|
Procedure Code
|
Explanation of code
|
DentSaveSM
Fee
|
Usual and Customary Rate
|
DentSaveSM Members Savings
|
|
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
|
325.00
|
150.00
|
|
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
|
|
2950
|
Core buildup, including any pins
|
100.00
|
235.00
|
135.00
|
|
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
|
191.00
|
106.00
|
|
4260
|
Osseous surgery,
per quad
|
475.00
|
880.00
|
405.00
|
|
4340
|
Full mouth perio
scaling
|
300.00
|
700.00
|
400.00
|
|
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
|
230.00
|
105.00
|
|
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
|
270.00
|
120.00
|
|
7285
|
Biopsy of oral
tissue - hard
|
210.00
|
321.00
|
111.00
|
|
7286
|
Biopsy of oral
tissue - soft
|
150.00
|
276
|
126
|
|
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
|
720.00
|
245.00
|
|
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
|
325.00
|
150.00
|
|
9221
|
Deep sedation/general
anesthesia - each additional 15 minutes
|
85.00
|
145.00
|
60.00
|
|
9310
|
Professional Consultation
|
75.00
|
100.00
|
25.00
|
