Plan Information

Solstice Dental Plus Basic Member Fee Schedule

The following member fees apply when a participating General Dentist performs services. Participating Specialists are available at fees discounted off of their usual and customary charges. An “*” denotes limitation on certain discounts (see “Exclusion/Limitations”)

This plan is not dental insurance. This plan provides discounts at certain dental providers for dental services. The plan does not make payments directly to the dental providers for dental services. . The plan member is obligated to pay for all dental care services, but will receive a discount from those providers who have contracted with Solstice Benefits.

Plan Features
Diagnostic
Clinical Oral Evaluation You Pay
D0120 periodic oral evaluation - established patient $10
D0140 limited oral evaluation - problem focused $15
D0150 comprehensive oral evaluation - new or established patient $20
D0160 detailed and extensive oral evaluation - problem focused, by report $20
D0170 re-evaluation - limited, problem focused (established patient; not post-operative visit) $10
D0180 comprehensive periodontal evaluation - new or established patient $15
Radiographs/Diagnostic Imaging (Including Interpretation) You Pay
D0210 intraoral - complete series (including bitewings) $20
D0220 intraoral - periapical first film $4
D0230 intraoral - periapical each additional film $4
D0240 intraoral - occlusal film $4
D0250 extraoral - first film $4
D0260 extraoral - each additional film $4
D0270 bitewing - single film $6
D0272 bitewings - two films $8
D0274 bitewings - four films $25
D0277 vertical bitewings - 7 to 8 films $30
D0290 posterior - anterior or lateral skull and facial bone survey film $150
D0310 sialography $150
D0320 temporomandibular joint arthrogram, including injection $250
D0321 other temporomandibular joint films, by report $150
D0322 tomographic survey $150
D0330 panoramic film $50
D0340 cephalometric film $150
D0350 oral/facial photographic images $20
Tests and Examinations You Pay
D0415 collection of microorganisms for culture and sensitivity No charge
D0425 caries susceptibility tests No charge
D0460 pulp vitality tests $10
D0470 diagnostic casts $25
Preventive
Dental Prophylaxis You Pay
D1110 prophylaxis - adult $10
D1120 prophylaxis - child $10
Topical Fluoride Treatment (Office Procedure) You Pay
D1203 topical application of fluoride - child $15
D1204 topical application of fluoride - adult $20
Other Preventive Services You Pay
D1310 nutritional counseling for control of dental disease $10
D1320 tobacco counseling for the control and prevention of oral disease $10
D1330 oral hygiene instructions $10
D1351 sealant - per tooth $15
Space Maintenance (Passive Appliances) You Pay
D1510 space maintainer - fixed - unilateral $120
D1515 space maintainer - fixed - bilateral $175
D1520 space maintainer - removable - unilateral $160
D1525 space maintainer - removable - bilateral $250
D1550 re-cementation of space maintainer $25
Restorative
Amalgam Restorations (Including Polishing) You Pay
D2140 amalgam - one surface, primary or permanent $50
D2150 amalgam - two surfaces, primary or permanent $55
D2160 amalgam - three surfaces, primary or permanent $60
D2161 amalgam - four or more surfaces, primary or permanent $75
Resin - Based Composite Restorations - Direct You Pay
D2330 resin-based composite - one surface, anterior $45
D2331 resin-based composite - two surfaces, anterior $65
D2332 resin-based composite - three surfaces, anterior $75
D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) $88
D2390 resin-based composite crown, anterior $125
D2391 resin-based composite - one surface, posterior $70
D2392 resin-based composite - two surfaces, posterior $80
D2393 resin-based composite - three surfaces, posterior $95
D2394 resin-based composite - four or more surfaces, posterior $120
Gold Foil Restorations You Pay
D2410 gold foil - one surface $75
D2420 gold foil - two surfaces $95
D2430 gold foil - three surfaces $125
Inlay/Onlay Restorations You Pay
D2510 inlay - metallic - one surface $300
D2520 inlay - metallic - two surfaces $320
D2530 inlay - metallic - three or more surfaces $340
D2542 onlay - metallic-two surfaces $325
D2543 onlay - metallic-three surfaces $330
D2544 onlay - metallic-four or more surfaces $355
D2610 inlay - porcelain/ceramic - one surface $325
D2620 inlay - porcelain/ceramic - two surfaces $350
D2630 inlay - porcelain/ceramic - three or more surfaces $375
D2642 onlay - porcelain/ceramic - two surface $395
D2643 onlay - porcelain/ceramic - three surfaces $415
D2644 onlay - porcelain/ceramic - four or more surfaces $445
D2650 inlay - resin-based composite - one surface $195
D2651 inlay - resin-based composite - two surfaces $250
D2652 inlay - resin-based composite - three or more surfaces $275
D2662 onlay - resin-based composite - two surfaces $250
D2663 onlay - resin-based composite - three surfaces $275
D2664 onlay - resin-based composite - four or more surfaces $290
Crowns - Single Restorations Only You Pay
D2710 crown - resin-based composite (indirect) $220
D2720 crown - resin with high noble metal $480
D2721 crown - resin with predominantly base metal $410
D2722 crown - resin with noble metal $425
D2740 crown - porcelain/ceramic substrate $525
D2750 crown - porcelain fused to high noble metal $525
D2751 crown - porcelain fused to predominantly base metal $425
D2752 crown - porcelain fused to noble metal $480
D2780 crown - 3/4 cast high noble metal $430
D2781 crown - 3/4 cast predominantly base metal $410
D2782 crown - 3/4 cast noble metal $420
D2783 crown - 3/4 porcelain/ceramic $450
D2790 crown - full cast high noble metal $499
D2791 crown - full cast predominantly base metal $425
D2792 crown - full cast noble metal $480
D2799 crown - provisional crown $130
Other Restorative Services You Pay
D2910 recement inlay, onlay, or partial coverage restoration $25
D2920 re-cement crown $25
D2930 prefabricated stainless steel crown - primary tooth $95
D2931 prefabricated stainless steel crown - permanent tooth $95
D2932 prefabricated resin crown $95
D2933 prefabricated stainless steel crown with resin window $145
D2940 protective restoration $40
D2950 core buildup, including any pins $85
D2951 pin retention - per tooth, in addition to restoration $20
D2952 post and core in additon to crown, indirectly fabricated $155
D2953 each additonal indirectly fabricated post - same tooth $105
D2954 prefabricated post and core in addition to crown $125
D2955 post removal (not in conjunction with endodontic therapy) $30
D2957 each additonal prefabricated post - same tooth $30
D2960 labial veneer (resin laminate) - chairside $205
D2961 labial veneer (resin laminate) - laboratory $260
D2962 labial veneer (porcelain laminate) - laboratory $425
D2970 temporary crown (fractured tooth) $75
D2980 crown repair, by report $95
Endodontics
Pulp Capping You Pay
D3110 pulp cap - direct (excluding final restoration) $25
D3120 pulp cap - indirect (excluding final restoration) $25
Pulpotomy You Pay
D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $75
D3221 pulpal debridement, primary and permanent teeth $95
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) $90
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) You Pay
D3310 endodontic therapy, anterior tooth (excluding final restoration) $320
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $385
D3330 endodontic therapy, molar (excluding final restoration) $495
D3331 treatment of root canal obstruction; non-surgical access $85
D3332 incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $125
D3333 internal root repair of perforation defects $130
Endodontic Retreatment You Pay
D3346 retreatment of previous root canal therapy - anterior $375
D3347 retreatment of previous root canal therapy - bicuspid $410
D3348 retreatment of previous root canal therapy - molar $550
Apexification/Recalcification Procedures You Pay
D3351 apexification/recalcification/pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) $155
D3352 apexification/recalcification/pulpal regeneration - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) $110
D3353 apexification/recalcification - final visit (includes completed root canal therapy -apical closure/calcific repair of perforations, root resorption, etc.) $110
Apicoectomy/Periradicular Services You Pay
D3410 apicoectomy/periradicular surgery - anterior $275
D3421 apicoectomy/periradicular surgery - bicuspid (first root) $325
D3425 apicoectomy/periradicular surgery - molar (first root) $350
D3426 apicoectomy/periradicular surgery (each additonal root) $115
D3430 retrograde filling - per root $85
D3450 root amputation - per root $199
D3470 intentional reimplantation (including necessary splinting) $180
Other Endodontic Procedures You Pay
D3910 surgical procedure for isolation of tooth with rubber dam $95
D3920 hemisection (including any root removal), not including root canal therapy $150
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 $195
D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant $50
D4240 gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quardant $325
D4241 gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quardant $250
D4245 apically positioned flap $150
D4249 clinical crown lengthening - hard tissue $250
D4260 osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant $450
D4261 osseous surgery (including flap entry and closure) - one to three teeth contiguous teeth or tooth bounded spaces per quadrant $420
D4263 bone replacement graft - first site in quadrant $200
D4264 bone replacement graft - each additonal site in quadrant $120
D4266 guided tissue regeneration - resorbable barrier, per site $191
D4267 guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) $224
D4270 pedicle soft tissue graft procedure $359
D4271 free soft tissue graft procedure (including donor site surgery) $340
D4273 subepithelial connective tissue graft procedures, per tooth $395
D4274 distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) $128
Non-Surgical Periodontal Service You Pay
D4341 periodontal scaling and root planing - four or more teeth per quadrant $80
D4342 periodontal scaling and root planing - one to three teeth per quadrant $60
D4355 full mouth debridement to enable comprehensive evaluation and diagnosis $80
D4381 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report $70
Other Periodontal Services You Pay
D4910 periodontal maintenance $55
D4920 unscheduled dressing change (by someone other than treating dentist) $25
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) You Pay
D5110 complete denture - maxillary $625
D5120 complete denture - mandibular $625
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) $450
D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $490
D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $655
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $655
Adjustments to Dentures You Pay
D5410 adjust complete dentures - maxillary $20
D5411 adjust complete dentures - mandibular $20
D5421 adjust partial denture - maxillary $20
D5422 adjust partial denture - mandibular $20
Repairs to Complete Dentures You Pay
D5510 repair broken complete denture base $75
D5520 replace missing or broken teeth - complete denture (each tooth) $70
Repairs to Partial Dentures You Pay
D5610 repair resin denture base $50
D5620 repair cast framework $55
D5630 repair or replace broken clasp $55
D5640 replace broken teeth - per tooth $45
D5650 add tooth to existing partial denture $65
D5660 add clasp to existing partial denture $75
Denture Rebase Procedures You Pay
D5710 rebase complete maxillary denture $195
D5711 rebase complete mandibular denture $195
D5720 rebase maxillary partial denture $175
D5721 rebase mandibular partial denture $175
Denture Reline Procedures You Pay
D5730 reline complete maxillary denture (chairside) $85
D5731 reline complete mandibular denture (chairside) $85
D5740 reline maxillary partial denture (chairside) $65
D5741 reline mandibular partial denture (chairside) $65
D5750 reline complete maxillary denture (laboratory) $150
D5751 reline complete mandibular denture (laboratory) $150
D5760 reline maxillary partial denture (laboratory) $110
D5761 reline mandibular partial denture (laboratory) $110
Interim Prosthesis You Pay
D5810 interim complete denture (maxillary) $250
D5811 interim complete denture (mandibular) $250
D5820 interim partial denture (maxillary) $250
D5821 interim partial denture (mandibular) $250
Other Removable Prosthetic Services You Pay
D5850 tissue conditioning, maxillary $55
D5851 tissue conditioning, mandibular $55
D5862 precision attachment, by report $150
D5899 unspecified removable prosthodontic procedure, by report No charge
Prosthodontics, fixed
Fixed Partial Denture Pontics You Pay
D6210 pontic - cast high noble metal $499
D6211 pontic - cast predominantly base metal $425
D6212 pontic - cast noble metal $480
D6240 pontic - porcelain fused to high noble metal $499
D6241 pontic - porcelain fused to predominantly base metal $425
D6242 pontic - porcelain fused to noble metal $480
D6245 pontic - porcelain/ceramic $495
D6250 pontic - resin with high noble metal $455
D6251 pontic - resin with predominantly base metal $405
D6252 pontic - resin with noble metal $425
Fixed Partial Denture Retainers-Inlays/Onlays You Pay
D6545 retainer - cast metal for resin bonded fixed prosthesis $190
D6548 retainer - porcelain/ceramic for resin bonded fixed prosthesis $230
Fixed Partial Denture Retainers-Crowns You Pay
D6720 crown - resin with high noble metal $455
D6721 crown - resin with predominantly base metal $405
D6722 crown - resin with noble metal $425
D6740 crown - porcelain/ceramic $495
D6750 crown - porcelain fused to high noble metal $499
D6751 crown - porcelain fused to predominantly base metal $425
D6752 crown - porcelain fused to noble metal $480
D6780 crown - 3/4 cast high noble metal $430
D6781 crown - 3/4 cast predominantly base metal $410
D6782 crown - 3/4 cast noble metal $420
D6783 crown - 3/4 porcelain/ceramic $410
D6790 crown - full cast high noble metal $499
D6791 crown - full cast predominantly base metal $425
D6792 crown - full cast noble metal $480
Other Fixed Partial Denture Services You Pay
D6930 re-cement fixed partial denture $40
D6940 stress breaker $125
D6950 precision attachment $195
D6970 post and core in addition to fixed partial denture retainer, indirectly fabricated $170
D6971 cast post as part of fixed partial denture retainer $165
D6972 prefabricated post and core in addition to fixed partial denture retainer $125
D6973 core build up for retainer, including any pins $95
D6975 coping - metal $95
D6976 each additional indirectly fabricated post - same tooth $75
D6977 each additional prefabricated post - same tooth $75
Oral and Maxillofacial Surgery
Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care) You Pay
D7111 extraction, coronal remnants - deciduous tooth $45
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) $70
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
D7220 removal of impacted tooth - soft tissue $125
D7230 removal of impacted tooth - partially bony $145
D7240 removal of impacted tooth - completely bony $165
D7241 removal of impacted tooth - completely bony, with unusual surgical complications $180
D7250 surgical removal of residual tooth roots (cutting procedure) $95
Other Surgical Prodecures You Pay
D7260 oroantral fistula closure $165
D7270 tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $56
D7280 surgical access of an unerupted tooth $130
Periodontics
Surgical Services (Including Usual Postoperative Care) You Pay
D7281 Surgical exposure of impacted or unerupted tooth to aid eruption $130
Oral and Maxillofacial Surgery
Other Surgical Prodecures You Pay
D7285 biopsy of oral tissue - hard (bone, tooth) $120
D7286 biopsy of oral tissue - soft $95
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 $130
Surgical Excision of Intra-Osseous Lesions You Pay
D7450 removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm $65
D7451 removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm $95
Periodontics
Surgical Services (Including Usual Postoperative Care) You Pay
D7470 Removal of exotosis $80
Oral and Maxillofacial Surgery
Surgical Incision You Pay
D7510 incision and drainage of abscess - intraoral soft tissue $55
Other Repair Procedures You Pay
D7960 frenulectomy (frenectomy or frenotomy) - separate procedure $110
D7970 excision of hyperplastic tissue - per arch $140
Orthodontics
Minor Treatment to Control Harmful Habits You Pay
D8210 removable appliance therapy $103
D8220 fixed appliance therapy $103
Adjunctive General Services
Anesthesia You Pay
D9215 local anesthesia No charge
D9220 deep sedation/general anesthesia-first 30 minutes $125
D9221 deep sedation/general anesthesia-each additional 15 minutes $55
D9230 analgesia, anxiolysis, inhalation of nitrous oxide $20
D9241 intravenous conscious sedation/analgesia-first 30 minutes $125
D9242 intravenous conscious sedation/analgesia-each additional 15 minutes $55
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 $10
D9440 office visit-after regularly scheduled hours $50
Miscellaneous Services You Pay
D9490 Broken Appointment Fee $10
Drugs You Pay
D9630 other drugs and/or medicaments, by report $15
Miscellaneous Services You Pay
D9910 application of desensitizing medicament $20
D9940 occlusal guard, by report $250
D9950 occlusion analysis - mounted case $75
D9951 occlusal adjustment - limited $25
D9952 occlusal adjustment - complete $150
D9972 external bleaching - per arch $150