DentSaveSM and Usual Fee Comparison

Procedure Code Explanation of code DentSaveSM
Fee
Usual and Customary Rate 90%** DentSaveSM Members Savings
Preventative Services
0120 Periodic oral examination 50.00 68.00 18.00
0140 Limited oral evaluation - problem focused 50.00 101.00 51.00
0150* Comprehensive oral evaluation - new or established patient *Free initial 119.00 119.00
0160 Detailed and extensive oral evaluation 150.00 198.00 48.00
0180 Comprehensive periodontal evaluation 90.00 128.00 38.00
0210 Intraoral complete series (14 Standard ) of x-rays 100.00 170.00 70.00
0220 Intraoral - periapical first film 20.00 40.00 20.00
0230 Intraoral - periapical each additional film 15.00 33.00 18.00
0240 Intraoral - Occlusal film, each 35.00 53.00 18.00
0270 Single Bitewing x-ray 20.00 38.00 18.00
0272 2 Bitewing x-rays 40.00 60.00 20.00
0274 4 Bitewing x-rays 65.00 84.00 19.00
0330 Panoramic film 120.00 144.00 24.00
1110 Prophylaxis-adult 90.00 118.00 28.00
1120 Prophylaxis-child (under 12) 70.00 90.00 20.00
1208 Fluoride treatment child and/or adult 35.00 52.00 17.00
1351 Sealants per tooth 40.00 72.00 32.00
Space Maintainers
1510/1515 Space Maintainer - fixed 250.00 399.00/525.00 149.00/275.00
1520/1525 Space Maintainer - removable 300.00 478.00/586.00 178.00/286.00
Restorative Services
2140 Amalgam one surface 100.00 188.00 88.00
2150 Amalgam - two surfaces 125.00 239.00 114.00
2160 Amalgam - three surfaces 150.00 290.00 140.00
2161 Amalgam - four or more surfaces 175.00 350.00 175.00
2330 Resin - one surface anterior tooth 100.00 225.00 125.00
2331 Resin - two surfaces anterior tooth 125.00 264.00 139.00
2332 Resin - three surfaces anterior tooth 150.00 326.00 176.00
2335 Composite incisal angle four surfaces 175.00 404.00 229.00
2391 Resin - one surface posterior tooth 150.00 235.00 85.00
2392 Resin - two surfaces posterior tooth 190.00 305.00 115.00
2393 Resin - three surfaces posterior tooth 225.00 376.00 151.00
2394 Resin - four or more surfaces posterior tooth 250.00 436.00 186.00
Inlays
2510 Inlay - metallic one surface 600.00 1194.00 594.00
2520 Inlay - metallic two surfaces 700.00 1217.00 517.00
2530 Inlay - metallic three surfaces 800.00 1295.00 495.00
2610 Inlay - porcelain/ceramic one surface 800.00 1243.00 443.00
2620 Inlay - porcelain/ceramic two surfaces 900.00 1265.00 365.00
2630 Inlay - porcelain/ceramic three surfaces 1000.00 1300.00 300.00
Crowns
2710 Resin 800.00 1248.00 448.00
2720 Resin - with high noble metal 900.00 1310.00 410.00
2721 Resin - with predominantly base metal 750.00 1260.00 510.00
2740 Porcelain/ceramic substrate 1100.00 1439.00 339.00
2750 Porcelain fused to high noble metal 1100.00 1430.00 330.00
2751 Porcelain fused to predominantly base metal 1100.00 1311.00 211.00
2752 Porcelain fused to noble metal 1100.00 1345.00 245.00
2790 Full Cast with Semi-Precious Metal 1100.00 1497.00 397.00
2910 Recement inlay 95.00 157.00 62.00
2920 Recement crown 95.00 151.00 56.00
2930 Stainless Steel primary tooth 200.00 349.00 149.00
2950 Core buildup, including any pins 250.00 350.00 100.00
2954 Post and Core 300.00 434.00 134.00
2961 Labial veneer resin laminate (lab) 1000.00 1300.00 300.00
2962 Labial veneer porcelain laminate (lab) 1200.00 1511.00 311.00
Endodontics/Root Canal Therapy
3220 Vital Pulpotomy 100.00 285.00 185.00
3410 Apicoectomy, first root 700.00 950.00 250.00
3421 Apicoectomy bicuspid first root 800.00 1054.00 254.00
3425 Apicoectomy molar first root 900.00 1178.00 278.00
3426 Apicoectomy each additional root 200.00 566.00 366.00
3310 Anterior Tooth, Traditional Therapy 700.00 964.00 264.00
3320 Bicuspid Tooth, Traditional Therapy 900.00 1100.00 200.00
3330 Molar Tooth 1000.00 1350.00 350.00
3346 Retreatment root canal-anterior 600.00 1124.00 524.00
3347 Retreatment root canal-premolar 700.00 1265.00 565.00
3348 Retreatment root canal-molar 800.00 1548.00 748.00
Periodontal Services
4210 Gingivectomy per quad 350.00 821.00 471.00
4260 Osseous surgery, per quad 500.00 1456.00 956.00
4341 Periol scaling per quad 120.00 330.00 210.00
4910 Periodontal Maintenance 140.00 181.00 41.00
Prosthodontics and Repairs
5110 Complete Maxillary Denture 1200.00 2112.00 912.00
5120 Complete Mandibular Denture 1200.00 2132.00 932.00
5130 Complete Immediate Upper 1700.00 2250.00 550.00
5140 Complete Immediate Lower 1700.00 2252.00 552.00
5211 Upper Partial acrylic base clsp/rests 1200.00 1865.00 665.00
5212 Lower Partial acrylic base clsp/rests 1200.00 1823.00 623.00
5213 Upper Partial 1800.00 2364.00 564.00
5214 Lower Partial 1800.00 2363.00 563.00
5281 Partial removable unilateral 750.00 1327.00 577.00
5410/5411 Adjust complete denture - upper/lower 95.00 120.00 25.00
Prosthetics and Repairs Continued
5421/5422 Adjust partial denture - upper/lower 75.00 120.00 45.00
5640 Replace one tooth in Partial Denture 125.00 262.00 137.00
5650 Adding tooth to Partial Denture to Replace Extracted Natural Teeth first tooth 125.00 298.00 173.00
5660 Add Clasp To Existing Partial Denture 150.00 298.00 148.00
5710 Upper Denture Rebase 300.00 784.00 484.00
5711 Lower Denture Rebase 300.00 761.00 461.00
5720 Partial Upper Rebase 300.00 733.00 433.00
5721 Partial Lower Rebase 300.00 733.00 433.00
5730 Upper Denture Reline chairside 200.00 460.00 260.00
5731 Lower Denture Reline chairside 200.00 456.00 256.00
5740 Partial Upper Reline chairside 180.00 448.00 268.00
5741 Partial Lower Reline chairside 180.00 450.00 270.00
Implants
6010 Surgical Placement of Implant Body 1900.00 2466.00 566.00
6057 Custom Abutment 950.00 1325.00 375.00
Fixed Prosthodontics
6210 Pontic-cast high noble metal 1000.00 1451.00 451.00
6211 Pontic cast predominantly base metal 1000.00 1325.00 325.00
6212 Pontic cast noble metal 1000.00 1344.00 344.00
6240 Pontic porcelain fused to high noble metal 1100.00 1440.00 340.00
6241 Pontic porcelain fused to predominantly base metal 1100.00 1327.00 227.00
6242 Pontic porcelain fused to noble metal 1100.00 1362.00 262.00
6250 Pontic resin with high noble metal 1100.00 1366.00 266.00
6251 Pontic resin with predominantly base metal 1100.00 1324.00 224.00
6252 Pontic resin with noble metal 1100.00 1325.00 225.00
6545 Cast metal retainer 400.00 1187.00 787.00
6720 Resin with high noble metal 1100.00 1365.00 265.00
6721 Resin with predominantly base metal 1000.00 1300.00 300.00
6722 Resin with noble metal 1100.00 1317.00 217.00
6750 Porcelain fused to high noble metal 1200.00 1453.00 253.00
6751 Porcelain fused to base metal 1100.00 1313.00 213.00
6752 Porcelain fused to noble metal 1100.00 1349.00 249.00
6780 3/4 cast high noble metal 1100.00 1415.00 315.00
6781 3/4 cast predominantly base metal 1100.00 1306.00 206.00
6782 3/4 cast noble metal 1100.00 1329.00 229.00
6790 Full cast high noble metal 1100.00 1425.00 325.00
6791 Full cast predominantly base metal 1000.00 1321.00 321.00
6792 Full cast noble metal 1000.00 1389.00 389.00
6930 Recement Crown or Bridge 120.00 227.00 107.00
Oral Surgery
7140 Extraction, erupted tooth or exposed root 125.00 247.00 122.00
7210 Surgical extraction 250.00 367.00 117.00
7220 Soft tissue Impaction 300.00 417.00 117.00
7230 Partially Bony Impaction 400.00 520.00 120.00
7240 Complete Bony Impaction 500.00 639.00 139.00
7250 Surgical Removal of residual tooth roots 150.00 417.00 267.00
7285 Biopsy of oral tissue - hard 210.00 720.00 510.00
7286 Biopsy of oral tissue - soft 150.00 450.00 300.00
7310 Alveoplasty per quad 200.00 400.00 200.00
7410 Removal of Cyst or benign lesion up to 1.25 cm 250.00 588.00 338.00
7960 Frenectomy 240.00 591.00 351.00
Orthodontics
8080 Initial Appliance 1500.00 6334.00 4834.00
8670 Periodic orthodontic treatment-monthly adjustments 100.00 402.00 302.00
8690 Passive treatment - once every 3 months 80.00 544.00 464.00
Miscellaneous
9110 Emergency Palliative Treatment 90.00 175.00 88.00
9215 Local anesthesia in conjunction with surgical procedures 50.00 82.00 32.00
9222/9223 Deep sedation/general anesthesia - each additional 15 minutes 100.00 332.00 232.00
9310 Professional Consultation 90.00 185.00 95.00
9940 Occlusal guard, by report 300.00 770.00 470.00
9972 External Bleaching-per arch-performed in office 100.00 478.00 378.00

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.

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