Membership Savings Matrix Current as of 8/1/17
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1 Membership Savings Matrix Current as of 8/1/17 Drainage Of Skin Abscess I & D Complicated Or Multiple I & D Pilonidal Cyst Simple I & D Pilonidal Cyst Complicated Remove Foreign Body Simple Remove Foreign Body Complicated Drainage Of Hematoma/Fluid Debride Skin/Tissue Lesion Single Lesion 2 to4 Lesion over Biopsy of Skin - Single Lesion Biopsy of Skin - Separate/ Additional Lesion Removal of Skin Tags Arms/Legs 0.5 cm or less Arms/Legs cm Arms/Legs cm Arms/Legs cm Arms/Legs cm Excision Malig Lesion Face/Ears 0.5 cm or less Excision Malig Lesion Face/Ears cm Debridement of nail(s) Debridement of nail(s) 6 or more Removal Of Nail Plate Removal Of Nail Plate Add-On Drain Blood From Under Nail Removal Of Nail Bed Removal, drug delivery implant Trunk, Arms, Legs to 2.5cm Trunk, Arms, Legs cm Trunk, Arms, Legs cm Trunk, Arms, Legs cm Trunk, Arms, Legs cm Superficial Repair of Face to 2.5cm Superficial Repair of Face cm Superficial Repair of Face cm Superficial Repair of Face cm Superficial Repair of Face cm Superficial Repair of Face more than 30cm Arms, Legs to 2.5cm
2 Arms, Legs cm Arms, Legs cm Arms, Legs cm Arms, Legs cm Feet to 2.5cm Feet cm Feet cm Layer Repair of Face to 2.5cm Layer Repair of Face Layer Repair of Face cm Layer Repair of Face cm Complex Repair of Scalp, Arms, Legs cm Complex Repair of Scalp, Arms, Legs -Each Additional 5cm Complex Repair of Head To 2.5cm Complex Repair of Head cm Dress/Debrid P-Thick Burn, S Dress/Debrid P-Thick Burn, M Destruction Premalignant 1st lesion Destruction Premalignant 2-14 lesions Destruction Premalignant lesions 15+ Destruction Of Lesions Other Than Skin Tag to 14 Destruction Of Lesions Other Than Skin Tag to Destruction of Malignant Lesion Puncture Asp of Cyst of Breast Removal FB Muscle Tendon Simple Removal FB Muscle Tendon Complex Inj Tendon Sheath/Ligament Inj Trigger Point, 1 or 2 Muscles Inject Trigger Points, 3 or More Muscles Drain/Inject, Joint/Bursa - Sm Joint Drain/Inject, Joint/Bursa - Intermediate Joint Drain/Inject, Joint/Bursa - Major Joint Treat Shoulder Dislocation Treat Elbow Dislocation Treat Distal Radial FX W/ Treat Metacarpal Fx W/ Treat Phalanx Prox/Mid Fx W/ Treat Phalanx Distal Fx W/ Treat Phalangeal Dislocation Treat Knee Dislocation Treat Patellar Dislocation Treat Tibia Fx W/ Treat Distal Fibular Fx W/ Treat Metatarsal Fx W/ Treat Metatarsal Dislocation Apply Short Arm Cast Shoulder to Hand Apply Short Arm Cast Elbow to Finger Apply Arm Cast Hand and Lower forearm Apply Long Arm Splint Apply Forearm Splint Apply Finger Splint Apply Long Leg Cast Thigh to Toes Apply Short Leg Cast Below Knee to Toes Apply Walking/Ambulatory Cast Application, Long Leg Splint Application Lower Leg Splint Removal/Revision Of Cast Remove Nasal Foreign Body Control Of Nosebleed, Simple IV Start Lab - Venipuncture Routine Removal Of FB From Pharynx Incision of Thrombosed Hemorrhoid, Ext Excision of Thrombosed Hemorrhoid, Ext Insert of Non-Indwelling Bladder Cathet Insert of Temp Indwelling Bladder Cathet Destruction of Lesion Penis Cryosurgery I & D Gland Abcess Destruction of Lesions Vulva Simple Destruction of Vaginal Lesions simple
3 Pelvic Exam Removal of Intrauterine Device (IUD) Digital Block Remove Foreign Body From Eye-Superficial Remove Foreign Body From Eye-Embedded Remove Foreign Body W/Out Slit Remove Foreign Body W/Slit Clear Outer Ear Canal Remove Impacted Ear Wax Xray - Eye for Detection of Foreign Body Xray - Mandible 3 or less Xray - Mandible 4 or More Xray - Facial Bones Less than 3 Xray - Facial Bones 3 or More Xray - Nasal Bones Xray - Orbits Xray - Sinuses Xray - Sinuses Xray - Skull X-Ray - Neck, Soft Tissue Xray - Chest 1 View Xray - Chest PA & Lateral Xray - Ribs Unilateral X-Ray - Ribs 2V, Posteroanterior Chest 3 View Xray - Ribs Unilateral Xray - Ribs Bilateral & Chest Xray - Sternum Xray - Sternoclavicular Joint Xray - Cervical Xray - Cervical Xray - Thoracic X-Ray - Thoracolumbar Xray - Lumbar Xray - Lumbar X-ray - Lumbar 6 Min. (includes bending) Xray - Pelvis Xray - Pelvis Complete X-Ray - Sacroiliac Joints 3 + X-Ray - Sacrum and Coccyx Xray - Clavical Compete Xray - Scapula Complete Xray - Shoulder Complete 2 X-Ray - Acromioclavicular Joints Bilateral Xray - Humerus Xray - Elbow Xray - Elbow Complete Xray - Forearm Xray - Wrist Xray - Wrist Complete Xray - Hand Xray - Finger Xray - Hip 1 View Xray - Hip Complete Xray - Hip Complete 4 or more Xray - Hip Bilateral Xray - Hip Bilateral Xray - Femur X-Ray - Knee 1 or Xray - Knee Xray - Tibia & Fibula Xray - Ankle Complete Xray - Ankle Complete Xray - Foot Xray - Foot Complete Xray - Calcaneus Xray - Toes X-Ray - Abdomen 1 View X-Ray - Abdomen X-Ray - Abdomen Radiologist X-Ray Interpretation (WC Only) Comprehensive Metabolic Panel * Lipid Panel * Drug Screen Non-DOT 5 Panel * x Drug Screen Non-DOT 6 Panel * x Drug Screen Non-DOT 8 Panel * x Drug Screen Non-DOT 9 Panel * x Drug Screen Non-DOT 10 Panel * Drug Screen DOT 5 Panel * x Urine Dip, Nonauto W/O Scope Breath Alcohol Test x Breath Alcohol Test Confirmation x Breath Alcohol Test - DOT x Occult Blood, Feces Glucose Screening Puncture
4 HCG Chorionic Gonadotropin Qualitative CBC W/Auto Diff WBC, Complete * Heterophile Antibody/Mono Screening H. Pylori Qualitative/ Semiquantitative KOH Tissue Exam Rapid Flu Test Trichomonas Vaginalsis Strep A Assay W/Optic Bacterial Vaginosis Hep B Immune Globulin (HBIG), IM Immunization Admin Immunization Admin, Each Add Flu Vaccine, 3+ Yrs & Adult, IM Td Vaccine No Prsrv, > 7 Yr, IM Tdap vaccine 7 yrs/> im Hep B Vaccine, Adult, IM Audiometric Testing, Pure Tone Air Electrocardiogram, Complete Rhythm ECG Tracing Only, No Interpret Spirometry/Pulmonary Function Test Airway Inhalation Treatment Pulse Oximetry Intracutaneous tests (TB Screening) Interavenous Infusion, 31 Min to 1 hour Interavenous Infusion, each add hour Injection Charge - IM SQ Injection Charge Therapeutic - IV Injection Charge Therapeutic/ Each Add Sq of new subst Active Wound Care/20 Sq Cm Or < Active Wound Care/Each Add 20 Sq Cm Or < Drug Screen DOT Collection Only Drug Screen Non DOT Screen Collect x Drug Screen Ecup x Drug Screen Hair Collection x Drug Screen Non-Ecup x OHS Mandated Drug Screen x Clinical Surcharge (After Hours Collection Fee) Report or Forms - WC x Brief Answers to 1-5 Questions (No Dictation) x New Patient - Brief or 10 New Patient - Limited or 10 New Patient - Intermediate or 10 New Patient - Extended or 10 New Patient - Comprehensive or 10 Established Patient - Nurse or 10 Established Patient - Brief or 10 Established Patient - Limited or 10 Established Patient - Intermediate or 10 Established Patient - Extended or 10 Office Consultation: Intermediate Office Consultation: Extended Physical: Work Related Disability Physical: Basic x Physical: Intermediate & DOT x Physical: Complete x Irrigation Tray *No Charge Catheter Tray *No Charge Surgical Trays *No Charge Splint - Finger *No Charge Long Arm Splint Supplies x Long Leg Splint Supplies x Short Arm Splint Supplies x Short Leg Splint Supplies x Special Casting Material - by the Inch Cannula Nasal *No Charge Adaptic Gauze *No Charge Ace Bandage *No Charge Attorney Conference (15 > Minutes) x IME Review and Response Crutch Underarm Pair No Wood Admin Influenza Virus Vac Injection - Adrenalin 0.1mg Injection - Ancef 1gm Injection - Rocephin 250 mg Injection - Rocephin 500 mg Injection - Rocephin 1gm Injection - Depo-Medrol 20mg Injection - Depo-Medrol 40mg
5 Injection - Depo-Medrol 80mg Injection - Decadron 1mg Injection - Decadron 2mg Injection - Benadryl 50mg Injection - Toradol 60mg Injection - Toradol 30mg Injection - Morphine 10mg Injection - Narcan - 1mg Injection - Zofran (Ondansetron) 1mg Injection - Phenergan 50mg Injection - Phenegran 25mg Injection - SoluMedrol 125mg Injection - Fentanyl 0.1mg Injection - Kenalog 10mg Injection - Diazepam (Valium) Unclassified Drugs - EpiPen Auto-Injector x Normal Saline Infusion 500ml Unit SYNVISC & Synvisc-One Prednisone Oral GI Cocktail Protocol - UC x Influenza (Fluvirin) 4 Yrs & > x x Supplies for Cast - Long Arm x x Supplies for Cast - Short Arm x x Suppies for Splint - Long Arm x x Suppies for Splint - Short Arm x x Supplies for Cast - Short Leg x x Supplies for Cast/Splint - Long Leg x x Suppies for Splint - Short Leg x x Note: This is not an Insurance Plan and does not replace your insurance plan. Insurance will not be billed or claims filed. Individual members will pay all medical services when services are rendered. Monthly membership is automatically billed through debit or credit card. The Department of Consumer and Business Services issued a certification to this practice. You can contact consumer advocates at the Department of Consumer and Business Services at (888) , dcbs.insmail@state.or.us, or oregon.gov. The practice provides only the limited scope of primary care services specified in the retainer medical agreement. No Appointment Necessary Walk-Ins Weclome Online Check-In Visit MyUrgentCare365.com for more info Medford Ashland Grants Pass Brookings Prices current as of 8/1/17. Prices subject to change. Please contact Valley Immediate Care for additional information or with any questions E724
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