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Texas Dental Plan (TDP) Schedule1

1Select a service below
 
SERVICES
 
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bulletGeneral
bulletDiagnostics
bulletCosmetic & Restorative
bulletCrown & Bridge
bulletEndodontics
bulletOral Surgery
bulletProsthodontics
bulletOrthodontics
bulletPeriodontics
 
bulletLimitations and Exclusions
 
GENERAL
ADA
Code
Procedure Member
Pays
D9110 Palliative (emergency) treatment of dental plan 20%
Discount
D9430 Office visit for observation (during regularly scheduled hours) 12
D9440 Office visit for observation (after regularly scheduled hours) UCR*
D9999 Broken appointments without 24 hours advanced notice 25
 
* UCR = Usual and Customary Charges
 
DIAGNOSTIC AND PREVENTIVE DENTISTRY
ADA
Code
Procedure Member
Pays
D0120 Periodic oral examination 15
D0150 Comprehensive oral evaluation 15
D0210 Intraoral - complete series (including bitewings) 30
D0220 Intraoral - periapical (first film) 5
D0230 Intraoral - periapical (each additional film) 4
D0270 Bitewing - single film 5
D0330 Panoramic films 30
D0460 Pulp vitality tests 12
D0470 Diagnostic casts 20
D1110 Prophylaxis - adult 29
D1120 Prophylaxis - child 29
D1351 Sealant per tooth 20%
Discount
(Patients who have not had regular cleanings may require gum treatment)
D4355 Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis 45
D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) 15/10
-Ortho
D9999 Infection control fee** 9
**Infection control guidelines have been established by OSHA and the American Dental Association. Infection control measures will be charged routinely by a participating dental office.
COSMETIC & RESTORATIVE DENTISTRY
(Permanent and "Baby" Teeth)
ADA
Code
Procedure Member
Pays
 
Amalgam Fillings (Silver Fillings)
D2110   Amalgam - one surface, primary   $34
D2120   Amalgam - two surfaces, primary   44
D2130   Amalgam - three surfaces, primary   54
D2140   Amalgam - one surface, permanent   34
D2150   Amalgam - two surfaces, permanent   44
D2160   Amalgam - three surfaces, permanent   54
 
Resin Fillings (Tooth Colored)
D2330   Resin - based composite - one surface, anterior   34
D2331   Resin - based composite - two surfaces, anterior   44
D2332   Resin - based composite - three surfaces, anterior   54
D2380   Resin - based composite - one surface, posterior primary   20%
Discount
D2381   Resin - based composite - two surfaces, posterior primary   20%
Discount
D2382   Resin - based composite - three surfaces, posterior primary   20%
Discount
D2385   Resin - based composite - one surface, posterior permanent   20%
Discount
D2386   Resin - based composite - two surfaces, posterior permanent   20%
Discount
D2387   Resin - based composite - three surfaces, posterior permanent   20%
Discount
D2388   Resin - based composite - four or more surfaces, posterior permanent   20%
Discount
D2951   Pin retention - per tooth, in addition to restoration   16
CROWNS & BRIDGES
ADA
Code
Procedure Member
Pays
D2751   Crown - porcelain fused to predominantly base metal* $321 + LAB
D2791   Crown - full cast predominantly base metal* 300 + LAB
D2810   Crown - 3/4 cast predominantly base metal* 300 + LAB
D2950   Core buildup, including any pins 20%
Discount
D6211 Pontic - cast predominantly base metal* 300 + LAB
D6241 Pontic - porcelain fused to predominately base metal* 321 + LAB
D6751   Crown - porcelain fused to predominately base metal* 321 + LAB
D6791   Crown - full cast predominantly base metal* 300 + LAB
 
**Lab fees are additional and are not subject to plan discounts
 
ENDODONTIC DENTISTRY
(Root Canal Treatment)
ADA
Code
Procedure Member
Pays
D3110   Pulp cap-direct (excluding final restoration)   $19
D3120   Pulp cap-indirect (excluding final restoration)   19
D3220   Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament   43
 
Root canals
D3310   Root canal therapy - anterior (excluding final restoration)   199
D3320   Root canal therapy - bicuspid (excluding final restoration)   236
D3330   Root canal therapy - molar (excluding final restoration)   279
 
Any Root Canal treatment or retreatment that presents unusual difficulties and circumstances may have an additional charge. Please discuss all fees with the general dentist prior to treatment.
 
ORAL SURGERY
ADA
Code
Procedure Member
Pays
D7110   Extraction, single tooth   $35
D7210   Surgical removal of erupted tooth requiring elevation of mucoperiostial flap and removal of bone and/or section of tooth   65
D7220   Removal of impacted tooth - soft tissue   99
D7230   Removal of impacted tooth - partially bony   120
D7240   Removal of impacted tooth - completely bony   142
D7510   Incision and drainage of abscess - intraoral soft tissue   32
 
Any tooth that presents unusual difficulties and circumstances may incur an additional charge. Please discuss all fees with the dentist prior to treatment
 
PROSTHODONTIC DENTISTRY (Dentures)*
ADA
Code
Procedure Member
Pays
D5110 Complete denture - maxillary* $414 + LAB
D5120 Complete denture - mandibular* 414 + LAB
D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth)* 403 + LAB
D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth)* 403 + LAB
D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)* 403 + LAB
D5214   Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)*   403 + LAB
 
Prosthetics (dentures) fees are our reduced fees for usual and customary services. Any prosthetic appliance that requires unusual services may be an additional charge. Discuss all fees with the general dentist prior to any treatment.
 
*Lab fees are additional and are not subject to plan discounts
ORTHODONTIC DENTISTRY (Braces by a General Dentist)
ADA
Code
Procedure Member
Pays
D8660 Pre - orthodontic treatment visit 120
D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) 15/10-Ortho
 
Orthodontic Treatment (Braces)
 
D8080 Comprehensive orthodontic treatment of the adolescent dentition 2,150
D8090 Comprehensive orthodontic treatment of the adult dentition 2,350
 
The above orthodontic charges are our reduced fees for full banded Class I malocclusion cases. Any orthodontic treatment that requires surgery, headgear, unusual or ancillary services or is extended because of lack of patient cooperation will have an additional charge. At the orthodontic consultation appointment, the general dentist will explain the length of treatment, all fees, and the payment schedule. Orthodontic services are offered on a space and time available basis only and are not available to any person that is currently in treatment or has had treatment planned by any dentist in the past 6 months. Broken or lost appliances will be and additional charge.
 
PERIODONTIC DENTISTRY (Gum Treatment)
ADA
Code
Procedure Member
Pays
D4250 Mucogingival Surgery - per quadrant $350
D4260 Osseous surgery (including flap entry and closure) - per quadrant 480
D4341 Periodontal scaling and root planning - per quadrant 65
D4910 Periodontal maintenance procedures (following active therapy) 48
 
At the diagnostic evaluation appointment, the participating general dentist will explain the treatment procedure and the fees. The above periodontic charges are our reduced fees for usual and customary periodontal services. Any periodontal treatment that requires tooth resection, gingival grafts, or other services will have an additional charge at a reduced rate. Discuss this with the dentist prior to beginning treatment.
 
All of the listed charges are reduced fees for services performed by a participating general dentist. Fees are subject to change without notice.
 
Any procedure not listed is available on a fee for service basis at a 20% discount. Consult with your participating general dentist prior to beginning any treatment.
 
Specialist Services
Any treatment provided by a participating specialist, if available, in Endodontics (root canal), Pediatric Dentistry (children's dentistry), Prosthodontics (Dentures), Orthodontics (teeth straightening), Periodontics (gum disease treatment) or Oral Surgery will be charged at a 20% reduction of participating specialist's fees for that particular procedure. Some specialists may require a consultation visit before treatment is initiated. Discuss each case with the specialist prior to beginning any treatment.
 

 

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