Download 2014 General Dentistry Fee Schedule

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20 Park Plaza, 4 Fl., Boston, MA 02116
P: (617) 859-1777 F: (617) 859-1441
www.universaldentalplan.com
2014 General Dentistry Fee Schedule
Note: This part of the fee schedule applies to procedures performed by General Dentists only.
ADA Code
D0150
D0120
D1330
D0140
D0150
D0210
D0220/30
D0272
D0274
D0270
D0330
D0460
D1110
D1120
D1208
D1351
D1510
D1515
Diagnostic & Preventive Procedures
Initial oral examination
Periodic oral examination
Oral hygiene instruction
Emergency oral examination
Comprehensive oral exam
Full mouth x-ray
Intraoral x-ray film, each
Bitewing x-ray films, two
Bitewing x-ray films, four
Bitewing x-ray films, each additional
Panoramic film
Pulp vitality test
Adult Cleaning
Child Cleaning
Topical fluoride application
Sealant per tooth
Space maintainer – fixed unilateral type
Space maintainer – fixed bilateral type
Member Pays
No Charge*
No Charge*
No Charge
$ 55.00
$ 55.00
$ 86.00
$ 18.00
$ 28.00
$ 40.00
$ 18.00
$ 76.00
$ 32.00
$ 68.00
$ 54.00
$ 26.00
$ 35.00
$ 272.00
$ 378.00
Usual Fee
$ 30.00
$ 40.00
$ 20.00
$ 125.00
$ 94.00
$ 132.00
$ 36.00
$ 64.00
$ 86.00
$ 36.00
$ 125.00
$ 90.00
$ 125.00
$ 84.00
$ 58.00
$ 55.00
$ 400.00
$ 495.00
You Save
$ 30.00
$ 40.00
$ 20.00
$ 70.00
$ 39.00
$ 46.00
$ 18.00
$ 36.00
$ 46.00
$ 18.00
$ 49.00
$ 58.00
$ 57.00
$ 30.00
$ 32.00
$ 20.00
$ 128.00
$ 117.00
ADA Code
Restorative Procedures
Primary: Silver fillings (Amalgams)
One surface
Two surfaces
Three surfaces
Four or more surfaces
Permanent: Silver fillings (Amalgams)
One surface
Two surfaces
Three surfaces
Four or more surfaces
Anterior: White fillings (Composite Resins)
One surface
Two surfaces
Three surfaces
Four or more surfaces
Posterior: White fillings (Composite Resins)
One surface
Two surfaces
Three surfaces
Four or more surfaces
Crown porcelain/ceramic
Crown porcelain fused to high noble metal
Crown full cast (base metal)
Re-cement crown
Prefab’d SS crown – primary tooth
Prefab’d SS crown – permanent tooth
Prefab’d resin crown
Core buildup, including any pins
Protective Restoration
Pin retention/tooth, in add. to rest
Cast post/core in addition to crown
Prefab’d post/core in add. to crown
Temporary crown (fractured tooth)
Member pays
Usual Fee
You Save
$ 98.00
$ 112.00
$ 122.00
$ 132.00
$ 125.00
$ 165.00
$ 178.00
$ 220.00
$
$
$
$
27.00
53.00
56.00
88.00
$
$
$
$
102.00
126.00
142.00
172.00
$ 148.00
$ 168.00
$ 206.00
$ 254.00
$
$
$
$
46.00
42.00
64.00
82.00
$
$
$
$
118.00
142.00
162.00
182.00
$ 158.00
$ 192.00
$ 224.00
$ 268.00
$
$
$
$
40.00
50.00
62.00
86.00
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
132.00
152.00
172.00
190.00
990.00
975.00
825.00
92.00
216.00
224.00
282.00
235.00
78.00
58.00
275.00
235.00
225.00
$ 176.00
$ 232.00
$ 268.00
$ 294.00
$1375.00
$1375.00
$1250.00
$ 124.00
$ 310.00
$ 286.00
$ 365.00
$ 325.00
$ 132.00
$ 82.00
$ 415.00
$ 365.00
$ 395.00
$ 44.00
$ 80.00
$ 96.00
$ 104.00
$ 385.00
$ 400.00
$ 425.00
$ 32.00
$ 94.00
$ 62.00
$ 83.00
$ 90.00
$ 54.00
$ 24.00
$ 140.00
$ 130.00
$ 170.00
D2140
D2150
D2160
D2161
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2391
D2392
D2393
D2394
D2740
D2750
D2791
D2920
D2930
D2931
D2932
D2950
D2940
D2951
D2952
D2954
D2970
General & Board Certified Specialist Dentistry Fee Schedule
May 2014, Universal Dental Plan
ADA Code
D3110/20
D3220
D3310
D3320
D3330
D3920
Endodontic Procedures
Pulp cap-direct & indirect (excl. final rest.)
Therapeutic pulpotomy (excl. final rest.)
Root canal – anterior (excl. final rest.)
Root canal – bicuspid (excl. final rest.)
Root canal – 3 or 4 canals (excl. final rest.)
Hemisection (incl. root removal; excl. RC)
Member Pays
$ 73.00
$ 128.00
$ 640.00
$ 755.00
$ 925.00
$ 295.00
Usual Fee
$ 110.00
$ 184.00
$ 985.00
$1095.00
$1450.00
$ 420.00
You Save
$ 37.00
$ 56.00
$ 345.00
$ 340.00
$ 525.00
$ 125.00
ADA Code
D4210
D4211
D4240
D4260
D4270
D4341
D4342
D4910
Periodontic Procedures
Gingivectomy or gingivoplasty – per quad
Gingivectomy or gingivoplasty – 1 to 3 teeth
Gingival flap proc., incl. root planing/quad
Osseous surg., incl. flap entry-close/quad
Pedicle soft tissue graft procedure
Periodontal scaling & root planing – 4+ teeth/quad
Periodontal scaling & root planing – 1-3 teeth/quad
Peridontal maint. Proc. (follow active therapy)
Member Pays
$ 425.00
$ 215.00
$ 675.00
$ 955.00
$ 580.00
$ 195.00
$ 155.00
$ 118.00
Usual Fee
$ 635.00
$ 295.00
$ 860.00
$1380.00
$ 745.00
$ 265.00
$ 223.00
$ 152.00
You Save
$ 210.00
$ 80.00
$ 185.00
$ 425.00
$ 165.00
$ 70.00
$ 68.00
$ 34.00
ADA Code
Member Pays
Usual Fee
You Save
$ 985.00
$1395.00
$ 410.00
$1095.00
$1582.00
$ 487.00
$ 735.00
$1125.00
$ 390.00
$1045.00
$1535.00
$ 490.00
D5410/1
D5421/2
D5510
D5520
D5610
D5630
D5640
D5650/60
D5710/21
D5730/1
D5750/1
D5810/1
D5820/1
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 or
complete new dentures)
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.)
Adjust part. upper or lower dent. (After 6 mos.)
Repair broken complete denture base
Repl. Missing/broken teeth-comp. dent./tooth
Repair partial denture resin saddle or base
Repair or replace denture broken clasp
Repair broken teeth-part. denture/tooth
Add tooth or clasp to existing part. denture
Rebase comp. or 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)
$ 68.00
$ 68.00
$ 172.00
$ 168.00
$ 164.00
$ 164.00
$ 120.00
$ 180.00
$ 375.00
$ 235.00
$ 285.00
$ 475.00
$ 385.00
$
$
$
$
$
$
$
$
$
$
$
$
$
116.00
116.00
296.00
272.00
267.00
267.00
228.00
282.00
537.00
355.00
456.00
652.00
563.00
$ 48.00
$ 48.00
$ 124.00
$ 104.00
$ 103.00
$ 103.00
$ 108.00
$ 102.00
$ 162.00
$ 120.00
$ 171.00
$ 177.00
$ 178.00
ADA Code
D6241
D6545
D6751
D6791
D6930
D6940
D6950
D2952
D2953
D2954
Fixed Prosthodontic Procedures
Pontic-porcelain fuse to metal (each wing)
Cast-metal retainer for acid bridge
Crown- (abutment) porcelain fuse to metal
Crown- (abutment) full cast base metal
Re-cement bridge
Stress breaker
Precision attachments (each)
Post/Core in add. to crown, indirectly fabricated
Each add. indirectly fabricated post – same tooth
Prefabricated post/core in add. to crown
Member Pays
$ 935.00
$ 435.00
$ 975.00
$ 865.00
$ 125.00
$ 245.00
$ 425.00
$ 295.00
$ 274.00
$ 245.00
Usual Fee
$1242.00
$ 720.00
$1300.00
$1125.00
$ 195.00
$ 336.00
$ 645.00
$ 370.00
$ 364.00
$ 322.00
You Save
$ 307.00
$ 285.00
$ 325.00
$ 260.00
$ 70.00
$ 91.00
$ 220.00
$ 75.00
$ 90.00
$ 77.00
D5110/20
D5130/40
D5211/2
D5213/4
General & Board Certified Specialist Dentistry Fee Schedule
May 2014, Universal Dental Plan
ADA Code
D7140
D7111
D7210
D7250
D7510
Oral Surgery Procedures
Extraction (simple) – Single tooth
Extraction - Primary tooth
Surgical removal of erupted tooth per tooth
Surgical removal of residual tooth roots
Incision/drainage of abscess
Member Pays
$ 130.00
$ 105.00
$ 235.00
$ 285.00
$ 215.00
Usual Fee
$ 205.00
$ 175.00
$ 315.00
$ 365.00
$ 295.00
You Save
$ 75.00
$ 70.00
$ 80.00
$ 80.00
$ 80.00
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.
ADA Code
D0016
D9110
D9940
Adjunctive General Services Unclassified
Failed appt. w/o 24 hr notice per 15 mins.
Palliative (ER) treatment of minor pain
Occlusal guard / Night guard
Member Pays
$ 54.00
$ 74.00
$ 385.00
Usual Fee
$ 80.00
$ 138.00
$ 650.00
You Save
$ 26.00
$ 64.00
$ 265.00
ADA Code
D2962
D9972
D2960
Cosmetic Procedures
Porcelain laminate veneer per tooth
External bleaching – per arch
Bonding (per tooth)
Member Pays
$ 965.00
$ 235.00
$ 275.00
Usual Fee
$1350.00
$ 450.00
$ 485.00
You Save
$ 385.00
$ 215.00
$ 210.00
2014 Board Certified Specialist Fee Schedule
Note: This part of the fee schedule applies to procedures performed by Board Specialized Dentists only.
ADA Code
D0150
D7140
D7210
D7220
D7230
D7240
D7241
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-complete bony w/
unusual 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
Member Pays
$ 60.00
$ 195.00
$ 345.00
$ 345.00
$ 445.00
$ 485.00
$ 565.00
Usual Fee
$ 120.00
$ 270.00
$ 475.00
$ 435.00
$ 550.00
$ 605.00
$ 720.00
You Save
$ 60.00
$ 75.00
$ 130.00
$ 90.00
$ 105.00
$ 120.00
$ 155.00
$ 315.00
$ 385.00
$ 345.00
$ 420.00
$ 485.00
$ 435.00
$ 265.00
$
$
$
$
$
$
$
465.00
520.00
455.00
515.00
595.00
555.00
360.00
$ 150.00
$ 135.00
$ 110.00
$ 95.00
$ 110.00
$ 120.00
$ 95.00
Member Pays
$ 60.00
Usual Fee
$ 120.00
You Save
$ 60.00
$ 525.00
$ 735.00
$ 210.00
$3895.00
$4265.00
20% off
$5565.00
$6685.00
-
$ 1670.00
$ 2420.00
-
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
$325.00
$485.00
$160.00
ADA Code
D0150
D3310
D3320
D3330
D3410
Endodontic Procedures
Comprehensive Oral Evaluation
Root canal – anterior (excl. final rest.)
Root canal – bicuspid (excl. final rest.)
Root canal – 3 or 4 canals (excl. final rest.)
Apicoectomy (per tooth) – first root
Member Pays
$ 60.00
$ 785.00
$ 890.00
$1125.00
$ 585.00
Usual Fee
$ 120.00
$ 985.00
$1115.00
$1420.00
$ 725.00
You Save
$ 60.00
$ 200.00
$ 225.00
$ 295.00
$ 140.00
D7250
D7280
D7310
D7320
D7960
D7970
D7971
ADA Code
D0150
General & Board Certified Specialist Dentistry Fee Schedule
May 2014, Universal Dental Plan
D3426
D3430
D3450
D3920
Apicoectomy (per tooth) – each add. root
Retrograde filling – per root
Root amputations – per root
Hemisection (incl. root removal; excl. RC)
$
$
$
$
ADA Code
D0150
D4240
D4260
D4270
D4341
D4342
Periodontic Procedures
Comprehensive Oral Evaluation
Gingival flap proc., incl. root planning/quad
Osseous surg., incl. flap entry-close/quad
Pedicle soft tissue graft procedure
Periodontal scaling & root planing – 4+ teeth/quad
Periodontal scaling & root planing – 1-3 teeth/quad
ADA Code
365.00
335.00
365.00
435.00
$
$
$
$
480.00
465.00
485.00
565.00
$ 115.00
$ 130.00
$ 120.00
$ 130.00
Member Pays
$ 60.00
$ 825.00
$1325.00
$ 885.00
$ 270.00
$ 235.00
Usual Fee
$ 120.00
$1135.00
$1685.00
$1125.00
$ 365.00
$ 315.00
You Save
$ 60.00
$ 310.00
$ 360.00
$ 240.00
$ 95.00
$ 80.00
TMJ Dentistry
Member Pays
20% off
Usual Fee
-
You Save
-
ADA Code
Pediatric Dentistry
Member Pays
20% off
Usual Fee
-
You Save
-
ADA Code
Prosthodontic Dentistry
Member Pays
20% off
Usual Fee
-
You Save
-
ADA Code
Implantology
Member Pays
Usual Fee You Save
20% off
The 20% Discount noted for Implants includes Stages 1 & 2. Any prosthetic services, i.e. crowns, fixed bridges,
complete or partial dentures are available at a 20% discount from a Specialist.
*The Oral examinations and Diagnosis at no charge are in conjunction with a cleaning or x-rays or
other procedures such as fillings, etc. If a patient chooses to do initial oral examination only, then the
$55 comprehensive oral examination (ADA0150) will apply.
Plan Guidelines:
1- Most office procedures are listed. For procedures not listed , members receive a 20% discount from the
dentist's usual and customary fees.
2- Consultations by participating specialists are also discounted 20%.
3- Any prosthetic services from Board Certified Prosthodontists (crowns, fixed bridges, complete or
partial dentures) are available at a 20% discount.
4- This fee schedule is subject to periodic change without prior notification.
5- Universal Dental Plan is NOT dental insurance. It is a Discount Dental Plan.
General & Board Certified Specialist Dentistry Fee Schedule
May 2014, Universal Dental Plan