A.D.A
SERVICE
NUMBER |
DENTAL SERVICE CATEGORY |
SCHEDULED BENEFIT |
|
|
|
|
I. PREVENTIVE |
|
| 0120 |
Periodic oral evaluation, six (6) month interval |
$20.00 |
| 0140 |
Limited oral evaluation – problem focused |
33.00 |
| 0150 |
Comprehensive oral evaluation |
33.00 |
| 1110 |
Prophylaxis – adult, once in a six (6) month interval |
52.00 |
| 1120 |
Prophylaxis – child, once in a six (6) month interval |
33.00 |
| 1203 |
Topical application of fluoride (prophylaxis not included) – at twelve (12) month intervals to age 19 |
20.00 |
| 1351 |
Sealants, per tooth – first and second molars within two years of eruption |
13.00 |
| 9110 |
Palliative (emergency) treatment of dental pain – minor procedure |
20.00 |
|
|
|
|
II. DIAGNOSTIC |
|
| 0210 |
Intraoral – complete series (including bitewings – thirty-six (36) month interval) |
$59.00 |
| 0220 |
Intraoral – periapical – first film |
13.00 |
| 0230 |
Intraoral – periapical – each additional film |
7.00 |
| 0240 |
Intraoral – occlusal film |
13.00 |
| 0270 |
Bitewing – single film – six (6) month interval |
20.00 |
| 0272 |
Bitewings – two films – six (6) month interval |
20.00 |
| 0274 |
Bitewings – four films – six (6) month interval |
26.00 |
| 0330 |
Panoramic film |
46.00 |
| 0340 |
Cephalometric film |
65.00 |
|
|
|
|
III. RESTORATIVE |
|
| 1520 |
Space maintainer – removable – unilateral |
$33.00 |
| 1525 |
Space maintainer – removable – bilateral |
65.00 |
| 2140 |
Amalgam – one surface, permanent |
39.00 |
| 2150 |
Amalgam – two surfaces, permanent |
46.00 |
| 2160 |
Amalgam – three surfaces, permanent |
46.00 |
| 2161 |
Amalgam – four or more surfaces, permanent |
46.00 |
| 2330 |
Resin – one surface, anterior |
39.00 |
| 2331 |
Resin – two surfaces, anterior |
46.00 |
| 2332 |
Resin – three surfaces, permanent |
59.00 |
| 2335 |
Resin – four or more surfaces or involving incisal angle (anterior) |
65.00 |
|
|
|
|
IV. RESTORATIVE – MAJOR |
|
| 2520 |
Inlay – metallic – two surface |
$189.00 |
| 2530 |
Inlay – metallic – three or more surfaces |
195.00 |
| 2543 |
Onlay – metallic – three surfaces |
202.00 |
| 2544 |
Onlay – metallic – four or more surfaces |
202.00 |
| 2620 |
Inlay – porcelain/ceramic – two surfaces |
189.00 |
| 2630 |
Inlay – porcelain/ceramic – three or more surfaces |
189.00 |
| 2643 |
Onlay – porcelain/ceramic – three surfaces |
189.00 |
| 2644 |
Onlay – porcelain/ceramic – four or more surfaces |
189.00 |
| 2710 |
Crown – resin (laboratory) |
130.00 |
| 2720 |
Crown – resin with high noble metal |
260.00 |
| 2721 |
Crown – resin with predominantly base metal |
234.00 |
| 2722 |
Crown – resin with noble metal |
273.00 |
| 2740 |
Crown – porcelain/ceramic substrate |
280.00 |
| 2750 |
Crown – porcelain fused to high noble metal |
299.00 |
| 2751 |
Crown – porcelain fused to predominantly base metal |
286.00 |
| 2752 |
Crown – porcelain fused to noble metal |
286.00 |
| 2780 |
Crown – ¾ cast metal |
286.00 |
| 2790 |
Crown – full cast high noble metal |
293.00 |
| 2791 |
Crown – full cast predominantly base metal |
280.00 |
| 2792 |
Crown – full cast noble metal |
280.00 |
| 2910 |
Recement inlay |
20.00 |
| 2920 |
Recement crown |
20.00 |
| 2930 |
Prefabricated stainless steel crown – primary tooth |
65.00 |
| 2950 |
Core buildup, including any pins |
59.00 |
| 2951 |
Pin retention – per tooth, in addition to restoration |
13.00 |
| 2952 |
Cast post and core in addition to crown |
89.00 |
|
|
|
|
V. ENDODONTICS |
|
| 3220 |
Therapeutic pulpotomy (excluding final restoration) |
26.00 |
| 3310 |
Root Canal – Anterior (excluding final restoration) |
163.00 |
| 3320 |
Root canal – Bicuspid (excluding final restoration) |
176.00 |
| 3330 |
Root Canal – Molar (excluding final restoration) |
182.00 |
| 3351 |
Apexification/recalcification – initial visit (apical closure/calcific repair of perforation, root resorption, etc.) |
91.00 |
| 3352 |
Apexification/recalcification – interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) |
52.00 |
| 3353 |
Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.) |
39.00 |
| 3410 |
Apicoectomy/Periradicular surgery – anterior |
150.00 |
| 3450 |
Root amputation – per root |
46.00 |
| 3920 |
Hemisection (including any root removal), not including root canal therapy |
104.00 |
| 3950 |
Canal preparation and fitting of preformed dowel or post |
33.00 |
|
|
|
|
VI. PERIODONTICS |
|
| 4210 |
Gingivectomy or gingivoplasty – per quadrant |
$98.00 |
| 4211 |
Gingivectomy or gingivoplasty – per tooth |
59.00 |
| 4240 |
Gingival flap procedure, including root planing – per quadrant |
143.00 |
| 4249 |
Clinical crown lengthening – hard tissue |
26.00 |
| 4260 |
Osseous surgery (including flap entry and closure) – per quadrant |
267.00 |
| 4261 |
Osseous surgery (including flap entry and closure) – one to three contiguous teeth or bounded teeth spaces – per quadrant |
267.00 |
| 4263 |
Bone replacement graft – first site in quadrant |
26.00 |
| 4270 |
Pedicle soft tissue graft procedure |
143.00 |
| 4271 |
Free soft tissue graft procedure (including donor site surgery) |
143.00 |
| 4341 |
Periodontal scaling and root planing – per quadrant |
39.00 |
| 4910 |
Periodontal maintenance procedures (following active therapy) |
46.00 |
|
|
|
|
VII. PROSTHETICS – REMOVABLE |
|
| 5110 |
Complete denture – maxillary |
$325.00 |
| 5120 |
Complete denture – mandibular |
325.00 |
| 5211 |
Maxillary partial denture – resin base (including any conventional clasps, rests and teeth) |
143.00 |
| 5212 |
Mandibular partial denture – resin base (including any conventional clasps, rests and teeth) |
143.00 |
| 5213 |
Maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) |
169.00 |
| 5214 |
Mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) |
169.00 |
| 5410 |
Adjust complete denture – maxillary |
20.00 |
| 5411 |
Adjust complete denture – mandibular |
20.00 |
| 5421 |
Adjust partial denture – maxillary |
20.00 |
| 5422 |
Adjust partial denture – mandibular |
20.00 |
| 5510 |
Repair broken complete denture base |
26.00 |
| 5520 |
Replace missing or broken teeth – complete denture (each tooth) |
26.00 |
| 5610 |
Repair resin denture base |
26.00 |
| 5620 |
Repair cast framework |
39.00 |
| 5630 |
Repair or replace broken clasp |
20.00 |
| 5640 |
Replace broken teeth – per tooth |
26.00 |
| 5650 |
Add tooth to existing partial denture |
52.00 |
| 5660 |
Add clasp to existing partial denture |
52.00 |
| 5710 |
Rebase complete maxillary denture |
59.00 |
| 5711 |
Rebase complete mandibular denture |
59.00 |
| 5720 |
Rebase maxillary partial denture |
59.00 |
| 5721 |
Rebase mandibular partial denture |
59.00 |
| 5730 |
Reline complete maxillary denture (chairside) |
72.00 |
| 5731 |
Reline complete mandibular denture (chairside) |
72.00 |
| 5740 |
Reline maxillary partial denture (chairside) |
72.00 |
| 5741 |
Reline mandibular partial denture (chairside) |
72.00 |
| 5750 |
Reline complete maxillary denture (laboratory) |
98.00 |
| 5751 |
Reline complete mandibular denture (laboratory) |
98.00 |
| 5760 |
Reline maxillary partial denture (laboratory) |
98.00 |
| 5761 |
Reline mandibular partial denture (laboratory) |
98.00 |
| 5850 |
Tissue conditioning, maxillary |
33.00 |
|
|
|
|
VIII. FIXED BRIDGE |
|
| 1510 |
Space maintainer – fixed – unilateral |
$117.00 |
| 1515 |
Space maintainer – fixed – bilateral |
150.00 |
| 6210 |
Pontic – cast high noble metal |
215.00 |
| 6211 |
Pontic – cast predominantly base metal |
241.00 |
| 6212 |
Pontic – cast noble metal |
241.00 |
| 6240 |
Pontic – porcelain fused to high noble metal |
260.00 |
| 6241 |
Pontic – porcelain fused to predominantly base metal |
260.00 |
| 6242 |
Pontic – porcelain fused to noble metal |
260.00 |
| 6250 |
Pontic – resin with high noble metal |
260.00 |
| 6251 |
Pontic – resin with predominantly base metal |
195.00 |
| 6252 |
Pontic – resin with noble metal |
195.00 |
| 6545 |
Retainer – cast metal for resin bonded fixed prosthesis |
195.00 |
| 6548 |
Retainer – porcelain/ceramic for resin bonded fixed prosthesis |
195.00 |
| 6720 |
Crown – resin with high noble metal |
221.00 |
| 6721 |
Crown – resin with predominantly base metal |
215.00 |
| 6722 |
Crown – resin with noble metal |
215.00 |
| 6750 |
Crown – porcelain fused to high noble metal |
234.00 |
| 6751 |
Crown – porcelain fused to predominantly base metal |
215.00 |
| 6752 |
Crown – porcelain fused to noble metal |
215.00 |
| 6780 |
Crown – ¾ cast high noble metal |
221.00 |
| 6790 |
Crown – full cast high noble metal |
228.00 |
| 6791 |
Crown – full cast predominantly base metal |
228.00 |
| 6792 |
Crown – full cast noble metal |
215.00 |
| 6930 |
Recement fixed partial denture |
33.00 |
|
|
|
|
IX. ORAL SURGERY |
|
| 7140 |
Single tooth |
$26.00 |
| 7210 |
Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth |
39.00 |
| 7220 |
Removal of impacted tooth – soft tissue |
59.00 |
| 7230 |
Removal of impacted tooth – partially bony |
91.00 |
| 7240 |
Removal of impacted tooth – completely bony |
111.00 |
| 7241 |
Removal of impacted tooth – completely bony, with unusual surgical complications |
111.00 |
| 7250 |
Surgical removal of residual tooth roots (cutting procedure) |
39.00 |
| 7285 |
Biopsy of oral tissue – hard |
33.00 |
| 7286 |
Biopsy of oral tissue – soft |
33.00 |
| 7320 |
Alveoloplasty in conjunction with extractions – per quadrant |
98.00 |
| 7410 |
Excision of benign tumor – lesion diameter up to 1.25 cm |
85.00 |
| 7411 |
Excision of benign tumor – lesion diameter greater than 1.25 cm |
85.00 |
| 7440 |
Excision of malignant tumor – lesion diameter up to 1.25 cm |
85.00 |
| 7441 |
Excision of malignant tumor – lesion diameter greater than 1.25 cm |
85.00 |
| 7450 |
Removal of odontogenic cyst or tumor – lesion diameter up to 1.25 cm |
91.00 |
| 7451 |
Removal of odontogenic cyst or tumor – lesion diameter greater than 1.25 cm |
91.00 |
| 7460 |
Removal of nonodontogenic cyst or tumor – lesion diameter up to 1.25 cm |
91.00 |
| 7461 |
Removal of nonodontogenic cyst or tumor – lesion diameter greater than 1.25cm |
91.00 |
| 7465 |
Destruction of lesion(s) by physical or chemical method, by report |
91.00 |
| 7471 |
Removal of exostosis – maxilla or mandible |
130.00 |
| 7510 |
Incision and drainage of abscess – intraoral soft tissue |
46.00 |
| 7960 |
Frenulectomy (frenectomy or frenotomy) – separate procedure |
78.00 |
| 7970 |
Excision of pericoronal gingival |
98.00 |
|
|
|
|
X. ADJUNCTIVE SERVICES |
|
| 9220 |
General anesthesia – first 30 minutes |
$65.00 |
| 9310 |
Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) |
26.00 |