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| Member Benefits and Dental Fee Schedule |
The following fees apply to General Dentists only. Any specialist (Oral Surgeon, Orthodontist, Periodontist, Pediatric Dentist, etc.) will charge a "member pay" fee equal to his regular fee minus 20%.
| Member Services | Member Pays |
|
| D0120 | Periodic Oral Evaluation | $22 |
| D0140 | Limited Oral Evaluation (Emergency Exam) | 31 |
| D0150 | In Depth Check-Up | 22 |
| D0210 | Complete Series X-ray | 56 |
| D0220 | Single Peri-apical X-ray | 12 |
| D0230 | Each Additional PA Film | 11 |
| D0272 | Bitewings - Two Films | 20 |
| D0330 | Panoramic X-ray | 48 |
| D0470 | Study Models | 48 |
| D1110 | Prophylaxis-Adult (Teeth Cleaning) | 41 |
| D1120 | Prophylaxis-Child (Teeth Cleaning) | 29 |
| D1203 | Fluoride Treatment | 17 |
| D1351 | Sealant (per tooth) | 24 |
| D1510 | Space Maintainer-Fixed Unilateral | 143 |
| D1515 | Space Maintainer-Fixed Bilateral | 198 |
| D9999 | Disposables | 10 |
| D9972 | Cosmetic Bleaching (per arch) | 165 |
| Restorative Dentistry | Member Pays |
|
| Amalgam Restorations Silver Fillings for Posterior (back) Teeth | ||
| D2140 | Cavities involving one surface | $56 |
| D2150 | Cavities involving two surfaces | 73 |
| D2160 | Cavities involving three surfaces | 90 |
| Composite Fillings (Tooth Colored) For Anterior (Front) Teeth | ||
| D2330 | Cavities involving one surface | 68 |
| D2331 | Cavities involving two surface | 84 |
| D2332 | Cavities involving three surface | 104 |
| D2335 | Composite Resin (involving incisal) | 132 |
| Composite Fillings (Tooth Colored) For Posterior (Back) Teeth | ||
| D2385 | Cavities involving one surface | 76 |
| D2386 | Cavities involving two surface | 101 |
| D2387 | Cavities involving three surface | 125 |
| Crown and Bridge Base Fees | Member Pays |
|
| D2740 | Crown- Porcelain | $550 |
| D2750 | Crown- Porcelain fused to high noble metal | 550+Metal |
| D2752 | Crown- Porcelain fused to noble metal | 550+Metal |
| D2790 | Crown- Full cast high noble metal | 550+Metal |
| D2792 | Crown- Full cast noble metal | 550 |
| D2782 | Crown- 3/4 cast noble metal | 550 |
| D2780 | Crown- 3/4 cast high noble metal | 550+Metal |
| D2931 | Prefabricated stainless steel crown | 140 |
| D2920 | Recement Crown | 48 |
| D2940 | Sedative Filling | 50 |
| D2950 | Core build up (including any pins) | 122 |
| D2951 | Pin retention (per tooth, in addition to restoration) | 31 |
| D2954 | Prefabricated post and core in addition to crown | 149 |
| Endodontics (Root Canal Treatment) | Member Pays |
|
| Diagnostic Exam | 20% Off U&C* | |
| D3110 | Pulp Cap- Direct (excluding final restorations) | 20% Off U&C* |
| D3220 | Therapeutic Pulpotomy (excluding final restorations) | 20% Off U&C* |
| Root Canals | ||
| D3310 | Anterior (excluding final restoration) | 20% Off U&C* |
| D3320 | Bicuspid (excluding final restoration) | 20% Off U&C* |
| D3330 | Molar (excluding final restoration) | 20% Off U&C* |
| D3340 | Molar (excluding final restoration) | 20% Off U&C* |
| Oral Surgery | Member Pays |
|
| Extractions (Include local anesthesia, suturing, if needed, and routine postoperative care) | ||
| D7110 | Routine Extraction (Single Tooth) | 20% Off U&C* |
| D7210 | Surgical Extraction | 20% Off U&C* |
| D7220 | Removal of Impacted Tooth- Soft Tissue | 20% Off U&C* |
| D7230 | Removal of Impacted Tooth- Partially Bony | 20% Off U&C* |
| D7240 | Removal of Impacted Tooth- Completely Bony | 20% Off U&C* |
| D7510 | Incision and Drainage of Abcess- Intraoral soft tissue | 20% Off U&C* |
| Prosthetics (Dentures) | Member Pays |
|
| D5110 | Complete Maxillary (Upper Denture) Excluding Extractions | $695 |
| D5120 | Complete Mandibular (Lower Denture) Excluding Extractions | 695 |
| D5211 | Upper Partial Denture- Resin Base (including any conventional clasps and rests) |
695 |
| D5212 | Lower Partial Denture- Resin Base (including any conventional clasps and rests) |
695 |
| D5213 | Upper Partial Denture- cast metal framework w/ resin denture bases (including any conventional clasps and rests) | 695 |
| D5214 | Lower Partial Denture- cast metal framework w/ resin denture bases (including any conventional clasps and rests) | 695 |
| D5710 | Rebase - Complete Upper Denture | 238 |
| D5711 | Rebase - Complete Lower Denture | 238 |
| D5730 | Reline Complete Upper Denture Chairside | 157 |
| D5731 | Reline Complete Lower Denture Chairside | 157 |
| Fixed Partial Denture Retainers-Crowns | ||
| 06750 | Fixed Bridge Per Unit-Porcelain fused to high noble metal | 500 |
| 06751 | Fixed Bridge Per Unit-Porcelain fused to predominantly base metal | 500 |
| (any prosthetic appliance that requires unusual services might be an additional charge. Discuss this with your patient prior to treatment.) | ||
| Periodontics | Member Pays | |
| D4421 | Gingivectomy or Gingivoplasty - per quadrant | 20% Off U&C* |
| D4341 | Periodontal Scaling and Root Planing - per quadrant | 20% Off U&C* |
| D4910 | Periodontal Prophylaxis | 20% Off U&C* |
| Orthodontics | Member Pays |
| All Orthodontic Treatments | 20% Off U&C* |
| (Includes placement of appliance, treatment for two years (24 months), removal of appliances, records and placement of retainer. Does not include the cost of the retainer to be paid by KDP member. The Orthodontist will explain the length of treatment, all fees and the payment schedule. Orthodontic discount is not available to any member currently in treatment. Orthodontic treatment that requires surgery or unusual services may require an additional charge. Discuss this with the Orthodontist prior to beginning treatment). | |
In the event that Providers Usual and Customary charge is equal to or less than the member pay amount,or if the procedure is not listed on the KDP Member Fee Schedule, Provider agrees to discount his Usual and Customary fee by a minimum of twenty percent (20%). In emergency situations, whereby Provider sees a KDP patient after hours or enters exnary circumstances, an additional fee of up to ten percent (10%) of the KDP scheduled fees may be added to Patient's billed charges.
| Limitations and Exclusions |
| 1. Any treatment which in the opinion of the attending dentist is not necessary for the patient's dental health or that cannot be performed because of the general health of the patient. |
| 2. Treatment for injuries or conditions that are covered under Workman's Compensation or Employees Liability Laws, Automobile, Medical, No Fault or similar types insurance. Services which are provided without cost to the patient by any County, Municipality or other political subdivision. |
| 3. Member Benefits and Dental Fees Schedule apply only when treatment is performed at a participating dental office. If the service of a non-participating dentist is required, or services are performed in a hospital facility, these dental fees do not apply and the patient will be responsible to the nonparticpating dentist or hospital for the usual fees. |
| 4. Any dental treatment already in progress will be excluded. Special arrangements may be made at the option of participating providers to assume treatment in progress. Fees for assumption of treatment should be negotiated by provider and member. These fees may or may not be relative to Kentucky Dental Plan, Inc. Member Fees Schedule. |
| 5. When the member's Membership is no longer valid. |
| 6. The members may select the dentist of their choice; however, if the dentist selected is not a participating dentist, the fees charged by the nonparticpating dentist must be paid by the member. Any licensed dentist is eligible to participate in the plan. Application to become a plan provider may be obtained from the Kentucky Dental Plan, Inc. office. A providers participation will be contingent on acceptance and notification by Kentucky Dental Plan, Inc. |
| 7. Fees listed on the Members Benefits and Dental Fees Schedule are for procedures done by participating general dentists and orthodontists and should be considered specialist's fees. |
| 8. Participating specialists charge a "member pay" fee equal to his regular fee minus 20%. |