 |
|
|
|
MEMBER COPAY |
|
APPOINTMENTS |
| D9310 |
Consultation (diagnostic service provided by dentist or
physician other than practitioner providing treatment) |
$0 |
| D9430 |
Office Visit (during regularly scheduled hours) |
$5 |
| D9440 |
Office Visit - after regularly scheduled hours |
$35 |
| |
|
|
| DIAGNOSTIC |
| D0120 |
Periodic oral evaluation |
$0 |
| D0140 |
Limited oral evaluation - problem focused |
$0 |
| D0150 |
Comprehensive oral evaluation |
$0 |
| D0160 |
Detailed & external oral evaluation - problem focused,
by report |
$0 |
| D0180 |
Comprehensive periodontal evaluation |
$0 |
| D0210 |
Intraoral - complete series (inc. bitewings) |
$0 |
| D0220 |
Intraoral - periapical - first film |
$0 |
| D0230 |
Intraoral - periapical each additional film |
$0 |
| D0240 |
Intraoral - occlusal film |
$0 |
| D0250 |
Extraoral - first film |
$0 |
| D0260 |
Extraoral - each additional film |
$0 |
| D0270 |
Bitewing - single film |
$0 |
| D0272 |
Bitewings - two films |
$0 |
| D0274 |
Bitewings - four films |
$0 |
| D0330 |
Panoramic film |
$0 |
| D0415 |
Bacteriologic studies for determination of path. agents |
$0 |
| D0425 |
Caries susceptibility test |
$0 |
| D0460 |
Pulp vitality test |
$0 |
| D0470 |
Diagnostic casts |
$0 |
| |
|
|
| PREVENTIVE CARE |
| D1110 |
Prophylaxis - adult (routine, once every 6 months) |
$0 |
| D1120 |
Prophylaxis - child (routine, once every 6 months) |
$0 |
| D1201 |
Topical application of fluoride (including prophylaxis) -
child |
$0 |
| D1203 |
Topical application of fluoride (prophylaxis not included)
- child |
$0 |
| D1330 |
Oral hygiene instructions |
$0 |
| D1351 |
Sealant - per tooth |
$8 |
| D1510 |
Space maintenance - fixed - unilateral |
$50 + Lab** |
| D1515 |
Space maintenance - fixed - bilateral |
$60 + Lab** |
| D1520 |
Space maintenance - removable - unilateral |
$60 + Lab** |
| D1525 |
Space maintenance - removable - bilateral |
$75 + Lab** |
| D1550 |
Recementation of space maintainer |
$15 |
| |
|
|
| RESTORATIVE |
| D2140 |
Amalgam - one surface, primary or permanent |
$10 |
| D2150 |
Amalgam - two surfaces, primary or permanent |
$15 |
| D2160 |
Amalgam - three surfaces, primary or permanent |
$20 |
| D2160 |
Amalgam - four or more surfaces, primary or permanent |
$25 |
| |
|
|
| RESIN RESTORATION |
| D2330 |
Resin-based composite - one surface, anterior |
$20 |
| D2331 |
Resin-based composite - two surfaces, anterior |
$30 |
| D2332 |
Resin-based composite - three surfaces, anterior |
$40 |
| D2335 |
Resin-based composite - four or more surfaces or involving
incisal angle (anterior) |
$45 |
| D2336 |
Resin-based composite crown, anterior - primary |
$55 |
| D2391 |
Resin-based composite - one surface, posterior |
$40 |
| D2392 |
Resin-based composite - two surfaces, posterior |
$55 |
| D2393 |
Resin-based composite - three surfaces, posterior |
$70 |
| D2394 |
Resin-based composite - four or more surfaces, posterior |
$70 |
| D2510 |
Inlay - metallic - one surface |
$85 |
| D2520 |
Inlay - metallic - two surfaces |
$95 |
| D2530 |
Inlay - metallic - three or more surfaces |
$105 |
| D2610 |
Inlay - porcelain/ceramic - one surface |
$190 + Lab** |
| D2620 |
Inlay - porcelain/ceramic - two surfaces |
$190 + Lab** |
| D2630 |
Inlay - porcelain/ceramic - three or more surfaces |
$190 + Lab** |
| |
|
|
| CROWN & BRIDGE |
| D2740 |
Crown porcelain/ceramic substrate |
$230 + Lab** |
| D2750* |
Crown - porcelain fused to high noble metal |
$230 |
| D2751 |
Crown - porcelain fused to predominantly base metal |
$230 |
| D2752* |
Crown - porcelain fused to noble metal |
$230 |
| D2790* |
Crown - full cast high noble metal |
$230 |
| D2791 |
Crown - full cast predominantly base metal |
$230 |
| D2792* |
Crown - full cast noble metal |
$230 |
| D2910 |
Recement inlay |
$15 |
| D2920 |
Recement crown |
$15 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
$55 |
| D2931 |
Prefabricated stainless steel crown - permanent tooth |
$35 |
| D2940 |
Sedative filling |
$5 |
| D2950 |
Core buildup, including any pins |
$50 |
| D2951 |
Pin retention - per tooth, in addition to any restoration |
$15 |
| D2952 |
Cast post & core, in addition to crown |
$75 + Lab** |
| D2953 |
Each additional cast post - same tooth |
$75 + Lab** |
| D2954 |
Prefabricated post & core, in add to crown |
$75 |
| D2960 |
Labial veneer (resin laminate) - chairside |
$200 |
| D2962 |
Labial veneer (porcelain laminate) |
$315 + Lab** |
| D9972 |
External bleaching - per arch |
$145 |
| |
|
|
| ENDODONTICS |
| D3110 |
Pulp cap - direct (excluding final restoration) |
$0 |
| D3120 |
Pulp cap - indirect (excluding final restoration) |
$0 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) -
removal of pulp coronal to the dentinocemental junction of medicament |
$20 |
| D3221 |
Pulpal debridement, primary and permanent teeth |
$50 |
| D3310 |
Root canal therapy - anterior (excluding final restoration) |
$100 |
| D3320 |
Root canal therapy - bicuspid (excluding final restoration) |
$145 |
| D3330 |
Root canal therapy - molar (excluding final restoration) |
$175 |
| D3351 |
Apexification/recalcification - initial visit (apical
closer/calcific repair of perforations, root resorption, etc.) |
$30 |
| D3352 |
Apexification/recalcification - interim medication
replacement (apical closer/calcific repair of perforations, root
resorption, etc.) |
$30 |
| D3353 |
Apexification/recalcification - final visit (apical
closer/calcific repair of perforations, root resorption, etc.) |
$30 |
| D3410 |
Apicoectomy/periradicular surgery - anterior |
$125 |
| D3421 |
Apicoectomy/periradicular surgery - bicuspid (first root) |
$170 |
| D3425 |
Apicoectomy/periradicular surgery - molar (first root) |
$180 |
| D3426 |
Apicoectomy/periradicular surgery (each additional root) |
$125 |
| D3430 |
Retrograde - filling per root |
$40 |
| D3450 |
Root amputation - per root |
$70 |
| D3920 |
Hemisection (including any root removal), not including
root canal therapy |
$75 |
| D3950 |
Canal preparation and fitting of preformed dowel or post |
$0 |
| |
|
|
| PERIODONTICS (Gum Treatment) |
| D4210 |
Gingivectomy or gingivoplasty - 4+ teeth per quad |
$120 |
| D4211 |
Gingivectomy or gingivoplasty - 1-3 teeth per quad |
$30 |
| D4260 |
Osseous surgery, 4+ teeth, per quad |
$300 |
| D4261 |
Osseous surgery, 1-3 teeth, per quad |
$300 |
| D4320 |
Provisional splinting - intracoronal |
$60 |
| D4321 |
Provisional splinting - extracoronal |
$50 |
| D4341 |
Periodontal scaling and root planing, 4+ teeth per quad |
$40 |
| D4342 |
Periodontal scaling and root planing, 1-3 teeth per quad |
$40 |
| D4355 |
Full mouth debridement to enable eval and diagnosis |
$30 |
| D4910 |
Periodontal maintenance |
$30 |
| |
|
|
| PROSTHODONTICS |
| D5110 |
Complete denture - maxillary |
$290 + Lab** |
| D5120 |
Complete denture - mandibular |
$290 + Lab** |
| D5130 |
Immediate denture - maxillary |
$325 + Lab** |
| D5140 |
Immediate denture - mandibular |
$325 + Lab** |
| D5211 |
Maxillary partial denture - resin base (including any
conventional clasps, rests and teeth) |
$290 + Lab** |
| D5212 |
Mandibular partial denture - resin base (including any
conventional clasps, rests and teeth) |
$290 + Lab** |
| D5213 |
Maxillary partial denture - cast metal framework with resin
denture bases (including any conventional clasps, rests and teeth) |
$325 + Lab** |
| D5214 |
Mandibular partial denture - cast metal framework with
resin denture bases (including any conventional clasps, rests and teeth) |
$325 + Lab** |
| D5410 |
Adjust complete denture - maxillary |
$10 |
| D5411 |
Adjust complete denture - mandibular |
$10 |
| D5421 |
Adjust partial denture - maxillary |
$10 |
| D5422 |
Adjust partial denture - mandibular |
$10 |
| |
|
|
| REPAIRS TO PROSTHETICS |
| D5510 |
Repair broken complete denture base |
$30 + Lab** |
| D5610 |
Repair resin denture base |
$30 + Lab** |
| D5620 |
Repair cast framework |
$30 + Lab** |
| D5630 |
Repair or replace broken clasp |
$30 + Lab** |
| D5640 |
Repair or replace broken teeth - per tooth |
$30 + Lab** |
| D5650 |
Add tooth to existing partial denture |
$30 + Lab** |
| D5660 |
Add clasp to existing partial denture |
$30 + Lab** |
| D5710 |
Rebase complete maxillary denture |
$90 + Lab** |
| D5711 |
Rebase complete mandibular denture |
$90 + Lab** |
| D5720 |
Rebase maxillary partial denture |
$90 + Lab** |
| D5721 |
Rebase mandibular partial denture |
$90 + Lab** |
| D5730 |
Reline complete maxillary denture (chairside) |
$60 |
| D5731 |
Reline complete mandibular denture (chairside) |
$60 |
| D5740 |
Reline maxillary partial denture (chairside) |
$60 |
| D5741 |
Reline mandibular partial denture (chairside) |
$60 |
| D5750 |
Reline complete maxillary denture (laboratory) |
$80 + Lab** |
| D5751 |
Reline complete mandibular denture (laboratory) |
$80 + Lab** |
| D5760 |
Reline maxillary partial denture (laboratory) |
$75 + Lab** |
| D5761 |
Reline mandibular partial denture (laboratory) |
$75 + Lab** |
| D5850 |
Tissue conditioning, maxillary |
$25 |
| D5851 |
Tissue conditioning, mandibular |
$25 |
| |
|
|
| PROSTHODONTICS (Fixed) |
| D6210* |
Pontic - cast high noble metal |
$230 |
| D6211 |
Pontic - cast predominantly base metal |
$230 |
| D6212* |
Pontic - cast noble metal |
$230 |
| D6240* |
Pontic - porcelain fused to high noble metal |
$230 |
| D6241 |
Pontic - porcelain fused to predominantly base metal |
$230 |
| D6242* |
Pontic - porcelain fused to noble metal |
$230 |
| D6750* |
Crown - porcelain fused to high noble metal |
$230 |
| D6751 |
Crown - porcelain fused to predominantly base metal |
$230 |
| D6752* |
Crown - porcelain fused to noble metal |
$230 |
| D6930 |
Recement fixed partial denture |
$15 |
| D6940 |
Stress breaker |
$125 + Lab** |
| D6950 |
Precision attachment |
$150 + Lab** |
| |
|
|
| EXTRACTIONS/ORAL AND MAXILLOFACIAL SURGERY |
| D7111 |
Coronal remnants, deciduous tooth |
$10 |
| D7140 |
Extraction, erupted tooth or exposed root |
$10 |
| D7210 |
Surgical removal of erupted tooth requiring elevation of
mucoperiostial flap and removal of bone and/or section of tooth |
$30 |
| D7220 |
Removal of impacted tooth - soft tissue |
$40 |
| D7230 |
Removal of impacted tooth - partially bony |
$60 |
| D7240 |
Removal of impacted tooth - completely bony |
$70 |
| D7241 |
Removal of impacted tooth - completely bony with unusual
surgical complications |
$80 |
| D7250 |
Surgical removal of residual tooth roots (cutting
procedures) |
$30 |
| D7281 |
Surgical exposure of impacted or unerupted tooth to aid
eruption |
$50 |
| D7310 |
Alveoplasty in conjunction with extractions - per quadrant |
$50 |
| D7320 |
Alveoplasty not in conjunction with extractions - per
quadrant |
$60 |
| D7510 |
Incision and drainage of abcess - intraoral soft tissue |
$25 |
| D7910 |
Suture of recent small wounds up to 5cm |
$0 |
| D7960 |
Frenulectomy (frenectomy or
frenotomy) - separate
procedure |
$40 |
| D7970 |
Excision of hyperplastic tissue - per arch |
$45 |
| |
|
|
| ORTHODONTICS |
| D8070 |
Comprehensive orthodontic treatment of the transitional
dentition |
|
| |
Consultation |
$0 |
| |
Evaluation |
$35 |
| |
Records/treatment planning |
$250 |
| |
Orthodontic treatment |
$1,800 |
| D8080 |
Comprehensive orthodontic treatment of adolescent dentition |
|
| |
Consultation |
$0 |
| |
Evaluation |
$35 |
| |
Records/treatment planning |
$250 |
| |
Orthodontic treatment |
$1,800 |
| D8090 |
Comprehensive orthodontic treatment of adult dentition |
|
| |
Consultation |
$0 |
| |
Evaluation |
$35 |
| |
Records/treatment planning |
$250 |
| |
Orthodontic treatment |
$2,100 |
| D8680 |
Orthodontic retention (removal of appliances, construction
and placement of retainer(s)). |
$450 |
| |
|
|
| ADJUNCTIVE GENERAL SERVICES |
| D9110 |
Palliative (emergency) treatment of dental pain - minor
procedurs |
$20 |
| D9210 |
Local anesthesia not in conjunction with operative or
surgical procedures |
$0 |
| D9215 |
Local anesthesia |
$0 |
| D9230 |
Analgesia, anxiolysis, inhalation of nitrous oxide |
$25 |
| D9250 |
Case presentation, detailed and extensive treatment
planning |
NO CHARGE |
| D9940 |
Fabrication of athletic mouth guard |
$100 |
| D9951 |
Occlusal adjustment - limited |
$35 |
| D9952 |
Occlusal adjustment - complete |
$175 |
| |
|
|
| * The above copayments 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. |
| ** Patient is responsible for Lab fees. |
| |
|
|
| Note:
1. NOT ALL PARTICIPATING DENTISTS PERFORM ALL LISTED
PROCEDURES, INCLUDING AMALGAMS. PLEASE CONSULT YOUR DENTIST PRIOR TO
TREATMENT FOR AVAILABILITY OF SERVICES.
2. Unlisted procedures are at the dentist's usual
fee less 25%, INCLUDING, BUT NOT LIMITED TO, MAXILLOFACIAL PROSTHETICS,
ENAMEL MICROABRASION, AND BLEACHING.
3. When crown and/or bridgework exceeds six units in
the same treatment plan, the patient may be charged an additional $50.00
per unit.
4. IF YOU BREAK YOUR APPOINTMENT WITH YOUR DENTIST
WITHOUT 24-HOUR ADVANCE NOTICE, YOU WILL BE SUBJECT TO YOUR DENTIST'S
BROKEN APPOINTMENT FEE. |
| |
|
|
|
SPECIALTY CARE
Should you need specialty care, (i.e., Endodontist,
Orthodontist, Oral Surgeon, Periodontist, Pediatric Dentist), you may be
referred by your Participating General Dentist, or you may refer yourself
to any Participating Specialty Dentist. Copayment amounts are applicable
when treatment is performed by Participating Specialty Dentists. Benefits
for procedures not listed on the schedule, that are performed by a
Participating Specialty Dentist, are available at the Participating
Specialty Dentist's usual and customary fee less 25%. |
| |
| RATES |
Employee |
$11.50 |
|
| |
Employee + Family |
$24.50 |
|
|
Current Dental Terminology © 2004 American Dental Association. All rights reserved
|
