Virgin Islands

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

CodeServicePrice
D0120Periodic Oral Evaluation - Established Patient$20
D0150Comprehensive Oral Evaluation - New or Established Patient$25
D0210X - Rays - Intraoral - Complete Series (including bitewings)$62
D0270Bitewing X - Ray - Single Film$14
D0272Bitewings - Two Films$19
D0273Bitewings - Three Films$25
D0274Bitewings - Four Films$32
D0330Panoramic Film$62
D1110Prophylaxis - Adult Cleaning$45
D1120Prophylaxis - Child Cleaning$39

504 - Restorative

CodeServiceFee
D2140Amalgam - One Surface, Primary or Permanent$62
D2330Resin - Based Composite - One Surface, Anterior$80
D2391Resin - Based Composite - One Surface, Posterior$101
D2750Crown - Porcelain Fused to High Noble Metal$701
D2790Crown - Full Cast High Noble Metal$687
D2950Core Buildup - Including Any Pins$146

504 - Endodontics

CodeServiceFee
D3110Pulp Cap Direct (excluding final restoration)$33
D3310Root Canal - Anterior (excluding final restoration)$399
D3320Root Canal - Bicuspid (excluding final restoration)$480
D3330Root Canal - Molar (excluding final restoration)$607

504 - Periodontics

CodeServiceFee
D4210Gingivectomy or Gingivoplasty - Four or More Contiguous Teeth or Bounded Teeth Spaces Per Quadrant$422
D4341Periodontal Scaling and Root Planing - Four or More$138
D4910Periodontal Maintenance$88

504 - Prosthodontics (Removable)

CodeServiceFee
D5110Complete Denture - Maxillary$884
D5120Complete Denture - Mandibular$884
D5211Maxillary Partial Denture - Resin Base (including any conventional clasps, rests and teeth)$865
D5212Mandibular Partial Denture - Resin Base (including any conventional clasps, rests and teeth)$865
D5213Maxillary Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth)$1,007
D5214Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth)$1,007
D5410Adjust Complete Denture - Maxillary$48
D5411Adjust Complete Denture - Mandibular$48
D5730Reline Complete Maxillary Denture (chairside)$196
D5731Reline Complete Mandibular Denture (chairside)$196

504 - Oral Surgery

CodeServicePrice
D7140Extraction,erupted Tooth or Exposed Root (elevation and/or forcepts removal)$80
D7220Removal of Impacted Tooth - Soft Tissue$164
D7240Removal of Impacted Tooth - Completely Bony$276

504 - Orthodontics

CodeServiceFee
D8080Complete Orthodontic Treatment - Adolescent Dentition20% Discount
D8090Complete Orthodontic Treatment - AdultDentition20% Discount

504 - Miscellaneous Services

CodeServiceFee
D9215Local Anesthesia$19
D9230Analgesia$34

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