PATIENT ENCOUNTER FORM – Empire’s Dental Care Network Fax number: 1-866-516-5616 Mail to: Empire Dental Care P.O. Box 852 Minneapolis, MN 55440-0852 Please Print and Fill in All the Blanks That Apply- AN INDIVIDUAL FORM MUST BE COMPLETED FOR EACH DATE OF SERVICE Service Date Group # Center # Dentist License # Patient Name Subscriber Identification Number First Last ADA Code Service Subscriber Name (if different than patient name) First Proc Compl Tooth No. Surf. ADA Code Service Proc Compl Last Tooth No Surf. Service ADA Cod DIAGNOSTIC CROWNS-SINGLE RESTORATIONS PROSTHODONTICS(REMOVABLE) 0120 2710 Crown resin, lab proc. 5110 Complete denture-maxillary Complete denture-mandibular Periodic oral exam/eval 0140 Limited oral exam/eval 2712 Crown – ¾ resin based 5120 0150 Comprehensive oral eval 2720 Crown resin/high noble metal 5130 Immediate denture-maxillary Crown resin/pred base metal 5140 Immediate denture-mandibular Maxillary denture-resin base 0160 Detailed & extensive eval 2721 0170 Re-eval - limit, prob focused 2722 Crown resin/noble metal 5211 0210 Intraoral-FMX (incl BW's) 2740 Crown porc/ceramic substr 5212 Mandibular denture-resin base Crown porc/fused high noble 5213 Max partial dent cast metal Mand partial dent cast metal 0220 Intraoral-periapical-first film 2750 0230 Intraoral-periapical-additional 2751 Crown porc/fused base metal 5214 0240 Intraoral-occlusal film 2752 Crown porc/fused noble metal 5225 Max partial dent - flexible 5226 Mand. partial dent - flexible 0270 Bitewings-single film 0272 Bitewings-two films 0274 Bitewings-four films 0330 Panoramic film OTHER RESTORATIVE SERVICES 2920 Re-cement crown 2930 Crown prefab SSC – prim 2931 Crown prefab SSC – perm 2932 Crown prefab resin 2933 Crown prefab SSC/resin window 2934 Crown prefab SSC/ coated 2940 Sedative filling 2950 Core build-up, include any pins AMALGAM RESTORATIONS 2951 Pin retention – per tooth 2140 Amalgam-(1) surface 2952 Post & core 2150 Amalgam-(2) surface 2953 Each addl. post –same tooth. 2160 Amalgam-(3) surface 2954 Prefabricated post & core 2161 Amalgam-(4+) surface 2957 Addl prefab post same tooth PREVENTIVE SERVICES 1110 Prophylaxis-adult 1120 Prophylaxis-child 1208 1351 Topical appl fluoride Sealant-per tooth 6205 Pontic – indirect resin based 6210 Pontic-cast high noble metal 6211 Pontic-cast pred base metal 6212 Pontic-cast noble metal 6240 Pontic-porc. pred base metal 6242 Pontic-porc. noble metal 6245 Pontic-porcelain/ceramic 6250 Pontic-resin - high noble metal 6251 Pontic-resin -pred base metal 6252 Pontic-resin - noble metal 6740 Crown-porc. ceramic 6750 Crown-porc high noble 6751 Crown-porc pred base metal ENDODONTIICS 2330 Resin-(1) surface-anterior 6752 Crown-porc noble metal 3110 Pulp cap-direct 2331 Resin-(2) surface- anterior 6790 Crown-full cast high noble 3120 Pulp cap-indirect 2332 Resin-(3) surface- anterior 6791 Crown-full cast base metal 3220 Therapeutic pulpotomy, 2335 Resin-(4) surface -incisal angle 6792 Crown-full cast noble metal 3221 Gross pulpal debridement, 2391 Resin-(1) surface- posterior 3230 Pulpal therapy-ant, primary 2392 Resin-(2) surface -posterior 3240 Pulpal therapy-post, primary 2393 Resin-(3+) surface -posterior 3310 RCT anterior- permanent 2394 Resin-(4) surface- posterior 3320 RCT bicuspid- permanent 3330 RCT molar- permanent PERIODONTICS 4210 Gingivectomy/gingplsty (4+ T) 4211 Gingivectomy/gingplsty (1-3 T) 4341 Perio SRP- per quad (4+teeth) 4342 Perio SRP per quad (1-3 T) 4355 Full mouth debridement 4910 Perio maintenance proc. Tooth No PROSTHODONTICS,FIXED RESIN RESTORATIONS ADDITIONAL PROCEDURES Proc Compl ORAL SURGERY 7111 Coronal remnants, primary 7140 Extraction, erupted or exp. 7210 Surg. removal - erupted tooth 7220 Impacted tooth-soft tissue ADJUNCTIVE GENERAL SERVICES 9110 Palliative (emergency) txt 9951 Occlusal adjust-limited Services provided by Empire HealthChoice Assurance, Inc., a licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Surf.
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