|
Dental Codes |
Refund Amount |
Description |
|
|
0120 |
28 |
Periodic oral evaluation |
|
|
0140 |
42 |
Limited oral evaluation - focused problem |
|
|
0150 |
46 |
Comprehensive oral evaluation |
|
|
0160 |
80 |
Detailed and extensive oral evaluation: problem focused by report |
|
|
0170 |
22 |
Re-evaluation limited, problem focused established patient not post operative |
|
|
0180 |
60 |
Comprehensive oral evaluation - new or established patient |
|
|
0210 |
82 |
Intraoral - complete series (including bitewings) |
|
|
0220 |
16 |
Intraoral - periapical first film |
|
|
0230 |
12 |
Intraoral - periapical each additional film |
|
|
0240 |
26 |
Intraoral - occusal film |
|
|
0250 |
34 |
Extraoral - first film |
|
|
0260 |
28 |
extraoral - each additional film |
|
|
0270 |
16 |
Bitewings - single film |
|
|
0272 |
28 |
Bitewings - two films |
|
|
0273 |
33 |
Bitewings - three films |
|
|
0274 |
38 |
Bitewings - four films |
|
|
0277 |
46 |
Vertical bitewings - 7-8 films |
|
|
0290 |
80 |
Posterior - anterior or lateral skull and facial bone survey film |
|
|
0310 |
120 |
Sialography |
|
|
0322 |
210 |
Tomographic survey |
|
|
0330 |
70 |
Panoramic film |
|
|
0340 |
80 |
Cephalometric film |
|
|
0350 |
32 |
Oral/facial images (including intra and extraoral images) |
|
|
0360 |
215 |
cone beam CT - craniofacial data capture |
|
|
0362 |
132 |
cone beam CT - two-dimensional image reconstruction using existing data, includes multiple images |
|
|
0363 |
138 |
cone beam CT - three-dimensional image reconstruction using existing data, includes multiple images |
|
|
0415 |
74 |
Bacteriologic studies for determination of pathologic agents |
|
|
0416 |
74 |
Viral culture |
|
|
0421 |
56 |
Genetic test for susceptibility to oral diseases |
|
|
0425 |
48 |
Caries susceptibility tests |
|
|
0431 |
28 |
Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures |
|
|
0460 |
34 |
Pulp vitality tests |
|
|
0470 |
62 |
Diagnostic casts |
|
|
0472 |
40 |
Accession of tissue, gross examination, preperation and transmission |
|
|
0473 |
67 |
Accession of tissue, gross and microscopic exam, preperation and transmission of written report |
|
|
0474 |
83 |
Accession of tissue, gross and microscopic exam, including assessment of surgical margins for presence of disease, preparation and transmission of written report |
|
|
0475 |
95 |
Decalcification process |
|
|
0476 |
148 |
Special stains for microorganisms |
|
|
0477 |
148 |
Special stains not for microorganisms |
|
|
0478 |
81 |
Immunohistochemical stains |
|
|
0479 |
109 |
Tissue in-situ hybridization, including interpretation |
|
|
0480 |
82 |
Processing and interpretation of cytologic smears, including the preperation |
|
|
0481 |
81 |
Electron microscopy - diagnostic |
|
|
0482 |
49 |
Direct immunofluorescence |
|
|
0483 |
53 |
Indirect immunofluorescence |
|
|
0484 |
77 |
Consultation on slides prepared elsewhere |
|
|
0485 |
77 |
Consultation, including preparation of slides from biopsy material supplied by referring source |
|
|
0486 |
72 |
Accession of brush biopsy sample,microscopic examination, preparation and transmission of written report |
|
|
0501 |
116 |
Histopathologic examination |
|
|
0502 |
106 |
Other oral pathology procedures, by report |
|
|
0999 |
IR |
Unspecified diagnostic procedure, by report |
|
|
Dental Codes |
Refund Amount |
Description |
|
|
1110 |
54 |
Prophy - adult |
|
|
1120 |
40 |
Prophy - child |
|
|
1201 |
55 |
Topical application of fluoride (including prophy - child) |
|
|
1203 |
15 |
Topical application of fluoride (excluding prophy - child) |
|
|
1204 |
15 |
Topical application of fluoride (excluding prophy - adult) |
|
|
1205 |
70 |
Topical application of fluoride (including prophy - adult) |
|
|
1206 |
22 |
Topical fluoride varnish; therapeutic application for moderate to high caries risk patients |
|
|
1310 |
21 |
Nutritional counseling for control of dental disease |
|
|
1320 |
0 |
Tobacco counseling |
|
|
1330 |
15 |
Oral hygiene instructions |
|
|
1351 |
15 |
Reimbursement through the age of 18 Only Sealant - per tooth |
|
|
1510 |
200 |
Space maintainer: fixed - unilateral |
|
|
1515 |
284 |
Space maintainer; fixed - bilateral |
|
|
1520 |
246 |
Space maintainer, removable - unilateral |
|
|
1525 |
314 |
Space maintainer; removable - bilateral |
|
|
1550 |
50 |
Recementation of space maintainer |
|
|
1555 |
48 |
Removal of fixed space maintainer |
|
|
|
|
|
|
|
|
******NOTE******* Reimbursement for sealants will only be covered through the age of 18. The plan no longer covers sealants on patients over the age 18. | |
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|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Dental Codes |
Refund Amount |
Description |
|
|
|
|
2110 |
29 |
Amalgam - one surface, |
|
|
|
|
|
2120 |
35 |
Amalgam - two surfaces; primary |
|
|
|
|
|
2130 |
44 |
Amalgam - three surfaces; primary |
|
|
|
|
|
2131 |
69 |
Amalgam - four or more surfaces; primary |
|
|
|
|
|
2140 |
80 |
Amalgam - one surface; permanent |
|
|
|
|
|
2150 |
90 |
Amalgam - two surfaces; permanent |
|
|
|
|
|
2160 |
110 |
Amalgam - three surfaces; permanent |
|
|
|
|
|
2161 |
123 |
Amalgam - four or more surfaces; permanent |
|
|
|
|
|
2330 |
95 |
Resin - based composite; one surface, anterior |
|
|
|
|
|
2331 |
115 |
Resin - based composite; two surface, anterior |
|
|
|
|
|
2332 |
135 |
Resin - based composite; three surface, anterior |
|
|
|
|
|
2335 |
155 |
Resin - based composite; four or more surfaces or involving incisal angle |
|
|
|
|
|
2390 |
219 |
Resin-based composite crown, anterior |
|
|
|
|
|
2391 |
120 |
Resin - based composite; one surface, posterior |
|
|
|
|
|
2392 |
165 |
Resin - based composite; two surfaces, posterior |
|
|
|
|
|
2393 |
195 |
Resin - based composite; three surfaces, posterior |
|
|
|
|
|
2394 |
215 |
Resin - based composite; four or more surfaces, posterior |
|
|
|
|
|
2410 |
120 |
Gold foil - one surface |
|
|
|
|
|
2420 |
135 |
Gold foil- two surfaces |
|
|
|
|
|
2430 |
150 |
Gold foil - three surfaces |
|
|
|
|
|
2510 |
72 |
Inlay - metallic; one surface |
|
|
|
|
|
2520 |
85 |
Inlay - metallic; two surfaces |
|
|
|
|
|
2530 |
100 |
Inlay - metallic; three or more surfaces |
|
|
|
|
|
2542 |
93 |
Onlay - metallic; two surfaces |
|
|
|
|
|
2543 |
115 |
Onlay - metallic; three surfaces |
|
|
|
|
|
2544 |
130 |
Onlay - metallic; four or more surfaces |
|
|
|
|
|
2610 |
90 |
Inlay - porcelain/ceramic; one surfaces |
|
|
|
|
|
2620 |
110 |
Inlay - porcelain/ceramic; two surfaces |
|
|
|
|
|
2630 |
125 |
Inlay - porcelain/ceramic; three or more surfaces |
|
|
|
|
|
2642 |
174 |
Onlay - porcelain/ceramic; two surfaces |
|
|
|
|
|
2643 |
195 |
Onlay - porcelain/ceramic; three surfaces |
|
|
|
|
|
2644 |
215 |
Onlay - porcelain/ceramic; four or more surfaces |
|
|
|
|
|
2650 |
105 |
Inlay - resin based composite; one surface |
|
|
|
|
|
2651 |
120 |
Inlay resin based composite; two surfaces |
|
|
|
|
|
2652 |
140 |
Inlay - resin based composite; three or more surfaces |
|
|
|
|
|
2662 |
150 |
Onlay - resin based composite; two surfaces |
|
|
|
|
|
2663 |
165 |
Onlay - resin based composite; three surfaces |
|
|
|
|
|
2664 |
190 |
Onlay - resin based composite; four or more surfaces |
|
|
|
|
|
2710 |
168 |
Crown - resin (indirect) |
|
|
|
|
|
2712 |
235 |
Crown - resin-based composite (indirect) |
|
|
|
|
|
2720 |
255 |
Crown - resin with high noble metal |
|
|
|
|
|
2721 |
231 |
Crown - resin with predominantly base metal |
|
|
|
|
|
2722 |
240 |
Crown - resin with noble metal |
|
|
|
|
|
2740 |
266 |
Crown - porcelain/ceramic substrate |
|
|
|
|
|
2750 |
263 |
Crown - porcelain fused to high noble metal |
|
|
|
|
|
2751 |
242 |
Crown - porcelain fused to predominantly base metal |
|
|
|
|
|
2752 |
252 |
Crown - porcelain fused to noble metal |
|
|
|
|
|
2780 |
263 |
Crown - 3/4 cast high noble metal |
|
|
|
|
|
2781 |
242 |
Crown - 3/4 cast predominantly base metal |
|
|
|
|
|
2782 |
251 |
Crown - 3/4 cast noble metal |
|
|
|
|
|
2783 |
266 |
Crown - 3/4 porcelain/ceramic |
|
|
|
|
|
2790 |
260 |
Crown - full cast high noble metal |
|
|
|
|
|
2791 |
237 |
Crown - full cast predominantly base metal |
|
|
|
|
|
2792 |
246 |
Crown - full cast noble metal |
|
|
|
|
|
2794 |
260 |
Crown - titanium |
|
|
|
|
|
2799 |
63 |
Provisional crown |
|
|
|
|
|
2910 |
23 |
Recement inlay |
|
|
|
|
|
2915 |
22 |
Recement cast or prefabricated post and core |
|
|
|
|
|
2920 |
23 |
Recement crown |
|
|
|
|
|
2930 |
63 |
Prefabricated stainless steel crown - primary tooth |
|
|
|
|
|
2931 |
74 |
Prefabricated stainless steel crown - permanent tooth |
|
|
|
|
|
2932 |
74 |
Prefabricated resin crown |
|
|
|
|
|
2933 |
84 |
Prefabricated stainless steel crown with resin window |
|
|
|
|
|
2934 |
90 |
Prefabricated esthetic coated stainless steel crown - primary tooth |
|
|
|
|
|
2940 |
24 |
Sedative filling |
|
|
|
|
|
2950 |
62 |
Core buildup, including any pins |
|
|
|
|
|
2951 |
14 |
Pin retention - per tooth, in addition to restoration |
|
|
|
|
|
2952 |
99 |
Cast post and core in addition to crown |
|
|
|
|
|
2953 |
35 |
Each additional cast post - same tooth |
|
|
|
|
|
2954 |
77 |
Prefabricated post and core in addition to crown |
|
|
|
|
|
2955 |
62 |
Post removal (not in conjunction with endodontic therapy) |
|
|
|
|
|
2957 |
18 |
Each additional prefabricated post - same tooth |
|
|
|
|
|
2960 |
119 |
Labial veneer (resin laminate);chair side |
|
|
|
|
|
2961 |
197 |
Labial veneer (resin laminate); laboratory |
|
|
|
|
|
2962 |
236 |
Labial veneer (porcelain laminate); laboratory |
|
|
|
|
|
2970 |
85 |
temporary crown (fractured tooth) |
|
|
|
|
|
2971 |
IR |
Additional procedures to construct new crown under existing partial denture framework |
|
|
|
|
|
2975 |
175 |
Coping |
|
|
|
|
|
2980 |
71 |
Crown repair; by report |
|
|
|
|
|
2999 |
IR |
Unspecified restorative procedure, by report |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Dental Codes |
Refund Amount |
Description |
|
|
|
|
3110 |
26 |
Pulp cap - direct (excluding final restoration) |
|
|
|
|
3120 |
26 |
Pulp cap - indirect (excluding final restoration) |
|
|
|
|
3220 |
57 |
Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal |
|
|
|
|
3221 |
39 |
Gross pulpal debridement, primary and permanent teeth |
|
|
|
|
3230 |
83 |
Pulpal therapy (restorable filling) anterior primary tooth ( excluding final restoration) |
|
|
|
|
3240 |
93 |
Pulpal therapy (restorable filling) posterior, primary tooth (excluding final restoration) |
|
|
|
|
3310 |
225 |
Anterior (excluding final restoration) |
|
|
|
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