Dental Payment Schedule
Please find the most frequently used procedures listed below.
| Out of | In | |||||
| DIAGNOSTIC | Network | Network | ||||
| Clinical Oral Examinations | ||||||
| 00120 | Periodic Oral Examination | $25.00 |
$15.00 | |||
| 00140 | Limited Oral Examination | $30.00 | $18.00 | |||
| 00150 | Comprehensive Oral Evaluation | $30.00 | $16.00 | |||
| Radiographs | ||||||
| 00210 | Intraoral – Complete Series (including bitewings) | $50.00 | $30.00 | |||
| 00220 | Intraoral – Periapical – first film | $15.00 | $9.00 | |||
| 00230 | Intraoral – Periapical – each additional film | $10.00 | $6.00 | |||
| 00272 | Bitewings – two films | $20.00 | $12.00 | |||
| 00274 | Bitewings – four films | $30.00 | $18.00 | |||
| 00330 | Panoramic film | $45.00 | $27.00 | |||
| 00340 | Cephalometric film | $33.00 | $19.80 | |||
| PREVENTIVE | ||||||
| Dental Prophylaxis | ||||||
| 01110 | Prophylaxis – adult | $40.00 | $24.00 | |||
| 01120 | Prophylaxis – child 12 years or younger | $30.00 | $18.00 | |||
| Fluoride Treatments | ||||||
| 01208 | Topical application of fluoride (prophy not included) |
$21.00 | $12.60 | |||
| 01351 | Sealant per tooth | $25.00 | $15.00 | |||
| RESTORATIVE | ||||||
| Amalgam Restorations (including polishing) | ||||||
| 02140 | Amalgam – one surface, permanent | $50.00 | $30.00 | |||
| 02150 | Amalgam – two surface, permanent | $55.00 | $33.00 | |||
| 02160 | Amalgam – three surface, permanent | $60.00 | $36.00 | |||
| 02161 | Amalgam – four or more surfaces, permanent | $70.00 | $42.00 | |||
| Resin Restorations | ||||||
| 02330 | Resin – one surface, anterior | $55.00 | $33.00 | |||
| 02331 | Resin – two surface, anterior | $60.00 | $36.00 | |||
| 02332 | Resin – three surface, anterior | $70.00 | $42.00 | |||
| 02335 | Resin – four or more surfaces or involving inscisal angle, ant. | $100.00 | $60.00 | |||
| 02391 | Resin based composite - one surface | $70.00 | $42.00 | |||
| 02392 | Resin based composite - two surfaces, posterior |
$85.00 | $51.00 | |||
| 02393 | Resin based composite - three surfaces | $95.00 | $57.00 | |||
| 02394 | Resin based composite - four or more surfaces | $100.00 | $60.00 | |||
| Inlay/Onlay Restorations | ||||||
| 02644 | onlay – porcelain/ceramic – four or more surfaces | $350.00 | $210.00 | |||
| Crowns – Single Restorations Only | ||||||
| 02740 | crown – porcelain/ceramic substrate | $400.00 | $240.00 | |||
| 02750 | crown – porcelain fused to high noble metal | $390.00 | $234.00 | |||
| 02751 | crown – porcelain fused to predominantly base metal | $360.00 | $216.00 | |||
| 02752 | crown – porcelain fused to noble metal | $360.00 | $216.00 | |||
| 02790 | crown – fused to cast high noble metal | $390.00 | $234.00 | |||
| Other Restorative Services | ||||||
| 02920 | recement crown | $40.00 | $24.00 | |||
| 02930 | prefabricated stainless steel crown – primary tooth | $90.00 | $54.00 | |||
| 02940 | sedative filling (to relieve pain) | $40.00 | $24.00 | |||
| 02950 | core buildup, including any pins | $100.00 | $60.00 | |||
| 02951 | pin retention – per tooth, in addition to restoration | $20.00 | $12.00 | |||
| 02952 | cast post & core in addition to crown | $140.00 | $84.00 | |||
| 02954 | prefabricated post & core in addition to crown | $150.00 | $90.00 | |||
| 02962 | labial veneer (porcelain laminate) – laboratory | $300.00 | $180.00 | |||
| ENDODONTICS | ||||||
| Pulp Capping & Therapy Procedures | ||||||
| 03110 | pulp cap – direct (excluding final restoration) | $25.00 | $15.00 | |||
| 03120 | pulp cap – indirect (excluding final restoration) | $22.00 | $13.00 | |||
| 03220 | therapeutic pulpotomy (excluding final restoration) | $85.00 | $51.00 | |||
| 03310 | anterior endodontic therapy (excluding final restoration) | $295.00 | $177.00 | |||
| 03320 | bicuspid endodontic therapy (excluding final restoration) | $325.00 | $195.00 | |||
| 03330 | molar endodontic therapy (excluding final restoration) | $390.00 | $234.00 | |||
| PERIODONTICS - (Based on Years of Service) |
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| Surgical Services | ||||||
| 04211 | gingivectomy or gingivoplasty – per tooth | $100.00 | $60.00 | |||
| 04249 | clinical crown lengthening – hard tissue | $150.00 | $90.00 | |||
| 04260 | osseous surgery (including flap entry/closure) per quad | $400.00 | $240.00 | |||
| 04263 | bone replacement graft – first site quadrant | $225.00 | $135.00 | |||
| Adjunctive Periodontal Services | ||||||
| 04341 | periodontal scaling and root planing – per quadrant | $95.00 | $57.00 | |||
| 04355 | full mouth debridement to enable evaluation & diagnosis | $75.00 | $45.00 | |||
| 04381 | localized delivery of chemotherapeutic agents | $60.00 | $36.00 | |||
| Other Periodontal Services | ||||||
| 04910 | periodontal maintenance (active therapy) | $120.00 | $72.00 | |||
| PROSTHODONTICS (REMOVABLE) | ||||||
| Complete Dentures (including Routine Post – Delivery Care) | ||||||
| 05110-20 | complete denture - maxillary or mandibular | $400.00 | $240.00 | |||
| 05130-40 | immediate denture – maxillary or mandibular | $375.00 | $225.00 | |||
| Partial Dentures (including Routine Post – Delivery Care) | ||||||
| 05213 | maxillary partial denture – cast metal frame | $325.00 | $195.00 | |||
| 05214 | mandibular partial denture – cast metal framework | $325.00 | $195.00 | |||
| Repairs to Partial Dentures | ||||||
| 05640 | replace broken teeth – per tooth | $40.00 | $24.00 | |||
| 05650 | add tooth to existing partial denture | $80.00 | $48.00 | |||
| PROSTHODONTICS (FIXED PARTIAL DENTURE) | ||||||
| Fixed Partial Denture | ||||||
| 06240 | pontic – porcelain fused to high noble metal | $400.00 | $240.00 | |||
| Fixed Partial Denture Retainers – Crowns | ||||||
| 06750 | crown – porcelain fused to high noble metal | $400.00 | $240.00 | |||
| 06751 | crown – porcelain fused to predominantly base metal | $400.00 | $204.00 | |||
| 06752 | crown – porcelain fused to noble metal | $400.00 | $240.00 | |||
| 06930 | recement fixed partial denture | $75.00 | $45.00 | |||
| ORAL & MAXILLOFACIAL SURGERY | ||||||
| Extractions (including Local Anesthesia, Suturing & Routine Care) | ||||||
| 07140 | extraction – erupted tooth or exposed root | $75.00 | $45.00 | |||
| 07210 | surgical removal of erupted tooth | $100.00 | $60.00 | |||
| 07220 | removal or impacted tooth – soft tissue | $105.00 | $63.00 | |||
| 07230 | removal of impacted tooth – partial bony | $125.00 | $75.00 | |||
| 07240 | removal of impacted tooth – completely bony | $150.00 | $90.00 | |||
| 07250 | surgical removal of residual tooth roots (cutting procedure) | $120.00 | $72.00 | |||
| 07310 | alveoplasty in conjunction with extractions – per quad. | $100.00 | $60.00 | |||
| 07510 | incision and drainage of abscess – intraoral soft tissue | $40.00 | $60.00 | |||
| ORTHODONTICS | ||||||
|
THE SBF ALLOWS THE MAXIMUM LIFETIME BENEFIT OF $1,100.00 PER PERSON FOR AN
ORTHODONTIC APPLIANCE OR PROCEDURE AS PER THE SBF SCHEDULE. CALL THE SBF AT
(716) 881-5462 FOR DETAILS.
|
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| ADJUSTED GENERAL SERVICES | ||||||
| Unclassified Treatment | ||||||
| 09110 | palliative (emergency) treatment of dental pain minor procedure | $40.00 | $24.00 | |||
| Anesthesia | ||||||
| 09230 | analgesia (including nitrous oxide) | $40.00 | $24.00 | |||
| Professional Consultation | ||||||
| 09310 | consultation – (diagnostic service provided by dentist) | $50.00 | $21.00 | |||
| Professional Visits | ||||||
| 09440 | office visits – after regular hours | $10.00 | $6.00 | |||
| Miscellaneous Services | ||||||
| 09910 | application of desensitizing medicament | $15.00 | $9.00 | |||
| 09951 | occlusal adjustment – limited | $50.00 | $30.00 | |||
| 09970 | enamel micro abrasion | $10.00 | $6.00 | |||