DentSaveSM and Usual Fee Comparison
| Procedure Code | Explanation of code | DentSaveSM Fee |
| Preventative Services | ||
| 0120 | Periodic oral examination | 100.00 |
| 0130 | Emergency oral examination | 125.00 |
| 0140 | Limited oral evaluation - problem focused | 125.00 |
| 0150* | Comprehensive oral evaluation - new or established patient | *Free initial |
| 0160 | Detailed and extensive oral evaluation | 150.00 |
| 0180 | Comprehensive periodontal evaluation | 125.00 |
| 0210 | Full mouth series (14 or more periapical x-rays incl bitewings) | 120.00 |
| 0220 | Intraoral - periapical first film | 30.00 |
| 0230 | Intraoral - periapical each additional film | 20.00 |
| 0240 | Intraoral - Occlusal film, each | 35.00 |
| 0270 | Single Bitewing x-ray | 20.00 |
| 0272 | 2 Bitewing x-rays | 40.00 |
| 0273 | 3 Bitewing x-rays | 50.00 |
| 0274 | 4 Bitewing x-rays | 65.00 |
| 0330 | Panoramic film | 120.00 |
| 1110 | Prophylaxis-adult | 120.00 |
| 1120 | Prophylaxis-child (under 12) | 100.00 |
| 1208 | Fluoride treatment child and/or adult | 40.00 |
| 1351 | Sealants per tooth | 40.00 |
| Space Maintainers | ||
| 1510/1515 | Space Maintainer - fixed | 250.00 |
| 1520/1525 | Space Maintainer - removable | 300.00 |
| Restorative Services | ||
| 2140 | Amalgam one surface | 125.00 |
| 2150 | Amalgam - two surfaces | 150.00 |
| 2160 | Amalgam - three surfaces | 175.00 |
| 2161 | Amalgam - four or more surfaces | 200.00 |
| 2330 | Resin - one surface anterior tooth | 125.00 |
| 2331 | Resin - two surfaces anterior tooth | 150.00 |
| 2332 | Resin - three surfaces anterior tooth | 175.00 |
| 2335 | Composite incisal angle four surfaces | 200.00 |
| 2391 | Resin - one surface posterior tooth | 150.00 |
| 2392 | Resin - two surfaces posterior tooth | 190.00 |
| 2393 | Resin - three surfaces posterior tooth | 225.00 |
| 2394 | Resin - four or more surfaces posterior tooth | 250.00 |
| Inlays | ||
| 2510 | Inlay - metallic one surface | 600.00 |
| 2520 | Inlay - metallic two surfaces | 700.00 |
| 2530 | Inlay - metallic three surfaces | 800.00 |
| 2610 | Inlay - porcelain/ceramic one surface | 800.00 |
| 2620 | Inlay - porcelain/ceramic two surfaces | 900.00 |
| 2630 | Inlay - porcelain/ceramic three surfaces | 1000.00 |
| Crowns | ||
| 2710 | Resin | 800.00 |
| 2720 | Resin - with high noble metal | 900.00 |
| 2721 | Resin - with predominantly base metal | 750.00 |
| 2740 | Porcelain/ceramic substrate | 1100.00 |
| 2750 | Porcelain fused to high noble metal | 1100.00 |
| 2751 | Porcelain fused to predominantly base metal | 1100.00 |
| 2752 | Porcelain fused to noble metal | 1100.00 |
| 2790 | Full Cast with Semi-Precious Metal | 1100.00 |
| 2910 | Recement inlay | 95.00 |
| 2920/2932 | Recement crown | 95.00 |
| 2930/2931 | Stainless Steel primary tooth | 200.00 |
| 2950 | Core buildup, including any pins | 250.00 |
| 2954 | Post and Core | 300.00 |
| 2961 | Labial veneer resin laminate (lab) | 1000.00 |
| 2962 | Labial veneer porcelain laminate (lab) | 1200.00 |
| Endodontics/Root Canal Therapy | ||
| 3220 | Vital Pulpotomy | 100.00 |
| 3410 | Apicoectomy, first root | 700.00 |
| 3421 | Apicoectomy bicuspid first root | 800.00 |
| 3425 | Apicoectomy molar first root | 900.00 |
| 3426 | Apicoectomy each additional root | 200.00 |
| 3310 | Root canal, Anterior Tooth, Traditional Therapy | 700.00 |
| 3320 | Root canal, Bicuspid Tooth, Traditional Therapy | 900.00 |
| 3330 | Root canal, Molar Tooth | 1000.00 |
| 3346 | Retreatment root canal-anterior | 600.00 |
| 3347 | Retreatment root canal-premolar | 700.00 |
| 3348 | Retreatment root canal-molar | 800.00 |
| Periodontal Services | ||
| 4210 | Gingivectomy per quad | 350.00 |
| 4260 | Osseous surgery, per quad | 500.00 |
| 4341 | Periol scaling per quad | 120.00 |
| 4910 | Periodontal Maintenance | 140.00 |
| Prosthodontics and Repairs | ||
| 5110 | Complete Maxillary Denture | 1500.00 |
| 5120 | Complete Mandibular Denture | 1500.00 |
| 5130 | Complete Immediate Upper | 1700.00 |
| 5140 | Complete Immediate Lower | 1700.00 |
| 5211 | Upper Partial acrylic base clasps/rests | 1200.00 |
| 5212 | Lower Partial acrylic base clsp/rests | 1200.00 |
| 5213 | Upper Partial | 1800.00 |
| 5214 | Lower Partial | 1800.00 |
| 5281 | Partial removable unilateral | 750.00 |
| 5410/5411 | Adjust complete denture - upper/lower | 95.00 |
| 5421/5422 | Adjust partial denture - upper/lower | 75.00 |
| 5640 | Replace one tooth in Partial Denture | 125.00 |
| 5650 | Adding tooth to Partial Denture to Replace Extracted Natural Teeth first tooth | 125.00 |
| 5660 | Add Clasp To Existing Partial Denture | 150.00 |
| 5710 | Upper Denture Rebase | 300.00 |
| 5711 | Lower Denture Rebase | 300.00 |
| 5720 | Partial Upper Rebase | 300.00 |
| 5721 | Partial Lower Rebase | 300.00 |
| 5730 | Upper Denture Reline chairside | 200.00 |
| 5731 | Lower Denture Reline chairside | 200.00 |
| 5740 | Partial Upper Reline chairside | 180.00 |
| 5741 | Partial Lower Reline chairside | 180.00 |
| Implants | ||
| 6010 | Surgical Placement of Implant Body | 1900.00 |
| 6057 | Custom Abutment | 950.00 |
| Fixed Prosthodontics | ||
| 6210 | Pontic-cast high noble metal | 1000.00 |
| 6211 | Pontic cast predominantly base metal | 1000.00 |
| 6212 | Pontic cast noble metal | 1000.00 |
| 6240 | Pontic porcelain fused to high noble metal | 1100.00 |
| 6241 | Pontic porcelain fused to predominantly base metal | 1100.00 |
| 6242 | Pontic porcelain fused to noble metal | 1100.00 |
| 6250 | Pontic resin with high noble metal | 1100.00 |
| 6251 | Pontic resin with predominantly base metal | 1100.00 |
| 6252 | Pontic resin with noble metal | 1100.00 |
| 6545 | Cast metal retainer | 400.00 |
| 6720 | Resin with high noble metal | 1100.00 |
| 6721 | Resin with predominantly base metal | 1000.00 |
| 6722 | Resin with noble metal | 1100.00 |
| 6750 | Porcelain fused to high noble metal | 1200.00 |
| 6751 | Porcelain fused to base metal | 1100.00 |
| 6752 | Porcelain fused to noble metal | 1100.00 |
| 6780 | 3/4 cast high noble metal | 1100.00 |
| 6781 | 3/4 cast predominantly base metal | 1100.00 |
| 6782 | 3/4 cast noble metal | 1100.00 |
| 6790 | Full cast high noble metal | 1100.00 |
| 6791 | Full cast predominantly base metal | 1000.00 |
| 6792 | Full cast noble metal | 1000.00 |
| 6930 | Recement Crown or Bridge | 120.00 |
| Oral Surgery | ||
| 7140 | Extraction, erupted tooth or exposed root | 125.00 |
| 7210 | Surgical extraction | 250.00 |
| 7220 | Soft tissue Impaction | 300.00 |
| 7230 | Partially Bony Impaction | 400.00 |
| 7240 | Complete Bony Impaction | 500.00 |
| 7250 | Surgical Removal of residual tooth roots | 150.00 |
| 7285 | Biopsy of oral tissue - hard | 210.00 |
| 7286 | Biopsy of oral tissue - soft | 150.00 |
| 7310 | Alveoplasty per quad | 200.00 |
| 7410 | Removal of Cyst or benign lesion up to 1.25 cm | 250.00 |
| 7960 | Frenectomy | 240.00 |
| Orthodontics | ||
| 8080 | Initial Appliance | 1400.00 |
| 8670 | Periodic orthodontic treatment-monthly adjustments | 120.00 |
| 8680 | Orthodontic retention (removal of appliance, constr. and placement of a set of retainers) | $700.00 upper denture - $350 lower denture - $350 |
| Adjunctive General Services | ||
| 9110 | Emergency Palliative Treatment | 80.00 |
| 9215 | Local anesthesia in conjunction with surgical procedures | 50.00 |
| 9222 | Deep sedation/general anesthesia - first 15 minutes | 90.00 |
| 9223 | Deep sedation/general anesthesia - each additional 15 minutes | 90.00 |
| 9230 | Inhalation of nitrous oxide/analgesia, anxiolysis | 75.00 |
| 9239 | Intravenous moderate (conscious) sedation/analgesia - first 15 minutes | 125.00 |
| 9243 | Intravenous moderate (conscious) sedation/analgesia - each additional 15 minutes | 125.00 |
| 9310 | Professional Consultation | 80.00 |
| 9410 | House calls | 110.00 |
| 9420 | Hospital calls | 115.00 |
| 9440 | Office visit – after regularly scheduled hours | 60.00 |
| 9910 | Application of desensitizing medic (per visit) | 95.00 |
| 9944/9945 | Occlusal guard, hard/soft | 250.00 |
| 9972 | External Bleaching-per arch-performed in office | 90.00 |
Disclosure:
Please note that this fee schedule is not permanently guaranteed to stay at current levels. From time to time there may be changes in the published fee schedule. Please check this site to obtain the latest scheduled fees for your dental services.
Copyright © 2021 by CPS Dental, Inc. All rights reserved