Plan Information

Schedule of Covered Services and Copayments

The following procedures are available to you when performed by a participating general dentist or orthodontist. Services provided by a specialist are not covered.

The following is a summary representation of the plan offered. For a full detail, please download your Schedule of Benefits... >> click here

Plan Features
Diagnostic
Clinical Oral Evaluation You Pay
D0120 periodic oral evaluation - established patient $5
D0140 limited oral evaluation - problem focused $5
D0145 oral evaluation for a patient under three years of age and counseling with primary caregiver $5
D0150 comprehensive oral evaluation - new or established patient $7
D0160 detailed and extensive oral evaluation - problem focused, by report $40
D0170 re-evaluation - limited, problem focused (established patient; not post-operative visit) $10
D0180 comprehensive periodontal evaluation - new or established patient $20
Radiographs/Diagnostic Imaging (Including Interpretation) You Pay
D0210 intraoral - complete series (including bitewings) $25
D0220 intraoral - periapical first film $7
D0230 intraoral - periapical each additional film $4
D0240 intraoral - occlusal film $9
D0250 extraoral - first film $9
D0260 extraoral - each additional film $6
D0270 bitewing - single film $10
D0272 bitewings - two films $13
D0273 bitewings - three films $15
D0274 bitewings - four films $17
D0277 vertical bitewings - 7 to 8 films $20
D0330 panoramic film $30
D0340 cephalometric film $30
D0350 oral/facial photographic images $10
Tests and Examinations You Pay
D0415 collection of microorganisms for culture and sensitivity $75
D0425 caries susceptibility tests $30
D0431 adjunctive pre-diagnostic test that aids in dection of mucosal abnormalities including premalignant and malignant lesions, not to incluede cytology or biopsy procedures $50
D0460 pulp vitality tests no charge
D0470 diagnostic casts $35
Clinical Oral Evaluation You Pay
D0999A office visit fee - per visit $10
Preventive
Dental Prophylaxis You Pay
D1110 prophylaxis - adult $25
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
D1310 nutritional counseling for control of dental disease no charge
D1320 tobacco counseling for the control and prevention of oral disease no charge
D1330 oral hygiene instructions no charge
D1351 sealant - per tooth $5
D1352 preventive resin restoration in a moderate to high caries risk patient - permanent tooth $50
Space Maintenance (Passive Appliances) You Pay
D1510 space maintainer - fixed - unilateral $125
D1515 space maintainer - fixed - bilateral $150
D1520 space maintainer - removable - unilateral $125
D1525 space maintainer - removable - bilateral $150
D1550 re-cementation of space maintainer $10
D1555 removal of fixed space maintainer $10
Restorative
Amalgam Restorations (Including Polishing) You Pay
D2140 amalgam - one surface, primary or permanent $47
D2150 amalgam - two surfaces, primary or permanent $52
D2160 amalgam - three surfaces, primary or permanent $62
D2161 amalgam - four or more surfaces, primary or permanent $77
Resin - Based Composite Restorations - Direct You Pay
D2330 resin-based composite - one surface, anterior $65
D2331 resin-based composite - two surfaces, anterior $75
D2332 resin-based composite - three surfaces, anterior $90
D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) $95
D2390 resin-based composite crown, anterior $120
D2391 resin-based composite - one surface, posterior $85
D2392 resin-based composite - two surfaces, posterior $100
D2393 resin-based composite - three surfaces, posterior $120
D2394 resin-based composite - four or more surfaces, posterior $135
Inlay/Onlay Restorations You Pay
D2510 inlay - metallic - one surface $400*
D2520 inlay - metallic - two surfaces $435*
D2530 inlay - metallic - three or more surfaces $465*
D2542 onlay - metallic-two surfaces $435*
D2543 onlay - metallic-three surfaces $435*
D2544 onlay - metallic-four or more surfaces $435*
D2610 inlay - porcelain/ceramic - one surface $400*
D2620 inlay - porcelain/ceramic - two surfaces $435*
D2630 inlay - porcelain/ceramic - three or more surfaces $465*
D2642 onlay - porcelain/ceramic - two surface $435*
D2643 onlay - porcelain/ceramic - three surfaces $465*
D2644 onlay - porcelain/ceramic - four or more surfaces $465*
D2650 inlay - resin-based composite - one surface $400*
D2651 inlay - resin-based composite - two surfaces $435*
D2652 inlay - resin-based composite - three or more surfaces $465*
D2662 onlay - resin-based composite - two surfaces $435*
D2663 onlay - resin-based composite - three surfaces $465*
D2664 onlay - resin-based composite - four or more surfaces $465*
Crowns - Single Restorations Only You Pay
D2710 crown - resin-based composite (indirect) $240
D2712 crown - 3/4 resin-based composite (indirect) $240
D2720 crown - resin with high noble metal $475*
D2721 crown - resin with predominantly base metal $475
D2722 crown - resin with noble metal $475*
D2740 crown - porcelain/ceramic substrate $475*
D2750 crown - porcelain fused to high noble metal $475*
D2751 crown - porcelain fused to predominantly base metal $475*
D2752 crown - porcelain fused to noble metal $475*
D2780 crown - 3/4 cast high noble metal $475*
D2781 crown - 3/4 cast predominantly base metal $475
D2782 crown - 3/4 cast noble metal $475*
D2783 crown - 3/4 porcelain/ceramic $475*
D2790 crown - full cast high noble metal $475*
D2791 crown - full cast predominantly base metal $475
D2792 crown - full cast noble metal $475*
D2794 crown - titanium $475*
Other Restorative Services You Pay
D2910 recement inlay, onlay, or partial coverage restoration $15
D2915 recement cast or prefabricated post and core $15
D2920 re-cement crown $15
D2930 prefabricated stainless steel crown - primary tooth $75
D2931 prefabricated stainless steel crown - permanent tooth $125
D2932 prefabricated resin crown $125
D2933 prefabricated stainless steel crown with resin window $110
D2934 prefabricated esthetic coated stainless steel crown - primary tooth $110
D2940 protective restoration $30
D2950 core buildup, including any pins $95
D2951 pin retention - per tooth, in addition to restoration $35
D2952 post and core in additon to crown, indirectly fabricated $100
D2953 each additonal indirectly fabricated post - same tooth $90
D2954 prefabricated post and core in addition to crown $100
D2955 post removal (not in conjunction with endodontic therapy) $125
D2957 each additonal prefabricated post - same tooth $80
D2960 labial veneer (resin laminate) - chairside $350
D2961 labial veneer (resin laminate) - laboratory $400
D2962 labial veneer (porcelain laminate) - laboratory $500
D2970 temporary crown (fractured tooth) $125
D2971 additional procedures to construct new crown under existing partial denture framework $20
D2975 coping $200
Endodontics
Pulp Capping You Pay
D3110 pulp cap - direct (excluding final restoration) $35
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 $55
D3221 pulpal debridement, primary and permanent teeth $55
D3222 partial pulpotomy for apexogenesis - permanent tooth with incomplete root development $55
Endodontic Therapy on Primary Teeth You Pay
D3230 pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) $80
D3240 pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) $80
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) You Pay
D3310 endodontic therapy, anterior tooth (excluding final restoration) $300
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $395
D3330 endodontic therapy, molar (excluding final restoration) $675
D3331 treatment of root canal obstruction; non-surgical access $175
D3332 incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $200
D3333 internal root repair of perforation defects $150
Endodontic Retreatment You Pay
D3346 retreatment of previous root canal therapy - anterior $600
D3347 retreatment of previous root canal therapy - bicuspid $700
D3348 retreatment of previous root canal therapy - molar $850
Apexification/Recalcification Procedures You Pay
D3351 apexification/recalcification/pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) $30
D3352 apexification/recalcification/pulpal regeneration - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) $30
D3353 apexification/recalcification - final visit (includes completed root canal therapy -apical closure/calcific repair of perforations, root resorption, etc.) $30
D3354 pulpal regeneration - (completion of regenerative treatment in an immature permanent thooth with a necrotic pulp); does not include final restoration $550
Apicoectomy/Periradicular Services You Pay
D3421 apicoectomy/periradicular surgery - bicuspid (first root) $375
D3425 apicoectomy/periradicular surgery - molar (first root) $425
D3426 apicoectomy/periradicular surgery (each additonal root) $140
D3430 retrograde filling - per root $120
D3450 root amputation - per root $200
Other Endodontic Procedures You Pay
D3920 hemisection (including any root removal), not including root canal therapy $300
D3950 canal preparation and fitting of preformed dowel or post $75
Periodontics
Surgical Services (Including Usual Postoperative Care) You Pay
D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $225
D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant $80
D4230 anatomical crown exposure - four or more contiguous teeth per quadrant $450
D4231 anatomical crown exposure - one to three teeth per quadrant $350
D4240 gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quardant $300
D4241 gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quardant $200
D4245 apically positioned flap $350
D4249 clinical crown lengthening - hard tissue $350
D4260 osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant $500
D4261 osseous surgery (including flap entry and closure) - one to three teeth contiguous teeth or tooth bounded spaces per quadrant $350
D4263 bone replacement graft - first site in quadrant $300
D4264 bone replacement graft - each additonal site in quadrant $350
D4266 guided tissue regeneration - resorbable barrier, per site $300
D4267 guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) $350
D4268 surgical revision procedure, per tooth $450
D4270 pedicle soft tissue graft procedure $450
D4274 distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) $250
Non-Surgical Periodontal Service You Pay
D4341 periodontal scaling and root planing - four or more teeth per quadrant $85
D4342 periodontal scaling and root planing - one to three teeth per quadrant $45
D4355 full mouth debridement to enable comprehensive evaluation and diagnosis $55
D4381 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report $40
Other Periodontal Services You Pay
D4910 periodontal maintenance $50
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) You Pay
D5110 complete denture - maxillary $825
D5120 complete denture - mandibular $825
D5130 immediate denture - maxillary $900
D5140 immediate denture - mandibular $900
Partial Dentures (Including Routine Post-Delivery Care) You Pay
D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $675
D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $675
D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $875
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $875
D5225 maxillary partial denture - flexible base (including any clasps, rests and teeth) $825
D5226 mandibular partial denture - flexible base (including any clasps, rests and teeth) $825
D5281 removable unilateral partial denture - one piece cast metal (including clasps and teeth) $425
Adjustments to Dentures You Pay
D5410 adjust complete dentures - maxillary $30
D5411 adjust complete dentures - mandibular $30
D5421 adjust partial denture - maxillary $30
D5422 adjust partial denture - mandibular $30
Repairs to Complete Dentures You Pay
D5510 repair broken complete denture base $130
D5520 replace missing or broken teeth - complete denture (each tooth) $125
Repairs to Partial Dentures You Pay
D5610 repair resin denture base $135
D5620 repair cast framework $135
D5630 repair or replace broken clasp $130
D5640 replace broken teeth - per tooth $130
D5650 add tooth to existing partial denture $130
D5660 add clasp to existing partial denture $135
D5670 replace all teeth and acrylic on cast metal framework (maxillary) $500
D5671 replace all teeth and acrylic on cast metal framework (mandibular) $500
Denture Rebase Procedures You Pay
D5710 rebase complete maxillary denture $225
D5711 rebase complete mandibular denture $225
D5720 rebase maxillary partial denture $225
D5721 rebase mandibular partial denture $225
Denture Reline Procedures You Pay
D5730 reline complete maxillary denture (chairside) $125
D5731 reline complete mandibular denture (chairside) $125
D5740 reline maxillary partial denture (chairside) $125
D5741 reline mandibular partial denture (chairside) $125
D5750 reline complete maxillary denture (laboratory) $200
D5751 reline complete mandibular denture (laboratory) $200
D5760 reline maxillary partial denture (laboratory) $200
D5761 reline mandibular partial denture (laboratory) $200
Interim Prosthesis You Pay
D5810 interim complete denture (maxillary) $325
D5811 interim complete denture (mandibular) $325
D5820 interim partial denture (maxillary) $325
D5821 interim partial denture (mandibular) $325
Other Removable Prosthetic Services You Pay
D5850 tissue conditioning, maxillary $30
D5851 tissue conditioning, mandibular $30
Implant Services
Implant Services You Pay
D6010 surgical placement of implant body: endosteal implant $1500
Implant Supported Prosthetics You Pay
D6053 implant/abutment supported removable denture for completely edentulous arch $2300
D6054 implant/abutment supported removable denture for partially edentulous arch $2300
D6056 prefabricated abutment - includes placement $450
D6057 custom abutment - includes placement $450
D6058 abutment supported porcelain/ceramic crown $1000*
D6059 abutment supported porcelain fused to metal crown (high noble metal) $1000*
D6060 abutment supported porcelain fused to metal crown (predominantly base metal) $1000
D6061 abutment supported porcelain fused to metal crown (noble metal) $1000*
D6062 abutment supported cast metal crown (high noble metal) $1000*
D6063 abutment supported cast metal crown (predominantly base metal) $1000
D6064 abutment supported cast metal crown (noble metal) $1000*
D6065 implant supported porcelain/ceramic crown $1000*
D6066 implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) $1000*
D6067 implant supported metal crown (titanium, titanium alloy, high noble metal) $1000*
D6068 abutment supported retainer for porcelain/ceramic FPD $1000*
D6069 abutment supported retainer for porcelain fused to metal FPD (high noble metal) $1000*
D6070 abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) $1000
D6071 abutment supported retainer for porcelain fused to metal FPD (noble metal) $1000*
D6072 abutment supported retainer for cast metal FPD (high noble metal) $1000*
D6073 abutment supported retainer for cast metal FPD (predominantly base metal) $1000
D6074 abutment supported retainer for cast metal FPD (noble metal) $1000*
D6075 implant supported retainer for ceramic FPD $1000*
D6076 implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) $1000*
D6077 implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) $1000*
Other Implant Services You Pay
D6092 recement implant/abutment supported crown $30
D6093 recement implant/abutment supported fixed partial denture $40
Implant Supported Prosthetics You Pay
D6094 abutment supported crown - (titanium) $500
D6194 abutment supported retainer crown for FPD - (titanium) $500
Prosthodontics, fixed
Fixed Partial Denture Pontics You Pay
D6205 pontic - indirect resin based composite $240
D6210 pontic - cast high noble metal $475*
D6211 pontic - cast predominantly base metal $475
D6212 pontic - cast noble metal $475*
D6214 pontic - titanium $475*
D6240 pontic - porcelain fused to high noble metal $475*
D6241 pontic - porcelain fused to predominantly base metal $475
D6242 pontic - porcelain fused to noble metal $475*
D6245 pontic - porcelain/ceramic $475*
D6250 pontic - resin with high noble metal $475*
D6251 pontic - resin with predominantly base metal $475
D6252 pontic - resin with noble metal $475*
Fixed Partial Denture Retainers-Inlays/Onlays You Pay
D6545 retainer - cast metal for resin bonded fixed prosthesis $310
D6548 retainer - porcelain/ceramic for resin bonded fixed prosthesis $550
D6600 inlay - procelain/ceramic, two surfaces $435*
D6601 inlay - porcelain/ceramic, three or more surfaces $475*
D6602 inlay - cast high noble metal, two surfaces $435*
D6603 inlay - cast high noble metal, three or more surfaces $475*
D6604 inlay - cast predominantly base metal, two surfaces $435
D6605 inlay - cast predominantly base metal, three or more surfaces $475
D6606 inlay - cast noble metal, two surfaces $435*
D6607 inlay - cast noble metal, three or more surfaces $475*
D6608 onlay - porcelain/ceramic, two surfaces $435*
D6609 onlay - porcelain/ceramic, three or more surfaces $475*
D6610 onlay - cast high noble metal, two surfaces $435*
D6611 onlay - cast high noble metal, three or more surfaces $475*
D6612 onlay - cast predominantly base metal, two surfaces $435
D6613 onlay - cast predominantly base metal, three or more surfaces $475
D6614 onlay - cast noble metal, two surfaces $435*
D6615 onlay - cast noble metal, three or more surfaces $475*
D6624 inlay - titanium $475*
D6634 onlay - titanium $475*
Fixed Partial Denture Retainers-Crowns You Pay
D6710 crown - indirect resin based composite $475
D6720 crown - resin with high noble metal $475*
D6721 crown - resin with predominantly base metal $475
D6722 crown - resin with noble metal $475*
D6740 crown - porcelain/ceramic $475*
D6750 crown - porcelain fused to high noble metal $475*
D6751 crown - porcelain fused to predominantly base metal $475
D6752 crown - porcelain fused to noble metal $475*
D6780 crown - 3/4 cast high noble metal $475*
D6781 crown - 3/4 cast predominantly base metal $475
D6782 crown - 3/4 cast noble metal $475*
D6783 crown - 3/4 porcelain/ceramic $475*
D6790 crown - full cast high noble metal $475*
D6791 crown - full cast predominantly base metal $475
D6792 crown - full cast noble metal $475*
D6794 crown - titanium $475*
Other Fixed Partial Denture Services You Pay
D6930 re-cement fixed partial denture $30
D6975 coping - metal $200
Oral and Maxillofacial Surgery
Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care) You Pay
D7111 extraction, coronal remnants - deciduous tooth $65
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) $65
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. $134
D7220 removal of impacted tooth - soft tissue $155
D7230 removal of impacted tooth - partially bony $195
D7240 removal of impacted tooth - completely bony $235
D7241 removal of impacted tooth - completely bony, with unusual surgical complications $275
D7250 surgical removal of residual tooth roots (cutting procedure) $150
Other Surgical Prodecures You Pay
D7270 tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $270
D7280 surgical access of an unerupted tooth $151
D7282 mobilization of erupted or malpositioned tooth to aid eruption $270
D7285 biopsy of oral tissue - hard (bone, tooth) $100
D7286 biopsy of oral tissue - soft $100
D7288 brush biopsy - transepithelial sample collection $25
Alveoloplasty-Surgical Preparation of Ridge for Dentures You Pay
D7310 alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $135
D7311 alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $150
D7320 alveoloplasty not in conjuction with extractions - four or more teeth or tooth spaces, per quadrant $165
D7321 alveoloplasty not in conjuction with extractions - one to three teeth or tooth spaces, per quadrant $105
Surgical Incision You Pay
D7510 incision and drainage of abscess - intraoral soft tissue $100
D7511 incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) $125
Other Repair Procedures You Pay
D7960 frenulectomy (frenectomy or frenotomy) - separate procedure $150
D7963 frenuloplasty $225
D7970 excision of hyperplastic tissue - per arch $125
D7971 excision of pericoronal gingiva $40
Orthodontics
Comprehensive Orthodontic Treatment You Pay
D8070 comprehensive orthodontic treatment of the transitional dentition $3,395
D8080 comprehensive orthodontic treatment of the adolescent dentition $3,395
D8090 comprehensive orthodontic treatment of the adult dentition $3,495
Minor Treatment to Control Harmful Habits You Pay
D8210 removable appliance therapy $250
D8220 fixed appliance therapy $230
Other Orthodontic Services You Pay
D8660 pre-orthodontic treatment visit $40
D8670 periodic orthodontic treatment visit (as part of contract) $5
D8680 orthodontic retention (removal of appliances, construction and placement of retainer(s)) $315
D8691 repair of orthodontic appliance $50
D8693 rebonding or recementing; and/or repair, as required, of fixed retainers $45
Adjunctive General Services
Unclassified Treatment You Pay
D9110 palliative (emergency) treatment of dental pain-minor procedure $30
D9120 fixed partial denture sectioning $35
Anesthesia You Pay
D9210 local anesthesia not in conjunction with operative or surgical procedures $50
D9211 regional block anesthesia $60
D9212 trigeminal division block anesthesia $150
D9215 local anesthesia no charge
D9220 deep sedation/general anesthesia-first 30 minutes $300
D9221 deep sedation/general anesthesia-each additional 15 minutes $100
D9230 analgesia, anxiolysis, inhalation of nitrous oxide $40
D9241 intravenous conscious sedation/analgesia-first 30 minutes $300
D9242 intravenous conscious sedation/analgesia-each additional 15 minutes $150
D9248 non-intravenous conscious sedation $250
Professional Consultation You Pay
D9310 consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician $20
Professional Visits You Pay
D9430 office visit for observation (during regularly scheduled hours)-no other services performed $25
D9440 office visit-after regularly scheduled hours $40
D9450 case presentation, detailed and extensive treatment planning no charge
Drugs You Pay
D9610 therapeutic parenteral drug, single administration $15
D9612 therapeutic parenteral drug, two or more administrations, different medications $30
D9630 other drugs and/or medicaments, by report $25
Miscellaneous Services You Pay
D9910 application of desensitizing medicament $15
D9911 application of desensitizing resin for cervical and/or root surface, per tooth $15
D9940 occlusal guard, by report $350
D9941 fabrication of athletic mouthguard $350
D9942 repair and/or reline of occlusal guard $75
D9951 occlusal adjustment - limited $35
D9952 occlusal adjustment - complete $75
D9970 enamel microabrasion $175
D9971 odontoplasty 1-2 teeth; includes removal of enamel projections $130
D9972 external bleaching - per arch $200
D9973 external bleaching - per tooth $40
D9974 internal bleaching - per tooth $75

*Patient is responsible for the cost of any laboratory charges.