Allowances for Non-Participating Dental Providers

(Click here for printable version) (Subject to a Yearly Maximum of $2,000.00) Effective 7/1/2017

		Fund Payment	FREQUENCY OF SERVICE
D0120	PERIODIC EXAMINATION	25.00	Exams covered every 6 months
D0140	LIMITED ORAL EVALUATION	25.00	Every 6 months
D0145	COMPREHENSIVE EXAM PT. UNDER 3 YRS.	40.00	Every 12 months
D0150	COMPREHENSIVE ORAL EXAMINATION	40.00	Every 12 months
D0180	COMPREHENSIVE PERIO EVALUATION	55.00	Every 12 months
D0210	FULL MOUTH X-RAY	55.00	Every 12 months
D0220	FIRST PERIAPICAL FILM	9.00	Every 6 months
D0230	EACH ADD’L PERIAPICAL	7.00	Every 6 months
D0240	EACH INTRAORAL FILM	9.00	Every 6 months
D0250	FIRST EXTRAORAL FILM	20.00	Every 6 months
D0260	EACH ADD’L EXTRAORAL FILM	25.00	Every 6 months
D0270	BITEWING – ONE FILM	8.00	Every 6 months
D0272	BITEWINGS – TWO FILMS	16.00	Every 6 months
D0273	BITEWINGS – THREE FILMS	24.00	Every 6 months
D0274	BITEWINGS – FOUR FILMS	32.00	Every 6 months
D0277	VERTICAL BITEWINGS	18.00	Every 6 months
D0290	SKULL & FACIAL FILMS	20.00	Every 6 months
D0310	SIALOGRAPHY	50.00	Every 6 months
D0320	TEMPOROMANDIBULAR FILM	70.00	Every 6 months
D0330	PANORAMIC FILM	58.00	Every 12 months
D0340	CEPHALOMETRIC FILM	55.00	Every 12 months
D0425	CARIES SUSCEPTIBILITY	15.00
D0460	PULP VITALITY	18.00
D0470	STUDY MODELS	48.00
D0502	TEST & LAB EXAM	0.00
D1110 –	ADULT PROPHYLAXIS	54.00	Prophylaxi covered every 6 months
D1120	CHILD PROPHYLAXIS	49.00	Every 6 months (up to age 15)
D1208	TOPICAL APPLICATION OF FLORIDE	22.00	Every 6 months (up to age 15)
D1351	SEALANT – PER QUADRANT (Molar Teeth Only)	30.00	Every 18 months, from ages 6-14 years old
D1510	SPACE MAINTAINER – FIXED UNILATERAL	156.00	Up to age 14
D1515	SPACE MAINTAINER – FIXED BILATERAL	223.00	Up to age 14
D1525	SPACE MAINTAINER – REMOVABLE	190.00	Up to age 14
D2140	AMALGAM – ADULT – 1 SURFACE	45.00	Every 12 months (Same Surface)
D2150	AMALGAM – ADULT – 2 SURFACES	50.00	Every 12 months (Same Surface)
D2160	AMALGAM – ADULT – 3 SURFACES	60.00	Every 12 months (Same Surface)
D2161	AMALGAM – ADULT – 4+ SURFACES	70.00	Every 12 months (Same Surface)
D2330	COMPOSITE/BONDING – 1 SURFACE	55.00	Every 12 months (Same Surface)
D2331	COMPOSITE/BONDING – 2 SURFACES	70.00	Every 12 months (Same Surface)
D2332	COMPOSITE/BONDING – 3 SURFACES	75.00	Every 12 months (Same Surface)
D2335	COMPOSITE/BONDING – 4+ SURFACE	90.00	Every 12 months (Same Surface)
D2391	RESIN BASED COMP. 1 SURF/POST	55.00	Every 12 months (Same Surface)
D2392	RESIN BASED COMP. 2 SURF/POST	70.00	Every 12 months (Same Surface)
D2393	RESIN BASED COMP. 3 SURF/POST	75.00	Every 12 months (Same Surface)
D2394	RESIN BASED COMP. 4 SURF/POST	90.00	Every 12 months (Same Surface)
D2410	GOLD FOIL – 1 SURFACE	44.00
D2420	GOLD FOIL – 2 SURFACES	125.00
D2430	GOLD FOIL – 3 SURFACES	145.00
D2510	INLAY – 1 SURFACE	90.00	Inlays covered every 5 years
D2520	INLAY – 2 SURFACES	145.00	Inlays covered every 5 years
D2530	INLAY – 3 SURFACES	150.00	Inlays covered every 5 years
D2610	INLAY-PORCELAIN/CERAMIC	55.00
D2710	CROWN – ACRYLIC	95.00	Crowns covered every 5 years
D2720	CROWN – PLASTIC W/METAL	245.00	Crowns covered every 5 years
D2740	CROWN – PORCELAIN	475.00	Crowns covered every 5 years
D2750	CROWN – CERAMCO	475.00	Crowns covered every 5 years
D2751	CROWN PORC. FUSED BASE SINGLE	475.00	Crowns covered every 5 years
D2752	PORC. FUSED METAL CROWN	475.00	Crowns covered every 5 years
D2783	3/4 PORC. LAMINATES	145.00	Crowns covered every 5 years
D2790	CROWN – FULL CAST HIGH NOBLE	273.00	Crowns covered every 5 years
D2791	CROWN – GOLD	220.00	Crowns covered every 5 years
D2910	RECEMENT INLAY	15.00
D2920	RECEMENT CROWN	21.00
D2930	PREFAB STAINLESS STEEL CROWN/PRIMARY	90.00	Crowns covered every 5 years
D2931	CROWN – STAINLESS STEEL	156.00	Crowns covered every 5 years
D2933	PREFAB STAINLESS STEEL CROWN	156.00	Crowns covered every 5 years
D2940	SEDATIVE FILLING	23.00
D2950	CROWN BUILD UP – PIN ADD’L	100.00
D2951	PIN RETENTION PER TOOTH	15.00
D2952	POST & CORE WITH CROWN	110.00
D2954	PREFAB POST & CORE	140.00
D2962	LABIAL VENEER PORC. LAMINATE	500.00
D2970	TEMPORARY CROWN	0.00
D3110	PULP CAP – DIRECT	12.00
D3120	PULP CAP- INDIRECT	12.00
D3220	VITAL PULPOTOMY	65.00
D3221	PULPAL DEBRIDEMENT	40.00
D3230	PULPAL THERAPY ANTERIOR	156.00
D3240	PULPAL THERAPY POSTERIOR	40.00
D3310 – –	ROOT CANAL – 1 CANAL	300.00
D3320 – –	ROOT CANAL – 2 CANALS	325.00
D3330 – –	ROOT CANAL – 3 CANALS	538.00
D3346 – –	RETREAT ROOT CANAL – ANTERIOR SPECIALIST ONLY	300.00
D3347 – –	RETREAT ROOT CANAL – BICUSPID SPECIALIST ONLY	325.00
D3348 – –	RETREAT ROOT CANAL – MOLAR SPECIALIST ONLY	538.00
D3410	APICOECTOMY ANTERIOR	305.00
D3421	APICOECTOMY – BICUSPID	305.00
D3425	APICOECTOMY – MOLAR	608.00
D3430	RETROFILLING	40.00
D3450	ROOT AMPUTATION – PER ROOT	55.00
D3910	RUBBER DAM – ROOT CANAL	25.00
D3920	HEMISECTION	275.00
D3950	CANAL/PULP ENLARGEMENT	50.00
D4210	GINGIVECTOMY – PER QUADRANT	50.00
D4240	GINGIVAL FLAP 4 OR MORE TEETH	50.00
D4249	CROWN LENGTHENING	200.00
D4260	OSSEOUS SURGERY	255.00
D4261	OSSEOUS GRAFT – SINGLE SITE	210.00
D4263	BONE REPLACE GRAFT/1st IN QUAD	180.00
D4270	PEDICAL SOFT TISSUE GRAFT	275.00
D4277	FREE SOFT TISSUE GRAFT 1st TOOTH	240.00
D4278	FREE SOFT TISSUE GRAFT EACH ADD’L TOOTH	240.00
D4320	INTRACORNAL PROV. SPLINT	80.00
D4321	EXTRACORNAL PROV. SPLINT	50.00
D4341	SCALING – 12 TEETH OR LESS	90.00	Not within 90 days of prophy
D4342 * –	PERIO SCALING RT PLANNING 1-3	85.00	Not within 90 days of prophy
D4355	FULL MOUTH DEBRIDEMENT	90.00	Not within 90 days of prophy/allowed every 6 mos
D4910 * –	PERIODONTAL MAINTENANCE	65.00
D4920	UNSCHEDULED DRESSING CHANGE	10.00
D5110	FULL UPPER DENTURE- MAXILLARY	650.00	Dentures/Bridges covered every 5 years
D5120	FULL LOWER DENTURE – MANDIBULAR	650.00	Dentures/Bridges covered every 5 years
D5130	IMMEDIATE DENTURE – MAXILLARY	520.00	Dentures/Bridges covered every 5 years
D5140	IMMEDIATE DENTURE – MANDIBULAR	520.00	Dentures/Bridges covered every 5 years
D5211	MAXILLARY PARTIAL DENTURE – RESIN BASE	450.00	Dentures/Bridges covered every 5 years
D5212	MANDIBULAR PARTIAL DENTURE – RESIN BASE	450.00	Dentures/Bridges covered every 5 years
D5213	MAXILLARY PARTIAL DENTURE	600.00	Dentures/Bridges covered every 5 years
D5214	MANDIBULAR PARTIAL DENTURE	600.00	Dentures/Bridges covered every 5 years
D5281	REMOVEABLE UNILATERAL PARTIAL DENTURE	50.00
D5410	ADJUST FULL DENTURE – MAXILLARY	20.00
D5411	ADJUST COMPLETE DENTURE- MANDIBULAR	20.00
D5421	ADJUST PARTIAL DENTURE – MAXILLARY	20.00
D5422	ADJUST PARTIAL DENTURE – MANDIBULAR	20.00
D5610	REPAIR BROKEN DENTURE	40.00
D5640	REPLACE BROKEN TOOTH	32.00
D5650	ADD TOOTH TO PARTIAL DENTURE	39.00
D5660	ADD’L CLASP FOR PARTIAL DENTURE	67.00
D5730	RELINE COMPLETE MAXILLARY DENTURE	56.00
D5731	RELINE COMPLETE MANDIBULAR DENTURE	56.00
D5740	RELINE PARTIAL MAXILLARY DENTURE	50.00
D5741	RELINE PARTIAL MANDIBULAR DENTURE	50.00
D5750	RELINE COMPLETE MAXILLARY DENTURE (LAB)	95.00
D5751	RELINE COMPLETE MANDIBULAR DENTURE (LAB)	95.00
D5760	RELINE PARTIAL MAXILLARY DENTURE (LAB)	125.00
D5761	RELINE PARTIAL MANDIBULAR DENTURE (LAB)	125.00
D5810	TEMPORARY FULL MAXILLARY DENTURE	0.00
D5820	TEMPORARY PARTIAL MANDIBULAR DENTURE	0.00
D5850	TISSUE CONDITIONING MAXILLARY	35.00
D5851	TISSUE CONDITIONING MANDIBULAR	35.00
D6010	SURGICAL PLACE. IMPLANT	475.00	Consultant Review
D6050	SURGICAL PLACE. TRANSOSTEAL IMPLANT	275.00	Consultant Review
D6210	PONTIC – CAST HIGH NOBLE METAL	475.00	Every 5 years
D6211	PONTIC CAST PRED. BASE/METAL	440.00	Every 5 years
D6240	PONTIC – PORC. FUSED TO HIGH NOBLE METAL	475.00	Every 5 years
D6241	PONTIC – PORC. FUSED TO BASE METAL	475.00	Every 5 years
D6242	PONTIC PORC. FUSED TO NOBLE	475.00	Every 5 years
D6250	PONTIC – RESIN w/HIGH NOBLE METAL	475.00	Every 5 years
D6251	PONTIC – RESIN w/BASE METAL	396.00	Every 5 years
D6545	RETAINER CAST MENTAL/RESIN BONDED PROS.	74.00	Every 5 years
D6720	CROWN – RESIN w/HIGH NOBLE METAL	261.00	Every 5 years
D6721	CROWN – RESIN w/PREDOMINANTLY BASE METAL	261.00	Every 5 years
D6750	CROWN – PORC. FUSED HIGH NOBLE METAL	475.00	Every 5 years
D6751	CROWN – PORC. FUSED TO PRED. BASE METAL	475.00	Every 5 years
D6752	CROWN – PORC. FUSED NOBLE METAL	475.00	Every 5 years
D6780	CROWN – 3/4 CAST HIGH NOBLE METAL	145.00	Every 5 years
D6790	CROWN – FULL CAST HIGH NOBLE METAL	295.00	Every 5 years
D6930	RECEMENT BRIDGE	25.00
D6940	STRESS BREAKER	75.00
D6950	PRECISION ATTACHMENT	200.00
D7111	CORONAL REMNANTS	20.00
D7140	SIMPLE EXTRACTION	20.00
D7210	SURG EXTRACTION SINGLE TOOTH	20.00
D7220	REMOVAL OF IMPACTED TOOTH – SOFT TISSUE	45.00
D7230	REMOVAL OF IMPACTED TOOTH – PARTIALLY BONY	150.00
D7240	REMOVE IMPACTED TOOTH FULL BONY	0.00
D7250	REMOVAL RETAINED ROOT	20.00
D7260	ORAL ANTRAL – FISTULA CLOSE	300.00
D7270	TOOTH REIMPLANTATION	75.00
D7272	TOOTH TRANSPLANTATION	125.00
D7280	SURG. ACCESS TO UNERUPTED TOOTH	95.00
D7285	BIOPSY & EXAM – HARD	25.00
D7286	BIOPSY & EXAM – SOFT	24.00
D7290	SURG. REPOSITIONING TEETH	125.00
D7310	ALVEOPLASTY w/ EXTRACTION	50.00
D7320	ALVEOPLASTY w/o EXTRACTION	65.00
D7340	VESTIBULOPLASTY – RIDGE EXTENSION	45.00
D7410	EXCISION OF BENIGN LESION – UP TO 1.25 cm	75.00
D7411	EXCISION OF BENIGN LESION – OVER 1.25 cm	100.00
D7490	RADICAL RESECTION OF MANDIBLE W/GRAFT	725.00
D7510	I & D ABSCESS INTRAORAL	15.00
D7520	I & D ABSCESS EXTRAORAL	100.00
D7530	REMOVAL FOREIGN BODY	75.00
D7540	REMOVAL REACTIVE LESION TO FOREIGN BODY	25.00
D7550	SEQUESTRECTOMY/OSTEO.	125.00
D7610	FRAC-SIMPLE-MAX-OPEN RED	425.00
D7620	FRAC-SIMPLE-MAX-CLOSED RED	175.00
D7630	FRAC-SIMPLE-MAND-OPEN RED	675.00
D7640	FRAC-SIMPLE-MAND-CLOSED RED	225.00
D7710	REDUCTION	675.00
D7770	FRAC-ALVEOLUS-OPEN RED	325.00
D7810	OPEN REDUCTION DISLOCATION	375.00
D7820	CLOSED REDUCTION DISLOCATION	25.00
D7830	MANIPULATION UNDER ANESTHESIA	25.00
D7840	CONDYLECTOMY	725.00
D7850	MENISECTOMY	675.00
D7860	ANTHROTOMY	725.00
D7870	ARTHROCENTESIS	20.00
D7911	SUTURE-COMPLEX WOUND TO 5 cm	105.00
D7912	COMPLICATED SUTURE – GREATER THAN 5 cm	105.00
D7920	SKIN GRAFT	425.00
D7940	OSTEOPLASTY	750.00
D7950	OSSEOUS GRAFT	725.00
D7955	REPAIR OF MAX. SOFT AND/OR HARD TISSUE DEFECT	25.00
D7960	FRENULECTOMY	175.00
D7970	EXC. OF HYPERPLASTIC TISSUE – PER ARCH	60.00
D7980	SIALOLITHOTOMY	225.00
D7981	EXCISION SALIVARY GLAND	475.00
D7982	SIALODOCHOPLASTY	150.00
D7983	CLOSURE SALIVARY FISTULA	50.00
D7990	EMERGENCY TRACHEOTOMY	275.00
D8080	COMPREHENSIVE ORTHO. TREATMENT- ADOLESCENT	3,800.00	From ages 10 – 18 years
D8210	REMOVABLE APPLIANCE THERAPY	175.00
D9110	PALLIATIVE EMERGENCY TREATMENT	32.00
D9210	LOCAL ANESTHESIA – NON SURGICAL	25.00	One per quadrant per day
D9211	REGIONAL BLOCK ANESTHESIA	32.00	One per quadrant per day
D9212	TRIGEMINAL DIVISON BLOCK ANES	32.00	One per quadrant per day
D9215	LOCAL ANESTHESIA	25.00	One per quadrant per day
D9220	GENERAL ANESTHESIA	230.00
D9230	ANALGESIA	40.00
D9248	NON IV CONSCIOUS SEDATION	0.00
D9310	CONSULTATION – SPECIALIST	50.00
D9610	THERAPEUTIC DRUG INJECTION	20.00
D9630	EMERGENCY PRESCRIPTION	16.00
D9910	APPLICATION DESENSITIZING MED	11.00
D9940	OCCLUSAL GUARDS BY PRE-D ONLY	425.00	Once per lifetime
D9951	OCCLUSAL ADJUSTMENT – LIMITED	50.00	One per quadrant per day
D9952	OCCLUSAL ADJUSTMENT – COMPL.	75.00	One per quadrant per day

* Service must be provided by a licensed periodontist ** Service must be performed by a licensed orthodontist; subject to lifetime limit – Periodontal services must be separated by 90 days — Root canal retreats by specialist only  (Click here for printable version)