NPD Elrancho DHMO Plan

Nevada Pacific Dental EL RANCHO Schedule of BenefitsADA Member ADA MemberCode Description Copayment Code Description Copayment DIAGNOSTIC RESTORATIVED0120 Periodic Oral Exam-Established Patient 0 D2331 Resin Composite - Two Surfaces, Ant. 6D0140 Lmtd. Oral Evaluation - Problem Focused 0 D2332 Resin Composite - Three Surfaces, Ant. 9D0145 Oral Eval-Pt Under 3 Years/Counseling 0 D2335 Resin Comp 4+ Surf or Incisal Edge, Ant. 12D0150 Comprehensive Oral Evaluation 0 D2710 Crown - Resin Composite (Indirect) 80D0160 Detailed & Exten. Oral Eval (spec. only) 0 D2712 Crown - 3/4 Resin Composite (Indirect) 80D0170 Re-Evaluation – Lmtd. Problem Focused 0 D2720 Crown - Resin With High Noble Metal 185D0180 Comprehensive Periodontal Evaluation 0 D2721 Crown - Resin W/ Predom Base Mtl. 288D0210 Intraoral - complete series (incl. bitewings) 0 D2722 Crown - Resin With Noble Metal 288D0220 Comprehensive Periodontal Evaluation 0 D2740 Crown - Porcelain/Ceramic Substrate 185D0230 Intraoral - periapical each additional film 0 D2750 Crown – Porc. used /High Noble Mtl 195D0240 Intraoral - Occlusal Film 0 D2751 Crown – Porc. Fused/Predom. Base Metal 150D0270 Bitewing - Single Film 0 D2752 Crown - Porcelain Fused To Noble Metal 288D0272 Bitewings - Two Films 0 D2790 Crown - Full Cast High Noble Metal 304D0273 Bitewings - Three Films 0 D2791 Crown - Full Cast Predom Base Mtl. 140D0274 Bitewings - Four Films 0 D2792 Crown - Full Cast Noble Metal 185D0277 Vertical Bitewings - 7 To 8 Films 0 D2794 Crown-Titanium 304D0290 Post-Ant.or Lat. Skull/Facial Bone Film 0 D2910 Recement Inlay 20D0310 Sialography 0 D2915 Recement Cast Or Prefab. Post And Core 20D0330 Panaoramic Film 0 D2920 Recement Crown 11D0340 Cephalometric Film 0 D2930 Prefab. Stain. St. Crown Prim 21D0415 Collct. Organisms for Cultr/Sensitivity 0 D2931 Prefab. Stain. St. Crown Perm 25D0416 Viral Culture 0 D2932 Prefabricated Resin Crown 50D0421 Susceptibility To Oral Diseases 0 D2933 Prefab. Steel Crown w/ Resin Window 21D0425 Caries Susceptibility Tests 0 D2934 Prefab Esthetic Coated Stain Crn Prim 21D0460 Pulp Vitality Tests 0 D2940 Sedative Filling 0D0470 Diagnostic Casts 0 D2950 Core Buildup, Including Any Pins 30D0999 Unspecified Diagnostic Proc. By Report 0 D2951 Pin Retention - Per Tooth, w/Restoration 0 PREVENTIVE D2952 Cast Post And Core In Add. To Crown, Ind. Fab 50D1110 Prophylaxis - Adult 0 D2953 Each Additional Cast Post - Same Tooth (incl. 50D1120 Prophylaxis - Child 0 canal prep)D1203 Topical Fluoride (Without Prohy) - Child 0 D2954 Prefab/Post & Core In Add. To Crown 30D1204 Topical Fluoride (Without Prohy) - Adult 0 D2970 Temporary crown (fractured tooth) 21D1206 Topical fluoride varnish 0 D2980 Crown Repair, By Report 25D1310 Nutritional Counseling 0 D2999 Unspecified Restorative Proc. By Report 0D1330 Oral Hygiene Instructions 0 ENDODONTICSD1351 Sealant - Per Tooth 0 D3110 Pulp Cap-Direct (w/o Final Restoration) 5D1510 Space Maintainer - Fixed - Unilateral 15 D3120 Pulp Cap-Indirect (w/o Final Restoration 8D1515 Space Maintainer - Fixed - Bilateral 34 D3220 Therapeutic Pulpotomy (w/o Final Rest) 8D1520 Space Maint. - Removable - Unilateral 33 D3230 Pulpal Therapy - Anterior, Primary Tooth 20D1525 Space Maintainer - Removable - Bilateral 40 D3240 Pulpal Therapy - Post Primary Tooth 20D1550 Recementation Of Space Maintainer 4 D3310 Anterior (Excluding Final Restoration) 50D1555 Removal of fixed space maintainer 4 D3320 Bicuspid (Excluding Final Restoration) 70 RESTORATIVE D3330 Molar (Excluding Final Restoration) 100D2140 Amalgam - One Surface 0 D3346 Retreatment Previous RCT - Anterior 85D2150 Amalgam - Two Surfaces 0 D3347 Retreatment Previous RCT - Bicuspid 125D2160 Amalgam - Three Surfaces 0 D3348 Retreatment Previous RCT - Molar 150D2161 Amalgam - Four Or More Surfaces 0 D3351 Apexification, 1st visit 43D2330 Resin Composite - One Surface, Anterior 4 D3410 Apicoectomy, Anterior 60 D3421 Apicoectomy, Bicuspid (First Root) 143 PDBI-NV-08DC CDT-7 (01/07) Nevada Pacific Dental 1432 South Jones Blvd. Las Vegas, NV 89146 (702) 737-8900 (800) 926-0925 Fax (702) 259-8381

ADA Member ADA MemberCode Description Copayment Code Description Copayment ENDODONTICS PROSTHODONTICS - REMOVABLED3425 Apicoectomy, Molar (First Root) 153 D5761 Reline Mandibular Partial Denture - Lab 38D3426 Apicoectomy, Each Additional Root 53 D5820 Interim Partial Upper (Maxillary) 40D3430 Retrograde Filling - Per Root 20 D5821 Interim Partial Lower (Mandibular) 40D3450 Root Amputation - Per Root 40 D5850 Tissue Conditioning, Maxillary 8D3920 Endodontic Hemisection 40 D5851 Tissue Conditioning, Mandibular 8D3999 Unspecified Endodontic Proc. By Report 0 PROSTHODONTICS - FIXED PERIODONTICS D6205 Pontic - Indirect Resin Based Composite 80D4210 Gingivectomy/Gingivoplasty (4+ Teeth) 72 D6210 Pontic - Cast High Noble Metal 140D4211 Gingivectomy/Gingivoplasty (1-3 Teeth) 20 D6211 Pontic - Cast Predominantly Base Metal 110D4240 Gingival Flap w/Root Planing (4+ Teeth) 110 D6212 Pontic - Cast Noble Metal 283D4241 Gingival Flap With Rp (1 to 3 Teeth) 72 D6214 Pontic - Titanium 140D4260 Osseous Surgery (4+ Teeth) 240 D6240 Pontic - Porcelain Fused / High Noble Mtl. 352D4261 Osseous Surgery (1 to 3 Teeth) 158 D6241 Pontic-Porcelain/Predom Base Metal 150D4270 Pedicle Soft Tissue Graft Procedure 157 D6242 Pontic - Porcelain Fused To Noble Metal 304D4271 Free Soft Tissue Graft Procedure 157 D6250 Pontic - Resin W/ High Noble Metal 312D4341 Perio Scaling/Root Planing, (4+ Teeth) 25 D6251 Pontic Resin with Predom. Base Metal 110D4342 Root Planing - 1 To 3 Teeth Per Quadrant 16 D6252 Pontic - Resin W/ Noble Metal 288D4355 Full Mouth Debridement 25 D6545 Cast Metal Retainer (Maryland) 72D4910 Periodontal Maintenance 25 D6710 Crown - Indirect Resin Based Composite 80D4999 Unspecified Periodontal Proc, By Report 0 D6720 Crown - Resin With High Noble Metal 288 PROSTHODONTICS - REMOVABLE D6721 Crown Res. proc. to Predom. Base Mtl. 288D5110 Complete Denture - Maxillary 120 D6722 Crown - Resin With Noble Metal 288D5120 Complete Denture - Mandibular 120 D6740 Crown- Porcelain/Ceramic 288D5130 Immediate Denture - Maxillary 140 D6750 Crown-Porc/High Noble Metal 320D5140 Immediate Denture - Mandibular 140 D6751 Crown-Porc/Predom Base Metal 224D5211 Maxillary Partial Denture - Resin Base 143 D6752 Crown - Porcelain Fused To Noble Metal 224D5212 Mandibular Partial Denture - Resin Base 172 D6780 Crown - 3/4 Cast High Noble Metal 288D5213 Max Partial Denture - Cast Metal Frame 140 D6790 Crown - Full Cast High Noble Metal 288D5214 Mand Partial Denture-Cast Metal Frame 140 D6791 Crown-Full Cast Predom Base Metal 288D5225 Maxillary Partial Denture - Flexible Base 143 D6792 Crown - Full Cast Noble Metal 288D5226 Mand Partial Denture-Flexible Base 172 D6794 Crown - Titanium 288D5410 Adjust Complete Denture - Maxillary 6 D6930 Recement Fixed Partial Denture 15D5411 Adjust Complete Denture - Mandibular 6 D6970 Cast Post and Core-Add to Partial Ret, Ind. Fab 64D5421 Adjust Partial Denture - Maxillary 27 D6972 Prefab. Post/Core-Add to Fixed Part Ret 52D5422 Adjust Partial Denture - Mandibular 27 D6980 Fixed Partial Denture Repair, By Report 34D5510 Repair Broken Complete Denture Base 20 D6999 Unspecified, Fixed Prosthodontic Proc, By Rep 0D5520 Replace Missing/Broken Teeth-Per Tooth 20 ORAL AND MAXILLOFACIAL SURGERYD5610 Repair Resin Denture Base 30 D7111 Coronal Remnants - Primary Tooth 0D5620 Repair Cast Framework 50 D7140 Extraction-Erupted Tooth/Exposed Root 0D5630 Repair Or Replace Broken Clasp 30 D7210 Surg Rem/Erupted Tooth-Req Elevation 9D5640 Replace Broken Teeth - Per Tooth 12 D7220 Removal Impacted Tooth - Soft Tissue 25D5650 Add Tooth To Existing Partial Denture 12 D7230 Removal Impacted Tooth - Part Bony 30D5660 Add Clasp To Existing Partial Denture 30 D7240 Rem. Impacted Tooth-Comp Bony 35D5670 Replace All Teeth - Maxillary 129 D7241 Rem. Impacted Tooth-Comp Bony w/Comp 86D5671 Replace All Teeth - Mandibular 155 D7250 Surgical Removal Residual Tooth Roots 10D5710 Rebase Complete Maxillary Denture 79 D7280 Surgical Access Of An Unerupted Tooth 10D5711 Rebase Complete Mandibular Denture 79 D7282 Mobilization Of Erupted Tooth 10D5720 Rebase Maxillary Partial Denture 80 D7285 Biopsy of Oral Tissue-Hard 50D5721 Rebase Mandibular Partial Denture 80 D7286 Biopsy Of Oral Tissue - Soft 50D5730 Reline Comp Maxillary Denture- Chair 30 D7287 Exfoliative Cytological Smpl. Collection 0D5731 Reline Comp Mandibular Denture-Chair 30 D7288 Brush Biopsy-Trans Sample Collection 0D5740 Reline Maxillary Partial Denture-Chair 42 D7290 Surgical Repositioning Of Teeth 65D5741 Reline Mandibular Partial Denture-Chair 43 D7291 Transseptal or Supra Crestal Fiberotomy 15D5750 Reline Complete Maxillary Denture-Lab 38 D7310 Alveoloplasty with extractions – four + 18D5751 Reline Complete Mandibular Denture-Lab 38 teeth/spaces, per quadrantD5760 Reline Maxillary Partial Denture - Lab 38 PDBI-NV-08DC CDT-7 (01/07) Nevada Pacific Dental 1432 South Jones Blvd. Las Vegas, NV 89146 (702) 737-8900 (800) 926-0925 Fax (702) 259-8381

ADA Member ADA MemberCode Description Copayment Code Description Copayment ORAL AND MAXILLOFACIAL SURGERY D7963 Frenuloplasty 25D7311 Alveoloplasty w/Extractions (1-3 Teeth) 12 ADJUNCTIVE GENERAL SERVICESD7320 Alveoloplasty w/o extractions –four+ 250 D9110 Palliative (Emergency) Treatment 0 teeth/spaces, per quadrant D9120 Fixed partial denture sectioning 34D7321 Alveoloplasty w/o Ext (1-3 Teeth) 165 D9230 Analgesia, Anxiolyses (Pedo. Only) 0D7340 Vestibuloplasty – Simple (spec.only) 96 D9310 Consultation (diagnostic service provided by another 20 dentist.)D7350 Vestibuloplasty – Extensive (spec.only) 200 D9420 Hospital Call 25D7410 Excision Benign Lesion to 1.25 Cm 25 D9430 Office Visit for Observation 0D7450 Removal Benign Odontogenic to 1.25 Cm 25 D9440 Office Visit After Regular Sched Hours 30D7460 Remv. Benign Nonodontogenic Lesion to 1.25 80D7471 Removal Of Lateral Exostosis 45 D9450 Case Presentation 0D7472 Removal Of Torus Palatinus 45 D9930 Treatment Of Complications 0D7473 Removal Of Torus Mandibularis 45 D9940 Occlusal Guard, By Report 93D7485 Surgical Reduction of Tuberosity 45 D9941 Fabrication Of Athletic Mouthgard 0D7510 I & D of Abscess, Intraoral Soft Tissue 15 D9942 Repair/Or Reline Of Occlusal Guard 20D7511 I & D of Abscess, Intraoral Complicated 15 D9950 Occlusion Analysis - Mounted Case 35D7530 Removal of Foreign Body 32 D9951 Occlusal Adjustment - Limited 10D7540 Removal Reaction-Prod. Foreign Bodies 32 D9952 Occlusal Adjustment - Complete 30D7550 Partial Ostectomy/Sequestrectomy 50 D9999 Unspecified Adjunctive Proc, By Report 0D7910 Suture Recent Small Wounds To 5 Cm 0D7960 Frenulectomy 25 10001 Failed Appointment 25 PDBI-NV-08DC CDT-7 (01/07) Nevada Pacific Dental 1432 South Jones Blvd. Las Vegas, NV 89146 (702) 737-8900 (800) 926-0925 Fax (702) 259-8381

NPD Elrancho DHMO Plan

by Ted DeCorte on Sep 11, 2011

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NPD Elrancho DHMO Plan Document Transcript