DentalCALL 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	30	48
140	Limited oral examination	40	88
150	Comprehensive Oral Examination	45*	79
170	Re-evaluation	30	64
210	Intraoral complete series (including bitewings)	65	129
220	Intraoral x-ray film, single first	15**	29
230	Intraoral x-ray film, each additional	12	25
240	Intraoral occlusal film	15	40
270	Bitewing x-ray film	12**	28
272	Bitewing x-ray films, two	20	44
273	Bitewing x-ray films, three	25	54
274	Bitewing x-ray films, four	30	64
330	Panoramic Film	60	111
425	Caries susceptibility tests	55	107
460	Pulp vitality tests	32	53
470	Diagnostic casts	50	114
471	Diagnostic photographs	32	65
501	Histopathologic examinations	60	154
9110	Palliative (emergency) treatment of dental pain	65	125
9440	Office visit after regular scheduled hours	70	147
9998	Sterile Pack	8	15

0	PREVENTATIVE PROCEDURES
1110	Prophylaxis - adult (simple cleaning)	50	150
1120	Prophylaxis - child	30	100
1201	Topical applic. of fluoride (incl. prophylaxis - child)	50	120
1203	Topical applic. of fluoride (excl. prophylaxis - child)	20	36
1204	Topical applic. of fluoride (excl. prophylaxis - adult)	25	36
1205	Topical applic. of fluoride (incl. prophylaxis - adult)	60	140
1330	Oral hygiene instructions	No Charge	47
1351	Sealant - per tooth	25	54
1510	Space maintainer - fixed unilateral	175	334
1515	Space maintainer - fixed bilateral	250	512
1520	Space maintainer- removable unilateral	210	500
1525	Space maintainer-removable bilateral	225	400
1550	Recementation of space maintainer	28	70

0	RESTORATIVE PROCEDURES
2140	Amalgam - 1 surface - permanent	70	151
2150	Amalgam - 2 surface - permanent	75	176
2160	Amalgam - 3 surface - permanent	85	221
2161	Amalgam - 4+ surfaces - permanent	110	260
2330	Resin - 1 surface anterior	80	176
2331	Resin - 2 surface - anterior	100	194
2332	Resin - 3 surface - anterior	120	232
2335	Resin - 4 or more surfaces	155	283
2380	Resin - 1 surface, posterior-primary	87	184
2381	Resin - 2 surfaces, posterior-primary	87	184
2382	Resin - 3+ surfaces, posterior-primary	120	207
2390	Full resin comp.	200	292
2391	Resin - 1 surface, posterior-permanent	90	171
2392	Resin - 2 surfaces, posterior-permanent	105	217
2393	Resin - 3+ surfaces, posterior-permanent	140	267
2394	Resin based 4 + post	160	314
2510	Inlay-metallic, 1 surface	325	670
2520	Inlay-metallic, 2 surfaces	400	704
2530	Inlay-metallic, 3+ surfaces	445	830
2610	Inlay porcelain/ceramic, 1 surface	355	670
2620	Inlay porcelain/ceramic, 2 surfaces	455	704
2630	Inlay porcelain/ceramic, 3+ surfaces	520	830
2650	Inlay composite/resin, 1 surface	340	670
2651	Inlay composite/resin, 2 surfaces	440	704
2652	Inlay composite/resin, 3+ surfaces	520	830
2740	Crown-porcelain/ceramic substrate	650	1157
2750	Crown-porcelain high noble metal	725	1085
2751	Crown - porcelain fused to based metal	660	1003
2752	Crown-porcelain noble metal	675	1049
2790	Crown full cast high noble metal	635	1052
2791	Crown full cast base metal	480	981
2792	Crown full cast noble metal	585	1029
2910	Recement Inlay	55	109
2920	Recement crown	55	104
2930	Prefab'd stainless steel crown - 1 deg. tooth	130	259
2931	Prefab'd stainless steel crown - 2 deg. tooth	160	290
2932	Prefab'd resin crown	155	275
2940	Sedative filling	55	114
2950	Crown buildup, includes any pins	135	274
2951	Pin retention - per tooth, in addition to restoration	30	55
2952	Cast post and core in addition to crown	195	395
2954	Prefab'd post and core in addition to crown	170	328
2955	Post removal	115	230
2960	Labial veneer (laminate) chairside	410	710
2961	Labial veneer (resin laminate) lab	525	771
2962	Labial veneer (porcelain laminate) lab	625	1042
2970	Temporary crown (fractured tooth)	155	262
2980	Crown repair	125	275

0	ENDODONTIC PROCEDURES
3110	Pulp cap - direct (excl. final restoration)	40	72
3120	Pulp cap - indirect (excl. final restoration)	40	68
3220	Therapeutic pulpotomy	95	195
3310	Root canal therapy - anterior (excl. final restoration)	365	818
3320	Root canal therapy - bicuspid (excl. final restoration)	435	935
3330	Root canal therapy - molar (excl. final restoration)	515	1106
3340	Root canal therapy - 4 or more canals	545	1050
3346	Retreatment of prev. root canal - anterior	450	1030
3347	Retreatment of prev. root canal - bicuspid	190	1150
3348	Retreatment of prev. root canal - molar	575	1294
3351	Apexification/recalcification - initial visit	218	520
3352	Apexification/recalcification - interim	138	340
3353	Apexification/recalcification - final visit	225	550
3410	Apicoectomy/periradicular-anterior	340	939
3426	Apicoectomy/periradicular-add'l root	150	375
3430	Retrograde filling-per root	120	300
3920	Hemisection	155	375
3960	Bleaching of discolored teeth (per arch)	225	435

0	PERIODONTIC PROCEDURES (gum treatment)
4210	Gingivectomy or gingivoplasty - per quadrant	275	620
4211	Gingivectomy or gingivoplasty - per tooth	135	259
4240	Gingival flap proc., incl. root planing, per quadrant	245	675
4249	Clinical crown lengthening-hard tissue	360	914
4260	Osseous surgery, incl. flap entry and closure, per quadrant	605	1157
4270	Pedicle soft tissue graft procedure	355	867
4341	Periodontal scaling and root planing, per quadrant	125	252
4345	Periodontal scaling, presence of gingival inflammation	100	250
4355	Full mouth debridement	85	163
4381	Local del. of chemical agents (per tooth)	65	84
4910	Periodontal maintenance procedures	70	132

0	PROSTHODONTIC PROCEDURES (removable)
5110	Complete upper denture	705	1571
5120	Complete lower denture	705	1571
5130	Immediate upper denture	800	1685
5140	Immediate lower denture	800	1685
5211	Upper partial denture - acrylic base, including any conventional clasps and rests	605	1244
5212	Lower partial denture - acrylic base, including any conventional clasps and rests	605	1328
5213	Upper partial denture - predominantly base cast base w/acrylic saddles, incl. any conventional clasps and rests	750	1631
5214	Lower partial denture - predominantly base cast base w/acrylic saddles, incl. any conventional claps and rests	750	1742
5215	Upper Partial denture high noble cast base	650	1250
5216	Lower partial denture high noble cast base	750	1975
5280	Removable unilateral partial denture noble cast	750	1975
5281	Removable unilateral partial denture cast metal	750	1975
5410	Adjust complete denture - upper (after 4 months)	43	75
5411	Adjust complete denture - lower (after 4 months)	43	75
5421	Adjust partial denture - upper (after 4 months)	43	75
5422	Adjust partial denture - lower (after 4 months)	43	75
5510	Repair broken complete denture base	120	500
5520	Replace missing or broken teeth - complete denture (each tooth)	95	153
5610	Repair partial denture resin saddle or base	160	450
5620	Repair cast framework	205	500
5640	Repair broken teeth - partial denture - per tooth	95	165
5650	Add tooth to existing partial denture	105	207
5660	Add clasp to existing partial denture	130	200
5710	Rebase complete upper denture (lab)	250	500
5711	Rebase complete lower denture (lab)	250	500
5720	Rebase upper partial denture (lab)	190	475
5721	Rebase lower partial denture (lab)	190	475
5730	Reline complete upper denture (chairside)	180	324
5731	Reline complete lower denture (chairside)	180	324
5740	Reline upper partial denture (chairside)	135	331
5741	Reline lower partial denture (chairside)	135	350
5750	Reline complete upper denture (lab)	185	445
5751	Reline complete lower denture (lab)	195	575
5760	Reline upper partial denture (lab)	185	445
5761	Reline lower partial denture (lab)	185	575
5810	Temporary complete denture (upper)	450	1025
5811	Temporary complete denture (lower)	450	1025
5820	Temporary partial-stayplate denture (upper)	300	750
5821	Temporary partial-stayplate denture (lower)	315	750
5850	Tissue conditioning maxillary (upper)	75	145
5851	Tissue conditioning mandibular (lower)	75	145
5860	Overdenture-complete	825	1650
5861	Overdenture-partial	825	1650
5862	Precision attachment	275	492

0	PROSTHODONTIC PROCEDURES (fixed)
6240	Pontic - porcelain fused-high noble metal	725	1085
6241	Pontic - porcelain fused to base metal	700	1004
6242	Pontic - porcelain fused to noble metal	750	1200
6545	Cast - metal retainer for acid etch bridge	325	478
6750	Crown - porcelain fused - high noble metal	750	1085
6751	Crown - (abutment) porcelain fused to base metal	600	1004
6752	Crown - porcelain fused - noble metal	750	1200
6790	Crown full cast high noble metal	650	1053
6792	Crown - full cast noble metal	650	1029
6920	Connector bar	700	1275
6930	Recement bridge	75	150
6940	Stress breaker	225	450
6950	Precision attachment (each)	255	439
6970	Cast post and core in addition to bridge retainer	160	400
6971	Cast post as part of bridge retainer	160	400
6972	Prefab'd post and core in addition to bridge retainer	150	375
6975	Coping-metal	225	550
6980	Fixed partial denture repair	135	325

0	ORALSURGERY PROCEDURES
7110	Extraction (simple) - single tooth	100	250
7120	Extraction (simple) - each additional tooth	80	200
7130	Extraction root removal - exposed roots	105	255
7210	Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and/or section of tooth-each tooth	155	275
7220	Removal of impacted tooth - soft tissue	180	332
7230	Removal of impacted tooth - partially bony	230	377
7240	Removal of impacted tooth -completely bony	255	444
7250	Surgical removal of residual tooth roots (cutting proc.)	150	255
7285	Biopsy of oral tissue - hard	155	275
7286	Biopsy of oral tissue - soft	155	250
7310	Alveolectomy or plasty in conjunction with extractions per quadrant	140	273
7320	Alveolectomy or plasty not in conjunction with extractions per quadrant	215	344
7510	Incision & drainage of abscess-intraoral	98	245
7960	Frenulectomy (frenectomy or frenotomy), separate procedure	240	396
7970	Excision of hyperplastic tissue - per arch	255	440
7971	Excision of pericoronal gingiva	125	225

	>>> S P E C I A L I S T __ F E E S <<<

0	DIAGNOSTIC/ADJUNCTIVE PROCEDURES
120	Periodic oral examination at Specialist	40	70
130	Emergency oral examination/visit at Specialist	45	75
150	Comprehensive Oral Examination	50	80
210	Intraoral complete series (including bitewings) at Specialist	70	135
220	Intraoral x-ray film, single first at Specialist	20	40
230	Intraoral x-ray film, each additional at Specialist	15	25
240	Intraoral occlusal film at Specialist	20	45
270	Bitewing x-ray film at Specialist	20	45
272	Bitewing x-ray films, two at Specialist	30	50
273	Bitewing x-ray films, three at Specialist	35	55
274	Bitewing x-ray films, four at Specialist	40	70
330	Panoramic Film at Specialist	65	105
470	Diagnostic casts at Specialist	50	90
471	Diagnostic photographs at Specialist	48	75
9110	Palliative (emergency) treatment of dental pain at Specialist	75	140
9440	Office visit after regular scheduled hours at Specialist	75	140
9998	Sterile Pack at Specialist	10	20

0	PEDODONTIC PROCEDURES (gum treatment)
1120	Prophylaxis-child at Specialist	60	100
1203	Top. application of fluoride at Specialist	25	45
1351	Sealant-per tooth at Specialist	35	60
1510	Space maintainer-fixed unilateral at Specialist	205	375
1515	Space maintainer-fixed bilateral at Specialist	305	475
2140	Amalgam-1 surface-permanent at Specialist	75	125
2150	Amalgam-2 surfaces-permanent at Specialist	85	145
2160	Amalgam-3 surfaces-permanent at Specialist	100	175
2930	Prefab'd stainless steel crown-1 tooth at Specialist	150	290

0	ENDODONTIC PROCEDURES
3110	Pulp cap - direct (excl. final restoration) at Specialist	100	185
3120	Pulp cap - indirect (excl. final restoration) at Specialist	75	160
3220	Therapeutic pulpotomy at Specialist	150	275
3310	Root canal therapy - anterior (excl. final restoration) at Specialist	605	1100
3320	Root canal therapy - bicuspid (excl. final restoration) at Specialist	660	1200
3330	Root canal therapy - molar (excl. final restoration) at Specialist	715	1300
3340	Root canal therapy - 4 or more canals at Specialist	775	1320
3346	Retreatment of prev. root canal - anterior at Specialist	700	1200
3347	Retreatment of prev. root canal - bicuspid at Specialist	750	1300
3348	Retreatment of prev. root canal - molar at Specialist	800	1400
3351	Apexification/recalcification - initial visit at Specialist	258	460
3352	Apexification/recalcification - interim at Specialist	144	250
3353	Apexification/recalcification - final visit at Specialist	255	460
3410	Apicoectomy/periradicular-anterior at Specialist	550	1000
3421	Apicoectomy/periradicular-bicuspid at Specialist	540	1035
3425	Apicoectomy/periradicular-molar at Specialist	630	1010
3426	Apicoectomy/periradicular-add'l root at Specialist	145	250
3430	Retrograde filling-per root at Specialist	145	250
3450	Root amputation-per root at Specialist	250	400

0	PERIODONTIC PROCEDURES (gum treatment)
4210	Gingivectomy or gingivoplasty - per quadrant at Specialist	575	900
4211	Gingivectomy or gingivoplasty - per tooth at Specialist	315	575
4240	Gingival flap proc., incl. root planing, per quadrant at Specialist	650	1100
4249	Clinical crown lengthening-hard tissue at Specialist	625	100
4260	Osseous surgery, incl. flap entry and closure, per quadrant at Specialist	715	1200
4270	Pedicle soft tissue graft procedure at Specialist	630	1035
4320	Provisional splinting-intracoronal at Specialist	350	635
4321	Provisional splinting-extracoronal at Specialist	345	630
4341	Periodontal scaling and root planing, per quadrant at Specialist	180	325
4345	Periodontal scaling, presence of gingival inflammation at Specialist	105	205
4355	Full mouth debridement at Specialist	135	240
4381	Local del. of chemical agents (per tooth) at Specialist	80	130
4910	Periodontal maintenance procedures at Specialist	105	160

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
	A 20% discount off individual providers customary fees for 1st Implant. A 25% discount for 2 or more Implants.
6061	Implant Abutment	400	900
6066	Implant Crown	780	1300

0	ORALSURGERY PROCEDURES
7110	Extraction (simple) - single tooth at Specialist	120	225
7120	Extraction (simple) - each additional tooth at Specialist	110	200
7130	Extraction root removal - exposed roots at Specialist	138	230
7210	Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and/or section of tooth-each tooth at Specialist	170	300
7220	Removal of impacted tooth - soft tissue at Specialist	220	400
7230	Removal of impacted tooth - partially bony at Specialist	270	475
7240	Removal of impacted tooth -completely bony at Specialist	290	525
7241	Removal of impacted tooth - completely bony, with unusual surgical complications at Specialist	430	745
7250	Surgical removal of residual tooth roots (cutting proc.) at Specialist	240	425
7280	Surgical exposure of impact/unerupted tooth at Specialist	515	920
7281	Surgical exposure of impacted or unerupted tooth to aid eruption at Specialist	300	550
7285	Biopsy of oral tissue - hard at Specialist	373	600
7286	Biopsy of oral tissue - soft at Specialist	220	400
7310	Alveolectomy or plasty in conjunction with extractions per quadrant at Specialist	225	405
7320	Alveolectomy or plasty not in conjunction with extractions per quadrant at Specialist	275	505
7510	Incision & drainage of abscess-intraoral at Specialist	126	240
7960	Frenulectomy (frenectomy or frenotomy), separate procedure at Specialist	305	550
7970	Excision of hyperplastic tissue - per arch at Specialist	385	700
7971	Excision of pericoronal gingiva at Specialist	188	345

0	TMJ SPECIALIST PROCEDURES
	A 25% discount off individual providers customary fees.

0	ORTHODONTIC PROCEDURES
8070	Comprehensive orthodontic treatment of the transitional dentition at Specialist	3450	5350
8080	Comprehensive orthodontic treatment of the adolescent dentition at Specialist	3650	5700
8090	Comprehensive orthodontic treatment of the adult dentiton at Specialist	3850	6000
8680	Orthodontic retention at Specialist	245	400
The comprehensive orthodontic codes listed above include: the initial consult/exam, x-rays, traditional metal braces, 1st retainer, visits, and plans & record keeping. Based on a 2 year standard course of treatment. Invisalign or other types of braces, palate expanders, durations of less than 2 years, and procedures not part of a 2 yr course of treatment, are to be discounted at 25% off the orthodontist's usual fees. * The portion of any comprehensive treatment that exceeds the 24th month is to be discounted at 40% off the orthodontist's usual fees.

Legal note: DentalCALL and other DBC plans are not insurance plans.