Annual Maximum = $2,000

DIAGNOSTIC TREATMENT
*Note:  Items with Prior Authorization Required:

Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed.

00270

By Report

Exam - 4 Bitewings & 2 PA

$82

This section added: Amendment 3.

00472	Accession of tissue, gross examination, preparation and transmission of written report	$115
00473	Accession of tissue, gross & microscopic examination, preparation and transmission of written report	$115
00474	Accession of tissue, gross & microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of report.	$115

PREVENTIVE SERVICES
*Note:  Items with Prior Authorization Required:

Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed.

$60

01520/01525

Space Maintainer - Removable - Unilateral, Bilateral

$212/$300

RESTORATIVE TREATMENT
*Note:  Items with Prior Authorization Required:

Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed.

02110

Amalgam - One Surface, Primary

$54

02120

Amalgam - Two Surfaces, Primary

$68

02130

Amalgam - Three Surfaces, Primary

$77

02131

Amalgam - Four or More Surfaces, Primary

$82

02140

Amalgam - One Surface, Permanent

$70

02150

Amalgam - Two Surfaces, Permanent

$79

02160

Amalgam - Three Surfaces, Permanent

$91

02161

Amalgam - Four or More Surfaces, Permanent

$100

02330

Resin - One Surface, Anterior

$77

02331

Resin - Two Surfaces, Anterior

$115

02332

Resin - Three Surfaces, Anterior

$130

02335

Resin - Four or More Surfaces or Involving Incisal Angle (Anterior)

$134

02336

Composite Resin Crown - Anterior - Primary

Not Covered

02380

Resin - One Surface - Posterior Primary

Not Covered

CROWNS
Plus additional cost of noble metal (gold) when used.
*Note:  Items with Prior Authorization Required:

Service or procedure must be reviewed and approved by the Allied Administrators in advance of service or procedure being performed.

02510

Inlay - Metallic - One Tooth Surface

Not Covered

02520

Inlay - Metallic - Two Tooth Surfaces

Not Covered

02530

Inlay - Metallic - Three or More Surfaces

$336

02543

Onlays - Metallic 3 Surfaces

$432

02544

Onlays - Metallic 4 or More Surfaces

$504

02740

Porcelain, Ceramic Substrate

Not Covered

02750

Porcelain Fused to High Noble Metal

$606

02751

Porcelain Fused to Predominantly Base Metal

$606

02752

Porcelain Fused to Noble Metal

$606

02790

Full Cast Crown High Noble Metal

$606

02791

Full Cast Predominantly Base Metal

$606

02792

Full Cast Noble Metal

$606

02780

3/4 Cast High Noble Metal

$606

02910

Recement Inlay

$40

02920

Recement Crown

$38

02930

Prefabricated Stainless Steel (Primary) - Redo

$108

02931

Prefabricated Stainless Steel (Permanent) - Redo

$108

02932

Prefabricated Resin Crown

$144

02933

Prefabricated Stainless Steel Crown with Resin Window

Not Covered

02940

Sedative Filling

Not Covered

02950

Core Buildup, Including Any Pins

$34

02951

Pin Retention - per Tooth, in Addition to Restoration

Not Covered

02952

Cast Post and Core

$130

02954

Prefabricated Post and Core in Addition to Crown

$115

02960

Labial Veneer (Laminate) - Chairside

$288

02980

Crown Repair, Prior Authorization Required*

See Note Above*

ENDODONTICS
*Note:  Items with Prior Authorization Required:

Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed.

03110

Pulp Cap - Direct (Excluding Final Restoration)

$38

03120

Pulp Cap - Indirect

Not Covered

03220

Therapeutic Pulpotomy (In Addition to Restoration)

$78

03310

Anterior Root Canal (Excluding Final Restoration)

$370

03320

Bicuspid Root Canal (Excluding Final Restoration)

$419

03330

Molar Root Canal (Excluding Final Restoration)

$530

03346

Retreatment - Anterior, Prior Authorization Required*

$370*

03347

Retreatment - Bicuspid, Prior Authorization Required*

$419*

03348

Retreatment - Molar, Prior Authorization Required*

$530*

03351

Apexification/Recalcification Initial Visit

$144

03352

Apexification/Recalcification Each Interim Visit

$144

03353

Apexification/Recalcification Final Visit

$144

03410

Apicoectomy (Separate) - Anterior

$444

03421

Apicoectomy/Peri Surgery - Bicuspid (1st Root)

$444

03425

Apicoectomy/Peri Surgery - Molar (1st Root)

$494

03426

Apicoectomy/Peri Surgery - Each Additional Root

Not Covered

03430

Retrograde Filling - per Root

$134

03940

Recalcification (Caoh, Temp. Restoration) per Tooth (not a procedure)

Not Covered

PERIODONTICS
*Note:  Items with Prior Authorization Required:

Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed.

04210

Gingivectomy or Gingivoplasty - per Quadrant

$226

04211

Gingivectomy/Gingivoplasty - per Tooth (Less than 6 Teeth)

$134

04220

Gingival Curettage, per Quad (2 Quadrants Maximum per Visit)

$125

04240

Gingival Flap Procedure, Including Root Planning per Quad.

Not Covered

04249

Clinical Crown Lengthening - Hard Tissue

$326

04260

Osseous or Muco-Gingival Surgery per Quad

$653

04271

Gingival Graft (Per Procedure)

Not Covered

04320

Provisional Splinting

Not Covered

04341

Scaling and Root Planning per Quadrant  (2 Quadrants Maximum per Visit)

$120

04355

Full Mouth Debridement to enable Comprehensive Period Evaluation

$239

04910

Periodontal Maintenance Procedure

$82

PROSTHODONTICS
*Note:  Items with Prior Authorization Required:

Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed.

05110

Complete Maxillary Denture

$544

05120

Complete Mandibular Denture

$566

05130/05140

Immediate Denture Upper/Lower

$566

05211/05212

Partial Acrylic Upper or Lower with Chrome Cobalt Alloy Clasps

$482

05213

Partial Upper - Cast Metal Framework

$870

05214

Partial Lower - Cast Metal Framework

$870

05410-05422

Denture Adjustments (Upper or Lower)

$18

05510

Complete Denture Repair (No Teeth Involved)

$70

05520

Complete Denture Repair, Replace Missing or Broken Teeth

$65

05610

Partial Repair Resin Denture Base

$70

05620

Denture Repair - Replace Teeth

$130

05630

Partial Denture Repair, Replace Broken Clasps - Extra (Maximum 2)

$115

05640

Replace Broken Teeth per Tooth - Partial Denture

$65

05650

Add Tooth to Existing Partial Denture

$94

05660

Add Clasp to Existing Partial Denture

$151

05710

Rebase Complete Maxillary Denture

$240

05711

Rebase Complete Mandibular Denture

$240

05720

Rebase Maxillary Partial Denture

$240

05721

Rebase Mandibular Partial Denture

$240

05730

Reline Complete Maxillary Denture, Chairside

$101

05731

Reline Complete Mandibular Denture, Chairside

$101

05740

Reline Maxillary Partial Denture, Chairside

$101

05741

Reline Mandibular Partial Denture, Chairside

$101

05750

Maxillary Denture Reline, Laboratory

$202

05751

Mandibular Denture Reline, Laboratory

$202

05760

Reline Maxillary Partial Denture (Lab)

$202

05761

Reline Mandibular Partial Denture (Lab)

$202

05820

Stayplate, Including Teeth and Clasps

$218

05850/05851

Special Tissue Conditioning, per Denture Unit Upper/Lower

$58

05976

Implant

Not Covered

BRIDGES AND PONTICS
Plus additional cost of noble metal (gold) when used.
*Note:  Items with Prior Authorization Required:

Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed.

06210

Pontic - Cast High Noble Metal

$403

06211

Pontic - Cast Predominantly Base Metal

$400

06212

Pontic - Cast Noble Metal

$400

06240

Pontic - Porcelain Fused to High Noble Metal

$403

06241

Pontic - Porcelain Fused to Predominantly Base Metal

$400

06242

Pontic - Porcelain Fused to Noble Metal

$426

06251

Pontic - Resin with Predominantly Base Metal

Not Covered

06252

Pontic - Resin with Noble Metal

Not Covered

06720

Crown - Resin with High Noble Metal

Not Covered

06721

Crown - Resin with Predominantly Base Metal

Not Covered

06722

Crown - Resin with Noble Metal

Not Covered

06750

Crown - Porcelain Fused to High Noble Metal

$606

06751

Crown - Porcelain Fused to Predominantly Base Metal

$606

06752

Crown - Porcelain Fused to Noble Metal

$606

06780

Crown - 3/4 Cast High Noble Metal

$606

06790

Crown - Full Cast High Noble Metal

$606

06791

Crown - Full Cast Predominantly Base Metal

$606

06792

Crown - Full Cast Noble Metal

$606

06930

Recement Bridge

$59

06940

Simple Stress Breaker

$144

06970

Cast Post and Core in Addition to Bridge Retainer

$130

06971

Cast Post as Part of Bridge Retainer

Not Covered

06972

Prefab. Post and Core in Addition to Bridge Retainer

Not Covered

06973

Core Buildup for Retainer Including Any Pins

Not Covered

06980

Bridge Repairs

$137

ORAL SURGERY
*Note:  Items with Prior Authorization Required:

Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed.

07110

Single Tooth Extraction, Uncomplicated

$52

07120

Each Additional Tooth Extracted

$48

07130

Root Removal - Exposed Roots

$90

07210

Surgical Removal of Erupted Tooth (Flap & Sut.)

$91

07220

Removal of Impacted Tooth - Soft Tissue

$113

07230

Removal of Impacted Tooth - Partially Bony

$142

07240

Removal of Impacted Tooth - Completely Bony

$173

07241

Removal of Impacted Tooth - Completely Bony with Unusual Surgical Complications

$209

07250

Surgical Removal of Residual Tooth Roots

$91

07260

Closure of Oral Fistula of Maxillary Sinus

$403

07272

Transplantation of Tooth or Tooth Bud

$154

07280

Crown Exposure for Orthodontia

$173

07285

Biopsy of Oral Tissue - Hard

$163

07286

Biopsy of Oral Tissue - Soft

$115

07310

Alveoplasty in Conjunction with Extractions - Per Quad

Not Covered

07320

Alveoplasty Not in Conjunction with Extractions

$245

07440

Excision of Malignant Tumor, Prior Authorization Required*

See Note Above*

07451

Excision of Cyst or Tumor Greater than 1.25 cm Diameter

$281

07471

Removal of Exostosis, Maxillary or Mandibular

$281

07490

Radical Resection of Bone for Tumor with Bone Graft, Prior Authorization Required*

See Note Above*

07510

Intra-Oral Incision and Drainage of Abscess

$68

07520

Extra-Oral Incision and Drainage of Abscess

$90

07530

Incision and Removal of Foreign Body from Soft Tissue, Prior Authorization Required*

See Note Above*

07540

Removal of Foreign Body from Musculoskeletal System, Prior Authorization Required*

See Note Above*

07550

Sequestomy for Osteomyletitis, Prior Authorization Required*

See Note Above*

07560

Maxillary Sinusotomy for Removal of Tooth Fragment

$612

07840

Condylectomy of Temporomandibular Joint

$842

07850

Meniscectomy of Temporomandibular Joint

$842

07910

Suture of Soft Tissue Wound or Injury, Prior Authorization Required*

See Note Above*

07960

Frenectomy

$170

07970

Excision of Hyper Plastic Tissue per Arch

$148

07971

Excision of Pericoronal Gingiva

$97

07980

Sialolithotomy

$281

07981

Removal of Salivary Gland

$612

07982

Dilation of Salivary Duct

Not Covered

07983

Closure of Salivary Fistula

$252

ADJUNCTIVE GENERAL SERVICES/MISCELLANEOUS
*Note:  Items with Prior Authorization Required:

Service or procedure must be reviewed and approved by Allied Administrators in advance of service or procedure being performed.

08210

Removable Appliance Therapy

$336

08220

Fixed or Cemented Appliance Therapy

$336

09110

Emergency Treatment Palliative per Visit

$72

08212

Trigeminal Division Block Anesthesia

$77

09215

Local Anesthesia

Not Covered

09220

Anesthesia General

$192

09310

Consultation (Diagnostic Service Provided by Dentist Other than Practitioner Providing Treatment)

$58

09430

Post Operative Visit

$38

09440

Office Visit after Regularly Scheduled Hours

$77

09610

General Dentists/Specialists

See Note Above*

09940

Therapeutic Drug Injection, Prior Authorization Required*

$150

09951

Occlusal Guard

$58

09952

Correction of Occlusion, Limited - Per Quad (Maximum 2)

Not Covered

09999

Correction of Occlusion, Complete
Broken Appointments - less than 24-Hour Notice, per 15 Min.
 Broken Appointment Maximums:
 Sealant
 Prophylaxis  Any Other Appointment

Not Covered