Ministry of Health Price List for Ambulatory and Hospitalization Services

Onset date: 01/07/12Sorted by service code

Service code Service name

Price for Patient

from Abroad

(ILS)

01996 Day care management of epidural/subarachnoid continuous drug administration675.00

01999 General anesthesia for ambulatory treatment, under anesthesiologist supervision1,734.00

10060 Incision and drainage of abscess/cyst 552.0011100 Biopsy, excluding breast 266.0011750 Excision of ingrown nail 423.0011770 Excision of cyst, eg, pilonidal 843.0011975 Insertion, implantable contraceptive capsules (eg, Norplant), including the cost of

contraceptive 2,534.00

11976 Removal, implantable contraceptive capsules 236.0012001 Simple repair of superficial wounds 200.0016030 Dressings and/or debridement, without anesthesia, large lesion 512.0017000 Removal of skin lesions, any method 266.0017311 Mohs micrographic technique 12,054.0017999 Soft laser treatment, 1/2 level, per treatment 266.0019100 Biopsy of breast; needle core, not using imaging guidance 266.0019101 Biopsy of breast; open, incisional 632.0019102 Biopsy of breast, using imaging guidance, excluding CT/MRI 3,026.0019499 Breast examination 0.0020205 Biopsy, muscle, including histological examinations 1,503.0020206 Biopsy, muscle, including all tests, stains, EM 4,223.0020220 Biopsy, bone, trocar/needle, superficial 342.0020520 Foreign body removal, muscle/tendon, local anaesthesia 188.0020600 Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes)

342.00

20605 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) 342.00

20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) 342.00

20902 Harvesting of cortical bone, cartilage 5,565.0021310 Closed treatment of nasal bone fracture 342.0028899 Intra compartment pressure 774.0029035 Application, body cast, shoulder to hips 441.0029065 Application, cast; shoulder to hand (long arm) 266.0029075 Application, cast, elbow to finger (short arm) 188.0029085 Application, cast, hand and lower forearm (gauntlet) 188.0029345 Application, cast, long leg (thigh to toes) 266.0029405 Application, cast, short leg (below knee to toes) 188.0029700 Cast removal 158.0029720 Repair of spica, body cast or jacket 0.0029999 Arthroscopy, diagnostic and/or surgical procedures, without using implants 10,332.0030110 Excision, nasal polyp(s), simple 342.0030200 Injection into turbinate(s) 194.0030300 Foreign body removal, intranasal, superficial 0.0030801 Cautery and/or ablation, mucosa of turbinates, unilateral/bilateral, any method

342.00

31002 Sinuses lavage 194.0031575 Laryngoscopy, flexible fiberoptic, diagnostic 128.0031579 Laryngoscopy, fiberoptic, with stroboscopy 215.0031622 Bronchoscopy, diagnostic, with/without brushing/washing 1,968.0031636 Bronchoscopy, rigid or flexible, with placement of bronchial stent(s) 17,798.0032000 Thoracentesis, puncture of pleural cavity for aspiration 342.0036005 Injection of contrast material, including radiology/fluoroscopy 725.0036468 Injections of sclerosing solutions, spider veins (telangiectasia) 158.0036511 Therapeutic apheresis, for white blood cells 4,961.0036513 Therapeutic apheresis, for platelets 3,999.0036515 Therapeutic apheresis; with extracorporeal immunoadsorption and plasma reinfusion

13,067.00

Service code Service name

Price for Patient

from Abroad

(ILS)

36522 Photopheresis, extracorporeal 10,505.0036590 Removal of tunneled central venous access device, with subcutaneous port or pump,

central or peripheral insertion 488.00

36600 Arterial blood sampling and diagnosis 266.0038220 Bone marrow aspiration and smear 549.0038221 Bone marrow biopsy and smear 549.0038505 Biopsy or excision of lymph node(s); by needle, superficial 266.0040808 Biopsy, vestibule of mouth 243.0040840 Vestibuloplasty, anterior 1,119.0041010 Incision of lingual frenum (frenotomy) 819.0042699 Salivary glands endoscopy 10,637.0042700 Incision and drainage of peritonsillar abscess 342.0042809 Foreign body removal, pharynx, superficial 0.0043200 Esophagoscopy, diagnostic 401.0043204 Esophagoscopy, with injection sclerosis of esophageal varices 4,916.0043219 Esophageal dilation and insertion of stent 23,801.0043235 UGI endoscopy, with/without sampling 1,655.0043240 Endoscopic drainage of pseudocyst of pancreas, using EUS guidance 13,583.0043259 Upper gastrointestinal endoscopy; with endoscopic ultrasound examination 1,998.0043260 ERCP (Endoscopic retrograde cholangiopancreatography), diagnostic 5,333.0043264 ERCP (Endoscopic retrograde cholangiopancreatography), therapeutic 9,056.0043450 Esophageal dilation, without using imaging guidance 401.0043750 PEG (Percutaneous Endoscopic Gastrostomy) 3,258.0043760 Replacement of PEG (Percutaneous Endoscopic Gastrostomy) 1,793.0044360 Small intestinal endoscopy, enteroscopy, diagnostic, with/without collection of

specimen(s) 3,698.00

45300 Proctosigmoidoscopy, diagnostic 293.0045331 Sigmoidoscopy, flexible, with/without biopsy 953.0045378 Colonoscopy, flexible; diagnostic, with/without collection of specimen(s),

population at risk 1,491.00

45383 Colonoscopy, with excision of lesion 3,054.0045387 Colonoscopy, with dilation and stent placement 23,801.0045905 Dilation of anal sphincter 453.0046080 Sphincterotomy, anal, division of sphincter under general/regional anesthesia 2,876.0046500 Injection of sclerosing solution, hemorrhoids 158.0046600 Anoscopy, diagnostic 120.0047999 Extracorporeal shockwave lithotripsy, biliary tract, simple 8,792.0049321 Laparoscopy, surgical, with biopsy (single or multiple) 8,075.0050040 Nephrostomy, nephrotomy with drainage 3,804.0050398 Repositioning/change of nephrostomy or pyelostomy tube 2,270.0050590 Extracorporeal shockwave lithotripsy, kidney; simple 9,117.0051045 Insertion of urethral or ureteral stent 3,804.0051700 Bladder irrigation, simple, lavage and/or instillation 188.0051703 Insertion of urethral catheter 194.0051720 Bladder instillation of anticarcinogenic agent 486.0051726 Cystometrogram 725.0051736 Simple uroflowmetry (UFR) 342.0051741 Complex uroflowmetry 2,375.0051772 Urethral pressure profile studies (UPP) (urethral closure pressure profile) 725.0051784 EMG of anal/urethral sphincter, any technique 725.0052000 Cystourethroscopy 708.0052204 Cystourethroscopy, with biopsy/other surgical procedure 1,844.0053000 Urethrotomy or urethrostomy 708.0053850 Destruction of prostate tissue by thermotherapy 6,431.0054235 Injection of corpora cavernosa 129.0054250 Nocturnal penile tumescence and/or rigidity test 935.0055000 Puncture aspiration of hydrocele, with/without injection of medication 401.0055700 Biopsy, prostate; needle or punch, single or multiple, any approach 2,541.0055870 Electroejaculation 8,918.0057452 Colposcopy, vaginoscopy 182.0057510 Cautery of cervix, any method 188.0058120 Dilation and curettage, diagnostic and/or therapeutic, excluding induced abortion

3,791.00

58300 Insertion of intrauterine device (IUD) 401.0058301 Removal of intrauterine device (IUD) 188.0058321 Artificial insemination, intra-cervical 188.00

Service code Service name

Price for Patient

from Abroad

(ILS)

58322 Artificial insemination, intra-uterine 257.0058323 Sperm washing for artificial insemination 776.0058345 Fallopian tube dilation, catheterization, diagnostic/therapeutic 5,615.0058555 Hysteroscopy 708.0058558 Hysteroscopy, surgica, with biopsy/other surgical procedure 1,293.0058563 Uterine thermal therapy 8,292.0058974 Cryopreserved embryos transfer, intrauterine 5,666.0059000 Amniocentesis 350.0059012 Cordocentesis (intrauterine), any method 3,986.0059020 Fetal contraction stress test 1,020.0059025 Fetal NST (non stress test) 480.0059866 Multifetal pregnancy reduction(s) (MPR), including US guidance 3,791.0059871 Removal of cerclage suture 266.0062270 Spinal puncture, lumbar, diagnostic 965.0062272 Spinal puncture, therapeutic 965.0062310 Injection, epidural/subarachnoid; cervical/thoracic 675.0062311 Injection, epidural/subarachnoid; lumbar/sacral (caudal) 675.0062360 Spinal intrathecal pump for pain relief 97,422.0064400 Injection, anesthetic agent (eg, Lignocaine) 333.0064470 Paravertebral injection 194.0064550 Application of surface (transcutaneous) neurostimulator 342.0064612 Botolinum Toxin, 10 units Botox administration 366.0065205 Foreign body removal, external eye, superficial 0.0066984 Extracapsular cataract removal with insertion of intraocular lens prosthesis, any

methods, lens included 7,589.00

66999 Intracorneal rings for keratoconus treatment, Intacs 9,941.0067210 Retinal photocoagulation, PDT, without material 2,571.0067912 Implantation of upper eyelid gold weight 6,567.0068810 Probing of nasolacrimal duct, with/without irrigation 1,803.0068811 Probing of nasolacrimal duct, with/without irrigation; requiring general anesthesia

4,862.00

69000 Puncture/drainage external ear abscess/hematoma 342.0069200 Foreign body removal, ear, superficial 0.0069210 Removal impacted cerumen 194.0069420 Myringotomy including puncture/aspiration 342.0069436 Tympanostomy (requiring insertion of ventilating tube), general anesthesia 2,076.0070030 Eye radiology, foreign body detection 416.0070100 Mandible radiology, up to two views 347.0070120 Mastoids radiology, up to two views 188.0070170 Dacryocystography, radiological supervision and interpretation 257.0070200 Orbits radiology, up to two views 248.0070210 Paranasal sinuses radiology, up to two views 245.0070240 Sella turcica radiology 342.0070250 Skull radiology, up to two views 171.0070332 TMJ arthrography, including injection and interpretation 441.0070336 TMJ (temporomandibular joint(s)) MRI 3,078.0070360 Neck, soft tissue radiology, trachea 552.0070390 Salivary glands radiology, sialography 519.0070540 Orbit, face and neck, without contrast material 3,078.0070551 Brain/brain stem MRI, without contrast material 3,078.0071020 Chest radiology, up to two views 159.0071023 Chest radiology, up to two views, with fluoroscopy 486.0071100 Ribs radiology, up to two views 239.0071120 Sternum radiology, up to two views 257.0071550 Thorax MRI, without contrast material 2,976.0072010 Spine radiology, entire, up to two views 248.0072040 Cervical spine radiology, up to two views 171.0072070 Thoracic spine radiology, up to two views 171.0072080 Thoracolumbar spine radiology, up to two views 171.0072100 Lumbosacral spine radiology, up to two views 171.0072141 Cervical spine, MRI, per patient 3,078.0072146 Thoracic spine, MRI, per patient 3,078.0072148 Lumbar spine, MRI, per patient 3,078.0072170 Pelvis radiology, up to two views 192.0072200 SIJ radiology, up to two views 257.0072270 Myelography 1,971.00

Service code Service name

Price for Patient

from Abroad

(ILS)

73000 Clavicle radiology 204.0073010 Scapula radiology 204.0073030 Shoulder radiology, complete, one side, up to two views 188.0073040 Shoulder arthrography, including injection and interpretation 441.0073060 Humerus radiology, up to two views 171.0073070 Elbow radiology, up to two views 171.0073085 Elbow arthrography, including injection and interpretation 441.0073090 Forearm radiology, up to two views 171.0073092 Upper extremity radiology, infant, up to two views 171.0073100 Wrist radiology, up to two views 171.0073115 Wrist, arthrography, including injection and interpretation 441.0073120 Hand radiology, up to two views 171.0073140 Finger(s) radiology, up to two views 171.0073221 Upper extremity joints MRI, without contrast material, per patient 2,976.0073500 Hip radiology, unilateral, one view 171.0073520 Hip radiology, bilateral, including pelvis 171.0073525 Hip arthrography, including injection and interpretation 441.0073542 SIJ arthrography, including injection and interpretation 441.0073550 Femur radiology, up to two views 171.0073560 Knee radiology, up to two views, per side 171.0073562 Knee radiology, third or more additional views 188.0073580 Knee arthrography, including injection and interpretation 441.0073590 Tibia and fibula radiology, up to two views 171.0073592 Lower extremity radiology, infant, up to two views 171.0073610 Ankle radiology, complete, one side 171.0073615 Ankle arthrography, including injection and interpretation 441.0073620 Foot radiology, up to two views 171.0073721 Lower extremity joints MRI, without contrast material, per patient 2,976.0074000 Abdomen radiology, without contrast material 245.0074181 Abdomen, MRI, per patient 3,078.0074220 Esophagus radiology 609.0074230 Swallowing function, with cineradiography/videoradiography 971.0074241 UGI fluoroscopy and/or radiology, with/without delayed films 1,020.0074245 UGI fluoroscopy, including serial films 1,260.0074249 Abdomen radiology, small intestine follow-through 609.0074270 Barium enema 725.0074280 Air barium enema, with/without glucagon 1,164.0074290 Cholecystography, oral contrast 606.0074360 Esophageal dilation, using imaging guidance 8,102.0074400 IVP, with or without tomography 899.0074420 Urography, retrograde 737.0074450 Urethrocystography, retrograde, radiological supervision and interpretation 572.0074455 Urethrocystography, radiological supervision and interpretation 714.0074740 Hysterosalpingography, radiology 743.0075552 MRI cardiac morphology, per patient 8,204.0075554 Cardiac FMRI; with/without morphology, complete study, per patient 8,204.0075803 Lymphangiography, extremities 2,867.0075822 Phlebography, venography, including injection and imaging 965.0076000 Fluoroscopy 158.0076120 Cineradiography/videoradiography, video capsule 7,287.0076140 Interpretation/consultation on imaging made elsewhere 188.0076390 MRS,Magnetic resonance spectroscopy, per patient 8,204.0076512 Ophthalmic US (ultrasound) 239.0076514 Ophthalmic US, corneal pachymetry, determination of corneal thickness, per patient

132.00

76536 Head and neck soft tissues US, with image documentation 480.0076604 Chest US, including mediastinum, with image documentation 825.0076645 Breasts and chest wall US, with image documentation 335.0076700 Abdomen US, with image documentation 480.0076805 Fetal anatomic US, with image documentation 1,235.0076813 Fetal nuchal translucency US, per one fetus, with image documentation 506.0076814 Fetal nuchal translucency US, per each additional fetus, with image documentation

335.00

76815 Obstetric US, with image documentation 675.0076825 Echocardiography, fetal, with image documentation 1,412.0076827 Doppler echocardiography, fetal 1,748.00

Service code Service name

Price for Patient

from Abroad

(ILS)

76830 TVUS (Transvaginal Ultrasound) 395.0076831 Uterus and fallopian tube sonography, with contrast material 1,373.0076857 Gynecological US, follicles 251.0076870 Scrotum US, with image documentation 825.0076872 TRUS (transrectal ultrasound), with image documentation 1,197.0076942 Biopsy/surgical procedure, US guidance 3,803.0077002 Biopsy/surgical procedure, using fluoroscopic guidance 3,803.0077012 Biopsy/surgical procedure, using CT guidance 6,887.0077021 Biopsy/surgical procedure, using MRI guidance 10,332.0077031 Stereotactic localization guidance for breast biopsy/needle placement, including

biopsy, using imaging guidance (eg, mammography) 6,884.00

77032 Mammographic guidance for needle placement, breast (eg, for wire localization or for injection), each lesion, radiological supervision and interpretation 1,046.00

77054 Mammary ductogram/galactogram, including interpretation 1,353.0077056 Mammography; bilateral 338.0077059 MRI, breast, without and/or with contrast material(s); bilateral 3,078.0077073 Bone length studies (orthoroentgenogram, scanogram) 483.0077080 DXA, bone density study 300.0077261 Therapeutic radiology treatment planning, radiotherapy 788.0077280 Radiotherapy simulation 3,134.0077295 Radiology simulation-aided field setting, three-dimensional 3,921.0077401 Radiation treatment delivery, per field 688.0078000 Thyroid uptake, single determination 395.0078001 Thyroid uptake, multiple determinations 672.0078007 Thyroid imaging, with uptake, multiple determinations 1,344.0078010 Thyroid imaging 875.0078018 Thyroid imaging; I-131, whole body 4,055.0078070 Parathyroid imaging 2,021.0078104 Bone marrow imaging, whole body 3,782.0078122 Whole blood volume determination, radiopharmaceutical technique 2,510.0078130 Red cell survival study 4,281.0078191 Platelet survival study 1,359.0078195 Lymphatics and lymph nodes imaging 3,744.0078205 Liver and spleen imaging, SPECT 1,182.0078215 Liver and spleen imaging, static 1,046.0078216 Liver and spleen imaging, dynamic and static 1,112.0078223 Hepatobiliary imaging, with/without pharmacologic intervention, with/without

quantitative measurement of gallbladder function 3,083.00

78231 Salivary gland imaging, with serial images 1,286.0078258 Esophageal motility, dynamic 1,331.0078262 Gastroesophageal reflux study 1,004.0078264 Gastric emptying study 3,990.0078270 Vitamin B-12 absorption, without intrinsic factor 960.0078271 Vitamin B-12 absorption, with intrinsic factor 1,316.0078278 Acute GI bleeding imaging, dynamic and static 3,890.0078290 Intestine imaging (eg, Meckel's, ectopic gastric mucosa) 1,928.0078291 Peritoneal-venous shunt patency test (eg, for LeVeen, Denver shunt) 2,724.0078300 Bone and/or joint imaging, limited area 1,625.0078306 Bone and/or joint imaging, whole body 1,017.0078315 Bone and/or joint imaging, three phase 3,276.0078320 Bone and/or joint imaging, SPECT 1,146.0078399 Bone and/or joint imaging, whole body, 24 hours later 467.0078428 Cardiac shunt detection, dynamic 1,070.0078445 Vascular flow imaging, perfusion 1,398.0078458 Venous thrombosis imaging, bilateral 1,845.0078461 Myocardial perfusion imaging, at rest and/or stress, planar 4,484.0078465 Myocardial perfusion imaging, rest and/or stress, SPECT 5,083.0078466 Myocardial imaging, infarct, planar 3,338.0078468 Myocardial imaging, infarct, planar first pass, EF 3,959.0078469 Myocardial imaging, infarct, SPECT 4,592.0078472 Cardiac BP imaging, gated planar, rest/stress, EF 2,103.0078473 Cardiac BP imaging, gated, rest and stress, EF 4,982.0078478 Myocardial perfusion imaging, with wall motion 6,213.0078480 Myocardial perfusion study with EF 6,495.0078481 Cardiac BP imaging, gated planar, rest/stress, first pass, EF 2,075.00

Service code Service name

Price for Patient

from Abroad

(ILS)

78499 Cardiac BP (pool imaging)imaging, static 1,007.0078580 Pulmonary imaging, perfusion 1,200.0078585 Pulmonary imaging, ventilation and perfusion, Xenon 2,807.0078587 Pulmonary imaging, ventilation, aerosol 2,312.0078594 Pulmonary imaging, ventilation, xenon 2,408.0078596 Pulmonary imaging, ventilation and perfusion, quantitative differential function

3,549.00

78605 Brain imaging, static 1,673.0078606 Brain imaging, dynamic and static 2,252.0078607 Brain imaging, SPECT 4,307.0078610 Brain imaging, dynamic 1,557.0078630 CSF (Cerebrospinal fluid) imaging, cisternography 6,462.0078645 CSF flow imaging, shunt evaluation 1,328.0078650 CSF leakage detection and localization 3,834.0078660 Radiopharmaceutical dacryocystography 1,616.0078699 Brain tumor imaging, SPECT 3,885.0078700 Kidney imaging, static 1,985.0078701 Kidney imaging, dynamic, GFR 2,252.0078707 Kidney imaging, dynamic, without pharmacological intervention 1,530.0078708 Kidney imaging, dynamic, with pharmacological intervention 1,826.0078710 Kidney imaging, SPECT 1,962.0078740 Ureteral reflux imaging (cystogram) 1,716.0078761 Testicular imaging, dynamic and static 996.0078802 Tumor imaging, planar 6,087.0078803 Tumor imaging, SPECT 5,306.0078805 Inflammatory process imaging, limited area 5,948.0078806 Inflammatory process imaging, whole body 7,311.0078807 Inflammatory process imaging, SPECT 5,306.0078813 PET-FDG imaging 6,060.0078999 Tumor imaging, monoclonal antibodies, SPECT 11,217.0079101 Radiopharmaceutical therapy, polycythemia vera 2,832.0079403 Radiopharmaceutical therapy, intravenous administration, Zevalin, 90Y-

Ibritumomab tiuxetan 2,408.00

79440 Radiopharmaceutical therapy, by intra-articular administration 7,775.0080053 Chemistry panel 83.0080061 Lipids panel - blood: Cholesterol, TG, HDL, LDL 66.0080076 Hepatic function panel 92.0080100 Drug, qualitative - urine 180.0080101 Drug, qualitative 266.0080162 Digoxin 128.0080178 Lithium 194.0080195 Sirolimus 438.0080299 Drug, quantitative 266.0080400 ACTH stimulation, including blood hormones levels 677.0080420 Dexamethasone suppression test, 48 hour, include: free cortisol, urine cortisol,

volume measurement 201.00

81000 Urinalysis, with microscopy 57.0081002 Urinalysis stick, manual - urine, panel billing code 26.0082010 Acetone, quantitative 120.0082013 Acetylcholinesterase - amniotic fluid 743.0082017 Acylcarnitine, quantitative - blood/urine 900.0082030 Cyclic AMP - blood and urine 1,064.0082040 Albumin - serum 23.0082042 Albumin, quantitative - urine/other source, excluding serum 23.0082043 Microalbumin - urine / 24 hours 128.0082085 Aldolase 266.0082088 Aldosterone 347.0082103 Alpha 1 antitrypsin, total 401.0082105 Alpha-fetoprotein - serum 48.0082128 Amino acids, qualitative 165.0082131 Amino acids, quantitative 474.0082135 Aminolevulinic acid (ALA), quantitative - urine 458.0082140 Ammonia 260.0082150 Amylase 47.0082154 Androstenedione/androstenediol glucoronide 285.0082160 Androsterone 572.00

Service code Service name

Price for Patient

from Abroad

(ILS)

82172 Apolipoprotein B1/A1 194.0082180 Vitamin C, ascorbic acid - blood 188.0082205 Barbiturates, qualitative - urine 266.0082232 Beta 2 microglobulin 399.0082239 Bile acids degradation test 402.0082247 Bilirubin, total 23.0082248 Bilirubin, direct 23.0082261 Biotinidase 378.0082270 Occult blood - feces 120.0082306 Calcifediol (25-OH Vitamin D-3) 167.0082307 Calciferol (Vitamin D) 167.0082308 Calcitonin 347.0082310 Calcium, total, excluding urine 23.0082340 Calcium - urine 45.0082360 Calculus, quantitative and qualitative analysis 1,410.0082374 Carbon dioxide (bicarbonate) 158.0082378 CEA (Carcinoembryonic Ag), including dilution 48.0082380 Carotene 188.0082382 Catecholamines, total 825.0082390 Ceruloplasmin 266.0082435 Chloride - blood 45.0082436 Chloride - urine 45.0082438 Chloride - other source, excluding blood/urine 45.0082465 Cholesterol, total - blood 23.0082480 Cholinesterase - serum 120.0082486 Chromatography, qualitative 194.0082492 Chromatography, quantitative, any method 194.0082525 Copper 105.0082533 Cortisol, total 57.0082540 Creatine 120.0082550 CK (Creatine Kinase, CPK), total 23.0082552 CK (Creatine Kinase, CPK) isoenzymes 381.0082565 Creatinine - blood 27.0082570 Creatinine - other fluids, excluding blood 57.0082575 Creatinine clearance test 81.0082585 Cryofibrinogen 389.0082595 Cryoglobulin, qualitative or semi-quantitative (eg, cryocrit) 194.0082607 Vitamin B-12, cyanocobalamin 215.0082608 Vitamin B-12, cyanocobalamin, binding capacity 77.0082626 Dehydroepiandrosterone (DHEA) 92.0082627 Dehydroepiandrosterone-sulfate (DHEA-S) 92.0082652 Vitamin D (Calciferol) 1,25-Dihydroxy 677.0082657 Enzyme activity in blood cells, cultured cells, or tissue, each 266.0082670 Estradiol 92.0082672 Estrogens, total, all derivatives 572.0082677 Estriol 401.0082679 Estrone 389.0082705 Fat, qualitative - feces 188.0082710 Fat, quantitative - feces 606.0082726 Very long chain fatty acids 1,287.0082728 Ferritin 44.0082731 Fetal fibronectin 627.0082746 Folic acid - serum 192.0082757 Fructose - seminal fluid 401.0082759 Galactokinase 1,128.0082760 Galactose 389.0082775 Galactose 1 phosphate uridyl transferase, quantitative 606.0082787 Gammaglobulin, immunoglobulin subclasses 954.0082800 Gases, pH only - blood 194.0082803 Gases - blood 243.0082941 Gastrin 347.0082945 Glucose - other fluids, excluding blood 120.0082947 Glucose, quantitative - blood 23.0082951 Glucose tolerance test (GTT) 266.0082955 Glucose-6-phosphate dehydrogenase (G6PD), quantitative 572.0082960 Glucose-6-phosphate dehydrogenase (G6PD), screen 389.00

Service code Service name

Price for Patient

from Abroad

(ILS)

82977 Gamma glutamyltransferase (GGT) 44.0082985 Fructosamine/glycated protein 572.0083001 Gonadotropin, FSH (Follicle stimulating hormone) 44.0083002 Gonadotropin, LH (Luteinizing hormone) 89.0083003 GH (Growth hormone), somatotropin 92.0083010 Haptoglobin, quantitative 441.0083013 Rapid urease test, helicobacter pylori - exhaled air 66.0083015 Heavy metal (arsenic, barium, beryllium, bismuth, antimony, mercury, thallium),

screen 266.00

83020 Hemoglobin, electrophoresis 161.0083036 Hemoglobin; glycosylated (A1C) 59.0083045 Hemoglobin, methemoglobin, qualitative 572.0083069 Hemoglobin - urine 333.0083070 Hemosiderin, qualitative - urine 342.0083071 Hemosiderin, quantitative - urine 342.0083090 Homocysteine 357.0083491 Hydroxycorticosteroids, 17- (17-OHCS) 440.0083497 Hydroxyindolacetic acid, 5-(HIAA) 209.0083525 Insulin, total 92.0083540 Iron 57.0083550 Iron binding capacity 266.0083586 Ketosteroids , total 389.0083593 Ketosteroids, 17- (17-KS), fractionation 2,153.0083605 Lactate (lactic acid) 138.0083615 Lactate dehydrogenase (LD), (LDH) 23.0083625 Lactate dehydrogenase (LD), (LDH), isoenzymes, total 572.0083655 Lead 128.0083661 Fetal lung maturity assessment, Lecithin/Sphingomyelin ratio - amniotic fluid

725.00

83690 Lipase 47.0083700 Lipoprotein, electrophoresis - blood 38.0083718 Lipoprotein, HDL cholesterol 45.0083719 Lipoprotein, VLDL cholesterol 45.0083735 Magnesium 23.0083825 Mercury, quantitative 266.0083866 Mucopolysaccharides, screen - urine, per patient 416.0083872 Mucin/other material - synovial fluid, including biochemistry, cytology and culture

416.00

83874 Myoglobin 359.0083896 Molecular diagnosis of hematologic malignancies 1,833.0083898 RT-PCR, molecular diagnostics 4,455.0083918 Organic acids, quantitative - urine 842.0083930 Osmolality - blood 120.0083935 Osmolality - urine 120.0083945 Oxalate, qualitative/quantitative - urine 480.0083970 Parathormone (parathyroid hormone) 329.0084060 Acid phosphatase, total 120.0084061 Acid phosphatase stain 266.0084066 Acid phosphatase, prostatic 188.0084075 Alkaline phosphatase 23.0084080 Alkaline phosphatase isoenzymes 572.0084100 Phosphorus - blood 23.0084105 Phosphorus - urine 23.0084110 Porphobilinogen, quantitative, collection - urine 336.0084119 Porphobilinogen, quantitative - urine 188.0084127 Porphyrins, qualitative - feces 299.0084132 Potassium - blood 23.0084135 Pregnanediol 389.0084138 Pregnanetriol 572.0084144 Progesterone 92.0084146 Prolactin 134.0084153 PSA (Prostate specific Ag), total 57.0084154 PSA (Prostate specific Ag), free 120.0084155 Protein, total - serum 23.0084156 Protein, total - urine 23.0084165 Protein electrophoretic 128.00

Service code Service name

Price for Patient

from Abroad

(ILS)

84207 Vitamin B-6 (pyridoxal phosphate) 407.0084210 Phenylpyruvic acid - urine 57.0084233 Receptor assay, estrogene 894.0084244 Renin 347.0084260 Serotonin 209.0084295 Sodium - blood 23.0084375 Sugars chromatography 194.0084376 Sugars (mono-, di-, and oligosaccharides), qualitative - body fluids 416.0084402 Testosterone, free 188.0084403 Testosterone, total 92.0084432 Thyroglobulin 494.0084436 Thyroxine, total 51.0084443 Thyroid stimulating hormone (TSH) 51.0084446 Tocopherol alpha (Vitamin E) 266.0084450 AST (GOT) Aspartate aminotransferase 44.0084460 ALT (GPT) Alanine amino transferase 44.0084466 Transferrin 170.0084478 Triglycerides 23.0084479 Thyroid hormone (T3/T4) uptake or binding ratio (THBR) 107.0084480 Triiodothyronine T3, total (TT-3) 107.0084484 Troponin, quantitative 221.0084490 Chymotrypsin, quantitative - feces 333.0084520 Urea, quantitative - blood 23.0084540 Urea, quantitative - urine/other fluids, excluding blood 57.0084550 Uric acid - blood 23.0084560 Uric acid - body fluids, excluding blood 57.0084585 Vanillylmandelic acid (VMA) - urine 266.0084588 Vasopressin (antidiuretic hormone, ADH) 677.0084590 Vitamin A 188.0084620 Xylose absorption test - blood/urine 194.0084681 C-peptide 188.0084702 hCG (Human chorionic gonadotropin), qualitative/quantitative 128.0085002 Bleeding time 113.0085007 Manual differential 54.0085009 Blood count, manual differential, buffy coat 266.0085025 CBC (complete blood count) with differential 38.0085032 Blood smear, manual test 158.0085044 Reticulocytes manual count 92.0085049 Platelet, thrombocyte 99.0085170 Clot retraction 158.0085210 Clotting, factor II, prothrombin 297.0085220 Clotting, factor V (AcG or proaccelerin) 389.0085230 Clotting, factor VII, proconvertin 297.0085244 Clotting, factor VIII related antigen 384.0085245 Clotting, factor VIII, ristocetin cofactor 899.0085250 Clotting, factor IX 432.0085260 Clotting, factor X (Stuart-Prower) 297.0085270 Clotting, factor XI (PTA) 297.0085280 Clotting, factor XII (Hageman) 725.0085290 Clotting, factor XIII (fibrin stabilizing) 389.0085301 Clotting anticoagulant, antithrombin III antigen 426.0085302 Protein C, anticoagulant 530.0085305 Protein S, anticoagulant 441.0085362 Fibrinogen degradation (split) products (FDP) (FSP 725.0085384 Fibrinogen activity 128.0085390 Fibrinolysins or coagulopathy, screen 572.0085460 HbF (Hemoglobin fetal) stain 266.0085475 Hemolysin, acid, Ham test 342.0085540 LAP (Leukocyte Alkaline Phosphatase) with count 389.0085549 Muramidase 677.0085557 Osmotic fragility 389.0085576 Platelet aggregation 606.0085597 Platelet neutralization 743.0085610 PT (Prothrombin time) 53.0085635 Reptilase test 266.0085651 Sedimentation rate - blood 26.00

Service code Service name

Price for Patient

from Abroad

(ILS)

85670 TT (Thrombin time) - plasma 120.0085730 PTT (Thromboplastin time) - plasma/blood 59.0085810 Viscosity - blood 389.0086000 Agglutinins, febrile, per test 158.0086021 Leucocyte, Ab 333.0086022 Platelet, Ab 686.0086038 ANA (Antinuclear antibodies) 350.0086060 ASL0 (Antistreptolysin 0), titer 194.0086140 C-reactive protein 69.0086147 Cardiolipin, Ab 92.0086155 Chemotaxis assay 1,830.0086156 Cold agglutinin, screen 158.0086157 Cold agglutinin, quantitative 158.0086162 Complement total hemolytic activity 1,053.0086171 Complement fixation 239.0086225 DNA, native or double stranded, Ab 1,173.0086235 Extractable nuclear antigen, antibody to, any method (eg, nRNP, SS-A, SS-B, Sm,

RNP, Sc170, J01), each antibody 161.00

86255 Fluorescent noninfectious agent Ab, not otherwise specified 134.0086300 CA 15.3 tumor antigen 66.0086301 CA 19.9, tumor antigen 135.0086304 CA 125 tumor antigen 57.0086320 Immunoelectrophoresis - serum 413.0086325 Immunoelectrophoresis - body fluids, excluding serum, eg, urine, CSF 120.0086336 Inhibin - serum 317.0086337 Insulin, Ab 378.0086341 Islet cell, Ab 161.0086344 Leukocyte phagocytosis 3,104.0086353 Lymphocyte transformation 2,232.0086359 T and B cell count 878.0086360 T cells absolute CD4 and CD8 count, including ratio 2,748.0086376 Microsomal antibodies, eg, thyroid or liver-kidney 374.0086382 Virus neutralization test 449.0086403 Agglutination, screen (latex, Rose Waller) 188.0086406 Agglutination, particle, titer, each Ab 401.0086431 Rheumatoid factor, qualitative/quantitative 158.0086580 Skin test; tuberculosis, intradermal 86.0086592 Syphilis test, VDRL, RPR, TPHA, FTA, ELISA 158.0086619 Borrelia (relapsing fever), Ab 528.0086644 CMV (cytomegalovirus) Ab 323.0086648 Diphtheria, Ab 266.0086677 Helicobacter pylori, Ab - B 66.0086692 Hepatitis delta, Ab 135.0086703 HIV screening, central blood bank 0.0086704 Hepatitis B core antibody (HBcAb), IgG and IgM 81.0086705 Hepatitis B core Ab (HBcAb), IgM 89.0086706 Hepatitis B surface Ab (HBsAb) 44.0086707 Hepatitis Be Ab (HBeAb) 111.0086708 Hepatitis A antibody (HAAb), total, IgG and IgM 116.0086709 Hepatitis A Ab (HAAb), IgM or IgG 141.0086720 Leptospira, Ab 239.0086738 Mycoplasma, Ab 333.0086762 Rubella virus IgG and IgM 161.0086778 Toxoplasma IgM 99.0086789 West Nile virus IgG and IgM 516.0086790 Virus/bacteria Ab, not otherwise specified 266.0086800 Thyroglobulin, Ab 401.0086803 Hepatitis C, Ab 48.0086805 Lymphocytotoxicity assay, visual crossmatch; with titration 425.0086813 HLA typing, A, B, C 2,178.0086817 HLA typing, DR/DQ 2,817.0086821 HLA typing, MLC (mixed lymphocyte culture) 2,817.0086880 DAT (Direct Antiglobulin Test) / Coombs 194.0086900 Blood typing, including RH 126.0086901 Rh test 158.0086903 Blood typing and Rh, Ab, screen 552.00

Service code Service name

Price for Patient

from Abroad

(ILS)

86904 Blood typing and Rh, Ab 1,092.0086905 Blood typing; RBC antigens, other than ABO or Rh (D) 1,664.0086940 Hemolysins and agglutinins, screen 572.0087001 Animal inoculation, eg, tuberculosis 572.0087040 Blood culture and susceptibility 119.0087045 Feces culture 158.0087070 Culture, other source, excluding blood/urine/feces 119.0087081 Urine culture, non quantitative 158.0087086 Urine culture, quantitative 320.0087088 Urine culture and susceptibility 179.0087106 Fungi culture 158.0087109 Mycoplasma culture 239.0087110 Chlamydia culture 486.0087116 Mycobacteria culture and identification 519.0087118 Mycobacterial definitive identification, MTb 264.0087140 Fluorescence or darkfield microscopy 158.0087177 Ova and parasites, direct smear, identification - feces 120.0087181 Susceptibility studies, antimicrobial agent, per agent 158.0087190 Susceptibility studies, antimycobacterial agent, mycobacteria 354.0087205 Smear interpretation, stain for bacteria, fungi, parasites or cell types 120.0087207 Smear, special stain for parasites 158.0087250 Virus isolation, including nucleic acid identification, polymerase chain reaction, PCR

609.00

87252 Virus isolation, tissue culture 194.0087253 Virus isolation and identification, tissue culture, any method 965.0087278 Legionella Ag - urine 236.0087299 Immunofluorescent study; not otherwise specified 333.0087340 Hepatitis B surface antigen (HBsAg), any method, including immunofluorescent

study 134.00

87350 Hepatitis Be antigen (HBeAg), any method, including immunofluorescent study111.00

87449 Infectious agent antigen detection, not otherwise specified 549.0087472 Bartonella henselae and Bartonella quintana, quantification 419.0087517 Hepatitis B virus DNA/RNA, quantitative 743.0087522 Hepatitis C virus DNA/RNA, quantitative 1,382.0087536 HIV-1 DNA/RNA, quantitative 1,934.0087539 HIV-2 DNA/RNA, quantitative 1,934.0087556 Mycobacteria tuberculosis, AMTD 665.0087590 Gonorrhoeae smear 0.0087620 Papillomavirus (HPV) - tissue, including biopsy 2,745.0087622 HPV (Human Papillomavirus) smear 573.0088036 Necropsy (autopsy), limited, gross and/or microscopic; regional 965.0088130 Sex chromatin identification, Barr bodies 194.0088141 Pap smear, cervical/vaginal, cytopathology, including sampling 162.0088160 Cytopathology examination and interpretation 266.0088230 Karyotype, leukocyte culture 1,668.0088233 Karyotype, tissue culture 2,153.0088240 Cryopreservation of cells (eg, bone marrow), per year 2,094.0088299 B &T cell receptor gene rearrangment analysis 1,559.0088305 Histologic examination, microscopy and interpretation 266.0088313 Bone marrow sampling and iron stain 606.0088319 Histochemistry/cytochemistry stain for enzyme identification 266.0088346 Immunofluorescent study, each antibody; direct method 1,410.0088347 Immunofluorescent study, each antibody; indirect method 1,410.0088348 EM (Electron microscopy), diagnostic 4,727.0089051 Cell count - body fluids, eg, CSF, joint fluid, excluding blood 188.0089258 Cryopreserved embryos storage for 5 years 965.0089259 Cryopreservation, sperm, one year, up to 5 test tubes/straws 1,062.0089280 Assisted oocyte fertilization, microtechnique 6,395.0089290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-

implantation genetic diagnosis) 13,776.00

89300 Semen analysis; presence and/or motility of sperm including Huhner test (post coital)363.00

89320 Semen analysis, complete (volume, count, motility, and differential) 222.0089325 Sperm Ab 354.0090371 HBIg (Hepatitis B immune globulin), IM 6,093.00

Service code Service name

Price for Patient

from Abroad

(ILS)

90375 Rlg (Rabies immune globulin), IM and/or subcutaneous 4,166.0090384 Rho(D) immune globulin (Rhlg), Anti-D 743.0090585 BCG (Bacillus Calmette-Guerin) vaccine for tuberculosis 0.0090586 BCG vaccine for bladder, live, for intravesical use, per treatment, including material

1,344.00

90749 Immune globulin (Ig), not otherwise specified 158.0090772 Subcutaneous/IM injection, therapeutic/prophylactic/diagnostic 54.0090862 Pharmacological management/review, mental health 162.0090870 Electroconvulsive therapy 1,656.0090880 Hypnotherapy 198.0090882 Psychosocial intervention - follow up 191.0090889 Psychiatric medical opinion 908.0090901 Biofeedback training 588.0090935 Hemodialysis procedure, per treatment 1,818.0090945 Dialysis procedure other than hemodialysis (eg, peritoneal dialysis) 822.0091010 Esophageal motility (manometric study) 1,631.0091034 Esophagus, acid reflux test, with intraluminal pH electrode for dection of

gastroesophageal reflux; prolonged recording 1,631.00

91065 Breath hydrogen test (eg, for detection of lactase deficiency) 300.0091122 Anorectal manometry 1,631.0092004 Ophthalmological examination, initial 725.0092065 Orthoptic evaluation and therapy 158.0092081 Computerised visual field examination 243.0092083 Visual field examination (eg, Goldmann visual fields) 194.0092230 Fluorescein angioscopy, unilateral 1,028.0092235 Fluorescein angioscopy, bilateral 1,416.0092240 ICGI eye imaging, with interpretation and report 2,598.0092250 Fundus photography, one eye 311.0092270 Electro-oculography with interpretation and report 486.0092275 Electroretinography with interpretation 1,125.0092283 Color vision examination 194.0092284 Dark adaptation examination with interpretation 572.0092285 External eye photography, with interpretation and report 609.0092286 Anterior segment photography, one eye 486.0092287 Anterior segment photography, two eyes 731.0092310 Contact lens fitting, including adjustment 158.0092355 Fitting of telescopic lens system, age-related macular degeneration 219.0092506 Evaluation of speech, language, voice 194.0092507 Speech therapy, individual 189.0092508 Speech therapy, group, per hour 158.0092512 Rhinomanometry 300.0092526 Feeding and swallowing therapy, per treatment 179.0092541 Spontaneous nystagmus test, ENG (electronystagmography) 725.0092551 Hearing test, screening 44.0092557 Hearing test, comprehensive 266.0092567 Tympanometry (impedance testing) 116.0092568 Acoustic reflex testing 257.0092585 Brain auditory evoked potentials, adult 923.0092588 Brain evoked potentials, child 1,256.0092590 Hearing aid fitting 350.0092593 Hearing aid check/counselling, binaural 266.0092601 Diagnostic analysis and programing of cochlear implant, binaural, under age 7

2,451.00

92602 Diagnostic analysis and subsequent programing of cochlear implant, monaural, under age 7 798.00

92603 Diagnostic analysis and programing of cochlear implant, binaural, age 7 or over2,451.00

92604 Diagnostic analysis and subsequent programing of cochlear implant, monaural, age 7 or over 798.00

92620 Central auditory function test(s) 521.0092633 Auditory rehabilitation following cochlear implant 188.0093000 ECG (Electrocardiogram), with interpretation and report 53.0093012 CardioBeeper device loan 278.0093015 Cardiovascular stress test 413.0093224 ECG monitoring for 24 hours (Holter) 735.0093307 TTE (transthoracic echocardiography) 621.00

Service code Service name

Price for Patient

from Abroad

(ILS)

93312 TEE (transesophageal echocardiography) 2,355.0093350 Effort or Dobutamine stress echocardiography (DSE) 1,467.0093720 Pulmonary function tests, infant, plethysmography, with interpretation 4,515.0093784 Blood pressure monitoring, for 24 hours 651.0093797 Cardiac rehabilitation, per month 1,212.0093880 Cervical arteries duplex, bilateral 576.0093923 Extremities arteries duplex, stress and rest 543.0093925 Extremity arteries/bypass grafts duplex 576.0093965 Peripheral vessels flow study (eg, Doppler) 239.0093975 Abdomen, pelvis and retroperitoneal vessels duplex 543.0093980 Penile vessels duplex, per patient 740.0094010 Spirometry, simple 168.0094060 Spirometry with bronchodilator 204.0094070 Prolonged bronchi evaluation, methacholine or other chemical agent 1,200.0094200 Maximal voluntary ventilation 83.0094240 Functional residual volume, noble gas 863.0094250 Expired gas collection, quantitative 431.0094360 Resistance to airflow, plethysmographic method 735.0094400 Breathing response to CO2 (CO2 response curve) 1,439.0094620 Pulmonary stress test, simple, including pre- and post-spirometry 236.0094621 Pulmonary stress testing, complex 1,818.0094640 Inhalation treatment 54.0094664 Demonstration of an aerosol/inhaler use 98.0094667 Physiotherapy, lung patient, per treatment 189.0094720 Carbon monoxide diffusing capacity 431.0094760 Noninvasive ear or pulse oximetry for oxygen saturation 120.0094762 Oxygen saturation, overnight oximetry 243.0094772 Pulmonary function tests, passive, child 4,508.0095004 Aeroallergens/food, up to 10 allergens, screen 188.0095012 Nitric oxide determination - exhaled air, per patient 453.0095028 Aeroallergens/food, 11 or over allergens, extended test 441.0095044 Patch or application skin alergy test 237.0095120 Allergen immunotherapy, normal allergen 264.0095130 Allergen immunotherapy, pure allergen 536.0095199 Susceptibility studies, antimicrobial agent; lymphocyte and serum 1,410.0095810 Polysomnography, including EEG 1,589.0095812 EEG (Electroencephalogram) 572.0095813 EEG (Electroencephalogram) extended monitoring 1,235.0095822 EEG (Electroencephalogram), sleep 935.0095830 EEG (Electroencephalogram), sphenoidal recording 1,020.0095857 Tensilon test for myasthenia gravis 257.0095861 EMG (electromyography) 342.0095872 EMG (Electromyography) 989.0095900 NCT (Nerve conduction test) 788.0095922 Testing of autonomic nervous system function; vasomotor adrenergic innervation

(sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least five minutes of passive tilt 687.00

95923 Electrolyte concentration determination, sweat imprint 194.0095930 VEP (visual evoked potential), adult 923.0095950 EEG (electroencephalogram), 24 hours 2,780.0095990 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal

(intrathecal, epidural) or brain (intraventricular) 1,259.00

96001 Computerized three dimensional motion and walking analysis, per patient 5,309.0096567 Photodynamic therapy (PDT), dermal lesions, non-melanoma/solar keratosis 1,275.0096910 Phototherapy by UVB and tar/petrolatum 192.0096912 Photochemotherapy by PUVA, including psoralens 222.0097001 Physiotherapy, evaluation and treatment planning, adult 299.0097003 Occupational therapy, evaluation and treatment planning, adult 299.0097113 Aquatic physiotherapy/rehabilitation, individual, hydrotherapy 291.0097140 Physiotherapy, individual 189.0097150 Physiotherapy/rehabilitation, group, 4 or more individuals, including child, per

individual 54.00

97530 Occupational therapy, individual 189.0097750 Physical performance test or measurement (eg, musculoskeletal, functional capacity),

with written report, eg, evaluation of pressure on sole 878.00

Service code Service name

Price for Patient

from Abroad

(ILS)

97802 Medical nutrition counselling and therapy 188.0097810 Acupuncture 266.0099001 Histopathology slides preparation for shipment 419.0099002 Histopathology slides preparation in Israel 606.0099075 Forensic medical opinion 2,451.0099080 Medical opinion 899.0099183 Elective hyperbaric oxygen therapy, per treatment, up to 2 hours 1,260.0099195 Phlebotomy 188.0099212 Follow up allergy testing after 95028 158.0099214 Post hospitalization examination 0.0099223 Pre-operation evaluation, serial tests 1,191.0099242 Physician examination, excluding tests with specific code 343.0099283 ER visit, global payment 1,116.0099315 Clinic nurse service, up to 30 minutes 107.0099316 Clinic nurse service, over 30 minutes (eg, guidance for patient with stoma) 228.0099362 Multidisciplinary team examination 725.0099371 Telephonic consultation for poisoning/medication information/teratology 288.0099600 Home visit, care worker 249.00C0443 Release of carpal tunnel, in surgical day care 2,729.00C0449 Peripheral nerve decompression/lysis of adhesions, excluding endoneurolysis, in

surgical day care 5,315.00

C0460 Peripheral nerve transposition, eg, ulnar nerve, in surgical day care 5,315.00C0476 Peripheral nerve repair, old traumatic injury, eg, ulnar nerve, in surgical day care

5,315.00

C0492 Implantation/replacement of sacral nerve stimulation electrode/lead, in surgical day care, excluding device cost 5,315.00

C0670 Excision of thyroglossal/branchial cleft cyst/sinus, in surgical day care 5,315.00C0823 Excision of lesion(s) and/or tissue of eyelid, excluding chalazion, in surgical day care

5,315.00

C0849 Repair of eyelid position, excluding complex repair, in surgical day care 5,315.00C0870 Reconstruction of eyelid, in surgical day care 5,315.00C0889 Repair of eyelid position, complex, in surgical day care 5,315.00C0920 Lacrimal system operation, excluding fistulization, in surgical day care 5,315.00C1000 Conjunctiva operation, excluding removal of superficial foreign body, in surgical

day care 5,315.00

C1139 Excision of pterygium, without graft, in surgical day care 5,315.00C1511 Extraocular muscle(s) operation for strabismus repair, in surgical day care 5,315.00C2169 Turbinectomy, in surgical day care 5,315.00C2189 Nose operation/rhinoplasty, in surgical day care 5,315.00C2220 Intranasal antrotomy, excluding FESS, in surgical day care 5,315.00C2840 Excision of tonsil tag/lingual tonsil or adenoidectomy without tonsillectomy, in

surgical day care 5,315.00

C3143 Laryngoscopy with biopsy, in surgical day care 5,315.00C3321 Bronchoscopy through artificial stoma, in surgical day care 5,315.00C3324 Bronchoscopy with biopsy, in surgical day care 5,315.00C4011 Biopsy of lymphatic structure, in surgical day care 5,315.00C4021 Excision of lymph node(s), excluding internal mammary, in surgical day care 5,315.00C4911 Anal fistulotomy/fistulectomy under general anesthesia, in surgical day care 5,315.00C4943 Destruction of hemorrhoids by cauterization/cryotherapy, in surgical day care 5,315.00C5011 Biopsy of liver, needle; percutaneous, not using CT/MRI guidance, in surgical day

care 5,315.00

C5349 Umbilical hernia repair, up to 5 years of age, in surgical day care 5,315.00C5810 Urethral meatotomy, in surgical day care 5,315.00C5860 Dilation of urethra, in surgical day care 5,315.00C6120 Excision of lesion(s) and/or hydrocele and/or varicocele of tunica

vaginalis/spermatic cord, in surgical day care 5,315.00

C6250 Orchiopexy, in surgical day care 5,315.00C6420 Excision/destruction of lesion(s) and/or tissue of penis under general anesthesia, in

surgical day care 5,315.00

C6720 Biopsy/conization of cervix, excluding by cauterization/cryosurgery, in surgical day care 5,315.00

C6739 Excision of lesion(s) of cervix, including by cauterization/cryosurgery, in surgical day care 5,315.00

C6759 Cerclage/repair of uterine cervix, in surgical day care 5,315.00C7011 Hymenotomy/hymenectomy, in surgical day care 5,315.00C7024 Biopsy/excision/destruction of lesion(s) of vagina, in surgical day care 5,315.00

Service code Service name

Price for Patient

from Abroad

(ILS)

C7129 Bartholin's gland/cyst operation under general anesthesia, in surgical day care5,315.00

C7744 Biopsy of bone/arthrotomy of hand/foot and finger(s)/toe(s), in surgical day care5,315.00

C7751 Bunion, eg, hallux valgus / hammer toe/claw operation, in surgical day care 5,315.00C7860 Removal of implanted device from bone, excluding face/hand/foot, in surgical day

care 5,315.00

C8044 Capsulotomy of hand/foot and finger(s)/toe(s), in surgical day care 5,315.00C8201 Tendon sheath incision, in surgical day care 5,315.00C8313 Tenotomy, excluding of hand, in surgical day care 5,315.00C8331 Excision of lesion(s) of tendon sheath, in surgical day care 5,315.00C8350 Excision of bursa, in surgical day care 5,315.00C8611 Biopsy of subcutaneous tissue under general anesthesia, in surgical day care 5,315.00C8630 Excision/destruction of lesions of skin and subcutaneous tissue, 4 or more, in

surgical day care 5,315.00

C8660 Free skin grafting, includes excision of skin for autogenous graft, in surgical day care5,315.00

C8689 Repair and reconstruction of skin and subcutaneous tissue, in surgical day care5,315.00

C8694 Implantation/replacement of sacral nerve stimulation generator, in surgical day care, excluding device cost 5,315.00

C9802 Esophagoscopy for removal of foreign body, in surgical day care 5,315.00C999C Surgical hospital day care, excluding procedures with specific code 5,315.00D0210 Intra oral radiograph - complete series 497.00D0220 Intraoral periapical film 54.00D0230 Intraoral periapical, each additional film 54.00D0240 Intraoral occlusal film 120.00D0330 Panoramic film 441.00D1201 Application of fluoride, complete 138.00D1351 Sealant - per tooth 204.00D1510 Space maintainer, fixed 1,029.00D2140 Restoration - one surface, local anesthesia 347.00D2150 Restoration -2/more surfaces, any material 441.00D2330 Resin-based composite restoration - one surface, anterior 593.00D2335 Resin-based composite restoration, anterior 732.00D2390 Resin-based composite restoration - crown 638.00D2752 Crown - porcelain fused to noble metal 3,749.00D2980 Crown repair 342.00D3220 Pulpotomy, primary/permanent tooth 321.00D3230 Pulpal therapy, resorbable filling - primary tooth, excluding final restoration 638.00D3310 Root canal therapy - anterior, excluding final restoration 1,308.00D3320 Root canal therapy - bicuspid, excluding final restoration 1,308.00D3330 Root canal therapy - molar, excluding final restoration 1,308.00D3351 Apexification 525.00D3410 Apicoectomy, anterior, including placement of retrograde filling material 1,311.00D3421 Apicoectomy - bicuspid, including placement of retrograde filling material 1,635.00D3425 Apicoectomy - molar, including placement of retrograde filling material 2,780.00D3450 Root amputation 1,635.00D3920 Hemisection 1,146.00D4240 Gingival flap, with root planing, per quadrant 1,124.00D4249 Clinical crown lengthening 1,047.00D4260 Osseous surgery, including flap entry and closure, per quadrant 1,445.00D4341 Periodontal scaling and root planing, per meeting, 30 minutes 194.00D5110 Complete acrylic denture - pair 10,964.00D5213 Partial denture 10,104.00D5730 Reline denture (chairside) 1,170.00D5750 Reline denture - laboratory 2,886.00D5951 Feeding aid; feeding prosthesis 906.00D5952 Speech aid prosthesis, pediatric 906.00D7111 Extraction, coronal remnants - deciduous tooth 345.00D7140 Extraction, erupted tooth or exposed root, single 345.00D7141 Extraction, erupted tooth or exposed root, second in the same session 257.00D7142 Extraction, erupted tooth or exposed root, each additional tooth in the same session

171.00

D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth 359.00

Service code Service name

Price for Patient

from Abroad

(ILS)

D7220 Removal of impacted tooth - soft tissue 819.00D7230 Removal of impacted tooth - partially bony 1,146.00D7240 Removal of impacted tooth - completely bony 1,146.00D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth

and/or alveolus 834.00

D7280 Exposure of impacted/unerupted tooth for orthodontic reasons, including orthodontic attachments 1,146.00

D7320 Alveoloplasty not in conjunction with extractions - per quadrant 843.00D7340 Vestibuloplasty - ridge extension (secondary epithelialization) 1,119.00D7450 Removal of odontogenic cyst 843.00D7960 Frenulectomy (frenectomy or frenotomy) 819.00D8080 Comprehensive orthodontic treatment of the adolescent dentition, for one year, up to

3 years 5,835.00

D8089 Follow up code of D8080, established adolescent patient for comprehensive orthodontic treatment 0.00

D8999 Orthodontic preparation for orthognatic face mask 2,201.00D9110 Emergency treatment of dental pain 243.00D9220 Deep sedation/general anesthesia, for dental procedure - first hour 1,734.00D9221 Deep sedation/general anesthesia, for complex dental procedure - more than one hour

1,962.00

D9230 Analgesia, including nitrous, excluding dental treatment 320.00J0011 Methylglutaconic aciduria, molecular diagnostics, special case 633.00J0021 Adrenoleukodystrophy X-linked, molecular diagnostics, special case 633.00J0031 Canavan disease, molecular diagnostics, special case 633.00J0041 Carnitine Palmitoyl Tranferase, molecular diagnostics, special case 633.00J0051 Cystinuria, molecular diagnostics, special case 633.00J0061 Glycogen storage disease type 1, molecular diagnostics, special case 633.00J0071 Hyperglycinemia, nonketotic, molecular diagnostics, special case 633.00J0081 Hyperoxaluria, primary, type 1, molecular diagnostics, special case 633.00J0091 Isovalericacidemia, molecular diagnostics, special case 633.00J0101 Lipoamide Dehydrogenase Deficiency, molecular diagnostics, special case 633.00J0111 Maple syrup urine disease, molecular diagnostics, special case 633.00J0121 Methylmalonicaciduria, mutase deficiency, molecular diagnostics, special case

633.00

J0131 Molybdenum cofactor deficiency, molecular diagnostics, special case 633.00J0141 Peroxysomal disorders, molecular diagnostics, special case 633.00J0151 Phenylketonuria, molecular diagnostics, special case 633.00J0161 Thiamine-responsive megaloblastic anemia, molecular diagnostics, special case

633.00

J0171 Tyrosinemia, molecular diagnostics, special case 633.00J0181 VLCAD (Very Long Chain Acyl CoA Dehydrogenase) deficiency, molecular

diagnostics, special case 633.00

J0191 Wilson disease, molecular diagnostics, special case 633.00J0201 Xanthinuria, type I, molecular diagnostics, special case 633.00J0211 CTX (Cerebrotendinous xanthomatosis), molecular diagnostics, special case 633.00J0221 Hypercholesterolemia, familial, molecular diagnostics, special case 633.00J0232 Lysosomal acid phosphatase deficiency, biochemical diagnostics 1,799.00J0241 Aspartylglucosaminuria, molecular diagnostics, special case 633.00J0242 Aspartylglucosaminuria, biochemical diagnostics 1,799.00J0251 Ceroid lipofuscinosis, molecular diagnostics, special case 633.00J0252 Ceroid lipofuscinosis, biochemical diagnostics 1,799.00J0262 Cholesteryl ester storage disease, biochemical diagnostics 1,799.00J0272 Cystinosis, nephropathic, biochemical diagnostics 1,799.00J0281 Fabry disease, molecular diagnostics, special case 633.00J0282 Fabry disease, biochemical diagnostics 1,799.00J0292 Free sialic acid storage disease, biochemical diagnostics 1,799.00J0302 Fucosidosis, biochemical diagnostics 1,799.00J0312 GM1 gangliosidosis, biochemical diagnostics 1,799.00J0322 Galactosialidosis, biochemical diagnostics 1,799.00J0331 Gaucher disease, molecular diagnostics, special case 816.00J0332 Gaucher disease, biochemical diagnostics 1,799.00J0341 Glycogen storage disease type 2, Pompe, molecular diagnostics, special case 633.00J0342 Glycogen storage disease type 2, Pompe, biochemical diagnostics 1,799.00J0351 Ichthyosis, X-linked, molecular diagnostics, special case 633.00J0352 Ichthyosis, X-linked, biochemical diagnostics 1,799.00J0361 Krabbe disease, molecular diagnostics, special case 633.00

Service code Service name

Price for Patient

from Abroad

(ILS)

J0362 Krabbe disease, biochemical diagnostics 1,799.00J0372 Mannosidosis, alpha, biochemical diagnostics 1,799.00J0382 Mannosidosis, beta, biochemical diagnostics 1,799.00J0392 Maroteaux-Lamy syndrome, biochemical diagnostics 1,799.00J0400 Metachromatic leukodystrophy, pseudo deficiency, molecular diagnostics 816.00J0401 Metachromatic leukodystrophy, molecular diagnostics, special case 633.00J0402 Metachromatic leukodystrophy, biochemical diagnostics 1,799.00J0412 Mucolipidosis II, biochemical diagnostics 4,091.00J0421 Mucolipidosis III, molecular diagnostics, special case 633.00J0422 Mucolipidosis III, biochemical diagnostics 4,091.00J0431 Mucolipidosis IV, molecular diagnostics, special case 633.00J0442 Mucopolysaccharidosis II, biochemical diagnostics 1,799.00J0452 Mucopolysaccharidosis IV, biochemical diagnostics 1,799.00J0462 Mucopolysaccharidosis I, biochemical diagnostics 1,799.00J0472 Mucopolysaccharidosis VII, biochemical diagnostics 1,799.00J0482 Multiple sulfatase deficiency, biochemical diagnostics 4,091.00J0491 Niemann-Pick disease, molecular diagnostics, special case 633.00J0492 Niemann-Pick disease, biochemical diagnostics 1,799.00J0501 Niemann-Pick disease, type C, molecular diagnostics, special case 633.00J0502 Niemann-Pick disease, type C, biochemical diagnostics 6,116.00J0511 Pycnodysostosis, molecular diagnostics, special case 633.00J0512 Pycnodysostosis, biochemical diagnostics 1,799.00J0522 Salla disease, biochemical diagnostics 1,799.00J0532 Sanfilippo syndrome, biochemical diagnostics 4,091.00J0542 Schindler disease, biochemical diagnostics 1,799.00J0552 Sialidosis, biochemical diagnostics 1,799.00J0561 Tay Sachs, molecular diagnostics, special case 633.00J0562 Tay Sachs, biochemical diagnostics 1,799.00J0572 Wolman disease, biochemical diagnostics 1,799.00J0581 Mitochondrial disorder, molecular diagnostics, special case 633.00J0582 Mitochondrial disorder, biochemical diagnosticsJ0591 Deafness, mitochondrial, molecular diagnostics, special case 633.00J0600 Kearns Sayre Syndrome, KSS, molecular diagnostics 1,494.00J0610 Leber Optic Atrophy, LHON, molecular diagnostics 816.00J0621 Leigh syndrome, molecular diagnostics, special case 633.00J0622 Leigh syndrome, biochemical diagnosticsJ0631 Mitochondrial myopathy, Encephalopathy, Lactic Acidosis and Stroke-like episodes,

MELAS, molecular diagnostics, special case 816.00

J0641 Myoclonic Epilepsy with Ragged Red Fibers, MERFF, molecular diagnostics, special case 1,494.00

J0651 Mitochondrial depletion syndrome, molecular diagnostics, special case 633.00J0652 Mitochondrial depletion syndrome, biochemical diagnosticsJ0661 Alzheimer, early onset/familial, molecular diagnostics, special case 633.00J0671 Ataxia Telangiectasia, molecular diagnostics, special case 633.00J0673 Ataxia Telangiectasia, cytogenetic diagnostics 4,613.00J0681 Charcot-Marie-Tooth neuropathy, molecular diagnostics, special case 1,292.00J0691 Creutzfeldt-Jakob disease, familial, molecular diagnostics, special case 633.00J0701 Duchenne, Becker muscular dystrophy, molecular diagnostics, special case 9,011.00J0710 Familial dysautonomia, molecular diagnostics 411.00J0720 Dystonia, torsion, molecular diagnostics 816.00J0730 Facioscapulohumeral muscular dystrophy-1A, molecular diagnostics 1,292.00J0740 Hereditary Nerve Pressure Palsy, HNPP, molecular diagnostics 1,494.00J0750 Huntington disease, molecular diagnostics 1,494.00J0761 Inclusion body myopathy, autosomal recessive, molecular diagnostics, special case

633.00

J0771 Insensitivity to pain, congenital, with anhidrosis, molecular diagnostics, special case633.00

J0781 LGMD (Limb girdle muscular dystrophy), dysferlin deficiency, molecular diagnostics, special case 633.00

J0790 Myotonic dystrophy, molecular diagnostics 1,494.00J0801 Neurofibromatosis, type 1, molecular diagnostics, special case 633.00J0810 Oculopharyngeal muscular dystrophy, molecular diagnostics 1,494.00J0820 SMA (Spinal Muscular Atrophy), molecular diagnostics 1,494.00J0830 Spinocerebellar ataxia due to an expansion including Friedrich ataxia, molecular

diagnostics 1,494.00

J0840 Adenomatous polyposis coli, molecular diagnostics 7,247.00

Service code Service name

Price for Patient

from Abroad

(ILS)

J0841 Adenomatous polyposis coli, molecular diagnostics, special case 633.00J0850 Multiple endocrine neoplasia 2A, molecular diagnostics 1,631.00J0851 Multiple endocrine neoplasia 2A, molecular diagnostics, special case 633.00J0860 Retinoblastoma, molecular diagnostics 7,247.00J0861 Retinoblastoma, molecular diagnostics, special case 633.00J0870 Von Hippel-Lindau, molecular diagnostics 1,329.00J0871 Von Hippel-Lindau, molecular diagnostics, special case 633.00J0881 Adrenal hyperplasia, congenital, 11-beta-hydroxylase deficiency, molecular

diagnostics, special case 633.00

J0891 Adrenal hyperplasia, congenital, 17-alpha-hydroxylase deficiency, molecular diagnostics, special case 633.00

J0901 Adrenal hyperplasia, congenital, 21-hydroxylase deficiency, molecular diagnostics, special case 633.00

J0911 Adrenal hypoplasia, congenital, molecular diagnostics, special case 633.00J0921 Pendred syndrome, molecular diagnostics, special case 633.00J0931 Persistent hyperinsulinemic hypoglycemia of infancy, molecular diagnostics, special

case 633.00

J0941 Combined factor V and VII deficiency, molecular diagnostics, special case 633.00J0951 Factor V deficiency, molecular diagnostics, special case 633.00J0961 Factor VII deficiency, molecular diagnostics, special case 633.00J0971 Factor XI deficiency, molecular diagnostics, special case 633.00J0981 Factor XIIIA deficiency, molecular diagnostics, special case 633.00J0991 Fanconi anemia, molecular diagnostics, special case 633.00J0993 Fanconi anemia, cytogenetic diagnostics 4,613.00J1001 Hemoglobinopathies alpha, alpha thalassemias, molecular diagnostics, special case

1,919.00

J1011 Hemoglobinopathies beta, beta thalassemias, molecular diagnostics, special case1,919.00

J1021 Hemophilia A, factor VIII deficiency, molecular diagnostics, special case 633.00J1031 Hemophilia B, factor IX deficiency, molecular diagnostics, special case 633.00J1040 Achondroplasia/thanatophoric dwarfism, molecular diagnostics 633.00J1051 Achromatopsia, molecular diagnostics, special case 633.00J1061 Albinism, molecular diagnostics, special case 633.00J1070 Angelman syndrome/Prader Willi, molecular diagnostics 1,292.00J1081 Autoimmune polyglandular disease, type I, molecular diagnostics, special case

633.00

J1091 Bardet-Biedl syndrome, molecular diagnostics, special case 633.00J1100 Beckwith-Wiedemann syndrome, molecular diagnostics 1,292.00J1111 Bloom syndrome, molecular diagnostics, special case 411.00J1113 Bloom syndrome, cytogenetic diagnostics 4,613.00J1121 Cockayne syndrome, molecular diagnostics, special case 633.00J1122 Cockayne syndrome, biochemical diagnostics 6,116.00J1131 Craniosynostosis, molecular diagnostics, special case 633.00J1140 Cystic fibrosis, molecular diagnostics 816.00J1151 Deafness, congenital, molecular diagnostics, special case 633.00J1161 Epidermolysis Bullosa, congenital, molecular diagnostics, special case 633.00J1171 Osteopetrosis, recessive, molecular diagnostics, special case 633.00J1181 Polycystic kidneys, dominant, molecular diagnostics, special case 633.00J1191 Polycystic kidneys, recessive, molecular diagnostics, special case 633.00J1203 Roberts syndrome, cytogenetic diagnostics 4,613.00J1211 Tuberous sclerosis, molecular diagnostics, special case 633.00J1222 Xeroderma pigmentosum, biochemical diagnostics 6,116.00J1233 DiGeorge/velocardiofacial syndrome, FISH, cytogenetic diagnostics 1,934.00J1243 Rubinstein-Taybi syndrome, FISH, cytogenetic diagnostics 1,934.00J1253 Smith-Magenis syndrome, FISH, cytogenetic diagnostics 1,934.00J1263 Williams syndrome, FISH, cytogenetic diagnostics 1,934.00J1271 FMF, molecular diagnostics, special case 816.00J1311 BRCA1/BRCA2 founder mutation analysis, breast/ovarian cancer, per patient 764.00J3001 Familial known mutation, molecular diagnostics 633.00J8003 Karyotype, cytogenetic diagnostics - chorionic villus 2,889.00J8891 Prenatal molecular diagnostics, basic 2,085.00J9001 Prenatal molecular diagnostics, complex 3,050.00J9900 Fragile X, molecular diagnostics 752.00J9903 Mental retardation, cytogenetic diagnostics 1,146.00J9913 Male infertility, cytogenetic diagnostics 1,146.00J9941 Y chromosome deletion, molecular diagnostics, special case 1,238.00

Service code Service name

Price for Patient

from Abroad

(ILS)

J9991 Monogenic disease in family, gene location known, molecular diagnostics, special case 4,622.00

L0005 Long cast, local anesthesia 389.00L0019 Elastic bandage, elstoplast 17.00L0020 Needle aspiration, US guidance, including cytology 713.00L0021 Breast needle aspiration, US guidance, including cytology 713.00L0022 Thyroid needle aspiration, US guidance, including cytology, per patient 2,100.00L0023 Bandage placement or replacement 113.00L0025 Stitches 0.00L0026 Stitches removal 60.00L0030 Parotid needle aspiration, US guidance, including cytology, per patient 1,913.00L0042 Nephrostomy tube removal 440.00L0062 Vaginal smear, sampling, processing and interpretation 266.00L0080 Rehabilitation day care 1,073.00L0100 TMJ radiology, up to two views 347.00L0106 Radiology additional view, not elsewhere specified 86.00L0107 Jaw radiology, third or more additional views 86.00L0108 Mastoids radiology, third or more additional views 86.00L0109 Nasal bones radiology, third or more additional views 86.00L0110 Paranasal sinuses radiology, third or more additional views 86.00L0111 Skull radiology, third or more additional views 86.00L0112 Pelvis radiology, third or more additional views 86.00L0113 Shoulder radiology, complete, one side, third or more additional views 86.00L0114 Elbow radiology, third or more additional views 86.00L0115 Wrist radiology, third or more additional views 86.00L0116 Hand radiology, third or more additional views 86.00L0117 Hip radiology, unilateral, second or more additional views 86.00L0118 Ankle radiology, third or more additional views 86.00L0119 Abdomen radiology, second or more additional views 86.00L0120 TMJ radiology, third or more additional views 86.00L0121 Calcaneus radiology, third or more additional views 86.00L0122 Toe(s) radiology, third or more additional views 86.00L0123 Cervicothoracic spine radiology, Pawlow/Twining, up to two views 86.00L0124 Cervicothoracic spine radiology, Pawlow/Twining, third or more additional views

86.00

L0125 Pelvis radiology, outlet 86.00L0126 Pelvis radiology, inlet 86.00L0138 Spine radiology, two parts, up to three views 389.00L0151 Arthrography, including injection and interpretation 441.00L0160 Chest radiology, third or more additional views 158.00L0167 Additional charge for device for insertion of left atrial appendage device 36,267.00L0168 Additional charge for device for implantation of diaphragmatic pacemaker for spinal

cord injured patients 163,350.00

L0169 Additional charge for device for implantation of diaphragmatic pacemaker for ALS patients 139,200.00

L0194 Large bandage, bandages & cotton 342.00L0209 Pregnancy termination approval committee 540.00L0210 Nasal bones radiology, up to two views 245.00L0248 Storage of corpse, 2 to 24 hours 473.00L0268 Spotting and copying patient records, first 10 pages 129.00L0269 Copying patient records, each 2 additional pages 2.00L0372 HBIg (Hepatitis B immune globulin), IV 8,766.00L0396 Varicella Zoster passive immunization, under 12 years of age, eg, varitect 3,806.00L0397 Varicella Zoster passive immunization, age 12 years or older, eg, varitect 13,335.00L0409 Small splints, occupational therapy, including cost of material and number of

sessions 279.00

L0410 Medium splints, static mouth splint, occupational therapy, including cost of material and number of sessions 539.00

L0411 Medium splints, occupational therapy, including cost of material and number of sessions 539.00

L0412 Complex medium splints, occupational therapy, including cost of material and number of sessions 786.00

L0413 Big splints, occupational therapy, including cost of material and number of sessions1,058.00

L0415 JOBST suit measurement 342.00

Service code Service name

Price for Patient

from Abroad

(ILS)

L0416 Complex medium splints, dynamic mouth splint, occupational therapy, including cost of material and number of sessions 786.00

L0438 TRH (Thyrotropin releasing hormone) stimulation panel 965.00L0444 MRI (Magnetic resonance imaging), excluding tests with specific code 3,134.00L0446 MRI under general anesthesia, per test 11,192.00L0486 Geriatric hospital day care 830.00L0487 Cognitive geriatric hospital day care 432.00L0491 Cytotoxic capacity testing 1,256.00L0534 Orthoptic treatment, per treatment 120.00L0546 Auditory test for cochlear implant surgery candidate 945.00L0554 FMRI (functional magnetic resonance imaging) 8,483.00L0560 Internal hospital day care 1,716.00L0561 Rehabilitative hospital day care 1,716.00L0564 Histochemical staining including immunohistochemistry 2,499.00L0574 Breathing capability test 120.00L0591 Extracorporeal shockwave lithotripsy, kidney; complex 28,632.00L0621 Kit test 1,359.00L0690 Hotel care, per day, including medical supervision 606.00L0692 Home care, per day, including medical supervision 909.00L0717 Harvesting of cornea 8,610.00L0749 MRI, additional payment for gadolinum contrast 345.00L0784 IV (Intravenous) infusion of fluids 342.00L0785 IV (Intravenous) infusion of drugs 342.00L0787 Deflux injection, vesicoureteral reflux therapy, unilateral 10,022.00L0788 Deflux injection, vesicoureteral reflux therapy, bilateral 17,705.00L0790 Preparation of blood unit, price per preparation of one unit 345.00L0791 Blood unit, price per one unit 250.00L0799 IV (Intravenous) ileoprost 1,617.00L0800 Psychotherapy, individual, combined 480.00L0801 Psychiatric clinic evaluation 231.00L0802 Diagnostic interview/intake 231.00L0803 Home visit, member of psychiatric team 198.00L0804 Home visit, psychiatric team 543.00L0805 Comprehensive cognitive testing, 3 visits 1,583.00L0806 Multiprofessional evaluation for rehabilitation planning 2,183.00L0807 Psychological assessment for rehabilitation framework 1,430.00L0808 Psychodiagnostic assessment - full battery 1,430.00L0809 Psychodiagnostic assessment - partial battery 734.00L0820 Psychiatric hospital day care, adult, all hospitals 549.00L0821 Psychiatric hospital day care, children and adolescents, all hospitals 588.00L0822 Psychiatric community day care, adult 593.00L0823 Psychiatric community day care, children and adolescents 639.00L0841 Psychotherapy/counseling, individual 347.00L0843 Patient's treatment framework assessment 1,430.00L0846 Family or conjoint therapy/counseling 581.00L0849 Psychotherapy, group, per session 162.00L0885 Psychotherapy/counselling, group, institutions/families/schools 734.00L0886 Guidance for other agencies, individual, within service site 405.00L0887 Guidance for other agencies, goup, within service site 275.00L0888 Guidance for other agencies, outside service site 581.00L0899 Psychosocial diagnosis and evaluation 245.00L0911 Hearing test, complete, anamnesis, child 342.00L0914 Biofeedback training, gastroenterology, single session 473.00L0915 Biofeedback training, gastroenterology, 6 sessions 2,840.00L0934 Circulating anticoagulants, eg, LAC 486.00L0959 Sexual counseling and therapy 572.00L0962 ER (Emergency room) medical examination 399.00L0964 ER (Emergency room) fee 267.00L0969 Collar or sling, including materials 188.00L1015 Enzymes activity with cells separation, six or more enzymes 1,830.00L1028 US (ultrasound), with image documentation 480.00L1030 FibroScan for assessment of liver fibrosis 638.00L1039 CT (Computed Tomography), excluding tests with specific code 863.00L1040 CTA / CTArthro / CT urography, per patient, excluding thorax coronary arteries

CTA 1,551.00

L1077 Surgical obturator, assessment and preparation 15,449.00

Service code Service name

Price for Patient

from Abroad

(ILS)

L1079 Interim obturator 8,112.00L1080 Definitive obturator 22,212.00L1133 Establishing paternity, per patient, including medical forensic opinion 2,505.00L1139 Pilot medical examination 2,057.00L1275 CTA chest, coronary arteries 3,821.00L1611 Initial insertion/replacement of speech prosthesis post laryngectomy 3,920.00L1720 Bladder instillation of Mitomycin, per treatment, including material 1,470.00L1721 Bladder hyperthermia and Mitomycin instillation, per treatment 6,209.00L1922 CT under general anesthesia 2,510.00L1996 Chronic pain control, infiltration 416.00L1997 Chronic pain control, nerves block, using fluoroscopic guidance, with contrast

material 2,079.00

L1998 Chronic pain control, nerves block, using fluoroscopic guidance, with neurolytic substance 2,079.00

L2001 Radiofrequency treatment for pain control, per treatment 6,620.00L2002 Loading of pump for spasticity treatment, Baclofen 4,797.00L2003 Ozone treatment for skin ulcers, per day 330.00L2004 Negative pressure treatment for skin ulcers, per session 852.00L2005 Maggot debridement therapy, per session 680.00L2013 Acetylcholinesterase, Ab - serum 543.00L2136 OCT3 (Optical Coherence Tomography), per patient 483.00L2196 Pelvis/genitalia MRI, excluding prostate 3,102.00L2197 Prostate MRI 6,197.00L2250 Fundus photography, two eyes 480.00L2340 Optometry by an optometrist, per patient 194.00L2498 Corneal imaging 254.00L2528 Nasal potential difference measurements for cystic fibrosis diagnonsis 2,136.00L2529 Rectal biopsy sampling and testing for Cystic Fibrosis diagnosis, per patient 2,136.00L2585 Auditory screening test, OAE, infant 0.00L2586 Auditory screening test, AABR, infant 0.00L2588 OAE (Otoacoustic Emissions), diagnostic 119.00L2589 Auditory screening test, AABR, subsequent test, baby 240.00L2699 Extracorporeal shock wave lithotripsy, salivary glands 6,992.00L2731 Fibronectin 627.00L2999 Arthroscopy, complex and/or high skill surgical procedures, using implants 20,663.00L3003 ECG monitoring, Flecainide infusion, IV 936.00L3013 Rapid urease test, helicobacter pylori, child - exhaled air 66.00L3239 Biopsy, additional payment to EUS, excluding EUS (Endoscopic ultrasound) 3,258.00L3250 Endoscopic polyp marking, in addition to endoscopy, per patient 1,161.00L3255 Balloon enteroscopy 15,152.00L3307 TTE (transthoracic echocardiography), child 621.00L3560 Patella radiology, up to two views, per side 171.00L3562 Patella radiology, third or more additional views 188.00L3620 Toe(s) radiology, up to two views 171.00L3621 Calcaneus radiology, up to two views 171.00L3711 Apolipoprotein E, genotype 591.00L3727 Implantation of loop recorder system, including retrieval of recorded and stored

ECG data, physician review and interpretation of retrieved ECG data, per ILR 17,136.00

L3795 External Counter Pulsation Therapy (ECPT) / Enhanced External Counter Pulsation (EECP) therapy 954.00

L3799 Rehabilitation workshop, lung diseases patients, per session 99.00L3890 Apolipoprotein E4, genotype 1,410.00L3900 Prenatal molecular diagnostics, age 35-37 years, including lab tests and US 3,582.00L3902 Prenatal molecular diagnostics, over 37 years of age, including lab tests and US

2,351.00

L4110 Porphobilinogen deaminase, quantitative - RBC 618.00L4152 Hospital circumcision, excluding newborn 3,485.00L4233 Her-2/neu, immunohistochemistry 486.00L4234 Her-2/neu, FISH method 4,251.00L4283 Enema 36.00L4298 Electrolytes, sodium and potassium 35.00L4450 Urethrocystography, retrograde, under sedation 1,608.00L4581 Additional charge for device for implantation/replacement of sacral nerve

stimulation electrode/lead 12,876.00

Service code Service name

Price for Patient

from Abroad

(ILS)

L4583 Additional charge for device for implantation/replacement of sacral nerve stimulation generator 57,727.00

L4612 Botolinum Toxin, 30 units Dysport administration 366.00L4705 hCG and PAPP-A, quantitative - serum 254.00L4793 Ambulatory evaluaiton of TB suspected patient 2,145.00L4794 Basic evaluation of Mantoux positive patient 263.00L4795 Treatment of active TB patient, first 5 months 10,263.00L4796 Treatment of active TB patient, last month 13,380.00L4797 Evaluation of close contact of Tb patient 852.00L4798 Ambulatory treatment of close contact patient, prevention 300.00L4799 Ambulatory pharmacological treatment of close contact patient, last month 401.00L4990 Genotype characterization by caryotype analysis 4,149.00L4991 Malignancies genotype, FISH (Fluorescent in Situ Hybridization) 1,856.00L4992 Malignancies genotype, DNA index 1,383.00L4999 Orotic acid - urine 117.00L5339 Laser, additional payment to endoscopy, excluding endoscopy 1,481.00L5378 Colonoscopy, flexible; diagnostic, with/without collection of specimen(s) 1,491.00L5400 Endoscopic Argon laser treatment 512.00L5441 Femur head from bone bank 2,210.00L5461 Kappa or Lambda light chain, Ig, free - blood 483.00L5799 Angiography 4,418.00L5810 Polysomnography, including EEG, child 1,589.00L5858 Tensilon test for myasthenia gravis; with electromyographic recording 725.00L5872 Single fiber electromyography, per patient 1,020.00L5925 Sensory evoked potentials (SEP) study, per patient 633.00L5990 Minor ambulatory surgery, including foreign body removal, local anesthesia 441.00L6002 Cytokins 399.00L6015 Gliadin, Ab 311.00L6031 Intraocular injection of Bevacizumab (Avastin) 929.00L6160 KRAS mutation, per patient 2,187.00L6171 Additional charge for intraocular shunt, eg, Ex-PRESS, for trabeculectomy 3,748.00L6312 CA 72.4 tumor antigen 185.00L6313 NSE (Neuron specific enolase), tumor antigen 185.00L6316 Immunoassay for tumor antigen, quantitative; CA 21-1 164.00L6358 Lymphocyte CD antigen determination, over 6 CD 3,863.00L6375 CT (Computed tomographic) virtual colonoscopy 1,562.00L6414 Hickman placement, angiography guidance 4,289.00L6415 Hickman placement under general anasthesia 6,429.00L6416 Portacath placement, angiography guidance 6,218.00L6417 Portacath placement under general anasthesia 8,558.00L6418 Declotting by thrombolytic agent of Hickman/portacath catheter 236.00L6497 Copying video, echo, catheterization, CD 138.00L6498 Administrative radiologic procedure 54.00L6499 Administrative radiologic procedure 26.00L6520 Low density lipoprotein (LDL) apheresis 13,776.00L6550 Oncological treatment, adult, with chemotherapeutic/biological medications, per

patient per day 1,956.00

L6551 Oncological treatment, child, with chemotherapeutic/biological medications, per patient per day 2,541.00

L6552 Oncological/hematological treatment, adult, without chemotherapeutic/ biological medications, per patient per day 1,175.00

L6553 Oncological/hematological treatment, child, without chemotherapeutic/ biological medications, per patient per day 1,526.00

L6611 Bartonella henselae (Cat scratch) IgG - blood 348.00L6612 Bartonella henselae (Cat scratch) IgM - blood 348.00L6689 HIV or HTLV resistance to medication 3,566.00L6705 HBV, HCV and HIV-1 detection, NAT, at blood bank 185.00L6707 Hepatitis E, Ab 347.00L6762 Rubella virus IgG or IgM 171.00L6776 Toxoplasma, Sabin Feldman dye test 306.00L6777 Toxoplasmosis confirmation test 794.00L6778 Toxoplasma avidity testing 423.00L6815 Ultrasound, pregnant uterus, without image documentation 440.00L6821 Ophthalmic YAG laser treatment, per patient 576.00L6822 Ophthalmic Argon laser treatment, per patient 447.00L6830 Creation of arteriovenous fistula for renal dialysis, native or using graft 18,083.00

Service code Service name

Price for Patient

from Abroad

(ILS)

L6831 Therapeutic catheterization of AV shunt for renal dialysis, native/with graft 30,402.00L6849 Interferon Ab 461.00L6856 Pelvis US, nonobstetric, with image documentation, complete 480.00L6857 Hips US 480.00L7001 Physiotherapy, evaluation and treatment planning, child 536.00L7002 Isokinetic assessment and treatment planning 354.00L7003 Occupational therapy, evaluation and treatment planning, child 536.00L7004 Isokinetic physiotherapeutic treatment 296.00L7118 NTM (Non Tuberculous Mycobacteria) identification 569.00L7140 Physiotherapy/rehabilitation, group, up to 4 individuals, including child, per

individual 116.00

L7154 Toxoplasma, molecular diagnostics - body fluids 1,557.00L7204 Spermatic veins embolization 10,455.00L7210 Photocoagulation, PDT, retina, including material 15,258.00L7525 Replacement/repositioning of biliary drain, percutaneous 3,888.00L7619 Malignant hyperthermia diagnosis test (muscle biopsy) 11,921.00L7751 Brachytherapy, gynecological 14,640.00L7752 Brachytherapy, lung cancer 9,134.00L7753 Brachytherapy, prostate cancer treatment 58,548.00L7771 Occupational therapy, group 116.00L8074 Adrenal imaging, medulla, I-123 MIBG, up to 7 years of age 14,129.00L8075 Adrenal imaging, medulla, I-123 MIBG, over 7 years of age 24,524.00L8076 Adrenal imaging, cortex 14,408.00L8170 Semen production from testis, surgical 8,490.00L8180 Chemotherapy resistance, Facs 1,122.00L8181 CD membrane antigen, up to 4 antigens 1,616.00L8182 Testes removal, for sperm isolation; cadaver, at the forensic medicine institute

1,628.00

L8183 Pathological specimen, preparation of slides, at the forensic medicine institute132.00

L8184 DNA analysis in liquid blood, soft tissue, semen, at the forensic institute 3,536.00L8186 DNA analysis in dry blood, at the forensic institute 3,726.00L8188 DNA analysis in bone tissue, at the forensic institute 12,999.00L8190 Harvesting of cardiac valve (homograft bank) 2,226.00L8213 Aminolevulinic acid dehydratase (ALA-D), quantitative - RBC 927.00L8242 Allogeneic donor lymphocyte infusions, DLI 4,959.00L8244 Allogeneic lymphocyte proliferation 7,460.00L8245 Allogeneic lymphocyte activation 47,195.00L8250 Chromosome 1 and 19 analysis, per patient 2,646.00L8252 FLT3 and NPM1 internal random duplications, PCR 1,092.00L8268 Cholyl-14-C-Glycine breath test for bile salts deconjugationL8269 C-13 urea test, helicobacter pylori - exhaled air 221.00L8299 Spleen imaging, with heated RBC (red blood cells) 1,548.00L8307 Examination of abortus for diagnosis of malformations 8,210.00L8379 EGFR (Epidermal Growth Factor Receptor) mutation, per patient 1,470.00L8380 ALK mutation, per patient 3,830.00L8381 BRAF mutation, per patient 975.00L8410 Porphyrins, qualitative - plasma 209.00L8411 Porphyrins, chromatography - plasma 788.00L8412 Porphyrins, chromatography - urine 729.00L8413 Porphyrins, chromatography - feces 834.00L8414 Porphyrins, chromatography - RBC 905.00L8599 Pulmonary imaging, dynamic, mucociliary clearence 5,037.00L8802 Somatostatin receptor scintegraphy 27,866.00L8970 First stage IVF, including hormonal tests 7,288.00L8971 First stage IVF, excluding hormonal tests 5,683.00L8972 Second stage IVF, excluding hospitalization days 8,790.00L8975 Ovarian tissue cryopreservation 7,241.00L8976 Cryopreserved ovarian tissue storage for 5 years 965.00L8977 Oocyte retrieval and cryopreservation, eg, vitrification 8,790.00L8978 Cryopreserved oocytes storage for 5 years 965.00L8979 Cryopreserved oocytes transfer, intrauterine, including thawing and fertilization

5,666.00

L9000 Radiopharmaceutical therapy, hyper-thyroidism 2,235.00L9015 Chorionic villus sampling, excluding laboratory processing and interpretation

641.00

Service code Service name

Price for Patient

from Abroad

(ILS)

L9030 Radiopharmaceutical ablation of gland for thyroid carcinoma 9,215.00L9035 Radiopharmaceutical therapy for metastases of thyroid carcinoma 14,625.00L9079 Injection (eg, neurolytic substance) 129.00L9080 Medical opinion for appointment of legal guardian, including completion of form

and reports 900.00

L9183 Emergency hyperbaric oxygen therapy, excluding diving accidents 15,443.00L9184 Hyperbaric pretreatment assessment 2,180.00L9201 Physician consulation for a patient insured by another sick fund 219.00L9211 Fire arm license physician examination 162.00L9212 Driving license physician examination 162.00L9215 Fire arm license specialist examination 480.00L9232 Routine examinations for candidates for renal transplantation 6,924.00L9241 Perenatal genetic consultation 764.00L9242 Examination by medical specialist for appointment of legal guardian, for established

patient 342.00

L9243 Genetic consultation 764.00L9244 Physician examination, oncologist 343.00L9245 Physician examination, hematologist 343.00L9246 Physician examination, hemato-oncologist 343.00L9247 Physician examination, internal physician 343.00L9248 Physician examination, urologist 343.00L9249 Physician examination, orthopedic physician 343.00L9250 Stammering treatment, individual/group, per course 11,978.00L9251 Stammering treatment, individual/group, per patient/session 230.00L9252 Physician examination, alergologist 343.00L9253 Physician examination, endocrinologist 343.00L9254 Physician examination, otorhinolaryngologist 343.00L9255 Physician examination, obstetrician/gynecologist 343.00L9256 Physician examination, genetician 343.00L9257 Physician examination, gastroenterologist 343.00L9258 Physician examination, pediatrician 343.00L9259 Cryopreservation, sperm, any additional year, up to 5 test tubes/straws 429.00L9260 Physician examination, surgeon 343.00L9261 Physician examination, thoracic surgeon 343.00L9262 Physician examination, vascular surgeon 343.00L9263 Physician examination, hand surgeon 343.00L9264 Physician examination, maxillofacial surgeon 343.00L9265 Physician examination, proctologist surgeon 343.00L9266 Physician examination, breast surgeon 343.00L9267 Physician examination, plastic surgeon 343.00L9268 Physician examination, anesthesiologist 343.00L9269 Physician examination, neurosurgeon 343.00L9270 Physician examination, neurologist 343.00L9271 Consultation with a specialist 572.00L9273 Physician examination, nephrologist 343.00L9274 Physician examination, dermatologist 343.00L9275 Physician examination, ophthalmologist 343.00L9276 Physician examination, cardiologist 343.00L9277 Physician examination, rheumatologist 343.00L9278 Physician examination, pulmonologist 343.00L9279 Physician examination, rehabilitation physician 343.00L9281 Emergency physician consulation at sick fund clinic 359.00L9301 Clinic nurse evaluation for a patient insured by another sick fund 156.00L9311 Home visit, nurse 194.00L9321 Outpatient social treatment 194.00L9331 Rehabilitative day care center - long term 374.00L9342 Prosthesis extension 347.00L9343 Sheltered housing, per day 47.00L9345 Care hostel, per day 173.00L9346 Care hostel, extended, per day 215.00L9347 Short term treatment center, per day 162.00L9348 Club activity, per month, 8 visits at least, child 465.00L9349 Treatment boarding school services, per month 9,498.00L9350 Club activity, per month, 8 visits at least 374.00L9351 Occupational club activity, per day 59.00L9352 Sheltered factory, per day 89.00

Service code Service name

Price for Patient

from Abroad

(ILS)

L9353 Occupational rehabilitation, extended, per day 107.00L9354 Sheltered housing, extended, per day 117.00L9355 School, per month, child/adolescent 1,463.00L9359 Medical evaluation based on documents 161.00L9360 Risk assessment of sex offenders 4,677.00L9377 Physician services in parent home 347.00L9379 Physician services in hostel 188.00L9394 Physician services in boarding school 116.00L9413 Medical records printout 57.00L9420 Calibration of instruments for measuring radiation 944.00L9480 Results reporting, free of charge 0.00L9490 Follow up service, free of charge 0.00L9499 Social worker services 209.00L9500 Medical examination, first visit - child development 879.00L9501 Medical examination, follow up - child development 525.00L9502 Psychological cognitive testing - child development 1,085.00L9503 Family workup and diagnosis - child development 525.00L9504 Psychoneurology assessment - child development 1,485.00L9505 Cognitive evaluation for rehabilitation - child development 1,349.00L9506 Learning disabilities evaluation - child development 1,830.00L9507 Multidisciplinary team for rehabilitation - child development 1,845.00L9510 Speech therapy, evaluation and treatment planning - child development 536.00L9511 Aquatic physiotherapy/rehabilitation, group, up to 4 individuals, inculding child,

hydrotherapy 207.00

L9512 Speech therapy, individual - child development 273.00L9513 Occupational therapy, individual - child development 273.00L9514 Physiotherapy, individual - child development 299.00L9516 Psycho/behavioral therapy - child development 333.00L9517 Developmental examination - nurse - child development 237.00L9518 Therapy/counseling, family/conjoint - child development 731.00L9519 Biofeedback training - child development 588.00L9520 Evaluation of supportive communication - child development 1,946.00L9521 Staff meeting with parents - child development 656.00L9523 Multiprofessional consulation for parents - child development 204.00L9525 Additional consulation - child development 254.00L9528 Physiotherapy, group - child development 215.00L9529 Speech therapy, group - child development 215.00L9530 Occupational therapy, group - child development 215.00L9600 Home visit, health care professional - child development 384.00L9617 Neuropsychological tests before epilepsy surgery 1,740.00L9637 Plerixafor (Mozobil) injection, including medication, per patient per cycle (up to 4

days) 104,002.00

L9855 Induced abortion, surgical, including curettage 3,791.00L9856 Induced abortion, pharmaceutical 2,730.00L9857 Induced abortion, surgical, following pharmaceutical abortion 0.00L9899 Prenatal course 825.00L9900 Provision of therapeutic radiopharmaceutical(s) 1,133.00L9999 Radiopharmaceutical therapy, pheochromocytoma/neuroblastoma; I-131-MIBG

37,619.00

G0018 Transjugular intrahepatic portosystemic stent/shunt, TIPS 30,368.00G0024 Obstetric and neonatal hospitalization 5,268.00G0026 Preterm infant hospitalization 5,268.00G0028 Cryotherapy of prostatic cancer 32,110.00G0031 Insertion of stent to abdominal aortic aneurysm, stent graft 103,320.00G0032 Bone marrow transplantation, haploid, including stem cells separation 534,479.00G0033 Isolated limb perfusion in patient with sarcoma 98,016.00G0035 Interventional neuroradiology for intracranial aneurysm embolization/occlusion by

catheterization, including use of stent, eg, SILK, and coils 86,099.00

G0036 Insertion of intraocular lens, lens included 7,589.00G0037 Tension free vaging tape for incontinence (TVT) 7,770.00G0045 Mastectomy, bilateral 23,776.00G0047 Breast reconstruction, bilateral 26,098.00G0048 Breast reconstruction following mastectomy, bilateral 45,692.00G0049 Breast reconstruction following mastectomy, unilateral 27,697.00G0050 Breast reconstruction, unilateral, including nipple reconstruction 22,960.00

Service code Service name

Price for Patient

from Abroad

(ILS)

G0051 Mastectomy, unilateral 15,848.00G0054 Lower extremities veins surgery, including varicose veins 10,718.00G0055 Blood vessels surgery, including nonautogenous graft 56,044.00G0057 Lung transplantation 341,603.00G0058 Heart-lung transplant 478,248.00G0059 Bone marrow transplantation; allogenic 317,168.00G0060 Bone marrow transplantation; autologous 208,378.00G0061 Renal and/or pancreas transplantation 227,736.00G0062 Heart transplantation 341,603.00G0063 Liver transplantation 984,369.00G0064 Corneal surgery, including cost of cornea 19,516.00G0066 Inguinal/femoral hernia repair, hospital day care 5,196.00G0067 Craniotomy 63,558.00G0070 Open prostatectomy 18,011.00G0072 Heart surgery, including bypass 74,142.00G0073 Diagnostic catheterization 14,341.00G0074 Therapeutic catheterization, excluding cardiac catheterization 33,607.00G0075 Hysterectomy 14,837.00G0077 Transurethral prostatectomy 11,128.00G0078 Hospital circumcision, excluding newborn 3,485.00G0083 Osteotomy of spine, including implants, diskectomy 27,655.00G0084 Osteotomy of spine, including implants - other surgeries 50,785.00G0085 Cardiac catheterization, therapeutic, including insertion of drug eluting stent(s)

40,303.00

G0089 Treatment of heavy burns 193,637.00G0090 Treatment of medium burns 110,645.00G0096 Laparoscopic gastric banding, excluding band cost 12,131.00G0100 Additional charge for DRG in multiple trauma, admission from ER 11,480.00G0101 ORIF/CRIF of pelvis, closed/open fracture 59,900.00G0102 Arthroplasty with prosthetic replacement/implant of radial head, excluding open

fracture 35,016.00

G0103 Arthroplasty with prosthetic replacement/implant of radial head, open fracture57,600.00

G0104 ORIF of foot, closed fracture, excluding calcaneus 37,856.00G0105 ORIF of foot, open fracture, excluding calcaneus 57,600.00G0106 ORIF of calcaneus/operation on femur, excluding neck, closed fracture 30,413.00G0107 ORIF of calcaneus/operation on femur, excluding neck, open fracture 47,633.00G0108 Operation on clavicle/humerus/forearm, closed fracture, including closed dislocation

of acromioclavicular joint, excluding distal humerus and shaft of radius/ulna, including bone graft

26,050.00

G0109 Operation on clavicle/humerus/forearm, open fracture, including open dislocation of acromioclavicular joint, excluding distal humerus and shaft of radius/ulna 38,792.00

G0110 ORIF/CRIF/EF of tibia and/or fibula, closed fracture 35,125.00G0111 ORIF/CRIF/EF of tibia and/or fibula, open fracture, including use of bone marrow

aspiration concentrate 60,466.00

G0112 ORIF of patella/ankle / CRIF of calcaneus, closed fracture 21,333.00G0113 ORIF of patella/ankle / CRIF of calcaneus, open fracture 35,349.00G0114 CRIF of ankle/foot, closed fracture, excluding calcaneus 11,970.00G0115 CRIF of ankle/foot, open fracture, excluding calcaneus 22,527.00G0116 Exploration of tendon/nerve of upper limb, including ganglion decompression/lysis

of adhesions 7,490.00

G0117 Suture of extensor tendons of hand, including delayed suture 12,642.00G0118 Suture of tendons/nerves of upper limb, including delayed suture, excluding

extensor tendons of hand 21,641.00

G0120 ORIF/EF of phalange of hand, closed fracture, including bone graft 12,909.00G0121 ORIF/EF of phalange of hand, open/complex fracture 19,122.00G0122 ORIF/EF of phalange of hand, with suture of tendons/nerves, closed/open fracture

28,874.00

G0123 ORIF/EF of phalanges of hand, closed fractures, including bone graft 18,779.00G0124 ORIF/EF of phalanges of hand, open/complex fractures 25,467.00G0125 ORIF/EF of phalanges of hand, with suture of tendons/nerves, closed/open fractures

35,219.00

G0126 ORIF/EF of metacarpal, closed fracture, including bone graft 14,219.00G0127 ORIF/EF of metacarpal, open/complex fracture 20,539.00G0128 ORIF/EF of metacarpal, with suture of tendons/nerves, closed/open fracture 30,291.00

Service code Service name

Price for Patient

from Abroad

(ILS)

G0129 ORIF/EF of metacarpals, closed fractures, including bone graft 22,109.00G0130 ORIF/EF of metacarpals, open/complex fractures 29,067.00G0131 ORIF/EF of metacarpals, with suture of tendons/nerves, closed/open fractures 38,821.00G0132 ORIF of carpal(s), closed fracture, including bone graft 18,817.00G0133 ORIF of carpal(s), open/complex fracture, including bone graft 25,507.00G0134 ORIF of carpal(s), with suture of tendons/nerves, closed/open fracture, including

bone graft 35,260.00

G0135 CRIF of hand, with suture of tendons/nerves, closed/open fracture(s) 32,279.00G0136 Open reduction of closed dislocation of wrist 22,109.00G0137 Open reduction of open/complex dislocation of wrist 29,067.00G0138 Open reduction of dislocation of wrist, with suture of tendons/nerves 38,821.00G0139 Reattachment of any part of upper extremity 66,025.00G0140 Open/close reduction of fracture(s) of zygoma/maxilla/mandible, including internal

fixation 22,571.00

G0141 Open reduction of fractures of orbit/ Le Fort type 2 or 3 / TMJ fracture with dislocation, with insertion of synthetic implant/bone graft to facial bone 35,051.00

G0142 Open reduction of comminuted fractures of facial bones, with insertion of synthetic implant/bone graft 99,971.00

G0144 ORIF of distal humerus, closed fracture, including bone graft 35,016.00G0145 ORIF of distal humerus, open fracture 57,600.00G0146 ORIF/EF of shaft of radius/ulna, closed fracture, including bone graft 19,731.00G0147 ORIF/EF of shaft of radius/ulna, open fracture 35,349.00G0148 CRIF of distal humerus/forearm/hand, closed fracture, including bone graft 11,074.00G0149 CRIF of distal humerus/forearm/hand, open fracture, including complex fracture(s)

of hand 22,527.00

G0150 Removal of gastric band 12,131.00G0151 Sleeve gastrectomy 41,898.00G0152 Sleeve gastrectomy with removal of gastric band 42,991.00G0153 Sleeve gastrectomy with repair of diaphragmatic hernia 42,991.00G0154 Sleeve gastrectomy with total cholecystectomy 44,326.00G0155 Gastric bypass surgery with removal of gastric band 52,788.00G0156 Gastric bypass surgery with repair of diaphragmatic hernia 52,788.00G0157 Gastric bypass surgery with total cholecystectomy 54,031.00G0158 Laparoscopic ovarian tissue retrieval 6,532.00G0160 Implantation/replacement/removal of cochlear prosthetic device, excluding device

cost 14,657.00

G0161 Repair of cystocele with graft/prosthesis 10,652.00G0162 Repair of rectocele with graft/prosthesis 10,652.00G0163 Repair of cystocele and rectocele with graft/prosthesis 17,340.00G0164 Repair of cystocele with graft/prosthesis and tension free vaging tape for

incontinence 15,794.00

G0165 Repair of rectocele with graft/prosthesis and tension free vaging tape for incontinence 15,794.00

G0166 Repair of cystocele and rectocele with graft/prosthesis and tension free vaging tape for incontinence 22,484.00

G0167 Percutaneous insertion of left atrial appendage device, excluding device cost 12,118.00G0168 Implantation of diaphragmatic pacemaker, excluding device cost 15,654.00G0169 Pump for spasticity treatment preimplantation assessment, Baclofen 13,032.00G0175 Open cholecystectomy, partial/complete 15,895.00G0176 Laparoscopic cholecystectomy, partial/complete 15,895.00G00A1 Transcatheter placement of an intravascular stent graft, thoracic aorta 166,370.00G00A2 Hyperbaric chamber treatment of patients injured in diving accidents, up to 8 hours

33,032.00

G00A3 Hyperbaric chamber treatment of patients injured in diving accidents, over 8 hours, and/or using a mixture of gases eg, Heliox 44,805.00

G00A4 Spermatic veins embolization 10,455.00G00A5 Chemotherapy administration, inpatients, in addition to inpatient day charge 4,134.00G00A6 Open/closed reduction with internal fixation of fracture of neck of femur or internal

fixation only of fracture of neck of femur 25,499.00

G00A8 Insertion of biventricular cardiac pacemaker 51,419.00G00A9 Insertion of cardiac pacemaker/defibrillator, excluding machine costG00B1 Repair of cleft lip 18,272.00G00B2 Correction of cleft palate (including Push-Back palatoplasty) 18,272.00G00B3 Revision of cleft palate repair, velopharyngoplasty 18,272.00G00B4 Repair of cleft lip & limited rhinoplasty, for cleft palate 18,272.00G00B5 Closure of fistulae of mouth, for cleft palate 12,384.00

Service code Service name

Price for Patient

from Abroad

(ILS)

G00B6 Bone graft to facial bone, for cleft palate 21,704.00G00B7 Bone distraction osteogenesis jaw without internal device, for cleft palate 18,272.00G00B8 Orthognatic surgery, for cleft palate 36,196.00G00C1 Fallopian tube catheterization, diagnostic or therapeutic 5,615.00G00C2 Radiofrequency ablation of liver lesion(s) (tumor or metastases) 13,966.00G00C3 Esophageal dilation and insertion of stent 23,801.00G00C4 Minimally invasive radioguided parathyroidectomy (MIRP) 5,881.00G00C5 Local excision of lesion or tissue of bone (i.e. osteoid osteoma), using CT guidance

8,681.00

G00C6 Intra-amniotic injection for late abortion 3,141.00G00C7 Arthroplasty with prosthetic replacement or implant of total or partial wrist (distal

radius, carpocarpal or carpometacarpal joints) 11,691.00

G00C8 Arthroplasty with prosthetic replacement or implant of foot or toe joint 20,262.00G00D1 Implantation or replacement of artificial urinary sphincter 45,919.00G00D2 Insertion of skin tissue expander(s), excluding breast 19,499.00G00D3 Closed (percutaneous) biopsy of brain, stereotactic method including burr holes

14,680.00

G00D4 Orthopedic oncologic surgery, excision of soft tissues 61,200.00G00D5 Orthopedic oncologic surgery, revision of an artificial joint or implant 194,777.00G00D6 Orthopedic oncologic surgery, complex amputation or disarticulation 70,458.00G00D7 Orthopedic oncologic surgery, destructive and reconstructive surgery 174,380.00G00D8 Thoracic surgery 37,795.00G00D9 Implantation or replacement of intracranial neurostimulator 132,448.00G00E1 Intra-arterial administration of chemotherapy or chemoembolization, under

angiography 12,042.00

G00E2 Arthroscopy, diagnostic and/or surgical procedures, without using implants 10,332.00G00E3 Arthroscopy, complex and/or high skill surgical procedures, using implants 20,663.00G00E4 Arthroscopy, complex, unusual surgical procedures, including cartilage

transplantation 27,551.00

G00E5 Insertion (initial or replacement) of single or dual chamber cardiac pacemaker 25,864.00G00E6 Radical trachelectomy and lymphadenectomy 16,056.00G00E7 Brachytherapy for ocular tumors 28,700.00G00E8 Implantation of vagus (vagal) nerve stimulator (VNS) ("pacemaker") for epilepsy

140,845.00

G00E9 Video and radio-telemetered electroencephalographic monitoring 44,277.00G00F1 Creation of arteriovenous fistula for renal dialysis, native or using graft 18,083.00G00F2 Laparoscopic gastric bypass 51,693.00G00F3 Thoracic sympathectomy 8,559.00G00F4 Thyroidectomy, complete/partial 15,499.00G00F5 Gastrectomy, total/partial 52,782.00G00F6 Laparoscopic appendectomy 16,890.00G00F7 Whipple operation (radical pancreatic duodenectomy or radical subtotal

pancreatectomy) 91,840.00

G00F8 Vertebroplasty 9,186.00G00F9 Wada test 10,028.00G00G1 Catheterization, insertion of umbrella like device for repair of cardial septal defects

or patent ductus arteriosus (PDA) 74,142.00

G00G2 Kyphoplasty 43,542.00G00G3 Mastectomy, partial (eg, lumpectomy), excludes biopsy of breast 8,036.00G00G4 Brachytherapy, prostate cancer treatment 58,548.00G00G5 Therapeutic catheterization of AV shunt for renal dialysis, native/with graft 30,402.00G00G6 Extracorporeal shockwave lithotripsy, salivary stones 6,992.00G00G7 Deflux injection, vesicoureteral reflux therapy, unilateral 10,022.00G00G8 Deflux injection, vesicoureteral reflux therapy, bilateral 17,705.00G00G9 Extracorporeal shockwave lithotripsy, kidney; simple 9,117.00G00H2 Inpatient, per day, up to 3 days in acute care hospital, excluding departments with

specific code 5,268.00

G00H4 Inpatient, per day, for fourth day or longer in acute care hospital, excluding departments with specific code 4,584.00

G00H5 Inpatient, per day, Dermatology and Venereology Department in acute care hospital4,584.00

G00H6 Inpatient, per day, Ophthalmology and Pediatric Ophthalmology Departments in acute care hospital 4,584.00

G00H7 Inpatient, per day, Rehabilitation Department in acute care hospital 4,584.00G00J3 Inpatient day, Acute Geriatric, Pulmonary and Tuberculosis Departments, geriatric

hospitals and centers 3,546.00

Service code Service name

Price for Patient

from Abroad

(ILS)

G00J4 Inpatient day, Geriatric Rehabilitation Department, geriatric hospitals and centers2,218.00

G00J5 Inpatient day, Complex Care Nursing Department, geriatric hospitals and centers1,338.00

G00J7 Inpatient day, Departments for the Independent, geriatric hospitals and centers490.00

G00J8 Inpatient day, Departments for the Frail, geriatric hospitals and centers 782.00G00M1 Inpatient day, Department of Internal Medicine in acute care hospital 3,732.00G00M2 Inpatient day, Rheumatology Department in acute care hospital 3,732.00G00M3 Inpatient day, Department of Pulmonary Medicine in acute care hospital 3,732.00G00M4 Inpatient day, Department of Geriatric Internal Medicine in acute care hospital

3,732.00

G00M5 Inpatient day, Gastroenterology Department in acute care hospital 3,732.00G00M6 Inpatient day, Observation Department in acute care hospital 3,732.00G00N1 Inpatient day, General Intensive Care Department in acute care hospital 4,584.00G00N3 Inpatient day, Respiratory Intensive Care Department in acute care hospital 4,584.00G00N5 Inpatient day, Pediatric Intensive Care Department in acute care hospital 4,584.00G00N7 Inpatient day, Neurosurgical Intensive Care Department in acute care hospital 4,584.00G00N9 Additional inpatient day charge, up to 4, in Intensive Care Departments: General,

Respirtory, Pediatric and Neurosurgical 9,176.00

G00P1 Inpatient day, Acute geriatric Department in acute care hospital 2,776.00G00P2 Inpatient day, Geriatric Rehabilitation Department in acute care hospital 2,776.00G00P3 Inpatient day, Department of high Dependency Nursing in acute care hospital 2,776.00G00Q1 Acute inpatient day, psychiatric departments, all hospitals 1,906.00G00Q2 Long term inpatient day, psychiatric departments, all hospitals 1,466.00G00Q3 Inpatient day, children and adolescents, psychiatric departments, all hospitals 2,290.00G00Q7 Artificial liver therapy, eg, MARS, additional inpatient day charge 36,381.00G00Q8 Chronic artificial ventilation care, per day, all hospitals 2,962.00G00R1 Extracorporeal shockwave lithotripsy, kidney; complex 28,632.00G00R2 Closed percutaneous biopsy using CT guidance 6,887.00G00R3 Closed percutaneous biopsy using MRI guidance 10,332.00G00R4 Continuous intra-arterial administration of chemotherapeutic substance 18,354.00G00R5 Vertebral excision and fusion 174,380.00G00R6 Vertebral refusion 194,777.00G00R7 Secondary insertion of intraocular lens prosthesis 3,221.00G00R8 Single suture loop pupilloplasty 5,151.00G00R9 Removal of vitreous 13,956.00G00S1 Bronchoscopy, rigid or flexible, with placement of bronchial stent(s) (including

tracheal/bronchial dilation as required) 17,798.00

G00S2 Partial/primary hip/shoulder replacement 40,180.00G00S3 Total joint replacement and/or revision 44,285.00G00S4 Radical neck lymph nodes dissection, unilateral/bilateral 25,404.00G00S5 Lobectomy of liver 75,212.00G00S6 Partial hepatectomy 42,098.00G00S7 Maxillectomy, total/partial, for insertion of surgical obturator 36,177.00G00S8 Stereotactic radiosurgery, brain 45,069.00G00S9 Implantation of heart assist system 518,390.00G00T1 Bone Anchored Hearing Aid (BAHA), adult 46,661.00G00T2 Bone Anchored Hearing Aid (BAHA), child 50,255.00G00T3 Isolated limb perfusion in patient with melanoma 98,016.00G00T4 Colonoscopy, with dilation and stent placement 23,801.00G00T5 Removal of heart pacemaker lead(s) (electrodes) without replacement 32,039.00G00T6 Removal of heart pacemaker lead(s) (electrodes) with replacement of electrodes and

pacemaker device 44,974.00

G00T7 Scoliosis/kyphosis repair operation 112,406.00G00T8 Emergency coronary artery catheterization for removal of obstruction, including

insertion of drug eluting stent(s) 49,708.00

G00T9 Radical hysterectomy, abdominal/vaginal 22,960.00G00U1 Colorectal surgery 46,009.00G00U2 Surgical fistulization of lacrimal tract to nasal cavity using balloon dilatation,

including dacryocystorhinostomy 6,690.00

G00U3 Intravenous injection of tPA, acute cerebrovascular stroke within 3 hours of stroke symptoms 40,180.00

G00U4 Therapeutic catheterization, acute cerebrovascular stroke within 8 hours of stroke symptoms 103,320.00

G00U5 Functional endoscopic nasal/sinus surgery (FESS), simple 13,775.00

Service code Service name

Price for Patient

from Abroad

(ILS)

G00U6 Functional endoscopic nasal/sinus surgery (FESS), complex 33,052.00G00U7 Tonsillectomy without/with adenoidectomy 3,786.00G00U8 Implantation of intrathecal pump system for spasticity treatment, Baclofen 76,158.00G00U9 Enucleation of eyeball 13,812.00G00V1 Implantation of vertical expandable prosthetic titanium rib system 155,573.00G00V2 Lengthening and adjustment of vertical expandable prosthetic titanium rib system

22,359.00

G00V3 Replacement of vertical expandable prosthetic titanium rib system implants 50,048.00G00V4 Percutaneous pulmonary valve replacement, excluding valve cost 37,762.00G00V5 Percutaneous aortic valve replacement, excluding valve cost 42,983.00G00V6 Repair of inguinal/femoral hernia, unilateral, inpatient 9,904.00G00V7 Repair of inguinal/femoral hernia, bilateral, inpatient 13,202.00G00V8 Plastic surgery following significant weight loss 31,464.00G00W1 Scleral buckling with implant 9,872.00G00W2 Trabeculectomy 4,778.00G00W3 Intraocular valve implantation, eg, Ahmed, for glaucoma therapy 13,071.00G00W4 Repair of blepharoptosis, under 18 years 7,623.00G00W5 Repair of blepharoptosis, 18 years and older 4,723.00G01H4 Inpatient, per day, for fourth day or longer in acute care hospital, excluding

departments with specific code - out of cap 4,584.00

G01H5 Inpatient, per day, Dermatology and Venereology Department in acute care hospital - out of cap 4,584.00

G01H6 Inpatient, per day, Ophthalmology and Pediatric Ophthalmology Departments in acute care hospital - out of cap 4,584.00

G01H7 Inpatient, per day, Rehabilitation Department in acute care hospital - out of cap4,584.00

G01M1 Inpatient day, Department of Internal Medicine in acute care hospital - out of cap3,732.00

G01M2 Inpatient day, Rheumatology Department in acute care hospital - out of cap 3,732.00G01M3 Inpatient day, Department of Pulmonary Medicine in acute care hospital - out of cap

3,732.00

G01M4 Inpatient day, Department of Geriatric Internal Medicine in acute care hospital - out of cap 3,732.00

G01M5 Inpatient day, Gastroenterology Department in acute care hospital - out of cap3,732.00

G01M6 Inpatient day, Observation Department in acute care hospital - out of cap 3,732.00G01N1 Inpatient day, General Intensive Care Department in acute care hospital - out of cap

4,584.00

G01N3 Inpatient day, Respiratory Intensive Care Department in acute care hospital - out of cap 4,584.00

G01N5 Inpatient day, Pediatric Intensive Care Department in acute care hospital - out of cap4,584.00

G01N7 Inpatient day, Neurosurgical Intensive Care Department in acute care hospital - out of cap 4,584.00

G01P1 Inpatient day, Acute geriatric Department in acute care hospital - out of cap 2,776.00G01P2 Inpatient day, Geriatric Rehabilitation Department in acute care hospital - out of cap

2,776.00

G01P3 Inpatient day, Department of high Dependency Nursing in acute care hospital - out of cap 2,776.00

G01Q8 Chronic artificial ventilation care, per day, all hospitals - out of cap 2,962.00