NOTES AND MODIFIERS APPLIED TO THE TABLE ... - Triple-S …NOTES AND MODIFIERS APPLIED TO THE TABLE OF COVERAGE OF TRIPLE-S SALUD GENERAL COMMENTS: 1 The numbers included in the table

NOTES AND MODIFIERS APPLIED TO THE TABLE OF COVERAGE OF TRIPLE-S SALUD

GENERAL COMMENTS:

1 The numbers included in the table represent the percentage ofcoinsurance responsible of the insured.

2 For official definitions of each code and payments policies

you must refer to the Dentist Participant Manual.

(In the table we only include notes for your references).

NOTES GOVERNMENT HEALTH PLAN

NOTE DEFINITION

SERVICIOS

X Services covered at 100%.ь It covers only bucal surface .ç D0160 service code cover only to the Oral and Maxillofacial Surgeons, (replaces the code D0150) .

v D1206 service code cover only to generalists and Pediatric dentists and is mutually exclusive with the code D1208 (it's one or the other), not both, until the age of 5 years.

Þ It covers a maximum of 6 periapical radiographs per policy year between the combination of D0220 and D0230 codes .ś (D9222, D9223) and (D9239, D9243) services code, are only covered on the Government Health Plan to Oral and Maxillofacial Surgeons (019 ) with active Sedation certificate.

With a fixed fee of $170.00 (not matter increment). (It must be billed using the corresponding codes, depending on the fact, the rate will be prorated, paying a flat rate of $ 170.00 for both codes).

NOTE DEFINITION

100 No Copayment.

110 Copayment per visit of $1.00; for preventive services, (only adults 21+ ) and copayment per visit of $1.00 for restorative services, (applies to all insured).



220 No Copayment.

230 No Copayment.






February 01, 2020


CC 100F 110F 120F 130F 220F 230F 300E 310E 320E 330E 400ECODES DESCRIPTION

Maximum Benefit Cover ($)

Note 100 110 110 110 110 230 300 310 320 330 400

Deductible N/A $1 / $1$1.50 $1.50

$2 / $2 N/A N/A $2 / $2 $2 / $2 $3 / $5 $5 / $6 $3 / $10

CATEGORY I

DIAGNOSTIC

Note

DIAG. AND PREV. EvaluationD0120 Periódic oral evaluation X X X X X X X X X X XD0140 Limited oral evalation - problem focused X X X X X X X X X X XD0150 Comprehensive oral evaluation X X X X X X X X X X XD0160 Detailed and extensive oral evaluation Xç Xç Xç Xç Xç Xç Xç Xç Xç Xç Xç

ImagingD0210 Intraoral - complete series of radiographic images X X X X X X X X X X XD0220 Intraoral - periapical first X Þ X Þ X Þ X Þ X Þ X Þ X Þ X Þ X Þ X Þ X ÞD0230 Additional radiographic image X X X X X X X X X X XD0270 Bitewing - single radiographic images X X X X X X X X X X XD0272 Bitewing - two radiographic images X X X X X X X X X X XD0330 Panoramic radiographic image X X X X X X X X X X X

PREVENTIVE

Note

ProphylaxisD1110 Prophylaxis - adult X X X X X X X X X X XD1120 Prophylaxis - child X X X X X X X X X X X

Topical Fluoride TreatmentD1206 Topical application of fluoride varnish X v X v X v X v X v X v X v X v X v X v X vD1208 Topical application of fluoride - child X X X X X X X X X X X

SealantD1351 Sealant - per tooth X X X X X X X X X X X

CATEGORY II

ROUTINES SERVICES RESTORATIVE

Note

D2140 Amalgam - one surface primary or permanent X X X X X X X X X X XD2150 Amalgam - two surface primary or permanent X X X X X X X X X X XD2160 Amalgam - three surface primary or permanent X X X X X X X X X X XD2161 Amalgam - four surface primary or permanent X X X X X X X X X X XD2330 Resin - one surface - anterior (primary or permanent) X X X X X X X X X X XD2331 Resin - two surface - anterior (primary or permanent) X X X X X X X X X X XD2332 Resin - three surface - anterior (primary or permanent) X X X X X X X X X X XD2335 Resin - four or more surface - anterior (primary or permanent) X X X X X X X X X X XD2391 Resin - one surface posterior (bucal): primary or permanent Xь Xь Xь Xь Xь Xь Xь Xь Xь Xь XьD2930 Prefabricated stainless steel crown – primary tooth X X X X X X X X X X XD2940 Protective restoration X X X X X X X X X X X

ENDODONTIC

Note

D3120 Pulp cap - indirect (excluding final restoration) X X X X X X X X X X XD3220 Therapeutic pulpotomy (excluding final restoration) X X X X X X X X X X XD3221 Pulpal debridement, primary and permanent teeth X X X X X X X X X X XD3310 Endodontic therapy, anterior (excluding final restoration) X X X X X X X X X X XD3320 Endodontic therapy, bicúspid (excluding final restoration) X X X X X X X X X X X

ORAL SURGERY

NoteExtractions

D7140 Extraction, erupted tooth or exposed root X X X X X X X X X X XD7510 Incision and drainage of abscess- intraoral soft tissue X X X X X X X X X X XD7210 Surgical removal of erupted tooth X X X X X X X X X X XD7220 Removal of impacted tooth – soft tissue / partially bony / completely bony X X X X X X X X X X XD7230 Removal of impacted tooth – soft tissue / partially bony / completely bony X X X X X X X X X X XD7240 Removal of impacted tooth – soft tissue / partially bony / completely bony X X X X X X X X X X XD7241 Removal of impacted tooth – completely bony, with unusual surgical complicationX X X X X X X X X X XD7250 Surgical removal of residual tooth roots X X X X X X X X X X X

CATEGORY IV

ADJUNCTIVE GENERAL SERVICES

Note

D9110 Palliative (emergency) treatment of dental pain – minor procedure X X X X X X X X X X XD9222 Deep sedation/general anesthesia – first 15 minutes X ś X ś X ś X ś X ś X ś X ś X ś X ś X ś X śD9223 Deep sedation/general anesthesia – each subsequent 15-minute X ś X ś X ś X ś X ś X ś X ś X ś X ś X ś X śD9239 Intravenous moderate (conscious) sedation/analgesia- first 15 minutes X ś X ś X ś X ś X ś X ś X ś X ś X ś X ś X śD9243 Intravenous moderate (conscious) sedation/analgesia – each X ś X ś X ś X ś X ś X ś X ś X ś X ś X ś X śD9420 Hospital or ambulatory surgical center call X X X X X X X X X X XD9930 Reatment of complications (post-surgical) - unusual circumstances, by reportX X X X X X X X X X X

COVERS GOVERNMENT HEALTH PLAN

February 01, 2020


February 01, 2020


GENERAL COMMENTS:

1 The numbers included in the table represent the percentage ofcoinsurance responsible of the insured.

2 For official definitions of each code and payments policiesyou must refer to the Dentist Participant Manual.

(In the table we only include notes for your references).

NOTE DEFINITION

MAXIMUM COVERAGE

P Maximum per policy year.₪ Maximum of $300 per year policy for each service category; periodontics and prosthodontics LL Maximum of $450 per arch for general dentist and $ 500 per arch for prosthodontists every 5 years.@ Maximum of $450 per arch for general dentist ($ 900 for the two arcs per year). Maximum of $ 500 per arc for prosthodontist (1,000 for the two arch per year)

all prostheses are limited to 1 every 5 years (fixed and removable).

m Maximum of $500.00 per policy year.I Maximum of $500 per policy year for Triple-S rate.

™ Maximum of $500 per policy year for periodontics services Қ Maximum of $500 per policy year for all covered dental services.

℠ Maximum of $500 per policy year for prosthodontics services , adjustments and repairs.⍙ Maximum of $500 per policy year for the following categories restorative, endodontics, oral surgery/surgical and general adjuntive services.

¤ Maximum of $500 per policy year for the following categories; diagnostic, preventive, restorative, endodontics, oral surgery andadjunctive general services

هللا Maximum of $700 per policy year for all covered dental services.ĳ Maximum of $750 per policy year for all covered dental services.

☼ Maximum of $750 per policy year for all covered dental services excluding orthodontics.

# Maximum of $800 between prosthodontics and periodontics services.Ϟ Maximum of $800 per policy year for all covered dental services.ש Maximum of $800 per policy year for prosthodontics services.ת Maximum of $800 per policy year for periodontics services .ΰ Maximum of $800 for all comprehensive, periodontics and prosthodontics services.� Maximum of $800 per policy year, per covered person for all covered dental services except orthodontics.

æ Maximum of $800 from D2140 to D2335 procedures, D2391, D3310, D3320, D7140 to D7240, D7250, D7510 and D7286.ⱴ Maximum of $800 per policy year, per covered person for all services, excluding periodontics and prosthodontics services.ß Maximum of $850.00 for all services including periodontics.ê Maximum of $1,000 per policy year, per covered person.Ψ Maximum of $1,000 for all services excluding prosthodonticsU Maximum of $1,000 for all services excluding orthodontics.¶ Maximum of $1,000 for all services excluding periodontics.ŧ Maximum of $1,000 for all services, including periodontics.

Œ Maximum of $1,000 per policy year for all prosthodontics services.Ƿ Maximum of $1,000 per policy year for all periodontics services.

M Maximum of $1,000 per policy year for all covered dental services.◙ Maximum of $1,000 per dentures for general dentists or specialist.■ Maximum of $1,000 per policy year, per covered person including periodontics.π Maximum of $1,000 for all services excluding prosthodontics, periodontics and orthodontics.Ø Maximum of $1,000 for all covered dental services for a period of two years.§ Maximum of $1,000 per policy year for preventive services, restorative and periodontics.⋈ Maximum of $1,000 per policy year for all dental services excluding periodontics and prosthodontics.

Æ Maximum of $1,000 per policy year for all dental services excluding periodontics and orthodontics.ϰ Maximum of $1,000 per policy year for all dental services, excluding prosthodontics,repairs and orthodontics.ť Maximum of $1,000 per policy year for all posterior resins and surgical services.

& Maximum of $1,000 per policy year for restorative, endodontics, prosthodontics, oral surgery and general adjunctive services.₸ Maximum of $1,000 per policy year excluding codes; D0120, D0140, D0150, D0220, D0230, D0270, D0272, D1110, D1120, D1206 and D1208.Ŧ Maximum of $1,000 per policy year, per covered person for all services, excluding implant services that maintain a separate $ 1,000 cap.≒ Maximum of $ 1,000 per policy year for prosthetic services including adjustments and repairs.ᴕ Maximum of $1,000 for all services excluding diagnostic and preventive services.B Maximum of $1,200 per policy year for all dental services covered excluding periodontics and orthodontics.♠ Maximum of $1,250 for all services covered excluding orthodontics.C Maximum of $1,300 per policy year for all dental services covered excluding periodontics and orthodontics.

Ø Maximum of $1,300 per policy year for all covered dental services, excluding orthodontics.

� Maximum of $1,333 per policy year for all covered dental services.

Ϡ Maximum of $1,333 per policy year for all prosthodontics services covered.ď Maximum of $1,500, does not apply to diagnostic and preventive services.

Ñ Maximum of $1,500 per policy year for all covered dental services except orthodontic.

⇞ Maximum of $1,500 per policy year for all covered dental services, excluding periodontics and orthodontics.

Maximum of $1,500 per policy year for all covered dental services, excluding periodontics and prothesis.

ӟ Máximum of $1,500 per policy year for all covered dental services, excluding periodontics, prothesis and orthodontics.

∻ Maximum of $1,500 per policy year for all covered prosthetic services, in remaining services maximum those not apply, except periodontic and orthodontic services which maintain their own maximum.

ά Maximum of $1,500 and an initial deductible of $ 50.00 per insured, per policy year, does not apply to services: diagnostic, preventive, restorative, oral surgery and

endodontics, required by federal law.

ε Maximum of $1,750 for all services excluding orthodontics and periodontics.Ü Maximum of $1,750 per policy year for all dental covered services except orthodontics.¥ The assignment rate may not exceed the maximum benefit of $1,750 per policy year established for covered dental services except orthodontics.Њ Maximum of $2,000 for all services excluding orthodontics℃ Maximum of $2,000 per policy year for prosthodontics services including adjustments and repairs.

∝ Maximum of $2,500 per policy year for all covered dental services except orthodontics.ξ Maximum of $2,500 per policy year for all covered dental services.≈ Maximum benefit does not apply to children under age 19 insured for the following categories of services: diagnostic, preventive, restorative, oral surgery and endodontics.

February 01, 2020


RADIOGRAPHS

: Covered service D0330 1 every 6 monthsp Covers D0210 or D0330 service, not both, 1 every 2 years.p- Covers D0210 service, 1 every 2 years, exclude under 12 years of ages.ϫ Covered D0272, two sets per policy year with iterval of 6 month.

ϫ+ Covered D0270 and D0272, one every six month, per policy year.¢ Covers up to 4 periapical radiographs per policy year between the combination of D0220 and D0230 codes.ю It covers a maximum of 5 periapicals per policy year between the combination of D0220 and D0230 codes.Þ It covers a maximum of 6 periapicals per policy year between the combination of D0220 and D0230 codes.δ Covers up to 6 periapical radiographs per calendar year between the combination of D0220 and D0230 codes.⋆ Covers up to 8 periapical radiographs per policy year between the combination of D0220 and D0230 codes.

• It covers a maximum of 13 periapical radiographs every 3 years between the combination of D0220 and D0230 codes.ř Periapical first D0220 or each additional radiographic image D0230 - up to 6 every 12 months.

WAITING PERIOD OR LIMIT

L 24-month limitZ One year contract▼ Has waiting period of one month.^^ Covers 1 every 6 months for insured persons age 19 and older, with no exclusions.

SERVICES

--- Service not covered.ᵾ Only covers D3450.X Services covered at 100%.« D2954 service is not covered.» D2952 service is not covered.Ξ D9950 service is not covered.Б Only cover code D1510 .ҩ Only cover code D7471.ɂ Only cover code D9440.ᵳ Only cover code D9944-D9946.ª Only cover codes D5730, D5731.ä Only cover codes D5820, D5821.Ǿ D2394 service is maintained with 30% coinsurance.Я Restaurative services (amalgam and composite resin) replacement with justification every twelve months.

Ш Covered only the group 1-20005 Platinum Select Service. ♣ Only covers dependent children up to age 22.ᴥ Only cover codes D2510, D2520, D2530, D2542, D2543, D2544.K Services not covered: D2722, D4270, D4271, D5650, D5810 and D5811.T Periodontics and Prosthodontics services DO NOT require predetermination.S Covered service if they are related to covered surgical procedure.V Covered service when the extraction of 7 or more permanent teeth is required.O Services covered if they are related to accident, the bill requires to be accompanied by a report.ъ Service code D0160 replaces the D0150 and applies only to the specialties of Endodontists (088) and Oral and Maxillofacial Surgeon (019).S The codes D3330, D3348 and D9110 are only covered for the Cesar Castillo Group and applies 25% coinsurance.

Ŀ D3330 service code only covered for the following groups: Lanco Manufacturing, Lanco / Enco Manufacturing Corp. and Harris Paints Open Access and applies 25 % coinsurance.v D1206 service code covers only generalists and Pediatric dentists and is mutually exclusive with code D1208 (it's one or the other), not both, until the age of 5 years. This code

covers the groups that qualify with Obama Federal Reform.

� Code D0120 limited to 2 per consecutive 12 months.

ҕ Implants will not be covered when teeth are not present natural at both ends of the toothless area.

ᶌ Service code D1206 is up to 16 years of age and is limited to 2 for 12 months.DEDUCTIBLE

º Deductible of $ 5.00 for this categories services ; restorative, endodontics, periodontics, prosthodontics( adjustments/ repairs) and oral surgery.ς Deductible of $ 1.00 for this categories services ; diagnostic, restorative, endodontics, periodontics and oral surgery.≙ Deductible of $25.00 (individual) and $100.00 (family) applies for all covered dental services.

Ď Deductible of $25.00 (individual) and $100.00 (family) applies to minor and mayor restorative services.₫ Deductible is $ 5.00 per service applies to the following categories: diagnostic, preventive, restorative and endodontic. If the rate is less than the deductible,

the insured will pay the lesser amount.

Ł Deductible is $ 10.00 per service applies to the following categories: diagnostic, preventive, restorative and endodontic. If the rate is less than the deductiblethe insured will pay the lesser amount.

ѓ Deductible is $ 1.00 per service applies to the following categories: diagnostic, preventive, restorative, endodontics. If the rate is less than the deductible,the insured will pay the lesser amount.

џ Deductible is $ 5.00 per service, it applies to the following categories: diagnostic, preventive, restorative, endodontics. If the rate is less than the deductible,the insured will pay the lesser amount.

ά Initial deductible of $ 50.00 per insured, per policy year, does not apply to the following services: diagnostic, preventive, restorative, oral surgery and

endodontics, required by federal law.

COINSURANCE

// Coinsurance service will be applied to assested service± No coinsurance applies to diagnostic, preventive and restorative services offered in the Integrated Care Centers More Health.

ORTHODONTIC

◊ Service covered without age limit.μ Has waiting period of 12 months.£ It has a waiting period of 24 months to receive service.Ə Orthodontic services shall be paid subject to the charge.ą Maximum of $ 250 per policy year for orthodontic services.ề Maximum of $ 1,000 per policy year, per person for orthodontic services.F Orthodontic services are paid by the covered Major Expense.Ð This code is part of the initial visit (D8660) of orthodontic treatment.Ə1 Orthodontic services will be paid at the cash submitted by January 1, 2012.® Breaks habit covered until 14 years of age.ф Orthodontic Service covered only up to age 18.∏ The orthodontic benefit is available only to dependent children. Orthodontic services are covered until the age of 18, inclusive, of the participant.** Covers direct dependents up to age 19.* Orthodontics service covered until their 19th birthday.

… Orthodontic Services are limited only to eligible children until the day they turn 19.ℓ Covers orthodontics only until age 21.Ω Covers orthodontics until the insured reaches 25 years.© Only covers dependent children up to age 25.W It covers the policyholder only orthodontics and dependents up to age 25.ő Orthodontic services are covered only for dependent children up to 26 years of age.� Effective March 1, 2014 the top orthodontic service changes to $1,200.

ï Policyholder service covers orthodontics and spouse without age limit and direct dependents up to age 26.Θ Orthodontic Services "covered only for orthodontic specialists (Orthodontists / 109)," as requested by the group.Ṩ Orthodontic services are exclusive to Silgan Containers Group.js Orthodonctic services for the group Jose Santiago is $1,000 per year policy.ủ Alternative Ultra will not have the Orthodontic Benefit.

February 01, 2020


OTHER

(P) For periodontists only.e Apply 20% for specialists.¤ Optional dependents are eligible.f This dental coverage has termination date 12/31/2013.Y Insured with 65 or more continue to be elegible.r Covers only through secured to Reimbursement Fee Submitted.^ Please refer to the Participating Dentist Manual policies relevant to this payment service.ċ For participants who have agreed to participate in the plan of Government Employees ELA Integrated Care.

February 01, 2020


CODES DESCRIPTION D01 D02 D04 D05Maximum Benefit Cover ($) 1000

Note ≈ ≈ U ≈Deductible

CATEGORY I

DIAGNOSTIC

Note

DIAG. AND PREV. EvaluationD0120 Periódic oral evaluation X X X XD0140 Limited oral evalation - problem focused X X X XD0150 Comprehensive oral evaluation X X X XD0160 Detailed and extensive oral evaluation --- --- --- ---

D0180 (P) Comprehensive periodontal evaluation --- X X XImaging

D0210 Intraoral - complete series of radiographic images X X X XD0220;D0230 Intraoral - periapical first or each additional radiographic image X X X X

D0240 Intraoral - occlusal radiographic image X X X XD0250 Extra-oral - 2D projection radiographic image --- --- --- ---D0251 Extra-oral - posterior dental radiographic image X X X X

D0270;D0272 Bitewing - single or two radiographic images X X X XD0273 Bitewings - three radiographic images --- --- --- ---D0274 Bitewings - four radiographic images --- --- --- ---D0277 Vertical bitewings - 7 to 8 radiographic images --- --- --- ---D0330 Panoramic radiographic image X X X XD0340 2D cephalometric radiographic image --- --- --- ---

OthersD0350 2D oral / facial photographic image --- --- --- ---D0415 Collection of microorganisms for culture and sensitivity --- --- --- ---D0460 Pulp vitality tests X X X XD0470 Diagnostic casts --- --- --- ---D0473 Accession of tissue, gross and microscopic examination --- --- --- ---D0999 Unspecified diagnostic procedure, by report X X X X

PREVENTIVE

Note

ProphylaxisD1110 Prophylaxis - adult X X X XD1120 Prophylaxis - child X X X X

Topical Fluoride TreatmentD1206 Topical application of fluoride varnish X X X ---D1208 Topical application of fluoride - child X X X XD1208 Topical application of fluoride - adult (by report) --- X^ X^ X^

SealantD1351 Sealant - per tooth --- X X X

Space MaintenanceD1510 Space maintainer - fixed - unilateral --- 20 20 X

D1516;D1517 Space maintainer - fixed - bilateral - maxillary / mandibular --- 20 20 XD1520 Space maintainer - removable- unilateral --- --- --- ---

D1526;D1527 Space maintainer - removable bilateral - maxillary / mandibular --- --- --- ---D1551-D1552 Removal of fixed bilateral space maintainer maxillary / mandibular --- 20 20 X

D1553 Re-cement or re-bond unilateral space maintainer-per quadrant --- 20 20 XD1556 Removal of fixed bilateral space maintainer per quadrant --- 20 20 X

D1557-D1558 Removal of fixed bilateral space maintainer maxillary / mandibular --- 20 20 XD1575 Distal shoe space maintainer-fixed-unilateral --- 20 20 XD1999 Unspecified preventive procedure, by report X // // X

CATEGORY II


Note

D2140-D2161 Amalgam - primary or permanent X X X 25D2330-D2335 Resin - based composite - anterior (primary or permanent) X X X 25

D2391 Resin - based composite - posterior (primary or permanent) 30 30 20 25D2392-D2394 Resin - based composite - posterior (primary or permanent) 30 30 20 25D2410-D2430 Gold foil --- --- --- ---D2510-D2620 Inlays - Onlays: metallic - porcelain / ceramic --- --- --- ---

D2630 Inlay- porcelain / ceramic - three or more surfaces --- --- --- ---D2642-D2664 Inlay -Onlay: porcelain / ceramic; resin- based composite --- --- --- ---

D2799 Provisional crown --- X X 25D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration X X X 25D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core--- X X 25D2920 Re-cement or re-bond crown X X X 25D2930 Prefabricated stainless steel crown – primary tooth X X X 25D2931 Prefabricated stainless steel crown – permanent tooth --- --- --- ---D2932 Prefabricated resin crown --- --- --- ---D2933 Prefabricated stainless steel crown with resin window --- --- --- ---D2940 Protective restoration X X X 25 D2950 Core buildup, including any pins when required --- X X 25D2951 Pin retention - per tooth, in addition to restoration X X X 25D2960 Labial veneer (resin laminate) – chairside --- --- --- ---

D2961;D2962 Labial veneer - resin / porcelain lamínate – laboratory --- --- --- ---D2980 Crown repair necessitated by restaurative material failure --- X X 25

D2981-D2983 Inlay, onlay, venner repair necessitated by restaurative material failure --- --- --- --- D2999 Unspecified restorative procedure, by report X X X 25

February 01, 2020




ENDODONTICS

Note

D3110 Pulp cap - direct (excluding final restoration) X X X 25D3120 Pulp cap - indirect (excluding final restoration) X X X 25D3220 Therapeutic pulpotomy (excluding final restoration) X X X 25D3221 Pulpal debridement, primary and permanent teeth X X X 25

D3310;D3320 Endodontic therapy, anterior / premolar (excluding final restoration) X X X 25D3330 Endodontic therapy, molar tooth (excluding final restoration) --- X X 25

D3346;D3347 Retreatment of previous root canal therapy - anterior / premolar X X X 25D3348 Retreatment of previous root canal therapy - molar --- X X 25

D3351-D3353 Apexification / recalcification - inicial / interim / final visit --- --- --- ---D3355-D3357 Pulpal regeneration - inicial / interim / final visit --- --- --- ---D3410;D3421 Apicoectomy - anterior / bicuspid (first root) X X X 25D3425;D3426 Apicoectomy - molar - first root / each additional root X X X 25

D3430 Retrograde filling – per root X X X 25D3450;D3920 Root amputation - per root / Hemisection --- --- --- ---

D3999 Unspecified endodontic procedure, by report X X X 25BASIC PERIODONTICS

Note

D4355 Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit--- X 20 XD4346 Scaling in presence of generalized moderate or severe gingival inflammation-full mouth, after oral evaluation--- X 20 XD4910 Periodontal maintenance --- X 20 X

PROSTHODONTICS

Note

Limit per policy year ($)

D5410;D5411 Adjust complete denture – maxillary / mandibular X X X XD5421;D5422 Adjust partial denture – maxillary / mandibular X X X XD5511,D5512 Repair broken complete denture base, mandibulary / maxillary X X X X

D5520 Replace missing or broken teeth-complete denture (each tooth) X X X XD5611,D5612 Repair resin denture base, mandibulary / maxillary X X X XD5621,D5622 Repair cast partial framework, mandibulary / maxillary --- --- --- ---

D5630 Repair or replace broken clasp - per tooth X X X XD5640 Replace broken teeth – per tooth X X X X

D5650;D5660 Add tooth / clasp to existing partial denture X X X XD5710-D5721 Rebase: complete / partial denture --- 50 50 50D5730-D5761 Reline:complete / partial denture --- 50 50 50D5850;D5851 Tissue conditioning, maxillary / mandibular --- --- --- ---

D6930 Re-cement or re-bond fixed partial denture X X X XD6980 Fixed partial denture repair necessitated by restorative material failure --- X X X

ORAL SURGERY

Note

ExtractionsD7111 Extraction, coronal remnants - primary tooth --- --- --- ---D7140 Extraction, erupted tooth or exposed root X X X 25D7510 Incision and drainage of abscess- intraoral soft tissue X X X 25

CATEGORY III

MAYOR SERVICES PERIODONTICS

Note ULimit per policy year ($) --- 1000 --- 1000Periodontics deductible ($) --- --- --- ---

D4210;D4211 Gingivectomy or gingivoplasty- four o more / one to three contiguous teeth--- X 20 XD4240;D4241 Gingival flap procedure incluying root planing - four o more / one to three contiguous teeth--- X 20 X

D4245 Apically positioned flap --- X 20 XD4249 Clinical crown lengthening - hard tissue --- X 20 X

D4260;D4261 Osseous surgery --- X 20 XD4263;D4264 Bone replacement graft -first / additional site in quadrant --- X 20 XD4266;D4267 Guided tissue regeneration - resorbable barrier / no resorbable barrier, per site --- X 20 XD4270;D4273 Pedicle soft tissue graft procedure / autogenous connective tissue graft, per tooth--- X 20 X

D4277 Free soft tissue graft procedure - first tooth, implant, or edentulous tooth--- X 20 XD4278 Free soft tissue graft procedure - each additional contiguous tooth, implant, or edontulous tooth--- --- --- ---D4320 Provisional splinting - intracoronal --- --- --- --- D4321 Provisional splinting - extracoronal --- X 20 X

D4341;D4342 Periodontal scaling and root planing / four or more / one to three teeth per quadrant--- X 20 XD4920 Unscheduled dressing change (by someone other than treating dentist or their staff)--- --- --- ---D4999 Unspecified periodontal procedure, by report --- X 20 X

PROSTHODONTICS

Note

Límit ($)

D2710 Crown - resin based composite (indirect) --- --- --- ---D2720 Crown - resin with high noble metal --- 57 50 50D2722 Crown - resin with noble metal --- 50 50 50D2740 Crown - porcelain / ceramic --- 50 50 50

February 01, 2020




D2750 Crown - porcelain fused to high noble metal --- 57 50 50D2751 Crown - porcelain fused to predominantly base metal --- 50 50 50D2752 Crown - porcelain fused to noble metal --- 50 50 50D2753 Crown-porcelain fused to titanium and titanium alloys --- 50 50 50D2780 Crown - ¾ cast high noble metal --- 57 50 50

D2781-D2783 Crown - ¾ cast base metal / noble metal / porcelain-ceramic --- 50 50 50D2790 Crown - full cast high noble metal --- 57 50 50D2791 Crown - full cast predominantly base metal --- 50 50 50D2792 Crown - full cast noble metal --- 50 50 50D2794 Crown - titanium --- 57 50 50

D2952;D2954 Post and core --- 50 50 50D2975 Coping --- --- --- ---

D5110;D5120 Complete denture - maxillary / mandibular --- 50 50 50D5130;D5140 Immediate denture - maxillary / mandibular --- 50 50 50D5211;D5212 Partial denture - resin base - maxillary / mandibular --- 50 50 50D5213;D5214 Partial denture - cast metal framework with resin base - maxillary / mandibular--- 50 50 50D5221;D5222 Immediate partial denture-resin base - maxillary / mandibular --- 50 50 50D5223;D5224 Immediate partial denture-cast metal framework with resin denture base - maxillary/mandibular--- 50 50 50D5282;D5283 Removable unilateral partial denture - one piece cast metal - maxillary / mandibular--- 50 50 50

D5286 Removable unilateral partial denture-one piece resin (including clasps and teeth)-per quadrant--- 50 50 50D5810-D5821 Interim complete and partial denture - maxillary / mandibular --- --- --- ---D5863-D5866 Overdentures:complete;partial - maxillary / mandibular --- --- --- ---

D5862 Precision attachment, by report --- --- --- ---D5899 Unspecified removable prosthodontic procedure, by report X 50 50 50D6058 Abutment supported porcelain / ceramic crown --- 50 50 50D6059 Abutment supported porcelain fused to metal crown (high noble metal) --- 57 50 50D6060 Abutment supported porcelain fused to metal crown predominantly base metal--- --- --- ---D6061 Abutment supported porcelain fused to metal crown (noble metal) --- 50 50 50D6062 Abutment supported cast metal crown (high noble metal) --- 57 50 50D6063 Abutment supprted cast metal crown (predominantly base metal) --- --- --- ---D6064 Abutment supported cast metal crown (noble metal) --- 50 50 50D6065 Implant supported porcelain / ceramic crown --- 50 50 50D6066 Implant supported porcelain fused to metal crown --- 57 50 50D6067 Implant supported metal crown --- 57 50 50D6068 Abutment supported retainer for porcelain/ceramic FPD --- 50 50 50D6075 Implant supported retainer for ceramic FPD --- 50 50 50D6076 Implant supported retainer for porcelain fused to metal FPD --- 57 50 50D6077 Implant supported retainer for cast metal FPD --- 57 50 50D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal)--- 57 50 50D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)--- 50 50 50D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal)--- 50 50 50D6072 Abutment supported retainer for cast metal FPD (high noble metal) --- 57 50 50D6073 Abutment supported retainer for cast metal FPD (predominantly base metal)--- 50 50 50D6074 Abutment supported retainer for cast metal FPD (noble metal) --- 50 50 50D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure--- --- --- ---D6082 Implant supported crown-porcelain fused to predominantly base alloys --- 50 50 50D6083 Implant supported crown-porcelain fused to noble alloys --- 50 50 50D6084 Implant supported crown-porcelain fused to titanium and titanium alloys --- 50 50 50D6086 Implant supported crown-predominantly base alloys --- 50 50 50D6087 Implant supported crown-noble alloys --- 50 50 50D6088 Implant supported crown-titanium and titanium alloys --- 50 50 50D6097 Abutment supported crown-porcelain fused to titanium and titanium alloys--- 50 50 50D6195 Abutment supported retainer-porcelain fused to titanium and titanium alloys--- 50 50 50D6210 Pontic - cast high noble metal --- 57 50 50D6211 Pontic - cast predominantly base metal --- 50 50 50D6212 Pontic - cast noble metal --- 50 50 50D6214 Pontic - titanium --- 57 50 50D6240 Pontic - porcelain fused to high noble metal --- 57 50 50D6241 Pontic - porcelain fused to predominantly base metal --- 50 50 50D6242 Pontic - porcelain fused to noble metal --- 50 50 50D6243 Pontic-porcelain fused to titanium and titanium alloys --- 50 50 50D6245 Pontic - porcelain / ceramic --- --- --- ---D6250 Pontic - resin with high noble metal --- 57 50 50

D6251;D6252 Pontic - resin with predominantly base metal / resin with noble metal --- --- --- ---D6253 Provisional pontic --- --- --- ---D6545 Retainer - cast metal for resin bonded fixed prosthesis --- 50 50 50D6548 Retainer - porcelain / ceramic for resin bonded fixed prosthesis --- --- --- ---

D6600-D6605 Retainer inlays: porcelain;metalic --- --- --- ---D6606;D6607 Retainer inlays - cast noble metal, two surfaces / three or more surfaces --- --- 50 50D6608-D6615 Retainer onlays:porcelain;metalic --- --- --- ---D6624;D6634 Retainer inlays / onlays - titanium --- --- --- ---

D6710 Retainer crown - indirect resin based composite --- --- --- ---D6720 Retainer crown - resin with high noble metal --- 57 50 50

D6721;D6722 Retainer crown - resin with predominantly base metal / resin with noble metal--- --- --- ---D6740 Retainer crown - porcelain / ceramic --- --- --- ---D6750 Retainer crown - porcelain fused to high noble metal --- 57 50 50D6751 Retainer crown - porcelain fused to predominantly base metal --- 50 50 50D6752 Retainer crown - porcelain fused to noble metal --- 50 50 50D6753 Retainer crown-porcelain fused to titanium and titanium alloys --- 50 50 50D6780 Retainer crown - ¾ cast high noble metal --- --- --- ---

D6781;D6782 Retainer crown - ¾ cast predominantly base metal / noble metal --- 50 50 50

February 01, 2020




D6783 Retainer crown - ¾ porcelain / ceramic --- --- --- ---D6784 Retainer crown 3/4 - titanium and titanium alloys --- --- --- ---

February 01, 2020




D6790 Retainer crown - full cast high noble metal --- 57 50 50D6791;D6792 Retainer crown - full cast predominantly base metal / noble metal --- 50 50 50

D6794 Retainer crown - titanium --- 57 50 50D6920 Connector bar --- --- --- ---D6940 Stress breaker --- --- --- ---D6950 Precision attachment --- --- --- ---D6999 Unspecified, fixed prosthodontic procedure, by report --- 50 50 50

MAXILOFACIAL PROSTHETIC

D5931-D5936 Obturator prosthesis: surgical / definitive / modification - mandibular resection --- --- --- ---D5951-D5955 Feeding aid / Speech aid (pediatric- adult) / Palatal (augmentation- lift) prosthesis --- --- --- ---D5982-D5985 Surgical stent / Radiation shield / Radiation cone locator --- --- --- ---

D5986 Fluoride gel carrier --- --- --- ---IMPLANTS SERVICES

Note

Límit ($)

D6010;D6011 Surgical placement of implant body; endosteal implant / second stage implant surgery--- --- --- ---D6012-D6199 Other Implant services --- --- --- ---

ORAL SURGERY (SURGICAL)

Note

D7210 Surgical removal of erupted tooth X 30 20 25D7220-D7240 Removal of impacted tooth – soft tissue / partially bony / completely bonyX 30 20 25

D7241 Removal of impacted tooth – completely bony, with unusual surgical complication--- --- --- ---D7250 Surgical removal of residual tooth roots X 30 20 25D7260 Oroantral fistula closure --- --- --- ---D7270 Tooth re-implantation and / or stabilization of accidentally evulsed or displaced tooth--- --- --- ---D7272 Tooth transplantation --- --- --- --- D7280 Surgical access of an unerupted tooth --- 30 20 25 D7283 Placement of device to facilitate eruption of impacted tooth --- 30 20 ---D7285 Incisional biopsy of oral tissue - hard (bone, tooth) --- --- --- ---D7286 Incisional biopsy of oral tissue - soft X 30 20 25D7290 Surgical repositioning of teeth --- --- --- ---D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report --- --- --- ---

D7310-D7321 Alveoloplasty in conjunction with extractions / not in conjunction with extractions--- 50 50 50D7340 Vestibuloplasty-ridge extension (secondary epithelialization) --- --- --- ---D7350 Vestibuloplasty-ridge extension (including soft tissue grafts….) --- --- --- ---

D7471-D7473 Removal of lateral exostosis / torus palatinus / torus mandibularis --- --- --- ---D7520 Incision and drainage of abscess – extraoral soft tissue --- --- --- ---D7550 Partial ostectomy /Sequestrectomy for removal of non-vital bone --- --- --- ---D7880 Occlusal orthotic device, by report --- --- --- ---D7881 Occlusal orthotic device adjustment --- --- --- ---D7910 Suture of recent small wounds up to 5 cm --- --- --- ---D7922 Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per siteX 30 20 25D7953 Bone replacement graft for ridge preservation – per site --- --- --- ---D7960 Frenulectomy (frenectomy or frenotomy) – separate procedure --- --- --- ---D7970 Excision of hyperplastic tissue - per arch --- --- --- ---D7971 Excision of pericoronal gingiva X 30 20 25D7999 Unspecified oral surgery procedure, by report X 30 20 25

CATEGORY IV


Note

D9110 Palliative (emergency) treatment of dental pain – minor procedure --- --- --- ---D9230 Inhalation of nitrous oxide / analgesia, anxiolysis --- --- --- ---D9239 Intravenous moderate (conscious) sedation/analgesia - first 15 minutes --- --- --- ---D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minutes increment--- --- --- ---D9310 Consultation - diagnostic service provided by dentist or physician --- --- --- ---D9410 House / extended care facility call --- --- --- ---D9420 Hospital or ambulatory surgical center call --- X X X

D9430;D9440 Office visits (during regularly scheduled hours/ after regularly scheduled hours)--- --- --- ---D9630 Other drugs and / or medicaments, by report X X X 25D9910 Application of desensitizing medicament X X X 25D9930 Reatment of complications (post-surgical) - unusual circumstances, by reportX X X 25

D9944-D9946 Occlusal guard - hard appliance, soft appliance, full arch and hard appliance, partial arch--- --- --- ---D9950 Occlusion analysis - mounted case --- --- --- ---D9943 Occlusal guard adjustment --- --- --- ---

D9951;D9952 Occlusal adjustment - limited / complete --- X X XD9973;D9974 External / Internal bleaching – per tooth --- --- --- ---

D9999 Unspecified adjunctive procedure – by report X X X XORTHODONTIC

D8210-D8702 Orthodontic Services --- X 50 ---Note --- Ə1 ** Ə ---Lifetime limit ($) --- 1000 1500 ---Deductible Orthodontics ($) --- --- --- ---Note --- --- --- ---Límit per policy year ($) --- --- --- ---Deductible Orthodontics ($) --- --- --- ---

February 01, 2020


CODES DESCRIPTIONMaximum Benefit Cover ($)

Note

Deductible

CATEGORY I

DIAGNOSTIC

Note

DIAG. AND PREV. EvaluationD0120 Periódic oral evaluationD0140 Limited oral evalation - problem focusedD0150 Comprehensive oral evaluationD0160 Detailed and extensive oral evaluation

D0180 (P) Comprehensive periodontal evaluationImaging

D0210 Intraoral - complete series of radiographic imagesD0220;D0230 Intraoral - periapical first or each additional radiographic image

D0240 Intraoral - occlusal radiographic imageD0250 Extra-oral - 2D projection radiographic imageD0251 Extra-oral - posterior dental radiographic image

D0270;D0272 Bitewing - single or two radiographic imagesD0273 Bitewings - three radiographic imagesD0274 Bitewings - four radiographic imagesD0277 Vertical bitewings - 7 to 8 radiographic imagesD0330 Panoramic radiographic imageD0340 2D cephalometric radiographic image

OthersD0350 2D oral / facial photographic image D0415 Collection of microorganisms for culture and sensitivityD0460 Pulp vitality testsD0470 Diagnostic castsD0473 Accession of tissue, gross and microscopic examinationD0999 Unspecified diagnostic procedure, by report

PREVENTIVE

Note

ProphylaxisD1110 Prophylaxis - adultD1120 Prophylaxis - child

Topical Fluoride TreatmentD1206 Topical application of fluoride varnishD1208 Topical application of fluoride - childD1208 Topical application of fluoride - adult (by report)

SealantD1351 Sealant - per tooth

Space MaintenanceD1510 Space maintainer - fixed - unilateral

D1516;D1517 Space maintainer - fixed - bilateral - maxillary / mandibularD1520 Space maintainer - removable- unilateral

D1526;D1527 Space maintainer - removable bilateral - maxillary / mandibularD1551-D1552 Removal of fixed bilateral space maintainer maxillary / mandibular

D1553 Re-cement or re-bond unilateral space maintainer-per quadrantD1556 Removal of fixed bilateral space maintainer per quadrant

D1557-D1558 Removal of fixed bilateral space maintainer maxillary / mandibularD1575 Distal shoe space maintainer-fixed-unilateralD1999 Unspecified preventive procedure, by report

CATEGORY II


Note

D2140-D2161 Amalgam - primary or permanentD2330-D2335 Resin - based composite - anterior (primary or permanent)

D2391 Resin - based composite - posterior (primary or permanent) D2392-D2394 Resin - based composite - posterior (primary or permanent)D2410-D2430 Gold foil D2510-D2620 Inlays - Onlays: metallic - porcelain / ceramic

D2630 Inlay- porcelain / ceramic - three or more surfacesD2642-D2664 Inlay -Onlay: porcelain / ceramic; resin- based composite

D2799 Provisional crown D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restorationD2915 Re-cement or re-bond indirectly fabricated or prefabricated post and coreD2920 Re-cement or re-bond crownD2930 Prefabricated stainless steel crown – primary toothD2931 Prefabricated stainless steel crown – permanent toothD2932 Prefabricated resin crownD2933 Prefabricated stainless steel crown with resin windowD2940 Protective restoration D2950 Core buildup, including any pins when requiredD2951 Pin retention - per tooth, in addition to restorationD2960 Labial veneer (resin laminate) – chairside

D2961;D2962 Labial veneer - resin / porcelain lamínate – laboratoryD2980 Crown repair necessitated by restaurative material failure

D2981-D2983 Inlay, onlay, venner repair necessitated by restaurative material failure D2999 Unspecified restorative procedure, by report

D06 D07 D08 D10 D12 D20

≈ ≈ ≈

X X Z X X 20 XX --- X X 20 XX X X X 20 X--- --- --- --- --- ---X --- --- X 20 X

X --- --- X 20 XX --- X δ X 20 X ÞX --- --- X 20 ------ --- --- --- --- ---X --- 30 X 20 XX --- X X 20 X--- --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ---X --- 30 X 20 X--- --- --- --- --- ---

------ --- --- --- --- ------ --- --- --- --- ---X --- --- X 20 X--- --- --- --- --- ------ --- --- --- --- ---X --- 30 X 20 X

X X X X 20 XX X X X 20 X

X --- --- X X ---X --- X X 20 X--- --- 30^ --- 20^ X^

--- --- --- --- 20 20

X --- --- 50 20 20X --- --- 50 20 20--- --- --- --- --- ------ --- --- --- --- ---X --- --- 50 20 20X --- --- 50 20 20X --- --- 50 20 20X --- --- 50 20 20X --- --- 50 20 20X X // // 20 //

X --- 30 X 30 20X --- 30 X 30 2030 --- 30 30 30 3030 --- 30 30 30 30--- --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ---X --- --- X 30 ---X --- --- X 30 ---X --- --- X 30 ---X --- --- X 30 ---X --- --- X 30 ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ---X --- 30 X 30 20X --- --- X 30 ---X --- 30 X 30 ------ --- --- --- --- ------ --- --- --- --- ---X --- --- X 30 ------ --- --- --- --- ---X --- 30 X 30 20

February 01, 2020



Note

Deductible

ENDODONTICS

Note

D3110 Pulp cap - direct (excluding final restoration)D3120 Pulp cap - indirect (excluding final restoration)D3220 Therapeutic pulpotomy (excluding final restoration)D3221 Pulpal debridement, primary and permanent teeth

D3310;D3320 Endodontic therapy, anterior / premolar (excluding final restoration)D3330 Endodontic therapy, molar tooth (excluding final restoration)

D3346;D3347 Retreatment of previous root canal therapy - anterior / premolarD3348 Retreatment of previous root canal therapy - molar

D3351-D3353 Apexification / recalcification - inicial / interim / final visitD3355-D3357 Pulpal regeneration - inicial / interim / final visitD3410;D3421 Apicoectomy - anterior / bicuspid (first root) D3425;D3426 Apicoectomy - molar - first root / each additional root

D3430 Retrograde filling – per rootD3450;D3920 Root amputation - per root / Hemisection

D3999 Unspecified endodontic procedure, by reportBASIC PERIODONTICS

Note

D4355 Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visitD4346 Scaling in presence of generalized moderate or severe gingival inflammation-full mouth, after oral evaluationD4910 Periodontal maintenance

PROSTHODONTICS

Note


D5410;D5411 Adjust complete denture – maxillary / mandibularD5421;D5422 Adjust partial denture – maxillary / mandibularD5511,D5512 Repair broken complete denture base, mandibulary / maxillary

D5520 Replace missing or broken teeth-complete denture (each tooth)D5611,D5612 Repair resin denture base, mandibulary / maxillaryD5621,D5622 Repair cast partial framework, mandibulary / maxillary

D5630 Repair or replace broken clasp - per toothD5640 Replace broken teeth – per tooth

D5650;D5660 Add tooth / clasp to existing partial denture D5710-D5721 Rebase: complete / partial dentureD5730-D5761 Reline:complete / partial dentureD5850;D5851 Tissue conditioning, maxillary / mandibular

D6930 Re-cement or re-bond fixed partial dentureD6980 Fixed partial denture repair necessitated by restorative material failure

ORAL SURGERY

Note

ExtractionsD7111 Extraction, coronal remnants - primary toothD7140 Extraction, erupted tooth or exposed rootD7510 Incision and drainage of abscess- intraoral soft tissue

CATEGORY III


Note


Periodontics deductible ($)

D4210;D4211 Gingivectomy or gingivoplasty- four o more / one to three contiguous teethD4240;D4241 Gingival flap procedure incluying root planing - four o more / one to three contiguous teeth

D4245 Apically positioned flapD4249 Clinical crown lengthening - hard tissue

D4260;D4261 Osseous surgery D4263;D4264 Bone replacement graft -first / additional site in quadrantD4266;D4267 Guided tissue regeneration - resorbable barrier / no resorbable barrier, per site D4270;D4273 Pedicle soft tissue graft procedure / autogenous connective tissue graft, per tooth

D4277 Free soft tissue graft procedure - first tooth, implant, or edentulous toothD4278 Free soft tissue graft procedure - each additional contiguous tooth, implant, or edontulous toothD4320 Provisional splinting - intracoronal D4321 Provisional splinting - extracoronal

D4341;D4342 Periodontal scaling and root planing / four or more / one to three teeth per quadrantD4920 Unscheduled dressing change (by someone other than treating dentist or their staff)D4999 Unspecified periodontal procedure, by report

PROSTHODONTICS

Note

Límit ($)

D2710 Crown - resin based composite (indirect)D2720 Crown - resin with high noble metalD2722 Crown - resin with noble metalD2740 Crown - porcelain / ceramic

D06 D07 D08 D10 D12 D20

≈ ≈ ≈

X --- 30 X 30 ---X --- 30 X 30 20X --- --- X 30 20X --- 30 X 30 20X --- --- X 30 20X --- --- X 30 20X --- --- X 30 20X --- --- X 30 ------ --- --- --- --- ------ --- --- --- --- ---X --- --- X 30 ---X --- --- X --- ---X --- --- X 30 ------ --- --- --- --- ---X --- --- X 30 20

X --- --- 50 30 ---X --- --- 50 30 ---X --- --- 50 30 20

X --- --- X X ---X --- --- X X 40X --- --- X X 40X --- --- X X ---X --- --- X X 40--- --- --- --- --- ---X --- --- X X ---X --- --- X X 40X --- --- X X ---X --- --- 50 50 40X --- --- 50 50 40--- --- --- --- --- ---X --- --- X X ---X --- --- X X ---

--- --- --- --- --- ---X X 30 X X 20X --- 30 X X 20

1000 --- --- 800 1000 ---50 --- --- 50 --- ---X --- --- 50 30 ---X --- --- 50 30 ---X --- --- 50 30 ---X --- --- 50 30 ---X --- --- 50 30 ---X --- --- 50 30 ---X --- --- 50 30 ---X --- --- 50 30 ---X --- --- 50 30 ------ --- --- --- --- ------ --- --- --- 30 ---X --- --- 50 30 ---X --- --- 50 30 20--- --- --- --- 30 ---X --- --- 50 30 ---

1000

--- --- --- --- --- ---X --- --- --- 50 ---X --- --- 50 50 ---X --- --- 50 50 ---

February 01, 2020



Note

Deductible

D2750 Crown - porcelain fused to high noble metalD2751 Crown - porcelain fused to predominantly base metalD2752 Crown - porcelain fused to noble metalD2753 Crown-porcelain fused to titanium and titanium alloysD2780 Crown - ¾ cast high noble metal

D2781-D2783 Crown - ¾ cast base metal / noble metal / porcelain-ceramicD2790 Crown - full cast high noble metalD2791 Crown - full cast predominantly base metalD2792 Crown - full cast noble metalD2794 Crown - titanium

D2952;D2954 Post and core D2975 Coping

D5110;D5120 Complete denture - maxillary / mandibularD5130;D5140 Immediate denture - maxillary / mandibularD5211;D5212 Partial denture - resin base - maxillary / mandibularD5213;D5214 Partial denture - cast metal framework with resin base - maxillary / mandibularD5221;D5222 Immediate partial denture-resin base - maxillary / mandibularD5223;D5224 Immediate partial denture-cast metal framework with resin denture base - maxillary/mandibularD5282;D5283 Removable unilateral partial denture - one piece cast metal - maxillary / mandibular

D5286 Removable unilateral partial denture-one piece resin (including clasps and teeth)-per quadrantD5810-D5821 Interim complete and partial denture - maxillary / mandibularD5863-D5866 Overdentures:complete;partial - maxillary / mandibular

D5862 Precision attachment, by reportD5899 Unspecified removable prosthodontic procedure, by report D6058 Abutment supported porcelain / ceramic crownD6059 Abutment supported porcelain fused to metal crown (high noble metal)D6060 Abutment supported porcelain fused to metal crown predominantly base metalD6061 Abutment supported porcelain fused to metal crown (noble metal)D6062 Abutment supported cast metal crown (high noble metal)D6063 Abutment supprted cast metal crown (predominantly base metal)D6064 Abutment supported cast metal crown (noble metal)D6065 Implant supported porcelain / ceramic crownD6066 Implant supported porcelain fused to metal crownD6067 Implant supported metal crown D6068 Abutment supported retainer for porcelain/ceramic FPDD6075 Implant supported retainer for ceramic FPDD6076 Implant supported retainer for porcelain fused to metal FPDD6077 Implant supported retainer for cast metal FPDD6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal)D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal)D6072 Abutment supported retainer for cast metal FPD (high noble metal)D6073 Abutment supported retainer for cast metal FPD (predominantly base metal)D6074 Abutment supported retainer for cast metal FPD (noble metal)D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closureD6082 Implant supported crown-porcelain fused to predominantly base alloysD6083 Implant supported crown-porcelain fused to noble alloysD6084 Implant supported crown-porcelain fused to titanium and titanium alloysD6086 Implant supported crown-predominantly base alloysD6087 Implant supported crown-noble alloysD6088 Implant supported crown-titanium and titanium alloysD6097 Abutment supported crown-porcelain fused to titanium and titanium alloysD6195 Abutment supported retainer-porcelain fused to titanium and titanium alloysD6210 Pontic - cast high noble metalD6211 Pontic - cast predominantly base metalD6212 Pontic - cast noble metalD6214 Pontic - titaniumD6240 Pontic - porcelain fused to high noble metalD6241 Pontic - porcelain fused to predominantly base metalD6242 Pontic - porcelain fused to noble metalD6243 Pontic-porcelain fused to titanium and titanium alloysD6245 Pontic - porcelain / ceramic D6250 Pontic - resin with high noble metal

D6251;D6252 Pontic - resin with predominantly base metal / resin with noble metalD6253 Provisional pontic D6545 Retainer - cast metal for resin bonded fixed prosthesisD6548 Retainer - porcelain / ceramic for resin bonded fixed prosthesis

D6600-D6605 Retainer inlays: porcelain;metalicD6606;D6607 Retainer inlays - cast noble metal, two surfaces / three or more surfacesD6608-D6615 Retainer onlays:porcelain;metalicD6624;D6634 Retainer inlays / onlays - titanium

D6710 Retainer crown - indirect resin based composite D6720 Retainer crown - resin with high noble metal

D6721;D6722 Retainer crown - resin with predominantly base metal / resin with noble metalD6740 Retainer crown - porcelain / ceramicD6750 Retainer crown - porcelain fused to high noble metalD6751 Retainer crown - porcelain fused to predominantly base metalD6752 Retainer crown - porcelain fused to noble metalD6753 Retainer crown-porcelain fused to titanium and titanium alloysD6780 Retainer crown - ¾ cast high noble metal

D6781;D6782 Retainer crown - ¾ cast predominantly base metal / noble metal

D06 D07 D08 D10 D12 D20

≈ ≈ ≈

X --- --- --- 50 ---X --- --- 50 50 ---X --- --- 50 50 ---X --- --- 50 50 ---X --- --- --- 50 ---X --- --- 50 50 ---X --- --- --- 50 ---X --- --- 50 50 ---X --- --- 50 50 ---X --- --- --- 50 ---X --- --- 50 50 ------ --- --- --- --- ---X --- --- 50 50 40X --- --- 50 50 ---X --- --- 50 50 ---X --- --- 50 50 40X --- --- 50 50 ---X --- --- 50 50 40X --- --- 50 50 ---X --- --- 50 50 ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ---X --- --- 50 50 40--- --- --- 50 50 ------ --- --- --- 50 ------ --- --- --- --- ------ --- --- 50 50 ------ --- --- --- 50 ------ --- --- --- --- ------ --- --- 50 50 ------ --- --- 50 50 ------ --- --- --- 50 ------ --- --- --- 50 ------ --- --- 50 50 ------ --- --- 50 50 ------ --- --- --- 50 ------ --- --- --- 50 ------ --- --- --- 50 ------ --- --- 50 50 ------ --- --- 50 50 ------ --- --- --- 50 ------ --- --- 50 50 ------ --- --- 50 50 ------ --- --- 50 --- ------ --- --- 50 50 ------ --- --- 50 50 ------ --- --- 50 50 ------ --- --- 50 50 ------ --- --- 50 50 ------ --- --- 50 50 ------ --- --- 50 50 ------ --- --- 50 50 ---X --- --- --- 50 ---X --- --- 50 50 ---X --- --- 50 50 ---X --- --- --- 50 ---X --- --- --- 50 ---X --- --- 50 50 ---X --- --- 50 50 ---X --- --- 50 50 ------ --- --- --- --- ---X --- --- --- 50 ------ --- --- --- --- ------ --- --- --- --- ---X --- --- 50 50 ------ --- --- --- --- ------ --- --- --- --- ---X --- --- 50 50 ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ---X --- --- --- 50 ------ --- --- --- --- ------ --- --- --- --- ---X --- --- --- 50 ---X --- --- 50 50 ---X --- --- 50 50 ---X --- --- 50 50 ------ --- --- --- --- ---X --- --- 50 50 ---

February 01, 2020



Note

Deductible

D6783 Retainer crown - ¾ porcelain / ceramicD6784 Retainer crown 3/4 - titanium and titanium alloys

D06 D07 D08 D10 D12 D20

≈ ≈ ≈

--- --- --- --- --- ------ --- --- --- --- ---

February 01, 2020



Note

Deductible

D6790 Retainer crown - full cast high noble metalD6791;D6792 Retainer crown - full cast predominantly base metal / noble metal

D6794 Retainer crown - titaniumD6920 Connector barD6940 Stress breakerD6950 Precision attachmentD6999 Unspecified, fixed prosthodontic procedure, by report


D5931-D5936 Obturator prosthesis: surgical / definitive / modification - mandibular resection D5951-D5955 Feeding aid / Speech aid (pediatric- adult) / Palatal (augmentation- lift) prosthesis D5982-D5985 Surgical stent / Radiation shield / Radiation cone locator

D5986 Fluoride gel carrierIMPLANTS SERVICES

Note

Límit ($)

D6010;D6011 Surgical placement of implant body; endosteal implant / second stage implant surgeryD6012-D6199 Other Implant services


Note

D7210 Surgical removal of erupted tooth D7220-D7240 Removal of impacted tooth – soft tissue / partially bony / completely bony

D7241 Removal of impacted tooth – completely bony, with unusual surgical complicationD7250 Surgical removal of residual tooth rootsD7260 Oroantral fistula closureD7270 Tooth re-implantation and / or stabilization of accidentally evulsed or displaced toothD7272 Tooth transplantation D7280 Surgical access of an unerupted tooth D7283 Placement of device to facilitate eruption of impacted toothD7285 Incisional biopsy of oral tissue - hard (bone, tooth)D7286 Incisional biopsy of oral tissue - softD7290 Surgical repositioning of teethD7291 Transseptal fiberotomy/supra crestal fiberotomy, by report

D7310-D7321 Alveoloplasty in conjunction with extractions / not in conjunction with extractionsD7340 Vestibuloplasty-ridge extension (secondary epithelialization)D7350 Vestibuloplasty-ridge extension (including soft tissue grafts….)

D7471-D7473 Removal of lateral exostosis / torus palatinus / torus mandibularisD7520 Incision and drainage of abscess – extraoral soft tissueD7550 Partial ostectomy /Sequestrectomy for removal of non-vital boneD7880 Occlusal orthotic device, by reportD7881 Occlusal orthotic device adjustmentD7910 Suture of recent small wounds up to 5 cmD7922 Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per siteD7953 Bone replacement graft for ridge preservation – per siteD7960 Frenulectomy (frenectomy or frenotomy) – separate procedureD7970 Excision of hyperplastic tissue - per archD7971 Excision of pericoronal gingivaD7999 Unspecified oral surgery procedure, by report

CATEGORY IV


Note

D9110 Palliative (emergency) treatment of dental pain – minor procedureD9230 Inhalation of nitrous oxide / analgesia, anxiolysisD9239 Intravenous moderate (conscious) sedation/analgesia - first 15 minutesD9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minutes incrementD9310 Consultation - diagnostic service provided by dentist or physicianD9410 House / extended care facility callD9420 Hospital or ambulatory surgical center call

D9430;D9440 Office visits (during regularly scheduled hours/ after regularly scheduled hours)D9630 Other drugs and / or medicaments, by reportD9910 Application of desensitizing medicamentD9930 Reatment of complications (post-surgical) - unusual circumstances, by report

D9944-D9946 Occlusal guard - hard appliance, soft appliance, full arch and hard appliance, partial archD9950 Occlusion analysis - mounted caseD9943 Occlusal guard adjustment

D9951;D9952 Occlusal adjustment - limited / completeD9973;D9974 External / Internal bleaching – per tooth

D9999 Unspecified adjunctive procedure – by reportORTHODONTIC

D8210-D8702 Orthodontic Services Note

Lifetime limit ($)

Deductible Orthodontics ($)

Note

Límit per policy year ($)Deductible Orthodontics ($)

D06 D07 D08 D10 D12 D20

≈ ≈ ≈

X --- --- --- 50 ---X --- --- 50 50 ---X --- --- --- 50 ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ---X --- --- 50 50 ---

--- --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ---

--- --- --- 50 --- ------ --- --- 50 --- ---

X --- 30 X 30 20X --- 30 X 30 20--- --- --- --- --- ---X --- 30 X 30 20--- --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ---X --- --- X --- ---X --- --- X --- ------ --- --- --- --- ---X --- --- X 30 ------ --- --- --- --- ------ --- --- --- --- ---X --- --- 50 50 ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---X --- 30 X 30 20--- --- --- X --- ------ --- --- --- --- ------ --- --- --- --- ---X --- --- X 30 ---X --- 30 X 30 20

--- --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ------ --- 30 --- X 20--- --- --- --- --- ---X --- --- X X ---X --- 30 X X 20X --- 30 X X 20--- --- --- X --- ------ --- --- X --- ------ --- --- --- --- ---X --- --- X --- ------ --- --- --- --- ---X --- 30 X X 20

X --- --- 50 --- ---Ə1 --- --- ◊ Ə --- ---

1000 --- --- 3000 --- ------ --- --- 50 --- ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ---

February 01, 2020



Note

Deductible

CATEGORY I

DIAGNOSTIC

Note

DIAG. AND PREV. EvaluationD0120 Periódic oral evaluationD0140 Limited oral evalation - problem focusedD0150 Comprehensive oral evaluationD0160 Detailed and extensive oral evaluation

D0180 (P) Comprehensive periodontal evaluationImaging

D0210 Intraoral - complete series of radiographic imagesD0220;D0230 Intraoral - periapical first or each additional radiographic image

D0240 Intraoral - occlusal radiographic imageD0250 Extra-oral - 2D projection radiographic imageD0251 Extra-oral - posterior dental radiographic image

D0270;D0272 Bitewing - single or two radiographic imagesD0273 Bitewings - three radiographic imagesD0274 Bitewings - four radiographic imagesD0277 Vertical bitewings - 7 to 8 radiographic imagesD0330 Panoramic radiographic imageD0340 2D cephalometric radiographic image

OthersD0350 2D oral / facial photographic image D0415 Collection of microorganisms for culture and sensitivityD0460 Pulp vitality testsD0470 Diagnostic castsD0473 Accession of tissue, gross and microscopic examinationD0999 Unspecified diagnostic procedure, by report

PREVENTIVE

Note

ProphylaxisD1110 Prophylaxis - adultD1120 Prophylaxis - child

Topical Fluoride TreatmentD1206 Topical application of fluoride varnishD1208 Topical application of fluoride - childD1208 Topical application of fluoride - adult (by report)

SealantD1351 Sealant - per tooth

Space MaintenanceD1510 Space maintainer - fixed - unilateral

D1516;D1517 Space maintainer - fixed - bilateral - maxillary / mandibularD1520 Space maintainer - removable- unilateral

D1526;D1527 Space maintainer - removable bilateral - maxillary / mandibularD1551-D1552 Removal of fixed bilateral space maintainer maxillary / mandibular

D1553 Re-cement or re-bond unilateral space maintainer-per quadrantD1556 Removal of fixed bilateral space maintainer per quadrant

D1557-D1558 Removal of fixed bilateral space maintainer maxillary / mandibularD1575 Distal shoe space maintainer-fixed-unilateralD1999 Unspecified preventive procedure, by report

CATEGORY II


Note

D2140-D2161 Amalgam - primary or permanentD2330-D2335 Resin - based composite - anterior (primary or permanent)

D2391 Resin - based composite - posterior (primary or permanent) D2392-D2394 Resin - based composite - posterior (primary or permanent)D2410-D2430 Gold foil D2510-D2620 Inlays - Onlays: metallic - porcelain / ceramic

D2630 Inlay- porcelain / ceramic - three or more surfacesD2642-D2664 Inlay -Onlay: porcelain / ceramic; resin- based composite

D2799 Provisional crown D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restorationD2915 Re-cement or re-bond indirectly fabricated or prefabricated post and coreD2920 Re-cement or re-bond crownD2930 Prefabricated stainless steel crown – primary toothD2931 Prefabricated stainless steel crown – permanent toothD2932 Prefabricated resin crownD2933 Prefabricated stainless steel crown with resin windowD2940 Protective restoration D2950 Core buildup, including any pins when requiredD2951 Pin retention - per tooth, in addition to restorationD2960 Labial veneer (resin laminate) – chairside

D2961;D2962 Labial veneer - resin / porcelain lamínate – laboratoryD2980 Crown repair necessitated by restaurative material failure

D2981-D2983 Inlay, onlay, venner repair necessitated by restaurative material failure D2999 Unspecified restorative procedure, by report

D21 D22 D24 D26 D27 D281000 1500

≈ M ≈ ӟ ≈ ≈

X X X X X � XX X X X X XX X X X X X--- --- --- --- --- ---X X X X X X

X X X X X XX X X X X ř XX X X X X X--- --- --- --- --- ---X X X X X XX X X X X X--- --- --- --- --- ------ --- --- X X ------ --- --- --- --- ---X X X X X X--- --- --- --- --- ---

--- --- --- --- --- --- --- --- --- --- --- ---X X X X X X--- --- --- --- --- --- --- --- --- --- --- ---X X X X X X

X X X X X XX X X X X X

--- --- X X X ᶌ XX X X X X X

X^ X^ X^ X^ X^ X^

X X X X X X

20 20 X X X 3020 20 X X X 30--- --- --- --- --- ------ --- --- --- --- ---20 20 X X X 3020 20 X X X 3020 20 X X X 3020 20 X X X 3020 20 X X X 30// // X X X //

X X X 20 20 25X X X 20 20 2530 20 30 20 20 2530 20 30 20 20 25 --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- ---X X X --- 20 25X X X 20 20 25X X X --- 20 25X X X 20 20 25X X X 20 20 25--- --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ---X X X 20 20 25X X X --- 20 25X X X 20 20 25--- --- --- --- --- --- --- --- --- --- --- ---X X X --- 20 25--- --- --- --- --- ---X X X 20 20 25

February 01, 2020



Note

Deductible

ENDODONTICS

Note

D3110 Pulp cap - direct (excluding final restoration)D3120 Pulp cap - indirect (excluding final restoration)D3220 Therapeutic pulpotomy (excluding final restoration)D3221 Pulpal debridement, primary and permanent teeth

D3310;D3320 Endodontic therapy, anterior / premolar (excluding final restoration)D3330 Endodontic therapy, molar tooth (excluding final restoration)

D3346;D3347 Retreatment of previous root canal therapy - anterior / premolarD3348 Retreatment of previous root canal therapy - molar

D3351-D3353 Apexification / recalcification - inicial / interim / final visitD3355-D3357 Pulpal regeneration - inicial / interim / final visitD3410;D3421 Apicoectomy - anterior / bicuspid (first root) D3425;D3426 Apicoectomy - molar - first root / each additional root

D3430 Retrograde filling – per rootD3450;D3920 Root amputation - per root / Hemisection

D3999 Unspecified endodontic procedure, by reportBASIC PERIODONTICS

Note

D4355 Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visitD4346 Scaling in presence of generalized moderate or severe gingival inflammation-full mouth, after oral evaluationD4910 Periodontal maintenance

PROSTHODONTICS

Note


D5410;D5411 Adjust complete denture – maxillary / mandibularD5421;D5422 Adjust partial denture – maxillary / mandibularD5511,D5512 Repair broken complete denture base, mandibulary / maxillary

D5520 Replace missing or broken teeth-complete denture (each tooth)D5611,D5612 Repair resin denture base, mandibulary / maxillaryD5621,D5622 Repair cast partial framework, mandibulary / maxillary

D5630 Repair or replace broken clasp - per toothD5640 Replace broken teeth – per tooth

D5650;D5660 Add tooth / clasp to existing partial denture D5710-D5721 Rebase: complete / partial dentureD5730-D5761 Reline:complete / partial dentureD5850;D5851 Tissue conditioning, maxillary / mandibular

D6930 Re-cement or re-bond fixed partial dentureD6980 Fixed partial denture repair necessitated by restorative material failure

ORAL SURGERY

Note

ExtractionsD7111 Extraction, coronal remnants - primary toothD7140 Extraction, erupted tooth or exposed rootD7510 Incision and drainage of abscess- intraoral soft tissue

CATEGORY III


Note


Periodontics deductible ($)

D4210;D4211 Gingivectomy or gingivoplasty- four o more / one to three contiguous teethD4240;D4241 Gingival flap procedure incluying root planing - four o more / one to three contiguous teeth

D4245 Apically positioned flapD4249 Clinical crown lengthening - hard tissue

D4260;D4261 Osseous surgery D4263;D4264 Bone replacement graft -first / additional site in quadrantD4266;D4267 Guided tissue regeneration - resorbable barrier / no resorbable barrier, per site D4270;D4273 Pedicle soft tissue graft procedure / autogenous connective tissue graft, per tooth

D4277 Free soft tissue graft procedure - first tooth, implant, or edentulous toothD4278 Free soft tissue graft procedure - each additional contiguous tooth, implant, or edontulous toothD4320 Provisional splinting - intracoronal D4321 Provisional splinting - extracoronal

D4341;D4342 Periodontal scaling and root planing / four or more / one to three teeth per quadrantD4920 Unscheduled dressing change (by someone other than treating dentist or their staff)D4999 Unspecified periodontal procedure, by report

PROSTHODONTICS

Note

Límit ($)

D2710 Crown - resin based composite (indirect)D2720 Crown - resin with high noble metalD2722 Crown - resin with noble metalD2740 Crown - porcelain / ceramic

D21 D22 D24 D26 D27 D281000 1500

≈ M ≈ ӟ ≈ ≈

X 50 30 20 20 25X 50 30 20 20 25X 50 30 20 20 25X 50 30 20 20 25X 50 30 20 20 25X 50 30 20 20 25X 50 30 20 20 25X 50 30 20 20 25--- --- --- --- --- ------ --- --- --- --- ---X 50 30 20 20 25X 50 30 20 20 25X 50 30 20 20 25--- --- --- --- --- ---X 50 30 20 20 25

X 50 30 20 20 50X 50 30 20 20 50X 50 30 20 20 50

X X X 30 X XX X X 30 X XX X X 30 X XX X X 30 X XX X X 30 X X--- --- --- --- --- ---X X X 30 X XX X X 30 X XX X X 30 X X50 50 50 --- 50 5050 50 50 --- 50 50--- --- --- --- --- ---X X X 30 X XX X X --- X X

--- --- --- --- --- ---X 50 X 20 20 XX 50 X 20 20 X

M ת1000 1000 1000 --- 800 800

--- --- --- --- --- ---X 50 30 20 20 50X 50 30 20 20 50X 50 30 20 20 50X 50 30 20 20 50X 50 30 20 20 50X 50 30 20 20 50X 50 30 20 20 50X 50 30 20 20 50X 50 30 20 20 50--- --- --- --- --- ------ --- --- --- --- ---X 50 30 20 20 50X 50 30 20 20 50

--- --- --- --- --- ---X 50 30 20 20 50

ש1000 800

--- --- --- --- --- ---57 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 50

February 01, 2020



Note

Deductible

D2750 Crown - porcelain fused to high noble metalD2751 Crown - porcelain fused to predominantly base metalD2752 Crown - porcelain fused to noble metalD2753 Crown-porcelain fused to titanium and titanium alloysD2780 Crown - ¾ cast high noble metal

D2781-D2783 Crown - ¾ cast base metal / noble metal / porcelain-ceramicD2790 Crown - full cast high noble metalD2791 Crown - full cast predominantly base metalD2792 Crown - full cast noble metalD2794 Crown - titanium

D2952;D2954 Post and core D2975 Coping

D5110;D5120 Complete denture - maxillary / mandibularD5130;D5140 Immediate denture - maxillary / mandibularD5211;D5212 Partial denture - resin base - maxillary / mandibularD5213;D5214 Partial denture - cast metal framework with resin base - maxillary / mandibularD5221;D5222 Immediate partial denture-resin base - maxillary / mandibularD5223;D5224 Immediate partial denture-cast metal framework with resin denture base - maxillary/mandibularD5282;D5283 Removable unilateral partial denture - one piece cast metal - maxillary / mandibular

D5286 Removable unilateral partial denture-one piece resin (including clasps and teeth)-per quadrantD5810-D5821 Interim complete and partial denture - maxillary / mandibularD5863-D5866 Overdentures:complete;partial - maxillary / mandibular

D5862 Precision attachment, by reportD5899 Unspecified removable prosthodontic procedure, by report D6058 Abutment supported porcelain / ceramic crownD6059 Abutment supported porcelain fused to metal crown (high noble metal)D6060 Abutment supported porcelain fused to metal crown predominantly base metalD6061 Abutment supported porcelain fused to metal crown (noble metal)D6062 Abutment supported cast metal crown (high noble metal)D6063 Abutment supprted cast metal crown (predominantly base metal)D6064 Abutment supported cast metal crown (noble metal)D6065 Implant supported porcelain / ceramic crownD6066 Implant supported porcelain fused to metal crownD6067 Implant supported metal crown D6068 Abutment supported retainer for porcelain/ceramic FPDD6075 Implant supported retainer for ceramic FPDD6076 Implant supported retainer for porcelain fused to metal FPDD6077 Implant supported retainer for cast metal FPDD6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal)D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal)D6072 Abutment supported retainer for cast metal FPD (high noble metal)D6073 Abutment supported retainer for cast metal FPD (predominantly base metal)D6074 Abutment supported retainer for cast metal FPD (noble metal)D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closureD6082 Implant supported crown-porcelain fused to predominantly base alloysD6083 Implant supported crown-porcelain fused to noble alloysD6084 Implant supported crown-porcelain fused to titanium and titanium alloysD6086 Implant supported crown-predominantly base alloysD6087 Implant supported crown-noble alloysD6088 Implant supported crown-titanium and titanium alloysD6097 Abutment supported crown-porcelain fused to titanium and titanium alloysD6195 Abutment supported retainer-porcelain fused to titanium and titanium alloysD6210 Pontic - cast high noble metalD6211 Pontic - cast predominantly base metalD6212 Pontic - cast noble metalD6214 Pontic - titaniumD6240 Pontic - porcelain fused to high noble metalD6241 Pontic - porcelain fused to predominantly base metalD6242 Pontic - porcelain fused to noble metalD6243 Pontic-porcelain fused to titanium and titanium alloysD6245 Pontic - porcelain / ceramic D6250 Pontic - resin with high noble metal

D6251;D6252 Pontic - resin with predominantly base metal / resin with noble metalD6253 Provisional pontic D6545 Retainer - cast metal for resin bonded fixed prosthesisD6548 Retainer - porcelain / ceramic for resin bonded fixed prosthesis

D6600-D6605 Retainer inlays: porcelain;metalicD6606;D6607 Retainer inlays - cast noble metal, two surfaces / three or more surfacesD6608-D6615 Retainer onlays:porcelain;metalicD6624;D6634 Retainer inlays / onlays - titanium

D6710 Retainer crown - indirect resin based composite D6720 Retainer crown - resin with high noble metal

D6721;D6722 Retainer crown - resin with predominantly base metal / resin with noble metalD6740 Retainer crown - porcelain / ceramicD6750 Retainer crown - porcelain fused to high noble metalD6751 Retainer crown - porcelain fused to predominantly base metalD6752 Retainer crown - porcelain fused to noble metalD6753 Retainer crown-porcelain fused to titanium and titanium alloysD6780 Retainer crown - ¾ cast high noble metal

D6781;D6782 Retainer crown - ¾ cast predominantly base metal / noble metal

D21 D22 D24 D26 D27 D281000 1500

≈ M ≈ ӟ ≈ ≈

57 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 5057 50 50 --- 50 5050 50 50 --- 50 5057 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 5057 50 50 --- 50 5050 50 50 --- 50 50 --- --- --- --- --- ---50 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 50 --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- ---50 50 50 30 50 5050 50 50 --- --- 5057 50 50 --- --- 50--- --- --- --- --- ---50 50 50 --- --- 5057 50 50 --- --- 50--- --- --- --- --- ---50 50 50 --- --- 5050 50 50 --- --- 5057 50 50 --- --- 5057 50 50 --- --- 5050 50 50 --- --- 5050 50 50 --- --- 5057 50 50 --- --- 5057 50 50 --- --- 5057 50 50 --- --- 5050 50 50 --- --- 5050 50 50 --- --- 5057 50 50 --- --- 5050 50 50 --- --- 5050 50 50 --- --- 50 --- --- --- --- --- ---50 50 50 --- --- 5050 50 50 --- --- 5050 50 50 --- --- 5050 50 50 --- --- 5050 50 50 --- --- 5050 50 50 --- --- 5050 50 50 --- --- 5050 50 50 --- --- 5057 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 5057 50 50 --- 50 5057 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 50--- --- --- --- --- ---57 50 50 --- 50 50--- --- --- --- --- ------ --- --- --- --- ---50 50 50 --- 50 50--- --- --- --- --- ------ --- --- --- --- ---50 50 50 --- 50 50--- --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ---57 50 50 --- 50 50--- --- --- --- --- ------ --- --- --- --- ---57 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 5050 50 50 --- 50 50--- --- --- --- --- ---50 50 50 --- 50 50

February 01, 2020



Note

Deductible

D6783 Retainer crown - ¾ porcelain / ceramicD6784 Retainer crown 3/4 - titanium and titanium alloys

D21 D22 D24 D26 D27 D281000 1500

≈ M ≈ ӟ ≈ ≈

--- --- --- --- --- ------ --- --- --- --- ---

February 01, 2020



Note

Deductible

D6790 Retainer crown - full cast high noble metalD6791;D6792 Retainer crown - full cast predominantly base metal / noble metal

D6794 Retainer crown - titaniumD6920 Connector barD6940 Stress breakerD6950 Precision attachmentD6999 Unspecified, fixed prosthodontic procedure, by report


D5931-D5936 Obturator prosthesis: surgical / definitive / modification - mandibular resection D5951-D5955 Feeding aid / Speech aid (pediatric- adult) / Palatal (augmentation- lift) prosthesis D5982-D5985 Surgical stent / Radiation shield / Radiation cone locator

D5986 Fluoride gel carrierIMPLANTS SERVICES

Note

Límit ($)

D6010;D6011 Surgical placement of implant body; endosteal implant / second stage implant surgeryD6012-D6199 Other Implant services


Note

D7210 Surgical removal of erupted tooth D7220-D7240 Removal of impacted tooth – soft tissue / partially bony / completely bony

D7241 Removal of impacted tooth – completely bony, with unusual surgical complicationD7250 Surgical removal of residual tooth rootsD7260 Oroantral fistula closureD7270 Tooth re-implantation and / or stabilization of accidentally evulsed or displaced toothD7272 Tooth transplantation D7280 Surgical access of an unerupted tooth D7283 Placement of device to facilitate eruption of impacted toothD7285 Incisional biopsy of oral tissue - hard (bone, tooth)D7286 Incisional biopsy of oral tissue - softD7290 Surgical repositioning of teethD7291 Transseptal fiberotomy/supra crestal fiberotomy, by report

D7310-D7321 Alveoloplasty in conjunction with extractions / not in conjunction with extractionsD7340 Vestibuloplasty-ridge extension (secondary epithelialization)D7350 Vestibuloplasty-ridge extension (including soft tissue grafts….)

D7471-D7473 Removal of lateral exostosis / torus palatinus / torus mandibularisD7520 Incision and drainage of abscess – extraoral soft tissueD7550 Partial ostectomy /Sequestrectomy for removal of non-vital boneD7880 Occlusal orthotic device, by reportD7881 Occlusal orthotic device adjustmentD7910 Suture of recent small wounds up to 5 cmD7922 Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per siteD7953 Bone replacement graft for ridge preservation – per siteD7960 Frenulectomy (frenectomy or frenotomy) – separate procedureD7970 Excision of hyperplastic tissue - per archD7971 Excision of pericoronal gingivaD7999 Unspecified oral surgery procedure, by report

CATEGORY IV


Note

D9110 Palliative (emergency) treatment of dental pain – minor procedureD9230 Inhalation of nitrous oxide / analgesia, anxiolysisD9239 Intravenous moderate (conscious) sedation/analgesia - first 15 minutesD9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minutes incrementD9310 Consultation - diagnostic service provided by dentist or physicianD9410 House / extended care facility callD9420 Hospital or ambulatory surgical center call

D9430;D9440 Office visits (during regularly scheduled hours/ after regularly scheduled hours)D9630 Other drugs and / or medicaments, by reportD9910 Application of desensitizing medicamentD9930 Reatment of complications (post-surgical) - unusual circumstances, by report

D9944-D9946 Occlusal guard - hard appliance, soft appliance, full arch and hard appliance, partial archD9950 Occlusion analysis - mounted caseD9943 Occlusal guard adjustment

D9951;D9952 Occlusal adjustment - limited / completeD9973;D9974 External / Internal bleaching – per tooth

D9999 Unspecified adjunctive procedure – by reportORTHODONTIC

D8210-D8702 Orthodontic Services Note

Lifetime limit ($)

Deductible Orthodontics ($)

Note

Límit per policy year ($)Deductible Orthodontics ($)

D21 D22 D24 D26 D27 D281000 1500

≈ M ≈ ӟ ≈ ≈

57 50 50 --- 50 5050 50 50 --- 50 5057 50 50 --- 50 50--- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- ---50 50 50 --- 50 50

--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

--- --- --- --- --- --- --- --- --- --- --- ---

X 50 30 20 20 30X 50 30 20 20 30--- --- --- 20 20 ---X 50 30 20 20 30--- --- --- 20 20 ------ --- --- --- --- --- --- --- --- --- --- ---30 50 30 20 20 3030 50 30 --- 20 30--- --- --- --- --- ---30 50 30 20 20 30--- --- --- --- --- --- --- --- --- --- --- ---50 50 50 --- 50 50--- --- --- --- --- ------ --- --- --- --- ------ --- --- 20 20 ------ --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---X 50 30 20 20 30

--- --- --- --- --- ------ --- --- 20 20 ------ --- --- --- --- ---30 50 30 20 20 3030 50 30 20 20 30

--- --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- ---X X X X X X

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Documents

NOTES AND MODIFIERS APPLIED TO THE TABLE ... - Triple-S …NOTES AND MODIFIERS APPLIED TO THE TABLE OF COVERAGE OF TRIPLE-S SALUD GENERAL COMMENTS: 1 The numbers included in the table