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 5
- Issued by
- Palm Beach County, Florida
About this file
This is a draft specification document for a Dental Health Maintenance Organization (DHMO) Plan (Basic) option under Florida's Multiple Option Dental Program RFP 26-041-DJ. The document outlines the basic DHMO plan structure as one of multiple dental coverage options being procured by the state. The plan is designed to provide dental health maintenance services to eligible participants through a network of contracted dental providers. The specification includes detailed requirements for plan design, covered services, provider networks, and administrative operations necessary to deliver dental benefits under the DHMO option.
The DHMO Plan (Basic) specification establishes benefit parameters, network requirements, and operational standards for the dental plan option. The document delineates covered preventive, basic restorative, and other dental services available to plan members, along with associated cost-sharing requirements such as copayments. It addresses provider network adequacy standards, claims processing requirements, member communication protocols, and quality assurance mechanisms. The specification includes requirements for customer service, enrollment procedures, and reporting obligations to the state. As a draft document in spreadsheet format, it serves as the preliminary framework for evaluating vendor proposals and establishing contractual terms for the selected dental plan administrator(s) under the state's multiple option dental program.
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 .