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■  Acute Care Savings Example

■ 
Family Savings Example

■  Dental Care Savings Example

■  Vision Care Savings Example

This sample schedule is an abbreviated list of common dental procedures indicating the reduced fees for services provided by participating dental providers. Fee schedules vary by region of the country. Member is responsible to pay the reduced fees to the provider at the time of service.

 Dental Care Savings Example*
Dental Code
 Benefit
Retail Cost 
CARExpress 
0120
 Periodic oral exam
$43 
$23 
0150
 Comprehensive oral evaluation
$59 
$48 
0210
 Intraoral-complete series (including bitewings)
$122 
$66 
0272
 Bitewings, 2 Films
$39 
$21 
0274
 Bitewings-4 films
$54 
$32 
0330
 X-Ray Panoramic film
$112 
$62 
1110
 Prophylaxis-adult
$90 
$50 
1120
 Prophylaxis-child
$54 
$33 
1351
 Sealant-per tooth
$49 
$27 
2140
 Amalgam-one surface, permanent
$99 
$58 
2150
 Amalgam-two surfaces, permanent
$128 
$76 
2160
 Amalgam-three surfaces, permanent
$166 
$93 
2330
 Resin-based composite-one surface, anterior
$132 
$73 
2331
 Resin-based composite-two surface, anterior
$164 
$96 
7240
 Removal of Impacted Tooth-Completely Bony
$409 
$245 
2750
 Crown-porcelain fused to high noble metal
$1,110 
$662 
9110
 Palliative of Dental Pain
$74 
$47 
3330
 Root canal therapy, molar (excluding final rest.)
$1,031 
$850 
4341
 Periodontal scaling and root planing, per quadrant
$225 
$150 
4910
 Periodontal maintenance procedures
$108 
$65 
5110
 Complete denture-maxillary
$1,398 
$794 
0140
 Limited Oral Evaluation-Problem Focused
$50 
$34 
7210
 Surgical removal of erupted tooth
$234 
$136 
8080
 Orthodontic treatment, adolescent
$5,589 
$3,619 
* Dental fee schedules vary depending upon the region of the country