MEMBER FEE No Charge* No Charge* No Charge*
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1 2019
2 2019 GENERAL DENTISTRY FEE SCHEDULE Note: This fee schedule applies to procedures performed by a General Dentist only. DIAGNOSTIC & PREVENTIVE PROCEDURES Periodic oral examination Comprehensive oral evaluation Oral hygiene instruction Limited oral evaluation Detailed oral evaluation (problem focused) Re-evaluation (problem focused) Intraoral - complete series of x-rays D0 D0 D1330 D01 D0 D0170 D0 D0220 D0230 D0270 D0272 D0274 D0330 D0460 D1 D1 D8 D1351 D1510 D1515 Pulp vitality test Prophylaxis (Cleaning)-adult Prophylaxis (Cleaning)-child Sealant per tooth No Charge* No Charge* No Charge* RESTORATIVE PROCEDURES D21 D2 D2 D2161 One surface Two surfaces Three surfaces Four or more surfaces D2330 D2331 D2332 D2335 One surface Two surfaces Three surfaces Four or more surfaces D2391 D2392 D2393 D2394 D2710 D27 D2750 D2751 D2790 D2791 D2920 D2930 One surface Two surfaces Three surfaces Four or more surfaces Crown resin composite (indirect) Crown porcelain/ceramic Crown porcelain fused to high noble metal Crown porcelain predominantly base metal Crown full cast (high noble) Crown full cast (base metal) Re-cement or re- bond crown Prefab d SS crown primary tooth
3 D2931 D2932 D29 D2950 D2951 D2952 D2954 D2970 D2980 Prefab d SS crown permanent tooth Prefab d resin crown Protective restoration Core buildup, including any pins Pin retention/tooth, in add. to rest Cast post/core in addition to crown Prefab d post/core in add. to crown Temporary Crown Crown repair D3/20 D3220 D3310 D3320 D3330 D3346 D3347 D3348 D3410 D3421 D3425 D0 ENDODONTIC PROCEDURES Re-treatment of root canal (anterior) Re-treatment of root canal (premolar) Re-treatment of root canal (posterior) Apicoectomy (anterior) Apicoectomy (premolar) Apicoectomy (posterior) Root amputation (per) D0180 D4 D4211 D42 D4241 D4249 D4260 D4261 D4270 D4341 D4342 D4381 D4910 PERIODONTIC PROCEDURES Comprehensive perio, evaluation Gingivectomy or gingivoplasty per quad Gingivectomy or gingivoplasty 1 to 3 teeth Clinical crown lengthening Pedicle soft tissue graft procedure Periodontal scaling & root planing 4+ teeth/quad Periodontal scaling & root planing 1-3 teeth/quad Delivery of antimicrobials Peridontal maint. Proc. (follow active therapy) D5/20 D5130/ D5211/2 D5213/4 D5410/1 REMOVABLE PROSTHODONTIC PROCEDURES Complete Dentures Complete upper or lower incl. 6 mos care Immediate upper or lower denture incl. 6 mos. care (does not incl. req. future rebasing/relining procedures) Partial Dentures Upper or lower partial acrylic base, incl. any conventional clasps & rests Upper or lower partial predominantly base case base w/ acrylic saddles incl. any conventional clasps & rests Denture Reline/Repair Adjust comp. upper or lower dent. (After 6 mos.)
4 D5421/2 D5511 D5520 D5611 D5630 D56 D50/60 D5710/20 D5730/1 D5750/1 D5810/1 D5820/1 Adjust part. upper or lower dent. (After 6 mos.) Repair broken complete denture base, mandibular Repl. Missing/broken teeth-comp. dent./tooth Repair resin partial denture base, mandibular Repair or replace denture broken clasp-per tooth Repair broken teeth-part. denture/tooth Add tooth or clasp to existing part. denture -per tooth Rebase comp. / part. upper or lower (LAB) Reline upper or lower Denture (Chair side) Reline upper or lower Denture (Laboratory) Temp. complete denture (upper or lower) Temp. partial-stay plate denture (upper or lower) D6241 D45 D67 D6751 D6791 D6930 FIXED PROSTHODONTIC PROCEDURES Pontic-porcelain fuse to metal (each wing) Cast-metal retainer for acid bridge Crown- porcelain ceramic Crown- (abutment) porcelain fuse to metal Crown- (abutment) full cast base metal Re-cement bridge D7111 D71 D7 D7250 D7510 ORAL SURGERY PROCEDURES Extraction - Primary tooth Extraction (simple) Single tooth Surgical removal of erupted tooth per tooth Surgical removal of residual tooth roots Incision/drainage of abscess Surgical procedures listed above include the administration of local anesthesia only. The administration of nitrous oxide, intravenous sedation or general anesthesia is available at 20% Discount to the subscriber D0016 D9 D99 ADJUNCTIVE GENERAL SERVICES UNCLASSIFIED Failed appt. w/o 24 hr notice per 15 mins. Palliative (ER) treatment of minor pain Occlusal guard / Night guard D2960 D2962 D9972 COSMETIC PROCEDURES Bonding (per tooth) Porcelain laminate veneer per tooth External bleaching per arch PARK PLAZA, 4TH FLOOR, BOSTON, MA (P): (617) (F): (617)
5 2019 BOARD CERTIFIED SPECIALIST FEE SCHEDULE Note: This fee schedule applies to procedures performed by a Board Specialized Dentist only. D0 D71 D7 D7220 D7230 D72 D7241 D7250 D7280 D7310 D7320 D7960 D7970 D7971 Oral Surgery Procedures Comprehensive oral evaluation Extraction (simple) Single tooth Surgical removal of erupted tooth per tooth Removal of impacted tooth-soft tissue Removal of impacted tooth-partial bony Removal of impacted tooth-complete bony Removal of impacted tooth-w/surgical complications Surgical removal of residual tooth roots Surgical access of an unerupted tooth Alveolectomy/plasty in conj. w/ ext./quad Alveolectomy/plasty not in conj. w/ ext./quad Frenulectomy (frenectomy or frenotomy) Excision of hyperplastic tissue-per arch Excision of periocoronal gingiva D0 D8680 Orthodontic Procedures Comprehensive Oral Evaluation Diagnosis / Records Work-up including full mouth series, Models Photographs, and a second visit for discussion and presentation. Comprehensive Orthodontic Treatment Class 1 - Maloclussion Class 2 - Maloclussion Class 3 - Maloclussion Continuation of orthodontic treatment beyond 24 months and other orthodontic services available at a 20% discount from usual/customary fees. Orthodontic Retention % D01 D3310 D3320 D3330 D3410 D3426 D0 D3920 Endodontic Procedures Comprehensive Oral Evaluation Apicoectomy (per tooth) each add. root Root amputations per root Hemisection (incl. root removal; excl. RC) D0180 D42 D4260 D4270 D4341 D4342 Periodontic Procedures Comprehensive Oral Evaluation Pedicle soft tissue graft procedure Periodontal scaling & root planing 4+ teeth/quad Periodontal scaling & root planing 1-3 teeth/quad
6 TMJ Dentistry Pediatric Dentistry Prosthodontic Dentistry Implantology The 20% Discount noted for Implants includes Stages 1 & 2. from a Specialist usual and costumary rates. *The Oral examinations and Diagnosis at no charge are in conjunction with a cleaning or full mouth x-rays comprehensive oral examination (ADA0) will apply. Plan Guidelines: usual and customary fees. - Consultations by participating specialists are also discounted 20% from the dentist's usual and customary fees. are available at a 20% discount from the dentist's usual and customary fees. - Universal Dental Plan does not guarantee the quality of the service of the providers. Universal Dental Plan is NOT dental insurance. It is a Discount Dental Plan. 20 PARK PLAZA, 4TH FLOOR, BOSTON, MA (P): (617) (F): (617)
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