Diagnostic. D0999 Unspecified diagnostic procedure, by report $20 No Cost Includes office visit, per visit (in addition to other services) Includes office visit, per visit (in addition to other services) D0120 Periodic oral evaluation - established patient No cost No Cost 1 of (D0120, D0150,D0180) per 6 months D0140 Limited oral evaluation - problem focused No cost No Cost 1 of (D0140, D0170)per Contract Dentist per 6 months Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver No cost Not a benefit D0150 Comprehensive oral evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180) per 6 months D0160 Detailed and extensive oral evaluation - problem focused, by report No cost No cost D0170 Re-evaluation - limited, problem focused (established patient; notpost-operative visit) No cost No cost 1 of (D0140, D0170)per Contract Dentist per 6 months D0171 Re-evaluation - post-operative office visit Not a benefit $5 D0180 Comprehensive periodontal evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180) per 6 months D0210 Intraoral - complete series of radiographic images $25 No cost 1 series per 60 months 1 series per 24 months D0220 Intraoral - periapical first radiographic image No cost No cost D0230 Intraoral - periapical each additional radiographic image No cost No cost D0240 Intraoral - occlusal radiographic image No cost No cost D0250 Extra-oral - 2D projection radiographic image created using a stationary radiationsource, and detector Not a benefit No cost D0270 Bitewing - single radiographic image No cost No cost 1 set per 6 months D0272 Bitewings - two radiographic images No cost No cost 1 set per 6 months D0273 Bitewings - three radiographic images No cost No cost 1 set per 6 months D0274 Bitewings - four radiographic images No cost No cost 1 set per 6 months 1 series per 6 months D0277 Vertical bitewings - 7 to 8 radiographic images No cost No cost 1 set per 6 months D0330 Panoramic radiographic image $25 No cost 1 image per 60 months D0340 2D cephalometric radiographic image - acquisition, measurement and analysis $25 Not a benefit D0350 2D oral/facial photographic image obtained intra-orally or extra-orally $25 Not a benefit Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report No cost Not a benefit D0415 Collection of microorganisms for culture and sensitivity Not a benefit No cost D0419 Assessment of salivary flow by measurement No cost No cost 1 per 12 months D0425 Caries susceptibility tests Not a benefit No cost D0460 Pulp vitality tests No cost No cost D0470 Diagnostic casts $10 No cost D0472 Accession of tissue, gross examination, preparation and transmission of written report Not a benefit No cost D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report Not a benefit No cost D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission ofwritten report Not a benefit No cost D0601 Caries risk assessment and documentation, with a finding of low risk No cost No cost 1 of (D0601, D0602,D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months D0602 Caries risk assessment and documentation, with a finding of moderate risk No cost No cost 1 of (D0601, D0602,D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months D0603 Caries risk assessment and documentation, with a finding of high risk No cost No cost 1 of (D0601, D0602,D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months
Appears in 1 contract
Diagnostic. D0999 Unspecified diagnostic procedure, by report $20 No Cost Includes office visit, per visit (in addition to other services) Includes office visit, per visit (in addition to other services) D0120 Periodic oral evaluation - established patient No cost No Cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months D0140 Limited oral evaluation - problem focused No cost No Cost 1 of (D0140, D0170)per D0170) per Contract Dentist per 6 months Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver No cost Not a benefit Code Description Pediatric Enrollee Cost Share1 Clarification/Limitations for Pediatric Enrollees D0150 Comprehensive oral evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months D0160 Detailed and extensive oral evaluation - problem focused, by report No cost No cost D0170 Re-evaluation - limited, problem focused (established patient; notpostnot post-operative visit) No cost No cost 1 of (D0140, D0170)per D0170) per Contract Dentist per 6 months D0171 Re-evaluation - post-operative office visit Not a benefit $5 D0180 Comprehensive periodontal evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months D0210 Intraoral - complete series of radiographic images $25 No cost 1 series per 60 months 1 series per 24 months D0220 Intraoral - periapical first radiographic image No cost No cost D0230 Intraoral - periapical each additional radiographic image No cost No cost D0240 Intraoral - occlusal radiographic image No cost No cost D0250 Extra-oral - 2D projection radiographic image created using a stationary radiationsource, and detector Not a benefit No cost D0270 Bitewing - single radiographic image No cost No cost 1 set per 6 months D0272 Bitewings - two radiographic images No cost No cost 1 set per 6 months D0273 Bitewings - three radiographic images No cost No cost 1 set per 6 months D0274 Bitewings - four radiographic images No cost No cost 1 set per 6 months 1 series per 6 months D0277 Vertical bitewings - 7 to 8 radiographic images No cost No cost 1 set per 6 months D0330 Panoramic radiographic image $25 No cost 1 image per 60 months D0340 2D cephalometric radiographic image - acquisition, measurement and analysis $25 Not a benefit D0350 2D oral/facial photographic image obtained intra-orally or extra-orally $25 Not a benefit Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report No cost Not a benefit D0415 Collection of microorganisms for culture and sensitivity Not a benefit No cost D0419 Assessment of salivary flow by measurement No cost No cost 1 per 12 months D0425 Caries susceptibility tests Not a benefit No cost D0460 Pulp vitality tests No cost No cost D0470 Diagnostic casts $10 No cost D0472 Accession of tissue, gross examination, preparation and transmission of written report Not a benefit No cost D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report Not a benefit No cost D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission ofwritten report Not a benefit No cost D0601 Caries risk assessment and documentation, with a finding of low risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months D0602 Caries risk assessment and documentation, with a finding of moderate risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months D0603 Caries risk assessment and documentation, with a finding of high risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 monthsoffice
Appears in 1 contract
Diagnostic. D0999 Unspecified diagnostic procedure, by report $20 No cost No Cost Includes office visit, per visit (in addition to other services) Includes office visit, per visit (in addition to other services) D0120 Periodic oral evaluation - established patient No cost No Cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months D0140 Limited oral evaluation - problem focused No cost No Cost 1 of (D0140, D0170)per D0170) per Contract Dentist per 6 months Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver No cost Not a benefit D0150 Comprehensive oral evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months D0160 Detailed and extensive oral evaluation - problem focused, by report No cost No cost D0170 Re-evaluation - limited, problem focused (established patient; notpostnot post-operative visit) No cost No cost 1 of (D0140, D0170)per D0170) per Contract Dentist per 6 months D0171 Re-evaluation - post-operative office visit Not a benefit $5 D0180 Comprehensive periodontal evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months D0210 Intraoral - complete series of radiographic images $25 No cost No cost 1 series per 60 months 1 series per 24 months D0220 Intraoral - periapical first radiographic image No cost No cost D0230 Intraoral - periapical each additional radiographic image No cost No cost D0240 Intraoral - occlusal radiographic image No cost No cost Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0250 Extra-oral - 2D projection radiographic image created using a stationary radiationsourceradiation source, and detector Not a benefit No cost D0270 Bitewing - single radiographic image No cost No cost 1 set per 6 months D0272 Bitewings - two radiographic images No cost No cost 1 set per 6 months D0273 Bitewings - three radiographic images No cost No cost 1 set per 6 months D0274 Bitewings - four radiographic images No cost No cost 1 set per 6 months 1 series per 6 months D0277 Vertical bitewings - 7 to 8 radiographic images No cost No cost 1 set per 6 months D0330 Panoramic radiographic image $25 No cost No cost 1 image per 60 months D0340 2D cephalometric radiographic image - acquisition, measurement and analysis $25 No cost Not a benefit D0350 2D oral/facial photographic image obtained intra-orally or extra-orally $25 No cost Not a benefit Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report No cost Not a benefit D0415 Collection of microorganisms for culture and sensitivity Not a benefit No cost D0419 Assessment of salivary flow by measurement No cost No cost 1 per 12 months D0425 Caries susceptibility tests Not a benefit No cost D0460 Pulp vitality tests No cost No cost D0470 Diagnostic casts $10 No cost No cost D0472 Accession of tissue, gross examination, preparation and transmission of written report Not a benefit No cost D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report Not a benefit No cost D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission ofwritten of written report Not a benefit No cost Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0601 Caries risk assessment and documentation, with a finding of low risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months D0602 Caries risk assessment and documentation, with a finding of moderate risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months D0603 Caries risk assessment and documentation, with a finding of high risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months D1000-D1999 II. PREVENTIVE D1110 Prophylaxis - adult No cost No cost Cleaning; 1 of (D1110, D1120, D4346) per 6 months 1 per 6 months D1120 Prophylaxis - child No cost Not a benefit Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1206 Topical application of fluoride varnish No cost No Cost 1 of (D1206, D1208) per 6 months 1 of (D1206 or D1208) per 6 months D1208 Topical application of fluoride - excluding varnish No cost No Cost 1 of (D1206, D1208) per 6 months 1 of (D1206 or D1208) per 6 months D1310 Nutritional counseling for control of dental disease Not a benefit No Cost D1330 Oral hygiene instructions Not a benefit No Cost D1351 Sealant - per tooth No cost Not a benefit Permanent molars without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth No cost Not a benefit Permanent molars without restorations or decay; 1 per 36 months D1354 Interim caries arresting medicament application - per tooth No cost No Cost 1 per 6 months D1510 Space maintainer - fixed, unilateral - per quadrant No cost Not a benefit D1516 Space maintainer - fixed - bilateral, maxillary No cost Not a benefit Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D1517 Space maintainer - fixed - bilateral, mandibular No cost Not a benefit D1520 Space maintainer - removable, unilateral - per quadrant No cost Not a benefit D1526 Space maintainer - removable - bilateral, maxillary No cost Not a benefit D1527 Space maintainer - removable - bilateral, mandibular No cost Not a benefit D1551 Re-cement or re-bond bilateral space maintainer - maxillary No cost Not a benefit D1552 Re-cement or re-bond bilateral space maintainer - mandibular No cost Not a benefit D1553 Re-cement or re-bond unilateral space maintainer - per quadrant No cost Not a benefit D1556 Removal of fixed unilateral space maintainer - per quadrant No cost Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1557 Removal of fixed bilateral space maintainer - maxillary No cost Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular No cost Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1575 Distal shoe space maintainer - fixed, unilateral - per quadrant No cost Not a benefit 1 per quadrant per lifetime; Age 8 and under D2000-D2999 III. RESTORATIVE Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D2140 Amalgam - one surface, primary or permanent No cost Not a benefit D2150 Amalgam - two surfaces, primary or permanent No cost Not a benefit D2160 Amalgam - three surfaces, primary or permanent No cost Not a benefit D2161 Amalgam - four or more surfaces, primary or permanent No cost Not a benefit D2330 Resin-based composite - one surface, anterior No cost Not a benefit D2331 Resin-based composite - two surfaces, anterior No cost Not a benefit D2332 Resin-based composite - three surfaces, anterior No cost Not a benefit D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) No cost Not a benefit D2510 Inlay - metallic - one surface No cost Not a benefit Base metal is the benefit; 1 per 60 months D2520 Inlay - metallic - two surfaces No cost Not a benefit Base metal is the benefit; 1 per 60 months D2530 Inlay - metallic - three or more surfaces No cost Not a benefit Base metal is the benefit; 1 per 60 months D2542 Onlay - metallic - two surfaces No cost Not a benefit Base metal is the benefit; 1 per 60 months D2543 Onlay - metallic - three surfaces No cost Not a benefit Base metal is the benefit; 1 per 60 months D2544 Onlay - metallic - four or more surfaces No cost Not a benefit Base metal is the benefit; 1 per 60 months D2740 Crown - porcelain/ceramic No cost Not a benefit 1 per 60 months D2750 Crown - porcelain fused to high noble metal No cost Not a benefit 1 per 60 months D2751 Crown - porcelain fused to predominantly base metal No cost Not a benefit 1 per 60 months D2752 Crown - porcelain fused to noble metal No cost Not a benefit 1 per 60 months Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D2753 Crown - porcelain fused to titanium and titanium alloys No cost Not a benefit 1 per 60 months D2780 Crown - 3/4 cast high noble metal No cost Not a benefit 1 per 60 months D2781 Crown - 3/4 cast predominantly base metal No cost Not a benefit 1 per 60 months D2782 Crown - 3/4 cast noble metal No cost Not a benefit 1 per 60 months D2783 Crown - 3/4 porcelain/ceramic No cost Not a benefit 1 per 60 months D2790 Crown - full cast high noble metal No cost Not a benefit 1 per 60 months D2791 Crown - full cast predominantly base metal No cost Not a benefit 1 per 60 months D2792 Crown - full cast noble metal No cost Not a benefit 1 per 60 months D2794 Crown - titanium and titanium alloys No cost Not a benefit 1 per 60 months D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration No cost Not a benefit 1 per 6 months; included at no additional cost within 12 months of placement by the same Contract Dentist/office D2920 Re-cement or re-bond crown No cost Not a benefit 1 per 6 months; included at no additional cost within 12 months of placement by the same Contract Dentist/office D2929 Prefabricated porcelain/ceramic crown - primary tooth No cost Not a benefit 1 per 60 months; through age 14 D2930 Prefabricated stainless steel crown - primary tooth No cost Not a benefit 1 per 60 months; through age 14 D2931 Prefabricated stainless steel crown - permanent tooth No cost Not a benefit 1 per 60 months; through age 14 D2940 Protective restoration No cost Not a benefit D2950 Core buildup, including any pins when required No cost Not a benefit 1 per 60 months D2951 Pin retention - per tooth, in addition to restoration No cost Not a benefit D2954 Prefabricated post and core in addition to crown No cost Not a benefit Includes canal preparation; 1 per 60 months Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D2980 Crown repair necessitated by restorative material failure No cost Not a benefit D2981 Inlay repair necessitated by restorative material failure No cost Not a benefit D2982 Onlay repair necessitated by restorative material failure No cost Not a benefit D2983 Veneer repair necessitated by restorative material failure No cost Not a benefit D2990 Resin infiltration of incipient smooth surface lesions No cost Not a benefit 1 per 36 months D3000-D3999 IV. ENDODONTICS D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament No cost Not a benefit If a root canal is within 45 days of the pulpotomy, the pulpotomy is not a covered service since it is considered a part of the root canal procedure. D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development No cost Not a benefit If a root canal is within 45 days of the pulpotomy, the pulpotomy is not a covered service since it is considered a part of the root canal procedure. D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) No cost Not a benefit 1 per tooth per lifetime; primary incisor up to age 6, primary molars up to age 11 D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) No cost Not a benefit 1 per tooth per lifetime; primary incisor up to age 6, primary molars up to age 11 D3310 Endodontic therapy, anterior tooth (excluding final restoration) No cost Not a benefit Root canal D3320 Endodontic therapy, premolar tooth (excluding final restoration) No cost Not a benefit Root canal D3330 Endodontic therapy, molar tooth (excluding final restoration) No cost Not a benefit Root canal D3331 Treatment of root canal obstruction; non-surgical access No cost Not a benefit Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth No cost Not a benefit D3333 Internal root repair of perforation defects No cost Not a benefit D3346 Retreatment of previous root canal therapy - anterior No cost Not a benefit D3347 Retreatment of previous root canal therapy - premolar No cost Not a benefit D3348 Retreatment of previous root canal therapy - molar No cost Not a benefit D3351 Apexification/recalcification - initial visit (apical closure / calcific repair of perforations, root resorption, etc.) No cost Not a benefit D3352 Apexification/recalcification - interim medication replacement No cost Not a benefit D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) No cost Not a benefit D3355 Pulpal regeneration - initial visit No cost Not a benefit D3356 Pulpal regeneration - interim medication replacement No cost Not a benefit D3357 Pulpal regeneration - completion of treatment No cost Not a benefit D3410 Apicoectomy - anterior No cost Not a benefit D3421 Apicoectomy - premolar (first root) No cost Not a benefit D3425 Apicoectomy - molar (first root) No cost Not a benefit D3426 Apicoectomy (each additional root) No cost Not a benefit D3427 Periradicular surgery without apicoectomy No cost Not a benefit D3430 Retrograde filling - per root No cost Not a benefit D3450 Root amputation - per root No cost Not a benefit D3920 Hemisection (including any root removal), not including root canal therapy No cost Not a benefit Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D4000-D4999 V. PERIODONTICS D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant No cost Not a benefit 1 per 36 months per quadrant D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant No cost Not a benefit 1 per 36 months per quadrant D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth No cost Not a benefit 1 per 36 months D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant No cost Not a benefit 1 per 36 months per quadrant D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant No cost Not a benefit 1 per 36 months per quadrant D4249 Clinical crown lengthening - hard tissue No cost Not a benefit D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant No cost Not a benefit 1 per 36 months per quadrant D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant No cost Not a benefit 1 per 36 months per quadrant D4263 Bone replacement graft - retained natural tooth - first site in quadrant No cost Not a benefit 1 per 36 months D4270 Pedicle soft tissue graft procedure No cost Not a benefit D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft No cost
Appears in 1 contract
Diagnostic. D0999 Unspecified diagnostic procedure, by report $20 No Cost Includes office visit, per visit (in addition to other services) Includes office visit, per visit (in addition to other services) D0120 Periodic oral evaluation - established patient No cost No Cost 1 of (D0120, D0150,D0180) per 6 months D0140 Limited oral evaluation - problem focused No cost No Cost 1 of (D0140, D0170)per Contract Dentist per 6 months Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver No cost Not a benefit D0150 Comprehensive oral evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180) per 6 months D0160 Detailed and extensive oral evaluation - problem focused, by report No cost No cost D0170 Re-evaluation - limited, problem focused (established patient; notpost-operative visit) No cost No cost 1 of (D0140, D0170)per Contract Dentist per 6 months D0171 Re-evaluation - post-operative office visit Not a benefit $5 D0180 Comprehensive periodontal evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180) per 6 months D0210 Intraoral - complete series of radiographic images $25 No cost 1 series per 60 months 1 series per 24 months D0220 Intraoral - periapical first radiographic image No cost No cost D0230 Intraoral - periapical each additional radiographic image No cost No cost D0240 Intraoral - occlusal radiographic image No cost No cost D0250 Extra-oral - 2D projection radiographic image created using a stationary radiationsourceradiation source, and detector Not a benefit No cost Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0270 Bitewing - single radiographic image No cost No cost 1 set per 6 months D0272 Bitewings - two radiographic images No cost No cost 1 set per 6 months D0273 Bitewings - three radiographic images No cost No cost 1 set per 6 months D0274 Bitewings - four radiographic images No cost No cost 1 set per 6 months 1 series per 6 months D0277 Vertical bitewings - 7 to 8 radiographic images No cost No cost 1 set per 6 months D0330 Panoramic radiographic image $25 No cost 1 image per 60 months D0340 2D cephalometric radiographic image - acquisition, measurement and analysis $25 Not a benefit D0350 2D oral/facial photographic image obtained intra-orally or extra-orally $25 Not a benefit Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report No cost Not a benefit D0415 Collection of microorganisms for culture and sensitivity Not a benefit No cost D0419 Assessment of salivary flow by measurement No cost No cost 1 per 12 months D0425 Caries susceptibility tests Not a benefit No cost D0460 Pulp vitality tests No cost No cost D0470 Diagnostic casts $10 No cost D0472 Accession of tissue, gross examination, preparation and transmission of written report Not a benefit No cost D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report Not a benefit No cost D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission ofwritten of written report Not a benefit No cost D0601 Caries risk assessment and documentation, with a finding of low risk No cost No cost 1 of (D0601, D0602,D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0602 Caries risk assessment and documentation, with a finding of moderate risk No cost No cost 1 of (D0601, D0602,D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months D0603 Caries risk assessment and documentation, with a finding of high risk No cost No cost 1 of (D0601, D0602,D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months
Appears in 1 contract
Diagnostic. D0999 Unspecified diagnostic procedure, by report $20 No Cost Includes office visit, per visit (in addition to other services) cost Includes office visit, per visit (in addition to other services) D0120 Periodic oral evaluation - established patient No cost No Cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months 6months D0140 Limited oral evaluation - problem focused No cost No Cost 1 of (D0140, D0170)per D0170) per Contract Dentist per 6 months Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver No cost Not a benefit D0150 Comprehensive oral evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months 6months D0160 Detailed and extensive oral evaluation - problem focused, by report No cost No cost D0170 Re-evaluation - limited, problem focused (established patient; notpostnot post-operative visit) No cost No cost 1 of (D0140, D0170)per D0170) per Contract Dentist per 6 months D0171 Re-evaluation - post-operative office visit Not a benefit $5 D0180 Comprehensive periodontal evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months 6months D0210 Intraoral - complete series of radiographic images $25 No cost 1 series per 60 months 1 series per 24 months D0220 Intraoral - periapical first radiographic image No cost No cost D0230 Intraoral - periapical each additional radiographic image No cost No cost D0240 Intraoral - occlusal radiographic image No cost No cost D0250 Extra-oral - 2D projection radiographic image created using a stationary radiationsource, and detector Not a benefit No cost D0270 Bitewing - single radiographic image No cost No cost 1 set per 6 months D0272 Bitewings - two radiographic images No cost No cost 1 set per 6 months D0273 Bitewings - three radiographic images No cost No cost 1 set per 6 months D0274 Bitewings - four radiographic images No cost No cost 1 set per 6 months 1 series per 6 months D0277 Vertical bitewings - 7 to 8 radiographic images No cost No cost 1 set per 6 months D0330 Panoramic radiographic image $25 No cost 1 image per 60 months D0340 2D cephalometric radiographic image - acquisition, measurement and analysis $25 Not a benefit No cost D0350 2D oral/facial photographic image obtained intra-orally or extra-orally $25 Not a benefit Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees No cost D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report No cost Not a benefit D0415 Collection of microorganisms Code Description Pediatric Enrollee Cost Share Clarification/Limitations for culture and sensitivity Not a benefit No cost Pediatric Enrollees D0419 Assessment of salivary flow by measurement No cost No cost 1 per 12 months D0425 Caries susceptibility tests Not a benefit No cost D0460 Pulp vitality tests No cost No cost D0470 Diagnostic casts $10 No cost D0472 Accession of tissue, gross examination, preparation and transmission of written report Not a benefit No cost D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report Not a benefit No cost D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission ofwritten report Not a benefit No cost D0601 Caries risk assessment and documentation, with a finding of low risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months 36months when performed by the same Contract Dentist or office 1 per 36 months D0602 Caries risk assessment and documentation, with a finding of moderate risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months 36months when performed by the same Contract Dentist or office 1 per 36 months D0603 Caries risk assessment and documentation, with a finding of high risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months 36months when performed by the same Contract Dentist or office 1 per 36 monthsoffice
Appears in 1 contract
Diagnostic. D0999 Unspecified diagnostic procedure, by report $20 No Cost Includes office visit, per visit (in addition to other services) Includes office visit, per visit (in addition to other services) D0120 Periodic oral evaluation - established patient No cost No Cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months D0140 Limited oral evaluation - problem focused No cost No Cost 1 of (D0140, D0170)per D0170) per Contract Dentist per 6 months Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Share1 Clarification/Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver No cost Not a benefit D0150 Comprehensive oral evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months D0160 Detailed and extensive oral evaluation - problem focused, by report No cost No cost D0170 Re-evaluation - limited, problem focused (established patient; notpostnot post-operative visit) No cost No cost 1 of (D0140, D0170)per D0170) per Contract Dentist per 6 months D0171 Re-evaluation - post-operative office visit Not a benefit $5 D0180 Comprehensive periodontal evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months D0210 Intraoral - complete series of radiographic images $25 No cost 1 series per 60 months 1 series per 24 months D0220 Intraoral - periapical first radiographic image No cost No cost D0230 Intraoral - periapical each additional radiographic image No cost No cost D0240 Intraoral - occlusal radiographic image No cost No cost D0250 Extra-oral - 2D projection radiographic image created using a stationary radiationsource, and detector Not a benefit No cost D0270 Bitewing - single radiographic image No cost No cost 1 set per 6 months D0272 Bitewings - two radiographic images No cost No cost 1 set per 6 months D0273 Bitewings - three radiographic images No cost No cost 1 set per 6 months D0274 Bitewings - four radiographic images No cost No cost 1 set per 6 months 1 series per 6 months D0277 Vertical bitewings - 7 to 8 radiographic images No cost No cost 1 set per 6 months D0330 Panoramic radiographic image $25 No cost 1 image per 60 months D0340 2D cephalometric radiographic image - acquisition, measurement and analysis $25 Not a benefit D0350 2D oral/facial photographic image obtained intra-orally or extra-orally $25 Not a benefit Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the ofthe image, including report No cost Not a benefit D0415 Collection of microorganisms for culture and sensitivity Not a benefit No cost D0419 Assessment of salivary flow by measurement No cost No cost 1 per 12 months D0425 Caries susceptibility tests Not a benefit No cost D0460 Pulp vitality tests No cost No cost D0470 Diagnostic casts $10 No cost D0472 Accession of tissue, gross examination, preparation and transmission of written report Not a benefit No cost D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report Not a benefit No cost D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission ofwritten report Not a benefit No cost D0601 Caries risk assessment and documentation, with a finding of low risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months when monthswhen performed by the same Contract Dentist or office 1 per 36 months D0602 Caries risk assessment and documentation, with a finding of moderate risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months D0603 Caries risk assessment and documentation, with a finding of high risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 monthsoffice
Appears in 1 contract
Diagnostic. D0999 Unspecified diagnostic procedure, by report $20 No Cost Includes office visit, per visit (in addition to other services) cost Includes office visit, per visit (in addition to other services) D0120 Periodic oral evaluation - established patient No cost No Cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months 6months D0140 Limited oral evaluation - problem focused No cost No Cost 1 of (D0140, D0170)per D0170) per Contract Dentist per 6 months Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver No cost Not a benefit D0150 Comprehensive oral evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months 6months D0160 Detailed and extensive oral evaluation - problem focused, by report No cost No cost D0170 Re-evaluation - limited, problem focused (established patient; notpostnot post-operative visit) No cost No cost 1 of (D0140, D0170)per D0170) per Contract Dentist per 6 months D0171 Re-evaluation - post-operative office visit Not a benefit $5 D0180 Comprehensive periodontal evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months 6months D0210 Intraoral - complete series of radiographic images $25 No cost 1 series per 60 months 1 series per 24 months D0220 Intraoral - periapical first radiographic image No cost No cost D0230 Intraoral - periapical each additional radiographic image No cost No cost D0240 Intraoral - occlusal radiographic image No cost No cost D0250 Extra-oral - 2D projection radiographic image created using a stationary radiationsource, and detector Not a benefit No cost D0270 Bitewing - single radiographic image No cost No cost 1 set per 6 months D0272 Bitewings - two radiographic images No cost No cost 1 set per 6 months Code Description Pediatric Enrollee Cost Share Clarification/Limitations for Pediatric Enrollees D0273 Bitewings - three radiographic images No cost No cost 1 set per 6 months D0274 Bitewings - four radiographic images No cost No cost 1 set per 6 months 1 series per 6 months D0277 Vertical bitewings - 7 to 8 radiographic images No cost No cost 1 set per 6 months D0330 Panoramic radiographic image $25 No cost 1 image per 60 months D0340 2D cephalometric radiographic image - acquisition, measurement and analysis $25 Not a benefit No cost D0350 2D oral/facial photographic image obtained intra-orally or extra-orally $25 Not a benefit Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees No cost D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report No cost Not a benefit D0415 Collection of microorganisms for culture and sensitivity Not a benefit No cost D0419 Assessment of salivary flow by measurement No cost No cost 1 per 12 months D0425 Caries susceptibility tests Not a benefit No cost D0460 Pulp vitality tests No cost No cost D0470 Diagnostic casts $10 No cost D0472 Accession of tissue, gross examination, preparation and transmission of written report Not a benefit No cost D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report Not a benefit No cost D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission ofwritten report Not a benefit No cost D0601 Caries risk assessment and documentation, with a finding of low risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months 36months when performed by the same Contract Dentist or office 1 per 36 months D0602 Caries risk assessment and documentation, with a finding of moderate risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months 36months when performed by the same Contract Dentist or office 1 per 36 months D0603 Caries risk assessment and documentation, with a finding of high risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months 36months when performed by the same Contract Dentist or office 1 per 36 monthsoffice
Appears in 1 contract
Diagnostic. D0999 Unspecified diagnostic procedure, by report $20 No Cost Includes office visit, per visit (in addition to other services) Includes office visit, per visit (in addition to other services) D0120 Periodic periodic oral evaluation - established patient No cost No Cost 1 of (D0120, D0150,D0180) per 6 months Charge D0140 Limited limited oral evaluation - problem focused No cost No Cost 1 of (D0140, D0170)per Contract Dentist per 6 months Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees Charge D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver No cost Not a benefit Charge D0150 Comprehensive comprehensive oral evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180) per 6 months Charge D0160 Detailed and extensive oral evaluation - problem focused, by report No cost No cost Charge D0170 Re-evaluation - limited, problem focused (established patient; notpostnot post-operative visit) No cost Charge D0180 Comprehensive periodontal evaluation No cost 1 of (D0140, D0170)per Contract Dentist per 6 months Charge D0171 Re-evaluation - – post-operative office visit No Charge D0190 screening of a patient Not Covered D0191 assessment of a benefit $5 D0180 Comprehensive periodontal evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180) per 6 months Not Covered D0210 Intraoral intraoral - complete series of radiographic images $25 No cost (including bitewings) - limited to 1 series per 60 every 36 months 1 series per 24 months No Charge D0220 Intraoral intraoral - periapical first radiographic image film No cost No cost Charge D0230 Intraoral intraoral - periapical each additional film No Charge D0240 intraoral - occlusal film No Charge D0250 Extraoral - first film No Charge D0251 Extra-oral posterior dental radiographic image No cost No cost D0240 Intraoral - occlusal radiographic image No cost No cost D0250 Extra-oral - 2D projection radiographic image created using a stationary radiationsource, and detector Not a benefit No cost Charge D0270 Bitewing bitewing - single radiographic image film No cost No cost 1 set per 6 months Charge D0272 Bitewings bitewings - two radiographic images films No cost No cost 1 set per 6 months Charge D0273 Bitewings - three radiographic images films No cost No cost Charge D0274 bitewings - four films - limited to 1 set per series every 6 months D0274 Bitewings - four radiographic images No cost No cost 1 set per 6 months 1 series per 6 months Charge D0277 Vertical bitewings - 7 to 8 radiographic images films No cost Charge D0310 Sialography No cost 1 set per 6 months Charge D0320 Temporomandibular joint arthrogram, including injection No Charge D0322 Tomographic survey No Charge D0330 Panoramic panoramic film No Charge D0340 Cephalometric radiographic image $25 No cost 1 image per 60 months D0340 2D cephalometric radiographic image - acquisition, measurement and analysis $25 Not a benefit Charge D0350 2D oral/facial photograph 1st No Charge D0351 3D photographic image obtained intra-orally or extra-orally $25 Not a benefit Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report No cost Not a benefit D0415 Collection of microorganisms for culture and sensitivity Not a benefit No cost Charge D0419 Assessment of salivary flow by measurement No cost No cost 1 per 12 months D0425 Caries susceptibility tests Not a benefit No cost 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 Not Covered D0460 Pulp pulp vitality tests No cost No cost Charge D0470 Diagnostic casts $10 may be provided only if one of the above conditions is present No cost D0472 Accession of tissueCharge D0502 Other oral pathology procedures, gross examination, preparation and transmission of written by report Not a benefit No cost D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report Not a benefit No cost D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission ofwritten report Not a benefit No cost Charge D0601 Caries caries risk assessment and documentation, with a finding of low risk No cost No cost 1 of (D0601, D0602,D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months Charge D0602 Caries caries risk assessment and documentation, with a finding of moderate risk No cost No cost 1 of (D0601, D0602,D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months Charge D0603 Caries caries risk assessment and documentation, with a finding of high risk No cost Charge D0999 Unspecified diagnostic procedure, by report No cost 1 Charge D1110 prophylaxis - adult No Charge Member Copayment Schedule 2021 California Dental Network Children’s Dental HMO D1120 prophylaxis - child No Charge D1206 topical fluoride varnish No Charge D1208 topical application of fluoride No Charge D1310 Nutritional counseling for control of dental disease No Charge D1320 Tobacco counseling for the control and prevention of oral disease No Charge D1330 oral hygiene instructions No Charge D1351 sealant - per tooth No Charge D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth No Charge D1353 Sealant repair – per tooth No Charge D1354 Interim caries arresting medicament application—per tooth No Charge D1510 space maintainer - fixed - unilateral No Charge D1516 space maintainer - fixed – bilateral, maxillary No Charge D1517 space maintainer - fixed – bilateral, mandibular No Charge D1520 Space maintainer-removable – unilateral No Charge D1526 space maintainer - removable – bilateral, maxillary No Charge D1527 space maintainer - removable – bilateral, mandibular No Charge D1551 Re-cement or re-bond bilateral space maintainer-maxillary No Charge D1552 Re-cement or re-bond bilateral space maintainer- mandibular No Charge D1553 Re-cement or re-bond bilateral space maintainer- per quadrant No Charge D1556 Removal of fixed unilateral space maintainer-per quadrant No Charge D1557 Removal of fixed space maintainer-maxillary No Charge D1558 Removal of fixed space maintainer-mandibular No Charge D1575 Distal shoe space maintainer – fixed – unilateral per quadrant No Charge D2140 amalgam - one surface permanent or primary $25 D2150 amalgam - two surfaces permanent or primary $30 D2160 amalgam - three surfaces permanent or primary $40 D2161 amalgam - four or more surfaces permanent or primary $45 D2330 resin-based composite - one surface, anterior $30 D2331 resin-based composite - two surfaces, anterior $45 D2332 resin-based composite - three surfaces, anterior $55 D2335 resin-based composite - four or more surfaces or involving incisal angle (D0601anterior) $60 D2390 Resin based composite crown, D0602,D0603anterior $50 D2391 Resin based composite - one surface, posterior $30 D2392 Resin based composite - two surfaces, posterior $40 D2393 Resin based composite - three surfaces, posterior $50 D2394 Resin based composite - four or more surfaces, posterior $70 D2542 onlay - metallic-two surfaces Not Covered D2543 onlay - metallic-three surfaces Not Covered D2544 onlay - metallic-four or more surfaces Not Covered D2642 Onlay - porcelain/ceramic - two surfaces Not Covered D2643 Onlay - porcelain/ceramic - three surfaces Not Covered D2644 Onlay - porcelain/ceramic - four or more surfaces Not Covered D2662 Onlay - resin-based composite - two surfaces Not Covered D2663 Onlay - resin-based composite - three surfaces Not Covered D2664 Onlay - resin-based composite - four or more surfaces Not Covered D2710 crown - resin-based composite laboratory $140 D2712 Crown - 3/4 resin-based composite (indirect) $190 D2720 Crown - resin with high noble metal Not Covered D2721 Crown - resin with predominantly base metal $300 D2722 Crown - resin with noble metal Not Covered D2740 crown - porcelain/ceramic substrate $300 D2750 crown - porcelain fused to high noble metal Not Covered Member Copayment Schedule 2021 California Dental Network Children’s Dental HMO D2751 crown - porcelain fused to predominantly base metal $300 D2752 crown - porcelain fused to noble metal Not Covered D2753 crown - porcelain fused to titanium and titanium alloys Not Covered D2780 Crown - 3/4 cast high noble metal Not Covered D2781 crown - 3/4 cast predominantly base metal $300 D2782 Crown - 3/4 cast noble metal Not Covered D2783 Crown – 3/4 porcelain/ceramic $310 D2790 crown - full cast high noble metal Not Covered D2791 crown - full cast predominantly base metal $300 D2792 crown - full cast noble metal Not Covered D2794 crown - titanium and titanium alloys Not Covered D2910 Recement inlay, onlay or partial coverage restoration $25 D2915 Recement cast or prefabricated post and core $25 D2920 Recement crown $25 D2921 Reattachment of tooth fragment, incisal edge or cusp $45 D2929 Prefabricated porcelain/ceramic crown - primary tooth $95 D2930 prefabricated stainless steel crown - primary tooth $65 D2931 prefabricated stainless steel crown - permanent tooth $75 D2932 Prefabricated resin crown $75 D2933 Prefabricated stainless steel crown with resin window $80 D2940 protective restoration $25 D2941 Interim therapeutic restoration – primary dentition $30 D2949 Restorative foundation for an indirect restoration $45 D2950 Core buildup, including any pins $20 D2951 pin retention - per 36 months when performed tooth, in addition to restoration $25 D2952 post and core in addition to crown, indirectly fabricated $100 D2953 Each additional indirectly fabricated post, same tooth $30 D2954 prefabricated post and core in addition to crown $90 D2955 Post removal $60 D2957 Each additional prefabricated post - same tooth $35 D2971 Additional procedures to construct new crown under existing partial denture framework $35 D2980 crown repair, by the report $50 D2999 Unspecified restorative procedure, by report $40 D3110 pulp cap - direct (excluding final restoration) $20 D3120 Pulp cap (indirect) excluding final restoration $25 D3220 therapeutic pulpotomy (excluding final restoration) $40 D3221 Pulpal debridement, primary and permanent teeth $40 D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development $60 D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) $55 D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) $55 D3310 root canal therapy, anterior tooth (excluding final restoration) $195 D3320 root canal therapy, bicuspid tooth (excluding final restoration) $235 D3330 root canal therapy, molar (excluding final restoration) $300 D3331 Treatment of root canal obstruction; non-surgical access $50 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Not Covered D3333 Internal root repair of perforation defects $80 D3346 retreatment of previous root canal therapy - anterior $240 D3347 retreatment of previous root canal therapy - bicuspid $295 D3348 retreatment of previous root canal therapy - molar $365 Member Copayment Schedule 2021 California Dental Network Children’s Dental HMO D3351 Apexification/recalcification – initial visit $85 D3352 Apexification/recalcification - interim $45 D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) Not Covered D3410 apicoectomy/periradicular surgery - anterior $240 D3421 apicoectomy/periradicular surgery - bicuspid (first root) $250 D3425 apicoectomy/periradicular surgery - molar (first root) $275 D3426 Apicoectomy / periradicular surgery - molar, each additional root $110 D3427 Periradicular surgery without apicoectomy $160 D3430 retrograde filling - per root $90 D3450 root amputation - per root Not Covered D3910 Surgical procedure for isolation of tooth with rubber dam $30 D3920 Hemisection (including any root removal; not including root canal therapy) Not Covered D3950 Canal preparation and fitting of preformed dowel or post Not Covered D3999 Unspecified endodontic procedure, by report $100 D4210 gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant $150 D4211 gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant $50 D4240 Gingival flap procedure including root planing four or more teeth per quadrant Not Covered D4241 Gingival flap procedure including root planing one to three teeth per quadrant Not Covered D4249 Clinical crown lengthening – hard tissue $165 D4260 Osseous – muco - gingival surgery per quadrant $265 D4261 Osseous surgery (including flap entry and closures) - one to three contiguous teeth or tooth bounded spaces - per quadrant $140 D4263 Bone replacement graft - first site in quadrant Not Covered D4264 Bone replacement graft - each additional site in quadrant Not Covered D4265 Biologic materials to aid in soft and osseous tissue regeneration $80 D4266 Guided tissue regeneration - resorbable barrier - per site Not Covered D4267 Guided tissue regeneration - non-resorbable barrier - per site (includes membrane removal) Not Covered D4270 Pedicle soft tissue graft procedure Not Covered D4273 Subepithelial connective tissue graft procedure - per tooth Not Covered D4275 Non-autogenous connective tissue graft procedure (including recipient site and donor material) – first tooth, implant or edentulous tooth position in same Contract Dentist graft site Not Covered D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – each additional contiguous tooth, implant or office 1 edentulous tooth position in same graft site 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 Not Covered D4341 periodontal scaling and root planing - four or more teeth per 36 monthsquadrant $55 D4342 periodontal scaling and root planing - one to three teeth per quadrant $30 D4346 Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation $40 D4355 full mouth debridement to enable comprehensive evaluation and diagnosis $40 D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth $10 D4910 Periodontal maintenance $30 D4920 Unscheduled dressing change (by someone other than treating dentist) $15 D4999 Unspecified periodontal procedure, by report $350 Member Copayment Schedule 2021 California Dental Network Children’s Dental HMO D5110 complete denture – maxillary $300 D5120 complete denture – mandibular $300 D5130 immediate denture - maxillary $300 D5140 immediate denture - mandibular $300 D5211 maxillary partial denture - resin based (including retentive/clasping materials, rests, and teeth) $300 D5212 mandibular partial denture - resin based (including retentive/clasping materials, rests, and teeth) $300 D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials any conventional clasps, rests and teeth) $335 D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials any conventional clasps, rests and teeth) $335 D5221 Immediate maxillary partial denture – resin base (including retentive/clasping materials, rests, and teeth) $275 D5222 Immediate mandibular partial denture – resin base (including retentive/clasping materials, rests, and teeth) $275 D5223 Immediate maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $330 D5224 Immediate mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $330 D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth) Not Covered D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth) Not Covered D5282 Removable unilateral partial denture - one piece cast metal (including clasps and teeth), maxillary Not Covered D5283 Removable unilateral partial denture - one piece cast metal (including clasps and teeth), mandibular Not Covered D5284 Removable unilateral partial denture – one piece flexible base (including clasps and teeth), per quadrant Not Covered D5286 Removable unilateral partial denture – one piece resin (including clasps and teeth), per quadrant Not Covered D5410 adjust complete denture - maxillary $20 D5411 adjust complete denture – mandibular $20 D5421 adjust partial denture – maxillary $20 D5422 adjust partial denture – mandibular $20 D5511 repair broken complete denture base-maxillary $40 D5512 repair broken complete denture base-mandibular $40 D5520 replace missing or broken teeth - complete denture (each tooth) $40 D5611 repair resin denture base-Maxillary $40 D5612 repair resin denture base-Mandibular $40 D5621 repair cast framework-Maxillary $40 D5622 repair cast framework-Mandibular $40 D5630 repair or replace broken clasp $50 D5640 replace broken teeth - per tooth $35 D5650 add tooth to existing partial denture $35 D5660 add clasp to existing partial denture $60 D5670 Replace all teeth and acrylic on cast framework - maxillary Not Covered D5671 Replace all teeth and acrylic on cast framework - mandibular Not Covered D5710 Rebase complete maxillary denture Not Covered D5711 Rebase complete mandibular denture Not Covered D5720 Rebase maxillary partial denture Not Covered D5721 Rebase mandibular partial denture Not Covered D5730 reline complete maxillary denture (chairside) $60 D5731 reline complete mandibular denture (chairside) $60 D5740 reline maxillary partial denture (chairside) $60 D5741 reline mandibular partial denture (chairside) $60 Member Copayment Schedule 2021 California Dental Network Children’s Dental HMO D5750 reline complete maxillary denture (laboratory) $90 D5751 reline complete mandibular denture (laboratory) $90 D5760 reline maxillary partial denture (laboratory) $80 D5761 reline mandibular partial denture (laboratory) $80 D5850 tissue conditioning, maxillary $30 D5851 tissue conditioning, mandibular $30 D5862 Precision attachment, by report $90 D5863 Overdenture – Complete Maxillary $300 D5864 Overdenture – partial maxillary $300 D5865 Overdenture – Complete Mandibular $300 D5866 Overdenture – partial mandibular $300 D5876 Add metal substructure to acrylic full denture (per arch) Not Covered D5899 Unspecified removable prosthodontic procedure, by report $350 D5911 Facial moulage (sectional) $285 D5912 Facial moulage (complete) $350 D5913 Nasal prosthesis $350 D5914 Auricular prosthesis $350 D5915 Orbital prosthesis $350 D5916 Ocular prosthesis $350 D5919 Facial prosthesi
Appears in 1 contract
Sources: Group Subscriber Agreement
Diagnostic. D0999 Unspecified diagnostic procedure, by report $20 No cost No Cost Includes office visit, per visit (in addition to other services) Includes office visit, per visit (in addition to other services) D0120 Periodic oral evaluation - established patient No cost No Cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months D0140 Limited oral evaluation - problem focused No cost No Cost 1 of (D0140, D0170)per D0170) per Contract Dentist per 6 months Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver No cost Not a benefit D0150 Comprehensive oral evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months D0160 Detailed and extensive oral evaluation - problem focused, by report No cost No cost D0170 Re-evaluation - limited, problem focused (established patient; notpostnot post-operative visit) No cost No cost 1 of (D0140, D0170)per D0170) per Contract Dentist per 6 months D0171 Re-evaluation - post-operative office visit Not a benefit $5 D0180 Comprehensive periodontal evaluation - new or established patient No cost No cost 1 of (D0120, D0150,D0180D0150, D0180) per 6 months D0210 Intraoral - complete series of radiographic images $25 No cost No cost 1 series per 60 months 1 series per 24 months D0220 Intraoral - periapical first radiographic image No cost No cost D0230 Intraoral - periapical each additional radiographic image No cost No cost D0240 Intraoral - occlusal radiographic image No cost No cost D0250 Extra-oral - 2D projection radiographic image created using a stationary radiationsourceradiation source, and detector Not a benefit No cost D0270 Bitewing - single radiographic image No cost No cost 1 set per 6 months Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0272 Bitewings - two radiographic images No cost No cost 1 set per 6 months D0273 Bitewings - three radiographic images No cost No cost 1 set per 6 months D0274 Bitewings - four radiographic images No cost No cost 1 set per 6 months 1 series per 6 months D0277 Vertical bitewings - 7 to 8 radiographic images No cost No cost 1 set per 6 months D0330 Panoramic radiographic image $25 No cost No cost 1 image per 60 months D0340 2D cephalometric radiographic image - acquisition, measurement and analysis $25 No cost Not a benefit D0350 2D oral/facial photographic image obtained intra-orally or extra-orally $25 No cost Not a benefit Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report No cost Not a benefit D0415 Collection of microorganisms for culture and sensitivity Not a benefit No cost D0419 Assessment of salivary flow by measurement No cost No cost 1 per 12 months D0425 Caries susceptibility tests Not a benefit No cost D0460 Pulp vitality tests No cost No cost D0470 Diagnostic casts $10 No cost No cost D0472 Accession of tissue, gross examination, preparation and transmission of written report Not a benefit No cost D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report Not a benefit No cost D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission ofwritten of written report Not a benefit No cost D0601 Caries risk assessment and documentation, with a finding of low risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D0602 Caries risk assessment and documentation, with a finding of moderate risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 months D0603 Caries risk assessment and documentation, with a finding of high risk No cost No cost 1 of (D0601, D0602,D0603D0602, D0603) per 36 months when performed by the same Contract Dentist or office 1 per 36 monthsmonths D1000-D1999 II. PREVENTIVE D1110 Prophylaxis - adult No cost No cost Cleaning; 1 of (D1110, D1120, D4346) per 6 months 1 per 6 months D1120 Prophylaxis - child No cost Not a benefit Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1206 Topical application of fluoride varnish No cost No Cost 1 of (D1206, D1208) per 6 months 1 of (D1206 or D1208) per 6 months D1208 Topical application of fluoride - excluding varnish No cost No Cost 1 of (D1206, D1208) per 6 months 1 of (D1206 or D1208) per 6 months D1310 Nutritional counseling for control of dental disease Not a benefit No Cost D1330 Oral hygiene instructions Not a benefit No Cost D1351 Sealant - per tooth No cost Not a benefit Permanent molars without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth No cost Not a benefit Permanent molars without restorations or decay; 1 per 36 months D1354 Interim caries arresting medicament application - per tooth No cost No Cost 1 per 6 months D1510 Space maintainer - fixed, unilateral - per quadrant No cost Not a benefit D1516 Space maintainer - fixed - bilateral, maxillary No cost Not a benefit D1517 Space maintainer - fixed - bilateral, mandibular No cost Not a benefit D1520 Space maintainer - removable, unilateral - per quadrant No cost Not a benefit D1526 Space maintainer - removable - bilateral, maxillary No cost Not a benefit Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D1527 Space maintainer - removable - bilateral, mandibular No cost Not a benefit D1551 Re-cement or re-bond bilateral space maintainer - maxillary No cost Not a benefit D1552 Re-cement or re-bond bilateral space maintainer - mandibular No cost Not a benefit D1553 Re-cement or re-bond unilateral space maintainer - per quadrant No cost Not a benefit D1556 Removal of fixed unilateral space maintainer - per quadrant No cost Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1557 Removal of fixed bilateral space maintainer - maxillary No cost Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular No cost Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1575 Distal shoe space maintainer - fixed, unilateral - per quadrant No cost Not a benefit 1 per quadrant per lifetime; Age 8 and under
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