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DENTAL Non-PPO ALLOWANCES |
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(Subject to a Yearly Maximum of $1,500.00) |
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PATIENT |
FUND |
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ALLOWED |
COPAY |
PYMT |
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D0110 |
ORAL EXAMINATION |
27.00 |
0.00 |
27.00 |
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D0120 |
PERIODIC EXAMINATION |
15.00 |
0.00 |
15.00 |
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D0130 |
EMERGENCY EXAMINATION |
12.00 |
0.00 |
12.00 |
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D0140 |
LIMITED ORAL EVALUATION |
12.00 |
0.00 |
12.00 |
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D0150 |
COMPREHENSIVE ORAL EXAMINATION |
27.00 |
0.00 |
27.00 |
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D0210 |
FULL MOUTH X-RAY |
50.00 |
0.00 |
50.00 |
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D0220 |
FIRST PERIAPICAL FILM |
9.00 |
0.00 |
9.00 |
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D0230 |
EACH ADD'L PERIAPICAL |
7.00 |
0.00 |
7.00 |
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D0240 |
EACH INTRAORAL FILM |
9.00 |
0.00 |
9.00 |
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D0250 |
FIRST EXTRAORAL FILM |
20.00 |
0.00 |
20.00 |
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D0260 |
EACH ADD'L EXTRAORAL FILM |
25.00 |
0.00 |
25.00 |
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D0270 |
BITEWING - ONE FILM |
8.00 |
0.00 |
8.00 |
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D0272 |
BITEWINGS - TWO FILMS |
10.00 |
0.00 |
10.00 |
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D0273 |
BITEWINGS - THREE FILMS |
15.00 |
0.00 |
15.00 |
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D0274 |
BITEWINGS - FOUR FILMS |
18.00 |
0.00 |
18.00 |
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D0277 |
VERTICAL BITEWINGS |
18.00 |
0.00 |
18.00 |
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D0290 |
SKULL & FACIAL FILMS |
20.00 |
0.00 |
20.00 |
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D0310 |
SIALOGRAPHY |
50.00 |
0.00 |
50.00 |
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D0320 |
TEMPOROMANDIBULAR FILM |
70.00 |
0.00 |
70.00 |
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D0330 |
PANORAMIC FILM |
55.00 |
0.00 |
55.00 |
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D0340 |
CEPHALOMETRIC FILM |
55.00 |
0.00 |
55.00 |
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D0410 |
BACTERIOLOGIC CULTURES |
20.00 |
0.00 |
20.00 |
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D0420 |
CARIES SUSCEPTIBILITY |
15.00 |
0.00 |
15.00 |
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D0425 |
CARIES SUSCEPTIBILITY |
15.00 |
0.00 |
15.00 |
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D0460 |
PULP VITALITY |
17.00 |
0.00 |
17.00 |
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D0470 |
STUDY MODELS |
23.00 |
0.00 |
23.00 |
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D0501 |
BIOPSY - LAB EXAM |
50.00 |
0.00 |
50.00 |
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D0502 |
TEST & LAB EXAM |
0.00 |
0.00 |
0.00 |
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D1110 |
ADULT PROPHYLAXIS |
40.00 |
0.00 |
40.00 |
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D1120 |
CHILD PROPHYLAXIS |
35.00 |
0.00 |
35.00 |
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D1200 |
FLUORIDE APPLICATION |
22.00 |
0.00 |
22.00 |
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D1351 |
SEALANT - PER QUADRANT |
30.00 |
0.00 |
30.00 |
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D1510 |
SPACE MAINTAINER - FIXED |
100.00 |
0.00 |
100.00 |
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D1515 |
SPACE MAINTAINER - CRW TY |
125.00 |
0.00 |
125.00 |
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D1525 |
SPACE MAINTAINER - REMOVABLE |
125.00 |
0.00 |
125.00 |
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D2110 |
AMALGAM - CHILD - 1 SURFACE |
30.00 |
0.00 |
30.00 |
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D2120 |
AMALGAM - CHILD - 2 SURFACES |
35.00 |
0.00 |
35.00 |
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D2130 |
AMALGAM - CHILD - 3 SURFACES |
45.00 |
0.00 |
45.00 |
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D2131 |
AMALGAM - CHILD - 4+ SURFACES |
50.00 |
0.00 |
50.00 |
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D2140 |
AMALGAM - ADULT - 1 SURFACE |
35.00 |
0.00 |
35.00 |
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D2150 |
AMALGAM - ADULT - 2 SURFACES |
40.00 |
0.00 |
40.00 |
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D2160 |
AMALGAM - ADULT - 3 SURFACES |
45.00 |
0.00 |
45.00 |
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D2161 |
AMALGAM - ADULT - 4+ SURFACES |
50.00 |
0.00 |
50.00 |
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D2170 |
PIN - AMALGAM |
15.00 |
0.00 |
15.00 |
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D2210 |
SILICATE-PER RESTORATION |
35.00 |
0.00 |
35.00 |
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D2330 |
COMPOSITE/BONDING - 1 SURFACE |
35.00 |
0.00 |
35.00 |
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D2331 |
COMPOSITE/BONDING - 2 SURFACES |
40.00 |
0.00 |
40.00 |
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D2332 |
COMPOSITE/BONDING - 3 SURFACES |
45.00 |
0.00 |
45.00 |
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D2335 |
COMPOSITE/BONDING - 4+ SURFACE |
50.00 |
0.00 |
50.00 |
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D2340 |
ACID ETCH TOOTH PREPARATION |
13.00 |
0.00 |
13.00 |
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D2385 |
RESIN BONDED SURFACE (POSTER.) |
35.00 |
0.00 |
35.00 |
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D2386 |
RESIN BONDED - 2 SURFACES (POSTER.) |
40.00 |
0.00 |
40.00 |
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D2387 |
RESIN BONDED - 3 SURFACES (POSTER.) |
45.00 |
0.00 |
45.00 |
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D2388 |
RESIN BONDED - 4 - SURFACES (POSTER.) |
50.00 |
0.00 |
50.00 |
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D2391 |
RESIN BASED COMP. 1 SURF/POST |
35.00 |
0.00 |
35.00 |
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D2392 |
RESIN BASED COMP. 2 SURF/POST |
40.00 |
0.00 |
40.00 |
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D2393 |
RESIN BASED COMP. 3 SURF/POST |
45.00 |
0.00 |
45.00 |
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D2394 |
RESIN BASED COMP. 4 SURF/POST |
50.00 |
0.00 |
50.00 |
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D2410 |
GOLD FOIL - 1 SURFACE |
44.00 |
0.00 |
44.00 |
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D2420 |
GOLD FOIL - 2 SURFACES |
125.00 |
0.00 |
125.00 |
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D2430 |
GOLD FOIL - 3 SURFACES |
145.00 |
0.00 |
145.00 |
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D2510 |
Health
& We
lfare
and Pension Funds
