Tarifas Mínimas Sugeridas para Procedimientos Dentales para VITAL Administración de Seguros de Salud de Puerto Rico (ASES) 1 Códigos D0120 D0140 D0150 D0160 D0210 D0220 D0230 D0270 D0272 D0330 D1110

Descripción de Procedimientos Diagnósticos Periodic oral evaluation Limited oral evaluation - problem focused Comprehensive oral evaluation - new or established patient Detailed and extensive oral evaluation - problem focused, by report Intraoral-complete series (radiographic image) Intraoral-periapical-first radiographic image Intraoral-periapical-each additional radiographic image Bitewing-single radiographic image Bitewings-two radiographic images Panoramic radiographic image Preventivos Dental prophylaxis adult

Tarifas Mínimas Sugeridas $14.28 $19.17 $22.58 $35.65 $44.76 $7.57 $7.60 $7.56 $13.35 $27.51 $25.85

1

De acuerdo con la evaluación económica del Dr. Heriberto A. Marín Centeno, asesor económico del CCDPR, el tarifario propuesto por ASES para VITAL implica un aumento en la tarifa dental promedio ponderada de 37.8% comparado con la tarifa promedio ponderada pagada en mi MI SALUD del 2015 al 2017. Este aumento equivale a su vez a un incremento potencial aproximado de $25.6 millones anuales en la facturación total por procedimientos dentales comparado con MI SALUD. Finalmente, el Dr. Marín estima que el tarifario dental propuesto para VITAL equivale en promedio al 50.5% del tarifario comercial que debería prevalecer en Puerto Rico según lo calculado por el Milliman Dental Cost Guideline.

1

D1120 D1206 D1208 D1351 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2391 D2930 D2940 D3120 D3220 D3221 D3310 D3320

Dental prophylaxis child Topical application of fluoride varnish Topical application of fluoride Dental sealant per tooth Restaurativos Amalgam - one surface, primary or permanent Amalgam - two surfaces, primary or permanent Amalgam - three surfaces, primary or permanent Amalgam - four or more surfaces, primary or permanent Resin-based composite - one surface, anterior Resin-based composite - two surfaces, anterior Resin-based composite - three surfaces, anterior Resin-based composite - four or more surfaces or involving incisal angle (anterior) Resin-based composite - one surface, posterior Prefabricated stainless steel crown - primary tooth Protective restoration Endodoncia Pulp cap - indirect (excluding final restoration) Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament Pulpal debridement, primary and permanent teeth Endodontic therapy, anterior tooth (excluding final restoration) Endodontic therapy, bicuspid tooth (excluding final restoration)

$18.40 $13.58 $13.58 $14.88 $34.67 $42.68 $50.92 $60.10 $39.93 $49.07 $58.81 $70.38 $43.74 $58.33 $31.25 $18.80 $48.85 $24.15 $136.90 $149.53

2

D7140 D7210 D7220 D7230 D7240 D7250 D7510 D9110 D9410 D9420 D9930 D9223 D9243

Oral & Maxilofacial Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated Removal of impacted tooth - soft tissue Removal of impacted tooth - partially bony Removal of impacted tooth - completely bony Removal of residual tooth roots (cutting procedure) Incision and drainage of abscess - intraoral soft tissue Servicios Generales Adjuntivos Palliative (emergency) treatment of dental pain - minor procedure House/extended care facility call Hospital or ambulatory surgical center call Treatment of complications (post-surgical) - unusual circumstances, by report Deep sedation/general anesthesia - each 15 minute increment Intravenous moderate (conscious) sedation/analgesia - each 15 minute increment

$39.28 $70.10 $112.15 $138.25 $159.81 $49.76 $22.41 $23.90 $37.72 $206.43 $18.42 $173.95 $79.49

3