New Jersey Fee Schedule
Please view the New Jersey fee schedule below. Please click the following link if you'd like to see a sample of Fees for our National Aetna Coverage.ADA Code |
Procedure Description |
Member Fee | Usual Customary Fee |
|---|---|---|---|
0 |
DIAGNOSTIC/ADJUNCTIVE PROCEDURES
|
||
120 |
Periodic oral examination |
20 |
45 |
130 |
Emergency oral examination/visit |
25 |
50 |
150 |
Comprehensive Oral Examination |
20* |
50 |
210 |
Intraoral complete series (including bitewings)
|
45** |
95 |
220 |
Intraoral x-ray film, single first |
8** |
20 |
230 |
Intraoral x-ray film, each additional |
6 |
17 |
240 |
Intraoral occlusal film |
9 |
30 |
270 |
Bitewing x-ray film |
6** |
18 |
272 |
Bitewing x-ray films, two |
14 |
36 |
273 |
Bitewing x-ray films, three |
16 |
42 |
274 |
Bitewing x-ray films, four |
20 |
50 |
330 |
Panoramic Film |
50 |
125 |
425 |
Caries susceptibility tests |
25 |
71 |
460 |
Pulp vitality tests |
20 |
45 |
470 |
Diagnostic casts |
25 |
60 |
471 |
Diagnostic photographs |
20 |
55 |
501 |
Histopathologic examinations |
50 |
134 |
9110 |
Palliative (emergency) treatment of dental pain |
25 |
51 |
9440 |
Office visit after regular scheduled hours |
45 |
95 |
9998 |
Sterile Pack |
5 |
10 |
0 |
PREVENTATIVE PROCEDURES
|
||
1110 |
Prophylaxis - adult (simple cleaning) |
50 |
100 |
1120 |
Prophylaxis - child |
30 |
75 |
1201 |
Topical applic. of fluoride (incl. prophylaxis - child) |
35 |
80 |
1203 |
Topical applic. of fluoride (excl. prophylaxis - child) |
22 |
50 |
1204 |
Topical applic. of fluoride (excl. prophylaxis - adult) |
22 |
50 |
1205 |
Topical applic. of fluoride (incl. prophylaxis - adult) |
50 |
120 |
1330 |
Oral hygiene instructions |
No Charge |
40 |
1351 |
Sealant - per tooth |
20 |
55 |
1510 |
Space maintainer - fixed unilateral |
120 |
235 |
1515 |
Space maintainer - fixed bilateral |
185 |
325 |
1520 |
Space maintainer- removable unilateral |
140 |
270 |
1525 |
Space maintainer-removable bilateral |
185 |
350 |
1550 |
Recementation of space maintainer |
20 |
55 |
0 |
RESTORATIVE PROCEDURES
|
||
2110 |
Amalgam - 1 surface - primary |
40 |
82 |
2120 |
Amalgam - 2 surface - primary |
50 |
95 |
2130 |
Amalgam - 3 surface - primary |
60 |
115 |
2131 |
Amalgam - 4 surface - primary |
70 |
136 |
2140 |
Amalgam - 1 surface - permanent |
65 |
130 |
2150 |
Amalgam - 2 surface - permanent |
70 |
140 |
2160 |
Amalgam - 3 surface - permanent |
80 |
150 |
2161 |
Amalgam - 4+ surfaces - permanent |
100 |
190 |
2330 |
Resin - 1 surface anterior |
75 |
140 |
2331 |
Resin - 2 surface - anterior |
95 |
190 |
2332 |
Resin - 3 surface - anterior |
115 |
230 |
2335 |
Resin - 4 or more surfaces |
175 |
300 |
2380 |
Resin - 1 surface, posterior-primary |
65 |
130 |
2381 |
Resin - 2 surfaces, posterior-primary |
80 |
160 |
2382 |
Resin - 3+ surfaces, posterior-primary |
110 |
180 |
2385 |
Resin - 1 surface, posterior-permanent |
75 |
140 |
2386 |
Resin - 2 surfaces, posterior-permanent |
90 |
160 |
2387 |
Resin - 3+ surfaces, posterior-permanent |
115 |
200 |
2510 |
Inlay-metallic, 1 surface |
275 |
550 |
2520 |
Inlay-metallic, 2 surfaces |
350 |
680 |
2530 |
Inlay-metallic, 3+ surfaces |
400 |
750 |
2610 |
Inlay porcelain/ceramic, 1 surface |
325 |
600 |
2620 |
Inlay porcelain/ceramic, 2 surfaces |
400 |
700 |
2630 |
Inlay porcelain/ceramic, 3+ surfaces |
500 |
800 |
2650 |
Inlay composite/resin, 1 surface |
700 |
1150 |
2651 |
Inlay composite/resin, 2 surfaces |
625 |
1050 |
2652 |
Inlay composite/resin, 3+ surfaces |
600 |
1000 |
2740 |
Crown-porcelain/ceramic substrate |
625 |
1050 |
2750 |
Crown-porcelain high noble metal |
700 |
1150 |
2751 |
Crown - porcelain fused to based metal |
625 |
1050 |
2752 |
Crown-porcelain noble metal |
650 |
1100 |
2790 |
Crown full cast high noble metal |
600 |
1000 |
2791 |
Crown full cast base metal |
475 |
900 |
2792 |
Crown full cast noble metal |
575 |
975 |
2910 |
Recement Inlay |
50 |
90 |
2920 |
Recement crown |
50 |
90 |
2930 |
Prefab'd stainless steel crown - 1 deg. tooth |
125 |
325 |
2931 |
Prefab'd stainless steel crown - 2 deg. tooth |
175 |
325 |
2932 |
Prefab'd resin crown |
150 |
325 |
2940 |
Sedative filling |
50 |
125 |
2950 |
Crown buildup, includes any pins |
125 |
250 |
2951 |
Pin retention - per tooth, in addition to restoration |
30 |
55 |
2952 |
Cast post and core in addition to crown |
170 |
350 |
2954 |
Prefab'd post and core in addition to crown |
145 |
275 |
2955 |
Post removal |
100 |
200 |
2960 |
Labial veneer (laminate) chairside |
400 |
700 |
2961 |
Labial veneer (resin laminate) lab |
500 |
800 |
2962 |
Labial veneer (porcelain laminate) lab |
600 |
950 |
2970 |
Temporary crown (fractured tooth) |
115 |
255 |
2980 |
Crown repair |
120 |
240 |
0 |
ENDODONTIC PROCEDURES
|
||
3110 |
Pulp cap - direct (excl. final restoration) |
30 |
55 |
3120 |
Pulp cap - indirect (excl. final restoration) |
30 |
55 |
3220 |
Therapeutic pulpotomy |
70 |
155 |
3310 |
Root canal therapy - anterior (excl. final restoration) |
375 |
700 |
3320 |
Root canal therapy - bicuspid (excl. final restoration) |
425 |
800 |
3330 |
Root canal therapy - molar (excl. final restoration) |
475 |
900 |
3340 |
Root canal therapy - 4 or more canals |
525 |
875 |
3346 |
Retreatment of prev. root canal - anterior |
325 |
625 |
3347 |
Retreatment of prev. root canal - bicuspid |
400 |
725 |
3348 |
Retreatment of prev. root canal - molar |
450 |
775 |
3351 |
Apexification/recalcification - initial visit |
160 |
325 |
3352 |
Apexification/recalcification - interim |
85 |
200 |
3353 |
Apexification/recalcification - final visit |
155 |
350 |
3410 |
Apicoectomy/periradicular-anterior |
250 |
550 |
3426 |
Apicoectomy/periradicular-add'l root |
110 |
240 |
3430 |
Retrograde filling-per root |
95 |
200 |
3920 |
Hemisection |
135 |
300 |
3960 |
Bleaching of discolored teeth (per arch) |
195 |
325 |
0 |
PERIODONTIC PROCEDURES
(gum treatment) |
||
4210 |
Gingivectomy or gingivoplasty - per quadrant |
210 |
425 |
4211 |
Gingivectomy or gingivoplasty - per tooth |
75 |
175 |
4240 |
Gingival flap proc., incl. root planing, per quadrant |
235 |
500 |
4249 |
Clinical crown lengthening-hard tissue |
225 |
530 |
4260 |
Osseous surgery, incl. flap entry and closure, per quadrant |
395 |
750 |
4270 |
Pedicle soft tissue graft procedure |
355 |
545 |
4341 |
Periodontal scaling and root planing, per quadrant |
95 |
200 |
4345 |
Periodontal scaling, presence of gingival inflammation |
75 |
120 |
4355 |
Full mouth debridement |
80 |
160 |
4381 |
Local del. of chemical agents (per tooth) |
75 |
160 |
4910 |
Periodontal maintenance procedures |
80 |
160 |
0 |
PROSTHODONTIC PROCEDURES (removable)
|
||
5110 |
Complete upper denture |
675 |
1300 |
5120 |
Complete lower denture |
675 |
1300 |
5130 |
Immediate upper denture |
750 |
1500 |
5140 |
Immediate lower denture |
750 |
1500 |
5211 |
Upper partial denture - acrylic base, including any conventional clasps and rests |
575 |
1250 |
5212 |
Lower partial denture - acrylic base, including any conventional clasps and rests |
575 |
1250 |
5213 |
Upper partial denture - predominantly base cast base w/acrylic saddles, incl. any conventional clasps and rests |
700 |
1300 |
5214 |
Lower partial denture - predominantly base cast base w/acrylic saddles, incl. any conventional claps and rests |
700 |
1300 |
5215 |
Upper Partial denture high noble cast base |
650 |
1250 |
5216 |
Lower partial denture high noble cast base |
650 |
1250 |
5280 |
Removable unilateral partial denture noble cast |
475 |
825 |
5281 |
Removable unilateral partial denture cast metal |
425 |
750 |
5410 |
Adjust complete denture - upper (after 4 months) |
40 |
70 |
5411 |
Adjust complete denture - lower (after 4 months) |
40 |
70 |
5421 |
Adjust partial denture - upper (after 4 months) |
40 |
70 |
5422 |
Adjust partial denture - lower (after 4 months) |
40 |
70 |
5510 |
Repair broken complete denture base |
130 |
235 |
5520 |
Replace missing or broken teeth - complete denture (each tooth) |
90 |
155 |
5610 |
Repair partial denture resin saddle or base |
125 |
240 |
5630 |
Repair or replace partial denture broken clasp |
150 |
250 |
5640 |
Repair broken teeth - partial denture - per tooth |
90 |
175 |
5650 |
Add tooth to existing partial denture |
90 |
175 |
5660 |
Add clasp to existing partial denture |
110 |
225 |
5710 |
Rebase complete upper denture (lab) |
200 |
400 |
5711 |
Rebase complete lower denture (lab) |
200 |
400 |
5720 |
Rebase upper partial denture (lab) |
185 |
375 |
5721 |
Rebase lower partial denture (lab) |
185 |
375 |
5730 |
Reline complete upper denture (chairside) |
135 |
300 |
5731 |
Reline complete lower denture (chairside) |
135 |
300 |
5740 |
Reline upper partial denture (chairside) |
125 |
250 |
5741 |
Reline lower partial denture (chairside) |
125 |
250 |
5750 |
Reline complete upper denture (lab) |
175 |
375 |
5751 |
Reline complete lower denture (lab) |
175 |
375 |
5760 |
Reline upper partial denture (lab) |
170 |
375 |
5761 |
Reline lower partial denture (lab) |
170 |
375 |
5810 |
Temporary complete denture (upper) |
450 |
850 |
5811 |
Temporary complete denture (lower) |
450 |
850 |
5820 |
Temporary partial-stayplate denture (upper) |
275 |
550 |
5821 |
Temporary partial-stayplate denture (lower) |
275 |
550 |
5850 |
Tissue conditioning maxillary (upper) |
75 |
150 |
5851 |
Tissue conditioning mandibular (lower) |
75 |
150 |
5860 |
Overdenture-complete |
825 |
1500 |
5861 |
Overdenture-partial |
825 |
1500 |
5862 |
Precision attachment |
300 |
450 |
0 |
PROSTHODONTIC PROCEDURES (fixed)
|
||
6240 |
Pontic - porcelain fused-high noble metal |
700 |
1150 |
6241 |
Pontic - porcelain fused to base metal |
625 |
1050 |
6242 |
Pontic - porcelain fused to noble metal |
650 |
1100 |
6545 |
Cast - metal retainer for acid etch bridge |
250 |
500 |
6750 |
Crown - porcelain fused - high noble metal |
700 |
1150 |
6751 |
Crown - (abutment) porcelain fused to base metal |
625 |
1050 |
6752 |
Crown - porcelain fused - noble metal |
650 |
1100 |
6790 |
Crown full cast high noble metal |
600 |
950 |
6792 |
Crown - full cast noble metal |
525 |
925 |
6920 |
Connector bar |
700 |
1200 |
6930 |
Recement bridge |
60 |
150 |
6940 |
Stress breaker |
225 |
400 |
6950 |
Precision attachment (each) |
325 |
500 |
6970 |
Cast post and core in addition to bridge retainer |
150 |
350 |
6971 |
Cast post as part of bridge retainer |
150 |
275 |
6972 |
Prefab'd post and core in addition to bridge retainer |
125 |
250 |
6975 |
Coping-metal |
225 |
500 |
6980 |
Fixed partial denture repair |
125 |
250 |
0 |
ORALSURGERY PROCEDURES
|
||
7110 |
Extraction (simple) - single tooth |
75 |
135 |
7120 |
Extraction (simple) - each additional tooth |
70 |
120 |
7130 |
Extraction root removal - exposed roots |
95 |
170 |
7210 |
Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and/or section of tooth-each tooth |
140 |
250 |
7220 |
Removal of impacted tooth - soft tissue |
150 |
275 |
7230 |
Removal of impacted tooth - partially bony |
180 |
350 |
7240 |
Removal of impacted tooth -completely bony |
235 |
450 |
7250 |
Surgical removal of residual tooth roots (cutting proc.) |
130 |
225 |
7285 |
Biopsy of oral tissue - hard |
155 |
275 |
7286 |
Biopsy of oral tissue - soft |
145 |
250 |
7310 |
Alveolectomy or plasty in conjunction with extractions per quadrant |
170 |
300 |
7320 |
Alveolectomy or plasty not in conjunction with extractions per quadrant |
190 |
350 |
7510 |
Incision & drainage of abscess-intraoral |
85 |
200 |
7960 |
Frenulectomy (frenectomy or frenotomy), separate procedure |
180 |
320 |
7970 |
Excision of hyperplastic tissue - per arch |
200 |
400 |
7971 |
Excision of pericoronal gingiva |
125 |
200 |
>>> S P E C I A L I S T __ F E E S <<<
|
|||
0 |
DIAGNOSTIC/ADJUNCTIVE PROCEDURES
|
||
120 |
Periodic oral examination at Specialist |
30 |
60 |
130 |
Emergency oral examination/visit at Specialist |
30 |
60 |
150 |
Comprehensive Oral Examination |
30 |
60 |
210 |
Intraoral complete series (including bitewings) at Specialist |
**50 |
100 |
220 |
Intraoral x-ray film, single first at Specialist |
10 |
20 |
230 |
Intraoral x-ray film, each additional at Specialist |
8 |
14 |
240 |
Intraoral occlusal film at Specialist |
10 |
20 |
270 |
Bitewing x-ray film at Specialist |
10 |
20 |
272 |
Bitewing x-ray films, two at Specialist |
15 |
30 |
273 |
Bitewing x-ray films, three at Specialist |
20 |
40 |
274 |
Bitewing x-ray films, four at Specialist |
25 |
45 |
330 |
Panoramic Film at Specialist |
50 |
105 |
340 |
Cephalometric film at Specialist |
30 |
70 |
470 |
Diagnostic casts at Specialist |
30 |
50 |
471 |
Diagnostic photographs at Specialist |
25 |
35 |
9110 |
Palliative (emergency) treatment of dental pain at Specialist |
40 |
80 |
9440 |
Office visit after regular scheduled hours at Specialist |
45 |
85 |
9998 |
Sterile Pack at Specialist |
5 |
10 |
0 |
PEDODONTIC PROCEDURES
(gum treatment) |
||
1120 |
Prophylaxis-child at Specialist |
50 |
95 |
1203 |
Top. application of fluoride at Specialist |
22 |
40 |
1351 |
Sealant-per tooth at Specialist |
36 |
65 |
1510 |
Space maintainer-fixed unilateral at Specialist |
195 |
350 |
1515 |
Space maintainer-fixed bilateral at Specialist |
300 |
550 |
2110 |
Amalgam-1 surface-primary at Specialist |
58 |
80 |
2120 |
Amalgam-2 surfaces-primary at Specialist |
78 |
100 |
2130 |
Amalgam-3 surfaces-primary at Specialist |
108 |
130 |
2140 |
Amalgam-1 surface-permanent at Specialist |
65 |
120 |
2150 |
Amalgam-2 surfaces-permanent at Specialist |
85 |
150 |
2160 |
Amalgam-3 surfaces-permanent at Specialist |
105 |
185 |
2930 |
Prefab'd stainless steel crown-1 tooth at Specialist |
130 |
250 |
0 |
ENDODONTIC PROCEDURES
|
||
3110 |
Pulp cap - direct (excl. final restoration) at Specialist |
60 |
125 |
3120 |
Pulp cap - indirect (excl. final restoration) at Specialist |
60 |
125 |
3220 |
Therapeutic pulpotomy at Specialist |
90 |
175 |
3310 |
Root canal therapy - anterior (excl. final restoration) at Specialist |
500 |
950 |
3320 |
Root canal therapy - bicuspid (excl. final restoration) at Specialist |
550 |
1000 |
3330 |
Root canal therapy - molar (excl. final restoration) at Specialist |
650 |
1100 |
3340 |
Root canal therapy - 4 or more canals at Specialist |
675 |
1150 |
3346 |
Retreatment of prev. root canal - anterior at Specialist |
450 |
850 |
3347 |
Retreatment of prev. root canal - bicuspid at Specialist |
500 |
950 |
3348 |
Retreatment of prev. root canal - molar at Specialist |
650 |
1050 |
3351 |
Apexification/recalcification - initial visit at Specialist |
225 |
400 |
3352 |
Apexification/recalcification - interim at Specialist |
125 |
220 |
3353 |
Apexification/recalcification - final visit at Specialist |
225 |
400 |
3410 |
Apicoectomy/periradicular-anterior at Specialist |
425 |
800 |
3421 |
Apicoectomy/periradicular-bicuspid at Specialist |
475 |
900 |
3425 |
Apicoectomy/periradicular-molar at Specialist |
550 |
875 |
3426 |
Apicoectomy/periradicular-add'l root at Specialist |
125 |
220 |
3430 |
Retrograde filling-per root at Specialist |
125 |
220 |
3450 |
Root amputation-per root at Specialist |
220 |
350 |
3920 |
Hemisection at Specialist |
215 |
400 |
0 |
PERIODONTIC PROCEDURES (gum treatment)
|
||
4210 |
Gingivectomy or gingivoplasty - per quadrant at Specialist |
525 |
700 |
4211 |
Gingivectomy or gingivoplasty - per tooth at Specialist |
150 |
225 |
4240 |
Gingival flap proc., incl. root planing, per quadrant at Specialist |
435 |
800 |
4249 |
Clinical crown lengthening-hard tissue at Specialist |
575 |
925 |
4260 |
Osseous surgery, incl. flap entry and closure, per quadrant at Specialist |
650 |
1000 |
4270 |
Pedicle soft tissue graft procedure at Specialist |
550 |
900 |
4320 |
Provisional splinting-intracoronal at Specialist |
305 |
550 |
4321 |
Provisional splinting-extracoronal at Specialist |
300 |
550 |
4341 |
Periodontal scaling and root planing, per quadrant at Specialist |
160 |
300 |
4345 |
Periodontal scaling, presence of gingival inflammation at Specialist |
90 |
180 |
4355 |
Full mouth debridement at Specialist |
110 |
200 |
4381 |
Local del. of chemical agents (per tooth) at Specialist |
75 |
160 |
4910 |
Periodontal maintenance procedures at Specialist |
90 |
180 |
0 |
PROSTHODONTIC PROCEDURES
|
||
5000 |
Removable- A 25% discount off individual providers customary fees. |
||
6200 |
Fixed- A 25% discount off individual providers customary fees. |
||
0 |
IMPLANT PROCEDURES
|
||
6000 |
A 20% discount off individual providers customary fees for 1st Implant. A 25% discount for 2 or more Implants. |
||
6035 |
Implant Abutment |
350 |
525 |
6065 |
Implant Crown |
700 |
1050 |
0 |
ORALSURGERY PROCEDURES
|
||
7110 |
Extraction (simple) - single tooth at Specialist |
105 |
195 |
7120 |
Extraction (simple) - each additional tooth at Specialist |
95 |
175 |
7130 |
Extraction root removal - exposed roots at Specialist |
120 |
200 |
7210 |
Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and/or section of tooth-each tooth at Specialist |
160 |
290 |
7220 |
Removal of impacted tooth - soft tissue at Specialist |
200 |
350 |
7230 |
Removal of impacted tooth - partially bony at Specialist |
260 |
480 |
7240 |
Removal of impacted tooth -completely bony at Specialist |
285 |
510 |
7241 |
Removal of impacted tooth - completely bony, with unusual surgical complications at Specialist |
375 |
650 |
7250 |
Surgical removal of residual tooth roots (cutting proc.) at Specialist |
225 |
400 |
7280 |
Surgical exposure of impact/unerupted tooth at Specialist |
450 |
800 |
7281 |
Surgical exposure of impacted or unerupted tooth to aid eruption at Specialist |
260 |
480 |
7285 |
Biopsy of oral tissue - hard at Specialist |
325 |
525 |
7286 |
Biopsy of oral tissue - soft at Specialist |
315 |
520 |
7310 |
Alveolectomy or plasty in conjunction with extractions per quadrant at Specialist |
200 |
380 |
7320 |
Alveolectomy or plasty not in conjunction with extractions per quadrant at Specialist |
260 |
480 |
7510 |
Incision & drainage of abscess-intraoral at Specialist |
110 |
210 |
7960 |
Frenulectomy (frenectomy or frenotomy), separate procedure at Specialist |
340 |
575 |
7970 |
Excision of hyperplastic tissue - per arch at Specialist |
345 |
600 |
7971 |
Excision of pericoronal gingiva at Specialist |
165 |
300 |
0 |
TMJ SPECIALIST PROCEDURES
|
||
7800 |
A 25% discount off individual providers customary fees. |
||
0 |
ORTHODONTIC PROCEDURES
|
||
8070 |
Comprehensive orthodontic treatment of the transitional dentition at Specialist |
3250 |
5400 |
8080 |
Comprehensive orthodontic treatment of the adolescent dentition at Specialist |
3250 |
5400 |
8090 |
Comprehensive orthodontic treatment of the adult dentiton at Specialist |
3350 |
5400 |
8680 |
Orthodontic retention at Specialist |
245 |
400 |
Legal note: DentalCALL and other DBC plans are not insurance plans.
