Sample Price Savings
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Dental Procedures |
Usual Price* | Medisaver Rate | Savings Rate | ||||||||||||||
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Two Surface Filling |
$ 152.00 | $ 35.00 | 77% | ||||||||||||||
| Crown, porcelain/gold | 929.00 | 300.00 | 68% | ||||||||||||||
| Root Canal, one | 552.00 | 125.00 | 77% | ||||||||||||||
| Root Canal, two | 663.00 | 175.00 | 74% | ||||||||||||||
| Root Canal, three | 832.00 | 225.00 | 73% | ||||||||||||||
| Denture, complete upper | 1280.00 | 225.00 | 75% | ||||||||||||||
| Denture, complete lower | 1219.00 | 320.00 | 74% | ||||||||||||||
| Periodic Exams | 39.00 | 12.00 | 69% | ||||||||||||||
| X-rays, full mouth series | 107.00 | 27.00 | 75% | ||||||||||||||
| Surgical Procedures | |||||||||||||||||
| Arthroscopy, knee | $ 3771.00 | $ 1535.00 | 59% | ||||||||||||||
| Coronary Artery bypass | 10,205.00 | 3810.00 | 63% | ||||||||||||||
| Sigmoidoscopy | 378.00 | 145.00 | 62% | ||||||||||||||
| Colonoscopy | 1911.00 | 600.00 | 69% | ||||||||||||||
| Total obstetric care | 4500.00 | 2000.00 | 56% | ||||||||||||||
| Radiology Procedures | |||||||||||||||||
| MRI, brain | $ 1745.00 | $ 400.00 | 77% | ||||||||||||||
| X-ray, chest, 2 views | 117.00 | 35.00 | 60% | ||||||||||||||
| X-ray, knee, multiple views | 167.00 | 25.00 | 85% | ||||||||||||||
| Mamography, bilateral | 229.00 | 70.00 | 69% | ||||||||||||||
| Laboratory Procedures | |||||||||||||||||
| Urinalysis | $ 26.00 | $ 3.71 | 86% | ||||||||||||||
| Cholesterol, serum | 33.00 | 4.40 | 87% | ||||||||||||||
| Thyroid Stimulating Hormone | 99.00 | 22.55 | 77% | ||||||||||||||
| Complete Blood Count (CBC) | 51.00 | 6.60 | 87% | ||||||||||||||
| Pap Smear, up to 3 | 42.00 | 13.00 | 69% | ||||||||||||||
| Prostate cancer screening | 95.00 | 16.50 | 83% | ||||||||||||||
| Lyme disease antibody | 122.00 | 32.73 | 73% | ||||||||||||||
| * Price samples are based upon an industry survey, factored for New York City. Your provider's usual and customary fees may vary. | |||||||||||||||||
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CLAIM AND FEE EXAMPLE
With the Gold Shield MediSavers Program, the provider's full charges will be charged to the account you authorized us to use when you enrolled. Your account will also be credited for seventy-five (75%) percent (in isolated instances, sixty-seven percent 67%) of the savings you realized, (less bank charges, if any), resulting from the difference between full charges and the special rates that the provider has agreed to charge our members under the Plan (see the above Claim and Fee example). Your credit card statement should reflect both the charge and the credit, although sometimes they may appear on two separate statements. There are no claim forms to fill out for this program. All the paperwork is handled through the National Health Plan system.
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