Cost of Plan:
Subscriber $7.95
Subscriber Plus 1 dependent $14.00
Subscriber plus Family $19.00
Plus one time enrollment fee $15.00
Take this plan before the 21st of any month and you can use it the 1st of the following month.
This plan works right away on all major dental work! No waiting Periods!
This is Margie Turner, you will need to call me at 214 399-3975 after you have had time to look at this plan.
I will be happy to sign you up for this plan when you are ready to take it out.
I will be happy to sign you up for this plan when you are ready to take it out.
This is Real Dental Insurance- I can sign you up over the phone or I can set up an appointment with you to come out to your home and visit or meet you at your local coffee shop. your choice. Monday- Saturday 8am / 8pm
This is the fee chart for ORAQUEST Dental - If you have any questions please contact me.
OraQuest Dental plans Fee Schedule of benefits
PREMIER – 120-01 PLAN
This plan allows for a $7 office visit co-payment per visit to cover administrative and supply expenses.
Diagnostics Services:
00120 Periodic Oral Evaluation ……………………………………………………………………………..…….$4
00140 Limited Oral Evaluation …………………………………………………………………………………….$6
00150 Comprehensive Oral Evaluation …………………………………………………………………………..$5
00210 Intraoral complete series(including bite wings)…………………………………………………………..$11
00220 Intraoral periodical – first film …… ……………………………………………………………………….$2
00230 Intraoral periodical – each additional film ………………………………………………………………..$2
00240 Intraoral Occlusion film ………………………………………………………………………………………$3
00250 Extra oral – first film …………………………………………………………………………………………$4
00260 Extra oral – each additional film ……………………………………………………………………………$3
00270 Bite wings – Single film………………………………………………………………………………………$3
00272 Bite wings – two film …………………………………………………………………………………………$3
00274 Bite wings – four film…………………………………………………………………………………………$5
00330 Panoramic ……………………………………………………………………………………………………$9
00415 Bacteriologic studies for determination of pathology agents …………………………………………..$0
00425 Caries susceptibility tests …………………………………………………………………………………..$0
00460 Pulp Vitality tests …………………………………………………………………………………………….$0
00470 Diagnostic casts ……………………………………………………………………………………………..$0
Preventive Services
01110 Prophylaxis – Adult …………………………………………………………………………………………..$9
01120 Prophylaxis – Child …………………………………………………………………………………………..$6
01201 Topical Application of Fluoride (including prophylaxis) – Child…………………………………………..$6
01203 Topical Application of Fluoride (including prophylaxis) – Child… ………………………………………$1
01204 Topical Application of Fluoride (Including Prophylaxis) – Adult …………………………………………$0
01310 Nutritional Counseling for the control of dental disease …………………………………………………$0
01330 Oral Hygiene Instructions ……………………………………………………………………………………$0
01351 Sealant per Tooth (for children under 14) ………………………………………………………………..$20
01510 Space Maintainer – fixed – unilateral ……………………………………………………………………$109
01515 Space Maintainer – fixed- bilateral ………………………………………………………………………$144
01520 Space Maintainer – Removable- unilateral……………………………………………………………..$135
01525 Space Maintainer – removable – bilateral ……………………………………………………………...$172
01550 Cementation of space maintainer ………………………………………………………………………..$23
Restorative Services
02140 Amalgam – One surface, primary permanent ………………………………………………………….$35
02150 Amalgam – two surface, primary permanent …………………………………………………………..$45
02160 Amalgam – three surface, primary permanent …………………………………………………………$56
02161 Amalgam – four or more surface, primary permanent …………………………………………………$69
02330 Resin – one surface – anterior……………………………………………………………………………$44
02331 Resin – two surface, anterior ……………………………………………………………………………..$57
02332 Resin – three surface, anterior……………………………………………………………………………$69
02335 Resin – four or more surface, or with incisal angle, anterior…………………………………………..$82
02390 Composite resin crown – anterior……………………………………………………………………….$97
02391 Resin – one surface, posterior ………………………………………………………………………….$53
02392 Resin – two surface, posterior ………………………………………………………………………….$63
02393 Resin – three surface, posterior………………………………………………………………………...$74
02510 Inlay – metallic - one surface ………………………………………………………………………….$325
02520 Inlay – metallic – two surface …………………………………………………………………………$365
02530 Inlay – metallic – three or more surfaces……………………………………………………………..$395
02543 Onlay- metallic –three surfaces ……………………………………………………………………….$405
02544 Onlay – metallic – four or more surfaces ……………………………………………………………$436
02610 Inlay – Porcelain ceramic – one surface …………………………………………………………….$275
02620 Inlay – Porcelain ceramic – two surfaces ……………………………………………………………$311
02630 Inlay – Porcelain ceramic – three or more surfaces ………………………………………………..$351
02642 Onlay – Porcelain ceramic – two surfaces ………………………………………………………….$324
02643 Onlay – Porcelain ceramic – three surfaces ………………………………………………………..$329
02644 Onlay – Porcelain ceramic – four or more surfaces ………………………………………………..$371
02650 Inlay – Composite / Resin – one surfaces(laboratory processed) ………………………………..$224
02651 Inlay – Composite / Resin – two surfaces(laboratory processed)…………………………………$270
02652 Inlay – Composite / Resin – three surfaces(laboratory processed) ………………………………$292
02710 Crown – Resin (Laboratory) …………………………………………………………………………..$207
02720 Crown –Resin with high noble metal ………………………………………………………………….$407
02721 Crown – Resin with predominantly base metal ………………………………………………………$395
02722 Crown –Resin with noble metal ………………………………………………………………………..$401
02750 Crown – Porcelain fused to high noble metal ………………………………………………………..$407
02751 Crown – Porcelain fused to predominantly base metal ……………………………………………..$395
02752 Crown – Porcelain fused to noble metal ………………………………………………………………$401
02780 Crown – ¾ cast metallic …………………………………………………………………………………$407
02790 Crown – Full cast high noble metal ……………………………………………………………………$407
02791 Crown – Full cast predominantly base metal …………………………………………………………$395
02792 Crown – Full cast noble metal ………………………………………………………………………….$401
02910 Re-cement Inlay (By other than treatment provider) ………………………………………………….$26
02920 Re-cement Crown (By other that treatment provider) ………………………………………………...$26
02930 Prefabricated Stainless steel crown (Primary Tooth) …………………………………………………$83
02931 Prefabricated steel crown (permanent Tooth) …………………………………………………………$93
02940 Sedative Filling (Temporary filling) ………………………………………………………………………$27
02950 Core buildup, including any pins ……………………………………………………………………….$125
02951 Pin retention – per tooth in addition to restoration …………………………………………………….$25
02952 Cast post and core in addition to crown……………………………………………………………….$156
02954 Prefabricated post and core in addition to crown ……………………………………………………$128
Endodontics Services
03110 Pulp cap – direct (excluding final restoration) …………………………………………………………$35
03120 Pulp cap – indirect (excluding final restoration) ……………………………………………………….$35
03220 Therapeutic pulpotomy (excluding final restoration) ………………………………………………….$65
Root Canal
03310 Anterior (excluding final restoration) …………………………………………………………………..$184
03320 Bicuspid (excluding final restoration) ………………………………………………………………….$226
03330 Molar (excluding final restoration) ……………………………………………………………………..$305
Periodontal Services
04210 Gingivectomy or gingivoplasty – Per Quadrant …………………………………………………………$179
04211 Gingivectomy or gingivoplasty – Per Tooth……………………………………………………………….$51
04320 Provisional Splinting – Intraoral ……………………………………………………………………………$131
04321 Provisional Splinting – extra oral …………………………………………………………………………..$120
04341 Periodontal Scaling and Root Planning – Per Quadrant ………………………………………………..$79
04365 Gross Scaling (full mouth debridement to enable periodontal evaluation) …………………………….$35
04910 Periodontal Maintenance procedures (following active therapy) ………………………………………..$41
Prosthodontics (Removable) Services
05110 Complete Upper Dentures – Maxillary …………………………………………………………………….$525
05120 Complete Lower Dentures – Mandibular ………………………………………………………………….$525
05130 Immediate Maxillary (Upper) ……………………………………………………………………………….$553
05140 Immediate Mandibular (Lower) …………………………………………………………………………….$553
05211 Upper Partial Denture – Resin base (Including any conventional clasps, rests and teeth) ………….$469
05212 Lower Partial Denture – Resin base (Including any conventional clasps, rests and teeth) …………$469
05213 Upper Partial Denture – cast metal framework with resin denture bases(including any conventional clasps, rests and teeth) ……………………………………………………………………………………………………...$595
05214 Lower Partial Denture – Cast metal framework with resin denture bases (Including and conventional clasps, rests, teeth) ……………………………………………………………………………………………………………$595
05510 Repair Broken Complete Denture base …………………………………………………………………….$85
05520 Replace Missing or Broken teeth – Complete denture (Each Tooth) ……………………………………$55
05610 Repair Resin Denture Base …………………………………………………………………………………..$85
05620 Repair Cast Framework ……………………………………………………………………………………….$85
05630 Repair or Replace Broken Clasp ……………………………………………………………………………..$85
05640 Replace Broken Teeth – Per Tooth …………………………………………………………………………..$55
05650 Add Tooth to Existing Partial Denture ………………………………………………………………………..$85
05660 Add Clasp to Existing Partial Denture ………………………………………………………………………..$85
05710 Rebase Complete Upper Denture (each) …………………………………………………………………..$163
05711 Rebase Complete Lower Denture (each) ……………………………………………………………………$172
05720 Rebase Upper Partial Denture (each) ……………………………………………………………………….$161
05721 Rebase Lower Partial Denture (each) ………………………………………………………………………$163
05730 Reline Complete Upper Denture (chairside) (each) …………………………………………………………$94
05731 Reline Complete Lower Denture (chairside) (each) …………………………………………………………$92
05740 Reline Upper Partial Denture (chairside) (each) ……………………………………………………………..$82
05741 Reline Lower Partial Denture (chairside) (each) ……………………………………………………………..$82
05750 Reline Complete Upper Denture (Laboratory) (each) ………………………………………………………$165
05751 Reline Complete Lower Denture (Laboratory) (each) ………………………………………………………$165
05760 Reline Upper Partial Denture (Laboratory) (each) …………………………………………………………..$165
05761 Reline Lower Partial Denture (Laboratory) (each) …………………………………………………………..$165
05810 Interim Complete Denture Upper (each) ……………………………………………………………………..$201
05811 Interim Complete Denture Lower (each) ……………………………………………………………………..$201
05820 Interim Partial Denture Upper (each) …………………………………………………………………………$144
05821 Interim Partial Denture Lowe (each) ………………………………………………………………………….$161
05850 Tissue Conditioning Upper per unit …………………….………………………………………………………$60
05851 Tissue Conditioning Lower per unit …………………………………………………………………………….$60
Prosthodontics (FIXED) Services
06210 Pontic – Cast High Noble Metal ……………………………………………………………………………..$407
06211 Pontic – Cast predominantly Base Metal …………………………………………………………………..$395
06212 Pontic – Cast Noble Metal ……………………………………………………………………………………$401
06240 Pontic – Porcelain Fused to High Metal …………………………………………………………………….$407
06241 Pontic – Porcelain Fused to Base Metal ……………………………………………………………………$395
06242 Pontic – Porcelain Fused Noble Metal ………………………………………………………………………$401
06250 Pontic – Resin with high noble predominantly base noble metal …………………………………………$407
06251 Pontic – Resin with high noble predominantly base noble metal ………………………………………...$395
06252 Pontic – Resin with high noble predominantly base noble metal …………………………………………$401
06602 Inlay – Cast high noble metal, two surfaces …………………………………………………………………$385
06603 Inlay – Cast high noble metal three or more surfaces ……………………………………………………..$395
06604 Inlay – Cast predominantly base metal , two surfaces ………………………………………………………$365
06605 Inlay – Cast predominantly base metal , three or more surfaces ………………………………………….$395
06606 Inlay – Cast noble metal , two surfaces ……………………………………………………………………..$365
06607 Inlay – Cast noble metal, three or more surfaces ………………………………………………………….$395
06610 Onlay – Cast high noble metal , two surfaces ………………………………………………………………$405
06611 Onlay – Cast high noble metal , three or more surfaces …………………………………………………..$436
06612 Onlay – Cast predominantly base metal, two surfaces ……………………………………………………$405
06613 Onlay – Cast predominantly base metal, three or more surfaces ………………………………………..$436
06614 Onlay – Cast noble metal , two surfaces …………………………………………………………………….$405
06615 Onlay – Cast noble metal , three or more surfaces ………………………………………………………..$436
06545 Retainer – Cast metal for resin bonded fixed prosthesis ………………………………………………….$245
06720 Crown – Resin with high noble metal ……………………………………………………………………….$407
06721 Crown – Resin with predominantly base metal …………………………………………………………….$395
06722 Crown – Resin with noble metal ………………………………………………………………………….…$401
06750 Crown – Porcelain fused to high noble metal ………………………………………………………………$407
06751 Crown – Porcelain fused predominantly base metal ……………………………………………………..$395
06752 Crown – Porcelain fused noble metal ………………………………………………………………………$401
06780 Crown – ¾ Cast high noble metal …………………………………………………………………………..$407
06790 Crown – Full cast high noble metal ………………………………………………………………………...$407
06791 Crown – Full cast predominantly base metal ………………………………………………………………$395
06792 Crown – Full cast noble metal ………………………………………………………………………………$401
06930 Re-cement Bridge …………………………………………………………………………………………….$39
06940 Stress Breaker ……………………………………………………………………………………………….$145
Oral Surgery Services
07140 Extraction, erupted tooth or exposed root (Elevation and/or forceps removal) …………………………$42-56
07210 Surgical removal of erupted Tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated……………………………………………………………………………………$84/105
07220 Removal of impacted Tooth – soft tissue …………………………………………………………………..$110/126
07250 Surgical Removal of residual tooth …………………………………………………………………………..$94/105
07310 Alveoloplasty in conjunction with Extractions – Per Quadrant …………………………………………….$86
07320 Alveoloplasty not in conjunction with Extractions – Per Quadrant ………………………………………..$137
07510 Incision and drainage of Abscess – intraoral soft tissue ……………………………………………………..$61
Adjective General Services
09110 Emergency treatment of dental pain ………………………………………………………………………..$6
09211 Regional Block Anesthesia (Except for Diagnostic purposes) …………………………………………….$0
09212 Trigeminal Division Block Anesthesia (Except for diagnostic purpose) …………………………………..$0
09215 Local Anesthesia (except for diagnostic purpose) …………………………………………………………..$0
09230 Nitrous Oxide (per 15 minutes) ………………………………………………………………………………$12
09310 Consultation (By provider other than treatment provider) …………………………………………………$11
09430 Office Visit During Regular Hours ($9 Office visit Copay not charged) ………………………………….$11
09440 Office Visit After Regular Hours ($9 Office visit copay not charged) …………………………………….$55
09941 Fabrication of Athletic mouth guards ………………………………………………………………………..$46
09950 Occlusion Analysis – Mounted case …………………………………………………………………………$84
09951 Occlusion Adjustment – Limited……………………………………………………………………………...$45
09952 Occlusion Adjustment – Complete …………………………………………………………………………..$193
09999 Unspecified Adjudicative procedure, by report………………………………………………………………..$9
Other Services
Temporary Crown with Permanent Crown ………………………………………………………………………….$0
Infection Control Charges …………………………………………………………………………………………….$0
Office or Dental Supple ……………………………………………………………………………………………….$0
Laboratory Expenses ………………………………………………………………………………………………….$0
Equipment and instruments necessary for treatment ………………………………………………………………$0
Any Other General Overhead expenses …………………………………………………………………………….$0
Acid edge charge ……………………………………………………………………………………………………..$0
Duplication of X-ray …………………………………………………………………………………………………...$0
Periodontal probing done with initial and periodic oral examinations …………………………………………….$0
Used of bonding materials (all bond, Amalga bond or comparable ………………………………………………$0
Materials – refer to code 09999 ……………………………………………………………………………………….$9
Additional charges of $125.00 per unit for multiple crown units (6 or more units of crown and/or bridge is same treatment plan and requires complete rehabilitation planning)
All procedures not included in this CPT CODE listing have a copayment of 75% of the dentist’s usual and customary charge. All procedures might not be performed by participating general dentists who do performs these services and are not applicable for services performed by a participating specialty dentist. Therefore, you are encouraged to discuss the availability of the scheduled services with your participating general dentist.
Specialty Dentists – Should you need a specialty dentist, you may be referred by your participating general dentist, or you may refer yourself to any participating specialty dentist from our directory. Upon identification of yourself as an Ora Quest member, your co-payment will be the following percentage of the specialty dentist’s usual fee.
Endodontist (root canals) 80%, Oral surgeon (Tooth Extractions) 75%, Orthodontist 75%, Periodontist (gum problems) 75%, Pediatric dentist (Children’s dentist) 75%,
Missed Appointment – A missed appointment without 24 hours’ notice may result in a missed appointment charge made by the participating general and specialty dentists. Please discuss this with your selected participating dentist.
Children under 5 years of age- Children under 5 years of age may be referred to a pediatric dentist. Please discuss this with your selected participating general dentist.
PREMIER – 120-01 PLAN
This plan allows for a $7 office visit co-payment per visit to cover administrative and supply expenses.
Diagnostics Services:
00120 Periodic Oral Evaluation ……………………………………………………………………………..…….$4
00140 Limited Oral Evaluation …………………………………………………………………………………….$6
00150 Comprehensive Oral Evaluation …………………………………………………………………………..$5
00210 Intraoral complete series(including bite wings)…………………………………………………………..$11
00220 Intraoral periodical – first film …… ……………………………………………………………………….$2
00230 Intraoral periodical – each additional film ………………………………………………………………..$2
00240 Intraoral Occlusion film ………………………………………………………………………………………$3
00250 Extra oral – first film …………………………………………………………………………………………$4
00260 Extra oral – each additional film ……………………………………………………………………………$3
00270 Bite wings – Single film………………………………………………………………………………………$3
00272 Bite wings – two film …………………………………………………………………………………………$3
00274 Bite wings – four film…………………………………………………………………………………………$5
00330 Panoramic ……………………………………………………………………………………………………$9
00415 Bacteriologic studies for determination of pathology agents …………………………………………..$0
00425 Caries susceptibility tests …………………………………………………………………………………..$0
00460 Pulp Vitality tests …………………………………………………………………………………………….$0
00470 Diagnostic casts ……………………………………………………………………………………………..$0
Preventive Services
01110 Prophylaxis – Adult …………………………………………………………………………………………..$9
01120 Prophylaxis – Child …………………………………………………………………………………………..$6
01201 Topical Application of Fluoride (including prophylaxis) – Child…………………………………………..$6
01203 Topical Application of Fluoride (including prophylaxis) – Child… ………………………………………$1
01204 Topical Application of Fluoride (Including Prophylaxis) – Adult …………………………………………$0
01310 Nutritional Counseling for the control of dental disease …………………………………………………$0
01330 Oral Hygiene Instructions ……………………………………………………………………………………$0
01351 Sealant per Tooth (for children under 14) ………………………………………………………………..$20
01510 Space Maintainer – fixed – unilateral ……………………………………………………………………$109
01515 Space Maintainer – fixed- bilateral ………………………………………………………………………$144
01520 Space Maintainer – Removable- unilateral……………………………………………………………..$135
01525 Space Maintainer – removable – bilateral ……………………………………………………………...$172
01550 Cementation of space maintainer ………………………………………………………………………..$23
Restorative Services
02140 Amalgam – One surface, primary permanent ………………………………………………………….$35
02150 Amalgam – two surface, primary permanent …………………………………………………………..$45
02160 Amalgam – three surface, primary permanent …………………………………………………………$56
02161 Amalgam – four or more surface, primary permanent …………………………………………………$69
02330 Resin – one surface – anterior……………………………………………………………………………$44
02331 Resin – two surface, anterior ……………………………………………………………………………..$57
02332 Resin – three surface, anterior……………………………………………………………………………$69
02335 Resin – four or more surface, or with incisal angle, anterior…………………………………………..$82
02390 Composite resin crown – anterior……………………………………………………………………….$97
02391 Resin – one surface, posterior ………………………………………………………………………….$53
02392 Resin – two surface, posterior ………………………………………………………………………….$63
02393 Resin – three surface, posterior………………………………………………………………………...$74
02510 Inlay – metallic - one surface ………………………………………………………………………….$325
02520 Inlay – metallic – two surface …………………………………………………………………………$365
02530 Inlay – metallic – three or more surfaces……………………………………………………………..$395
02543 Onlay- metallic –three surfaces ……………………………………………………………………….$405
02544 Onlay – metallic – four or more surfaces ……………………………………………………………$436
02610 Inlay – Porcelain ceramic – one surface …………………………………………………………….$275
02620 Inlay – Porcelain ceramic – two surfaces ……………………………………………………………$311
02630 Inlay – Porcelain ceramic – three or more surfaces ………………………………………………..$351
02642 Onlay – Porcelain ceramic – two surfaces ………………………………………………………….$324
02643 Onlay – Porcelain ceramic – three surfaces ………………………………………………………..$329
02644 Onlay – Porcelain ceramic – four or more surfaces ………………………………………………..$371
02650 Inlay – Composite / Resin – one surfaces(laboratory processed) ………………………………..$224
02651 Inlay – Composite / Resin – two surfaces(laboratory processed)…………………………………$270
02652 Inlay – Composite / Resin – three surfaces(laboratory processed) ………………………………$292
02710 Crown – Resin (Laboratory) …………………………………………………………………………..$207
02720 Crown –Resin with high noble metal ………………………………………………………………….$407
02721 Crown – Resin with predominantly base metal ………………………………………………………$395
02722 Crown –Resin with noble metal ………………………………………………………………………..$401
02750 Crown – Porcelain fused to high noble metal ………………………………………………………..$407
02751 Crown – Porcelain fused to predominantly base metal ……………………………………………..$395
02752 Crown – Porcelain fused to noble metal ………………………………………………………………$401
02780 Crown – ¾ cast metallic …………………………………………………………………………………$407
02790 Crown – Full cast high noble metal ……………………………………………………………………$407
02791 Crown – Full cast predominantly base metal …………………………………………………………$395
02792 Crown – Full cast noble metal ………………………………………………………………………….$401
02910 Re-cement Inlay (By other than treatment provider) ………………………………………………….$26
02920 Re-cement Crown (By other that treatment provider) ………………………………………………...$26
02930 Prefabricated Stainless steel crown (Primary Tooth) …………………………………………………$83
02931 Prefabricated steel crown (permanent Tooth) …………………………………………………………$93
02940 Sedative Filling (Temporary filling) ………………………………………………………………………$27
02950 Core buildup, including any pins ……………………………………………………………………….$125
02951 Pin retention – per tooth in addition to restoration …………………………………………………….$25
02952 Cast post and core in addition to crown……………………………………………………………….$156
02954 Prefabricated post and core in addition to crown ……………………………………………………$128
Endodontics Services
03110 Pulp cap – direct (excluding final restoration) …………………………………………………………$35
03120 Pulp cap – indirect (excluding final restoration) ……………………………………………………….$35
03220 Therapeutic pulpotomy (excluding final restoration) ………………………………………………….$65
Root Canal
03310 Anterior (excluding final restoration) …………………………………………………………………..$184
03320 Bicuspid (excluding final restoration) ………………………………………………………………….$226
03330 Molar (excluding final restoration) ……………………………………………………………………..$305
Periodontal Services
04210 Gingivectomy or gingivoplasty – Per Quadrant …………………………………………………………$179
04211 Gingivectomy or gingivoplasty – Per Tooth……………………………………………………………….$51
04320 Provisional Splinting – Intraoral ……………………………………………………………………………$131
04321 Provisional Splinting – extra oral …………………………………………………………………………..$120
04341 Periodontal Scaling and Root Planning – Per Quadrant ………………………………………………..$79
04365 Gross Scaling (full mouth debridement to enable periodontal evaluation) …………………………….$35
04910 Periodontal Maintenance procedures (following active therapy) ………………………………………..$41
Prosthodontics (Removable) Services
05110 Complete Upper Dentures – Maxillary …………………………………………………………………….$525
05120 Complete Lower Dentures – Mandibular ………………………………………………………………….$525
05130 Immediate Maxillary (Upper) ……………………………………………………………………………….$553
05140 Immediate Mandibular (Lower) …………………………………………………………………………….$553
05211 Upper Partial Denture – Resin base (Including any conventional clasps, rests and teeth) ………….$469
05212 Lower Partial Denture – Resin base (Including any conventional clasps, rests and teeth) …………$469
05213 Upper Partial Denture – cast metal framework with resin denture bases(including any conventional clasps, rests and teeth) ……………………………………………………………………………………………………...$595
05214 Lower Partial Denture – Cast metal framework with resin denture bases (Including and conventional clasps, rests, teeth) ……………………………………………………………………………………………………………$595
05510 Repair Broken Complete Denture base …………………………………………………………………….$85
05520 Replace Missing or Broken teeth – Complete denture (Each Tooth) ……………………………………$55
05610 Repair Resin Denture Base …………………………………………………………………………………..$85
05620 Repair Cast Framework ……………………………………………………………………………………….$85
05630 Repair or Replace Broken Clasp ……………………………………………………………………………..$85
05640 Replace Broken Teeth – Per Tooth …………………………………………………………………………..$55
05650 Add Tooth to Existing Partial Denture ………………………………………………………………………..$85
05660 Add Clasp to Existing Partial Denture ………………………………………………………………………..$85
05710 Rebase Complete Upper Denture (each) …………………………………………………………………..$163
05711 Rebase Complete Lower Denture (each) ……………………………………………………………………$172
05720 Rebase Upper Partial Denture (each) ……………………………………………………………………….$161
05721 Rebase Lower Partial Denture (each) ………………………………………………………………………$163
05730 Reline Complete Upper Denture (chairside) (each) …………………………………………………………$94
05731 Reline Complete Lower Denture (chairside) (each) …………………………………………………………$92
05740 Reline Upper Partial Denture (chairside) (each) ……………………………………………………………..$82
05741 Reline Lower Partial Denture (chairside) (each) ……………………………………………………………..$82
05750 Reline Complete Upper Denture (Laboratory) (each) ………………………………………………………$165
05751 Reline Complete Lower Denture (Laboratory) (each) ………………………………………………………$165
05760 Reline Upper Partial Denture (Laboratory) (each) …………………………………………………………..$165
05761 Reline Lower Partial Denture (Laboratory) (each) …………………………………………………………..$165
05810 Interim Complete Denture Upper (each) ……………………………………………………………………..$201
05811 Interim Complete Denture Lower (each) ……………………………………………………………………..$201
05820 Interim Partial Denture Upper (each) …………………………………………………………………………$144
05821 Interim Partial Denture Lowe (each) ………………………………………………………………………….$161
05850 Tissue Conditioning Upper per unit …………………….………………………………………………………$60
05851 Tissue Conditioning Lower per unit …………………………………………………………………………….$60
Prosthodontics (FIXED) Services
06210 Pontic – Cast High Noble Metal ……………………………………………………………………………..$407
06211 Pontic – Cast predominantly Base Metal …………………………………………………………………..$395
06212 Pontic – Cast Noble Metal ……………………………………………………………………………………$401
06240 Pontic – Porcelain Fused to High Metal …………………………………………………………………….$407
06241 Pontic – Porcelain Fused to Base Metal ……………………………………………………………………$395
06242 Pontic – Porcelain Fused Noble Metal ………………………………………………………………………$401
06250 Pontic – Resin with high noble predominantly base noble metal …………………………………………$407
06251 Pontic – Resin with high noble predominantly base noble metal ………………………………………...$395
06252 Pontic – Resin with high noble predominantly base noble metal …………………………………………$401
06602 Inlay – Cast high noble metal, two surfaces …………………………………………………………………$385
06603 Inlay – Cast high noble metal three or more surfaces ……………………………………………………..$395
06604 Inlay – Cast predominantly base metal , two surfaces ………………………………………………………$365
06605 Inlay – Cast predominantly base metal , three or more surfaces ………………………………………….$395
06606 Inlay – Cast noble metal , two surfaces ……………………………………………………………………..$365
06607 Inlay – Cast noble metal, three or more surfaces ………………………………………………………….$395
06610 Onlay – Cast high noble metal , two surfaces ………………………………………………………………$405
06611 Onlay – Cast high noble metal , three or more surfaces …………………………………………………..$436
06612 Onlay – Cast predominantly base metal, two surfaces ……………………………………………………$405
06613 Onlay – Cast predominantly base metal, three or more surfaces ………………………………………..$436
06614 Onlay – Cast noble metal , two surfaces …………………………………………………………………….$405
06615 Onlay – Cast noble metal , three or more surfaces ………………………………………………………..$436
06545 Retainer – Cast metal for resin bonded fixed prosthesis ………………………………………………….$245
06720 Crown – Resin with high noble metal ……………………………………………………………………….$407
06721 Crown – Resin with predominantly base metal …………………………………………………………….$395
06722 Crown – Resin with noble metal ………………………………………………………………………….…$401
06750 Crown – Porcelain fused to high noble metal ………………………………………………………………$407
06751 Crown – Porcelain fused predominantly base metal ……………………………………………………..$395
06752 Crown – Porcelain fused noble metal ………………………………………………………………………$401
06780 Crown – ¾ Cast high noble metal …………………………………………………………………………..$407
06790 Crown – Full cast high noble metal ………………………………………………………………………...$407
06791 Crown – Full cast predominantly base metal ………………………………………………………………$395
06792 Crown – Full cast noble metal ………………………………………………………………………………$401
06930 Re-cement Bridge …………………………………………………………………………………………….$39
06940 Stress Breaker ……………………………………………………………………………………………….$145
Oral Surgery Services
07140 Extraction, erupted tooth or exposed root (Elevation and/or forceps removal) …………………………$42-56
07210 Surgical removal of erupted Tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated……………………………………………………………………………………$84/105
07220 Removal of impacted Tooth – soft tissue …………………………………………………………………..$110/126
07250 Surgical Removal of residual tooth …………………………………………………………………………..$94/105
07310 Alveoloplasty in conjunction with Extractions – Per Quadrant …………………………………………….$86
07320 Alveoloplasty not in conjunction with Extractions – Per Quadrant ………………………………………..$137
07510 Incision and drainage of Abscess – intraoral soft tissue ……………………………………………………..$61
Adjective General Services
09110 Emergency treatment of dental pain ………………………………………………………………………..$6
09211 Regional Block Anesthesia (Except for Diagnostic purposes) …………………………………………….$0
09212 Trigeminal Division Block Anesthesia (Except for diagnostic purpose) …………………………………..$0
09215 Local Anesthesia (except for diagnostic purpose) …………………………………………………………..$0
09230 Nitrous Oxide (per 15 minutes) ………………………………………………………………………………$12
09310 Consultation (By provider other than treatment provider) …………………………………………………$11
09430 Office Visit During Regular Hours ($9 Office visit Copay not charged) ………………………………….$11
09440 Office Visit After Regular Hours ($9 Office visit copay not charged) …………………………………….$55
09941 Fabrication of Athletic mouth guards ………………………………………………………………………..$46
09950 Occlusion Analysis – Mounted case …………………………………………………………………………$84
09951 Occlusion Adjustment – Limited……………………………………………………………………………...$45
09952 Occlusion Adjustment – Complete …………………………………………………………………………..$193
09999 Unspecified Adjudicative procedure, by report………………………………………………………………..$9
Other Services
Temporary Crown with Permanent Crown ………………………………………………………………………….$0
Infection Control Charges …………………………………………………………………………………………….$0
Office or Dental Supple ……………………………………………………………………………………………….$0
Laboratory Expenses ………………………………………………………………………………………………….$0
Equipment and instruments necessary for treatment ………………………………………………………………$0
Any Other General Overhead expenses …………………………………………………………………………….$0
Acid edge charge ……………………………………………………………………………………………………..$0
Duplication of X-ray …………………………………………………………………………………………………...$0
Periodontal probing done with initial and periodic oral examinations …………………………………………….$0
Used of bonding materials (all bond, Amalga bond or comparable ………………………………………………$0
Materials – refer to code 09999 ……………………………………………………………………………………….$9
Additional charges of $125.00 per unit for multiple crown units (6 or more units of crown and/or bridge is same treatment plan and requires complete rehabilitation planning)
All procedures not included in this CPT CODE listing have a copayment of 75% of the dentist’s usual and customary charge. All procedures might not be performed by participating general dentists who do performs these services and are not applicable for services performed by a participating specialty dentist. Therefore, you are encouraged to discuss the availability of the scheduled services with your participating general dentist.
Specialty Dentists – Should you need a specialty dentist, you may be referred by your participating general dentist, or you may refer yourself to any participating specialty dentist from our directory. Upon identification of yourself as an Ora Quest member, your co-payment will be the following percentage of the specialty dentist’s usual fee.
Endodontist (root canals) 80%, Oral surgeon (Tooth Extractions) 75%, Orthodontist 75%, Periodontist (gum problems) 75%, Pediatric dentist (Children’s dentist) 75%,
Missed Appointment – A missed appointment without 24 hours’ notice may result in a missed appointment charge made by the participating general and specialty dentists. Please discuss this with your selected participating dentist.
Children under 5 years of age- Children under 5 years of age may be referred to a pediatric dentist. Please discuss this with your selected participating general dentist.