-
9232 NE 1106
Two evaluations will be allowed in a Benefit Period. A D0120,
D0150,or D0180 counts toward this maximum allowance. D0150 and
D0180will be limited to once per provider.
Bitewing films are limited to 2 allowances in a Benefit Period.
An D0270,D0272, D0274, or D0277 counts toward this maximum
allowance. In addition, D0277 will be limited to once in a 3-year
period.*
Prophylaxis (cleaning) will be allowed twice in a Benefit
Period. A D1110or D1120 counts toward this maximum allowance.
Periodontalmaintenance may be substituted for a cleaning (see
requirementsunder Type I(B) section). Benefits will not be
available if performed onthe same date as periodontal services. An
adult prophylaxis isconsidered for individuals age 14 and over. A
child prophylaxis isconsidered for individuals age 13 and
under.
PERSONAL AND DEPENDENT DENTAL CARE INSURANCE
TABLE OF DENTAL PROCEDURESThe following list of dental
procedures for which benefits are payable under this section is
based upon the CurrentDental Terminology© American Dental
Association. No benefits are payable for a procedure that is not
listed.
For procedures which reference a Benefit Period, see the
Schedule of Benefits for the definition of Benefit Period.BR means
By Report. Any dollar amount is a Maximum Covered Expense. Please
read the sectionDENTAL EXPENSE BENEFITS and "Limitations" for
additional coverage information.
TYPE I(A) PROCEDURES - Preventive
PROC. MAXIMUMNO. COVERED EXPENSE
D0120 Periodic oral evaluation. $30.00D0150 Comprehensive oral
evaluation - new or established patient. 46.00D0180 Comprehensive
periodontal evaluation - new or established patient. 46.00
D0270 Bitewing, single film. 15.00D0272 Bitewings - two films.
27.00D0274 Bitewings - four films. 42.00D0277 Vertical bitewings -
7 to 8 films. 64.00
D1110 Prophylaxis - adult. 64.00D1120 Prophylaxis - child.
45.00
*The frequency is measured forward from the last covered date of
service for the procedure.
Current Dental Terminology© American Dental Association
-
D1203: Coverage for fluoride treatment is limited to persons
age18 and under and to one treatment in a Benefit Period.
D1510-1525: Coverage is limited to space maintenance for
uneruptedteeth, following extraction of primary teeth. Allowance
includes alladjustments within 6 months after installation.
D8210-8220: Coverage is limited to the correction of
thumb-sucking.
PROC. MAXIMUMNO. COVERED EXPENSE
D1203 Topical fluoride (reported as a separate code) in
$25.00
conjunction with prophylaxis - child.
D1510 Space maintainer - fixed - unilateral. 226.00D1515 Space
maintainer - fixed - bilateral. 370.00D1520 Space maintainer -
removable - unilateral. 354.00D1525 Space maintainer - removable -
bilateral. 432.00
D1550 Recement space maintainer. 46.00D8210 Removable appliance
therapy. 340.00D8220 Fixed appliance therapy. 340.00
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D0140 and D0170: Coverage is limited to accidental injury only.
If not due to an accident, will be considered as a D0120 and count
toward this maximum allowance.
D0210 or D0330: One of these procedures will be allowed in a
3-year period.*
D0472-0474: Coverage is limited to one examination per
biopsy/excision.
D1351: Coverage is limited to treatment of the occlusal surface
of permanent molar teeth once during a 3-year period for persons
age16 and under.*
D4355: Coverage is limited to once during a 5-year period.*
TYPE I(B) PROCEDURES - Basic
PROC. MAXIMUMNO. COVERED EXPENSE
MISCELLANEOUS PROCEDURES.
D0140 Limited oral evaluation - problem focused. $32.00D0170
Re-evaluation - limited, problem focused (established patient;
32.00
not post-operative visit).
D0210 Intraoral - complete series (including bitewings).
64.00D0330 Panoramic film. 51.00
D0220 Periapical radiograph - first film. 12.00D0230 Additional
periapical film, each. 9.00D0240 Intraoral, occlusal film.
16.00D0250 Extraoral, first film. 21.00D0260 Extraoral, each
additional film. 16.00D0472 Accession of tissue, gross examination,
preparation and 38.00
transmission of written report.D0473 Accession of tissue, gross
and microscopic examination, 75.00
preparation and transmission of written report.D0474 Accession
of tissue, gross and microscopic examination, including 75.00
assessment of surgical margins for presence of disease,
preparation and transmission of written report.
D1351 Sealant - per tooth. 23.00
D2910 Recement inlay. 43.00D2920 Recement crown. 42.00D6930
Recement fixed partial denture. 59.00D4355 Full mouth debridement
to enable comprehensive 67.00
evaluation and diagnosis.
*The frequency is measured forward from the last covered date of
service for the procedure.
-
D4910: This procedure is available in place of an eligible
routineprophylaxis (D1110-1120) as listed above. Coverage is
contingent uponevidence of full mouth active periodontal therapy
and limited to 2allowances in a Benefit Period (a D1110 or D1120
counts toward this maximum allowance). Benefits will not be
available if performed on thesame date as other periodontal
services.
D5730-5761: Coverage for relines is limited to service dates
more than 6 months after installation.
D9110: Not covered in conjunction with other procedures, except
diagnostic x-ray films.
D9310: Coverage is limited to one allowance per provider.
D9440: Payment will be made on basis of services rendered or
visit, whichever is greater.
D9951-9952: Coverage is limited to adjustment performed in
conjunction with treatment of periodontal disease.
PROC. MAXIMUMNO. COVERED EXPENSE
D4910 Periodontal maintenance. $68.00
D5510 Repair broken complete denture base. 68.00D5520 Replace
missing or broken teeth - complete denture (each tooth). 57.00D5610
Repair resin denture base - partial denture. 68.00D5620 Repair cast
framework - partial denture. 80.00D5630 Repair or replace broken
clasp - partial denture. 84.00D5640 Replace broken teeth (per
tooth) - partial denture. 60.00D5730 Reline complete maxillary
denture (chairside). 126.00D5731 Reline complete mandibular denture
(chairside). 125.00D5740 Reline maxillary partial denture
(chairside). 113.00D5741 Reline mandibular partial denture
(chairside). 113.00D5750 Reline complete maxillary denture
(laboratory). 187.00D5751 Reline complete mandibular denture
(laboratory). 184.00D5760 Reline maxillary partial denture
(laboratory). 187.00D5761 Reline mandibular partial denture
(laboratory). 188.00
D9110 Palliative (emergency) treatment of dental pain 45.00 -
minor procedure.
D9310 Consultation (diagnostic service provided by dentist or
46.00 physician other than practitioner providing treatment).
D9440 Office visit after regularly scheduled hours. 56.00
D9911 Application of desensitizing resin for cervical and/or
root surface, 66.00 per tooth.
D9930 Treatment of complications (post-surgical) - unusual 34.00
circumstances, by report.
D9951 Occlusal adjustment, limited. 43.00D9952 Occlusal
adjustment, complete. 217.00
Station1Text BoxCurrent Dental Terminology©American Dental
Association
-
D2391-2394: Coverage is limited to permanent bicuspid teeth.
D2390, D2930-2932: Coverage is limited to persons age 18 and
under.
PROC. MAXIMUMNO. COVERED EXPENSE
RESTORATIVE (Excluding inlays, crowns).
D2140 Amalgam - one surface, primary or permanent. $54.00D2150
Amalgam - two surfaces, primary or permanent. 68.00D2160 Amalgam -
three surfaces, primary or permanent. 83.00D2161 Amalgam - four or
more surfaces, primary or permanent. 99.00D2330 Resin-based
composite - one surface, anterior. 66.00D2331 Resin-based composite
- two surfaces, anterior. 83.00D2332 Resin-based composite - three
surfaces, anterior. 104.00D2335 Resin-based composite - four or
more surfaces or involving incisal 114.00
angle, anterior.D2391 Resin-based composite - one surface,
posterior 72.00D2392 Resin-based composite - two surfaces,
posterior. 91.00D2393 Resin-based composite - three surfaces,
posterior. 114.00D2394 Resin-based composite - four or more
surfaces, posterior. 126.00
D2390 Resin-based composite crown, anterior. 140.00D2930
Prefabricated stainless steel crown - primary tooth. 117.00D2931
Stainless steel crown - permanent tooth. 124.00D2932 Prefabricated
resin crown. 140.00
D2951 Pin retention, per tooth, in addition to restoration.
21.00
ORAL SURGERY.
D7111 Coronal remnants - deciduous tooth 60.00D7140 Extraction,
erupted tooth or exposed root (elevation 60.00
and/or forceps removal).D7210 Surgical removal of erupted tooth.
116.00D7220 Surgical removal of impacted tooth - soft tissue.
145.00D7230 Surgical removal of impacted tooth - partially bony.
193.00D7240 Surgical removal of impacted tooth - completely bony.
225.00D7241 Removal of impacted tooth completely bony, with
257.00
unusual surgical complications, by report.D7250 Surgical removal
of residual tooth roots (cutting procedure). 121.00D7260 Oral
antral fistula closure. 284.00D7261 Primary closure of a sinus
perforation. 284.00D7270 Tooth re-implantation and/or stabilization
of accidentally 172.00
evulsed or displaced tooth.D7272 Tooth transplantation (includes
reimplantation from one 172.00
site to another and splinting and/or stabilization).D7280
Surgical access of an unerupted tooth. 266.00D7281 Surgical
exposure of impacted or unerupted tooth to aid 192.00
eruption.D7282 Mobilization of erupted or malpositioned tooth to
aid eruption. 192.00D7285 Biopsy of oral tissue - hard (bone,
tooth). 244.00D7286 Biopsy of oral tissue - soft (all others).
131.00D7287 Cytology sample collection. 66.00
-
D7471-7473: A maximum of 5 allowances will be considered.
PROC. MAXIMUMNO. COVERED EXPENSE
D7310 Alveoloplasty in conjunction with extractions-per
quadrant. $100.00D7320 Alveoloplasty not in conjunction with
extractions-per quadrant. 127.00D7340 Vestibuloplasty - ridge
extension (secondary epithelialization). 184.00D7350
Vestibuloplasty - ridge extension (including soft tissue 456.00
grafts, muscle reattachment, revision of soft tissue attachment
and management of hypertrophied and hyperplastic tissue).
D7410 Excision of benign lesion up to 1.25 cm. 182.00D7411
Excision of benign lesion greater than 1.25 cm. 233.00D7412
Excision of benign lesion, complicated. 257.00D7413 Excision of
malignant lesion up to 1.25 cm. 246.00D7414 Excision of malignant
lesion greater than 1.25 cm. 180.00D7415 Excision of malignant
lesion, complicated. 198.00D7440 Excision of malignant tumor-lesion
diameter up to 1.25 cm. 246.00D7441 Excision of malignant
tumor-lesion diameter greater than 1.25 cm. 180.00D7450 Removal of
benign odontogenic cyst or tumor 182.00
- lesion diameter up to 1.25 cm.D7451 Removal of benign
odontogenic cyst or tumor 233.00
- lesion diameter greater than 1.25 cm.D7460 Removal of benign
nonodontogenic cyst or tumor 182.00
- lesion diameter up to 1.25 cm.D7461 Removal of benign
nonodontogenic cyst or tumor 233.00
- lesion diameter greater than 1.25 cm.D7465 Destruction of
lesion(s) by physical or chemical method, 55.00
by report.D7471 Removal of lateral exostosis - (maxilla or
mandible). 162.00D7472 Removal of torus palatinus. 162.00D7473
Removal of torus mandibularis. 162.00
D7485 Surgical reduction of osseous tuberosity. 264.00D7490
Radical resection of mandible with bone graft. 246.00D7510 Incision
and drainage of abscess - intraoral soft tissue. 81.00D7520
Incision and drainage of abscess - extraoral soft tissue.
94.00D7530 Removal of foreign body from mucosa, skin, 75.00
or subcutaneous alveolar tissue.D7540 Removal of
reaction-producing foreign bodies - 205.00
musculoskeletal system.D7550 Partial ostectomy/sequestrectomy
for removal of non-vital bone. 205.00D7560 Maxillary sinusotomy for
removal of tooth fragment or 270.00
foreign body.D7910 Suture of recent small wounds - up to 5 cm.
36.00D7911 Complicated suture - up to 5 cm. 41.00D7912 Complicated
suture - greater than 5 cm. 59.00D7960 Frenulectomy (frenectomy or
frenotomy)-separate procedure. 195.00D7970 Excision of hyperplastic
tissue - per arch. 150.00D7980 Sialolithotomy. 225.00D7983 Closure
of salivary fistula. 72.00
Station1Text BoxCurrent Dental Terminology©American Dental
Association
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D9220-9242: Coverage is not available without a cutting
procedure.Verification of the dentist’s anesthesia permit and a
copy of theanesthesia report is required. A maximum of two
additional units (D9221or D9242) will be considered.
PROC. MAXIMUMNO. COVERED EXPENSE
ANESTHESIA.
D9220 Deep sedation/general anesthesia - first 30 minutes.
$173.00D9221 Deep sedation/general anesthesia - each additional 15
minutes. 57.00D9241 Intravenous conscious sedation/analgesia -
first 30 minutes. 114.00D9242 Intravenous conscious
sedation/analgesia 28.00
- each additional 15 minutes.
-
D3310-3333: Coverage is limited to permanent teeth.
Allowanceincludes intraoperative films and cultures but excludes
finalrestoration.
D3346-3348: Coverage is limited to permanent teeth and to
service datesmore than 12 months after root canal therapy or a
previous retreatment.Allowance includes intraoperative films and
cultures but excludes finalrestoration.
TYPE II PROCEDURES
PROC. MAXIMUMNO. COVERED EXPENSE
ENDODONTICS.
D3220 Therapeutic pulpotomy (excluding final restoration) -
removal of pulp $41.00 coronal to the dentinocemental junction and
application of medicament. Limited to treatment of primary
teeth.
D3221 Pulpal debridement, primary and permanent teeth.
41.00D3230 Pulpal therapy (resorbable filling) - anterior, primary
tooth. 54.00D3240 Pulpal therapy (resorbable filling) - posterior,
primary tooth. 47.00D3310 Root canal, anterior (excluding final
restoration). 185.00D3320 Root canal, bicuspid (excluding final
restoration). 218.00D3330 Root canal, molar (excluding final
restoration). 286.00D3332 Incomplete endodontic therapy; inoperable
or fractured tooth. 109.00D3333 Internal root repair of perforation
defects. 67.00
D3346 Retreatment of previous root canal therapy - anterior.
231.00D3347 Retreatment of previous root canal therapy - bicuspid.
266.00D3348 Retreatment of previous root canal therapy - molar.
330.00
D3351 Apexification/recalcification - initial visit. 67.00D3352
Apexification/recalcification - interim medication replacement.
45.00D3353 Apexification/recalcification - final visit. 132.00D3410
Apicoectomy/periradicular surgery - anterior. 191.00D3421
Apicoectomy/periradicular surgery - bicuspid (first root).
220.00D3425 Apicoectomy/periradicular surgery - molar (first root).
238.00D3426 Apicoectomy/periradicular surgery - (each additional
root). 85.00D3430 Retrograde filling - per root. 52.00D3450 Root
amputation - per root. 124.00D3920 Hemisection (including any root
removal), not including 105.00
root canal therapy.
PERIODONTICS. Surgical Procedures (including postoperative
visits).
D4210 Gingivectomy or gingivoplasty - four or more contiguous
teeth or 121.00 bounded teeth spaces per quadrant.
D4211 Gingivectomy or gingivoplasty - one to three teeth, 61.00
per quadrant.
D4240 Gingival flap procedure, including root planing - four or
more 166.00 contiguous teeth or bounded teeth spaces per
quadrant.
D4241 Gingival flap procedure, including root planing - one to
three teeth, 83.00 per quadrant.
-
D4210-4265: Each procedure is eligible for consideration once in
a 3-year period.*
D4270-4273, D4275-4276: A maximum of two sites per quadrant will
be considered in a 3-year period. Coverage is limited to treatment
of periodontal disease.*
D4341-4342: Each quadrant is eligible for consideration once in
a 2-year period.*
D4381: A scaling and planing (D4341) must be performed between
six weeks and two years prior to treatment. A maximum of two
sitesper quadrant will be considered and the frequency is limited
to once in any 2-year period.*
PROC. MAXIMUMNO. COVERED EXPENSE
D4260 Osseous surgery (including flap entry and closure) - four
or more $304.00 contiguous teeth or bounded teeth spaces per
quadrant.
D4261 Osseous surgery (including flap entry and closure) one to
three teeth, 152.00 per quadrant.
D4263 Bone replacement graft - first site in quadrant.
99.00D4264 Bone replacement graft - each additional site in
quadrant. 75.00D4265 Biologic materials to aid in soft and osseous
tissue regeneration. 50.00
D4270 Pedicle soft tissue graft procedure. 224.00D4271 Free soft
tissue graft procedure (including donor site surgery). 237.00D4273
Subepithelial connective tissue graft procedures. 276.00D4275 Soft
tissue allograft. 237.00D4276 Combined connective tissue and double
pedicle graft. 276.00
D4274 Distal or proximal wedge procedure (when not performed in
133.00 conjunction with surgical procedures in the same anatomical
area).
Non-surgical Periodontal Procedures.
D4341 Periodontal scaling and root planing - four or more
contiguous 62.00 teeth or bounded teeth spaces per quadrant.
D4342 Periodontal scaling and root planing, one to three teeth,
per quadrant. 31.00
D4381 Localized delivery of chemotherapeutic agents via a
controlled 46.00 release vehicle into diseased crevicular tissue,
per tooth.
RESTORATIVE - Inlays and Crowns.
D2390 Resin-based composite crown, anterior. 78.00D2510 Inlay -
metallic - one surface. 204.00D2520 Inlay - metallic - two
surfaces. 243.00D2530 Inlay - metallic - three or more surfaces.
262.00
*The frequency is measured forward from the last covered date of
service for the procedure.
-
D2390-2932: These procedures are limited to necessary
placementresulting from decay or traumatic injury. Inlays will be
reimbursed atthe alternate allowance of an amalgam or composite
restoration.
TYPE II PROCEDURES (Continued)
PROC. MAXIMUMNO. COVERED EXPENSE
D2542 Onlay - metallic - two surfaces. $265.00D2543 Onlay -
metallic - three surfaces. 296.00D2544 Onlay - metallic - four or
more surfaces. 308.00D2610 Inlay - porcelain/ceramic - one surface.
225.00D2620 Inlay - porcelain/ceramic - two surfaces. 245.00D2630
Inlay - porcelain/ceramic - three or more surfaces. 268.00D2642
Onlay - porcelain/ceramic - two surfaces. 265.00D2643 Onlay -
porcelain/ceramic - three surfaces. 297.00D2644 Onlay -
porcelain/ceramic - four or more surfaces. 306.00D2650 Inlay -
resin-based composite composite/resin - one surface. 234.00D2651
Inlay - resin-based composite composite/resin - two surfaces.
231.00D2652 Inlay - resin-based composite composite/resin - three
or more surfaces. 239.00D2662 Onlay - resin-based composite
composite/resin - two surfaces. 248.00D2663 Onlay - resin-based
composite composite/resin - three surfaces. 256.00D2664 Onlay -
resin-based composite composite/resin - four or more surfaces.
272.00D2710 Crown - resin (indirect). 116.00D2720 Crown - resin
with high noble metal. 296.00D2721 Crown - resin with predominantly
base metal. 225.00D2722 Crown - resin with noble metal. 276.00D2740
Crown - porcelain/ceramic substrate. 319.00D2750 Crown - porcelain
fused to high noble metal. 310.00D2751 Crown - porcelain fused to
predominantly base metal. 266.00D2752 Crown - porcelain fused to
noble metal. 285.00D2780 Crown - 3/4 cast high noble metal.
295.00D2781 Crown - 3/4 cast predominantly base metal. 256.00D2782
Crown - 3/4 cast noble metal. 268.00D2783 Crown - 3/4
porcelain/ceramic. 319.00D2790 Crown - full cast high noble metal.
295.00D2791 Crown - full cast predominantly base metal. 256.00D2792
Crown - full cast noble metal. 268.00D2930 Prefabricated stainless
steel crown - primary tooth. 65.00D2931 Prefabricated stainless
steel crown - permanent tooth. 69.00D2932 Prefabricated resin
crown. 78.00
D2950 Core build-up, including any pins. 64.00D2952 Cast post
and core - in addition to crown. 102.00D2954 Prefabricated post and
core - in addition to crown. 85.00D2980 Crown repair, by report.
52.00D4249 Clinical crown lengthening, hard tissue. 183.00
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D6058-6077: Although implants are not a covered benefit,
theseprocedures can qualify for benefits. Coverage is subject to
thereplacement and extraction provisions as defined under the
limitationssection of this contract.
PROC. MAXIMUMNO. COVERED EXPENSE
PROSTHODONTICS - FIXED. Pontics.
D6210 Cast high noble metal. $301.00D6211 Cast predominantly
base metal. 301.00D6212 Cast noble metal. 326.00D6240 Porcelain
fused to high noble metal. 301.00D6241 Porcelain fused to
predominantly base metal. 301.00D6242 Porcelain fused to noble
metal. 275.00D6245 Porcelain/ceramic. 275.00D6250 Resin with high
noble metal. 301.00D6251 Resin with predominantly base metal.
275.00D6252 Resin with noble metal. 326.00
Implant Supported.
D6058 Abutment supported porcelain/ceramic crown. 275.00D6059
Abutment supported porcelain fused to metal crown 301.00
(high noble metal).D6060 Abutment supported porcelain fused to
metal crown 301.00
(predominantly base metal).D6061 Abutment supported porcelain
fused to metal crown (noble metal). 275.00D6062 Abutment supported
cast metal crown (high noble metal). 301.00D6063 Abutment supported
cast metal crown (predominantly base metal). 301.00D6064 Abutment
supported cast metal crown (noble metal). 326.00D6065 Implant
supported porcelain/ceramic crown. 275.00D6066 Implant supported
porcelain fused to metal crown (titanium, 301.00
titanium alloy, high noble metal).D6067 Implant supported metal
crown (titanium, titanium alloy, 301.00
high noble metal).D6068 Abutment supported retainer of
porcelain/ceramic FPD. 275.00D6069 Abutment supported retainer for
porcelain fused to metal FPD 301.00
(high noble metal).D6070 Abutment supported retainer for
porcelain fused to metal FPD 301.00
(predominantly base metal).D6071 Abutment supported retainer for
porcelain fused to metal FPD 275.00
(noble metal).D6072 Abutment supported retainer for cast metal
FPD (high noble metal). 301.00D6073 Abutment supported retainer for
cast metal FPD (predominantly 301.00
base metal).D6074 Abutment supported retainer for cast metal FPD
(noble metal). 326.00D6075 Implant supported retainer for ceramic
FPD. 275.00D6076 Implant supported retainer for porcelain fused to
metal FPD 301.00
(titanium, titanium alloy, or high noble metal).D6077 Implant
supported retainer for cast metal FPD 301.00
(titanium, titanium alloy, or high noble metal).
-
TYPE II PROCEDURES (Continued)
PROC. MAXIMUMNO. COVERED EXPENSE
Retainers (Abutments).
D6545 Retainer - cast metal for resin bonded fixed prosthesis.
$100.00D6548 Retainer - porcelain/ceramic for resin bonded fixed
prosthesis. 100.00D6600 Inlay - porcelain/ceramic, two surfaces.
245.00D6601 Inlay - porcelain/ceramic, three or more surfaces.
269.00D6602 Inlay - cast high noble metal, two surfaces.
220.00D6603 Inlay - cast high noble metal, three or more surfaces.
242.00D6604 Inlay - cast predominantly base metal, two surfaces.
190.00D6605 Inlay - cast predominantly base metal, three or more
surfaces. 209.00D6606 Inlay - cast noble metal, two surfaces.
200.00D6607 Inlay - cast noble metal, three or more surfaces.
220.00D6608 Onlay - porcelain/ceramic, two surfaces. 265.00D6609
Onlay - porcelain/ceramic, three or more surfaces. 292.00D6610
Onlay - cast high noble metal, two surfaces. 242.00D6611 Onlay -
cast high noble metal, three or more surfaces. 266.00D6612 Onlay -
cast predominantly base metal, two surfaces. 209.00D6613 Onlay -
cast predominantly base metal, three or more surfaces. 230.00D6614
Onlay - cast noble metal, two surfaces. 220.00D6615 Onlay - cast
noble metal, three or more surfaces. 242.00D6720 Crown - resin with
high noble metal. 301.00D6721 Crown - resin with predominantly base
metal. 156.00D6722 Crown - resin with noble metal. 250.00D6740
Crown - porcelain/ceramic. 275.00D6750 Crown - porcelain fused to
high noble metal. 326.00D6751 Crown - porcelain fused to
predominantly base metal. 301.00D6752 Crown - porcelain fused to
noble metal. 275.00D6780 Crown - 3/4 cast high noble metal.
326.00D6781 Crown - 3/4 cast predominantly base metal. 301.00D6782
Crown - 3/4 cast noble metal. 275.00D6783 Crown - 3/4
porcelain/ceramic. 275.00D6790 Crown - full cast high noble metal.
301.00D6791 Crown - full cast predominantly base metal. 301.00D6792
Crown - full cast noble metal. 275.00D6940 Stress breaker.
83.00D6970 Cast post and core in addition to fixed partial denture
90.00
retainer. D6972 Prefabricated post and core in addition to fixed
partial 90.00
denture retainer.D6980 Fixed partial denture repair, by report.
58.00
PROSTHODONTICS - REMOVABLE.
D5110 Complete denture - maxillary. 330.00D5120 Complete denture
- mandibular. 320.00D5130 Immediate denture - maxillary.
358.00D5140 Immediate denture - mandibular. 346.00
-
D5110-5281: Allowances for partial and complete dentures include
adjustments within 6 months after installation. Precision
attachments, implants, overdentures, specialized techniques and
characterizations are considered optional and the additional
expense for these shall be borne by the patient. All partial
allowances include conventional clasps, rests and teeth.
D5410-5422: Coverage is limited to an adjustment with a date
ofservice more than 6 months after installation.
D5670-5671: Prosthetic replacement limitation applies. See
Limitations section.
PROC. MAXIMUMNO. COVERED EXPENSE
D5211 Maxillary partial denture - resin base. $237.00D5212
Mandibular partial denture - resin base. 275.00D5213 Maxillary
partial denture-cast metal framework with resin 383.00
denture bases.D5214 Mandibular partial denture-cast metal
framework with resin 383.00
denture bases.D5281 Removable unilateral partial denture - one
piece cast 205.00
metal.
D5410 Adjust complete denture - maxillary. 19.00D5411 Adjust
complete denture - mandibular. 18.00D5421 Adjust partial denture -
maxillary. 20.00D5422 Adjust partial denture - mandibular.
19.00
D5650 Add tooth to existing partial denture. 43.00D5660 Add
clasp to existing partial denture. 50.00D5670 Replace all teeth and
acrylic on cast metal framework (maxillary). 237.00D5671 Replace
all teeth and acrylic on cast metal framework (mandibular).
275.00
D5710 Rebase complete maxillary denture. 120.00D5711 Rebase
complete mandibular denture. 127.00D5720 Rebase maxillary partial
denture. 115.00D5721 Rebase mandibular partial denture. 121.00D5810
Interim complete denture (maxillary). 146.00D5811 Interim complete
denture (mandibular). 154.00D5820 Interim partial denture
(maxillary). 128.00D5821 Interim partial denture (mandibular).
135.00D5850 Tissue conditioning - maxillary. 34.00D5851 Tissue
conditioning - mandibular. 36.00