TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COPAGO
CÓDIGO
COPAGO
CÓDIGO
COPAGO
A-01
A-02 
A-03
A-04 k
A-05
A-06
A-07
A-08
A-09
A-10 
A-11
A-12
A-13
A-14
A-15
A-16 
A-17
A-18
A-19
A-20
A-21
A-22
A-23
A-24
A-25
A-26
A-27 
A-28
A-29
A-30
A-31
A-32
A-33 k
A-34
A-35
A-36
A-37 k
A-38
A-39
A-40
A-41
A-42
A-43
A-44
A-45
A-46 h,
A-47
A-48
A-49
A-50
NADA
$7.00
$10.00
$7.00
$5.00
$5.00
c
$5.00
NADA
$7.00
$5.00
$5.00
c
$7.00
$7.00
$10.00
$5.00
$5.00
$5.00
$7.00
$5.00
N/C
N/C
$7.00
$7.00
$5.00
$5.00
$10.00
NADA
$10.00
NADA
NADA
$7.00
$5.00
$5.00
$5.00
$7.00
*
NADA
*
$5.00
*
$5.00
$5.00
$5.00
$7.00
*
$5.00
$5.00
$5.00
A-51
A-52
A-53
A-54
A-55
A-56
A-57
A-58
A-59
A-60
A-61
A-62
A-63
A-64
A-65
A-66
A-67
A-68
A-69
A-70
A-71
A-72
A-73
A-74
A-75
A-76
A-77
A-78
A-79
A-80 f
A-81
A-82
A-83
A-84 h
A-85
A-86
A-87
A-88
A-89
A-90
A-91
A-92
A-93
A-94
A-95 b
A-96
A-97
A-98
A-99
AA-01
$7.00
$15.00
$5.00
$5.00
$5.00
$5.00
$7.00
*
$5.00
$5.00
$7.00
*
*
*
$5.00
$7.00
NADA
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
NADA
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$7.00
*
$5.00
*
$5.00
$10.00
*
$20.00
$7.00
$10.00
$5.00
$10.00
$7.00
$5.00
$5.00
$7.00
$5.00
AA-02
AA-03
AA-04
AA-05
AA-06
AA-07
AA-08
AA-09
AA-10
AA-11
AA-12
AA-13
AA-14
AA-15
AA-16
AA-17
AA-18
AA-19
AA-20
AA-21
AA-22
AA-23
AA-24
AA-25
AA-26
AA-27
AA-28
AA-29
AA-30
AA-31 r
AA-32
AA-33
AA-34
AA-35
AA-36
AA-37
AA-38
AA-39
AA-40
AA-41
AA-42
AA-43
AA-44
AA-45
AA-46
AA-47
AA-48
AA-49
AA-50
AA-51
$10.00
NADA
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$5.00
$7.00
$5.00
$10.00
*
$5.00
$7.00
NADA
$5.00
$5.00
$5.00
NADA
$5.00
$5.00
$10.00
$5.00
$5.00
$6.50
$5.00
$5.00
$5.00
*
$5.00
$5.00
$10.00
$5.00
*
$2.00
$5.00
$5.00
*
$10.00
$5.00
$5.00
$7.00
*
$7.00
$7.00
$7.00
08-13-2015
1
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COPAGO
CÓDIGO
COPAGO
CÓDIGO
COPAGO
AA-52
AA-53
AA-54
AA-55
AA-56
AA-57
AA-58
AA-59
AA-60
AA-61
AA-62
AA-63
AA-64
AA-65
AA-66
AA-67
AA-68
AA-69
AA-70
AA-71
AA-72
AA-73
AA-74
AA-75
AA-76
AA-77
AA-78
AA-79
AA-80
AA-81 d
AA-82
AA-83
AA-84
AA-85
AA-86
AA-87
AA-88
AA-89
AA-90
AA-91
AA-92
AA-93
AA-94
AA-95
AA-96
AA-97
AA-98
AA-99
AB-01
AB-02
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
*
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$7.00
$5.00
$5.00
NADA
$5.00
$7.00
$5.00
NADA
$7.00
$7.00
$7.00
$7.00
$15.00
$5.00
*
N/C
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
$7.00
NADA
$7.00
NADA
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
NADA
AB-03
AB-04
AB-05 b
AB-06
AB-07
AB-08
AB-09
AB-10
AB-11
AB-12
AB-13
AB-14
AB-15
AB-16
AB-17
AB-18
AB-19
AB-20
AB-21
AB-22
AB-23
AB-24
AB-25
AB-26
AB-27
AB-28
AB-29
AB-30
AB-31
AB-32
AB-33
AB-34
AB-35
AB-36
AB-37
AB-38
AB-39
AB-40
AB-41
AB-42
AB-43
AB-44
AB-45
AB-46
AB-47
AB-48
AB-49
AB-50
AB-51
AB-52
*
$5.00
$15.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$10.00
$7.00
*
$5.00
$7.00
$5.00
*
$5.00
*
$5.00
$5.00
$5.00
*
$5.00
$7.00
$7.00
*
$10.00
$5.00
$5.00
$7.00
$7.00
$5.00
$10.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
NADA
$5.00
$5.00
$5.00
$5.00
$10.00
AB-53
AB-54
AB-55
AB-56
AB-57
AB-58
AB-59
AB-60
AB-61
AB-62
AB-63 c
AB-64
AB-65
AB-66
AB-67 
AB-68
AB-69
AB-70
AB-71
AB-72 c
AB-73
AB-74
AB-75
AB-76
AB-77
AB-78
AB-79
AB-80
AB-81
AB-82
AB-83
AB-84
AB-85
AB-86
AB-87
AB-88
AB-89
AB-90
AB-91
AB-92
AB-93
AB-94
AB-95
AB-96
AB-97
AB-98
AB-99
AC-01
AC-02
AC-03
$5.00
NADA
*
$5.00
$7.00
$5.00
*
$5.00
$5.00
$5.00
NADA
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
NADA
*
$5.00
$5.00
$5.00
$5.00
NADA
$10.00
$5.00
NADA
$5.00
$5.00
$10.00
$5.00
$5.00
$7.00
$5.00
$7.00
$5.00
$7.00
*
$5.00
$5.00
$5.00
$7.00
$7.00
$5.00
$10.00
c
$7.00
$5.00
08-13-2015
2
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COPAGO
CÓDIGO
COPAGO
CÓDIGO
COPAGO
AC-04
AC-05
AC-06
AC-07
AC-08
AC-09
AC-10
AC-11
AC-12
AC-13
AC-14
AC-15
AC-16
AC-17
AC-18
AC-19
AC-20
AC-21
AC-22
AC-23
AC-24
AC-25
AC-26
AC-27
AC-28
AC-29
AC-30
AC-31
AC-32
AC-33
AC-34
AC-35
AC-36
AC-37
AC-38
AC-39
AC-40
AC-41
AC-42
AC-43
AC-44
AC-45
AC-46
AC-47
AC-48
AC-49
AC-50
AC-51
AC-52
AC-53
AC-54
$5.00
$5.00
$10.00
*
$5.00
$5.00
$5.00
$5.00
$5.00
$10.00
$5.00
$5.00
$5.00
*
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
*
*
*
*
*
*
$5.00
*
*
$5.00
NADA
$5.00
$8.00
$5.00
$5.00
*
$5.00
*
*
*
*
NADA
$5.00
c
NADA
$10.00
$7.00
$5.00
NADA
AC-55
AC-56
AC-57
AC-58
AC-59
AC-60 l,
AC-61
AC-62
AC-63
AC-64
AC-65
AC-66
AC-67
AC-68
AC-69
AC-70
AC-71
AC-72
AC-73
AC-74
AC-75
AC-76
AC-77
AC-78
AC-79
AC-80
AC-81
AC-82
AC-83
AC-84
AC-85
AC-86
AC-87
AC-88
AC-89
AC-90
AC-91 c
AC-92
AC-93 c
AC-94
AC-95
AC-96
AC-97
AC-98
AC-99
AD-18
AD-19
AD-20
AD-21
AD-22
AD-23
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
*
$5.00
$5.00
$10.00
$5.00
$5.00
*
$5.00
$10.00
$7.00
$5.00
$6.00
$5.00
$5.00
NADA
$5.00
$10.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
NADA
*
NADA
$5.00
$12.00
$5.00
$7.00
$10.00
$5.00
$5.00
$5.00
$7.00
NADA
$5.00
$7.00
AD-24
AD-25
AD-26
AD-27
AD-28
AD-29
AD-30
AD-31
AD-32
AD-33
AD-34
AD-35
AD-36 c
AD-37 c
AD-38 c
AD-39 c
AD-40
AD-41 c
AD-42 c
AD-43
AD-44
AD-45
AD-46
AD-47
AD-48
AD-49
AD-50
AD-51
AD-52
AD-53
AD-54
AD-55
AD-56
AD-57
AD-58
AD-59
AD-60
AD-61
AD-62
AD-63
AD-64
AD-65
AD-66
AD-67
AD-68
AD-69
AD-70
AD-71
AD-72
AD-73
AD-74
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
NADA
NADA
$5.00
NADA
NADA
NADA
NADA
$7.00
NADA
NADA
$7.00
$5.00
$5.00
$7.00
$5.00
*
NADA
$7.00
$5.00
$5.00
$10.00
$5.00
$5.00
$5.00
$7.00
$10.00
$5.00
$5.00
$7.00
$5.00
*
$5.00
$5.00
*
*
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
08-13-2015
3
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COPAGO
CÓDIGO
COPAGO
CÓDIGO
COPAGO
AD-75
AD-76
AD-77
AD-78
AD-79
AD-80
AD-81
AD-82
AD-83
AD-84
AD-85
AD-86
AD-87
AD-88
AD-89
AD-90
AD-91
AD-92
AD-93
AD-94
AD-95
AD-96
AD-97
AD-98
AD-99 c
AE-01
AE-02
AE-03
AE-04
AE-05
AE-06
AE-07
AE-08
AE-09
AE-10
AE-11
AE-12
AE-13
AE-14
AE-15
AE-16
AE-17
AE-18
AE-19
AE-20
AE-21
$7.00
$5.00
$5.00
$7.00
*
NADA
$5.00
$5.00
$7.00
$10.00
*
$5.00
$5.00
$6.00
$7.00
$5.00
$5.00
*
$5.00
$10.00
$10.00
$10.00
$7.00
$7.00
NADA
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$10.00
*
*
$7.00
$7.00
*
$5.00
NADA
$5.00
$10.00
NADA
NADA
NADA
NADA
NADA
AE-22
AE-23
AE-24
AE-25
AE-26
AE-27
AE-28
AE-29
AE-30
AE-31
AE-32
AE-33
AE-34
AE-35
AE-36
AE-37
AE-38
AE-39
AE-40
AE-41
AE-42
AE-43
AE-44
AE-45
AE-46
AE-47
AE-48
AE-49 e
AE-50 e
AE-51
AE-52
AE-53
AE-54
AE-55
AE-56
AE-57
AE-58
AE-59
AE-60
AE-61
AE-62
AE-63
AE-64
AE-65
AE-66
AE-67
*
$5.00
NADA
NADA
$5.00
$5.00
NADA
$7.00
$5.00
$5.00
$5.00
$15.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$5.00
$5.00
*
*
$5.00
$5.00
$7.00
$12.00
$10.00
$5.00
10%
$5.00
*
$7.00
$5.00
$5.00
$5.00
$7.00
*
$7.00
$7.00
NADA
$10.00
$5.00
$10.00
NADA
AE-68
AE-69
AE-70
AE-71
AE-72
AE-73
AE-74
AE-75
AE-76
AE-77
AE-78
AE-79
AE-80
AE-81
AE-82 c
AE-83
AE-84
AE-85 c
AE-86
AE-87
AE-88 c
AE-89
AE-90
AE-91
AE-92
AE-93 q
AE-94
AE-95
AE-96
AE-97
AE-98 f
AE-99
AF-01
AF-02
AF-03
AF-04
AF-05
AF-06
AF-07
AF-08
AF-09
AF-10
AF-11
AF-12
AF-13
AF-14
$7.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
$10.00
$5.00
NADA
$8.00
*
NADA
$5.00
$7.00
NADA
$5.00
$10.00
$7.00
$5.00
$10.00
$15.00
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
80%
$5.00
$5.00
$10.00
*
$10.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
08-13-2015
4
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COPAGO
CÓDIGO
COPAGO
CÓDIGO
COPAGO
AF-15
AF-16
AF-17
AF-18
AF-19
AF-20
AF-21
AF-22
AF-23
AF-24
AF-25
AF-26
AF-27
AF-28
AF-29
AF-30
AF-31
AF-32
AF-33
AF-34
AF-35
AF-36
AF-37
AF-38
AF-39
AF-40 f, 
AF-41 f
AF-42
AF-43
AF-44
AF-45
AF-46
AF-47
AF-48
AF-49
AF-50
AF-51
AF-52
AF-53
AF-54
AF-55
AF-56 
AF-57
AF-58
AF-59
AF-60
AF-61
AF-62
AF-63
$5.00
$7.00
$5.00
*
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
*
$7.00
$5.00
$5.00
$7.00
$7.00
$5.00
$5.00
*
*
NADA
NADA
*
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
*
$5.00
$5.00
$5.00
AF-64
AF-65
AF-66
AF-67
AF-68
AF-69
AF-70
AF-71
AF-72
AF-73
AF-74
AF-75
AF-76
AF-77
AF-78
AF-79
AF-80
AF-81
AF-82
AF-83
AF-84
AF-85
AF-86
AF-87
AF-88
AF-89
AF-90
AF-91
AF-92
AF-93
AF-94
AF-95
AF-96
AF-97
AF-98
AF-99
AG-01
AG-02
AG-03
AG-04
AG-05
AG-06
AG-07
AG-08
AG-09
AG-10
AG-11
AG-12
AG-13
$5.00
NADA
$5.00
$5.00
$5.00
NADA
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
NADA
*
$5.00
*
*
*
$5.00
*
$5.00
$7.00
$5.00
$5.00
NADA
$5.00
$10.00
$5.00
$10.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$10.00
NADA
$5.00
$7.00
AG-14
AG-15
AG-16
AG-17
AG-18
AG-19
AG-20 l
AG-21
AG-22
AG-23
AG-24
AG-25
AG-26
AG-27
AG-28
AG-29
AG-30
AG-31
AG-32
AG-33
AG-34 
AG-35
AG-36 
AG-37
AG-38
AG-39
AG-40
AG-41
AG-42
AG-43
AG-44
AG-45
AG-46
AG-47
AG-48
AG-49
AG-50
AG-51
AG-52
AG-53
AG-54
AG-55
AG-56
AG-57
AG-58
AG-59
AG-60
AG-61
AG-62
$5.00
$7.00
$5.00
*
$7.00
*
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
N/C
$7.00
$5.00
$7.00
$7.00
$5.00
$8.00
$5.00
$5.00
$5.00
$5.00
$10.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$8.00
$5.00
$5.00
$5.00
NADA
*
$7.00
$5.00
$5.00
$7.00
$5.00
08-13-2015
5
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COPAGO
CÓDIGO
COPAGO
CÓDIGO
COPAGO
AG-63
AG-64
AG-65
AG-66
AG-67
AG-68
AG-69
AG-70
AG-71
AG-72
AG-73 g
AG-74
AG-75
AG-76
AG-77
AG-78
AG-79
AG-80
AG-81
AG-82 f
AG-83
AG-84
AG-85
AG-86
AG-87
AG-88
AG-89
AG-90
AG-91
AG-92
AG-93
AG-94
AG-95
AG-96
AG-97 e
AG-98
AG-99
AH-01
AH-02
AH-03
AH-04 f
AH-05
AH-06
AH-07
AH-08
AH-09
AH-10
AH-11
AH-12
$5.00
NADA
$10.00
$7.00
$7.00
$5.00
$7.00
$5.00
$5.00
$5.00
NADA
$7.00
$7.00
$5.00
$5.00
NADA
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$10.00
$10.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$5.00
$5.00
$7.00
$5.00
$7.00
$5.00
$5.00
$7.00
$7.00
$5.00
$10.00
$15.00
N/C
$10.00
$7.00
$5.00
$7.00
AH-13
AH-14
AH-15
AH-16
AH-17
AH-18
AH-19
AH-20
AH-21
AH-22
AH-23
AH-24
AH-25
AH-26
AH-27
AH-28
AH-29
AH-30
AH-31
AH-32
AH-33
AH-34
AH-35
AH-36
AH-37
AH-38
AH-39
AH-40
AH-41
AH-42
AH-43
AH-44
AH-45
AH-46
AH-47
AH-48
AH-49
AH-50
AH-51
AH-52 j
AH-53
AH-54
AH-55
AH-56
AH-57
AH-58
AH-59
AH-60
AH-61
$10.00
$7.00
$7.00
$8.00
NADA
$5.00
$7.00
$5.00
$7.00
$5.00
$7.00
$7.00
$15.00
$7.00
$7.00
$5.00
*
$7.00
$5.00
$7.00
$7.00
$10.00
$10.00
NADA
$10.00
$7.00
$10.00
$5.00
$7.00
$7.00
$7.00
NADA
$5.00
$10.00
$10.00
$10.00
$12.00
$8.00
$8.00
NADA
$5.00
NADA
$7.00
NADA
NADA
$7.00
$7.00
$7.00
$7.00
AH-62
AH-63
AH-64
AH-65
AH-66
AH-67
AH-68
AH-69
AH-70
AH-71
AH-72
AH-73 o
AH-74
AH-75
AH-76
AH-77
AH-78
AH-79
AH-80
AH-81
AH-82
AH-83
AH-84
AH-85
AH-86
AH-87
AH-88
AH-89
AH-90
AH-91 j
AH-92 j
AH-93
AH-94 l
AH-95 f
AH-96
AH-97
AH-98
AH-99
AI-01
AI-02
AI-03
AI-04
AI-05
AI-06
AI-07 p
AI-08
AI-09
AI-10 k
AI-11 l
$7.00
$5.00
NADA
*
$5.00
*
$15.00
*
$7.00
$5.00
$7.00
$10.00
$5.00
$10.00
$5.00
*
$5.00
$7.00
$5.00
$5.00
$5.00
*
$7.00
$7.00
$7.00
$15.00
$7.00
$15.00
$5.00
$7.00
$7.00
NADA
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
NADA
*
$10.00
$5.00
$7.00
$5.00
$5.00
08-13-2015
6
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COPAGO
CÓDIGO
COPAGO
CÓDIGO
COPAGO
AI-12
AI-13
AI-14
AI-15
AI-16
AI-17
AI-18
AI-19
AI-20 h
AI-21
AI-22
AI-23
AI-24
AI-25
AI-26 j
AI-27 h
AI-28
AI-29
AI-30
AI-31
AI-32
AI-33
AI-34
AI-35
AI-36
AI-37
AI-38
AI-39
AI-40
AI-41
AI-42
AI-43
AI-44
AI-45
AI-46
AI-47
AI-48 
AI-49 
AI-50 
AI-51
AI-52
AI-53 
AI-54
AI-55
AI-56
AI-57
AI-58
AI-59
AI-60
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$10.00
$5.00
$7.00
NADA
NADA
NADA
$5.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$8.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
*
*
$5.00
*
*
*
*
*
$10.00
*
AI-61
AI-62
AI-63
AI-64
AI-65
AI-66
AI-67
AI-68
AI-69
AI-70
AI-71
AI-72
AI-73
AI-74
AI-75
AI-76
AI-77
AI-78
AI-79
AI-80
AI-81
AI-82
AI-83
AI-84
AI-85
AI-86
AI-87
AI-88 f
AI-89
AI-90
AI-91
AI-92
AI-93
AI-94 f
AI-95
AI-96
AI-97
AI-98
AI-99
AJ-01
AJ-02
AJ-03
AJ-04
AJ-05
AJ-06
AJ-07
AJ-08 n
AJ-09
AJ-10
*
$7.00
*
$5.00
$5.00
$5.00
$7.00
$5.00
$7.00
$5.00
*
*
*
*
*
*
*
*
*
*
*
*
*
$5.00
*
*
$5.00
$5.00
$5.00
NADA
$7.00
$7.00
$7.00
$7.00
$5.00
$10.00
$5.00
$7.00
$5.00
NADA
NADA
NADA
NADA
N/C
NADA
$5.00
$7.00
NADA
$5.00
AJ-11 m
AJ-12
AJ-13
AJ-14
AJ-15
AJ-16
AJ-17
AJ-18
AJ-19
AJ-20
AJ-21
AJ-22
AJ-23
AJ-24
AJ-25
AJ-26
AJ-27
AJ-28
AJ-29
AJ-30
AJ-31
AJ-32
AJ-33
AJ-34
AJ-35
AJ-36
AJ-37
AJ-38
AJ-39
AJ-40
AJ-41
AJ-42
AJ-43
AJ-44
AJ-45
AJ-46
AJ-47
AJ-48
AJ-49
AJ-50
AJ-51
AJ-52
AJ-53
AJ-54
AJ-55 m
AJ-56
AJ-57
AJ-58
AJ-59
$5.00
$10.00
*
$5.00
$5.00
$2.00
NADA
NADA
NADA
$10.00
$10.00
$10.00
$7.00
$10.00
$5.00
$7.00
$5.00
$7.00
$15.00
$15.00
$7.00
$10.00
$10.00
*
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$10.00
$5.00
$10.00
*
$7.00
$7.00
NADA
$7.00
*
$7.00
$7.00
$10.00
*
$5.00
$5.00
$10.00
$7.00
$5.00
$5.00
08-13-2015
7
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COPAGO
CÓDIGO
COPAGO
CÓDIGO
COPAGO
AJ-60
AJ-61
AJ-62
AJ-63
AJ-64
AJ-65
AJ-66
AJ-67
AJ-68
AJ-69
AJ-70
AJ-71
AJ-72
AJ-73
AJ-74
AJ-75
AJ-76
AJ-77
AJ-78
AJ-79
AJ-80
AJ-81
AJ-82
AJ-83
AJ-84
AJ-85
AJ-86
AJ-87
AJ-88
AJ-89
AJ-90
AJ-91 h
AJ-92
AJ-93 h
AJ-94
AJ-95
AJ-96
AJ-97
AJ-98
AJ-99
AK-01
AK-02
AK-03
AK-04 f
AK-05
AK-06
AK-07
AK-08
AK-09
$7.00
*
$10.00
$5.00
$5.00
*
*
$10.00
$10.00
*
$5.00
$10.00
NADA
$7.00
*
$10.00
$10.00
*
$15.00
*
$10.00
$10.00
NADA
$10.00
*
$5.00
NADA
$10.00
$5.00
NADA
*
$7.00
*
$7.00
$5.00
$10.00
$5.00
$5.00
$5.00
$7.00
$5.00
NADA
NADA
$15.00
NADA
NADA
NADA
$10.00
$5.00
AK-10
AK-11 k
AK-12
AK-13 f
AK-14
AK-15 f, 
AK-16 f
AK-17 f
AK-18
AK-19
AK-20
AK-21
AK-22
AK-23
AK-24
AK-25 k
AK-26
AK-27 f
AK-28 f
AK-29 f
AK-30 k
AK-31 f
AK-32 j
AK-33
AK-34
AK-35 j
AK-36 k
AK-37 k
AK-38
AK-39
AK-40 k
AK-41
AK-42
AK-43
AK-44
AK-45
AK-46
AK-47
AK-48
AK-49
AK-50
AK-51 h
AK-52 h
AK-53
AK-54
AK-55
AK-56
AK-57
AK-58
$7.00
$7.00
$5.00
$7.00
$5.00
$10.00
$7.00
$7.00
*
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$10.00
$5.00
$10.00
NADA
$7.00
$7.00
$5.00
$10.00
$7.00
*
*
$7.00
$7.00
$7.00
$10.00
$7.00
$5.00
$5.00
$7.00
AK-59
AK-60
AK-61
AK-62
AK-63
AK-64
AK-65
AK-66
AK-67
AK-68
AK-69
AK-70
AK-71
AK-72 h
AK-73
AK-74
AK-75
AK-76
AK-77
AK-78
AK-79
AK-80
AK-81
AK-82
AK-83
AK-84
AK-85
AK-86
AK-87
AK-88
AK-89
AK-90
AK-91
AK-92
AK-93
AK-94
AK-95
AK-96
AK-97
AK-98
AK-99
AL-01
AL-02
AL-03
AL-04
AL-05 f, 
AL-06 f, 
AL-07 f, 
AL-08
$7.00
$7.00
*
NADA
$5.00
$5.00
*
$5.00
$7.00
*
*
*
*
$7.00
*
*
$7.00
*
$10.00
*
*
*
*
*
*
*
$5.00
$7.00
$10.00
$7.00
*
*
*
*
*
$5.00
$7.00
$7.00
*
*
*
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
08-13-2015
8
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COPAGO
CÓDIGO
COPAGO
CÓDIGO
COPAGO
AL-09 f
AL-10 f, 
AL-11 f, 
AL-12 f, 
AL-13 f, 
AL-14 f, 
AL-15 f
AL-16
AL-17
AL-18 f
AL-19 
AL-20
AL-21
AL-22
AL-23
AL-24
AL-25 c
AL-26
AL-27
AL-28
AL-29
AL-30
AL-31
AL-32
AL-33
AL-34
AL-35
AL-36 
AL-37 
AL-38 
AL-39 
AL-40 
AL-41 
AL-42
AL-43 
AL-44
AL-45 
AL-46 
AL-47
AL-48 f, 
AL-49 f, 
AL-50 f, 
AL-51 f, 
AL-52 f, 
AL-53 f, 
AL-54
AL-55 f, 
AL-56 f, 
AL-57 f, 
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
NADA
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
AL-58
AL-59 f, 
AL-60
AL-61 f, 
AL-62 f, 
AL-63 f, 
AL-64 f, 
AL-65
AL-66 f, 
AL-67
AL-68
AL-69
AL-70
AL-71
AL-72
AL-73
AL-74 f, 
AL-75 f, 
AL-76
AL-77
AL-78
AL-79
AL-80
AL-81
AL-82
AL-83
AL-84
AL-85
AL-86
AL-87
AL-88
AL-89 f, 
AL-90
AL-91 f, 
AL-92
AL-93 f, 
AL-94 
AL-95 
AL-96 
AL-97 
AL-98 
AL-99
AM-01
AM-02
AM-03
AM-04
AM-05
AM-06
AM-07
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$10.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
NADA
$7.00
NADA
$7.00
AM-08
AM-09 c
AM-10
AM-11
AM-12
AM-13
AM-14
AM-15
AM-16
AM-17
AM-18
AM-19
AM-20
AM-21
AM-22
AM-23
AM-24 j
AM-25
AM-26
AM-27 i
AM-28
AM-29
AM-30
AM-31
AM-32
AM-33
AM-34
AM-35
AM-36
AM-37
AM-38
AM-39
AM-40
AM-41
AM-42 
AM-43
AM-44
AM-45
AM-46
AM-47
AM-48
AM-49
AM-50
AM-51 m, 
AM-52 m, 
AM-53
AM-54
AM-55
AM-56
NADA
NADA
$7.00
$5.00
$7.00
NADA
$5.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$8.00
$7.00
NADA
NADA
$5.00
$5.00
$7.00
$7.00
NADA
$7.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$2.00
$5.00
*
*
*
$7.00
$5.00
NADA
NADA
$5.00
$7.00
$7.00
$5.00
08-13-2015
9
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COPAGO
CÓDIGO
COPAGO
CÓDIGO
COPAGO
AM-57
AM-58
AM-59
AM-60
AM-61
AM-62 h
AM-63 h
AM-64
AM-65
AM-66
AM-67
AM-68
AM-69
AM-70
AM-71
AM-72
AM-73
AM-74
AM-75
AM-76
AM-77
AM-78
AM-79
AM-80
AM-81
AM-82
AM-83
AM-84
AM-85 h
AM-86
AM-87
AM-88
AM-89
AM-90 h
AM-91 f
AM-92 f
AM-93 j
AM-94
AM-95
AM-96
AM-97
AM-98
AM-99
*
*
*
$7.00
$5.00
$5.00
$5.00
*
$5.00
$5.00
$7.00
$5.00
$5.00
$7.00
*
*
*
*
$7.00
$7.00
$7.00
$5.00
$7.00
*
$7.00
$10.00
$7.00
$5.00
NADA
$5.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$10.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
08-13-2015
10
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COPAGO
CÓDIGO
COPAGO
CÓDIGO
COPAGO
AN-01
AN-02
AN-03
AN-04
AN-05
AN-06
AN-07
AN-08
AN-09
AN-10
AN-11
AN-12
AN-13
AN-14
AN-15
AN-16
AN-17
AN-18
AN-19
AN-20 h
AN-21
AN-22
AN-23
AN-24
AN-25
AN-26
AN-27 f
AN-28 k
AN-29
AN-30
AN-31
AN-32 f
AN-33
AN-34
AN-35
AN-36
AN-37
AN-38 
AN-39
AN-40
AN-41
AN-42
AN-43
AN-44
AN-45
AN-46 f
AN-47 p
AN-48
AN-49 f
AN-50
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
NADA
NADA
NADA
$7.00
$7.00
$10.00
$10.00
$7.00
*
*
*
*
$7.00
*
$7.00
*
$7.00
*
$7.00
$7.00
$10.00
$15.00
$7.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$5.00
NADA
*
$7.00
$20.00
$10.00
$5.00
$5.00
AN-51
AN-52
AN-53
AN-54 f
AN-55
AN-56 f
AN-57
AN-58
AN-59
AN-60
AN-61
AN-62
AN-63
AN-64 f
AN-65 f
AN-66
AN-67 f
AN-68
AN-69
AN-70
AN-71
AN-72 k
AN-73
AN-74
AN-75
AN-76 n
AN-77
AN-78
AN-79
AN-80
AN-81
AN-82
AN-83
AN-84
AN-85
AN-86
AN-87
AN-88
AN-89
AN-90
AN-91
AN-92
AN-93
AN-94
AN-95
AN-96
AN-97
AN-98
AN-99
*
$7.00
$5.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
NADA
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
*
$5.00
$5.00
$5.00
$5.00
$5.00
NADA
$7.00
$5.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$10.00
$10.00
$10.00
$7.00
$10.00
$10.00
$7.00
$7.00
$7.00
$5.00
*
*
$5.00
$5.00
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
AN-51
AN-52
AN-53
AN-54
AN-55
AN-56
AN-57
AN-58
AN-59
AN-60
AN-61
AN-62
AN-63
AN-64
AN-65
AN-66
AN-67
AN-69
AN-69
AN-70
AN-71
AN-72
AN-73
AN-74
AN-75
AN-76
AN-77
AN-78
AN-79
AN-80
AN-81
AN-82
AN-83
AN-84
AN-85
AN-86
AN-87
AN-88
AN-89
AN-90
AN-91
AN-92
AN-93
AN-94
AN-95
AN-96
AN-97
AN-98
AN-99
08-13-2015
11
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COPAGO
CÓDIGO
COPAGO
CÓDIGO
COPAGO
AP-01
AP-02
AP-03
AP-04
AP-05
AP-06
AP-07
AP-08
AP-09
AP-10
AP-11
AP-12
AP-13
AP-14
AP-15
AP-16
AP-17
AP-18
AP-19
AP-20
AP-21
AP-22
AP-23
AP-24
AP-25
AP-26
AP-27
AP-28
AP-29
AP-30
AP-31
AP-32
AP-33
AP-34
AP-35
AP-36
AP-37
AP-38
AP-39
AP-40 h
AP-41 h, 
AP-42
AP-43 j
AP-44 j
AP-45
AP-46
AP-47
AP-48
AP-49
AP-50
*
$7.00
$7.00
$5.00
$5.00
$15.00
$10.00
$5.00
$7.00
$5.00
$10.00
$7.00
$10.00
NADA
NADA
NADA
NADA
*
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
*
$7.00
$10.00
$5.00
20%
$7.00
$7.00
*
NADA
$7.00
$10.00
$15.00
NADA
$7.00
$7.00
NADA
$18.00
$12.00
$7.00
N/C
$5.00
$10.00
$10.00
$7.00
AP-51
AP-52
AP-53
AP-54
AP-55
AP-56
AP-57
AP-58
AP-59
AP-60
AP-61
AP-62
AP-63
AP-64
AP-65
AP-66
AP-67 k
AP-68
AP-69
AP-70
AP-71
AP-72 k
AP-73 k
AP-74
AP-75 k
AP-76 h
AP-77
AP-78 k
AP-79 k
AP-80 k
AP-81 k
AP-82
AP-83
AP-84
AP-85
AP-86
AP-87
AP-88
AP-89
AP-90
AP-91
AP-92
AP-93
AP-94
AP-95
AP-96
AP-97
AP-98
AP-99
*
$7.00
$5.00
$5.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$10.00
$5.00
$10.00
$10.00
$10.00
$7.00
$5.00
$5.00
$10.00
$7.00
$5.00
10%
$7.00
$7.00
$5.00
$5.00
$5.00
$20.00
$20.00
$7.00
$10.00
$7.00
*
$12.00
$15.00
$5.00
$7.00
$7.00
$7.00
$7.00
*
*
*
*
*
*
$7.00
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
08-13-2015
12
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
NOTAS:
*
Código sin asignar.
N/C No cubre.
a. Aplica periodo de espera.
b. $5.00 para terapia del habla y terapia ocupacional.
c.
Aplica al Programa Medicare Advantage
d. Aplica un límite de veinte (20) terapias, en conjunto, por servicios de acupuntura para el manejo del
dolor prestados por doctores en medicinas, certificados para ejercer estos servicios; de
quiroprácticos y de terapia física. No aplica copagos.
e. Aplica un límite de noventa (90) sesiones por terapia física, terapia del habla, terapia ocupacional y
quiroprácticos.
f.
Terapia física y manipulaciones de quiroprácticos, hasta un máximo de veinte (20) sesiones, en
conjunto, por año póliza. Cubre una visita inicial cada tres (3) años y una visita subsiguiente por año
póliza.
g. Cubre 45 terapias adicionales, sujeto a preautorización.
h. Aplica un máximo de veinte (20) terapias físicas y manipulaciones por quiroprácticos, en conjunto.
i.
Terapia física y manipulaciones de quiroprácticos, hasta un máximo de veinte (15) sesiones, en
conjunto, por año póliza. Estos servicios están sujetos a un copago de $18.00.
j.
Terapia física hasta un máximo de veinte (15) sesiones por año póliza.
k. Aplica un máximo de veinte (20) terapias por año póliza.
l.
Aplica un máximo de treinta (30) terapias por año póliza.
m. Terapia física (provista por un médico especialista en fisiatría o bajo la supervisión de éste y facturada
por éste), hasta una (1) sesión diaria y hasta un máximo de 30 por año póliza. En este caso la
supervisión no requiere la intervención directa (cara a cara) del médico, pero sí su requiere la
intervención directa (cara a cara) del médico, pero sí su disponibilidad en el lugar para que pueda
evaluar o recomendar un cambio en el plan de tratamiento, de ser necesario. Las terapias físicas
pueden ser ofrecidas por quiroprácticos.
n. Terapia física (provista por un médico especialista en fisiatría o bajo la supervisión de éste y facturada
por éste), hasta veinte (20) terapias por año póliza. En este caso la supervisión no requiere la
intervención directa (cara a cara) del médico, pero sí pero sí su disponibilidad en el lugar para que
pueda evaluar o recomendar un cambio en el plan de tratamiento, de ser necesario.
o. Aplica un máximo de diez (10) terapias por año póliza.
p. Cubre un máximo de 120 días por condición.
q. Cubre 60 terapias por condición.
r.
Aplica un máximo de treinta (40) terapias por año póliza.
08-13-2015
13
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
()
Versión de Cubiertas de Reforma de Salud Federal que incluyen beneficios que se considerarán como
Servicios Preventivos
08-13-2015
14
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
Grupo Triple-S
CÓDIGO
COASEGURO
B1
B2
B3
B4
B5
B6
B7
B8
B9
B10
B11
B12
B13
B14
B15
B16
B17
B18
B19
B20
B21
B22
B23
B24
NADA
$5.00
$5.00
$5.00
NADA
NADA
NADA
NADA
NADA
NADA
NADA
NADA
NADA
NADA
NADA
NADA
$5.00
NADA
NADA
NADA
NADA
NADA
NADA
NADA
08-13-2015
15
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B25
B26
B27
B28
B29
B30
B31
B32
B33
B34
B35
B36
B37
B38
B39
B40
B41
B42
B43
B44
B45
B46
B47
B48
B49
B50
B51
B52
B53
B54
B55
B56
B57
B58
B59
B60
B61
B62
B63
B64
B65
B66
B67
B68
B69
B70
B71
B72
B73
B74
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B75
B76
B77
B78
B79
B80
B81
B82
B83
B84
B85
B86
B87
B88
B89
B90
B91
B92
B93
B94
B95
B96
B97
B98
B99
B100
B101
B102
B103
B104
B105
B106
B107
B108
B109
B110
B111
B112
B113
B114
B115
B116
B117
B118
B119
B120
B121
B122
B123
B124
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B125
B126
B127
B128
B129
B130
B131
B132
B133
B134
B135
B136
B137
B138
B139
B140
B141
B142
B143
B144
B145
B146
B147
B148
B149
B150
B151
B152
B153
B154
B155
B156
B157
B158
B159
B160
B161
B162
B163
B164
B165
B166
B167
B168
B169
B170
B171
B172
B173
B174
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
16
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B175
B176
B177
B178
B179
B180
B181
B182
B183
B184
B185
B186
B187
B188
B189
B190
B191
B192
B193
B194
B195
B196
B197
B198
B199
B200
B201
B202
B203
B204
B205
B206
B207
B208
B209
B210
B211
B212
B213
B214
B215
B216
B217
B218
B219
B220
B221
B222
B223
B224
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B225
B226
B227
B228
B229
B230
B231
B232
B233
B234
B235
B236
B237
B238
B239
B240
B241
B242
B243
B244
B245
B246
B247
B248
B249
B250
B251
B252
B253
B254
B255
B256
B257
B258
B259
B438
B439
B440
B441
B442
B443
B444
B445
B446
B447
B448
B449
B450
B451
B452
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B453
B454
B455
B456
B457
B458
B459
B460
B461
B462
B463
B464
B465
B466
B467
B468
B469
B470
B471
B472
B473
B474
B475
B476
B477
B478
B479
B480
B481
B482
B483
B484
B485
B486
B487
B488
B489
B490
B491
B492
B493
B494
B495
B496
B497
B498
B499
B500
B501
B502
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
17
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B503
B504
B505
B506
B507
B508
B509
B510
B511
B512
B513
B514
B515
B516
B517
B518
B519
B520
B521
B522
B523
B524
B525
B526
B527
B528
B529
B530
B531
B532
B533
B534
B535
B536
B537
B538
B539
B540
B541
B542
B543
B544
B545
B546
B547
B548
B549
B550
B551
B552
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B553
B554
B555
B556
B557
B558
B559
B560
B561
B562
B563
B564
B565
B566
B567
B568
B569
B570
B571
B572
B573
B574
B575
B576
B577
B578
B579
B580
B581
B582
B583
B584
B585
B586
B587
B588
B589
B590
B591
B592
B593
B594
B595
B596
B597
B598
B599
B600
B601
B602
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B603
B604
B605
B606
B607
B608
B609
B610
B611
B612
B613
B614
B615
B616
B617
B618
B619
B620
B621
B622
B623
B624
B625
B626
B627
B628
B629
B630
B631
B632
B633
B634
B635
B636
B637
B638
B639
B640
B641
B642
B643
B644
B645
B646
B647
B648
B649
B650
B651
B652
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
18
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B653
B654
B655
B656
B657
B658
B659
B660
B661
B662
B663
B664
B665
B666
B667
B668
B669
B670
B671
B672
B673
B674
B675
B676
B677
B678
B679
B680
B681
B682
B683
B684
B685
B686
B687
B688
B689
B690
B691
B692
B693
B694
B695
B696
B697
B698
B699
B700
B701
B702
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B703
B704
B705
B706
B707
B708
B709
B710
B711
B712
B713
B714
B715
B716
B717
B718
B719
B720
B721
B722
B723
B724
B725
B726
B727
B728
B729
B730
B731
B732
B733
B734
B735
B736
B737
B738
B739
B740
B741
B742
B743
B744
B745
B746
B747
B748
B749
B750
B751
B752
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B753
B754
B755
B756
B757
B758
B759
B760
B761
B762
B763
B764
B765
B766
B767
B768
B769
B770
B771
B772
B773
B774
B775
B776
B777
B778
B779
B780
B781
B782
B783
B784
B785
B786
B787
B788
B789
B790
B791
B792
B793
B794
B795
B796
B797
B798
B799
B800
B801
B802
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
19
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B803
B804
B805
B806
B807
B808
B809
B810
B811
B812
B813
B814
B815
B816
B817
B818
B819
B820
B821
B822
B823
B824
B825
B826
B827
B828
B829
B830
B831
B832
B833
B834
B835
B836
B837
B838
B839
B840
B841
B842
B843
B844
B845
B846
B847
B848
B849
B850
B851
B852
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B853
B854
B855
B856
B857
B858
B859
B860
B861
B862
B863
B864
B865
B866
B867
B868
B869
B870
B871
B872
B873
B874
B875
B876
B877
B878
B879
B880
B881
B882
B883
B884
B885
B886
B887
B888
B889
B890
B891
B892
B893
B894
B895
B896
B897
B898
B899
B900
B901
B902
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B903
B904
B905
B906
B907
B908
B909
B910
B911
B912
B913
B914
B915
B916
B917
B918
B919
B920
B921
B922
B923
B924
B925
B926
B927
B928
B929
B930
B931
B932
B933
B934
B935
B936
B937
B938
B939
B940
B941
B942
B943
B944
B945
B946
B947
B948
B949
B950
B951
B952
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
20
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B953
B954
B955
B956
B957
B958
B959
B960
B961
B962
B963
B964
B965
B966
B967
B968
B969
B970
B971
B972
B973
B974
B975
B976
B977
B978
B979
B980
B981
B982
B983
B984
B985
B986
B987
B988
B989
B990
B991
B992
B993
B994
B995
B996
B997
B998
B999
B1000
B1001
B1002
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B1003
B1004
B1005
B1006
B1007
B1008
B1009
B1010
B1011
B1012
B1013
B1014
B1015
B1016
B1017
B1018
B1019
B1020
B1021
B1022
B1023
B1024
B1025
B1026
B1027
B1028
B1029
B1030
B1031
B1032
B1033
B1034
B1035
B1036
B1037
B1038
B1039
B1040
B1041
B1042
B1043
B1044
B1045
B1046
B1047
B1048
B1049
B1050
B1051
B1052
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B1053
B1054
B1055
B1056
B1057
B1058
B1059
B1060
B1061
B1062
B1063
B1064
B1065
B1066
B1067
B1068
B1069
B1070
B1071
B1072
B1073
B1074
B1075
B1076
B1077
B1078
B1079
B1080
B1081
B1082
B1083
B1084
B1085
B1086
B1087
B1088
B1089
B1090
B1091
B1092
B1093
B1094
B1095
B1096
B1097
B1098
B1099
B1100
B1101
B1102
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
21
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B1103
B1104
B1105
B1106
B1107
B1289
B1290
B1291
B1292
B1293
B1294
B1295
B1296
B1297
B1298
B1299
B1300
B1301
B1302
B1303
B1304
B1305
B1306
B1307
B1308
B1309
B1310
B1311
B1312
B1313
B1314
B1315
B1316
B1317
B1318
B1319
B1320
B1321
B1322
B1323
B1324
B1325
B1326
B1327
B1328
B1329
B1330
B1331
B1332
B1333
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B1334
B1335
B1336
B1337
B1338
B1339
B1340
B1341
B1342
B1343
B1344
B1345
B1346
B1347
B1348
B1349
B1350
B1351
B1352
B1353
B1354
B1355
B1356
B1357
B1358
B1359
B1360
B1361
B1362
B1363
B1364
B1365
B1366
B1367
B1368
B1369
B1370
B1371
B1372
B1373
B1374
B1375
B1376
B1377
B1378
B1379
B1380
B1381
B1382
B1383
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B1384
B1385
B1386
B1387
B1388
B1389
B1390
B1391
B1392
B1393
B1394
B1395
B1396
B1397
B1398
B1399
B1400
B1401
B1402
B1403
B1404
B1405
B1406
B1407
B1408
B1409
B1410
B1411
B1412
B1413
B1414
B1415
B1416
B1417
B1418
B1419
B1420
B1421
B1422
B1423
B1424
B1425
B1426
B1427
B1428
B1429
B1430
B1431
B1432
B1433
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
22
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B1434
B1435
B1436
B1437
B1438
B1439
B1440
B1441
B1442
B1443
B1444
B1445
B1446
B1447
B1448
B1449
B1450
B1451
B1452
B1453
B1454
B1455
B1456
B1457
B1458
B1459
B1460
B1461
B1462
B1463
B1464
B1465
B1466
B1467
B1468
B1469
B1470
B1471
B1472
B1473
B1474
B1475
B1574
B1575
B1576
B1592
B1593
B1594
B1595
B1596
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
B1597
B1598
B1599
B1600
B1601
B1602
B1603
B1604
B1609
B1706
B1707
B1708
B1709
B1710
B1711
B1712
B1713
B1715
B1716
B1718
B1719
B1720
B1721
B1722
B1723
B1724
B1725
B1726
B1727
B1728
B1733
B1734
B1735
B1736
B1737
B1738
B1739
B1740
B1741
B1742
B1743
B1744
B1745
B1746
B1753
B1754
B1760
B1761
B1814
B1815
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$10.00
$5.00
$7.00
$5.00
$7.00
$7.00
$5.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$7.00
B1816
B1817
B1818
B1819
B1820
B1821
B1822
B1823
B1824
B1825
B1826
B1827
B1828
B1829
B1830
B1831
B1832
B1833
B1834
B1835
B1836
B1837
B1839
B1840
B1841
B1842
B1843
B1844
B1845
B1846
B1847
B1848
B1849
B1850
B1851
B1853
B1854
B1857
B1858
B1860
B1861
B1862
B1863
B1867
B1870
B1872
B1875
B1876
B1878
B1879
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
23
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B1881
B1882
B1883
B1884
B1886
B1887
B1888
B1890
B1891
B1906 
B1907
B1908 
B1909
B1910
B1911 
B1912
B1913
B1914 
B1915
B1916
B1917 
B1918
B1919 
B1920
B1921
B1922
B1923
B1924
B1925
B1926 
B1927
B1929
B1930
B1931 
B1932 
B1933 
B1934 
B1935
B1936
B1937 
B1938
B1939
B1940
B1941
B1942
B1943
B1944 
B1945
B1946
B1947 
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B1948
B1949 
B1950
B1951 
B1952 
B1953
B1954
B1955
B1956
B1957 
B1958
B1959
B1960
B1961
B1962
B1963
B1964
B1965
B1966
B1967
B1968
B1969
B1970
B1971
B1972
B1973
B1974
B1975
B1976
B1977
B1978
B1979
B1980 
B1981
B1982
B1983
B1984 
B1985
B1986
B1987
B1988
B1989 
B1990
B1991
B1992 
B1993
B1994
B1995
B1996
B1997
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B1998 
B1999
B2000
B2001
B2002 
B2003
B2004
B2005 
B2006 
B2007 
B2008 
B2009
B2010
B2011
B2012
B2013 
B2014
B2015 
B2016
B2017
B2018 
B2019
B2020
B2021
B2022
B2023
B2024
B2025
B2026
B2027
B2028
B2029
B2030
B2031
B2032
B2033
B2034
B2035
B2036
B2037
B2038
B2039
B2040
B2041
B2042
B2043
B2044
B2045
B2046
B2047
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
24
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B2048
B2049
B2050
B2051
B2052
B2053
B2054
B2055
B2056
B2057
B2058
B2059
B2060
B2061
B2062
B2063
B2064
B2065
B2066
B2067
B2068
B2069
B2070
B2071
B2072
B2073
B2074
B2075
B2076
B2077
B2078
B2079
B2080
B2081
B2082
B2083
B2084
B2085
B2086
B2087
B2088
B2089
B2090
B2091
B2092
B2093
B2094
B2095
B2096
B2097
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$7.00
B2098
B2099
B2100
B2101
B2102
B2103
B2104
B2105
B2106
B2107
B2108
B2109
B2110
B2111
B2112
B2113
B2114
B2115
B2116
B2117
B2118
B2119
B2120
B2121
B2122
B2123
B2124
B2125
B2126
B2127
B2128
B2129
B2130
B2131
B2132
B2133
B2134
B2135
B2136
B2137
B2138
B2139
B2140
B2141
B2142
B2143
B2144
B2145
B2146
B2147
$7.00
$7.00
$5.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$10.00
N/C
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
N/C
N/C
$7.00
$15.00
$7.00
$10.00
$7.00
$8.00
$8.00
$8.00
$8.00
$8.00
$8.00
$7.00
B2148
B2149
B2150
B2151
B2152
B2153
B2154
B2155
B2156
B2157
B2158
B2159
B2160
B2161
B2162
B2163
B2164
B2165
B2166
B2167
B2168
B2169
B2170
B2171
B2172
B2173
B2174
B2175
B2176
B2177
B2178
B2179
B2180
B2181
B2182
B2183
B2184
B2185
B2186
B2187
B2188
B2189
B2190
B2191
B2192
B2193
B2194
B2195
B2196
B2197
$7.00
$7.00
$5.00
$5.00
$5.00
N/C
$5.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
N/C
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
25
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B2198
B2199
B2200
B2201
B2202
B2203
B2204
B2205
B2206
B2207
B2208
B2209
B2210
B2211
B2212
B2213
B2214
B2215
B2216
B2217
B2218
B2219
B2220
B2221
B2222
B2223
B2224
B2225
B2226
B2227
B2228
B2229
B2230
B2231
B2232
B2233
B2234
B2235
B2236
B2237
B2238
B2239
B2240
B2241
B2242
B2243
B2244
B2245
B2246
B2247
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$8.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
N/C
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B2248
B2249
B2250
B2251
B2252
B2253
B2254
B2255
B2256
B2257
B2258
B2259
B2260
B2261
B2262
B2263
B2264
B2265
B2266
B2267
B2268
B2269
B2270
B2271
B2272
B2273
B2274
B2275
B2276
B2277
B2278
B2279
B2280
B2281
B2282
B2283
B2284
B2285
B2286
B2287
B2288
B2289
B2290
B2291
B2292
B2293
B2294
B2295
B2296
B2297
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$5.00
$5.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$5.00
$5.00
$10.00
$10.00
$10.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
$0.00
$5.00
$7.00
$10.00
$5.00
$5.00
$5.00
$7.00
$10.00
$5.00
$5.00
$10.00
B2298
B2299
B2300
B2301
B2302
B2303
B2304
B2305
B2306
B2307
B2308
B2309
B2310
B2311
B2312
B2313
B2315
B2316
B2317
B2318
B2319
B2320
B2321
B2322
B2323
B2324
B2325
B2326
B2327
B2328
B2329
B2330
B2331
B2332
B2333
B2334
B2335
B2336
B2337
B2338
B2339
B2340
B2341
B2342
B2343
B2344
B2345
B2346
B2347
B2348
$10.00
$5.00
$5.00
$10.00
$5.00
$5.00
$5.00
$7.00
$7.00
$10.00
$7.00
$7.00
$10.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
N/C
N/C
$7.00
$5.00
$5.00
$7.00
$10.00
$7.00
$7.00
$7.00
N/C
N/C
$7.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$7.00
$7.00
$5.00
$7.00
$5.00
$7.00
08-13-2015
26
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B2349
B2350
B2351
B2352
B2353
B2354
B2355
B2356
B2357
B2358
B2359
B2360
B2361
B2362
B2363
B2364
B2365
B2366
B2367
B2368
B2369
B2370
B2371
B2372
B2373
B2374
B2375
B2376
B2377
B2378
B2379
B2380
B2381
B2382
B2383
B2384
B2385
B2386
B2387
B2388
B2389
B2390
B2391
B2392
B2393
B2394
B2395
B2396
B2397
B2398
$7.00
$5.00
$5.00
$5.00
$5.00
N/C
$7.00
$7.00
$7.00
$7.00
$10.00
N/C
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
$8.00
$8.00
$7.00
$5.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
N/C
$15.00
$10.00
$10.00
$7.00
$7.00
$20.00
B2399
B2400
B2401
B2402
B2403
B2404
B2405
B2406
B2407
B2408
B2409
B2410
B2411
B2412
B2413
B2414
B2415
B2416
B2417
B2418
B2419
B2420
B2421
B2422
B2423
B2424
B2425
B2426
B2427
B2428
B2429
B2430
B2431
B2432
B2433
B2434
B2435
B2436
B2437
B2438
B2439
B2440
B2441
B2442
B2443
B2444
B2445
B2446
B2447
B2448
$7.00
$5.00
$5.00
$7.00
$7.00
$5.00
$5.00
$7.00
$5.00
N/C
N/C
$7.00
$10.00
$15.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
N/C
$5.00
N/C
N/C
$20.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
N/C
$7.00
$7.00
$5.00
$5.00
B2449
B2450
B2451
B2452
B2453
B2454
B2455
B2456
B2457
B2458
B2459
B2460
B2461
B2462
B2463
B2464
B2465
B2466
B2467
B2468
B2469
B2470
B2471
B2472
B2473
B2474
B2475
B2476
B2477
B2478
B2479
B2480
B2481
B2482
B2483
B2484
B2485
B2486
B2487
B2488
B2489
B2490
B2491
B2492
B2493
B2494
B2495
B2496
B2497
B2498
$5.00
$5.00
$12.00
$7.00
$7.00
$5.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$5.00
$5.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
N/C
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$8.00
$5.00
$5.00
08-13-2015
27
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B2499
B2500
B2501
B2502
B2503
B2504
B2505
B2506
B2507
B2508
B2509
B2510
B2511
B2512
B2513
B2514
B2515
B2516
B2517
B2518
B2519
B2520
B2521
B2522
B2523
B2524
B2525
B2526
B2527
B2528
B2529
B2530
B2531
B2532
B2533
B2534
B2535
B2536
B2537
B2538
B2539
B2540
B2541
B2542
B2543
B2544
B2545
B2546
B2547
B2548
$7.00
$5.00
$7.00
$5.00
$5.00
$10.00
$7.00
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$5.00
$0.00
$10.00
$7.00
$5.00
$7.00
$0.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
N/C
N/C
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$5.00
$7.00
$7.00
N/C
$7.00
$7.00
$7.00
$7.00
$10.00
B2549
B2550
B2551
B2552
B2553
B2554
B2555
B2556
B2557
B2558
B2559
B2560
B2561
B2562
B2563
B2564
B2565
B2566
B2567
B2568
B2569
B2570
B2571
B2572
B2573
B2574
B2575
B2576
B2577
B2578
B2579
B2580
B2581
B2582
B2583
B2584
B2585
B2586
B2587
B2588
B2589
B2590
B2591
B2592
B2593
B2594
B2595
B2596
B2597
B2598
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
N/C
$7.00
$7.00
$7.00
$7.00
$7.00
N/C
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B2599
B2600
B2601
B2602
B2603
B2604
B2605
B2606
B2607
B2608
B2609
B2610
B2611
B2612
B2613
B2614
B2615
B2616
B2617
B2618
B2619
B2620
B2621
B2622
B2623
B2624
B2625
B2626
B2627
B2628
B2629
B2630
B2631
B2632
B2633
B2634
B2635
B2636
B2637
B2638
B2639
B2640
B2641
B2642
B2643
B2644
B2645
B2646
B2647
B2648
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$10.00
$7.00
N/C
$7.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
28
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B2649
B2650
B2651
B2652
B2653
B2654
B2655
B2656
B2657
B2658
B2659
B2660
B2661
B2662
B2663
B2664
B2665
B2666
B2667
B2668
B2669
B2670
B2671
B2672
B2673
B2674
B2675
B2676
B2677
B2678
B2679
B2680
B2681
B2682
B2683
B2684
B2685
B2686
B2687
B2688
B2689
B2690
B2691
B2692
B2693
B2694
B2695
B2696
B2697
B2698
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
N/C
$7.00
$7.00
$5.00
$7.00
$8.00
$5.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$10.00
$10.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$10.00
$10.00
$7.00
$5.00
$7.00
B2699
B2700
B2701
B2702
B2703
B2704
B2705
B2706
B2707
B2708
B2709
B2710
B2711
B2712
B2713
B2714
B2715
B2716
B2717
B2718
B2719
B2720
B2721
B2722
B2723
B2724
B2725
B2726
B2727
B2728
B2729
B2730
B2731
B2732
B2733
B2734
B2735
B2736
B2737
B2738
B2739
B2740
B2741
B2742
B2743
B2744
B2745
B2746
B2747
B2748
$5.00
$5.00
$7.00
$7.00
$10.00
$7.00
$5.00
$2.00
$7.00
$7.00
$7.00
$10.00
$10.00
$10.00
N/C
$7.00
$5.00
$7.00
$7.00
$5.00
$10.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$0.00
$7.00
N/C
$10.00
$5.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$10.00
$10.00
$10.00
$10.00
$10.00
$5.00
$5.00
B2749
B2750
B2751
B2752
B2753
B2754
B2755
B2756
B2757
B2758
B2759
B2760
B2761
B2762
B2763
B2764
B2765
B2766
B2767
B2768
B2769
B2770
B2771
B2772
B2773
B2774
B2775
B2776
B2777
B2778
B2779
B2780
B2781
B2782
B2783
B2784
B2785
B2786
B2787
B2788
B2789
B2790
B2791
B2792
B2793
B2794
B2795
B2796
B2797
B2798
$5.00
$12.00
$15.00
$12.00
$15.00
$10.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
N/C
N/C
N/C
N/C
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$8.00
$5.00
$8.00
$7.00
$7.00
$2.00
$2.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
29
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B2799
B2800
B2801
B2802
B2803
B2804
B2805
B2806
B2807
B2808
B2809
B2810
B2811
B2812
B2813
B2814
B2815
B2816
B2817
B2818
B2819
B2820
B2821
B2822
B2823
B2824
B2825
B2826
B2827
B2828
B2829
B2830
B2831
B2832
B2833
B2834
B2835
B2836
B2837
B2838
B2839
B2840
B2841
B2842
B2843
B2844
B2845
B2846
B2847
B2848
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B2849
B2850
B2851
B2852
B2853
B2854
B2855
B2856
B2857
B2858
B2859
B2860
B2861
B2862
B2863
B2864
B2865
B2866
B2867
B2868
B2869
B2870
B2871
B2872
B2873
B2874
B2875
B2876
B2877
B2878
B2879
B2880
B2881
B2882
B2883
B2884
B2885
B2886
B2887
B2888
B2889
B2890
B2891
B2892
B2893
B2894
B2895
B2896
B2897
B2898
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
N/C
N/C
$7.00
$7.00
$10.00
$10.00
$10.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$8.00
$7.00
$7.00
$7.00
$12.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
B2899
B2900
B2901
B2902
B2903
B2904
B2905
B2906
B2907
B2908
B2909
B2910
B2911
B2912
B2913
B2914
B2915
B2916
B2917
B2918
B2919
B2920
B2921
B2922
B2923
B2924
B2925
B2926
B2927
B2928
B2929
B2930
B2931
B2932
B2933
B2934
B2935
B2936
B2937
B2938
B2939
B2940
B2941
B2942
B2943
B2944
B2945
B2946
B2947
B2948
$7.00
$7.00
$10.00
$10.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$7.00
08-13-2015
30
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B2949
B2950
B2951
B2952
B2953
B2954
B2955
B2956
B2957
B2958
B2959
B2960
B2961
B2962
B2963
B2964
B2965
B2966
B2967
B2968
B2969
B2970
B2971
B2972
B2973
B2974
B2975
B2976
B2977
B2978
B2979
B2980
B2981
B2982
B2983
B2984
B2985
B2986
B2987
B2988
B2989
B2990
B2991
B2992
B2993
B2994
B2995
B2996
B2997
B2998
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$10.00
$7.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
NADA
$10.00
$15.00
$7.00
B2999
B3000
B3001
B3002
B3003
B3004
B3005
B3006
B3007
B3008
B3009
B3010
B3011
B3012
B3013
B3014
B3015
B3016
B3017
B3018
B3019
B3020
B3021
B3022
B3023
B3024
B3025
B3026
B3027
B3028
B3029
B3030
B3031
B3032
B3033
B3034
B3035
B3036
B3037
B3038
B3039
B3040
B3041
B3042
B3043
B3044
B3045
B3046
B3047
B3048
$7.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
NADA
$7.00
$5.00
$5.00
NADA
$5.00
$5.00
$0.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
NADA
NADA
$10.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B3049
B3050
B3051
B3052
B3053
B3054
B3055
B3056
B3057
B3058
B3059
B3060
B3061
B3062
B3063
B3064
B3065
B3066
B3067
B3068
B3069
B3070
B3071
B3072
B3073
B3074
B3075
B3076
B3077
B3078
B3079
B3080
B3081
B3082
B3083
B3084
B3085
B3086
B3087
B3088
B3089
B3090
B3091
B3092
B3093
B3094
B3095
B3096
B3097
B3098
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$15.00
NADA
NADA
NADA
NADA
NADA
NADA
$5.00
$5.00
$5.00
$7.00
$7.00
$5.00
$7.00
$5.00
$5.00
$10.00
$10.00
$15.00
$5.00
$7.00
$5.00
$7.00
$5.00
$0.00
$5.00
$5.00
$5.00
$5.00
$15.00
$5.00
$7.00
$5.00
NADA
NADA
$5.00
NADA
08-13-2015
31
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B3099
B3100
B3101
B3102
B3103
B3104
B3105
B3106
B3107
B3108
B3109
B3110
B3111
B3112
B3113
B3114
B3115
B3116
B3117
B3118
B3119
B3120
B3121
B3122
B3123
B3124
B3125
B3126
B3127
B3128
B3129
B3130
B3131
B3132
B3133
B3134
B3135
B3136
B3137
B3138
B3139
B3140
B3141
B3142
B3143
B3144
B3145
B3146
B3147
B3148
$10.00
$12.00
$5.00
$5.00
$10.00
$7.00
$7.00
$7.00
$10.00
$5.00
$7.00
$7.00
$10.00
$10.00
$5.00
$10.00
$5.00
$10.00
$7.00
$5.00
$5.00
NADA
NADA
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$15.00
$10.00
$10.00
$7.00
$6.50
$6.50
NADA
$10.00
$10.00
NADA
NADA
NADA
NADA
NADA
$7.00
$7.00
$15.00
$10.00
$7.00
B3149
B3150
B3151
B3152
B3153
B3154
B3155
B3156
B3157
B3158
B3159
B3160
B3161
B3162
B3163
B3164
B3165
B3166
B3167
B3168
B3169
B3170
B3171
B3172
B3173
B3174
B3175
B3176
B3177
B3178
B3179
B3180
B3181
B3182
B3183
B3184
B3185
B3186
B3187
B3188
B3189
B3190
B3191
B3192
B3193
B3194
B3195
B3196
B3197
B3198
NADA
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$10.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B3199
B3200
B3201
B3202
B3203
B3204
B3205
B3206
B3207
B3208
B3209
B3210
B3211
B3212
B3213
B3214
B3215
B3216
B3217
B3218
B3219
B3220
B3221
B3222
B3223
B3224
B3225
B3226
B3227
B3228
B3229
B3230
B3231
B3232
B3233
B3234
B3235
B3236
B3237
B3238
B3239
B3240
B3241
B3242
B3243
B3244
B3245
B3246
B3247
B3248
NADA
$5.00
$5.00
$10.00
$10.00
NADA
$5.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$10.00
$5.00
$7.00
NADA
NADA
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
$5.00
$5.00
$5.00
$10.00
$5.00
$10.00
$10.00
$10.00
$7.00
$10.00
$7.00
$7.00
$7.00
$10.00
$7.00
NADA
$7.00
$7.00
$5.00
08-13-2015
32
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B3249
B3250
B3251
B3252
B3253
B3254
B3255
B3256
B3257
B3258
B3259
B3260
B3261
B3262
B3263
B3264
B3265
B3266
B3267
B3268
B3269
B3270
B3271
B3272
B3273
B3274
B3275
B3276
B3277
B3278
B3279
B3280
B3281
B3282
B3283
B3284
B3285
B3286
B3287
B3288
B3289
B3290
B3291
B3292
B3293
B3294
B3295
B3296
B3297
B3298
NADA
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
$5.00
$7.00
$5.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$5.00
$5.00
NADA
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$10.00
$10.00
$7.00
$7.00
$7.00
$10.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$7.00
$7.00
$5.00
$7.00
NADA
B3299
B3300
B3301
B3302
B3303
B3304
B3305
B3306
B3307
B3308
B3309
B3310
B3311
B3312
B3313
B3314
B3315
B3316
B3317
B3318
B3319
B3320
B3321
B3322
B3323
B3324
B3325
B3326
B3327
B3328
B3329
B3330
B3331
B3332
B3333
B3334
B3335
B3336
B3337
B3338
B3339
B3340
B3341
B3342
B3343
B3344
B3345
B3346
B3347
B3348
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
NADA
$5.00
$5.00
$5.00
$5.00
$5.00
NADA
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$7.00
$5.00
$5.00
NADA
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
B3349
B3350
B3351
B3352
B3353
B3354
B3355
B3356
B3357
B3358
B3359
B3360
B3361
B3362
B3363
B3364
B3365
B3366
B3367
B3368
B3369
B3370
B3371
B3372
B3373
B3374
B3375
B3376
B3377
B3378
B3379
B3380
B3381
B3382
B3383
B3384
B3385
B3386
B3387
B3388
B3389
B3390
B3391
B3392
B3393
B3394
B3395
B3396
B3397
B3398
$7.00
$7.00
$15.00
$20.00
$7.00
$7.00
$5.00
$5.00
$10.00
$10.00
$7.00
$7.00
$5.00
$7.00
$20.00
$10.00
NADA
NADA
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$15.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
33
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B3399
B3400
B3401
B3402
B3403
B3404
B3405
B3406
B3407
B3408
B3409
B3410
B3411
B3412 
B3413 
B3414
B3415
B3416 
B3417 
B3418 
B3419 
B3420 
B3421 
B3422
B3423
B3424
B3425 
B3426
B3427 
B3428 
B3429 
B3430 
B3431 
B3432
B3433 
B3434 
B3435 
B3436 
B3437 
B3438 
B3439 
B3440 
B3441 
B3442 
B3443 
B3444 
B3445
B3446
B3447 
B3448
$20.00
$7.00
$5.00
$20.00
$20.00
$7.00
$7.00
$7.00
$7.00
$7.00
$20.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$10.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
NADA
NADA
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B3449
B3450
B3451 
B3452
B3453
B3454
B3455 
B3456 
B3457
B3458 
B3459 
B3460 
B3461 
B3462 
B3463 
B3464
B3465
B3466 
B3467 
B3468 
B3469 
B3470 
B3471
B3472
B3473
B3474 
B3475 
B3476 
B3477 
B3478 
B3479 
B3480 
B3481 
B3482 
B3483 
B3484 
B3485
B3486
B3487
B3488 
B3489 
B3490 
B3491
B3492
B3493 
B3494 
B3495
B3496 
B3497
B3498
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$5.00
$10.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$10.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$7.00
$10.00
$10.00
$10.00
$10.00
$10.00
$10.00
$7.00
$7.00
$10.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
B3499 
B3500
B3501
B3502
B3503
B3504
B3505 
B3506 
B3507 
B3508 
B3509 
B3510
B3511
B3512
B3513 
B3514 
B3515 
B3516 
B3517 
B3518
B3519 
B3520 
B3521 
B3522 
B3523 
B3524 
B3525
B3526 
B3527
B3528
B3529 
B3530 
B3531 
B3532 
B3533 
B3534 
B3535 
B3536
B3537 
B3538
B3539
B3540
B3541
B3542
B3543
B3544
B3545
B3546 
B3547 
B3548 
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$10.00
$10.00
$10.00
$7.00
$5.00
$10.00
$7.00
$5.00
$10.00
$5.00
08-13-2015
34
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B3549 
B3550 
B3551
B3552
B3553 
B3554 
B3555 
B3556 
B3557
B3558 
B3559 
B3560 
B3561 
B3562
B3563
B3564 
B3565 
B3566
B3567
B3568
B3569
B3570 
B3571 
B3572 
B3573 
B3574
B3575 
B3576 
B3577
B3578 
B3579 
B3580 
B3581
B3582
B3583 
B3584
B3585
B3586
B3587 
B3588 
B3589
B3590 
B3591 
B3592 
B3593
B3594 
B3595 
B3596 
B3597 
B3598 
$15.00
$15.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$8.00
$8.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$5.00
$5.00
$5.00
$8.00
$10.00
$5.00
$5.00
$10.00
$7.00
$10.00
$10.00
$10.00
$7.00
$7.00
$0.00
$10.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
B3599
B3600 
B3601 
B3602 
B3603 
B3604 
B3605 
B3606 
B3607 
B3609
B3610
B3611 
B3612 
B3613 
B3614
B3615 
B3616 
B3617 
B3618 
B3619 
B3620
B3621
B3622
B3623 
B3624
B3625
B3626
B3627
B3628
B3629
B3630
B3631 
B3632 
B3633 
B3634 
B3635 
B3636 
B3637 
B3638
B3639 
B3640
B3641
B3642
B3643
B3644
B3645
B3646 
B3647
B3648 
B3649 
$7.00
$12.00
$12.00
$12.00
$12.00
$12.00
$7.00
$7.00
$5.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$8.00
B3650 
B3651
B3652 
B3653
B3654 
B3655
B3656
B3657 
B3658 
B3659
B3660
B3661 
B3662
B3663
B3664
B3665
B3666
B3667 
B3668 
B3669 
B3670 
B3671 
B3672 
B3673
B3674
B3675 
B3676
B3677
B3678 
B3679
B3680
B3681
B3682 
B3683
B3684
B3685
B3686
B3687 
B3688 
B3689 
B3690
B3691
B3692 
B3693
B3694
B3695
B3696
B3697 
B3698
B3699
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$12.00
$12.00
$5.00
$7.00
$7.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
35
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B3700 
B3701
B3702 
B3703 
B3704
B3705
B3706
B3707
B3708 
B3709 
B3710
B3711
B3712
B3713
B3714 
B3715
B3716 
B3717
B3718 
B3719
B3720 
B3721
B3722
B3723
B3724
B3725 
B3726 
B3727 
B3728
B3729
B3730
B3731
B3732
B3733
B3734
B3735 
B3736
B3737 
B3738
B3739
B3740
B3741
B3742
B3743
B3744 
B3745 
B3746
B3747 
B3748
B3749
$7.00
$10.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$12.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$5.00
NADA
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$15.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
B3750
B3751
B3752
B3753
B3754
B3755
B3756
B3757
B3758
B3759
B3760
B3761
B3762
B3763
B3764
B3765
B3766 
B3767
B3768 
B3769 
B3770
B3771
B3772
B3773
B3774
B3775
B3776
B3777
B3778
B3779
B3780
B3781
B3782
B3783
B3784 
B3785
B3786
B3787
B3788
B3789
B3790
B3791
B3792
B3793
B3794
B3795
B3796
B3797
B3798
B3799
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B3800
B3801
B3802
B3803
B3804
B3805
B3806
B3807
B3808
B3809
B3810
B3811
B3812
B3813
B3814
B3815
B3816
B3817 
B3818 
B3819 
B3820 
B3821 
B3822 
B3823 
B3824 
B3825 
B3826
B3827
B3828 
B3829 
B3830
B3831
B3832
B3833
B3834
B3835
B3836
B3837
B3838
B3839 
B3840
B3841
B3842
B3843
B3844
B3845
B3846
B3847
B3848
B3849 
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
36
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B3850 
B3851
B3852 
B3853 
B3854
B3855 
B3856 
B3857 
B3858
B3859 
B3860
B3861
B3862
B3863 
B3864 
B3865
B3866
B3867
B3868
B3869
B3870
B3871
B3872
B3873
B3874
B3875
B3876
B3877
B3878
B3879
B3880
B3881
B3882
B3883
B3884
B3885
B3886
B3887
B3888
B3889
B3890
B3891
B3892 
B3893
B3894 
B3895 
B3896
B3897
B3898
B3899 
$7.00
$7.00
$7.00
$7.00
$7.00
$8.00
$8.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
B3900 
B3901
B3902
B3903
B3904
B3905
B3906
B3907
B3908
B3909
B3910
B3911
B3912
B3913
B3914 
B3915 
B3916 
B3917 
B3918
B3919
B3920
B3921
B3922
B3923
B3924
B3925
B3926
B3927
B3928 
B3929
B3930
B3931
B3932 
B3933
B3934
B3935
B3936
B3937 
B3938 
B3939
B3940
B3941
B3942
B3943 
B3944 
B3945 
B3946
B3947
B3948
B3949
NADA
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B3950
B3951
B3952
B3953 
B3954 
B3955 
B3956 
B3957 
B3958 
B3959 
B3960 
B3961 
B3962 
B3963 
B3964 
B3965 
B3966 
B3967
B3968
B3969
B3970
B3971
B3972 
B3973
B3974
B3975
B3976
B3977
B3978
B3979
B3980
B3981
B3982
B3983 
B3984 
B3985
B3986
B3987
B3988
B3989
B3990 
B3991
B3992
B3993
B3994
B3995
B3996
B3997
B3998
B3999 
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$8.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
37
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B4000
B4001
B4002
B4003
B4004
B4005
B4006
B4007
B4008
B4009
B4010
B4011
B4012
B4013 
B4014 
B4015 
B4016
B4017
B4018 
B4019 
B4020 
B4021
B4022
B4023
B4024 
B4025 
B4026 
B4027
B4028
B4029 
B4030 
B4031 
B4032
B4033
B4034
B4035
B4036
B4037
B4038
B4039
B4040
B4041
B4042 
B4043
B4044
B4045
B4046
B4047 
B4048 
B4049
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$2.00
NADA
NADA
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
NADA
NADA
NADA
$7.00
$7.00
$7.00
$5.00
B4050
B4051
B4052
B4053
B4054 
B4055
B4056
B4057
B4058
B4059
B4060
B4061
B4062
B4063 
B4064 
B4065
B4066 
B4067
B4068
B4069
B4070
B4071 
B4072 
B4073
B4074
B4075 
B4076 
B4077
B4078
B4079
B4080 
B4081 
B4082
B4083
B4084
B4085
B4086
B4087
B4088
B4089
B4090
B4091
B4092
B4093 
B4094 
B4095 
B4096
B4097 
B4098 
B4099 
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B4100 
B4101 
B4102 
B4103 
B4104
B4105
B4106
B4107
B4108
B4109
B4110
B4111 
B4112
B4113
B4114
B4115
B4116
B4117
B4118 
B4119 
B4120 
B4121
B4122 
B4123 
B4124
B4125
B4126
B4127 
B4128 
B4129 
B4130 
B4131
B4132
B4133 
B4134 
B4135
B4136
B4137
B4138
B4139
B4140 
B4141
B4142
B4143
B4144
B4145
B4146 
B4147
B4148
B4149
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$10.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
38
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B4150 
B4151 
B4152 
B4153 
B4154
B4155
B4156 
B4157 
B4158
B4159
B4160 
B4161 
B4162
B4163 
B4164
B4165
B4166
B4167
B4168
B4169 
B4170
B4171
B4172
B4173 
B4174 
B4175 
B4176
B4177 
B4178
B4179
B4180
B4181
B4182 
B4183 
B4184
B4185
B4186
B4187
B4188
B4189 
B4190 
B4191 
B4192 
B4193 
B4194
B4195 
B4196 
B4197 
B4198
B4199
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
NADA
$7.00
$7.00
$5.00
$10.00
$7.00
$5.00
$7.00
$7.00
$7.00
B4200
B4201 
B4202
B4203 
B4204 
B4205
B4206
B4207
B4208 
B4209
B4210 
B4211 
B4212 
B4213
B4214
B4215
B4216
B4217
B4218
B4219 
B4220 
B4221 
B4222
B4223 
B4224
B4225
B4226 
B4227 
B4228 
B4229
B4230 
B4231
B4232
B4233
B4234
B4235
B4236 
B4237
B4238 
B4239
B4240
B4241
B4242
B4243
B4244
B4245
B4246
B4247 
B4248
B4249
$7.00
NADA
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
NADA
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B4250
B4251
B4252 
B4253
B4254
B4255
B4256 
B4257
B4258
B4259
B4260
B4261
B4262 
B4263 
B4264 
B4265 
B4266 
B4267 
B4268 
B4269
B4270
B4271
B4272 
B4273 
B4274
B4275
B4276
B4277
B4278 
B4279
B4280
B4281 
B4282 
B4283
B4284
B4285 
B4286
B4287
B4288
B4289 
B4290
B4291 
B4292
B4293
B4294 
B4295
B4296 
B4297
B4298 
B4299
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
08-13-2015
39
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B4300
B4301
B4302
B4303
B4304
B4305 
B4306 
B4307 
B4308 
B4309
B4310
B4311
B4312
B4313
B4314
B4315
B4316 
B4317
B4318 
B4319 
B4320 
B4321 
B4322 
B4323 
B4324
B4325 
B4326 
B4327 
B4328 
B4329 
B4330
B4331
B4332 
B4333
B4334
B4335
B4336 
B4337 
B4338 
B4339
B4340 
B4341 
B4342
B4343
B4344
B4345
B4346
B4347 
B4348
B4349 
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$7.00
B4350 
B4351
B4352 
B4353
B4354
B4355
B4356
B4357
B4358 
B4359 
B4360 
B4361
B4362
B4363
B4364
B4365
B4366
B4367
B4368 
B4369 
B4370
B4371
B4372
B4373
B4374
B4375
B4376
B4377
B4378
B4379
B4380
B4381
B4382
B4383
B4384
B4385
B4386
B4387
B4388
B4389
B4390
B4391
B4392
B4393
B4394
B4395
B4396
B4397
B4398
B4399
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
NADA
NADA
$5.00
NADA
$5.00
$5.00
NADA
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$5.00
B4400 
B4401 
B4402 
B4403
B4404
B4405
B4406 
B4407 
B4408
B4409
B4410
B4411
B4412 
B4413
B4414
B4415 
B4416
B4417
B4418 
B4419
B4420 
B4421
B4422
B4423
B4424
B4425
B4426 
B4427 
B4428 
B4429 
B4430
B4431
B4432
B4433
B4434
B4435 
B4436 
B4437 
B4438 
B4439 
B4440 
B4441 
B4442 
B4443 
B4444 
B4445 
B4446 
B4447 
B4448 
B4449 
$5.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$5.00
$7.00
$7.00
$5.00
$10.00
$7.00
$5.00
$5.00
$7.00
$10.00
$7.00
$7.00
$7.00
08-13-2015
40
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B4450
B4451 
B4452 
B4453 
B4454
B4455 
B4456 
B4457 
B4458 
B4459
B4460
B4461
B4462
B4463 
B4464
B4465
B4466 
B4467 
B4468 
B4469 
B4470 
B4471
B4472
B4473
B4474 
B4475 
B4476 
B4477
B4478 
B4479
B4480
B4481
B4482 
B4483
B4484 
B4485 
B4486 
B4487 
B4488 
B4489
B4490
B4491
B4492
B4493
B4494
B4495 
B4496
B4497
B4498
B4499
$5.00
$10.00
$7.00
$5.00
$10.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$8.00
$8.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
B4500 
B4501 
B4502
B4503 
B4504 
B4505
B4506
B4507
B4508
B4509
B4510
B4511
B4512 
B4513
B4514
B4515
B4516
B4517
B4518
B4519
B4520
B4521
B4522
B4523
B4524
B4525
B4526
B4527 
B4528 
B4529 
B4530 
B4531
B4532
B4533 
B4534 
B4535
B4536 
B4537 
B4538 
B4539
B4540
B4541
B4542 
B4543 
B4544
B4545
B4546
B4547 
B4548 
B4549 
$8.00
$10.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
NADA
$5.00
$5.00
$7.00
$7.00
$10.00
B4550
B4551 
B4552
B4553
B4554
B4555
B4556
B4557
B4558
B4559
B4560 
B4561 
B4562
B4563
B4564
B4565
B4566 
B4567
B4568
B4569
B4570
B4571 
B4572
B4573 
B4574 
B4575
B4576
B4577
B4578
B4579
B4580
B4581
B4582 
B4583
B4584 
B4585 
B4586 
B4587
B4588
B4589
B4590
B4591
B4592
B4593
B4594
B4595
B4596
B4597
B4598
B4599
$7.00
$7.00
$10.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
NADA
$5.00
$5.00
$5.00
$7.00
$7.00
$10.00
$10.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
$7.00
NADA
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$5.00
08-13-2015
41
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B4600
B4601
B4602 
B4603
B4604
B4605
B4606
B4607
B4608 
B4609 
B4610
B4611
B4612 
B4613
B4614 
B4615
B4616 
B4617
B4618
B4619
B4620 
B4621
B4622
B4623 
B4624
B4625 
B4626 
B4627 
B4628
B4629
B4630
B4631 
B4632 
B4633
B4634 
B4635 
B4636 
B4637
B4638 
B4639 
B4640 
B4641 
B4642 
B4643
B4644 
B4645 
B4646 
B4647 
B4648
B4649
NADA
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
NADA
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
B4650 
B4651 
B4652 
B4653 
B4654 
B4655 
B4656 
B4657 
B4658 
B4659 
B4660 
B4661 
B4662 
B4663 
B4664 
B4665
B4666 
B4667 
B4668 
B4669 
B4670
B4671 
B4672 
B4673 
B4674
B4675 
B4676 
B4677 
B4678 
B4679 
B4680 
B4681 
B4682 
B4683 
B4684 
B4685 
B4686 
B4687 
B4688 
B4689 
B4690 
B4691 
B4692 
B4693 
B4694 
B4695 
B4696 
B4697 
B4698 
B4699 
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$7.00
$10.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$15.00
$10.00
$7.00
$15.00
$10.00
$15.00
B4700 
B4701 
B4702 
B4703 
B4704 
B4705 
B4706 
B4707 
B4708 
B4709
B4710 
B4711 
B4712 
B4713 
B4714
B4715 
B4716 
B4717 
B4718 
B4719
B4720 
B4721 
B4722 
B4723 
B4724 
B4725 
B4726 
B4727 
B4728 
B4729
B4730 
B4731 
B4732 
B4733 
B4734 
B4735 
B4736
B4737 
B4738 
B4739 
B4740 
B4741 
B4742 
B4743
B4744 
B4745 
B4746 
B4747 
B4748 
B4749 
$10.00
$10.00
$5.00
$5.00
$7.00
$15.00
$7.00
$15.00
$7.00
$7.00
$7.00
$15.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$15.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
42
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B4750 
B4751 
B4752 
B4753
B4754
B4755
B4756 
B4757 
B4758
B4759
B4760 
B4761
B4762 
B4763 
B4764
B4765
B4766 
B4767
B4768
B4769
B4770
B4771
B4772
B4773
B4774
B4775 
B4776 
B4777 
B4778 
B4779
B4780
B4781
B4782
B4783
B4784
B4785
B4786
B4787
B4788
B4789
B4790
B4791
B4792
B4793
B4794
B4795
B4796
B4797
B4798
B4799
$12.00
$15.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B4800
B4801
B4802
B4803
B4804
B4805
B4806
B4807
B4808
B4809
B4810
B4811
B4812
B4813
B4814
B4815
B4816
B4817
B4818
B4819
B4820
B4821
B4822
B4823
B4824
B4825
B4826
B4827
B4828
B4829
B4830
B4831
B4832
B4833
B4834
B4835
B4836
B4837
B4838
B4839
B4840
B4841
B4842
B4843
B4844
B4845
B4846
B4847
B4848
B4849
$15.00
$7.00
$7.00
$10.00
$10.00
$7.00
$20.00
$7.00
$7.00
$5.00
$12.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$20.00
NADA
NADA
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$15.00
$12.00
$12.00
B4850
B4851
B4852
B4853
B4854
B4855
B4856
B4857
B4858
B4859
B4860
B4861
B4862
B4863
B4864
B4865
B4866
B4867
B4868
B4869
B4870
B4871
B4872
B4873
B4874
B4875
B4876
B4877
B4878
B4879
B4880
B4881
B4882
B4883
B4884
B4885 
B4886 
B4887
B4888 
B4889
B4890
B4891 
B4892 
B4893
B4894 
B4895
B4896 
B4897
B4898 
B4899 
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$12.00
$5.00
$5.00
$5.00
$15.00
$7.00
$7.00
$7.00
$10.00
$10.00
$10.00
$10.00
$10.00
$12.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$15.00
$12.00
08-13-2015
43
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B4900 
B4901
B4902 
B4903 
B4904 
B4905 
B4906 
B4907 
B4908
B4909 
B4910
B4911 
B4912
B4913
B4914
B4915
B4916
B4917
B4918 
B4919 
B4920 
B4921 
B4922
B4923
B4924
B4925
B4926
B4927 
B4928 
B4929
B4930
B4931
B4932
B4933
B4934 
B4935 
B4936 
B4937 
B4938 
B4939
B4940 
B4941
B4942 
B4943 
B4944
B4945
B4946 
B4947 
B4948 
B4949 
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$12.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$5.00
$12.00
$5.00
$12.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B4950 
B4951
B4952 
B4953 
B4954
B4955 
B4956 
B4957
B4958 
B4959
B4960
B4961
B4962 
B4963 
B4964 
B4965 
B4966 
B4967
B4968 
B4969
B4970 
B4971 
B4972 
B4973
B4974
B4975
B4976
B4977
B4978 
B4979 
B4980 
B4981 
B4982
B4983 
B4984 
B4985
B4986
B4987
B4988
B4989
B4990
B4991 
B4992 
B4993
B4994 
B4995 
B4996
B4997
B4998
B4999 
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$10.00
$10.00
$15.00
$7.00
$10.00
$5.00
$10.00
$10.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
B5000 
B5001 
B5002 
B5003
B5004
B5005 
B5006 
B5007 
B5008 
B5009 
B5010
B5011
B5012 
B5013
B5014
B5015
B5016 
B5017
B5018 
B5019 
B5020 
B5021
B5022 
B5023
B5024 
B5025 
B5026
B5027 
B5028 
B5029 
B5030 
B5031 
B5032 
B5033
B5034 
B5035
B5036 
B5037
B5038 
B5039 
B5040
B5041 
B5042
B5043 
B5044 
B5045
B5046
B5047 
B5048 
B5049 
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$15.00
$12.00
$5.00
$5.00
$7.00
$7.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$12.00
$7.00
$7.00
$10.00
$5.00
$7.00
$10.00
$7.00
$7.00
$10.00
$7.00
$7.00
$10.00
$10.00
$10.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
08-13-2015
44
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B5050
B5051
B5052
B5053
B5054
B5055
B5056
B5057 
B5058 
B5059
B5060 
B5061
B5062 
B5063 
B5064
B5065
B5066
B5067
B5068
B5069 
B5070 
B5071 
B5072 
B5073
B5074 
B5075 
B5076 
B5077 
B5078 
B5079 
B5080
B5081
B5082
B5083 
B5084
B5085 
B5086 
B5087 
B5088 
B5089 
B5090 
B5091
B5092
B5093 
B5094 
B5095
B5096 
B5097 
B5098 
B5099 
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$12.00
$7.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$15.00
$7.00
$5.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$15.00
$5.00
$7.00
B5100
B5101 
B5102 
B5103 
B5104 
B5105
B5106
B5107 
B5108
B5109 
B5110 
B5111 
B5112 
B5113
B5114
B5115
B5116 
B5117 
B5118
B5119
B5120 
B5121 
B5122
B5123 
B5124 
B5125 
B5126
B5127
B5128
B5129 
B5130
B5131
B5132 
B5133 
B5134 
B5135
B5136
B5137
B5138
B5139 
B5140 
B5141
B5142
B5143
B5144 
B5145 
B5146
B5147 
B5148
B5149 
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$12.00
$7.00
$7.00
$7.00
$8.00
$7.00
$7.00
$8.00
$7.00
$7.00
B5150 
B5151
B5152 
B5153
B5154 
B5155 
B5156 
B5157 
B5158
B5159
B5160
B5161
B5162
B5163 
B5164 
B5165 
B5166
B5167 
B5168
B5169
B5170
B5171 
B5172
B5173 
B5174
B5175 
B5176
B5177
B5178 
B5179 
B5180 
B5181 
B5182 
B5183 
B5184
B5185 
B5186
B5187
B5188 
B5189
B5190 
B5191 
B5192 
B5193
B5194 
B5195 
B5196 
B5197 
B5198 
B5199
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$15.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
45
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B5200
B5201 
B5202 
B5203 
B5204 
B5205 
B5206 
B5207 
B5208 
B5209 
B5210 
B5211 
B5212 
B5213
B5214 
B5215 
B5216 
B5217 
B5218 
B5219 
B5220 
B5221
B5222
B5223 
B5224 
B5225 
B5226 
B5227 
B5228 
B5229 
B5230 
B5231 
B5232 
B5233 
B5234
B5235 
B5236 
B5237 
B5238 
B5239
B5240 
B5241 
B5242
B5243 
B5244
B5245 
B5246 
B5247
B5248
B5249
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$5.00
$5.00
$7.00
$10.00
$10.00
$10.00
$7.00
$7.00
$5.00
$10.00
$10.00
$10.00
$10.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$12.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$10.00
$7.00
$12.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
NADA
$7.00
$7.00
$7.00
B5250 
B5251 
B5252 
B5253 
B5254 
B5255 
B5256 
B5257 
B5258
B5259
B5260 
B5261
B5262
B5263
B5264 
B5265 
B5266 
B5267 
B5268 
B5269 
B5270 
B5271 
B5272 
B5273 
B5274 
B5275 
B5276 
B5277 
B5278 
B5279 
B5280
B5281 
B5282
B5283
B5284 
B5286
B5287
B5288
B5289
B5290
B5291 
B5292 
B5293 
B5294
B5295 
B5296 
B5297 
B5298 
B5299 
B5300 
$7.00
$7.00
$5.00
$7.00
$5.00
$15.00
$7.00
$5.00
$7.00
$7.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$8.00
$7.00
$7.00
$7.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$12.00
$12.00
$7.00
$7.00
$12.00
$15.00
$12.00
NADA
$10.00
B5301 
B5302 
B5303 
B5304 
B5305 
B5306 
B5307 
B5308 
B5309
B5310 
B5311 
B5312
B5313
B5314 
B5315 
B5316 
B5317 
B5318 
B5319
B5320
B5321 
B5322 
B5323
B5324
B5325
B5326
B5327
B5328
B5329 
B5330 
B5331 
B5332
B5333
B5334
B5335 
B5336 
B5337 
B5338
B5339 
B5340 
B5341 
B5342
B5343
B5344
B5345 
B5346 
B5347 
B5348 
B5349 
B5350
$10.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$12.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
NADA
NADA
$7.00
NADA
$7.00
$7.00
$12.00
$5.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$12.00
$7.00
$12.00
$7.00
$7.00
$10.00
$5.00
NADA
NADA
$5.00
$5.00
NADA
NADA
NADA
NADA
$5.00
08-13-2015
46
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B5351
B5352
B5353
B5354
B5355
B5356
B5357
B5358
B5359
B5360 
B5361 
B5362 
B5363 
B5364 
B5365 
B5366
B5367
B5368
B5369 
B5370 
B5371 
B5372 
B5373 
B5374 
B5375 
B5376 
B5377 
B5378 
B5379 
B5380 
B5381 
B5382 
B5383 
B5384 
B5385 
B5386
B5387
B5388 
B5389 
B5390 
B5391 
B5392 
B5393 
B5394 
B5395
B5396
B5397
B5398 
B5399 
B5400 
NADA
NADA
NADA
NADA
$5.00
NADA
NADA
NADA
NADA
$12.00
$7.00
$7.00
NADA
NADA
NADA
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$10.00
$7.00
$15.00
$15.00
$15.00
$8.00
$10.00
NADA
NADA
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$12.00
$5.00
$7.00
$7.00
$7.00
NADA
$7.00
$7.00
B5401
B5402
B5403
B5404
B5405
B5406
B5407
B5408
B5409
B5410
B5411
B5412
B5413 
B5414
B5415
B5416 
B5417 
B5418 
B5419 
B5420 
B5421 
B5422 
B5423 
B5424 
B5425
B5426 
B5427 
B5428 
B5429
B5430 
B5431
B5431 
B5432 
B5433 
B5434 
B5436
B5437 
B5438 
B5439 
B5440 
B5441 
B5442
B5443
B5444 
B5445 
B5446 
B5447
B5448 
B5449
B5450 
$7.00
$7.00
$7.00
$7.00
$10.00
$10.00
$7.00
$7.00
$10.00
$10.00
$10.00
$10.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
NADA
NADA
NADA
NADA
$7.00
$15.00
$7.00
$12.00
$7.00
$7.00
$5.00
$5.00
NADA
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
B5451
B5452 
B5453 
B5454 
B5455
B5456 
B5457 
B5458 
B5459 
B5460 
B5461 
B5462 
B5463 
B5464 
B5465 
B5466 
B5467 
B5468 
B5469 
B5470 
B5471 
B5472 
B5473 
B5474 
B5475 
B5476
B5477 
B5478
B5479 
B5480 
B5481 
B5482 
B5483 
B5484 
B5485 
B5486 
B5487 
B5488 
B5489 
B5490 
B5491 
B5492 
B5493 
B5494 
B5495 
B5496 
B5497 
B5498 
B5499 
B5500 
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$7.00
NADA
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
08-13-2015
47
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B5501 
B5502 
B5503 
B5504 
B5505 
B5506 
B5507 
B5508 
B5509 
B5510 
B5511 
B5512 
B5513 
B5514 
B5515 
B5516 
B5517 
B5518 
B5519 
B5520 
B5521 
B5522 
B5523 
B5524 
B5525 
B5526 
B5527
B5528 
B5529 
B5530 
B5531 
B5532 
B5533 
B5534 
B5535 
B5536 
B5537 
B5538 
B5539 
B5540 
B5541 
B5542 
B5543 
B5544 
B5545 
B5546
B5547
B5548
B5549 
B5550 
$7.00
$7.00
$7.00
NADA
NADA
$7.00
NADA
NADA
$7.00
NADA
NADA
$5.00
$5.00
NADA
NADA
NADA
$7.00
$7.00
NADA
$12.00
NADA
NADA
NADA
NADA
$5.00
$7.00
$7.00
$7.00
$10.00
$10.00
NADA
NADA
NADA
$10.00
$7.00
NADA
$7.00
NADA
$5.00
$7.00
$10.00
$10.00
$7.00
$7.00
$12.00
$5.00
$5.00
$7.00
$7.00
$15.00
B5551 
B5552 
B5553 
B5554 
B5555 
B5556 
B5557
B5558 
B5559 
B5560 
B5561 
B5562
B5563 
B5564 
B5565 
B5566 
B5567 
B5568 
B5569 
B5570 
B5571 
B5572 
B5573 
B5574 
B5575
B5576 
B5577 
B5578 
B5579 
B5580 
B5581 
B5582 
B5583 
B5584 
B5585
B5586 
B5587 
B5588 
B5589 
B5590 
B5591 
B5592 
B5593 
B5594 
B5595 
B5596 
B5597 
B5598 
B5599 
B5600 
$15.00
$12.00
$12.00
$5.00
$5.00
$7.00
$7.00
$7.00
$12.00
$15.00
$7.00
$7.00
$5.00
$15.00
$15.00
$7.00
$7.00
$15.00
$20.00
$20.00
$20.00
$5.00
$15.00
$12.00
$7.00
$7.00
$12.00
$20.00
$20.00
$20.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$12.00
$5.00
$7.00
$7.00
$7.00
$10.00
NADA
NADA
$7.00
NADA
$5.00
$5.00
$5.00
$5.00
B5601 
B5602 
B5603 
B5604 
B5605 
B5606 
B5607 
B5608 
B5609 
B5610 
B5611 
B5612 
B5613 
B5614 
B5615 
B5616 
B5617 
B5618 
B5619 
B5620 
B5621 
B5622 
B5623
B5624 
B5625 
B5626 
B5627 
B5628 
B5629
B5630 
B5631 
B5632 
B5633 
B5634
B5635 
B5636 
B5637
B5638 
B5639 
B5640
B5641 
B5642 
B5643 
B5644 
B5645 
B5646
B5647 
B5648 
B5649 
B5650
$7.00
$7.00
$7.00
NADA
$10.00
$12.00
$7.00
NADA
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$12.00
$7.00
$7.00
NADA
$7.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
48
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B5651 
B5652
B5653 
B5654
B5655 
B5656 
B5657 
B5658 
B5659 
B5660 
B5661 
B5662 
B5663 
B5664 
B5665 
B5666
B5667 
B5668 
B5669 
B5670
B5671
B5672 
B5673
B5674 
B5675 
B5676
B5677 
B5678 
B5679
B5680 
B5681 
B5682 
B5683 
B5684 
B5685 
B5686 
B5687 
B5688 
B5689 
B5690 
B5691 
B5692 
B5693 
B5694 
B5695 
B5696 
B5697
B5698 
B5699 
B5700 
$7.00
$7.00
$7.00
$7.00
$7.00
$15.00
$5.00
$7.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$12.00
$7.00
$5.00
$12.00
$15.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$7.00
$5.00
$10.00
$7.00
$7.00
$5.00
$10.00
$7.00
$7.00
$5.00
$7.00
$7.00
$10.00
$10.00
$7.00
NADA
$7.00
$7.00
$5.00
$10.00
$15.00
$7.00
$5.00
NADA
NADA
B5701 
B5702 
B5703 
B5704 
B5705 
B5706 
B5707 
B5708 
B5709 
B5710 
B5711 
B5712 
B5713 
B5714 
B5715 
B5716 
B5717 
B5718 
B5719 
B5720 
B5721 
B5722 
B5725 
B5726 
B5729
B5730 
B5731 
B5732 
B5733 
B5734 
B5735 
B5736 
B5737 
B5738 
B5740 
B5741 
B5742 
B5745 
B5746 
B5749 
B5754 
B5755 
B5757 
B5760
B5761 
B5762 
B5764 
B5765 
B5766 
B5769 
$7.00
$10.00
$5.00
$7.00
$7.00
$12.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$12.00
$7.00
$5.00
$7.00
$10.00
NADA
NADA
$7.00
$7.00
$7.00
$15.00
$7.00
$10.00
$10.00
$10.00
$10.00
$5.00
$5.00
$10.00
$10.00
$10.00
NADA
NADA
$15.00
$7.00
$7.00
$7.00
$7.00
$5.00
$12.00
$10.00
$12.00
NADA
$7.00
$7.00
B5770 
B5771 
B5772 
B5773 
B5774 
B5777 
B5778 
B5781 
B5782 
B5783 
B5784 
B5785 
B5786 
B5787 
B5788 
B5789 
B5790 
B5797 
B5798 
B5799 
B5800 
B5801 
B5803 
B5807 
B5808 
B5810 
B5811 
B5812 
B5813 
B5814 
B5815 
B5817 
B5818 
B5819 
B5820 
B5821 
B5822 
B5823 
B5824 
B5825 
B5826 
B5827 
B5828 
B5829 
B5830 
B5831 
B5832 
B5833 
B5834 
B5835
$7.00
$5.00
$5.00
$5.00
$5.00
NADA
$7.00
$10.00
$10.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
NADA
NADA
NADA
$5.00
$7.00
$7.00
$10.00
NADA
NADA
$5.00
$5.00
$10.00
$5.00
$7.00
$10.00
$10.00
$15.00
$12.00
$7.00
$7.00
$7.00
$7.00
$10.00
$10.00
$10.00
$10.00
$10.00
$7.00
$10.00
$7.00
$5.00
08-13-2015
49
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B5836 
B5837 
B5838 
B5839 
B5840 
B5841 
B5842 
B5843 
B5844 
B5845 
B5846 
B5847 
B5848 
B5849 
B5850 
B5851 
B5852 
B5853
B5854 
B5855 
B5856 
B5857 
B5858 
B5859 
B5860 
B5861 
B5862 
B5863 
B5864 
B5865 
B5866 
B5867 
B5868 
B5869 
B5870 
B5871 
B5872 
B5873 
B5874 
B5875 
B5876 
B5877 
B5878 
B5879 
B5880 
B5881 
B5883 
B5884 
B5885 
B5886 
$5.00
$5.00
$10.00
NADA
NADA
$8.00
$7.00
$7.00
$7.00
$15.00
$7.00
$5.00
$8.00
NADA
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$8.00
$5.00
NADA
$5.00
$5.00
$5.00
$5.00
$5.00
NADA
NADA
NADA
$10.00
$7.00
$7.00
$5.00
$7.00
$15.00
$7.00
$5.00
$5.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
NADA
NADA
B5887 
B5888 
B5889 
B5890 
B5891 
B5892 
B5893 
B5894 
B5895 
B5896 
B5897 
B5898 
B5899 
B5900 
B5901 
B5902 
B5903 
B5904
B5905 
B5906 
B5907 
B5908
B5909 
B5910 
B5911 
B5912 
B5913 
B5914
B5915 
B5916 
B5917 
B5918 
B5919 
B5920 
B5921
B5923
B5924 
B5925 
B5926 
B5927
B5928 
B5931 
B5932 
B5933 
B5934 
B5935 
B5936 
B5937 
B5938 
B5939 
$7.00
NADA
$5.00
$5.00
$7.00
NADA
$5.00
$5.00
$5.00
$5.00
$10.00
$10.00
$10.00
$7.00
$10.00
$7.00
$10.00
$7.00
NADA
NADA
NADA
$7.00
$5.00
$5.00
$7.00
$7.00
$5.00
$7.00
$5.00
$8.00
$15.00
$10.00
$10.00
$7.00
$10.00
$5.00
$10.00
$10.00
$10.00
$7.00
$10.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
B5940 
B5941 
B5942 
B5943 
B5944 
B5945 
B5946 
B5947 
B5948 
B5949 
B5950 
B5951 
B5952 
B5953 
B5954 
B5955 
B5956
B5957
B5958
B5959 
B5961 
B5962
B5963
B5964
B5965 
B5966 
B5967 
B5968
B5969
B5970
B5971 
B5972 
B5973 
B5974 
B5975 
B5976 
B5977 
B5978 
B5979 
B5980 
B5981 
B5982 
B5983 
B5984 
B5985 
B5986 
B5987 
B5988 
B5989 
B5990 
$10.00
$10.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$10.00
$10.00
$7.00
$5.00
$7.00
$10.00
$7.00
$5.00
$7.00
$7.00
$5.00
$10.00
$5.00
$5.00
$7.00
$10.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
$10.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$10.00
$5.00
$7.00
$5.00
$5.00
$5.00
$10.00
$7.00
$10.00
08-13-2015
50
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B5991
B5992 
B5993 
B5994 
B5995 
B5996 
B5997 
B5998 
B5999 
B6000 
B6001 
B6002 
B6003 
B6004 
B6005 
B6006 
B6007 
B6008 
B6009 
B6010 
B6011 
B6012
B6013 
B6014 
B6015 
B6016 
B6017 
B6018 
B6019 
B6020 
B6021 
B6022 
B6023 
B6024 
B6025 
B6026 
B6027 
B6028 
B6029 
B6030 
B6031 
B6032 
B6033 
B6034 
B6036 
B6037 
B6038 
B6039 
B6040
B6041 
$7.00
$5.00
$10.00
$7.00
$7.00
$7.00
$10.00
$8.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$10.00
$5.00
$5.00
$10.00
$7.00
$10.00
$5.00
$7.00
$7.00
$7.00
$10.00
$10.00
$10.00
$7.00
$10.00
$7.00
$10.00
$7.00
$7.00
$10.00
$10.00
$10.00
$10.00
$7.00
$7.00
$10.00
$7.00
B6042 
B6043 
B6044 
B6045
B6046
B6047 
B6048
B6049 
B6050 
B6051 
B6052 
B6053 
B6054 
B6055 
B6056 
B6057 
B6058 
B6059 
B6060 
B6061 
B6062 
B6063 
B6064 
B6065 
B6066 
B6067
B6068 
B6069 
B6070 
B6071 
B6072 
B6073 
B6074 
B6075 
B6076 
B6077 
B6078 
B6079 
B6080 
B6081 
B6082 
B6083 
B6084 
B6085 
B6086 
B6087 
B6088 
B6089 
B6090 
B6091 
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$7.00
$5.00
NADA
$7.00
$7.00
$7.00
$5.00
$10.00
$5.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$10.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$10.00
$10.00
$7.00
$7.00
$7.00
$10.00
$7.00
$15.00
$5.00
$7.00
$7.00
$7.00
B6092 
B6093 
B6094 
B6095 
B6096 
B6097 
B6098 
B6099 
B6100 
B6101 
B6102 
B6103 
B6104 
B6105 
B6106 
B6109 
B6110 
B6111 
B6112 
B6113 
B6115 
B6116 
B6117 
B6118 
B6119 
B6120
B6121 
B6122 
B6123 
B6124 
B6125 
B6126 
B6127 
B6128 
B6129 
B6130 
B6131 
B6132 
B6133 
B6134 
B6135 
B6136 
B6137 
B6138 
B6139 
B6140 
B6141 
B6142 
B6143 
B6144 
$7.00
NADA
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$10.00
$7.00
$10.00
$7.00
NADA
NADA
$10.00
$10.00
$7.00
NADA
$7.00
$7.00
$5.00
$7.00
NADA
$10.00
NADA
$10.00
$10.00
$7.00
NADA
$5.00
$10.00
NADA
NADA
$7.00
$5.00
$5.00
$10.00
$7.00
$10.00
$5.00
$7.00
08-13-2015
51
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B6145 
B6146 
B6147 
B6148 
B6149 
B6150 
B6151 
B6152 
B6153 
B6154 
B6156 
B6159 
B6160 
B6163 
B6164 
B6165 
B6166 
B6167 
B6168 
B6172 
B6173 
B6180 
B6181 
B6182 
B6183 
B6184 
B6185 
B6187 
B6188 
B6189 
B6190 
B6191 
B6192 
B6193 
B6194 
B6195 
B6196 
B6197 
B6198 
B6199 
B6200 
B6201 
B6202 
B6203 
B6204 
B6205 
B6206 
B6207 
B6208 
B6209 
$10.00
$7.00
$10.00
$7.00
$10.00
$10.00
$7.00
$10.00
$10.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$8.00
$10.00
$10.00
$10.00
$10.00
$7.00
$10.00
$7.00
$7.00
$5.00
$7.00
$7.00
NADA
NADA
$7.00
NADA
NADA
$5.00
$10.00
$10.00
$5.00
$10.00
$5.00
$10.00
$10.00
NADA
$10.00
$10.00
NADA
$7.00
$7.00
NADA
$7.00
NADA
$5.00
B6210 
B6211 
B6212 
B6213 
B6214 
B6215 
B6216 
B6217 
B6218 
B6219 
B6220 
B6221 
B6222 
B6223 
B6224 
B6225 
B6226 
B6227 
B6228 
B6229 
B6230 
B6231 
B6232 
B6233 
B6234 
B6235 
B6236 
B6237 
B6238 
B6239 
B6240 
B6241 
B6242 
B6243 
B6244 
B6245 
B6246 
B6248 
B6249 
B6250 
B6251 
B6252 
B6253 
B6254 
B6255 
B6256 
B6257 
B6258 
B6259 
B6260 
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$10.00
$5.00
$5.00
$8.00
$7.00
$5.00
$5.00
$5.00
$5.00
$15.00
$5.00
$5.00
$15.00
$7.00
$7.00
$5.00
$5.00
$5.00
$2.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
NADA
$5.00
$7.00
$5.00
B6261 
B6262 
B6263 
B6264 
B6265 
B6266 
B6267 
B6268 
B6269 
B6270 
B6271 
B6273 
B6274 
B6275 
B6277 
B6278 
B6279 
B6280 
B6281 
B6282 
B6283 
B6284 
B6285 
B6286 
B6287 
B6288 
B6289 
B6290 
B6291 
B6292 
B6293 
B6295 
B6296 
B6297 
B6299 
B6300 
B6301 
B6302 
B6303 
B6304 
B6305 
B6307 
B6308 
B6309 
B6312 
B6313 
B6314 
B6315 
B6316 
B6317 
$7.00
$10.00
$7.00
$5.00
$7.00
$5.00
$5.00
NADA
$5.00
$5.00
$5.00
$5.00
$7.00
$10.00
$10.00
$15.00
$7.00
$7.00
NADA
$5.00
$10.00
$7.00
$10.00
NADA
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
NADA
$7.00
$7.00
$7.00
$15.00
$7.00
$7.00
$10.00
$5.00
$5.00
08-13-2015
52
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B6319 
B6321 
B6322 
B6323 
B6324 
B6325 
B6326 
B6327 
B6328 
B6329 
B6330 
B6331 
B6332 
B6333 
B6334 
B6335 
B6336 
B6337 
B6338 
B6339 
B6340 
B6341 
B6342 
B6343 
B6344 
B6345 
B6346 
B6347 
B6348 
B6349 
B6350 
B6351 
B6352 
B6353 
B6354 
B6355 
B6356 
B6357 
B6358 
B6359 
B6360 
B6361 
B6362 
B6363 
B6364 
B6365 
B6366 
B6367 
B6368 
B6369 
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$5.00
$10.00
$7.00
$7.00
$7.00
$7.00
$10.00
$10.00
$10.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$5.00
$10.00
$7.00
$7.00
$7.00
$7.00
B6370 
B6371 
B6372 
B6373 
B6374 
B6375 
B6376 
B6377 
B6378 
B6379 
B6380 
B6381 
B6382 
B6383 
B6384 
B6385 
B6386 
B6387 
B6388 
B6389 
B6390 
B6391 
B6392 
B6393 
B6394 
B6395 
B6396 
B6397 
B6398 
B6399 
B6400 
B6401 
B6402 
B6403 
B6404 
B6405 
B6406 
B6407 
B6408 
B6409 
B6410 
B6411 
B6412 
B6413 
B6414 
B6415 
B6416 
B6417 
B6418 
B6419 
$7.00
$7.00
$10.00
$10.00
$10.00
$5.00
$5.00
$5.00
$7.00
$7.00
$5.00
$10.00
$7.00
$7.00
$10.00
$7.00
$5.00
$5.00
$5.00
$10.00
$5.00
$7.00
$7.00
$10.00
$10.00
$10.00
$15.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$5.00
$7.00
$7.00
$20.00
$20.00
$20.00
$7.00
$20.00
$20.00
$20.00
$7.00
B6420 
B6421 
B6422 
B6423 
B6424 
B6425 
B6426 
B6427 
B6428 
B6429 
B6430 
B6431 
B6432 
B6433 
B6434 
B6435 
B6436 
B6437 
B6438 
B6439 
B6440 
B6441 
B6442 
B6443 
B6444 
B6445 
B6446 
B6447 
B6448 
B6449 
B6450 
B6451 
B6452 
B6453 
B6454 
B6455 
B6456 
B6457 
B6458 
B6459 
B6460 
B6461 
B6462 
B6463 
B6464 
B6465 
B6466 
B6467 
B6468 
B6469 
$7.00
$7.00
$7.00
$7.00
$15.00
NADA
$5.00
$5.00
$5.00
NADA
NADA
$10.00
$7.00
$5.00
$7.00
$5.00
$7.00
$7.00
$10.00
$5.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
NADA
$10.00
$7.00
$10.00
$7.00
$5.00
$7.00
$7.00
$10.00
$7.00
$5.00
$5.00
$7.00
$5.00
$5.00
$7.00
08-13-2015
53
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B6470 
B6471 
B6472 
B6473 
B6474 
B6475 
B6476 
B6477 
B6478 
B6479 
B6480 
B6481
B6483 
B6484 
B6485 
B6486 
B6487 
B6488 
B6489 
B6490 
B6493 
B6494 
B6495 
B6496 
B6498 
B6499
B6500 
B6501 
B6502 
B6503 
B6504 
B6506 
B6507
B6508 
B6509 
B6510 
B6513 
B6514 
B6515 
B6518 
B6519 
B6520 
B6521 
B6522 
B6523 
B6524 
B6525 
B6526 
B6527 
B6528 
$5.00
$5.00
$7.00
$7.00
NADA
$5.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$5.00
$5.00
$10.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$5.00
$5.00
$5.00
$5.00
$7.00
$12.00
$12.00
NADA
$7.00
NADA
NADA
$5.00
$7.00
$7.00
$10.00
B6529 
B6530 
B6531 
B6532 
B6533 
B6534 
B6535 
B6536 
B6537 
B6538 
B6539 
B6540
B6541 
B6542 
B6543 
B6544 
B6545 
B6546 
B6547 
B6548 
B6549 
B6550 
B6551 
B6552 
B6553 
B6554 
B6555 
B6556 
B6557 
B6558 
B6559 
B6560 
B6561 
B6562 
B6563 
B6564 
B6565 
B6566 
B6567 
B6568 
B6569 
B6570 
B6571 
B6572 
B6573 
B6574 
B6575 
B6576 
B6577 
B6578 
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$5.00
$7.00
$5.00
$5.00
$10.00
$7.00
$7.00
$7.00
$7.00
$15.00
$7.00
$12.00
$7.00
$7.00
$7.00
$10.00
NADA
NADA
$7.00
$5.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$5.00
$10.00
$7.00
$10.00
$5.00
$5.00
B6579 
B6580 
B6581 
B6582 
B6583 
B6584 
B6585 
B6586 
B6587 
B6588 
B6589 
B6590 
B6591 
B6592 
B6593 
B6594 
B6595 
B6596 
B6597 
B6598 
B6599 
B6600 
B6601 
B6602 
B6603 
B6604 
B6605 
B6606 
B6607 
B6608 
B6609 
B6610 
B6611 
B6612 
B6613 
B6614 
B6615 
B6616 
B6617 
B6618 
B6619 
B6620 
B6621 
B6622 
B6623 
B6624 
B6625 
B6626 
B6627 
B6628 
$7.00
$5.00
NADA
NADA
NADA
NADA
NADA
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
NADA
NADA
$7.00
$5.00
$5.00
$10.00
$10.00
$10.00
$10.00
$7.00
$7.00
$5.00
$10.00
$10.00
$5.00
$7.00
$10.00
$7.00
NADA
NADA
$7.00
$7.00
$7.00
$7.00
08-13-2015
54
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B6629 
B6630 
B6631 
B6632 
B6633 
B6634 
B6635 
B6636 
B6637 
B6638 
B6639 
B6640 
B6641 
B6642 
B6643 
B6644 
B6645 
B6646 
B6647 
B6648 
B6649 
B6650 
B6651 
B6652 
B6653 
B6654 
B6655 
B6656 
B6657 
B6658 
B6659 
B6660 
B6661 
B6662 
B6663 
B6664 
B6665 
B6666 
B6667 
B6668 
B6669 
B6670 
B6671 
B6672 
B6673 
B6674 
B6675 
B6676 
B6677 
B6678 
NADA
NADA
$7.00
NADA
NADA
$7.00
$8.00
$8.00
$5.00
$5.00
$5.00
$5.00
$5.00
NADA
NADA
$7.00
$5.00
$5.00
$5.00
NADA
NADA
NADA
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$12.00
$7.00
NADA
$7.00
$10.00
$5.00
$5.00
$15.00
$7.00
$15.00
$5.00
$5.00
NADA
NADA
$5.00
$5.00
$5.00
$10.00
$10.00
$10.00
B6679 
B6680 
B6681 
B6682 
B6683 
B6684 
B6685 
B6686 
B6687 
B6688 
B6689 
B6690 
B6691 
B6692 
B6693 
B6694 
B6695 
B6696 
B6697 
B6698 
B6699 
B6700 
B6701 
B6702 
B6703 
B6704 
B6705
B6706 
B6707 
B6708 
B6709 
B6710 
B6711 
B6712 
B6713 
B6714 
B6715 
B6716 
B6717 
B6718 
B6719 
B6720
B6721 
B6722 
B6723 
B6724 
B6725 
B6726 
B6727
B6728 
$7.00
$7.00
$7.00
$7.00
NADA
NADA
$10.00
NADA
$5.00
$10.00
$10.00
$7.00
$7.00
$10.00
$7.00
$5.00
$7.00
NADA
$10.00
$10.00
$5.00
$5.00
$7.00
$10.00
$7.00
$5.00
$7.00
$10.00
$7.00
$7.00
$7.00
$5.00
$10.00
$10.00
$7.00
$7.00
$7.00
NADA
$5.00
$5.00
$7.00
$10.00
$7.00
$7.00
$7.00
$10.00
$7.00
$5.00
$7.00
NADA
B6729 
B6730 
B6731 
B6732 
B6733 
B6734 
B6735 
B6736 
B6737 
B6738 
B6739 
B6740 
B6741 
B6742 
B6743 
B6744 
B6745
B6746 
B6747 
B6748 
B6749 
B6750 
B6751 
B6752 
B6753 
B6754 
B6755 
B6756 
B6757 
B6758 
B6759 
B6760 
B6761 
B6762 
B6763 
B6764 
B6765 
B6766 
B6767 
B6768 
B6769 
B6770 
B6771
B6772 
B6773 
B6774 
B6775 
B6776
B6777 
B6778 
$10.00
$5.00
$7.00
$10.00
$10.00
$10.00
$10.00
$10.00
$5.00
$5.00
$5.00
$7.00
$10.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$12.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$15.00
$5.00
$7.00
$10.00
$10.00
$5.00
$7.00
$5.00
NADA
NADA
NADA
NADA
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$5.00
08-13-2015
55
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B6779 
B6780 
B6781 
B6782 
B6783 
B6784 
B6785 
B6788 
B6789 
B6790 
B6791 
B6792 
B6793 
B6794 
B6795 
B6796 
B6797 
B6798 
B6799 
B6800 
B6801 
B6802 
B6803 
B6804 
B6805 
B6806 
B6807 
B6808 
B6809 
B6810 
B6811 
B6812 
B6813 
B6814 
B6815 
B6816 
B6817 
B6818 
B6819 
B6820 
B6821 
B6822 
B6823 
B6824 
B6825 
B6826 
B6827 
B6828 
B6829 
B6830 
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
$7.00
$7.00
B6831 
B6832 
B6833 
B6834 
B6835 
B6836 
B6837 
B6838 
B6839 
B6840 
B6841 
B6842 
B6843 
B6844 
B6845 
B6846 
B6847 
B6848 
B6849 
B6850 
B6851 
B6852 
B6853 
B6854 
B6855 
B6856 
B6857 
B6858 
B6859 
B6860 
B6861 
B6862 
B6863 
B6864 
B6865 
B6866 
B6867 
B6868 
B6869 
B6870 
B6871 
B6872 
B6873 
B6874 
B6875 
B6876 
B6877 
B6878 
B6879 
B6880 
NADA
$7.00
$10.00
$10.00
NADA
$5.00
$7.00
$5.00
$10.00
NADA
$7.00
$7.00
$7.00
$7.00
$7.00
NADA
NADA
$7.00
$7.00
$7.00
$7.00
$10.00
$10.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
NADA
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$10.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$10.00
$5.00
B6881 
B6882 
B6883 
B6884 
B6885 
B6886 
B6887 
B6888 
B6889 
B6890 
B6891 
B6892 
B6893 
B6894 
B6895 
B6896 
B6897 
B6898 
B6899 
B6900 
B6901 
B6902 
B6903 
B6904 
B6905 
B6906 
B6907 
B6908 
B6909 
B6910 
B6911 
B6912 
B6913 
B6914 
B6915 
B6916 
B6917 
B6918 
B6919 
B6920 
B6921 
B6922 
B6923 
B6924 
B6925 
B6926 
B6927 
B6928 
B6929 
B6930 
$7.00
$7.00
$7.00
NADA
$7.00
$10.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
NADA
$7.00
$7.00
$7.00
$10.00
$15.00
$5.00
$5.00
$7.00
$10.00
$7.00
$7.00
$10.00
$8.00
$5.00
$10.00
$5.00
$7.00
$7.00
$10.00
$15.00
$10.00
$5.00
$5.00
$5.00
$7.00
$10.00
$7.00
$7.00
$10.00
$10.00
$7.00
$10.00
$5.00
$5.00
$7.00
$7.00
$7.00
08-13-2015
56
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B6931 
B6932 
B6933 
B6934 
B6935 
B6936 
B6937 
B6938 
B6939 
B6940 
B6941 
B6942 
B6943 
B6944 
B6945 
B6946 
B6947 
B6948 
B6949 
B6950 
B6951 
B6952 
B6953 
B6954 
B6955 
B6956 
B6957 
B6958 
B6959 
B6960 
B6961 
B6962 
B6963 
B6964 
B6965 
B6966 
B6967 
B6968 
B6969 
B6970 
B6971 
B6972 
B6973 
B6974 
B6975 
B6976 
B6977 
B6978 
B6979 
B6980 
$5.00
$7.00
$10.00
$10.00
$7.00
$10.00
$5.00
$10.00
$5.00
$7.00
$5.00
$5.00
$5.00
$7.00
$10.00
$7.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$7.00
$7.00
$5.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$10.00
$10.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
NADA
B6981 
B6982 
B6983 
B6984 
B6985 
B6986 
B6987 
B6988 
B6989 
B6990 
B6991 
B6992 
B6993 
B6994 
B6995 
B6996 
B6997 
B6998 
B6999 
B7000 
B7001 
B7002 
B7003 
B7004 
B7005 
B7006 
B7007 
B7008 
B7009 
B7010 
B7011 
B7012 
B7013 
B7014 
B7015 
B7016 
B7017 
B7018 
B7020 
B7022 
B7023 
B7024 
B7025 
B7026 
B7027 
B7028 
B7029 
B7030 
B7031 
B7032 
$10.00
$15.00
$5.00
$10.00
$10.00
$5.00
$7.00
$10.00
NADA
$7.00
$7.00
$10.00
$10.00
$5.00
$7.00
$7.00
$7.00
$10.00
$7.00
NADA
$7.00
$7.00
$10.00
$7.00
$5.00
$7.00
NADA
$7.00
$7.00
$7.00
$7.00
$5.00
$10.00
$15.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$5.00
$10.00
$10.00
NADA
$7.00
$10.00
$10.00
$7.00
$7.00
$7.00
B7033 
B7034 
B7035 
B7036 
B7037 
B7038 
B7039 
B7040 
B7041 
B7042 
B7043 
B7044 
B7045 
B7046 
B7047 
B7048 
B7049 
B7050 
B7051 
B7052 
B7053 
B7054 
B7055 
B7056 
B7057 
B7058 
B7059 
B7060 
B7061 
B7062 
B7063 
B7064 
B7065 
B7066 
B7067 
B7068 
B7069 
B7070 
B7071 
B7072 
B7073 
B7074 
B7075 
B7076 
B7077 
B7079 
B7080 
B7081 
B7082 
B7083 
$5.00
NADA
$7.00
NADA
$7.00
$10.00
$7.00
$10.00
$10.00
$10.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$10.00
$10.00
$7.00
NADA
$7.00
$10.00
$10.00
$10.00
$10.00
$7.00
$10.00
$7.00
$10.00
$10.00
$7.00
$10.00
NADA
$7.00
$7.00
$10.00
$10.00
$10.00
NADA
$7.00
$5.00
$10.00
$7.00
$5.00
$7.00
08-13-2015
57
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B7084 
B7085 
B7086 
B7087 
B7088 
B7089 
B7090 
B7091 
B7092 
B7093 
B7094 
B7095 
B7096 
B7097 
B7099 
B7100 
B7101 
B7104 
B7109 
B7111 
B7112 
B7113 
B7114 
B7115 
B7116 
B7117 
B7118 
B7119 
B7120 
B7121 
B7122 
B7123 
B7124 
B7125 
B7126 
B7127 
B7128 
B7129 
B7130 
B7131 
B7132 
B7133 
B7134 
B7135 
B7136 
B7137 
B7138 
B7139 
B7140 
B7141 
$7.00
$7.00
$5.00
$10.00
$15.00
$15.00
$7.00
$5.00
$7.00
$7.00
$10.00
$7.00
$10.00
NADA
$10.00
$10.00
$7.00
$5.00
$10.00
$7.00
$5.00
$10.00
$7.00
$7.00
$5.00
$10.00
$10.00
$10.00
$10.00
$5.00
$5.00
$5.00
$5.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$5.00
$10.00
$5.00
$5.00
$5.00
NADA
NADA
$5.00
$5.00
$5.00
$7.00
B7142 
B7143 
B7144 
B7145 
B7146 
B7147 
B7148 
B7149 
B7150 
B7151 
B7152 
B7153 
B7154 
B7155 
B7156 
B7157 
B7158 
B7159 
B7160 
B7161 
B7162 
B7163 
B7164 
B7165 
B7166 
B7167 
B7168 
B7169 
B7170 
B7171 
B7172 
B7173 
B7174 
B7175 
B7176 
B7177 
B7178 
B7179 
B7180 
B7181 
B7182 
B7183 
B7184 
B7185 
B7186 
B7187 
B7188 
B7189 
B7190 
B7191 
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
NADA
$10.00
$5.00
$10.00
$10.00
$10.00
$7.00
NADA
$5.00
$5.00
$5.00
$5.00
$10.00
$7.00
NADA
NADA
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$7.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
B7192 
B7193 
B7194 
B7195 
B7196 
B7197 
B7198 
B7199 
B7200 
B7201 
B7202 
B7203 
B7204 
B7205 
B7206 
B7207 
B7208 
B7209 
B7210 
B7211 
B7213 
B7214 
B7218 
B7219 
B7220 
B7221 
B7222 
B7223 
B7224 
B7225 
B7226 
B7227 
B7228 
B7229 
B7230 
B7231 
B7234 
B7235 
B7236 
B7237 
B7238 
B7240 
B7241 
B7242 
B7243 
B7244 
B7245 
B7246 
B7247 
B7248 
$5.00
$5.00
$5.00
$10.00
$10.00
$10.00
$7.00
$7.00
$7.00
$7.00
$10.00
NADA
NADA
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$10.00
$7.00
$10.00
$10.00
$5.00
NADA
$7.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$5.00
$8.00
$7.00
$5.00
$7.00
$7.00
$5.00
$7.00
$10.00
$7.00
$5.00
$8.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
58
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
B7249 
B7250 
B7251 
B7252 
B7253 
B7254 
B7255 
B7256 
B7257 
B7258 
B7259 
B7260 
B7261 
B7262 
B7263 
B7264 
B7265 
B7266 
B7267 
B7268 
B7269 
B7270 
B7271 
B7272 
B7273 
B7274 
B7275 
B7276 
B7277 
B7278 
B7279 
B7280 
B7281 
B7283 
B7284 
B7285 
B7286 
B7288 
B7290 
B7291 
B7292 
B7297 
B7298 
B7299 
B7300 
B7301 
B7303 
B7304 
B7305 
B7308 
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$5.00
$5.00
$5.00
$5.00
$2.00
$5.00
$7.00
$7.00
$10.00
$10.00
$7.00
$10.00
$10.00
$10.00
$7.00
$10.00
$7.00
$7.00
$7.00
$10.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$5.00
$5.00
$5.00
$10.00
$7.00
$5.00
B7309 
B7310 
B7313 
B7314 
B7315 
B7316 
B7317 
B7318 
B7319 
B7320 
B7321 
B7322 
B7323 
B7324 
B7325 
B7326 
B7330 
B7331 
B7332 
B7333 
B7334 
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
$10.00
$10.00
$10.00
$7.00
$7.00
$10.00
$10.00
$10.00
$10.00
$10.00
$10.00
$10.00
$5.00
$7.00
$10.00
$10.00
NADA
$7.00
$7.00
$7.00
$7.00
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
08-13-2015
59
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
BA1
BA2
BA3
BA4
BA5
BA6
BA7
BA8
BA9
BA10
BA11
BA12
BA13
BA14
BA15
BA16
BA17
BA18
BA19
BA20
BA21
BA22
BA23
BA24
BA25
BA26
BA27
BA28
BA29
BA30
BA31
BA32
BA33
BA34
BA35
BA36
BA37
BA220
BA221
BA222
BA247
BA248
BA249
BA250
BA251
BA252
BA253
BA254
BA255
BA256
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
BA257
BA258
BA259
BA260
BA261
BA262
BA263
BA264
BA265
BA266
BA267
BA268
BA269
BA270
BA271
BA272
BA274
BA275
BA276
BA277
BA278
BA279
BA280
BA281
BA282
BA283
BA284
BA285
BA286
BA287
BA288
BA289
BA290
BA291
BA292
BA293
BA294
BA295
BA297
BA298
BA299
BA301
BA303
BA304
BA305
BA306
BA307
BA308
BA310
BA311
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
BA312
BA313
BA314
BA316
BA319
BA320
BA322
BA323
BA324
BA325
BA326
BA327
BA328
BA330
BA331
BA333
BA334
BA335
BA336
BA337
BA338
BA339
BA340
BA341
BA342
BA343
BA344
BA345
BA346
BA347
BA348
BA349
BA350
BA352
BA353
BA354
BA355
BA356
BA357
BA358
BA359
BA360
BA361
BA362
BA364
BA365
BA366
BA367
BA368
BA369
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
08-13-2015
60
TERAPIA FÍSICA
Códigos de Cubiertas/Copagos
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
CÓDIGO
COASEGURO
BA370
BA371
BA372
BA373
BA375
BA377
BA378
BA379
BA380
BA382
BA383
BA384
BA385
BA386
BA387
BA389
BA390
BA391
BA392
BA393
BA394
BA395
BA396
BA397
BA398
BA399
BA400
BA401
BA402
BA403
BA404
BA405
BA406
BA407
BA408
BA409
BA410
BA411
BA412
BA415
BA416
BA417
BA418
BA419
BA420
BA421
BA422
BA423
BA424
BA426
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
BA429
BA430
BA431
BA432
BA433
BA434
BA435
BA436
BA437
BA438
BA439
BA440
BA462
BA463
BA464
BA465
BA466
BA467
BA468
BA469
BA470
BA471
BA472
BA473
BA474
BA475
BA476
BA496
BA498
BA499
BA500
BA517
BA518
BA519
BA520
BA521
BA522
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$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$5.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
$7.00
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08-13-2015
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