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Sample
Discounted Dental Fee Schedule
| ADA Code |
Procedure |
Usual Fee * |
Discounted Fee |
Member
Savings |
| 0120 |
Routine 6 Month Check-Up |
$35 |
$14 |
$21 |
| 0150 |
In Depth Check-Up |
$62 |
$16 |
$46 |
| 0210 |
Full Mouth X-Rays |
$95 |
$38 |
$57 |
| 0274 |
Bitewings - Four Films |
$45 |
$19 |
$26 |
| 0330 |
Panoramic Film |
$80 |
$38 |
$42 |
| 1110 |
Adult Cleaning |
$60 |
$33 |
$27 |
| 1120 |
Child Cleaning |
$45 |
$27 |
$18 |
| 1351 |
Sealant - Per Tooth |
$35 |
$18 |
$17 |
| 2110 |
Silver Filling |
$77 |
$49 |
$28 |
| 2330 |
White Filling |
$105 |
$60 |
$45 |
| 3310 |
Root Canal - Anterior |
$495 |
$280 |
$215 |
| 3320 |
Root Canal - Bicuspid |
$580 |
$380 |
$200 |
| 3330 |
Root Canal - Molar |
$696 |
$475 |
$221 |
| 4341 |
Perio scaling and root planing (per
quadrant) |
$175 |
$115 |
$60 |
| 5110 |
Upper Denture (Complete) |
$1200 |
$642 |
$558 |
| 7110 |
Single Tooth Extraction |
$116 |
$68 |
$48 |
| 7120 |
Each Additional Tooth Extraction
|
$110 |
$63 |
$47 |
|
|
