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This is what the QCD member pays the QCD Affiliate Network dentist at the time of service. and is also known as Allowable Expenses.
| 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
| 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.
All Cosmetic Dentistry is provided at a 20% discount from the dentist’s usual and customary fee.
| 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 | $56.00 |
| 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 |
| D3110 | Pulp Cap, Direct | $19.00 |
| D3120 | Pulp Cap, Indirect | $24.00 |
| D3220 | Pulpotomy $35.00 | $35.00 |
| D3310 | Root Canal, Anterior | $185.00 |
| D3320 | Root Canal, Bicuspid | $209.00 |
| D3330 | Root Canal, Molar | $259.00 |
| D3920 | Hemisection | $65.00 |
| 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 |
| 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 Upper Partial (Chairside) | $75.00 |
| D5740 | Reline Lower Partial (Chairside) | $75.00 |
| D5741 | Temporary Complete Denture Upper | $75.00 |
| D5810 | Temporary Complete Denture Lower | $200.00 |
| D5811 | Temporary Partial – Stay Plate Upper | $200.00 |
| D5820 | Temporary Partial – Stay Plate Lower | $180.00 |
| D5821 | Temporary Partial – Stay Plate Lower | $180.00 |
| 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 |
| 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 | $78.00 |
| D7320 | Alveoloplasty (per Quadrant, without Extractions) | $84.00 |
| D7960 | Frenectomy | $99.00 |
| 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.
| 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 |
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.
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
The QCD Red Discount Plan does not meet the minimum creditable coverage requirements under M.G.L. c. 111M and 956 CMR 5.00. This plan is not a Qualified Health Plan under the Affordable Care Act. This is not a Medicare prescription drug plan. The range of discounts will vary depending on the type of provider and service. The plan does not pay providers directly. Plan members must pay for all services but will receive a discount from participating providers. The list of participating providers is at http://www.qcdofamerica.com/finddentists/index. A written list of participating providers is available upon request. You may cancel within the first 30 days after receipt of membership materials and receive a full refund, less a nominal processing fee (nominal fee for MD residents is $5, AR and TN residents will be refunded processing fee). Discount Medical Plan Organization and administrator QCD of America 1664 Keller Pkwy. Suite 101, Keller, Tx 76248.
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