QCD Schedule of Program Fees

This is what the QCD member pays the QCD Affiliate Network dentist at the time of service.

Diagnostic Dentistry

D0120 Periodical Oral Examination $9.00
 
D0140 Limited Oral Examination, Problem Focused $12.00
 
D0150 Comprehensive Oral Examination $18.00
 
D0210 Intraoral-X-Ray Complete Series $28.00
 
D0460 Pulp Vitality Test $15.00
 
D9999 Asepsis Fee (Infection Control) $8.00
 

All Bitewing/Single Film X-Rays 20% Discount

Preventative Dentistry

D1110 Prophylaxis - Adult $24.00
 
D1120 Prophylaxis - Child $24.00
 
D1203 Application Topical Fluoride - Child $5.00
 
D1204 Application Topical Fluoride - Adult $5.00
 
D1351 Sealant - Per Tooth $14.00
 
D1510 Space Maintainer - Fixed Unilateral $60.00
 
D1515 Space Maintainer - Fixed Bilateral $75.00
 

A specific preventative treatment may present unusual circumstances requiring an additional cost. Please consult the affiliated dentist as to the total procedure cost prior to treatment.

Cosmetic Dentistry

All Cosmetic Dentistry is provided at a 20% discount from the dentist's usual and customary fee.

Restorative Dentistry

D2140 Amalgam - 1 Surface, Permanent $28.00
 
D2150 Amalgam - 2 Surfaces, Permanent $36.00
 
D2160 Amalgam - 3 Surfaces, Permanent $46.00
 
D2161 Amalgam - 4 or More Surfaces, Permanent $56.00
 
D2330 Composite Resin - 1 Surface, Anterior $38.00
 
D2331 Composite Resin - 2 Surfaces, Anterior $46.00
 
D2332 Composite Resin - 3 Surfaces, Anterior $56.00
 
D2335 Composite Resin - 4 or More Surfaces or Involving Incisal Angle, Anterior $66.00
 
D2391 Composite Resin - 1 Surface, Posterior $50.00
 
D2392 Composite Resin - 2 Surfaces, Posterior $65.00
 
D2393 Composite Resin - 3 Surfaces, Posterior $85.00
 
D2394 Composite Resin - 4 or More Surfaces, Posterior $95.00
 
D2750 Crown -- Porcelain to High Noble Metal (Gold and Lab Fees additional) $350.00
 
D2751 Crown -- Porcelain to Base Metal (Lab Fees additional) $320.00
 
D2920 Recement Crown $20.00
 
D2931 Prefabricated Stainless Steel Crown $48.00
 
D2940 Sedative Filling $16.00
 
D2950 Core Buildup, Including Any Pins $55.00
 
D2951 Pin Retention - Per Tooth $20.00
 
D2952 Cast Post and Core In Additional to Crown $75.00
 
D2953 Each Additional Cast Post Same Tooth $40.00
 
D2954 Prefab Post / Core In Additional to Crown $60.00
 
D2970 Temporary Crown (Fractured Tooth) $40.00
 

Endodontics

D3110 Pulp Cap, Direct $19.00
 
D3120 Pulp Cap, Indirect $24.00
 
D3220 Pulpotomy $35.00
 
D3310 Root Canal, Anterior $185.00
 
D3320 Root Canal, Bicuspid $209.00
 
D3330 Root Canal, Molar $259.00
 
D3920 Hemisection $65.00
 

Periodontics

D4210 Gingivectomy/Gingivoplasty - Per Quadrant $180.00
 
D4211 Gingivectomy/Gingivoplasty - Per Tooth $50.00
 
D4240 Gingival Flap Procedure, Including Root Planing - Per Quadrant $200.00
 
D4260 Osseous Surgery - Per Quadrant (Including Flap Entry and Closure) $260.00
 
D4341 Periodontal Scaling and Root Planing - (Per Quadrant) $75.00
 
D4355 Full Mouth Debridement $70.00
 
D4910 Periodontal Maintenance Procedures Following Active Therapy $30.00
 

Prosthodontics - Removable

D5110 Complete Upper Denture (Including Six Months Post Care) $400.00
 
D5120 Complete Lower Denture (Including Six Months Post Care) $400.00
 
D5130 Immediate Upper $420.00
 
D5140 Immediate Lower $420.00
 
D5211 Upper Partial Denture - Resin Base $250.00
 
D5212 Lower Partial Denture - Resin Base $250.00
 
D5213 Upper Partial - Predominantly Cast Base $400.00
 
D5214 Lower Partial - Predominantly Cast Base $400.00
 
D5410 Adjust Complete Denture $15.00
 
D5510 Repair Broken Complete Denture Base $40.00
 
D5610 Repair Resin Denture Base $35.00
 
D5630 Repair or Replace Broken Clasp $45.00
 
D5640 Replace Broken Teeth - Per Tooth $30.00
 
D5650 Add Tooth to Existing Partial Denture $45.00
 
D5660 Add Clasp to Existing Partial Denture $65.00
 
D5730 Reline Complete Upper (Chairside) $75.00
 
D5731 Reline Complete Lower (Chairside) $75.00
 
D5740 Reline Upper Partial (Chairside) $75.00
 
D5741 Reline Lower Partial (Chairside) $75.00
 
D5810 Temporary Complete Denture Upper $200.00
 
D5811 Temporary Complete Denture Lower $200.00
 
D5820 Temporary Partial - Stay Plate Upper $180.00
 
D5821 Temporary Partial - Stay Plate Lower $180.00
 

Prosthodontics - Fixed Bridges

D6241 Pontic - Porcelain Fused to Base Metal $320.00
 
D6751 Crown - Porcelain Fused to Base Metal $320.00
 
D6791 Crown - Full Cast Fused to Base Metal $270.00
 
D6930 Recement Bridge $20.00
 
D6940 Stress Breaker $90.00
 
D6950 Precision Attachment (Each) $225.00
 

Oral Surgery

D7110 Single Tooth Extraction $36.00
 
D7120 Each Additional Tooth $34.00
 
D7130 Root Removal - Exposed Roots $48.00
 
D7210 Surgical Extraction - Erupted $68.00
 
D7220 Removal of Impacted Tooth - Soft Tissue $78.00
 
D7230 Removal of Impacted Tooth - Partially Bony $109.00
 
D7240 Removal of Impacted Tooth - Completely Bony $129.00
 
D7241 Removal of Impacted Tooth - Completely Bony with Unusual Surgical Complications $189.00
 
D7250 Root Recovery $72.00
 
D7280 Surgical Exposure per Tooth $66.00
 
D7310 Alveoloplasty (per Quadrant, with Extractions) $78.00
 
D7320 Alveoloplasty (per Quadrant, without Extractions) $84.00
 
D7960 Frenectomy $99.00
 

Orthodontics (QCD General Dentists Only)

D8999 Diagnostic Work-Up Radiographs, Model, Records $120.00
 
D8080 Child (QCD General Dentist) Class I or II for 24 Month Treatment $2200.00
 
D8090 Adult (QCD General Dentist) Class I or II for 24 Month Treatment $2400.00
 
D8680 Orthodontic Retention $230.00
 

A specific orthodontic treatment may present unusual circumstances requiring an additional cost. During the orthodontic consultation appointment, the affiliated dentist will explain all needed procedures, length of treatment, required fees and payment schedule.

General Services

D9999 Failed Appointment (Without 24 Hours Notice) $30.00
 
D9999 Palliative (Emergency) Treatment of Dental Pain - Minor Procedures $20.00
 
D9999 Office Visit - After Hours $45.00
 

Specialty Care Services

All scheduled charges listed are for services rendered by a QCD of America® affiliated general dentist. All treatments provided by a QCD of America® affiliated specialty dentist (advanced degree) in Endodontics, Periodontics, Prosthodontics, Oral Surgery, Pediatric Dentistry or Orthodontics (Board Certified or Board Eligible only) will be charged at a 20% discount from the affiliated dentist's usual and customary fee for the treatment.

Other Procedures and Payment for Services

Any procedure not listed on the QCD of America® Schedule of Dental Program Fees is available at the affiliated dentist's usual and customary fee less a 20% discount -- this includes all lab fees. All fees included in the Schedule of Dental Fees are for payment at time of service. The member may negotiate payment terms with the affiliated dentist; however, an additional charge may be added for payment terms.Asepsis Fee

An asepsis fee of $8.00 per patient appointment is charged by all affiliated dentists to insure proper infection control for all QCD of America® members.Exclusions and Limitations

1) The following exclusions and limitations apply:

Services covered under workmen's compensation or employer's liability laws;
Cost of any dental care covered by any insurance;
Services which, in the opinion of the attending dentist, are not necessary for the patient's dental health or cannot be performed because of the general health of the patient;
General anesthesia, I.V. sedation, hospitalization, and hospital or medical charges of any type.

2) QCD of America® member fees apply only to services rendered by affiliated dental offices and are subject to change in the future.

3) QCD of America® member fees do not apply to work in progress or if the patient's membership is no longer valid.

4) QCD of America® makes no representations concerning the competency of the affiliated dentists or to the quality of their services and assumes no responsibility or liability for services rendered by affiliated dentists.

5) Any QCD of America® member accepted for orthodontic treatment must remain a member of the plan for the complete duration of the treatment or risk additional charges by the affiliated dentist.

6) Any procedure may present unusual circumstances requiring an additional cost. Please consult the affiliated dentist as to the total treatment cost prior to any services being rendered.

Important Notice

The QCD of America® Dental Benefit Program does not constitute dental insurance and is not a health maintenance organization contract. QCD of America┬« does not reimburse the affiliated dentist or indemnify the member for the cost of dental services received by the member.