Crown Dental Plan Fee Schedule: Code 0111 0120 0140 0145 0150 0160 0170 0180 0210 0220 0230 0240 0250 0260 0270 0272 0273 0274 0277 0330 0415 0431 0460 0470 0486 0502 Description Infection Control (Sterilization Fee) Periodic Oral Exam ** Limited Oral Exam ** Oral evaluation 3 yrs of age or younger ** Comprehensive Exam ** Detailed Oral Evaluation by Periodontic Report Re-Evaluation Comprehensive Periodontic Evaluation X-Rays Complete Series ** X-Ray 1st film X-Rays each additional X-Ray Occlusal Film X-Ray Extra oral First Film X-Ray Extra oral Each Additional Film X-Ray Bitewing Single Film X-Ray Bitewing Two Films X-Ray Bitewing Three Films X-Ray Bitewing Four Films Vertical bitewings 7 to 8 films X-Ray Panoramic Film ** Collection of micro organisms for culture Oral Cancer Screening Pulp Vitality tests Diagnostic casts Accession of brush biopsy sample Other oral pathology procedures, by report Description of benefits is on the last page! Your Cost $ 10 $ 23 $ 28 $ 38 $ 40 $ 35 $ 25 $ 30 $ 65 $ 8 $ 8 $ 8 $ 8 $ 8 $ 8 $ 15 $ 18 $ 29 $ 49 $ 55 $ 49 $ 45 $ 21 $ 45 $ 177 $ 181 Savings $ 15 $ 25 $ 32 $ 15 $ 25 $ 60 $ 23 $ 44 $ 33 $ 14 $ 12 $ 39 $ 39 $ 28 $ 14 $ 21 $ 22 $ 19 $ 26 $ 32 $ 26 $ 20 $ 15 $ 15 $ 43 $ 69 Without our Plan $ 25 $ 48 $ 60 $ 53 $ 65 $ 95 $ 48 $ 74 $ 98 $ 22 $ 20 $ 47 $ 47 $ 36 $ 22 $ 36 $ 40 $ 48 $ 75 $ 87 $ 75 $ 65 $ 36 $ 60 $ 220 $ 250 Your Cost $ 51 $ 42 $ 48 $ 16 $ 16 $ 56 $ 25 $ 26 Savings $ 24 $ 22 $ 21 $ 13 $ 14 $ 34 $ 15 $ 16 Without our Plan $ 75 $ 60 $ 69 $ 29 $ 30 $ 90 $ 40 $ 42 Preventive Procedures ** (Cleanings) These procedures are for preventing oral diseases. Code 1110 1120 1201 1203 1204 1205 1206 1351 Description Adult Cleanings (Prophylaxis) Child Cleanings (Prophylaxis) Child Fluoride & (Prophylaxis) Fluoride Application (Child) Adult Fluoride Application Adult Fluoride & (Prophylaxis) Topical fluoride varnish Sealant Per Tooth ** ** Restorative Procedures ** (Fillings) to restore lost tooth structures. 2330 2331 2332 2335 2390 2391 2392 2393 Resin Composite 1 Surface Anterior Resin Composite 2 Surface Anterior Resin Composite 3 Surface Anterior Resin Composite 4 or More Surface Anterior Resin Based composite crown Resin Based Composite 1 Surface Posterior Resin Based Composite 2 Surface Posterior Resin Based Composite 3 Surface Posterior $ 75 $ 85 $ 95 $ 110 $ 291 $ 90 $ 115 $ 140 $ 47 $ 74 $104 $113 $ 59 $ 70 $ 54 $ 69 $ 122 $ 159 $ 199 $ 223 $ 350 $ 160 $ 169 $ 209 Code 2394 2510 2520 2530 2542 2543 2544 2610 2620 2630 2642 2643 2644 2662 2663 2664 Description Your Cost Resin Based Composite 4 or more Surface Posterior $ 185 Inlay Metal 1 Surface $ 450 Inlay Metal 2 Surface $ 540 Inlay Metal 3 or more Surfaces $ 540 On lay Metallic 2 Surfaces $ 625 On lay Metallic 3 Surfaces $ 625 On lay Metallic 4 or More Surfaces $ 625 In lay Porcelain 1 Surfaces $ 675 In lay Porcelain 2 Surfaces $ 675 In lay Porcelain 3 or More Surfaces $ 675 On lay Porcelain 2 Surfaces $ 675 On lay Porcelain 3 Surfaces $ 675 On lay Porcelain 4 or More Surfaces $ 600 On lay Resin Composite 2 Surfaces $ 600 On lay Resin Composite 3 Surfaces $ 600 On lay Resin Composite 4 or More Surfaces $ 600 Savings $ 68 $ 238 $ 202 $ 259 $ 213 $ 223 $ 233 $ 175 $ 175 $ 150 $ 175 $ 175 $ 275 $ 275 $ 275 $ 275 Without our Plan $ 253 $ 688 $ 742 $ 799 $ 838 $ 848 $ 858 $ 850 $ 850 $ 825 $ 850 $ 850 $ 875 $ 875 $ 875 $ 875 Savings $ 210 $ 205 $ 195 $ 205 $ 205 $ 200 $ 205 $ 32 $ 32 $ 99 $ 185 $ 108 $ 98 $ 10 $ 94 $ 27 $ 169 $ 120 $ 210 $ 266 $ 390 $ 195 $ 70 $ 20 $ 80 Without our Plan $ 950 $ 830 $ 800 $ 825 $ 830 $ 825 $ 830 $ 81 $ 81 $ 204 $ 295 $ 300 $ 300 $ 85 $ 195 $ 65 $ 334 $ 255 $ 550 $ 756 $1200 $ 295 $ 185 $ 80 $ 165 Crown & Bridge Procedures Procedures ** (NOTE: Extra charge for GOLD) Code 2740 2750 2751 2752 2790 2791 2792 2910 2920 2930 2931 2932 2933 2940 2950 2951 2952 2954 2960 2961 2962 2970 2971 2975 2980 Description Crown Porcelain / Ceramic Substrate * Crown Porcelain High Noble Metal * Crown Porcelain Base Metal * Crown Porcelain Noble Metal * Full Cast Gold Crown * Crown full cast predominantly base metal * Crown full cast noble metal * Re-cement Inlay * Re-cement Crown * Stainless Steel Crown Prefab Primary Stainless Steel Crown Prefab Permanent Prefab Resin Crown Prefab stainless steel crown with resin window Sedative filling Core Build-Up / Pins Pin Retention per Tooth Cast Post & Core in Addition / Crown Prefab Post / Core in Addition / Crown Labial (Laminate) Veneer (Chair side) Labial Veneer (Resin) Lab Labial Veneer Porcelain Lab Temporary Crown Additional procedures to const. new crown Coping Crown Repair Your Cost $ 740 $ 625 $ 605 $ 620 $ 625 $ 620 $ 625 $ 49 $ 49 $ 105 $ 110 $ 192 $ 202 $ 75 $ 101 $ 38 $ 165 $ 135 $ 340 $ 490 $ 810 $ 100 $ 115 $ 60 $ 85 Endodontist Procedures ** (Root Canal Canal Therapy) For disease of the dental pulp. 3110 3220 3221 3310 3320 3330 Pulp Cap Direct (excluding Final) Therapeutic Pulpotomy (excluding Final Crown) Pulpal therapy (resorbable filling) anterior prim. Root Canal Anterior (excluding Final Crown) Root Canal Bicuspid (excluding Final Crown) Root Canal Molar (excluding Final Crown) $ 68 $ 60 $ 150 $ 429 $ 515 $ 605 $ 27 $ 93 $ 135 $ 241 $ 243 $ 330 $ $ $ $ $ $ 95 153 285 670 758 935 Code 3346 3347 3348 3351 3410 3421 3425 3426 3430 3450 Description Root Canal Re-treatment Anterior Root Canal Re-treatment Bicuspid Root Canal Re-treatment Molar Apexification / Re-calcification Initial Apicoectomy / periodontic Surg-Anterior Apicoectomy / Bicuspid 1st Root Apicoectomy / Molar 1st Root Apicoectomy / Peri. Surgery Additional Root Retrograde Filling Root amputation – per tooth Your Cost $ 325 $ 355 $ 590 $ 95 $ 345 $ 390 $ 395 $ 140 $ 80 $ 196 Savings $ 470 $ 440 $ 250 $ 195 $ 365 $ 405 $ 430 $ 131 $ 135 $ 89 Without our Plan $ 795 $ 795 $ 840 $ 290 $ 710 $ 795 $ 825 $ 271 $ 215 $ 284 Periodontist Procedures Procedures ** (Gum Treatment) Treating diseases of the gingival tissues. 4210 4211 4240 4241 4249 4260 4263 4264 4265 4266 4267 4268 4270 4271 4341 4342 4355 4381 4910 4920 Gingivectomy / gingivoplasty Per Quad Gingiv / gingivoplasty per Tooth Gingival Flap Procedure incl. rt. planning per quad Gingival Flap Includes Root Plan 1-3 Crown Length – Hard by report Osseous Surg. Inc. Flap Ent. Grafts & Closures Bone replacement graft first site in quadrant Bone replacement graft each additional site/ quad Biologic materials to aid in soft & osseous tissues Guided tissue regeneration resorbable barrier / site Guided tissue regeneration non-resorbable barrier Surgical revision procedure, per tooth Pedicle Tissue Graft Free Soft Tissue Graft & Donor Site Perio Scaling Root Planning > 4 Teeth Periodontal RPC (1 to 3 Teeth) Full Mouth Debridement Localized delivery of antimicrobial agents Periodontal Maintenance Unscheduled dressing change $ 228 $ 85 $ 250 $ 172 $ 275 $ 425 $ 380 $ 305 $ 295 $ 330 $ 244 $ 315 $ 375 $ 400 $ 172 $ 92 $ 90 $ 61 $ 74 $ 20 $ 248 $ 100 $ 385 $ 218 $ 435 $ 265 $ 95 $ 135 $ 100 $ 95 $ 74 $ 125 $ 300 $ 361 $ 80 $ 76 $ 63 $ 20 $ 46 $ 15 $ 476 $ 185 $ 635 $ 390 $ 710 $ 690 $ 475 $ 440 $ 395 $ 425 $ 318 $ 440 $ 675 $ 761 $ 252 $ 168 $ 153 $ 81 $ 120 $ 35 Prosthodontist Procedures ** (Dentures) for providing providing artificial replacements for missing natural teeth. Code 5110 5120 5130 5140 5211 5212 5213 5214 5225 5226 5281 5410 5411 5421 5422 5510 5520 Description Complete Denture Upper (High Quality) Complete Denture Lower (High Quality) Immediate Dentures Upper (High Quality) Immediate Dentures Lower (High Quality) Upper Partial Denture Resin Base Lower Partial Denture Resin Base Upper Partial Denture (Cast Metal) Lower Partial Denture (Cast Metal) Maxillary partial denture flexible base Mandibular partial denture flexible base Removable Unilateral Partial Denture Adjust Complete Denture Uppers Adjust Complete Denture Lowers Adjust Partial Denture Uppers Adjust Partial Denture Lowers Repair Broken Complete Denture Base Replace Missing / Broken Teeth Comp. Dent. Your Cost $1175 $1175 $1380 $1380 $1010 $1010 $1085 $1085 $ 975 $ 975 $ 425 $ 55 $ 55 $ 55 $ 55 $ 85 $ 80 Savings $ 410 $ 410 $ 470 $ 470 $ 265 $ 265 $ 305 $ 305 $ 346 $ 346 $ 95 $ 34 $ 34 $ 34 $ 34 $ 67 $ 56 Without our Plan $ 1585 $ 1585 $ 1850 $ 1850 $ 1295 $ 1295 $ 1390 $ 1390 $ 1325 $ 1325 $ 505 $ 89 $ 89 $ 89 $ 89 $ 152 $ 136 Code 5610 5620 5630 5640 5650 5660 5710 5711 5720 5721 5730 5731 5740 5741 5750 5751 5760 5761 5820 5821 5850 5851 5860 5861 5862 Description Repair Resin Denture Base Repair Cast Framework Repair / replace Broken Clasp Replace Broken Teeth – Per Tooth Add Tooth to Existing Partial Denture Add Clasp To Existing Partial Denture Rebase Complete Upper Denture Rebase Complete Lower Denture Rebase Upper Partial Denture Rebase Lower Partial Denture Reline Complete Upper Denture (chair side) Reline Complete Lower Denture (chair side) Reline Upper Partial Denture (chair side) Reline Lower Partial Denture (chair side) Reline Complete Upper Denture (Lab) Reline Complete Lower Denture (Lab) Reline Upper Partial Dentures (Lab) Reline Lower Partial Dentures (Lab) Interim Partial Denture Upper Interim Partial Denture Lower Tissue Conditioning Upper Tissue Conditioning Lower Over denture complete by report Over denture partial by report Precision attachment, by report Your Cost $ 85 $ 90 $ 100 $ 75 $ 121 $ 110 $ 340 $ 340 $ 315 $ 315 $ 97 $ 97 $ 114 $ 114 $ 255 $ 255 $ 255 $ 255 $ 400 $ 400 $ 51 $ 51 $ 890 $ 890 $ 380 Savings $ 95 $ 160 $ 97 $ 63 $ 69 $ 82 $ 96 $ 96 $ 107 $ 107 $ 198 $ 198 $ 181 $ 181 $ 85 $ 85 $ 67 $ 67 $ 140 $ 140 $ 103 $ 105 $ 420 $ 420 $ 125 Without our Plan $ 180 $ 250 $ 197 $ 138 $ 190 $ 192 $ 436 $ 436 $ 422 $ 422 $ 295 $ 295 $ 295 $ 295 $ 340 $ 340 $ 322 $ 322 $ 540 $ 540 $ 154 $ 156 $1310 $1310 $ 505 Savings $ 238 $ 239 $ 245 $ 200 $ 233 $ 225 $ 225 $ 205 $ 200 $ 200 $ 210 $ 200 $ 275 $ 275 $ 75 $ 95 $ 155 $ 135 $ 125 $ 124 $ 102 $ 35 $ 149 Without our Plan $ 925 $ 915 $ 925 $ 860 $ 915 $ 980 $ 980 $ 945 $ 920 $ 930 $ 940 $ 880 $ 915 $ 915 $ 140 $ 315 $ 460 $ 315 $ 290 $ 245 $ 201 $ 90 $ 270 Pontics Procedures ** (Bridge work) (NOTE: Extra charge for GOLD) For providing artificial replacements for missing natural teeth. Code 6210 6212 6240 6241 6242 6245 6740 6750 6751 6752 6780 6790 6791 6792 6930 6940 6950 6970 6971 6972 6973 6975 6980 Description Pontic High Noble * Pontic Noble Metal * Pontic Porcelain / High Noble Metal * Pontic Porcelain / Metal* Pontic Porcelain / Noble Metal * Pontic porcelain / Ceramic Retainer Crown Porcelain / Ceramic Retainer Crown Porcelain High Noble Metal * Retainer Crown porcelain fused Base metal* Retainer Crown Porcelain Base Metal * Retainer crown ¾ cast high noble metal* Crown Full Cast High Noble Metal * Crown Full Cast Base Metal * Crown Full Cast Noble Metal * Re-cement fixed partial denture Stress breaker Precision attachment Cast Post / Core + Fix Part. Dent. Retainer Cast Post / Partial of bridge retainer Prefab. Post and Core Core Build Up Retain Including Pins Coping metal Bridge Repair by Report Your Cost $ 687 $ 676 $ 680 $ 660 $ 682 $ 755 $ 755 $ 740 $ 720 $ 730 $ 730 $ 680 $ 640 $ 640 $ 65 $ 220 $ 305 $ 180 $ 165 $ 121 $ 99 $ 55 $ 121 Extraction Procedures ** These are procedures for treating teeth that are nonnon-restorable. Code 7111 7140 7210 7220 7230 7240 7241 7250 7260 7261 7270 7280 7285 7286 7287 7290 7310 7320 7471 7473 7510 7511 7520 7970 7971 Description Your Cost Coronal Remnants Deciduous (Including Soft) $ 48 Simple Extraction, Erupted or Exposed Tooth $ 80 Surg. Removal of Tooth $ 175 Remove Impact Tooth Soft Tissue $ 140 Remove Impact Tooth Part Bony $ 210 Remove Impact Tooth Complete Bony $ 241 Surg. Removal / Tooth W/ Complications $ 255 Surgical Removal of Root $ 160 Oroantral fistula closure $ 490 Primary closure of sinus perforation $ 191 Tooth Re-implantations / Stabilization $ 220 Surgical Access of Un-erupted Tooth $ 165 Biopsy Oral Tissue Hard $ 150 Biopsy Oral Tissue Soft $ 100 Exfoliative cytological sample collection $ 164 Tooth Repositioned Surg. $ 110 Ridge Prep Conj. W/ Exits $ 95 Ridge Prep Not W / Exits $ 110 Removal of exostosis per site $ 220 Removal of torus mandibularis $ 318 Incision & drainage of abscess intra oral soft tissue $ 188 Incision & drainage of abscess complicated $ 240 Incision and drainage of abscess extra oral $ 175 Excision of hyperplastic tissue per arch $ 251 Excision of pericoronal gingival $ 244 Savings $ 43 $ 40 $ 85 $ 98 $ 140 $ 99 $ 157 $ 100 $ 191 $ 79 $ 195 $ 215 $ 150 $ 490 $ 64 $ 180 $ 95 $ 185 $ 87 $ 106 $ 62 $ 80 $ 45 $ 109 $ 96 Without our Plan $ 91 $ 120 $ 260 $ 238 $ 350 $ 340 $ 412 $ 260 $ 681 $ 270 $ 415 $ 380 $ 300 $ 590 $ 228 $ 290 $ 190 $ 295 $ 307 $ 424 $ 250 $ 320 $ 220 $ 360 $ 340 Savings $ 35 $ 60 Without our Plan $ 75 $ 150 Emergency Treatments Code Description 9110 Palliative (emergency) During Hours 9440 Palliative (emergency) After Hours Membership Benefits Your Cost $ 40 $ 90 Membership Costs * Super savings on all dental procedures * New Annual Memberships fees are often one-third * No deductibles or co-payments of the cost of traditional dental health insurance * No annual maximum * Member pays procedural fee to provider on the same * No waiting periods or pre-existing condition exclusions day of service * Broad choice of quality dentists and specialists * Usual Customary Rate (USUAL CUSTOMARY RATE) * Specialist rates reduced by 20% is the average cost patient would expect to pay for procedure * Dentist who perform Specialists procedures provide without belonging to Crown Dental Plan. 20% off their UCR * Dental procedures not listed on fee schedule are discounted 20% • Endodontic (extensive root canals) • Orthodontics (braces) • Oral Surgery (TMJ, major extractions) • Prosthodontics (bridges and dentures) • Periodontics (gum treatment) Appointments * Appointments are accepted after the effective date of coverage shown on your membership card * Dental providers may need to perform a complete work-up in order to determine an effective oral treatment plan * Dentists and Specialists are subject to change without notice * If services are required immediately Crown Dental Association will verify coverage with your dentist on the day your enrollment fee is received * Missed appointment without a 24 hour advanced to the provider shall result in a $40 missed appointment fee * Crown Dental Association reassigns primary dentists to the nearest home/office location or by member choice should your dentist decide not to continue with Crown Eligible Dependents * All dependents are covered under the age of 19 or full time students up to age 26 years old or family members incapable of self-sustaining employment by reason of a developmental disability or physical handicap. * All eligible dependents must reside in the same house * Dependents may not be added to Crown Dental Plan once your membership card is issued Exclusions/Limitations * Services for injuries covered by workman’s Compensation * Oral surgery requiring the setting of fractures or dislocations * Services covered by other medical/dental insurance plans * Treatment of malignancies, cysts, or congenital defects Enrollment *Crown Dental Plan enrollment form is found on the last page * Crown Dental Plans website crowndentalplan.com contain a provider list: *Select primary dentist and enter provider code in the area go to “dentists page” tab on the upper left section of the web indicated on the enrollment form and include membership fee * Sign, include payment, and mail to: Crown Dental Plan 1237 S Val Vista * Membership card arrives within three to five business days Mesa, AZ 85204 after your membership application is processed * After membership card is mailed the annual fee is non-refundable On the following pages you will find the fee schedule for dental procedures as categorized by America Dental Association (ADA) for 2015 Regional Survey of dental fees. Crown members can identify price and savings per procedure, as compared to the usual customary rates charged for those procedures. Fee Schedule for dental procedures listed in this brochure is subject to change without notice. * Extra charge for gold, high noble metal and lab fees. ** Some dentists also perform listed procedures above as specialists. If your dentist is performing these services as a specialist, their office agrees to discount those procedures by 20% off the specialist USUAL CUSTOMARY RATE. Services performed by mobile dentists charge additional fees for the first visit and no trip charge will apply. Subsequent mobile services will charge a trip fee in addition to plan fees for services rendered. Be sure you understand those fees before professional services are rendered. UCR = (Usual Customary Rate) is the fee charged by a dentist for a specific dental procedure. The USUAL CUSTOMARY RATE’S listed above, represent “average fees” charged for dental procedures performed within the state. USUAL CUSTOMARY RATE’S do vary by dentist, so be sure to understand the specific usual customary rates of your dentist before professional services are rendered. Procedures not listed are discounted by 20%% off the dentist’s usual customary rates. The normal rate (USUAL CUSTOMARY RATE) column has been calculated as the average cost of dental procedures performed within your state. Price averages do vary, so be sure to understand your dentist or specialist USUAL CUSTOMARY RATE before professional services are rendered. Lab fees vary from dentist to dentist but should not be a major factor in the cost of procedures. Missed appointment without a 24 hour advanced notice to the dentist shall result in a $40 missed appointment fee. If your primary general dentists’ office is closed you may contact another primary general dentist on the plan for dental services without that office being listed on your membership card. That office may require however complete workups including an office visit fee and xrays prior to rendering any services even though you may have had a recent visit and x-rays with your primary general dentists. Fee Schedule for dental procedures listed in this brochure is subject to change without notice. You may visit our website at www.crowndentalplan.com for the most current fee schedule or contact us at (480) 964964-7449 Crown Dental Plan 1237 S Val Vista Dr. Mesa, AZ 85204 Crown Dental Plan is here to serve you. (Revised March 2015)
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