Direct Compensation Affinity Plan
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Direct Compensation Affinity Plan

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Direct Compensation Affinity Plan Direct Compensation Affinity Plan Document Transcript

  • Nevada Pacific Dental AFFINITY Schedule of Benefits ADA Code Description Member Copayment DIAGNOSTIC D0120 Periodic Oral Evaluation 0 D0140 Limited Oral Evaluation (Problem focused) 0 D0150 Comprehensive Oral Evaluation 0 D0160 Detail & Extensive Oral Eval (Specialist Only) 0 D0170 Re-evaluation - limited 0 D0180 Comprehensive Periodontal Evaluation 0 D0210 Full Mouth X-rays 0 D0220 Single Film 0 D0230 Additional Films 0 D0240 Occlusal Film 0 D0270 1 Bitewing Film 0 D0272 2 Bitewing Films 0 D0274 4 Bitewing Films 0 D0277 Vertical Bitewings - 7 to 8 films 0 D0290 X-ray Post-ant.or Lat. Skull/Fac.Bone Film 0 D0310 Sialography 0 D0330 Panorex Film 0 D0340 Cephalometric 0 D0415 Bacteriologic Study 0 D0425 Caries Susceptibility Tests 0 D0460 Pulp Vitality Tests 0 D0470 Diagnostic Casts 0 D0999 Unspecified Diagnostic Procedure, by report 0 PREVENTIVE D1110 Prophylaxis, Adult 0 D1120 Prophylaxis, Children 0 D1201 Prophy w/ Fluoride Child 0 D1203 Flouride w/o Prophy Child (BY REPORT) 0 D1204 Flouride w/o Prophy Adult (BY REPORT) 0 D1205 Prophy w/ Fluoride Adult 0 D1310 Nutritional Counseling (w/licensed dietician) 0 D1330 Oral Hygiene Instruction (No RVU Value) 0 D1351 Sealant,per tooth (1 series per 24 months to age 16. Perm.1st & 2nd molars only) 5 D1510 Fixed Space Maintainer Unilateral 33 D1515 Fixed Lingual/Palatal Bar 46 D1525 Space Maint. Rem. Bilat 39 D1550 Recementation Space Maint. 10 RESTORATIVE D2140 Amalgam One Surface 12 D2150 Amalgam Two Surface 15 D2160 Amalgam Three Surface 18 D2161 Amalgam Four + Surface 22 D2330 Resin 1 Surface Anterior 16 D2331 Resin 2 Surface Anterior 24 D2332 Resion 3 Surface Anterior 26 D2335 Resin 4 Surface/Incis. Angle Ant. 26 D2720 Crown Resin Hi Noble 158 ADA Code Description Member Copayment RESTORATIVE D2721 Crown Resin Predom. Base 159 D2722 Crown Resin Noble 167 D2740 Porcelain Crown 219 D2750 Porcelain with Gold Crown 239 D2751 Porcelain with Metal Crn. 201 D2752 Porcelain Semiprec. Crown 219 D2790 Full Gold Crown 219 D2791 Full Metal Crn. 219 D2792 Crown, Noble Metal 223 D2810 3/4 Gold Crown 219 D2910 Inlay Recementation 17 D2920 Crown Recementation 18 D2930 Prefab. Stain. St. Crown prim 38 D2931 Prefab. Stain. St. Crown perm 45 D2932 Prefab. Resin Crown 39 D2940 Sedative Fillings 22 D2950 Core Build Up w/ pins 50 D2951 Pin Retention, per tooth 17 D2952 Cast Post and Core 93 D2953 Each Additional Cast Post 93 D2954 Prefab Post and Core 41 D2970 Temporary Crown - fractured tooth 48 D2980 Crown Repair 30 D2999 Unspecified Restorative Procedure, by report 0 ENDODONTICS D3110 Pulp Capping 16 D3120 Pulp Cap-Indirect 12 D3220 Pulpotomy 24 D3230 Pulpal Therapy - Anterior, Primary Tooth 24 D3240 Pulpal Therapy - Posterior, Primary Tooth 24 D3310 Root Canal, Anterior 114 D3320 Root Canal, Bicuspid 157 D3330 Root Canal, Molar 200 D3346 Retreatment of RCT - Anterior 157 D3347 Retreatment of RCT - Bicuspid 200 D3348 Retreatment of RCT - Molar 261 D3351 Apexification, 1st visit 43 D3410 Apicoectomy Surgery - Anterior 109 D3421 Apicoectomy Surgery-Bicuspid (1st root) 171 D3425 Apicoectomy Surgery, Molar (1st root) 257 D3426 Apicoectomy Surgery, (each additional root) 134 D3430 Retrograde Filling 134 D3450 Root Amputation 86 D3920 Endodontic Hemisection 35 D3999 Unspecified Endodontic Procedure, by report 0 PERIODONTICS D4210 Gingivectomy - 4+ teeth 89 D4211 Gingivectomy - 1 To 3 teeth 43 CDT-4 (9/1/03) Nevada Pacific Dental 1432 South Jones Blvd. Las Vegas, NV 89146 (702) 737-8900 (800) 926-0925 Fax (702) 259-8381
  • CDT-4 (9/1/03) Nevada Pacific Dental 1432 South Jones Blvd. Las Vegas, NV 89146 (702) 737-8900 (800) 926-0925 Fax (702) 259-8381 ADA Code Description Member Copayment PERIODONTICS D4240 Ging. Flap - 4+ teeth 40 D4241 Ging. Flap - 1 to 3 teeth 26 D4260 Osseous Surgery - 4+ teeth 239 D4261 Osseous Surgery - 1 to 3 teeth 158 D4270 Pedicle Soft Tiss. Proc. 162 D4271 Free Soft Tiss. Graft 162 D4341 Root Planing - 4+ teeth 57 D4342 Root Planing - 1 to 3 teeth 38 D4355 Full Mouth Debridement 30 D4910 Perio. Maint. 22 D4999 Unspecified Periodontal Procedure, by report 0 PROSTHODONTICS - REMOVABLE D5110 Complete Upper Denture 323 D5120 Complete Lower Denture 323 D5130 Immediate Upper 304 D5140 Immediate Lower 304 D5211 Upper Partial - Resin Base 195 D5212 Lower Partial - Resin Base 173 D5213 Upper Partial - Cast Mtl Frame w/Resin Bases 173 D5214 Lower Partial - C159 345 D5410 Adjust Complete Denture - Upper 18 D5411 Adjust Complete Denture - Lower 11 D5421 Adjust Partial Denture - Upper 33 D5422 Adjust Partial - Lower 33 D5510 Repair Broken Complete Denture Base 27 D5520 Replace Missing/Broken Teeth - (each tooth) 25 D5610 Repair Acrylic Saddle 28 D5620 Repair Framework 24 D5630 Repair/Replace Broken Clasp 30 D5640 Replace Broken Teeth - per tooth 34 D5650 Add Tooth to Existing Partial 38 D5660 Add Clasp to Existing Partial 62 D5670 Replace all Teeth - Maxillary 176 D5671 Replace all Teeth - Mandibular 156 D5710 Rebase Complete Denture - Upper 143 D5711 Rebase Complete Denture - Lower 98 D5720 Rebase Partial Denture - Upper 98 D5721 Rebase Partial Denture - Lower 98 D5730 Reline Complete Denture - Lower (Chairside) 73 D5731 Reline Complete Denture - Upper (Chairside) 73 D5740 Reline Partial Upper (Chairside) 73 D5741 Reline Partial Lower (Chairside) 73 D5750 Reline Comp. Denture Upper (Lab) 88 D5751 Reline Comp. Denture Lower (Lab) 73 D5760 Reline Partial Upper (Lab) 75 D5761 Reline Partial Lower (Lab) 75 D5820 Interim Partial Upper 76 D5821 Interim Partial Lower 73 D5850 Tissue Conditioning - Upper 29 D5851 Tissue Conditioning - Lower 29 PROSTHODONTICS - FIXED D6210 Pontic - Cast High Noble Metal 189 D6211 Pontic - Cast Predominantly Base Metal 187 D6212 Pontic - Cast Noble Metal 185 D6240 Pontic - Porcelain Fused to High Noble Metal 183 ADA Code Description Member Copayment PROSTHODONTICS - FIXED D6241 Pontic - Porcelain Fused to Predom. Base Metal 217 D6242 Pontic - Porcelain Fused to Noble Metal 211 D6250 Pontic - Resin w/ High Noble Metal 179 D6251 Pontic - Resin with Predominantly Base Metal 178 D6252 Pontic - Resin w/ Noble Metal 202 D6545 Retainer-Cast Mtl/Resin Bonded Fixed Prosthesis 112 D6720 Crown - Resin w/ High Noble Metal 174 D6721 Crown - Resin w/ Predoninantly Base Metal 175 D6722 Crown - Resin with Noble Metal 198 D6740 Crown- Porc/Ceramic 198 D6750 Crown - Porclain Fused to High Noble Metal 233 D6751 Crown - Porcelain Fused to Predom. Base Metal 209 D6752 Crown - Porcelain Fused to Noble Metal 182 D6780 Crown - 3/4 Cast High Noble Metal 219 D6790 Crown - Full Cast High Noble Metal 219 D6791 Crown - Full Cast Predominantly Base Metal 219 D6792 Crown - Full Cast Noble Metal 219 D6930 Recement Bridge 26 D6970 Cast Post and Core 61 D6971 Cast Post and Core w/ Bridge 54 D6972 Prefab. Post and Core 44 D6980 Bridge Repair - by report 29 D6999 Unspecified, Fixed Prosthodontic Proc., report 0 ORAL AND MAXILLOFACIAL SURGERY D7111 Coronal Remnants - Deciduous Tooth 16 D7140 Extraction, Erupted Tooth or Exposed Root 26 D7210 Surgical Extraction 36 D7220 Impacted (soft tissue) 50 D7230 Impacted (partially bony) 62 D7240 Impacted (completely bony) 80 D7241 Impaction (unusual complications) 114 D7250 Root Removal - Surgical 46 D7280 Surgical Access of Unerupted Tooth 46 D7281 Surgical Exposure for Eruption 46 D7282 Mobilization of Erupted Tooth 46 D7285 Biopsy - hard 80 D7286 Biopsy -Soft 80 D7287 Cytology Sample Collection 0 D7290 Surgical Repositioning 65 D7291 Transseptal Fiberotomy 15 D7310 Alveolectomy (w/ extrac.) 36 D7320 Alveolectomy per quadrant 38 D7340 Vestibuloplasty, Simple (spec. ony) 125 D7350 Vestibuloplasty, Extensive (spec. only) 200 D7410 Excision Benign to 1.25 cm 48 D7450 Removal Benign Odontogenic to 1.25 cm 76 D7460 Removal Benign Nonodontogenic to 1.25 cm 80 D7471 Removal of Lateral Exostosis 48 D7472 Removal of Torus Palatinus 50 D7473 Removal of Torus Mandibularis 50 D7485 Surgical Reduction of Tuberosity 50 D7510 I & D - Intraoral 23 D7530 Removal of Foreign Body, Skin or Subcutaneous Alveolar Tissue 40 D7540 Removal of Reaction-Producing Foreign Bodies, Musculoskeletal System 40
  • CDT-4 (9/1/03) Nevada Pacific Dental 1432 South Jones Blvd. Las Vegas, NV 89146 (702) 737-8900 (800) 926-0925 Fax (702) 259-8381 ADA Code Description Member Copayment ORAL AND MAXILLOFACIAL SURGERY D7550 Part Ostectomy/Sequestrectomy 60 D7910 Suture Wounds to 5 cm 0 D7960 Frenulectomy 35 ADJUNCTIVE GENERAL SERVICES D9110 Palliative (Emergency) Treatment of Dental Pain - Minor Procedure 12 D9230 Analgesia (pedo. only) 0 D9310 Consultation (diagnostic service provided by dentist or physician orhter than provider of service) 0 D9420 Hospital call 25 D9430 Office Visit for Observation (no other procedures performed) 0 ADA Code Description Member Copayment ADJUNCTIVE GENERAL SERVICES D9440 Office Visit - After Regularly Scheduled Hours 25 D9450 Case Presentation 0 D9930 Treatment of Complications (post-surgical) - Unusual Circumstances, by report 0 D9940 Occlusal Guard, by report 25 D9941 Fabrication of Athletic Mouthgard 0 D9951 Occlusal Adjustment - Limited 20 D9952 Occlusal Adjustment - Complete 60 D9999 Unspecified Adjunctive Procedure, by report 0 10001 Failed Appointment (without 24 hour notice) 25 10002 Canceled Appointment 0 10003 Continued Treatment 0