Benefits
What You Can Expect To Pay At The Dentist
Dental (Specialist) Fee Schedule
Please make sure to confirm your provider matches this fee schedule.
Diagnostic/Preventative
Code
Service
Discounted Rate
D0140
Limited oral evaluation - problem focused
Diagnostic/Preventative
$45.00
D0145
Oral evaluation - patient under 3 years of age
Diagnostic/Preventative
$45.00
D0150
Comprehensive oral evaluation - new or established patient
Diagnostic/Preventative
$50.00
D0160
Detailed and extensive oral eval - problem focused
Diagnostic/Preventative
$46.00
D0170
Re-evaluation - problem focused
Diagnostic/Preventative
$34.00
D0180
Comprehensive periodontal eval. - est. patient
Diagnostic/Preventative
$51.00
D0190
Screening of patient
Diagnostic/Preventative
$22.00
D0191
Assessment of patient
Diagnostic/Preventative
$26.00
D0210
Intraoral - complete series - including bitewings
Diagnostic/Preventative
$100.00
D0220
Intraoral - periapical first film
Diagnostic/Preventative
$20.00
D0230
Intraoral - periapical each add film
Diagnostic/Preventative
$15.00
D0240
Intraoral - occlusal film
Diagnostic/Preventative
$25.00
D0250/60
Extraoral - first film and each add. film
Diagnostic/Preventative
$42.00
D0270
Bitewing x-ray - single film
Diagnostic/Preventative
$20.00
D0272
Bitewing x-ray - two films
Diagnostic/Preventative
$28.00
D0273
Bitewing x-ray - three films
Diagnostic/Preventative
$36.00
D0274
Bitewing x-ray - four films
Diagnostic/Preventative
$42.00
D0277
Vertical bitewings - 5 to 8 films
Diagnostic/Preventative
$65.00
D0330
Panoramic film
Diagnostic/Preventative
$80.00
D0340
Cephalometric film
Diagnostic/Preventative
$0.00
D0350
Oral/facial photographic images
Diagnostic/Preventative
$0.00
D0363
Cone Beam - 3D image reconstruction, inc. multiple images
Diagnostic/Preventative
$185.00
D0417
Collection and preparation of saliva sample for lab. diag. testing
Diagnostic/Preventative
$26.00
D0418
Analysis of saliva sample
Diagnostic/Preventative
$67.00
D0460
Pulp vitality tests
Diagnostic/Preventative
$0.00
D0470
Diagnostic casts
Diagnostic/Preventative
$56.00
D1110
Prophylaxis cleaning - adult
Diagnostic/Preventative
$60.00
D1120
Prophylaxis cleaning - child
Diagnostic/Preventative
$43.00
D1203
Topical application of fluoride - child
Diagnostic/Preventative
$19.00
D1204
Topical application of fluoride - adult
Diagnostic/Preventative
$19.00
D1206
Topical flouride varnish
Diagnostic/Preventative
$23.50
D1208
Topical application of flouride
Diagnostic/Preventative
$21.00
D1351
Sealant - per tooth
Diagnostic/Preventative
$36.00
D1352
Prev. resin rest. mnd/high caries risk - perm. tooth
Diagnostic/Preventative
$41.00
D1354
Silver diamine flouride
Diagnostic/Preventative
$30.00
D1510/20
Space maintainer - fixed/removable - unilateral
Diagnostic/Preventative
$217.00
D1515/25
Space maintainer - fixed/removable - bilateral
Diagnostic/Preventative
$270.00
D1550
Re-cementation of space retainer
Diagnostic/Preventative
$45.00
Restorative Dentistry (Fillings)
Code
Service
Discounted Rate
Amalgam Restorations (silver)
Restorative Dentistry (Fillings)
D2140
Amalgam - one surface, prim. or perm.
Restorative Dentistry (Fillings)
$83.50
D2150
Amalgam - two surface, prim. or perm.
Restorative Dentistry (Fillings)
$103.00
D2160
Amalgam - three surface, prim. or perm.
Restorative Dentistry (Fillings)
$122.00
D2161
Amalgam - >=4 surface, prim. or perm.
Restorative Dentistry (Fillings)
$146.00
Resin/Composite Restorations (tooth colored)
Restorative Dentistry (Fillings)
D2330
Resin based composite - one surface, anterior
Restorative Dentistry (Fillings)
$106.00
D2331
Resin based composite - two surface, anterior
Restorative Dentistry (Fillings)
$128.00
D2332
Resin based composite - three surface, anterior
Restorative Dentistry (Fillings)
$147.00
D2335
Resin based composite - >=4 surface, anterior
Restorative Dentistry (Fillings)
$177.00
D2390
Resin based composite crown - anterior
Restorative Dentistry (Fillings)
$186.00
D2391
Resin based composite - one surface, posterior
Restorative Dentistry (Fillings)
$117.00
D2392
Resin based composite - two surface, posterior
Restorative Dentistry (Fillings)
$147.00
D2393
Resin based composite - three surface, posterior
Restorative Dentistry (Fillings)
$172.00
D2394
Resin based composite - >=4 surface, posterior
Restorative Dentistry (Fillings)
$196.00
D2940
Sedative filling
Restorative Dentistry (Fillings)
$54.00
D2951
Pin retention - per tooth, in addition to restoration
Restorative Dentistry (Fillings)
$30.50
D3110/20
Pulp cap - direct/indirect (excl. final restoration)
Restorative Dentistry (Fillings)
$45.00
Crown and Bridge
Code
Service
Discounted Rate
D2390
Resin-based composite crown, anterior
Crown and Bridge
$246.00
D2391
Resin-based composit - one surface, posterior
Crown and Bridge
$129.00
D2392
Resin-based composit - two surface, posterior
Crown and Bridge
$163.00
D2393
Resin-based composit - three surface, posterior
Crown and Bridge
$195.00
D2394
Resin-based composit - four or more surface, posterior
Crown and Bridge
$231.00
D2510
Inlay - metallic - one surface
Crown and Bridge
$593.00
D2520
Inlay - metallic - two surface
Crown and Bridge
$593.00
D2530
Inlay - metallic - three or more surfaces
Crown and Bridge
$625.00
D2542
Onlay - metallic - two surface
Crown and Bridge
$665.00
D2543
Onlay - metallic - three surface
Crown and Bridge
$734.00
D2544
Onlay - metallic - four or more surfaces
Crown and Bridge
$734.00
D2610
Inlay - porcelain/ceramic - one surface
Crown and Bridge
$674.00
D2620
Inlay - porcelain/ceramic - two surface
Crown and Bridge
$674.00
D2630
Inlay - porcelain/ceramic - >=3 surface
Crown and Bridge
$693.00
D2642
Onlay - porcelain/ceramic - two surface
Crown and Bridge
$744.00
D2643
Onlay - porcelain/ceramic - three surface
Crown and Bridge
$791.00
D2644
Onlay - porcelain/ceramic - >=4 surface
Crown and Bridge
$837.00
D2650
Inlay - resin-based composite - one surface
Crown and Bridge
$538.00
D2651
Inlay - resin-based composite - two surface
Crown and Bridge
$558.00
D2652
Inlay - resin-based composite - >=3 surface
Crown and Bridge
$578.00
D2662
Onlay - resin-based composite - two surface
Crown and Bridge
$604.00
D2663
Onlay - resin-based composite - two surface
Crown and Bridge
$640.00
D2664
Onlay - resin-based composite - >=4 surface
Crown and Bridge
$691.00
D2710
Crown - resin-based composite (indirect)
Crown and Bridge
$411.00
D2712
Crown - 3/4 resin based composite (indirect)
Crown and Bridge
$772.00
D2721/22/23
Crowns - resin with metal
Crown and Bridge
$785.00
D2740
Crown - porcelain/ceramic substrate
Crown and Bridge
$875.00
D2750
Crown - porcelain fused to high noble metal
Crown and Bridge
$857.00
D2751
Crown - porcelain fused to perdominantly base metal
Crown and Bridge
$791.00
D2752
Crown - porcelain fused to noble metal
Crown and Bridge
$822.00
D2780/81/82
Crown 3/4 cast with metal
Crown and Bridge
$837.00
D2783
Crown 3/4 porcelain/ceramic
Crown and Bridge
$850.00
D2790/91/92
Crown full cast metal
Crown and Bridge
$869.00
D2799
Provisional crown
Crown and Bridge
$186.00
D2910/20
Recement inlay, only crown or partial coverage rest
Crown and Bridge
$74.00
D2929
Prefab. Porcelain/ceramic crown - primary tooth
Crown and Bridge
$171.00
D2930
Prefab. stainless steel crown - prim. tooth
Crown and Bridge
$190.00
D2931
Prefab. stainless steel crown - perm. tooth
Crown and Bridge
$223.00
D2932
Prefabricated resin crown
Crown and Bridge
$247.00
D2934
Anterior primary crown
Crown and Bridge
$220.00
D2940
Protective restoration
Crown and Bridge
$72.00
D2950
Core buildup including pins
Crown and Bridge
$186.00
D2952
Cast post and core in addition to crown
Crown and Bridge
$274.00
D2954
Prefab. Post and core in addition to crown
Crown and Bridge
$232.00
D2955
Post removal - not in conj. with endo. therapy
Crown and Bridge
$150.00
D2961
Labial veneer (resin laminate) - laboratory
Crown and Bridge
$597.00
D2962
Labial veneer (porcelain laminate) - laboratory
Crown and Bridge
$837.00
D2970
Temporary crown (fractured tooth)
Crown and Bridge
$173.00
D2980
Crown repair, by report
Crown and Bridge
$150.00
D2981
Inlay Repair necessitated by restorative material failure
Crown and Bridge
$134.00
D2982
Onlay Repair necessitated by restorative material failure
Crown and Bridge
$139.00
D2983
Veneer Repair necessitated by restorative material failure
Crown and Bridge
$137.00
D2990
Resin infiltration of incipient smooth surface lesions
Crown and Bridge
$68.00
Prosthetics (Dentures)
Code
Service
Discounted Rate
All
Dentures and Denture Related Items
Prosthetics (Dentures)
10% Discount
Bridge & Pontics
Code
Service
Discounted Rate
D0360-D0363
Implant Crowns and Abutments
Bridge & Pontics
15% Discount
D6000-D6199
Implants - The greater of 15% Discount or Member Cost
Bridge & Pontics
15% Disc. or MC
D6010
Surgical placement of implant body:Endosteal implant
Bridge & Pontics
$1,495.00
D6012
Surgical placement of interimimplant body for transitional prosthesis: endosteal implant
Bridge & Pontics
$850.00
D6051
Interim abutment
Bridge & Pontics
$250.00
D6053
Implant/abutment supported removable denture for completely edentulous arch
Bridge & Pontics
$1,100.00
D6055
Connecting bar - implant supported or abutment supported
Bridge & Pontics
$524.00
D6056
Prefabricated abutment - includes modification and placement
Bridge & Pontics
$464.00
D6057
Custom Fabricated abutment - includes placement
Bridge & Pontics
$585.00
D6058
Abutment supported porcelain/ceramic crown
Bridge & Pontics
$1065.00
D6059
Abutment supported porcelain fused to metal crown (high noble)
Bridge & Pontics
$773.00
D6066
Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)
Bridge & Pontics
$931.00
D6069
Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
Bridge & Pontics
$936.00
D6076
Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal)
Bridge & Pontics
$905.00
D6080
Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis
Bridge & Pontics
$78.00
D6104
Bone graft at time of implant placement
Bridge & Pontics
$249.00
D6210/11/12
Pontic - metal
Bridge & Pontics
$736.00
D6240/41/42
Pontic - porcelain fused metal
Bridge & Pontics
$779.00
D6245
Pontic - porcelain/ceramic
Bridge & Pontics
$787.00
D6250/51/52
Pontic - resin with metal
Bridge & Pontics
$695.00
D6253
Provisional pontic
Bridge & Pontics
$145.00
D6545
Retainer - cast metal for resin bonded fixed prosthesis
Bridge & Pontics
$286.00
D6548
Ret. - porc./ceramic for resin bonded fixed prosthesis
Bridge & Pontics
$551.00
D6600
Inlay - porc./ceramic, two surface
Bridge & Pontics
$600.00
D6601
Inlay - porc./ceramic, >=3 surface
Bridge & Pontics
$625.00
D6602
Inlay - cast high noble metal, two surface
Bridge & Pontics
$572.00
D6603
Inlay - cast high noble metal, >=3 surface
Bridge & Pontics
$597.00
D6604
Inlay - cast predominantly base metal, two surface
Bridge & Pontics
$572.00
D6605
Inlay - cast predominantly base metal, >=3 surface
Bridge & Pontics
$597.00
D6606
Inlay - cast noble metal, two surface
Bridge & Pontics
$572.00
D6607
Inlay - cast noble metal, >=3 surface
Bridge & Pontics
$592.00
D6608
Onlay - porc./ceramic, two surface
Bridge & Pontics
$673.00
D6609
Onlay - porc./ceramic, >=3 surface
Bridge & Pontics
$701.00
D6610
Onlay - cast high noble metal, two surface
Bridge & Pontics
$644.00
D6611
Onlay - cast high noble metal, >=3 surface
Bridge & Pontics
$736.00
D6612
Onlay - cast predominantly base metal, two surface
Bridge & Pontics
$644.00
D6613
Onlay - cast predominantly base metal, >=3 surface
Bridge & Pontics
$736.00
D6614
Onlay - cast noble metal, two surface
Bridge & Pontics
$644.00
D6615
Onlay - cast noble metal, >=3 surface
Bridge & Pontics
$736.00
D6710
Crown - indirect resin-based composit
Bridge & Pontics
$436.00
D6720/21/22
Crown - resin with metal
Bridge & Pontics
$695.00
D6740
Crown - porcelain/ceramic
Bridge & Pontics
$787.00
D6750/52
Crown - porcelain fused metal
Bridge & Pontics
$736.00
D6751
Crown - pordelain fused to predominantly base metal
Bridge & Pontics
$727.00
D6780
Crown - 3/4 cast high noble metal
Bridge & Pontics
$660.00
D6781
Crown 3/4 cast predominantly base metal
Bridge & Pontics
$660.00
D6782
Crown - 3/4 cast noble metal
Bridge & Pontics
$660.00
D6783
Crown - 3/4 porc./ceramic
Bridge & Pontics
$717.00
D6790/91/92
Crown - full cast metal
Bridge & Pontics
$695.00
D6793
Provisional retainer crown
Bridge & Pontics
$145.00
D6930
Recement fixed partial denture
Bridge & Pontics
$97.00
D6970
Post and core in addition to fixed partial dent. ret
Bridge & Pontics
$260.00
D6972
Prefab post and core in addition to fixed part. dent. ret
Bridge & Pontics
$216.00
D6973
Core buildup for retainer, including pins
Bridge & Pontics
$175.00
D6975
Coping - metal
Bridge & Pontics
$456.00
D6976
Each add. Indirectly fabricated post - same tooth
Bridge & Pontics
$182.00
D6977
Each add. Prefab post - same tooth
Bridge & Pontics
$84.00
D6980
Fixed Partial denture repair, by report
Bridge & Pontics
$241.00
Adjunctive General Services
Code
Service
Discounted Rate
D9110
Palliative (emergency) treatment of dental pain
Adjunctive General Services
$58.00
D9210/15
Local anesthesia
Adjunctive General Services
$24.00
D9211
Regional block anesthesia
Adjunctive General Services
$0.00
D9212
Trigeminal division block anesthesia
Adjunctive General Services
$0.00
D9223
Deep sedation/general anesthesia - each additional 15 m
Adjunctive General Services
$130.00
D9230
Inhalation of nitris oxide/analgesia - first 30 min.
Adjunctive General Services
$57.00
D9241
Intravenous sedation first 30m
Adjunctive General Services
$270.00
D9242
IV conscious sedation/analgesia - each add. 15 min.
Adjunctive General Services
$49.00
D9243
Intravenous sedation each 15m
Adjunctive General Services
$135.00
D9248
Non-intravenous conscious sedation
Adjunctive General Services
$145.00
D9310
Consultation (diagnostic service by non treating dentist)
Adjunctive General Services
$63.00
D9430
Office visit for observation (during regulary scheduled hours)
Adjunctive General Services
$34.00
D9440
Office visit - after regulary scheduled hours
Adjunctive General Services
20% Discount
D9910/11
Application of desensitizing medicament
Adjunctive General Services
$34.00
D9930
Treatment of complications (post-surgery)
Adjunctive General Services
$54.00
D9940
Occusual guard, by report
Adjunctive General Services
$350.00
D9941
Fabrication of athletic mouthguard
Adjunctive General Services
$120.00
D9951
Occlusal adjustment - limited
Adjunctive General Services
$71.00
D9952
Occlusal adjustment - complete
Adjunctive General Services
$257.00
D9972
External bleaching - per arch - performed in office
Adjunctive General Services
$174.00
D9974
Internal bleaching - per tooth
Adjunctive General Services
$150.00
D9990
Broken office appointment
Adjunctive General Services
$50.00
Endodontics
Code
Service
Discounted Rate
D3220
Therapeutic pulpotomy (excl. final rest.)
Endodontics
$103.00
D3221
Pulpal debridement, prim. and perm. teeth
Endodontics
$104.00
D3222
Partial pulpotomy for apexogenesis - perm. tooth inc. tooth dev.
Endodontics
$104.00
D3230
Pulpal therapy, anterior, primary tooth
Endodontics
$123.00
D3240
Pulpal therapy, posterior, primary tooth
Endodontics
$117.00
D3310
Endodontic therapy, anterior tooth
Endodontics
$631.00
D3320
Endodontic therapy, bicuspid tooth
Endodontics
$742.00
D3330
Endodontic therapy, molar
Endodontics
$850.00
D3331
Treatment of root canal obstruction; non - surgical access
Endodontics
$165.00
D3332
Inc. endodontic therapy; inoperable, unrestorable, frac. tooth
Endodontics
$166.00
D3333
Internal root repair of perforation defects
Endodontics
$151.00
D3346
Retreat of perv. root canal therapy, anterior
Endodontics
$630.00
D3347
Retreat of perv. root canal therapy, bicuspid
Endodontics
$727.00
D3348
Retreat of perv. root canal therapy, molar
Endodontics
$873.00
D3410
Apicoectomy/periradicular surgery, anterior
Endodontics
$451.00
D3421
Apicoectomy/periradicular surgery, bicuspid (first root)
Endodontics
$375.00
D3425
Apicoectomy/periradicular surgery, molar (first root)
Endodontics
$481.00
D3426
Apicoectomy/periradicular surgery, each add. root
Endodontics
$208.00
D3430
Retrograde filling - per root
Endodontics
$167.00
D3450
Root amputation - per root
Endodontics
$318.00
D3920
Hemisection, not inc. root canal therapy
Endodontics
$324.00
D3950
Canal prep/fitting of preformed dowel or post
Endodontics
$186.00
Periodontics
Code
Service
Discounted Rate
D0180
Comp. periodontal eval - new or established patient
Periodontics
$49.00
D4210
Gingivectomy or gingivoplasty - >3 cont. teeth, per quad
Periodontics
$275.00
D4211
Gingivectomy or gingivoplasty - <= cont. teeth, per quad
Periodontics
$124.00
D4240
Gingival flap proc., inc. root plan ->3 cont teeth, per quad
Periodontics
$333.00
D4241
Gingival flap proc., inc. root plan <=3 cont teeth, per quad
Periodontics
$200.00
D4249
Clinical crown lengthing - hard tissue
Periodontics
$349.00
D4260
Osseous surgery - >3 cont. teeth, per quad
Periodontics
$542.00
D4261
Osseous surgery - <=3 cont. teeth, per quad
Periodontics
$339.00
D4263
Bone replacement graft, retained natural tooth, first site in quad
Periodontics
$318.00
D4264
Bone replacement graft, retained natural tooth, each additional site quad
Periodontics
$213.00
D4266
Guided tissue regeneration - resorbable barrier, per site
Periodontics
$210.00
D4267
Guided tissue regeneration - nonresorbable barrier, per site
Periodontics
$325.00
D4268
Surgical revision proc., per tooth
Periodontics
$465.00
D4273
Subepithelial connective tissue graft procedures, per tooth
Periodontics
$568.00
D4274
Mesial/Distal wedge procedure, single tooth
Periodontics
$400.00
D4275
Soft tissue allograft
Periodontics
$532.00
D4277
Free soft tissue graft procedure, first or edentulous tooth pos.
Periodontics
$410.00
D4321
Provisional splinting - extracoronal
Periodontics
$149.00
D4341
Perio scaling and root planing >3 cont teeth, per quad
Periodontics
$175.00
D4342
Perio scaling and root planing <=3 cont teeth, per quad
Periodontics
$110.00
D4355
Full mouth debridement
Periodontics
$105.00
D4381
Localized delivery of chemotherapeutic agents
Periodontics
$60.00
D4910
Periodontal maintenance
Periodontics
$91.00
D9940
Occlusal guard, by report
Periodontics
$353.00
D9950
Occusion analysis - mounted case
Periodontics
$134.00
D9951
Occlusal adjustment - limited
Periodontics
$83.00
D9952
Occlusal adjustment - complete
Periodontics
$354.00
Oral Surgery
Code
Service
Discounted Rate
D7111
Extraction, coronal remnants - deciduous tooth
Oral Surgery
$70.00
D7140
Extraction, erupted tooth or exposed root
Oral Surgery
$115.00
D7210
Surgical rem. of erupted tooth req. bone cut
Oral Surgery
$190.00
D7220
Removal of impacted tooth - soft tissue
Oral Surgery
$205.00
D7230
Removal of impacted tooth - partially bony
Oral Surgery
$295.00
D7240
Removal of impacted tooth - completely bony
Oral Surgery
$345.00
D7241
Removal of imp. tooth-com. bony w/ surg. complications
Oral Surgery
$395.00
D7250
Surgical removal of residual tooth roots
Oral Surgery
$195.00
D7270
Tooth reimplant./stabiliz. of acc. evulsed/displaced tooth
Oral Surgery
$284.00
D7280
Surgical access of an unerupted tooth
Oral Surgery
$295.00
D7286
Biopsy of oral tissue - soft
Oral Surgery
$146.00
D7287
Exfoliative cytological sample collection
Oral Surgery
$96.00
D2788
Brush biopsy - transepithelial sample collection
Oral Surgery
$86.00
D7291
Transseptal fiberotomy/supra crestal fiberatomy, by report
Oral Surgery
$75.00
D7310
Alveoloplasty in conjunction with extractions, four+ per quad
Oral Surgery
$225.00
D7320
Alveoloplasty not in conjunction w/ extractions, four+ per quad"
Oral Surgery
$290.00
D7410
Excision of benign lesion up to 1.25 cm
Oral Surgery
$152.00
D7440
Excision of malignant tumor - lesion diameter up to 1.25 cm
Oral Surgery
$142.00
D7450
Rem. of benign odontogenic cyst or tumor - dia. up to 1.25 cm
Oral Surgery
$165.00
D7510
Incision and drainage of abscess - intraoral soft tissue
Oral Surgery
$120.00
D7960
Frenulectomy (frenectomy/frenotomy) - separate proc.
Oral Surgery
$330.00
Orthodontics
Code
Service
Discounted Rate
All
Orthodontics
10% Discount
10% discount for any procedure code not listed.
Last Revised: 02/24/2017