ADA Code Cosmetic Procedures Member Fee Usual Fee You Save Bonding (per tooth): D2960 Full face buildup chairside $
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1 New England General Dentistry Fee Schedule Connecticut, Massachusetts, New Hampshire & Rhode Island Please note: This fee schedule applies to procedures performed by a General Dentists only. Rates are subject to periodic change without prior notification. ADA Code Diagnostic & Preventive Procedures Member Fee Usual Fee You Save D0220 Single x ray (any type) D0210 X rays (up to full mouth, or at least 3 films taken) D0330 Panorex D0150 Oral examination and diagnosis No Charge* D1120 Child cleaning and polishing excluding flouride D1110 Adult cleaning, polishing and scaling D1203 Topical fluoride treatment for children D9110 Pallative Treatment (emergency treatment of pain) D1351 Sealants (pit and fissure, per tooth) D0140 Consultation (including 2nd opinion and/or extensive examination) * See "Please Note" Section ADA Code Restorative Procedures (Fillings) Member Fee Usual Fee You Save Silver amalgams: Primary: D2140 one surface D2150 two surfaces D2160 three surfaces D2161 four or more surfaces Permanent: D2140 one surface D2150 two surfaces D2160 three surfaces D2161 four or more surfaces Composite Resins: Anterior Composites: D2330 one surface D2331 two surfaces D2332 three surfaces D2335 four or more surfaces D2391 Posterior Composites: one surface D2392 two surfaces D2393 three surfaces or more D2951 Pin retention, per pin D2940 Sedative Filling ADA Code Cosmetic Procedures Member Fee Usual Fee You Save Bonding (per tooth): D2960 Full face buildup chairside ADA Code Endodontic Procedures Member Fee Usual Fee You Save D3110 Pulp capping (excl. final restoration) D3220 Pulpotomy (excl. final restoration) Root Canal Therapy (excluding final restoration): D3310 anterior D3320 bicuspid D3330 molar New England General Dentistry Fee Schedule
2 ADA Code Periodontic Procedures Member Fee Usual Fee You Save D4341 Peridontal scaling and root planing (per quadrant) D4260 Osseous or mucogingival surgery(per quadrant) D4910 Perio maintenance ADA Code Oral Surgery Procedures Member Fee Usual Fee You Save D7111 Extraction, coronal remnants deciduous tooth D7140 Extraction, erupted tooth or exposed root D7210 Surgical Extraction D7510 Incision and drainage of abscess D7130 Root removal D7220 Extraction soft tissue impaction D7230 Extraction partial bony impaction D7240 Extraction full bony impaction ADA Code Fixed Prosthodontic Procedures Member Fee Usual Fee You Save D2751 Porcelain on non precious metal crown D2791 All metal crown (not gold) D6250 Pontics , D2750 Porcelain on semi to high noble metal crown , D2954 Post and core (chairside) D2950 Core buildup including pins D2952 Cast post (non gold) laboratory D2920 Re cement crown D6930 Re cement bridge per abutment D2999 Laboratory processed temporary (per tooth) D2999 Temporary crown (as part of crown procedure) No Charge ADA Code Removable Prosthodontic Procedures Member Fee Usual Fee You Save Complete Dentures: D5110 Complete maxillary denture (including adjustments) , D5120 Complete andibular denture (including adjustments) , D5130 Immediate Dentures Maxillary , D5140 Immediate Dentures Mandibular , Partials Dentures: D5211 D5212 Acrylic (upper or lower metal clasps) , D5213 D5214D5214 Cast alloy with palatal or lingual bar , Dentures Reline/Repair: D5410 D5411 Denture adjustments (for dentures made at another office) D5730 D5731 Reline: In office D5750 D5751 Reline: Laboratory processed D5510 Broken denture (no teeth involved) D5520 Replace tooth on denture D9940 Nite guard of flipper Space maintainers: D1520 unilateral D1525 bilateral Non listed procedures, performed by general dentists and Specialists, are provided to all members at 20% off the dentists usual and customary fee. In the event the participating dentist s usual fee is equal to or lower than the Member Fee listed, the dentist shall give the member a 10% discount off the dentists usual fee. New England General Dentistry Fee Schedule
3 New England Specialists Fee Schedule Connecticut, Massachusetts, New Hampshire & Rhode Island Please note: This fee schedule applies to procedures performed by Specialist only. Rates are subject to periodic change without prior notification. ADA Code Oral Surgeon Member Fee Usual Fee You Save D0150 Comprehensive Oral Evaluation Extractions D7140 Simple Extraction (single tooth) (each additional tooth) D7210 Surgical Extraction D7220 Soft Tissue Impaction D7230 Partial Bony Impaction D7240 Full Bony Impaction D7241 Full Bony Impaction with unusual surgical complications , D0330 Panorex D9220 General anesthesia per unit D9221 additional 15 minutes ADA Code Orthodontist Member Fee UsualFee You Save D0150 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 I Malocclusion 3, , , Class II Maloclussion 4, , , Class III Maloclussion 15% off 8, , D8030/D8040 Partial Case (Evaluated on an individual basis) 15% off D8750 Post Treatment stabilization each retainer Specialist's Initial Consultation fee will be applied towards Diagnosis/Records/Charting unless performed as a separate visit ADA Code Endodontist Member Fee Usual Fee You Save D0150 Comprehensive Oral Evaluation D3110 Pulp Capping D3220 Pulpotomy D3430 Retrograde filling per root D3920 Root Resection per root (HEMISECTION) D7510 Incision and Drainage Root Canal Therapy (excluding final restoration): D3310 Anterior D3320 Bicuspid , D3330 Molar , New England Specialty Dentistry Fee Schedule
4 Apicoectomy: D3410 Anterior D3421 Bicuspid first root D3425 Molar first root D3426 Each additional root Retreatment of a Root Canal is performed at 25% courtesy fee Root canal treatment fees include filling the canals, it does not include final restorations (which are sometimes called fillings) ADA Code Periodontist Member Fee Usual Fee You Save D0150 Initial Consultation Not including Diagnosis Diagnosis/Records/Charting: Including 5 or more x rays including 4 x rays or less D4341 Periodontal scaling/per quadrant (root planing curettage) D4355 Scaling (full mouth) D4211 Gingivectomy or gingivoplasty per tooth D4210 Gingivectomy or gingivoplasty per quadrant D4240 Gingival flap procedure, including root planing per quadrant D4260 Osseous Surgery (including flap entry and closure) per quad , D4270 Pedicle soft tissue graft procedure D4271 Free soft tissue graft procedure (including donor site) D4245 Apically repositioned flap procedure Occlusal Equilibration: A. As Part of full surgical case No Charge No Charge D9952 B. As a separate procedure, not to exceed 3 visits iit D4910 Perio Maintenance, included exam (following active therapy) Full Surgical Case: Includes 4 Quadrants of osseous surgery, occlusal adjustment, 4 quadrants of periodontal scaling 4, , , Prosthodontist Participating Prosthodontists will provide a 30% discount off their usual rates for all plan members Pedodontist Participating Pedodontists will provide a 20% discount off their usual rates for all plan members Implantology Participating Dentists will provide a 20% discount off their usual rates for all plan members TMJ Specialist (Temporomandibular Joint Syndrome) Providers who treat TMJ will provide a 20% discount off their usual rates for all plan members Non listed procedures, performed by general dentists and Specialists, are provided to all members at 20% off the dentists usual and customary fee. In the event the participating dentist s usual fee is equal to or lower than the Member Fee listed, the dentist shall give the member a 10% discount off the dentists usual fee. New England Specialty Dentistry Fee Schedule
5 PLEASE NOTE *Oral Examination and Diagnosis at no charge is in conjunction with cleaning and x rays only. DentalSave/Northeast Southeast Dental Plan is NOT INSURANCE. We do not pay claims. All charges for dental services are to be paid by the member directly to the dentist. USUAL FEE represents average current rate dentists charge NON PLAN patients based on a survey of dentists in the geographical area of the plan. MEMBER FEE represents the discounted fee the PATIENT pays directly to the plan dentist. Schedule I & II fees apply only to fees charged by plan General Dentists NOT SPECIALISTS. Please refer to your Directory of Dentists for your Dentist s Schedule. Schedule I is higher than Schedule II. The difference between Schedule I & II is based upon a fair discount off these dentists usual fees. All listed procedures are offered at reduced rates, which must be performed by participating dentists. In the event the participating dentist s usual fee is equal to or lower than the Member Fee listed, the dentist shall give the member a 10% discount off the dentists usual fee. Non listed procedures, performed by general dentists and Specialists, are provided to all members at 20% off the dentists usual and customary fee. Members are entitled to two cleanings at the member fee per enrollment period. Additional cleanings are offered at 20% off the dentist usual fee. Dentists may surcharge for precious restorations based upon their increased laboratory costs. Dentists may charge for broken appointments. Dentists may surcharge 5.00 per office visit. Dentists may charge for sweet air (nitrous oxide). Dentists may charge for providing copies of x rays to members. Dentists will decide whether fees for services are due on the spot or in installments. It is at the dentist s discretion whether or not to co ordinate benefits with another dental plan or insurance. Members may change their dentist at any time, but they must call The Plan member services to make sure the dentist to whom they are switching is still on the plan. Frequently, dentists join, and occasionally, withdraw from the Plan. It is the members responsibility to confirm when calling for an appointment that the dentist is currently participating with the Plan and let the dentist know that they are a member of DentalSave/Northeast Southeast Dental Plan. Failure to do so will result in the member paying the usual and customary fees. Any member accepted for orthodontic treatment must remain a member of the Dental Plan for the full duration of their treatment or risk additional charges from their participating Orthodontist. Partial Cases and non listed procedures performed by a participating orthodontist are available to members at 15% off the dentist usual fee. Orthodontists will discount 25% off usual fees for a replacement retainer. Memberships are yearly, and are effective for one full year from the day the enrollment is received. CANCELLATION POLICY: Membership fees are fully refundable within 30 days upon receipt of your application. New England Region
ADA Code Restorative Procedures (Fillings) Member Fee Usual Fee You Save D2951 Pin retention per tooth $ 35.00
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SOLSTICE S700PB SCHEDULE OF BENEFITS Members of the Solstice S700 dental plan are eligible to receive benefits immediately upon the effective date of coverage with: No Waiting Periods No Deductibles No
APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE
: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures
23XX2293 R3/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company
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Please note a few important reminders to help expedite the process of dental claims/estimates:
To: Valued Members and Providers From: Member Services Date: January 2019 RE: Attached is the for all members. Note: The Plan Pays amount on the fee schedule already has the percentages factored in. The
Service Office visit - per visit (including all fees for sterilization and/or infection control) Diagnostic Treatment
SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan* CITY OF DALLAS This SCHEDULE OF BENEFITS lists the Covered Services available to You
Dental Benefits Summary
CODE PROCEDURE Office Visit Copay PATIENT PAYS $0 D2510 Inlay - Metallic 1 Surf D6073 Abutment Supported Retainer for Cast Metal FPD (Predominantly Base Metal) D2520 Inlay - Metallic 2 Surf D6074 Abutment
CCPOA PRIMARY DENTAL. CCPOA s Fee-for-Service. Procedure Code List
CCPOA PRIMARY DENTAL CCPOA s Fee-for-Service Procedure Code List Effective December 2017 We have provided these payment allowances for informational purposes only and not as a guarantee of payment. All
Dental Benefits Summary
CODE PROCEDURE Office Visit Copay PATIENT PAYS $0 CODE DIAGNOSTIC PROCEDURE PATIENT PAYS D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 Full mouth series X-rays D0330 Panoramic
LOUISIANA MEDICAID PROGRAM ISSUED: 08/18/14 REPLACED: 09/15/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16
APPENDIX A: FEE SCHEDULE DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program.
SCHEDULE OF BENEFITS Self-Referral Dental Plan
SCHEDULE OF BENEFITS Self-Referral Dental Plan SG245D-IP This Schedule of Benefits lists the services available to you under your SafeGuard plan as well as the co-payments associated with each procedure.
IRON WORKERS BENEFIT TRUST SCHEDULE OF DENTAL SERVICES AND SUPPLIES D0100-D0999 I. Diagnostic Clinical Oral Evaluations periodic oral evaluation
D0120 IRON WORKERS BENEFIT TRUST SCHEDULE OF DENTAL SERVICES AND SUPPLIES D0100-D0999 I. Diagnostic Clinical Oral Evaluations periodic oral evaluation established patient* $ 66.50 D0140 limited oral evaluation
Improve your smile and overall well-being with. Dental Health Services. Dental Health Services. Difference today!
Improve your smile and overall well-being with Dental Health Services Great oral health is essential for your overall well-being. With a Dental Health Services plan, you can achieve a healthy smile while
LOUISIANA MEDICAID PROGRAM ISSUED: 09/15/13 REPLACED: 03/28/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16
APPENDIX A: FEE SCHEDULE DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program.
Kaiser Permanente and Delta Dental
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BOSTON TEACHERS UNION PARAPROFESSIONAL HEALTH AND WELFARE FUND Schedule of Covered Dental Procedures for the Dental Plan - Effective January 1, 2009
TYPE 1 D0120 Periodic oral evaluation 27.81 D0140 Limited oral evaluation - problem focused 43.15 D0145 Oral evaluation for a patient under three years of age and 22.20 counseling with primary caregiver
SafeGuard HMO Dental Plan
Summary of Benefi ts Schedule of Benefi ts, Exclusions & Limitations Please refer to your Certifi cate of Insurance for full benefi t information. SafeGuard HMO Dental Plan Dental & Vision Benefi ts provided