| Dental
Care Savings Example* |
Dental
Code |
Benefit |
Retail
Cost
|
CARExpress
|
0120 |
Periodic oral exam |
$43
|
$25
|
0150 |
Comprehensive oral evaluation |
$59
|
$31
|
0210 |
Intraoral-complete series (including bitewings) |
$122
|
$68
|
0272 |
Bitewings, 2 Films |
$39
|
$21
|
0274 |
Bitewings-4 films |
$54
|
$30
|
0330 |
X-Ray Panoramic film |
$112
|
$59
|
1110 |
Prophylaxis-adult |
$90
|
$50
|
1120 |
Prophylaxis-child |
$54
|
$32
|
1351 |
Sealant-per tooth |
$49
|
$28
|
2140 |
Amalgam-one surface, permanent |
$99
|
$58
|
2150 |
Amalgam-two surfaces, permanent |
$128
|
$75
|
2160 |
Amalgam-three surfaces, permanent |
$166
|
$92
|
2330 |
Resin-based composite-one surface, anterior |
$132
|
$73
|
2331 |
Resin-based composite-two surface, anterior |
$164
|
$97
|
7240 |
Removal of Impacted Tooth-Completely Bony |
$409
|
$241
|
2750 |
Crown-porcelain fused to high noble metal |
$1,110
|
$653
|
9110 |
Palliative of Dental Pain |
$74
|
$44
|
3330 |
Root canal therapy, molar (excluding final rest.) |
$1,031
|
$607
|
1204 |
Fluoride Application Adults (No-Prophylaxis ) |
$35
|
$21
|
4341 |
Periodontal scaling and root planing, per quadrant |
$225
|
$132
|
4910 |
Periodontal maintenance procedures |
$108
|
$61
|
5110 |
Complete denture-maxillary |
$1,398
|
$807
|
0140 |
Limited Oral Evaluation-Problem Focused |
$50
|
$29
|
7210 |
Surgical removal of erupted tooth |
$234
|
$130
|
8080 |
Orthodontic treatment, adolescent |
$5,589
|
$3,288
|
| * Dental
fee schedules vary depending upon the region of the country |
|
|
