COMFORT DENTAL GOLD MEMBERSHIP PLAN
TEXAS REDUCED FEE SCHEDULE
ADA MEMBER'S
UCR** MEMBER
ADA MEMBER'S UCR** MEMBER
CODE SERVICES PAYS CODE SERVICES PAYS
PREVENTIVE AND DIAGNOSTIC
0110
0120
0130
0210
0220
0230
0274
0330
0470
9430
1110
1203
1330
1351
1510
1515
9310
9440
----
0431
----
----
----
----
----
----
----
8680
RESTORATIVE (FILLINGS)
Amalgam Restorations/Permanent-Primary Teeth
2140
2150
2160
2161
Anterior Resin Restorations
2330
2331
2332
2335
Posterior Resin Restorations
2391
2392
2393
2394
7140
7120
7210
7220
7230
7240
7250
7270
7280
7286
7310
7320
7510
205
205
245
285
450
500
215
400
350
325
250
230
150
3220
3221
3310
3320
3330
3410
3331
4999
4210
4220
4260
4341
4342
435
4910
180
225
615
715
925
750
336
55
450
200
700
225
185
210
140
100
125
400
465
695
450
268
40
300
110
360
135
95
100
95
110
110
150
185
250
310
150
200
200
200
150
125
80
Initial Oral Exam
Periodic Oral Exam
Emergency Oral Exam (office hours)
Complete Series X-Rays
Single Periapical X-Ray
Each additional film
Bitewing X-Rays
Pano
Diagnostic Casts
Office Visit
Simple teeth cleaning (children and adults)
(up to 2 per year). Patients with gum
disease are not covered under this category
(Refer to Periodontics Section)
Fluoride Treatment (Limit one per year
to age 18)
Preventive Dental Education, Home Care
Sealants (Pit & Fissure) per tooth
Space Maintainer Unilateral
Space Maintainer Bilateral
Consultation
After hours Office Visit
Missed/Canceled Appointments (without
24 hours notice)
VelScope Cancer S
creening
Orthodontic Consultation
Records
To-Start Braces (Records/First Month’s Fee)
Down Payment
Monthly Adjustment Fee (Child)
Monthly Adjustment Fee (Adult)
Retainers
Orthodontic Retension
One tooth surface
Two surfaces
Three surfaces
Four or more surfaces
One surface
Two surfaces
Three surfaces
Four or more surfaces
One surface
Two surfaces
Three surfaces
Four or more
80
60
80
97
28
22
49
85
75
40
105
40
42
76
300
350
60
150
50
50
N/C
400
399
499
189
219
800
85
110
140
180
211
150
190
240
350
175
195
245
355
N/C
N/C
N/C
N/C
N/C
N/C
N/C
65
25
25
N/C
N/C
N/C
25
175
250
15
60
50
10
N/C
250
350
N/C
149
159
400
65
95
105
120
175
85
95
120
175
115
135
155
175
2740
2750-52
2790
2810
2930
2910
2950
2952
2954
2962
6210-12
6240-42
6545
6750-52
6780
6790-92
5110
5120
5130
5140
5213
5214
5225/5226
5820
9940
5410-22
5510
5520
5620-30
5650
5710
5730
5750
9110
9210
9230
9951
9972
----
2951
2940
3110-20
Porcelain Crown
Porcelain with Metal Crown
Full Crown
3/4
Metal Crown
Stainless Steel Crown (Primary)
Recement Crown
Crown Build-up including any pins
Cast Post and Core
Pre-fab post & core
Cosmetic Porcelain Veneer
Cast Pontic
Porcelain with metal Pontic
Maryland Bridge per unit
Porcelain with metal Bridge Abutment
3/4 Metal Bridge Abutment
Full Metal Crown
Complete Upper Denture
Complete Lower Denture
Immediate Upper Denture
Immediate Lower Denture
Upper Partial - Cast
Lower Partial - Cast
Valplast Partial
Treatment Partial - Acrylic/Flipper
Nightguard (occlusal guard)
Denture adjustment
s
(Upper or Lower, complete or partial)
Repair broken complete denture base
Replace missing or broken teeth
complete or partial denture (per tooth)
Repair Cast Framework/Clasp
Add tooth to existing partial denture
Rebase
Reline Chairside
Reline Lab
Emergency Palliative Treatment
Local Anesthetic
Nitrous Oxide - Flat Fee
Occlusal Adjustment - limited
Take Home Bleaching- per arch
In Office Bleaching- per arch
Pin Retention per tooth
Sedative Filling
Pulp Cap
1200
1200
1200
1200
290
105
250
350
300
950
1200
1200
1200
1200
1200
1200
1200
1200
1200
1200
1200
1200
1250
500
550
70
400
225
300
175
420
250
350
90
N/C
65
70
250
550
50
87
95
699
699
699
699
150
60
150
175
175
730
699
699
700
700
700
699
800
800
850
850
850
850
899
325
350
50
300
150
250
135
270
150
250
40
N/C
45
35
100
250
25
55
65
The following Orthodontic fees apply only when treatment is performed at a
Comfort Braces Center.
ORTHODONTICS (BRACES) CHILDREN/ADULTS
The following ORAL SURGERY, ENDODONTIC and PERIODONTIC payments apply only when treatment is performed at a participating dental office. If the services of a specialist
are required, these payments do not apply and the patient will receive services from a participating specialist, where available, at a 20% discount off of the specialist's UCR.
Simple Extraction
Each Additional Routine Extraction
Surgical Extraction Erupted
Soft Tissue Impaction
Partia
l Bony Impaction
Complete Bony Impaction
Surgical Root Recovery
Tooth Reimplantation and Stabilization
Surgical Exposure of Impacted Tooth
Biopsy of Oral-Tissue-soft
Alveoloplasty/Quad with Extraction
Alveoloplasty/Quad without Extractions
Intra-Oral I & D Abscess
6010
6056
6057
6065
6058
6059
1400
300
500
1250
1200
1200
1095
150
400
900
850
850
Implant
Simple Abutment
Custom Abutment
Abutment supported - Screw retained crown
Implant Abut Supported Ceramic
Implant Abut Supported PFM
ORAL SURGERY
IMPLANTS
Therapeutic Pulpotomy
Pulpal debridement
Rct Anterior
Rct Bicuspid
Rct Molor
Apicoectomy
Treatment of Root Canal Obstruction
Periodontal Exam and Charting
Gingivectormy/Quad
Gingival Curettage/Quad
Osseous surgery/Quad (including flap
entry and closur
e
Scaling/Root Planing/Quad
Scaling/Root Planing/1-3teeth/Quad
Debridement
Periodontal Maintenance (following therapy)
ENDODONTICS (root canal treatment)
PERIODONTICS (gum treatment)
REPAIRS/RELINES
OTHER SERVICES
PROSTHODONTICS- REMOVABLE
CROWN AND BRIDGE
*All patient payments are exclusive of gold. If gold is used, there will be an additional cost added to the patient payments ***Plus Lab Fee.
UCR**- Usual, Customary and Reasonable Fees for Texas. Procedures or services not listed will be performed at UCR.
