Document BqBBQaNEzKG2n4xZqY9Lx9X4

U* r Depeaeott *iw undcreM auch oponi PLAINTIFF'S EXHIBIT aCBEDULE or SURGICAL CFi3UTI0NS (Other Than Radiation Therapy) The maximum payment for any surgical operation not specified la the following schedule or for any multi-stage operation, ahall he dateraised hy the Znauraaee Coapany oo the haaie of the severity of the type of operation, la as amount eon* olataat with the maxiaua payaenta for operation* lifted. Zf nore than one operation 1* performed at the same operative esseioa la the same operative field by the some surgical teas, the total payment for all such operations shall not ezeeed the maximum payment for that one of aueh operations for vhleb the largest amount is payable. Zf aore than one operation 1* performed at the same operative session in separate operative fields by the sane surgical teaa, and through separate incisions, the total payaent for all sueh operations shall not exceed the payment for that one of sueh operations for vhleh the largest amount is payabla, plus of the aaxiinua payaent for eaeh of the other operations, unless otherwise specified in the schedule. Zf bilateral slailar operations are performed at the same operative session in separate operative fields, the total payment for both operations shall not exceed 1$0 of the maTimas payment for tbs slagla operation, ualsas otherwise specified in the schedule. In no event, however, shall the maxima payment determined in accordance with any of the paragraphs immediately preceding exceed the Karimas Surgical Operation Benefit in foree hereunder on account of the Employee or Dependent who has undergone aueh operations. Surgical Operation CARDIOVASCULAR StSTZM Connieeuretoay or valvulotomy, altral...................................... Aortic, pulmonic, or tricuspid............................................ Cardiotomy or perlenrdioteay with coloration, drainage, or removal of foreign body........... ............................................. .. ArterlotogQr, ei^le, with exploretloo nr removal of embolism Xntratberaele or intra-abdominal.................... Seek......................................................... ..................... ................... . extremities.......... .......................... Veins' Ligation and division of long saphenous vein at sapbenofeenral Junction, with er without retrograde injection, or distal istomqytlsna Unilateral............................................................................ Bilateral............................................................. Schedule Applic to Eaployeei end Dependent p. $1*25 500 350 275 200 150 7$ 125 JWmO&P.dJO) March 1M1 seomooMMdk #500 Applicable to toployeea Whose Max luauraaee Benefit is $500 Semes f. MAXIMUM PAYMENTS FOR SURGICAL OPERATIONS-- Surgical Optratloo Sohedule Applicable to Employee* and Dependents ~~ CARDIOVASCULAR SYSTSN - (Cont'd) Valna - (Cont'd) Ligation and dlvialon of abort saphenous vela at aaphaaopopliteal Junction (independent procedure)........................ Ligation and dlvialon and complete etrlpping long or abort aapbeaoua vclna Unilateral............................................................................ Bilateral..................... Long and short aapbeaoua valna Unilateral................................................................................ Bilateral...................................... Injection of aeleroslng solution, each treatment (not more than five)........................ ' $ 50 100 17$ 140 200 10 DIGESTIVE system Appendectomy (independent procedure).............................. Cholceysteetomy.................................................................................................. With open exploration of common duet.............................................. Colectomy Partial, vith anastomosis, vitta orvlthout colostomy................. For malignant tumor vlth regional lymph node dissection.......... Gastrectomy Total, for aallgnaney with regional lymph node dissection.... Subtotal, vith or vlthout vagotomy........... *................................. Gaotroentcrootomy............. ` Zntcreetomy: resection of email lntastlaa vith anastomosis or enterostomy............................................................... Tonsillectomy, vith or vlthout adcnoidtotooQr Age 14 or ovar................................................. ..................... ............ Under age 14............. Ssophogoeeopy Diagnostic................. Vith biopsy, add......................................... with removal of farcin body cr exelsloa of turner............. . Oastrooeopy Diagnostic, vith or vlthout biopsy................... ............... ............ Proctosigmoidoscopy, diagnostic Initial............. Catoifutat.......................... Bomorrholdacteagr (vith cr without flaauraeto^r, with * r vlthout sphincterotomy) External, claglo.............................. Multiple, collate.......... .............. Internal, or Internal and sxtermal............................................ Radical (Rule or Whitehead)................................ 150 200 250 275 500 500 275 200 75 50 50 20 65 50 10 10 Lo 70 100 150 25 FwnGLr.RQ) March 1942 500 [ Sceneir 9. MAXIMUM PAYMENTS POR SURGICAL OPERATIONS*--Cmuiaafd gurgled Operation Schedule Applicable to weploycca and Dcpcndcntt Hanima Paymcat .DIGESTIVE SYStZM (Cent'4) Enucleation or axelaIon of external throabotle heaonrhold.......... Plctulotony or flatuleeteoy Subauaeular............... .......................................................................... Subcutaneous..................................... Couplete proctactony, eonblned abdoolaoperineal, one or two ...................................................................... ................................. $ 10 . 150 3$ 350 BTOOCRDfE SYSTEM Thyroidectooy Total or subtotal for aallpiaacy with radical sock dlaaectlon. Subtotal or partial, benign condition........ ................................... Total thyroid lobeetoasy,unilateral.............. . local exelaloo of saull eyat or adencaa of thyroid............. 350 225 175 150 HEMIC AND LYMPHATIC SYSTEMS Splenectomy........................ Blopey or excision of lymph node (Independent procedure), except anterior oealeno........................... 200 20 2HTESWENTARY SYSTM (Skin, Subcutoneoua, Areolar Tlaauea, lreaat) Skin and eubeutaneoua tlaaue Xnelalon and drainage, eyota (up to 5), earbusda or abseeca.................................................... Zxclalon of pilonidal eyat or alnua......................................... . Kxelalon (Ineluding aiaplc repair) of hiatalogleally trifled nallgnant neoplaana Trunk, ana or laga Diaaeter up to 3/L Inch............................................. .. Bead, sack, haoda, feet or genital* Dlaaater 1/2 Inch or laaa................... .................................. Diaaeter ever 1/2 Inch but leaa than 3A inch*>* Eydlda, llpa or suceua aeabrane Diaaeter 1/2 Inch or laea...................... .............................. Dlaaater over 1/2 laeh but leae than 3A Inch............... . 10 100 35 50 70 TO 85 Exclalon, benign tuaora (ether thin superficial), any ^pe Unilateral................................................................................ Bilateral............................................................... Kaateetoagr, ecaplete (alapla)...................................................... Partial, unilateral................................................................................. bilateral........................................... ...... Radleal fbr aa.IIgnancy, Including pectord a-. axillary 1y^h aodae. ............... ... 100 60 $0 300 60 Penn G.S.P* 630) March 1X2 aaiwTcete uojl 500 ww cAptoycs er -xpeaesat no wnocrfoaa mjc.1 optnoco. SCHEDULE or SURGICAL OPERATIONS (Other Then Radiation Therapy) The maximum payment for nay eureleol operation not (pacified in the following eehedule or for any multi-stage operation, shall ho determined hy the Zaouraaeo Conpaay on the basis of the severity of the type of operation, in an amount con sistent vith the maximum payments for operations listed. Zf more than one operation is perfomed at the seme operative session in the sea* operative field toy the saae surgical teas, the total payment for all such operations shall not exceed the maximum payment for that one of sueh operations for which the largest aaouat is payahla> If more than one operation is performed at the saae operative session in separate operative fields toy the ease surgical team, and through separate incisions, the total payment for all sueh operations shall not exceed the nnxiaua payment for that one of eueh operations for vhiah the largest amount is payable, plus 50% of the maxisum payment for each of the other operations, unless otherwise specified in the schedule. If toiletoral similar operations are performed at the same operative session in separate operative fields, the total payment for tooth operations shall not exceed of the maximum payment for the single operation, unless otherwise specified in the schedule. In no event, however, shall the maximum payment determined in accordance with any of the para^aphs immediately preceding exceed the Maxima Surgical Operation Benefit in force hereunder on account of the Kxployee or Bependent who has undergone such operations. Surgical 'Operation CARDIOVASCULAR STSTEM Commissurotomy or valvulotoaqr, mitral.......... ........... Aortic, pulmocle, or tricuspid....*..............*............................... Cardiotomy or pericardiotomy with exploration, drainage, or removal of fenlgt body.............. ......................... ...................... Areerlotony, simple, with exploration or removal of embolism Zntrathoraeie or intra-abdominal........ ............................................ Pooh................................................................ .................................... . Xxtrsmitisa......................*.....*..* Veins Zigstion and division of long saphenous vein at saphanofsacrml junction, with nr without retrograde injection, or distal interruptions Uni lateral............... ................................... .. Bilateral........................ ............. . Schedule Applicable to Enployees and Dependents Mart ana Payment $$10.00 600.00 120.00 330.00 240.00 160.00 90.00 150.00 Perm OJJ. OCO March 1942 fiwmwwa 500 Applicable to Snploysee cad Dependents fees# Maxima Surgical operation Insurance Benefit is $600 l I Surgical Operation fruAGlCAL OPERATIONS--- gehedule Applicable to Employees end Dependents Hairlmw Paynaat CA2I8ZOVJSCULM SYSTEM - (Cost'd) Veins - (Cont'd) Ligation sad division of short saphenous vela at sapbaao* popliteal Junction (independent proeedure)........ . Ligation and division and complete stripping Long or short saphenous veins Unilateral..................................................................................... . Bilateral............................................................................................ Long and short saphenous veins Unilateral..................... ................................................. Bilateral................................................................................................ Injection of seleroslng solution, each troatasat (net nore than five)........ .............................. ................................... # #0.00 120.00 210.00 168.00 240.00 12.00 DIGESTIVE SYSTEM Appendectomy (independent procedure)......................................... Cbolecysteetoay............................................. .............................. . With open exploration of cornea duet.......................................... .. Colectomy Partial, vlth anastomosis, with or vlthout colostomy.......... . For malignant tumor with regional lymph node dissection...... Oestrectomy Total, for mallgnaney vlth regional lymph node dissection.... Subtotal, vlth or vlthout vagotomy........................ .................... Oaatroenterostoay........ ............................................... * Interectomy: resection of small intestine vlth anastomosis or enterostomy......................................... ..................... Tonsillectomy, vlth or vlthout odcaoldootony Age lb or over............ ............................................................ Under age lb................................ .............................. . Xeophagoaeopy Diagnostic........ ........... ................................ ................... Vlth biopsy, add........................................................ Vlth removal of forel^t body or excision of tumor............ Osstroscepy Diagnostic, vlth or vlthout biopsy.......... . Proctosigmoidoscopy, dlatpsontlc Initial...................... .......... .................................................................... Subsequent.............. .................................... ........... ............ .. cmerrholdcctomy (vlth or vlthout flesureetoor, vlth or vlthout cphlneteroto^r) External, ciagle............................... Multiple, icnpl if............................................................. . Internal, or Internal and asternal................. Badloal (Bull or Whitehead).................................................. 180.00 2UO.OO 300.00 330.00 600.00 600.00 330.00 240.00 300.00 90.00 60.00 60.00 24.00 102.00 60.00 12.00 12.00 48.00 64.00 120.00 180.00 Fern OS-F.dKM March 19*2 rourrseix ue.a #500 B*CTJO* * MAAiAWM I'AIAAAijl fWA dWAWWW UfAJSAttwn gurgical Operation .DIGESTIVE SYSTEM - (Coat'd) Eaueleetlen or axelaloo of external throabotic heaozrboid..... Fistuloteay or fietuleatoay Subauseuler............................................................................. . Subcutaneous.............. ................................ ....................... Coopiate proctectomy, eooblaad abdominoperineal, one or tvo stages................................. ................ ............ . TXXCRSXZ SYSTEM Thyroidectomy Total or subtotal for malignancy vith radical neck dlaaoctioo. Subtotal or partial, bcalgsi ...................................... ...................... Total thyroid lobectomy, unilateral................................. Local excision of snail cyst car adoaooa of thyroid..* XEK2C AND LYMPHATIC SY5T1M3 Spleneetony................. ................................................................. .. Biopsy or excision of lymph aoda (independent procedure), except anterior scalene................... gchedule Applicable to Employees ead Dependents Watlsus Payment $12.00 160.00 42.00 420.00 420.00 270.00 210.00 ISO.00 240.00 24.00 ZRTESUMSTTART SYSTEM (Skis. Subcutaneous, Areolar Tissues, Breast) kin and subcutaneous tissue Incision and drainage, cysts (up to 5), earbuaale or abscess............................................. Excision of pilonidal cyst or sinus............... Excision (including simple repair) of histologically verified malignant neoplaaas TSrunk, ins or legs Disaster up to 3/4 inch................................... Bead, neck, hands, feet or genitals Diameter 1/2 inch or less................. ...................................... Disaster ever 1/2 inch but less than 3/4 lash.......... Eyelids, lips or xucous acabraae Dlaaeter 1/2 inch or loss........................ Disaster ever 1/2 inch but less than 3/4 lMh .. 12.00 120.00 42.00 60.00 64.00 64.00 102.00 Breast Excision, benign tuaors (ether than superfioial), any type Unilateral............ .......................... ...................................* Bilateral.............................................. . ,, Mastectoegr, eoaplete (simple)........ .. Partial, unilateral................................ ......................*v*......... Bilateral..*.......... Badieal for malignancy, including pastoral wise)as and aadJLlary lyaph nodes.......... ............................... ........................ 72.00 106.00 120.00 72.00 106.00 360.00 farm G3J. 6301 Kerch 1942 saixTssw aa 1500 gurgleal Operation MUSCULOSHEIETAL SrSTXM kn*i Osteoplasty Shortening of boae Femur, tibia or humerus............................................................... Radius or ulna.................................................................. . Radical resection of boas for tumor with boos erafa Large bone.............. ............ .................................... Snnll bone........................................ ........................ ...................... . Excision of bone cyst. chondroma or exostosis Large bones.......................................'.................... ............................. Snail boaea............................................. .................... Dislocations Closed reduction, simple Shoulder............................................................................. . Elbow................................... ........................... ..................................... Finger or thumb.................................................................................. Hip.............................................................................................. .......... Knee (except patella)..................................................................... Patella........................................................ ........................................ Open reduction, simple or compound Shoulder or elbow (fresh)................................ . Hip........................................................................................................ Knee (exeept patella)................................................... Patella...................................................................... . Freetuxes Closed reduction Otber than chip or avulsion fractures Clavicle, simple, age 14 or over....................... Under age 14........ ....................... ............ . Rib or ribs, simple, strapping................................................ . Humerus Surgical neck, requiring manipulation................. Shaft, simple, age 14 or over...................................... . Under age 14.............. .................................... Elbow, involving 2 or 3 bones, simple, age 14 or ewer.... Under age 14...... Radius, bead, immobilisation only....................... Radius, shaft, with or without manipulation Age 14 or over..................................................... .............. . Under age 14................................... . Ulna, shaft, with or without nsnlpulstisn Ago 14 or over............................................................ . Under sga 14............................................................ .. Schedule ApplieaSua to Employees and Dependents Hea.lsujB Payment $420.00 270.00 420.00 270.00 210.00 132.00 72.00 48.00 24.00 150.00 46.00 30.00 210.00 300.00 240.00 150.00 72.00 48.00 24.00 132.00 162.00 108.00 162.00 106.00 48.00 72.00 48.00 $4.00 36.00 FwaCIF.IN* Mfc4 1R42 saurrsmm vaa 8 6900 Surgical Operation .KUSCULOSJCLETAL SYSTD-I - (Cont'd) Fractures - Cleoad reduction - (Cont'd) Badius and ulna, abaft*, requiring manipulation Age 14 or over.............................................. Under age 14................... ....................................... Metacarpal, one, lnoblllxatlon only Age It or over........................................ ........... .................... .. Under age It..................................................... .......................... For each additional metacarpal, odd................................... Phalanx or phalange*, on* finger or thumb, immobilisation only........................... ................... Tor each additional finger, add........................ Pelvi* (exeept sacrum). *lBple, elngle................................. Complicated or multiple................................ Temur, simple, neck or shaft, including supracondylar Age It or over...................................... .................................. Under age 14........................... ................................................... Temur, Intertrochanteric, simple, reduction vita fixation Age It or over........................................................................ Under age Ik............................................. ..................... . Patella, simple. Immobilisation only..................................... Tibia, shaft, simple, mobilization only Age It or arver......................................... Under age It................................... ..................................... . fibula, shaft, simple........................................ ................ Tibia and fibula, ahafta, age It or ever............................... Under age It................................... Ankle, blnalleolar or trimalleolar (including Potts) Slmpls....................................................... Tarsal, simple One (except astragalus snd os calels).......... ................... Astragalus or e* calels.................. .................................... Phalanx or phalanges, on* toe, simple, exeept great to*.. Great toe......................... .............................................. For each additional toe, edd................................................. For debridement of any compound fracture add 1/3 of thm amount for clooed reduction Insertion of Klrchncr vire or metal pins far traction or cast fixation, add..................... .......................... .................. Chip or avulsloo fractures............................... .......... . Open reduction (except chip or avulsion fractures) Pelvis (exeept sacrum), one or more homes simple or eoepousd.......... ....................... .. Sacrum, simple or sompouod................................. ............ . lumerus, shaft r amok, slmpls or compound............... .. Badius, hood, sls^l* or eo^ouad.......... ............... Schedule Applicable SO employee* and Dependent* frllTl T*** $160.00 76.00 36.00 24.00 6.00 24.00 12.00 120.00 210.00 240.00 141.00 300.00 *210.00 46.00 144.00. 72.00 46.00 192*00 120.00 144.00 46.00 72.00 16.00 , 24.00 12.00 24.00 16.00 390.00 160.00 &0.00 166.00 Perm G-S.P- 6X0 Msfch 1942 paiirrsB in vxa. 4$oo Surgleal Operation MUSCULOSKEIETAl SYSTEM - {Coat'd') Tr*aturea - Open reduction - (Cost'd) feaur, seek, aicpla or eoapouad, with internal flaUoo. . Teaur, shaft, aiaple or eoapouad, Age 11 or over................... Under tge 11...................... Tibia, shaft, sieple or coapcund, Age 11 or error.............. potato Under tf( 11....................... Excision: Intervertebral disk with splnsl fusion.................... Scallunur cartilage of knee joist...................... Synovectosy Wrist.................................................................................. ringer or tburnt, lnterphalaageal joist................... For each additional, add...................................... Sip...................................................................................... Knee...................................................... ............ ............. . Canglloneetoay of wrist or haad................. ................. Arthrotoay or espsulotoay with exploratloa, drainage, or re*oval of loose body Elbow or ankle.................................... Shoulder or knee.................................... .. Arthroplasty Shoulder................................. .................................. Elbow, wrist or aakla....................................................... Hip or knee........ ......................................... . Padlcal bualoa operation with aatatareal osteotomy Unilateral....... .......................... ............. Bilateral............................................................ Arthrodesis Wrist.................................. .................................. Hip.......................................................................................... Knee............................................................ Haaaer toe One toe, except great toe.............. ............................. Cmt toe, latarphalaogeal jolat............................... Tor each additional toe, add..................... .. Muscles or Teadoas Muscle biopsy Superficial........ .............................. ............................ .. Seep......................................................................... .............. Teadoas Zaclsloa Hip sUastcn, opoa, unilateral............................. Bilateral........ ................... Sever (or ilitisr) procedure of the shoulder tor Hrb'a palay Schedule Applicahl to Employees and Dependents Healana ftyoar* $360.00 300.00 160.00 210.00 180.00 510.00 210.00 210.00 ?3.00 36.00 390.00 210.00 72.00 162.00 210.00 330.00 300.00 120.00 180.00 270.00 240.00 180.00 330.00 60.00 120.00 21.00 18.00 30.00 106.00 111.00 300.00 Pam GAP. MM March 1M2 reiKTseiff was. *500 Surgical Operation KBSCULOSJOSLETAL SYSTEM . (Cost'd) Muscles or Tendons - (Cost'd) Kxelslon Pnseletomy or foaclectomy for Dupuytrea's contracture (open) Partial........................................... Radical......................................................................................... Repair or suture of exteoaor tesdo&i Slagle, forearm, log, Rond or foot........................................... lech additional Forearm or leg........................................... ^............................................................................................... rot................................. ............................................................. pise Spinal fualoo 2 vertebrae.................................................... 3*7 vertebrae................................... &*15 vertebrae, one ar two stages................... Coecygeetomy....................................................................... . RIOTOUS SYSTEM Peripheral serves txeiilon of histologically eosflrsad aaurcaia of tbs head or foot Cutaneous........................................................................................ Zntcrdlgltal, one............................ For each additional, add.......... . Stoefel's neureetoay.................. Sympathectomy Cervieothoraelc (Smltbwlekt type, supra-aod Inffm* diaphragnatic) Unilateral................ ............... Bilateral, concomitant or delayed................... ..... Lumbar, unilateral.................. Bilateral.......... .............................................................. Brain and Spinal Cord Craniotomy, osteoplastic, for excision of brain tumor, abacsss, or cyst, supratentorial............... .............. Craniotomy, suboccipltal for brain tumor..................... Craniotomy, for depressed skull fracture.................. With debridement of brain and repair Of dika................. . Burr boles vitb vmntrisulo^apby............... . Laninsetoay for dsoo^rosslon of tbs spinal sord mod nerve roots......*.*......... |Ckedul Applicant* to Employees and Dependents Payment *144.00 330.00 72.00 72.00 18.00 21.00 330.00 460.00 600.00 96.00 30.OO 60.00 6!oO l68!oo 300.00 420.00 240.00 300.00 540.00 600.00 330.00 420.00 64.00 420.00 Fmrm GSJ. 30) March 1M2 O 6600 Surgical Operation RESPIRATORY SYSTEM Cheat lobeetosy or pnauaoneetomy................................................................. Wedge rcaeetlon, single or multiple............................................... Thoracotomy, with open drainage or empyema cavity by rib reseetlon (independent procedure)............ ............. lose and Throat Removal of nasal polyp, one or more, unilateral or bilateral. Prontal sinusotomy, external, timpla (trephine operation).... Radical, obliterative, unilateral or bilateral.............. Antrotomy, lntranaaal Unilateral......................... .................................... ............................ Bilateral..................................... ..................... .. Masai septua, suboueous reseetlon......................... . With grafts............................................................. ........................... Bronchoscopy Diagnostic....................................................... .................... . With biopsy, add.......................................... .................. ............... With removal of foreign body or exalsloo of tuner........... laryngoscopy, direct Diagnostic, Independent proeadure................... . With biopsy, add......................................................%........................ With renoval of foreign body........................ ............................... SPECIAL SENSE (SOARS Bar Mastoidectomy, simple................................... Radical......................... ........................... ..................... . Stapedectomy, vith or without vela graft.................... Bye Cataract Dlselssion; needling of lent Initial............................... ..................... ..................................... Subsequent........ ........................................... ................. Extraction of lens, any type, unilateral..................... Excision of pteryglua.......... ...................................... . Reattachmcnt of retina Electrocoagulation, scleral rasaotlon, bunlrl1ng or partial tubing................................................ ........... . Light coagulation, euparsonle or any othar extra ocular method........................... . Ocular museleai any ^rpe of operation Involving ana or nor* nuaolaa in one or both eyas done La ana stags*........... . Corneal taransylant............................................................................... Schedule Applleabls to Employees and Dependents Maximum Payment U420.00 I 330.00 168.00 30.00 84.00 240.00 60.00 102.00 120.00 180.00 60.00 24.00 102.00 42.00 18.00 84.00 210.00 300.00 420.00 84.00 42.00 330.00 102.00 420.00 168.00 240.00 420.00 OS.T.6M} March 1M2 wsm is vaa. I $$00 Surgical Operation to Employee* and Dependent* flf <,, n.y^rt. BRoesrrrrAL srs'nx female Genital Repair of cysteeele, with or without urethrocele....................... $150.00 Repair of eystoeele and reetocele, with perineoplasty, with or without repair of urethroeele............... .................210.00 Repair of rcctoeele, independent procedure................................. 120.00 Salpingectomy, oophorectomy, or ealpingo-oopboreetomy, complete or partial, unilateral or bilateral, independent procedure.......................................................................... 160.00 lyatcrcctomy (with or without removal of tutoea, with or without removal of ovaries) Total, vaginal or abdominal......................... ............................ 21*0.00 Suprneervlcal or subtotal....................... .................... *............. 210.00 Radical for malignant tumor with regional lymph node diaaeetlen................................................. 1*20.00 with removal of bladder and ureteral transplant........ 460.00 with rectal rejection, with or without removal of bladder and ureteral transplant........................................ 600.00 Amputation of cervix (independent procedure)............. 64,00 filiation and curettage (non-puerperal) (independent procedure)................. 60.00 With local exelsloa of leelos of cervix, or cauterisation.................. 72.00 Delivery of child or children.......................................... ............... 106.00 Caesarean Section, Including delivery, or abdominal operation for enrautarine pregnaney.................................. 1&0.00 Miscarriage................................................... 46.00 Male Genital Circumcision Clamp or dorsal slit......................................................................... 12.00 Other than damp or dorsal slit Age 14 or elder........................................................................ 42.00 Under age 14................................. ................................................... 30.00 Orchiectomy, elaple, unilateral............... 64.00 Bilateral.......................................................... 102.00 Excision of varicocele, hydrocele, or spermatocele, independent procedure.................... 120.00 Prostateetomy, with or without vasectomy.................................. . 330.00 Urinary Cystotomy or eystostomy with drainage or removal of calculus. 210.00 With figuration, add................................ 90.00 Mephreetamy, Including partial ureterectomy through came incision....................................................i................. .......... 330.00 With total ureterectomy, two incisions, add#.............. . 90.00 Cystoscopy, <1 agnnotio Initial (Independent procedure).......... .................................. 30.00 Subsequent, within 30 days................................. 16.00 With ureteral eatheterication, unilateral or bilateral, add. 12.00 With biopsy of bladder, add............... 6.00 Peon GSJ. 6300 March IMS reiirnotiiua-a $500 w/ob. Surgical Operation ~ corojciess hot associated vxnt a single sxssm Exploratory laparotomy or ealietony.................................................. Hernia Hittui or diaphragmatic..................................................... Herniotomy, Inguinal, unllateral..................................................... BUittnl...................................................... hrMMtoili........ ............................................................... w and Dependents nTimm raynaat >$ 166.00 150.00 210.00 SCHEDULE OF RADIATION TBERAPT For the purpose* of Surgleal Operation Insurance hereunder. X-ray. radius. cobalt^ and radioactive isotope therapy shall be deeaed surgical operations and any benefits therefor shall be subject to the tens and limitations applicable to benefits for sur gical operations; but no benefits shall be payable hereunder for any charges made by a hospital or other institution for services la connection vlth such therapy. The maximum payment for any X-ray. radius, cobalt, or radioactive isotope therapy not specified la the following schedule shall be determined by the Insurance Company 1^ - an amount consistent with the maximum payments for therapies listed. The eaounts sped* fled are the maximum payments for the treatments shown. dosage ealeulatlrns and use of facilities. Schedule Applicable to Employees Treatment _ and Dependents Karinua Payment *"* X-RAI AND RADIUM THERAPI All treatment (except concomitant surgical procedures) and retreatnent within a period of 12 eonsoeutlve months for the following conditions (subject to the maximum per treatment below): Histologically verified malignancies Shin. 1 centimeter diameter or lees................................. Over 1 centimeter diameter. Other soft tissue and bene Breast (except postaastoeteey)......................... TBstassteetoy................................................................. Intra-abdominal ami latrathoraelc. Head and neck... Central nervous system.......i Benign Tumors....... Par treatment X-ray (500 XV? or loss) Histologically verified malignancies.... ....... ........... Benign turners.< Surfaeo application ndlan or ocher eealed radioactive source.i X-ray (over 500 W?), cobalt, ... ................................................... 660.00 '120.00 240.00 166.00 240.00 330.00 300.00 42*00 12.00 6.40 12.00 16.00 300.00 16.00 r~m esr.uea MsrdilM faivraui sa #500 t*> beatteat &AS2CACTXVS ISOTOPS THCRAPY All treatment (except concomitant surgical procedure*) and retreetment vlthla a period ef 12 consecutive months for: Hyperthyroidism........................ Thyroid suppression (cardiac)......................... Interstitial or Intracavitary therapy vlth radioactive colloids Radioactive gold............... Radioactive phosphorus........................................ All treatment (except concomitant surgical procedures) and retreatmeat vlthla a period of 3 consecutive months for: Polyeythenle vara............................ Chronic leukemia............. Schedule Applicable to Employees and Dependents Haylmum Payment $210.00 210.00 120.00 64.00 12.00 12.00 If Surgical Operation Insurance Seaefits are paid hereunder for a surgical operation performed outside of a legally constituted hospital while Hospital Sepease Insurance under the Croup Policy Is la force ea aecouat ef the person vho underveat such operation, the Insurance Caspany shall pay. la addition to the paymaata ctharvlsa provided, the aaeuat of the actual axpeass. If any. charged for a general aaasthasla and tha adalalatratlea thereof la coanectloa vlth such operation up to a arimie ef $10.