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0110 Initial Oral Examination
........................................
0120 Periodic Oral Examination ...................................
0130 Emergency Oral Examination .............................
0210 X-Rays, 16-19 Films, Inc. Bw ..............................
0220 X-Ray, Single Intraoral, Pa ..................................
0222 X-Ray, Intraoral 2 Films .......................................
0223 X-Ray, Intraoral 3 Films .......................................
0224 X-Ray, Intraoral 4 Films .......................................
0225 X-Ray, Intraoral 5 Films .......................................
0226 X-Ray, Intraoral 6 Films .......................................
0227 X-Ray, Intraoral 7 Films .......................................
0228 X-Ray, Intraoral 8 Films .......................................
0229 X-Ray, Intraoral 9 Films .......................................
0230 X-Ray, Intraoral Pa, Ea. Add. Film .......................
0231 X-Ray, Intraoral 10 Films .....................................
0240 X-Ray, Intraoral Occlusal Films ..........................
0250 X-Ray, Intraoral, Single First Film ........................
0260 X-Ray, Intraoral, Ea. Add. Film ............................
0270 X-Ray, Bitewing, Single Film ...............................
0272 X-Ray, Bitewing, Two Films.................................
0273 X-Ray, Bitewing, Three Films ..............................
0274 X-Ray, Bitewing, Four Films ................................
0290 X-Ray, Survey Film, Face and Skull ....................
0310 X-Ray, Sialography
..............................................
0321 X-Ray, Temporomandibular Joint Film ................
0330 X-Ray, Panoramic ...............................................
0340 X-Ray, Cephalometric .........................................
0410 Exam, Culture for Pathogenic Agents .................
0420 Exam. Caries Susceptibility Tests ......................
0450 Histopathologic Examination ...............................
0460 Pulp Vitality Test ..................................................
0470 Diagnostic Study Models .....................................
0471 Diagnostic Photographs ......................................
1110 Prophylaxis, Adult ................................................
1120 Prophylaxis, Child Under 12 ................................
1210 Sod. Fluor. applic 4 Treat, Excl.Prophy ...............
1211 Sod. Fluor. Applic 4 Treat,Include Prophy............
1220 Stan. Fluor. Treatment Excl. Prophy ...................
1221 Stan. Fluor. Treatment Inc. Prophy .....................
1230 Acid Fluor. Treatment Excl. Prophy ....................
1231 Acid Fluor. Treatment Inc. Prophy .......................
1310 Dietary Planning ..................................................
1330 Oral Hygiene Instruction.......................................
1340 Preventive Dental Care Training .........................
1350 Topical Application of Sealants, Per Quad...........
1510 Space Maintainer, Fixed Unilateral ......................
1515 Space Maintainer, Fixed Bilateral ........................
1520 Space Maintainer, Removable Unilateral ............
1525 Space Maintainer, Removable Bilateral ..............
1540 Additional Charges and/or Activat. Wires ............
1550 Recementation of Space Maintainer ...................
2110 Amalgam, 1 Surface Deciduous .........................
2120 Amalgam, 2 Surface Deciduous .........................
2130 Amalgam, 3 Surface Deciduous .........................
2131 Amalgam, 4 or More Surface Deciduous ............
2140 Amalgam, 1 Surface Permanent .........................
2150 Amalgam, 2 Surface Permanent .........................
2160 Amalgam, 3 Surface Permanent .........................
2161 Amalgam, 4 or More Surfaces, Permanent ........
2190 Reinforcement Pin, Each ....................................
2210 Silicate Cement, Per Restoration ........................
2330 Composite Resin 1 Surface, Class 3 or 5 ..........
2331 Composite Resin 2 Surfaces, Class 3 or 5 ........
2332 Composite Resin 3 Surfaces, Class 3 or 5 ........
2334 Reinforcement Pin, Each ....................................
2335 Composite Resin, Class 4 ..................................
2340 Acid Etch for Restorations ..................................
2410 Gold Foil Restoration, 1 Surface .........................
2420 Gold Foil Restoration, 2 Surfaces/Tooth .............
2430 Gold Foil Restoration, 3+ Surfaces .....................
2510 Gold Inlay, 1 Surface ...........................................
2520 Gold Inlay, 2 Surfaces Per Tooth ........................
2530 Gold Inlay, 3 or More Surfaces/Tooth ..................
2540 Gold Inlay, Per Tooth ...........................................
2610 Porcelain Inlay, 1 Surface ....................................
2710 Crown, Lab Processed Acrylic ............................
2711 Crown, Prefabricated Plastic...............................
2720 Crown, Acrylic Fused to Gold ..............................
2721 Crown, Acrylic Fused to Metal .............................
2722 Crown, Acrylic Fused to Semi-Prec. Metal .........
2740 Crown, Porcelain Jacket .....................................
2750 Crown, Porcelain Fused to Gold .........................
2751 Crown, Porcelain Fused to Non-Prec. Metal .......
2752 Crown, Porcelain Fused to Semi-Prec.Metal.......
2790 Crown, Full Cast Gold .........................................
2791 Crown, Full Cast Non-Precious Metal .................
2792 Crown, Full Cast Semi-Precious Metal ...............
2810 Crown, 3/4 Cast Gold ..........................................
2830 Crown, Stainless Steel ........................................
2840 Crown, Temporary for Fractured Tooth ..............
2891 Cast Post and Core In Addition to Crown ...........
2892 Preformed Post and Core Build-Up ....................
2910 Recement Inlays ..................................................
2920 Recement Crown or Each Abutment ..................
2940 Sedative Filling as Palliative Treat .......................
2950 Crown Build-Up, Pin Retained .............................
3110 Pulp Cap, Direct ..................................................
3120 Pulp Cap, Indirect ................................................
3220 Vital Pulpotomy ....................................................
3310 Root Canal, Anterior ............................................
3320 Root Canal, Bicuspid ...........................................
3330 Root Canal, Molar ................................................
3350 Apexification (Apical Closure) ..............................
3410 Apicoectomy, Separate Surgical Procedure .......
3420 Apicoectomy, In Conjunction W/Endo .................
3430 Retrograde Filling ................................................
3440 Apical Curettage ..................................................
3450 Root Resection/Amputation ................................
3460 Endodontic Implants ............................................
3910 Isolate Tooth for Rubber Dam .............................
3920 Hemisection .........................................................
3940 Recalcification of Perforations ............................
3950 Canal Prep and Fitting Dowel or Post .................
3960 Bleaching of Dead/Discolored Tooth ..................
4210 Gingivectomy or Gingivoplasty Per Quad ...........
4212 Gingivectomy 1 Tooth ..........................................
4220 Gingival Curettage Per Quadrant ........................
4230 Distal Wedge Procedure .....................................
4240 Gingival Flap Procedure Per Quadrant ...............
4250 Mucogingival Surgery Per Quadrant ...................
4260 Osseous Surgery Per Quadrant Inc. Ging ..........
4261 Osseous Graft, Single Site ..................................
4262 Osseous Grafts, Multiple Sites ............................
4265 Edentulous Area Surgery, No Other Surg ...........
4270 Pedicle Soft Tissue Graphs ................................
4271 Free Soft Tissue Grafts (Inc. Donor Site) ...........
4272 Vestibuloplasty, Per Arch ....................................
4280 Periodontal Pulpal Procedures ............................
4320 Provisional Splinting, Intracoronal/Quad .............
4321 Provisional Splinting, Extracoronal/Quad ............
4330 Occlusal Adjustment, Per Quad 4/Series ...........
4331 Occlusal Adjustment, Full Mouth 1/Series ..........
4340 Periodontal Scaling/Root Planning,FM ................
4341 Periodontal Scaling/Root Planning, Quad ...........
4350 Tooth Movement For Periodontal Purposes .......
4360 Special Periodontal Appliances............................
4370 Case Pattern Modifiers ........................................
4380 Re-evaluation of Perio Therapy ...........................
4500 Gingivitis, Type 1 .................................................
4600 Early Periodontitis, Type 2 ...................................
4700 Moderate Periodontitis, Type 3 ............................
4800 Advanced Periodontitis, Type 4 ...........................
4910 Periodontal Preventive Procedures .....................
4920 Unscheduled Perio Dressing Change .................
5110 Complete Upper Denture ....................................
5120 Complete Lower Denture ....................................
5130 Immediate Complete Upper Denture NB/Temp ..
5140 Immediate Complete Lower Denture NB/Temp ..
5211 Partial Upper Denture W/O Clasps Acrylic .........
5212 Partial Lower Denture W/O Clasps Acrylic .........
5215 Part. Upper Dent. 2 Gold Clasps/Rests ..............
5216 Part. Upper Dent. 2 Chrm Clasps/Rests ............
5217 Part. Lower Dent. 2 Gold Clasps/Rests ..............
5218 Part. Lower Dent. 2 Chrm Clasps/Rests ............
5230 Part. Lwr Dent. Gld Lingl Bar, 2 Clasps ..............
5231 Part. Lwr Dent. Chrm Lingl Bar, 2 Clasps ..........
5240 Part. Lwr Dent. Gld Lingl Bar, 2 Clasps ..............
5241 Part. Lwr Dent. Chrm Lingl Bar, 2 Clasps ..........
5250 Part. Upper Dent. Gld Pltl Bar, 2 Clasps .............
5251 Part. Upper Dent. Chrm Pltl Bar, 2 Clasps .........
5260 Part. Upper Dent. Gld Pltl Bar, 2 Clasps .............
5261 Part. Upper Dent. Chrm Pltl Bar, 2 Clasps .........
5280 Removable Unilateral Part. Dent. 1 Piece ...........
5281 Removable Unilateral Part. Dent. 1 Piece ...........
5291 Part Uppr Dent. Full Cast, 2 Gold Clasps ...........
5292 Part Uppr Dent. Full Cast, 2 Chrm Clasps .........
5293 Part Lwr Dent. Full Cast, 2 Gold Clasps .............
5294 Part Lwr Dent. Full Cast, 2 Chrm Clasps ...........
5310 Each Add. Partial Denture Clasp W/Rest............
5320 Each Additional Tooth ........................................
5410 Adjustment, Complete Denture ...........................
5421 Adjustment, Partial Upper Denture ......................
5422 Adjustment, Partial Lower Denture .....................
5610 Denture Repair, Complete or Partial ...................
5620 Dent. Repair, Comp. or Part./Rep. 1 Tooth ........
5630 Replace Additional Teeth, Per Tooth ...................
5640 Replace Broken Tooth on Denture ......................
5650 Add Tooth to Partial Denture ...............................
5660 Add Tooth to Part. In. Clsp or Abutment ..............
5670 Reattach Damaged Clasp on Denture ................
5680 Replace Broken Denture Clasp ..........................
5690 Each Clasp W/Rest added to Denture ...............
5710 Duplicate Upper or Lower Comp. Denture ..........
5720 Duplicate Upper Lower Part. Denture .................
5730 Off. Reline Uppr/Lwr Comp. Denture ..................
5740 Off. Reline Uppr/Lwr Part. Denture .....................
5750 Lab Reline Uppr/Lwr Comp. Denture ..................
5760 Lab Reline Uppr/Lwr Part. Denture .....................
5810 Temp. Complete Upper Denture .........................
5811 Temp. Complete Lower Denture .........................
5820 Temp. Denture, Partial Uppr Stayplate ...............
5821 Temp. Denture, Partial Lwr Stayplate .................
5830 Obturator for Surg. Ex Palatal Tissue .................
5840 Obturator Status Post Cleft Palate ......................
5850 Tissue Conditioning Per Denture ........................
5860 Overdenture, Complete .......................................
5861 Overdenture, Partial ............................................
5971* Simple Implant ...................................................
* Lifetime benefit for lower jaw,
removable full denture only.
6210 Pontic, Cast Gold ................................................
6211 Pontic, Cast Non-Precious Metal ........................
6212 Pontic, Cast Semi-Precious Metal.......................
6220 Pontic, Cast Gold, Slotted Facing .......................
6230 Pontic, Cast Gold, Slotted Pontic ........................
6235 Pontic, Cast Gold, Pin Facing .............................
6240 Pontic, Porcelain Fused to Gold ..........................
6241 Pontic, Prcln Fused to Non-Precious Metal ........
6242 Pontic, Prcln Fused to Semi-Precious Metal.......
6250 Pontic, Plastic Processed to Gold ......................
6251 Pontic, Plstc Proc. to Non-Precious Metal ..........
6252 Pontic, Plstc Proc. to Semi-Precious Metal ........
6520 Abutment, Two Surf. Gold Inlay ...........................
6530 Abutment, Three or More Surf. Gold Inlay ...........
6540 Abutment, Gold Inlay, Onlaying Cusps ................
6545 Cast Metal Retainer..............................................
6610 Replace Broken Pin Facing .................................
6620 Replace Broken Facing/Post Is Intact .................
6630 Replace Broken Facing/Post Back Broken .........
6640 Replace Broken Facing W/Acrylic ......................
6650 Replace Broken Pontic ........................................
6710 Crown, Lab Processed Plastic ...........................
6720 Crown, Plastic Processed to Gold ......................
6721 Crown, Plstc Proc. to Non-Precious Metal .........
6722 Crown, Plstc Proc. to Semi-Precious Metal .......
6740 Crown, Porcelain Jacket .....................................
6750 Crown, Porcelain Fused to Gold .........................
6751 Crown, Prcln Fused to Non-Precious Metal ........
6752 Crown, Prcln Fused to Semi-Precious Metal ......
6760 Crown, Reverse Pin Facing and Metal ................
6780 Crown, 3/4 Cast Gold ..........................................
6790 Crown, Full Cast Gold .........................................
6791 Crown, Full Cast Non-Precious Metal .................
6792 Crown, Full Cast Semi-Precious Metal ...............
6930 Recement Bridge ................................................
6940 Stress Breaker ....................................................
6950 Precision Attachments ........................................
7110 Routine Extraction, Single Tooth .........................
7120 Routine Extraction, Each Add. Tooth ..................
7210 Surgical Extract. Erupted Tooth ..........................
7220 Extract, Sft Tissue Impact. W/Tis. Inc ................
7230 Extract, Ptl Bony Impact. W/Bone Removal .......
7240 Extract, Impact, Tooth/Section of Tooth ..............
7241 Extract, Impact. Tooth-Unusual Difficulty ............
7250 Surg. Removal of Residual Root .........................
7260 Oral-Antral Fistula Closure ..................................
7270 Tooth Replantation ..............................................
7271 Tooth Implantation ...............................................
7272 Tooth Transplantation ..........................................
7280 Surg. Exp. Impctd/Unrptd Tooth (for Ortho) ........
7281 Surg. Exp. Impctd/Unrptd Tooth (Aid Erupt) ........
7285 Biopsy of Hard Oral Tissue .................................
7286 Biopsy of Soft Oral Tissue ..................................
7290 Surgical Repositioning of Teeth ..........................
7310 Alveoloplasty/Quad W/Extraction ........................
7320 Alveoloplasty/Quad No Extraction .......................
7340 Stomatoplasty, Per Arch, Uncomplicated ...........
7350 Stomatoplasty, Per Arch, Complicated ...............
7410 Radical Excision of Lesion Up to 1.25 Cm ..........
7420 Radical Excision of Lesion Over 1.5 Cm ............
7425 Excision of Pericoronal Gingiva ...........................
7430 Excision of Benign Tumor, Up to 1.25 Cm ..........
7431 Excision of Benign Tumor, Over 1.25 Cm ..........
7440 Excision of Malig. Tumor Up to 1.25 Cm .............
7441 Excision of Malig. Tumor Over 1.25 Cm .............
7450 Removal Odontogenic Cyst/Tumor to 1.25 ........
7451 Removal Odontogenic Cyst/Tumor Over 1.25 ...
7460 Rmvl Non-Odontogenic Cyst/Tumor to 1.25 .......
7461 Rmvl Non-Odontogenic Cyst/Tumor Over 1.25 ..
7465 Non-Surgical Destruction of Lesions ..................
7470 Excision of Exostosis, Maxilla/Mandible ..............
7480 Partial Ostectomy ................................................
7490 Radical Resection of Mandible W/Graft ..............
7510 Surgical Incision and Drainage, Intraoral .............
7520 Surgical Incision and Drainage, Extraoral ...........
7530 Surgical Incision, Removal Foreign Body ...........
7540 Removal Reaction Producing Foreign Body .......
7550 Sequestrectomy of Osteomyelitis .......................
7560 Maxillary Sinusotomy ...........................................
7610 Fracture, Simple Open Reduct. of Maxilla ..........
7620 Fracture, Simple Clsd Reduct. of Maxilla ............
7630 Fracture, Simple Open Reduct. of Mandible .......
7640 Fracture, Simple Clsd Reduct. of Mandible.........
7650 Fracture, Smpl-Open Reduct. Malar/Zygom .......
7660 Fracture, Smpl-Clsd Reduct. Malar/Zygom.........
7670 Fracture, Simple Open Stab. of Alveolus ............
7680 Fracture, Complex Reduct. Facial Bones............
7710 Fracture, Compound, Open Reduct-Maxilla .......
7720 Fracture, Compound, Clsd Reduct. Mandible .....
7730 Fracture, Cmpnd, Open Reduct. Mandible .........
7740 Fracture, Cmpnd, Closed Reduct. Mandible .......
7750 Fracture, Cmpnd, Open Reduct. Malar/Zygom ...
7760 Fracture, Cmpnd, Closed Reduct. Malar/Zygom.
7770 Fracture, Cmpnd, Open Stab. Alveolus ..............
7780 Fracture, Cmpnd, Complex Reduct Face Bones
7810 Open Reduction of Tm Joint Dislocation ............
7820 Closed Reduct. of Tm Joint Dislocation ..............
7830 Manipulation W/Anesthesia Tm Joint Dis ............
7840 Condylectomy ......................................................
7850 Meniscectomy .....................................................
7860 Arthrotomy ...........................................................
7870 Arthrocentesis .....................................................
7910 Suture of Small Wounds Up to 5 Cm ..................
7911 Complex Suturing Up to 5 CM .............................
7912 Complex Suturing Over 5 Cm .............................
7920 Skin Graft .............................................................
7930 Inject Trigeminal Nerve for Destruction ...............
7931 Avulsion of Trigenial Nerve Branches .................
7940 Osteoplasty for Orthognathic Deformities ..........
7950 Mandibular Grafts, Auto. or Non-Autogenous ......
7955 Repair of Maxillofacial Tissue Defects ................
7960 Frenulectomy, Separate Procedure ....................
7970 Excision of Hyperplastic Tissue/Arch ..................
7980 Sialolithotomy ......................................................
7981 Excision of Salivary Gland ...................................
7982 Sialodochoplasty .................................................
7983 Closure of Salivary Fistula ...................................
7990 Emergency Tracheotomy ....................................
8110 Removable Appliance Minor Tooth Guidance .....
8120 Fixed or Cemented Appliance Mnr Tooth Guid ...
8210 Removable Appliance for Habit Control ..............
8220 Fixed/Cemented Appliance for Habit Control ......
8360 Removable Appliance- Interceptive Ortho ...........
8370 Fixed Appliance for Interceptive Ortho ................
8460 Diag/Initial App. Class 1 Trans. Dent ..................
8470 Diag/Initial App. Class 2 Trans. Dent ..................
8480 Diag/Initial App. Class 3 Trans. Dent ..................
8560 Diag/Initial App. Class 1 Perm. Dent....................
8570 Diag/Initial App. Class 2 Perm. Dent....................
8580 Diag/Initial App. Class 3 Perm. Dent....................
8591 Ortho Active Tx/Month-Adj Visit ...........................
8592 Ortho Active Tx/Month-Adj Visit ...........................
8593 Ortho Active Tx/Month-Adj Visit ...........................
8650 Treat. Atyp. or Extend. Skeletal Case .................
8750 Orthodontic Post Treatment Stabilization ...........
9110 Palliative Treatment of Dental Pain .....................
9210 Anesthesia, Local ................................................
9211 Anesthesia, Regional Block .................................
9212 Anesthesia, Trigeminal Division Block ................
9220 Anesthesia, General ............................................
9230 Analgesia .............................................................
9310 Professional Consultation By Specialist .............
9410 Professional Visit, House Call .............................
9420 Professional Visit, Hospital Call ...........................
9430 Office Visit in Conjunction W/Treatment .............
9440 Office Visit in Conj. W/Treat. After Hours ............
9610 Therapeutic Drug Injection ..................................
9630 Other Drugs and/or Medicaments .......................
9910 Applic. Desensitizing Medicaments ....................
9920 Special Consultant Appointment .........................
9930 Complications, Post Surgical ..............................
9950 Occlusion Analysis, Mounted Case ....................
9960 Completion of Claim Form ..................................
9999 Unspecified ..........................................................
* NB-No Benefit
** IC-Individual Consideration
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$ 25.00
25.00
25.00
40.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
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10.00
1.00
11.00
5.00
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1.00
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4.00
5.00
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15.00
40.00
10.00
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25.00
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15.00
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5.00
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35.00
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55.00
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9.00
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75.00
90.00
120.00
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95.00
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150.00
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150.00
155.00
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250.00
250.00
220.00
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60.00
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5.00
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20.00
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20.00
150.00
195.00
300.00
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130.00
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42.00
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85.00
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300.00
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110.00
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165.00
165.00
165.00
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325.00
325.00
325.00
325.00
325.00
325.00
325.00
325.00
100.00
100.00
325.00
325.00
325.00
325.00
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NB*
15.00
10.00
10.00
30.00
45.00
20.00
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35.00
27.00
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80.00
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20.00
60.00
IC**
225.00
225.00
IC**
170.00
170.00
170.00
170.00
120.00
100.00
200.00
200.00
200.00
160.00
160.00
160.00
55.00
70.00
70.00
125.00
20.00
20.00
25.00
20.00
40.00
95.00
150.00
150.00
150.00
155.00
250.00
250.00
250.00
250.00
100.00
220.00
220.00
220.00
20.00
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35.00
35.00
50.00
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175.00
175.00
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70.00
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70.00
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50.00
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70.00
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65.00
35.00
45.00
35.00
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75.00
125.00
500.00
10.00
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120.00
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60.00
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400.00
400.00
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