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)
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