I.B.E.W. Napa - Freedom 140 Plan                                       2004-2005 Schedule of Benefits                     ...
NAPA PLAN                                                                                  FREEDOM 140ADA CODE            ...
NAPA PLAN                                                                                      FREEDOM 140ADA CODE        ...
NAPA PLAN                                                                                FREEDOM 140ADA CODE              ...
NAPA PLAN                                                                                                                 ...
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IBEW Napa Freedom 140 Plan 09 04

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IBEW Napa Freedom 140 Plan 09 04

  1. 1. I.B.E.W. Napa - Freedom 140 Plan 2004-2005 Schedule of Benefits OUT OF EXCLUSIVE Nevada Pacific Dental IN-NETWORK NETWORK Deductible 1432 South Jones Blvd. BENEFIT $100/$200 Las Vegas, NV 89146 No Deductibles Annual No Annual Member Services: 1-800-926-0925 / 702-737-8900 Max. Maximum NAPA PLAN $3000 FREEDOM 140ADA CODE 1008-P ADA CODE DESCRIPTION 1021-P CDT-4 MEMBER PLAN PAYS PAYS DIAGNOSTIC D0120 Periodic Oral Evaluation 0 32 D0140 Limited Oral Evaluation (Problem focused) 0 27 D0150 Comprehensive Oral Evaluation 0 32 D0160 Detailed & Extensive Oral Evaluation (Specialist Only) 0 32 D0170 Re-evaluation - limited 0 28 D0180 Comprehensive Periodontal Evaluation 0 28 D0210 Full Mouth X-rays 0 56 D0220 Single Film 0 14 D0230 Additional Films 0 14 D0240 Occlusal Film 0 13 D0270 1 Bitewing Film 0 10 D0272 2 Bitewing Films 0 13 D0274 4 Bitewing Films 0 20 D0277 Vertical Bitewings - 7 to 8 films 0 20 D0290 X-ray Post.-ant. or Lat. Skull/Fac.Bone Survey Film 0 22 D0310 Sialography 0 50 D0330 Panorex Film 0 33 D0340 Cephalometric 0 40 D0415 Bacteriologic Study 0 23 D0425 Caries Susceptibility Tests 0 23 D0460 Pulp Vitality Tests 0 6 D0470 Diagnostic Casts 0 21 D0999 Unspecified Diagnostic Procedure, by report 0 20 PREVENTIVE D1110 Prophylaxis, Adult 0 55 D1120 Prophylaxis, Children 0 40 D1201 Prophy w/ Fluoride Child 0 45 D1203 Flouride w/o Prophy Child 0 12 D1204 Flouride w/o Prophy Adult 0 12 D1205 Prophy w/ Fluoride Adult 0 48 D1310 Nutritional Counseling (w/ licensed dietician only) 0 10 D1330 Oral Hygiene Instruction 0 8 D1351 Sealant,per tooth (Perm.1st & 2nd molars only) 0 16 D1510 Fixed Space Maintainer Unilateral 0 84 D1515 Fixed Lingual/Palatal Bar 0 156 D1520 Space Maint. Rem. Unilat. 0 101 D1525 Space Maint. Rem. Bilat. 0 1478/10/2004 1
  2. 2. NAPA PLAN FREEDOM 140ADA CODE 1008-P ADA CODE DESCRIPTION 1021-P CDT-4 MEMBER PLAN PAYS PAYS D1550 Recementation Space Maint. 0 13 RESTORATIVE D2140 Amalgam One Surface 0 42 D2150 Amalgam Two Surface 0 60 D2160 Amalgam Three Surface 0 73 D2161 Amalgam Four + Surface 0 87 D2330 Resin 1 Surface Anterior 0 42 D2331 Resin 2 Surface Anterior 0 63 D2332 Resion 3 Surface Anterior 0 72 D2335 Resin 4 Surface/Incis. Angle Ant. 0 84 D2720 Crown Resin Hi Noble 59 336 D2721 Crown Resin Predom. Base 60 252 D2722 Crown Resin Noble 63 286 D2740 Porcelain Crown 66 336 D2750 Porcelain with Gold Crown 73 370 D2751 Porcelain with Metal Crn. 66 269 D2752 Porcelain Semiprec. Crown 70 302 D2790 Full Gold Crown 73 319 D2791 Full Metal Crn. 64 235 D2792 Crown, Noble Metal 69 269 D2810 3/4 Gold Crown 70 200 D2910 Inlay Recementation 6 25 D2920 Crown Recementation 7 25 D2930 Prefab. Stain. St. Crown prim 14 67 D2931 Prefab. Stain. St. Crown perm 17 94 D2932 Prefab. Resin Crown 14 50 D2940 Sedative Fillings 0 23 D2950 Core Build Up w/ pins 14 50 D2951 Pin Retention, per tooth 6 16 D2952 Cast Post and Core 22 106 D2953 Each Additional Cast Post 22 75 D2954 Prefab Post and Core 16 84 D2970 Temporary Crown - fractured tooth 0 67 D2980 Crown Repair 25 20 D2999 Unspecified Restorative Procedure, by report 0 20 ENDODONTICS D3110 Pulp Capping 0 17 D3120 Pulp Cap-Indirect 0 13 D3220 Pulpotomy 0 45 D3230 Pulpal Therapy - Anterior, Primary Tooth 0 25 D3240 Pulpal Therapy - Posterior, Primary Tooth 0 35 D3310 Root Canal, Anterior 0 118 D3320 Root Canal, Bicuspid 0 151 D3330 Root Canal, Molar 60 269 D3346 Retreatment of RCT - Anterior 0 118 D3347 Retreatment of RCT - Bicuspid 0 151 D3348 Retreatment of RCT - Molar 60 269 D3351 Apexification, 1st visit 9 44 D3410 Apicoectomy/Periradicular Surgery - Anterior 32 118 D3421 Apicoectomy/Periradicular Surgery - Bicuspid (first root) 64 235 D3425 Apicoectomy/Periradicular Surgery, Molar (first root) 96 2778/10/2004 2
  3. 3. NAPA PLAN FREEDOM 140ADA CODE 1008-P ADA CODE DESCRIPTION 1021-P CDT-4 MEMBER PLAN PAYS PAYS D3426 Apicoectomy/Periradicular Surgery, (each additional root) 50 92 D3430 Retrograde Filling 50 50 D3450 Root Amputation 23 75 D3920 Endodontic Hemisection 21 67 D3999 Unspecified Endodontic Procedure, by report 0 20 PERIODONTICS D4210 Gingivectomy - 4+ teeth 0 101 D4211 Gingivectomy - 1 To 3 teeth 0 34 D4240 Ging. Flap - 4+ teeth 0 101 D4241 Ging. Flap - 1 to 3 teeth 0 34 D4260 Osseous Surgery - 4+ teeth 56 336 D4261 Osseous Surgery - 1 to 3 teeth 37 88 D4270 Pedicle Soft Tiss. Proc. 61 101 D4271 Free Soft Tiss. Graft 61 134 D4341 Root Planing - 4+ teeth 0 64 D4342 Root Planing - 1 to 3 teeth 0 17 D4355 Full Mouth Debridement 0 34 D4910 Perio. Maint. 0 34 D4999 Unspecified Periodontal Procedure, by report 0 20 PROSTHODONTICS - REMOVABLE D5110 Complete Upper Denture 93 420 D5120 Complete Lower Denture 93 420 D5130 Immediate Upper 93 420 D5140 Immediate Lower 93 420 D5211 Upper Partial - Resin Base 63 168 D5212 Lower Partial - Resin Base 65 168 D5213 Upper Partial - Cast Metal Framework with Resin Denture Bases 80 420 D5214 Lower Partial - C159 77 420 D5410 Adjust Complete Denture - Upper 0 17 D5411 Adjust Complete Denture - Lower 0 17 D5421 Adjust Partial Denture - Upper 10 17 D5422 Adjust Partial - Lower 10 17 D5510 Repair Broken Complete Denture Base 5 50 D5520 Replace Missing/Broken Teeth - Complete Denture (each tooth) 5 34 D5610 Repair Acrylic Saddle 10 50 D5620 Repair Framework 9 80 D5630 Repair/Replace Broken Clasp 11 80 D5640 Replace Broken Teeth - per tooth 13 50 D5650 Add Tooth to Existing Partial 8 50 D5660 Add Clasp to Existing Partial 17 75 D5670 Replace all Teeth - Maxillary 57 106 D5671 Replace all Teeth - Mandibular 59 106 D5710 Rebase Complete Denture - Upper 35 156 D5711 Rebase Complete Denture - Lower 35 156 D5720 Rebase Partial Denture - Upper 30 134 D5721 Rebase Partial Denture - Lower 28 134 D5730 Reline Complete Denture - Lower (Chairside) 16 90 D5731 Reline Complete Denture - Upper (Chairside) 16 90 D5740 Reline Partial Upper (Chairside) 16 78 D5741 Reline Partial Lower (Chairside) 16 78 D5750 Reline Comp. Denture Upper (Lab) 27 1348/10/2004 3
  4. 4. NAPA PLAN FREEDOM 140ADA CODE 1008-P ADA CODE DESCRIPTION 1021-P CDT-4 MEMBER PLAN PAYS PAYS D5751 Reline Comp. Denture Lower (Lab) 27 134 D5760 Reline Partial Upper (Lab) 28 134 D5761 Reline Partial Lower (Lab) 28 134 D5820 Interim Partial Upper 28 150 D5821 Interim Partial Lower 27 150 D5850 Tissue Conditioning - Upper 8 25 D5851 Tissue Conditioning - Lower 8 25 PROSTHODONTICS - FIXED D6210 Pontic - Cast High Noble Metal 67 325 D6211 Pontic - Cast Predominantly Base Metal 58 235 D6212 Pontic - Cast Noble Metal 64 269 D6240 Pontic - Porcelain Fused to High Noble Metal 69 370 D6241 Pontic - Porcelain Fused to Predominantly Base Metal 63 302 D6242 Pontic - Porcelain Fused to Noble Metal 66 319 D6250 Pontic - Resin w/ High Noble Metal 62 325 D6251 Pontic - Resin with Predominantly Base Metal 58 235 D6252 Pontic - Resin w/ Noble Metal 61 302 D6545 Retainer - Cast Metal for Resin Bonded Fixed Prosthesis 33 134 D6720 Crown - Resin w/ High Noble Metal 69 325 D6721 Crown - Resin w/ Predoninantly Base Metal 66 252 D6722 Crown - Resin with Noble Metal 62 286 D6740 Crown- Porc/Ceramic 62 275 D6750 Crown - Porclain Fused to High Noble Metal 73 395 D6751 Crown - Porcelain Fused to Predominantly Base Metal 69 269 D6752 Crown - Porcelain Fused to Noble Metal 72 325 D6780 Crown - 3/4 Cast High Noble Metal 72 319 D6790 Crown - Full Cast High Noble Metal 74 319 D6791 Crown - Full Cast Predominantly Base Metal 69 235 D6792 Crown - Full Cast Noble Metal 70 286 D6930 Recement Bridge 10 30 D6970 Cast Post and Core 23 90 D6971 Cast Post and Core w/ Bridge 20 106 D6972 Prefab. Post and Core 16 75 D6980 Bridge Repair - by report 20 20 D6999 Unspecified, Fixed Prosthodontic Procedure, by report 0 20 ORAL AND MAXILLOFACIAL SURGERY D7111 Coronal Remnants - Deciduous Tooth 0 34 D7140 Extraction, Erupted Tooth or Exposed Root 0 45 D7210 Surgical Extraction 0 67 D7220 Impacted (soft tissue) 17 92 D7230 Impacted (partially bony) 23 120 D7240 Impacted (completely bony) 30 168 D7241 Impaction (unusual complications) 31 165 D7250 Root Removal - Surgical 14 62 D7280 Surgical Access of Unerupted Tooth 14 65 D7281 Surgical Exposure for Eruption 14 65 D7282 Mobilization of Erupted Tooth 14 65 D7285 Biopsy - hard 30 55 D7286 Biopsy -Soft 30 45 D7287 Cytology Sample Collection 0 25 D7290 Surgical Repositioning 65 55 D7291 Transseptal Fiberotomy 15 558/10/2004 4
  5. 5. NAPA PLAN FREEDOM 140ADA CODE 1008-P ADA CODE DESCRIPTION 1021-P CDT-4 MEMBER PLAN PAYS PAYS D7310 Alveolectomy (w/ extrac.) 13 65 D7320 Alveolectomy per quadrant 14 90 D7340 Vestibuloplasty, Simple (spec. ony) 0 187 D7350 Vestibuloplasty, Extensive (spec. only) 0 312 D7410 Excision Benign to 1.25 cm 25 100 D7450 Removal Benign Odontogenic to 1.25 cm 25 100 D7460 Removal Benign Nonodontogenic to 1.25 cm 80 100 D7471 Removal of Lateral Exostosis 38 100 D7472 Removal of Torus Palatinus 38 100 D7473 Removal of Torus Mandibularis 38 100 D7485 Surgical Reduction of Tuberosity 38 100 D7510 I & D - Intraoral 8 60 D7530 Removal of Foreign Body, Skin or Subcutaneous Alveolar Tissue 20 67 D7540 Removal of Reaction-Producing Foreign Bodies, Musculoskeletal System 20 27 D7550 Part Ostectomy/Sequestrectomy 25 27 D7910 Suture Wounds to 5 cm 0 27 D7960 Frenulectomy 25 67 ADJUNCTIVE GENERAL SERVICES D9110 Palliative (Emergency) Treatment of Dental Pain - Minor Procedure 0 27 D9230 Analgesia (pedo. only) 0 20 D9310 Consultation (diagnostic service provided by dentist or physician orhter than provider of service) 0 50 D9420 Hospital call 25 30 D9430 Office Visit for Observation (no other procedures performed) 0 20 D9440 Office Visit - After Regularly Scheduled Hours 25 40 D9930 Treatment of Complications (post-surgical) - Unusual Circumstances, by report 0 10 D9940 Occlusal Guard, by report 25 25 D9941 Fabrication of Athletic Mouthgard 0 20 D9951 Occlusal Adjustment - Limited 8 42 D9952 Occlusal Adjustment - Complete 24 80 D9999 Unspecified Adjunctive Procedure, by report 0 20 10001 Failed Appointment (without 24 hour notice) 25 0 10002 Canceled Appointment 0 0 10003 Continued Treatment 0 0 EXCLUSIVE IN-NETWORK BENEFIT – Member has no deductible and no annual maximum. Member pays In-Network Copayment. Member must receive treatment from NPD Exclusive Provider or Specialist. In- Network Specialty Benefit must be referred by NPD Exclusive Provider and pre-authorized by NPD. OUT-OF-NETWORK BENEFIT – Member has a calendar year deductible and a calendar year annual maximum. The difference between the out-of-network dentist’s billed charges and the Out-Of-Network Schedule of Allowances payments by the Plan are the responsibility of the Member (balance billing). To receive the In-Network Specialty Benefit, Member must be under the care of a NPD Exclusive Provider and specialty treatment must be pre-authorized by NPD. Submit Out-Of-Network Claims to: Nevada Pacific Dental, 1432 South Jones Blvd., Las Vegas, NV 89146.8/10/2004 5

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