GENERAL DENTAL CARE – ADA CODES
Fees valid if performed by General Dentists exclusively at The Dentists’ Office. Rates start at the pricing shown and may differ depending on doctor recommendation.
| Service | Plan Fee | Usual Fee | Savings |
| Evaluations | |||
| 0120 Exam-Periodic | $39 | $70 | 45% |
| 0140 Exam - Limited | $56 | $102 | 45% |
| 0145 Oral Examination under 3 | $57 | $103 | 45% |
| 0150 Comprehensive Exam | $61/td> | $111 | 45% |
| Preventative | |||
| 0210 Full Mouth X-Ray | $116 | $178 | 35% |
| 0220-0230 Single X-Ray | $19 | $38 | 50% |
| 0270-0274 Bitewings | $42 | $84 | 50% |
| 0330 Panoramic X-ray | $81 | $161 | 50% |
| 1110 Basic Cleaning – Adult | $71 | $119 | 40% |
| 1110 Basic Cleaning – Teen | $60 | $100 | 40% |
| 1120 Basic Cleaning – Child | $59 | $90 | 35% |
| 1206 Fluoride Treatment | $23 | $42 | 45% |
| 1351 Sealant – Per Tooth | $38 | $69 | 45% |
| Restorations (Fillings) | |||
| Composite Fillings – Anterior | |||
| 2330 1 Surface | $168 | $224 | 25% |
| 12331 2 Surface | $201 | $268 | 25% |
| 2332 3 Surface | $243 | $324 | 25% |
| 2335 4 Surface | $311 | $389 | 20% |
| Composite Fillings – Posterior | |||
| 2391 1 Surface | $186 | $248 | 25% |
| 2392 2 Surface | $237 | $316 | 25% |
| 2393 3 Surface | $263 | $405 | 35% |
| 2394 4 Surface | $315 | $485 | 35% |
| Inlay/Onlay Restorations | |||
| Porcelain Inlay | |||
| 2610 1 Surface | $1079 | $1396 | 20% |
| 2620 2 Surface | $1116 | $1396 | 20% |
| 2630 3+ Surface | $1188 | $1485 | 20% |
| Porcelain/Ceramic/CEREC Onlay | |||
| 2642 2 Surface | $1198 | $1410 | 15% |
| 2643 3 Surface | $1231 | $1449 | 15% |
| 2644 4 + Surface | $1298 | $1527 | 15% |
| Service | Plan Fee | Usual Fee | Savings |
| Crown/Single Restorations | |||
| 2740 Crown – Porcelain/Ceramic | $1072 | $1340 | 20% |
| 2740 Crown – CEREC | $1072 | $1340 | 20% |
| 2750 Crown – Porcelain/High Noble | $1137 | $1338 | 15% |
| 2790 Crown – Full Cast High Noble | $1227 | $1443 | 15% |
| 2920 Replacement Perm Crown | $106 | $141 | 25% |
| 2929 Porcelain Crown/Primary Tooth | $358 | $447 | 20% |
| 2930 PreFab Stainless – Primary | $242 | $322 | 25% |
| 2933 Stainless Steel Crown/Resin Window | $339 | $424 | 20% |
| 2950 Core Buildup, Including Pins | $180 | $327 | 45% |
| 2954 PreFab Post & Core-Per Tooth | $234 | $426 | 45% |
| 2962 Porcelain Veneer | $1206 | $1507 | 20% |
| Implant Restorations | |||
| 6052 Precision Attachment | $520 | $578 | 10% |
| 6056 Prefabricated Abutment | $698 | $776 | 10% |
| 6057 Custom Implant Abutment | $833 | $926 | 10% |
| 6059 Abutment Supported PFM | $1513 | $1681 | 10% |
| 6061 Abutment Supported All Porc. | $1513 | $1681 | 10% |
| Endodontics | |||
| 3220 Therapeutic Pulpotomy | $227 | $252 | 10% |
| 3221 Pulpal Debridement | $249 | $277 | 10% |
| 3310 Root Canal – Anterior | $833 | $925 | 10% |
| 3320 Root Canal – Bicuspid | $941 | $1046 | 10% |
| 3330 Root Canal – Molar | $1152 | $1280 | 10% |
| Periodontics | |||
| 4342 Scaling/Root Planing 1-3 Teeth Per Quadrant |
$174 | $218 | 20% |
| 4341 Scaling/Root Planing 4 or more Teeth Per Quadrant |
$216 | $308 | 30% |
| 4355 Full Mouth Debridement | $161 | $214 | 25% |
| 4910 Periodontal Maintenance | $139 | $174 | 20% |
| 4381 Arestin – Minocycline HCI | $102 | $113 | 10% |
| Service | Plan Fee | Usual Fee | Savings |
| Dentures and Partials | |||
| 5110 Complete Denture (Upper) | $1511 | $1889 | 20% |
| 5120 Complete Denture (Lower) | $1511 | $1889 | 20% |
| 5130 Immediate Denture (Upper) | $1675 | $2094 | 20% |
| 5140 Immediate Denture (Lower) | $1675 | $2094 | 20% |
| 5211 Partial Denture Acrylic (Upper) | $1214 | $1428 | 15% |
| 5212 Partial Denture Acrylic (Lower) | $1250 | $1471 | 15% |
| 5213 Partial Denture Metal (Upper) | $1748 | $2057 | 15% |
| 5214 Partial Denture Metal (Lower) | $1748 | $2057 | 15% |
| 5511-5512 Repair Denture - Broken Base | $259 | $324 | 20% |
| 5520 Repair Tooth | $235 | $294 | 20% |
| 5611-5612 Repair Partial Acrylic | $251 | $295 | 15% |
| 5640 Repair Partial Tooth | $251 | $295 | 15% |
| 5850 Tissue Conditioning (Upper) | $166 | $237 | 30% |
| 5851 Tissue Conditioning (Lower) | $166 | $237 | 30% |
| Adjustments to Dentures | |||
| 5650 Add Tooth to Existing Partial | $250 | $294 | 15% |
| 5750-5751 Reline Denture, In Lab, Per Arch |
$415 | $593 | 30% |
| 5760-5761 Reline Partial, In Lab, Per Arch |
$368 | $525 | 30% |
| 5820-5821 Interim Partial Denture, Per Arch |
$493 | $616 | 20% |
| Fixed Bridge Work | |||
| 6210 Maryland Bridge Pontic | $1168 | $1374 | 15% |
| 6240 Porcelain/Metal Pontic | $1168 | $1374 | 15% |
| 6545 Maryland Bridge Abutment | $745 | $876 | 15% |
| 6750 Porcelain/Metal Abutment | $1178 | $1386 | 15% |
| 6930 Recement Fixed Bridge | $176 | $207 | 15% |
| Extractions | |||
| 7111 Primary Tooth Remnant Coronal | $98 | $163 | 40% |
| 7140 Extraction Erupted Tooth | $144 | $205 | 30% |
| 7210 Surgical Removal - Erupted Tooth | $297 | $330 | 10% |
| Miscellaneous | |||
| 1510 Space Maintainer (Unilateral) | $309 | $386 | 20% |
| 1516-1517 Space Maintainer (Fixed Bilateral) Upper & Lower |
$442 | $552 | 20% |
| 9110 Palliative Treatment | $97 | $176 | 45% |
| 9230 Nitrous | $63 | $90 | 30% |
| 9940 Occlusal Guard (Hard/Soft) | $466 | $583 | 20% |
| Teeth Whitening Procedures | |||
| 9975 Whitening Take Home | $221 | $368 | 40% |
SPECIALTY DENTAL CARE – ADA CODES
Fees valid if performed by Dentists exclusively at The Dentists’ Office. Rates start at the pricing shown and may differ depending on doctor recommendation.
| Service | Plan Fee | Usual Fee | Savings |
| Oral Surgery | |||
| 4266 Guided Tissue Regeneration | $232 | $258 | 10% |
| 6010 Single Implant | $1871 | $2079 | 10% |
| 6104 Bone Graft at time of Implant | $552 | $613 | 10% |
| 7140 Erupted Extraction | $185 | $205 | 10% |
| 7210 Surgical Extraction | $297 | $330 | 10% |
| 7220 Soft Tissue Impaction | $369 | $410 | 10% |
| 7230 Partial Bony Impaction | $460 | $511 | 10% |
| 7240 Full Bony Impaction | $554 | $616 | 10% |
| 7241 Fully Bony – Complicated | $643 | $714 | 10% |
| 7280 Surgical Access of Tooth | $606 | $673 | 10% |
| 7283 Placement of Device to Facilitate Eruption |
$489 | $543 | 10% |
| 7286 Biopsy of Oral Soft Tissue | $437 | $486 | 10% |
| 7310 Alveoplasty 4+ Teeth per Quadrant | $349 | $388 | 10% |
| 7311 Alveoplasty 1-3 Teeth per Quadrant | $313 | $348 | 10% |
| 7951 Sinus Lift | $1724 | $1916 | 10% |
| 7953 Bone Graft for Ridge Preservation | $552 | $613 | 10% |
| 9222-9223 General Anesthetic (15 minutes) |
$246 | $273 | 10% |
| 9310 Consultation | $161 | $179 | 10% |
| 9610 Therapeutic Parenteral Drug | $69 | $77 | 10% |
Please note, fees are subject to change
