| Type III – Major Dental Services |
 |
|
|
ADA
Code |
Procedure |
Maximum
Reimbursement |
| 470 |
Diagnostic Casts |
$20 |
 |
| 2510 |
Inlay-Metallic-One Surface |
147 |
|
| 2520 |
Inlay-Metallic-Two Surfaces |
171 |
|
| 2530 |
Inlay-Metallic-Three Or More Surfaces |
204 |
|
| 2610 |
Inlay-Porcelain/Ceramic-One Surface |
142 |
|
| 2620 |
Inlay-Porcelain/Ceramic-Two Surfaces |
158 |
|
| 2630 |
Inlay-Porcelain/Ceramic-Three Or More
Surfaces |
173 |
|
| 2710 |
Crown-Resin-Laboratory |
50 |
|
| 2720 |
Crown-Resin W/High Noble Metal |
105 |
|
| 2721 |
Crown-Resin W/Predominantly Base Metal |
95 |
|
| 2722 |
Crown-Resin W/Noble Metal |
100 |
|
| 2740 |
Crown-Porcelain/Ceramic Substrate |
250 |
|
| 2750 |
Crown-Porcelain Fused To High Noble
Metal |
226 |
|
| 2751 |
Crown-Porcelain Fused To Predominantly
Base Metal |
210 |
|
| 2752 |
Crown-Porcelain Fused To Noble Metal |
224 |
|
| 2790 |
Crown-Full Cast High Noble Metal |
236 |
|
| 2791 |
Crown-Full Cast Predominantly Base
Metal |
213 |
|
| 2792 |
Crown-Full Cast Noble Metal |
224 |
|
| 2810 |
Crown-3/4 Cast Metallic |
250 |
|
| 2930 |
Prefabricated Stainless Steel
Crown-Primary Tooth |
50 |
|
| 2931 |
Prefabricated Stainless Steel
Crown-Permanent Tooth |
56 |
|
| 2952 |
Cast Post And Core In Addition To Crown |
74 |
|
| 2954 |
Prefabricated Post And Core In Addition
To Crown |
71 |
|
| 2970 |
Temporary Crown (Fractured Tooth) |
50 |
|
| 3426 |
Apicoectomy/Periradicular Surgery-Each
Additional Root |
121 |
|
| 5110 |
Complete Denture-Maxillary |
261 |
|
| 5120 |
Complete Denture-Mandibular |
259 |
|
| 5130 |
Immediate Denture-Maxillary |
289 |
|
| 5140 |
Immediate Denture-Mandibular |
277 |
|
| 5211 |
Maxillary Part Denture-Resin Base
(Clasp/Rests) |
313 |
|
| 5212 |
Mandibular Part Denture-Resin Base
(Clasp/Rests) |
315 |
|
| 5213 |
Maxillary Part Denture-Metal Frame
W/Resin Base |
236 |
|
| 5214 |
Mandibular Part Denture-Metal Frame
W/Resin Base |
236 |
|
| 5281 |
Remov Unilat Part Denture-1 Piece Metal
(W/Teeth) |
126 |
|
| 5410 |
Adjust Complete Denture-Maxillary |
15 |
|
| 5411 |
Adjust Complete Denture-Mandibular |
16 |
|
| 5421 |
Adjust Partial Denture-Maxillary |
14 |
|
| 5422 |
Adjust Partial Denture-Mandibular |
15 |
|
| 5730 |
Reline Complete Maxillary Denture (Chairside) |
58 |
|
| 5731 |
Reline Complete Mandibular Denture (Chairside) |
66 |
|
| 5740 |
Reline Maxillary Partial Denture (Chairside) |
63 |
|
| 5741 |
Reline Mandibular Partial Denture (Chairside) |
63 |
|
| 5750 |
Reline Complete Maxillary Denture
(Laboratory) |
81 |
|
| 5751 |
Reline Complete Mandibular Denture
(Laboratory) |
82 |
|
| 5760 |
Reline Maxillary Partialdenture
(Laboratory) |
84 |
|
| 5761 |
Reline Mandibular Partial Denture
(Laboratory) |
79 |
|
| 6210 |
Pontic-Cast High Noble Metal |
236 |
|
| 6211 |
Pontic-Cast Predominantly Base Metal |
197 |
|
| 6212 |
Pontic-Castnoble Metal |
203 |
|
| 6240 |
Pontic-Porcelain Fused To High Noble
Metal |
224 |
|
| 6241 |
Pontic-Porcelain Fused To Predom. Base
Metal |
210 |
|
| 6242 |
Pontic-Porcelain Fused To Noble Metal |
224 |
|
| 6250 |
Pontic-Resin W/High Noble Metal |
224 |
|
| 6251 |
Pontic-Resin W/predominantly base metal |
213 |
|
| 6252 |
Pontic-Resin W/Noble Metal |
218 |
|
| 6520 |
Retainer-Inlay-Metallic-Two Surfaces |
184 |
|
| 6530 |
Retainer-Inlay-Metallic-Three Or More
Surfaces |
210 |
|
| 6720 |
Crown-Resin W/High Noble Metal |
184 |
|
| 6721 |
Crown-Resin W/Predominantly Base Metal |
171 |
|
| 6722 |
Crown-Resin W/Noble Metal |
184 |
|
| 6750 |
Crown-Retainer-Porcelain Fused High
Noble Metal |
224 |
|
| 6751 |
Crown-Retainer-Porcelain Fused Pred.
Base Metal |
210 |
|
| 6752 |
Crown-Retainer-Porcelain Fused To Noble
Metal |
224 |
|
| 6780 |
Crown-Retainer 3/4 Cast High Noble
Metal |
211 |
|
| 6790 |
Crown-Retainer-Full Cast High Noble
Metal |
239 |
|
| 6791 |
Crown-Retainer-Full Cast Predom. Base
Metal |
208 |
|
| 6792 |
Crown-Retainer-Full Cast Noble Metal |
218 |
| |
