Plan Information

Schedule of Benefits

The following schedule lists all the benefits and the applicable copayments. Should you require the care of a specialist, you may be treated by any CapDent participating endodontist, periodontist, oral surgeon or orthodontist. In such cases, your copayment will be different than the amounts shown on the Schedule.

*Services rendered by a participating specialist will be charged to you at 25% less than usual fees. Referral forms are not necessary.

Plan Features
Diagnostic
Clinical Oral Evaluation You Pay
D0120 periodic oral evaluation - established patient no charge
D0150 comprehensive oral 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
D0330 panoramic film no charge
Preventive
Dental Prophylaxis You Pay
D1110 prophylaxis - adult no charge
D1120 prophylaxis - child no charge
Topical Fluoride Treatment (Office Procedure) You Pay
D1203 topical application of fluoride - child no charge
Other Preventive Services You Pay
D1351 sealant - per tooth no charge*
Restorative
Amalgam Restorations (Including Polishing) You Pay
D2140 amalgam - one surface, primary or permanent $20
D2150 amalgam - two surfaces, primary or permanent $35
D2160 amalgam - three surfaces, primary or permanent $50
Resin - Based Composite Restorations - Direct You Pay
D2330 resin-based composite - one surface, anterior $25
D2331 resin-based composite - two surfaces, anterior $40
D2332 resin-based composite - three surfaces, anterior $55
Crowns - Single Restorations Only You Pay
D2740 crown - porcelain/ceramic substrate $385
D2750 crown - porcelain fused to high noble metal $425
D2790 crown - full cast high noble metal $295
Other Restorative Services You Pay
D2920 re-cement crown $35
D2930 prefabricated stainless steel crown - primary tooth $95
D2951 pin retention - per tooth, in addition to restoration $10
D2952 post and core in additon to crown, indirectly fabricated $95
D2954 prefabricated post and core in addition to crown $95
D2962 labial veneer (porcelain laminate) - laboratory $295
Endodontics
Pulp Capping You Pay
D3110 pulp cap - direct (excluding final restoration) $10*
D3120 pulp cap - indirect (excluding final restoration) $10*
Pulpotomy You Pay
D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $35*
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) You Pay
D3310 endodontic therapy, anterior tooth (excluding final restoration) $225*
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $290*
D3330 endodontic therapy, molar (excluding final restoration) $395*
Apicoectomy/Periradicular Services You Pay
D3410 apicoectomy/periradicular surgery - anterior $175*
Periodontics
Surgical Services (Including Usual Postoperative Care) You Pay
D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $125*
D4260 osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant $425*
Non-Surgical Periodontal Service You Pay
D4341 periodontal scaling and root planing - four or more teeth per quadrant $25*
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) You Pay
D5110 complete denture - maxillary $395
D5120 complete denture - mandibular $395
Partial Dentures (Including Routine Post-Delivery Care) You Pay
D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $395
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $395
Repairs to Complete Dentures You Pay
D5510 repair broken complete denture base $35-$95
D5520 replace missing or broken teeth - complete denture (each tooth) $35-$95
Repairs to Partial Dentures You Pay
D5610 repair resin denture base $35-$95
D5620 repair cast framework $35-$95
D5630 repair or replace broken clasp $35-$95
D5640 replace broken teeth - per tooth $35-$95
D5650 add tooth to existing partial denture $35-$95
Denture Reline Procedures You Pay
D5730 reline complete maxillary denture (chairside) $95
D5731 reline complete mandibular denture (chairside) $95
D5740 reline maxillary partial denture (chairside) $95
D5741 reline mandibular partial denture (chairside) $95
D5750 reline complete maxillary denture (laboratory) $150
D5751 reline complete mandibular denture (laboratory) $150
D5760 reline maxillary partial denture (laboratory) $150
D5761 reline mandibular partial denture (laboratory) $150
Prosthodontics, fixed
Fixed Partial Denture Pontics You Pay
D6240 pontic - porcelain fused to high noble metal $425
D6250 pontic - resin with high noble metal $295
Fixed Partial Denture Retainers-Crowns You Pay
D6720 crown - resin with high noble metal $295
D6750 crown - porcelain fused to high noble metal $425
D6790 crown - full cast high noble metal $295
Other Fixed Partial Denture Services You Pay
D6930 re-cement fixed partial denture $35
Oral and Maxillofacial Surgery
Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care) You Pay
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) $45*
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. $75*
D7220 removal of impacted tooth - soft tissue $95*
D7230 removal of impacted tooth - partially bony $125*
D7240 removal of impacted tooth - completely bony $160*
Alveoloplasty-Surgical Preparation of Ridge for Dentures You Pay
D7310 alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $95*
D7320 alveoloplasty not in conjuction with extractions - four or more teeth or tooth spaces, per quadrant $95*
Orthodontics
Limited Orthodontic Treatment You Pay
D8010 limited orthodontic treatment of the primary dentition 75%*
D8020 limited orthodontic treatment of the transitional dentition 75%*
D8030 limited orthodontic treatment of the adolescent dentition 75%*
D8040 limited orthodontic treatment of the adult dentition 75%*
Comprehensive Orthodontic Treatment You Pay
D8070 comprehensive orthodontic treatment of the transitional dentition 75%*
D8080 comprehensive orthodontic treatment of the adolescent dentition 75%*
D8090 comprehensive orthodontic treatment of the adult dentition 75%*
Adjunctive General Services
Unclassified Treatment You Pay
D9110 palliative (emergency) treatment of dental pain-minor procedure no charge

*sealant - per tooth - for dependent children between 5 and 15 years of age, restricted to previously unrestored permanent first and second molars, permitted once every five (5) years.