Professional visit after hours (payment will be made on the basis of services rendered the charge for the after-hours visit, whichever is greater)
Consultation (by other than the treating provider)
Treatment of complications (post surgical) unusual circumstances, by report Images and pathology
Upper or lower jaw, extra-oral Therapeutic drug injection, by report
Oral surgery
Extraction, coronal remnants-deciduous tooth
Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
Surgical removal of erupted tooth requiring removal of bone and/or resectioning of tooth Coronal remnants
Surgical removal of erupted tooth/root tip Surgical removal of impacted teeth
Removal of impacted tooth (soft tissue) Removal of impacted tooth (partially bony) Removal of impacted tooth (completely bony)
Removal of impacted tooth (completely bony with unusual surgical complications) Odontogenic cysts and neoplasms
Incision and drainage of abscess Removal of odontogenic cyst or tumor Surgical access of an unerupted tooth
Alveoplasty, in conjunction with extractions - per quadrant
Alveoplasty, in conjunction with extractions, 1 to 3 teeth or tooth spaces - per quadrant Alveoplasty, not in conjunction with extraction - per quadrant
Alveoplasty, not in conjunction with extractions, 1 to 3 teeth or tooth spaces - per quadrant Sialolithotomy: removal of salivary calculus
Closure of salivary fistula Excision of hyperplastic tissue Removal of exostosis
Tooth reimplantation
Transplantation of tooth or tooth bud Closure of oral fistula of maxillary sinus Sequestrectomy
Crown exposure to aid eruption
Removal of foreign body from soft tissue Frenectomy
Suture of soft tissue injury Excision of pericornal gingiva Periodontics
Occlusal adjustment (other than with an appliance or by restoration)
Periodontal scaling and root planing, per quadrant (limited to 4 separate quadrants every 2 years) Root planing and scaling – 1 to 3 teeth per quadrant (limited to once per site every 2 years)
Periodontal maintenance procedures following active therapy (limited to: 4 in 12 months) (combined with prophylaxis after completion of active periodontal therapy)
Endodontics Pulp capping Pulpotomy Pulpal therapy Pulpal regeneration Restorative dentistry
Exclused inlays, crowns (other than prefabricated stainless steel or resin) and bridges. Multiple restorations in 1 surface will be considered as a single restoration.
Amalgam restorations
Resin-based composite – one, two three, four or more surfaces, anterior Resin-based composite crown, anterior
Resin-based composite - one, two, three, four or more surfaces, posterior Pins
Pin retention—per tooth, in addition to amalgam or resin restoration Crowns (when tooth cannot be restored with a filling material) Prefabricated stainless steel
Prefabricated resin crown (excluding temporary crowns) Protective resin Re-cementation Inlay Crown Bridge Prosthodontics Dentures and partials
Office reline, complete denture - maxillary or mandibular Office reline, partial denture - maxillary or mandibular
Reline, complete denture - maxillary or mandibular - laboratory Reline, partial denture - maxillary or mandibular - laboratory Special tissue conditioning, per denture - maxillary or mandibular Rebase complete denture - maxillary or mandibular
Rebase partial denture - maxillary or mandibular
Adjustment to complete denture - maxillary or mandibular (adjustments made within 6 months after installation, by the same dentist who installed it, are inclusive to the denture)
Adjustment to partial denture - maxillary or mandibular (adjustments made within 6 months after installation, by the same dentist who installed it, are inclusive to the partial denture)
Repairs: Dentures and partial dentures Fixed partial denture repair, by report Repair broken complete denture base
Replace missing or broken teeth – complete denture (each tooth) Repair resin denture base
Repair cast framework
Broken denture clasp, no teeth involved Replacing missing or broken teeth, each tooth Adding teeth to existing partial denture Each tooth
General anesthesia and intravenous sedation
Only when medically necessary and only when provided in conjunction with a covered dental surgical procedure
Deep sedation/general anesthesia – first 30 minutes
Deep sedation/general anesthesia – each additional 15 minutes Intravenous conscious sedation – first 301 minutes
Intravenous conscious sedation – each additional 15 minutes
Type C Services: Major Restorative Care
Periodontics
Osseous surgery, including flap and closure, 1 to 3 teeth per quadrant (limited to 1 per site every 3 years)
Osseous surgery, including flap and closure, (limited to 1 per quadrant every 3 years) Pedicle soft tissue graft procedure
Free soft tissue graft procedures
Subepithelial connective tissue graft procedure (including donor site surgery) Gingivectomy, per quadrant (limited to 1 per quadrant every 3 years) Gingivectomy, 1 to 3 teeth per quadrant
Gingival flap procedure - per quadrant (limited to 1 per quadrant every 3 years) Gingival flap procedure – 1 to 3 teeth per quadrant (limited to 1 per site every 3 years) Clinical crown lengthening
Full mouth debridement (limited to 1 treatment per lifetime) Endodontics
Apexification/recalcification
Apicoectomy/periradicular surgery – anterior/bicuspid/molar/each additional root Pulpal regeneration
Root canal therapy including medically necessary images: Anterior
Bicuspid Molar
Retreatment of previous root canal therapy including medically necessary images: Anterior
Bicuspid Molar
Root amputation
Hemisection (including any root removal) Restorative
Inlays, onlays, labial veneers and crowns when provided as treatment for decay or acute traumatic injury and only when teeth cannot be restored with a filling material or when the tooth is an abutment to a fixed bridge (limited to: 1 per tooth every 5 years)
Inlays/Onlays (limited to: 1 tooth every 5 years) Inlay – metallic, one, two, three surfaces
Onlay – metallic, one, two, three and four or more surfaces Inlay – porcelain/ceramic, one, two, three or more surfaces Onlay– porcelain/ceramic, two, three and four or more surfaces Inlay – resin based composite, one, two, three or more surfaces Onlay – resin based composite, two, three and four or more surfaces
Crowns (limited to: 1 tooth every 5 years) Resin
Resin with noble metal Resin with base metal Porcelain/ceramic substrate Porcelain fused to noble metal
Porcelain fused to predominately base metal (limited to: 1 tooth every 5 years) Porcelain fused to noble metal
Full cast high noble metal Base metal (full cast) Noble metal (full cast) 3/4 cast high noble metal 3/4 cast base metal 3/4 cast noble metal 3/4 porcelain/ceramic Titanium
Core build-up, including any pins
Post and core in addition to crown, indirectly fabricated Prefabricated post and core, in addition to crown Crown repair
Prosthodontics
Installation of dentures and bridges is covered only if needed to replace teeth which were not abutments to a denture or bridge/partial denture less than 5 years old
Replacement of existing bridges/partial denture or dentures (limited to: 1 every 5 years)
Bridge/partial denture abutments (See Inlays/Onlays and Crowns) (limited to: 1 tooth every 5 years) Pontics (limited to: 1 tooth every 5 years)
Cast high noble metal Cast base metal Cast noble metal Titanium
Porcelain fused to high noble metal Porcelain fused to base metal Porcelain fused to noble metal Porcelain/ceramic
Resin with high noble Resin with base metal Resin with noble metal
Retainer cast metal for resin bonded fixed prosthesis (limited to: 1 tooth every 5 years) Retainer porcelain/ceramic for resin bonded fixed prosthesis (limited to: 1 tooth every 5 years) Fixed partial denture retainers-Crowns (limited to: 1 tooth every 5 years)
Porcelain/ceramic
Porcelain fused to high noble metal Porcelain fused to base metal Porcelain fused to noble metal 3/4 cast high noble metal 3/4 cast base metal 3/4 cast noble metal 3/4 porcelain/ceramic Full cast high noble metal
Full cast base metal Full cast noble metal Titanium
Removable partial denture (unilateral) (limited to: 1 every 5 years)
One piece casting, chrome cobalt alloy clasp attachment (all types) per unit, including pontics (limited to: 1 every 5 years)
Dentures and Partials (limited to: 1 every 5 years)
(Fees for dentures and partial dentures include relines, rebases and adjustments within 6 months after installation. Fees for relines and rebases include adjustments within 6 months after installation. Specialized techniques and characterizations are not eligible)
Complete upper denture Complete lower denture Immediate upper denture Immediate lower denture
Partial upper or lower, resin base (including any conventional clasps, rests and teeth) (limited to: 1 set every 5 years)
Partial upper or lower, cast metal base with resin saddles (including any conventional clasps, rests and teeth) (limited to: 1 set every 5 years)
Implants and implant supported services (Only if determined as a dental necessity and limited to 1 every 5 years)
Endosteal Implant
Surgical placement of interium implant body Eposteal implant
Transosteal implant, including hardware
Connecting bar – implant or abutment supported Prefabricated abutment
Abutment supported porcelain ceramic crown
Abutment supported porcelain fused to high noble metal
Abutment supported porcelain fused to predominately base metal crown Abutment supported porcelain fused to noble metal crown
Abutment supported cast high noble metal crown
Abutment supported cast predominately base metal crown Abutment supported cast noble metal crown
Implant supported porcelain/ceramic crown
Implant supported porcelain fused to high noble metal Implant supported metal crown
Abutment supported retainer for porcelain/ceramic fixed partial denture
Abutment supported retainer for porcelain fused to high noble metal fixed partial denture Abutment supported retainer for porcelain fused to predominately base metal fixed partial denture
Abutment supported retainer for porcelain fused to noble metal fixed partial denture Abutment supported retainer for cast high noble metal fixed partial denture
Abutment supported retainer for predominately base metal fixed partial denture Abutment supported retainer for cast noble metal fixed partial denture
Implant supported retainer for ceramic fixed partial denture
Implant supported retainer for porcelain fused to high noble metal fixed partial denture Implant supported retainer for cast metal fixed partial denture
Implant supported complete denture, partial denture Implant maintenance procedures (limited to 1 every 5 years) Repair implant prosthesis
Abutment supported crown titanium Repair implant abutment
Implant removal, by report
Implant/abutment supported removable denture, maxillary or mandibular
Implant/abutment supported removable denture for partially edentulous arch, maxillary or mandibular
Implant/abutment supported fixed denture for completely edentulous arch – maxillary or mandibular
Implant/abutment supported fixed denture for partially edentulous arch – maxillary or mandibular
Implant removal, by report Implant index
Abutment supported retainer crown for fixed partial denture titanium Stress breakers
Interim partial denture (stayplate), anterior only Occlusal guard, by report
Removable appliance therapy Fixed appliance therapy Orthodontic services
• Medically necessary comprehensive treatment Limited orthodontic treatment of the primary dentition Limited orthodontic treatment of the transitional dentition Limited orthodontic treatment of the adolescent dentition Limited orthodontic treatment of the adult dentition Interceptive orthodontic treatment of the primary dentition Interceptive orthodontic treatment of the transitional dentition Comprehensive orthodontic treatment of the transitional dentition Comprehensive orthodontic treatment of the adolescent dentition Comprehensive treatment of adult dentition
Pre-orthodontic treatment examination to monitor growth and development Periodic orthodontic treatment visit (as part of contract)
Orthodontic retention (removal of appliances, construction and placement of retainer(s) Repair of orthodontic appliance
Rebonding or recementing; and/or repair, as required of fixed retainers Repair of fixed retainers
Orthodontic treatment (includes removal of appliance, construction and placement of retainer) Replacement of retainer (limited to: 1 per lifetime)
Note: Benefits for panoramic images, cephalometric images, oral facial photographic images and diagnostic images will be considered orthodontia when performed as part of orthodontic treatment.