Dental Care Schedule
Applies to Covered Services Provided by General Dentists Only
Covered dental services shown in the Dental Care Schedule must be performed by general dentists at the dental office location; except for Referral Care to specialty dentists when approved by Aetna or for Out-Of-Area Emergency Dental Care.
The Dental Care Schedule shows the patient payment that applies to some dental services. You are responsible for making the patient payment to the general dentist at the time services are performed.
Only services in the schedule below are covered under the Plan. Any services not specifically listed are the responsibility of the member and are payable at the dentist's usual and prevailing charge.
Specialty Dentists: If your general dentist cannot perform the covered dental procedure because of individual case circumstances or the severity of your condition, the general dentist may refer you to a specialty dentist. You may also see a participating specialty dentist without a referral. Specialty dentists include oral surgeons, orthodontists, endodontists, periodontists, pedodontists, and prosthodontists.
The Patient Payment for services provided by a specialty dentist is 75% of the dentist's usual and prevailing charge for the service. Payment is required at the time the service is rendered.
The Aetna DMO Participating Dentist Listing for the State of Texas DMO Plan can be viewed under "Insurance," “Dental,” then “Dental HMO” (Provider Look-up).
If you wish to select or change your general dentist or need assistance with selecting a specialty dentist, please contact Aetna Customer Service at 1-800-275-1794.
Diagnostic Dentistry
|
ADA Codes
|
Procedure
|
Copayment
|
|
D0120
|
Periodic oral exam/evaluation
(2 per plan year*)
|
No Charge
|
|
D0140
|
Oral evaluation -
problem focused
|
$22
|
|
D0145
|
Oral evaluation for a patient under three years of age and counseling with primary caregiver
|
No Charge
|
|
D0150
|
Clinical oral exam/evaluation (initial)
|
No Charge
|
|
D0160
|
Detailed and extensive oral evaluation - problem focused, by report
|
No Charge
|
|
D0170
|
Re-evaluation - limited, problem focused
|
No Charge
|
|
D0180
|
Comprehensive periodontal evaluation - new or established patient
|
No Charge
|
|
D0210
|
X-ray intraoral - complete series (including bitewings)
|
No Charge
|
|
D0220
|
X-ray intraoral - periapical - first film
|
No Charge
|
|
D0230
|
X-ray intraoral - periapical - each additional film
|
No Charge
|
|
D0240
|
X-ray intraoral - occlusal film
|
No Charge
|
|
D0250
|
X-ray extraoral - first film
|
No Charge
|
|
D0260
|
X-ray extraoral - each additional film
|
No Charge
|
|
D0270
|
X-ray bitewing - single film
|
No Charge
|
|
D0272
|
X-ray bitewings - two films
|
No Charge
|
|
D0273
|
X-ray bitewings - three films
|
No Charge
|
|
D0274
|
X-ray bitewings - four films
|
No Charge
|
|
D0277
|
X-ray vertical bitewings - 7 to 8 films
|
No Charge
|
|
D0330
|
X-ray panoramic
|
No Charge
|
|
D0350
|
Oral/facial images
|
No Charge
|
|
D0415
|
Collection of microorganisms for culture and sensitivity
|
No Charge
|
|
D0425
|
Caries susceptibility tests
|
No Charge
|
|
D0460
|
Pulp vitality tests
|
No Charge
|
|
D0470
|
Diagnostic casts (excluding ortho)
|
No Charge
|
|
D0472-80
|
Oral pathology procedures
|
No Charge
|
|
D0486
|
Accession of brush biopsy sample, microscopic examination, preparation and transmission of written report
|
$42
|
|
D0502
|
Other oral pathology procedures (by report)
|
No Charge
|
|
D0999
|
Unspecified diagnostic procedures (by report)
|
No Charge
|
|
D4999
|
Periodontal probing
|
$13
|
|
D9430
|
Office visit
|
No Charge
|
|
D9440
|
Office visit after regularly scheduled hours
|
$30
|
|
D0999
|
Sterilization fee
|
$7
|
|
*Plan year is a year starting September 1 and extending through August 31.
|
|
Preventive
|
ADA Codes
|
Procedure
|
Copayment
|
|
D1110
|
Dental cleaning / prophylaxis - adult (2 per plan year*)
|
$12
|
|
D1120
|
Dental cleaning / prophylaxis - child (12 years and under) (2 per plan year*)
|
$12
|
|
D1203
|
Topical application of fluoride - child
|
No Charge
|
|
D1204
|
Topical application of fluoride - adult
|
No Charge
|
|
D1206
|
Topical fluoride varnish; therapeutic application for moderate to high caries risk patients
|
No Charge
|
|
D1310
|
Nutritional counseling for the control of dental disease
|
No Charge
|
|
D1330
|
Oral hygiene instructions
|
No Charge
|
|
D1351
|
Sealant -- per tooth
|
$10
|
|
D1510
|
Space maintainer - fixed - unilateral
|
$90
|
|
D1515
|
Space maintainer - fixed - bilateral
|
$90
|
|
D1520
|
Space maintainer - removable - unilateral
|
$90
|
|
D1525
|
Space maintainer - removable - bilateral
|
$90
|
|
D1550
|
Recementation of space maintainer
|
$10
|
|
D1555
|
Removal of fixed space maintainer (by original dentist)
|
No Charge
|
|
D1555
|
Removal of fixed space maintainer (by different dentist)
|
$12
|
|
*Plan year is a year starting September 1 and extending through August 31.
|
|
Restorative
|
ADA Codes
|
Procedure
|
Copayment
|
|
D2140
|
Amalgam - 1 surface, primary or permanent
|
$22
|
|
D2150
|
Amalgam - 2 surfaces, primary or permanent
|
$27
|
|
D2160
|
Amalgam - 3 surfaces, primary or permanent
|
$32
|
|
D2161
|
Amalgam - 4 or more surfaces, primary or permanent
|
$37
|
|
D2330
|
Resin-based composite - 1 surface, anterior
|
$27
|
|
D2331
|
Resin-based composite - 2 surfaces, anterior
|
$32
|
|
D2332
|
Resin-based composite - 3 surfaces, anterior
|
$37
|
|
D2335
|
Resin-based composite - 4 or more surfaces or involving incisal angle, anterior
|
$52
|
|
D2390
|
Resin-based composite crown - anterior
|
$40
|
|
D2391
|
Resin-based composite - 1 surface posterior
|
$47
|
|
D2392
|
Resin-based composite - 2 surfaces posterior
|
$57
|
|
D2393
|
Resin-based composite - 3 surfaces posterior
|
$67
|
|
D2394
|
Resin-based composite - 4 or more surfaces, posterior
|
$74
|
|
D2410
|
Gold foil restoration - 1 surface
|
$60
|
|
D2420
|
Gold foil restoration - 2 surfaces
|
$140
|
|
D2430
|
Gold foil restoration - 3 surfaces
|
$180
|
|
Major Restorative
|
ADA Codes
|
Procedure
|
Copayment
|
|
D2510
|
Inlay - metallic - 1 surface
|
$140
|
|
D2520
|
Inlay - metallic - 2 surfaces
|
$170
|
|
D2530
|
Inlay - metallic - 3 or more surfaces
|
$200
|
|
D2542
|
Onlay - metallic - 2 surfaces
|
$250
|
|
D2543
|
Onlay - metallic - 3 surfaces
|
$260
|
|
D2544
|
Onlay - metallic - 4 or more surfaces
|
$270
|
|
D2610
|
Inlay - porcelain/ceramic - 1 surface
|
$247
|
|
D2620
|
Inlay - porcelain/ceramic - 2 surfaces
|
$297
|
|
D2630
|
Inlay - porcelain/ceramic - 3 or more surfaces
|
$297
|
|
D2642
|
Onlay - porcelain/ceramic - 2 surfaces
|
$317
|
|
D2643
|
Onlay - porcelain/ceramic - 3 surfaces
|
$317
|
|
D2644
|
Onlay - porcelain/ceramic - 4 or more surfaces
|
$327
|
|
D2650
|
Inlay - resin-based composite - 1 surface
|
$172
|
|
D2651
|
Inlay - resin-based composite - 2 surfaces
|
$182
|
|
D2652
|
Inlay - resin-based composite - 3 or more surfaces
|
$212
|
|
D2662
|
Onlay-resin-based composite - 2 surfaces
|
$212
|
|
D2663
|
Onlay-resin-based composite - 3 surfaces
|
$222
|
|
D2664
|
Onlay-resin-based composite - 4 or more surfaces
|
$237
|
|
D2710
|
Crown resin based composite (indirect)
|
$318
|
|
D2712
|
Crown - ¾ resin-based composite (indirect)
|
$318
|
|
D2720
|
Crown resin with high noble metal
|
$368
|
|
D2721
|
Crown resin with predominantly base metal
|
$260
|
|
D2722
|
Crown resin with noble metal
|
$299
|
|
D2740
|
Crown - porcelain/ceramic substrate
|
$410
|
|
D2750
|
Crown - porcelain fused to high noble metal
|
$410
|
|
D2751
|
Crown - porcelain fused to predominantly base metal
|
$360
|
|
D2752
|
Crown - porcelain fused to noble metal
|
$399
|
|
D2780
|
Crown - ¾ cast high noble metal
|
$399
|
|
D2781
|
Crown - ¾ cast predominately base metal
|
$350
|
|
D2782
|
Crown - ¾ cast noble metal
|
$389
|
|
D2783
|
Crown - ¾ cast porcelain/ceramic
|
$350
|
|
D2790
|
Crown - full cast high noble metal
|
$410
|
|
D2791
|
Crown - full cast predominantly base metal
|
$360
|
|
D2792
|
Crown - full cast noble metal
|
$399
|
|
D2794
|
Crown - titanium
|
$410
|
|
D2910
|
Recement inlay, onlay or partial coverage restoration (by original dentist)
|
No Charge
|
|
D2910
|
Recement inlay, onlay or partial coverage restoration (by new dentist)
|
$5
|
|
D2915
|
Recement cast or prefabricated post and core
|
$5
|
|
D2920
|
Recement crown (by original dentist)
|
No Charge
|
|
D2920
|
Recement crown (by new dentist)
|
$5
|
|
D2930
|
Prefabricated stainless steel crown - primary tooth
|
$50
|
|
D2931
|
Prefabricated stainless steel crown - permanent tooth
|
$55
|
|
D2932
|
Prefabricated resin crown
|
No Charge
|
|
D2933
|
Prefabricated stainless steel crown with resin window
|
$65
|
|
D2934
|
Prefabricated esthetic coated stainless steel crown - primary tooth
|
$65
|
|
D2940
|
Sedative filling
|
$5
|
|
D2950
|
Core buildup, including any pins
|
$65
|
|
D2951
|
Pin retention - per tooth, in addition to restoration
|
No Charge
|
|
D2952
|
Post and core, in addition to crown, indirectly fabricated
|
$62
|
|
D2953
|
Each additional indirectly fabricated post - same tooth
|
$18
|
|
D2954
|
Prefabricated post and core, in addition to crown
|
$58
|
|
D2957
|
Each additional prefabricated post - same tooth
|
$15
|
|
D2961
|
Labial veneer (resin laminate) - laboratory
|
$297
|
|
D2962
|
Labial veneer (porcelain laminate) - laboratory
|
$380
|
|
D2970
|
Temporary crown (fractured tooth)
|
$25
|
|
D2971
|
Additional procedures to construct new crown under existing partial denture framework
|
$15
|
|
D2975
|
Coping
|
$148
|
|
D2980
|
Crown repair (by report)
|
$30
|
|
D2999
|
Unspecified restorative procedure (by report)
|
No Charge
|
|
D2999
|
Temporary metal crown (with permanent)
|
No Charge
|
|
Endodontics
|
ADA Codes
|
Procedure
|
Copayment
|
|
D3999
|
Endodontic consultation
|
No Charge
|
|
D3110
|
Pulp cap direct (excluding final restoration)
|
No Charge
|
|
D3120
|
Pulp cap indirect (excluding final restoration)
|
No Charge
|
|
D3220
|
Therapeutic pulpotomy (excluding final restoration)
|
$35
|
|
D3310
|
Root Canal - Anterior
|
$170
|
|
D3320
|
Root Canal - Bicuspid
|
$190
|
|
D3330
|
Root Canal - Molar
|
$250
|
|
D3351-53
|
Apexification / Recalcification
|
No Charge
|
|
D3410
|
Apicoectomy/periradicular surgery - anterior
|
$140
|
|
D3421
|
Apicoectomy/periradicular surgery - bicuspid (first root)
|
$140
|
|
D3425
|
Apicoectomy/Periradicular surgery molar - first root
|
$170
|
|
D3426
|
Apicoectomy/Periradicular surgery - each add'l root
|
$90
|
|
D3430
|
Retrograde filling - per root
|
$35
|
|
D3450
|
Root amputation - per root
|
$55
|
|
D3470
|
Intentional replantation (including necessary splinting)
|
$55
|
|
D3910
|
Surgical procedure for isolation of tooth with rubber dam
|
$3
|
|
D3920
|
Hemisection (including any root removal), not including root therapy
|
$66
|
|
D3999
|
Unspecified endodontic procedure (by report)
|
No Charge
|
|
D3999
|
Culturing canal
|
No Charge
|
|
Periodontics
|
ADA Codes
|
Procedure
|
Copayment
|
|
D4999
|
Periodontal consultation, evaluation and treatment plan
|
No Charge
|
|
D4210
|
Gingivectomy or gingivoplasty - 4 or more contiguous teeth or bounded teeth spaces per quadrant
|
$156
|
|
D4211
|
Gingivectomy or gingivoplasty - 1 to 3 contiguous teeth or bounded teeth spaces, per quadrant
|
$94
|
|
D4240
|
Gingival flap procedure, including root planing - 4 or more contiguous teeth or bounded teeth spaces per quadrant
|
$220
|
|
D4241
|
Gingival flap procedure, including root planing - 1 to 3 contiguous teeth or bounded teeth spaces, per quadrant
|
$132
|
|
D4260
|
Osseous surgery (incl. flap entry and closure) - 4 or more contiguous teeth or bounded teeth spaces per quadrant
|
$220
|
|
D4261
|
Osseous surgery (incl. flap entry and closure) - 1 to 3 contiguous teeth or bounded teeth spaces per quadrant
|
$132
|
|
D4263
|
Bone replacement graft - first site in quadrant
|
$150
|
|
D4264
|
Bone replacement graft - each add'l site in quadrant
|
$150
|
|
D4265
|
Biologic materials to aid in soft and osseous tissue regeneration
|
$150
|
|
D4320
|
Provisional splinting - intracoronal
|
$60
|
|
D4321
|
Provisional splinting - extracoronal
|
$60
|
|
D4341
|
Periodontal scaling and root planing - 4 or more teeth per quadrant
|
$50
|
|
D4342
|
Periodontal scaling and root planing - 1 to 3 teeth per quadrant
|
$32
|
|
D4355
|
Full mouth debridement to enable comprehensive evaluation and diagnosis
|
$42
|
|
D4910
|
Periodontal maintenance procedures (following active therapy)
|
$37
|
|
D4920
|
Unscheduled dressing change (other than treating dentist)
|
No Charge
|
|
D4999
|
Unspecified periodontal procedure (by report)
|
No Charge
|
|
D4999
|
Home care instructions for periodontal management
|
No Charge
|
|
D4999
|
Post-therapeutic evaluation
|
No Charge
|
|
D4999
|
Non-surgical service periodontal
|
No Charge
|
|
Prosthodontics - Removable
|
ADA Codes
|
Procedure
|
Copayment
|
|
D5110
|
Complete denture, maxillary
|
$490
|
|
D5120
|
Complete denture, mandibular
|
$490
|
|
D5110
|
Complete denture, maxillary (duplicate)
|
$260
|
|
D5120
|
Complete denture, mandibular (duplicate)
|
$260
|
|
D5130
|
Immediate denture - maxillary
|
$518
|
|
D5140
|
Immediate denture - mandibular
|
$518
|
|
D5211
|
Maxillary partial denture - resin base, including any conventional clasps, rests & teeth
|
$503
|
|
D5212
|
Mandibular partial denture - resin base, including any conventional clasps, rests & teeth
|
$503
|
|
D5213
|
Maxillary partial denture - cast metal framework with resin denture bases, including any conventional clasps, rests & teeth
|
$578
|
|
D5214
|
Mandibular partial denture - cast metal framework with resin denture bases, including any conventional clasps, rests & teeth
|
$578
|
|
D5225
|
Maxillary partial denture - flexible base (including any clasps, rests and teeth)
|
$538
|
|
D5226
|
Mandibular partial denture - flexible base (including any clasps, rests and teeth)
|
$538
|
|
D5410
|
Adjustment complete denture - maxillary (by original dentist)
|
No Charge
|
|
D5410
|
Adjustments complete denture - maxillary (by new dentist)
|
$10
|
|
D5411
|
Adjustments complete denture - mandibular (by original dentist)
|
No Charge
|
|
D5411
|
Adjustments complete denture - mandibular (by new dentist)
|
$10
|
|
D5421
|
Adjustments partial denture - maxillary (by original dentist)
|
No Charge
|
|
D5421
|
Adjustments partial denture - maxillary (by new dentist)
|
$10
|
|
D5422
|
Adjustments partial denture - mandibular (by original dentist)
|
No Charge
|
|
D5422
|
Adjustments partial denture - mandibular (by new dentist)
|
$10
|
|
D5510
|
Repair broken complete denture base
|
$35
|
|
D5520
|
Repair missing or broken teeth - complete denture (per tooth)
|
$20
|
|
D5610
|
Repair resin denture base
|
$78
|
|
D5620
|
Repair cast framework
|
$78
|
|
D5630
|
Repair or replace broken clasp
|
$78
|
|
D5640
|
Replace broken teeth (per tooth)
|
$78
|
|
D5650
|
Add tooth to existing partial denture
|
$78
|
|
D5660
|
Add clasp to existing partial denture
|
$78
|
|
D5670
|
Replace all teeth and acrylic on cast metal framework (maxillary)
|
$164
|
|
D5671
|
Replace all teeth and acrylic on cast metal framework (mandibular)
|
$164
|
|
D5710
|
Rebase complete maxillary denture
|
$164
|
|
D5711
|
Rebase complete mandibular denture
|
$164
|
|
D5720
|
Rebase maxillary partial denture
|
$164
|
|
D5721
|
Rebase mandibular partial denture
|
$164
|
|
D5730
|
Reline complete maxillary denture (chairside)
|
$60
|
|
D5731
|
Reline complete mandibular denture (chairside)
|
$60
|
|
D5740
|
Reline maxillary partial denture (chairside)
|
$60
|
|
D5741
|
Reline mandibular partial denture (chairside)
|
$60
|
|
D5750
|
Reline complete maxillary denture (laboratory)
|
$75
|
|
D5751
|
Reline complete mandibular denture (laboratory)
|
$75
|
|
D5760
|
Reline maxillary partial denture (laboratory)
|
$75
|
|
D5761
|
Reline mandibular partial denture (laboratory)
|
$75
|
|
D5810
|
Interim complete denture (maxillary)
|
$60
|
|
D5811
|
Interim complete denture (mandibular )
|
$60
|
|
D5820
|
Interim partial denture (maxillary )
|
$90
|
|
D5821
|
Interim partial denture (mandibular )
|
$90
|
|
D5850
|
Tissue conditioning, maxillary
|
$20
|
|
D5851
|
Tissue conditioning, mandibular
|
$20
|
|
D5862
|
Precision attachment (by report)
|
$150
|
|
D5899
|
Unspecified removable prosthodontic procedure, by report
|
No Charge
|
|
Implant Services
|
ADA Codes
|
Procedure
|
Copayment
|
|
D6010
|
Surgical placement of implant body: endosteal implant
|
$900
|
|
Implant Supported Prosthetics
|
ADA Codes
|
Procedure
|
Copayment
|
|
D6053
|
Implant/abutment supported removable denture for completely edentulous arch
|
$590
|
|
D6054
|
Implant/abutment supported removable denture for partially edentulous arch
|
$687
|
|
D6058
|
Abutment supported porcelain/ceramic crown
|
$461
|
|
D6059
|
Abutment supported porcelain fused to metal crown (high noble metal)
|
$461
|
|
D6060
|
Abutment supported porcelain fused to metal crown (predominantly base metal)
|
$412
|
|
D6061
|
Abutment supported porcelain fused to metal crown (noble metal)
|
$451
|
|
D6062
|
Abutment supported cast metal crown (high noble metal)
|
$461
|
|
D6063
|
Abutment supported cast metal crown (predominantly base metal)
|
$412
|
|
D6064
|
Abutment supported cast metal crown (noble metal)
|
$451
|
|
D6065
|
Implant supported porcelain/ceramic crown
|
$461
|
|
D6066
|
Implant supported porcelain fused to metal crown (titanium, titanium alloy, or high noble metal)
|
$461
|
|
D6067
|
Implant supported metal crown (titanium, titanium alloy, or high noble metal)
|
$461
|
|
D6068
|
Abutment supported retainer for porcelain/ceramic fixed partial denture
|
$461
|
|
D6069
|
Abutment supported retainer for porcelain fused to metal fixed partial denture (high noble metal)
|
$461
|
|
D6070
|
Abutment supported retainer for porcelain fused to metal fixed partial denture (predominantly base metal)
|
$412
|
|
D6071
|
Abutment supported retainer for porcelain fused to metal fixed partial denture (noble metal)
|
$451
|
|
D6072
|
Abutment supported retainer for cast metal fixed partial denture (high noble metal)
|
$461
|
|
D6073
|
Abutment supported retainer for cast metal fixed partial denture (predominantly base metal)
|
$412
|
|
D6074
|
Abutment supported retainer for cast metal fixed partial denture (noble metal)
|
$451
|
|
D6075
|
Implant supported retainer for ceramic fixed partial denture
|
$461
|
|
D6076
|
Implant supported retainer for porcelain fused to metal fixed partial denture (titanium, titanium alloy, or high noble metal)
|
$461
|
|
D6077
|
Implant supported retainer for cast metal fixed partial denture (titanium, titanium alloy, or high noble metal)
|
$461
|
|
D6091
|
Replacement of semi-precision or precision attachment
|
$155
|
|
D6092
|
Recement implant / abutment supported crown
|
$20
|
|
D6093
|
Recement implant / abutment supported fixed partial denture
|
$20
|
|
D6094
|
Abutment supported crown - titanium
|
$461
|
|
D6194
|
Abutment supported retainer crown for FPD - titanium
|
$461
|
|
Prosthodontics - Fixed
|
ADA Codes
|
Procedure
|
Copayment
|
|
The following bridge prices are listed on a per unit basis. A unit equals each tooth restored or replaced.
|
|
D6205
|
Pontic - indirect resin based composite
|
$350
|
|
D6210
|
Pontic - cast high noble metal
|
$410
|
|
D6211
|
Pontic - cast predominantly base metal
|
$360
|
|
D6212
|
Pontic - cast noble metal
|
$399
|
|
D6214
|
Pontic - titanium
|
$410
|
|
D6240
|
Pontic - porcelain fused to high noble metal
|
$410
|
|
D6241
|
Pontic - porcelain fused to predominantly base metal
|
$360
|
|
D6242
|
Pontic - porcelain fused to noble metal
|
$399
|
|
D6245
|
Pontic - porcelain/ceramic
|
$360
|
|
D6250
|
Pontic - resin with high noble metal
|
$399
|
|
D6251
|
Pontic - resin with predominantly base metal
|
$350
|
|
D6252
|
Pontic - resin with noble metal
|
$389
|
|
D6253
|
Provisional pontic (interim of at least 6 months)
|
$200
|
|
D6545
|
Retainer - cast metal for resin bonded ("Maryland") fixed prosthesis
|
$236
|
|
D6548
|
Retainer - porcelain/ceramic for resin bonded fixed prosthesis
|
$236
|
|
D6600
|
Inlay - porcelain / ceramic, two surfaces
|
$297
|
|
D6601
|
Inlay - porcelain / ceramic, three or more surfaces
|
$297
|
|
D6602
|
Inlay - cast high noble metal, two surfaces
|
$200
|
|
D6603
|
Inlay - cast high noble metal, three and more surfaces
|
$230
|
|
D6604
|
Inlay - cast predominantly base metal, two surfaces
|
$170
|
|
D6605
|
Inlay - cast predominantly base metal, three or more surfaces
|
$200
|
|
D6606
|
Inlay - cast noble metal, two surfaces
|
$190
|
|
D6607
|
Inlay - cast noble metal, three or more surfaces
|
$220
|
|
D6608
|
Onlay - porcelain / ceramic, two surfaces
|
$317
|
|
D6609
|
Onlay - porcelain / ceramic, three or more surfaces
|
$317
|
|
D6610
|
Onlay - cast high noble metal, two surfaces
|
$280
|
|
D6611
|
Onlay - cast high noble metal, three or more surfaces
|
$290
|
|
D6612
|
Onlay - cast predominantly base metal, two surfaces
|
$250
|
|
D6613
|
Onlay - cast predominantly base metal, three or more surfaces
|
$260
|
|
D6614
|
Onlay - cast noble metal, two surfaces
|
$270
|
|
D6615
|
Onlay - cast noble metal, three or more surfaces
|
$280
|
|
D6624
|
Inlay - Titanium
|
$200
|
|
D6634
|
Onlay - Titanium
|
$280
|
|
D6710
|
Crown - indirect resin based composite
|
$260
|
|
D6720
|
Crown - resin with high noble metal
|
$368
|
|
D6721
|
Crown - resin with predominantly base metal
|
$260
|
|
D6722
|
Crown - resin with noble metal
|
$299
|
|
D6740
|
Crown - porcelain/ceramic
|
$410
|
|
D6750
|
Crown - porcelain fused to high noble metal
|
$410
|
|
D6751
|
Crown - porcelain fused to predominantly base metal
|
$360
|
|
D6752
|
Crown - porcelain fused to noble metal
|
$399
|
|
D6780
|
Crown - ¾ cast high noble metal
|
$399
|
|
D6781
|
Crown - ¾ cast predominately base metal
|
$350
|
|
D6782
|
Crown - ¾ cast noble metal
|
$389
|
|
D6783
|
Crown - ¾ porcelain/ceramic
|
$350
|
|
D6790
|
Crown - full cast high noble metal
|
$410
|
|
D6791
|
Crown - full cast predominantly base metal
|
$360
|
|
D6792
|
Crown - full cast noble metal
|
$399
|
|
D6793
|
Provisional retainer crown (interim of at least 6 months)
|
$200
|
|
D6794
|
Crown - titanium
|
$410
|
|
D6930
|
Recement fixed partial denture (by original dentist)
|
No Charge
|
|
D6930
|
Recement fixed partial denture (by new dentist)
|
$15
|
|
D6940
|
Stress breaker
|
$148
|
|
D6950
|
Precision attachment
|
$145
|
|
D6970
|
Post and core in addition to fixed partial denture retainer, indirectly fabricated
|
$62
|
|
D6972
|
Prefabricated post and core in addition to fixed partial denture retainer
|
$58
|
|
D6973
|
Core build up for retainer, including any pins
|
$65
|
|
D6975
|
Coping - metal
|
$148
|
|
D6976
|
Each additional indirectly fabricated post - same tooth
|
$18
|
|
D6977
|
Each additional prefabricated post - same tooth
|
$15
|
|
D6980
|
Fixed partial denture repair (by report)
|
$123
|
|
|
|
|
|
Oral Surgery
|
ADA Codes
|
Procedure
|
Copayment
|
|
D7111
|
Extraction, coronal remnants - deciduous tooth
|
$15
|
|
D7140
|
Extraction, erupted tooth or exposed tooth (elevation and/or forceps removal)
|
$28
|
|
D7210
|
Surgical removal of erupted tooth
|
$42
|
|
D7220
|
Removal of impacted tooth, soft tissue
|
$64
|
|
D7230
|
Removal of impacted tooth, partially bony
|
$78
|
|
D7240
|
Removal of impacted tooth, completely bony
|
$115
|
|
D7241
|
Removal of impacted tooth - completely bony with unusual surgical complications
|
$126
|
|
D7250
|
Surgical removal of residual tooth roots (cutting procedure)
|
$50
|
|
D7280
|
Surgical access of an unerupted tooth to aid eruption
|
$90
|
|
D7282
|
Mobilization of erupted or malpositioned tooth to aid eruption
|
$75
|
|
D7283
|
Placement of device to facilitate eruption of impacted tooth
|
$18
|
|
D7285
|
Biopsy of oral tissue - hard (bone, tooth)
|
$150
|
|
D7286
|
Biopsy of oral tissue - soft
|
$150
|
|
D7287
|
Exfoliative cytology sample collection
|
$40
|
|
D7288
|
Brush biopsy - transepithelial sample collection
|
$40
|
|
D7310
|
Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant
|
$50
|
|
D7311
|
Alveoplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant
|
$25
|
|
D7320
|
Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces, per quadrant
|
$75
|
|
D7321
|
Alveoplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant
|
$38
|
|
D7471
|
Removal of lateral exostosis (maxilla or mandible)
|
$150
|
|
D7472
|
Removal of torus palatinus
|
$150
|
|
D7473
|
Removal of torus mandibularis
|
$150
|
|
D7485
|
Surgical reduction of osseous tuberosity
|
$150
|
|
D7510
|
Incision and drainage per abscess - intraoral soft tissue
|
$35
|
|
D7511
|
Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces)
|
$38
|
|
D7520
|
Incision and drainage per abscess - extraoral soft tissue
|
$40
|
|
D7521
|
Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces)
|
$44
|
|
D7950
|
Osseous, osteoperiosteal, periosteal, or cartilage graft of the mandible or facial bones - autogenous or nonautogenous by report
|
$150
|
|
D7953
|
Bone replacement graft for ridge preservation - per site
|
$18
|
|
D7960
|
Frenulectomy (frenectomy or frenotomy) separate procedure
|
$84
|
|
D7963
|
Frenuloplasty
|
$86
|
|
D7970
|
Excision of hyperplastic tissue (per arch)
|
$100
|
|
D7972
|
Surgical reduction of fibrous tuberosity
|
$50
|
|
Orthodontics
|
ADA Codes
|
Procedure
|
Copayment
|
|
D8999
|
Orthodontic exam (including consultation)
|
$126
|
|
D8010
|
Limited orthodontic treatment of the primary dentition
|
$500
|
|
D8020
|
Limited orthodontic treatment of the transitional dentition
|
$500
|
|
D8070
|
Comprehensive orthodontic treatment of transitional dentition
|
$1,800
|
|
D8080
|
Comprehensive treatment of adolescent dentition
|
$2,100
|
|
D8090
|
Comprehensive treatment of adult dentition
|
$2,100
|
|
D8220
|
Fixed appliance therapy (habit appliance)
|
$250
|
|
D8680
|
Orthodontic retention (removal of appliances, construction and placement of retainer(s))
|
$100
|
|
D8999
|
Adjusting retainers
|
No Charge
|
|
D8999
|
Elastics
|
No Charge
|
|
D8999
|
Final orthodontic records
|
No Charge
|
|
D8999
|
Reattach brackets and bands
(limit 3)
|
No Charge
|
|
D8999
|
Replace broken ligature wires
(limit 3)
|
No Charge
|
|
Other Services
|
ADA Codes
|
Procedure
|
Copayment
|
|
D9110
|
Palliative (emergency) treatment of dental pain - minor procedure
|
$15
|
|
D9120
|
Fixed partial denture sectioning
|
$125
|
|
D9211
|
Regional block anesthesia
|
No Charge
|
|
D9212
|
Trigeminal division block anesthesia
|
No Charge
|
|
D9215
|
Local anesthesia
|
No Charge
|
|
D9230
|
Analgesia, anxiolysis, inhalation of nitrous oxide
|
$10
|
|
D9310
|
Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment)
|
No Charge
|
|
D9450
|
Case presentation, detailed and extensive treatment planning
|
No Charge
|
|
D9940
|
Occlusal guard, by report
|
$150
|
|
D9942
|
Repair and/or relining of occlusal guard
|
$39
|
|
D9951
|
Occlusal adjustment - limited
|
$10
|
|
D9952
|
Occlusal adjustment - complete
|
$40
|
|
D0999
|
Preparatory fee
|
No Charge
|
|
Any services not specifically listed are the responsibility of the member and are payable at the participating dentist's usual and prevailing charge. If in doubt, ask your dentist.
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| Document Utilities |
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