Key Dental Plan provides members with access to a network of highly qualified dentists and specialists in your area, making it possible for you to get the services you need, at an affordable cost.
504 - Diagnostic and Preventive
| Code | Service | Price |
| D0120 | Periodic Oral Evaluation - Established Patient | $20 |
| D0150 | Comprehensive Oral Evaluation - New or Established Patient | $25 |
| D0210 | X - Rays - Intraoral - Complete Series (including bitewings) | $62 |
| D0270 | Bitewing X - Ray - Single Film | $14 |
| D0272 | Bitewings - Two Films | $19 |
| D0273 | Bitewings - Three Films | $25 |
| D0274 | Bitewings - Four Films | $32 |
| D0330 | Panoramic Film | $62 |
| D1110 | Prophylaxis - Adult Cleaning | $45 |
| D1120 | Prophylaxis - Child Cleaning | $39 |
504 - Restorative
| Code | Service | Fee |
| D2140 | Amalgam - One Surface, Primary or Permanent | $62 |
| D2330 | Resin - Based Composite - One Surface, Anterior | $80 |
| D2391 | Resin - Based Composite - One Surface, Posterior | $101 |
| D2750 | Crown - Porcelain Fused to High Noble Metal | $701 |
| D2790 | Crown - Full Cast High Noble Metal | $687 |
| D2950 | Core Buildup - Including Any Pins | $146 |
504 - Endodontics
| Code | Service | Fee |
| D3110 | Pulp Cap Direct (excluding final restoration) | $33 |
| D3310 | Root Canal - Anterior (excluding final restoration) | $399 |
| D3320 | Root Canal - Bicuspid (excluding final restoration) | $480 |
| D3330 | Root Canal - Molar (excluding final restoration) | $607 |
504 - Periodontics
| Code | Service | Fee |
| D4210 | Gingivectomy or Gingivoplasty - Four or More Contiguous Teeth or Bounded Teeth Spaces Per Quadrant | $422 |
| D4341 | Periodontal Scaling and Root Planing - Four or More | $138 |
| D4910 | Periodontal Maintenance | $88 |
504 - Prosthodontics (Removable)
| Code | Service | Fee |
| D5110 | Complete Denture - Maxillary | $884 |
| D5120 | Complete Denture - Mandibular | $884 |
| D5211 | Maxillary Partial Denture - Resin Base (including any conventional clasps, rests and teeth) | $865 |
| D5212 | Mandibular Partial Denture - Resin Base (including any conventional clasps, rests and teeth) | $865 |
| D5213 | Maxillary Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth) | $1,007 |
| D5214 | Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth) | $1,007 |
| D5410 | Adjust Complete Denture - Maxillary | $48 |
| D5411 | Adjust Complete Denture - Mandibular | $48 |
| D5730 | Reline Complete Maxillary Denture (chairside) | $196 |
| D5731 | Reline Complete Mandibular Denture (chairside) | $196 |
504 - Oral Surgery
| Code | Service | Price |
| D7140 | Extraction,erupted Tooth or Exposed Root (elevation and/or forcepts removal) | $80 |
| D7220 | Removal of Impacted Tooth - Soft Tissue | $164 |
| D7240 | Removal of Impacted Tooth - Completely Bony | $276 |
504 - Orthodontics
| Code | Service | Fee |
| D8080 | Complete Orthodontic Treatment - Adolescent Dentition | 20% Discount |
| D8090 | Complete Orthodontic Treatment - AdultDentition | 20% Discount |
504 - Miscellaneous Services
| Code | Service | Fee |
| D9215 | Local Anesthesia | $19 |
| D9230 | Analgesia | $34 |
