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 | *$550 |
| D2520 | inlay - metallic - two surfaces | *$585 |
| D2530 | inlay - metallic - three or more surfaces | *$615 |
| D2542 | onlay - metallic-two surfaces | *$585 |
| D2543 | onlay - metallic-three surfaces | *$585 |
| D2544 | onlay - metallic-four or more surfaces | *$585 |
| 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 | $550 |
| D2651 | inlay - resin-based composite - two surfaces | $585 |
| D2652 | inlay - resin-based composite - three or more surfaces | $615 |
| D2662 | onlay - resin-based composite - two surfaces | $585 |
| D2663 | onlay - resin-based composite - three surfaces | $615 |
| D2664 | onlay - resin-based composite - four or more surfaces | $615 |
| 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 | *$625 |
| D2721 | crown - resin with predominantly base metal | $475 |
| D2722 | crown - resin with noble metal | *$600 |
| D2740 | crown - porcelain/ceramic substrate | *$475 |
| D2750 | crown - porcelain fused to high noble metal | *$625 |
| D2751 | crown - porcelain fused to predominantly base metal | $475 |
| D2752 | crown - porcelain fused to noble metal | *$600 |
| D2780 | crown - 3/4 cast high noble metal | *$625 |
| D2781 | crown - 3/4 cast predominantly base metal | $475 |
| D2782 | crown - 3/4 cast noble metal | *$600 |
| D2783 | crown - 3/4 porcelain/ceramic | $475 |
| D2790 | crown - full cast high noble metal | *$625 |
| D2791 | crown - full cast predominantly base metal | $475 |
| D2792 | crown - full cast noble metal | *$600 |
| D2794 | crown - titanium | *$625 |
| 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 |
| 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 |
|
| 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) | *$1,150 |
| D6060 | abutment supported porcelain fused to metal crown (predominantly base metal) | $1,000 |
| D6061 | abutment supported porcelain fused to metal crown (noble metal) | *$1,125 |
| D6062 | abutment supported cast metal crown (high noble metal) | *$1,150 |
| D6063 | abutment supported cast metal crown (predominantly base metal) | $1,000 |
| D6064 | abutment supported cast metal crown (noble metal) | *$1,125 |
| D6065 | implant supported porcelain/ceramic crown | $1,000 |
| D6066 | implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) | *$1,150 |
| D6067 | implant supported metal crown (titanium, titanium alloy, high noble metal) | *$1,150 |
| D6068 | abutment supported retainer for porcelain/ceramic FPD | *$1,000 |
| D6069 | abutment supported retainer for porcelain fused to metal FPD (high noble metal) | *$1,150 |
| 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) | *$1,125 |
| D6072 | abutment supported retainer for cast metal FPD (high noble metal) | *$1,150 |
| D6073 | abutment supported retainer for cast metal FPD (predominantly base metal) | $1,000 |
| D6074 | abutment supported retainer for cast metal FPD (noble metal) | *$1,125 |
| 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) | *$1,150 |
| D6077 | implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) | *$1,150 |
| 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 | *$625 |
| D6211 | pontic - cast predominantly base metal | $475 |
| D6212 | pontic - cast noble metal | *$600 |
| D6214 | pontic - titanium | *$625 |
| D6240 | pontic - porcelain fused to high noble metal | *$625 |
| D6241 | pontic - porcelain fused to predominantly base metal | $475 |
| D6242 | pontic - porcelain fused to noble metal | *$600 |
| D6245 | pontic - porcelain/ceramic | *$475 |
| D6250 | pontic - resin with high noble metal | *$625 |
| D6251 | pontic - resin with predominantly base metal | $475 |
| D6252 | pontic - resin with noble metal | *$600 |
| 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 | *$585 |
| D6603 | inlay - cast high noble metal, three or more surfaces | *$625 |
| 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 | *$560 |
| D6607 | inlay - cast noble metal, three or more surfaces | *$600 |
| D6608 | onlay - porcelain/ceramic, two surfaces | $435 |
| D6609 | onlay - porcelain/ceramic, three or more surfaces | $475 |
| D6610 | onlay - cast high noble metal, two surfaces | *$585 |
| D6611 | onlay - cast high noble metal, three or more surfaces | *$585 |
| 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 | *$560 |
| D6615 | onlay - cast noble metal, three or more surfaces | *$600 |
| D6624 | inlay - titanium | *$585 |
| D6634 | onlay - titanium | *$585 |
| Fixed Partial Denture Retainers-Crowns | You Pay |
|
| D6710 | crown - indirect resin based composite | $475 |
| D6720 | crown - resin with high noble metal | *$625 |
| D6721 | crown - resin with predominantly base metal | $475 |
| D6722 | crown - resin with noble metal | *$600 |
| D6740 | crown - porcelain/ceramic | $475 |
| D6750 | crown - porcelain fused to high noble metal | *$625 |
| D6751 | crown - porcelain fused to predominantly base metal | $475 |
| D6752 | crown - porcelain fused to noble metal | *$600 |
| D6780 | crown - 3/4 cast high noble metal | *$625 |
| D6781 | crown - 3/4 cast predominantly base metal | $475 |
| D6782 | crown - 3/4 cast noble metal | *$600 |
| D6783 | crown - 3/4 porcelain/ceramic | $475 |
| D6790 | crown - full cast high noble metal | *$625 |
| D6791 | crown - full cast predominantly base metal | $475 |
| D6792 | crown - full cast noble metal | *$600 |
| D6794 | crown - titanium | *$625 |
| Other Fixed Partial Denture Services | You Pay |
|
| D6930 | re-cement fixed partial denture | $30 |
| 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 | $550 |
| D8220 | fixed appliance therapy | $550 |
| 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 |
| 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 |
| D9230 | analgesia, anxiolysis, inhalation of nitrous oxide | $40 |
| 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.