Plan Information

Fee Schedule

The following is a summary representation of the plan offered. For a full detail, please download your Schedule of Benefits. D.C., Maryland, New Jersey, New York, Pennsylvania, Virginia.

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Plan Features
Clinical Oral Evaluation You Pay
D0120 periodic oral evaluation - established patient No Charge*
D0140 limited oral evaluation - problem focused $45
D0150 comprehensive oral evaluation - new or established patient No Charge*
Radiographs/Diagnostic Imaging (Including Interpretation) You Pay
D0210 intraoral - complete series (including bitewings) $45-$70
D0220 intraoral - periapical first film $14-$17
D0230 intraoral - periapical each additional film $9-$10
D0270 bitewing - single film $12-$15
D0272 bitewings - two films $15-$20
D0274 bitewings - four films $35-$40
D0330 panoramic film $45-$55
Dental Prophylaxis You Pay
D1110 prophylaxis - adult $60
D1120 prophylaxis - child $40
Topical Fluoride Treatment (Office Procedure) You Pay
D1203 topical application of fluoride - child $22
Other Preventive Services You Pay
D1351 sealant - per tooth $30
Space Maintenance (Passive Appliances) You Pay
D1510 space maintainer - fixed - unilateral $150-$200
D1515 space maintainer - fixed - bilateral $225-$300
Amalgam Restorations (Including Polishing) You Pay
D2140 amalgam - one surface, primary or permanent $55-$70
D2150 amalgam - two surfaces, primary or permanent $75-$90
D2160 amalgam - three surfaces, primary or permanent $90-$110
D2161 amalgam - four or more surfaces, primary or permanent $120-$140
Resin - Based Composite Restorations - Direct You Pay
D2330 resin-based composite - one surface, anterior $75-$90
D2331 resin-based composite - two surfaces, anterior $90-$105
D2332 resin-based composite - three surfaces, anterior $110-$125
D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) $135-$150
D2391 resin-based composite - one surface, posterior $75-$90
D2392 resin-based composite - two surfaces, posterior $95-$115
D2393 resin-based composite - three surfaces, posterior $125-$155
D2394 resin-based composite - four or more surfaces, posterior $135-$175
Crowns - Single Restorations Only You Pay
D2750 crown - porcelain fused to high noble metal $600-$750
D2751 crown - porcelain fused to predominantly base metal $515-$600
D2752 crown - porcelain fused to noble metal $595-$650
D2799 crown - provisional crown $350-$425
Other Restorative Services You Pay
D2920 re-cement crown $45-$60
D2940 protective restoration $40-$50
D2950 core buildup, including any pins $135-$165
D2951 pin retention - per tooth, in addition to restoration $30-$35
D2952 post and core in additon to crown, indirectly fabricated $235-$262
D2954 prefabricated post and core in addition to crown $158-$185
D2960 labial veneer (resin laminate) - chairside $295-$355
D2962 labial veneer (porcelain laminate) - laboratory $480-$600
Pulp Capping You Pay
D3110 pulp cap - direct (excluding final restoration) $35-$45
Pulpotomy You Pay
D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $70-$95
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) You Pay
D3310 endodontic therapy, anterior tooth (excluding final restoration) $355-$400
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $415-$465
D3330 endodontic therapy, molar (excluding final restoration) $555-$625
Non-Surgical Periodontal Service You Pay
D4341 periodontal scaling and root planing - four or more teeth per quadrant $90-$105
D4355 full mouth debridement to enable comprehensive evaluation and diagnosis $70-$85
Other Periodontal Services You Pay
D4910 periodontal maintenance $65-$75
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) You Pay
D5110 complete denture - maxillary $750-$825
D5120 complete denture - mandibular $750-$825
D5130 immediate denture - maxillary $800-$925
D5140 immediate denture - mandibular $800-$925
Partial Dentures (Including Routine Post-Delivery Care) You Pay
D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $575-$675
D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $575-$675
D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $695-$875
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $695-$875
Adjustments to Dentures You Pay
D5410 adjust complete dentures - maxillary $45-$55
D5411 adjust complete dentures - mandibular $45-$55
Repairs to Complete Dentures You Pay
D5510 repair broken complete denture base $100-$115
D5520 replace missing or broken teeth - complete denture (each tooth) $85-$95
Repairs to Partial Dentures You Pay
D5650 add tooth to existing partial denture $105-$120
D5660 add clasp to existing partial denture $125-$140
Denture Reline Procedures You Pay
D5730 reline complete maxillary denture (chairside) $180-$210
D5731 reline complete mandibular denture (chairside) $180-$210
D5740 reline maxillary partial denture (chairside) $170-$195
D5741 reline mandibular partial denture (chairside) $170-$195
D5750 reline complete maxillary denture (laboratory) $225-$285
D5751 reline complete mandibular denture (laboratory) $225-$285
D5760 reline maxillary partial denture (laboratory) $195-$220
D5761 reline mandibular partial denture (laboratory) $195-$220
Prosthodontics, fixed
Fixed Partial Denture Pontics You Pay
D6240 pontic - porcelain fused to high noble metal $590-$725
D6241 pontic - porcelain fused to predominantly base metal $505-$595
D6242 pontic - porcelain fused to noble metal $585-$625
Fixed Partial Denture Retainers-Crowns You Pay
D6750 crown - porcelain fused to high noble metal $595-$735
D6751 crown - porcelain fused to predominantly base metal $510-$600
D6752 crown - porcelain fused to noble metal $590-$630
Other Fixed Partial Denture Services You Pay
D6930 re-cement fixed partial denture $60-$80
Oral and Maxillofacial Surgery
Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care) You Pay
D7111 extraction, coronal remnants - deciduous tooth $60-$70
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) $65-$90
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. $120-$150
D7250 surgical removal of residual tooth roots (cutting procedure) $130-$160
Surgical Incision You Pay
D7510 incision and drainage of abscess - intraoral soft tissue $100-$125

This plan does not meet the minimum creditable coverage requirements under M.G.L. c. 111M and 956 CMR 5.00. The plan provides discounts at certain health care providers for medical services. The range of discounts will vary depending on the type of provider and service. The plan does not make payments directly to the providers of medical services. Plan members are obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount medical plan organization. You may access a list of participating health care providers at this website. Upon request the plan will make available a written list of participating health care providers. You have the right to cancel within the first 30 days after receipt of membership materials and receive a full refund, less a nominal processing fee (nominal fee for MD residents is $5). Discount Medical Plan Organization and administrator: Careington International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034; phone 800-441-0380.

The program and its administrators have no liability for providing or guaranteeing service by providers or the quality of service rendered by providers. This program is not available in Montana and Vermont. This plan is not currently available in Washington.

*Medicare statement applies to MD residents when pharmacy discounts are part of program.

* Oral Examination and Diagnosis at no charge is in conjunction with cleaning and x-rays only.