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)