• Appendectomy, freeing of adhesions or exploration of, or cutting into, the abdominal cavity

• Removal of, or other operation on gall bladder 

• Gastro-enterostomy

• Resection of stomach, bowel or rectum 

ABSCESSES (See Tumors)

• Thigh, leg

• Upper arm, forearm, entire hand or foot 

• Fingers or toes,each

• Removal of benign tumor or cyst 

• Simple amputation

• Radical amputation

• Complete thoracoplasty, transthoracic approach to stomach, diaphragm or esophagus; sympathectomy or laryngectomy

• Removal of lung or portion of lung cauterization or conization, polypectomy, 

• Brochoscopy, esophagoscopy

• Induction of artificial pneumothorax, initial refills each (not more than 12) 

CYSTS (See Tumors)

DISLOCATION, REDUCTION OF

• Hip, vertebra or vertebrae, ankle joint, elbow or knee joint (patella excepted)

• Shoulder 

• Lower jaw, collar bone, wrist or patella 

For a dislocation requiring an open operation, the maximum will be twice the amount shown above

• Hip joint 

• Shoulder, knee joint, semilunar cartilage, elbow, wrist or ankle joint

• Removal of diseased portion of bone, including curettage (alveolar process excepted

• Mastoidectomy, one or both sides: Simple; Radical

• Tonsillectomy, adenoidectomy, or both

• Sinus operation by cutting( puncture of antrum excepted)

• Submucuos resection of nasal septum 

• Tracheotomy 

• Any other cutting operation

• Operation for detached retina 

• Cataract, removal of 

• Any other cutting operation into the eyeball (through the cornea or sclera) or cutting operation on eye muscles

• Removal of eyeball 

• Thigh, vertebra or vertebrae, pelvis, (coccyx excepted)

• Leg, kneecap, upper arm, ankle (Potts) 

• Lower jaw (alveolar process excepted), collar bone, shoulder blade, forearm, wrist (Colles), skull

• Hand, foot

• Fingers or toes, each 

• Nose

• Rib or ribs, three or more, or fewer than three 

For a fracture requiring an open operation with grafting, bone splinting, or metallic fixation at point of fracture, the maximum will be twice the amount for the corresponding simple fracture.

• Removal of, or cutting into, kidney

• Fixation of kidney 

• Removal of tumors or stones in ureter or bladder: 

• by cutting operation 

• by endoscopic means 

• Cystoscopy

• Prostatectomy

• Simple punch for median bar

• Partial resection via cytoscope 

• Complete removal, any approach 

• Varicocele, hydrocele, orchidectomy or epididymectomy, single or bilateral

• Hysterectomy or panhysterectomy 

• Other cutting operations on uterus and its appendages with abdominal approach

• Cervix amputations

• Vaginal plastic, operation for cystocele or rectocele

• Removal of thyroid, subtotal 

• Removal or adenoma or benign tumor of thyroid

• Single hernia 

• More than one hernia

• Incision into, tapping excepted 

• Cutting or transplant, single or multiple

• Suturing of tendon, single or multiple

• Fenestration, one or both sides

• Tapping

• Removal of

• Hemorrhoidectomy, external, internal or internal and external 

• Cutting operation for fissure

• Cutting operation for thrombosed hemorrhoids

• Cutting operation for fistula-in-ano, single, multiple

• Cutting into cranial cavity (trephine excepted) 

• Trephine

• Operation for spinal cord tumor

• Operation with removal of portion of vertebra or  vertebrae (except coccyx, transverse or spinuous process) 

• Removal of part or all of coccyx, or of transverse or spinuous process

• Benign or superficial tumors and cysts or abscesses

• Malignant tumors of face, lip or skin 

• Injection treatment, complete procedure; One or both legs 

• Cutting operation, complete procedure; One or both legs