Download member fee schedule - Universal Dental Plan

A Harvard Pilgrim Healthcare Member
Savings Program Participant
Plan Guidelines:
2017
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
feeMA
schedule
(F): 617-859-1441
BOSTON,
02116 is subject to periodic change without prior notification.
Universal Dental Plan is NOT dental insurance. It is a Discount Dental Plan.
2017 GENERAL DENTISTRY FEE SCHEDULE
Note: This fee schedule applies to procedures performed by a General Dentist only.
DIAGNOSTIC & PREVENTIVE PROCEDURES
MEMBER FEE
ADA CODE
Periodic oral examination
No Charge*
D0120
Comprehensive
oral
evaluation
No Charge*
D0150
Oral hygiene instruction
No Charge*
D1330
Limited oral evaluation
78
D0140
Detailed
oral
evaluation
(problem
focused)
94
D0160
Re-evaluation (problem focused)
60
D0170
Full
mouth
X-Rays
116
D0210
Intraoral X-ray film, single first
30
D0220
Intraoral X-ray films, each additional
28
D0230
Bitewing
X-ray
film,
single
34
D0270
Bitewing X-ray films, two
42
D0272
Bitewing
X-ray
films,
four
64
D0274
Panoramic film
114
D0330
Pulp vitality test
74
D0460
Prophylaxis
(Cleaning)-adult
72
D1110
Prophylaxis (Cleaning)-child
62
D1120
Topical
fluoride
application-adult
34
D1208
Sealant per tooth
38
D1351
Space maintainer-fixed unilateral type
380
D1510
Space
maintainer-fixed
bilateral
type
440
D1515
ADA CODE
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2391
D2392
D2393
D2394
D2710
D2740
D2750
D2751
D2790
D2791
D2920
D2930
RESTORATIVE PROCEDURES
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
145
25
138
166
110
164
42
40
55
68
90
160
110
125
90
58
57
525
650
YOU SAVE
40
145
25
60
72
50
48
12
12
21
26
26
46
36
53
28
20
19
145
210
MEMBER FEE
AVG FEE
YOU SAVE
140
148
172
184
176
210
240
290
36
62
68
106
148
164
196
224
186
235
285
348
38
71
89
124
156
194
220
272
475
1065
1045
1020
1035
985
105
295
208
270
335
365
695
1460
1420
1385
1435
1370
145
375
52
76
115
93
220
395
375
365
400
385
40
80
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
315
305
94
315
58
365
345
325
205
420
390
137
425
82
460
470
460
255
105
85
43
110
24
95
125
135
50
ADA CODE
D3110/20
D3220
D3310
D3320
D3330
D3346
D3347
D3348
D3410
D3421
D3425
D3450
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)
MEMBER FEE
73
167
845
935
1125
1165
1195
1235
875
915
1125
395
AVG FEE
110
232
1125
1295
1480
1595
1675
1725
1265
1225
1465
635
YOU SAVE
37
65
280
360
355
430
480
490
390
310
340
240
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
85
565
315
875
585
945
1245
1065
835
235
170
120
125
AVG FEE
145
715
415
1295
965
1295
1625
1425
1045
325
227
185
166
YOU SAVE
60
150
120
420
380
350
380
360
210
90
57
65
41
ADA CODE
REMOVABLE PROSTHODONTIC PROCEDURES
MEMBER FEE
Complete Dentures
Complete upper or lower incl. 6 mos care
1095
Immediate upper or lower denture incl. 6 mos. care (does not
1215
incl. req. future rebasing/relining procedures)
Partial Dentures
Upper or lower partial–acrylic base, incl. any conventional
985
clasps & rests
Upper or lower partial–predominantly base case base w/
1175
acrylic saddles incl. any conventional clasps & rests
Denture Reline/Repair
Adjust comp. upper or lower dent. (After 6 mos.)
88
AVG FEE
YOU SAVE
1445
1585
350
370
1375
390
1535
360
120
32
D5110/20
D5130/40
D5211/2
D5213/4
D5410/1
88
142
172
164
174
144
225
380
315
345
485
475
120
225
245
235
260
225
297
522
438
468
660
630
32
83
73
71
86
81
70
142
123
123
175
155
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
MEMBER FEE
985
455
1065
985
965
130
AVG FEE
1272
720
1460
1310
1275
195
YOU SAVE
287
265
395
325
310
65
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
142
240
290
235
AVG FEE
175
207
320
395
315
YOU SAVE
70
65
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
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
65
95
415
AVG FEE
85
150
660
YOU SAVE
30
55
245
ADA CODE
D2960
D2962
D9972
COSMETIC PROCEDURES
Bonding (per tooth)
Porcelain laminate veneer per tooth
External bleaching – per arch
MEMBER FEE
725
965
235
AVG FEE
935
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
2017 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
85
195
345
345
425
485
565
305
415
325
420
485
435
265
Avg Fee
150
270
475
465
580
645
720
465
620
455
565
635
555
360
You Save
65
75
130
120
140
160
155
160
205
130
145
150
120
95
ADA Code
D0150
Avg Fee
150
You Save
65
745
210
5565
6685
-
1670
2420
-
D8680
Orthodontic Procedures
Member Fee
Comprehensive Oral Evaluation
85
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
D0140
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
85
925
1085
1375
985
480
595
445
Avg Fee
150
1185
1375
1725
1260
645
765
595
You Save
65
260
290
350
275
165
170
150
ADA Code
D0180
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
85
1085
1395
985
265
215
Avg Fee
150
1450
1745
1375
365
315
You Save
65
365
350
390
100
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 does not guarantee the quality of the service of the providers
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