Price lookup
Search a service and see its price with and without membership.
Member fee schedule, version 1
416 services
| Service | Code | Price without membership | Essential | Plus | Premier |
|---|---|---|---|---|---|
| Vitamin D, 25-Hydroxy Laboratory | SRV-9Z5KF5 | $40.00 | $36.00 | $34.00 | $32.00 |
| Diphenhydramine HCL Medication | J1200 | $40.00 | $36.00 | $34.00 | $32.00 |
| Hydroxyzine HCL Medication | J3410 | $40.00 | $36.00 | $34.00 | $32.00 |
| Ketorolac Tromethamine Medication | J1885 | $40.00 | $36.00 | $34.00 | $32.00 |
| Magnesium Sulfate Medication | J3475 | $40.00 | $36.00 | $34.00 | $32.00 |
| Methylprednisolone Acetate Medication | J1010 | $40.00 | $36.00 | $34.00 | $32.00 |
| Ondansetron Hydrochloride Medication | J2405 | $40.00 | $36.00 | $34.00 | $32.00 |
| Potassium Chloride Medication | J3480 | $40.00 | $36.00 | $34.00 | $32.00 |
| Prochlorperazine Medication | J0780 | $40.00 | $36.00 | $34.00 | $32.00 |
| Promethazine HCL Medication | J2550 | $40.00 | $36.00 | $34.00 | $32.00 |
| Pyridoxine Hydrochloride (Vitamin B6) Medication | J3415 | $40.00 | $36.00 | $34.00 | $32.00 |
| Thiamine Hydrochloride (Vitamin B1) Medication | J3411 | $40.00 | $36.00 | $34.00 | $32.00 |
| Triamcinolone Acetonide Medication | J3301 | $40.00 | $36.00 | $34.00 | $32.00 |
| Advanced 25 Minutes Office Visit | 99214 | $150.00 | $105.00 | $90.00 | $75.00 |
| Advanced 45 Minutes Office Visit | 99204 | $180.00 | $126.00 | $108.00 | $90.00 |
| Brief 10 Minutes Office Visit | 99201 | $180.00 | $126.00 | $108.00 | $90.00 |
| Brief 5 Minutes Office Visit | 99211 | $150.00 | $105.00 | $90.00 | $75.00 |
| Comprehensive 40 Minutes Office Visit | 99215 | $150.00 | $105.00 | $90.00 | $75.00 |
| Comprehensive 60 Minutes Office Visit | 99205 | $180.00 | $126.00 | $108.00 | $90.00 |
| Comprehensive Eye Exam Office Visit | SRV-6WFSG8 | $39.00 | $35.10 | $33.15 | $31.20 |
“—”: the plan has no special price for that service; its benefits or the price without membership apply.
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