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 | $40 | $72 | 45% |
| 0140 Exam - Limited | $58 | $105 | 45% |
| 0145 Oral Examination under 3 | $58 | $106 | 45% |
| 0150 Comprehensive Exam | $63 | $114 | 45% |
| Preventative | |||
| 0210 Full Mouth X-Ray | $119 | $183 | 35% |
| 0220Single X-Ray | $20 | $39 | 50% |
| 0230 Single X-Ray | $16 | $32 | 50% |
| 0330 Panoramic X-ray | $83 | $166 | 50% |
| 1110 Basic Cleaning – Adult | $74 | $123 | 40% |
| 1120 Basic Cleaning – Child | $60 | $93 | 35% |
| 1206 Fluoride Treatment | $24 | $43 | 45% |
| 1351 Sealant – Per Tooth | $39 | $71 | 45% |
| Restorations (Fillings) | |||
| Composite Fillings – Anterior | |||
| 2330 1 Surface | $173 | $231 | 25% |
| 12331 2 Surface | $207 | $276 | 25% |
| 2332 3 Surface | $250 | $334 | 25% |
| 2335 4 Surface | $321 | $401 | 20% |
| Composite Fillings – Posterior | |||
| 2391 1 Surface | $192 | $255 | 25% |
| 2392 2 Surface | $244 | $325 | 25% |
| 2393 3 Surface | $271 | $417 | 35% |
| 2394 4 Surface | $325 | $500 | 35% |
| Inlay/Onlay Restorations | |||
| Porcelain Inlay | |||
| 2610 1 Surface | $1112 | $1389 | 20% |
| 2620 2 Surface | $1150 | $1438 | 20% |
| 2630 3+ Surface | $1224 | $1530 | 20% |
| Porcelain/Ceramic/CEREC Onlay | |||
| 2642 2 Surface | $1234 | $1452 | 15% |
| 2643 3 Surface | $1269 | $1492 | 15% |
| 2644 4 + Surface | $1337 | $1573 | 15% |
| Service | Plan Fee | Usual Fee | Savings |
| Crown/Single Restorations | |||
| 2740 Crown – Porcelain/Ceramic | $1104 | $1380 | 20% |
| 2740 Crown – CEREC | $1104 | $1380 | 20% |
| 2750 Crown – Porcelain/High Noble | $1171 | $1378 | 15% |
| 2790 Crown – Full Cast High Noble | $1263 | $1486 | 15% |
| 2920 Replacement Perm Crown | $109 | $145 | 25% |
| 2929 Porcelain Crown/Primary Tooth | $368 | $460 | 20% |
| 2930 PreFab Stainless – Primary | $249 | $332 | 25% |
| 2933 Stainless Steel Crown/Resin Window | $349 | $437 | 20% |
| 2950 Core Buildup, Including Pins | $185 | $337 | 45% |
| 2954 PreFab Post & Core-Per Tooth | $241 | $439 | 45% |
| 2962 Porcelain Veneer | $1242 | $1552 | 20% |
| Implant Restorations | |||
| 6052 Precision Attachment | $536 | $595 | 10% |
| 6056 Prefabricated Abutment | $719 | $799 | 10% |
| 6057 Custom Implant Abutment | $858 | $954 | 10% |
| 6059 Abutment Supported PFM | $1558 | $1731 | 10% |
| 6061 Abutment Supported All Porc. | $1558 | $1731 | 10% |
| Endodontics | |||
| 3220 Therapeutic Pulpotomy | $232 | $258 | 10% |
| 3221 Pulpal Debridement | $257 | $285 | 10% |
| 3310 Root Canal – Anterior | $857 | $953 | 10% |
| 3320 Root Canal – Bicuspid | $970 | $1077 | 10% |
| 3330 Root Canal – Molar | $1187 | $1318 | 10% |
| Periodontics | |||
| 4342 Scaling/Root Planing 1-3 Teeth Per Quadrant |
$157 | $225 | 30% |
| 4341 Scaling/Root Planing 4 or more Teeth Per Quadrant |
$254 | $317 | 20% |
| 4355 Full Mouth Debridement | $165 | $220 | 25% |
| 4910 Periodontal Maintenance | $161 | $179 | 10% |
| 4381 Arestin – Minocycline HCI | $93 | $116 | 20% |
| Service | Plan Fee | Usual Fee | Savings |
| Dentures and Partials | |||
| 5110 Complete Denture (Upper) | $1557 | $1946 | 20% |
| 5120 Complete Denture (Lower) | $1557 | $1946 | 20% |
| 5130 Immediate Denture (Upper) | $1725 | $2157 | 20% |
| 5140 Immediate Denture (Lower) | $1725 | $2157 | 20% |
| 5211 Partial Denture Acrylic (Upper) | $1288 | $1515 | 15% |
| 5212 Partial Denture Acrylic (Lower) | $1288 | $1515 | 15% |
| 5213 Partial Denture Metal (Upper) | $1801 | $2119 | 15% |
| 5214 Partial Denture Metal (Lower) | $1801 | $2119 | 15% |
| 5511-5512 Repair Denture - Broken Base | $267 | $334 | 20% |
| 5520 Repair Tooth | $242 | $303 | 20% |
| 5611-5612 Repair Partial Acrylic | $257 | $303 | 15% |
| 5640 Repair Partial Tooth | $257 | $303 | 15% |
| 5750 Implant Retained Complete Maxillary Denture | $591 | $845 | 30% | 5751 Implant Retained Complete Mandibular Denture | $591 | $845 | 30% |
| 5851 Tissue Conditioning (Lower) | $171 | $244 | 30% |
| Adjustments to Dentures | |||
| 5650 Add Tooth to Existing Partial | $257 | $303 | 15% |
| 5750 Reline Denture, In Lab, Per Arch |
$428 | $611 | 30% |
| 5760 Reline Partial, In Lab, Per Arch |
$379 | $541 | 30% |
| 5820-5821 Interim Partial Denture, Per Arch |
$508 | $634 | 20% |
| Fixed Bridge Work | |||
| 6210 Maryland Bridge Pontic | $1203 | $1415 | 15% |
| 6240 Porcelain/Metal Pontic | $1203 | $1415 | 15% |
| 6545 Maryland Bridge Abutment | $767 | $902 | 15% |
| 6750 Porcelain/Metal Abutment | $1213 | $1428 | 15% |
| 6930 Recement Fixed Bridge | $181 | $213 | 15% |
| Extractions | |||
| 7111 Primary Tooth Remnant Coronal | $101 | $168 | 40% |
| 7140 Extraction Erupted Tooth | $148 | $211 | 30% |
| 7210 Surgical Removal - Erupted Tooth | $306 | $340 | 10% |
| Miscellaneous | |||
| 1510 Space Maintainer (Unilateral) | $318 | $398 | 20% |
| 1516-1517 Space Maintainer (Fixed Bilateral) Upper & Lower |
$455 | $569 | 20% |
| 9110 Palliative Treatment | $100 | $181 | 45% |
| 9230 Nitrous | $65 | $93 | 30% |
| 9940 Occlusal Guard (Hard/Soft) | $480 | $600 | 20% |
| Teeth Whitening Procedures | |||
| 9975 Whitening Take Home | $227 | $379 | 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 | $239 | $266 | 10% |
| 6010 Single Implant | $1927 | $2141 | 10% |
| 6061 Porcelain Fused Metal Crown | $1558 | $1731 | 10% |
| 6104 Bone Graft at time of Implant | $568 | $631 | 10% |
| 7140 Erupted Extraction | $190 | $211 | 10% |
| 7210 Surgical Extraction | $306 | $340 | 10% |
| 7220 Soft Tissue Impaction | $380 | $422 | 10% |
| 7230 Partial Bony Impaction | $474 | $526 | 10% |
| 7240 Full Bony Impaction | $571 | $634 | 10% |
| 7241 Fully Bony – Complicated | $662 | $735 | 10% |
| 7280 Surgical Access of Tooth | $568 | $631 | 10% |
| 7286 Biopsy of Oral Soft Tissue | $451 | $501 | 10% |
| 7310 Alveoplasty 4+ Teeth per Quadrant | $360 | $400 | 10% |
| 7311 Alveoplasty 1-3 Teeth per Quadrant | $323 | $358 | 10% |
| 7951 Sinus Lift | $1776 | $1973 | 10% |
| 7953 Bone Graft for Ridge Preservation | $568 | $631 | 10% |
| 9222-9223 General Anesthetic (15 minutes) |
$253 | $281 | 10% |
| 9310 Consultation | $166 | $184 | 10% |
| 9610 Therapeutic Parenteral Drug | $71 | $79 | 10% |
Please note, fees are subject to change
