DENTAL Fee Schedule for General Dentistry
ADA

Description of Services

 Average Member
CODE Charge Pays
Diagnostic and Preventive Services
00120 Periodic Oral Examination $26 $16
00140 Limited Oral Evaluation $44 $26
00150 Comprehensive Oral Evaluation - Problem Focused (Emergency) $46 $21
09110 Palliative (Emergency) Treatment of Dental Pain $62 $26
00220 Single Periapical X-ray $16 $6
00210 Complete Series X-rays (including bite-wings) $80 $48
00230 Each additional PA Film $16 $6
00272 Bite-wing X-rays (2) $25 $13
00330 Panoramic X-rays $71 $49
00470 Study Models $54 $20
01110 Teeth Cleaning (Adult) $51 $32
01120 Teeth Cleaning (Child) $36 $23
01203 Fluoride Treatment (Child) $21 $10
01351 Sealant (Per Tooth) $30 $20
01510 Space Maintainer - Fixed Unilateral $224 $144
01515 Space Maintainer - Fixed Bilateral $265 $173
09960 Disposables $9 $6
09972 Cosmetic Bleaching (external bleaching with tray) $200 $190
(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            $21
Bite-Wing X-rays (2)                                  $13
Cleaning (Adult)                                         $32
Disposables                                                 $ 6
Total                                                             $72
2nd Visit
Examination and Diagnosis                       $16
Cleaning (Adult)                                         $32
Disposables                                                 $ 6
Total                                                             $54
Restorative Dentistry
Amalgam Restoration
Silver Fillings for Posterior (Back) Teeth
02140 Cavities involving one surface $74 $44
02150 Cavities involving two surfaces $96 $57
02160 Cavities involving three surfaces $117 $69
Composite Fillings (Tooth Colored) for anterior (Front) Adult Teeth
02330 Cavities involving one surface $96 $58
02331 Cavities involving two surfaces $117 $73
02332 Cavities involving three surfaces $163 $99
02335 Composite Resin (involving incisal angle) $179 $99
Composite Fillings (tooth colored) for posterior (back) teeth
02391 Cavities involving one surface $117 $69
02392 Cavities involving two surfaces $163 $84
02393 Cavities involving three surfaces $190 $110
02940 Sedative filling $62 $26
02951 Pin retention (per tooth in addition to restoration) $35 $18
 

Crown and Bridge Base Fees
02740 Porcelain crown 25% Off
02750 Porcelain crown (gold) 25% Off
02752 Porcelain/Metal crown 25% Off
02790 Full crown (gold) 25% Off
02792 Full crown (nonprecious metal) 25% Off
02810 3/4 Crown (metal) 25% Off
02820 3/4 Crown (gold) 25% Off
02931 Stainless steel crown (Adult Tooth) 25% Off
02950 Crown build up (including any pins) 25% Off
02954 Post and core (prefabricated) in addition to crown 25% Off
06750 Fixed bridge per unit porcelain/gold 25% Off
06751 Fixed bridge per unit porcelain/metal 25% Off
 

Endodontics (Root Canal Treatment)

Diagnostic Exam

 $21 $14
03110 Pulp capping (excluding restoration) $41 $18
03220 Vital pulpotomy $97 $52

Root Canals
03310 RCT 1 Canal (excluding final restoration) Anterior 20% Off
03320 RCT 2 Canals (Excluding final restoration ) Bicuspid 20% Off
03330 RCT 3 Canals (Excluding final restoration) Molar 20% Off
03340 RCT 4 Canals (Excluding final restoration) 20% Off
 

Oral Surgery
07140 Routine Extraction (single tooth) $82 $55
07210 Surgical Extraction $154 $92
07220 Removal of Impacted Tooth - Soft Tissue $195 $94
07230 Removal of Impacted Tooth - Partially Bony $257 $152
07240 Removal of Impacted Tooth - Completely Bony $302 $189
07510 Intra-Oral I & D Abscess $172 $41
(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)
05110 Complete Maxillary Upper Denture (No Extractions) $909 $633
05120 Complete Mandibular Lower Denture (No Extractions) $909 $633
05211 Upper Partial - Acrylic Base $687 $455
(Including any conventional clasps and rests)
05212 Lower Partial - Acrylic Base $798 $455
(Including any conventional clasps and rests)
05213 Upper Partial - Predominantly Base Cast $959 $702
Base with Acrylic Saddles
(Including any conventional clasps and rests)
05214 Lower Partial - Predominantly Base Cast $959 $702
Base with Acrylic Saddles
(Including any conventional clasps and rests)
05710 Rebase - Complete Upper $330 $211
05711 Rebase - Complete Lower $316 $211
05730 Reline Complete Upper Denture Chair Side $186 $112
05731 Reline Complete Lower Denture Chair Side $186 $112
(Any prosthetic appliance that requires unusual services may be an additional charge.  Discuss with dentists prior to treatment.)
 

Periodontics
04210 Gingivectomy (per 1/4 mouth) $424 $138
04341 Periodontal Scaling (per 1/4 mouth) $156 $101
04910 Periodontal Prophylaxis $86 $43
04355 Gross Scaling $96 $46
(The above charges apply to general dentists only.)
 

Orthodontics
Initial Exam $150 No Chg
Orthodontic Treatment (all ages)
08070 Class 1 Treatment $3700 $3048
08080 Class 2 Treatment $3900 $3322
08090 Class 3 Treatment $4100 $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.