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As a Member of The HealthPlus Dental Plan you always know ahead of time what your charges are going to be. Below is the actual fee schedule the dentist uses when performing services. We have Hundreds of providers and specialist to choose from. Why Wait? Enroll now and your benefits will begin immediately! |
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ADA CODE PROCEDURE MEMBER FEE DIAGNOSTIC 00100 Clinical Oral Exam No Charge 00110 Initial Oral Exam No Charge 00120 Periodic Oral Exam No Charge 00130 Emergency Oral Exam $ 37.00 00210 X-Ray Complete Series $ 45.00 00272 X-Ray Bite Wing (Two) No Charge 00274 X-Ray Bite Wing (Four) No Charge 00280 X-Ray Bite Wing (Ea. Additional) $ 5.00 00330 X-Ray Panorex $ 45.00 Material Sterilization Fee Per Visit $ 10.00 Broken Appointment (Without 24hr Notice) $ 25.00 X-Rays Duplicating Fee $ 20.00
PREVENTIVE
01110 Adult Cleaning $47.00 01120 Child Cleaning $36.00 01130 Difficult Cleaning $58.00 01203 Fluoride (Child 1 Per Year) No Charge 01203 Fluoride (Child Additional) $ 10.00 01204 Fluoride Treatment (Adult) $ 12.00 01300 Sealant/ Tooth $ 20.00 01330 Oral Hygiene Instructions No Charge 01340 Preventative Care Instructions No Charge
*RESTORATIVE (Fillings) 02110 Amalgam - 1 Surf. Decid. $ 39.00 02120 Amalgam - 2 Surf. Decid $ 46.00 02130 Amalgam - 3 Surf. Decid. $ 58.00 02131 Amalgam - 4 Surf. Decid. $ 66.00 02140 Amalgam - 1 Surf. Perm $ 43.00 02150 Amalgam - 2 Surf. Perm $ 55.00 02160 Amalgam - 3 Surf. Perm $ 69.00 02161 Amalgam - 4 Surf. Perm $ 72.00 02210 Silicate Cement No Charge 02330 1 Surf Resin Anterior $ 53.00 02331 2 Surf Resin Anterior $ 64.00 02332 3 Surf Resin Anterior $ 74.00 02335 4 Surf Resin (Incisal Edge) $ 94.00 02380 1 Surf Resin Posterior Primary $ 53.00 02381 2 Surf Resin Posterior Primary $ 78.00 02382 3 Surf Resin Posterior Primary $ 90.00 02391 1 Surf Resin Posterior Perm $ 58.00 02392 2 Surf Resin Posterior Perm $ 83.00 02393 3 Surf Resin Posterior Perm $ 98.00 *Acid Etching Add to resin Composite Filling $ 10.00 Precision Cast Fillings InLays/ OnLays… 25% OFF UCR All Other Fillings not shown………………… 25% OFF UCR
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ADA CODE PROCEDURE MEMBER FEE **CROWNS & BRIDGES 02710 Crown/ Resin $255.00 02740 Porcelain Crown/ $397.00 02750 Porcelain Crown/ High Noble $468.00 02751 Porcelain Crown/ Metal $399.00 02752 Porcelain Crown/ Noble $439.00 02791 Full Cast Crown $379.00 02810 3/4 Crown/ Metal $310.00 02930 Crown/ Stainless Steel $125.00 02910 Recement inlay $ 37.00 02920 Recement Crown $ 37.00 02940 Sedative Filling (each Tooth) $ 12.00 02950 Crown Build up $ 77.00 02951 Pin Retention $ 29.00 02970 Temporary Crown/ With Perm. No Charge 02970 Temporary Crown/ W/O Perm. $115.00 02960 Bonding Per Tooth 25% OFF UCR Laminate Veneer 25% OFF UCR **PERIODONTICS (Gum treatment)04100 Perio Hygiene Instructions N/CHG 04210 Gingioplasty/ Quad $239.00 04211 Gingivectomy Per Tooth $ 81.00 04260 Osseous Surgery/ Quad $330.00 04910 Perio Prophy (Cleaning) $ 68.00 04341 Perio Scaling / Planing Per Quad 25% Off UCR 04355 Full Mouth Debridement 25% Off UCR
** PROSTHODONTICS (Removable) 05110 Comp. Upper Dentures $585.00 05120 Comp. Lower Dentures $585.00 05130 Immediate Uppers $599.00 05140 Immediate Lowers $599.00 05211 Upper Partial/ Resin Base $515.00 05212 Lower Partial/ Resin Base $515.00 05213 Upper Partial/ Resin W / Metal $565.00 05214 Lower Partial/ Resin W / Metal $565.00 05750 Reline Upper (Laboratory) $131.00 05751 Reline Lower (Laboratory) $131.00 05730 Reline Upper (office) $129.00 05731 Reline Lower (office) $129.00 05999 Adjustments Upper / Lower $ 38.00 05640 Replace Per Tooth $ 48.00 05510 Repair Denture base $ 88.00 "THIS IS A DISCOUNT PROGRAM," " THIS IS NOT INSURANCE" |
ADA CODE PROCEDURE MEMBER FEE ENDODONTICS (Root Canal Treatment) 03110 Pulp Cap Direct $ 35.00 03120 Pulp Cap Indirect $ 31.00 03220 Vital Pulpotomy $ 58.00 03310 Root Canal Therapy 1 Canal 25% Off UCR 03320 Root Canal Therapy 2 Canals 25% Off UCR 03330 Root Canal Therapy 3 Canals 25% Off UCR 03340 Root Canal Therapy 4 Canals 25% Off UCR 03940 Recalcification Per Tooth $ 38.00 PONTICS (Fixed) 06545 Cast Metal Retainer $318.00 06241 Pontic Porcelain / Base Metal $338.00 06251 Crown Porcelain / Base Metal $338.00 06930 Recementation $ 45.00 ORAL SURGERY 07110 Extractions Single Tooth 25% OFF UCR 07120 Extractions Additional Per Tooth 25% OFF UCR Molar Removal 25% OFF UCR Surgical Removal 25 % OFF UCR IMPLANTS 25 % OFF UCR ORTHODONTICS
Orthodontics as performed by a provider in our provider directory 25% OFF UCR Membership must be current for Orthodontics Benefit & Discounts OTHER SPECIALTY SERVICES
Treatments provided by a participating specialist if available, will be at 20% - 25% OFF USUAL, CUSTOMARY, & REGULAR for Endodontics, Pedodontics (children), Prosthodontic, Orthodontics, Periodontics and Oral Surgery. Please discuss your case with the Specialist prior to beginning service. *USUAL CUSTOMARY & REASONABLE FEES WILL VARY IN EACH AREA ** ADDITIONAL CHARGES FOR PRECIOUS METALS ** ADDITIONAL CHARGES FOR LAB FEE (not to exceed $125.00)
"FEE SCHEDULE" As performed by a General Practitioner
PLEASE NOTE THAT SERVICES NOT OUTLINED ARE DISCOUNTED AT 25% "FEE SCHEDULE IS SUBJECT TO CHANGE" Please call your network provider in advance to confirm their Plan Participation and fees.
Effective 07/ 2009 |
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OTHER SPECIALTY SERVICES
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