MEDICAL FEE SCHEDULE
Section 13: Dental Fee Schedule
Effective May 1, 2007
- Dental claims will be submitted on the American Dental Association’s
standard billing form.
- Whenever a dentist's fees exceed those listed
herein, complete written additional information must be furnished in order
to justify any additional approval.
| Code |
Allowance |
|
00120 |
$48.00 |
|
00140 |
$32.00 |
|
00145 |
$82.00 |
|
00150 |
$48.00 |
|
00160 |
$90.00 |
|
00170 |
BR |
|
00180 |
BR |
|
00210 |
$100.00 |
|
00220 |
$19.00 |
|
00230 |
$18.00 |
|
00240 |
$19.00 |
|
00250 |
$75.00 |
|
00260 |
$75.00 |
|
00270 |
$18.00 |
|
00272 |
$33.00 |
|
00273 |
$46.00 |
|
00274 |
$42.00 |
|
00277 |
BR |
|
00290 |
$75.00 |
|
00310 |
$184.00 |
|
00320 |
$25.00 |
|
00321 |
$100.00 |
|
00322 |
BR |
|
00330 |
$100.00 |
|
00340 |
$100.00 |
|
00350 |
BR |
|
00360 |
$248.00 |
|
00362 |
$260.00 |
|
00363 |
$285.00 |
|
00415 |
$26.00 |
|
00416 |
BR |
|
00421 |
BR |
|
00425 |
$30.00 |
|
00431 |
BR |
|
00460 |
$45.00 |
|
00470 |
$52.00 |
|
00472 |
BR |
|
00473 |
BR |
|
00474 |
BR |
|
00475 |
BR |
|
00476 |
BR |
|
00477 |
BR |
|
00478 |
BR |
|
00479 |
BR |
|
00480 |
BR |
|
00481 |
BR |
|
00482 |
BR |
|
00483 |
BR |
|
00484 |
BR |
|
00485 |
BR |
|
00486 |
BR |
|
00502 |
$45.00 |
|
00999 |
BR |
|
01110 |
$53.00 |
|
01120 |
$38.00 |
|
01203 |
$20.00 |
|
01204 |
$20.00 |
|
01206 |
$31.00 |
|
01310 |
$30.00 |
|
01320 |
BR |
|
01330 |
$30.00 |
|
01351 |
$35.00 |
|
01510 |
$250.00 |
|
01515 |
$380.00 |
|
01520 |
$279.00 |
|
01525 |
$197.00 |
|
01550 |
$33.00 |
|
01555 |
$60.00 |
|
02140 |
$90.00 |
|
02150 |
$105.00 |
|
02160 |
$125.00 |
|
02161 |
$175.00 |
|
02330 |
$95.00 |
|
02331 |
$117.00 |
|
02332 |
$160.00 |
|
02335 |
$200.00 |
|
02390 |
$200.00 |
|
02391 |
$95.00 |
|
02392 |
$117.00 |
|
02393 |
$160.00 |
|
02394 |
$200.00 |
|
02410 |
BR |
|
02420 |
BR |
|
02430 |
BR |
|
02510 |
$382.00 |
|
02520 |
$442.00 |
|
02530 |
$492.00 |
|
02542 |
BR |
|
02543 |
$594.00 |
|
02544 |
$612.00 |
|
02610 |
$385.00 |
|
02620 |
$500.00 |
|
02630 |
$650.00 |
|
02642 |
BR |
|
02643 |
BR |
|
02644 |
BR |
|
02650 |
BR |
|
02651 |
BR |
|
02652 |
BR |
|
02662 |
BR |
|
02663 |
BR |
|
02664 |
BR |
|
02710 |
$175.00 |
|
02712 |
BR |
|
02720 |
$504.00 |
|
02721 |
$504.00 |
|
02722 |
$504.00 |
|
02740 |
$800.00 |
|
02750 |
$775.00 |
|
02751 |
$650.00 |
|
02752 |
$750.00 |
|
02780 |
BR |
|
02781 |
BR |
|
02782 |
BR |
|
02783 |
BR |
|
02790 |
$750.00 |
|
02791 |
$650.00 |
|
02792 |
$504.00 |
|
02794 |
BR |
|
02799 |
BR |
|
02910 |
$76.00 |
|
02915 |
BR |
|
02920 |
$76.00 |
|
02930 |
$200.00 |
|
02931 |
$200.00 |
|
02932 |
$200.00 |
|
02933 |
$250.00 |
|
02934 |
BR |
|
02940 |
$76.00 |
|
02950 |
$142.00 |
|
02951 |
$41.00 |
|
02952 |
$247.00 |
|
02953 |
$150.50 |
|
02954 |
$200.00 |
|
02955 |
BR |
|
02957 |
BR |
|
02960 |
$200.00 |
|
02961 |
$600.00 |
|
02962 |
$600.00 |
|
02970 |
$167.00 |
|
02971 |
BR |
|
02975 |
BR |
|
02980 |
BR |
|
02999 |
BR |
|
03110 |
$36.00 |
|
03120 |
$42.00 |
|
03220 |
$121.00 |
|
03221 |
$121.00 |
|
03230 |
BR |
|
03240 |
BR |
|
03310 |
$495.00 |
|
03320 |
$550.00 |
|
03330 |
$680.00 |
|
03331 |
BR |
|
03332 |
BR |
|
03333 |
BR |
|
03346 |
$500.00 |
|
03347 |
$600.00 |
|
03348 |
$700.00 |
|
03351 |
$200.00 |
|
03352 |
$200.00 |
|
03353 |
$500.00 |
|
03410 |
$700.00 |
|
03421 |
$750.00 |
|
03425 |
$800.00 |
|
03426 |
BR |
|
03430 |
$100.00 |
|
03450 |
$210.00 |
|
03460 |
BR |
|
03470 |
BR |
|
03910 |
$126.00 |
|
03920 |
$210.00 |
|
03950 |
BR |
|
03999 |
BR |
|
04210 |
$372.00 |
|
04211 |
$75.00 |
|
04230 |
$1,000.00 |
|
04231 |
$798.00 |
|
04240 |
$372.00 |
|
04241 |
BR |
|
04245 |
BR |
|
04249 |
$272.00 |
|
04260 |
$550.00 |
|
04261 |
$350.00 |
|
04263 |
BR |
|
04264 |
BR |
|
04265 |
BR |
|
04266 |
BR |
|
04267 |
BR |
|
04268 |
BR |
|
04270 |
BR |
|
04271 |
BR |
|
04273 |
BR |
|
04274 |
BR |
|
04275 |
BR |
|
04276 |
BR |
|
04320 |
BR |
|
04321 |
$200.00 |
|
04341 |
$150.00 |
|
04342 |
$230.00 |
|
04355 |
$105.00 |
|
04381 |
$48.00 |
|
04910 |
$72.00 |
|
04920 |
BR |
|
04999 |
BR |
|
05110 |
$1,000.00 |
|
05120 |
$1,000.00 |
|
05130 |
$1,100.00 |
|
05140 |
$1,100.00 |
|
05211 |
$550.00 |
|
05212 |
$550.00 |
|
05213 |
$1,100.00 |
|
05214 |
$1,100.00 |
|
05225 |
BR |
|
05226 |
BR |
|
05281 |
$950.00 |
|
No Code |
$1,500.00 |
|
No Code |
$1,500.00 |
|
05410 |
$39.00 |
|
05411 |
$39.00 |
|
05421 |
$39.00 |
|
05422 |
$39.00 |
|
05510 |
$150.00 |
|
05520 |
$124.00 |
|
05610 |
$124.00 |
|
05620 |
$212.00 |
|
05630 |
$210.00 |
|
05640 |
$104.00 |
|
05650 |
$200.00 |
|
05660 |
$232.00 |
|
05670 |
BR |
|
05671 |
BR |
|
05710 |
$350.00 |
|
05711 |
$350.00 |
|
05720 |
$300.00 |
|
05721 |
$300.00 |
|
05730 |
$175.00 |
|
05731 |
$175.00 |
|
05740 |
$175.00 |
|
05741 |
$175.00 |
|
05750 |
$275.00 |
|
05751 |
$275.00 |
|
05760 |
$275.00 |
|
05761 |
$275.00 |
|
05810 |
$450.00 |
|
05811 |
$450.00 |
|
05820 |
$450.00 |
|
05821 |
$450.00 |
|
05850 |
$72.00 |
|
05851 |
$72.00 |
|
05860 |
$1,200.00 |
|
05861 |
BR |
|
05862 |
$300.00 |
|
05867 |
BR |
|
05875 |
BR |
|
05899 |
BR |
|
05911 |
BR |
|
05912 |
BR |
|
05913 |
$1,455.00 |
|
05914 |
$1,698.00 |
|
05915 |
$2,183.00 |
|
05916 |
$1,455.00 |
|
05919 |
$728.00 |
|
05922 |
BR |
|
05923 |
BR |
|
05924 |
BR |
|
05925 |
BR |
|
05926 |
BR |
|
05927 |
BR |
|
05928 |
BR |
|
05929 |
BR |
|
05931 |
$728.00 |
|
05932 |
$2,183.00 |
|
05933 |
$509.00 |
|
05934 |
$1,698.00 |
|
05935 |
$1,698.00 |
|
05936 |
BR |
|
05937 |
BR |
|
05951 |
$728.00 |
|
05952 |
$1,698.00 |
|
05953 |
$2,183.00 |
|
05954 |
$2,183.00 |
|
05955 |
$2,183.00 |
|
05958 |
BR |
|
05959 |
BR |
|
05960 |
BR |
|
05982 |
$1,091.00 |
|
05983 |
$1,698.00 |
|
05984 |
$1,091.00 |
|
05985 |
$1,091.00 |
|
05986 |
$72.00 |
|
05987 |
BR |
|
05988 |
BR |
|
05999 |
BR |
|
06010 |
$1,350.00 |
|
06012 |
$1,988.00 |
|
06040 |
BR |
|
06050 |
BR |
|
06053 |
BR |
|
06054 |
BR |
|
06055 |
BR |
|
06056 |
BR |
|
06057 |
BR |
|
06058 |
BR |
|
06059 |
BR |
|
06060 |
BR |
|
06061 |
BR |
|
06062 |
BR |
|
06063 |
BR |
|
06064 |
BR |
|
06094 |
BR |
|
06065 |
BR |
|
06066 |
BR |
|
06067 |
BR |
|
06068 |
BR |
|
06069 |
BR |
|
06070 |
BR |
|
06071 |
BR |
|
06072 |
BR |
|
06073 |
BR |
|
06074 |
BR |
|
06194 |
BR |
|
06075 |
BR |
|
06076 |
BR |
|
06077 |
BR |
|
06078 |
BR |
|
06079 |
BR |
|
06080 |
BR |
|
06090 |
BR |
|
06091 |
$75.00 |
|
06092 |
$94.00 |
|
06093 |
$138.00 |
| 06095 |
BR |
| 06100 |
BR |
|
06190 |
BR |
|
06199 |
BR |
|
06205 |
BR |
|
06210 |
$750.00 |
|
06211 |
$700.00 |
|
06212 |
$750.00 |
|
06214 |
$672.00 |
|
06240 |
$750.00 |
|
06241 |
$700.00 |
|
06242 |
$700.00 |
|
06245 |
BR |
|
06250 |
$504.00 |
|
06251 |
$504.00 |
|
06252 |
$504.00 |
|
06253 |
BR |
|
06545 |
$324.00 |
|
06548 |
BR |
|
06600 |
BR |
|
06601 |
BR |
|
06602 |
BR |
|
06603 |
BR |
|
06604 |
BR |
|
06605 |
BR |
|
06606 |
BR |
|
06607 |
BR |
|
06624 |
BR |
|
06608 |
BR |
|
06609 |
BR |
|
06610 |
BR |
|
06611 |
BR |
|
06612 |
BR |
|
06613 |
BR |
|
06614 |
BR |
|
06615 |
BR |
|
06634 |
BR |
|
06710 |
$504.00 |
|
06720 |
$504.00 |
|
06721 |
$504.00 |
|
06722 |
$504.00 |
|
06740 |
$504.00 |
|
06750 |
$750.00 |
|
06751 |
$750.00 |
|
06752 |
$750.00 |
|
06780 |
$750.00 |
|
06781 |
BR |
|
06782 |
BR |
|
06783 |
BR |
|
06790 |
$750.00 |
|
06791 |
$700.00 |
|
06792 |
$750.00 |
|
06794 |
BR |
|
06793 |
BR |
|
06920 |
BR |
|
06930 |
$105.00 |
|
06940 |
$145.00 |
|
06950 |
$286.00 |
|
06970 |
$275.00 |
|
06972 |
$200.00 |
|
06973 |
$175.00 |
|
06975 |
BR |
|
06976 |
BR |
|
06977 |
BR |
|
06980 |
BR |
|
06985 |
BR |
|
06999 |
BR |
|
07111 |
$90.00 |
|
07140 |
$110.00 |
|
07210 |
$250.00 |
|
07220 |
$200.00 |
|
07230 |
$300.00 |
|
07240 |
$400.00 |
|
07241 |
$500.00 |
|
07250 |
$75.00 |
|
07260 |
$300.00 |
|
07261 |
BR |
|
07270 |
$400.00 |
|
07272 |
BR |
|
07280 |
$400.00 |
|
07282 |
BR |
|
07283 |
BR |
|
07285 |
$200.00 |
|
07286 |
$200.00 |
|
07287 |
BR |
|
07288 |
BR |
|
07290 |
BR |
|
07291 |
$110.00 |
|
07292 |
$1,500.00 |
|
07293 |
$1,500.00 |
|
07294 |
$800.00 |
|
07310 |
$100.00 |
|
07311 |
BR |
|
07320 |
$210.00 |
|
07321 |
BR |
|
07340 |
BR |
|
07350 |
BR |
|
07410 |
$150.00 |
|
07411 |
BR |
|
07412 |
BR |
|
07413 |
BR |
|
07414 |
BR |
|
07415 |
BR |
|
07465 |
BR |
|
07440 |
BR |
|
07441 |
BR |
|
07450 |
BR |
|
07451 |
$250.00 |
|
07460 |
$250.00 |
|
07461 |
$250.00 |
|
07471 |
BR |
|
07472 |
BR |
|
07473 |
BR |
|
07485 |
BR |
|
07490 |
BR |
|
07510 |
$101.50 |
|
07511 |
BR |
|
07520 |
$200.00 |
|
07521 |
BR |
|
07530 |
$250.00 |
|
07540 |
BR |
|
07550 |
BR |
|
07560 |
BR |
|
07610 |
BR |
|
07620 |
BR |
|
07630 |
BR |
|
07640 |
BR |
|
07650 |
BR |
|
07660 |
BR |
|
07670 |
BR |
|
07671 |
BR |
|
07680 |
BR |
|
07710 |
BR |
|
07720 |
BR |
|
07730 |
BR |
|
07740 |
BR |
|
07750 |
BR |
|
07760 |
BR |
|
07770 |
BR |
|
07771 |
BR |
|
07780 |
BR |
|
07810 |
BR |
|
07820 |
BR |
|
07830 |
BR |
|
07840 |
BR |
|
07850 |
BR |
|
07852 |
BR |
|
07854 |
BR |
|
07856 |
BR |
|
07858 |
BR |
|
07860 |
BR |
|
07865 |
BR |
|
07870 |
BR |
|
07871 |
BR |
|
07872 |
BR |
|
07873 |
BR |
|
07874 |
BR |
|
07875 |
BR |
|
07876 |
BR |
|
07877 |
BR |
|
07880 |
BR |
|
07899 |
BR |
|
07910 |
$325.00 |
|
07911 |
$524.00 |
|
07912 |
BR |
|
07920 |
BR |
|
07940 |
BR |
|
07941 |
BR |
|
07943 |
BR |
|
07944 |
BR |
|
07945 |
BR |
|
07946 |
BR |
|
07947 |
BR |
|
07948 |
BR |
|
07949 |
BR |
|
07950 |
BR |
|
07951 |
$3,000.00 |
|
07953 |
BR |
|
07955 |
BR |
|
07960 |
BR |
|
07963 |
BR |
|
07970 |
BR |
|
07971 |
BR |
|
07972 |
BR |
|
07980 |
$165.00 |
|
07981 |
BR |
|
07982 |
BR |
|
07983 |
BR |
|
07990 |
BR |
|
07991 |
BR |
|
07995 |
BR |
|
07996 |
BR |
|
07997 |
BR |
|
07998 |
BR |
|
07999 |
BR |
|
08010 |
BR |
|
08020 |
BR |
|
08030 |
BR |
|
08040 |
BR |
|
08050 |
BR |
|
08060 |
BR |
|
08070 |
BR |
|
08080 |
BR |
|
08090 |
BR |
|
08210 |
$472.00 |
|
08220 |
$472.00 |
|
08660 |
BR |
|
08670 |
BR |
|
08680 |
BR |
|
08690 |
BR |
|
08691 |
BR |
|
08692 |
BR |
|
08693 |
$75.00 |
|
08999 |
BR |
|
09110 |
$75.00 |
|
09120 |
$60.00 |
|
09210 |
$42.00 |
|
09211 |
BR |
|
09212 |
BR |
|
09215 |
$42.00 |
|
09220 |
BR |
|
09221 |
BR |
|
09230 |
BR |
|
09241 |
BR |
|
09242 |
BR |
|
09248 |
BR |
|
09310 |
$42.00 |
|
09410 |
BR |
|
09420 |
$75.00 |
|
09430 |
$24.50 |
|
09440 |
$75.00 |
|
09450 |
BR |
|
09610 |
BR |
|
09612 |
$90.00 |
|
09630 |
BR |
|
09910 |
$35.00 |
|
09911 |
BR |
|
09920 |
BR |
|
09930 |
BR |
|
09940 |
$475.00 |
|
09941 |
$140.00 |
|
09942 |
BR |
|
09950 |
$110.00 |
|
09951 |
$82.50 |
|
09952 |
$400.00 |
|
09970 |
BR |
|
09971 |
BR |
|
09972 |
BR |
|
09973 |
BR |
|
09974 |
BR |
|
09999 |
BR |
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Reserved.