Fee Schedule A

SPECIALIST SERVICES
CODE
as performed by Board Eligible or
Board Certified dental specialists
ORAL SURGERY
D7111 Extraction, coronal remnants deciduous tooth $99 $170
$67
erupted tooth or exposed root $103 $201
D7140 Extraction
$98
(elevation and/or forceps removal)
Surgical removal of erupted tooth requiring
D7210 elevation of mucoperiosteal flap and/or $134 $297 $163
section of tooth - each tooth
D7220 Removal of impacted tooth-soft tissue
$173 $339 $166
D7230 Removal of impacted tooth-partially bony
$212 $424 $212
D7240 Removal of impacted tooth-completely bony $257 $479 $222
of impacted tooth - completely bony $314 $557 $243
D7241 Removal
with unusual surgical complications
removal of residual tooth roots $162 $352 $190
D7250 Surgical
(cutting procedure)
D7280 Surgical access of an unerupted tooth
$223 $318
$95
or plasty in conjunction with $134 $382 $248
D7310 Alveolectomy
extractions - per quadrant
or plasty not in conjunction with $180 $602 $422
D7320 Alveolectomy
extractions - per quadrant
Frenulectomy (frenectomy or frenotomy), separate $212 $557 $345
D7960 procedure
D7970 Excision of hyperplastic tissue - per arch
$253 $795 $542
D7971 Excision of pericoronal gingiva
$142 N/A
N/A
Surgical procedures listed above include the administration of local anesthesia only.
The administration of nitrous oxide, intravenous sedation, or general anesthesia is
available at additional cost to the participating specialist.
PERIODONTIC PROCEDURES
or gingivoplasty, 4+ contiguous
D4210 Gingivectomy
teeth/quad
or gingivoplasty, 1-3 contiguous
D4211 Gingivectomy
teeth/quad
flap procedure-incl root planing,
D4240 Gingival
per quadrant
surgery-incl flap entry and closure,
D4260 Osseous
per quadrant
D4270 Pedicle soft tissue graft procedure
scaling and root planing, per
D4341 Periodontal
quadrant
mouth debridement to enable
D4355 Full
comprehensive evaluation and diagnosis
maintenance procedures (following
D4910 Periodontal
active therapy)
$356 $1,060 $704
$151
$890
$739
$435
N/A
N/A
$613 $1,685 $1,072
$360
N/A
N/A
$152
$356
$204
$112 $148
$70
$78
$79
$140
ENDODONTIC PROCEDURES
D3310
D3320
D3330
D3410
D3426
D3430
D3450
D3920
Root Canal therapy-anterior (excl final restoration)
Root Canal therapy-bicuspid (excl final restoration)
Root Canal therapy-molar (excl final restoration)
Apicoectomy (per tooth) - first root
Apicoectomy (per tooth) - each additional tooth
Retorgrade filling - per root
Root amputation - per root
Hemisection (incl. root removal; excl. root canal therapy)
$399
$473
$618
$356
$145
$139
$178
$200
$1,007
$1,087
$1,325
$1,105
N/A
N/A
N/A
N/A
Typical You
Cost* SAVE
DENTAL DIRECTORY SERVICES
A Registered Trademark of United
Health Programs of America, Inc.
160 Eileen Way, Syosset, NY 11791
800-238-3884
ORTHODONTICS - COMPREHENSIVE CASE, CLASS 1, 11, 111
(up to and including age 16) D8070, D8080
DDS Typical You
A
Cost* SAVE
CODE
DDS
A
$608
$614
$707
$749
N/A
N/A
N/A
N/A
Orthodontic records, treatment plan and consultation
Initial ortho. appliance, construction and installation
Active treatment phase - up to 24 months
Retention phase per retainer
Total for those up to and including age 16
$112 N/A
N/A
$428 N/A
N/A
$2,587 N/A
N/A
$210 N/A
N/A
$3,338 $5,809 $2,471
Continuation of orthodontic treatment beyond 24 months and other orthodontic
services available at a 25% discount from usual and customary fees charged by
orthodontists listed in the DDS Dental Directory. Orthodontic treatment includes the
treatment of primary, transitional, and/or adolescent dentitions under the D8000D8999 series procedure codes. Orthodontic treatment for patients over the age of
16 is a 25% reduction from the dentist's usual and customary fee. Invisalign braces
are 25% off the usual and customary fee of the participating provider.
Fee Schedule A
Effective for programs beginning with 2015 & 2016
start dates and programs with no expiration date.
DENTAL DIRECTORY SERVICES (DDS), TERMS AND CONDITIONS
1.
The dental services appearing in this schedule are available from genera
practitioners and specialists listed in the DDS Dental Directory. Any
services that are not listed are available at a 25% discount from usual
and customary fees charged by participating general practitioners and
specialists, including pedodontics, prosthodontics and implantology.
2. Aside from the Annual Check-up, additional exams, x-rays and
consultations are available at a 25% discount at general practitioners.
All exams, x-rays and consultations at all specialists are 25% of the
dentist’s usual and customary fee. Invisalign braces are 25% of the
dentist usual and customary fees.
3. All participating providers may charge an OSHA sterilization fee per
visit and a lab fee for crown, bridges and denture work.
4. The administration of nitrous oxide intravenous sedation or general
anesthesia is available at a 25% discount from usual and customary fees
charged by the participating general practitioners and specialists.
5. Britesmile is not a covered procedure.
6. It is the Member’s responsibility to verify that the dentist is a participating
Provider for DDS before seeking any treatment. Any dental procedures
performed by a non-participating dentist are not covered.
7. The dollar amount specified for each procedure may not be the only
cost incurred for a given treatment. Many treatments may require more
than one dental procedure. Please consult with your DDS provider for
a detailed treatment plan before beginning any dental work.
8. DDS can not guarantee the continued participation of any dentist. If
the dentist that you use leaves the plan, you will need to select another
participating provider. Not all dental specialists are available in all
areas.
9. While participating DDS providers are professionally licensed in the
state in which they practice, DDS does not guarantee the quality of
service of the providers. Any quality of care concerns involving any
participating provider should be directed to the DDS Provider Relations
Department.
10. Provider listings and/or fee schedules can be updated or changed
without notice.
*Typical cost provided by ADA Dental Survey 2006, 90th percentile.
NOTE: Typical cost for annual check-up prophylaxis includes comprehensive oral
exam and intraoral complete series of x-ray films.
2014 ©ALL RIGHTS RESERVED TO UNITED HEALTH PROGRAMS OF AMERICA, INC.
SAMPLE SAVINGS
Typical DDS
You
Cost
A
SAVE
Complete Series X-ray Films
$133 $0** $133
Oral Exam
$81
$0**
$81
Filling, 1 surface permanent
$133
$48
$85
Root Canal, Anterior Tooth
$694 $270 $424
Full Denture, upper or lower
$1,590 $594 $996
Orthodontics
$5,830 $3,338 $2,492
Note: Typical Cost may vary from one doctor to another.
PROCEDURES
*Provided by ADA Dental Survey 2014.
** In conjunction with paid annual check-up prophylaxis
(cleaning). Prices as of 1/14 and are subject to change without
notice.
...because maintaining your
family's health should be
simple and affordable.
D-001_012810_V01
GENERAL DENTIST FEES
as performed by General Practitioners
ENDODONTIC PROCEDURES
DDS Typical You
A
Cost* SAVE
CODE
DIAGNOSTIC PROCEDURES
D0120 Periodic oral examination
D0140 Limited Oral Evaluation
D0150 Comprehensive oral examination
0**
0**
0**
$53
$69
$81
$53
$69
$81
D0210
0**
$133
$133
(including bitewings)
D0220
0**
$28
$28
0**
$21
$21
D0230
D0270
0**
N/A
N/A
0**
$42
$42
D0272
D0274
0**
$81
$81
0** $106 $106
D0330
**In conjunction with paid annual check-up prophylaxis (cleaning), $58.00 for adults
and $40.00 for children. Children are up to and including 16 years of age.
PREVENTATIVE PROCEDURES
D1110
D1120
DD1130
DD1140
Prophylaxis-adult (additional in same membership year)
Prophylaxis-child (additional in same membership year)
Annual Check-up prophylaxis - Adult
Annual Check-up prophylaxis - Child
application of fluoride (excluding
D1206 Topical
prophylaxis-child)
application of fluoride (excluding
D1208 Topical
prophylaxis-adult)
D1351 Sealant - per tooth
D1510
D1515
RESTORATIVE PROCEDURES
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2391
D2392
D2393
D2750
D2751
D2752
D2791
D2920
D2930
D2931
D2932
D2940
D2950
D2951
D2952
D2953
D2954
D2960
D2970
Amalgam-1surface, permanent or primary
Amalgam-2 surface, permanent or primary
Amalgam-3 surface, permanent or primary
Amalgam-4 surface, permanent or primary
Resin-1 surface, anterior
Resin-2 surface, anterior
Resin-3 surface, anterior
Resin-4+ surfaces or involving incisal angle
Resin-1 surface, posterior
Resin-2 surface, posterior
Resin-3 surface, posterior
Crown-porcelain fused to high noble metal
Crown-porcelain fused to base metal
Crown-porcelain fused to noble metal
Crown-full cast (base metal)
Re-cement crown
Prefab'd stainless steel crown-1 tooth
Prefab'd stainless steel crown-2 tooth
Prefab'd resin crown
Protective Restoration
Core buildup, including any pins
Pin retention-per tooth, in add. to restoration
Cast post and core, in addition to crown
Cast post (each additional cast post as part of tooth)
Prefab'd post and core in add. to crown
Labial veneer (resin laminate), chairside
Temporary crown (Fractured tooth)
Additional procedures to construct new crown
D2971 under
existing partial denture framework
DDS Typical You
A
Cost* SAVE
CODE
$39
$28
$58
$40
$94
$71
$307
$284
$55
$43
$249
$244
$14
$40
$26
$12
$42
$30
$18
$118
$172
$53
$318
$423
$35
$200
$251
$50
$64
$76
$91
$61
$76
$95
$119
$74
$101
$126
$534
$473
$501
$428
$39
$111
$131
$123
$45
$111
$27
$167
$134
$139
$323
$111
$133
$160
$192
$229
$159
$196
$239
$288
$175
$228
$302
$971
$901
$949
N/A
$95
$255
$296
N/A
$101
$253
N/A
$371
N/A
N/A
$636
N/A
$83
$96
$116
$138
$98
$120
$144
$169
$101
$127
$176
$437
$428
$448
N/A
$56
$144
$165
N/A
$56
$142
N/A
$204
N/A
N/A
$313
N/A
$111
N/A
N/A
D3110
D3120
D3220
D3310
D3320
D3330
D3920
Pulp cap - direct
Pulp cap - indirect
Therapeutic pulpotomy
Root Canal therapy - anterior
Root Canal therapy - bicuspid
Root Canal therapy - molar
Hemisection (incl root removal; excl root canal therapy)
$28
$28
$67
$284
$342
$428
$145
$90
$94
$199
$694
$806
$969
N/A
$62
$66
$132
$410
$464
$541
N/A
$628
$394
$318
$228
N/A
N/A
PERIODONTIC PROCEDURES
Gingivectomy or gingivoplasty, 4+ contiguous
$234
teeth/quad
Gingivectomy or gingivoplasty, 1-3 contiguous
D4211
$90
teeth/quad
G
D4240
$312
per quadrant
D4210
D4260
$428 $1,034 $606
quadrant
D4270 Pedicle soft tissue graft procedure
$323 N/A
N/A
Periodontal scaling and root planing, per
D4341
$101 $242 $141
quadrant
Periodontal scaling in the presence of gingival
$112 N/A
N/A
D4345
Full mouth debridement to enable comprehensive
$84
evaluation and diagnosis
Periodontal maintenance procedures (following
D4910
$61
active therapy)
D4355
N/A
N/A
$140
$79
PROSTHODONTICS, REMOVABLE
upper denture, incl 6 months postD5110 Complete
insertion care
lower denture, incl 6 months postD5120 Complete
insertion care
Immediate upper denture, incl 6 months
care; does not include required
D5130 post-insertion
future rebasing/relining care; or a complete
new denture
Immediate lower denture, incl 6 months postcare; does not include required
D5140 insertion
future rebasing/relining care; or a complete
new denture
partial denture -resin base, including
D5211 Upper
any conventional clasps and rests
partial denture - resin base, including
D5212 Lower
any conventional clasps and rests
Upper partial denture - predominantly base
D5213 cast base with resin base incl any conventional
clasps and rests
Lower partial denture-predominantly base
D5214 cast base with resin base incl any conventional
clasps and rests
D5410 Adjust complete denture-upper (after 6 mos)
D5411 Adjust complete denture-lower (after 6 mos)
D5421 Adjust partial denture-upper (after 6 mos)
D5422 Adjust partial denture-lower (after 6 mos)
D5510 Repair broken complete denture base
missing/broken teeth, complete
D5520 Replace
denture-each tooth
D5610 Repair partial denture resin saddle or base
D5630 Repair or replace partial denture broken clasp
D5640 Replace broken teeth - partial denture - per tooth
D5650 Add tooth to existing partial denture
D5660 Add clasp to existing partial denture
D5710 Rebase complete upper denture (LAB)
$623 $1,590 $967
$623 $1,590 $967
$695 $1,696 $1,001
$695 $1,696 $1,001
$507 $1,346 $839
$507 $1,373 $866
$657 $1,696 $1,039
$657 $1,696 $1,039
$39
$39
$39
$39
$70
N/A
N/A
N/A
N/A
$223
N/A
N/A
N/A
N/A
$153
$58
$180
$122
$78
$84
$67
$83
$71
$224
$212
N/A
$180
$210
$261
$530
$134
N/A
$113
$127
$178
$306
DDS Typical You
A
Cost* SAVE
CODE
PROSTHODONTICS, REMOVABLE continued
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5810
D5811
D5820
D5821
Rebase complete lower denture (LAB)
Rebase partial upper denture (LAB)
Rebase partial lower denture (LAB)
Reline complete upper denture (chairside)
Reline complete lower denture (chairside)
Reline upper partial denture (chairside)
Reline lower partial denture (chairside)
Temporary complete denture (upper)
Temporary complete denture (lower)
Temporary partial - stayplate denture (upper)
Temporary partial - stayplate denture (lower)
$228
$228
$228
$145
$145
$145
$145
$339
$339
$301
$301
N/A
N/A
N/A
$355
$355
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
$210
$210
N/A
N/A
N/A
N/A
N/A
N/A
D6210 Pontic - cast high noble metal
D6240 Pontic - porcelain fused to high noble metal
D6241 Pontic - porcelain fused to base metal
$501
$498
$462
$954
$974
$925
$453
$476
$463
D6545 prosthesis
Crown (abutment) - porcelain fused to base metal
Crown - full cast hight noble metal
Crown (abutment) - full cast base metal
Re-cement bridge
Stress breaker
Precision attachment (each)
$228
$795
$567
$470
$504
$420
$61
$173
$306
$922
$954
N/A
$148
N/A
N/A
$452
$451
N/A
$87
N/A
N/A
PROSTHODONTICS, FIXED BRIDGES
D6751
D6790
D6791
D6930
D6940
D6950
ORAL SURGERY
D7111 Extraction, coronal remnants deciduous tooth $61 $119 $58
erupted tooth or exposed root $75 $149 $74
D7140 Extraction
(elevation and/or forceps removal)
Surgical removal of erupted tooth requiring
$94 $246 $152
D7210
section of tooth - each tooth
D7220 Removal of impacted tooth - soft tissue
$123 $292 $169
D7230 Removal of impacted tooth - partially bony
$158 $367 $209
D7240 Removal of impacted tooth - completely bony $212 $438 $226
of impacted tooth - completely bony $250 $530 $280
D7241 Removal
withunusual surgical complications
removal of residual tooth roots $106 $273 $167
D7250 Surgical
(cutting procedure)
D7280 Surgical access of an unerupted tooth
$151 N/A N/A
Alveolectomy or plasty in conjunction with $94 $270 $176
D7310 extractions
- per quadrant
or plasty not in conjunction with $139 $413 $274
D7320 Alveolectomy
extractions - per quadrant
(frenectomy or frenotomy), separate $139 $384 $245
D7960 Frenulectomy
procedure
D7970 Excision of hyperplastic tissue - per arch
$106 $455 $349
D7971 Excision of pericoronal gingiva
$78
N/A N/A
Surgical procedures listed above include the administration of local anesthesia only.
The administration of nitrous oxide, intravenous sedation, or general anesthesia is
available at additional cost to the subscriber.
ADJUNCTIVE GENERAL SERVICES - UNCLASSIFIED TREATMENT
D9110
Palliative (emergency) treatment of dental
hours
D9440
D9940 Occlusal Guard
$24
$133
$109
$61
$267
$159
$583
$98
$316