MMC Benefits Handbook
Covered Service Benefits and ADA Codes
Diagnostic
ADA Code
Description
In-Network
Out-of-Network
Clinical Oral Examinations
120
Periodic oral evaluation—two per calendar year
100%
100%
140
Limited oral evaluation—no more than two per calendar year in lieu of standard exams
100%
100%
150
Comprehensive oral evaluation—two per calendar year
100%
100%
160
Detailed & extensive oral evaluation—no more than two per calendar year in lieu of standard exams
100%
100%
170
Re-evaluation-limited, problem—no more than two per calendar year in lieu of standard exams
100%
100%
180
Comprehensive periodontal evaluation—no more than two per calendar year in lieu of standard exams
100%
100%
Radiographs
210
Intraoral-complete series (including bitewings)—once per 36 months
100%
100%
220
Intraoral periapical—first film
80%
80%
230
Intraoral periapical—each additional film
80%
80%
272
Bitewings-two films—two per calendar year
100%
100%
274
Bitewings-four films—two per calendar year
100%
100%
330
Panoramic film—once per 36 months
100%
100%
Preventive Services
ADA Code
Description
In-Network
Out-of-Network
Dental Prophylaxis
1110
Prophylaxis-adult (limited to twice yearly)
100%
100%
1120
Prophylaxis-child (limited to twice yearly)
100%
100%
1201
Topical application of fluoride (including prophylaxis)—one per calendar year through age 18
100%
100%
1203
Topical application of fluoride (excluding prophylaxis)—one per calendar year through age 18
100%
100%
Other Preventive Services
1351
Sealant-per tooth, non restored permanent 1st and 2nd molars only—to age 19, one per 60 months
100%
100%
Space Maintenance (Passive Appliances)
1510
Fixed, unilateral type
100%
100%
1515
Fixed, bilateral type
100%
100%
1520
Removable, unilateral type
100%
100%
1525
Removable, bilateral type
100%
100%
Other Periodontal Services
4910
Periodontal maintenance procedure following active therapy where treatment including scaling, root planing, and osseous surgery have been performed. No more then 4 four per calendar year when combined with regular cleanings
80%
80%
Unclassified Treatment
9110
Palliative (emergency) treatment of dental pain—minor procedures
80%
80%
Restorative
ADA Code
Description
In-Network
Out-of-Network
Amalgam Restorations (including polishing)
2140
Amalgam—one surface, permanent
80%
80%
2150
Amalgam—two surfaces, permanent
80%
80%
2160
Amalgam—three surfaces, permanent
80%
80%
2161
Amalgam—four or more surfaces, permanent
80%
80%
Resin Restorations
2330
Resin—one surface, anterior
80%
80%
2331
Resin—two surfaces, anterior
80%
80%
2332
Resin—three surfaces, anterior
80%
80%
2335
Resin—four or more surfaces, anterior
80%
80%
2390
Resin-based composite crown, anterior
50%
50%
2391
Resin-based composite—one surface, posterior
80%
80%
2392
Resin-based composite—two surfaces, posterior
80%
80%
2393
Resin-based composite—three surfaces, posterior
80%
80%
2394
Resin-based composite—four or more surfaces, posterior
80%
80%
Inlay Restorations
2650
Inlay, composite/resin—one surface—one per 84 months
50%
50%
2651
Inlay, composite/resin—two surfaces—one per 84 months
50%
50%
2652
Inlay, composite/resin—three or more surfaces—one per 84 months
50%
50%
2662
Onlay, composite/resin two surfaces laboratory processed—one per 84 months
50%
50%
2663
Onlay, composite/resin three surfaces laboratory processed—one per 84 months
50%
50%
2664
Onlay, composite/resin four or more surfaces laboratory processed—one per 84 months
50%
50%
Crowns-Single Restorations Only
2740
Porcelain/ceramic substrate—one per 84 months
50%
50%
2750
Porcelain fused to high noble metal—one per 84 months
50%
50%
2751
Porcelain fused to predominantly base metal—one per 84 months
50%
50%
2752
Porcelain fused to noble metal—one per 84 months
50%
50%
2790
Full cast high noble metal—one per 84 months
50%
50%
2810
3/4 cast metallic—one per 84 months
50%
50%
Other Restorative Services
2930
Prefabricated stainless steel crown, primary tooth—one per 84 months
80%
80%
2940
Sedative filling
80%
80%
2950
Core buildup, including any pins – one per 84 months
50%
50%
2952
Cast post and core in addition to crown – one per 84 months
50%
50%
2954
Prefabricated post and core in addition to crown – one per 84 months
50%
50%
Endodontics
ADA Code
Description
In-Network
Out-of-Network
 
Pulp Capping
3110
Pulp cap—direct (excluding final restoration)
80%
80%
 
3120
Pulp cap—indirect (excluding final restoration)
80%
80%
 
Pulpotomy
3220
Therapeutic pulpotomy (excluding final restoration)
80%
80%
 
Root Canal Therapy (including treatment plan, clinical procedures, and follow-up care)
3310
Anterior (excluding final restoration)
80%
80%
 
3320
Bicuspid (excluding final restoration)
80%
80%
 
3330
Molar (excluding final restoration)
80%
80%
 
Periapical Services
3410
Apicoectomy/periradicular surgery—anterior
80%
80%
 
3421
Apicoectomy/periradicular surgery—bicuspid (1st root)
80%
80%
 
3425
Apicoectomy/periradicular surgery—molar (1st root)
80%
80%
 
3426
Apicoectomy/periradicular surgery (each additional root)
80%
80%
 
Periodontics
ADA Code
Description
In-Network
Out-of-Network
Surgical and Non-Surgical Services
4210
Gingivectomy or gingivoplasty—per quadrant—one per 36 months
80%
80%
4211
Gingivectomy or gingivoplasty—one to three teeth per quadrant—one per 36 months
80%
80%
4249
Clinical crown lengthening—hard tissue—one per 36 months
80%
80%
4260
Osseous surgery (including flap entry and closure)—four or more contiguous teeth per quadrant—one per 36 months
80%
80%
4261
Osseous surgery (including flap entry and closure)—one to three teeth per quadrant—one per 36 months
80%
80%
4263
Bone replacement graft—1st tooth in quadrant—one per 36 months
80%
80%
4264
Bone replacement graft—each additional tooth in quadrant—one per 36 months
80%
80%
4271
Free soft tissue graft procedure, including donor site surgery—one per 36 months
80%
80%
Adjunctive Periodontal Services
4341
Periodontal scaling and root planing-four or more contiguous teeth per quadrant—one per 24 months
80%`
80%
4342
Periodontal scaling and root planing-one to three teeth per quadrant—one per 24 months
80%
80%
4355
Debridement – one per lifetime
80%
80%
Prosthodontics
ADA Code
Description
In-Network
Out-of-Network
Complete Dentures (including routine post-delivery care)
5110
Complete denture, upper—one per 84 months
50%
50%
5120
Complete denture, lower—one per 84 months
50%
50%
Partial Dentures (including routine post-delivery care)
5211
Upper partial denture-resin base (including any conventional clasps, rests and teeth)—one per 84 months
50%
50%
5212
Lower partial denture-resin base (including any conventional clasps, rests and teeth)—one per 84 months
50%
50%
5213
Upper partial denture-cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)—one per 84 months
50%
50%
5214
Lower partial denture-cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth)—one per 84 months
50%
50%
5730
Relines – one per 36 months
50%
50%
5710
Rebase – one per 36 months
50%
50%
Repairs to Complete Dentures
5520
Replace missing or broken teeth, complete denture (each tooth)
80%
80%
Repairs to Partial Dentures
5640
Replace broken teeth-per tooth
80%
80%
Prosthodontics, Fixed
ADA Code
Description
In-Network
Out-of-Network
Bridge Pontics
6010
Implant—one per 84 months
50%
50%
6092
Recements
80%
80%
6240
Pontic-porcelain fused to high noble metal—one per 84 months
50%
50%
6242
Pontic-porcelain fused to noble metal—one per 84 months
50%
50%
Bridge Retainers-Crowns
6750
Crown-porcelain fused to high noble metal—one per 84 months
50%
50%
6751
Crown-porcelain fused to predominantly base metal—one per 84 months
50%
50%
6752
Crown-porcelain fused to noble metal—one per 84 months
50%
50%
Oral Surgery
ADA Code
Description
In-Network
Out-of-Network
Extractions (including local anesthesia and routine post-operative care)
7140
Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
80%
80%
Surgical Extractions (including local anesthesia and routine post-operative care)
7210
Surgical removal of erupted tooth
80%
80%
7220
Removal of impacted tooth-soft tissue
80%
80%
7230
Removal of impacted tooth-partially bony
80%
80%
7240
Removal of impacted tooth-completely bony
80%
80%
7250
Surgical removal of residual root (cutting procedure)
80%
80%
Surgical Incisions
7510
Incision and drainage of abscess, intraoral soft tissue
80%
80%
Adjunctive General Services
ADA Code
Description
In-Network
Out-of-Network
Anesthesia
9220
General anesthesia-first 30 minutes
80%
80%
9221
General anesthesia-each additional 15 minutes
80%
80%
9240
Intravenous sedation
80%
80%
Professional Consultation
9310
Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment)
50%
50%
Drugs
9610
Therapeutic drug injection, by report
80%
80%
Miscellaneous Services
9910
Application of desensitizing medicaments
80%
80%
9940
Occlusal guards, by report
80%
80%
9951
Occlusal adjustment-limited
80%
80%
9952
Occlusal adjustment-complete
80%
80%
8210
Harmful Habits
Premier Plan: 50%
Standard Plan: Not Covered
Premier Plan: 50%
Standard Plan: Not Covered