PPO and Non-PPO Plan Allowance Comparison


Emergency Room and Inpatient Consultations & Visits

   Emergency Department Visit - High Severity
   Emergency Department Visit - Low Severity
   Emergency Department Visit - Minor Severity
   Emergency Department Visit - Moderate Severity
   Follow-up Inpatient Visit 15 minutes
   Follow-up Inpatient Visit 25 minutes
   Initial Inpatient Consultation 20 minutes
   Initial Inpatient Consultation 40 minutes
   Initial Inpatient Consultation 55 minutes
   Initial Inpatient Visit 30 minutes
   Initial Inpatient Visit 50 minutes


   Immunization/Vaccination Additional
   Immunization/Vaccination Under 19 yrs
   Immunization/Vaccination Under 19 yrs Additional


   Allergy Testing (Per Test)
   Basic Metabolic Panel
   Chlamydia Test
   Cholesterol (Total)
   Complete Blood Count (CBC)
   Comprehensive Metabolic Panel
   Fecal Occult Blood Test
   General Health Panel
   Hemoglobin; Glycosylated (A1C)
   Hepatitis C
   Lipid Panel
   Liver Function Panel
   Obstetric Panel
   Pap Smear
   Prothrombin Time (PT)
   Renal Function Panel
   Strep Test
   Surgical Pathology
   Thyrotropin-releasing Hormone Test

Miscellaneous Services

   Allergy Injection
   Allergy Injections
   Collection of blood for lab work (capillary)
   Collection of blood for lab work (vein)

Office Consultations & Visits

   Office Consultation 15 minutes
   Office Consultation 30 minutes
   Office Visit 10 minutes
   Office Visit 15 minutes
   Office Visit 25 minutes


   Bone Density Study or DEXA Scan
   CT (CAT Scan) Head, no contrast
   CT (CAT Scan) Head, with contrast
   Chest X-ray, Single View
   Chest X-ray, Two Views
   X-ray, Ankle
   X-ray, Colon
   X-ray, Forearm
   X-ray, Hips
   X-ray, Knee
   X-ray, Lower Back
   X-ray, Lower leg
   X-ray, Shoulder
   X-ray, Upper Back
   X-ray, Upper GI tract
   X-ray, Upper arm
   X-ray, Upper leg
   X-ray, Wrist
   X-ray, small intestine


   Arm cast
   Below knee cast
   Biopsy - skin sample
   Cataract Surgery
   Central Venous Catheter Insertion
   Cutting or Trimming of nails - 6 or greater
   Cutting or Trimming of nails - up to five
   EGD - Esophagogastroduodenoscopy
   EGD - Esophagogastroduodenoscopy w/biopsy.
   Ear - removal of hardened ear wax
   Fluid withdrawal from breast cyst
   Injection into a tendon
   Knee - arthroscopic procedure
   Knee Replacement (Total Knee)
   Large joint aspiration or injection
   Lower back injection
   Medium joint aspiration or injection
   Muscle injections - three or more muscles
   Muscle injections - up to two muscles
   Newborn - by cesarean delivery
   Newborn - by vaginal delivery
   Prostate Biopsy
   Shoulder - arthroscopic procedure I
   Shoulder - arthroscopic procedure II
   Strapping of Lower Extremity, Unna boot
   Surgical removal of a single skin lesion
   Surgical removal of skin lesions - greater than 15
   Surgical removal of skin lesions - up to 14
   Surgical repair of inguinal hernia
   Surgical skin removal, cutting or trimming
   Tonsillectomy for Adult
   Tonsillectomy for Child
   Tube insertion into artery
   YAG Laser Capsulotomy


   Occupational Therapy
   Occupational Therapy - initial visit
   Physical Therapy
   Physical Therapy - initial visit
   Speech Therapy
   Speech Therapy Evaluation

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This tool is to provide you with basic information regarding the general cost of some standard health care services and the ability to compare our Network allowance with our standard Plan allowance. The amounts shown represent the most current data as obtained by the Plan. Rates are subject to change. The Network rate is based on the average PPO negotiated rate within a geographical area as determined by the zip code entered. Our Plan allowance is based on data gathered from health care sources that compare charges of other providers for similar services within the geographical area as determined by the zip code entered. This information is provided for illustrative purposes only. The amounts shown DO NOT include charges that may be incurred by a facility, such as a hospital, other professional fees, or prescription drug charges and also do not include copays or coinsurance. The actual provider charges may be different due to varying factors. Other charges from the provider may be associated with these services. Please refer to the current Plan Brochure for specific benefits. All benefits are subject to the definitions, limitations and exclusions of the Plan brochure. Please contact the Plan toll free at 1-888-636-NALC (6252) if you have additional questions.