ADA
CODE |
|
Procedure |
|
Member Pays |
| |
| APPOINTMENTS |
 |
|
|
|
|
| 9310 |
|
Consultation
(diagnostic service provided by dentist other than practitioner
providing treatment) |
|
15.00 |
|
|
| 9430 |
|
Office visit (normal hours) |
|
5.00 |
|
|
| 9440 |
|
Office Visit
(after regularly
scheduled hours) |
|
35.00 |
|
|
| 9999 |
|
Emergency visit during regularly
scheduled hours, by report |
|
20.00 |
|
|
| 9999 |
|
Broken appointments
(without 24 hr notice, per 15 min.)
Maximum $40 per broken appointment. No Charge will be made due to emergencies |
|
10.00 |
|
|
| |
| DIAGNOSTICS |
|
|
|
|
|
|
| 0120 |
|
Periodic oral examination |
|
No Charge |
0140/
0150/
0160 |
|
Limited/Comprehensive oral evaluation |
|
No Charge |
|
|
| 0180 |
|
Comprehensive oral evaluation |
|
10.00 |
|
|
| 0210 |
|
X-Ray Intraoral - complete series
including bitewings |
|
No Charge |
|
|
| 0220 |
|
X-Ray Intraoral - periapical (first film) |
|
No Charge |
|
|
| 0230 |
|
X-Ray Intraoral - periapical
(each additional
film) |
|
No Charge |
|
|
| 0270 |
|
X-Ray Bitewings - single film |
|
No Charge |
|
|
| 0272 |
|
X-Ray Bitewings - two films |
|
No Charge |
|
|
| 0274 |
|
Bitewings - four films |
|
No Charge |
|
|
| 0330 |
|
Panoramic film |
|
No Charge |
|
|
| 0460 |
|
Pulp vitality tests |
|
No Charge |
|
|
| 0470 |
|
Diagnostic casts |
|
No Charge |
|
|
| |
| PREVENTIVE CARE |
|
|
|
|
|
|
1110/
1120 |
|
Prophylaxis - adult/child (routine, once every 6 months) |
|
No Charge |
|
|
1110/
1120 |
|
Prophylaxis - adult/child (additional) |
|
20.00 |
|
|
| 1201 |
|
Topical application of fluoride
(including prophylaxis)
child (up to 16 years of age) |
|
No Charge |
|
|
| 1203 |
|
Topical application of fluoride
(not
including prophylaxis)
child (up to 16 years of age) |
|
No Charge |
|
|
| 1351 |
|
Sealant - per tooth |
|
10.00 |
|
|
| 1330 |
|
Oral hygiene instruction |
|
No Charge |
|
|
| 1510 |
|
Space Maintainer - fixed - unilateral |
|
45 + LAB |
|
|
| 1515 |
|
Space Maintainer - fixed - bilateral |
|
45 + LAB |
|
|
| 1520 |
|
Space Maintainer -
removable -
unilateral |
|
85 + LAB |
|
|
| 1525 |
|
Space Maintainer -
removable -
bilateral |
|
85 + LAB |
|
|
| 1550 |
|
Recementation of space maintainer |
|
10.00 |
|
|
| |
| RESTORATIVE |
|
|
|
|
|
|
| 2140 |
|
Amalgam - one surface, primary or
permanent |
|
No Charge |
|
|
| 2150 |
|
Amalgam - two surfaces, primary or
permanent |
|
No Charge |
|
|
| 2160 |
|
Amalgam - three surfaces, primary or
permanent |
|
No Charge |
|
|
| 2161 |
|
Amalgam - four or more surfaces,
primary or permanent |
|
No Charge |
|
|
| 2940 |
|
Sedative filling |
|
15.00 |
|
|
| 2999 |
|
Sedative base (Under fillings), by
report |
|
No Charge |
|
|
| |
| RESIN RESTORATION |
|
|
|
|
|
|
| 2330 |
|
Resin - one surface, anterior |
|
35.00 |
|
|
| 2331 |
|
Resin - two surfaces, anterior |
|
40.00 |
|
|
| 2332 |
|
Resin - three surfaces, anterior |
|
50.00 |
|
|
| 2391 |
|
Resin - based composite - one surface,
posterior |
|
60.00 |
|
|
| 2392 |
|
Resin - based composite - two surfaces,
posterior |
|
80.00 |
|
|
| 2393 |
|
Resin - based composite - three
surfaces, posterior |
|
100.00 |
|
|
| 2394 |
|
Resin - based composite - four or more
surfaces, posterior |
|
120.00 |
|
|
| 2510 |
|
Inlay - metallic - one surface |
|
95.00 |
|
|
| 2520 |
|
Inlay - metallic - two surfaces |
|
105.00 |
|
|
| 2530 |
|
Inlay - metallic - three or more
surfaces |
|
130.00 |
|
|
| |
| CROWN & BRIDGE |
|
|
|
|
|
|
| 2740 |
|
Crown - porcelain/ceramic substrate |
|
280 + LAB |
|
|
| 2750* |
|
Crown - porcelain fused to high noble
metal |
|
280.00 |
|
|
| 2751 |
|
Crown - porcelain fused to
predominantly base metal |
|
280.00 |
|
|
| 2752* |
|
Crown - porcelain fused to noble metal |
|
280.00 |
|
|
| 2790* |
|
Crown - full cast high noble metal |
|
280.00 |
|
|
| 2791 |
|
Crown - full cast predominantly base
metal |
|
280.00 |
|
|
| 2792* |
|
Crown - full cast noble metal |
|
280.00 |
|
|
| 2910 |
|
Recement inlay |
|
15.00 |
|
|
| 2920 |
|
Recement crown |
|
15.00 |
|
|
| 2930 |
|
Prefabricated stainless steel crown -
primary tooth |
|
75.00 |
|
|
| 2950 |
|
Core buildup, including any pins |
|
45.00 |
|
|
| 2951 |
|
Pin retention - per tooth |
|
15.00 |
|
|
| 2952 |
|
Cast post and core in addition to crown |
|
90 + LAB |
|
|
| 2953 |
|
Each additional cast post - same tooth |
|
90 + LAB |
|
|
| 2954 |
|
Prefabricated post and core in addition
to crown |
|
90.00 |
|
|
| 2962 |
|
Labial veneer (porcelain laminate) -
laboratory |
|
280 + LAB |
|
|
| |
| ENDODONTICS |
|
|
|
|
|
|
| 3220 |
|
Therapeutic pulpotomy/pulpectomy |
|
35.00 |
|
|
| 3221 |
|
Pulpal debridement, primary and
permanent teeth |
|
100.00 |
|
|
|
|
Root canals |
|
|
|
|
| 3310 |
|
Root canal therapy - anterior
(excluding final restoration) |
|
100.00 |
|
|
| 3320 |
|
Root canal therapy - bicuspid
(excluding final restoration) |
|
200.00 |
|
|
| 3330 |
|
Root canal therapy - molar (excluding
final restoration) |
|
250.00 |
|
|
| 3410 |
|
Apicoectomy/periradicular surgery -
anterior |
|
125.00 |
|
|
| |
| PERIODONTICS (Gum Treatment) |
|
|
|
|
|
|
| 4210 |
|
Gingivectomy/gingivoplasty
(4+ teeth per quad ) |
|
125.00 |
|
|
| 4211 |
|
Gingivectomy/gingivoplasty
(1-3 teeth per quad ) |
|
40.00 |
|
|
| 4260 |
|
Osseous surgery,
(4+ teeth, per quad ) |
|
350.00 |
|
|
| 4261 |
|
Osseous surgery,
(1-3 teeth, per quad ) |
|
350.00 |
|
|
| 4271 |
|
Free soft tissue graft procedure
(including donor site surgery) |
|
225.00 |
|
|
| 4341 |
|
Periodontal scaling and root planning
(4+ teeth per quad ) |
|
50.00 |
|
|
| 4342 |
|
Periodontal scaling and root planning
(1-3 teeth per quad) |
|
50.00 |
|
|
| 4355 |
|
Full mouth debridement to enable
evaluation and diagnosis |
|
45.00 |
|
|
| 4381 |
|
Localized delivery of chemotherapeutic
agents (per tooth) |
|
45.00 |
|
|
| 4910 |
|
Periodontal maintenance |
|
50.00 |
|
|
