Download member fee schedule - Universal Dental Plan

A Harvard Pilgrim Healthcare Member
Savings Program Participant
Plan Guidelines:
2016
MEMBER FEE SCHEDULE
-Most office procedures are listed. For procedures not listed , members receive a 20% discount from the dentist's
usual and customary fees.
-Consultations by participating specialists are also discounted 20%.
-Any prosthetic services from Board Certified Prosthodontists (crowns, fixed bridges, complete or partial dentures)
available
at a1401
20% discount.
(P): 617-859-1777
20are
PARK
PLAZA, STE.
WWW.UNIVERSALDENTALPLAN.COM
-This
fee
schedule
is
subject
to
periodic
change
without
prior
notification.
(F): 617-859-1441
BOSTON, MA 02116
Universal Dental Plan is NOT dental insurance. It is a Discount Dental Plan.
2016 GENERAL DENTISTRY FEE SCHEDULE
Note: This fee schedule applies to procedures performed by a General Dentist only.
MEMBER FEE
DIAGNOSTIC & PREVENTIVE ISSUES
ADA CODE
No Charge*
Periodic
oral
examination
D0120
Comprehensive oral evaluation
No Charge*
D0150
Oral
hygiene
instruction
No Charge*
D1330
57
Limited oral evaluation
D0140
88
Detailed oral evaluation (problem focused)
D0160
60
Re-evaluation
(problem
focused)
D0170
Full mouth X-Rays
88
D0210
23
Intraoral
X-ray
film,
single
first
D0220
Intraoral X-ray films, each additional
23
D0230
28
Bitewing X-ray film, single
D0270
34
Bitewing
X-ray
films,
two
D0272
54
Bitewing X-ray films, four
D0274
88
Panoramic
film
D0330
Pulp vitality test
34
D0460
68
Prophylaxis (Cleaning)-adult
D1110
54
Prophylaxis
(Cleaning)-child
D1120
30
Topical fluoride application-adult
D1208
38
Sealant
per
tooth
D1351
314
Space maintainer-fixed unilateral type
D1510
380
Space maintainer-fixed bilateral type
D1515
ADA CODE
D2140
D2150
D2160
D2161
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2391
D2392
D2393
D2394
D2710
D2740
D2750
D2751
D2790
D2791
D2920
D2930
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 resin composite (indirect)
Crown porcelain/ceramic
Crown porcelain fused to high noble metal
Crown porcelain predominantly base metal
Crown full cast (high noble)
Crown full cast (base metal)
Re-cement or re- bond crown
Prefab’d SS crown – primary tooth
AVG FEE
40
90
20
127
158
110
134
41
41
55
68
90
136
92
125
84
58
57
432
497
YOU SAVE
40
90
20
70
70
50
46
18
18
27
34
36
48
58
57
30
28
19
118
117
MEMBER FEE
AVG FEE
YOU SAVE
108
120
138
148
145
169
194
230
37
49
56
82
112
128
144
176
158
170
208
258
46
42
64
82
128
154
186
198
178
227
280
284
50
73
94
86
138
168
182
238
480
998
990
945
985
925
96
270
182
257
276
352
695
1460
1395
1340
1435
1290
138
365
44
89
94
114
215
462
405
395
450
365
42
95
D2931
D2932
D2940
D2950
D2951
D2952
D2954
D2970
D2980
Prefab’d SS crown – permanent tooth
Prefab’d resin crown
Protective restoration
Core buildup, including any pins
Pin retention/tooth, in add. to rest
Cast post/core in addition to crown
Prefab’d post/core in add. to crown
Temporary Crown
Crown repair
ADA CODE
D3110/20
D3220
D3310
D3320
D3330
D3346
D3347
D3348
D3410
D3421
D3425
D3450
D3920
270
288
84
266
58
315
305
325
188
365
375
132
346
82
445
415
485
283
95
87
48
80
24
130
110
160
95
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.)
Re-treatment of root canal (anterior)
Re-treatment of root canal (biscuspid)
Re-treatment of root canal (posterior)
Apicoectomy (anterior)
Apicoectomy (bicuspid)
Apicoectomy (posterior)
Root amputation (per)
Hemisection (incl. root removal; excl. RC)
MEMBER FEE
73
142
678
797
985
795
935
1085
685
762
865
325
365
AVG FEE
110
198
993
1127
1430
1090
1275
1455
925
972
1180
580
485
YOU SAVE
37
56
315
330
445
295
340
370
240
210
315
255
120
ADA CODE
D0180
D4210
D4211
D4240
D4241
D4249
D4260
D4261
D4270
D4341
D4342
D4381
D4910
PERIODONTIC PROCEDURES
Comprehensive perio, evaluation
Gingivectomy or gingivoplasty – per quad
Gingivectomy or gingivoplasty – 1 to 3 teeth
Gingival flap proc., w/ root planning/4+
Gingival flap proc., w/ root planning/1-3
Clinical crown lengthening
Osseous surg., incl. flap entry-close/ 4+
Osseous surg., incl. flap entry-closed/ 1-3
Pedicle soft tissue graft procedure
Periodontal scaling & root planing – 4+ teeth/quad
Periodontal scaling & root planing – 1-3 teeth/quad
Delivery of antimicrobials
Peridontal maint. Proc. (follow active therapy)
MEMBER FEE
60
480
295
695
385
795
1025
895
695
195
160
125
122
AVG FEE
90
685
415
960
620
1045
1450
1185
960
278
227
185
166
YOU SAVE
30
205
120
265
235
250
425
290
265
83
67
60
44
ADA CODE
REMOVABLE PROSTHODONTIC PROCEDURES
MEMBER FEE
Complete Dentures
Complete upper or lower incl. 6 mos care
995
Immediate upper or lower denture incl. 6 mos. care (does not
1100
incl. req. future rebasing/relining procedures)
Partial Dentures
Upper or lower partial–acrylic base, incl. any conventional
785
clasps & rests
Upper or lower partial–predominantly base case base w/
1085
acrylic saddles incl. any conventional clasps & rests
Denture Reline/Repair
Adjust comp. upper or lower dent. (After 6 mos.)
74
AVG FEE
YOU SAVE
1405
1587
410
487
1175
390
1575
490
120
46
D5110/20
D5130/40
D5211/2
D5213/4
D5410/1
74
172
172
164
164
125
195
380
238
295
485
410
120
296
296
267
267
233
297
542
358
461
660
588
46
124
124
103
103
108
102
162
120
166
175
178
FIXED PROSTHODONTIC PROCEDURES
Pontic-porcelain fuse to metal (each wing)
Cast-metal retainer for acid bridge
Crown- porcelain ceramic
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 FEE
945
435
998
985
915
130
255
445
295
284
255
AVG FEE
1252
720
1380
1310
1235
195
346
655
395
374
342
YOU SAVE
307
285
382
325
320
65
91
210
100
90
87
ORAL SURGERY PROCEDURES
Extraction - Primary tooth
Extraction (simple) – Single tooth
Surgical removal of erupted tooth per tooth
Surgical removal of residual tooth roots
Incision/drainage of abscess
MEMBER FEE
105
132
240
290
235
AVG FEE
175
207
320
395
315
YOU SAVE
70
75
80
105
80
D5421/2
D5510
D5520
D5610
D5630
D5640
D5650/60
D5710/20
D5730/1
D5750/1
D5810/1
D5820/1
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-per tooth
Repair broken teeth-part. denture/tooth
Add tooth or clasp to existing part. denture -per tooth
Rebase comp. / 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)
ADA CODE
D6241
D6545
D6740
D6751
D6791
D6930
D6940
D6950
D2952
D2953
D2954
ADA CODE
D7111
D7140
D7210
D7250
D7510
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 FEE
55
75
395
AVG FEE
85
139
660
YOU SAVE
30
64
265
ADA CODE
D2960
D2962
D9972
COSMETIC PROCEDURES
Bonding (per tooth)
Porcelain laminate veneer per tooth
External bleaching – per arch
MEMBER FEE
275
965
235
AVG FEE
485
1350
450
YOU SAVE
210
385
215
20 PARK PLAZA, STE. 1401 BOSTON, MA 02116
(P): (617) 859-1777 (F): (617) 859-1441
WWW.UNIVERSALDENTALPLAN.COM
2016 BOARD CERTIFIED SPECIALIST FEE SCHEDULE
Note: This fee schedule applies to procedures performed by a Board Specialized Dentist only.
ADA Code
D0150
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7280
D7310
D7320
D7960
D7970
D7971
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-w/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 Fee
60
195
345
345
440
485
565
305
415
325
420
485
435
265
Avg Fee
120
270
475
465
580
645
720
465
620
455
565
635
555
360
You Save
60
75
130
120
140
160
155
160
205
130
145
150
120
95
ADA Code
D0150
Avg Fee
120
You Save
50
745
210
5565
6685
-
1670
2420
-
D8680
Orthodontic Procedures
Member Fee
Comprehensive Oral Evaluation
70
Diagnosis / Records
Work-up including full mouth series, Models Photographs,
and a second visit for discussion and presentation.
535
Comprehensive Orthodontic Treatment
Class 1 - Maloclussion
3895
Class 2 - Maloclussion
4265
Class 3 - Maloclussion
20%
Continuation of orthodontic treatment beyond 24 months
and other orthodontic services available at a 20% discount
from usual/customary fees.
Orthodontic Retention
325
485
160
ADA Code
D0150
D3310
D3320
D3330
D3410
D3426
D3450
D3920
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
Apicoectomy (per tooth) – each add. root
Root amputations – per root
Hemisection (incl. root removal; excl. RC)
Member Fee
60
895
990
1195
795
465
395
445
Avg Fee
120
1185
1315
1575
1130
645
590
595
You Save
60
290
325
380
335
180
195
150
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
Member Fee
60
1035
1325
945
260
215
Avg Fee
120
1450
1685
1375
365
315
You Save
60
415
360
430
105
100
ADA Code
TMJ Dentistry
ADA Code
Pediatric Dentistry
ADA Code
Prosthodontic Dentistry
ADA Code
Implantology
Member Fee
20% off
Member Fee
20% off
Member Fee
20% off
Member Fee
20% off
Avg Fee
You Save
Avg Fee
You Save
Avg Fee
You Save
Avg Fee
You Save
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 usual and costumary rates.
*The Oral examinations and Diagnosis at no charge are in conjunction with a cleaning or full mouth 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:
- Most office procedures are listed. For procedures not listed , members receive a 20% discount from the dentist's
usual and customary fees.
- Consultations by participating specialists are also discounted 20% from the dentist's usual and customary fees.
- Any prosthetic services from Board Certified Prosthodontists (crowns, fixed bridges, complete or partial dentures)
are available at a 20% discount from the dentist's usual and customary fees.
- This fee schedule is subject to periodic change without prior notification.
- The list of Partcipating dentists is subject to change without prior notification.
Universal Dental Plan is NOT dental insurance. It is a Discount Dental Plan.
20 PARK PLAZA, STE. 1401 BOSTON, MA 02116
(P): (617) 859-1777 (F): (617) 859-1441
WWW.UNIVERSALDENTALPLAN.COM