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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