Plan Information

Fee Schedule

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 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 $2
D0140 limited oral evaluation - problem focused $2
D0145 oral evaluation for a patient under three years of age and counseling with primary caregiver $2
D0150 comprehensive oral evaluation - new or established patient $5
D0160 detailed and extensive oral evaluation - problem focused, by report $40
D0170 re-evaluation - limited, problem focused (established patient; not post-operative visit) $2
D0180 comprehensive periodontal evaluation - new or established patient $12
Radiographs/Diagnostic Imaging (Including Interpretation) You Pay
D0210 intraoral - complete series (including bitewings) $0
D0220 intraoral - periapical first film $0
D0230 intraoral - periapical each additional film $0
D0240 intraoral - occlusal film $0
D0250 extraoral - first film $0
D0260 extraoral - each additional film $0
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 $18
D0340 cephalometric film $25
D0350 oral/facial photographic images $0
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 $0
D0470 diagnostic casts $35
Clinical Oral Evaluation You Pay
D0999A office visit fee - per visit $7
Preventive
Dental Prophylaxis You Pay
D1110 prophylaxis - adult $12
D1120 prophylaxis - child $12
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 $0
D1320 tobacco counseling for the control and prevention of oral disease $0
D1330 oral hygiene instructions $0
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 $25
D2150 amalgam - two surfaces, primary or permanent $35
D2160 amalgam - three surfaces, primary or permanent $48
D2161 amalgam - four or more surfaces, primary or permanent $60
Resin - Based Composite Restorations - Direct You Pay
D2330 resin-based composite - one surface, anterior $47
D2331 resin-based composite - two surfaces, anterior $57
D2332 resin-based composite - three surfaces, anterior $67
D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) $77
D2390 resin-based composite crown, anterior $90
D2391 resin-based composite - one surface, posterior $60
D2392 resin-based composite - two surfaces, posterior $75
D2393 resin-based composite - three surfaces, posterior $90
D2394 resin-based composite - four or more surfaces, posterior $105
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) $275
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $370
D3330 endodontic therapy, molar (excluding final restoration) $575
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 $70
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 $40
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 $1,500
Implant Supported Prosthetics You Pay
D6053 implant/abutment supported removable denture for completely edentulous arch $2,300
D6054 implant/abutment supported removable denture for partially edentulous arch $2,300
D6056 prefabricated abutment - includes placement $450
D6057 custom abutment - includes placement $450
D6058 abutment supported porcelain/ceramic crown *$1,000
D6059 abutment supported porcelain fused to metal crown (high noble metal) $1,000
D6060 abutment supported porcelain fused to metal crown (predominantly base metal) $1,000
D6061 abutment supported porcelain fused to metal crown (noble metal) *$1,000
D6062 abutment supported cast metal crown (high noble metal) *$1,000
D6063 abutment supported cast metal crown (predominantly base metal) $1,000
D6064 abutment supported cast metal crown (noble metal) *$1,000
D6065 implant supported porcelain/ceramic crown *$1,000
D6066 implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) *$1,000
D6067 implant supported metal crown (titanium, titanium alloy, high noble metal) $1,000
D6068 abutment supported retainer for porcelain/ceramic FPD *$1,000
D6069 abutment supported retainer for porcelain fused to metal FPD (high noble metal) *$1,000
D6070 abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) $1,000
D6071 abutment supported retainer for porcelain fused to metal FPD (noble metal) $1,000
D6072 abutment supported retainer for cast metal FPD (high noble metal) *$1,000
D6073 abutment supported retainer for cast metal FPD (predominantly base metal) $1,000
D6074 abutment supported retainer for cast metal FPD (noble metal) *$1,000
D6075 implant supported retainer for ceramic FPD *$1,000
D6076 implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) *$1,000
D6077 implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) *$1,000
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 $60
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) $60
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. $135
D7220 removal of impacted tooth - soft tissue $150
D7230 removal of impacted tooth - partially bony $180
D7240 removal of impacted tooth - completely bony $215
D7241 removal of impacted tooth - completely bony, with unusual surgical complications $265
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 $125
D7282 mobilization of erupted or malpositioned tooth to aid eruption $275
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 $110
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 $140
D7321 alveoloplasty not in conjuction with extractions - one to three teeth or tooth spaces, per quadrant $80
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 $0
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 $0
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 responisble for the cost of any laboratory charges.