Louisiana Dental Plan

The following fees apply to General Dentists and Orthodontists. Any specialist (Oral Surgeon, Periodontist, Pediatric Dentist, etc.) will charge a "member pay" fee equal to his regular fee minus 15-20%. Please refer to the Provider list to determine which fee schedule prices your General Dentist and/or Orthodontist will charge. If there is an A by the Provider's name, he/she will follow the A schedule prices. If there is a B beside the Provider's name, he/she will follow the B schedule prices.

Member Services		Fee Schedules
		A	B
D0120	Periodic Oral Evaluation	$11	$14
D0140	Limited Oral Evaluation (Emergency Exam)	21	22
D0210	Complete Series X-ray	33	41
D0220	Single Peri-apical X-ray	3	5
D0230	Each Additional PA Film	3	5
D0272	Bite Wing X-ray	4	11
D0330	Panoramic X-ray	33	42
D0470	Study Models	16	17
D1110	Prophylaxis-Adult (Teeth Cleaning)	22	27
D1120	Prophylaxis-Child (Teeth Cleaning)	16	20
D1203	Fluoride Treatment	7	8
D1351	Sealant (per tooth)	13	17
D1510	Space Maintainer-Fixed Unilateral	64	125
D1515	Space Maintainer-Fixed Bilateral	94	150
D9999	Disposables	5	5
D9972	Cosmetic Bleaching (per arch)	160	165

Restorative Dentistry		Fee Schedules
		A	B
	*Amalgam Restorations Silver Fillings for Posterior (back) Teeth*
D2140	Cavities involving one surface	$30	$38
D2150	Cavities involving two surfaces	40	49
D2160	Cavities involving three surfaces	50	60
	*Composite Fillings (Tooth Colored) For Anterior (Front) Teeth*
D2330	Cavities involving one surface	33	50
D2331	Cavities involving two surface	53	63
D2332	Cavities involving three surface	72	86
D2335	Composite Resin (involving incisal)	72	86
	*Composite Fillings (Tooth Colored) For Posterior (Back) Teeth*
D2385	Cavities involving one surface	42	60
D2386	Cavities involving two surface	55	73
D2387	Cavities involving three surface	80	95

Crown and Bridge Base Fees		Fee Services
		A	B
D2740	Crown- Porcelain	$380	$500
D2750	Crown- Porcelain fused to high noble metal	350	430+metal
D2752	Crown- Porcelain fused to noble metal	350	430+
D2790	Crown- Full cast high noble metal	355	430+metal
D2792	Crown- Full cast noble metal	355	430
D2782	Crown- 3/4 cast noble metal	320	350
D2780	Crown- 3/4 cast high noble metal	340	350+meal
D2931	Prefabricated stainless steel crown	80	96
D2940	Sedative Filling	22	22
D2950	Core build up (including any pins)	58	75
D2954	Prefabricated post and core in addition to crown	68	88

Endodontics (Root Canal Treatment)		Fee Services
		A	B
	Diagnostic Exam	$11	$12
D3110	Pulp Cap- Direct (excluding final restorations)	6	15
D3220	Therapeutic Pulpotomy (excluding final restorations)	43	45
	*Root Canals*
D3310	Anterior (excluding final restoration)	145	%20 Off
D3320	Bicuspid (excluding final restoration)	185	%20 Off
D3330	Molar (excluding final restoration)	240	%20 Off
D3340	Molar (excluding final restoration)	265	%20 Off

Oral Surgery		Fee Services
		A	B
D7110	Routine Extraction (Single Tooth)	$29	$47
D7210	Surgical Extraction	60	80
D7220	Removal of Impacted Tooth- Soft Tissue	59	81
D7230	Removal of Impacted Tooth- Partially Bony	110	132
D7240	Removal of Impacted Tooth- Completely Bony	140	164
D7510	Incision and Drainage of Abcess- Intraoral soft tissue	33	35

Prosthetics (Dentures)		Fee Services
		A	B
D5110	Complete Maxillary (Upper Denture) Excluding Extractions	$450	$550
D5120	Complete Mandibular (Lower Denture) Excluding Extractions	450	550
D5211	Upper Partial Denture- Resin Base (including any conventional clasps and rests)	350	395
D5212	Lower Partial Denture- Resin Base (including any conventional clasps and rests)	350	395
D5213	Upper Partial Denture- cast metal framework w/ resin denture bases (including any conventional clasps and rests)	540	610
D5214	Lower Partial Denture- cast metal framework w/ resin denture bases (including any conventional clasps and rests)	540	610
D5710	Rebase - Complete Upper Denture	155	183
D5711	Rebase - Complete Lower Denture	155	183
D5730	Reline Complete Upper Denture Chairside	85	97
D5731	Reline Complete Lower Denture Chairside	85	97
	Fixed Partial Denture Retainers-Crowns
06750	Fixed Bridge Per Unit-Porcelain fused to high noble metal	340	430
06751	Fixed Bridge Per Unit-Porcelain fused to predominantly base metal	340	430

Orthodontics	Fee Services
	A	B
Initial Exam	No Charge	No Charge
*Orthodontic Treatment (all ages)*
Class 1 Treatment	$2,325	$2,650
Class 2 Treatment	2,525	2,888
Class 3 Treatment	2,795	3,111
(Includes placement of appliance, treatment for two years (24 months), removal of appliances, records and placement of retainer. Does not include the cost of the retainer to be paid by LDP member. The Orthodontist will explain the length of treatment, all fees and the payment schedule. Orthodontic treatment that requires surgery or unusual services may require an additional charge. Discuss this with the Orthodontist prior to beginning treatment).

Limitations and Exclusions

1. Any treatment which in the opinion of the attending dentist is not necessary for the patient's dental health or that cannot be performed because of the general health of the patient.

2. Treatment for injuries or conditions that are covered under Workman's Compensation or Employees Liability Laws, Automobile, Medical, No Fault or similar types insurance. Services which are provided without cost to the patient by any County, Municipality or other political subdivision.

3. Member Benefits and Dental Fees Schedule apply only when treatment is performed at a participating dental office. If the service of a non-participating dentist is required, or services are performed in a hospital facility, these dental fees do not apply and the patient will be responsible to the nonparticpating dentist or hospital for the usual fees.

4. Any dental treatment already in progress will be excluded. Special arrangements may be made at the option of participating providers to assume treatment in progress. Fees for assumption of treatment should be negotiated by provider and member. These fees may or may not be relative to Louisiana Dental Plan, Inc. Member Fees Schedule.

5. When the member's Membership is no longer valid.

6. The members may select the dentist of their choice; however, if the dentist selected is not a participating dentist, the fees charged by the nonparticpating dentist must be paid by the member. Any licensed dentist is eligible to participate in the plan. Application to become a plan provider may be obtained from the Louisiana Dental Plan, Inc. office. A providers participation will be contingent on acceptance and notification by Louisiana Dental Plan, Inc.

7. Fees listed on the Members Benefits and Dental Fees Schedule are for procedures done by participating general dentists and orthodontists and should be considered specialist's fees.

8. Participating specialists, other than an orthodontist, charge a "member pay" fee equal to his regular fee minus 15-20%.

Periodontics		Fee Services
		A	B
D4421	Gingivectomy or Gingivoplasty (per 1/4 mouth)	$115	$120
D4341	Periodontal Scaling and Root Planing (per 1/4 mouth)	82	87
D4910	Periodontal Prophylaxis	38	40