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See Frequently Asked Questions for more information about coverage, deductibles and more.
See Coverage for more information on what the Delta Plan covers.
Group Numbers: 6125, 6126, 6127
Maine Public Employees Retiree Program
February 1, 2011
Table of Allowances
Coverage A View Details
Diagnostic |
||
|---|---|---|
| Clinical Oral Evaluations | ||
| Procedure Code |
Description | Maximum Allowance |
| D0120 | periodic oral evaluation | $23 |
| D0140 | limited oral evaluation - problem focused | $49 |
| D0145 | oral evaluation for a patient under three years of age and counseling with primary caregiver | $37 |
| D0150 | comprehensive oral evaluation - new or established patient | $41 |
| D0170 | re-evaluation - limited, problem focused (established patient; not post-operative visit) | $49 |
| D0180 | comprehensive periodontal evaluation - new or established patient | $51 |
| Radiographs/Diagnostic Imaging (Including interpretation) | ||
| D0210 | intraoral - complete series (including bitewings) | $87 |
| D0220 | intraoral - periapical first film | $16 |
| D0230 | intraoral - periapical each additional film | $14 |
| D0240 | intraoral - occlusal film | $20 |
| D0250 | extraoral - first film | $16 |
| D0260 | extraoral - each additional film | $16 |
| D0270 | bitewing - single film | $16 |
| D0272 | bitewing - two films | $29 |
| D0273 | bitewings - three films | $35 |
| D0274 | bitewings - four films | $41 |
| D0277 | vertical bitewings - 7 to 8 films | $87 |
| D0330 | panaromic film | $76 |
Tests and Examinations |
||
| D0431 | adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures | $38 |
Preventive |
||
| Dental Prophylaxis | ||
| D1110 | prophylaxis - adult | $60 |
| D1120 | prophylaxis - child | $42 |
| Topical Fluoride Treatment (Office Procedure) | ||
| D1203 | topical application of fluoride - child | $23 |
| D1204 | topical application of fluoride - adult | $24 |
| D1206 | topical fluoride varnish; therapeutic application for moderate to high caries risk patients | $24 |
| Other Preventive Services | ||
| D1351 | sealant - per tooth | $31 |
| Space Maintenance (Passive Appliances) | ||
| D1510 | space maintainer - fixed - unilateral | $179 |
| D1515 | space maintainer - fixed - bilateral | $254 |
| D1520 | space maintainer - removable - unilateral | $215 |
| D1525 | space maintainer - removable - bilateral | $258 |
| D1555 | removal of fixed space maintainer | $38 |
| Non-Surgical Periodontal Service | ||
| D4355 | full mouth debridement to enable comprehensive evaluation and diagnosis | $81 |
Oral and Maxillofacial Surgery |
||
| Other Surgical Procedures | ||
| D17288 | brush biopsy - transepithelial sample collection | $90 |
Coverage B View Details
| Oral Pathology Laboratory | ||
|---|---|---|
| Procedure Code |
Description | Maximum Allowance |
| D0484 | consultation on slides prepares elsewhere | $50 |
| Space Maintenance (Passive Appliances) | ||
| D1550 | re-cementation of space maintainer | $38 |
Restorative |
||
| Amalgam Restorations (Including Polishing) | ||
| D2140 | amalgam - one surface, primary or permanent | $57 |
| D2150 | amalgam - two surfaces, primary of permanent | $73 |
| D2160 | amalgam - three surfaces, primary or permanent | $89 |
| D2161 | amalgam - four or more surfaces, primary or permanent | $109 |
| Resin-Based Composite Restorations - Direct | ||
| D2330 | resin-based composite - one surface, anterior | $68 |
| D1 | resin-based composite - two surfaces, anterior | $86 |
| D1 | resin-based composite - three surfaces, anterior | $105 |
| D1 | resin-based composite - four or more surfaces or involving incisal angle (anterior) | $130 |
| D1 | resin-based composite - crown, anterior | $330 |
| Other Restorative Services | ||
| D2910 | recement inlay, onlay, or partial coverage restoration | $49 |
| D2915 | recement cast or prefabricated post and core | $49 |
| D2920 | recement crown | $49 |
| D2930 | prefabricated stainless steel crown - primary tooth | $125 |
| D2931 | prefabricated stainless steel crown - permanent tooth | $155 |
| D2940 | sedative filling | $55 |
| D2951 | pin retention - per tooth, in addition to restoration | $31 |
| Pulp Capping | ||
| D3110 | pulb cap - direct (excluding final restoration) | $32 |
| D3120 | pulp cap - indirect (excluding final restoration) | $30 |
Endodontics |
||
| Pulpotomy | ||
| D3220 | therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament | $76 |
| D3221 | pulpal debridement, primary and permanent teeth | $76 |
| D3222 | partial pulpotomy for apexogenesis - permanent tooth with incomplete root development | $76 |
| Endodontic Therapy on Primary Teeth | ||
| D3240 | pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) | $76 |
| Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care | ||
| D3310 | endodontic therapy, anterior tooth (excluding final restoration) | $331 |
| D3320 | endodontic therapy, bicuspid tooth (excluding final restoration) | $419 |
| D3330 | endodontic therapy, molar (excluding final restoration) | $562 |
| D3333 | internal root repair of perforation defects | $227 |
| Endodontic Retreatment | ||
| D3346 | retreatment of previous root canal therapy - anterior | $432 |
| D3347 | retreatment of previous root canal therapy - bicuspid | $558 |
| D3348 | retreatment of previous root canal therapy - molar | $575 |
| Apexification/Recalcification Procedures | ||
| D3351 | apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) | $89 |
| D3352 | apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) | $89 |
| D3353 | apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) | $89 |
| Apicoectomy/Periradicular Services | ||
| D3410 | apicoectomy/periradicular surgery - anterior | $227 |
| D3421 | apicoectomy/periradicular surgery - bicuspid (first root) | $227 |
| D3425 | apicoectomy/periradicular surgery - molar (first root) | $227 |
| D3426 | apicoectomy/periradicular surgery (each additional root) | $116 |
| D3430 | retrograde filling - per root | $57 |
| D3450 | root amputation - per root | $171 |
| Other Endodontic Procedures | ||
| D3920 | hemisection (including any root removal), not including root canal therapy........................... | $174 |
Periodontics |
||
| Surgical Services (Including usual Postoperative Care) | ||
| D4210 | gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant | $266 |
| D4211 | gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant | $174 |
| D4240 | gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant | $322 |
| D4241 | gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant | $242 |
| D4245 | apically positioned flap | $386 |
| D4249 | clinical crown lengthening - hard tissue | $648 |
| D4260 | osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant | $450 |
| D4261 | osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant | $337 |
| D4263 | bone replacement graft - first site in quadrant | $157 |
| D4264 | bone replacement graft - each additional site in quadrant | $112 |
| D4270 | pedicle soft tissue graft procedure | $334 |
| D4271 | free soft tissue graft procedure (including donor site surgery) | $383 |
| D4273 | subepithelial connective tissue graft procedures, per tooth | $421 |
| D4274 | distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) | $225 |
| Non-Surgical Periodontal Service | ||
| D4341 | periodontal scaling and root planing - four or more contiguous teeth or bounded teeth spaces per quadrant | $112 |
| D4342 | periodontal scaling and root planing - one to three teeth per quadrant | $85 |
| Other Periodontal Service | ||
| D4910 | periodontal maintenance | $67 |
| D4920 | unscheduled dressing change (by someone other than treating dentist) | $43 |
Prosthodontics (Removable) |
||
| Adjustments to Dentures | ||
| D5410 | adjust complete denture - maxillary | $41 |
| D5411 | adjust complete denture - mandibular | $41 |
| D5421 | adjust partial denture - maxillary | $41 |
| D5422 | adjust partial denture - mandibular | $41 |
| Repairs to Complete Dentures | ||
| D5510 | repair broken complete denture base | $92 |
| D5520 | replace missing or broken teeth - complete denture (each tooth) | $85 |
| Repairs to Partial Dentures | ||
| D5610 | repair resin denture base | $87 |
| D5620 | repair cast framework | $134 |
| D5630 | repair or replace broken clasp | $119 |
| D5640 | replace broken teeth - per tooth | $81 |
Implant Services |
||
| Repairs to Partial Dentures | ||
| D6092 | recement implant/abutment supported crown ... ... | $49 |
Oral and Maxillofacial Surgery |
||
| Extractions (Includes local anesthesia, suturing, if needed, and routine postoperative care) | ||
| D7111 | extraction, coronal remnants - deciduous tooth | $18 |
| D7140 | extraction, erupted tooth or exposed root (elevation and/or forceps removal) | $72 |
| Surgical Extractions (Includes local anesthesia, suturing, if needed, and routine postoperative care) | ||
| D7210 | surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth | $122 |
| D7220 | removal of impacted tooth - soft tissue | $143 |
| D7230 | removal of impacted tooth - partially bony | $184 |
| D7240 | removal of impacted tooth - completely bony | $222 |
| D7241 | removal of impacted tooth - completely bony, with unusual surgical complication | $222 |
| D7250 | surgical removal of residual tooth roots (cutting procedure) | $122 |
| D7251 | coronectomy - intentional partial tooth removal | $222 |
| Other Surgical Procedures | ||
| D7270 | tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth | $174 |
| D7280 | surgical access of an unerupted tooth | $150 |
| D7282 | mobilization of erupted or malpositioned tooth to aid eruption | $107 |
| D7285 | biopsy of oral tissue - hard (bone, tooth) | $106 |
| D7286 | biopsy of oral tissue - soft (all others) | $92 |
| D7291 | transseptal fiberotomy/supra crestal fiberotomy | $163 |
| Alveoplasty - Surgical Preparation of Ridge | ||
| D7310 | alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant | $106 |
| D7311 | alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant | $80 |
| D7320 | alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant | $156 |
| D7321 | alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant | $117 |
| Vestibuloplasty | ||
| D7340 | vestibuloplasty - ridge extension (secondary epithelialization) | $197 |
| Vestibuloplasty | ||
| D7510 | incision and drainage of abscess - intraoral soft tissue | $81 |
| D7511 | incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) | $101 |
| D7520 | incision and drainage of abscess - extraoral soft tissue | $92 |
| D7521 | incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces) | $114 |
| Other Repair Procedures | ||
| D7960 | frenulectomy (frenectomy or frenotomy) - separate procedure | $163 |
| D7963 | frenuloplasty | $204 |
Adjunctive General Services |
||
| Unclassified Treatment | ||
| D9110 | palliative (emergency) treatment of dental pain - minor procedure | $57 |
| Anesthesia | ||
| D9220 | deep sedation/general anesthesia - first 30 minutes | $145 |
| D9221 | deep sedation/general anesthesia - each additional 15 minutes | $69 |
| D9241 | intravenous conscious sedation/analgesia - first 30 minutes | $138 |
| D9242 | intravenous conscious sedation/analgesia - each additional 15 minutes | $66 |
| Professional Consultation | ||
| D9310 | consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) | $50 |
| Professional Visit | ||
| D9440 | office visit - after regularly scheduled hours | $61 |
| Miscellaneous Services | ||
| D9910 | application of desensitizing medicament | $41 |
| D9911 | application of desensitizing resin for cervical and/or root surface, per tooth | $41 |
Coverage C View Details
Restorative |
||
|---|---|---|
| Procedure Code |
Description | Maximum Allowance |
| Inlay/Onlay Restorations | ||
| D2542 | onlay - metallic-two surfaces | $337 |
| D2543 | onlay - metallic-three surfaces | $374 |
| D2544 | onlay - metallic-four or more surfaces | $413 |
| Porcelain/Ceramic inlays/Onlays include all indeirect Ceramic and Porcelain type Inlays/Onlays | ||
| D2642 | onlay - porcelain/ceramic - two surfaces | $371 |
| D2643 | onlay - porcelain/ceramic - three surfaces | $413 |
| D2644 | onlay - porcelain/ceramic - four or more surfaces | $453 |
| Resin-Based Composite Inlays/Onlays must utilize indirect technique | ||
| D2662 | onlay - resin-based composite - two surfaces | $404 |
| D2663 | onlay - resin-based composite - three surfaces | $450 |
| D2664 | onlay - resin-based composite - four or more surfaces | $495 |
| Crowns - Single Restoration Only | ||
| D2710 | crown - resin-based composite (indirect) | $168 |
| D2712 | crown - % resin-based composite (indirect) | $168 |
| D2720 | crown - resin with high noble metal | $362 |
| D2721 | crown - resin with predominantly base metal | $326 |
| D2722 | crown - resin with noble metal | $362 |
| D2740 | crown - porcelain/ceramic substrate | $405 |
| D2750 | crown - porcelain fused to high noble metal | $426 |
| D2751 | crown - porcelain fused to predominantly base metal | $390 |
| D2752 | crown - porcelain fused to noble metal | $408 |
| D2780 | crown - % cast high noble metal | $426 |
| D2781 | crown - % cast predominantly base metal | $364 |
| D2782 | crown - % cast noble metal | $399 |
| D2783 | crown - % porcelain/ceramic | $405 |
| D2790 | crown - full cast high noble metal | $426 |
| D2791 | crown - full cast predominantly base metal | $364 |
| D2792 | crown - full cast noble metal | $399 |
| D2794 | crown - titanium | $426 |
| Other Restorative Services | ||
| D2932 | prefabricated resin crown | $105 |
| D2950 | core buildup, including any pins | $91 |
| D2952 | cast post and core in addition to crown | $134 |
| D2954 | prefabricated post and core in addition to crown | $109 |
| D2955 | post removal (not in conjunction with endodontic therapy) | $135 |
| D2970 | temporary crown (fractured tooth) | $94 |
| D2971 | additional procedures to construct new crown under existing partial denture framework | $85 |
| D2980 | crown repair | $42 |
Prosthodontics (Removable) |
||
| Complete Dentures (Including routine post-delivery care) | ||
| D5110 | complete denture - maxillary | $464 |
| D5120 | complete denture - mandibular | $464 |
| D5130 | immediate denture - maxillary | $498 |
| D5140 | immediate denture - mandibular | $498 |
| Partial Dentures (Including routine post-delivery care) | ||
| D5211 | maxillary partial denture - resin base (including any conventional clasps, rests and teeth) | $317 |
| D5212 | mandibular partial denture - resin base (including any conventional clasps, rests and teeth) | $317 |
| D5213 | maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $498 |
| D5214 | mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $498 |
| D5225 | maxillary partial denture - flexible base (including any clasps, rests and teeth) | $374 |
| D5226 | mandibular partial denture - flexible base (including any clasps, rests and teeth) | $374 |
| D5281 | removable unilateral partial denture - one piece cast metal (including clasps and teeth) | $264 |
| Repairs to Partial Dentures | ||
| D5650 | add tooth to existing partial denture | $62 |
| D5660 | add clasp to existing partial denture | $78 |
| D5670 | replace all teeth and acrylic on cast metal framework (maxillary) | $333 |
| D5671 | replace all teeth and acrylic on cast metal framework (mandibular) | $333 |
| Denture Rebase Procedures | ||
| D5710 | rebase complete maxillary denture | $168 |
| D5711 | rebase complete mandibular denture | $168 |
| D5720 | rebase maxillary partial denture | $157 |
| D5721 | rebase mandibular partial denture | $157 |
| Denture Reline Procedures | ||
| D5730 | reline complete maxillary denture (chairside) | $94 |
| D5731 | reline complete mandibular denture (chairside) | $94 |
| D5740 | reline maxillary partial denture (chairside) | $92 |
| D5741 | reline mandibular partial denture (chairside) | $92 |
| D5750 | reline complete maxillary denture (laboratory) | $145 |
| D5751 | reline complete mandibular denture (laboratory) | $145 |
| D5760 | reline maxillary partial denture (laboratory) | $137 |
| D5761 | reline mandibular partial denture (laboratory) | $137 |
| Other Removable Prosthetic Services | ||
| D5875 | modification of removable prosthesis following implant surgery | $162 |
Implant Services |
||
| Implant Supported Prosthetics | ||
| D6053 | implant/abutment supported removable denture for completely edentulous arch | $464 |
| D6054 | implant/abutment supported removable denture for partially edentulous arch | $498 |
| D6058 | abutment supported porcelain/ceramic crown | $576 |
| D6059 | abutment supported porcelain fused to metal crown (high noble metal) | $596 |
| D6060 | abutment supported porcelain fused to metal crown (predominantly base metal) | $559 |
| D6061 | abutment supported porcelain fused to metal crown (noble meta!) | $577 |
| D6062 | abutment supported cast metal crown (high noble metal) | $596 |
| D6063 | abutment supported cast metal crown (predominantly base metal) | $533 |
| D6064 | abutment supported cast metal crown (noble metal) | $569 |
| D6065 | implant supported porcelain/ceramic crown | $576 |
| D6066 | implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) | $596 |
| D6067 | implant supported metal crown (titanium, titanium alloy, high noble metal) | $596 |
| D6068 | abutment supported retainer for porcelain/ceramic FPD | $576 |
| D6069 | abutment supported retainer for porcelain fused to metal FPD (high noble metal) | $596 |
| D6070 | abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) | $559 |
| D6071 | abutment supported retainer for porcelain fused to metal FPD (noble metal) | $577 |
| D6072 | abutment supported retainer for cast metal FPD (high noble metal) | $593 |
| D6073 | abutment supported retainer for cast metal FPD (predominantly base metal) | $541 |
| D6074 | abutment supported retainer for cast metal FPD (noble metal) | $571 |
| D6075 | implant supported retainer for ceramic FPD | $576 |
| D6076 | implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) | $596 |
| D6077 | implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) | $596 |
| D6078 | implant/abutment supported fixed denture for completely edentulous arch | $929 |
| D6079 | implant/abutment supported fixed denture for partially edentulous arch | $997 |
| D6094 | abutment supported crown - (titanium) | $596 |
| D6194 | abutment supported retainer crown for FPD - (titanium) | $593 |
| Other Implant Services | ||
| D6093 | recement implant/abutment supported fixed partial denture | $43 |
Prosthodontics, Fixed |
||
| Fixed Partial Denture Pontics | ||
| D6205 | pontic - indirect resin based composite | $168 |
| D6210 | pontic - cast high noble metal | $422 |
| D6211 | pontic - cast predominantly base metal | $372 |
| D6212 | pontic - cast noble metal | $401 |
| D6214 | pontic - titanium | $422 |
| D6240 | pontic - porcelain fused to high noble metal | $426 |
| D6241 | pontic - porcelain fused to predominantly base metal | $385 |
| D6242 | pontic - porcelain fused to noble metal | $405 |
| D6245 | pontic - porcelain/ceramic | $405 |
| D6250 | pontic - resin with high noble metal | $374 |
| D6251 | pontic - resin with predominantly base metal | $312 |
| D6252 | pontic - resin with noble metal | $357 |
| Fixed Partial Retainers - Inlays/Onlays | ||
| D6545 | retainer - cast metal for resin bonded fixed prosthesis | $137 |
| D6548 | retainer - porcelain/ceramic for resin bonded fixed prosthesis | $150 |
| D6600 | inlay - porcelain/ceramic, two surfaces | $351 |
| D6601 | inlay - porcelain/ceramic, three or more surfaces | $417 |
| D6602 | inlay - cast high noble metal, two surfaces | $266 |
| D6603 | inlay - cast high noble metal, three or more surfaces | $304 |
| D6604 | inlay - cast predominantly base metal, two surfaces | $277 |
| D6605 | inlay - cast predominantly base metal, three or more surfaces | $317 |
| D6606 | inlay - cast noble metal, two surfaces | $285 |
| D6607 | inlay - cast noble metal, three or more surfaces | $327 |
| D6608 | onlay - porcelain/ceramic, two surfaces | $395 |
| D6609 | onlay - porce:lain/ceramic, three or more surfaces | $460 |
| D6610 | onlay - cast high noble metal, two surfaces | $337 |
| D6611 | onlay - cast high noble metal, three or more surfaces | $374 |
| D6612 | onlay - cast predominantly base metal, two surfaces | $413 |
| D6613 | onlay - cast predominantly base metal, three or more surfaces | $475 |
| D6614 | onlay - cast noble metal, two surfaces | $304 |
| D6615 | onlay - cast noble metal, three or more surfaces | $337 |
| D6624 | inlay - titanium | $304 |
| D6634 | on lay - titanium | $374 |
| Fixed Partial Denture Retainers - Crowns | ||
| D6710 | crown - indirect resin based composite | $168 |
| D6720 | crown - resin with high noble metal | $345 |
| D6721 | crown - resin with predominantly base metal | $308 |
| D6722 | crown - resin with noble metal | $370 |
| D6740 | crown - porcelain/ceramic | $405 |
| D6750 | crown - porcelain fused to high noble metal | $426 |
| D6751 | crown - porcelain fused to predominantly base metal | $390 |
| D6752 | crown - porcelain fused to noble metal | $408 |
| D6780 | crown - 3/4 cast high noble metal | $405 |
| D6781 | crown - 3/4 cast predominantly base metal | $364 |
| D6782 | crown - 3/4 cast noble metal | $399 |
| D6783 | crown - 3/4 porcelain/ceramic | $405 |
| D6790 | crown - full cast high noble metal | $423 |
| D6791 | crown - full cast predominantly base metal | $372 |
| D6792 | crown - full cast noble metal | $402 |
| D6794 | crown - titanium | $423 |
| Other Fixed Partial Denture Services | ||
| D6930 | recement fixed partial denture | $43 |
| D6970 | cast post and core in addition to fixed partial denture retainer | $135 |
| D6972 | prefabricated post and core in addition to fixed partial denture retainer | $109 |
| D6973 | core build up for retainer, including any pins | $91 |
| D6980 | fixed partial denture repair | $42 |
Adjunctive General Services |
||
| Other Repair Procedures | ||
| D9120 | fixed partial denture sectioning | $54 |
This program pays the least of the dentist's accepted fees, the fees actually charged, or the Maximum Allowances shown above. This Table of Allowances includes most dental procedures. If a dental procedure not listed in this Table of Allowances is performed on an eligible patient the Maximum Allowance for that procedure will be based upon the Maximum Allowances for similar procedures. (In no case will this program pay more than the Maximum Allowances shown above.)