Fees to Patients

Most offices charge $600-800 for a set of trays and 3 tubes of gel. At $800, patients utilizing Care Credit pay $67/month for 12 months.


We recommend you present cost in one treatment plan for all patients exhibiting bleeding at 10+ sites. Templates of treatment plans list below allow you to insert you own fees:


Office Use

Patient Presentation

** Perio Protect thanks Dr. Michael Fulbright, Patti DiGangi and Dr. Alan Friedel for help formulating these plans.

Perio Tray™ prescriptions are documented with these codes:

  • D5995 Periodontal medicament carrier with peripheral seal – maxillary.
    • A custom fabricated, laboratory processed carrier that covers the teeth and alveolar mucosa. Used as a vehicle to deliver prescribed medicaments for sustained contact with the gingiva, alveolar mucosa, and into the periodontal sulcus or pocket.
  • D5996 Periodontal medicament carrier with peripheral seal – mandibular.
    • A custom fabricated, laboratory processed carrier that covers the teeth and alveolar mucosa. Used as a vehicle to deliver prescribed medicaments for sustained contact with the gingiva, alveolar mucosa, and into the periodontal sulcus or pocket.

When submitting a claim for D5995 and D5996, it may be important to document the rational for periodontal medicament delivery. This documentation could include the periodontal diagnosis, pocket probing depth charts, the extent of the tissue ulceration in the form of bleeding points, patient health history of systemic diseases, and/or brief description of prior periodontal treatment history.

Perio Gel and Perio GelXcan be submitted with this code:

  • D9630 Drugs or medicaments dispensed in the office for home use.
    • Includes but is not limited to oral antibiotics, oral analgesics, and topical fluoride dispensed in the office for home use; does not include writing prescriptions.

D9630 is used for all medication dispensed from your office, so you may want to establish a specific identifying number or name for Perio Gel  in your practice management software. It is important to track how much Perio Gel a patient uses to be sure patients get enough gel over time. Patients using Perio Tray delivery 1x/day will need approximately 8 tubes a year (2 tubes every 3 months).


For Perio Gel submissions, you can put an explanation like this one in the remarks field: D9630, Supplies and Materials = OTC Perio Gel, 3.0 oz (85g). Antiseptic Oral Cleanser with active ingredient Hydrogen peroxide 1.7%, used as a debriding agent.


Talking to Patients about Perio Protect

With any insurance plan, there can be no guarantee of payment. Most patients will maximize their insurance benefits and still have some out-of-pocket expenses. Listed below are ideas to help you talk to the patients. 

  • Dental care is vital to health and wellness. Chronic infections and inflammation of the gingival tissues can make it harder for type 2 diabetics to manage blood sugar, can lead to inflammation in the cells lining the arteries, and appears to speed up the progression of dementia. Gum disease is also associated with other chronic systemic inflammatory conditions like ED, pulmonary diseases, cancers, rheumatoid arthritis, and pregnancy complications. Be sure to refer to the patient's health history. 
  • It's important to treat an infection. Left untreated, the infections place a chronic inflammatory burden on the immune system. As gum disease progresses, it is the leading cause of tooth loss and can impact a person’s smile, appearance, and ability to chew and enjoy food. Treatment now saves money and teeth in the long run!
  • Discuss the cost of your whitening services and explain that gradual whitening is a positive side effect of the hydrogen peroxide in Perio Tray therapy. It's like free whitening without the sensitivity. 
  • For fearful patients, you can emphasize the uniquely non-invasive delivery technique offered with Perio Protect.
  • If you charge $800 for a set of Perio Tray carriers, homecare kit, and 4 tubes of Perio Gel, that works out to $67/month for 12 months. After that, the cost of Perio Gel ($25/tube) is $.54/day. (Less than a postage stamp!)

Health Savings Accounts (HSA) and Medical Flexible Spending Accounts (FSA) 

For patients with a medical FSA or HSA, Perio Tray therapy and the medicaments prescribed for use in them will often apply. Perio Tray therapy is cleared by the FDA as a prescription medical device and the medications for use are often obtained with a written prescription. Please see the below template explaining this to patients

These documents will automatically download to your computer. Please check your browser or File Explorer to view them. 

The Internal Revenue Service specifically states in Publication 502 that whitening treatments are not valid for FSA, but under subhead Dental Treatment, it is clear that “You can include in medical expenses the amounts you pay for the prevention and alleviation of dental diseases.” http://www.irs.gov/publications/p502/ar02.html#en_US_2012_publink1000178851 .


If there are any questions, be sure to have patients check their account plans.

Medical Billing Information and Codes

The Canadian Dental Association recommends that offices contact provincial associations to confirm code information. The suggested USC&LS codes (not available in Quebec) follow here:

  • 12701 Medication, custom appliance, maxillary arch +L
  • 12702 Medication, custom appliance, mandibular arch +L
  • Lab fees should be reported using the appropriate codes from the 99000 Laboratory and expense procedures Class of codes, most likely 99111 +L Commercial laboratory procedures
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