Minneapolis, MN 55438

(952) 857-1177

Dental Costs at the Dentist for CAPS Dental Plan Members

D0120 periodic oral evaluation established patient $64.00
D0140 limited oral evaluation problem focused $80.00
D0145 oral evaluation for patient under three years of age And counseling with primary caregiver $68.00
D0150 comprehensive oral evaluation new or established patient $91.00
D0180 comprehensive periodontal evaluation new/established patient $92.00
D0220 bitewing – PA first film $35.00
D0272 bitewings – two radiographic images $55.00
D0273 bitewings – three radiographic images $62.00
D0274 bitewings – four radiographic images $73.00
D0277 vertical bitewings 7 to 8 radiographic images $93.00
D0330 panoramic film $148.00
D1110 prophylaxis adult $110.00
D1120 prophylaxis child $84.00
D1206 fluoride varnish $45.00
D1351 sealant – per tooth $62.00
Restorative (D2000-D2999) Members’ Cost
Resin-based composite restorations direct
D2330 resin-based composite one surface, anterior $179.00
D2331 resin-based composite two surfaces, anterior $228.00
D2332 resin-based composite three surfaces, anterior $278.00
D2335 resin-based composite four or more surfaces or involving incisal angle, anterior $332.00
D2390 resin-based composite crown, anterior $458.00
D2391 resin-based composite one surface, posterior $198.00
D2392 resin-based composite two surfaces, posterior $257.00
D2393 resin-based composite three surfaces, posterior $312.00
D2394 resin-based composite four or more surfaces, posterior $366.00
Crowns single restorations only
D2740 crown porcelain/ceramic substrate $1,285.00
D2750 crown porcelain fused to high noble metal $1,195.00
D2751 crown porcelain fused to predominantly base metal $1,115.00
D2752 crown porcelain fused to noble metal $1,185.00
D2780 crown cast high noble metal $1,073.00
D2781 crown cast predominantly base metal $1,028.00
D2782 crown cast noble metal $1,050.00
D2783 crown porcelain/ceramic $1,101.00
D2790 crown full cast high noble metal $1,102.00
D2791 crown full cast predominantly base metal $1,006.00
D2792 crown full cast noble metal $1,052.00
D2794 crown titanium $1,030.00
D2950 core build up $310.00
Other restorative services Members’ Cost
Extractions
D7140 simple extractions $225.00
D7210 surgical extractions $385.00
 Implant Services
D6010 surgical placement of implant $2,248.00
Dentures
D5120 lower full denture $2,200.00
D5130 immediate denture maxillaries $2,225.00
D5213 upper partial $2,248.00
Orthodontics
Under the age of 19 $6,094.00
Over the age of 19 $6,463.00
Orthodontic treatment not listed 15% savings
Dental Services Not Listed
Dental care rendered by a board certified general dentist not listed are rendered at an 18% savings below the dental offices usual & customary fees. Dental care rendered by a board certified oral surgeon, periodontist, endodontist are rendered at a 15% savings below the dental offices’ usual & customary fee.
Payment for Dental Services
Payment for dental care are required at the time of treatment. For members convenience the use of debt and credit cards is accepted.

Fee Schedule  #52- Effective February 1, 2025