|
DIAGNOSTIC (Exams, X-Rays)*
|
|
ADA code
|
Procedure
|
Typical Fee
|
Discount Plan
|
Dental Ins
|
|
0120
|
periodic oral evaluation - established patient
|
$49
|
$13
|
$0
|
|
0140
|
limited oral evaluation - problem focused
|
$74
|
$15
|
$0
|
|
0150
|
comprehensive oral evaluation - new or established patient
|
$85
|
$15
|
$0
|
|
0210
|
intraoral - complete series (including bitewings)
|
$125
|
$38
|
$0
|
|
0220
|
intraoral - periapical first film
|
$28
|
$9
|
$0
|
|
0230
|
intraoral - periapical each additional film
|
$24
|
$4
|
$0
|
|
0270
|
bitewing - single film
|
$27
|
$9
|
$0
|
|
0272
|
bitewings - two films
|
$44
|
$12
|
$0
|
|
0273
|
bitewings - three films
|
$53
|
$16
|
$0
|
|
0274
|
bitewings - four films
|
$62
|
$19
|
$0
|
|
0330
|
panoramic film
|
$106
|
$38
|
$0
|
|
PREVENTIVE (Cleanings, etc.)*
|
|
ADA code
|
Procedure
|
Typical Fee
|
Discount Plan
|
Dental Ins
|
|
1110
|
prophylaxis - adult
|
$90
|
$27
|
$0
|
|
1120
|
prophylaxis - child
|
$65
|
$20
|
$0
|
|
1351
|
sealant - per tooth
|
$52
|
$19
|
$0
|
|
1510
|
space maintainer - fixed - unilateral
|
$308
|
$82
|
$25
|
|
1515
|
space maintainer - fixed - bilateral
|
$427
|
$120
|
$25
|
|
1520
|
space maintainer - removable - unilateral
|
$378
|
$107
|
$35
|
|
1525
|
space maintainer - removable – bilateral
|
$482
|
$135
|
$35
|
|
RESTORATIVE (Fillings)*
|
|
ADA code
|
Procedure
|
Typical Fee
|
Discount Plan
|
Dental Ins
|
|
2140
|
amalgam - one surface, primary or permanent
|
$135
|
$38
|
$0
|
|
2150
|
amalgam - two surfaces, primary or permanent
|
$172
|
$48
|
$0
|
|
2160
|
amalgam - three surfaces, primary or permanent
|
$209
|
$57
|
$0
|
|
2161
|
amalgam - four or more surfaces, primary or permanent
|
$249
|
$69
|
$0
|
|
2330
|
resin-based composite - one surface, anterior
|
$159
|
$48
|
$0
|
|
2331
|
resin-based composite - two surfaces, anterior
|
$194
|
$58
|
$0
|
|
2332
|
resin-based composite - three surfaces, anterior
|
$243
|
$73
|
$0
|
|
2335
|
resin-based composite - four or more surfaces or involving incisal angle (anterior)
|
$298
|
$92
|
$0
|
|
2391
|
resin-based composite - one surface, posterior
|
$174
|
$60
|
$30
|
|
2392
|
resin-based composite - two surfaces, posterior
|
$224
|
$89
|
$45
|
|
2393
|
resin-based composite - three surfaces, posterior
|
$278
|
$112
|
$65
|
|
2394
|
resin-based composite - four or more surfaces, posterior
|
$333
|
$130
|
$65
|
|
RESTORATIVE (Crowns)*
|
|
ADA code
|
Procedure
|
Typical Fee
|
Discount Plan
|
Dental Ins
|
|
2750
|
crown - porcelain fused to high noble metal
|
$1043
|
$446
|
$245
|
|
2751
|
crown - porcelain fused to predominantly base metal
|
$967
|
$404
|
$245
|
|
2752
|
crown - porcelain fused to noble metal
|
$988
|
$422
|
$245
|
|
2790
|
crown - full cast high noble metal
|
$1043
|
$439
|
$245
|
|
2791
|
crown – full cast predominantly base metal
|
$944
|
$393
|
$245
|
|
2930
|
prefabricated stainless steel crown - primary tooth
|
$259
|
$88
|
$25
|
|
2931
|
prefabricated stainless steel crown - permanent tooth
|
$310
|
$100
|
$25
|
|
2950
|
core buildup, including any pins
|
$263
|
$88
|
$70
|
|
2951
|
pin retention - per tooth, in addition to restoration
|
$75
|
$22
|
$10
|
|
2952
|
post and core in addition to crown, indirectly fabricated
|
$411
|
$138
|
$50
|
|
2954
|
prefabricated post and core in addition to crown
|
$330
|
$108
|
$30
|
|
ENDODONTICS (Root Canals, etc.)*
|
|
ADA code
|
Procedure
|
Typical Fee
|
Discount Plan
|
Dental Ins
|
|
3110
|
pulp cap - direct (excluding final restoration)
|
$79
|
$20
|
$5
|
|
3120
|
pulp cap - indirect (excluding final restoration)
|
$80
|
$20
|
$5
|
|
3220
|
therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament
|
$197
|
$48
|
$30
|
|
3310
|
endodontic therapy, anterior tooth (excluding final restoration)
|
$695
|
$257
|
$100
|
|
3320
|
endodontic therapy, bicuspid tooth (excluding final restoration)
|
$809
|
$304
|
$152
|
|
3330
|
endodontic therapy, molar (excluding final restoration)
|
$971
|
$383
|
$210
|
|
PERIODONTICS (Scaling / Deep Cleaning / Root Planing, etc.)*
|
|
ADA code
|
Procedure
|
Typical Fee
|
Discount Plan
|
Dental Ins
|
|
4210
|
gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant
|
$618
|
$256
|
$110
|
|
4341
|
periodontal scaling and root planing - four or more teeth per quadrant
|
$240
|
$89
|
$50
|
|
4910
|
periodontal maintenance
|
$135
|
$57
|
$40
|
|
PROSTHODONTICS (Dentures - Removable, Partials, etc.)*
|
|
ADA code
|
Procedure
|
Typical Fee
|
Discount Plan
|
Dental Ins
|
|
5110
|
complete denture - maxillary
|
$1625
|
$561
|
$325
|
|
5120
|
complete denture - mandibular
|
$1635
|
$561
|
$325
|
|
5130
|
immediate denture - maxillary
|
$1738
|
$584
|
$350
|
|
5140
|
immediate denture - mandibular
|
$1748
|
$584
|
$350
|
|
5211
|
maxillary partial denture - resin base (including any conventional clasps, rests and teeth)
|
$1268
|
$550
|
$400
|
|
5212
|
mandibular partial denture - resin base (including any conventional clasps, rests and teeth)
|
$1273
|
$550
|
$400
|
|
5213
|
maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)
|
$1688
|
$637
|
$425
|
|
5214
|
mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)
|
$1688
|
$637
|
$425
|
|
5410
|
adjust complete denture - maxillary
|
$85
|
$32
|
$10
|
|
5411
|
adjust complete denture - mandibular
|
$85
|
$32
|
$10
|
|
5510
|
repair broken complete denture base
|
$199
|
$50
|
$35
|
|
5520
|
replace missing or broken teeth - complete denture (each tooth)
|
$180
|
$48
|
$35
|
|
5630
|
repair or replace broken clasp
|
$259
|
$58
|
$35
|
|
5650
|
add tooth to existing partial denture
|
$222
|
$50
|
$35
|
|
5660
|
add clasp to existing partial denture
|
$264
|
$64
|
$35
|
|
5730
|
reline complete maxillary denture (chairside)
|
$361
|
$119
|
$65
|
|
5731
|
reline complete mandibular denture (chairside)
|
$360
|
$119
|
$65
|
|
5740
|
reline maxillary partial denture (chairside)
|
$357
|
$113
|
$65
|
|
5741
|
reline mandibular partial denture (chairside)
|
$358
|
$113
|
$65
|
|
5750
|
reline complete maxillary denture (laboratory)
|
$450
|
$156
|
$85
|
|
5751
|
reline complete mandibular denture (laboratory)
|
$454
|
$156
|
$85
|
|
PROSTHODONTICS - FIXED (Bridges, Dentures, etc.)*
|
|
ADA code
|
Procedure
|
Typical Fee
|
Discount Plan
|
Dental Ins
|
|
6240
|
pontic - porcelain fused to high noble metal
|
$1068
|
$388
|
$245
|
|
6241
|
pontic - porcelain fused to predominantly base metal
|
$988
|
$358
|
$245
|
|
6242
|
pontic - porcelain fused to noble metal
|
$993
|
$374
|
$245
|
|
6750
|
crown - porcelain fused to high noble metal
|
$1043
|
$427
|
$245
|
|
6751
|
crown - porcelain fused to predominantly base metal
|
$964
|
$385
|
$245
|
|
6752
|
crown - porcelain fused to noble metal
|
$988
|
$400
|
$245
|
|
ORAL SURGERY (Tooth Extractions, etc.)*
|
|
ADA code
|
Procedure
|
Typical Fee
|
Discount Plan
|
Dental Ins
|
|
7140
|
extraction, erupted tooth or exposed root (elevation and/or forceps removal)
|
$165
|
$48
|
$5
|
|
7220
|
removal of impacted tooth - soft tissue
|
$308
|
$98
|
$50
|
|
7230
|
removal of impacted tooth - partially bony
|
$383
|
$128
|
$65
|
|
7240
|
removal of impacted tooth - completely bony
|
$472
|
$185
|
$80
|
|
7250
|
surgical removal of residual tooth roots (cutting procedure)
|
$298
|
$98
|
$40
|
|
7310
|
alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant
|
$291
|
$82
|
$40
|
|
7320
|
alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant
|
$448
|
$118
|
$60
|
|
7510
|
incision and drainage of abscess - intraoral soft tissue
|
$227
|
$60
|
$35
|
|
ORTHODONTICS (Braces - Children and Adults, etc.)*
|
|
ADA code
|
Procedure
|
Typical Fee
|
Discount Plan
|
Dental Ins
|
|
8070
|
comprehensive orthodontic treatment of the transitional dentition
|
$5099
|
20% Discount
|
$1,850
|
|
8080
|
comprehensive orthodontic treatment of the adolescent dentition
|
$5212
|
20% Discount
|
$1,850
|
|
8090
|
comprehensive orthodontic treatment of the adult dentition
|
$5452
|
20% Discount
|
$1,850
|
|
ADJUNCTIVE SERVICES (Anesthesia, Analgesia, etc.)*
|
|
ADA code
|
Procedure
|
Typical Fee
|
Discount Plan
|
Dental Ins
|
|
9110
|
palliative (emergency) treatment of dental pain - minor procedure
|
$125
|
$32
|
$10
|
|
9215
|
local anesthesia
|
$65
|
$11
|
$0
|
|
9230
|
analgesia, anxiolysis, inhalation of nitrous oxide
|
$79
|
$23
|
$15
|
|
9951
|
occlusal adjustment - limited
|
$179
|
$44
|
$30
|
|
9952
|
occlusal adjustment - complete
|
$631
|
$177
|
$100
|