HNA Fee Schedule Specialist

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ADA Code ADA Description MAC Specialist
D0120 Periodic oral evaluation - established patient 50
D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver 50
D0150 Comprehensive oral evaluation - new or established patient 77
D0160 Detailed and extensive oral evaluation - problem focused 83
D0170 Re-evaluation - limited, problem focused 55
D0180 Comprehensive periodontal evaluation - new or established patient 76
D0425 Caries susceptibility to oral diseases 50
D1110 Prophylaxis - adult 67
D1120 Prophylaxis - child 50
D1203 Topical application of fluoride - child 50
D1204 Topical application of fluoride - adult 50
D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients 50
D1310 Nutritional counseling for control of dental disease 50
D1320 Tobacco counseling for control and prevention of oral disease 50
D1330 Oral hygiene instructions 50
D4910 Periodontal maintenance procedures following active therapy 100
D9430 Office visit for observation (during regularly scheduled hours) - no other services performed 78
D9910 Application of desensitizing medicament 50
ADA Code ADA Description
D0210 Intraoral - complete series (including bite wings) 35
D0220 Intraoral - periapical first film 35
D0230 Intraoral - periapical each additional film 35
D0240 Intraoral - occlusal film 35
D0250 Extraoral - first film 35
D0260 Extraoral - each additional film 35
D0270 Bitewing - single film 35
D0272 Bitewings - two films 35
D0273 Bitewings - three films 35
D0274 Bitewings - four films 38
D0277 Vertical bitewings - 7 to 8 films 64
D0330 Panoramic film 68
D0340 Cephalometric film 75
FILLINGS AND BASIC SERVICES
ADA Code ADA Description
D0140 Limited oral evaluation - problem focused 70
D0290 Posterior - anterior or lateral skull and facial bone survey film 78
D0310 Sialography 190
D0415 Collection of microorganisms for culture and sensitivity-Bacteriologic Studies for Det of Path 40
D0417 Collection and preparation of saliva sample for laboratory diagnostic testing 53
D0418 Analysis of saliva sample 133
D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities 40
D0460 Pulp vitality tests 35
D0470 Diagnostic casts 67
D2140 Amalgam - one surface, primary 77
permanent 77
D2150 Amalgam - two surfaces, primary 95
permanent 95
D2160 Amalgam - three surfaces, primary 111
permanent 85
D2161 Amalgam - four or more surfaces, primary 115
permanent 95
D2330 Resin-based composite - one surface, anterior 92
D2331 Resin-based composite - two surfaces, anterior 110
D2332 Resin-based composite - three surfaces, anterior 134
D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) 159
D2390 Resin-based composite crown, anterior 235
D2391 Resin-based composite - one surface, posterior, Primary 110
Permanent 70
D2392 Resin-based composite - two surfaces, posterior, Primary 140
Permanent 85
D2393 Resin-based composite - three surfaces, posterior, Primary 170
Permanent 100
D2394 Resin-based composite - four or more surfaces, posterior, Primary 200
Permanent 100
D2410 Gold foil - one surface 345
D2420 Gold foil - two surfaces 437
PAIN MANAGEMENT AND ADJUNCTIVE SERVICES
ADA Code ADA Description
D9110 Palliative (emergency) treatment dental pain - minor procedure 68
D9220 Deep sedation/general anesthesia - first 30 minutes 220
D9221 Deep sedation/general anesthesia - each additional 1 5 minutes 107
D9230 Inhalation of nitrous oxide/analgesia, anxiolysis 141
D9241 Intravenous conscious sedation/analgesia - first 30 minutes 140
D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 130
D9410 House/extended care facility call 107
D9420 Hospital or ambulatory surgical center call 105
D9440 Office visit - after regular office hours 75
D9450 Case presentation, detailed and extensive treatment planning 52
OTHER PREVENTIVE SERVICES
ADA Code ADA Description
D1351 Sealant - per tooth 33
D1510 Space maintainer - fixed - unilateral 176
D1515 Space maintainer - fixed - bilateral 240
D1520 Space maintainer - removable - unilateral 273
D1525 Space maintainer - removable - bilateral 330
D1550 Re-cementation of space maintainer 45
D1555 Removal of fixed space maintainer 95
ORAL SURGERY, GUM TREATMENTS AND PROSTHETIC REPAIR
ADA Code ADA Description
D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quad 900
D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quad 700
D4230 Anatomical Crown Exposure (four or more contiguous teeth per quad) 160
D4231 Anatomical Crown Exposure (one to three teeth per quad) 50
D4240 Ging flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quad 875
D4241 Gingival flap procedure, including root planning - one to three contiguous teeth or tooth bounded spaces per quad 725
D4249 Clinical crown lengthening - hard tissue 636
D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quad 300
D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quad 960
D4263 Bone replacement graft - first site in quad 325
D4264 Bone replacement graft - each additional site in quad 250
D4270 Pedicle soft tissue graft procedure 498
D4271 Free soft tissue graft procedure (including donor site surgery) 635
D4273 Sub epithelial connective tissue graft .procedures, per tooth 906
D4275 Soft tissue allograft 625
D4320 Provisional splinting - intracoronal 230
D4321 Provisional splinting - extracoronal 265
D4341 Periodontal scaling and root planning - four or more teeth per quad 225
D4342 Periodontal scaling and root planning - one to three teeth per quad 110
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis 130
D5410 Adjust complete denture - maxillary 61
D5411 Adjust complete denture - mandibular 61
D5421 Adjust partial denture - maxillary 61
D5422 Adjust partial denture - mandibular 61
D5510 Repair broken complete denture base 125
D5520 Replace missing or broken teeth - complete denture (each tooth) 94
D5610 Repair resin denture base 110
D5620 Repair cast framework 140
D5630 Repair or replace broken clasp 134
D5640 Replace broken teeth - per tooth 120
D5650 Add tooth to existing partial denture 140
D5660 Add clasp to existing partial denture 160
D5710 Rebase complete maxillary denture 370
D5711 Rebase complete mandibular denture 370
D5720 Rebase maxillary partial denture 290
D5721 Rebase mandibular partial denture 290
D5730 Reline complete maxillary denture (chairside) 188
D5731 Reline complete mandibular denture (chairside) 188
D5740 Reline maxillary partial denture (chairside) 188
D5741 Reline mandibular partial denture (chairside) 188
D5620 Reline complete maxillary denture (lab) 320
D5621 Reline complete mandibular denture (lab) 320
D5760 Reline maxillary partial denture (lab) 320
D5761 Reline mandibular partial denture (lab) 320
D5850 Tissue conditioning, maxillary 95
D5851 Tissue conditioning, mandibular 95
D6090 Repair implant supported prosthesis 515
D6091 Replacement of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment 424
D6092 Recement implant/abutment supported crown 130
D6093 Recement implant/abutment supported fixed partial denture 130
D6095 Repair implant abutment 200
D6100 Implant removal 300
D6930 Recement fixed partial denture 100
D7111 Extraction, coronal remnants, deciduous tooth 95
D7140 Extraction, erupted tooth or exposed root 95
D7210 Surgical removal of erupted tooth 154
D7220 Removal of impacted tooth - soft tissue 195
D7230 Removal of impacted tooth - partial bony 225
D7240 Removal of impacted tooth - completely bony 290
D7241 Removal of impacted tooth - completely bony, with unusual surgical complications 305
D7250 Surgical removal residual tooth roots (cutting procedure) 165
D7260 Oroantral fistula closure 501
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth 269
D7280 Surgical access of an unerupted tooth 270
D7282 Mobilization of erupted or malpositioned tooth to aid eruption 250
D7283 Placement of device to facilitate eruption of impacted tooth 115
D7285 Biopsy of oral tissue - hard (bone, tooth) 425
D7286 Biopsy of oral tissue - soft 205
D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quad 210
D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quad 175
D7320 Alveoloplasty not in conjunction with extractions -four or more teeth or tooth spaces, per quad 285
D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quad 121
D7340 Vestibuloplasty - uncomplicated 975
D7350 Vestibuloplasty - complicated 1685
D7410 Excision of benign lesion up to 1.25 cm 650
D7411 Excision of benign lesion greater than 1.25 cm 650
D7412 Excision of benign lesion, complicated 650
D7413 Excision of malignant lesion up to 1.25 cm 800
D7414 Excision of malignant lesion greater than 1.25 cm 800
D7415 Excision of malignant lesion, complicated 800
D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm 800
D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm 800
D7450 Removal of benign odontogenic cyst or tumor- lesion diameter up to 1.25 cm 650
D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1 .25 cm 650
D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1 .25 cm 650
D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm 665
D7471 Removal of lateral exostosis (maxilla or mandible) 450
D7472 Removal of torus palatinus 450
D7473 Removal of torus mandibularis 478
D7485 Surgical reduction of osseous tuberosity 550
D7510 Incision and drainage of abscess - intraoral soft tissue 143
D7511 Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) 562
D7520 Incision and drainage of abscess - extraoral soft tissue 562
D7521 Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces) 562
D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue 200
D7540 Removal of reaction producing foreign bodies, musculoskeletal system 225
D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone 206
D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body 1289
D7610 Maxilla - open reduction (simple) 3694
D7620 Maxilla - closed reduction (simple) 2829
D7630 Mandible - open reduction (simple) 4151
D7640 Mandible - closed reduction (simple) 3060
D7650 Malar and/or zygomatic arch - open reduction (simple) 2599
D7660 Malar and/or zygomatic arch - closed reduction (simple) 1346
D7670 Alveolus - closed reduction, may include stabilization of teeth (simple) 902
D7671 Alveolus - open reduction, may include stabilization of teeth (simple) 1913
D7710 Maxilla - open reduction (compound) , 4358
D7720 Maxilla - closed reduction (compound) 2987
D7730 Mandible - open reduction (compound) 5383
D7740 Mandible - closed reduction (compound) 3036
D7750 Malar and/or zygomatic arch - open reduction (compound) 4181
D7760 Malar and/or zygomatic arch - closed reduction (compound) 1570
D7770 Alveolus - open reduction stabilization of teeth (compound) 2034
D7771 Alveolus - closed reduction stabilization of teeth (compound) 1561
D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another 251
D7963 Frenuloplasty 423
D7970 Excision of hyperplastic tissue - per arch 263
D7971 Excision of pericoronal gingiva 250
D9120 Fixed partial denture sectioning 44
CROWNS AND MAJOR SERVICES
D2510 Inlay - metallic - one surface 455
D2520 Inlay - metallic - two surfaces 475
D2530 Inlay - metallic - three or more surfaces 487
D2542 Onlay - metallic - two surfaces 465
D2543 Onlay - metallic - three surfaces 560
D2544 Onlay - metallic - four or more surfaces 570
D2610 Inlay - porcelain/ceramic - one surface 445
D2620 Inlay - porcelain/ceramic - two surfaces 546
D2630 Inlay - porcelain/ceramic - three or more surfaces 592
D2642 Onlay - porcelain/ceramic - two surfaces 660
D2643 Onlay - porcelain/ceramic - three surfaces 685
D2644 Onlay - porcelain/ceramic - four or more surfaces 698
D2650 Inlay - resin-based composite - one surface 378
D2651 Inlay - resin-based composite - two surfaces 445
D2652 Inlay - resin-based composite - three or more surfaces 489
D2662 Onlay - resin-based composite - two surfaces 450
D2663 Onlay - resin-based composite - three surfaces 487
D2664 Onlay - resin-based composite - four or more surfaces 510
D2710 Crown - resin-based composite (indirect) 455
D2712 Crown - 3/4 resin-based composite (indirect) 700
D2720 Crown - resin with high noble metal 685
D2721 Crown - resin with predominantly base metal 632
D2722 Crown - resin with noble metal 641
D2740 Crown - porcelain/ceramic substrate 740
D2750 Crown - porcelain fused to high noble metal 740
D2751 Crown - porcelain fused to predominantly base metal 690
D2752 Crown - porcelain fused to noble metal 710
D2780 Crown - 3/4 cast high noble metal 746
D2781 Crown - 3/4 cast predominantly base metal 694
D2782 Crown - 3/4 cast noble metal 715
D2783 Crown - 3/4 porcelain/ceramic 770
D2790 Crown - full cast high noble metal 756
D2791 Crown - full cast predominantly base metal 700
D2792 Crown - full cast noble metal 732
D2794 Crown - titanium 626
D2910 Recement inlay, onlay, or partial coverage restoration 66
D2915 Recement cast or prefabricated post and core 57
D2920 Recement crown 57
D2930 Prefabricated stainless steel crown - primary tooth 150
D2931 Prefabricated stainless steel crown - permanent tooth 185
D2932 Prefabricated resin crown 210
D2933 Prefabricated stainless steel crown with resin window 200
D2934 Prefabricated esthetic coated stainless steel crown - primary tooth 199
D2940 Protective restoration 66
D2950 Crown buildup - including any pins 150
D2951 Pin retention - per tooth in addition to restoration 45
D2952 Post and core in addition to crown, indirectly fabricated 294
D2954 Prefabricated post & core in addition to crown 200
D2955 Post removal (not in conjunction with endodontic therapy) 139
D2970 Temporary crown (fractured tooth) 165
D2980 Crown repair 0
D3110 Pulp cap - direct (excluding final restoration) 55
D3120 Pulp cap - indirect (excluding final restoration) 44
D3220 Therapeutic pulpotomy (excluding final restoration) 114
D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development 114
D3230 Pulpal therapy - anterior, primary tooth (excluding final restoration) 135
D3240 Pulpal therapy - posterior, primary tooth (excluding final restoration) 141
D3310 Endodontic therapy, anterior tooth (excluding final restoration) 610
D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) 745
D3330 Endodontic therapy, molar (excluding final restoration) 950
D3346 Retreatment of previous root canal therapy- anterior 917
D3347 Retreatment of previous root canal therapy- bicuspid 1080
D3348 Retreatment of previous root canal therapy- molar 1336
D3351 Apexification/recalcification/pulpal regeneration - initial visit ' 240
D3352 Apexification/recalcification/pulpal regeneration - interim medication replacement 139
D3353 Apexification/recalcification - final visit 560
D3410 Apicoectomy/periradicular surgery - anterior 670
D3421 Apicoectomy/periradicular surgery - bicuspid (first root) 785
D3425 Apicoectomy/periradicular surgery - molar (first root) 825
D3426 Apicoectomy/periradicular surgery (each additional root) 183
D3430 Retrograde filling - per root 130
D3450 Root amputation - per root 207
D3920 Hemisection - (including root removal); not including root canal therapy 305
D3950 Canal preparation and fitting of preformed dowel or post 125
MAJOR PROSTHETIC SERVICES
ADA Code ADA Description
D5110 Complete denture - maxillary 1385
D5120 Complete denture - mandibular 1385
D5130 Immediate denture - maxillary 1540
D5140 Immediate denture - mandibular 1540
D5211 Maxillary partial denture - resin base (including any conventional clasps, rests, and teeth) 810
D5212 Mandibular partial denture - resin base (including any conventional clasps, rests, and teeth) 810
D5213 Max partial denture -cast metal frame with resin denture bases (including clasps, rests, teeth) 1365
D5214 Mand partial denture -cast metal frame with resin denture bases (including clasps, rests, teeth) 1365
D5225 Maxillary partial denture - flexible base (including clasps, rests, and teeth) 1152
D5226 Mandibular partial denture - flexible base (including clasps, rests, and teeth) 1152
D5281 Removable unilateral partial denture - one piece cast metal (including clasps and teeth) 540
D5670 Replace all teeth and acrylic on cast metal framework (maxillary) 790
D5671 Replace all teeth and acrylic on cast metal framework (mandibular) 790
D5810 Interim complete denture (maxillary) 450
D5811 Interim complete denture (mandibular) 450
D5820 Interim partial denture (maxillary) 360
D5821 Interim partial denture (mandibular) 360
D6010 Surgical placement of implant body: endosteal implant 1875
D6012 Surgical Placement of Interim Implant Body for Transitional Prosthetics: Endosteal Implant 650
D6040 Surgical placement: eposteal implant 6215
D6050 Surgical placement : transosteal implant 4250
D6056 Prefabricated abutment - includes placement 650
D6057 Custom abutment - includes placement 650
D6058 Abutment supported porcelain/ceramic crown 860
D6059 Abutment supported porcelain fused to metal crown (high noble metal) 900
D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) 760
D6061 Abutment supported porcelain fused to metal crown (noble metal) 834
D6062 Abutment supported cast metal crown (high noble metal) 840
D6063 Abutment supported cast metal crown (predominantly base metal) 775
D6064 Abutment supported cast metal crown (noble metal) 840
D6065 Implant supported porcelain/ceramic crown 965
D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) 965
D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal) 945
D6068 Abutment supported retainer for porcelain/ceramic FPD 865
D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) 850
D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) 750
D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) 785
D6072 Abutment supported retainer for cast metal FPD (high noble metal) 850
D6073 Abutment supported retainer for cast meta! FPD (predominantly base metal) 779
D6074 Abutment supported retainer for cast metal FPD (noble metal) 840
D6075 Implant supported retainer for ceramic FPD 955
D6076 Implant supported retainer for porcelain fused to metal FPD (ti,  ti alloy, high noble metal) 935
D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, high noble metal) 930
D6078 Implant/abutment supported fixed denture for completely edentulous arch 2375
D6079 Implant/abutment supported fixed denture for partially edentulous arch 1590
D6080 Implant maintenance procedures 225
D6094 Abutment supported crown (titanium) 710
D6194 Abutment supported retainer crown for FPD (titanium) 829
D6205 Pontic - indirect resin based composite 678
D6210 Pontic - cast high noble metal 756
D6211 Pontic - cast predominantly base metal 700
D6212 Pontic - cast noble metal 735
D6214 Pontic - titanium 735
D6240 Pontic - porcelain fused to high noble metal 740
D6241 Pontic - porcelain fused to predominantly base metal 690
D6242 Pontic - porcelain fused to noble metal 715
D6245 Pontic - porcelain/ceramic 740
D6250 Pontic - resin with high noble metal 716
D6251 Pontic - resin with predominantly base metal 655
D6252 Pontic - resin with noble metal 710
D6253 Provisional pontic 1375
D6545 Cast metal retainer for resin bonded fixed prosthesis 355
D6548 Porcelain/ceramic retainer for resin bonded fixed prosthesis 590
D6600 Inlay - porcelain/ceramic, two surfaces 563
D6601 Inlay - porcelain/ceramic, three or more surfaces 611
D6602 Inlay - cast high noble metal, two surfaces 615
D6603 Inlay - cast high noble metal, three or more surfaces 675
D6604 Inlay - cast predominantly base metal, two surfaces 562
D6605 Inlay - cast predominantly base metal, three or more surfaces 580
D6606 Inlay - cast noble metal, two surfaces 560
D6607 Inlay - cast noble metal, three or more surfaces 615
D6608 Onlay - porcelain/ceramic, two surfaces 663
D6609 Onlay - porcelain/ceramic, three or more surfaces 725
D6610 Onlay - cast high noble metal, two surfaces 675
D6611 Onlay - cash high noble metal, three or more surfaces 569
D6612 Onlay - cast predominantly base metal, two surfaces 562
D66I3 Onlay - cast predominantly base metal, three or more surfaces 640
D6614 Onlay - cast noble metal, two surfaces 615
D6615 Onlay - cast noble metal, three or more surfaces 675
D6624 Inlay - titanium 600
D6634 Onlay - titanium 655
D6710 Crown - indirect resin based composite 651
D6720 Crown - resin with high noble metal 800
D6721 Crown - resin with predominantly base, metal 685
D6722 Crown - resin with noble metal 710
D6740 Crown - porcelain/ceramic 740
D6750 Crown - porcelain fused to high noble metal 740
D6751 Crown - porcelain fused to predominantly base metal 690
D6752 Crown - porcelain fused to noble metal 715
D6780 Crown - 3/4 cast high noble metal 750
D6781 Crown - 3/4 cast predominantly base metal 692
D6782 Crown - 3/4 cast noble metal 720
D6783 Crown - 3/4 porcelain/ceramic 775
D6790 Crown - full cast high noble metal 758
D6791 Crown - full cast predominantly base metal 700
D6792 Crown - full cast noble metal 735
D6793 Provisional retainer crown 375
D6794 Crown - titanium 639
D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated 273
D6972 Prefabricated post and core in addition to fixed partial denture retainer 200
D6973 Core build up for retainer, including any pins 185
D6975 Coping - metal 420
Disclaimer: This is not health insurance; the dental discount plan provides discounts from dental providers. The dental discount plan does not make payments directly to the providers of health care. The member will be required to pay for all dental treatment but will receive a discount from those providers that accept Health Networks of America’s Discount Dental Plan. Health Networks of America can be reached at 1-877-335-7526.