Plan Information

Discount Fee Schedule

What we do as a carrier is pre-negotiate discounted fees with dentists in your community and pass these savings on to you. We also offer the contracted dentists a guaranteed income every month as they are receiving a portion of the month premium you are paying us regardless of if you (or a family member) visit their office that month or not. When you see your plan dentist, the negotiated fee is considered payment in full!

This schedule is an extensive list of most common dental procedures. Pre-negotiated lab fees are not included and are to be paid in full by the member as required. The purpose of this schedule is to establish the maximum fee that you will pay for each dental procedure listed below at the time you see your plan dentist.

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

Plan Features
Diagnostic
Clinical Oral Evaluation You Pay
D0120 periodic oral evaluation - established patient $0
D0140 limited oral evaluation - problem focused $17
D0150 comprehensive oral evaluation - new or established patient $13
D0160 detailed and extensive oral evaluation - problem focused, by report $39
D0170 re-evaluation - limited, problem focused (established patient; not post-operative visit) $21
D0180 comprehensive periodontal evaluation - new or established patient $25
Radiographs/Diagnostic Imaging (Including Interpretation) You Pay
D0210 intraoral - complete series (including bitewings) $35
D0220 intraoral - periapical first film $6
D0230 intraoral - periapical each additional film $6
D0240 intraoral - occlusal film $5
D0250 extraoral - first film $5
D0260 extraoral - each additional film $5
D0270 bitewing - single film $0
D0272 bitewings - two films $0
D0273 bitewings - three films $0
D0274 bitewings - four films $0
D0277 vertical bitewings - 7 to 8 films $0
D0330 panoramic film $54
D0340 cephalometric film $61
Tests and Examinations You Pay
D0460 pulp vitality tests $0
D0470 diagnostic casts $55
Clinical Oral Evaluation You Pay
D0999A office visit fee - per visit $5
D0999B Emergency visit during regularly scheduled hours, by report $25
D0999C Failed/no-show appointment without 24-hour notice $30
Preventive
Dental Prophylaxis You Pay
D1110 prophylaxis - adult $18
D1120 prophylaxis - child $18
Topical Fluoride Treatment (Office Procedure) You Pay
D1206 topical fluoride varnish; therapeutic application for moderate to high caries risk patients $12
Other Preventive Services You Pay
D1330 oral hygiene instructions $0
D1351 sealant - per tooth $13
Space Maintenance (Passive Appliances) You Pay
D1510 space maintainer - fixed - unilateral $198
D1515 space maintainer - fixed - bilateral $283
D1520 space maintainer - removable - unilateral $226
D1525 space maintainer - removable - bilateral $262
D1550 re-cementation of space maintainer $24
D1999 additional prophy (for perio maintenance) $45
Restorative
Amalgam Restorations (Including Polishing) You Pay
D2140 amalgam - one surface, primary or permanent $44
D2150 amalgam - two surfaces, primary or permanent $55
D2160 amalgam - three surfaces, primary or permanent $66
D2161 amalgam - four or more surfaces, primary or permanent $77
Resin - Based Composite Restorations - Direct You Pay
D2330 resin-based composite - one surface, anterior $59
D2331 resin-based composite - two surfaces, anterior $70
D2332 resin-based composite - three surfaces, anterior $91
D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) $139
D2390 resin-based composite crown, anterior $290
D2391 resin-based composite - one surface, posterior $116
D2392 resin-based composite - two surfaces, posterior $161
D2393 resin-based composite - three surfaces, posterior $201
D2394 resin-based composite - four or more surfaces, posterior $220
Inlay/Onlay Restorations You Pay
D2510 inlay - metallic - one surface $351
D2520 inlay - metallic - two surfaces $369
D2530 inlay - metallic - three or more surfaces $394
D2542 onlay - metallic-two surfaces $406
D2543 onlay - metallic-three surfaces $415
D2544 onlay - metallic-four or more surfaces $430
D2610 inlay - porcelain/ceramic - one surface $374
D2620 inlay - porcelain/ceramic - two surfaces $363
D2630 inlay - porcelain/ceramic - three or more surfaces $392
D2642 onlay - porcelain/ceramic - two surface $393
D2643 onlay - porcelain/ceramic - three surfaces $432
D2644 onlay - porcelain/ceramic - four or more surfaces $447
D2650 inlay - resin-based composite - one surface $355
D2651 inlay - resin-based composite - two surfaces $367
D2652 inlay - resin-based composite - three or more surfaces $383
D2662 onlay - resin-based composite - two surfaces $435
D2663 onlay - resin-based composite - three surfaces $447
D2664 onlay - resin-based composite - four or more surfaces $455
Crowns - Single Restorations Only You Pay
D2710 crown - resin-based composite (indirect) $380
D2720 crown - resin with high noble metal $430
D2721 crown - resin with predominantly base metal $408
D2722 crown - resin with noble metal $429
D2740 crown - porcelain/ceramic substrate $467
D2750 crown - porcelain fused to high noble metal $452
D2751 crown - porcelain fused to predominantly base metal $379
D2752 crown - porcelain fused to noble metal $437
D2780 crown - 3/4 cast high noble metal $503
D2781 crown - 3/4 cast predominantly base metal $467
D2782 crown - 3/4 cast noble metal $483
D2783 crown - 3/4 porcelain/ceramic $502
D2790 crown - full cast high noble metal $439
D2791 crown - full cast predominantly base metal $378
D2792 crown - full cast noble metal $415
Other Restorative Services You Pay
D2910 recement inlay, onlay, or partial coverage restoration $21
D2920 re-cement crown $40
D2930 prefabricated stainless steel crown - primary tooth $119
D2931 prefabricated stainless steel crown - permanent tooth $149
D2932 prefabricated resin crown $172
D2933 prefabricated stainless steel crown with resin window $188
D2940 protective restoration $46
D2950 core buildup, including any pins $99
D2951 pin retention - per tooth, in addition to restoration $31
D2952 post and core in additon to crown, indirectly fabricated $156
D2953 each additonal indirectly fabricated post - same tooth $110
D2954 prefabricated post and core in addition to crown $119
D2955 post removal (not in conjunction with endodontic therapy) $150
D2957 each additonal prefabricated post - same tooth $96
D2960 labial veneer (resin laminate) - chairside $204
D2999 unspecified restorative procedure, by report $135
Endodontics
Pulp Capping You Pay
D3110 pulp cap - direct (excluding final restoration) $32
D3120 pulp cap - indirect (excluding final restoration) $35
Pulpotomy You Pay
D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $83
D3221 pulpal debridement, primary and permanent teeth $93
Endodontic Therapy on Primary Teeth You Pay
D3230 pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) $101
D3240 pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) $110
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) You Pay
D3310 endodontic therapy, anterior tooth (excluding final restoration) $323
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $381
D3330 endodontic therapy, molar (excluding final restoration) $472
D3331 treatment of root canal obstruction; non-surgical access $308
D3332 incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $216
D3333 internal root repair of perforation defects $171
Endodontic Retreatment You Pay
D3346 retreatment of previous root canal therapy - anterior $399
D3347 retreatment of previous root canal therapy - bicuspid $444
D3348 retreatment of previous root canal therapy - molar $528
Apexification/Recalcification Procedures You Pay
D3351 apexification/recalcification/pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) $167
D3352 apexification/recalcification/pulpal regeneration - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) $125
D3353 apexification/recalcification - final visit (includes completed root canal therapy -apical closure/calcific repair of perforations, root resorption, etc.) $251
Apicoectomy/Periradicular Services You Pay
D3410 apicoectomy/periradicular surgery - anterior $361
D3421 apicoectomy/periradicular surgery - bicuspid (first root) $414
D3425 apicoectomy/periradicular surgery - molar (first root) $462
D3426 apicoectomy/periradicular surgery (each additonal root) $171
D3430 retrograde filling - per root $120
D3450 root amputation - per root $213
D3470 intentional reimplantation (including necessary splinting) $356
Other Endodontic Procedures You Pay
D3910 surgical procedure for isolation of tooth with rubber dam $64
D3920 hemisection (including any root removal), not including root canal therapy $253
D3950 canal preparation and fitting of preformed dowel or post $135
Periodontics
Surgical Services (Including Usual Postoperative Care) You Pay
D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $351
D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant $206
D4240 gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quardant $368
D4241 gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quardant $306
D4245 apically positioned flap $406
D4249 clinical crown lengthening - hard tissue $379
D4260 osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant $590
D4261 osseous surgery (including flap entry and closure) - one to three teeth contiguous teeth or tooth bounded spaces per quadrant $465
D4263 bone replacement graft - first site in quadrant $369
D4264 bone replacement graft - each additonal site in quadrant $271
D4266 guided tissue regeneration - resorbable barrier, per site $404
D4267 guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) $496
D4268 surgical revision procedure, per tooth $417
D4270 pedicle soft tissue graft procedure $416
Non-Surgical Periodontal Service You Pay
D4320 provisional splinting - intracoronal $290
D4321 provisional splinting - extracoronal $279
D4341 periodontal scaling and root planing - four or more teeth per quadrant $145
D4342 periodontal scaling and root planing - one to three teeth per quadrant $89
D4355 full mouth debridement to enable comprehensive evaluation and diagnosis $106
Other Periodontal Services You Pay
D4910 periodontal maintenance $66
D4920 unscheduled dressing change (by someone other than treating dentist) $55
D4999 unspecified periodontal procedure, by report $17
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) You Pay
D5110 complete denture - maxillary $626
D5120 complete denture - mandibular $626
D5130 immediate denture - maxillary $857
D5140 immediate denture - mandibular $858
Partial Dentures (Including Routine Post-Delivery Care) You Pay
D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $503
D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $489
D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $614
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $616
D5281 removable unilateral partial denture - one piece cast metal (including clasps and teeth) $364
Adjustments to Dentures You Pay
D5410 adjust complete dentures - maxillary $39
D5411 adjust complete dentures - mandibular $39
D5421 adjust partial denture - maxillary $39
D5422 adjust partial denture - mandibular $39
Repairs to Complete Dentures You Pay
D5510 repair broken complete denture base $94
D5520 replace missing or broken teeth - complete denture (each tooth) $68
Repairs to Partial Dentures You Pay
D5610 repair resin denture base $87
D5620 repair cast framework $148
D5630 repair or replace broken clasp $113
D5640 replace broken teeth - per tooth $73
D5650 add tooth to existing partial denture $101
D5660 add clasp to existing partial denture $131
Denture Rebase Procedures You Pay
D5710 rebase complete maxillary denture $297
D5711 rebase complete mandibular denture $295
D5720 rebase maxillary partial denture $260
D5721 rebase mandibular partial denture $261
Denture Reline Procedures You Pay
D5730 reline complete maxillary denture (chairside) $188
D5731 reline complete mandibular denture (chairside) $188
D5740 reline maxillary partial denture (chairside) $178
D5741 reline mandibular partial denture (chairside) $179
D5750 reline complete maxillary denture (laboratory) $189
D5751 reline complete mandibular denture (laboratory) $190
D5760 reline maxillary partial denture (laboratory) $174
D5761 reline mandibular partial denture (laboratory) $173
Interim Prosthesis You Pay
D5810 interim complete denture (maxillary) $374
D5811 interim complete denture (mandibular) $377
D5820 interim partial denture (maxillary) $299
D5821 interim partial denture (mandibular) $291
Other Removable Prosthetic Services You Pay
D5850 tissue conditioning, maxillary $76
D5851 tissue conditioning, mandibular $74
Prosthodontics, fixed
Fixed Partial Denture Pontics You Pay
D6210 pontic - cast high noble metal $422
D6211 pontic - cast predominantly base metal $374
D6212 pontic - cast noble metal $406
D6240 pontic - porcelain fused to high noble metal $451
D6241 pontic - porcelain fused to predominantly base metal $415
D6242 pontic - porcelain fused to noble metal $432
D6245 pontic - porcelain/ceramic $425
D6250 pontic - resin with high noble metal $426
D6251 pontic - resin with predominantly base metal $415
D6252 pontic - resin with noble metal $414
Fixed Partial Denture Retainers-Inlays/Onlays You Pay
D6545 retainer - cast metal for resin bonded fixed prosthesis $370
D6548 retainer - porcelain/ceramic for resin bonded fixed prosthesis $396
Fixed Partial Denture Retainers-Crowns You Pay
D6720 crown - resin with high noble metal $439
D6721 crown - resin with predominantly base metal $426
D6722 crown - resin with noble metal $441
D6740 crown - porcelain/ceramic $469
D6750 crown - porcelain fused to high noble metal $455
D6751 crown - porcelain fused to predominantly base metal $419
D6752 crown - porcelain fused to noble metal $430
D6780 crown - 3/4 cast high noble metal $414
D6781 crown - 3/4 cast predominantly base metal $396
D6782 crown - 3/4 cast noble metal $415
D6783 crown - 3/4 porcelain/ceramic $425
D6790 crown - full cast high noble metal $422
D6791 crown - full cast predominantly base metal $396
D6792 crown - full cast noble metal $413
Other Fixed Partial Denture Services You Pay
D6930 re-cement fixed partial denture $75
Oral and Maxillofacial Surgery
Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care) You Pay
D7111 extraction, coronal remnants - deciduous tooth $51
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) $57
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. $95
D7220 removal of impacted tooth - soft tissue $103
D7230 removal of impacted tooth - partially bony $184
D7240 removal of impacted tooth - completely bony $225
D7241 removal of impacted tooth - completely bony, with unusual surgical complications $270
D7250 surgical removal of residual tooth roots (cutting procedure) $135
Other Surgical Prodecures You Pay
D7270 tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $255
D7272 tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) $468
D7280 surgical access of an unerupted tooth $242
D7285 biopsy of oral tissue - hard (bone, tooth) $225
D7286 biopsy of oral tissue - soft $165
Alveoloplasty-Surgical Preparation of Ridge for Dentures You Pay
D7310 alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $138
D7320 alveoloplasty not in conjuction with extractions - four or more teeth or tooth spaces, per quadrant $200
Surgical Excision of Intra-Osseous Lesions You Pay
D7450 removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm $256
D7451 removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm $360
D7460 removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm $240
D7461 removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm $389
Surgical Incision You Pay
D7510 incision and drainage of abscess - intraoral soft tissue $107
Repair of Traumatic Wounds You Pay
D7910 suture of recent small wounds up to 5 cm $0
Complicated Suturing (Reconstruction Requiring Delicate Handling of Tissues and Wide Undermining for You Pay
D7911 complicated suture - up to 5 cm $292
D7912 complicated suture - greater than 5 cm $459
Other Repair Procedures You Pay
D7960 frenulectomy (frenectomy or frenotomy) - separate procedure $143
D7970 excision of hyperplastic tissue - per arch $217
D7971 excision of pericoronal gingiva $165
Orthodontics
Other Orthodontic Services You Pay
D8660 pre-orthodontic treatment visit $0
D8670 periodic orthodontic treatment visit (as part of contract) $155
D8680 orthodontic retention (removal of appliances, construction and placement of retainer(s)) $382
D8693 rebonding or recementing; and/or repair, as required, of fixed retainers $204
D8999 unspecified orthodontic procedure, by report $211
Adjunctive General Services
Unclassified Treatment You Pay
D9110 palliative (emergency) treatment of dental pain-minor procedure $54
Anesthesia You Pay
D9210 local anesthesia not in conjunction with operative or surgical procedures $42
D9230 analgesia, anxiolysis, inhalation of nitrous oxide $25
D9241 intravenous conscious sedation/analgesia-first 30 minutes $250
D9242 intravenous conscious sedation/analgesia-each additional 15 minutes $100
Professional Consultation You Pay
D9310 consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician $0
Professional Visits You Pay
D9430 office visit for observation (during regularly scheduled hours)-no other services performed $39
D9440 office visit-after regularly scheduled hours $90
Miscellaneous Services You Pay
D9910 application of desensitizing medicament $6
D9911 application of desensitizing resin for cervical and/or root surface, per tooth $37
D9941 fabrication of athletic mouthguard $108
D9950 occlusion analysis - mounted case $187
D9951 occlusal adjustment - limited $77
D9952 occlusal adjustment - complete $296
D9970 enamel microabrasion $92
D9972 external bleaching - per arch $180
D9973 external bleaching - per tooth $125
D9974 internal bleaching - per tooth $156
D9975 external bleaching for home application, per arch; includes materials and fabrication $175
D9986 missed appointment (without 24 hour notice) $41
D9987 cancelled appointment (without 24 hour notice) $35

* These co-payments do not include an allowable $151 lab fee (per unit). Doctors should make sure that all members understand what their fees will be and what the savings are from their Usual and Customary fee.
** For Orthodontic Benefits and All Plans General Limitations and Exclusions, please download your Dental Fee Schedule.