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 | $185 |
2751 | crown - porcelain fused to predominantly base metal | $967 | $404 | $185 |
2752 | crown - porcelain fused to noble metal | $988 | $422 | $185 |
2790 | crown - full cast high noble metal | $1043 | $439 | $185 |
2791 | crown – full cast predominantly base metal | $944 | $393 | $185 |
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 | $50 |
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 | $0 |
3120 | pulp cap - indirect (excluding final restoration) | $80 | $20 | $0 |
3220 | therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament | $197 | $48 | $10 |
3310 | endodontic therapy, anterior tooth (excluding final restoration) | $695 | $257 | $80 |
3320 | endodontic therapy, bicuspid tooth (excluding final restoration) | $809 | $304 | $115 |
3330 | endodontic therapy, molar (excluding final restoration) | $971 | $383 | $200 |
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 | $90 |
4341 | periodontal scaling and root planing - four or more teeth per quadrant | $240 | $89 | $40 |
4910 | periodontal maintenance | $135 | $57 | $30 |
PROSTHODONTICS (Dentures - Removable, Partials, etc.)* |
ADA code | Procedure | Typical Fee | Discount Plan | Dental Ins |
5110 | complete denture - maxillary | $1625 | $561 | $210 |
5120 | complete denture - mandibular | $1635 | $561 | $210 |
5130 | immediate denture - maxillary | $1738 | $584 | $225 |
5140 | immediate denture - mandibular | $1748 | $584 | $225 |
5211 | maxillary partial denture - resin base (including any conventional clasps, rests and teeth) | $1268 | $550 | $240 |
5212 | mandibular partial denture - resin base (including any conventional clasps, rests and teeth) | $1273 | $550 | $240 |
5213 | maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $1688 | $637 | $260 |
5214 | mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $1688 | $637 | $260 |
5410 | adjust complete denture - maxillary | $85 | $32 | $0 |
5411 | adjust complete denture - mandibular | $85 | $32 | $0 |
5510 | repair broken complete denture base | $199 | $50 | $0 |
5520 | replace missing or broken teeth - complete denture (each tooth) | $180 | $48 | $30 |
5630 | repair or replace broken clasp | $259 | $58 | $30 |
5650 | add tooth to existing partial denture | $222 | $50 | $30 |
5660 | add clasp to existing partial denture | $264 | $64 | $30 |
5730 | reline complete maxillary denture (chairside) | $361 | $119 | $60 |
5731 | reline complete mandibular denture (chairside) | $360 | $119 | $35 |
5740 | reline maxillary partial denture (chairside) | $357 | $113 | $35 |
5741 | reline mandibular partial denture (chairside) | $358 | $113 | $35 |
5750 | reline complete maxillary denture (laboratory) | $450 | $156 | $60 |
5751 | reline complete mandibular denture (laboratory) | $454 | $156 | $60 |
PROSTHODONTICS - FIXED (Bridges, Dentures, etc.)* |
ADA code | Procedure | Typical Fee | Discount Plan | Dental Ins |
6240 | pontic - porcelain fused to high noble metal | $1068 | $388 | $185 |
6241 | pontic - porcelain fused to predominantly base metal | $988 | $358 | $185 |
6242 | pontic - porcelain fused to noble metal | $993 | $374 | $185 |
6750 | crown - porcelain fused to high noble metal | $1043 | $427 | $185 |
6751 | crown - porcelain fused to predominantly base metal | $964 | $385 | $185 |
6752 | crown - porcelain fused to noble metal | $988 | $400 | $185 |
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 | $0 |
7220 | removal of impacted tooth - soft tissue | $308 | $98 | $45 |
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 | $35 |
7320 | alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant | $448 | $118 | $40 |
7510 | incision and drainage of abscess - intraoral soft tissue | $227 | $60 | $30 |
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 | $1,695 |
8080 | comprehensive orthodontic treatment of the adolescent dentition | $5212 | 20% Discount | $1,695 |
8090 | comprehensive orthodontic treatment of the adult dentition | $5452 | 20% Discount | $1,695 |
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 | $0 |
9215 | local anesthesia | $65 | $11 | $0 |
9230 | analgesia, anxiolysis, inhalation of nitrous oxide | $79 | $23 | $15 |
9951 | occlusal adjustment - limited | $179 | $44 | $15 |
9952 | occlusal adjustment - complete | $631 | $177 | $50 |