Attachment_C_-_Network_and_Procedure_Compare.xlsx

XLSX spreadsheet 62 KB Posted

Attached to
Brevard County Group Dental Plan State and local contract opportunity
Solicitation number
RFP-1-25-18
Issued by
Brevard County, Florida

About this file

The document is a comprehensive dental provider network and procedure comparison spreadsheet for the Brevard County Group Dental Plan in Florida. The spreadsheet contains detailed information on Dental Health Maintenance Organization (DHMO) and Preferred Provider Organization (PPO) dental providers, including their Tax Identification Numbers (TINs), facility names, addresses, and network participation status. The document is part of a solicitation for a fully insured group dental insurance plan for Brevard County's active employees, retirees, and eligible dependents, effective January 1, 2026, with a proposed five-year contract term. The request for proposals (RFP No. 1-25-18) requires vendors to have at least five years of experience insuring groups of 4,000 or more employees, with proposals due on June 4, 2025, at 4:00 p.m.

The spreadsheet includes extensive listings of dental providers across multiple Florida counties, with detailed coding for various dental procedures and their associated costs. The document breaks down provider information into DHMO Providers, PPO Providers, DHMO Copay Compare, and PPO Fee Compare sections, offering a comprehensive view of potential network coverage. The current incumbent is Cigna, which has maintained stable enrollment and claims performance, with historical data showing approximately 4,210 total enrolled participants and total annual claims around $1.6 million. Monthly premium rates currently range from $12.91 to $106.07, depending on the plan and coverage tier. The most popular plans are the Dental PPO High and Dental PPO Low options, with the county anticipating a potential contract value of approximately $10.5 million over the five-year term.

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Other files for this state and local contract opportunity

Other files attached to Brevard County Group Dental Plan, newest first.
File Type Posted
Public_Meeting_Notice.pdf PDF
Public_Meeting_Notice.pdf PDF
RFP_Tabulation_-_Names_Only.pdf PDF
RFP_Tabulation_-_Names_Only.pdf PDF
RFP_Tabulation_-_Names_Only.pdf PDF
Addendum_4.pdf PDF
Attachment_B_WORD_-_Proposal_Worksheet.docx DOCX document
Attachment_B_WORD_-_Proposal_Worksheet.docx DOCX document
Addendum_3.pdf PDF
Addendum_2.pdf PDF
Addendum_2.pdf PDF
Addendum_1.pdf PDF
Revised_Exhibit_A_-_Census.xlsx XLSX spreadsheet
Revised_Exhibit_A_-_Census.xlsx XLSX spreadsheet
Addendum_1.pdf PDF
Exhibit_A_-_Census.pdf PDF
Exhibit_C3-Dental_Utilization_Report_2023_2024.pdf PDF
Attachment_A_-_Mandatory_Features_Checklist.pdf PDF
Attachment_C_-_Network_and_Procedure_Compare.xlsx XLSX spreadsheet
Exhibit_A_-_Census.pdf PDF
Exhibit_B1-Ben_Sum_DPPOH_01.01.2025_Brevard_County_Board_of_County_Commissioners_3308988.pdf PDF
Exhibit_B5-DPPO_High_Plan_Certificate_of_Coverage.pdf PDF
Exhibit_B6-DPPO_Low_Plan_Certificate_of_Coverage.pdf PDF
Attachment_A_-_Mandatory_Features_Checklist.pdf PDF
Exhibit_B1-Ben_Sum_DPPOH_01.01.2025_Brevard_County_Board_of_County_Commissioners_3308988.pdf PDF
Exhibit_C2-BREVARD_COUNTY_BOCC_FL_exp_pkg.xls XLS spreadsheet
Exhibit_C3-Dental_Utilization_Report_2023_2024.pdf PDF
Exhibit_D_-_Draft_Contract.pdf PDF
Exhibit_B2-Ben_Sum_DPPOL_01.01.2025_Brevard_County_Board_of_County_Commissioners_3308988.pdf PDF
RFP12518_INV_&_SPEC.pdf PDF
Exhibit_B1-Ben_Sum_DPPOH_01.01.2025_Brevard_County_Board_of_County_Commissioners_3308988.pdf PDF
Exhibit_C1-Brevard_BOCC_2024_DPPO_DHMO_Cigna.xls XLS spreadsheet
Exhibit_C1-Brevard_BOCC_2024_DPPO_DHMO_Cigna.xls XLS spreadsheet
Exhibit_B2-Ben_Sum_DPPOL_01.01.2025_Brevard_County_Board_of_County_Commissioners_3308988.pdf PDF
Exhibit_B5-DPPO_High_Plan_Certificate_of_Coverage.pdf PDF
RFP12518_INV_&_SPEC.pdf PDF
Exhibit_B1-Ben_Sum_DPPOH_01.01.2025_Brevard_County_Board_of_County_Commissioners_3308988.pdf PDF
Exhibit_B2-Ben_Sum_DPPOL_01.01.2025_Brevard_County_Board_of_County_Commissioners_3308988.pdf PDF
Exhibit_B4-DHMO_Schedule_of_Benefits.pdf PDF
Exhibit_B5-DPPO_High_Plan_Certificate_of_Coverage.pdf PDF
Exhibit_C2-BREVARD_COUNTY_BOCC_FL_exp_pkg.xls XLS spreadsheet
Exhibit_B4-DHMO_Schedule_of_Benefits.pdf PDF
Exhibit_C2-BREVARD_COUNTY_BOCC_FL_exp_pkg.xls XLS spreadsheet
Exhibit_C3-Dental_Utilization_Report_2023_2024.pdf PDF
Exhibit_B1-Ben_Sum_DPPOH_01.01.2025_Brevard_County_Board_of_County_Commissioners_3308988.pdf PDF
Exhibit_B2-Ben_Sum_DPPOL_01.01.2025_Brevard_County_Board_of_County_Commissioners_3308988.pdf PDF
Exhibit_B6-DPPO_Low_Plan_Certificate_of_Coverage.pdf PDF
Attachment_B_-_Proposal_Worksheet.pdf PDF
Exhibit_B4-DHMO_Schedule_of_Benefits.pdf PDF
Exhibit_C2-BREVARD_COUNTY_BOCC_FL_exp_pkg.xls XLS spreadsheet
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DHMO Providers

DHMO Provider Compare
Instructions: For each dental provider listed, in the far right columns indicate with an "X" if the provider is participating in your DHMO network and is accepting new patients. Include this Worksheet in Tab 2.
TINFacility NameAddressCityStateZIPContracted DHMO In-Network Provider
831266756YOUR FAMILY DENTAL4245 N COURTNEY PKWYMERRITT ISLANDFL32953
593356849BRIGHT NOW! DENTAL1324 HIGHWAY A1ASATELLITE BEACHFL32937
593356849BRIGHT NOW! DENTAL1051 PORT MALABAR BLVD NEPALM BAYFL32905
593356849BRIGHT NOW! DENTAL1770 N WICKHAM RDMELBOURNEFL32935
593365515COAST DENTAL - MERRITT ISLAND229 CROCKETT BLVDMERRITT ISLANDFL32953
593365515COAST DENTAL - S TITUSVILLE4400 S WASHINGTON AVETITUSVILLEFL32780
593365515COAST DENTAL- MELBOURNE7777 N WICKHAM RDMELBOURNEFL32940
474011990ASPEN DENTAL800 E MERRITT ISLAND CSWYMERRITT ISLANDFL32952
383927199SEBASTIAN SMILES PEDIATRIC DEN621 SEBASTIAN BLVD STE CSEBASTIANFL32958
921987087SAGE DENTAL OF TITUSVILLE PLLC2560 S WASHINGTON AVETITUSVILLEFL32780
824030927DENTISTS OF MELBOURNE6455 N WICKHAM RDMELBOURNEFL32940
474011990ASPEN DENTAL1795 W NEW HAVEN AVE UNIT 103MELBOURNEFL32904
593365515COAST DENTAL-TITUSVILLE3245 GARDEN STTITUSVILLEFL32796
650719035GREAT EXPRESSIONS DENTAL CNTRS1748 BRUCE B DOWNS BLVDWESLEY CHAPELFL33543
650719035GREAT EXPRESSIONS DENTAL CTRS205 PALM BAY RDMELBOURNEFL32904
593386079ROBERT L BURNS DMD481 N HARBOR CITY BLVDMELBOURNEFL32935
593424266WAYNE W KEARNEY DDS MS PA2179 JULIAN AVE NEPALM BAYFL32905
271141419BRILLIANT SMILES ORTHODONTICS580 MALABAR RD SE STE 1PALM BAYFL32907
650719035GREAT EXPRESSIONS DENTAL CTRS10845 BLOOMINGDALE AVERIVERVIEWFL33578
832653266SHAPIRO FAMILY DENTISTRY9868 S STATE RD 7BOYNTON BEACHFL33472
474011990ASPEN DENTAL6431 LAKE ANDREW DRMELBOURNEFL32940
931848038SAGE DENTAL OF VIERA PLLC7500 LAKE ANDREW DRMELBOURNEFL32940
830695561PEARL PEDIATRIC DENTAL1035 N APOLLO BLVDMELBOURNEFL32935
593365515COAST DENTAL- PALM BAY145 PALM BAY RD NEMELBOURNEFL32904
824030927DENTISTS OF MELBOURNE6455 N WICKHAM ROADMELBOURNEFL32940
822112086VIERA MODERN DENTISTRY2328 CITADEL WAYMELBOURNEFL32940
200185918KANDOR DENTAL5515 VISTA VIEW WAY STE 1051OVIEDOFL32765
923442449NULIFE DENTAL AND MED CENTER106 N DEAN RDORLANDOFL32825
843810614PLANES DENTAL ARTS VERO BEACH4755 US HIGHWAY A1AVERO BEACHFL32963
823501612VAKANI ORTHODONTICS2099 PALM BAY RD NEPALM BAYFL32905
593563684MICHAEL A SHERMAN DDS PA2233 PARK AVEORANGE PARKFL32073
650719035GREAT EXPRESSIONS DENTAL CENTE9 SAINT JOHNS MEDICAL PARK DRSAINT AUGUSTINEFL32086
650719035GREAT EXPRESSIONS DENTAL CTRS9119 MERRILL RDJACKSONVILLEFL32225
593365515COAST DENTAL - SOUTH FT MYERS13401 SUMMERLIN RDFORT MYERSFL33919
650719035GREAT EXPRESSIONS-NAPLES5022 AIRPORT PULLING RD NNAPLESFL34105
650719035GREAT EXPRESSIONS-CITRUS PARK6552 GUNN HWYTAMPAFL33625
263975070GREENBERG DENTAL & ORTHODONTIC3727 N GOLDENROD RDWINTER PARKFL32792
200107794TENNESSEE VALLEY PERIODONTICS7213 NOAH REID RDCHATTANOOGATN37421
263975070GREENBERG DENTAL & ORTHODONTIC4045B 13TH STREETSAINT CLOUDFL34769
842809230APPALACHIAN DENTAL ASSOCIATES1 VANDERBILT PARK DRASHEVILLENC28803
993950173ASPEN DENTAL59 HIGHLANDS SQUARE DRHENDERSONVILLENC28792
593143599JOLYON LAMWATT DMD PA6068 S APOPKA VINELAND RDORLANDOFL32819
843810614OVIEDO DENTAL ARTS9436 NARCOOSSEE RDORLANDOFL32827
263975070GREENBERG DENTAL & ORTHODONTIC50 PLAZA DRIVEPALM COASTFL32137
593622516MARK L JOHNSON DDS PA215 S 3RD STFLAGLER BEACHFL32136
541454328QUINN FAMILY DENTISTRY2204 EXECUTIVE DRHAMPTONVA23666
454942189SAGE DENTAL OF PORT ST LUCIE1722 SW ST LUCIE W BLVDPORT SAINT LUCIEFL34986
831266756WOODLAND LAKES DENTAL422 S ALAFAYA TRLORLANDOFL32828
593736325OROFACIAL & DENTAL IMPLANT SUR7352 STONEROCK CIRCLEORLANDOFL32819
650210178BOYNTON DENTAL1325 S CONGRESS AVEBOYNTON BEACHFL33426

PPO Providers PPO Provider Compare

Instructions: For each dental provider listed, in the far right columns indicate with an "X" if the provider is participating in your PPO network. Include this Worksheet in Tab 2.

TINDental Office NameProvider First NameProvider Last NameDental Office Address 1CITYSTATEZIPIn PPO Network
591779529TODD R DENSON DMD PATODDDENSON2191 GARDEN STTITUSVILLEFL32796
593771037ZRALLACK DENTAL INCMICHELEZRALLACK2670 GARDEN STTITUSVILLEFL32796
593667021OCEAN BREEZE DENTAL PAJASONWETMORE817 WESTPORT DRROCKLEDGEFL32955
270863289SUNSHINE SMILES PEDIATRIC DENTISTRY PAKRISTINMIRDA8061 SPYGLASS HILL RDMELBOURNEFL32940
591779529TODD R DENSON DMD PARYANHUHN2191 GARDEN STTITUSVILLEFL32796
270693847PERIEU FAMILY DENTISTRY LLCLIE-YINGPERIU650 CLASSIC CTMELBOURNEFL32940
830695561MORVARID MOINI DMD LLCMORVARIDMOINI1035 N APOLLO BLVDMELBOURNEFL32935
593545488SCOTT G MILO DMD PASCOTTMILO2405 N COURTENAY PKWYMERRITT ISLANDFL32953
261372981SHREE ANITHA PRASANNA DMDANITHAPRASANNA1490 CHENEY HWYTITUSVILLEFL32780
651251162CHANDANDEEP WILKU DMD PACHANDANDEEPWILKHU256 MCLEOD STMERRITT ISLANDFL32953
932896489KEO & FERRERA AMAZING SMILES PLLCDUONGVANNAKKEO295 S PLUMOSA STMERRITT ISLANDFL32952
873173825CAMILLE BURNESCAMILLECASSELLA17 NELSON AVEMELBOURNEFL32935
900155014COCOA BEACH DENTISTRYDAVIDCHE495 MINUTEMEN CSWYCOCOA BEACHFL32931
204521122THOMAS J LUNSTRUM DMD PATHOMASLUNSTRUM96 WILLARD STCOCOAFL32922
650487535G TORRES DMDGARYTORRES2185 CHENEY HWYTITUSVILLEFL32780
200185918COMFORTABLE CARE DENTAL HEALTH PROF PAEDGARDOLEIVA CARDONA5364 STADIUM PKWYROCKLEDGEFL32955
201272092CDPG PAEMMANUELGAVUA696 COUNTRY CLUB DRTITUSVILLEFL32780
452923252JEFFREY R MABRY DMD PAMAHKAMEHMOINI1025 N APOLLO BLVDMELBOURNEFL32935
593771037ZRALLACK DENTAL INCSTEPHENSLADE2670 GARDEN STTITUSVILLEFL32796
813305953DALIA WAHBADALIAWAHBA214 COUNTRY CLUB DRTITUSVILLEFL32780
200185918COMFORTABLE CARE DENTAL HEALTH PROF PAMELISSAKING5364 STADIUM PKWYROCKLEDGEFL32955
200185918COMFORTABLE CARE DENTAL HEALTH PROF PANATALIEGODOY6709 COLONNADE AVEVIERAFL32940
200185918COMFORTABLE CARE DENTAL HEALTH PROF PAMARTHABROWN5364 STADIUM PKWYROCKLEDGEFL32955
593290578DR ANTHONY DIPASQUALEANTHONYDIPASQUALE115 CAPRON TRAILMELBOURNEFL32940
452923252JEFFREY R MABRY DMD PAJEFFREYMABRY1025 N APOLLO BLVDMELBOURNEFL32935
205390000DENTAL HEALTH PROFESSIONAL ATJAMESROPPA5600 PORADA DRVIERAFL32940
450713714HIBISCUS DENTAL PASWETAGUNNELL1024 HIGHWAY A1ASATELLITE BEACHFL32937
881490471JOHN FARAH PAJOHNFARAH55 N CARPENTER RDTITUSVILLEFL32796
814484945ULTIMATE SMILE DESIGN LLCEMILYMILLINGEN730 EMERSON DR NEPALM BAYFL32907
830695561MORVARID MOINI DMD LLCALTANKIHM1035 N APOLLO BLVDMELBOURNEFL32935
270863289SUNSHINE SMILES PEDIATRIC DENTISTRY PAIDAIGNAALVAREZ8061 SPYGLASS HILL RDMELBOURNEFL32940
593467927BRIAN P BAKER DMDBRIANBAKER600 S HOPKINS AVETITUSVILLEFL32796
592993939C LEE STEWART DMD PACHADSTEWART895 BARTON BLVDROCKLEDGEFL32955
934844575EKOS ROCKLEDGE PLLCDANNACABRAL ABREU3650 MURRELL RDROCKLEDGEFL32955
384087341PROFESSIONAL DENTAL ALLIANCE OF LAKE WASHINGTON PLMOHAMMEDMUJEEB3226 LAKE WASHINGTON RDMELBOURNEFL32934
384087309PROFESSIONAL DENTAL ALLIANCE OF SUNTREE PLLCVLADIACOELHO7827 N WICKHAM RDMELBOURNEFL32940
872824110JORDAN ROBBINS DMD PACLARKBROWN JR1801 W HIBISCUS BLVDMELBOURNEFL32901
591228697ROCKLEDGE DENTAL PANESTORGUZMAN1950 ROCKLEDGE BLVDROCKLEDGEFL32955
593033865JOHN R LINDEMAN DDSJOHNLINDEMAN329 4TH AVEINDIALANTICFL32903
593694205CAPESIDE DENTAL PASAMUELARTLEY4545 DURHAM DRWEST MELBOURNEFL32904
814484945ULTIMATE SMILE DESIGN LLCNATALIATHILLET730 EMERSON DR NEPALM BAYFL32907
900796228BRAZDO MARYAM DMD PAMARYAMBRAZDO1061 S WICKHAM RDWEST MELBOURNEFL32904
932896489KEO & FERRERA AMAZING SMILES PLLCYACIELFERRERA295 S PLUMOSA STMERRITT ISLANDFL32952
593287624JOHN M ANDREWS DDSJOHNANDREWS1705 GARDEN STTITUSVILLEFL32796
824915243BARBARA WETMOREBARBARAWETMORE4095 US HIGHWAY 1ROCKLEDGEFL32955
208087495DR THEODORE G SCHROPP PATHEODORESCHROPP4521 N WICKHAM RDMELBOURNEFL32935
821967970DENTAL CHOICE OF MELBOURNEIOULIABUNKER402 N BABCOCK STMELBOURNEFL32935
200185918COMFORTABLE CARE DENTAL HEALTH PROF PATATIANACOJOCARU3135 COLUMBIA BLVDTITUSVILLEFL32780
200185918COMFORTABLE CARE DENTAL HEALTH PROF PAGIRGISSALEEB3135 COLUMBIA BLVDTITUSVILLEFL32780
205511864ANTHUMANICKAM S KUMAR DMD PASADESHKUMAR2960 BUSH DRMELBOURNEFL32935
591299709SATELLITE FAMILY DENTISTRY PAJOSHUACHAPMAN210 JACKSON AVESATELLITE BEACHFL32937
591299709SATELLITE FAMILY DENTISTRY PAJONATHANCALDERON210 JACKSON AVESATELLITE BEACHFL32937
824427634VIERA PEDIATRICYOSHITAPATEL HOSKING5600 PORADA DRVIERAFL32940
873173825CAMILLE BURNESCHARLESBURNES17 NELSON AVEMELBOURNEFL32935
593335198VALORIE M HOUK DMD PAVALORIEHOUK8255 N WICKHAM RDMELBOURNEFL32940
593386079ROBERT L BURNS DMDROBERTBURNS JR481 N HARBOR CITY BLVDMELBOURNEFL32935
593761090BRAD A BAGWELL DMD PABRADBAGWELL4200 STATE ROAD 524COCOAFL32926
200159759R LANCE TUTTLE DMDROBERTTUTTLE302 E STRAWBRIDGE AVEMELBOURNEFL32901
591299709SATELLITE FAMILY DENTISTRY PATAMARAROBISON210 JACKSON AVESATELLITE BEACHFL32937
842809356GALLIGAN DENTAL LLCKRISTINAGALLIGAN7954 N WICKHAM RD STE 109MELBOURNEFL32940
364749860NICHOLAS B ROWLEY DMDNICHOLASROWLEY205 W NEW HAVEN AVEMELBOURNEFL32901
383927199VC MANAGEMENTERIKAKING621 SEBASTIAN BLVD STE CSEBASTIANFL32958
562523917SYED Z QUADRISYEDQUADRI2090 PALM BAY RD NEPALM BAYFL32905
200185918COMFORTABLE CARE DENTAL HEALTH PROF PAMEAGANTHOMAS2900 LAKE WASHINGTON RDMELBOURNEFL32935
200185918COMFORTABLE CARE DENTAL HEALTH PROF PAMATTHEWMILLER715 PALM BAY RD NEW MELBOURNEFL32904
463609090SYED Z QUADRINENARBARAZI3440 BAYSIDE LAKES BLVD SEPALM BAYFL32909
464217607ELEY FAMILY DENTISTRY PADANIELELEY2301 W EAU GALLIE BLVDMELBOURNEFL32935
593418281KATHLEEN O'CONNOR DDSRONALDKOHLBRAND980 US HIGHWAY 1ROCKLEDGEFL32955
823941847CLASS ACT DENTISTRYEMILYSCHROEDER RUTSIS100 FORTENBERRY RDMERRITT ISLANDFL32952
593694205CAPESIDE DENTAL PASAMUELARTLEY3265 BAYSIDE LAKES BLVDPALM BAYFL32909
201272092CDPG PAHAINGUYEN3819 MURRELL RDROCKLEDGEFL32955
593385787ANTHONY SIDOR DDSANTHONYSIDOR225 S PLUMOSA STMERRITT ISLANDFL32952
593483433DEBORAH L KEARNEY DDSDEBORAHKEARNEY645 BREVARD AVECOCOAFL32922
852700000SPACE COAST ENDODONTICS PLLCMICHAELHOSKING5600 PORADA DRMELBOURNEFL32940
200185918COMFORTABLE CARE DENTAL HEALTH PROF PAJESSICANGUYEN3420 BAYSIDE LAKES BLVD SEPALM BAYFL32909
651009895MICHAEL J MACKAY DMD PAMICHAELMACKAY481 N HARBOR CITY BLVDMELBOURNEFL32935
872824110JORDAN ROBBINS DMD PACOLEHERZIK1801 W HIBISCUS BLVDMELBOURNEFL32901
452601859DR ANU DESHPANDE BDS DMD MS PAANNAPURNADESHPANDE96 WILLARD STCOCOAFL32922
461555026NEW IMAGE MAXILLOFACIAL LLCTRAVISAUSTIN1325 S PINE STMELBOURNEFL32901
472197818PERIODONTAL ARTISTRY PLLCJAMESANTOON1281 FLORIDA AVE SROCKLEDGEFL32955
882903000SMILE ENCHANCING SOLUTIONSGIRIJANAIDU41 N ORLANDO AVECOCOA BEACHFL32931
205527248MICHAEL S FOWLER DMD PAMICHAELFOWLER38 SUNTREE PLMELBOURNEFL32940
593286555GREGORY L GULLIKS DDSGREGORYGULLIKS1853 KNOX MCRAE DRTITUSVILLEFL32780
814250189TROPICAL SMILESKENDALLSCHUMACHER418 E NEW HAVEN AVEMELBOURNEFL32901
824915243BARBARA WETMOREJUSTINLIENECK4095 US HIGHWAY 1ROCKLEDGEFL32955
200185918COMFORTABLE CARE DENTAL HEALTH PROF PATHOMASTOLLES3420 BAYSIDE LAKES BLVD SEPALM BAYFL32909
201272092CDPG PAANJAYKALRA6300 N WICKHAM RDMELBOURNEFL32940
474011990HEALING SMILES PLLCJEAN MARYMARIUS800 E MERRITT ISLAND CSWYMERRITT ISLANDFL32952
474011990HEALING SMILES PLLCREINIERTEJEDA GONZALEZ249 PALM BAY RD NEMELBOURNEFL32904
650487535G TORRES DMDGARYTORRES2185 CHENEY HWYTITUSVILLEFL32780
201272092CDPG PAMONADURANI775 E MERRITT ISLAND CSWYMERRITT ISLANDFL32952
384087309PROFESSIONAL DENTAL ALLIANCE OF SUNTREE PLLCJOHNFIFE7827 N WICKHAM RDMELBOURNEFL32940
384087375PROFESSIONAL DENTAL ALLIANCE OF W MELBOURNE PLLCMISHALLWAHEED2235 WEST NEW HAVEN AVEWEST MELBOURNEFL32904
474011990HEALING SMILES PLLCSAMDIRAWI3150 CHENEY HWYTITUSVILLEFL32780
593540434JOEL C SCALERA DDS PAJOELSCALERA33 SUNTREE PLMELBOURNEFL32940
813901151CARL JONESCARLJONES1360 BEDFORD DRMELBOURNEFL32940
872824110JORDAN ROBBINS DMD PAJORDANROBBINS1801 W HIBISCUS BLVDMELBOURNEFL32901
874098350WILLIAM COLE WAGGENER PLLCWILLIAMWAGGENER115 PARNELL STMERRITT ISLANDFL32953
882903000SMILE ENCHANCING SOLUTIONSBHAWNACHANDRA41 N ORLANDO AVECOCOA BEACHFL32931
923552188BARLOW & BENFIELD ORTHODONTICSJEFFREYBARLOW105 N GROVE STMERRITT ISLANDFL32953

DHMO Copay Compare

DHMO Copay Compare
Instructions: For each ADA code listed, complete the Patient Cost Proposed column and identify any limits or deviations from the current plan. Include this Worksheet in Tab 2.
Complete in Full
ADA CodeBenefit DescriptionPatient Cost ProposedLimits/ Deviations
D0120Periodic oral evaluation - Established patient
D0140Limited oral evaluation - Problem focused
D0145Oral evaluation for a patient under 3 years of age and counseling with primary caregiver
D0150Comprehensive oral evaluation - New or established patient
D0160Detailed and extensive oral evaluation - Problem focused, by report (limit 2 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation)
D0170Re-evaluation - Limited, problem focused (established patient; not post-operative visit)
D0171Re-evaluation - Post-operative office visit
D0180Comprehensive periodontal evaluation - New or established patient
D0210X-rays intraoral - Comprehensive series of radiographic images (limited to 1 D0210 or D0709 every 3 years)
D0220X-rays intraoral - Periapical - First radiographic image
D0230X-rays intraoral - Periapical - Each additional radiographic image
D0240Intraoral - occlusal radiographic image
D0250X-rays extra-oral - 2D projection radiographic image created using a stationary radiation source, and detector
D0251X-rays extra-oral posterior dental radiographic image (limit 1 D0251 or D0705 per calendar year)
D0270Bitewing - single radiographic image
D0272Bitewings - two radiographic images
D0273Bitewings three radiographic images
D0274Bitewings - four radiographic images - limited to 1 series every 6 months
D0277Vertical bitewings - 7 to 8 radiographic images
D0330Panoramic radiographic image - limited to 1 of (DO210 or DO330) per 24 months. Either one (1) DO210 or one (1) DO330 permitted
D03402D cephalometric radiographic image - Acquisition, measurement and analysis (when utilized for orthodontic services, see D8999)
D03502D oral/facial photographic images obtained intra-orally or extra-orally (when utilized for orthodontic services, see D8999)
D0368Cone beam CT capture and interpretation for TMJ series including two or more exposures (limit 1 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation)
D0372Intraoral tomosynthesis - Comprehensive series of radiographic images
D0373Intraoral tomosynthesis - Bitewing radiographic image
D0374Intraoral tomosynthesis - Periapical radiographic image
D0387Intraoral tomosynthesis - Comprehensive series of radiographic images - Image capture only
D0388Intraoral tomosynthesis - Bitewing radiographic image - Image capture only
D0389Intraoral tomosynthesis - Periapical radiographic image - Image capture only
D0391Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report
D0393Virtual treatment simulation using 3D image volume or surface scan
D0394Digital subtraction of two or more images or image volumes of the same modality
D0395Fusion of two or more 3D image volumes of one or more modalities
D03963D printing of a 3D dental surface scan
D0414Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation, and transmission of written report
D0415Collection of microorganisms for culture and sensitivity
D0425Caries susceptibility tests
D0431Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures
D0460Pulp vitality tests
D0470Diagnostic casts
D0472Accession of tissue, gross examination, preparation and transmission of written report
D0473Accession of tissue, gross and microscopic examination, preparation and transmission of written report
D0474Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report
D0486Laboratory accession of brush biopsy sample, microscopic examination, preparation and transmission of written report
D0600Non-ionizing diagnostic procedure capable of quantifying, monitoring and recording changes in structure of enamel, dentin and cementum
D0701Panoramic radiographic image - image capture only
D07022-D cephalometric radiographic image - image capture only
D07032-D oral/facial photographic image obtained intra- orally or extra-orally - image capture only
D0705Extra-oral posterior dental radiographic image - image capture only
D0706Intraoral - occlusal radiographic image - image capture only
D0707Intraoral - periapical radiographic image - image capture only
D0708Intraoral - bitewing radiographic image - image capture only
D0709Intraoral - comprehensive series of radiographic images - image capture only
D08013D dental surface scan - Direct (when utilized for orthodontic services, see D8999)
D08023D dental surface scan - Indirect (when utilized for orthodontic services, see D8999)
D08033D facial surface scan - Direct (when utilized for orthodontic services, see D8999)
D08043D facial surface scan - Indirect (when utilized for orthodontic services, see D8999)
D1110Prophylaxis cleaning- adult - limited to 2 D1110, D1120 or D4346 per calendar year
D1120Prophylaxis cleaning - child - limited to 2 D1110, D1120 or D4346 per calendar year
D1206Topical application of fluoride varnish - child to age 19; 2 D1206 or D1208 per calendar year
D1208Topical application of fluoride - excluding varnish - child to age 19; 2 D1206 or D1208 per calendar year
D1310Nutritional counseling for control of dental disease
D1320Tobacco counseling for the control and prevention of oral disease
D1321Counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use
D1330Oral hygiene instructions
D1351Sealant - per tooth - limited to permanent molars through age 15
D1352Preventive resin restoration in a moderate to high caries risk patient - permanent tooth - limited to permanent molars through age 15
D1353Sealant repair - per tooth - limited to permanent molars through age 15
D1354Application of caries arresting medicament - per tooth - child to age 19; 2 per calendar year
D1355Caries preventive medicament application - Per tooth
D1510Space maintainer - fixed - unilateral - per quadrant
D1516Space maintainer - fixed - bilateral, maxillary
D1517Space maintainer - fixed - bilateral, mandibular
D1520Space maintainer - Removable - Unilateral - Per quadrant
D1526Space maintainer - Removable - Bilateral, upper
D1527Space maintainer - Removable - Bilateral, lower
D1551Re-cement or re-bond bilateral space maintainer - Upper
D1552Re-cement or re-bond bilateral space maintainer - Lower
D1553Re-cement or re-bond unilateral space maintainer - Per quadrant
D1556Removal of fixed unilateral space maintainer - per quadrant
D1557Removal of fixed bilateral space maintainer - maxillary
D1558Removal of fixed bilateral space maintainer - mandibular
D1575Distal shoe space maintainer - fixed, unilateral - per quadrant - child to age 9
D2140Amalgam - one surface, primary or permanent
D2150Amalgam - two surfaces, primary or permanent
D2160Amalgam - three surfaces, primary or permanent
D2161Amalgam - four or more surfaces, primary or permanent
D2330Resin-based composite - one surface, anterior
D2331Resin-based composite - two surfaces, anterior
D2332Resin-based composite - three surfaces, anterior
D2335Resin-based composite - four or more surfaces (anterior)
D2390Resin-based composite crown, anterior
D2391Resin-based composite - one surface, posterior
D2392Resin-based composite - two surfaces, posterior
D2393Resin-based composite - three surfaces, posterior
D2394Resin-based composite - four or more surfaces, posterior
D2510Inlay - metallic - one surface
D2520Inlay - metallic - two surfaces
D2530Inlay - metallic - three or more surfaces
D2542Onlay - metallic - two surfaces
D2543Onlay - metallic - three surfaces
D2544Onlay - metallic - four or more surfaces
D2610Inlay - Porcelain/ceramic, 1 surface
D2620Inlay - Porcelain/ceramic, 2 surfaces
D2630Inlay - Porcelain/ceramic, 3 or more surfaces
D2642Onlay - Porcelain/ceramic, 2 surfaces
D2643Onlay - Porcelain/ceramic, 3 surfaces
D2644Onlay - Porcelain/ceramic, 4 or more surfaces
D2650Inlay - Resin-based composite, 1 surface
D2651Inlay - Resin-based composite, 2 surfaces
D2652Inlay - Resin-based composite, 3 or more surfaces
D2662Onlay - Resin-based composite, 2 surfaces
D2663Onlay - Resin-based composite, 3 surfaces
D2664Onlay - Resin-based composite, 4 or more surfaces
D2710Crown - Resin-based composite, indirect
D2712Crown - 3/4 resin-based composite, indirect
D2720Crown - Resin with high noble metal
D2721Crown - Resin with predominantly base metal
D2722Crown - Resin with noble metal
D2740Crown - porcelain/ceramic
D2750Crown - porcelain fused to high noble metal
D2751Crown - porcelain fused to predominantly base metal
D2752Crown - porcelain fused to noble metal
D2753Crown - porcelain fused to titanium and titanium alloys
D2780Crown - 3/4 cast high noble metal
D2781Crown - 3/4 cast predominantly base metal
D2782Crown - 3/4 cast noble metal
D2783Crown - 3/4 porcelain/ceramic
D2790Crown - full cast high noble metal
D2791Crown - full cast predominantly base metal
D2792Crown - full cast noble metal
D2794Crown - titanium and titanium alloys
D2799Interim crown (not to be used as a temporary crown for a routine prosthetic restoration)
D2910Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration
D2915Re-cement or re-bond indirectly fabricated or prefabricated post and core
D2920Re-cement or re-bond crown
D2928Prefabricated porcelain/ceramic crown - permanent tooth
D2929Prefabricated porcelain/ceramic crown - primary tooth - anterior
D2930Prefabricated stainless steel crown - primary tooth
D2931Prefabricated stainless steel crown - permanent tooth
D2932Prefabricated resin crown - anterior primary tooth
D2933Prefabricated stainless steel crown with resin window - anterior primary tooth
D2934Prefabricated esthetic coated stainless steel crown - primary tooth
D2940Placement of interim direct restoration
D2941Interim therapeutic restoration - Primary dentition
D2950Core buildup, including any pins when required
D2951Pin retention - per tooth, in addition to restoration
D2952Post and core in addition to crown, indirectly fabricated - includes canal preparation
D2953Each additional indirectly prefabricated post - Same tooth
D2954Prefabricated post and core in addition to crown - base metal post; includes canal preparation
D2957Each additional prefabricated post - Same tooth
D2960Labial veneer (resin laminate) - direct
D2971Additional procedures to customize a crown to fit under an existing partial denture framework
D2976Band stabilization - per tooth - limited to once in a lifetime per tooth
D2980Crown repair, necessitated by restorative material failure
D2983Veneer repair necessitated by restorative material failure
D2989Excavation of a tooth resulting in the determination of non-restorability
D2991Application of hydroxyapatite regeneration medicament - Per tooth
D3110Pulp cap - direct (excluding final restoration)
D3120Pulp cap - indirect (excluding final restoration)
D3220Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament
D3221Pulpal debridement, primary and permanent teeth
D3222Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development
D3230Pulpal therapy (resorbable filling) - Anterior, primary tooth (excluding final restoration)
D3240Pulpal therapy (resorbable filling) - Posterior, primary tooth (excluding final restoration)
D3310Root canal - endodontic therapy, anterior tooth (excluding final restoration)
D3320Root canal - endodontic therapy, premolar tooth (excluding final restoration)
D3330Root canal - endodontic therapy, molar tooth (excluding final restoration)
D3331Treatment of root canal obstruction; non-surgical access
D3332Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth
D3333Internal root repair of perforation defects
D3346Retreatment of previous root canal therapy - anterior
D3347Retreatment of previous root canal therapy - premolar
D3348Retreatment of previous root canal therapy - molar
D3351Apexification/recalcification - Initial visit (apical closure/ calcific repair of perforations, root resorption, etc.)
D3352Apexification/recalcification - Interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.)
D3353Apexification/recalcification - Final visit (includes completed root canal therapy - Apical closure/calcific repair of perforations, root resorption, etc.)
D3410Apicoectomy - anterior
D3421Apicoectomy - premolar (first root)
D3425Apicoectomy - molar (first root)
D3426Apicoectomy (each additional root)
D3430Retrograde filling - per root
D3450Root amputation - Per root
D3471Surgical repair of root resorption - anterior
D3472Surgical repair of root resorption - premolar
D3473Surgical repair of root resorption - molar
D3501Surgical exposure of root surface without apicoectomy or repair of root resorption - anterior
D3502Surgical exposure of root surface without apicoectomy or repair of root resorption - premolar
D3503Surgical exposure of root surface without apicoectomy or repair of root resorption - molar
D3911Intraorifice barrier
D3920Hemisection (including any root removal), not including root canal therapy
D3921Decoronation or submergence of an erupted tooth
D4210Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant
D4211Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant
D4212Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth
D4240Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant
D4241Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant
D4245Apically positioned flap
D4249Clinical crown lengthening - hard tissue
D4260Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant
D4261Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant
D4263Bone replacement graft - retained natural tooth - first site in quadrant
D4264Bone replacement graft - retained natural tooth - each additional site in quadrant
D4265Biologic materials to aid in soft and osseous tissue regeneration, per site
D4266Guided tissue regeneration, natural teeth - resorbable barrier, per site
D4267Guided tissue regeneration, natural teeth - non-resorbable barrier, per site
D4270Pedicle soft tissue graft procedure
D4273Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position
D4274Mesial/distal wedge procedure single tooth (when not performed in conjunction with surgical procedures in the same anatomical area)
D4275Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft
D4277Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant, or edentulous tooth position in graft
D4278Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site
D4283Autogenous connective tissue graft procedure (including donor and recipient surgical sites) - Each additional contiguous tooth, implant or edentulous tooth position in same graft site
D4285Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) - each additional contiguous tooth, implant or edentulous tooth position in same graft site
D4286Removal of non-resorbable barrier
D4341Periodontal scaling and root planing - four or more teeth per quadrant - limited to 4 quadrants during any 12 consecutive months
D4342Periodontal scaling and root planing - one to three teeth per quadrant - limited to 4 quadrants during any 12 consecutive months
D4346Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation - limited to 2 D1110, D1120 or D4346 per calendar year
D4355Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit - limited to 1 treatment in any 12 consecutive months
D4381Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth
D4910Periodontal maintenance - limited to 2 per calendar year
D4921Gingival irrigation with a medicinal agent - per quadrant
D5110Complete denture - maxillary
D5120Complete denture - mandibular
D5130Immediate denture - maxillary
D5140Immediate denture - mandibular
D5211Maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth)
D5212Mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth)
D5213Maxillary partial denture - cast metal framework with resin denture bases (including retentive/ clasping materials, rests and teeth)
D5214Mandibular partial denture - cast metal framework with resin denture bases (including retentive/ clasping materials, rests and teeth)
D5221Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth)
D5222Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth)
D5223Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)
D5224Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)
D5225Maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth) - prosthetic appliances will be replaced only after five years have elapsed from the time of delivery
D5226Mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth)
D5227Immediate maxillary partial denture - flexible base (including any clasps, rests and teeth)
D5228Immediate mandibular partial denture - flexible base (including any clasps, rests and teeth)
D5282Removable unilateral partial denture - One piece cast metal (including retentive/clasping materials, rests and teeth), upper
D5283Removable unilateral partial denture - One piece cast metal (including retentive/clasping materials, rests and teeth), lower
D5284Removable unilateral partial denture - One piece flexible base (including retentive/clasping materials, rests and teeth) - Per quadrant
D5286Removable unilateral partial denture - One piece resin base (including retentive/clasping materials, rests and teeth) - Per quadrant
D5410Adjust complete denture - maxillary
D5411Adjust complete denture - mandibular
D5421Adjust partial denture - maxillary
D5422Adjust partial denture - mandibular
D5511Repair broken complete denture base, mandibular
D5512Repair broken complete denture base, maxillary
D5520Replace missing or broken teeth - complete denture - per tooth
D5611Repair resin partial denture base, mandibular
D5612Repair resin partial denture base, maxillary
D5621Repair cast partial framework - Lower
D5622Repair cast partial framework - Upper
D5630Repair or replace broken retentive/clasping materials - per tooth
D5640Replace missing or broken teeth - partial denture - per tooth
D5650Add tooth to existing partial denture - per tooth
D5660Add clasp to existing partial denture - per tooth
D5670Replace all teeth and acrylic on cast metal framework - Upper
D5671Replace all teeth and acrylic on cast metal framework - Lower
D5710Rebase complete maxillary denture
D5711Rebase complete mandibular denture
D5720Rebase maxillary partial denture
D5721Rebase mandibular partial denture
D5725Rebase hybrid prosthesis
D5730Reline complete maxillary denture (chairside)
D5731Reline complete mandibular denture (chairside)
D5740Reline maxillary partial denture (chairside)
D5741Reline mandibular partial denture (chairside)
D5750Reline complete maxillary denture (laboratory)
D5751Reline complete mandibular denture (laboratory)
D5760Reline maxillary partial denture (laboratory)
D5761Reline mandibular partial denture (laboratory)
D5765Soft liner for complete or partial removable denture - indirect
D5810Interim complete denture (maxillary)
D5811Interim complete denture (mandibular)
D5820Interim partial denture (including retentive/ clasping materials, rests, and teeth), maxillary - limited to 1 in any 12 consecutive months
D5821Interim partial denture (including retentive/ clasping materials, rests, and teeth), mandibular - limited to 1 in any 12 consecutive months
D5850Tissue conditioning - Upper
D5851Tissue conditioning - Lower
D5862Precision attachment - By report
D5875Modification of removable prosthesis following implant surgery
D5876Add metal substructure to acrylic full denture (per arch)
D6058Abutment supported porcelain/ceramic crown
D6059Abutment supported porcelain fused to metal crown (high noble metal)
D6060Abutment supported porcelain fused to metal crown (predominantly base metal)
D6061Abutment supported porcelain fused to metal crown (noble metal)
D6062Abutment supported cast metal crown (high noble metal)
D6063Abutment supported cast metal crown (predominantly base metal)
D6064Abutment supported cast metal crown (noble metal)
D6065Implant supported porcelain/ceramic crown
D6066Implant supported crown - Porcelain fused to high noble alloys
D6067Implant supported crown - High noble alloys
D6068Abutment supported retainer for porcelain/ceramic fixed partial denture
D6069Abutment supported retainer for porcelain fused to metal fixed partial denture (high noble metal)
D6070Abutment supported retainer for porcelain fused to metal fixed partial denture (predominantly base metal)
D6071Abutment supported retainer for porcelain fused to metal fixed partial denture (noble metal)
D6072Abutment supported retainer for cast metal fixed partial denture (high noble metal)
D6073Abutment supported retainer for cast metal fixed partial denture (predominantly base metal)
D6074Abutment supported retainer for cast metal fixed partial denture (noble metal)
D6075Implant supported retainer for ceramic fixed partial denture
D6076Implant supported retainer for fixed partial denture - Porcelain fused to high noble alloys
D6077Implant supported retainer for metal fixed partial denture - High noble alloys
D6082Implant supported crown - Porcelain fused to predominantly base alloys
D6083Implant supported crown - Porcelain fused to noble alloys
D6084Implant supported crown - Porcelain fused to titanium and titanium alloys
D6085Interim implant crown
D6086Implant supported crown - Predominantly base alloys
D6087Implant supported crown - Noble alloys
D6088Implant supported crown - Titanium and titanium alloys
D6089Accessing and retorquing loose implant screw - Per screw
D6092Re-cement implant/abutment supported crown
D6093Re-cement implant/abutment supported fixed partial denture
D6094Abutment supported crown - Titanium and titanium alloys
D6096Remove broken implant retaining screw
D6097Abutment supported crown - Porcelain fused to titanium and titanium alloys
D6098Implant supported retainer - Porcelain fused to predominantly base alloys
D6099Implant supported retainer for fixed partial denture - Porcelain fused to noble alloys
D6106Guided tissue regeneration - Resorbable barrier, per implant
D6107Guided tissue regeneration - Non-resorbable barrier, per implant
D6110Implant /abutment supported removable denture for edentulous arch - Upper
D6111Implant /abutment supported removable denture for edentulous arch - Lower
D6112Implant /abutment supported removable denture for partially edentulous arch - Upper
D6113Implant /abutment supported removable denture for partially edentulous arch - Lower
D6114Implant /abutment supported fixed denture for edentulous arch - Upper
D6115Implant /abutment supported fixed denture for edentulous arch - Lower
D6116Implant /abutment supported fixed denture for partially edentulous arch - Upper
D6117Implant /abutment supported fixed denture for partially edentulous arch - Lower
D6118Implant/abutment supported interim fixed denture for edentulous arch - Lower
D6119Implant/abutment supported interim fixed denture for edentulous arch - Upper
D6120Implant supported retainer - Porcelain fused to titanium and titanium alloys
D6121Implant supported retainer for metal fixed partial denture - Predominantly base alloys
D6122Implant supported retainer for metal fixed partial denture - Noble alloys
D6123Implant supported retainer for metal fixed partial denture - Titanium and titanium alloys
D6192Semi-precision attachment - Placement
D6194Abutment supported retainer crown for fixed partial denture - Titanium and titanium alloys
D6195Abutment supported retainer - Porcelain fused to titanium and titanium alloys
D6197Replacement of restorative material used to close an access opening of a screw-retained implant supported prosthesis, per implant
D6198Remove interim implant component
D6210Pontic - cast high noble metal
D6211Pontic - cast predominantly base metal
D6212Pontic - cast noble metal
D6214Pontic - titanium and titanium alloys
D6240Pontic - porcelain fused to high noble metal
D6241Pontic - porcelain fused to predominantly base metal
D6242Pontic - porcelain fused to noble metal
D6243Pontic - porcelain fused to titanium and titanium alloys
D6245Pontic - porcelain/ceramic
D6250Pontic - Resin with high noble metal
D6251Pontic - Resin with predominantly base metal
D6252Pontic - Resin with noble metal
D6253Interim Pontic
D6545Retainer - Cast metal for resin bonded fixed prosthesis
D6600Retainer inlay - Porcelain/ceramic, 2 surfaces
D6601Retainer inlay - Porcelain/ceramic, 3 or more surfaces
D6602Retainer inlay - cast high noble metal, two surfaces
D6603Retainer inlay - cast high noble metal, three or more surfaces
D6604Retainer inlay - cast predominantly base metal, two surfaces
D6605Retainer inlay - cast predominantly base metal, three or more surfaces
D6606Retainer inlay - cast noble metal, two surfaces
D6607Retainer inlay - cast noble metal, three or more surfaces
D6608Retainer onlay - Porcelain/ceramic, 2 surfaces
D6609Retainer onlay - Porcelain/ceramic, 3 or more surfaces
D6610Retainer onlay - cast high noble metal, two surfaces
D6611Retainer onlay - cast high noble metal, three or more surfaces
D6612Retainer onlay - cast predominantly base metal, two surfaces
D6613Retainer onlay - cast predominantly base metal, three or more surfaces
D6614Retainer onlay - cast noble metal, two surfaces
D6615Retainer onlay - cast noble metal, three or more surfaces
D6624Retainer inlay - titanium
D6634Retainer onlay - titanium
D6710Retainer crown - Indirect resin based composite
D6720Retainer crown - Resin with high noble metal
D6721Retainer crown - Resin with predominantly base metal
D6722Retainer crown - Resin with noble metal
D6740Retainer crown - porcelain/ceramic
D6750Retainer crown - porcelain fused to high noble metal
D6751Retainer crown - porcelain fused to predominantly base metal
D6752Retainer crown - porcelain fused to noble metal
D6753Retainer crown - porcelain fused to titanium and titanium alloys
D6780Retainer crown - 3/4 cast high noble metal
D6781Retainer crown - 3/4 cast predominantly base metal
D6782Retainer crown - 3/4 cast noble metal
D6783Retainer crown - 3/4 porcelain/ceramic
D6784Retainer crown - 3/4 titanium and titanium alloys
D6790Retainer crown - full cast high noble metal
D6791Retainer crown - full cast predominantly base metal
D6792Retainer crown - full cast noble metal
D6794Retainer crown - titanium and titanium alloys
D6930Re-cement or re-bond fixed partial denture
D6950Precision attachment
D7111Extraction, coronal remnants - primary tooth
D7140Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
D7210Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated
D7220Removal of impacted tooth - soft tissue
D7230Removal of impacted tooth - partially bony
D7240Removal of impacted tooth - completely bony
D7241Removal of impacted tooth - completely bony, with unusual surgical complications
D7250Removal of residual tooth roots (cutting procedure)
D7251Coronectomy - intentional partial tooth removal, impacted teeth only
D7260Oroantral fistula closure
D7261Primary closure of sinus perforation
D7270Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
D7280Exposure of an unerupted tooth
D7283Placement of device to facilitate eruption of impacted tooth
D7285Incisional biopsy of oral tissue-hard (bone, tooth)
D7286Incisional biopsy of oral tissue - soft - does not include pathology laboratory procedures
D7287Exfoliative cytological sample collection
D7288Brush biopsy - transepithelial sample collection
D7310Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant
D7311Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant
D7320Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant
D7321Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant
D7450Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm
D7451Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm
D7471Removal of lateral exostosis (maxilla or mandible)
D7472Removal of torus palatinus
D7473Removal of torus mandibularis
D7485Reduction of osseous tuberosity
D7510Incision and drainage of abscess - intraoral soft tissue
D7511Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces)
D7520Incision and drainage of abscess - Extraoral soft tissue
D7521Incision and drainage of abscess - Extraoral soft tissue - Complicated (includes drainage of multiple fascial spaces)
D7880Occlusal orthotic device, by report - (limit 1 per 24 months; only covered in conjunction with Temporomandibular Joint (TMJ) treatment)
D7881Occlusal orthotic device adjustment
D7910Suture of recent small wounds up to 5cm
D7922Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site
D7961Buccal/labial frenectomy (frenulectomy)
D7963Frenuloplasty
D8010Limited orthodontic treatment of the primary dentition - Banding
D8020Limited orthodontic treatment of the transitional dentition - Banding
D8030Limited orthodontic treatment of the adolescent dentition - Banding
D8040Limited orthodontic treatment of the adult dentition - Banding
D8070Comprehensive orthodontic treatment of the transitional dentition - Banding
D8080Comprehensive orthodontic treatment of the adolescent dentition - Banding
D8090Comprehensive orthodontic treatment of the adult dentition - Banding
D8210Removable appliance therapy
D8220Fixed appliance therapy
D8660Pre-orthodontic treatment examination to monitor growth and development
D8670Periodic orthodontic treatment visit
D8680Orthodontic retention - Removal of appliances, construction and placement of retainer(s)
D8681Removable orthodontic retainer adjustment
D8695Removal of fixed orthodontic appliances for reasons other than completion of treatment
D8698Re-cement or re-bond fixed retainer - Upper
D8699Re-cement or re-bond fixed retainer - Lower
D8701Repair of fixed retainer, includes reattachment - Upper
D8702Repair of fixed retainer, includes reattachment - Lower
D8999Unspecified orthodontic procedure - By report (orthodontic treatment plan and records including all necessary images)
D9110Palliative treatment of dental pain - per visit
D9120Fixed partial denture sectioning
D9211Regional block anesthesia
D9212Trigeminal division block anesthesia
D9215Local anesthesia
D9222Deep sedation/general anesthesia - first 15 minutes
D9223Deep sedation/general anesthesia - each subsequent 15 minute increment
D9230Inhalation of nitrous oxide / analgesia, anxiolysis
D9239Intravenous moderate (conscious) sedation/ analgesia - first 15 minutes
D9243Intravenous moderate (conscious) sedation/ analgesia - each subsequent 15 minute increment
D9310Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician
D9311Consultation with a medical health care professional
D9430Office visit for observation (during regularly scheduled hours) - no other services performed
D9440Office visit - after regularly scheduled hours
D9450Case presentation, subsequent to detailed and extensive treatment planning
D9610Therapeutic parenteral drug, single administration
D9612Therapeutic parenteral drugs, 2 or more administrations, different medications
D9613Infiltration of sustained release therapeutic drug, per quadrant (patient charge is per quadrant)
D9630Drugs or medicaments dispensed in the office for home use
D9910Application of desensitizing medicament
D9911Application of desensitizing resin for cervical and/or root surface, per tooth
D9912Pre-visit patient screening
D9938Fabrication of a custom removable clear plastic temporary aesthetic appliance
D9939Placement of a custom removable clear plastic temporary aesthetic appliance
D9941Fabrication of athletic mouthguard (limit 1 per 12 months)
D9942Repair and/or reline of occlusal guard
D9943Occlusal guard adjustment
D9944Occlusal guard - hard appliance, full arch - limited to 1 D9944, D9945 or D9946 in 24 months
D9945Occlusal guard - soft appliance, full arch - limited to 1 D9944, D9945 or D9946 in 24 months
D9946Occlusal guard - hard appliance, partial arch - limited to 1 D9944, D9945 or D9946 in 24 months
D9951Occlusal adjustment, limited
D9952Occlusal adjustment, complete
D9961Duplicate/copy patient's records
D9975External bleaching for home application, per arch; includes materials and fabrication of custom trays - limited to one bleaching tray and gel for two weeks of self-treatment
D9990Certified translation or sign-language services - per visit
D9995Teledentistry - synchronous; real-time encounter
D9996Teledentistry - asynchronous; information stored and forwarded to Dentist for subsequent review
Other
Unlisted Covered Dental Care Services

PPO Fee Compare

PPO Dental Procedures Cost Comparison
Instructions: For each ADA code listed, indicate if the benefit is a Type I, II or III procedure; indicate the PPO approved allowance; and list any benefit or frequency limitations. Include this Worksheet in Tab 2.
Complete in Full
Beneift DescriptionADA CodeADA DescriptonIndicate Type I, II, IIIPPO Maximum Allowable AmountIndicate Any Limitations
Prophylaxis - adultD1110Preventive
Periodic oral evaluation - established patientD0120Diagnostic
Bitewings - four radiographic imagesD0274Diagnostic
Intraoral - periapical first radiographic imageD0220Diagnostic
Topical application of fluoride varnishD1206Preventive
Intraoral - periapical each additional radiographic imageD0230Diagnostic
Prophylaxis - childD1120Preventive
Periodontal maintenanceD4910Non-Surgical Periodontics
Comprehensive oral evaluation - new or established patientD0150Diagnostic
Limited oral evaluation - problem focusedD0140Diagnostic
Topical application of fluoride - excluding varnishD1208Preventive

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