ADA Code Diagnostic & Preventative You Pay
D9430 Office Visit $5.00
D0150 Comprehensive oral evaluation No Charge
D0120 Periodic oral evaluation – (2 per year) No Charge
D0140 Limited oral evaluation – problem focused No Charge
D0210 Intraoral – complete series of radiographic images No Charge
D0220 Intraoral – periapical first radiographic image No Charge
D0230 Intraoral – periapical each additional radiographic image No Charge
D0272 Bitewings – two radiographic images No Charge
D0274 Bitewings – four radiographic images No Charge
D0330 Panoramic radiographic image $70.00
D1110 Prophylaxis (Cleaning) – Adult $69.00
D1120 Prophylaxis (Cleaning) – Child $45.00
D1351 Sealant – per tooth $35.00
D1206 Topical application of fluoride varnish $22.00
D1208 Topical application of fluoride $25.00
ADA Code Restorative You Pay
Resin-based Composite-anterior
D2330 One surface $105.00
D2331 Two surfaces $125.00
D2332 Three surfaces $148.00
D2335 Four or more surfaces $208.00
Resin-based Composite-posterior
D2391 One surface $129.00
D2392 Two surfaces $169.00
D2393 Three surfaces $185.00
D2394 Four or more surfaces $218.00
ADA Code Crowns You Pay
D2740 Crown – porcelain/ceramic substrate $999.00
D2750 Crown – porcelain fused to high noble metal $850.00
D2950 Core buildup $190.40
ADA Code Endodontics You Pay
D3220 Therapeutic pulpotomy $150.00
D3310 Root canal (anterior) $440.00
D3320 Root canal (bicuspid) $600.00
D3330 Root canal (molar) $850.00
ADA Code Periodontics You Pay
D4263 Bone replacement graft – first site in quadrant $461.30
D4341 Periodontal scaling and root planing – four or more teeth per quadrant $155.00
D4342 Periodontal scaling and root planing – one to three teeth per quadrant $128.80
D4355 Full mouth debridement $130.00
D4910 Periodontal maintenance $98.00
ADA Code Prosthodontics You Pay
Removable
D5110 Complete denture – maxillary (upper) $1,190.00
D5120 Complete denture – mandibular (lower) $1,190.70
D5213 Maxillary partial denture (upper) – cast metal framework with resin denture bases $1,249.50
D5214 Mandibular partial denture (lower) – cast metal framework with resin denture bases $1,251.60
D5750 Reline complete maxillary denture (laboratory) $343.00
D5751 Reline complete mandibular denture (laboratory) $343.00
Bridge
D6740 Crown – porcelain/ceramic substrate (per unit) $850.00
D6750 Crown – porcelain fused to high noble metal (per unit) $847.00
ADA Code Oral surgery You Pay
D7111 Extraction, coronal remnants – deciduous tooth $94.50
D7140 Extraction, erupted tooth of exposed root $120.00
D7210 Surgical removal or erupted tooth $210.00
D7220 Removal of impacted tooth – Soft tissue $218.00
D7230 Removal of impacted tooth – Partially Bony $270.00
D7240 Removal of impacted tooth – Completely Bony $320.00
D7241 Removal of impacted tooth – Completely Bony w/unusual surgical complications $400.40
ADA Code Other services You Pay
D6010 Surgical placement of implant body: endosteal implant $1,504.30
D8010 – D8999 Orthodontic Treatment * 30% discount
D9230 Inhalation of nitrous oxide/anxiolysis, analgesia $60.00
D9940 Occlusal guard, by report $410.20

For a complete summary of your discounts click here

* The 30% discount is the amount you will pay less the Providers Usual and Customary Rate Fee (UCR). “Usual” refers to the normal rate charged for the service by the Provider rendering the treatment, and “customary” is defined as the usual rates of the Provider’s competitors in that local area. The UCR fee can vary by location.