|
Prosthodontics (removable) |
| 5110, 5120 |
Complete denture - maxillary & mandibular |
$145.00 |
| 5130, 5140 |
Immediate denture - maxillary & mandibular |
$165.00 |
| 5211, 5212 |
Maxillary or Mandibular partial denture -
resin base |
$120.00 |
| 5213, 5214 |
Maxillary or Mandibular partial denture -
cast metal framework with resin denture bases |
$160.00 |
| 5225, 5226 |
Maxillary or Mandibular partial denture -
flexible base |
$210.00 |
| 5410, 5411, 5421, 5422 |
Adjust complete or partial denture |
$10.00 |
| 5510 |
Repair broken complete denture base |
$20.00 |
| 5520 |
Replace missing or broken teeth (each tooth) |
$10.00 |
| 5610, 5620, 5630 |
Repair resin denture base or cast framework |
$20.00 |
| 5640, 5650, 5660 |
Add tooth or clasp to existing structure |
$10.00 |
| 5670, 5671 |
Replace all teeth and acrylic on cast metal
framework |
$135.00 |
| 5710, 5711, 5720, 5721 |
Rebase complete or partial denture |
$55.00 |
| 5730, 5731, 5740, 5741 |
Reline complete or partial denture (chairside) |
$20.00 |
| 5750, 5751, 5760, 5761 |
Reline complete or partial denture
(laboratory) |
$60.00 |
| 5820, 5821 |
Interim partial denture - limited to 1 in any
12 consecutive months |
$75.00 |
| 5850, 5851 |
Tissue conditioning |
No Cost |
|
Prosthodontics,
Fixed each retainer and each pontic constitutes a unit in a
fixed partial denture (bridge) When a crown and /or pontic exceed six
units, an enroll may be charged an additional $100.00 per unit, beyond the
6th unit. |
| 6210 |
Pontic - cast high noble metal |
$210.00 |
| 6211 |
Pontic - cast predominantly base metal |
$110.00 |
| 6212 |
Pontic - cast noble metal |
$150.00 |
| 6240 |
Pontic - porcelain fused to high noble metal |
$240.00 |
| 6241 |
Pontic - porcelain fused to predominantly
base metal |
$140.00 |
| 6242 |
Pontic - porcelain fused to noble metal |
$180.00 |
| 6245 |
Pontic - porcelain/ceramic |
$240.00 |
| 6250 |
Pontic - resin with high noble metal |
$195.00 |
| 6251 |
Pontic - resin with predominantly base metal |
$95.00 |
| 6252 |
Pontic - resin with noble metal |
$135.00 |
| 6600 |
Inlay - porcelain/ceramic, two surfaces |
$190.00 |
| 6601 |
Inlay - porcelain/ceramic, three or more
surfaces |
$200.00 |
| 6602, 6603 |
Inlay - Cast high noble metal |
$100.00 |
| 6604, 6605 |
Inlay - cast predominantly base metal |
No Cost |
| 6606, 6607 |
Inlay cast noble metal |
$40.00 |
| 6608 |
Onlay - porcelain/ceramic, two surfaces |
$185.00 |
| 6609 |
Onlay - porcelain/ceramic, three or more
surfaces |
$205.00 |
| 6610, 6611 |
Onlay - Cast high noble metal |
$100.00 |
| 6612, 6613 |
Onlay - cast predominantly base metal |
No Cost |
| 6614, 6615 |
Onlay cast noble metal |
$40.00 |
| 6720 |
Crown - resin with high noble metal |
$195.00 |
| 6721 |
Crown - resin with predominantly base metal |
$95.00 |
| 6722 |
Crown - resin with noble metal |
$135.00 |
| 6740 |
Crown - porcelain/ceramic |
$240.00 |
| 6750 |
Crown - Porcelain fused to high noble metal |
$240.00 |
| 6751 |
Crown - porcelain fused to predominantly base
medal |
$140.00 |
| 6752 |
Crown - porcelain fused to noble metal |
$180.00 |
| 6780 |
Crown - 3/4 cast high noble metal |
$210.00 |
| 6781 |
Crown - 3/4 cast predominantly base metal |
$110.00 |
| 6782 |
Crown - 3/4 cast noble metal |
$150.00 |
| 6783 |
Crown 3/4 porcelain/ceramic |
$240.00 |
| 6790 |
Crown - full cast high noble metal |
$210.00 |
| 6791 |
Crown - full cast predominantly base metal |
$110.00 |
| 6792 |
Crown - full cast noble metal |
$150.00 |
| 6930 |
Recement fixed partial denture |
No Cost |
| 6940 |
Stress Breaker |
No Cost |
| 6970 |
Cast post and core in addition to fixed
partial denture retainer |
$35.00 |
| 6971 |
Cast post as part of fixed partial denture
retainer |
$35.00 |
| 6972 |
Prefabricated post and core in addition to
fixed partial denture retainer |
$20.00 |
| 6973 |
Core buildup for retainer, including any pins |
$15.00 |
| 6976 |
Each additional cast post - same tooth |
$25.00 |
| 6977 |
Each additional prefabricated post - same
tooth - base metal post |
$15.00 |
| 6980 |
Fixed partial denture repair, by report |
$15.00 |
|
Oral and Maxillofacial
Surgery |
| 7111 |
Extraction, coronal remnants - deciduous
tooth |
No Cost |
| 7140 |
Extraction, erupted tooth or exposed root |
$5.00 |
| 7210 |
Surgical removal of erupted tooth requiring
elevation of mucoperiosteal flap and removal of bone and/or section of tooth |
$25.00 |
| 7220 |
Removal of impacted tooth - soft tissue |
$50.00 |
| 7230 |
Removal of impacted tooth - partially bony |
$70.00 |
| 7240 |
Removal of impacted tooth - completely bony |
$90.00 |
| 7241 |
Removal of impacted tooth - completely bony
with unusual surgical complications |
$110.00 |
| 7250 |
Surgical removal of residual tooth roots
(cutting procedure) |
No cost |
| 7270 |
Tooth reimplantation and/or stabilization of
accidently evulsed or displaced tooth |
$85.00 |
| 7280 |
Surgical access of an unerupted tooth |
$90.00 |
| 7282 |
Mobilization of erupted or malpositioned
tooth to aid eruption |
$90.00 |
| 7293 |
Placement of device to facilitate eruption of
impacted tooth |
No Cost |
| 7286 |
Biopsy of oral tissue - soft |
No Cost |
| 7310, 7311 |
Alveoloplasty in conjunction with extractions |
$50.00 |
| 7320, 7321 |
Alveoloplasty not in conjunction with
extractions |
$70.00 |
| 7450, 7451 |
Removal of benign odontogenic cyst or tumor |
No Cost |
| 7471 |
Removal of lateral exostosis |
No Cost |
| 7472, 7473 |
Removal of torus |
No Cost |
| 7510 |
Incision and drainage of abscess |
No Cost |
| 7960 |
Frenulectomy - separate procedure |
No Cost |
| 7970 |
Excision hyperplastic tissue - per arch |
$55.00 |
| 7971 |
Excision of pericoronal gingiva |
$55.00 |
|
Orthodontics |
| Includes: 210, 322, 330, 340, 350, 470 |
The benefit for pre-treatment records and
diagnostic services includes: Intraoral - complete series (including
bitewings), Tomographic survay, Panoramic film, Celhalometic film,
Oral/facial photographic images. diagnostic casts |
$200.00 |
| Includes: 210, 470 |
The benefit for post-treatment records
includes: Intraoral - complete series, diagnostic casts |
$70.00 |
| 8010 |
Limited orthodontic treatment of the primary
dentition |
$950.00 |
| 8020, 8030 |
Limited orthodontic treatment of the
transitional or adolescent (to age 19) dentition |
$950.00 |
| 8040 |
Limited orthodontic treatment of the adult
dentition |
$1150.00 |
| 8050, 8060 |
Interceptive orthodontic treatment of the
primary or transitional dentition |
$950.00 |
| 8070, 8080 |
Comprehensive orthodontic treatment of the
transitional or adolescent (to age 19) dentition |
$1700.00 |
| 8090 |
Comprehensive orthodontic treatment of the
adult dentition |
$1900.00 |
| 8660 |
Pre-orthodontic treatment visit |
$25.00 |
| 8680 |
Orthodontic retention (removal of appliances,
construction and placement of removable retainers) |
$275.00 |
| 8999 |
Unspecified orthodontic procedure, by report
- includes treatment planning session |
$100.00 |
| |
|
|
|
Adjunctive General Services |
| 9110 |
Palliative (emergency) treatment of dental
pain |
$5.00 |
| 9211 |
Regional block anesthesia |
No Cost |
| 9212 |
Trigeminal division block anesthesia |
No Cost |
| 9215 |
Local anesthesia |
No Cost |
| 9220 |
Deep sedation/general anesthesia - first 30
minutes |
$165.00 |
| 9221 |
Deep sedation/general anesthesia - each
additional 15 minutes |
$80.00 |
| 9241 |
Intravenous conscious sedation analgesia -
first 30 minutes |
$165.00 |
| 9242 |
Intravenous conscious sedation analgesia -
each additional 15 minutes |
$80.00 |
| 9310 |
Consultation (diagnostic service provided by
dentist or physician other that practitioner providing treatment) |
$10.00 |
| 9430 |
Office visit for observation |
$5.00 |
| 9440 |
Office visit - after regularly scheduled
hours |
$25.00 |
| 9450 |
Case Presentation, detailed and extensive
treatment planning |
No Cost |
| 9940 |
Occlusal guard by report - limited to 1 in 3
years |
$100.00 |
| 9951 |
Occlusal adjustment, limited |
$35.00 |
| 9952 |
Occlusal adjustment, complete |
$55.00 |
| 9972 |
External bleaching - per arch - limited to
one bleaching tray and gel for two weeks of self treatment |
$125.00 |
| 9999 |
Unspecified adjunctive procedure, by report -
includes failed appointments without 24 hour notice - pre 15 minutes of
appointment time - up to an overall maximum of $40.00 |
$10.00 |
| |
| The above procedures are
performed as needed and deemed necessary by your attending network dentist
subject to the limitations, exclusions and governing administrative policies
of the program |