Allowances for Non-Participating Dental Providers
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(Subject to a Yearly Maximum of $2,000.00) Effective7/1/2015
* 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)
| Fund Payment | FREQUENCY OF SERVICE | ||
| D0120 | PERIODIC EXAMINATION | 25.00 | Exams covered every 6 months |
| D0140 | LIMITED ORAL EVALUATION | 17.00 | 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 | 10.00 | Every 6 months |
| D0273 | BITEWINGS – THREE FILMS | 15.00 | Every 6 months |
| D0274 | BITEWINGS – FOUR FILMS | 18.00 | 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 | 55.00 | Every 12 months |
| D0340 | CEPHALOMETRIC FILM | 55.00 | Every 12 months |
| D0425 | CARIES SUSCEPTIBILITY | 15.00 | |
| D0460 | PULP VITALITY | 17.00 | |
| 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) |
| D1203 | CHILD FLUORIDE APPLICATION | 22.00 | 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 | 100.00 | |
| D1515 | SPACE MAINTAINER – FIXED BILATERAL | 125.00 | |
| D1525 | SPACE MAINTAINER – REMOVABLE | 125.00 | |
| 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 | 250.00 | Crowns covered every 5 years |
| D2791 | CROWN – GOLD | 220.00 | Crowns covered every 5 years |
| D2910 | RECEMENT INLAY | 15.00 | |
| D2920 | RECEMENT CROWN | 20.00 | |
| D2930 | PREFAB STAINLESS STEEL CROWN/PRIMARY | 90.00 | Crowns covered every 5 years |
| D2931 | CROWN – STAINLESS STEEL | 45.00 | Crowns covered every 5 years |
| D2933 | PREFAB STAINLESS STEEL CROWN | 45.00 | Crowns covered every 5 years |
| D2940 | SEDATIVE FILLING | 23.00 | |
| D2950 | CROWN BUILD UP – PIN ADD’L | 40.00 | |
| D2951 | PIN RETENTION PER TOOTH | 15.00 | |
| D2952 | POST & CORE WITH CROWN | 110.00 | |
| D2954 | PREFAB POST & CORE | 100.00 | |
| D2962 | LABIAL VENEER PORC. LAMINATE | 345.00 | |
| 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 | 40.00 | |
| 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 | 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 | 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 | 85.00 | 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 | 600.00 | Dentures/Bridges covered every 5 years |
| D5120 | FULL LOWER DENTURE – MANDIBULAR | 600.00 | 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 | 575.00 | Dentures/Bridges covered every 5 years |
| D5214 | MANDIBULAR PARTIAL DENTURE | 575.00 | Dentures/Bridges covered every 5 years |
| D5281 | REMOVEABLE UNILATERAL PARTIAL DENTURE | 50.00 | |
| D5410 | ADJUST FULL DENTURE – MAXILLARY | 15.00 | |
| D5411 | ADJUST COMPLETE DENTURE- MANDIBULAR | 15.00 | |
| D5421 | ADJUST PARTIAL DENTURE – MAXILLARY | 15.00 | |
| D5422 | ADJUST PARTIAL DENTURE – MANDIBULAR | 15.00 | |
| D5610 | REPAIR BROKEN DENTURE | 35.00 | |
| D5640 | REPLACE BROKEN TOOTH | 30.00 | |
| D5650 | REPLACE EXTRACTED TOOTH | 37.00 | |
| D5660 | ADD’L EXTRACTED TOOTH & CLASP | 63.00 | |
| D5730 | RELINE COMPLETE MAXILLARY DENTURE | 45.00 | |
| D5731 | RELINE COMPLETE MANDIBULAR DENTURE | 45.00 | |
| D5740 | RELINE PARTIAL MAXILLARY DENTURE | 40.00 | |
| D5741 | RELINE PARTIAL MANDIBULAR DENTURE | 40.00 | |
| D5750 | RELINE COMPLETE MAXILLARY DENTURE (LAB) | 75.00 | |
| D5751 | RELINE COMPLETE MANDIBULAR DENTURE (LAB) | 75.00 | |
| D5760 | RELINE PARTIAL MAXILLARY DENTURE (LAB) | 100.00 | |
| D5761 | RELINE PARTIAL MANDIBULAR DENTURE (LAB) | 100.00 | |
| 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 | 270.00 | Every 5 years |
| D6211 | PONTIC CAST PRED. BASE/METAL | 245.00 | 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 | 245.00 | Every 5 years |
| D6251 | PONTIC – RESIN w/BASE METAL | 170.00 | Every 5 years |
| D6545 | RETAINER CAST MENTAL/RESIN BONDED PROS. | 70.00 | Every 5 years |
| D6720 | CROWN – RESIN w/HIGH NOBLE METAL | 245.00 | Every 5 years |
| D6721 | CROWN – RESIN w/PREDOMINANTLY BASE METAL | 245.00 | 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 | 65.00 | |
| 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 | 3,600.00 | From ages 10 – 18 years |
| D8210 | REMOVABLE APPLIANCE THERAPY | 175.00 | |
| D9110 | PALLIATIVE EMERGENCY TREATMENT | 30.00 | |
| 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 | |
| D9951 | OCCLUSAL ADJUSTMENT – LIMITED | 50.00 | One per quadrant per day |
| D9952 | OCCLUSAL ADJUSTMENT – COMPL. | 75.00 | One per quadrant per day |