Minneapolis, MN 55438

(952) 857-1177

Dental Costs at the Dentist for CAPS Dental Plan Members

D0120 periodic oral evaluation established patient $45.19
D0140 limited oral evaluation problem focused $62.33
D0145 oral evaluation for patient under three years of age And counseling with primary caregiver $56.90
D0150 comprehensive oral evaluation new or established patient $72.29
D0160 detailed and extensive oral evaluation problem focused, by report $128.71
D0170 re-evaluation limited, problem focused (established patient; not post operative visit) $57.71
D0180 comprehensive periodontal evaluation new or established patient $77.66
D0210 intraoral complete series of radiographic images $113.87
D0220 intraoral periapical first radiographic image $25.28
D0230 intraoral periapical each additional radiographic image $21.67
D0240 intraoral occlusal radiographic image $36.14
D0250 extraoral first radiographic image $55.12
D0260 extraoral each additional radiographic image $45.19
D0270 bitewing single radiographic image $24.41
D0272 bitewings two radiographic images $39.75
D0273 bitewings three radiographic images $47.87
D0274 bitewings four radiographic images $55.12
D0277 vertical bitewings 7 to 8 radiographic images $84.93
D0290 posterior anterior or lateral skull and facial bone survey radiographic image $118.18
Oral Pathology Laboratory (D0472-D0502) 10% savings
D1110 prophylaxis adult $81.33
D1120 prophylaxis child $64.59
D1208 topical application of fluoride $36.14
D1320 tobacco counseling for the control and prevention of oral disease $69.60
D1330 oral hygiene instructions $45.19
D1351 sealant per tooth $47.01
D1352 preventive resin restoration in a moderate to high caries risk patient permanent tooth $79.49
Restorative (D2000-D2999) Members’ Cost
Amalgam restoration (including polishing)
D2140 amalgam one surface, primary or permanent $119.20
D2150 amalgam two surfaces, primary or permanent $149.22
D2160 amalgam three surfaces, primary or permanent $181.00
D2161 amalgam four or more surfaces, primary or permanent $215.26
Resin-based composite restorations direct
D2330 resin-based composite one surface, anterior $137.70
D2331 resin-based composite two surfaces, anterior $172.17
D2332 resin-based composite three surfaces, anterior $211.92
D2335 resin-based composite four or more surfaces or involving incisal angle, anterior $264.91
D2390 resin-based composite crown, anterior $375.24
D2391 resin-based composite one surface, posterior $153.61
D2392 resin-based composite two surfaces, posterior $198.70
D2393 resin-based composite three surfaces, posterior $245.39
D2394 resin-based composite four or more surfaces, posterior $290.46
Inlay/onlay restorations Members’ Cost
D2510 inlay metallic one surface $707.61
D2520 inlay metallic two surfaces $771.73
D2530 inlay metallic three surfaces $830.03
D2542 onlay metallic-two surfaces $835.25
D2543 onlay metakkuc-three surfaces $869.89
D2544 onlay metallic-four or more surfaces $906.74
Porcelain/ceramic inlays/onlays include all indirect ceramic and porcelain type inlays/onlays
D2610 inlay porcelain/ceramic one surface $773.50
D2620 inlay porcelain/ceramic two surfaces $784.48
D2630 inlay porcelain/ceramic three surfaces $834.55
D2642 onlay porcelain/ceramic two surfaces $851.45
D2643 onlay porcelain/ceramic three surfaces $905.94
D2644 onlay porcelain/ceramic four or more surfaces $931.53
Resin-based composite inlays/onlays must utilize indirect technique
D2650 inlay resin based composite one surface $730.26
D2651 inlay resin based composite two surfaces $759.46
D2652 inlay resin based composite three surfaces $794.08
D2662 onlay resin based composite two surfaces $812.34
D2663 onlay resin based composite three surfaces $842.95
D2664 onlay resin based composite four or more surfaces $863.69
Crowns single restorations only
D2710 crown resin-based composite (indirect) $779.69
D2712 crown resin-based composite (indirect) $879.46
D2720 crown resin with high noble metal $920.03
D2721 crown resin with predominantly base metal $849.45
D2722 crown resin with noble metal $883.03
D2740 crown porcelain/ceramic substrate $958.89
D2750 crown porcelain fused to high noble metal $955.42
D2751 crown porcelain fused to predominantly base metal $882.15
D2752 crown porcelain fused to noble metal $916.59
D2780 crown cast high noble metal $927.77
D2781 crown cast predominantly base metal $888.39
D2782 crown cast noble metal $907.76
D2783 crown porcelain/ceramic $952.08
D2790 crown full cast high noble metal $962.47
D2791 crown full cast predominantly base metal $869.78
D2792 crown full cast noble metal $909.47
D2794 crown titanium $927.18
D2799 provisional crown-further treatment or completion of diagnosis necessary prior to final impression $359.31
Other restorative services Members’ Cost
D2910 recement inlay, onlay, or partial coverage restoration $92.73
D2915 recement cast or prefabricated post and core $95.30
D2920 recement crown $93.58
D2930 prefabricated stainless steel crown primary tooth $229.57
D2931 prefabricated stainless steel crown permanent tooth $276.37
D2932 prefabricated resin crown $303.75
D2933 prefabricated stainless steel crown with resin window $309.02
D2934 prefabricated esthetic coated stainless steel crown primary tooth $310.14
D2940 protective restoration $101.55
D2950 core buildup, including pins $233.13
D2951 pin retention per tooth, in addition to restoration $60.89
D2952 post and core in addition to crown, indirectly fabricated $357.59
D2953 each additional indirectly fabricated post same tooth $260.45
D2954 prefabricated post and core in addition to crown $290.85
D2955 post removal $251.62
D2957 each additional prefabricated post same tooth $171.32
D2960 labial veneer (resin laminate) chairside $551.88
D2961 labial veneer (resin laminate) laboratory $836.39
D2962 labial veneer (porcelain laminate) laboratory $979.24
D2970 temporary crown (fractured tooth) $309.93
D2971 additional procedures to construct new crown under existing partial denture framework $144.87
D2975 coping $525.42
D2980 crown repair necessitated by restorative material $246.35
Endodontics (D3000 D3999) 15% savings
Periodontics services (D4000-D4999) (including usual postoperative care) 15% savings
Prosthodontics (removable) (D5000-D5899) 15% saving
Implant Services (D6000-D6199) 15% savings
Maxillofacial Prosthetics (D5900-D5999) 15% savings
Prosthodontics, fixed (D6200-D6999) 15% savings
Oral & Maxillofacial Surgery (D7000-D7999) 15% savings
Orthodontics (D8000-D8999)
Under the age of 19 $5516.10
Over the age of 19 $5850.03
Orthodontic treatments not listed 15% savings
Adjunctive General Services (D9000-D9999) 10% savings
Adjunctive General Services (D9000-D9999) 10% savings
Dental Services Not Listed
Dental procedures not listed are available on a fee for service basis and will be billed 15% below the dental providers usual and customary fee.
Payment for Dental Services
Payment for dental services must be made to the dental office at time of service. For members convenience the use of debt and credit cards is accepted.

Fee Schedule  #44- Effective February 1, 2017