BENEFICIO ADICIONAL DENTAL INTEGRAMEDICA PLUS 70 - IDPL ARANCEL INTEGRAMEDICA Página 1 de 13

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1 ACCIONES GENERALES 6,001,001 EXAMEN CLINICO INICIAL Y PLAN ,001,002 INTERCONSULTA CON INFORME ESCRITO 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 6,001,004 INFORMES PERICIALES (EJ. EVALUACION PARA INGRESO A FUERZAS ARMADAS) 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,001,009 CONSULTA CON INDICACIONES Y PRESCRIPCION 17,480 20,658 19,864 15,891 18,275 16,686 5,244 6,197 5,959 4,767 5,483 5,006 ACCIONES DE PREVENCION, INTERCEPCION E HIGIENE 6,002,001 HIGIENE O PROFILAXIS EN ADULTOS 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 6,002,002 HIGIENE O PROFILAXIS EN NIÑOS 17,480 20,658 19,864 15,891 18,275 16,686 5,244 6,197 5,959 4,767 5,483 5,006 6,002,003 INSTRUCCION Y CONTROL HIGIENE ORAL ADULTOS 17,480 20,658 19,864 15,891 18,275 16,686 5,244 6,197 5,959 4,767 5,483 5,006 6,002,004 INSTRUCCION Y CONTROL HIGIENE ORAL NIÑOS 17,480 20,658 19,864 15,891 18,275 16,686 5,244 6,197 5,959 4,767 5,483 5,006 6,002,005 APLICACION FLUOR GEL TOTAL ADULTOS 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 6,002,006 APLICACION FLUOR GEL TOTAL NIÑOS 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 6,002,007 APLICACION FLUOR TOTAL SILANO 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,002,008 APLICACION SELLANTE FOTOCURADO PIEZA DEFINITIVA 26,220 30,987 29,796 23,837 27,412 25,028 7,866 9,296 8,939 7,151 8,224 7,508 6,002,009 APLICACION SELLANTE FOTOCURADO PIEZA TEMPORAL 17,480 20,658 19,864 15,891 18,275 16,686 5,244 6,197 5,959 4,767 5,483 5,006 6,002,010 MANTENEDOR ESPACIO FIJO UNILATERAL 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,002,011 MANTENEDOR ESPACIO UNI-BILATERAL REMOVIBLE 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 RADIOLOGIA BUCAL 6,301,001 INFORME INTERPETACION RADIOGRAFICA 2,622 3,099 2,980 2,384 2,741 2, ,301,002 RADIOGRAFIA RETROALVEOLAR (CADA PLACA) 9,614 11,362 10,925 8,740 10,051 9,177 2,884 3,409 3,278 2,622 3,015 2,753 6,301,003 RADIOGRAFIA RETROALVEOLAR TOTAL 90, , ,696 82,156 94,480 86,264 27,112 32,041 30,809 24,647 28,344 25,879 6,301,004 RADIOGRAFIA ALETA MORDIDA (CADA PLACA) 9,614 11,362 10,925 8,740 10,051 9,177 2,884 3,409 3,278 2,622 3,015 2,753 6,301,005 RADIOGRAFIA OCLUSAL 19,228 22,724 21,850 17,480 20,102 18,354 5,768 6,817 6,555 5,244 6,031 5,506 RADIOLOGIA MAXILOFACIAL 6,302,010 TRAZADO CEFALOMETRICO 33,212 39,251 37,741 30,193 34,722 31,703 9,964 11,775 11,322 9,058 10,417 9,511 6,302,011 TELERADIOGRAFIA LATERAL 30,765 36,359 34,960 27,968 32,163 29,367 9,230 10,908 10,488 8,390 9,649 8,810 6,302,012 TELERADIOGRAFIA FRONTAL 30,765 36,359 34,960 27,968 32,163 29,367 9,230 10,908 10,488 8,390 9,649 8,810 6,302,013 TOMOGRAFIA CONVENCIONAL MAXILA 152, , , , , ,164 45,623 53,918 51,845 41,476 47,697 43,549 6,302,014 RADIOGRAFIA PANORAMICA 61,530 72,717 69,920 55,936 64,327 58,733 18,459 21,815 20,976 16,781 19,298 17,620 6,302,015 TRAZADO CEFALOMETRICO LATERAL RICKETTS 33,212 39,251 37,741 30,193 34,722 31,703 9,964 11,775 11,322 9,058 10,417 9,511 6,302,016 TRAZADO CEFALOMETRICO LATERAL JARABAK 33,212 39,251 37,741 30,193 34,722 31,703 9,964 11,775 11,322 9,058 10,417 9,511 6,302,017 TRAZADO CEFALOMETRICO LATERAL ROTH 33,212 39,251 37,741 30,193 34,722 31,703 9,964 11,775 11,322 9,058 10,417 9,511 6,302,018 TRAZADO CEFALOMETRICO LATERAL SASSOUNI P 33,212 39,251 37,741 30,193 34,722 31,703 9,964 11,775 11,322 9,058 10,417 9,511 6,302,019 TRAZADO CEFALOMETRICO LATERAL STEINER 33,212 39,251 37,741 30,193 34,722 31,703 9,964 11,775 11,322 9,058 10,417 9,511 6,302,020 TRAZADO CEFALOMETRICO FRONTAL RICKETTS 33,212 39,251 37,741 30,193 34,722 31,703 9,964 11,775 11,322 9,058 10,417 9,511 OPERATORIA 6,003,001 RECEMENTACION INCRUSTACIONES C/S AJUSTE OPERATORIO 43,700 51,646 49,659 39,728 45,687 41,714 13,110 15,494 14,898 11,918 13,706 12,514 6,003,002 RECUBRIMIENTO PULPAR DIRECTO + CURACION 26,220 30,987 29,796 23,837 27,412 25,028 7,866 9,296 8,939 7,151 8,224 7,508 6,003,003 TRATAMIENTO TOPICO SENSIBILIDAD DE CUELLOS (CADA UNO) 8,740 10,329 9,932 7,946 9,137 8,343 2,622 3,099 2,980 2,384 2,741 2,503 6,003,004 BLANQUEAMIENTO POR PIEZA 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 6,003,005 OBTURACION AMALGAMA SIMPLE 26,220 30,987 29,796 23,837 27,412 25,028 7,866 9,296 8,939 7,151 8,224 7,508 6,003,006 OBTURACION AMALGAMA COMPUESTA 43,700 51,646 49,659 39,728 45,687 41,714 13,110 15,494 14,898 11,918 13,706 12,514 6,003,007 OBTURACION AMALGAMA COMPLEJA 73,416 86,765 83,428 66,742 76,754 70,079 22,025 26,030 25,028 20,023 23,026 21,024 6,003,011 RESTAURACION FOTOCURADO SIMPLE ANTERIOR 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,003,012 MUÑON FOTOCURADO CON PERNO AL CONDUCTO 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,003,013 RESTAURACION CERVICAL FOTOCURADO C/S CAVIDAD 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 6,003,014 RESTAURACION FOTOCURADO ANTERIOR CON ANGULO 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 6,003,015 RESTAURACION FOTOCURADO SIMPLE POSTERIOR 61,180 72,304 69,523 55,619 63,961 58,399 18,354 21,691 20,857 16,686 19,188 17,520 Página 1 de 13

2 6,003,016 RESTAURACION FOTOCURADO COMPUESTA POSTERIOR 78,660 92,962 89,387 71,510 82,236 75,085 23,598 27,889 26,816 21,453 24,671 22,526 6,003,017 RECONSTRUCCION PARCIAL DE CORONAS 78,660 92,962 89,387 71,510 82,236 75,085 23,598 27,889 26,816 21,453 24,671 22,526 6,003,018 INCRUSTACION COMPUESTA / ONLAY ISOSIT 122, , , , , ,799 36,708 43,382 41,714 33,371 38,377 35,040 6,003,019 CARILLA RESINA DIRECTA 104, , ,183 95, , ,113 31,464 37,185 35,755 28,604 32,894 30,034 6,003,020 CARILLA CERAMICA 157, , , , , ,170 47,196 55,778 53,632 42,906 49,342 45,051 6,003,021 BLANQUEAMIENTO TOTAL 529, , , , , , , , , , , ,672 6,003,024 OBTURACION CEMENTO VIDRIO IONOMERO ADULTO 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 PROTESIS FIJA 6,004,001 RECEMENTACION CORONA C/S AJUSTE OPERATORIO 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,004,002 CORONA TEMPORAL ACRILICO 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,004,003 CORONA METALICA COMPLETA 227, , , , , ,912 68,172 80,567 77,469 61,975 71,271 65,074 6,004,005 CORONA DE PORCELANA PURA 244, , , , , ,598 73,416 86,765 83,428 66,742 76,754 70,079 6,004,006 CORONA DE PORCELANA SOBRE METAL 227, , , , , ,912 68,172 80,567 77,469 61,975 71,271 65,074 6,004,007 CORONA INSERCION PROTESIS FIJA 262, , , , , ,283 78,661 92,963 89,387 71,510 82,236 75,085 6,004,008 INCRUSTACION METALICA COMO INSERCION 139, , , , , ,484 41,952 49,580 47,673 38,138 43,859 40,045 6,004,009 INTERMEDIARIO EN PROTESIS FIJA 174, , , , , ,856 52,440 61,975 59,591 47,673 54,824 50,057 6,004,010 ARTIFICIOS COMO ANCLAJES DE PRECISION 43,700 51,646 49,659 39,728 45,687 41,714 13,110 15,494 14,898 11,918 13,706 12,514 6,004,011 INSERCION PARA PUENTE MARYLAN 122, , , , , ,799 36,708 43,382 41,714 33,371 38,377 35,040 6,004,012 INTERMEDIARIO PARA PUENTE MARYLAN 104, , ,183 95, , ,113 31,464 37,185 35,755 28,604 32,894 30,034 6,004,013 RECEMENTACION PUENTE C/S AJUSTE OPERATORIO 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 6,004,014 ESPIGA MUÑON SIMPLE O BIPARTITO (METALICO O RESINA) 104, , ,183 95, , ,113 31,464 37,185 35,755 28,604 32,894 30,034 6,004,015 MUÑON CON PERNO O PINES DE RETENCION (METALICO O RESINA) 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,004,016 CONTROL DE LA ESPECIALIDAD PROTESIS FIJA 17,480 20,658 19,864 15,891 18,275 16,686 5,244 6,197 5,959 4,767 5,483 5,006 6,004,023 CORONA INDIVIDUAL PROCERA - IN 349, , , , , , , , ,183 95, , ,113 6,004,024 INSERCION PROTESIS FIJA PROCER 393, , , , , , , , , , , ,628 6,004,025 INTERMEDIARIO PROTESIS FIJA PR 262, , , , , ,283 78,661 92,963 89,387 71,510 82,236 75,085 PROTESIS REMOVIBLE 6,005,001 PROTESIS TOTAL SUPERIOR ACRILICA 262, , , , , ,283 78,661 92,963 89,387 71,510 82,236 75,085 6,005,002 PROTESIS TOTAL INFERIOR ACRILICA 305, , , , , ,997 91, , ,285 83,428 95,942 87,599 6,005,003 JUEGO DE PROTESIS TOTALES SUPERIOR E INFERIOR 611, , , , , , , , , , , ,198 6,005,004 PROTESIS PARCIAL SUPERIOR O INFERIOR BASE ACRILICA 262, , , , , ,283 78,661 92,963 89,387 71,510 82,236 75,085 6,005,005 PROTESIS PARCIAL SUPERIOR O INFERIOR BASE METALICA 279, , , , , ,969 83,905 99,160 95,346 76,277 87,718 80,091 6,005,006 PROTESIS SUPERIOR O INFERIOR UNILATERAL 279, , , , , ,969 83,905 99,160 95,346 76,277 87,718 80,091 6,005,007 PROTESIS INMEDIATAS 279, , , , , ,969 83,905 99,160 95,346 76,277 87,718 80,091 6,005,008 REBASADO TOTAL 61,180 72,304 69,523 55,619 63,961 58,399 18,354 21,691 20,857 16,686 19,188 17,520 6,005,009 REPARACION DE PROTESIS 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,005,010 ARTIFICIOS COMPLEMENTARIOS DE ANCLAJE 43,700 51,646 49,659 39,728 45,687 41,714 13,110 15,494 14,898 11,918 13,706 12,514 6,005,011 CONTROLES DE LA ESPECIALIDAD PROTESIS REMOVIBLE 17,480 20,658 19,864 15,891 18,275 16,686 5,244 6,197 5,959 4,767 5,483 5,006 6,005,012 PUENTE ACRILICO 2-3 PIEZAS 131, , , , , ,142 39,330 46,481 44,693 35,755 41,118 37,543 ENDODONCIA 6,006,001 TREPANACION DE URGENCIA 43,700 51,646 49,659 39,728 45,687 41,714 13,110 15,494 14,898 11,918 13,706 12,514 6,006,002 PULPOTOMIA EN PIEZA PERMANENTE 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,006,003 INDUCCION AL CIERRE APICAL 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,006,004 VACIAMIENTO DE ABSCESOS 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,006,005 ENDODONCIA INCISIVOS Y CANINOS SANOS 139, , , , , ,484 41,952 49,580 47,673 38,138 43,859 40,045 6,006,006 ENDODONCIA PREMOLARES SANOS 157, , , , , ,170 47,196 55,778 53,632 42,906 49,342 45,051 6,006,007 ENDODONCIA MOLARES SANOS 227, , , , , ,912 68,172 80,567 77,469 61,975 71,271 65,074 6,006,008 DESOBTURACION PARCIAL DE CONDUCTOS 26,220 30,987 29,796 23,837 27,412 25,028 7,866 9,296 8,939 7,151 8,224 7,508 Página 2 de 13

3 6,006,009 ENDODONCIA EN DIENTES ANTERIORES CON LESION APICAL 148, , , , , ,827 44,574 52,679 50,653 40,522 46,601 42,548 6,006,010 ENDODONCIA PREMOLARES CON LESION APICAL 174, , , , , ,856 52,440 61,975 59,591 47,673 54,824 50,057 6,006,011 ENDODONCIA MOLARES CON LESION APICAL 262, , , , , ,283 78,661 92,963 89,387 71,510 82,236 75,085 6,006,012 BLANQUEAMIENTO DIENTE DEVITALIZADO 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,006,013 GINGIVECTOMIA UNITARIA PARA ENDODONCIA 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 6,006,014 RETIRAR ESPIGA METALICA DEL CONDUCTO 78,660 92,962 89,387 71,510 82,236 75,085 23,598 27,889 26,816 21,453 24,671 22,526 6,006,015 FERULIZACION POR GRUPO 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,006,016 TREPANACION DE INCRUSTACIONES Y FERULAS 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 6,006,017 DESOBTURACION PARA REPETIR TRATAMIENTO 26,220 30,987 29,796 23,837 27,412 25,028 7,866 9,296 8,939 7,151 8,224 7,508 6,006,018 CONTROL DE LA ESPECIALIDAD ENDODONCIA 17,480 20,658 19,864 15,891 18,275 16,686 5,244 6,197 5,959 4,767 5,483 5,006 6,006,019 INSTRUMENTACION MECANIZADA 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,006,020 SESION DE RECAMBIO DE PASTAS ALCALINAS 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,006,021 SELLADO DE PERFORACIONES Y FALSAS VIAS 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 6,006,022 RETIRO DE INSTRUMENTO FRACTURADO 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 6,006,023 SELLADO CERVICAL 26,220 30,987 29,796 23,837 27,412 25,028 7,866 9,296 8,939 7,151 8,224 7,508 6,006,024 ENDODONCIA ANTERIOR (INCISIVOS Y CANNOS) 210, , , , , ,061 63,191 74,680 71,807 57,446 66,063 60,318 6,006,025 ENDODONCIA PREMOLARES 234, , , , , ,586 70,270 83,046 79,852 63,882 73,464 67,076 6,006,026 ENDODONCIA MOLARES 316, , , , , ,008 94, , ,860 86,288 99,231 90,602 6,006,027 REOBTURACION ENDODONCIA ANTERIOR 236, , , , , ,089 71,057 83,976 80,746 64,597 74,287 67,827 6,006,028 REOBTURACION ENDODONCIA PREMOLAR 286, , , , , ,643 86, ,639 97,730 78,184 89,911 82,093 6,006,029 REOBTURACION ENDODONCIA MOLAR 395, , , , , , , , , , , ,128 PERIODONCIA 6,007,001 TRATAMIENTO DE URGENCIA GUNA POR SESION 78,660 92,962 89,387 71,510 82,236 75,085 23,598 27,889 26,816 21,453 24,671 22,526 6,007,002 DESTARTRAJE SUPRAGINGIVAL Y LIMPIEZA CORONARIA POR SEXTANTE 26,220 30,987 29,796 23,837 27,412 25,028 7,866 9,296 8,939 7,151 8,224 7,508 6,007,003 DESTARTRAJE SUBGINGIVAL POR SEXTANTE 26,220 30,987 29,796 23,837 27,412 25,028 7,866 9,296 8,939 7,151 8,224 7,508 6,007,004 TRATAMIENTO DE ABSCESO PERIODONTAL 43,700 51,646 49,659 39,728 45,687 41,714 13,110 15,494 14,898 11,918 13,706 12,514 6,007,005 CONTROL DE LA ESPECIALIDAD PERIODONCIA 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 6,007,006 PULIDO RADICULAR PERIODONTITIS INCIPIENTE 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,007,007 PULIDO RADICULAR PERIODONTITIS MODERADA 104, , ,183 95, , ,113 31,464 37,185 35,755 28,604 32,894 30,034 6,007,008 PULIDO RADICULAR PERIODONTITIS AVANZADA 122, , , , , ,799 36,708 43,382 41,714 33,371 38,377 35,040 6,007,011 EXAMEN PERIODONTAL Y CONFECCION DE PERIODONTOGRAMA 61,180 72,304 69,523 55,619 63,961 58,399 18,354 21,691 20,857 16,686 19,188 17,520 6,007,012 ENSEOANZA Y ADIESTRAM. EN TECNICAS DE HIGIENE ORAL POR SESION 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 6,007,013 TRATAMIENTO QUIMICO DEL SACO PERIODONTAL POR SEXTANTE 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 6,007,014 FERULIZACIONES TEMPORALES POR GRUPO 104, , ,183 95, , ,113 31,464 37,185 35,755 28,604 32,894 30,034 6,007,015 TRATAMIENTO INFECCION PERIMPLANTARIA 113, , , , , ,456 34,086 40,284 38,734 30,988 35,636 32,537 6,007,016 GINGIVECTOMIA EN PACIENTES SIN COMPROMISO GENERAL POR GRUPO 122, , , , , ,799 36,708 43,382 41,714 33,371 38,377 35,040 6,007,017 GINGIVECTOMIA EN PACIENTES CON ENFERMEDAD GENERAL POR GRUPO 183, , , , , ,198 55,062 65,074 62,571 50,057 57,565 52,559 6,007,019 DISECCION QUIRURGICA DE INJERTO EN ZONA DONANTE 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,007,020 INJERTO GINGIVAL POR ZONA A INJERTAR 157, , , , , ,170 47,196 55,778 53,632 42,906 49,342 45,051 6,007,021 INJERTO OSEO (NO INCLUYE COLGAJO) 174, , , , , ,856 52,440 61,975 59,591 47,673 54,824 50,057 6,007,022 COLGAJO PERIODONTAL DE ACCESO POR SITIO QUIRURGICO 122, , , , , ,799 36,708 43,382 41,714 33,371 38,377 35,040 6,007,023 COLGAJO REPOSICIONADO POR GRUPO 139, , , , , ,484 41,952 49,580 47,673 38,138 43,859 40,045 6,007,024 COLGAJO PARA PRESERVACION DE PAPILA 139, , , , , ,484 41,952 49,580 47,673 38,138 43,859 40,045 6,007,025 TUNELIZACION EN COMPROMISO DE BIFURCACION 104, , ,183 95, , ,113 31,464 37,185 35,755 28,604 32,894 30,034 6,007,026 INJERTOS ALOPLASTICOS (NO INCLUYE MATERIAL NI COLGAJOS) 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,007,027 CIRUGIA PERIMPLANTARIA DE MANEJO DE TEJIDOS BLANDOS POR SITIO 157, , , , , ,170 47,196 55,778 53,632 42,906 49,342 45,051 6,007,028 REGENERACION TISULAR GUIADA POR SITIO 174, , , , , ,856 52,440 61,975 59,591 47,673 54,824 50,057 6,007,029 FRENECTOMIA 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 Página 3 de 13

4 6,007,030 INJERTO DE TEJIDO CONECTIVO POR ZONA 148, , , , , ,827 44,574 52,679 50,653 40,522 46,601 42,548 6,007,031 CIRUGIA OSEA RECECTIVA POR GRUPO 139, , , , , ,484 41,952 49,580 47,673 38,138 43,859 40,045 6,007,032 COBERTURA ACRILICA POST OPERATORIA 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,007,033 ESTUDIO PRELIMINAR CLINICO, RX Y MODELOS 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 6,007,034 EXAMEN DE PATOLOGIA DISFUNCIONAL 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 6,007,035 PLACA DE ALIVIO OCLUSAL (NO INCLUYE LABORATORIO) 131, , , , , ,142 39,330 46,481 44,693 35,755 41,118 37,543 6,007,036 DESGASTE SELECTIVO POR SESION 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,007,037 RADECTOMIA U ODONTOSECCION 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 6,007,039 TRATAMIENTO COMPLICACIONES POST QUIRURGICAS POR SESION 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,007,041 TERAPIA MANTENCION DE IMPLANTE POR SESION 96, , ,251 87, ,511 91,771 28,842 34,086 32,775 26,220 30,153 27,531 6,007,042 TERAPIA MANTENCION PERIODONTAL 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,007,043 TRATAMIENTO DE HIPERSENSIBILIDAD DENTINARIA, POS TERAPIA, POR SESION 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 6,007,044 CIRUGIA DE ANCHO BIOLOGICO 262, , , , , ,283 78,661 92,963 89,387 71,510 82,236 75,085 ODONTOPEDIATRIA 6,008,001 OBTURACION AMALGAMA SIMPLE 40,379 47,721 45,885 36,708 42,214 38,544 12,114 14,316 13,766 11,012 12,664 11,563 6,008,002 OBTURACION AMALGAMA COMPUESTA 50,517 59,702 57,406 45,925 52,814 48,221 15,155 17,911 17,222 13,778 15,844 14,466 6,008,003 RESTAURACION FOTOCURADO SIMPLE 50,517 59,702 57,406 45,925 52,814 48,221 15,155 17,911 17,222 13,778 15,844 14,466 6,008,004 RESTAURACION FOTOCURADO COMPUESTA 60,656 71,684 68,927 55,142 63,413 57,899 18,197 21,505 20,678 16,543 19,024 17,370 6,008,005 CORONA METALICA PREFORMADA EN PIEZA TEMPORAL 101, , ,812 91, ,627 96,442 30,311 35,822 34,444 27,555 31,688 28,933 6,008,006 PULPOTOMIA EN PIEZA TEMPORAL 40,379 47,721 45,885 36,708 42,214 38,544 12,114 14,316 13,766 11,012 12,664 11,563 6,008,007 PULPECTOMIA EN PIEZA TEMPORAL 60,656 71,684 68,927 55,142 63,413 57,899 18,197 21,505 20,678 16,543 19,024 17,370 6,008,008 HIGIENE Y PROFILAXIS EN NIÑOS 40,379 47,721 45,885 36,708 42,214 38,544 12,114 14,316 13,766 11,012 12,664 11,563 6,008,009 DESGASTE DE INTERFERENCIAS CUSPIDEAS 50,517 59,702 57,406 45,925 52,814 48,221 15,155 17,911 17,222 13,778 15,844 14,466 6,008,010 EXODONCIA PIEZA TEMPORAL 50,517 59,702 57,406 45,925 52,814 48,221 15,155 17,911 17,222 13,778 15,844 14,466 6,008,011 TRATAMIENTO MANEJO NIÑO DIFICIL POR SESION 30,415 35,945 34,563 27,650 31,798 29,033 9,125 10,784 10,369 8,295 9,539 8,710 6,008,012 CONTROL DE LA ESPECIALIDAD ODONTOPEDIATRIA 30,415 35,945 34,563 27,650 31,798 29,033 9,125 10,784 10,369 8,295 9,539 8,710 6,008,013 EDUCACION HIGIENE ORAL POR SESION 30,415 35,945 34,563 27,650 31,798 29,033 9,125 10,784 10,369 8,295 9,539 8,710 6,008,014 FLUORACION TOPICA CON GEL 40,379 47,721 45,885 36,708 42,214 38,544 12,114 14,316 13,766 11,012 12,664 11,563 6,008,015 FLUORACION TOPICA CON BARNIZ RESINA 101, , ,812 91, ,627 96,442 30,311 35,822 34,444 27,555 31,688 28,933 6,008,016 SELLANTE POR PIEZA DENTARIA 30,415 35,945 34,563 27,650 31,798 29,033 9,125 10,784 10,369 8,295 9,539 8,710 6,008,017 OBTURACION DE CEMENTO INTERMEDIO 30,415 35,945 34,563 27,650 31,798 29,033 9,125 10,784 10,369 8,295 9,539 8,710 6,008,018 OBTURACION CEMENTO VIDRIO IONOMERO 50,517 59,702 57,406 45,925 52,814 48,221 15,155 17,911 17,222 13,778 15,844 14,466 6,008,019 INMOVILIZACION EN TRAUMATISMO DENTOALVEOLAR 101, , ,812 91, ,627 96,442 30,311 35,822 34,444 27,555 31,688 28,933 6,008,020 TRATAMIENTO DE CONDUCTO EN PIEZA TEMPORAL ANTERIOR 60,656 71,684 68,927 55,142 63,413 57,899 18,197 21,505 20,678 16,543 19,024 17,370 6,008,021 TRATAMIENTO DE CONDUCTO EN PIEZA TEMPORAL POSTERIOR 80,758 95,441 91,771 73,416 84,429 77,087 24,227 28,632 27,531 22,025 25,329 23,126 6,008,022 PULPOTOMIA EN PIEZA PERMANENTE 70,794 83,666 80,448 64,359 74,012 67,576 21,238 25,100 24,134 19,308 22,204 20,273 6,008,023 RECUBRIMIENTO PULPAR INDIRECTO PIEZA PERMANENTE 50,517 59,702 57,406 45,925 52,814 48,221 15,155 17,911 17,222 13,778 15,844 14,466 6,008,024 CORONA DE RESINA CON ANCLAJE 60,656 71,684 68,927 55,142 63,413 57,899 18,197 21,505 20,678 16,543 19,024 17,370 6,008,025 MANTENEDOR DE ESPACIO FIJO/REMOV. (NO INCLUYE LABORATORIO) 80,758 95,441 91,771 73,416 84,429 77,087 24,227 28,632 27,531 22,025 25,329 23,126 6,008,026 ATENCION CON PREMEDICACION POR SESION 60,656 71,684 68,927 55,142 63,413 57,899 18,197 21,505 20,678 16,543 19,024 17,370 6,008,027 REMINERALIZACION POR SESION 40,379 47,721 45,885 36,708 42,214 38,544 12,114 14,316 13,766 11,012 12,664 11,563 6,008,028 INACTIVACION DE CARIES 40,379 47,721 45,885 36,708 42,214 38,544 12,114 14,316 13,766 11,012 12,664 11,563 6,008,029 OBTURACION PREVENTIVA(OBT.+SELLANTE) 60,656 71,684 68,927 55,142 63,413 57,899 18,197 21,505 20,678 16,543 19,024 17,370 6,008,030 APLICACION TOPICA BARNIZ DE CLORHEXIDINA 80,758 95,441 91,771 73,416 84,429 77,087 24,227 28,632 27,531 22,025 25,329 23,126 PATOLOGIA BUCO MAXILO FACIAL 6,009,001 CONSULTA DE LA ESPECIALIDAD PATOLOGIA B.M.F. 50,692 59,909 57,605 46,084 52,996 48,388 15,208 17,973 17,282 13,825 15,899 14,516 6,009,002 TOMA DE BIOPSIA TEJIDOS BLANDOS 125, , , , , ,136 37,757 44,622 42,906 34,325 39,473 36,041 6,009,003 CITOLOGIA EXFOLIATIVA 26,220 30,987 29,796 23,837 27,412 25,028 7,866 9,296 8,939 7,151 8,224 7,508 Página 4 de 13

5 6,009,004 TOMA DE MUESTRA EXAMENES MICROBIOLOGICOS 26,220 30,987 29,796 23,837 27,412 25,028 7,866 9,296 8,939 7,151 8,224 7,508 6,009,005 TEST DE AZUL DE TOLUIDINA 26,220 30,987 29,796 23,837 27,412 25,028 7,866 9,296 8,939 7,151 8,224 7,508 6,009,006 INFORME DE ANATOMO PATOLOGO 192, , , , , ,541 57,684 68,172 65,550 52,440 60,306 55,062 CIRUGIA MAXILO FACIAL 6,010,001 CONTROL DE LA ESPECIALIDAD CIRUGIA 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 6,010,002 INTERCONSULTA DE LA ESPECIALIDAD CIRUGIA 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 6,010,003 EXODONCIA SIMPLE 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,010,004 EXODONCIA SEMI INCLUIDA 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,010,005 EXODONCIA A COLGAJO 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 6,010,006 EXODONCIA DE PIEZAS INCLUIDAS 139, , , , , ,484 41,952 49,580 47,673 38,138 43,859 40,045 6,010,007 TRATAMIENTO DE ALVEOLORRAGIA, ALVEOLITIS U OTROS 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,010,008 ALVEOLOPLASTIA POR HEMIARCADA 174, , , , , ,856 52,440 61,975 59,591 47,673 54,824 50,057 6,010,009 APICECTOMIA (NO INCLUYE VALOR ENDODONCIA) 139, , , , , ,484 41,952 49,580 47,673 38,138 43,859 40,045 6,010,010 APICECTOMIA Y OBTURACION A RETRO 174, , , , , ,856 52,440 61,975 59,591 47,673 54,824 50,057 6,010,011 EXERESIS DE QUISTES Y/O GRANULOMAS 244, , , , , ,598 73,416 86,765 83,428 66,742 76,754 70,079 6,010,012 FENESTRACIONES DENTARIAS 139, , , , , ,484 41,952 49,580 47,673 38,138 43,859 40,045 6,010,013 TRATAMIENTO DE COMUNICACION BUCO SINUSAL 349, , , , , , , , ,183 95, , ,113 6,010,014 BIOPSIA DE MUCOSA 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 6,010,015 BIOPSIA DE PIEL 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,010,016 BIOPSIA DE HUESO 139, , , , , ,484 41,952 49,580 47,673 38,138 43,859 40,045 6,010,017 EXERESIS GRANDES QUISTES PERIAPICALES 437, , , , , , , , , , , ,142 6,010,018 EXERESIS QUISTES Y TUMORES ODONTOGENICOS 1,5 CM. O MENOS 786, , , , , , , , , , , ,255 6,010,019 EXERESIS QUISTES Y TUMORES ODONTOGENICOS MAYORES 1,5 CM. 1,048,806 1,239,498 1,191, ,460 1,096,479 1,001, , , , , , ,340 6,010,021 EXERESIS DE RANULAS CON SUBLINGUECTOMIA 524, , , , , , , , , , , ,170 6,010,022 EXERESIS DE MUCOCELE 174, , , , , ,856 52,440 61,975 59,591 47,673 54,824 50,057 6,010,023 EXERESIS DE CALCULOS SALIVALES 314, , , , , ,340 94, , ,264 85,811 98,683 90,102 6,010,024 EXERESIS DE GLANDULA SUBMAXILAR 1,048,806 1,239,498 1,191, ,460 1,096,479 1,001, , , , , , ,340 6,010,025 ABSCESOS MUCOSOS DENTO ALVEOLAR 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,010,026 ABSCESOS CUTANEOS 104, , ,183 95, , ,113 31,464 37,185 35,755 28,604 32,894 30,034 6,010,027 FLEGMONES O ADENOFLEGMONES 244, , , , , ,598 73,416 86,765 83,428 66,742 76,754 70,079 6,010,028 FLEGMON O ADENOFLEGMON CON GRAN COMPROMISO DEL ESTADO GENERAL 524, , , , , , , , , , , ,170 6,010,029 TRATAMIENTO DE HERIDAS CUTANEAS FACIALES 279, , , , , ,969 83,905 99,160 95,346 76,277 87,718 80,091 6,010,030 TRATAMIENTO DE HERIDAS INTRABUCALES 139, , , , , ,484 41,952 49,580 47,673 38,138 43,859 40,045 6,010,031 REDUCCION LUXACION DENTARIA CONTENSION SIMPLE 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,010,032 TRATAMIENTO FRACTURA DENTOALVEOLAR CADA SEGMENTO 174, , , , , ,856 52,440 61,975 59,591 47,673 54,824 50,057 6,010,033 TRATAMIENTO ORTOPEDICO FRACTURA MAXILAR O MADIBULA 524, , , , , , , , , , , ,170 6,010,034 TRATAMIENTO QUIRURGICO FRACTURA MAXILAR O MANDIBULA 699, , , , , , , , , , , ,227 6,010,035 TRATAMIENTO QUIRURGICO FRACTURA CIGOMATO MALAR 349, , , , , , , , ,183 95, , ,113 6,010,036 TRATAMIENTO QUIRURGICO FRACTURA FACIAL COMPLEJA 1,048,806 1,239,498 1,191, ,460 1,096,479 1,001, , , , , , ,340 6,010,037 TRATAMIENTO QUIRURGICO FRACTURA MACIZO FACIAL ABORDAJES MULTIPLES 874,005 1,032, , , , , , , , , , ,283 6,010,038 RESECCION O PLASTIA FRENILLOS 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,010,039 VESTIBULO PLASTIA SIMPLE 174, , , , , ,856 52,440 61,975 59,591 47,673 54,824 50,057 6,010,040 VESTIBULO PLASTIA COMPLEJA 454, , , , , , , , , , , ,147 6,010,041 RECONSTRUCCION REBORDES CON AUTO U HOMO INJERTO 349, , , , , , , , ,183 95, , ,113 6,010,042 REMODELACION QUIRURGICA REBORDES - PALADAR 349, , , , , , , , ,183 95, , ,113 6,010,043 GLOSOPLASTIA 349, , , , , , , , ,183 95, , ,113 6,010,044 MENTOPLASTIA 524, , , , , , , , , , , ,170 6,010,045 OSTEOTOMIA SEGMENTARIA MAXILAR O MANDIBULA 524, , , , , , , , , , , ,170 Página 5 de 13

6 6,010,046 OSTEOTOMIA MANDIBULAR EN CUERPO 874,005 1,032, , , , , , , , , , ,283 6,010,047 OSTEOTOMIA MANDIBULAR EN RAMA 1,223,607 1,446,081 1,390,463 1,112,370 1,279,226 1,167, , , , , , ,397 6,010,048 OSTEOTOMIA TOTAL DE MAXILA TIPO LE FORT 1 1,485,809 1,755,956 1,688,419 1,350,735 1,553,345 1,418, , , , , , ,482 6,010,049 CIRUGIA ORTOGNATICA COMBINADA 2,097,612 2,478,996 2,383,650 1,906,920 2,192,958 2,002, , , , , , ,680 6,010,050 TRATAMIENTO QUIRURGICO FISTULA SALIVAL 349, , , , , , , , ,183 95, , ,113 6,010,051 TRATAMIENTO DE FISTULA BUCO SINUSAL 349, , , , , , , , ,183 95, , ,113 6,010,052 TRATAMIENTO QUIRURGICO DE FISURO VELOPALATINA 524, , , , , , , , , , , ,170 6,010,053 SECUESTRECTOMIA 209, , , , , ,227 62,928 74,370 71,510 57,208 65,789 60,068 6,010,054 ARTROTOMIA EXPLORATORIA 174, , , , , ,856 52,440 61,975 59,591 47,673 54,824 50,057 6,010,055 ARTROSCOPIA 349, , , , , , , , ,183 95, , ,113 6,010,056 CIRUGIA A.T.M. 874,005 1,032, , , , , , , , , , ,283 6,010,057 TRATAMIENTO NEURALGIA - NEUROTOMIA 174, , , , , ,856 52,440 61,975 59,591 47,673 54,824 50,057 6,010,058 EXODONCIA POR INTERCONSULTA DE ORTODONCIA 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 DISFUNCION ATM 6,021,001 CONSULTA DE LA ESPECIALIDAD DISFUNCION 43,700 51,646 49,659 39,728 45,687 41,714 13,110 15,494 14,898 11,918 13,706 12,514 6,021,002 ESTUDIO DE EXAMENES COMPLEMENTARIOS 43,700 51,646 49,659 39,728 45,687 41,714 13,110 15,494 14,898 11,918 13,706 12,514 6,021,003 MONTAJE EN ARTICULADOS 73,416 86,765 83,428 66,742 76,754 70,079 22,025 26,030 25,028 20,023 23,026 21,024 6,021,004 BLOQUEO ANESTESICO 43,700 51,646 49,659 39,728 45,687 41,714 13,110 15,494 14,898 11,918 13,706 12,514 6,021,005 PROGRAMA TERAPEUTICO NEUROMUSCULAR 437, , , , , , , , , , , ,142 6,021,006 PROGRAMA TERAPEUTICO NEUROMUSCULAR CRONICO 1,311,008 1,549,373 1,489,781 1,191,825 1,370,599 1,251, , , , , , ,425 6,021,007 PROGRAMA TERAPEUTICO ARTICULAR 874,005 1,032, , , , , , , , , , ,283 6,021,008 PROGRAMA TERAPEUTICO ARTICULAR CRONICO 1,748,010 2,065,830 1,986,375 1,589,100 1,827,465 1,668, , , , , , ,567 6,021,009 PLANO DE ALIVIO 110, , , , , ,119 33,038 39,044 37,543 30,034 34,539 31,536 6,021,010 DEPROGRAMADOR JIG 192, , , , , ,541 57,684 68,172 65,550 52,440 60,306 55,062 6,021,011 APLICACION DE ELECTRO FISICA 61,180 72,304 69,523 55,619 63,961 58,399 18,354 21,691 20,857 16,686 19,188 17,520 6,021,012 TECNICA DE MOVILIZACION MANDIBULAR ASISTIDA 61,180 72,304 69,523 55,619 63,961 58,399 18,354 21,691 20,857 16,686 19,188 17,520 6,021,013 TERAPIA BIOCONDUCTUAL 61,180 72,304 69,523 55,619 63,961 58,399 18,354 21,691 20,857 16,686 19,188 17,520 ORTODONCIA 6,101,001 ESTUDIO INICIAL Y PLAN DE TRATAMIENTO 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,101,002 TRATAMIENTO CON APARATO FIJO PRIMER AÑO (VALOR MENSUAL) 107, , ,361 97, , ,783 32,303 38,177 36,708 29,367 33,772 30,835 6,101,003 TRATAMIENTO CON APARATO FIJO SEGUNDO AÑO (VALOR MENSUAL) 94, , ,662 86,129 99,049 90,436 28,423 33,590 32,299 25,839 29,715 27,131 6,101,004 TRATAMIENTO CON APARATO FIJO QUIRURGICO PRIMER AÑO (VALOR MENSUAL) 140, , , , , ,651 42,005 49,642 47,733 38,186 43,914 40,095 6,101,005 TRATAMIENTO CON APARATO FIJO QUIRURGICO SEGUNDO AÑO (VALOR MENSUAL) 123, , , , , ,633 36,971 43,692 42,012 33,610 38,651 35,290 6,101,006 TRATAMIENTO DE CONTENCION (VALOR MENSUAL) 36,359 42,969 41,317 33,053 38,011 34,706 10,908 12,891 12,395 9,916 11,403 10,412 6,101,007 TRATAMIENTO CON APARATO REMOVIBLE (VALOR MENSUAL) 58,209 68,792 66,146 52,917 60,855 55,563 17,463 20,638 19,844 15,875 18,257 16,669 6,101,008 TRATAMIENTO APARATO FIJO TECNICA LINGUAL (VALOR MENSUAL) 101, , ,806 92, ,541 97,277 30,573 36,131 34,742 27,794 31,962 29,183 6,101,009 APARATO FIJO STANDARD (COSTO POR CADA ARCO) 262, , , , , ,283 78,661 92,963 89,387 71,510 82,236 75,085 6,101,010 APARATO FIJO TECNICA ARCO RECTO (COSTO POR CADA ARCO) 349, , , , , , , , ,183 95, , ,113 6,101,011 APARATO FIJO TECNICA ARCO LINGUAL (COSTO POR CADA ARCO) 699, , , , , , , , , , , ,227 6,101,012 PRE ESTUDIO CON MODELOS PARA CIRUGIA ORTOGNATICA 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,101,013 APARATO REMOVIBLE (COSTO POR CADA ARCO) 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,101,014 MENTONERA O CASQUETE FUERZA EXTRA ORAL 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,101,015 ESTUDIO CEFALOMETRICO 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 6,101,016 MONTAJE MODELOS EN ARTICULADOR 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,101,017 CONFECCION Y AJUSTE DE PLANO DEPROGRAMADOR 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 6,101,018 PREDICCION QUIRURGICA CIRUGIA ORTOGNATICA 174, , , , , ,856 52,440 61,975 59,591 47,673 54,824 50,057 6,101,019 FUERZA EXTRAORAL 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,101,020 MASCARA DE DELAIRE 349, , , , , , , , ,183 95, , ,113 Página 6 de 13

7 6,101,021 ARCO TRANSPALATINO O LINGUAL 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,101,022 CONTENCION RIGIDA LINGUAL O PALATINA 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,101,023 HIGIENIZACION 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,101,024 REPOSICION DE BRAQUETS SIN MODIFICACION 17,480 20,658 19,864 15,891 18,275 16,686 5,244 6,197 5,959 4,767 5,483 5,006 6,101,025 RETIRO APARATOS FIJOS 78,660 92,962 89,387 71,510 82,236 75,085 23,598 27,889 26,816 21,453 24,671 22,526 6,101,026 IMPRESION 5,244 6,197 5,959 4,767 5,482 5,006 1,573 1,859 1,788 1,430 1,645 1,502 6,101,027 APARATO FIJO CERAMICO, TECNICA ARCO RECTO 524, , , , , , , , , , , ,170 6,101,028 MOVER PIEZA EN MORDIDA INVERTIDA A NORMAL 34,960 41,317 39,728 31,782 36,549 33,371 10,488 12,395 11,918 9,535 10,965 10,011 6,101,029 ESTUDIO FOTOGRAFICO ORTODONCIC 76,912 90,897 87,401 69,920 80,408 73,416 23,074 27,269 26,220 20,976 24,122 22,025 6,101,030 DISYUNTOR CEMENTADO 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 IMPLANTOLOGIA ESTUDIO 6,201,001 EVALUACION PREQUIRURGICA PARA 41,952 49,580 47,673 38,138 43,859 40,045 12,586 14,874 14,302 11,441 13,158 12,014 6,201,002 GUIA QUIRURGICA (por maxilar) 41,952 49,580 47,673 38,138 43,859 40,045 12,586 14,874 14,302 11,441 13,158 12,014 6,201,003 EXTRACCION SIMPLE PARA IMPLANTE (solo especialista implantologia) 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 6,201,004 EXTRACCION COMPLEJA PARA IMPLANTE (solo especialista implantologia) 122, , , , , ,799 36,708 43,382 41,714 33,371 38,377 35,040 6,201,005 INSTALACION QUIRURGICA DE IMPLANTE 386, , , , , , , , , , , ,625 6,201,006 INSTALACION IMPLANTE INMEDIATO (incluye extracción) 496, , , , , , , , , , , ,161 6,201,007 INSTALACION IMPLANTE PROVISIONAL 92, , ,682 83,746 96,307 87,933 27,636 32,661 31,405 25,124 28,892 26,380 6,201,008 REGENERACION OSEA GUIADA 195, , , , , ,878 58,733 69,412 66,742 53,394 61,403 56,063 6,201,009 INJERTO OSEO (no incluye material de injerto) 258, , , , , ,946 77,612 91,723 88,195 70,556 81,140 74,084 6,201,010 INJERTO SUB ANTRAL ( no incluye material de relleno) 597, , , , , , , , , , , ,194 6,201,011 INJERTO TEJIDO BLANDO 433, , , , , , , , , , , ,141 6,201,012 REMOCION IMPLANTE FIBRO INTEGRADO (paciente externo) 76,912 90,897 87,401 69,920 80,408 73,416 23,074 27,269 26,220 20,976 24,122 22,025 6,201,013 REMOCION IMPLANTE OSEO INTEGRADO (paciente externo) 258, , , , , ,946 77,612 91,723 88,195 70,556 81,140 74,084 6,201,014 CONEXION (paciente Integramedica) 59,432 70,238 67,537 54,029 62,134 56,731 17,830 21,071 20,261 16,209 18,640 17,019 6,201,015 CONEXION (paciente externo) 104, , ,183 95, , ,113 31,464 37,185 35,755 28,604 32,894 30,034 6,201,016 AYUDANTIA QUIRURGICA PROFESIONAL (POR IMPLANTE) 87, ,292 99,319 79,455 91,373 83,428 26,220 30,988 29,796 23,837 27,412 25,028 ETAPA DE REHABILITACION ESTUDIO 6,201,017 EVALUACION REHABILITACION SOBRE IMPLANTE(PACIENTE EXTERNO) 52,440 61,975 59,591 47,673 54,824 50,057 15,732 18,593 17,877 14,302 16,447 15,017 6,201,018 ENCERADO DIAGNOSTICO (por maxilar) 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 REHABILITACION PROTESIS FIJA SOBRE IMPLANTE 6,201,019 PROVISORIO SOBRE IMPLANTE 157, , , , , ,170 47,196 55,778 53,632 42,906 49,342 45,051 6,201,020 CORONA CEMENTADA SOBRE IMPLANTE 436, , , , , , , , , , , ,941 6,201,021 PROTESIS FIJA ATORNILLADA DIRECTA 436, , , , , , , , , , , ,941 6,201,022 PROTESIS FIJA ATORNILLADA (4 a 6 implantes) 1,223,607 1,446,081 1,390,463 1,112,370 1,279,226 1,167, , , , , , ,397 6,201,023 INTERMEDIARIO SOBRE IMPLANTE 307, , , , , ,666 92, , ,881 83,905 96,490 88,100 6,201,024 CANTILEVER 307, , , , , ,666 92, , ,881 83,905 96,490 88,100 6,201,025 CONTROL PROTESIS FIJA 83,904 99,160 95,346 76,277 87,718 80,091 25,171 29,748 28,604 22,883 26,315 24,027 REHABILITACION PROTESIS REMOVIBLE SOBRE IMPLANTE 6,201,026 BARRA PARA PROTESIS ( 2 IMPLANTES) 615, , , , , , , , , , , ,199 6,201,027 BARRA PARA PROTESIS ( 4 IMPLANTES) 783, , , , , , , , , , , ,254 6,201,028 PROTESIS REMOVIBLE SOBRE BARRA U O-RING ( 2 ) 503, , , , , , , , , , , ,163 6,201,029 PROTESIS REMOVIBLE SOBRE BARRA ( 4 ) 587, , , , , , , , , , , ,190 6,201,030 RECAMBIO O-RING O CLIP PARA BARRA 97, , ,237 88, ,338 93,439 29,367 34,706 33,371 26,697 30,701 28,032 6,201,031 AJUSTE Y RETOQUE DE PROTESIS 69,920 82,633 79,455 63,564 73,099 66,742 20,976 24,790 23,837 19,069 21,930 20,023 6,201,032 ACONDICIONADOR DE TEJIDO 125, , , , , ,136 37,757 44,622 42,906 34,325 39,473 36,041 Página 7 de 13

8 6,201,033 DESMONTAJE DE PROTESIS Y PROFILAXIS 153, , , , , ,833 46,148 54,538 52,440 41,952 48,245 44,050 6,201,034 CAMBIO DE TORNILLOS PROTESICOS (cada uno) 76,912 90,897 87,401 69,920 80,408 73,416 23,074 27,269 26,220 20,976 24,122 22,025 6,201,035 CONTROL PROTESIS REMOVIBLE 83,904 99,160 95,346 76,277 87,718 80,091 25,171 29,748 28,604 22,883 26,315 24,027 DERECHOS DE PABELLON DENTALES 6,401,001 PABELLON IMPLANTE 166, , , , , ,513 49,818 58,876 56,612 45,290 52,083 47,554 6,401,002 PABELLON SEDACION 262, , , , , ,283 78,661 92,963 89,387 71,510 82,236 75,085 6,401,003 PABELLON CIRUGIA BUCAL 104, , ,183 95, , ,113 31,464 37,185 35,755 28,604 32,894 30,034 LABORATORIO DENTAL LABORATORIO PRIMERA ETAPA QUIRURGICA 2,701,001 SERVICIO COSTO LABORATORIO GUIA QUIRURG 47,196 55,777 53,632 42,906 49,342 45,051 14,159 16,733 16,090 12,872 14,803 13,515 2,701,002 SERVICIO COSTO LABORATORIO ENCERADO DIA 98, , ,429 89, ,435 94,440 29,681 35,078 33,729 26,983 31,031 28,332 LABORATORIO PROTESIS FIJA SOBRE IMPLANTE 2,702,001 SERVICIO LABORATORIO PROVISORIO SOBRE IMPLANTE 34,611 40,903 39,330 31,464 36,184 33,037 10,383 12,271 11,799 9,439 10,855 9,911 2,702,002 SERVICIO LABORATORIO CORONA CEMENTADA SOBRE IMPLANTE 140, , , , , ,818 42,057 49,704 47,792 38,234 43,969 40,145 2,702,003 SERVICIO LABORATORIO PROTESIS FIJA ATORNILLADA DIRECTA 192, , , , , ,042 57,842 68,358 65,729 52,583 60,471 55,213 2,702,004 SERVICIO LABORATORIO PROTESIS FIJA ATORNILLADA (4 a 6 implantes) 667, , , , , , , , , , , ,166 2,702,005 SERVICIO LABORATORIO INTERMEDIARIO SOBREIMPLANTE 140, , , , , ,818 42,057 49,704 47,792 38,234 43,969 40,145 2,702,006 SERVICIO LABORATORIO CANTILEVER 140, , , , , ,818 42,057 49,704 47,792 38,234 43,969 40,145 2,702,007 SERVICIO MUÑON SOBRE IMPLANTE METAL NO PRECIOSO 94, , ,867 85,494 98,318 89,768 28,213 33,343 32,060 25,648 29,495 26,930 2,702,008 SERVICIO MUÑON SOBRE IMPLANTE METAL AG-PD 158, , , , , ,004 47,459 56,087 53,930 43,144 49,616 45,301 2,702,009 SERVICIO TALLAR MUÑON TITANIO 49,469 58,463 56,214 44,972 51,717 47,220 14,841 17,539 16,864 13,492 15,515 14,166 2,702,010 SERVICIO ORO CERAMICO PARA IMPLANTES 98, , ,429 89, ,435 94,440 29,681 35,078 33,729 26,983 31,031 28,332 2,702,011 SERVICIO CORONA O PILAR SIN TORNILLO : 179, , , , , ,527 53,909 63,710 61,260 49,008 56,359 51,458 2,702,012 SERVICIO CORONA O PILAR CON TORNILLO : 265, , , , , ,120 79,552 94,016 90,400 72,320 83,168 75,936 2,702,013 SERVICIO INTERMEDIARIO : 104, , ,189 94, ,734 99,279 31,202 36,875 35,457 28,365 32,620 29,784 LABORATORIO REHABILITACION SOBRE IMPLANTE 2,702,014 SERVICIO PROTESIS AD-MODUM BRANEMARK 795, , , , , , , , , , , ,758 2,702,015 SERVICIO BARRA TIPO DOLDER 340, , , , , , , , ,203 92, ,907 97,610 2,702,016 SERVICIO GUIA QUIRURUGICA 76,738 90,690 87,202 69,761 80,226 73,250 23,021 27,207 26,161 20,928 24,068 21,975 2,702,017 SERVICIO PROTESIS TOTAL NEOPRONT 795, , , , , , , , , , , ,758 2,702,018 SERVICIO ENFILADO ESTETICO 170, , , , , ,684 51,129 60,425 58,102 46,481 53,453 48,805 2,702,019 SERVICIO PROTESIS AD-MPDUM NEODENT 804, , , , , , , , , , , ,461 2,702,020 SERVICIO GUIA MULTIFUNCIONAL 52,091 61,562 59,194 47,355 54,458 49,723 15,627 18,469 17,758 14,207 16,337 14,917 2,702,021 SERVICIO CORONA SOBRE IMPLANTE 151, , , , , ,664 45,466 53,732 51,666 41,333 47,532 43,399 2,702,022 SERVICIO INTERMEDIARIO SOBRE IMPLANTE 151, , , , , ,664 45,466 53,732 51,666 41,333 47,532 43,399 2,702,023 SERVICIO MUÑON SOBRE IMPLANTE 66,250 78,295 75,284 60,227 69,261 63,238 19,875 23,489 22,585 18,068 20,778 18,971 2,702,024 SERVICIO PROVISORIO SOBRE IMPLANTE 19,403 22,931 22,049 17,639 20,285 18,521 5,821 6,879 6,615 5,292 6,086 5,556 2,702,025 SERVICIO ENCERADO DIAGNOSTICO (POR PIEZA) 7,167 8,470 8,144 6,515 7,493 6,841 2,150 2,541 2,443 1,955 2,248 2,052 2,702,026 SERVICIO PROTESIS REMOV SOBRE IMPLANTE 194, , , , , ,210 58,209 68,792 66,146 52,917 60,855 55,563 LABORATORIO REHABILITACION SOBRE IMPLANTES ZAHNEN 2,702,027 CORONA ATORNILLADA EN TITANIO (zahnen) 258, , , , , ,779 77,559 91,661 88,136 70,508 81,085 74,034 2,702,028 CORONA CEMENTADA EN TITANIO (zahnen) 237, , , , , ,256 71,109 84,038 80,806 64,645 74,341 67,877 2,702,029 PUENTE EN TITANIO POR CORONA (zahnen) 237, , , , , ,256 71,109 84,038 80,806 64,645 74,341 67,877 2,702,030 INCRUSTACION EN TITANIO (zahnen) 107, , ,559 98, , ,950 32,356 38,239 36,768 29,414 33,827 30,885 2,702,031 PERNO MUÑON EN TITANIO (zahnen) 86, ,845 97,928 78,343 90,094 82,260 25,853 30,554 29,378 23,503 27,028 24,678 2,702,032 PERNO BIPARTITO TITANIO (zahnen) 118, , , , , ,128 35,555 42,019 40,403 32,322 37,171 33,938 2,702,033 PERNO PASANTE TITANIO (zahnen) 107, , ,559 98, , ,950 32,356 38,239 36,768 29,414 33,827 30,885 2,702,034 PROTESIS TIPO ADMODUM TERMINADA (zahnen) 1,938,543 2,291,005 2,202,890 1,762,312 2,026,659 1,850, , , , , , ,128 Página 8 de 13

9 2,702,035 TRAMO DE BARRA DOLDER EN TITANIO PREFORM. Y SO 301, , , , , ,993 90, , ,854 82,284 94,626 86,398 2,702,036 ALL IN ONE ( SOLO ESTRUCTURA TOTAL) (zahnen) 2,154,073 2,545,722 2,447,810 1,958,248 2,251,985 2,056, , , , , , ,848 2,702,037 CORONAS DE TITANIO SOBRE ALL IN ONE C/U (zahnen) 237, , , , , ,256 71,109 84,038 80,806 64,645 74,341 67,877 2,702,038 CORONAS DE ZIRCONIO SOBRE ALL IN ONE C/U (zahnen) 301, , , , , ,993 90, , ,854 82,284 94,626 86,398 2,702,039 CORONAS DE PROCERA SOBRE ALL IN ONE C/U (zahnen) 245, , , , , ,432 73,679 87,075 83,726 66,981 77,028 70,330 2,702,040 PREPARCION DE PILAR METALICO (zahnen) 25,871 30,574 29,398 23,519 27,046 24,695 7,761 9,172 8,819 7,056 8,114 7,409 2,702,041 GUIA MULTIFUNCIONAL (zahnen) 86, ,845 97,928 78,343 90,094 82,260 25,853 30,554 29,378 23,503 27,028 24,678 2,702,042 DUPLICADO DE PROTESIS TRANSPARENTE (zahnen) 86, ,845 97,928 78,343 90,094 82,260 25,853 30,554 29,378 23,503 27,028 24,678 2,702,043 PROTESIS PROVISIONAL SOBRE IMPLANTES (zahnen) 430, , , , , , , , , , , ,340 2,702,044 GUIA QUIRURGICA ESTAMPADA (zahnen) 43,176 51,026 49,063 39,251 45,138 41,213 12,953 15,308 14,719 11,775 13,541 12,364 2,702,045 GUIA QUIRURGICAS TERMOPOLIMERIZADO (zahnen) 77,612 91,723 88,195 70,556 81,139 74,084 23,284 27,517 26,459 21,167 24,342 22,225 2,702,046 TABLILLAS DE DIENTE IVOCLAR C/U (zahnen) 86, ,845 97,928 78,343 90,094 82,260 25,853 30,554 29,378 23,503 27,028 24,678 2,702,047 PROVISORIO SOBRE IMPLANTE (zahnen) 30,241 35,739 34,364 27,491 31,615 28,866 9,072 10,722 10,309 8,247 9,485 8,660 LABORATORIO PROTESIS REMOVIBLE SOBRE IMPLANTE 2,703,001 SERVICIO LABORATORIO PROTESIS REMOVIBLE SOBRE BARRA U O-RING ( 2 ) 461, , , , , , , , , , , ,250 2,703,002 SERVICIO LABORATORIO PROTESIS REMOVIBLE SOBRE BARRA ( 4 ) 659, , , , , , , , , , , ,914 LABORATORIO PROTESIS FIJA SINGULAR Y PLURAL 2,704,001 SERVICIO CORONA DE SUSTITUCION: 113, , , , , ,623 34,139 40,346 38,794 31,035 35,690 32,587 2,704,002 SERVICIO CORONA PERIFERICA: 113, , , , , ,623 34,139 40,346 38,794 31,035 35,690 32,587 2,704,003 SERVICIO CORONA PERIFERICA CON PERNO MUÑON COLADO: 143, , , , , ,822 43,001 50,819 48,865 39,092 44,956 41,047 2,704,004 SERVICIO CORONA PERIFERICA CON PERNO MUÑON PLATA-PALADIO: 168, , , , , ,515 50,448 59,620 57,327 45,861 52,741 48,155 2,704,005 SERVICIO PROVISORIO: 14,334 16,940 16,288 13,031 14,985 13,682 4,300 5,082 4,886 3,909 4,496 4,105 2,704,006 SERVICIO CERAMICA ALUMINOSA ANTERIOR O POSTERIOR 138, , , , , ,150 41,533 49,084 47,196 37,757 43,421 39,645 2,704,007 SERVICIO PILAR, INSERCION O PUNTO DE APOYO PERIFERICO O DE 113, , , , , ,623 34,139 40,346 38,794 31,035 35,690 32,587 2,704,008 SERVICIO PILAR, INSERCION O PUNTO DE APOYO CON PERNO MUÑON: 143, , , , , ,822 43,001 50,819 48,865 39,092 44,956 41,047 2,704,009 SERVICIO PILAR,INSERCION O PUNTO DE APOYO CON PERNO MUÑON PLATA-PALADIO: 187, , , , , ,370 56,373 66,623 64,061 51,248 58,936 53,811 2,704,010 SERVICIO PILAR, INSERCION O PUNTO DE APOYO CON INCRUSTACION: 66,774 78,915 75,880 60,704 69,809 63,739 20,032 23,675 22,764 18,211 20,943 19,122 2,704,011 SERVICIO PILAR,INSERCION O PUNTO DE APOYO CON INCRUSTACION PLATA-PALADIO: 91, , ,887 83,110 95,576 87,265 27,426 32,413 31,166 24,933 28,673 26,180 2,704,012 SERVICIO INTERMEDIARIO O PONTICO: 110, , , , , ,453 33,142 39,168 37,662 30,129 34,649 31,636 2,704,013 SERVICIO PROVISORIO ( POR PIEZA): 14,334 16,940 16,288 13,031 14,985 13,682 4,300 5,082 4,886 3,909 4,496 4,105 2,704,014 SERVICIO ORO MONEDA 59,432 70,238 67,537 54,029 62,134 56,731 17,830 21,071 20,261 16,209 18,640 17,019 2,704,015 SERVICIO CORONA IN CERAM 187, , , , , ,370 56,373 66,623 64,061 51,248 58,936 53,811 2,704,016 SERVICIO CORONA PROCERA 257, , , , , ,444 77,140 91,165 87,659 70,127 80,646 73,633 2,704,017 SERVICIO PUENTES DE ZIRCONA (POR PIEZA) 370, , , , , , , , , , , ,220 2,704,030 SERVICIO INTERMEDIARIO PARA PUENTE PROCERA 257, , , , , ,444 77,140 91,165 87,659 70,127 80,646 73,633 2,704,031 PERNO MUÑON METALICO 50,168 59,289 57,009 45,607 52,448 47,888 15,050 17,787 17,103 13,682 15,734 14,366 LABORATORIO EMPRESS 2,704,018 INLAY-ONLAY EMPRESS 192, , , , , ,042 57,842 68,358 65,729 52,583 60,471 55,213 2,704,019 CARILLA EMPRESS 192, , , , , ,042 57,842 68,358 65,729 52,583 60,471 55,213 LABORATORIO CEROMEROS 2,704,020 PERNO MUÑON DE FIBRA CEROMEROS 83,030 98,127 94,353 75,482 86,805 79,256 24,909 29,438 28,306 22,645 26,042 23,777 2,704,021 PTE MARYLAND EN CEROMEROS/METAL(CORONA+APOYO O INCRUSTACION) 198, , , , , ,715 59,625 70,466 67,755 54,204 62,335 56,915 2,704,022 PTE MARYLAND EN CEROMEROS/FIBRA(CORONA+APOYO O INCRUSTACION) 459, , , , , , , , , , , ,449 LABORATORIO VALPLAST 2,704,023 PROTESIS VALPLAST PARCIAL 271, , , , , ,627 81,597 96,433 92,724 74,179 85,306 77,888 2,704,024 PROTESIS VALPLAST TOTAL 321, , , , , ,847 96, , ,588 87, ,821 92,054 2,704,025 PROTESIS METALICA CON VALPLAST(RETENEDORES ESTETICOS) 395, , , , , , , , , , , ,278 2,704,026 PROTESIS VALPLAST UNILATERAL(HASTA 4 PZAS) 197, , , , , ,880 59,363 70,156 67,457 53,966 62,061 56,664 Página 9 de 13