Direct Compensation Meadows Plan
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Direct Compensation Meadows Plan

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Direct Compensation Meadows Plan Direct Compensation Meadows Plan Document Transcript

  • Nevada Pacific Dental MEADOWS Schedule of Benefits ADA Code Description Member Copayment DIAGNOSTIC D0120 Periodic Oral Evaluation 6 D0140 Limited Oral Evaluation (Problem focused) 9 D0150 Comprehensive Oral Evaluation 9 D0160 Detail & Extensive Oral Eval (Specialist Only) 9 D0170 Re-evaluation - limited 9 D0180 Comprehensive Periodontal Evaluation 6 D0210 Full Mouth X-rays 19 D0220 Single Film 4 D0230 Additional Films 2 D0240 Occlusal Film 5 D0270 1 Bitewing Film 3 D0272 2 Bitewing Films 6 D0274 4 Bitewing Films 9 D0277 Vertical Bitewings - 7 to 8 films 9 D0290 X-ray Post-ant.or Lat. Skull/Fac.Bone Film 9 D0310 Sialography 9 D0330 Panorex Film 15 D0340 Cephalometric 15 D0415 Bacteriologic Study 15 D0425 Caries Susceptibility Tests 15 D0460 Pulp Vitality Tests 7 D0470 Diagnostic Casts 14 D0999 Unspecified Diagnostic Procedure, by report 0 PREVENTIVE D1110 Prophylaxis, Adult 13 D1120 Prophylaxis, Children 9 D1201 Prophy w/ Fluoride Child 14 D1203 Flouride w/o Prophy Child (BY REPORT) 5 D1204 Flouride w/o Prophy Adult (BY REPORT) 5 D1205 Prophy w/ Fluoride Adult 17 D1310 Nutritional Counseling (w/licensed dietician) 6 D1330 Oral Hygiene Instruction (No RVU Value) 7 D1351 Sealant,per tooth (1 series per 24 months to age 16. Perm.1st & 2nd molars only) 46 D1510 Fixed Space Maintainer Unilateral 77 D1515 Fixed Lingual/Palatal Bar 90 D1525 Space Maint. Rem. Bilat 10 D1550 Recementation Space Maint. 0 RESTORATIVE D2140 Amalgam One Surface 17 D2150 Amalgam Two Surface 21 D2160 Amalgam Three Surface 25 D2161 Amalgam Four + Surface 30 D2330 Resin 1 Surface Anterior 20 D2331 Resin 2 Surface Anterior 25 D2332 Resion 3 Surface Anterior 32 D2335 Resin 4 Surface/Incis. Angle Ant. 32 D2720 Crown Resin Hi Noble 416 ADA Code Description Member Copayment RESTORATIVE D2721 Crown Resin Predom. Base 303 D2722 Crown Resin Noble 309 D2740 Porcelain Crown 446 D2750 Porcelain with Gold Crown 424 D2751 Porcelain with Metal Crn. 329 D2752 Porcelain Semiprec. Crown 349 D2790 Full Gold Crown 391 D2791 Full Metal Crn. 359 D2792 Crown, Noble Metal 369 D2810 3/4 Gold Crown 433 D2910 Inlay Recementation 33 D2920 Crown Recementation 32 D2930 Prefab. Stain. St. Crown prim 90 D2931 Prefab. Stain. St. Crown perm 97 D2932 Prefab. Resin Crown 112 D2940 Sedative Fillings 34 D2950 Core Build Up w/ pins 92 D2951 Pin Retention, per tooth 16 D2952 Cast Post and Core 141 D2953 Each Additional Cast Post 141 D2954 Prefab Post and Core 119 D2970 Temporary Crown - fractured tooth 80 D2980 Crown Repair 30 D2999 Unspecified Restorative Procedure, by report 0 ENDODONTICS D3110 Pulp Capping 25 D3120 Pulp Cap-Indirect 19 D3220 Pulpotomy 57 D3230 Pulpal Therapy - Anterior, Primary Tooth 74 D3240 Pulpal Therapy - Posterior, Primary Tooth 61 D3310 Root Canal, Anterior 257 D3320 Root Canal, Bicuspid 305 D3330 Root Canal, Molar 401 D3346 Retreatment of RCT - Anterior 337 D3347 Retreatment of RCT - Bicuspid 388 D3348 Retreatment of RCT - Molar 481 D3351 Apexification, 1st visit 97 D3410 Apicoectomy Surgery - Anterior 273 D3421 Apicoectomy Surgery-Bicuspid (1st root) 321 D3425 Apicoectomy Surgery, Molar (1st root) 343 D3426 Apicoectomy Surgery, (each additional root) 119 D3430 Retrograde Filling 76 D3450 Root Amputation 118 D3920 Endodontic Hemisection 145 D3999 Unspecified Endodontic Procedure, by report 0 PERIODONTICS D4210 Gingivectomy - 4+ teeth 64 D4211 Gingivectomy - 1 To 3 teeth 24 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 99 D4241 Ging. Flap - 1 to 3 teeth 65 D4260 Osseous Surgery - 4+ teeth 177 D4261 Osseous Surgery - 1 to 3 teeth 117 D4270 Pedicle Soft Tiss. Proc. 114 D4271 Free Soft Tiss. Graft 140 D4341 Root Planing - 4+ teeth 37 D4342 Root Planing - 1 to 3 teeth 24 D4355 Full Mouth Debridement 21 D4910 Perio. Maint. 21 D4999 Unspecified Periodontal Procedure, by report 0 PROSTHODONTICS - REMOVABLE D5110 Complete Upper Denture 471 D5120 Complete Lower Denture 455 D5130 Immediate Upper 505 D5140 Immediate Lower 497 D5211 Upper Partial - Resin Base 321 D5212 Lower Partial - Resin Base 385 D5213 Upper Partial - Cast Mtl Frame w/Resin Bases 523 D5214 Lower Partial - C159 523 D5410 Adjust Complete Denture - Upper 26 D5411 Adjust Complete Denture - Lower 26 D5421 Adjust Partial Denture - Upper 29 D5422 Adjust Partial - Lower 26 D5510 Repair Broken Complete Denture Base 54 D5520 Replace Missing/Broken Teeth - (each tooth) 45 D5610 Repair Acrylic Saddle 54 D5620 Repair Framework 61 D5630 Repair/Replace Broken Clasp 68 D5640 Replace Broken Teeth - per tooth 48 D5650 Add Tooth to Existing Partial 61 D5660 Add Clasp to Existing Partial 71 D5670 Replace all Teeth - Maxillary 289 D5671 Replace all Teeth - Mandibular 347 D5710 Rebase Complete Denture - Upper 177 D5711 Rebase Complete Denture - Lower 177 D5720 Rebase Partial Denture - Upper 162 D5721 Rebase Partial Denture - Lower 178 D5730 Reline Complete Denture - Lower (Chairside) 97 D5731 Reline Complete Denture - Upper (Chairside) 97 D5740 Reline Partial Upper (Chairside) 94 D5741 Reline Partial Lower (Chairside) 97 D5750 Reline Comp. Denture Upper (Lab) 145 D5751 Reline Comp. Denture Lower (Lab) 145 D5760 Reline Partial Upper (Lab) 148 D5761 Reline Partial Lower (Lab) 148 D5820 Interim Partial Upper 186 D5821 Interim Partial Lower 192 D5850 Tissue Conditioning - Upper 48 D5851 Tissue Conditioning - Lower 48 PROSTHODONTICS - FIXED D6210 Pontic - Cast High Noble Metal 401 D6211 Pontic - Cast Predominantly Base Metal 303 D6212 Pontic - Cast Noble Metal 378 D6240 Pontic - Porcelain Fused to High Noble Metal 417 ADA Code Description Member Copayment PROSTHODONTICS - FIXED D6241 Pontic - Porcelain Fused to Predom. Base Metal 369 D6242 Pontic - Porcelain Fused to Noble Metal 385 D6250 Pontic - Resin w/ High Noble Metal 417 D6251 Pontic - Resin with Predominantly Base Metal 286 D6252 Pontic - Resin w/ Noble Metal 401 D6545 Retainer-Cast Mtl/Resin Bonded Fixed Prosthesis 160 D6720 Crown - Resin w/ High Noble Metal 309 D6721 Crown - Resin w/ Predoninantly Base Metal 366 D6722 Crown - Resin with Noble Metal 309 D6740 Crown- Porc/Ceramic 309 D6750 Crown - Porclain Fused to High Noble Metal 424 D6751 Crown - Porcelain Fused to Predom. Base Metal 372 D6752 Crown - Porcelain Fused to Noble Metal 394 D6780 Crown - 3/4 Cast High Noble Metal 401 D6790 Crown - Full Cast High Noble Metal 362 D6791 Crown - Full Cast Predominantly Base Metal 323 D6792 Crown - Full Cast Noble Metal 349 D6930 Recement Bridge 48 D6970 Cast Post and Core 145 D6971 Cast Post and Core w/ Bridge 177 D6972 Prefab. Post and Core 116 D6980 Bridge Repair - by report 77 D6999 Unspecified, Fixed Prosthodontic Proc., report 0 ORAL AND MAXILLOFACIAL SURGERY D7111 Coronal Remnants - Deciduous Tooth 12 D7140 Extraction, Erupted Tooth or Exposed Root 19 D7210 Surgical Extraction 37 D7220 Impacted (soft tissue) 45 D7230 Impacted (partially bony) 59 D7240 Impacted (completely bony) 69 D7241 Impaction (unusual complications) 77 D7250 Root Removal - Surgical 39 D7280 Surgical Access of Unerupted Tooth 39 D7281 Surgical Exposure for Eruption 39 D7282 Mobilization of Erupted Tooth 39 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.) 32 D7320 Alveolectomy per quadrant 39 D7340 Vestibuloplasty, Simple (spec. ony) 125 D7350 Vestibuloplasty, Extensive (spec. only) 250 D7410 Excision Benign to 1.25 cm 65 D7450 Removal Benign Odontogenic to 1.25 cm 85 D7460 Removal Benign Nonodontogenic to 1.25 cm 80 D7471 Removal of Lateral Exostosis 77 D7472 Removal of Torus Palatinus 50 D7473 Removal of Torus Mandibularis 50 D7485 Surgical Reduction of Tuberosity 50 D7510 I & D - Intraoral 25 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 14 D9230 Analgesia (pedo. only) 0 D9310 Consultation (diagnostic service provided by dentist or physician orhter than provider of service) 14 D9420 Hospital call 25 D9430 Office Visit for Observation (no other procedures performed) 9 ADA Code Description Member Copayment ADJUNCTIVE GENERAL SERVICES D9440 Office Visit - After Regularly Scheduled Hours 18 D9930 Treatment of Complications (post-surgical) - Unusual Circumstances, by report 10 D9940 Occlusal Guard, by report 83 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