| TAKE ADVANTAGE OF THE DR. ZAK DENTAL PLAN SAVINGS |
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| DIAGNOSTIC AND PREVENTATIVE |
| MEMBER SERVICE |
COPAYMENT |
| Full Mouth X-rays |
Full Mouth X-rays CODE:D0210X-rays of diagnostic quality and properly identified and dated. Is a part of the patient’s clinical record and the original images should be retained by the dentist.  |
NO CHARGE |
| Single film |
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NO CHARGE |
| Each additional film |
|
NO CHARGE |
| Oral exam and diagnosis |
Oral exam and diagnosis CODE:D0120An evaluation performed on a patient of record to determine any changes in the patient's dental and medical health status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation and periodontal screening where indicated, and may require interpretation of information acquired through additional diagnostic procedures.  |
NO CHARGE |
Prophylaxis (Cleaning)* (*Limited to one treatment per year) |
Prophylaxis (Cleaning) CODE:D1110Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors.  |
NO CHARGE |
| Each additional adult cleaning |
|
$50.00 |
Prophylaxis (Child)* (*Limited to one treatment per year) |
Prophylaxis (Child) CODE:D1110Removal of plaque, calculus and stains from the tooth structures in the primary and transitional dentition. It is intended to control local irritational factors.  |
NO CHARGE |
| Each additional child cleaning |
|
$30.00 |
| Sealants (per tooth) |
|
$24.00 |
| RESTORATIVE DENTISTRY (FILLINGS) |
| MEMBER SERVICE |
COPAYMENT |
| Amalgam Restorations (primary) |
| 1 Surface |
1 Surface CODE:D2140Tooth preparation, all adhesives (including amalgam bonding agents), liners and bases are included as part of the restoration.  |
$45.00 |
| 2 Surfaces |
2 Surfaces CODE:D2150Tooth preparation, all adhesives (including amalgam bonding agents), liners and bases are included as part of the restoration.  |
$55.00 |
| 3 Surfaces |
3 Surfaces CODE:D2160Tooth preparation, all adhesives (including amalgam bonding agents), liners and bases are included as part of the restoration.  |
$75.00 |
| 4 or more Surfaces |
4 or more Surfaces CODE:D2161Tooth preparation, all adhesives (including amalgam bonding agents), liners and bases are included as part of the restoration.  |
$95.00 |
| Amalgam Restorations (permanent) |
| 1 Surface |
1 Surface CODE:D2140Tooth preparation, all adhesives (including amalgam bonding agents), liners and bases are included as part of the restoration.  |
$55.00 |
| 2 Surfaces |
2 Surfaces CODE:D2150Tooth preparation, all adhesives (including amalgam bonding agents), liners and bases are included as part of the restoration.  |
$65.00 |
| 3 Surfaces |
3 Surfaces CODE:D2160Tooth preparation, all adhesives (including amalgam bonding agents), liners and bases are included as part of the restoration.  |
$85.00 |
| 4 or more Surfaces |
4 or more Surfaces CODE:D2161Tooth preparation, all adhesives (including amalgam bonding agents), liners and bases are included as part of the restoration.  |
$105.00 |
| Composite Restoration (anterior) |
| 1 Surface |
4 or more Surfaces CODE:D2330Resin-based composite refers to a broad category of materials including but not limited to composites. May include bonded composite, light-cured composite, etc. Tooth preparation, acid etching, adhesives (including resin bonding agents), liners and bases and curing are included as part of the restoration.  |
$95.00 |
| 2 Surfaces |
4 or more Surfaces CODE:D2331Resin-based composite refers to a broad category of materials including but not limited to composites. May include bonded composite, light-cured composite, etc. Tooth preparation, acid etching, adhesives (including resin bonding agents), liners and bases and curing are included as part of the restoration.  |
$115.00 |
| 3 Surfaces |
4 or more Surfaces CODE:D2332Resin-based composite refers to a broad category of materials including but not limited to composites. May include bonded composite, light-cured composite, etc. Tooth preparation, acid etching, adhesives (including resin bonding agents), liners and bases and curing are included as part of the restoration.  |
$145.00 |
| 4 or more Surfaces |
4 or more Surfaces CODE:D2335/D2390Full resin-based composite coverage of tooth.  |
$195.00 |
| Composite Restoration (posterior) |
| 1 Surface |
1 Surface CODE:D2391Resin-based composite refers to a broad category of materials including but not limited to composites. May include bonded composite, light-cured composite, etc. Tooth preparation, acid etching, adhesives (including resin bonding agents), liners and bases and curing are included as part of the restoration.  |
$125.00 |
| 2 Surfaces |
2 Surfaces CODE:D2335/D2390Resin-based composite refers to a broad category of materials including but not limited to composites. May include bonded composite, light-cured composite, etc. Tooth preparation, acid etching, adhesives (including resin bonding agents), liners and bases and curing are included as part of the restoration.  |
$155.00 |
| 3 Surfaces |
3 Surfaces CODE:D2393Resin-based composite refers to a broad category of materials including but not limited to composites. May include bonded composite, light-cured composite, etc. Tooth preparation, acid etching, adhesives (including resin bonding agents), liners and bases and curing are included as part of the restoration.  |
$175.00 |
| 4 or more Surfaces |
4 or more Surfaces CODE:D2394Resin-based composite refers to a broad category of materials including but not limited to composites. May include bonded composite, light-cured composite, etc. Tooth preparation, acid etching, adhesives (including resin bonding agents), liners and bases and curing are included as part of the restoration.  |
$195.00 |
| CROWNS AND BRIDGE |
| MEMBER SERVICE |
COPAYMENT |
| Porcelain fused to base metal crown |
Crown refers to the restoration of teeth where a fabricated crown is used to cap or completely cover a tooth. Porcelain fused to base metal crown CODE:D2751Base Metal- Palladium (Pd), and/or Platinum (Pt) < 25%.  |
$447.00 |
| Porcelain fused to noble metal crown |
Crown refers to the restoration of teeth where a fabricated crown is used to cap or completely cover a tooth. Porcelain fused to noble metal crown CODE:D2752Noble Metal - Palladium (Pd), and/or Platinum (Pt)3 25%  |
$477.00 |
| Porcelain fused to high noble metal crown* |
Crown refers to the restoration of teeth where a fabricated crown is used to cap or completely cover a tooth. Porcelain fused to high noble metal crown* CODE:D2750High Noble Metal - Palladium (Pd), and/or Platinum (Pt)>= 60% (with at least 40% Gold (Au)); titanium and titanium alloys - Titanium (Ti) > 85%;  |
$497.00 |
| All porcelain crown |
Crown refers to the restoration of teeth where a fabricated crown is used to cap or completely cover a tooth. All porcelain crown CODE:D2740Refers to those non-metal, non-resin inorganic refractory compounds processed at high temperatures (600§C/1112§F and above) and pressed, polished or milled - including porcelains, glasses, and glass-ceramics.  |
$697.00 |
| Porcelain Pontic |
Crown refers to the restoration of teeth where a fabricated crown is used to cap or completely cover a tooth. Porcelain Pontic CODE:D6240A portion of the bridge that replaces the missing tooth(teeth)  |
$597.00 |
| Abutment Crown |
Crown refers to the restoration of teeth where a fabricated crown is used to cap or completely cover a tooth. Abutment Crown CODE:D6750A portion of the bridge that holds that supports the missing tooth (teeth)  |
$597.00 |
| Core buildup |
Crown refers to the restoration of teeth where a fabricated crown is used to cap or completely cover a tooth. Core buildup CODE:D6950Refers to building up of anatomical crown when restorative crown will be placed. A material is placed in the tooth preparation for a crown when there is insufficient tooth strength and retention for the crown procedure.  |
$135.00 |
| Porcelain Inlay or Onlay (1-4 Surfaces) |
Crown refers to the restoration of teeth where a fabricated crown is used to cap or completely cover a tooth. Porcelain Inlay or Onlay (1-4 Surfaces) CODE:D2610A filling consisting of a solid substance (i.e. porcelain) fitted to a cavity in a tooth and cemented into place  |
$497.00 |
| Recement crown |
Crown refers to the restoration of teeth where a fabricated crown is used to cap or completely cover a tooth. Reattach crown CODE:D2920Reattach crown  |
$105.00 |
| Recement bridge |
Crown refers to the restoration of teeth where a fabricated crown is used to cap or completely cover a tooth. Reattach bridge CODE:D6930Reattach fixed partial denture (bridge)  |
$125.00 |
| (*Gold will be charged at an additional fee) |
| ORAL SURGERY |
| MEMBER SERVICE |
COPAYMENT |
| Simple extraction with local anesthesia |
Simple extraction with local anesthesia CODE:D7110Removal of Erupted Tooth, Uncomplicated  |
$95.00 |
| Surginal extraction |
Surginal extraction CODE:D7210Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth Includes cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone and closure.  |
$150.00 |
| Soft tissue impaction |
Soft tissue impaction CODE:D7220Occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation.  |
$195.00 |
| Partial bony impaction |
Partial bony impaction CODE:D7230Part of crown covered by bone; requires mucoperiosteal flap elevation and bone removal.  |
$245.00 |
| Full bony impaction |
Full bony impaction CODE:D7240Most or all of crown covered by bone; requires mucoperiosteal flap elevation and bone removal.  |
$325.00 |
| Surgical removal of residual root tips |
Surgical removal of residual root tips CODE:D7250Includes cutting of soft tissue and bone, removal of tooth structure, and closure.  |
$150.00 |
| Synthetic bone graft |
Synthetic bone graft CODE:D7953Osseous autograft, allograft or non-osseous graft is placed in an extraction site at the time of the extraction to preserve ridge integrity (e.g., clinically indicated in preparation for implant reconstruction or where alveolar contour is critical to planned prosthetic reconstruction).  |
$229.00 |
| PERIODONTICS (TREATMENT OF GUMS) |
| MEMBER SERVICE |
COPAYMENT |
| Scaling and root planing (per quadrant) |
Scaling and root planing (per quadrant) CODE:D4341This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as a part of pre-surgical procedures in others. D4342 periodontal scaling and root planing - one to three teeth.  |
$75.00 |
| Periodontal irrigation (per quadrant) |
Periodontal irrigation (per quadrant) CODE:D9630Includes, but is not limited to oral antibiotics, oral analgesics, and topical fluoride dispensed in the office for home use; does not include writing prescriptions.  |
$53.00 |
| Periodontal irrigation (generalized) |
Periodontal irrigation (generalized) CODE:D9632Includes, but is not limited to oral antibiotics, oral analgesics, and topical fluoride dispensed in the office for home use; does not include writing prescriptions.  |
$89.00 |
| Full mouth debridement |
Full mouth debridement CODE:D4355The gross removal of plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation. This preliminary procedure does not preclude the need for additional procedures.  |
$99.00 |
| Periodontal maintenance |
Periodontal maintenance CODE:D4910This procedure is instituted following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated, and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered.  |
$89.00 |
| Arestin (per site) |
Arestin (per site) CODE:D4381FDA approved subgingival delivery devices containing antimicrobial medication(s) are inserted into periodontal pockets to suppress the pathogenic microbiota. These devices slowly release the pharmacological agents so they can remain at the intended site of action in a therapeutic concentration for a sufficient length of time.  |
$49.00 |
| ENDODONTICS (ROOT CANAL THERAPY) |
| MEMBER SERVICE |
COPAYMENT |
| Pulp Cap - direct* |
Pulp Cap - direct* CODE:D3110Procedure in which the exposed pulp is covered with a dressing or cement that protects the pulp and promotes healing and repair.  |
$75.00 |
| Pulp Cap - indirect* |
Pulp Cap - indirect* CODE:D3120Procedure in which the nearly exposed pulp is covered with a protective dressing to protect the pulp from additional injury and to promote healing and repair via formation of secondary dentin.  |
$70.00 |
| Therapeutic pulpotomy |
Therapeutic pulpotomy CODE:D3220Pulpotomy is the surgical removal of a portion of the pulp with the aim of maintaining the vitality of the remaining portion by means of an adequate dressing.To be performed on primary or permanent teeth.  |
$125.00 |
| Root Canal - anterior |
Root Canal - anterior CODE:D3310Root canal treatment, also known as endodontic treatment, is a dental procedure in which the diseased or damaged pulp (core) of a tooth is removed and the inside areas (the pulp chamber and root canals) are filled and sealed.  |
$405.00 |
| Root Canal - bicuspid |
Root Canal - bicuspid CODE:D3320Root canal treatment, also known as endodontic treatment, is a dental procedure in which the diseased or damaged pulp (core) of a tooth is removed and the inside areas (the pulp chamber and root canals) are filled and sealed. Applies to multiple canals.  |
$495.00 |
| Root Canal - molar |
Root Canal - molar CODE:D3330Root canal treatment, also known as endodontic treatment, is a dental procedure in which the diseased or damaged pulp (core) of a tooth is removed and the inside areas (the pulp chamber and root canals) are filled and sealed. Applies to multiple canals.  |
$645.00 |
| (*Excluding final restoration) |
| PROSTHETICS (DENTURED) |
| MEMBER SERVICE |
COPAYMENT |
| Complete maxillary denture |
Complete maxillary denture CODE:D5110Dentures are prosthetic devices constructed to replace missing teeth, and which are supported by surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable, however there are many different denture designs, some which rely on bonding or clipping onto teeth.  |
$789.00 |
| Complete mandibular denture |
Complete mandibular denture CODE:D5120Dentures are prosthetic devices constructed to replace missing teeth, and which are supported by surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable, however there are many different denture designs, some which rely on bonding or clipping onto teeth.  |
$789.00 |
| Partial maxillary denture |
Partial maxillary denture CODE:D5211Dentures are prosthetic devices constructed to replace missing teeth, and which are supported by surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable, however there are many different denture designs, some which rely on bonding or clipping onto teeth.  |
$495.00 |
| Partial mandibular denture |
Partial mandibular denture CODE:D5212Dentures are prosthetic devices constructed to replace missing teeth, and which are supported by surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable, however there are many different denture designs, some which rely on bonding or clipping onto teeth.  |
$495.00 |
| Denture adjustment |
Denture adjustment CODE:D5421-2Slight modifications to existing denture to relieve discomfort.  |
$50.00 |
| Add clasp to existing denture |
Add clasp to existing denture CODE:D5660The addition of a clast to a denture to improve denture retention.  |
$125.00 |
| Interim stayplate |
Interim stayplate CODE:D5820A provisional prosthesis designed for use over a limited period of time, after which it is to be replaced by a more definitive restoration.  |
$380.00 |
| Tissue Conditioning |
Tissue Conditioning CODE:D5850-1Treatment reline using materials designed to heal unhealthy ridges prior to more definitive final restoration.  |
$125.00 |
| Denture Reline (chairside) |
Denture Reline (chairside) CODE:D5730-41Reline is the process of resurfacing the tissue side of a denture with new base material.  |
$125.00 |
| Denture Reline (lab) |
Denture Reline (lab) CODE:D5750-61Reline is the process of resurfacing the tissue side of a denture with new base material.  |
$225.00 |
| Denture Rebase |
Denture Rebase CODE:D5710-21Rebase - process of refitting a denture by replacing the base material.  |
$275.00 |
| Replace tooth on denture |
Replace tooth on denture CODE:D5650Adding/Replacing tooth to existing partial denture.  |
$50.00 |
| ORTHODONTICS (BRACES) |
| MEMBER SERVICE |
COPAYMENT |
| Orthodontic treatment for adolescents* |
Orthodontic treatment for adolescents* CODE:D8070Diagnosis and treatment leading to the improvement of a patient's craniofacial dysfunction and/or dentofacial deformity including anatomical, functional and aesthetic relationships. Treatment usually, but not necessarily, utilizes fixed orthodontic appliances. Adjunctive procedures, such as extractions, maxillofacial surgery, nasopharyngeal surgery, myofunctional or speech therapy and restorative or periodontal care, may be coordinated disciplines. Optimal care requires long-term consideration of patient's needs and periodic re-evaluation. Treatment may incorporate several phases with specific objectives at various stages of dentofacial development.  |
$3,432.00 |
| Orthodontic treatment for adults* |
Orthodontic treatment for adults* CODE:D8090Diagnosis and treatment leading to the improvement of a patient's craniofacial dysfunction and/or dentofacial deformity including anatomical, functional and aesthetic relationships. Treatment usually, but not necessarily, utilizes fixed orthodontic appliances. Adjunctive procedures, such as extractions, maxillofacial surgery, nasopharyngeal surgery, myofunctional or speech therapy and restorative or periodontal care, may be coordinated disciplines. Optimal care requires long-term consideration of patient's needs and periodic re-evaluation. Treatment may incorporate several phases with specific objectives at various stages of dentofacial development.  |
$3,432.00 |
| (*Cosmetic braces extra) |
| Invisalign |
InvisalignClear, custom-fabricated device used for straightening teeth. These retainers are designed to gradually realign teeth and are meant to replace traditional braces. Cosmetically, invisible retainers are more appealing because they are difficult to notice, making them particularly popular among adults who wish to straighten their teeth without the use of traditional metal braces. Such retainers are easily removed during eating and tooth brushing.  |
$4,200.00 |
| OTHER CHARGES |
| MEMBER SERVICE |
COPAYMENT |
| Appointment Cancellations (no 24 hour notice) |
|
$50.00 |
| The above prices are quoted for procedures performed by general dentists. Procedures not listed in the above benefit schedule, including those performed by specialists (i.e. oral surgeons, endodontists, periodontists) may still be a covered benefit and available to members. Please check complete fee schedule for specialty benefits. |