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 $40.00     
        $24.00
00140 Limited Oral Examination $48.00   $29.00
00150 Comprehensive Oral Evaluation                            $48.00   $29.00
   
Radiographs
00210 Intraoral – Complete Series (including bitewings) $80.00   $48.00
00220 Intraoral – Periapical – first film $24.00   $15.00
00230 Intraoral – Periapical – each additional film $16.00   $10.00
00272 Bitewings – two films $32.00   $20.00
00274 Bitewings – four films $48.00   $29.00
00330 Panoramic film $72.00   $44.00
00340 Cephalometric film $53.00   $32.00
   
PREVENTIVE
Dental Prophylaxis
01110 Prophylaxis – adult $64.00   $39.00
01120 Prophylaxis – child 12 years or younger $48.00   $29.00
   
Fluoride Treatments
01208 Topical application of fluoride (prophy not included)
$34.00   $21.00
01351 Sealant per tooth $40.00   $24.00
   
RESTORATIVE
Amalgam Restorations (including polishing)
02140 Amalgam – one surface, permanent $80.00   $48.00
02150 Amalgam – two surface, permanent $88.00   $53.00
02160 Amalgam – three surface, permanent $96.00   $58.00
02161 Amalgam – four or more surfaces, permanent $112.00   $68.00
   
Resin Restorations
02330 Resin – one surface, anterior $88.00   $53.00
02331 Resin – two surface, anterior $96.00   $58.00
02332 Resin – three surface, anterior $112.00   $68.00
02335 Resin – four or more surfaces or involving inscisal angle, ant. $160.00   $96.00
02391 Resin based composite - one surface $112.00   $68.00
02392 Resin based composite - two surfaces, posterior
$136.00   $82.00
02393 Resin based composite - three surfaces $156.00   $92.00
02394 Resin based composite - four or more surfaces $160.00   $96.00
   
Inlay/Onlay Restorations
02644 onlay – porcelain/ceramic – four or more surfaces $560.00   $336.00
   
Crowns – Single Restorations Only
02740 crown – porcelain/ceramic substrate $640.00   $384.00
02750 crown – porcelain fused to high noble metal $624.00   $375.00
02751 crown – porcelain fused to predominantly base metal $576.00   $346.00
02752 crown – porcelain fused to noble metal $576.00   $346.00
02790 crown – fused to cast high noble metal $624.00   $375.00
   
Other Restorative Services
02920 recement crown $64.00   $39.00
02930 prefabricated stainless steel crown – primary tooth $144.00   $87.00
02940 sedative filling (to relieve pain) $64.00   $39.00
02950 core buildup, including any pins $160.00   $96.00
02951 pin retention – per tooth, in addition to restoration $32.00   $20.00
02952 cast post & core in addition to crown $224.00   $135.00
02954 prefabricated post & core in addition to crown $240.00   $144.00
02962 labial veneer (porcelain laminate) – laboratory $480.00   $288.00
   
ENDODONTICS
Pulp Capping & Therapy Procedures
03110 pulp cap – direct (excluding final restoration) $40.00   $24.00
03120 pulp cap – indirect (excluding final restoration) $36.00   $22.00
03220 therapeutic pulpotomy (excluding final restoration) $136.00   $82.00
03310 anterior endodontic therapy (excluding final restoration) $472.00   $284.00
03320 bicuspid endodontic therapy (excluding final restoration) $520.00   $312.00
03330 molar endodontic therapy (excluding final restoration) $624.00   $375.00
   
PERIODONTICS - (Based on Years of Service)
Surgical Services
04211 gingivectomy or gingivoplasty – per tooth $160.00   $96.00
04249 clinical crown lengthening – hard tissue $240.00   $144.00
04260 osseous surgery (including flap entry/closure) per quad $640.00   $384.00
04263 bone replacement graft – first site quadrant $360.00   $216.00
   
Adjunctive Periodontal Services
04341 periodontal scaling and root planing – per quadrant $152.00   $92.00
04355 full mouth debridement to enable evaluation & diagnosis $120.00   $72.00
04381 localized delivery of chemotherapeutic agents $96.00   $58.00
   
Other Periodontal Services
04910 periodontal maintenance (active therapy) $192.00   $116.00
   
PROSTHODONTICS (REMOVABLE)
Complete Dentures (including Routine Post – Delivery Care)
05110-20 complete denture - maxillary or mandibular $640.00   $384.00
05130-40 immediate denture – maxillary or mandibular $600.00   $360.00
   
Partial Dentures (including Routine Post – Delivery Care)
05213 maxillary partial denture – cast metal frame $520.00   $312.00
05214 mandibular partial denture – cast metal framework $520.00   $312.00
   
Repairs to Partial Dentures
05640 replace broken teeth – per tooth $64.00   $39.00
05650 add tooth to existing partial denture $128.00   $77.00
   
PROSTHODONTICS (FIXED PARTIAL DENTURE)
Fixed Partial Denture
06240 pontic – porcelain fused to high noble metal $640.00   $384.00
   
Fixed Partial Denture Retainers – Crowns
06750 crown – porcelain fused to high noble metal $640.00   $384.00
06751 crown – porcelain fused to predominantly base metal $544.00   $327.00
06752 crown – porcelain fused to noble metal $640.00   $384.00
06930 recement fixed partial denture $120.00   $72.00
   
ORAL & MAXILLOFACIAL SURGERY
Extractions (including Local Anesthesia, Suturing & Routine Care)
07140 extraction – erupted tooth or exposed root $120.00   $72.00
07210 surgical removal of erupted tooth $160.00   $96.00
07220 removal or impacted tooth – soft tissue $168.00   $101.00
07230 removal of impacted tooth – partial bony $200.00   $120.00
07240 removal of impacted tooth – completely bony $240.00   $144.00
07250 surgical removal of residual tooth roots (cutting procedure) $192.00   $116.00
07310 alveoplasty in conjunction with extractions – per quad. $160.00   $96.00
07510 incision and drainage of abscess – intraoral soft tissue $160.00   $96.00
   
ORTHODONTICS
THE SBF ALLOWS THE MAXIMUM LIFETIME BENEFIT OF $1,760.00 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 $64.00   $.00
   
Anesthesia
09230 analgesia (including nitrous oxide) $40.00   $39.00
   
Professional Consultation
09310 consultation – (diagnostic service provided by dentist) $56.00   $34.00
   
Professional Visits
09440 office visits – after regular hours $16.00   $10.00
   
Miscellaneous Services
09910 application of desensitizing medicament $24.00   $15.00
09951 occlusal adjustment – limited $80.00   $48.00
09970 enamel micro abrasion $16.00   $10.00