Plan Information

Discount Fee Schedule

This schedule is an extensive list of most common procedures. Due to plan variations, however, not every procedure is discounted. The purpose of this schedule is to establish the maximum fee that you will pay for the procedure listed below.

The following is a summary representation of the discounts offered.
For a full detail, please download your discount fee schedule… >> click here

*In conjunction with paid annual check-up prophylaxis (cleaning), $58.00 for adults and $40.00 for children.

Plan Features
Diagnostic
Clinical Oral Evaluation You Pay
D0120 periodic oral evaluation - established patient no charge*
D0140 limited oral evaluation - problem focused 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*
D0270 bitewing - single film no charge*
D0272 bitewings - two films no charge*
D0274 bitewings - four films no charge*
D0330 panoramic film no charge*
Preventive
Dental Prophylaxis You Pay
D1110 prophylaxis - adult $39
D1120 prophylaxis - child $28
Topical Fluoride Treatment (Office Procedure) You Pay
D1206 topical fluoride varnish; therapeutic application for moderate to high caries risk patients $14
D1208 topical application of fluoride $12
Other Preventive Services You Pay
D1351 sealant - per tooth $18
Space Maintenance (Passive Appliances) You Pay
D1510 space maintainer - fixed - unilateral $118
D1515 space maintainer - fixed - bilateral $172
Restorative
Amalgam Restorations (Including Polishing) You Pay
D2140 amalgam - one surface, primary or permanent $50
D2150 amalgam - two surfaces, primary or permanent $64
D2160 amalgam - three surfaces, primary or permanent $76
D2161 amalgam - four or more surfaces, primary or permanent $91
Resin - Based Composite Restorations - Direct You Pay
D2330 resin-based composite - one surface, anterior $61
D2331 resin-based composite - two surfaces, anterior $76
D2332 resin-based composite - three surfaces, anterior $95
D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) $119
D2391 resin-based composite - one surface, posterior $74
D2392 resin-based composite - two surfaces, posterior $101
D2393 resin-based composite - three surfaces, posterior $126
Crowns - Single Restorations Only You Pay
D2750 crown - porcelain fused to high noble metal $534
D2751 crown - porcelain fused to predominantly base metal $473
D2752 crown - porcelain fused to noble metal $501
D2791 crown - full cast predominantly base metal $428
Other Restorative Services You Pay
D2920 re-cement crown $39
D2930 prefabricated stainless steel crown - primary tooth $111
D2931 prefabricated stainless steel crown - permanent tooth $131
D2932 prefabricated resin crown $123
D2940 protective restoration $45
D2950 core buildup, including any pins $111
D2951 pin retention - per tooth, in addition to restoration $27
D2952 post and core in additon to crown, indirectly fabricated $167
D2953 each additonal indirectly fabricated post - same tooth $134
D2954 prefabricated post and core in addition to crown $139
D2960 labial veneer (resin laminate) - chairside $323
D2970 temporary crown (fractured tooth) $111
D2971 additional procedures to construct new crown under existing partial denture framework $111
Endodontics
Pulp Capping You Pay
D3110 pulp cap - direct (excluding final restoration) $28
D3120 pulp cap - indirect (excluding final restoration) $28
Pulpotomy You Pay
D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $67
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) You Pay
D3310 endodontic therapy, anterior tooth (excluding final restoration) $284
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $342
D3330 endodontic therapy, molar (excluding final restoration) $428
Apicoectomy/Periradicular Services You Pay
D3410 apicoectomy/periradicular surgery - anterior $356
D3426 apicoectomy/periradicular surgery (each additonal root) $145
D3430 retrograde filling - per root $139
D3450 root amputation - per root $178
Other Endodontic Procedures You Pay
D3920 hemisection (including any root removal), not including root canal therapy $145
Periodontics
Surgical Services (Including Usual Postoperative Care) You Pay
D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $234
D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant $90
D4240 gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quardant $312
D4260 osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant $428
D4270 pedicle soft tissue graft procedure $323
Non-Surgical Periodontal Service You Pay
D4341 periodontal scaling and root planing - four or more teeth per quadrant $101
D4345 periodontal scaling in the presence of gingival inflammation $112
D4355 full mouth debridement to enable comprehensive evaluation and diagnosis $84
Other Periodontal Services You Pay
D4910 periodontal maintenance $61
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) You Pay
D5110 complete denture - maxillary $623
D5120 complete denture - mandibular $623
D5130 immediate denture - maxillary $695
D5140 immediate denture - mandibular $695
Partial Dentures (Including Routine Post-Delivery Care) You Pay
D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $507
D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $507
D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $657
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $657
Adjustments to Dentures You Pay
D5410 adjust complete dentures - maxillary $39
D5411 adjust complete dentures - mandibular $39
D5421 adjust partial denture - maxillary $39
D5422 adjust partial denture - mandibular $39
Repairs to Complete Dentures You Pay
D5510 repair broken complete denture base $70
D5520 replace missing or broken teeth - complete denture (each tooth) $58
Repairs to Partial Dentures You Pay
D5610 repair resin denture base $78
D5630 repair or replace broken clasp $84
D5640 replace broken teeth - per tooth $67
D5650 add tooth to existing partial denture $83
D5660 add clasp to existing partial denture $71
Denture Rebase Procedures You Pay
D5710 rebase complete maxillary denture $224
D5711 rebase complete mandibular denture $228
D5720 rebase maxillary partial denture $228
D5721 rebase mandibular partial denture $228
Denture Reline Procedures You Pay
D5730 reline complete maxillary denture (chairside) $145
D5731 reline complete mandibular denture (chairside) $145
D5740 reline maxillary partial denture (chairside) $145
D5741 reline mandibular partial denture (chairside) $145
Interim Prosthesis You Pay
D5810 interim complete denture (maxillary) $339
D5811 interim complete denture (mandibular) $339
D5820 interim partial denture (maxillary) $301
D5821 interim partial denture (mandibular) $301
Prosthodontics, fixed
Fixed Partial Denture Pontics You Pay
D6210 pontic - cast high noble metal $501
D6240 pontic - porcelain fused to high noble metal $498
D6241 pontic - porcelain fused to predominantly base metal $462
Fixed Partial Denture Retainers-Inlays/Onlays You Pay
D6545 retainer - cast metal for resin bonded fixed prosthesis $228
Fixed Partial Denture Retainers-Crowns You Pay
D6751 crown - porcelain fused to predominantly base metal $470
D6790 crown - full cast high noble metal $504
D6791 crown - full cast predominantly base metal $420
Other Fixed Partial Denture Services You Pay
D6930 re-cement fixed partial denture $61
D6940 stress breaker $173
D6950 precision attachment $306
Oral and Maxillofacial Surgery
Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care) You Pay
D7111 extraction, coronal remnants - deciduous tooth $61
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) $75
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. $94
D7220 removal of impacted tooth - soft tissue $123
D7230 removal of impacted tooth - partially bony $158
D7240 removal of impacted tooth - completely bony $212
D7241 removal of impacted tooth - completely bony, with unusual surgical complications $250
D7250 surgical removal of residual tooth roots (cutting procedure) $106
Other Surgical Prodecures You Pay
D7280 surgical access of an unerupted tooth $0
Alveoloplasty-Surgical Preparation of Ridge for Dentures You Pay
D7310 alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $94
D7320 alveoloplasty not in conjuction with extractions - four or more teeth or tooth spaces, per quadrant $139
Other Repair Procedures You Pay
D7960 frenulectomy (frenectomy or frenotomy) - separate procedure $139
D7970 excision of hyperplastic tissue - per arch $106
D7971 excision of pericoronal gingiva $78
Orthodontics
Comprehensive Orthodontic Treatment You Pay
D8080 comprehensive orthodontic treatment of the adolescent dentition $3127**
D8090 comprehensive orthodontic treatment of the adult dentition 25% Discount
Adjunctive General Services
Unclassified Treatment You Pay
D9110 palliative (emergency) treatment of dental pain-minor procedure $24
Professional Visits You Pay
D9440 office visit-after regularly scheduled hours $61
Miscellaneous Services You Pay
D9940 occlusal guard, by report $267

** Continuation of orthodontic treatment beyond 24 months and other orthodontic services available at a 25% discount from usual and customary fees charged by orthodontists listed in the DDS Dental Directory. Orthodontic treatment includes the treatment of mixed and/or permanent dentitions under the 08400 and 08500 series procedure code. Orthodontic treatment for patients over the age of 16 is a 25% reduction from the dentist's usual and customary fee. Invisalign braces are 25% off the usual and customary fee.

Discount medical plan is provided by Patriot Health Florida, Inc., a discount medical plan organization. The plan is not a health insurance policy. The plan provides discounts at certain health care providers for medical services and does not make payments directly to the providers of medical services. The member is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with Patriot Health Florida, Inc., located at 160 Eileen Way, Syosset, New York 11791. Phone: 800-292-3797 Plan not available in MT, ND, SD and VT.