178797V1 - Active SPD - Final Version
CALIFORNIA IRONWORKERS FIELD WELFARE PLAN
DENTAL fEE Schedule
CDT-4Procedure
Code / DESCRIPTION / Allowance
DIAGNOSTIC
0120 / Periodic oral evaluation / $23.00
0140 / Limited oral evaluation - problem focused / 32.00
0150 / Comprehensive oral evaluation - new or established patient / 40.00
0160 / Detailed & extensive oral evaluation - problem focused, by report / BR
0210 / Intraoral - complete series (including bitewings) / 60.00
0220 / Intraoral - periapical first film / 12.00
0230 / Intraoral - periapical each additional film / 10.00
0240 / Intraoral occlusal film / 20.00
0250 / Extraoral first film / 32.00
0260 / Extraoral each additional film / 26.00
0270 / Bitewing - single film / 12.00
0272 / Bitewings - two films / 20.00
0274 / Bitewings - four films / 29.00
0290 / Posterior-anterior or lateral skull and facial bone survey film / 64.00
0310 / Sialography / 111.00
0320 / Temporomandibular joint arthrogram, including injection / Not Covered
0321 / Other temporomandibular joint films, by report / Not Covered
0322 / Tomographic survey / 119.00
0330 / Panoramic film / 50.00
0340 / Cephalometric film / 65.00
0415 / Bacteriological studies for determination of pathologic agents / 68.00
0425 / Caries susceptibility tests / 47.00
0460 / Pulp vitality tests / 27.00
0470 / Diagnostic casts / 47.00
0471 / Diagnostic Photographs / 32.00
0472 / Accession of tissue, gross examination, preparation and transmission of written report / 97.00
0502 / Other oral pathology procedures, by report / 77.00
0999 / Unspecified diagnostic procedure, by report / BR
PREVENTIVE CARE
1110 / Prophylaxis – adult / 43.00
1120 / Prophylaxis – child / 32.00
1201 / Topical application of fluoride (including prophylaxis) - child / 43.00
1203 / Topical application of fluoride (not including prophylaxis) - child / 17.00
1204 / Topical application of fluoride (not including prophylaxis) - adult / 19.00
1205 / Topical application of fluoride (including prophylaxis) - adult / 54.00
1310 / Nutritional counseling for the control of dental disease / Not Covered
1320 / Tobacco counseling for the control and prevention of oral disease / Not Covered
1330 / Oral hygiene instructions / Not Covered
1351 / Sealant - per tooth / 25.00
1510 / Space maintainer - fixed – unilateral / 151.00
1515 / Space maintainer - fixed – bilateral / 214.00
1520 / Space maintainer - removable – unilateral / 204.00
1525 / Space maintainer - removable – bilateral / 248.00
1550 / Recementation of space maintainer / 37.00
RESTORATIVE
2140 / Amalgam - one surface, primary or permanent / 52.00
2150 / Amalgam - two surfaces, primary or permanent / 64.00
2160 / Amalgam - three surfaces, primary or permanent / 77.00
2161 / Amalgam - four or more surfaces, primary or permanent / 90.00
2330 / Resin-based composite - one surface, anterior / 65.00
2331 / Resin-based composite - two surfaces, anterior / 86.00
2332 / Resin-based composite - three surfaces, anterior / 105.00
2335 / Resin-based composite - four or more surfaces involving incisal angle, anterior / 116.00
2390 / Resin-based composite crown, anterior / 131.00
2391 / Resin-based composite - one surface, posterior / 72.00
2392 / Resin-based composite - two surfaces, posterior / 105.00
2393 / Resin-based composite - three surfaces, posterior / 132.00
2394 / Resin-based composite - four surfaces, posterior / 132.00
2410 / Gold foil - one surface / 293.00
2420 / Gold foil - two surfaces / 360.00
2430 / Gold foil - three surfaces / 375.00
2510 / Inlay - metallic - one surface / 350.00
2520 / Inlay - metallic - two surfaces / 389.00
2530 / Inlay - metallic - three or more surfaces / 435.00
2542 / Onlay- metallic - two surfaces / 421.00
2543 / Onlay- metallic - three surfaces / 442.00
2544 / Onlay- metallic - four or more surfaces / 462.00
2610 / Inlay, porcelain/ceramic - one surface / 365.00
2620 / Inlay - porcelain/ceramic - two surfaces / 380.00
2630 / Inlay - porcelain/ceramic - three or more surfaces / 413.00
2642 / Onlay-porcelain/ceramic-two surfaces / 472.00
2643 / Onlay-porcelain/ceramic-three surfaces / 437.00
2644 / Onlay-porcelain/ceramic-four or more surfaces / 476.00
2650 / Inlay-resin based composite - one surface / 326.00
2651 / Inlay-resin based composite -two surfaces / $345.00
2652 / Inlay-resin based composite -three or more surfaces / 365.00
2662 / Onlay-resin based composite -two surfaces / 423.00
2663 / Onlay-resin based composite -three surfaces / 413.00
2664 / Onlay-resin based composite -four or more surfaces / 437.00
2710 / Crown resin (indirect) / 292.00
2720 / Crown - resin with high noble metal / 457.00
2721 / Crown-resin with predominantly base metal / 447.00
2722 / Crown-resin with noble metal / 462.00
2740 / Crown - porcelain/ceramic substrate / 437.00
2750 / Crown - porcelain fused to high noble metal / 472.00
2751 / Crown - porcelain fused to predominantly base metal / 428.00
2752 / Crown - porcelain fused to noble metal / 462.00
2780 / Crown 3/4 cast noble metal / 452.00
2790 / Crown - full cast high noble metal / 462.00
2791 / Crown - full cast predominantly base metal / 423.00
2792 / Crown - full cast noble metal / 437.00
2910 / Recement Inlay / 41.00
2920 / Recement Crown / 41.00
2930 / Prefabricated stainless steel - primary tooth / 117.00
2931 / Prefabricated stainless steel, permanent tooth / 141.00
2932 / Prefabricated resin crown / 141.00
2933 / Prefabricated stainless steel crown with resin window / 166.00
2940 / Sedative filling / 44.00
2950 / Core build-up, including any pins / 112.00
2951 / Pin retention-per tooth, in addition to restoration / 49.00
2952 / Cast post and core in addition to crown / 185.00
2954 / Prefabricated post and core in addition to crown / 141.00
2955 / Post removal (not in conjunction with endodontic therapy) / 117.00
2960 / Labial veneer (laminate)-chair side / Not Covered
2961 / Labial veneer (resin laminate) – laboratory / Not Covered
2962 / Labial veneer (porcelain laminate) – laboratory / Not Covered
2970 / Temporary crown (fractured tooth) / B/R
2980 / Crown repair, by report / B/R
2999 / Unspecified restorative procedure, by report / B/R
ENDODONTICS
3110 / Pulp cap - direct (excluding final restoration) / 38.00
3120 / Pulp cap - indirect (excluding final restoration) / 38.00
3220 / Therapeutic pulpotomy (excluding final restoration) / 73.00
3230 / Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) / $112.00
3240 / Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) / 136.00
3310 / Anterior (excluding final restoration) / 287.00
3320 / Bicuspid (excluding final restoration) / 335.00
3330 / Molar (excluding final restoration) / 434.00
3346 / Retreatment of previous root canal - anterior / 306.00
3347 / Retreatment of previous root canal - bicuspid / 350.00
3348 / Retreatment of previous root canal - molar / 463.00
3351 / Apexification/recalcification - initial visit / 146.00
3352 / Apexification/recalcification - interim medication replacement / 117.00
3353 / Apexification/recalcification - final visit / 190.00
3410 / Apicoectomy/periradicular surgery - anterior / 271.00
3421 / Apicoectomy/periradicular surgery-bicuspid (first root) / 306.00
3425 / Apicoectomy/periradicular surgery-molar (first root) / 330.00
3426 / Apicoectomy/periradicular surgery-molar (each additional root) / 156.00
3430 / Retrograde filling, per root / 136.00
3450 / Root amputation - per root / 214.00
3460 / Endodontic endosseous implant / 803.00
3470 / Intentional reimplantation (including necessary splinting) / 353.00
3910 / Surgical procedure for isolation of tooth with rubber dam / 98.00
3920 / Hemisection (including any root removal), not including root canal therapy / 194.00
3950 / Canal preparation and fitting of performed dowel or post / 119.00
3999 / Unspecified endodontic procedure, by report / B/R
PERIODONTICS
4210 / Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant / 325.00
4211 / Gingivectomy or gingivoplasty - one to three teeth, per quadrant / 101.00
4240 / Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant / 370.00
4249 / Clinical crown lengthening - hard tissue / 336.00
4260 / Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant / 496.00
4263 / Bone replacement graft -first site in quadrant / 567.00
4264 / Bone replacement graft -each additional site in quadrant / 330.00
4266 / Guided tissue regeneration - resorbable barrier, per site / 578.00
4267 / Guided tissue regeneration -nonresorbable barrier, per site 9includes membrane removal / 652.00
4270 / Pedicle soft tissue graft procedure / 391.00
4271 / Free soft tissue graft procedure (including donor site surgery) / 406.00
4320 / Provisional splinting - intracoronal / $233.00
4321 / Provisional splinting - extracoronal / 264.00
4341 / Periodontal scaling and root planing - four or more contiguous teeth or bounded teeth spaces per quadrant / 114.00
4381 / Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report / 124.00
4910 / Periodontic maintenance / 65.00
4920 / Unscheduled dressing change (by someone other than treating dentist) / 49.00
4999 / Unspecified periodontal procedure by report / B/R
PROSTHODONTICS (removable)
5110 / Complete denture - maxillary / 627.00
5120 / Complete denture - mandibular / 627.00
5130 / Immediate denture - maxillary / 680.00
5140 / Immediate denture - mandibular / 680.00
5211 / Maxillary partial denture - resin base / 520.00
5212 / Mandibular partial denture -resin base / 520.00
5213 / Maxillary partial denture - cast metal framework with resin denture bases / 676.00
5214 / Mandibular partial denture - cast metal framework with resin denture bases / 676.00
5281 / Removable unilateral partial denture -one piece cast metal / 466.00
5410 / Adjust complete denture - maxillary / 35.00
5411 / Adjust complete denture - mandibular / 35.00
5421 / Adjust partial denture - maxillary / 35.00
5422 / Adjust partial denture - mandibular / 35.00
5510 / Repair broken complete denture base / 81.00
5520 / Replace missing or broken teeth - complete denture (each tooth) / 68.00
5610 / Repair resin denture base / 84.00
5620 / Repair cast framework / 122.00
5630 / Repair or replace broken clasp / 109.00
5640 / Replace broken teeth - per tooth / 68.00
5650 / Add tooth to existing partial denture / 93.00
5660 / Add clasp to existing partial denture / 124.00
5710 / Rebase complete maxillary denture / 271.00
5711 / Rebase complete mandibular denture / 271.00
5720 / Rebase maxillary partial denture / 263.00
5721 / Rebase mandibular partial denture / 260.00
5730 / Reline complete maxillary denture (chair side) / 171.00
5731 / Reline complete mandibular denture (chair side) / 171.00
5740 / Reline maxillary partial denture (chair side) / 156.00
5741 / Reline mandibular partial denture (chair side) / 159.00
5750 / Reline complete maxillary denture (laboratory) / 226.00
5751 / Reline complete mandibular denture (laboratory) / $223.00
5760 / Reline maxillary partial denture (laboratory) / 221.00
5761 / Reline mandibular partial denture (laboratory) / 221.00
5810 / Interim complete denture (maxillary) / 389.00
5811 / Interim complete denture (mandibular) / 389.00
5820 / Interim partial denture (maxillary) / 311.00
5821 / Interim partial denture (mandibular) / 311.00
5850 / Tissue conditioning, maxillary / 86.00
5851 / Tissue conditioning, mandibular / 97.00
5860 / Overdenture-complete by, report / B/R
5861 / Overdenture-partial, by report / B/R
5862 / Precision attachment, by report / B/R
5899 / Unspecified removable prosthodontic procedure, by report / B/R
PROSTHODONTICS (fixed)
6210 / Pontic - cast high noble metal / 452.00
6211 / Pontic - cast predominantly base metal / 418.00
6212 / Pontic - cast noble metal / 437.00
6240 / Pontic - porcelain fused to high noble metal / 466.00
6241 / Pontic - porcelain fused to predominantly base metal / 423.00
6242 / Pontic - porcelain fused to noble metal / 437.00
6250 / Pontic - resin with high noble metal / 457.00
6251 / Pontic - resin with predominantly base metal / 423.00
6252 / Pontic - resin with noble metal / 447.00
6545 / Retainer-cast metal for resin bonded fixed prosthesis / 277.00
6602 / Inlay - cast high noble metal, two surfaces / 350.00
6603 / Inlay - cast high noble metal, three or more surfaces / 389.00
6610 / Onlay - cast high noble metal, two surfaces / 476.00
6611 / Onlay - cast high noble metal, three or more surfaces / 486.00
6720 / Crown - resin with high noble metal / 462.00
6721 / Crown - resin with predominantly base metal / 462.00
6722 / Crown - resin with noble metal / 452.00
6750 / Crown - porcelain fused to high noble metal / 472.00
6751 / Crown - porcelain fused to predominantly base metal / 433.00
6752 / Crown - porcelain fused to noble metal / 437.00
6780 / Crown - 3/4 cast high noble metal / 447.00
6790 / Crown - full cast high noble metal / 462.00
6791 / Crown - full cast predominately base metal / 418.00
6792 / Crown - full cast noble metal / 442.00
6920 / Connector bar / B/R
6930 / Recement fixed partial denture / 63.00
6940 / Stress breaker / $175.00
6950 / Precision attachment / 292.00
6970 / Cast post and core in addition to fixed partial denture retainer / 185.00
6971 / Cast post as part of a fixed partial denture retainer / 185.00
6972 / Prefabricated post & core in addition to fixed partial denture retainer / 136.00
6973 / Core build up for retainer, including any pins / 117.00
6975 / Coping - metal / 316.00
6980 / Fixed partial denture repair, by report / 170.00
6999 / Unspecified fixed prosthodontic procedure, by report / B/R
ORAL SURGERY
7111 / Coronal remnants - deciduous tooth / 59.00
7140 / Extraction, erupted tooth or exposed root (elevation and/or forceps removal) / 81.00
7210 / Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth / 113.00
7220 / Removal of impacted tooth - soft tissue / 127.00
7230 / Removal of impacted tooth - partially bony / 175.00
7240 / Removal of impacted tooth - completely bony / 209.00
7241 / Removal of impacted tooth - completely bony, with unusual surgical complications / 257.00
7250 / Surgical removal of residual tooth roots / 126.00
7260 / Oroantral fistula closure / 462.00
7270 / Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth / 229.00
7272 / Tooth transplantation (includes reimplantation form one site to another and splinting and/or stabilization) / 350.00
7280 / Surgical access of an unerupted tooth / 194.00
7281 / Surgical exposure of impacted or unerupted tooth to aid eruption / 141.00
7285 / Biopsy of oral tissue - hard (bone, tooth) / 156.00
7286 / Biopsy of oral tissue - soft (all others) / 126.00
7290 / Surgical repositioning of teeth / 229.00
7291 / Transseptal fiberotomy/supra crestal fiberotomy, by report / 169.00
7310 / Alveoplasty in conjunction with extractions - per quadrant / 126.00
7320 / Alveoplasty not in conjunction with extractions - per quadrant / 190.00
7340 / Vestibuloplasty - ridge extension (secondary epithelialization) / B/R
7350 / Vestibuloplasty - ridge extension (including grafts) / B/R
7410 / Excision of benign lesion up to 1.25 cm / 204.00
7411 / Excision of benign lesion greater than 1.25 cm / 267.00
7414 / Excision of malignant lesion up to 1.25 cm / B/R
7415 / Excision of malignant tumor greater than 1.25 cm / B/R
7450 / Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm / 272.00
7451 / Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm / $409.00
7460 / Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm / 306.00
7461 / Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm / 476.00
7465 / Destruction of lesion(s) by physical or chemical methods, by report / 156.00
7472 / Removal of torus palatinus / 277.00
7473 / Removal of torus mandibularis / 277.00
7490 / Radical resection of mandible with bone graft / B/R
7510 / Incision and drainage of abscess, intraoral soft tissue / 86.00
7520 / Incision and drainage of abscess, extraoral soft tissue / 166.00
7530 / Removal of foreign body from mucosa, skin or subcutaneous alveolar tissue / 126.00
7540 / Removal of reaction producing foreign bodies, musculoskeletal system / 320.00
7550 / Partial ostectomy/sequestrectomy for removal of non-vital bone / 253.00
7560 / Maxillary sinusotomy for removal of tooth fragment or foreign body / B/R
7610 / Maxilla - open reduction (teeth immobilized, if present) / B/R
7620 / Maxilla - closed reduction (teeth immobilized, if present) / B/R
7630 / Mandible - open reduction (teeth immobilized, if present) / B/R
7640 / Mandible - closed reduction (teeth immobilized, if present) / B/R
7650 / Malar and/or zygomatic arch - open reduction / B/R
7660 / Malar and/or zygomatic arch - closed reduction / B/R
7670 / Alveolus - closed reduction, may include stabilization of teeth / B/R
7680 / Facial bones - complicated reduction with fixation and multiple surgical approaches / B/R
7770 / Alveolus - open reduction stabilization of teeth / B/R
7830 / Manipulation under anesthesia / B/R
7960 / Frenulectomy (frenectomy or frenotomy) - separate procedure / 175.00
7970 / Excision of hyperplastic tissue - per arch / 233.00
ADJUNCTIVE GENERAL SERVICES
9110 / Palliative (emergency) treatment of dental pain - minor procedure / 53.00
9212 / Trigeminal division block anesthesia / 123.00
9215 / Local anesthesia / 29.00
9220 / Deep sedation/general anesthesia - first 30 minutes / 190.00
9221 / Deep sedation/general anesthesia - each additional 15 minutes / 68.00
9310 / Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) / 52.00
9420 / Hospital call / 83.00
9430 / Office visit for observation (during regular office hours) - no other services performed / 32.00
9440 / Office visit - after regularly scheduled hours / 59.00
9910 / Application of desensitizing Medicament / Not Covered
9920 / Behavior management, by report / $63.00
9930 / Treatment of complications (post-surgical) - unusual circumstances, by report / 70.00
9940 / Occlusal guard, by report / 282.00
9941 / Fabrication of athletic mouthguard / 119.00
9950 / Occlusion analysis - mounted case / 146.00
9951 / Occlusal Adjustment - limited / 73.00
9952 / Occlusal adjustment - complete / 306.00
9970 / Enamel microabrasion / 89.00
9999 / Unspecified Adjunctive Procedure, by report / B/R
1
California Ironworkers Field Welfare Plan for Active Employees and Their Eligible Dependents