Schedule of Benefits
About the Plan
Board of Trustees
Contract Administrator
Health & Welfare Plan Document
| Procedure | Maximum Benefit |
| Abdomen, paracentesis | 10.00 |
| Abdominal: cholangiopancreateography | 100.00 |
| Abscess incision & drainage Furuncles excepted | 15.00 |
| Abscess, ischio-rectal or peri-rectal drainage | 50.00 |
| Abscess of peritoneum | 125.00 |
| Acromioplasty (shoulder tendon) | 100.00 |
| Adenoidectomy | 25.00 |
| Alveoplasty | 125.00 |
| Amniocentesis | 50.00 |
| Anal Warts | 75.00 |
| Anaplasty | 40.00 |
| Aneurysmorrhaphy | 200.00 |
| Angiogram | 50.00 |
| Angiography | 100.00 |
| Angioplasty | 175.00 |
| Ankle talus dislocation (closed) | 100.00 |
| Anocopy | 45.00 |
| Anorectal Manometry | 50.00 |
| Antrostomy - bilateral intranasal | 125.00 |
| Antrum, Caldwell-Luc | 75.00 |
| Antrum puncture and irrigation | 40.00 |
| Antrum window | 55.00 |
| Aortogram | 45.00 |
| Appendectomy | 100.00 |
| Appendiceal, absess, drainage | 100.00 |
| Arterial catheterization | 50.00 |
| Arteriogram | 45.00 |
| Arterio-venous fistula, intracranial | 200.00 |
| Arthoplasty, any major joint | 175.00 |
| Arthroscopy with debridement | 125.00 |
| Arthrodesis of knee, hip shoulder or elbow | 175.00 |
| Arthrogram | 70.00 |
| Arthrography | 70.00 |
| Arthroplasty | 175.00 |
| Arthrotomy, any major joint | 100.00 |
| Artificial Insemination | 75.00 |
| Atresia of vagina, plastic | 200.00 |
| Aspiration of joint (orthocentesis) | 30.00 |
| A & P packing nasal hemorrhage | 35.00 |
| A.V. shunt (insertion dialysis catheter Intra-aortic balloon) | 75.00 |
| Amputations Elbow Forearm Hand Finger, single each additional Finger Foot Hip Knee Leg Scalpulothoracic Shoulder, disarticulation Toe each additional Toe Thigh Upper arm |
75.00 75.00 50.00 75.00 10.00 75.00 150.00 100.00 100.00 200.00 125.00 35.00 10.00 35.00 75.00 |
| Balloon dilation prostate | 150.00 |
| Barthollin's gland - excision | 50.00 |
| Bartholin's gland - incision | 35.00 |
| Bartholiss abscess | 35.00 |
| Bilateral lumbar sympathectomy | 150.00 |
| Bilateral thoracolumbar Sympathectomy | 200.00 |
| Bimalleolar (compound fracture) | 200.00 |
| Biopsy, bone or bone marrow | 40.00 |
| Biopsy, needle aspiration | 10.00 |
| Biopsy, superficial (independent procedure) | 35.00 |
| Blaloch procedure | 200.00 |
| Bladder tumor, diverticula, etc. (resection) open operation | 125.00 |
| Blepharoplasty (eye lids) | 175.00 |
| Bone graft (nucleation of lesion with biopsy-by oral surgeon) | 100.00 |
| Bone plate, removal of | 75.00 |
| Body scan | 100.00 |
| Bone scan | 70.00 |
| Bone spur | 75.00 |
| Brachiogram Bilateral |
45.00 70.00 |
| Brain Scan | 100.00 |
| Brain tumors | 200.00 |
| Branchial cyst, removal | 125.00 |
| Breast abscess, drainage | 35.00 |
| Breast biopsy | 70.00 |
| Breast cyst or abscess, aspiration | 10.00 |
| Breast deformity | 100.00 |
| Breast lesion | 50.00 |
| Breast reconstruction (1) | 100.00 |
| Breast reconstruction (2) | 175.00 |
| Breast radical removal, (1) including axillary dissection | 100.00 |
| Breast radical removal, (2) including axillary dissection | 175.00 |
| Breast simple removal | 75.00 |
| Breast tumor benign, removal | 75.00 |
| Bronchogram | 50.00 |
| Bronchosocpy, diagnostic preceding surgery operative |
45.00 75.00 |
| Bunion osteotomy (orthopaedic) | 125.00 |
| Bunionectomy | 50.00 |
| Bunionectomy - McBride's | 125.00 |
| Burns - major | 200.00 |
| Burns - minor | 75.00 |
| Bursectomy | 70.00 |
| Caesarean section, abdominal | 150.00 |
| Caesarean section, vaginal | 175.00 |
| Cancer of lip (local operation) same with neck dessection |
35.00 100.00 |
| Capsulotomy (eye) | 100.00 |
| Carbuncle (mole removal) | 45.00 |
| Carcinoma of rectum resection | 175.00 |
| Carotidogram Bilateral |
50.00 75.00 |
| Carpal tunnel syndrome, wrist | 100.00 |
| Cartilege of condyle of femur, removal | 75.00 |
| Caruncle excision | 40.00 |
| Caruncle fulguration | 40.00 |
| Casts - no surgery | 100.00 |
| Casts - surgery done | 100.00 |
| CAT scan | 75.00 |
| Cataract, needling | 75.00 |
| Cataract, removal | 175.00 |
| Catheter, insertion of | 10.00 |
| Catheter insertion for dialysis | 75.00 |
| Cauterization, electric | 35.00 |
| Cauterization of nose Bilateral |
30.00 40.00 |
| Central line portacath for chemotherapy | 100.00 |
| Cervical polyp removal | 25.00 |
| Cervix amputation | 75.00 |
| Cervix biopsy | 30.00 |
| Chalazion (excision) simple multiple |
30.00 45.00 |
| Chest wall deformity repair, dorsal muscle flaps | 125.00 |
| Cholecystectomy | 125.00 |
| Cholecystoduodenostomy | 200.00 |
| Cholecystography | 50.00 |
| Cholecystotomy | 100.00 |
| Cholongeogiane | 45.00 |
| Choroidectomy for hydrocephalus | 200.00 |
| Circumcision, infant not requiring anesthesia | 25.00 |
| Circumcision, excepting the above | 50.00 |
| Circumferential | 75.00 |
| Claw foot, except bone surgery | 100.00 |
| Cleft palate | 100.00 |
| Coagulation & excision of vaginal warts | 50.00 |
| Coccygectomy | 75.00 |
| Coccyx. excision of | 100.00 |
| Cold cone biopsy of cervix | 75.00 |
| Colectomy | 200.00 |
| Colon, resection | 175.00 |
| Colonoscopy | 75.00 |
| Colonoscopy with biopsy | 100.00 |
| Colostomy | 125.00 |
| Colposcopy with cervical biopsy | 50.00 |
| Coloscopy with biopsy | 40.00 |
| Colporrhaphy | 75.00 |
| Commissurotomy | 200.00 |
| Common duct, resection or reconstruction | 200.00 |
| Common duct with or without cholecystectomy | 175.00 |
| Cone biopsy | 75.00 |
| Conjuctival flap for corneal ulcer, etc. | 75.00 |
| Conjuctival suture | 45.00 |
| Cornea, paracentesis | 50.00 |
| Corneal ulcer cauterization | 25.00 |
| Corneal ulcer delimiting keratotomy | 40.00 |
| Cortizone injection | 30.00 |
| Craniotomy for brain abscess | 200.00 |
| Craniotomy for conditions not listed herewith | 200.00 |
| Cryosurgery of cervix (nabathian cysts) | 50.00 |
| Cul-de-sac, drainage | 35.00 |
| Culdoscopy | 40.00 |
| Cyst, sebaceous, removal Each additional |
45.00 15.00 |
| Cystectomy | 200.00 |
| Cystic masses (finger) | 60.00 |
| Cystocele | 100.00 |
| Cystocele & Urethrocele repair | 75.00 |
| Cystocopy Observation (preceding surgery) Operative Ureteral catheterization |
45.00 50.00 45.00 |
| Cystostomy with fulguration | 100.00 |
| Cystostomy or cystostomy | 100.00 |
| Cystourethrogram | 50.00 |
| Cystourethroscopy - medium Large |
125.00 150.00 |
| Dacryocystorhinostomy | 150.00 |
| Deep cervical abscess | 45.00 |
| Detached retina | 175.00 |
| Diagnostic arthroscopy | 70.00 |
| Dilation & curettage with or without cauterization | 50.00 |
| Dilation of uretha | 40.00 |
| Discogram | 50.00 |
| Dislocations - Closed Carpal bone, one Each additional Clavicle Elbow Finger, one Each additional Hip Knee Manedible Patella Metacarpal bone, one Each additional Metatarsal bone, one Each additional Radius (arm) Splint Rib Shoulder Tarsal bone, one Each additional Thumb Toe, one Each additional Vertebra, one or more |
50.00 20.00 50.00 50.00 25.00 100.00 100.00 25.00 40.00 40.00 20.00 40.00 15.00 75.00 25.00 30.00 75.00 80.00 15.00 40.00 25.00 15.00 40.00 150.00 |
| Dissection glands of neck deepchain | 100.00 |
| Diverticulum intestinal (Meckel's) | 125.00 |
| Echocardiogram | 45.00 |
| Echocardiography | 50.00 |
| Echogram | 45.00 |
| EGD biopsy | 125.00 |
| Elbow lesion | 50.00 |
| Electrocardiogram(ECG/EKG) | 50.00 |
| Electroencephalogram (EEG) | 50.00 |
| EMG | 50.00 |
| Empyema, closed drainage | 75.00 |
| Empyema, rib section | 100.00 |
| Endarterectomy (heart bypass [embolectomy]) | 200.00 |
| Endoscopy | 50.00 |
| Entropion or ectropion, plastic operation | 100.00 |
| Entropion or ectropion, plaster operation grafts or flaps | 150.00 |
| Entropion or ectropion, Zeigler's puncture | 35.00 |
| Enucleation or evisceration | 75.00 |
| Enucleation with implant | 125.00 |
| Epididymectomy | 70.00 |
| Epithelioma of face, surgical removal Same with neck dissection |
20.00 150.00 |
| Esophageal diverticulum | 200.00 |
| Esophagoduodenostomy | 75.00 |
| Esophagogastroduodenoscopy with biopsy |
50.00 75.00 |
| Esophagoscopy | 70.00 |
| Ethmoidectomy | 50.00 |
| Excision & suture of urinary fistula (suprapubic) (vaginal) |
50.00 100.00 |
| Excision folliclecyst | 75.00 |
| Excision - intra-abdominal or retroperitoneal tumors or cysts | 75.00 |
| Excisional menisectomy | 125.00 |
| Excision of hidradenitis suppuratina, I & D of armpit | 100.00 |
| Excision of meningocele | 100.00 |
| Excision, tumor, upper arm or elbow area, subcutaneous | 100.00 |
| Exostosectomy | 100.00 |
| Exploratory trephination, one side two sides |
50.00 75.00 |
| Extradural hematoma | 125.00 |
| Facial paralysis - suspension of inferior lip | 75.00 |
| Fasciotomy | 100.00 |
| Fermorogram Bilateral |
50.00 75.00 |
| Fenestration | 200.00 |
| Fissurectomy, Office Hospital |
75.00 100.00 |
| Fistula, recto-vaginal | 150.00 |
| Fistula, vesico - vaginal | 150.00 |
| Fistulectomy, single excision of tract multiple excision of tracts |
175.00 185.00 |
| Foot stabilization | 150.00 |
| Foreign body, removal, within anterior or posterior chamber (ophthalmology) | 100.00 |
| Foreign body removal (pins, etc.) (eye, ear, nose) | 30.00 |
| Fractures - simple, closed: Carpal bone, one Each additional Clavicle Coccyx Femur (upper leg) Finger, one simple Each additional Extension with traction Additional Humerus (shoulder & elbow) Lower jaw Manus (hand) Metacarpal bone, one Each additional Metatarsal bone, one Each additional Nasal bone or bones, reduced Os calcis or astragalus or both Patella, closed (front of knee) Pelvis Pott's or Cotton's fracture Radius or ulna or both (arm) Rib, one or more Sacrum Scapula Skull Sternum Tarsal bone, one (exclude os calcis & astragalus) Tibia or fibula or both (leg) Toe, one Each additional Vertebra, one or more Zygoma |
75.00 20.00 75.00 25.00 150.00 25.00 10.00 35.00 15.00 100.00 75.00 75.00 75.00 15.00 55.00 15.00 60.00 100.00 75.00 100.00 100.00 75.00 55.00 60.00 60.00 75.00 60.00 75.00 100.00 40.00 10.00 150.00 60.00 |
| Frenalectomy | 50.00 |
| Frenoplasty (tongue-tie) | 75.00 |
| Frontal sinus, radical | 100.00 |
| Ganglion cysts (wrist) | 55.00 |
| Gastro-enterostomy | 150.00 |
| Gastrectomy, total | 200.00 |
| Gastroscopy Operative |
50.00 70.00 |
| Gastroplasty | 200.00 |
| Gastrotomy or gastrostomy | 125.00 |
| Glands, superficial, removal | 25.00 |
| Glaucoma, filtration operation | 100.00 |
| Hallux valgus, single radical | 100.00 |
| Hallux valgus, bilateral radical | 150.00 |
| Hammer toe, operation for | 100.00 |
| Head scan | 100.00 |
| Heart catheterization Bilateral |
100.00 150.00 |
| Heel spur | 100.00 |
| Hemephlongectomy | 100.00 |
| Hemiocolectomy | 200.00 |
| Heminephrectomy | 150.00 |
| Hemithyroidectomy | 150.00 |
| Hemogram | fee charged |
| Hemorrhoidectomy, complete | 175.00 |
| Hemorrhoids, injection, each maximum |
10.00 50.00 |
| Hemorrhoids, external, single incision | 25.00 |
| Hemorrhoids, thrombosis, incision | 25.00 |
| Herniotomy, single, inguinal, femoral or umbilical | 100.00 |
| Herniotomy, bilateral, inguinal or femoral | 150.00 |
| Herniotomy, ventral or incisional | 100.00 |
| Herniotomy. hiatus or diaphragmatic | 200.00 |
| Hickman catheter insertion | 50.00 |
| Hydrocele, radical operation | 75.00 |
| Hysterectomy (subtotal) | 100.00 |
| Hysterectomy (total) | 150.00 |
| Hysterosalpingogram | 50.00 |
| Hysteroscopy | 100.00 |
| I & D breast abscess needle localization | 75.00 |
| I & D Ichiorectal abscess | 100.00 |
| I & D joints and bursa | 35.00 |
| I & D of neck abscess | 75.00 |
| Ichorgram | 45.00 |
| Implant - drug or radioactive pellets - per pellet (limit 3 pellets per day) | 75.00 |
| Induction of artificial pneumothrax refills |
10.00 5.00 |
| Injection varicose veins, complete procedure | 50.00 |
| Injection without ligation, each Maximum |
5.00 50.00 |
| Intestines anastomosis | 150.00 |
| Intestines (small) resection | 150.00 |
| Intracath needle insertion, artery | 75.00 |
| Intracortial, clot | 175.00 |
| Iridectomy (opthamology) | 75.00 |
| Iridotomy (laser) | 125.00 |
| Keloid scar - minor major |
35.00 55.00 |
| Knee (orthopedic) | 150.00 |
| Kidney biopsy | 125.00 |
| Kidney scan | 100.00 |
| Labyrinthectomy | 200.00 |
| Lacerations, extensive, including debridement | 45.00 |
| Lacerations, minor | 15.00 |
| Lacrimal sac, plastic | 125.00 |
| Lamenatomy / ectomy | 100.00 |
| Laminectomy, decompressive | 150.00 |
| Laminotomy | 100.00 |
| Laparoscopic exam with lysis adhesions | 100.00 |
| Laparoscopy cholecystectomy with cholangiogram | 150.00 |
| Laparoscopy - exploratory | 100.00 |
| Laparoscopy - operative | 175.00 |
| Laparotomy | 100.00 |
| Laparatomy, exploratory | 125.00 |
| Laryngectomy | 150.00 |
| Larygoscopy | 100.00 |
| Laser ablation of cervix | 75.00 |
| Laser surgery | 100.00 |
| Leep surgery (gyn-takes place of cone biopsy cervix) | 75.00 |
| Left suprascapular nerve block | 100.00 |
| Lepoma, large | 100.00 |
| Lesion drainage | 50.00 |
| Ligation, saphenous vein single, including retrograde injection, if done Bilateral |
100.00 175.00 |
| Litholapaxy | 75.00 |
| Lithotripsy | 200.00 |
| Liver biopsy | 125.00 |
| Liver scan | 100.00 |
| Lobectomy | 200.00 |
| Lumbar puncture (with fracture or operative work only) (diagnostic included) | 35.00 |
| Lung biopsy | 70.00 |
| Lung scan | 100.00 |
| Lymph node biopsy | 70.00 |
| Lymphadenectomy | 150.00 |
| Malignant disease, accessory sinuses Radical operation one sinus Multiple |
175.00 200.00 |
| Malignant disease, tonsil & pharynx radical operation | 200.00 |
| Mammography | 50.00 |
| Mandibular - bilateral sagittal (split osteotomies) | 150.00 |
| Mastoid, right, large lesion | 100.00 |
| Matrisectomy (removal of nail) | 25.00 |
| Meatoplasty | 50.00 |
| Meatotomy | 25.00 |
| Mediastinoscopy | 45.00 |
| Miscarriage (curettage) | 50.00 |
| Morton neuroma | 100.00 |
| Multiple injections - sclerosi varicose veins | 125.00 |
| Myelogram | 50.00 |
| Myelography | 75.00 |
| Myocardiogram | 75.00 |
| Myofibromotosis Biopsy Removal |
45.00 100.00 |
| Myomectomy | 100.00 |
| Myringoplasty (ear) | 100.00 |
| Myringatory | 100.00 |
| Myringotomy tympanometry | 50.00 |
| Myringotomy - with tubes
Bilateral One side |
75.00 37.50 |
| Nailbed reconstruction | 75.00 |
| Nasal polyps, removal | 35.00 |
| Nasopharynagoscopy | 35.00 |
| Nephrectomy | 150.00 |
| Nephropexy | 100.00 |
| Nephrostomy | 125.00 |
| Nephrotomogram | 200.00 |
| Nephrotomy | 125.00 |
| Neurectomy | 125.00 |
| Neuroplasty | 150.00 |
| Nose lesion | 75.00 |
| Nose reconstruction | 175.00 |
| Occipital scalp, right (1/2Ó lesion) | 25.00 |
| Oophorectomy or resection of ovaries | 100.00 |
| Open heart massage | 125.00 |
| Operation for pain associated with malignancy or similar untreatable disease requiring intrspinal nerve sections or cordotomy | 150.00 |
| Operation for scalenus anticus syndrome | 125.00 |
| Opthalmoscopy (retinal detachment) | 50.00 |
| Orbital decompression, bilateral | 150.00 |
| Orchidectomy, simple Bilateral With gland dissection |
75.00 150.00 |
| Orchiopexy | 50.00 |
| Orthularea graft (eye) | 100.00 |
| Osteomyelitis, sequestrum removal | 100.00 |
| Osteotomy | 75.00 |
| Osteotripsy | 40.00 |
| Pacemaker insertion | 150.00 |
| Pacemaker repair Temporary (3x/KM) |
75.00 50.00 |
| Palatorrhaphy | 125.00 |
| Pancrealochotongeography | 200.00 |
| Pancreas drainage | 125.00 |
| Pancreatogram | 100.00 |
| Panendeoscopy | 100.00 |
| Parathyroidectomy | 150.00 |
| Parotid tumor, removal | 100.00 |
| Paratoidectomy | 125.00 |
| Parietal scalp, 1/2Ó lesion | 25.00 |
| Patellar Mechanism | 75.00 |
| Patent ductus, ligation | 200.00 |
| Penile prosthesis | 100.00 |
| Penis amputation Same with groin dissection |
100.00 175.00 |
| Peptic ulcer, perforated, closure | 125.00 |
| Peptic ulcer, subtotal gastrectomy | 175.00 |
| Pericardectomy, extensive | 200.00 |
| Pericardial top or aspiration | 25.00 |
| Pericardial wound - suture | 175.00 |
| Perincoplasty with urethral repair | 150.00 |
| Peritoncoscopy | 50.00 |
| Peritoneal cyst | 100.00 |
| Phalagectomy (bone spur) | 75.00 |
| Pharyngeal flap | 125.00 |
| Phelebography | 50.00 |
| Photocoagulation (retinal tear) (use of light to reattach retina) | 167.00 |
| Phrenic nerve crusing | 75.00 |
| Pilonidal cyst or sinus | 75.00 |
| Planters wart | 65.00 |
| Plastic hypospadias or epispadias | 200.00 |
| Plastic on pelvis & ureter | 150.00 |
| Plethysmography | 50.00 |
| Pleura, paracenteses | 30.00 |
| Pneumoencephalogram | 35.00 |
| Pneumogram | 50.00 |
| Pneumolysis | 125.00 |
| Polypectomy | 50.00 |
| Polysommography (sleep analysis) | 75.00 |
| Polysonogram | 125.00 |
| Popscan (minor scan- ear passage) | 50.00 |
| Potts procedure | 200.00 |
| Pregnancy, delivery (does not include prenatal and postnatal care) | 100.00 |
| Pregnancy, ectopic | 150.00 |
| Preparotod mass of salivery gland | 85.00 |
| Proclosigmoidoscopy | 50.00 |
| Prolapsed rectum, repair or injection | 100.00 |
| Prostatectomy, Perineal Radical |
150.00 200.00 |
| Prostatectomy suprapubic, one stage including vasectomy | 150.00 |
| Prostatectomy suprapubic, two stage including vasectomy | 150.00 |
| Prostatectomy, transurethral | 150.00 |
| Prostatic abscess | 50.00 |
| Prerygia, bilateral | 125.00 |
| Pterygium | 50.00 |
| Ptosis (single) | 125.00 |
| Punch operation with suprapubic drainage | 100.00 |
| Puncture wound | 50.00 |
| Pyelalitatomy (kidney) | 100.00 |
| Pyelogram | 50.00 |
| Pyloric stenosis - (ramstedt's in infant) | 125.00 |
| Quadrectomy | 100.00 |
| Radial Keratotomy One eye Bilateral |
125.00 175.00 |
| Radical Axilla or groin (glands) | 100.00 |
| Rectocele Combined cystocele & rectocele |
100.00 100.00 |
| Removal foreign body or cornea | 35.00 |
| Removal maxillary sinus cyst | 75.00 |
| Removal of mediport for chemotherapy | 125.00 |
| Removal of nail - hip joint | 50.00 |
| Removal of or exploration for an extruded nucleus, pulposus or ruptured intervertebral disc | 150.00 |
| Removal of submaxillary salivary gland | 50.00 |
| Removal of wires and screws | 50.00 |
| Renal biopsy | 125.00 |
| Renal exploration | 125.00 |
| Renogram | 50.00 |
| Resection - hip joint any other major joint any joint, fingers and toes |
175.00 150.00 50.00 |
| Resection of pre-sacral plexus | 100.00 |
| Retinopathy | 125.00 |
| Retinoscopy | 50.00 |
| Rhinoplasty | 100.00 |
| Salpingectomy | 100.00 |
| Salpingo-oophorextomy | 100.00 |
| Scalene node biopsy | 70.00 |
| Scrotal hematoma | 75.00 |
| Seborrheic keratosis of face | 75.00 |
| Section of anterior or posterior roots (spinal cord) | 150.00 |
| Section of sensory root for 5th nerve neuralgia | 150.00 |
| Section of vestibular nerve for Meniere's disease or aural vertigo | 150.00 |
| Semilunar cartilage, removal from joint | 100.00 |
| Septic finger (tendon sheath involvement) | 45.00 |
| Septic hand (tendon sheath and compartment) | 55.00 |
| Septoplasty | 185.00 |
| Septorhinoplasty | 200.00 |
| Sesamoidectomy | 75.00 |
| Short leg cast | 35.00 |
| Sigmoidoscopy | 35.00 |
| Sigmoidoscopy & biopsy | 25.00 |
| Simple fracture (non-operable) with brain injury depressed compound |
50.00 125.00 87.50 |
| Sinusotomy | 125.00 |
| Skin grafts | 100.00 |
| Skin tags | 75.00 |
| Sonogram | 50.00 |
| Spermatocele | 100.00 |
| Spermatocelectomy | 100.00 |
| Sphincterotomy | 100.00 |
| Spinal cord tumors | 200.00 |
| Spinal fusion | 200.00 |
| Spine scan | 100.00 |
| Spleen scan | 100.00 |
| Splenectomy | 150.00 |
| Stapedectomy | 125.00 |
| Stone, submaxillary or parotid duct | 50.00 |
| Strabismus, one or more muscles | 125.00 |
| Subdiaphragmatic abscess | 100.00 |
| Subdural hematoma | 125.00 |
| Submeatal mass | 200.00 |
| Submucous resection | 75.00 |
| Symblepharon, release | 40.00 |
| Synovectomy | 175.00 |
| Talipes, Metatarsus vargus Calcaneous valgus Equinovarus |
100.00 100.00 150.00 |
| Tarsorrhaphy, orbicularis paralysis | 70.00 |
| Tendon, repair, one Each additional |
45.00 15.00 |
| Tenkoff catheter | 100.00 |
| Tenolysis/foot tendon | 100.00 |
| Tenotomy, simple, open Closed |
75.00 50.00 |
| Testicle biopsy | 70.00 |
| Thacheostomy | 75.00 |
| Thermography | 50.00 |
| Thoracentesis | 50.00 |
| Thoracoplasty (first stage or partial) Complete |
85.00 200.00 |
| Thoracotomy By Nile resection |
100.00 70.00 |
| Thorascopy | 50.00 |
| Thorax scan | 100.00 |
| Thyroglossal cyst, removal | 100.00 |
| Thyroidectomy, subtotal | 125.00 |
| Thyroidectomy, two-stage subtotal, (with or without ligation) | 150.00 |
| TMJ (by an oral surgeon) | 200.00 |
| Toe nail, ingrown, removal radical | 45.00 |
| Tomography | 70.00 |
| Tonsillectomy and adenoidectomy, Under 15 Over 15 |
50.00 75.00 |
| Torsion of testis | 100.00 |
| Torticollis, operation for | 75.00 |
| Trabeculectomy oculus sinister for glaucoma | 100.00 |
| Trachelorrhaphy | 45.00 |
| Tracheotomy | 100.00 |
| Transectal femoral artery & vein | 200.00 |
| Transfusion, complete (newborn) | 75.00 |
| Traumatism of the scrotal sack | 175.00 |
| Trigger finger release | 35.00 |
| Tubal, bilateral RE: Anastomosis | 150.00 |
| Tubal Ligation (independent procedure) | 100.00 |
| Tumor, exenteration of obit | 200.00 |
| Tumors, benign external removal each additional |
25.00 10.00 |
| Tumors, benign, removal deep | 35.00 |
| TUR bladder tumor | 100.00 |
| TUR divertculum | 50.00 |
| TUR prostate | 150.00 |
| TUR vesicule neck - female | 100.00 |
| Turbinectomy | 25.00 |
| Tympanic mastoidectomy | 100.00 |
| Tympanometry | fee charged |
| Tympanoplasty, Simple Complicated Types 1, 2 & 5 |
75.00 100.00 200.00 |
| Ulcer, surface excision | 25.00 |
| Ulnar nerve | 50.00 |
| Ultrasonography | 75.00 |
| Ultrasound | 50.00 |
| Unilateral lumbar sympathectomy | 100.00 |
| Unnaboot | 25.00 |
| Ureter transplantation, single Bilateral |
125.00 175.00 |
| Ureteral catheterization | 35.00 |
| Uretero-lithotomy | 125.00 |
| Ureteroplasty | 125.00 |
| Ureterotomy | 125.00 |
| Urethropexy | 175.00 |
| Urethrotomy (vision) | 75.00 |
| Urethroplasty, Marshall-Marchetti | 100.00 |
| Urethroscopy | 50.00 |
| Urography | 50.00 |
| Uterine flexions, etc. correction (plus surgery of tubes and ovaries) Same with vaginal plastic work |
100.00 150.00 |
| Uterine polyp removal with dilation and curettage | 50.00 |
| Uvulopalatoplasty (located under tongue) | 200.00 |
| Vaginal warts Coagulation and excision | 50.00 |
| Vagotomy with pyloroplasty | 100.00 |
| Varicecelectomy Bilateral |
50.00 75.00 |
| Varicose veins | 125.00 |
| Vasectomy (when not preliminary to prostatectomy) | 35.00 |
| Vein scan | 100.00 |
| Veneral warts | 75.00 |
| Ventriculogram | 50.00 |
| Vesiculectomy | 125.00 |
| Vulva biopsy | 50.00 |
| Vulvlectomy With groin dissection |
100.00 175.00 |
| Yag laser capsulotomy | 100.00 |
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