Content copyright 2021. Spokane Dental Providers. All rights reserved.
|
Diagnostic and Preventive ServicesDescription of Services * |
Code |
UCR Fees |
DSP Patient |
DSP Savings
|
DS Direct Care Savings |
DS Direct Care Patient Portion |
|
Periodic Oral Evaluation |
D0120 |
$61 |
$44 |
25% |
100% |
$0 2/yr |
|
Limited Oral Evaluation |
D0140 |
$100 |
$66 |
34% |
50% |
$50 |
|
Comprehensive Oral Evaluation |
D0150 |
$93 |
$80 |
14% |
100% |
$0 1 /3yr |
|
Prophylaxis- Adult |
D1110 |
$125 |
$83 |
34% |
100% |
$0 2 /yr |
|
Periodontal Maintenance |
D4910 |
$184 |
$121 |
34% |
100% |
$0 2 /yr |
|
Periodontal Maintenance 3+/yr |
D4910 |
$184 |
$121 |
34% |
80% |
$37 2 /yr |
|
Panoramic X-ray |
D0330 |
$115 |
$68 |
41% |
100% |
$0 1 / 3yr |
|
Bitewings-four films |
D0274 |
$68 |
$53 |
22% |
100% |
$0 2/ yr |
|
Intraoral-periapical-1st film |
D0220 |
$32 |
$22 |
31% |
50% |
$16 |
|
Fluoride- Adult |
D1208 |
$46 |
$12 |
74% |
100% |
$0 |
|
New Patient: Comp Exam, x-rays, cleaning, fluoride |
|
$447 |
$277 |
38% |
100% |
$0 1/ 3yr |
|
Bi-annual Periodic exam, x-rays, cleaning, fluoride |
|
$300 |
$207 |
31% |
100% |
$0 2 /yr |
Dental Savings Plan (DSP)
*No frequency limitations for the Dental Saving Plan- 2 mandatory cleanings, exams and x-rays per year to qualify for discounted fees
** 6 month waiting period for Restorative and Major Services at saving rate
*** A 1 year enrollment commitment
Dental Savings Direct Care (DS-Direct Care)
Yearly Maximum $1000/year, $0 deductible @ $39 per month
Yearly Maximum $1500/year, $0 deductible @ $59 per month
*Frequency limitations for Dental Savings Direct Care- 2 exams per year, limited or periodic, 2 cleanings/yr, prophy or periodontal maintenance, 2 sets of bw’s/yr, panorex/3yrs, comprehensive exam/3yrs
** 6 month waiting period for Restorative and Major Services at reduced rates
***A 1 year enrollment commitment
-Percentage savings are rounded up
|
Restorative and Major |
Code |
UCR |
DSP |
DSP
|
DS Direct Care Savings |
DS Direct Care Patient Portion |
|
Resin-Composite Filling- 1 Surface, Anterior |
D2330 |
$179 |
$125 |
30% |
50% |
$89 |
|
Resin-Composite Filling- 2 Surfaces, Anterior |
D2331 |
$223 |
$158 |
29% |
50% |
$111 |
|
Resin-Composite Filling- 3 Surfaces, Anterior |
D2332 |
$274 |
$219 |
20% |
50% |
$137 |
|
Resin-Composite Filling- 4+ w/incisal, Anterior |
D2335 |
$320 |
$218 |
32% |
50% |
$160 |
|
Resin-Composite Filling- 1 Surface, Posterior |
D2391 |
$206 |
$154 |
25% |
50% |
$103 |
|
Resin-Composite Filling- 2 Surfaces, Posterior |
D2392 |
$264 |
$206 |
22% |
50% |
$132 |
|
Resin-Composite Filling- 3Surfaces, Posterior |
D2393 |
$314 |
$214 |
32% |
50% |
$157 |
|
Resin-Composite Filling- 4+ Surfaces, Posterior |
D2394 |
$479 |
$335 |
30% |
50% |
$240 |
|
Inlay-Porcelain/Ceramic-1 Surface |
D2610 |
$1164 |
$838 |
28% |
50% |
$582 |
|
Inlay-Porcelain/Ceramic-2 Surfaces |
D2620 |
$1229 |
$922 |
25% |
50% |
$615 |
|
Inlay-Porcelain/Ceramic-3+Surfaces |
D2630 |
$1309 |
$982 |
25% |
50% |
$655 |
|
Onlay-Porcelain/Ceramic-2 Surfaces |
D2642 |
$1272 |
$1081 |
15% |
50% |
$636 |
|
Onlay-Porcelain/Ceramic-3 Surfaces |
D2643 |
$1089 |
$926 |
15% |
50% |
$545 |
|
Crown-Porcelain/Ceramic |
D2740 |
$1242 |
$956 |
23% |
50% |
$621 |
|
Re-cement Crown |
D2920 |
$115 |
$75 |
35% |
50% |
$58 |
|
Pre-Fab Post and Core in Addition to Crown |
D2954 |
$398 |
$219 |
45% |
50% |
$199 |
|
Cast Post and Core in Addition to Crown |
D2952 |
$636 |
$382 |
40% |
50% |
$318 |
|
Crown Buildup, including any pins |
D2950 |
$286 |
$154 |
46% |
50% |
$143 |
|
Pin retention-/tooth (+rest) |
D2951 |
$51 |
$35 |
32% |
50% |
$26 |
|
Provisional Crown |
D2799 |
$664 |
$378 |
43% |
50% |
$332 |
|
Bridge Retainer PFM(per end unit) |
D6059 |
$1564 |
$1095 |
30% |
50% |
$782 |
|
Bridge Pontic PFM (per unit) |
D6240 |
$1185 |
$889 |
25% |
50% |
$593 |
|
Extraction-Surgical/erupt tooth |
D7210 |
$320 |
$234 |
27% |
50% |
$160 |
|
Extraction of 3rd molars (wisdom) |
Referral |
|
Referral |
|
Referral |
|
|
Extraction-Simple |
D7140 |
$174 |
$148 |
15% |
50% |
$87 |
|
Alveoloplasty w/ extract-quad |
D7310 |
$357 |
$179 |
50% |
50% |
$179 |
|
Pulpal Debridement-perm |
D3221 |
$225 |
$133 |
41% |
50% |
$113 |
|
Root canal therapy-anterior |
D3310 |
$845 |
$651 |
23% |
50% |
$423 |
|
Root canal therapy-bicuspid |
D3320 |
$965 |
$820 |
15% |
50% |
$483 |
|
Root canal therapy- molar |
D3330 |
$1272 |
$1068 |
16% |
50% |
$636 |
|
Root canal re-treat-anterior |
D3346 |
$1053 |
$821 |
22% |
50% |
$527 |
|
Root canal re-treat- molar |
Referral |
|
Referral |
|
Referral |
|
|
Gingivectomy- 1-3 teeth for fills |
D4211 |
$365 |
$183 |
50% |
50% |
$183 |
|
Gingivectomy- 4+ teeth |
D4210 |
$894 |
$581 |
35% |
50% |
$447 |
|
Clinical Crown lengthening |
D4249 |
$1031 |
$804 |
22% |
50% |
$516 |
|
Osseous Surgery- 4+ per quad |
D4260 |
$1504 |
$1068 |
29% |
50% |
$752 |
|
Distal/proximal wedge procedure |
D4274 |
$732 |
$534 |
27% |
50% |
$366 |
|
Perio scale&root pln-4+per quad |
D4341 |
$294 |
$215 |
27% |
50% |
$147 |
|
Periodontal Maintenance |
D4910 |
$184 |
$134 |
27% |
50% |
$92 |
|
Complete Maxillary Denture |
D5110 |
$1753 |
$1402 |
20% |
50% |
$877 |
|
Complete Mandibular Denture |
D5120 |
$1659 |
$1377 |
17% |
50% |
$830 |
|
Maxillary Partial-metal base |
D5213 |
$1821 |
$1439 |
21% |
50% |
$911 |
|
Mandibular Partial- metal base |
D5214 |
$1821 |
$1439 |
21% |
50% |
$911 |
|
Replace teeth-comp denture (ea th) |
D5520 |
$182 |
$138 |
24% |
50% |
$91 |
|
Reline Maxillary Denture |
D5750 |
$504 |
$423 |
16% |
50% |
$252 |
|
Interm Maxillary Denture |
D5810 |
$819 |
$581 |
29% |
50% |
$410 |
|
Surgical Placement Implant:endosteal |
D6010 |
$2938 |
$2350 |
20% |
50% |
$1469 |
|
Pre-fab Implant abutment |
D6056 |
$817 |
$515 |
37% |
50% |
$409 |
|
Implant Crown |
D6058 |
$1585 |
$1268 |
20% |
50% |
$793 |
|
Precision attachment |
D5862 |
$854 |
$615 |
28% |
50% |
$427 |