|
DENTAmax Plus Fee Schedule for General Dentistry |
| ADA |
Description of Services |
Average | Member | ||
| CODE | Charge | Pays | |||
| Diagnostic and Preventive Services |
| D0120 | Periodic Oral Examination | $36 | $18 | |
| D0140 | Limited Oral Evaluation - Problem Focused (Emergency) | $55 | $26 | |
| D0150 | Comprehensive Oral Evaluation | $67 | $23 | |
| D9110 | Palliative (Emergency) Treatment of Dental Pain | $90 | $27 | |
| D0220 | Single Periapical X-ray | $21 | $8 | |
| D0210 | Complete Series X-rays (including bite-wings) | $94 | $48 | |
| D0230 | Each additional PA Film | $18 | $7 | |
| D0272 | Bite-wing X-rays (2) | $34 | $16 | |
| D0330 | Panoramic X-rays | $82 | $49 | |
| D0470 | Study Models | $99 | $26 | |
| D1110 | Teeth Cleaning (Adult) | $68 | $32 | |
| D1120 | Teeth Cleaning (Child) | $50 | $23 | |
| D1203 | Fluoride Treatment (Child) | $32 | $12 | |
| D1351 | Sealant (Per Tooth) | $40 | $22 | |
| D1510 | Space Maintainer - Fixed Unilateral | $244 | $144 | |
| D1515 | Space Maintainer - Fixed Bilateral | $333 | $185 | |
| D9960 | Disposables | $12 | $8 | |
| D9972 | Cosmetic Bleaching (external bleaching with tray) | $263 | $200 | |
| (Heavy staining may require extra bleaching. Please consult with your chosen dentist relative to the charge.) | (Per Arch) | |||
| *Fee does not include complete series of panoramic x-rays. Please consult with your chosen dentist relative to the charge. | ||||
| Example of Typical Semi-Annual Oral Exam* | ||||
| Initial Visit | ||||
| Initial Examination and Diagnosis $23 | ||||
| Bite-Wing X-rays (2) $16 | ||||
| Cleaning (Adult) $32 | ||||
| Disposables $ 8 | ||||
| Total $79 | ||||
| 2nd Visit | ||||
| Examination and Diagnosis $18 | ||||
| Cleaning (Adult) $32 | ||||
| Disposables $ 8 | ||||
| Total $58 | ||||
| Restorative Dentistry | ||||
| Amalgam Restoration | ||||
| Silver Fillings for Posterior (Back) Teeth | ||||
| D2140 | Cavities involving one surface | $98 | $50 | |
| D2150 | Cavities involving two surfaces | $127 | $60 | |
| D2160 | Cavities involving three surfaces | $155 | $70 | |
| Composite Fillings (Tooth Colored) for anterior (Front) Adult Teeth | ||||
| D2330 | Cavities involving one surface | $115 | $60 | |
| D2331 | Cavities involving two surfaces | $144 | $75 | |
| D2332 | Cavities involving three surfaces | $177 | $100 | |
| D2335 | Composite Resin (involving incisal angle) | $222 | $110 | |
| Composite Fillings (tooth colored) for posterior (back) teeth | ||||
| D2391 | Cavities involving one surface | $135 | $72 | |
| D2392 | Cavities involving two surfaces | $174 | $88 | |
| D2393 | Cavities involving three surfaces | $213 | $115 | |
| D2940 | Sedative filling | $100 | $28 | |
| D2951 | Pin retention (per tooth in addition to restoration) | $53 | $19 | |
|
Crown and Bridge Base Fees |
||||
| D2740 | Porcelain crown | $975 | 25% Off | |
| D2750 | Porcelain crown (gold) | $812 | 25% Off | |
| D2752 | Porcelain/Metal crown | $785 | 25% Off | |
| D2790 | Full crown (gold) | $798 | 25% Off | |
| D2792 | Full crown (non-precious metal) | $777 | 25% Off | |
| D2810 | 3/4 Crown (metal) | $749 | 25% Off | |
| D2820 | 3/4 Crown (gold) | $725 | 25% Off | |
| D2931 | Stainless steel crown (Adult Tooth) | $244 | 25% Off | |
| D2950 | Crown build up (including any pins) | $217 | 25% Off | |
| D2954 | Post and core (prefabricated) in addition to crown | $253 | 25% Off | |
| D6750 | Fixed bridge per unit porcelain/gold | $817 | 25% Off | |
| D6751 | Fixed bridge per unit porcelain/metal | $750 | 25% Off | |
| If
semi-precious or precious metal (gold) is desired, the cost of the metal only will be added to the above listed fees. Endodontics (Root Canal Treatment) |
||||
|
Diagnostic Exam |
||||
| D3110 | Pulp capping (excluding restoration) | $62 | $19 | |
| D3220 | Vital pulpotomy | $147 | $52 | |
|
Root Canals |
||||
| D3310 | RCT 1 Canal (excluding final restoration) Anterior | 25% Off | ||
| D3320 | RCT 2 Canals (Excluding final restoration ) Bicuspid | 25% Off | ||
| D3330 | RCT 3 Canals (Excluding final restoration) Molar | 25% Off | ||
| D3340 | RCT 4 Canals (Excluding final restoration) | 25% Off | ||
|
Oral Surgery |
||||
| D7140 | Routine Extraction (single tooth) | $120 | $55 | |
| D7210 | Surgical Extraction | $245 | $95 | |
| D7220 | Removal of Impacted Tooth - Soft Tissue | $234 | $102 | |
| D7230 | Removal of Impacted Tooth - Partially Bony | $301 | $156 | |
| D7240 | Removal of Impacted Tooth - Completely Bony | $364 | $192 | |
| D7510 | Intra-Oral I & D Abscess | $185 | $45 | |
| (Does not include the cost of anesthesia - Does not apply to procedures provided in a hospital. Above charges apply to general dentists only. Oral surgeon specialist fees are covered under the provision for Specialists) | ||||
|
Prosthetics (Dentures) |
||||
| D5110 | Complete Maxillary Upper Denture (No Extractions) | $1241 | $633 | |
| D5120 | Complete Mandibular Lower Denture (No Extractions) | $1222 | $633 | |
| D5130 | Immediate Denture - Maxillary | $1222 | $633 | |
| D5140 | Immediate Denture - Mandibular | $1333 | $633 | |
| D5211 | Upper Partial - Acrylic Base | $687 | $455 | |
| (Including any conventional clasps and rests) | ||||
| D5212 | Lower Partial - Acrylic Base | $933 | $460 | |
| (Including any conventional clasps and rests) | ||||
| D5213 | Upper Partial - Predominantly Base Cast | $1302 | $702 | |
| Base with Acrylic Saddles | ||||
| (Including any conventional clasps and rests) | ||||
| D5214 | Lower Partial - Predominantly Base Cast | $1332 | $702 | |
| Base with Acrylic Saddles | ||||
| (Including any conventional clasps and rests) | ||||
| D5710 | Rebase - Complete Upper | $434 | $215 | |
| D5711 | Rebase - Complete Lower | $434 | $215 | |
| D5730 | Reline Complete Upper Denture Chair Side | $284 | $115 | |
| D5731 | Reline Complete Lower Denture Chair Side | $284 | $115 | |
| (Any prosthetic appliance that requires unusual services may be an additional charge. Discuss with dentists prior to treatment.) | ||||
|
Periodontics |
||||
| D4210 | Gingivectomy (per 1/4 mouth) | $469 | $145 | |
| D4341 | Periodontal Scaling (per 1/4 mouth) | $187 | $101 | |
| D4910 | Periodontal Prophylaxis | $104 | $45 | |
| D4355 | Gross Scaling | $142 | $50 | |
| D4910 | Periodontal Maintenance | $104 | $45 | |
| (The above charges apply to general dentists only.) | ||||
|
Orthodontics |
||||
| Initial Exam | $150 | No Chg | ||
| Orthodontic Treatment (all ages) | ||||
| D8070 | Class 1 Treatment | $4100 | $3048 | |
| D8080 | Class 2 Treatment | $4348 | $3322 | |
| D8090 | Class 3 Treatment | $4542 | $3578 | |
| Emergency Visit During Office Hours | $35 | $29 | ||
| Includes placement of appliances, treatment for two years, removal of appliances, records and placement of retainer. *Does not include cost of retainer to be paid by Plan member. Orthodontist will explain the length of treatment, all fees and the payment schedule. Orthodontic benefit is not available to any member currently receiving treatment. Orthodontic treatment that requires surgery or unusual services may require an additional charge. | ||||