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Texas Dental Plan (TDP) Schedule1

1Select a service below
 
SERVICES
 
bulletView All Services
 
bulletGeneral
bulletDiagnostics
bulletCosmetic & Restorative
bulletCrown & Bridge
bulletEndodontics
bulletOral Surgery
bulletProsthodontics
bulletOrthodontics
bulletPeriodontics
 
bulletLimitations and Exclusions
 
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
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 case. Some specialists may require a consultation visit before treatment is initiated. Discuss each case with the specialist prior to beginning any treatment.
 

 

Current Dental Terminology © 2004 American Dental Association. All rights reserved


 

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