Making Dentistry Affordable for Everyone is What We Do

Freedom Dental Plan provides transparent pricing so plan members know exactly what to expect when it comes to their dental care needs. Plan members receive member-only 25-45% SAVINGS on all dental procedures including preventive, basic, major, cosmetic, and even orthodontics!

Freedom Dental Plan keeps it simple and features no waiting periods, exclusions or maximums.

Diagnostic And Preventive
Code Description Member Savings*
D0120 Periodic oral evaluation- established patient 45%
D0140 Limited oral evaluation- problem focused 45%
D0150 Comprehensive oral evaluation- new or established patient 45%
D0210 Intraoral- complete series of radiographic images 45%
D0220 Intraoral- periapical first radiographic image 45%
D0274 Bitewings- four radiographic images 45%
D0330 Panoramic radiographic image 45%
D1110 Prophylaxis- adult 45%
D1120 Prophylaxis- child 45%
D1208 Topical application of fluoride – excluding varnish 45%
D1351 Sealant – per tooth 45%
RESTORATIVE – AMALGAM FILLINGS
Code Description Member Savings*
D2140 Amalgam- one surface, primary or permanent 25%
D2150 Amalgam- two surfaces, primary or permanent 25%
D2160 Amalgam- three surfaces, primary or permanent 25%
RESTORATIVE – COMPOSITE FILLINGS (RESIN BASED)
Code Description Member Savings*
D2330 Resin-based composite- one surface, anterior 25%
D2331 Resin-based composite- two surfaces, anterior 25%
D2332 Resin-based composite- three surfaces, anterior 25%
D2335 Resin-based composite- four or more surfaces or involving incisal angle 25%
D2391 Resin-based composite- one surface, posterior 25%
D2392 Resin-based composite- two surfaces, posterior 25%
D2393 Resin-based composite- three surfaces, posterior 25%
CROWNS
Code Description Member Savings*
D2740 Crown- porcelain/ceramic substrate 25%
D2750 Crown- porcelain fused to high noble metal 25%
D2751 Crown- porcelain fused to predominantly base metal 25%
D2752 Crown- porcelain fused to noble metal 25%
D2950 Core buildup, including any pins when required 25%
D2952 Post and core in addition to crown, indirectly fabricated 25%
ROOT CANALS
Code Description Member Savings*
D3310 Endodontic therapy, anterior tooth (excluding final restoration) 25%
D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) 25%
D3330 Endodontic therapy, molar (excluding final restoration) 25%
PERIODONTICS
Code Description Member Savings*
RESTORATIVE – AMALGAM FILLINGS
Code Description Member Savings*
D4341 Periodontal scaling and root planing- four or more teeth per quadrant 25%
D4342 Periodontal scaling and root planing- one to three teeth per quadrant 25%
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into 25%
D4910 Periodontal Maintenance 25%
DENTURES
Code Description Member Savings*
D5110 Complete denture- maxillary 25%
D5120 Complete denture- mandibular 25%
D5510 Repair broken complete denture base 25%
D5730 Reline complete maxillary denture (chairside) 25%
D5731 Reline complete mandibular denture (chairside) 25%
D5740 Reline maxillary partial denture (chairside) 25%
D5741 Reline mandibular partial denture (chairside) 25%
D5750 Reline complete maxillary denture (laboratory) 25%
D5751 Reline complete mandibular denture (laboratory) 25%
BRIDGES
Code Description Member Savings*
D6010 Surgical placement of implant body: endosteal implant 25%
D6057 Custom fabricated abutment- includes placement 25%
D6058 Abutment supported porcelain/ceramic crown 25%
D6060 Abutment supported porcelain fused to metal crown (predominantly base 25%
D6750 Retainer crown- porcelain fused to high noble metal 25%
D6751 Retainer crown- porcelain fused to predominantly base metal 25%
D6752 Retainer crown- porcelain fused to noble metal 25%
EXTRACTIONS
Code Description Member Savings*
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) 25%
X-RAY
Code Description Member Savings*
D0210 lntraoral- complete series of radiographic images 0%
D0220 lntraoral – periapical first radiographic image 0%
D0230 lntraoral – periapical each additional radiographic image 0%
D0240 lntraoral – Occlusal radiographic image 0%
D0272 Bitewings – two radiographic images 0%
D0330 Panoramic radiographic image 0%
D1206 Topica l application of fluoride varnish 0%
Other
Code Description Member Savings*
D0145 Oral evaluation for a patient under three years of age and counseling with 45%
D0160 Detailed and extensive oral evaluation- problem focused, by report 45%
D0170 Re-evaluation- limited, problem focused (established patient; not post- 45%
D0171 Re-evaluation- post-operative office visit 45%
D0180 Comprehensive periodontal evaluation- new or established patient 45%
D0190 Screening of a patient 45%
D0191 Assessment of a patient 45%
D0230 Intraoral- periapical each additional radiographic image 45%
D0240 Intraoral- occlusal radiographic image 45%
D0250 Extra-oral -2D projection radiographic image created using a stationary 45%
D0251 Extra-oral posterior dental radiographic image 45%
D0270 Bitewing- single radiographic image 45%
D0272 Bitewings- two radiographic images 45%
D0273 Bitewings- three radiographic images 45%
D0277 Vertical bitewings- 7 to 8 radiographic images 45%
D0290 Posterior-anterior or lateral skull and facial bone survey radiographic image 45%
D0310 Sialography 45%
D0320 Temporomandibular joint arthrogram, including injection 45%
D0321 Other temporomandibular joint radiographic images, by report 45%
D0322 Tomographic survey 45%
D0340 2D cephalometric radiographic image – acquisition, measurement and analysis 45%
D0350 2D oral/facial photographic image obtained intra-orally or extra-orally 45%
D0351 3D photographic image 45%
D0364 Cone beam CT capture and interpretation with limited field of view- less than 45%
D0365 Cone beam CT capture and interpretation with field of view of one full dental 45%
D0366 Cone beam CT capture and interpretation with field of view of one full dental 45%
D0367 Cone beam CT capture and interpretation with field of view of both jaws; with 45%
D0368 Cone beam CT capture and interpretation for TMJ series including two or more 45%
D0380 Cone beam CT image capture with limited field of view- less than one whole 45%
D0381 Cone beam CT image capture with field of view of one full dental arch- 45%
D0382 Cone beam CT image capture with field of view of one full dental arch- maxilla, 45%
D0383 Cone beam CT image capture with field of view of both jaws, with or without 45%
D0384 Cone beam CT image capture for TMJ series including two or more exposures 45%
D0391 Interpretation of diagnostic image by a practitioner not associated with 45%
D0393 Treatment simulation using 3D image volume 45%
D0394 Digital subtraction of two or more images or image volumes of the same 45%
D0395 Fusion of two or more 3D image volumes of one or more modalities 45%
D0415 Collection of microorganisms for culture and sensitivity 45%
D0417 Collection and preparation of saliva sample for laboratory diagnostic testing 45%
D0418 Analysis of saliva sample 45%
D0422 Collection and preparation of genetic sample material for laboratory analysis 45%
D0423 Genetic test for susceptibility to diseases – specimen analysis 45%
D0425 Caries susceptibility tests 45%
D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities 45%
D0460 Pulp vitality tests 45%
D0470 Diagnostic casts 45%
D0472 Accession of tissue, gross examination, preparation and transmission of 45%
D0473 Accession of tissue, gross and microscopic examination, preparation and 45%
D0474 Accession of tissue, gross and microscopic examination, including assessment 45%
D0475 Decalcification procedure 45%
D0476 Special stains for microorganisms 45%
D0477 Special stains, not for microorganisms 45%
D0478 Immunohistochemical stains 45%
D0479 Tissue in-situ hybridization, including interpretation 45%
D0480 preparation and transmission of written report 45%
D0481 Electron microscopy 45%
D0482 Direct immunofluorescence 45%
D0483 Indirect immunofluorescence 45%
D0484 Consultation on slides prepared elsewhere 45%
D0485 Consultation, including preparation of slides from biopsy material supplied by 45%
D0486 Laboratory accession of transepithelial cytologic sample, microscopic 45%
D0601 Caries risk assessment and documentation, with a finding of low risk 45%
D0602 Caries risk assessment and documentation, with a finding of moderate risk 45%
D0603 Caries risk assessment and documentation, with a finding of high risk 45%
D1206 Topical application of fluoride varnish 45%
D1310 Nutritional counseling for control of dental disease 45%
D1320 Tobacco counseling for the control and prevention of oral disease 45%
D1352 Preventive resin restoration in a moderate to high caries risk patient- 45%
D1353 Sealant repair- per tooth 45%
D1354 Interim caries arresting medicament application 45%
D1510 Space maintainer- fixed – unilateral 45%
D1515 Space maintainer- fixed – bilateral 45%
D1520 Space maintainer- removable- unilateral 45%
D1525 Space maintainer- removable- bilateral 45%
D1550 Re-cement or re-bond space maintainer 45%
D1555 Removal of fixed space maintainer 45%
D1575 Distal shoe soace maintainer- fixed- unilateral 45%
D2161 Amalgam- four or more surfaces, primary or permanent 25%
D2390 Resin-based composite crown, anterior 25%
D2394 Resin-based composite- four or more surfaces, posterior 25%
D2510 Inlay- metallic- one surface 25%
D2520 Inlay- metallic- two surfaces 25%
D2530 Inlay- metallic- three or more surfaces 25%
D2542 Onlay- metallic- two surfaces 25%
D2543 Onlay- metallic- three surfaces 25%
D2544 Onlay- metallic- four or more surfaces 25%
D2610 Inlay- porcelain/ceramic- one surface 25%
D2620 Inlay- porcelain/ceramic- two surfaces 25%
D2630 Inlay- porcelain/ceramic- three or more surfaces 25%
D2642 Onlay- porcelain/ceramic- two surfaces 25%
D2643 Onlay- porcelain/ceramic- three surfaces 25%
D2644 Onlay- porcelain/ceramic- four or more surfaces 25%
D2650 Inlay- resin-based composite- one surface 25%
D2651 Inlay- resin-based composite- two surfaces 25%
D2652 Inlay- resin-based composite- three or more surfaces 25%
D2662 Onlay- resin-based composite- two surfaces 25%
D2663 Onlay- resin-based composite- three surfaces 25%
D2664 Onlay- resin-based composite- four or more surfaces 25%
D2710 Crown- resin-based composite (indirect) 25%
D2712 Crown- resin-based composite (indirect) 25%
D2720 Crown- resin with high noble metal 25%
D2721 Crown- resin with predominantly base metal 25%
D2722 Crown- resin with noble metal 25%
D2780 Crown- cast high noble metal 25%
D2781 Crown- cast predominantly base metal 25%
D2782 Crown- cast noble metal 25%
D2783 Crown- porcelain/ceramic 25%
D2790 Crown- full cast high noble metal 25%
D2791 Crown- full cast predominantly base metal 25%
D2792 Crown- full cast noble metal 25%
D2794 Crown- titanium 25%
D2799 Provisional crown – further treatment or completion of diagnosis necessary 25%
D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration 25%
D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core 25%
D2920 Re-cement or re-bond crown 25%
D2921 Reattachment of tooth fragment, incisal edge or cusp 25%
D2929 Prefabricated porcelain/ceramic crown- primary tooth 25%
D2930 Prefabricated stainless steel crown- primary tooth 25%
D2931 Prefabricated stainless steel crown- permanent tooth 25%
D2932 Prefabricated resin crown 25%
D2933 Prefabricated stainless steel crown with resin window 25%
D2934 Prefabricated esthetic coated stainless steel crown- primary tooth 25%
D2940 Protective restoration 25%
D2941 Interim therapeutic restoration- primary dentition 25%
D2949 Restorative foundation for an indirect restoration 25%
D2951 Pin retention- per tooth, in addition to restoration 25%
D2953 Each additional indirectly fabricated post- same tooth 25%
D2954 Prefabricated post and core in addition to crown 25%
D2955 Post removal 25%
D2957 Each additional prefabricated post- same tooth 25%
D2960 Labial veneer (resin laminate)- chairside 25%
D2961 Labial veneer (resin laminate)- laboratory 25%
D2962 Labial veneer (porcelain laminate)- laboratory 25%
D2970 Temporary Crown (Fractured Tooth) 25%
D2971 Additional procedures to construct new crown under existing partial denture 25%
D2975 Coping 25%
D2980 Crown repair necessitated by restorative material failure 25%
D2981 Inlay repair necessitated by restorative material failure 25%
D2982 Onlay repair necessitated by restorative material failure 25%
D2983 Veneer repair necessitated by restorative material failure 25%
D2990 Resin infiltration of incipient smooth surface lesions 25%
D3110 Pulp cap- direct (excluding final restoration) 25%
D3120 Pulp cap- indirect (excluding final restoration) 25%
D3220 Therapeutic pulpotomy (excluding final restoration)- removal of pulp coronal 25%
D3221 Pulpal debridement, primary and permanent teeth 25%
D3222 Partial pulpotomy for apexogenesis- permanent tooth with incomplete root 25%
D3230 Pulpal therapy (resorbable filling)- anterior, primary tooth (excluding final 25%
D3240 Pulpal therapy (resorbable filling)- posterior, primary tooth (excluding final 25%
D3331 Treatment of root canal obstruction; non-surgical access 25%
D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth 25%
D3333 Internal root repair of perforation defects 25%
D3346 Retreatment of previous root canal therapy- anterior 25%
D3347 Retreatment of previous root canal therapy- bicuspid 25%
D3348 Retreatment of previous root canal therapy- molar 25%
D3351 Apexification/recalcification- initial visit (apical closure / calcific repair of 25%
D3352 Apexification/recalcification- interim medication replacement 25%
D3353 Apexification/recalcification- final visit (includes completed root canal therapy- 25%
D3355 Pulpal regeneration- initial visit 25%
D3356 Pulpal regeneration- interim medication replacement 25%
D3357 Pulpal regeneration- completion of treatment 25%
D3410 Apicoectomy- anterior 25%
D3421 Apicoectomy- bicuspid (first root) 25%
D3425 Apicoectomy- molar (first root) 25%
D3426 Apicoectomy (each additional root) 25%
D3427 Periradicular surgery without apicoectomy 25%
D3428 Bone graft in conjunction with periradicular surgery- per tooth, single site 25%
D3429 Bone graft in conjunction with periradicular surgery- each additional 25%
D3430 Retrograde filling- per root 25%
D3431 Biologic materials to aid in soft and osseous tissue regeneration in conjunction 25%
D3432 Guided tissue regeneration, resorbable barrier, per site, in conjunction with 25%
D3450 Root amputation- per root 25%
D3470 Intentional re-implantation (including necessary splinting) 25%
D3910 Surgical procedure for isolation of tooth with rubber dam 25%
D3920 Hemisection (including any root removal), not including root canal therapy 25%
D3950 Canal preparation and fitting of preformed dowel or post 25%
D4210 Gingivectomy or gingivoplasty- four or more contiguous teeth or tooth 25%
D4211 Gingivectomy or gingivoplasty- one to three contiguous teeth or tooth 25%
D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per 25%
D4230 Anatomical crown exposure- four or more contiguous teeth per quadrant 25%
D4231 Anatomical crown exposure- one to three teeth per quadrant 25%
D4240 Gingival flap procedure, including root planing- four or more contiguous teeth 25%
D4241 Gingival flap procedure, including root planing- one to three contiguous teeth 25%
D4245 Apically positioned flap 25%
D4249 Clinical crown lengthening- hard tissue 25%
D4260 Osseous surgery (including elevation of a full thickness flap and closure)- four 25%
D4261 Osseous surgery (including elevation of a full thickness flap and closure)- one 25%
D4263 Bone replacement graft- first site in quadrant 25%
D4264 Bone replacement graft- each additional site in quadrant 25%
D4265 Biologic materials to aid in soft and osseous tissue regeneration 25%
D4266 Guided tissue regeneration- resorbable barrier, per site 25%
D4267 Guided tissue regeneration- non-resorbable barrier, per site (includes 25%
D4268 Surgical revision procedure, per tooth 25%
D4270 Pedicle soft tissue graft procedure 25%
D4273 Autogenous connective tissue graft procedure (including donor and recipient 25%
D4274 Distal or proximal wedge procedure (when not performed in conjunction with 25%
D4275 Non-autogenous connective tissue graft (including recipient site and donor 25%
D4276 Combined connective tissue and double pedicle graft, per tooth 25%
D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) 25%
D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) 25%
D4283 Autogenous connective tissue graft procedure (including donor and recipient 25%
D4285 Non-autogenous connective tissue graft procedure (including recipient surgical 25%
D4320 Provisional splinting- intracoronal 25%
D4321 Provisional splinting- extracoronal 25%
D4346 Scaling in presence of generalized moderate or severe gingival inflammation- 25%
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis 25%
D4920 Unscheduled dressing change (by someone other than treating dentist or their 25%
D4921 Gingival irrigation- per quadrant 25%
D5130 Immediate denture- maxillary 25%
D5140 Immediate denture- mandibular 25%
D5211 Maxillary partial denture- resin base (including any conventional clasps, rests 25%
D5212 Mandibular partial denture- resin base (including any conventional clasps, 25%
D5213 Maxillary partial denture- cast metal framework with resin denture bases 25%
D5214 Mandibular partial denture- cast metal framework with resin denture bases 25%
D5221 Immediate maxillary partial denture – resin base (including any conventional 25%
D5222 Immediate mandibular partial denture – resin base (including any conventional 25%
D5223 Immediate maxillary partial denture – cast metal framework with resin denture 25%
D5224 Immediate mandibular partial denture – cast metal framework with resin 25%
D5225 Maxillary partial denture- flexible base (including any clasps, rests and teeth) 25%
D5226 Mandibular partial denture- flexible base (including any clasps, rests and 25%
D5281 Removable unilateral partial denture- one piece cast metal (including clasps 25%
D5410 Adjust complete denture- maxillary 25%
D5411 Adjust complete denture- mandibular 25%
D5421 Adjust partial denture- maxillary 25%
D5422 Adjust partial denture- mandibular 25%
D5520 Replace missing or broken teeth- complete denture (each tooth) 25%
D5610 Repair resin denture base 25%
D5620 Repair cast framework 25%
D5630 Repair or replace broken clasp – per tooth 25%
D5640 Replace broken teeth – per tooth 25%
D5650 Add tooth to existing partial denture 25%
D5660 Add clasp to existing partial denture – per tooth 25%
D5670 Replace all teeth and acrylic on cast metal framework (maxillary) 25%
D5671 Replace all teeth and acrylic on cast metal framework (mandibular) 25%
D5710 Rebase complete maxillary denture 25%
D5711 Rebase complete mandibular denture 25%
D5720 Rebase maxillary partial denture 25%
D5721 Rebase mandibular partial denture 25%
D5760 Reline maxillary partial denture (laboratory) 25%
D5761 Reline mandibular partial denture (laboratory) 25%
D5810 Interim complete denture (maxillary) 25%
D5811 Interim complete denture (mandibular) 25%
D5820 Interim partial denture (maxillary) 25%
D5821 Interim partial denture (mandibular) 25%
D5850 Tissue conditioning, maxillary 25%
D5851 Tissue conditioning, mandibular 25%
D5862 Precision attachment, by report 25%
D5863 Overdenture- complete maxillary 25%
D5864 Overdenture- partial maxillary 25%
D5865 Overdenture- complete mandibular 25%
D5866 Overdenture- partial mandibular 25%
D5867 Replacement of replaceable part of semi-precision or precision attachment 25%
D5875 Modification of removable prosthesis following implant surgery 25%
D5982 Surgical stent 25%
D5986 Fluoride gel carrier 25%
D5988 Surgical splint 25%
D5991 Vesiculobullous disease medicament carrier 25%
D5993 Maintenance and cleaning of a maxillofacial prosthesis (extra- or intra-oral) 25%
D5994 Periodontal medicament carrier with peripheral seal- laboratory processed 25%
D6011 Second stage implant surgery 25%
D6012 Surgical placement of interim implant body for transitional prosthesis: 25%
D6013 Surgical placement of mini implant 25%
D6040 Surgical placement: eposteal implant 25%
D6050 Surgical placement: transosteal implant 25%
D6051 Interim abutment 25%
D6052 Semi-precision attachment abutment 25%
D6055 Connecting bar- implant supported or abutment supported 25%
D6056 Prefabricated abutment- includes modification and placement 25%
D6059 Abutment supported porcelain fused to metal crown (high noble metal) 25%
D6061 Abutment supported porcelain fused to metal crown (noble metal) 25%
D6062 Abutment supported cast metal crown (high noble metal) 25%
D6063 Abutment supported cast metal crown (predominantly base metal) 25%
D6064 Abutment supported cast metal crown (noble metal) 25%
D6065 Implant supported porcelain/ceramic crown 25%
D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, 25%
D6067 Implant supported metal crown (titanium, titanium alloy, high Ghostwriter erfahrungen Ghostwriter kosten noble metal) 25%
D6068 Abutment supported retainer for porcelain/ceramic FPD 25%
D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble 25%
D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly 25%
D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) 25%
D6072 Abutment supported retainer for cast metal FPD (high noble metal) 25%
D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) 25%
D6074 Abutment supported retainer for cast metal FPD (noble metal) 25%
D6075 Implant supported retainer for ceramic FPD 25%
D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, 25%
D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or 25%
D6080 Implant maintenance procedures when prostheses are removed and 25%
D6085 Provisional implant crown 25%
D6091 Replacement of semi-precision or precision attachment (male or female 25%
D6092 Re-cement or re-bond implant/abutment supported crown 25%
D6093 Re-cement or re-bond implant/abutment supported fixed partial denture 25%
D6094 Abutment supported crown (titanium) 25%
D6095 Repair implant abutment, by report 25%
D6100 Implant removal, by report 25%
D6101 Debridement of a peri-implant defect or defects surrounding a single implant, 25%
D6102 Debridement and osseous contouring of a peri-implant defect or defects 25%
D6103 Bone graft for repair of peri-implant defect – does not include flap entry and 25%
D6104 Bone graft at time of implant placement 25%
D6110 Implant /abutment supported removable denture for edentulous arch- 25%
D6111 Implant /abutment supported removable denture for edentulous arch- 25%
D6112 Implant /abutment supported removable denture for partially edentulous arch- 25%
D6113 Implant /abutment supported removable denture for partially edentulous arch- 25%
D6114 Implant /abutment supported fixed denture for edentulous arch- maxillary 25%
D6115 Implant /abutment supported fixed denture for edentulous arch- mandibular 25%
D6116 Implant /abutment supported fixed denture for partially edentulous arch- 25%
D6117 Implant /abutment supported fixed denture for partially edentulous arch- 25%
D6194 Abutment supported retainer crown for FPD (titanium) 25%
D6205 Pontic- indirect resin based composite 25%
D6210 Pontic- cast high noble metal 25%
D6211 Pontic- cast predominantly base metal 25%
D6212 Pontic- cast noble metal 25%
D6214 Pontic- titanium 25%
D6240 Pontic- porcelain fused to high noble metal 25%
D6241 Pontic- porcelain fused to predominantly base metal 25%
D6242 Pontic- porcelain fused to noble metal 25%
D6245 Pontic- porcelain/ceramic 25%
D6250 Pontic- resin with high noble metal 25%
D6251 Pontic- resin with predominantly base metal 25%
D6252 Pontic- resin with noble metal 25%
D6253 Provisional pontic – further treatment or completion of diagnosis necessary 25%
D6545 Retainer- cast metal for resin bonded fixed prosthesis 25%
D6548 Retainer- porcelain/ceramic for resin bonded fixed prosthesis 25%
D6549 Resin retainer- for resin bonded fixed prosthesis 25%
D6600 Retainer Inlay – porcelain/ceramic, two surfaces 25%
D6601 Retainer inlay- porcelain/ceramic, three or more surfaces 25%
D6602 Retainer Inlay – cast high noble metal, two surfaces 25%
D6603 Retainer Inlay – cast noble metal, three or more surfaces 25%
D6604 Retainer Inlay – cast predominantly base metal, two surfaces 25%
D6605 Retainer Inlay – cast predominantly base metal, three or more surfaces 25%
D6606 Retainer Inlay – cast noble metal, two surfaces 25%
D6607 Retainer Inlay – cast noble metal – three or more surfaces 25%
D6608 Retainer Onlay – porcelain/ ceramic, two surfaces 25%
D6609 Retainer Onlay porcelain/ ceramic, three or more surfaces 25%
D6610 Retainer Onlay – cast high noble metal, two surfaces 25%
D6611 Retainer Onlay – cast high noble metal, three or more surfaces 25%
D6612 Retainer Onlay – cast predominantly base metal, two surfaces 25%
D6613 Retainer Onlay – cast predominantly base metal, three or more surfaces 25%
D6614 Retainer Onlay – cast noble metal, two surfaces 25%
D6615 Retainer Onlay – cast noble metal, three or more surfaces 25%
D6624 Retainer Inlay – titanium 25%
D6634 Retainer Onlay – titanium 25%
D6710 Retainer crown- indirect resin based composite 25%
D6720 Retainer crown- resin with high noble metal 25%
D6721 Retainer crown- resin with predominantly base metal 25%
D6722 Retainer crown- resin with noble metal 25%
D6740 Retainer crown- porcelain/ceramic 25%
D6780 Retainer crown- 3/4 cast high noble metal 25%
D6781 Retainer crown- 3/4 cast predominantly base metal 25%
D6782 Retainer crown- 3/4 cast noble metal 25%
D6783 Retainer crown- 3/4 porcelain/ceramic 25%
D6790 Retainer crown- full cast high noble metal 25%
D6791 Retainer crown – full cast predominantly base metal 25%
D6792 Retainer crown – full cast noble metal 25%
D6793 Provisional retainer crown – further treatment or completion of diagnosis 25%
D6794 Retainer crown- titanium 25%
D6920 Connector bar 25%
D6930 Re-cement or re-bond fixed partial denture 25%
D6940 Stress breaker 25%
D6950 Precision attachment 25%
D6980 Fixed partial denture repair necessitated by restorative material failure 25%
D6985 Pediatric partial denture, fixed 25%
D7111 Extraction, coronal remnants- deciduous tooth 25%
D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning 25%
D7220 Removal of impacted tooth- soft tissue 25%
D7230 Removal of impacted tooth- partially bony 25%
D7240 Removal of impacted tooth- completely bony 25%
D7241 Removal of impacted tooth- completely bony, with unusual surgical 25%
D7250 Surgical removal of residual tooth roots (cutting procedure) 25%
D7251 Coronectomy- intentional partial tooth removal 25%
D7260 Oroantral fistula closure 25%
D7261 Primary closure of a sinus perforation 25%
D7270 Tooth re-implantation and/or stabilization of accidentally evulsed or displaced 25%
D7280 Surgical access of an unerupted tooth 25%
D7282 Mobilization of erupted or malpositioned tooth to aid eruption 25%
D7283 Placement of device to facilitate eruption of impacted tooth 25%
D7285 Incisional biopsy of oral tissue- hard (bone, tooth) 25%
D7286 Incisional biopsy of oral tissue- soft 25%
D7288 Brush biopsy- transepithelial sample collection 25%
D7290 Surgical repositioning of teeth 25%
D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report 25%
D7292 Surgical placement of temporary anchorage device [screw retained plate] 25%
D7293 Surgical placement of temporary anchorage device requiring flap; includes 25%
D7294 Surgical placement of temporary anchorage device without flap; includes 25%
D7295 Harvest of bone for use in autogenous grafting procedure 25%
D7310 Alveoloplasty in conjunction with extractions- four or more teeth or tooth 25%
D7311 Alveoloplasty in conjunction with extractions- one to three teeth or tooth 25%
D7320 Alveoloplasty not in conjunction with extractions- four or more teeth or tooth 25%
D7340 Vestibuloplasty- ridge extension (secondary epithelialization) 25%
D7350 Vestibuloplasty- ridge extension (including soft tissue grafts, muscle 25%
D7410 Excision of benign lesion up to 1.25 cm 25%
D7411 Excision of benign lesion greater than 1.25 cm 25%
D7412 Excision of benign lesion, complicated 25%
D7413 Excision of malignant lesion up to 1.25 cm 25%
D7414 Excision of malignant lesion greater than 1.25 cm 25%
D7415 Excision of malignant lesion, complicated 25%
D7440 Excision of malignant tumor- lesion diameter up to 1.25 cm 25%
D7441 Excision of malignant tumor- lesion diameter greater than 1.25 cm 25%
D7450 Removal of benign odontogenic cyst or tumor- lesion diameter up to 1.25 cm 25%
D7451 Removal of benign odontogenic cyst or tumor- lesion diameter greater than 25%
D7460 Removal of benign nonodontogenic cyst or tumor- lesion diameter up to 1.25 25%
D7461 Removal of benign nonodontogenic cyst or tumor- lesion diameter greater 25%
D7471 Removal of lateral exostosis (maxilla or mandible) 25%
D7472 Removal of torus palatinus 25%
D7473 Removal of torus mandibularis 25%
D7485 Surgical reduction of osseous tuberosity 25%
D7510 Incision and drainage of abscess- intraoral soft tissue 25%
D7511 Incision and drainage of abscess- intraoral soft tissue- complicated (includes 25%
D7520 Incision and drainage of abscess- extraoral soft tissue 25%
D7521 Incision and drainage of abscess- extraoral soft tissue- complicated (includes 25%
D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue 25%
D7540 Removal of reaction producing foreign bodies, musculoskeletal system 25%
D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone 25%
D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body 25%
D7640 Mandible- closed reduction (teeth immobilized, if present) 25%
D7670 Alveolus- closed reduction, may include stabilization of teeth 25%
D7870 Arthrocentesis 25%
D7880 Occlusal orthotic device, by report 25%
D7881 Occlusal orthotic device adjustment 25%
D7910 Suture of recent small wounds up to 5 cm 25%
D7911 Complicated suture- up to 5 cm 25%
D7921 Collection and application of autologous blood concentrate product 25%
D7949 LeFort II or LeFort III- with bone graft 25%
D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla- 25%
D7951 Sinus augmentation with bone or bone substitutes via a lateral open approach 25%
D7952 Sinus augmentation via a vertical approach 25%
D7953 Bone replacement graft for ridge preservation- per site 25%
D7955 Repair of maxillofacial soft and/or hard tissue defect 25%
D7960 Frenulectomy- also known as frenectomy or frenotomy- separate procedure 25%
D7963 Frenuloplasty 25%
D7970 Excision of hyperplastic tissue – per arch 25%
D7971 Excision of pericoronal gingiva 25%
D7972 Surgical reduction of fibrous tuberosity 25%
D7980 Sialolithotomy 25%
D7997 Appliance removal (not by dentist who placed appliance), includes removal of 25%
D7998 Intraoral placement of a fixation device not in conjunction with a fracture 25%
D8010 Limited orthodontic treatment of the primary dentition 25%
D8020 Limited orthodontic treatment of the transitional dentition 25%
D8030 Limited orthodontic treatment of the adolescent dentition 25%
D8040 Limited orthodontic treatment of the adult dentition 25%
D8050 Interceptive orthodontic treatment of the primary dentition 25%
D8060 Interceptive orthodontic treatment of the transitional dentition 25%
D8070 Comprehensive orthodontic treatment of the transitional dentition 25%
D8080 Comprehensive orthodontic treatment of the adolescent dentition 25%
D8090 Comprehensive orthodontic treatment of the adult dentition 25%
D8210 Removable appliance therapy 25%
D8220 Fixed appliance therapy 25%
D8660 Pre-orthodontic treatment examination to monitor growth and development 25%
D8670 Periodic orthodontic treatment visit 25%
D8680 Orthodontic retention (removal of appliances, construction and placement of 25%
D8681 Removable orthodontic retainer adjustment 25%
D8690 Orthodontic treatment (alternative billing to a contract fee) 25%
D8691 Repair of orthodontic appliance 25%
D8692 Replacement of lost or broken retainer 25%
D8693 Re-cement or re-bond fixed retainer 25%
D8694 Repair of fixed retainers, includes reattachment 25%
D9110 Palliative (emergency) treatment of dental pain – minor procedure 25%
D9120 Fixed partial denture sectioning 25%
D9210 Local anesthesia not in conjunction with operative or surgical procedures 25%
D9211 Regional block anesthesia 25%
D9212 Trigeminal division block anesthesia 25%
D9215 Local anesthesia in conjunction with operative or surgical procedures 25%
D9219 Evaluation for deep sedation or general anesthesia 25%
D9223 Deep sedation/general anesthesia – each 15 minute increment 25%
D9230 Inhalation of nitrous oxide/analgesia, anxiolysis 25%
D9243 Intravenous moderate (conscious) sedation/analgesia – each 15 minute 25%
D9248 Non-intravenous conscious sedation 25%
D9310 Consultation- diagnostic service provided by dentist or physician other than 25%
D9410 House/extended care facility call 25%
D9420 Hospital or ambulatory surgical center call 25%
D9430 Office visit for observation (during regularly scheduled hours)- no other 25%
D9440 Office visit- after regularly scheduled hours 25%
D9450 Case presentation, detailed and extensive treatment planning 25%
D9610 Therapeutic parenteral drug, single administration 25%
D9612 Therapeutic parenteral drugs, two or more administrations, different 25%
D9630 Other drugs and/or medicaments, by report 25%
D9910 Application of desensitizing medicament 25%
D9911 Application of desensitizing resin for cervical and/or root surface, per tooth 25%
D9920 Behavior management, by report 25%
D9930 Treatment of complications (post-surgical)- unusual circumstances, by report 25%
D9932 Cleaning and inspection of removable complete denture, maxillary 25%
D9933 Cleaning and inspection of removable complete denture, mandibular 25%
D9934 Cleaning and inspection of removable partial denture, maxillary 25%
D9935 Cleaning and inspection of removable partial denture, mandibular 25%
D9940 Occlusal guard, by report 25%
D9941 Fabrication of athletic mouthguard 25%
D9942 Repair and/or reline of occlusal guard 25%
D9943 Occlusal guard adjustment 25%
D9950 Occlusion analysis – mounted case 25%
D9951 Occlusal adjustment- limited 25%
D9952 Occlusal adjustment- complete 25%
D9970 Enamel microabrasion 25%
D9971 Odontoplasty 1-2 teeth; includes removal of enamel projections 25%
D9972 External bleaching- per arch- performed in office 25%
D9973 External bleaching- per tooth 25%
D9974 Internal bleaching- per tooth 25%
D9975 External bleaching for home application, per arch; includes materials and 25%
D9991 Dental case management- addressing appointment compliance barriers 25%
D9992 Dental case management – care coordination 25%
ORTHODONTIC CODES
Code Description Member Savings*
D8010 Limited orthodontic treatment of the primary dentition 0%
D8020 Limited orthodontic treatment of the transitional dentition 0%
D8030 Limited orthodontic treatment of the adolescent dentition 0%
D8040 Limited orthodontic treatment of the adult dentition 0%
D8050 Interceptive orthodontic treatment of the primary dentition 0%
D8060 Interceptive orthodontic treatment of the transitional dentition 0%
D8070 Comprehensive orthodontic treatment of the transitional dentition 0%
D8080 Comprehensive orthodontic treatment of the adolescent dentition 0%
D8090 Comprehensive orthodontic treatment of the adult dentition 0%
D8210 Removable appliance therapy 0%
D8220 Fixed appliance therapy 0%
D8660 Pre-orthodontic treatment examination to monitor growth and development 0%
D8670 Periodic orthodontic treatment visit 0%
D8680 Orthodontic retention (removal A appliances, construction and placement of retainer(s)) 0%
D8681 Removable orthodontic retainer adjustment 0%
D8690 Orthodontic treatment (alternative billing to a contract fee) 0%
D8691 Repaire of orthodontic appliance 0%
D8692 Replacement of lost or broken retainer 0%
D8693 Re-cement or re-bond fixed retainer 0%
D8694 Repair of fixed retainers, includes reattachment 0%
D8999 Unspecified orthodontic procedure, by report 0%
D0150 Comprehensive oral evaluation 0%
D0330 Panoramic radiographic image 0%
D0340 2D Cephalornetric radiographic image 0%
D0350 2D oral/facial photographic image obtained intra-orally or extra-orally 0%
D0351 3D photographic image 0%
D0364 Cone beam CT capture and interpretation with limited field of view — less than one whole jaw 0%
D0365 Cone beam CT capture and interpretation with field of view of one full dental arch 0%
D0366 Cone beam CT capture and interpretation with field of view of one full dental arch 0%
D0368 Cone beam CT capture and interpretation for TMJ series including two or more exposures 0%
D0380 Cone beam CT image capture with limited field of view — less than one whole jaw (image capture only) 0%
D0381 Cone beam CT image capture with field of view of one full dental arch 0%
D0382 Cone beam CT image capture with field of view of one full dental arch 0%
D0383 Cone beam CT image capture with f Aid of view of both jaws, with or without cranium (image capture only) 0%
D0384 Cone beam CT image capture for TMJ series including two or more exposures (image capture only) 0%
D0470 Diagnostic casts — Also known as diagnostic models or study models. 0%
D7292 Placement of temporary anchorage device [screw retained plate] requiring flap; includes device removal 0%
D7293 Placement of temporary anchorage device requiring flap; includes device removal 0%
D7294 Placement of temporary anchorage device without flap; includes device removal 0%
D7880 Occlusal orthotic device, by report — Presently includes splints provided for treatment of temporomandibular joint dysfunction. 0%
D7881 Occlusal orthotic device adjustment 0%
D9450 Case presentation, detailed and extensive treatment planning — Established patient. Not performed on same day as evaluation 0%
D9940 Occlusal guard, by report — Removable dental appliances, which are designed to minimize the effects of bruxism (grinding) and other occlusal factors. 0%
D9971 Odontoplasty 1 — 2 teeth: includes removal of enamel projections. 0%

*Member Savings is the amount the member pays less their affiliated provider’s Retail Fee. The Retail Fee refers to the normal rate charged to uninsured patients for services rendered by the provider.  Retail Fees and Member Savings can vary by affiliated provider. Plan savings and incentives are not available to patients whose dental care is covered by Medicaid.

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