IBEW-NECA

*ADA Procedure Code*	*PROCEDURE OR SERVICE*	*Maximum Benefit Payable Per Procedure*
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.
00120 00140 00150 00210 00220 00230 00240 00250 00260 00270 00272 00274 00321 00330 00460 00470 By Report	Periodic Oral Examination, once every 12 months Limited Oral Evaluation, once every 12 months Comprehensive Oral Examination, once every 12 months Intraoral - Complete Series (Including Bitewings) Intraoral - Periapical - First Film/Single Film Intraoral - Periapical - Each Additional Film Intraoral - Occlusal Film Extra-Oral - First Film Extra-Oral - Each Additional Film Bitewings - Single Film Bitewings - Two Films Bitewings - Four Films Temporomandibular Joint Film Panorex Pulp Vitality Tests Diagnostic Casts (Study Models) Exam - 4 Bitewings & 2 PA	$36 $42 $54 $84 $22 $14 $36 $58 $54 $24 $30 $42 Not Covered $66 Not Covered Individually but Covered When a Root Canal Is Performed. $60 $82
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.
01110 01120 01201 01203 01330 01351 01510 01515 01520/01525	Prophylaxis - Adult – Each 6 Months and with a letter of medical necessity a cleaning is allowed every 3 months Prophylaxis - Children to Age 14 Topical Application of Fluoride (Including Prophylaxis) under Age 17 Topical Application of Fluoride (Excluding Prophylaxis) Child Oral Hygiene Instructions Sealant per Tooth, Under Age 16 Space Maintainer - Fixed Unilateral Space Maintainer - Fixed Bilateral Space Maintainer - Removable - Unilateral, Bilateral	$65 $53 $60 Not Covered Not Covered $30 $212 $300 $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 02120 02130 02131 02140 02150 02160 02161 02330 02331 02332 02335 02336 02380	Amalgam - One Surface, Primary Amalgam - Two Surfaces, Primary Amalgam - Three Surfaces, Primary Amalgam - Four or More Surfaces, Primary Amalgam - One Surface, Permanent Amalgam - Two Surfaces, Permanent Amalgam - Three Surfaces, Permanent Amalgam - Four or More Surfaces, Permanent Resin - One Surface, Anterior Resin - Two Surfaces, Anterior Resin - Three Surfaces, Anterior Resin - Four or More Surfaces or Involving Incisal Angle (Anterior) Composite Resin Crown - Anterior - Primary Resin - One Surface - Posterior Primary	$54 $68 $77 $82 $70 $79 $91 $100 $77 $115 $130 $134 Not Covered 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 02520 02530 02543 02544 02740 02750 02751 02752 02790 02791 02792 02780 02910 02920 02930 02931 02932 02933 02940 02950 02951 02952 02954 02960 02980	Inlay - Metallic - One Tooth Surface Inlay - Metallic - Two Tooth Surfaces Inlay - Metallic - Three or More Surfaces Onlays - Metallic 3 Surfaces Onlays - Metallic 4 or More Surfaces Porcelain, Ceramic Substrate Porcelain Fused to High Noble Metal Porcelain Fused to Predominantly Base Metal Porcelain Fused to Noble Metal Full Cast Crown High Noble Metal Full Cast Predominantly Base Metal Full Cast Noble Metal 3/4 Cast High Noble Metal Recement Inlay Recement Crown Prefabricated Stainless Steel (Primary) - Redo Prefabricated Stainless Steel (Permanent) - Redo Prefabricated Resin Crown Prefabricated Stainless Steel Crown with Resin Window Sedative Filling Core Buildup, Including Any Pins Pin Retention - per Tooth, in Addition to Restoration Cast Post and Core Prefabricated Post and Core in Addition to Crown Labial Veneer (Laminate) - Chairside Crown Repair, Prior Authorization Required*	Not Covered Not Covered $336 $432 $504 Not Covered $606 $606 $606 $606 $606 $606 $606 $40 $38 $108 $108 $144 Not Covered Not Covered $34 Not Covered $130 $115 $288 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 03120 03220 03310 03320 03330 03346 03347 03348 03351 03352 03353 03410 03421 03425 03426 03430 03940	Pulp Cap - Direct (Excluding Final Restoration) Pulp Cap - Indirect Therapeutic Pulpotomy (In Addition to Restoration) Anterior Root Canal (Excluding Final Restoration) Bicuspid Root Canal (Excluding Final Restoration) Molar Root Canal (Excluding Final Restoration) Retreatment - Anterior, Prior Authorization Required* Retreatment - Bicuspid, Prior Authorization Required* Retreatment - Molar, Prior Authorization Required* Apexification/Recalcification Initial Visit Apexification/Recalcification Each Interim Visit Apexification/Recalcification Final Visit Apicoectomy (Separate) - Anterior Apicoectomy/Peri Surgery - Bicuspid (1st Root) Apicoectomy/Peri Surgery - Molar (1st Root) Apicoectomy/Peri Surgery - Each Additional Root Retrograde Filling - per Root Recalcification (Caoh, Temp. Restoration) per Tooth (not a procedure)	$38 Not Covered $78 $370 $419 $530 $370* $419* $530* $144 $144 $144 $444 $444 $494 Not Covered $134 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 04211 04220 04240 04249 04260 04271 04320 04341 04355 04910	Gingivectomy or Gingivoplasty - per Quadrant Gingivectomy/Gingivoplasty - per Tooth (Less than 6 Teeth) Gingival Curettage, per Quad (2 Quadrants Maximum per Visit) Gingival Flap Procedure, Including Root Planning per Quad. Clinical Crown Lengthening - Hard Tissue Osseous or Muco-Gingival Surgery per Quad Gingival Graft (Per Procedure) Provisional Splinting Scaling and Root Planning per Quadrant (2 Quadrants Maximum per Visit) Full Mouth Debridement to enable Comprehensive Period Evaluation Periodontal Maintenance Procedure	$226 $134 $125 Not Covered $326 $653 Not Covered Not Covered $120 $239 $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 05120 05130/05140 05211/05212 05213 05214 05410-05422 05510 05520 05610 05620 05630 05640 05650 05660 05710 05711 05720 05721 05730 05731 05740 05741 05750 05751 05760 05761 05820 05850/05851 05976	Complete Maxillary Denture Complete Mandibular Denture Immediate Denture Upper/Lower Partial Acrylic Upper or Lower with Chrome Cobalt Alloy Clasps Partial Upper - Cast Metal Framework Partial Lower - Cast Metal Framework Denture Adjustments (Upper or Lower) Complete Denture Repair (No Teeth Involved) Complete Denture Repair, Replace Missing or Broken Teeth Partial Repair Resin Denture Base Denture Repair - Replace Teeth Partial Denture Repair, Replace Broken Clasps - Extra (Maximum 2) Replace Broken Teeth per Tooth - Partial Denture Add Tooth to Existing Partial Denture Add Clasp to Existing Partial Denture Rebase Complete Maxillary Denture Rebase Complete Mandibular Denture Rebase Maxillary Partial Denture Rebase Mandibular Partial Denture Reline Complete Maxillary Denture, Chairside Reline Complete Mandibular Denture, Chairside Reline Maxillary Partial Denture, Chairside Reline Mandibular Partial Denture, Chairside Maxillary Denture Reline, Laboratory Mandibular Denture Reline, Laboratory Reline Maxillary Partial Denture (Lab) Reline Mandibular Partial Denture (Lab) Stayplate, Including Teeth and Clasps Special Tissue Conditioning, per Denture Unit Upper/Lower Implant	$544 $566 $566 $482 $870 $870 $18 $70 $65 $70 $130 $115 $65 $94 $151 $240 $240 $240 $240 $101 $101 $101 $101 $202 $202 $202 $202 $218 $58 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 06211 06212 06240 06241 06242 06251 06252 06720 06721 06722 06750 06751 06752 06780 06790 06791 06792 06930 06940 06970 06971 06972 06973 06980	Pontic - Cast High Noble Metal Pontic - Cast Predominantly Base Metal Pontic - Cast Noble Metal Pontic - Porcelain Fused to High Noble Metal Pontic - Porcelain Fused to Predominantly Base Metal Pontic - Porcelain Fused to Noble Metal Pontic - Resin with Predominantly Base Metal Pontic - Resin with Noble Metal Crown - Resin with High Noble Metal Crown - Resin with Predominantly Base Metal Crown - Resin with Noble Metal Crown - Porcelain Fused to High Noble Metal Crown - Porcelain Fused to Predominantly Base Metal Crown - Porcelain Fused to Noble Metal Crown - 3/4 Cast High Noble Metal Crown - Full Cast High Noble Metal Crown - Full Cast Predominantly Base Metal Crown - Full Cast Noble Metal Recement Bridge Simple Stress Breaker Cast Post and Core in Addition to Bridge Retainer Cast Post as Part of Bridge Retainer Prefab. Post and Core in Addition to Bridge Retainer Core Buildup for Retainer Including Any Pins Bridge Repairs	$403 $400 $400 $403 $400 $426 Not Covered Not Covered Not Covered Not Covered Not Covered $606 $606 $606 $606 $606 $606 $606 $59 $144 $130 Not Covered Not Covered Not Covered $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 07120 07130 07210 07220 07230 07240 07241 07250 07260 07272 07280 07285 07286 07310 07320 07440 07451 07471 07490 07510 07520 07530 07540 07550 07560 07840 07850 07910 07960 07970 07971 07980 07981 07982 07983	Single Tooth Extraction, Uncomplicated Each Additional Tooth Extracted Root Removal - Exposed Roots Surgical Removal of Erupted Tooth (Flap & Sut.) Removal of Impacted Tooth - Soft Tissue Removal of Impacted Tooth - Partially Bony Removal of Impacted Tooth - Completely Bony Removal of Impacted Tooth - Completely Bony with Unusual Surgical Complications Surgical Removal of Residual Tooth Roots Closure of Oral Fistula of Maxillary Sinus Transplantation of Tooth or Tooth Bud Crown Exposure for Orthodontia Biopsy of Oral Tissue - Hard Biopsy of Oral Tissue - Soft Alveoplasty in Conjunction with Extractions - Per Quad Alveoplasty Not in Conjunction with Extractions Excision of Malignant Tumor, Prior Authorization Required* Excision of Cyst or Tumor Greater than 1.25 cm Diameter Removal of Exostosis, Maxillary or Mandibular Radical Resection of Bone for Tumor with Bone Graft, Prior Authorization Required* Intra-Oral Incision and Drainage of Abscess Extra-Oral Incision and Drainage of Abscess Incision and Removal of Foreign Body from Soft Tissue, Prior Authorization Required* Removal of Foreign Body from Musculoskeletal System, Prior Authorization Required* Sequestomy for Osteomyletitis, Prior Authorization Required* Maxillary Sinusotomy for Removal of Tooth Fragment Condylectomy of Temporomandibular Joint Meniscectomy of Temporomandibular Joint Suture of Soft Tissue Wound or Injury, Prior Authorization Required* Frenectomy Excision of Hyper Plastic Tissue per Arch Excision of Pericoronal Gingiva Sialolithotomy Removal of Salivary Gland Dilation of Salivary Duct Closure of Salivary Fistula	$52 $48 $90 $91 $113 $142 $173 $209 $91 $403 $154 $173 $163 $115 Not Covered $245 See Note Above* $281 $281 See Note Above* $68 $90 See Note Above* See Note Above* See Note Above* $612 $842 $842 See Note Above* $170 $148 $97 $281 $612 Not Covered $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 08220 09110 08212 09215 09220 09310 09430 09440 09610 09940 09951 09952 09999	Removable Appliance Therapy Fixed or Cemented Appliance Therapy Emergency Treatment Palliative per Visit Trigeminal Division Block Anesthesia Local Anesthesia Anesthesia General Consultation (Diagnostic Service Provided by Dentist Other than Practitioner Providing Treatment) Post Operative Visit Office Visit after Regularly Scheduled Hours General Dentists/Specialists Therapeutic Drug Injection, Prior Authorization Required* Occlusal Guard Correction of Occlusion, Limited - Per Quad (Maximum 2) Correction of Occlusion, Complete Broken Appointments - less than 24-Hour Notice, per 15 Min. Broken Appointment Maximums: Sealant Prophylaxis Any Other Appointment	$336 $336 $72 $77 Not Covered $192 $58 $38 $77 See Note Above* $150 $58 Not Covered Not Covered