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DIRECT DENTAL PLANS OF AMERICA, INC.GENERAL DENTIST FEE SCHEDULEPage 1 of 8DIAGNOSTIC SERVICESADACodeADA DescriptionMember ADAADA DescriptionCost CodeClinical Oral EvaluationsD0120Periodic Oral Evaluation – Established PatientD0145Oral Evaluation for a Patient under Three Years of Ageand Counseling with Primary CaregiverD0160D01710MemberCostD0140Limited Oral Evaluation – Problem Focused1840D0150Comprehensive Oral Evaluation – New or EstablishedPatient0Detailed and Extensive Oral Evaluation – ProblemFocused, by Report42D0170Re-Evaluation – Post-Operative Office Visit21D0180D0199Infection Control11D0999Routine Office Visit0D9110Palliative (Emergency) Treatment of Dental Pain –Minor Procedure26D9430Office Visit for Observation (during RegularlyScheduled Hours) – No Other Services Performed30D9440Office Visit – after Regularly Scheduled Hours75D0210Intraoral – Complete Series of Radiographic ImagesRe-Evaluation – Limited, Problem Focused(Established Patient, Not Post-Operative Visit)Comprehensive Periodontal Evaluation – New orEstablished Patient2330Diagnostic ImagingD0230D0250Intraoral – Periapical Each Additional RadiographicImageExtra-Oral – 2D Projection Radiographic ImageCreated Using a Stationary Radiation Source, andDetector30D0220Intraoral – Periapical First Radiographic Image77D0240Intraoral – Occlusal Radiographic Image7D0270Bitewing – Single Radiographic Image6D0272Bitewings – Two Radiographic Images12D0274Bitewings – Four Radiographic Images20D0290Posterior, Anterior or Lateral Skull and Facial BoneSurvey Radiographic Image3188D0330Panoramic Radiographic Image4855D0350268D0365273D03677D0273Bitewings – Three Radiographic Images16D0277Vertical Bitewings – 7 to 8 Radiographic 8Other Temporomandibular Joint Radiographic Images,by Report2D Cephalometric Radiographic Image – Acquisition,Measurement and AnalysisCone Beam CT Capture and Interpretation withLimited Field of View – Less than One Whole JawCone Beam CT Capture and Interpretation with Fieldof View of One Full Dental Arch – Maxilla, with orwithout CraniumCone Beam CT Capture and Interpretation for TMJSeries including Two or More Exposures2D Oral/Facial Photographic Image Obtained IntraOrally or Extra-OrallyCone Beam CT Capture and Interpretation with Fieldof View of One Full Dental Arch – MandibleCone Beam CT Capture and Interpretation with Fieldof View of Both Jaws; with or without Cranium24279301268Tests and ExaminationsD0431Adjunctive Pre-Diagnostic Test that Aids in Detectionof Mucosal Abnormalities including Premalignant andMalignant Lesions, not to include Cytology or BiopsyProcedures12D0460Pulp Vitality Tests0D0470Diagnostic Casts48PREVENTIVEDental Prophylaxis & Topical Fluoride Treatment (Office Procedure)D1110Prophylaxis – Adult (first visit in 12-month period)D1110Prophylaxis – Adult (second or more visits in 12month period)16D1120Prophylaxis – Child (once every 6 months)1620D1120Prophylaxis – Child (second or more visits in 12month period)20D1999Additional Prophy (for Perio Maintenance)45D1206Topical Application of Fluoride Varnish0D1330Oral Hygiene Instructions0D1353Sealant Repair – per Tooth9D1510Space Maintainer – Fixed - UnilateralOther Preventive ServicesD1351Sealant – per Tooth11Periodontal Screening and Scoring11Space Maintenance (Passive Appliances)155D1515Space Maintainer – Fixed - Bilateral24211178 Huron St., Suite 3, Northglenn, Colorado 80234 303.457.9794 800.377.2924 Fax: 303.457.6956 Email: DDP@DirectDentalPlan.comRevised January 2016
GENERAL DENTIST FEE SCHEDULE Page 2 of 8ADACodeADA DescriptionMember ADACost CodeD1520Space Maintainer – Removable - Unilateral212D1525Space Maintainer – Removable - Bilateral251D1550Re-Cement or Re-bond Space Maintainer20D1555Removal of Fixed Space Maintainer17ADA DescriptionMemberCostRESTORATIVE SERVICESAmalgam Restorations (Including Polishing)D2140Amalgam – One Surface, Primary or Permanent42D2150Amalgam – Two Surfaces, Primary or Permanent50D2160Amalgam – Three Surfaces, Primary or Permanent62D2161Amalgam – Four or More Surfaces, Primary orPermanent74Resin-Based Composite Restorations - DirectD2330Resin-Based Composite – One Surface, Anterior49D2332Resin-Based Composite – Three Surfaces, Anterior62D2331Resin-Based Composite – Two Surfaces, Anterior62D2390Resin-Based Composite Crown, Anterior268D2335Resin-Based Composite – Four or More Surfaces orInvolving Incisal Angle (Anterior)122D2391Resin-Based Composite – One Surface, Posterior95D2392Resin-Based Composite – Two Surfaces, Posterior130D2393Resin-Based Composite – Three Surfaces, Posterior165D2394Resin-Based Composite – Four or More Surfaces,Posterior190Gold Foil RestorationsD2410Gold Foil – One Surface319D2430Gold Foil – Three Surfaces401D2420Gold Foil – Two Surfaces334D2510Inlay - Metallic – One Surface295D2520Inlay - Metallic – Two Surfaces342D2530Inlay - Metallic – Three or More Surfaces368D2542Onlay - Metallic – Two Surfaces362D2543Onlay - Metallic – Three Surfaces380D2544Onlay - Metallic – Four or More Surfaces395Inlay/Onlay RestorationsPorcelain/Ceramic Inlays/Onlays Include all Indirect Ceramic and Porcelain Type Inlays/OnlaysD2610Inlay - Porcelain/Ceramic – One Surfaces320D2620Inlay - Porcelain/Ceramic – Two Surfaces345D2630Inlay - Porcelain/Ceramic – Three or More Surfaces378D2642Onlay - Porcelain/Ceramic – Two Surfaces399D2643Onlay - Porcelain/Ceramic – Three Surfaces425D2644Onlay - Porcelain/Ceramic – Four or More Surfaces445Resin-Based Composite Inlays/Onlays Must Utilize Indirect TechniqueD2650Inlay - Resin-Based Composite – One Surface339D2651Inlay - Resin-Based Composite – Two Surfaces351D2652Inlay - Resin-Based Composite – Three or MoreSurfaces370D2662Onlay - Resin-Based Composite – Two Surfaces420D2663Onlay - Resin-Based Composite – Three Surfaces435D2664Onlay - Resin-Based Composite – Four or MoreSurfaces448Crowns - Single Restorations OnlyD2710Crown – Resin-Based Composite (Indirect)325D2712Crown – 3/4 Resin-Based Composite (Indirect)375D2720Crown – Resin with High Noble Metal398D2721Crown – Resin with Predominantly Base Metal355D2722Crown – Resin with Noble Metal385D2740Crown – Porcelain/Ceramic Substrate405D2750Crown – Porcelain Fused to High Noble Metal395D2751Crown – Porcelain Fused to Predominantly BaseMetal375D2752Crown – Porcelain Fused to Noble Metal399D2780Crown – 3/4 Cast High Noble Metal475D2781Crown – 3/4 Cast Predominantly Base Metal405D2782Crown – 3/4 Cast Noble Metal444D2783Crown – 3/4 Porcelain/Ceramic464D2790Crown – Full Cast High Noble Metal409D2791Crown – Full Cast Predominantly Base Metal354D2792Crown – Full Cast Noble Metal387D2799Provisional Crown – Further Treatment orCompletion of Diagnosis Necessary Prior to FinalImpression215D2794Crown – Titanium411D2910Re-Cement or Re-Bond Inlay, Onlay, or PartialCoverage Restoration19D2920Re-Cement or Re-Bond Crown35D2930Prefabricated Stainless Steel Crown – Primary Tooth110D2931Prefabricated Stainless Steel Crown – PermanentTooth120Other Restorative Services11178 Huron St., Suite 3, Northglenn, Colorado 80234 303.457.9794 800.377.2924 Fax: 303.457.6956 Email: DDP@DirectDentalPlan.comRevised January 2016
GENERAL DENTIST FEE SCHEDULE Page 3 of 8ADACodeADA DescriptionD2932Prefabricated Resin Crown167D2933Prefabricated Stainless Steel Crown with ResinWindowD2940Protective Restoration45D2950Core Buildup, including any Pins when Required90D2951Pin Retention – per Tooth, in Addition to Restoration28D2952Post and Core in Addition to Crown, IndirectlyFabricated149D2953Each Additional Indirectly Fabricated Post – SameTooth117D2954Prefabricated Post and Core in Addition to Crown107D2955Post Removal142D2957Each Additional Prefabricated Post – Same Tooth88D2960Labial Veneer (Resin Laminate) – Chairside197D2961Labial Veneer (Resin Laminate) – Laboratory376D2962Labial Veneer (Porcelain Laminate) – Laboratory425D2980D2982Member ADACost CodeCrown Repair Necessitated by Restorative MaterialFailureOnlay Repair Necessitated by Restorative MaterialFailurePins for Core Build-up122D2981101D298387D2999ADA DescriptionInlay Repair Necessitated by Restorative MaterialFailureVeneer Repair Necessitated by Restorative MaterialFailureComplex Rehabilitation on Crown and BridgeProcedures (6 or more) per Unit in the sameTreatment PlanMemberCost17797104135ENDODONTIC SERVICESPulp CappingD3110Pulp Cap – Direct (excluding Final Restoration)29D3220Therapeutic Pulpotomy (excluding Final Restoration)– Removal of Pulp Coronal to the DentinocementalJunction and Application of MedicamentD3120Pulp Cap – Indirect (excluding Final Restoration)29Pulpal Debridement, Primary and Permanent Teeth85Pulpotomy72D3221Endodontic TherapyD3230D3310D3330D3332Pulpal Therapy (Resorbable Filling) – Anterior, PrimaryTooth (excluding Final Restoration)Endodontic Therapy, Anterior Tooth (excluding FinalRestoration)Endodontic Therapy, Molar (excluding rable,Unrestorable or Fractured Tooth111D3240288D3320412D3331217D3333Pulpal Therapy (Resorbable Filling) – Posterior,Primary Tooth (excluding Final Restoration)Endodontic Therapy, Bicuspid Tooth (excluding FinalRestoration)Treatment of Root Canal Obstruction; Non-SurgicalAccess357Internal Root Repair of Perforation Defects165121295Endodontic RetreatmentD3346Retreatment of Previous Root Canal Therapy –Anterior412D3348Retreatment of Previous Root Canal Therapy – Molar535D3347Retreatment of Previous Root Canal Therapy 352Apexification/Recalcification – Initial Visit (ApicalClosure / Calcific Repair of Perforations, RootResorption, etc.)Apexification / Recalcification / Pulpal Regeneration –Interim Medication n – Final Visit (includesCompleted Root Canal Therapy - Apical Closure /Calcific Repair of Perforations, Root Resorption, etc.)268Pulpal RegenerationD3355Pulpal Regeneration – Initial Visit268D3357Pulpal Regeneration – Completion of Treatment189D3356Pulpal ectomy/Periradicular lar Surgery – AnteriorApicoectomy/Periradicular Surgery – Molar (FirstRoot)Bone Graft in Conjunction with Periradicular Surgery –per Tooth, Single SiteRetrograde Filling, per icular Surgery – Bicuspid (FirstRoot)Apicoectomy/Periradicular Surgery (each AdditionalRoot)Bone Graft in Conjunction with Periradicular Surgery– each Additional Contiguous Tooth in the SameSurgical Site40315818911178 Huron St., Suite 3, Northglenn, Colorado 80234 303.457.9794 800.377.2924 Fax: 303.457.6956 Email: DDP@DirectDentalPlan.comRevised January 2016
GENERAL DENTIST FEE SCHEDULE Page 4 of 8ADACodeADA DescriptionD3431Biologic Materials to Aid in Soft and Osseous TissueRegeneration in Conjunction with PeriradicularSurgeryD3450Root Amputation, per RootMember ADACost CodeMemberCostADA Description188D3432Guided Tissue Regeneration, Resorbable Barrier, perSite, in Conjunction with Periradicular tation(includingNecessaryOther Endodontic ProceduresD3910D3950Surgical Procedure for Isolation of Tooth with RubberDamCanal Preparation and Fitting of Preformed Dowel orPost69D3920Hemisection (including any Root Removal), notincluding Root Canal Therapy245136PERIODONTIC SERVICESSurgical Services (Including Usual Postoperative Care)D4210Gingivectomy or Gingivoplasty – Four or MoreContiguous Teeth or Tooth Bounded Spaces, perQuadrant319D4211D4212Gingivectomy or Gingivoplasty to Allow Access forRestorative Procedure, per Tooth221D4240D4241D4260Gingival Flap Procedure, including Root Planing – Oneto Three Contiguous Teeth or Tooth Bounded Spaces,per QuadrantOsseous Surgery (including Elevation of Full ThicknessFlap and Closure) – Four or More Contiguous Teeth orTooth Bounded Spaces, per Quadrant302394D4249Clinical Crown Lengthening – Hard Tissue377505D4261Bone Replacement Graft – First Site in Quadrant385D4264D4265297D4266D4267Guided Tissue Regeneration – Nonresorbable Barrier,per Site (includes Membrane Removal)487533375Apically Positioned FlapBiologic Materials to Aid in Soft and Osseous TissueRegenerationAutogenous Connective Tissue Graft Procedures(including Donor and Recipient Surgical Sites) FirstTooth, Implant or Edentulous Tooth Position170D4245D4263D4273Gingivectomy or Gingivoplasty – One to ThreeContiguous Teeth or Tooth Bounded Spaces, perQuadrantGingival Flap Procedure, including Root Planing –Four or More Contiguous Teeth or Tooth BoundedSpaces, per QuadrantD4268Osseous Surgery (including Elevation of Full ThicknessFlap and Closure) – One to Three Contiguous Teeth orTooth Bounded Spaces, per QuadrantBone Replacement Graft – Each Additional Site inQuadrantGuided Tissue Regeneration – Resorbable Barrier, perSite443282392Surgical Revision Procedure, per Tooth402D4270Pedicle Soft Tissue Graft Procedure402D4283Autogenous Connective Tissue Graft Procedures(including Donor and Recipient Surgical Sites) EachAdditional Contiguous Tooth, Implant or EdentulousTooth Position in Same Graft Site375Non-Surgical Periodontal ServiceD4320Provisional Splinting – IntracoronalD4341Periodontal Scaling and Root Planing – Four or MoreTeeth, per Quadrant265D4321115D4342D4355Full Mouth Debridement to Enable ComprehensiveEvaluation and Diagnosis93D4381Provisional Splinting – ExtracoronalPeriodontal Scaling and Root Planing – One to ThreeTeeth, per QuadrantLocalized Delivery of Antimicrobial Agents via aControlled Release Vehicle into Diseased CrevicularTissue, per Tooth2508568Other Periodontal ServicesD4910Periodontal Maintenance59D4920Unscheduled Dressing Change (by Someone otherthan Treating Dentist)58D4921Gingival Irrigation – per Quadrant41D4999Perio Hygiene Instruction15PROSTHODONTIC SERVICES - REMOVABLEComplete and Partial Dentures (Including Routine Post-Delivery Care)D5110Complete Denture – Maxillary565D5120Complete Denture – Mandibular565D5130Immediate Denture – Maxillary810D5140Immediate Denture – 21Maxillary Partial Denture – Resin Base (including anyConventional Clasps, Rests and Teeth)Maxillary Partial Denture – Cast Metal Frameworkwith Resin Denture Bases (including any ConventionalClasps, Rests and Teeth)Immediate Maxillary Partial Denture – Resin Base(including any Conventional Clasps, Rests and Teeth)Mandibular Partial Denture – Resin Base (includingany Conventional Clasps, Rests and Teeth)Mandibular Partial Denture – Cast Metal Frameworkwith Resin Denture Bases (including any ConventionalClasps, Rests and Teeth)Immediate Mandibular Partial Denture – Resin Base(including any Conventional Clasps, Rests and Teeth)47563027511178 Huron St., Suite 3, Northglenn, Colorado 80234 303.457.9794 800.377.2924 Fax: 303.457.6956 Email: DDP@DirectDentalPlan.comRevised January 2016
GENERAL DENTIST FEE SCHEDULE Page 5 of 8ADACodeD5223D5225D5281ADA DescriptionImmediate Maxillary Partial Denture – Cast MetalFramework with Resin Denture Base (including anyConventional Clasps, Rests and Teeth)Maxillary Partial Denture – Flexible Base (Includingany Clasps, Rests and Teeth)Removable Unilateral Partial Denture – One PieceCast Metal (including Clasps and Teeth)Member ADACost Code350D5224755D5226ADA DescriptionImmediate Mandibular Partial Denture – Cast MetalFramework with Resin Denture Base (including anyConventional Clasps, Rests and Teeth)Mandibular Partial Denture – Flexible Base (includingany Clasps, Rests and Teeth)MemberCost350755355Adjustments to DenturesD5410Adjust Complete Denture – Maxillary37D5411Adjust Complete Denture – Mandibular37D5421Adjust Partial Denture – Maxillary37D5422Adjust Partial Denture – Mandibular37Repairs to Complete and Partial DenturesD5510Repair Broken Complete Denture Base79D5520Replace Missing or Broken Teeth – Complete Denture(each Tooth)71D5610Repair Resin Denture Base82D5620Repair Cast Framework138D5630Repair or Replace Broken Clasp, per Tooth95D5640Replace Broken Teeth, per Tooth68D5650Add Tooth to Existing Partial Denture90D5660Add Clasp to Existing Partial Denture, per Tooth111Denture Rebase and Reline ProceduresD5710Rebase Complete Maxillary Denture265D5711Rebase Complete Mandibular Denture265D5720Rebase Maxillary Partial Denture238D5721Rebase Mandibular Partial Denture238D5730Reline Complete Maxillary Denture (Chairside)162D5731Reline Complete Mandibular Denture (Chairside)162D5740Reline Maxillary Partial Denture (Chairside)154D5741Reline Mandibular Partial Denture (Chairside)154D5750Reline Complete Maxillary Denture (Laboratory)157D5751Reline Complete Mandibular Denture (Laboratory)157D5760Reline Maxillary Partial Denture (Laboratory)155D5761Reline Mandibular Partial Denture (Laboratory)155Interim ProsthesisD5810Interim Complete Denture (Maxillary)377D5811Interim Complete Denture (Mandibular)380D5820Interim Partial Denture (Maxillary)290D5821Interim Partial Denture (Mandibular)290D5850Tissue Conditioning, MaxillaryOther Removable Prosthetic Services75D5851Tissue Conditioning, Mandibular75IMPLANT SERVICESSurgical ServicesD6010Surgical Placement of Implant Body: EndostealImplant1,175D6012Surgical Placement of Interim Implant Body forTransitional Prosthesis: Endosteal Implant1,241D6101D6103Debridement of a Peri-Implant Defect or DefectsSurrounding a Single Implant, and Surface Cleaning ofthe Exposed Implant Surfaces, including Flap Entryand ClosureBone Graft for Repair of Peri-implant Defect – doesnot include Flap Entry and ClosureD6011Second Stage Implant SurgeryD6013Surgical Placement of Mini Implant4731,483D6100Implant Removal, by Report552387D6102Debridement and Osseous Contouring of a Periimplant Defect or Defects Surrounding a SingleImplant and includes Surface Cleaning of the ExposedImplant Surfaces, including Flap Entry and Closure538479D6104Bone Graft at Time of Implant Placement511Implant Supported Prosthetics: Supporting StructuresD6055Connecting Bar – Implant Supported or AbutmentSupported2,111D6056Prefabricated Abutment – includes Modification andPlacement599D6057Custom Fabricated Abutment – includes Placement609D6051Interim Abutment437D6052Semi-Precision Attachment Abutment537Implant Supported Prosthetics: Implant/Abutment Supported Removable DenturesD6110D6112Implant/Abutment Supported Removable Denture forEdentulous Arch – MaxillaryImplant/Abutment Supported Removable Denture forPartially Edentulous Arch – Maxillary2,603D61111,911D6113Implant/Abutment Supported Removable Denturefor Edentulous Arch – MandibularImplant/Abutment Supported Removable Denturefor Partially Edentulous Arch – Mandibular2,3491,96611178 Huron St., Suite 3, Northglenn, Colorado 80234 303.457.9794 800.377.2924 Fax: 303.457.6956 Email: DDP@DirectDentalPlan.comRevised January 2016
GENERAL DENTIST FEE SCHEDULE Page 6 of 8ADACodeD6114D6116Member ADAADA DescriptionCost CodeImplant Supported Prosthetics: Implant/Abutment Supported Fixes Dentures (Hybrid Prosthesis)ADA DescriptionImplant/Abutment Supported Fixed Denture forEdentulous Arch – MaxillaryImplant/Abutment Supported Fixed Denture forPartially Edentulous Arch – Maxillary3,561D61152,722D6117Implant/Abutment Supported Fixed Denture forEdentulous Arch – MandibularImplant/Abutment Supported Fixed Denture forPartially Edentulous Arch – MandibularMemberCost3,7032,608Implant Supported Prosthetics: Single Crowns, Abutment SupportedD6058D6060D6062D6064Abutment Supported Porcelain/Ceramic CrownAbutment Supported Porcelain Fused to Metal Crown(Predominantly Base Metal)Abutment Supported Cast Metal Crown (High NobleMetal)Abutment Supported Cast Metal Crown (Noble Metal)1,033D6059999D6061997D6063932D6094Abutment Supported Porcelain Fused to Metal Crown(High Noble Metal)Abutment Supported Porcelain Fused to Metal Crown(Noble y Base Metal)Abutment Supported Crown (Titanium)9781,029962899Implant Supported Prosthetics: Single Crowns, Implant Supp
DIRECT DENTAL PLANS OF AMERICA, INC. GENERAL DENTIST FEE SCHEDULE Page 1 of 8 11178 Huron St., Suite 3, Northglenn, Colorado 80234 303.457.9794 800.377.2924 Fax: 303.457.6956 Email: DDP@DirectDentalPlan.com Revised January
