Service
ADA Code |
Usual
Fee |
Member
Fee |
Member
Savings |
| Evaluations |
| D0120 Exam, Periodic |
$44.00 |
$15.00 |
66 % |
| D0140 Limited Exam, Problem focused |
$78.00 |
$20.00 |
74 % |
| D0150 Comprehensive Exam |
$84.00 |
$25.00 |
70 % |
| D0170 Re-evaluation Problem focused |
$75.00 |
$30.00 |
60 % |
| D0180 Exam, with Periodontal Charting |
$84.00 |
$24.00 |
71 % |
| D9440 Exam, problem focused, after hours |
$110.00 |
$65.00 |
41 % |
| D0210 Full mouth x-rays |
$111.00 |
$25.00 |
77 % |
| D0220 Single x-ray, Periapical |
$25.00 |
$10.00 |
60 % |
| D0230 Additional Periapical |
$21.00 |
$5.00 |
76 % |
| D0270 Bitewing x-ray 1 film |
$25.00 |
$10.00 |
60 % |
| D0272 Bitewing x-ray, 2 films |
$39.00 |
$15.00 |
62 % |
| D0274 Bitewing x-ray, 4 films |
$55.00 |
$20.00 |
64 % |
| D0330 Panoramic x-ray |
$103.00 |
$30.00 |
71 % |
| D0350 Oral/facial images (photographs) |
$35.00 |
$10.00 |
71 % |
| D0425 Caries Susceptibility test – per tooth |
$40.00 |
$5.00 |
88 % |
| D0460 Pulp Tests – 1 or more teeth |
$58.00 |
$20.00 |
66 % |
| D0470 Diagnostic Casts |
$96.00 |
$35.00 |
64 % |
| Preventative |
| D1110 Prophylaxis (Cleaning) Adult |
$81.00 |
$35.00 |
57 % |
| D1120 Prophylaxis (Cleaning) Child |
$60.00 |
$30.00 |
50 % |
| D1201 Fluoride and cleaning – Child |
$84.00 |
$35.00 |
58 % |
| D1203 Fluoride Child - No cleaning |
$33.00 |
$5.00 |
85 % |
| D1204 Fluoride Adult – No cleaning |
$34.00 |
$5.00 |
85 % |
| D1205 Fluoride and cleaning – Adult |
$95.00 |
$40.00 |
58 % |
| D1351 Sealant-per tooth |
$54.00 |
$20.00 |
63 % |
| Space Maintenance |
| D1510 Maintainer fixed – unilateral |
$280.00 |
$125.00 |
55 % |
| D1515 Maintainer fixed – bilateral |
$320.00 |
$150.00 |
53 % |
| D1520 Maintainer removable – unilateral |
$150.00 |
$75.00 |
50 % |
| D1525 Maintainer removable – bilateral |
$200.00 |
$75.00 |
63 % |
| Restorative |
| D2140 Amalgam, 1 surface |
$135.00 |
$55.00 |
59 % |
| D2150 Amalgam, 2 surface |
$175.00 |
$65.00 |
63 % |
| D2160 Amalgam, 3 surface |
$215.00 |
$75.00 |
65 % |
| D2161 Amalgam, 4 surface |
$250.00 |
$110.00 |
56 % |
| D2330 Anterior Composite,(white filling)1 surface |
$140.00 |
$61.00 |
56 % |
| D2331 Anterior Composite, 2 surface |
$173.00 |
$71.00 |
59 % |
| D2332 Anterior Composite, 3 surface |
$215.00 |
$91.00 |
58 % |
| D2335 Anterior Composite, 4 surface |
$269.00 |
$111.00 |
59 % |
| D2391 Posterior Composite,(white filling)1 surface |
$153.00 |
$73.00 |
52 % |
| D2392 Posterior Composite, 2 surface |
$211.00 |
$93.00 |
56 % |
| D2393 Posterior Composite, 3 surface |
$252.00 |
$103.00 |
59 % |
| D2394 Posterior Composite, 4 + surfaces |
$303.00 |
$113.00 |
63 % |
| Inlay/Onlay and Crown Restorative |
| D2510 Inlay-metallic 1-surface |
$475.00 |
$300.00 |
37 % |
| D2520 Inlay-metallic 2-surface |
$500.00 |
$350.00 |
30 % |
| D2530 Inlay-metallic 3-or more surfaces |
$700.00 |
$380.00 |
46 % |
| D2542 Onlay-metallic 2 surfaces |
$550.00 |
$245.00 |
55 % |
| D2543 Onlay-metallic 3 surfaces |
$745.00 |
$380.00 |
49 % |
| D2544 Onlay-metallic 4 or more surfaces |
$910.00 |
$430.00 |
53 % |
| D2610 Inlay-ceramic 1 surface |
$445.00 |
$323.00 |
27 % |
| D2620 Inlay-ceramic 2 surface |
$645.00 |
$343.00 |
47 % |
| D2630 Inlay-ceramic 3 or more surfaces |
$710.00 |
$363.00 |
49 % |
| D2642 Onlay, porcelain/ceramic 2 surface |
$886.00 |
$373.00 |
58 % |
| D2643 Onlay, porcelain/ceramic 3 surface |
$917.00 |
$393.00 |
57 % |
| D2644 Onlay, porcelain/ceramic 4 surface |
$958.00 |
$418.00 |
56 % |
| D2740 Crown, All Porcelain |
$997.00 |
$670.00 |
33 % |
| D2750 Crown, Porcelain fused to High Noble |
$968.00 |
$590.00 |
39 % |
| D2751 Crown, Porcelain fused to base Metal |
$920.00 |
$545.00 |
41 % |
| D2752 Crown, Porcelain fused to metal |
$948.00 |
$555.00 |
41 % |
| D2790 Crown, full cast high noble |
$850.00 |
$595.00 |
30 % |
| D2791 Crown, full cast base metal |
$785.00 |
$545.00 |
31 % |
| D2792 Crown, full cast noble metal |
$812.00 |
$560.00 |
31 % |
| D2920 Re-cement Crown |
$96.00 |
$60.00 |
38 % |
| D2940 Sedative Filling |
$98.00 |
$70.00 |
29 % |
| D2930 Prefab stainless steel crown – primary |
$242.00 |
$145.00 |
40 % |
| D2931 Prefab stainless steel crown – permanent |
$275.00 |
$155.00 |
44 % |
| D2931 Prefabricated resin crown |
$230.00 |
$115.00 |
50 % |
| D2950 Core Build Up including any pins |
$262.00 |
$140.00 |
47 % |
| D2952 Cast Post and Core |
$410.00 |
$150.00 |
63 % |
| D2954 Prefab post & Core in addition to crown |
$295.00 |
$190.00 |
36 % |
| D2955 Post Removal |
$85.00 |
$30.00 |
65 % |
| D2960 Labial Veneer resin – chairside |
$553.00 |
$340.00 |
39 % |
| D2961 Labial Veneer resin – laboratory |
$730.00 |
$500.00 |
32 % |
| Endodontics When Preformed By General Dentist |
| D3220 Pulpotomy |
$190.00 |
$115.00 |
39 % |
| D3230 Pulp therapy – anterior, primary tooth |
$180.00 |
$105.00 |
42 % |
| D3240 Pulp therapy – posterior, primary tooth |
$195.00 |
$123.00 |
37 % |
| D3310 Root Canal Therapy-anterior |
$945.00 |
$385.00 |
59 % |
| D3320 Root Canal Therapy-bicuspid |
$1,050.00 |
$450.00 |
57 % |
| D3330 Root Canal Therapy-molar |
$1,230.00 |
$595.00 |
52 % |
| Periodontics When Preformed By General Dentist |
| D4210 Gingivectomy - 4+ teeth per quadrant |
$544.00 |
$295.00 |
46 % |
| D4211 Gingivectomy 1 to 3 teeth per quadrant |
$262.00 |
$85.00 |
68 % |
| D4240 Gingival flap – 4+ contiguous teeth/quad. |
$661.00 |
$295.00 |
55 % |
| D4241 Gingival flap – 1 to 3 teeth per quadrant |
$345.00 |
$195.00 |
43 % |
| D4341 Scaling/root planing, 4+ teeth per quad |
$222.00 |
$110.00 |
50 % |
| D4342 Scaling/root planning, 1 to 3 teeth per quad |
$140.00 |
$63.00 |
55 % |
| D4355 Full mouth debridement |
$185.00 |
$75.00 |
59 % |
| D4910 Periodontal maintenance, per visit |
$146.00 |
$63.00 |
57 % |
| Complete Dentures |
| D5110 Complete denture-maxillary |
$1,628.00 |
$645.00 |
60 % |
| D5120 Complete denture-mandibular |
$1,650.00 |
$645.00 |
61 % |
| D5130 Complete Immed denture-maxillary |
$1,800.00 |
$695.00 |
61 % |
| D5140 Complete Immed denture-mandibular |
$1,800.00 |
$695.00 |
61 % |
| Partial Dentures |
| D5211 Maxillary partial denture – resin base |
$1,313.00 |
$575.00 |
56 % |
| D5212 Mandibular partial denture – resin base |
$1,313.00 |
$575.00 |
56 % |
| D5213 Maxillary partial denture – cast metal |
$1,767.00 |
$685.00 |
61 % |
| D5214 Mandibular partial denture – cast metal |
$1,767.00 |
$685.00 |
61 % |
| Adjustments to Dentures |
| D5410 Adjust compete denture – maxillary |
$88.00 |
$45.00 |
49 % |
| D5411 Adjust compete denture – mandibular |
$88.00 |
$45.00 |
49 % |
| D5421 Adjust partial denture – maxillary |
$88.00 |
$45.00 |
49 % |
| D5422 Adjust partial denture – mandibular |
$88.00 |
$45.00 |
49 % |
| Repairs to Dentures |
| D5510 Repair broken complete denture base |
$185.00 |
$93.00 |
50 % |
| D5520 Replace missing/broken teeth, each tooth |
$188.00 |
$90.00 |
52 % |
| D5610 Repair resin denture base |
$189.00 |
$93.00 |
51 % |
| D5620 Repair cast framework |
$259.00 |
$95.00 |
63 % |
| D5630 Repair or replace broken clasp |
$237.00 |
$95.00 |
60 % |
| D5730 Reline complete maxillary denture, chairside |
$338.00 |
$190.00 |
44 % |
| D5731 Reline complete mandib denture, chairside |
$338.00 |
$190.00 |
44 % |
| D5740 Reline maxillary partial denture, chairside |
$328.00 |
$190.00 |
42 % |
| D5741 Reline mandibular partial denture, chairside |
$333.00 |
$190.00 |
43 % |
| D5750 Reline complete Maxillary denture - Lab |
$419.00 |
$230.00 |
45 % |
| D5751 Reline complete Mandibular denture - Lab |
$423.00 |
$230.00 |
46 % |
| D5760 Reline maxillary partial denture - Lab |
$419.00 |
$230.00 |
45 % |
| D5761 Reline mandibular partial denture - Lab |
$423.00 |
$230.00 |
46 % |
| D5850 Tissue conditioning, maxillary |
$197.00 |
$90.00 |
54 % |
| D5851 Tissue conditioning, mandibular |
$198.00 |
$90.00 |
55 % |
| Fixed Bridge Work |
| D6210 Pontic – cast high noble metal |
$847.00 |
$595.00 |
30 % |
| D6211 Pontic – cast predominantly base metal |
$804.00 |
$550.00 |
32 % |
| D6212 Pontic – cast noble metal |
$807.00 |
$560.00 |
31 % |
| D6240 Pontic – porcelain fused high noble metal |
$968.00 |
$595.00 |
39 % |
| D6241 Pontic – Porcelain to base metal |
$920.00 |
$548.00 |
40 % |
| D6242 Pontic – Porcelain to Noble metal |
$948.00 |
$560.00 |
41 % |
| D6750 Abutment – Porcelain – High Noble metal |
$968.00 |
$595.00 |
39 % |
| D6751 Abutment – porcelain fused to base metal |
$920.00 |
$548.00 |
40 % |
| D6752 Abutment – Porcelain – to Noble Metal |
$948.00 |
$560.00 |
41 % |
| D6790 Abutment – full cast high noble metal |
$850.00 |
$595.00 |
30 % |
| D6791 Abutment – full cast base metal |
$785.00 |
$545.00 |
31 % |
| D6792 Abutment – full cast noble metal |
$812.00 |
$560.00 |
31 % |
| D6950 Precision attachment |
$245.00 |
$100.00 |
59 % |
| D6970 Cast post/core in addition to bridge |
$399.00 |
$150.00 |
62 % |
| Extractions |
| D7111 Extraction-coronal remnants, primary teeth |
$121.00 |
$45.00 |
63 % |
| D7140 Extraction-erupted tooth |
$173.00 |
$95.00 |
45 % |
| D7210 Extraction-erupted tooth surgical |
$245.00 |
$150.00 |
39 % |
| D7220 Extraction-soft tissue impaction |
$277.00 |
$180.00 |
35 % |
| D7230 Extraction-partial bony impaction |
$353.00 |
$240.00 |
32 % |
| D7240 Extraction-comp bony impaction |
$434.00 |
$280.00 |
35 % |
| D7241 Extraction of impacted tooth complications |
$544.00 |
$325.00 |
40 % |
| D7250 Surgical removal of residual tooth roots |
$285.00 |
$185.00 |
35 % |
| D7270 Tooth reimplantation |
$501.00 |
$135.00 |
73 % |
| D7280 Surgical access of an unerupted tooth |
$439.00 |
$134.00 |
69 % |
| D7310 Alveoplasty with extraction per quadrant |
$285.00 |
$175.00 |
39 % |
| D7320 Alveoplasty with no extraction per quadrant |
$396.00 |
$210.00 |
47 % |
| Cosmetic Dentistry and Unclassified Treatment |
| D9110 Emergency treatment of dental pain |
$108.00 |
$70.00 |
35 % |
| D9310 Consultation and/or second opinion |
$114.00 |
$25.00 |
78 % |
| D9910 Application of desensitizing medicament |
$58.00 |
$10.00 |
83 % |
| D9951 Occlusal adjustment – limited |
$85.00 |
$40.00 |
53 % |
| D9952 Occlusal adjustment – complete |
$230.00 |
$140.00 |
39 % |
| D2962 Labial Veneer (porcelain laminate) |
|
|
20 % |
| D9940 Occlusal guard, by report |
|
|
20 % |
| D9941 Fabrication of athletic mouthguard |
|
|
20 % |
| D9972 Bleaching-take home trays |
|
|
20 % |
| D9999 Bleaching-in office bleaching |
|
|
20 % |