MANUAL DE AFILIADO                                                                  MEMBERS MANUAL                        ...
2
CORDIAL SALUDO                                    Bienvenido a Best Care Medical Plan, Inc.Estimado(a) Afiliado(a):Le damo...
GREETINGS                                  Welcome to Best Care Medical Plan, Inc.Dear Member:Welcome to Best Care Medical...
Tabla de Contenido  Quienes Somos                                     7  Ventajas                                         ...
Table of Contents  About Us                                     8  Advantage                                    10  Import...
Quienes SomosBest Care Medical Plan es un plan de descuentos médicos licenciado en el estadode Florida. Best Care Medical ...
ABOUT USBest Care Medical Plan is a medical discount plan licensed in the State Florida. BestCare Medical Plan is supporte...
 No existen diferencias de precios  según la edad                           REFIERA A UN Se aceptan todas las personas s...
   There are no price differences    per age group                                        REFERRED A   All persons are a...
DATOS IMPORTANTESComo identificarse para recibir los beneficios:   Doctores y Hospitales > Como miembro de Beech Street...
WHAT YOU MUST KNOWHow to identify yourself to receive services:   Doctors and Hospitals > As a Beech Street PPO Network...
Ahorre en Doctores Primarios, Especialistas y HospitalesComo Usar los BeneficiosEl programa de Consumer Card de Beech Stre...
Save on Primary Doctors, Specialists, and Hospitals.How You BenefitConsumer Card program through Beech Street PPO Network,...
Línea gratis de Enfermeras Registradas                                                                                    ...
Nurse Line                                                                                                    24 hours a D...
Beneficios de FarmaciasComo miembro de Best Care Medical Plan usted obtendrá precios de descuento entodos los medicamentos...
Pharmacy BenefitsAs a member of Best Care Medical Plan you can obtain discount prices on all prescribedmedications. You ca...
Ahorre un 52%* en Medicamentos Genéricos                                                         Ahorre un 15%* en Medicam...
Save 52%* on Generic Medications                                                               Save 15%* on Brand Name Med...
Como Usar los BeneficiosUsted podrá adquirir sus medicamentos en cualquiera de las más de 50,000 farmacias que componen la...
How To Use Your Benefits You will need to present your new card to a participating pharmacy at the time you order a new or...
Beneficios de FarmaciasComo afiliado de Best Care Medical Plan ahora tendrá acceso a más de 50,000* farmacias participante...
Beneficios de Farmacias                 24
Ahorre hasta un 65%* en el cuidado dental Como Usar los Beneficios Access Dental es un programa de descuentos dentales con...
Save up to 65%* on dental care  How To Use Your Benefits  Access Dental is a dental discount program with over 20,000 part...
Calidad y ConvenienciaComo Usar los BeneficiosEl programa Access Vision le ofrece a usted y a las personas participantes e...
Quality and ConvenienceHow To Use Your BenefitsThe Access Vision program offers you and your eligible family members valua...
Mejor Audición Mediante Cuidado ProfesionalComo se BeneficiaCon su Membresía usted es elegible a recibir un 15%* de descue...
Better Hearing thru Professional CareHow To Use Your BenefitsWith your membership in Protective Health Options you are eli...
Como se BeneficiaUsted podrá recibir cuidado inmediato con descuentos considerables, en más de 13,500 doctoresQuiropráctic...
How to Use Your BenefitsYou and your eligible family members can receive immediate care with significant discounts at over...
LABORATORIOSDIAGNOSTICOSCIRUGIA GENERALSERVICIO DENTALOPTOMETRIAURGENCIASMATERNIDADCHEQUEOS PREVENTIVOSLABORATORIESDIAGNOS...
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PROFILES         FEE                PROFILES             FEEACUTE HEPATITIS             $60.00   C-PEPTIDE                ...
PROFILES            FEE                 PROFILES        FEEL.E. SCREEN                    $15.00   THYROID BINDING GLOBULI...
37
DIAGNOSTIC RADIOLOGY                                       HEADCODE                       SERVICES DESCRIPTION            ...
73060   HUMERUS, MINIMUM OF TWO VIEWS                     $     25.0073070   ELBOW, ANTEROPOSTERIOR & LATERAL VIEWS       ...
DIAGNOSTIC ULTRASOUND                                        HEAD & NECK  CODE                           SERVICES DESCRIPT...
CEREBROVASCULAR ARTERIAL STUDIESCODE                          SERVICES DESCRIPTION                             FEE93875938...
NUCLEAR MEDICINE FEE SCHEDULE               SERVICES DESCRIPTION                 FEETHALLIUM STRESS TEST                  ...
43
INTEGUMENTARY SYSTEM                       INCISION AND DRAINAGECODE    SERVICES DESCRIPTION                              ...
EXCISION, BENIGN LESION, EXCEPT SKIN TAG, SCALP,11424        NECK, HANDS, FEET, GENITALIA; LESION DIAMETER      $     185....
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP,12004        NECK, AXILLA, EXTERNAL GENITALIA, TRUNK AND OR   $     150.00120...
UPPER EXTREMITY                                CASTSCODE    SERVICES DESCRIPTION                              FEE29058   V...
REMOVALCODE    SERVICES DESCRIPTION                              FEE29700   REMOVAL BOOT CAST                             ...
GASTROINTESTINAL ENDOSCOPIES                              ENDOSCOPYCODE    SERVICE DESCRIPTION                            ...
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DIAGNOSTICSERVICE DESCRIPTION                                       CODE          FE EPERIODIC ORAL EVALUATION (NO CHARGE ...
Bc book   fl. miami.dade  - broward
Bc book   fl. miami.dade  - broward
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Bc book   fl. miami.dade  - broward
Bc book   fl. miami.dade  - broward
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Bc book   fl. miami.dade  - broward
Bc book   fl. miami.dade  - broward
Bc book   fl. miami.dade  - broward
Bc book   fl. miami.dade  - broward
Bc book   fl. miami.dade  - broward
Bc book   fl. miami.dade  - broward
Bc book   fl. miami.dade  - broward
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Bc book   fl. miami.dade  - broward
Bc book   fl. miami.dade  - broward
Bc book   fl. miami.dade  - broward
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  1. 1. MANUAL DE AFILIADO MEMBERS MANUAL 20118880 Northwest 20th Street, Suite J - Doral, FL 33172 .(c) 2011 Best Care Medical Plan, Inc. Best Care Medical Plan, Inc. is a discount medicalplan licensed in the State of Florida. Best Care Medical Plan, Inc. is not an insurancecompany, Health Insurance Company or a medical insurance company. Best Care MedicalPlans, Inc. does not make direct payments to the providers of medical services. The 1members of Best Care Medical Plan, Inc. are required to pay for all of their health careservices, but will receive a discount by the health care providers contracted by Best CareMedical Plan, Inc. Licensed by Florida OIR #06-651269644 / Texas TDI 1617486
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  3. 3. CORDIAL SALUDO Bienvenido a Best Care Medical Plan, Inc.Estimado(a) Afiliado(a):Le damos una cordial bienvenida a Best Care Medical Plan, su mejor alternativa en el cuidado dela salud. Como miembro usted tendrá la oportunidad de disfrutar de una gran variedad deservicios a través de una amplia red de proveedores médicos disponibles en su comunidad.Los Planes de Best Care NO son planes de seguro. Adjunto le enviamos las tarjetas de membresíao identificación que deberán ser presentadas para recibir los servicios de descuentos que le ofrecenuestro plan.Usted puede acceder a la lista detallada de proveedores participantes haciendo Clic en“Proveedores” visitando nuestra página de Internet en: www.usabestcare.comRECOMENDAMOS: Para un listado actualizado de doctores llame al 1-877-527-6161 ynuestras operadoras gustosamente le concertarán una cita con el médico más cercano a sudomicilio y en el horario más apropiado para usted. No obstante, adjunto le enviamos undirectorio limitado de doctores primarios y hospitales de su localidad.Una vez más le damos la bienvenida y le agradecemos por escoger a Best Care Medical Plan, paraproteger la salud de su familia.AtentamenteBest Care Medical PlanDepartamento de Servicio al Cliente 3
  4. 4. GREETINGS Welcome to Best Care Medical Plan, Inc.Dear Member:Welcome to Best Care Medical Plan, your best alternative to healthcare protection. As amember you will benefit of the incredible variety of services through an extensive healthcareprovider network available on your community.The Best Care Medical Plans are NOT insurance plans. Attach you will find yourmembership ID cards, which must be presented at the time of services in order to receive theapplicable discounts accessible through our plan.You may access a full detail list of healthcare participant providers by visiting “ProviderNetwork” on our Website at: www.usabestcare.comRECOMENDATIONS: For an up-to-date list of provider, please call: 1-877-527-6161 oneof our customer service operators will be pleased to schedule an appointment with a nearestprovider of your neighborhood at the time and date that will suit your needs. Never the less,enclose you will find a local directory of primary care doctors and hospitals on your area.Once again, we are pleased to welcome you and thank you for choosing Best Care MedicalPlan to protect the health of your family.Sincerely,Best Care Medical PlanCustomer Services Department 4
  5. 5. Tabla de Contenido Quienes Somos 7 Ventajas 9 Datos Importante 11 Beech Street Network 13 Linea Gratis de Enfermeras Registradas 15 Beneficios de Farmacia 17 Wal-Mart Presciption Plan 19 Atlantic Prescription Services (APS) 21 Farmacias Participantes 23 Prescripcion por Correo 24 Access Dental Network 25 Access Vision Network 27 Beltone 29 Comprehensive Health Group 31 Listado de Precios (Miami-Dade/Broward) 33 Laboratorios 34 Diagnosticos 37 Cirugia Menor 43 Dental 50 Optometria 56 Centro de Urgencias 59 Maternidad 61 Chequeos Preventivos GRATIS 62 Red de Proveedores 64 5
  6. 6. Table of Contents About Us 8 Advantage 10 Important Information 12 Beech Street Network 14 Free Nurse Line 16 Pharmacy Benefits 18 Wal-Mart Presciption Plan 20 Atlantic Prescription Services (APS) 22 Participating Pharmacies 23 Mail Prescriptions 24 Access Dental Network 26 Access Vision Network 28 Beltone 30 Comprehensive Health Group 32 Fee Schedules (Miami-Dade/Broward) 33 Laboratories 34 Diagnostics 37 Menor Surgery 43 Dental 50 Optometry 56 Urgent Care 59 Maternity 61 FREE Preventive Check Ups 62 Provider Network 64 6
  7. 7. Quienes SomosBest Care Medical Plan es un plan de descuentos médicos licenciado en el estadode Florida. Best Care Medical Plan está respaldado por una extensa red deproveedores constituida por un selecto grupo de Doctores con una vasta experienciaen el campo de la medicina; brindando una gran variedad de servicios, quesatisfacen la mayoría de las necesidades de salud de nuestros afiliados. De estamanera, nuestros miembros podrán obtener servicios médicos de muy alta calidad aprecios inigualables. SU FAMILIA DISFRUTARA DE LOS SIGUIENTES BENEFICIOS: Hospitalización y Centros de Urgencias Visitas a Médicos Generales y Especialistas Exámenes de Laboratorios Rayos X y Ultrasonidos Mamografías Cirugías Audición Quiroprácticos Estudios de Diagnóstico como: CT Scan y MRI Medicina Nuclear Endoscopias Además de: Ópticas, Dentistas, Farmacias y Una línea de enfermeras 24 horas al día 7
  8. 8. ABOUT USBest Care Medical Plan is a medical discount plan licensed in the State Florida. BestCare Medical Plan is supported by an extended network of providers made up of aselected group of Physicians with extensive experience in the medical field, offering awide variety of services that satisfy most of our affiliate’s health needs. This way, ourmembers will have high quality medical services of the highest quality at unbeatableprices. YOUR FAMILY CAN BENEFIT FORM THE FOLLOWING SERVICES: Hospitalization and Urgent Care Visits to General Medicine Practitioners and Specialists Laboratory tests X-Rays and Ultrasound Mammograms Surgery Hearing Chiropractors Diagnosis Studies like: CT San & MRI Nuclear Medicine Endoscopies As well as: Vision, Dental, Pharmacies And a 24 Hours Nurses Line 8
  9. 9.  No existen diferencias de precios según la edad REFIERA A UN Se aceptan todas las personas sin AMIGO Y RECIBA importar su estado de salud $10.00 Usted escoge su propio médico DE DESCUENTO EN SU PROXIMA No se requiere referido para visitar MENSUALIDAD un especialista No existe período de espera, de manera que usted puede comenzar a ahorrar en el cuidado de su salud desde el momento de la afiliación Le garantizamos que el costo de la membresía no se incrementará por el tiempo que esté afiliado al Plan. Eso significa que todos los años usted pagará la misma tarifa Pagos directo automatizado, facilitándole un mejor servicio sin interrupciones en la membresía que disfrutar de las diferentes promociones durante todo el año Un plan que puede afiliar a CINCO personas sin importar la edad o el vínculo familiar 9
  10. 10.  There are no price differences per age group REFERRED A All persons are accepted FRIEND regardless their health status AND RECEIVE You choose your own doctor $10.00 OFF ON YOUR NEXT No reference is required to MONTHLY visit a specialist PAYMENT There is no waiting period so you may start saving on your medical services since the moment you register We guarantee that the membership fee will not be increased for the time you remain affiliated to the plan. This means that every year you will pay the same rate. Automatic direct payments, which facilitates a better service without interruptions in your membership and you may benefit from several promotions during the time you are affiliated. A plan that can affiliate FIVE persons regardless their age or family relationship. 10
  11. 11. DATOS IMPORTANTESComo identificarse para recibir los beneficios: Doctores y Hospitales > Como miembro de Beech Street PPO Network. Línea de Enfermería > Como miembro de Best Care Medical Plan. Farmacias > Wal-Mart > Como miembro de Best Care Medical Plan. Otras Farmacias Participantes > Como miembro Atlantic Prescription Services (APS). Dentistas > Como miembro de Access Dental Network. Visión > Como miembro de Access Vision Network. Audición > Como miembro de Beltone. Quiroprácticos > Como miembro de Comprehensive Health Group. Servicio al Cliente 8880 NW 20 ST Suite J Miami, Florida 33172 Telefono: 1 (877) 527-6161 (305) 227-6161 Fax:(305) 227-6162 11
  12. 12. WHAT YOU MUST KNOWHow to identify yourself to receive services: Doctors and Hospitals > As a Beech Street PPO Network’s member. 24hours Nurse Line > As a Best Care Medical Plan’s member. Pharmacy > Wal-Mart > As a Best Care Medical Plan’s member. Other Pharmacy Networks > As a Atlantic Prescription Services (APS) ’s member. Dentists > As an Access Dental Network’s member. Vision > As an Access Vision Network’s member. Hearing > As a Beltone’s member. Chiropractics > As a Comprehensive Health Group’s member. Customer Service 8880 NW 20 ST Suite J Miami, Florida 33172 1 (877) 527-6161 (305) 227-6161 Fax:(305) 227-6162 12
  13. 13. Ahorre en Doctores Primarios, Especialistas y HospitalesComo Usar los BeneficiosEl programa de Consumer Card de Beech Street PPO Network, es un programa de descuentos médicoscon más de 400,000 proveedores en más de 25 estados participantes*. Como afiliado, usted podrá visitarcualquier proveedor participante las veces que sea necesario y recibir cuidado inmediato con descuentosconsiderables.Con Beech Street PPO Network, usted solo paga, al proveedor participante, los precios dedescuentos que le brinda el programa en el momento del servicio. Además, usted también cuentacon:  Ahorros ilimitados durante el año.  No limites en el número de visitas o servicios que usted recibirá.  No tramite, ni papeles que llenar.  Ahorros inmediatos* Para los estados participantes llámenos o viste nuestra página de Internet Ahorros en Servicios Médicos (Ejemplos solamente) BS Costo Cantidad aProcedimiento % de Ahorro* Promedio PagarColonoscopía con biopsia (45380) Naciona $846.85 (como $613.88 37.95%MRI Columna Lumbar (72148) l* $1,036.91 miembro) $754.61 37.41%Artroscopía de Rodilla / Cirugía (29881) $908.31 $618.32 46.90%Polisomnografía / Estudio del Sueño $1,245.22 $870.66 43.02%(95810) de Esfuerzo Cardiaca (93015)Prueba $246.86 $175.63 40.56% * Los ahorros están basados en el Listado de Precios Florida Top 100 CPT with Reinbursement en proveedores participantes (los precios pueden variar por región) comparado con el reporte Average Savings by States 2007 (promedio en Ahorros 28.5%). Ahorros Actuales pueden variar.Como Utilizar su Programa 1. Seleccione a un proveedor participante** 2. Identifíquese como un miembro de “Beech Street PPO Network” para hacer una cita, o deje que un representante de servicio al cliente le ayude a concertar una cita. 3. Presente la tarjeta de membresía… y ¡ahorre!** Para localizar un proveedor participante haga Clic en “Proveedores” en el menú de nuestra página de Internet, www.usabestcare.com o llame al Departamento de Servicio al Cliente para un listado actualizado o para hacer una cita > 877-527-6161 13
  14. 14. Save on Primary Doctors, Specialists, and Hospitals.How You BenefitConsumer Card program through Beech Street PPO Network, is a discount medical program with over400,000Healthcare providers through the participated states.* As a Member, you can visit any participatingprovider as often as you like and receive substantial discounts rates immediately.With Beech Street PPO Network, you will only pay, to the participating provider, the discounted ratesavailable only through the program at the time of service. Additionally, you also can count on:  Unlimited Saving through the year.  No limits on the number of visit or services you receive.  No paperwork to fill out.  Immediate savings.* For participating States call or visit our website Medical Services Savings (Sample Only) BS National Amount Paid*Procedure % Saved* Average (With Membership)COLONOSCOPY AND BIOPSY (45380) Charge* $846.85 $613.88 37.95%MRI LUMBAR SPINE W/O DYE (72148) $1,036.91 $754.61 37.41%KNEE ARTHROSCOPY/SURGERY $908.31 $618.32 46.90%(29881)POLYSOMNOGRAPHY, 4+ (95810) $1,245.22 $870.66 43.02%CARDIOVASCULAR STRESS TEST $246.86 $175.63 40.56%(93015) * Savings are based on Florida Top 100 CPT with Reimbursement for participating providers (fees vary by region) Compared to the Average Savings by status 2007 report (Average Saving 28.5%) Actual savings may varyHow to Use Your Program 1. Select a participating provider** 2. Identify yourself as member of “Beech Street PPO Network” to make an appointment, or just let one of our customer service representative help you arrange your appointment. 3. Present your Member ID Card...and save! ** To locate additional participating providers, Click “Providers” on our website menu at www.usabestcare.com or call the Customer Service Department for an updated list of provider or to make an appointment > 877-527-6161 14
  15. 15. Línea gratis de Enfermeras Registradas 24 horas al díaComo Usar los BeneficiosEste servicio le ofrece un número de teléfono gratuito donde usted tendrá acceso aenfermeras registradas con una vasta experiencia, 24 horas al día, 365 días al año.Incluyendo un recurso inmediato y confiable de información de la salud y/omedicamentos. También le provee consejería confidencial que le ayuda a tomarmejores decisiones acerca del cuidado médico que usted recibe. Además, invaluableinformación como son:  Acceso a una audio-librería con más de 450 temas relacionado con la salud.  Técnicas de auto cuidado para síntomas comunes.  Explicación de lo que puede esperar durante un examen médico.  Ayuda de una enfermera registrada para responder preguntas referentes a: o Diagnósticos o procedimientos quirúrgicos. o Una condición médica recientemente diagnosticada. o Información sobre prescripciones o medicamentos sin receta médica.  Todas las llamadas son atendidas por representantes médicos y transferidas a una enfermera registrada con conocimientos apropiados.  Todas las llamadas se mantienen confidenciales. Como Utilizar su Programa 1. Solo marque el número para La Línea de Enfermeras que aparece en la tarjeta de miembro o a la línea de Servicio al cliente > 877-527-6161 2. Marque el #3 para entrar al menú de miembros de Best Care Medical Plan. 3. Marque el #4 para conectar su llamada a la Línea de Enfermeras Registradas. 4. Pida hablar con una Enfermera Registrada para preguntas médicas. 15
  16. 16. Nurse Line 24 hours a DayHow to Use Your BenefitsThis service offers a toll free telephone access to experienced registered nurses, 24-hoursa day, 365 days a year. It includes an immediate and reliable source for health and medicalinformation. It also provides confidential medical counseling to help you make informeddecisions about the medical care you receive. Plus, other valuable information such as:  Access to an audio library of over 450 health related topics.  Self care techniques for common symptoms.  Explanations on what to expect during a medical test.  Help from a registered nurse who can answer questions regarding: o Diagnostic and surgical procedures. o A recently diagnosed medical condition. o Prescription and over the counter medication information.  All calls are answered by a medical service representative and transferred to a registered nurse with the  appropriate knowledge.  All calls are kept confidential.How To Use Your Program 1. Simple call the Nurse Line number on your Membership ID Card or contact our customer services line at > 877-527-6161 2. Dial #3 for Best Care Medical Plan members’ menu. 3. Dial #4 to connect your call to the Nurse Line. 4. Ask to speak with a registered nurse regarding your medical question. 16
  17. 17. Beneficios de FarmaciasComo miembro de Best Care Medical Plan usted obtendrá precios de descuento entodos los medicamentos recetados. Usted podrá adquirir sus medicamentos a través delos siguientes programas:  Wal-Mart Prescription Plan.  Atlantic Prescription Services (APS).Recomendaciones para lograr Mayores Descuentos:  Utilizar las farmacias Wal-Mart para obtener un mayor porcentaje de descuentos.  Pídale a su doctor que le prescriba un medicamento de tipo Genérico (si es apropiado).  Ordene sus medicamentos por Correo.Para los programa de Wal-Mart y APS, ver las paginas siguientes. 17
  18. 18. Pharmacy BenefitsAs a member of Best Care Medical Plan you can obtain discount prices on all prescribedmedications. You can acquire these medications through the followings two programs:  Wal-Mart Prescription Plan.  Atlantic Prescription Services (APS).Recommendations to obtain better Discounts:  Buy your medications through Wal-Mart Pharmacy, to obtain higher discounts percentage.  As your doctor to prescribe Generic medications (if appropriate).  Order your medications by Mail.For Wal-Mart and APS programs see following pages. 18
  19. 19. Ahorre un 52%* en Medicamentos Genéricos Ahorre un 15%* en Medicamentos de MarcaComo Usar los BeneficiosEn la próxima visita a su farmacia Wal-Mart, por favor presente la tarjeta de membresía así,los empleados de las farmacias Wal-Mart podrán obtener la información apropiada deusted. Si usted usa más de un establecimiento, usted tendrá que presentar su tarjeta encada uno de ellos. Usted podrá obtener sus medicamentos en cualquier establecimientoWal-Mart, SAM’S Club o Wal-Mart Neighborhood Market Pharmacy.Preguntas frecuentes con referencia a su plan de prescripciones mediante Best CareMedical Plan:  ¿Cuál número de identificación tengo que mostrar en la farmacia? – Todos los miembros de Best Care Medical Plan tienen en su tarjeta de identificación un número asignado específicamente para usar en las farmacias Wal-Mart.  ¿Cuanto es mi DESCUENTO? Los precios están especialmente negociados entre Best Care Medical Plan y Wal-Mart Prescriptions Plan. En caso de existir diferencias, entre el precio negociado de nuestro plan y algún precio de promoción de Wal-Mart’s Every Day Low price, usted siempre pagará el precio más bajo.* El porcentaje de descuento esta basado en el promedio del precio al por mayor (AWP).Medicamentos Genéricos: 52% menos + $1.99 por manejo y procesamiento.Medicamentos de Marca: 15% menos + $1.99 por manejo y procesamiento.Como Usar su Programa 1. Identifíquese como un miembro de “Best Care Medical Plan” cuando visite una de las farmacias Wal-Mart, SAM’S Club o Wal-Mart Neighborhood Market Pharmacy 2. Presente la tarjeta de membresía… y ¡ahorre!* Para localizar un proveedor participante haga Clic en “Proveedores” en el menú de nuestra página de Internet, www.usabestcare.com o llame al Departamento de Servicio al Cliente para un listado actualizado o para hacer una cita > 877-527-6161 19
  20. 20. Save 52%* on Generic Medications Save 15%* on Brand Name MedicationsHow To Use Your BenefitsOn your next visit to your Wal-Mart Pharmacy; please present your member ID card. TheWal-Mart Pharmacy staff will then obtain the appropriate information from you. Please keepthe card with you. Please note that if you use more than one pharmacy location, you willneed to present the card at each location the first time you use the card. This card entitlesyou to special negotiated pricing on prescription drugs at any Wal-Mart, SAM’S Club orWal-Mart Neighborhood Market Pharmacy.Frequently asked questions concerning my prescription plan through BEST CAREMEDICAL:  Whose identification number should be given to the pharmacy? – The Best Care Medical Plan member should use his/her member ID card that is made assigned to them upon the affiliation on the plan.  How much is the DISCOUNT? – The pricing is a special negotiated rate between the Best Care Medical Plan and WMS Prescriptions. In the event that the negotiated rate would ever be higher on a particular drug that Wal-Mart’s Every Day Low usual and customary price, you will always be charged the lower of the two prices. * Retail Prescriptions will be priced on average Wholesale Price (AWP). GenericDrugs: AWP less 52% plus $1.99 dispensing fee. Brand Name Drugs: AWP less 15%plus $1.99 dispensing fee.How To Use Your Program 1. Identify yourself as a member of “Best Care Medical Plan” when visiting one of the Wal-Mart, SAM’S Club or Wal-Mart Neighborhood Market Pharmacies. 2. Present your Member ID card… and Save!* To locate additional participating providers, Click “Providers” on our website menu at www.usabestcare.com or call the Customer Service Department for an updated list of provider or to make an appointment > 877-527-6161 20
  21. 21. Como Usar los BeneficiosUsted podrá adquirir sus medicamentos en cualquiera de las más de 50,000 farmacias que componen la red a nivelnacional, siempre necesita presentar la tarjeta de membresía en la farmacia participante de su elección, al momentode ordenar o reordenar una prescripción.Beneficio de Orden por CorreoAtlantic Prescription Services (APS) se place en proveerle los servicios de ordenar sus medicamentos por correo. Estebeneficio está diseñado para que el suministro de medicamentos sea continuo. Usted recibirá hasta 90 días desuministros con la comodidad de entrega a domicilio. Además, cuando usted hace su primer pedido, tendrá lacomodidad del programa APS Autofill, ofreciéndole la tranquilidad de saber que estamos alerta para ordenarle suprescripción antes de que sus medicamentos corrientes se le agoten. Instrucciones para Nuevas Prescripciones: Solicitar una nueva prescripción para entrega a domicilio es muy simple siempre que sea ordenada por correo o enviada por fax desde la oficina de su doctor. Usted puede solicitarle a su doctor que le prescriba hasta 3 meses de medicamentos para entrega a domicilio y además ordenar sus medicamentos por hasta un año. Pídale a su doctor que envié por fax su prescripción o simplemente usted puede enviar por correo su prescripción usando las instrucciones abajo mencionadas y sus medicamentos serán enviados a su hogar dentro de 5-7 días laborables después de haber recibido su prescripción.Como Utilizar su Programa 1. Seleccione una farmacia participante* 2. Identifíquese como un miembro de “ATLANTIC PRESCRIPTION SERVICE (APS)”. 3. Presente la tarjeta de membresía… y ¡ahorre! * Para localizar un proveedor participante haga Clic en “Proveedores” en el menú de nuestra página de Internet, www.usabestcare.com o llame al Departamento de Servicio al Cliente para un listado actualizado o para hacer una cita al: 1-877-527-6161Correo 1. Solicite una nueva prescripción para un mínimo de 3 meses, mas ordenar sus medicamentos (si es apropiado) hasta por un año. 2. Mandar por correo la(s) nueva(s) prescripción(es) y su pago junto con la forma de órdenes (ver ORDER FORM FOR NEW PRESCRIPTIONS AND REFILLS). Provea una tarjeta de crédito para mantenerla en su expediente para futuras órdenes. El cargo será efectuado después de que sus medicamentos hayan sido procesadosFax 1. Solicite una nueva prescripción para hasta 3 meses, mas ordenar sus medicamentos (si es apropiado) por hasta un año. Provéale a su doctor su número de miembro localizado en la tarjeta de membresía. 2. Solicite a su doctor que envié la prescripción por fax al: 763-422-8719. Proveer una tarjeta de crédito para mantener en su expediente para futuras órdenes. Prescripciones enviadas por los pacientes NO son validas. Se le efectuará el cargo después de que sus medicamentos hayan sido procesados.Re-Ordenar 1. Teléfono: Llamando a 877-APSRX-72 (877-277-7972). Tenga a mano el número de prescripción y una tarjeta de crédito válida para pagar. 2. Correo: Completar la información de la forma de órdenes que vendrá adjunta en su primer envió de medicamentos, incluyendo su pago y envíela por correo en un sobre. Métodos de pagos son: Discover, Mastercard, Visa, Cheque o Money Order. 3. APS Autofill: Usted puede tomar la opción que le brinda el programa APS Autofill y su prescripción será enviada automáticamente antes de que sus medicamentos corrientes se le agoten. Solo seleccione la opción de APS AUTOFILL PROGRAM en la forma de ordenes (ver ORDER FORM FOR NEW PRESCRIPTIONS AND REFILLS) 21
  22. 22. How To Use Your Benefits You will need to present your new card to a participating pharmacy at the time you order a new or refill prescription. You may use this card at any participating pharmacy. With our pharmacy network, you can get your prescription at many of the more than 50,000 participation pharmacies located nationwide. Order by Mail Benefits Atlantic Prescription Services (APS) is pleased to provide you with a mail service benefit designed to provide you with your maintenance medications. Receive up to a 90 day supply of medications conveniently delivered to your home. In addition, when you sign up for the APS Auto fill Program, the timing of your refills is tracked by APS Mail Service and your medications are sent to you before your current prescription runs out. New Prescriptions Instructions: Requesting a new prescription for home delivery is simple whether you are ordering by mail or your doctor send a fax. You can ask your doctor to prescribe up to a 3 month supply for home delivery, plus refills for up to one year. Have your doctor fax your prescription or you can mail your prescription using the instructions below and have your prescription filled within 5-7 business days of receipt and mail to your home. How To Use Your Program 1. Choose one of the participating pharmacies * 2. Identify yourself as a member of “ATLANTIC PRESCRIPTION SERVICE (APS)”. 3. Present your Member ID card… and Save! * To locate additional participating providers, Click “Providers” on our website menu at www.usabestcare.com or call the Customer Service Department for an updated list of provider or to make an appointment at: 1- 877-527-6161 Mail 1. Ask your doctor to write a new prescription for up to 3 months, plus refills (is appropriate) for up to 1 year 2. Mail the new prescription(s) and payments along with the order form (see ORDER FORM FOR NEW PRESCRIPTIONS AND REFILLS). Providing a credit card on file assists in future refills. Fax 1. Ask your doctor to write a new prescription for up to 3 months, plus refills (if appropriate) for up to 1 year. Provide your doctor your member ID number which is on your Member ID card. 2. Ask your doctor to fax the prescription to 763-422-8719. You will be billed after the prescription has been filled. Prescriptions faxed by the patient are not validRefills Instructions: 1. Phone: Call APS at 877-APSRX-72 (877-277-7972). Have your prescription number available and a credit card for payment. 2. Mail: Complete the information on the new order form that will accompany your initial prescription medicine. After completing the requested information, include your payment and mail the envelope. Accepted methods of payments are discover, MasterCard, Visa or by check or money order.. 3. APS Auto fill: You can choose the option of APS Auto fill program and your medications will be mail automatic before your current prescription runs out. Sign up for the APS Auto fill program by checking the appropriate boxes on the order form. (see ORDER FORM FOR NEW PRESCRIPTIONS AND REFILLS) 22
  23. 23. Beneficios de FarmaciasComo afiliado de Best Care Medical Plan ahora tendrá acceso a más de 50,000* farmacias participantes a nivelnacional. Esta red incluye a cadenas farmacéuticas como son: Wal-Mart, CVS, Walgreens, K-Mart, Publix,Winn-Dixie y muchos más.As member of Best Care Medical Plan, now you can have access to over more than 50,000* participatingpharmacies nationwide. This network includes pharmacies chains as: Wal-Mart, CVS, Walgreens, K-Mart,Publix, Winn-Dixie and more. ALBERTSONS FRED MEYER PHARMACY OSCO DRUGA AND P PHARMACY FREDS PHARMACY PAMIDA PHARMACYARBOR DRUGS FRUTH PHARMACY PATHMARK PHARMACYARROW CENTER FRYS FOOD & DRUG PHAR-MORAURORA PHARMACY FURRS PHARMACY PRICE CHOPPERBARTELL DRUGS GENOVESE DRUG STORE PUBLIX PHARMACYBIG BEAR PHARMACY GIANT EAGLE RAINBOW PHARMACYBI-LO PHARMACY GRAND UNION RITE AID PHARMACYBI-MART PHARMACY HARRIS TEETER SAFEWAY PHARMACYBROOKS PHARMACY HOMELAND PHARMACY SAVE-ONBROOKSHIRE BROS HORIZON PHARMACY SAVE MART PHARMACYBROOKSHIRE PHARMACY HY-VEE PHARMACY SCHNUCKS PHARMACYBRUNOS PHARMACY KERR DRUG SEELY SNYDER DRUGCUB PHARMACY KING SOOPERS SHOPKO PHARMACYCVS PHARMACY KINNEY DRUGS, INC SHOPRITE PHARMACYDILLON PHARMACY KIGHT DRUGS STAR PHARMACYDISCONT DRUG MART KROGER PHARMACY STOP & SHOPDOMINICKS PHARMACY LEGEND TARGET PHARMACYDRUG EMPORIUM LEWIS FAMILY DRUG TIMES PHARMACYD & W FOOD CENTERS LONGS TOPS PHARMACYEAGLE PHARMACY MARCS UKROPS PHARMACYECONFOODS MED-X DRUG UNITED PHARMACYECKERD DRUG MEDIC DISCOUNT DRUG VONS PHARMACYEDWARDS PHARMACY MIC DRUG WAL-MART PHARMACYEPIC MEDICAP PHARMACY WALDBAUMS PHARMACYFAGEN PHARMACY MEDICINE SHOPPE, THE WALGREENSFAIRVIEW PHARMACY MEIJER PHARMACY WEGMAN PHARMACYFARMCO DRUG CENTER METRO PHARMACY WEIS PHARMACYFARMER JACK MORE 4 FAMILY WHITE DRUGFOOD TOWN PHARMACY NCS HEALTHCARE WINN DIXIE PHARMACY* Para localizar una Farmacia participante además de las ya listadas haga clic en “Proveedores” en el menú de nuestra página de Internet. www.usabestcare.com o llamar al Departamento de Servicio al Cliente: 1-877-527-6161* To locate a participating pharmacy, other than listed above, Click “Providers” on our website menu atwww.usabestcare.com or call the Customer Service Department: 1-877-527-616 23
  24. 24. Beneficios de Farmacias 24
  25. 25. Ahorre hasta un 65%* en el cuidado dental Como Usar los Beneficios Access Dental es un programa de descuentos dentales con más de 20,000 localidades de dentistas participantes a nivel nacional. Como afiliado, usted podrá visitar cualquier dentista participante las veces que sea necesario y ahorrar hasta un 65%* en el cuidado dental. El programa dental incluye absolutamente todo, desde un chequeo rutinario, empastes, coronas, “braces” y hasta trabajos cosméticos. Además, con Access Dental, cuenta con:  Ahorros ilimitados durante todo el año.  No límites en el número de visitas o servicios que usted recibirá.  No trámites de papeles que llenar.  Ahorros inmediatos. Ahorros en Servicios Dentales (Ejemplos Solamente) Procedimiento Costo Promedio Cantidad a Pagar % de Ahorro* Nacional* (como miembro) Evaluación Oral Detallada $57.00 $20.00 64.9% Rayos-X (Bitewing) – 4 vistas $44.00 $25.00 43.2% Corona – Porcelana $790.00 $500.00 36.7% Dentadura Completa – Maxilar $1,120.00 $650.00 42% Amalgama de una superficie (Empaste) $90.00 $50.00 44.4% Profilaxis (Limpieza) – Adulto $64.00 $35.00 45.3% Especialistas 20% de Descuentos Procedimiento Ejemplo de Ejemplo a % de Ahorro* Costo* Pagar** Ortodoncia para Adolescente $3,900.00 $3,120.00 20% * Los ahorros están basados en el Listado de Precios de Access Serie 200 para dentistas generales participantes (los precios pueden variar por región) comparado con la Consejería de Promedio de Servicios Dentales Nacional (promedio de Ahorros 34%). Ahorros Actuales pueden variar.** Dentistas especialistas participantes proveen un descuento de 20% del precio de venta al publico (15% en los dentistas especialistas MN). El ejemplo de costo no esta basado en costos actúales de un especialista y es para propósito de ilustración solamente. La cantidad a pagar es basada en el 20% de descuento aplicado al ejemplo de costo y puede variar.Exclusiones Los siguientes servicios o tratamientos son excluidos del programa dental: servicios de cuidado dental en proceso o proporcionados antes de la fecha efectiva de su membresía, procedimientos experimentales, sedación IV, servicios fuera del rango de conocimientos de un dentista participante. Los proveedores no están obligados a cobrar ningún precio específico para estos servicios excluidos. Como Utilizar su Programa 1. Seleccione a un Dentista participante* 2. Identifíquese como un miembro de “Access” para hacer una cita, o deje que un representante de servicio al cliente le ayude a concertar una cita. 3. Presente la tarjeta de membresía… y ¡ahorre! * Para localizar un proveedor participante haga Clic en “Proveedores” en el menú de nuestra página de Internet, www.usabestcare.com o llame al Departamento de Servicio al Cliente para un listado actualizado o para hacer una cita > 877-527-6161 25
  26. 26. Save up to 65%* on dental care How To Use Your Benefits Access Dental is a dental discount program with over 20,000 participating dentist locations nationwide. As a Member, you can visit any participating dentist as often as you like and save up to 65%* for dental care for you and all your eligible family members. The dental program includes virtually everything from routine check-ups, to fillings, crowns, braces and even cosmetic work. Plus, with Access Dental, there are:  No annual limits on savings.  No limits on the number of visits or services you receive.  No paperwork to fill out.  Immediate savings. Dentist Services Savings (Samples Only) National Avg. Amount Paid* Procedure % Saved* Charge* (With Membership)Comprehensive Oral Evaluation $57.00 $20.00 64.9%Bitewing (X-Ray) - Four Films $44.00 $25.00 43.2%Crown - Porcelain $790.00 $500.00 36.7%Complete Denture - Maxillary $1,120.00 $650.00 42One Surface Amalgam (Filling) $90.00 $50.00 % 44.4%Prophylaxis (Cleaning) - Adult $64.00 $35.00 45.3%SPECIALIST WORK: 20% DISCOUNT Example Example Procedure % Saved** Charge** Amount Paid** Adolescent Orthodontics $3,900.00 $3,120.00 20* Savings based on Access’s 200 Series Dental Fee Schedule for participating general % dentists (fees vary by region) compared to the 2004 National Dental Advisory Service National Average (Average Savings 34%). Actual savings may vary.** Participating specialty dentists provide a discount of 20% off their normal retail charges (15% for MN specialty dentists). The example charge is not based on an actual specialist’s charge and is for illustration purposes only. Amount paid is based on the 20% discount applied to the example charge and may vary.Exclusions The following services or treatments are excluded from the dental program: dental care services in progress or provided before the membership effective date in the program; experimental procedures; IV sedation; services outside the scope of the participating dentist’s practice. Providers are not obligated to charge Members any specified rates for such excluded services. How To Use Your Program 1. Select a participating Dentist provider* 2. Identify yourself as a member of “Access” to make an appointment, or just let one of our customer service representative help you arrange your appointment. 3. Present your Member ID Card...and save! * To locate additional participating providers, Click “Providers” on our website menu at www.usabestcare.com or call the Customer Service Department for an updated list of provider or to make an appointment > 877-527-6161 26
  27. 27. Calidad y ConvenienciaComo Usar los BeneficiosEl programa Access Vision le ofrece a usted y a las personas participantes en su membresía valiososahorros en lentes, sobre lentes “add-ons”, armaduras, lentes de contacto, lentes de sol sin prescripción ymás.Con Access Vision, usted solo paga, al proveedor participante, los precios de descuento que le brinda elprograma en el momento del servicio. Como miembro, usted es elegible a recibir los siguientesdescuentos del precio de venta al publico.*  20% de Descuento en Exámenes para Lentes de Contacto.  15-25% de Descuento en Todas las Armaduras.  10-20% Descuento en Lentes de Contacto.  25% de Descuento en Lentes de Sol sin Prescripción.Y ahorros adicionales en todos los lentes y sobre lentes “add-ons”. No hay restricciones en tamaño, estilo,cantidad o fabricante. Los proveedores participantes pueden incluir a optometristas independientes o acadenas nacionales como son: LensCrafters, Sterling Vision y D.O.C Optical. No en todas las localidadesproveen todos los servicios.* Los ahorros están basados en descuentos actuales del precio habitual de venta al público. Ahorrosactuales pueden variar.En California, Los exámenes de vista, exámenes para lentes de contactos, precios por ajuste dearmaduras y cualquier otro servicio profesional son excluidos del programa y serán cobrados en base alprecio de venta al público promedio, usual o acostumbrado.Como Usar su Programa 1. Seleccione a un proveedor participante* 2. Identifíquese como un miembro de “Access” para hacer una cita, o deje que un representante de servicioal cliente le ayude a concertar una cita. (o solo visite la localidad participante más cercana a usted) 3. Presente la tarjeta de membresía… y ¡ahorre!* Para localizar un proveedor participante haga Clic en “Proveedores” en el menú de nuestra página de Internet, www.usabestcare.com o llame al Departamento de Servicio al Cliente para un listado actualizado o para hacer una cita > 877-527-6161 27
  28. 28. Quality and ConvenienceHow To Use Your BenefitsThe Access Vision program offers you and your eligible family members valuable savings on lenses andlens add-ons, frames, contact lenses, non-prescription sunglasses, and more.With Access Vision, pay the participating provider the reduced program fees at the time of service. Asa member, you are eligible to receive the following discounts off normal retail prices.*  20% Discount on Contact Lens Exams  15-25% Discount on All Frames  10-20% Discount on Contact Lenses  25% Discount on Non-Prescription SunglassesAdditionally, you can save on all other lens and lens add-ons. No restrictions on size, style,quantity or manufacturer. Participating providers include independent optometrists as well asnational chains such as: LensCrafters, Sterling Vision and D.O.C. Optical. Not all locationsprovide all services.*Savings based on actual discounts off participating provider’s normal retail charges. Actual savings mayvary.In California, eye exams, contact lens exams, fitting fees and all other professional services are excludedfrom the program and shall be charged at the provider’s usual and customary rates.How To Use Your Program 1. Select a participating Dentist provider* 2. Identify yourself as a member of “Access” to make an appointment, or just let one of our customer service representative help you arrange your appointment. 3. Present your Member ID Card...and save!* To locate additional participating providers, Click “Providers” on our website menu at www.usabestcare.com or call the Customer Service Department for an updated list of provider or to make an appointment > 877-527-6161 28
  29. 29. Mejor Audición Mediante Cuidado ProfesionalComo se BeneficiaCon su Membresía usted es elegible a recibir un 15%* de descuentos en aparatos de audición Beltone encualquiera de sus 1,800 localidades independientes de Beltone. Su membresía le proporciona acceso atener un examen de audición gratis, limpieza y ajuste de su aparato de audición. Además, podrá disfrutarde la conveniencia de NO tener formas de reclamos, deducibles o tiempo de espera. ¡No espere más!* Los ahorros están basados en descuentos actuales del precio habitual de venta al público. Ahorrosactuales pueden variar.Como Usar su Programa 1. Seleccione a un proveedor participante* 2. Identifíquese como un miembro de “Beltone” para hacer una cita, o deje que un representante de servicio al cliente le ayude a concertar una cita.(o solo visite la localidad participante mas cercana a usted) 3. Presente la tarjeta de membresía… y ¡ahorre!* Para localizar un proveedor participante haga Clic en “Proveedores” en el menú de nuestra página de Internet, www.usabestcare.com o llame al Departamento de Servicio al Cliente para un listado actualizado o para hacer una cita > 877-527-6161 29
  30. 30. Better Hearing thru Professional CareHow To Use Your BenefitsWith your membership in Protective Health Options you are eligible to receive a 15%* discount on Beltonehearing aids at any of their 1,800 Beltone independent locations. Your membership allows you access tofree hearing exams and hearing aid cleanings and adjustments.*All percentage savings based on Beltone’s normal retail prices. Actual savings may vary.How To Use Your Program 1. Select a participating Dentist provider* 2. Identify yourself as a member of “Beltone” to make an appointment, or just let one of our customer service representative help you arrange your appointment (or visit a Beltone location nearest you). 3. Present your Member ID Card...and save!* To locate additional participating providers, Click “Providers” on our website menu at www.usabestcare.com or call the Customer Service Department for an updated list of provider or to make an appointment > 877-527-6161 30
  31. 31. Como se BeneficiaUsted podrá recibir cuidado inmediato con descuentos considerables, en más de 13,500 doctoresQuiroprácticos contratados a nivel nacional. Esto le asegura que usted siempre encontrará un doctorcalificado en su área, no solo para tratamiento de un problema agudo o crónico, sino también paracuidados preventivos regulares.Usted podrá recibir los siguientes descuentos:  Ahorro de un 50% en todos los servicios de diagnósticos y rayos-x (excepto en CO).  Ahorro de un 30% en todos los servicios, con acceso ilimitado al cuidado médico.  No limites en el número de las visitas.  Consulta inicial GRATIS.Como Usar su Programa 1. Seleccione a un Quiropráctico participante* 2. Identifíquese como un miembro de “Comprehensive Health Group” para hacer una cita, o deje que un representante de servicio al cliente le ayude a concertar una cita. 3. Presente la tarjeta de membresía… y ¡ahorre!* Para localizar un proveedor participante haga Clic en “Proveedores” en el menú de nuestra página de Internet, www.usabestcare.com o llame al Departamento de Servicio al Cliente para un listado actualizado o para hacer una cita > 877-527-6161 31
  32. 32. How to Use Your BenefitsYou and your eligible family members can receive immediate care with significant discounts at over 15,000participating Chiropractic doctor locations. This widespread availability allows access for discounts ontreatment of acute and chronic problems and for regular preventive maintenance care.You will receive the following savings off the providers normal charges:  Save 50%* on all diagnostic services and x-rays (except x-rays excluded in CO).  Members also save 30%* on all other services with unlimited access to care and no limits on the number of visits.  FREE initial consultation.How To Use Your Program 1. Select a participating Dentist provider* 2. Identify yourself as a member of “Comprehensive Health Group” to make an appointment, or just let one of our customer service representative help you arrange your appointment. 3. Present your Member ID Card...and save!* To locate additional participating providers, Click “Providers” on our website menu at www.usabestcare.com or call the Customer Service Department for an updated list of provider or to make an appointment > 877-527-6161 32
  33. 33. LABORATORIOSDIAGNOSTICOSCIRUGIA GENERALSERVICIO DENTALOPTOMETRIAURGENCIASMATERNIDADCHEQUEOS PREVENTIVOSLABORATORIESDIAGNOSTICSGENERAL SURGERYDENTAL SERVICESOPTOMETRYURGENT CAREMATERNITYPREVENTIVE CHECK-UPS 33
  34. 34. 34
  35. 35. PROFILES FEE PROFILES FEEACUTE HEPATITIS $60.00 C-PEPTIDE $20.00ANEMIC PANEL $40.00 CREATININE $10.00ARTHRITIS PANEL $25.00 CREATININE 24 HR $10.00BASIC METABOLIC $10.00 CREATININE CLEARANCE $15.00COMP. METABOLIC $12.00 CREATININE SPOT URINE $10.00ELECTROLYTES $10.00 CRP $15.00HEPATIC FUNCTION $10.00 CYSTIC FIBROSIS $320.00LIPID PANEL $12.00 DIGOXIN (LANOXIN) $15.00LIVER PROFILE $10.00 DRUG SCREEN (7DRUGS) $25.00OBSTETRIC PANEL $35.00 ESTRADIOL $20.00RENAL PANEL $12.00 FERRITIN, SERUM $15.00TORCH PANEL $135.00 FIBRINOGEN $12.00 INDIVIDUAL TEST FEE FOLIC ACID $12.00AFP TRIPLE SCREEN $60.00 FREE PSA AND TOTAL $30.00AFP TUMOR MARKER $20.00 FSH $15.00ALBUMIN $10.00 FSH & LH $25.00ALKALINE PHOSPH $10.00 GAMMA GT $10.00ALLERGY PANEL EACH GENTAMYCIN $25.00 $14.00ALLERGEN GLUCOSE $10.00ALT (SGPT) $10.00 GLUCOSE 2 HRS. PP $10.00AMMONIA $20.00 GLUCOSE GRAY TUBE $10.00AMYLASE SERUM $10.00 GLUCOSE TOL 2 HRS $10.00ANA $15.00 GLUCOSE TOL 3 HRS $10.00ANTIBODY SCREENING $15.00 GLUCOSE TOL 4 HRS $10.00AST (SGOT) $10.00 GLYCOHEMOGLOBIN(HGB A1C) $12.00B12 $15.00 H. PYLORI ANTIBODY $20.00B12 & FOLIC ACID $35.00 HCG-BETA, QUAL(PREGNANCY) $10.00BILIRUBIN TOTAL $10.00 HCG-BETA, QUANTITATIVE $12.00BILIRUBIN, DIRECT $10.00 HDL-CHOLETEROL $8.00BIOPSY 1 SPECIMEN $35.00 HEAVY METAL SCREENING $50.00BLOOD TYPE & RH $10.00 HEMOGLOBIN / HEMATOCRIT $6.00BUN $10.00 HEMOGLOBIN ELECTROPHO. $25.00CA – 125 $40.00 HEPATITIS A IgM $20.00CALCIUM $10.00 HEPATITIS A TOTAL $12.00CARBAMAZEPINE (TEGRETOL) $15.00 HEPATITIS Bs ANTIBODY $12.00CARDIO CRP $20.00 HEPATITIS Bs ANTIGEN $12.00CBC W/O PLAT $10.00 HEPATITIS C ANTIBODY $30.00CBC WITH PLAT $10.00 HERPES I & II TOTAL IgG $55.00CBC, PLAT, MANUAL DIFF $10.00 HIV RNA by PCR (VIRAL LOAD) $200.00CD4 $35.00 HIV W. REFLEX TO W.B. $15.00CD4 / CD8 $50.00 IgE TOTAL $15.00CEA $15.00 IMMIGRATION PROFILE $20.00CHOLESTEROL $10.00 IMMUNOELECTROPHO. SER. $70.00CK MB B14 $20.00 IMMUNOGLOBULIN IgG,A,M $60.00CK TOTAL $10.00 INSULIN ANTIBODY $60.00CMV - IgG $35.00 IRON $10.00CMV - IgM $35.00 IRON & IBC $12.00CORTISOL $25.00 35
  36. 36. PROFILES FEE PROFILES FEEL.E. SCREEN $15.00 THYROID BINDING GLOBULIN $20.00LDH $12.00 TOBRAMYCIN $36.00LDL- CALCULATED $8.00 TOXOPLASMA IgG $15.00LEAD $12.00 TOXOPLASMA IgM $15.00LH $20.00 TRIGLYCERIDES $10.00LIPASE $15.00 TSH $15.00LITHIUM $15.00 URIC ACID $10.00LITHIUM (ESKALITH) $20.00 URINALYSIS $10.00MAGNESIUM $10.00 VALPROIC ACID (DEPAKENE) $20.00MONO TEST $12.00 VANCOMYCIN PEAK $25.00P.T.H (INTACT) $55.00 VANCOMYCIN TROUGH $25.00PHENYTOIN (DILANTIN) $20.00 VARICELA ZOSTER IGG $25.00PHOSPHATASE ACID PROSTATIC $20.00 VIT. B12 $15.00PHOSPHORUS $10.00 MICROBIOLOGY FEEPLATELET COUNT $10.00 ACID FAST CULT & SMEAR $25.00POTASSIUM $10.00 BLOOD CULTURE $25.00PREGNANCY TEST-URINE $12.00 CHLAMYDIA & GC (DNA) $30.00PRIMIDONE (MYSOLINE) $40.00 CHLAMYDIA (DNA) $20.00PROCAINAMIDE (PRONESTYL) $35.00 CLOSTRIDIUM DIFF. TOX $35.00PROGESTERONE $20.00 CULTURE & $15.00PROLACTIN $20.00 SENSITIVITY(SOURCE) CYTO, GYN (PAP SMEAR) 1 $20.00PROTEIN ELECTROPHO. $20.00 CYTO, GYN (PAP SMEAR) 2 $20.00PROTEIN, TOTAL 24 HR $15.00 CYTO, THINPREP PAP $40.00PROTEIN, TOTAL SERUM $10.00 FUNGUS CULTURE $15.00PSA O DX O scr $15.00 GC (CULTURE ONLY) $15.00PT+INR ANTICOAG. O YES O NO $10.00 GC (DNA PROBE) $25.00PTT ANTICOAG. O YES O NO $10.00 GRAM STAIN $15.00QUINIDINE $60.00 H. PYLORI (STOOL) $65.00RETIC COUNT $10.00 OCCULT BLOOD FECES 3 $20.00RHEUMATOID FACTOR (RA) $15.00 OVA & PARASITES x slide $10.00RPR (SYPHILLIS) $12.00 SPUTUM CULTURE, SENS. $15.00RUBELLA IgG $15.00 STOOL CULTURE, SENS $15.00RUBELLA IgM $20.00 THROAT CULTURE, SENS $15.00SEDIMENTATION RATE $10.00 URINE C & S $15.00SICKLE CELL PREP $10.00 VAGINAL C & S $15.00SODIUM $10.00 WOUND C & S $15.00STONE ANALYSIS $35.00T LYMPH AND SUB SETS $65.00T3 FREE $15.00T3 TOTAL $15.00T3 UP $10.00T4 TOTAL $10.00T4 $10.00T4 FREE $15.00TESTOSTERONE $20.00THEOPHYLLINE $25.00THYROGLOBULIN $15.00 36
  37. 37. 37
  38. 38. DIAGNOSTIC RADIOLOGY HEADCODE SERVICES DESCRIPTION FEE70100 MANDIBLE; LESSS THAN FOUR VIEWS $ 20.0070130 MASTOIDS; MINIMUM OF THREE VIEWS PER SIDE $ 30.0070150 FACIAL BONES; MINIMUM OF THREE VIEWS $ 28.0070160 NASAL BONES; MINIMUM OF THREE VIEWS $ 22.0070200 ORBITS $ 28.0070220 PARANASAL SINUSES; MINIMUM OF THREE VIEWS $ 30.0070240 SELLA TURCICA $ 20.0070250 SKULL; LESS THAN FOUR VIEWS $ 30.0070328 TEMPOROMANDIBULAR JOINT, OPEN & CLOSED MOUTH $ 20.00 CHESTCODE SERVICES DESCRIPTION FEE71010 CHEST, SINGLE VIEW, FRONTAL $ 20.0071020 CHEST, TWO VIEWS, FRONTAL & LATERAL $ 25.0071030 CHEST, COMPLETE, MINIMUM OF FOUR VIEWS $ 35.0071100 RIBS, UNILATERAL; TWO VIEWS $ 25.0071120 STERNUM, MINIMUM OF TWO VIEWS $ 25.0077055 MAMMOGRAPHY, UNILATERAL OR BILATERAL $ 50.00 SCREENING MAMMOGRAPHY; PRODUCTION DIRECT DIG. IMAGE,G0202 BILATERAL. (ALL VIEWS) WITH IMPLANT (S) $ 70.00 DIAGNOSTIC MAMMOGRAPHY; PRODUCTION DIRECT DIG. IMAGE,G0204 BILATERAL. (ALL VIEWS) WITH IMPLANT (S) $ 90.00 DIAGNOSTIC MAMMOGRAPHY; PRODUCTION DIRECT DIG. IMAGE,G0206 (ALL VIEWS)NO IMPLANTS $ 70.00 NOTE: FEES INCLUDE CODES 77051 AND 77052 SPINECODE SERVICES DESCRIPTION FEE72020 SPINE, SINGLE VIEW, SPECIFY LEVEL $ 20.0072040 CERVICAL SPINE, ANTEROPOSTERIOR & LATERAL $ 30.0072070 THORACIC SPINE, ANTEROPOSTERIOR & LATERAL $ 30.0072100 LUMBOSACRAL SPINE, ANTEROPOSTERIOR & LATERAL $ 30.0072220 SACRUM AND COCCYX, MINIMUM OF TWO VIEWS $ 25.0077080 BONE DENSITOMETRY $ 70.00 PELVISCODE SERVICES DESCRIPTION FEE72170 PELVIS, ANTEROPOSTERIOR ONLY $ 20.0073510 HIP, COMPLETE,MINIMUM OF TOW VIEWS $ 25.00 UPPER EXTREMITIESCODE SERVICES DESCRIPTION FEE73000 CLAVICLE $ 20.0073010 SCAPULA $ 20.0073030 SHOULDER, MINIMUM OF TWO VIEWS $ 25.00 38
  39. 39. 73060 HUMERUS, MINIMUM OF TWO VIEWS $ 25.0073070 ELBOW, ANTEROPOSTERIOR & LATERAL VIEWS $ 20.0073090 FOREARM, ANTEROPOSTERIOR & LATERAL VIEWS $ 25.0073100 WRIST, ANTEROPOSTERIOR & LATERAL VIEWS $ 20.0073130 HAND, MINIMUM OF THREE VIEWS $ 20.0073140 FINGER(S), MINIMUM OF TWO VIEWS $ 20.00 LOWER EXTREMITIESCODE SERVICES DESCRIPTION FEE73550 FEMUR, ANTEROPOSTERIOR & LATERAL VIEWS $ 25.0073562 KNEE, TWO OR THREE VIEWS $ 25.0073590 TIBIA & FIBULA, ANTEROPOSTERIOR & LATERAL VIEWS $ 25.0073610 ANKLE, COMPLETE, MINIMUM OF THREE VIEWS $ 25.0073630 FOOT, COMPLETE, MINIMUM OF THREE VIEWS $ 25.0073650 CALCANEUS, MINIMUM TOW VIEWS $ 20.0073660 TOES, MINIMUM TOW VIEWS $ 20.00 ABDOMENCODE SERVICES DESCRIPTION FEE74000 ABDOMEN, SINGLE ANTEROPOSTERIOR VIEW (KUB) $ 20.0074020 ABDOMEN, TWO VIEWS (DECUBITUS & ERECT) $ 28.0074220 ESOPHAGOGRAM $ 50.0074241 UPPER GASTROINTESTINAL TRACT WITH KUB $ 70.0074245 UPPER GASTROINTESTINAL TRACT WITH SMALL BOWEL $ 100.0074270 COLON, BARIUM ENEMA $ 80.0074290 CHOLECYSTOGRAPHY, ORAL CONTRAST $ 40.0074400 PYELOGRAPHY INTRAVENOUS $ 100.00 39
  40. 40. DIAGNOSTIC ULTRASOUND HEAD & NECK CODE SERVICES DESCRIPTION FEE 76536 SOFT TISSUES OF HEAD & NECK $ 45.00 76536 THYROID, PARATHYROID, PAROTID $ 45.00 CHEST CODE SERVICES DESCRIPTION FEE 76604 CHEST ECHOGRAPHY (INCLUDES MEDIASTINUM) $ 45.00 76645 BREST(S) ECHOGRAPHY (UNILATERAL OR BILATERAL) $ 45.00 ABDOMEN & RETROPERITONEUM CODE SERVICES DESCRIPTION FEE 76700 ABDOMINAL ECHOGRAPHY, COMPLETE $ 90.00 76705 LIVER ECHOGRAPHY $ 45.00 76705 GALLBLADDER ECHOGRAPHY $ 45.00 76705 PANCREAS ECHOGRAPHY $ 45.00 76705 SPLEEN ECHOGRAPHY $ 45.00 76770 RETROPERITONEAL ECHOGRAPHY, COMPLETE $ 80.00 76775 RENAL ECHOGRAPHY $ 45.00 76775 AORTA ECHOGRAPHY $ 45.00 PELVIS CODE SERVICES DESCRIPTION FEE76805-76816 ECHOGRAPHY, PREGNANT UTERUS $ 90.00 76830 TRANSVAGINAL ECHOGRAPHY $ 100.00 76856 PELVIC ECHOGRAPHY (NONOBSTETRIC) $ 60.00 76856 PROSTATIC ECHOGRAPHY $ 60.00 76857 BLADDER ECHOGRAPHY $ 40.00 GENITALIA CODE SERVICES DESCRIPTION FEE 76870 SCROTUM & CONTENTS ECHOGRAPHY $ 45.00 76872 PROSTATIC TRANSRECTAL ECHOGRAPHY $ 100.00 EXTREMITIES CODE SERVICES DESCRIPTION FEE 76880 EXTREMITY ECHOGRAPHY, NON-VASCULAR (eg, AXILLAE) $ 45.00 ECHOCARDIOGRAPHY CODE SERVICES DESCRIPTION FEE ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL TIME WITH IMAGE 93307 DOCUMENTATION (2M) WITH OR WITHOUT M-MODE RECORDING, COMPLETE 93320 93325 DOPPLER ECHOCARDIOGRAPHY COLOR FLOW $ 100.00 40
  41. 41. CEREBROVASCULAR ARTERIAL STUDIESCODE SERVICES DESCRIPTION FEE9387593880 CAROTID DOPPLER, COMPLETE BILATERAL STUDY $ 60.00 EXTREMITY ARTERIAL STUDIESCODE SERVICES DESCRIPTION FEE93923 DOPPLER OF UPPER OR LOWER EXTREMITY ARTERIES, COMPLETE93925 BILATERAL STUDY $ 60.00 EXTREMITY VENOUS STUDIESCODE SERVICES DESCRIPTION FEE93965 DOPPLER OF UPPER OR LOWER EXTREMITY VEINS, COMPLETE93970 BILATERAL STUDY $ 60.00 CARDIOLOGY PROCEDURESCODE SERVICES DESCRIPTION FEE ELECTROCARDIOGRAM WITH AT LEAST 12 LEADS, WITH93000 INTERPRETATION AND REPORT $ 20.00 ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS WITH93230 PHYSICIAN INTERPRETATION AND REPORT (HOLTER MONITOR) $ 80.0093015 STRESS TEST (PLAIN) $ 200.00 SLEEP TESTNGCODE SERVICES DESCRIPTION FEE95806 SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION,95807 RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN $ 580.00 SATURATION, ATTENDED OR UNATTENDED BY A TECHNOLOGIST NEUROLOGY & NEUROMUSCULAR PROCEDURESCODE SERVICES DESCRIPTION FEE95812 ELECTROENCEPHALOGRAM $ 150.009590095903 NERVE CONDUCTION VELOCITY ( UPPER ) $ 100.00959049590095903 NERVE CONDUCTION VELOCITY ( LOWER ) $ 100.0095904 41
  42. 42. NUCLEAR MEDICINE FEE SCHEDULE SERVICES DESCRIPTION FEETHALLIUM STRESS TEST $450.00BONE SCAN / FLOW $200.00TESTICULAR SCAN $300.00THYROID UPTAKE SCAN $300.00LIVER FLOW SCAN $280.00RENAL FLOW SCAN $280.00GALLBLADDER SCAN $280.00BRAIN FLOW SCAN $280.00LUNG SCAN $280.00GI BLEEDING SCAN $300.00GALLIUM SCAN $280.00RED CELL VENOGRAM $280.00MECKEL’S DIVERTICULUM SCAN $300.00PYB $325.00PIPIDA SCAN $300.00 MAGNETIC RESONANCE IMAGING & COMPUTARIZED AXIAL TOMOGRAPHY SERVICES DESCRIPTION FEEMAGNETIC RESONANCE IMAGING WITH CONTRAST $350.00MATERIAL(S)MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST $300.00MATERIAL(S)COMPUTERIZED AXIAL TOMOGRAPHY WITH CONTRAST $250.00MATERIAL(S)COMPUTERIZED AXIAL TOMOGRAPHY WITHOUT CONTRAST $200.00MATERIAL(S)COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMINAL; WITH $300.00CONTRAST MATERIAL(S)COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMINAL; $250.00WITHOUT CONTRAST MATERIAL(S) 42
  43. 43. 43
  44. 44. INTEGUMENTARY SYSTEM INCISION AND DRAINAGECODE SERVICES DESCRIPTION FEE ACNE SURGERY (MARSUPIALIZATION, OPENING OR10040 REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, $ 50.00 PUSTULES) INCISION AND DRAINAGE OF ABSCESS; SIMPLE OR10060 $ 65.00 SINGLE. INCISION AND DRAINAGE OF ABSCESS; COMPLICATED10061 $ 95.00 OR MULTIPLE.10080 INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE. $ 70.00 INCISION AND REMOVAL OF FOREIGN BODY,10120 $ 60.00 SUBCUTANEOUS TISSUES; SIMPLE. INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR10140 $ 70.00 FLUID COLLECTION. PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA OR10160 $ 50.00 CYST. BIOPSYCODE SERVICES DESCRIPTION FEE BIOPSY SKIN, SUBCUTANEOUS TISSUE AND/ OR11100 $ 40.00 MUCOUS MEMBRANE, SINGLE LESION.11101 EACH SEPARATE / ADDITIONAL LESION. $ 20.0019000 PUNCTURE ASPIRATION OF CYST OF BREAST. $ 50.0019001 EACH ADDITIONAL CYST OF BREAST. $ 20.0060100 BIOPSY, THYROID PERCUTANEOUS CORE NEEDLE $ 150.00 REMOVAL OF SKIN TAGSCODE SERVICES DESCRIPTION FEE REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS11200 $ 38.00 TAGS, ANY AREA; UP TO AND INCLUDING 5 LESIONS.11201 EACH ADDITIONAL TEN LESSIONS. $ 15.00 EXCISION OF BENIGN LESIONSCODE SERVICES DESCRIPTION FEE11400 EXCISION, BENIGN LESION, EXCEPT SKIN TAG, TRUNK, $ 65.0011401 ARM OR LEGS; LESION DIAMETER 1.0 CM OR LESS.11402 EXCISION, BENIGN LESION, EXCEPT SKIN TAG, TRUNK, $ 100.0011403 ARM OR LEGS; LESION DIAMETER 1.1 TO 3.0 CM.11404 EXCISION, BENIGN LESION, EXCEPT SKIN TAG, TRUNK, $ 150.0011406 ARM OR LEGS; LESION DIAMETER OVER 3.1 CM. EXCISION, BENIGN LESION, EXCEPT SKIN TAG, SCALP,11420 NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.0 $ 75.0011421 CM OR LESS. EXCISION, BENIGN LESION, EXCEPT SKIN TAG, SCALP,11422 NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 $ 165.0011423 TO 3.0 CM. 44
  45. 45. EXCISION, BENIGN LESION, EXCEPT SKIN TAG, SCALP,11424 NECK, HANDS, FEET, GENITALIA; LESION DIAMETER $ 185.0011426 OVER 3.1 CM. EXCISION, OTHER BENIGN LESION, FACE, EARS,11440 EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION $ 85.0011441 DIAMETER 1.0 CM OR LESS. EXCISION, OTHER BENIGN LESION, FACE, EARS,11442 EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION $ 130.0011443 DIAMETER 1.1 TO 3.0 CM. EXCISION, OTHER BENIGN LESION, FACE, EARS,11444 EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION $ 225.0011446 DIAMETER OVER 3.1 CM. EXCISION OF MALIGNANT LESIONSCODE SERVICES DESCRIPTION FEE11600 EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR11601 $ 80.00 LEGS; LESION DIAMETER 2.0 CM OR LESS.1160211603 EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR11604 $ 170.00 LEGS; LESION DIAMETER OVER 2.1 CM.1160611620 EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS,11621 $ 110.00 FEET, GENITALIA; LESION DIAMETER 2.0 CM OR LESS.1162211623 EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS,11624 $ 220.00 FEET, GENITALIA; LESION DIAMETER OVER 2.1 CM.1162611640 EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS,11641 $ 135.00 NOSE, LIPS; LESION DIAMETER 2.0 CM OR LESS.11642 NAILSCODE SERVICES DESCRIPTION FEE11719 TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER. $ 6.00 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); ONE TO11720 $ 15.00 FIVE. DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); SIX OR11721 $ 22.00 MORE.11730 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE. $ 40.0011740 EVACUATION OF SUBUNGUAL HEMATOMA. $ 20.00 EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR11750 $ 55.00 COMPLETE. INTEGUMENTARY SYSTEMCODE SERVICES DESCRIPTION FEE SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP,12001 NECK, AXILLA, EXTERNAL GENITALIA, TRUNK AND OR $ 80.0012002 EXTREMITIES (7.5 CM OR LESS) 45
  46. 46. SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP,12004 NECK, AXILLA, EXTERNAL GENITALIA, TRUNK AND OR $ 150.0012005 EXTREMITIES (7.6 CM TO 20 CM) SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP,12006 NECK, AXILLA, EXTERNAL GENITALIA, TRUNK AND OR $ 220.0012007 EXTREMITIES (20.1 CM OR MORE) SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE,12011 EARS, EYELIDS, NOSE, LIPS, AND / OR MUCOUS $ 100.0012013 MEMBRANES SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE,12014 EARS, EYELIDS, NOSE, LIPS, AND / OR MUCOUS $ 200.0012015 MEMBRANES SUTURES BURNSCODE SERVICES DESCRIPTION FEE INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO16000 $ 30.00 MORE THAN LOCAL TREATMENT IS REQUIRED.16020 BURN DRESSING AND/ OR DEBRIDEMENT. $ 35.00 DESTRUCTION OF BENIGN OR PREMALIGNANT LESIONSCODE SERVICES DESCRIPTION FEE DESTRUCTION BY ANY METHOD ALL BENIGN OR17000 $ 38.00 PREMALIGNANT LESIONS; UP TO 3 LESIONS. DESTRUCTION BY ANY METHOD ALL BENIGN OR TH17003 PREMALIGNANT LESIONS; 4 THROUGH 14 LESIONS $ 8.00 (EACH). DESTRUCTION BY ANY METHOD OF FLAT WARTS,17110 MOLLUSCUM CONTAGIOSUM, OR MILIA; UP TO 14 $ 40.00 LESIONS.17250 CHEMICALCAUTERIZATION OF GRANULATION TISSUE. $ 15.00 MUSCULOSKELETAL SYSTEM INTRODUCTIONCODE SERVICES DESCRIPTION FEE20550 INJECTION, TRIGGER POINT $ 45.00 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION;20600 $ 50.00 SMALL JOINT, BURSA (eg, FINGERS, TOES) ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; INTERMEDIATE JOINT BURSA (eg,20605 $ 50.00 TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA) ARTHROCENTESIS, ASPIRATION AND/OR INJECTION;20610 MAJOR JOINT OR BURSA (eg, SHOULDER, HIP, KNEE $ 50.00 JOINT, SUBACROMIAL BURSA) 46
  47. 47. UPPER EXTREMITY CASTSCODE SERVICES DESCRIPTION FEE29058 VELPEAU $ 70.0029065 SHOULDER TO HAND ( LONG ARM ) $ 55.0029075 ELBOW TO FINGER ( SHORT ARM ) $ 45.0029085 HAND AND LOWER FORE ARM (GAUNTLET) $ 45.00 SPLINTSCODE SERVICES DESCRIPTION FEE29105 SHOULDER TO HAND ( LONG ARM ) $ 45.0029125 FOREARM TO HAND $ 30.0029130 FINGER $ 20.00 STRAPPINGCODE SERVICES DESCRIPTION FEE29240 SHOULDER (eg, VELPEAU). $ 35.0029260 ELBOW OR WRIST. $ 25.0029280 HAND OR FINGER. $ 25.00 REMOVALCODE SERVICES DESCRIPTION FEE29705 REMOVAL FULL ARM CAST. $ 40.00 LOWER EXTREMITY CASTSCODE SERVICES DESCRIPTION FEE29345 APPLICATION OF LONG LEG CAST (THIGH TO TOES). $ 65.0029355 -WALKER OR AMBULATORY TYPE. $ 75.0029365 APPLICATION OF CYLINDER CAST (THIGH TO ANKLE). $ 60.00 APPLICATION OF SHORT LEG CAST (BELOW KNEE TO29405 $ 55.00 TOES).29425 -WALKER OR AMBULATORY TYPE. $ 65.0029440 ADDING WALKER TO PREVIOUSLY APPLIED CAST. $ 25.00 SPLINTSCODE SERVICES DESCRIPTION FEE APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE29505 $ 45.00 OR TOES).29515 APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT). $ 35.00 STRAPPINGCODE SERVICES DESCRIPTION FEE29530 STRAPPING; KNEE $ 30.0029540 STRAPPING; ANKLE $ 30.0029550 STRAPPING; TOES $ 25.0029580 UNNA BOOT $ 30.00 47
  48. 48. REMOVALCODE SERVICES DESCRIPTION FEE29700 REMOVAL BOOT CAST $ 40.0029705 REMOVAL FULL LEG CAST. $ 40.00 URINARY & GENITAL SYSTEM MANIPULATIONCODE SERVICES DESCRIPTION FEE53670 CATHETERIZATION, URETHRA; SIMPLE $ 35.00 DESTRUCTIONCODE SERVICES DESCRIPTION FEE DESTRUCTION OF LESION(S), PENIS (eg, CONDYLOMA,54050 PAPILLOMA, MOLLUSCUM CONTGIOSUM, HERPETIC $ 40.00 VESICLE), SIMPLE; CHEMICAL54055 - ELECTRODESICCATION $ 50.0054056 - CRYOSURGERY $ 50.0054057 - LASER SURGERY $ 100.0054060 - SURGICAL EXCISION $ 70.00 EAR, NOSE & THROAT INCISIONCODE SERVICES DESCRIPTION FEE69000 DRAINAGE EXTERNAL EAR, ABSCESS OR HAMATOMA $ 70.0069020 DRAINAGE EXTERNAL AUDITORY CANAL, ABSCESS $ 70.0069090 EAR PIERCING $ 20.00 REMOVALCODE SERVICES DESCRIPTION FEE REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY69200 $ 30.00 CANAL; WITHOUT GENERAL ANESTHESIA69210 REMOVAL IMPACTED CERUMEN, ONE OR BOTH EARS $ 35.0030300 REMOVAL FOREIGN BODY, INTRANASAL $ 40.00 ENDOSCOPYCODE SERVICES DESCRIPTION FEE31575 LARINGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC $ 75.00 48
  49. 49. GASTROINTESTINAL ENDOSCOPIES ENDOSCOPYCODE SERVICE DESCRIPTION FEE UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM43239 $ 400.00 AND/OR JEJUNUM, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) COLONOSCOPY, WITH OR WITHOUT COLLECTION OF45378 $ 575.00 SPECIMEN(S) SIGMOIDOSCOPY, WITH OR WITHOUT COLLECTION OF45330 $ 300.00 SPECIMEN(S) 49
  50. 50. 50
  51. 51. DIAGNOSTICSERVICE DESCRIPTION CODE FE EPERIODIC ORAL EVALUATION (NO CHARGE WITH TREATMENT) D 0120 $ 20.00LIMITED ORAL EVALUATION-PROBLEM FOCUSED D 0140 $ 20.00COMPREHENSIVE ORAL EXAM D 0150 $ 35.00 X-RAYSSERVICE DESCRIPTION CODE FE EINTRAORAL X-RAYS, COMPLETE SERIES (INCLUDING BITEWING) D 0210 $ 35.00INTRAORAL-PERIAPICAL FIRST FILM (NO CHARGE WITHTREATMENT) D 0220 $ 5.00INTRAORAL-OCCLUSAL FILM D 0240 $ 10.00EXTRAORAL- FIRST FILM D 0250 $ 12.00BITEWING SINGLE FILM D 0270 $ 9.00BITEWINGS DOUBLE FILM D 0272 $ 13.00BITEWINGS FOUR FILMS D 0274 $ 20.00POSTERIOR / ANT OR LATERAL SKULL & FACIAL BONE SURVEYFILM D 0290 $ 44.00PANORAMIC FILM D 0330 $ 50.00CEPHALOMETRIC FILM D 0340 $ 45.00ORAL / FACIAL IMAGES, INCLUDE INTRA & EXTRAORAL IMAGES D 0350 $ 20.00DIAGNOSTIC PHOTOGRAPHS D 0471 $ 25.00 TEST & LABORATORY EXAMINATIONSSERVICE DESCRIPTION CODE FE EPULP VITALITY TEST D 0460 $ 12.00DIAGNOSTIC CASTS D 0470 $ 12.00 PREVENTIVESERVICE DESCRIPTION CODE FE EPROPHYLAXIS ADULTS D 1110 $ 40.00PROPHYLAXIS CHILD D 1120 $ 40.00 $ -TOPICAL APPLICATION OF FLUORIDE (NO CHARGE WITHTREATMENT) D 1203 $ -TOPICAL APPLICATION OF FLUORIDE – ADULT (NO CHARGE WITHTREATMENT) D 1204TOBACCO COUNSELING (NO CHARGE WITH TREATMENT) D 1320 $ - $ -ORAL HYGIENE INSTRUCTIONS (NO CHARGE WITH TREATMENT) D 1330SEALANT- PER TOOTH D 1351 $ 22.00SPACE MAINTAINER-FIXED UNILATERAL D 1510 $ 135.00SPACE MAINTAINER-FIXED BILATERAL D 1515 $ 105.00SPACE MAINTAINER-REMOVABLE BILATERAL D 1525 $ 185.00RECEMENTATION OF SPACE MAINTAINER D 1550 $ 32.00 RESTORATIVESERVICE DESCRIPTION CODE FE EAMALGAM-ONE SURFACE, PRIMARY D 2110 $ 35.00AMALGAM-TWO SURFACES, PRIMARY D 2120 $ 42.00AMALGAM-THREE SURFACES, PRIMARY D 2130 $ 50.00 51

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