May 18, 2012

Discount Dental Program General Dental Fees 

As Performed by General Practitioners

 
CODE TYPICAL COST* DDS YOU SAVE
 
DIAGNOSTIC PROCEDURES
D0120 Periodic oral evaluation 53 0** 53
D0140 Limited oral evaluation 69 0** 69
D0150 Comprehensive oral evaluation 81 0** 81
D0210 Intraoral complete series x-ray (including bitewings) 133 0** 133
D0220 Intraoral x-ray film, single, first 28 0** 28
D0230 Intraoral x-ray film, each additional film 21 0** 21
D0270 Bitewing x-ray film, single, first N/A 0** N/A
D0272 Bitewing x-ray film, two 42 0** 42
D0274 Bitewing x-ray film, four 81 0** 81
D0330 Panoramic film 106 0** 106
 
PREVENTIVE PROCEDURES
D1110 Prophylaxis – adult (additional in same membership year) 94 39 55
D1120 Prophylaxis – child (additional in same membership year) 71 28 43
D1130 Annual Check-up prophylaxis – adult 307† 58 219
D1140 Annual Check-up prophylaxis – child 284† 40 218
D1203 Topical application of fluoride (excl. prophylaxis – child) 40 14 27
D1204 Topical application of fluoride (excl. prophylaxis – adult) 42 12 31
D1351 Sealant – per tooth 53 18 35
D1510 Space maintainer – fixed unilateral type 318 118 200
D1515 Space maintainer – fixed bilateral type 423 172 251
 
RESTORATIVE PROCEDURES
D2140 Amalgam – one surface, permanent or primary 133 50 83
D2150 Amalgam – two surfaces, permanent or primary 160 64 96
D2160 Amalgam – three surfaces, permanent or primary 192 76 116
D2161 Amalgam – four or more surfaces, permanent or primary 229 91 138
D2330 Resin – one surface, anterior 159 61 98
D2331 Resin – two surfaces, anterior 196 76 120
D2332 Resin – three surfaces, anterior 239 95 143
D2335 Resin – four+ surfaces or involving incisal angle 288 119 170
D2391 Resin – 1 surface, posterior 175 74 101
D2392 Resin – 2 surfaces, posterior 228 101 127
D2393 Resin – 3 surfaces, posterior 302 126 176
D2750 Crown – porcelain fused to high noble metal 971 534 437
D2751 Crown – porcelain fused to base metal 901 473 428
D2752 Crown – porcelain fused to noble metal 949 501 447
D2791 Crown – full cast (base metal) N/A 428 N/A
D2920 Recement crown 95 39 56
D2930 Prefab'd stainless steel crown – primary tooth 255 111 144
D2931 Prefab'd stainless steel crown – permanent tooth 296 131 164
D2932 Prefab'd resin crown N/A 123 N/A
D2940 Sedative filling 101 45 56
D2950 Core buildup, including any pins 253 111 142
D2951 Pin retention – per tooth, in addition to restoration N/A 27 N/A
D2952 Cast post and core in addition to crown 371 167 204
D2953 Cast post as part of crown N/A 134 N/A
D2954 Pefab'd post and core in addition to crown N/A 139 N/A
D2960 Labial veneer (porcelain laminate), chairside 636 323 313
D2970 Temporary crown (fractured tooth) N/A 111 N/A
D2971 Additional procedures to construct new crown under existing partial dential framework N/A 111 N/A
 
ENDODONTIC PROCEDURES (Root Canal Therapy)
D3110 Pulp cap – direct (excl final restoration) 90 28 63
D3120 Pulp cap – indirect (excl final restoration) 94 28 67
D3220 Therapeutic pulpotomy (excluding final restoration) 199 67 133
D3310 Root Canal – anterior (excluding final restoration) 694 284 410
D3320 Root canal – bicuspid (excluding final restoration) 806 342 463
D3330 Root Canal – molar (excluding final restoration) 969 428 541
D3920 Hemisection (including any root removal; excl root canal therapy N/A 145 N/A
 
PERIODONTIC PROCEDURES
D4210 Gingivectomy or gingivoplasty – 4+ continguous teeth/quad 628 234 393
D4211 Gingivectomy or gingivoplasty – 1-3 contiguous teeth/quad 318 90 228
D4240 Gingival flap procedure, incl root planing – per quad N/A 312 N/A
D4260 Osseous surgery - incl flap entry & closure, per quad 1034 428 605
D4270 Pedicle soft tissue graft procedure N/A 323 N/A
D4341 Periodontal scaling and root planing – per quad 242 101 141
D4345 Periodontal scaling in the presence of gingival inflammation N/A 112 N/A
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis N/A 84 N/A
D4910 Periodontal maintenance procedures (following active therapy) 140 61 78
 
PROSTHETICS, REMOVABLE
D5110 Complete upper denture, incl 6 months post-insertion care 1590 623 967
D5120 Complete lower denture, incl 6 months post-insertion care 1590 623 967
D5130 Immediate upper denture, incl 6 months post-insertion care; does not incl required future rebasing/refining procedures or a complete new denture 1696 695 1001
D5140 Immediate lower denture, incl 6 months post-insertion care; does not incl required future rebasing/refining procedures or a complete new denture 1696 695 1001
D5211 Upper partial denture – resin base, including any conventional clasps and rests 1373 507 866
D5212 Lower partial denture – resin base, including any conventional clasps and rests 1373 507 866
D5213 Upper partial denture – predominantly base cast with resin base incl any conventional clasps and rests 1696 657 1039
D5214 Lower partial denture – predominantly base cast with resin base incl any conventional clasps and rests 1696 657 1039
D5410 Adjust complete denture – upper (after 6 mo) N/A 39 N/A
D5411 Adjust complete denture – lower (after 6 mo) N/A 39 N/A
D5421 Adjust partial denture – upper (after 6 mo) N/A 39 N/A
D5422 Adjust partial denture – lower (after 6 mo) N/A 39 N/A
D5510 Repair broken complete denture base 223 70 153
D5520 Replace missing or broken teeth, complete denture – each tooth 180 58 122
D5610 Repair resin denture resin saddle or base 212 78 134
D5630 Repair or replace partial denture broken clasp N/A 84 N/A
D5640 Replace broken teeth – partial denture, per tooth 180 67 113
D5650 Add tooth to existing partial denture 210 83 127
D5660 Add clasp to existing partial denture 261 71 190
D5710 Rebase complete upper denture (LAB) 530 224 306
D5711 Rebase complete lower denture (LAB) N/A 228 N/A
D5720 Rebase partial upper denture (LAB) N/A 228 N/A
D5721 Rebase partial lower denture (LAB) N/A 228 N/A
D5730 Reline complete upper denture (chairside) 355 145 210
D5731 Reline complete lower denture (chairside) 355 145 210
D5740 Reline upper partial denture (chairside) N/A 145 N/A
D5741 Reline lower partial denture (chairside) N/A 145 N/A
D5810 Temporary complete denture (upper) N/A 339 N/A
D5811 Temporary complete denture (lower) N/A 339 N/A
D5820 Temporary partial – stayplate denture (upper) N/A 301 N/A
D5821 Temporary partial – stayplate denture (lower) N/A 301 N/A
 
PROSTHODONTICS, FIXED BRIDGE
D6210 Pontic – cast high noble metal 954 501 453
D6240 Pontic – porcelain fused to high noble metal 974 498 476
D6241 Pontic – porcelain fused to base metal 925 462 463
D6545 Cast metal retainer for resin bonded fixed prosthesis 795 228 567
D6751 Crown (abutment) porcelain fused to base metal 922 470 453
D6790 Crown – full cast high noble metal 954 504 451
D6791 Crown (abutment) full cast base metal N/A 420 N/A
D6930 Recement bridge 148 61 87
D6940 Stressbreaker N/A 173 N/A
D6950 Precision attachmen t(each) N/A 306 N/A
D6970 Cast post and core in addition to bridge retainer N/A 170 N/A
D6971 Cast post as part of bridge retainer N/A 134 N/A
D6972 Prefab'd post & core in addition to bridge retainer N/A 139 N/A
 
ORAL SURGERY
D7111 Extraction, coronal remnants – deciduous tooth 119 61 57
D7140 Extraction erupted tooth or exposed root 149 75 74
D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and/or section of tooth – ea tooth 246 94 152
D7220 Removal of impacted tooth – soft tissue 292 123 169
D7230 Removal of impacted tooth – partially bony 367 158 209
D7240 Removal of impacted tooth – completely bony 438 212 226
D7241 Removal of impacted tooth – completely bony, with unusual surgical complications 530 250 280
D7250 Surgical removal of residual tooth roots (cutting procedure) 273 106 167
D7280 Surgical access of an unerupted tooth N/A 151 N/A
D7310 Alveolectomy or plasty in conjunction with extractions – per quadrant 270 94 176
D7320 Alveolectomy or plasty not in conjunction with extractions – per quadrant 413 139 275
D7960 Frenulectomy (frenectomy or frenotomy) – separate procedure 384 139 245
D7970 Excision of hyperplastic tissue – per arch 455 106 349
D7971 Excision of pericornonal gingival N/A 78 N/A
 
Surgical procedures listed above include the administration of local anesthesia only. The administration of nitrous oxide, intravenous sedation, or general anesthesia is available at additional cost to the subscriber.
 
ADJUNCTIVE SERVICES – UNCLASSIFIED TREATMENT
D9110 Palliative (emergency) treatment of dental pain, minor procedure, during regular office hours 133 24 108
D9440 Office visit after regular scheduled office hours 159 61 98
D9940 Occlusal Guard 583 267 316
 
SPECIALIST SERVICES
As Performed by Board Eligible or Board Certified Dental Specialists
 
ORAL SURGURY
D7111 Extraction, coronal remnants – deciduous tooth 170 99 71
D7140 Extraction erupted tooth or exposed root 201 103 99
D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and/or section of tooth – ea tooth 297 134 163
D7220 Removal of impacted tooth- soft tissue 339 173 166
D7230 Removal of impacted tooth – partially bony 424 212 212
D7240 Removal of impacted tooth – completely bony 479 257 223
D7241 Removal of impacted tooth – completely bony, with unusual surgical complications 557 314 243
D7250 Surgical removal of residual tooth roots (cutting procedure) 352 162 190
D7280 Surgical access of an unerupted tooth 318 223 95
D7310 Alveolectomy or plasty in conjunction with extractions – per quadrant 382 134 248
D7320 Alveolectomy or plasty not in conjunction with extractions – per quadrant 602 180 422
D7960 Frenulectomy (frenectomy or frenotomy) – separate procedure 557 212 345
D7970 Excision of hyperplastic tissue – per arch 795 253 542
D7971 Excision of pericornonal gingival N/A 142 N/A
 
Surgical procedures listed above include the administration of local anesthesia only. The administration of nitrous oxide, intravenous sedation, or general anesthesia is available at additional cost to the subscriber.
 
PERIODONTIC PROCEDURES
D4210 Gingivectomy or gingivoplasty – 4+ continguous teeth/quad 1060 356 704
D4211 Gingivectomy or gingivoplasty – 1-3 contiguous teeth/quad 890 151 740
D4240 Gingival flap procedure, incl root planing – per quad N/A 435 N/A
D4260 Osseous surgery - incl flap entry & closure, per quad 1685 613 1073
D4270 Pedicle soft tissue graft procedure N/A 360 N/A
D4341 Periodontal scaling and root planing – per quad 356 152 205
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis 148 78 70
D4910 Periodontal maintenance procedures (following active therapy) 140 61 78
 
ENDODONTIC PROCEDURES (Root Canal Therapy)
D3310 Root canal therapy – anterior (excl final restoration) 1007 399 608
D3320 Root canal – bicuspid (excluding final restoration) 1087 473 614
D3330 Root Canal – molar (excluding final restoration) 1325 618 707
D3920 Hemisection (including any root removal; excl root canal therapy N/A 200 N/A
 
ORTHODONTICS – COMPREHENSIVE CASE
Class I, II, III (up to and including age 16)
 
D8070, D8080
Orthodontic records, treatment plan and consultation N/A 112 N/A
Initial ortho appliance, construction and installation N/A 428 N/A
Active treatment phase – up to 24 months N/A 2375 N/A
Retention phase per retainer N/A 210 N/A
Total for those up to and including age 16 5809 3125 2471

 

Continuation of orthodontic treatment beyond 24 months and other orthodontic services available at a 25% discount from usual and customary fees charged by orthodontists listed in the DDS Dental Directory. Orthodontic treatment includes the treatment of primary, transitional, and/or adolescent dentitions under the D8000-D8999 series procedures codes. Orthodontic treatment for patients over the age of 16 is a 25% reduction from the dentist's usual and customary fee. Invisalign braces are 25% off the usual and customary fee of the participating provider.

*Typical cost provided by ADA Dental Survey 2005, 90th percentile.
**In conjunction with paid annual check-up prophylaxis (cleaning) $58 for adults and $40 for children.
Children are up to and including 16 years of age.
†Typical cost for annual check-up prophylaxis includes comprehensive oral exam and intraoral complete series x-ray films.

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