Dental Payment Schedule

Dental Payment Schedule


Below please find the most frequently used procedures covered under the BTF-SBF Dental Plan. To receive a copy of the payment schedule in its entirety, please contact the Supplemental Benefit Fund office at (716) 881-5462.

 

DIAGNOSTIC   
  Clinical Oral Examinations
                  00120 Periodic Oral Examination                       $ 20.00
    00150 Comprehensive Oral Evaluation                            $ 20.00
           
  Radiographs
    00210 Intraoral – Complete Series (including bitewings)   $ 40.00
    00220 Intraoral – Periapical – first film   $ 8.00
    00230 Intraoral – Periapical – each additional film   $ 6.00
    00272 Bitewings – two films   $ 17.00
    00274 Bitewings – four films   $ 25.00
    00330 Panoramic film   $ 35.00
    00340 Cephalometric film   $ 30.00
           
PREVENTIVE
  Dental Prophylaxis
    01110 Prophylaxis – adult   $ 30.00
    01120 Prophylaxis – child 12 years or younger   $ 25.00
           
  Fluoride Treatments
    01203 Topical application of fluoride (prophy not included) – child   $ 15.00
    01204 Topical application of fluoride (prophy not included) – adult   $ 18.00
    01351 Sealant per tooth   $ 18.00
           
RESTORATIVE
Amalgam Restorations (including polishing)
    02140 Amalgam – one surface, permanent $ 40.00
    02150 Amalgam – two surface, permanent $ 45.00
    02160 Amalgam – three surface, permanent $ 50.00
    02161 Amalgam – four or more surfaces, permanent   $ 60.00
           
  Resin Restorations
    02330 resin – one surface, anterior   $ 45.00
    02331 resin – two surface, anterior   $ 50.00
    02332 resin – three surface, anterior   $ 60.00
    02335 resin - four or more surfaces or involving inscisal angle, ant.   $ 75.00
           
  Inlay/Onlay Restorations
    02644 onlay – porcelain/ceramic – four or more surfaces   $300.00
           
  Crowns – Single Restorations Only
    02740 crown – porcelain/ceramic substrate   $340.00
    02750 crown – porcelain fused to high noble metal   $340.00
    02751 crown – porcelain fused to predominantly base metal   $325.00
    02752 crown – porcelain fused to noble metal   $325.00
    02790 crown – fused to cast high noble metal   $340.00
           
  Other Restorative Services
    02920 recement crown   $ 25.00
    02930 prefabricated stainless steel crown – primary tooth   $ 50.00
    02940 sedative filling (to relieve pain)   $ 30.00
    02950 core buildup, including any pins   $ 85.00
    02951 pin retention – per tooth, in addition to restoration   $ 13.00
    02952 cast post & core in addition to crown   $100.00
    02954 prefabricated post & core in addition to crown   $100.00
    02962 labial veneer (porcelain laminate) – laboratory   $260.00
    02970 temporary crown (fractured tooth)   $ 75.00
           
ENDODONTICS
  Pulp Capping & Therapy Procedures
    03110 pulp cap – direct (excluding final restoration)   $ 20.00
    03120 pulp cap – indirect (excluding final restoration)   $ 15.00
    03220 therapeutic pulpotomy (excluding final restoration)   $ 40.00
    03310 anterior endodontic therapy (excluding final restoration)   $ 240.00
    03320 bicuspid endodontic therapy (excluding final restoration)   $ 275.00
    03330 molar endodontic therapy (excluding final restoration)   $ 350.00
           
PERIODONTICS 
  Surgical Services
    04211 gingivectomy or gingivoplasty – per tooth   $ 50.00
    04249 clinical crown lengthening – hard tissue   $150.00
    04260 osseous surgery (including flap entry/closure) per quad   $400.00
    04263 bone replacement graft – first site quadrant   $225.00
           
  Adjunctive Periodontal Services
    04341 periodontal scaling and root planing – per quadrant   $ 50.00
    04355 full mouth debridement to enable evaluation & diagnosis   $ 40.00
    04381 localized delivery of chemotherapeutic agents   $ 60.00
           
  Other Periodontal Services
    04910 periodontal maintenance (active therapy)   $120.00
           
PROSTHODONTICS (REMOVABLE)
  Complete Dentures (including Routine Post – Delivery Care)
    05110-20 complete denture - maxillary or mandibular   $350.00
    05130-40 immediate denture – maxillary or mandibular   $375.00
           
  Partial Dentures (including Routine Post – Delivery Care)
    05213 maxillary partial denture – cast metal frame   $275.00
    05214 mandibular partial denture – cast metal framework   $275.00
           
  Repairs to Partial Dentures
    05610 repair resin denture base   $ 40.00
    05640 replace broken teeth – per tooth   $ 40.00
    05650 add tooth to existing partial denture   $ 55.00
           
PROSTHODONTICS (FIXED PARTIAL DENTURE)
  Fixed Partial Denture
    06240 pontic – porcelain fused to high noble metal   $250.00
           
  Fixed Partial Denture Retainers – Crowns
    06750 crown – porcelain fused to high noble metal   $340.00
    06751 crown – porcelain fused to predominantly base metal   $340.00
    06752 crown – porcelain fused to noble metal   $340.00
    06790 crown – full cast high noble metal   $325.00
    06930 recement fixed partial denture   $ 40.00
           
ORAL & MAXILLOFACIAL SURGERY
  Extractions (including Local Anesthesia, Suturing & Routine Care)
    07110 single tooth extraction   $ 45.00
    07120 each additional tooth extracted   $ 45.00
    07130 root removal – exposed roots   $ 40.00
    07210 surgical removal of erupted tooth   $ 70.00
    07220 removal or impacted tooth – soft tissue   $ 75.00
    07230 removal of impacted tooth – partial bony   $ 100.00
    07240 removal of impacted tooth – completely bony   $ 110.00
    07250 surgical removal of residual tooth roots (cutting procedure)   $ 80.00
    07310 alveoplasty in conjunction with extractions – per quad.   $ 80.00
    07510 incision and drainage of abscess – intraoral soft tissue   $ 40.00
           
ORTHODONTICS
THE SBF ALLOWS THE MAXIMUM LIFETIME BENEFIT OF $850.00 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   $ 30.00
           
  Anesthesia
    09220 general anesthesia – first 30 minutes   $ 75.00
    09230 analgesia (including nitrous oxide)   $ 35.00
    09241 intravenous sedation   $ 100.00
           
  Professional Consultation
    09310 consultation – (diagnostic service provided by dentist)   $ 25.00
           
  Professional Visits
    09440 office visits – after regular hours   $ 10.00
           
  Miscellaneous Services
    09910 application of desensitizing medicament   $ 15.00
    09940 occlusal guard/ bruxism appliance   $ 120.00
    09951 occlusal adjustment – limited   $ 50.00
    09970 enamel micro abrasion   $ 10.00

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