Plan Information

Discount Fee Schedule

The below discounts contained in this Fee Schedule are valid only when treatment is provided by a Participating General Dentist. If the services of a Participating Specialist are recommended and available, then the above discounts DO NOT apply and the member's charge will be the Participating Specialist's usual and customary fee, less a discount of 25%. If a service is not listed above, it may be available at the Participating Dental Provider's usual and customary fee, less a discount of 25%.

The following is a summary representation of the plan offered. For a full detail, please download your Discount Fee Schedule.

Plan Features
Diagnostic
Clinical Oral Evaluation You Pay
D0120 periodic oral evaluation - established patient $20
D0140 limited oral evaluation - problem focused $40
D0145 oral evaluation for a patient under three years of age and counseling with primary caregiver $40
D0150 comprehensive oral evaluation - new or established patient $35
D0160 detailed and extensive oral evaluation - problem focused, by report $70
D0180 comprehensive periodontal evaluation - new or established patient $55
Radiographs/Diagnostic Imaging (Including Interpretation) You Pay
D0210 intraoral - complete series (including bitewings) $65
D0220 intraoral - periapical first film $12
D0230 intraoral - periapical each additional film $12
D0240 intraoral - occlusal film $18
D0250 extraoral - first film $23
D0260 extraoral - each additional film $22
D0270 bitewing - single film $10
D0272 bitewings - two films $18
D0273 bitewings - three films $25
D0274 bitewings - four films $28
D0277 vertical bitewings - 7 to 8 films $44
D0290 posterior - anterior or lateral skull and facial bone survey film $86
D0321 other temporomandibular joint films, by report $240
D0322 tomographic survey $376
D0330 panoramic film $50
D0340 cephalometric film $57
D0350 oral/facial photographic images $32
Tests and Examinations You Pay
D0460 pulp vitality tests $35
D0470 diagnostic casts $53
Clinical Oral Evaluation You Pay
D0999C Failed/no-show appointment without 24-hour notice $25-$40
Preventive
Dental Prophylaxis You Pay
D1110 prophylaxis - adult $50
D1120 prophylaxis - child $35
Topical Fluoride Treatment (Office Procedure) You Pay
D1203 topical application of fluoride - child $15
D1204 topical application of fluoride - adult $15
D1206 topical fluoride varnish; therapeutic application for moderate to high caries risk patients $15
Other Preventive Services You Pay
D1351 sealant - per tooth $25
Space Maintenance (Passive Appliances) You Pay
D1510 space maintainer - fixed - unilateral $315
D1515 space maintainer - fixed - bilateral $365
D1520 space maintainer - removable - unilateral $335
D1525 space maintainer - removable - bilateral $405
D1550 re-cementation of space maintainer $35
D1555 removal of fixed space maintainer $35
Restorative
Amalgam Restorations (Including Polishing) You Pay
D2140 amalgam - one surface, primary or permanent $70
D2150 amalgam - two surfaces, primary or permanent $80
D2160 amalgam - three surfaces, primary or permanent $95
D2161 amalgam - four or more surfaces, primary or permanent $105
Resin - Based Composite Restorations - Direct You Pay
D2330 resin-based composite - one surface, anterior $80
D2331 resin-based composite - two surfaces, anterior $100
D2332 resin-based composite - three surfaces, anterior $110
D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) $135
D2390 resin-based composite crown, anterior $165
D2391 resin-based composite - one surface, posterior $88
D2392 resin-based composite - two surfaces, posterior $112
D2393 resin-based composite - three surfaces, posterior $140
D2394 resin-based composite - four or more surfaces, posterior $165
Gold Foil Restorations You Pay
D2410 gold foil - one surface $164
D2420 gold foil - two surfaces $274
D2430 gold foil - three surfaces $475
Inlay/Onlay Restorations You Pay
D2510 inlay - metallic - one surface $435
D2520 inlay - metallic - two surfaces $496
D2530 inlay - metallic - three or more surfaces $572
D2543 onlay - metallic-three surfaces $565
D2544 onlay - metallic-four or more surfaces $562
D2610 inlay - porcelain/ceramic - one surface $507
D2620 inlay - porcelain/ceramic - two surfaces $512
D2630 inlay - porcelain/ceramic - three or more surfaces $518
D2642 onlay - porcelain/ceramic - two surface $579
D2643 onlay - porcelain/ceramic - three surfaces $587
D2644 onlay - porcelain/ceramic - four or more surfaces $583
D2650 inlay - resin-based composite - one surface $309
D2651 inlay - resin-based composite - two surfaces $391
D2652 inlay - resin-based composite - three or more surfaces $414
D2662 onlay - resin-based composite - two surfaces $366
D2663 onlay - resin-based composite - three surfaces $403
D2664 onlay - resin-based composite - four or more surfaces $445
Crowns - Single Restorations Only You Pay
D2710 crown - resin-based composite (indirect) $397
D2720 crown - resin with high noble metal $640
D2721 crown - resin with predominantly base metal $590
D2722 crown - resin with noble metal $610
D2740 crown - porcelain/ceramic substrate $650
D2750 crown - porcelain fused to high noble metal $640
D2751 crown - porcelain fused to predominantly base metal $590
D2752 crown - porcelain fused to noble metal $610
D2780 crown - 3/4 cast high noble metal $640
D2781 crown - 3/4 cast predominantly base metal $590
D2782 crown - 3/4 cast noble metal $610
D2783 crown - 3/4 porcelain/ceramic $640
D2790 crown - full cast high noble metal $640
D2791 crown - full cast predominantly base metal $590
D2792 crown - full cast noble metal $610
Other Restorative Services You Pay
D2910 recement inlay, onlay, or partial coverage restoration $50
D2915 recement cast or prefabricated post and core $48
D2920 re-cement crown $52
D2930 prefabricated stainless steel crown - primary tooth $110
D2931 prefabricated stainless steel crown - permanent tooth $150
D2932 prefabricated resin crown $174
D2933 prefabricated stainless steel crown with resin window $190
D2940 protective restoration $57
D2950 core buildup, including any pins $137
D2952 post and core in additon to crown, indirectly fabricated $188
D2953 each additonal indirectly fabricated post - same tooth $106
D2954 prefabricated post and core in addition to crown $165
D2955 post removal (not in conjunction with endodontic therapy) $152
D2957 each additonal prefabricated post - same tooth $94
D2960 labial veneer (resin laminate) - chairside $288
D2961 labial veneer (resin laminate) - laboratory $575
D2962 labial veneer (porcelain laminate) - laboratory $720
D2970 temporary crown (fractured tooth) $45
Endodontics
Pulp Capping You Pay
D3110 pulp cap - direct (excluding final restoration) $30
D3120 pulp cap - indirect (excluding final restoration) $30
Pulpotomy You Pay
D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $105
D3221 pulpal debridement, primary and permanent teeth $110
Endodontic Therapy on Primary Teeth You Pay
D3230 pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) $110
D3240 pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) $136
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) You Pay
D3310 endodontic therapy, anterior tooth (excluding final restoration) $425
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $515
D3330 endodontic therapy, molar (excluding final restoration) $675
D3332 incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $410
Endodontic Retreatment You Pay
D3346 retreatment of previous root canal therapy - anterior $548
D3347 retreatment of previous root canal therapy - bicuspid $582
D3348 retreatment of previous root canal therapy - molar $675
Apexification/Recalcification Procedures You Pay
D3351 apexification/recalcification/pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) $210
D3352 apexification/recalcification/pulpal regeneration - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) $175
D3353 apexification/recalcification - final visit (includes completed root canal therapy -apical closure/calcific repair of perforations, root resorption, etc.) $310
Apicoectomy/Periradicular Services You Pay
D3410 apicoectomy/periradicular surgery - anterior $400
D3421 apicoectomy/periradicular surgery - bicuspid (first root) $510
D3425 apicoectomy/periradicular surgery - molar (first root) $610
D3426 apicoectomy/periradicular surgery (each additonal root) $295
D3430 retrograde filling - per root $137
D3450 root amputation - per root $309
D3460 endodontic endosseous implant $1,373
D3470 intentional reimplantation (including necessary splinting) $572
Other Endodontic Procedures You Pay
D3910 surgical procedure for isolation of tooth with rubber dam $82
D3920 hemisection (including any root removal), not including root canal therapy $226
D3950 canal preparation and fitting of preformed dowel or post $86
Periodontics
Surgical Services (Including Usual Postoperative Care) You Pay
D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $275
D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant $140
D4240 gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quardant $371
D4241 gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quardant $271
D4245 apically positioned flap $270
D4249 clinical crown lengthening - hard tissue $225
D4260 osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant $675
D4261 osseous surgery (including flap entry and closure) - one to three teeth contiguous teeth or tooth bounded spaces per quadrant $560
D4263 bone replacement graft - first site in quadrant $280
D4264 bone replacement graft - each additonal site in quadrant $111
D4266 guided tissue regeneration - resorbable barrier, per site $307
D4267 guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) $296
D4270 pedicle soft tissue graft procedure $454
D4271 free soft tissue graft procedure (including donor site surgery) $516
D4274 distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) $173
Non-Surgical Periodontal Service You Pay
D4320 provisional splinting - intracoronal $175
D4321 provisional splinting - extracoronal $200
D4341 periodontal scaling and root planing - four or more teeth per quadrant $140
D4342 periodontal scaling and root planing - one to three teeth per quadrant $85
D4355 full mouth debridement to enable comprehensive evaluation and diagnosis $85
Other Periodontal Services You Pay
D4910 periodontal maintenance $65
D4920 unscheduled dressing change (by someone other than treating dentist) $65
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) You Pay
D5110 complete denture - maxillary $775
D5120 complete denture - mandibular $775
D5130 immediate denture - maxillary $845
D5140 immediate denture - mandibular $845
Partial Dentures (Including Routine Post-Delivery Care) You Pay
D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $725
D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $725
D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $805
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $805
D5281 removable unilateral partial denture - one piece cast metal (including clasps and teeth) $545
Repairs to Complete Dentures You Pay
D5510 repair broken complete denture base $235
D5520 replace missing or broken teeth - complete denture (each tooth) $215
Repairs to Partial Dentures You Pay
D5610 repair resin denture base $215
D5620 repair cast framework $235
D5630 repair or replace broken clasp $235
D5640 replace broken teeth - per tooth $215
D5650 add tooth to existing partial denture $215
D5660 add clasp to existing partial denture $245
Denture Rebase Procedures You Pay
D5710 rebase complete maxillary denture $325
D5711 rebase complete mandibular denture $325
D5720 rebase maxillary partial denture $300
D5721 rebase mandibular partial denture $300
Denture Reline Procedures You Pay
D5730 reline complete maxillary denture (chairside) $95
D5731 reline complete mandibular denture (chairside) $95
D5740 reline maxillary partial denture (chairside) $95
D5741 reline mandibular partial denture (chairside) $95
D5750 reline complete maxillary denture (laboratory) $245
D5751 reline complete mandibular denture (laboratory) $245
D5760 reline maxillary partial denture (laboratory) $255
D5761 reline mandibular partial denture (laboratory) $255
Interim Prosthesis You Pay
D5810 interim complete denture (maxillary) $365
D5811 interim complete denture (mandibular) $365
D5820 interim partial denture (maxillary) $320
D5821 interim partial denture (mandibular) $320
Other Removable Prosthetic Services You Pay
D5850 tissue conditioning, maxillary $80
D5851 tissue conditioning, mandibular $80
D5860 overdenture - complete, by report $900
D5861 overdenture - partial, by report $850
Maxillofacial Prosthetics
Maxillofacial Prosthetics You Pay
D5986 fluoride gel carrier $77
D5987 commissure splint $1,360
Implant Services
Implant Services You Pay
D6010 surgical placement of implant body: endosteal implant $1,110
D6040 surgical placement: eposteal implant $5,926
D6050 surgical placement: transosteal implant $4,140
Implant Supported Prosthetics You Pay
D6055 dental implant supported connecting bar $368
Other Implant Services You Pay
D6080 implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis $73
Prosthodontics, fixed
Fixed Partial Denture Pontics You Pay
D6210 pontic - cast high noble metal $640
D6211 pontic - cast predominantly base metal $590
D6212 pontic - cast noble metal $610
D6214 pontic - titanium $645
D6240 pontic - porcelain fused to high noble metal $640
D6241 pontic - porcelain fused to predominantly base metal $590
D6242 pontic - porcelain fused to noble metal $610
D6250 pontic - resin with high noble metal $640
D6251 pontic - resin with predominantly base metal $590
D6252 pontic - resin with noble metal $610
Fixed Partial Denture Retainers-Inlays/Onlays You Pay
D6545 retainer - cast metal for resin bonded fixed prosthesis $350
Fixed Partial Denture Retainers-Crowns You Pay
D6720 crown - resin with high noble metal $640
D6721 crown - resin with predominantly base metal $590
D6722 crown - resin with noble metal $610
D6750 crown - porcelain fused to high noble metal $640
D6751 crown - porcelain fused to predominantly base metal $590
D6752 crown - porcelain fused to noble metal $610
D6780 crown - 3/4 cast high noble metal $640
D6781 crown - 3/4 cast predominantly base metal $590
D6782 crown - 3/4 cast noble metal $610
D6783 crown - 3/4 porcelain/ceramic $640
D6790 crown - full cast high noble metal $640
D6791 crown - full cast predominantly base metal $590
D6792 crown - full cast noble metal $610
Other Fixed Partial Denture Services You Pay
D6920 connector bar $101
D6930 re-cement fixed partial denture $65
D6940 stress breaker $315
D6950 precision attachment $445
D6970 post and core in addition to fixed partial denture retainer, indirectly fabricated $193
D6972 prefabricated post and core in addition to fixed partial denture retainer $160
D6973 core build up for retainer, including any pins $130
D6975 coping - metal $355
D6976 each additional indirectly fabricated post - same tooth $83
D6977 each additional prefabricated post - same tooth $80
Oral and Maxillofacial Surgery
Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care) You Pay
D7111 extraction, coronal remnants - deciduous tooth $60
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) $85
Surgical Extractions (Includes Local Anesthesia, Suturing, If Needed, and Routine Postoperative Care You Pay
D7210 surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth. $140
D7220 removal of impacted tooth - soft tissue $170
D7230 removal of impacted tooth - partially bony $195
D7240 removal of impacted tooth - completely bony $220
D7241 removal of impacted tooth - completely bony, with unusual surgical complications $295
D7250 surgical removal of residual tooth roots (cutting procedure) $120
Other Surgical Prodecures You Pay
D7260 oroantral fistula closure $1,200
D7270 tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $293
D7272 tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) $434
D7280 surgical access of an unerupted tooth $180
D7285 biopsy of oral tissue - hard (bone, tooth) $225
D7286 biopsy of oral tissue - soft $140
D7290 surgical repositioning of teeth $275
Alveoloplasty-Surgical Preparation of Ridge for Dentures You Pay
D7310 alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $85
D7311 alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $50
D7320 alveoloplasty not in conjuction with extractions - four or more teeth or tooth spaces, per quadrant $185
D7321 alveoloplasty not in conjuction with extractions - one to three teeth or tooth spaces, per quadrant $125
Vestibuloplasty You Pay
D7340 vestibuloplasty - ridge extension (secondary epithelialization) $625
D7350 vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) $4,136
Surgical Excision of Soft Tissue Lesions You Pay
D7410 excision of benign lesion up to 1.25 cm $275
D7411 excision of benign lesion greater than 1.25 cm $325
D7412 excision of benign lesion, complicated $425
Surgical Excision of Intra-Osseous Lesions You Pay
D7440 excision of malignant tumor - lesion diameter up to 1.25 cm $931
D7441 excision of malignant tumor - lesion diameter greater than 1.25 cm $1,447
D7450 removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm $275
D7451 removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm $425
D7460 removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm $275
D7461 removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm $325
Surgical Excision of Soft Tissue Lesions You Pay
D7465 destruction of lesion(s) by physical or chemical method, by report $205
Excision of Bone Tissue You Pay
D7471 removal of lateral exostosis (maxilla or mandible) $250
D7472 removal of torus palatinus $325
D7473 removal of torus mandibularis $275
Surgical Incision You Pay
D7510 incision and drainage of abscess - intraoral soft tissue $95
D7511 incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) $175
D7520 incision and drainage of abscess - extraoral soft tissue $225
D7521 incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces) $250
D7530 removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue $271
D7540 removal of reaction producing foreign bodies, musculoskeletal system $300
D7550 partial ostectomy/sequestrectomy for removal of non-vital bone $187
D7560 maxillary sinusotomy for removal of tooth fragment or foreign body $1,489
Treatment of Fractures-Simple You Pay
D7670 alveolus - closed reduction, may include stabilization of teeth $595
Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfuctions You Pay
D7880 occlusal orthotic device, by report $375
Other Repair Procedures You Pay
D7940 osteoplasty - for orthognathic deformities $2,300
D7950 osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report $1,199
D7960 frenulectomy (frenectomy or frenotomy) - separate procedure $185
D7963 frenuloplasty $185
D7970 excision of hyperplastic tissue - per arch $185
D7971 excision of pericoronal gingiva $80
D7983 closure of salivary fistula $1,312
Orthodontics
Limited Orthodontic Treatment You Pay
D8010 limited orthodontic treatment of the primary dentition $1,500
D8020 limited orthodontic treatment of the transitional dentition $1,500
D8030 limited orthodontic treatment of the adolescent dentition $1,500
D8040 limited orthodontic treatment of the adult dentition $1,500
Comprehensive Orthodontic Treatment You Pay
D8070 comprehensive orthodontic treatment of the transitional dentition $2,950
D8080 comprehensive orthodontic treatment of the adolescent dentition $2,950
D8090 comprehensive orthodontic treatment of the adult dentition $2,950
Other Orthodontic Services You Pay
D8660 pre-orthodontic treatment visit $45
D8670 periodic orthodontic treatment visit (as part of contract) $45
D8680 orthodontic retention (removal of appliances, construction and placement of retainer(s)) $400
Adjunctive General Services
Unclassified Treatment You Pay
D9110 palliative (emergency) treatment of dental pain-minor procedure $40
Anesthesia You Pay
D9210 local anesthesia not in conjunction with operative or surgical procedures $25
D9211 regional block anesthesia $28
D9212 trigeminal division block anesthesia $54
D9220 deep sedation/general anesthesia-first 30 minutes $210
D9221 deep sedation/general anesthesia-each additional 15 minutes $80
D9230 analgesia, anxiolysis, inhalation of nitrous oxide $50
D9241 intravenous conscious sedation/analgesia-first 30 minutes $185
D9242 intravenous conscious sedation/analgesia-each additional 15 minutes $70
D9248 non-intravenous conscious sedation $54
Professional Consultation You Pay
D9310 consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician $45
Professional Visits You Pay
D9410 house/extended care facility call $175
D9420 hospital call $175
D9440 office visit-after regularly scheduled hours $75
Drugs You Pay
D9610 therapeutic parenteral drug, single administration $35
D9612 therapeutic parenteral drug, two or more administrations, different medications $50
D9630 other drugs and/or medicaments, by report $25
Miscellaneous Services You Pay
D9910 application of desensitizing medicament $25
D9941 fabrication of athletic mouthguard $100
D9950 occlusion analysis - mounted case $95
D9951 occlusal adjustment - limited $50
D9952 occlusal adjustment - complete $295
D9970 enamel microabrasion $32
D9972 external bleaching - per arch $200
D9973 external bleaching - per tooth $22
D9974 internal bleaching - per tooth $148

*This Plan is not insurance and does not make payments directly to providers of service. The Plan member is obligated to pay for all health care services and will receive a discount from providers who participate in the network.