days 1-5) h) ECG. d) DISCHARGE SUMMARY OF DAY CARE
Given every 3 weeks i) 2D-ECHO DEPARTMENT.
976 Medical Oncology MO Medical Oncology MO009 CT for Ewing Sarcoma MO009B 11445 12589 13734 14878 16023 16595 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
Vincristine 1.5mg/m2 (day 1 and 8)
Adriamyicn: 60mg/m2 (day 1) m) Hysterectomy report n) Papsmear Reoprt REGIMEN.
Cyclophosphamide 600mg/m2 (day 1) o) Govt. referral form. f) TRANFUSION SLIPS.
Given 2-3 weekly Invoice of Medicinel) Tumor board meeting
Vincristine 1.5mg/m2 (day 1 and 8) report
Cyclophosphamide 600mg/m2 (day 1) m) Hysterectomy report
Dactinomycin1mg/m2 (day1) n) Papsmear Reoprt
Given 3 weekly o) Govt. referral form.

c) PET CT (PATHOLOGY, RADIOLOGY,
d) CT CHEST MICROBIOLOGY, HEMATOLOGY,
Vincristine + Topotecan + Cyclophosphamide + e) BONE SCAN. BIOCHEMISTRY,ETC.)
Irinotecan + Temozolamide f) Bone marrow studies. c) DISCHARGE SUMMARY OF INPATIENT
Vincristine 1.5mg/m2( day 1) g) Biopsy. DEPARTMENT.
Topotecan 1.5mg/m2 (day 1-5) h) ECG. d) DISCHARGE SUMMARY OF DAY CARE
977 Medical Oncology MO Medical Oncology MO009 CT for Ewing Sarcoma MO009A Cyclophosphamide 250mg/m2 (days 1-5) 26775 29452 32130 34807 37485 38823 i) 2D-ECHO DEPARTMENT.
Given every 3 weeks l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
Irinotecan 10-50 mg/sqM days 1-5 and days 8- m) Hysterectomy report n) Papsmear Reoprt REGIMEN.
12 Temozolamide 100mg/m2 days 1-5 of each o) Govt. referral form. f) TRANFUSION SLIPS.
cycle every 3 weeks Invoice of Medicinel) Tumor board meeting
report
n) Papsmear Reoprt
5 FU 1200mg/m2 D1 D2 h) Histopathology d) DISCHARGE SUMMARY OF DAY CARE
CT for Gall Bladder Cancer / i) FNAC. DEPARTMENT.
978 Medical Oncology MO Medical Oncology MO019 MO019C Leucovorin 400mg/m2 D1 11130 12243 13356 14469 15582 16138
Cholangiocarcinoma j) CA19.9. e) CHARTS OF CHEMOTHERAPY
Irinotecan 180mg/m2 85 mg/m2 D1 every 14
days l) Tumor board meeting report REGIMEN.
report
n) Papsmear Reoprt
5FU + Leucovorin + Oxaliplatin h) Histopathology d) DISCHARGE SUMMARY OF DAY CARE
CT for Gall Bladder Cancer / 5 FU 1200mg/m2 D1 D2 i) FNAC. DEPARTMENT.
979 Medical Oncology MO Medical Oncology MO019 MO019H 15855 17440 19026 20611 22197 22989
Cholangiocarcinoma Leucovorin 400mg/m2 D1 j) CA19.9. e) CHARTS OF CHEMOTHERAPY
Oxaliplatin 85 mg/m2 D1 every 14 days l) Tumor board meeting report REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Capecitabine + Irinotecan h) Histopathology d) DISCHARGE SUMMARY OF DAY CARE
980 Medical Oncology MO Medical Oncology MO019 MO019G Capecitabine 1000mg/m2 D1-D14 14490 15939 17388 18837 20286 21010
Irinotecan 200 mg/m2 D1 every 21 days
report
n) Papsmear Reoprt
Capecitabine h) Histopathology d) DISCHARGE SUMMARY OF DAY CARE
981 Medical Oncology MO Medical Oncology MO019 MO019A Capecitabine 1000 - 1250 mg/m2 twice daily D1 - 8500 9350 10200 11050 11900 12325
D14 every 21 days
report
n) Papsmear Reoprt
Cisplatin + Gemcitabine h) Histopathology d) DISCHARGE SUMMARY OF DAY CARE
982 Medical Oncology MO Medical Oncology MO019 MO019B Gemcitabine 1000 mg/m2 D1 D8 14070 15477 16884 18291 19698 20401
Cisplatin 25 mg/m2 D1 D8 every 21 days
report
n) Papsmear Reoprt
h) Histopathology d) DISCHARGE SUMMARY OF DAY CARE
CT for Gall Bladder Cancer / Gemcitabine i) FNAC. DEPARTMENT.
983 Medical Oncology MO Medical Oncology MO019 MO019E 10395 11434 12474 13513 14553 15072
Cholangiocarcinoma Gemcitabine 1000mg /m2 D1 D8 every 21 days j) CA19.9. e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Gemcitabine h) Histopathology d) DISCHARGE SUMMARY OF DAY CARE
984 Medical Oncology MO Medical Oncology MO019 MO019D Gemcitabine 300 mg/m2 D 1every week (till RT 4620 5082 5544 6006 6468 6699
ends)
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Oxaliplatin + Gemcitabine h) Histopathology d) DISCHARGE SUMMARY OF DAY CARE
985 Medical Oncology MO Medical Oncology MO019 MO019F Gemcitabine 1000 mg/m2 D1 20160 22176 24192 26208 28224 29232
Oxaliplatin 100 mg/m2 D1 every 14 days
report
n) Papsmear Reoprt
Imatinib i) FNAC. DEPARTMENT.
986 Medical Oncology MO Medical Oncology MO020 CT for Gastointestinal stromal tumor MO020A 19400 21340 23280 25220 27160 28130
Imatinib 400 mg once daily j) Ckit-mutation (not mandatory) e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Sunitinib i) FNAC. DEPARTMENT.
987 Medical Oncology MO Medical Oncology MO020 CT for Gastointestinal stromal tumor MO020B 24400 26840 29280 31720 34160 35380
Sunitinb 37.5 mg once daily j) Ckit-mutation (not mandatory) e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
a) RFT, LFT a) BAR CODE OF THE DRUGS.
b) skeletal survey b) REPORTS OF THE TESTS
c) bone scan (PATHOLOGY, RADIOLOGY,
d) PET-CT MICROBIOLOGY, HEMATOLOGY,
e) HPE l) Tumor board meeting report BIOCHEMISTRY,ETC.)
m) Hysterectomy report n) Papsmear Reoprt c) DISCHARGE SUMMARY OF INPATIENT
o) Govt. referral form. DEPARTMENT.
Denosumab d) DISCHARGE SUMMARY OF DAY CARE
Denosumab 120 mg s/c D1, 8, 15 then every 28 DEPARTMENT.
988 Medical Oncology MO Medical Oncology MO075 CT for GCT of bone MO075A 20790 22869 24948 27027 29106 30145
days e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
e) Beta-HCG. BIOCHEMISTRY,ETC.)
f) AFP. c) DISCHARGE SUMMARY OF INPATIENT
g) LDH. DEPARTMENT.
h) CECT Thorax. d) DISCHARGE SUMMARY OF DAY CARE
Etoposide + Cisplatin i) Abdomen DEPARTMENT.
989 Medical Oncology MO Medical Oncology MO004 CT for Germ Cell Tumor MO004C Cisplatin 20 mg/m2 IV D1-D5 12600 13860 15120 16380 17640 18270 j) Pelvis. e) CHARTS OF CHEMOTHERAPY
Etoposide 100mg/m2 D1-D5 every 21 days k) ECG. REGIMEN.
l) PFT DLCo. f) TRANFUSION SLIPS.
m) Histopathology -Ovarian. Invoice of Medicinel) Tumor board meeting
n) testicular. report
o) mediastinal m) Hysterectomy report
Outside State
Bed Cost Cost
Cost
g) LDH. DEPARTMENT.
Bleomycin + Etoposide + Cisplatin h) CECT Thorax. d) DISCHARGE SUMMARY OF DAY CARE
Bleomycin 30 units D1 D8 D15 i) Abdomen DEPARTMENT.
990 Medical Oncology MO Medical Oncology MO004 CT for Germ Cell Tumor MO004B 14280 15708 17136 18564 19992 20706 j) Pelvis. e) CHARTS OF CHEMOTHERAPY
Cisplatin 20 mg/m2 IV D1-D5
Etoposide 100mg/m2 D1-D5 every 21 days k) ECG. REGIMEN.
e) Beta- HCG. DEPARTMENT.
f) AFP. d) DISCHARGE SUMMARY OF DAY CARE
Carboplatin (AUC 7) g) LDH. DEPARTMENT.
991 Medical Oncology MO Medical Oncology MO004 CT for Germ Cell Tumor MO004A 8500 9350 10200 11050 11900 12325
Carboplatin AUC 7 every 21 days h) CECT Thorax. e) CHARTS OF CHEMOTHERAPY
i) Abdomen REGIMEN.
j) Pelvis. f) TRANFUSION SLIPS.
k) ECG. Invoice of Medicinel) Tumor board meeting
l) Histopathology -testicular seminoma report
g) LDH. DEPARTMENT.
Gemcitabine + Oxaliplatin i) Abdomen DEPARTMENT.
992 Medical Oncology MO Medical Oncology MO004 CT for Germ Cell Tumor MO004D Gemcitabine 1000mg/m2 D1 D8 20265 22291 24318 26344 28371 29384 j) Pelvis. e) CHARTS OF CHEMOTHERAPY
Oxaiplatin 130mg/m2 D1 every 21 days k) ECG. REGIMEN.
g) LDH. DEPARTMENT.
Gemcitabine + Paclitaxel i) Abdomen DEPARTMENT.
993 Medical Oncology MO Medical Oncology MO004 CT for Germ Cell Tumor MO004E Gemcitabine 1000mg/m2 D1 D8 D15 20265 22291 24318 26344 28371 29384 j) Pelvis. e) CHARTS OF CHEMOTHERAPY
Paclitaxel 100 mg/m2 D1 D8 D15 every 28 days k) ECG. REGIMEN.
g) LDH. DEPARTMENT.
Paclitaxel + Ifosfamide + Cisplatin h) CECT Thorax. d) DISCHARGE SUMMARY OF DAY CARE
Paclitaxel 240 mg/m2 D1 i) Abdomen DEPARTMENT.
994 Medical Oncology MO Medical Oncology MO004 CT for Germ Cell Tumor MO004F Ifosfamide 1500mg/m2 D2-D5 28245 31069 33894 36718 39543 40955 j) Pelvis. e) CHARTS OF CHEMOTHERAPY
Mesna 300 mg/m2 0h 4h 8h D2-D5 k) ECG. REGIMEN.
Cisplatin 25mg/m2 D2-D5 every 21 days l) PFT DLCo. f) TRANFUSION SLIPS.
Outside State
Bed Cost Cost
Cost
g) LDH. DEPARTMENT.
Vinblastin + Ifosfamide + Cisplatin h) CECT Thorax. d) DISCHARGE SUMMARY OF DAY CARE
Vinblastine 0.11 mg/kg IV D1-D2 i) Abdomen DEPARTMENT.
995 Medical Oncology MO Medical Oncology MO004 CT for Germ Cell Tumor MO004G Mesna 240mg/m2 0h 4h 8h D1-D5 15750 17325 18900 20475 22050 22837 j) Pelvis. e) CHARTS OF CHEMOTHERAPY
Ifosfamide 1200mg/m2 D1-D5 k) ECG. REGIMEN.
Cisplatin 20 mg/m2 D1-D5 every 21 days l) PFT DLCo. f) TRANFUSION SLIPS.
e) Beta- HCG. BIOCHEMISTRY,ETC.)
g) Abdomen DEPARTMENT.
h) Pelvis d) DISCHARGE SUMMARY OF DAY CARE
Dactinomycin l) Tumor board meeting report DEPARTMENT.
996 Medical Oncology MO Medical Oncology MO005 CT for Gestational Trophoblastic Neoplasia MO005D 8085 8893 9702 10510 11319 11723
Inj Dactinomycin 0.5 mg D1- D5 every 14 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Etoposide + Methotrexate + Dactinomycin + f) CECT Thorax. c) DISCHARGE SUMMARY OF INPATIENT
Cisplatin g) Abdomen DEPARTMENT.
Etoposide 100mg/m2 IV D1 D2 D8 h) Pelvis d) DISCHARGE SUMMARY OF DAY CARE
997 Medical Oncology MO Medical Oncology MO005 CT for Gestational Trophoblastic Neoplasia MO005B Dactinomycin 0.5 mg IV push D1 D2 14805 16285 17766 19246 20727 21467 l) Tumor board meeting report DEPARTMENT.
Methotrexate 300 mg /m2 D1 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Leucovorin 15 mg PO every 12 hrs for 4 doses o) Govt. referral form. REGIMEN.
Cisplatin 75mg/m2 D8 every 2 weeks f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
Etoposide + Methotrexate + Dactinomycin- f) CECT Thorax. c) DISCHARGE SUMMARY OF INPATIENT
Cyclophosphamide + Vincristine g) Abdomen DEPARTMENT.
Etoposide 100mg/m2 IV D1 D2 h) Pelvis d) DISCHARGE SUMMARY OF DAY CARE
Dactinomycin 0.5 mg IV push D1 D2 l) Tumor board meeting report DEPARTMENT.
998 Medical Oncology MO Medical Oncology MO005 CT for Gestational Trophoblastic Neoplasia MO005A 13965 15361 16758 18154 19551 20249
Methotrexate 300 mg /m2 D1 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Leucovorin 15 mg PO every 12 hrs for 4 doses o) Govt. referral form. REGIMEN.
Cyclophosphamide 600mg/m2 D8 f) TRANFUSION SLIPS.
Vincrstine 1 mg/m2 D8 every 2 weeks Invoice of Medicinel) Tumor board meeting
report
n) Papsmear Reoprt
Methotrexate g) Abdomen DEPARTMENT.
Methotrexate 1/mg/kg IM every other day x 4 h) Pelvis d) DISCHARGE SUMMARY OF DAY CARE
999 Medical Oncology MO Medical Oncology MO005 CT for Gestational Trophoblastic Neoplasia MO005C days D1 3 D5 D7 1470 1617 1764 1911 2058 2131 l) Tumor board meeting report DEPARTMENT.
Alternating every other day with m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Leucovorin 15 mg PO repeat every 14 days o) Govt. referral form. REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
e) Triphasic CECT Thorax . BIOCHEMISTRY,ETC.)
Doxorubicin (TACE) i) AFP. DEPARTMENT.
1000 Medical Oncology MO Medical Oncology MO017 CT for Hepatocellular Carcinoma MO017A 26040 28644 31248 33852 36456 37758
Doxorubicin 30-75 mg/m2 one course j) MRI e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
1001 Medical Oncology MO Medical Oncology MO017 CT for Hepatocellular Carcinoma MO017C Lenvatinib 12 mg daily 19635 21598 23562 25525 27489 28470 i) AFP. DEPARTMENT.
j) Lipid Profile. e) CHARTS OF CHEMOTHERAPY
k) Urine R/M. REGIMEN.
l) 2D ECHO f) TRANFUSION SLIPS.
n) Papsmear Reoprt
Sorafenib i) AFP. DEPARTMENT.
1002 Medical Oncology MO Medical Oncology MO017 CT for Hepatocellular Carcinoma MO017B 10395 11434 12474 13513 14553 15072
Sorafenib 400mg PO twice daily j) Lipid Profile. e) CHARTS OF CHEMOTHERAPY
k) Urine R/M. REGIMEN.
l) 2D ECHO f) TRANFUSION SLIPS.
n) Papsmear Reoprt
Rituxmab + Dexamethasone + High Dose f) Biopsy or fluid flow cytometry. c) DISCHARGE SUMMARY OF INPATIENT
Cytarabine + Cisplatin l) Tumor board meeting report DEPARTMENT.
Rituximab 375mg/m2 Day 1 m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
Cytarabine 2g/m2 BD on day 2 o) Govt. referral form. DEPARTMENT.
1003 Medical Oncology MO Medical Oncology MO030 CT for High - Grade NHL - B Cell MO030A 40320 44352 48384 52416 56448 58464
Dexamethasone 40 mg Day 1 - 4 e) CHARTS OF CHEMOTHERAPY
Cisplatin 75mg/m2 or REGIMEN.
Carboplatin AUC-5 on day 1 f) TRANFUSION SLIPS.
Cycle to be repeated every 21days Invoice of Medicinel) Tumor board meeting
report
n) Papsmear Reoprt
f) node Biopsy. c) DISCHARGE SUMMARY OF INPATIENT
ABVD l) Tumor board meeting report DEPARTMENT.
Adriamycin 25mg/m2 m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
Bleomycin 10unit/m2 o) Govt. referral form. DEPARTMENT.
1004 Medical Oncology MO Medical Oncology MO039 CT for Hodgkin's Lymphoma MO039B 11865 13051 14238 15424 16611 17204
Vinblastine 6mg/m2 e) CHARTS OF CHEMOTHERAPY
Dacarbazine 375 mg/m2 Day 1,15 REGIMEN.
Every 28 days for 6 cycles f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
AEVD l) Tumor board meeting report DEPARTMENT.
Adriamycin 25mg/m2 m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
Vinblastine 6mg/m2 o) Govt. referral form. DEPARTMENT.
1005 Medical Oncology MO Medical Oncology MO039 CT for Hodgkin's Lymphoma MO039C 11865 13051 14238 15424 16611 17204
Dacarbazine 375 mg/m2 Day 1,15 e) CHARTS OF CHEMOTHERAPY
Etoposide 65mg/m2 Day 1-3, 15-17 REGIMEN.
Every 28 days for 6 cycles f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
COPP l) Tumor board meeting report DEPARTMENT.
Cyclophosphamide 650mg/m2 D1, 8 m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
Vincristine 1.4mg/m2 D1, 8 o) Govt. referral form. DEPARTMENT.
1006 Medical Oncology MO Medical Oncology MO039 CT for Hodgkin's Lymphoma MO039A 4515 4966 5418 5869 6321 6546
Procarbazine 100 mg/m2 D1-14 e) CHARTS OF CHEMOTHERAPY
Prednisolone 40mg/m2 D1-14 REGIMEN.
Every 28days. Total 6 - 8 cycles f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
g) SKELETAL SURVEY DEPARTMENT.
h) PET CECT d) DISCHARGE SUMMARY OF DAY CARE
Langerhans Cell Histiocytosis l) Tumor board meeting report DEPARTMENT.
1007 Medical Oncology MO Medical Oncology MO054 CT for Langerhans Cell Histiocytosis MO054A 29295 32224 35154 38083 41013 42477
(Histiocytosis Protocol - Induction) m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
f) SKELETAL SURVEY c) DISCHARGE SUMMARY OF INPATIENT
g) PET CECT DEPARTMENT.
Langerhans Cell Histiocytosis m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
1008 Medical Oncology MO Medical Oncology MO054 CT for Langerhans Cell Histiocytosis MO054B 33390 36729 40068 43407 46746 48415
(Histiocytosis Protocol - Maintenance) o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Bendamustine + Rituximab m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
Bendamustine 90mg/m2 on day 1, 2 o) Govt. referral form. DEPARTMENT.
1009 Medical Oncology MO Medical Oncology MO034 CT for Low Grade B - Cell NHL MO034A 30700 33770 36840 39910 42980 44515
Rituximab 375mg/m2 on day 1 e) CHARTS OF CHEMOTHERAPY
Repeat every 28 days, Total 6 cycles REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Lenalidomide + Rituximab m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
1010 Medical Oncology MO Medical Oncology MO034 CT for Low Grade B - Cell NHL MO034B Rituximab 375mg/m2 Day 1 27500 30250 33000 35750 38500 39875 o) Govt. referral form. DEPARTMENT.
Lenlidomide 25 mg D1-28, for 8 cycles e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
c) MRI. (PATHOLOGY, RADIOLOGY,
d) Biopsy MICROBIOLOGY, HEMATOLOGY,
l) Tumor board meeting report BIOCHEMISTRY,ETC.)
d) DISCHARGE SUMMARY OF DAY CARE
Vinblastin DEPARTMENT.
1011 Medical Oncology MO Medical Oncology MO055 CT for Low Grade Glioma MO055B 3885 4273 4662 5050 5439 5633
Vinblastine 6 mg/m2 every week e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
c) MRI. (PATHOLOGY, RADIOLOGY,
d) Biopsy MICROBIOLOGY, HEMATOLOGY,
Vincristine + Carboplatin o) Govt. referral form. DEPARTMENT.
Vincristine 1.5mg/m2 (day 1, 8 and 15 for first 4 d) DISCHARGE SUMMARY OF DAY CARE
1012 Medical Oncology MO Medical Oncology MO055 CT for Low Grade Glioma MO055A cycles and then only day 1 from cycle 5 to 17) 6825 7507 8190 8872 9555 9896 DEPARTMENT.
Carboplatin 550mg/m2 every 3 weeks (all e) CHARTS OF CHEMOTHERAPY
cycles) REGIMEN.
report
n) Papsmear Reoprt
a) CBC, a) BAR CODE OF THE DRUGS.
b) Biochemistry, b) REPORTS OF THE TESTS
c) USG abdmen (PATHOLOGY, RADIOLOGY,
d) Pelvis CECT Chest abdomen MICROBIOLOGY, HEMATOLOGY,
e) pelvis, BIOCHEMISTRY,ETC.)
Rituximab + Cyclophosphamide + Vincristine + f) Bone marrow studies, c) DISCHARGE SUMMARY OF INPATIENT
Prednisolone g) Biopsy or fluid flow cytometry. DEPARTMENT.
Rituximab 375 mg/m2 l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
1013 Medical Oncology MO Medical Oncology MO035 CT for Low Grade NHL MO035B Cyclophosphamide 750mg/m2 25800 28380 30960 33540 36120 37410 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Vincristine 1.4mg/m2 Day 1 o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
Prednisolone 100 mg Day 1 - 5 REGIMEN.
Repeat every 21days. Total 6 cycles f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
Rituximab o) Govt. referral form. DEPARTMENT.
1014 Medical Oncology MO Medical Oncology MO035 CT for Low Grade NHL MO035A 24800 27280 29760 32240 34720 35960
Rituximab 375mg/m2 per week for 6 weeks e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
6 Mercaptopurine 50 mg/M2 daily and i) BONE MARROW FLOW CYTOMETRY. DEPARTMENT.
1015 Medical Oncology MO Medical Oncology MO048 CT for Lymphoblastic Lymphoma MO048C 4620 5082 5544 6006 6468 6699
Methotrexate 25 mg/M2 Weekly for 2 Years j) CYTOGENETICS. e) CHARTS OF CHEMOTHERAPY
k) NGS. REGIMEN.
l) BIOPSY f) TRANFUSION SLIPS.
n) Papsmear Reoprt
1016 Medical Oncology MO Medical Oncology MO048 CT for Lymphoblastic Lymphoma MO048B 143010 157311 171612 185913 200214 207364 i) CYTOGENETICS. e) CHARTS OF CHEMOTHERAPY
HyperCVAD
GMALL k) BIOPSY. f) TRANFUSION SLIPS.

BFM-90 g) CSF CYTOMORPHOLOGY. DEPARTMENT.
BFM-95 h) FLOW CYTOMETRY. d) DISCHARGE SUMMARY OF DAY CARE
BFM-2000 i) BONE MARROW FLOW CYTOMETRY. DEPARTMENT.
1017 Medical Oncology MO Medical Oncology MO048 CT for Lymphoblastic Lymphoma MO048A 184800 203280 221760 240240 258720 267960
HyperCVAD j) CYTOGENETICS. e) CHARTS OF CHEMOTHERAPY
UKALL k) NGS. REGIMEN.
GMALL l) BIOPSY f) TRANFUSION SLIPS.
n) Papsmear Reoprt
c) MRI (BRAIN AND SPINE). (PATHOLOGY, RADIOLOGY,
d) Biopsy. MICROBIOLOGY, HEMATOLOGY,
e) CSF CYTOLOGY. BIOCHEMISTRY,ETC.)
l) Tumor board meeting report c) DISCHARGE SUMMARY OF INPATIENT
Cisplatin + Cyclophosphamide + Vincristine m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Cyclophosphamide 1000mg/m2 (2 days every o) Govt. referral form. d) DISCHARGE SUMMARY OF DAY CARE
cycles) DEPARTMENT.
1018 Medical Oncology MO Medical Oncology MO056 CT FOR MEDULLOBLASTOMA MO056B 9660 10626 11592 12558 13524 14007
Vincristine 1.5mg/m2 (days 1 and 8) e) CHARTS OF CHEMOTHERAPY
Cisplatin 100mg/m2 (1 day per cycle) REGIMEN.
Cycles given every 3 weekly f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
c) MRI (BRAIN AND SPINE). (PATHOLOGY, RADIOLOGY,
d) Biopsy. MICROBIOLOGY, HEMATOLOGY,
e) CSF CYTOLOGY. BIOCHEMISTRY,ETC.)
m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
o) Govt. referral form. d) DISCHARGE SUMMARY OF DAY CARE
1019 Medical Oncology MO Medical Oncology MO056 CT FOR MEDULLOBLASTOMA MO056A PACKER 7350 8085 8820 9555 10290 10657 DEPARTMENT.
e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Gemcitabine + Cisplatin h) histopathology d) DISCHARGE SUMMARY OF DAY CARE
1020 Medical Oncology MO Medical Oncology MO022 CT for Mesothelioma MO022A Gemcitabine 1000 mg/m2 D1 D8 14070 15477 16884 18291 19698 20401 l) Tumor board meeting report DEPARTMENT.
Cisplatin 75 mg/m2 D1 every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Pemetrexed + Carboplatin h) histopathology d) DISCHARGE SUMMARY OF DAY CARE
1021 Medical Oncology MO Medical Oncology MO022 CT for Mesothelioma MO022C Pemetrexed 500mg/m2 D1 11760 12936 14112 15288 16464 17052 l) Tumor board meeting report DEPARTMENT.
report
n) Papsmear Reoprt
Pemetrexed + Cisplatin h) histopathology d) DISCHARGE SUMMARY OF DAY CARE
1022 Medical Oncology MO Medical Oncology MO022 CT for Mesothelioma MO022B Pemetrexed 500mg/m2 D1 10920 12012 13104 14196 15288 15834 l) Tumor board meeting report DEPARTMENT.
Cisplatin 75 mg/m2 D1 every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
a) RFT. a) BAR CODE OF THE DRUGS.
b) skeletal survey b) REPORTS OF THE TESTS
c) bone scan (PATHOLOGY, RADIOLOGY,
d) PET-CT showing bone metastasis MICROBIOLOGY, HEMATOLOGY,
histopathology showing myeloma. BIOCHEMISTRY,ETC.)
e) lung cancer. c) DISCHARGE SUMMARY OF INPATIENT
f) Breast cancer. DEPARTMENT.
g) renal cancer or other cancer d) DISCHARGE SUMMARY OF DAY CARE
CT for Metastatic bone malignancy and Zoledronic Acid l) Tumor board meeting report DEPARTMENT.
multiple myeloma Zoledronic acid 4 mg IV Monthly m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Dacarbazine + Cisplatin h) histopathology d) DISCHARGE SUMMARY OF DAY CARE
1024 Medical Oncology MO Medical Oncology MO012 CT for Metastatic Melanoma MO012A Dacarbazine 250mg/m2 D1-D5 8295 9124 9954 10783 11613 12027 l) Tumor board meeting report DEPARTMENT.
Cisplatin 75 mg/m2 Every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Imatinib l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
1025 Medical Oncology MO Medical Oncology MO012 CT for Metastatic Melanoma MO012C Tab Imatinib 400/800 mg daily 5775 6352 6930 7507 8085 8373 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Temozolamide m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
1026 Medical Oncology MO Medical Oncology MO012 CT for Metastatic Melanoma MO012B 5775 6352 6930 7507 8085 8373
Temozolamide 200mg/m2 D1-D5 every 28 days o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
a) CBC. b) REPORTS OF THE TESTS
b) Biochemistry. (PATHOLOGY, RADIOLOGY,
c) Serum protein electrophoresis. MICROBIOLOGY, HEMATOLOGY,
d) Bone marrow studies. BIOCHEMISTRY,ETC.)
e) skeletal survey. c) DISCHARGE SUMMARY OF INPATIENT
Bortezomib + Cyclophosphamide + f) Urine BJP. DEPARTMENT.
Dexamethasone l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
Cyclophosphamide - 300 mg/m2 day 1, 8, 15, 22 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
1027 Medical Oncology MO Medical Oncology MO043 CT for MM / Amyloidosis MO043C 16905 18595 20286 21976 23667 24512
Dexamethasone 40mg Day 1, 8, 15, 22 o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
Bortezomib 1.3 mg/m2 Day1, 8, 15, 22 REGIMEN.
Every 28 days f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
c) Serum protein electrophoresis. (PATHOLOGY, RADIOLOGY,
d) Immunofixation. MICROBIOLOGY, HEMATOLOGY,
e) Serum free light chain assay. BIOCHEMISTRY,ETC.)
f) Bone marrow studies. c) DISCHARGE SUMMARY OF INPATIENT
g) Skeletal survey. DEPARTMENT.
Bortezomib + Dexamethasone h) Urine BJP d) DISCHARGE SUMMARY OF DAY CARE
Bortezomib 1.3 mg/m2 Day1, 8, 15, 22 l) Tumor board meeting report DEPARTMENT.
1028 Medical Oncology MO Medical Oncology MO043 CT for MM / Amyloidosis MO043D 15435 16978 18522 20065 21609 22380
Dexamethasone 40mg Day1, 8, 15, 22 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Every 28 day o) Govt. referral form. REGIMEN.
report
n) Papsmear Reoprt
Bortezomib + Lenalidomide + Dexamethasone g) Skeletal survey. DEPARTMENT.
Lenalidomide 25 mg daily Day 1 - 21 h) Urine BJP d) DISCHARGE SUMMARY OF DAY CARE
1029 Medical Oncology MO Medical Oncology MO043 CT for MM / Amyloidosis MO043F Dexamethasone 40mg Day 1, 8, 15, 22 20580 22638 24696 26754 28812 29841 l) Tumor board meeting report DEPARTMENT.
Bortezomib 1.3 mg/m2 Day 1, 8, 15, 22 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Every 28 days o) Govt. referral form. REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Bortezomib + Melphalan + Prednsiolone g) Skeletal survey. DEPARTMENT.
Melphalan 9mg/m2 D1-D4 h) Urine BJP d) DISCHARGE SUMMARY OF DAY CARE
1030 Medical Oncology MO Medical Oncology MO043 CT for MM / Amyloidosis MO043E Prednisolone 100mg Day 1-4 14595 16054 17514 18973 20433 21162 l) Tumor board meeting report DEPARTMENT.
report
n) Papsmear Reoprt
Bortezomib + Thalidomide + Dexamethasone g) Skeletal survey. DEPARTMENT.
Thalidomide 100 mg daily Day 1 - 28 h) Urine BJP d) DISCHARGE SUMMARY OF DAY CARE
1031 Medical Oncology MO Medical Oncology MO043 CT for MM / Amyloidosis MO043G Dexamethasone 40 mg Day 1, 8, 15, 22 17325 19057 20790 22522 24255 25121 l) Tumor board meeting report DEPARTMENT.
report
n) Papsmear Reoprt
Cyclophosphamide + Thalidomide + g) Skeletal survey. DEPARTMENT.
Dexamethasone h) Urine BJP d) DISCHARGE SUMMARY OF DAY CARE
Cyclophosphamide 100mg D1-D14 l) Tumor board meeting report DEPARTMENT.
1032 Medical Oncology MO Medical Oncology MO043 CT for MM / Amyloidosis MO043A 4725 5197 5670 6142 6615 6851
Thalidomide 100-200 mg daily Day 1-28 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Dexamethasone 40mg Day 1, 8, 15, 22 o) Govt. referral form. REGIMEN.
report
n) Papsmear Reoprt
Melphalan + Thalidomide + Prednisolone g) Skeletal survey. DEPARTMENT.
Melphalan 9mg/m2 D1-D4 h) Urine BJP d) DISCHARGE SUMMARY OF DAY CARE
1033 Medical Oncology MO Medical Oncology MO043 CT for MM / Amyloidosis MO043B Thalidomide 100mg D1-28 4830 5313 5796 6279 6762 7003 l) Tumor board meeting report DEPARTMENT.
Prednisolone 100mg Day1-4 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Every 28days o) Govt. referral form. REGIMEN.
report
n) Papsmear Reoprt
Lenalidomide + Dexamethasone h) Urine BJP d) DISCHARGE SUMMARY OF DAY CARE
Lenalidomide 25 mg daily Day1-21 l) Tumor board meeting report DEPARTMENT.
1034 Medical Oncology MO Medical Oncology MO042 CT for MM / Amyloidosis / POEMS MO042A 6090 6699 7308 7917 8526 8830
Dexamethasone 40mg Day 1, 8, 15, 22 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Every 28days o) Govt. referral form. REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Pomalidomide + Dexamethasone h) Urine BJP d) DISCHARGE SUMMARY OF DAY CARE
Pomalidomide 4 mg daily Day 1-21 l) Tumor board meeting report DEPARTMENT.
1035 Medical Oncology MO Medical Oncology MO042 CT for MM / Amyloidosis / POEMS MO042B 8295 9124 9954 10783 11613 12027
Dexamethasone 40mg Day 1, 8, 15, 22 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
e) BONE MARROW . BIOCHEMISTRY,ETC.)
f) CYTOGENETICS c) DISCHARGE SUMMARY OF INPATIENT
Hydroxurea m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
1036 Medical Oncology MO Medical Oncology MO045 CT for Myeloproliferative Neoplasm MO045A Hydroxurea daily 2625 2887 3150 3412 3675 3806 o) Govt. referral form. DEPARTMENT.
(Dose will be based on blood counts) e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
b) Biochemistry b) REPORTS OF THE TESTS
l) Tumor board meeting report (PATHOLOGY, RADIOLOGY,
m) Hysterectomy report n) Papsmear Reoprt MICROBIOLOGY, HEMATOLOGY,
o) Govt. referral form. BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY OF INPATIENT
DEPARTMENT.
13-cis retinoic acid 160mg/m2 per day for 2 d) DISCHARGE SUMMARY OF DAY CARE
1037 Medical Oncology MO Medical Oncology MO057 CT for Neuroblastoma MO057C weeks 2415 2656 2898 3139 3381 3501 DEPARTMENT.
Each cycle given 4 weekly e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
c) CECT (PATHOLOGY, RADIOLOGY,
d) MRI. MICROBIOLOGY, HEMATOLOGY,
e) BONE MARROW STUDIES. BIOCHEMISTRY,ETC.)
f) MIBG OR BONE OR PET CT SCAN. c) DISCHARGE SUMMARY OF INPATIENT
Cabroplatin + Etoposide + Cyclophosphamide + g) BIOPSY. DEPARTMENT.
Doxorubicin h) FISH d) DISCHARGE SUMMARY OF DAY CARE
Carboplatin 600mg/m2 l) Tumor board meeting report DEPARTMENT.
1038 Medical Oncology MO Medical Oncology MO057 CT for Neuroblastoma MO057A 9975 10972 11970 12967 13965 14463
Etoposide 100mg/m2 (days 1-5) m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Cyclophosphamide o) Govt. referral form. REGIMEN.
Doxorubicin f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
c) CECT (PATHOLOGY, RADIOLOGY,
d) MRI. MICROBIOLOGY, HEMATOLOGY,
e) BONE MARROW STUDIES. BIOCHEMISTRY,ETC.)
f) MIBG OR BONE OR PET CT SCAN. c) DISCHARGE SUMMARY OF INPATIENT
g) BIOPSY. DEPARTMENT.
h) FISH d) DISCHARGE SUMMARY OF DAY CARE
Carboplatin + Cisplatin + Cyclophosphamide + DEPARTMENT.
1039 Medical Oncology MO Medical Oncology MO057 CT for Neuroblastoma MO057B 8820 9702 10584 11466 12348 12789
Vincristine + Etoposide l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
c) LDH. (PATHOLOGY, RADIOLOGY,
d) PET CECT MICROBIOLOGY, HEMATOLOGY,
e) CECT chest abdomen BIOCHEMISTRY,ETC.)
GELOX g) Bone marrow studies. DEPARTMENT.
Gemcitabine 1000mg/m2 D1 and D8 h) Biopsy d) DISCHARGE SUMMARY OF DAY CARE
1040 Medical Oncology MO Medical Oncology MO038 CT for NK - T Cell Lymphoma MO038A Oxaliplatin 130mg/m2 D1 22365 24601 26838 29074 31311 32429 l) Tumor board meeting report DEPARTMENT.
L- asparginase 6000 U/m2 D1-7 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Repeat every 21 days o) Govt. referral form. REGIMEN.
report
n) Papsmear Reoprt
LVP g) Bone marrow studies. DEPARTMENT.
L-asparginase 6000U/m2 D1-5 h) Biopsy d) DISCHARGE SUMMARY OF DAY CARE
1041 Medical Oncology MO Medical Oncology MO038 CT for NK - T Cell Lymphoma MO038B Vincristine 1.4mg/m2 D1 9240 10164 11088 12012 12936 13398 l) Tumor board meeting report DEPARTMENT.
Prednisolone 100mg D1-5 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Repeat every 21 days o) Govt. referral form. REGIMEN.
report
n) Papsmear Reoprt
e) DTPA GFR. BIOCHEMISTRY,ETC.)
f) NCCT chest. c) DISCHARGE SUMMARY OF INPATIENT
g) MRI of the involved site. DEPARTMENT.
Doxorubicin + Cisplatin h) 2D ECHO. d) DISCHARGE SUMMARY OF DAY CARE
1042 Medical Oncology MO Medical Oncology MO010 CT for Osteogenic Sarcoma MO010A Cisplatin 100mg/m2 21800 23980 26160 28340 30520 31610 i) Pure tone audiometry.histopathology DEPARTMENT.
Doxorubicin 75mg/m2 given every 3 weeks l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
(PATHOLOGY, RADIOLOGY,
a) CBC. MICROBIOLOGY, HEMATOLOGY,
b) Biochemistry. BIOCHEMISTRY,ETC.)
c) CT CHEST. c) DISCHARGE SUMMARY OF INPATIENT
Methotrexate + Doxorubicin + Cisplatin for d) BONE SCAN. DEPARTMENT.
Relapsed Osteogenic Sarcoma e) Biopsy. d) DISCHARGE SUMMARY OF DAY CARE
Cisplatin 120mg/sq.m f) ECG. DEPARTMENT.
1043 Medical Oncology MO Medical Oncology MO010 CT for Osteogenic Sarcoma MO010B 31185 34303 37422 40540 43659 45218
Doxorubicin 75mg/m2 g) 2D-ECHO. e) CHARTS OF CHEMOTHERAPY
Methotrexate 8-12 gram/m2 h) AUDIOMETRY. REGIMEN.
Each cycle for 5 weeks i) GFR f) TRANFUSION SLIPS.
n) Papsmear Reoprt
f) NCCT chest. c) DISCHARGE SUMMARY OF INPATIENT
OGS - 12 g) MRI of the involved site. DEPARTMENT.
Ifosfamide 1800 mg/m2 D1-D5 h) 2D ECHO. d) DISCHARGE SUMMARY OF DAY CARE
1044 Medical Oncology MO Medical Oncology MO010 CT for Osteogenic Sarcoma MO010C Mesna 600mg/m2 0h 3h 6h 9h D1-D5 34230 37653 41076 44499 47922 49633 i) Pure tone audiometry.histopathology DEPARTMENT.
Adriamycin 25mg/m2 D1- D3 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
Cisplatin 33 mg/m2 D1-D3 every 21 days m) Hysterectomy report n) Papsmear Reoprt REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
g) Pure tone. DEPARTMENT.
OGS - 12 h) histopathology d) DISCHARGE SUMMARY OF DAY CARE
Ifosfamide 1800 mg/m2 D1-D5 l) Tumor board meeting report DEPARTMENT.
1045 Medical Oncology MO Medical Oncology MO010 CT for Osteogenic Sarcoma MO010D 36200 39820 43440 47060 50680 52490
Mesna 600mg/m2 0h 3h 6h 9h D1-D5 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Cisplatin 33 mg/m2 D1-D3 every 21 days o) Govt. referral form. REGIMEN.
report
n) Papsmear Reoprt
5FU + Leucovorin + Oxaliplatin + Irinotecan g) Pelvis. DEPARTMENT.
5 FU 1200mg/m2 D1 D2 h) Histopathology d) DISCHARGE SUMMARY OF DAY CARE
1046 Medical Oncology MO Medical Oncology MO018 CT for Panceratic Cancer MO018D Leucovorin 400mg/m2 D1 21840 24024 26208 28392 30576 31668 i) FNAC. DEPARTMENT.
Oxaliplatin 85 mg/m2 D1 j) CA19.9. e) CHARTS OF CHEMOTHERAPY
Irinotecan 180mg/m2 every 14 days l) Tumor board meeting report REGIMEN.
report
n) Papsmear Reoprt
Capecitabine + Gemcitabine h) Histopathology d) DISCHARGE SUMMARY OF DAY CARE
Gemcitabine 1000mg/m2 D1 D8 D15 i) FNAC. DEPARTMENT.
1047 Medical Oncology MO Medical Oncology MO018 CT for Panceratic Cancer MO018F 39480 43428 47376 51324 55272 57246
Capecitabine 830mg/m2 twice daily D1-D21 j) CA19.9. e) CHARTS OF CHEMOTHERAPY
every 28 days l) Tumor board meeting report REGIMEN.
report
n) Papsmear Reoprt
Capecitabine i) FNAC. DEPARTMENT.
1048 Medical Oncology MO Medical Oncology MO018 CT for Panceratic Cancer MO018E 8400 9240 10080 10920 11760 12180
Capecitabine 825 mg/m2 twice daily j) CA19.9. e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Gemcitabine + Nanopaclitaxel h) Histopathology d) DISCHARGE SUMMARY OF DAY CARE
Gemcitabine 1000mg/m2 D1 D8 D16 i) FNAC. DEPARTMENT.
1049 Medical Oncology MO Medical Oncology MO018 CT for Panceratic Cancer MO018A 32865 36151 39438 42724 46011 47654
Albumin bound Paclitaxel 125mg/m2 D1 D8 D15 j) CA19.9. e) CHARTS OF CHEMOTHERAPY
every 28 days l) Tumor board meeting report REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Gemcitabine i) FNAC. DEPARTMENT.
1050 Medical Oncology MO Medical Oncology MO018 CT for Panceratic Cancer MO018B 10395 11434 12474 13513 14553 15072
Gemcitabine 1000mg /m2 D1 D8 every 21 days j) CA19.9. e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Gemcitabine i) FNAC. DEPARTMENT.
1051 Medical Oncology MO Medical Oncology MO018 CT for Panceratic Cancer MO018C 4620 5082 5544 6006 6468 6699
Gemcitabine 300mg/m2 weekly j) CA19.9. e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
b) MDC. OF THE TESTS (PATHOLOGY,
c) HIV. RADIOLOGY, MICROBIOLOGY,
d) HBSAG. HEMATOLOGY, BIOCHEMISTRY,ETC.)
e) HCV. DISCHARGE SUMMARY OF INPATIENT
f) BIOCHEM. DEPARTMENT, DISCHARGE SUMMARY
6 - Mercaptopurine 75mg/m2 daily g) CSF CYTOMORPHOLOGY. OF DAY CARE DEPARTMENT, CHARTS
CT for Pediatric Acute Lymphoblastic Methotrexate 20mg/m2 weekly h) FLOW CYTOMETRY. OF CHEMOTHERAPY REGIMEN Invoice of
1052 Medical Oncology MO Medical Oncology MO062 MO062C 3150 3465 3780 4095 4410 4567
Leukemia Vincristine 1.5mg/m2 monthly i) BONE MARROW FLOW CYTOMETRY. Medicinel) Tumor board meeting report
Intrathecal methotrexate 12 mg 3 monthly j) CYTOGENETICS. m) Hysterectomy report
k) NGS. n) Papsmear Reoprt
l) BIOPSY o) Govt. referral form.
a) CBC BIOCHEM. l) Tumor board meeting a) BAR CODE OF THE DRUGS.
report m) Hysterectomy report b) REPORTS OF THE TESTS
n) Papsmear Reoprt o) Govt. referral form. (PATHOLOGY, RADIOLOGY,
MICROBIOLOGY, HEMATOLOGY,
BIOCHEMISTRY,ETC.)
DEPARTMENT.
CT for Pediatric Acute Lymphoblastic Consolidation DEPARTMENT.
Leukemia (Phase II, CNS Therapy Reinduction) e) CHARTS OF CHEMOTHERAPY
REGIMEN.

report
n) Papsmear Reoprt
g) CSF CYTOMORPHOLOGY. OF DAY CARE DEPARTMENT, CHARTS
CT FOR PEDIATRIC ACUTE Dasatinib + chemo (to be used only with ALL h) FLOW CYTOMETRY. OF CHEMOTHERAPY REGIMEN Invoice of
1054 Medical Oncology MO Medical Oncology MO062 MO062D 5775 6352 6930 7507 8085 8373
LYMPHOBLASTIC LEUKEMIA therapy) i) BONE MARROW FLOW CYTOMETRY. Medicinel) Tumor board meeting report
j) CYTOGENETICS. m) Hysterectomy report
Outside State
Bed Cost Cost
Cost
g) NCCT CHEST. DEPARTMENT.
ICICLE h) BONE MARROW or Peripheral bloodFLOW d) DISCHARGE SUMMARY OF DAY CARE
CT for Pediatric Acute Lymphoblastic BFM CYTOMETRY. DEPARTMENT.
1055 Medical Oncology MO Medical Oncology MO062 MO062B 100485 110533 120582 130630 140679 145703 i) CYTOGENETICS. e) CHARTS OF CHEMOTHERAPY
Leukemia KLALL
MCP:841 j) Molecular. REGIMEN.
k) BIOPSY.

g) CSF CYTOMORPHOLOGY. OF DAY CARE DEPARTMENT, CHARTS
CT FOR PEDIATRIC ACUTE Imatinib + chemo ((to be used only with ALL h) FLOW CYTOMETRY. OF CHEMOTHERAPY REGIMEN Invoice of
1056 Medical Oncology MO Medical Oncology MO062 MO062E 5775 6352 6930 7507 8085 8373
LYMPHOBLASTIC LEUKEMIA therapy) i) BONE MARROW FLOW CYTOMETRY. Medicinel) Tumor board meeting report
j) CYTOGENETICS. m) Hysterectomy report
Cytrabine 100-200mg/m2/day days 1-7 and h) Molecular DEPARTMENT.
1057 Medical Oncology MO Medical Oncology MO064 CT for Pediatric Acute Myeloid Leukemia MO064C 121170 133287 145404 157521 169638 175696
Daunorubicin 50mg/m2 days 1, 3 and 5 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Cytrabine 200mg/m2/day days 1-10 and g) cytogenetics. d) DISCHARGE SUMMARY OF DAY CARE
1058 Medical Oncology MO Medical Oncology MO064 CT for Pediatric Acute Myeloid Leukemia MO064B Daunorubicin 50mg/m2 days 1, 3 and 5 121590 133749 145908 158067 170226 176305 h) Molecular DEPARTMENT.
Etposide 100mg/m2 days 1-5 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Cytrabine 3 gram/m2 twice a day h) Molecular DEPARTMENT.
1059 Medical Oncology MO Medical Oncology MO064 CT for Pediatric Acute Myeloid Leukemia MO064A 66570 73227 79884 86541 93198 96526
Days 1, 3 and 5 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
DEPARTMENT.
CT for Pediatric Acute Promyelocytic DEPARTMENT.
1060 Medical Oncology MO Medical Oncology MO065 MO065A Consolidation 67935 74728 81522 88315 95109 98505
Leukemia e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
DEPARTMENT.
CT for Pediatric Acute Promyelocytic d) DISCHARGE SUMMARY OF DAY CARE
1061 Medical Oncology MO Medical Oncology MO065 MO065B Induction 149520 164472 179424 194376 209328 216804 DEPARTMENT.
Leukemia
REGIMEN.
report
n) Papsmear Reoprt
g) PT. DEPARTMENT.
h) APTT. d) DISCHARGE SUMMARY OF DAY CARE
CT for Pediatric Acute Promyelocytic i) FIBRINOGEN. DEPARTMENT.
1062 Medical Oncology MO Medical Oncology MO065 MO065C Maintenance (18 months total cost) 45465 50011 54558 59104 63651 65924 j) 2D ECHO. e) CHARTS OF CHEMOTHERAPY
Leukemia
k) NCCT CHEST. REGIMEN.
c) CECT CHEST (PATHOLOGY, RADIOLOGY,
d) ABDOMEN. MICROBIOLOGY, HEMATOLOGY,
e) Biopsy. BIOCHEMISTRY,ETC.)
f) ECG. c) DISCHARGE SUMMARY OF INPATIENT
g) 2D-ECHO. DEPARTMENT.
h) AUDIOMETRY. d) DISCHARGE SUMMARY OF DAY CARE
1063 Medical Oncology MO Medical Oncology MO070 CT for Pediatric Hepatoblastoma MO070A Carboplatin + Cisplatin + Doxorubicin 6510 7161 7812 8463 9114 9439 i) GFR DEPARTMENT.
l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
c) S.AFP. (PATHOLOGY, RADIOLOGY,
d) CECT CHEST MICROBIOLOGY, HEMATOLOGY,
e) ABDOMEN. BIOCHEMISTRY,ETC.)
f) Biopsy. c) DISCHARGE SUMMARY OF INPATIENT
g) AUDIOMETRY. DEPARTMENT.
h) GFR d) DISCHARGE SUMMARY OF DAY CARE
1064 Medical Oncology MO Medical Oncology MO070 CT for Pediatric Hepatoblastoma MO070B Cisplatin 6510 7161 7812 8463 9114 9439 l) Tumor board meeting report DEPARTMENT.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
1065 Medical Oncology MO Medical Oncology MO066 CT for Pediatric Hodgkins Lymphoma MO066A COPDAC 10920 12012 13104 14196 15288 15834 o) Govt. referral form. DEPARTMENT.
REGIMEN.
report
n) Papsmear Reoprt
1066 Medical Oncology MO Medical Oncology MO066 CT for Pediatric Hodgkins Lymphoma MO066B OPEA 15015 16516 18018 19519 21021 21771 o) Govt. referral form. DEPARTMENT.
REGIMEN.
report
n) Papsmear Reoprt
DEPARTMENT.
CT for Pediatric Hodgkins Lymphoma m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
1067 Medical Oncology MO Medical Oncology MO067 MO067B DECA 17800 19580 21360 23140 24920 25810
Relapse o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.

report
n) Papsmear Reoprt
CT for Pediatric Hodgkins Lymphoma m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
1068 Medical Oncology MO Medical Oncology MO067 MO067A ICE 21500 23650 25800 27950 30100 31175 o) Govt. referral form. DEPARTMENT.
Relapse
REGIMEN.
report
n) Papsmear Reoprt
CT for Pediatric Hodgkins Lymphoma m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
1069 Medical Oncology MO Medical Oncology MO067 MO067C IGVD 39270 43197 47124 51051 54978 56941 o) Govt. referral form. DEPARTMENT.
Relapse
REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
6 - Mercaptopurine 75mg/m2 daily h) FLOW CYTOMETRY. d) DISCHARGE SUMMARY OF DAY CARE
Methotrexate 20mg/m2 weekly i) BONE MARROW FLOW CYTOMETRY. DEPARTMENT.
1070 Medical Oncology MO Medical Oncology MO063 CT for Pediatric Lymphoblastic Lymphoma MO063C 3150 3465 3780 4095 4410 4567
Vincristine 1.5mg/m2 monthly j) CYTOGENETICS. e) CHARTS OF CHEMOTHERAPY
Intrathecal methotrexate 12 mg 3 monthly k) NGS. REGIMEN.
l) BIOPSY
n) Papsmear Reoprt
Consolidation i) BONE MARROW FLOW CYTOMETRY. DEPARTMENT.
1071 Medical Oncology MO Medical Oncology MO063 CT for Pediatric Lymphoblastic Lymphoma MO063A 276885 304573 332262 359950 387639 401483
(Phase II, CNS Therapy Reinduction) j) CYTOGENETICS. e) CHARTS OF CHEMOTHERAPY
k) NGS. REGIMEN.
l) BIOPSY
n) Papsmear Reoprt
a) CBC. b) REPORTS OF THE TESTS
b) MDC. (PATHOLOGY, RADIOLOGY,
c) HIV. MICROBIOLOGY, HEMATOLOGY,
d) HBSAG BIOCHEMISTRY,ETC.)
e) HCV. c) DISCHARGE SUMMARY OF INPATIENT
f) 2D ECHO. DEPARTMENT.
g) NCCT CHEST. d) DISCHARGE SUMMARY OF DAY CARE
ICICLE h) BONE MARROW or Peripheral bloodFLOW DEPARTMENT.
BFM CYTOMETRY. e) CHARTS OF CHEMOTHERAPY
1072 Medical Oncology MO Medical Oncology MO063 CT for Pediatric Lymphoblastic Lymphoma MO063B 100485 110533 120582 130630 140679 145703
KLALL i) CYTOGENETICS. REGIMEN.
MCP:841 j) Molecular.
k) BIOPSY. Invoice of Medicinel) Tumor board meeting
l) PET-CT or CECT chest abdomen report
m) Pelvis(if LBL) m) Hysterectomy report

g) ECG. DEPARTMENT.
1073 Medical Oncology MO Medical Oncology MO068 CT for Pediatric Non Hodgkins Lymphoma MO068A LMB 89 - 96 - Consolidation (second month) 49245 54169 59094 64018 68943 71405 l) Tumor board meeting report DEPARTMENT.

report
n) Papsmear Reoprt
g) ECG. DEPARTMENT.
LMB 89 - 96 - Induction - COPADAM ( first l) Tumor board meeting report DEPARTMENT.
1074 Medical Oncology MO Medical Oncology MO068 CT for Pediatric Non Hodgkins Lymphoma MO068B 49035 53938 58842 63745 68649 71100
month) m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY

report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
g) ECG. DEPARTMENT.
1075 Medical Oncology MO Medical Oncology MO068 CT for Pediatric Non Hodgkins Lymphoma MO068C LMB 89 - 96 - Maintenance 76020 83622 91224 98826 106428 110229 l) Tumor board meeting report DEPARTMENT.

report
n) Papsmear Reoprt
g) ECG. DEPARTMENT.
1076 Medical Oncology MO Medical Oncology MO068 CT for Pediatric Non Hodgkins Lymphoma MO068D MCP - 842 114030 125433 136836 148239 159642 165343 l) Tumor board meeting report DEPARTMENT.

report
n) Papsmear Reoprt
d) PET CECT or CECT chest abdomen MICROBIOLOGY, HEMATOLOGY,
e) pelvis. BIOCHEMISTRY,ETC.)
CHOEP f) Bone marrow studies. c) DISCHARGE SUMMARY OF INPATIENT
Cyclophosphamide 750mg/m2 D1 g) Biopsy DEPARTMENT.
Vincristine 1.4mg/m2 D1 l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
1077 Medical Oncology MO Medical Oncology MO037 CT for Peripheral T - Cell Lymphoma MO037A Adriamycin 50 mg/m2 D1 6090 6699 7308 7917 8526 8830 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Etoposide 100mg/m2 D1-3 o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
Prednisolone 100 mg D1-5 REGIMEN.
Every 21days. Total 6 cycles f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
CHOP g) Biopsy DEPARTMENT.
Cyclophosphamide 750mg/m2 D1 l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
Vincristine 1.4mg/m2 D1 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
1078 Medical Oncology MO Medical Oncology MO037 CT for Peripheral T - Cell Lymphoma MO037B 5985 6583 7182 7780 8379 8678
Adriamycin 50 mg/m2 D1 o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
Prednisolone 100 mg D1-5 REGIMEN.
Every 21days. Total 6 cycles f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
SMILE g) Bone marrow studies. DEPARTMENT.
Methotrexate 2gm/m2 D1 h) Biopsy d) DISCHARGE SUMMARY OF DAY CARE
Ifosfamide 1500mg/m2 D2-4 l) Tumor board meeting report DEPARTMENT.
1079 Medical Oncology MO Medical Oncology MO037 CT for Peripheral T - Cell Lymphoma MO037C 22785 25063 27342 29620 31899 33038
Etoposide 100mg/m2 D2-4 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
L-asparginase 6000U/m2 D8,10,12,14,16,18,20 o) Govt. referral form. REGIMEN.
Dexamethasone 40mg D1-4 every 28 days f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Etoposide + Prednsiolone + Vincristine + d) pelvis. MICROBIOLOGY, HEMATOLOGY,
Cyclophosphamide + Doxorubicin e) Bone marrow studies. BIOCHEMISTRY,ETC.)
Rituximab 375mg/m2 Day 1 f) Biopsy or fluid flow cytometry. c) DISCHARGE SUMMARY OF INPATIENT
Etoposide 50mg/m2 g) ECG. DEPARTMENT.
VCR 0.4mg/m2 h) 2D-ECHO d) DISCHARGE SUMMARY OF DAY CARE
CT for PMBCL / Burkitt's Lymphoma /
Doxorubicin 10mg/m2 Day1 - 4 l) Tumor board meeting report DEPARTMENT.
1080 Medical Oncology MO Medical Oncology MO032 Seropositive MO032A 36645 40309 43974 47638 51303 53135
Cyclophosphamide 750mg/m2 on day 5 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
B - Cell NHLR
Prednisolone 100 mg day 1-5 o) Govt. referral form. REGIMEN.
Dose adjustment each cycle depending on nadir Invoice of Medicinel) Tumor board meeting
counts report
Total- 6 cycles m) Hysterectomy report
n) Papsmear Reoprt
g) Biopsy/HPE DEPARTMENT.
De-Angelis/MTR (methotrexate, dexamethasone, l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
1081 Medical Oncology MO Medical Oncology MO073 CT for primary CNS lymphoma MO073A procarbazine, vincristine, intrathecal MTX, 41580 45738 49896 54054 58212 60291 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
CYTARABINE) o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
c) MRI OR CECT. (PATHOLOGY, RADIOLOGY,
Vincristine + Topotecan + Cyclophosphamide d) BONE MARROW STUDIES. MICROBIOLOGY, HEMATOLOGY,
and e) BONE SCAN OR PET CT. BIOCHEMISTRY,ETC.)
Vincristine + Adriamycin + Cyclophosphamide f) Biopsy. c) DISCHARGE SUMMARY OF INPATIENT
Vincristine 1.5mg/m2 (day 1) g) 2D ECHO DEPARTMENT.
Topotecan 1.5mg/m2 (day 1-5) l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
1082 Medical Oncology MO Medical Oncology MO060 CT for Relapse Rhabdomyosarcoma MO060A Cyclophosphamide 250mg/m2 (days 1-5) 14385 15823 17262 18700 20139 20858 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
3 - weekly o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
Vincristine 1.5mg/m2 REGIMEN.
Adriamyicn 60mg/m2 f) TRANFUSION SLIPS.
Cyclophosphamide 600mg/m2 (all Day 1) Invoice of Medicinel) Tumor board meeting
Every 3 weeks. Cycles given in couplets report
n) Papsmear Reoprt
GDP - R f) Biopsy or fluid flow cytometry. c) DISCHARGE SUMMARY OF INPATIENT
Rituximab 375mg/m2 Day 1 l) Tumor board meeting report DEPARTMENT.
Gemcitabine 1000mg/m2 on day 1 and 8 m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
CT for Relapsed B - Cell NHL - High Grade o) Govt. referral form. DEPARTMENT.
1083 Medical Oncology MO Medical Oncology MO031 MO031A Dexamethasone 40 mg Day 1 - 4 40845 44929 49014 53098 57183 59225
(Except Burkitt's & PCNSL) e) CHARTS OF CHEMOTHERAPY
Cisplatin 75mg/m2 on day 1
Cycle to be repeated every 21days REGIMEN.
Total- 6 cycles f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
b) Biochemistry. MICROBIOLOGY, HEMATOLOGY,
c) PET CT or CECT Chest abdomen BIOCHEMISTRY,ETC.)
ICE - R d) pelvis. c) DISCHARGE SUMMARY OF INPATIENT
Rituximab 375mg/m2 e) Bone marrow studies. DEPARTMENT.
Ifosfamide 1.66g/m2 on day 1 - 3 f) Biopsy or fluid flow cytometry. d) DISCHARGE SUMMARY OF DAY CARE
CT for Relapsed B - Cell NHL - High Grade l) Tumor board meeting report DEPARTMENT.
1084 Medical Oncology MO Medical Oncology MO031 MO031B Mesna 1.66g/m2 day 1 - 3 36855 40540 44226 47911 51597 53439
(Except Burkitt's & PCNSL) m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
Carboplatin AUC 5 on day 1
Etoposide 100mg/m2 on day 1 - 3 o) Govt. referral form. REGIMEN.
Cycle every 21days for 6 cycles f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
ICE g) Biopsy DEPARTMENT.
Ifosfamide 1.5 mg/m2 D1-3 l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
1085 Medical Oncology MO Medical Oncology MO040 CT for Relapsed Hodgkin Lymphoma MO040A Carboplatin AUC5 D2 12180 13398 14616 15834 17052 17661 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Every 3 weeks REGIMEN.
report
n) Papsmear Reoprt
MINE g) Biopsy DEPARTMENT.
Ifosfamide 4 gm/m2 over 3days (D1-3) l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
1086 Medical Oncology MO Medical Oncology MO040 CT for Relapsed Hodgkin Lymphoma MO040B Mitoxantrone 8mg/m2 12180 13398 14616 15834 17052 17661 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Every 3 weeks REGIMEN.
report
n) Papsmear Reoprt
PTCL - GDP l) Tumor board meeting report DEPARTMENT.
Gemcitabine 1000mg/m2 D1 and D8 m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
Dexamethasone 40mg D1-4 o) Govt. referral form. DEPARTMENT.
1087 Medical Oncology MO Medical Oncology MO040 CT for Relapsed Hodgkin Lymphoma MO040C 17115 18826 20538 22249 23961 24816
Cisplatin 75mg/m2 D1 or e) CHARTS OF CHEMOTHERAPY
Cacrboplatin AUC-5 REGIMEN.
Every 3 weeks f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
DHAP l) Tumor board meeting report DEPARTMENT.
Dexamethasone 40mg D1-4 m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
Cisplatin 100mg/m2 or o) Govt. referral form. DEPARTMENT.
1088 Medical Oncology MO Medical Oncology MO041 CT for Relapsed NHL & HL MO041A 14490 15939 17388 18837 20286 21010
Carboplatin AUC-5D1 e) CHARTS OF CHEMOTHERAPY
Cytarabine 2 gm/m2 BD D2 REGIMEN.
Repeat every 21 days f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
c) RBS. (PATHOLOGY, RADIOLOGY,
g) lipid profile. DEPARTMENT.
Cabozantinib 60 mg od x 1 month h) 2 D ECHO. d) DISCHARGE SUMMARY OF DAY CARE
1089 Medical Oncology MO Medical Oncology MO025 CT for Renal Cell Cancer MO025B every 4 weeks 15015 16516 18018 19519 21021 21771 i) TFT. DEPARTMENT.
j) 24 hour urine protein e) CHARTS OF CHEMOTHERAPY
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
c) RBS. (PATHOLOGY, RADIOLOGY,
g) lipid profile. DEPARTMENT.
h) 2 D ECHO. d) DISCHARGE SUMMARY OF DAY CARE
Sunitinib i) TFT. DEPARTMENT.
1090 Medical Oncology MO Medical Oncology MO025 CT for Renal Cell Cancer MO025A 11550 12705 13860 15015 16170 16747
50 mg once daily 4 weeks on 2 weeks off j) 24 hour urine protein e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
c) MRI (BRAIN AND ORBITS). (PATHOLOGY, RADIOLOGY,
d) CT (BRAIN AND ORBITS). MICROBIOLOGY, HEMATOLOGY,
e) ULTRASONOGRAPHY. BIOCHEMISTRY,ETC.)
f) BONE MARROW c) DISCHARGE SUMMARY OF INPATIENT
g) CSF STUDIES DEPARTMENT.
Vincristine + Carboplatin + Etoposide l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
Carboplatin 600mg/m2 day 1 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
1091 Medical Oncology MO Medical Oncology MO058 CT for Retinoblastoma MO058A 8610 9471 10332 11193 12054 12484
Etoposide 150mg/m2 days 1-3 o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
Vincristine1.5mg/m2 day 1 REGIMEN.
report
n) Papsmear Reoprt
d) BONE MARROW STUDIES. MICROBIOLOGY, HEMATOLOGY,
e) BONE SCAN OR PET CT. BIOCHEMISTRY,ETC.)
f) Biopsy c) DISCHARGE SUMMARY OF INPATIENT
Vincristine + Cyclophosphamide + Dactinomycin l) Tumor board meeting report DEPARTMENT.
Vincristine 1.5mg/m2 (day 1, 8 and 15) m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
1092 Medical Oncology MO Medical Oncology MO059 CT for Rhabdomyosarcoma MO059A Cyclophosphamie 1200 - 2200 mg/m2 (day 1) 6615 7276 7938 8599 9261 9591 o) Govt. referral form. DEPARTMENT.
Dactinomycin 1.5mg / m2 (day 1) e) CHARTS OF CHEMOTHERAPY
3 weekly cycle REGIMEN.
report
n) Papsmear Reoprt
d) BONE MARROW STUDIES. MICROBIOLOGY, HEMATOLOGY,
e) BONE SCAN OR PET CT. BIOCHEMISTRY,ETC.)
f) Biopsy c) DISCHARGE SUMMARY OF INPATIENT
Vincristine + Ifosfamide + Etoposide l) Tumor board meeting report DEPARTMENT.
Vincristine 1.5mg/m2 (days 1, 8 and 15) m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
1093 Medical Oncology MO Medical Oncology MO059 CT for Rhabdomyosarcoma MO059B Ifosfamide 1.8gm/m2 (days 1-5) 18795 20674 22554 24433 26313 27252 o) Govt. referral form. DEPARTMENT.
Etoposide 100mg/m2 (days 1-5) e) CHARTS OF CHEMOTHERAPY
Each cycle every 3 weeks REGIMEN.
report
n) Papsmear Reoprt
c) ECHO. (PATHOLOGY, RADIOLOGY,
d) MRI of the involved part. MICROBIOLOGY, HEMATOLOGY,
1094 Medical Oncology MO Medical Oncology MO011 CT for Soft Tissue Sarcoma MO011C Doxorubicin 60-75/m2, every 21 days 4620 5082 5544 6006 6468 6699 l) Tumor board meeting report DEPARTMENT.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Gemcitabine + Docetaxel h) histopathology d) DISCHARGE SUMMARY OF DAY CARE
1095 Medical Oncology MO Medical Oncology MO011 CT for Soft Tissue Sarcoma MO011A Gemcitabine 900 mg/m2 D1 D8 30900 33990 37080 40170 43260 44805 l) Tumor board meeting report DEPARTMENT.
Docetaxel 100 mg/m2 D8 every 21 days m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Ifosfamide + Adriamycin g) Pelvis. DEPARTMENT.
Doxorubicin 30mg/m2 D1 D2 h) histopathology d) DISCHARGE SUMMARY OF DAY CARE
1096 Medical Oncology MO Medical Oncology MO011 CT for Soft Tissue Sarcoma MO011B Ifosfamide 2000 to 3000mg/m2 15855 17440 19026 20611 22197 22989 l) Tumor board meeting report DEPARTMENT.
Mesna 400 to 600 mg/m2 0h 4h 8h D1 - D3 m) Hysterectomy report n) Papsmear Reoprt e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Cisplatin + Adriamycin + Cyclophosphamide g) Pelvis. DEPARTMENT.
Cisplatin 50 mg/m2 D1 h) histopathology . d) DISCHARGE SUMMARY OF DAY CARE
1097 Medical Oncology MO Medical Oncology MO023 CT for Thymic Carcinoma MO023B Doxorubicin 50 mg/m2 D1 6825 7507 8190 8872 9555 9896 i) ECHO DEPARTMENT.
Cyclophosphamide 500 mg/m2 D1 every 21 l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Cisplatin + Etoposide h) histopathology . d) DISCHARGE SUMMARY OF DAY CARE
1098 Medical Oncology MO Medical Oncology MO023 CT for Thymic Carcinoma MO023A Etoposide 100mg/m2 D1 - D3 8190 9009 9828 10647 11466 11875 i) ECHO DEPARTMENT.
Cisplatin 75-100 mg/m2 D1 every 21 days l) Tumor board meeting report e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
g) MRI. DEPARTMENT.
Carboplatin + Gemcitabine h) histopathology d) DISCHARGE SUMMARY OF DAY CARE
1099 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026B Gemcitabine 1000 mg/m2 D1 D8 16065 17671 19278 20884 22491 23294 l) Tumor board meeting report DEPARTMENT.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Cisplatin + 5 FU l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
1100 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026D 5 FU 1000mg/m2 D1-D4 9450 10395 11340 12285 13230 13702 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Cisplatin 75mg/m2 D1 every 4 weeks o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
g) MRI. DEPARTMENT.
Cisplatin + Gemcitabine h) ECG. d) DISCHARGE SUMMARY OF DAY CARE
1101 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026C Gemcitabine 1000 mg/m2 D1 D8 14070 15477 16884 18291 19698 20401 i) 2D-ECHO DEPARTMENT.
Cisplatin 75 mg/m2 D1 every 21 days j) .Histopathology e) CHARTS OF CHEMOTHERAPY
report
n) Papsmear Reoprt
Cisplatin + Methotrexate + Vinblastin g) histopathology DEPARTMENT.
Methotrexate 30mg/m2 D1 D8 l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
Vinblastine 4 mg/m2 D1 D8 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
1102 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026A 7875 8662 9450 10237 11025 11418
Doxorubicin 30 mg/m2 D2 o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
Cisplatin 100 mg/m2 D2 REGIMEN.
Leucovorin 15 mg PO D2 D9 every 21 days f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
Cisplatin + Paclitaxel l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
1103 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026E Paclitaxel 175 mg /m2 D1 15435 16978 18522 20065 21609 22380 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Cisplatin 75 mg /m2 D1 every 21 days o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
1104 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026F 14400 15840 17280 18720 20160 20880
Docetaxel 75 mg/m2 D1 every 21 days o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
Gemcitabine + Paclitaxel l) Tumor board meeting report d) DISCHARGE SUMMARY OF DAY CARE
1105 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026G Gemcitabine 2500 mg/m2 D1 17955 19750 21546 23341 25137 26034 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Paclitaxel 150 mg/m2 D1 every 14 days o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Gemcitabine m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
1106 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026H 10395 11434 12474 13513 14553 15072
Gemcitabine 1000mg /m2 D1 D8 every 21 days o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Methotrexate + Vinblastin + Doxorubicin + g) MRI. DEPARTMENT.
Cisplatin h) histopathology. d) DISCHARGE SUMMARY OF DAY CARE
Methotrexate 30mg/m2 D1 i) ECG. DEPARTMENT.
1107 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026I 8715 9586 10458 11329 12201 12636
Vinblastine 3 mg/m2 D2 j) ECHO e) CHARTS OF CHEMOTHERAPY
Doxorubicin 30 mg/m2 D2 l) Tumor board meeting report REGIMEN.
Cuisplatin 70 mg/m2 D2 every 14 days m) Hysterectomy report n) Papsmear Reoprt f) TRANFUSION SLIPS.
report
n) Papsmear Reoprt
1108 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026J Paclitaxel 175mg/m2 D1 16800 18480 20160 21840 23520 24360 m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
REGIMEN.
report
n) Papsmear Reoprt
1109 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026K 7455 8200 8946 9691 10437 10809
Paclitaxel 80 mg/m2 D1 every week o) Govt. referral form. e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
e) MRI pelvis. BIOCHEMISTRY,ETC.)
f) histopathology c) DISCHARGE SUMMARY OF INPATIENT
Carboplatin + Paclitaxel m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
1110 Medical Oncology MO Medical Oncology MO008 CT for Vulvar Cancer MO008C Paclitaxel 175mg/m2 D1 16800 18480 20160 21840 23520 24360 o) Govt. referral form. DEPARTMENT.
Carboplatin AUC 5 D1 every 21 days e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Cisplatin + 5 FU m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
1111 Medical Oncology MO Medical Oncology MO008 CT for Vulvar Cancer MO008A 5 FU 1000mg/m2 D1-D4 9555 10510 11466 12421 13377 13854 o) Govt. referral form. DEPARTMENT.
Cisplatin 75mg/m2 D1 every 3 weeks e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Cisplatin o) Govt. referral form. DEPARTMENT.
1112 Medical Oncology MO Medical Oncology MO008 CT for Vulvar Cancer MO008B 2730 3003 3276 3549 3822 3958
Cisplatin 40 mg/m2 every week e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
c) CT CHEST ABDOMEN. (PATHOLOGY, RADIOLOGY,
d) ULTRASONOGRAPHY. MICROBIOLOGY, HEMATOLOGY,
e) BIOPSY. BIOCHEMISTRY,ETC.)
Cyclophosphamide + Doxorubicin + Etoposide + f) 2D ECHO c) DISCHARGE SUMMARY OF INPATIENT
Vincristine + Dactinomycin l) Tumor board meeting report DEPARTMENT.
Vincristine 1.5 mg/m2 m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
Dactinomycin 45 microgram/kg o) Govt. referral form. DEPARTMENT.
1113 Medical Oncology MO Medical Oncology MO061 CT for Wilms Tumor MO061C 17640 19404 21168 22932 24696 25578
Adriamyicn 60mg/m2 e) CHARTS OF CHEMOTHERAPY
Cyclophosphamide REGIMEN.
Etoposide f) TRANFUSION SLIPS.
Weekly chemotherapy - varying hybrid regimen Invoice of Medicinel) Tumor board meeting
report
n) Papsmear Reoprt
e) BIOPSY. BIOCHEMISTRY,ETC.)
f) 2D ECHO c) DISCHARGE SUMMARY OF INPATIENT
Vincristine + Actinomycin D + Doxorubicin l) Tumor board meeting report DEPARTMENT.
Vincristine 1.5 mg/m2 weekly for 12 weeks and m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
1114 Medical Oncology MO Medical Oncology MO061 CT for Wilms Tumor MO061B then 3 weekly 5775 6352 6930 7507 8085 8373 o) Govt. referral form. DEPARTMENT.
Actinomycin D 45 microgram/kg 3 weekly e) CHARTS OF CHEMOTHERAPY
Doxorubicin 60mg/m2 for 24 weeks REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
e) BIOPSY BIOCHEMISTRY,ETC.)
Vincristine + Actinomycin D m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Vincristine 1.5 mg/m2 weekly for 12 weeks and o) Govt. referral form. d) DISCHARGE SUMMARY OF DAY CARE
1115 Medical Oncology MO Medical Oncology MO061 CT for Wilms Tumor MO061A then 3 weekly 4410 4851 5292 5733 6174 6394 DEPARTMENT.
Actinomycin D 45 microgram / kg 3 weekly for e) CHARTS OF CHEMOTHERAPY
24 weeks REGIMEN.
report
n) Papsmear Reoprt
b) BIOCHEM. b) REPORTS OF THE TESTS
c) ECG. (PATHOLOGY, RADIOLOGY,
Cefoperazone + Sulbactum d) BONE MARROW. MICROBIOLOGY, HEMATOLOGY,
Piperalicillin + Tazobactum e) RQ PCR. BIOCHEMISTRY,ETC.)
Cefoperazone f) PML RARA c) DISCHARGE SUMMARY OF INPATIENT
Piperacillin l) Tumor board meeting report DEPARTMENT.
Amikacin m) Hysterectomy report n) Papsmear Reoprt d) DISCHARGE SUMMARY OF DAY CARE
1116 Medical Oncology MO Medical Oncology MO051 Febrile Neutopenia MO051A Gentamicin 38430 42273 46116 49959 53802 55723 o) Govt. referral form. DEPARTMENT.
Cefipime e) CHARTS OF CHEMOTHERAPY
Levofloxacin REGIMEN.
Amoxycillin and clavulanate f) TRANFUSION SLIPS.
Teicoplanin Invoice of Medicinel) Tumor board meeting
Vancomycin report
n) Papsmear Reoprt
c) RQ (PATHOLOGY, RADIOLOGY,
d) PCR. MICROBIOLOGY, HEMATOLOGY,
e) PML RARA BIOCHEMISTRY,ETC.)
Meropenem l) Tumor board meeting report c) DISCHARGE SUMMARY OF INPATIENT
Imipenem m) Hysterectomy report n) Papsmear Reoprt DEPARTMENT.
Colistin o) Govt. referral form. d) DISCHARGE SUMMARY OF DAY CARE
Tigecyclin DEPARTMENT.
1117 Medical Oncology MO Medical Oncology MO051 Febrile Neutopenia MO051B 91035 100138 109242 118345 127449 132000
Linezolid e) CHARTS OF CHEMOTHERAPY
Voriconazole REGIMEN.
Caspfungin f) TRANFUSION SLIPS.
Amphotericin - B Invoice of Medicinel) Tumor board meeting
report
n) Papsmear Reoprt
g) LDH. DEPARTMENT.
i) Abdomen DEPARTMENT.
1118 Medical Oncology MO Medical Oncology M0074 GCT Testis MO074A SA Carboplatin AUC 7 once every 3 weeks 6930 7623 8316 9009 9702 10048 j) Pelvis. e) CHARTS OF CHEMOTHERAPY
k) ECG. REGIMEN.
a)CBC, RFT, LFT (b)PET CT (C) USG (d) HPE l) a) BAR CODE OF THE DRUGS.
Tumor board meeting report b) REPORTS OF THE TESTS
m) Hysterectomy report n) Papsmear Reoprt (PATHOLOGY, RADIOLOGY,
o) Govt. referral form. MICROBIOLOGY, HEMATOLOGY,
BIOCHEMISTRY,ETC.)
DEPARTMENT.
GEP NET NEUROENDOCRINE Carboplatin AUC 5 + Etoposide 100mg/m2 D1- DEPARTMENT.
1119 Medical Oncology MO Medical Oncology MO076 MO076B 15540 17094 18648 20202 21756 22533
CARCINOMA D3 every 21 days e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
Outside State
Bed Cost Cost
Cost
a)CBC, RFT, LFT (b)PET CT (C) USG (d) HPE l) a) BAR CODE OF THE DRUGS.
Tumor board meeting report b) REPORTS OF THE TESTS
m) Hysterectomy report n) Papsmear Reoprt (PATHOLOGY, RADIOLOGY,
o) Govt. referral form. MICROBIOLOGY, HEMATOLOGY,
BIOCHEMISTRY,ETC.)
DEPARTMENT.
GEP NET NEUROENDOCRINE Temozolamide 150mg/m2 D9-14 + Capecitabine DEPARTMENT.
CARCINOMA 1gm/me D1-14 every 28 days e) CHARTS OF CHEMOTHERAPY
REGIMEN.
report
n) Papsmear Reoprt
b) Bone marrow. b) REPORTS OF THE TESTS
d) LFT MICROBIOLOGY, HEMATOLOGY,
5 microgram / kg / day d) DISCHARGE SUMMARY OF DAY CARE
(max 300 microgram per day) for 7 days or DEPARTMENT.
1121 Medical Oncology MO Medical Oncology MO053 Granulocyte Colony Stimulating Factor Use MO053A 5250 5775 6300 6825 7350 7612
PEG - GCSF 6mg one single dose per e) CHARTS OF CHEMOTHERAPY
chemotherapy cycle REGIMEN.
report
n) Papsmear Reoprt
c) TUMOR MARKERS. (PATHOLOGY, RADIOLOGY,
d) CECT CHEST MICROBIOLOGY, HEMATOLOGY,
e) ABDOMEN. BIOCHEMISTRY,ETC.)
f) Biopsy. c) DISCHARGE SUMMARY OF INPATIENT
g) AUDIOMETRY. DEPARTMENT.
h) GFR d) DISCHARGE SUMMARY OF DAY CARE
1122 Medical Oncology MO Medical Oncology MO069 PEDIATRIC-GCT/JEB MO069A Pediatric - Germ Cell Tumor / JEB 12390 13629 14868 16107 17346 17965 l) Tumor board meeting report DEPARTMENT.
report
n) Papsmear Reoprt
A)Detailed history with chronicity. a) Detailed treatment notes b) Relevant
B) need for specific treatment. investigations
C)expected results. 1. Complete hemogram
Behavioral and motional Disorders of D) Admission under empanneled Psychiatrist is a 2. Liver function test
1123 Mental Disorders MM Mental Disorders MM011 MM011D Anxiety and Depressive Disorders 2250 2475 2700 2925 3150 3262
Childhood and Adolescence must 3. Serum electrolytes
4. Random blood glucose c) Detailed
Discharge Summary
1124 Mental Disorders MM Mental Disorders MM011 MM011B Conduct Disorder 2250 2475 2700 2925 3150 3262
Discharge Summary
1125 Mental Disorders MM Mental Disorders MM011 MM011C Mixed Disorder of Conduct and Emotions 2250 2475 2700 2925 3150 3262
Discharge Summary
1126 Mental Disorders MM Mental Disorders MM011 MM011A Oppositional Defiant Disorder 2250 2475 2700 2925 3150 3262
Discharge Summary
Behavioral and motional Disorders of Other Internalizing and Externalizing Disorders of D) Admission under empanneled Psychiatrist is a 2. Liver function test
1127 Mental Disorders MM Mental Disorders MM011 MM011E 2250 2475 2700 2925 3150 3262
Childhood and Adolescence Childhood and Adolescence must 3. Serum electrolytes
Discharge Summary
Behavioural syndromes associated with a) Clinical notes with detailed history and chronicity a) Detailed treatment notes b) Detailed
Behavioural syndromes associated with
1128 Mental Disorders MM Mental Disorders MM006 physiological disturbances and physical MM006A 2250 2475 2700 2925 3150 3262 b) Admission document signed by empanelled Discharge Summary
physiological disturbances and physical factors
factors psychiatrist
A)Detailed history with chronicity. A)Detailed treatment notes.
B) need for specific treatment. B) all investigations done.
Electro Convulsive Therapy (ECT) - per
1129 Mental Disorders MM Mental Disorders MM009 MM009A Electro Convulsive Therapy (ECT) - per session 3465 3811 4158 4504 4851 5024 C)expected results. C)detailed discharge summary.
session
D) Admission under empanneled Psychiatrist is a
must
Outside State
Bed Cost Cost
Cost
a) Clinical notes with detailed history and chronicity a) Detailed treatment notes b) Relevant
b) Admission document signed by empanelled investigations
psychiatrist 1. Complete hemogram
Mental and Behavioural disorders due to Mental and Behavioural disorders due to 2. Liver function test
1130 Mental Disorders MM Mental Disorders MM007 MM007A 2250 2475 2700 2925 3150 3262
psychoactive substance use psychoactive substance use 3. Serum electrolytes
Discharge Summary
a) Clinical notes with detailed history and chronicity a) Detailed treatment notes b)
b) Admission document signed by empanelled investigations require
2. Thyroid function test
3. Biochemistry
Mental disorders - Organic, including Mental disorders - Organic, including 4. liver function test
symptomatic symptomatic 5. VDRL
6. Vit. D level
7. Vit. B12 level
8. Neuroimaging (CT/MRI) c) Detailed
Discharge Summary
a) Clinical notes with detailed history and chronicity a) Detailed treatment notes b) Relevant
Intellectual Disability (ID) b) Admission document signed by empanelled investigations
1132 Mental Disorders MM Mental Disorders MM001 Mental Retardation (intellectual disability) MM001A 2250 2475 2700 2925 3150 3262 psychiatrist 1. Neuroimaging
2. Thyroid function Test c) Detailed
Discharge Summary
a) Clinical notes with detailed history and chronicity a) Detailed treatment notes b)
b) Admission document signed by empaneled Investigations require
1133 Mental Disorders MM Mental Disorders MM005 Mood (affective) disorders MM005A Mood (affective) disorders 2250 2475 2700 2925 3150 3262 2. Thyroid function test
3. Serum sodium
4. Resting ECG c) Detailed
Discharge Summary
NeuroDevelopmental Disorders (NDD) D) Admission under empanneled Psychiatrist is a 2. Liver function test
1134 Mental Disorders MM Mental Disorders MM010 MM010D Attention Deficit Hyperactivity Disorder (ADHD) 2250 2475 2700 2925 3150 3262
Other than Intellectual Disability must 3. Serum electrolytes
Discharge Summary
1135 Mental Disorders MM Mental Disorders MM010 MM010A Autism Spectrum Disorder 2250 2475 2700 2925 3150 3262
Discharge Summary
1136 Mental Disorders MM Mental Disorders MM010 MM010B Mixed Developmental Disorder 2250 2475 2700 2925 3150 3262
Discharge Summary
1137 Mental Disorders MM Mental Disorders MM010 MM010E Specific Developmental Disorders 2250 2475 2700 2925 3150 3262
Discharge Summary
1138 Mental Disorders MM Mental Disorders MM010 MM010C Tourette Syndrome / Chronic Tic Disorder 2250 2475 2700 2925 3150 3262
Discharge Summary
a) Clinical notes with detailed history and chronicity a) Detailed treatment notes b) Detailed
Neurotic, stress-related and somatoform Neurotic, stress-related and somatoform
1139 Mental Disorders MM Mental Disorders MM004 MM004A 2250 2475 2700 2925 3150 3262 b) Admission document signed by empanelled Discharge Summary
disorders disorders
psychiatrist
Psychological, Behavioural and Developmental B) need for specific treatment. investigations
and Educational Interventions (Typically Includes C)expected results. 1. Complete hemogram
Child Counselling / Psychotherapy, Family D) Admission under empanneled Psychiatrist is a 2. Liver function test
Counselling / Psychotherapy / Training Such As must 3. Serum electrolytes
Parent Management Training, Behavioral / 4. Random blood glucose c) Detailed
1140 Mental Disorders MM Mental Disorders MM012 Non-Pharmacological Interventions MM012A Cognitive-Behavioral Interventions, 3465 3811 4158 4504 4851 5024 Discharge Summary
Developmental Interventions Such As Early
Intervention, Speech / Language Therapy,
Occupational Therapy, Physiotherapy,
Remediation For Specific Learning Disability and
Other Rehabilitative / Psychosocial Interventions)
Package (Cognitive Tests, Complete Package (Cognitive Tests, Complete A)Detailed history with chronicity. A)Detailed treatment notes.
Haemogram, Liver Function Test, Renal Haemogram, Liver Function Test, Renal B) need for specific treatment. B) all investigations done.
Function Test, Serum Electrolytes, Electro Function Test, Serum Electrolytes, Electro C)expected results. C)detailed discharge summary.
Cardiogram (ECG), CT / MRI Brain, Cardiogram (ECG), CT / MRI Brain, D) Admission under empanneled Psychiatrist is a
Electroencephalogram, Thyroid Function Electroencephalogram, Thyroid Function Test, must
Test, VDRL, HIV Test, Vitamin B12 levels, VDRL, HIV Test, Vitamin B12 levels, Folate
Folate levels, Lipid Profile, Homocysteine levels, Lipid Profile, Homocysteine levels), serum
levels), serum Lithium level Lithium level
Common Medications Used in Management of C)expected results. 1. Complete hemogram
1142 Mental Disorders MM Mental Disorders MM013 Pharmacological Interventions MM013A Child & Adult Psycholoigical DisordersiIncluding 2310 2541 2772 3003 3234 3349 D) Admission under empanneled Psychiatrist is a 2. Liver function test
Anti-ADHD Medication must 3. Serum electrolytes
Discharge Summary
Outside State
Bed Cost Cost
Cost
Psychological Assessments (Includes IQ Testing, B) need for specific treatment. investigations
Specific Learning Disability Assessments, C)expected results. 1. Complete hemogram
Psychological / Psychosocial Assessment D) Admission under empanneled Psychiatrist is a 2. Liver function test
Assessments For Autism Spectrum Disorder,
1143 Mental Disorders MM Mental Disorders MM014 Package for All Child And Adolescent MM014A 3000 3300 3600 3900 4200 4350
Developmental Assessments, Projective Tests must 3. Serum electrolytes
Psychiatric Disorders 4. Random blood glucose c) Detailed
and Other Tests Of Psychopathology), Other
Psychosocial Assessments (Family, Schooling) Discharge Summary
a) Clinical notes with detailed history and chronicity a) Detailed treatment notes b) Detailed
Schizophrenia, schizotypal and delusional Schizophrenia, schizotypal and delusional
1144 Mental Disorders MM Mental Disorders MM003 MM003A 2250 2475 2700 2925 3150 3262 b) Admission document signed by empanelled Discharge Summary
disorders disorders
psychiatrist
a) Clinical notes including evaluation findings and a) Detailed Indoor case papers
planned line of management b) b) Investigations reports (if done)
Babies with birthweight of 1200-1499 g c) Detailed Procedure notes and indication (if
Advanced Neonatal Care Package: *Ballard scoring any)
Babies with birthweight of 1200-1499 g Neonates between 1200-1499 g OR *Birth weight d) Detailed discharge summary
or Neonates of any weight with at least one of the *Gestation age
Babies of any birthweight with at least one of following conditions: *Respiratory support - Silverman score need for
the following conditions: • Any condition requiring invasive ventilation Surfactant/Chest X-ray/CPAP/MV
• Any condition requiring invasive ventilation longer than 24 hours *Retinopathy of Prematurity (ROP) screening (can
longer than 24 hours • Moderate to Severe Hypoxic Ischemic be discharged – First ROP screening venue/date
• Hypoxic Ischemic encephalopathy requiring encephalopathy should be documented on the discharge summary
Therapeutic Hypothermia • Cardiac rhythm disorders needing intervention to be done before 30 days of age and <2kg
• Cardiac rhythm disorders needing (the cost of cardiac surgery or implant will be weight)
intervention (the cost of cardiac surgery or covered under cardiac surgery packages) *Neurosonogram c)
1145 Neo - natal Care MN Neo - natal Care MN004 MN004A 8150 8965 9780 10595 11410 11817
implant will be covered under cardiac • Sepsis with complications such as meningitis Investigation *Chest X-ray
surgery packages) or bone and joint infection, DIC or shock *Arterial Blood Gas analysis
• Sepsis with complications such as • Renal failure requiring dialysis *Pre & post ductal saturation d) Hypoxic
meningitis or bone and joint infection, DIC or • Inborn errors of metabolism Ischemic encephalopathy (HIE) requiring
shock The above list is illustrative but not limited to Therapeutic Hypothermia
• Renal failure requiring dialysis these conditions. *Complete blood count
• Inborn errors of metabolism The package includes mandatory stay and food *Electrolytes/Renal function test
Mother's stay and food in the hospital for of the mother in the hospital for breastfeeding, *Coagulation profile *Liver function
breastfeeding, family centred care and Kangaroo Mother Care (KMC) and Family test
(Kangaroo Mother Care) KMC is mandatory centered care *Arterial blood gases (ABG)
and included in the package rate *Cranial Ultrasonography
*HIE scoring e) Cardiac
rhythm disorders needing intervention
*Electrocardiogram (ECG)
Advanced Surgery for Retinopathy of Advanced Surgery for Retinopathy b) Indirect ophthalmoscopy examination b) Intra-procedure photograph(optional)
Prematurity of Prematurity c) Planned line of treatment c) Detailed Procedure / operative notes
a) Clinical notes including evaluation findings and a) Indoor case papers / clinical notes
Documentation of feeding difficulties c) Detailed Procedure notes and indication (if
c) Clinical photograph (in case orofacial any)
deformities) d) Birth asphyxia
* Neonate resuscitation notes
*Indication for monitoring in postnatal ward
*Neonate vital monitoring e) Moderate
jaundice requiring phototherapy
*Total serum bilirubin
Neonates > 2.5 kg nursed with mother : Includes *Blood group: Mother and baby f) Large for dates
clinical monitoring, breastfeeding support, birth (>97 percentile) Babies
1147 Neo - natal Care MN Neo - natal Care MN011 Basic neonatal care (Level IA) MN011A 820 902 984 1066 1148 1189
vaccination, thyroid screening, universal hearing *Blood glucose
screening and pre-discharge counselling *Serum calcium
*Complete blood count
*Feeding monitoring
*Vitals monitoring g)
Small for gestation age (<3 percentile) Babies
*Blood glucose
*Serum calcium
*Feeding monitoring
*Vitals monitoring
a) Clinical notes including evaluation findings and a) Indoor case papers / clinical notes
Documentation of feeding difficulties c) Detailed Procedure notes and indication (if
c) Clinical photograph (in case orofacial any)
Neonates 1800-2500g OR Neonates of any deformities) d) Birth asphyxia
Basic neonatal care package: Babies that weight requiring closer monitoring or short-term * Neonate resuscitation notes
can be managed by side of mother in care on mother's bedside for conditions like, but *Indication for monitoring in postnatal ward
postnatal ward without requiring admission in not limited to: *Neonate vital monitoring e) Moderate
SNCU/NICU: o Birth asphyxia (need for positive pressure jaundice requiring phototherapy
• Any newborn needing feeding support ventilation at birth; no HIE) *Total serum bilirubin
• Babies requiring closer monitoring or short- o Moderate jaundice requiring phototherapy *Blood group: Mother and baby f) Large for dates
1148 Neo - natal Care MN Neo - natal Care MN001 term care for conditions like: MN001A o Large for dates (>97 percentile) or Small for 1050 1155 1260 1365 1470 1522 (>97 percentile) Babies
o Birth asphyxia (need for positive pressure gestational age (less than 3rd centile) *Blood glucose
ventilation; no HIE) o Rule-out sepsis . *Serum calcium
o Moderate jaundice requiring phototherapy o Investigations warranted because of antenatal *Complete blood count
o Large for dates (>97 percentile) Babies scan findings. *Feeding monitoring
o Small for gestational age (less than 3rd Includes activities listed under Basic Neonatal *Vitals monitoring g)
centile) care package and Kangaroo Mother Care Small for gestation age (<3 percentile) Babies
support *Blood glucose
*Serum calcium
*Feeding monitoring
*Vitals monitoring

BERAn (Brainstem Evoked Response procedure& advise for admission) c) Detailed Discharge summary
1149 Neo - natal Care MN Neo - natal Care MN013 MN013A BERA 1740 1914 2088 2262 2436 2523
Audiometry) b) Audiometry report confirming conductive d) Intra-operative photograph with time and
Outside State
Bed Cost Cost
Cost
planned line of management b) Investigations reports (if done)
Neonates in Special Neonatal Care, Special b) Necrotizing Enterocolitis c) Detailed Procedure notes and indication (if
Chronic Care Package: If the baby requires *Complete blood count any)
Neonatal Care-Plus, Intensive Neonatal Care or
stay beyond the upper limit of usual stay in *Arterial Blood Gas (ABG) Analysis d) Detailed discharge summary
Critical Neonatal Care packages
Package no MN004A or MN005A for *Serum Electrolytes
1150 Neo - natal Care MN Neo - natal Care MN006 MN006A (MN002,MN003,MN004, MN005) who have not 4200 4620 5040 5460 5880 6090
conditions like severe BPD requiring *Occult stool test
fully recovered and continue to require
respiratory support, severe NEC requiring *Abdominal X-ray(AP & lateral decubitus)
NICU/SNCU care, e.g. for respiratory support,
prolonged TPN support *USG Abdomen c)
gavage feeding, thermal support, etc.,
Bronchopulmonary dysplasia
Chest X-ray
a) Clinical notes including evaluation findings and a) Detailed Indoor case papers b) Birth
planned line of management weight documentation c) Chest X-ray/ABG d)
b) Babies with birthweight of <1200 g Documentation of Indication for requirement
*Ballard scoring to determine maturity mechanical ventilation and multiple inotropes
*Birth weight e) 2D ECHO report
Neonates <1200 g OR *Gestation age f) Detailed Procedure notes and indication (if
Critical Care Neonatal Package: Neonates of any weight with at least one of the *Respiratory support - Silverman score need for any)
Babies with birthweight of <1200 g following conditions: Surfactant/Chest X-ray/CPAP/MV g) Detailed discharge summary
or • Severe Respiratory Failure requiring High *Retinopathy of Prematurity (ROP) screening
Babies of any birthweight with at least one of Frequency Ventilation or inhaled Nitric Oxide *Neurosonogram
the following conditions: (iNO) *Caffeine administration documentation
• Severe Respiratory Failure requiring High • Multisystem failure requiring multiple organ c) Severe Respiratory Failure requiring High
Frequency Ventilation or inhaled Nitric Oxide support including mechanical ventilation and Frequency Ventilation or inhaled Nitric Oxide (iNO)
(iNO) multiple inotropes *Chest X-ray while on conventional ventilator
• Multisystem failure requiring multiple organ • Reuiring parenteral nutrition *Arterial Base Gas (ABG) and settings while of
support including mechanical ventilation and Critical congenital heart disease (excluding conventional ventilator
multiple inotropes surgical costs) *2D ECHO (for iNO) d)
• Critical congenital heart disease The above list is illustrative but not limited to Multisystem failure requiring multiple organ support
Mother's stay and food in the hospital for these conditions. including mechanical ventilation and multiple
breastfeeding, family centred care and The package includes mandatory stay and food inotropes
(Kangaroo Mother Care) KMC is mandatory of the mother in the hospital for breastfeeding, *Chest X-ray
and included in the package rate Kangaroo Mother Care (KMC) and Family *Blood pressure
centered care *Renal function test
*Liver Function test
*Serum lactate
*Arterial Blood Gas (ABG)
*Urine output
*Level of consciousness (Volpe`s score)
a) Discharge summary of the last admission a) Progress notes at the time of visit
Includes but not limited to minimum six follow-up
b) Clinical examination of the current visit
visits at 40 weeks PMA, and corrected ages of
High Risk Newborn Post Discharge Care
1152 Neo - natal Care MN Neo - natal Care MN007 MN007A 3,6,9, 12 and 18 months for Assessment and 1050 1155 1260 1365 1470 1522
Package (Protocol Driven)
Management of growth and development.
Neurosonogram at 40 weeks PMA if indicated.
Babies with birthweight 1500-1799 g Birth weight c) Detailed Procedure notes and indication (if
Intensive Neonatal Care Package *Gestation age any)
Babies with birthweight 1500-1799 g Neonates of any birthweight with moderate *Ballard scoring for determining maturity d) Detailed discharge summary
or illness like *Respiratory support - Silverman score need for
Babies of any birthweight and at least one of • Need for mechanical ventilation for less than Surfactant/Chest X-ray/CPAP/MV
the following conditions: 24 hours or non-invasive respiratory support *Retinopathy of Prematurity (ROP) screening (can
• Need for mechanical ventilation for less (CPAP, HFFNC) be discharged – First ROP screening venue/date
than 24 hours or non-invasive respiratory • Sepsis / pneumonia without complications should be documented on the discharge summary
support (CPAP, HFFNC) • Hyperbilirubinemia requiring exchange to be done before 30 days of age and <2kg
• Sepsis / pneumonia without complications transfusion weight) c) Need for mechanical ventilation
• Hyperbilirubinemia requiring exchange • Seizures requring anti-convulsants for less than 24 hours or non-invasive respiratory
transfusion • Major congenital malformations (pre-surgical support Pulse oximetry
• Seizures stabilization) *Chest X-Ray
• Major congenital malformations (pre- • Cholestasis requiring investigations and in- *Arterial Blood Gas (ABG) analysis d) Sepsis /
surgical stabilization, not requiring hospital management pneumonia without complications
ventilation) • Congestive heart failure or shock *Chest X-ray
• Cholestasis significant enough requiring The above list is illustrative but not limited to *Septic screen e)
work up and in-hospital management these conditions. Hyperbilirubinemia requiring exchange transfusion
• Congestive heart failure or shock The package includes mandatory stay and food *Liver function test
Mother's stay and food in the hospital for of the mother in the hospital for breastfeeding, *Coomb`s test (Direct)
breastfeeding, family centred care and Kangaroo Mother Care (KMC) and Family *Complete blood count
(Kangaroo Mother Care) KMC is mandatory centered care *Blood grouping (mother and newborn)
and included in the package rate *Hearing assessment (BERA) – can be discharged
with documentation of BERA screening planned
before 3 months age with venue/date f)
Seizures
b) Indirect ophthalmoscopy examination b) Intra-procedure photograph(optional)
1154 Neo - natal Care MN Neo - natal Care MN012 ROP screening MN012A ROP screening 580 638 696 754 812 841
c) Planned line of treatment c) Detailed Procedure / operative notes
Outside State
Bed Cost Cost
Cost
Mild Respiratory Distress/tachypnea c) Detailed Procedure notes and indication (if
*Chest X-ray any)
*Hemoglobin d) Detailed discharge summary
Neonates between 1500-1799g OR Neonates
*Blood sugar
of any weight with mild illness like, but not limited
Special Neonatal Care Package: Babies that *Sepsis screen
to:
required admission to SNCU or NICU: *Blood culture c) Mild
• Mild Respiratory Distress/tachypnea
Babies admitted for short term care for encephalopathy
• Mild encephalopathy
conditions like: *Arterial Blood Gas (ABG)/Cord blood analysis
• Severe jaundice requiring intensive
• Mild Respiratory Distress/tachypnea *Blood sugar
phototherapy
• Mild encephalopathy *Serum Electrolytes
• Unwell baby requiring monitoring
• Severe jaundice requiring intensive *Serum Creatinine d)Severe
• Some dehydration
phototherapy jaundice requiring intensive phototherapy
1155 Neo - natal Care MN Neo - natal Care MN002 MN002A • Hypoglycaemia 4200 4620 5040 5460 5880 6090
• Haemorrhagic disease of newborn *Liver function test
The above list is illustrative but not limited to
• Unwell baby requiring monitoring *Coomb`s test (Direct)
these conditions.
• Some dehydration *Hemoglobin, reticulocyte count, peripheral smear
The required procedures may include radiant
• Hypoglycaemia for evidence of hemolysis
warmer care, gavage feeding, oxygen therapy,
Mother's stay and food in the hospital for *Blood grouping (mother and newborn)
IV fluid administration, blood transfusion.
breastfeeding, family centred care and e) Haemorrhagic disease of newborn
The package includes food and stay for the
(Kangaroo Mother Care) KMC is mandatory *Complete blood count
mother in the hospital for breastfeeding,
and included in the package rate *Coagulation profile – Prothrombin Time, Activated
Kangaroo Mother Care (KMC) and Family
*Partial Thromboplastin Time
centered care.
*Sepsis screen f)
Unwell baby requiring monitoring
*Blood sugar
*Serum Calcium
*Sepsis screen
Ventriculoperitoneal Shunt Surgery (VP) or Ventriculoperitoneal Shunt Surgery (VP) or
b) Clinical picture b) Post-procedure photograph (Optional)
1156 Neo - natal Care MN Neo - natal Care MN010 Omaya Reservoir or External Drainage for MN010A Omaya Reservoir or External Drainage for 20000 22000 24000 26000 28000 29000
c) Neurosonogram/CT Brain/MRI Brain c) Detailed Procedure / operative notes
Hydrocephalus Hydrocephalus
d) Planned line of treatment d) Detailed discharge summary
Laser Therapy for Retinopathy of Laser Therapy for Retinopathy of Prematurity
Neo - natal b) Indirect ophthalmoscopy examination b) Intra-procedure photograph(optional)
1157 Neo - natal Care MN MN008 Prematurity (Irrespective of no. of eyes MN008A (Irrespective of no. of eyes affected) 2000 2200 2400 2600 2800 2900
Care/opthalmology c) Planned line of treatment c) Detailed Procedure / operative notes
affected) - per session per session
a) Clinical notes with signs, symptoms, indications, a) Detailed Indoor case papers (ICPs)
planned line of management and advice for b) Detailed Procedure / operative notes
Craniotomy/Burr hole and Tapping of Brain
1158 Neurosurgery SN Neurosurgery SN011 Abscess Tapping SN011A 32865 36151 39438 42724 46011 47654 admission c) CT brain (Preop & Post op)
Abscess
b) Clinical Evaluation d) Histopathology examination
c) CECT/MRI brain e) Detailed discharge summary
indication of implant, and planned line of b) Detailed Procedure/ Operation notes
management c) Invoice/barcode of clips used
1159 Neurosurgery SN Neurosurgery SN023 Aneurysm Clipping including angiogram SN023A Aneurysm Clipping including DSA or CTA 90300 99330 108360 117390 126420 130935
b) CTA/ MRA/ DSA (Digital Subtraction d) Detailed discharge summary
Angiography) report of brain establishing need for
surgery
indication for procedure, and planned line of b) Detailed Procedure / operative notes
Craniotmy and excision of arteriovenous
1160 Neurosurgery SN Neurosurgery SN025 Arterio venous malformation (AVM) excision SN025A 90300 99330 108360 117390 126420 130935 management c) Detailed discharge summary
malformation
b) CT/MRI Brain/Spine
c) Angiography
1161 Neurosurgery SN Neurosurgery SN025 Arterio venous malformation (AVM) excision SN025C Excision of scalp arteriovenous malformation 45150 49665 54180 58695 63210 65467 management c) Detailed discharge summary
c) Angiography
Laminectomy/Laminotomy and excision of
1162 Neurosurgery SN Neurosurgery SN025 Arterio venous malformation (AVM) excision SN025B 90300 99330 108360 117390 126420 130935 management c) Detailed discharge summary
Intraspinal arteriovenous malformation
c) Angiography
a) Clinical notes. a) Post procedure Imaging with film (CT).
b) MRA. b) Post procedure Clinical photgraph
c) DSA report. showing Post procedure Clinical photgraph
showing scar.
1163 Neurosurgery SN Neurosurgery SN064 AVM EMBOLISATION SN064A AVM EMBOLISATION/THROMBECTOMY 229740 252714 275688 298662 321636 333123
c) Detailed discharge summary.
d) Detailed Procedure.
e) Operative Notes.

1164 Neurosurgery SN Neurosurgery SN045 Brachial Plexus – Repair SN045A Brachial Plexus repair 48090 52899 57708 62517 67326 69730 c) Electromyography (EMG) c) In case of accidents – FIR (optional)
d) Nerve conduction studies e) Planned d) Detailed discharge summary
line of treatment
a) Clinical notes. a) Histopathology.
b) CT. b) Post procedure Clinical photgraph
c) MRI. showing scar.
d) Suspected differential diagnosis. c) Detailed discharge summary.
1165 Neurosurgery SN Neurosurgery SN013 Brain Biopsy SN013A Brain Biopsy- Open/Stereotactic guided 22155 24370 26586 28801 31017 32124
e) Operative Notes.

b) Clinical Evaluation b) CT Brain
c) CT Scan/MRI brain c) Detailed Procedure / operative notes
Burr hole surgery for evacuation of hematoma/ d) Optional d) Detailed discharge summary
1166 Neurosurgery SN Neurosurgery SN008 Burr hole surgery SN008A biopsy/ pus drainage/Placement of ICP 14490 15939 17388 18837 20286 21010
Complete Blood Count
monitoring device C-reactive protein
X ray - skull
Outside State
Bed Cost Cost
Cost
b) Clinical Evaluation b) CT Brain
c) CT Scan/MRI brain c) Detailed Procedure / operative notes
Burr hole surgery with chronic Sub Dural d) Optional d) Detailed discharge summary
1167 Neurosurgery SN Neurosurgery SN008 Burr hole surgery SN008B 32865 36151 39438 42724 46011 47654
Haematoma Complete Blood Count
C-reactive protein
X ray - skull
a) Clinical notes with evaluation findings, indication a)Detailed Indoor case papers
of procedure, and planned line of treatment b) Detailed Procedure / operative notes
1168 Neurosurgery SN Neurosurgery SN030 Cervical Disc Multiple level without Fusion SN030A Anterior cervical discectomy without fusion 65625 72187 78750 85312 91875 95156 b) Clinical photograph c) Detailed discharge summary
c) X-ray / MRI Cervical spine

d) Any investigations done. d) All investigations reports.
Conservative management of high cervical e) Planned line of management.
1169 Neurosurgery SN Neurosurgery SN063 SN063C Conservatively managed Severe Head injury 2350 2585 2820 3055 3290 3407
injury f) Copy of MLC.
g) FIR (if required).
a) Clinical notes with planned line of treatment a) Detailed ICPs.

including planned line of treatment. b) Treatment details.
Conservative management of high cervical Conservatively managed spinal injury with
1170 Neurosurgery SN Neurosurgery SN063 SN063A 2350 2585 2820 3055 3290 3407 b) X-ray films with reports. c) Detailed discharge summary.
injury ventilator
d) All investigations reports.

1171 Neurosurgery SN Neurosurgery SN063 SN063B Moderate head injury 2350 2585 2820 3055 3290 3407

1172 Neurosurgery SN Neurosurgery SN063 SN063D Simple head injury 2350 2585 2820 3055 3290 3407

b) Clinical evaluation b)Detailed Procedure / operative notes
1173 Neurosurgery SN Neurosurgery SN048 Cranial Nerve Anastomosis SN048A Cranial nerve re-anastomosis/Repair (Facial/) 32865 36151 39438 42724 46011 47654 c) EMG (Electromyography) c) Detailed discharge summary
d) Nerve conduction study
indication of procedure, and planned line of b) Post Procedure X-ray with report of skull
1174 Neurosurgery SN Neurosurgery SN002 CranioPlasty SN002A Cranioplasty with autologus bone graft 36120 39732 43344 46956 50568 52374 treatment c) Detailed Procedure/ Operative notes
b. CT/ MRI report of skull d) Detailed discharge summary

indication of procedure, and planned line of b) Post Procedure X-ray with report of skull
treatment c) Detailed Procedure/ Operative notes
1175 Neurosurgery SN Neurosurgery SN002 CranioPlasty SN002B Cranioplasty with exogenous Graft 36120 39732 43344 46956 50568 52374
b) CT/ MRI report of skull d) Invoice/Barcode details of implant
c) Indication of implant requirement e) Detailed discharge summary

indication of procedure and planned line of b) Post Procedure X-ray with report of skull
Cranial vault remodeling/ surgery for
1176 Neurosurgery SN Neurosurgery SN004 Craniostenosis SN004A 49560 54516 59472 64428 69384 71862 management c) Detailed Procedure/ Operation notes
"Craniosynostosis"
b) CT/ MRI report of skull establishing need for d) Detailed discharge summary
surgery
Craniectomy/ DECRA for head injury/acute c) Examination findings. c) Detailed discharge summary.
1177 Neurosurgery SN Neurosurgery SN066 Decompressive Caniectomy SN066A 98490 108339 118188 128037 137886 142810
stroke/cerebral venous thrombosis d) Any investigations done. d) All investigations reports.

b) CT confirming diagnosis. b) Post procedure Clinical photgraph
showing scar.
1178 Neurosurgery SN Neurosurgery SN001 Depressed Skull Fracture SN001A Surgery for Depressed Skull fracture 52500 57750 63000 68250 73500 76125
e) Operative Notes.
a) Clinical notes. a) Post procedure Imaging with film (CT)

b) CT-angio. showing clips.
c) MRA. b) Post procedure Clinical photgraph
d) DSA. showing scar.
Diagnostic Cerebral / Spinal Angiography Diagnostic Cerebral / Spinal Angiography (DSA - c) Detailed discharge summary.
1179 Neurosurgery SN Neurosurgery SN061 SN061A 21840 24024 26208 28392 30576 31668 d) Detailed Procedure.
(DSA - Digital Substraction Angiography) Digital Substraction Angiography)
e) Operative Notes.
f) Invoice of all the clip(s) used.
a) Clinical notes. a) Intra procedure still photograph Post

b) MRI. procedure Clinical photgraph showing scar.
b) Detailed discharge summary.
c) Detailed Procedure.
1180 Neurosurgery SN Neurosurgery SN060 Discectomy - Dorsal SN060A Discectomy - Dorsal 44310 48741 53172 57603 62034 64249
d) Operative Notes.
Outside State
Bed Cost Cost
Cost
a) Clinical notes with signs, symptoms, indications, a) Detailed Indoor case papers
planned line of management and advice for b) Post-op CT CVJ (craniovertebral junction)
admission c) Implant details if applicable
Duroplasty with Endogenous graft- (May be b) Clinical photograph (optional) for associated (barcode/invoice)
1181 Neurosurgery SN Neurosurgery SN007 Duroplasty SN007A 16485 18133 19782 21430 23079 23903
perfomed as a add-on procedure) conditions d) Detailed Procedure / operative notes
c) MRI Brain and Spine e) Detailed discharge summary
d) Indication of implant requirement if applicable
a) Clinical notes with signs, symptoms, indications, a) Detailed Indoor case papers
planned line of management and advice for b) Post-op CT CVJ (craniovertebral junction)
admission c) Implant details if applicable
Duroplasty with Exogenous graft- (May be b) Clinical photograph (optional) for associated (barcode/invoice)
1182 Neurosurgery SN Neurosurgery SN007 Duroplasty SN007B perfomed as an add-on procedure) Cost of graft 16485 18133 19782 21430 23079 23903
conditions d) Detailed Procedure / operative notes
will be extra c) MRI Brain and Spine e) Detailed discharge summary
d) Indication of implant requirement if applicable
a) Clinical history. a) Detailed discharge summary.

b) CT. b) Detailed Procedure.
c) MRI. c) Operative Notes.
1183 Neurosurgery SN Neurosurgery SN057 Endoscopic Third Ventriculostomy SN057A Endoscopic Third ventriculostomy 48090 52899 57708 62517 67326 69730
d) Pre-op clinical photograph. d) Intra procedure clinical photograph.
admission c) Preop MRI & Postop MRI/CT
1184 Neurosurgery SN Neurosurgery SN012 Epilepsy Surgery SN012A Epilepsy Surgery 90300 99330 108360 117390 126420 130935 b) Clinical Evaluation d) Post op EEG
c) Electroencephalogram (EEG) e) Detailed discharge summary
d) Video EEG
e) CT/MRI brain
1185 Neurosurgery SN Neurosurgery SN010 Excision of Brain Abscess SN010A Excision of Brain abscess 65520 72072 78624 85176 91728 95004 admission c) CT brain (Preop & Post op)
b) Clinical Evaluation d) Histopathology examination
c) CECT/MRI brain e) Detailed discharge summary
b) CT. b) Post procedure Imaging with film (CT).
c) MRI. c) Post procedure Clinical photgraph showing
scar.
1186 Neurosurgery SN Neurosurgery SN015 Excision of Brain Tumor Supratentorial SN015D C P Angle 67725 74497 81270 88042 94815 98201 d) Detailed discharge summary. e)Detailed
Procedure.
f) Operative Notes.

scar.
1187 Neurosurgery SN Neurosurgery SN015 Excision of Brain Tumor Supratentorial SN015A Parasagital Tumours 67725 74497 81270 88042 94815 98201 d) Detailed discharge summary. e)Detailed
Procedure.
f) Operative Notes.

scar.
1188 Neurosurgery SN Neurosurgery SN015 Excision of Brain Tumor Supratentorial SN015B Skull Base Tumours 67725 74497 81270 88042 94815 98201 d) Detailed discharge summary. e)Detailed
Procedure.
f) Operative Notes.

scar.
1189 Neurosurgery SN Neurosurgery SN015 Excision of Brain Tumor Supratentorial SN015E Supratentorial & other Tumours 73920 81312 88704 96096 103488 107184 d) Detailed discharge summary. e)Detailed
Procedure.
f) Operative Notes.

scar.
1190 Neurosurgery SN Neurosurgery SN015 Excision of Brain Tumor Supratentorial SN015C Surgerey for infratentorial intra-axial tumours 67725 74497 81270 88042 94815 98201 d) Detailed discharge summary. e)Detailed
Procedure.
f) Operative Notes.

b) Clinical photograph b) Detailed Procedure / operative notes
1191 Neurosurgery SN Neurosurgery SN031 Excision of Cervical Ribs SN031A Excision of Cervical Ribs 37800 41580 45360 49140 52920 54810 c) Cervical X-ray c) Cervical/Chest X-ray
CT/MRI Chest and Cervical Spine d) Planned line d) Detailed discharge summary
of treatment
b) CT. b) Post procedure Clinical photgraph
c) MRI report. showing scar.
1192 Neurosurgery SN Neurosurgery SN014 Excision of Orbital Tumour SN014A Excision of Orbital Tumour 65625 72187 78750 85312 91875 95156 d) Detailed Procedure.
e) Operative Notes.
f) HPE report.
Outside State
Bed Cost Cost
Cost
External Ventricular Drainage (EVD) c) CT/MRI brain c) CT brain (Preop & Post op)
1193 Neurosurgery SN Neurosurgery SN020 SN020A External Ventricular Drainage (EVD) 44310 48741 53172 57603 62034 64249
including antibiotics d) Cerebrospinal Fluid (CSF) Analysis d) Histopathology examination
e) Coagulation Profile e) Detailed discharge summary
f) Planned line of treatment
planned line of management and advice for b) Post-operative photographs (optional)
Foramen magnum decompression for Chiari
admission c) Post-op CT CVJ (craniovertebral junction)
1194 Neurosurgery SN Neurosurgery SN026 Foramen Magnum Decompression SN026A malormation with or without duraplasty or 98490 108339 118188 128037 137886 142810
b) Clinical picture (optional) for associated d) Detailed Procedure / operative notes
tonsillar resection.
conditions c) MRI Brain and Spine e) Detailed discharge summary

Gamma Knife radiosurgery (GKRS) / SRS indication b) Histopathological report of muscle biopsy
Gamma Knife Radiosurgery for tumors/AVMs/
1195 Neurosurgery SN Neurosurgery SN054 for tumours / Arteriovenous malformation SN054A 98490 108339 118188 128037 137886 142810 of procedure and planned line of management c) Detailed Procedure/ Operative notes
Trigeminal Neuralgia
(AVM) b) Electromyography (EMG) report d) Detailed discharge summary

Microscopic/Endoscopic Lumbar Discectomy b) Clinical Evaluation b) Detailed Procedure / operative notes
1196 Neurosurgery SN Neurosurgery SN033 Lumbar Discectomy SN033A 44310 48741 53172 57603 62034 64249
(One level) c) MRI Lumbar spine c) Detailed discharge summary
Anterior cranial fossa admission b) Clinical c) Detailed discharge summary
1197 Neurosurgery SN Neurosurgery SN005 Meningocele SN005A 65520 72072 78624 85176 91728 95004
encephalocele/meningocele repair picture
c) Plain X-ray skull
CT/MRI Brain/Spine
Posterior cranial fossa admission b) Clinical c) Detailed discharge summary
1198 Neurosurgery SN Neurosurgery SN005 Meningocele SN005C 67725 74497 81270 88042 94815 98201
encephalocele/meningocele repair picture
CT/MRI Brain/Spine
admission b) Clinical c) Detailed discharge summary
1199 Neurosurgery SN Neurosurgery SN005 Meningocele SN005B Surgery for spina bifida cystica/occulta 49245 54169 59094 64018 68943 71405
picture
CT/MRI Brain/Spine
Anterior Cervical Discectomy with fusion (Cost of
1200 Neurosurgery SN Neurosurgery SN036 Micro discectomy SN036A 65625 72187 78750 85312 91875 95156 b) Clinical photograph c) Detailed discharge summary
implants to be extra)

b) Clinical Evaluation b) Histopathological examination
1201 Neurosurgery SN Neurosurgery SN051 Muscle Biopsy with report SN051A Muscle Biopsy 9870 10857 11844 12831 13818 14311
1202 Neurosurgery SN Neurosurgery SN050 Nerve Biopsy excluding Hensens SN050A Nerve Biopsy excluding Hansen's 9870 10857 11844 12831 13818 14311 c) Electromyography (EMG) c) In case of accidents – FIR (optional)
d) Nerve conduction studies e) Planned d) Detailed discharge summary
line of treatment
a) Clinical notes confirming the diagnosis a) Detailed Indoor Case Papers
b) Ultrasound imaging (USG) labelled with patient b) Detailed Procedure / Operative Notes
1203 Neurosurgery SN Neurosurgery SN047 Nerve Decompression SN047A Peripheral nerve repair/Neurolysis 22470 24717 26964 29211 31458 32581 ID, date and side (Left/ Right) of affected limb c) Detailed discharge summary
c) Nerve Conduction Velocity (NCV)
a) Clinical notes including clinical evaluation, a) Detailed Indoor case papers

indication of procedure, and planned line of b) Detailed Procedure / operative notes
1204 Neurosurgery SN Neurosurgery SN035 Neurectomy SN035A Peripheral Neurectomy 26250 28875 31500 34125 36750 38062
management c) Detailed discharge summary
b) MRI Brain / MRI Angiography
1205 Neurosurgery SN Neurosurgery SN049 Peripheral Nerve Surgery SN049B Peripheral nerve tumor excision and repair 44310 48741 53172 57603 62034 64249 ID, date and side (Left/ Right) of affected limb c) Detailed discharge summary
Posterior cervical laminoforaminotomy and
1206 Neurosurgery SN Neurosurgery SN028 Posterior Cervical Discetomy without implant SN028A 44310 48741 53172 57603 62034 64249 b) Clinical photograph c) Detailed discharge summary
discectomy
Posterior Cervical Fusion with implant Posterior cervical fusion using lateral mass or b) Clinical photograph c) Detailed discharge summary d) Implant
1207 Neurosurgery SN Neurosurgery SN029 SN029A 68985 75883 82782 89680 96579 100028
(Lateral mass fixation) pedicle screws and rods c) X-ray / MRI Cervical spine d) Indication details (invoice/barcode)
of implant requirement
a) Clinical notes establishing diagnosis . a) Intra procedure clinical CD.

b) Justification of local neurectomy with MRI. b) Series of still photographs.
c) CT. c) Detailed Procedure.
d) Operative Notes.
1208 Neurosurgery SN Neurosurgery SN059 R. F. Lesioning SN059B Radiofrequency lesioning for chronic back pain 10710 11781 12852 13923 14994 15529
f) Invoice of RF probe.
a) Clinical notes establishing diagnosis of a) Intra procedure clinical CD.

sacroilitis. b) Series of still photographs.
b) Justification of local neurectomy with MRI. c) Detailed Procedure.
c) CT. d) Operative Notes.
1209 Neurosurgery SN Neurosurgery SN059 R. F. Lesioning SN059A Radiofrequency lesioning for sacroilitis 10710 11781 12852 13923 14994 15529
f) Invoice of RF probe.

1210 Neurosurgery SN Neurosurgery SN044 R. F. Lesioning for Trigeminal Neuralgia SN044A R. F. Lesioning for Trigeminal Neuralgia 26250 28875 31500 34125 36750 38062
Outside State
Bed Cost Cost
Cost
b) EEG. b) Post procedure Clinical photgraph
c) Neurologist report. showing Post procedure Clinical photgraph
d) CT. showing scar.
1211 Neurosurgery SN Neurosurgery SN062 Reexploration for Cranial / Spinal surgeries SN062A Reexploration for Cranial / Spinal surgeries 32865 36151 39438 42724 46011 47654
e) MRI. c) Detailed discharge summary.
e) Operative Notes.
a) Clinical Notes including evaluation findings and a) Detailed Indoor Case Papers
Theco - peritoneal Shunt (Low/Medium/High
1212 Neurosurgery SN Neurosurgery SN022 Shunt Surgery SN022D 44310 48741 53172 57603 62034 64249 planned line of treatment b) Detailed Procedure/ Operative notes
Pressure or Flow regulated valve)
b) CT/ MRI report of brain c) Detailed discharge summary
Ventriculo - atrial Shunt (Low/Medium/High
1213 Neurosurgery SN Neurosurgery SN022 Shunt Surgery SN022C 44310 48741 53172 57603 62034 64249 planned line of treatment b) Detailed Procedure/ Operative notes
Ventriculo - pleural Shunt (Low/Medium/High
1214 Neurosurgery SN Neurosurgery SN022 Shunt Surgery SN022B 44310 48741 53172 57603 62034 64249 planned line of treatment b) Detailed Procedure/ Operative notes
Ventriculo-Peritoneal Shunt (Low/Medium/High
1215 Neurosurgery SN Neurosurgery SN022 Shunt Surgery SN022A 44310 48741 53172 57603 62034 64249 planned line of treatment b) Detailed Procedure/ Operative notes
b) Clinical evaluation b) Post-procedure photograph (optional)
c) Cervical X-ray/CT/MRI c) Lateral C-spine X-rays within 6 hours after
d) Planned line of treatment application of traction
1216 Neurosurgery SN Neurosurgery SN027 Skull Traction SN027A Skull Traction 13125 14437 15750 17062 18375 19031
d) In case of accident was FIR done
(optional)
e) Detailed Procedure / operative notes
of procedure, and planned line of management b) Detailed Procedure / operative notes
1217 Neurosurgery SN Neurosurgery SN039 Spine - Extradural Haematoma SN039A Intraspinal Extradural hematoma evacuation 44310 48741 53172 57603 62034 64249
b) CT/MRI Spine c) Post-op X-ray Spine
a) Clinical notes including evaluation findings a) Detailed Indoor case papers
b) Based on Etiology b) Detailed Procedure / operative notes
*CT/ MRI Brain/Spine *Positron c) Post-op CT Spine
emission tomography (PET) scan d) Histopathological/Biopsy report
1218 Neurosurgery SN Neurosurgery SN041 Spine - Extradural Tumour SN041A Excision of extradural spinal tumor 56700 62370 68040 73710 79380 82215 *Chest X-ray *
Mammography * Ultrasound of
abdomen *Bone scan
*CT/MRI of other regions if symptomatic
c) Planned line of treatment
b) Based on Etiology b) Detailed Procedure / operative notes
*CT/ MRI Brain/Spine *Positron c) Post-op CT Spine
emission tomography (PET) scan d) Implant details (barcode/invoice)
Excision of extradural spinal tumor with fusion *Chest X-ray * e) Histopathological/Biopsy report
1219 Neurosurgery SN Neurosurgery SN041 Spine - Extradural Tumour SN041B 56700 62370 68040 73710 79380 82215 Mammography * Ultrasound of
and fixation (Cost of implants to be extra)
abdomen *Bone scan
*CT/MRI of other regions if symptomatic
c) Planned line of treatment d) Indication of
implant requirement
b) CT/ MRI Spine c) b) Detailed Procedure / operative notes
1220 Neurosurgery SN Neurosurgery SN042 Spine - Intradural Tumour SN042A Excision of Intradural extramedullary tumor 65625 72187 78750 85312 91875 95156 Planned line of treatment c) Post-op CT Spine
d) Histopathological/Biopsy report
Excision of Intradural extramedullary tumor with Indication of implant requirement c) Post-op CT Spine
1221 Neurosurgery SN Neurosurgery SN042 Spine - Intradural Tumour SN042B 71400 78540 85680 92820 99960 103530
fusion and ficxation (Cost of implants to be extra) d) Planned line of treatment d) Implant details (barcode/invoice)
e) Histopathological/Biopsy report
Planned line of treatment Optional c) Post-op CT Spine
*PET scan *Chest X- d) Histopathological/Biopsy report
1222 Neurosurgery SN Neurosurgery SN043 Spine - Intramedullar Tumour SN043A Excision of Intramedullary tumor of spine 67725 74497 81270 88042 94815 98201 ray *Bone scan e) Detailed discharge summary
*Mammography *Ultrasound of
abdomen *CT/MRI of other regions if
symptomatic

Excision of Intramedullary tumor with fusion and Indication of implant requirement c) Post-op CT Spine
1223 Neurosurgery SN Neurosurgery SN043 Spine - Intramedullar Tumour SN043B 67725 74497 81270 88042 94815 98201
ficxation (Cost of implants to be extra) d) Planned line of treatment d) Implant details (barcode/invoice)
e) Histopathological/Biopsy report
1224 Neurosurgery SN Neurosurgery SN016 Stereotactic Lesioning SN016A Stereotactic Lesioning for movement disoders 98490 108339 118188 128037 137886 142810
indication of procedure and planned line of b) Detailed Procedure/ Operation notes
Superficial Temporal Artery (STA): middle Superficial Temporal Artery (STA): middle
1225 Neurosurgery SN Neurosurgery SN024 cerebral artery (MCA) or (other EC - IC) SN024A cerebral artery (MCA) or (other EC - IC) Bypass 88620 97482 106344 115206 124068 128499
b) MRA/Digital Subtraction Angiography (DSA)
Bypass procedure procedure
report
of brain establishing need for surgery
a) Clinical notes including evaluation findings, and a) Detailed Indoor case papers
planned line of management b) Detailed Procedure / operative notes
b) Glasgow coma score (GCS) c) Glasgow coma score (GCS)/ Pediatric
Evacuation of Post-trauamtic Intraparenchymal c) Blood pressure monitoring GCS documentation
1226 Neurosurgery SN Neurosurgery SN009 Surgery for Haematoma - Intracranial SN009A 73920 81312 88704 96096 103488 107184
Hematoma d) Fundus examination d) Detailed discharge summary
e) Coagulation profile
f) CT/MRI Brain
Outside State
Bed Cost Cost
Cost
b) Pediatric GCS (<2 years/>2 years) c) Glasgow coma score (GCS)/ Pediatric
Evacuation of Post-trauamtic Intraparenchymal c) Blood pressure monitoring GCS documentation
1227 Neurosurgery SN Neurosurgery SN009 Surgery for Haematoma - Intracranial SN009C 67725 74497 81270 88042 94815 98201
Hematoma in Pediatric Age group d) Fundus examination d) Detailed discharge summary
f) CT/MRI Brain
b) Glasgow coma score (GCS) c) Glasgow coma score (GCS)/ Pediatric
Spontaneous Intraparenchymal hematoma c) Blood pressure monitoring GCS documentation
1228 Neurosurgery SN Neurosurgery SN009 Surgery for Haematoma - Intracranial SN009B 67725 74497 81270 88042 94815 98201
evacuation d) Fundus examination d) Detailed discharge summary
f) CT/MRI Brain
b) CT/ MRI Brain c) b) Detailed Procedure / operative notes
Surgery for infratentorial Planned line of treatment c) Post-op CT Brain
1229 Neurosurgery SN Neurosurgery SN006 Surgery for tumour meninges SN006B 67725 74497 81270 88042 94815 98201
ExtraaxialTumour(meningioma etc) Yes
d) Histopathological Examination report
b) CT/ MRI Brain c) b) Detailed Procedure / operative notes
Surgery for supratentorial Extra-axial Tumours Planned line of treatment c) Post-op CT Brain
1230 Neurosurgery SN Neurosurgery SN006 Surgery for tumour meninges SN006A 67725 74497 81270 88042 94815 98201
(Meningioma etc) Yes
d) Histopathological Examination report
planned line of management and advice for b) Preop and post op CT-CVJ
admission c) Detailed Procedure / operative notes
1231 Neurosurgery SN Neurosurgery SN018 Trans oral Surgery SN018A Trans oral Surgery 71400 78540 85680 92820 99960 103530
b) Clinical Evaluation d) Detailed discharge summary
c) CT/ MRI CVJ/ cervical spine - X ray
b) MRI supporting surgery. b) Post procedure Imaging with film (MRI).
c) Detailed Procedure.
Endoscpic/Microscopic Trans Sphenoidal d) Operative Notes.
1232 Neurosurgery SN Neurosurgery SN017 Trans Sphenoidal Surgery SN017A 67725 74497 81270 88042 94815 98201
Surgery e) Detailed discharge summary.
a) Clinical notes including indication of implant a) Detailed Indoor case papers

requirement, evaluation findings confirming the b) Post op CT-CVJ (Craniovertebral junction)
Transoral surgery (Anterior) and CV Junction Trans oral anterior decompression and Posterior diagnosis report
1233 Neurosurgery SN Neurosurgery SN019 SN019A 97650 107415 117180 126945 136710 141592
(Posterior Sterilisation) stabilisation ov C V junction b) CT + MRI CVJ (Craniovertebral junction) + c) Detailed Procedure / operative notes
cervical spine - X ray d) Implant details (barcode/invoice)
c) Planned line of treatment e) Detailed discharge summary
planned line of management and advice for b) CT Brain
1234 Neurosurgery SN Neurosurgery SN003 Twist Drill Craniostomy SN003A Twist Drill Craniostomy 19740 21714 23688 25662 27636 28623 admission c) Detailed Procedure / operative notes
b) Clinical Evaluation e) Detailed discharge summary
c) CT/MRI Brain
c) CT/MRI brain c) CT brain (Preop & Post op)
1235 Neurosurgery SN Neurosurgery SN021 Ventricular Puncture SN021A Ventricular Tap 19740 21714 23688 25662 27636 28623
d) Cerebrospinal Fluid (CSF) Analysis d) Histopathology examination
e) Coagulation Profile e) Detailed discharge summary
f) Planned line of treatment
a) Clinical note. a) Analysis.
b) CT. b) C/S of pus.
c) Fluid removed.
d) Post procedure Imaging with film (CT).
Ventricular tapping with Omayya e) Post procedure Clinical photgraph
1236 Neurosurgery SN Neurosurgery SN065 Ventricular tap SN065A 26250 28875 31500 34125 36750 38062 showing scar.
reservoir/external ventricular drain
f) Detailed discharge summary.
g) Detailed Procedure.
h) Operative Notes.

Neurosurgery, ENT, Oral & indication of procedure, and planned line of b) Detailed Procedure / operative notes
1237 Neurosurgery SN SN035 Neurectomy SN035B Trigeminal Nerve Neurectomy 32655 35920 39186 42451 45717 47349
Maxillofacial Surgery management c) Detailed discharge summary
1238 Neurosurgery SN Neurosurgery, Orthopedics SN046 Carpal Tunnel Release SN046A Carpal tunnel release 19740 21714 23688 25662 27636 28623 ID, date and side (Left/ Right) of affected limb c) Detailed discharge summary
a) Clinical notes. a) Post procedure X-ray showing fixation &

b) MRI establishing need of surgery. fusion.
b) Post procedure Clinical photgraph
Laminectomy with fusion and fixation for showing scar.
lumbar/cervical/thoracic canal stenosis or for c) Detailed discharge summary Detailed
1239 Neurosurgery SN Neurosurgery, Orthopedics SN034 Laminectomy SN034B 71400 78540 85680 92820 99960 103530
tumor / trauma/Bleed(Cost of implants to be Procedure.
extra) d) Operative Notes.
a) Clinical notes. a) Post procedure X-ray showing fixation &

b) MRI establishing need of surgery. fusion.
b) Post procedure Clinical photgraph
showing scar.
Laminectomy without fusion for lumbar or c) Detailed discharge summary Detailed
1240 Neurosurgery SN Neurosurgery, Orthopedics SN034 Laminectomy SN034A 65625 72187 78750 85312 91875 95156
cervical canal stenosis Procedure.
d) Operative Notes.
Outside State
Bed Cost Cost
Cost
planned line of management and advice for c) Post procedure Imaging with film (X ray)
Cervical/Thoracic/ Lumbar corpectomy with admission showing the implants
1241 Neurosurgery SN Neurosurgery, Orthopedics SN032 Thoracic / Lumbar Corpectomy with fusion SN032A 98490 108339 118188 128037 137886 142810
fusion for Tumor/Infection/Trauma b) MRI labelled with patient ID, date and side (Left/ d) Post procedure Clinical photograph
Right) - affected part showing scar
e) Invoice/barcode of implant
f) Discharge Summary
a)Clinical notes establishing indication. a)Detailed Operative notes.
b)USG Abdomen Pelvis. b)HPE.
c) MRI abdomen. Pap smear. c) Pic of specimen removed- Gross and
1242 Obstetrics & Gynecology SO OBG & Gynec SO006 Abdominal Myomectomy SO006A Abdominal Myomectomy 26250 28875 31500 34125 36750 38062
Histopathology.
d)Detailed discharge summary
a) Detailed Clinical notes with history, indications, a) Detailed indoor case papers
symptoms, signs, examination findings and advice b) Investigation reports (If done)
Abdomino Perineal repair for Mullerian for admission c) Detailed procedure/operative notes
1243 Obstetrics & Gynecology SO OBG & Gynec SO037 SO037A Abdomino Perineal repair for Mullerian Anomaly 36435 40078 43722 47365 51009 52830
Anomaly b) USG Transvaginal/Trans abdominal (TVS/TAS) d) Detailed Discharge Summary
a) Detailed clinical notes with history, indications, a) Detailed Indoor Case Papers (ICPs) with
symptoms, signs, examination findings and advice details of indication
for admission b) Detailed procedure notes
b) Report of biochemical tests c) Claim processing submission with amniotic
1244 Obstetrics & Gynecology SO OBG & Gynec SO047 Amniocentesis SO047A Amniocentesis 14500 15950 17400 18850 20300 21025
c) Nuchal translucency (NT) and/or Early TIFFA fluid report (usually within 2 weeks)
(Targeted imaging for fetal anomalies) scan d) Detailed Discharge Summary
reports
symptoms, signs, examination findings and advice b) Detailed operative/procedure notes
for admission c) Detailed Discharge Summary
1245 Obstetrics & Gynecology SO OBG & Gynec SO030 Anterior & Posterior Colpoperineorrhapy SO030A Anterior & Posterior Colpoperineorrhapy 11865 13051 14238 15424 16611 17204
b) USG abdomen/pelvis d) Blood transfusion notes (if blood
c) Pap smear transfusion was given)
a)Admission Notes comprising of history. a)Procedure.
b) Examination with indications for the procedure. b)Operative Notes.
c) Relavant Investigations (establishing diagnosis). c) Intraop. Stills.
Biopsy- Cervical, Endometrial EA/ ECC; Biopsy- Cervical, Endometrial EA/ ECC; Vulvar; d)USG showing polyp. d)Pic of specimen.
1246 Obstetrics & Gynecology SO OBG & Gynec SO073 SO073A 5250 5775 6300 6825 7350 7612
Vulvar; Polypectomy Polypectomy e) Histopathology report.
f) Detailed Discharge Summary.
a) Detailed Clinical notes with history, indications, a) Detailed Indoor Case Papers
symptoms, signs, evaluation findings, planned line b) Investigation reports (if required)
1247 Obstetrics & Gynecology SO OBG & Gynec SO043 Burch SO043A Abdominal 30000 33000 36000 39000 42000 43500 of management, and advice for admission c) Detailed procedure/operative notes
b) Clinical diagnosis d) Detailed Discharge Summary
1248 Obstetrics & Gynecology SO OBG & Gynec SO043 Burch SO043B Laparoscopic 30000 33000 36000 39000 42000 43500 of management, and advice for admission c) Detailed procedure/operative notes
a) Admission Notes comprising of history. a) Detailed Procedure.

b) examination with detailed Ante natal care b) Operative Notes.
records. c) status of the child at the time of delivery
c) reasons for non-availability of ANC records. and at the time of discharge.
1249 Obstetrics & Gynecology SO OBG & Gynec SO057 Caesarean Delivery SO057A Caesarean Delivery 15000 16500 18000 19500 21000 21750 Indications for the procedure. USG Obstetrics with d) progress notes.
Doppler is case specific & optional. Labor charting, e) Detailed discharge summary.
CTG if available.
a. Clinical notes clearly indicating reason(s) for a. Detailed Operative notes

being a life-saving procedure and performing b. Discharge summary with follow up advise
caesarean hysterectomy c. Delivery note (including birth outcomes)
b. Lab investigations (Complete Blood count, d. Pictures of specimen removed (Gross)
Blood sugar- fasting and post prandial, Renal e. Histopathology report of the specimen
1250 Obstetrics & Gynecology SO OBG & Gynec SO011 Caesarean hysterectomy SO011A Caesarean hysterectomy 21000 23100 25200 27300 29400 30450 function test, liver function test, Urine- routine and removed
microscopy)
c. Ultrasonography (USG) Abdomen (Pregnancy
USG report / scan) d) Pap smear report
symptoms, signs, examination findings and advice b) Detailed procedure/operative notes
for admission b) Planned line c) Nuchal translucency (NT) and Early TIFFA
1251 Obstetrics & Gynecology SO OBG & Gynec SO048 Chorionic villus sampling SO048A Chorionic villus sampling 14500 15950 17400 18850 20300 21025
of treatment (Targeted imaging for fetal anomalies) scan
reports
a) Detailed clinical notes including history a) Detailed Indoor Case Papers
symptoms, signs, examination findings, planned b) Investigation reports (If required)
1252 Obstetrics & Gynecology SO OBG & Gynec SO038 Colpotomy SO038A Colpotomy 5145 5659 6174 6688 7203 7460 line of treatment, and admission advice c) Detailed operative/ procedure notes
b) Complete blood count (CBC) d) Detailed Discharge Summary
c) USG abdomen/pelvis
b) examination with indications for the procedure. b) Operative Notes.
c) need of procedure. c) Intraop. Stills.
1253 Obstetrics & Gynecology SO OBG & Gynec SO068 Complete Perineal Tear SO068A Complete Perineal Tear 26250 28875 31500 34125 36750 38062 d) Progress notes.
Clinical notes with supporting investigations a) Picture of specimen

b) Histopathology report
1254 Obstetrics & Gynecology SO OBG & Gynec SO072 Cone biopsy SO072A Cone biopsy 7350 8085 8820 9555 10290 10657
c) Discharge summary
symptoms, signs, examination findings and advice b) Detailed procedure/operative notes
for admission c) Nuchal translucency (NT) and Early TIFFA
1255 Obstetrics & Gynecology SO OBG & Gynec SO049 Cordocentesis SO049A Cordocentesis 14500 15950 17400 18850 20300 21025
b) Planned line of treatment (Targeted imaging for fetal anomalies) scan
reports
Outside State
Bed Cost Cost
Cost
symptoms, signs, examination findings and advice b) Investigation reports if done
for admission c) Detailed procedure/operative notes
1256 Obstetrics & Gynecology SO OBG & Gynec SO041 Cystectomy SO041A Lap 21000 23100 25200 27300 29400 30450
b) USG Abdomen/pelvis d) Histopathological Examination
c) CA 125 Tumor marker d) e) Detailed Discharge Summary
1257 Obstetrics & Gynecology SO OBG & Gynec SO062 Cystectomy SO062A Open 21000 23100 25200 27300 29400 30450
Histopathology.
symptoms, signs, examination findings and advice b) Detailed operative/procedure notes
for admission c) Detailed Discharge Summary
1258 Obstetrics & Gynecology SO OBG & Gynec SO042 Cystocele - Anterior repair SO042A Cystocele - Anterior repair 8400 9240 10080 10920 11760 12180
b) USG abdomen/pelvis d) Blood transfusion notes (if blood
c) Pap smear transfusion was given)
b) examination with indications for the b) Operative Notes.
procedure,Relavant Investigations (establishing c) Intraop. Stills.
diagnosis). d) Histopathology of curetted material.
1259 Obstetrics & Gynecology SO OBG & Gynec SO018 D&C (Dilatation&curretage) SO018A D&C (Dilatation&curretage) 5250 5775 6300 6825 7350 7612
c) (USG Abdomen + Pelvis)- optional. e) Progress notes.

b) Examination. b) Operative Notes together with indication of
c) Relavant Investigations surgery.
(establishing diagnosis). c) Intraop. stills with date & patient ID.
d) pic off gross specimen removed .
1260 Obstetrics & Gynecology SO OBG & Gynec SO039 Diagnostic laparoscopy SO039A Diagnostic laparoscopy 12600 13860 15120 16380 17640 18270 e) HPE.
f) Progress notes.
g) detailed discharge summary.

b) examination with indications for the procedure. b) Operative Notes together with indication of
c) Relavant Investigations (establishing diagnosis). surgery.
d) USG uterus & adnexa . c) Intraop. stills with date & patient ID.
Diagnostic Hystero - Laparoscopy with/ Diagnostic Hystero - Laparoscopy with/ without d) pic off gross specimen removed .
1261 Obstetrics & Gynecology SO OBG & Gynec SO066 SO066A 15750 17325 18900 20475 22050 22837 e) HPE of biopsy specimen,Progress notes.
without Chromopertubation Chromopertubation
a) Detailed clinical notes with history, symptoms, a) Detailed Indoor Case Papers
signs, examination findings, indications, and advice b) Diagnostic hysteroscopy
for admission c) Histopathology report
1262 Obstetrics & Gynecology SO OBG & Gynec SO016 Diagnostic hysteroscopy SO016A With biopsy 8400 9240 10080 10920 11760 12180
b) Hemoglobin, Complete blood count d) Photograph of removed IUCD
c) Urine complete examination (CUE) e) Detailed operative/ procedure notes
d) USG abdomen/pelvis f) Detailed Discharge Summary
signs, examination findings, indications, and advice b) Diagnostic hysteroscopy
for admission c) Detailed operative/ procedure notes
1263 Obstetrics & Gynecology SO OBG & Gynec SO016 Diagnostic hysteroscopy SO016B Without biopsy 8400 9240 10080 10920 11760 12180
b) Hemoglobin, Complete blood count d) Detailed Discharge Summary
c) Urine complete examination (CUE)
d) USG abdomen/pelvis
signs, examination findings, indications, and advice b) Detailed operative/ procedure notes
for admission c) Investigation reports (if required)
b) Ultrasound report for establishing the diagnosis d) however in certain conditions such as
1264 Obstetrics & Gynecology SO OBG & Gynec SO019 Dilation and Evacuation (D&E) SO019A Dilation and Evacuation (D&E) 5250 5775 6300 6825 7350 7612
c) Rh ABO blood grouping molar pregnancy or any other suspected
d) Complete blood count pathology it should be available
e) Serum HCG levels (for hydatidiform mole) e) Detailed Discharge Summary
a) Detailed clinical notes with history, symptoms, a) Detailed clinical notes

signs, examination findings, indications, and advice b) Investigation reports
1265 Obstetrics & Gynecology SO OBG & Gynec SO044 Electro Cauterisation / Cryo Surgery SO044A Electro Cauterisation / Cryo Surgery 5985 6583 7182 7780 8379 8678
b) Patient is in post-menstrual phase d) Post procedure instructions
c) Pap smear – mandatory or Colposcopy
(optional) findings, if available
symptoms, signs, examination findings and advice Yes
for admission b) Detailed procedure/operative notes
EUA for (minor girls / unmarried sexually EUA for (minor girls / unmarried sexually inactive b) Vaginal examination c) Medicolegal case documentation (in cases
inactive / victims of sexual abuse) / victims of sexual abuse) c) Vaginal swab (in cases of sexual assault) of sexual assault)
d) Informed consent from parents/adult patient d) Detailed Discharge Summary
symptoms, signs, examination findings and advice b) Investigation reports (if done)
1267 Obstetrics & Gynecology SO OBG & Gynec SO028 Excision of Vaginal Septum (vaginal route) SO028A Excision of Vaginal Septum (vaginal route) 25935 28528 31122 33715 36309 37605
b) Clinical Examination d) Detailed Discharge Summary
c) Pelvic/Abdominal USG / MRI
a) Admission Notes comprising of history. a) Detailed delivery notes.
b) detailed Ante natal care records. b) PNC notes along with relevant
c) reasons for non-availability of ANC records. investigation details.
Obstetric USG. All high risk deliveries are to be c) status of the child at the time of delivery
Major Fetal malformation requiring intervention clubbed & case specific documents required. and at the time of discharge.
1268 Obstetrics & Gynecology SO OBG & Gynec SO054 High risk delivery SO054C 15750 17325 18900 20475 22050 22837
immediately after birth d) progress notes.
Outside State
Bed Cost Cost
Cost
Mothers with eclampsia / imminent eclampsia / clubbed & case specific documents required. and at the time of discharge.
1269 Obstetrics & Gynecology SO OBG & Gynec SO054 High risk delivery SO054B 15750 17325 18900 20475 22050 22837
severe pre-eclampsia d) progress notes.

1270 Obstetrics & Gynecology SO OBG & Gynec SO054 High risk delivery SO054D Mothers with severe anaemia (<7 g/dL) 11500 12650 13800 14950 16100 16675 clubbed & case specific documents required. and at the time of discharge.
d) progress notes.

b) detailed Ante natal care records with special b) PNC notes along with relevant
reference to investigations supporting the investigation details.
Other maternal and fetal conditions as per diagnosis. c) status of the child at the time of delivery
guidelines-eg previous caesarean section, c) reasons for non-availability of ANC records. and at the time of discharge.
1271 Obstetrics & Gynecology SO OBG & Gynec SO054 High risk delivery SO054E 11500 12650 13800 14950 16100 16675
diabetes, severe growth retardation, etc that Obstetric USG. All high risk deliveries are to be d) progress notes.
qualify for high risk delivery. clubbed & case specific documents required. e) Detailed discharge summary.
signs, examination findings, planned line for b) Investigation reports (if done)
management, and advice for admission c) Detailed operative/procedure notes, (if
b) Blood pressure documentation applicable)
1272 Obstetrics & Gynecology SO OBG & Gynec SO046 Hospitalisation for Antenatal Complications SO046A Hospitalisation for Antenatal Complications 2200 2420 2640 2860 3080 3190 c) Complete Blood Count d) Blood transfusion notes, if given
d) Urine routine and microscopic examination e) Detailed Discharge Summary
e) Blood glucose
f) USG Abdomen/pelvis g) Oral Glucose
Tolerance Test (OGTT)
symptoms, signs, examination findings and advice b) Investigation reports
1273 Obstetrics & Gynecology SO OBG & Gynec SO029 Hymenectomy for imperforate hymen SO029A Hymenectomy for imperforate hymen 3570 3927 4284 4641 4998 5176
b) USG pelvis d) Detailed Discharge Summary
a) Clinical notes clearly indicating reason(s) for a. Indoor case papers
hysterectomy including medical management tried b. Detailed Operative notes
for at least 4-6 months, of which at least 2-3 c. Discharge summary with follow up advise
months (i.e. 2-3 cycles) should be of hormone d. Picture(s) of specimen removed (Gross)
therapy and it failed, or it was not indicated, with e. Histopathology report of the specimen
reason thereof b) Lab investigations removed
(Complete Blood count, Blood sugar- fasting and
post prandial, Renal function test, liver function
test, Urine- routine and microscopy)
c)Electrocardiogram d) X-ray chest
1274 Obstetrics & Gynecology SO OBG & Gynec SO010 Hysterectomy SO010A Abdominal Hysterectomy 21000 23100 25200 27300 29400 30450 e)Ultrasonography (USG) Abdomen + Pelvis
f )Pap smear & Cervical biopsy (Both these
investigations are essential only in those
hysterectomy cases which are getting operated
due to benign conditions of Cervix)
g) Documentary evidence of appropriate
counselling given to the patient and informed
consent form signed by the patient in all cases of
hysterectomy especially when performing removal
of ovaries (oophorectomy- U/L or B/L)

reason thereof b) Lab investigations removed f)Intra-operative stills (in
(Complete Blood count, Blood sugar- fasting and cases of laparoscopy)
Abdominal Hysterectomy + Salpingo- e)Ultrasonography (USG) Abdomen + Pelvis
1275 Obstetrics & Gynecology SO OBG & Gynec SO010 Hysterectomy SO010B 21000 23100 25200 27300 29400 30450
oophorectomy f )Pap smear & Cervical biopsy (Both these
Outside State
Bed Cost Cost
Cost
1276 Obstetrics & Gynecology SO OBG & Gynec SO010 Hysterectomy SO010E Laparoscopic hysterectomy (TLH) 21000 23100 25200 27300 29400 30450 e)Ultrasonography (USG) Abdomen + Pelvis

Laparoscopically assisted vaginal hysterectomy e)Ultrasonography (USG) Abdomen + Pelvis
1277 Obstetrics & Gynecology SO OBG & Gynec SO010 Hysterectomy SO010F 21000 23100 25200 27300 29400 30450
(LAVH) f )Pap smear & Cervical biopsy (Both these

1278 Obstetrics & Gynecology SO OBG & Gynec SO010 Hysterectomy SO010C Non descent vaginal hysterectomy 21000 23100 25200 27300 29400 30450 e)Ultrasonography (USG) Abdomen + Pelvis

Vaginal hysterectomy with anterior and posterior e)Ultrasonography (USG) Abdomen + Pelvis
1279 Obstetrics & Gynecology SO OBG & Gynec SO010 Hysterectomy SO010D 21000 23100 25200 27300 29400 30450
colpoperineorrhaphy f )Pap smear & Cervical biopsy (Both these
symptoms, signs, examination findings and advice b) Investigation reports (If done)
1280 Obstetrics & Gynecology SO OBG & Gynec SO022 Hysteroscopic adhesiolysis SO022A Hysteroscopic adhesiolysis 8400 9240 10080 10920 11760 12180 for admission c) Detailed operative/procedure notes
b) USG Pelvis/Abdomen c) Planned d) Detailed Discharge Summary
line of treatment
signs, examination findings, indications, and advice b) Photograph of removed IUCD
1281 Obstetrics & Gynecology SO OBG & Gynec SO017 Hysteroscopic IUCD removal SO017A Hysteroscopic IUCD removal 5250 5775 6300 6825 7350 7612
b) Hemoglobin, Complete blood count d) Detailed Discharge Summary
c) Urine complete examination (CUE)
d) USG abdomen/pelvis
Outside State
Bed Cost Cost
Cost
a)physical examination findings with indications for a)Detailed Operative notes.
the procedure. USG pelvis b) HPE.
1282 Obstetrics & Gynecology SO OBG & Gynec SO007 Hysteroscopic Myomectomy SO007A Hysteroscopic Myomectomy 12600 13860 15120 16380 17640 18270 b) MRI Pelvis c) Intraop stills with date & patient ID.
a)Admission Notes comprising of history. a)Detailed Procedure.

b) Examination with indications for the procedure. b)Operative Notes together with indication of
1283 Obstetrics & Gynecology SO OBG & Gynec SO009 Hysteroscopic polypectomy SO009A Hysteroscopic polypectomy 11025 12127 13230 14332 15435 15986 d)USG showing polyp. c)Intraop. stills with date & patient ID.
d)Pic off specimenremoved.HPE.
e)Progress notes.
f)detailed discharge summary.
signs, examination findings and advice for b) Documentation of indication of surgery
admission c) Detailed operative/procedure notes
1284 Obstetrics & Gynecology SO OBG & Gynec SO014 Hysterotomy SO014A Hysterotomy 6720 7392 8064 8736 9408 9744 b) History and clinical presentation confirming the d) Histopathological Examination
diagnosis e) Blood transfusion notes (if blood
c) Planned line of treatment transfusion was given)
f) Detailed Discharge Summary
signs, examination findings, indication for b) Detailed Procedure / operative notes
procedure, planned line for treatment and advice c) Fetal blood sampling/cordocentesis
for admission d) Blood transfusion notes (if required)
b) Ultrasound report for foetal signs of haemolytic e) Detailed Discharge Summary
1285 Obstetrics & Gynecology SO OBG & Gynec SO021 Intrauterine transfusions SO021A Intrauterine transfusions 10500 11550 12600 13650 14700 15225 disease & gestation age
c) Complete blood count (CBC)
d) ABO Rh of both partners
e) Indirect Coomb`s test and titre
f) Color Doppler study of MCA-PSV
signs, examination findings, indication for b) Investigation reports (if required)
Lap. Surgery for Endometriosis Lap. Surgery for Endometriosis
1286 Obstetrics & Gynecology SO OBG & Gynec SO015 SO015A 18270 20097 21924 23751 25578 26491 procedure, planned line of treatment, advice for c) Detailed Procedure / operative notes
(Other than Hysterectomy) (Other than Hysterectomy)
admission d) Histopathology examination report
b) USG Abdomen/pelvis c) Pap smear report e) Detailed discharge summary
for admission c) Detailed operative notes
1287 Obstetrics & Gynecology SO OBG & Gynec SO023 Laparoscopic adhesiolysis SO023A Laparoscopic adhesiolysis 10290 11319 12348 13377 14406 14920
b) USG Pelvis d) Detailed Discharge Summary
e) Blood transfusion notes (if blood
transfusion was given)
Laparoscopy for Ectopic/ other benign c) MRI abdomen. Pap smear. c) Pic of specimen removed- Gross and
1288 Obstetrics & Gynecology SO OBG & Gynec SO063 SO063A lap 21000 23100 25200 27300 29400 30450
disorders Histopathology.
a)Clinical notes with physical examination findings a)Detailed discharge summary.

Laparotomy for Broad Ligament Hematoma supported by evidence of hematoma (USG). b) Detailed Operative notes. Intra procedure
1289 Obstetrics & Gynecology SO OBG & Gynec SO067 Laparotomy for Broad Ligament Hematoma SO067A 36750 40425 44100 47775 51450 53287
(with internal iliac ligation) clinical photograph.
signs, examination findings, planned line of b) Serum Beta Hcg level follow-up for
treatment, and advice for admission medical management
1290 Obstetrics & Gynecology SO OBG & Gynec SO040 Laparotomy for ectopic/ benign disorders SO040A Open 21000 23100 25200 27300 29400 30450
b) Serum Beta human chorionic gonadotropin c) Blood transfusion notes (if blood
(hCG) titers c) USG transfusion was given)
abdomen/pelvis d) Detailed Discharge Summary
b) Hemogram with Erythrocyte sedimentation rate, d) Detailed Discharge Summary
1291 Obstetrics & Gynecology SO OBG & Gynec SO040 Laparotomy for ectopic/ benign disorders SO040B PID 21000 23100 25200 27300 29400 30450
liver function test, renal function test, serum e) Blood transfusion notes (if blood
electrolytes, blood culture transfusion was given)
c) USG abdomen and pelvis (if adnexal mass)
c) Relavant Investigations (establishing diagnosis). c) Intraop. stills with date & patient ID.
d) Evidence of cervical pre-cancer (PAP smear) d) HPE of specimen.
LLETZ (including PAP smear and Colposcopiy. e) Progress notes.
1292 Obstetrics & Gynecology SO OBG & Gynec SO026 SO026A LLETZ (including PAP smear and colposcopy) 9900 10890 11880 12870 13860 14355 e) Cervical Biopsy is optional. f) Detailed discharge summary.
colposcopy)
symptoms, signs, examination findings confirming b) Investigation reports (If required)
diagnosis and advice for admission c) Detailed procedure/operative notes
1293 Obstetrics & Gynecology SO OBG & Gynec SO012 Manchester Repair SO012A Manchester Repair 21000 23100 25200 27300 29400 30450
b) Planned line of treatment d) Detailed Discharge Summary
a) Detailed clinical notes including Delivery notes (if Detailed indoor case papers
available) with history, symptoms, signs, Yes
examination findings, indications and advice for a) Investigation reports (last Pre-delivery
admission reports incl. Haemoglobin, Urine albumin,
sugar, ABO-Rh & post-delivery:
Haemoglobin)
1294 Obstetrics & Gynecology SO OBG & Gynec SO055 Manual removal of placenta SO055A Manual removal of placenta 8925 9817 10710 11602 12495 12941 b) Detailed operative / procedure notes
c) Documentation of General anaesthesia
(preferable) or Intravenous sedation
d) Detailed discharge summary including
follow up advice
Outside State
Bed Cost Cost
Cost
a) Detailed clinical notes with history, symptoms, a) Indoor case papers b)
signs, indications & examination findings Investigation reports including detailed USG
b) Investigations such as USG report (if available) scan c) Detailed procedural /
1295 Obstetrics & Gynecology SO OBG & Gynec SO050 McDonald's stitch SO050A McDonald's stitch 8400 9240 10080 10920 11760 12180 c) Antenatal record of current pregnancy, if operative notes d)
available Detailed discharge summary, including
advice on getting the cerclage removal at
37th week
signs, examination findings, planned line of b) Detailed operative/procedure notes
treatment, and advice for admission c) Histopathological Examination
1296 Obstetrics & Gynecology SO OBG & Gynec SO052 Medical management of ectopic pregnancy SO052A Medical management of ectopic pregnancy 2200 2420 2640 2860 3080 3190 b) Indication of procedure documentation d) Blood transfusion notes (if blood
c) Serum Beta human chorionic gonadotropin transfusion was given)
(hCG) titers d) USG e) Detailed Discharge Summary
abdomen/pelvis
a) Detailed Admission notes with History & a) Detailed Operative notes:
indication • Method used for termination
b) Findings of clinical examination • Medications/anaesthesia used
c) How was pregnancy confirmed? UPT/ Clinical • Outcomes of the procedure
examination/ USG b) Detailed Discharge Summary:
d) Reports of mandatory investigations: • Prescription of drugs
o Hemoglobin, Packed cell volume (PCV) • Warning signs and symptoms
o Urine routine examination • Contraceptive use
1297 Obstetrics & Gynecology SO OBG & Gynec SO053 Medical Termination of Pregnancy SO053C MTP > 12 weeks 7350 8085 8820 9555 10290 10657 o ABO Rh (MTP >8 weeks) • Follow up visit date c)
o USG (if available), mandatory for pregnancy >8 Completed entry in MTP/Admission Register
weeks-12 weeks & >12 weeks to 20 weeks e)
MTP form
f) Detailed operative note
g) Age proof
h) Completed Consent form
i) Completed RMP Opinion Form
1298 Obstetrics & Gynecology SO OBG & Gynec SO053 Medical Termination of Pregnancy SO053B MTP 8 to 12 weeks 7350 8085 8820 9555 10290 10657 o ABO Rh (MTP >8 weeks) • Follow up visit date c)
MTP form
g) Age proof
1299 Obstetrics & Gynecology SO OBG & Gynec SO053 Medical Termination of Pregnancy SO053A MTP upto 8 weeks 5250 5775 6300 6825 7350 7612 o ABO Rh (MTP >8 weeks) • Follow up visit date c)
MTP form
g) Age proof
a)Clinical notes establishing indication for the a)Histopathology.
procedure. b) Detailed Operative notes.
1300 Obstetrics & Gynecology SO OBG & Gynec SO069 Molar follow up for chemotherapy SO069A Molar follow up for chemotherapy 6300 6930 7560 8190 8820 9135 b) USG uterus & adnexa. c)per op pic of specimen removed.
c) Beta HCG. d)Detailed Discharge Summary.

b) detailed Ante natal care records with special b) PNC notes along with relevant
reference to investigations supporting the investigation details.
diagnosis. c) status of the child at the time of delivery
Operative vaginal delivery (Vacuum/ c) reasons for non-availability of ANC records. and at the time of discharge.
1301 Obstetrics & Gynecology SO OBG & Gynec SO075 SO075A Operative vaginal delivery (Vacuum/ forceps) 10500 11550 12600 13650 14700 15225
forceps) Obstetric USG. All high risk deliveries are to be d) progress notes.
clubbed & case specific documents required. e) Detailed discharge summary.

1302 Obstetrics & Gynecology SO OBG & Gynec SO071 Post coital / Injury Repair SO071A Post coital / Injury Repair 7350 8085 8820 9555 10290 10657 d) Progress notes.
a) Detailed clinical notes with history, symptoms, a) Detailed indoor case papers
signs, examination findings, indication for b) Detailed operative/ procedure notes
procedure, planned line of treatment, and advice c) Culture & sensitivity report of the drained
1303 Obstetrics & Gynecology SO OBG & Gynec SO020 Pyometra drainage SO020A Pyometra drainage 5250 5775 6300 6825 7350 7612 for admission b) pus/ fluid
Ultrasound Abdomen/pelvis d) Histopathological examination
c) Urine routine, microscopic examination e) Detailed discharge summary
d) Complete Blood Count
Outside State
Bed Cost Cost
Cost
b) examination with indications for the procedure. b) Operative Notes together with indication of
d) vulval biopsy. c) Intraop. stills with date & patient ID.
Radical Vulvectomy with Inguinal and Pelvic Radical Vulvectomy with Inguinal and Pelvic e) CT/MRI for staging. d) pic off gross specimen removed.
1304 Obstetrics & Gynecology SO OBG & Gynec SO036 SO036A 52500 57750 63000 68250 73500 76125 e) HPE.
lymph node disection lymph node disection
f) Progress notes.
g) detailed discharge summary.

c) Relavant Investigations (establishing diagnosis) . c) Intraop. stills with date & patient ID.
1305 Obstetrics & Gynecology SO OBG & Gynec SO033 Rectovaginal fistula repair SO033A Rectovaginal fistula repair 26250 28875 31500 34125 36750 38062 d) Progress notes.
e) detailed discharge summary.

1306 Obstetrics & Gynecology SO OBG & Gynec SO070 Resuturing of wounds SO070A Resuturing of wounds 5250 5775 6300 6825 7350 7612 d) Progress notes.
a)Indication of the procedure preferably with record a)Detailed discharge summary.

Reversal of Sterilisation/ Tuboplasty (lap/ of previous sterilization. b) Detailed Operative notes. Intra procedure
1307 Obstetrics & Gynecology SO OBG & Gynec SO065 SO065A Reversal of Sterilisation/ Tuboplasty (lap/ open) 26250 28875 31500 34125 36750 38062
open) b) HSG Report with film. C) USG clinical photograph.
symptoms, signs, examination findings and advice b) Investigation reports (if required)
1308 Obstetrics & Gynecology SO OBG & Gynec SO025 Sacrocolpopexy (Abdominal) SO025B Lap. 23900 26290 28680 31070 33460 34655 for admission c) Detailed procedure/operative notes
b) Pelvic/Abdominal USG d) Detailed Discharge Summary
1309 Obstetrics & Gynecology SO OBG & Gynec SO025 Sacrocolpopexy (Abdominal) SO025A Open 23900 26290 28680 31070 33460 34655 for admission c) Detailed procedure/operative notes
a)Clinical notes establishing indication. a)Detailed Operative notes,HPE Pic of
b)USG Abdomen Pelvis/ CT/ MRI abdomen Pelvis. specimen. Intraop stills with date & patient
1310 Obstetrics & Gynecology SO OBG & Gynec SO077 Salpingoophorectomy SO077B Lap. 26250 28875 31500 34125 36750 38062 ID.

1311 Obstetrics & Gynecology SO OBG & Gynec SO077 Salpingoophorectomy SO077A Open 26250 28875 31500 34125 36750 38062 ID.
signs, examination findings, indications, planned b) Local swab for culture & sensitivity Report
line of treatment and advice for admission c) Detailed operative/procedure notes
1312 Obstetrics & Gynecology SO OBG & Gynec SO056 Secondary suturing of episiotomy SO056A Secondary suturing of episiotomy 3150 3465 3780 4095 4410 4567 b) Delivery notes, if available d) Detailed Discharge Summary including
c) Complete blood count (CBC); Urine albumin, care of the episiotomy site
sugar, microscopic examination
a) Detailed clinical notes with history, symptoms, a) Indoor case papers b)

signs, indications & examination findings Investigation reports including detailed USG
b) Investigations such as USG report (if available) scan c) Detailed procedural /
1313 Obstetrics & Gynecology SO OBG & Gynec SO051 Shirodkar's stitch SO051A Shirodkar's stitch 4725 5197 5670 6142 6615 6851 c) Antenatal record of current pregnancy, if operative notes d)
available Detailed discharge summary, including
advice on getting the cerclage removal at
37th week
1314 Obstetrics & Gynecology SO OBG & Gynec SO013 Sling Surgeries for Prolapse SO013A Surgeries for Prolapse - Sling Surgeries 32865 36151 39438 42724 46011 47654 for admission c) Detailed procedure/operative notes
b) USG Abdomen/pelvis
a) Admission Notes comprising of history a) Detailed Procedure

b) examination with indications for the procedure b) Operative Notes together with indication of
c) Clinical notes with planned line of treatment surgery
(clearly indicating medical management tried and c) Intraop. stills with date & patient ID
failed or not indicated. If failed documents proving d) pic off gross specimen removed
duration of treatment and failure. The medical e) HPE
management should have been tried for atleast 4- f) Progress notes
6 months covering 1 course of hormone cycle) g) detailed discharge summary.
d) USG Abdomen
Staging laparotomy for ovarian cancer Hysterrectomy + salpingo opherectomy + e) Pelvis
(simple) omentectomy + BPLND- Open f) CT
g) MRI abdomen
h) Pelvis confirming the indication
i) Pap smear
j) EB
k) EAC
a) Clincal profile. a) Detailed Procedure.

b) Blood sugar level. b) Operative Notes.
c) CBC. c) Intraop. Stills.
1316 Obstetrics & Gynecology SO OBG & Gynec SO064 Sterilisation SO064B Sterilisation- Lap 10500 11550 12600 13650 14700 15225 d) HCG Report d) Progress notes.
Outside State
Bed Cost Cost
Cost
a) Clincal profile. a) Detailed Procedure.
b) Blood sugar level. b) Operative Notes.
c) CBC. c) Intraop. Stills.
1317 Obstetrics & Gynecology SO OBG & Gynec SO064 Sterilisation SO064A Sterilisation- Open 7350 8085 8820 9555 10290 10657 d) HCG Report d) Progress notes.

b) examination with indications for the b) Operative Notes.
procedure,Relavant Investigations (establishing c) Intraop. stills with date & patient ID.
Surgical management of PPH after vaginal Surgical management of PPH after vaginal diagnosis). d) Progress notes.
delivery delivery c) USG e) Detailed discharge summary
1319 Obstetrics & Gynecology SO OBG & Gynec SO024 Trans - vaginal tape / Trans-obturator tape SO024B Trans-obturator tape 8400 9240 10080 10920 11760 12180 of management, and advice for admission c) Detailed procedure/operative notes
1320 Obstetrics & Gynecology SO OBG & Gynec SO024 Trans - vaginal tape / Trans-obturator tape SO024A Trans-vaginal tape 8400 9240 10080 10920 11760 12180 of management, and advice for admission c) Detailed procedure/operative notes

1321 Obstetrics & Gynecology SO OBG & Gynec SO061 Vaginal Myomectomy SO061A Vaginal Myomectomy 15750 17325 18900 20475 22050 22837
Histopathology.
symptoms, signs, examination findings and advice b) Investigation reports (If required)
Vaginal repair for vesico-vaginal fistula for admission c) Detailed procedure/operative notes
1322 Obstetrics & Gynecology SO OBG & Gynec SO032 SO032A Vaginal repair for vesico-vaginal fistula (Open) 42000 46200 50400 54600 58800 60900
(Repair for VVF) b)Cystoscopy/Cystourethroscopy d) Detailed Discharge Summary
c) Complete Urine Examination (CUE)
1323 Obstetrics & Gynecology SO OBG & Gynec SO027 Vaginal Sacrospinus fixation with repair SO027A Vaginal Sacrospinus fixation with repair 17745 19519 21294 23068 24843 25730 for admission c) Detailed procedure/operative notes
1324 Obstetrics & Gynecology SO OBG & Gynec SO031 Vaginoplasty (McIndoe procedure) SO031A Vaginoplasty (McIndoe procedure) 21000 23100 25200 27300 29400 30450 for admission c) Detailed procedure/operative notes
symptoms, signs, examination findings and advice b) Investigation reports
for admission c) Detailed operative notes
1325 Obstetrics & Gynecology SO OBG & Gynec SO034 Vulval Hematoma drainage SO034A Vulval Hematoma drainage 3570 3927 4284 4641 4998 5176
b) Delivery notes (whether haematoma is formed d) Detailed Discharge Summary
after delivery), if available/ reason for non- e) Blood transfusion notes (if blood
availability transfusion was given)
c) Relavant Investigations (establishing diagnosis) c) Intra procedure clinical photograph.
with Evidence (biopsy). Clinical pic if patient d) Stills.
1326 Obstetrics & Gynecology SO OBG & Gynec SO035 Vulvectomy simple SO035A Vulvectomy simple 21000 23100 25200 27300 29400 30450 permits e) Histopathology.
f) progress notes.
g) Detailed discharge summary.
procedure and advice for admission c) Investigation report (if required)
b) Complete blood count (CBC), Complete urine d) Culture & sensitivity report of aspirated
examination (CUE) fluid
c) Planned line of treatment d)Optional e) Detailed Discharge Summary
• If cyst was aspirated earlier, fluid for:
Vulvo vaginal / bartholin cyst/ abscess ➢ culture & sensitivity,
1327 Obstetrics & Gynecology SO OBG & Gynec SO059 SO059B Vulvo vaginal/ bartholin cyst/ abscess drainage 7350 8085 8820 9555 10290 10657
enucleation / drainage ➢ Gram staining
• MRI (in case of huge cyst to assess the extent)
• Blood glucose
• USG of the affected part
• C-reactive protein (CRP)
procedure and advice for admission c) Investigation report (if required)
b) Complete blood count (CBC), Complete urine d) Histopathological examination report
examination (CUE) e) Detailed Discharge Summary
c) Planned line of treatment d)Optional
• If cyst was aspirated earlier, fluid for:
Vulvo vaginal / bartholin cyst/ abscess Vulvo vaginal/ bartholin cyst/ abscess ➢ culture & sensitivity,
enucleation / drainage enucleation ➢ Gram staining
• MRI (in case of huge cyst to assess the extent)
• Blood glucose
• USG of the affected part
• C-reactive protein (CRP)

1329 Obstetrics & Gynecology SO Obstetrics & Gynecology SO001 Lap. Salpingo-oophrectomy SO001A Lap. Salpingo-oophrectomy 14000 15400 16800 18200 19600 20300 ID.
Outside State
Bed Cost Cost
Cost
a)Clinical notes with physical examination findings a)Detailed discharge summary.
supported by evidence of hematoma (USG). b) Detailed Operative notes. Intra procedure
1330 Obstetrics & Gynecology SO Obstetrics & Gynecology SO005 Laparotomy for broad ligament haematoma SO005A Laparotomy for broad ligament haematoma 16000 17600 19200 20800 22400 23200
clinical photograph.
a) Clinical notes (detailing when was cataract a) Detailed Discharge summary

surgery done & indications for doing the procedure b) Procedure note/ operative note
with details of vision and fundus examination) c) Intraoperative photograph with time and
1331 Ophthalmology SE Ophthalmology SE022 Capsulotomy (YAG) SE022A Capsulotomy (YAG) 1995 2194 2394 2593 2793 2892
b) Admission Notes c) Clinical date (Optional)
Photograph of the affected eye
a) Clinical notes b) Occular a) Still image(Pre operative & post operative-

Biometry c) Slit lamp Examination affected eye) of the patient undergoing the
d)Clinical photograph of the affected part with full procedure with patient ID and date with
Phaco emulsification with foldable hydrophobic face picture of the patient e) Other phaco parameters b.)Operative notes
1332 Ophthalmology SE Ophthalmology SE020 Cataract surgery SE020A 4725 5197 5670 6142 6615 6851
acrylic IOL essential investigations- Blood Pressure & Blood c )Detailed discharge summary d )Post
Sugar (Fasting, PP and Random) operative BCVA e) Barcode of IOL f)
Invoice of Implant
a) Clinical notes b) Occular a) Still image of the patient undergoing the

Biometry c) Slit lamp Examination procedure with patient ID and date
d)Clinical photograph of the affected part with full b.)Operative notes c )Detailed
1333 Ophthalmology SE Ophthalmology SE020 Cataract surgery SE020B SICS with non-foldable IOL 4200 4620 5040 5460 5880 6090 face picture of the patient e) Other discharge summary d )Barcode of IOL
essential investigations- Blood Pressure & Blood
Sugar (Fasting, PP and Random)
a) Clinical notes b) a) Operative/ procedure notes b) Detailed

Admission Notes c) Clinical Discharge summary c)
1334 Ophthalmology SE Ophthalmology SE007 Chalazion Removal SE007A Chalazion Removal 2100 2310 2520 2730 2940 3045 Photograph Histopathology report d)
Intraoperative photograph with time and date
stamp
a) Clinical notes b) a) Detailed Discharge summary
Admission Notes c) Clinical b) Operative/ procedure notes c)
Photograph of the affected eye Histopathology report d)
Conjunctival tumour excision including Conjunctival tumour excision including Amniotic Intraoperative photograph with Patient ID,
1335 Ophthalmology SE Ophthalmology SE009 SE009A 7350 8085 8820 9555 10290 10657
Amniotic Membrane Graft Membrane Graft time and date stamp (optional)
e) Postoperative photograph after excision

Admission Notes c) Clinical b) Operative/ procedure notes c) Details of
1336 Ophthalmology SE Ophthalmology SE016 Corneal / Scleral Patch Graft SE016A Corneal / Scleral Patch Graft 7665 8431 9198 9964 10731 11114 Photograph of the affected eye donor cornea
d) Ultrasound B-scan e) Slit
lamp examination
Admission Notes c) Clinical b) Operative/ procedure notes
1337 Ophthalmology SE Ophthalmology SE013 Corneal Collagen Crosslinking SE013A Corneal Collagen Crosslinking 18375 20212 22050 23887 25725 26643
d) Pentacam progression maps 3 to 6 months
apart e) Slit lamp
examination
a)Discharge summery of the surgery a)ICP notes including clinical examination
note & procedure note.
1338 Ophthalmology SE Ophthalmology SE012 Corneal Grafting SE012B Corneal Graft - Follow Up 2000 2200 2400 2600 2800 2900 b) All investigation reports
c)Discharge summery

Photograph of the affected eye Histopathology/ Microbiology report of the
1339 Ophthalmology SE Ophthalmology SE012 Corneal Grafting SE012A Corneal Grafting 14385 15823 17262 18700 20139 20858
d) Ultrasound B-scan e) Slit host tissue/sample d)
lamp examination f) History of Details of donor cornea
corneal grafting in the same eye
Photograph of the affected eye Histopathology/ Microbiology report of the
1340 Ophthalmology SE Ophthalmology SE012 Corneal Grafting SE012C Lamellar Keratoplasty 18060 19866 21672 23478 25284 26187
d) Ultrasound B-scan e) Slit host tissue/sample d)
lamp examination f) History of Details of donor cornea
corneal grafting in the same eye e) Vision correction after surgery
1341 Ophthalmology SE Ophthalmology SE011 Corneal Ulcer Management SE011A Corneal Ulcer Management 5250 5775 6300 6825 7350 7612 Photograph of the affected eye Histopathology/ Microbiology report of the
d) Ultrasound B-scan e) Slit host tissue/sample
lamp examination
1342 Ophthalmology SE Ophthalmology SE015 Corneo / Scleral / Corneo scleral tear repair SE015A Corneo / Scleral / Corneo scleral tear repair 11500 12650 13800 14950 16100 16675 Photograph of the affected eye
d) Ultrasound B-scan e) Slit
lamp examination
Admission Notes c) Clinical b) Operative/ Procedure notes c)
Canaliculo Dacryocystorhinostomy with Silicon Photograph d) Dye disappearance Intraoperative photograph with time and date
1343 Ophthalmology SE Ophthalmology SE010 Dacryocystorhinostomy SE010A 13125 14437 15750 17062 18375 19031
Tube / Stent test e) Tear meniscus height (Optional) d) Invoice/ barcode/ sticker of
measurement f) implant
Probing & irrigation
Canaliculo Dacryocystorhinostomy without Silicon Photograph d) Dye disappearance Intraoperative photograph with time and date
1344 Ophthalmology SE Ophthalmology SE010 Dacryocystorhinostomy SE010B 10500 11550 12600 13650 14700 15225
Tube / Stent test e) Tear meniscus height (Optional)
measurement f)
Probing & irrigation
1345 Ophthalmology SE Ophthalmology SE010 Dacryocystorhinostomy SE010C Dacryocystorhinostomy with Silicon Tube / Stent 13125 14437 15750 17062 18375 19031 Photograph d) Dye disappearance Intraoperative photograph with time and date
test e) Probing & irrigation (Optional) d) Histopathology report
e) Invoice/ barcode/ sticker of implant
Dacryocystorhinostomy without Silicon Tube /
1346 Ophthalmology SE Ophthalmology SE010 Dacryocystorhinostomy SE010D 10500 11550 12600 13650 14700 15225 Photograph d) Dye disappearance Intraoperative photograph with time and date
Stent
test e) Probing & irrigation (Optional) d) Histopathology report
Outside State
Bed Cost Cost
Cost
1347 Ophthalmology SE Ophthalmology SE003 Ectropion correction SE003A Ectropion correction 6825 7507 8190 8872 9555 9896
Photograph of the affected eye (Photograph in
primary position & lateral gazes)
a) Clinical notes with indications and planned line of a) Still image of the patient undergoing the
management b) Clinical procedure with patient ID, date & time
1348 Ophthalmology SE Ophthalmology SE034 Endophthalmitis (excluding Vitrectomy) SE034A Endophthalmitis (excluding Vitrectomy) 8000 8800 9600 10400 11200 11600
photograph of the affected part with full face b) Operative/ Procedure notes c) Detailed
picture of the patient discharge summary d) Barcode of IOL
1349 Ophthalmology SE Ophthalmology SE002 Entropion correction SE002A Entropion correction 6930 7623 8316 9009 9702 10048
a) Clinical notes with indication b) a) Detailed Discharge summary
Recommendation/ opinion of 2 ophthalmologists b) Procedure/ operative notes c)
for the procedure Histopathology report/ filled specimen form
1350 Ophthalmology SE Ophthalmology SE035 Enucleation SE035B With implant 13965 15361 16758 18154 19551 20249 c) Admission Notes d) Clinical sent for histopathology d)
Photograph of the affected eye Barcode/ sticker of the implant used
e) CT-scan/ MRI of Head (including affected eye)

1351 Ophthalmology SE Ophthalmology SE035 Enucleation SE035A Without implant 12495 13744 14994 16243 17493 18117 c) Admission Notes d) Clinical sent for histopathology
a) Clinical notes b) a) Detailed Discharge summary with

Indication(Pediatric Glaucoma) Intraocular pressure, Fundus and corneal
c) Admission Notes d) Clinical diameter b) Procedure/
Photograph operative notes c) Pre-anesthesia check-up
1352 Ophthalmology SE Ophthalmology SE028 EUA for Confirmation of Pediatric Glaucoma SE028A EUA for Confirmation of Pediatric Glaucoma 3150 3465 3780 4095 4410 4567 d) Documentation of Examination
Under Anesthesia (EUA) e)
Intraoperative photograph with patient ID,
time and date (optional)

1353 Ophthalmology SE Ophthalmology SE036 Evisceration SE036A Evisceration 13965 15361 16758 18154 19551 20249 c) Admission Notes d) Clinical sent for histopathology

Indication (Open angle Glaucoma: Moderate/ Intraocular pressure, Fundus and corneal
advanced Glaucoma/ end stage refractory diameter b) Procedure/
1354 Ophthalmology SE Ophthalmology SE027 Glaucoma Surgery SE027A Cyclocryotherapy / Cyclophotocoagulation 4935 5428 5922 6415 6909 7155 Glaucoma) c) operative notes c) Intraoperative photograph
Documentation of recent field of vision (Perimetry with patient ID, time and date (optional)
examination) d)
Admission Notes e) Clinical Photograph
Indication(Open angle Glaucoma: Moderate/ Intraocular pressure, Fundus and corneal
Advanced Glaucoma) diameter b) Procedure/
c) Documentation of recent field of vision operative notes c) Intraoperative photograph
1355 Ophthalmology SE Ophthalmology SE027 Glaucoma Surgery SE027C Glaucoma Shunt Surgery 17115 18826 20538 22249 23961 24816 (Perimetry examination) with patient ID, time and date (optional)
d) Intra-ocular pressure measurement
e) Evidence of failed Trabeculectomy
f) Admission Notes g) Clinical
Photograp
Indication(Open angle Glaucoma: Moderate/ Intraocular pressure, Fundus and corneal
Glaucoma Surgery (Trabeculectomy only) with or Advanced Glaucoma; Closed angle Glaucoma) diameter b) Procedure/
without Mitomycin C, including postoperative c) Documentation of recent field of vision operative notes c) Intraoperative photograph
medications for 12 weeks (Perimetry examination) with patient ID, time and date (optional)
1356 Ophthalmology SE Ophthalmology SE027 Glaucoma Surgery SE027B 14910 16401 17892 19383 20874 21619
(and wherever surgical or laser procedures d) Intra-ocular pressure measurement
required for bleb augmentation and anterior d) Evidence of failed Trabeculectomy
chamber maintenance) e) Admission Notes f) Clinical
Photograph
Pediatric Glaucoma c) Intraocular pressure, Fundus and corneal
Documentation of recent field of vision (Perimetry diameter b) Procedure/
examination) d) Intra- operative notes c) Pre-anesthesia check-up
1357 Ophthalmology SE Ophthalmology SE027 Glaucoma Surgery SE027D Pediatric Glaucoma Surgery 19740 21714 23688 25662 27636 28623 ocular pressure measurement d) Documentation of Examination
e) Admission Notes f) Clinical Under Anesthesia (EUA) e)
Photograph Intraoperative photograph with patient ID,
a) Clinical notes with indication for the procedure c) Detailed Procedure / Operative Notes
1358 Ophthalmology SE Ophthalmology SE045 Intravitreal injection of Ranibizumab SE045A Intravitreal injection of Ranibizumab 2700 2970 3240 3510 3780 3915 b)Investigation reports. d) Detailed Discharge summary
a) Clinical notes a) Detailed Discharge summary

b) Admission Notes b) Procedure/ operative note
c) Clinical Photograph of the affected eye c) Histopathology report (incase of
1359 Ophthalmology SE Ophthalmology SE026 Iridectomy SE026A Iridectomy 2100 2310 2520 2730 2940 3045
d) Tonometry report Melanoma of iris)
e) Gonioscopy report d) Intraoperative photograph with patient ID,
time and date (Optional)
1360 Ophthalmology SE Ophthalmology SE025 IRIS Prolapse – Repair SE025A IRIS Prolapse – Repair 4725 5197 5670 6142 6615 6851
picture of the patient discharge summary
1361 Ophthalmology SE Ophthalmology SE005 Lid Abscess Drainage SE005A Lid Abscess Drainage 5985 6583 7182 7780 8379 8678
Photograph of the affected eye (Photograph in Histopathology/ microbiology report of host
primary position & lateral gazes) tissue
1362 Ophthalmology SE Ophthalmology SE004 Lid Tear Repair SE004A Lid Tear Repair 8085 8893 9702 10510 11319 11723
Outside State
Bed Cost Cost
Cost
1363 Ophthalmology SE Ophthalmology SE006 Lid Tumor excision + Lid Reconstruction SE006A Lid Tumor excision + Lid Reconstruction 14700 16170 17640 19110 20580 21315
Photograph of the affected eye (Photograph in Histopathology/ microbiology report of host
primary position & lateral gazes) tissue
a) Clinical notes with indication b) Admission Notes a) Detailed Discharge summary
c) Clinical Photograph of the affected eye b) Procedure/ operative notes
c) Intraoperative photograph with Patient ID,
1364 Ophthalmology SE Ophthalmology SE019 Limbal Dermoid Removal SE019A Limbal Dermoid Removal 2625 2887 3150 3412 3675 3806
d) Evidence of submission of removed tissue
for histopathology examination
a) Clinical notes with indication for surgery a) Detailed Indoor case papers
b) Imaging reports such as CT/ MRI justifying b) Post-operative imaging labelled with
surgery patient ID, date
1365 Ophthalmology SE Ophthalmology SE041 Orbital fracture repair SE041A Orbital fracture repair under GA 11025 12127 13230 14332 15435 15986
c) MLC/ FIR (if traumatic patient) c) Detailed Procedure / Operative Notes
e) Implant invoice/ Barcode
a) Clinical notes with indication a) Detailed Discharge summary
b) Admission Notes b) Procedure/ operative notes
c) CT scan of Head (including affected eye) c) Histopathology report
1366 Ophthalmology SE Ophthalmology SE039 Orbitotomy SE039A Orbitotomy 18375 20212 22050 23887 25725 26643 d) Clinical Photograph of the affected eye d) Intraoperative photograph with patient ID,
e) Still image of the gross specimen
removed
a) Clinical notes b) a) Still image of the patient undergoing the
Keratometry c) procedure with patient ID and date
Retinoscopy or Autorefraction (AR) b) Other essential investigations- Blood
1367 Ophthalmology SE Ophthalmology SE014 Pterygium + Conjunctival Autograft SE014A Pterygium + Conjunctival Autograft 12285 13513 14742 15970 17199 17813 d) Clinical photograph of the affected part with full Pressure & Blood Sugar (Fasting, PP and
face picture of the patient Random) c) Operative
notes d) Detailed discharge
summary
1368 Ophthalmology SE Ophthalmology SE001 Ptosis Surgery SE001A Ptosis Surgery 8400 9240 10080 10920 11760 12180
a) Clinical notes with indication for procedure a) Detailed Discharge summary
b) Admission Notes b) Operative/ procedure notes
1369 Ophthalmology SE Ophthalmology SE031 Retinal Cryopexy SE031A Retinal Cryopexy 3990 4389 4788 5187 5586 5785
c) Intraoperative photograph with Patient ID,
b) Admission Notes b) Procedure notes/ Operative notes
1370 Ophthalmology SE Ophthalmology SE029 Retinal Laser Photocoagulation SE029A For retinal tear repair Per Eye Per Sitting 1575 1732 1890 2047 2205 2283
c) Intra-Procedure photograph with time and
date (optional)
Pan Retinal Photocoagulation (PRP) - Retinal a) Clinical notes a) Detailed Discharge summary
Laser including 3 sittings / package of retino b) Procedure notes/ Operative notes
1371 Ophthalmology SE Ophthalmology SE029 Retinal Laser Photocoagulation SE029B 8925 9817 10710 11602 12495 12941
laser photocoagulation c) Intra-Procedure photograph with time and
(3 sittings per eye for both eyes) date (optional)
b) Indirect ophthalmoscopy examination b) Intra-procedure photograph(optional)
1372 Ophthalmology SE Ophthalmology SE030 ROP Laser - Per Eye SE030A ROP Laser - Per Eye 5250 5775 6300 6825 7350 7612
a) Clinical notes with indication for surgery a) Detailed Discharge summary
c) Clinical Photograph of the affected eye c) Microbiology report of the host tissue
1373 Ophthalmology SE Ophthalmology SE018 Scleral Buckle Removal SE018A Scleral Buckle Removal 7245 7969 8694 9418 10143 10505 d) Investigation reports- Fundus examination/
B-scan
e) Intraoperative photograph with Patient ID,
time and date(optional)
a) Clinical notes with indication for surgery a) Detailed Discharge summary
c) Clinical Photograph of the affected eye c) Investigation reports- Fundus examination/
1374 Ophthalmology SE Ophthalmology SE017 Scleral buckling surgery SE017A Scleral buckling surgery 25935 28528 31122 33715 36309 37605
B-scan
e) Intraoperative photograph with Patient ID,
time and date(optional)
1375 Ophthalmology SE Ophthalmology SE024 Secondary IOL / IOL Exchange / Explant SE024A Secondary IOL / IOL Exchange / Explant 6510 7161 7812 8463 9114 9439
picture of the patient discharge summary
1376 Ophthalmology SE Ophthalmology SE023 SFIOL (inclusive of Vitrectomy) SE023A SFIOL (inclusive of Vitrectomy) 19740 21714 23688 25662 27636 28623
picture of the patient discharge summary d) Barcode of IOL
Recommendation/ opinion of 2 ophthalmologists b) Procedure/ operative notes
for the procedure
Socket Reconstruction including Amniotic Socket Reconstruction including Amniotic c) Admission Notes d) Clinical
1377 Ophthalmology SE Ophthalmology SE038 SE038A 14700 16170 17640 19110 20580 21315
Membrane Graft Membrane Graft Photograph of the affected eye

c) Fundus examination c) Sticker/ Barcode of the Intraocular lens
1378 Ophthalmology SE Ophthalmology SE033 SOR (Silicon Oil Removal) SE033A SOR (Silicon Oil Removal) 9765 10741 11718 12694 13671 14159
d) B-Scan(optional) (IOL) (If IOL Used)
d) Intraoperative photograph with patient ID,
time and date stamp (optional)
a) Clinical notes detailing which muscle is affected a) Detailed Discharge summary
b) Admission Notes b) Procedure notes/ operative notes
Major - 3 or more muscles (complex surgery
1379 Ophthalmology SE Ophthalmology SE008 Squint correction SE008B 14000 15400 16800 18200 19600 20300 c) Clinical Photograph c) Intraoperative photograph with patient ID,
involving four muscles or oblique muscles)
d) Indication for GA, if required date and time (optional)
a) Clinical notes detailing which muscle is affected a) Detailed Discharge summary

b) Admission Notes b) Procedure notes/ operative notes
1380 Ophthalmology SE Ophthalmology SE008 Squint correction SE008A Minor - upto 2 muscles 4300 4730 5160 5590 6020 6235 c) Clinical Photograph c) Intraoperative photograph with patient ID,
d) Indication for GA, if required date and time (optional)
Outside State
Bed Cost Cost
Cost
a) Clinical notes (detailing Indication for a) Detailed Discharge summary with visual
Lensectomy /pediatric lens aspiration/ outcomes
membranectomy and supporting investigation) b) Procedure/ Operative notes
1381 Ophthalmology SE Ophthalmology SE021 Surgery for Pediatric Cataract SE021A Paediatric lensectomy 12075 13282 14490 15697 16905 17508
b) Admission Notes c) Intraoperative photograph with time and
c) Clinical Photograph date (optional)
d) Barcode of IOL used
membranectomy and supporting investigation) b) Procedure/ Operative notes
1382 Ophthalmology SE Ophthalmology SE021 Surgery for Pediatric Cataract SE021C Paediatric Membranectomy & anterior vitrectomy 10500 11550 12600 13650 14700 15225
b) Admission Notes c) Intraoperative photograph with time and
Pediatric lens aspiration with posterior membranectomy and supporting investigation) b) Procedure/ Operative notes
1383 Ophthalmology SE Ophthalmology SE021 Surgery for Pediatric Cataract SE021B 12075 13282 14490 15697 16905 17508
capsulotomy & anterior vitrectomy b) Admission Notes c) Intraoperative photograph with time and
Vitreoretinal Surgery (with Silicon Oil c) Fundus examination c) Sticker/ Barcode of the Intraocular lens
1384 Ophthalmology SE Ophthalmology SE032 SE032A Vitreoretinal Surgery (with Silicon Oil Insertion) 26565 29221 31878 34534 37191 38519
Insertion) d) B-Scan(optional) (IOL) (If IOL Used)
d) Intraoperative photograph with patient ID,
time and date stamp (optional)
Clinical Notes justifying the need for GA in the a) Clinical Notes for the associated surgery.
associated surgery b) disease along with Pre OP.
Ophthalmology, ENT, c) Operative and Anesthesia.
1385 Ophthalmology SE General Surgery, Radiation SE040 GA / EUA separate add on package SE040A GA / EUA separate add on package 3150 3465 3780 4095 4410 4567 d) Post OP notes.
Oncology

Ophthalmology, Surgical c) Admission Notes d) Clinical sent for histopathology
1386 Ophthalmology SE SE037 Exenteration SE037A Exenteration 24885 27373 29862 32350 34839 36083
Oncology Photograph of the affected eye
a) Clinical notes after routine eye exam, a)ICP notes including clinical examination
Ophthalmoscopy b) note & procedure note.
Ophthalmology,Pediatric Admission Notes c) Clinical b) All investigation reports
1387 Ophthalmology SE Medical Management, MP007 Optic neuritis SE042A Optic neuritis 2200 2420 2640 2860 3080 3190 Photograph of the affected eye c)Discharge summery
General Medicine d) MRI/ Optical coherence tomography (OCT),
Visual field test/ Visual evoked response & other
investigation reports
Ophthalmology/ General a) Clinical notes after routine eye exam & a) Examination report
1388 Ophthalmology SE SE044 Diabetic Retinopathy Screening SE044A Vision refraction,fundus photo and OCT 1050 1155 1260 1365 1470 1522
Medicine Ophthalmoscopy for indication of the procedure b) Further plan of treatment
Ophthalmology/ General a) Clinical notes after routine eye exam & a) Examination report
1389 Ophthalmology SE SE043 Glaucoma Screening SE043A Vision Refraction-IOP & Fundus 840 924 1008 1092 1176 1218
Medicine Ophthalmoscopy for indication of the procedure b) Further plan of treatment
Ophthalmology/ General Vision Refraction-IOP & Fundus OCT & Visual a) Clinical notes after routine eye exam & a) Examination report
1390 Ophthalmology SE SE043 Glaucoma Screening SE043B 1575 1732 1890 2047 2205 2283
Medicine Fields Ophthalmoscopy for indication of the procedure b) Further plan of treatment
examination findings, indications for doing the written)
procedure) b) Procedure note/ operative note &
Apicoectomy (A) b) Document required for Investigation: Anesthesia notes
Oral & Maxillofacial
1391 SM Oral & Maxillofacial Surgery SM008 Apicoectomy (A) Tooth SM008A (1-3 teeth) LA/GA 1575 1732 1890 2047 2205 2283
Surgery • Pre-op photo (extraoral and intraoral) (where applicable)
3-6:4000 c) Radiological imaging c) Discharge summary
d) Photograph of affected part/Treated part.
a) Clinical notes with planned line of treatment a) Indoor case papers & Consent (informed
b) Cone beam computed tomography (CBCT) written)
Oral & Maxillofacial c) Valsalva test (nose blowing test) b) Procedure note/ operative note &
1392 SM Oral & Maxillofacial Surgery SM009 Correction of oro-antral communication SM009A Correction of oro-antral Fistula 7350 8085 8820 9555 10290 10657
Surgery Anesthesia notes
(where applicable)
c) Discharge summary
a) Clinical notes with indication for surgery a) Post Procedure clinical photograph
b) X-ray & other imaging labelled with patient ID, b) Post op X-ray is labelled with patient ID,
date. date and side (Left/ Right) showing affected
Oral & Maxillofacial Dentoalveolar trauma - wiring (dental /trauma C) Clinical photograph of affected part part.
1393 SM Oral & Maxillofacial Surgery SM011 Dentoalveolar trauma - wiring SM011A 3150 3465 3780 4095 4410 4567
Surgery wiring- one jaw) c) Detailed operative note
d) Discharge Summary including Implant
invoice.
b) Document required for Investigation: Anesthesia notes
Oral & Maxillofacial • Pre-op photo (extraoral and intraoral) (where applicable)
1394 SM Oral & Maxillofacial Surgery SM001 Extraction of impacted tooth under LA SM001A Extraction of impacted tooth under LA 840 924 1008 1092 1176 1218
Surgery c) Radiological imaging of Impacted tooth c) Barcode of Implants
d) Investigation reports (post procedure)
• Photograph of affected part/Treated part.
a) Circumstances that led to fracture. a) Detailed Discharge Summary.

b) MLC copy with number. b) Detailed Procedure.
Oral & Maxillofacial Closed reduction (1 jaw) using wires - under c) Clinical Photograph. c) Operative Notes.
1395 SM Oral & Maxillofacial Surgery SM004 Fixation of fracture of jaw SM004A 5250 5775 6300 6825 7350 7612
Surgery LA/GA d) X Ray Mandible. d) Post procedure X ray mandible showing
wires used.
a) Circumstances that led to fracture. a) Detailed Discharge Summary.

b) MLC copy with number. b) Detailed Procedure.
Open reduction (1 jaw) and fixing of plates / wire
Oral & Maxillofacial c) Clinical Photograph. c) Operative Notes.
1396 SM Oral & Maxillofacial Surgery SM004 Fixation of fracture of jaw SM004B – under LA/GA 12600 13860 15120 16380 17640 18270
Surgery d) X Ray Mandible. d) Post procedure X ray mandible showing
Cost of implant Titanium:- TBF at pre-auth
wires used.
Outside State
Bed Cost Cost
Cost
a) Are the Clinical notes (detailing signs, a) Indoor case papers & Consent (informed
symptoms, examination findings, clinical written)
photographs (intraoral and extraoral), indications b) Are the Procedure note/ operative note &
for doing the procedure & advise for admission Anesthesia notes (where
submitted? applicable) submitted? c) Are the
b) Are the Investigation reports of Cyst/Tumour barcode of Implants used submitted?
such as: d) Are the Investigation report of
Oral & Maxillofacial Mandible Tumour Resection and Maxilla / Mandible neoplastic Tumour Resection X-ray for Odontogenic cyst Cyst/Tumour such as:
1397 SM Oral & Maxillofacial Surgery SM006 SM006A 14175 15592 17010 18427 19845 20553
Surgery reconstruction / Cancer surgery and reconstruction (Cancer surgery) CBCT or CT of Jaws or Intraoral Radiograph and/ X-ray for Odontogenic cyst Or Intraoral
OPG Orthopantomography to confirm the Radiograph &/ or
existence submitted? OPG Orthopantomography to confirm the
existence &
Histopathology report, Biopsy or FNAC
Submitted?
2.Osteoradionecrosis of Jaws management by b) Imaging reports such as CT/ MRI justifying b) Post-operative imaging labelled with
Oral & Maxillofacial Osteoradionecrosis management by
1398 SM Oral & Maxillofacial Surgery SM014 SM014B excision and / or reconstruction under GA + 15750 17325 18900 20475 22050 22837 surgery patient ID, date
Surgery excision
Implant : 12000 +Implant c) MLC/ FIR (if traumatic patient) c) Detailed Procedure / Operative Notes
Osteoradionecrosis of jaws management by b) Imaging reports such as CT/ MRI justifying b) Post-operative imaging labelled with
Oral & Maxillofacial Osteoradionecrosis management by
1399 SM Oral & Maxillofacial Surgery SM014 SM014A excision under LA 5250 5775 6300 6825 7350 7612 surgery patient ID, date
Surgery excision
c) MLC/ FIR (if traumatic patient) c) Detailed Procedure / Operative Notes
Oral & Maxillofacial b) Investigation: Conventional Sialography, CT, MR- Anesthesia notes
1400 SM Oral & Maxillofacial Surgery SM012 Parotid sialolithotomy SM012A Extraoral parotid sialolithotomy under GA 12600 13860 15120 16380 17640 18270
Surgery Sialography, Sialography (where applicable)
• Pre-op photo (extraoral and intraoral) c) Discharge summary
1401 SM Oral & Maxillofacial Surgery SM012 Parotid sialolithotomy SM012B Intraoral parotid sialolithotomy 7350 8085 8820 9555 10290 10657
b) X-ray & other imaging labelled with patient ID, b) Post op X-ray is labelled with patient ID,
Re-implantation of Avulsed tooth with wiring (1-3 date. date and side (Left/ Right) showing affected
Oral & Maxillofacial C) Clinical photograph of affected part part.
1402 SM Oral & Maxillofacial Surgery SM013 Re-implantation of Avulsed tooth with wiring SM013A teeth) 1785 1963 2142 2320 2499 2588
Surgery c) Detailed operative note
3-6 :6000
d) Discharge Summary including Implant
invoice.
& extraoral) indications for doing the procedure & b) Procedure note/ operative note &
Oral & Maxillofacial Release of fibrous bands & grafting - in 2. Release of fibrous release bands & advise for admission). Anesthesia notes
1403 SM Oral & Maxillofacial Surgery SM007 SM007B 19740 21714 23688 25662 27636 28623
Surgery (OSMF) treatment under GA coronoidectomy with grafting - in (OSMF) B) X-ray: OPG/ CBCT/CT/ Lateral Oblique and PA c) Investigation reports (post procedure):
treatment under GA mandible Histopathology report showing OSMF to
confirm the existence
1.Release of fibrous bands & grafting - in & extraoral) indications for doing the procedure & b) Procedure note/ operative note &
Oral & Maxillofacial Release of fibrous bands & grafting - in advise for admission). Anesthesia notes
1404 SM Oral & Maxillofacial Surgery SM007 SM007A (OSMF) treatment under LA: 5000 3465 3811 4158 4504 4851 5024
Surgery (OSMF) treatment under GA B) X-ray: OPG/ CBCT/CT/ Lateral Oblique and PA c) Investigation reports (post procedure):
mandible Histopathology report showing OSMF to
confirm the existence
a) Clinical notes b) a)ICP notes including clinical examination
Admission Notes c) Clinical note & procedure note.
Oral & Maxillofacial Osteomyelitis -Acute
1405 SM Oral & Maxillofacial Surgery SM002 Sequestrectomy Debridement SM002A 2100 2310 2520 2730 2940 3045 Photograph of the affected eye b) All investigation reports
Surgery
d) Imaging reports such as Xray/ CT/ MRI c)Discharge summery
e) Bone biopsy if any
a) Clinical notes b) a)ICP notes including clinical examination
Admission Notes c) Clinical note & procedure note.
1406 SM Oral & Maxillofacial Surgery SM002 Sequestrectomy Debridement SM002B Osteomyelitis-Chronic 3990 4389 4788 5187 5586 5785 Photograph of the affected eye b) All investigation reports
Surgery
d) Imaging reports such as Xray/ CT/ MRI c)Discharge summery
e) Bone biopsy if any
1407 SM Oral & Maxillofacial Surgery SM010 Submandibular sialolithotomy SM010A Intraoral submandibular sialolithotomy LA/ GA 7350 8085 8820 9555 10290 10657
1408 SM Oral & Maxillofacial Surgery SM010 Submandibular sialolithotomy SM010C Submandibular sialolithotomy 9450 10395 11340 12285 13230 13702
Outside State
Bed Cost Cost
Cost
Oral & Maxillofacial Surgery for Cyst & tumour of Maxilla / Enucleation / excision of cyst / tumour of jaws X-ray for Odontogenic cyst Cyst/Tumour such as:
1409 SM Oral & Maxillofacial Surgery SM005 SM005A 2835 3118 3402 3685 3969 4110
Surgery Mandible under LA +cost of implant CBCT or CT of Jaws or Intraoral Radiograph and/ X-ray for Odontogenic cyst Or Intraoral
OPG Orthopantomography to confirm the Radiograph &/ or
existence &
Submitted?
Oral & Maxillofacial Surgery for Cyst & tumour of Maxilla / X-ray for Odontogenic cyst Cyst/Tumour such as:
1410 SM Oral & Maxillofacial Surgery SM005 SM005B 5775 6352 6930 7507 8085 8373
Surgery Mandible Enucleation / excision of cyst / tumour of jaws CBCT or CT of Jaws or Intraoral Radiograph and/ X-ray for Odontogenic cyst Or Intraoral
under GA OPG Orthopantomography to confirm the Radiograph &/ or
existence &
Submitted?
a) Clinical Photograph. a) Post procedure clinical photograph with

1.TM joint ankylosis of both jaws - under GA
b) X-Ray/ CT/ MRI of affected area. mouth open.
Oral & Maxillofacial (Unilateral)
1411 SM Oral & Maxillofacial Surgery SM003 TM joint ankylosis of both jaws - under GA SM003A 15750 17325 18900 20475 22050 22837 c) Clinical note justifying diagnosis. b) X Ray.
Surgery
d) Detailed Procedure/ Operative Notes.
a) Clinical Photograph. a) Post procedure clinical photograph with
2.TM joint ankylosis of both jaws - under GA b) X-Ray/ CT/ MRI of affected area. mouth open.
1412 SM Oral & Maxillofacial Surgery SM003 TM joint ankylosis of both jaws - under GA SM003B (Bilateral)- 32865 36151 39438 42724 46011 47654 c) Clinical note justifying diagnosis. b) X Ray.
Surgery
(Covering Reconstruction) c) Detailed discharge summary.
d) Detailed Procedure/ Operative Notes.
a. Eligibility Criteria a. Treatement Details
Maximum Rs Maximum Rs Maximum Rs Maximum Rs Maximum Rs Maximum Rs b. Identification proof doner and b. Discharge Summery
1000000 (Male 1000000 (Male 1000000 (Male 1000000 (Male 1000000 (Male 1000000 (Male receipnt c. OT Notes
members Rs 5 members Rs 5 members Rs 5 members Rs 5 members Rs 5 members Rs 5 c. NOC from THOT d. All investigation reports
Lakh and for Lakh and for Lakh and for Lakh and for Lakh and for Lakh and for (Transplantation of Human e. Post OT and USG and relative
Female member Female member Female member Female member Female member Female member Organ & Tissue)/ Concern photographs
1413 Organ & Tissue Transplant OT Organ & Tissue Transplant OT001 Bone Marrow Transplantation OT001A Bone Marrow Transplantation authority
Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be
utilized) with utilized) with utilized) with utilized) with utilized) with utilized) with d. Clinical notes detailing
validation of validation of validation of validation of validation of validation of history
balance available in balance available in balance available balance available balance available balance available e. Examination findings
the card the card in the card in the card in the card in the card f. Relevent investigation done.
g. Planned line of management
Maximum Rs Maximum Rs Maximum Rs Maximum Rs Maximum Rs Maximum Rs b. Identification proof doner and b. Discharge Summery
1000000 (Male 1000000 (Male 1000000 (Male 1000000 (Male 1000000 (Male 1000000 (Male receipnt c. OT Notes
members Rs 5 members Rs 5 members Rs 5 members Rs 5 members Rs 5 members Rs 5 c. NOC from THOT d. All investigation reports
Lakh and for Lakh and for Lakh and for Lakh and for Lakh and for Lakh and for (Transplantation of Human e. Post OT and USG and relative
Female member Female member Female member Female member Female member Female member Organ & Tissue)/ Concern photographs
1414 Organ & Tissue Transplant OT Organ & Tissue Transplant OT002 Liver Transplantation OT002A Liver Transplantation authority
Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be
utilized) with utilized) with utilized) with utilized) with utilized) with utilized) with d. Clinical notes detailing
validation of validation of validation of validation of validation of validation of history
balance available in balance available in balance available balance available balance available balance available e. Examination findings
the card the card in the card in the card in the card in the card f. Relevent investigation done.
b. Identification proof doner and b. Discharge Summery
receipnt c. OT Notes
c. NOC from THOT d. All investigation reports
Renal Transplant with (Transplant surgery (Transplantation of Human e. Post OT and USG and relative
including doner nephrectoy, indution, Intervention Organ & Tissue)/ Concern photographs
1415 Organ & Tissue Transplant OT Urology OT003 Renal Transplant OT003A 700000 770000 840000 910000 980000 1015000 authority
for acute reject, post transplant medication 1 to
12 Months) d. Clinical notes detailing
history
e. Examination findings
f. Relevent investigation done.
a) Clinical notes confirming the diagnosis a) Detailed Indoor case papers
b) X-ray/ MRI labelled with patient ID, date and b) Post-op X-ray labelled with patient ID, date
side (Left/ Right) of affected limb and side (Left/ Right) of operated limb
1416 Orthopedics SB Orthopedics SB032 AC Joint reconstruction / Stabilization SB032A Rockwood Type - I 21525 23677 25830 27982 30135 31211 c) Detailed Procedure / Operative Notes
d) Invoice and barcode of implant

1417 Orthopedics SB Orthopedics SB032 AC Joint reconstruction / Stabilization SB032B Rockwood Type - II 21525 23677 25830 27982 30135 31211 c) Detailed Procedure / Operative Notes

1418 Orthopedics SB Orthopedics SB032 AC Joint reconstruction / Stabilization SB032C Rockwood Type - III 21525 23677 25830 27982 30135 31211 c) Detailed Procedure / Operative Notes
Outside State
Bed Cost Cost
Cost
1419 Orthopedics SB Orthopedics SB032 AC Joint reconstruction / Stabilization SB032D Rockwood Type - IV 21525 23677 25830 27982 30135 31211 c) Detailed Procedure / Operative Notes

1420 Orthopedics SB Orthopedics SB032 AC Joint reconstruction / Stabilization SB032E Rockwood Type - V 21525 23677 25830 27982 30135 31211 c) Detailed Procedure / Operative Notes

1421 Orthopedics SB Orthopedics SB032 AC Joint reconstruction / Stabilization SB032F Rockwood Type - VI 21525 23677 25830 27982 30135 31211 c) Detailed Procedure / Operative Notes
b) X-ray labelled with patient ID, date and side b) Post-operative X-ray labelled with patient
(Left/ Right) of affected limb/part ID, date and side (Left/ Right) showing
1422 Orthopedics SB Orthopedics SB045 Amputation - Fingers / Toes SB045A Finger(s) 14175 15592 17010 18427 19845 20553
c) MLC/ FIR (if traumatic patient) affected part
c) Detailed Procedure / Operative Notes
1423 Orthopedics SB Orthopedics SB045 Amputation - Fingers / Toes SB045B Toe(s) 14175 15592 17010 18427 19845 20553
b) X-ray labelled with patient ID, date and side b) Post op X-ray is labelled with patient ID,
(Left/ Right) -affected limb. date and side (Left/ Right) showing affected
ORIF of medial malleolus or bimalleolar fracture C) Clinical photograph of affected part part.
1424 Orthopedics SB Orthopedics SB020 Ankle Fractures SB020A 16380 18018 19656 21294 22932 23751
or Trimalleolar fracture c) Detailed operative note
d) Discharge Summary including follow up
advice
a) Clinical notes with indication for surgery a) Detailed Indoor case papers (ICPs)
b) Clinical photograph of affected part b) Detailed Procedure / Operative Notes.
1425 Orthopedics SB Orthopedics SB003 Application of P.O.P. casts SB003B Lower Limbs 3150 3465 3780 4095 4410 4567 c) X-ray labelled with patient ID, date and side c) Post Procedure clinical photograph with
(Left/ Right) of affected limb. POP cast
a. Clinical notes with indication for surgery a. Detailed Indoor case papers (ICPs)
b. Clinical photograph of affected part b. Post Procedure clinical photograph with

pins.
c. X-ray labelled with patient ID, date and side
(Left/ Right) of affected limb. c. Post Procedure clinical photograph with
POP cast
1426 Orthopedics SB Orthopedics SB003 Application of P.O.P. casts SB076B POP slab 2310 2541 2772 3003 3234 3349 d. Post Procedure clinical photograph with
POP Spika
e. Post Procedure clinical photograph with

POP Jacket
f. Detailed Procedure / Operative Notes.
g. Discharge Summary
1427 Orthopedics SB Orthopedics SB003 Application of P.O.P. casts SB003A Upper Limbs 3150 3465 3780 4095 4410 4567 c) X-ray labelled with patient ID, date and side c) Post Procedure clinical photograph with
(Left/ Right) of affected limb. POP cast
b) Clinical photograph of affected part b) Post Procedure clinical photograph with
1428 Orthopedics SB Orthopedics SB004 Application of P.O.P. Spikas & Jackets SB004B Jackets 3675 4042 4410 4777 5145 5328 c) X-ray labelled with patient ID, date and side POP Jacket c) Detailed Procedure /
(Left/ Right) of affected limb. Operative Notes d) Discharge
Summary
1429 Orthopedics SB Orthopedics SB004 Application of P.O.P. Spikas & Jackets SB004A Spikas 3675 4042 4410 4777 5145 5328 c) X-ray labelled with patient ID, date and side POP Spika c) Detailed Procedure /
(Left/ Right) of affected limb. Operative Notes. d)
Discharge Summary
a. Clinical notes with indication for surgery a. Detailed Indoor case papers (ICPs)
b. Clinical photograph of affected part b. Post Procedure clinical photograph with

pins.
c. X-ray labelled with patient ID, date and side
(Left/ Right) of affected limb. c. Post Procedure clinical photograph with
POP cast
1430 Orthopedics SB Orthopedics SB002 Application of Traction SB075A crutchfiled tong cervical spine traction 5250 5775 6300 6825 7350 7612 d. Post Procedure clinical photograph with
POP Spika
e. Post Procedure clinical photograph with

POP Jacket
f. Detailed Procedure / Operative Notes.
g. Discharge Summary
Outside State
Bed Cost Cost
Cost
a. Clinical notes with history, signs, symptoms, a. Detailed Indoor case papers (ICPs)
evaluation findings, indication for procedure,
planned line of management and advice for b. Procedure / operation notes
admission
c. Intra operative still image (Arthroscopy)
1431 Orthopedics SB Orthopedics SB002 Application of Traction SB076A POP slab 2100 2310 2520 2730 2940 3045 b. MRI/X -ray of affected part labelled with patient
ID, date and side (Left/ Right) d. Post Procedure clinical photograph
c. Clinical Photograph of affected part e. Discharge Summary
1432 Orthopedics SB Orthopedics SB002 Application of Traction SB002A Skeletal Tractions with pin 3675 4042 4410 4777 5145 5328 c) X-ray labelled with patient ID, date and side pins. c) Detailed Procedure /
(Left/ Right) of affected limb. Operative Notes. d) Discharge
Summary
1433 Orthopedics SB Orthopedics SB002 Application of Traction SB002B Skin Traction 945 1039 1134 1228 1323 1370
c) X-ray labelled with patient ID, date and side c) Discharge Summary
(Left/ Right) of affected limb.
b) X-ray labelled with patient ID, date and side b) Post-procedure X-ray labelled with patient
(Left/ Right) of affected part ID, date and side (Left/ Right) of affected
1434 Orthopedics SB Orthopedics SB024 Arthorotomy of any joint SB024A Arthorotomy of any joint 14700 16170 17640 19110 20580 21315 c) Clinical photograph of affected part part
d) Post procedure clinical photograph
a) Clinical notes detailing indication a) Detailed Indoor case papers
b) Clinical photograph of affected part b) Detailed Procedure / Operative Notes
c) X-ray labelled with patient ID, date and side c) Post procedure X-ray labelled with patient
1435 Orthopedics SB Orthopedics SB026 Arthrodesis SB026A Ankle / Triple with implant 17955 19750 21546 23341 25137 26034
part
d) Invoice and bar code of implant
e) Post Procedure clinical photograph
1436 Orthopedics SB Orthopedics SB026 Arthrodesis SB026G Ankle / Triple without implant 18270 20097 21924 23751 25578 26491 (Left/ Right) of affected part ID, date and side (Left/ Right) of affected
part
d) Post Procedure clinical photograph
1437 Orthopedics SB Orthopedics SB026 Arthrodesis SB026D Knee, Knee with plating/Nailing 17955 19750 21546 23341 25137 26034
part
1438 Orthopedics SB Orthopedics SB026 Arthrodesis SB026B Shoulder 17955 19750 21546 23341 25137 26034
part
1439 Orthopedics SB Orthopedics SB026 Arthrodesis SB026C Wrist, Wrist with plating 17955 19750 21546 23341 25137 26034
part
1440 Orthopedics SB Orthopedics SB025 Arthrolysis of joint SB025C Ankle 15750 17325 18900 20475 22050 22837 c) Clinical photograph of affected part part
1441 Orthopedics SB Orthopedics SB025 Arthrolysis of joint SB025A Elbow 15750 17325 18900 20475 22050 22837 c) Clinical photograph of affected part part
1442 Orthopedics SB Orthopedics SB025 Arthrolysis of joint SB025B Knee 15750 17325 18900 20475 22050 22837 c) Clinical photograph of affected part part
a) Clinical notes with history, signs, symptoms, a) Detailed Indoor case papers (ICPs)
planned line of management and advice for c) Intra operative still image with patient
Arthroscopic Meniscus Repair / admission name d) Post Procedure
1443 Orthopedics SB Orthopedics SB036 SB036A Arthroscopic Meniscus Repair / Meniscectomy 12600 13860 15120 16380 17640 18270
Meniscectomy b) MRI scan of affected part labelled with patient clinical photograph
ID, date and side (Left/ Right) e) Discharge Summary
c) Clinical Photograph of affected part
Outside State
Bed Cost Cost
Cost
planned line of management and advice for b. Procedure / operation notes
admission
c. Intra operative still image (Arthroscopy)
1444 Orthopedics SB Orthopedics SB074 Arthroscopy / open - synovectomy SB074A Arthroscopy / open - synovectomy 10500 11550 12600 13650 14700 15225 b. MRI/X -ray of affected part labelled with patient
ID, date and side (Left/ Right) d. Post Procedure clinical photograph
c. Clinical Photograph of affected part e. Discharge Summary
a) Clinical notes detailing earlier surgery that a) Post Procedure clinical photograph of
resulted in non-union donor and recipient sites
b) Clinical photograph of affected part b) Post procedure imaging study (X-ray
1445 Orthopedics SB Orthopedics SB023 Bone grafting for Non union SB023A Bone grafting for Fracture Non union 19530 21483 23436 25389 27342 28318 c) Radiological investigations confirming the labelled with patient ID, date and side (Left/
diagnosis (X-ray labelled with patient ID, date and Right) showing affected part)
side (Left/ Right) showing affected part.) c) Detailed procedure/ operative notes
a) Clinical notes justifying need of this surgery. a) Post procedure imaging study (X Ray).
b) X-ray. b) Post Procedure clinical photgraph of both
c) MRI of affected part. donor. c)Recipient sites.
d) Biopsy. d) Detailed Procedure.
Bone Tumour (benign) curettage / Excision Bone Tumour (benign) curettage / Excision and e) Clinical photograph of affected part. e) Operative Notes.
1446 Orthopedics SB Orthopedics SB042 SB042A 29085 31993 34902 37810 40719 42173 f) Histopathology of curreted tissue.
and bone grafting bone grafting
g) Detailed Discharge summary.
a) Clinical notes with planned line of Treatment a) Detailed Indoor case papers
b) X-ray/MRI labelled with patient ID, date and side b) Procedure / operation notes
(Left/ Right) of affected part c) Histopathology of excised tissue
Bone Tumour Excision (malignant) including Bone Tumour Excision (malignant) including c) Biopsy report d) Clinical d) Invoice and bar code of implant
1447 Orthopedics SB Orthopedics SB040 GCT + Joint replacement SB040A GCT + Joint replacement 85365 93901 102438 110974 119511 123779 photograph of affected part e) Post procedure X-ray labelled with patient
(depending upon type of joint and implant) (depending upon type of joint and implant) ID, date and side (Left/ Right) of affected
part
f) Post Procedure clinical photograph
g) Detailed Discharge Summary
a) Clinical notes with planned line of treatment a) Detailed Indoor Case Papers (ICPs)
(Left/ Right) - affected part ID, date and side (Left/ Right) - affected part
1448 Orthopedics SB Orthopedics SB021 Cervical spine fixation including odontoid SB021A Cervical spine fixation including odontoid 28035 30838 33642 36445 39249 40650 c) Detailed Procedure / Operative Notes
e) Invoice and barcode of implant
planned line of management and advice for c) Post procedure X-ray labelled with patient
1449 Orthopedics SB Orthopedics SB028 Closed reduction of joint dislocation SB028C Elbow 13860 15246 16632 18018 19404 20097 admission ID, date and side (Left/ Right) of affected
b) Clinical photograph of affected part part
c) X-ray labelled with patient ID, date and side d) Post Procedure clinical photograph
(Left/ Right) of affected part e) Discharge Summary
1450 Orthopedics SB Orthopedics SB028 Closed reduction of joint dislocation SB028A Hip 11970 13167 14364 15561 16758 17356 admission ID, date and side (Left/ Right) of affected
1451 Orthopedics SB Orthopedics SB028 Closed reduction of joint dislocation SB028D Knee 11970 13167 14364 15561 16758 17356 admission ID, date and side (Left/ Right) of affected
1452 Orthopedics SB Orthopedics SB028 Closed reduction of joint dislocation SB028B Shoulder 5775 6352 6930 7507 8085 8373 admission ID, date and side (Left/ Right) of affected
a. Clinical notes including evaluation findings, a. Detailed Indoor case papers (ICPs)
indication for procedure, and planned line of
management, advise for the procedure. b. Post op X-ray with film showing fusion with
patient ID, date and side (Left/ Right).
b. MRI report labelled with patient ID, date.
1453 Orthopedics SB Orthopedics SB072 Core Decompression SB072A Core Decompression 14800 16280 17760 19240 20720 21460 c. Detailed procedure / operative notes
evaluation findings, indication for procedure, b) Post procedure clinical photograph with
planned line of management and advice for cast
admission c)Detailed Procedure / Operative Notes
1454 Orthopedics SB Orthopedics SB062 Correction of club foot per cast SB062A Correction of club foot per cast 5985 6583 7182 7780 8379 8678
b) X-ray/MRI labelled with patient ID, date and side d) Post procedure X-ray labelled with patient
(Left/ Right) of affected part ID, date and side (Left/ Right) - affected part
c) Clinical photograph of affected part e) Detailed Discharge summary
a) Clinical notes with planned line of a) Detailed indoor case papers

Surgery/Treatment b) Procedure / operation notes c) Post
b) X-ray/MRI labelled with patient ID, date and side procedure X-ray labelled with patient ID, date
1455 Orthopedics SB Orthopedics SB061 Corrective Surgery for foot deformities SB061B Other foot deformities 15750 17325 18900 20475 22050 22837 (Left/ Right) of affected part and side (Left/ Right) of affected part
c) Clinical photograph of affected part d) Post Procedure clinical photograph
e) Discharge Summary
Outside State
Bed Cost Cost
Cost
a) Clinical notes with planned line of a) Detailed indoor case papers
Surgery/Treatment b) Procedure / operation notes c) Post
b) X-ray/MRI labelled with patient ID, date and side procedure X-ray labelled with patient ID, date
1456 Orthopedics SB Orthopedics SB061 Corrective Surgery for foot deformities SB061A Vertical Talus 15750 17325 18900 20475 22050 22837 (Left/ Right) of affected part and side (Left/ Right) of affected part
c) Clinical photograph of affected part d) Post Procedure clinical photograph
evaluation findings, indication for procedure, b) Post procedure clinical photograph with
planned line of management and advice for cast
admission c) Invoice/bar code of implant
Corrective Surgery in Club Foot / JESS b) X-ray/MRI labelled with patient ID, date and side d) Detailed Procedure / Operative Notes
1457 Orthopedics SB Orthopedics SB063 SB063A Corrective Surgery in Club Foot / JESS Fixator 20000 22000 24000 26000 28000 29000
Fixator (Left/ Right) of affected part e) Post procedure X-ray labelled with patient
c) Clinical photograph of affected part ID, date and side (Left/ Right) - affected part
b) X-ray labelled with patient ID, date and side b) Post-procedure clinical photograph
Debridement & Closure of injuries -
1458 Orthopedics SB Orthopedics SB052 SB052B Anti-biotic + dressing - minimum of 2 sessions 5145 5659 6174 6688 7203 7460 (Left/ Right) - affected part and confirming the c) Evidence of dressing sessions
contused lacerated wounds
diagnosis d) Detailed Procedure / Operative Notes
b) X-ray labelled with patient ID, date and side b) Post-procedure clinical photograph
Debridement & Closure of injuries -
1459 Orthopedics SB Orthopedics SB052 SB052A Anti-biotic + dressing - minimum of 5 sessions 15750 17325 18900 20475 22050 22837 (Left/ Right) - affected part and confirming the c) Evidence of dressing sessions
contused lacerated wounds
diagnosis d) Detailed Procedure / Operative Notes
a) Clinical notes justifying the diagnosis and a) Detailed Indoor case Papers (ICPs)
indication for proceeding with surgery along with b) Post-procedure clinical photograph
planned line of treatment c) Detailed Procedure / Operative Notes
b) X-ray/MRI/PET labelled with patient ID, date and d) Detailed Discharge summary
1460 Orthopedics SB Orthopedics SB027 Disarticulation SB027B Fore quarter 26250 28875 31500 34125 36750 38062
side (Left/ Right) -affected limb
c) Clinical photograph of the affected part showing
the gangrene/injury/severe anatomical deformity
a) Clinical notes justifying the diagnosis and a) Detailed Indoor case Papers (ICPs)
indication for proceeding with surgery along with b) Post-procedure clinical photograph
planned line of treatment c) Detailed Procedure / Operative Notes
b) X-ray/MRI/PET labelled with patient ID, date and d) Detailed Discharge summary
1461 Orthopedics SB Orthopedics SB027 Disarticulation SB027A Hind quarter 32865 36151 39438 42724 46011 47654
side (Left/ Right) -affected limb
c) Clinical photograph of the affected part showing
the gangrene/injury/severe anatomical deformity
evaluation findings, indication for procedure, b) Did the Post-procedure X-ray labelled with
planned line of management and advice for patient ID, date and side (Left/ Right)
admission showing implant?
1462 Orthopedics SB Orthopedics SB017 Displaced Clavicle Fracture SB017A Open Reduction Internal Fixation 20000 22000 24000 26000 28000 29000 b) X-ray labelled with patient ID, date and side c) Post-procedure clinical photographs
(Left/ Right) confirming the diagnosis d) Detailed procedure / Operative Notes
e) Invoice/barcode of Implant used.
f) Discharge summary with follow-up advise
at the time of discharge.
evaluation findings, indication for procedure, b) Post-procedure X-ray films labelled with
planned line of management and advice for patient ID, date and side (Left/ Right) -
Dorsal and lumber spine fixation THROUGH admission affected part
1463 Orthopedics SB Orthopedics SB022 Dorsal and lumber spine fixation SB022A 52500 57750 63000 68250 73500 76125
Anterior approach b) X-ray films labelled with patient ID, date and c) Detailed Procedure / Operative Notes
side (Left/ Right) -affected part d) Detailed Discharge summary
evaluation findings, indication for procedure, b) Post-procedure X-ray films labelled with
planned line of management and advice for patient ID, date and side (Left/ Right) -
Dorsal and lumber spine fixation THROUGH admission affected part
1464 Orthopedics SB Orthopedics SB022 Dorsal and lumber spine fixation SB022B 39375 43312 47250 51187 55125 57093
Posterior approach b) X-ray films labelled with patient ID, date and c) Detailed Procedure / Operative Notes
side (Left/ Right) -affected part d) Detailed Discharge summary
evaluation findings, indication for procedure, b) Post-Procedure clinical photograph
planned line of management and advice for c) Detailed Procedure / Operative Notes
Duputryen’s Contracture release + admission d) Detailed Discharge summary
1465 Orthopedics SB Orthopedics SB051 SB051A Duputryen’s Contracture release + rehabilitation 14490 15939 17388 18837 20286 21010
rehabilitation b) USG report labelled with patient ID, date and
side (Left/ Right) of Affected part
c) Clinical photograph of affected part
indication for procedure, and planned line of b) Detailed procedure / operation notes
management, advise for the procedure. c) Post procedure X-ray labelled with patient
1466 Orthopedics SB Orthopedics SB007 Elastic nailing for fracture fixation SB007A Femur + shaft tibia 11550 12705 13860 15015 16170 16747
b) Clinical photograph of affected part ID, date and side (Left/ Right) - affected part
c) X-ray labelled with patient ID, date and side d) Discharge Summary
(Left/ Right) of affected part
1467 Orthopedics SB Orthopedics SB007 Elastic nailing for fracture fixation SB007C Forearm 18165 19981 21798 23614 25431 26339
1468 Orthopedics SB Orthopedics SB007 Elastic nailing for fracture fixation SB007B Humerus 20055 22060 24066 26071 28077 29079
a) Clinical notes a) Post Procedure clinical photograph
b) X-ray/ CT labelled with patient ID, date and side b) Detailed discharge summary.
(Left/ Right)-affected limb justifying the surgery c) Detailed Procedure / Operative Notes.
1469 Orthopedics SB Orthopedics SB037 Elbow replacement SB037A Elbow replacement 35000 38500 42000 45500 49000 50750 d) Post op X-ray labelled with patient ID,
date and side (Left/ Right)-affected limb,
showing the implant
e) Invoice / bar code of implant
Outside State
Bed Cost Cost
Cost
evaluation findings, indication for procedure, b) Post-operative clinical photograph
1470 Orthopedics SB Orthopedics SB033 Excision Arthoplasty of Femur head SB033A Excision Arthoplasty of Femur head 18375 20212 22050 23887 25725 26643 admission d) Detailed Discharge summary
b) Clinical photograph of affected part
c) X-ray/MRI labelled with patient ID, date and side
(Left/ Right) - affected limb
1471 Orthopedics SB Orthopedics SB064 Excision of Osteochondroma / Exostosis SB064B Exostosis 10500 11550 12600 13650 14700 15225
c) Clinical photograph of affected part d) Detailed Discharge Summary
1472 Orthopedics SB Orthopedics SB064 Excision of Osteochondroma / Exostosis SB064A Osteochondroma 10500 11550 12600 13650 14700 15225
c) Clinical photograph of affected part d) Detailed Discharge Summary
evaluation findings, indication for procedure, b) Post Procedure clinical photograph
planned line of management and advice for c) Detailed procedure / Operative Notes
1473 Orthopedics SB Orthopedics SB069 Exploration and Ulnar nerve Repair SB069A Exploration and Ulnar nerve Repair 10290 11319 12348 13377 14406 14920
admission b) d) Discharge summary with follow-up advise
Radiological investigations confirming the need of at the time of discharge
surgery; +/- NCV report
b) Clinical photograph of affected part b) Post Procedure clinical photograph
1474 Orthopedics SB Orthopedics SB005 External fixation of Fracture SB005D Both bones - forearms + JESS Ligamentotaxis 15000 16500 18000 19500 21000 21750 c) X-ray labelled with patient ID, date and side c) Detailed Procedure / Operative Notes
(Left/ Right) of affected part d) Invoice and barcode of implant
1475 Orthopedics SB Orthopedics SB005 External fixation of Fracture SB005A Long bone 14700 16170 17640 19110 20580 21315 c) X-ray labelled with patient ID, date and side c) Detailed Procedure / Operative Notes
1476 Orthopedics SB Orthopedics SB005 External fixation of Fracture SB005C Pelvis 20160 22176 24192 26208 28224 29232 c) X-ray labelled with patient ID, date and side c) Detailed Procedure / Operative Notes
1477 Orthopedics SB Orthopedics SB005 External fixation of Fracture SB005B Small bone 9975 10972 11970 12967 13965 14463 c) X-ray labelled with patient ID, date and side c) Detailed Procedure / Operative Notes
evaluation findings, indication for procedure, b) Post-Procedure clinical photograph
1478 Orthopedics SB Orthopedics SB050 Fasciotomy SB050A Fasciotomy 11025 12127 13230 14332 15435 15986 admission d) Detailed Discharge summary
b) USG report labelled with patient ID, date and
side (Left/ Right) of Affected part
admission name
Closed Reduction & Internal Fixation of long b) X-ray labelled with patient ID, date and side d) Post procedure X-ray showing implant
1479 Orthopedics SB Orthopedics SB010 Fixation of Diaphyseal Fracture - Long Bone SB010B 21840 24024 26208 28392 30576 31668 (Left/ Right) - affected part labelled with patient ID, date and side (Left/
bones Fixation
c) Clinical Photograph of affected part Right) - affected part
e) Invoice and bar code of implant
g) Discharge Summary
admission name
b) X-ray labelled with patient ID, date and side d) Post procedure X-ray showing implant
1480 Orthopedics SB Orthopedics SB010 Fixation of Diaphyseal Fracture - Long Bone SB010A ORIF Long Bones 21840 24024 26208 28392 30576 31668 (Left/ Right) - affected part labelled with patient ID, date and side (Left/
c) Clinical Photograph of affected part Right) - affected part
e) Invoice and bar code of implant
a) Clinical notes with history, signs, symptoms, a) Detailed Indoor Case Papers (ICPs)
planned line of management and advice for c) Invoice and bar code of implant
1481 Orthopedics SB Orthopedics SB018 Fracture - Acetabulum SB018B ORIF THROUGH combined Approach PLATING 35175 38692 42210 45727 49245 51003 admission d) Post procedure X-ray labelled with patient
b) X-ray labelled with patient ID, date and side ID, date and side (Left/ Right) - affected limb
(Left/ Right) - affected limb e) Discharge Summary
a) Clinical notes with history, signs, symptoms, a) Detailed Indoor Case Papers (ICPs)
planned line of management and advice for c) Invoice and bar code of implant
1482 Orthopedics SB Orthopedics SB018 Fracture - Acetabulum SB018A ORIF THROUGH Single Approach PLATING 29400 32340 35280 38220 41160 42630 admission d) Post procedure X-ray labelled with patient
b) X-ray labelled with patient ID, date and side ID, date and side (Left/ Right) - affected limb
(Left/ Right) - affected limb e) Discharge Summary
evaluation findings, indication for procedure, b) Post-procedure X-ray labelled with patient
planned line of management and advice for ID, date and side (Left/ Right) –Showing
Fracture - Both Bones - Forearm - ORIF - Fracture - Both Bones - Forearm - ORIF - Plating admission implant c) Post procedure clinical
1483 Orthopedics SB Orthopedics SB014 SB014A 16900 18590 20280 21970 23660 24505
Plating / Nailing / Nailing /DCP/LCP b) X-ray labelled with patient ID, date and side photograph
(Left/ Right) – confirming the diagnosis d) Detailed Procedure / Operative Notes
c) Clinical photograph of affected part e) Invoice/barcode of Implant used
1484 Orthopedics SB Orthopedics SB009 Fracture - Long Bones - Metaphyseal - ORIF SB009A Fracture - Long Bones - Metaphyseal - ORIF 17220 18942 20664 22386 24108 24969 of accident (if applicable) c. X- c. Post op X-ray film and report of chest
d. Clinical photograph of affected part e. Detailed discharge summary
Outside State
Bed Cost Cost
Cost
A)Clinical notes. B)X-ray A)Post procedure imaging study (X Ray).
confirming the diagnosis. B)Post Procedure clinical photgraph.
Closed Reduction and Percutaneous Screw C)Clinical photograph of affected part. C)Detailed Procedure. D)Operative Notes.
1485 Orthopedics SB Orthopedics SB019 Fracture - Neck Femur SB019A 16275 17902 19530 21157 22785 23598
Fixation E)Invoice. F)Barcode of
implant.

ORIF Intertrochanteric Fracture with Dynamic C)Clinical photograph of affected part. C)Detailed Procedure. D)Operative Notes.
1486 Orthopedics SB Orthopedics SB019 Fracture - Neck Femur SB019B 19320 21252 23184 25116 27048 28014
Hip Screw E)Invoice. F)Barcode of
implant.

ORIF Intertrochanteric Fracture with Proximal C)Clinical photograph of affected part. C)Detailed Procedure. D)Operative Notes.
1487 Orthopedics SB Orthopedics SB019 Fracture - Neck Femur SB019C 16900 18590 20280 21970 23660 24505
Femoral Nail E)Invoice. F)Barcode of
implant.
planned line of management and advice for ID, date and side (Left/ Right) –Showing
Fracture - Single Bone - Forearm - ORIF - Fracture - Single Bone - Forearm - ORIF - admission implant c) Post procedure clinical
Plating / Nailing Plating / Nailing/DCP/LCP b) X-ray labelled with patient ID, date and side photograph
(Left/ Right) – confirming the diagnosis d) Detailed Procedure / Operative Notes
c) Clinical photograph of affected part e) Invoice/barcode of Implant used
A)Clinical notes. B)X-ray A)Post Procedure clinical photgraph.
confirming the diagnosis. B)Post procedure X-rayshowing implant.
C)Clinical photograph of affected part. C)Detailed Procedure. D)Operative Notes .
1489 Orthopedics SB Orthopedics SB015 Fracture Condyle - Humerus - ORIF SB015A Lateral Condyle 8925 9817 10710 11602 12495 12941
E)Detailed discharge summary. E)Invoice.
F)Barcode of implant.
planned line of management and advice for b. Post-procedure X-ray labelled with patient
admission ID, date and side (Left/ Right) –Showing
implant
b. X-ray labelled with patient ID, date and side
(Left/ Right) – confirming the diagnosis c. Post procedure clinical photograph
1490 Orthopedics SB Orthopedics SB015 Fracture Condyle - Humerus - ORIF SB078A ORIF with screw of proximal humerus 8925 9817 10710 11602 12495 12941
c. Clinical photograph of affected part d. Detailed Procedure / Operative Notes
e. Invoice or barcode of Implant used

(optional)
f. Detailed Discharge summary

A)Clinical notes. B)X-ray A)Clinical notes. B)X-
1491 Orthopedics SB Orthopedics SB015 Fracture Condyle - Humerus - ORIF SB015B ORIF with screw/wire of Medial Condyle 8925 9817 10710 11602 12495 12941 confirming the diagnosis. ray confirming the diagnosis.
C)Clinical photograph of affected part. C)Clinical photograph of affected part.
a) Clinical notes detailing indication a) Indoor case papers
b) Clinical photograph of affected part b) Procedure / operation notes
1492 Orthopedics SB Orthopedics SB012 Fracture Head radius SB012B Excision 9660 10626 11592 12558 13524 14007 (Left/ Right) - affected part ID, date and side (Left/ Right) - affected part

(Left/ Right) - affected part ID, date and side (Left/ Right) - affected part
1493 Orthopedics SB Orthopedics SB012 Fracture Head radius SB012A Fixation 10500 11550 12600 13650 14700 15225
a. Clinical notes including evaluation findings and a. Indoor case papers

planned line
of treatment b. Procedure / operation notes
b. Clinical photograph of affected part c. Post procedure X-ray labelled with patient
ID,
1494 Orthopedics SB Orthopedics SB012 Fracture Head radius SB077A Replacement with Head Radius Prosthesis 10500 11550 12600 13650 14700 15225 C. X-ray labelled with patient ID, date and date and side (Left/ Right) - affected part
side (Left/ Right) - affected part
d. Invoice and barcode of implant
e. Post Procedure clinical photograph
f. Discharge Summary
Fracture intercondylar Humerus + olecranon ORIF Fracture intercondylar Humerus + (Left/ Right) - affected part ID, date and side (Left/ Right) - affected part
osteotomy olecranon osteotomy + TBW d) Invoice and barcode of implant
planned line of management and advice for ID, date and side (Left/ Right) - affected limb
1496 Orthopedics SB Orthopedics SB060 Growth Modulation and fixation SB060A Growth Modulation and fixation 5985 6583 7182 7780 8379 8678 admission c) Detailed Procedure / Operative Notes
b) X-ray labelled with patient ID, date and side d) Invoice and bar code of implant
(Left/ Right) - affected limb e) Detailed Discharge summary
Outside State
Bed Cost Cost
Cost
A)Clinical notes. B)X-ray. A)Post Procedure clinical photgraph.
C)CT justifying the surgery. B)Detailed discharge summary. C)Detailed
Procedure. D)Operative Notes.
1497 Orthopedics SB Orthopedics SB031 Hemiarthroplasty SB031C Bipolar (Modular) cemented/non cemented 18270 20097 21924 23751 25578 26491 E)Post op X-ray showing the implant.
F)Invoice. G)Bar
code of implant.

Bipolar (Non - Modular) cemented /non E)Post op X-ray showing the implant.
1498 Orthopedics SB Orthopedics SB031 Hemiarthroplasty SB031B 18270 20097 21924 23751 25578 26491
cemented F)Invoice. G)Bar
code of implant.

1499 Orthopedics SB Orthopedics SB031 Hemiarthroplasty SB031A Unipolar 18270 20097 21924 23751 25578 26491 E)Post op X-ray showing the implant.
F)Invoice. G)Bar
code of implant.
a) Clinical notes with indication for surgery a) Post operation clinical photograph
b) Weightbearing (FLWB)/ Standing X-ray labelled b) Post op X-ray is labelled with patient ID,
with patient ID, date and side (Left/ Right)-affected date and side (Left/ Right) showing affected
1500 Orthopedics SB Orthopedics SB057 High Tibial Osteotomy SB057A High Tibial Osteotomy 16800 18480 20160 21840 23520 24360
limb justifying the indication; part.
c) Detailed operative note
planned line of management and advice for c) Post procedure clinical photograph
admission d) Post procedure X-ray showing implant
1501 Orthopedics SB Orthopedics SB058 Ilizarov Fixation SB058A Ilizarov Fixation 15750 17325 18900 20475 22050 22837 b) Radiological investigations confirming the labelled with patient ID, date and side (Left/
diagnosis Right) - affected part
c) Clinical photograph of affected part e) Intra procedure still pictures
f) Invoice/barcode of implant
indication for procedure, and planned line of b) Post-op X-ray labelled with patient ID, date
management, advise for the procedure. and side (Left/ Right) - confirm the removal
1502 Orthopedics SB Orthopedics SB070 Implant Removal under LA SB070A K - Wire 5250 5775 6300 6825 7350 7612
b) X-ray labelled with patient ID, date and side of Implant
(Left/ Right) - affected part c) Detailed procedure / operative notes
1503 Orthopedics SB Orthopedics SB070 Implant Removal under LA SB070B Screw 5250 5775 6300 6825 7350 7612
1504 Orthopedics SB Orthopedics SB071 Implant Removal under RA / GA SB071A Nail 15750 17325 18900 20475 22050 22837
1505 Orthopedics SB Orthopedics SB071 Implant Removal under RA / GA SB071B Plate 15750 17325 18900 20475 22050 22837
planned line of management and advice for ID, date and side (Left/ Right) showing
admission implant
1506 Orthopedics SB Orthopedics SB008 Internal Fixation of Small Bones SB008A ORIF Small Bones 11865 13051 14238 15424 16611 17204 b) X-ray labelled with patient ID, date and side c) Post-operative photographs
(Left/ Right) d)Detailed procedure / Operative Notes
c) Clinical photograph of affected part e) Invoice of Implant
f) Discharge summary with follow-up advise.
planned line of management and advice for c) Post procedure clinical photograph
admission d) Post procedure X-ray showing implant
Limb Lengthening / Bone Transport by b) Radiological investigations confirming the labelled with patient ID, date and side (Left/
1507 Orthopedics SB Orthopedics SB059 SB059A Limb Lengthening / Bone Transport by Ilizarov 24885 27373 29862 32350 34839 36083
Ilizarov diagnosis Right) - affected part
c) Clinical photograph of affected part e) Intra procedure still pictures
f) Invoice/barcode of implant
1508 Orthopedics SB Orthopedics SB067 Nerve Repair Surgery SB067A Nerve Repair Surgery 14490 15939 17388 18837 20286 21010
admission d) Discharge summary with follow-up advise
b) MRI / EMG/ NCV report to confirm the diagnosis at the time of discharge
b) EMG/NCV/MRI labelled with patient ID, date b) Detailed Procedure / operation notes
1509 Orthopedics SB Orthopedics SB066 Nerve Transposition / Release / Neurolysis SB066C Nerve Neurolysis 13650 15015 16380 17745 19110 19792
and side (Left/ Right) of affected part c) Post procedure clinical photograph
1510 Orthopedics SB Orthopedics SB066 Nerve Transposition / Release / Neurolysis SB066B Nerve Release 13650 15015 16380 17745 19110 19792
1511 Orthopedics SB Orthopedics SB066 Nerve Transposition / Release / Neurolysis SB066A Nerve Transposition 13650 15015 16380 17745 19110 19792
Outside State
Bed Cost Cost
Cost
a) Clinical notes confirming CDH a) Post-op X-ray labelled with patient ID, date
b) X-ray/Ultrasonography –both Hips confirming and side (Left/ Right)
1512 Orthopedics SB Orthopedics SB034 Open Reduction of CDH SB034A Open Reduction of CDH 21000 23100 25200 27300 29400 30450 CDH labelled with patient ID, date. b) Post Procedure clinical photograph
c) Clinical photograph c) detailed Procedure / Operative Notes
evaluation findings, indication for procedure, b) Post-op X-ray -ray labelled with patient ID,
planned line of management and advice for date and side (Left/ Right) - affected limb
Open Reduction of Small Joint without admission c) Post procedure clinical photograph
1513 Orthopedics SB Orthopedics SB029 Open Reduction of Small Joint SB029A fixation/Open Reduction of Small Joint with 8925 9817 10710 11602 12495 12941
b) X-ray labelled with patient ID, date and side d) Invoice and barcode of implant
fixation (Left/ Right) - affected limb e) Detailed Procedure / Operative Notes
c) Clinical photograph of child/Patient f) Detailed Discharge summary
evaluation findings, indication for procedure, b) Procedure / operation notes c) Post
planned line of management and advice for procedure X-ray with patient ID, date and
1514 Orthopedics SB Orthopedics SB055 Osteotomy SB055A Long Bone 20000 22000 24000 26000 28000 29000 admission side (Left/ Right)
b) X-ray with patient ID, date and side (Left/ Right) - d) Invoice and barcode of implant
affected part justifying the procedure e) Post procedure clinical photograph
c) Clinical photograph of affected part f) Discharge Summary
evaluation findings, indication for procedure, b) Procedure / operation notes c) Post
planned line of management and advice for procedure X-ray with patient ID, date and
1515 Orthopedics SB Orthopedics SB055 Osteotomy SB055B Small Bone 10500 11550 12600 13650 14700 15225 admission side (Left/ Right)
b) X-ray with patient ID, date and side (Left/ Right) - d) Post procedure clinical photograph
affected part justifying the procedure e) Discharge Summary
a) Clinical notes a) Post Procedure clinical photograph
b) X-ray of the patella justifying the procedure with b) Post procedure imaging study (X Ray)
1516 Orthopedics SB Orthopedics SB035 Patellectomy SB035A Patellectomy 11550 12705 13860 15015 16170 16747
patient ID, date and side (Left/ Right) c) Detailed Procedure / Operative Notes.
c) Clinical photograph of affected part d) Detailed discharge summary.
evaluation findings, indication for procedure, b) Post-procedure clinical photograph
planned line of management and advice for c) Post procedure imaging study (X Ray)
1517 Orthopedics SB Orthopedics SB056 Pelvic Osteotomy and fixation SB056A Pelvic Osteotomy and fixation 21000 23100 25200 27300 29400 30450 admission pelvis labelled with patient ID, date and side
b) Clinical photograph of affected part (Left/ Right)
c) X-ray of pelvis labelled with patient ID, date and d) Detailed Procedure / Operative Notes
side (Left/ Right) e) Detailed Discharge summary
1518 Orthopedics SB Orthopedics SB006 Percutaneous - Fixation of Fracture SB006A Percutaneous - Fixation of Fracture 3150 3465 3780 4095 4410 4567
admission name
b) MRI scan of affected part labelled with patient (In case of Arthroscopic surgery)
Reconstruction of Cruciate Ligament with ID, date and side (Left/ Right) d) Post procedure X-ray showing implant
1519 Orthopedics SB Orthopedics SB049 SB049A Anterior 33810 37191 40572 43953 47334 49024 c) Clinical Photograph of affected part labelled with patient ID, date and side (Left/
implant and brace
Right) - affected part
e) Invoice and bar code of implant ensure
brace is provided in package cost.
admission name
b) MRI scan of affected part labelled with patient (In case of Arthroscopic surgery)
Reconstruction of Cruciate Ligament with ID, date and side (Left/ Right) d) Post procedure X-ray showing implant
1520 Orthopedics SB Orthopedics SB049 SB049B Posterior 33810 37191 40572 43953 47334 49024 c) Clinical Photograph of affected part labelled with patient ID, date and side (Left/
implant and brace
Right) - affected part
e) Invoice and bar code of implant ensure
brace is provided in package cost.
evaluation findings, indication for procedure, b) Post-op X-ray labelled with patient ID, date
planned line of management and advice for and side (Left/ Right) - affected part
1521 Orthopedics SB Orthopedics SB053 Sequestectomy / Curettage SB053A Sequestectomy / Curettage 10500 11550 12600 13650 14700 15225
admission c) Detailed Procedure / Operative Notes
b) X-ray/CT labelled with patient ID, date and side d) Detailed Discharge summary
(Left/ Right) - affected part
1522 Orthopedics SB Orthopedics SB043 Single Stage Amputation SB043A Above Elbow 16334 17967 19600 21234 22867 23684
1523 Orthopedics SB Orthopedics SB043 Single Stage Amputation SB043C Above Knee 19000 20900 22800 24700 26600 27550
1524 Orthopedics SB Orthopedics SB043 Single Stage Amputation SB043B Below Elbow 17010 18711 20412 22113 23814 24664
1525 Orthopedics SB Orthopedics SB043 Single Stage Amputation SB043D Below Knee 19530 21483 23436 25389 27342 28318
Outside State
Bed Cost Cost
Cost
1526 Orthopedics SB Orthopedics SB043 Single Stage Amputation SB043E Foot 19530 21483 23436 25389 27342 28318
1527 Orthopedics SB Orthopedics SB043 Single Stage Amputation SB043F Hand 19530 21483 23436 25389 27342 28318
1528 Orthopedics SB Orthopedics SB043 Single Stage Amputation SB043G Wrist 19530 21483 23436 25389 27342 28318
a. Clinical notes confirming the diagnosis a. Clinical notes confirming the diagnosis
b. MRI with patient ID, date and side (Left/ Right) b. MRI with patient ID, date and side (Left/
Combined spinal segment - front and back of affected part justifying surgery Right) of affected part justifying surgery
(anterior/posterior/ combined anterior and
1529 Orthopedics SB Orthopedics SB054 Spine deformity correction SB080A 47250 51975 56700 61425 66150 68512 c. X-ray with film with patient ID, date and
posterior) For 8 to 10 screws for Spine deformity
correction side (Left/ Right) of affected part
a. Clinical notes confirming the diagnosis a. Clinical notes confirming the diagnosis
b. MRI with patient ID, date and side (Left/ Right) b. MRI with patient ID, date and side (Left/
Combined spinal segment - front and back of affected part justifying surgery Right) of affected part justifying surgery
(anterior/posterior/ combined anterior and
1530 Orthopedics SB Orthopedics SB054 Spine deformity correction SB080B 57750 63525 69300 75075 80850 83737 c. X-ray with film with patient ID, date and
posterior) More than 10 screws for Spine
deformity correction side (Left/ Right) of affected part

b) X-ray with film with patient ID, date and side b) Detailed Procedure / operation notes
(Left/ Right) of affected part c) Post-operative X-ray with film showing
1531 Orthopedics SB Orthopedics SB054 Spine deformity correction SB054A For 8 to 10 screws for Spine deformity correction 47250 51975 56700 61425 66150 68512 implant labelled with patient ID, date and side
b) X-ray with film with patient ID, date and side b) Detailed Procedure / operation notes
(Left/ Right) of affected part c) Post-operative X-ray with film showing
More than 10 screws for Spine deformity implant labelled with patient ID, date and side
1532 Orthopedics SB Orthopedics SB054 Spine deformity correction SB054B 57750 63525 69300 75075 80850 83737
correction (Left/ Right) of affected part
Surgery for Comminuted Fracture - (Left/ Right) - affected part ID, date and side (Left/ Right) - affected part
1533 Orthopedics SB Orthopedics SB011 SB011A Plating olecrenon fracture, ulna 12390 13629 14868 16107 17346 17965
Olecranon of Ulna d) Invoice and barcode of implant
planned line of management and advice for c) Post Procedure clinical photograph of
admission affected part (of donor and recipient sites- for
1534 Orthopedics SB Orthopedics SB046 Tendon Grafting / Repair SB046A Tendon Grafting 16380 18018 19656 21294 22932 23751 b) Clinical photograph of affected part tendon graft) (Only for Tendon grafting)
d) Post Procedure clinical photograph of
affected part
1535 Orthopedics SB Orthopedics SB046 Tendon Grafting / Repair SB046B Tendon Repair 16380 18018 19656 21294 22932 23751 b) Clinical photograph of affected part tendon graft) (Only for Tendon grafting)
affected part
1536 Orthopedics SB Orthopedics SB047 Tendon Release / Tenotomy SB047A Tendon Release / Tenotomy 5250 5775 6300 6825 7350 7612 b) Clinical photograph of affected part tendon graft) (Only for Tendon grafting)
affected part
1537 Orthopedics SB Orthopedics SB048 Tenolysis SB048A Tenolysis 5250 5775 6300 6825 7350 7612 planned line of management and advice for c) Detailed procedure/operative notes
admission including agent used for lysis of tendon
b) Clinical photograph of affected part d) Detailed Discharge Summary
evaluation findings, indication for procedure, b) Post-op X-ray labelled with patient ID, date
planned line of management and advice for and side (Left/ Right) - affected limb
1538 Orthopedics SB Orthopedics SB030 Tension Band Wiring SB030A Tension Band Wiring 13650 15015 16380 17745 19110 19792
admission c) Invoice and barcode of implant
b) X-ray labelled with patient ID, date and side d) Detailed Procedure / Operative Notes
(Left/ Right) - affected limb e) Detailed Discharge summary
Outside State
Bed Cost Cost
Cost
a )Clinical notes with indication for surgery a) Indoor case papers b) Post op
b) X-ray / CT of Hip labelled with patient ID, date clinical photograph c) Post op X-ray showing
and side (Left/ Right) the implant. The X-ray is labelled with patient
1539 Orthopedics SB Orthopedics SB038 Total Hip Replacement SB038A Cemented 64680 71148 77616 84084 90552 93786
ID, date and side (Left/ Right)
d ) Invoice / bar code of implant
e) Detailed OT note
1540 Orthopedics SB Orthopedics SB038 Total Hip Replacement SB038B Cementless 48615 53476 58338 63199 68061 70491
e) Detailed OT note
1541 Orthopedics SB Orthopedics SB038 Total Hip Replacement SB038C Hybrid 66885 73573 80262 86950 93639 96983
e) Detailed OT note
1542 Orthopedics SB Orthopedics SB038 Total Hip Replacement SB038D Revision - Total Hip Replacement 140000 154000 168000 182000 196000 203000
c) Pre-op X – ray of the affected hip shows implant ID, date and side (Left/ Right)
e) Detailed OT note
a. Clinical notes with indication for surgery a. Indoor case papers
b. Post op clinical photograph
b. X-ray / CT of Hip labelled with patient ID, date c. Post op X-ray showing the implant. The X-
and side (Left/ Right) ray is labelled with patient ID, date and side
1543 Orthopedics SB Orthopedics SB038 Total Hip Replacement SB079A Revision of failed hemi Arthroplasty in to THR 55125 60637 66150 71662 77175 79931 (Left/ Right)
c. Pre-op X – ray of the affected hip shows d. Invoice / bar code of implant
implant e. Detailed OT note
f. Discharge Summary
a) Clinical notes with indication for surgery a) Indoor case papers b) Post op
b) X-ray / CT of Knee labelled with patient ID, date clinical photograph c) Post op X-ray of the
and side (Left/ Right) operated knee showing the implant. The X-
ray is labelled with patient ID, date and side
1544 Orthopedics SB Orthopedics SB039 Total Knee Replacement SB039A Primary - Total Knee Replacement 100000 110000 120000 130000 140000 145000
(Left/ Right) d) Invoice / bar
code of implant e) Detailed operative /
procedure note f) Discharge
Summary
a) Clinical notes with indication for surgery a) Indoor case papers b) Post op
b) X-ray / CT of Knee labelled with patient ID, date clinical photograph c) Post op X-ray of the
and side (Left/ Right) c) operated knee showing the implant. The X-
Pre-op X – ray of the affected knee shows implant ray is labelled with patient ID, date and side
1545 Orthopedics SB Orthopedics SB039 Total Knee Replacement SB039B Revision - Total Knee Replacement 130000 143000 156000 169000 182000 188500
(Left/ Right) d) Invoice / bar
code of implant e) Detailed operative /
procedure note f) Discharge
Summary
1546 Orthopedics SB Orthopedics SB044 Two Stage Amputation SB044A Above Elbow 24360 26796 29232 31668 34104 35322
1547 Orthopedics SB Orthopedics SB044 Two Stage Amputation SB044C Above Knee 24360 26796 29232 31668 34104 35322
1548 Orthopedics SB Orthopedics SB044 Two Stage Amputation SB044B Below Elbow 24360 26796 29232 31668 34104 35322
1549 Orthopedics SB Orthopedics SB044 Two Stage Amputation SB044D Below Knee 24360 26796 29232 31668 34104 35322
1550 Orthopedics SB Orthopedics SB044 Two Stage Amputation SB044E Foot 24360 26796 29232 31668 34104 35322
1551 Orthopedics SB Orthopedics SB044 Two Stage Amputation SB044F Hand 24360 26796 29232 31668 34104 35322
1552 Orthopedics SB Orthopedics SB044 Two Stage Amputation SB044G Wrist 24360 26796 29232 31668 34104 35322
a) Clinical notes detailing findings confirming the a) Post-procedure clinical photograph
diagnosis b) Detailed Procedure / Operative Notes
Orthopedics, b) Clinical photograph of the affected part c) Detailed Discharge summary
1553 Orthopedics SB SB065 Excision of Bursa SB065A Excision of Bursa 3150 3465 3780 4095 4410 4567
General Surgery c) X-ray labelled with patient ID, date and side
(Left/ Right) -affected part justifying the indication.
Outside State
Bed Cost Cost
Cost
evaluation findings, indication for procedure, b) Post procedure X-ray labelled with patient
Orthopedics, Emergency Fracture - Conservative Management - Fracture - Conservative Management - planned line of management and advice for ID, date and side (Left/ Right) of affected
1554 Orthopedics SB SB001 SB001A 2415 2656 2898 3139 3381 3501
Room Packages Without plaster Without plaster admission part
b) X-ray of affected part labelled with patient ID, c) Detailed Procedure / Operative Notes
date and side (Left/ Right) d) Detailed Discharge summary
1555 Orthopedics SB Orthopedics, Neurosurgery SB068 Nerve root block SB068A Nerve root block 3150 3465 3780 4095 4410 4567
admission b) X- d) Discharge summary with follow-up advise
ray of affected part labelled with patient ID, date at the time of discharge
and side (Left/ Right)
Orthopedics, Surgical (Left/ Right) of affected part ID, date and side (Left/ Right) of affected
1556 Orthopedics SB SB026 Arthrodesis SB026F Foot 28350 31185 34020 36855 39690 41107
Oncology part
Orthopedics, Surgical (Left/ Right) of affected part ID, date and side (Left/ Right) of affected
1557 Orthopedics SB SB026 Arthrodesis SB026E Hand 28350 31185 34020 36855 39690 41107
Oncology part
A)Clinical notes justifying need of this surgery. a) Post procedure imaging study (X Ray).
B)X-ray. b) Post procedure clinical photgraph.
C)MRI of affected part. c) Detailed Procedure.
Orthopedics, Surgical D)Biopsy. d) Operative Note.
1558 Orthopedics SB SB041 Bone Tumour Excision + reconstruction SB041A Bone Tumour Excision + reconstruction 39375 43312 47250 51187 55125 57093
Oncology E)Clinical photograph of affected part. e) Detailed discharge summary.
f) Invoice and barcode of implant.
1.Treatment records for primary cancer including a) Detailed Indoor case papers with
Tumour board report and all high end imaging treatment details
reports,histpathology report,USg reports b) Detailed procedure notes
etc,2.Clinical note or other document proving c) Detailed Discharge Summary,d)relevant
Celiac Plexus Block/Hypogastric plexus continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
Anaesthesiology/Pain
1559 Palliative Medicine PM PM041 block/ganglion impar block and Neurolysis in PM041A Cancer pain plexus interventions 11550 12705 13860 15015 16170 16747 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
specialists/Radiology
advanced cancer patients continuiing symptomatic clinical device/implant used,g)Pre op and post op
condition,4.Palliative plan of management as per Xray/CT/MRI /LymphoScintigraphyreport(If
TBR reqd)
Anaesthesiology/Pain Spinal/Epidural/Regional Nerve block, continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1560 Palliative Medicine PM PM040 PM040A Cancer pain interventions 8715 9586 10458 11329 12201 12636 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
specialists/Radiology Radiofrequency ablation (RFA) for analgesia
continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Cardiac, Neuro, Pulmonary, Palliative and supportive care for non- continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1561 Palliative Medicine PM Nephrology & Geriatric PM039 malignant disease at advanced or end PM039C Palliative care end stage disease 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
Medicine stage continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Cardiac, Neuro, Pulmonary, Palliative and supportive care for non- continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1562 Palliative Medicine PM Nephrology & Geriatric PM039 malignant disease at advanced or end PM039D Palliative care end stage disease 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
Medicine stage continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
General medicine/Medical Management of Diarrhea in cancer patients - continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1563 Palliative Medicine PM PM038 PM038A Palliative care in Diarrhoea 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
& Radiation Oncology Conservative management
TBR reqd)
Palliative care management of Nausea & continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
Medical & Radiation
1564 Palliative Medicine PM PM037 Vomiting in cancer patients-Conservative PM037A Pallitive care in Nausea and vomiting. 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
Oncology
management continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Outside State
Bed Cost Cost
Cost
Medical / Radiation continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1565 Palliative Medicine PM PM036 PALLIATIVE CARE MANAGEMENT PM036B Thrombosis and Embolism in chronic disease 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
Oncology
TBR reqd)
Medical / Surgical oncology/ etc,2.Clinical note or other document proving c) Detailed Discharge Summary,d)relevant
gastroenterology / / continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1566 Palliative Medicine PM PM036 PALLIATIVE CARE MANAGEMENT PM036A Palliative Bowel Obstruction interventions 46200 50820 55440 60060 64680 66990 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
Radiation Oncology &
Radiology continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Palliative Care Management of Constipation continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1567 Palliative Medicine PM Medical Oncology PM034 in advanced cancer patients - Conservative PM034A Palliative care in Constipation 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
menagament continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Palliative Care management of Malignant continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
Palliative care in Bowel Obstruction Conservative
1568 Palliative Medicine PM Medical Oncology PM035 bowel obstruction -Conservative PM035A 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
management
TBR reqd)
Medical, Surgical Radiation continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1569 Palliative Medicine PM PM033 Vertebroplasty/Kyphoplasty PM033A Vertebroplasty/Kyphoplasty 46200 50820 55440 60060 64680 66990 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
Oncology / Orthopaedics
TBR reqd)
Palliative Radiological Interventions. Like- continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
Medical/Surigal & Radiation Palliative Radiological and endoscopical
1570 Palliative Medicine PM PM032 PM032A PTBD/ERCP/PCN//Pericardiostomy, DJ 23100 25410 27720 30030 32340 33495 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
Oncology Interventions
Stenting, etc continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Palliative Care Management of etc,2.Clinical note or other document proving c) Detailed Discharge Summary,d)relevant
Medical/Surigal / Radiation Lymphadema in cancer patients including continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1571 Palliative Medicine PM PM031 PM031A Conservative management of Lymphedema 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
oncology (Information, Education, Communication
(IEC), and pneumatic compression therapy continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Palliative Care Management of Constipation etc,2.Clinical note or other document proving c) Detailed Discharge Summary,d)relevant
Medical/Surigal / Radiation in advanced cancer patients - continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1572 Palliative Medicine PM PM029 PM029A Constipation - Palliative Invasive interventions 34650 38115 41580 45045 48510 50242 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
oncology & Radiology endoscopic/Surgical/Radiological
interventions continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Palliative care management of Nausea etc,2.Clinical note or other document proving c) Detailed Discharge Summary,d)relevant
Medical/Surigal / Radiation &Vomiting in advanced cancer patients- continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1573 Palliative Medicine PM PM030 PM030A Pallitive Nausea and vomiting interventions 34650 38115 41580 45045 48510 50242 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
Oncology & Radiology Endoscopic/Surgical/Radiological,
Radiotherapy interventions. continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Outside State
Bed Cost Cost
Cost
Palliative Care approach for malignant etc,2.Clinical note or other document proving c) Detailed Discharge Summary,d)relevant
Medical/Surigal wound -Conservative management using continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1574 Palliative Medicine PM PM028 PM028A Palliative Wound Conservative management 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
Oncology/Radiotherapy drugs and dressings including special
dressings. continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Symptom Management of Delirium in continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
Medical/Surigal/ Radiation
1575 Palliative Medicine PM PM027 advanced chronic diseases -Conservative PM027A Palliative Delirium in advance chronic disease 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
Oncology
TBR reqd)
Palliative care management of etc,2.Clinical note or other document proving c) Detailed Discharge Summary,d)relevant
Medical/Surigal/ Radiation Breathlessness in advanced cancers and continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1576 Palliative Medicine PM Oncology and Pulmonary PM026 chronic respiraroty diseases- PM026A Palliative Breathlessness Intervntions 46200 50820 55440 60060 64680 66990 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
Medicine endoscopic/Surgical/Radiological, continuiing symptomatic clinical device/implant used,g)Pre op and post op
Radiotherpay interventions condition,4.Palliative plan of management as per Xray/CT/MRI /LymphoScintigraphyreport(If
TBR reqd)
Symptom Management of Cough in etc,2.Clinical note or other document proving c) Detailed Discharge Summary,d)relevant
Medical/Surigal/ Radiation continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
advanced cancer patients-
1577 Palliative Medicine PM Oncology and Pulmonary PM025 PM025A Malignant Cough- Invasive intervantions 46200 50820 55440 60060 64680 66990 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
endoscopic/Surgical/Radiological/Radiotherp
Medicine continuiing symptomatic clinical device/implant used,g)Pre op and post op
ay interventions
TBR reqd)
Medical/Surigal/Radiation Malignant Ascites drainage with catheter Management of malignant Ascitis,Tapping & continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1578 Palliative Medicine PM PM024 PM024A 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
Oncology & Radiology insertion in advanced cancer patients conservative management
TBR reqd)
Medical/Surigal/Radiation Malignant Pleural Effusion for Pleural tap continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1579 Palliative Medicine PM Oncology and Pulmonary PM023 with Pig tail catheter/chest tube insertion with PM023A Pleural effusion & Pleurodesis 8715 9586 10458 11329 12201 12636 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
Medicine Pleurodesis in advanced cancer patients continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Central lines in cancer patients for drug continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
Pallative medicine/medical
1580 Palliative Medicine PM PM018 therapy -Silicon catheters in advanced PM018A Long term indwelling venous catheter 11550 12705 13860 15015 16170 16747 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
oncology
cancer patients- Long term central lines continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Malignant Ascites drainage with long term continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1581 Palliative Medicine PM PM016 catheter insertion in advanced cancer PM016A Ascitis tapping with long term indwelling catheter 46200 50820 55440 60060 64680 66990 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
oncology
patients continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Pallative medicine/medical Management of terminal /fatal bleeding Conservative management of fatal bleeding in continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1582 Palliative Medicine PM PM021 PM021A 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
oncology malignant head and neck / inguinal lesions cancer patients
TBR reqd)
Outside State
Bed Cost Cost
Cost
Palliative Care Approach to managing continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1583 Palliative Medicine PM PM017 Haematuria in advanced cancer patients - PM017A Hematuria in advance cancer patient 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
oncology
Conservative management continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Palliative Care Management of Symptom continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1584 Palliative Medicine PM PM022 Cluster – Fatigue in advanced cancer PM022A Fatigue in Palliative care 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
oncology
patients continuiing symptomatic clinical device/implant used,g)Pre op and post op
TBR reqd)
Pallative medicine/medical Palliative Care Management of Trismus, continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1585 Palliative Medicine PM PM020 PM020A Palliative care in Trismus mucositis 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
oncology mucositis in advanced cancer patient
TBR reqd)
Symptom Management of Cough in continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
Pallative medicine/medical Intractable Cough in cancer patients -
1586 Palliative Medicine PM PM019 advanced cancer patients -Conservative PM019A 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
oncology Conservative management
TBR reqd)
1.Treatment records for primary cancer including 1.Plan of communication with detail steps
Tumour board report and all high end imaging with qualification of Counselling
Communications in Adavnced chronic reports,histpathology report,USg reports person.2.Consent form of
diseases/ terminal stage of illness, for etc,2.Clinical note or other document proving relatives/patient.3Complete diagnosis and
Palliativemedcine /general Communications terminal stage/ end of life care
1587 Palliative Medicine PM PM010 patient and family members with discussions PM010A 2350 2585 2820 3055 3290 3407
medicine Conservative continuing haematuria despite trt as per management synopsis of concerned
on Goals of care and facilitated shared TBR,3.investigation report suggesting continuiing malignancy/terminal disease.
decision making haematuria,Palliative plan of management as per
TBR
Conservative management of post etc,2.Clinical note or other document proving c) Detailed Discharge Summary,d)relevant
procedural or teratment related continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
Palliativemedcine /general
1588 Palliative Medicine PM PM015 complications in palliative medicine including PM015A Complications in palliative care patients 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
medicine
electrolyte disorders (including continuiing symptomatic clinical device/implant used,g)Pre op and post op
hypercalcemia and ketoacidosis). condition,4.Palliative plan of management as per Xray/CT/MRI /LymphoScintigraphyreport(If
TBR reqd)
Palliativemedcine /general Palliative Care approach to managing continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1589 Palliative Medicine PM PM013 PM013A Pressure sore-in palliative care 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
medicine Pressure sore -Conservative management
TBR reqd)
Palliative care management of etc,2.Clinical note or other document proving c) Detailed Discharge Summary,d)relevant
Palliativemedcine /general Breathlessness in advanced cancers and continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1590 Palliative Medicine PM PM011 PM011A Palliative Management of Breathlessnes 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
medicine chronic respiratory diseases -Conservative
TBR reqd)
Palliativemedcine /general Palliative Care Management of Pain for continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1591 Palliative Medicine PM PM012 PM012A Cancer Pain Management 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
medicine treating Pain crisis, analgesic titration
TBR reqd)
Palliativemedcine /general continuing symptomatic clinical condition despite trt Investigation repot, e)Any other document
1592 Palliative Medicine PM PM014 Palliative Care Package for Hiccups PM014A Hiccups in Palliative care 2350 2585 2820 3055 3290 3407 as per TBR,3.investigation report suggesting reqd by CPD/SNA,f)Invoice of assisted
medicine
TBR reqd)
Outside State
Bed Cost Cost
Cost
Palliative Care Management of continuing haematuria despite trt as per Investigation repot, e)Any other document
palliativemedicine / TBR,3.investigation report suggesting continuiing reqd by CPD/SNA,f)Invoice of assisted
1593 Palliative Medicine PM PM009 Osteoradionecrosis -Conservative PM009A Osteoradionecrosis -Conservative 2350 2585 2820 3055 3290 3407
orthopedics haematuria,Palliative plan of management as per device/implant used,g)Pre op and post op
management
TBR Xray/CT/MRI /LymphoScintigraphyreport(If
reqd),g0Plan of management
Malignant Spinal Cord compression with continuing haematuria despite trt as per Investigation repot, e)Any other document
Radiation TBR,3.investigation report suggesting continuiing reqd by CPD/SNA,f)Invoice of assisted
1594 Palliative Medicine PM PM007 Diagnostics, palliative radiotherapy, Brace in PM007A Malignant Spinal cord compression 17325 19057 20790 22522 24255 25121
Oncology/Neurosurgery haematuria,Palliative plan of management as per device/implant used,g)Pre op and post op
advanced cancer patients
1.Treatmentt records for primary cancer including a) Detailed Indoor case papers with
continuing haematuria despite trt as per Investigation repot, e)Any other document
Radiation Palliative nerurosurgical interventions for TBR,3.investigation report suggesting continuiing reqd by CPD/SNA,f)Invoice of assisted
1595 Palliative Medicine PM PM008 PM008A Palliative neurological interventions 69300 76230 83160 90090 97020 100485
Oncology/Neurosurgery secondary vertebral and brain metastasis haematuria,Palliative plan of management as per device/implant used,g)Pre op and post op
Palliative surgical interventions like- etc,2.Clinical note or other document proving c) Detailed Discharge Summary,d)relevant
Colostomy, Tracheostomy, Feeding continuing haematuria despite trt as per Investigation repot, e)Any other document
Surgical / Medical / TBR,3.investigation report suggesting continuiing reqd by CPD/SNA,f)Invoice of assisted
1596 Palliative Medicine PM PM006 Jejunostomy/Gastrostomy, Bowel bypas, PM006A Palliative surgical interventions 46200 50820 55440 60060 64680 66990
Radiation Oncology haematuria,Palliative plan of management as per device/implant used,g)Pre op and post op
Fistulas, Urinary diversions etc.in advanced
cancer patients TBR Xray/CT/MRI /LymphoScintigraphyreport(If
Palliative Care approach to managing continuing haematuria despite trt as per Investigation repot, e)Any other document
Surgical Oncology / PMR / TBR,3.investigation report suggesting continuiing reqd by CPD/SNA,f)Invoice of assisted
1597 Palliative Medicine PM PM005 Pressure sore in advanced chronic diseases PM005A Pressure sore-Interventions 46200 50820 55440 60060 64680 66990
General Surgery haematuria,Palliative plan of management as per device/implant used,g)Pre op and post op
who are bed ridden-Surgical
Surgical Oncology/ Oro- continuing haematuria despite trt as per Investigation repot, e)Any other document
Palliative Care Management of TBR,3.investigation report suggesting continuiing reqd by CPD/SNA,f)Invoice of assisted
1598 Palliative Medicine PM facio-maxillary surgeons / PM004 PM004A Osteoradionecrosis -Surgical intervention 46200 50820 55440 60060 64680 66990
Osteoradionecrosis -Surgical intervention haematuria,Palliative plan of management as per device/implant used,g)Pre op and post op
Radiation Oncology
Surgical continuing haematuria despite trt as per Investigation repot, e)Any other document
Management of bleeding in malignant head TBR,3.investigation report suggesting continuiing reqd by CPD/SNA,f)Invoice of assisted
1599 Palliative Medicine PM Oncology/Radiation PM003 PM003A Trans arterial Embolization 69300 76230 83160 90090 97020 100485
and neck / inguinal malignancies haematuria,Palliative plan of management as per device/implant used,g)Pre op and post op
Oncology
Surgical continuing haematuria despite trt as per Investigation repot, e)Any other document
Management of bleeding malignant head Haemostatic Surgery in advance cancer TBR,3.investigation report suggesting continuiing reqd by CPD/SNA,f)Invoice of assisted
1600 Palliative Medicine PM Oncology/Radiation PM002 PM002A 46200 50820 55440 60060 64680 66990
and neck / inguinal lesions patient/Haemostatic Radiotherapy haematuria,Palliative plan of management as per device/implant used,g)Pre op and post op
Oncology / Genral Surgery
Outside State
Bed Cost Cost
Cost
Palliative Care Approach to managing continuing haematuria despite trt as per Investigation repot, e)Any other document
Urology/Medical/Surigal Haematuria in advanced cancer patients- TBR,3.investigation report suggesting continuiing reqd by CPD/SNA,f)Invoice of assisted
1601 Palliative Medicine PM PM001 PM001A Hematuria Palliative Interventions 46200 50820 55440 60060 64680 66990
Oncology/Radiotherapy Endoscopic/Surgical/Radiological, haematuria,Palliative plan of management as per device/implant used,g)Pre op and post op
Radiotherpay interventions TBR l) Tumor board meeting report Xray/CT/MRI /LymphoScintigraphyreport(If
m) Hysterectomy report n) Papsmear Reoprt reqd),g0Plan of management
a) Clinical notes showing vitals, examination a) Detailed Indoor case papers (ICPs) with
findings, planned line of treatment and advice for treatment details
admission b) Nerve conduction test
b) Nerve conduction test (ENMG)/MRI/CT (ENMG)/MRI/CT/Viral serology (Optional)
c) Viral serology d) Optional c) Detailed discharge summary
Pediatric Medical Pediatric Medical based on etiology and availability
1602 MP MP016 Acute ataxia MP016A Acute ataxia 2250 2475 2700 2925 3150 3262
Management Management Toxicological testing, blood glucose, metabolic
evaluation, Cerebrospinal fluid examination, Viral
serology, Urinalysis, Serum Electrolytes, Vitamins,
Complete blood count, liver function test

Pediatric Medical Pediatric Medical c) planned line management. c) detailed discharge summary.
1603 MP MP025 Acute glomerulonephritis MP025A Acute glomerulonephritis 2250 2475 2700 2925 3150 3262
Management Management d) investigations done. d) All investigations reports.
a) Clinical notes including a) Detailed Indoor case papers

history, evaluation findings, vital monitoring,and (including any cross-specialty
planned referral that has been done) b) Investigation
Pediatric Medical Pediatric Medical ACUTE INFECTIOUS MENINGITIS AND line of management b) Lumbar reports (if
1604 MP MP005 MP005C Febrile encephalopathy fungal 2250 2475 2700 2925 3150 3262
Management Management MENINGOENCEPHALITIS. Puncture c) Complete blood count required) c) Detailed
d) CT/MRI scan e) Blood Discharge Summary
culture
a) Clinical notes including a) Detailed Indoor case papers

history, evaluation findings, vital monitoring,and (including any cross-specialty
planned referral that has been done) b) Investigation
Pediatric Medical Pediatric Medical ACUTE INFECTIOUS MENINGITIS AND line of management b) Lumbar reports (if
1605 MP MP005 MP005E Metabolic encephalopathy parasitic, 2250 2475 2700 2925 3150 3262
Management Management MENINGOENCEPHALITIS. Puncture c) Complete blood count required) c) Detailed
d) CT/MRI scan e) Blood Discharge Summary
culture
a) Clinical notes detailing a) Detailed ICPs.

history. b) Treatment details.
b) Admission notes showing c) detailed discharge summary.
Pediatric Medical Pediatric Medical vitals. d) All investigations reports
1606 MP MP017 Acute ischemic stroke MP017A Acute ischemic stroke 2250 2475 2700 2925 3150 3262
Management Management c) examination findings.
d) any investigations done.
e) planned line of management.
a) Still image of the child at the time of admission a) Still image of the child at the time of
with patient ID and date discharge with patient ID and date
b) Clinical notes with indications such as: b) Detailed indoor case papers with
i. Faulty feeding habits (Not exclusively Breast fed treatment details indicating
for 6 months/ bottle feeding/ delayed or inadequate i. Monitoring of vitals with Input-output
complementary feeding) charting as well as urine frequency, stool/
ii. Poor appetite vomitus volumes
iii. Lethargy/ Irritability ii. Intake: IV fluids (IVF) (DNS) 4ml/ Kg/hr for
iv. Any delayed developmental milestones 2-3 days with early/ concomitant initiation of
including Weight oral feeds (130 ml/kg/day)
v. Vitals- Pulse rate (PR), respiratory rate (RR), iii. Condition/ complication specific treatment
Capillary refill time (CRT) such as Antibiotics for Infection, Dextrose for
vi. Loss of Subcutaneous fat, muscle wasting, Hypoglycemia/ severe dehydration,
Pediatric Medical Pediatric Medical pallor, mid-upper arm circumference (MUAC) less Potassium/ Magnesium for electrolyte
1607 MP MP031 Acute severe malnutrition MP031A Acute severe malnutrition 2250 2475 2700 2925 3150 3262
Management Management than normal imbalance, Whole blood/ PRBC transfusion
vii. Signs of Vitamin B, K and A deficiencies (if any for Anemia. c) Detailed essential
of these symptoms are present) investigation reports
viii. Dehydration i. Haemogram
ix. Respiratory distress c) Essential ii. Random Blood sugar (RBS)
Investigations such as: iii. LFT
I. Haemogram
II. Random Blood sugar (RBS)
III. LFT
IV. KFT
V. Chest X-ray
VI. RDT-HIV (only where available/ possible)
VII. Gastric aspirate for CBNAAT/ AFB (only where
available/ possible)
Pediatric Medical Pediatric Medical c) planned line management. c) detailed discharge summary.
1608 MP MP020 Acute urticaria / Anaphylaxis MP020A Acute urticaria/anaphylaxis 2250 2475 2700 2925 3150 3262
Management Management d) specify the trigger. d) All investigations reports.

c) examination findings. c) detailed discharge summary.
Pediatric Medical Pediatric Medical Celiac disease-requiring admission for Work Up d) any investigations done. d) All investigations reports.
1609 MP MP022 Celiac disease MP022A 2250 2475 2700 2925 3150 3262
Management Management and/or in-patient management e) planned line of management.
Outside State
Bed Cost Cost
Cost
a) Clinical notes including history, evaluation a) Detailed Indoor Case Papers
findings, and b) Investigation reports (if required)
planned line of management b) Based on Etiology c) Detailed Discharge Summary
*Whole body scanning *
DNA/chromosomal /biochemical assay
*Skeletal Survey
Pediatric Medical Pediatric Medical Children with dysmorphic features- requiring *USG
1610 MP MP034 Children with dysmorphic features MP034A 2250 2475 2700 2925 3150 3262
Management Management admission for work-up *Electrocardiogram (ECG)
*2D ECHO
*Thyroid profile
*Viral Serology markers
a) Clinical notes a) Detailed Indoor case papers (ICPs) with

b) Investigations treatment details
1. Chest X-ray b) Investigations/Imaging reports
2. Blood gas analysis c) Detailed Discharge summary with follow-
3. Echocardiography up advise at the time of discharge
4. Complete blood count, serum ferritin, blood
Pediatric Medical Pediatric Medical glucose
1611 MP MP040 Cyanotic spells MP040B Cyanotic spells with CHD 2250 2475 2700 2925 3150 3262
Management Management 5. Serum Calcium
6. Hyperoxia test
7. ECG/ECHO
8. Measurement of oxygen saturation / co-oximetry
signs, vitals, examination findings, planned line of treatment details
treatment and advice for admission 1. Intellectual b) All investigation done
Disorders (ID) c) Detailed discharge summary
i. Intelligence Quotient (IQ) test
Maturity Scale - VSMS)
iv. CT/MRI Brain (Optional) 2. Global
developmental delay (GDD)
i. Imaging: EEG, CT, MRI, MRS (as per the patient
condition)
ii. IQ test (>5 years)
Pediatric Medical Pediatric Medical Developmental and behavioral disorders for iii. Social maturity assessment (VSMS)
1612 MP MP032 Developmental and behavioral disorders MP032A 2250 2475 2700 2925 3150 3262
Management Management Work Up and/or in-patient management iv. Developmental screening test (DST)
v. CT/MRI Brain (Optional)
vi. Lab: CBC, glucose, RFT, LFT, Sr electrolytes,
ferritin, b12, toxicology screening, ABG, urinalysis,
metabolic screening, TORCH profile (as per the
patient condition)
vii. CT/MRI, EEG (if necessary)
viii. Karyotyping, genetic testing (if necessary) ▪ 3.
Autism spectrum disorders (ASD)
i. Toddler
▪ M-CHAT-R (modified checklist for autism in
toddlers revised scoring)
ii. Children > 3 yr
c) planned line management. c) detailed discharge summary.
Pediatric Medical Pediatric Medical d) past h. d) All investigations reports.
1613 MP MP002 Epileptic encephalopathy MP002A Epileptic encephalopathy 2250 2475 2700 2925 3150 3262
Management Management e) epilepsy.
a) Clinical notes including history, evaluation a) Detailed Indoor Case Papers mentioning
findings, and the treatment details b) Investigation reports
planned line of management (if required) c)
b) Based on Etiology Detailed Discharge Summary
*CT or MRI
*Neurosonogram
*Muscle and nerve biopsy
Pediatric Medical Pediatric Medical Floppy infant syndrome requiring admission for *Electromyography (EMG)
1614 MP MP035 Floppy infant syndrome MP035A 2250 2475 2700 2925 3150 3262
Management Management work-up *Electroencephalogram (EEG)
*X-Ray (chest or limb etc.)
*Spinal tap
*Blood culture
*Genetic testing
*Metabolic profile
Outside State
Bed Cost Cost
Cost
signs, vitals, examination findings, planned line of treatment details
treatment and advice for admission 1. Intellectual b) All investigation done
Disorders (ID) c) Detailed discharge summary
i. Intelligence Quotient (IQ) test
Maturity Scale - VSMS)
iv. CT/MRI Brain (Optional) 2. Global
developmental delay (GDD)
i. Imaging: EEG, CT, MRI, MRS (as per the patient
condition)
ii. IQ test (>5 years)
Global developmental delay/Intellectual disability-
Pediatric Medical Pediatric Medical Global developmental delay / Intellectual iii. Social maturity assessment (VSMS)
1615 MP MP029 MP029A requiring admission for Work Up and/or in- 2250 2475 2700 2925 3150 3262
Management Management disability of unknown etiology iv. Developmental screening test (DST)
patient management
v. CT/MRI Brain (Optional)
vi. Lab: CBC, glucose, RFT, LFT, Sr electrolytes,
ferritin, b12, toxicology screening, ABG, urinalysis,
metabolic screening, TORCH profile (as per the
patient condition)
vii. CT/MRI, EEG (if necessary)
viii. Karyotyping, genetic testing (if necessary) ▪ 3.
Autism spectrum disorders (ASD)
i. Toddler
▪ M-CHAT-R (modified checklist for autism in
toddlers revised scoring)
ii. Children > 3 yr
a) Clinical notes detailing history. a) Detailed Indoor case papers (ICPs) with
b) Admission notes showing vitals. treatment details
c) examination findings (incl neurological b) Investigations(CBC,APTT,PT,CLOTING
examination). FACTOR TEST)/Imaging reports
Pediatric Medical Pediatric Medical d) any investigations c) Detailed Discharge summary with follow-
1616 MP MP048 Hemostatic Disorders MP048A Hemophilia 2250 2475 2700 2925 3150 3262 done.(CBC,APTT,PT,CLOTING FACTOR TEST) up advise at the time of discharge
Management Management
c) examination findings (incl neurological b) Investigations(CBC,APTT,PT,CLOTING
examination). FACTOR TEST)/Imaging reports
Pediatric Medical Pediatric Medical d) any investigations c) Detailed Discharge summary with follow-
1617 MP MP048 Hemostatic Disorders MP048B Platelet disorders 2350 2585 2820 3055 3290 3407 done.(CBC,APTT,PT,CLOTING FACTOR TEST) up advise at the time of discharge

Pediatric Medical Pediatric Medical d) any investigations done. d) All investigations reports.
1618 MP MP042 Idiopathic Thrombocytopenic Purpura MP042A Idiopathic Thrombocytopenic Purpura 2250 2475 2700 2925 3150 3262
Management Management e) planned line of management.
a) Clinical notes including history, evaluation a) Detailed ICPs mentioning the treatment
findings, and details
planned line of management b)Based on Etiology b) Detailed Discharge Summary
*Cerebrospinal fluid (CSF) examination
*Liver Function Test
*Kidney Function Test
*Arterial blood gas
*Ammonia
Pediatric Medical Pediatric Medical Inborn errors of metabolism-requiring admission *Urine for ketones and reducing substance
1619 MP MP036 Inborn errors of metabolism MP036A 2250 2475 2700 2925 3150 3262 *USG
Management Management for work-up and/or inpatient care
*CT/MRI
*X Ray
*Tandem Mass Spectrometer (TMS)
*Gas chromatography-mass spectrometry
(GCMS)
*Gene testing
*Exome sequencing
findings, planned line of treatment & advice for treatment details
admission b) Improved Glasgow coma scale score
Pediatric Medical Pediatric Medical INTRACRANIAL SPACE OCCUPYING b) Glasgow coma scale findings and examination c) Cranial ultrasonography /CT/MRI Brain
1620 MP MP009 MP009A Intracranial hemorrhage 2250 2475 2700 2925 3150 3262
Management Management LESIONS findings d) Detailed Operative /Procedures notes
c) Cranial ultrasonography/CT/MRI Brain (optional) e) Detailed discharge
d) Electroencephalography (optional) summary
Pediatric Medical Pediatric Medical INTRACRANIAL SPACE OCCUPYING d) any investigations done. d) All investigations reports.
1621 MP MP010 MP010A Intracranial space occupying lesion tuberculoma, 2350 2585 2820 3055 3290 3407
Management Management LESIONS e) planned line of management.

Pediatric Medical Pediatric Medical d) any investigations done. d) All investigations reports.
1622 MP MP038 Juvenile Arthritis MP038A Juvenile Arthritis 2250 2475 2700 2925 3150 3262
Management Management e) planned line of management.
Outside State
Bed Cost Cost
Cost
c) examination findings (incl neurological c) detailed discharge summary.
Pediatric Medical Pediatric Medical examination). d) All investigations reports.
1623 MP MP046 Ketogenic diet initiation in refractory epilepsy MP046A Ketogenic diet initiation in refractory epilepsy 2250 2475 2700 2925 3150 3262
Management Management d) any investigations done.

c) examination findings (incl neurological c) detailed discharge summary.
Pediatric Medical Pediatric Medical examination). d) All investigations reports.
1624 MP MP006 Meningitis MP006A Chronic meningitis 2350 2585 2820 3055 3290 3407
Pediatric Medical Pediatric Medical c) planned line management. b) Investigations/Imaging reports
1625 MP MP001 Pediatric seizure disorders MP001A Febrile seizures 2250 2475 2700 2925 3150 3262
Management Management d) 1st seizure or past history. c) Detailed Discharge summary with follow-
up advise at the time of discharge
findings, planned line of treatment and advice for treatment details
admission b) b) Detailed discharge summary
Investigations
1. X-ray
PA wrist/radius/ulna or Knee/tibia/fibula
Pediatric Medical Pediatric Medical Rickets - requiring admission for Work Up and/or 2. Serum Calcium
1626 MP MP030 Rickets - requiring admission for Work Up MP030A 2250 2475 2700 2925 3150 3262
Management Management in-patient management 3. Serum Phosphorus
4. Alkaline phosphatase c) Based
on clinical condition and availability
Desirable:
25-OH-Vitamin D, Complete blood count, Serum
electrolytes, Renal function tests
admission b) DCT, CBC, peripheral smear
b) Direct Coomb`s test (DCT) c) Detailed discharge summary
c) Complete blood count (CBC), peripheral smear,
Pediatric Medical Pediatric Medical urinalysis, reticulocyte, haptoglobin, total serum
1627 MP MP041 SEVERE ANEMIA IN CHILDREN MP041A Iron deficiency anemia 2250 2475 2700 2925 3150 3262 bilirubin d) Optional (based
on clinical condition and availability)
Indirect Coomb`s test (ICT), Kidney function tests,
Bone marrow aspiration, Chest X-ray, lactate
dehydrogenase (LDH), viral serology
1628 MP MP041 SEVERE ANEMIA IN CHILDREN MP041D Other anemias 2350 2585 2820 3055 3290 3407 bilirubin d) Optional (based
1629 MP MP041 SEVERE ANEMIA IN CHILDREN MP041B Thalessmia 2350 2585 2820 3055 3290 3407 bilirubin d) Optional (based
findings, planned line of treatment and advice for treatment details including Establishing
admission b) diagnosis/clinical improvement b) Detailed
Investigations: discharge summary
Complete blood count, Erythrocyte sedimentation
rate, Serum electrolytes, Liver function test, Kidney
function test, Urine analysis, Stool analysis, X-ray
Pediatric Medical Pediatric Medical of left hand and wrist/X-ray elbow AP
1630 MP MP033 Short stature MP033A Short stature- requiring admission for Work Up 2250 2475 2700 2925 3150 3262 c) Optional based on Etiology and availability
Tuberculin test and chest X-ray, thyroid hormones
(T4 and TSH), blood gas analysis, tests for celiac
disease (anti-endomysial and transglutaminase
antibodies), Serum IGF-1, Chromosome analysis
and karyotype, growth hormone provocation test,
MRI brain
c) examination findings (incl neurological b) Investigations/Imaging reports
Pediatric Medical Pediatric Medical examination). c) Detailed Discharge summary with follow-
1631 MP MP051 Staphylococcal scalded skin syndrome MP051A Staphylococcal scalded skin syndrome 2350 2585 2820 3055 3290 3407
Management Management d) any investigations done. up advise at the time of discharge
Outside State
Bed Cost Cost
Cost
a) Clinical notes detailing history (incl drug intake a) Detailed ICPs.
history). b) Treatment details.
b) Admission notes showing vitals. c) detailed discharge summary.
Pediatric Medical Pediatric Medical c) examination findings. d) All investigations reports.
1632 MP MP044 Steve Johnson syndrome MP044A Steve Johnson syndrome 2250 2475 2700 2925 3150 3262
a) Clinical notes b) Serum a) Detailed Indoor case papers (ICPs)

ceruloplasmin c) 24-hour urine b) Detailed Discharge Summary
Pediatric Medical Pediatric Medical Wilson’s disease-requiring admission for work-up
1633 MP MP037 Wilson’s disease MP037A 2250 2475 2700 2925 3150 3262 copper d) Slit lamp examination c) Serum ceruloplasmin d) 24-hour
Management Management and/or inpatient care
(Kayser-Fleischer ring)(If available) urine copper
c) examination findings (incl neurological b) Investigations, microscopy and bacterial
examination). culture/Imaging reports
Pediatric Medical d) any investigations done,Cerebrospinal fluid c) Detailed Discharge summary with follow-
Pediatric Medical
1634 MP Management, General MP021 Acute abdomen MP021A Acute abdomen pain 2250 2475 2700 2925 3150 3262 (CSF) microscopy and bacterial culture/CBNAAT up advise at the time of discharge
Management
Medicine e) planned line of management.
a) Clinical notes with APACHE a)Still photograph of the patient undergoing

score b the treatment (+/- ventilatory
)Investigations support) b) Detailed
1. CBC Indoor case papers having treatment and
2. Chest X-ray management c) Relevant
Pediatric Medical 3. ABG (if investigations including serial ABGs
Pediatric Medical available) d) Detailed discharge summary
1635 MP Management, General MP018 Acute childhood asthma MP018A Acute asthma/Status asthmaticus 2250 2475 2700 2925 3150 3262
Management 4. ECG c )Clinical
Medicine
photograph of the patient on
bed
c) examination findings (incl neurological b) Investigations,Cerebrospinal fluid (CSF)
Pediatric Medical examination). microscopy and bacterial culture/Imaging
Pediatric Medical d) any investigations done,Cerebrospinal fluid reports
1636 MP Management, General MP003 ACUTE ENCEPHALOPATHY MP003A Acute Febrile encephalopathy 2250 2475 2700 2925 3150 3262
Management (CSF) microscopy and bacterial culture c) Detailed Discharge summary with follow-
Medicine
e) planned line of management. up advise at the time of discharge
1637 MP Management, General MP003 ACUTE ENCEPHALOPATHY MP003B Acute Disseminated Encephalomyelitis 2250 2475 2700 2925 3150 3262
Management (CSF) microscopy and bacterial culture c) Detailed Discharge summary with follow-
Medicine
Pediatric Medical hypertensive/metabolic/febrile/hepatic d) any investigations done,Cerebrospinal fluid reports
1638 MP Management, General MP004 ACUTE ENCEPHALOPATHY MP004A 2350 2585 2820 3055 3290 3407
Management encephalopathy (CSF) microscopy and bacterial culture c) Detailed Discharge summary with follow-
Medicine
Pediatric Medical ACUTE INFECTIOUS MENINGITIS AND Brain abscess/Intracranial abscess/ Aseptic d) any investigations done,Cerebrospinal fluid reports
1639 MP Management, General MP005 MP005G 2250 2475 2700 2925 3150 3262
Management MENINGOENCEPHALITIS. meningitis (CSF) microscopy and bacterial culture c) Detailed Discharge summary with follow-
Medicine
Pediatric Medical ACUTE INFECTIOUS MENINGITIS AND d) any investigations done,Cerebrospinal fluid reports
1640 MP Management, General MP005 MP005A Acute meningo encephalitis pyogenic 2350 2585 2820 3055 3290 3407
Management MENINGOENCEPHALITIS. (CSF) microscopy and bacterial culture c) Detailed Discharge summary with follow-
Medicine
1641 MP Management, General MP005 MP005D Hypertensive encehalopathy viral, 2250 2475 2700 2925 3150 3262
Medicine
Outside State
Bed Cost Cost
Cost
1642 MP Management, General MP005 MP005B Aseptic meningitis tubercular, 2250 2475 2700 2925 3150 3262
Medicine
c) examination findings (incl neurological b) Investigations,py and bacterial
Pediatric Medical d) any investigations done,Cerebrospinal fluid c) Detailed Discharge summary with follow-
Pediatric Medical
1643 MP Management, General MP020 Acute urticaria / Anaphylaxis MP020B Steven Johnson syndrome 2250 2475 2700 2925 3150 3262 (CSF) microscopy and bacterial culture/CBNAAT up advise at the time of discharge
Management
c) examination findings (incl neurological b) Investigations reports, microscopy and
Pediatric Medical examination). bacterial culture/Imaging reports
Pediatric Medical d)Detail investigations done(blood, urine),any c) Detailed Discharge summary with follow-
1644 MP Management, General MP047 Croup syndrome MP047A Acute laryngotracheobronchitis/Acute epiglottitis 2250 2475 2700 2925 3150 3262
Management microscopy and bacterial culture. e) planned line of up advise at the time of discharge
Medicine
management.
examination). microscopy and bacterial culture/Imaging
Pediatric Medical
1645 MP Management, General MP040 Cyanotic spells MP040A Cyanotic spells without CHD 2250 2475 2700 2925 3150 3262 (CSF) microscopy and bacterial culture/CBNAAT c) Detailed Discharge summary with follow-
Management
Medicine e) planned line of management. up advise at the time of discharge
Pediatric Medical d) any investigations done,microscopy and reports
1646 MP Management, General MP027 Haemolytic uremic syndrome MP027A Haemolytic uremic syndrome 2250 2475 2700 2925 3150 3262
Management bacterial culture/CBNAAT c) Detailed Discharge summary with follow-
Medicine
Pediatric Medical INTRACRANIAL SPACE OCCUPYING
1647 MP Management, General MP011 MP011A neurocysticercosis, brain tumours 2350 2585 2820 3055 3290 3407 (CSF) microscopy and bacterial culture/CBNAAT, c) Detailed Discharge summary with follow-
Management LESIONS
Medicine X-ray/CT/MRI up advise at the time of discharge
Pediatric Medical Juvenile myasthenia- requiring admission for
1648 MP Management, General MP015 Juvenile myasthenia MP015A 2350 2585 2820 3055 3290 3407 (CSF) microscopy and bacterial culture/CBNAAT, c) Detailed Discharge summary with follow-
Management work-up or in-patient care
Medicine X-ray/CT/MRI up advise at the time of discharge
Pediatric Medical
1649 MP Management, General MP043 Kawasaki Disease MP043A Kawasaki Disease 2250 2475 2700 2925 3150 3262 (CSF) microscopy and bacterial culture/CBNAAT c) Detailed Discharge summary with follow-
Management
Pediatric Medical Raised ICP due to neuro surgical d) any investigations done,Cerebrospinal fluid reports
Pediatric Medical Medical Management for Raised intracranial
1650 MP Management, General MP008 MP008A procedures/due to trauma/malignancies/ 2250 2475 2700 2925 3150 3262 (CSF) microscopy and bacterial culture/CBNAAT c) Detailed Discharge summary with follow-
Management pressure
Medicine meningo-encephalitis e) planned line of management. up advise at the time of discharge
Pediatric Medical
1651 MP Management, General MP006 Meningitis MP006E Acute meningitis 2250 2475 2700 2925 3150 3262 (CSF) microscopy and bacterial culture/CBNAAT c) Detailed Discharge summary with follow-
Management
Outside State
Bed Cost Cost
Cost
Pediatric Medical
1652 MP Management, General MP006 Meningitis MP006D Complicated bacterial meningitis 2250 2475 2700 2925 3150 3262 (CSF) microscopy and bacterial culture/CBNAAT c) Detailed Discharge summary with follow-
Management
Pediatric Medical
1653 MP Management, General MP006 Meningitis MP006C Neuro tuberculosis 2250 2475 2700 2925 3150 3262 (CSF) microscopy and bacterial culture/CBNAAT c) Detailed Discharge summary with follow-
Management
Pediatric Medical
1654 MP Management, General MP006 Meningitis MP006B Partially treated pyogenic meningitis 2250 2475 2700 2925 3150 3262 (CSF) microscopy and bacterial culture/CBNAAT c) Detailed Discharge summary with follow-
Management
c) examination findings . b) Investigations,Cerebrospinal fluid (CSF)
Pediatric Medical d) any investigations done,microscopy and microscopy and bacterial culture/Imaging
Pediatric Medical
1655 MP Management, General MP024 Neonatal/ Infantile cholestasis MP024A Neonatal/infantile cholestasis / Choledochal cysts 2250 2475 2700 2925 3150 3262
Management bacterial culture reports
Medicine e) planned line of management. c) Detailed Discharge summary with follow-
F) USG up advise at the time of discharge
c) examination findings (incl neurological b) Investigations, microscopy and bacterial
Pediatric Medical d) any investigations done,microscopy and c) Detailed Discharge summary with follow-
Pediatric Medical
1656 MP Management, General MP026 NEPHROTIC SYNDROME MP026A Nephrotic syndrome with peritonitis 2250 2475 2700 2925 3150 3262 bacterial culture up advise at the time of discharge
Management
Medicine e) planned line of management. F)
ultrasonography Abd & Pelvis
Pediatric Medical
1657 MP Management, General MP026 NEPHROTIC SYNDROME MP026B Steroid dependent or resistent 2350 2585 2820 3055 3290 3407 (CSF) microscopy and bacterial culture/CBNAAT c) Detailed Discharge summary with follow-
Management
Pediatric Medical
1658 MP Management, General MP050 NEPHROTIC SYNDROME MP050A Uncomplicated steroid sensitive 2350 2585 2820 3055 3290 3407 (CSF) microscopy and bacterial culture/CBNAAT c) Detailed Discharge summary with follow-
Management
c) examination findings (incl neurological b) Investigations/Imaging reports
Pediatric Medical examination). c) Detailed Discharge summary with follow-
Pediatric Medical
1659 MP Management, General MP001 Pediatric seizure disorders MP001D Acute non-febrile seizures 2250 2475 2700 2925 3150 3262
Management d) any investigations done. up advise at the time of discharge
c) examination findings (incl neurological b) Investigations,microscopy and bacterial
Pediatric Medical examination). culture/Imaging reports
Pediatric Medical Acute rheumatic fever d) Blood investigations done,microscopy and c) Detailed Discharge summary with follow-
1660 MP Management, General MP039 Rheumatic fever MP039A 2250 2475 2700 2925 3150 3262
Management bacterial culture/ASO/RA FACTOR up advise at the time of discharge
Medicine
Pediatric Medical
1661 MP Management, General MP039 Rheumatic fever MP039B Rheumatic valvular heart disease 2350 2585 2820 3055 3290 3407 (CSF) microscopy and bacterial culture/CBNAAT c) Detailed Discharge summary with follow-
Management
Outside State
Bed Cost Cost
Cost
Pediatric Medical Unexplained hepatosplenomegaly-requiring d) any investigations done,Cerebrospinal fluid reports
Pediatric Medical
1662 MP Management, General MP023 Unexplained hepatosplenomegaly MP023A admission for Work Up and/or in-patient 2250 2475 2700 2925 3150 3262 (CSF) microscopy and bacterial culture/CBNAAT c) Detailed Discharge summary with follow-
Management
Medicine management e) planned line of management. up advise at the time of discharge
Pediatric Medical Pediatric Medical c) planned line management. b) Investigations/Imaging reports
1663 MP MP052 Pediatric seizure disorders MP052A Status epilepticus 2250 2475 2700 2925 3150 3262
Management Management,Neurology d) 1st seizure or past history. c) Detailed Discharge summary with follow-
up advise at the time of discharge

1664 Pediatric Surgery SS Pediatric Surgery SS041 STAGED AIRWAY RECONSTRUCTION SS041A Staged airway reconstruction 65625 72187 78750 85312 91875 95156 B) CT Chest B) Discharge summary
a)Clinical notes with indications b)Grading of a) Indoor case papers b)

ankyloglossia Detailed Procedure / operative notes
c) Detailed discharge summary d) Pre &
1665 Pediatric Surgery SS Pediatric Surgery SS002 Ankyloglossia SS002B Ankyloglossia Major 19740 21714 23688 25662 27636 28623 Post-operative photograph
e) Documentary evidence of failed/ non-
indicated conservative management of
ankyloglossia in patient aged >/= 2 years
a)Clinical notes with indications b)Grading of a) Indoor case papers b)
ankyloglossia Detailed Procedure / operative notes
c) Detailed discharge summary d) Pre &
1666 Pediatric Surgery SS Pediatric Surgery SS002 Ankyloglossia SS002A Ankyloglossia Minor 9450 10395 11340 12285 13230 13702 Post-operative photograph
e) Documentary evidence of failed/ non-
indicated conservative management of
ankyloglossia in patient aged >/= 2 years
a) Clinical notes indicating whether other a)Indoor case papers b)Detailed Procedure /

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Outside State

Outside State NABH Entry Outside State

A) OPD PRESCRIPTION WITH CLINICAL A) OPD PRESCRIPTION WITH CLINICAL

A) OPD PRESCRIPTION WITH CLINICAL A) OPD PRESCRIPTION WITH CLINICAL

A) OPD PRESCRIPTION WITH CLINICAL A) OPD PRESCRIPTION WITH CLINICAL

a) Clinical notes b) Detailed a) Procedure / Operative notes b) Post

a) Clinical notes b) Doppler a) Procedure / Operative notes b) Post

a) Clinical notes b) ECG a) Indoor case papers b)

a) Clinical notes including evaluation findings, a) Detailed Indoor case papers

a) Clinical notes including evaluation findings, a) Detailed Indoor case papers

a) Clinical notes including evaluation findings, a) Detailed Indoor case papers

a) Clinical notes including evaluation findings, a) Detailed Indoor case papers

a) Clinical notes including evaluation findings, a) Detailed Indoor case papers

a) Clinical notes with planned line of treatment a) Procedure / Operative notes

a) Clinical notes b) Patient a) Still image of the patient undergoing the

a) Clinical notes including evaluation findings, a) Detailed Indoor case papers

a) Clinical notes b) Patient a) Still image of the patient undergoing the

A)Clinical notes. A)Detailed Operation notes.

a) Clinical notes including evaluation findings, a) Detailed Indoor case papers

a) Clinical notes including evaluation findings, a) Detailed Indoor case papers

a) Clinical notes b) Detailed a) Procedure / Operative notes b) Post

a) Clinical notes b) a) Procedure / Operative notes b) Post

A)Clinical notes. A)Detailed Operation notes.

a) Clinical notes b) ECG a) Indoor case papers b)

a) Clinical notes b) a) Procedure/ Operation notes b) Post

a)Clinical notes b)Echo/Doppler report a)Procedure / Operative notes b) Post

a) Clinical notes b) a) Procedure / Operative notes b) Post

a) Clinical notes b) Echo/ a) Indoor case papers b)

a) Clinical notes b) a) Indoor case papers b)

a) Clinical notes b) a) Procedure / Operative notes b) Post

a) Clinical Notes including evaluation findings, a) Detailed Indoor Case Papers

a) Clinical notes including evaluation findings, a) Detailed Indoor case papers

a) Clinical notes including evaluation findings, a) Detailed Indoor case papers

a) Clinical notes including evaluation findings, a) Detailed Indoor case papers

A)Clinical notes. A)Detailed Procedure .

a) Clinical notes (detailing signs, symptoms, a) Detailed Discharge summary

a) Clinical notes (detailing signs, symptoms, a) Indoor case papers b)

a) History a) Histopath report

a) Clinical notes a) Histopathology report

a) Clinical notes to establish indication; Biopsy if a) Histopathology report

a) Clinical notes : (detailing a) Clinical notes b) Procedure

a) Clinical notes confirming the indication for the a) Scar photo

a) Clinical notes a) Photograph of patient while undergoing

a) Clinical notes a) Photograph of patient while undergoing

a) CT Scan a) Histopathology report

a) CT Scan a) Histopathology report

Indication for surgery with supporting investigation a) Histopathology report

Indication for surgery with supporting investigation a) Histopathology report

Indication for surgery with supporting investigation a) Histopathology report

a) Clinical notes (detailing signs, symptoms, a) Detailed Indoor case papers

a) Clinical notes (detailing signs, symptoms, a) Detailed Indoor case papers

a) Doctor's notes with presenting complaints a) C/S of pus

a) Clinical notes (detailing signs, symptoms, a) Indoor case papers

Clinical notes with planned line of treatment a) Procedure Notes

Clinical notes with planned line of treatment a) Procedure Notes

Clinical notes with planned line of treatment and a) Procedure Notes

Clinical notes with planned line of treatment and a) Procedure Notes

a) Clinical notes with planned line of treatment a) Procedure Notes