Bc book fl. miami.dade - broward

MANUAL DE AFILIADO
MEMBERS MANUAL

2011

8880 Northwest 20th Street, Suite J - Doral, FL 33172 .
(c) 2011 Best Care Medical Plan, Inc. Best Care Medical Plan, Inc. is a discount medical
plan licensed in the State of Florida. Best Care Medical Plan, Inc. is not an insurance
company, Health Insurance Company or a medical insurance company. Best Care Medical
Plans, Inc. does not make direct payments to the providers of medical services. The

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members of Best Care Medical Plan, Inc. are required to pay for all of their health care
services, but will receive a discount by the health care providers contracted by Best Care
Medical Plan, Inc. Licensed by Florida OIR #06-651269644 / Texas TDI 1617486

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 de
la salud. Como miembro usted tendrá la oportunidad de disfrutar de una gran variedad de
servicios 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 membresía
o identificación que deberán ser presentadas para recibir los servicios de descuentos que le ofrece
nuestro plan.

Usted puede acceder a la lista detallada de proveedores participantes haciendo Clic en
“Proveedores” visitando nuestra página de Internet en: www.usabestcare.com

RECOMENDAMOS: Para un listado actualizado de doctores llame al 1-877-527-6161 y
nuestras operadoras gustosamente le concertarán una cita con el médico más cercano a su
domicilio y en el horario más apropiado para usted. No obstante, adjunto le enviamos un
directorio 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, para
proteger la salud de su familia.

Atentamente

Best Care Medical Plan
Departamento de Servicio al Cliente

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GREETINGS
Welcome to Best Care Medical Plan, Inc.

Dear Member:

Welcome to Best Care Medical Plan, your best alternative to healthcare protection. As a
member you will benefit of the incredible variety of services through an extensive healthcare
provider network available on your community.

The Best Care Medical Plans are NOT insurance plans. Attach you will find your
membership ID cards, which must be presented at the time of services in order to receive the
applicable discounts accessible through our plan.

You may access a full detail list of healthcare participant providers by visiting “Provider
Network” on our Website at: www.usabestcare.com

RECOMENDATIONS: For an up-to-date list of provider, please call: 1-877-527-6161 one
of our customer service operators will be pleased to schedule an appointment with a nearest
provider 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 Medical
Plan to protect the health of your family.

Sincerely,

Best Care Medical Plan
Customer Services Department

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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

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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

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Quienes Somos
Best Care Medical Plan es un plan de descuentos médicos licenciado en el estado
de Florida. Best Care Medical Plan está respaldado por una extensa red de
proveedores constituida por un selecto grupo de Doctores con una vasta experiencia
en el campo de la medicina; brindando una gran variedad de servicios, que
satisfacen la mayoría de las necesidades de salud de nuestros afiliados. De esta
manera, nuestros miembros podrán obtener servicios médicos de muy alta calidad a
precios 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

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ABOUT US
Best Care Medical Plan is a medical discount plan licensed in the State Florida. Best
Care Medical Plan is supported by an extended network of providers made up of a
selected group of Physicians with extensive experience in the medical field, offering a
wide variety of services that satisfy most of our affiliate’s health needs. This way, our
members will have high quality medical services of the highest quality at unbeatable
prices.

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

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 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

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 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.

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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

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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

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Ahorre en Doctores Primarios, Especialistas y Hospitales
Como Usar los Beneficios
El programa de Consumer Card de Beech Street PPO Network, es un programa de descuentos médicos
con más de 400,000 proveedores en más de 25 estados participantes*. Como afiliado, usted podrá visitar
cualquier proveedor participante las veces que sea necesario y recibir cuidado inmediato con descuentos
considerables.

Con Beech Street PPO Network, usted solo paga, al proveedor participante, los precios de
descuentos que le brinda el programa en el momento del servicio. Además, usted también cuenta
con:

 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 a
Procedimiento % de Ahorro*
Promedio Pagar
Colonoscopía 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

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Save on Primary Doctors, Specialists, and Hospitals.

How You Benefit
Consumer Card program through Beech Street PPO Network, is a discount medical program with over
400,000
Healthcare providers through the participated states.* As a Member, you can visit any participating
provider 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 rates
available 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 vary

How 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

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Línea gratis de Enfermeras Registradas
24 horas al día

Este servicio le ofrece un número de teléfono gratuito donde usted tendrá acceso a
enfermeras 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/o
medicamentos. También le provee consejería confidencial que le ayuda a tomar
mejores decisiones acerca del cuidado médico que usted recibe. Además, invaluable
información 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.


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.

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Nurse Line
24 hours a Day

How to Use Your Benefits
This service offers a toll free telephone access to experienced registered nurses, 24-hours
a day, 365 days a year. It includes an immediate and reliable source for health and medical
information. It also provides confidential medical counseling to help you make informed
decisions 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.

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Beneficios de Farmacias

Como miembro de Best Care Medical Plan usted obtendrá precios de descuento en
todos los medicamentos recetados. Usted podrá adquirir sus medicamentos a través de
los 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.

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Pharmacy Benefits

As a member of Best Care Medical Plan you can obtain discount prices on all prescribed
medications. 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.

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Ahorre un 52%* en Medicamentos Genéricos
Ahorre un 15%* en Medicamentos de Marca

En 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 de
usted. Si usted usa más de un establecimiento, usted tendrá que presentar su tarjeta en
cada uno de ellos. Usted podrá obtener sus medicamentos en cualquier establecimiento
Wal-Mart, SAM’S Club o Wal-Mart Neighborhood Market Pharmacy.

Preguntas frecuentes con referencia a su plan de prescripciones mediante Best Care
Medical 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


* 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

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Save 52%* on Generic Medications
Save 15%* on Brand Name Medications

How To Use Your Benefits
On your next visit to your Wal-Mart Pharmacy; please present your member ID card. The
Wal-Mart Pharmacy staff will then obtain the appropriate information from you. Please keep
the card with you. Please note that if you use more than one pharmacy location, you will
need to present the card at each location the first time you use the card. This card entitles
you to special negotiated pricing on prescription drugs at any Wal-Mart, SAM’S Club or
Wal-Mart Neighborhood Market Pharmacy.

Frequently asked questions concerning my prescription plan through BEST CARE
MEDICAL:

 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). Generic
Drugs: AWP less 52% plus $1.99 dispensing fee. Brand Name Drugs: AWP less 15%
plus $1.99 dispensing fee.


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

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Usted podrá adquirir sus medicamentos en cualquiera de las más de 50,000 farmacias que componen la red a nivel
nacional, siempre necesita presentar la tarjeta de membresía en la farmacia participante de su elección, al momento
de ordenar o reordenar una prescripción.

Beneficio de Orden por Correo
Atlantic Prescription Services (APS) se place en proveerle los servicios de ordenar sus medicamentos por correo. Este
beneficio está diseñado para que el suministro de medicamentos sea continuo. Usted recibirá hasta 90 días de
suministros con la comodidad de entrega a domicilio. Además, cuando usted hace su primer pedido, tendrá la
comodidad del programa APS Autofill, ofreciéndole la tranquilidad de saber que estamos alerta para ordenarle su
prescripción 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.

1. Seleccione una farmacia participante*
2. Identifíquese como un miembro de “ATLANTIC PRESCRIPTION SERVICE (APS)”.

* 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: 1-877-527-6161

Correo
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 procesados
Fax
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

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.

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!

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 valid
Refills 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


Como afiliado de Best Care Medical Plan ahora tendrá acceso a más de 50,000* farmacias participantes a nivel
nacional. 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* participating
pharmacies nationwide. This network includes pharmacies chains as: Wal-Mart, CVS, Walgreens, K-Mart,
Publix, Winn-Dixie and more.
ALBERTSONS FRED MEYER PHARMACY OSCO DRUG
A AND P PHARMACY FRED'S PHARMACY PAMIDA PHARMACY
ARBOR DRUGS FRUTH PHARMACY PATHMARK PHARMACY
ARROW CENTER FRY'S FOOD & DRUG PHAR-MOR
AURORA PHARMACY FURR'S PHARMACY PRICE CHOPPER
BARTELL DRUGS GENOVESE DRUG STORE PUBLIX PHARMACY
BIG BEAR PHARMACY GIANT EAGLE RAINBOW PHARMACY
BI-LO PHARMACY GRAND UNION RITE AID PHARMACY
BI-MART PHARMACY HARRIS TEETER SAFEWAY PHARMACY
BROOKS PHARMACY HOMELAND PHARMACY SAVE-ON
BROOKSHIRE BROS HORIZON PHARMACY SAVE MART PHARMACY
BROOKSHIRE PHARMACY HY-VEE PHARMACY SCHNUCKS PHARMACY
BRUNO'S PHARMACY KERR DRUG SEELY SNYDER DRUG
CUB PHARMACY KING SOOPERS SHOPKO PHARMACY
CVS PHARMACY KINNEY DRUGS, INC SHOPRITE PHARMACY
DILLON PHARMACY KIGHT DRUGS STAR PHARMACY
DISCONT DRUG MART KROGER PHARMACY STOP & SHOP
DOMINICK'S PHARMACY LEGEND TARGET PHARMACY
DRUG EMPORIUM LEWIS FAMILY DRUG TIMES PHARMACY
D & W FOOD CENTERS LONG'S TOPS PHARMACY
EAGLE PHARMACY MARC'S UKROPS PHARMACY
ECONFOODS MED-X DRUG UNITED PHARMACY
ECKERD DRUG MEDIC DISCOUNT DRUG VON'S PHARMACY
EDWARDS PHARMACY MIC DRUG WAL-MART PHARMACY
EPIC MEDICAP PHARMACY WALDBAUM'S PHARMACY
FAGEN PHARMACY MEDICINE SHOPPE, THE WALGREENS
FAIRVIEW PHARMACY MEIJER PHARMACY WEGMAN PHARMACY
FARMCO DRUG CENTER METRO PHARMACY WEIS PHARMACY
FARMER JACK MORE 4 FAMILY WHITE DRUG
FOOD 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 at
www.usabestcare.com or call the Customer Service Department: 1-877-527-616

23


24

Ahorre hasta un 65%* en el cuidado dental
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.

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.

* 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

Save up to 65%* on dental care
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 42
One 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.

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.

www.usabestcare.com or call the Customer Service Department for an updated list of
provider or to make an appointment > 877-527-6161

26

Calidad y Conveniencia

El programa Access Vision le ofrece a usted y a las personas participantes en su membresía valiosos
ahorros en lentes, sobre lentes “add-ons”, armaduras, lentes de contacto, lentes de sol sin prescripción y
más.

Con Access Vision, usted solo paga, al proveedor participante, los precios de descuento que le brinda el
programa en el momento del servicio. Como miembro, usted es elegible a recibir los siguientes
descuentos 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 a
cadenas nacionales como son: LensCrafters, Sterling Vision y D.O.C Optical. No en todas las localidades
proveen todos los servicios.

* Los ahorros están basados en descuentos actuales del precio habitual de venta al público. Ahorros
actuales pueden variar.

En California, Los exámenes de vista, exámenes para lentes de contactos, precios por ajuste de
armaduras y cualquier otro servicio profesional son excluidos del programa y serán cobrados en base al
precio de venta al público promedio, usual o acostumbrado.


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)

Internet, www.usabestcare.com o llame al Departamento de Servicio al Cliente para un listado

27

Quality and Convenience

The Access Vision program offers you and your eligible family members valuable savings on lenses and
lens 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. As
a 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 Sunglasses

Additionally, 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 as
national chains such as: LensCrafters, Sterling Vision and D.O.C. Optical. Not all locations
provide all services.

*Savings based on actual discounts off participating provider’s normal retail charges. Actual savings may
vary.

In California, eye exams, contact lens exams, fitting fees and all other professional services are excluded
from the program and shall be charged at the provider’s usual and customary rates.


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.


28

Mejor Audición Mediante Cuidado Profesional

Como se Beneficia
Con su Membresía usted es elegible a recibir un 15%* de descuentos en aparatos de audición Beltone en
cualquiera de sus 1,800 localidades independientes de Beltone. Su membresía le proporciona acceso a
tener un examen de audición gratis, limpieza y ajuste de su aparato de audición. Además, podrá disfrutar
de 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. Ahorros
actuales pueden variar.


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)


29

Better Hearing thru Professional Care

With your membership in Protective Health Options you are eligible to receive a 15%* discount on Beltone
hearing aids at any of their 1,800 Beltone independent locations. Your membership allows you access to
free hearing exams and hearing aid cleanings and adjustments.

*All percentage savings based on Beltone’s normal retail prices. Actual savings may vary.


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).


30

Como se Beneficia
Usted podrá recibir cuidado inmediato con descuentos considerables, en más de 13,500 doctores
Quiroprácticos contratados a nivel nacional. Esto le asegura que usted siempre encontrará un doctor
calificado en su área, no solo para tratamiento de un problema agudo o crónico, sino también para
cuidados 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.


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.


31

How to Use Your Benefits
You and your eligible family members can receive immediate care with significant discounts at over 15,000
participating Chiropractic doctor locations. This widespread availability allows access for discounts on
treatment of acute and chronic problems and for regular preventive maintenance care.

You will receive the following savings off the provider's 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.

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.


32

LABORATORIOS
DIAGNOSTICOS
CIRUGIA GENERAL
SERVICIO DENTAL
OPTOMETRIA
URGENCIAS
MATERNIDAD
CHEQUEOS PREVENTIVOS

LABORATORIES
DIAGNOSTICS
GENERAL SURGERY
DENTAL SERVICES
OPTOMETRY
URGENT CARE
MATERNITY
PREVENTIVE CHECK-UPS

33

PROFILES FEE PROFILES FEE
ACUTE HEPATITIS $60.00 C-PEPTIDE $20.00
ANEMIC PANEL $40.00 CREATININE $10.00
ARTHRITIS PANEL $25.00 CREATININE 24 HR $10.00
BASIC METABOLIC $10.00 CREATININE CLEARANCE $15.00
COMP. METABOLIC $12.00 CREATININE SPOT URINE $10.00
ELECTROLYTES $10.00 CRP $15.00
HEPATIC FUNCTION $10.00 CYSTIC FIBROSIS $320.00
LIPID PANEL $12.00 DIGOXIN (LANOXIN) $15.00
LIVER PROFILE $10.00 DRUG SCREEN (7DRUGS) $25.00
OBSTETRIC PANEL $35.00 ESTRADIOL $20.00
RENAL PANEL $12.00 FERRITIN, SERUM $15.00
TORCH PANEL $135.00 FIBRINOGEN $12.00
INDIVIDUAL TEST FEE FOLIC ACID $12.00
AFP TRIPLE SCREEN $60.00 FREE PSA AND TOTAL $30.00
AFP TUMOR MARKER $20.00 FSH $15.00
ALBUMIN $10.00 FSH & LH $25.00
ALKALINE PHOSPH $10.00 GAMMA GT $10.00
ALLERGY PANEL EACH GENTAMYCIN $25.00
$14.00
ALLERGEN GLUCOSE $10.00
ALT (SGPT) $10.00
GLUCOSE 2 HRS. PP $10.00
AMMONIA $20.00
GLUCOSE GRAY TUBE $10.00
AMYLASE SERUM $10.00
GLUCOSE TOL 2 HRS $10.00
ANA $15.00
ANTIBODY SCREENING $15.00
AST (SGOT) $10.00
GLYCOHEMOGLOBIN(HGB A1C) $12.00
B12 $15.00
H. PYLORI ANTIBODY $20.00
B12 & FOLIC ACID $35.00
HCG-BETA, QUAL(PREGNANCY) $10.00
BILIRUBIN TOTAL $10.00
HCG-BETA, QUANTITATIVE $12.00
BILIRUBIN, DIRECT $10.00
HDL-CHOLETEROL $8.00
BIOPSY 1 SPECIMEN $35.00
HEAVY METAL SCREENING $50.00
BLOOD TYPE & RH $10.00
HEMOGLOBIN / HEMATOCRIT $6.00
BUN $10.00
HEMOGLOBIN ELECTROPHO. $25.00
CA – 125 $40.00
HEPATITIS A IgM $20.00
CALCIUM $10.00
HEPATITIS A TOTAL $12.00
CARBAMAZEPINE (TEGRETOL) $15.00
HEPATITIS Bs ANTIBODY $12.00
CARDIO CRP $20.00
HEPATITIS Bs ANTIGEN $12.00
CBC W/O PLAT $10.00
HEPATITIS C ANTIBODY $30.00
CBC WITH PLAT $10.00
HERPES I & II TOTAL IgG $55.00
CBC, PLAT, MANUAL DIFF $10.00
HIV RNA by PCR (VIRAL LOAD) $200.00
CD4 $35.00
HIV W. REFLEX TO W.B. $15.00
CD4 / CD8 $50.00
IgE TOTAL $15.00
CEA $15.00
IMMIGRATION PROFILE $20.00
CHOLESTEROL $10.00
IMMUNOELECTROPHO. SER. $70.00
CK MB B14 $20.00
IMMUNOGLOBULIN IgG,A,M $60.00
CK TOTAL $10.00
INSULIN ANTIBODY $60.00
CMV - IgG $35.00
IRON $10.00
CMV - IgM $35.00
IRON & IBC $12.00
CORTISOL $25.00

35

PROFILES FEE PROFILES FEE
L.E. SCREEN $15.00 THYROID BINDING GLOBULIN $20.00
LDH $12.00 TOBRAMYCIN $36.00
LDL- CALCULATED $8.00 TOXOPLASMA IgG $15.00
LEAD $12.00 TOXOPLASMA IgM $15.00
LH $20.00 TRIGLYCERIDES $10.00
LIPASE $15.00 TSH $15.00
LITHIUM $15.00 URIC ACID $10.00
LITHIUM (ESKALITH) $20.00 URINALYSIS $10.00
MAGNESIUM $10.00 VALPROIC ACID (DEPAKENE) $20.00
MONO TEST $12.00 VANCOMYCIN PEAK $25.00
P.T.H (INTACT) $55.00 VANCOMYCIN TROUGH $25.00
PHENYTOIN (DILANTIN) $20.00 VARICELA ZOSTER IGG $25.00
PHOSPHATASE ACID PROSTATIC $20.00 VIT. B12 $15.00
PHOSPHORUS $10.00 MICROBIOLOGY FEE
PLATELET COUNT $10.00 ACID FAST CULT & SMEAR $25.00
POTASSIUM $10.00 BLOOD CULTURE $25.00
PREGNANCY TEST-URINE $12.00 CHLAMYDIA & GC (DNA) $30.00
PRIMIDONE (MYSOLINE) $40.00 CHLAMYDIA (DNA) $20.00
PROCAINAMIDE (PRONESTYL) $35.00 CLOSTRIDIUM DIFF. TOX $35.00
PROGESTERONE $20.00 CULTURE &
$15.00
PROLACTIN $20.00 SENSITIVITY(SOURCE)
CYTO, GYN (PAP SMEAR) 1 $20.00
PROTEIN ELECTROPHO. $20.00
CYTO, GYN (PAP SMEAR) 2 $20.00
PROTEIN, TOTAL 24 HR $15.00
CYTO, THINPREP PAP $40.00
PROTEIN, TOTAL SERUM $10.00
FUNGUS CULTURE $15.00
PSA O DX O scr $15.00
GC (CULTURE ONLY) $15.00
PT+INR ANTICOAG. O YES O NO $10.00
GC (DNA PROBE) $25.00
PTT ANTICOAG. O YES O NO $10.00
GRAM STAIN $15.00
QUINIDINE $60.00
H. PYLORI (STOOL) $65.00
RETIC COUNT $10.00
OCCULT BLOOD FECES 3 $20.00
RHEUMATOID FACTOR (RA) $15.00
OVA & PARASITES x slide $10.00
RPR (SYPHILLIS) $12.00
SPUTUM CULTURE, SENS. $15.00
RUBELLA IgG $15.00
STOOL CULTURE, SENS $15.00
RUBELLA IgM $20.00
THROAT CULTURE, SENS $15.00
SEDIMENTATION RATE $10.00
URINE C & S $15.00
SICKLE CELL PREP $10.00
VAGINAL C & S $15.00
SODIUM $10.00
WOUND C & S $15.00
STONE ANALYSIS $35.00
T LYMPH AND SUB SETS $65.00
T3 FREE $15.00
T3 TOTAL $15.00
T3 UP $10.00
T4 TOTAL $10.00
T4 $10.00
T4 FREE $15.00
TESTOSTERONE $20.00
THEOPHYLLINE $25.00
THYROGLOBULIN $15.00

36

DIAGNOSTIC RADIOLOGY

HEAD
CODE SERVICES DESCRIPTION FEE
70100 MANDIBLE; LESSS THAN FOUR VIEWS $ 20.00
70130 MASTOIDS; MINIMUM OF THREE VIEWS PER SIDE $ 30.00
70150 FACIAL BONES; MINIMUM OF THREE VIEWS $ 28.00
70160 NASAL BONES; MINIMUM OF THREE VIEWS $ 22.00
70200 ORBITS $ 28.00
70220 PARANASAL SINUSES; MINIMUM OF THREE VIEWS $ 30.00
70240 SELLA TURCICA $ 20.00
70250 SKULL; LESS THAN FOUR VIEWS $ 30.00
70328 TEMPOROMANDIBULAR JOINT, OPEN & CLOSED MOUTH $ 20.00

CHEST
71010 CHEST, SINGLE VIEW, FRONTAL $ 20.00
71020 CHEST, TWO VIEWS, FRONTAL & LATERAL $ 25.00
71030 CHEST, COMPLETE, MINIMUM OF FOUR VIEWS $ 35.00
71100 RIBS, UNILATERAL; TWO VIEWS $ 25.00
71120 STERNUM, MINIMUM OF TWO VIEWS $ 25.00
77055 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

SPINE
72020 SPINE, SINGLE VIEW, SPECIFY LEVEL $ 20.00
72040 CERVICAL SPINE, ANTEROPOSTERIOR & LATERAL $ 30.00
72070 THORACIC SPINE, ANTEROPOSTERIOR & LATERAL $ 30.00
72100 LUMBOSACRAL SPINE, ANTEROPOSTERIOR & LATERAL $ 30.00
72220 SACRUM AND COCCYX, MINIMUM OF TWO VIEWS $ 25.00
77080 BONE DENSITOMETRY $ 70.00

PELVIS
72170 PELVIS, ANTEROPOSTERIOR ONLY $ 20.00
73510 HIP, COMPLETE,MINIMUM OF TOW VIEWS $ 25.00

UPPER EXTREMITIES
73000 CLAVICLE $ 20.00
73010 SCAPULA $ 20.00
73030 SHOULDER, MINIMUM OF TWO VIEWS $ 25.00

38

73060 HUMERUS, MINIMUM OF TWO VIEWS $ 25.00
73070 ELBOW, ANTEROPOSTERIOR & LATERAL VIEWS $ 20.00
73090 FOREARM, ANTEROPOSTERIOR & LATERAL VIEWS $ 25.00
73100 WRIST, ANTEROPOSTERIOR & LATERAL VIEWS $ 20.00
73130 HAND, MINIMUM OF THREE VIEWS $ 20.00
73140 FINGER(S), MINIMUM OF TWO VIEWS $ 20.00

LOWER EXTREMITIES
73550 FEMUR, ANTEROPOSTERIOR & LATERAL VIEWS $ 25.00
73562 KNEE, TWO OR THREE VIEWS $ 25.00
73590 TIBIA & FIBULA, ANTEROPOSTERIOR & LATERAL VIEWS $ 25.00
73610 ANKLE, COMPLETE, MINIMUM OF THREE VIEWS $ 25.00
73630 FOOT, COMPLETE, MINIMUM OF THREE VIEWS $ 25.00
73650 CALCANEUS, MINIMUM TOW VIEWS $ 20.00
73660 TOES, MINIMUM TOW VIEWS $ 20.00

ABDOMEN
74000 ABDOMEN, SINGLE ANTEROPOSTERIOR VIEW (KUB) $ 20.00
74020 ABDOMEN, TWO VIEWS (DECUBITUS & ERECT) $ 28.00
74220 ESOPHAGOGRAM $ 50.00
74241 UPPER GASTROINTESTINAL TRACT WITH KUB $ 70.00
74245 UPPER GASTROINTESTINAL TRACT WITH SMALL BOWEL $ 100.00
74270 COLON, BARIUM ENEMA $ 80.00
74290 CHOLECYSTOGRAPHY, ORAL CONTRAST $ 40.00
74400 PYELOGRAPHY INTRAVENOUS $ 100.00

39

DIAGNOSTIC ULTRASOUND

HEAD & NECK
76536 SOFT TISSUES OF HEAD & NECK $ 45.00
76536 THYROID, PARATHYROID, PAROTID $ 45.00

CHEST
76604 CHEST ECHOGRAPHY (INCLUDES MEDIASTINUM) $ 45.00
76645 BREST(S) ECHOGRAPHY (UNILATERAL OR BILATERAL) $ 45.00

ABDOMEN & RETROPERITONEUM
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
76805-76816 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
76870 SCROTUM & CONTENTS ECHOGRAPHY $ 45.00
76872 PROSTATIC TRANSRECTAL ECHOGRAPHY $ 100.00

EXTREMITIES
76880 EXTREMITY ECHOGRAPHY, NON-VASCULAR (eg, AXILLAE) $ 45.00

ECHOCARDIOGRAPHY
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

CEREBROVASCULAR ARTERIAL STUDIES
93875
93880
CAROTID DOPPLER, COMPLETE BILATERAL STUDY $ 60.00

EXTREMITY ARTERIAL STUDIES
93923 DOPPLER OF UPPER OR LOWER EXTREMITY ARTERIES, COMPLETE
93925 BILATERAL STUDY $ 60.00

EXTREMITY VENOUS STUDIES
93965 DOPPLER OF UPPER OR LOWER EXTREMITY VEINS, COMPLETE
93970 BILATERAL STUDY $ 60.00

CARDIOLOGY PROCEDURES
ELECTROCARDIOGRAM WITH AT LEAST 12 LEADS, WITH
93000
INTERPRETATION AND REPORT $ 20.00

ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS WITH
93230
PHYSICIAN INTERPRETATION AND REPORT (HOLTER MONITOR) $ 80.00
93015 STRESS TEST (PLAIN) $ 200.00

SLEEP TESTNG

95806 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 PROCEDURES

95812 ELECTROENCEPHALOGRAM $ 150.00
95900
95903 NERVE CONDUCTION VELOCITY ( UPPER ) $ 100.00
95904
95900
95903 NERVE CONDUCTION VELOCITY ( LOWER ) $ 100.00
95904

41

NUCLEAR MEDICINE FEE SCHEDULE
SERVICES DESCRIPTION FEE
THALLIUM STRESS TEST $450.00
BONE SCAN / FLOW $200.00
TESTICULAR SCAN $300.00
THYROID UPTAKE SCAN $300.00
LIVER FLOW SCAN $280.00
RENAL FLOW SCAN $280.00
GALLBLADDER SCAN $280.00
BRAIN FLOW SCAN $280.00
LUNG SCAN $280.00
GI BLEEDING SCAN $300.00
GALLIUM SCAN $280.00
RED CELL VENOGRAM $280.00
MECKEL’S DIVERTICULUM SCAN $300.00
PYB $325.00
PIPIDA SCAN $300.00

MAGNETIC RESONANCE IMAGING
&
COMPUTARIZED AXIAL TOMOGRAPHY
SERVICES DESCRIPTION FEE
MAGNETIC RESONANCE IMAGING WITH CONTRAST
$350.00
MATERIAL(S)
MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST
$300.00
MATERIAL(S)
COMPUTERIZED AXIAL TOMOGRAPHY WITH CONTRAST
$250.00
MATERIAL(S)
COMPUTERIZED AXIAL TOMOGRAPHY WITHOUT CONTRAST
$200.00
MATERIAL(S)
COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMINAL; WITH
$300.00
CONTRAST MATERIAL(S)
COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMINAL;
$250.00
WITHOUT CONTRAST MATERIAL(S)

42

INTEGUMENTARY SYSTEM

INCISION AND DRAINAGE
ACNE SURGERY (MARSUPIALIZATION, OPENING OR
10040 REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, $ 50.00
PUSTULES)
INCISION AND DRAINAGE OF ABSCESS; SIMPLE OR
10060 $ 65.00
SINGLE.
INCISION AND DRAINAGE OF ABSCESS; COMPLICATED
10061 $ 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 OR
10140 $ 70.00
FLUID COLLECTION.
PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA OR
10160 $ 50.00
CYST.

BIOPSY
BIOPSY SKIN, SUBCUTANEOUS TISSUE AND/ OR
11100 $ 40.00
MUCOUS MEMBRANE, SINGLE LESION.
11101 EACH SEPARATE / ADDITIONAL LESION. $ 20.00
19000 PUNCTURE ASPIRATION OF CYST OF BREAST. $ 50.00
19001 EACH ADDITIONAL CYST OF BREAST. $ 20.00
60100 BIOPSY, THYROID PERCUTANEOUS CORE NEEDLE $ 150.00

REMOVAL OF SKIN TAGS
REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS
11200 $ 38.00
TAGS, ANY AREA; UP TO AND INCLUDING 5 LESIONS.
11201 EACH ADDITIONAL TEN LESSIONS. $ 15.00

EXCISION OF BENIGN LESIONS
11400 EXCISION, BENIGN LESION, EXCEPT SKIN TAG, TRUNK,
$ 65.00
11401 ARM OR LEGS; LESION DIAMETER 1.0 CM OR LESS.
$ 100.00
11403 ARM OR LEGS; LESION DIAMETER 1.1 TO 3.0 CM.
$ 150.00
11406 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 $ 75.00
11421
CM OR LESS.
11422
NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 $ 165.00
11423
TO 3.0 CM.

44

11424
NECK, HANDS, FEET, GENITALIA; LESION DIAMETER $ 185.00
11426
OVER 3.1 CM.
EXCISION, OTHER BENIGN LESION, FACE, EARS,
11440
EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION $ 85.00
11441
DIAMETER 1.0 CM OR LESS.
11442
11443
DIAMETER 1.1 TO 3.0 CM.
11444
11446
DIAMETER OVER 3.1 CM.

EXCISION OF MALIGNANT LESIONS
11600
EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR
11601 $ 80.00
LEGS; LESION DIAMETER 2.0 CM OR LESS.
11602
11603
EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR
11604 $ 170.00
LEGS; LESION DIAMETER OVER 2.1 CM.
11606
11620
EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS,
11621 $ 110.00
FEET, GENITALIA; LESION DIAMETER 2.0 CM OR LESS.
11622
11623
EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS,
11624 $ 220.00
FEET, GENITALIA; LESION DIAMETER OVER 2.1 CM.
11626
11640
EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS,
11641 $ 135.00
NOSE, LIPS; LESION DIAMETER 2.0 CM OR LESS.
11642

NAILS
11719 TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER. $ 6.00
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); ONE TO
11720 $ 15.00
FIVE.
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); SIX OR
11721 $ 22.00
MORE.
11730 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE. $ 40.00
11740 EVACUATION OF SUBUNGUAL HEMATOMA. $ 20.00
EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR
11750 $ 55.00
COMPLETE.

INTEGUMENTARY SYSTEM
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP,
12001
NECK, AXILLA, EXTERNAL GENITALIA, TRUNK AND OR $ 80.00
12002
EXTREMITIES (7.5 CM OR LESS)

45

12004
12005
EXTREMITIES (7.6 CM TO 20 CM)
12006
12007
EXTREMITIES (20.1 CM OR MORE)
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE,
12011
EARS, EYELIDS, NOSE, LIPS, AND / OR MUCOUS $ 100.00
12013
MEMBRANES
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE,
12014
EARS, EYELIDS, NOSE, LIPS, AND / OR MUCOUS $ 200.00
12015
MEMBRANES

SUTURES

BURNS
INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO
16000 $ 30.00
MORE THAN LOCAL TREATMENT IS REQUIRED.
16020 BURN DRESSING AND/ OR DEBRIDEMENT. $ 35.00

DESTRUCTION OF BENIGN OR PREMALIGNANT LESIONS
DESTRUCTION BY ANY METHOD ALL BENIGN OR
17000 $ 38.00
PREMALIGNANT LESIONS; UP TO 3 LESIONS.
DESTRUCTION BY ANY METHOD ALL BENIGN OR
TH
17003 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

INTRODUCTION
20550 INJECTION, TRIGGER POINT $ 45.00
ARTHROCENTESIS, ASPIRATION AND/OR INJECTION;
20600 $ 50.00
SMALL JOINT, BURSA (eg, FINGERS, TOES)
INTERMEDIATE JOINT BURSA (eg,
20605 $ 50.00
TEMPOROMANDIBULAR, ACROMIOCLAVICULAR,
WRIST, ELBOW OR ANKLE, OLECRANON BURSA)
20610 MAJOR JOINT OR BURSA (eg, SHOULDER, HIP, KNEE $ 50.00
JOINT, SUBACROMIAL BURSA)

46

UPPER EXTREMITY

CASTS
29058 VELPEAU $ 70.00
29065 SHOULDER TO HAND ( LONG ARM ) $ 55.00
29075 ELBOW TO FINGER ( SHORT ARM ) $ 45.00
29085 HAND AND LOWER FORE ARM (GAUNTLET) $ 45.00

SPLINTS
29105 SHOULDER TO HAND ( LONG ARM ) $ 45.00
29125 FOREARM TO HAND $ 30.00
29130 FINGER $ 20.00

STRAPPING
29240 SHOULDER (eg, VELPEAU). $ 35.00
29260 ELBOW OR WRIST. $ 25.00
29280 HAND OR FINGER. $ 25.00

REMOVAL
29705 REMOVAL FULL ARM CAST. $ 40.00

LOWER EXTREMITY

CASTS
29345 APPLICATION OF LONG LEG CAST (THIGH TO TOES). $ 65.00
29355 -WALKER OR AMBULATORY TYPE. $ 75.00
29365 APPLICATION OF CYLINDER CAST (THIGH TO ANKLE). $ 60.00
APPLICATION OF SHORT LEG CAST (BELOW KNEE TO
29405 $ 55.00
TOES).
29425 -WALKER OR AMBULATORY TYPE. $ 65.00
29440 ADDING WALKER TO PREVIOUSLY APPLIED CAST. $ 25.00

SPLINTS
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE
29505 $ 45.00
OR TOES).
29515 APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT). $ 35.00

STRAPPING
29530 STRAPPING; KNEE $ 30.00
29540 STRAPPING; ANKLE $ 30.00
29550 STRAPPING; TOES $ 25.00
29580 UNNA BOOT $ 30.00

47

REMOVAL
29700 REMOVAL BOOT CAST $ 40.00
29705 REMOVAL FULL LEG CAST. $ 40.00

URINARY & GENITAL SYSTEM

MANIPULATION
53670 CATHETERIZATION, URETHRA; SIMPLE $ 35.00

DESTRUCTION
DESTRUCTION OF LESION(S), PENIS (eg, CONDYLOMA,
54050 PAPILLOMA, MOLLUSCUM CONTGIOSUM, HERPETIC $ 40.00
VESICLE), SIMPLE; CHEMICAL
54055 - ELECTRODESICCATION $ 50.00
54056 - CRYOSURGERY $ 50.00
54057 - LASER SURGERY $ 100.00
54060 - SURGICAL EXCISION $ 70.00

EAR, NOSE & THROAT

INCISION
69000 DRAINAGE EXTERNAL EAR, ABSCESS OR HAMATOMA $ 70.00
69020 DRAINAGE EXTERNAL AUDITORY CANAL, ABSCESS $ 70.00
69090 EAR PIERCING $ 20.00

REMOVAL
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY
69200 $ 30.00
CANAL; WITHOUT GENERAL ANESTHESIA
69210 REMOVAL IMPACTED CERUMEN, ONE OR BOTH EARS $ 35.00
30300 REMOVAL FOREIGN BODY, INTRANASAL $ 40.00

ENDOSCOPY
31575 LARINGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC $ 75.00

48

GASTROINTESTINAL ENDOSCOPIES

ENDOSCOPY
CODE SERVICE DESCRIPTION FEE
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
43239 $ 400.00
AND/OR JEJUNUM, WITH OR WITHOUT COLLECTION OF
SPECIMEN(S)
COLONOSCOPY, WITH OR WITHOUT COLLECTION OF
45378 $ 575.00
SPECIMEN(S)
SIGMOIDOSCOPY, WITH OR WITHOUT COLLECTION OF
45330 $ 300.00
SPECIMEN(S)

49

DIAGNOSTIC
SERVICE DESCRIPTION CODE FE E

PERIODIC ORAL EVALUATION (NO CHARGE WITH TREATMENT) D 0120 $ 20.00
LIMITED ORAL EVALUATION-PROBLEM FOCUSED D 0140 $ 20.00
COMPREHENSIVE ORAL EXAM D 0150 $ 35.00
X-RAYS

INTRAORAL X-RAYS, COMPLETE SERIES (INCLUDING BITEWING) D 0210 $ 35.00

INTRAORAL-PERIAPICAL FIRST FILM (NO CHARGE WITH
TREATMENT) D 0220 $ 5.00
INTRAORAL-OCCLUSAL FILM D 0240 $ 10.00
EXTRAORAL- FIRST FILM D 0250 $ 12.00
BITEWING SINGLE FILM D 0270 $ 9.00
BITEWINGS DOUBLE FILM D 0272 $ 13.00
BITEWINGS FOUR FILMS D 0274 $ 20.00

POSTERIOR / ANT OR LATERAL SKULL & FACIAL BONE SURVEY
FILM D 0290 $ 44.00
PANORAMIC FILM D 0330 $ 50.00
CEPHALOMETRIC FILM D 0340 $ 45.00

ORAL / FACIAL IMAGES, INCLUDE INTRA & EXTRAORAL IMAGES D 0350 $ 20.00
DIAGNOSTIC PHOTOGRAPHS D 0471 $ 25.00
TEST & LABORATORY EXAMINATIONS
PULP VITALITY TEST D 0460 $ 12.00
DIAGNOSTIC CASTS D 0470 $ 12.00
PREVENTIVE
PROPHYLAXIS ADULTS D 1110 $ 40.00
PROPHYLAXIS CHILD D 1120 $ 40.00
$ -
TOPICAL APPLICATION OF FLUORIDE (NO CHARGE WITH
TREATMENT) D 1203
$ -
TOPICAL APPLICATION OF FLUORIDE – ADULT (NO CHARGE WITH
TREATMENT) D 1204
TOBACCO COUNSELING (NO CHARGE WITH TREATMENT) D 1320 $ -
$ -

ORAL HYGIENE INSTRUCTIONS (NO CHARGE WITH TREATMENT) D 1330
SEALANT- PER TOOTH D 1351 $ 22.00

SPACE MAINTAINER-FIXED UNILATERAL D 1510 $ 135.00
SPACE MAINTAINER-FIXED BILATERAL D 1515 $ 105.00
SPACE MAINTAINER-REMOVABLE BILATERAL D 1525 $ 185.00
RECEMENTATION OF SPACE MAINTAINER D 1550 $ 32.00
RESTORATIVE
AMALGAM-ONE SURFACE, PRIMARY D 2110 $ 35.00
AMALGAM-TWO SURFACES, PRIMARY D 2120 $ 42.00
AMALGAM-THREE SURFACES, PRIMARY D 2130 $ 50.00

51

AMALGAM-FOUR OR MORE SURFACES, PRIMARY D 2131 $ 66.00
AMALGAM-ONE SURFACE, PERMANENT D 2140 $ 50.00
AMALGAM-TWO SURFACES, PERMANENT D 2150 $ 60.00
AMALGAM-THREE SURFACES, PERMANENT D 2160 $ 65.00
AMALGAM-FOUR OR MORE SURFACES, PERMANENT D 2161 $ 82.00
RESIN-ONE SURFACE, ANTERIOR D 2330 $ 55.00
RESIN-ANTERIOR TWO SURFACES D 2331 $ 70.00
RESIN-ANTERIOR THREE SURFACES D 2332 $ 85.00
RESIN-FOUR OR MORE SURFACES WITH INCISAL ANGLE D 2335 $ 115.00
COMPOSITE RESIN CROWN ANTERIOR PRIMARY D 2336 $ 30.00
RESIN-BASE RESIN CROWN ANTERIOR PERMANENT D 2337 $ 35.00
ONE SURFACE POSTERIOR PRIMARY D 2380 $ 50.00
TWO SURFACE POSTERIOR PRIMARY D 2381 $ 70.00
THREE SURFACE POSTERIOR PRIMARY D 2382 $ 84.00
ONE SURFACE POSTERIOR PERMANENT D 2385 $ 70.00
TWO SURFACE POSTERIOR PERMANENT D 2386 $ 85.00
THREE SURFACE POSTERIOR PERMANENT D 2387 $ 95.00
CROWN-RESIN (LABORATORY) D 2710 $ 200.00
CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL D 2750 $ 435.00

CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL D 2751 $ 390.00
CROWN-PORCELAIN FUSED TO NOBLE METAL D 2752 $ 390.00
CROWN-3/4 CAST HIGH NOBLE METAL D 2780 $ 375.00
CROWN-3/4 CAST PREDOMINANTLY BASE METAL D 2781 $ 360.00
CROWN-3/4 CAST NOBLE METAL D 2782 $ 375.00
FULL CAST CROWN-HIGH NOBLE METAL D 2790 $ 437.00
FULL CAST CROWN-PREDOMINANTLY BASE METAL D 2791 $ 395.00
FULL CAST CROWN-NOBLE METAL D 2792 $ 400.00
RECEMENT INLAY D 2910 $ 25.00
RECEMENT CROWN D 2920 $ 30.00
PREFABRICATED STAINLESS STEEL CROWN (PRIMARY) D 2930 $ 85.00
PREFABRICATED STAINLESS STEEL CROWN(PERMANENT) D 2931 $ 85.00
PREFABRICATED RESIN CROWN D 2932 $ 100.00
SEDATIVE FILLING D 2940 $ 30.00
CORE BUILDUP D 2950 $ 85.00
PIN RETENTION- PER TOOTH, ADDITION TO RESTORATION D 2951 $ 15.00
CAST POST/PIN AND CORE D 2952 $ 115.00
PREFABRICATED POST AND CORE IN ADDITION TO CROWN D 2954 $ 75.00
RESIN LAMINATE- CHAIRSIDE (PER TOOTH) D 2960 $ 200.00
RESIN LAMINATE- LABORATORY (PER TOOTH) D 2961 $ 360.00
PORCELAIN LAMINATE- LABORATORY (PER TOOTH) D 2962 $ 390.00
TEMPORARY CROWN D 2970 $ 50.00
ENDODONTICS
DIRECT PUL CAP D 3110 $ 15.00
INDIRECT PUL CAP D 3120 $ 15.00

THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) D 3220 $ 65.00
GROSE PULPAL DEBRIDEMENT PRIMARY & PERMANENT D 3221 $ 80.00

52

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