Cypress-Fairbanks Independent School District
MS of A Dent All

MS of A Dent All

Fee Schedule

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SUMMARY OF SERVICES FEE SCHEDULE

These are the actual fees you will pay at the dentist office. These fees have already been discounted. You will save an average of 50% off the usual and customary fees on your general dentistry. If you need a specialist, ours offer a 25% discount from their usual and customary fees (unless otherwise noted in the provider listing). You may go to any participating dentist at any time.

Dental Procedures ADA Code Plan Fees
Infection Control - per visit $10
Diagnostic Dentistry
Initial Office Visit & Oral Exam D0150 $36
Periodic Oral Exam D0120 $30
Emergency Oral Exam D9110 $40
X-Ray-Complete Series D0210 $48
X-Ray Single D0220 $9
X-Ray Intraoral-periapical -each additional film D0230 $9
X-Ray-Bitewing (2 Films) D0272 $16
X-Ray-Bitewing (4 Films) D0274 $28
X-Ray-Vertical Bitewings - 7 to 8 Films D0277 $48
X-Ray-Panoramic D0330 $52
Preventative Dentistry
Teeth Cleaning (Adult-include scaling) D1110 $42
Teeth Cleaning (Child-up to 12 yrs old) D1120 $35
Teeth Cleaning - Over 1 yr since last D4999 $65
Deep Scaling (Full Mouth) D4345 $115
Stannous Fluoride Treatment D1201, D1205 25% Discount
Topical Application of Fluoride D1203, D1204 $10
Space Maintainer Fixed - Unilateral D1510 $160
Space Maintainer Fixed - Bilateral D1515 $185
Restorative Dentistry
Amalgam Filling (1 Surface) D2140 $58
Amalgam Filling (2 Surface) D2150 $68
Amalgam Filling (3 Surface) D2160 $83
Composite Filling (1 Surface-Anterior) D2330 $73
Composite Filling (2 Surface-Anterior) D2331 $93
Composite Filling (3 Surface-Anterior) D2332 $108
Composite Filling Involving Incisal Angle D2335 $160
Composite Filling (1 Surface-Posterior) D2391 $88
Composite Filling (2 Surface-Posterior) D2392 $102
Composite Filling (3 Surface-Posterior) D2393 $130
Crowns and Bridges
Crown - Porcelain D2740 $662
Crown - Porcelain fused to High Noble D2750 $662
Crown - Porcelain fused to Metal D2751 $550
Crown - Porcelain fused to Noble Metal D2752 $550
Crown - Full Cast High Noble Metal D2790 $662
Crown - Full Cast Predom. Base Metal D2791 $530
Crown - Full Cast Noble Metal D2792 $550
Crown - 3/4 Cast Metallic D2810 $525
Crown - Stainless - Child D2930 $160
Crown - Stainless - Permanent Tooth D2931 $175
Core Buildup with pins D2950 $152
Pin Retention (per tooth) D2951 $28
Cast Post and Core in addition to Crown D2952 $193
Post & Core Buildup (prefabricated post) D2954 $170
Fixed Bridge (per unit) porcelain HNM D6750 $655
Fixed Bridge (per unit) porcelain PBM D6751 $595
Endodontics (performed by general dentist)
Pulp Cap Direct D3110 $38
Vital Pulpotomy D3220 $78
Root Canal Therapy 1Canal D3310 $335
Root Canal Therapy 2 Canals D3320 $425
Root Canal Therapy 3 Canals D3330 $515
Root Canal Therapy 4 Canals D3340 25% Discount
Routine Oral Surgery (performed by general dentist)
Simple Extraction D7110 $70
Root Removal - Exposed D7130 $90
Surgical Extraction D7210 25% Discount
Soft Tissue Impaction D7220 25% Discount
Bony Impaction D7230, D7240 25% Discount
Prosthodontics (performed by general dentist)
Full Denture (per unit-maxillary) D5110 $795
Full Denture (per unit-mandibular) D5120 $795
Partial Denture (chrome Lingual or Palatal Bar, 2 Clasps, Acrylic Base) D5211, D5212 $545
All Other Partial Dentures D6999 25% Discount
Reline (chair side) D5730, D5731 $175
Reline-upper or lower partial (chair side) D5740, D5741 $175
Reline (laboratory) D5750, D5751 $210
Prosthodontic Services Not Listed D5899 25% Discount
Routine Periodontics (performed by general dentist)
Gingivectomy or Gingivoplasty-per Quad. D4210 $305
Gingivectomy or Gingivoplasty-per Tooth D4211 $150
Osseous (bone) surgery per Quadrant D4260 $490
Periodontal Scaling & Root Planning - per Quadrant D4341 $115
Post Operative Exam and Prophylaxis D4910 $60
Other Services
Cosmetic Bonding/Veneers 25% Discount
Sealant - per tooth D1351 25% Discount
Office Visit No Treatment D9430 $10
Missed Appointment w/o 24 Hr Notice $30
Emergency Treatment After Regular Office Hours Not Covered
Orthodontics - 25% Discount off usual and customary fees unless otherwise noted in the provider listing.
Specialists give a 25% Discount off usual and customary fees unless otherwise noted in the provider listing.
Lab fees are included in all procedures - no extra lab fees.
PROCEDURES NOT LISTED: 25% DISCOUNT
PAYMENT IS DUE AT TIME OF SERVICE.
PRICES SUBJECT TO CHANGE WITHOUT NOTICE. PLAN CANNOT BE COORDINATED WITH OTHER PROGRAMS OR INSURANCE POLICIES.
MS of A Dent All
MS of A Dent-all Representative
Mr. Wes Ryan: 281-894-5080

P.O. Box 1418
Tomball, TX 77377-1418

Dent-All Plan Member Services: 281-351-2484
Toll Free: 1-866-362-1517