ADA CODE |
Procedure |
Member Pays |
|
APPOINTMENTS |
 |
9310 |
Consultation
(diagnostic service provided by dentist other than practitioner
providing treatment) |
15.00 |
 |
9430 |
Office visit (normal hours) |
5.00 |
 |
9440 |
Emergency visit (after regularly
scheduled hours) |
35.00 |
 |
9999 |
Emergency visit during regularly
scheduled hours, by report |
20.00 |
 |
9999 |
Broken appointments
(without 24 hr notice, per 30 min.)
Maximum $40 per broken appointment. No Charge will be
made due to emergencies |
10.00 |
 |
|
DIAGNOSTICS |
 |
0120 |
Periodic oral examination |
No Charge |
0140/
0150/
0160 |
Limited/Comprehensive oral evaluation |
No Charge |
 |
0180 |
Comprehensive oral evaluation |
10.00 |
 |
0210 |
X-Ray Intraoral - complete series including
bitewings |
No Charge |
 |
0220 |
X-Ray Intraoral - periapical (first film) |
No Charge |
 |
0230 |
X-Ray Intraoral - periapical
(each additional film) |
No Charge |
 |
0270 |
X-Ray Bitewings - single film |
No Charge |
 |
0272 |
X-Ray Bitewings - two films |
No Charge |
 |
0274 |
Bitewings - four films |
No Charge |
 |
0330 |
Panoramic film |
No Charge |
 |
0460 |
Pulp vitality tests |
No Charge |
 |
0470 |
Diagnostic casts |
No Charge |
 |
|
PREVENTIVE CARE |
 |
1110/
1120 |
Prophylaxis - adult/child (routine, once every 6
months) |
No Charge |
 |
1110/
1120 |
Prophylaxis - adult/child (additional) |
20.00 |
 |
1201 |
Topical application of fluoride (including
prophylaxis) child (up to 16 years of age) |
No Charge |
 |
1203 |
Topical application of fluoride (not including
prophylaxis) child (up to 16 years of age) |
No Charge |
 |
1351 |
Sealant - per tooth |
10.00 |
 |
1330 |
Oral hygiene instruction |
No Charge |
 |
1510 |
Space Maintainer - fixed - unilateral |
45 + LAB |
 |
1515 |
Space Maintainer - fixed - bilateral |
45 + LAB |
 |
1520 |
Space Maintainer - removable - unilateral |
85 + LAB |
 |
1525 |
Space Maintainer - removable - bilateral |
85 + LAB |
 |
1550 |
Recementation of space maintainer |
10.00 |
 |
|
RESTORATIVE |
 |
2140 |
Amalgam - one surface, primary or
permanent |
No Charge |
 |
2150 |
Amalgam - two surfaces, primary or
permanent |
No Charge |
 |
2160 |
Amalgam - three surfaces, primary or
permanent |
No Charge |
 |
2161 |
Amalgam - four or more surfaces,
primary or permanent |
No Charge |
 |
2940 |
Sedative filling |
15.00 |
 |
2999 |
Sedative base (Under fillings), by
report |
No Charge |
 |
|
RESIN RESTORATION |
 |
2330 |
Resin - one surface, anterior |
35.00 |
 |
2331 |
Resin - two surfaces, anterior |
40.00 |
 |
2332 |
Resin - three surfaces, anterior |
50.00 |
 |
2391 |
Resin - based composite - one surface, posterior |
60.00 |
 |
2392 |
Resin - based composite - two surfaces, posterior |
80.00 |
 |
2393 |
Resin - based composite - three surfaces, posterior |
100.00 |
 |
2394 |
Resin - based composite - four or more surfaces,
posterior |
120.00 |
 |
|
CROWN & BRIDGE |
 |
2740 |
Crown - porcelain/ceramic substrate |
280 + LAB |
 |
2750* |
Crown - porcelain fused to high noble metal |
280.00 |
 |
2751 |
Crown - porcelain fused to predominantly base metal |
280.00 |
 |
2752* |
Crown - porcelain fused to noble metal |
280.00 |
 |
2790* |
Crown - full cast high noble metal |
280.00 |
 |
2791 |
Crown - full cast predominantly base metal |
280.00 |
 |
2792* |
Crown - full cast noble metal |
280.00 |
 |
2910 |
Recement inlay |
15.00 |
 |
2920 |
Recement crown |
15.00 |
 |
2930 |
Prefabricated stainless steel crown - primary tooth |
75.00 |
 |
2950 |
Core buildup, including any pins |
45.00 |
 |
2951 |
Pin retention - per tooth |
15.00 |
 |
2952 |
Cast post and core in addition to crown |
90 + LAB |
 |
2953 |
Each additional cast post - same tooth |
90 + LAB |
 |
2954 |
Prefabricated post and core in addition to crown |
90.00 |
 |
2962 |
Labial veneer (porcelain laminate) - laboratory |
280 + LAB |
 |
|
ENDODONTICS |
 |
3220 |
Therapeutic pulpotomy/pulpectomy |
35.00 |
 |
3221 |
Pulpal debridement, primary and permanent teeth |
100.00 |
 |
|
Root canals |
|
 |
3310 |
Root canal therapy - anterior (excluding final
restoration) |
100.00 |
 |
3320 |
Root canal therapy - bicuspid (excluding final
restoration) |
200.00 |
 |
3330 |
Root canal therapy - molar (excluding final
restoration) |
250.00 |
 |
3410 |
Apicoectomy/periradicular surgery - anterior |
125.00 |
 |
|
PERIODONTICS (Gum Treatment) |
 |
4210 |
Gingivectomy/gingivoplasty
(4+ teeth per quad ) |
125.00 |
 |
4211 |
Gingivectomy/gingivoplasty
(1-3 teeth per quad ) |
40.00 |
 |
4260 |
Osseous surgery,
(4+ teeth, per quad ) |
350.00 |
 |
4261 |
Osseous surgery,
(1-3 teeth, per quad ) |
350.00 |
 |
4271 |
Free soft tissue graft procedure
(inc. donor site surgery) |
225.00 |
 |
4341 |
Periodontal scaling and root planning (4+ teeth per
quad ) |
50.00 |
 |
4342 |
Periodontal scaling and root planning (1-3 teeth
per quad) |
50.00 |
 |
4355 |
Full mouth debridement to enable evaluation and
diagnosis |
45.00 |
 |
4381 |
Localized delivery of chemotherapeutic agents (per
tooth) |
45.00 |
 |
4910 |
Periodontal maintenance |
50.00 |
 |
|
PROSTHODONTICS |
 |
5110 |
Complete denture - maxillary |
300 + LAB |
 |
5120 |
Complete denture - mandibular |
300 + LAB |
 |
5130 |
Immediate denture - maxillary |
300 + LAB |
 |
5140 |
Immediate denture - mandibular |
300 + LAB |
 |
5211 |
Maxillary partial denture - resin base |
300 + LAB |
 |
5212 |
Mandibular partial denture - resin base |
300 + LAB |
 |
5213 |
Maxillary partial denture - cast metal framework,
resin denture bases |
300 + LAB |
 |
5214 |
Mandibular partial denture - cast metal framework,
resin denture bases |
300 + LAB |
 |
5410 |
Adjust complete denture - maxillary |
15.00 |
 |
5411 |
Adjust complete denture - mandibular |
15.00 |
 |
5421 |
Adjust partial denture - maxillary |
15.00 |
 |
5422 |
Adjust partial denture - mandibular |
15.00 |
 |
|
REPAIRS TO PROSTHETICS |
 |
5510 |
Repair broken complete denture base |
15 + LAB |
  |
5520 |
Replace missing or broken teeth - complete denture
(each tooth) |
15 + LAB |
  |
5610 |
Repair resin denture base |
15 + LAB |
  |
5630 |
Repair or replace broken clasp |
15 + LAB |
  |
5640 |
Replace broken teeth - per tooth |
15 + LAB |
  |
5650 |
Add tooth to existing partial denture |
30 + LAB |
  |
5730 |
Reline complete maxillary denture (chairside) |
50.00 |
  |
5731 |
Reline complete mandibular denture (chairside) |
50.00 |
  |
5740 |
Reline maxillary partial denture (chairside) |
50.00 |
  |
5741 |
Reline mandibular partial denture (chairside) |
50.00 |
  |
5750 |
Reline complete maxillary denture (laboratory) |
35 + LAB |
  |
5751 |
Reline complete mandibular denture (laboratory) |
35 + LAB |
  |
5760 |
Reline maxillary partial denture (laboratory) |
35 + LAB |
  |
5761 |
Reline mandibular partial denture (laboratory) |
35 + LAB |
  |
5850 |
Tissue conditioning - maxillary |
30.00 |
  |
5851 |
Tissue conditioning - mandibular |
30.00 |
  |
|
PROSTHODONTICS (Fixed) |
 |
6210* |
Pontic - cast high noble metal |
280.00 |
 |
6211 |
Pontic - cast predominantly base metal |
280.00 |
 |
6212* |
Pontic - cast noble metal |
280.00 |
 |
6240* |
Pontic - porcelain fused to high noble metal |
280.00 |
 |
6241 |
Pontic - porcelain fused to predominantly base
metal |
280.00 |
 |
6242* |
Pontic - porcelain fused to noble metal |
280.00 |
 |
6750* |
Crown - porcelain fused to high noble metal |
280.00 |
 |
6751 |
Crown - porcelain fused to predominantly base metal |
280.00 |
 |
6752* |
Crown - porcelain fused to noble metal |
280.00 |
 |
6790* |
Crown - full cast high noble metal |
280.00 |
 |
6791 |
Crown - full cast predominantly base metal |
280.00 |
 |
6792* |
Crown - full cast noble metal |
280.00 |
 |
6930 |
Recement fixed partial denture
(per unit) |
10.00 |
 |
|
EXTRACTIONS/ORAL AND MAXILLOFACIAL
SURGERY |
 |
7111 |
Coronal remnants, deciduous tooth |
No Charge |
 |
7140 |
Extraction
(erupted tooth or exposed root ) |
No Charge |
 |
7210 |
Surgical removal of erupted tooth |
40.00 |
 |
7220 |
Removal of impacted tooth - soft tissue |
50.00 |
 |
7230 |
Removal of impacted tooth - partially bony |
70.00 |
 |
7240 |
Removal of impacted tooth - completely bony |
85.00 |
 |
7250 |
Surgical removal of residual tooth roots |
35.00 |
 |
7310 |
Alveoloplasty in conjunction with extractions - per
quadrant |
35.00 |
 |
7320 |
Alveoloplasty not in conjunction with extractions -
per quadrant |
70.00 |
 |
7510 |
Incision and drainage of abscess - intraoral |
25.00 |
 |
|
ORTHODONTICS |
 |
8070/
8080 |
Comprehensive orthodontic treatment of
the transitional/adolescent dentition. |
|
Children up to 19 years of age
Up to 24 months of routine (full-banded) orthodontic treatment for
Class I and Class II cases |
 |
|
Consultation |
No Charge |
 |
|
Evaluation |
35.00 |
 |
|
Records/Treatment Planning |
250.00 |
 |
|
Orthodontic Treatment |
1,800.00 |
 |
8090 |
Comprehensive orthodontic treatment of
the adult dentition.
Adults 19 years of age and over |
|
Up to 24 months of routine
(full-banded) orthodontic treatment
for Class I and Class II cases |
|
Consultation |
No Charge |
 |
|
Evaluation |
35.00 |
 |
|
Records/Treatment Planning |
250.00 |
 |
|
Orthodontic Treatment |
2,000.00 |
 |
8680 |
Retention |
450.00 |
 |
|
ADJUNCTIVE GENERAL SERVICES |
 |
9215 |
Local anesthesia |
No Charge |
 |
9230 |
Analgesia
(nitrous oxide - per 15 minutes) |
15.00 |
 |
9450 |
Case presentation, detailed and extensive treatment
planning |
No Charge |
 |
9951 |
Occlusal adjustment - limited |
25.00 |
 |
9952 |
Occlusal adjustment - complete |
150.00 |
 |
|
* THE ABOVE CO-PAYMENTS DO NOT
INCLUDE THE ADDITIONAL COST OF PRECIOUS (HIGH NOBLE) AND
SEMI-PRECIOUS (NOBLE) METAL.
THE ADDITIONAL COST OF PRECIOUS METAL SHALL NOT EXCEED $125 PER UNIT
AND $75 PER UNIT FOR SEMI-PRECIOUS METAL. |
|
NOTE:
- Not all participating dentists perform all listed procedures,
including amalgams. Please consult your dentist prior to treatment
for availability of services.
- Unlisted procedures are at the dentist's usual fee less 25%.
- When crown and/or bridgework exceeds six units in the same
treatment plan, the patient may be charged an additional 50.00 per
unit.
|
|
SPECIALIST SERVICES
Should you need a specialist, (i.e., Endodontist, Oral Surgeon,
Periodontist, Pediatric Dentist), you may be referred by your
Participating General Dentist, or you may refer yourself to any
Participating Specialist. Co-payment amounts are applicable when
treatment is performed by Participating Specialists. Benefits for
procedures not listed on the schedule, that are performed by a
Participating Specialist, are available at the Participating
Specialist's usual and customary fee less 25%. |
|
NOTE: When crown and/or
bridgework exceeds six consecutive units, the patient may be charged
an additional $25.00 per unit. |
|