| Dental Discount - Example Pricing These are nation wide averages; Actual prices vary by State. |
| ADA |
CODEDIAGNOSTIC AND PREVENTIVE |
MEMBER PAYS |
| 120 | PERIODIC ORAL EVALUATION | $16.00 |
| 140 | LIMITED ORAL EVALUATION-PROBLEM FOCUS | $20.00 |
| 150 | COMPREHENSIVE ORAL EVALUATION-NEW OR ESTABLISHED PATIENT | $20.00 |
| 210 | X-RAYS-INTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS) | $48.00 |
| 220 | X-RAYS-INTRAORAL-PERIAPICAL-1ST FILM | $11.00 |
| 230 | X-RAYS-INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM | $5.00 |
| 270 | BITEWING X-RAY-SINGLE FILM | $12.00 |
| 272 | BITEWINGS-TWO FILMS | $15. |
| 274 | BITEWINGS-FOUR FILMS | $24.00 |
| 330 | PANORAMIC FILM | $48.00 |
| 1110 | PROPHYLAXIS-ADULT CLEANING | $36.00 |
| 1120 | PROPHYLAXIS-CHILD CLEANING | $29.00 |
| 1201 | TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHYLAXIS)-CHILD | $40.00 |
| 1351 | SEALANT-PER TOOTH | $23.00 |
| 1510 | SPACE MAINTAINER-FIXED-UNILATERAL | $105.00 |
| 1515 | SPACE MAINTAINER-FIXED-BILATERAL | $154.00 |
| 1520 | SPACE MAINTAINER-REMOVEABLE-UNILATERAL | $137.00 |
| 1525 | SPACE MAINTAINER-REMOVEABLE-BILATERAL | $174.00 |
| ADA |
RESTORATIVE |
MEMBER PAYS |
| 2140 | AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT | $48.00 |
| 2150 | AMALGAM-TWO SURFACES, PRIMARY OR PERMANENT | $61.00 |
| 2160 | AMALGAM-THREE SURFACES, PRIMARY OR PERMANENT | $72.00 |
| 2161 | AMALGAM-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT | $89.00 |
| 2330 | RESIN-BASED COMPOSITE-ONE SURFACE, ANTERIOR | $61.00 |
| 2331 | RESIN-BASED COMPOSITE-TWO SURFACES, ANTERIOR | $74.00 |
| 2332 | RESIN-BASED COMPOSITE-THREE SURFACES, ANTERIOR | $93.00 |
| 2335 | RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, ANTERIOR | $117.00 |
| 2391 | RESIN-BASED COMPOSITE-ONE SURFACE, POSTERIOR | $81.00 |
| 2392 | RESIN-BASED COMPOSITE-TWO SURFACES, POSTERIOR | $115.00 |
| 2393 | RESIN-BASED COMPOSITE-THREE SURFACES, POSTERIOR | $153.00 |
| 2394 | RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, POSTERIOR | $176.00 |
| 2750 | CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL | $550.00 |
| 2751 | CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL | $496.00 |
| 2752 | CROWN-PORCELAIN FUSED TO NOBLE METAL | $525.00 |
| 2790 | CROWN-FULL CAST HIGH NOBLE METAL | $530.00 |
| 2791 | CROWN-FULL CAST PREDOMINANTLY BASE METAL | $505.00 |
| 2930 | PREFABRICATED STAINLESS STEEL CROWN-PRIMARY | $113.00 |
| 2931 | PREFABRICATED STAINLESS STEEL CROWN-PERMANENT | $129.00 |
| 2950 | CORE BUILDUP-INCLUDING ANY PINS | $113.00 |
| 2951 | PIN RETENTION PER TOOTH IN ADDITION TO RESTORATION | $26.00 |
| 2952 | CAST POST AND CORE IN ADDITION TO CROWN | $177.00 |
| 2954 | PREFABRICATED POST AND CORE IN ADDITION TO CROWN | $138.00 |
| ADA |
ENDODONTICS |
MEMBER PAYS |
| 3120 | PULP CAP INDIRECT (EXCLUDING FINAL RESTORATION) | $25.00 |
| 3220 | THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) | $61.00 |
| 3310 | ROOT CANAL-ANTERIOR (EXCLUDING FINAL RESTORATION) | $330.00 |
| 3320 | ROOT CANAL-BICUSPID (EXCLUDING FINAL RESTORATION) | $391.00 |
| ADA |
PERIODONTICS |
MEMBER PAYS |
| 4210 | GINGIVECTOMY OR GINGIVOPLASTY-FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT | $330.00 |
| 4341 | PERIODONTAL SCALING AND ROOT PLANING-FOUR OR MORE TEETH PER QUADRANT | $110.00 |
| 4910 | PERIODONTAL MAINTENANCE | $70.00 |
| ADA |
PROSTHODONTICS (REMOVABLE) |
MEMBER PAYS |
| 5110 | COMPLETE DENTURE-MAXILLARY | $715.00 |
| 5120 | COMPLETE DENTURE-MANDIBULAR | $715.00 |
| 5130 | IMMEDIATE DENTURE-MAXILLARY | $760.00 |
| 5140 | IMMEDIATE DENTURE-MANDIBULAR | $760.00 |
| 5211 | MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) | $701.00 |
| 5212 | MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH | $701.00 |
| 5213 | MAXILLARY PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS OR TEETH) | $798.00 |
| 5214 | MANDIBULAR PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH) | $798.00 |
| 5410 | ADJUST COMPLETE DENTURE-MAXILLARY | $38.00 |
| 5411 | ADJUST COMPLETE DENTURE-MANDIBULAR | $38.00 |
| 5510 | REPAIR BROKEN COMPLETE DENTURE BASE | $64.00 |
| 5520 | REPLACE MISSING OR BROKEN TEETH | $61.00 |
| 5630 | REPAIR OR REPLACE BROKEN CLASP | $74.00 |
| 5650 | ADD TOOTH TO EXISTING PARTIAL DENTURE | $64.00 |
| 5660 | ADD CLASP TO EXISTING PARTIAL DENTURE | $82.00 |
| 5730 | RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) | $153.00 |
| 5731 | RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) | $153.00 |
| 5740 | RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) | $145.00 |
| 5741 | RELINE MANDIBULAR PARTIAL DENT (CHAIRSIDE) | $145.00 |
| 5750 | RELINE COMPLETE MAXILLARY DENTURE (LAB) | $200.00 |
| 5751 | RELINE COMPLETE MANDIBULAR DENTURE (LAB) | $200.00 |
| ADA |
PROSTHODONTICS (FIXED) |
MEMBER PAYS |
| 6240 | PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL | $539.00 |
| 6241 | PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL | $451.00 |
| 6242 | PONTIC-PORCELAIN FUSED TO NOBLE METAL | $491.00 |
| 6750 | CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL | $515.00 |
| 6751 | CROWN-PORCELAIN FUSED TO PREDOM BASE METAL | $479.00 |
| 6752 | CROWN-PORCELAIN FUSED TO NOBLE METAL | $490.00 |
| ADA |
ORAL SURGERY |
MEMBER PAYS |
| 7140 | EXTRACTION,ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPTS REMOVAL) | $61.00 |
| 7220 | REMOVAL OF IMPACTED TOOTH-SOFT TISSUE | $125.00 |
| 7230 | REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY | $164.00 |
| 7240 | REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY | $219.00 |
| 7250 | SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS | $115.00 |
| 7310 | ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTION PER QUAD | $105.00 |
| 7320 | ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTION PER QUAD | $152.00 |
| 7510 | INCISION/DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE | $77.00 |
| ADA |
ORTHODONTICS |
>MEMBER PAYS |
| 8070 | COMPLETE ORTHODONTIC TREATMENT-TRANSITIONAL DENTITION | 20% Discount |
| 8080 | COMPLETE ORTHODONTIC TREATMENT-ADOLESCENT DENTITION | 20% Discount |
| 8090 | COMPLETE ORHTODONTIC TREATMENT-ADULT DENTITION | 20% Discount |
| ADA |
MISCELLANEOUS SERVICES |
MEMBER PAYS |
| 9110 | PALLIATIVE TREATMENT DENTAL PAIN-MINOR PROCEDURE | $40.00 |
| 9215 | LOCAL ANESTHESIA | $15.00 |
| 9230 | ANALGESIA | $25.00 |
| 9951 | OCCLUSAL ADJUSTMENT LIMITED | $56.00 |
| 9952 | OCCLUSAL ADJUSTMENT COMPLETE | $227.00 |
