** Any treatment provided by a participating specialist, if available, in Oral Surgery, Orthodontics, Periodontics, Pedodontics, Prosthodontics or Endodontics, will be charged at a 25% reduction of participating specialist’s fees for that particular case.
| ADA | Diagnostics | Amount |
| 120 | Periodic Oral Evaluation | 14 |
| 140 | Limited Oral Evaluation – Problem Focused (Emergency) | 32 |
| 150 | Comprehensive Oral Evaluation | 21 |
| 210 | X-Rays Intraoral – Complete Series (Incl. Bitewings) | 39 |
| 220 | X-Rays Intraoral – Periapical – First Film | 9 |
| 230 | X-Rays Intraoral – Periapical – Each Additional Film | 7 |
| 240 | X-Rays – Intraoral – Occlusal Film | 19 |
| 270 | X-Rays – Bitewing – Single Film | 8 |
| 272 | X-Rays – Bitewing – Two Films | 15 |
| 274 | X-Rays – Bitewing – Four Films | 28 |
| 330 | X-Ray Panoramic Film | 42 |
| ADA | Preventative | Amount |
| 1110 | Dental Prophylaxis Adult(Cleaning) | 34 |
| 1120 | Dental Prophylaxis Children | 29 |
| 1204 | Topical Fluoride Application | 15 |
| 1351 | Topical Sealants – Per Tooth | 18 |
| ADA | Restorative (fillings) | Amount |
| 2110 | Amalgam – 1 Surface, Primary | 35 |
| 2120 | Amalgam – 2 Surfaces, Primary | 50 |
| 2140 | Amalgam – 1 Surface, Permanent | 42 |
| 2150 | Amalgam – 2 Surfaces, Permanent | 53 |
| 2160 | Amalgam – 3 Surfaces, Permanent | 74 |
| 2161 | Amalgam – 4 or more Surfaces, Permanent | 91 |
| 2330 | Resin – 1 Surface, Anterior | 55 |
| 2331 | Resin – 2 Surfaces, Anterior | 79 |
| 2332 | Resin – 3 Surfaces, Anterior | 94 |
| 2335 | Resin – 4+ Surf Or Inv. Incisal Angle | 115 |
| 2380 | Resin – 1 Surface – Posterior – Primary | 52 |
| 2381 | Resin – 2 Surfaces – Posterior – Primary | 70 |
| 2382 | Resin – 3+ Surfaces – Posterior – Primary | 90 |
| 2391 | Resin – 1 Surface – Posterior – Permanent | 72 |
| 2392 | Resin – 2 Surfaces – Posterior – Permanent | 95 |
| 2393 | Resin – 2 Surfaces – Posterior – Permanent | 110 |
| 2394 | Resin – 4+ Surfaces – Posterior – Permanent | 125 |
| ADA | Crowns (lab fees additional) | Amount |
| 2740 | Crown – Porcelain/Ceramic Substrate | 535 |
| 2750 | Crown – Porcelain/High Noble Metal | 495 |
| 2751 | Crown – Porcelain/Predominate Base Metal | 460 |
| 2752 | Crown – Porcelain/Noble Metal | 470 |
| 2790 | Crown – Full Cast High Noble Metal | 485 |
| 2791 | Crown – Full Cast Predominantly Base Metal | 415 |
| 2920 | Re-cement Crown | 40 |
| 2930 | Prefabricated Stainless Steel Crown – Primary Tooth | 125 |
| 2931 | Prefabricated Stainless Steel Crown – Perm Tooth | 130 |
| 2932 | Prefab Resin Crown | 141 |
| 2950 | Core Buildup, Including Any Pins | 95 |
| 2951 | Pin Retention Per Tooth (W/O Restoration) | 24 |
| 2952 | Cast Post/Core (Addition to Crown) | 190 |
| 2954 | Prefabricated Post and Core (Addition to Crown) | 150 |
| 2960 | Labial Veneer (Resin-Laminate) Chairside | 229 |
| 2961 | Labial Veneer (Resin-Laminate) Laboratory | 300 |
| 2962 | Labial Veneer (Porcelain-Laminate) Laboratory | 369 |
| 2970 | Temporary Crown (Fractured Tooth) | 105 |
| ADA | Endodontics (General Dentist) exc. Final Restoration | Amount |
| 3220 | Therapeutic Pulpotomy | 69 |
| 3310 | Root Canal Anterior | 295 |
| 3320 | Root Canal Bicuspid | 385 |
| 3330 | Root Canal Molar | 485 |
| ADA | Prosthodontics (Performed by a General Dentist) | Amount |
| 4210 | Gingivectomy/Gingivoplasty – 4+ contiguous teeth | 295 |
| 4260 | Osseous Surgery (W/ Flap Entry & Closure) P/Quad | 455 |
| 4341 | Perio. Scaling & Root Planning per Quad | 115 |
| 4355 | Full Mouth Debridement | 65 |
| 4910 | Periodontal Maintenance | 60 |
| ADA | Prosthodontics, Removable (lab fees additional) | Amount |
| 5110 | Complete Upper Denture | 575 |
| 5120 | Complete Lower Denture | 575 |
| 5130 | Immediate Upper | 659 |
| 5140 | Immediate Lower | 659 |
| 5211 | Upper Partial-Resin Base | 460 |
| 5212 | Lower Partial-Resin Base | 460 |
| 5213 | Partial Upper Cast Metal Base | 639 |
| 5214 | Partial Lower Cast Metal Base | 639 |
| 5410 | Adjust Denture (Upper) | 34 |
| 5411 | Adjust Denture (Lower) | 34 |
| 5510 | Repair Broken Complete Denture Base | 80 |
| 5520 | Repair Missing or Broken Teeth/Each Tooth | 59 |
| 5610 | Repair Resin Denture Base | 79 |
| 5630 | Repair or Replace Broken Clasp | 69 |
| 5640 | Repair Broken Teeth – Per Tooth | 60 |
| 5650 | Add Tooth to Existing Partial Denture | 65 |
| 5660 | Add Clasp to Existing Partial Denture | 80 |
| 5730 | Reline Upper Denture – Chairside | 115 |
| 5731 | Reline Lower Denture – Chairside | 115 |
| ADA | Prosthodontics, Fixed (lab fees additional) | Amount |
| 6240 | Pontic – Porcelain/High Noble Metal | 495 |
| 6241 | Pontic – Porcelain/Predominate Base Metal | 440 |
| 6242 | Pontic – Porcelain/Noble Metal | 455 |
| 6750 | Crown – Porcelain/High Noble Metal | 495 |
| 6751 | Crown – Procelain/Predominate Base Metal | 450 |
| 6752 | Crown – Porcelain/Noble Metal | 440 |
| 6930 | Re-cement Bridge | 60 |
| ADA | Oral Surgery | Amount |
| 7140 | Single Tooth Extraction | 62 |
| 7120 | Each Additional Extraction | 55 |
| 7210 | Surgical Removal of Erupted Tooth | 110 |
| 7220 | Removal of Impacted Tooth/Soft Tissue | 125 |
| 7230 | Removal of Impacted Tooth/Partially Bony | 160 |
| 7240 | Removal of Impacted Tooth/Completely Bony | 195 |
| 7250 | Surgical Removal of Residual Tooth Roots | 105 |
| 7510 | Incision & Drainage of Abscess/Intraoral | 69 |
| ADA | Orthodontics | Amount |
| 8080 | Comprehensive Treatment – Adolescent | 25% off |
| 8090 | Comprehensive Treatment – Adult | 25% off |
| ADA | Adjunctive Services | Amount |
| 9110 | Palliative Treatment (emergency) Pain-minor | 34 |
| 9610 | Therapeutic Drug Injection | 21 |
*Please see a professional dentist for full treatment plan.
*** Same day enrollment is available.
