Procedure Code | Explanation of code | DentSaveSM
Fee * | Usual and Customary Rate ** | DentSaveSMMembers Savings /td> |
Preventative Services |
| 0120* | Periodic oral examination | 40.00 | 65.00 | 25.00 |
0140* | Limited oral evaluation - problem focused | 50.00 | 100.00 | 50.00 |
0150* | Comprehensive oral evaluation new or established patient | 40.00 | 70.00 | 30.00 |
0210* | Intraoral complete series (14 Standard) of x-rays | 65.00 | 102.00 | 37.00 |
0220* | Intraoral - periapical first film | 15.00 | 23.00 | 8.00 |
0230* | Intraoral - periapical each additional film | 10.00 | 19.00 | 9.00 |
0240* | Intraoral-Occlusal film, each | 25.00 | 35.00 | 10.00 |
0270* | Single Bitewing x-ray | 15.00 | 23.00 | 8.00 |
0272* | 2 Bitewing x-rays | 25.00 | 36.00 | 11.00 |
0274* | 4 Bitewing x-rays | 40.00 | 50.00 | 10.00 |
0290* | Lateral view, per film | 60.00 | 108.00 | 48.00 |
0330* | Panoramic Survey film | 65.00 | 90.00 | 25.00 |
1110 | Prophylaxis-adult | 55.00 | 75.00 | 20.00 |
1120 | Prophylaxis-child (under 12) | 50.00 | 55.00 | 5.00 |
1203 | Fluoride treatment | 35.00 | 35.00 | 0.00 |
1351 | Sealants per tooth | 30.00 | 44.00 | 14.00 |
Space Maintainers |
1510/1515 | Space Maintainer - fixed | 235.00 | 265.00 | 30.00 |
1520/1525 | Space Maintainer - removable | 245.00 | 323.00 | 78.00 |
Restorative Services |
2140 | Amalgam one surface | 55.00 | 104.00 | 49.00 |
2150 | Amalgam - two surfaces | 75.00 | 134.00 | 59.00 |
2160 | Amalgam - three surfaces | 90.00 | 164.00 | 74.00 |
2161 | Amalgam - four or more surfaces | 110.00 | 195.00 | 85.00 |
2330 | Resin - one surface anterior tooth | 60.00 | 125.00 | 65.00 |
| 2331 | Resin - two surfaces anterior tooth | 78.00 | 185.00 | 107.00 |
2332 | Resin - three surfaces anterior tooth | 95.00 | 230.00 | 135.00 |
2335 | Composite incisal angle four surfaces | 125.00 | 240.00 | 115.00 |
2391 | Resin - one surface posterior tooth | 60.00 | 141.00 | 81.00 |
2392 | Resin - two surfaces posterior tooth | 78.00 | 185.00 | 107.00 |
2393 | Resin - three surfaces posterior tooth | 95.00 | 230.00 | 135.00 |
2394 | Resin - four or more surfaces, posterior tooth | 125.00 | 275.00 | 150.00 |
Inlays |
2510 | Inlay - metallic one surface | 350.00 | 675.00 | 325.00 |
2520 | Inlay - metallic two surfaces | 410.00 | 724.00 | 314.00 |
2530 | Inlay - metallic three surfaces | 475.00 | 771.00 | 296.00 |
2610 | Inlay - porcelain/ceramic one surface | 395.00 | 727.00 | 332.00 |
2620 | Inlay - porcelain/ceramic two surfaces | 430.00 | 777.00 | 347.00 |
2630 | Inlay - porcelain/ceramic three surfaces | 495.00 | 815.00 | 320.00 |
Crowns |
2710 | Resin | 395.00 | 737.00 | 342.00 |
2720 | Resin - with high noble metal | 475.00 | 850.00 | 375.00 |
| 2721 | Resin - with predominantly base metal | 455.00 | 795.00 | 340.00 |
2740 | Porcelain/ceramic substrate | 515.00 | 907.00 | 392.00 |
2750 | Porcelain fused to high noble metal | 525.00 | 890.00 | 365.00 |
2751 | Porcelain fused to predominantly base metal | 500.00 | 825.00 | 325.00 |
2752 | Porcelain fused to noble metal | 500.00 | 855.00 | 355.00 |
2790 | Full Cast with Semi-Precious Metal | 500.00 | 878.00 | 378.00 |
| 2891 | Post and Core | 175.00 | | |
2910 | Recement inlay | 50.00 | 86.00 | 36.00 |
2920 | Recement crown | 50.00 | 89.00 | 39.00 |
2930 | Stainless Steel primary tooth | 155.00 | 223.00 | 68.00 |
2954 | Post and Core | 175.00 | 275.00 | 100.00 |
2961 | Labial veneer resin laminate (lab) | 425.00 | 750.00 | 325.00 |
| 2962 | Labial veneer porcelain laminate (lab) | 475.00 | 870.00 | 395.00 |
Endodontics/Root Canal Therapy |
3220 | Vital Pulpotomy | 95.00 | 156.00 | 61.00 |
| 3410 | Apicoectomy, first root | 370.00 | 551.00 | 181.00 |
| 3421 | Apicoectomy bicuspid first root | 450.00 | 610.00 | 160.00 |
3425 | Apicoectomy molar first root | 550.00 | 713.00 | 163.00 |
3426 | Apicoectomy each additional root | 180.00 | 301.00 | 121.00 |
3310 | Anterior Tooth, Traditional Therapy | 295.00 | 575.00 | 280.00 |
3320 | Bicuspid Tooth, Traditional Therapy | 405.00 | 675.00 | 270.00 |
3330 | Molar Tooth | 495.00 | 825.00 | 330.00 |
Periodontal Services |
4210 | Gingivectomy per quad | 275.00 | 513.00 | 238.00 |
4220 | Gingival curretage per quad | 85.00 | | |
4260 | Osseous surgery, per quad | 450.00 | 865.00 | 415.00 |
4340 | Full mouth perio scaling | 300.00 | | |
4341 | Periol scaling per quad | 75.00 | 201.00 | 126.00 |
4910 | Periodontal Maintenance | 80.00 | 113.00 | 33.00 |
Prosthodontics and Repairs |
| 5110 | Complete Maxillary Denture | 600.00 | 1347.00 | 747.00 |
5120 | Complete Mandibular Denture | 600.00 | 1350.00 | 750.00 |
5130 | Complete Immediate Upper | 600.00 | 1460.00 | 860.00 |
5140 | Complete Immediate Lower | 600.00 | 1474.00 | 874.00 |
5211 | Upper Partial acrylic base clsp/rests | 480.00 | 996.00 | 516.00 |
5212 | Lower Partial acrylic base clsp/rests | 480.00 | 1013.00 | 533.00 |
5213 | Upper Partial | 545.00 | 1417.00 | 872.00 |
5214 | Lower Partial | 545.00 | 1420.00 | 875.00 |
5281 | Partial removable unilateral | 385.00 | 806.00 | 421.00 |
5410/5411 | Adjust complete denture - upper/lower | 55.00 | 72.00 | 17.00 |
Prosthetics and Repairs Continued |
5420/5421 | Adjust partial denture - upper/lower | 55.00 | 72.00 | 17.00 |
5510 | Repair broken complete denture base | 90.00 | 169.00 | 79.00 |
5520 | Replace missing or broken teeth in complete denture | 80.00 | 149.00 | 69.00 |
5640 | Replace one tooth in Partial Denture | 85.00 | 150.00 | 65.00 |
5650 | Adding tooth to Partial Denture to Replace Extracted Natural Teeth first tooth | 100.00 | 179.00 | 79.00 |
5660 | Add Clasp To Existing Partial Denture | 125.00 | | |
5710 | Upper Denture Rebase | 225.00 | 473.00 | 248.00 |
5711 | Lower Denture Rebase | 225.00 | 474.00 | 249.00 |
5720 | Partial Upper Rebase | 225.00 | 451.00 | 226.00 |
5721 | Partial Lower Rebase | 225.00 | 452.00 | 227.00 |
5730 | Upper Denture Reline chairside | 170.00 | 302.00 | 132.00 |
5731 | Lower Denture Reline chairside | 170.00 | 303.00 | 133.00 |
5740 | Partial Upper Reline chairside | 170.00 | 300.00 | 130.00 |
5741 | Partial Lower Reline chairside | 170.00 | 300.00 | 130.00 |
5932/5933 | Obturator | 385.00 | 500.00 | 115.00 |
Fixed Prosthodontics |
6210 | Pontic-cast high noble metal | 445.00 | 875.00 | 430.00 |
6211 | Pontic cast predominantly base metal | 395.00 | 800.00 | 405.00 |
6212 | Pontic cast noble metal | 415.00 | 842.00 | 427.00 |
6240 | Pontic porcelain fused to high noble metal | 510.00 | 893.00 | 383.00 |
6241 | Pontic porcelain fused to predominantly base metal | 475.00 | 825.00 | 350.00 |
6242 | Pontic porcelain fused to noble metal | 495.00 | 860.00 | 365.00 |
6250 | Pontic resin with high noble metal | 510.00 | 853.00 | 343.00 |
6251 | Pontic resin with predominantly base metal | 475.00 | 825.00 | 350.00 |
6252 | Pontic resin with noble metal | 495.00 | 850.00 | 355.00 |
6545 | Cast metal retainer | 295.00 | 650.00 | 355.00 |
6720 | Resin with high noble metal | 510.00 | 860.00 | 350.00 |
6721 | Resin with predominantly base metal | 475.00 | 820.00 | 345.00 |
6722 | Resin with noble metal | 495.00 | 850.00 | 355.00 |
6750 | Porcelain fused to high noble metal | 525.00 | 895.00 | 370.00 |
6751 | Porcelain fused to base metal | 500.00 | 825.00 | 325.00 |
6752 | Porcelain fused to noble metal | 500.00 | 861.00 | 361.00 |
6780 | 3/4 cast high noble metal | 510.00 | 875.00 | 365.00 |
6781 | 3/4 cast predominantly base metal | 495.00 | 830.00 | 335.00 |
6782 | 3/4 cast noble metal | 495.00 | 854.00 | 359.00 |
6790 | Full cast high noble metal | 510.00 | 880.00 | 370.00 |
6791 | Full cast predominantly base metal | 475.00 | 805.00 | 330.00 |
6792 | Full cast noble metal | 495.00 | 850.00 | 355.00 |
6930 | Recement Crown or Bridge | 65.00 | 135.00 | 70.00 |
| Oral Surgery |
7140 | Extraction, erupted tooth or exposed root | 65.00 | 130.00 | 65.00 |
7210 | Surgical extraction | 115.00 | 220.00 | 105.00 |
7220 | Soft tissue Impaction | 175.00 | 255.00 | 80.00 |
7230 | Partially Bony Impaction | 225.00 | 325.00 | 100.00 |
7240 | Complete Bony Impaction | 265.00 | 400.00 | 135.00 |
7250 | Surgical Removal of residual tooth roots | 150.00 | | |
7285 | Biopsy of oral tissue - hard | 210.00 | 321.00 | 111.00 |
7286 | Biopsy of oral tissue - soft | 150.00 | | |
7310 | Alveoplasty per quad | 145.00 | 237.00 | 92.00 |
7410 | Removal of Cyst or benign lesion up to 1.25 cm | 250.00 | 328.00 | 78.00 |
7960 | Frenectomy | 240.00 | 372.00 | 132.00 |
Orthodontics |
8080 | Initial Appliance | 800.00 | 1000.00 | 200.00 |
8210 | Removable appliance therapy | 475.00 | | |
8680 | Active treatment - monthly | 90.00 | 246.00 | 156.00 |
8690 | Passive treatment -once every 3 months | 60.00 | 217.00 | 157.00 |
Miscellaneous |
9110 | Emergency Palliative Treatment | 55.00 | 98.00 | 43.00 |
9220 | Deep sedation/general anesthesia - first 30 minutes | 175.00 | | |
9221 | Deep sedation/general anesthesia - each additional 15 minutes | 85.00 | | |
9310 | Professional Consultation | 75.00 | 100.00 | 25.00 |
