|
Code |
Diagnostic |
Member
Pays
|
Code |
Fixed
Crown
and
Bridge
|
Member
Pays |
Code |
Removable
Prosthodontics
(Dentures,
Partials)
|
Member
Pays
|
|
D0120 |
Periodic
Oral
Exam
|
14 |
D2740 |
Crown,
porcelain (not including lab costs) |
595 |
D5110 |
Upper
Denture
|
679 |
|
D0140 |
Limited
Oral
evalution-problem
focused
|
21 |
D2750 |
Crown,
porcelain
fused
to
high
noble
met (not including lab costs)
|
630 |
D5120 |
Lower
Denture
|
679 |
| D0150 |
Comprehensive
Oral
Exam |
14 |
D2751 |
Crown,
porcelain
fused
to
base
metal (not including lab costs)
|
546 |
D5130 |
Immediate
upper
denture
|
735 |
| D0460 |
Pulp
vitality
test
|
21 |
D2752 |
Crown,
porcelain
fused
to
noble
metal (not including lab costs)
|
560 |
D5211 |
Acrylic
upper
partial
with
2
clasps
|
588 |
| D0470 |
Diagnostic
cast
|
42 |
D2790 |
Full
cast
crown,
high
noble
metal (not including lab costs)
|
616 |
D5212 |
Acrylic
lower
partial
with
2
clasps
|
560 |
| D0999 |
Diagnosis/treatment
plan
presentation
|
0 |
D2791 |
Full
cast
crown,
base
metal (not including lab costs)
|
532 |
D5213 |
Base
cast
metal
upper
part.
With
2 clasp
acrylic
saddles
|
686 |
| |
X-Rays |
|
D2792
D2930 |
Full
cast
crown,
noble
metal (not including lab costs)
Prefab, stainless
steel
crown,
primary
|
560
|
D5124 |
Base
cast
metal
lower
part.
With
2 clasp
acrylic
saddles
|
686 |
| D0210 |
Intraoral
complete
series,
once
per
3
yrs.
|
42 |
D2931 |
Prefab, stainless
steel
crown,
primary
|
98 |
D5410 |
Adjust
compl.
upper
denture
after
3
adjustments
per
adjust.
|
28 |
| D0220 |
Periapical
first
film
|
10 |
D2932
|
Prefabricated
Resin
Crown |
84 |
D5411 |
Adjust
complete
lower
denture
after
3
adj./adjustment
|
28 |
| D0230 |
Periapical
each
additional
film
|
7 |
D2940 |
Sedative
filling
|
35 |
D5421 |
Adjust
complete
upper
denture
after
3
adjust
per
adjustment
|
28 |
| D0270 |
Bitewing
-
single
film,
once
per
year
|
10 |
D2950 |
Core
buildup,
including
any
pins
|
105 |
D5422 |
Adjust
complete
lower
denture
after
3
adjust
per
adjustment
|
28 |
| D0272 |
Bitewing
-
two
films,
once
per
year
|
17 |
D2951 |
Pin
retention,
per
tooth,
in
addition
to
restore
at.
|
28 |
D5510 |
Repair
broken
complete
denture
base
|
45 |
| D0272 |
Bitewing
-
two
films,
once
per
year
|
12 |
D2952 |
Cast
post
core,
in
addition
to
crown
|
161 |
D5520 |
Replace
missing/broken
tooth
on
compl.dent.1
tooth
|
50 |
| D0274 |
Bitewing
-
four
films,
once
per
year
|
21 |
D2954 |
Prefabricated
post
core,
in
addition
to
crown
|
140 |
D5630 |
Repair
or
replace
broken
clasp
|
45 |
| D0274 |
Bitewing
-
four
films,
once
per
year
|
14 |
D2970 |
Temporary
crown
|
105 |
D5640 |
Replace
broken
tooth
on
partial
denture
1
tooth
|
63 |
| D0330 |
Panoramic
film,
once
per
3
years
|
49 |
D6210
D6211
D6212
|
Pontic,
full
cast,
high
noble
metal
Pontic,
full
cast,
base
metal
Pontic,
full
cast
noble
metal
|
595
525
560 |
D5650
D5660
D5730
D5731
|
Add
tooth
to
existing
partial
Add
clasp
to
existing
partial
Reline
upper
complete,
chairside
Reline
lower
complete,
chairside
|
81
98
84
84
|
| |
Preventive |
|
D6240 |
Pontic,
porcelain
to
high
noble
metal
|
630 |
D5740 |
Reline
upper
partial
chairside
|
98 |
| D1110 |
Routine
Adult
Prophylaxis,
1
per
year
|
0 |
D6241 |
Pontic,
porcelain
to
base
metal
|
546 |
D5741 |
Reline
lower
partial,
chairside
|
98 |
| D1110 |
Routine
Adult
Prophylaxis,
each
additional
|
35 |
D6242 |
Pontic,
porcelain
to
noble
metal
|
560 |
D5750 |
Reline
upper
complete,
laboratory
|
168 |
| D1120 |
Routine
child
prophylaxis,
1
per
year
|
0 |
D6750 |
Abutment,
porcelain
to
high
noble
metal
|
560 |
D5751 |
Reline
lower
complete,
laboratory
|
168 |
| D1120 |
Routine
child
prophylaxis,
each
additional
|
28 |
D6751 |
Abutment,
porcelain
to
base
metal
|
525 |
D5760 |
Reline
upper
partial,
laboratory
|
168 |
| D1203 |
Topical
application
of
fluoride,
child
|
12 |
D6752 |
Abutment,
porcelain
to
noble
metal
|
560 |
D5761 |
Reline
lower
partial,
laboratory
|
168 |
| D1330 |
Oral
hygiene
instruction |
0 |
D6790 |
Abutment,
full
cast,
high
noble
metal
|
546 |
D5850 |
Tissue
conditioning
(max)
|
49 |
| D1351 |
Sealant,
per
tooth,
permanent
posterior
|
14 |
D6791 |
Abutment,
full
cast,
base
metal
|
518 |
D5851 |
Tissue
conditioning
(mand) |
49 |
| D1510 |
Space
maintainer
-
fixed
unilateral
|
175 |
D6792 |
Abutment,
full
cast,
noble
metal
|
532 |
|
Oral
Surgery
(Extractions) |
|
| D1515 |
Space
maintainer
-
fixed
bilateral
|
217 |
D2910 |
Recement
inlay
|
28 |
D7140 |
Simple
extraction,
first
tooth
|
63 |
| D1525 |
Space
maintainer
-
removable
bilateral
|
245 |
D2920 |
Recement
crown
|
35 |
D7140 |
Simple
extraction
each
additional
tooth
per
treatment
plan
|
56 |
| |
Restorative
(fillings)
|
|
D6930 |
Recement
fixed
partial
denture
|
49 |
D7210 |
Surgical
extraction,
erpted
tooth
|
105 |
| D2140 |
Amalgam
-
1
surface,
Primary
Amalgam
-
1
surface,
Permanent |
42
49
|
|
Endodontics
(root
canals) |
|
D7220 |
Soft
tissue
impaction
|
140 |
| D2150 |
Amalgam
-
2
surface,
Primary
Amalgam
-
2
surface,
Permanent |
56
63 |
D3110 |
Pulp
cap,
direct,
excl.
final
restoration
|
28 |
D7230 |
Partial
bony
impaction
|
135 |
| D2160 |
Amalgam
-
3
surface,
Primary
Amalgam
-
3
surface,
Permanent |
70
77
|
D3120 |
Pulp
cap,
indirect,
excl.
final
restoration
|
28 |
D7240 |
Complete
bony
impaction
|
224 |
| D2161 |
Amalgam
-
4
surface,
Primary
Amalgam
-
4
surface,
Permanent |
84
98
|
D3220 |
Pulpotomy,
excluding
final
restoration
|
70 |
D7250 |
Surgical
extraction
of
residula
roots
|
98 |
| D2330 |
Resin
-
1
surface,
anterior
|
63 |
D3310 |
Root
canal,
one
canal
|
350 |
D7280 |
Surgical
exposure
of
impacted/unerup.
tooth
for
orth.
reas.
|
210 |
| D2331 |
Resin
-
2
surface,
anterior |
77 |
D3320 |
Root
canal,
two
canals |
378 |
D7310 |
Alveoloplasty
with
extraction,
per
quadrant
|
105 |
| D2332 |
Resin
-
3
surface,
anterior |
98 |
D3330 |
Root
canal,
three
canals |
560 |
D7320 |
Alveoloplasty
not
in
conjunction
with
extract.
Per
quadrant.
|
105 |
| D2335 |
Resin
-
4
or
more
or
involving
incisal
angle
,
anterior
|
120 |
D3410 |
Apicoectomy,
per
tooth,
anterior
|
350 |
D7471 |
Removal
of
exostosis
|
217 |
| D2391 |
Resin
-
1
surface,
posterior
|
70 |
|
Periodontics
(gum
treatment)
|
|
D7510 |
Incision
and
drainage
of
abscess
,
introral
|
77 |
| D2392 |
Resin
-
2
surface,
posterior |
112 |
D4210 |
Gingivectomy
or
gingivoplasty,
4
per
quadrant
|
245 |
D7960 |
Frenectomy,
seperate
procedure
|
175 |
| D2393 |
Resin
-
3
surface,
posterior |
140 |
D4211 |
Gingivec.
or
gingivopl.
3
per
quad,
per
tooth
|
42 |
D7970 |
Exision
of
hyperplastic
tissue,
per
arch
|
126 |
| D2394 |
Resin
-
4
or
more
or
involving
incisal
angle,
posterior
|
168 |
D4240 |
Gingival
flap
proced.
incl.
root
pl.
per
quadrant
|
280 |
|
Adjunctive
General
Services
|
|
| |
|
|
D4241 |
Gingival
flap
proced.
incl.
root
pl.
3
teeth,
per
quad,
per
tooth
|
49 |
D9110 |
Palliative
(emergency)
treatment
dental
pain
|
35 |
| |
|
|
D4260 |
Osseous
surgery,
4+
teeth
per
quad
|
630 |
D9230 |
Analgesia,
per
visit
|
21 |
| |
|
|
D4261 |
Osseous
surgery,
up
to
3
teeth
per
quad
per
tooth
|
105 |
D9430 |
Office
visit,
normal
hours
|
0 |
| |
|
|
D4271 |
Free
soft
tissue
graft,
per
procedure
|
420 |
D9440 |
Office
visit,
after
hours
|
70 |
| |
|
|
D4341 |
Periodontal
scaling
&
root
plan,
p.quad,
p.quad,
4
teeth
|
105 |
D9630 |
Other
drugs
or
medicaments
by
report
|
14 |
| |
|
|
D4342 |
Periodontal
scal.
&
root
plan.
3
t.p.quad.p.tooth
|
21 |
D9950 |
Occlusion
analusis
(mounted
case)
|
56 |
| |
|
|
D4910 |
Periodontal
maintenance
procedures
|
70 |
D9951 |
Occlusal
adjustment,
limited
|
56 |
| |
|
|
|
|
|
D9952 |
Occlusal
adjustment,
complete
|
140 |
| |
|
|
|
|
|
D9999 |
Broken
appt.
Less
than
24
hrs.
notice
per
15
minutes
unit.
(maximum
$40)
|
14 |