Direct Compensation Advantage Plan
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  • 1. Nevada Pacific Dental ADVANTAGE Schedule of Benefits ADA Code Description Member Copayment DIAGNOSTIC D0120 Periodic Oral Evaluation 15 D0140 Limited Oral Evaluation (Problem focused) 15 D0150 Comprehensive Oral Evaluation 15 D0160 Detail & Extensive Oral Eval (Specialist Only) 15 D0170 Re-evaluation - limited 15 D0180 Comprehensive Periodontal Evaluation 15 D0210 Full Mouth X-rays 15 D0220 Single Film 8 D0230 Additional Films 3 D0240 Occlusal Film 8 D0270 1 Bitewing Film 3 D0272 2 Bitewing Films 6 D0274 4 Bitewing Films 10 D0277 Vertical Bitewings - 7 to 8 films 10 D0290 X-ray Post-ant.or Lat. Skull/Fac.Bone Film 10 D0310 Sialography 10 D0330 Panorex Film 15 D0340 Cephalometric 15 D0415 Bacteriologic Study 15 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 15 D1120 Prophylaxis, Children 15 D1201 Prophy w/ Fluoride Child 15 D1203 Flouride w/o Prophy Child (BY REPORT) 15 D1204 Flouride w/o Prophy Adult (BY REPORT) 15 D1205 Prophy w/ Fluoride Adult 15 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 175 D2750 Porcelain with Gold Crown 195 D2751 Porcelain with Metal Crn. 175 D2752 Porcelain Semiprec. Crown 185 D2790 Full Gold Crown 196 D2791 Full Metal Crn. 170 D2792 Crown, Noble Metal 185 D2810 3/4 Gold Crown 187 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 36 D2940 Sedative Fillings 13 D2950 Core Build Up w/ pins 37 D2951 Pin Retention, per tooth 15 D2952 Cast Post and Core 59 D2953 Each Additional Cast Post 59 D2954 Prefab Post and Core 43 D2970 Temporary Crown - fractured tooth 20 D2980 Crown Repair 30 D2999 Unspecified Restorative Procedure, by report 0 ENDODONTICS D3110 Pulp Capping 8 D3120 Pulp Cap-Indirect 12 D3220 Pulpotomy 14 D3230 Pulpal Therapy - Anterior, Primary Tooth 20 D3240 Pulpal Therapy - Posterior, Primary Tooth 20 D3310 Root Canal, Anterior 68 D3320 Root Canal, Bicuspid 81 D3330 Root Canal, Molar 161 D3346 Retreatment of RCT - Anterior 81 D3347 Retreatment of RCT - Bicuspid 161 D3348 Retreatment of RCT - Molar 240 D3351 Apexification, 1st visit 25 D3410 Apicoectomy Surgery - Anterior 86 D3421 Apicoectomy Surgery-Bicuspid (1st root) 171 D3425 Apicoectomy Surgery, Molar (1st root) 257 D3426 Apicoectomy Surgery, (each additional root) 134 D3430 Retrograde Filling 61 D3450 Root Amputation 48 D3920 Endodontic Hemisection 56 D3999 Unspecified Endodontic Procedure, by report 0 PERIODONTICS D4210 Gingivectomy - 4+ teeth 57 D4211 Gingivectomy - 1 To 3 teeth 18 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 40 D4241 Ging. Flap - 1 to 3 teeth 26 D4260 Osseous Surgery - 4+ teeth 150 D4261 Osseous Surgery - 1 to 3 teeth 99 D4270 Pedicle Soft Tiss. Proc. 162 D4271 Free Soft Tiss. Graft 162 D4341 Root Planing - 4+ teeth 23 D4342 Root Planing - 1 to 3 teeth 15 D4355 Full Mouth Debridement 25 D4910 Perio. Maint. 17 D4999 Unspecified Periodontal Procedure, by report 0 PROSTHODONTICS - REMOVABLE D5110 Complete Upper Denture 247 D5120 Complete Lower Denture 248 D5130 Immediate Upper 248 D5140 Immediate Lower 248 D5211 Upper Partial - Resin Base 168 D5212 Lower Partial - Resin Base 173 D5213 Upper Partial - Cast Mtl Frame w/Resin Bases 212 D5214 Lower Partial - C159 206 D5410 Adjust Complete Denture - Upper 0 D5411 Adjust Complete Denture - Lower 0 D5421 Adjust Partial Denture - Upper 27 D5422 Adjust Partial - Lower 27 D5510 Repair Broken Complete Denture Base 25 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 21 D5660 Add Clasp to Existing Partial 46 D5670 Replace all Teeth - Maxillary 151 D5671 Replace all Teeth - Mandibular 156 D5710 Rebase Complete Denture - Upper 94 D5711 Rebase Complete Denture - Lower 94 D5720 Rebase Partial Denture - Upper 79 D5721 Rebase Partial Denture - Lower 75 D5730 Reline Complete Denture - Lower (Chairside) 42 D5731 Reline Complete Denture - Upper (Chairside) 43 D5740 Reline Partial Upper (Chairside) 43 D5741 Reline Partial Lower (Chairside) 43 D5750 Reline Comp. Denture Upper (Lab) 72 D5751 Reline Comp. Denture Lower (Lab) 73 D5760 Reline Partial Upper (Lab) 75 D5761 Reline Partial Lower (Lab) 75 D5820 Interim Partial Upper 74 D5821 Interim Partial Lower 73 D5850 Tissue Conditioning - Upper 22 D5851 Tissue Conditioning - Lower 22 PROSTHODONTICS - FIXED D6210 Pontic - Cast High Noble Metal 179 D6211 Pontic - Cast Predominantly Base Metal 156 D6212 Pontic - Cast Noble Metal 171 D6240 Pontic - Porcelain Fused to High Noble Metal 185 ADA Code Description Member Copayment PROSTHODONTICS - FIXED D6241 Pontic - Porcelain Fused to Predom. Base Metal 167 D6242 Pontic - Porcelain Fused to Noble Metal 177 D6250 Pontic - Resin w/ High Noble Metal 165 D6251 Pontic - Resin with Predominantly Base Metal 154 D6252 Pontic - Resin w/ Noble Metal 162 D6545 Retainer-Cast Mtl/Resin Bonded Fixed Prosthesis 87 D6720 Crown - Resin w/ High Noble Metal 183 D6721 Crown - Resin w/ Predoninantly Base Metal 175 D6722 Crown - Resin with Noble Metal 166 D6740 Crown- Porc/Ceramic 166 D6750 Crown - Porclain Fused to High Noble Metal 194 D6751 Crown - Porcelain Fused to Predom. Base Metal 185 D6752 Crown - Porcelain Fused to Noble Metal 192 D6780 Crown - 3/4 Cast High Noble Metal 192 D6790 Crown - Full Cast High Noble Metal 198 D6791 Crown - Full Cast Predominantly Base Metal 185 D6792 Crown - Full Cast Noble Metal 187 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 25 D6999 Unspecified, Fixed Prosthodontic Proc., report 0 ORAL AND MAXILLOFACIAL SURGERY D7111 Coronal Remnants - Deciduous Tooth 8 D7140 Extraction, Erupted Tooth or Exposed Root 13 D7210 Surgical Extraction 22 D7220 Impacted (soft tissue) 43 D7230 Impacted (partially bony) 62 D7240 Impacted (completely bony) 80 D7241 Impaction (unusual complications) 83 D7250 Root Removal - Surgical 37 D7280 Surgical Access of Unerupted Tooth 37 D7281 Surgical Exposure for Eruption 37 D7282 Mobilization of Erupted Tooth 37 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.) 34 D7320 Alveolectomy per quadrant 38 D7340 Vestibuloplasty, Simple (spec. ony) 125 D7350 Vestibuloplasty, Extensive (spec. only) 200 D7410 Excision Benign to 1.25 cm 38 D7450 Removal Benign Odontogenic to 1.25 cm 38 D7460 Removal Benign Nonodontogenic to 1.25 cm 80 D7471 Removal of Lateral Exostosis 38 D7472 Removal of Torus Palatinus 38 D7473 Removal of Torus Mandibularis 38 D7485 Surgical Reduction of Tuberosity 38 D7510 I & D - Intraoral 23 D7530 Removal of Foreign Body, Skin or Subcutaneous Alveolar Tissue 32 D7540 Removal of Reaction-Producing Foreign Bodies, Musculoskeletal System 32
  • 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 25 D7910 Suture Wounds to 5 cm 0 D7960 Frenulectomy 25 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