Basix Student 9/25/21, 10:53 PM

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making your student health plan better.

Fee schedule for Robert

Serinsky

General information
This is the fee schedule for Robert Serinsky. Full payment
(or other payment terms acceptable to the provider) is due
at the time of service, otherwise the provider is owed their
full charge. If staff members are unaware of the Basix
Savings Program, reach out to the person (or reference the
code number) listed under Administrative Contact.

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Basix Student 9/25/21, 10:53 PM

Name: Robert Serinsky, DMD

Specialty:
Remember, payment isGeneral Dentistry
due at the time of service,
otherwise the dentist is5 owed
Address: their
Benefit full charge. Also,
Street
discounts may not be combined
Providence,with
RIother
02904offers or dental
insurance except at the discretion of the provider.
School: Tufts University
Occasionally, a staff person will not be aware of the Basix
Phone: 401-521-3822
Dental Savings Program (they may be a new employee, or
it mayFax:
simply slip their 401-521-1020
mind since they have to keep track
of dozens of plans). The administrative contact person
Admin. contact: Deborah
coordinates with Basix to assure the Program operates
Fee schedule:
smoothly. Modified
So, if there are Savings
questions, the quickest way to
resolve them is to ask to speak with the administrative
contact person, or to otherwise follow the instructions in
the Administrative Contact area.

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Schedule name: ri_providence_serinsky

ADA Discount
Codes Service Description Price

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Basix Student 9/25/21, 10:53 PM

DIAGNOSTIC

120 Periodic Oral Evaluation $23.00

140 Limited Oral Evaluation - $40.00

Problem Focused
(Emergency)

150 Comprehensive Oral $40.00

Evaluation

210 X-Rays Intraoral - $72.00

Complete Series (Incl.
Bitewings)

220 X-Rays Intraoral - $15.00

Periapical - First Film

230 X-Rays Intraoral - $15.00

Periapical - Each Additional
Film

270 X-Rays - Bitewing - One $15.00

Film

272 X-Rays - Bitewing - Two $24.00

Films

274 X-Rays - Bitewing - Four $29.00

Films

PREVENTIVE

1110 Prophylaxis - Adult $55.00

1351 Sealant - Per Tooth $28.00

RESTORATIVE

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Basix Student 9/25/21, 10:53 PM

2330 Resin - 1 Surface, Anterior $95.00

2331 Resin - 2 Surfaces, Anterior $130.00

2332 Resin - 3 Surfaces, Anterior $150.00

2335 Resin - 4 Surfaces or $160.00

Involving Incisal Angle

2391 Resin Based Composite - 1 $85.00

Surface

2392 Resin Based Composite - 2 $150.00

Surface

2393 Resin Based Composite - 3 $170.00

Surface

2394 Resin Based Composite - 4 $180.00

Surface

2940 Sedative Filling $50.00

CROWNS

2740 Crown - Porcelain Fused to $915.00

Ceramic Substrate

2750 Crown - Porcelain Fused to $915.00

High Noble Metal

2790 Crown - Full Cast High $915.00

Noble Metal

2920 Recement Crown $70.00

2950 Crown Build Up, Including $140.00

Any Pins

2954 Prefabricated Post and $190.00

Core in Addition to Crown

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Basix Student 9/25/21, 10:53 PM

6240 Bridge Pontic - $915.00

Porcelain/High Noble Metal

6750 Bridge Abutment $915.00

Porcelain/High Noble Metal

ENDODONTICS

3310 Root Canal Anterior $485.00

Excluding Final Restoration

3320 Root Canal Bicuspid $560.00

Excluding Final Restoration

3330 Root Canal Molar $685.00

Excluding Final Restoration

PERIODONTICS

4341 Peridontal Scaling & Root $75.00

Planning - Per Quadrant

4910 Peridontal Maintenance $72.00

Proc. (Following Active
Therapy)

ORAL SURGERY

7140 Extraction, Erupted Tooth $90.00

or Exposed Tooth

PALLIATIVE TREATMENT

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Basix Student 9/25/21, 10:53 PM

9110 Palliative Treatment $50.00

Additional Info:
Services not listed above
shall be priced at 80% of
the Provider's usual and
customary fee. If the
Provider's fee is lower than
the fee for a service listed
above, that service will be
priced at 100% of the
Provider's fee.

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Basix Student 9/25/21, 10:53 PM

Information for the dentist: The Basix Dental Savings

Program is a discount plan. There are no covered benefits
under our Program. The student simply pays you the
amount owed, as determined by the fee schedule, at the
time of service, or makes payment arrangements
acceptable to you.

If you would like to confirm the patient is eligible for our

Program, please call this number: Gallagher Student
Health & Special Risk 1-877-320-4347

Patient Name: __________________________

When calling for eligibility, simply ask if the student (or their
covered dependent) is enrolled in the student health
insurance plan. If you ask about dental benefits, the
customer service person might reply there are none
(because our program is a discount plan, there are no
covered benefits). If the student is enrolled in the health
plan, they have access to our Program.

Your administrative contact is particularly important, this is

the person the student would ask to speak with if there are
questions about the Program.

If any of this has changed, please forward the correct

information to: webcontact@basixservices.com or fax to: 1-
866-422-1247

If you have questions, please call Basix at: 888-274-9961

Back to main page

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