Welcome employees and retirees of The University of Texas System

Sample Copayment Schedule Heritage Series - Plus Plan

The following is a list of commonly used dental treatments.  After you enroll, a complete list of copayments will be provided to you along with your Evidence of Coverage.

The dental services listed in the following schedule are covered only when provided by the Member's selected Plan Dentist. The Member will be responsible for paying the amount listed in the "Member Copayment" column (plus any applicable lab fees*) at the time the service is received, or in accordance with the selected Plan Dentist's billing procedures. Services marked with a single asterisk (*) below also require separate payment of laboratory charges. The laboratory charges must be paid to the Plan Dentist in addition to any applicable copayment for the service.  Payment for each service of a Non-Plan Dentist (at that dentist's normal retail charge) is the responsibility of the Member, except for Plan Benefits for covered dental
Emergency Services.

Sample Copayment Schedule

ADA Code** Service Description** Member Copayment
Appointments
None Office visit - during regularly scheduled hours*** No Charge
D0120 Periodic oral evaluation‡ (once in any 6 calendar months) No Charge
D0140 Limited oral evaluation - problem focused $20
D0150 Comprehensive oral evaluation - new or established patient‡ (once in any 6 calendar months) No Charge
D0160 Detailed and extensive oral evaluation - problem focused, by report $15
D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) $15
D0180 Comprehensive periodontal evaluation - new or established patient $15
D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) $55
D9440 Office visit - after regularly scheduled hours $40
Diagnostic Dentistry
D0210 Intraoral - complete series (including bitewings)‡ (once in any 3 calendar years) No Charge
D0220 Intraoral - periapical first film No Charge
D0230 Intraoral - periapical each additional film No Charge
D0240 Intraoral - occlusal film No Charge
D0250 Extraoral - first film No Charge
D0260 Extraoral - each additional film No Charge
D0270 Bitewing - single film No Charge
D0272 Bitewings - two films‡ (once in any 6 calendar months) No Charge
D0274 Bitewings - four films‡ (once in any 6 calendar months) No Charge
D0277 Vertical bitewings - 7 to 8 films No Charge
D0330 Panoramic film‡ (once in any 3 calendar years) $5
D0415 Collection of microorganisms for culture and sensitivity No Charge
D0425 Caries susceptibility tests No Charge
D0460 Pulp vitality tests No Charge
Preventive Dentistry
D1110 Prophylaxis - adult (once in any 6 calendar months) No Charge
D1120 Prophylaxis - child (once in any 6 calendar months) No Charge
D1203 Topical application of fluoride (prophylaxis not included) - child No Charge
D1310 Nutritional counseling for control of dental disease No Charge
D1330 Oral hygiene instructions No Charge
D1351 Sealant - per tooth $10
D1510 Space maintainer - fixed - unilateral* $60
D1515 Space maintainer - fixed - bilateral* $60
D1520 Space maintainer - removable - unilateral* $85
D1525 Space maintainer - removable - bilateral* $105
D1550 Re-cementation of space maintainer $15
None Additional prophylaxis (D1110 or D1120 service does not apply to patients with periodontal disease)*** $25
Restorative Dentistry
D2140 Amalgam - one surface, primary or permanent $10
D2150 Amalgam - two surfaces, primary or permanent $15
D2160 Amalgam - three surfaces, primary or permanent $25
D2161 Amalgam - four or more surfaces, primary or permanent $35
D2330 Resin-based composite - one surface, anterior $30
D2331 Resin-based composite - two surfaces, anterior $40
D2332 Resin-based composite - three surfaces, anterior $50
D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) $65
D2391 Resin-based composite - one surface, posterior $60
D2392 Resin-based composite - two surfaces, posterior $70
D2393 Resin-based composite - three surfaces, posterior $80
D2394 Resin-based composite - four or more surfaces, posterior $110
D2510 Inlay - metallic - one surface* $102
D2520 Inlay - metallic - two surfaces* $125
D2530 Inlay - metallic - three or more surfaces* $150
D2542 Onlay - metallic - two surfaces* $215
D2543 Onlay - metallic - three surfaces* $220
D2544 Onlay - metallic - four or more surfaces* $220
D2610 Inlay - porcelain/ceramic one surface* $200
D2620 Inlay - porcelain/ceramic two surfaces* $210
D2630 Inlay - porcelain/ceramic three or more surfaces* $220
D2740 Crown - porcelain/ceramic substrate* $275
D2750 Crown - porcelain fused to high noble metal* $275
D2751 Crown - porcelain fused to predominantly base metal* $275
D2752 Crown - porcelain fused to noble metal* $275
D2790 Crown - full cast high noble metal* $275
D2791 Crown -  full cast predominantly base metal* $275
D2792 Crown -  full cast noble metal* $275
D2910 Recement inlay, onlay, or partial coverage restoration $15
D2920 Recement crown $15
D2930 Prefabricated stainless steel crown - primary tooth $80
D2940 Sedative filling $15
D2950 Core buildup, including any pins $75
D2951 Pin retention - per tooth, in addition to restoration $15
D2952 Cast post and core in addition to crown* $90
D2954 Prefabricated post and core in addition to crown $80
D2962 Labial veneer (porcelain laminate) - laboratory* $290
D2980 Crown repair, by report* $25
None Temporary filling*** $15
Endodontics
D3110 Pulp cap - direct (excluding final restoration) $15
D3120 Pulp cap - indirect (excluding final restoration) $10
D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament $40
D3310 Anterior (excluding final restoration) $95
D3320 Bicuspid (excluding final restoration) $165
D3330 Molar (excluding final restoration) $175
D3346 Retreatment of previous root canal therapy - anterior $320
D3347 Retreatment of previous root canal therapy - bicuspid $380
D3348 Retreatment of previous root canal therapy - molar $460
D3410 Apicoectomy/periradicular surgery - anterior $125
D3421 Apicoectomy/periradicular surgery - bicuspid (first root) $170
D3425 Apicoectomy/periradicular surgery - molar (first root) $220
D3426 Apicoectomy/periradicular surgery  (each additional root) $100
D3430 Retrograde filling - per root $40
D3450 Root amputation - per root $70
D3920 Hemisection (including any root removal), not including root canal therapy $80
Periodontics
D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant $120
D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant $65
D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant $140
D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth spaces per quadrant $100
D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant $350
D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant $203
D4320 Provisional splinting - intracoronal $80
D4321 Provisional splinting - extracoronal $75
D4341 Periodontal scaling and root planing - four or more teeth per quadrant $45
D4342 Periodontal scaling and root planing - one to three teeth per quadrant $27
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $50
D4910 Periodontal maintenance $45
None Periodontal hygiene instructions*** No Charge
Removable Prosthodontics (Removable Dentures)
D5110 Complete denture - maxillary* $295
D5120 Complete denture - mandibular* $295
D5130 Immediate denture - maxillary* $400
D5140 Immediate denture - mandibular* $400
D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth)* $355
D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth)* $335
D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)* $365
D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)* $365
D5410 Adjust complete denture - maxillary $15
D5411 Adjust complete denture - mandibular $15
D5421 Adjust partial denture - maxillary $15
D5422 Adjust partial denture - mandibular $15
D5510 Repair broken complete denture base* $30
D5610 Repair resin denture base* $35
D5620 Repair cast framework* $35
D5630 Repair or replace broken clasp* $35
D5640 Replace broken teeth - per tooth* $35
D5650 Add tooth to existing partial denture* $35
D5730 Reline complete maxillary denture (chairside) $60
D5731 Reline complete mandibular denture (chairside) $60
D5740 Reline maxillary partial denture (chairside) $60
D5741 Reline mandibular partial denture (chairside) $60
D5750 Reline complete maxillary denture (laboratory)* $95
D5751 Reline complete mandibular denture (laboratory)* $95
D5760 Reline maxillary partial denture (laboratory)* $95
D5761 Reline mandibular partial denture (laboratory)* $95
D5850 Tissue conditioning, maxillary $25
D5851 Tissue conditioning, mandibular $25
D5862 Precision attachment, by report* $145
Fixed Prosthodontics (Bridges or Fixed Partial Dentures)
D6210 Pontic - cast high noble metal* $275
D6211 Pontic - cast predominantly base metal* $275
D6212 Pontic - cast noble metal* $275
D6240 Pontic - porcelain fused to high noble metal* $275
D6241 Pontic - porcelain fused to predominantly base metal* $275
D6242 Pontic - porcelain fused to noble metal* $275
D6251 Pontic - resin with predominantly base metal* $275
D6545 Retainer - cast metal for resin bonded fixed prosthesis* $140
D6721 Crown - resin with predominantly base metal* $275
D6750 Crown - porcelain fused to high noble metal* $275
D6751 Crown - porcelain fused to predominantly base metal* $275
D6752 Crown - porcelain fused to noble metal* $275
D6780 Crown - 3/4 cast high noble metal* $275
D6790 Crown - full cast high noble metal* $275
D6791 Crown - full cast predominantly base metal* $275
D6792 Crown - full cast noble metal* $275
D6930 Recement fixed partial denture $15
D6940 Stress breaker $150
D6950 Precision attachment $195
D6980 Fixed partial denture repair, by report* $45
None Resin bonded bridge pontic, per unit***(*) $235
Oral Surgery
D7111 Extraction, coronal remnants - deciduous tooth $15
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $15
D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth $50
D7220 Removal of impacted tooth - soft tissue $60
D7230 Removal of impacted tooth - partially bony $75
D7240 Removal of impacted tooth - completely bony $100
D7241 Removal of impacted tooth - completely bony, with unusual surgical complications $135
D7250 Surgical removal of residual tooth roots (cutting procedure) $40
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $100
D7280 Surgical access of an unerupted tooth $85
D7310 Alveoloplasty in conjunction with extractions - per quadrant $60
D7320 Alveoloplasty not in conjunction with extractions - per quadrant $90
D7510 Incision and drainage of abscess - intraoral soft tissue $35
D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure $125
Other Services
D9110 Palliative (emergency) treatment of dental pain - minor procedure $25
D9220 Deep sedation/general anesthesia - first 30 minutes $180
D9230 Analgesia, anxiolysis, inhalation of nitrous oxide $15
D9241 Intravenous conscious sedation/analgesia - first 30 minutes $165
D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes $35
D9940 Occlusal guard, by report* $85
D9951 Occlusal adjustment - limited $30
D9952 Occlusal adjustment - complete Bleaching $145
D9972 External bleaching - per arch Bleaching $155
D9972 External bleaching - per arch $155

This is a sample Member Copayment Schedule only. It is not an Evidence of Coverage. Please see the Group Dental Service Agreement, Evidence of Coverage, and Copayment Schedule, which determine all rights, benefits, and applicable limitations and exclusions.

Listed copayments apply only to Plan Dentists who perform the corresponding listed services.  The Plan Dentist selected by the Member may not perform all listed services. Plan Specialty Dentists may not perform or offer all services listed.  Availability and participation of Plan Dentists and Plan Specialty Dentists are subject to change.

* Members are responsible for additional laboratory fees for
these services.

** Current and prior versions of the Current Dental Terminology (CDT) codes (in the ADA Code column) and descriptors (in the Service Description column) are copyrighted by the American Dental Association (ADA) and are used by permission. © 2004 American Dental Association.  All rights reserved.

*** Service does not have an American Dental Association Current Dental Terminology code or descriptor.

‡ More often if medically necessary as determined by attending Plan Dentist.

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