2019 premier plan - welcome - med|plan · • med plan does not make payments directly to our...

2019

Florida Office of Insurance Regulation: Med Plan, LLC Date of Insurance: July 27, 2010 N 10-800522755

MEMCOM-MEMHND-001

V06/18/2019

Premier Plan Provider Directory

(305) 262-1610

www.floridamedplan.com

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Dear Member, Welcome to the Med Plan Family! You may begin to use you plan immediately but please note, that you must present your membership card and a picture ID at the time of service in order to verify your eligibility. For general questions, appointment assistance or customer service please call 305.857.4395 from 8:30am - 5:00pm. We encourage our new members to take a moment and familiarize yourself with this booklet so that you can better understand how Med Plan works. The more informed you are

and the more often you take advantage of the great services and exclusive pricing that Med Plan offers you, the better your experience will be. Remember your Health is the

most precious gift you have, thank you for trusting Med Plan to protect your family’s health.

Estimado Asociado, ¡Bienvenido a la Familia Med Plan! Usted puede empezar a usar su plan inmediatamente, pero tenga en cuenta que debe presentar su tarjeta de membresía y una identificación con foto en el momento del servicio para verificar su elegibilidad. Para preguntas generales, asistencia para citas o servicio al cliente, llame al 305.857.4395 de 8:30 am a 5:00 pm. Animamos a nuestros nuevos miembros a tomar un momento y familiarizarse con este folleto para que usted pueda entender mejor cómo funciona Med Plan. Cuanto más

informado esté de los excelentes servicios y precios exclusivos que Med Plan le ofrece, mejor será su experiencia. Recuerde que su salud es el regalo más precioso que tiene,

gracias por confiar en Med Plan para proteger la salud de su familia.

Disclosures

• Med plan is not a health insurance policy

• Med plan provides discounts at contracted health care providers for medical services.

• Med Plan does not make payments directly to our providers for medical services

• Med Plan members are obligated to pay for all health care costs at the time of the service but will receive a discount by providers contracted with our discount plan organization.

• Med Plan LLC is located at 6840 SW 40th Street Suite 201A, Miami, FL 33155 Información Legal

• Med Plan no es Seguro Medico

• Med Plan ofrece descuentos en ciertos proveedores por servicios médicos.

• Med Plan no realiza pagos directamente a los proveedores por servicios médicos.

• Miembros de Med Plan están obligados a pagar todos los servicios de atención médica, en el momento del servicio directamente al proveedor.

• Med Plan está localizado en 6840 SW 40th Street Suite 201A, Miami, FL 33155

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Table of Contents / Tabla de Contenido

- Welcome & Disclosure / Bienvenida & Información Legal 2 - Disclaimer of Liability / Excepcion de Responsabilidad Civil 5 - Independent Providers / Proveedores Independientes 6 - Terms and Conditions / Términos y Condiciones 7 - Med Plan Clinics & Med Care Quality Medical Centers 8 - Primary Care Doctors/ Médicos Primarios 9 - Primary Care Physician & Specialist Provider Service Fee / Precios de los Servicios de Médicos Primarios y Especialistas 14 - Medical Centers / Centros Médicos 16 - Allergist / Alergista 18 - Cardiology / Cardiólogo 18 - Cardiovascular/ Cardiovascular ……………………………………………………………………………………………………………………………….19 - Chiropractor / Quiropráctico 19 - Cosmetic Surgery / Cirugía Cosmética 20 - Dermatology / Dermatología 23 - Endocrinology / Endocrinología 23 - ENT / Otorrino 24 - Gastroenterology / Gastroenterólogo 24 - Gynecology & Obstetrics / Ginecología y Obstetricia 25 - Maternity Package / Paquete de Maternidad 26 - Infectologist/ Infectologo ……………………………………………………………………………………………………………………………………… 27 - Internal Medicine / Medicina Interna 27 - Nephrology / Nefrología 28 - Neurology / Neurología 29 - Pediatric Neurology / Neurología Pediátrica 29 - Neurological Studies / Estudios Neurológicos 30 - Ophthalmology / Oftalmología 31 - Orthopedics / Ortopedia 31 - Orthopedics Therapy/ Terapia ortopedica ……………………………………………………………………………………………………………………31 - Pain Management / Manejo del Dolor 31 - Pediatrics / Pediatra 32 - Podiatry / Podiatra 33 - Psychiatry / Psiquiatría 34 - Psychology / Psicología 35

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- Pulmonology / Neumología 35 - Rheumatology / Reumatología 36 - Surgery / Cirugía 36 - Urology / Urología 36 - Urgent Care Centers / Centros de Urgencia 37 - Dental Services / Servicios Dentales 40 - Optical Services / Óptica 47 - Clinical Laboratories / Laboratorios Clínicos 50 - Pharmacy / Farmacia 57 - Diagnostic Centers / Centros Diagnósticos 59 - Perinatal Diagnostic Services / Diagnósticos Perinatal 66 - Sleep Study / Estudios del Sueño 67 - Alternative Medicine / Medicina Alternativa 67 - Hearing Aids / Suplementos Auditivos 67 - Physical Therapy / Terapia Física 67 - Home Health Services / Servicios de Salud al Hogar 68 - Ancillary Services / Servicios Auxiliares 69 - Orthopedic Supplies / Suplementos Ortopédicos 70 - Diabetic Supplies / Suministros para Diabéticos 72 - Transportation / Transportación 73

Table of Contents / Tabla de Contenido

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Disclaimer of Liability

In consideration of the monthly payment fees to be paid to Med Plan by you or on your behalf, Med Plan agrees to arrange for the delivery of health care services in accordance with and subject to the terms of the Agreement entered between you or on your behalf, and Med Plan. Med Plan, in so arranging for the delivery of health care services and supplies, does not directly provide these services nor supply them. Rather, Independent Contractors provide these services and supplies. The health care providers listed in this directory are not employees or agents of Med Plan. Med Plan shall not be liable for any negligent act or omission committed by any of the providers listed in this directory, or any of their employees or agents who may, from time to time provide medical services to you. Med Plan expressly refuses any agency relationship, actual or implied, with any health care provider. Med Plan does not exercise any control or direction over the medical judgement or clinical decisions of any health care provider listed in this directory and does not interfere with the physician patient relationship between you and any health care provider. It is important for you to know when you enroll in Med Plan that the continued participation of any one doctor, hospital or other provider cannot be guaranteed. This directory is current as of date of publication. Some plan providers may have been added or removed from this list after this directory was printed. To get the most up-to-date information about Med Plan providers in your area, you can visit www.floridamedplan.com/provider.cfm or call our Customer Service Department at (305) 857- 4395, Monday through Friday, 8:30am to 5:00pm. The fact that a provider is listed does not guarantee that they are still in the network or accepting new patients. The “Plan Providers” listed in this directory have agreed to provide you with your health care coverage at fixed discounted from their usual and customary pricing rate. Members are limited to only those providers that are affiliated to the Med Plan Network of Providers. Participating physicians and other providers listed in this directory or on our website www.floridamedplan.com are not agents, employees, or partners of Med Plan or any of its subsidiaries. Med Plan is not a medical services provider, a medical insurance plan nor an HMO. Med Plan does not control nor endorse the judgement or clinical treatment recommendations made by the physicians or other providers listed in our directory, or in our website www.floridamedplan.com nor those that you chose to select. All Med Plan providers are independent contractors. You may go to any of our plan providers listed in this directory; however, some services may require a prescription or medical treatment plan provided by a licensed medical physician. If you have been going to one plan provider, you are not required to continue going to that same provider.

Excepción de Responsabilidad

Med Plan, en consideración al pago de su membrecía, está de acuerdo en ofrecerle el acceso a la red de proveedores establecida que prestan sus servicios a nuestros miembros. Med Plan coordinará su primera cita con el proveedor que usted elija dentro del directorio si usted lo desea. Med Plan no asigna a ningún proveedor. Es responsabilidad del miembro elegir el médico que le prestará los servicios. Med Plan no ofrece los servicios médicos directamente, sino a través de proveedores independientes que proveen estos servicios y sus suplementos. Los proveedores que aparecen en este directorio no son empleados o agentes de Med Plan. Los empleados o agentes de Med Plan no deben ser responsables legalmente por alguna negligencia o acto de omisión cometida en cualquier momento por algún proveedor que aparezca en este directorio. Med Plan específicamente no se responsabiliza en ningún momento y no tiene ninguna relación de agencia con ningún proveedor médico. Med Plan no ejerce ningún control o dirección respecto a un criterio médico o decisión clínica de algún proveedor del directorio ni interfiere en la relación entre el paciente y su médico. Es importante que al convertirse en miembro de Med Plan, la persona sepa que no se le garantiza la continua participación de un doctor, hospital, u otro proveedor. Este directorio está vigente desde el día en que fue publicado. Es muy posible que a partir de ese día se hayan agregado o eliminado de la lista algunos proveedores. Para obtener una información actualizada de los proveedores en su área, visítenos en www.floridamedplan.com/provider.cfm o llame a nuestro Departamento de Servicio al Cliente, al (305) 857-4395 de lunes a viernes, de 8:30 am a 5:00 pm. El hecho de que un proveedor se encuentre en la lista no garantiza que todavía se encuentre en la red o que participe consultando nuevos pacientes. Los proveedores listados en este directorio han acordado en proveerles a los miembros de Med Plan sus servicios de cuidado a su salud con una tarifa fija que representa un Ahorro sobre la tarifa regular. Usted puede ir a cualquiera de nuestros proveedores en este directorio y no necesita ser referido por el médico primario que le atiende para visitar a un especialista dentro de la red, pero los servicios, de exámenes de laboratorio, radiología o diagnóstico sí requieren de una orden por parte del doctor para completar estos procedimientos. Si usted ha ido a uno de nuestros proveedores y no se siente satisfecho con sus servicios, usted no está en la obligación de seguir visitándolo. Los miembros están limitados a los proveedores que están afiliados a la red de Med Plan. Los proveedores participantes en este directorio o en www.floridamedplan.com no son agentes, empleados o socios de Med Plan, ni ninguno de sus subsidios. Med Plan no es un proveedor de servicios médicos, ni tampoco un plan de seguros médicos ni un HMO. Med Plan no apoya los diagnósticos ni los tratamientos médicos dados por los proveedores participantes en la red de Med Plan listados en este directorio, ni en www.floridamedplan.com, ni los proveedores escogidos por nuestros miembros.

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Independent Providers

The providers in this directory have been classified by type of provider and by county. Should you need assistance locating or making an appointment, please contact our Customer Care Department at (305) 857-4395 from 8:30am to 5:00pm. Providers are contracted Med Plan to render services at a FIXED discounted rate. All rates are clearly listed in this book If you use a provider outside of the Med Plan network, you will not receive the negotiated rate and you will have to pay the full rate that the provider requires. You have the right to get timely access to plan providers and to all discounts covered by the plan. Timely access means that you can get appointments and services within a reasonable period. You have the right to get full information from your providers when you go for medical care. You have the right to participate fully in decisions about your healthcare. You have the right to refuse care. Med Plan does not limit its members from visiting any provider contracted by Med Plan. You can visit any provider or service without any limitation or need for referral. Other services such as Dental and Optical can be accessed directly by the member at any time without providing notification to your PCP. The provider directory is constantly changing and is therefore subject to change without notice. The Provider Book is updated periodically and the link is sent via text message or email.

Proveedores Independientes

Los proveedores de este directorio han sido clasificados por tipo de proveedor y por condado. Si necesita ayuda para localizar o concertar una cita, comuníquese con nuestro Departamento de Atención al Cliente al (305) 857-4395 de 8:30am a 5:00pm. Los proveedores están contratados por Med Plan para prestar servicios a una tarifa FIJA con descuento. Todas las tarifas están claramente enumeradas en este libro y los miembros de Med Plan son responsables de pagar a los proveedores en el momento en que los servicios se prestan. Los descuentos y las tarifas de servicio están sujetas a cambios sin previo aviso. Si utiliza un proveedor fuera de la red de Med Plan, no recibirá la tarifa negociada y tendrá que pagar la tarifa completa que el proveedor requiere. Usted tiene el derecho de obtener acceso oportuno a los proveedores del plan ya todos los descuentos cubiertos por el plan. El acceso oportuno significa que usted puede obtener citas y servicios dentro de un período de tiempo razonable. Usted tiene el derecho de obtener información completa de sus proveedores cuando usted va para atención médica. Usted tiene derecho a participar plenamente en las decisiones sobre su atención médica. Usted tiene el derecho de rechazar el cuidado. Med Plan no limita a sus miembros a visitar a ningún proveedor contratado por Med Plan. Puede visitar cualquier proveedor o servicio sin ninguna limitación o necesidad de referencia. Otros servicios como Dental y Óptica pueden ser accedidos directamente por el miembro en cualquier momento sin notificar a su PCP. El directorio de proveedores está cambiando constantemente y por lo tanto está sujeto a cambios sin previo aviso. El Libro de proveedores se actualiza periódicamente y el enlace se envía por mensaje de texto o correo electrónico.

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Terms & Conditions

1 - Primary member is defined as the person who is responsible for the monthly payments for membership fees and is of legal age. The primary member, spouse, and all legal dependents listed on the enrollment application can access the services and exclusive pricing at Med Plan Contracted service providers. 2 - Participating provider may be added or removed from the respective network in which they are associated with at any time. These changes are made in best interest of our members. Updated Provider information will be made available online at www.floridamedplan.com/provider.cfm 3 - Companies contracted to provide benefits and services in this program are not a licensed insurer, health maintenance organization (HMO), or any other underwriters of healthcare services. No portion of any provider fees will be reimbursed or otherwise paid. 4 - The Exclusive Med Plan pricing contained herein may not be used in conjunction with any other medical plan or discount program. All listed or quoted prices are current prices from participating providers and subject to change without notice. From time to time, certain providers may offer products and /or services to the public at prices lower than the prices available through this program. In such event, members will be charged the lowest price. 5 - Providers are subject to change without notice and programs may vary in some states. This is a discount membership program only, not insurance, and may be discounted or modified at any time. 6 - Savings are based upon the provider’s normal fees. Actual savings will vary depending upon location and specific services or products purchased. 7 - This discount medical plan does not warrant professional services, nor is it responsible for the quality of care provided by participating providers. 8-(30) Day Money Back Guarantee: If you cancel for any reason within 30 days, you will receive a full refund. Nonrefundable one-time fees will be disclosed at time of application. 9 - All applicable limitations, exclusions and exceptions of the discount medical plan benefits are listed with each benefit description.

Términos y Condiciones 1 - El titular es definido como miembro principal, siendo el responsable de los pagos mensuales y debe ser mayor de edad. Dicho titular, el cónyuge y todos los dependientes legales adicionales contaran automáticamente con los mismos beneficios que se ofrecen en el plan. 2 - En cualquier momento, un proveedor participante puede ser eliminado de la red de Med Plan. Estos cambios se realizan para beneficio de nuestros miembros. Usted encontrará esta información actualizada en el sitio web www.floridamedplan.com/provider.cfm 3 - Las compañías proveedoras de servicios asociadas a nuestro plan no son aseguradoras, organizaciones de la salud (HMO) o evaluadores de servicios de salud. Cualquier honorario que usted les pague a estas compañías no le será reembolsado. 4 - Los descuentos que figuran en este documento no pueden ser utilizados en combinación con cualquier otro plan de descuento médico o programa de descuentos. Todos los precios cotizados son los precios actuales de los proveedores participantes y están sujetos a cambios sin previo aviso. De vez en vez, algún proveedor puede ofrecer productos y / o servicios al público en general a precios inferiores a los precios disponibles en este programa. En tal caso, se cobrará el precio más bajo. 5 - Los proveedores están sujetos a cambios sin previo aviso, los programas pueden variar en algunos términos. Este es un programa de membrecía de descuentos, no un seguro médico, y puede ser cancelado o modificado en cualquier momento. 6 - Los ahorros se basan en las tasas normales del proveedor. Los ahorros reales variarán dependiendo de la localización de los servicios específicos o productos comprados. 7 - Este plan médico de descuentos no ofrece garantía por la calidad de los servicios profesionales brindados por los proveedores participantes. 8 - Garantía de Reembolso por 30 Días: Si cancela por cualquier razón en un plazo de 30 días, usted recibirá un reembolso completo de su mensualidad. Tasa no reembolsable se revelará en el momento de aplicación. 9 - Las limitaciones, exclusiones o excepciones que apliquen dentro este plan médico de descuentos se enumeran en la descripción de cada servicio.

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For Appointments or more information CALL us we are here to help! ¡Llámenos para citas o más información, estamos para servirle!

MED PLAN CLINICS & MED CARE QUALITY MEDICAL CENTERS

Primary Care Physician / Médico Primario 1st Visit is ONLY $25.00 & Follow-up are ONLY $20.00

1ra visita SOLO $25.00 y seguimiento SOLO $20.00

** Services / Servicios

✓ Laboratory / Laboratorio ✓ Ultrasound /Ultrasonido ✓ X-Rays / Rayos X ✓ Electrocardiogram /Electrocardiograma ✓ Pap Smear / Papanicolau ✓ Pharmacy Dispensary / Dispensario de Farmacia *

MIAMI GARDENS 4767 NW 183 Street Miami Gardens, FL 33055

WEST HIALEAH * 900 West 49 Street # 308 Hialeah, FL 33012

EAST HIALEAH 4218 East 4 Ave Hialeah, FL 33013

BLUE LAGOON * 7200 NW 7 Street # 202 Miami, FL 33126

LITTLE HAVANA * 1149 SW 27 Ave Miami, FL 33135

CORAL WAY * 11825 SW 26 Street Miami, FL 33175

EUREKA * 10980 SW 184 Street Miami, FL 33157

** Services are only for members

with their PCP in these centers.

** Los Servicios son solo para

miembros con su médico primario en estos centros.

305-266-2929

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Baudilio Cusco Prieto MD Glez & Glez Medical Center 3804 NW 167 Street Opalocka, FL 33054 305-624-2700

Israel Grinberg MD Miami Hialeah Medical 1025 E 25 Street Hialeah, FL 33013 305-696-0842

Monica Grinberg MD Miami Hialeah Medical 1025 E 25 Street Hialeah, FL 33013 305-696-0842

Conchita Jackson MD Santiago Cardenas MD John Padron MD Vida Health Centers 881 E 2 Ave Hialeah, FL 33010 305-882-1100

Juan Salinas MD 4212 W 16 Ave Hialeah, FL 33012 305-821-5525

Sebastián Padrón MD Efrain Gubieda MD Sergio Alzugaray MD Prime Care Medical Center 4305 E 8 Ave # E Hialeah, FL 33013 305-769-5601

Rafael S Grillo MD Clinic Center 3800 W 12 Ave Hialeah, FL 33012 305-557-7777

Ricardo A Gomez ARNP Miami Community Health 891/893 E 10 Ave Hialeah, FL 33010 305-381-5150

Margarita del Val MD Perry Robinson MD New Life Health Care 14750 NW 77 CT # 106 Miami Lakes, FL 33016 305-698-4000

Martin Valdes MD Healing Touch C and C Inc 15100 NW 67 Ave # 203 Miami Lakes, FL 33014 305-631-2405

Martin Valdes MD Healing Touch C and C Inc 4385 W 16 Ave Hialeah, FL 33012 305-824-0637

Manuel de J Gonzalez MD 11300 NW 87 CT # 141 Hialeah Gardens, FL 33018 305-392-0257

Lucky Flores MD 1140 W 50 Street # 301 Hialeah, FL 33012 305-827-0208

Yunior Perez ARNP Rosbel Mirabal ARNP Olidaysi Alvarez ARNP Felicidad Medical Center 4410 W 16 Ave # 55 Hialeah, FL 33012 305-824-8559

Miguel A Chamah MD 1800 W 68 Street # 127 Hialeah, FL 33014 305-820-0903

Felix A Rodriguez MD American Family Health 1840 W 49 Street # 425 Hialeah, FL 33012 305-231-8996

Odalys Frontela MD FACP 801 W 48 Street # A Hialeah, FL 33012 305-698-7172

Rolando Diaz MD 5590 W 20 Ave # 100 Hialeah, FL 33016 305-828-3997

Carlos Delgado MD 1957 W 60 Street Hialeah, FL 33012 305-825-8170

Primary Care Physicians / Medicos Primarios Miami-Dade (North/Central) 1st Visit $40 / Follow up $ 20

Johanne Zephir MD 7th Ave Medical Plaza 10071 NW 7 Ave Miami, FL 33150 305-403-7777

Jorge Hernandez MD Ernesto Matamoros MD La Quinta Medical Center 1923 W 60 Street Hialeah, FL 33012 305-381-5801

Jorge Hernandez MD Ernesto Matamoros MD La Quinta Medical Center 700 E 1 Ave Hialeah, FL 33010 305-883-1060

Yirka Marin MD 11300 NW 87 CT # 141 Hialeah Gardens, FL 33018 305-392-0257

Vicente Rodriguez MD 1 NE 167 Street North Miami Beach, FL 33162 305-432-9565

Javier Puentes MD Venaverte Medical Center 5341 W 20 Ave Hialeah, FL 33012 786-542-1882 1st Visit $25 / follow up $20

Yolaine Torres MD 900 W 49 Street # 450 Hialeah, FL 33012 305-560-4995

John Padron MD OPA Medical Center 1865 NE 163 Street North Miami, FL 33162 305-948-9958

Carlos Perez MD 400 Arthur Godfrey Road # 200 Miami Beach, FL 33140 305-254-8900

Leonard Kyle Berkowitz MD Atigur Rahman MD 20803 Biscayne Blvd # 202 Aventura, FL 33180 305-254-8900

Cesar Perez MD Damaris Valdes ARNP 3750 W 16 Ave # 130U Hialeah, FL 33012 786-431-1036

Jose Garcia MD 7357 W Flagler ST Miami, FL 33126 305-254-8900

Elizabeth Valdes ARNP 7600 W 20 Ave # 102 Hialeah, FL 33016 786-636-6952

Milko R Moriya ARNP Mercedes Garcia ARNP 3750 W 16 Ave # 126U Hialeah, FL 33012 305-557-3444

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Cesar Perez MD Rosendo Rodriguez MD 8370 W Flagler Street Ste 120 Miami, FL 33144 305-222-8365

Leonardo Allende MD Mayelin Gonzalez ARNP 8181 NW 36 Street # 23, 24 Doral, FL 33166 786-801-1168

Gamaliel Mattos MD 4001 NW 97 Ave # 101 Doral, FL 33178 305-418-2233

Fausto Castillo MD Ramon Hernandez MD Las Mias Medical Center 6445 SW 8 Street Miami, FL 33144 305-448-8557

Sara Llerena MD 1451 SW 1 Street # 1 Miami, FL 33135 305-541-5090

Luis E de Armas MD 11373 W Flagler Street # 212 Miami, FL 33174 305-220-7730

Eduardo Almaguer MD 330 SW 27 Ave # 404 Miami, FL 33135 305-644-9798

Ariel Duran Mondragon MD 10760 W Flagler Street # 11 Miami, FL 33174 305-554-5144

Mauricio Vargas MD Private Medical Center 10 NW 42 Ave # 300, Miami, FL 33126 305-774-0742 1st Visit $30 / follow up $20

Conchita Jackson MD Jose Pena MD Private Medical Center 10 NW 42 Ave # 300, Miami, FL 33126 305-774-0742 1st Visit $20 / follow up $20

Omar Benitez MD Lizaida Enamorado ARNP Competent Group Services 8370 W Flagler Street # 234 Miami, FL 33144 305-226-1987

Enrique Vazquez MD Kendall South Medical Center 2433 SW 147 Ave Miami, FL 33185 305-388-1118

Mario R Villoch MD AV Medical Center 2075 SW 27 Ave # 101 Miami, FL 33145 305-856-6081

Orlando Rossel MD Maria E Mesa ARNP First Step Medical Center 600 NW 35 Ave # 101 Miami, FL 33125 305-642-1866

Hector Rodriguez MD Alejandro Oporto MD Acevedo Medical Group 2400 NW 54 Street Miami, FL 33142 305-633-9090

Primary Care Physicians / Medicos Primarios Miami-Dade (North/Central/South) 1st Visit $40 / Follow up $ 20

Lázaro Miguel García MD PA 3626 NW 7 Street Miami, FL 33125 305-643-4343

Arles Perdomo MD 7959 NW 2 Street Miami, FL 33126 305-267-6060

Rosa Suarez MD Carlos Roig MD Francisco Suarez MD St John Medical Center 161 NW 29 Street Miami, FL 33127 305-576-0231

Adolfo R Martinez MD 8480 SW 8 Street Miami, FL 33144 305-264-1131

Yolaine Torres MD 2450 SW 137 Ave #230-232 Miami, FL 33175 305-560-4995

Julian N Guerrero MD Emmanuel Medical Center 10404 W Flagler Street Suite 15 Miami, FL 33174 786-558-8509

Marta R Fernandez MD Ydania Santaclara ARNP 10740 W Flagler Street # 4 Miami, FL 33174 786-502-8902

Julio Reyes Gavilan MD Nahir Fraga ARNP Paraiso Medical Center 85 Grand Canal Dr Suite 104 Miami, FL 33144 305-549-8890/95

Sebastian Padron MD 4131 SW 6 Street Miami, FL 33125 305-443-5031

Olga Lopez MD 351 NW 42 Ave Suite 403 Miami, FL 33126 305-643-6447

Monserrat Bula MD Lucinda Cuervo MD 2921 SW 8 ST Miami, FL 33135 305-385-5582

Hermes Milanes MD Celina del C Diaz ARNP 711 NW 23 Ave Suite 301 Miami, FL 33121 305-643-4797

Miriam Lacayo MD 3271 NW 7 ST Suite 206 Miami, FL 33125 305-649-7511

Jorge Dominguez ARNP 2150 Coral Way 2nd Floor Miami, FL 33145 305-304-6120 Milko R Moriya ARNP Mercedes Garcia ARNP 3701 SW 107 Ave Miami, FL 33165 305-559-3167

Luis Campillo Rafael Mota Qtrials Inc 6587 W Flagler ST Miami, FL 33144 786-207-0075

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Julio C Reyes-Gavilan MD Paradigma Medical Center 2402 SW 137 Ave Miami, FL 33175 305-549-8896

Myriam Lacayo MD The Children Medical Center Group 8300 SW 8 Street # 302 Miami, FL 33144 305-225-4434

Alicia Chilito MD 12485 SW 137 Ave Miami, FL 33186 305-269-1988

Miriam Garcia-Portela MD 8900 Coral Way # 202 Miami, FL 33165 305-392-0765

Jose Pena MD Selecta Physical Therapy 3934 SW 8 Street # 308 Coral Gables, FL 33134 786-953-6735

Ariel Duran Mondragon MD Selecta Physical Therapy 3934 SW 8 Street # 308 Coral Gables, FL 33134 786-953-6735

Julio C Rosales MD Kendall Medical Plaza 11880 SW 40 Street # 120 Miami, FL 33175 305-225-7330

Mayda Pereira Vega Medical Center 3720 SW 107 Ave Miami, FL 33165 305-554-4270

Juan Blemil Fernandez MD PA 13303 SW 42 Street Miami, FL 33175 305-227-6497

Herbert R Slavin MD Leda Medical Center 5450 SW 8 ST Suite 202 Miami, FL 33134 305-262-4801 / 305-262-4803

Carlos J Bello MD 7171 Coral Way # 307 Miami, FL 33155 786-502-8449

Valdemir Santos MD ACN Physician Group 7490 SW 23 Street # 201 Miami, FL 33155 786-953-8221

Rodolfo Binker MD 6700 SW 21 Street Miami, FL 33155 305-266-0006

Jorge Paoli-Bruno MD La Salud Family Medicine 8415 SW 24 Street # 203 Miami, FL 33155 305-559-2121

Jorge Santander MD 4080 SW 84 Ave # D Miami, FL 33155 305-223-1140 Nery Avila

Omar Benitez Jesus Rodriguez MD Royal Medical Center 13373 SW Bird Road Miami, FL 33175 305-640-5538

Marta Rosa Fernandez MD Milaydys Dorta ARNP U Care Center 12535 South Dixie Hwy Pinecrest, FL 33156 786-678-0601

Primary Care Physicians / Medicos Primarios Miami-Dade (South) 1st Visit $40 / Follow up $ 20

Lester de Leon MD 10260 SW 56 Street Suite 106 Miami, FL 33165 786-360-4425

Josefina Hernandez MD 8480 SW 8 Street Miami, FL 33144 305-264-1131

Leonardo Marquez MD J.O Medical Center 2260 SW 8 Street # 200 Miami, FL 33135 305-642-7704

Leonardo Allende MD Lisette Cruz ARNP 7801 Coral Way Suite 114 Miami, FL 33155 786-801-1168

Rosabel M Bencomo MD 6840 SW 40 ST # 209 Miami, FL 33155 786-222-8807/305-397-8960

Blanca Gonzalez MD United Medical of S. Florida 14750 SW 26 Street # 213 Miami, FL 33185 786-476-7314

Erick Juarez MD Yorlien Leyva ARNP 9722 SW 184 Street Miami, FL 33157 786-429-3312

Julio C Rosales MD Hammocks Medical Center 15122 SW 72 Street Miami, FL 33193 305-383-3848

Mario E Jimenez Kendall South Medical Ctr 14740 SW 26 Street Ste 107 Miami, FL 33185 305-388-1118

Arturo Perez MD Luis Robaina MD Odalys Gonzalez Marey MD New life Medical Center 861 SW 8 ST Miami, FL 33130 305-857-9800

Monserrat Bula MD Lucienda Cuervo MD 10201 Hammocks Blvd # 123 Miami, FL 33196 305-385-5582 Rolando Diaz MD 11865 Coral Way Ste B7-B15 Miami, FL 33175 305-442-1740

Antonio J Reyes 1350 SW 57 Ave Suite 314 Miami, FL 33144 305-267-2182

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Emmanuel Eloi MD Sunshine Medical & Chiropractic Care 2764 W Oakland Park Blvd # B Oakland Park, FL 33311 954-766-4233

Herbert Pardell DO Emerald Health Medical 3990 Sheridan Street # 101 Hollywood, FL 33021 954-987-4455

Aimee Diaz MD Irai Gonzalez MD Ricardo Zamora MD Colony Spring Medical Center 7737 N University Dr # 107 Tamarac, FL 33321 954-720-0056

Rafael N Hernandez MD Clemente Wilson MD Johnson Medical Center 7900 NW 33 Street # 101 Hollywood, FL 33024 954-962-5300 1st visit $40 / follow up $20

Yaneth Trujillo MD Nubia Fonseca MD Xochil Echena ARNP Trujillo Medical Center 2300 N Commerce Blvd # 300 Weston, FL 33326 954-436-8036 1st visit $60 / follow up $40

Primary Care Physicians / Medicos Primarios Broward 1st Visit $40 / Follow up $ 40

Elsa Pichardo Matos MD Sunset Strip Medical Center 4269 NW 88 Ave Sunrise, FL 33351 954-578-0200

Hilda M Brito MD 14285 SW 42 Street # 208/209 Miami, FL 33175 305-220-6917

Maria C Cubillas MD 27543 South Dixie Hwy Homestead, FL 33032 305-246-0047

Maria Delgado MD Marta Delgado MD Homestead Medical Clinic 43 NE 15 Street Homestead, FL 33030 786-243-1909

Josefa L Binker MD 70 NW 8 Street Homestead, FL 33030 305-242-5225

Orlando Arrazola MD 13550 SW 88 ST # 280 Miami, FL 33186 305-245-9222

Mileidis Fernandez MD Omnia Perez MD All Family Care 38 NW 8 Street Homestead FL 33030 305-246-0460

Primary Care Physicians / Medicos Primarios Miami-Dade (South) 1st Visit $40 / Follow up $ 20

Yaneth Trujillo MD Nubia Fonseca MD Xochil Echena ARNP Trujillo Medical Center 14601 SW 29 Street Ste 209 Miramar, FL 33027 954-436-8036 1st visit $60 / follow up $40

Ricardo Betancourt ARNP Vida Medical Group 26847 S Dixie Hwy Homestead, FL 33032 305-258-9352

Lidia R Bermudez MD Bermudez Medical Group 2601 Davie Blvd Fort Lauderdale, FL 33312 754-216-2458

Francelot Moise MD 5015 Hollywood Blvd Hollywood, FL 33021 954-237-6409

Armen Derian MD 239 North Krome Suite A Homestead, FL 33030 786-349-4753

Sultan S Ahmed MD 6151 Miramar Parkway Ste 104 Miramar, FL 33023 954-965-6001

Felix A Ramirez Labrada MD Deborah Ibarra ARNP 5928 Sheridan Street Hollywood, FL 33021 954-374-6131

Yaneth Trujillo MD Nubia Fonseca MD Xochil Echena ARNP Trujillo Medical Center 8130 Royal Palm Blvd # 201 Coral Springs, FL 33065 954-436-8036 1st visit $60 / follow up $40

Ernesto Fernandez MD 14150 SW 119 Ave # 102 Miami, FL 33186 786-709-9362

Jayner Moya MD Karen Prida MD Pines Care Medical Center 501 NW 103 Ave Pembroke Pines, FL 33026 954-251-1497

Thomas Warthon MD 311 NE 8 ST # 110 Homestead, FL 33030 305-712-2250

Marta Fernandez Gutleber Medical Center 139 NE 15 ST Homestead, FL 33030 305-247-1213 Milko R Moriya ARNP

Mercedes Garcia ARNP 950 N Krome Ave Ste 405 Homestead, FL 33030 786-504-2063

13

Joseph Pierre-Paul Cadet MD Polyclinic de Palm Beach 5333 W Atlantic Ave # 405 Delray Beach, FL 33346 561-276-3000

Ricardo Zamora MD Colony Spring Medical Center of Palm Beach

130 JFK Dr # 131 Atlantis, FL 33462 561-439-7070

Agustin Arold Joseph 4301 West Sunrise Blvd Plantation FL 33313 954-514-7712

Primary Care Physicians / Medicos Primarios Collier / Lee 1st Visit $40 / Follow up $ 40

Paul Murray MD Boca Family Practice 7100 W Camino Real # 200 Boca Raton, FL 33433 561-391-6552

Martha Fernandez MD Olga L Mendoza SW Florida Regional Medical Center 5580 19 CT SW #2 Naples, FL 34116 239-304-2471

Pura Medina MD Mirtha Toledo MD Del Prado Medical Center 2500 Del Prado Blvd South Cape Coral, FL 33954 239-772-1194 / 239-772-1195

Rafael Ubeda MD Johnson Medical Services 2531 N Dixie Highway Lake Worth, FL 33460 561-582-0330 Basic Gynecology

Daniel Hernandez MD Johnson Medical Services 2531 N Dixie Highway Lake Worth, FL 33460 561-469-6409 Basic Gynecology

Manuel Abreu MD Johnson Medical Services 2531 N Dixie Highway Lake Worth, FL 33460 561-469-6409 Basic Gynecology

Bob M Gairaj MD Boca Family Practice 7100 W Camino Real # 200 Boca Raton, FL 33433 561-391-6552

Primary Care Physicians / Medicos Primarios Palm Beach 1st Visit $40 / Follow up $ 40

Jose E Rodriguez MD Manuel Diaz MD SE General Healthcare Center 20 Barkley Circle Ste 203 Fort Myers, FL 33907 239-931-7061

Primary Care Physicians / Medicos Primarios Broward 1st Visit $40 / Follow up $ 40

Richard A Saitta 80 Wilson Blvd Suite 11 Naples, FL 34117 239-208-5390

Jose F Perez MD Julio Cesar Gavilan MD Pura Medina ARNP Odalys Pena MD Lehigh Medical and Research 5624 8 Street W Suite 112 Lehigh Acres, FL 33971 239-491-6159

Juan Zapata MD Seneca Health Care 4603 N University Dr Lauderhill, FL 33351 954-368-6604

Pilar F Trueba 3472 Forest Hill Blvd # 26 Palm Spring, FL 33334 561-296-1116

Joseph Pierre-Paul Cadet MD 734 Belvedere Rd West Palm Beach, FL 33405 561-835-8385

Dale Evans Fahie MD Foy’s Medical Center 4600 N Federal Hwy Fort Lauderdale, FL 33308 954-202-9948

Dale Evans Fahie MD Martine Veclrine ARNP West Dixie Health Center 703 S Dixie Hwy W Pompano Beach, FL 33060 954-942-4299

14

Primary Care Physician & Specialist Provider Service Fees / Tarifa de servicios de médicos primarios y especialistas

Family and General Practice Consultation Fees

Initial Office Visit $40.00

Follow-Up Office Visit $20.00

Specialist Physician Practice Consultation Fees



Pediatric / Pediatrician



Codes Cardiovascular Fee

93000 EKG $10.00

93922 ABI $15.00

93307 Echo $90.00

93320 Echo Doppler $90.00

93325 Color Flow Doppler $25.00

93324 Holter Monitor 24 hr $55.00

Codes Diagnostics US Fee

76705 Abdomen / Single $70.00

76700 Abdomen / Complete $70.00

76645 Breast $70.00

76856 Pelvic $70.00

76873 Prostate $70.00

76770 Kidney / Renal $70.00

76536 Thyroid $70.00

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

Codes Injections Fee

J0780 Compazine 10 mg Cost + $ 10.00

J1100 Decadron up to 5mg 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 to1000 mg Cost + $ 10.00

J1670 Tetanun (Globulin) Cost + $ 10.00

J3180 Tetanun Toxoid Cost + $ 10.00

J0500 Bentyl Cost + $ 10.00

J3450 Tigan Cost + $ 10.00

J1885 Tiradol Cost + $ 10.00

J1200 Benadryl Cost + $ 10.00

Codes Pulmonary Fee

94060 Bronchospasm Eval $12.50

94664 Nebulizer Treatment $12.50

94665 Nebulizer Subsequent $12.50

94010 Spirometry $30.00

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 Collection $12.50

All immunizations will follow CDC protocols for age requirements. (See attached).

Persons under the age of 19 years are eligible for Free Vaccines offered by VFC

Program. Med Plan providers will charge our members $10.00 for the

administration of each vaccine only.

Todas las inmunizaciones seguirán los protocolos de CDC para los requisitos de edad. (Ver

adjunto). Las personas menores de 19 años son elegibles para vacunas gratuitas ofrecidas por

el programa VFC. Los proveedores del Med Plan cobrarán $10.00 por la administración de cada vacuna solamente.

15

Primary Care Physician & Specialist Provider Service Fees / Tarifa de servicios de medicos primarios y especialistas

Codes X Ray Procedures Fee

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 Therapies Fee

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

97022 Whirpool $10.00

97026 Infrared $13.20

97035 Ultrasound $10.00

97039 Vibratory massage $17.50

97110 Therapeutic Exercise $57.00

97112 Neuromuscular Re-Education $63.00

97124 Massage $47.00

97139 Hydro massage $17.00

97140 Manual Therapy $65.00

97140 Manual Traction $65.00

E0217 Water Circulating Cold $91.00

E0218 Water Circulating Hot $91.00

97535 Self/Home Care $41.00

Codes Other Procedures Fee

69210 Ear Lavage $5.00

88150 PAP Smear $35.00

BS (Blood Sugar Finger Stick) $2.50

16

Healing Touch C and C 15100 NW 67 Ave # 203 Miami Lakes, FL 33014 305-631-2405 General Medicine / Chiropractic / Neurology / Psychology / Psychiatry

Healing Touch C and C 4385 W 16 Ave Hialeah, FL 33012 305-824-0637 General Medicine / Chiropractic / Neurology / Psychology / Psychiatry

Homestead Medical Clinic PA 43 NE 15 Street Homestead, FL 33030 786-243-1909 General Medicine / Pediatrics

Vida Health Medical Center 881 E 2 Ave Hialeah, FL 33010 305-882-1100 General Medicine/ Gynecology/ Gastroenterology/ Psychiatry

Felicidad Medical Center 4410 W 16 Ave # 55 Hialeah, FL 33012 305-824-8559 General Medicine / Internal Medicine / Pediatrics / Urgent Care

Clinic Center 3800 W 12 Ave Hialeah, FL 33012 305-557-7777 General Medicine / Gynecology / Physical Therapy / Endocrinology

AMED Practice 8181 NW 36 Street # 23, 24 Doral, FL 33166 786-801-1168 General Medicine / Endocrinology / Chiropractic / Psychology / Pulmonology / Pain Management

Private Medical Center 10 NW 42 Ave # 300 Miami, FL 33126 305-774-0742 General Medicine / Internal Medicine / Cardiology / Gynecology / Podiatry

St John Clinic Medical Center 161 NW 29 Street Miami, FL 33127 305-576-0231 General Medicine / Pediatrics / Podiatry / Gynecology

Las Mias Medical Center 6445 SW 8 Street Miami, FL 33144 305-448-8557 General Medicine/ Gynecology

All Family Care 38 NW 8 Street Homestead, FL 33030 305-246-0460 General Medicine / Pediatrics

Medical Centers / Centros Médicos Miami-Dade

Green Cross Clinic LLC 950 N Krome Ave # 405 Homestead, FL 33030 786-504-2063 General Medicine / Neurology / Psychiatry

American Health Clinic 3701 SW 107 Ave Miami, FL 33165 305-559-3167 General Medicine / Neurology / Psychiatry

Green Cross Clinic LLC 3750 W 16 Ave # 126U Hialeah, FL 33012 305-557-3444 General Medicine / Neurology / Psychiatry

17

Jireh Medical Center 7900 NW 33 Street # 101 Hollywood, FL 33024 954-962-5300 General Medicine / Internal Medicine / Gynecology / Pediatrics

Pines Care Medical Center 501 NW 103 Ave Pembroke Pines, FL 33026 954-251-1497 General Medicine / Internal Medicine

Emerald Health Medical Center 3990 Sheridan Street # 102 Hollywood, FL 33021 954-987-4455 General Medicine / Internal Medicine

Medical Centers / Centros Médicos Palm Beach

Pediatrics by the Sea 285 SE 5 Ave Delray Beach, FL 33483 561-272-8991 Pediatrics

Johnson Medical Service 2531 N Dixie Highway Lake Worth, FL 33460 561-469-6409 General Medicine / Pediatric

Medical Centers / Centros Médicos Lee/ Cape Coral

Del Prado Medical Center 2500 Del Prado Blvd South Cape Coral, FL 33954 239-772-1194 / 239-772-1195 General Medicine / Internal Medicine / Podiatry

Medical Centers / Centros Médicos Broward

18

Mauricio Vargas MD Private Medical Center 10 NW 42 Ave # 300 Miami, FL 33126 305-774-0742 1st Visit $50 / follow up $40 (7 years and up)

Mario R Villoch MD AV Medical Center 2075 SW 27 Ave # 101 Miami, FL 33145 305-856-6081

Vicente A Chavarria MD 10700 N Kendall Dr # 304 Miami, FL 33176 305-670-7006

José E Escalante MD 777 E 25 Street # 214 Hialeah, FL 33013 305-836-1997

Vicente A Chavarria MD 1840 W 49 ST # 515 Hialeah, FL 33012 305-670-7006

Physician Specialists / Médicos Especialistas

Allergist / Alergista Miami-Dade 1st visit $80 / follow up $ 50

Cardiology / Cardiólogo Miami-Dade 1st visit $60 / follow up $ 40

Jorge Bordenave MD FACP 8720 SW 88 Street Suite 115 Miami, FL 33176 305-446-2444

Michaqel Bahrami MD Glades Medical Centers 2390 NE 186 Street Miami, FL 33186 305-432-9565

Allergist / Alergista Broward 1st visit $80 / follow up $ 50

Shahid Ranphawa MD 2510 East Oakland Park Blvd Fort Lauderdale, FL 33306 954-717-1919

Shahid Ranphawa MD 3939 Hollywood Blvd # 2B Hollywood, FL 33021 954-504-2593

Alvaro Ignacio Martinez 400 Arthur Godfrey Rd # 200 Miami Beach, FL 33140 305-254-8900

Alvaro Ignacio Martinez 20803 Biscayne Blvd # 202 Aventura FL 33180 305-254-8900

Alvaro Ignacio Martinez 7357 W Flagler ST Miami, FL 33126 305-254-8900

Yaimy Bensimon MD 1501 Presidential Way # 15 West Palm Beach, FL 33401 561-686-8200 1st Visit $60 / follow up $60

Richard Polakoff 4850 W Oakland Park Blvd # 143 Lauderdale Lakes, FL 33313 954-676-9080 1st Visit $100 / follow up $75

Richard Polakoff 7170 Nob Hill Rd Tamarac, FL 33321 954-726-8267 1st Visit $100 / follow up $75

Aniel Artola MD Vidal Medical Group 26847 S Dixie Hwy Homestead, FL 33032 305-258-9352

Francisco Diegues MD 145 E 49 ST Hialeah, FL 33013 305-575-1776

Salah Amer 2100 E Hallandale Blvd Hallandale, FL 33009 954-239-0578 1st Visit $100 / follow up $80

Cardiology / Cardiólogo Broward / Palm Beach

19

Maria del Campillo, DC 3625 NW 82 Ave # 320 Doral, FL 33166 305-593-1555

Aixa Goodrich, DC 7990 SW 117 Ave # 205 Miami, FL 33183 305-271-7447

William Rojas Healing Touch 15100 NW 67 Ave # 203 Miami Lakes, FL 33014 305-631-2405

Dennis Kogut, DC 9999 NE 2 Ave # 202 Miami Shores, FL 33138 305-240-7041

Arturo García, DC/ Iris M García, DC Miami Back Center 3785 NW 82 Ave # 315 Miami, FL 33166 305-303-9306

William Rojas Healing Touch 4385 W 16 Ave Hialeah, FL 33012 305-824-0637

Yolaris Garcia, DC 980 NE 126 Street North Miami, FL 33161 305-981-0899

Charles Wolter, DC Region Medical Center 3900 Broadway # 1 Bldg A Fort Myers, FL 33976 239-288-5413

David Shwartz, DC SFL Medical & Wellness Clinic 5931 S University Dr Davie, FL 33328 954-252-3339

Jan Scott Buchholz, DC Hands-on Healthcare 2901 W Oakland Park Blvd # A23 Fort Lauderdale, FL 33311 954-731-8097

Cardiovascular / Cardiovascular Broward 1st visit $60 / follow up $ 40

Chiropractor / Quiropráctico Broward 1st visit $60 / follow up $60

Chiropractor / Quiropráctico Collier / Lee 1st visit $60 / follow up $40

Eduardo Ramirez DC 8181 NW 36 Street # 23,24 Doral, FL 33166 786-801-1168

Milagros Alvarez, DC / Danay González,DC Miami Back Center 3785 NW 82 Ave # 315 Miami, FL 33166 305-303-9306

Chiropractor / Quiropráctico Miami-Dade 1st visit $60 / follow up $ 40

Ross Pine DC 611 E Atlantic Blvd Pompano Beach, FL 33060 954-782-7006

David J Pines 611 E Atlantic Blvd Pompano Beach, FL 33060 954-782-7006

Eduardo Ramirez 7801 Coral Way # 114 Miami, FL 33155 786-801-1168

Enrique Rodriguez George Rodriguez 7421 N University Dr # 112 Tamarac, FL 33321 954-726-9561

20

Juventus Cosmetic Center 920 SW 82 Ave, Miami, FL 33144

305-262-3999 Board Certified Plastic Surgeons / Cirujanos Plasticos Certificados

Julio L Arronte, MD

Cosmetic Surgery / Cirugía Cosmética

PROCEDURES / PROCEDIMIENTOS ORIGINAL PRICE

Med Plan FEE

Breast Augmentation (saline breast implants) $3,500.00 $2,800.00

Breast Augmentation (silicone breast implants) $4,900.00 $3,900.00

Breast Lift Surgery (saline breast implants) $6,000.00 $4,500.00

Breast Lift Surgery (silicone breast implants) $7,000.00 $5,500.00

Breast Augmentation (Saline Aero plastics) $4,800.00 $3,800.00

Breast Augmentation (Silicone Aero plastics) $5,800.00 $4,600.00

Breast Lift Surgery without implants $5,500.00 $4,000.00

Hypertrophic Breast Reduction $7,500.00 $6,000.00

Breast Aug w/Exchange Implants Saline $4,200.00 $3,400.00

Breast Augmentation With Exchange (saline breast implants) $5,400.00 $4,300.00

Breast Augmentation With Exchange (silicone breast implants) $4,900.00 $3,900.00

Breast Augmentation with Exchange (capsule implants) $5,900.00 $4,700.00

MiniTummy Tuck (Mini-Abdominoplastia) $3,300.00 $2,500.00

Tummy Tuck I (Abdominoplasty) $4,900.00 $3,900.00

Tummy Tuck II (Abdominoplasty) $5,500.00 $4,500.00

Tummy Tuck III (Abdominoplasty) $7,000.00 $5,500.00

Lipo sculpture $3,700.00 $3,000.00

Lipo sculpture + Fat Transfer $5,000.00 $4,000.00

Lipo x Areas (each area) 4 areas minimum $600.00 $300.00

Arms Lipo (each arm) $1,200.00 $900.00

Arm Surgery (both arms) $3,900.00 $3,000.00

Inner Thighs Lipo $1,200.00 $900.00

Outer Thighs Lipo $1,200.00 $900.00

Lipo (double chin) combo $1,200.00 $900.00

Permanent Makeup ORIGINAL

PRICE Med Plan

FEE

Eyebrows $200.00 $150.00

3 lines $300.00 $250.00

Bottom Line $130.00 $90.00

Upper Line $130.00 $90.00

Lighting $130.00 $90.00

Lips Alignment $200.00 $150.00

Wax

Eyebrows (Con Pinza) $15.99 $10.00

Eyebrows (between) $7.99 $5.00

Upper Lip $9.99 $6.00

Armpits $20.00 $15.00

Full face (Brows Included) $52.99 $45.00

Bikini Line $21.99 $18.00

Full Bikini $29.99 $22.00

Brazilian Bikini $50.00 $40.00

Full Arms (w/hands) $36.99 $30.00

Chest $20.99 $15.00

Chest with Stomach $36.99 $29.00

Stomach $21.99 $16.00

Back with Shoulders $35.00 $29.00

Full Legs (w/Toes) $70.00 $55.00

Upper Legs $35.00 $29.00

Lower Legs (w/Toes) $29.99 $25.00

Toes $15.00 $10.00

21

PROCEDURES / PROCEDIMIENTOS ORIGINAL PRICE Med Plan FEE

Lipo (double chin) only $3,000.00 $2,400.00

“Z” Neck Surgery $3,700.00 $3,000.00

“Z” Neck Surgery (combo) $1,700.00 $1,400.00

Face Lift $6,500.00 $4,500.00

Eyebrow Lift $4,000.00 $3,000.00

Eyelids (Up and Down) $4,000.00 $3,000.00

Eyelids (Up) $2,000.00 $1,500.00

Eyelids (Down) $2,000.00 $1,500.00

Nose (cartilage only) $4,000.00 $3,000.00

Nose (bone + cartilage) $6,500.00 $4,000.00

Laser Skin Rejuvenation (Face) $3,500.00 $2,500.00

Microdermabrasion Treatment $800.00 $600.00

Chin Implant $2,500.00 $2,000.00

Otoplasty (Ear Surgery) $4,000.00 $2,800.00

Vagina Rejuvenation $4,500.00 $2,500.00

Gastric Banding $14,000.00 $9,900.00

Therapies $750.00 $550.00

Torso Lift through Thighs $4,700.00 $3,000.00

SPA TREATMENTS / TRATAMIENTOS DE SPA ORIGINAL PRICE Med Plan FEE

Cavitation (10 sections) $1,200.00 $750.00

Cavitation (1 section) $120.00 $85.00

Reductive Massage (10 sections) $700.00 $500.00

Reductive Massage (1 section) $120.00 $85.00

Passive Gymnastics (10 sections) $400.00 $300.00

Passive Gymnastics (1 section) $45.00 $35.00

Butt Lift (10 sections) $400.00 $300.00

Butt Lift (1 section) $45.00 $35.00

Vacum Therapy (10 sections) $450.00 $350.00

Mesotherapy (10 sections) $800.00 $650.00

Mesotherapy (1 section) $90.00 $75.00

Carboderm facial (1 section) $70.00 $55.00

Laser Treatments / Tratamientos de Láser ORIGINAL PRICE

Med Plan FEE

Laser Hair Removal (1 section) $30.00 $20.00

Laser Hair Removal (10 sections) $250.00 $170.00

Chin (1 section) $55.00 $45.00

Chin (10 sections) $450.00 $400.00

Double Chin (1 section) $75.00 $65.00

Double Chin (10 sections) $600.00 $500.00

Sideburn (1 section) $40.00 $30.00

Sideburn (10 sections) $350.00 $250.00

Full Face (1 section) $150.00 $110.00

Full face (10 sections) $1,300.00 $1,000.00

Armpits (1 section) $50.00 $35.00

Armpits (10 sections) $400.00 $300.00

Linea Alba (1 section) $40.00 $30.00

Linea Alba (10 sections) $350.00 $250.00

Thighs (1 section) $200.00 $150.00

Thighs (10 sections) $1,800.00 $1,300.00

Legs (1 section) $150.00 $100.00

Legs (10 sections) $1,200.00 $900.00

Full Legs (1 section) $350.00 $250.00

Full Legs (10 sections) $2,800.00 $2,300.00

Buttocks (1 section) $70.00 $50.00

Buttocks (10 sections) $600.00 $400.00

Bikini Line (1 section) $80.00 $50.00

Bikini Line (10 sections) $650.00 $450.00

Back of male (10 sections) $2,200.00 $1,700.00

Full Chest (1 section) $140.00 $85.00

Full Chest (10 sections) $1,200.00 $700.00

Full Bikini (1 section) $150.00 $110.00

Full Bikini (10 sections) $1,300.00 $900.00


22


Carboderm facial (10 sections) $650.00 $500.00

Carboderm body (5 sections) $750.00 $500.00

Carboderm body (10 sections) $1,350.00 $1,100.00

Endermology (10 sections) $550.00 $500.00

Yeso Therapies (1 section) $150.00 $100.00

Parafango (10 sections) $950.00 $700.00

Parafango (5 sections) $525.00 $400.00

Plasma $300.00 $200.00

Basic Facial $75.00 $50.00

Facial Acne $75.00 $60.00

Facial Oxygen $90.00 $70.00

Facial con radio frequencies $120.00 $60.00

Peeling $90.00 $70.00

Collagen Hydra Gel Mask $25.00 $16.00

Micro Dermabrasion (1 section) $85.00 $65.00

Micro Dermabrasion (3 sections) $225.00 $185.00

Micro Dermabrasion (5 sections) $350.00 $260.00

Paraffin treatment (10 sections) $650.00 $500.00

Body Wrap (1 section) $85.00 $60.00

Body Wrap (10 sections) $750.00 $500.00

Radiofrequency (10 sections) $1,200.00 $900.00

Radiofrequency (5 sections) $550.00 $450.00

Radiofrequency (1 section) $90.00 $60.00

Varicose Veins Treatment (1 section) $40.00 $30.00

Varicose Veins Treatment (10 sections) $350.00 $250.00

Package 10 Relax Massages (Full Body) ** $750.00 $650.00

1 Relax Massage (Full Body) ** $100.00 $70.00

Package 10 Swedish Massage ** $750.00 $650.00


1 Swedish Massage ** $85.00 $70.00

Post-Surgery Therapy (1 section) $100.00 $60.00



Laser Spots / Láser para manchas ORIGINAL PRICE Med Plan FEE

Hands (1 section) $45.00 $35.00

Hands (10 sections) $350.00 $300.00

Cheeks (1 section) $40.00 $30.00

Cheeks (10 sections) $300.00 $200.00

Full Face (1 section) $100.00 $80.00

Full Face (10 sections) $900.00 $700.00

Forearm (1 section) $75.00 $65.00

Forearm (10 sections) $600.00 $500.00

Arm (1 section) $90.00 $70.00

Arm (10 sections) $750.00 $600.00

Laser Acne (1 section) $75.00 $60.00

Laser Acne (10 sections) $650.00 $500.00

GENERIC PRODUCTS / PRODUCTOS GENERICOS ORIGINAL PRICE Med Plan FEE

Botox (Regular) 40 unidades $350.00 $325.00

Juvederm (1 jeringuilla) $550.00 $500.00

Arnica $30.00 $25.00

Lipocell $35.00 $28.00

Kelocote $70.00 $60.00

Latisse $125.00 $100.00

Scarguard (para proteger heridas) $70.00 $60.00

Procolagen $60.00 $50.00

Cocoa Butter $25.00 $18.00

VEIN TREATMENTS ORIGINAL PRICE Med Plan FEE

1 Section (one at a time) $75.00 $55.00

Package (6) Treatment $450.00 $330.00



Package (12) Treatment $1,020.00 $600.00

** Include Free Trigger Point or Neuromuscular


23

Alejandro Pedrozo MD 935 W 49 Street # 107 Hialeah, FL 33012 305-827-2268 1st visit $100 / follow up $60

Carlos Barrera MD 151 NW 11 Street # 102B Homestead, FL 33030 305-274-4339 1st visit $125 / follow up $95

Sabrina Christian MD Competent Group Services 8370 W Flagler Street # 234 Miami, FL 33144 305-226-1987

Maria Cartaya MD 7805 Coral Way # 131 Miami, FL 33175 305-261-4474 1st visit $80 Follow up $40

Carlos Barrera MD 7190 SW 87 Ave # 306 Miami, FL 33173 305-274-4339 1st visit $125 / follow up $95

Dermatology / Dermatología Miami-Dade 1st visit $60 / follow up $40

Emilio Castañeda MD Guadalupe Medical Center 4469 S Congress Ave # 106 Lake Worth, FL 33461 561-642-0268 1st visit $150 / follow up $90

Endocrinology / Endocrinología Miami-Dade

Endocrinology / Endocrinología Palm Beach

Emilio Castañeda MD 8181 NW 36 Street #23,24 Doral, FL 33166 786-801-1168 1st visit $150 / follow up $90

Hector Wiltz MD Eric W Bussear, MPH, PA-C 11760 SW 40 Street # 451 Miami, FL 33175 305-227-9233

Hector Wiltz MD Eric W Bussear, MPH, PA-C 1036 NW 1 ST Homestead, FL 33030 305-245-1332

Josefa L Binker, MD 70 NW 8 Street Homestead, FL 33030 305-242-5225

Emilio Castañeda MD 7801 Coral Way # 114 Miami, FL 33155 786-801-1168 1st visit $150 / follow up $90

Alejandro Pedrozo MD 351 NW 42 Ave Suite 502 Miami, FL 33126 305-827-2268 1st visit $100 / follow up $60

Endocrinology / Endocrinología Broward

Emilio Castañeda MD 2100 E Hallandale Blvd Hallandale, FL 33009 1st visit $150 / follow up $90

24

Juan C Sarol MD 87 E 49 Street Hialeah, FL 33013 786-313-3640 1st visit $60 / follow up $40 Endoscopy/ Endoscopia $600 Colonoscopy/ Colonoscopia $600

Carlos A Selema MD 747 Ponce de Leon Blvd # 510 Coral Gables, FL 33134 305-443-2611 1st visit $60 / follow up $40

Maria T Llopiz MD 330 SW 27 Ave # 603 Miami, FL 33135 305-649-5455 Otolaryngologist ENT/ Otorrino 1st visit $100 / follow up $70

Orlando Torres MD 4791 W 4 Ave Hialeah, FL 33012 305-825-0500 1st visit $70 / follow up $50 Endoscopy/ Endoscopia $1060 Sigmoidoscopy/ Sigmoidoscopia $230 Colonoscopy/ Colonoscopia without biobsy/ sin biopsy $1270 Colonoscopy/ Colonoscopia with biobsy/ con biopsy $1510

Juan Sarol MD Vida Health Medical Centers 881 E 2 Ave Hialeah, FL 33010 305-882-1100 1st visit $60 / follow up $40

ENT / Otorrino Miami-Dade

Gastroenterology / Gastroenterólogo Miami-Dade

25

PAP SMEAR special for patients with their PCP in

MED CARE & MED PLAN CLINICS centers. $50.00 includes sample and pathology results.

Please call for an appointment 305-266-2929 For centers’ address refer to page 8

Ramon Hechevarria, MD GYN Private Medical Center 10 NW 42 Ave # 300 Miami, FL 33126 305-774-0742 1st visit $50 / follow up $40

Zenaida Fritz Competent Group Services 8370 W Flagler Street # 234 Miami, FL 33144 305-226-1987

Rolando Padrón, MD GYN 15439 SW 137 Ave Miami, FL 33177 305-259-5570

Conchita Jackson, MD GYN Private Medical Center 10 NW 42 Ave # 300 Miami, FL 33126 305-774-0742 1st visit $50 / follow up $40

Tomas Seville, MD OB-GYN Las Mias Medical Center 6445 SW 8 Street Miami, FL 33144 305-448-8557 / 305-397-7230

Josefa L Binker, MD GYN 70 NW 8 Street Homestead, FL 33030 305-242-5225

Esperanza A Nuñez, MD OB-GYN 1840 W 49 Street # 420 Hialeah, FL 33012 305-823-3000

Emilio Blanco, MD OB-GYN Vida Health Centers 881 E 2 Ave Hialeah, FL 33010 305-882-1100

Eduardo Lavado, MD OB-GYN 4160 W 16 Ave # 406 Hialeah, FL 33012 305-822-4561

Martha Fernandez MD Jireh Medical Center Corp 7900 NW 33 Street # 101 Hollywood, FL 33024 954-962-5300

Julio A Diaz-Jane, MD OB-GYN 777 E 25 Street # 201 Hialeah, FL 33013 305-822-8123

Carlos M Verdeza, MD GYN 2475 NW 95 Ave # 2 Doral, FL 33172 305-553-8033

Liliam C García, MD Teresa Acosta-Avila NRAP Clinic Center 3800 W 12 Ave Hialeah, FL 33012 305-557-7777 1st visit $50 / follow up 40

Gynecology & Obstetrics / Ginecología y Obstetricia Miami-Dade 1st visit $60 / follow up $40

Oferta Especial de PAPANICOLAU para pacientes con su médico primario en los

centros de MED CARE & MED PLAN CLINICS. $50.00 le incluye la toma de la muestra y el resultado de la Patología

Llama para una cita 305-266-2929 Para la dirección de los centros refiérase página 8

Gynecology & Obstetrics / Ginecología y Obstetricia Broward 1st visit $60 / follow up $60

Esperanza Nunez MD Glez & Glez Medical Center 3804 NW 167 Street Opalocka, FL 33054 305-624-2700

Chatoor B Singh MD OB-GYN 2620 N Andrew Ave Fort Lauderdale, FL 33311 954-565-7686

26

Maternity Package / Paquete de Maternidad Miami-Dade

Provider/ Location Normal Birth C-Section Birth

Dr Eduardo Lavado’s office

4160 W 16 Ave # 406 Hialeah, FL 33012 305-822-4561 1st Visit $100

$ 1,600.00 $ 1,900.00

Inclusions/ Exclusions

*All office visits (after initial visit) *Post-partum *Labs & Ultrasounds are NOT included *Initial visit is NOT included

Proveedor/ Ubicación Parto Normal Parto Cesárea

Dr Eduardo Lavado 4160 W 16 Ave # 406 Hialeah, FL 33012 305-822-4561 1ra Visita $100

$ 1,600.00 $ 1,900.00

Incluye/ Excluye

*Todas las visitas (después de la primera visita) *Postparto *No incluye Laboratorios ni Ultrasonidos *Primera visita no está incluida

Provider/ Location Normal Birth C-Section Birth

Dr Eduardo Lavado Hialeah Hospital 651 E 25 Street Hialeah, FL 33013

$ 4,050.00 $ 5,100.00

Includes Includes

*Hospitalization (2 nights) *Pathology *Neonatal *Epidural

*Hospitalization (3 nights) *Pathology *Neonatal *Epidural *Surgical Assistant

Proveedor/ Ubicación Parto Normal Parto Cesárea

Dr. Eduardo Lavado Hialeah Hospital 651 E 25 Street Hialeah, FL 33013

$ 4,050.00 $ 5,100.00

Incluye Incluye

*Hospitalización (2

noches) *Patología *Neonatal *Epidural

*Hospitalización (3 noches) *Patología Neonatal *Epidural *Asistente de cirugía

27

Juan M Fernandez MD 2322 NW 8 Street Miami, FL 33142 305-633-3667

Humberto Hernandez MD 900 W 49 Street Suite 448 Hialeah, FL 33012 305-885-3111

Mauricio Vargas MD Private Medical Center 10 NW 42 Ave # 300 Miami, FL 33126 305-774-0742 1st visit $50 / follow up $40

Mario R Villoch MD AV Medical Center 2075 SW 27 Ave #101 Miami, FL 33145 305-856-6081

Francisco Bautista MD Felicidad Medical Center 4410 W 16 Ave #55 Hialeah, FL 33012 305-824-8559

Ramses Vega MD 3720 SW 107 Ave Miami, FL 33165 305-554-4270

Carlos A Riveros MD United Medical Specialties 2601 SW 37 Ave # 904 Miami, FL 33133 305-444-1213

Renato C Dominguez MD Miami Community Health 891/893 E 10 Ave Hialeah, Fl 33010 305-381-5150

Margarita del Val, MD New Life Health Care 14750 NW 77 CT # 106 Miami Lakes, FL 33016 305-698-4000

Mayre Urdaneta MD 843 NW 119 ST Miami, FL 33168 305-846-9789

Felix A Rodriguez MD American Family Health 1840 W 49 Street # 425 Hialeah, FL 33012 305-231-8996

Juan Sarol MD 87 E 49 Street Hialeah, FL 33013 786-536-5001

Odalys Frontela, MD FFCP 801 W 48 Street # A Hialeah, Fl 33012 305-698-7172

Juan M Fernandez MD 9600 SW 8 Street # 30 Miami, FL 33174 305-633-3667

Maray Rocher MD 87 E 49 Street Hialeah, FL 33013 786-536-5001

Infectologist/ Infectologo Palm Beach 1st visit $100 / follow up $80

Mayra M Delgado MD Unique Medical Ctr Miami 3850 SW 87 Ave Suite 201 Miami, FL 33165 786-801-1360

Internal Medicine / Medicina Interna Miami-Dade 1st visit $60 / follow up $40

Jasmin T Jose MD Indira M Marmelejos MD 6238 W Atlantic Ave # 2 Delray Beach, FL 33484 561-404-9845

Jesus Rodriguez MD 9835 SW 72 ST Suite 203 Miami, FL 33173 786-483-7669

Alejandro de la Cruz 13214 SW 8 ST Miami, FL 33184 305-831-2789

Luis Campillo Rafael Mota Qtrials Inc 6587 W Flagler Street Miami, FL 33144 786-207-0075

28

Emilio Castañeda MD Guadalupe Medical Center 4469 S Congress Ave # 106 Lake Worth, FL 33461 561-642-0768

José Francisco Perez MD 12264 Tamiami Trail E # 203 Naples, FL 34113 239-304-9071

Emilio A Pando MD 12781 Miramar Parkway # 206 Miramar, FL 33027 954-450-0228

Saad Mirza MD 2297 S University Dr P. Pines, FL 33024 954-322-0600

Martha Fernandez MD Jireh Medical Center 7900 NW 33 Street # 101 Hollywood, FL 33024 954-962-5300

Jean-Luc Michel MD 1800 Forest Hill Blvd # B9 W Palm Beach, FL 33406 561-968-7288

Herbert Pardell DO Emerald Health Medical Cntr 3990 Sheridan Street # 101 Hollywood, FL 33021 954-987-4455

Immaculada Michel MD 1800 Forest Hill Blvd # B9 W Palm Beach, FL 33406 561-968-7288

Rodolfo Freyre MD 12264 Tamiami Trail E #203 Naples, FL 34113 239-304-9071

Jorge L Posada MD 747 Ponce de Leon Blvd # 605 Coral Gables, FL 33134 305-445-4535

Luis García-Mayol MD 747 Ponce de Leon Blvd # 605 Coral Gables, FL 33134 305-445-4535

Internal Medicine / Medicina Interna Broward 1st visit $60 / follow up $60

Internal Medicine / Medicina Interna Collier / Lee 1st visit $60 / follow up $60

Nephrology / Nefrología Miami-Dade 1st visit $80 / follow up $50

Alejandro Barreda MD Jose Perez MD Del Prado Medical Center 2500 Del Prado Blvd S Cape Coral, FL 33954 239-772-1194 / 239-772-1195

Mohamed T Javed MD 3460 S Congress Ave Palm Springs, FL 33461 561-969-1595

Jose Perez MD 5624 8 Street W Suite 112 Lehigh Acres, FL 33971 239-491-6159

David O Kateb 4760 W Atlantic Ave Delray Beach, FL 33445 561-637-3933

Jaimy Bensimon 1501 Presidential Way # 15 W Palm beach, FL 33401 561-686-8200

Richard Polakoff 4850 W Oakland Park Blvd # 143 Lauderdale Lakes, FL 33313 954-676-9080

Richard Polakoff 7170 Nob Hill Rd Tamarac, FL 33321 954-726-8267

Internal Medicine / Medicina Interna Palm Beach 1st visit $60 / follow up $60

David Elickman 2100 E Hallandale Blvd Hallandale, FL 33009 954-239-0578 1st visit $90 / follow up $60

Patricia Martindale 8395 W Oakland Ste D Sunrise, FL 33351 954-749-1102

29

Silvana González Reiley MD 15100 NW 67 Ave # 203 Miami Lakes, FL 33014 305-631-2405

Silvana González Reiley MD 4385 W 16 Ave Hialeah, FL 33012 305-824-0637

Martha Bustamante MD 4160 W 16 Ave # 100 Hialeah, FL 33012 305-826-5655

Joaquin S Maury MD 8200 SW 117 Ave # 416 Miami, FL 33183 786-409-7662

Neurology / Neurología Miami-Dade 1st visit $100 / follow up $80

Neurology Pediatric / Neurología Pediátrica Miami-Dade 1st visit $150 / follow up $75

Silvana González Reiley MD 8181 NW 36 Street # 24 Doral, FL 33166 786-452-1067

Angel Carasco MD 1555 Krome Ave Homestead, FL 33030 305-266-0222

Angel Carrasco MD 14221 SW 120 Street # 214 Miami, FL 33186 305-266-0222

Neurology / Neurología Broward 1st visit $100 / follow up $80

Silvana González Reiley MD 2100 East Hallandale Beach Blvd # 202 Hallandale Beach, Fl 33009 954-239-0578

Sonia V Tolgyesy MD Monan Peochand MD 10661 N Kendall Dr Suite 104 Miami, FL 33176 305-270-7771

Bashar Mohsen MD 14750 NW 77 CT # 106 Miami Lakes, FL 33016 305-698-4000

Neurology / Neurología Palm Beach 1st visit $160 / follow up $95

Shabad Kidway MD 2000 N Federal Hwy # 203 Pompano Beach, FL 33062 954-783-0222

30

Neurology Mobile System Associates 10661 N Kendall Dr Suite 104 Miami, FL 33176 305-270-7771

Neurological Studies / Estudios Neurológicos

Miami-Dade

See procedures and fee schedule for this center in the chart below:

Consulte los precios de los procedimientos de este centro en el cuadro siguiente:

PROCEDURE DESCRIPTION CPT CODES Fees

Soft-Tissue Ultrasound

Cervical Soft Tissue 76536 $100.00

Spinal Canal & Contents 76800 $100.00

Extremities Leg / Arm 76880 $100.00

Neurological Studies

NCS Upper Motor 95900 $125.00

NCS Upper Motor + F-Wave 95903 $125.00

NCS Upper Sensory 95904 $125.00

NCS Lower Motor 95900 $125.00

NCS Lower Motor + F-Wave 95903 $125.00

NCS Lower Sensory 95904 $125.00

EEG - Electroencephalogram 95819 $150.00

BAER - Brainstem Auditory Evoked Response 92585 $125.00

VER - Visual Evoked Response 92280 $125.00

VEP - Visual Evoked Potential 95930 $125.00

EMG - 1 Extremity 95860 $130.00

EMG - 2 Extremities 95861 $180.00



Orbucularis Ocull - Blink 95933

31

Arnaldo V Lopez MD Orthopedic Medicine & Surgery 1545 SW 1 Street # 200 Miami, FL 33135 305-541-3230

Angel Carasco MD 1555 Krome Ave Homestead, FL 33030 305-266-0222

Rigoberto Reguero MD Orthopedic Medicine & Surgery 5450 SW 8 Street # 203 Coral Gables, FL 33134 305-649-1700

Gustavo Torres MD Orthopedic Medicine & Surgery 900 W 49 Street # 450 Hialeah, FL 33012 305-821-4020

Joaquin S Maury MD 8200 SW 117 Ave # 416 Miami, FL 33183 786-409-7662

Manuel Frade MD, PA 8080 W Flagler Street # 1B Miami, FL 33144 305-262-8280

Angel Carrasco MD 14221 SW 120 Street # 214 Miami, FL 33186 305-266-0222

Drs Airala Laser & Cataract Institute 2441 SW 37 Ave Miami, FL 33145 305-442-0066

Alejandro de la Cruz MD 13214 SW 8 Street Miami, FL 33184 305-831-2789

Jennine Cabanellas MD Douglas Shapiro MD PA Kenneth Pearlberg MD Shapiro and Specialty Vision 8700 N Kendall Dr # 101 Miami, FL 33172 305-275-0038

Ismael Montane MD Pedro Ramon Bustelo Juan Y Herrera MD Orthopedic Medicine & Surgery 777 E 25 Street # 508 Hialeah, FL 33013 305-696-7772

Drs Airala Laser & Cataract Institute 202 E 49 Street Hialeah, FL 33013 305-442-0066

José L Ponce de Leon MD 3501 SW 107 Ave Miami, FL 33165 305-229-1227

Ophthalmology / Oftalmología Miami-Dade 1st visit $60 / follow up $40

Pain Management / Mánejo de Dolor Miami-Dade 1st visit $60 / follow up $40

Orthopedics / Ortopedía Miami-Dade 1st visit $60 / follow up $40

Leonardo Allende MD 8181 NW 36 Street # 23, 24 Doral, FL 33166 786-801-1168

José L Ponce de Leon MD 9774 SW 24 ST Miami, FL 33165 786-536-2377

Florencio Sanchez Lopez 1241 SW 1 ST Miami, FL 33135 305-541-2000

Orthopedics Therapy / Terapia Ortopedica Broward 1st visit $100 / follow up $80

Nasser Eftekhari 2100 E Hallandale Blvd Hallandale, FL 33009 954-239-0578

Drs Airala Laser & Cataract Institute 2050 NE 163 Street North Miami Beach, FL 33162 305-442-0066

32

Johanne Zephir MD 7th Ave Medical Plaza 10071 NW 7 Ave Miami, FL 33150 305-403-7777

Olabisi Oyadiran MD 18425 NW 2 Ave PH 7 Miami Gardens, FL 33169 305-625-4100

Jorge L Alsina MD 4999 W 8 Ave # 26 Hialeah, FL 33012 305-556-4447

Pilar Delgado MD 5590 W 20 Ave # 100 Hialeah, FL 33016 305-828-3997

Francisco Bautista Felicidad Medical Center 4410 W 16 Ave #55 Hialeah, FL 33012 305-824-8559

Rodolfo B Ferretti MD 3228 NW 7 Street Miami, FL 33125 305-642-5090

Eduardo Diaz MD Lourdes M Falcon 5703 NW 7 Street Miami, FL 33126 305-267-3462 1st Visit $50 / Follow up $40 Juan del Sol MD

St John Medical Center 161 NW 29 Street Miami, FL 33127 305-576-0231

Armando Acevedo MD Mari Elie-De Jean MD Acevedo Medical Group 2400 NW 54 Street Miami, FL 33142 305-633-9090

Sebastian Padron 4131 SW 6 Street Miami, FL 33134 305-443-5031

Martha Delgado Maria I Delgado MD Homestead Medical Clinic PA 43 NE 15 Street Homestead, FL 33030 786-243-1909

Alfredo Machado MD Dorses Goosby MD Pedriatic Associates of Florida 151 NW 11 Street # E204 Homestead, FL 33030 305-245-3220 Milady Fernandez MD All Family Care 38 NW 8 Street Homestead, FL 33030 305-246-0460

Antonio J Reyes MD 1350 SW 57 Ave # 314 Miami, FL 33144 305-267-2182

Luis E De Armas MD 11373 W Flagler Street # 212 Miami, FL 33174 305-220-7730

Rodolfo Sidron MD 7285 W Flagler Street Miami, FL 33144 786-388-9877

Jose Herrera MD Children Medical Center Group 8300 SW 8 Street # 302 Miami, FL 33144 305-225-4434

Juan Ruiz MD 8900 SW 24 Street # 204 Miami, FL 33165 305-554-6666

Gloria Lopez MD 747 Ponce de Leon Blvd # 607 Coral Gables, FL 33134 305-443-2324

Hilda M Brito MD 14285 SW 42 Street # 208/209 Miami, FL 33175 305-220-6917

Pedro C Reimon MD Child Obesity Specialist 13155 SW 42 Street # 106 Miami, FL 33175 305-220-1310

Orlando Arrazola MD 13550 SW 88 Street Ste 280 Miami, FL 33186 305-245-9222

Sandra Mitjans MD Sebastian Padron MD Efrain Gubieda 4305 E 8 Ave # E Hialeah, FL 33013 305-769-5601

Efrem Gubieda MD 5590 W 20 Ave Hialeah, FL 33016 305-828-3997

Marisela C Jaquez-Gutierrez 9835 SW 72 Street # 203 Miami, FL 33173 786-483-7669

Rodolfo Ferretti MD 7765 SW 87 Ave Suite 209 Miami, FL 33173 305-642-5090

Pediatrics / Pediatría Miami-Dade 1st visit $40 / follow up $30

Sergio Alzuragay 11865 Coral Way #B7, B15 Miami, FL 33175 305-220-6128

33

Rafael Hernandez MD Jireh Medical Center 7900 NW 33 Street # 101 Hollywood, FL 33024 954-962-5300

Monica Andres DPM 825 SW 87 Ave Suite I Miami, FL 33174 305-244-8346

Maria Fundora DPM 1380 NW Miami Gardens Dr # 209 Miami, FL 33169 305-945-7575

Richard Mallia, DOM St John Medical Center 161 NW 29 Street Miami, FL 33127 305-576-0231

Juliette Perez DPM Hialeah Foot Center 4410 W 16 Ave # 53 Hialeah, FL 33012 305-558-7437

Yanssel Delgado DPM 5590 W 20 Ave # 404 Hialeah, FL 33016 305-819-9240 / 305-819-9239

Nguyen Phu DPM 3661 S Miami Ave # 309 Miami, FL 33133 305-854-6600

Juliette Perez DPM Perfect Feet Care Podiatry Center 13651 SW 26 Street Miami, FL 33175 305-225-4277

Oscar Barreto DPM, FACFAS 7975 NW 154 Street # 390 Miami Lakes, FL 33016 305-825-5633

Podiatry / Podiatra Miami-Dade 1st visit $60 / follow up $40

Pediatrics / Pediatría Broward 1st visit $40 / follow up $40

Bamidele Olupona DPM United Medical Specialties 2601 SW 37 Ave # 904 Miami, FL 33133 305-587-4247 Eric Zephirin DPM

Jodee Brown DPM 3800 W 12 Ave Hialeah, FL 33012 305-681-2600

Bamilde Olopuna DMP Coral Gables Podiatry Ctr 2645 SW 37 Ave # 704 Miami, FL 33133 305-444-9587

Rafael Ubeda MD 2531 N Dixie Hwy Lake Worth, FL 33460 561-469-6409 9 years and old

Daniel Hernandez MD 2531 N Dixie Hwy Lake Worth, FL 33460 561-469-6409 9 years and old

Pediatrics / Pediatría Other county 1st visit $40 / follow up $40

Bradley Bradliy MD 285 SE 5 Ave Delray Beach, FL 33483 561-272-8991

Deborah Stemp MD Jideama Ernestine MD 285 SE 5 Ave Delray Beach, FL 33483 561-272-8991

Mario H Cala DPM 13651 SW 26 Street Miami, FL 33175 305-225-4278

Juan Yuri Herrera 777 E 25 Street # 508 Miami, FL 33013 305-225-4278

Jose M Leon MD 5640 W Atlantic Blvd Margate, FL 33063 954-701-5515

Joseph Wirth MD 10179 W Sunrise Blvd Plantation, FL 33322 954-475-2290

Ausberto Hidalgo 302 NW 179 Ave # 103 Pembroke Pines, FL 33029 954-442-8380

Ambertpet Ye Rathaman MD 6765 Sunset Strip Suite 6 Sunrise, FL 33313 954-572-7755

Deborah Stemp Jideama Ernestine Bradley Badford 13660 Jog Rd # 6 Delray Beach, FL 33446 561-303-3707

Maria Fundora MD 10 NW 42 ST Suite 300 Miami, FL 33126 305-774-0742

34

Nelson González DPM Del Prado Medical Center 2500 Del Prado Blvd S Cape Coral, FL 33954 239-772-1194 / 239-772-1195

Ernesto Matos MD Healing Touch 15100 NW 67 Ave # 203 Miami Lakes, FL 33014 305-631-2405

Hugo M Espinosa MD Healing Touch 15100 NW 67 Ave # 203 Miami Lakes, FL 33014 305-631-2405

Adrian de Castro MD Healing Touch 15100 NW 67 Ave # 203 Miami Lakes, FL 33014 305-631-2405

Hugo M Espinosa MD Healing Touch 4385 W 16 Ave Hialeah, FL 33012 305-824-0637

Adrian de Castro MD Healing Touch 4385 W 16 Ave Hialeah, FL 33012 305-824-0637

Ernesto Matos MD Healing Touch 4385 W 16 Ave Hialeah, FL 33012 305-824-0637

José C Lopez-Escobar, MD Florida Medical Center 1501 NW 36 Street Miami, FL 33142 786-378-8200

Psychiatry / Psiquiatría Miami-Dade 1st visit $100 / follow up $75

Podiatry / Podiatra Orange 1st visit $60 / follow up $60

Podiatry / Podiatra Broward 1st visit $60 / follow up $60

Patrice Mechelle Torrence DPO 2601 Davie Blvd Fort Lauderdale, FL 33312 754-216-2458

Craig B Stam DPM Affordable Foot & Leg Clinic 2100 E Hallandale Beach Blvd # 204 Hallandale Beach, FL 33009 954-458-1248

Jay G Rhodes 5642 W Atlantic Blvd Margate, FL 33063 954-974-3535

Louis M Newman 512 W Oakland Park Blvd Wilton Manors, FL 33311 954-561-2778

Lazaro Cordovez MD 4410 W 16 Ave Suite 55 Hialeah, FL 33012 305-824-8559

Brian Finke 7144 NOB Hill Rd Tamarac, FL 33321 954-720-5922

Brian Finke 208 NE 3 Ave Okeechobee, FL 34972 954-720-5922

Hamlet R Hassan 950 N Krome Ave Ste 405 Homestead, FL 33030 1st visit $100 / Follow up $80

Hamlet R Hassan 3750 W 16 Ave # 126U Hialeah, FL 33012 305-557-3444 1st visit $100 / Follow up $80

Hamlet R Hassan 3701 SW 107 Ave Miami, FL 33165 305-559-3167 1st visit $100 / Follow up $80

Yolanda Burgo Qtrails Inc 6587 W Flagler Street Miami, FL 33144 786-207-0075

35

Melissa Becher Psy D 8181 NW 36 Street # 23,24 Doral, FL 33166 786-801-1168

Calixto Garcia MD 8390 West Flagler Street # 107 Miami, FL 33144 305-856-9090

Mercedes Llenin MD 13930 SW 47 Street Miami, FL 33175 305-387-7850

Maria Moncayo MD 10406 Taft Street Pembroke Pines, FL 33026 954-436-3880 1st $ 100 – follow up $75

Maria Patricia Gomez Healing Touch 4385 W 16 Ave Hialeah, FL 33012 305-824-0637

Humberto Hernandez MD 900 W 49 Street # 448 Hialeah, FL 33012 305-885-3111

Psychology / Psicología Miami-Dade 1st visit $100 / follow up $75

Psychology / Psicología Broward / Palm Beach

Pulmonology / Neumología Miami-Dade 1st visit $60 / follow up $40

Melissa Becher Psy D 7035 Beracasa Way #201-W Boca Raton, FL 33433 561-430-3526 **See price on fee schedule A

Fee Schedule A

Procedure Med Plan Price

Initial Consultation $100.00

Psych Immigration Evaluation $1,200.00

Short Form N-648 (disability) $800.00

Psychoeducational $1,200.00

Therapy Sessions $145.00 / per hour

Yelena Iguanzo Felicidad Medical Center 4410 W 16 Ave Suite 55 Hialeah, FL 33012 305-814-8559

36

Luis F Maggiolo MD 747 Ponce de Leon Blvd # 502 Coral Gables, FL 33134 305-444-2858

Ariel Duran Mondragon MD 10760 W Flagler Street # 11 Miami, FL 33174 305-554-5144 1st visit $80 – follow up $50

Dr Felix Dolorit Surgical Coordinator/ Coordinador de Cirugía 1535 SW 87 Ave Miami, FL 33174 305-771-5928 / 786-443-0068 Free Surgical Orientation Consultation / Consulta de Orientación Quirúrgica Gratis

Juan B Suarez MD 2601 SW 37 Ave # 804 Miami, FL 33133 305-443-8041 Follow up only/ No accepting new patient

Azarel Abinader MD 1330 Coral Way # 401 Miami, FL 33145 305-854-0919 1st visit $100 – follow up $75

Pulmonology / Neumología Broward 1st visit $60 / follow up $60

Surgery / Cirugía Miami-Dade

Urology / Urología Miami-Dade 1st visit $60- follow up $ 40

Rheumatology / Reumatología Miami-Dade

David O Kateb 4760 W Atlantic Ave Delray Beach, FL 33445 561-637-3933

Urology / Urología Broward 1st visit $60- follow up $ 60

Dongihua Xie MD 5605 NW 29 Street Margate, FL 33063 954-854-9429

Agustin Arold Joseph 4301 West Sunrise Blvd Plantation, FL 33313 954-514-7712

Rafael Antun 2601 SW 37 Ave Suite 905 Miami, FL 33133 305-548-4005

37

Urgent Care Centers vs Emergency Care

•Falls from greater than 7 feet •Loss of consciousness •Infants less than 6 months of age or with a temperature greater than 103 degrees •Pregnancy bleeding or complications •Life-threatening allergic reactions •Severe burns •Severe choking (cannot breathe or talk) •Severe abdominal pain •Signs or symptoms of stroke or heart attack • Amputation of a body part •Near drowning •Electrical shock •Open or angulated fractures

If you or a family member is experiencing life-threatening illness or injury-such as major head trauma, chest pain, severe abdominal pain, or loss of consciousness – you should go directly to an Emergency Room (ER). See the list below for guidance on which situations require ER treatment.

Centros De Urgencia vs Atención de Emergencia

Si usted o algún miembro de la familia está sufriendo una enfermedad potencialmente mortal o lesiones - como: Traumatismos craneales importantes, Dolor torácico, Dolor abdominal intenso o pérdida de la conciencia debe ir directamente a una sala de emergencias. Vea la lista a continuación para obtener orientación sobre las situaciones que requieren atención de emergencia.

•Caídas de más de 7 pies de altura. •Pérdida de conciencia. • Los bebés menores de seis meses de edad o con una temperatura superior a 103 grados. •Sangrado o complicaciones de embarazo. •Reacciones alérgicas que puedan poner en peligro la vida •Quemaduras graves •Asfixia severa que le impide respirar o hablar •Dolor abdominal severo •Signos o síntomas de derrame cerebral o ataque al corazón •Pérdida o desmembramiento de una parte del cuerpo •Si usted está a punto de ahogarse •Una descarga eléctrica •Fracturas abiertas o anguladas

38

Urgent Family Care 5673 SW 137 Ave Miami, FL 33183 305-385-3949 Mon – Fri 9am – 5pm Sat 9am – 3pm

Campbell Urgent Care 1855 NE 8 Street Homestead, FL 33033 305-242-8025 Mon – Fri 8am – 8pm Sat & Sun 10am – 4pm $150 each Visit

Pines Professional Campus 302 NW 179 Ave # 103 Pembroke Pines, FL 33029 954-442-8380 Mon – Fri 9am – 9pm Sat & Sun 9am – 6pm

Urgent Care Surgery Center 3500 Hollywood Blvd Hollywood, FL 33021 954-239-6060 Mon – Thu 9am – 4 pm

Felicidad Medical Center 4410 W 16 Ave # 55 Hialeah, FL 33012 305-824-8559 Mon-Fri 8am-9pm Sat 8am-2pm/ Sun on Call

Dispensary/Dispensario *

Urgent Care Center UrgentMed 2337 S University Dr Davie, FL 33324 954-423-9234 Mon – Fri 9am – 9:30pm Sat & Sun 9am – 5pm


Primary and Urgent Care 3460 S Congress Ave Palm Springs, FL 33461 561-969-1595 Mon- Fri 9am – 5 PM Sat 9am – 5 PM (call After Hours)

Urgent Care Center UrgentMed 10199 Cleary Blvd Plantation, FL 33324 954-473-8565 Mon – Fri 9am – 9:30pm Sat & Sun 9am – 5pm


Urgent Care Centers / Centros de Urgencia Miami-Dade

Urgent Care Centers / Centros de Urgencia Broward

Urgent Care Centers / Centros de Urgencia Palm Beach

*See Fee Schedule on Page 39

*Referirse a la tarifa de precios pag-39

*Dispensaries are only for members that went to the urgent care center *Los servicios dispensarios son solo para pacientes que vallan a un centro de urgencia

Vida Medical Group 26847 S Dixie Hwy Homestead, FL 33032 305-258-9352 Mon – Fri 8am – 8pm Sat & Sun 8am – 6pm

Pronto Urgent Care 2500 E Commercial Blvd Suite D Fort Lauderdale, FL 33308 954-909-5708 Mon – Sun 8am – 8pm

39

Urgent Care Fees / Costo para los Centros de Urgencia Miami-Dade, Broward & Palm Beach

Tier 1 (Basic Visit) - $60.00 All levels of service, including initial visits and established patient visits. Instant test(s) are performed at the center. •Urine dipstick test •Instant streptococci •Mononucleosis •Flu •Pregnancy Test •Hemoccult •Glucose •HIV Test Tier 2 (Intermediate Visit) - $120.00 Tier 1 (Basic Visit) above PLUS •X-rays of single body area performed at the center •Injection of pain medications or antibiotics •Vaccine administration (vaccine charged as exclusion below) •Venipuncture or specimen collection for any lab outside reference lab (lab test charged as exclusion below) Tier 3 (Advanced Visit) - $145.00 Tier 2 (Intermediate Visit) PLUS Single procedures performed in the center including but not limited to: •Nebulizer treatment •Laceration repair •Burn care / debridement •Foreign body removal •Cast / Splint application •IV Therapy •EKG

Nivel 1 (Visita Básica) - $60.00 Todo nivel de servicio, incluyendo visitas iniciales y visitas establecidas a los pacientes. Pruebas instantáneas realizadas en el centro. •Prueba de la tira reactiva de orina •Estreptococo instantáneo •Mononoclosis •Gripe •Prueba de Embarazo •Hemocultivo •Glucosa •Prueba de VIH Nivel 2 (Visita Intermedia) - $120.00 Nivel 1 (Visita Básica) MAS •Rayos X de área de un solo cuerpo realizados en el centro. •Inyección de analgésicos o antibióticos. •Administración de vacunas (vacuna cargada como exclusión abajo) •Venopunción o recolección de muestras para cualquier laboratorio fuera del laboratorio de referencia (prueba de laboratorio cargada como exclusión abajo) Nivel 3 (Visita Avanzada) - $145.00 Nivel 2 (Visita Intermedia) MAS Procedimientos únicos realizados en el centro incluyendo, pero no limitado a: •Tratamiento del nebulizador •Reparación de laceración •Cuidado de quemadura / desbridamiento •Eliminación de cuerpos extraños Aplicación de yeso / férula •Terapia IV •EKG

40

Dentistry / Odontología MP. D. FS 01/13

FREE Dental Services for Med Plan each member (every 12 months*) include: •Comprehensive Oral Evaluation •Full-mouth x-rays •Simple Prophylaxis (cleaning) - including topical anesthesia •Topical Application of Fluoride Treatment •Single Restoration – One Surface •Simple Tooth Extraction (1) *Free services may only be done at participating associated dental offices. New members will be able to access these services after the first 90 days of membership. As a special bonus Med Plan members are also eligible to receive one premium teeth whitening service

with a value of $450.00 for only $150.00 (every 24 months)

Los exámenes dentales GRATUITOS para los miembros del Med Plan (cada 12 meses *) incluyen: •Evaluación Oral Integral •Rayos X de boca completa •Profilaxis Simple (limpieza) - incluyendo anestesia tópica •Aplicación Tópica de tratamiento con flúor •Restauración Individual - de una superficie •Extracción simple (1) *Los servicios gratuitos sólo pueden realizarse en las oficinas dentales asociadas participantes. Nuevos miembros podrán acceder a estos servicios después de los primeros 90 días de membresía. Como un bono especial miembros del Med Plan también son elegibles para recibir un servicio de

blanqueamiento dental con un valor de $ 450.00 por sólo $150.00 (cada 24 meses)

41

World Dental Care 1370 E 4 Ave Hialeah, FL 33010 305-888-1458

Jeps Dental Group LLC 5323 W 20 Ave Hialeah, FL 33012 305-556-5966

Maria J Alvarez DDS Dental Group of South Florida II 11336 SW 184 Street Miami, FL 33157 305-251-4262

Med Dental Associated* 7200 NW 7 Street # 333 Miami, FL 33126 305-264-0063

Hialeah Dental Associated* 4240 W 16 Ave Hialeah, FL 33012 305-823-1882

Pines Dental Associated* 17868 NW 2 Street Pembroke Pines, FL 33029 954-538-0047

Ronald Askowitz DDS Beautiful Smile 1871 NE 163 Street North Miami Beach, FL 33162 305-945-7030

Dental Group of South Florida 101 West Ward Dr Miami Springs, FL 33166 305-885-1357

Life Dental Care 123 N Powerline Road Deerfield Beach, FL 33442 954-429-8840

Dentistry / Odontología Miami-Dade MP. D. FS 01/13

Dentistry / Odontología Broward MP. D. FS 01/13

*If you have a dental emergency and need to see a dentist, please visit any dental clinic listed. Dental Associated does not provide emergency dental assistance.

*Si a usted se le presenta alguna emergencia dental, visite cualquiera de las clínicas dentales. Dental Associated no ofrece servicios dentales de emergencia.

Jeps Dental Group LLC 19517 NW 57 Ave Miami Gardens, FL 33055 305-627-3402

Shiny Smile Dental Care 482 Fisherman Street Opa Locka, FL 33054 305-687-6880

Enrique C Escofet DDS, PA 1330 Coral Way # 203 Miami, FL 33145 305-858-6085

42

Dentistry Fee Schedule / Tarifa de Odontología

*Free services may only be done at participating associated dental offices. New members will be able to access these services after the first 90 days of membership. *Los servicios gratuitos sólo pueden realizarse en las oficinas dentales asociadas participantes. Nuevos miembros podrán acceder a estos servicios después de los

primeros 90 días de membresía.

ADA CODES

FREE SERVICES (EVERY 12 MONTHS) / SERVICIOS GRATIS (CADA 12 MESES) (* only at Dental Associated/ *solo en Dental Associated) FEE

D 0150 Comprehensive Oral Evaluation (1 Annually) $0.00

D 0210 Full Mouth X-Rays (1 Annually) $0.00

D 1110 Simple Prophylaxis (1 Annually) $0.00

D 2330 Single Restoration One Surface (1 Annually) $0.00

D 1203 Topical Application Of Fluoride - Child (1 Annually) $0.00

D 1204 Topical Application Of Fluoride - Adult (1 Annually) $0.00

D 7110 Simple Tooth Extraction (1 Annually) $0.00

D 9972 Blanqueamiento (1 Cada 2 Años) Whitening (1 Every Two Years) $150.00

ADA CODES GENERAL DENTISTRY/ ODONTOLOGIA GENERAL FEE

D 2330 Single Restoration Per Surface $45.00

D 2331 Resin Based Composite Filling Two Surface Anterior $55.00

D 2332 Resin Based Composite Filling - Three Surfaces Anterior $65.00

D 2335 Resin Based Composite Filling - Four Or More Surfaces Anterior $75.00

D 7110 Simple Extraction $60.00

D 3310 Root Canal Anterior $350.00

D 3320 Root Canal – Bicuspid $450.00

D 3330 Root Canal - Molar $550.00

D 2952 Cast Post/Core In Addition To Crown $120.00

D 2750 Crown Porcelain Fused To High Noble Metal $395.00

D 2740 Crown Porcelain Ceramic $450.00

D 4341* Periodontal Scaling And Root Planning/Quad $60.00

D 4342 Periodontal Scaling And Root Planning - 1 To 3 Teeth Per Quadrant $45.00

D 5110 Complete Denture - Maxillary $375.00

D 5120 Complete Denture - Mandibular $375.00

D 5213 Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases $395.00

D 5214 Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases $395.00

ADA CODES GENERAL DENTISTRY/ ODONTOLOGIA GENERAL FEE

D0120 Periodic Oral Exam $20.00

D0140 Limited Oral Evaluation-Problem Focused $15.00

D0150 Comprehensive Oral Eval-New Or Established Patient No Charge

D0160 Detailed & Extensive Eval-Problem Focused No Charge

D0170 Re-Evaluation-Limited, Problem Focused $15.00

D0180 Comprehensive Periodontal Evaluation $15.00

ADA CODES

RADIOGRAPHY/DIAGNOSTIC DENTISTRY – RADIOGRAFIA/DIAGNOSTICOS FEE

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 No Charge

D0260 X-Ray - Extraoral - Each Additional Film No Charge

D0270 X-Ray - Bitewing- Single Film $5.00

D0272 X-Ray - Bitewing - 2 Films $5.00

ADA CODES

RADIOGRAPHY/DIAGNOSTIC DENTISTRY – RADIOGRAFIA/DIAGNOSTICOS FEE

NOT TO BE TAKEN IF 274 WAS DONE W/IN PRIOR 6 MONTHS/ NO HACERLO SI D274 SE HIZO DENTRO DE 6 MESES

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

43


ADA CODES PERIODONTIC SERVICES FEE

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 $60.00

D4342 Periodontal Scaling Root Planing - 1 To 3 Teeth, Per Quad $45.00

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 $375.00

D5120 Complete Denture - Mandibular Basic $375.00

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 $395.00

D5214 Partial Denture - Mandibular Vast Metal - Acrylic $395.00

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

ADA CODES PREVENTIVE DENTISTRY/ PROCEDIMIENTOS PREVENTIVOS FEE

PREVENTIVE DENTISTRY TO BE TAKEN IF 274 WAS DONE W/IN PRIOR 6 MOTHS/ NO HACERLO SI D274 SE HIZO DENTRO DE 6 MESES

D1110 Routine Prophylaxis Adult (Once Every 6 Months) $49.00

D1120 Routine Prophylaxis - Children Under 16 Yrs (Once Every 6 Months) $35.00

D1203 Topical Application Of Flouride For Children Under 16 No Charge

D1204 Topical Application Of Flouride For Adults No Charge

D1310 Nutritional Counseling For Control Of Dental Disease No Charge

D1320 Tobbaco Counseling For Control & Prevention Of Oral Diseases No Charge

D1330 Oral Hygiene Instructions No Charge

D1351 Application Of Sealant Per Tooth - Children Under 16 $15.00

D1510 Space Maintainer - Fixed $120.00

D1515 Space Maintainer - Fixed $175.00

D1520 Space Maintainer - Removable $160.00

D1525 Space Maintainer - Removable $250.00

D1550 Re-Cementation Of Space Maintainer $25.00

D2330 Resin-Based Composite - 1 Surface, Anterior $45.00

D2331 Resin-Based Composite - 2 Surfaces, Anterior $55.00

D2332 Resin-Based Composite - 3 Surfaces, Anterior $65.00

D2335 Composited Resin - 4 Or More Surfaces $75.00

D2391 Resin - Based Composite - 1 Surface, Posterior $60.00

D2392 Resin-Based Composite - 2 Surfaces, Posterior $70.00

D2393 Resin-Based Composite - 3 Surfaces, Posterior $80.00

D2394 Resin-Based Composite - 4 Or + Surfaces, Posterior $90.00

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

ADA CODES PREVENTIVE DENTISTRY/ PROCEDIMIENTOS PREVENTIVOS FEE

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 $450.00

D2750 Crown - Porcelain Fused To High Noble Metal $395.00

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

44




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

ADA CODES PROSTHODONTICS - FIXED FEE

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

ADA CODES PREVENTIVE DENTISTRY FEE

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 $120.00

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


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

ADA CODES ENDODONTIC SERVICES FEE

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 $350.00

D3320 Root Canal Therapy - Bicuspid $450.00

D3330 Root Canal Therapy - Molar $550.00

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


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 $60.00

D4342 Periodontal Scaling Root Planing - 1 To 3 Teeth, Per Quad $45.00

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 $375.00

D5120 Complete Denture - Mandibular Basic $375.00

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 $395.00

D5214 Partial Denture - Mandibular Vast Metal - Acrylic $395.00

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

45



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



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


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

ADA CODES ORAL SURGERY FEE

D7110 Single Tooth Extraction $70.00

D7140 Extraction Of Erupted Tooth Or Exposed Root $70.00

D7210 Extraction - Surgical/Erupt Tooth $110.00

D7310 Alveoloplasty With Extractions - Per Quadrant $95.00

D7320 Alveoloplasty Without Extractions - Per Quadrant $130.00

D7510 Incision And Drainage Of Abscess - Intraoral Soft Tissue $55.00

D9215 Local Anesthesia No Charge

ADA CODES MISCELLANOUS SERVICES FEE

D9230 Analgesia Nitrous Oxide Per 1/2 Hour $20.00

D9630 Oral Irrigation/Other Drugs/Medicament Per Quad $10.00

D9940 Occlusal Guard $195.00

D9950 Occlusal Analysis - Mounted Case $75.00

D9951 Occlusal Adjustment - Limited $25.00

D9952 Occlusal Adjustment - Complete $150.00

ADA CODES ENDODONTIC SERVICES FEE

Ed3310 Root Canal Therapy - Anterior $695.00

Ed3320 Root Canal Therapy - Bicuspid $775.00

Ed3330 Root Canal Therapy - Molar $925.00

Ed3346 Retreat, Prev Rct - Anterior $750.00

Ed3347 Retreat, Prev Rct - Bicuspid $825.00

Ed3348 Retreat. Prev Rct - Molar $1,125.00

46

Specialty Dentistry Fee Schedule / Tarifa de Especialistas de Odontología

ADA CODES PERDIODONTIC SERVICES FEE

D4210 Gingivectomy 4 Or + Per Quadrant $450.00

D4249 Clinic Crown Lengthen - Hard Tissue $800.00

D4260 Osseous Surgery 4 Or + Per Quadrant $900.00

D4263 Bone Replace Graft - 1st Site/Qu $650.00

D4264 Bone Replace Graft - Each Add/Qu $500.00

D4266 Guided Tiss Regen-Resorb-Per $900.00

D4275 Soft Tissue Allograft Rb-Per $1,200.00

D7953 Bone Repl Graft Ridge Prsv/Site $400.00

D7960 Frenulectomy - Separate Procedure $500.00

ADA CODES ORAL SURGERY FEE

D7210 Extraction - Surgical/Erupt Tooth $240.00

D7220 Extraction - Impactedl/Soft Tissue $300.00

D7230 Extraction - Impactedl/Part Bony $395.00

D7240 Extraction - Impacted/Complbony (Cordales) $450.00

D7241 Remov Impact - Comp Bony W/Comp $500.00

D7250 Surgic Removl Resid Tooth Root $250.00

D7285 Biopsy Of Oral Tissue - Hard (Bone, Tooth) $120.00

D7286 Biopsy Of Oral Tissue - Soft (All Other) $95.00

Biopsy Lab $50.00

ADA CODES ORTHODONTICS FEE

D8080 Comprehensive Ortho, Adolescent $3,490.00

D8090 Comprehensive Ortho, Adult $3,490.00

ADA CODES IMPLANTS FEE

D6010 Surg Place Implant, Endosteal $1,200.00

D6010/D6059 Completed Crown Implant $1,950.00

D0000 Overdenture Upper With 4 Implants $4,650.00

D0000 Overdenture Lower With 3 Implants $3,650.00

47

Optical Services / Óptica

In the following vision centers, Med Plan members will receive a comprehensive eye exam at $35 which includes: •Vision Evaluation •Intraocular Pressure Evaluation to check for Glaucoma •Dilated Eye Exam to determine eye health and to look for disease such as high blood pressure and diabetes •External eye health evaluation

En los siguientes centros de visión, los miembros de Med Plan recibirán un (1) examen ocular completo con un costo de $35 que incluye: •Evaluación de la vista - (Optometría) •Evaluación de la Presión Intraocular para verificar evidencia de glaucoma. •Dilatación de la pupila para determinar la salud y para identificar enfermedades tales como presión alta o diabetes. •Evaluación externa para determinar la salud de los ojos.

Optical & Vision Centers / Centros Ópticos Miami-Dade

South Florida Vision Navarro Pharmacy 32 Harrold Forrest, OD James Hagen, OD Martha Alfonso OD 366 E 4 Ave Hialeah, FL 33010 305-888-9910

Optica Arias Vision Center Optica 9160 NW 122 Street # 28 Hialeah Gardens, FL 33018 305-512-4408

South Florida Vision Navarro Pharmacy 32 Harrold Forrest, OD James Hagen, OD Martha Alfonso OD 11865-A SW 26 Street Miami, FL 33175 305-552-9100 / 305-225-4004

Vision Center Optical Gerald D Furnari OD FAAO Robert L Lofton OD FAAO Patrick F Vecchio OD FAAO 948 N Krome Ave Homestead, FL 33030 305-247-2331

AventVision Vision Center Optica 767 NW 37 Ave Miami, FL 33125 786-452-8544

Vision World Optical Corp Vision Center Optica 7367 SW 8 Street Miami, FL 33144 305-265-7778

Vista Vision Eye Care ***

13641 SW 26 Street Miami, FL 33175 305-559-1314

Vivien’s Optical ***

1931 W 60 Street Hialeah, FL 33012 305-556-2020

Santa Lucia Optical ***

11300 NW 87 Court Hialeah Gardens, FL 33018 305-817-1818

Note: (***) Evaluation does NOT include intra-ocular exam

to detect glaucoma, diabetes and high blood pressure.

Nota: (***) La evaluación NO incluye examen intraocular

para verificar si hay glaucoma, diabetes y presión alta.

Shapiro and Specialty Vision 8700 N Kendall Dr # 101 Miami, FL 33176 305-263-9050

Pro Vision Care 920 SW 67 Ave Miami, FL 33144 305-264-6991

48

South Florida Vision Miriam Faraq OD Christopher Boaldin OD Jerrold Mills OD 3181 N State Road # 7 Margate, FL 33063 954-974-7695

South Florida Vision Christopher Boaldin OD Ronie Zaruches OD 143 N Powerline Road Deerfield Beach, FL 33442 954-429-9600

South Florida Vision Karen Puchalski OD Jason Aronson OD 2905-G B Military Trail West Palm Beach, FL 33409 561-684-5548

South Florida Vision Harold Forrest OD Christopher Boaldin OD Laurie Lesser 12538 Pines Blvd Pembroke Pines, FL 33027 954-430-4030

South Florida Vision Laura DeMarco OD 1666 E Oakland Park Blvd Fort Lauderdale, FL 33334 954-566-1404

South Florida Vision Ashley Nochomson OD Karen Puchalski OD Miriam Farag OD 9851 B S Military Trail Boynton Beach, FL 33436 561-742-8701

South Florida Vision Mitchell Biderman OD Karen Puchalski OD Lori Raynor OD 6618 W Atlantic Ave Delray Beach, FL 33446 561-498-5007

South Florida Vision Eric Dupuis OD Christopher Boaldin OD Robert Coppola OD 2900 W Cypress Creek Road # 1 Fort Lauderdale, FL 33309 954-979-2191

South Florida Vision Christopher Boaldin OD Robert Coppola OD 1205 South Powerline Road Pompano Beach, FL 33069 954-977-6636

South Florida Vision Mitchell Biderman OD Christopher Boaldin OD Lori Raynor OD Ashley Nochomson OD 6266 S Congress Ave # 9 Lantana, FL 33462 561-966-9000

St Lucie Vision Center Mitchell Biderman OD 10077 S Federal Hwy Port St Lucie, FL 34952 772-398-3244

South Florida Vision Eric Dupuis OD Christopher Boaldin OD Laurie Lesser OD 2551 S University Dr Davie, FL 33324 954-370-5883

Optical & Vision Centers / Centros Ópticos Broward

Optical & Vision Centers / Centros Ópticos Palm Beach / St. Lucie

49

Vision and Optical Fee Schedule / Tarifas de Servicios Ópticos

Frames and Standard Lenses

Eye Exam/ Examen

Bifocal Lens Fitting / Fijacion de lentes Bifocales

Contact Lens Single Vision / Lentes de contacto Simple

$ 35.00 $ 35.00 Single Vision Contact Lense Fitting: $ 60.00

Standard Stock CR-39



Standard Stock Progressive

Bifocal Transition Lens

Transition Progressive Lens

39-Single Vision $35.00

Bi-Focal FT-28 $35.00

Tri Focal 7x28 $45.00

Bi-Focal $60.00

$80.00

$90.00

50

Clinical Labs / Laboratorios Clínicos

Over one thousand Lab tests available 80% of the tests are priced below $20.00

Six complementary laboratory tests are offered to each Med Plan member every 12 months FREE:

•CBC • Comprehensive Metabolic Panel • Lipid Panel • TSH • Urinalysis • Uric Acid •

All Laboratories require that the tests being requested are ordered by a licensed healthcare professional that is authorized to practice medicine in the State of Florida. The order must be written in a Physicians prescription or on the Laboratories requisition form that is signed by the ordering physician. All Laboratory results will be sent to the office of the Physician or Specialist that has ordered the test. This procedure is to protect the confidential information regarding the outcome or the test results.

Más de mil pruebas de laboratorio disponibles, 80% de las pruebas tienen un precio menos de $ 20.00

Se ofrecen seis paneles de laboratorio complementarias a cada miembro del Med Plan cada 12 meses GRATIS:

•CBC • Panel metabólico completo. • Perfil de lípidos. • TSH (Tiroides) • Análisis de orina • Ácido Úrico • Todos los laboratorios requieren que los exámenes que se solicitan hayan sido previamente indicados por un profesional de la salud con licencia que le autoriza a

ejercer la práctica de la medicina en el Estado de la Florida. La indicación del examen debe estar escrita en una receta médica o en su lugar en el formulario de

solicitud establecida para los Laboratorios y firmada por el médico que la indica. Todos los laboratorios cumplirán el procedimiento legal establecido de

confidencialidad del paciente y para proteger este derecho enviarán los resultados de sus exámenes a la oficina de su doctor.

51

Complete Bio Solution 904 Lee Blvd # 107 Lehigh Acres, FL 33936 239-491-6948

Complete Bio Solution 2207 S 25 Street Fort Pierce, FL 34947 772-577-4200

Complete Bio Solution Homestead Home Blood Collection / Extracción a domicilio 305-477-6520 Venipuncture fee $15.00

Complete Bio Solution 3150 North Side Dr Key West, FL 33040 305-440-3364

Luis Munoz 786-366-1706 Home Blood Collection-Naples to Cape Coral Extracción a domicilio-Napes a Cape Coral

Venipuncture $15.00

Complete Bio Solution 1916 W Dr Martin Luther King Jr Blvd Tampa, FL 33603 813-304-0073

Complete Bio Solution 3626 NW 7 Street Miami, FL 33125 305-643-4343

Complete Bio Solution 2400 Rhode Island Ave # 4 Fort Pierce, FL 34950 772-466-4259

Complete Bio Solution 3720 SW 107 Ave Miami, FL 33165 305-554-4270

First Quality Lab 11460 Interchange Circle North Miramar, FL 33025 954-430-4424 Home blood collection $15 Labs and Doctor’s Office collection $10.00

First Quality Lab 3472 Forest Hill Blvd Suite 2C Palm Springs, FL 33406 561-296-1116

Complete Bio Solution 1578 SE Port St. Lucie Blvd Port St. Lucie, FL 34952 772-207-5951

Clinical Labs / Laboratorios Clínicos Miami-Dade Venipuncture fee $10.00

Clinical Labs / Laboratorios Clínicos Broward Venipuncture fee $10.00

Clinical Labs/ Laboratorios Clínicos Palm Beach/ Lee / Cape Coral Venipuncture fee $10.00

Clinical Labs/ Laboratorios Clínicos Other Venipuncture fee $10.00

Complete Bio Solution 26847 S Dixie Hwy Homestead, FL 33032 305-258-9352

Complete Bio Solution 6500 NW 77 CT Miami, FL 33166 305-261-5333 Venipuncture fee $5.00

52

Laboratory Services- Fee Schedule / Tarifas de los Servicios de Laboratorios MP. LAB. FS 01/13

All the Gynecology collections will cost $20 / Todas las colecciones ginecológicas tendrán un costo de $20

PATHOLOGY TEST/ EXAMEN DE PATOLOGÍA

ONE ANNUAL HEALTH SCREENING LABORATORY PER MEMBER PER CONTRACT YEAR AT NO CHARGE

CBC

COMP. METABOLIC PANEL

TSH

LIPID PANEL

URINE

URIC ACID

PATHOLOGY TEST/ EXAMEN DE PATOLOGÍA

TEST NAME TEST CODE FEE

PAP LIQUID SUREPATH 9142 $25.00

HUMAN PAPILOMA VIRUS hc2 1845 $38.00

CHLAMYDIA & GC DNA 5344 $25.00

CHLAMYDIA & GC DNA hc2 9193 $35.00

PAP PANEL (liquid pap+HPVhc2+chlamydia&GC hc2 9190 $99.00

*The fees for the biopsies level (I-II-III-IV-V-VI) will be determined by the specimen site, number of the specimens and any special stains required for the final diagnosis. * Las tarifas para el nivel de biopsias (I-II-III-IV-V-VI) se determinará por el sitio de muestra, el número de muestras y las manchas especiales requeridas para el diagnóstico final.

TEST CODE FEE

BIOPSY Level I - Gross only 9181 $30.00

BIOPSY Level II 9182 $40.00

BIOPSY Level III 9183 $65.00

BIOPSY Level IV 9184 $85.00

53



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 $10.00

Allergen Respiratory Panel(Sub-Tropical) Each Allergen (9) 7304 $10.00

Allergy Panel Per Allergen Each Allergen (9) $10.00

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 (Sgot) 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 Page 52) 9181

Bleeding Time 4108 $4.50

Blood Type & Rh 4200 $18.00

Bnp 1430 $40.00

Bun 8142 $5.00

CBC 4110 $7.00

C3 Complement 6115 $20.00

C4 Complement 6126 $20.00


Ca 125 1462 $19.50

Ca 15-3 1462 $19.50

Ca 19-9 1463 $19.50

Ca 27-29 1664 $19.50

Calcium 8172 $4.50

Calcium Ionized 2130 $11.00

Calculus (Stone) Analysis 1318 $27.00

Carbamazepin 3119 $15.00

Cea 7214 $19.50

Ceruloplasmin 6119 $36.00

Chlamydia & Gc In Urine 5346 $60.00

Chlamydia & Gc Dna 5344 $25.00

Cholesterol 8146 $4.50

Ck (Cpk Total) 8156 $7.00

Cmv Igg 1353 $14.50

Cmv Igm 5210 $12.50

Comprenh. Metabolic Panel 8112 $9.00

Coombs Direct 4214 $10.00

Coombs Indirect 4215 $10.00

Cortisol 7206 $17.50

C-Peptide 1431 $15.00

Cpk - Mb (Creatine Kinase Mb Fraction) 6127 $12.50

C-Reactive Protein - Quant 3595 $12.50

C-Reactive Protein (Crp) 4216 $5.00

C-Reactive Protein (Crp) Ultrasensitive 6657 $12.50

Creatinine 24 Hrs 2115 $10.00

Creatinine Clearance 2127 $9.50

Creatinine Serum 8150 $4.00

Culture & Sensit 5145 $14.00

Cystic Fibrosis 6442 $250.00

Depakene (Valproic Acid) 1938 $14.00

Dhea (Dehydroepiandrosterone 7171 $26.00

Dhea-S 1655 $26.00

54



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 $69.99

Estrogen Total 7227 $54.00

Esr (Sed Rate) 4160 $8.00

Eye Culture & Sensitivity 5145 $12.00

Ferritin 7275 $14.00

Fibrinogen 4223 $22.00

Folic Acid 7229 $13.00

Free T3 1603 $7.00

Free T4 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

Gliadin 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 Igm 1297 $15.00

H. Pylori In Stool (Antigen) 1294 $43.00

Haptoglobulin 6147 $25.00

Hcg Qual 7282 $7.00

Hcg Quant 7240 $15.50

Hemoglobin A1c 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

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 Ii 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 1846 $39.00

IGA (Immunoglobulin) 6140 $9.00

IGE (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

55


TEST NAME

TEST CODE FEE

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

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

Mycoplasma Igm Titer Pneumoniae Antibody 1985 $60.00

Mycoplasma Pneumoniae Antibody 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

Ova And Parasites 4321 $9.00

Oxalates - 24hrs 2173 $13.00


Oxalates - Urine Random 2172 $13.00

Pap Smear 9161 $15.00

Pap Liquid Surepath 9142 $25.00

Phenobarbital 3155 $11.00

Phosphorus 8174 $4.00

Platelet Count 4149 $6.00

Potasium 8210 $4.00

Potasium In Urine 8223 $4.00

Pre - Albumin 2011 $7.00

Pregnancy Test In Urine 4330 $6.50

Primidone 3162 $15.00

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 $15.00

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

Rubella Antibody Igm 1752 $15.00

Rpr 4272 $4.50

56



Rubella Antibody Igm 1752 $15.00

Sed Rate 4160 $3.50

Semen Analysis 4331 $50.00

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 $310.00

Thyroglobulin Quant. 1201 $14.00

Tobramycin 3185 $16.00

Torch Panel 8420 $60.00

Toxoplasma Igg 5236 $15.00

Transferrin 6175 $15.00

Trazodone 1798 $70.00

Treponema Pallidum Total Antibodies (Fta) 5220 $22.00

Triglycerides 8148 $6.00

Troponin I 8157 $15.50

Tsh 7264 $14.00


Urinalysis 4340 $2.00

Uric Acid 8144 $3.00

Urine Culture 5113 $13.50

Urine Cytology $25.00

Varicella Antibody 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 1833 $35.00

Wet Mount $4.00

Wbc In Stool 4319 $8.00

Zinc 2199 $11.50

57

Pharmacy / Farmacía Miami-Dade


Dispensaries below located in our Med Plan & Med Care Clinics *Dispensaries are only for members with their PCP in these centers

Dispensarios localizados en nuestras clínicas Med Plan y Med Care *Los servicios dispensarios son solo para pacientes que tienen su PCP (doctor primario) en estos centros

MED PLAN Delivery Policy & Procedure / Med Plan Póliza y procedimiento de Entrega

305-857-4425 / 305-857-4407

Monday- Friday 8:00am – 4:30pm

Call for pricing / Llame para precios

Little Havana *

305-857-4371

West Hialeah *

305-857-4375

Blue Lagoon * 305-857-4373

Coral Way *

305-857-4372

Eureka * 305-857-4376

Delivery Fee / Costo de Envio DADE COUNTY $5 next day before 1 pm / próximo día antes de las 1pm DADE COUNTY $10 stat within 4 hours / dentro de 4 horas BROWARD COUNTY $10 next day before 1 pm / próximo día antes de las 1pm BROWARD COUNTY $20 stat within 6 hours / dentro de 6 horas

DELIVERY PROTOCOL 1. Confirm patient address and phone number 2. Advise patient of the delivery charge according to fee structure. 3. Advise patient that medication must be paid via phone with any major credit card (Visa, MasterCard, American Express, and Discover) to expedite delivery. Cash on delivery is also available only when necessary.

PROTOCOLO DE ENTREGA 1. Confirme la dirección y el número de teléfono del paciente 2. Asesorar al paciente de la tarifa de entrega de acuerdo con la estructura de tarifas. 3. Asesorar al paciente que el medicamento debe ser pagado por teléfono con cualquier tarjeta de crédito (Visa, MasterCard, American Express y Discover) para agilizar la entrega. El efectivo a la entrega también está disponible sólo cuando es necesario.

Sylvestre Pharmacy 1268 Palm Ave Hialeah, FL 33010 305-885-8888 Mon-Fri 9am – 6pm Sat 9am - 2pm

58

Direct Med of Florida 800 E Hallandale Beach Blvd Hallandale Beach, FL 33009 954-454-8118 Home Delivery Service / Free Mail Order Services

Pharmacy / Farmacía Lee/ Cape Coral

St Jude Pharmacy 1202 NE Pines Island Road # 1V Cape Coral, FL 33909 239-673-7777 Home Delivery Service

Pharmacy / Farmacía Palm Beach

Garcia Pharmacy 2525 N Dixie Hwy Lake Worth, FL 33460 561-588-2252

Farmacía Las Americas 1800 Forest Hill Blvd # B12 West Palm Beach, FL 33406 561-642-7590

Pharmacy / Farmacía Broward

Del Prado Pharmacy 2504 Del Prado Blvd S Cape Coral, FL 33904 239-673-9415 Home Delivery Service

Family Pharmacy 9861 Bernwood PL Dr # 145 Fort Myers, FL 33907 239-288-6997 Home Delivery Service


Med Plan are now been accepted at over 65,000 pharmacies nation-wide such as: CVS, Publix, Winn Dixie. Discount on over 10,000 medication, saving up

to 80 % off regular Price for Med Plan Members.

Med Plan ahora se acepta en mas de 65,000 farmacias en todo el país como: CVS, Publix, Winn Dixie. Descuento en mas de 10,000 medicamentos,

ahorrando hasta un 80% de descuento en los precios regulares para los miembros de Med Plan.

59

Digital Medical Diagnostic 41 Tamiami Canal Road Miami, FL 33144 305-269-0833 Digital Mammo $50.00

Vital Imaging Diagnostic 7101 SW 99 Ave # 106 Miami, FL 33173 305-596-9992 Transportation

Vital Imaging Diagnostic 692 N Homestead Blvd # 106 Homestead, FL 33030 305-596-9992

Rivero Radiology 285 W 49 Street Hialeah, FL 33012 305-826-6040

South Florida US Management Portable Services

6850 Coral Way Suite 204 Miami, FL 33155 786-773-2558

Lakes Radiology 15600 NW 67 Ave # 07 Miami Lakes, FL 33014 305-231-1115

Universal Imaging of Florida 14462 Commerce Way Miami Lakes, FL 33016 305-821-8585 Digital Mammo $ 50.00

Vital Imaging Diagnostic 3320 Palm Ave Hialeah, FL 33012 305-596-9992 Transportation

B& G Diagnostic Services 444 W 51 PL Hialeah, FL 33012 305-818-2006 Digital Mammo $50.00 Free Transportation Miami Dade-Broward

CT Imaging 10 NW 42 Ave Ste 300 Miami, FL 33126 305-887-7562

Millennium Open MRI 7360 Coral Way #27A Miami, FL 33155 305-261-6744

Diagnostic Centers / Centros de Diagnósticos

Over 300 Diagnostic Tests available which include / Mas de procedimientos de diagnóstico están disponible e incluyen:

All Diagnostic Centers requires that the tests being requested are ordered by a licensed healthcare professional that is authorized to practice medicine in the State of Florida. The order must be written in a Physicians prescription or on the Diagnostic Centers requisition form that is signed by a physician. All test results will be sent to the office of the Physician or Specialist that ordered the test. Todos los Centros de Diagnóstico requieren que los exámenes que se solicitan hayan sido previamente indicados por un profesional de la salud con licencia que le autoriza a ejercer la práctica de la medicina en el estado de la Florida. La indicación del procedimiento debe estar escrita en una receta médica o en su lugar en el formulario de solicitud establecida para los procedimientos de Diagnósticos y firmada por el médico que la indica. Todos los exámenes de diagnósticos cumplirán el procedimiento legal establecido de confidencialidad del paciente y para proteger este derecho enviaran los resultados de sus exámenes a la oficina del doctor que lo indicó.

Diagnostic Radiology / Centros de Diagnosticos Refer to Fee Schedule / Refierase a la lista de tarifas Miami-Dade

Pinnacle Imaging 2390 NW 7 Street # 103 Miami, FL 33125 305-642-7388 Digital Mammo $50.00

CMS Open MRI 9200 SW 72 Street Bldg 4 Miami, FL 33173 305-227-2500

✓ Digital Mammography/ Mamografía Digital ✓ MRI/ Tomografía Computarizada ✓ CT Scans ✓ PET CT Scans

✓ Ultrasound/ Ultrasonido ✓ X-Ray/ Rayos X ✓ Sleep Studies / Estudios del sueño

Idaca LLC 49 W 49 Street Hialeah, FL 33012 305-557-0330

Unlimited Diagnostic Ctr 2360 W 68 Street # 128 Hialeah, FL 33016 786-431-5876

Vital Imaging Diagnostic 3146 Coral Way Miami, FL 33145 305-596-9992

De La Pedraja Radiology 4776 SW 8 ST Coral Gables, FL 33134 305-447-1415

Alfa Diagnostic LLC 21355 E Dixie Hwy #101 Aventura, FL 33180 305-705-4775

Neurology Mobile System Associates 10661 N Kendall Dr # 104 Miami, FL 33176 305-270-7771

Ambulatory Diagnostic Center 747 Ponce de Leon Blvd Coral Gables, FL 3134 305-446-7893

Ambulatory Diagnostic Ctr 9090 SW 47 CT Miami, FL 33176 305-446-7893 Medical City

3595 W 20 Ave #145 Hialeah, FL 33012 305-557-4424

60

Pan Am Diagnostics *** 1820 N University Dr Pembroke Pines, FL 33024 954-704-1966 ***MRI ONLY

Diagnostic Professional 10950 Pines Blvd Pembroke Pines, FL 33026 954-430-2044

A1 Imaging of Orange Park 1566 Kingsley Ave Orange Park, FL 32073 904-278-2128 Closed and Open MRI

A1 Imaging of Mandarin 3753 Cardinal Point Dr Jacksonville, FL 32223 904-636-5674 Open MRI

A1 Imaging of Cape Coral 1003 Del Prado Blvd # 102 Cape Coral, FL 33990 239-573-6333 Open MRI

A1 Imaging of Kissimmee 810 N John Young Pkwy Kissimmee, FL 34741 407-847-6745 Open MRI

A1 Imaging of Orlando 500 N Semoran Blvd # 103 Orlando, FL 32807 407-275-6072 Open MRI

A1 Imaging of Ocala 301 SE 17 Street # 102 Ocala, FL 34471 352-622-7459 Open MRI

Diagnostic Professional 7301 NW 4 Street # 107 Plantation, FL 33317 954-449-7023

Broward Pet Imaging Center 4850 W Oakland Park Blvd # 1A Lauderdale Lakes, FL 33313 954-735-6330

Pan Am Diagnostic Center 6421 Milner Blvd # 1 Orlando, FL 32809 407-857-1700

A1 Imaging of Ft Lauderdale 5100 N Federal Hwy #102 Ft Lauderdale, FL 33308 954-202-3400 Open MRI

A1 Imaging of Aventura 20880 W Dixie Hwy # 111 & 106 North Miami Beach, FL 33180 305-933-9565 Closed & Open MRI

A1 Imaging of Pembroke Pines 8384 Pines Blvd Pembroke Pines, FL 33024 954-450-4020 Open MRI

Diagnostic Professional 1799 West Oakland Park Blvd # 105 Fort Lauderdale, FL 33311 954-777-3466

Diagnostic Professional 6808 N State Road 7 Coconut Creek, FL 33073 954-570-5560

Primary and Urgent Care 3460 S Congress Ave Palm Springs, FL 33461 561-969-1595

A1 Imaging of Plantation 150 N University Dr # 110 Plantation, FL 33324 954-423-3674 Closed and Open MRI

A1 Imaging of St Augustine 200 Southpark Blvd Suite 210 St Augustine, FL 32086 904-819-0920 Open MRI

A1 Imaging of Deerfield 1890 W Hilllsboro Blvd Deerfield Beach, FL 33442 954-429-8381 Open MRI

Diagnostic Radiology / Centros de Diagnósticos Refer to Fee Schedule / Refiérase a la lista de tarifas Broward

A1 Imaging Centers, LLC-MRI Only/ MRI Solamente Refer to Fee Schedule / Refiérase a la lista de tarifa Florida

Diagnostic Radiology / Centros de Diagnósticos Refer to Fee Schedule / Refiérase a la lista de tarifas Orange

A1 Imaging of Ococee 9450 W Colonial Dr # 12 Ocoee, FL 34761 407-822-0999 Open MRI

Cleveland Radiology Center 12995 S Cleveland Blvd # 182 Fort Myers, FL 33904 239-791-8426

61

Diagnostic & Radiology Service Schedule / Tarifa de Servicios de Diagnóstico y Radiología

BREAST DIAGNOSTIC RADIOLOGY PROCEDURES

PROCEDURE CPT FEE

Diagnostic Digital Mammo G0204 $70.00

Screening Digital Mammo G0202 $70.00

US Breast Unilateral or Bilateral 76645 $70.00

Breast Biopsy Unilateral or Bilateral

19103

$600.00

19295*

76942**

G0206***

77051****

ULTRASOUNDS

ABDOMEN & RETROPERITINIUM

ECHOGRAPHY

PROCEDURE CPT FEE PROCEDURE CPT FEE

Abdomen Complete 76700 $70.00 Echo Complete W/Color & Flow Ultrasound 93306 $150.00

RUQ (Liver, Gallbladder & Pancreas) 76705 $70.00 Echo Stress Test W/Color & Flow 93306 $350.00

Liver 76705 $70.00 SMALL PARTS

Gallbladder 76705 $70.00 Abdominal Aorta 93979 $90.00

Pancreas 76705 $70.00 Carotid Doppler 93880 $90.00

Spleen 76705 $70.00 Arterial Lower Extremity Bilateral 93925/93923 $100.00

Renal 76775 $70.00 Arterial Lower Extremity Unilateral 93926/93923 $100.00

Bladder 76857 $70.00 Thyroid or Parotid Glands 76536 $60.00

Renal & Bladder 76770 $70.00 Head or Neck 76880 $60.00

Arterial Upper Extremity Bilateral 93930/93923 $90.00

PELVIS VENOUS STUDIES

Pelvic Complete 76856 $70.00 Arterial Upper Extremity Unilateral 93931/93923 $90.00

Pelvic Transvaginal 76830 $70.00 Venous Duplex Bilateral 93970 $90.00

Prostate Transabdominal 76857 $70.00

*19295 At time the surgeon may choose to do a biopsy and, at the same operative session, leave a metallic localization clip so that the site may be found later if it is necessary to

remove more tissue. The placement of a clip is reported using add-on code 19295, Image guided placement, metallic localization clip, percutaneous, during breast biopsy.

**76942 Ultrasonic guidance for needle placement (e.g. Biopsy, aspiration, injection, localization device), imaging supervision and interpretation.

***G0206 Diagnostic mammography, producing direct digital image, unilateral, all views.

****77051 Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitalization

of film radiographic images; diagnostic mammography (list separately in addition to code for primary procedure)

62


DIGITAL X-RAYS

PROCEDURE CPT FEE

PROCEDURE CPT FEE

Ankle (2 views) 73600 $25.00 Each View Hand (2 views) 73120 $25.00 each view

Ankle Complete (3 views) 73610 $25.00 Each View Hand (3 views) 73130 $25.00 each view

Bone Age 77072 $25.00 Hip Unilateral (1 view) 73500 $25.00 each view

Bone Length 77073 $25.00 Hip Bilateral (2 views) 73520 $25.00 each view

Calcaneus (2 views) 73650 $25.00 Each View Hip Complete (2 views) 73510 $25.00 each view

Cervical Spine (2 or 3 views) 72040 $25.00 Each View Knee (1 or 2 views) 73560 $25.00 each view

Cervical Spine (4 or more views) 72050 $25.00 Each View Knee (3 views) 73562 $25.00 each view

Cervical Spine Complete 72052 $25.00 Knee Complete (4 or more Views) 73564 $25.00 each view

Chest (Single View) 71010 $25.00 Knee Bilateral Standing 73565 $25.00

Chest (2 views) 71020 $25.00 Each View Lumbosacral (4 or more) 72110 $25.00

Chest Complete (4 views) 71030 $25.00 Lumbosacral Comp (Band V) 72114 $25.00

Chest (Special Views) 71035 $25.00 Mastoids 70120 $25.00

Chest (Oblique Projections) 71022 $25.00 Mastoids Complete (3 views) 70130 $25.00 each view

Chest (Stereo Frontal) 71015 $25.00 Nasal Bones 70160 $25.00

Chest (Apical Lordotic Proc) 71021 $25.00 Neck 70360 $25.00

Clavicle Complete 73000 $25.00 Osseous Survey (Single View) 77077 $25.00

Elbow (2 views) 73070 $25.00 Each View Osseous Survey Limited 77074 $25.00

Elbow Complete (3 views) 73080 $25.00 Each View Osseous Survey C Axial P 77075 $25.00

Eye 70030 $25.00 Pelvis (1 or 2 views) 72170 $25.00

Femur (2 views) 73550 $25.00 Each View Pelvis Complete (3 views) 72190 $25.00 each view

Fingers (2 views) 73140 $25.00 Each View Ribs Unilateral (2 views) 71100 $25.00 each view

Foot (2 views) 73620 $25.00 Each View Ribs Bilateral (3 views) 71110 $25.00 each view

Foot Complete (3 views) 73630 $25.00 Each View Ribs Posteroanter Chest (3V) 71101 $25.00

Forearm (2 views) 73090 $25.00 Each View Ribs Posteroanter Chest (4V) 71111 $25.00

63


NUCLEAR MEDICINE

PROCEDURE CPT MEDPLAN PROCEDURE CPT MEDPLAN

Bone Scan Whole Body 78306 $250.00 Stress Test Cardiolite 93015 / 78465 $450.00

78320 78478 / 78480 / A9500

A9503 Stress Test Thallium 93015 / 78465 $450.00

Bone Scan Limited $250.00 78478 / 78480 / A9505

78320 Multiple Renal Function 78709 $400.00

A9503 W/Vascular Flow W/Med A9562

Bone Scan 3 Phase 78315 $300.00 Lasix/Capt

78320 Renal Function W/O Pharmalogica 78707 $400.00

A9503 Renal Scan (morphology) 78700 $400.00

Bone Scan Multiple Areas 78305 $250.00 W/ Vascular Flow A9540 $425.00

78320 Renal Scan W/O Vascular 78700 $400.00

A9503 Flow A9540

Thyroid Scan Only 78010 $300.00 Renal Function W/ Vascular 78707 $400.00

A9516 Flow W/O Med A9562

Parathyroid Scan 78070 $250.00 Single Renal Function 78708 $450.00

A9500 W/ Vascular Flow W/Med A9562

Thyroid 24 hours (Uptake) 78001 $250.00 Lasix/Capt

Scan (Single) 78006 Gastric Emtying Study 78264 / A9541 $300.00

A9528 Hepabiliary Ductal System 78223

Thyroid 24 hours (Uptake) 78001 $250.00 Gallbladder HIDA A9537

Scan (Multiple) 98007 Hepatobiliary (HIDA) 78220 $300.00

A9528 Liver and Spleen Study 78215 $300.00

Muga Scan 93015 $300.00 Static A9541

78494/A9502/78465/78478/78480 Liver Spect W/O Vascular 78205 $300.00

Flow A9560

BONE DENSITOMETRY Liver Hemangomia W Flow and Spect 78206 / A9560 $300.00

PROCEDURE CPT MEDPLAN Liver Hemangomia W Flow / Flow 78202 / A9537 $300.00

DEXA Bone Density 77080 $65.00 Lung Perfusion Scan 78580 $300.00

Quantitative A9540

64


“MRI” MAGNETIC RESONANCE IMAGING

PROCEDURE CPT FEE

PROCEDURE CPT FEE

Abdomen W 74182 $325.00 ILIAC W/O 70551 $275.00

Abdomen W & W/O 74183 $375.00 Knee W 73722 $325.00

Abdomen W/O 74181 $275.00 Knee W & W/O 73723 $375.00

Ankle W 73722 $325.00 Knee W/O 73721 $275.00

Ankle W & W/O 73723 $375.00 Leg-Femur-TIB-FIB W 73719 $325.00

Ankle W/O 73721 $275.00 Leg-Femur-TIB-FIB W&W/O 73720 $375.00

Arm W 73219 $325.00 Leg-Femur-TIB-FIB W/O 73718 $275.00

Arm W & W/O 73220 $375.00 Lumbar Spine W 72149 $325.00

Arm W/O 73218 $275.00 Lumbar Spine W & W/O 72158 $375.00

Brain W 70552 $325.00 Lumbar Spine W/O 72148 $275.00

Brain W & W/O 70553 $375.00 Neck W 70542 $325.00

Brain W/O 70551 $275.00 Neck W & W/O 70543 $375.00

Breast Unilat W & W/O 77058 $475.00 Neck W/O 70540 $275.00

Breast Bilat W & W/O 77059 $475.00 Orbit W 70542 $325.00

Breast Implant W & W/O 77059 $475.00 Orbit W & W/O 70543 $375.00

Cervical Spine W 72142 $325.00 Orbit W/O 70540 $275.00

Cervical Spine W & W/O 72156 $375.00 Pelvis W 72196 $325.00

Cervical Spine W/O 72141 $275.00 Pelvis W & W/O 72197 $375.00

Chest W 71551 $325.00 Pelvis W/O 72195 $275.00

Chest W & W/O 71552 $375.00 Pituitary W 70552 $325.00

Chest W/O 71550 $275.00 Pituitary W & W/O 70553 $375.00

Elbow W 73222 $325.00 Pituitary W/O 70551 $275.00

Elbow W & W/O 73223 $375.00 Prostate W 72196 $325.00

Elbow W/O 73221 $275.00 Prostate W & W/O 72197 $375.00

Facial W 70542 $325.00 Prostate W/O 72195 $275.00

Facial W & W/O 70543 $375.00 Scrotum W 72196 $325.00

Facial W/O 70540 $275.00 Scrotum W & W/O 72197 $375.00

Foot W 73719 $325.00 Scrotum W/O 72195 $275.00

Foot W & W/O 73720 $375.00 Shoulder W 73222 $325.00

Foot W/O 73718 $275.00 Shoulder W & W/O 73223 $375.00

Hand W 73219 $325.00 Shoulder W/O 73221 $275.00

65


“MRI” MAGNETIC RESONANCE IMAGING

PROCEDURE CPT FEE

PROCEDURE CPT FEE

Hand W - W/O 73220 $375.00 Thoracic Spine W 72147 $325.00

Hand W/O 73218 $275.00 Thoracic Spine W & W/O 72157 $375.00

Hip W 73722 $325.00 Thoracic Spine W/O 72146 $275.00

Hip W & W/O 73723 $375.00 TMJ Joints W/O 70336 $275.00

Hip W/O 73721 $275.00 Wrist W 73222 $325.00

ILIAC W 70552 $325.00 Wrist W & W/O 73223 $375.00

ILIAC W & W/O 70553 $375.00 Wrist W/O 73221 $275.00

“CT SCAN” COMPUTED TOMOGRAPHY

PROCEDURE CPT FEE

PROCEDURE CPT FEE

Abdomen W 74160 $200.00 Lumbar Spine W 72132 $200.00

Abdomen W & W/O 74170 $275.00 Lumbar Spine W & W/O 72133 $275.00

Abdomen W/O 74150 $150.00 Lumbar Spine W/O 72131 $150.00

Cervical Spine W 72126 $200.00 Maxilofacial W 70487 $200.00

Cervical Spine W & W/O 72127 $275.00 Maxilofacial W & W/O 70488 $275.00

Cervical Spine W/O 72125 $150.00 Maxilofacial W/O 70486 $150.00

Chest W 71260 $200.00 Pelvis W 72193 $200.00

Chest W & W/O 71270 $275.00 Pelvis W & W/O 72194 $275.00

Chest W/O 71250 $150.00 Pelvis W/O 72192 $150.00

Head/Brain W 70460 $200.00 Sinuses W 70487 $200.00

Head/Brain W & W/O 70470 $275.00 Sinuses W & W/O 70488 $275.00

Head/Brain W/O 70450 $150.00 Sinuses W/O 70486 $150.00

IACS W 70481 $200.00 Soft Tissue Neck W 70491 $200.00

IACS W & W/O 70482 $275.00 Soft Tissue W & W/O 70492 $275.00

IACS W/O 70480 $150.00 Soft Tissue Neck W/O 70490 $150.00

Leg/Femur/TIB/FIB W 73701 $200.00 Thoracic Spine W 72129 $200.00

Leg/Femur/TIB/FIB W & W/O 73702 $275.00 Thoracic Spine W & W/O 72130 $275.00

Leg/Femur/TIB/FIB W/O 73700 $150.00 Thoracic Spine W/O 72128 $150.00

66

Kendall Regional Medical Office 11760 Bird Road # 714 Miami, FL 33175 786-621-5300

North Shore Medical Center 1100 NW 95 Street, S Lobby 1st Floor3 Miami, FL 33150 305-691-2180

South Miami 6200 Sunset Dr # 301 Miami, FL 33143 305-669-9521

Baptist Medical Arts Building 8940 N Kendall Dr # 901E Miami, FL 33176 786-621-7770

Mercy Hospital 3663 S Miami Ave # 5335 Miami, FL 33133 305-403-7600

Hialeah Hospital Office 777 E 25 Street # 402 Hialeah, FL 33013 305-835-7909

Mt Sinai Medical Center 4308 Alton Road #730 Miami Beach, FL 33140 305-403-1234

Perinatal Diagnostic Services Miami-Dade

PERINATAL DIAGNOSTIC SERVICES FEE SCHEDULE

SFPM Rates Ultrasound Fees Ultrasound SFPM Rates Fees

1st Tri<14 wks New 76801 $240.00 99241 Minor 15 minutes $125.00

1st Tri each Add Gest w/76801 76802 $140.00 99242 Low 30 Min $160.00

Complete Routine 76805 $245.00 99243 Moderate 40 Min $210.00

Comp Routine each Add Gestw/76805 76810 $230.00 99244 Mod High 60 Min $265.00

>1 Tri High Risk Detailed Targ - New 76811 $415.00 99251 Inpatient Consult 20 Min $115.00

>1 Tri High Risk Detailed Tgt eachAdd Gest w/76811 76812 $265.00 99252 Inpatient Consult 40 Min $175.00

OB/US Nuchal Measurement I Gest 76813 $230.00 99254 Inpatient Consult 80 Min $280.00

Nuchal Measurement each additional Gestation 76814 $155.00 59025 NST $125.00

Limited-quick look @1or more elements 76815 $175.00

Follow Up (re-eva org susp abnormal) 76816 $160.00 HIGH RISK PREGNANCY TESTS

OB Transvag (use in addition to transadom code) 76817 $230.00 Ultrasound Includes Counseling - SFPM Rates Fees

BPP w/NST 76818 $245.00 AMNIO

Guidance, Amnio 1,645.00

BPP w/out NST 76819 $230.00 Guidance, Amnio (Twins) 2,700.00

Doppler UA 76820 $180.00 CVS

Guidance, CVS 1,665.00

Doppler CA 76821 $225.00 CVS (Twins) 2,775.00

Vag. Ultra (non-obstetrical purposes) 76830 $265.00 1ST TRIMESTER SCREENING

Labs & Nuchal Translucency 805.00

Pelvic TR 76856 $225.00 Labs & Nuchal Translucency (Twins) 1,100.00

CVS Guidance 76945 $245.00 INTEGRATED SCREENING

NT 1st & 2nd Labs Included 900.00

Amnio Guidance 76946 $230.00 NT 1st & 2nd Labs Included (Twins) 1,195.00

Amnio 59000 $300.00 SEQUENTIAL SCREENING

NT and first part Labs 825.00

CVS 59015 $370.00 NT and first part Labs (Twins) 1,120.00

Minor 5 minute established 99211 $70.00

67

Sleep Study of South Florida Acuworks 14750 SW 26 Street # 213 Miami, FL 33185 786-476-7314

United Medical of South FL 14750 SW 26 Street # 213 Miami, FL 33185 786-476-7314

United Wellcare Center 12150 SW 128 CT #129 Miami, FL 33186 786-732-2593

Oscar Morell AP Health Promotions 912 SW 67 Ave Miami, FL 33144 305-261-4677

Larking Community Hospital Imaging Center 9835 SW 72 Street # 107 Miami, FL 33173 305-596-9992

Belgica Mock- Hearing Technician 8508 Bird Road Miami, FL 33155 305-610-5801 Wed Only

RT Professional 7374 NW 35 Ter # 102 Miami, FL 33122 305-418-8990

Belgica Mock- Hearing Specialist 1715 E Hallandale Beach Blvd Hallandale, FL 33009 305-610-5801 Mon, Tue & Thu

Selecta Physical Therapy 3934 SW 8 Street # 308 Coral Gables, FL 33134 786-953-6735

Associates Rehabilitation 13238 SW 8 Street Miami, FL 33184 305-552-9505

Florida Sleep and Neuro Diagnostic Services 14394 Commerce Way Miami Lakes, FL 33016 305-370-3100 Special Price $485.00 Free Transportation in Miami Dade and Broward

Sleep Study / Estudio del Sueño Miami-Dade $500.00

Alternative Medicine / Medicina Alternativa Miami-Dade 1st visit $60 – follow up $50

Hearing Aids / Suplementos Auditivos 1st visit $60 – follow up $40

Physical Therapy / Terapia física Refer to Fee Schedule / Refiérase a la lista de tarifas

Motion Recovery Corp 664 E 25 Street Suite 102 Hialeah, FL 33013 786-732-0189

Motion Recovery Corp 12595 SW 137 Ave Suite 104 Miami, FL 33186 786-732-0189

Ramon Garcia / Dayami Repelli One Stop Rehab Center 261 Westward Dr Suite 108-109 Miami Springs, FL 33166 305-200-5176

68

Physical Therapy Services Fee Schedule / Tarifa de precios y servicios Terapia física

Home Health Services / Servicios de Salud al Hogar Miami-Dade

CODES SERVICES Fees CODES SERVICES Fees

97010 Hot / Cold Pack $12.00 97110 Therapeutic Exercise $57.00

97010 Ice / Cryotherapy $12.00 97112 Neuromuscular Re-Education $63.00

97012 Mechanical Traction $33.34 97124 Massage $47.00

97014 E.M.S $26.50 97139 Hydro massage $17.00

97018 Paraffin Bath $18.40 97140 Manual Therapy $65.00

97026 Infrared $13.20 97140 Manual Traction $65.00

97032 E.M.S Attended $34.16 E0217 Water Circulating Cold $91.00

97034 Contrast Bath $32.00 E0218 Water Circulating Hot $91.00

97035 Ultrasound $27.50 97535 Self / Home Care $41.00

97039 Vibratory Massage $17.50

Alc Home Health Services & Physical Therapy Per Visit

Home Health Care. Preferred Home Health Agency Per Visit 13275 SW 124 Street, Miami, FL 33186 (305) 828-5310 13903 NW 67 Ave #420, Miami Lakes, FL 33014 (305) 231-4250

Home Health Aid $15.00 Home Health Aid $30.00

RN $29.00 Skilled Nursing $45.00

Physical Therapy $80.00 Physical Therapy $80.00

Occupational Therapy $80.00 Occupational Therapy $80.00

HHA or CAN $15.00

69

Ancillary Services / Servicios Auxiliares Miami-Dade

AMERIHEALTH MEDICAL GROUP 13985 SW 140th Street

Miami, FL 33189 305-238-8088

Durable Medical Supplies When ordering medical equipment, you must have a valid prescription signed by a licensed and authorized healthcare professional in the State of Florida indicating the supplies or equipment needed. You must present your Med Plan membership card with a picture ID so that your eligibility can be verified before your supplies are delivered and receive exclusive pricing. The Durable Medical Supplies offered to Med Plan members are as follows:

80% saving off provider's regular prices

Unlimited Access to all Durable Medical Services

Suministros Médicos Durables Al ordenar el equipo médico debe tener una prescripción valida firmada por un profesional de la salud licenciado y autorizado en el estado de la Florida que indique los suministros o equipo necesario. Debe presentar su tarjeta de membresía con una identificación con foto para que su elegibilidad pueda ser verificada antes de que sus suministros sean entregados y reciban precios exclusivos.

Los equipos Médicos Durables ofrecidos por Med Plan son los siguientes:

80% de descuento del precio regular del proveedor

Acceso ilimitado a todos los servicios de equipos médicos duraderos.

Durable Medical Equipment:

Description Price Additional Price

Wheelchair (purchase) / Silla de Ruedas (compra) $125.00

Hospital Bed (purchase) / Cama de Hospital (compra) $650.00

Oxygen (Monthly rental-Concentrator and 2 Portable Unites) $125.00

Additional Portable Units- $30.00/Tank Cada Tanque portatil adicional- $30.00 Oxigeno (renta mensual- concentrador y 2 unidades portatiles)

Cane / Baston $15.00

Walker / Andador $50.00

Crutches / Muletas $25.00

70

Orthopedic Supplies / Suplementos Ortopédicos Miami-Dade

Orthotics Center Inc Durable Medical Equipment (DME)

14331 SW 120 Street # 212 Miami, FL 33186

305-640-5966

Cpt Code Services Description New

A5500 X2 Off Shelf Diab Shoe/Zapatos $85.00

A5512 X2 Diab Multidensity Inserts/ Soporte De Diab Prefab $30.00

A5513 X2 Diab Multidensity Custom Insert / Soporte De Diab $50.00

L3002 X2 Diab Plastazote Custom Insert/ Soporte Acodativos De Diabéticos $131.00

L3350 X2 Heelwedge/ Soporte De Talón $35.00

L5000 X1 Insert For Missing Toes/Soporte Para Dedos Amputados $100.00

A6530 X2 Below Knee 13-30 Compression Stocking /Medias Para La Circulación A La Rodilla 18-30 $45.00

A6531 X2 Below Knee 30-40 Compression Stocking / Medias Para La Circulación A La Rodilla 30-40 $55.00

A6532 X2 Thigh Length 18-30 Compression Stocking/ Medias Para La Circulación Al Muslo 18-30 $60.00

A6534 X2 Thigh Length 30-40 Compression Stocking/ Medias Para La Circulación Al Muslo 30-40 $62.00

A6539 X2 Waist Length 18-30 Compression Stocking / Medias Para La Circulación Panty 18-30 Mmhg $170.00

A6540 X2 Waist Length 30-40 Compression Stocking / Medias Para La Circulación Panty 30-40 Mmhg $170.00

A6541 X2 Waist Lenght 40-50 Compression Stocking / Medias Para La Circulación Panty 40-50 Mmhg $179.00

L4360 X1 Air Cast Prefab $48.00

L4360 X1 Pneumatic Cam Walker Prefab / Bota De Marcha Inmovilizadora Neumática $141.00

L4386 X1 Regular Cam Walker Prefab / Bota De Marcha Inmovilizadora Corta O Larga $90.00

L4396 X1 Night Splint Prefab $79.00

L3000 X2 Ucbl Custom Foot Orthotic / Soporte A La Medida Tipo Ucb $286.00

L3010 X2 Custom Longitudinal Arch Support / Soporte Arco Longitudinal $131.00


L3020 X2 Custom Metatarsal Arch Support/ Soporte Longitudinal Metatarsiano $131.00

L1902 X2 Afo Gaulet Prefab / Afo Aoarato Para El Pie Tipo Guante Prefabricado $35.00

L1906 X1 Afo For Pptd Prefab / Afo Para Estabilizar El Pie Prefabricado $70.00

L1930 X1 Afo Plastic Prefab / Afo Plástico Prefabricado $67.00

L1940 X1 Afo Custom Fab/ Afo A La Medida $185.00

L 1960 X1 Afo Posterior Solid Ankle Custom / Afo A La Medida Con Refuerzo En El Tobillo $213.00

L8000 X1 Mastectomie Bras/ Ajustador De Mastectomía $22.00

L8020 X1 Breast Prosthesis Mastectomie Form Foam / Prótesis De Seno De Espuma $109.00

L8030 X1 Breast Prosthesis Silicone Or Equal / Prótesis De Seno En Silicona $118.00

L1810 X1 Ko, Elastic With Joints Prefab / Rodillera Sencilla Prefabricada $67.00

L1832 X1 Ko, Adjustable Knee Joint, Rigid Support Prefab / Rodillera Con Articulación Prefabricada $450.00

L1845 X1 Ko Double Upright, Thigh And Calf Prefab $450.00

L1847 X1 Ko Double Upright Air Prefab / Rodillera Con Articulación Prefab $300.00

L0190 X1 Cervical Collar Taylor Types/ Collar Cervical Tipo Taylor $220.00

L0700 X1 Ctlso Minerva Type Custom / Ctlso Tipo Minerva A La Medida $1,195.00

L0710 X1 Ctlso Anterior/Posterior Control Minerva Type Custom $1,319.00

L1300 X1 Scoliosis Jacket Custom/ Scoliosis Jacket A La Medida -

Lo462 X1 Tlso Triplanar 3 Plastic Shells/Tlso Triplanar 3 Módulos Plásticos $440.00

71

Orthopedic Supplies / Suplementos Ortopédicos Miami-Dade


L0464 X1 Tlso Modular Segmented 4 Plastic Sheels /Tlso Modular Segmentado 4 Plasticos $440.00

L0482 X1 Tlso Triplanar Control One Piece Rigid Plastic Sheel/ Tlso Control Triplanar Una Pieza Rigida En Plastico $795.00

L0486 X1 Tlso Triplanar Control Two Piece Rigid Plastic Shell/ Tlso Control Triplanar Dos Piezas Rigidas En Plastico $867.00

L0488 X1 Tlso Triplanar Control One Piece Rigid Plastic Shell $192.00

L0627 X1 Lso Sagital Control Rigid Panels/ Lso Control Sagital Paneles Rigidos $250.00

L0631 X1 Lso Sagital Control Posterior Extends, Reduce Load $600.00

L1686 X1 Hip Orthosis Abduction Control Prefab/ Aparato De Cadera Controla Abduccion $458.00

L2112 X1 Afo Tibial Fracture Orthosis, Soft Prefab / Afo Aparato Para Fractura Tibal Suave $281.00

L2114 X1 Afo Tibial Fracture Orthosis Semi Rigid Prefab $395.00

L2116 X1 Afo Tibial Fracture Orthosis Rigid Prefab / Aparato Para Fractura Femoral A La Medida $395.00

L2128 X1 Kafo Femoral Fracture Cast Orthosis Custom/ Kafo Aparato Para Fractura Femoral A La Medida $829.00

L2134 X1 Kafo Femoral Fracture Cast Orthosis Semirigid Prefab/ Aparato Para Fractura Femoral Semirigido Prefabricado $373.00

L3670 X1 So ( Canvas And Webbing Type ) Prefab/Cablestrillo De Brazo Prefabricado $46.00

L3760 X1 Elbow Orthosis With Adjustble Position Prefab/ Aparato De Codo Ajustable Prefabricado $227.00

L3908 X1 Wrist Hand Orthosis Prefab/ Muñequera Prefabricada $14.50

L3931 X1 Wrist Hand Finger Orthosis Prefab/ Muñequera Con Dedo Gordo $109.00

L3982 X1 Humeral Racture Orthosis Prefab/ Aparato De Fractura De Humerus Prefabricado $102.00

L3982 X1 Radius Ulnar Fracture Orthosis Prefab $185.00

L3984 X1 Wrist Fracture Orthosis Prefab / Aparato De Fractura De Nuñeca Prefabricada $207.00

L39995 X1 Addit Fracture Sock Or Equal $9.85

L8300 X1 Single Abdominal Binder / Faja Abdominal Sencilla $76.00

L8310 X1 Bilateral Abdominal Binder/ Fal Abdominal Bilateral $136.00

L1843 Perfect For Patient With Mild To Moderate Osteoarthritis Of The Knee $450.00

L1830 Designed For Acl Mcl Pcl And Soft Tissue Injuries $91.00

L3807 Ideal In Treating The Quervain Sydrome Game Keepers Thumb Carpometacarpal Instability $150.00

L3660 Designed To Treat Rotator Cuff Injuries, Shoulder Instabilities And Anterior Dislocation Of The G-H Joint $70.00

L1971 Designed For Acute And Chronic Ankle Sprains $220.00

L1951 Indicated For Peroneal Paralysis, Ankle Joint Arthritis And Post Operative Achilles Treatment $490.00

L4350 Indicated For Acute Ankle Sprains, Ankle Stability And Prophylactic Use $50.00

L3350 Designed To Correct Heel Posture And Uneven Shoe Wear , Heel Wedges Help Control Pronation $16.00

L3170 Molded From Medical Grade Soft Silicone With Soft Areas At Th Eheel Region To Help Reduce Pain $38.00

L0621 Sacroiliac Orthosis, Flexible Provides Sacral Support $67.00

L0174 Designed For Post-Operative Support And Control Of Unwanted Fexion And Extension -

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Diabetic Supplies / Suministros para Diabéticos Miami-Dade

Free Home Delivery* Unlimited Access to all Diabetic Supplies

When ordering diabetic supplies, you must have a valid prescription signed by a Med Plan participating physician indicating the supplies needed. *Note: Free delivery service is provided as a courtesy to Med Plan members but is subject to the Diabetes Medical Supply provider’s ability and the distance to the member’s delivery address.

Please call the provider for more details.

Entrega Gratis a Domicilio* Acceso ilimitado de todos los suministros para diabéticos

Al pedir suministros para Diabetes o algún equipo médico debe tener una receta de prescripción valida formada por su doctor donde se indique los suministros y equipos que necesita. *Nota: El servicio a domicilio es gratuito y se ofrece como una cortesía para los miembros de Med Plan, pero está sujeto a la capacidad del proveedor de los suministros y la distancia donde se encuentre el miembro como punto de entrega.

Por favor, llame al proveedor para obtener más detalles

Please Call Provider / Por favor llame al proveedor DIRECT MEDS OF FLORIDA

(954) 454-8118 Free shipping anywhere in the United States/ Envio gratis a cualquier lugar de Estados Unidos

Product Quantity Total Fee

Glucose Meter (glucometro) 1

$19.95 Lancets 100

Test Strips 50

MONTHLY RENEWABLE SUPPLIES

Product Quantity Total Fee

Glucose Meter Replacement (glucometro) 1 $2.50

Lancets 100 $9.99

Test Strips 50 $19.99

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Transportation Services / Servicios de transportación Miami-Dade

Medical Care Transportation

Patient Transportation Services

2766 NW 62 Ave Miami, FL 33147

305-633-0553

$26.00 Round trip within Miami-Dade

Reservation 24 hours in advance

$26.00 Ida y regreso dentro de Miami-Dade

Reservaciones con 24 horas de antelación

2019 premier plan - welcome - med|plan · • med plan does not make payments directly to our...

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