Covered Service Benefits and ADA Codes


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%


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 than 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%


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%


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%


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%


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%


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%


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%


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