Northeast General Dentistry Fee Schedule I District of Columbia, Maryland, New Jersey, New York, Pennsylvania, Virginia 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 D0150 Comprehensive oral evaluation new or established no charge* 60.00 60.00 D0120 Periodic oral evaluation established patient no charge* 60.00 60.00 D0140 Consultation (limited oral evaluation problem focused) 45.00 75.00 30.00 D0220 Single x ray (any type) 14.00 25.00 11.00 D0210 X rays (up to full mouth, or at least 3 films taken) 50.00 115.00 65.00 D0330 X rays Panoramic film 45.00 110.00 65.00 D1110 Adult cleaning, polishing and scaling 60.0000 120.0000 60.0000 D1120 Child cleaning and polishing excluding fluoride 40.00 85.00 45.00 D1203 Topical fluoride treatment for children 22.00 42.00 20.00 D9110 Palliative (emergency) treatment of dental pain 40.00 99.00 59.00 D1351 Sealant per tooth 30.00 50.00 20.00 * See "Please Note" Section ADA Code Restorative Procedures (Fillings) Member Fee Usual Fee You Save D2951 Pin retention per tooth 35.00 65.00 30.00 D2940 Sedative filling 50.00 89.00 39.00 Silver amalgams: Permanent D2140 one surface 64.00 112.00 48.00 D2150 two surfaces 80.00 147.00 67.00 D2160 three surfaces 90.00 168.00 78.00 D2161 four or more surfaces 120.00 202.00 82.00 D2330 Composite Resins: Permanent Anterior Composites: one surface 75.00 118.00 43.00 D2331 two surfaces 90.00 160.00 70.00 D2332 three surfaces 112.00 200.00 88.00 D2335 four or more surfaces 140.00 235.00 95.00 Posterior Composites: D2391 one surface 87.00 150.00 63.00 D2392 two surfaces 111.00 195.00 84.00 D2393 three surfaces 152.00 260.00 108.00 D2394 four or more surfaces 170.0000 315.00 145.00 ADA Code Cosmetic Procedures Member Fee Usual Fee You Save Bonding/Veneers (per tooth) D2960 Labial veneer (resin) chair side 280.00 425.00 145.00 D2962 Labial veneer (porcelain) laboratory 540.00 910.00 370.00 ADA Code Endodontic Procedures Member Fee Usual Fee You Save D3110 Pulp capping (excl. final restoration) 45.00 72.00 27.00 D3220 Pulpotomy (excl. final restoration) 90.00 156.00 66.00 Root Canal Therapy (excluding final restoration) D3310 Anterior 400.00 575.00 175.00 D3320 Bicuspid 465.00 740.00 275.00 D3330 Molar 600.00 830.00 230.00 Northeast General Dentistry Fee Schedule I
ADA Code Periodontic Procedures Member Fee Usual Fee You Save D4341 Periodontal scaling and root planing (per quadrant) 95.00 205.00 110.00 D4260 Osseous or mucogingival surgery (per quadrant) 530.0000 878.00 348.00 D4910 Perio maintenance 70.00 112.00 42.00 ADA Code Oral Surgery Procedures Member Fee Usual Fee You Save D7111 Extraction, coronal remnants deciduous tooth 70.00 125.00 55.00 D7140 Extraction, erupted tooth or exposed root 80.00 125.00 45.00 D7210 Surgical Extraction 120.00 218.00 98.00 D7220 Extraction soft tissue impaction 170.00 270.00 100.00 D7230 Extraction partial p bony impaction 215.00 360.00 145.00 D7240 Extraction full bony impaction 260.00 475.00 215.00 D7510 Incision and drainage of abscess 80.00 182.00 102.00 ADA Code Fixed Prosthodontic Procedures Member Fee Usual Fee You Save D6240 Pontic Porcelain fused to high noble metal 705.00 1,100.00 395.00 D6241 Pontic Porcelain fused to predominantly base metal 555.00 800.00 245.00 D6242 Pontic Porcelain fused to noble metal 595.00 795.00 200.00 D2750/D6750 Crown Porcelain fused to high noble metal 705.00 1,100.00 395.00 D2751/D6751 Crown Porcelain fused to predominantly base metal 555.00 825.00 270.00 D2752/D6752 Crown Porcelain fused to noble metal 595.00 860.00 265.00 D2954/D6972 Post and core (prefabricated) 185.00 275.00 90.00 D2950/D6973 Core buildup including pins 165.00 225.00 60.00 D2952/D6970 Post and core (non gold) laboratory 260.00 351.00 91.00 D2920 Recement crown 60.00 92.00 32.00 D6930 Re cement fixed bridge 70.00 97.00 27.00 D2999/D6999 Crown Temporary (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) 825.00 1,300.00 475.00 D5120 Complete mandibular denture (including adjustments) 825.00 1,300.00 475.00 D5410 5411 Denture adjustments (for dentures made at another office) 55.00 76.00 21.00 Partial Dentures D5211 D5212 Acrylic resin base (resin or wrought wire clasps) 585.00 979.00 394.00 D5213 D5214 Cast metal framework with resin base 825.00 1,389.00 564.00 Denture reline/repair D5730 D5731 Reline denture (chair side) 205.00 306.00 101.00 D5750 D5751 Reline denture (laboratory) 280.00 386.00 106.00 D5510 Repair broken denture base (no teeth involved) 110.00 164.00 54.00 D5520 Replace tooth on denture 90.00 142.00 52.00 D9940 Occlusal guard 350.00 480.00 130.00 Space maintainers: D1520 Unilateral removable 240.00 315.00 75.00 D1525 Bilateral removable 290.0000 365.00 75.00 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. Northeast General Dentistry Fee Schedule I
Northeast General Dentistry Fee Schedule II District of Columbia, Maryland, New Jersey, New York, Pennsylvania, Virginia 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 D0150 Comprehensive oral evaluation new or established no charge* 60.00 60.00 D0120 Periodic oral evaluation established patient no charge* 60.00 60.00 D0140 Consultation (limited oral evaluation problem focused) 45.00 75.00 30.00 D0220 Single x ray (any type) 14.00 25.00 11.00 D0210 X rays (up to full mouth, or at least 3 films taken) 45.00 115.00 70.00 D0330 X rays Panoramic film 45.00 110.00 65.00 D1110 Adult cleaning, polishing and scaling 60.0000 120.0000 60.0000 D1120 Child cleaning and polishing excluding fluoride 40.00 85.00 45.00 D1203 Topical fluoride treatment for children 22.00 42.00 20.00 D9110 Palliative (emergency) treatment of dental pain 40.00 99.00 59.00 D1351 Sealant per tooth 30.00 50.00 20.00 * See "Please Note" Section ADA Code Restorative Procedures (Fillings) Member Fee Usual Fee You Save D2951 Pin retention per tooth 32.00 65.00 33.00 D2940 Sedative filling 44.00 89.00 45.00 Silver amalgams Permanent D2140 one surface 55.00 112.00 57.00 D2150 two surfaces 68.00 147.00 79.00 D2160 three surfaces 80.00 168.00 88.00 D2161 four or more surfaces 110.00 202.00 92.00 Composite Resins: Permanent Anterior Composites: D2330 one surface 69.00 118.00 49.00 D2331 two surfaces 83.00 160.00 77.00 D2332 three surfaces 104.00 200.00 96.00 D2335 four or more surfaces 134.00 235.00 101.00 Posterior Composites: D2391 one surface 75.00 150.00 75.00 D2392 two surfaces 96.00 195.00 99.00 D2393 three surfaces 123.00 260.00 137.00 D2394 four or more surfaces 135.00 315.00 180.0000 ADA Code Cosmetic Procedures Member Fee Usual Fee You Save Bonding/Veneers (per tooth) D2960 Labial veneer (resin) chair side 240.00 425.00 185.00 D2962 Labial veneer (porcelain) laboratory 480.00 910.00 430.00 ADA Code Endodontic Procedures Member Fee Usual Fee You Save D3110 Pulp capping (excl. final restoration) 35.00 72.00 37.00 D3220 Pulpotomy (excl. final restoration) 70.00 156.00 86.00 Root Canal Therapy (excluding final restoration) D3310 Anterior 355.00 575.00 220.00 D3320 Bicuspid 410.00 740.00 330.00 D3330 Molar 510.00 830.00 320.00 Northeast General Dentistry Fee Schedule II
ADA Code Periodontic Procedures Member Fee Usual Fee You Save D4341 Periodontal scaling and root planing (per quadrant) 75.00 205.00 130.00 D4260 Osseous or mucogingival surgery (per quadrant) 485.00 878.00 393.00 D4910 Perio maintenance 65.00 112.00 47.00 ADA Code Oral Surgery Procedures Member Fee Usual Fee You Save D7111 Extraction, coronal remnants deciduous tooth 60.00 125.00 65.00 D7140 Extraction, erupted tooth or exposed root 65.00 125.00 60.00 D7210 Surgical Extraction 100.00 218.00 118.00 D7220 Extraction soft tissue impaction 155.00 270.00 115.00 D7230 Extraction partial p bony impaction 195.00 360.00 165.00 D7240 Extraction full bony impaction 240.00 475.00 235.00 D7510 Incision and drainage of abscess 70.00 182.00 112.00 ADA Code Fixed Prosthodontic Procedures Member Fee Usual Fee You Save D6240 Pontic Porcelain fused to high noble metal 600.00 1,100.00 500.00 D6241 Pontic Porcelain fused to predominantly base metal 515.00 800.00 285.00 D6242 Pontic Porcelain fused to noble metal 595.00 795.00 200.00 D2750/D6750 Crown Porcelain fused to high noble metal 600.00 1,100.00 500.00 D2751/D6751 Crown Porcelain fused to predominantly base metal 515.00 825.00 310.00 D2752/D6752 Crown Porcelain fused to noble metal 595.00 860.00 265.00 D2954/D6972 Post and core (prefabricated) 158.00 275.00 117.00 D2950/D6973 Core buildup including pins 135.00 225.00 90.00 D2952/D6970 Post and core (non gold) laboratory 233.00 351.00 118.00 D2920 Recement crown 45.00 92.00 47.00 D6930 Re cement fixed bridge 54.00 97.00 43.00 D2999/D6999 Crown Temporary (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) 700.00 1,300.00 600.00 D5120 Complete mandibular denture (including adjustments) 700.00 1,300.00 600.00 D5410 5411 Denture adjustments (for dentures made at another office) 45.00 76.00 31.00 Partial Dentures D5211 D5212 Acrylic resin base (resin or wrought wire clasps) 485.00 979.00 494.00 D5213 D5214 Cast metal framework with resin base 640.00 1,389.00 749.00 Denture reline/repair D5730 D5731 Reline denture (chair side) 175.00 306.00 131.00 D5750 D5751 Reline denture (laboratory) 225.00 386.00 161.00 D5510 Repair broken denture base (no teeth involved) 110.00 164.00 54.00 D5520 Replace tooth on denture 85.00 142.00 57.00 D9940 Occlusal guard 320.00 480.00 160.00 Space maintainers: D1520 Unilateral removable 217.00 315.00 98.00 D1525 Bilateral removable 275.00 365.00 90.0000 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. Northeast General Dentistry Fee Schedule II
Northeast Specialists Fee Schedule District of Columbia, Maryland, New Jersey, New York, Pennsylvania, Virginia 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 new or established 95.00 195.00 100.00 D0330 Panorex 75.00 118.00 43.00 Extractions D7210 Surgical Extraction 185.00 310.00 125.00 D7220 Soft Tissue Impaction 225.00 423.00 198.00 D7230 Partial Bony Impaction 300.00 492.00 192.00 D7240 Full Bony Impaction 405.00 580.00 175.00 D9220 General anesthesia first 30 minutes 155.00 345.00 190.00 D9221 additional 15 minutes 75.00 190.00 115.00 ADA Code Orthodontist Member Fee Usual Fee You Save D0150 Comprehensive Oral Evaluation 75.00 125.00 50.00 Diagnosis/Records: Work up, including full mouth series, Models, Photographs, and a second visit for discussion and presentation 180.00 330.00 150.00 Comprehensive Orthodontic Treatment D8080 Adolescent Dentition 25% Off D8090 Adult Dentition 25% Off D8030/D8040 Partial Case (Evaluated on an individual basis) 15% Off D8680 Post Treatment stabilization each retainer 260.00 372.00 112.00 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 75.00 125.00 50.00 D3110 Pulp Capping 105.00 157.00 52.00 D3220 Pulpotomy 175.00 317.00 142.00 D3430 Retrograde filling per root 205.00 310.00 105.00 D3920 Root Resection per root (HEMISECTION) 355.00 460.00 105.00 D7510 Incision and Drainage 165.00 250.00 85.00 Root Canal Therapy (excluding final restoration) D3310 Anterior 575.00 767.00 192.00 D3320 Bicuspid 675.00 915.00 240.00 D3330 Molar 765.00 1,127.00 362.00 Northeast Specialty Dentistry Fee Schedule
Apicoectomy D3410 Anterior first root 495.00 697.00 202.00 D3421 Bicuspid first root 575.00 765.00 190.00 D3425 Molar first root 675.00 895.00 220.0000 D3426 Each additional root 265.00 385.00 120.00 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 D0180 Comprehensive periodontal evaluation 75.00 125.00 50.00 Diagnosis/Records/Charting (Including x rays) 170.00 275.00 105.00 D4341 Periodontal scaling/per quadrant (root planing curettage) 185.00 250.00 65.00 D4211 Gingivectomy or gingivoplasty per tooth 200.00 385.00 185.00 D4210 Gingivectomy or gingivoplasty per quad. 475.00 637.00 162.00 D4240 Gingival flap procedure, including root planing per quadrant 615.00 769.00 154.00 D4260 Osseous Surgery (including flap entry and closure) per quad. 805.00 995.00 190.00 D4270 Pedicle soft tissue graft procedure 555.00 813.00 258.00 D4271 Free soft tissue graft procedure (including donor site) 575.00 877.00 302.00 D4245 Apically repositioned flap procedure 625.00 775.00 150.00 Occlusal Equilibration: A. As Part of full surgical case no charge D9952 B. As a separate procedure, not to exceed 3 visits 160.00 240.00 80.00 D4910 Perio Maintenance Procedure, includes exam 135.00 185.00 50.00 Specialist's Initial Consultation fee will be applied towards Diagnosis/Records/Charting unless performed as a separate visit 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 dby general dentists t 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. Northeast Specialty Dentistry Fee Schedule
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. Requests must be made by calling us at 800.828.2222. Northeast Region