| ADA CODES | DIAGNOSTIC AND PREVENTIVE SERVICES |
MEMBER PAYS |
|
0120 |
PERIODIC ORAL EVALUATION |
$10.00 |
|
0140 |
LIMITED ORAL EVALUATION--PROBLEM FOCUS |
$12.00 |
|
0150 |
COMPREHENSIVE ORAL EVALUATION |
$12.00 |
|
0210 |
INTRAORAL--COMPLETE SERIES (INC. BITEWINGS) |
$30.00 |
|
0220 |
INTRAORAL--PERIAPICAL--1ST FILM |
$7.00 |
|
0230 |
INTRAORAL PERIAPICAL--EACH ADDITIONAL FILM |
$3.00 |
|
0270 |
BITEWING--SINGLE FILM |
$7.00 |
|
0272 |
BITEWINGS--TWO FILMS |
$9.00 |
|
0274 |
BITEWINGS--FOUR FILMS |
$15.00 |
|
0330 |
PANORAMIC FILM |
$30.00 |
|
1110 |
PROPHY-ADULT (CLEANING - six months) |
$22.00 |
|
1120 |
PROPHY-CHILD (CLEANING - six months) |
$16.00 |
|
1201 |
TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHY)-CHILD |
$20.00 |
|
1351 |
SEALANT-PER TOOTH |
$15.00 |
|
1510 |
SPACE MAINTAINER-FIXED-UNILATERAL |
$65.00 |
|
1515 |
SPACE MAINTAINER-FIXED-BILATERAL |
$96.00 |
|
1520 |
SPACE MAINTAINER-REMOVEABLE-UNILATERAL |
$85.00 |
|
1525 |
SPACE MAINTAINER-REMOVEABLE-BILATERAL |
$108.00 |
| ADA CODES | RESTORATIVE |
MEMBER PAYS |
|
2110 |
AMALGAM-ONE SURFACE PRIMARY |
$26.00 |
|
2120 |
AMALGAM-TWO SURFACE PRIMARY |
$34.00 |
|
2130 |
AMALGAM-THREE SURFACE PRIMARY |
$41.00 |
|
2131 |
AMALGAM-FOUR OR MORE-PRIMARY |
$48.00 |
|
2140 |
AMALGAM-ONE SURFACE PERMANENT |
$30.00 |
|
2150 |
AMALGAM-TWO SURFACE PERMANENT |
$38.00 |
|
2160 |
AMALGAM-THREE SURFACE PERMANENT |
$45.00 |
|
2161 |
AMALGAM-FOUR OR MORE PERMANENT |
$55.00 |
|
2330 |
RESIN-ONE SURFACE ANTERIOR |
$38.00 |
|
2331 |
RESIN-TWO SURFACE ANTERIOR |
$46.00 |
|
2332 |
RESIN-THREE SURFACE ANTERIOR |
$58.00 |
|
2335 |
RESIN-FOUR OR MORE SURFACES |
$73.00 |
|
2385 |
RESIN-ONE SURF-POSTERIOR-PERMANENT |
$55.00 |
|
2386 |
RESIN-TWO SURF-POSTERIOR-PERMANENT |
$80.00 |
|
2387 |
RESIN-THREE OR MORE-POSTERIOR PERMANENT |
$102.00 |
| ADA CODES | CROWNS |
MEMBER PAYS |
|
2750 |
CROWN-PORCELAIN FUSED HIGH NOBLE METAL |
$375.00 |
|
2751 |
CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL |
$340.00 |
|
2752 |
CROWN-PORCELAIN FUSED TO NOBLE METAL |
$354.00 |
|
2790 |
CROWN-FULL CAST HIGH NOBLE METAL |
$369.00 |
|
2791 |
CROWN-FULL CAST-PREDOMINANTLY BASE METAL |
$330.00 |
|
2930 |
PREFAB STAINLESS STEEL CROWN- PRIMARY |
$70.00 |
|
2931 |
PREFAB STAINLESS STEEL CROWN- PERMANENT |
$80.00 |
|
2950 |
CORE BUILDUP-INCLUDING ANY PINS |
$70.00 |
|
2951 |
PIN RETENTION/TOOTH IN ADDITION TO RESTORATION |
$18.00 |
|
2952 |
CAST POST AND CORE IN ADDITION TO CROWN |
$110.00 |
|
2954 |
PREFAB POST AND CORE IN ADDITION TO CROWN |
$86.00 |
|
3110 |
PULP CAP DIRECT (EXCL FNL REST) |
$16.00 |
|
3120 |
PULP CAP INDIRECT (EXCL FNL REST) |
$16.00 |
|
3220 |
THERAPEUTIC PULPOTOMY (EXCL FNL REST) |
$38.00 |
|
3310 |
ROOT CANAL--ANTERIOR (EXCL FNL REST) |
$205.00 |
|
3320 |
ROOT CANAL--BICUSPID (EXCL FNL REST) |
$243.00 |
|
3330 |
ROOT CANAL--MOLAR (EXCL FNL REST) |
$305.00 |
| ADA CODES | PERIODONTICS |
MEMBER PAYS |
|
4210 |
GINGIVECTOMY OR GINGIVOPLASTY/QUAD |
$215.00 |
|
4341 |
PERIO SCALING AND ROOT PLANING/QUAD |
$75.00 |
|
4910 |
PERIO MAINTENANCE |
$48.00 |
| ADA CODES | PROSTHODONTICS |
MEMBER PAYS |
|
PROSTHODONTICS |
||
|
5110 |
COMPLETE DENTURE-MAXILLARY |
$448.00 |
|
5120 |
COMPLETE DENTURE-MANDIBULAR |
$448.00 |
|
5130 |
IMMEDIATE DENTURE-MAXILLARY |
$466.00 |
|
5140 |
IMMEDIATE DENTURE-MANDIBULAR |
$466.00 |
|
5211 |
MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) |
$448.00 |
|
5212 |
MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) |
$466.00 |
|
5213 |
MAXILLARY PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES(INCLUDING ANY CONVENTIONAL CLASPS, RESTS OR TEETH) |
$508.00 |
|
5214 |
MAXILLARY PARTIAL DENT-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES(INCLUDING ANY CONVENTIONAL CLASPS, RESTS OR TEETH) |
$508.00
|
|
5410 |
ADJUST COMPLETE DENTURE-MAXILLARY |
$25.00 |
|
5411 |
ADJUST COMPLETE DENTURE-MANDIBULAR |
$25.00 |
|
5510 |
REPAIR BROKEN COMPLETE DENTURE BASE |
$40.00 |
|
5520 |
REPLACE MISSING/BROKEN TEETH |
$38.00 |
|
5630 |
REPAIR OR REPLACE BROKEN CLASP |
$46.00 |
|
5650 |
ADD TOOTH TO EXISTING PARTIAL DENTURE |
$40.00 |
|
5660 |
ADD CLASP TO EXISTING PARTIAL DENTURE |
$51.00 |
|
5730 |
RELINE COMPLETE MAX DENTURE (CHAIRSIDE) |
$95.00 |
|
5731 |
RELINE COMPLETE MAND DENTURE (CHAIRSIDE) |
$95.00 |
|
5740 |
RELINE MAX PARTIAL DENTURE (CHAIRSIDE) |
$90.00 |
|
5741 |
RELINE MAND PARTIAL DENT (CHAIRSIDE) |
$90.00 |
|
5750 |
RELINE COMPLETE MAX DENTURE (LAB) |
$124.00 |
|
5761 |
RELINE COMPLETE MAND DENTURE (LAB) |
$124.00 |
| ADA CODES | FIXED PROSTHETICS |
MEMBER PAYS |
|
6240 |
PONTIC PORCELAIN FUSED TO HIGH NOBLE METAL |
$349.00 |
|
6241 |
PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL |
$321.00 |
|
6242 |
PONTIC PORCELAIN FUSED TO NOBLE METAL |
$335.00 |
|
6750 |
CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL |
$341.00 |
|
6751 |
CROWN PORCELAIN FUSED TO PREDOM BASE METAL |
$307.00 |
|
6752 |
CROWN-PORCELAIN FUSED TO NOBLE METAL |
$319.00 |
| ADA CODES | ORAL SURGERY |
MEMBER PAYS |
|
7110 |
SINGLE TOOTH EXTRACTION |
$38.00 |
|
7120 |
EACH ADDITIONAL TOOTH |
$36.00 |
|
7130 |
ROOT REMOVAL-EXPOSED ROOTS |
$47.00 |
|
7220 |
REMOVAL OF IMPACTED TOOTH-SOFT TISSUE |
$78.00 |
|
7230 |
REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY |
$102.00 |
|
7240 |
REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY |
$150.00 |
|
7250 |
SURG REMOVAL OF RESIDUAL TOOTH ROOTS |
$79.00 |
|
7310 |
ALVEOLOPLASTY IN CONJUNCT W/ EXTRACTIONS/QUAD |
$65.00 |
|
7320 |
ALVEOLOPLASTY NOT IN CONJUNCTION W/ EXT/QUAD |
$94.00 |
|
7510 |
INCISION/DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE |
$48.00 |
| ADA CODES | ORTHODONTICS |
MEMBER PAYS |
|
8070 |
COMP ORTHO TREATMENT--TRANSITIONAL DENTITION |
$2,120.00 |
|
8080 |
COMP ORTHO TREATMENT--ADOLESCENT DENTITION |
$2,180.00 |
|
8090 |
COMP ORHTO TREATMENT--ADULT DENTITION |
$2,210.00 |
| ADA CODES | MISCELLANEOUS SERVICES |
MEMBER PAYS |
|
9110 |
PALLIATIVE TREATMENT DENT PAIN-MINOR PROCEDURE |
$25.00 |
|
9215 |
LOCAL ANESTHESIA |
$15.00 |
|
9230 |
ANALGESIA |
$28.00 |
|
9951 |
OCCLUSAL ADJUSTMENT LIMITED |
$35.00 |
|
9952 |
OCCLUSAL ADJUSTMENT COMPLETE |
$141.00 |
| All of the above charges are reduced fees for services performed by a participating general dentist. Any procedure not listed is available on a fee for service basis at a 20% discount from the participating provider's fee schedule. Consult with your participating dentist prior to beginning any treatment. Some discretion of the general dentist, may need to be referred to a specialist (advanced degree). Any treatment provided by a participating specialist, if available, in Oral Surgery, Orthodontics, Periodontics, Pedodontics or Endodontics will be charged at a 20% reduction of that participating specialist's fees for the services, 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. PAYMENT IS REQUIRED AT THE TIME OF SERVICE. FEES DO NOT INCLUDE LAB COSTS WHICH ARE THE MEMBER'S RESPONSIBILITY. | ||