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
02970 temporary crown (fractured tooth) $75.00    
   
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)
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
05610 repair resin denture base $50.00    
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)
07110 single tooth extraction $75.00    
07120 each additional tooth extracted $45.00    
07130 root removal – exposed roots $40.00    
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.
   
ADJUSTED GENERAL SERVICES
Unclassified Treatment
09110 palliative (emergency) treatment of dental pain minor procedure $40.00   $24.00
   
Anesthesia
09220 general anesthesia – first 30 minutes $75.00    
09230 analgesia (including nitrous oxide) $40.00   $24.00
09241 intravenous sedation $125.00    
   
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
09940 occlusal guard/ bruxism appliance $150.00    
09951 occlusal adjustment – limited $50.00   $30.00
09970 enamel micro abrasion $10.00   $6.00