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TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles 08-13-2015 1 CÓDIGO COPAGO CÓDIGO COPAGO CÓDIGO COPAGO A-01 NADA A-51 $7.00 AA-02 $10.00 A-02 $5.00 A-52 $15.00 AA-03 NADA A-03 $5.00 A-53 $5.00 AA-04 $7.00 A-04 $5.00 A-54 $5.00 AA-05 $5.00 A-05 $5.00 A-55 $5.00 AA-06 $7.00 A-06 $5.00 A-56 $5.00 AA-07 $7.00 A-07 b A-57 $7.00 AA-08 $7.00 A-08 $5.00 A-58 * AA-09 $5.00 A-09 NADA A-59 $5.00 AA-10 $5.00 A-10 $5.00 A-60 $5.00 AA-11 $7.00 A-11 $5.00 A-61 $5.00 AA-12 $5.00 A-12 $5.00 A-62 * AA-13 $5.00 A-13 b A-63 * AA-14 $5.00 A-14 $7.00 A-64 * AA-15 $5.00 A-15 $7.00 A-65 $5.00 AA-16 $5.00 A-16 $10.00 A-66 $7.00 AA-17 * A-17 $5.00 A-67 NADA AA-18 $5.00 A-18 $5.00 A-68 $5.00 AA-19 $7.00 A-19 $5.00 A-69 $7.00 AA-20 NADA A-20 $7.00 A-70 $5.00 AA-21 $5.00 A-21 $5.00 A-71 $5.00 AA-22 $5.00 A-22 N/C A-72 $2.00 AA-23 $5.00 A-23 N/C A-73 $5.00 AA-24 NADA A-24 $7.00 A-74 NADA AA-25 $5.00 A-25 $7.00 A-75 $5.00 AA-26 $5.00 A-26 $5.00 A-76 NADA AA-27 * A-27 $5.00 A-77 $5.00 AA-28 $5.00 A-28 $5.00 A-78 NADA AA-29 $5.00 A-29 NADA A-79 NADA AA-30 $6.50 A-30 $10.00 A-80 $5.00 AA-31 NADA A-31 NADA A-81 $5.00 AA-32 $5.00 A-32 NADA A-82 $5.00 AA-33 $15.00 A-33 $5.00 A-83 $5.00 AA-34 * A-34 $5.00 A-84 $5.00 AA-35 $5.00 A-35 $5.00 A-85 * AA-36 $5.00 A-36 $5.00 A-86 $5.00 AA-37 $10.00 A-37 $5.00 A-87 * AA-38 $5.00 A-38 $5.00 A-88 $5.00 AA-39 * A-39 NADA A-89 NADA AA-40 NADA A-40 * A-90 * AA-41 $5.00 A-41 * A-91 NADA AA-42 $5.00 A-42 * A-92 NADA AA-43 * A-43 $5.00 A-93 NADA AA-44 $5.00 A-44 $5.00 A-94 $5.00 AA-45 $5.00 A-45 $5.00 A-95 $10.00 AA-46 $5.00 A-46 $5.00 A-96 $5.00 AA-47 $7.00 A-47 * A-97 NADA AA-48 * A-48 $5.00 A-98 $5.00 AA-49 $7.00 A-49 $5.00 A-99 NADA AA-50 $7.00 A-50 $5.00 AA-01 $5.00 AA-51 $7.00
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TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
1
CÓDIGO COPAGO CÓDIGO COPAGO CÓDIGO COPAGO
A-01 NADA A-51 $7.00 AA-02 $10.00 A-02 $5.00 A-52 $15.00 AA-03 NADA
A-03 $5.00 A-53 $5.00 AA-04 $7.00
A-04 $5.00 A-54 $5.00 AA-05 $5.00
A-05 $5.00 A-55 $5.00 AA-06 $7.00
A-06 $5.00 A-56 $5.00 AA-07 $7.00
A-07 b A-57 $7.00 AA-08 $7.00
A-08 $5.00 A-58 * AA-09 $5.00
A-09 NADA A-59 $5.00 AA-10 $5.00
A-10 $5.00 A-60 $5.00 AA-11 $7.00
A-11 $5.00 A-61 $5.00 AA-12 $5.00
A-12 $5.00 A-62 * AA-13 $5.00
A-13 b A-63 * AA-14 $5.00
A-14 $7.00 A-64 * AA-15 $5.00
A-15 $7.00 A-65 $5.00 AA-16 $5.00
A-16 $10.00 A-66 $7.00 AA-17 *
A-17 $5.00 A-67 NADA AA-18 $5.00
A-18 $5.00 A-68 $5.00 AA-19 $7.00
A-19 $5.00 A-69 $7.00 AA-20 NADA
A-20 $7.00 A-70 $5.00 AA-21 $5.00
A-21 $5.00 A-71 $5.00 AA-22 $5.00
A-22 N/C A-72 $2.00 AA-23 $5.00
A-23 N/C A-73 $5.00 AA-24 NADA
A-24 $7.00 A-74 NADA AA-25 $5.00
A-25 $7.00 A-75 $5.00 AA-26 $5.00
A-26 $5.00 A-76 NADA AA-27 *
A-27 $5.00 A-77 $5.00 AA-28 $5.00
A-28 $5.00 A-78 NADA AA-29 $5.00
A-29 NADA A-79 NADA AA-30 $6.50
A-30 $10.00 A-80 $5.00 AA-31 NADA
A-31 NADA A-81 $5.00 AA-32 $5.00
A-32 NADA A-82 $5.00 AA-33 $15.00
A-33 $5.00 A-83 $5.00 AA-34 *
A-34 $5.00 A-84 $5.00 AA-35 $5.00
A-35 $5.00 A-85 * AA-36 $5.00
A-36 $5.00 A-86 $5.00 AA-37 $10.00
A-37 $5.00 A-87 * AA-38 $5.00
A-38 $5.00 A-88 $5.00 AA-39 *
A-39 NADA A-89 NADA AA-40 NADA
A-40 * A-90 * AA-41 $5.00
A-41 * A-91 NADA AA-42 $5.00
A-42 * A-92 NADA AA-43 *
A-43 $5.00 A-93 NADA AA-44 $5.00
A-44 $5.00 A-94 $5.00 AA-45 $5.00
A-45 $5.00 A-95 $10.00 AA-46 $5.00
A-46 $5.00 A-96 $5.00 AA-47 $7.00
A-47 * A-97 NADA AA-48 *
A-48 $5.00 A-98 $5.00 AA-49 $7.00
A-49 $5.00 A-99 NADA AA-50 $7.00
A-50 $5.00 AA-01 $5.00 AA-51 $7.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
2
CÓDIGO COPAGO CÓDIGO COPAGO CÓDIGO COPAGO
AA-52 $5.00 AB-03 N/C AB-53 $5.00 AA-53 $5.00 AB-04 $5.00 AB-54 NADA
AA-54 $5.00 AB-05 $15.00 AB-55 *
AA-55 $5.00 AB-06 $5.00 AB-56 $5.00
AA-56 $5.00 AB-07 $5.00 AB-57 $7.00
AA-57 NADA AB-08 $5.00 AB-58 $5.00
AA-58 $5.00 AB-09 $7.00 AB-59 *
AA-59 $7.00 AB-10 $7.00 AB-60 $5.00
AA-60 NADA AB-11 $7.00 AB-61 $5.00
AA-61 N/C AB-12 $5.00 AB-62 $5.00
AA-62 $5.00 AB-13 $5.00 AB-63 B
AA-63 $5.00 AB-14 $5.00 AB-64 $5.00
AA-64 $5.00 AB-15 $10.00 AB-65 $5.00
AA-65 $5.00 AB-16 $7.00 AB-66 $5.00
AA-66 NADA AB-17 $5.00 AB-67 $5.00
AA-67 $5.00 AB-18 $5.00 AB-68 $5.00
AA-68 $5.00 AB-19 NADA AB-69 $5.00
AA-69 NADA AB-20 $5.00 AB-70 $5.00
AA-70 $5.00 AB-21 * AB-71 NADA
AA-71 $5.00 AB-22 $5.00 AB-72 B
AA-72 NADA AB-23 * AB-73 *
AA-73 $5.00 AB-24 $5.00 AB-74 $5.00
AA-74 $7.00 AB-25 $5.00 AB-75 $5.00
AA-75 $7.00 AB-26 $5.00 AB-76 NADA
AA-76 NADA AB-27 * AB-77 $5.00
AA-77 $7.00 AB-28 $5.00 AB-78 NADA
AA-78 $7.00 AB-29 $5.00 AB-79 $5.00
AA-79 $7.00 AB-30 $7.00 AB-80 $5.00
AA-80 $7.00 AB-31 * AB-81 NADA
AA-81 $15.00 AB-32 $10.00 AB-82 $5.00 AA-82 $5.00 AB-33 $5.00 AB-83 $5.00
AA-83 * AB-34 $5.00 AB-84 $10.00
AA-84 N/C
AB-35 NADA AB-85 $5.00
AA-85 $5.00
AB-36 $7.00 AB-86 $5.00
AA-86 $5.00
AB-37 $5.00 AB-87 $7.00
AA-87 $5.00
AB-38 $10.00
AB-88 $5.00 AA-88 $5.00
AB-39 $5.00
AB-89 $7.00
AA-89 $7.00
AB-40 NADA
AB-90 $5.00
AA-90 $5.00
AB-41 $5.00
AB-91 $7.00
AA-91 $7.00
AB-42 $5.00
AB-92 * AA-92 NADA
AB-43 $5.00
AB-93 $5.00 AA-93 $5.00
AB-44 $5.00
AB-94 $5.00
AA-94 NADA
AB-45 $5.00 AB-95 $5.00
AA-95 $5.00
AB-46 $7.00
AB-96 $5.00 AA-96 $5.00
AB-47 $5.00
AB-97 $7.00
AA-97 $5.00
AB-48 $5.00
AB-98 $5.00
AA-98 $7.00
AB-49 NADA
AB-99 $10.00 AA-99 $5.00
AB-50 $5.00
AC-01 b AB-01 $5.00
AB-51 $5.00
AC-02 $7.00
AB-02 NADA
AB-52 $10.00
AC-03 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
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CÓDIGO COPAGO CÓDIGO COPAGO CÓDIGO COPAGO
AC-04 $5.00 AC-55 $7.00 AD-24 $5.00 AC-05 $5.00 AC-56 $5.00 AD-25 $5.00
AC-06 $10.00 AC-57 $5.00 AD-26 $5.00
AC-07 * AC-58 $7.00 AD-27 $7.00
AC-08 $10.00 AC-59 $7.00 AD-28 $5.00
AC-09 $5.00 AC-60 $10.00 AD-29 $5.00
AC-10 $5.00 AC-61 $5.00 AD-30 $5.00
AC-11 $5.00 AC-62 * AD-31 $5.00
AC-12 $5.00 AC-63 $5.00 AD-32 $5.00
AC-13 $10.00 AC-64 $5.00 AD-33 NADA
AC-14 $5.00 AC-65 $10.00 AD-34 NADA
AC-15 $5.00 AC-66 $5.00 AD-35 $5.00
AC-16 $5.00 AC-67 $5.00 AD-36 B
AC-17 * AC-68 * AD-37 B
AC-18 $5.00 AC-69 $5.00 AD-38 B
AC-19 $5.00 AC-70 $10.00 AD-39 B
AC-20 $5.00 AC-71 $7.00 AD-40 $7.00
AC-21 $5.00 AC-72 $5.00 AD-41 b
AC-22 $5.00 AC-73 $5.00 AD-42 b
AC-23 $5.00 AC-74 $5.00 AD-43 $7.00 AC-24 $5.00 AC-75 $5.00 AD-44 $5.00
AC-25 $5.00 AC-76 NADA AD-45 $5.00
AC-26 * AC-77 $5.00 AD-46 $7.00
AC-27 * AC-78 $10.00 AD-47 $5.00
AC-28 * AC-79 $5.00 AD-48 *
AC-29 * AC-80 $5.00
AD-49 NADA
AC-30 * AC-81 $5.00 AD-50 $7.00
AC-31 * AC-82 $5.00 AD-51 $5.00
AC-32 $5.00 AC-83 $5.00 AD-52 $5.00
AC-33 * AC-84 $5.00 AD-53 $5.00
AC-34 * AC-85 $5.00 AD-54 $5.00
AC-35 $5.00 AC-86 $5.00 AD-55 $5.00
AC-36 NADA AC-87 $5.00 AD-56 $5.00
AC-37 $5.00 AC-88 $5.00 AD-57 $5.00
AC-38 $8.00 AC-89 $5.00 AD-58 $10.00
AC-39 $5.00 AC-90 $5.00 AD-59 $5.00
AC-40 $5.00 AC-91 B AD-60 $5.00
AC-41 * AC-92 * AD-61 $5.00
AC-42 $5.00 AC-93 B AD-62 $5.00
AC-43 * AC-94 $5.00 AD-63 *
AC-44 $5.00
AC-95 NADA AD-64 $5.00
AC-45 * AC-96 $5.00 AD-65 $5.00
AC-46 * AC-97 $7.00 AD-66 *
AC-47 NADA AC-98 NADA AD-67 *
AC-48 $5.00 AC-99 $5.00 AD-68 $5.00
AC-49 b AD-18 $5.00 AD-69 $5.00
AC-50 NADA AD-19 $5.00 AD-70 $5.00
AC-51 $10.00 AD-20 $7.00 AD-71 $5.00
AC-52 $7.00 AD-21 $7.00 AD-72 $5.00
AC-53 5.00 AD-22 $5.00 AD-73 $5.00
AC-54 NADA AD-23 $7.00 AD-74 $7.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
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CÓDIGO COPAGO CÓDIGO COPAGO CÓDIGO COPAGO
AD-75 $7.00 AE-22 * AE-68 $7.00 AD-76 $5.00 AE-23 $5.00 AE-69 $5.00
AD-77 $5.00 AE-24 NADA AE-70 $5.00
AD-78 $7.00 AE-25 NADA AE-71 $5.00
AD-79 * AE-26 $5.00 AE-72 $5.00
AD-80 NADA AE-27 $5.00 AE-73 $5.00
AD-81 $5.00 AE-28 NADA AE-74 $5.00
AD-82 $5.00 AE-29 $10.00 AE-75 $5.00
AD-83 $7.00 AE-30 $5.00 AE-76 $7.00
AD-84 $5.00 AE-31 $5.00 AE-77 $7.00
AD-85 * AE-32 $5.00 AE-78 $7.00
AD-86 $5.00
AE-33 $15.00 AE-79 $5.00
AD-87 $5.00
AE-34 $7.00 AE-80 $10.00
AD-88 $6.00
AE-35 $5.00 AE-81 $5.00
AD-89 $7.00
AE-36 $5.00 AE-82 b
AD-90 $5.00
AE-37 $5.00 AE-83 $8.00
AD-91 $5.00
AE-38 $5.00 AE-84 *
AD-92 * AE-39 $5.00 AE-85 b
AD-93 $5.00
AE-40 $7.00 AE-86 $5.00
AD-94 $10.00
AE-41 $7.00 AE-87 $7.00
AD-95 $10.00
AE-42 $5.00 AE-88 N/C
AD-96 $10.00
AE-43 $5.00 AE-89 $5.00
AD-97 $7.00
AE-44 N/C AE-90 $10.00
AD-98 $5.00
AE-45 * AE-91 NADA
AD-99 b
AE-46 $5.00 AE-92 $5.00
AE-01 $5.00 AE-47 $5.00 AE-93 $10.00
AE-02 $5.00 AE-48 $7.00 AE-94 $15.00
AE-03 $5.00 AE-49 NADA AE-95 $5.00
AE-04 $5.00 AE-50 NADA AE-96 $5.00
AE-05 $5.00 AE-51 $5.00 AE-97 $5.00
AE-06 $5.00 AE-52 NADA AE-98 c $5.00
AE-07 $10.00 AE-53 $2.00 AE-99 $5.00
AE-08 * AE-54 * AF-01 $5.00
AE-09 * AE-55 $7.00 AF-02 80%
AE-10 $7.00 AE-56 $5.00 AF-03 $5.00
AE-11 $5.00 AE-57 $5.00 AF-04 $5.00
AE-12 * AE-58 $5.00 AF-05 $10.00
AE-13 $5.00 AE-59 $7.00 AF-06 *
AE-14 NADA AE-60 * AF-07 $10.00
AE-15 $5.00 AE-61 $7.00 AF-08 $5.00
AE-16 $5.00 AE-62 $7.00 AF-09 $5.00
AE-17 NADA AE-63 b AF-10 $5.00
AE-18 NADA AE-64 $10.00 AF-11 NADA
AE-19 NADA AE-65 $5.00 AF-12 $5.00
AE-20 NADA AE-66 $10.00 AF-13 $5.00
AE-21 NADA AE-67 NADA AF-14 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
5
CÓDIGO COPAGO CÓDIGO COPAGO CÓDIGO COPAGO
AF-15 $5.00 AF-64 $5.00 AG-14 $5.00 AF-16 $5.00 AF-65 NADA AG-15 $7.00
AF-17 $5.00 AF-66 $5.00 AG-16 $5.00
AF-18 * AF-67 $5.00 AG-17 $5.00
AF-19 $7.00 AF-68 $5.00 AG-18 $7.00
AF-20 $7.00 AF-69 NADA AG-19 *
AF-21 $7.00 AF-70 * AG-20 $5.00
AF-22 $7.00 AF-71 * AG-21 $5.00
AF-23 $7.00 AF-72 * AG-22 $7.00
AF-24 $5.00 AF-73 * AG-23 $5.00
AF-25 $5.00 AF-74 * AG-24 $5.00
AF-26 $5.00 AF-75 * AG-25 $5.00
AF-27 $7.00 AF-76 * AG-26 $5.00
AF-28 $5.00 AF-77 * AG-27 $5.00
AF-29 $5.00 AF-78 * AG-28 $5.00
AF-30 * AF-79 * AG-29 $5.00
AF-31 $7.00 AF-80 * AG-30 $5.00
AF-32 $5.00 AF-81 * AG-31 $7.00
AF-33 $5.00 AF-82 * AG-32 $7.00
AF-34 $7.00 AF-83 * AG-33 $5.00
AF-35 $7.00 AF-84 * AG-34 N/C
AF-36 $5.00 AF-85 * AG-35 $5.00
AF-37 $5.00 AF-86 NADA AG-36 $5.00
AF-38 * AF-87 * AG-37 $5.00
AF-39 * AF-88 $5.00 AG-38 $7.00
AF-40 NADA AF-89 * AG-39 $5.00
AF-41 NADA AF-90 * AG-40 $8.00
AF-42 * AF-91 * AG-41 $5.00
AF-43 $5.00 AF-92 $5.00 AG-42 $5.00
AF-44 $5.00 AF-93 * AG-43 $5.00
AF-45 $5.00 AF-94 b AG-44 $5.00
AF-46 $5.00 AF-95 $5.00 AG-45 $10.00
AF-47 $5.00 AF-96 $5.00 AG-46 $5.00
AF-48 $5.00 AF-97 $5.00 AG-47 $5.00
AF-49 $5.00 AF-98 NADA AG-48 $5.00
AF-50 $5.00 AF-99 $5.00 AG-49 $5.00
AF-51 $5.00 AG-01 $10.00 AG-50 NADA
AF-52 $5.00 AG-02 $5.00 AG-51 $5.00
AF-53 NADA AG-03 $10.00 AG-52 $8.00
AF-54 NADA AG-04 $5.00 AG-53 $5.00
AF-55 $7.00 AG-05 $5.00 AG-54 $5.00
AF-56 $5.00 AG-06 $5.00 AG-55 $5.00
AF-57 $5.00 AG-07 NADA AG-56 NADA
AF-58 NADA AG-08 NADA AG-57 *
AF-59 $5.00 AG-09 $5.00 AG-58 $7.00
AF-60 * AG-10 $10.00 AG-59 $5.00
AF-61 $5.00 AG-11 NADA AG-60 $5.00
AF-62 $5.00 AG-12 $5.00 AG-61 $5.00
AF-63 $5.00 AG-13 $7.00 AG-62 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
6
CÓDIGO COPAGO CÓDIGO COPAGO CÓDIGO COPAGO
AG-63 $5.00 AH-13 $10.00 AH-62 $7.00 AG-64 NADA AH-14 $5.00 AH-63 $5.00 AG-65 $10.00 AH-15 $5.00 AH-64 NADA AG-66 $5.00 AH-16 $8.00 AH-65 * AG-67 $5.00 AH-17 NADA AH-66 $5.00 AG-68 $5.00 AH-18 $5.00 AH-67 * AG-69 $7.00 AH-19 $5.00 AH-68 $15.00
AG-70 $5.00 AH-20 $5.00 AH-69 *
AG-71 $5.00 AH-21 $5.00 AH-70 $7.00
AG-72 $5.00 AH-22 $5.00 AH-71 $5.00
AG-73 d NADA AH-23 $5.00 AH-72 $7.00 AG-74 $7.00 AH-24 $5.00 AH-73 k,j $10.00 AG-75 $5.00 AH-25 $5.00 AH-74 $5.00 AG-76 $5.00 AH-26 $7.00 AH-75 $10.00 AG-77 $5.00 AH-27 $7.00 AH-76 $5.00
AG-78 NADA AH-28 NADA AH-77 *
AG-79 $5.00 AH-29 * AH-78 $5.00 AG-80 $5.00 AH-30 $7.00 AH-79 $7.00
AG-81 * AH-31 $5.00 AH-80 $5.00 AG-82 $5.00 AH-32 $7.00 AH-81 $5.00 AG-83 $5.00 AH-33 $7.00 AH-82 $5.00 AG-84 $7.00 AH-34 $10.00 AH-83 N/C
AG-85 $5.00 AH-35 $10.00 AH-84 $5.00 AG-86 $5.00 AH-36 $25.00 AH-85 $5.00 AG-87 $10.00 AH-37 $10.00 AH-86 $5.00 AG-88 $10.00 AH-38 $5.00 AH-87 $15.00
AG-89 $10.00 AH-39 $10.00 AH-88 $5.00 AG-90 $5.00 AH-40 $5.00 AH-89 $10.00 AG-91 $5.00 AH-41 $5.00 AH-90 $5.00
AG-92 $5.00 AH-42 $5.00 AH-91 k, j $5.00 AG-93 $5.00 AH-43 $7.00 AH-92 k, j $5.00 AG-94 $5.00 AH-44 NADA AH-93 NADA AG-95 $5.00 AH-45 $5.00 AH-94 $7.00 AG-96 $5.00 AH-46 $7.00 AH-95 $5.00
AG-97 $5.00 AH-47 $10.00 AH-96 $5.00
AG-98 $5.00 AH-48 d NADA AH-97 $7.00
AG-99 $7.00 AH-49 $5.00 AH-98 $7.00
AH-01 $5.00 AH-50 $5.00 AH-99 $5.00
AH-02 $5.00 AH-51 $5.00 AI-01 $5.00
AH-03 $7.00 AH-52 NADA AI-02 $7.00
AH-04 $5.00 AH-53 $5.00 AI-03 $5.00
AH-05 $5.00 AH-54 NADA AI-04 $5.00
AH-06 d, NADA AH-55 $7.00 AI-05 N/C AH-07 d, NADA AH-56 NADA AI-06 * AH-08 N/C AH-57 NADA AI-07 l $10.00 AH-09 $5.00 AH-58 $7.00 AI-08 $5.00 AH-10 $5.00 AH-59 $7.00 AI-09 $7.00
AH-11 $5.00 AH-60 $7.00 AI-10 $5.00 AH-12 $7.00 AH-61 $7.00 AI-11 c, k $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
7
CÓDIGO COPAGO CÓDIGO COPAGO CÓDIGO COPAGO
AI-12 $5.00 AI-61 * AJ-11 n $5.00
AI-13 $7.00 AI-62 $5.00 AJ-12 $10.00
AI-14 $5.00 AI-63 * AJ-13 *
AI-15 $5.00 AI-64 $5.00 AJ-14 $5.00
AI-16 $7.00 AI-65 $5.00 AJ-15 $5.00
AI-17 $5.00 AI-66 $5.00 AJ-16 $2.00
AI-18 $5.00 AI-67 $7.00 AJ-17 NADA
AI-19 $5.00 AI-68 $5.00 AJ-18 NADA
AI-20 $5.00 AI-69 $5.00 AJ-19 NADA
AI-21 $5.00 AI-70 $5.00 AJ-20 $10.00
AI-22 $5.00 AI-71 * AJ-21 $10.00
AI-23 $5.00 AI-72 * AJ-22 $10.00
AI-24 $5.00 AI-73 * AJ-23 $7.00
AI-25 $5.00 AI-74 * AJ-24 $10.00
AI-26 $5.00 AI-75 * AJ-25 $5.00
AI-27 $15.00 AI-76 * AJ-26 $7.00
AI-28 $5.00 AI-77 * AJ-27 $5.00
AI-29 $5.00 AI-78 * AJ-28 $7.00
AI-30 b AI-79 * AJ-29 $15.00
AI-31 NADA AI-80 * AJ-30 $15.00
AI-32 NADA AI-81 * AJ-31 $7.00
AI-33 $5.00 AI-82 * AJ-32 $10.00
AI-34 $5.00 AI-83 * AJ-33 $10.00
AI-35 $5.00 AI-84 $5.00 AJ-34 *
AI-36 $5.00 AI-85 * AJ-35 $7.00
AI-37 NADA AI-86 * AJ-36 $7.00
AI-38 $10.00 AI-87 $5.00 AJ-37 $7.00
AI-39 $5.00 AI-88 $5.00 AJ-38 $5.00
AI-40 $8.00 AI-89 $5.00 AJ-39 $7.00
AI-41 NADA AI-90 b AJ-40 $7.00
AI-42 $5.00 AI-91 $7.00 AJ-41 $10.00
AI-43 $5.00 AI-92 $7.00 AJ-42 $5.00
AI-44 $5.00 AI-93 $5.00 AJ-43 $10.00
AI-45 NADA AI-94 $5.00 AJ-44 *
AI-46 NADA AI-95 $5.00 AJ-45 $7.00
AI-47 $5.00 AI-96 $10.00 AJ-46 $7.00
AI-48 $5.00 AI-97 $5.00 AJ-47 NADA
AI-49 $7.00 AI-98 $7.00 AJ-48 $7.00
AI-50 $7.00 AI-99 $5.00 AJ-49 *
AI-51 * AJ-01 NADA AJ-50 $7.00
AI-52 * AJ-02 NADA AJ-51 $7.00
AI-53 $5.00 AJ-03 NADA AJ-52 $10.00
AI-54 * AJ-04 NADA AJ-53 *
AI-55 * AJ-05 N/C AJ-54 $5.00
AI-56 * AJ-06 N/C AJ-55 n $5.00
AI-57 * AJ-07 $5.00 AJ-56 $10.00
AI-58 * AJ-08 $7.00 AJ-57 $7.00
AI-59 NADA AJ-09 NADA AJ-58 $5.00
AI-60 * AJ-10 N/C AJ-59 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
8
CÓDIGO COPAGO CÓDIGO COPAGO CÓDIGO COPAGO
AJ-60 $7.00 AK-10 $5.00 AK-59 $7.00
AJ-61 * AK-11 c, k $7.00 AK-60 $7.00
AJ-62 $10.00 AK-12 $5.00 AK-61 *
AJ-63 $5.00 AK-13 $7.00 AK-62 $0.00
AJ-64 $5.00 AK-14 $5.00 AK-63 $5.00
AJ-65 * AK-15 $10.00 AK-64 $5.00
AJ-66 * AK-16 $7.00 AK-65 *
AJ-67 $10.00 AK-17 $5.00 AK-66 $5.00
AJ-68 $10.00 AK-18 * AK-67 $5.00
AJ-69 * AK-19 $5.00 AK-68 *
AJ-70 $5.00 AK-20 $5.00 AK-69 *
AJ-71 $10.00 AK-21 $5.00 AK-70 *
AJ-72 NADA AK-22 $5.00 AK-71 *
AJ-73 $7.00 AK-23 $5.00 AK-72 $5.00
AJ-74 * AK-24 $5.00 AK-73 *
AJ-75 $10.00 AK-25 $5.00 AK-74 *
AJ-76 $10.00 AK-26 $5.00 AK-75 $5.00
AJ-77 * AK-27 $5.00 AK-76 *
AJ-78 NADA AK-28 $5.00 AK-77 $10.00
AJ-79 * AK-29 $5.00 AK-78 *
AJ-80 $10.00 AK-30 $5.00 AK-79 *
AJ-81 $10.00 AK-31 $5.00 AK-80 *
AJ-82 NADA AK-32 $5.00 AK-81 *
AJ-83 $10.00 AK-33 $5.00 AK-82 *
AJ-84 * AK-34 $7.00 AK-83 *
AJ-85 $5.00 AK-35 $5.00 AK-84 *
AJ-86 NADA AK-36 $5.00 AK-85 $5.00
AJ-87 $10.00 AK-37 $5.00 AK-86 $7.00
AJ-88 $5.00 AK-38 $5.00 AK-87 $10.00
AJ-89 NADA AK-39 $5.00 AK-88 $5.00
AJ-90 * AK-40 $7.00 AK-89 *
AJ-91 $7.00 AK-41 $5.00 AK-90 *
AJ-92 * AK-42 $10.00 AK-91 *
AJ-93 $7.00 AK-43 b AK-92 *
AJ-94 $5.00 AK-44 $7.00 AK-93 *
AJ-95 $10.00 AK-45 $7.00 AK-94 $5.00
AJ-96 $5.00 AK-46 $5.00 AK-95 $5.00
AJ-97 $5.00 AK-47 $10.00 AK-96 $7.00
AJ-98 NADA AK-48 $7.00 AK-97 *
AJ-99 $7.00 AK-49 b AK-98 *
AK-01 $5.00 AK-50 b AK-99 *
AK-02 d NADA AK-51 $7.00 AL-01 $5.00
AK-03 d NADA AK-52 $5.00 AL-02 $5.00
AK-04 $15.00 AK-53 $5.00 AL-03 d $5.00
AK-05 NADA AK-54 $10.00 AL-04 $5.00
AK-06 NADA AK-55 $7.00 AL-05 $5.00
AK-07 NADA AK-56 $5.00 AL-06 $5.00
AK-08 $10.00 AK-57 $5.00 AL-07 $5.00
AK-09 $5.00 AK-58 $5.00 AL-08 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
9
CÓDIGO COPAGO CÓDIGO COPAGO CÓDIGO COPAGO
AL-09 $5.00 AL-58 $7.00 AM-08 NADA
AL-10 $5.00 AL-59 $7.00 AM-09 b
AL-11 $5.00 AL-60 $10.00 AM-10 $5.00
AL-12 $5.00 AL-61 $7.00 AM-11 NADA
AL-13 $5.00 AL-62 $7.00 AM-12 $5.00
AL-14 $5.00 AL-63 $7.00 AM-13 NADA
AL-15 $5.00 AL-64 $7.00 AM-14 $5.00
AL-16 $5.00 AL-65 $5.00 AM-15 $5.00
AL-17 $5.00 AL-66 $7.00 AM-16 $7.00
AL-18 $5.00 AL-67 $5.00 AM-17 $5.00
AL-19 $5.00 AL-68 $7.00 AM-18 $5.00
AL-20 $5.00 AL-69 $5.00 AM-19 $5.00
AL-21 $5.00 AL-70 $10.00 AM-20 $5.00
AL-22 $5.00 AL-71 $5.00 AM-21 $5.00
AL-23 $7.00 AL-72 $7.00 AM-22 $8.00
AL-24 $7.00 AL-73 $5.00 AM-23 $7.00
AL-25 b AL-74 $7.00 AM-24 f NADA
AL-26 $5.00 AL-75 $7.00 AM-25 NADA
AL-27 $5.00 AL-76 $5.00 AM-26 $5.00
AL-28 $5.00 AL-77 $5.00 AM-27 $5.00
AL-29 $5.00 AL-78 $7.00 AM-28 $7.00
AL-30 $5.00 AL-79 $5.00 AM-29 $7.00
AL-31 $5.00 AL-80 $7.00 AM-30 NADA
AL-32 $5.00 AL-81 $5.00 AM-31 $5.00
AL-33 $5.00 AL-82 $5.00 AM-32 $5.00
AL-34 $5.00 AL-83 $5.00 AM-33 $5.00
AL-35 $5.00 AL-84 $5.00 AM-34 NADA
AL-36 $5.00 AL-85 $7.00 AM-35 $5.00
AL-37 $5.00 AL-86 $5.00 AM-36 $5.00
AL-38 $5.00 AL-87 $7.00 AM-37 $5.00
AL-39 $5.00 AL-88 $5.00 AM-38 $5.00
AL-40 $5.00 AL-89 $7.00 AM-39 $5.00
AL-41 $5.00 AL-90 $5.00 AM-40 $5.00
AL-42 $5.00 AL-91 $7.00 AM-41 $7.00
AL-43 $5.00 AL-92 $5.00 AM-42 $7.00
AL-44 $5.00 AL-93 $7.00 AM-43 $7.00
AL-45 $5.00 AL-94 $7.00 AM-44 g NADA
AL-46 $5.00 AL-95 $7.00 AM-45 $5.00
AL-47 $5.00 AL-96 $7.00 AM-46 *
AL-48 $5.00 AL-97 $7.00 AM-47 *
AL-49 $5.00 AL-98 $7.00 AM-48 *
AL-50 $5.00 AL-99 $5.00 AM-49 $5.00
AL-51 $5.00 AM-01 $5.00 AM-50 $5.00
AL-52 $5.00 AM-02 $5.00 AM-51 i, $4.00
AL-53 $5.00 AM-03 $5.00 AM-52 i, $4.00
AL-54 $5.00 AM-04 NADA AM-53 $5.00
AL-55 $5.00 AM-05 $7.00 AM-54 $7.00
AL-56 $5.00 AM-06 NADA AM-55 $7.00
AL-57 $7.00 AM-07 $5.00 AM-56 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
10
CÓDIGO COPAGO CÓDIGO COPAGO CÓDIGO COPAGO
AM-57 $5.00 * * * *
AM-58 $5.00 * * * *
AM-59 $5.00 * * * *
AM-60 $5.00 * * * *
AM-61 * * * * *
AM-62 $5.00 * * * *
AM-63 $5.00 * * * *
AM-64 $7.00 * * * *
AM-65 $5.00 * * * *
AM-66 $5.00 * * * *
AM-67 $5.00 * * * *
AM-68 * * * * *
AM-69 * * * * *
AM-70 * * * * *
AM-71 * * * * *
AM-72 $7.00 * * * *
AM-73 $7.00 * * * *
AM-74 $5.00 * * * *
AM-75 $5.00 * * * *
AM-76 $7.00 * * * *
AM-77 * * * * *
AM-78 $5.00 * * * *
AM-79 $10.00 * * * *
AM-80 $7.00 * * * *
AM-81 $5.00 * * * *
AM-82 b * * * *
AM-83 $5.00 * * * *
AM-84 $7.00 * * * *
AM-85 $5.00 * * * *
AM-86 $5.00 * * * *
AM-87 $5.00 * * * *
AM-88 $5.00 * * * *
AM-89 $5.00 * * * *
AM-90 $5.00 * * * *
AM-91 $5.00 * * * *
AM-92 $5.00 * * * *
AM-93 $10.00 * * * *
AM-94 $5.00 * * * *
AM-95 $5.00 * * * *
AM-96 $5.00 * * * *
AM-97 $5.00 * * * *
AM-98 $5.00 * * * *
AM-99 $5.00 * * * *
* * * * * *
* * * * * *
* * * * * *
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
11
CÓDIGO COPAGO CÓDIGO COPAGO CÓDIGO COPAGO
AN-01 $5.00 AN-51 $7.00 * *
AN-02 $5.00 AN-52 $5.00 * *
AN-03 $5.00 AN-53 $7.00 * *
AN-04 $5.00 AN-54 $7.00 * *
AN-05 $5.00 AN-55 $5.00 * *
AN-06 $5.00 AN-56 c, k $5.00 * *
AN-07 $5.00 AN-57 $10.00 * *
AN-08 * AN-58 $5.00 * *
AN-09 * AN-59 $5.00 * *
AN-10 * AN-60 $7.00 * *
AN-11 $7.00 AN-61 $7.00 * *
AN-12 $7.00 AN-62 $5.00 * *
AN-13 $10.00 AN-63 * * *
AN-14 $10.00 AN-64 $5.00 * *
AN-15 $10.00 AN-65 $7.00 * *
AN-16 * AN-66 $5.00 * *
AN-17 * AN-67 g $7.00 * *
AN-18 * AN-68 $5.00 * *
AN-19 * AN-69 $5.00 * *
AN-20 $5.00 AN-70 $5.00 * *
AN-21 * AN-71 * * *
AN-22 $5.00 AN-72 $5.00 * *
AN-23 * AN-73 $5.00 * *
AN-24 $5.00 AN-74 $5.00 * *
AN-25 * AN-75 $7.00 * *
AN-26 $7.00 AN-76 k, c $5.00 * *
AN-27 $5.00 AN-77 NADA * *
AN-28 $10.00 AN-78 $7.00 * *
AN-29 j $15.00 AN-79 NADA * *
AN-30 $5.00 AN-80 $7.00 * *
AN-31 $5.00 AN-81 $7.00 * *
AN-32 $5.00 AN-82 $5.00 * *
AN-33 $7.00 AN-83 $5.00 * *
AN-34 $5.00 AN-84 $5.00 * *
AN-35 $7.00 AN-85 $5.00 * *
AN-36 $7.00 AN-86 $10.00 * *
AN-37 $7.00 AN-87 $10.00 * *
AN-38 $7.00 AN-88 $10.00 * *
AN-39 $7.00 AN-89 $7.00 * *
AN-40 $5.00 AN-90 $10.00 * *
AN-41 * AN-91 $10.00 * *
AN-42 * AN-92 $5.00 * *
AN-43 * AN-93 $7.00 * *
AN-44 AN-94 $5.00 * *
AN-45 * AN-95 $5.00 * *
AN-46 $5.00 AN-96 * * *
AN-47 l $20.00 AN-97 * * *
AN-48 $10.00 AN-98 $5.00 * *
AN-49 $5.00 AN-99 $5.00 * *
AN-50 $5.00 * * * *
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
12
CÓDIGO COPAGO CÓDIGO COPAGO CÓDIGO COPAGO
AP-01 * AP-47 $5.00 AP-93 *
AP-02 $7.00 AP-48 $10.00 AP-94 *
AP-03 $7.00 AP-49 $10.00 AP-95 *
AP-04 $5.00 AP-50 $7.00 AP-96 *
AP-05 $5.00 AP-51 $5.00 AP-97 *
AP-06 $15.00 AP-52 $5.00 AP-98 *
AP-07 $10.00 AP-53 $5.00 AP-99 $7.00
AP-08 $5.00 AP-54 $10.00 *
AP-09 $7.00 AP-55 $7.00 * *
AP-10 $5.00 AP-56 $5.00 * *
AP-11 $10.00 AP-57 $5.00 * *
AP-12 $7.00 AP-58 $7.00 * *
AP-13 $10.00 AP-59 $7.00 * *
AP-14 NADA AP-60 $5.00 * *
AP-15 NADA AP-61 $5.00 * *
AP-16 NADA AP-62 $5.00 * *
AP-17 NADA AP-63 $10.00 * *
AP-18 * AP-64 NADA * *
AP-19 $7.00 AP-65 NADA * *
AP-20 NADA AP-66 $7.00 * *
AP-21 $7.00 AP-67 $10.00 * *
AP-22 $7.00 AP-68 $7.00 * *
AP-23 $7.00 AP-69 $5.00 * *
AP-24 $7.00 AP-70 $5.00 * *
AP-25 $7.00 AP-71 $10.00 * *
AP-26 $5.00 AP-72 $5.00 * *
AP-27 * AP-73 $5.00 * *
AP-28 $7.00 AP-74 NADA * *
AP-29 $10.00 AP-75 $7.00 * *
AP-30 $5.00 AP-76 $7.00 * *
AP-31 20% AP-77 $7.00 * *
AP-32 $7.00 AP-78 $7.00 * *
AP-33 $7.00 AP-79 $7.00 * *
AP-34 * AP-80 $10.00 * *
AP-35 NADA AP-81 $10.00 * *
AP-36 $7.00 AP-82 $7.00 * *
AP-37 $10.00 AP-83 $10.00 * *
AP-38 $15.00 AP-84 $7.00 * *
AP-39 NADA AP-85 * * *
AP-40 $5.00 AP-86 NADA * *
AP-41 $7.00 AP-87 NADA * *
AP-42 N/C AP-88 $5.00 * *
AP-43 $5.00 AP-89 $5.00 * *
AP-44 $5.00 AP-90 $7.00 * *
AP-45 $7.00 AP-91 $7.00 * *
AP-46 NADA AP-92 $7.00 * *
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
13
NOTAS: * Código sin asignar. N/C No cubre. (a) Periodo de espera. (b) Aplica al Programa Medicare Advantage
(c) Aplica hasta veinte (20) terapias por persona, por año póliza. (d) Sin límite. (e) Aplica hasta cuarenta (40) terapias por persona, por año póliza. (f) Aplica hasta quince (15) terapias por persona, por año póliza. (g) Aplica 3 tratamientos por día. (h) 40 por año póliza. (i) Hasta dos (2) por día hasta un máximo de cuarenta (40), por año póliza. (j) Aplica hasta un límite de diez (10) terapias por año póliza. (k) Aplica hasta dos (2) terapias diarias. (l) Cubre hasta 120 días por condición. () Versión de Cubiertas de Reforma de Salud Federal que incluyen beneficios que se considerarán como
Servicios Preventivos
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
14
Grupo Triple-S
CÓDIGO COASEGURO
B1 NADA
B2 $5.00
B3 $5.00
B4 $5.00
B5 NADA
B6 NADA
B7 NADA
B8 NADA
B9 NADA
B10 NADA
B11 NADA
B12 NADA
B13 NADA
B14 NADA
B15 NADA
B16 NADA
B17 $5.00
B18 NADA
B19 NADA
B20 NADA
B21 NADA
B22 NADA
B23 NADA
B24 NADA
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
15
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B25 $5.00 B75 $5.00 B125 $5.00 B26 $5.00 B76 $5.00 B126 $5.00 B27 $5.00 B77 $5.00 B127 $5.00 B28 $5.00 B78 $5.00 B128 $5.00 B29 $5.00 B79 $5.00 B129 $5.00 B30 $5.00 B80 $5.00 B130 $5.00 B31 $5.00 B81 $5.00 B131 $5.00 B32 $5.00 B82 $5.00 B132 $5.00 B33 $5.00 B83 $5.00 B133 $5.00 B34 $5.00 B84 $5.00 B134 $5.00 B35 $5.00 B85 $5.00 B135 $5.00 B36 $5.00 B86 $5.00 B136 $5.00 B37 $5.00 B87 $5.00 B137 $5.00 B38 $5.00 B88 $5.00 B138 $5.00 B39 $5.00 B89 $5.00 B139 $5.00 B40 $5.00 B90 $5.00 B140 $5.00 B41 $5.00 B91 $5.00 B141 $5.00 B42 $5.00 B92 $5.00 B142 $5.00 B43 $5.00 B93 $5.00 B143 $5.00 B44 $5.00 B94 $5.00 B144 $5.00 B45 $5.00 B95 $5.00 B145 $5.00 B46 $5.00 B96 $5.00 B146 $5.00 B47 $5.00 B97 $5.00 B147 $5.00 B48 $5.00 B98 $5.00 B148 $5.00 B49 $5.00 B99 $5.00 B149 $5.00 B50 $5.00 B100 $5.00 B150 $5.00 B51 $5.00 B101 $5.00 B151 $5.00 B52 $5.00 B102 $5.00 B152 $5.00 B53 $5.00 B103 $5.00 B153 $5.00 B54 $5.00 B104 $5.00 B154 $5.00 B55 $5.00 B105 $5.00 B155 $5.00 B56 $5.00 B106 $5.00 B156 $5.00 B57 $5.00 B107 $5.00 B157 $5.00 B58 $5.00 B108 $5.00 B158 $5.00 B59 $5.00 B109 $5.00 B159 $5.00 B60 $5.00 B110 $5.00 B160 $5.00 B61 $5.00 B111 $5.00 B161 $5.00 B62 $5.00 B112 $5.00 B162 $5.00 B63 $5.00 B113 $5.00 B163 $5.00 B64 $5.00 B114 $5.00 B164 $5.00 B65 $5.00 B115 $5.00 B165 $5.00 B66 $5.00 B116 $5.00 B166 $5.00 B67 $5.00 B117 $5.00 B167 $5.00 B68 $5.00 B118 $5.00 B168 $5.00 B69 $5.00 B119 $5.00 B169 $5.00 B70 $5.00 B120 $5.00 B170 $5.00 B71 $5.00 B121 $5.00 B171 $5.00 B72 $5.00 B122 $5.00 B172 $5.00 B73 $5.00 B123 $5.00 B173 $5.00 B74 $5.00 B124 $5.00 B174 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
16
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B175 $5.00 B225 $5.00 B275 $5.00 B176 $5.00 B226 $5.00 B276 $5.00 B177 $5.00 B227 $5.00 B277 $5.00 B178 $5.00 B228 $5.00 B278 $5.00 B179 $5.00 B229 $5.00 B279 $5.00 B180 $5.00 B230 $5.00 B280 $5.00 B181 $5.00 B231 $5.00 B281 $5.00 B182 $5.00 B232 $5.00 B282 $5.00 B183 $5.00 B233 $5.00 B283 $5.00 B184 $5.00 B234 $5.00 B284 $5.00 B185 $5.00 B235 $5.00 B285 $5.00 B186 $5.00 B236 $5.00 B286 $5.00 B187 $5.00 B237 $5.00 B287 $5.00 B188 $5.00 B238 $5.00 B288 $5.00 B189 $5.00 B239 $5.00 B289 $5.00 B190 $5.00 B240 $5.00 B290 $5.00 B191 $5.00 B241 $5.00 B291 $5.00 B192 $5.00 B242 $5.00 B292 $5.00 B193 $5.00 B243 $5.00 B293 $5.00 B194 $5.00 B244 $5.00 B294 $5.00 B195 $5.00 B245 $5.00 B295 $5.00 B196 $5.00 B246 $5.00 B296 $5.00 B197 $5.00 B247 $5.00 B297 $5.00 B198 $5.00 B248 $5.00 B298 $5.00 B199 $5.00 B249 $5.00 B299 $5.00 B200 $5.00 B250 $5.00 B300 $5.00 B201 $5.00 B251 $5.00 B301 $5.00 B202 $5.00 B252 $5.00 B302 $5.00 B203 $5.00 B253 $5.00 B303 $5.00 B204 $5.00 B254 $5.00 B304 $5.00 B205 $5.00 B255 $5.00 B305 $5.00 B206 $5.00 B256 $5.00 B306 $5.00 B207 $5.00 B257 $5.00 B307 $5.00 B208 $5.00 B258 $5.00 B308 $5.00 B209 $5.00 B259 $5.00 B309 $5.00 B210 $5.00 B260 $5.00 B310 $5.00 B211 $5.00 B261 $5.00 B311 $5.00 B212 $5.00 B262 $5.00 B312 $5.00 B213 $5.00 B263 $5.00 B313 $5.00 B214 $5.00 B264 $5.00 B314 $5.00 B215 $5.00 B265 $5.00 B315 $5.00 B216 $5.00 B266 $5.00 B316 $5.00 B217 $5.00 B267 $5.00 B317 $5.00 B218 $5.00 B268 $5.00 B318 $5.00 B219 $5.00 B269 $5.00 B319 $5.00 B220 $5.00 B270 $5.00 B320 $5.00 B221 $5.00 B271 $5.00 B321 $5.00 B222 $5.00 B272 $5.00 B322 $5.00 B223 $5.00 B273 $5.00 B323 $5.00 B224 $5.00 B274 $5.00 B324 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
17
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B325 $5.00 B375 $5.00 B425 $5.00 B326 $5.00 B376 $5.00 B426 $5.00 B327 $5.00 B377 $5.00 B427 $5.00 B328 $5.00 B378 $5.00 B428 $5.00 B329 $5.00 B379 $5.00 B429 $5.00 B330 $5.00 B380 $5.00 B430 $5.00 B331 $5.00 B381 $5.00 B431 $5.00 B332 $5.00 B382 $5.00 B432 $5.00 B333 $5.00 B383 $5.00 B433 $5.00 B334 $5.00 B384 $5.00 B434 $5.00 B335 $5.00 B385 $5.00 B435 $5.00 B336 $5.00 B386 $5.00 B436 $5.00 B337 $5.00 B387 $5.00 B437 $5.00 B338 $5.00 B388 $5.00 B438 $5.00 B339 $5.00 B389 $5.00 B439 $5.00 B340 $5.00 B390 $5.00 B440 $5.00 B341 $5.00 B391 $5.00 B441 $5.00 B342 $5.00 B392 $5.00 B442 $5.00 B343 $5.00 B393 $5.00 B443 $5.00 B344 $5.00 B394 $5.00 B444 $5.00 B345 $5.00 B395 $5.00 B445 $5.00 B346 $5.00 B396 $5.00 B446 $5.00 B347 $5.00 B397 $5.00 B447 $5.00 B348 $5.00 B398 $5.00 B448 $5.00 B349 $5.00 B399 $5.00 B449 $5.00 B350 $5.00 B400 $5.00 B450 $5.00 B351 $5.00 B401 $5.00 B451 $5.00 B352 $5.00 B402 $5.00 B452 $5.00 B353 $5.00 B403 $5.00 B453 $5.00 B354 $5.00 B404 $5.00 B454 $5.00 B355 $5.00 B405 $5.00 B455 $5.00 B356 $5.00 B406 $5.00 B456 $5.00 B357 $5.00 B407 $5.00 B457 $5.00 B358 $5.00 B408 $5.00 B458 $5.00 B359 $5.00 B409 $5.00 B459 $5.00 B360 $5.00 B410 $5.00 B460 $5.00 B361 $5.00 B411 $5.00 B461 $5.00 B362 $5.00 B412 $5.00 B462 $5.00 B363 $5.00 B413 $5.00 B463 $5.00 B364 $5.00 B414 $5.00 B464 $5.00 B365 $5.00 B415 $5.00 B465 $5.00 B366 $5.00 B416 $5.00 B466 $5.00 B367 $5.00 B417 $5.00 B467 $5.00 B368 $5.00 B418 $5.00 B468 $5.00 B369 $5.00 B419 $5.00 B469 $5.00 B370 $5.00 B420 $5.00 B470 $5.00 B371 $5.00 B421 $5.00 B471 $5.00 B372 $5.00 B422 $5.00 B472 $5.00 B373 $5.00 B423 $5.00 B473 $5.00 B374 $5.00 B424 $5.00 B474 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
18
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B475 $5.00 B525 $5.00 B575 $5.00 B476 $5.00 B526 $5.00 B576 $5.00 B477 $5.00 B527 $5.00 B577 $5.00 B478 $5.00 B528 $5.00 B578 $5.00 B479 $5.00 B529 $5.00 B579 $5.00 B480 $5.00 B530 $5.00 B580 $5.00 B481 $5.00 B531 $5.00 B581 $5.00 B482 $5.00 B532 $5.00 B582 $5.00 B483 $5.00 B533 $5.00 B583 $5.00 B484 $5.00 B534 $5.00 B584 $5.00 B485 $5.00 B535 $5.00 B585 $5.00 B486 $5.00 B536 $5.00 B586 $5.00 B487 $5.00 B537 $5.00 B587 $5.00 B488 $5.00 B538 $5.00 B588 $5.00 B489 $5.00 B539 $5.00 B589 $5.00 B490 $5.00 B540 $5.00 B590 $5.00 B491 $5.00 B541 $5.00 B591 $5.00 B492 $5.00 B542 $5.00 B592 $5.00 B493 $5.00 B543 $5.00 B593 $5.00 B494 $5.00 B544 $5.00 B594 $5.00 B495 $5.00 B545 $5.00 B595 $5.00 B496 $5.00 B546 $5.00 B596 $5.00 B497 $5.00 B547 $5.00 B597 $5.00 B498 $5.00 B548 $5.00 B598 $5.00 B499 $5.00 B549 $5.00 B599 $5.00 B500 $5.00 B550 $5.00 B600 $5.00 B501 $5.00 B551 $5.00 B601 $5.00 B502 $5.00 B552 $5.00 B602 $5.00 B503 $5.00 B553 $5.00 B603 $5.00 B504 $5.00 B554 $5.00 B604 $5.00 B505 $5.00 B555 $5.00 B605 $5.00 B506 $5.00 B556 $5.00 B606 $5.00 B507 $5.00 B557 $5.00 B607 $5.00 B508 $5.00 B558 $5.00 B608 $5.00 B509 $5.00 B559 $5.00 B609 $5.00 B510 $5.00 B560 $5.00 B610 $5.00 B511 $5.00 B561 $5.00 B611 $5.00 B512 $5.00 B562 $5.00 B612 $5.00 B513 $5.00 B563 $5.00 B613 $5.00 B514 $5.00 B564 $5.00 B614 $5.00 B515 $5.00 B565 $5.00 B615 $5.00 B516 $5.00 B566 $5.00 B616 $5.00 B517 $5.00 B567 $5.00 B617 $5.00 B518 $5.00 B568 $5.00 B618 $5.00 B519 $5.00 B569 $5.00 B619 $5.00 B520 $5.00 B570 $5.00 B620 $5.00 B521 $5.00 B571 $5.00 B621 $5.00 B522 $5.00 B572 $5.00 B622 $5.00 B523 $5.00 B573 $5.00 B623 $5.00 B524 $5.00 B574 $5.00 B624 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
19
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B625 $5.00 B675 $5.00 B725 $5.00 B626 $5.00 B676 $5.00 B726 $5.00 B627 $5.00 B677 $5.00 B727 $5.00 B628 $5.00 B678 $5.00 B728 $5.00 B629 $5.00 B679 $5.00 B729 $5.00 B630 $5.00 B680 $5.00 B730 $5.00 B631 $5.00 B681 $5.00 B731 $5.00 B632 $5.00 B682 $5.00 B732 $5.00 B633 $5.00 B683 $5.00 B733 $5.00 B634 $5.00 B684 $5.00 B734 $5.00 B635 $5.00 B685 $5.00 B735 $5.00 B636 $5.00 B686 $5.00 B736 $5.00 B637 $5.00 B687 $5.00 B737 $5.00 B638 $5.00 B688 $5.00 B738 $5.00 B639 $5.00 B689 $5.00 B739 $5.00 B640 $5.00 B690 $5.00 B740 $5.00 B641 $5.00 B691 $5.00 B741 $5.00 B642 $5.00 B692 $5.00 B742 $5.00 B643 $5.00 B693 $5.00 B743 $5.00 B644 $5.00 B694 $5.00 B744 $5.00 B645 $5.00 B695 $5.00 B745 $5.00 B646 $5.00 B696 $5.00 B746 $5.00 B647 $5.00 B697 $5.00 B747 $5.00 B648 $5.00 B698 $5.00 B748 $5.00 B649 $5.00 B699 $5.00 B749 $5.00 B650 $5.00 B700 $5.00 B750 $5.00 B651 $5.00 B701 $5.00 B751 $5.00 B652 $5.00 B702 $5.00 B752 $5.00 B653 $5.00 B703 $5.00 B753 $5.00 B654 $5.00 B704 $5.00 B754 $5.00 B655 $5.00 B705 $5.00 B755 $5.00 B656 $5.00 B706 $5.00 B756 $5.00 B657 $5.00 B707 $5.00 B757 $5.00 B658 $5.00 B708 $5.00 B758 $5.00 B659 $5.00 B709 $5.00 B759 $5.00 B660 $5.00 B710 $5.00 B760 $5.00 B661 $5.00 B711 $5.00 B761 $5.00 B662 $5.00 B712 $5.00 B762 $5.00 B663 $5.00 B713 $5.00 B763 $5.00 B664 $5.00 B714 $5.00 B764 $5.00 B665 $5.00 B715 $5.00 B765 $5.00 B666 $5.00 B716 $5.00 B766 $5.00 B667 $5.00 B717 $5.00 B767 $5.00 B668 $5.00 B718 $5.00 B768 $5.00 B669 $5.00 B719 $5.00 B769 $5.00 B670 $5.00 B720 $5.00 B770 $5.00 B671 $5.00 B721 $5.00 B771 $5.00 B672 $5.00 B722 $5.00 B772 $5.00 B673 $5.00 B723 $5.00 B773 $5.00 B674 $5.00 B724 $5.00 B774 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
20
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B775 $5.00 B825 $5.00 B875 $5.00 B776 $5.00 B826 $5.00 B876 $5.00 B777 $5.00 B827 $5.00 B877 $5.00 B778 $5.00 B828 $5.00 B878 $5.00 B779 $5.00 B829 $5.00 B879 $5.00 B780 $5.00 B830 $5.00 B880 $5.00 B781 $5.00 B831 $5.00 B881 $5.00 B782 $5.00 B832 $5.00 B882 $5.00 B783 $5.00 B833 $5.00 B883 $5.00 B784 $5.00 B834 $5.00 B884 $5.00 B785 $5.00 B835 $5.00 B885 $5.00 B786 $5.00 B836 $5.00 B886 $5.00 B787 $5.00 B837 $5.00 B887 $5.00 B788 $5.00 B838 $5.00 B888 $5.00 B789 $5.00 B839 $5.00 B889 $5.00 B790 $5.00 B840 $5.00 B890 $5.00 B791 $5.00 B841 $5.00 B891 $5.00 B792 $5.00 B842 $5.00 B892 $5.00 B793 $5.00 B843 $5.00 B893 $5.00 B794 $5.00 B844 $5.00 B894 $5.00 B795 $5.00 B845 $5.00 B895 $5.00 B796 $5.00 B846 $5.00 B896 $5.00 B797 $5.00 B847 $5.00 B897 $5.00 B798 $5.00 B848 $5.00 B898 $5.00 B799 $5.00 B849 $5.00 B899 $5.00 B800 $5.00 B850 $5.00 B900 $5.00 B801 $5.00 B851 $5.00 B901 $5.00 B802 $5.00 B852 $5.00 B902 $5.00 B803 $5.00 B853 $5.00 B903 $5.00 B804 $5.00 B854 $5.00 B904 $5.00 B805 $5.00 B855 $5.00 B905 $5.00 B806 $5.00 B856 $5.00 B906 $5.00 B807 $5.00 B857 $5.00 B907 $5.00 B808 $5.00 B858 $5.00 B908 $5.00 B809 $5.00 B859 $5.00 B909 $5.00 B810 $5.00 B860 $5.00 B910 $5.00 B811 $5.00 B861 $5.00 B911 $5.00 B812 $5.00 B862 $5.00 B912 $5.00 B813 $5.00 B863 $5.00 B913 $5.00 B814 $5.00 B864 $5.00 B914 $5.00 B815 $5.00 B865 $5.00 B915 $5.00 B816 $5.00 B866 $5.00 B916 $5.00 B817 $5.00 B867 $5.00 B917 $5.00 B818 $5.00 B868 $5.00 B918 $5.00 B819 $5.00 B869 $5.00 B919 $5.00 B820 $5.00 B870 $5.00 B920 $5.00 B821 $5.00 B871 $5.00 B921 $5.00 B822 $5.00 B872 $5.00 B922 $5.00 B823 $5.00 B873 $5.00 B923 $5.00 B824 $5.00 B874 $5.00 B924 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
21
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B925 $5.00 B975 $5.00 B1053 $5.00
B926 $5.00 B976 $5.00 B1054 $5.00
B927 $5.00 B977 $5.00 B1055 $5.00
B928 $5.00 B978 $5.00 B1056 $5.00
B929 $5.00 B979 $5.00 B1057 $5.00
B930 $5.00 B980 $5.00 B1062 $5.00
B931 $5.00 B981 $5.00 B1063 $5.00
B932 $5.00 B982 $5.00 B1064 $5.00
B933 $5.00 B983 $5.00 B1065 $5.00
B934 $5.00 B984 $5.00 B1066 $5.00
B935 $5.00 B985 $5.00 B1081 $5.00
B936 $5.00 B986 $5.00 B1082 $5.00
B937 $5.00 B987 $5.00 B1083 $5.00
B938 $5.00 B988 $5.00 B1092 $5.00
B939 $5.00 B989 $5.00 B1107 $5.00
B940 $5.00 B990 $5.00 B1290 $7.00
B941 $5.00 B991 $5.00 B1291 $7.00
B942 $5.00 B992 $5.00 B1300 $5.00
B943 $5.00 B993 $5.00 B1301 $5.00
B944 $5.00 B994 $5.00 B1302 $5.00
B945 $5.00 B995 $5.00 B1303 $5.00
B946 $5.00 B996 $5.00 B1304 $5.00
B947 $5.00 B997 $5.00 B1305 $5.00
B948 $5.00 B998 $5.00 B1322 $5.00
B949 $5.00 B999 $5.00 B1323 $5.00
B950 $5.00 B1000 $5.00 B1326 $5.00
B951 $5.00 B1010 $5.00 B1327 $5.00
B952 $5.00 B1012 $5.00 B1338 $5.00
B953 $5.00 B1017 $5.00 B1339 $5.00
B954 $5.00 B1018 $5.00 B1340 $5.00
B955 $5.00 B1019 $5.00 B1341 $5.00
B956 $5.00 B1020 $5.00 B1342 $5.00
B957 $5.00 B1023 $5.00 B1343 $5.00
B958 $5.00 B1024 $5.00 B1346 $5.00
B959 $5.00 B1025 $5.00 B1347 $5.00
B960 $5.00 B1027 $5.00 B1348 $5.00
B961 $5.00 B1028 $5.00 B1349 $5.00
B962 $5.00 B1029 $5.00 B1350 $5.00
B963 $5.00 B1036 $5.00 B1351 $5.00
B964 $5.00 B1037 $5.00 B1352 $5.00
B965 $5.00 B1038 $5.00 B1353 $5.00
B966 $5.00 B1044 $5.00 B1354 $5.00
B967 $5.00 B1045 $5.00 B1355 $5.00
B968 $5.00 B1046 $5.00 B1356 $5.00
B969 $5.00 B1047 $5.00 B1362 $5.00
B970 $5.00 B1048 $5.00 B1363 $5.00
B971 $5.00 B1049 $5.00 B1368 $5.00
B972 $5.00 B1050 $5.00 B1369 $5.00
B973 $5.00 B1051 $5.00 B1373 $5.00
B974 $5.00 B1052 $5.00 B1381 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
22
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B1382 $5.00 B1715 $5.00 B1941 $5.00
B1388 $5.00 B1716 $5.00 B1942 $5.00
B1389 $5.00 B1718 $10.00 B1943 $5.00
B1390 $5.00 B1719 $5.00 B1944 $5.00
B1396 $5.00 B1720 $7.00 B1945 $5.00
B1397 $5.00 B1721 $5.00 B1946 $5.00
B1407 $5.00 B1723 $5.00 B1947 $5.00
B1408 $5.00 B1724 $5.00 B1948 $5.00
B1409 $5.00 B1725 $5.00 B1949 $5.00
B1410 $5.00 B1727 $5.00 B1950 $5.00
B1411 $5.00 B1728 $5.00 B1951 $5.00
B1412 $5.00 B1734 $5.00 B1952 $5.00
B1413 $5.00 B1753 $5.00 B1953 $5.00
B1414 $5.00 B1754 $5.00 B1954 $5.00
B1415 $5.00 B1761 $5.00 B1955 $7.00
B1416 $5.00 B1882 $10.00 B1956 $5.00
B1419 $5.00 B1906 $5.00 B1957 $5.00
B1423 $5.00 B1907 $5.00 B1958 $5.00
B1424 $5.00 B1908 $5.00 B1959 $5.00
B1425 $5.00 B1909 $5.00 B1960 $5.00
B1429 $5.00 B1910 $5.00 B1961 $5.00
B1430 $5.00 B1911 $5.00 B1962 $5.00
B1431 $5.00 B1912 $5.00 B1963 $5.00
B1432 $5.00 B1913 $5.00 B1964 $5.00
B1433 $5.00 B1914 $5.00 B1965 $5.00
B1434 $5.00 B1915 $5.00 B1966 $5.00
B1437 $5.00 B1916 $5.00 B1967 $5.00
B1438 $5.00 B1917 $5.00 B1968 $5.00
B1440 $5.00 B1918 $5.00 B1969 $5.00
B1441 $5.00 B1919 $5.00 B1970 $5.00
B1447 $5.00 B1920 $5.00 B1971 $5.00
B1456 $5.00 B1921 $5.00 B1972 $5.00
B1461 $5.00 B1922 $5.00 B1973 $5.00
B1473 $5.00 B1923 $5.00 B1974 $5.00
B1574 $7.00 B1924 $5.00 B1975 $5.00
B1575 $7.00 B1925 $5.00 B1976 $5.00
B1602 $5.00 B1926 $7.00 B1977 $5.00
B1603 $5.00 B1927 $5.00 B1978 $5.00
B1608 $5.00 B1929 $5.00 B1979 $5.00
B1609 $5.00 B1930 $5.00 B1980 $5.00
B1623 $7.00 B1931 $5.00 B1981 $5.00
B1706 $5.00 B1932 $5.00 B1982 $5.00
B1707 $5.00 B1933 $5.00 B1983 $5.00
B1708 $5.00 B1934 $5.00 B1984
B1709 $5.00 B1935 $5.00 B1985 $5.00
B1710 $5.00 B1936 $5.00 B1986 $5.00
B1711 $5.00 B1937 $5.00 B1987 $5.00
B1712 $5.00 B1938 $5.00 B1988 $5.00
B1713 $5.00 B1939 $7.00 B1989 $5.00
B1714 N/C B1940 $5.00 B1990 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
23
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B1991 $5.00 B2041 $5.00 B2091 $5.00
B1992 $5.00 B2042 $5.00 B2092 $5.00
B1993 $5.00 B2043 $5.00 B2093 $5.00
B1994 $5.00 B2044 $5.00 B2094 $5.00
B1995 $5.00 B2045 $5.00 B2095 $5.00
B1996 $5.00 B2046 $5.00 B2096 $5.00
B1997 $5.00 B2047 $5.00 B2097 $7.00
B1998 $5.00 B2048 $5.00 B2098 $7.00
B1999 $5.00 B2049 $5.00 B2099 $7.00
B2000 $5.00 B2050 $5.00 B2100 $5.00
B2001 $5.00 B2051 $5.00 B2101 $7.00
B2002 $5.00 B2052 $5.00 B2102 $5.00
B2003 $5.00 B2053 $5.00 B2103 $10.00
B2004 $5.00 B2054 $5.00 B2104 $5.00
B2005 $5.00 B2055 $5.00 B2105 $7.00
B2006 $5.00 B2056 $5.00 B2106 $7.00
B2007 $5.00 B2057 $5.00 B2107 $10.00
B2008 $5.00 B2058 $5.00 B2108 N/C
B2009 $5.00 B2059 $5.00 B2109 $5.00
B2010 $5.00 B2060 $5.00 B2110 $5.00
B2011 $5.00 B2061 $7.00 B2111 $2.00
B2012 $5.00 B2062 $5.00 B2112 $5.00
B2013 $5.00 B2063 $5.00 B2113 $5.00
B2014 $5.00 B2064 $5.00 B2114 $5.00
B2015 $5.00 B2065 $5.00 B2115 $5.00
B2016 $5.00 B2066 $5.00 B2116 $10.00
B2017 $5.00 B2067 $7.00 B2117 $5.00
B2018 $5.00 B2068 $5.00 B2118 $5.00
B2019 $5.00 B2069 $7.00 B2119 $5.00
B2020 $5.00 B2070 $5.00 B2120 $5.00
B2021 $5.00 B2071 $5.00 B2121 $5.00
B2022 $5.00 B2072 $5.00 B2122 $5.00
B2023 $5.00 B2073 $5.00 B2123 $5.00
B2024 $5.00 B2074 $5.00 B2124 $5.00
B2025 $5.00 B2075 $5.00 B2125 $5.00
B2026 $5.00 B2076 $5.00 B2126 $7.00
B2027 $5.00 B2077 $5.00 B2127 $5.00
B2028 $5.00 B2078 $7.00 B2128 $5.00
B2029 $5.00 B2079 $5.00 B2129 $5.00
B2030 $5.00 B2080 $5.00 B2130 N/C
B2031 $5.00 B2081 $5.00 B2131 $5.00
B2032 $5.00 B2082 $5.00 B2132 $5.00
B2033 $5.00 B2083 $5.00 B2133 $5.00
B2034 $5.00 B2084 $5.00 B2134 N/C
B2035 $5.00 B2085 $5.00 B2135 N/C
B2036 $5.00 B2086 $5.00 B2136 $5.00
B2037 $5.00 B2087 $5.00 B2137 $15.00
B2038 $5.00 B2088 $7.00 B2138 $5.00
B2039 $5.00 B2089 $5.00 B2139 $10.00
B2040 $5.00 B2090 $5.00 B2140 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
24
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B2141 $8.00 B2191 $5.00 B2241 $5.00
B2142 $8.00 B2192 $5.00 B2242 $5.00
B2143 $8.00 B2193 $5.00 B2243 $5.00
B2144 $8.00 B2194 $5.00 B2244 $5.00
B2145 $8.00 B2195 $5.00 B2245 $5.00
B2146 $8.00 B2196 $7.00 B2246 $5.00
B2147 $5.00 B2197 $5.00 B2247 $5.00
B2148 $5.00 B2198 $5.00 B2248 $5.00
B2149 $5.00 B2199 $5.00 B2249 $5.00
B2150 $5.00 B2200 $5.00 B2250 $5.00
B2151 $5.00 B2201 $5.00 B2251 $5.00
B2152 $5.00 B2202 $5.00 B2252 $5.00
B2153 N/C B2203 N/C B2253 $5.00
B2154 $5.00 B2204 $5.00 B2254 $5.00
B2155 $5.00 B2205 $8.00 B2255 $5.00
B2156 $5.00 B2206 $7.00 B2256 $5.00
B2157 $5.00 B2207 $5.00 B2257 $7.00
B2158 $5.00 B2208 $5.00 B2258 $5.00
B2159 $5.00 B2209 $5.00 B2259 $5.00
B2160 $5.00 B2210 $5.00 B2260 $5.00
B2161 N/C B2211 $5.00 B2261 $7.00
B2162 $5.00 B2212 $5.00 B2262 $10.00
B2163 $5.00 B2213 $5.00 B2263 $5.00
B2164 $5.00 B2214 $5.00 B2264 $7.00
B2165 $5.00 B2215 $5.00 B2265 $5.00
B2166 $5.00 B2216 $5.00 B2266 $5.00
B2167 $5.00 B2217 $5.00 B2267 $5.00
B2168 $5.00 B2218 $5.00 B2268 $5.00
B2169 $5.00 B2219 $5.00 B2269 $5.00
B2170 $5.00 B2220 $5.00 B2270 $7.00
B2171 $5.00 B2221 $5.00 B2271 $7.00
B2172 $5.00 B2222 $5.00 B2272 $5.00
B2173 $5.00 B2223 $5.00 B2273 $7.00
B2174 $7.00 B2224 $5.00 B2274 $5.00
B2175 $5.00 B2225 $5.00 B2275 $5.00
B2176 $5.00 B2226 $5.00 B2276 $5.00
B2177 $5.00 B2227 $5.00 B2277 $10.00
B2178 $5.00 B2228 $5.00 B2278 $10.00
B2179 $5.00 B2229 $5.00 B2279 $10.00
B2180 $5.00 B2230 $5.00 B2280 $5.00
B2181 $5.00 B2231 $5.00 B2281 $5.00
B2182 $5.00 B2232 $5.00 B2282 N/C
B2183 $5.00 B2233 $5.00 B2283 $5.00
B2184 $5.00 B2234 $5.00 B2284 $5.00
B2185 $5.00 B2235 $5.00 B2285 $5.00
B2186 $5.00 B2236 $5.00 B2286 $0.00
B2187 $5.00 B2237 $5.00 B2287 $5.00
B2188 $5.00 B2238 $5.00 B2288 $5.00
B2189 $5.00 B2239 $7.00 B2289 $10.00
B2190 $5.00 B2240 $7.00 B2290 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
25
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B2291 $5.00 B2342 $5.00 B2392 N/C
B2292 $5.00 B2343 $5.00 B2393 $10.00
B2293 $5.00 B2344 $5.00 B2394 $10.00
B2294 $10.00 B2345 $5.00 B2395 $10.00
B2295 $5.00 B2346 $5.00 B2396 $5.00
B2296 $5.00 B2347 $5.00 B2397 $5.00
B2297 $10.00 B2348 $5.00 B2398 $10.00
B2298 $10.00 B2349 $5.00 B2399 $5.00
B2299 $5.00 B2350 $5.00 B2400 $5.00
B2300 $5.00 B2351 $5.00 B2401 $5.00
B2301 $10.00 B2352 $5.00 B2402 N/C
B2302 $10.00 B2353 $5.00 B2403 N/C
B2303 $10.00 B2354 N/C B2404 $5.00
B2304 $5.00 B2355 $7.00 B2405
B2305 $7.00 B2356 $7.00 B2406 $7.00
B2306 $5.00 B2357 $5.00 B2407 $5.00
B2307 $10.00 B2358 $5.00 B2408 N/C
B2308 $5.00 B2359 $10.00 B2409 N/C
B2309 $5.00 B2360 N/C B2410 $7.00
B2310 $10.00 B2361 $5.00 B2411 $10.00
B2311 $5.00 B2362 $5.00 B2412 N/C
B2312 $5.00 B2363 $7.00 B2413 $5.00
B2313 $7.00 B2364 $5.00 B2414 $5.00
B2315 $7.00 B2365 $5.00 B2415 $5.00
B2316 $7.00 B2366 $5.00 B2416 $5.00
B2317 $5.00 B2367 $7.00 B2417 $5.00
B2318 $7.00 B2368 $5.00 B2418 $5.00
B2319 $7.00 B2369 $5.00 B2419 $5.00
B2320 $5.00 B2370 $7.00 B2420 $5.00
B2321 $5.00 B2371 $5.00 B2421 $5.00
B2322 $7.00 B2372 $7.00 B2422 N/C
B2323 $5.00 B2373 $7.00 B2423 N/C
B2324 N/C B2374 $7.00 B2424 $10.00
B2325 N/C B2375 $5.00 B2425 $5.00
B2326 $5.00 B2376 $5.00 B2426 $5.00
B2327 $5.00 B2377 $5.00 B2427 $5.00
B2328 $5.00 B2378 $5.00 B2428 $7.00
B2329 $5.00 B2379 $5.00 B2429 $7.00
B2330 $10.00 B2380 $5.00 B2430 $7.00
B2331 $5.00 B2381 $5.00 B2431 $7.00
B2332 $5.00 B2382 $8.00 B2432 $7.00
B2333 $7.00 B2383 $8.00 B2433 $7.00
B2334 N/C B2384 $5.00 B2434 $7.00
B2335 N/C B2385 $5.00 B2435 $7.00
B2336 $5.00 B2386 $7.00 B2436 $7.00
B2337 $5.00 B2387 $5.00 B2437 $7.00
B2338 $5.00 B2388 $5.00 B2438 $7.00
B2339 $5.00 B2389 $5.00 B2439 $7.00
B2340 $5.00 B2390 $5.00 B2440 $7.00
B2341 $5.00 B2391 $5.00 B2441 $7.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
26
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B2442 $7.00 B2492 $5.00 B2542 $5.00
B2443 $7.00 B2493 $5.00 B2543 N/C
B2444 N/C B2494 $5.00 B2544 $5.00
B2445 $5.00 B2495 $5.00 B2545 $5.00
B2446 $5.00 B2496 $5.00 B2546 $5.00
B2447 $5.00 B2497 $5.00 B2547 N/C
B2448 $5.00 B2498 $5.00 B2548 $10.00
B2449 $5.00 B2499 $5.00 B2549 $5.00
B2450 $5.00 B2500 $5.00 B2550 $5.00
B2451 N/C B2501 $5.00 B2551 $5.00
B2452 $7.00 B2502 $5.00 B2552 $5.00
B2453 $7.00 B2503 $5.00 B2553 $5.00
B2454 $5.00 B2504 $10.00 B2554 $5.00
B2455 $5.00 B2505 $5.00 B2555 $5.00
B2456 $7.00 B2506 $5.00 B2556 $5.00
B2457 $7.00 B2507 $5.00 B2557 $5.00
B2458 $7.00 B2508 $5.00 B2558 $5.00
B2459 $7.00 B2509 $5.00 B2559 $5.00
B2460 $5.00 B2510 $5.00 B2560 $5.00
B2461 $10.00 B2511 $5.00 B2561 $5.00
B2462 $5.00 B2512 $5.00 B2562 $7.00
B2463 $5.00 B2513 $5.00 B2563 $5.00
B2464 $5.00 B2514 $5.00 B2564 $5.00
B2465 $5.00 B2515 $5.00 B2565 $5.00
B2466 $5.00 B2516 $5.00 B2566 $5.00
B2467 $5.00 B2517 $0.00 B2567 $5.00
B2468 N/C B2518 $10.00 B2568 $7.00
B2469 $7.00 B2519 $10.00 B2569 $5.00
B2470 $7.00 B2520 $5.00 B2570 $5.00
B2471 N/C B2521 $7.00 B2571 N/C
B2472 N/C B2522 N/C B2572 $5.00
B2473 $7.00 B2523 $0.00 B2573 $5.00
B2474 $5.00 B2524 $5.00 B2574 $5.00
B2475 $5.00 B2525 $5.00 B2575 $5.00
B2476 $7.00 B2526 $5.00 B2576 $5.00
B2477 N/C B2527 $5.00 B2577 $7.00
B2478 $5.00 B2528 $5.00 B2578 $7.00
B2479 $7.00 B2529 N/C B2579 $5.00
B2480 $7.00 B2530 N/C B2580 $5.00
B2481 $7.00 B2531 $5.00 B2581 $5.00
B2482 $5.00 B2532 $5.00 B2582 $5.00
B2483 $5.00 B2533 $7.00 B2583 $5.00
B2484 $7.00 B2534 $7.00 B2584 $5.00
B2485 $7.00 B2535 $7.00 B2585 $5.00
B2486 $5.00 B2536 $5.00 B2586 $5.00
B2487 $5.00 B2537 $5.00 B2587 $5.00
B2488 $5.00 B2538 $5.00 B2588 $5.00
B2489 $5.00 B2539 $5.00 B2589 $5.00
B2490 $7.00 B2540 $5.00 B2590 $5.00
B2491 $5.00 B2541 $5.00 B2591 $7.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
27
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B2592 $5.00 B2642 $5.00 B2692 $5.00
B2593 $7.00 B2643 $5.00 B2693 $5.00
B2594 $5.00 B2644 $5.00 B2694 $10.00
B2595 $5.00 B2645 $5.00 B2695 $10.00
B2596 $5.00 B2646 $5.00 B2696 $5.00
B2597 $5.00 B2647 $5.00 B2697 $5.00
B2598 $5.00 B2648 $5.00 B2698 $5.00
B2599 $5.00 B2649 $5.00 B2699 $5.00
B2600 $5.00 B2650 $5.00 B2700 $5.00
B2601 $5.00 B2651 $5.00 B2701 $5.00
B2602 $5.00 B2652 $5.00 B2702 $5.00
B2603 $5.00 B2653 $5.00 B2703 $7.00
B2604 $5.00 B2654 $5.00 B2704 $7.00
B2605 $7.00 B2655 $5.00 B2705 $5.00
B2606 $5.00 B2656 $5.00 B2706 N/C
B2607 $5.00 B2657 $5.00 B2707 $7.00
B2608 $5.00 B2658 $5.00 B2708 $7.00
B2609 $5.00 B2659 $5.00 B2709 $7.00
B2610 $5.00 B2660 $10.00 B2710 $10.00
B2611 $5.00 B2661 $5.00 B2711 $10.00
B2612 $5.00 B2662 $5.00 B2712 $10.00
B2613 $5.00 B2663 N/C B2713 N/C
B2614 $5.00 B2664 $5.00 B2714 $5.00
B2615 $5.00 B2665 $5.00 B2715 $5.00
B2616 $5.00 B2666 $7.00 B2716 $10.00
B2617 $5.00 B2667 $5.00 B2717 $7.00
B2618 $5.00 B2668 $5.00 B2718 $5.00
B2619 $5.00 B2669 $7.00 B2719 $10.00
B2620 $5.00 B2670 $5.00 B2720 $7.00
B2621 $5.00 B2671 $5.00 B2721 $7.00
B2622 $5.00 B2672 N/C B2722 $5.00
B2623 $5.00 B2673 $5.00 B2723 N/C
B2624 $5.00 B2674 $5.00 B2724 N/C
B2625 $5.00 B2675 $5.00 B2725 $5.00
B2626 $5.00 B2676 $5.00 B2726 $5.00
B2627 $5.00 B2677 $8.00 B2727 $5.00
B2628 $5.00 B2678 $5.00 B2728 $5.00
B2629 $7.00 B2679 $5.00 B2729 $5.00
B2630 $5.00 B2680 $10.00 B2730 $5.00
B2631 $5.00 B2681 $5.00 B2731 $0.00
B2632 $5.00 B2682 $5.00 B2732 $7.00
B2633 $5.00 B2683 $5.00 B2733 N/C
B2634 $5.00 B2684 $5.00 B2734 $10.00
B2635 $5.00 B2685 $10.00 B2735 $5.00
B2636 $10.00 B2686 $10.00 B2736 $7.00
B2637 $5.00 B2687 $5.00 B2737 $5.00
B2638 N/C B2688 $5.00 B2738 $5.00
B2639 $7.00 B2689 $5.00 B2739 $5.00
B2640 $5.00 B2690 $5.00 B2740 $7.00
B2641 $5.00 B2691 $5.00 B2741 $7.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
28
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B2742 $10.00 B2792 N/C B2842 $5.00
B2743 $10.00 B2793 $5.00 B2843 $5.00
B2744 $10.00 B2794 $5.00 B2844 $5.00
B2745 $10.00 B2795 $7.00 B2845 $5.00
B2746 $10.00 B2796 $5.00 B2846 $5.00
B2747 $5.00 B2797 N/C B2847 $5.00
B2748 $5.00 B2798 $5.00 B2848 $5.00
B2749 N/C B2799 $7.00 B2849 $5.00
B2750 N/C B2800 $7.00 B2850 $5.00
B2751 N/C B2801 $7.00 B2851 $7.00
B2752 N/C B2802 $7.00 B2852 $5.00
B2753 N/C B2803 $7.00 B2853 $7.00
B2754 $10.00 B2804 $5.00 B2854 $7.00
B2755 $5.00 B2805 $5.00 B2855 $7.00
B2756 $5.00 B2806 $5.00 B2856 $7.00
B2757 $5.00 B2807 $5.00 B2857 $5.00
B2758 $5.00 B2808 $7.00 B2858 $5.00
B2759 $5.00 B2809 $5.00 B2859 N/C
B2760 $5.00 B2810 $5.00 B2860 N/C
B2761 $5.00 B2811 $10.00 B2861 $5.00
B2762 $5.00 B2812 $5.00 B2862 $5.00
B2763 $5.00 B2813 $5.00 B2863 $10.00
B2764 $5.00 B2814 $5.00 B2864 $10.00
B2765 $7.00 B2815 $7.00 B2865 $10.00
B2766 N/C B2816 $7.00 B2866 $7.00
B2767 $7.00 B2817 $7.00 B2867 $5.00
B2768 $5.00 B2818 $5.00 B2868 $7.00
B2769 $7.00 B2819 $5.00 B2869 $5.00
B2770 $7.00 B2820 $5.00 B2870 $5.00
B2771 $7.00 B2821 $5.00 B2871 $5.00
B2772 $7.00 B2822 $5.00 B2872 $5.00
B2773 $10.00 B2823 $5.00 B2873 $5.00
B2774 $5.00 B2824 $5.00 B2874 $5.00
B2775 N/C B2825 $5.00 B2875 $5.00
B2776 N/C B2826 $5.00 B2876 NADA
B2777 N/C B2827 $5.00 B2877 NADA
B2778 N/C B2828 $5.00 B2878 $5.00
B2779 $5.00 B2829 $5.00 B2879 $5.00
B2780 $5.00 B2830 $7.00 B2880 $8.00
B2781 $5.00 B2831 $7.00 B2881 $5.00
B2782 $5.00 B2832 $7.00 B2882 $7.00
B2783 $7.00 B2833 $5.00 B2883 $7.00
B2784 $7.00 B2834 $5.00 B2884 $8.00
B2785 $7.00 B2835 $5.00 B2885 $5.00
B2786 $8.00 B2836 $7.00 B2886 $5.00
B2787 $5.00 B2837 $5.00 B2887 $5.00
B2788 $8.00 B2838 $7.00 B2888 $5.00
B2789 $5.00 B2839 $5.00 B2889 $5.00
B2790 $5.00 B2840 $5.00 B2890 $5.00
B2791 B2841 $5.00 B2891 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
29
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B2892 $5.00 B2942 $5.00 B2992 $5.00
B2893 $5.00 B2943 $5.00 B2993 $5.00
B2894 $5.00 B2944 $5.00 B2994 $5.00
B2895 $5.00 B2945 $5.00 B2995 $0.00
B2896 $5.00 B2946 $5.00 B2996 $10.00
B2897 $5.00 B2947 $5.00 B2997 $15.00
B2898 $5.00 B2948 $5.00 B2998 $7.00
B2899 $7.00 B2949 $5.00 B2999 $7.00
B2900 $5.00 B2950 $5.00 B3000 $5.00
B2901 $10.00 B2951 $5.00 B3001 $5.00
B2902 $10.00 B2952 $5.00 B3002 $5.00
B2903 $5.00 B2953 $5.00 B3003 $5.00
B2904 $5.00 B2954 $5.00 B3004 $7.00
B2905 $5.00 B2955 $5.00 B3005 $7.00
B2906 $10.00 B2956 $5.00 B3006 $7.00
B2907 $5.00 B2957 $5.00 B3007 $7.00
B2908 $5.00 B2958 $5.00 B3008 $7.00
B2909 $7.00 B2959 $5.00 B3009 $5.00
B2910 $5.00 B2960 $5.00 B3010 $0.00
B2911 $5.00 B2961 $5.00 B3011 $5.00
B2912 $5.00 B2962 $5.00 B3012 $7.00
B2913 $5.00 B2963 $5.00 B3013 $5.00
B2914 $7.00 B2964 $5.00 B3014 $5.00
B2915 $5.00 B2965 $5.00 B3015 NADA
B2916 $5.00 B2966 $5.00 B3016 $7.00
B2917 $5.00 B2967 $5.00 B3017 $5.00
B2918 $5.00 B2968 $5.00 B3018 $5.00
B2919 $7.00 B2969 $5.00 B3019 NADA
B2920 $5.00 B2970 $5.00 B3020 $5.00
B2921 $5.00 B2971 $5.00 B3021 $5.00
B2922 $5.00 B2972 $5.00 B3022 NADA
B2923 $5.00 B2973 $5.00 B3023 $5.00
B2924 $5.00 B2974 $5.00 B3024 $5.00
B2925 $5.00 B2975 $5.00 B3025 $5.00
B2926 $7.00 B2976 $10.00 B3026 $5.00
B2927 $5.00 B2977 $5.00 B3027 $5.00
B2928 $5.00 B2978 $5.00 B3028 $5.00
B2929 $5.00 B2979 $7.00 B3029 $5.00
B2930 $5.00 B2980 $5.00 B3030 $5.00
B2931 $5.00 B2981 $5.00 B3031 $5.00
B2932 $5.00 B2982 $5.00 B3032 $5.00
B2933 $5.00 B2983 $5.00 B3033 $7.00
B2934 $5.00 B2984 $5.00 B3034 NADA
B2935 $5.00 B2985 $5.00 B3035 NADA
B2936 $5.00 B2986 $5.00 B3036 $10.00
B2937 $5.00 B2987 $5.00 B3037 $10.00
B2938 $5.00 B2988 $5.00 B3038 $5.00
B2939 $5.00 B2989 $5.00 B3039 $5.00
B2940 $5.00 B2990 $5.00 B3040 $5.00
B2941 $5.00 B2991 $5.00 B3041 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
30
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B3042 $5.00 B3092 $5.00 B3142 NADA
B3043 $5.00 B3093 $7.00 B3143 NADA
B3044 $5.00 B3094 $10.00 B3144 $7.00
B3045 $5.00 B3095 NADA B3145 $7.00
B3046 $5.00 B3096 NADA B3146 NADA
B3047 $5.00 B3097 $5.00 B3147 $10.00
B3048 $5.00 B3098 NADA B3148 $7.00
B3049 $5.00 B3099 NADA B3149 NADA
B3050 $5.00 B3100 NADA B3150 $5.00
B3051 $5.00 B3101 $5.00 B3151 $5.00
B3052 $5.00 B3102 $5.00 B3152 $5.00
B3053 $5.00 B3103 $10.00 B3153 $5.00
B3054 $5.00 B3104 $7.00 B3154 $5.00
B3055 $5.00 B3105 $7.00 B3155 $7.00
B3056 $5.00 B3106 $7.00 B3156 $7.00
B3057 $5.00 B3107 $10.00 B3157 $7.00
B3058 $5.00 B3108 $5.00 B3158 $10.00
B3059 $5.00 B3109 $7.00 B3159 $7.00
B3060 $7.00 B3110 $7.00 B3160 $5.00
B3061 $5.00 B3111 $10.00 B3161 $5.00
B3062 $15.00 B3112 $10.00 B3162 $5.00
B3063 $4.00 B3113 $5.00 B3163 $5.00
B3064 $4.00 B3114 $5.00 B3164 $5.00
B3065 NADA B3115 $5.00 B3165 $5.00
B3066 NADA B3116 $10.00 B3166 $5.00
B3067 NADA B3117 $5.00 B3167 $5.00
B3068 NADA B3118 $5.00 B3168 $5.00
B3069 $5.00 B3119 $5.00 B3169 $5.00
B3070 $5.00 B3120 $5.00 B3170 $5.00
B3071 $5.00 B3121 NADA B3171 $5.00
B3072 $7.00 B3122 $5.00 B3172 $5.00
B3073 $7.00 B3123 $5.00 B3173 $5.00
B3074 $5.00 B3124 $7.00 B3174 $5.00
B3075 $7.00 B3125 $10.00 B3175 $5.00
B3076 $5.00 B3126 $5.00 B3176 $5.00
B3077 $5.00 B3127 $7.00 B3177 $5.00
B3078 $5.00 B3128 $7.00 B3178 $5.00
B3079 $10.00 B3129 $7.00 B3179 $5.00
B3080 $15.00 B3130 $15.00 B3180 $5.00
B3081 $5.00 B3131 $10.00 B3181 $5.00
B3082 $7.00 B3132 $10.00 B3182 $5.00
B3083 $5.00 B3133 $7.00 B3183 $5.00
B3084 $7.00 B3134 $6.50 B3184 $5.00
B3085 $5.00 B3135 $6.50 B3185 $5.00
B3086 NADA B3136 NADA B3186 $5.00
B3087 NADA B3137 $10.00 B3187 $5.00
B3088 $5.00 B3138 $5.00 B3188 $5.00
B3089 $5.00 B3139 NADA B3189 $5.00
B3090 $5.00 B3140 NADA B3190 $5.00
B3091 $15.00 B3141 NADA B3191 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
31
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B3192 $5.00 B3242 $7.00 B3292 NADA
B3193 $5.00 B3243 $10.00 B3293 $5.00
B3194 $5.00 B3244 $5.00 B3294 $5.00
B3195 $5.00 B3245 NADA B3295 $5.00
B3196 $5.00 B3246 $7.00 B3296 $5.00
B3197 $5.00 B3247 $7.00 B3297 $5.00
B3198 $5.00 B3248 $5.00 B3298 NADA
B3199 $0.00 B3249 NADA B3299 $5.00
B3200 $5.00 B3250 $7.00 B3300 $5.00
B3201 $5.00 B3251 $7.00 B3301 $5.00
B3202 $10.00 B3252 $7.00 B3302 $5.00
B3203 $10.00 B3253 $7.00 B3303 $5.00
B3204 NADA B3254 $5.00 B3304 $5.00
B3205 $5.00 B3255 $5.00 B3305 $5.00
B3206 $5.00 B3256 NADA B3306 $5.00
B3207 $5.00 B3257 $5.00 B3307 $5.00
B3208 $5.00 B3258 $5.00 B3308 $7.00
B3209 $5.00 B3259 $5.00 B3309 $5.00
B3210 $5.00 B3260 $5.00 B3310 NADA
B3211 $5.00 B3261 $5.00 B3311 $5.00
B3212 $5.00 B3262 $5.00 B3312 $5.00
B3213 $5.00 B3263 $5.00 B3313 $5.00
B3214 NADA B3264 $5.00 B3314 $5.00
B3215 $7.00 B3265 $5.00 B3315 $5.00
B3216 $10.00 B3266 $5.00 B3316 NADA
B3217 $5.00 B3267 $5.00 B3317 $5.00
B3218 $7.00 B3268 NADA B3318 $5.00
B3219 NADA B3269 $5.00 B3319 $5.00
B3220 NADA B3270 $10.00 B3320 $5.00
B3221 $7.00 B3271 $5.00 B3321 $7.00
B3222 $7.00 B3272 $5.00 B3322 $7.00
B3223 $5.00 B3273 $5.00 B3323 $7.00
B3224 $5.00 B3274 $7.00 B3324 $5.00
B3225 $5.00 B3275 $5.00 B3325 $5.00
B3226 $5.00 B3276 $7.00 B3326 $7.00
B3227 $5.00 B3277 $5.00 B3327 NADA
B3228 $5.00 B3278 $10.00 B3328 $5.00
B3229 NADA B3279 $10.00 B3329 $5.00
B3230 $5.00 B3280 $10.00 B3330 $5.00
B3231 $5.00 B3281 $5.00 B3331 $5.00
B3232 $5.00 B3282 $5.00 B3332 $5.00
B3233 $10.00 B3283 $5.00 B3333 $5.00
B3234 $5.00 B3284 $10.00 B3334 $5.00
B3235 $10.00 B3285 $5.00 B3335 $5.00
B3236 $10.00 B3286 $10.00 B3336 $5.00
B3237 $7.00 B3287 $5.00 B3336 $5.00
B3238 $5.00 B3288 $5.00 B3337 $5.00
B3239 $10.00 B3289 $5.00 B3338 $5.00
B3240 $5.00 B3290 $5.00 B3339 $5.00
B3241 $5.00 B3291 $7.00 B3340 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
32
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B3341 $5.00 B3391 $5.00 B3441 $5.00
B3342 $5.00 B3392 $7.00 B3442 $7.00
B3343 $5.00 B3393 $5.00 B3443 $7.00
B3344 $5.00 B3394 $10.00 B3444 $7.00
B3345 $5.00 B3395 $5.00 B3445 $5.00
B3346 $5.00 B3396 $5.00 B3446 $5.00
B3347 $5.00 B3397 $5.00 B3447 $5.00
B3348 $5.00 B3398 $5.00 B3448 $5.00
B3349 $5.00 B3399 $10.00 B3449 $5.00
B3350 $5.00 B3400 $5.00 B3450 $7.00
B3351 $10.00 B3401 $5.00 B3451 $7.00
B3352 $10.00 B3402 $10.00 B3452 $5.00
B3353 $5.00 B3403 $10.00 B3453 $7.00
B3354 $5.00 B3404 $5.00 B3454 $7.00
B3355 $5.00 B3405 $5.00 B3455 $7.00
B3356 $5.00 B3406 $7.00 B3456 $5.00
B3357 $10.00 B3407 $7.00 B3457 $7.00
B3358 $10.00 B3408 $5.00 B3458 $7.00
B3359 $5.00 B3409 $10.00 B3459 $7.00
B3360 $7.00 B3410 $5.00 B3460 $7.00
B3361 $5.00 B3411 $7.00 B3461 $7.00
B3362 $5.00 B3412 $5.00 B3462 $5.00
B3363 $10.00 B3413 $5.00 B3463 NADA
B3364 $10.00 B3414 $5.00 B3464 $5.00
B3365 $5.00 B3415 $5.00 B3465 $5.00
B3366 $5.00 B3416 $7.00 B3466 $10.00
B3367 $5.00 B3417 NADA B3467 $10.00
B3368 $5.00 B3418 $10.00 B3468 $5.00
B3369 $5.00 B3419 $7.00 B3469 $7.00
B3370 $2.00 B3420 $5.00 B3470 $5.00
B3371 $5.00 B3421 $5.00 B3471 $7.00
B3372 $5.00 B3422 $5.00 B3472 $7.00
B3373 $7.00 B3423 $5.00 B3473 $5.00
B3374 $7.00 B3424 $5.00 B3474 $10.00
B3375 $5.00 B3425 $7.00 B3475 $5.00
B3376 $5.00 B3426 $5.00 B3476 $7.00
B3377 $5.00 B3427 $10.00 B3477 $5.00
B3378 $5.00 B3428 $10.00 B3478 $7.00
B3379 $5.00 B3429 $10.00 B3479 NADA
B3380 $5.00 B3430 $5.00 B3480 $5.00
B3381 $7.00 B3431 $7.00 B3481 $5.00
B3382 $5.00 B3432 $5.00 B3482 $10.00
B3383 $5.00 B3433 NADA B3483 $10.00
B3384 $5.00 B3434 NADA B3484 $10.00
B3385 $5.00 B3435 NADA B3485 $10.00
B3386 $10.00 B3436 NADA B3486 $10.00
B3387 $5.00 B3437 NADA B3487 $10.00
B3388 $5.00 B3438 NADA B3488 $10.00
B3389 $5.00 B3439 $5.00 B3489 $10.00
B3390 $5.00 B3440 $5.00 B3490 $10.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
33
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B3491 $5.00 B3541 $10.00 B3591 $5.00
B3492 $5.00 B3542 NADA B3592 $5.00
B3493 $5.00 B3543 NADA B3593 $5.00
B3494 $5.00 B3544 NADA B3594 $7.00
B3495 $5.00 B3545 NADA B3595 $5.00
B3496 $7.00 B3546 NADA B3596 $7.00
B3497 $5.00 B3547 NADA B3597 $7.00
B3498 $5.00 B3548 $5.00 B3598 $5.00
B3499 NADA B3549 $10.00 B3599 $5.00
B3500 $7.00 B3550 $10.00 B3600 NADA
B3501 $5.00 B3551 $5.00 B3601 NADA
B3502 $5.00 B3552 $5.00 B3602 NADA
B3503 $5.00 B3553 $5.00 B3603 $12.00
B3504 $5.00 B3554 $5.00 B3604 $12.00
B3505 $7.00 B3555 $5.00 B3605 $7.00
B3506 $7.00 B3556 $7.00 B3606 $5.00
B3507 $5.00 B3557 $5.00 B3607 $5.00
B3508 $5.00 B3558 $7.00 B3609 $5.00
B3509 $7.00 B3559 $7.00 B3610 $10.00
B3510 $5.00 B3560 $8.00 B3611 $5.00
B3511 $5.00 B3561 $8.00 B3612 $7.00
B3512 $5.00 B3562 $5.00 B3613 $5.00
B3513 $5.00 B3563 $5.00 B3614 $5.00
B3514 $7.00 B3564 $5.00 B3615 $5.00
B3515 $7.00 B3565 $10.00 B3616 $7.00
B3516 $5.00 B3566 $5.00 B3617 $5.00
B3517 $7.00 B3567 $5.00 B3618 $5.00
B3518 $7.00 B3568 $5.00 B3619 $5.00
B3519 $7.00 B3569 $5.00 B3620 $5.00
B3520 $7.00 B3570 $5.00 B3621 $7.00
B3521 $5.00 B3571 $5.00 B3622 $7.00
B3522 $7.00 B3572 $5.00 B3623 $5.00
B3523 $7.00 B3573 $7.00 B3624 $5.00
B3524 $7.00 B3574 $5.00 B3625 $5.00
B3525 $5.00 B3575 $5.00 B3626 $5.00
B3526 $7.00 B3576 $5.00 B3627 $5.00
B3527 $5.00 B3577 $5.00 B3628 $5.00
B3528 $5.00 B3578 $5.00 B3629 $5.00
B3529 $7.00 B3579 NADA B3630 $5.00
B3530 $5.00 B3580 NADA B3631 $5.00
B3531 $5.00 B3581 $5.00 B3632 $5.00
B3532 $5.00 B3582 NADA B3633 $5.00
B3533 $5.00 B3583 NADA B3634 $5.00
B3534 $5.00 B3584 $10.00 B3635 $5.00
B3535 $5.00 B3585 $10.00 B3636 $5.00
B3536 $5.00 B3586 $10.00 B3637 $5.00
B3537 $5.00 B3587 $6.50 B3638 $5.00
B3538 $5.00 B3588 $7.00 B3639 $5.00
B3539 $10.00 B3589 NADA B3640 $5.00
B3540 $10.00 B3590 $5.00 B3641 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
34
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B3642 $5.00 B3692 NADA B3742 $5.00
B3643 $5.00 B3693 $5.00 B3743 $5.00
B3644 $5.00 B3694 $5.00 B3744 $7.00
B3645 $5.00 B3695 $5.00 B3745 $5.00
B3646 $5.00 B3696 $5.00 B3746 $5.00
B3647 $5.00 B3697 $7.00 B3747 $5.00
B3648 $5.00 B3698 $5.00 B3748 $5.00
B3649 $5.00 B3699 $5.00 B3749 $5.00
B3650 $5.00 B3700 $5.00 B3750 $5.00
B3651 $5.00 B3701 $5.00 B3751 $5.00
B3652 $5.00 B3702 $7.00 B3752 $5.00
B3653 $5.00 B3703 $7.00 B3753 $5.00
B3654 $5.00 B3704 $5.00 B3754 $5.00
B3655 $5.00 B3705 $5.00 B3755 $5.00
B3656 $5.00 B3706 $5.00 B3756 $5.00
B3657 $5.00 B3707 $5.00 B3757 $5.00
B3658 $5.00 B3708 $12.00 B3758 $7.00
B3659 $5.00 B3709 $5.00 B3759 $5.00
B3660 $5.00 B3710 $7.00 B3760 $5.00
B3661 $5.00 B3711 $5.00 B3761 $5.00
B3662 $5.00 B3712 $5.00 B3762 $5.00
B3663 $5.00 B3713 $5.00 B3763 $5.00
B3664 $5.00 B3714 $5.00 B3764 $5.00
B3665 $5.00 B3715 $7.00 B3765 $5.00
B3666 $5.00 B3716 $5.00 B3766 $5.00
B3667 $5.00 B3717 $5.00 B3767 $5.00
B3668 $5.00 B3718 $5.00 B3768 $5.00
B3669 $5.00 B3719 $5.00 B3769 $5.00
B3670 $5.00 B3720 $5.00 B3770 $5.00
B3671 $5.00 B3721 $5.00 B3771 $5.00
B3672 $7.00 B3722 $10.00 B3772 $7.00
B3673 $5.00 B3723 $5.00 B3773 $5.00
B3674 NADA B3724 NADA B3774 $5.00
B3675 NADA B3725 $7.00 B3775 $5.00
B3676 $5.00 B3726 $5.00 B3776 $5.00
B3677 $5.00 B3727 $5.00 B3777 $5.00
B3678 $7.00 B3728 $5.00 B3778 $5.00
B3679 $5.00 B3729 $5.00 B3779 $5.00
B3680 $5.00 B3730 $5.00 B3780 $5.00
B3681 $5.00 B3731 $5.00 B3781 $5.00
B3682 $5.00 B3732 $5.00 B3782 $5.00
B3683 $7.00 B3733 $15.00 B3783 $5.00
B3684 $7.00 B3734 $5.00 B3784 $5.00
B3685 $5.00 B3735 $5.00 B3785 $5.00
B3686 $5.00 B3736 $5.00 B3786 $5.00
B3687 $12.00 B3737 $5.00 B3787 $5.00
B3688 $12.00 B3738 $5.00 B3788 $5.00
B3689 $5.00 B3739 $5.00 B3789 $5.00
B3690 $5.00 B3740 $5.00 B3790 $5.00
B3691 $5.00 B3741 $5.00 B3791 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
35
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B3792 $5.00 B3842 $5.00 B3892 $5.00
B3793 $5.00 B3843 $5.00 B3893 $7.00
B3794 $5.00 B3844 $5.00 B3894 $5.00
B3795 $5.00 B3845 $5.00 B3895 $5.00
B3796 $5.00 B3846 $5.00 B3896 $5.00
B3797 $5.00 B3847 $5.00 B3897 $5.00
B3798 $5.00 B3848 $5.00 B3898 $5.00
B3799 $5.00 B3849 $5.00 B3899 NADA
B3800 $5.00 B3850 $5.00 B3900 NADA
B3801 $5.00 B3851 $5.00 B3901 $5.00
B3802 $5.00 B3852 $5.00 B3902 $5.00
B3803 $5.00 B3853 $5.00 B3903 $5.00
B3804 $5.00 B3854 $5.00 B3904 $5.00
B3805 $5.00 B3855 $8.00 B3905 $5.00
B3806 $5.00 B3856 $8.00 B3906 $5.00
B3807 $5.00 B3857 $5.00 B3907 $5.00
B3808 $5.00 B3858 $5.00 B3908 $5.00
B3809 $5.00 B3859 $5.00 B3909 $5.00
B3810 $5.00 B3860 $5.00 B3910 $5.00
B3811 $5.00 B3861 $5.00 B3911 $5.00
B3812 $5.00 B3862 $5.00 B3912 $5.00
B3813 $5.00 B3863 $5.00 B3913 $5.00
B3814 $5.00 B3864 $5.00 B3914 $5.00
B3815 $5.00 B3865 $5.00 B3915 $5.00
B3816 $5.00 B3866 $5.00 B3916 $5.00
B3817 $5.00 B3867 $5.00 B3917 NADA
B3818 $5.00 B3868 $5.00 B3918 $5.00
B3819 $5.00 B3869 $5.00 B3919 $5.00
B3820 $5.00 B3870 $5.00 B3920 $5.00
B3821 $5.00 B3871 $5.00 B3921 $5.00
B3822 $5.00 B3872 $5.00 B3922 $5.00
B3823 $5.00 B3873 $5.00 B3923 $5.00
B3824 $5.00 B3874 $5.00 B3924 $5.00
B3825 $5.00 B3875 $5.00 B3925 $5.00
B3826 $5.00 B3876 $5.00 B3926 $5.00
B3827 $5.00 B3877 $5.00 B3927 $5.00
B3828 $5.00 B3878 $5.00 B3928 $5.00
B3829 $5.00 B3879 $5.00 B3929 $5.00
B3830 $5.00 B3880 $5.00 B3930 $5.00
B3831 $5.00 B3881 $5.00 B3931 $5.00
B3832 $5.00 B3882 $5.00 B3932 $5.00
B3833 $5.00 B3883 $5.00 B3933 $5.00
B3834 $5.00 B3884 $5.00 B3934 $5.00
B3835 $5.00 B3885 $5.00 B3935 $5.00
B3836 $5.00 B3886 $5.00 B3936 $5.00
B3837 $5.00 B3887 $5.00 B3937 $5.00
B3838 $5.00 B3888 $5.00 B3938 $5.00
B3839 $5.00 B3889 $5.00 B3939 $5.00
B3840 $5.00 B3890 $5.00 B3940 $5.00
B3841 $5.00 B3891 $5.00 B3941 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
36
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B3942 $5.00 B3992 $5.00 B4042 $7.00
B3943 $5.00 B3993 $5.00 B4043 NADA
B3944 $5.00 B3994 $5.00 B4044 NADA
B3945 $5.00 B3995 $5.00 B4045 NADA
B3946 $5.00 B3996 $5.00 B4046 $7.00
B3947 $7.00 B3997 $5.00 B4047 NADA
B3948 $5.00 B3998 $5.00 B4048 NADA
B3949 $5.00 B3999 $5.00 B4049 $5.00
B3950 $5.00 B4000 $5.00 B4050 $5.00
B3951 $5.00 B4001 $5.00 B4051 $7.00
B3952 $5.00 B4002 $5.00 B4052 $5.00
B3953 $5.00 B4003 $5.00 B4053 $5.00
B3954 $5.00 B4004 $5.00 B4054 $7.00
B3955 $7.00 B4005 $5.00 B4055 $5.00
B3956 $5.00 B4006 $5.00 B4056 $5.00
B3957 $5.00 B4007 $5.00 B4057 $5.00
B3958 $5.00 B4008 $5.00 B4058 $5.00
B3959 $5.00 B4009 $5.00 B4059 $5.00
B3960 $5.00 B4010 $5.00 B4060 $5.00
B3961 $5.00 B4011 $5.00 B4061 $5.00
B3962 $5.00 B4012 $5.00 B4062 $5.00
B3963 $5.00 B4013 $5.00 B4063 $5.00
B3964 $7.00 B4014 $7.00 B4064 $5.00
B3965 $5.00 B4015 $5.00 B4065 $5.00
B3966 $5.00 B4016 $5.00 B4066 $7.00
B3967 $8.00 B4017 $5.00 B4067 $5.00
B3968 $5.00 B4018 $5.00 B4068 $5.00
B3969 $5.00 B4019 $5.00 B4069 $5.00
B3970 $5.00 B4020 $5.00 B4070 $5.00
B3971 $5.00 B4021 $2.00 B4071 $5.00
B3972 $5.00 B4022 NADA B4072 $5.00
B3973 $5.00 B4023 NADA B4073 $5.00
B3974 $5.00 B4024 $7.00 B4074 $5.00
B3975 $5.00 B4025 $5.00 B4075 $5.00
B3976 $5.00 B4026 $7.00 B4076 $5.00
B3977 $5.00 B4027 $5.00 B4077 $5.00
B3978 $5.00 B4028 $5.00 B4078 $5.00
B3979 $5.00 B4029 $5.00 B4079 $5.00
B3980 $5.00 B4030 $5.00 B4080 $5.00
B3981 $5.00 B4031 $5.00 B4081 $5.00
B3982 $5.00 B4032 $5.00 B4082 $5.00
B3983 $5.00 B4033 $5.00 B4083 $5.00
B3984 $5.00 B4034 $5.00 B4084 $5.00
B3985 $5.00 B4035 $5.00 B4085 $5.00
B3986 $5.00 B4036 $5.00 B4086 $5.00
B3987 $5.00 B4037 $5.00 B4087 $5.00
B3988 $5.00 B4038 $5.00 B4088 $5.00
B3989 $5.00 B4039 $5.00 B4089 $5.00
B3990 $5.00 B4040 $5.00 B4090 $5.00
B3991 $5.00 B4041 $7.00 B4091 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
37
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B4092 $5.00 B4142 $5.00 B4192 NADA
B4093 $5.00 B4143 $5.00 B4193 $5.00
B4094 $5.00 B4144 $5.00 B4194 $5.00
B4095 $5.00 B4145 $5.00 B4195 $5.00
B4096 $5.00 B4146 $5.00 B4196 $5.00
B4097 $5.00 B4147 $5.00 B4197 $7.00
B4098 $5.00 B4148 $7.00 B4198 $5.00
B4099 $5.00 B4149 $5.00 B4199 NADA
B4100 $5.00 B4150 $7.00 B4200 $5.00
B4101 $5.00 B4151 $7.00 B4201 NADA
B4102 $5.00 B4152 $7.00 B4202 $5.00
B4103 $5.00 B4153 $5.00 B4203 $5.00
B4104 $5.00 B4154 $5.00 B4204 $5.00
B4105 $7.00 B4155 $5.00 B4205 $5.00
B4106 $5.00 B4156 $5.00 B4206 $5.00
B4107 $10.00 B4157 $7.00 B4207 $5.00
B4108 $5.00 B4158 $7.00 B4208 $5.00
B4109 $5.00 B4159 $5.00 B4209 $5.00
B4110 $5.00 B4160 $5.00 B4210 NADA
B4111 $5.00 B4161 $5.00 B4211 NADA
B4112 $5.00 B4162 $7.00 B4212 $5.00
B4113 $5.00 B4163 $7.00 B4213 $5.00
B4114 $5.00 B4164 $5.00 B4214 $5.00
B4115 $5.00 B4165 $5.00 B4215 $5.00
B4116 $5.00 B4166 $5.00 B4216 $5.00
B4117 $5.00 B4167 $5.00 B4217 $5.00
B4118 $5.00 B4168 $5.00 B4218 $5.00
B4119 $7.00 B4169 $5.00 B4219 $5.00
B4120 $5.00 B4170 $5.00 B4220 $5.00
B4121 $5.00 B4171 $5.00 B4221 $5.00
B4122 $5.00 B4172 $5.00 B4222 $5.00
B4123 $5.00 B4173 $5.00 B4223 $5.00
B4124 $5.00 B4174 $7.00 B4224 $5.00
B4125 $5.00 B4175 $5.00 B4225 $5.00
B4126 $5.00 B4176 $5.00 B4226 $5.00
B4127 $5.00 B4177 $7.00 B4227 $5.00
B4128 $5.00 B4178 $5.00 B4228 $5.00
B4129 $5.00 B4179 $5.00 B4229 $5.00
B4130 $5.00 B4180 $5.00 B4230 $10.00
B4131 $5.00 B4181 $5.00 B4231 $5.00
B4132 $5.00 B4182 $7.00 B4232 $7.00
B4133 $5.00 B4183 $5.00 B4233 $5.00
B4134 $5.00 B4184 $5.00 B4234 $5.00
B4135 $5.00 B4185 $5.00 B4235 $5.00
B4136 $5.00 B4186 $5.00 B4236 $5.00
B4137 $5.00 B4187 $5.00 B4237 $5.00
B4138 $5.00 B4188 $5.00 B4238 $5.00
B4139 $5.00 B4189 $5.00 B4239 $5.00
B4140 $5.00 B4190 NADA B4240 $5.00
B4141 $7.00 B4191 $5.00 B4241 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
38
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B4242 $5.00 B4292 $5.00 B4342 $5.00
B4243 $5.00 B4293 $5.00 B4343 $5.00
B4244 $5.00 B4294 $5.00 B4344 $5.00
B4245 $5.00 B4295 $5.00 B4345 $5.00
B4246 $5.00 B4296 $5.00 B4346 $5.00
B4247 $5.00 B4297 $5.00 B4347 NADA
B4248 $5.00 B4298 $5.00 B4348 $5.00
B4249 $5.00 B4299 $5.00 B4349 $5.00
B4250 $5.00 B4300 $5.00 B4350 $5.00
B4251 $5.00 B4301 $5.00 B4351 $5.00
B4252 $10.00 B4302 $5.00 B4352 $5.00
B4253 $5.00 B4303 $5.00 B4353 $7.00
B4254 $5.00 B4304 $5.00 B4354 $7.00
B4255 $5.00 B4305 $5.00 B4355 $7.00
B4256 $5.00 B4306 $10.00 B4356 $7.00
B4257 $5.00 B4307 $7.00 B4357 $7.00
B4258 $5.00 B4308 $7.00 B4358 $5.00
B4259 $5.00 B4309 $5.00 B4359 $5.00
B4260 $5.00 B4310 $5.00 B4360 $5.00
B4261 $5.00 B4311 $10.00 B4361 $5.00
B4262 $5.00 B4312 $7.00 B4362 $5.00
B4263 $5.00 B4313 $5.00 B4363 $5.00
B4264 $5.00 B4314 $5.00 B4364 NADA
B4265 $5.00 B4315 $5.00 B4365 $5.00
B4266 $5.00 B4316 $7.00 B4366 $5.00
B4267 $7.00 B4317 $5.00 B4367 $7.00
B4268 $5.00 B4318 $5.00 B4368 $5.00
B4269 $5.00 B4319 $5.00 B4369 $5.00
B4270 $5.00 B4320 $5.00 B4370 $7.00
B4271 $5.00 B4321 NADA B4371 $5.00
B4272 $5.00 B4322 $7.00 B4372 $5.00
B4273 $5.00 B4323 $7.00 B4373 $5.00
B4274 $5.00 B4324 $5.00 B4374 NADA
B4275 $5.00 B4325 $7.00 B4375 NADA
B4276 $5.00 B4326 $5.00 B4376 NADA
B4277 $5.00 B4327 $5.00 B4377 NADA
B4278 $5.00 B4328 $7.00 B4378 NADA
B4279 $5.00 B4329 NADA B4379 NADA
B4280 $5.00 B4330 $5.00 B4380 NADA
B4281 $5.00 B4331 $5.00 B4381 NADA
B4282 $5.00 B4332 $7.00 B4382 $5.00
B4283 $5.00 B4333 $5.00 B4383 NADA
B4284 $5.00 B4334 $5.00 B4384 NADA
B4285 $5.00 B4335 $5.00 B4385 NADA
B4286 $5.00 B4336 $5.00 B4386 NADA
B4287 $5.00 B4337 $5.00 B4387 $5.00
B4288 $5.00 B4338 $5.00 B4388 $5.00
B4289 $5.00 B4339 $5.00 B4389 $5.00
B4290 $5.00 B4340 $5.00 B4390 $5.00
B4291 $5.00 B4341 $5.00 B4391 NADA
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
39
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B4392 NADA B4442 $7.00 B4492 $5.00
B4393 NADA B4443 $5.00 B4493 $5.00
B4394 NADA B4444 $5.00 B4494 $5.00
B4395 NADA B4445 $7.00 B4495 $10.00
B4396 $5.00 B4446 $10.00 B4496 $5.00
B4397 $5.00 B4447 $7.00 B4497 $5.00
B4398 $5.00 B4448 $7.00 B4498 $5.00
B4399 $5.00 B4449 $7.00 B4499 $5.00
B4400 $5.00 B4450 $5.00 B4500 $8.00
B4401 $5.00 B4451 $10.00 B4501 $10.00
B4402 $5.00 B4452 $7.00 B4502 $5.00
B4403 $5.00 B4453 $5.00 B4503 $5.00
B4404 $5.00 B4454 $10.00 B4504 $5.00
B4405 $5.00 B4455 $7.00 B4505 $5.00
B4406 $5.00 B4456 $5.00 B4506 $5.00
B4407 $5.00 B4457 $7.00 B4507 $5.00
B4408 $5.00 B4458 $7.00 B4508 $5.00
B4409 $5.00 B4459 $5.00 B4509 $5.00
B4410 $5.00 B4460 $5.00 B4510 $5.00
B4411 $5.00 B4461 $5.00 B4511 $7.00
B4412 NADA B4462 $5.00 B4512 $5.00
B4413 $5.00 B4463 $5.00 B4513 $5.00
B4414 $5.00 B4464 $5.00 B4514 $5.00
B4415 $5.00 B4465 $5.00 B4515 $5.00
B4416 $5.00 B4466 $5.00 B4516 $5.00
B4417 $5.00 B4467 $5.00 B4517 $5.00
B4418 $5.00 B4468 $5.00 B4518 $5.00
B4419 $5.00 B4469 $5.00 B4519 $5.00
B4420 $5.00 B4470 $10.00 B4520 $5.00
B4421 $5.00 B4471 $5.00 B4521 $5.00
B4422 $5.00 B4472 $5.00 B4522 $5.00
B4423 $10.00 B4473 $5.00 B4523 $5.00
B4424 $5.00 B4474 $5.00 B4524 $5.00
B4425 $5.00 B4475 $5.00 B4525 $5.00
B4426 $5.00 B4476 $7.00 B4526 $5.00
B4427 $5.00 B4477 $5.00 B4527 $5.00
B4428 $5.00 B4478 $5.00 B4528 $5.00
B4429 $7.00 B4479 $5.00 B4529 $5.00
B4430 $7.00 B4480 $5.00 B4530 $5.00
B4431 $7.00 B4481 $5.00 B4531 $5.00
B4432 $7.00 B4482 $5.00 B4532 $5.00
B4433 $7.00 B4483 $5.00 B4533 $5.00
B4434 $5.00 B4484 $5.00 B4534 $5.00
B4435 $5.00 B4485 $8.00 B4535 $7.00
B4436 $10.00 B4486 $8.00 B4536 $5.00
B4437 $5.00 B4487 $5.00 B4537 $5.00
B4438 $5.00 B4488 $5.00 B4538 $5.00
B4439 $10.00 B4489 $5.00 B4539 $5.00
B4440 $5.00 B4490 $5.00 B4540 $5.00
B4441 $10.00 B4491 $5.00 B4541 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
40
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B4542 $7.00 B4592 $5.00 B4642 $7.00
B4543 $5.00 B4593 $5.00 B4643 $7.00
B4544 NADA B4594 $5.00 B4644 $5.00
B4545 $5.00 B4595 $5.00 B4645 $5.00
B4546 $5.00 B4596 $5.00 B4646 $5.00
B4547 $7.00 B4597 $5.00 B4647 $5.00
B4548 $5.00 B4598 $5.00 B4648 $5.00
B4549 $10.00 B4599 $5.00 B4649 $5.00
B4550 $5.00 B4600 NADA B4650 $5.00
B4551 $5.00 B4601 $5.00 B4651 $5.00
B4552 $10.00 B4602 $7.00 B4652 $5.00
B4553 $5.00 B4603 $5.00 B4653 $5.00
B4554 $5.00 B4604 $5.00 B4654 $5.00
B4555 $5.00 B4605 $5.00 B4655 $5.00
B4556 $5.00 B4606 $5.00 B4656 $5.00
B4557 $5.00 B4607 $5.00 B4657 $5.00
B4558 $5.00 B4608 $5.00 B4658 $5.00
B4559 $5.00 B4609 $5.00 B4659 $5.00
B4560 $5.00 B4610 $5.00 B4660 $5.00
B4561 $5.00 B4611 $5.00 B4661 $5.00
B4562 $5.00 B4612 $5.00 B4662 $10.00
B4563 $5.00 B4613 $5.00 B4663 $5.00
B4564 $5.00 B4614 NADA B4664 $5.00
B4565 $5.00 B4615 $5.00 B4665 $5.00
B4566 $5.00 B4616 $5.00 B4666 $5.00
B4567 NADA B4617 $5.00 B4667 $5.00
B4568 $5.00 B4618 $5.00 B4668 $5.00
B4569 $5.00 B4619 $5.00 B4669 $5.00
B4570 $5.00 B4620 $5.00 B4670 $5.00
B4571 $7.00 B4621 $5.00 B4671 $5.00
B4572 $5.00 B4622 $5.00 B4672 $5.00
B4573 $10.00 B4623 $5.00 B4673 $5.00
B4574 $10.00 B4624 $5.00 B4674 $5.00
B4575 $5.00 B4625 $5.00 B4675 $5.00
B4576 $5.00 B4626 $5.00 B4676 $5.00
B4577 $5.00 B4627 $5.00 B4677 $7.00
B4578 $5.00 B4628 $5.00 B4678 $5.00
B4579 $5.00 B4629 $5.00 B4679 $5.00
B4580 $5.00 B4630 $5.00 B4680 $5.00
B4581 $5.00 B4631 $5.00 B4681 $5.00
B4582 $5.00 B4632 $5.00 B4682 $5.00
B4583 $5.00 B4633 $5.00 B4683 $5.00
B4584 $5.00 B4634 $5.00 B4684 $5.00
B4585 NADA B4635 $5.00 B4685 $5.00
B4586 $5.00 B4636 $5.00 B4686 $5.00
B4587 $5.00 B4637 $5.00 B4687 $15.00
B4588 $5.00 B4638 $5.00 B4688 $5.00
B4589 $5.00 B4639 $5.00 B4689 $5.00
B4590 $5.00 B4640 $5.00 B4690 $5.00
B4591 $5.00 B4641 $7.00 B4691 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
41
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B4692 $7.00 B4742 $5.00 B4792 $5.00
B4693 $10.00 B4743 $5.00 B4793 $5.00
B4694 $15.00 B4744 $5.00 B4794 $5.00
B4695 $10.00 B4745 $5.00 B4795 $5.00
B4696 $5.00 B4746 $5.00 B4796 $5.00
B4697 $15.00 B4747 $5.00 B4797 $7.00
B4698 $10.00 B4748 $5.00 B4798 $7.00
B4699 $15.00 B4749 $5.00 B4799 $5.00
B4700 $10.00 B4750 $12.00 B4800 $15.00
B4701 $10.00 B4751 $15.00 B4801 $7.00
B4702 $5.00 B4752 $15.00 B4802 $5.00
B4703 $5.00 B4753 $5.00 B4803 $10.00
B4704 $7.00 B4754 $5.00 B4804 $10.00
B4705 $15.00 B4755 $5.00 B4805 $5.00
B4706 $5.00 B4756 $5.00 B4806 $10.00
B4707 $15.00 B4757 $5.00 B4807 $5.00
B4708 $5.00 B4758 $5.00 B4808 $7.00
B4709 $5.00 B4759 $5.00 B4809 $5.00
B4710 $5.00 B4760 $5.00 B4810 $12.00
B4711 $15.00 B4761 $5.00 B4811 $15.00
B4712 $5.00 B4762 $5.00 B4812 $5.00
B4713 $5.00 B4763 $5.00 B4813 $5.00
B4714 $5.00 B4764 $5.00 B4814 $5.00
B4715 $5.00 B4765 $5.00 B4815 $5.00
B4716 $5.00 B4766 $5.00 B4816 $7.00
B4717 $5.00 B4767 $5.00 B4817 $5.00
B4718 $5.00 B4768 $5.00 B4818 $7.00
B4719 $5.00 B4769 $5.00 B4819 $7.00
B4720 $15.00 B4770 $5.00 B4820 $7.00
B4721 $5.00 B4771 $5.00 B4821 $7.00
B4722 $5.00 B4772 $5.00 B4822 $5.00
B4723 $5.00 B4773 $5.00 B4823 $5.00
B4724 $7.00 B4774 $5.00 B4824 $5.00
B4725 $7.00 B4775 $5.00 B4825 $5.00
B4726 $7.00 B4776 $5.00 B4826 $5.00
B4727 $5.00 B4777 $7.00 B4827 $5.00
B4728 NADA B4778 $15.00 B4828 $7.00
B4729 $5.00 B4779 $5.00 B4829 $5.00
B4730 $5.00 B4780 $5.00 B4830 $5.00
B4731 $5.00 B4781 $5.00 B4831 $5.00
B4732 $5.00 B4782 $5.00 B4832 $5.00
B4733 $10.00 B4783 $5.00 B4833 $5.00
B4734 $5.00 B4784 $5.00 B4834 $5.00
B4735 $5.00 B4785 $5.00 B4835 $5.00
B4736 $5.00 B4786 $5.00 B4836 $10.00
B4737 $5.00 B4787 $5.00 B4837 NADA
B4738 $7.00 B4788 $5.00 B4838 NADA
B4739 $5.00 B4789 $5.00 B4839 $15.00
B4740 $5.00 B4790 $5.00 B4840 $5.00
B4741 $5.00 B4791 $5.00 B4841 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
42
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B4842 $5.00 B4892 $5.00 B4942 $12.00
B4843 $5.00 B4893 $5.00 B4943 $5.00
B4844 $5.00 B4894 $5.00 B4944 $5.00
B4845 $5.00 B4895 $5.00 B4945 $5.00
B4846 $5.00 B4896 $5.00 B4946 $5.00
B4847 $15.00 B4897 $5.00 B4947 $5.00
B4848 $12.00 B4898 $15.00 B4948 $5.00
B4849 $12.00 B4899 $12.00 B4949 $5.00
B4850 $7.00 B4900 NADA B4950 $5.00
B4851 $5.00 B4901 $5.00 B4951 $5.00
B4852 $5.00 B4902 $5.00 B4952 $5.00
B4853 $5.00 B4903 $5.00 B4953 $5.00
B4854 $5.00 B4904 $5.00 B4954 $5.00
B4855 $5.00 B4905 $5.00 B4955 $5.00
B4856 $5.00 B4906 NADA B4956 $5.00
B4857 $5.00 B4907 NADA B4957 $5.00
B4858 $5.00 B4908 NADA B4958 $5.00
B4859 $5.00 B4909 $5.00 B4959 $5.00
B4860 $7.00 B4910 $5.00 B4960 $5.00
B4861 $5.00 B4911 $12.00 B4961 $5.00
B4862 $5.00 B4912 $5.00 B4962 $5.00
B4863 $5.00 B4913 $5.00 B4963 $5.00
B4864 $12.00 B4914 NADA B4964 $10.00
B4865 $5.00 B4915 $5.00 B4965 $5.00
B4866 $5.00 B4916 $5.00 B4966 $5.00
B4867 $5.00 B4917 $5.00 B4967 $5.00
B4868 $15.00 B4918 $7.00 B4968 $10.00
B4869 $5.00 B4919 $7.00 B4969 $5.00
B4870 $7.00 B4920 $7.00 B4970 $10.00
B4871 $7.00 B4921 NADA B4971 $10.00
B4872 $10.00 B4922 $5.00 B4972 $10.00
B4873 $10.00 B4923 $5.00 B4973 $5.00
B4874 $10.00 B4924 $5.00 B4974 $5.00
B4875 $10.00 B4925 $5.00 B4975 $5.00
B4876 $10.00 B4926 $5.00 B4976 $5.00
B4877 $12.00 B4927 $5.00 B4977 $5.00
B4878 $5.00 B4928 $5.00 B4978 $5.00
B4879 $5.00 B4929 $5.00 B4979 $5.00
B4880 $5.00 B4930 $5.00 B4980 $5.00
B4881 $5.00 B4931 $5.00 B4981 $7.00
B4882 $5.00 B4932 $5.00 B4982 $5.00
B4883 $5.00 B4933 $5.00 B4983 $5.00
B4884 $5.00 B4934 $10.00 B4984 $5.00
B4885 $5.00 B4935 $10.00 B4985 $5.00
B4886 $7.00 B4936 $10.00 B4986 $10.00
B4887 $5.00 B4937 $7.00 B4987 $5.00
B4888 $5.00 B4938 NADA B4988 $5.00
B4889 $5.00 B4939 $5.00 B4989 $5.00
B4890 $5.00 B4940 $12.00 B4990 $5.00
B4891 $5.00 B4941 $5.00 B4991 $6.50
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
43
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B4992 $10.00 B5042 $5.00 B5092 $5.00
B4993 $5.00 B5043 $5.00 B5093 $5.00
B4994 $5.00 B5044 $5.00 B5094 $5.00
B4995 $5.00 B5045 $5.00 B5095 $5.00
B4996 $7.00 B5046 $5.00 B5096 $5.00
B4997 $7.00 B5047 $7.00 B5097 $15.00
B4998 $7.00 B5048 $7.00 B5098 $5.00
B4999 $5.00 B5049 $5.00 B5099 $5.00
B5000 $5.00 B5050 $5.00 B5100 $5.00
B5001 $5.00 B5051 $5.00 B5101 $5.00
B5002 $5.00 B5052 $5.00 B5102 $7.00
B5003 $5.00 B5053 $5.00 B5103 $5.00
B5004 NADA B5054 $5.00 B5104 $7.00
B5005 $5.00 B5055 $5.00 B5105 $5.00
B5006 $15.00 B5056 $5.00 B5106 $5.00
B5007 $12.00 B5057 $7.00 B5107 $10.00
B5008 $5.00 B5058 $12.00 B5108 $5.00
B5009 $5.00 B5059 $10.00 B5109 $5.00
B5010 $5.00 B5060 $5.00 B5110 $5.00
B5011 $5.00 B5061 NADA B5111 $10.00
B5012 $15.00 B5062 $5.00 B5112 $5.00
B5013 $5.00 B5063 $5.00 B5113 $5.00
B5014 $5.00 B5064 NADA B5114 $5.00
B5015 $7.00 B5065 NADA B5115 $5.00
B5016 $7.00 B5066 NADA B5116 $5.00
B5017 $5.00 B5067 NADA B5117 $5.00
B5018 NADA B5068 $5.00 B5118 $5.00
B5019 $7.00 B5069 $5.00 B5119 $5.00
B5020 $5.00 B5070 $5.00 B5120 $5.00
B5021 $10.00 B5071 $5.00 B5121 $5.00
B5022 $5.00 B5072 $5.00 B5122 $5.00
B5023 $5.00 B5073 $5.00 B5123 $5.00
B5024 $5.00 B5074 $15.00 B5124 $5.00
B5025 $7.00 B5075 $7.00 B5125 $5.00
B5026 $5.00 B5076 $5.00 B5125 $5.00
B5027 $10.00 B5077 $7.00 B5126 $5.00
B5028 $7.00 B5078 $5.00 B5127 $5.00
B5029 $7.00 B5079 $5.00 B5128 $5.00
B5030 NADA B5080 $5.00 B5129 $5.00
B5031 $10.00 B5081 $5.00 B5130 $5.00
B5032 $10.00 B5082 $5.00 B5131 $5.00
B5033 $5.00 B5083 $5.00 B5132 $5.00
B5034 $10.00 B5084 $5.00 B5133 $5.00
B5035 $5.00 B5085 $5.00 B5134 $5.00
B5036 $5.00 B5086 $5.00 B5135 $5.00
B5037 $5.00 B5087 $5.00 B5136 $5.00
B5038 NADA B5088 NADA B5137 $5.00
B5039 $5.00 B5089 $5.00 B5138 $5.00
B5040 $5.00 B5090 $5.00 B5139 $5.00
B5041 $5.00 B5091 $5.00 B5140 $12.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
44
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B5141 $5.00 B5191 $5.00 B5241 $7.00
B5142 $5.00 B5192 $15.00 B5242 $5.00
B5143 $5.00 B5193 $5.00 B5243 $5.00
B5144 $8.00 B5194 $5.00 B5244 $7.00
B5145 $5.00 B5195 $7.00 B5245 $5.00
B5146 $5.00 B5196 $7.00 B5246 $5.00
B5147 $8.00 B5197 $7.00 B5247 $5.00
B5148 $5.00 B5198 $5.00 B5248 $5.00
B5149 $5.00 B5199 $5.00 B5249 $5.00
B5150 $7.00 B5200 $5.00 B5250 $5.00
B5151 $5.00 B5201 $5.00 B5251 $5.00
B5152 $5.00 B5202 $5.00 B5252 $5.00
B5153 $5.00 B5203 $5.00 B5253 $5.00
B5154 $7.00 B5204 $5.00 B5254 $5.00
B5155 $7.00 B5205 $5.00 B5255 $15.00
B5156 $5.00 B5206 $5.00 B5256 $7.00
B5157 $5.00 B5207 $5.00 B5257 $5.00
B5158 $5.00 B5208 $7.00 B5258 $5.00
B5159 $5.00 B5209 $10.00 B5259 $5.00
B5160 $5.00 B5210 $10.00 B5260 $15.00
B5161 $5.00 B5211 $10.00 B5261 $7.00
B5162 $5.00 B5212 $7.00 B5262 $5.00
B5163 $5.00 B5213 $5.00 B5263 $5.00
B5164 $5.00 B5214 $5.00 B5264 $5.00
B5165 $7.00 B5215 $10.00 B5265 $5.00
B5166 $5.00 B5216 $10.00 B5266 $5.00
B5167 $5.00 B5217 $10.00 B5267 $5.00
B5168 $5.00 B5218 $10.00 B5268 $5.00
B5169 $5.00 B5219 $5.00 B5269 $5.00
B5170 $5.00 B5220 $5.00 B5270 $5.00
B5171 $5.00 B5221 $5.00 B5271 $7.00
B5172 $5.00 B5222 $5.00 B5272 $7.00
B5173 $5.00 B5223 $5.00 B5273 $7.00
B5174 $5.00 B5224 $5.00 B5274 $5.00
B5175 $5.00 B5225 $5.00 B5275 $7.00
B5176 $5.00 B5226 $12.00 B5276 $5.00
B5177 $5.00 B5227 $5.00 B5277 $10.00
B5178 $7.00 B5228 $7.00 B5278 $5.00
B5179 $7.00 B5229 $5.00 B5279 $7.00
B5180 $5.00 B5230 $5.00 B5280 $5.00
B5181 $5.00 B5231 $5.00 B5281 $15.00
B5182 $15.00 B5232 $5.00 B5282 $7.00
B5183 $5.00 B5233 $5.00 B5283 $7.00
B5184 $5.00 B5234 $10.00 B5284 $7.00
B5185 $5.00 B5235 $5.00 B5286 $5.00
B5186 $5.00 B5236 $12.00 B5287 $5.00
B5187 $5.00 B5237 $7.00 B5288 $5.00
B5188 $7.00 B5238 $7.00 B5289 $7.00
B5189 $5.00 B5239 $5.00 B5290 $5.00
B5190 $5.00 B5240 $7.00 B5291 $7.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
45
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B5292 $12.00 B5342 NADA B5392 $7.00
B5293 $12.00 B5343 NADA B5393 $12.00
B5294 $5.00 B5344 $5.00 B5394 NADA
B5295 $5.00 B5345 $5.00 B5395 $5.00
B5296 $12.00 B5346 NADA B5396 $5.00
B5297 $15.00 B5347 NADA B5397 $5.00
B5298 $12.00 B5348 NADA B5398 NADA
B5299 NADA B5349 NADA B5399 $7.00
B5300 $10.00 B5350 $5.00 B5400 $7.00
B5301 $10.00 B5351 NADA B5401 $5.00
B5302 NADA B5352 NADA B5402 $5.00
B5303 NADA B5353 NADA B5403 $7.00
B5304 NADA B5354 NADA B5404 $7.00
B5305 NADA B5355 $5.00 B5405 $10.00
B5306 NADA B5356 NADA B5406 $10.00
B5307 NADA B5357 NADA B5407 $7.00
B5308 $12.00 B5358 NADA B5408 $7.00
B5309 $5.00 B5359 NADA B5409 $10.00
B5310 $5.00 B5360 $12.00 B5410 $10.00
B5311 $5.00 B5361 $5.00 B5411 $10.00
B5312 $5.00 B5362 $5.00 B5412 $10.00
B5313 NADA B5363 NADA B5413 $5.00
B5314 $7.00 B5364 NADA B5414 $10.00
B5315 NADA B5365 NADA B5415 $5.00
B5316 NADA B5366 $5.00 B5416 $7.00
B5317 $5.00 B5367 $5.00 B5417 $7.00
B5318 NADA B5368 $5.00 B5418 $7.00
B5319 $5.00 B5369 $5.00 B5419 $7.00
B5320 $5.00 B5370 $5.00 B5420 $5.00
B5321 $12.00 B5371 $5.00 B5421 NADA
B5322 $5.00 B5372 $7.00 B5422 NADA
B5323 $5.00 B5373 $7.00 B5423 NADA
B5324 $7.00 B5374 $5.00 B5424 NADA
B5325 $5.00 B5375 $7.00 B5425 $5.00
B5326 $5.00 B5376 $7.00 B5426 $15.00
B5327 NADA B5377 $5.00 B5427 $7.00
B5328 $5.00 B5378 $10.00 B5428 $12.00
B5329 $5.00 B5379 $10.00 B5429 $5.00
B5330 $5.00 B5380 $15.00 B5430 $5.00
B5331 $7.00 B5381 $8.00 B5431 $5.00
B5332 $5.00 B5382 $10.00 B5431 $5.00
B5333 $5.00 B5383 NADA B5432 NADA
B5334 $5.00 B5384 NADA B5433 $5.00
B5335 $12.00 B5385 $5.00 B5434 $5.00
B5336 $5.00 B5386 $5.00 B5436 $5.00
B5337 $12.00 B5387 $5.00 B5437 $5.00
B5338 $5.00 B5388 $5.00 B5438 $5.00
B5339 $7.00 B5389 $5.00 B5439 $5.00
B5340 $10.00 B5390 $10.00 B5440 $5.00
B5341 $5.00 B5391 $7.00 B5441 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
46
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B5442 $7.00 B5492 $5.00 B5542 $10.00
B5443 $7.00 B5493 $5.00 B5543 $7.00
B5444 $5.00 B5494 $5.00 B5544 $7.00
B5445 $5.00 B5495 $5.00 B5545 $12.00
B5446 $5.00 B5496 $5.00 B5546 $5.00
B5447 $7.00 B5497 $5.00 B5547 $5.00
B5448 $5.00 B5498 $5.00 B5548 $5.00
B5449 $5.00 B5499 $5.00 B5549 $5.00
B5450 $5.00 B5500 $5.00 B5550 $15.00
B5451 $5.00 B5501 $5.00 B5551 $15.00
B5452 $5.00 B5502 $7.00 B5552 $12.00
B5453 $7.00 B5503 $5.00 B5553 $12.00
B5454 $7.00 B5504 NADA B5554 $5.00
B5455 $5.00 B5505 NADA B5555 $5.00
B5456 $5.00 B5506 $5.00 B5556 $5.00
B5457 $5.00 B5507 NADA B5557 $5.00
B5458 $5.00 B5508 NADA B5558 $5.00
B5459 $5.00 B5509 $5.00 B5559 $12.00
B5460 $5.00 B5510 NADA B5560 $15.00
B5461 $5.00 B5511 NADA B5561 $5.00
B5462 $5.00 B5512 $5.00 B5562 $5.00
B5463 $5.00 B5513 $5.00 B5563 $5.00
B5464 $5.00 B5514 NADA B5564 $15.00
B5465 $5.00 B5515 NADA B5565 $15.00
B5466 $5.00 B5516 NADA B5566 $5.00
B5467 $5.00 B5517 $5.00 B5567 $5.00
B5468 $5.00 B5518 $5.00 B5568 $15.00
B5469 $5.00 B5519 NADA B5569 $10.00
B5470 $5.00 B5520 $12.00 B5570 $10.00
B5471 $5.00 B5521 NADA B5571 $10.00
B5472 $5.00 B5522 NADA B5572 $5.00
B5473 $5.00 B5523 NADA B5573 $15.00
B5474 $5.00 B5524 NADA B5574 $12.00
B5475 $5.00 B5525 $5.00 B5575 $5.00
B5476 NADA B5526 $5.00 B5576 $5.00
B5477 $5.00 B5527 $5.00 B5577 $12.00
B5478 $5.00 B5528 $5.00 B5578 $10.00
B5479 $5.00 B5529 NADA B5579 $10.00
B5480 $5.00 B5530 NADA B5580 $10.00
B5481 $5.00 B5531 NADA B5581 $7.00
B5482 $5.00 B5532 NADA B5582 $10.00
B5483 $5.00 B5533 NADA B5583 $7.00
B5484 $5.00 B5534 $10.00 B5584 $5.00
B5485 $5.00 B5535 $5.00 B5585 $5.00
B5486 $7.00 B5536 NADA B5586 $7.00
B5487 $5.00 B5537 $5.00 B5587 $12.00
B5488 $5.00 B5538 NADA B5588 $5.00
B5489 $5.00 B5539 $5.00 B5589 $7.00
B5490 $5.00 B5540 $5.00 B5590 $7.00
B5491 $5.00 B5541 $10.00 B5591 $7.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
47
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B5592 $10.00 B5642 $5.00 B5692 $7.00
B5593 NADA B5643 $7.00 B5693 $7.00
B5594 NADA B5644 $5.00 B5694 $5.00
B5595 $5.00 B5645 $5.00 B5695 $5.00
B5596 NADA B5646 $7.00 B5696 $5.00
B5597 $5.00 B5647 $10.00 B5697 $7.00
B5598 $5.00 B5648 $10.00 B5698 NADA
B5599 $5.00 B5649 $7.00 B5699 NADA
B5600 $5.00 B5650 $7.00 B5700 NADA
B5601 $5.00 B5651 $7.00 B5701 $5.00
B5602 $5.00 B5652 $5.00 B5702 $10.00
B5603 $5.00 B5653 $5.00 B5703 $5.00
B5604 NADA B5654 $5.00 B5704 $5.00
B5605 $10.00 B5655 $5.00 B5705 $5.00
B5606 $12.00 B5656 $15.00 B5706 $12.00
B5607 $5.00 B5657 $5.00 B5707 $5.00
B5608 NADA B5658 $5.00 B5708 $5.00
B5609 $5.00 B5659 $5.00 B5709 $5.00
B5610 $7.00 B5660 $5.00 B5710 $5.00
B5611 $7.00 B5661 $5.00 B5711 $5.00
B5612 $7.00 B5662 $5.00 B5712 $5.00
B5613 $7.00 B5663 $5.00 B5713 $5.00
B5614 $7.00 B5664 $5.00 B5714 $5.00
B5615 $7.00 B5665 $12.00 B5715 $5.00
B5616 $7.00 B5666 $5.00 B5716 $12.00
B5617 $7.00 B5667 $5.00 B5717 $7.00
B5618 $7.00 B5668 NADA B5718 $5.00
B5619 $7.00 B5669 NADA B5719 $7.00
B5620 $7.00 B5670 $5.00 B5720 NADA
B5621 $7.00 B5671 $5.00 B5721 NADA
B5622 $7.00 B5672 $7.00 B5722 NADA
B5623 $5.00 B5673 $7.00 B5725 $5.00
B5624 $7.00 B5674 $5.00 B5726 $5.00
B5625 $12.00 B5675 $5.00 B5729 $5.00
B5626 $5.00 B5676 $7.00 B5730 $15.00
B5627 $5.00 B5677 $5.00 B5731 $5.00
B5628 NADA B5678 $10.00 B5732 $10.00
B5629 $5.00 B5679 $7.00 B5733 $10.00
B5630 $15.00 B5680 $7.00 B5734 $10.00
B5631 $7.00 B5681 $5.00 B5735 $10.00
B5632 $7.00 B5682 $10.00 B5736 $5.00
B5633 $7.00 B5683 $7.00 B5737 $5.00
B5634 $7.00 B5684 $7.00 B5738 $10.00
B5635 $5.00 B5685 $5.00 B5740 NADA
B5636 $5.00 B5686 $5.00 B5741 NADA
B5637 $5.00 B5687 $5.00 B5742 NADA
B5638 $10.00 B5688 $10.00 B5745 NADA
B5639 $5.00 B5689 $5.00 B5746 $15.00
B5640 $5.00 B5690 $7.00 B5749 $5.00
B5641 $5.00 B5691 NADA B5754 $7.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
48
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B5755 $7.00 B5827 $10.00 B5877 NADA
B5757 $7.00 B5828 $10.00 B5878 $5.00
B5760 $5.00 B5829 $10.00 B5879 $7.00
B5761 $12.00 B5830 $10.00 B5880 $5.00
B5762 $5.00 B5831 $7.00 B5881 $5.00
B5764 $12.00 B5832 $7.00 B5883 NADA
B5765 NADA B5833 $10.00 B5884 $5.00
B5766 $7.00 B5834 $7.00 B5885 NADA
B5769 $7.00 B5835 $10.00 B5886 NADA
B5770 $7.00 B5836 NADA B5887 NADA
B5771 $5.00 B5837 NADA B5888 NADA
B5772 $5.00 B5838 NADA B5889 $5.00
B5773 $5.00 B5839 NADA B5890 $5.00
B5774 $5.00 B5840 NADA B5891 $7.00
B5777 NADA B5841 $8.00 B5892 NADA
B5778 $5.00 B5842 $7.00 B5893 $5.00
B5781 $10.00 B5843 $7.00 B5894 NADA
B5782 $10.00 B5844 $5.00 B5895 $5.00
B5783 $7.00 B5845 NADA B5896 $5.00
B5784 $7.00 B5846 $5.00 B5897 $10.00
B5785 NADA B5847 $5.00 B5898 $7.00
B5786 NADA B5848 $8.00 B5899 $10.00
B5787 $5.00 B5849 NADA B5900 $7.00
B5788 NADA B5850 NADA B5901 $7.00
B5789 $5.00 B5851 $5.00 B5902 $7.00
B5790 NADA B5852 $5.00 B5903 $7.00
B5797 $5.00 B5853 $7.00 B5904 $5.00
B5798 $5.00 B5854 $7.00 B5905 $5.00
B5799 NADA B5855 $7.00 B5906 $5.00
B5800 NADA B5856 $7.00 B5907 $5.00
B5801 NADA B5857 $5.00 B5908 $5.00
B5803 $5.00 B5858 $8.00 B5909 $5.00
B5807 $7.00 B5859 $5.00 B5910 $5.00
B5808 $7.00 B5860 NADA B5911 $7.00
B5810 NADA B5861 NADA B5912 $7.00
B5811 NADA B5862 NADA B5913 $5.00
B5812 NADA B5863 $5.00 B5914 $5.00
B5813 $5.00 B5864 $5.00 B5915 $5.00
B5814 $5.00 B5865 $5.00 B5916 $8.00
B5815 $10.00 B5866 NADA B5917 $15.00
B5817 $5.00 B5867 NADA B5918 $10.00
B5818 $7.00 B5868 NADA B5919 $10.00
B5819 $7.00 B5869 $5.00 B5920 NADA
B5820 $7.00 B5870 $7.00 B5921 $10.00
B5821 $5.00 B5871 $7.00 B5923 $5.00
B5822 $12.00 B5872 $5.00 B5924 $7.00
B5823 $5.00 B5873 $5.00 B5925 $10.00
B5824 $7.00 B5874 NADA B5926 $10.00
B5825 $7.00 B5875 $7.00 B5927 $7.00
B5826 $7.00 B5876 $5.00 B5928 $10.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
49
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B5931 $5.00 B5982 $10.00 B6032 $7.00
B5932 $7.00 B5983 NADA B6033 NADA
B5933 $5.00 B5984 $7.00 B6034 $10.00
B5934 $7.00 B5985 $5.00 B6036 $10.00
B5935 $5.00 B5986 $5.00 B6037 $5.00
B5936 $5.00 B5987 $5.00 B6038 $7.00
B5937 $7.00 B5988 $10.00 B6039 $7.00
B5938 $10.00 B5989 $7.00 B6040 $10.00
B5939 $7.00 B5990 NADA B6041 $7.00
B5940 NADA B5991 $5.00 B6042 $7.00
B5941 NADA B5992 $5.00 B6043 $7.00
B5942 $7.00 B5993 $7.00 B6044 $7.00
B5943 NADA B5994 $7.00 B6045 $7.00
B5944 $5.00 B5995 $7.00 B6046 $7.00
B5945 $5.00 B5996 $7.00 B6047 $7.00
B5946 $5.00 B5997 NADA B6048 $7.00
B5947 $7.00 B5998 $8.00 B6049 NADA
B5948 $7.00 B5999 $7.00 B6050 $7.00
B5949 $7.00 B6000 $7.00 B6051 $7.00
B5950 $7.00 B6001 $7.00 B6052 $5.00
B5951 $10.00 B6002 $5.00 B6053 NADA
B5952 $10.00 B6003 $5.00 B6054 $5.00
B5953 $7.00 B6004 $5.00 B6055 $5.00
B5954 $5.00 B6005 $5.00 B6056 $5.00
B5955 $10.00 B6006 $5.00 B6057 $5.00
B5956 $10.00 B6007 $7.00 B6058 NADA
B5957 $7.00 B6008 $7.00 B6059 $5.00
B5958 $5.00 B6009 $10.00 B6060 NADA
B5959 $7.00 B6010 $7.00 B6061 $7.00
B5961 $7.00 B6011 $7.00 B6062 $7.00
B5962 $5.00 B6012 $5.00 B6063 $7.00
B5963 $10.00 B6013 $7.00 B6064 $5.00
B5964 $5.00 B6014 $10.00 B6065 $5.00
B5965 $5.00 B6015 $5.00 B6066 NADA
B5966 $7.00 B6016 $5.00 B6067 $7.00
B5967 $10.00 B6017 $5.00 B6068 $5.00
B5968 $5.00 B6018 $7.00 B6069 $7.00
B5969 $5.00 B6019 NADA B6070 $7.00
B5970 $5.00 B6020 $5.00 B6071 $5.00
B5971 $10.00 B6021 $7.00 B6072 $5.00
B5972 $7.00 B6022 $5.00 B6073 $7.00
B5973 $7.00 B6023 $7.00 B6074 $7.00
B5974 $5.00 B6024 $10.00 B6075 $5.00
B5975 NADA B6025 $10.00 B6076 $5.00
B5976 $7.00 B6026 $10.00 B6077 $7.00
B5977 $7.00 B6027 $7.00 B6078 $7.00
B5978 $7.00 B6028 $10.00 B6079 $7.00
B5979 $7.00 B6029 $7.00 B6080 $5.00
B5980 $10.00 B6030 $5.00 B6081 $10.00
B5981 $7.00 B6031 $7.00 B6082 $7.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
50
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B6083 $7.00 B6136 NADA B6201 $10.00
B6084 $7.00 B6137 $5.00 B6202 $10.00
B6085 NADA B6138 $5.00 B6203 NADA
B6086 $7.00 B6139 $5.00 B6204 $5.00
B6087 $15.00 B6140 $10.00 B6205 $7.00
B6088 $5.00 B6141 $5.00 B6206 NADA
B6089 $7.00 B6142 NADA B6207 $7.00
B6090 $7.00 B6143 $5.00 B6208 NADA
B6091 $7.00 B6144 $7.00 B6209 $5.00
B6092 $7.00 B6145 $10.00 B6210 $5.00
B6093 NADA B6146 $7.00 B6211 $5.00
B6094 $7.00 B6147 $10.00 B6212 $5.00
B6095 $5.00 B6148 $7.00 B6213 $5.00
B6096 $5.00 B6149 $7.00 B6214 $5.00
B6097 $7.00 B6150 $10.00 B6215 $5.00
B6098 $7.00 B6151 $5.00 B6216 $5.00
B6099 $7.00 B6152 $10.00 B6217 $10.00
B6100 $15.00 B6153 $10.00 B6218 $5.00
B6101 $7.00 B6154 $7.00 B6219 $5.00
B6102 $7.00 B6156 $7.00 B6220 $8.00
B6103 $5.00 B6159 $5.00 B6221 $7.00
B6104 $7.00 B6160 $7.00 B6222 $5.00
B6105 $5.00 B6163 $10.00 B6223 $5.00
B6106 $5.00 B6164 $7.00 B6224 $5.00
B6109 $5.00 B6165 $5.00 B6225 $5.00
B6110 $7.00 B6166 $10.00 B6226 $15.00
B6111 $10.00 B6167 $10.00 B6227 $5.00
B6112 $7.00 B6168 $10.00 B6228 $5.00
B6113 $10.00 B6172 $10.00 B6229 $15.00
B6115 $5.00 B6173 $7.00 B6230 $7.00
B6116 NADA B6180 $10.00 B6231 $7.00
B6117 NADA B6181 $7.00 B6232 $5.00
B6118 NADA B6182 $7.00 B6233 $5.00
B6119 NADA B6183 $5.00 B6234 $5.00
B6120 $5.00 B6184 $5.00 B6235 $2.00
B6121 NADA B6185 $5.00 B6236 NADA
B6122 $7.00 B6187 NADA B6237 $5.00
B6123 $5.00 B6188 NADA B6238 $7.00
B6124 $5.00 B6189 $7.00 B6239 $5.00
B6125 $7.00 B6190 NADA B6240 $5.00
B6126 NADA B6191 NADA B6241 $5.00
B6127 $10.00 B6192 $5.00 B6242 $5.00
B6128 NADA B6193 $10.00 B6243 $5.00
B6129 $10.00 B6194 $10.00 B6244 $7.00
B6130 $10.00 B6195 $5.00 B6245 $7.00
B6131 $7.00 B6196 $10.00 B6246 $7.00
B6132 NADA B6197 $5.00 B6248 $5.00
B6133 $5.00 B6198 $10.00 B6249 $5.00
B6134 $10.00 B6199 $10.00 B6250 $5.00
B6135 NADA B6200 NADA B6251 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
51
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B6252 $7.00 B6307 $7.00 B6361 $5.00
B6253 $5.00 B6308 $7.00 B6362 $7.00
B6254 $5.00 B6309 $7.00 B6363 $7.00
B6255 $5.00 B6312 $15.00 B6364 $5.00
B6256 $5.00 B6313 $7.00 B6365 $10.00
B6257 NADA B6314 $7.00 B6366 $5.00
B6258 $5.00 B6315 $10.00 B6367 $7.00
B6259 $7.00 B6316 $5.00 B6368 $5.00
B6260 $5.00 B6317 $5.00 B6369 $7.00
B6261 $7.00 B6319 $10.00 B6370 $7.00
B6262 $10.00 B6321 $7.00 B6371 $7.00
B6263 $5.00 B6322 $5.00 B6372 $5.00
B6264 $5.00 B6323 $7.00 B6373 $10.00
B6265 $7.00 B6324 $7.00 B6374 $10.00
B6266 $5.00 B6325 $7.00 B6375 $5.00
B6267 $5.00 B6326 $7.00 B6376 $5.00
B6268 NADA B6327 $5.00 B6377 $5.00
B6269 $5.00 B6328 $7.00 B6378 $7.00
B6270 $5.00 B6329 $5.00 B6379 $7.00
B6271 $5.00 B6330 $5.00 B6380 $5.00
B6273 $5.00 B6331 $5.00 B6381 $10.00
B6274 $7.00 B6332 $5.00 B6382 $7.00
B6275 $10.00 B6333 $7.00 B6383 $7.00
B6277 $10.00 B6334 $5.00 B6384 $10.00
B6278 $15.00 B6335 $5.00 B6385 $5.00
B6279 $7.00 B6336 $5.00 B6386 $5.00
B6280 $7.00 B6337 $5.00 B6387 $5.00
B6281 NADA B6338 $7.00 B6388 $5.00
B6282 $5.00 B6339 $5.00 B6389 $10.00
B6283 $10.00 B6340 $7.00 B6390 $5.00
B6284 $7.00 B6341 $7.00 B6391 $7.00
B6285 $10.00 B6342 $7.00 B6392 $7.00
B6286 NADA B6343 $7.00 B6393 $10.00
B6287 $7.00 B6344 $7.00 B6394 $10.00
B6288 $7.00 B6345 $5.00 B6395 $5.00
B6289 $7.00 B6346 $10.00 B6396 $5.00
B6290 $10.00 B6347 $7.00 B6397 $7.00
B6291 $7.00 B6348 $5.00 B6398 $7.00
B6292 $7.00 B6349 $10.00 B6399 $7.00
B6293 $7.00 B6350 $7.00 B6400 $7.00
B6295 $7.00 B6351 $7.00 B6401 $7.00
B6296 $5.00 B6352 $7.00 B6402 $7.00
B6297 $7.00 B6353 $5.00 B6403 $5.00
B6299 $7.00 B6354 $10.00 B6404 $5.00
B6300 $7.00 B6355 $7.00 B6405 $7.00
B6301 $5.00 B6356 $10.00 B6406 $5.00
B6302 $5.00 B6357 $5.00 B6407 $5.00
B6303 $10.00 B6358 $5.00 B6408 NADA
B6304 $7.00 B6359 $5.00 B6409 $5.00
B6305 NADA B6360 $5.00 B6410 $7.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
52
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B6411 $7.00 B6461 $5.00 B6521 NADA
B6412 $10.00 B6462 $10.00 B6522 $7.00
B6413 $10.00 B6463 $5.00 B6523 NADA
B6414 $10.00 B6464 $5.00 B6524 NADA
B6415 $7.00 B6465 $5.00 B6525 $5.00
B6416 $10.00 B6466 $7.00 B6526 $7.00
B6417 $10.00 B6467 $5.00 B6527 $7.00
B6418 $10.00 B6468 $5.00 B6528 $10.00
B6419 $7.00 B6469 $5.00 B6529 $5.00
B6420 $5.00 B6470 $5.00 B6530 $10.00
B6421 $5.00 B6471 $5.00 B6531 $10.00
B6422 $5.00 B6472 $5.00 B6532 $5.00
B6423 $7.00 B6473 NADA B6533 NADA
B6424 $15.00 B6474 NADA B6534 $7.00
B6425 NADA B6475 $5.00 B6535 $5.00
B6426 $5.00 B6476 $7.00 B6536 $5.00
B6427 $5.00 B6477 $5.00 B6537 $5.00
B6428 $5.00 B6478 $5.00 B6538 $5.00
B6429 $4.00 B6479 $5.00 B6539 $10.00
B6430 $4.00 B6481 $5.00 B6540 $5.00
B6431 $10.00 B6483 $7.00 B6541 $5.00
B6432 $7.00 B6484 $7.00 B6542 $5.00
B6433 $5.00 B6485 $7.00 B6543 $7.00
B6434 $5.00 B6486 $10.00 B6544 NADA
B6435 $5.00 B6487 $7.00 B6545 $5.00
B6436 $5.00 B6488 $7.00 B6546 NADA
B6437 $5.00 B6489 $7.00 B6547 $7.00
B6438 $10.00 B6490 $10.00 B6548 $5.00
B6439 $5.00 B6493 $5.00 B6549 $5.00
B6440 $7.00 B6494 $5.00 B6550 NADA
B6441 $7.00 B6495 $5.00 B6551 NADA
B6442 $10.00 B6496 $5.00 B6552 NADA
B6443 $7.00 B6498 $2.00 B6553 $5.00
B6444 $7.00 B6499 $10.00 B6554 $5.00
B6445 $7.00 B6500 $10.00 B6555 $7.00
B6446 $5.00 B6501 $5.00 B6556 $7.00
B6447 $7.00 B6502 $5.00 B6557 $7.00
B6448 $5.00 B6503 $7.00 B6558 $10.00
B6449 $5.00 B6504 $5.00 B6559 $7.00
B6450 $7.00 B6506 $7.00 B6560 $7.00
B6451 $10.00 B6507 $5.00 B6561 $5.00
B6452 $7.00 B6508 $7.00 B6562 $5.00
B6453 $5.00 B6509 $5.00 B6563 $7.00
B6454 NADA B6510 $5.00 B6564 $5.00
B6455 $10.00 B6513 $5.00 B6565 $5.00
B6456 $7.00 B6514 $5.00 B6566 $5.00
B6457 $10.00 B6515 $5.00 B6567 $7.00
B6458 $5.00 B6518 $7.00 B6568 $5.00
B6459 $5.00 B6519 $12.00 B6569 $5.00
B6460 $7.00 B6520 $12.00 B6570 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
53
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B6571 $5.00 B6621 $7.00 B6671 NADA
B6572 $7.00 B6622 $5.00 B6672 NADA
B6573 $5.00 B6623 NADA B6673 $5.00
B6574 $10.00 B6624 NADA B6674 $5.00
B6575 $5.00 B6625 NADA B6675 $5.00
B6576 $5.00 B6626 $10.00 B6676 $7.00
B6577 $5.00 B6627 $10.00 B6677 $7.00
B6578 $5.00 B6628 $7.00 B6678 $5.00
B6579 $7.00 B6629 NADA B6679 $7.00
B6580 $5.00 B6630 NADA B6680 $5.00
B6581 NADA B6631 $7.00 B6681 $7.00
B6582 NADA B6632 NADA B6682 $7.00
B6583 NADA B6633 NADA B6683 NADA
B6584 NADA B6634 $7.00 B6684 NADA
B6585 NADA B6635 $8.00 B6685 $10.00
B6586 $7.00 B6636 $8.00 B6686 NADA
B6587 $7.00 B6637 $5.00 B6687 $5.00
B6588 $5.00 B6638 $5.00 B6688 $10.00
B6589 $5.00 B6639 $5.00 B6689 $10.00
B6590 $5.00 B6640 $5.00 B6690 $7.00
B6591 $5.00 B6641 $5.00 B6691 $7.00
B6592 $5.00 B6642 NADA B6692 $10.00
B6593 $5.00 B6643 NADA B6693 $7.00
B6594 $5.00 B6644 $7.00 B6694 $5.00
B6595 $5.00 B6645 $5.00 B6695 $7.00
B6596 NADA B6646 $5.00 B6696 NADA
B6597 NADA B6647 $5.00 B6697 $10.00
B6598 $6.50 B6648 NADA B6698 $10.00
B6599 NADA B6649 NADA B6699 $5.00
B6600 NADA B6650 NADA B6700 $5.00
B6601 $5.00 B6651 $5.00 B6701 $5.00
B6602 $5.00 B6652 $5.00 B6702 $5.00
B6603 $5.00 B6653 $5.00 B6703 $7.00
B6604 $5.00 B6654 $5.00 B6704 $5.00
B6605 NADA B6655 $5.00 B6705 $5.00
B6606 NADA B6656 $5.00 B6706 $5.00
B6607 $5.00 B6657 $5.00 B6707 $7.00
B6608 $5.00 B6658 $7.00 B6708 NADA
B6609 $5.00 B6659 NADA B6709 NADA
B6610 $10.00 B6660 $7.00 B6710 $5.00
B6611 $10.00 B6661 NADA B6711 $7.00
B6612 $10.00 B6662 $5.00 B6712 $15.00
B6613 $10.00 B6663 $5.00 B6713 $7.00
B6614 $7.00 B6664 $5.00 B6714 NADA
B6615 $7.00 B6665 $5.00 B6715 $5.00
B6616 $5.00 B6666 $15.00 B6716 NADA
B6617 $10.00 B6667 $5.00 B6717 $5.00
B6618 NADA B6668 $5.00 B6718 $5.00
B6619 $5.00 B6669 $5.00 B6719 $7.00
B6620 $5.00 B6670 $5.00 B6720 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
54
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B6721 $5.00 B6771 $5.00 B6823 $7.00
B6722 $5.00 B6772 $7.00 B6824 $5.00
B6723 $7.00 B6773 $7.00 B6825 $5.00
B6724 $10.00 B6774 $7.00 B6826 $7.00
B6725 $5.00 B6775 $7.00 B6827 $7.00
B6726 $5.00 B6776 $5.00 B6828 $7.00
B6727 $5.00 B6777 $7.00 B6829 $5.00
B6728 NADA B6778 $5.00 B6830 $7.00
B6729 $10.00 B6779 $5.00 B6831 $7.00
B6730 $5.00 B6780 NADA B6832 $7.00
B6731 $7.00 B6781 $5.00 B6833 $10.00
B6732 $7.00 B6782 $5.00 B6834 $10.00
B6733 NADA B6783 $5.00 B6835 NADA
B6734 NADA B6784 $5.00 B6836 $5.00
B6735 $10.00 B6785 $5.00 B6837 $7.00
B6736 $10.00 B6788 $7.00 B6838 $5.00
B6737 $5.00 B6789 $7.00 B6839 $10.00
B6738 $5.00 B6790 $5.00 B6840 $7.00
B6739 $5.00 B6791 $5.00 B6841 $7.00
B6740 $5.00 B6792 $5.00 B6842 $7.00
B6741 $10.00 B6793 $7.00 B6843 $7.00
B6742 $5.00 B6794 $7.00 B6844 $7.00
B6743 $7.00 B6795 $7.00 B6845 $7.00
B6744 NADA B6796 $5.00 B6846 $5.00
B6745 NADA B6797 $7.00 B6847 $5.00
B6746 $7.00 B6798 $10.00 B6848 $7.00
B6747 $5.00 B6799 $10.00 B6849 $7.00
B6748 $10.00 B6800 $5.00 B6850 $7.00
B6749 $7.00 B6801 $7.00 B6851 $7.00
B6750 $7.00 B6802 $7.00 B6852 $10.00
B6751 $5.00 B6803 $7.00 B6853 $10.00
B6752 $7.00 B6804 $7.00 B6854 $5.00
B6753 $5.00 B6805 $5.00 B6855 $7.00
B6754 $5.00 B6806 $5.00 B6856 $5.00
B6755 NADA B6807 $7.00 B6857 $10.00
B6756 $5.00 B6808 $10.00 B6858 $7.00
B6757 $7.00 B6809 $5.00 B6859 $5.00
B6758 $10.00 B6810 $5.00 B6860 $7.00
B6759 $10.00 B6811 $5.00 B6861 $7.00
B6760 $5.00 B6812 $7.00 B6862 $7.00
B6761 $7.00 B6813 $5.00 B6863 $7.00
B6762 $5.00 B6814 $5.00 B6864 $7.00
B6763 NADA B6815 $5.00 B6865 $5.00
B6764 NADA B6816 $5.00 B6866 $5.00
B6765 NADA B6817 $5.00 B6867 $7.00
B6766 NADA B6818 $10.00 B6868 $5.00
B6767 $5.00 B6819 $7.00 B6869 $5.00
B6768 $10.00 B6820 $5.00 B6870 $10.00
B6769 $7.00 B6821 $7.00 B6871 $5.00
B6770 $7.00 B6822 $5.00 B6872 $7.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
55
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B6873 $5.00 B6923 $10.00 B6973 $5.00
B6874 $5.00 B6924 $7.00 B6974 $5.00
B6875 $5.00 B6925 $10.00 B6975 $5.00
B6876 $7.00 B6926 $5.00 B6976 $5.00
B6877 $5.00 B6927 $5.00 B6977 $5.00
B6878 $5.00 B6928 $10.00 B6978 $7.00
B6879 $10.00 B6929 $7.00 B6979 $5.00
B6880 $5.00 B6930 $5.00 B6980 NADA
B6881 $5.00 B6931 $5.00 B6981 $10.00
B6882 $5.00 B6932 $7.00 B6982 $10.00
B6883 $7.00 B6933 $5.00 B6983 $5.00
B6884 $7.00 B6934 $10.00 B6984 $10.00
B6885 $5.00 B6935 $7.00 B6985 $10.00
B6886 $10.00 B6936 $10.00 B6986 $5.00
B6887 $7.00 B6937 $5.00 B6987 $7.00
B6888 $7.00 B6938 $10.00 B6988 $10.00
B6889 $7.00 B6939 $5.00 B6989 NADA
B6890 $10.00 B6940 $7.00 B6990 $7.00
B6891 $7.00 B6941 $5.00 B6991 $7.00
B6892 $5.00 B6942 $5.00 B6992 $7.00
B6893 NADA B6943 NADA B6993 $10.00
B6894 $7.00 B6944 $5.00 B6994 $5.00
B6895 $5.00 B6945 $7.00 B6995 $5.00
B6896 $7.00 B6946 $5.00 B6996 $5.00
B6897 $7.00 B6947 $5.00 B6997 $7.00
B6898 $15.00 B6948 $7.00 B6998 $10.00
B6899 NADA B6949 $5.00 B6999 $7.00
B6900 NADA B6950 $7.00 B7000 NADA
B6901 $7.00 B6951 $7.00 B7001 $7.00
B6902 $10.00 B6952 $7.00 B7002 $7.00
B6903 $7.00 B6953 $5.00 B7003 $7.00
B6904 $7.00 B6954 $5.00 B7004 $7.00
B6905 $10.00 B6955 $5.00 B7005 $5.00
B6906 $10.00 B6956 $5.00 B7006 $7.00
B6907 $5.00 B6957 $5.00 B7007 NADA
B6908 $10.00 B6958 $5.00 B7008 $7.00
B6909 $5.00 B6959 $5.00 B7009 $7.00
B6910 $5.00 B6960 $7.00 B7010 $7.00
B6911 $5.00 B6961 $7.00 B7011 $5.00
B6912 $10.00 B6962 $7.00 B7012 $5.00
B6913 NADA B6963 $7.00 B7013 $7.00
B6914 $10.00 B6964 $7.00 B7014 $15.00
B6915 $5.00 B6965 $7.00 B7015 $7.00
B6916 $5.00 B6966 $7.00 B7016 $7.00
B6917 $5.00 B6967 $10.00 B7017 $7.00
B6918 $7.00 B6968 $5.00 B7018 $10.00
B6919 $7.00 B6969 $7.00 B7020 $7.00
B6920 $5.00 B6970 $7.00 B7022 $7.00
B6921 $5.00 B6971 $10.00 B7023 $5.00
B6922 NADA B6972 $10.00 B7024 $10.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
56
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B7025 $10.00 B7075 $10.00 B7134 $5.00
B7026 NADA B7076 NADA B7135 $5.00
B7027 $5.00 B7077 $5.00 B7136 NADA
B7028 $5.00 B7079 $5.00 B7137 NADA
B7029 $10.00 B7080 $10.00 B7138 $5.00
B7030 $5.00 B7081 $7.00 B7139 $5.00
B7031 $5.00 B7082 $7.00 B7140 $5.00
B7032 $5.00 B7083 $7.00 B7141 $7.00
B7033 $5.00 B7084 $7.00 B7142 $5.00
B7034 NADA B7085 $5.00 B7143 $5.00
B7035 $5.00 B7086 $5.00 B7144 $5.00
B7036 NADA B7087 $10.00 B7145 $5.00
B7037 $5.00 B7088 $10.00 B7146 $5.00
B7038 $10.00 B7089 $10.00 B7147 $7.00
B7039 $5.00 B7090 $5.00 B7148 $5.00
B7040 $10.00 B7091 $5.00 B7149 $5.00
B7041 $10.00 B7092 $5.00 B7150 $5.00
B7042 $10.00 B7093 $5.00 B7151 $5.00
B7043 $5.00 B7094 $10.00 B7152 $5.00
B7044 $5.00 B7095 $7.00 B7153 $5.00
B7045 $7.00 B7096 $10.00 B7154 $5.00
B7046 $7.00 B7097 NADA B7155 NADA
B7047 $7.00 B7099 $10.00 B7156 $10.00
B7048 $7.00 B7100 $10.00 B7157 $5.00
B7049 $7.00 B7101 $7.00 B7158 $10.00
B7050 $7.00 B7104 $5.00 B7159 $10.00
B7051 $7.00 B7109 $10.00 B7160 $10.00
B7052 $10.00 B7111 $7.00 B7161 $5.00
B7053 $5.00 B7112 $5.00 B7162 NADA
B7054 $7.00 B7113 $10.00 B7163 $5.00
B7055 $10.00 B7114 $5.00 B7164 $5.00
B7056 $5.00 B7115 $5.00 B7165 $5.00
B7057 NADA B7116 $5.00 B7166 $5.00
B7058 $7.00 B7117 $10.00 B7167 $10.00
B7059 $10.00 B7118 $10.00 B7168 $7.00
B7060 $10.00 B7119 NADA B7169 NADA
B7061 $10.00 B7120 NADA B7170 NADA
B7062 $10.00 B7121 $5.00 B7171 NADA
B7063 $7.00 B7122 $5.00 B7172 $5.00
B7064 $10.00 B7123 $5.00 B7173 $5.00
B7065 $7.00 B7124 $5.00 B7174 $5.00
B7066 $10.00 B7125 $7.00 B7175 $7.00
B7067 $10.00 B7126 $7.00 B7176 $5.00
B7068 $5.00 B7127 $7.00 B7177 $5.00
B7069 $5.00 B7128 $5.00 B7178 $5.00
B7070 NADA B7129 $5.00 B7179 $5.00
B7071 $7.00 B7130 $5.00 B7180 $5.00
B7072 $7.00 B7131 $5.00 B7181 $5.00
B7073 $10.00 B7132 $10.00 B7182 $5.00
B7074 $10.00 B7133 $5.00 B7183 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
57
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
B7184 $5.00 B7241 $7.00 B7298 $7.00
B7185 $5.00 B7242 $5.00 B7299 $7.00
B7186 $5.00 B7243 $8.00 B7300 $5.00
B7187 $5.00 B7244 $5.00 B7301 $5.00
B7188 $5.00 B7245 $5.00 B7303 $5.00
B7189 $5.00 B7246 $7.00 B7304 $10.00
B7190 $5.00 B7247 $7.00 B7305 $7.00
B7191 $5.00 B7248 $7.00 B7308 $5.00
B7192 $5.00 B7249 $5.00 B7309 $10.00
B7193 $5.00 B7250 $5.00 B7310 $10.00
B7194 $5.00 B7251 $5.00 B7313 $10.00
B7195 $10.00 B7252 $7.00 B7314 $7.00
B7196 $5.00 B7253 $7.00 B7315 $7.00
B7197 $10.00 B7254 $5.00 B7316 $10.00
B7198 $5.00 B7255 $7.00 B7317 $10.00
B7199 $7.00 B7256 $5.00 B7318 $10.00
B7200 $7.00 B7257 $7.00 B7319 $7.00
B7201 $7.00 B7258 $5.00 B7320 $10.00
B7202 $10.00 B7259 $5.00 B7321 $10.00
B7203 NADA B7260 $5.00 B7322 $10.00
B7204 NADA B7261 $7.00 B7323 $5.00
B7205 $7.00 B7262 $5.00 B7324 $5.00
B7206 $7.00 B7263 $7.00 B7325 $10.00
B7207 $7.00 B7264 $5.00 B7326 $10.00
B7208 $7.00 B7265 $5.00 B7330 NADA
B7209 $5.00 B7266 $5.00 B7331 $7.00
B7210 $7.00 B7267 $5.00 B7332 $7.00
B7211 $10.00 B7268 $5.00 B7333 $5.00
B7213 $7.00 B7269 $2.00 B7334 $5.00
B7214 $10.00 B7270 $5.00 * *
B7218 $10.00 B7271 $7.00 * *
B7219 $5.00 B7272 $7.00 * *
B7220 NADA B7273 $10.00 * *
B7221 $7.00 B7274 $10.00 * *
B7222 $7.00 B7275 $7.00 * *
B7223 $7.00 B7276 $10.00 * *
B7224 $7.00 B7277 $10.00 * *
B7225 $10.00 B7278 $10.00 * *
B7226 $5.00 B7279 $7.00 * *
B7227 $7.00 B7280 $10.00 * *
B7228 $5.00 B7281 $7.00 * *
B7229 $5.00 B7283 $7.00 * *
B7230 $8.00 B7284 $7.00 * *
B7231 $5.00 B7285 $10.00 * *
B7234 $5.00 B7286 $5.00 * *
B7235 $5.00 B7288 $7.00 * *
B7236 $7.00 B7290 $7.00 * *
B7237 $5.00 B7291 $7.00 * *
B7238 $5.00 B7292 $5.00 * *
B7240 $10.00 B7297 $7.00 * *
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
58
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
BA1 $5.00 BA51 $5.00 BA101 $5.00 BA2 $5.00 BA52 $5.00 BA102 $5.00 BA3 $5.00 BA53 $5.00 BA103 $5.00 BA4 $5.00 BA54 $5.00 BA104 $5.00 BA5 $5.00 BA55 $5.00 BA105 $5.00 BA6 $5.00 BA56 $5.00 BA106 $5.00 BA7 $5.00 BA57 $5.00 BA107 $5.00 BA8 $5.00 BA58 $5.00 BA108 $5.00 BA9 $5.00 BA59 $5.00 BA109 $5.00 BA10 $5.00 BA60 $5.00 BA110 $5.00 BA11 $5.00 BA61 $5.00 BA111 $5.00 BA12 $5.00 BA62 $5.00 BA112 $5.00 BA13 $5.00 BA63 $5.00 BA113 $5.00 BA14 $5.00 BA64 $5.00 BA114 $5.00 BA15 $5.00 BA65 $5.00 BA115 $5.00 BA16 $5.00 BA66 $5.00 BA116 $5.00 BA17 $5.00 BA67 $5.00 BA117 $5.00 BA18 $5.00 BA68 $5.00 BA118 $5.00 BA19 $5.00 BA69 $5.00 BA119 $5.00 BA20 $5.00 BA70 $5.00 BA120 $5.00 BA21 $5.00 BA71 $5.00 BA121 $5.00 BA22 $5.00 BA72 $5.00 BA122 $5.00 BA23 $5.00 BA73 $5.00 BA123 $5.00 BA24 $5.00 BA74 $5.00 BA124 $5.00 BA25 $5.00 BA75 $5.00 BA125 $5.00 BA26 $5.00 BA76 $5.00 BA126 $5.00 BA27 $5.00 BA77 $5.00 BA127 $5.00 BA28 $5.00 BA78 $5.00 BA128 $5.00 BA29 $5.00 BA79 $5.00 BA129 $5.00 BA30 $5.00 BA80 $5.00 BA130 $5.00 BA31 $5.00 BA81 $5.00 BA131 $5.00 BA32 $5.00 BA82 $5.00 BA132 $5.00 BA33 $5.00 BA83 $5.00 BA133 $5.00 BA34 $5.00 BA84 $5.00 BA134 $5.00 BA35 $5.00 BA85 $5.00 BA135 $5.00 BA36 $5.00 BA86 $5.00 BA136 $5.00 BA37 $5.00 BA87 $5.00 BA137 $5.00 BA38 $5.00 BA88 $5.00 BA138 $5.00 BA39 $5.00 BA89 $5.00 BA139 $5.00 BA40 $5.00 BA90 $5.00 BA140 $5.00 BA41 $5.00 BA91 $5.00 BA141 $5.00 BA42 $5.00 BA92 $5.00 BA142 $5.00 BA43 $5.00 BA93 $5.00 BA143 $5.00 BA44 $5.00 BA94 $5.00 BA144 $5.00 BA45 $5.00 BA95 $5.00 BA145 $5.00 BA46 $5.00 BA96 $5.00 BA146 $5.00 BA47 $5.00 BA97 $5.00 BA147 $5.00 BA48 $5.00 BA98 $5.00 BA148 $5.00 BA49 $5.00 BA99 $5.00 BA149 $5.00 BA50 $5.00 BA100 $5.00 BA150 $5.00
TERAPIA RESPIRATORIA Códigos de Cubiertas/Deducibles
08-13-2015
59
CÓDIGO COASEGURO CÓDIGO COASEGURO CÓDIGO COASEGURO
BA151 $5.00 BA201 $5.00 BA320 $5.00
BA152 $5.00 BA202 $5.00 BA338 $5.00
BA153 $5.00 BA203 $5.00 BA340 $5.00
BA154 $5.00 BA204 $5.00 BA350 $5.00
BA155 $5.00 BA205 $5.00 BA354 $5.00
BA156 $5.00 BA206 $5.00 BA364 $5.00
BA157 $5.00 BA207 $5.00 BA366 $5.00
BA158 $5.00 BA208 $5.00 BA375 $5.00
BA159 $5.00 BA209 $5.00 BA391 $5.00
BA160 $5.00 BA210 $5.00 BA392 $5.00
BA161 $5.00 BA211 $5.00 BA405 $5.00
BA162 $5.00 BA212 $5.00 BA410 $5.00
BA163 $5.00 BA213 $5.00 BA415 $5.00
BA164 $5.00 BA214 $5.00 BA430 $5.00
BA165 $5.00 BA215 $5.00 BA434 $5.00
BA166 $5.00 BA216 $5.00 BA435 $5.00
BA167 $5.00 BA217 $5.00 BA436 $5.00
BA168 $5.00 BA218 $5.00 BA464 $5.00
BA169 $5.00 BA219 $5.00 BA468 $5.00
BA170 $5.00 BA220 $7.00 BA474 $5.00
BA171 $5.00 BA221 $7.00 BA500 $5.00
BA172 $5.00 BA222 $7.00 * *
BA173 $5.00 BA223 $5.00 * *
BA174 $5.00 BA224 $5.00 * *
BA175 $5.00 BA225 $5.00 * *
BA176 $5.00 BA226 $5.00 * *
BA177 $5.00 BA227 $5.00 * *
BA178 $5.00 BA228 $5.00 * *
BA179 $5.00 BA229 $5.00 * *
BA180 $5.00 BA279 $5.00 * *
BA181 $5.00 BA280 $5.00 * *
BA182 $5.00 BA281 $5.00 * *
BA183 $5.00 BA282 $5.00 * *
BA184 $5.00 BA283 $5.00 * *
BA185 $5.00 BA285 $5.00 * *
BA186 $5.00 BA286 $5.00 * *
BA187 $5.00 BA287 $5.00 * *
BA188 $5.00 BA289 $5.00 * *
BA189 $5.00 BA290 $5.00 * *
BA190 $5.00 BA291 $5.00 * *
BA191 $5.00 BA293 $5.00 * *
BA192 $5.00 BA294 $5.00 * *
BA193 $5.00 BA295 $5.00 * *
BA194 $5.00 BA297 $5.00 * *
BA195 $5.00 BA298 $5.00 * *
BA196 $5.00 BA303 $5.00 * *
BA197 $5.00 BA304 $5.00 * *
BA198 $5.00 BA307 $5.00 * *
BA199 $5.00 BA310 $5.00 * *
BA200 $5.00 BA316 $5.00 * *
