DentSaveSM and Usual Fee Comparison

Procedure Code

Explanation of code

DentSaveSM
Fee

Usual and Customary Rate

DentSaveSM Members Savings

Preventative Services

0120

Periodic oral examination

40.00

65.00

25.00

0140

Limited oral evaluation - problem focused

50.00

100.00

50.00

0150

Comprehensive oral evaluation new or established patient

40.00

70.00

30.00

0210

Intraoral complete series (14 Standard) of x-rays

65.00

102.00

37.00

0220

Intraoral - periapical first film

15.00

23.00

8.00

0230

Intraoral - periapical each additional film

10.00

19.00

9.00

0240

Intraoral-Occlusal film, each

25.00

35.00

10.00

0270

Single Bitewing x-ray

15.00

23.00

8.00

0272

2 Bitewing x-rays

25.00

36.00

11.00

0274

4 Bitewing x-rays

40.00

50.00

10.00

0290

Lateral view, per film

60.00

108.00

48.00

0330

Panoramic Survey film

65.00

90.00

25.00

1110

Prophylaxis-adult

55.00

75.00

20.00

1120

Prophylaxis-child (under 12)

50.00

55.00

5.00

1203

Fluoride treatment

35.00

35.00

0.00

1351

Sealants per tooth

30.00

44.00

14.00

Space Maintainers

1510/1515

Space Maintainer - fixed

235.00

265.00

30.00

1520/1525

Space Maintainer - removable

245.00

323.00

78.00

Restorative Services

2140

Amalgam one surface

55.00

104.00

49.00

2150

Amalgam - two surfaces

75.00

134.00

59.00

2160

Amalgam - three surfaces

90.00

164.00

74.00

2161

Amalgam - four or more surfaces

110.00

195.00

85.00

2330

Resin - one surface anterior tooth

60.00

125.00

65.00

2331

Resin - two surfaces anterior tooth

78.00

185.00

107.00

2332

Resin - three surfaces anterior tooth

95.00

230.00

135.00

2335

Composite incisal angle four surfaces

125.00

240.00

115.00

2391

Resin - one surface posterior tooth

60.00

141.00

81.00

2392

Resin - two surfaces posterior tooth

78.00

185.00

107.00

2393

Resin - three surfaces posterior tooth

95.00

230.00

135.00

2394

Resin - four or more surfaces, posterior tooth

125.00

275.00

150.00

Inlays

2510

Inlay - metallic one surface

350.00

675.00

325.00

2520

Inlay - metallic two surfaces

410.00

724.00

314.00

2530

Inlay - metallic three surfaces

475.00

771.00

296.00

2610

Inlay - porcelain/ceramic one surface

395.00

727.00

332.00

2620

Inlay - porcelain/ceramic two surfaces

430.00

777.00

347.00

2630

Inlay - porcelain/ceramic three surfaces

495.00

815.00

320.00

Crowns

2710

Resin

395.00

737.00

342.00

2720

Resin - with high noble metal

475.00

850.00

375.00

2721

Resin - with predominantly base metal

455.00

795.00

340.00

2740

Porcelain/ceramic substrate

515.00

907.00

392.00

2750

Porcelain fused to high noble metal

525.00

890.00

365.00

2751

Porcelain fused to predominantly base metal

500.00

825.00

325.00

2752

Porcelain fused to noble metal

500.00

855.00

355.00

2790

Full Cast with Semi-Precious Metal

500.00

878.00

378.00

2891

Post and Core

175.00

325.00

150.00

2910

Recement inlay

50.00

86.00

36.00

2920

Recement crown

50.00

89.00

39.00

2930

Stainless Steel primary tooth

155.00

223.00

68.00

2950

Core buildup, including any pins

100.00

235.00

135.00

2954

Post and Core

175.00

275.00

100.00

2961

Labial veneer resin laminate (lab)

425.00

750.00

325.00

2962

Labial veneer porcelain laminate (lab)

475.00

870.00

395.00

Endodontics/Root Canal Therapy

3220

Vital Pulpotomy

95.00

156.00

61.00

3410

Apicoectomy, first root

370.00

551.00

181.00

3421

Apicoectomy bicuspid first root

450.00

610.00

160.00

3425

Apicoectomy molar first root

550.00

713.00

163.00

3426

Apicoectomy each additional root

180.00

301.00

121.00

3310

Anterior Tooth, Traditional Therapy

295.00

575.00

280.00

3320

Bicuspid Tooth, Traditional Therapy

405.00

675.00

270.00

3330

Molar Tooth

495.00

825.00

330.00

Periodontal Services

4210

Gingivectomy per quad

275.00

513.00

238.00

4220

Gingival curretage per quad

85.00

191.00

106.00

4260

Osseous surgery, per quad

475.00

880.00

405.00

4340

Full mouth perio scaling

300.00

700.00

400.00

4341

Periol scaling per quad

75.00

201.00

126.00

4910

Periodontal Maintenance

80.00

113.00

33.00

Prosthodontics and Repairs

5110

Complete Maxillary Denture

600.00

1347.00

747.00

5120

Complete Mandibular Denture

600.00

1350.00

750.00

5130

Complete Immediate Upper

600.00

1460.00

860.00

5140

Complete Immediate Lower

600.00

1474.00

874.00

5211

Upper Partial acrylic base clsp/rests

480.00

996.00

516.00

5212

Lower Partial acrylic base clsp/rests

480.00

1013.00

533.00

5213

Upper Partial

545.00

1417.00

872.00

5214

Lower Partial

545.00

1420.00

875.00

5281

Partial removable unilateral

385.00

806.00

421.00

5410/5411

Adjust complete denture - upper/lower

55.00

72.00

17.00

Prosthetics and Repairs Continued

5420/5421

Adjust partial denture - upper/lower

55.00

72.00

17.00

5510

Repair broken complete denture base

90.00

169.00

79.00

5520

Replace missing or broken teeth in complete denture

80.00

149.00

69.00

5640

Replace one tooth in Partial Denture

85.00

150.00

65.00

5650

Adding tooth to Partial Denture to Replace Extracted Natural Teeth first tooth

100.00

179.00

79.00

5660

Add Clasp To Existing Partial Denture

125.00

230.00

105.00

5710

Upper Denture Rebase

225.00

473.00

248.00

5711

Lower Denture Rebase

225.00

474.00

249.00

5720

Partial Upper Rebase

225.00

451.00

226.00

5721

Partial Lower Rebase

225.00

452.00

227.00

5730

Upper Denture Reline chairside

170.00

302.00

132.00

5731

Lower Denture Reline chairside

170.00

303.00

133.00

5740

Partial Upper Reline chairside

170.00

300.00

130.00

5741

Partial Lower Reline chairside

170.00

300.00

130.00

5932/5933

Obturator

385.00

500.00

115.00

Fixed Prosthodontics

6210

Pontic-cast high noble metal

445.00

875.00

430.00

6211

Pontic cast predominantly base metal

395.00

800.00

405.00

6212

Pontic cast noble metal

415.00

842.00

427.00

6240

Pontic porcelain fused to high noble metal

510.00

893.00

383.00

6241

Pontic porcelain fused to predominantly base metal

475.00

825.00

350.00

6242

Pontic porcelain fused to noble metal

495.00

860.00

365.00

6250

Pontic resin with high noble metal

510.00

853.00

343.00

6251

Pontic resin with predominantly base metal

475.00

825.00

350.00

6252

Pontic resin with noble metal

495.00

850.00

355.00

6545

Cast metal retainer

295.00

650.00

355.00

6720

Resin with high noble metal

510.00

860.00

350.00

6721

Resin with predominantly base metal

475.00

820.00

345.00

6722

Resin with noble metal

495.00

850.00

355.00

6750

Porcelain fused to high noble metal

525.00

895.00

370.00

6751

Porcelain fused to base metal

500.00

825.00

325.00

6752

Porcelain fused to noble metal

500.00

861.00

361.00

6780

3/4 cast high noble metal

510.00

875.00

365.00

6781

3/4 cast predominantly base metal

495.00

830.00

335.00

6782

3/4 cast noble metal

495.00

854.00

359.00

6790

Full cast high noble metal

510.00

880.00

370.00

6791

Full cast predominantly base metal

475.00

805.00

330.00

6792

Full cast noble metal

495.00

850.00

355.00

6930

Recement Crown or Bridge

65.00

135.00

70.00

Oral Surgery

7140

Extraction, erupted tooth or exposed root

65.00

130.00

65.00

7210

Surgical extraction

115.00

220.00

105.00

7220

Soft tissue Impaction

175.00

255.00

80.00

7230

Partially Bony Impaction

225.00

325.00

100.00

7240

Complete Bony Impaction

265.00

400.00

135.00

7250

Surgical Removal of residual tooth roots

150.00

270.00

120.00

7285

Biopsy of oral tissue - hard

210.00

321.00

111.00

7286

Biopsy of oral tissue - soft

150.00

276

126

7310

Alveoplasty per quad

145.00

237.00

92.00

7410

Removal of Cyst or benign lesion up to 1.25 cm

250.00

328.00

78.00

7960

Frenectomy

240.00

372.00

132.00

Orthodontics

8080

Initial Appliance

800.00

1000.00

200.00

8210

Removable appliance therapy

475.00

720.00

245.00

8680

Active treatment - monthly

90.00

246.00

156.00

8690

Passive treatment -once every 3 months

60.00

217.00

157.00

Miscellaneous

9110

Emergency Palliative Treatment

55.00

98.00

43.00

9220

Deep sedation/general anesthesia - first 30 minutes

175.00

325.00

150.00

9221

Deep sedation/general anesthesia - each additional 15 minutes

85.00

145.00

60.00

9310

Professional Consultation

75.00

100.00

25.00

Disclosure:
Please note that this fee schedule is not permanently guaranteed to stay at current levels. From time to time there may be changes in the published fee schedule. Please check this site to obtain the latest scheduled fees for your dental services.

Copyright 2010 by CPS Dental, Inc. All rights reserved