Summary Plan Description

Dental Fee Schedule

This is a list of some of the more frequently covered procedures and the amount allowed by the plan. Allowances for other procedures are available by calling Delta Dental of Washington at (800) 554-1907.

Dental Code Description Western and Central Washington Benefit Package Eastern Washington, Idaho, Montana, and Wyoming Benefit Package
Diagnostic
D0120 Periodic oral evaluation $61.00 $24.00
D0140 Problem focus evaluation $80.00 $33.60
D0150 Comprehensive oral evaluation $85.00 $26.40
X-Rays
D0210 Intraoral – complete series $128.00 $51.60
D0220 Intraoral – periapical first film $27.00 $11.00
D0230 Intraoral – periapical each additional $20.00 $7.20
D0272 Bitewings – two films $44.00 $15.60
D0274 Bitewings – four films $62.00 $27.00
D0330 Panoramic film $102.00 $48.00
Preventive
D1110 Prophylaxis – ages 14 and over $115.00 $51.00
D1120 Prophylaxis – children to age 14 $76.00 $30.00
D1206 Topical application of fluoride $45.00 $18.00
D1351 Sealant (per tooth) $52.00 $22.00
Restorative
D2140 Amalgam – 1 surface $112.00 $49.00
D2150 Amalgam – 2 surfaces $141.00 $64.00
D2160 Amalgam – 3 surfaces $167.00 $78.00
D2161 Amalgam – 4 or more surfaces $197.00 $95.00
D2330 Composite – 1 surface, anterior $123.00 $56.00
D2331 Composite – 2 surfaces, anterior $152.00 $75.00
D2332 Composite – 3 surfaces, anterior $185.00 $93.00
D2335 Composite – 4 surfaces, anterior $225.00 $111.00
D2391 Composite – 1 surface, posterior $112.00 $56.00
D2392 Composite – 2 surfaces, posterior $141.00 $75.00
D2393 Composite – 3 surfaces, posterior $167.00 $93.00
D2394 Composite – 4 or more surfaces, posterior $197.00 $93.00
Crowns – Single Restoration
D2750 Porcelain to high noble $770.00 $400.00
D2751 Porcelain to base $653.00 $400.00
D2752 Porcelain to noble $690.00 $400.00
D2790 Full cast high noble $700.00 $400.00
D2930 Stainless steel, primary $167.00 $90.00
D2950 Buildup, including pins $176.00 $97.00
D2954 Prefabricated post and core $217.00 $100.00
Endodontics
D3220 Pulpotomy $133.00 $55.00
D3310 Root canal therapy – anterior $514.00 $263.00
D3320 Root canal therapy – bicuspid $615.00 $314.00
D3330 Root canal therapy – molar $794.00 $418.00
Periodontics
D4211 Gingivectomy – per tooth $253.00 $25.00
D4260 Osseous surgery $1,145.00 $532.00
D4341 Scaling and root planing – 4+ teeth per quad $189.00 $87.00
D4342 Scaling and root planing – 1-3 teeth per quad $117.00 $87.00
D4910 Periodontal maintenance $148.00 $66.00
Full Dentures and Partial Dentures
D5110 Complete upper $906.00 $510.00
D5120 Complete lower $906.00 $510.00
D5213 Upper partial – cast with palatal bar $1,036.00 $654.00
D5214 Lower partial – cast with lingual bar $1,029.00 $654.00
D5520 Replace missing or broken tooth $78.00 $35.00
D5750 Reline complete denture $282.00 $150.00
D5760 Reline partial denture $233.00 $150.00
Bridge Pontics
D6240 Porcelain to high noble $710.00 $400.00
D6241 Porcelain to base $634.00 $400.00
D6242 Porcelain to noble $665.00 $400.00
Bridge Abutments – Crowns
D6750 Porcelain to high noble $719.00 $400.00
D6751 Porcelain to base $629.00 $400.00
D6752 Porcelain to noble $674.00 $400.00
Oral Surgery
D7140 Single tooth $128.00 $49.00
D7210 Surgical removal of erupted tooth $219.00 $96.00
D7220 Removal of impacted tooth – soft tissue $259.00 $111.00
D7230 Removal of impacted tooth – partially bony $333.00 $137.00
D7240 Removal of impacted tooth – complete bony $411.00 $177.00
Other Services
D9110 Palliative (emergency) treatment $126.00 $42.00
D9220 General anesthesia $306.00 $135.00