Texas Dental Plan Schedule


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Texas Dental Plan (TDP) Schedule¹

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SERVICES

View All Services

	General
	Diagnostics
	Cosmetic & Restorative
	Crown & Bridge
	Endodontics

	Oral Surgery
	Prosthodontics
	Orthodontics
	Periodontics

Limitations 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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