1.800.525.9313

Asequible Planes Dentales De Nueva Jersey

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.

Fee Schedule Notes

Procedures not listed in the general and specialist sections are available to the patient at a 25% discount from the participating provider's usual and customary fees.

If the provider's usual and customary fee is equal to or less than any corresponding schedule member fee, the provider will offer the patient a 10% discount off their usual and customary fee. Procedures for which the provider normally does not charge, shall remain free of charge regardless of any schedule fee.

The administration of any local anesthesia is included in the general and specialist fees. Nitrous oxide, intravenous sedation, or any other general sedation is to be discounted by 25% off the provider's usual rates.

Lab fees incurred by work done at a facility not owned or operated by the treating provider or office, and normally passed on to the patient as an additional charge, are to be discounted at a 25% discount off the provider's actual lab costs. However, lab work done in (or by) the provider's office is included in the member fees.

U.C.R. figures are estimates of customary fees charged by metro area dentists. Prices subject to change.

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

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