Medisaver Member Prices
This is a Complete List of prices for
Medisaver members from our providers
To download in Spanish Version, Click here.
| Family and General Practice Consultation Fees | ||
|---|---|---|
| Initial Office Visit | $25.00 | |
| Follow-Up Office Visit | $20.00 | |
| Head: Specialist Physician Practice Consultation Fees | ||
| Initial Office Visit | $60.00 | |
| Follow-Up Office Visit | $40.00 | |
| Head: Pediatric / Pediatrician | ||
| Initial Office Visit | $40.00 | |
| Follow-Up Office Visit | $30.00 | |
| Codes | Head: Cardiovscular | Med Plan |
| 93000 | ECG | $10.00 |
| 93307 | Echo | $90.00 |
| 93320 | Echo Doppler | $40.00 |
| 93325 | Color Flow Doppler | $18.00 |
| 93324 | Holter Monitor 24 hr | $55.00 |
| Codes | Head: Diagnostic US | Med Plan |
| 76705 | Abdomen / Single | $50.00 |
| 76700 | Abdomen / Complete | $50.00 |
| 76645 | Breast | $50.00 |
| 76856 | Pelvic | $50.00 |
| 76873 | Prostate | $50.00 |
| 76770 | Kidney / Renal | $50.00 |
| 76536 | Thyroid | $50.00 |
| 93923 | US Arterial Upper-lower | $70.00 |
| 93925 | Duplex Scan Arterial | $70.00 |
| 93965 | US venous extremity | $70.00 |
| 93970 | Duplex scan venous | $70.00 |
| 76705 | Abdomen / Single | $50.00 |
| Codes | Head: Injections | Med Plan |
| J0780 | Compazine 10 mg Cost | Cost +$10.00 |
| J1100 | Decadron up to 5mg Cost | Cost +$10.00 |
| J1030 | Depo-Medrol 40 mg | Cost +$10.00 |
| J1040 | Depo-Medrol 80 mg | Cost +$10.00 |
| J2480 | Terramycin up 50 mg | Cost +$10.00 |
| J3120 | Testosterone to 100 mg | Cost *$10.00 |
| J3410 | Vistaril to 25 mg | Cost *$10.00 |
| J3420 | Vitamin B12 tol 000 mg | Cost +$10.00 |
| J1670 | Tetanun (Globulin) | Cost +$10.00 |
| J3180 | Tetanun Toxoid Cost | Cost *$10.00 |
| J0500 | Bentyl | Cost +$10.00 |
| J3450 | Tigan | Cost +$10.00 |
| J1885 | Tiradol | Cost +$10.00 |
| J1200 | Benadryl | Cost +$10.00 |
| Codes | Head: X-Ray Procedures | Med Plan |
| 73600 | Ankle 2 views | $25.00 |
| 71010 | Chest PA only | $25.00 |
| 71020 | Chest PA & LA | $25.00 |
| 73070 | Elbow 2 Views | $25.00 |
| 73620 | Foot 2 Views | $25.00 |
| 73090 | Forearm 2 Views | $25.00 |
| 73120 | Hand 2 Views | $25.00 |
| 73500 | Hip 1 Views | $25.00 |
| 73510 | Hip 2 views | $25.00 |
| 73520 | Hip Bilateral | $25.00 |
| 73060 | Humerus 2 views | $25.00 |
| 74020 | KUB 2 Views | $25.00 |
| 72110 | Lumbo Sacral Spine | $25.00 |
| 71100 | Ribs 2 views | $25.00 |
| 73020 | Shoulder 1 views | $25.00 |
| 73030 | Shoulder 2 views | $25.00 |
| 73590 | Tibia 2 views | $25.00 |
| 73100 | Wrist 2 views | $25.00 |
| 73560 | Calcaneus | $25.00 |
| 73550 | Femur | $25.00 |
| 73140 | Finger(s) | $25.00 |
| 72040 | Cervical Spine | $25.00 |
| 72070 | Thoracic Spine | $25.00 |
| 73562 | Knee | $25.00 |
| 70220 | Sinus | $25.00 |
| 70260 | Skull Series | $25.00 |
| 70160 | Nasal Bones | $25.00 |
| 70110 | Mandible | $25.00 |
| 70200 | Orbits | $25.00 |
| Codes | Head: Therapies | Med Plan |
| 97010 | Hot Pack Therapy | $10.00 |
| 97010 | Cold Pack Therapy | $10.00 |
| 97012 | Tractional Mechanical | $10.00 |
| 97014 | EMS (High Frequence) | $10.00 |
| 97018 | Paraffin Bath | $10.00 |
| 97028 | Ultra Sound | $10.00 |
| 97022 | Whirpool | $10.00 |
| Codes | Head: Pulmonary | Med Plan |
| 94060 | Bronchospasm Eval | $12.50 |
| 94664 | Nebulizer Treatment | $12.50 |
| 94665 | Nebulizer Subsequent | $12.50 |
| 94010 | Spirometry | $12.50 |
| 94060 | Spirometry W bronco sp. | $12.50 |
| 94070 | Prolonged Broncho sp. | $12.50 |
| 94200 | Maximum Breathing cap. | $12.50 |
| 94240 | Func. Resd. Cap. | $12.50 |
| 94250 | Exp. Gas Collecion | $12.50 |
| Codes | Head: Pulmonary | Med Plan |
| 69210 | Ear Lavage | $5.00 |
| PAP Smear Papanicolau Liquid | $35.00 | |
| PAP Papanicolau Slide | $20.00 | |
| ADA CODES | Head: DESCRIPTION | FEES |
| DO120 | PERIODIC ORAL EXAM | NO CHARGE |
| D0140 | LIMITED ORAL EVALUATION-PROBLEM FOCUSED | $10.00 |
| DO150 | COMPREHENSIVE ORAL EVAL-NEW OR ESTABLISHED PATIENT | $20.00 |
| DO160 | DETAILED & EXTENSIVE EVAL-PROBLEM FOCUSED | $5.00 |
| DO170 | RE-EVALUATION-LIMITED, PROBLEM FOCUSED | $5.00 |
| DO180 | COMPREHENSIVE PERIODONTAL EVALUATION | $15.00 |
| Head: RADIOGRAPHY/DIAGNOSTIC DENTISTRY | ||
| D0210 | X-RAY - INTRAORAL - COMPLETE SERIES (INCLUDING BITEWINGS) | $30.00 |
| D0220 | X-RAY - INTRAORAL - PERIAPICAL FIRST FILM | $15.00 |
| D0230 | X-RAY - INTRAORAL - PERIAPICAL EACH ADDITIONAL FILM | $5.00 |
| D0240 | X-RAY INTRAORAL - OCCLUSAL FILM | $5.00 |
| D0250 | X-RAY - EXTRAORAL - FIRST FILM | $5.00 |
| D0260 | X-RAY EXTRAORAL - EACH ADDITIONAL FILM | $5.00 |
| D0270 | X-RAY - BITEWING- SINGLE FILM | $5.00 |
| D0272 | X-RAY - BITEWING - 2 FILMS | $5.00 |
| Head: NOT TO BE TAKEN IF 274 WAS DONE W/IN PRIOR 6 MOS | ||
| D0330 | PANORAMIC FILM | $25.00 |
| D0340 | CEPHALOMETRIC FILM, NON-ORTHODONTIC | $75.00 |
| D0350 | DIAGNOSTIC PHOTOGRAPHS | $20.00 |
| D0460 | PULP VITALITY TEST | $10.00 |
| D0470 | DIAGNOSTIC CASTS | $25.00 |
| Head: PREVENTIVE DENTISTRY | ||
| D1110 | ROUTINE PROPHYLAXIS ADULT (ONCE EVERY 6 MONTHS) | $49.00 |
| D1120 | ROUTINE PROPHYLAXIS - CHILDREN UNDER 16 YRS (ONCE EVERY 6 MONTHS) | $35.00 |
| D1201 | TOPICAL APPLICATION OF FLOURIDE FOR CHILDREN UNDER 16 | $5.00 |
| D1203 | TOPICAL APPLICATION OF FLOURIDE FOR CHILDREN UNDER 16 | $5.00 |
| D1204 | TOPICAL APPLICATION OF FLOURIDE FOR ADULTS | $20.00 |
| D1310 | NUTRITIONAL COUNSELING FOR CONTROL OF DENTAL DISEASE | $5.00 |
| D1320 | TOBBACO COUNSELING FOR CONTROL & PREVENTION OF ORAL DISEASES | $5.00 |
| D1330 | ORAL HYGIENE INSTRUCTIONS | $5.00 |
| D1351 | APPLICATION OF SEALANT PER TOOTH - CHILDREN UNDER 16 | $15.00 |
| D1510 | SPACE MAINTAINER - FIXED | $120.00 |
| D1515 | SPACE MAINTAINER - FIXED | $125.00 |
| D1520 | SPACE MAINTAINER - REMOVABLE | $130.00 |
| D1525 | SPACE MAINTAINER - REMOVABLE | $200.00 |
| D1550 | RE-CEMENTATION OF SPACE MAINTAINER | $25.00 |
| D2330 | RESIN-BASED COMPOSITE- 1 SURFACE, ANTERIOR (EMPASTES) | $52.00 |
| D2331 | RESIN-BASED COMPOSITE - 2 SURFACES, ANTERIOR (EMPASTES ) | $60.00 |
| D2332 | RESIN-BASED COMPOSITE - 3 SURFACES, ANTERIOR (EMPASTES ) | $75.00 |
| 2335 | COMPOSITED RESIN - 4 OR MORE SURFACES (EMPASTES) | $80.00 |
| D2391 | RESIN - BASED COMPOSITE - 1 SURFACE, POSTERIOR (EMPASTES) | $53.00 |
| D2392 | RESIN-BASED COMPOSITE -2 SURFACES, POSTERIOR (EMPASTES) | $60.00 |
| D2393 | RESIN-BASED COMPOSITE - 3 SURFACES, POSTERIOR (EMPASTES) | $75.00 |
| D2394 | RESIN-BASED COMPOSITE -4 OR + SURFACES, POSTERIOR (EMPASTES) | $80.00 |
| D2410 | GOLD FOIL- 1 SURFACE | $75.00 |
| D2420 | GOLD FOIL - 2 SURFACES | $95.00 |
| D2430 | GOLD FOIL - 3 SURFACES | $125.00 |
| D2510 | INLAY - METALLIC - 1 SURFACE | $300.00 |
| D2520 | INLAY - METALLIC - 2 SURFACES | $320.00 |
| D2530 | INLAY - METALLIC - 3 OR MORE SURFACES | $340.00 |
| D2542 | ONLAY - METALLIC - 2 SURFACES | $325.00 |
| D2543 | ONLAY - METALLIC - 3 SURFACES | $330.00 |
| D2544 | ONLAY - METALLIC - 4 OR MORE SURFACES | $355.00 |
| D2610 | INLAY - PORCELAIN/CERAMIC - 1 SURFACE | $325.00 |
| D2620 | INLAY - PORCELAIN/CERAMIC - 2 SURFACES | $350.00 |
| D2630 | INLAY - PORCELAIN/CERAMIC - 3 OR MORE SURFACES | $375.00 |
| D2642 | ONLAY - PORCELAIN/CERAMIC - 2 SURFACES | $395.00 |
| D2643 | ONLAY - PORCELAIN/CERAMIC - 3 SURFACES | $415.00 |
| D2644 | ONLAY - PORCELAIN/CERAMIC - 4 OR MORE SURFACES | $445.00 |
| D2650 | INLAY - RESIN - BASED COMPOSITE - 1 SURFACE | $195.00 |
| D2651 | INLAY - RESIN - BASED COMPOSITE - 2 SURFACES | $250.00 |
| D2652 | INLAY - RESIN - BASED COMPOSITE - 3 OR MORE SURFACES | $275.00 |
| D2662 | ONLAY - RESIN - BASED COMPOSITE - 2 SURFACES | $250.00 |
| D2663 | ONLAY - RESIN - BASED COMPOSITE - 3 SURFACES | $275.00 |
| D2664 | ONLAY - RESIN - BASED COMPOSITE - 4 OR MORE SURFACES | $290.00 |
| D2710 | CROWN - RESIN (INDIRECT) | $210.00 |
| D2720 | CROWN - RESIN WITH HIGH NOBLE METAL | $455.00 |
| D2721 | CROWN - RESIN WITH PREDOMINNATLY BASE METAL | $405.00 |
| D2722 | CROWN - RESIN WITH NOBLE METAL | $425.00 |
| D2740 | CROWN - PORCELAIN/CERAMIC SUBSTRATE | $595.00 |
| D2750 | CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL | $495.00 |
| D2751 | CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL | $495.00 |
| D2752 | CROWN - PORCELAIN FUSED TO NOBLE METAL | $495.00 |
| D2780 | CROWN 3/4 CAST HIGH NOBLE METAL | $530.00 |
| D2781 | CROWN - 3/4 CAST PREDOMINANTLY BASE METAL | $410.00 |
| D2782 | CROWN - 3/4 CAST NOBLE METAL | $520.00 |
| D2783 | CROWN - 3/4 PORCELAIN/CERAMIC | $550.00 |
| D2790 | CROWN - FULL CAST HIGH NOBEL METAL | $699.00 |
| D2791 | CROWN - FULL CAST PREDOMINANTLY BASE METAL | $525.00 |
| D2792 | CROWN - FULL CAST NOBLE METAL | $580.00 |
| D2799 | PROVISIONAL CROWN | $50.00 |
| D2910 | RECEMENT INLAY | $25.00 |
| D2920 | RECEMENT CROWN | $25.00 |
| D2930 | PREFABRICATED STAINLESS STEEL CROWN-PRIMARY TOOTH | $95.00 |
| D2931 | PREFABRICATED STAINLESS STEEL CROWN-PERMANENT TOOTH | $95.00 |
| D2932 | PREFABRICATED RESIN CROWN | $95.00 |
| D2933 | PREFABRICATED STAINLESS STEEL CROWN WITH RESIN WINDOW | $145.00 |
| D2940 | SEDATIVE FILLING | $40.00 |
| D2950 | CORE BUILDUP, INCLUDING ANY PINS | $85.00 |
| D2951 | PIN RETENTION - PER TOOTH, IN ADDITION TO RESTORATION | $20.00 |
| D2952 | CAST POST & CORE IN ADDITION TO CROWN | $155.00 |
| D2953 | EACH ADDITIONAL CAST POST - SAME TOOTH | $105.00 |
| D2954 | PREFABRICATED POST & CORE IN ADDITION TO CROWN | $125.00 |
| D2955 | POST REMOVAL (NOT IN CONJUNTION WITH ENDODONTIC THERAPY) | $30.00 |
| D2957 | EACH ADDITIONAL PREFABRICATED POST - SAME TOOTH | $30.00 |
| D2960 | LABIAL VENEER (RESIN LAMINATE) - CHAIRSIDE | $205.00 |
| D2961 | LABIAL VENEER RESIN LAMINATE) - LABORATORY | $260.00 |
| D2962 | LABIAL VENEER (PORCELAIN LAMINATE - LABORATORY | $425.00 |
| D2970 | TEMPORARY CROWN (FRACTURED TOOTH) | $50.00 |
| D2980 | CROWN REPAIR/ When crown and/or bridgework exceeds six (6) consecutive units, there will be an additional charge of $30.00 per unit. | $95.00 |
| Head: ENDODONTICS SERVICES | ||
| D3110 | PULP CAP-DIRECT (EXCLUDING FINAL RESTORATION) | $25.00 |
| D3120 | PULP CAP-INDIRECT (EXCLUDING FINAL RESTORATION) | $25.00 |
| D3220 | THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) | $75.00 |
| D3221 | PUPAL DEBRIDEMENT, PRIMARY AND PERMANENT TEETH | $95.00 |
| D3230 | PUPAL THERAPY (RESORB FILLING) - ANTERIOR, PRIMARY | $80.00 |
| D3240 | PUPLAM THERAPY (RESORBABLE FILLING) - POSTERIOR, PRIMARY | $90.00 |
| D3310 | ROOT CANAL THERAPY - ANTERIOR | $395.00 |
| D3320 | ROOT CANAL THERAPY - BICUSPID | $495.00 |
| D3330 | ROOT CANAL THERAPY - MOLAR | $595.00 |
| D3331 | TREATMENT OF ROOT CANAL OBSTRUCTION, NON-SURGICAL ACCESS | $85.00 |
| D3346 | RETREAT, PREV RCT - ANTERIOR | $495.00 |
| D3347 | RETREAT, PREV RCT - BICUSPID | $595.00 |
| D3348 | RETREAT, PREV RCT - MOLAR | $695.00 |
| D3950 | CANAL PREPARATION AND FITTING OF PREFORMED DOWEL OR POST | $75.00 |
| Head: PERODONTICS SERVICES | ||
| D4211 | GINGIVECTOMY/GINGIVOPLASTY - 1 -TO 3 TEETH, PER QUAD | $50.00 |
| D4220 | GINGIVAL CURETTAGE PER QUADRANT EXCLUDING ROOT PLANNING | $75.00 |
| D4240 | GINGIVAL FLAP PROCEDURE- 4 OR MORE | $325.00 |
| D4241 | GINGIVAL FLAP PROCEDURE - 1 TO 3 TEETH PER QUAD | $250.00 |
| D4245 | APICALLY POSITIONED FLAP | $150.00 |
| D4341 | PERIODONTAL SCALING & ROOT PLANING - 4 OR MORE CONTIGUOUS TEETH | $75.00 |
| D4342 | PERIODONTAL SCALING $ ROOT PLANING - 1 TO 3 TEETH, PER QUAD | $60.00 |
| D4355 | FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE EVALUATION | $80.00 |
| D4381 | LOCAL DELIVERY ANTIBIOTIC (ARESTIN) | $30.00 |
| D4910 | PERIODONTAL MAINTENANCE | $55.00 |
| D5110 | COMPLETE DENTURE - MAXILLARY BASIC | $495.00 |
| D5120 | COMPLETE DENTURE - MANDIBULAR BASIC | $495.00 |
| D5211 | MAXILLARY PARTIAL DENTURE - RESIN BASE (INCLUDING CLASPS | $450.00 |
| D5212 | MANDIBULAR PARTIAL DENTURE - RESIN BASE (INCLUDING CLASPS) | $450.00 |
| D5213 | PARTIAL DENTURE - MAXILLARY CAST METAL - ACRYLIC | $575.00 |
| D5214 | PARTIAL DENTURE - MANDIBULAR VAST METAL - ACRYLIC | $575.00 |
| D5410 | ADJUSTMENT - COMPLETE DENTURE - MAXILLARY | $20.00 |
| D5411 | ADJUSTMENT - COMPLETE DENTURE - MANDIBULAR | $20.00 |
| D5421 | ADJUSTMENT - PARTIAL DENTURE - MAXILLARY | $20.00 |
| D5422 | ADJUSTMENT - PARTIAL DENTURE - MANDIBULAR | $20.00 |
| D5510 | REPAIR BROKEN COMPLETE DENTURE BASE | $75.00 |
| D5520 | REPLACE BROKEN TOOTH - COMPLETE DENTURE (EACH TOOTH) | $70.00 |
| D5610 | REPAIR DENTURE RESIN BASE | $50.00 |
| D5620 | REPAIR CAST FRAMEWORK | $55.00 |
| D5630 | REPAIR OR REPLACE BROKEN CLASP | $55.00 |
| D5640 | REPAIR BROKEN TEETH - PER TOOTH | $45.00 |
| D5650 | ADD TOOTH TO EXISTING PARTIAL DENTURE | $65.00 |
| D5660 | ADD CLASP TO EXISTING PARTIAL DENTURE | $75.00 |
| D5710 | REBASE COMPLETE MAXILLARY DENTURE | $195.00 |
| D5711 | REBASE COMPLETE MANDIBULAR CENTURE | $195.00 |
| D5720 | REBASE MAXILLARY PARTIAL DENTURE | $175.00 |
| D5721 | REBASE MANDIBULAR PARTIAL DENTURE | $175.00 |
| D5730 | RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) | $85.00 |
| D5731 | RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) | $85.00 |
| D5740 | RELINE PARTIAL COMPLETE MAXILLARY DENTURE (CHAIRSIDE) | $65.00 |
| D5741 | RELINE PARTIAL COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) | $65.00 |
| D5750 | RELINE COMPLETE MAXILLARY DENTURE (LABORATORY | $150.00 |
| D5751 | RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY) | $150.00 |
| D5760 | RELINE PARTIAL MAXILLARY DENTURE (LABORATORY) | $110.00 |
| D5761 | RELINE PARTIAL MANDIBULAR DENTURE (LABORATORY) | $110.00 |
| D5810 | INTERIM COMPLETE DENTURE - MAXILLARY | $250.00 |
| D5811 | INTERIM COMPLETE DENTURE - MANDIBULAR | $250.00 |
| D5820 | INTERIM PARTIAL DENTURE - MAXILLARY | $250.00 |
| D5821 | INTERIM PARTIAL DENTURE - MANDIBULAR | $250.00 |
| D5850 | TISSUE CONDITIONING - MAXILLARY | $55.00 |
| D5851 | TISSUE CONDITIONING - MANDIBULAR | $55.00 |
| D5862 | PRECISION ATTACHMENT | $150.00 |
| Head: PROSTHODONTICS - FIXED | ||
| D6210 | PONTIC - CAST HIGH NOBLE METAL | $400.00 |
| D6211 | PONTIC - CAST PREDOMINANTLY BASE METAL | $400.00 |
| D6212 | PONTIC - CAST NOBLE METAL | $400.00 |
| D6240 | PONTIC - PORCELAIN FUSED TO HIGH NOBLE METAL | $400.00 |
| D6241 | PONTIC - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL | $400.00 |
| D6242 | PONTIC - PORCELAIN FUSED TO NOBLE METAL | $400.00 |
| D6245 | PONTIC - PORCELAIN/CERAMIC | $595.00 |
| D6740 | CROWN - PORCELAIN/CERAMIC | $595.00 |
| D6750 | CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL | $495.00 |
| D6751 | CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASED METAL | $495.00 |
| D6752 | CROWN - PORCELAIN FUSED TO NOBLE METAL | $495.00 |
| D6780 | CROWN - 3/4 CAST HIGH NOBLE METAL | $530.00 |
| D6781 | CROWN - 3/4 CAST PREDOMINANTLY BASED METAL | $510.00 |
| D6782 | CROWN - 3/4 CAST NOBLE METAL | $520.00 |
| D6783 | CROWN - 3/4 PORCELAIN/CERAMIC | $510.00 |
| D6790 | CROWN - FULL CAST HIGH NOBLE METAL | $495.00 |
| D6791 | CROWN - FULL CAST PREDOMIANTLY BASED METAL | $495.00 |
| D6792 | CROWN - FULL CAST NOBLE METAL | $495.00 |
| D6930 | RECEMENT FIXED PARTIAL DENTURE | $40.00 |
| D6950 | PRECISION ATTACHMENT | $150.00 |
| D6970 | CAST POST & CORE ADDITION TO FIXED PARTIAL DENTURE RETAINER | $125.00 |
| D6971 | CAST POST AS PART OF A FIXED PARTIAL DENTURE RETAINER | $125.00 |
| D6972 | PREFABRICATED POST & CORE IN ADDITION TO FIXED PARTIAL DENTURE | $125.00 |
| D6973 | CORE BUILD UP FOR RETAINER, INCLUDING PINS | $95.00 |
| D6975 | COPING METAL | $95,00 |
| Head: ORAL SURGERY | ||
| D7110 | SINGLE TOOTH EXTRACTION EXTRACCION) | $60.00 |
| D7140 | EXTRACTION OF ERUPTED TOOTH OR EXPOSED ROOT | $70.00 |
| D7310 | ALVEOLOPLASTY WITH EXTRACTIONS - PER QUADRANT | $75.00 |
| D7320 | ALVEOLOPLASTY WITHOUT EXTRACTIONS - PER QUADRANT | $90.00 |
| D7510 | INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE | $55.00 |
| D9215 | LOCAL ANESTHESIA | |
| ADA CODES | Head: MISCELLANEOUS SERVICE | FEES |
| D9230 | ANALGESIA NITROUS OXIDE PER 1/2 hour | $20.00 |
| D9630 | ORAL IRRÄGATION/OTHER DRUGS/MEDICAMENT PER QUAD | $10.00 |
| D9940 | OCCLUSAL GUARD | $100.00 |
| D9950 | OCCLUSAL ANALYSIS - MOUNTED CASE | $75.00 |
| D9951 | OCCLUSAL ADJUSTMENT - LIMITED | $25.00 |
| D9952 | OCCLUSAL ADJUSTMENT - COMPLETE | $75.00 |
| ADA CODES | Head: ENDODONTICS | FEES |
| ED3310 | ROOT CANAL THERAPY - ANTERIOR | $400.00 |
| ED3320 | ROOT CANAL THERAPY - BICUSPID | $500.00 |
| ED3330 | ROOT CANAL THERAPY - MOLAR | $600.00 |
| ED3346 | RETREAT, PREV RCT -ANTERIOR | $650.00 |
| ED3347 | RETREAT, PREV RCT - BICUSPID | $700.00 |
| ED3348 | RETREAT. PREV RCT - MOLAR | $800.00 |
| Head: PERIODONTICS | ||
| D4210 | GINGIVECTOMY 4 OR + PER QUADRANT | $450.00 |
| D4249 | CLINIC CROWN LENGTHEN - HARD TISSUE | $700.00 |
| D4260 | OSSEOUS SURGERY 4 OR + PER QUADRANT | $800.00 |
| D4263 | BONE REPLACE GRAFT - 1ST SITE/QU | $650.00 |
| D4264 | BONE REPLACE GRAFT - EACH ADD/QU | $500.00 |
| D4266 | GUIDED TISS REGEN-RESORB-PER | $750.00 |
| D4275 | SOFT TISSUE ALLOGRAFT RB-PER | $900.00 |
| D7953 | BONE REPL GRAFT RIDGE PRSV/SITE | $400.00 |
| D7960 | FRENULECTOMY - SEPARATE PROCEDURE | $500.00 |
| Head: ORAL SURGERY | ||
| D7210 | EXTRACTION - SURGICAL/ERUPT TOOTH | $100.00 |
| D7220 | EXTRACTION - IMPACTEDL/SOFT TISSUE | $150.00 |
| D7230 | EXTRACTION - IMPACTEDL/PART BONY | $200.00 |
| D7240 | EXTRACTION - IMPACTED/COMPLBONY (Cordales) | $150.00 |
| D7241 | REMOV IMPACT - COMP BONY W/COMP | $250.00 |
| D7250 | SURGIC REMOVL RESID TOOTH ROOT | $150.00 |
| D7285 | BIOPSY OF ORAL TISSUE - HARD (BONE, TOOTH) | $75.00 |
| D7286 | BIOPSY OF ORAL TISSUE - SOFT (ALL OTHER) | $65.00 |
| BIOPSY LAB | $40.00 | |
| Head: ORTHODONTICS | ||
| D8080 | COMPREHENSIVE ORTHO, ADOLESCENT | $3,490.00 |
| D8090 | COMPREHENSIVE ORTHO, ADULT | $3,490.00 |
| Head: IMPLANTS | ||
| D6010 | SURG PLACE IMPLANT, ENDOSTEAL | $1,200.00 |
| D6010/D6059 | COMPLETED CROWN IMPLANT (IMPLANTE Y CORONA) | $1,950.00 |
| D0000 | OVERDENTURE UPPER WITH 4 IMPLANTS | $4,650.00 |
| D0000 | OVERDENTURE LOWER WITH 3 IMPLANTS | $3,650.00 |
| Head: TEST NAME | TEST CODE | FEE |
| AMYLASE | 1106 | $6.00 |
| ACTH (ADRENOCORTICOTROPIC HORMONE) | 7200 | $37.00 |
| AFP TUMOR MARKER | 1274 | $15.50 |
| ALBUMIN | 8170 | $2.50 |
| ALCOHOL IN URINE | 3525 | $12.00 |
| ALDOLASE | 1102 | $9.50 |
| ALKALINE PHOSPHATASE | 8160 | $2.50 |
| ALLERGEN FOOD PANEL (ADULT) each allergen ($9) | 7302 | $9.00 |
| ALLERGEN RESPIRATORY PANEL SUB-TROPICAL each allergen ($9) | 7304 | $9.00 |
| ALLERGY PANEL PER ALLERGEN each allergen ($9) | $9.00 | |
| ALPHA PHETO PROTEIN QUAD SCREEN | 1673 | $82.00 |
| ALPHA PHETO PROTEIN TRIPLE SCREEN | 8260 | $56.00 |
| ALT SGPT | 8154 | $8.00 |
| AMIKACIN SERUM | 1695 | $15.50 |
| AMMONIA | 1104 | $12.50 |
| ANA | 5200 | $12.00 |
| ANTIBODY SCREENING | 4259 | $11.50 |
| ASO | 4201 | $15.00 |
| AST (SCOT) | 8152 | $8.00 |
| B-12 & FOLID ACID | 8794 | $30.00 |
| B-12 | 7272 | $12.50 |
| BASIC METAB PANEL | 8118 | $8.00 |
| BETA 2 MICROGLOBULIN | 1404 | $16.50 |
| BILIRUBIN DIRECT | 8149 | $4.50 |
| BILIRUBIN TOTAL | 8166 | $4.50 |
| BIOPSY (see comments at the end) | 9181 | $4.50 |
| BLEEDING TIME | 4108 | $18.00 |
| Head: TEST NAME | TEST CODE | FEE |
| BLOOD TYPE & RH | 4200 | $40.00 |
| BNP | 1430 | $5.00 |
| BUN | 8142 | $7.00 |
| CBC | 4110 | $20.00 |
| C3 COMPLEMENT | 6115 | $20.00 |
| C4 COMPLEMENT | 6126 | $19.50 |
| CA 125 | 1462 | $19.50 |
| CA 15-3 | 1462 | $19.50 |
| CA 19-9 | 1463 | $19.50 |
| CA 27-29 | 1664 | $4.50 |
| CALCIUM | 8172 | $11.00 |
| CALCIUM IONIZED | 2130 | $27.00 |
| CALCULUS (stone) ANALYSIS | 1318 | $15.00 |
| CARBAMAZEPIN | 3119 | $19.50 |
| CEA | 7214 | $36.00 |
| CERULOPLASMIN | 6119 | $60.00 |
| CHLAMYDIA & GC IN URINE | 5346 | $25.00 |
| CHLAMYDIA & GC DNA | 5344 | $4.50 |
| CHOLESTEROL | 8146 | $7.00 |
| CK CPK TOTAL) | 8156 | $14.50 |
| CMV IgG | 1353 | $12.50 |
| CMV IgM | 5210 | $9.00 |
| COMPRENH. METABOLIC PANEL | 8112 | $10.00 |
| COOMBS DIRECT | 4214 | $10.00 |
| COOMBS INDIRECT | 4215 | $17.50 |
| CORTISOL | 7206 | $15.00 |
| C-PEPTIDE | 1431 | $12.50 |
| CPK - MB (CREATINE KINASE MB FRACTION) | 6127 | $12.50 |
| C-REACTIVE PROTEIN - QUANT | 3595 | $5.00 |
| Head: TEST NAME | TEST CODE | FEE |
| C-REACTIVE PROTEIN (CRP) | 4216 | $4>.50 |
| C-REACTIVE PROTEIN (CRP) ULTRASENSITIVE | 6657 | $10.00 |
| CREATININE 24 HRS | 2115 | $0.50 |
| CREATININE CLEARANCE | 2127 | $4.00 |
| CREATININE SERUM | 8150 | $14.00 |
| CULTURE & SENSIT | 5145 | $250.00 |
| CYSTIC FIBROSIS | 6442 | $14.00 |
| DEPAKENE (VALPROIC ACID) | 1938 | $26.00 |
| DHEA (DEHYDROEPIANDROSTERONE | 7171 | $26.00 |
| DHEA-S | 1655 | $6.00 |
| DIHYDROTESTOSTERONE DHT | $26.50 | |
| D-DIMER | $22.50 | |
| DILANTIN LEVEL | 3126 | $15.00 |
| DRUG SCREEN IN URINE | 3223 | $23.00 |
| ELECTROLYTE PANEL | 8200 | $6.50 |
| EPSTEIN BARR VIRAL CAPSIDE ANTIGEN (VCA) IgG & IgM | 1920 | $14.00 |
| EPSTEIN BARR VIRUS EARLY | 1632 | $14.00 |
| EPSTEIN BARR VIRUS NUCLEAR ANTIGEN IgG ANTIBODY | 1861 | $17.50 |
| EPSTEIN BARR VIRUS NUCLEAR ANTIGEN IgM ANTIBODY | 1902 | $17.50 |
| ERYTHROPOIETIN | 5215 | $18.50 |
| ESTRADIOL | 7226 | $22.00 |
| ESTRIOL | 7224 | $28.00 |
| ESTROGEN TOTAL | 7227 | $22.00 |
| ESR (SED RATE) | 4160 | $8.00 |
| EYE CULTURE & SENSITIVITY | 5145 | $42.00 |
| FERRITIN | 7275 | $14.00 |
| FIBRINOGEN | 4223 | $22.00 |
| FOLIC ACID | 7229 | $13.00 |
| FREE T3 | 1603 | $7.00 |
| Head: TEST NAME | TEST CODE | FEE |
| FREE T 4 | 7120 | $7.00 |
| FSH | 7228 | $17.00 |
| FSH & LH | 7261 | $34.00 |
| FINE NEEDLE ASPIRATION | $69.00 | |
| FTA AG | 5220 | $35.00 |
| FUNGUS CULTURE | 5114 | $35.00 |
| GAMMA GT GGTP | 1116 | $5.00 |
| GC CULTURE | 5118 | $35.00 |
| GENTAMYCIN | 7232 | $28.00 |
| GLIADINI IgA, IgG | 1432 | $80.00 |
| GLUCOSE 2 HRS P.P | 8180 | $7.00 |
| GLUCOSE 2 HRS TOLERANCE TEST | 8188 | $13.00 |
| GLUCOSE 3 HRS | 8189 | $17.00 |
| GLUCOSE GRAY TUBE | 8141 | $3.50 |
| GLUCOSE SERUM | 8140 | $3.50 |
| GLYCOHEMOGLOBIN | 6145 | $9.00 |
| H. PYLORI AB IgG | 1295 | $15.00 |
| H. PYLORI AB lgM | 1297 | 15 |
| H. PYLORI IN STOOL (ANTIGEN) | 1294 | $43.00 |
| HAPTOGLOBULIN | 6147 | $25.00 |
| HCG QUAL | 7282 | $7.00 |
| HCG QUANT | 7240 | $15.50 |
| HEMOGLOBIN AIC | 6145 | $9.50 |
| HEMOGLOBIN ELECTROPHORESIS | 6151 | $12.00 |
| HEMOGLOBIN/HEMATOCRIT | 4132 | $12.00 |
| HEPATIC FUNCTION PANEL | 8698 | $7.50 |
| HEPATITIS A IgM | 1376 | $11.50 |
| HEPATITIS A TOTAL | 1621 | $10.50 |
| HEPATITIS B CORE IgM ANTIBODIES | 1799 | $11.50 |
| Head: TEST NAME | TEST CODE | FEE |
| HEPATITIS B CORE TOTAL ANTIBODY | 1614 | $11.50 |
| HEPATITIS Bs ANTIBODY | 7237 | $11.00 |
| HEPATITIS Bs ANTIGEN | 7236 | $10.00 |
| HEPATITIS C ANTIBODY | 1711 | $13.50 |
| HEPATITIS PANEL ABC | 2298 | $44.00 |
| HERPES CULTURE | 1716 | $35.00 |
| HERPES I SELECT | 1439 | $12.50 |
| HERPES SELT IgG | 1440 | $18.50 |
| HIV 1 & 2 SCREEN | 1437 | $9.50 |
| HLA-B-27 | 1398 | $70.00 |
| HOMOCYSTEINE | 1227 | $28.00 |
| HUMAN GROWTH HORMONE | 7238 | $16.00 |
| HUMAN PAPILOMA VIRUS hc2 | 1 846 | $39.00 |
| lgA (Immunoglobulin) | 6140 | $9.00 |
| lgE (Immunoglobulin E) | 7248 | $16.00 |
| IgG (Immunoglobulin) | 6142 | $9.00 |
| IgM (Immunoglobulin M) | 6143 | $9.00 |
| IMMUNOELECTROPHORESIS | 6160 | $21.50 |
| IMMUNOGLOBULIN IgG-A-M | 6156 | $27.00 |
| INSULINE LEVEL | 7250 | $11.50 |
| INSULINE LIKE GROWTH FACTOR I SOMATOMEDIN-C IgF1 | 1666 | $30.00 |
| IRON | 8162 | $5.00 |
| IRON & IBC | 8161 | $8.50 |
| LEAD BLOOD | 2160 | $10.50 |
| L.E. SCREEN | 3662 | $10.00 |
| LDH | 8158 | $4.00 |
| LH | 7244 | $19.50 |
| LIPASE | 1126 | $6.50 |
| LIPID PANEL | 6188 | $9.00 |
| Head: TEST NAME | TEST CODE | FEE |
| LIPOPROTEIN A | 6165 | $33.20 |
| LITHIUM | 2163 | $7.00 |
| LIVER PROFILE I | 8158 | $10.00 |
| MAGNESIUM SERUM | 2166 | $6.50 |
| MEASLES ANTIBODY IgG | 2362 | $12.50 |
| MEASLES ANTIBODY IgM | 2361 | $12.50 |
| METANEPHRINE 24 HRS URINE | 2169 | $80.00 |
| MICROALBUMIN 24 HRS URINE | 1208 | $35.00 |
| MICROALBUMIN RANDOM | 1209 | $4.00 |
| MITOCHONDRIAL TOTAL AUTOANTIBODIES | 5226 | $55.00 |
| MONO TEST | 4213 | $12.00 |
| MUMPS ANTIBODY IgG | 1362 | $12.50 |
| MUMPS ANTIBODY IgM | 1317 | $12.50 |
| MYCOPLASMAI M TITER PNEUMONIAE ANTIBODY | 1985 | $60.00 |
| MYCOPLASMA PNEUMONIAEANTIBODY IgG, IgM | 1363 | $65.00 |
| MYELIN BASIC PROTEIN (MBP) AUTOANTIBODIES | 1404 | $90.00 |
| MYSOLINE (PRIMIDONE) | 3162 | $55.00 |
| NEURONTIN (GABAPENTIN) | 1609 | $50.00 |
| NICOTINE METABOLITE URINE | 3198 | $24.50 |
| OBSTETRIC PANEL | 8136 | $45.23 |
| OCCULT BLOOD PER SPECIMEN | 4320 | $5.00 |
| OVAAND PARASITES | 4321 | $9.00 |
| OXALATES - 24HRS | 2173 | $13.00 |
| OXALATES - URINE RANDOM | 2172 | $13.öo |
| PAP SMEAR | 9161 | $15.00 |
| PAP LIQUID SUREPATH | 9142 | $25.00 |
| PHENOBARBITAL | 3155 | $11.00 |
| PHOSPHORUS | 8174 | $4.00 |
| PLATELET COUNT | 4149 | $6.00 |
| Head: TEST NAME | TEST CODE | FEE |
| POTASIUM | 8210 | $4.00 |
| POTASIUM IN URINE | 8223 | $4.00 |
| PRE -ALBUMIN | 2011 | $7.00 |
| PREGNANCY TEST IN URINE | 4330 | $6.50 |
| PRIMIDONE | 3162 | S15.oo |
| PROCAINAMIDE (PRONESTYL + NAPA) | 3163 | $16.50 |
| PROGESTERONE | 7256 | $26.00 |
| PROLACTIN | 7252 | $19.50 |
| PROTEIN ELECTROPHORESIS | 6129 | $10.00 |
| PROTEIN TOTAL 24HRS | 2305 | $3.50 |
| PROTEIN TOTAL SERUM | 8168 | $5.00 |
| PSA FREE & TOTAL | 2216 | $29.00 |
| PSA SCREEN | 1937 | $h5.oo |
| PT | 4254 | $3.50 |
| PTH INTACT | 1373 | $35.00 |
| PTT | 4253 | $3.50 |
| QUINIDINE | 2183 | $14.50 |
| R A LATEX | 4257 | $7.00 |
| RENAL FUNCTION PANEL | 8108 | $8.00 |
| RENIN | 7258 | $18.50 |
| RETIC COUNT | 4154 | $4.00 |
| RH FACTOR (ONLY) | 4202 | $5.50 |
| RHEUMATOID FACTOR | 4257 | $6.00 |
| RUBELLA ANTIBODY IgG | 5230 | $15.00 |
| RUBELLAANTIBODYI IgM | 1752 | $15.00 |
| RPR | 4272 | $4.50 |
| RUBELLA ANTIBODY IgM | 1752 | $15.00 |
| SED RATE | 4160 | $3.50 |
| SEMEN ANALYSIS | 4331 | $50.00 |
| Head: TEST NAME | TEST CODE | FEE |
| SEROTONIN (5-HIAA) | 2186 | $11.00 |
| SICKLE CELL SCREEN | 4161 | $6.00 |
| SMOOTH MUSCLE ANTIBODY | 1601 | $30.00 |
| SODIUM (U) 12 HRS | 2334 | $4.50 |
| SODIUM (U) 24 HRS | 2335 | $4.50 |
| SODIUM IN URINE | 8221 | $4.50 |
| SODIUM SERUM | 8205 | $4.00 |
| STONE ANALYSIS (KIDNEY) | 1318 | $27.00 |
| STOOL CULTURE | 5113 | $13.50 |
| T-3 FREE | 1603 | $7.00 |
| T3 TOTAL | 7260 | $7.00 |
| T3-UPTAKE | 7105 | $6.00 |
| T4 | 7110 | $6.00 |
| TACROLIMUS (PROGRAF) | 1282 | $16.00 |
| TESTOSTERONE | 7268 | $25.00 |
| TESTOSTERONE FREE & TOTAL | 7269 | $27.50 |
| THEOPHYLLINE | 3174 | $14.50 |
| THIAMINE LEVEL (VITAMIN B1) | 7175 | $6.00 |
| THROAT CULTURE | 5155 | $13.50 |
| THYROGLOBULIN Abs SCREEN | 5202 | $16.00 |
| THYROGLOBULIN QUANT | 1201 | $14.00 |
| THYROID Il PANEL (TSH) | 7121 | $29.00 |
| THYROID PEROXIDE AB (TPO) | 5205 | $15.00 |
| THYROID STIMULATING IMMUNOGLOBULINS (TSI) | 1389 | $12.50 |
| THYROXIDE BINDING GLOBULIN | 1391 | $11.00 |
| TOBRAMYCIN | 3185 | $16.00 |
| TORCH PANEL | 8420 | $60.00 |
| TOXOPLASMA IgG | 5236 | $15.00 |
| TRANSFERRIN | 6175 | $15.00 |
| Head: TEST NAME | TEST CODE | FEE |
| TRAZODONE | 1798 | $70.00 |
| TREPONEMA PALLIDIJM TOTAL ANTIBODIES (FTA) | 5220 | $22.00 |
| TRIGLYCERIDES | 8148 | $6.00 |
| TROPONIN I | 8157 | $15.50 |
| TSH | 7264 | $14.60 |
| URINALYSIS | 4340 | $2.00 |
| URIC ACID | 8144 | $3.00 |
| URINE CULTURE | 5113 | $13.50 |
| URINE CYTOLOGY | $25.00 | |
| VARICELLAANTIBODY IgG | 2772 | $15.00 |
| VITAMIN D25 | 1300 | $33.50 |
| VITAMIN D | 1301 | $33.50 |
| VITAMIN B-6 | 1346 | $14.00 |
| VAGINAL CULTURE | 5156 | $13.50 |
| VARICELLA ZOSTER ANTIBODY IgM | 2772 | $15.00 |
| VITAMIN B-1 (THIAMINE) | 7175 | $6.00 |
| VMA (VANILLYLMANDELIC ACID 24 HRS URINE) | 2196 | $12.50 |
| VALPROIC ACID | 1938 | $14.00 |
| VITAMIN B-12 | 7272 | $15.00 |
| WESTERN BLOT ANALYSIS | 1 833 | $35.00 |
| WET MOUNT | $4.00 | |
| WBC IN STOOL | 4319 | $8.00 |
| ZINC | 2199 | $11.50 |
| Head: PROCEDURE | CPT | FEE |
| Abdomen W | 74182 | $325.00 |
| Abdomen W & W/O | 74183 | $375.00 |
| Abdomen W/O | 74181 | $275.00 |
| Ankle W | 73722 | $325.00 |
| Ankle W & W/O | 73723 | $375.00 |
| Ankle W/O | 73721 | $275.00 |
| Arm W | 73219 | $325.00 |
| Arm W & W/O | 73220 | $325.00 |
| Arm W/O | 73218 | $275.00 |
| Brain W | 70552 | $325.00 |
| Brain W & W/O | 70553 | $375.00 |
| Brain W/O | 70551 | $275.00 |
| Breast Unilat W & W/O | 77058 | $375.00 |
| Breast Bilat W & W/O | 77059 | $375.00 |
| Breast Implant W & W/O | 77059 | $450.00 |
| Cervical Spine W | 72142 | $325.00 |
| Cervical Spine W & W/O | 72156 | $325.00 |
| Cervical Spine W/O | 72141 | $325.00 |
| Chest W | 71551 | $325.00 |
| Chest W & W/O | 71552 | $325.00 |
| Chest W/O | 71550 | $275.00 |
| Elbow W | 73222 | $325.00 |
| Elbow W & W/O | 73223 | $325.00 |
| Elbow W/O | 73221 | $275.00 |
| Facial W | 70542 | $325.00 |
| Facial W & W/O | 70543 | $375.00 |
| Facial W/O | 70540 | $275.00 |
| Foot W | 73719 | $325.00 |
| Foot W & W/O | 73720 | $325.00 |
| Foot W/O | 73718 | $275.00 |
| Hand W | 73219 | $325.00 |
| Hand W $ W/O | 73220 | $325.00 |
| Hand W/O | 73218 | $275.00 |
| Hip W | 73722 | $325.00 |
| Hip W & W/O | 73723 | $325.00 |
| Hip W/O | 73721 | $275.00 |
| ILIAC W | 70552 | $325.00 |
| ILIAC W & W/O | 70553 | $325.00 |
| ILIAC W/O | 70551 | $275.00 |
| Knee W | 73722 | $325.00 |
| Knee W & W/O | 73723 | $325.00 |
| Knee W/O | 73721 | $275.00 |
| Le -Femur-TIB-FIB W | 73719 | $325.00 |
| Leg-Fernur-TIB-FIB W&W/O | 73720 | $325.00 |
| Leg-Femur-TIB-FIB W/O | 73718 | $275.00 |
| Lumbar Spine W | 72149 | $325.00 |
| Lumbar Spine W & W/O | 72158 | $325.00 |
| Lumbar Spine W/O | 72148 | $275.00 |
| Neck W | 70542 | $325.00 |
| Neck W & W/O | 70543 | $325.00 |
| Neck W/O | 70540 | $275.00 |
| Orbit W | 70542 | $325.00 |
| Orbit W & W/O | 70543 | $325.00 |
| Orbit W/O | 70540 | $275.00 |
| pelvis W | 72196 | $325.00 |
| Pelvis W & W/O | 72197 | $325.00 |
| Pelvis W/O | 72195 | $275.00 |
| Pituitary W | 70552 | $325.00 |
| Pituitary W & W/O | 70553 | $325.00 |
| Pituita W/O | 70551 | $275.00 |
| Prostate W | 72196 | $325.00 |
| Prostate W & W/O | 72197 | $325.00 |
| Prostate W/O | 72195 | $275.00 |
| Scrotum W | 72196 | $325.00 |
| Scrotum W & W/O | 72197 | $325.00 |
| Scrotum W/O | 72195 | $275.00 |
| Shoulder W | 73222 | $325.00 |
| Shoulder W & W/O | 73223 | $325.00 |
| Shoulder W/O | 73221 | $275.00 |
| Thoracic Spine W | 72147 | $325.00 |
| Thoracic Spine W & W/O | 72157 | $325.00 |
| Thoracic Spine W/O | 72146 | $275.00 |
| TMJ Joints W/O | 70336 | $275.00 |
| Wrist W | 73222 | $325.00 |
| Wrist W & W/O | 73223 | $325.00 |
| Wrist W/O | 73221 | $275.00 |
| Head: PROCEDURE | CPT | FEE |
| Abdomen W | 74160 | $200.00 |
| Abdomen W & W/O | 74170 | $275.00 |
| Abdomen W/O | 74150 | $150.00 |
| Cervical S ine W | 72126 | $200.00 |
| Cervical Spine W & W/O | 72127 | $275.00 |
| Cervical Spine W/O | 72125 | $150.00 |
| Chest W | 71260 | $200.00 |
| Chest W & W/O | 71270 | $275.00 |
| Chest W/O | 71250 | $150.00 |
| Head/Brain W | 70460 | $200.00 |
| Head/Brain W & W/O | 70470 | $275.00 |
| Head/Brain W/O | 70450 | $150.00 |
| IACS W | 70481 | $200.00 |
| 'ACS W & W/O | 70482 | $275.00 |
| IACS W/O | 70480 | $150.00 |
| Leg/Femur/TlB/FlB W | 73701 | $200.00 |
| Leg/Femur/TlB/FlB W & W/O | 73702 | $275.00 |
| Leg/Femur/TlB/FlB W/O | 73700 | $150.00 |
| Lumbar Spine W | 72132 | $200.00 |
| Lumbar Spine W & W/O | 72133 | $275.00 |
| Lumbar Spine W/O | 72131 | $150.00 |
| Maxilofacial W | 70487 | $200.00 |
| Maxilofacial W & W/O | 70488 | $275.00 |
| Maxilofacial W/O | 70486 | $150.00 |
| pelvis W | 72193 | $200.00 |
| Pelvis w & w/o | 72194 | $275.00 |
| Pelvis W/O | 72192 | $150.00 |
| Sinuses W | 70487 | $200.00 |
| Sinuses W & W/O | 70488 | $275.00 |
| Sinuses W/O | 70486 | $150.00 |
| Soft Tissue Neck W | 70491 | $200.00 |
| Soft Tissue W & W/O | 70492 | $275.00 |
| Soft Tissue Neck W/O | 70490 | $150.00 |
| Thoracic Spine W | 72129 | $200.00 |
| Thoracic Spine W & W/O | 72130 | $275.00 |
| Thoracic Spine W/O | 72128 | $150.00 |
| Head: ABDOMEN & RETROPERITINIUM | ||
| PROCEDURE | CPT | FEE |
| Abdomen Complete | 76700 | $70.00 |
| RIJQ (Liver, Gallbladder & Pancreas) | 76705 | $60.00 |
| Liver | 76705 | $60.00 |
| Gallbladder | 76705 | $60.00 |
| Pancreas | 76705 | $60.00 |
| Spleen | 76705 | $60.00 |
| Renal | 76775 | $60.00 |
| Bladder | 76857 | $60.00 |
| Renal & Bladder | 76770 | $70.00 |
| Head: PELVIS | ||
| Pelvic Complete | 76856 | $70.00 |
| Pelvic Transva inal | 76830 | $70.00 |
| Prostate Transabdominal | 76857 | $70.00 |
| Prostate Transrectal | 76872 | $70.00 |
| Scrotum & Contents | 76870 | $70.00 |
| Head: ECHOGRAPHY | ||
| Echo Complete W/Color & Flow | 93306 | $150.00 |
| Echo Stress Test W/C010r & Flow | 93306 | $350.00 |
| Head: SMALL PARTS | ||
| Abdominal Aorta | 93979 | $90.00 |
| Carotid Doppler | 93880 | $90.00 |
| Arterial Lower Extremity Bilateral | 93925 93923 | $100.00 |
| Arterial Lower Extremity Unilateral | 93926 93923 | $100.00 |
| Arterial Upper Extremity Bilateral | 93930 93923 | $90.00 |
| Arterial Upper Extremity Unilateral | 93931 93923 | $90.00 |
| Head: VENOUS STUDIES | ||
| Venous Duplex Bilateral | 93970 | $90.00 |
| Venous Duplex Unilateral | 93971 | $90.00 |
| Head: DIGITAL X-RAYS | ||
| Ankle (2 views) | 73600 | $25.00 |
| Ankle Complete (3 views) | 73610 | $25.00 |
| Bone Age | 77072 | $25.00 |
| Bone Length | 77073 | $25.00 |
| Calcaneus (2 views) | 73650 | $25.00 |
| Cervical Spine (2 or 3 views) | 72040 | $25.00 |
| Cervical Spine (4 or more views) | 72050 | $25.00 |
| Cervical Spine Complete | 72052 | $25.00 |
| Chest (Single View) | 71010 | $25.00 |
| Chest (2 views) | 71020 | $25.00 |
| Chest Complete (4 views) | 71030 | $25.00 |
| Chest (Special Views) | 71035 | $25.00 |
| Chest (Oblique Projections) | 71022 | $25.00 |
| Chest (Stereo Frontal) | 71015 | $25.00 |
| Chest (Apical Lordoctic Proc) | 71021 | $25.00 |
| Clavicle Complete | 73000 | $25.00 |
| Elbow (2 views) | 73070 | $25.00 |
| Elbow Complete (3 views) | 73080 | $25.00 |
| Eye | 70030 | $25.00 |
| Femur (2 views) | 73550 | $25.00 |
| Fingers (2 views) | 73140 | $25.00 |
| Foot (2 views) | 73620 | $25.00 |
| Foot Complete (3 views) | 73630 | $25.00 |
| Forearm (2 views) | 73090 | $25.00 |
| Hand (2 views) | 73120 | $25.00 |
| Hand (3 views) | 73130 | $25.00 |
| Hip Unilateral (1 view) | 73500 | $25.00 |
| Hi Bilateral (2 views) | 73520 | $25.00 |
| Hi Complete (2 views) | 73510 | $25.00 |
| Knee (1 or 2 views) | 73560 | $25.00 |
| Knee (3 views) | 73562 | $25.00 |
| Knee Complete (4 or more Views) | 73564 | $25.00 |
| Knee Bilateral Standing | 73565 | $25.00 |
| Lumbosacral (4 or more) | 72110 | $25.00 |
| Lumbosacral Comp (Band V) | 72114 | $25.00 |
| Mastoids | 70120 | $25.00 |
| Mastoids Complete (3 views) | 70130 | $25.00 |
| Nasal Bones | 70160 | $25.00 |
| Neck | 70360 | $25.00 |
| Osseus Survey (Single View) | 77077 | $25.00 |
| Osseus Survey Limited | 77074 | $25.00 |
| Osseus Survey C Axial P | 77075 | $25.00 |
| Pelvis (1 or 2 views) | 72170 | $25.00 |
| Pelvis Complete (3 views) | 72190 | $25.00 |
| Ribs Unilateral (2 views | 71100 | $25.00 |
| Ribs Bilateral (3 views) | 71110 | $25.00 |
| Ribs Posteroanter Chest (3V) | 71101 | $25.00 |
| Ribs Posteroanter Chest (4V) | 71111 | $25.00 |
*The basic cleaning does not apply if you have any periodontal disease.
*The dental procedures not listed in your pricing list will apply to a discount of 25%. The dentists and specialists are the only responsible parties for the treatment and its charges. Med Plan is not responsible for payments nor for orthodontics indications performed by the dentists or specialists associated with our plan.
*La limpieza simple no aplica si Usted tiene evidencia de enfermedad periodontal.
*A los procedimientos que no aparecen en su lista de precios se les aplicara un descuento del 25% de 10 usual y razonable. Los dentistas y especialistas son los unicos responsables por el tratamiento y precio del mismo. Med Plan no es responsable por los pagos ni por las indicaciones odontologicas hechas por los dentistas y especialistas asociados a nuestro plan.