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 covered and listed on schedule of benefits.

The following is a summary representation of the plan offered. For full detail and orthodontic benefit information, please download your Schedule of Benefits.

Plan Features
Diagnostic
Clinical Oral Evaluation You Pay
D0120 periodic oral evaluation - established patient no charge
D0140 limited oral evaluation - problem focused no charge
D0145 oral evaluation for a patient under three years of age and counseling with primary caregiver no charge
D0150 comprehensive oral evaluation - new or established patient no charge
D0160 detailed and extensive oral evaluation - problem focused, by report no charge
D0170 re-evaluation - limited, problem focused (established patient; not post-operative visit) no charge
D0180 comprehensive periodontal evaluation - new or established patient no charge
Radiographs/Diagnostic Imaging (Including Interpretation) You Pay
D0210 intraoral - complete series (including bitewings) no charge
D0220 intraoral - periapical first film no charge
D0230 intraoral - periapical each additional film no charge
D0240 intraoral - occlusal film no charge
D0250 extraoral - first film no charge
D0260 extraoral - each additional film no charge
D0270 bitewing - single film no charge
D0272 bitewings - two films no charge
D0273 bitewings - three films no charge
D0274 bitewings - four films no charge
D0277 vertical bitewings - 7 to 8 films no charge
D0330 panoramic film no charge
Tests and Examinations You Pay
D0460 pulp vitality tests no charge
D0470 diagnostic casts $5
Clinical Oral Evaluation You Pay
D0999A office visit fee - per visit $4
Preventive
Dental Prophylaxis You Pay
D1110 prophylaxis - adult no charge
D1120 prophylaxis - child no charge
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 no charge
D1351 sealant - per tooth $5
Space Maintenance (Passive Appliances) You Pay
D1510 space maintainer - fixed - unilateral $40
D1515 space maintainer - fixed - bilateral $60
D1520 space maintainer - removable - unilateral $30
D1525 space maintainer - removable - bilateral $40
D1550 re-cementation of space maintainer no charge
D1555 removal of fixed space maintainer no charge
Restorative
Amalgam Restorations (Including Polishing) You Pay
D2140 amalgam - one surface, primary or permanent no charge
D2150 amalgam - two surfaces, primary or permanent no charge
D2160 amalgam - three surfaces, primary or permanent no charge
D2161 amalgam - four or more surfaces, primary or permanent no charge
Resin - Based Composite Restorations - Direct You Pay
D2330 resin-based composite - one surface, anterior $20
D2331 resin-based composite - two surfaces, anterior $33
D2332 resin-based composite - three surfaces, anterior $46
D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) $60
D2390 resin-based composite crown, anterior $60
D2391 resin-based composite - one surface, posterior $85
D2392 resin-based composite - two surfaces, posterior $120
D2393 resin-based composite - three surfaces, posterior $150
D2394 resin-based composite - four or more surfaces, posterior $160
Inlay/Onlay Restorations You Pay
D2510 inlay - metallic - one surface $200
D2520 inlay - metallic - two surfaces $200
D2530 inlay - metallic - three or more surfaces $200
D2542 onlay - metallic-two surfaces $200
D2543 onlay - metallic-three surfaces $200
D2544 onlay - metallic-four or more surfaces $200
D2610 inlay - porcelain/ceramic - one surface $340
D2620 inlay - porcelain/ceramic - two surfaces $340
D2630 inlay - porcelain/ceramic - three or more surfaces $340
D2642 onlay - porcelain/ceramic - two surface $340
D2643 onlay - porcelain/ceramic - three surfaces $340
D2644 onlay - porcelain/ceramic - four or more surfaces $340
D2650 inlay - resin-based composite - one surface $230
D2651 inlay - resin-based composite - two surfaces $250
D2652 inlay - resin-based composite - three or more surfaces $250
D2662 onlay - resin-based composite - two surfaces $250
D2663 onlay - resin-based composite - three surfaces $250
D2664 onlay - resin-based composite - four or more surfaces $250
Crowns - Single Restorations Only You Pay
D2710 crown - resin-based composite (indirect) $120
D2712 crown - 3/4 resin-based composite (indirect) $120
D2720 crown - resin with high noble metal $120*
D2721 crown - resin with predominantly base metal $120
D2722 crown - resin with noble metal $120*
D2740 crown - porcelain/ceramic substrate $240
D2750 crown - porcelain fused to high noble metal $240*
D2751 crown - porcelain fused to predominantly base metal $240
D2752 crown - porcelain fused to noble metal $240*
D2780 crown - 3/4 cast high noble metal $225*
D2781 crown - 3/4 cast predominantly base metal $225
D2782 crown - 3/4 cast noble metal $225*
D2783 crown - 3/4 porcelain/ceramic $240
D2790 crown - full cast high noble metal $225*
D2791 crown - full cast predominantly base metal $225
D2792 crown - full cast noble metal $225*
D2794 crown - titanium $225
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 $50
D2931 prefabricated stainless steel crown - permanent tooth $50
D2932 prefabricated resin crown $50
D2933 prefabricated stainless steel crown with resin window $70
D2934 prefabricated esthetic coated stainless steel crown - primary tooth $70
D2940 protective restoration no charge
D2950 core buildup, including any pins $25
D2951 pin retention - per tooth, in addition to restoration $20
D2952 post and core in additon to crown, indirectly fabricated $60
D2953 each additonal indirectly fabricated post - same tooth no charge
D2954 prefabricated post and core in addition to crown $55
D2955 post removal (not in conjunction with endodontic therapy) $55
D2957 each additonal prefabricated post - same tooth no charge
D2960 labial veneer (resin laminate) - chairside $220
D2961 labial veneer (resin laminate) - laboratory $260
D2962 labial veneer (porcelain laminate) - laboratory $340
D2970 temporary crown (fractured tooth) $50
D2971 additional procedures to construct new crown under existing partial denture framework $25
D2975 coping $200
Endodontics
Pulp Capping You Pay
D3110 pulp cap - direct (excluding final restoration) $10
D3120 pulp cap - indirect (excluding final restoration) $4
Pulpotomy You Pay
D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $15
D3221 pulpal debridement, primary and permanent teeth $15
D3222 partial pulpotomy for apexogenesis - permanent tooth with incomplete root development $15
Endodontic Therapy on Primary Teeth You Pay
D3230 pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) $45
D3240 pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) $55
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) You Pay
D3310 endodontic therapy, anterior tooth (excluding final restoration) $100
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $175
D3330 endodontic therapy, molar (excluding final restoration) $300
D3331 treatment of root canal obstruction; non-surgical access $45
D3332 incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $70
D3333 internal root repair of perforation defects $45
Endodontic Retreatment You Pay
D3346 retreatment of previous root canal therapy - anterior $150
D3347 retreatment of previous root canal therapy - bicuspid $250
D3348 retreatment of previous root canal therapy - molar $350
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
Apicoectomy/Periradicular Services You Pay
D3410 apicoectomy/periradicular surgery - anterior $150
D3421 apicoectomy/periradicular surgery - bicuspid (first root) $150
D3425 apicoectomy/periradicular surgery - molar (first root) $150
D3426 apicoectomy/periradicular surgery (each additonal root) $100
D3430 retrograde filling - per root $80
Other Endodontic Procedures You Pay
D3950 canal preparation and fitting of preformed dowel or post $55
Periodontics
Surgical Services (Including Usual Postoperative Care) You Pay
D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $120
D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant $50
D4240 gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quardant $250
D4241 gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quardant $200
D4245 apically positioned flap $200
D4249 clinical crown lengthening - hard tissue $250
D4260 osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant $300
D4261 osseous surgery (including flap entry and closure) - one to three teeth contiguous teeth or tooth bounded spaces per quadrant $200
Non-Surgical Periodontal Service You Pay
D4341 periodontal scaling and root planing - four or more teeth per quadrant $45
D4342 periodontal scaling and root planing - one to three teeth per quadrant $30
D4355 full mouth debridement to enable comprehensive evaluation and diagnosis $45
D4381 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report $50
Other Periodontal Services You Pay
D4910 periodontal maintenance $45
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) You Pay
D5110 complete denture - maxillary $310
D5120 complete denture - mandibular $310
D5130 immediate denture - maxillary $320
D5140 immediate denture - mandibular $320
Partial Dentures (Including Routine Post-Delivery Care) You Pay
D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $180
D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $180
D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $410
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $410
D5225 maxillary partial denture - flexible base (including any clasps, rests and teeth) $610
D5226 mandibular partial denture - flexible base (including any clasps, rests and teeth) $610
D5281 removable unilateral partial denture - one piece cast metal (including clasps and teeth) $130
Adjustments to Dentures You Pay
D5410 adjust complete dentures - maxillary no charge
D5411 adjust complete dentures - mandibular no charge
D5421 adjust partial denture - maxillary no charge
D5422 adjust partial denture - mandibular no charge
Repairs to Complete Dentures You Pay
D5510 repair broken complete denture base $30
D5520 replace missing or broken teeth - complete denture (each tooth) $20
Repairs to Partial Dentures You Pay
D5610 repair resin denture base $30
D5620 repair cast framework $50
D5630 repair or replace broken clasp $40
D5640 replace broken teeth - per tooth $20
D5650 add tooth to existing partial denture $20
D5660 add clasp to existing partial denture $30
D5670 replace all teeth and acrylic on cast metal framework (maxillary) $220
D5671 replace all teeth and acrylic on cast metal framework (mandibular) $220
Denture Rebase Procedures You Pay
D5710 rebase complete maxillary denture $120
D5711 rebase complete mandibular denture $120
D5720 rebase maxillary partial denture $120
D5721 rebase mandibular partial denture $120
Denture Reline Procedures You Pay
D5730 reline complete maxillary denture (chairside) $60
D5731 reline complete mandibular denture (chairside) $60
D5740 reline maxillary partial denture (chairside) $60
D5741 reline mandibular partial denture (chairside) $60
D5750 reline complete maxillary denture (laboratory) $90
D5751 reline complete mandibular denture (laboratory) $90
D5760 reline maxillary partial denture (laboratory) $90
D5761 reline mandibular partial denture (laboratory) $90
Interim Prosthesis You Pay
D5810 interim complete denture (maxillary) $100
D5811 interim complete denture (mandibular) $100
D5820 interim partial denture (maxillary) $100
D5821 interim partial denture (mandibular) $100
Other Removable Prosthetic Services You Pay
D5850 tissue conditioning, maxillary $25
D5851 tissue conditioning, mandibular $25
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 $120
D6210 pontic - cast high noble metal $225*
D6211 pontic - cast predominantly base metal $225
D6212 pontic - cast noble metal $225*
D6214 pontic - titanium $225
D6240 pontic - porcelain fused to high noble metal $240*
D6241 pontic - porcelain fused to predominantly base metal $240
D6242 pontic - porcelain fused to noble metal $240*
D6245 pontic - porcelain/ceramic $240
D6250 pontic - resin with high noble metal $120*
D6251 pontic - resin with predominantly base metal $120
D6252 pontic - resin with noble metal $120*
Fixed Partial Denture Retainers-Inlays/Onlays You Pay
D6545 retainer - cast metal for resin bonded fixed prosthesis $170
D6548 retainer - porcelain/ceramic for resin bonded fixed prosthesis $170
D6600 inlay - procelain/ceramic, two surfaces $240
D6601 inlay - porcelain/ceramic, three or more surfaces $240
D6602 inlay - cast high noble metal, two surfaces $230*
D6603 inlay - cast high noble metal, three or more surfaces $230*
D6604 inlay - cast predominantly base metal, two surfaces $230
D6605 inlay - cast predominantly base metal, three or more surfaces $230
D6606 inlay - cast noble metal, two surfaces $230*
D6607 inlay - cast noble metal, three or more surfaces $230*
D6608 onlay - porcelain/ceramic, two surfaces $230
D6609 onlay - porcelain/ceramic, three or more surfaces $230
D6610 onlay - cast high noble metal, two surfaces $230*
D6611 onlay - cast high noble metal, three or more surfaces $230*
D6612 onlay - cast predominantly base metal, two surfaces $230
D6613 onlay - cast predominantly base metal, three or more surfaces $230
D6614 onlay - cast noble metal, two surfaces $230*
D6615 onlay - cast noble metal, three or more surfaces $230*
D6624 inlay - titanium $225
D6634 onlay - titanium $225
Fixed Partial Denture Retainers-Crowns You Pay
D6710 crown - indirect resin based composite $120
D6720 crown - resin with high noble metal $120*
D6721 crown - resin with predominantly base metal $120
D6722 crown - resin with noble metal $120*
D6740 crown - porcelain/ceramic $230
D6750 crown - porcelain fused to high noble metal $240*
D6751 crown - porcelain fused to predominantly base metal $240
D6752 crown - porcelain fused to noble metal $240*
D6780 crown - 3/4 cast high noble metal $225*
D6781 crown - 3/4 cast predominantly base metal $225
D6782 crown - 3/4 cast noble metal $225*
D6783 crown - 3/4 porcelain/ceramic $250
D6790 crown - full cast high noble metal $225*
D6791 crown - full cast predominantly base metal $225
D6792 crown - full cast noble metal $225*
D6794 crown - titanium $225
Other Fixed Partial Denture Services You Pay
D6930 re-cement fixed partial denture $20
D6975 coping - metal $60*
Oral and Maxillofacial Surgery
Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care) You Pay
D7111 extraction, coronal remnants - deciduous tooth no charge
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) no charge
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. $30
D7220 removal of impacted tooth - soft tissue $50
D7230 removal of impacted tooth - partially bony $75
D7240 removal of impacted tooth - completely bony $100
D7250 surgical removal of residual tooth roots (cutting procedure) $120
Other Surgical Prodecures You Pay
D7270 tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $200
Alveoloplasty-Surgical Preparation of Ridge for Dentures You Pay
D7310 alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $55
D7311 alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $55
D7320 alveoloplasty not in conjuction with extractions - four or more teeth or tooth spaces, per quadrant $55
D7321 alveoloplasty not in conjuction with extractions - one to three teeth or tooth spaces, per quadrant $55
Surgical Incision You Pay
D7510 incision and drainage of abscess - intraoral soft tissue $5
D7511 incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) $100
Adjunctive General Services
Unclassified Treatment You Pay
D9110 palliative (emergency) treatment of dental pain-minor procedure $10
Anesthesia You Pay
D9215 local anesthesia no charge
Professional Consultation You Pay
D9310 consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician no charge
Professional Visits You Pay
D9440 office visit-after regularly scheduled hours $50
D9450 case presentation, detailed and extensive treatment planning no charge
Drugs You Pay
D9630 other drugs and/or medicaments, by report $25
Miscellaneous Services You Pay
D9910 application of desensitizing medicament $20
D9911 application of desensitizing resin for cervical and/or root surface, per tooth $20
D9940 occlusal guard, by report $180
D9941 fabrication of athletic mouthguard $100
D9970 enamel microabrasion $20
D9971 odontoplasty 1-2 teeth; includes removal of enamel projections $20
D9972 external bleaching - per arch $200
D9973 external bleaching - per tooth $100
D9974 internal bleaching - per tooth $100
* Additional charges of $125 for noble metal, $150 for high noble metal. Add $100 for porcelain on molars, $50 for porcelain butt margin, $200 for specialized crowns such as Lava, Captek, Empress, Procera, etc.