| Type II – Basic Dental Services |
 |
|
|
ADA
Code |
Procedure |
Maximum
Reimbursement |
 |
| 2110 |
Amalgam-One Surface, Primary* |
$34 |
 |
| 2120 |
Amalgam-Two Surfaces, Primary* |
43 |
|
| 2130 |
Amalgam-Three Surfaces, Primary* |
54 |
|
| 2131 |
Amalgam-Four Or More Surfaces, Primary* |
71 |
|
|
2140 |
Amalgam-One
Surface, Permanent* |
32 |
|
| 2150 |
Amalgam-Two Surfaces, Permanent* |
42 |
|
| 2160 |
Amalgam-Three
Surfaces, Permanent* |
53 |
|
| 2161 |
Amalgam-Four Or More Surfaces, Permanent*
*(multiple restorations on one surface will be covered as a single
filling) |
63 |
|
| 2210 |
Silicate
Cement-Per Restoration** |
21 |
|
| 2330 |
Resin-One Surface, Anterior** |
37 |
|
| 2331 |
Resin-Two Surfaces, Anterior** |
47 |
|
| 2332 |
Resin-Three Surfaces, Anterior** |
58 |
|
| 2335 |
Resin-Four +
Surfaces Or Involving Incisal Angle** |
63 |
|
| 2380 |
Resin-One Surface, Posterior-Primary** |
42 |
|
| 2381 |
Resin-Two
Surfaces, Posterior-Primary** |
57 |
|
| 2382 |
Resin-Three Or More Surfaces, Posterior-Primary** |
65 |
|
| 2385 |
Resin-One Surface, Posterior-Permanent** |
42 |
|
| 2386 |
Resin-Two Surfaces, Posterior-Permanent** |
63 |
|
| 2387 |
Resin-Three Or More Surfaces, Posterior-Permanent**
**(mesial-lingual, distal-lingual, misial-buccal, & distal-buccal
restorations on anterior teeth will be deemed single surface
restorations) |
76 |
|
| 2910 |
Recement Inlay |
25 |
|
| 2920 |
Recement Crown |
29 |
|
| 2940 |
Sedative Filling |
34 |
|
| 2950 |
Core Build-Up, Including Any Pins |
84 |
|
| 2951 |
Pin Retention/Per Tooth, In Addition To Restoration |
19 |
|
| 3220 |
Therapeutic Pulpotomy (Excluding Final Restoration) |
55 |
|
| 3310 |
Rootcanal-Anterior |
210 |
|
| 3320 |
Rootcanal-Bicuspid |
242 |
|
| 3330 |
Rootcanal-Molar |
273 |
|
| 3351 |
Apexification/Recalcification-Initial Visit |
84 |
|
| 3352 |
Apexification/Recalcification-Initialinterim
Medication |
84 |
|
| 3353 |
Apexification/Recalcification-Final Visit |
84 |
|
| 3410 |
Apicoectomy/Periradicular Surgery- Anterior |
248 |
|
| 3421 |
Apicoectomy/Periradicular Surgery-Bicuspid |
210 |
|
| 3425 |
Apicoectomy/Periradicular Surgery-Molar |
210 |
|
| 3430 |
Retrograde Filling-Per Tooth |
67 |
|
| 3450 |
Root Amputation-Per Root |
168 |
|
| 3920 |
Hemisection (Including Any Root Removal) |
155 |
|
| 4210 |
Gingivectomy or Gingivoplasty-Per Quadrant*** |
105 |
|
| 4211 |
Gingivectomyor Gingivoplasty-Per Tooth*** |
63 |
|
| 4220 |
Gingival Curettage, Surgical, Per Quadrant*** |
42 |
|
| 4240 |
Gingival Flap Procedure , Per Quadrant*** |
158 |
|
| 4250 |
Mucogingival Surgery-Per Quadrant***
***(only one of these procedures is covered per area of the mouth
per 12 consecutive months) |
134 |
|
| 4260 |
Osseous Surgery-Per Quadrant |
315 |
|
| 4270 |
Pedicle Soft Tissue Graft Procedure |
311 |
|
| 4271 |
Free Soft Tissue Graft Procedure |
302 |
|
| 4320 |
Provisional Splinting-Intracoronal |
118 |
|
| 4321 |
Provisional Splinting-Extracoronal |
84 |
|
| 4341 |
Periodontal Scaling/Root Planing-Per Quadrant
(covered twice per area of the mouth per 12 consecutive months) |
74 |
|
| 4910 |
Periodontal Maintenance Procedures
(covered twice per area of the mouth per 12 consecutive months) |
42 |
|
| 5510 |
Repair Broken Complete Denture Base **** |
46 |
|
| 5520 |
Replace Missing/Broken Teeth-Complete Denture**** |
42 |
|
| 5610 |
Repair Resin Saddle or Base**** |
55 |
|
| 5620 |
Repair Cast Framework**** |
46 |
|
| 5630 |
Repair Or Replace Broken Clasp**** |
71 |
|
| 5640 |
Replace Broken Teeth-Per Tooth**** |
46 |
|
| 5650 |
Add Tooth To Existing Partial Denture**** |
67 |
|
| 5660 |
Add Clasp To Existing Partial Denture**** |
75 |
|
| 5710 |
Rebase Complete Upper Denture**** |
84 |
|
| 5711 |
Rebase Complete Lower Denture |
84 |
|
| 5720 |
Rebase Upper Partial Denture**** |
84 |
|
| 5721 |
Rebase Lower Partial Denture****
****(covered only if repairs/adjustments are done more than 1 year
after the initial insertion) |
84 |
|
| 6930 |
Recement Bridge |
42 |
|
| 7110 |
Extraction-Single Tooth |
38 |
|
| 7120 |
Extraction-Each Additional Tooth |
36 |
|
| 7210 |
Surgical Removal of Erupted Tooth |
76 |
|
| 7230 |
Removal of Impacted Tooth-Partially Bony |
153 |
|
| 7240 |
Removal of Impacted Tooth-Completely Bony |
164 |
|
| 7250 |
Surgical Removal Of Residual Tooth Roots |
63 |
|
| 7270 |
Tooth Reimplantation |
86 |
|
| 7272 |
Tooth Transplantation |
84 |
|
| 7310 |
Alveoloplasty In Conjunction With Extractions-Per Quadrant |
76 |
|
| 7320 |
Alveoloplasty Not In Conjunc With Extractions-Per Quadrant |
96 |
|
| 7340 |
Vestibuloplasty-Ridge Exten (Secndry Epitheliztn) |
151 |
|
| 7350 |
Vestibuloplasty-Ridge Exten (W/Soft Tiss Gft) |
168 |
|
| 7510 |
I & D Abscess Intraoral-Soft Tissue |
50 |
|
| 7520 |
I & D Absc-Extraoral Soft Tissue |
76 |
|
| 7960 |
Frenulectomy (Frenectomy/Frenotomy) Separate Procedure |
147 |
|
| 7970 |
Excision Of Hyperplastic Tissue/ Per Arch |
92 |
|
| 9220 |
General anesthesia-First 30 Minutes |
116 |
|
| 9221 |
General Anesthesia-Each Additional15 Minutes |
79 |
|
| 9610 |
Therapeutic Drug Injection |
17 |
|
| 9951 |
Occlusion Adjustment-Limited |
29 |
|
| 9952 |
Occlusion Adjustment-Complete |
126 |
