RFP_26-041-DJ_Appendix C_Option I_DHMO Plan (Basic) - draft.xlsx
XLSX spreadsheet 42 KB Posted
- Attached to
- Multiple Option Dental Program
- Solicitation number
- RFP 680 26-041/DJ 3
- Issued by
- Palm Beach County, Florida
About this file
This document is an Appendix C Benefit Comparison Worksheet for a Multiple Option Dental Program (RFP 26-041/DJ) in Florida, specifically detailing the proposed benefits and cost-sharing structure for Option I - DHMO Plan (Basic). The worksheet outlines comprehensive dental service coverage across multiple categories including diagnostic and preventive services, restorative dentistry, endodontic services, periodontic services, prosthodontics, implant-supported prosthetics, oral surgery, orthodontics, and miscellaneous dental procedures. Each service line item includes the ADA procedure code, service description, network copayment amount, out-of-network reimbursement amount, and coverage status (covered or not covered).
The DHMO Plan (Basic) establishes a network-based model with low or no copayments for preventive and diagnostic services to encourage utilization, including periodic oral evaluations at $0 copay, prophylaxis services at $0 copay, and most radiographic imaging at $0 to minimal copayments. However, the plan demonstrates significant coverage restrictions on advanced services, with most endodontic services, periodontic surgical procedures, prosthodontic services, implant-supported prosthetics, orthodontic treatments, and advanced oral surgery marked as "Not Covered." Out-of-network reimbursement is limited primarily to basic diagnostic and preventive services with specified reimbursement amounts, while most advanced treatment options are excluded from out-of-network coverage. This benefit structure indicates a cost-containment approach emphasizing preventive care and basic restorative services through an in-network provider system.
View the file
Other files
Show all 19
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Appendix C - Opt I DHMO
| APPENDIX C | ||||||||
| BENEFIT COMPARISON WORKSHEET | ||||||||
| RFP NO. 26-041/DJ | ||||||||
| OPTION I - DHMO PLAN (BASIC) | ||||||||
| PROPOSER'S RESPONSE | ||||||||
| BENEFIT DESCRIPTION & LIMITATION | NETWORK COPAYMENT | OUT-OF-NETWORK REIMBURSEMENT AMOUNT | COVERED - Y/N | COPAY | OUT-OF-NETWORK REIMBURSEMENT AMOUNT | LIMITATIONS | EXCLUSIONS | |
| APPOINTMENTS | ||||||||
| D0120 *Periodic oral evaluation - established patient | $0 | $20 | ||||||
| D0140 Limited oral evaluation - problem focused | $0 | $20 | ||||||
| D0145 *Oral evaluation for a patient under three years of age and counseling with primary caregiver | $0 | $20 | ||||||
| D0150 *Comprehensive oral evaluation - new or established | ||||||||
| patient | $0 | $20 | ||||||
| D0160 *Detailed and extensive oral evaluation - problem focused, by report | $0 | $20 | ||||||
| D0170 Re-evaluation - limited, problem focused (established | ||||||||
| patient; not post-operative visit) | $0 | $20 | ||||||
| D0171 Re-evaluation – post-operative office visit | $0 | Not Covered | ||||||
| D0180 *Comprehensive periodontal evaluation - new or established patient | $0 | $20 | ||||||
| RADIOGRAPHY / DIAGNOSTIC DENTISTRY | ||||||||
| D0210 *Intraoral - complete series of radiographic images | $0 | $25 | ||||||
| D0220 Intraoral - periapical first radiographic image | $4 | $4 | ||||||
| D0230 Intraoral - periapical each additional radiographic image | $2 | $2 | ||||||
| D0240 Intraoral - occlusal radiographic image | $0 | Not Covered | ||||||
| D0250 Extra-oral – 2d projection radiographic image created using a stationary radiation source, and detector | $0 | Not Covered | ||||||
| D0251 *Extra-oral posterior dental radiographic image | $0 | Not Covered | ||||||
| D0270 *Bitewing - single radiographic image | $0 | $10 | ||||||
| D0272 *Bitewings - two radiographic images | $0 | $15 | ||||||
| D0273 *Bitewings - three radiographic images | $0 | $20 | ||||||
| D0274 *Bitewings - four radiographic images | $0 | $23 | ||||||
| D0277 *Vertical bitewings - 7 to 8 radiographic images | $29 | $25 | ||||||
| D0310 Sialography | $150 | Not Covered | ||||||
| D0320 Temporomandibular joint arthrogram, including injection | $250 | Not Covered | ||||||
| D0321 Other temporomandibular joint radiographic images, by report | $150 | Not Covered | ||||||
| D0322 Tomographic survey | $150 | Not Covered | ||||||
| D0330 *Panoramic radiographic image | $50 | $25 | ||||||
| D0340 2d cephalometric radiographic image – acquisition, measurement and analysis | $125 | Not Covered | ||||||
| D0350 2d oral/facial photographic image obtained intra-orally or extra-orally | $20 | $15 | ||||||
| D0364 *Cone beam ct capture and interpretation with limited field of view – less than one whole jaw | $169 | Not Covered | ||||||
| D0365 *Cone beam ct capture and interpretation with field of view of one full dental arch – mandible | $149 | Not Covered | ||||||
| D0366 *Cone beam ct capture and interpretation with field of view of one full dental arch – maxilla, with or without cranium | $139 | Not Covered | ||||||
| D0367 *Cone beam ct capture and interpretation with field of view of both jaws; with or without cranium | $139 | Not Covered | ||||||
| D0368 *Cone beam ct capture and interpretation for tmj series including two or more exposures | $184 | Not Covered | ||||||
| D0369 *Maxillofacial mri capture and interpretation | $139 | Not Covered | ||||||
| D0370 *Maxillofacial ultrasound capture and interpretation | $189 | Not Covered | ||||||
| D0371 *Sialoendoscopy capture and interpretation | $169 | Not Covered | ||||||
| D0380 *Cone beam ct image capture with limited field of view – | ||||||||
| less than one whole jaw | $169 | Not Covered | ||||||
| D0381 *Cone beam ct image capture with field of view of one full dental arch – mandible | $149 | Not Covered | ||||||
| D0382 *Cone beam ct image capture with field of view of one full dental arch – maxilla, with or without cranium | $139 | Not Covered | ||||||
| D0383 *Cone beam ct image capture with field of view of both jaws; with or without cranium | $139 | Not Covered | ||||||
| D0384 *Cone beam ct image capture for tmj series including two or more exposures | $184 | Not Covered | ||||||
| D0385 *Maxillofacial mri image capture | $139 | Not Covered | ||||||
| D0386 *Maxillofacial ultrasound image capture | $169 | Not Covered | ||||||
| D0393 *Treatment simulation using 3d image volume | $9 | Not Covered | ||||||
| D0394 *Digital subtraction of two or more images or image volumes of the same modality | $9 | Not Covered | ||||||
| D0395 *Fusion of two or more 3d image volumes of one or more modalities | $9 | Not Covered | ||||||
| D0415 Collection of microorganisms for culture and sensitivity | $0 | Not Covered | ||||||
| D0425 Caries susceptibility tests | $0 | Not Covered | ||||||
| D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures | $65 | Not Covered | ||||||
| D0460 Pulp vitality tests | $0 | Not Covered | ||||||
| D0470 Diagnostic casts | $0 | Not Covered | ||||||
| D0472 Accession of tissue, gross examination, preparation and transmission of written report | $0 | Not Covered | ||||||
| D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report | $0 | Not Covered | ||||||
| D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report | $0 | Not Covered | ||||||
| D0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report | $0 | Not Covered | ||||||
| D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report | $0 | Not Covered | ||||||
| D0502 Other oral pathology procedures, by report | $0 | Not Covered | ||||||
| D0600 Non-ionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin, and cementum | $0 | Not Covered | ||||||
| D0601 Caries risk assessment and documentation, with a finding of low risk | $0 | Not Covered | ||||||
| D0602 Caries risk assessment and documentation, with a finding of moderate risk | $0 | Not Covered | ||||||
| D0603 Caries risk assessment and documentation, with a finding of high risk | $0 | Not Covered | ||||||
| D0701 *Panoramic radiographic image – image capture only | $50 | $25 | ||||||
| D0702 *2-D cephalometric radiographic image – image capture only | $125 | Not Covered | ||||||
| D0703 *2-D oral/facial photographic image obtained intra-orally or extra-orally – image capture only | $20 | $15 | ||||||
| D0705 *Extra-oral posterior dental radiographic image – image capture only | $0 | Not Covered | ||||||
| D0706 *Intraoral – occlusal radiographic image – image capture only | $0 | Not Covered | ||||||
| D0707 *Intraoral – periapical radiographic image – image capture only | $2 | $2 | ||||||
| D0708 *Intraoral – bitewing radiographic image – image capture only | $0 | $10 | ||||||
| D0709 *Intraoral – complete series of radiographic images – image capture only | $0 | $25 | ||||||
| D0999 Unspecified diagnostic procedure, by report | $0 | Not Covered | ||||||
| PREVENTIVE DENTISTRY | ||||||||
| D1110 *Prophylaxis - adult | $0 | $35 | ||||||
| D1110 Prophylaxis - adult additional | $20 | Not Covered | ||||||
| D1120 *Prophylaxis - child | $0 | $25 | ||||||
| D1120 Prophylaxis - child additional | $20 | Not Covered | ||||||
| D1206 *Topical application of fluoride varnish | $15 | Not Covered | ||||||
| D1208 *Topical application of fluoride – excluding varnish | $0 | $10 | ||||||
| D1310 Nutritional counseling for control of dental disease | $0 | Not Covered | ||||||
| D1320 Tobacco counseling for the control and prevention of oral disease | $0 | Not Covered | ||||||
| D1330 Oral hygiene instructions | $0 | Not Covered | ||||||
| D1351 *Sealant - per tooth | $0 | $20 | ||||||
| D1352 *Preventive resin restoration in a moderate to high caries risk patient – permanent tooth | $0 | Not Covered | ||||||
| D1353 Sealant repair – per tooth | $0 | Not Covered | ||||||
| D1354 *Interim caries arresting medicament application – per tooth | $20 | Not Covered | ||||||
| D1355 Caries preventive medicament application – per tooth | $20 | Not Covered | ||||||
| D1510 *Space maintainer - fixed - unilateral | $0 | $50 | ||||||
| D1516 *Space maintainer – fixed – bilateral, maxillary | $0 | $75 | ||||||
| D1517 *Space maintainer – fixed – bilateral, mandibular | $0 | $75 | ||||||
| D1520 *Space maintainer - removable - unilateral | $0 | $50 | ||||||
| D1526 *Space maintainer – removable – bilateral, maxillary | $0 | $75 | ||||||
| D1527 *Space maintainer – removable – bilateral, mandibular | $0 | $75 | ||||||
| D1551 Re-cement or re-bond bilateral space maintainer - maxillary | $15 | Not Covered | ||||||
| D1552 Re-cement or re-bond bilateral space maintainer - mandibular | $15 | Not Covered | ||||||
| D1553 Re-cement or re-bond unilateral space maintainer - per quadrant | $15 | Not Covered | ||||||
| D1556 Removal of fixed unilateral space maintainer - per quadrant | $15 | Not Covered | ||||||
| D1557 Removal of fixed bilateral space maintainer - maxillary | $15 | Not Covered | ||||||
| D1558 Removal of fixed bilateral space maintainer - mandibular | $15 | Not Covered | ||||||
| D1575 Distal shoe space maintainer – fixed – unilateral | $0 | Not Covered | ||||||
| RESTORATIVE DENTISTRY | ||||||||
| D2140 Amalgam - one surface, primary or permanent | $0 | $15 | ||||||
| D2150 Amalgam - two surfaces, primary or permanent | $0 | $20 | ||||||
| D2160 Amalgam - three surfaces, primary or permanent | $0 | $25 | ||||||
| D2161 Amalgam - four or more surfaces, primary or permanent | $0 | $25 | ||||||
| D2330 Resin-based composite - one surface, anterior | $30 | $15 | ||||||
| D2331 Resin-based composite - two surfaces, anterior | $37 | $20 | ||||||
| D2332 Resin-based composite - three surfaces, anterior | $50 | $25 | ||||||
| D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) | $80 | $25 | ||||||
| D2390 Resin-based composite crown, anterior | $115 | Not Covered | ||||||
| D2391 Resin-based composite - one surface, posterior | $65 | Not Covered | ||||||
| D2392 Resin-based composite - two surfaces, posterior | $75 | Not Covered | ||||||
| D2393 Resin-based composite - three surfaces, posterior | $90 | Not Covered | ||||||
| D2394 Resin-based composite - four or more surfaces, posterior | $115 | Not Covered | ||||||
| D2410 Gold foil - one surface | $75 | Not Covered | ||||||
| D2420 Gold foil - two surfaces | $95 | Not Covered | ||||||
| D2430 Gold foil - three surfaces | $125 | Not Covered | ||||||
| D2510 Inlay - metallic - one surface | $225 | Not Covered | ||||||
| D2520 Inlay - metallic - two surfaces | $235 | Not Covered | ||||||
| D2530 Inlay - metallic - three or more surfaces | $245 | Not Covered | ||||||
| D2542 Onlay - metallic - two surfaces | $325 | Not Covered | ||||||
| D2543 Onlay - metallic - three surfaces | $340 | Not Covered | ||||||
| D2544 Onlay - metallic - four or more surfaces | $350 | Not Covered | ||||||
| D2610 Inlay - porcelain/ceramic - one surface | $275* | Not Covered | ||||||
| D2620 Inlay - porcelain/ceramic - two surfaces | $300* | Not Covered | ||||||
| D2630 Inlay - porcelain/ceramic - three or more surfaces | $325* | Not Covered | ||||||
| D2642 Onlay - porcelain/ceramic - two surfaces | $360* | Not Covered | ||||||
| D2643 Onlay - porcelain/ceramic - three surfaces | $390* | Not Covered | ||||||
| D2644 Onlay - porcelain/ceramic - four or more surfaces | $400* | Not Covered | ||||||
| D2650 Inlay - resin-based composite - one surface | $200 | Not Covered | ||||||
| D2651 Inlay - resin-based composite - two surfaces | $220 | Not Covered | ||||||
| D2652 Inlay - resin-based composite - three or more surfaces | $260 | Not Covered | ||||||
| D2662 Onlay - resin-based composite - two surfaces | $240 | Not Covered | ||||||
| D2663 Onlay - resin-based composite - three surfaces | $260 | Not Covered | ||||||
| D2664 Onlay - resin-based composite - four or more surfaces | $283 | Not Covered | ||||||
| D2710 *Crown - resin-based composite (indirect) | $195 | Not Covered | ||||||
| D2712 *Crown - ¾ resin-based composite (indirect) | $195 | Not Covered | ||||||
| D2720 *Crown - resin with high noble metal | $245* | Not Covered | ||||||
| D2721 *Crown - resin with predominantly base metal | $245* | Not Covered | ||||||
| D2722 *Crown - resin with noble metal | $245* | Not Covered | ||||||
| D2740 *Crown - porcelain/ceramic | $245* | Not Covered | ||||||
| D2750 *Crown - porcelain fused to high noble metal | $245* | Not Covered | ||||||
| D2751 *Crown - porcelain fused to predominantly base metal | $245* | Not Covered | ||||||
| D2752 *Crown - porcelain fused to noble metal | $245* | Not Covered | ||||||
| D2753 *Crown - porcelain fused to titanium and titanium alloys | $245* | Not Covered | ||||||
| D2780 *Crown - 3/4 cast high noble metal | $245* | Not Covered | ||||||
| D2781 *Crown - 3/4 cast predominantly base metal | $245* | Not Covered | ||||||
| D2782 *Crown - 3/4 cast noble metal | $245* | Not Covered | ||||||
| D2783 *Crown - 3/4 porcelain/ceramic | $245* | Not Covered | ||||||
| D2790 *Crown - full cast high noble metal | $245* | Not Covered | ||||||
| D2791 *Crown - full cast predominantly base metal | $245* | Not Covered | ||||||
| D2792 *Crown - full cast noble metal | $245* | Not Covered | ||||||
| D2794 *Crown - titanium | $245* | Not Covered | ||||||
| D2799 *Provisional crown– further treatment or completion of diagnosis necessary prior to final impression | $125 | Not Covered | ||||||
| D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration | $15 | Not Covered | ||||||
| D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core | $20 | Not Covered | ||||||
| D2920 Re-cement or re-bond crown | $15 | Not Covered | ||||||
| D2921 Reattachment of tooth fragment, incisal edge or cusp | $15 | Not Covered | ||||||
| D2928 *Prefabricated porcelain/ceramic crown – permanent tooth | $49* | Not Covered | ||||||
| D2929 *Prefabricated porcelain/ceramic crown – primary tooth | $49* | Not Covered | ||||||
| D2930 Prefabricated stainless steel crown - primary tooth | $45 | Not Covered | ||||||
| D2931 Prefabricated stainless steel crown - permanent tooth | $55 | Not Covered | ||||||
| D2932 Prefabricated resin crown | $95 | Not Covered | ||||||
| D2933 Prefabricated stainless steel crown with resin window | $145 | Not Covered | ||||||
| D2940 Protective restoration | $15 | Not Covered | ||||||
| D2941 Interim therapeutic restoration – primary dentition | $15 | Not Covered | ||||||
| D2949 Restorative foundation for an indirect restoration | $20 | Not Covered | ||||||
| D2950 Core buildup, including any pins when required | $70 | Not Covered | ||||||
| D2951 Pin retention - per tooth, in addition to restoration | $15 | Not Covered | ||||||
| D2952 Post and core in addition to crown, indirectly fabricated | $88 | Not Covered | ||||||
| D2953 Each additional indirectly fabricated post - same tooth | $95 | Not Covered | ||||||
| D2954 Prefabricated post and core in addition to crown | $75 | Not Covered | ||||||
| D2955 Post removal | $30 | Not Covered | ||||||
| D2957 Each additional prefabricated post - same tooth | $30 | Not Covered | ||||||
| D2960 Labial veneer (resin laminate) - direct | $200 | Not Covered | ||||||
| D2961 Labial veneer (resin laminate) - indirect | $255* | Not Covered | ||||||
| D2962 Labial veneer (porcelain laminate) - indirect | $390* | Not Covered | ||||||
| D2971 Additional procedures to construct new crown under existing partial denture framework | $45 | Not Covered | ||||||
| D2975 Coping | $95 | Not Covered | ||||||
| D2980 Crown repair necessitated by restorative material failure | $95 | Not Covered | ||||||
| D2981 Inlay repair necessitated by restorative material failure | $95 | Not Covered | ||||||
| D2982 Onlay repair necessitated by restorative material failure | $95 | Not Covered | ||||||
| D2983 Veneer repair necessitated by restorative material failure | $95 | Not Covered | ||||||
| D2990 Resin infiltration of incipient smooth surface lesions | $29 | Not Covered | ||||||
| ENDODONTIC SERVICES | ||||||||
| D3110 Pulp cap - direct (excluding final restoration) | $25 | Not Covered | ||||||
| D3120 Pulp cap - indirect (excluding final restoration) | $25 | Not Covered | ||||||
| D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament | $30 | Not Covered | ||||||
| D3221 Pulpal debridement, primary and permanent teeth | $95 | Not Covered | ||||||
| D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development | $75 | Not Covered | ||||||
| D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) | $50 | Not Covered | ||||||
| D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) | $50 | Not Covered | ||||||
| D3310 Endodontic therapy, anterior tooth (excluding final restoration) | $110 | Not Covered | ||||||
| D3320 Endodontic therapy, premolar tooth (excluding final restoration) | $195 | Not Covered | ||||||
| D3330 Endodontic therapy, molar tooth (excluding final restoration) | $245 | Not Covered | ||||||
| D3331 Treatment of root canal obstruction; non-surgical access | $85 | Not Covered | ||||||
| D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth | $75 | Not Covered | ||||||
| D3333 Internal root repair of perforation defects | $125 | Not Covered | ||||||
| D3346 Retreatment of previous root canal therapy - anterior | $300 | Not Covered | ||||||
| D3347 Retreatment of previous root canal therapy - premolar | $350 | Not Covered | ||||||
| D3348 Retreatment of previous root canal therapy - molar | $440 | Not Covered | ||||||
| D3351 Apexification/recalcification – initial visit (apical closure / calcific repair of perforations, root resorption, etc.) | $90 | Not Covered | ||||||
| D3352 Apexification/recalcification – interim medication replacement | $90 | Not Covered | ||||||
| D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) | $90 | Not Covered | ||||||
| D3410 Apicoectomy - anterior | $100 | Not Covered | ||||||
| D3421 Apicoectomy - premolar (first root) | $315 | Not Covered | ||||||
| D3425 Apicoectomy - molar (first root) | $340 | Not Covered | ||||||
| D3426 Apicoectomy (each additional root) | $95 | Not Covered | ||||||
| D3428 Bone graft in conjunction with periradicular surgery – per tooth, single site | $47 | Not Covered | ||||||
| D3429 Bone graft in conjunction with periradicular surgery – each additional contiguous tooth in the same surgical site | $42 | Not Covered | ||||||
| D3430 Retrograde filling - per root | $75 | Not Covered | ||||||
| D3431 Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery | $150 | Not Covered | ||||||
| D3432 Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery | $150 | Not Covered | ||||||
| D3450 Root amputation - per root | $110 | Not Covered | ||||||
| D3460 Endodontic endosseous implant | $545 | Not Covered | ||||||
| D3470 Intentional reimplantation (including necessary splinting) | $175 | Not Covered | ||||||
| D3471 Surgical repair of root resorption – anterior | $100 | Not Covered | ||||||
| D3472 Surgical repair of root resorption – premolar | $315 | Not Covered | ||||||
| D3473 Surgical repair of root resorption – molar | $340 | Not Covered | ||||||
| D3501 Surgical exposure of root surface without apicoectomy or repair of root resorption – anterior | $100 | Not Covered | ||||||
| D3502 Surgical exposure of root surface without apicoectomy or repair of root resorption – premolar | $100 | Not Covered | ||||||
| D3503 Surgical exposure of root surface without apicoectomy or repair of root resorption – molar | $100 | Not Covered | ||||||
| D3910 Surgical procedure for isolation of tooth with rubber dam | $95 | Not Covered | ||||||
| D3920 Hemisection (including any root removal), not including root canal therapy | $90 | Not Covered | ||||||
| D3950 Canal preparation and fitting of preformed dowel or post | $75 | Not Covered | ||||||
| PERIODONTIC SERVICES | ||||||||
| D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant | $175 | Not Covered | ||||||
| D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant | $81 | Not Covered | ||||||
| D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth | $49 | Not Covered | ||||||
| D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant | $195 | Not Covered | ||||||
| D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant | $185 | Not Covered | ||||||
| D4245 Apically positioned flap | $150 | Not Covered | ||||||
| D4249 Clinical crown lengthening – hard tissue | $230 | Not Covered | ||||||
| D4260 Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant | $375 | Not Covered | ||||||
| D4261 Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant | $325 | Not Covered | ||||||
| D4263 Bone replacement graft – retained natural tooth – first site in quadrant | $450 | Not Covered | ||||||
| D4264 Bone replacement graft – retained natural tooth – each additional site in quadrant | $325 | Not Covered | ||||||
| D4265 Biologic materials to aid in soft and osseous tissue regeneration | $325 | Not Covered | ||||||
| D4266 Guided tissue regeneration - resorbable barrier, per site | $325 | Not Covered | ||||||
| D4267 Guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) | $325 | Not Covered | ||||||
| D4268 Surgical revision procedure, per tooth | $0 | Not Covered | ||||||
| D4270 Pedicle soft tissue graft procedure | $250 | Not Covered | ||||||
| D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft | $335 | Not Covered | ||||||
| D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) | $125 | Not Covered | ||||||
| D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft | $502 | Not Covered | ||||||
| D4276 Combined connective tissue and double pedicle graft, per tooth | $65 | Not Covered | ||||||
| D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft | $215 | Not Covered | ||||||
| D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant or edentulous tooth position in same graft site | $75 | Not Covered | ||||||
| D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – each additional contiguous tooth, implant or edentulous tooth position in same graft site | $299 | Not Covered | ||||||
| D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site | $392 | Not Covered | ||||||
| D4320 Provisional splinting - intracoronal | $115 | Not Covered | ||||||
| D4321 Provisional splinting - extracoronal | $105 | Not Covered | ||||||
| D4341 *Periodontal scaling and root planing - four or more teeth per quadrant | $50† | Not Covered | ||||||
| D4342 *Periodontal scaling and root planing - one to three teeth per quadrant | $43† | Not Covered | ||||||
| D4346 Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation | $50† | Not Covered | ||||||
| D4355 *Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit | $50† | Not Covered | ||||||
| D4381 *Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth | $60† | Not Covered | ||||||
| D4910 *Periodontal maintenance | $50 | Not Covered | ||||||
| D4910 Additional Periodontal maintenance procedure | $100 | Not Covered | ||||||
| D4920 Unscheduled dressing change (by someone other than treating dentist or their staff) | $25 | Not Covered | ||||||
| D4921 Gingival irrigation – per quadrant | $15 | Not Covered | ||||||
| D4999 Unspecified periodontal procedure, by report | $0 | Not Covered | ||||||
| PROSTHODONTICS REMOVABLE | ||||||||
| D5110 *Complete denture - maxillary | $325* | Not Covered | ||||||
| D5120 *Complete denture - mandibular | $325* | Not Covered | ||||||
| D5130 *Immediate denture - maxillary | $350* | Not Covered | ||||||
| D5140 *Immediate denture - mandibular | $350* | Not Covered | ||||||
| D5211 *Maxillary partial denture – resin base (including, retentive/clasping materials, rests, and teeth) | $400* | Not Covered | ||||||
| D5212 *Mandibular partial denture – resin base (including, retentive/clasping materials, rests, and teeth) | $400* | Not Covered | ||||||
| D5213 *Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $425* | Not Covered | ||||||
| D5214 *Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $425* | Not Covered | ||||||
| D5221 *Immediate maxillary partial denture – resin base (including any conventional clasps, rests and teeth) | $420* | Not Covered | ||||||
| D5222 *Immediate mandibular partial denture – resin base (including any conventional clasps, rests and teeth) | $420* | Not Covered | ||||||
| D5223 *Immediate maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $445* | Not Covered | ||||||
| D5224 *Immediate mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $445* | Not Covered | ||||||
| D5225 *Maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth) | $425* | Not Covered | ||||||
| D5226 *Mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth) | $425* | Not Covered | ||||||
| D5282 *Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), | ||||||||
| maxillary | $245* | Not Covered | ||||||
| D5283 *Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), | ||||||||
| mandibular | $245* | Not Covered | ||||||
| D5410 Adjust complete denture - maxillary | $15 | Not Covered | ||||||
| D5411 Adjust complete denture - mandibular | $15 | Not Covered | ||||||
| D5421 Adjust partial denture - maxillary | $15 | Not Covered | ||||||
| D5422 Adjust partial denture - mandibular | $15 | Not Covered | ||||||
| D5511 *Repair broken complete denture base, mandibular | $35* | Not Covered | ||||||
| D5512 *Repair broken complete denture base, maxillary | $35* | Not Covered | ||||||
| D5520 *Replace missing or broken teeth - complete denture (each tooth) | $35* | Not Covered | ||||||
| D5611 *Repair resin partial denture base, mandibular | $35* | Not Covered | ||||||
| D5612 *Repair resin partial denture base, maxillary | $35* | Not Covered | ||||||
| D5621 *Repair cast partial framework, mandibular | $35* | Not Covered | ||||||
| D5622 *Repair cast partial framework, maxillary | $35* | Not Covered | ||||||
| D5630 *Repair or replace broken retentive clasping materials – per tooth | $35* | Not Covered | ||||||
| D5640 *Replace broken teeth - per tooth | $35* | Not Covered | ||||||
| D5650 *Add tooth to existing partial denture | $35* | Not Covered | ||||||
| D5660 *Add clasp to existing partial denture - per tooth | $35* | Not Covered | ||||||
| D5670 *Replace all teeth and acrylic on cast metal framework (maxillary) | $155* | Not Covered | ||||||
| D5671 *Replace all teeth and acrylic on cast metal framework (mandibular) | $155* | Not Covered | ||||||
| D5710 *Rebase complete maxillary denture | $135* | Not Covered | ||||||
| D5711 *Rebase complete mandibular denture | $135* | Not Covered | ||||||
| D5720 *Rebase maxillary partial denture | $155* | Not Covered | ||||||
| D5721 *Rebase mandibular partial denture | $155* | Not Covered | ||||||
| D5730 *Reline complete maxillary denture (direct) | $65* | Not Covered | ||||||
| D5731 *Reline complete mandibular denture (direct) | $65* | Not Covered | ||||||
| D5740 *Reline maxillary partial denture (direct) | $65* | Not Covered | ||||||
| D5741 *Reline mandibular partial denture (direct) | $65* | Not Covered | ||||||
| D5750 *Reline complete maxillary denture (indirect) | $85* | Not Covered | ||||||
| D5751 *Reline complete mandibular denture (indirect) | $85* | Not Covered | ||||||
| D5760 *Reline maxillary partial denture (indirect) | $85* | Not Covered | ||||||
| D5761 *Reline mandibular partial denture (indirect) | $85* | Not Covered | ||||||
| D5810 *Interim complete denture (maxillary) | $250* | Not Covered | ||||||
| D5811 *Interim complete denture (mandibular) | $250* | Not Covered | ||||||
| D5820 *Interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary | $175* | Not Covered | ||||||
| D5821 *Interim partial denture (including retentive/clasping materials, rests, and teeth), mandibular | $175* | Not Covered | ||||||
| D5850 Tissue conditioning, maxillary | $20 | Not Covered | ||||||
| D5851 Tissue conditioning, mandibular | $20 | Not Covered | ||||||
| D5862 Precision attachment, by report | $150 | Not Covered | ||||||
| D5899 Unspecified removable prosthodontic procedure, by report | $0 | Not Covered | ||||||
| D5982 Surgical stent | $150* | Not Covered | ||||||
| D5987 Commissure splint | $150* | Not Covered | ||||||
| D5988 Surgical splint | $150* | Not Covered | ||||||
| IMPLANT SUPPORTED PROSTHETICS | ||||||||
| D6010 *Surgical placement of implant body: endosteal implant | $1010 | Not Covered | ||||||
| D6012 *Surgical placement of interim implant body for transitional prosthesis: endosteal implant | $1010 | Not Covered | ||||||
| D6056 *Prefabricated abutment – includes modification and placement | $440 | Not Covered | ||||||
| D6057 *Custom fabricated abutment – includes placement | $550 | Not Covered | ||||||
| D6058 *Abutment supported porcelain/ceramic crown | $750 | Not Covered | ||||||
| D6059 *Abutment supported porcelain fused to metal crown (high noble metal) | $750 | Not Covered | ||||||
| D6060 *Abutment supported porcelain fused to metal crown (predominantly base metal) | $750 | Not Covered | ||||||
| D6061 *Abutment supported porcelain fused to metal crown (noble metal) | $750 | Not Covered | ||||||
| D6062 *Abutment supported cast metal crown (high noble metal) | $750 | Not Covered | ||||||
| D6063 *Abutment supported cast metal crown (predominantly base metal) | $750 | Not Covered | ||||||
| D6064 *Abutment supported cast metal crown (noble metal) | $750 | Not Covered | ||||||
| D6065 *Implant supported porcelain/ceramic crown | $750 | Not Covered | ||||||
| D6066 *Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) | $750 | Not Covered | ||||||
| D6067 *Implant supported metal crown (titanium, titanium alloy, high noble metal) | $750 | Not Covered | ||||||
| D6068 *Abutment supported retainer for porcelain/ceramic fpd | $750 | Not Covered | ||||||
| D6069 *Abutment supported retainer for porcelain fused to metal fpd (high noble metal) | $750 | Not Covered | ||||||
| D6070 *Abutment supported retainer for porcelain fused to metal fpd (predominantly base metal) | $750 | Not Covered | ||||||
| D6071 *Abutment supported retainer for porcelain fused to metal fpd (noble metal) | $750 | Not Covered | ||||||
| D6072 *Abutment supported retainer for cast metal fpd (high noble metal) | $750 | Not Covered | ||||||
| D6073 *Abutment supported retainer for cast metal fpd (predominantly base metal) | $750 | Not Covered | ||||||
| D6074 *Abutment supported retainer for cast metal fpd (noble metal) | $750 | Not Covered | ||||||
| D6075 *Implant supported retainer for ceramic fpd | $750 | Not Covered | ||||||
| D6076 *Implant supported retainer for porcelain fused to metal fpd (titanium, titanium alloy, or high noble metal) | $750 | Not Covered | ||||||
| D6077 *Implant supported retainer for cast metal fpd (titanium, titanium alloy, or high noble metal) | $750 | Not Covered | ||||||
| D6080 Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments | $180 | Not Covered | ||||||
| D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure | $50† | Not Covered | ||||||
| D6082 *Implant supported crown - porcelain fused to predominantly base alloys | $750 | Not Covered | ||||||
| D6083 *Implant supported crown - porcelain fused to noble alloys | $750 | Not Covered | ||||||
| D6084 *Implant supported crown - porcelain fused to titanium and titanium alloys | $750 | Not Covered | ||||||
| D6085 Provisional implant crown | $125 | Not Covered | ||||||
| D6086 *Implant supported crown - predominantly base alloys | $750 | Not Covered | ||||||
| D6087 *Implant supported crown - noble alloys | $750 | Not Covered | ||||||
| D6088 *Implant supported crown - titanium and titanium alloys | $750 | Not Covered | ||||||
| D6090 Repair implant supported prosthesis, by report | $400 | Not Covered | ||||||
| D6092 Re-cement or re-bond implant/abutment supported crown | $45 | Not Covered | ||||||
| D6093 Re-cement or re-bond implant/abutment supported fixed partial denture | $65 | Not Covered | ||||||
| D6094 *Abutment supported crown - (titanium) | $750 | Not Covered | ||||||
| D6095 Repair implant abutment, by report | $220 | Not Covered | ||||||
| D6096 Remove broken implant retaining screw | $500 | Not Covered | ||||||
| D6097 *Abutment supported crown - porcelain fused to titanium and titanium alloys | $750 | Not Covered | ||||||
| D6098 *Implant supported retainer - porcelain fused to predominantly base alloys | $750 | Not Covered | ||||||
| D6099 *Implant supported retainer for FPD - porcelain fused to noble alloys | $750 | Not Covered | ||||||
| D6100 Implant removal, by report | $700 | Not Covered | ||||||
| D6110 *Implant /abutment supported removable denture for edentulous arch – maxillary | $1255 | Not Covered | ||||||
| D6111 *Implant /abutment supported removable denture for edentulous arch – mandibular | $1255 | Not Covered | ||||||
| D6112 *Implant /abutment supported removable denture for partially edentulous arch – maxillary | $995 | Not Covered | ||||||
| D6113 *Implant /abutment supported removable denture for partially edentulous arch – mandibular | $995 | Not Covered | ||||||
| D6114 *Implant /abutment supported fixed denture for edentulous arch – maxillary | $3855 | Not Covered | ||||||
| D6115 *Implant /abutment supported fixed denture for edentulous arch – mandibular | $3855 | Not Covered | ||||||
| D6116 *Implant /abutment supported fixed denture for partially edentulous arch – maxillary | $2255 | Not Covered | ||||||
| D6117 *Implant /abutment supported fixed denture for partially edentulous arch – mandibular | $2255 | Not Covered | ||||||
| D6118 *Implant/abutment supported interim fixed denture for edentulous arch – mandibular | $1804 | Not Covered | ||||||
| D6119 *Implant/abutment supported interim fixed denture for edentulous arch – maxillary | $1804 | Not Covered | ||||||
| D6120 *Implant supported retainer – porcelain fused to titanium and titanium alloys | $750 | Not Covered | ||||||
| D6121 *Implant supported retainer for metal FPD – predominantly base alloys | $750 | Not Covered | ||||||
| D6122 *Implant supported retainer for metal FPD – noble alloys | $750 | Not Covered | ||||||
| D6123 *Implant supported retainer for metal FPD – titanium and titanium alloys | $750 | Not Covered | ||||||
| D6190 Radiographic/surgical implant index, by report | $235 | Not Covered | ||||||
| PROSTHODONTICS FIXED | ||||||||
| D6205 *Pontic - indirect resin based composite | $750 | Not Covered | ||||||
| D6210 *Pontic - cast high noble metal | $245* | Not Covered | ||||||
| D6211 *Pontic - cast predominantly base metal | $245* | Not Covered | ||||||
| D6212 *Pontic - cast noble metal | $245* | Not Covered | ||||||
| D6214 *Pontic - titanium | $245* | Not Covered | ||||||
| D6240 *Pontic - porcelain fused to high noble metal | $245* | Not Covered | ||||||
| D6241 *Pontic - porcelain fused to predominantly base metal | $245* | Not Covered | ||||||
| D6242 *Pontic - porcelain fused to noble metal | $245* | Not Covered | ||||||
| D6243 *Pontic - porcelain fused to titanium and titanium alloys | $245* | Not Covered | ||||||
| D6245 *Pontic - porcelain/ceramic | $245* | Not Covered | ||||||
| D6250 *Pontic - resin with high noble metal | $245* | Not Covered | ||||||
| D6251 *Pontic - resin with predominantly base metal | $245* | Not Covered | ||||||
| D6252 *Pontic - resin with noble metal | $245* | Not Covered | ||||||
| D6253 *Provisional pontic - further treatment or completion of diagnosis necessary prior to final impression | $0 | Not Covered | ||||||
| D6545 Retainer - cast metal for resin bonded fixed prosthesis | $390 | Not Covered | ||||||
| D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis | $225* | Not Covered | ||||||
| D6600 Retainer inlay - porcelain/ceramic, two surfaces | $245* | Not Covered | ||||||
| D6601 Retainer inlay - porcelain/ceramic, three or more surfaces | $245* | Not Covered | ||||||
| D6602 Retainer inlay - cast high noble metal, two surfaces | $245* | Not Covered | ||||||
| D6603 Retainer inlay - cast high noble metal, three or more surfaces | $245* | Not Covered | ||||||
| D6604 Retainer inlay - cast predominantly base metal, two surfaces | $245* | Not Covered | ||||||
| D6605 Retainer inlay - cast predominantly base metal, three or more surfaces | $245* | Not Covered | ||||||
| D6606 Retainer inlay - cast noble metal, two surfaces | $245* | Not Covered | ||||||
| D6607 Retainer inlay - cast noble metal, three or more surfaces | $245* | Not Covered | ||||||
| D6608 Retainer onlay - porcelain/ceramic, two surfaces | $245* | Not Covered | ||||||
| D6609 Retainer onlay - porcelain/ceramic, three or more surfaces | $245* | Not Covered | ||||||
| D6610 Retainer onlay - cast high noble metal, two surfaces | $245* | Not Covered | ||||||
| D6611 Retainer onlay - cast high noble metal, three or more surfaces | $245* | Not Covered | ||||||
| D6612 Retainer onlay - cast predominantly base metal, two surfaces | $245* | Not Covered | ||||||
| D6613 Retainer onlay - cast predominantly base metal, three or more surfaces | $245* | Not Covered | ||||||
| D6614 Retainer onlay - cast noble metal, two surfaces | $245* | Not Covered | ||||||
| D6615 Retainer onlay - cast noble metal, three or more surfaces | $245* | Not Covered | ||||||
| D6624 Retainer inlay - titanium | $245* | Not Covered | ||||||
| D6634 Retainer onlay - titanium | $245* | Not Covered | ||||||
| D6710 *Retainer crown - indirect resin based composite | $245* | Not Covered | ||||||
| D6720 *Retainer crown - resin with high noble metal | $245* | Not Covered | ||||||
| D6721 *Retainer crown - resin with predominantly base metal | $245* | Not Covered | ||||||
| D6722 *Retainer crown - resin with noble metal | $245* | Not Covered | ||||||
| D6740 *Retainer crown - porcelain/ceramic | $245* | Not Covered | ||||||
| D6750 *Retainer crown - porcelain fused to high noble metal | $245* | Not Covered | ||||||
| D6751 *Retainer crown - porcelain fused to predominantly base metal | $245* | Not Covered | ||||||
| D6752 *Retainer crown - porcelain fused to noble metal | $245* | Not Covered | ||||||
| D6753 *Retainer crown - porcelain fused to titanium and titanium alloys | $245* | Not Covered | ||||||
| D6780 *Retainer crown - 3/4 cast high noble metal | $245* | Not Covered | ||||||
| D6781 *Retainer crown - 3/4 cast predominantly base metal | $245* | Not Covered | ||||||
| D6782 *Retainer crown - 3/4 cast noble metal | $245* | Not Covered | ||||||
| D6783 *Retainer crown - 3/4 porcelain/ceramic | $245* | Not Covered | ||||||
| D6784 *Retainer crown ¾ - titanium and titanium alloys | $245* | Not Covered | ||||||
| D6790 *Retainer crown - full cast high noble metal | $245* | Not Covered | ||||||
| D6791 *Retainer crown - full cast predominantly base metal | $245* | Not Covered | ||||||
| D6792 *Retainer crown - full cast noble metal | $245* | Not Covered | ||||||
| D6793 *Provisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression | $125 | Not Covered | ||||||
| D6794 *Retainer crown - titanium | $245* | Not Covered | ||||||
| D6930 Re-cement or re-bond fixed partial denture | $15 | Not Covered | ||||||
| D6940 Stress breaker | $125 | Not Covered | ||||||
| D6950 Precision attachment | $195 | Not Covered | ||||||
| D6980 Fixed partial denture repair necessitated by restorative material failure | $80 | Not Covered | ||||||
| ORAL SURGERY | ||||||||
| D7111 Extraction, coronal remnants – primary tooth | $50 | Not Covered | ||||||
| D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) | $20 | Not Covered | ||||||
| D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated | $30 | Not Covered | ||||||
| D7220 Removal of impacted tooth - soft tissue | $50 | Not Covered | ||||||
| D7230 Removal of impacted tooth - partially bony | $65 | Not Covered | ||||||
| D7240 Removal of impacted tooth - completely bony | $80 | Not Covered | ||||||
| D7241 Removal of impacted tooth - completely bony, with unusual surgical complications | $135 | Not Covered | ||||||
| D7250 Removal of residual tooth roots (cutting procedure) | $40 | Not Covered | ||||||
| D7251 Coronectomy – intentional partial tooth removal | $270 | Not Covered | ||||||
| D7260 Oroantral fistula closure | $160 | Not Covered | ||||||
| D7261 Primary closure of a sinus perforation | $275 | Not Covered | ||||||
| D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth | $50 | Not Covered | ||||||
| D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) | $100 | Not Covered | ||||||
| D7280 Exposure of an unerupted tooth | $125 | Not Covered | ||||||
| D7282 Mobilization of erupted or malpositioned tooth to aid eruption | $125 | Not Covered | ||||||
| D7283 Placement of device to facilitate eruption of impacted tooth | $80 | Not Covered | ||||||
| D7285 Incisional biopsy of oral tissue-hard (bone, tooth) | $125 | Not Covered | ||||||
| D7286 Incisional biopsy of oral tissue-soft | $85 | Not Covered | ||||||
| D7287 Exfoliative cytological sample collection | $75 | Not Covered | ||||||
| D7288 Brush biopsy - transepithelial sample collection | $25 | Not Covered | ||||||
| D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report | $40 | Not Covered | ||||||
| D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant | $40 | Not Covered | ||||||
| D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant | $40 | Not Covered | ||||||
| D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant | $60 | Not Covered | ||||||
| D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant | $60 | Not Covered | ||||||
| D7340 Vestibuloplasty - ridge extension (secondary epithelialization) | $370 | Not Covered | ||||||
| D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) | $990 | Not Covered | ||||||
| D7410 Excision of benign lesion up to 1.25 cm | $25 | Not Covered | ||||||
| D7411 Excision of benign lesion greater than 1.25 cm | $50 | Not Covered | ||||||
| D7412 Excision of benign lesion, complicated | $55 | Not Covered | ||||||
| D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm | $65 | Not Covered | ||||||
| D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm | $95 | Not Covered | ||||||
| D7471 Removal of lateral exostosis (maxilla or mandible) | $95 | Not Covered | ||||||
| D7472 Removal of torus palatinus | $95 | Not Covered | ||||||
| D7473 Removal of torus mandibularis | $95 | Not Covered | ||||||
| D7485 Reduction of osseous tuberosity | $95 | Not Covered | ||||||
| D7510 Incision and drainage of abscess - intraoral soft tissue | $20 | Not Covered | ||||||
| D7511 Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) | $20 | Not Covered | ||||||
| D7520 Incision and drainage of abscess - extraoral soft tissue | $20 | Not Covered | ||||||
| D7521 Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces) | $20 | Not Covered | ||||||
| D7910 Suture of recent small wounds up to 5 cm | $35 | Not Covered | ||||||
| D7921 Collection and application of autologous blood concentrate product | $125 | Not Covered | ||||||
| D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report | $350 | Not Covered | ||||||
| D7951 Sinus augmentation with bone or bone substitutes via a lateral open approach | $800 | Not Covered | ||||||
| D7952 Sinus augmentation via a vertical approach | $350 | Not Covered | ||||||
| D7953 Bone replacement graft for ridge preservation - per site | $100 | Not Covered | ||||||
| D7961 Buccal / labial frenectomy (frenulectomy) | $105 | Not Covered | ||||||
| D7962 Lingual frenectomy (frenulectomy) | $105 | Not Covered | ||||||
| D7963 Frenuloplasty | $105 | Not Covered | ||||||
| D7970 Excision of hyperplastic tissue - per arch | $140 | Not Covered | ||||||
| D7971 Excision of pericoronal gingiva | $102 | Not Covered | ||||||
| D7972 Surgical reduction of fibrous tuberosity | $125 | Not Covered | ||||||
| ORTHODONTIC | ||||||||
| D8010 Limited orthodontic treatment of the primary dentition | $1000 | Not Covered | ||||||
| D8020 Limited orthodontic treatment of the transitional dentition | $1000 | Not Covered | ||||||
| D8030 Limited orthodontic treatment of the adolescent dentition | $1000 | Not Covered | ||||||
| D8040 Limited orthodontic treatment of the adult dentition | $1350 | Not Covered | ||||||
| D8070 Comprehensive orthodontic treatment of the transitional dentition | $2200 | Not Covered | ||||||
| D8080 Comprehensive orthodontic treatment of the adolescent dentition | $2250 | Not Covered | ||||||
| D8090 Comprehensive orthodontic treatment of the adult dentition | $2350 | Not Covered | ||||||
| D8210 *Removable appliance therapy | $103 | Not Covered | ||||||
| D8220 *Fixed appliance therapy | $103 | Not Covered | ||||||
| D8660 Pre-orthodontic treatment examination to monitor growth and development | $35 | Not Covered | ||||||
| D8670 Periodic orthodontic treatment visit | $0 | Not Covered | ||||||
| D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) | $300 | Not Covered | ||||||
| D8681 Removable orthodontic retainer adjustment | $0 | Not Covered | ||||||
| D8698 Re-cement or re-bond fixed retainer – maxillary | $0 | Not Covered | ||||||
| D8699 Re-cement or re-bond fixed retainer – mandibular | $0 | Not Covered | ||||||
| D8999 Unspecified orthodontic procedure, by report | $250 | Not Covered | ||||||
| MISCELLANEOUS | ||||||||
| D9110 Palliative (emergency) treatment of dental pain - minor procedure | $0 | Not Covered | ||||||
| D9120 Fixed partial denture sectioning | $0 | Not Covered | ||||||
| D9210 Local anesthesia not in conjunction with operative or surgical procedures | $0 | Not Covered | ||||||
| D9211 Regional block anesthesia | $0 | Not Covered | ||||||
| D9212 Trigeminal division block anesthesia | $0 | Not Covered | ||||||
| D9215 Local anesthesia in conjunction with operative or surgical procedures | $0 | Not Covered | ||||||
| D9222 Deep sedation/general anesthesia – first 15 minutes | $50 | Not Covered | ||||||
| D9223 Deep sedation/general anesthesia – each subsequent 15 minute increment | $50 | Not Covered | ||||||
| D9230 Inhalation of nitrous oxide/analgesia, anxiolysis | $20 | Not Covered | ||||||
| D9239 Intravenous moderate (conscious) sedation/analgesia-first 15 minutes | $65 | Not Covered | ||||||
| D9243 Intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minute increment | $65 | Not Covered | ||||||
| D9248 Non-intravenous conscious sedation | $15 | Not Covered | ||||||
| D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician | $25 | Not Covered | ||||||
| D9430 Office visit for observation (during regularly scheduled hours) - no other services performed | $0 | Not Covered | ||||||
| D9440 Office visit - after regularly scheduled hours | $35 | Not Covered | ||||||
| D9450 Case presentation, detailed and extensive treatment planning | $0 | Not Covered | ||||||
| D9610 Therapeutic parenteral drug, single administration | $15 | Not Covered | ||||||
| D9630 Drugs or medicaments dispensed in the office for home use | $15 | Not Covered | ||||||
| D9910 *Application of desensitizing medicament | $20 | Not Covered | ||||||
| D9911 Application of desensitizing resin for cervical and/or root surface, per tooth | $0 | Not Covered | ||||||
| D9930 Treatment of complications (post-surgical) - unusual circumstances, by report | $0 | Not Covered | ||||||
| D9932 Cleaning and inspection of removable complete denture, maxillary | $0 | Not Covered | ||||||
| D9933 Cleaning and inspection of removable complete denture, mandibular | $0 | Not Covered | ||||||
| D9934 Cleaning and inspection of removable partial denture, maxillary | $0 | Not Covered | ||||||
| D9935 Cleaning and inspection of removable partial denture, mandibular | $0 | Not Covered | ||||||
| D9942 Repair and/or reline of occlusal guard | $40 | Not Covered | ||||||
| D9943 Occlusal guard adjustment | $25 | Not Covered | ||||||
| D9944 *Occlusal guard – hard appliance, full arch | $250 | Not Covered | ||||||
| D9945 *Occlusal guard – soft appliance, full arch | $250 | Not Covered | ||||||
| D9946 *Occlusal guard – hard appliance, partial arch | $250 | Not Covered | ||||||
| D9950 Occlusion analysis - mounted case | $75 | Not Covered | ||||||
| D9951 Occlusal adjustment - limited | $30 | Not Covered | ||||||
| D9952 Occlusal adjustment - complete | $100 | Not Covered | ||||||
| D9972 External bleaching - per arch - performed in office | $150 | Not Covered | ||||||
| D9973 External bleaching - per tooth | $30 | Not Covered | ||||||
| D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays | $240 | Not Covered | ||||||
| D9986 Missed appointment | $25 | Not Covered | ||||||
| D9991 Dental case management – addressing appointment compliance barriers | $0 | Not Covered | ||||||
| D9992 Dental case management – care coordination | $0 | Not Covered | ||||||
| D9993 Dental case management – motivational interviewing | $0 | Not Covered | ||||||
| D9994 Dental case management – patient education to improve oral health literacy | $0 | Not Covered | ||||||
| D9995 Teledentistry – synchronous; real-time encounter | $20 | Not Covered | ||||||
| D9996 Teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review | $20 | Not Covered | ||||||
| D9997 Dental case management - patients with special health care needs | $0 | Not Covered |
&"Arial,Regular"APPENDIX C - OPTION I - DHMO PLAN (BASIC) &"Arial,Regular"CONFIDENTIAL AND PROPRIETARY &"Arial,Regular"Page &P of &N
File details come from the government source that posted it. Updated .