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 an Excel spreadsheet titled "Attachment_C_-_Network_and_Procedure_Compare.xlsx" related to the Brevard County Group Dental Plan, which contains comprehensive dental provider network and procedure comparison information for DHMO and PPO providers. The spreadsheet includes detailed listings of dental providers across multiple Florida counties, with tax identification numbers, facility names, addresses, and spaces for network participation and new patient status tracking. The document serves as a critical reference for dental network comparison, listing over 100 dental practices primarily located in Brevard, Orange, Palm Bay, Melbourne, Titusville, and surrounding Florida areas.
The spreadsheet includes three primary worksheets: DHMO Providers Compare, PPO Providers Compare, and DHMO Copay Compare, which provide extensive information on dental procedure codes, their descriptions, patient costs, and potential limitations. The document appears to be a supporting exhibit for the Brevard County dental insurance procurement, offering a granular view of potential network providers, procedure costs, and coverage details. It provides a comprehensive framework for evaluating dental provider networks, with specific attention to procedure types, geographical coverage, and potential patient costs across different dental service categories such as preventive, basic, major, and specialized treatments.
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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. | ||||||
| TIN | Facility Name | Address | City | State | ZIP | Contracted DHMO In-Network Provider |
| 831266756 | YOUR FAMILY DENTAL | 4245 N COURTNEY PKWY | MERRITT ISLAND | FL | 32953 | |
| 593356849 | BRIGHT NOW! DENTAL | 1324 HIGHWAY A1A | SATELLITE BEACH | FL | 32937 | |
| 593356849 | BRIGHT NOW! DENTAL | 1051 PORT MALABAR BLVD NE | PALM BAY | FL | 32905 | |
| 593356849 | BRIGHT NOW! DENTAL | 1770 N WICKHAM RD | MELBOURNE | FL | 32935 | |
| 593365515 | COAST DENTAL - MERRITT ISLAND | 229 CROCKETT BLVD | MERRITT ISLAND | FL | 32953 | |
| 593365515 | COAST DENTAL - S TITUSVILLE | 4400 S WASHINGTON AVE | TITUSVILLE | FL | 32780 | |
| 593365515 | COAST DENTAL- MELBOURNE | 7777 N WICKHAM RD | MELBOURNE | FL | 32940 | |
| 474011990 | ASPEN DENTAL | 800 E MERRITT ISLAND CSWY | MERRITT ISLAND | FL | 32952 | |
| 383927199 | SEBASTIAN SMILES PEDIATRIC DEN | 621 SEBASTIAN BLVD STE C | SEBASTIAN | FL | 32958 | |
| 921987087 | SAGE DENTAL OF TITUSVILLE PLLC | 2560 S WASHINGTON AVE | TITUSVILLE | FL | 32780 | |
| 824030927 | DENTISTS OF MELBOURNE | 6455 N WICKHAM RD | MELBOURNE | FL | 32940 | |
| 474011990 | ASPEN DENTAL | 1795 W NEW HAVEN AVE UNIT 103 | MELBOURNE | FL | 32904 | |
| 593365515 | COAST DENTAL-TITUSVILLE | 3245 GARDEN ST | TITUSVILLE | FL | 32796 | |
| 650719035 | GREAT EXPRESSIONS DENTAL CNTRS | 1748 BRUCE B DOWNS BLVD | WESLEY CHAPEL | FL | 33543 | |
| 650719035 | GREAT EXPRESSIONS DENTAL CTRS | 205 PALM BAY RD | MELBOURNE | FL | 32904 | |
| 593386079 | ROBERT L BURNS DMD | 481 N HARBOR CITY BLVD | MELBOURNE | FL | 32935 | |
| 593424266 | WAYNE W KEARNEY DDS MS PA | 2179 JULIAN AVE NE | PALM BAY | FL | 32905 | |
| 271141419 | BRILLIANT SMILES ORTHODONTICS | 580 MALABAR RD SE STE 1 | PALM BAY | FL | 32907 | |
| 650719035 | GREAT EXPRESSIONS DENTAL CTRS | 10845 BLOOMINGDALE AVE | RIVERVIEW | FL | 33578 | |
| 832653266 | SHAPIRO FAMILY DENTISTRY | 9868 S STATE RD 7 | BOYNTON BEACH | FL | 33472 | |
| 474011990 | ASPEN DENTAL | 6431 LAKE ANDREW DR | MELBOURNE | FL | 32940 | |
| 931848038 | SAGE DENTAL OF VIERA PLLC | 7500 LAKE ANDREW DR | MELBOURNE | FL | 32940 | |
| 830695561 | PEARL PEDIATRIC DENTAL | 1035 N APOLLO BLVD | MELBOURNE | FL | 32935 | |
| 593365515 | COAST DENTAL- PALM BAY | 145 PALM BAY RD NE | MELBOURNE | FL | 32904 | |
| 824030927 | DENTISTS OF MELBOURNE | 6455 N WICKHAM ROAD | MELBOURNE | FL | 32940 | |
| 822112086 | VIERA MODERN DENTISTRY | 2328 CITADEL WAY | MELBOURNE | FL | 32940 | |
| 200185918 | KANDOR DENTAL | 5515 VISTA VIEW WAY STE 1051 | OVIEDO | FL | 32765 | |
| 923442449 | NULIFE DENTAL AND MED CENTER | 106 N DEAN RD | ORLANDO | FL | 32825 | |
| 843810614 | PLANES DENTAL ARTS VERO BEACH | 4755 US HIGHWAY A1A | VERO BEACH | FL | 32963 | |
| 823501612 | VAKANI ORTHODONTICS | 2099 PALM BAY RD NE | PALM BAY | FL | 32905 | |
| 593563684 | MICHAEL A SHERMAN DDS PA | 2233 PARK AVE | ORANGE PARK | FL | 32073 | |
| 650719035 | GREAT EXPRESSIONS DENTAL CENTE | 9 SAINT JOHNS MEDICAL PARK DR | SAINT AUGUSTINE | FL | 32086 | |
| 650719035 | GREAT EXPRESSIONS DENTAL CTRS | 9119 MERRILL RD | JACKSONVILLE | FL | 32225 | |
| 593365515 | COAST DENTAL - SOUTH FT MYERS | 13401 SUMMERLIN RD | FORT MYERS | FL | 33919 | |
| 650719035 | GREAT EXPRESSIONS-NAPLES | 5022 AIRPORT PULLING RD N | NAPLES | FL | 34105 | |
| 650719035 | GREAT EXPRESSIONS-CITRUS PARK | 6552 GUNN HWY | TAMPA | FL | 33625 | |
| 263975070 | GREENBERG DENTAL & ORTHODONTIC | 3727 N GOLDENROD RD | WINTER PARK | FL | 32792 | |
| 200107794 | TENNESSEE VALLEY PERIODONTICS | 7213 NOAH REID RD | CHATTANOOGA | TN | 37421 | |
| 263975070 | GREENBERG DENTAL & ORTHODONTIC | 4045B 13TH STREET | SAINT CLOUD | FL | 34769 | |
| 842809230 | APPALACHIAN DENTAL ASSOCIATES | 1 VANDERBILT PARK DR | ASHEVILLE | NC | 28803 | |
| 993950173 | ASPEN DENTAL | 59 HIGHLANDS SQUARE DR | HENDERSONVILLE | NC | 28792 | |
| 593143599 | JOLYON LAMWATT DMD PA | 6068 S APOPKA VINELAND RD | ORLANDO | FL | 32819 | |
| 843810614 | OVIEDO DENTAL ARTS | 9436 NARCOOSSEE RD | ORLANDO | FL | 32827 | |
| 263975070 | GREENBERG DENTAL & ORTHODONTIC | 50 PLAZA DRIVE | PALM COAST | FL | 32137 | |
| 593622516 | MARK L JOHNSON DDS PA | 215 S 3RD ST | FLAGLER BEACH | FL | 32136 | |
| 541454328 | QUINN FAMILY DENTISTRY | 2204 EXECUTIVE DR | HAMPTON | VA | 23666 | |
| 454942189 | SAGE DENTAL OF PORT ST LUCIE | 1722 SW ST LUCIE W BLVD | PORT SAINT LUCIE | FL | 34986 | |
| 831266756 | WOODLAND LAKES DENTAL | 422 S ALAFAYA TRL | ORLANDO | FL | 32828 | |
| 593736325 | OROFACIAL & DENTAL IMPLANT SUR | 7352 STONEROCK CIRCLE | ORLANDO | FL | 32819 | |
| 650210178 | BOYNTON DENTAL | 1325 S CONGRESS AVE | BOYNTON BEACH | FL | 33426 |
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.
| TIN | Dental Office Name | Provider First Name | Provider Last Name | Dental Office Address 1 | CITY | STATE | ZIP | In PPO Network |
| 591779529 | TODD R DENSON DMD PA | TODD | DENSON | 2191 GARDEN ST | TITUSVILLE | FL | 32796 | |
| 593771037 | ZRALLACK DENTAL INC | MICHELE | ZRALLACK | 2670 GARDEN ST | TITUSVILLE | FL | 32796 | |
| 593667021 | OCEAN BREEZE DENTAL PA | JASON | WETMORE | 817 WESTPORT DR | ROCKLEDGE | FL | 32955 | |
| 270863289 | SUNSHINE SMILES PEDIATRIC DENTISTRY PA | KRISTIN | MIRDA | 8061 SPYGLASS HILL RD | MELBOURNE | FL | 32940 | |
| 591779529 | TODD R DENSON DMD PA | RYAN | HUHN | 2191 GARDEN ST | TITUSVILLE | FL | 32796 | |
| 270693847 | PERIEU FAMILY DENTISTRY LLC | LIE-YING | PERIU | 650 CLASSIC CT | MELBOURNE | FL | 32940 | |
| 830695561 | MORVARID MOINI DMD LLC | MORVARID | MOINI | 1035 N APOLLO BLVD | MELBOURNE | FL | 32935 | |
| 593545488 | SCOTT G MILO DMD PA | SCOTT | MILO | 2405 N COURTENAY PKWY | MERRITT ISLAND | FL | 32953 | |
| 261372981 | SHREE ANITHA PRASANNA DMD | ANITHA | PRASANNA | 1490 CHENEY HWY | TITUSVILLE | FL | 32780 | |
| 651251162 | CHANDANDEEP WILKU DMD PA | CHANDANDEEP | WILKHU | 256 MCLEOD ST | MERRITT ISLAND | FL | 32953 | |
| 932896489 | KEO & FERRERA AMAZING SMILES PLLC | DUONGVANNAK | KEO | 295 S PLUMOSA ST | MERRITT ISLAND | FL | 32952 | |
| 873173825 | CAMILLE BURNES | CAMILLE | CASSELLA | 17 NELSON AVE | MELBOURNE | FL | 32935 | |
| 900155014 | COCOA BEACH DENTISTRY | DAVID | CHE | 495 MINUTEMEN CSWY | COCOA BEACH | FL | 32931 | |
| 204521122 | THOMAS J LUNSTRUM DMD PA | THOMAS | LUNSTRUM | 96 WILLARD ST | COCOA | FL | 32922 | |
| 650487535 | G TORRES DMD | GARY | TORRES | 2185 CHENEY HWY | TITUSVILLE | FL | 32780 | |
| 200185918 | COMFORTABLE CARE DENTAL HEALTH PROF PA | EDGARDO | LEIVA CARDONA | 5364 STADIUM PKWY | ROCKLEDGE | FL | 32955 | |
| 201272092 | CDPG PA | EMMANUEL | GAVUA | 696 COUNTRY CLUB DR | TITUSVILLE | FL | 32780 | |
| 452923252 | JEFFREY R MABRY DMD PA | MAHKAMEH | MOINI | 1025 N APOLLO BLVD | MELBOURNE | FL | 32935 | |
| 593771037 | ZRALLACK DENTAL INC | STEPHEN | SLADE | 2670 GARDEN ST | TITUSVILLE | FL | 32796 | |
| 813305953 | DALIA WAHBA | DALIA | WAHBA | 214 COUNTRY CLUB DR | TITUSVILLE | FL | 32780 | |
| 200185918 | COMFORTABLE CARE DENTAL HEALTH PROF PA | MELISSA | KING | 5364 STADIUM PKWY | ROCKLEDGE | FL | 32955 | |
| 200185918 | COMFORTABLE CARE DENTAL HEALTH PROF PA | NATALIE | GODOY | 6709 COLONNADE AVE | VIERA | FL | 32940 | |
| 200185918 | COMFORTABLE CARE DENTAL HEALTH PROF PA | MARTHA | BROWN | 5364 STADIUM PKWY | ROCKLEDGE | FL | 32955 | |
| 593290578 | DR ANTHONY DIPASQUALE | ANTHONY | DIPASQUALE | 115 CAPRON TRAIL | MELBOURNE | FL | 32940 | |
| 452923252 | JEFFREY R MABRY DMD PA | JEFFREY | MABRY | 1025 N APOLLO BLVD | MELBOURNE | FL | 32935 | |
| 205390000 | DENTAL HEALTH PROFESSIONAL AT | JAMES | ROPPA | 5600 PORADA DR | VIERA | FL | 32940 | |
| 450713714 | HIBISCUS DENTAL PA | SWETA | GUNNELL | 1024 HIGHWAY A1A | SATELLITE BEACH | FL | 32937 | |
| 881490471 | JOHN FARAH PA | JOHN | FARAH | 55 N CARPENTER RD | TITUSVILLE | FL | 32796 | |
| 814484945 | ULTIMATE SMILE DESIGN LLC | EMILY | MILLINGEN | 730 EMERSON DR NE | PALM BAY | FL | 32907 | |
| 830695561 | MORVARID MOINI DMD LLC | ALTAN | KIHM | 1035 N APOLLO BLVD | MELBOURNE | FL | 32935 | |
| 270863289 | SUNSHINE SMILES PEDIATRIC DENTISTRY PA | IDAIGNA | ALVAREZ | 8061 SPYGLASS HILL RD | MELBOURNE | FL | 32940 | |
| 593467927 | BRIAN P BAKER DMD | BRIAN | BAKER | 600 S HOPKINS AVE | TITUSVILLE | FL | 32796 | |
| 592993939 | C LEE STEWART DMD PA | CHAD | STEWART | 895 BARTON BLVD | ROCKLEDGE | FL | 32955 | |
| 934844575 | EKOS ROCKLEDGE PLLC | DANNA | CABRAL ABREU | 3650 MURRELL RD | ROCKLEDGE | FL | 32955 | |
| 384087341 | PROFESSIONAL DENTAL ALLIANCE OF LAKE WASHINGTON PL | MOHAMMED | MUJEEB | 3226 LAKE WASHINGTON RD | MELBOURNE | FL | 32934 | |
| 384087309 | PROFESSIONAL DENTAL ALLIANCE OF SUNTREE PLLC | VLADIA | COELHO | 7827 N WICKHAM RD | MELBOURNE | FL | 32940 | |
| 872824110 | JORDAN ROBBINS DMD PA | CLARK | BROWN JR | 1801 W HIBISCUS BLVD | MELBOURNE | FL | 32901 | |
| 591228697 | ROCKLEDGE DENTAL PA | NESTOR | GUZMAN | 1950 ROCKLEDGE BLVD | ROCKLEDGE | FL | 32955 | |
| 593033865 | JOHN R LINDEMAN DDS | JOHN | LINDEMAN | 329 4TH AVE | INDIALANTIC | FL | 32903 | |
| 593694205 | CAPESIDE DENTAL PA | SAMUEL | ARTLEY | 4545 DURHAM DR | WEST MELBOURNE | FL | 32904 | |
| 814484945 | ULTIMATE SMILE DESIGN LLC | NATALIA | THILLET | 730 EMERSON DR NE | PALM BAY | FL | 32907 | |
| 900796228 | BRAZDO MARYAM DMD PA | MARYAM | BRAZDO | 1061 S WICKHAM RD | WEST MELBOURNE | FL | 32904 | |
| 932896489 | KEO & FERRERA AMAZING SMILES PLLC | YACIEL | FERRERA | 295 S PLUMOSA ST | MERRITT ISLAND | FL | 32952 | |
| 593287624 | JOHN M ANDREWS DDS | JOHN | ANDREWS | 1705 GARDEN ST | TITUSVILLE | FL | 32796 | |
| 824915243 | BARBARA WETMORE | BARBARA | WETMORE | 4095 US HIGHWAY 1 | ROCKLEDGE | FL | 32955 | |
| 208087495 | DR THEODORE G SCHROPP PA | THEODORE | SCHROPP | 4521 N WICKHAM RD | MELBOURNE | FL | 32935 | |
| 821967970 | DENTAL CHOICE OF MELBOURNE | IOULIA | BUNKER | 402 N BABCOCK ST | MELBOURNE | FL | 32935 | |
| 200185918 | COMFORTABLE CARE DENTAL HEALTH PROF PA | TATIANA | COJOCARU | 3135 COLUMBIA BLVD | TITUSVILLE | FL | 32780 | |
| 200185918 | COMFORTABLE CARE DENTAL HEALTH PROF PA | GIRGIS | SALEEB | 3135 COLUMBIA BLVD | TITUSVILLE | FL | 32780 | |
| 205511864 | ANTHUMANICKAM S KUMAR DMD PA | SADESH | KUMAR | 2960 BUSH DR | MELBOURNE | FL | 32935 | |
| 591299709 | SATELLITE FAMILY DENTISTRY PA | JOSHUA | CHAPMAN | 210 JACKSON AVE | SATELLITE BEACH | FL | 32937 | |
| 591299709 | SATELLITE FAMILY DENTISTRY PA | JONATHAN | CALDERON | 210 JACKSON AVE | SATELLITE BEACH | FL | 32937 | |
| 824427634 | VIERA PEDIATRIC | YOSHITA | PATEL HOSKING | 5600 PORADA DR | VIERA | FL | 32940 | |
| 873173825 | CAMILLE BURNES | CHARLES | BURNES | 17 NELSON AVE | MELBOURNE | FL | 32935 | |
| 593335198 | VALORIE M HOUK DMD PA | VALORIE | HOUK | 8255 N WICKHAM RD | MELBOURNE | FL | 32940 | |
| 593386079 | ROBERT L BURNS DMD | ROBERT | BURNS JR | 481 N HARBOR CITY BLVD | MELBOURNE | FL | 32935 | |
| 593761090 | BRAD A BAGWELL DMD PA | BRAD | BAGWELL | 4200 STATE ROAD 524 | COCOA | FL | 32926 | |
| 200159759 | R LANCE TUTTLE DMD | ROBERT | TUTTLE | 302 E STRAWBRIDGE AVE | MELBOURNE | FL | 32901 | |
| 591299709 | SATELLITE FAMILY DENTISTRY PA | TAMARA | ROBISON | 210 JACKSON AVE | SATELLITE BEACH | FL | 32937 | |
| 842809356 | GALLIGAN DENTAL LLC | KRISTINA | GALLIGAN | 7954 N WICKHAM RD STE 109 | MELBOURNE | FL | 32940 | |
| 364749860 | NICHOLAS B ROWLEY DMD | NICHOLAS | ROWLEY | 205 W NEW HAVEN AVE | MELBOURNE | FL | 32901 | |
| 383927199 | VC MANAGEMENT | ERIKA | KING | 621 SEBASTIAN BLVD STE C | SEBASTIAN | FL | 32958 | |
| 562523917 | SYED Z QUADRI | SYED | QUADRI | 2090 PALM BAY RD NE | PALM BAY | FL | 32905 | |
| 200185918 | COMFORTABLE CARE DENTAL HEALTH PROF PA | MEAGAN | THOMAS | 2900 LAKE WASHINGTON RD | MELBOURNE | FL | 32935 | |
| 200185918 | COMFORTABLE CARE DENTAL HEALTH PROF PA | MATTHEW | MILLER | 715 PALM BAY RD NE | W MELBOURNE | FL | 32904 | |
| 463609090 | SYED Z QUADRI | NENAR | BARAZI | 3440 BAYSIDE LAKES BLVD SE | PALM BAY | FL | 32909 | |
| 464217607 | ELEY FAMILY DENTISTRY PA | DANIEL | ELEY | 2301 W EAU GALLIE BLVD | MELBOURNE | FL | 32935 | |
| 593418281 | KATHLEEN O'CONNOR DDS | RONALD | KOHLBRAND | 980 US HIGHWAY 1 | ROCKLEDGE | FL | 32955 | |
| 823941847 | CLASS ACT DENTISTRY | EMILY | SCHROEDER RUTSIS | 100 FORTENBERRY RD | MERRITT ISLAND | FL | 32952 | |
| 593694205 | CAPESIDE DENTAL PA | SAMUEL | ARTLEY | 3265 BAYSIDE LAKES BLVD | PALM BAY | FL | 32909 | |
| 201272092 | CDPG PA | HAI | NGUYEN | 3819 MURRELL RD | ROCKLEDGE | FL | 32955 | |
| 593385787 | ANTHONY SIDOR DDS | ANTHONY | SIDOR | 225 S PLUMOSA ST | MERRITT ISLAND | FL | 32952 | |
| 593483433 | DEBORAH L KEARNEY DDS | DEBORAH | KEARNEY | 645 BREVARD AVE | COCOA | FL | 32922 | |
| 852700000 | SPACE COAST ENDODONTICS PLLC | MICHAEL | HOSKING | 5600 PORADA DR | MELBOURNE | FL | 32940 | |
| 200185918 | COMFORTABLE CARE DENTAL HEALTH PROF PA | JESSICA | NGUYEN | 3420 BAYSIDE LAKES BLVD SE | PALM BAY | FL | 32909 | |
| 651009895 | MICHAEL J MACKAY DMD PA | MICHAEL | MACKAY | 481 N HARBOR CITY BLVD | MELBOURNE | FL | 32935 | |
| 872824110 | JORDAN ROBBINS DMD PA | COLE | HERZIK | 1801 W HIBISCUS BLVD | MELBOURNE | FL | 32901 | |
| 452601859 | DR ANU DESHPANDE BDS DMD MS PA | ANNAPURNA | DESHPANDE | 96 WILLARD ST | COCOA | FL | 32922 | |
| 461555026 | NEW IMAGE MAXILLOFACIAL LLC | TRAVIS | AUSTIN | 1325 S PINE ST | MELBOURNE | FL | 32901 | |
| 472197818 | PERIODONTAL ARTISTRY PLLC | JAMES | ANTOON | 1281 FLORIDA AVE S | ROCKLEDGE | FL | 32955 | |
| 882903000 | SMILE ENCHANCING SOLUTIONS | GIRIJA | NAIDU | 41 N ORLANDO AVE | COCOA BEACH | FL | 32931 | |
| 205527248 | MICHAEL S FOWLER DMD PA | MICHAEL | FOWLER | 38 SUNTREE PL | MELBOURNE | FL | 32940 | |
| 593286555 | GREGORY L GULLIKS DDS | GREGORY | GULLIKS | 1853 KNOX MCRAE DR | TITUSVILLE | FL | 32780 | |
| 814250189 | TROPICAL SMILES | KENDALL | SCHUMACHER | 418 E NEW HAVEN AVE | MELBOURNE | FL | 32901 | |
| 824915243 | BARBARA WETMORE | JUSTIN | LIENECK | 4095 US HIGHWAY 1 | ROCKLEDGE | FL | 32955 | |
| 200185918 | COMFORTABLE CARE DENTAL HEALTH PROF PA | THOMAS | TOLLES | 3420 BAYSIDE LAKES BLVD SE | PALM BAY | FL | 32909 | |
| 201272092 | CDPG PA | ANJAY | KALRA | 6300 N WICKHAM RD | MELBOURNE | FL | 32940 | |
| 474011990 | HEALING SMILES PLLC | JEAN MARY | MARIUS | 800 E MERRITT ISLAND CSWY | MERRITT ISLAND | FL | 32952 | |
| 474011990 | HEALING SMILES PLLC | REINIER | TEJEDA GONZALEZ | 249 PALM BAY RD NE | MELBOURNE | FL | 32904 | |
| 650487535 | G TORRES DMD | GARY | TORRES | 2185 CHENEY HWY | TITUSVILLE | FL | 32780 | |
| 201272092 | CDPG PA | MONA | DURANI | 775 E MERRITT ISLAND CSWY | MERRITT ISLAND | FL | 32952 | |
| 384087309 | PROFESSIONAL DENTAL ALLIANCE OF SUNTREE PLLC | JOHN | FIFE | 7827 N WICKHAM RD | MELBOURNE | FL | 32940 | |
| 384087375 | PROFESSIONAL DENTAL ALLIANCE OF W MELBOURNE PLLC | MISHALL | WAHEED | 2235 WEST NEW HAVEN AVE | WEST MELBOURNE | FL | 32904 | |
| 474011990 | HEALING SMILES PLLC | SAM | DIRAWI | 3150 CHENEY HWY | TITUSVILLE | FL | 32780 | |
| 593540434 | JOEL C SCALERA DDS PA | JOEL | SCALERA | 33 SUNTREE PL | MELBOURNE | FL | 32940 | |
| 813901151 | CARL JONES | CARL | JONES | 1360 BEDFORD DR | MELBOURNE | FL | 32940 | |
| 872824110 | JORDAN ROBBINS DMD PA | JORDAN | ROBBINS | 1801 W HIBISCUS BLVD | MELBOURNE | FL | 32901 | |
| 874098350 | WILLIAM COLE WAGGENER PLLC | WILLIAM | WAGGENER | 115 PARNELL ST | MERRITT ISLAND | FL | 32953 | |
| 882903000 | SMILE ENCHANCING SOLUTIONS | BHAWNA | CHANDRA | 41 N ORLANDO AVE | COCOA BEACH | FL | 32931 | |
| 923552188 | BARLOW & BENFIELD ORTHODONTICS | JEFFREY | BARLOW | 105 N GROVE ST | MERRITT ISLAND | FL | 32953 |
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 Code | Benefit Description | Patient Cost Proposed | Limits/ Deviations |
| D0120 | Periodic oral evaluation - Established patient | ||
| D0140 | Limited oral evaluation - Problem focused | ||
| D0145 | Oral evaluation for a patient under 3 years of age and counseling with primary caregiver | ||
| D0150 | Comprehensive oral evaluation - New or established patient | ||
| D0160 | Detailed and extensive oral evaluation - Problem focused, by report (limit 2 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation) | ||
| D0170 | Re-evaluation - Limited, problem focused (established patient; not post-operative visit) | ||
| D0171 | Re-evaluation - Post-operative office visit | ||
| D0180 | Comprehensive periodontal evaluation - New or established patient | ||
| D0210 | X-rays intraoral - Comprehensive series of radiographic images (limited to 1 D0210 or D0709 every 3 years) | ||
| D0220 | X-rays intraoral - Periapical - First radiographic image | ||
| D0230 | X-rays intraoral - Periapical - Each additional radiographic image | ||
| D0240 | Intraoral - occlusal radiographic image | ||
| D0250 | X-rays extra-oral - 2D projection radiographic image created using a stationary radiation source, and detector | ||
| D0251 | X-rays extra-oral posterior dental radiographic image (limit 1 D0251 or D0705 per calendar year) | ||
| D0270 | Bitewing - single radiographic image | ||
| D0272 | Bitewings - two radiographic images | ||
| D0273 | Bitewings three radiographic images | ||
| D0274 | Bitewings - four radiographic images - limited to 1 series every 6 months | ||
| D0277 | Vertical bitewings - 7 to 8 radiographic images | ||
| D0330 | Panoramic radiographic image - limited to 1 of (DO210 or DO330) per 24 months. Either one (1) DO210 or one (1) DO330 permitted | ||
| D0340 | 2D cephalometric radiographic image - Acquisition, measurement and analysis (when utilized for orthodontic services, see D8999) | ||
| D0350 | 2D oral/facial photographic images obtained intra-orally or extra-orally (when utilized for orthodontic services, see D8999) | ||
| D0368 | Cone 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) | ||
| D0372 | Intraoral tomosynthesis - Comprehensive series of radiographic images | ||
| D0373 | Intraoral tomosynthesis - Bitewing radiographic image | ||
| D0374 | Intraoral tomosynthesis - Periapical radiographic image | ||
| D0387 | Intraoral tomosynthesis - Comprehensive series of radiographic images - Image capture only | ||
| D0388 | Intraoral tomosynthesis - Bitewing radiographic image - Image capture only | ||
| D0389 | Intraoral tomosynthesis - Periapical radiographic image - Image capture only | ||
| D0391 | Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report | ||
| D0393 | Virtual treatment simulation using 3D image volume or surface scan | ||
| D0394 | Digital subtraction of two or more images or image volumes of the same modality | ||
| D0395 | Fusion of two or more 3D image volumes of one or more modalities | ||
| D0396 | 3D printing of a 3D dental surface scan | ||
| D0414 | Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation, and transmission of written report | ||
| D0415 | Collection of microorganisms for culture and sensitivity | ||
| D0425 | Caries susceptibility tests | ||
| D0431 | Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures | ||
| D0460 | Pulp vitality tests | ||
| D0470 | Diagnostic casts | ||
| D0472 | Accession of tissue, gross examination, preparation and transmission of written report | ||
| D0473 | Accession of tissue, gross and microscopic examination, preparation and transmission of written report | ||
| D0474 | Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report | ||
| D0486 | Laboratory accession of brush biopsy sample, microscopic examination, preparation and transmission of written report | ||
| D0600 | Non-ionizing diagnostic procedure capable of quantifying, monitoring and recording changes in structure of enamel, dentin and cementum | ||
| D0701 | Panoramic radiographic image - image capture only | ||
| D0702 | 2-D cephalometric radiographic image - image capture only | ||
| D0703 | 2-D oral/facial photographic image obtained intra- orally or extra-orally - image capture only | ||
| D0705 | Extra-oral posterior dental radiographic image - image capture only | ||
| D0706 | Intraoral - occlusal radiographic image - image capture only | ||
| D0707 | Intraoral - periapical radiographic image - image capture only | ||
| D0708 | Intraoral - bitewing radiographic image - image capture only | ||
| D0709 | Intraoral - comprehensive series of radiographic images - image capture only | ||
| D0801 | 3D dental surface scan - Direct (when utilized for orthodontic services, see D8999) | ||
| D0802 | 3D dental surface scan - Indirect (when utilized for orthodontic services, see D8999) | ||
| D0803 | 3D facial surface scan - Direct (when utilized for orthodontic services, see D8999) | ||
| D0804 | 3D facial surface scan - Indirect (when utilized for orthodontic services, see D8999) | ||
| D1110 | Prophylaxis cleaning- adult - limited to 2 D1110, D1120 or D4346 per calendar year | ||
| D1120 | Prophylaxis cleaning - child - limited to 2 D1110, D1120 or D4346 per calendar year | ||
| D1206 | Topical application of fluoride varnish - child to age 19; 2 D1206 or D1208 per calendar year | ||
| D1208 | Topical application of fluoride - excluding varnish - child to age 19; 2 D1206 or D1208 per calendar year | ||
| D1310 | Nutritional counseling for control of dental disease | ||
| D1320 | Tobacco counseling for the control and prevention of oral disease | ||
| D1321 | Counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use | ||
| D1330 | Oral hygiene instructions | ||
| D1351 | Sealant - per tooth - limited to permanent molars through age 15 | ||
| D1352 | Preventive resin restoration in a moderate to high caries risk patient - permanent tooth - limited to permanent molars through age 15 | ||
| D1353 | Sealant repair - per tooth - limited to permanent molars through age 15 | ||
| D1354 | Application of caries arresting medicament - per tooth - child to age 19; 2 per calendar year | ||
| D1355 | Caries preventive medicament application - Per tooth | ||
| D1510 | Space maintainer - fixed - unilateral - per quadrant | ||
| D1516 | Space maintainer - fixed - bilateral, maxillary | ||
| D1517 | Space maintainer - fixed - bilateral, mandibular | ||
| D1520 | Space maintainer - Removable - Unilateral - Per quadrant | ||
| D1526 | Space maintainer - Removable - Bilateral, upper | ||
| D1527 | Space maintainer - Removable - Bilateral, lower | ||
| D1551 | Re-cement or re-bond bilateral space maintainer - Upper | ||
| D1552 | Re-cement or re-bond bilateral space maintainer - Lower | ||
| D1553 | Re-cement or re-bond unilateral space maintainer - Per quadrant | ||
| D1556 | Removal of fixed unilateral space maintainer - per quadrant | ||
| D1557 | Removal of fixed bilateral space maintainer - maxillary | ||
| D1558 | Removal of fixed bilateral space maintainer - mandibular | ||
| D1575 | Distal shoe space maintainer - fixed, unilateral - per quadrant - child to age 9 | ||
| D2140 | Amalgam - one surface, primary or permanent | ||
| D2150 | Amalgam - two surfaces, primary or permanent | ||
| D2160 | Amalgam - three surfaces, primary or permanent | ||
| D2161 | Amalgam - four or more surfaces, primary or permanent | ||
| D2330 | Resin-based composite - one surface, anterior | ||
| D2331 | Resin-based composite - two surfaces, anterior | ||
| D2332 | Resin-based composite - three surfaces, anterior | ||
| D2335 | Resin-based composite - four or more surfaces (anterior) | ||
| D2390 | Resin-based composite crown, anterior | ||
| D2391 | Resin-based composite - one surface, posterior | ||
| D2392 | Resin-based composite - two surfaces, posterior | ||
| D2393 | Resin-based composite - three surfaces, posterior | ||
| D2394 | Resin-based composite - four or more surfaces, posterior | ||
| D2510 | Inlay - metallic - one surface | ||
| D2520 | Inlay - metallic - two surfaces | ||
| D2530 | Inlay - metallic - three or more surfaces | ||
| D2542 | Onlay - metallic - two surfaces | ||
| D2543 | Onlay - metallic - three surfaces | ||
| D2544 | Onlay - metallic - four or more surfaces | ||
| D2610 | Inlay - Porcelain/ceramic, 1 surface | ||
| D2620 | Inlay - Porcelain/ceramic, 2 surfaces | ||
| D2630 | Inlay - Porcelain/ceramic, 3 or more surfaces | ||
| D2642 | Onlay - Porcelain/ceramic, 2 surfaces | ||
| D2643 | Onlay - Porcelain/ceramic, 3 surfaces | ||
| D2644 | Onlay - Porcelain/ceramic, 4 or more surfaces | ||
| D2650 | Inlay - Resin-based composite, 1 surface | ||
| D2651 | Inlay - Resin-based composite, 2 surfaces | ||
| D2652 | Inlay - Resin-based composite, 3 or more surfaces | ||
| D2662 | Onlay - Resin-based composite, 2 surfaces | ||
| D2663 | Onlay - Resin-based composite, 3 surfaces | ||
| D2664 | Onlay - Resin-based composite, 4 or more surfaces | ||
| D2710 | Crown - Resin-based composite, indirect | ||
| D2712 | Crown - 3/4 resin-based composite, indirect | ||
| D2720 | Crown - Resin with high noble metal | ||
| D2721 | Crown - Resin with predominantly base metal | ||
| D2722 | Crown - Resin with noble metal | ||
| D2740 | Crown - porcelain/ceramic | ||
| D2750 | Crown - porcelain fused to high noble metal | ||
| D2751 | Crown - porcelain fused to predominantly base metal | ||
| D2752 | Crown - porcelain fused to noble metal | ||
| D2753 | Crown - porcelain fused to titanium and titanium alloys | ||
| D2780 | Crown - 3/4 cast high noble metal | ||
| D2781 | Crown - 3/4 cast predominantly base metal | ||
| D2782 | Crown - 3/4 cast noble metal | ||
| D2783 | Crown - 3/4 porcelain/ceramic | ||
| D2790 | Crown - full cast high noble metal | ||
| D2791 | Crown - full cast predominantly base metal | ||
| D2792 | Crown - full cast noble metal | ||
| D2794 | Crown - titanium and titanium alloys | ||
| D2799 | Interim crown (not to be used as a temporary crown for a routine prosthetic restoration) | ||
| D2910 | Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration | ||
| D2915 | Re-cement or re-bond indirectly fabricated or prefabricated post and core | ||
| D2920 | Re-cement or re-bond crown | ||
| D2928 | Prefabricated porcelain/ceramic crown - permanent tooth | ||
| D2929 | Prefabricated porcelain/ceramic crown - primary tooth - anterior | ||
| D2930 | Prefabricated stainless steel crown - primary tooth | ||
| D2931 | Prefabricated stainless steel crown - permanent tooth | ||
| D2932 | Prefabricated resin crown - anterior primary tooth | ||
| D2933 | Prefabricated stainless steel crown with resin window - anterior primary tooth | ||
| D2934 | Prefabricated esthetic coated stainless steel crown - primary tooth | ||
| D2940 | Placement of interim direct restoration | ||
| D2941 | Interim therapeutic restoration - Primary dentition | ||
| D2950 | Core buildup, including any pins when required | ||
| D2951 | Pin retention - per tooth, in addition to restoration | ||
| D2952 | Post and core in addition to crown, indirectly fabricated - includes canal preparation | ||
| D2953 | Each additional indirectly prefabricated post - Same tooth | ||
| D2954 | Prefabricated post and core in addition to crown - base metal post; includes canal preparation | ||
| D2957 | Each additional prefabricated post - Same tooth | ||
| D2960 | Labial veneer (resin laminate) - direct | ||
| D2971 | Additional procedures to customize a crown to fit under an existing partial denture framework | ||
| D2976 | Band stabilization - per tooth - limited to once in a lifetime per tooth | ||
| D2980 | Crown repair, necessitated by restorative material failure | ||
| D2983 | Veneer repair necessitated by restorative material failure | ||
| D2989 | Excavation of a tooth resulting in the determination of non-restorability | ||
| D2991 | Application of hydroxyapatite regeneration medicament - Per tooth | ||
| D3110 | Pulp cap - direct (excluding final restoration) | ||
| D3120 | Pulp cap - indirect (excluding final restoration) | ||
| D3220 | Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament | ||
| D3221 | Pulpal debridement, primary and permanent teeth | ||
| D3222 | Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development | ||
| D3230 | Pulpal therapy (resorbable filling) - Anterior, primary tooth (excluding final restoration) | ||
| D3240 | Pulpal therapy (resorbable filling) - Posterior, primary tooth (excluding final restoration) | ||
| D3310 | Root canal - endodontic therapy, anterior tooth (excluding final restoration) | ||
| D3320 | Root canal - endodontic therapy, premolar tooth (excluding final restoration) | ||
| D3330 | Root canal - endodontic therapy, molar tooth (excluding final restoration) | ||
| D3331 | Treatment of root canal obstruction; non-surgical access | ||
| D3332 | Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth | ||
| D3333 | Internal root repair of perforation defects | ||
| D3346 | Retreatment of previous root canal therapy - anterior | ||
| D3347 | Retreatment of previous root canal therapy - premolar | ||
| D3348 | Retreatment of previous root canal therapy - molar | ||
| D3351 | Apexification/recalcification - Initial visit (apical closure/ calcific repair of perforations, root resorption, etc.) | ||
| D3352 | Apexification/recalcification - Interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) | ||
| D3353 | Apexification/recalcification - Final visit (includes completed root canal therapy - Apical closure/calcific repair of perforations, root resorption, etc.) | ||
| D3410 | Apicoectomy - anterior | ||
| D3421 | Apicoectomy - premolar (first root) | ||
| D3425 | Apicoectomy - molar (first root) | ||
| D3426 | Apicoectomy (each additional root) | ||
| D3430 | Retrograde filling - per root | ||
| D3450 | Root amputation - Per root | ||
| D3471 | Surgical repair of root resorption - anterior | ||
| D3472 | Surgical repair of root resorption - premolar | ||
| D3473 | Surgical repair of root resorption - molar | ||
| D3501 | Surgical exposure of root surface without apicoectomy or repair of root resorption - anterior | ||
| D3502 | Surgical exposure of root surface without apicoectomy or repair of root resorption - premolar | ||
| D3503 | Surgical exposure of root surface without apicoectomy or repair of root resorption - molar | ||
| D3911 | Intraorifice barrier | ||
| D3920 | Hemisection (including any root removal), not including root canal therapy | ||
| D3921 | Decoronation or submergence of an erupted tooth | ||
| D4210 | Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant | ||
| D4211 | Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant | ||
| D4212 | Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth | ||
| D4240 | Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant | ||
| D4241 | Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant | ||
| D4245 | Apically positioned flap | ||
| D4249 | Clinical crown lengthening - hard tissue | ||
| D4260 | Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant | ||
| D4261 | Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant | ||
| D4263 | Bone replacement graft - retained natural tooth - first site in quadrant | ||
| D4264 | Bone replacement graft - retained natural tooth - each additional site in quadrant | ||
| D4265 | Biologic materials to aid in soft and osseous tissue regeneration, per site | ||
| D4266 | Guided tissue regeneration, natural teeth - resorbable barrier, per site | ||
| D4267 | Guided tissue regeneration, natural teeth - non-resorbable barrier, per site | ||
| D4270 | Pedicle soft tissue graft procedure | ||
| D4273 | Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position | ||
| D4274 | Mesial/distal wedge procedure single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) | ||
| D4275 | Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft | ||
| D4277 | Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant, or edentulous tooth position in graft | ||
| D4278 | Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site | ||
| D4283 | Autogenous connective tissue graft procedure (including donor and recipient surgical sites) - Each additional contiguous tooth, implant or edentulous tooth position in same graft site | ||
| D4285 | Non-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 | ||
| D4286 | Removal of non-resorbable barrier | ||
| D4341 | Periodontal scaling and root planing - four or more teeth per quadrant - limited to 4 quadrants during any 12 consecutive months | ||
| D4342 | Periodontal scaling and root planing - one to three teeth per quadrant - limited to 4 quadrants during any 12 consecutive months | ||
| D4346 | Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation - limited to 2 D1110, D1120 or D4346 per calendar year | ||
| D4355 | Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit - limited to 1 treatment in any 12 consecutive months | ||
| D4381 | Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth | ||
| D4910 | Periodontal maintenance - limited to 2 per calendar year | ||
| D4921 | Gingival irrigation with a medicinal agent - per quadrant | ||
| D5110 | Complete denture - maxillary | ||
| D5120 | Complete denture - mandibular | ||
| D5130 | Immediate denture - maxillary | ||
| D5140 | Immediate denture - mandibular | ||
| D5211 | Maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth) | ||
| D5212 | Mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth) | ||
| D5213 | Maxillary partial denture - cast metal framework with resin denture bases (including retentive/ clasping materials, rests and teeth) | ||
| D5214 | Mandibular partial denture - cast metal framework with resin denture bases (including retentive/ clasping materials, rests and teeth) | ||
| D5221 | Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth) | ||
| D5222 | Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth) | ||
| D5223 | Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) | ||
| D5224 | Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) | ||
| D5225 | Maxillary 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 | ||
| D5226 | Mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth) | ||
| D5227 | Immediate maxillary partial denture - flexible base (including any clasps, rests and teeth) | ||
| D5228 | Immediate mandibular partial denture - flexible base (including any clasps, rests and teeth) | ||
| D5282 | Removable unilateral partial denture - One piece cast metal (including retentive/clasping materials, rests and teeth), upper | ||
| D5283 | Removable unilateral partial denture - One piece cast metal (including retentive/clasping materials, rests and teeth), lower | ||
| D5284 | Removable unilateral partial denture - One piece flexible base (including retentive/clasping materials, rests and teeth) - Per quadrant | ||
| D5286 | Removable unilateral partial denture - One piece resin base (including retentive/clasping materials, rests and teeth) - Per quadrant | ||
| D5410 | Adjust complete denture - maxillary | ||
| D5411 | Adjust complete denture - mandibular | ||
| D5421 | Adjust partial denture - maxillary | ||
| D5422 | Adjust partial denture - mandibular | ||
| D5511 | Repair broken complete denture base, mandibular | ||
| D5512 | Repair broken complete denture base, maxillary | ||
| D5520 | Replace missing or broken teeth - complete denture - per tooth | ||
| D5611 | Repair resin partial denture base, mandibular | ||
| D5612 | Repair resin partial denture base, maxillary | ||
| D5621 | Repair cast partial framework - Lower | ||
| D5622 | Repair cast partial framework - Upper | ||
| D5630 | Repair or replace broken retentive/clasping materials - per tooth | ||
| D5640 | Replace missing or broken teeth - partial denture - per tooth | ||
| D5650 | Add tooth to existing partial denture - per tooth | ||
| D5660 | Add clasp to existing partial denture - per tooth | ||
| D5670 | Replace all teeth and acrylic on cast metal framework - Upper | ||
| D5671 | Replace all teeth and acrylic on cast metal framework - Lower | ||
| D5710 | Rebase complete maxillary denture | ||
| D5711 | Rebase complete mandibular denture | ||
| D5720 | Rebase maxillary partial denture | ||
| D5721 | Rebase mandibular partial denture | ||
| D5725 | Rebase hybrid prosthesis | ||
| D5730 | Reline complete maxillary denture (chairside) | ||
| D5731 | Reline complete mandibular denture (chairside) | ||
| D5740 | Reline maxillary partial denture (chairside) | ||
| D5741 | Reline mandibular partial denture (chairside) | ||
| D5750 | Reline complete maxillary denture (laboratory) | ||
| D5751 | Reline complete mandibular denture (laboratory) | ||
| D5760 | Reline maxillary partial denture (laboratory) | ||
| D5761 | Reline mandibular partial denture (laboratory) | ||
| D5765 | Soft liner for complete or partial removable denture - indirect | ||
| D5810 | Interim complete denture (maxillary) | ||
| D5811 | Interim complete denture (mandibular) | ||
| D5820 | Interim partial denture (including retentive/ clasping materials, rests, and teeth), maxillary - limited to 1 in any 12 consecutive months | ||
| D5821 | Interim partial denture (including retentive/ clasping materials, rests, and teeth), mandibular - limited to 1 in any 12 consecutive months | ||
| D5850 | Tissue conditioning - Upper | ||
| D5851 | Tissue conditioning - Lower | ||
| D5862 | Precision attachment - By report | ||
| D5875 | Modification of removable prosthesis following implant surgery | ||
| D5876 | Add metal substructure to acrylic full denture (per arch) | ||
| D6058 | Abutment supported porcelain/ceramic crown | ||
| D6059 | Abutment supported porcelain fused to metal crown (high noble metal) | ||
| D6060 | Abutment supported porcelain fused to metal crown (predominantly base metal) | ||
| D6061 | Abutment supported porcelain fused to metal crown (noble metal) | ||
| D6062 | Abutment supported cast metal crown (high noble metal) | ||
| D6063 | Abutment supported cast metal crown (predominantly base metal) | ||
| D6064 | Abutment supported cast metal crown (noble metal) | ||
| D6065 | Implant supported porcelain/ceramic crown | ||
| D6066 | Implant supported crown - Porcelain fused to high noble alloys | ||
| D6067 | Implant supported crown - High noble alloys | ||
| D6068 | Abutment supported retainer for porcelain/ceramic fixed partial denture | ||
| D6069 | Abutment supported retainer for porcelain fused to metal fixed partial denture (high noble metal) | ||
| D6070 | Abutment supported retainer for porcelain fused to metal fixed partial denture (predominantly base metal) | ||
| D6071 | Abutment supported retainer for porcelain fused to metal fixed partial denture (noble metal) | ||
| D6072 | Abutment supported retainer for cast metal fixed partial denture (high noble metal) | ||
| D6073 | Abutment supported retainer for cast metal fixed partial denture (predominantly base metal) | ||
| D6074 | Abutment supported retainer for cast metal fixed partial denture (noble metal) | ||
| D6075 | Implant supported retainer for ceramic fixed partial denture | ||
| D6076 | Implant supported retainer for fixed partial denture - Porcelain fused to high noble alloys | ||
| D6077 | Implant supported retainer for metal fixed partial denture - High noble alloys | ||
| D6082 | Implant supported crown - Porcelain fused to predominantly base alloys | ||
| D6083 | Implant supported crown - Porcelain fused to noble alloys | ||
| D6084 | Implant supported crown - Porcelain fused to titanium and titanium alloys | ||
| D6085 | Interim implant crown | ||
| D6086 | Implant supported crown - Predominantly base alloys | ||
| D6087 | Implant supported crown - Noble alloys | ||
| D6088 | Implant supported crown - Titanium and titanium alloys | ||
| D6089 | Accessing and retorquing loose implant screw - Per screw | ||
| D6092 | Re-cement implant/abutment supported crown | ||
| D6093 | Re-cement implant/abutment supported fixed partial denture | ||
| D6094 | Abutment supported crown - Titanium and titanium alloys | ||
| D6096 | Remove broken implant retaining screw | ||
| D6097 | Abutment supported crown - Porcelain fused to titanium and titanium alloys | ||
| D6098 | Implant supported retainer - Porcelain fused to predominantly base alloys | ||
| D6099 | Implant supported retainer for fixed partial denture - Porcelain fused to noble alloys | ||
| D6106 | Guided tissue regeneration - Resorbable barrier, per implant | ||
| D6107 | Guided tissue regeneration - Non-resorbable barrier, per implant | ||
| D6110 | Implant /abutment supported removable denture for edentulous arch - Upper | ||
| D6111 | Implant /abutment supported removable denture for edentulous arch - Lower | ||
| D6112 | Implant /abutment supported removable denture for partially edentulous arch - Upper | ||
| D6113 | Implant /abutment supported removable denture for partially edentulous arch - Lower | ||
| D6114 | Implant /abutment supported fixed denture for edentulous arch - Upper | ||
| D6115 | Implant /abutment supported fixed denture for edentulous arch - Lower | ||
| D6116 | Implant /abutment supported fixed denture for partially edentulous arch - Upper | ||
| D6117 | Implant /abutment supported fixed denture for partially edentulous arch - Lower | ||
| D6118 | Implant/abutment supported interim fixed denture for edentulous arch - Lower | ||
| D6119 | Implant/abutment supported interim fixed denture for edentulous arch - Upper | ||
| D6120 | Implant supported retainer - Porcelain fused to titanium and titanium alloys | ||
| D6121 | Implant supported retainer for metal fixed partial denture - Predominantly base alloys | ||
| D6122 | Implant supported retainer for metal fixed partial denture - Noble alloys | ||
| D6123 | Implant supported retainer for metal fixed partial denture - Titanium and titanium alloys | ||
| D6192 | Semi-precision attachment - Placement | ||
| D6194 | Abutment supported retainer crown for fixed partial denture - Titanium and titanium alloys | ||
| D6195 | Abutment supported retainer - Porcelain fused to titanium and titanium alloys | ||
| D6197 | Replacement of restorative material used to close an access opening of a screw-retained implant supported prosthesis, per implant | ||
| D6198 | Remove interim implant component | ||
| D6210 | Pontic - cast high noble metal | ||
| D6211 | Pontic - cast predominantly base metal | ||
| D6212 | Pontic - cast noble metal | ||
| D6214 | Pontic - titanium and titanium alloys | ||
| D6240 | Pontic - porcelain fused to high noble metal | ||
| D6241 | Pontic - porcelain fused to predominantly base metal | ||
| D6242 | Pontic - porcelain fused to noble metal | ||
| D6243 | Pontic - porcelain fused to titanium and titanium alloys | ||
| D6245 | Pontic - porcelain/ceramic | ||
| D6250 | Pontic - Resin with high noble metal | ||
| D6251 | Pontic - Resin with predominantly base metal | ||
| D6252 | Pontic - Resin with noble metal | ||
| D6253 | Interim Pontic | ||
| D6545 | Retainer - Cast metal for resin bonded fixed prosthesis | ||
| D6600 | Retainer inlay - Porcelain/ceramic, 2 surfaces | ||
| D6601 | Retainer inlay - Porcelain/ceramic, 3 or more surfaces | ||
| D6602 | Retainer inlay - cast high noble metal, two surfaces | ||
| D6603 | Retainer inlay - cast high noble metal, three or more surfaces | ||
| D6604 | Retainer inlay - cast predominantly base metal, two surfaces | ||
| D6605 | Retainer inlay - cast predominantly base metal, three or more surfaces | ||
| D6606 | Retainer inlay - cast noble metal, two surfaces | ||
| D6607 | Retainer inlay - cast noble metal, three or more surfaces | ||
| D6608 | Retainer onlay - Porcelain/ceramic, 2 surfaces | ||
| D6609 | Retainer onlay - Porcelain/ceramic, 3 or more surfaces | ||
| D6610 | Retainer onlay - cast high noble metal, two surfaces | ||
| D6611 | Retainer onlay - cast high noble metal, three or more surfaces | ||
| D6612 | Retainer onlay - cast predominantly base metal, two surfaces | ||
| D6613 | Retainer onlay - cast predominantly base metal, three or more surfaces | ||
| D6614 | Retainer onlay - cast noble metal, two surfaces | ||
| D6615 | Retainer onlay - cast noble metal, three or more surfaces | ||
| D6624 | Retainer inlay - titanium | ||
| D6634 | Retainer onlay - titanium | ||
| D6710 | Retainer crown - Indirect resin based composite | ||
| D6720 | Retainer crown - Resin with high noble metal | ||
| D6721 | Retainer crown - Resin with predominantly base metal | ||
| D6722 | Retainer crown - Resin with noble metal | ||
| D6740 | Retainer crown - porcelain/ceramic | ||
| D6750 | Retainer crown - porcelain fused to high noble metal | ||
| D6751 | Retainer crown - porcelain fused to predominantly base metal | ||
| D6752 | Retainer crown - porcelain fused to noble metal | ||
| D6753 | Retainer crown - porcelain fused to titanium and titanium alloys | ||
| D6780 | Retainer crown - 3/4 cast high noble metal | ||
| D6781 | Retainer crown - 3/4 cast predominantly base metal | ||
| D6782 | Retainer crown - 3/4 cast noble metal | ||
| D6783 | Retainer crown - 3/4 porcelain/ceramic | ||
| D6784 | Retainer crown - 3/4 titanium and titanium alloys | ||
| D6790 | Retainer crown - full cast high noble metal | ||
| D6791 | Retainer crown - full cast predominantly base metal | ||
| D6792 | Retainer crown - full cast noble metal | ||
| D6794 | Retainer crown - titanium and titanium alloys | ||
| D6930 | Re-cement or re-bond fixed partial denture | ||
| D6950 | Precision attachment | ||
| D7111 | Extraction, coronal remnants - primary tooth | ||
| D7140 | Extraction, erupted tooth or exposed root (elevation and/or forceps removal) | ||
| D7210 | Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated | ||
| D7220 | Removal of impacted tooth - soft tissue | ||
| D7230 | Removal of impacted tooth - partially bony | ||
| D7240 | Removal of impacted tooth - completely bony | ||
| D7241 | Removal of impacted tooth - completely bony, with unusual surgical complications | ||
| D7250 | Removal of residual tooth roots (cutting procedure) | ||
| D7251 | Coronectomy - intentional partial tooth removal, impacted teeth only | ||
| D7260 | Oroantral fistula closure | ||
| D7261 | Primary closure of sinus perforation | ||
| D7270 | Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth | ||
| D7280 | Exposure of an unerupted tooth | ||
| D7283 | Placement of device to facilitate eruption of impacted tooth | ||
| D7285 | Incisional biopsy of oral tissue-hard (bone, tooth) | ||
| D7286 | Incisional biopsy of oral tissue - soft - does not include pathology laboratory procedures | ||
| D7287 | Exfoliative cytological sample collection | ||
| D7288 | Brush biopsy - transepithelial sample collection | ||
| D7310 | Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant | ||
| D7311 | Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant | ||
| D7320 | Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant | ||
| D7321 | Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant | ||
| D7450 | Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm | ||
| D7451 | Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm | ||
| D7471 | Removal of lateral exostosis (maxilla or mandible) | ||
| D7472 | Removal of torus palatinus | ||
| D7473 | Removal of torus mandibularis | ||
| D7485 | Reduction of osseous tuberosity | ||
| D7510 | Incision and drainage of abscess - intraoral soft tissue | ||
| D7511 | Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) | ||
| D7520 | Incision and drainage of abscess - Extraoral soft tissue | ||
| D7521 | Incision and drainage of abscess - Extraoral soft tissue - Complicated (includes drainage of multiple fascial spaces) | ||
| D7880 | Occlusal orthotic device, by report - (limit 1 per 24 months; only covered in conjunction with Temporomandibular Joint (TMJ) treatment) | ||
| D7881 | Occlusal orthotic device adjustment | ||
| D7910 | Suture of recent small wounds up to 5cm | ||
| D7922 | Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site | ||
| D7961 | Buccal/labial frenectomy (frenulectomy) | ||
| D7963 | Frenuloplasty | ||
| D8010 | Limited orthodontic treatment of the primary dentition - Banding | ||
| D8020 | Limited orthodontic treatment of the transitional dentition - Banding | ||
| D8030 | Limited orthodontic treatment of the adolescent dentition - Banding | ||
| D8040 | Limited orthodontic treatment of the adult dentition - Banding | ||
| D8070 | Comprehensive orthodontic treatment of the transitional dentition - Banding | ||
| D8080 | Comprehensive orthodontic treatment of the adolescent dentition - Banding | ||
| D8090 | Comprehensive orthodontic treatment of the adult dentition - Banding | ||
| D8210 | Removable appliance therapy | ||
| D8220 | Fixed appliance therapy | ||
| D8660 | Pre-orthodontic treatment examination to monitor growth and development | ||
| D8670 | Periodic orthodontic treatment visit | ||
| D8680 | Orthodontic retention - Removal of appliances, construction and placement of retainer(s) | ||
| D8681 | Removable orthodontic retainer adjustment | ||
| D8695 | Removal of fixed orthodontic appliances for reasons other than completion of treatment | ||
| D8698 | Re-cement or re-bond fixed retainer - Upper | ||
| D8699 | Re-cement or re-bond fixed retainer - Lower | ||
| D8701 | Repair of fixed retainer, includes reattachment - Upper | ||
| D8702 | Repair of fixed retainer, includes reattachment - Lower | ||
| D8999 | Unspecified orthodontic procedure - By report (orthodontic treatment plan and records including all necessary images) | ||
| D9110 | Palliative treatment of dental pain - per visit | ||
| D9120 | Fixed partial denture sectioning | ||
| D9211 | Regional block anesthesia | ||
| D9212 | Trigeminal division block anesthesia | ||
| D9215 | Local anesthesia | ||
| D9222 | Deep sedation/general anesthesia - first 15 minutes | ||
| D9223 | Deep sedation/general anesthesia - each subsequent 15 minute increment | ||
| 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 minute increment | ||
| D9310 | Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician | ||
| D9311 | Consultation with a medical health care professional | ||
| D9430 | Office visit for observation (during regularly scheduled hours) - no other services performed | ||
| D9440 | Office visit - after regularly scheduled hours | ||
| D9450 | Case presentation, subsequent to detailed and extensive treatment planning | ||
| D9610 | Therapeutic parenteral drug, single administration | ||
| D9612 | Therapeutic parenteral drugs, 2 or more administrations, different medications | ||
| D9613 | Infiltration of sustained release therapeutic drug, per quadrant (patient charge is per quadrant) | ||
| D9630 | Drugs or medicaments dispensed in the office for home use | ||
| D9910 | Application of desensitizing medicament | ||
| D9911 | Application of desensitizing resin for cervical and/or root surface, per tooth | ||
| D9912 | Pre-visit patient screening | ||
| D9938 | Fabrication of a custom removable clear plastic temporary aesthetic appliance | ||
| D9939 | Placement of a custom removable clear plastic temporary aesthetic appliance | ||
| D9941 | Fabrication of athletic mouthguard (limit 1 per 12 months) | ||
| D9942 | Repair and/or reline of occlusal guard | ||
| D9943 | Occlusal guard adjustment | ||
| D9944 | Occlusal guard - hard appliance, full arch - limited to 1 D9944, D9945 or D9946 in 24 months | ||
| D9945 | Occlusal guard - soft appliance, full arch - limited to 1 D9944, D9945 or D9946 in 24 months | ||
| D9946 | Occlusal guard - hard appliance, partial arch - limited to 1 D9944, D9945 or D9946 in 24 months | ||
| D9951 | Occlusal adjustment, limited | ||
| D9952 | Occlusal adjustment, complete | ||
| D9961 | Duplicate/copy patient's records | ||
| D9975 | External 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 | ||
| D9990 | Certified translation or sign-language services - per visit | ||
| D9995 | Teledentistry - synchronous; real-time encounter | ||
| D9996 | Teledentistry - 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 Description | ADA Code | ADA Descripton | Indicate Type I, II, III | PPO Maximum Allowable Amount | Indicate Any Limitations |
| Prophylaxis - adult | D1110 | Preventive | |||
| Periodic oral evaluation - established patient | D0120 | Diagnostic | |||
| Bitewings - four radiographic images | D0274 | Diagnostic | |||
| Intraoral - periapical first radiographic image | D0220 | Diagnostic | |||
| Topical application of fluoride varnish | D1206 | Preventive | |||
| Intraoral - periapical each additional radiographic image | D0230 | Diagnostic | |||
| Prophylaxis - child | D1120 | Preventive | |||
| Periodontal maintenance | D4910 | Non-Surgical Periodontics | |||
| Comprehensive oral evaluation - new or established patient | D0150 | Diagnostic | |||
| Limited oral evaluation - problem focused | D0140 | Diagnostic | |||
| Topical application of fluoride - excluding varnish | D1208 | Preventive |
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File details come from the government source that posted it. Updated .