General Dentistry Fee Schedule

Diagnostic

D0120
Periodic Exam
$25
D0140
Problem focused exam
$30
D0150
New or comprehensive exam
$45
D0180
Periodontal (including charting)
$47
Missed
Missed/Cancelled appt. w/o 48 hours notice
$50

Preventative

D0210
Full Mouth x-ray
$40
D0220-0230
Single x-ray, intraoral, periapical
$12
D0272
Bitewing x-ray, 2 films
$12
D0274
Bitewing x-rays, 4 films
$20
D0330
Panoramic x-ray
$45
D1110
Prophylaxis cleaning (Adult)
$39
D1120
Prophylaxis cleaning (Child)
$26
D1203-04
Flouride treatment (topical)
$16
D1351
Sealant-per tooth
$25
D1510
Space maintaner- fixed unilateral
$185
D1510
Space maintaner- fixed unilateral
$185
D1515
Space maintaner- fixed bilateral
$280
D1550
Recement Space Maintainer
$35

Restorative (Fillings)

D2330
Resin 1 surface-anterior
$78
D2331
Resin 2 surface-anterior
$93
D2332
Resin 3 surface-anterior
$130
D2335
Resin 4 or more surface-anterior
$175
D2391
Resin 1 surface-posterior
$88
D2392
Resin 2 surface-posterior
$120
D2393
Resin 3 surface-posterior
$140
D2394
Resin 4 surface-posterior
$225

Inlay/Onlay Restorations

D2620
Inlay-ceramic 2 surface
$550
D2630
Inlay-ceramic 3 or more surfaces
$604
D2642
Onlay-ceramic 2 surface
$570
D2643
Onlay-ceramic 3 surface
$650
D2644
Onlay -ceramic 4 or more surfaces
$690

Periodontics by General Dentist

D4210
Gingivectomy/ 4 + teeth per Quadrant
$298
D4211
Gingivectomy/ 1-3 teeth per Quadrant
$170
D4341
Scaling/root planing, 4 + teeth per quad
$125
D4342
Scaling/root planing, 1-3 teeth per quad
$75
D4355
Full Mouth Debridement to enable evaluation and diagnosis
$88
D4910
Periodontal maintenance, per visit
$75
D4921
Quadrant anti-microbial irrigation per quadrant
$35
40820
Periodontal laser therapy
$45

Removable Prosthodontics

D5110-5120
Complete denture-per arch
$790
D5130-5140
Complete Immediate denture per arch
$875
D5213-5214
Partial denture/metal cast frame per arch
$975
D5281
Removeable unilateral partial
$450
D5510-5610
Partial dent-repair base per arch
$150
D5520-5640
Dent./Partial replace per tooth
$89
D5620
Partial denture-repair cast framework
$120
D5630-5660
Partial dent repair/replace/add clasp
$160
D5730-5731
Reline complete denture, chairside per arch
$170
D5740-5741
Reline partial denture, chairside per arch
$145
D5750-5751
Reline complete denture in lab per arch
$250
D5760-5761
Reline partial denture in lab per arch
$250
D5820-5821
Interim partial denture per arch
$365
D9120
Partial Sectioning
$150
D2971
Fit Partial to Crown
$175
Upgraded Ivocap acrylic per arch
$257
Upgraded Ivoclar teeth per arch
$257

Crowns

D2740
Crown-Porcelain/ceramic
$675
D2750
Crown-Porcelain high noble metal
$680
D2752
Crown-Porcelain fused to base metal
$605
D2790
Crown-full cast high noble metal
$640
D2920
Recementation of crown
$42
D2950
Core build up including pins, per tooth
$109
D2952
Cast post/core in addition to crown
$183
D2954
Prefab/post/core in addition to crown
$149
D2962
Labial Veneer (porcelain laminate)
$985
D9940
Occlusal Guard
$375
**Lab Fees are included in the fees listed
**Zirconia upgrade
$150

Fixed Prosthodontics (Bridges/Implants)

D6240
Pontic- Porcelain/high noble metal
$680
D6242
Pontic-Porcelain /noble metal
$680
D6245
Pontic-Porcelain /ceramic
$675
D6740
Crown-Porcelain ceramic
$675
D6750
Crown-Porcelain/high nobel metal
$680
D6752
Crown-Porcelain noble metal
$605
D6790
Crown-Cast high noble metal (Gold)
$640
D6930
Recementation of bridge
$62
D5862/6950
Precision attachment
$435
D6065
Abut. Supp porc/cer crown
$1,200
D6056
Prefab abutment
$435
D6053
Imp/abut remov, comp edent arch
$2,450

Oral Surgery PERFORMED by General Dentist

D7111
Extraction-coronal remnants, prim
$74
D7140
Extraction-erupted tooth
$60
D7210
Extraction-erupted tooth surgical
$89
D7250
Removal of tooth (root)
$95
**any procedure code not listed 25% off of the office UCR rate (usual and customary rate)

Whitening

ZOOM
Zoom w/out trays
$290
ZOOM
Zoom w/ trays
$375

Specialist Fee Schedule

Oral Surgery

D0140
Limited oral exam
$55
D9310
TMJ consultation
$70
D0330
Panoramic x-ray
$45
D0363
Cone beam-3D
$125
D6010
Surgical placement of Implant
$1,600
D6104
Bone graft- implant placement
$490
D7140
Extraction- erupted tooth
$95
D7210
Extraction-erupted tooth surgical
$147
D7220
Extraction-soft tissue impaction
$180
D7230
Extraction-partial bony impaction
$290
D7240
Extraction-comp bony impaction
$330
D7250
Surgical removal residual tooth (root)
$171
D7280
Surgical access unerupted tooth
$300
D7283
Placement of device to facil erupted tooth
$175
D7285
Biopsy of oral tissue-hard
$365
D7286
Biopsy of oral tissue-soft
$310
D7310
Alveoloplasty w/extract-/quad
$160
D7460
Rem benign odont-diam <=1.25cm
$700
D7461
Rem benign odont-diam >=1.25cm
$700
D7870
Arthrocentesis
$575
D7880
TMJ orthotic splint
$850
D7999
TMJ adjustments
$65
D9223
Deep sedation/gen sedation ea. 15 min.
$140
Heal
Healing abutment
$50

Endodontics (Specialist)

D0140
Limited oral exam
$55
D0220
Single/ea. addit. x-ray, intraoral
$12
D0270
Bitewing x-ray, 1 film
$12
D3220
Therapeutic pulpotomy
$180
D3310
Root canal therapy-anterior
$480
D3320
Root canal therapy-bicuspid
$650
D3330
Root canal therapy-molar
$830
D3331
Treatment of root canal obstruct
$100
D3346
Retreat, prev Rct-anterior
$650
D3347
Retreat, prev Rct-bicuspid
$772
D3348
Retreat, prev Rct-molar
$918

Periodontics (Specialist)

D0180
Comprehensive perio evaluation
$65
D0140
Limited oral exam
$55
D0210
Intra-oral complete series
$75
D0220-0230
Single x-ray, intraoral
$12
D4210
Gingivectomy-4 + per quadrant
$500
D4211
Gingivectomy- 1-3 contig th/quad.
$300
D4249
Clinc crown lengthen-hard tissue
$600
D4260
Osseous surgery- 4 +per quad
$884
D4261
Osseous surgery- 1-3 contg th/quad
$580
D4263
Bone replace graft-1st site
$490
D4266-4267
Guided tissue regeneration
$490
D4277
Free soft tissue graft 1st th./site
$571
D4278
Free soft tissue graft ea. addit site in graft
$571
D4341
Perio scaling & root plan. / quad
$165
D4910
Periodontal maintenance
$88
Laser
Laser therapy per quad
$45

Orthodontics (Specialist)

Consult
Consult - complimentary
---
D8999
Diagnosti workup, x-rays/models
$300
D8030
Limited ortho, treatment under 19
$3,000
D8040
Limited ortho treatment, 19 and over
$3,400
D8080
Comprehensive ortho treatment under 19
$4,300
D8090
Comprehensive ortho treatment 19 and over
$4,500
D8210
Removeable appliance therapy
$750
D8220
Fixed appliance therapy
$750
D8660
Pre-orthodontic treatment per visit
$55
D8670
Periodic ortho visit (per contract)
$125
D8680
Ortho retention(removal of appliances, construction/replacement of
$175
D8691
Repair functional appliance/palatal expanders
$300
D8692
Replace lost or irreparable retainer
$265
D8999
Final Ortho records
$125

Orthodontic Exclusions and Limitations

1. No benefits will apply for a treatment program that began BEFORE the Member/Subscriber enrolled in orthodontic plan.
2. No benefits will apply for lost or broken appliances, except provided herein
3. Ortho extractions ARE NOT included as a benefit
4. No benefits will apply for the following:
a. Care required in excess of 24 mo. From the time of banding
b. Gross non-cooperation and compliance
c. Accidents occurring during the period of treatment.
d. Cases involving surgical orthodontics.
e. Cases involving myofunctional therapy or TMJ
5. If the Member and/or Subscriber relocates to an area and is unable to receive treatment from a member orthodontist, coverage under the plan ceases and it becomes the obligation of the Member and/or Subscriber to pay the usual and customary fee of the Orthodontist where the treatment is completed.
6. Choice of Orthodontist is limited to Orthodontists participating who will accept the fees outlined in the Plan.
7. If the Member and/or Subscriber become ineligible for benefits or this Plan ceases, it becomes the obligation of the Member and/or the Subscriber to pay the remaining balance due to the Orthodontist.