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Direct Compensation Imperial Plan
Direct Compensation Imperial Plan
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Direct Compensation Imperial Plan

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  • 1. Nevada Pacific Dental IMPERIAL 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) 0 D1510 Fixed Space Maintainer Unilateral 0 D1515 Fixed Lingual/Palatal Bar 0 D1525 Space Maint. Rem. Bilat 0 D1550 Recementation Space Maint. 0 RESTORATIVE D2140 Amalgam One Surface 0 D2150 Amalgam Two Surface 0 D2160 Amalgam Three Surface 0 D2161 Amalgam Four + Surface 0 D2330 Resin 1 Surface Anterior 0 D2331 Resin 2 Surface Anterior 0 D2332 Resion 3 Surface Anterior 0 D2335 Resin 4 Surface/Incis. Angle Ant. 0 D2720 Crown Resin Hi Noble 0 ADA Code Description Member Copayment RESTORATIVE 0 D2721 Crown Resin Predom. Base 0 D2722 Crown Resin Noble 0 D2740 Porcelain Crown 0 D2750 Porcelain with Gold Crown 0 D2751 Porcelain with Metal Crn. 0 D2752 Porcelain Semiprec. Crown 0 D2790 Full Gold Crown 0 D2791 Full Metal Crn. 0 D2792 Crown, Noble Metal 0 D2810 3/4 Gold Crown 0 D2910 Inlay Recementation 0 D2920 Crown Recementation 0 D2930 Prefab. Stain. St. Crown prim 0 D2931 Prefab. Stain. St. Crown perm 0 D2932 Prefab. Resin Crown 0 D2940 Sedative Fillings 0 D2950 Core Build Up w/ pins 0 D2951 Pin Retention, per tooth 0 D2952 Cast Post and Core 0 D2953 Each Additional Cast Post 0 D2954 Prefab Post and Core 0 D2970 Temporary Crown - fractured tooth 0 D2980 Crown Repair 0 D2999 Unspecified Restorative Procedure, by report 0 ENDODONTICS D3110 Pulp Capping 0 D3120 Pulp Cap-Indirect 0 D3220 Pulpotomy 0 D3230 Pulpal Therapy - Anterior, Primary Tooth 0 D3240 Pulpal Therapy - Posterior, Primary Tooth 0 D3310 Root Canal, Anterior 0 D3320 Root Canal, Bicuspid 0 D3330 Root Canal, Molar 0 D3346 Retreatment of RCT - Anterior 0 D3347 Retreatment of RCT - Bicuspid 0 D3348 Retreatment of RCT - Molar 0 D3351 Apexification, 1st visit 0 D3410 Apicoectomy Surgery - Anterior 0 D3421 Apicoectomy Surgery-Bicuspid (1st root) 0 D3425 Apicoectomy Surgery, Molar (1st root) 0 D3426 Apicoectomy Surgery, (each additional root) 0 D3430 Retrograde Filling 0 D3450 Root Amputation 0 D3920 Endodontic Hemisection 0 D3999 Unspecified Endodontic Procedure, by report 0 PERIODONTICS D4210 Gingivectomy - 4+ teeth 0 D4211 Gingivectomy - 1 To 3 teeth 0 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
  • 2. 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 0 D4241 Ging. Flap - 1 to 3 teeth 0 D4260 Osseous Surgery - 4+ teeth 0 D4261 Osseous Surgery - 1 to 3 teeth 0 D4270 Pedicle Soft Tiss. Proc. 0 D4271 Free Soft Tiss. Graft 0 D4341 Root Planing - 4+ teeth 0 D4342 Root Planing - 1 to 3 teeth 0 D4355 Full Mouth Debridement 0 D4910 Perio. Maint. 0 D4999 Unspecified Periodontal Procedure, by report 0 PROSTHODONTICS - REMOVABLE D5110 Complete Upper Denture 0 D5120 Complete Lower Denture 0 D5130 Immediate Upper 0 D5140 Immediate Lower 0 D5211 Upper Partial - Resin Base 0 D5212 Lower Partial - Resin Base 0 D5213 Upper Partial - Cast Mtl Frame w/Resin Bases 0 D5214 Lower Partial - C159 0 D5410 Adjust Complete Denture - Upper 0 D5411 Adjust Complete Denture - Lower 0 D5421 Adjust Partial Denture - Upper 0 D5422 Adjust Partial - Lower 0 D5510 Repair Broken Complete Denture Base 0 D5520 Replace Missing/Broken Teeth - (each tooth) 0 D5610 Repair Acrylic Saddle 0 D5620 Repair Framework 0 D5630 Repair/Replace Broken Clasp 0 D5640 Replace Broken Teeth - per tooth 0 D5650 Add Tooth to Existing Partial 0 D5660 Add Clasp to Existing Partial 0 D5670 Replace all Teeth - Maxillary 0 D5671 Replace all Teeth - Mandibular 0 D5710 Rebase Complete Denture - Upper 0 D5711 Rebase Complete Denture - Lower 0 D5720 Rebase Partial Denture - Upper 0 D5721 Rebase Partial Denture - Lower 0 D5730 Reline Complete Denture - Lower (Chairside) 0 D5731 Reline Complete Denture - Upper (Chairside) 0 D5740 Reline Partial Upper (Chairside) 0 D5741 Reline Partial Lower (Chairside) 0 D5750 Reline Comp. Denture Upper (Lab) 0 D5751 Reline Comp. Denture Lower (Lab) 0 D5760 Reline Partial Upper (Lab) 0 D5761 Reline Partial Lower (Lab) 0 D5820 Interim Partial Upper 0 D5821 Interim Partial Lower 0 D5850 Tissue Conditioning - Upper 0 D5851 Tissue Conditioning - Lower 0 PROSTHODONTICS - FIXED D6210 Pontic - Cast High Noble Metal 0 D6211 Pontic - Cast Predominantly Base Metal 0 D6212 Pontic - Cast Noble Metal 0 D6240 Pontic - Porcelain Fused to High Noble Metal 0 ADA Code Description Member Copayment PROSTHODONTICS - FIXED D6241 Pontic - Porcelain Fused to Predom. Base Metal 0 D6242 Pontic - Porcelain Fused to Noble Metal 0 D6250 Pontic - Resin w/ High Noble Metal 0 D6251 Pontic - Resin with Predominantly Base Metal 0 D6252 Pontic - Resin w/ Noble Metal 0 D6545 Retainer-Cast Mtl/Resin Bonded Fixed Prosthesis 0 D6720 Crown - Resin w/ High Noble Metal 0 D6721 Crown - Resin w/ Predoninantly Base Metal 0 D6722 Crown - Resin with Noble Metal 0 D6740 Crown- Porc/Ceramic 0 D6750 Crown - Porclain Fused to High Noble Metal 0 D6751 Crown - Porcelain Fused to Predom. Base Metal 0 D6752 Crown - Porcelain Fused to Noble Metal 0 D6780 Crown - 3/4 Cast High Noble Metal 0 D6790 Crown - Full Cast High Noble Metal 0 D6791 Crown - Full Cast Predominantly Base Metal 0 D6792 Crown - Full Cast Noble Metal 0 D6930 Recement Bridge 0 D6970 Cast Post and Core 0 D6971 Cast Post and Core w/ Bridge 0 D6972 Prefab. Post and Core 0 D6980 Bridge Repair - by report 0 D6999 Unspecified, Fixed Prosthodontic Proc., report 0 ORAL AND MAXILLOFACIAL SURGERY D7111 Coronal Remnants - Deciduous Tooth 0 D7140 Extraction, Erupted Tooth or Exposed Root 0 D7210 Surgical Extraction 0 D7220 Impacted (soft tissue) 0 D7230 Impacted (partially bony) 0 D7240 Impacted (completely bony) 0 D7241 Impaction (unusual complications) 0 D7250 Root Removal - Surgical 0 D7280 Surgical Access of Unerupted Tooth 0 D7281 Surgical Exposure for Eruption 0 D7282 Mobilization of Erupted Tooth 0 D7285 Biopsy - hard 0 D7286 Biopsy -Soft 0 D7287 Cytology Sample Collection 0 D7290 Surgical Repositioning 0 D7291 Transseptal Fiberotomy 0 D7310 Alveolectomy (w/ extrac.) 0 D7320 Alveolectomy per quadrant 0 D7340 Vestibuloplasty, Simple (spec. ony) 0 D7350 Vestibuloplasty, Extensive (spec. only) 0 D7410 Excision Benign to 1.25 cm 0 D7450 Removal Benign Odontogenic to 1.25 cm 0 D7460 Removal Benign Nonodontogenic to 1.25 cm 0 D7471 Removal of Lateral Exostosis 0 D7472 Removal of Torus Palatinus 0 D7473 Removal of Torus Mandibularis 0 D7485 Surgical Reduction of Tuberosity 0 D7510 I & D - Intraoral 0 D7530 Removal of Foreign Body, Skin or Subcutaneous Alveolar Tissue 0 D7540 Removal of Reaction-Producing Foreign Bodies, Musculoskeletal System 0
  • 3. 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 0 D7910 Suture Wounds to 5 cm 0 D7960 Frenulectomy 0 ADJUNCTIVE GENERAL SERVICES D9110 Palliative (Emergency) Treatment of Dental Pain - Minor Procedure 0 D9230 Analgesia (pedo. only) 0 D9310 Consultation (diagnostic service provided by dentist or physician orhter than provider of service) 0 D9420 Hospital call 0 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 0 D9450 Case Presentation 0 D9930 Treatment of Complications (post-surgical) - Unusual Circumstances, by report 0 D9940 Occlusal Guard, by report 0 D9941 Fabrication of Athletic Mouthgard 0 D9951 Occlusal Adjustment - Limited 0 D9952 Occlusal Adjustment - Complete 0 D9999 Unspecified Adjunctive Procedure, by report 0 10001 Failed Appointment (without 24 hour notice) 0 10002 Canceled Appointment 0 10003 Continued Treatment 0

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