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$17
D0150Comprehensive Oral Evaluation - New or Established Patient$21
D0210X - Rays - Intraoral - Complete Series (including bitewings)$53
D0270Bitewing X - Ray - Single Film$12
D0272Bitewings - Two Films$16
D0273Bitewings - Three Films$21
D0274Bitewings - Four Films$27
D0330Panoramic Film$53
D1110Prophylaxis - Adult Cleaning$38
D1120Prophylaxis - Child Cleaning$33

504 - Restorative

CodeServiceFee
D2140Amalgam - One Surface, Primary or Permanent$53
D2330Resin - Based Composite - One Surface, Anterior$68
D2391Resin - Based Composite - One Surface, Posterior$86
D2750Crown - Porcelain Fused to High Noble Metal$595
D2790Crown - Full Cast High Noble Metal$583
D2950Core Buildup - Including Any Pins$124

504 - Endodontics

CodeServiceFee
D3110Pulp Cap Direct (excluding final restoration)$28
D3310Root Canal - Anterior (excluding final restoration)$339
D3320Root Canal - Bicuspid (excluding final restoration)$407
D3330Root Canal - Molar (excluding final restoration)$516

504 - Periodontics

CodeServiceFee
D4210Gingivectomy or Gingivoplasty - Four or More Contiguous Teeth or Bounded Teeth Spaces Per Quadrant$358
D4341Periodontal Scaling and Root Planing - Four or More$118
D4910Periodontal Maintenance$75

504 - Prosthodontics (Removable)

CodeServiceFee
D5110Complete Denture - Maxillary$751
D5120Complete Denture - Mandibular$751
D5211Maxillary Partial Denture - Resin Base (including any conventional clasps, rests and teeth)$735
D5212Mandibular Partial Denture - Resin Base (including any conventional clasps, rests and teeth)$735
D5213Maxillary Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth)$856
D5214Mandibular Partial Denture - Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth)$856
D5410Adjust Complete Denture - Maxillary$41
D5411Adjust Complete Denture - Mandibular$41
D5730Reline Complete Maxillary Denture (chairside)$167
D5731Reline Complete Mandibular Denture (chairside)$167

504 - Oral Surgery

CodeServicePrice
D7140Extraction,erupted Tooth or Exposed Root (elevation and/or forcepts removal)$68
D7220Removal of Impacted Tooth - Soft Tissue$139
D7240Removal of Impacted Tooth - Completely Bony$234

504 - Orthodontics

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

504 - Miscellaneous Services

CodeServiceFee
D9215Local Anesthesia$16
D9230Analgesia$29

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