table of dental procedures - healthplan services · d7472 removal of torus palatinus. 162.00 d7473...

9232 NE 1106

Two evaluations will be allowed in a Benefit Period. A D0120, D0150,or D0180 counts toward this maximum allowance. D0150 and D0180will be limited to once per provider.

Bitewing films are limited to 2 allowances in a Benefit Period. An D0270,D0272, D0274, or D0277 counts toward this maximum allowance. In addition, D0277 will be limited to once in a 3-year period.*

Prophylaxis (cleaning) will be allowed twice in a Benefit Period. A D1110or D1120 counts toward this maximum allowance. Periodontalmaintenance may be substituted for a cleaning (see requirementsunder Type I(B) section). Benefits will not be available if performed onthe same date as periodontal services. An adult prophylaxis isconsidered for individuals age 14 and over. A child prophylaxis isconsidered for individuals age 13 and under.

PERSONAL AND DEPENDENT DENTAL CARE INSURANCE

TABLE OF DENTAL PROCEDURESThe following list of dental procedures for which benefits are payable under this section is based upon the CurrentDental Terminology© American Dental Association. No benefits are payable for a procedure that is not listed.

For procedures which reference a Benefit Period, see the Schedule of Benefits for the definition of Benefit Period.BR means By Report. Any dollar amount is a Maximum Covered Expense. Please read the sectionDENTAL EXPENSE BENEFITS and "Limitations" for additional coverage information.

TYPE I(A) PROCEDURES - Preventive

PROC. MAXIMUMNO. COVERED EXPENSE

D0120 Periodic oral evaluation. $30.00D0150 Comprehensive oral evaluation - new or established patient. 46.00D0180 Comprehensive periodontal evaluation - new or established patient. 46.00

D0270 Bitewing, single film. 15.00D0272 Bitewings - two films. 27.00D0274 Bitewings - four films. 42.00D0277 Vertical bitewings - 7 to 8 films. 64.00

D1110 Prophylaxis - adult. 64.00D1120 Prophylaxis - child. 45.00

*The frequency is measured forward from the last covered date of service for the procedure.

Current Dental Terminology© American Dental Association

D1203: Coverage for fluoride treatment is limited to persons age18 and under and to one treatment in a Benefit Period.

D1510-1525: Coverage is limited to space maintenance for uneruptedteeth, following extraction of primary teeth. Allowance includes alladjustments within 6 months after installation.

D8210-8220: Coverage is limited to the correction of thumb-sucking.


D1203 Topical fluoride (reported as a separate code) in $25.00

conjunction with prophylaxis - child.

D1510 Space maintainer - fixed - unilateral. 226.00D1515 Space maintainer - fixed - bilateral. 370.00D1520 Space maintainer - removable - unilateral. 354.00D1525 Space maintainer - removable - bilateral. 432.00

D1550 Recement space maintainer. 46.00D8210 Removable appliance therapy. 340.00D8220 Fixed appliance therapy. 340.00

D0140 and D0170: Coverage is limited to accidental injury only. If not due to an accident, will be considered as a D0120 and count toward this maximum allowance.

D0210 or D0330: One of these procedures will be allowed in a 3-year period.*

D0472-0474: Coverage is limited to one examination per biopsy/excision.

D1351: Coverage is limited to treatment of the occlusal surface of permanent molar teeth once during a 3-year period for persons age16 and under.*

D4355: Coverage is limited to once during a 5-year period.*

TYPE I(B) PROCEDURES - Basic


MISCELLANEOUS PROCEDURES.

D0140 Limited oral evaluation - problem focused. $32.00D0170 Re-evaluation - limited, problem focused (established patient; 32.00

not post-operative visit).

D0210 Intraoral - complete series (including bitewings). 64.00D0330 Panoramic film. 51.00

D0220 Periapical radiograph - first film. 12.00D0230 Additional periapical film, each. 9.00D0240 Intraoral, occlusal film. 16.00D0250 Extraoral, first film. 21.00D0260 Extraoral, each additional film. 16.00D0472 Accession of tissue, gross examination, preparation and 38.00

transmission of written report.D0473 Accession of tissue, gross and microscopic examination, 75.00

preparation and transmission of written report.D0474 Accession of tissue, gross and microscopic examination, including 75.00

assessment of surgical margins for presence of disease, preparation and transmission of written report.

D1351 Sealant - per tooth. 23.00

D2910 Recement inlay. 43.00D2920 Recement crown. 42.00D6930 Recement fixed partial denture. 59.00D4355 Full mouth debridement to enable comprehensive 67.00

evaluation and diagnosis.


D4910: This procedure is available in place of an eligible routineprophylaxis (D1110-1120) as listed above. Coverage is contingent uponevidence of full mouth active periodontal therapy and limited to 2allowances in a Benefit Period (a D1110 or D1120 counts toward this maximum allowance). Benefits will not be available if performed on thesame date as other periodontal services.

D5730-5761: Coverage for relines is limited to service dates more than 6 months after installation.

D9110: Not covered in conjunction with other procedures, except diagnostic x-ray films.

D9310: Coverage is limited to one allowance per provider.

D9440: Payment will be made on basis of services rendered or visit, whichever is greater.

D9951-9952: Coverage is limited to adjustment performed in conjunction with treatment of periodontal disease.


D4910 Periodontal maintenance. $68.00

D5510 Repair broken complete denture base. 68.00D5520 Replace missing or broken teeth - complete denture (each tooth). 57.00D5610 Repair resin denture base - partial denture. 68.00D5620 Repair cast framework - partial denture. 80.00D5630 Repair or replace broken clasp - partial denture. 84.00D5640 Replace broken teeth (per tooth) - partial denture. 60.00D5730 Reline complete maxillary denture (chairside). 126.00D5731 Reline complete mandibular denture (chairside). 125.00D5740 Reline maxillary partial denture (chairside). 113.00D5741 Reline mandibular partial denture (chairside). 113.00D5750 Reline complete maxillary denture (laboratory). 187.00D5751 Reline complete mandibular denture (laboratory). 184.00D5760 Reline maxillary partial denture (laboratory). 187.00D5761 Reline mandibular partial denture (laboratory). 188.00

D9110 Palliative (emergency) treatment of dental pain 45.00 - minor procedure.

D9310 Consultation (diagnostic service provided by dentist or 46.00 physician other than practitioner providing treatment).

D9440 Office visit after regularly scheduled hours. 56.00

D9911 Application of desensitizing resin for cervical and/or root surface, 66.00 per tooth.

D9930 Treatment of complications (post-surgical) - unusual 34.00 circumstances, by report.

D9951 Occlusal adjustment, limited. 43.00D9952 Occlusal adjustment, complete. 217.00

Station1Text BoxCurrent Dental Terminology©American Dental Association

D2391-2394: Coverage is limited to permanent bicuspid teeth.

D2390, D2930-2932: Coverage is limited to persons age 18 and under.


RESTORATIVE (Excluding inlays, crowns).

D2140 Amalgam - one surface, primary or permanent. $54.00D2150 Amalgam - two surfaces, primary or permanent. 68.00D2160 Amalgam - three surfaces, primary or permanent. 83.00D2161 Amalgam - four or more surfaces, primary or permanent. 99.00D2330 Resin-based composite - one surface, anterior. 66.00D2331 Resin-based composite - two surfaces, anterior. 83.00D2332 Resin-based composite - three surfaces, anterior. 104.00D2335 Resin-based composite - four or more surfaces or involving incisal 114.00

angle, anterior.D2391 Resin-based composite - one surface, posterior 72.00D2392 Resin-based composite - two surfaces, posterior. 91.00D2393 Resin-based composite - three surfaces, posterior. 114.00D2394 Resin-based composite - four or more surfaces, posterior. 126.00

D2390 Resin-based composite crown, anterior. 140.00D2930 Prefabricated stainless steel crown - primary tooth. 117.00D2931 Stainless steel crown - permanent tooth. 124.00D2932 Prefabricated resin crown. 140.00

D2951 Pin retention, per tooth, in addition to restoration. 21.00

ORAL SURGERY.

D7111 Coronal remnants - deciduous tooth 60.00D7140 Extraction, erupted tooth or exposed root (elevation 60.00

and/or forceps removal).D7210 Surgical removal of erupted tooth. 116.00D7220 Surgical removal of impacted tooth - soft tissue. 145.00D7230 Surgical removal of impacted tooth - partially bony. 193.00D7240 Surgical removal of impacted tooth - completely bony. 225.00D7241 Removal of impacted tooth completely bony, with 257.00

unusual surgical complications, by report.D7250 Surgical removal of residual tooth roots (cutting procedure). 121.00D7260 Oral antral fistula closure. 284.00D7261 Primary closure of a sinus perforation. 284.00D7270 Tooth re-implantation and/or stabilization of accidentally 172.00

evulsed or displaced tooth.D7272 Tooth transplantation (includes reimplantation from one 172.00

site to another and splinting and/or stabilization).D7280 Surgical access of an unerupted tooth. 266.00D7281 Surgical exposure of impacted or unerupted tooth to aid 192.00

eruption.D7282 Mobilization of erupted or malpositioned tooth to aid eruption. 192.00D7285 Biopsy of oral tissue - hard (bone, tooth). 244.00D7286 Biopsy of oral tissue - soft (all others). 131.00D7287 Cytology sample collection. 66.00

D7471-7473: A maximum of 5 allowances will be considered.


D7310 Alveoloplasty in conjunction with extractions-per quadrant. $100.00D7320 Alveoloplasty not in conjunction with extractions-per quadrant. 127.00D7340 Vestibuloplasty - ridge extension (secondary epithelialization). 184.00D7350 Vestibuloplasty - ridge extension (including soft tissue 456.00

grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue).

D7410 Excision of benign lesion up to 1.25 cm. 182.00D7411 Excision of benign lesion greater than 1.25 cm. 233.00D7412 Excision of benign lesion, complicated. 257.00D7413 Excision of malignant lesion up to 1.25 cm. 246.00D7414 Excision of malignant lesion greater than 1.25 cm. 180.00D7415 Excision of malignant lesion, complicated. 198.00D7440 Excision of malignant tumor-lesion diameter up to 1.25 cm. 246.00D7441 Excision of malignant tumor-lesion diameter greater than 1.25 cm. 180.00D7450 Removal of benign odontogenic cyst or tumor 182.00

- lesion diameter up to 1.25 cm.D7451 Removal of benign odontogenic cyst or tumor 233.00

- lesion diameter greater than 1.25 cm.D7460 Removal of benign nonodontogenic cyst or tumor 182.00

- lesion diameter up to 1.25 cm.D7461 Removal of benign nonodontogenic cyst or tumor 233.00

- lesion diameter greater than 1.25 cm.D7465 Destruction of lesion(s) by physical or chemical method, 55.00

by report.D7471 Removal of lateral exostosis - (maxilla or mandible). 162.00D7472 Removal of torus palatinus. 162.00D7473 Removal of torus mandibularis. 162.00

D7485 Surgical reduction of osseous tuberosity. 264.00D7490 Radical resection of mandible with bone graft. 246.00D7510 Incision and drainage of abscess - intraoral soft tissue. 81.00D7520 Incision and drainage of abscess - extraoral soft tissue. 94.00D7530 Removal of foreign body from mucosa, skin, 75.00

or subcutaneous alveolar tissue.D7540 Removal of reaction-producing foreign bodies - 205.00

musculoskeletal system.D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone. 205.00D7560 Maxillary sinusotomy for removal of tooth fragment or 270.00

foreign body.D7910 Suture of recent small wounds - up to 5 cm. 36.00D7911 Complicated suture - up to 5 cm. 41.00D7912 Complicated suture - greater than 5 cm. 59.00D7960 Frenulectomy (frenectomy or frenotomy)-separate procedure. 195.00D7970 Excision of hyperplastic tissue - per arch. 150.00D7980 Sialolithotomy. 225.00D7983 Closure of salivary fistula. 72.00

Station1Text BoxCurrent Dental Terminology©American Dental Association

D9220-9242: Coverage is not available without a cutting procedure.Verification of the dentist’s anesthesia permit and a copy of theanesthesia report is required. A maximum of two additional units (D9221or D9242) will be considered.


ANESTHESIA.

D9220 Deep sedation/general anesthesia - first 30 minutes. $173.00D9221 Deep sedation/general anesthesia - each additional 15 minutes. 57.00D9241 Intravenous conscious sedation/analgesia - first 30 minutes. 114.00D9242 Intravenous conscious sedation/analgesia 28.00

- each additional 15 minutes.

D3310-3333: Coverage is limited to permanent teeth. Allowanceincludes intraoperative films and cultures but excludes finalrestoration.

D3346-3348: Coverage is limited to permanent teeth and to service datesmore than 12 months after root canal therapy or a previous retreatment.Allowance includes intraoperative films and cultures but excludes finalrestoration.

TYPE II PROCEDURES


ENDODONTICS.

D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp $41.00 coronal to the dentinocemental junction and application of medicament. Limited to treatment of primary teeth.

D3221 Pulpal debridement, primary and permanent teeth. 41.00D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth. 54.00D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth. 47.00D3310 Root canal, anterior (excluding final restoration). 185.00D3320 Root canal, bicuspid (excluding final restoration). 218.00D3330 Root canal, molar (excluding final restoration). 286.00D3332 Incomplete endodontic therapy; inoperable or fractured tooth. 109.00D3333 Internal root repair of perforation defects. 67.00

D3346 Retreatment of previous root canal therapy - anterior. 231.00D3347 Retreatment of previous root canal therapy - bicuspid. 266.00D3348 Retreatment of previous root canal therapy - molar. 330.00

D3351 Apexification/recalcification - initial visit. 67.00D3352 Apexification/recalcification - interim medication replacement. 45.00D3353 Apexification/recalcification - final visit. 132.00D3410 Apicoectomy/periradicular surgery - anterior. 191.00D3421 Apicoectomy/periradicular surgery - bicuspid (first root). 220.00D3425 Apicoectomy/periradicular surgery - molar (first root). 238.00D3426 Apicoectomy/periradicular surgery - (each additional root). 85.00D3430 Retrograde filling - per root. 52.00D3450 Root amputation - per root. 124.00D3920 Hemisection (including any root removal), not including 105.00

root canal therapy.

PERIODONTICS. Surgical Procedures (including postoperative visits).

D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or 121.00 bounded teeth spaces per quadrant.

D4211 Gingivectomy or gingivoplasty - one to three teeth, 61.00 per quadrant.

D4240 Gingival flap procedure, including root planing - four or more 166.00 contiguous teeth or bounded teeth spaces per quadrant.

D4241 Gingival flap procedure, including root planing - one to three teeth, 83.00 per quadrant.

D4210-4265: Each procedure is eligible for consideration once in a 3-year period.*

D4270-4273, D4275-4276: A maximum of two sites per quadrant will be considered in a 3-year period. Coverage is limited to treatment of periodontal disease.*

D4341-4342: Each quadrant is eligible for consideration once in a 2-year period.*

D4381: A scaling and planing (D4341) must be performed between six weeks and two years prior to treatment. A maximum of two sitesper quadrant will be considered and the frequency is limited to once in any 2-year period.*


D4260 Osseous surgery (including flap entry and closure) - four or more $304.00 contiguous teeth or bounded teeth spaces per quadrant.

D4261 Osseous surgery (including flap entry and closure) one to three teeth, 152.00 per quadrant.

D4263 Bone replacement graft - first site in quadrant. 99.00D4264 Bone replacement graft - each additional site in quadrant. 75.00D4265 Biologic materials to aid in soft and osseous tissue regeneration. 50.00

D4270 Pedicle soft tissue graft procedure. 224.00D4271 Free soft tissue graft procedure (including donor site surgery). 237.00D4273 Subepithelial connective tissue graft procedures. 276.00D4275 Soft tissue allograft. 237.00D4276 Combined connective tissue and double pedicle graft. 276.00

D4274 Distal or proximal wedge procedure (when not performed in 133.00 conjunction with surgical procedures in the same anatomical area).

Non-surgical Periodontal Procedures.

D4341 Periodontal scaling and root planing - four or more contiguous 62.00 teeth or bounded teeth spaces per quadrant.

D4342 Periodontal scaling and root planing, one to three teeth, per quadrant. 31.00

D4381 Localized delivery of chemotherapeutic agents via a controlled 46.00 release vehicle into diseased crevicular tissue, per tooth.

RESTORATIVE - Inlays and Crowns.

D2390 Resin-based composite crown, anterior. 78.00D2510 Inlay - metallic - one surface. 204.00D2520 Inlay - metallic - two surfaces. 243.00D2530 Inlay - metallic - three or more surfaces. 262.00


D2390-2932: These procedures are limited to necessary placementresulting from decay or traumatic injury. Inlays will be reimbursed atthe alternate allowance of an amalgam or composite restoration.

TYPE II PROCEDURES (Continued)


D2542 Onlay - metallic - two surfaces. $265.00D2543 Onlay - metallic - three surfaces. 296.00D2544 Onlay - metallic - four or more surfaces. 308.00D2610 Inlay - porcelain/ceramic - one surface. 225.00D2620 Inlay - porcelain/ceramic - two surfaces. 245.00D2630 Inlay - porcelain/ceramic - three or more surfaces. 268.00D2642 Onlay - porcelain/ceramic - two surfaces. 265.00D2643 Onlay - porcelain/ceramic - three surfaces. 297.00D2644 Onlay - porcelain/ceramic - four or more surfaces. 306.00D2650 Inlay - resin-based composite composite/resin - one surface. 234.00D2651 Inlay - resin-based composite composite/resin - two surfaces. 231.00D2652 Inlay - resin-based composite composite/resin - three or more surfaces. 239.00D2662 Onlay - resin-based composite composite/resin - two surfaces. 248.00D2663 Onlay - resin-based composite composite/resin - three surfaces. 256.00D2664 Onlay - resin-based composite composite/resin - four or more surfaces. 272.00D2710 Crown - resin (indirect). 116.00D2720 Crown - resin with high noble metal. 296.00D2721 Crown - resin with predominantly base metal. 225.00D2722 Crown - resin with noble metal. 276.00D2740 Crown - porcelain/ceramic substrate. 319.00D2750 Crown - porcelain fused to high noble metal. 310.00D2751 Crown - porcelain fused to predominantly base metal. 266.00D2752 Crown - porcelain fused to noble metal. 285.00D2780 Crown - 3/4 cast high noble metal. 295.00D2781 Crown - 3/4 cast predominantly base metal. 256.00D2782 Crown - 3/4 cast noble metal. 268.00D2783 Crown - 3/4 porcelain/ceramic. 319.00D2790 Crown - full cast high noble metal. 295.00D2791 Crown - full cast predominantly base metal. 256.00D2792 Crown - full cast noble metal. 268.00D2930 Prefabricated stainless steel crown - primary tooth. 65.00D2931 Prefabricated stainless steel crown - permanent tooth. 69.00D2932 Prefabricated resin crown. 78.00

D2950 Core build-up, including any pins. 64.00D2952 Cast post and core - in addition to crown. 102.00D2954 Prefabricated post and core - in addition to crown. 85.00D2980 Crown repair, by report. 52.00D4249 Clinical crown lengthening, hard tissue. 183.00

D6058-6077: Although implants are not a covered benefit, theseprocedures can qualify for benefits. Coverage is subject to thereplacement and extraction provisions as defined under the limitationssection of this contract.


PROSTHODONTICS - FIXED. Pontics.

D6210 Cast high noble metal. $301.00D6211 Cast predominantly base metal. 301.00D6212 Cast noble metal. 326.00D6240 Porcelain fused to high noble metal. 301.00D6241 Porcelain fused to predominantly base metal. 301.00D6242 Porcelain fused to noble metal. 275.00D6245 Porcelain/ceramic. 275.00D6250 Resin with high noble metal. 301.00D6251 Resin with predominantly base metal. 275.00D6252 Resin with noble metal. 326.00

Implant Supported.

D6058 Abutment supported porcelain/ceramic crown. 275.00D6059 Abutment supported porcelain fused to metal crown 301.00

(high noble metal).D6060 Abutment supported porcelain fused to metal crown 301.00

(predominantly base metal).D6061 Abutment supported porcelain fused to metal crown (noble metal). 275.00D6062 Abutment supported cast metal crown (high noble metal). 301.00D6063 Abutment supported cast metal crown (predominantly base metal). 301.00D6064 Abutment supported cast metal crown (noble metal). 326.00D6065 Implant supported porcelain/ceramic crown. 275.00D6066 Implant supported porcelain fused to metal crown (titanium, 301.00

titanium alloy, high noble metal).D6067 Implant supported metal crown (titanium, titanium alloy, 301.00

high noble metal).D6068 Abutment supported retainer of porcelain/ceramic FPD. 275.00D6069 Abutment supported retainer for porcelain fused to metal FPD 301.00

(high noble metal).D6070 Abutment supported retainer for porcelain fused to metal FPD 301.00

(predominantly base metal).D6071 Abutment supported retainer for porcelain fused to metal FPD 275.00

(noble metal).D6072 Abutment supported retainer for cast metal FPD (high noble metal). 301.00D6073 Abutment supported retainer for cast metal FPD (predominantly 301.00

base metal).D6074 Abutment supported retainer for cast metal FPD (noble metal). 326.00D6075 Implant supported retainer for ceramic FPD. 275.00D6076 Implant supported retainer for porcelain fused to metal FPD 301.00

(titanium, titanium alloy, or high noble metal).D6077 Implant supported retainer for cast metal FPD 301.00

(titanium, titanium alloy, or high noble metal).

TYPE II PROCEDURES (Continued)


Retainers (Abutments).

D6545 Retainer - cast metal for resin bonded fixed prosthesis. $100.00D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis. 100.00D6600 Inlay - porcelain/ceramic, two surfaces. 245.00D6601 Inlay - porcelain/ceramic, three or more surfaces. 269.00D6602 Inlay - cast high noble metal, two surfaces. 220.00D6603 Inlay - cast high noble metal, three or more surfaces. 242.00D6604 Inlay - cast predominantly base metal, two surfaces. 190.00D6605 Inlay - cast predominantly base metal, three or more surfaces. 209.00D6606 Inlay - cast noble metal, two surfaces. 200.00D6607 Inlay - cast noble metal, three or more surfaces. 220.00D6608 Onlay - porcelain/ceramic, two surfaces. 265.00D6609 Onlay - porcelain/ceramic, three or more surfaces. 292.00D6610 Onlay - cast high noble metal, two surfaces. 242.00D6611 Onlay - cast high noble metal, three or more surfaces. 266.00D6612 Onlay - cast predominantly base metal, two surfaces. 209.00D6613 Onlay - cast predominantly base metal, three or more surfaces. 230.00D6614 Onlay - cast noble metal, two surfaces. 220.00D6615 Onlay - cast noble metal, three or more surfaces. 242.00D6720 Crown - resin with high noble metal. 301.00D6721 Crown - resin with predominantly base metal. 156.00D6722 Crown - resin with noble metal. 250.00D6740 Crown - porcelain/ceramic. 275.00D6750 Crown - porcelain fused to high noble metal. 326.00D6751 Crown - porcelain fused to predominantly base metal. 301.00D6752 Crown - porcelain fused to noble metal. 275.00D6780 Crown - 3/4 cast high noble metal. 326.00D6781 Crown - 3/4 cast predominantly base metal. 301.00D6782 Crown - 3/4 cast noble metal. 275.00D6783 Crown - 3/4 porcelain/ceramic. 275.00D6790 Crown - full cast high noble metal. 301.00D6791 Crown - full cast predominantly base metal. 301.00D6792 Crown - full cast noble metal. 275.00D6940 Stress breaker. 83.00D6970 Cast post and core in addition to fixed partial denture 90.00

retainer. D6972 Prefabricated post and core in addition to fixed partial 90.00

denture retainer.D6980 Fixed partial denture repair, by report. 58.00

PROSTHODONTICS - REMOVABLE.

D5110 Complete denture - maxillary. 330.00D5120 Complete denture - mandibular. 320.00D5130 Immediate denture - maxillary. 358.00D5140 Immediate denture - mandibular. 346.00

D5110-5281: Allowances for partial and complete dentures include adjustments within 6 months after installation. Precision attachments, implants, overdentures, specialized techniques and characterizations are considered optional and the additional expense for these shall be borne by the patient. All partial allowances include conventional clasps, rests and teeth.

D5410-5422: Coverage is limited to an adjustment with a date ofservice more than 6 months after installation.

D5670-5671: Prosthetic replacement limitation applies. See Limitations section.


D5211 Maxillary partial denture - resin base. $237.00D5212 Mandibular partial denture - resin base. 275.00D5213 Maxillary partial denture-cast metal framework with resin 383.00

denture bases.D5214 Mandibular partial denture-cast metal framework with resin 383.00

denture bases.D5281 Removable unilateral partial denture - one piece cast 205.00

metal.

D5410 Adjust complete denture - maxillary. 19.00D5411 Adjust complete denture - mandibular. 18.00D5421 Adjust partial denture - maxillary. 20.00D5422 Adjust partial denture - mandibular. 19.00

D5650 Add tooth to existing partial denture. 43.00D5660 Add clasp to existing partial denture. 50.00D5670 Replace all teeth and acrylic on cast metal framework (maxillary). 237.00D5671 Replace all teeth and acrylic on cast metal framework (mandibular). 275.00

D5710 Rebase complete maxillary denture. 120.00D5711 Rebase complete mandibular denture. 127.00D5720 Rebase maxillary partial denture. 115.00D5721 Rebase mandibular partial denture. 121.00D5810 Interim complete denture (maxillary). 146.00D5811 Interim complete denture (mandibular). 154.00D5820 Interim partial denture (maxillary). 128.00D5821 Interim partial denture (mandibular). 135.00D5850 Tissue conditioning - maxillary. 34.00D5851 Tissue conditioning - mandibular. 36.00

table of dental procedures - healthplan services · d7472 removal of torus palatinus. 162.00 d7473...

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