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 |