CARTA CIRCULAR #M0908345 NUEVA VERSIÓN DE ...publicaciones.ssspr.com/Cartas/Documents/M0908345.pdfR...

CARTA CIRCULAR #M0908345 27 de agosto 2009 A TODOS LOS DENTISTAS PARTICIPANTES DE TRIPLE-S SALUD

NUEVA VERSIÓN DE CUBIERTA DB-94

Triple-S Salud ofrece nueva versión de cubierta de servicios dentales identificada con el código DB-94. Versión de

Cubierta

Cubierta

Base

Efectividad Características

DB-94 D-64 Inmediata No incluye servicios de prótesis

Incluimos la Tabla de Cubiertas Dentales actualizada. Si necesita información adicional, comuníquese con nuestro Departamento de Relaciones Profesionales al 787-749-4700 ó al 1-877-357-9777 (libre de cargos para llamadas de larga distancia). Cordialmente, Francisco Joglar Pesquera, MD, FACP Fernando Haddock, DDS Vicepresidente Senior Director Dental División de Asuntos Médicos, División de Asuntos Médicos, Dentales y Profesionales Dentales y Profesionales ns Anejo

NOTAS Y MODIFICADORES APLICABLES A TABLA DE CUBIERTAS TRIPLE-S SALUD

OBSERVACIONES GENERALES:1 Los números incluídos en la tabla representan el porciento de

coaseguro responsabilidad del asegurado.

2 Para las definiciones oficiales de cada código, así como las políticas de pago debe referirse al Manual del Odontólogo Participante.En la tabla sólo se han incluído definiciones abreviadas como ayuda.

NOTA DEFINICION

X Servicio cubierto al 100%

--- No tiene cubierta

¢ Cubre 4 radiografías periapicales por año poliza.

Þ Cubre 6 radiografías periapicales por año poliza.

(P) Para periodoncistas solamente.

L Límite de 24 meses

LL Máximo de $450 para dentistas generalistas y de $500 para prostodoncistas por arco.

^ Favor referirse al Manual del Odontólogo Participante para la política de pago correspondiente a este servicio.

^^ Cubre 1 cada 6 meses para asegurados de 19 años en adelante, sin exclusiones.

I Máximo de $500 de la tarifa Triple-S

# Máximo de $800 entre prótesis y periodoncia

æ Máximo de $800 entre los procedimientos D2140 al D2335, D2391, D3310, D3320, D7140 al D7240, D7250, D7510 y D7286.

Ø Máximo de $1,000 para todos los servicios dentales cubiertos por dos años.

ê Máximo de $1,000 por año póliza, por persona asegurada.

U Máximo de $1,000 para todos los servicios excluyendo ortodoncia

¶ Máximo de $1,000 para todos los servicios excluyendo periodoncia

Æ Máximo de $1,000 por año póliza para todos los servicios dentales excluyendo periodoncia y ortodoncia.

M Máximo de $1,000 por año póliza para todos los servicios dentales cubiertos.

Ñ Máximo de $1,500 por año póliza para todos los servicios dentales cubiertos, excepto ortodoncia.

Ü Máximo de $1,750 para todos los servicios excluyendo ortodoncia.

¥

K Se excluyen procedimientos D2722, D4249, D4270, D4271, D5650, D5810 y D5811.

£ Tiene periodo de espera de 24 meses.

R Ver carta circular de Reforma #M0810A17 para deducibles o coaseguros correspondientes

Z Uno por año contrato

O Servicios cubiertos si están relacionados a accidente, la factura requiere venir acompañada de un reporte

S Servicio cubierto si está relacionado a procedimiento quirúrgico cubierto

V Servicio cubierto cuando se requiera la extracción de 7 o más dientes permanentes

§ Máximo de $1,000 por año póliza, para los servicios preventivos, restaurativos y de periodoncia.

◊ Sin limite de edad

ø Cubre ortodoncia sólo hasta los 18 años

* Cubre ortodoncia sólo hasta 19 años

** Cubre dependientes directos hasta los 19 años

© Cubre solamente a los dependientes hijos hasta los 25 años

Ω Cubre ortodoncia hasta que el asegurado cumpla 25 años

¤ Dependientes opcionales serán elegibles

YB Máximo de $1,200 por año póliza para todos los servicios dentales excluyendo periodoncia y ortodoncia.

@ Máximo de $900 para dentistas generalistas y de $1,000 para prostodoncistas.

// Se aplicará el coaseguro del servicio que se esté evaluando

& Máximo de $1,000 por año póliza para servicios dentales restaurativos, endodoncias, prostodoncia, cirugía oral

y servicios generales adjuntos.

∏ Cubre ortodoncia a dependientes directos hasta los 18 años

T Los asegurados menores de 18 años no pagarán deducible para ninguno de los servicios de Diagnóstico,

Preventivos y Paleativos.

™ Deducible por visita de $3 en asegurados mayores de 19 años

ª Deducible por visita de $10

Ð Este código es parte de la visita inicial (D8660) del tratamiento de ortodoncia

Ĝ El 20% de coaseguro aplica solo al servicio D2740

ĳ Máximo de $750 por año póliza para todos los servicios dentales cubiertos.

Cubre solo en superficie bucal.

Ə Servicios de ortodoncia se pagarán al cargo sometido.

Ш Servicio cubierto solo al grupo 1-20005 Selecto Platino

Ǿ El servicio D2394 se mantiene con 30% de coaseguro

Ψ Máximo de $1,000 para todos los servicios excluyendo prótesis

Ξ Servicio D9950 no está cubierto

π Máximo de $1,000 para todos los servicios excluyendo prótesis, periodoncia y ortodoncia

Қ Máximo de $500 por año póliza para todos los servicios dentales cubiertos.

ю Cubre 5 radiografías periapicales por año poliza.

P Máximo por año poliza.

C Máximo de $1,300 por año póliza para todos los servicios dentales excluyendo periodoncia y ortodoncia.

F Servicios de ortodoncia se pagarán por la cubierta de Gastos Mayores.

W Cubre ortodoncia solamente al asegurado principal y los dependientes hasta los 25 años

Máximo de $1,000 por año póliza, por persona asegurada.$1,000 por año poliza por asegurado, incluyendo periodoncia.

♠ Máximo de $1,250 para todos los servicios excluyendo ortodoncia.

La tarifa asignada no podrá exceder el beneficio máximo de $1,750 por año póliza establecido para los servicios dentales cubiertos, excepto ortodoncia.

Asegurados con 65 años o más continuan siendo elegibles

9 de septiembre de 2009

TABLA DE CUBIERTAS DENTALES TRIPLE-S SALUD

CODIGOS DESCRIPCION DD02 DC05 DC06 DC07 DC08 DC09 D01 D02 D04 D05 D06 D07 D08 D10 D12 D20 D21 D22 D24 D25 D26 D27 D28 D29 D30 D33 D34 D36 D37 D38 D40 D41 D42 D45Máximo por cubierta ($) 1000 1000 1500

Nota T T T T T U M ÑDeducible por visita R $0 $1 $2 $3

CATEGORIA I DIAGNOSTICODIAG. Y PREV. Evaluaciones OS

D0120 Periódica X X X X X X X X X X X X Z X X 20 X X X X 30 X X X X Z X X X X X X X X X XD0140 Limitada X X X X X X X X X X X --- X X 20 X X X X 30 X X X --- X X X X X X X X X XD0150 Comprensiva X X X X X X X X X X X X X X 20 X X X X 30 X X X X X X X X X X X X X X

D0180 (P) Periodontal Comprensiva X --- --- --- --- --- --- X X X X --- --- X 20 X X X X 30 X X X --- X X --- X X X X X X XRadiografías OS

D0210 Intraoral:Serie completa X X X X X X X X X X X --- --- X 20 X X X X 30 X X X --- X X X X X X X X X XD0220;D0230 Periapical individual X X Þ X Þ X Þ X Þ X Þ X X X X X --- X Þ X 20 X Þ X X X 30 X X X --- X X Þ X X X X X X X X

D0240 Oclusal X --- --- --- --- --- X X X X X --- --- X 20 --- X X X 30 X X X --- X X X X X X X X X XD0250;D0260 Extraoral X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D0270;D0272 Mordida,una;dos X X X X X X X X X X X --- X X 20 X X X X 30 X X X --- X X X X X X X X X X

D0274 Mordida,cuatro --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- X --- ---D0277 Mordida vertical,siete a ocho --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- X --- ---D0290 Antero-posterior o lateral craneal --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D0330 Panorámica X X X X X X X X X X X --- 30 X 20 X X X X 30 X X X --- X X X X X X X X X XD0340 Cefalométrica X Ð --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- X Ð --- ---

Otros --- ---D0350 Imágenes fotográficas orales/faciales --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D0415 Estudios bacteriológicos cultivo/sensitividad --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D0460 Prueba de vitalidad --- --- --- --- --- --- X X X X X --- --- X 20 X X X X 30 X X X --- X X X X X X X --- X XD0470 Modelos de estudio --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D0473 Muestra de tejido para examen microscópico --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D0999 Proc. no especificado --- X X X X X X X X X X --- 30 X 20 X X X X 30 X X X --- X X X X X X X X X X

PREVENTIVA Prophylaxis

D1110 Adulto --- X™ X X X X X X X X X X X X 20 X X X X 30 X X X X X X X X X X X X X XD1120 Niño --- X X X X X X X X X X X X X 20 X X X X 30 X X X X X X X X X X X X X X

Flúor sin prophyD1203 Niño --- X X X X X X X X X X --- X X 20 X X X X 30 X X X --- X X X X X X X X X XD1204 Adulto --- --- --- --- --- --- --- X^ X^ X^ --- --- 30^ --- 20^ X^ X^ X^ X^ 30^ X^ X^ X^ --- X^ X^ X^ --- X^ X^ X^ X^ --- X^

SellantesD1351 Sellante de fisura --- X X X X X --- X X X --- --- --- --- 20 20 X X X 30 X X X --- X X X X X X X X --- X

Mantenedores EspacioD1510;D1515 Fijo unilateral; bilateral --- --- --- --- --- --- --- 20 20 X X --- --- 50 20 20 20 20 X 20 X X 30 --- 20 X 20 50 20 X 50 --- 50 X

D1520 Removible,unilateral --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D1525 Removible bilateral --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D1550 Recementación --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

CATEGORIA II

SERVICIOS de RUTINA RESTAURATIVA O

D2140-D2161 Amalgama:primario;perm. X Xª X X X X X X X 25 X --- 30 X 30 20 X X X 30 X X 25 --- 20 X X X X 30 X 30 X 20

D2330-D2335 Resina anterior X Xª X X X X X X X 25 X --- 30 X 30 20 X X X 30 30 X 25 --- 20 X X X X 30 X 30 X 20

D2391 Resina posterior:primario;perm. X Xª X X X X 30 30 20 25 30 --- 30 30 30 30 30 20 30 30 30 20 25 --- 20 X 30 30 30 30 30 30 30 20

D2392-D2394 Resina posterior:primario;perm. X --- --- --- --- --- 30 30 20 25 30 --- 30 30 30 30 30 20 30 30 30 20 25 --- 20 X 30 30 30 30 30 30 30 20

D2410-D2430 Oro cohesivo --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D2510-D2620 Inlays,Onlays:metálicos;porcelana --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D2630 Inlay-porcelana --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D2642-D2664 Inlays,Onlays:resina;porcelana --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D2799 Corona provisional X --- --- --- --- --- --- X X 25 X --- --- X 30 --- X X X 30 --- X 25 --- 20 X X X X X X 30 X 20

D2910 Recementar inlay X --- --- --- --- --- X X X 25 X --- --- X 30 --- X X X 30 30 X 25 --- 20 X X X X X X 30 X 20

9 de septiembre de 2009Todo procedimiento que aparece cubierto en ésta tabla, está sujeto a las políticas de pago y limitaciones establecidas en el Manual del Odontólogo Participante.

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D2915 Recementar poste y muñón X --- --- --- --- --- --- X X 25 X --- --- X 30 --- X X X 30 --- X 25 --- 20 --- X X --- X X 30 X 20

D2920 Recementar corona X --- --- --- --- --- X X X 25 X --- --- X 30 --- X X X 30 30 X 25 --- 20 X X X X X X 30 X 20

D2930 Corona inoxidable:prim. X --- --- --- --- --- X X X 25 X --- --- X 30 --- X X X 30 20 20 25 --- 20 X X X X X X 30 X 20

D2931 Corona inoxidable:perm. --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D2932 Corona prefabr. resina --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D2933 Corona inoxidable-resina --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D2940 Restauración sedativa X Xª X X X X X X X 25 X --- 30 X 30 20 X X X 30 30 X X --- 20 X X X X X X 30 X 20

D2950 Construcción muñón X --- --- --- --- --- --- X X 25 X --- --- X 30 --- X X X 30 --- X 25 --- 20 --- X X --- X X 30 X 20

D2951 Perno (Pin) X --- --- --- --- --- X X X 25 X --- 30 X 30 --- X X X 30 30 X 25 --- 20 X X X X X X 30 X 20

D2960 Laminado directo --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D2961;D2962 Laminado Lab.(resina;porcelana) --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D2980 Reparación corona X --- --- --- --- --- --- X X 25 X --- --- X 30 --- X X X 30 --- X 25 --- 20 --- X X --- X X 30 X 20

D2999 Proc. no especificado X Xª X X X X X X X 25 X --- 30 X 30 20 X X X 30 30 X 25 --- 20 X X X X X X 30 X 20

ENDODONCIA O

D3110 Recubrimiento pulpar directo X --- --- --- --- --- X X X 25 X --- 30 X 30 --- X 50 30 X 30 X 25 --- X X X X X 30 X 30 X 20

D3120 Recubrimiento pulpar indirecto X Xª X X X X X X X 25 X --- 30 X 30 20 X 50 30 X 30 X 25 --- X X X X X 30 X 30 X 20

D3220 Pulpotomía X --- --- --- --- --- X X X 25 X --- --- X 30 20 X 50 30 X 30 X 25 --- X X X X X 30 X 30 X 20

D3221 Drenaje endodóntico (Tx. paleativo de emerg.) --- X X X X X X X X 25 X --- 30 X 30 20 X 50 30 X 30 X 25 --- X X X X X 30 X 30 X 20

D3310;D3320 Trat. canal: anterior; bicúspide X X X X X X X X X 25 X --- --- X 30 20 X 50 30 X 20 20 25 --- X X X X X 30 X 30 X 20

D3330 Trat.canal:molar X --- --- --- --- --- --- X X 25 X --- --- X 30 20 X 50 30 X 20 20 25 --- X X X X --- 30 X 30 X 20

D3346;D3347 Retratamiento: anterior; bicúspide X X X X X X X X X 25 X --- --- X 30 20 X 50 30 X 20 20 25 --- X X X X X 30 X 30 X 20

D3348 Retratamiento: molar X --- --- --- --- --- --- X X 25 X --- --- X 30 --- X 50 30 X 20 20 25 --- X --- X X --- 30 X 30 X 20

D3351-D3353 Apexificación --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D3410;D3421 Apicectomía-ant.;bicúsp. X --- --- --- --- --- X X X 25 X --- --- X 30 --- X 50 30 X 30 X 25 --- X X X X X 30 X --- X 20

D3425;D3426 Apicectomía-molar X --- --- --- --- --- X X X 25 X --- --- X --- --- X 50 30 X --- X 25 --- X X --- X --- 30 X --- X 20

D3430 Restauración retrograda X --- --- --- --- --- X X X 25 X --- --- X 30 --- X 50 30 X 30 X 25 --- X X X X X 30 X --- X 20

D3450;D3920 Amputación de raíz; Hemisección --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D3999 Proc. no especificado X X X X X X X X X 25 X --- --- X 30 20 X 50 30 X 30 X 25 --- X X X X X 30 X 30 X 20PERIODONCIA BÁSICA

D4355 Detrartaje completo preev. --- --- --- --- --- --- --- X 20 X X --- --- 50 30 --- X X 30 X 20 20 50 --- X --- --- X --- 30 X --- 50 50

D4910 Mantenimiento periodontal X --- --- --- --- --- --- X 20 X X --- --- 50 30 20 X X 30 X 20 20 50 --- X X --- X 50 30 X 30 50 50PROSTODONCIANotaLímite por año póliza ($)

D5410;D5411 Ajustes protesis rem. X --- --- --- --- --- X X X X X --- --- X X --- X X X X 30 X X --- X X X X X X X 30 X X

D5421;D5422 Ajustes protesis rem. X --- --- --- --- --- X X X X X --- --- X X 40 X X X X 30 X X --- X X X X X X X 30 X X

D5510 Reparación dent. completa X --- --- --- --- --- X X X X X --- --- X X 40 X X X X 30 X X --- X X ê X X X X X 30 X X

D5520 Reparación dent. completa X --- --- --- --- --- X X X X X --- --- X X --- X X X X 30 X X --- X X ê X X X X X 30 X X

D5610 Reparación dent. parcial X --- --- --- --- --- X X X X X --- --- X X 40 X X X X 30 X X --- X X ê X X X X X 30 X X

D5620 Reparación metal --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D5630 Reparación dent. parcial X --- --- --- --- --- X X X X X --- --- X X --- X X X X 30 X X --- X X X X X X X 30 X X

D5640 Remplazo diente X --- --- --- --- --- X X X X X --- --- X X 40 X X X X 30 X X --- X X X X X X X 30 X X

D5650;D5660 Reparación dent. parcial X --- --- --- --- --- X X X X X --- --- X X --- X X X X 30 X X --- X X ê X X X X X 30 X X

D5710-D5721 Rebasado: compl.;parcial X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 40 50 50 50 50 --- 50 50 --- 50 X 50 50 --- 50 50 30 50 50

D5730-D5761 Reline:completas;parciales X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 40 50 50 50 50 --- 50 50 --- 50 X 50 50 --- 50 50 30 50 50

D5850;D5851 Condicionador maxilar; mandibular --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---


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D5899 Proc. no especificado X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 30 50 50

D6930 Recementación puente X --- --- --- --- --- X X X X X --- --- X X --- X X X X 30 X X --- X X ê X X X X X 30 X X

D6980 Reparación puente X --- --- --- --- --- --- X X X X --- --- X X --- X X X X --- X X --- X X ê X --- X X X 30 X X

CIRUGIA ORAL

Extracciones OV

D7140 Sencilla/Raíz Expuesta X X X X X X X X X 25 X X 30 X X 20 X X X X 20 20 X 15 X X X X X X X 30 X 20

Extracciones Quirúrgicas O

D7210 Dientes erupcionados X X X X X X X 30 20 25 X --- 30 X 30 20 X 50 30 30 20 20 30 --- 30 X 30 30 30 30 30 30 X 20

D7250 Raíz residual X X X X X X X 30 20 25 X --- 30 X 30 20 X 50 30 30 20 20 30 --- 30 X 30 30 30 30 30 30 X 20

D7510 Drenaje tejido blando X X X X X X X X X 25 X --- 30 X X 20 X X X X X X X --- X X X X X X X 30 X X

CATEGORIA III

SERVICIOS MAYORES PERIODONCIA Nota U M Ñ #Límite por año póliza ($) 800 --- --- --- --- --- --- 1000 --- 1000 1000 --- --- 800 1000 --- 1000 1000 1000 1000 --- --- 800 --- 1500 --- --- 800 1000 1200 800 --- 800 1000Deducible Periodoncia ($) --- --- --- --- --- --- --- --- --- --- 50 --- --- 50 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 50 --- 50 ---

D4210;D4211 Gingivectomía X --- --- --- --- --- --- X 20 X X --- --- 50 30 --- X X 30 X 20 20 50 --- X --- --- X 50 30 X --- 50 50

D4240;D4241 Colgajo/alisado radicular --- --- --- --- --- --- --- X 20 X X --- --- 50 30 --- X X 30 X 20 20 50 --- X --- --- X 50 30 X --- 50 50

D4245 Cirugía mucogingival --- --- --- --- --- --- --- X 20 X X --- --- 50 30 --- X X 30 X 20 20 50 --- X --- --- X 50 30 X --- 50 50

D4249 Alargamiento corona X --- --- --- --- --- --- X 20 X X --- --- 50 30 --- X X 30 X 20 20 50 --- X --- --- X 50 30 X --- 50 50

D4260;D4261 Cirugía ósea X --- --- --- --- --- --- X 20 X X --- --- 50 30 --- X X 30 X 20 20 50 --- X --- --- X 50 30 X --- 50 50

D4263;D4264 Injerto óseo X --- --- --- --- --- --- X 20 X X --- --- 50 30 --- X X 30 X 20 20 50 --- X --- --- X 50 30 X --- 50 50

D4266;D4267 Regeneración guiada X --- --- --- --- --- --- X 20 X X --- --- 50 30 --- X X 30 X 20 20 50 --- X --- --- X 50 30 X --- 50 50

D4270-D4273 Injertos tejido blando --- --- --- --- --- --- --- X 20 X X --- --- 50 30 --- X X 30 X 20 20 50 --- X --- --- X 50 30 X --- 50 50

D4320 Férula prov. intracoronal X --- --- --- --- --- --- --- --- --- --- --- --- --- 30 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D4321 Férula prov. extracoronal X --- --- --- --- --- --- X 20 X X --- --- 50 30 --- X X 30 X 20 20 50 --- X --- --- X 50 30 X --- 50 50

D4341;D4342 Alisado radicular --- --- --- --- --- --- --- X 20 X X --- --- 50 30 20 X X 30 X 20 20 50 --- X X --- X 50 30 X 30 50 50

D4920 Unscheduled dressing change --- --- --- --- --- --- --- --- --- --- --- --- --- --- 30 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D4999 Proc. no especificado X --- --- --- --- --- --- X 20 X X --- --- 50 30 --- X X 30 X 20 20 50 --- X --- --- X 50 30 X 30 50 50

PROSTODONCIA Nota #Límite ($) 1000 800 800

D2710 Corona-resina (lab.) --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D2720 Corona/metal alta nobl. y resina X --- --- --- --- --- --- 57 50 50 X --- --- --- 50 --- 57 50 50 57 --- 50 50 --- 50 --- 57 57 --- 50 57 60 57 50

D2722;D2740 Coronas sencillas X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50

D2750 Corona/metal alta nobl. y porcelana X --- --- --- --- --- --- 57 50 50 X --- --- --- 50 --- 57 50 50 57 --- 50 50 --- 50 --- 57 57 --- 50 57 60 57 50

D2751 Corona-porc./metal base y porcelana X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50

D2752 Corona metal noble y porcelana X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50

D2780 Corona ¾ metal alta nobl. X --- --- --- --- --- --- 57 50 50 X --- --- --- 50 --- 57 50 50 57 --- 50 50 --- 50 --- 57 57 --- 50 57 60 57 50

D2781-D2783 Coronas sencillas ¾ X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50

D2790 Corona/metal alta nobl. X --- --- --- --- --- --- 57 50 50 X --- --- --- 50 --- 57 50 50 57 --- 50 50 --- 50 --- 57 57 --- 50 57 60 57 50

D2791 Corona/toda metal base X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50

D2792 Corona sencilla metal noble X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50

D2794 Corona completa/titanio X --- --- --- --- --- --- 57 50 50 X --- --- --- 50 --- 57 50 50 57 --- 50 50 --- 50 --- 57 57 --- 50 57 60 57 50

D2952;D2954 Poste y muñón X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 30 50 50

D5110;D5120 Dentaduras:compl. X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 40 50 50 50 50 --- 50 50 --- 50 X 50 50 --- 50 50 60 50 50

D5130;D5140 Dentaduras:inmediatas X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 --- 50 50D5211;D5212 Dentaduras:parc. base de resina X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 --- 50 50D5213;D5214 Dentaduras:parc. combinación X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 40 50 50 50 50 --- 50 50 --- 50 X 50 50 --- 50 50 60 50 50

D5281 Dentadura unilateral X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 --- 50 50


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D5810-D5821 Dentaduras temporeras:completas;parciales --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D5860;D5861 Sobredentaduras:completas;parciales --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D5862 Agarre de precisión: prótesis rem. --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D6058 Corona sobre pilar de un implante/porc. --- --- --- --- --- --- --- 50 50 50 --- --- --- 50 50 --- 50 50 50 50 --- --- 50 --- 50 --- 50 --- --- 50 50 --- --- 50D6059 Corona sobre pilar de un implante/metal alta nobl. --- --- --- --- --- --- --- 57 50 50 --- --- --- --- 50 --- 57 50 50 57 --- --- 50 --- 50 --- 57 --- --- 50 57 --- --- 50D6060 Corona sobre pilar de un implante/metal base --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D6061 Corona sobre pilar de un implante/metal noble --- --- --- --- --- --- --- 50 50 50 --- --- --- 50 50 --- 50 50 50 50 --- --- 50 --- 50 --- 50 --- --- 50 50 --- --- 50D6062 Corona sobre pilar de un implante/metal alta nobl. --- --- --- --- --- --- --- 57 50 50 --- --- --- --- 50 --- 57 50 50 57 --- --- 50 --- 50 --- 57 --- --- 50 57 --- --- 50D6063 Corona sobre pilar de un implante/metal base --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D6064 Corona sobre pilar de un implante/metal noble --- --- --- --- --- --- --- 50 50 50 --- --- --- 50 50 --- 50 50 50 50 --- --- 50 --- 50 --- 50 --- --- 50 50 --- --- 50D6065 Corona sobre implante/porc. --- --- --- --- --- --- --- 50 50 50 --- --- --- 50 50 --- 50 50 50 50 --- --- 50 --- 50 --- 50 --- --- 50 50 --- --- 50D6066 Corona sobre implante/metal alta nobl. --- --- --- --- --- --- --- 57 50 50 --- --- --- --- 50 --- 57 50 50 57 --- --- 50 --- 50 --- 57 --- --- 50 57 --- --- 50D6067 Corona sobre implante/metal alta nobl. --- --- --- --- --- --- --- 57 50 50 --- --- --- --- 50 --- 57 50 50 57 --- --- 50 --- 50 --- 57 --- --- 50 57 --- --- 50D6068 Corona sobre implante/porc. --- --- --- --- --- --- --- 50 50 50 --- --- --- 50 50 --- 50 50 50 50 --- --- 50 --- 50 --- 50 --- --- 50 50 --- --- 50D6075 Corona sobre implante/porc. --- --- --- --- --- --- --- 50 50 50 --- --- --- 50 50 --- 50 50 50 50 --- --- 50 --- 50 --- 50 --- --- 50 50 --- --- 50D6076 Corona sobre implante/metal alta nobl. --- --- --- --- --- --- --- 57 50 50 --- --- --- --- 50 --- 57 50 50 57 --- --- 50 --- 50 --- 57 --- --- 50 57 --- --- 50D6077 Corona sobre implante/metal alta nobl. --- --- --- --- --- --- --- 57 50 50 --- --- --- --- 50 --- 57 50 50 57 --- --- 50 --- 50 --- 57 --- --- 50 57 --- --- 50D6069 Corona de puente sobre implante/metal alta nobl. --- --- --- --- --- --- --- 57 50 50 --- --- --- --- 50 --- 57 50 50 57 --- --- 50 --- 50 --- 57 --- --- 50 57 --- --- 50D6070 Corona de puente sobre implante/metal base --- --- --- --- --- --- --- 50 50 50 --- --- --- 50 50 --- 50 50 50 50 --- --- 50 --- 50 --- 50 --- --- 50 50 --- --- 50D6071 Corona de puente sobre implante/metal noble --- --- --- --- --- --- --- 50 50 50 --- --- --- 50 50 --- 50 50 50 50 --- --- 50 --- 50 --- 50 --- --- 50 50 --- --- 50D6072 Coronas de puente sobre implante/metal alta nobl. --- --- --- --- --- --- --- 57 50 50 --- --- --- --- 50 --- 57 50 50 57 --- --- 50 --- 50 --- 57 --- --- 50 57 --- --- 50D6073 Coronas de puente sobre implante/metal base --- --- --- --- --- --- --- 50 50 50 --- --- --- 50 50 --- 50 50 50 50 --- --- 50 --- 50 --- 50 --- --- 50 50 --- --- 50D6074 Coronas de puente implante/metal noble --- --- --- --- --- --- --- 50 50 50 --- --- --- 50 50 --- 50 50 50 50 --- --- 50 --- 50 --- 50 --- --- 50 50 --- --- 50D6210 Póntico/metal alta nobl. X --- --- --- --- --- --- 57 50 50 X --- --- --- 50 --- 57 50 50 57 --- 50 50 --- 50 --- 57 57 --- 50 57 60 57 50D6211 Póntico/metal base X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 --- 50 50D6212 Póntico/metal noble X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50D6214 Póntico/titanio X --- --- --- --- --- --- 57 50 50 X --- --- --- 50 --- 57 50 50 57 --- 50 50 --- 50 --- 57 57 --- 50 57 --- 57 50D6240 Póntico/metal alta nobl. y porcelana X --- --- --- --- --- --- 57 50 50 X --- --- --- 50 --- 57 50 50 57 --- 50 50 --- 50 --- 57 57 --- 50 57 60 57 50

D6241;D6242 Póntico/metal y porcelana X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50D6245 Póntico/porcelana completa --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---D6250 Póntico/resina y metal alta nobl. X --- --- --- --- --- --- 57 50 50 X --- --- --- 50 --- 57 50 50 57 --- 50 50 --- 50 --- 57 57 --- 50 57 60 57 50

D6251;D6252 Póntico/metal y resina --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---D6253 Póntico provisional --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---D6545 Retenedor tipo maryland X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50D6548 Retenedor/porcelana completa --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---

D6600-D6605 Inlays: porcelana;metalicos --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---D6606;D6607 Inlays:metal noble X --- --- --- --- --- --- --- 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50D6608-D6615 Onlays:porcelana;metálicos --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---D6624;D6634 Inlays, Onlays:titanio --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---

D6710 Corona/resina compuesta indirecta --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---D6720 Corona/metal alta nobl. y resina compuesta X --- --- --- --- --- --- 57 50 50 X --- --- --- 50 --- 57 50 50 57 --- 50 50 --- 50 --- 57 57 --- 50 57 60 57 50

D6721;D6722 Corona en resina compuesta/metalica --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---D6740 Corona/porcelana completa --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---D6750 Corona/metal alta nobl. y porcelana X --- --- --- --- --- --- 57 50 50 X --- --- --- 50 --- 57 50 50 57 --- 50 50 --- 50 --- 57 57 --- 50 57 60 57 50D6751 Corona porc./metal base X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50D6752 Corona/porcelana y metal noble X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50D6780 Corona ¾ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---

D6781;D6782 Coronas ¾ metal X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50D6783 Corona ¾ porcelana --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---D6790 Corona/metal alta nobl. X --- --- --- --- --- --- 57 50 50 X --- --- --- 50 --- 57 50 50 57 --- 50 50 --- 50 --- 57 57 --- 50 57 60 57 50

D6791;D6792 Corona completa/metalica X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50D6794 Corona/titanio X --- --- --- --- --- --- 57 50 50 X --- --- --- 50 --- 57 50 50 57 --- 50 50 --- 50 --- 57 57 --- 50 57 60 57 50D6920 Connector bar --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---D6940 Stress breaker --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---


Página 4




D6950 Agarre de precisión: prótesis fija --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 60 --- ---D6970;D6972 Postes X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50D6973;D6975 Retainer crown buildup;Coping --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D6999 Proc. no especificado X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 50 --- 50 50 60 50 50PROTESIS MAXILOFACIAL

D5931-D5936 Prótesis:defectos adquiridos --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D5951-D5955 Prótesis: defectos congénitos --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D5982-D5985 Prótesis de tratamientos --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D5986 Cubeta fluor tópico --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---IMPLANTES

D6010-D6199 Inserción,reparación,remoción,recementación, no esp. --- --- --- --- --- --- --- --- --- --- --- --- --- 50 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---CIRUGIA ORAL

D7220-D7240 Dientes Impactados X X X X X X X 30 20 25 X --- 30 X 30 20 X 50 30 30 20 20 30 --- 30 X 30 30 30 30 30 30 X 20D7260 Cierre de fistula oro-antral --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D7270 Tooth reimplantation and/or etc. O --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D7272 Tooth transplantation --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- D7280 Exposición quirúrgica diente impactado --- --- --- --- --- --- --- 30 30 25 X --- --- X --- --- 30 50 30 30 --- 20 30 --- 30 X --- 30 30 30 --- 30 X 30 D7283 Inserción de bracket ortodóntico --- --- --- --- --- --- --- 30 30 --- X --- --- X --- --- 30 50 30 30 --- 20 30 --- 30 --- --- 30 --- 30 --- 30 X 30D7285 Biopsía tejido duro --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D7286 Biopsía tejido blando --- --- --- --- --- --- X 30 30 25 X --- --- X 30 --- 30 50 30 30 30 20 30 --- 30 X 30 30 30 30 30 30 X 30D7290 Reposición quir. dientes --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D7291 Transseptal fibertomy --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D7310-D7321 Alveoloplastía X --- --- --- --- --- --- 50 50 50 X --- --- 50 50 --- 50 50 50 50 --- 50 50 --- 50 --- 50 --- --- 50 50 --- 50 50D7340 Vestibuloplastía --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D7350 Vestibuloplastía --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D7471-D7473 Remoción de exostosis (sobrehueso) --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 20 20 --- --- --- --- --- --- --- --- --- --- --- ---D7520 Drenaje extraoral X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D7550 Secuestrectomía --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D7880 Occlusal Orthotic Device --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D7953 Injerto óseo para implantes --- --- --- --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D7960 Frenulectomía --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 20 20 --- --- --- --- --- --- --- --- --- --- --- ---D7970 Exc.tejido hiperplástico --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D7971 Exc. gingiva pericororonal X --- --- --- --- --- X 30 30 25 X --- --- X 30 --- 30 50 30 30 20 20 30 --- 30 X 30 30 30 30 30 30 X 30D7999 Proc. no especificado X X X X X X X 30 30 25 X --- 30 X 30 20 30 50 30 30 30 20 30 --- 30 X 30 30 30 30 30 30 X 30

CATEGORIA IV SERVICIOS GENERALES ADJUNTOSD9310 Consulta --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D9410 House call --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D9420 Hospital Call --- --- --- --- --- --- --- X X X --- --- 30 --- X 20 X X X X X X X --- X X X --- --- X --- X --- X

D9430;D9440 Office visits --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D9630 Dispensar medicamento O --- --- --- --- --- X X X 25 X --- --- X X --- X X X X X X X --- X X X X X X X --- X XD9910 Aplicar desensitizante --- X X X X X X X X 25 X --- 30 X X 20 X X X X X X X --- X X X X X X X X X XD9930 Complicación post-cirugía O X X X X X X X X 25 X --- 30 X X 20 X X X X X X X --- X X X X X X X X X X

D9940;D9950 Férula;Análisis oclusal --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---D9951;D9952 Ajuste oclusal-lim.compl. X --- --- --- --- --- --- X X X X --- --- X --- --- X X X X --- X 50 --- X --- --- X --- X X --- X XD9973;D9974 Blanqueamiento externo/interno --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

D9999 Proc. no especificado --- --- --- --- --- --- X X X X X --- 30 X X 20 X X X X X X X --- X X X X X X X X X XD8210-D8690 ORTODONCIA --- --- --- --- --- --- --- X 50 **Ə --- X --- --- 50◊Ə --- --- X X ø 50 X --- 50Ə 50 --- X --- --- X * --- --- --- 50 £* 50* 50Ə

D8691 Reparar aparato ortodónc. --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---Límite por vida ($) --- --- --- --- --- --- --- 1000 1500 --- 1000 --- --- 3000 --- --- 1250 1500 1000 1000 --- 1500 1000 1500 1000 1500 1050 650Deducible Ortodoncia ($) --- --- --- --- --- --- --- --- --- --- --- --- --- 50 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 50 ---


Página 5


CODIGOS DESCRIPCIONMáximo por cubierta ($)

NotaDeducible por visita

CATEGORIA I DIAGNOSTICODIAG. Y PREV. Evaluaciones

D0120 PeriódicaD0140 LimitadaD0150 Comprensiva

D0180 (P) Periodontal ComprensivaRadiografías

D0210 Intraoral:Serie completaD0220;D0230 Periapical individual

D0240 Oclusal D0250;D0260 Extraoral D0270;D0272 Mordida,una;dos

D0274 Mordida,cuatroD0277 Mordida vertical,siete a ochoD0290 Antero-posterior o lateral cranealD0330 PanorámicaD0340 Cefalométrica

OtrosD0350 Imágenes fotográficas orales/facialesD0415 Estudios bacteriológicos cultivo/sensitividadD0460 Prueba de vitalidadD0470 Modelos de estudioD0473 Muestra de tejido para examen microscópicoD0999 Proc. no especificado


D1110 AdultoD1120 Niño

Flúor sin prophyD1203 NiñoD1204 Adulto

SellantesD1351 Sellante de fisura

Mantenedores EspacioD1510;D1515 Fijo unilateral; bilateral

D1520 Removible,unilateralD1525 Removible bilateralD1550 Recementación

CATEGORIA II

SERVICIOS de RUTINA RESTAURATIVA

D2140-D2161 Amalgama:primario;perm.

D2330-D2335 Resina anterior

D2391 Resina posterior:primario;perm.

D2392-D2394 Resina posterior:primario;perm.

D2410-D2430 Oro cohesivo

D2510-D2620 Inlays,Onlays:metálicos;porcelana

D2630 Inlay-porcelana

D2642-D2664 Inlays,Onlays:resina;porcelana

D2799 Corona provisional

D2910 Recementar inlay

D47 D48 D49 D50 D51 D53 D54 D57 D58 D59 D60 D61 D63 D64 D66 D67 D68 D75 D77 D78 D80 D82 D83 D85 D86 D87 D88 D89 D90 D91 D99 DA02 DA07 DA121750Ü

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

X X X X X X X X X X 30 X X X X X X X X X X X X X X 20 X X X X X X X XX X X X X X X X X X 30 X X X X X X X X X X X X X X 20 X X X X X X X XX X X X X X X X X X 30 X X X X X X X X X X X X X X 20 X X X X X X X X--- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---X X X X X X X X X X 30 X X X X X X X X X X X X X X 20 X X X X X X X X--- --- --- --- --- --- XL --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---X X X X X X X X X X 30 X X X X X X X X X X X X X X 20 X X X X X X X X--- --- --- --- --- --- X Ð --- --- --- --- --- --- --- --- --- --- X Ð --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

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

X X X X X X X X X X 30 X X X X X X X X X X X X X X 20 X X X X X X X XX X X X X X X X X X 30 X X X X X X X X X X X X X X 20 X X X X X X X X

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50 X 50 20 20 X 50 50 40 X 30 20 20 20 30 X 20 X 20 20 X X 20 20 X 20 20 X 20 20 X 20 X 20--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- 50 --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- 50 --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

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X X X X 20 X X X 20 X 30 X X X X X X 20 X X X 20 X X X 20 20 20 X X X X 25 20

30 30 30 30 20 30 30 30 20 30 30 30 30 30 30 X 30 20 30 30 X 20 30 30 20 20 20 20 30 30 X 20 25 20

30 30 30 30 20 30 30 30 20 30 30 30 30 30 30 X 30 20 30 30 X 20 30 30 20 20 20 20 30 30 X 20 25 20

--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- 20 --- --- 50 --- --- --- --- --- ---

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X X X X 20 X X X 20 X 30 X X X X X X 20 X X X 20 X 30 X 20 X 20 X X X X 25 20


Página 6




CATEGORIA I DIAGNOSTICOD2915 Recementar poste y muñón

D2920 Recementar corona

D2930 Corona inoxidable:prim.

D2931 Corona inoxidable:perm.

D2932 Corona prefabr. resina

D2933 Corona inoxidable-resina

D2940 Restauración sedativa

D2950 Construcción muñón

D2951 Perno (Pin)

D2960 Laminado directo

D2961;D2962 Laminado Lab.(resina;porcelana)

D2980 Reparación corona

D2999 Proc. no especificado

ENDODONCIA

D3110 Recubrimiento pulpar directo

D3120 Recubrimiento pulpar indirecto

D3220 Pulpotomía

D3221 Drenaje endodóntico (Tx. paleativo de emerg.)

D3310;D3320 Trat. canal: anterior; bicúspide

D3330 Trat.canal:molar

D3346;D3347 Retratamiento: anterior; bicúspide

D3348 Retratamiento: molar

D3351-D3353 Apexificación

D3410;D3421 Apicectomía-ant.;bicúsp.

D3425;D3426 Apicectomía-molar

D3430 Restauración retrograda

D3450;D3920 Amputación de raíz; Hemisección


PERIODONCIA BÁSICA

D4355 Detrartaje completo preev.

D4910 Mantenimiento periodontalPROSTODONCIANotaLímite por año póliza ($)

D5410;D5411 Ajustes protesis rem.


D5510 Reparación dent. completa


D5610 Reparación dent. parcial

D5620 Reparación metal


D5640 Remplazo diente

D5650;D5660 Reparación dent. parcial

D5710-D5721 Rebasado: compl.;parcial

D5730-D5761 Reline:completas;parciales

D5850;D5851 Condicionador maxilar; mandibular


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



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X X X X X X X X X X 30 X X X X X X 40 X X X 20 X 50 X 20 20 X X X X X X X

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--- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---




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

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

--- --- --- --- --- --- 50 --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---


Página 7




CATEGORIA I DIAGNOSTICOD5899 Proc. no especificado

D6930 Recementación puente

D6980 Reparación puente

CIRUGIA ORAL

Extracciones

D7140 Sencilla/Raíz Expuesta

Extracciones Quirúrgicas

D7210 Dientes erupcionados

D7250 Raíz residual

D7510 Drenaje tejido blando

CATEGORIA III

SERVICIOS MAYORES PERIODONCIA NotaLímite por año póliza ($)Deducible Periodoncia ($)

D4210;D4211 Gingivectomía

D4240;D4241 Colgajo/alisado radicular

D4245 Cirugía mucogingival

D4249 Alargamiento corona

D4260;D4261 Cirugía ósea

D4263;D4264 Injerto óseo

D4266;D4267 Regeneración guiada

D4270-D4273 Injertos tejido blando

D4320 Férula prov. intracoronal

D4321 Férula prov. extracoronal

D4341;D4342 Alisado radicular

D4920 Unscheduled dressing change


PROSTODONCIA NotaLímite ($)

D2710 Corona-resina (lab.)

D2720 Corona/metal alta nobl. y resina

D2722;D2740 Coronas sencillas

D2750 Corona/metal alta nobl. y porcelana

D2751 Corona-porc./metal base y porcelana

D2752 Corona metal noble y porcelana

D2780 Corona ¾ metal alta nobl.

D2781-D2783 Coronas sencillas ¾

D2790 Corona/metal alta nobl.

D2791 Corona/toda metal base

D2792 Corona sencilla metal noble

D2794 Corona completa/titanio

D2952;D2954 Poste y muñón

D5110;D5120 Dentaduras:compl.

D5130;D5140 Dentaduras:inmediatasD5211;D5212 Dentaduras:parc. base de resina D5213;D5214 Dentaduras:parc. combinación

D5281 Dentadura unilateral


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

X X X X X X X X X X 30 X X X X X X X X X X 20 X 30 X 20 20 X X X X X X X

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

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

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

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

# Ü800 1000 800 1000 1000 1000 1000 1000 1000 1000 --- 1000 --- --- 800 1000 1000 --- 1000 1000 1250 1000 --- 1000 1000 --- 1000 1000 --- 1000 1000 1000 1000 1000 --- --- 50 --- --- --- --- --- --- 50 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---









--- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---


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

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


#800

--- --- --- --- --- --- 50 --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

57 57 50 57 50 50 50 57 40 X --- 57 --- 57 --- X 57 40 57 57 40 40 --- 50 50 --- 40 50 --- 57 X 50 57 57

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

57 57 50 57 50 50 50 57 40 X --- 57 --- 57 --- X 57 40 57 57 40 40 --- 50 50 --- 40 50 --- 57 X 50 57 57

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

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

57 57 50 57 50 50 50 57 40 X --- 57 --- 57 --- X 57 40 57 57 40 40 --- 50 50 --- 40 50 --- 57 X 50 57 57

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

57 57 50 57 50 50 50 57 40 X --- 57 --- 57 --- X 57 40 57 57 40 40 --- 50 50 --- 40 50 --- 57 X 50 57 57

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

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

57 57 50 57 50 50 50 57 40 X --- 57 --- 57 --- X 57 40 57 57 40 40 --- 50 50 --- 40 50 --- 57 X 50 57 57

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

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

50 50 50 50 50 50 50 50 40 X --- 50 --- 50 50 X 50 40 50 50 40 40 --- 50 50 --- 40 50 --- 50 X 50 50 5050 50 50 50 50 50 50 50 40 X --- 50 --- 50 50 X 50 40 50 50 40 40 --- 50 50 --- 40 50 --- 50 X 50 50 5050 X 50 50 50 50 50 50 40 X --- 50 --- 50 50 X 50 40 50 50 40 40 --- 50 50 --- 40 50 --- 50 X 50 50 5050 50 50 50 50 50 50 50 40 X --- 50 --- 50 50 X 50 40 50 50 40 40 --- 50 50 --- 40 50 --- 50 X 50 50 50


Página 8




CATEGORIA I DIAGNOSTICOD5810-D5821 Dentaduras temporeras:completas;parcialesD5860;D5861 Sobredentaduras:completas;parciales

D5862 Agarre de precisión: prótesis rem.D6058 Corona sobre pilar de un implante/porc.D6059 Corona sobre pilar de un implante/metal alta nobl.D6060 Corona sobre pilar de un implante/metal baseD6061 Corona sobre pilar de un implante/metal nobleD6062 Corona sobre pilar de un implante/metal alta nobl.D6063 Corona sobre pilar de un implante/metal baseD6064 Corona sobre pilar de un implante/metal nobleD6065 Corona sobre implante/porc.D6066 Corona sobre implante/metal alta nobl.D6067 Corona sobre implante/metal alta nobl.D6068 Corona sobre implante/porc.D6075 Corona sobre implante/porc.D6076 Corona sobre implante/metal alta nobl.D6077 Corona sobre implante/metal alta nobl.D6069 Corona de puente sobre implante/metal alta nobl.D6070 Corona de puente sobre implante/metal baseD6071 Corona de puente sobre implante/metal nobleD6072 Coronas de puente sobre implante/metal alta nobl.D6073 Coronas de puente sobre implante/metal baseD6074 Coronas de puente implante/metal nobleD6210 Póntico/metal alta nobl.D6211 Póntico/metal baseD6212 Póntico/metal nobleD6214 Póntico/titanioD6240 Póntico/metal alta nobl. y porcelana

D6241;D6242 Póntico/metal y porcelanaD6245 Póntico/porcelana completa D6250 Póntico/resina y metal alta nobl.

D6251;D6252 Póntico/metal y resinaD6253 Póntico provisionalD6545 Retenedor tipo marylandD6548 Retenedor/porcelana completa

D6600-D6605 Inlays: porcelana;metalicosD6606;D6607 Inlays:metal nobleD6608-D6615 Onlays:porcelana;metálicosD6624;D6634 Inlays, Onlays:titanio

D6710 Corona/resina compuesta indirectaD6720 Corona/metal alta nobl. y resina compuesta

D6721;D6722 Corona en resina compuesta/metalicaD6740 Corona/porcelana completaD6750 Corona/metal alta nobl. y porcelanaD6751 Corona porc./metal baseD6752 Corona/porcelana y metal nobleD6780 Corona ¾

D6781;D6782 Coronas ¾ metalD6783 Corona ¾ porcelanaD6790 Corona/metal alta nobl.

D6791;D6792 Corona completa/metalica D6794 Corona/titanioD6920 Connector barD6940 Stress breaker


--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- 50 --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ 50 --- 50 50 50 50 50 --- --- --- 50 --- 50 --- --- --- 40 --- 50 --- 40 --- 50 50 --- 40 50 --- 50 X --- 50 ------ 57 --- 57 50 50 50 57 --- --- --- 57 --- 57 --- --- --- 40 --- 57 --- 40 --- 50 50 --- 40 50 --- 57 X --- 57 ------ --- --- --- --- --- 50 --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ 50 --- 50 50 50 50 50 --- --- --- 50 --- 50 --- --- --- 40 --- 50 --- 40 --- 50 50 --- 40 50 --- 50 X --- 50 ------ 57 --- 57 50 50 50 57 --- --- --- 57 --- 57 --- --- --- 40 --- 57 --- 40 --- 50 50 --- 40 50 --- 57 X --- 57 ------ --- --- --- --- --- 50 --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ 50 --- 50 50 50 50 50 --- --- --- 50 --- 50 --- --- --- 40 --- 50 --- 40 --- 50 50 --- 40 50 --- 50 X --- 50 ------ 50 --- 50 50 50 50 50 --- --- --- 50 --- 50 --- --- --- 40 --- 50 --- 40 --- 50 50 --- 40 50 --- 50 X --- 50 ------ 57 --- 57 50 50 50 57 --- --- --- 57 --- 57 --- --- --- 40 --- 57 --- 40 --- 50 50 --- 40 50 --- 57 X --- 57 ------ 57 --- 57 50 50 50 57 --- --- --- 57 --- 57 --- --- --- 40 --- 57 --- 40 --- 50 50 --- 40 50 --- 57 X --- 57 ------ 50 --- 50 50 50 50 50 --- --- --- 50 --- 50 --- --- --- 40 --- 50 --- 40 --- 50 50 --- 40 50 --- 50 X --- 50 ------ 50 --- 50 50 50 50 50 --- --- --- 50 --- 50 --- --- --- 40 --- 50 --- 40 --- 50 50 --- 40 50 --- 50 X --- 50 ------ 57 --- 57 50 50 50 57 --- --- --- 57 --- 57 --- --- --- 40 --- 57 --- 40 --- 50 50 --- 40 50 --- 57 X --- 57 ------ 57 --- 57 50 50 50 57 --- --- --- 57 --- 57 --- --- --- 40 --- 57 --- 40 --- 50 50 --- 40 50 --- 57 X --- 57 ------ 57 --- 57 50 50 50 57 --- --- --- 57 --- 57 --- --- --- 40 --- 57 --- 40 --- 50 50 --- 40 50 --- 57 X --- 57 ------ 50 --- 50 50 50 50 50 --- --- --- 50 --- 50 --- --- --- 40 --- 50 --- 40 --- 50 50 --- 40 50 --- 50 X --- 50 ------ 50 --- 50 50 50 50 50 --- --- --- 50 --- 50 --- --- --- 40 --- 50 --- 40 --- 50 50 --- 40 50 --- 50 X --- 50 ------ 57 --- 57 50 50 50 57 --- --- --- 57 --- 57 --- --- --- 40 --- 57 --- 40 --- 50 50 --- 40 50 --- 57 X --- 57 ------ 50 --- 50 50 50 50 50 --- --- --- 50 --- 50 --- --- --- 40 --- 50 --- 40 --- 50 50 --- 40 50 --- 50 X --- 50 ------ 50 --- 50 50 50 50 50 --- --- --- 50 --- 50 --- --- --- 40 --- 50 --- 40 --- 50 50 --- 40 50 --- 50 X --- 50 ---50 57 50 57 50 50 50 57 40 X --- 57 --- 57 --- X 57 40 57 57 40 40 --- 50 50 --- 40 50 --- 57 X 50 57 5750 50 50 50 50 50 50 50 40 X --- 50 --- 50 50 X 50 40 50 50 40 40 --- 50 50 --- 40 50 --- 50 X 50 50 5050 50 50 50 50 50 50 50 40 X --- 50 --- 50 50 X 50 40 50 50 40 40 --- 50 50 --- 40 50 --- 50 X 50 50 5050 57 50 57 50 50 50 57 40 X --- 57 --- 57 --- X 57 40 57 57 40 40 --- 50 50 --- 40 50 --- 57 X 50 57 5750 57 50 57 50 50 50 57 40 X --- 57 --- 57 --- X 57 40 57 57 40 40 --- 50 50 --- 40 50 --- 57 X 50 57 5750 50 50 50 50 50 50 50 40 X --- 50 --- 50 50 X 50 40 50 50 40 40 --- 50 50 --- 40 50 --- 50 X 50 50 50--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---50 57 50 57 50 50 50 57 40 X --- 57 --- 57 --- X 57 40 57 57 40 40 --- 50 50 --- 40 50 --- 57 X 50 57 57--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---50 50 50 50 50 50 50 50 40 X --- 50 --- 50 50 X 50 40 50 50 40 40 --- 50 50 --- 40 50 --- 50 X 50 50 50--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---50 50 50 50 50 50 50 50 40 X --- 50 --- 50 50 X 50 40 50 50 40 40 --- 50 50 --- 40 50 --- 50 X 50 50 50--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---50 57 50 57 50 50 50 57 40 X --- 57 --- 57 --- X 57 40 57 57 40 40 --- 50 50 --- 40 50 --- 57 X 50 57 57--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---50 57 50 57 50 50 50 57 40 X --- 57 --- 57 --- X 57 40 57 57 40 40 --- 50 50 --- 40 50 --- 57 X 50 57 5750 50 50 50 50 50 50 50 40 X --- 50 --- 50 50 X 50 40 50 50 40 40 --- 50 50 --- 40 50 --- 50 X 50 50 5050 50 50 50 50 50 50 50 40 X --- 50 --- 50 50 X 50 40 50 50 40 40 --- 50 50 --- 40 50 --- 50 X 50 50 50--- --- --- --- --- --- 50 --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---50 50 50 50 50 50 50 50 40 X --- 50 --- 50 50 X 50 40 50 50 40 40 --- 50 50 --- 40 50 --- 50 X 50 50 50--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---50 57 50 57 50 50 50 57 40 X --- 57 --- 57 --- X 57 40 57 57 40 40 --- 50 50 --- 40 50 --- 57 X 50 57 5750 50 50 50 50 50 50 50 40 X --- 50 --- 50 50 X 50 40 50 50 40 40 --- 50 50 --- 40 50 --- 50 X 50 50 5050 57 50 57 50 50 50 57 40 X --- 57 --- 57 --- X 57 40 57 57 40 40 --- 50 50 --- 40 50 --- 57 X 50 57 57--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---


Página 9




CATEGORIA I DIAGNOSTICOD6950 Agarre de precisión: prótesis fijaD6970;D6972 PostesD6973;D6975 Retainer crown buildup;Coping

D6999 Proc. no especificadoPROTESIS MAXILOFACIAL

D5931-D5936 Prótesis:defectos adquiridosD5951-D5955 Prótesis: defectos congénitosD5982-D5985 Prótesis de tratamientos

D5986 Cubeta fluor tópicoIMPLANTES

D6010-D6199 Inserción,reparación,remoción,recementación, no esp.CIRUGIA ORAL

D7220-D7240 Dientes ImpactadosD7260 Cierre de fistula oro-antralD7270 Tooth reimplantation and/or etc.D7272 Tooth transplantation D7280 Exposición quirúrgica diente impactado D7283 Inserción de bracket ortodónticoD7285 Biopsía tejido duroD7286 Biopsía tejido blandoD7290 Reposición quir. dientesD7291 Transseptal fibertomy

D7310-D7321 Alveoloplastía D7340 VestibuloplastíaD7350 Vestibuloplastía

D7471-D7473 Remoción de exostosis (sobrehueso)D7520 Drenaje extraoralD7550 SecuestrectomíaD7880 Occlusal Orthotic DeviceD7953 Injerto óseo para implantesD7960 FrenulectomíaD7970 Exc.tejido hiperplástico D7971 Exc. gingiva pericororonalD7999 Proc. no especificado

CATEGORIA IV SERVICIOS GENERALES ADJUNTOSD9310 ConsultaD9410 House callD9420 Hospital Call

D9430;D9440 Office visitsD9630 Dispensar medicamentoD9910 Aplicar desensitizanteD9930 Complicación post-cirugía

D9940;D9950 Férula;Análisis oclusal D9951;D9952 Ajuste oclusal-lim.compl.D9973;D9974 Blanqueamiento externo/interno

D9999 Proc. no especificadoD8210-D8690 ORTODONCIA

D8691 Reparar aparato ortodónc.Límite por vida ($)Deducible Ortodoncia ($)


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

--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

ê --- --- --- --- --- --- 50 --- --- --- --- --- --- --- --- --- --- 40 ¥ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

30 20 30 30 20 30 30 30 X X 30 30 30 30 30 X 30 20 30 30 X 20 30 30 20 20 20 20 30 30 X 20 25 50--- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---30 30 30 30 --- 30 30 30 X X --- 30 30 --- --- X 30 20 30 30 X 20 30 --- 20 --- 20 --- --- 30 X 20 25 5030 30 30 30 --- 30 30 30 X X --- 30 --- --- --- X 30 20 30 30 X 20 --- --- 20 --- 20 --- --- 30 X 20 25 ------ --- --- --- --- --- 30 --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---30 30 30 30 20 30 30 30 X X 30 30 30 30 30 X 30 20 30 30 X 20 30 30 20 20 20 20 30 30 X 20 25 ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---50 50 50 50 50 50 50 50 40 X --- 50 --- 50 50 X 50 20 50 50 40 40 --- 50 50 --- 40 50 --- 50 X 50 50 ------ --- --- --- --- --- 30 --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- ------ --- --- --- --- --- 30 --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- 30 --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 30 --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---30 30 30 30 20 30 X 30 X X 30 30 30 30 30 X 30 20 30 30 X 20 30 30 20 20 20 20 30 30 X 20 25 ---30 20 30 30 20 30 X 30 X X 30 30 30 30 30 X 30 20 30 30 X 20 30 30 20 20 20 20 30 30 X 20 25 ---

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

50*Ə X X 50 --- X 50Ə X 50Ə X --- X --- --- X** XƏ X 50Ə X 50 X X --- --- X --- 50 --- --- X X 50Ə 50 ------ --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

1000 1000 1000 1000 --- 2000 2000 1500 2000 1000 --- 1250 --- --- 1000 2000 1000 1750 1250 1000 1250 1000 --- --- 1000 --- 1500 --- --- 1000 1000 1500 1000 ------ --- 50 --- --- --- 50 50 50 --- --- --- --- --- --- --- --- --- 50 --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---


Página 10

















CATEGORIA II












DA13 DA14 DA16 DA18 DA20 DA22 DA24 DA25 DA26 DA27 DA28 DA33 DA38 DA40 DA43 DA45 DA46 DA47 DA49 DA50 DA51 DA52 DA53 DA54 DA55 DA56 DA59 DA61 DA63 DA65 DA66 DA68 DA71 DA721750Ü

X X X X X X X X X X X X X X X X 30 X X X X X X X X X X X X X X X X XX X X X X X X X X X X X X X X X 30 X X X X X X X X X X X X X X X X XX X X X X X X X X X X X X X X X 30 X X X X X X X X X X X X X X X X X--- X X X X X X X --- X X --- X X --- X 30 X X X X X X X X X X X --- X X X X X

X X X X X X X X X X X --- X X X X 30 10 X X X X X X X X X X X X X X X XX X X X X X X X X X X X Þ X X X X 30 10 X X X X X X X X X X X X X X X XX X X X X X X X X X X --- X X X X --- 10 X X X X X X X X X X X --- X X X X--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---X X X X X X X X X X X X X X X X 30 10 X X X X X X X X X X X X X X X X--- --- --- --- --- --- --- --- --- --- --- --- --- X --- --- 30 --- --- --- --- --- --- --- --- --- --- --- --- X --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---X X X X X X X X X X X --- X X X X 30 10 X X X X X X X X X X X X X X X X--- --- --- --- --- --- --- --- --- --- --- --- --- X Ð --- --- 30 Ð --- --- --- --- --- --- --- --- --- --- --- --- X Ð --- --- --- ---

--- --- --- --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---X X X X X X X X X X X --- X X X X --- X X X X X X X X X X X X --- X X X X--- --- --- --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---X X X X X X X X X X X 30 X X X X 30 X X X X X X X X X X X X X X X X X

X X X X X X X X X X X X X X X X 30 X X X X X X X X X X X X X X X X XX X X X X X X X X X X X X X X X 30 X X X X X X X X X X X X X X X X X

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

X X X X X X X X X X X --- X X X X 30 X X X X X X X --- X X X X X --- X X X

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

X X 25 X X X X 20 X X X 30 X X X X 30 10 X X X X X X X X X X X X X 20 X 30

X X 25 X X X X 20 X X 20 30 X 20 X X 30 10 X X X X X X X X X X X X X 20 X 30

X 30 25 30 30 30 30 20 30 30 20 30 30 20 30 30 30 10 30 30 30 30 30 30 30 30 30 X 30 X 30 20 30 30

X 30 25 30 30 30 30 20 30 30 20 30 30 20 30 30 30 10 30 30 30 30 30 30 30 30 30 X 30 X 30 20 30 30

--- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

--- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

--- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

--- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

X X 25 X X X X 20 X X X --- X 20 X X --- 10 X X X X X X X X X X X --- X 20 X 30

X X 25 X X X X 20 X X X --- X 20 X X 30 10 X X X X X X X X X X X X X 20 X 30


Página 11












D2951 Perno (Pin)





ENDODONCIA



D3220 Pulpotomía












PERIODONCIA BÁSICA
















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X X 25 X X X X 20 X X X 30 X 20 X X 30 10 X X X X X X X X X X X X X 20 X 30

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X X 25 X X X X 20 X X X 30 X 20 X X 30 10 X X X X X X X X X X X X X 20 X 30

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--- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- 50 --- --- --- --- --- --- --- --- --- --- --- --- 50 --- --- --- ---



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Página 12







CIRUGIA ORAL

Extracciones






CATEGORIA III

































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X X X X X X X 50 X X 20 30 X 20 X X 30 10 X X X X X X X X X X X 30 X X X 30

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Página 13














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Página 14


















--- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ 50 50 --- 50 50 50 50 50 50 50 --- 50 40 --- 50 50 50 50 50 50 30 50 50 50 50 50 40 --- 50 50 50 50 50 --- --- --- --- --- --- --- --- --- --- --- --- --- 40 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ 50 50 --- 50 50 50 50 50 50 50 --- 50 40 --- 50 50 50 50 50 50 30 50 50 50 50 50 40 --- 50 50 50 50 50

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X 20 30 30 30 20 30 50 30 X 20 30 30 20 30 25 50 20 30 30 30 30 30 30 X 30 30 X 30 50 X 20 30 30--- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- 30 --- --- --- --- --- --- --- --- --- --- --- --- 30 --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- 30 --- --- --- --- --- --- --- --- --- --- --- --- 30 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ 20 30 --- 30 20 30 50 --- X 20 --- 30 20 --- --- 30 20 30 30 30 --- 30 30 X 30 30 X --- 30 30 20 30 30--- 20 30 --- 30 20 30 50 --- X 20 --- 30 20 --- --- 30 20 30 30 30 --- 30 30 X 30 --- X --- 30 30 20 30 30--- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- 30 --- --- --- --- --- --- --- --- --- --- --- --- 30 --- --- --- ---X 20 30 30 30 20 30 50 30 X 20 --- 30 20 30 25 30 20 30 30 30 30 30 30 X 30 --- X 30 30 30 20 30 30--- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- 30 --- --- --- --- --- --- --- --- --- --- --- --- 30 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ 50 50 --- 50 50 50 50 50 50 50 --- 50 20 --- 50 50 50 50 50 50 50 50 50 50 50 --- 40 --- 50 50 50 50 50--- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- 30 --- --- --- --- --- --- --- --- --- --- --- --- 30 --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- 20 --- --- 30 --- --- --- --- --- --- --- --- --- --- --- --- 30 --- --- --- ---X 20 30 30 30 20 30 50 30 X 20 --- 30 20 30 25 30 20 30 30 30 30 30 30 X 30 --- X 30 30 30 20 30 30X 20 30 30 30 20 30 50 30 X 20 30 30 20 30 25 30 20 30 30 30 30 30 30 X 30 --- X 30 30 30 20 30 30

--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 30 --- --- --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- X X X X X X --- X --- --- 30 X X --- X 30 X X X X X X X --- X X X --- X --- X X X --- --- --- --- --- --- --- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---X X X X X X X X X X X --- X X X X 30 X X X X X X X X X X X X X X X X XX X X X X X X X X X X 30 X X X X 30 X X X X X X X X X X X X X X X X XX X X X X X X X X X X 30 X X X X 30 X X X X X X X X X X X X X X X X X--- --- --- --- --- --- --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ 20 50 --- X 20 X X --- X X --- X 20 --- --- 30 X X X X --- X X X X X X --- X X X X X--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---X X X X X X X X X X X 30 X X X X 30 X X X X X X X X X X X X X X X X X--- 50© 50 --- X 50 50 50 --- 50* 50 --- X 50Ə --- --- X 50 X X X 50 W X X 50ΩƏ X X X --- X X 50 * X 50--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ 1500 3000 --- 1000 1500 1000 1000 --- 1000 2000 --- 1250 1750 --- --- 1000 1100 1500 1500 1000 2000 1500 1500 3000 1000 1000 1000 --- 1000 1000 1000 1500 1000--- --- --- --- --- --- --- --- --- 50 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 50 --- --- ---


Página 15

















CATEGORIA II












DA73 DA78 DA80 DA81 DA82 DA84 DA85 DA86 DA87 DA88 DA89 DA90 DA91 DA92 DA93 DA94 DA95 DA96 DA97 DA98 DA99 DB01 DB02 DB03 DB04 DB06 DB10 DB12 DB13 DB14 DB15 DB16 DB17 DB181500 1500 1000 1500 1000 1000 1000Ñ Ñ æ U Ñ Ø Ø M

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Página 16












D2951 Perno (Pin)





ENDODONCIA



D3220 Pulpotomía












PERIODONCIA BÁSICA
















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Página 17







CIRUGIA ORAL

Extracciones






CATEGORIA III

































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

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

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@ 800

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Página 18














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Página 19


















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

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Página 20

















CATEGORIA II












DB19 DB20 DB21 DB22 DB23 DB24 DB25 DB26 DB27 DB28 DB29 DB30 DB31 DB32 DB33 DB34 DB35 DB36 DB37 DB38 DB39 DB40 DB41 DB42 DB44 DB45 DB46 DB47 DB48 DB49 DB50 DB51 DB52 DB531000 1000 1000 1000 1200 1200 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000¶ Æ Æ Æ B B & Æ ¶ Æ U § ¶ ¶ ¶ ¶

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Página 21












D2951 Perno (Pin)





ENDODONCIA



D3220 Pulpotomía












PERIODONCIA BÁSICA
















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Página 22







CIRUGIA ORAL

Extracciones






CATEGORIA III

































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§1000 1000 1000 1000 1000 1000 1000 1000 1200 1200 1000 1000 --- 1000 1000 --- --- 1000 1000 1000 --- 1000 --- --- --- 1000 800 --- 1000 1000 1000 1000 1000 1000--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

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Página 23














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50 --- --- 57 50 50 50 50 --- --- 40 50 --- --- 50 50 50 50 50 30--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---


Página 24


















--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---50 50 50 50 50 50 50 50 50 50 50 50 --- 50 50 --- --- 50 50 50 50 50 --- --- 40 50 --- --- 50 50 50 50 50 30 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---50 50 50 50 50 50 50 50 50 50 50 50 --- 50 50 --- --- 50 50 50 50 50 --- --- 40 50 --- --- 50 50 50 50 50 30

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

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

30 30 20 30 30 30 30 20 20 20 30 20 25 50 20 30 X 25 20 30 50 30 20 20 20 50 X X 30 20 30 30 30 30--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---30 30 20 30 30 30 30 20 20 20 30 --- 30 50 20 30 --- --- 20 30 50 30 --- 20 20 50 X --- 30 20 30 30 30 3030 30 20 30 30 30 30 20 20 20 30 --- --- 50 20 --- --- --- --- 30 50 30 --- --- 20 --- --- --- 30 20 --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---30 30 20 30 30 30 30 20 20 20 30 20 30 50 20 30 X 25 20 30 50 30 --- 20 20 50 X --- 30 20 30 30 30 30--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---50 50 50 50 50 50 50 50 50 50 50 50 --- 50 50 --- --- 50 50 50 50 50 --- --- 40 50 --- --- 50 50 50 50 50 30--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 30 30 30 30--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ------ --- --- --- --- --- --- 20 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- 30 30 30 30--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---30 30 20 30 30 30 30 20 20 20 30 20 30 50 20 30 X 25 20 30 50 30 --- 20 20 50 X --- 30 20 30 30 30 3030 30 20 30 30 30 30 20 20 20 30 20 30 50 20 30 X 25 20 30 50 30 20 20 20 50 X X 30 20 30 30 30 30

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Página 25

















CATEGORIA II












DB54 DB55 DB56 DB57 DB58 DB59 DB60 DB61 DB62 DB63 DB64 DB65 DB66 DB67 DB68 DB69 DB70 DB71 DB72 DB73 DB74 DB76 DB77 DB78 DB87 DB88 DB89 DB90 DB91 DB92 DB93 DB94 DB95 DB961000 750 1000 1000 1000 1000 1000 1500 1000 750 750 1000 1000 500 1300 1000 1000ê ĳ U ê M M M Ñ Ψ ĳ ĳ Æ ê Қ C ¶

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Página 26












D2951 Perno (Pin)





ENDODONCIA



D3220 Pulpotomía












PERIODONCIA BÁSICA
















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

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

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



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


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X X X 30 30 X X X 50 50 50 X X 20 X 50 --- 30 X X X X X X X X X X X X 40 X 40 50


X X X 30 30 X X X 50 50 50 X X 20 X 50 40 30 X X X X X X X X X X X X 40 X 40 50

--- --- --- 30 30 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

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Página 27







CIRUGIA ORAL

Extracciones






CATEGORIA III

































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

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@ @ @ 1000 @ @ 1000 1000

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Página 28














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Página 29


















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Página 30

















CATEGORIA II












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Página 31












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ENDODONCIA



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PERIODONCIA BÁSICA
















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Página 32







CIRUGIA ORAL

Extracciones






CATEGORIA III

































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Página 33














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--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---X X --- --- --- --- --- --- 20 --- X --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---X X --- --- --- --- --- --- --- --- X --- X --- --- --- --- 30 --- --- X X 20 XX X X X --- --- X --- 20 X X 25 X 20 30 20 20 30 20 20 X X 20 XX X X X X X X --- 20 X X 25 X 20 30 20 20 30 20 20 X X 20 X--- --- --- --- --- --- --- --- 20 --- X --- 50 Ξ --- --- --- 20 Ξ --- --- 20 Ξ 20 Ξ --- 20 ---X X --- --- --- --- --- --- 20 --- X --- 50 --- --- --- 20 30 --- 20 X X 20 X--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---X X --- --- X X --- --- 20 X X 25 X 20 30 --- 20 30 20 20 X X 20 XX F X* X* --- --- X* --- --- --- X 30 ø 50* 50 --- 50* 50 X --- 50 X* --- --- ------ --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

1250 --- 800 800 --- --- 800 --- --- --- 1500 800 3000 1000 --- 1000 1000 1000 --- 1000 1000 --- --- ---50 --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---


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