DIrect Compensation El Rancho Plan
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  • 1. Nevada Pacific Dental EL RANCHO 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 15 D1515 Fixed Lingual/Palatal Bar 34 D1525 Space Maint. Rem. Bilat 40 D1550 Recementation Space Maint. 4 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 4 D2331 Resin 2 Surface Anterior 6 D2332 Resion 3 Surface Anterior 9 D2335 Resin 4 Surface/Incis. Angle Ant. 12 D2720 Crown Resin Hi Noble 185 ADA Code Description Member Copayment RESTORATIVE D2721 Crown Resin Predom. Base 288 D2722 Crown Resin Noble 288 D2740 Porcelain Crown 185 D2750 Porcelain with Gold Crown 195 D2751 Porcelain with Metal Crn. 150 D2752 Porcelain Semiprec. Crown 288 D2790 Full Gold Crown 304 D2791 Full Metal Crn. 140 D2792 Crown, Noble Metal 185 D2810 3/4 Gold Crown 185 D2910 Inlay Recementation 20 D2920 Crown Recementation 11 D2930 Prefab. Stain. St. Crown prim 21 D2931 Prefab. Stain. St. Crown perm 25 D2932 Prefab. Resin Crown 50 D2940 Sedative Fillings 0 D2950 Core Build Up w/ pins 30 D2951 Pin Retention, per tooth 0 D2952 Cast Post and Core 50 D2953 Each Additional Cast Post 50 D2954 Prefab Post and Core 30 D2970 Temporary Crown - fractured tooth 15 D2980 Crown Repair 25 D2999 Unspecified Restorative Procedure, by report 0 ENDODONTICS D3110 Pulp Capping 5 D3120 Pulp Cap-Indirect 8 D3220 Pulpotomy 8 D3230 Pulpal Therapy - Anterior, Primary Tooth 20 D3240 Pulpal Therapy - Posterior, Primary Tooth 20 D3310 Root Canal, Anterior 50 D3320 Root Canal, Bicuspid 70 D3330 Root Canal, Molar 100 D3346 Retreatment of RCT - Anterior 85 D3347 Retreatment of RCT - Bicuspid 125 D3348 Retreatment of RCT - Molar 150 D3351 Apexification, 1st visit 43 D3410 Apicoectomy Surgery - Anterior 60 D3421 Apicoectomy Surgery-Bicuspid (1st root) 143 D3425 Apicoectomy Surgery, Molar (1st root) 153 D3426 Apicoectomy Surgery, (each additional root) 53 D3430 Retrograde Filling 20 D3450 Root Amputation 40 D3920 Endodontic Hemisection 40 D3999 Unspecified Endodontic Procedure, by report 0 PERIODONTICS D4210 Gingivectomy - 4+ teeth 72 D4211 Gingivectomy - 1 To 3 teeth 20 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 110 D4241 Ging. Flap - 1 to 3 teeth 72 D4260 Osseous Surgery - 4+ teeth 240 D4261 Osseous Surgery - 1 to 3 teeth 158 D4270 Pedicle Soft Tiss. Proc. 157 D4271 Free Soft Tiss. Graft 157 D4341 Root Planing - 4+ teeth 25 D4342 Root Planing - 1 to 3 teeth 16 D4355 Full Mouth Debridement 25 D4910 Perio. Maint. 25 D4999 Unspecified Periodontal Procedure, by report 0 PROSTHODONTICS - REMOVABLE D5110 Complete Upper Denture 120 D5120 Complete Lower Denture 120 D5130 Immediate Upper 140 D5140 Immediate Lower 140 D5211 Upper Partial - Resin Base 143 D5212 Lower Partial - Resin Base 172 D5213 Upper Partial - Cast Mtl Frame w/Resin Bases 140 D5214 Lower Partial - C159 140 D5410 Adjust Complete Denture - Upper 6 D5411 Adjust Complete Denture - Lower 6 D5421 Adjust Partial Denture - Upper 27 D5422 Adjust Partial - Lower 27 D5510 Repair Broken Complete Denture Base 20 D5520 Replace Missing/Broken Teeth - (each tooth) 20 D5610 Repair Acrylic Saddle 30 D5620 Repair Framework 50 D5630 Repair/Replace Broken Clasp 30 D5640 Replace Broken Teeth - per tooth 12 D5650 Add Tooth to Existing Partial 12 D5660 Add Clasp to Existing Partial 30 D5670 Replace all Teeth - Maxillary 129 D5671 Replace all Teeth - Mandibular 155 D5710 Rebase Complete Denture - Upper 79 D5711 Rebase Complete Denture - Lower 79 D5720 Rebase Partial Denture - Upper 80 D5721 Rebase Partial Denture - Lower 80 D5730 Reline Complete Denture - Lower (Chairside) 30 D5731 Reline Complete Denture - Upper (Chairside) 30 D5740 Reline Partial Upper (Chairside) 42 D5741 Reline Partial Lower (Chairside) 43 D5750 Reline Comp. Denture Upper (Lab) 38 D5751 Reline Comp. Denture Lower (Lab) 38 D5760 Reline Partial Upper (Lab) 38 D5761 Reline Partial Lower (Lab) 38 D5820 Interim Partial Upper 40 D5821 Interim Partial Lower 40 D5850 Tissue Conditioning - Upper 8 D5851 Tissue Conditioning - Lower 8 PROSTHODONTICS - FIXED D6210 Pontic - Cast High Noble Metal 140 D6211 Pontic - Cast Predominantly Base Metal 110 D6212 Pontic - Cast Noble Metal 283 D6240 Pontic - Porcelain Fused to High Noble Metal 352 ADA Code Description Member Copayment PROSTHODONTICS - FIXED D6241 Pontic - Porcelain Fused to Predom. Base Metal 150 D6242 Pontic - Porcelain Fused to Noble Metal 304 D6250 Pontic - Resin w/ High Noble Metal 312 D6251 Pontic - Resin with Predominantly Base Metal 110 D6252 Pontic - Resin w/ Noble Metal 288 D6545 Retainer-Cast Mtl/Resin Bonded Fixed Prosthesis 72 D6720 Crown - Resin w/ High Noble Metal 288 D6721 Crown - Resin w/ Predoninantly Base Metal 288 D6722 Crown - Resin with Noble Metal 288 D6740 Crown- Porc/Ceramic 288 D6750 Crown - Porclain Fused to High Noble Metal 320 D6751 Crown - Porcelain Fused to Predom. Base Metal 224 D6752 Crown - Porcelain Fused to Noble Metal 224 D6780 Crown - 3/4 Cast High Noble Metal 288 D6790 Crown - Full Cast High Noble Metal 288 D6791 Crown - Full Cast Predominantly Base Metal 288 D6792 Crown - Full Cast Noble Metal 288 D6930 Recement Bridge 15 D6970 Cast Post and Core 64 D6971 Cast Post and Core w/ Bridge 79 D6972 Prefab. Post and Core 52 D6980 Bridge Repair - by report 34 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 9 D7220 Impacted (soft tissue) 25 D7230 Impacted (partially bony) 30 D7240 Impacted (completely bony) 35 D7241 Impaction (unusual complications) 86 D7250 Root Removal - Surgical 10 D7280 Surgical Access of Unerupted Tooth 10 D7281 Surgical Exposure for Eruption 10 D7282 Mobilization of Erupted Tooth 10 D7285 Biopsy - hard 50 D7286 Biopsy -Soft 50 D7287 Cytology Sample Collection 0 D7290 Surgical Repositioning 65 D7291 Transseptal Fiberotomy 15 D7310 Alveolectomy (w/ extrac.) 18 D7320 Alveolectomy per quadrant 250 D7340 Vestibuloplasty, Simple (spec. ony) 96 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 45 D7472 Removal of Torus Palatinus 45 D7473 Removal of Torus Mandibularis 45 D7485 Surgical Reduction of Tuberosity 45 D7510 I & D - Intraoral 15 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 50 D7910 Suture Wounds to 5 cm 0 D7960 Frenulectomy 25 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) 20 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 30 D9450 Case Presentation 0 D9930 Treatment of Complications (post-surgical) - Unusual Circumstances, by report 0 D9940 Occlusal Guard, by report 93 D9941 Fabrication of Athletic Mouthgard 0 D9951 Occlusal Adjustment - Limited 10 D9952 Occlusal Adjustment - Complete 30 D9999 Unspecified Adjunctive Procedure, by report 0 10001 Failed Appointment (without 24 hour notice) 25 10002 Canceled Appointment 0 10003 Continued Treatment 0