2022 Fee Schedule

Title Treatment Type Procedures Notes Member Fee
PREVENTIVE PROCEDURE Additional Cleanings $45
D0120 DIAGNOSTIC PROCEDURE Periodic Oral Exam Routine 6 month check-up Free
D0150 DIAGNOSTIC PROCEDURE Comprehensive Oral Examination Free
D0210 DIAGNOSTIC PROCEDURE Intraoral Complete X-rays (inc. Bitewings) $60
D0220 DIAGNOSTIC PROCEDURE Periapical X-ray (not with exam.) Per Film $12
D0330 DIAGNOSTIC PROCEDURE X-Ray - Panoramic Film $55
D1110 PREVENTIVE PROCEDURE Adult Cleaning & Polishing - 1 Per Year Free
D1120 PREVENTIVE PROCEDURE Child Cleaning & Polishing - 1 per year Free
D1204 PREVENTIVE PROCEDURE Topical Application of Flouride Child $18
D1351 PREVENTIVE PROCEDURE Sealant Per Tooth $22
D1520 PROSTHODONTICS, REMOVABLE BRIDGES Performed by General Dentist Space Maintainer - Removable Unilateral $175
D1525 PROSTHODONTICS, REMOVABLE BRIDGES Performed by General Dentist Space Maintainer - Removable Unilateral $225
D2140 RESTORATIVE PROCEDURE Silver Amalgam - One Surface $55
D2150 RESTORATIVE PROCEDURE Silver Amalgam - Two Surfaces $68
D2160 RESTORATIVE PROCEDURE Silver Amalgam - Three Surfaces $80
D2161 RESTORATIVE PROCEDURE Silver Amalgam - Four or more Surfaces $100
D2330 RESTORATIVE PROCEDURE Composite Resin - Anterior - One Surface $60
D2331 RESTORATIVE PROCEDURE Composite Resin - Anterior - Two Surfaces $80
D2332 RESTORATIVE PROCEDURE Composite Resin - Anterior - Three Surfaces $95
D2335 RESTORATIVE PROCEDURE Composite Resin - Anterior - Four or more surfaces $120
D2391 RESTORATIVE PROCEDURE Composite Resin - Posterior - One Surface $95
D2392 RESTORATIVE PROCEDURE Composite Resin - Posterior - Two Surfaces $105
D2393 RESTORATIVE PROCEDURE Composite Resin - Posterior - Three Surfaces $110
D2394 RESTORATIVE PROCEDURE Composite Resin - Posterior - Four or more surfaces $135
D2740 CROWNS - Fees Do Not Include Lab Charges Crown - Porcelain fused to base metal $550
D2920 RESTORATIVE PROCEDURE Recement Crown $40
D2940 RESTORATIVE PROCEDURE Sedative Filling $50
D2950 RESTORATIVE PROCEDURE Core Buildup, including any pins $105
D2952 CROWNS - Fees Do Not Include Lab Charges CastPost-Core $200
D2954 CROWNS - Fees Do Not Include Lab Charges Prefabricated Post-Core $150
D2960 COSMETIC PROCEDURE Performed by General Dentist Veneer - Resin - Chairside $300
D2962 COSMETIC PROCEDURE Performed by General Dentist Porcelain Laminates - Per Tooth Laboratory $425
D2970 CROWNS - Fees Do Not Include Lab Charges Temporary Crown $100
D3220 ENDODONTIC PROCEDURES (Excluding Final Restoration) Performed by General Dentist Therapeutic Pulpotomy $75
D3310 ENDODONTIC PROCEDURES (Excluding Final Restoration) Performed by General Dentist Root Canal Therapy - Anterior $350
D3320 ENDODONTIC PROCEDURES (Excluding Final Restoration) Performed by General Dentist Root Canal Therapy - Bicuspid $450
D3330 ENDODONTIC PROCEDURES (Excluding Final Restoration) Performed by General Dentist RootCanal Therapy - Molar $550
D4210 PERIODONTIC PROCEDURE - Performed by a General Dentist Gingivectomy or Gingivoplasty - Per Quadrant $300
D4211 PERIODONTIC PROCEDURE - Performed by a General Dentist Gingivectomy or Gingivoplasty - Per Tooth $75
D4240 PERIODONTIC PROCEDURE - Performed by a General Dentist Gingival Flap Procedure, including root planing-Per Quadrant $300
D4260 PERIODONTIC PROCEDURE - Performed by a General Dentist Osseous Surgery - Per Quadrant $500
D4270 PERIODONTIC PROCEDURE - Performed by a General Dentist Pedicle Soft Tissue Graft Procedure $225
D4341 PERIODONTIC PROCEDURE - Performed by a General Dentist Periodontal Scaling & Root Planing - Per Quadrant $140
D5110 PROSTHODONTICS, REMOVABLE BRIDGES Performed by General Dentist Complete Upper - (including 6 months post care) $650
D5120 PROSTHODONTICS, REMOVABLE BRIDGES Performed by General Dentist Complete Lower - (er - (including 6 months post care) $650
D5211 PROSTHODONTICS, REMOVABLE BRIDGES Performed by General Dentist Upper Partial - Acrylic Base $500
D5212 PROSTHODONTICS, REMOVABLE BRIDGES Performed by General Dentist Lower Partial - Acrylic Base $500
D5213 PROSTHODONTICS, REMOVABLE BRIDGES Performed by General Dentist Upper Partial - Cast metal framework/resin base $700
D5214 PROSTHODONTICS, REMOVABLE BRIDGES Performed by General Dentist Lower Partial - Cast metal framework/resin base $700
D5510 PROSTHODONTICS, REMOVABLE BRIDGES Performed by General Dentist Repair Denture Base $90
D5520 PROSTHODONTICS, REMOVABLE BRIDGES Performed by General Dentist Repair Missing or Broken Tooth on Complete Denture (per tooth) $80
D5730 PROSTHODONTICS, REMOVABLE BRIDGES Performed by General Dentist Reline Complete Upper Denture - Chairside $150
D5731 PROSTHODONTICS, REMOVABLE BRIDGES Performed by General Dentist Reline Complete Lower Denture - Chairside $150
D5750 PROSTHODONTICS, REMOVABLE BRIDGES Performed by General Dentist Reline Complete Upper Denture - Laboratory $240
D5751 PROSTHODONTICS, REMOVABLE BRIDGES Performed by General Dentist Reline Complete Lower Denture - Laboratory $240
D6240 PROSTHODONTICS, FIXED BRIDGES Performed by General Dentist Pontic- Porcelain/Metal $600
D6751 RESTORATIVE PROCEDURE Crown - Porcelain fused to base metal $550
D6752 RESTORATIVE PROCEDURE Crown -Porcelain fused to noble metal $600
D6930 PROSTHODONTICS, FIXED BRIDGES Performed by General Dentist Recement Fixed Partial Denture $75
D6970 PROSTHODONTICS, FIXED BRIDGES Performed by General Dentist Cast Post&Core $190
D6971 PROSTHODONTICS, FIXED BRIDGES Performed by General Dentist Cast Post $125
D6972 PROSTHODONTICS, FIXED BRIDGES Performed by General Dentist Prefabricated Post & Core $150
D7140 ORAL SURGERY Performed by General Dentist Extraction-Single Tooth (Simple) $75
D7220 ORAL SURGERY Performed by General Dentist Removal of Impacted Tooth-Soft Tissue $150
D7230 ORAL SURGERY Performed by General Dentist Removal of Impacted Tooth- Patially Boney $175
D7240 ORAL SURGERY Performed by General Dentist Remoaval of Impacted Tooth-Completely Boney $210
D7510 ORAL SURGERY Performed by General Dentist Incision & Drainage of Abscess $180
D9110 DIAGNOSTIC PROCEDURE Emergency Treatment of Dental Pain $50