| ADA
Code |
Description |
LOW
OPTION
Co-payments** apply to CapDent
Primary Care General Dentists* |
MEDIUM
OPTION
Co-payments** apply to CapDent
Primary Care General Dentists* |
HIGH
OPTION
Co-payments** apply to CapDent
Primary Care General Dentists and non-CapDent Specialists' |
| 2740 |
Porcelain
Crown |
$385 |
$270 |
$150 |
| 2751 |
Porcelain/metal
crown |
425 |
270 |
150 |
| 2791 |
Full cast
crown |
295 |
150 |
150 |
| 2962 |
Porcelain
laminates |
295 |
270 |
150 |
| 2930 |
Stainless
steel crown |
95 |
50 |
0 |
| 2952/2954 |
Cast and
prefab post |
95 |
50 |
0 |
| 2920/6930 |
Replacement
crown/bridge |
35 |
0 |
0 |
| 3110/3120 |
Direct/indirect
pulp cap |
10 |
0 |
0 |
| 3220 |
Pulpotomy |
35 |
0 |
0 |
| 3310 |
Root canal
one |
225 |
125 |
0 |
| 3320 |
Root canal
two |
290 |
190 |
0 |
| 3330 |
Root canal
three/four |
395 |
335 |
150 |
| 3410 |
Apicoectomy
inc. retrograde |
175 |
125 |
0 |
| 4220 |
Gingival
curettage |
50 Q |
60 Q |
0 |
| 4210 |
Gingivectomy |
125 Q |
95 Q |
0 |
| 4240/4260 |
Perio
surgery muco/osseous |
395 Q/425 Q |
350 Q/350 Q |
150 |
| 4341 |
Scaling/root
planing |
25 Q |
45 FM |
0 |
| 5110/5120 |
Full
dentures |
395 |
295 |
150 |
| 5213/5214 |
Partial
dentures, chrome |
395 |
295 |
150 |
| 5510 |
Denture
repairs incl. addin. |
teeth 35-95 |
25-75 |
0 |
| 5740 |
Office
reline |
95 |
50 |
0 |
| 5750 |
Lab reline |
150 |
95 |
0 |
| 6241 |
Porcelain/metal
contic |
425 |
270 |
150 |
| 6251 |
Acrylic/metal
pontic |
295 |
150 |
150 |
| 6721 |
Acrylic/metal
abutment |
295 |
150 |
150 |
| 6751 |
Porcelain/metal
abutment |
425 |
270 |
150 |
| 6791 |
Full cast
abutment |
295 |
150 |
150 |
| 6545 |
Resin
retainer |
Not covered |
220 |
0 |
| 7110 |
Simple
extraction |
45 |
25 |
0 |
| 7210 |
Surgical
extraction |
75 |
50 |
0 |
| 7220 |
Soft tissue
impaction |
95 |
50 |
0 |
| 7230/7240 |
Partial/full
bony impaction |
125/160 |
75/100 |
0 |
| 7310 |
Alveolectomy |
95 Q |
50 Q |
0 |
| 9110 |
Palliative
treatment |
0 |
0 |
0 |
| 9951/9952 |
Occlusal
adjustment complete/limit |
lete/limit
0 |
0 |
0 |
*CapDent Specialists will charge their
usual fees, less a discount of 25 percent.
**Not a comprehensive list of services and co-payments.
The High Option Plan requires $150 per service co-pay per procedure for
all crowns (other than stainless steel), all units of bridgework,
dentures, molar root canals and periodontal surgery. Not all services
which require this co-pay are listed above.
|
