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Series 501
ADA Code	Procedure	Typical Fee	You Pay	Savings
0120	Periodic Oral Evaluation - Established Patient	$51.30	$14	73%
0140	Limited Oral Evaluation - Problem Focused	$76.30	$18	76%
0150	Comprehensive Oral Evaluation - New Or Established Patient	$89.50	$18	80%
0210	Intraoral - Complete Series (Including Bitewings)	$130.60	$40	69%
0220	Intraoral - Periapical First Film	$28.60	$10	65%
0230	Intraoral - Periapical Each Additional Film	$24.90	$6	76%
0270	Bitewing - Single Film	$28.60	$10	65%
0272	Bitewing - Two Films	$45.60	$13	71%
0273	Bitewing - Three Films	$56.60	$17	70%
0274	Bitewing - Four Films	$66.10	$20	70%
0330	Panoramic Film	$110.00	$40	64%
1110	prophylaxis - adult	$91.30	$29	68%
1120	Prophylaxis - Adult	$66.90	$21	69%
1351	Sealant - Per Tooth	$55.50	$20	64%
1510	Space Maintainer - Fixed - Unilateral	$317.00	$87	73%
1515	Space Maintainer - Fixed - Bilateral	$427.40	$127	70%
1520	Space Maintainer - Removable - Unilateral	$388.20	$113	71%
1525	Space Maintainer - Removable - Bilateral	$487.50	$143	71%
2140	Amalgam - One Surface, Primary Or Permanent	$141.10	$40	72%
2150	Amalgam - Two Surfaces, Primary Or Permanent	$179.50	$51	72%
2160	Amalgam - Three Surfaces, Primary Or Permanent	$221.30	$60	73%
2161	Amalgam - Four Or More Surfaces, Primary Or Permanent	$259.00	$73	72%
2330	Resin-Based Composite - One Surface, Anterior	$163.40	$51	69%
2331	Resin-Based Composite - Two Surfaces, Anterior	$201.80	$61	70%
2332	Resin-Based Composite - Three Surfaces, Anterior	$252.50	$77	70%
2335	Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior)	$313.10	$98	69%
2391	Resin-Based Composite - One Surface, Posterior	$181.00	$64	65%
2392	Resin-Based Composite - Two Surfaces, Posterior	$234.70	$94	60%
2393	Resin-Based Composite - Three Surfaces, Posterior	$290.80	$119	59%
2394	Resin-Based Composite - Four Or More Surfaces, Posterior	$346.10	$138	60%
2710	Crown - Resin-Based Composite (Indirect)	$966.80	$191	80%
2720	Crown - Resin With High Noble Metal	$1,062.30	$403	62%
2750	Crown - Porcelain Fused To High Noble Metal	$1,118.50	$473	58%
2751	Crown - Porcelain Fused To Predominantly Base Metal	$1,030.60	$428	58%
2752	Crown - Porcelain Fused To Noble Metal	$1,054.00	$447	58%
2790	Crown - Full Cast High Noble Metal	$1,124.30	$465	59%
2791	Crown - Full Cast Predominantly Base Metal	$994.00	$417	58%
2930	Prefabricated Stainless Steel Crown - Primary Tooth	$267.40	$93	65%
2931	Prefabricated Stainless Steel Crown - Permanent Tooth	$325.50	$106	67%
2950	Core Buildup, Including Any Pins	$267.40	$93	65%
2951	Pin Retention - Per Tooth, In Addition To Restoration	$74.40	$23	69%
2952	Post And Core In Addition To Crown, Indirectly Fabricated	$418.10	$146	65%
2954	Prefabricated Post And Core In Addition To Crown	$333.90	$114	66%
3110	Pulp Cap - Direct (Excluding Final Restoration)	$82.80	$21	75%
3120	Pulp Cap - Indirect (Excluding Final Restoration)	$84.90	$21	75%
3220	Therapeutic Pulpotomy (Excluding Final Restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament	$198.20	$51	74%
3310	Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)	$725.20	$272	62%
3320	Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)	$836.80	$322	62%
3330	Endodontic Therapy, Molar (Excluding Final Restoration)	$1,013.70	$406	60%
4210	Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant	$632.50	$271	57%
4341	Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant	$258.10	$94	64%
4910	Periodontal Maintenance	$139.20	$60	57%
5110	Complete Denture - Maxillary	$1,709.60	$595	65%
5120	Complete Denture - Mandibular	$1,709.60	$595	65%
5130	Immediate Denture - Maxillary	$1,826.50	$619	66%
5140	Immediate Denture - Mandibular	$1,827.30	$619	66%
5211	Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,355.40	$583	57%
5212	Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,358.30	$583	57%
5213	Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$1,777.90	$675	62%
5214	Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$1,779.70	$675	62%
5410	Adjust Complete Denture - Maxillary	$89.50	$34	62%
5411	Adjust Complete Denture - Mandibular	$89.50	$34	62%
5510	Repair Broken Complete Denture Base	$211.20	$53	75%
5520	Replace Missing Or Broken Teeth - Complete Denture (Each Tooth)	$187.80	$51	73%
5630	Repair Or Replace Broken Clasp	$262.60	$61	77%
5650	Add Tooth To Existing Partial Denture	$222.30	$53	76%
5660	Add Clasp To Existing Partial Denture	$271.20	$68	75%
5730	Reline Complete Maxillary Denture (Chairside)	$373.10	$126	66%
5731	Reline Complete Mandibular Denture (Chairside)	$370.30	$126	66%
5740	Reline Maxillary Partial Denture (Chairside)	$365.60	$120	67%
5741	Reline Mandibular Partial Denture (Chairside)	$370.30	$120	68%
5750	Reline Complete Maxillary Denture (Laboratory)	$477.10	$165	65%
5751	Reline Complete Mandibular Denture (laboratory)	$477.10	$165	65%
6040	Surgical Placement: Eposteal Implant	$8,130.50	20%	$1,626.10
6050	Surgical Placement: Transosteal Implant	$5,621.90	20%	$1,124.38
6065	Implant Supported Porcelain/Ceramic Crown	$1,556.90	20%	$311.38
6066	Implant Supported Porcelain Fused To Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,559.60	20%	$311.92
6067	Implant Supported Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,580.20	20%	$316.04
6240	Pontic - Porcelain Fused To High Noble Metal	$1,114.90	$411	63%
6241	Pontic - Porcelain Fused To Predominantly Base Metal	$1,030.60	$379	63%
6242	Pontic - Porcelain Fused To Noble Metal	$1,057.70	$395	63%
6750	Crown - Porcelain Fused To High Noble Metal	$1,119.50	$453	60%
6751	Crown - Porcelain Fused To Predominantly Base Metal	$1,013.70	$408	60%
6752	Crown - Porcelain Fused To Noble Metal	$1,047.40	$424	60%
7140	Extraction, Erupted Tooth Or Exposed Root (elevation And/or Forceps Removal)	$173.70	$51	71%
7210	Surgical Removal Of Erupted Tooth Requiring Removal Of Bone And/or Sectioning Of Tooth, And Including Elevation Of Mucoperiosteal Flap If Indicated	$275.70	$130	53%
7220	Removal Of Impacted Tooth - Soft Tissue	$312.20	$104	67%
7230	Removal Of Impacted Tooth - Partially Bony	$395.70	$136	66%
7240	Removal Of Impacted Tooth - Completely Bony	$482.60	$196	59%
7250	Surgical Removal Of Residual Tooth Roots (Cutting Procedure)	$312.20	$104	67%
7310	Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant	$305.00	$87	71%
7320	Alveoloplasty Not In Conjunction With Extractions -four Or More Teeth Or Tooth Spaces, Per Quadrant	$445.30	$125	72%
7510	Incision And Drainage Of Abscess - Intraoral Soft Tissue	$234.70	$64	73%
8070	Comprehensive Orthodontic Treatment Of The Transitional Dentition	$5,130.20	20%	$1,026.04
8080	Comprehensive Orthodontic Treatment Of The Adolescent Dentition	$5,182.70	20%	$1,036.54
8090	Comprehensive Orthodontic Treatment Of The Adult Dentition	$5,207.80	20%	$1,041.56
9110	Palliative (Emergency) Treatment Of Dental Pain - Minor Procedure	$129.60	$34	74%
9215	Local Anesthesia In Conjunction With Operative Or Surgical Procedures	$66.10	$12	82%
9230	Inhalation Of Nitrous Oxide / Anxiolysis, Analgesia	$80.10	$24	70%
9951	Occlusal Adjustment - Limited	$187.80	$47	75%
9952	Occlusal Adjustment - Complete	$699.90	$188	73%

Series 502
ADA Code	Procedure	Typical Fee	You Pay	Savings
0120	Periodic Oral Evaluation - Established Patient	$53.00	$15	72%
0140	Limited Oral Evaluation - Problem Focused	$79.36	$20	75%
0150	Comprehensive Oral Evaluation - New Or Established Patient	$92.82	$24	74%
0210	Intraoral - Complete Series (Including Bitewings)	$135.73	$46	66%
0220	Intraoral - Periapical First Film	$29.55	$11	63%
0230	Intraoral - Periapical Each Additional Film	$25.82	$8	69%
0270	Bitewing - Single Film	$29.55	$11	63%
0272	Bitewing - Two Films	$47.09	$14	70%
0273	Bitewing - Three Films	$58.82	$19	68%
0274	Bitewings - Four Films	$68.64	$23	66%
0330	Panoramic Film	$114.27	$46	60%
1110	Prophylaxis - Adult	$94.82	$34	64%
1120	Prophylaxis - Child	$69.55	$24	65%
1351	Sealant - Per Tooth	$57.91	$23	60%
1510	Space Maintainer - Fixed - Unilateral	$329.36	$98	70%
1515	Space Maintainer - Fixed - Bilateral	$444.00	$143	68%
1520	Space Maintainer - Removable - Unilateral	$403.09	$127	68%
1525	Space Maintainer - Removable - Bilateral	$506.27	$162	68%
2140	Amalgam - One Surface, Primary Or Permanent	$146.45	$46	69%
2150	Amalgam - Two Surfaces, Primary Or Permanent	$186.27	$57	69%
2160	Amalgam - Three Surfaces, Primary Or Permanent	$230.18	$69	70%
2161	Amalgam - Four Or More Surfaces, Primary Or Permanent	$268.82	$83	69%
2330	Resin-Based Composite - One Surface, Anterior	$169.82	$56	67%
2331	Resin-Based Composite - Two Surfaces, Anterior	$209.55	$69	67%
2332	Resin-Based Composite - Three Surfaces, Anterior	$262.00	$88	66%
2335	Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior)	$325.36	$108	67%
2391	Resin-Based Composite - One Surface, Posterior	$188.18	$75	60%
2392	Resin-Based Composite - Two Surfaces, Posterior	$243.82	$110	55%
2393	Resin-Based Composite - Three Surfaces, Posterior	$302.00	$136	55%
2394	Resin-Based Composite - Four Or More Surfaces, Posterior	$359.27	$155	57%
2710	Crown - Resin-Based Composite (Indirect)	$1,004.09	$213	79%
2720	Crown - Resin With High Noble Metal	$1,103.45	$452	59%
2750	Crown - Porcelain Fused To High Noble Metal	$1,161.73	$535	54%
2751	Crown - Porcelain Fused To Predominantly Base Metal	$1,070.27	$485	55%
2752	Crown - Porcelain Fused To Noble Metal	$1,094.64	$505	54%
2790	Crown - Full Cast High Noble Metal	$1,167.64	$527	55%
2791	Crown - Full Cast Predominantly Base Metal	$1,032.45	$491	52%
2930	Prefabricated Stainless Steel Crown - Primary Tooth	$277.55	$105	62%
2931	Prefabricated Stainless Steel Crown - Permanent Tooth	$338.00	$120	64%
2950	Core Buildup, Including Any Pins	$277.55	$105	62%
2951	Pin Retention - Per Tooth, In Addition To Restoration	$77.45	$25	68%
2952	Post And Core In Addition To Crown, Indirectly Fabricated	$434.45	$165	62%
2954	Prefabricated Post And Core In Addition To Crown	$346.73	$129	63%
3110	Pulp Cap - Direct (Excluding Final Restoration)	$86.09	$23	73%
3120	Pulp Cap - Indirect (Excluding Final Restoration)	$88.00	$23	74%
3220	Therapeutic Pulpotomy (Excluding Final Restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament	$205.64	$56	73%
3310	Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)	$753.18	$308	59%
3320	Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)	$869.00	$365	58%
3330	Endodontic Therapy, Molar (Excluding Final Restoration)	$1,052.82	$459	56%
4210	Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant	$657.09	$313	52%
4341	Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant	$267.91	$104	61%
4910	Periodontal Maintenance	$144.55	$64	56%
5110	Complete Denture - Maxillary	$1,775.36	$672	62%
5120	Complete Denture - Mandibular	$1,775.36	$672	62%
5130	Immediate Denture - Maxillary	$1,897.00	$701	63%
5140	Immediate Denture - Mandibular	$1,897.91	$701	63%
5211	Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,407.91	$613	56%
5212	Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,410.82	$613	57%
5213	Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$1,846.45	$762	59%
5214	Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$1,848.45	$762	59%
5410	Adjust Complete Denture - Maxillary	$92.82	$35	62%
5411	Adjust Complete Denture - Mandibular	$92.82	$35	62%
5510	Repair Broken Complete Denture Base	$219.45	$60	73%
5520	Replace Missing Or Broken Teeth - Complete Denture (Each Tooth)	$195.00	$56	71%
5630	Repair Or Replace Broken Clasp	$272.73	$69	75%
5650	Add Tooth To Existing Partial Denture	$231.09	$60	74%
5660	Add Clasp To Existing Partial Denture	$281.64	$77	73%
5730	Reline Complete Maxillary Denture (Chairside)	$387.64	$142	63%
5731	Reline Complete Mandibular Denture (Chairside)	$384.73	$142	63%
5740	Reline Maxillary Partial Denture (Chairside)	$379.82	$136	64%
5741	Reline Mandibular Partial Denture (Chairside)	$384.73	$136	65%
5750	Reline Complete Maxillary Denture (Laboratory)	$495.64	$186	62%
5751	Reline Complete Mandibular Denture (laboratory)	$495.64	$186	62%
6040	Surgical Placement: Eposteal Implant	$8,444.45	20%	$ 1,688.89
6050	Surgical Placement: Transosteal Implant	$5,838.91	20%	$ 1,167.78
6065	Implant Supported Porcelain/Ceramic Crown	$1,616.91	20%	$323.38
6066	Implant Supported Porcelain Fused To Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,620.00	20%	$324.00
6067	Implant Supported Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,641.27	20%	$328.25
6240	Pontic - Porcelain Fused To High Noble Metal	$1,157.91	$461	60%
6241	Pontic - Porcelain Fused To Predominantly Base Metal	$1,070.27	$428	60%
6242	Pontic - Porcelain Fused To Noble Metal	$1,098.55	$447	59%
6750	Crown - Porcelain Fused To High Noble Metal	$1,162.73	$512	56%
6751	Crown - Porcelain Fused To Predominantly Base Metal	$1,052.82	$461	56%
6752	Crown - Porcelain Fused To Noble Metal	$1,087.82	$478	56%
7140	Extraction, Erupted Tooth Or Exposed Root (elevation And/or Forceps Removal)	$180.45	$56	69%
7210	Surgical Removal Of Erupted Tooth Requiring Removal Of Bone And/or Sectioning Of Tooth, And Including Elevation Of Mucoperiosteal Flap If Indicated	$286.45	$140	51%
7220	Removal Of Impacted Tooth - Soft Tissue	$324.36	$117	64%
7230	Removal Of Impacted Tooth - Partially Bony	$410.82	$153	63%
7240	Removal Of Impacted Tooth - Completely Bony	$501.36	$214	57%
7250	Surgical Removal Of Residual Tooth Roots (Cutting Procedure)	$324.36	$118	64%
7310	Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant	$316.55	$98	69%
7320	Alveoloplasty Not In Conjunction With Extractions -four Or More Teeth Or Tooth Spaces, Per Quadrant	$462.45	$141	70%
7510	Incision And Drainage Of Abscess - Intraoral Soft Tissue	$243.82	$72	70%
8070	Comprehensive Orthodontic Treatment Of The Transitional Dentition	$5,328.27	20%	$ 1,065.65
8080	Comprehensive Orthodontic Treatment Of The Adolescent Dentition	$5,382.64	20%	$ 1,076.53
8090	Comprehensive Orthodontic Treatment Of The Adult Dentition	$5,408.91	20%	$ 1,081.78
9110	Palliative (Emergency) Treatment Of Dental Pain - Minor Procedure	$134.73	$37	73%
9215	Local Anesthesia In Conjunction With Operative Or Surgical Procedures	$68.64	$14	80%
9230	Inhalation Of Nitrous Oxide / Anxiolysis, Analgesia	$83.27	$25	70%
9951	Occlusal Adjustment - Limited	$195.00	$53	73%
9952	Occlusal Adjustment - Complete	$726.91	$211	71%

Series 503
ADA Code	Procedure	Typical Fee	You Pay	Savings
0120	Periodic Oral Evaluation - Established Patient	$53	$16	70%
0140	Limited Oral Evaluation - Problem Focused	$79	$18	77%
0150	Comprehensive Oral Evaluation - New Or Established Patient	$92	$20	78%
0210	Intraoral - Complete Series (Including Bitewings)	$134	$48	64%
0220	Intraoral - Periapical First Film	$29	$11	63%
0230	Intraoral - Periapical Each Additional Film	$25	$7	72%
0270	Bitewing - Single Film	$29	$11	63%
0272	Bitewing - Two Films	$47	$15	68%
0273	Bitewing - Three Films	$58	$20	66%
0274	Bitewing - Four Films	$68	$24	65%
0330	Panoramic Film	$113	$48	58%
1110	prophylaxis - adult	$94	$35	63%
1120	Prophylaxis - Adult	$69	$29	58%
1351	Sealant - Per Tooth	$57	$24	58%
1510	Space Maintainer - Fixed - Unilateral	$326	$104	68%
1515	Space Maintainer - Fixed - Bilateral	$439	$153	65%
1520	Space Maintainer - Removable - Unilateral	$399	$136	66%
1525	Space Maintainer - Removable - Bilateral	$501	$174	65%
2140	Amalgam - One Surface, Primary Or Permanent	$145	$48	67%
2150	Amalgam - Two Surfaces, Primary Or Permanent	$184	$61	67%
2160	Amalgam - Three Surfaces, Primary Or Permanent	$228	$72	68%
2161	Amalgam - Four Or More Surfaces, Primary Or Permanent	$266	$88	67%
2330	Resin-Based Composite - One Surface, Anterior	$168	$61	64%
2331	Resin-Based Composite - Two Surfaces, Anterior	$208	$73	65%
2332	Resin-Based Composite - Three Surfaces, Anterior	$259	$93	64%
2335	Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior)	$322	$117	64%
2391	Resin-Based Composite - One Surface, Posterior	$186	$77	59%
2392	Resin-Based Composite - Two Surfaces, Posterior	$241	$110	54%
2393	Resin-Based Composite - Three Surfaces, Posterior	$299	$139	53%
2394	Resin-Based Composite - Four Or More Surfaces, Posterior	$355	$160	55%
2710	Crown - Resin-Based Composite (Indirect)	$993	$228	77%
2720	Crown - Resin With High Noble Metal	$1,091	$483	56%
2750	Crown - Porcelain Fused To High Noble Metal	$1,149	$572	50%
2751	Crown - Porcelain Fused To Predominantly Base Metal	$1,058	$520	51%
2752	Crown - Porcelain Fused To Noble Metal	$1,083	$558	48%
2790	Crown - Full Cast High Noble Metal	$1,155	$560	51%
2791	Crown - Full Cast Predominantly Base Metal	$1,021	$520	49%
2930	Prefabricated Stainless Steel Crown - Primary Tooth	$275	$112	59%
2931	Prefabricated Stainless Steel Crown - Permanent Tooth	$334	$127	62%
2950	Core Buildup, Including Any Pins	$275	$112	59%
2951	Pin Retention - Per Tooth, In Addition To Restoration	$77	$27	65%
2952	Post And Core In Addition To Crown, Indirectly Fabricated	$430	$176	59%
2954	Prefabricated Post And Core In Addition To Crown	$343	$137	60%
3110	Pulp Cap - Direct (Excluding Final Restoration)	$85	$25	71%
3120	Pulp Cap - Indirect (Excluding Final Restoration)	$87	$25	71%
3220	Therapeutic Pulpotomy (Excluding Final Restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament	$204	$61	70%
3310	Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)	$745	$326	56%
3320	Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)	$859	$388	55%
3330	Endodontic Therapy, Molar (Excluding Final Restoration)	$1,041	$487	53%
4210	Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant	$650	$325	50%
4341	Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant	$265	$116	56%
4910	Periodontal Maintenance	$143	$69	52%
5110	Complete Denture - Maxillary	$1,756	$702	60%
5120	Complete Denture - Mandibular	$1,756	$702	60%
5130	Immediate Denture - Maxillary	$1,876	$729	61%
5140	Immediate Denture - Mandibular	$1,877	$729	61%
5211	Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,392	$685	51%
5212	Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,395	$685	51%
5213	Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$1,826	$796	56%
5214	Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$1,828	$796	56%
5410	Adjust Complete Denture - Maxillary	$92	$40	57%
5411	Adjust Complete Denture - Mandibular	$92	$40	57%
5510	Repair Broken Complete Denture Base	$217	$64	70%
5520	Replace Missing Or Broken Teeth - Complete Denture (Each Tooth)	$193	$61	68%
5630	Repair Or Replace Broken Clasp	$270	$73	73%
5650	Add Tooth To Existing Partial Denture	$228	$64	72%
5660	Add Clasp To Existing Partial Denture	$278	$81	71%
5730	Reline Complete Maxillary Denture (Chairside)	$383	$152	60%
5731	Reline Complete Mandibular Denture (Chairside)	$381	$152	60%
5740	Reline Maxillary Partial Denture (Chairside)	$376	$143	62%
5741	Reline Mandibular Partial Denture (Chairside)	$381	$143	62%
5750	Reline Complete Maxillary Denture (Laboratory)	$490	$197	60%
5751	Reline Complete Mandibular Denture (laboratory)	$490	$197	60%
6040	Surgical Placement: Eposteal Implant	$8,351	20%	$1,670.10
6050	Surgical Placement: Transosteal Implant	$5,774	20%	$1,154.80
6065	Implant Supported Porcelain/Ceramic Crown	$1,599	20%	$319.82
6066	Implant Supported Porcelain Fused To Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,602	20%	$320.38
6067	Implant Supported Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,623	20%	$324.62
6240	Pontic - Porcelain Fused To High Noble Metal	$1,145	$491	57%
6241	Pontic - Porcelain Fused To Predominantly Base Metal	$1,058	$454	57%
6242	Pontic - Porcelain Fused To Noble Metal	$1,086	$474	56%
6750	Crown - Porcelain Fused To High Noble Metal	$1,150	$537	53%
6751	Crown - Porcelain Fused To Predominantly Base Metal	$1,041	$489	53%
6752	Crown - Porcelain Fused To Noble Metal	$1,076	$509	53%
7140	Extraction, Erupted Tooth Or Exposed Root (elevation And/or Forceps Removal)	$178	$61	66%
7210	Surgical Removal Of Erupted Tooth Requiring Removal Of Bone And/or Sectioning Of Tooth, And Including Elevation Of Mucoperiosteal Flap If Indicated	$283	$148	48%
7220	Removal Of Impacted Tooth - Soft Tissue	$321	$125	61%
7230	Removal Of Impacted Tooth - Partially Bony	$407	$162	60%
7240	Removal Of Impacted Tooth - Completely Bony	$496	$228	54%
7250	Surgical Removal Of Residual Tooth Roots (Cutting Procedure)	$321	$118	63%
7310	Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant	$313	$104	67%
7320	Alveoloplasty Not In Conjunction With Extractions -four Or More Teeth Or Tooth Spaces, Per Quadrant	$457	$151	67%
7510	Incision And Drainage Of Abscess - Intraoral Soft Tissue	$241	$77	68%
8070	Comprehensive Orthodontic Treatment Of The Transitional Dentition	$5,269	20%	$1,053.82
8080	Comprehensive Orthodontic Treatment Of The Adolescent Dentition	$5,323	20%	$1,064.58
8090	Comprehensive Orthodontic Treatment Of The Adult Dentition	$5,349	20%	$1,069.76
9110	Palliative (Emergency) Treatment Of Dental Pain - Minor Procedure	$133	$40	70%
9215	Local Anesthesia In Conjunction With Operative Or Surgical Procedures	$68	$15	78%
9230	Inhalation Of Nitrous Oxide / Anxiolysis, Analgesia	$82	$27	67%
9951	Occlusal Adjustment - Limited	$193	$55	71%
9952	Occlusal Adjustment - Complete	$719	$224	69%

Series 504
ADA Code	Procedure	Typical Fee	You Pay	Savings
0120	Periodic Oral Evaluation - Established Patient	$55	$17	69%
0140	Limited Oral Evaluation - Problem Focused	$82	$21	74%
0150	Comprehensive Oral Evaluation - New Or Established Patient	$96	$21	78%
0210	Intraoral - Complete Series (Including Bitewings)	$140	$53	62%
0220	Intraoral - Periapical First Film	$31	$12	61%
0230	Intraoral - Periapical Each Additional Film	$27	$7	74%
0270	Bitewing - Single Film	$31	$12	61%
0272	Bitewing - Two Films	$49	$16	67%
0273	Bitewing - Three Films	$61	$21	65%
0274	Bitewing - Four Films	$71	$27	62%
0330	Panoramic Film	$118	$53	55%
1110	prophylaxis - adult	$98	$38	61%
1120	Prophylaxis - Adult	$72	$33	54%
1351	Sealant - Per Tooth	$60	$25	58%
1510	Space Maintainer - Fixed - Unilateral	$339	$114	66%
1515	Space Maintainer - Fixed - Bilateral	$458	$170	63%
1520	Space Maintainer - Removable - Unilateral	$416	$151	64%
1525	Space Maintainer - Removable - Bilateral	$522	$192	63%
2140	Amalgam - One Surface, Primary Or Permanent	$151	$53	65%
2150	Amalgam - Two Surfaces, Primary Or Permanent	$192	$68	65%
2160	Amalgam - Three Surfaces, Primary Or Permanent	$237	$80	66%
2161	Amalgam - Four Or More Surfaces, Primary Or Permanent	$278	$98	65%
2330	Resin-Based Composite - One Surface, Anterior	$175	$68	61%
2331	Resin-Based Composite - Two Surfaces, Anterior	$216	$81	63%
2332	Resin-Based Composite - Three Surfaces, Anterior	$270	$103	62%
2335	Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior)	$336	$129	62%
2391	Resin-Based Composite - One Surface, Posterior	$194	$86	56%
2392	Resin-Based Composite - Two Surfaces, Posterior	$251	$124	51%
2393	Resin-Based Composite - Three Surfaces, Posterior	$312	$159	49%
2394	Resin-Based Composite - Four Or More Surfaces, Posterior	$371	$183	51%
2710	Crown - Resin-Based Composite (Indirect)	$1,036	$240	77%
2720	Crown - Resin With High Noble Metal	$1,138	$508	55%
2750	Crown - Porcelain Fused To High Noble Metal	$1,198	$595	50%
2751	Crown - Porcelain Fused To Predominantly Base Metal	$1,104	$542	51%
2752	Crown - Porcelain Fused To Noble Metal	$1,129	$578	49%
2790	Crown - Full Cast High Noble Metal	$1,204	$583	52%
2791	Crown - Full Cast Predominantly Base Metal	$1,065	$549	48%
2930	Prefabricated Stainless Steel Crown - Primary Tooth	$286	$124	57%
2931	Prefabricated Stainless Steel Crown - Permanent Tooth	$349	$141	60%
2950	Core Buildup, Including Any Pins	$286	$124	57%
2951	Pin Retention - Per Tooth, In Addition To Restoration	$80	$28	65%
2952	Post And Core In Addition To Crown, Indirectly Fabricated	$448	$194	57%
2954	Prefabricated Post And Core In Addition To Crown	$358	$152	58%
3110	Pulp Cap - Direct (Excluding Final Restoration)	$89	$28	68%
3120	Pulp Cap - Indirect (Excluding Final Restoration)	$91	$28	69%
3220	Therapeutic Pulpotomy (Excluding Final Restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament	$212	$68	68%
3310	Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)	$777	$339	56%
3320	Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)	$896	$407	55%
3330	Endodontic Therapy, Molar (Excluding Final Restoration)	$1,086	$516	52%
4210	Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant	$678	$358	47%
4341	Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant	$276	$118	57%
4910	Periodontal Maintenance	$149	$75	50%
5110	Complete Denture - Maxillary	$1,831	$751	59%
5120	Complete Denture - Mandibular	$1,831	$751	59%
5130	Immediate Denture - Maxillary	$1,957	$808	59%
5140	Immediate Denture - Mandibular	$1,958	$808	59%
5211	Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,452	$735	49%
5212	Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,455	$735	50%
5213	Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$1,905	$856	55%
5214	Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$1,907	$856	55%
5410	Adjust Complete Denture - Maxillary	$96	$41	57%
5411	Adjust Complete Denture - Mandibular	$96	$41	57%
5510	Repair Broken Complete Denture Base	$226	$70	69%
5520	Replace Missing Or Broken Teeth - Complete Denture (Each Tooth)	$201	$68	66%
5630	Repair Or Replace Broken Clasp	$281	$81	71%
5650	Add Tooth To Existing Partial Denture	$238	$70	71%
5660	Add Clasp To Existing Partial Denture	$290	$90	69%
5730	Reline Complete Maxillary Denture (Chairside)	$400	$167	58%
5731	Reline Complete Mandibular Denture (Chairside)	$397	$167	58%
5740	Reline Maxillary Partial Denture (Chairside)	$392	$159	59%
5741	Reline Mandibular Partial Denture (Chairside)	$397	$159	60%
5750	Reline Complete Maxillary Denture (Laboratory)	$511	$219	57%
5751	Reline Complete Mandibular Denture (laboratory)	$511	$219	57%
6040	Surgical Placement: Eposteal Implant	$8,711	20%	$1,742
6050	Surgical Placement: Transosteal Implant	$6,023	20%	$1,205
6065	Implant Supported Porcelain/Ceramic Crown	$1,668	20%	$334
6066	Implant Supported Porcelain Fused To Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,671	20%	$334
6067	Implant Supported Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,693	20%	$339
6240	Pontic - Porcelain Fused To High Noble Metal	$1,194	$538	55%
6241	Pontic - Porcelain Fused To Predominantly Base Metal	$1,104	$496	55%
6242	Pontic - Porcelain Fused To Noble Metal	$1,133	$516	54%
6750	Crown - Porcelain Fused To High Noble Metal	$1,199	$561	53%
6751	Crown - Porcelain Fused To Predominantly Base Metal	$1,086	$520	52%
6752	Crown - Porcelain Fused To Noble Metal	$1,122	$541	52%
7140	Extraction, Erupted Tooth Or Exposed Root (elevation And/or Forceps Removal)	$186	$68	63%
7210	Surgical Removal Of Erupted Tooth Requiring Removal Of Bone And/or Sectioning Of Tooth, And Including Elevation Of Mucoperiosteal Flap If Indicated	$296	$157	47%
7220	Removal Of Impacted Tooth - Soft Tissue	$335	$139	58%
7230	Removal Of Impacted Tooth - Partially Bony	$424	$180	58%
7240	Removal Of Impacted Tooth - Completely Bony	$517	$234	55%
7250	Surgical Removal Of Residual Tooth Roots (Cutting Procedure)	$335	$125	63%
7310	Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant	$326	$114	65%
7320	Alveoloplasty Not In Conjunction With Extractions -four Or More Teeth Or Tooth Spaces, Per Quadrant	$477	$166	65%
7510	Incision And Drainage Of Abscess - Intraoral Soft Tissue	$251	$86	66%
8070	Comprehensive Orthodontic Treatment Of The Transitional Dentition	$5,496	20%	$1,099
8080	Comprehensive Orthodontic Treatment Of The Adolescent Dentition	$5,553	20%	$1,111
8090	Comprehensive Orthodontic Treatment Of The Adult Dentition	$5,580	20%	$1,116
9110	Palliative (Emergency) Treatment Of Dental Pain - Minor Procedure	$139	$43	69%
9215	Local Anesthesia In Conjunction With Operative Or Surgical Procedures	$71	$16	77%
9230	Inhalation Of Nitrous Oxide / Anxiolysis, Analgesia	$86	$29	66%
9951	Occlusal Adjustment - Limited	$201	$63	69%
9952	Occlusal Adjustment - Complete	$750	$249	67%

Series 505
ADA Code	Procedure	Typical Fee	You Pay	Savings
0120	Periodic Oral Evaluation - Established Patient	$56	$21	62%
0140	Limited Oral Evaluation - Problem Focused	$83	$25	70%
0150	Comprehensive Oral Evaluation - New Or Established Patient	$98	$31	68%
0210	Intraoral - Complete Series (Including Bitewings)	$143	$64	55%
0220	Intraoral - Periapical First Film	$31	$15	52%
0230	Intraoral - Periapical Each Additional Film	$27	$9	67%
0270	Bitewing - Single Film	$31	$15	52%
0272	Bitewing - Two Films	$50	$18	64%
0273	Bitewing - Three Films	$62	$23	63%
0274	Bitewing - Four Films	$72	$28	61%
0330	Panoramic Film	$120	$64	47%
1110	prophylaxis - adult	$100	$47	53%
1120	Prophylaxis - Adult	$73	$38	48%
1351	Sealant - Per Tooth	$61	$33	46%
1510	Space Maintainer - Fixed - Unilateral	$346	$139	60%
1515	Space Maintainer - Fixed - Bilateral	$467	$205	56%
1520	Space Maintainer - Removable - Unilateral	$424	$180	58%
1525	Space Maintainer - Removable - Bilateral	$533	$230	57%
2140	Amalgam - One Surface, Primary Or Permanent	$154	$64	58%
2150	Amalgam - Two Surfaces, Primary Or Permanent	$196	$81	59%
2160	Amalgam - Three Surfaces, Primary Or Permanent	$242	$95	61%
2161	Amalgam - Four Or More Surfaces, Primary Or Permanent	$283	$117	59%
2330	Resin-Based Composite - One Surface, Anterior	$179	$81	55%
2331	Resin-Based Composite - Two Surfaces, Anterior	$220	$99	55%
2332	Resin-Based Composite - Three Surfaces, Anterior	$276	$124	55%
2335	Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior)	$342	$156	54%
2391	Resin-Based Composite - One Surface, Posterior	$198	$104	47%
2392	Resin-Based Composite - Two Surfaces, Posterior	$256	$152	41%
2393	Resin-Based Composite - Three Surfaces, Posterior	$318	$192	40%
2394	Resin-Based Composite - Four Or More Surfaces, Posterior	$378	$219	42%
2710	Crown - Resin-Based Composite (Indirect)	$1,056	$284	73%
2720	Crown - Resin With High Noble Metal	$1,161	$603	48%
2750	Crown - Porcelain Fused To High Noble Metal	$1,222	$710	42%
2751	Crown - Porcelain Fused To Predominantly Base Metal	$1,126	$693	38%
2752	Crown - Porcelain Fused To Noble Metal	$1,152	$703	39%
2790	Crown - Full Cast High Noble Metal	$1,228	$726	41%
2791	Crown - Full Cast Predominantly Base Metal	$1,086	$688	37%
2930	Prefabricated Stainless Steel Crown - Primary Tooth	$292	$142	51%
2931	Prefabricated Stainless Steel Crown - Permanent Tooth	$356	$159	55%
2950	Core Buildup, Including Any Pins	$292	$139	52%
2951	Pin Retention - Per Tooth, In Addition To Restoration	$81	$35	57%
2952	Post And Core In Addition To Crown, Indirectly Fabricated	$457	$230	50%
2954	Prefabricated Post And Core In Addition To Crown	$365	$174	52%
3110	Pulp Cap - Direct (Excluding Final Restoration)	$91	$35	61%
3120	Pulp Cap - Indirect (Excluding Final Restoration)	$93	$33	64%
3220	Therapeutic Pulpotomy (Excluding Final Restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament	$216	$81	63%
3310	Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)	$792	$436	45%
3320	Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)	$914	$516	44%
3330	Endodontic Therapy, Molar (Excluding Final Restoration)	$1,108	$648	41%
4210	Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant	$691	$449	35%
4341	Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant	$282	$146	48%
4910	Periodontal Maintenance	$152	$91	40%
5110	Complete Denture - Maxillary	$1,868	$941	50%
5120	Complete Denture - Mandibular	$1,868	$941	50%
5130	Immediate Denture - Maxillary	$1,996	$991	50%
5140	Immediate Denture - Mandibular	$1,997	$991	50%
5211	Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,481	$925	38%
5212	Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,484	$925	38%
5213	Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$1,943	$1,057	46%
5214	Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$1,945	$1,057	46%
5410	Adjust Complete Denture - Maxillary	$98	$50	49%
5411	Adjust Complete Denture - Mandibular	$98	$50	49%
5510	Repair Broken Complete Denture Base	$231	$86	63%
5520	Replace Missing Or Broken Teeth - Complete Denture (Each Tooth)	$205	$81	60%
5630	Repair Or Replace Broken Clasp	$287	$99	66%
5650	Add Tooth To Existing Partial Denture	$243	$86	65%
5660	Add Clasp To Existing Partial Denture	$296	$108	64%
5730	Reline Complete Maxillary Denture (Chairside)	$408	$196	52%
5731	Reline Complete Mandibular Denture (Chairside)	$405	$196	52%
5740	Reline Maxillary Partial Denture (Chairside)	$400	$184	54%
5741	Reline Mandibular Partial Denture (Chairside)	$405	$184	55%
5750	Reline Complete Maxillary Denture (Laboratory)	$521	$254	51%
5751	Reline Complete Mandibular Denture (laboratory)	$521	$254	51%
6040	Surgical Placement: Eposteal Implant	$8,883	20%	$1,776.63
6050	Surgical Placement: Transosteal Implant	$6,142	20%	$1,228.48
6065	Implant Supported Porcelain/Ceramic Crown	$1,701	20%	$340.18
6066	Implant Supported Porcelain Fused To Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,704	20%	$340.78
6067	Implant Supported Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,727	20%	$345.30
6240	Pontic - Porcelain Fused To High Noble Metal	$1,218	$651	47%
6241	Pontic - Porcelain Fused To Predominantly Base Metal	$1,126	$601	47%
6242	Pontic - Porcelain Fused To Noble Metal	$1,156	$619	46%
6750	Crown - Porcelain Fused To High Noble Metal	$1,223	$693	43%
6751	Crown - Porcelain Fused To Predominantly Base Metal	$1,108	$653	41%
6752	Crown - Porcelain Fused To Noble Metal	$1,144	$678	41%
7140	Extraction, Erupted Tooth Or Exposed Root (elevation And/or Forceps Removal)	$190	$81	57%
7210	Surgical Removal Of Erupted Tooth Requiring Removal Of Bone And/or Sectioning Of Tooth, And Including Elevation Of Mucoperiosteal Flap If Indicated	$301	$169	44%
7220	Removal Of Impacted Tooth - Soft Tissue	$341	$166	51%
7230	Removal Of Impacted Tooth - Partially Bony	$432	$216	50%
7240	Removal Of Impacted Tooth - Completely Bony	$527	$283	46%
7250	Surgical Removal Of Residual Tooth Roots (Cutting Procedure)	$341	$156	54%
7310	Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant	$333	$139	58%
7320	Alveoloplasty Not In Conjunction With Extractions -four Or More Teeth Or Tooth Spaces, Per Quadrant	$487	$200	59%
7510	Incision And Drainage Of Abscess - Intraoral Soft Tissue	$256	$103	60%
8070	Comprehensive Orthodontic Treatment Of The Transitional Dentition	$5,605	20%	$1,121.03
8080	Comprehensive Orthodontic Treatment Of The Adolescent Dentition	$5,663	20%	$1,132.50
8090	Comprehensive Orthodontic Treatment Of The Adult Dentition	$5,690	20%	$1,138.00
9110	Palliative (Emergency) Treatment Of Dental Pain - Minor Procedure	$142	$53	63%
9215	Local Anesthesia In Conjunction With Operative Or Surgical Procedures	$72	$21	71%
9230	Inhalation Of Nitrous Oxide / Anxiolysis, Analgesia	$88	$35	60%
9951	Occlusal Adjustment - Limited	$205	$74	64%
9952	Occlusal Adjustment - Complete	$765	$300	61%

Series 506
ADA Code	Procedure	Typical Fee	You Pay	Savings
0120	Periodic Oral Evaluation - Established Patient	$56	$21	62%
0140	Limited Oral Evaluation - Problem Focused	$83	$25	70%
0150	Comprehensive Oral Evaluation - New Or Established Patient	$98	$31	68%
0210	Intraoral - Complete Series (Including Bitewings)	$143	$64	55%
0220	Intraoral - Periapical First Film	$31	$15	52%
0230	Intraoral - Periapical Each Additional Film	$27	$9	67%
0270	Bitewing - Single Film	$31	$15	52%
0272	Bitewing - Two Films	$50	$18	64%
0273	Bitewing - Three Films	$62	$23	63%
0274	Bitewing - Four Films	$72	$28	61%
0330	Panoramic Film	$120	$64	47%
1110	prophylaxis - adult	$100	$47	53%
1120	Prophylaxis - Adult	$73	$38	48%
1351	Sealant - Per Tooth	$61	$33	46%
1510	Space Maintainer - Fixed - Unilateral	$346	$139	60%
1515	Space Maintainer - Fixed - Bilateral	$467	$205	56%
1520	Space Maintainer - Removable - Unilateral	$424	$180	58%
1525	Space Maintainer - Removable - Bilateral	$533	$230	57%
2140	Amalgam - One Surface, Primary Or Permanent	$154	$64	58%
2150	Amalgam - Two Surfaces, Primary Or Permanent	$196	$81	59%
2160	Amalgam - Three Surfaces, Primary Or Permanent	$242	$95	61%
2161	Amalgam - Four Or More Surfaces, Primary Or Permanent	$283	$117	59%
2330	Resin-Based Composite - One Surface, Anterior	$179	$81	55%
2331	Resin-Based Composite - Two Surfaces, Anterior	$220	$99	55%
2332	Resin-Based Composite - Three Surfaces, Anterior	$276	$124	55%
2335	Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior)	$342	$156	54%
2391	Resin-Based Composite - One Surface, Posterior	$198	$104	47%
2392	Resin-Based Composite - Two Surfaces, Posterior	$256	$152	41%
2393	Resin-Based Composite - Three Surfaces, Posterior	$318	$192	40%
2394	Resin-Based Composite - Four Or More Surfaces, Posterior	$378	$219	42%
2710	Crown - Resin-Based Composite (Indirect)	$1,056	$284	73%
2720	Crown - Resin With High Noble Metal	$1,161	$603	48%
2750	Crown - Porcelain Fused To High Noble Metal	$1,222	$710	42%
2751	Crown - Porcelain Fused To Predominantly Base Metal	$1,126	$693	38%
2752	Crown - Porcelain Fused To Noble Metal	$1,152	$703	39%
2790	Crown - Full Cast High Noble Metal	$1,228	$726	41%
2791	Crown - Full Cast Predominantly Base Metal	$1,086	$688	37%
2930	Prefabricated Stainless Steel Crown - Primary Tooth	$292	$142	51%
2931	Prefabricated Stainless Steel Crown - Permanent Tooth	$356	$159	55%
2950	Core Buildup, Including Any Pins	$292	$139	52%
2951	Pin Retention - Per Tooth, In Addition To Restoration	$81	$35	57%
2952	Post And Core In Addition To Crown, Indirectly Fabricated	$457	$230	50%
2954	Prefabricated Post And Core In Addition To Crown	$365	$174	52%
3110	Pulp Cap - Direct (Excluding Final Restoration)	$91	$35	61%
3120	Pulp Cap - Indirect (Excluding Final Restoration)	$93	$33	64%
3220	Therapeutic Pulpotomy (Excluding Final Restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament	$216	$81	63%
3310	Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)	$792	$436	45%
3320	Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)	$914	$516	44%
3330	Endodontic Therapy, Molar (Excluding Final Restoration)	$1,108	$648	41%
4210	Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant	$691	$449	35%
4341	Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant	$282	$146	48%
4910	Periodontal Maintenance	$152	$91	40%
5110	Complete Denture - Maxillary	$1,868	$941	50%
5120	Complete Denture - Mandibular	$1,868	$941	50%
5130	Immediate Denture - Maxillary	$1,996	$991	50%
5140	Immediate Denture - Mandibular	$1,997	$991	50%
5211	Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,481	$925	38%
5212	Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,484	$925	38%
5213	Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$1,943	$1,057	46%
5214	Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$1,945	$1,057	46%
5410	Adjust Complete Denture - Maxillary	$98	$50	49%
5411	Adjust Complete Denture - Mandibular	$98	$50	49%
5510	Repair Broken Complete Denture Base	$231	$86	63%
5520	Replace Missing Or Broken Teeth - Complete Denture (Each Tooth)	$205	$81	60%
5630	Repair Or Replace Broken Clasp	$287	$99	66%
5650	Add Tooth To Existing Partial Denture	$243	$86	65%
5660	Add Clasp To Existing Partial Denture	$296	$108	64%
5730	Reline Complete Maxillary Denture (Chairside)	$408	$196	52%
5731	Reline Complete Mandibular Denture (Chairside)	$405	$196	52%
5740	Reline Maxillary Partial Denture (Chairside)	$400	$184	54%
5741	Reline Mandibular Partial Denture (Chairside)	$405	$184	55%
5750	Reline Complete Maxillary Denture (Laboratory)	$521	$254	51%
5751	Reline Complete Mandibular Denture (laboratory)	$521	$254	51%
6040	Surgical Placement: Eposteal Implant	$8,883	20%	$1,776.63
6050	Surgical Placement: Transosteal Implant	$6,142	20%	$1,228.48
6065	Implant Supported Porcelain/Ceramic Crown	$1,701	20%	$340.18
6066	Implant Supported Porcelain Fused To Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,704	20%	$340.78
6067	Implant Supported Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,727	20%	$345.30
6240	Pontic - Porcelain Fused To High Noble Metal	$1,218	$651	47%
6241	Pontic - Porcelain Fused To Predominantly Base Metal	$1,126	$601	47%
6242	Pontic - Porcelain Fused To Noble Metal	$1,156	$619	46%
6750	Crown - Porcelain Fused To High Noble Metal	$1,223	$693	43%
6751	Crown - Porcelain Fused To Predominantly Base Metal	$1,108	$653	41%
6752	Crown - Porcelain Fused To Noble Metal	$1,144	$678	41%
7140	Extraction, Erupted Tooth Or Exposed Root (elevation And/or Forceps Removal)	$190	$81	57%
7210	Surgical Removal Of Erupted Tooth Requiring Removal Of Bone And/or Sectioning Of Tooth, And Including Elevation Of Mucoperiosteal Flap If Indicated	$301	$169	44%
7220	Removal Of Impacted Tooth - Soft Tissue	$341	$166	51%
7230	Removal Of Impacted Tooth - Partially Bony	$432	$216	50%
7240	Removal Of Impacted Tooth - Completely Bony	$527	$283	46%
7250	Surgical Removal Of Residual Tooth Roots (Cutting Procedure)	$341	$156	54%
7310	Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant	$333	$139	58%
7320	Alveoloplasty Not In Conjunction With Extractions -four Or More Teeth Or Tooth Spaces, Per Quadrant	$487	$200	59%
7510	Incision And Drainage Of Abscess - Intraoral Soft Tissue	$256	$103	60%
8070	Comprehensive Orthodontic Treatment Of The Transitional Dentition	$5,605	20%	$1,121.03
8080	Comprehensive Orthodontic Treatment Of The Adolescent Dentition	$5,663	20%	$1,132.50
8090	Comprehensive Orthodontic Treatment Of The Adult Dentition	$5,690	20%	$1,138.00
9110	Palliative (Emergency) Treatment Of Dental Pain - Minor Procedure	$142	$53	63%
9215	Local Anesthesia In Conjunction With Operative Or Surgical Procedures	$72	$21	71%
9230	Inhalation Of Nitrous Oxide / Anxiolysis, Analgesia	$88	$35	60%
9951	Occlusal Adjustment - Limited	$205	$74	64%
9952	Occlusal Adjustment - Complete	$765	$300	61%

Series 507
ADA Code	Procedure	Typical Fee	You Pay	Savings
0120	Periodic Oral Evaluation - Established Patient	$59	$22	63%
0140	Limited Oral Evaluation - Problem Focused	$88	$33	63%
0150	Comprehensive Oral Evaluation - New Or Established Patient	$104	$37	64%
0210	Intraoral - Complete Series (Including Bitewings)	$151	$64	58%
0220	Intraoral - Periapical First Film	$33	$13	60%
0230	Intraoral - Periapical Each Additional Film	$29	$11	62%
0270	Bitewing - Single Film	$33	$12	64%
0272	Bitewing - Two Films	$53	$17	68%
0273	Bitewing - Three Films	$66	$21	68%
0274	Bitewing - Four Films	$77	$25	67%
0330	Panoramic Film	$127	$54	58%
1110	prophylaxis - adult	$106	$42	60%
1120	Prophylaxis - Adult	$78	$33	57%
1351	Sealant - Per Tooth	$64	$25	61%
1510	Space Maintainer - Fixed - Unilateral	$367	$159	57%
1515	Space Maintainer - Fixed - Bilateral	$495	$227	54%
1520	Space Maintainer - Removable - Unilateral	$450	$190	58%
1525	Space Maintainer - Removable - Bilateral	$565	$236	58%
2140	Amalgam - One Surface, Primary Or Permanent	$163	$53	68%
2150	Amalgam - Two Surfaces, Primary Or Permanent	$208	$70	66%
2160	Amalgam - Three Surfaces, Primary Or Permanent	$257	$85	67%
2161	Amalgam - Four Or More Surfaces, Primary Or Permanent	$300	$104	65%
2330	Resin-Based Composite - One Surface, Anterior	$189	$66	65%
2331	Resin-Based Composite - Two Surfaces, Anterior	$234	$83	64%
2332	Resin-Based Composite - Three Surfaces, Anterior	$293	$107	63%
2335	Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior)	$363	$133	63%
2391	Resin-Based Composite - One Surface, Posterior	$210	$74	65%
2392	Resin-Based Composite - Two Surfaces, Posterior	$272	$104	62%
2393	Resin-Based Composite - Three Surfaces, Posterior	$337	$133	61%
2394	Resin-Based Composite - Four Or More Surfaces, Posterior	$401	$157	61%
2710	Crown - Resin-Based Composite (Indirect)	$1,120	$227	80%
2720	Crown - Resin With High Noble Metal	$1,231	$482	61%
2750	Crown - Porcelain Fused To High Noble Metal	$1,296	$567	56%
2751	Crown - Porcelain Fused To Predominantly Base Metal	$1,194	$509	57%
2752	Crown - Porcelain Fused To Noble Metal	$1,221	$531	57%
2790	Crown - Full Cast High Noble Metal	$1,303	$549	58%
2791	Crown - Full Cast Predominantly Base Metal	$1,152	$479	58%
2930	Prefabricated Stainless Steel Crown - Primary Tooth	$310	$128	59%
2931	Prefabricated Stainless Steel Crown - Permanent Tooth	$377	$148	61%
2950	Core Buildup, Including Any Pins	$310	$129	58%
2951	Pin Retention - Per Tooth, In Addition To Restoration	$86	$28	68%
2952	Post And Core In Addition To Crown, Indirectly Fabricated	$484	$202	58%
2954	Prefabricated Post And Core In Addition To Crown	$387	$159	59%
3110	Pulp Cap - Direct (Excluding Final Restoration)	$96	$34	65%
3120	Pulp Cap - Indirect (Excluding Final Restoration)	$98	$34	65%
3220	Therapeutic Pulpotomy (Excluding Final Restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament	$230	$81	65%
3310	Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)	$840	$323	62%
3320	Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)	$969	$388	60%
3330	Endodontic Therapy, Molar (Excluding Final Restoration)	$1,175	$489	58%
4210	Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant	$733	$306	58%
4341	Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant	$299	$113	62%
4910	Periodontal Maintenance	$161	$66	59%
5110	Complete Denture - Maxillary	$1,981	$730	63%
5120	Complete Denture - Mandibular	$1,981	$730	63%
5130	Immediate Denture - Maxillary	$2,116	$769	64%
5140	Immediate Denture - Mandibular	$2,117	$774	63%
5211	Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,571	$548	65%
5212	Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,574	$548	65%
5213	Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$2,060	$785	62%
5214	Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$2,062	$789	62%
5410	Adjust Complete Denture - Maxillary	$104	$39	62%
5411	Adjust Complete Denture - Mandibular	$104	$39	62%
5510	Repair Broken Complete Denture Base	$245	$88	64%
5520	Replace Missing Or Broken Teeth - Complete Denture (Each Tooth)	$218	$80	63%
5630	Repair Or Replace Broken Clasp	$304	$113	63%
5650	Add Tooth To Existing Partial Denture	$258	$98	62%
5660	Add Clasp To Existing Partial Denture	$314	$119	62%
5730	Reline Complete Maxillary Denture (Chairside)	$432	$166	62%
5731	Reline Complete Mandibular Denture (Chairside)	$429	$166	61%
5740	Reline Maxillary Partial Denture (Chairside)	$424	$155	63%
5741	Reline Mandibular Partial Denture (Chairside)	$429	$155	64%
5750	Reline Complete Maxillary Denture (Laboratory)	$553	$223	60%
5751	Reline Complete Mandibular Denture (laboratory)	$553	$220	60%
6040	Surgical Placement: Eposteal Implant	$9,421	20%	$1,884.14
6050	Surgical Placement: Transosteal Implant	$6,514	20%	$1,302.80
6065	Implant Supported Porcelain/Ceramic Crown	$1,804	20%	$360.78
6066	Implant Supported Porcelain Fused To Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,807	20%	$361.44
6067	Implant Supported Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,831	20%	$366.22
6240	Pontic - Porcelain Fused To High Noble Metal	$1,292	$548	58%
6241	Pontic - Porcelain Fused To Predominantly Base Metal	$1,194	$511	57%
6242	Pontic - Porcelain Fused To Noble Metal	$1,225	$526	57%
6750	Crown - Porcelain Fused To High Noble Metal	$1,297	$566	56%
6751	Crown - Porcelain Fused To Predominantly Base Metal	$1,175	$511	56%
6752	Crown - Porcelain Fused To Noble Metal	$1,214	$529	56%
7140	Extraction, Erupted Tooth Or Exposed Root (elevation And/or Forceps Removal)	$201	$68	66%
7210	Surgical Removal Of Erupted Tooth Requiring Removal Of Bone And/or Sectioning Of Tooth, And Including Elevation Of Mucoperiosteal Flap If Indicated	$320	$169	47%
7220	Removal Of Impacted Tooth - Soft Tissue	$362	$151	58%
7230	Removal Of Impacted Tooth - Partially Bony	$459	$191	58%
7240	Removal Of Impacted Tooth - Completely Bony	$559	$235	58%
7250	Surgical Removal Of Residual Tooth Roots (Cutting Procedure)	$362	$139	62%
7310	Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant	$353	$137	61%
7320	Alveoloplasty Not In Conjunction With Extractions -four Or More Teeth Or Tooth Spaces, Per Quadrant	$516	$192	63%
7510	Incision And Drainage Of Abscess - Intraoral Soft Tissue	$272	$90	67%
8070	Comprehensive Orthodontic Treatment Of The Transitional Dentition	$5,944	20%	$1,188.88
8080	Comprehensive Orthodontic Treatment Of The Adolescent Dentition	$6,005	20%	$1,201.00
8090	Comprehensive Orthodontic Treatment Of The Adult Dentition	$6,034	20%	$1,206.88
9110	Palliative (Emergency) Treatment Of Dental Pain - Minor Procedure	$150	$49	67%
9215	Local Anesthesia In Conjunction With Operative Or Surgical Procedures	$77	$21	73%
9230	Inhalation Of Nitrous Oxide / Anxiolysis, Analgesia	$93	$29	69%
9951	Occlusal Adjustment - Limited	$218	$75	66%
9952	Occlusal Adjustment - Complete	$811	$306	62%

Series 508
ADA Code	Procedure	Typical Fee	You Pay	Savings
0120	Periodic Oral Evaluation - Established Patient	$54	$24	55%
0140	Limited Oral Evaluation - Problem Focused	$80	$36	55%
0150	Comprehensive Oral Evaluation - New Or Established Patient	$94	$40	57%
0210	Intraoral - Complete Series (Including Bitewings)	$137	$70	49%
0220	Intraoral - Periapical First Film	$30	$13	57%
0230	Intraoral - Periapical Each Additional Film	$26	$10	62%
0270	Bitewing - Single Film	$30	$13	57%
0272	Bitewing - Two Films	$48	$21	56%
0273	Bitewing - Three Films	$60	$25	58%
0274	Bitewing - Four Films	$69	$30	57%
0330	Panoramic Film	$116	$61	47%
1110	prophylaxis - adult	$96	$49	49%
1120	Prophylaxis - Adult	$70	$34	52%
1351	Sealant - Per Tooth	$59	$28	52%
1510	Space Maintainer - Fixed - Unilateral	$333	$178	47%
1515	Space Maintainer - Fixed - Bilateral	$450	$254	44%
1520	Space Maintainer - Removable - Unilateral	$408	$213	48%
1525	Space Maintainer - Removable - Bilateral	$513	$265	48%
2140	Amalgam - One Surface, Primary Or Permanent	$148	$66	55%
2150	Amalgam - Two Surfaces, Primary Or Permanent	$189	$87	54%
2160	Amalgam - Three Surfaces, Primary Or Permanent	$233	$103	56%
2161	Amalgam - Four Or More Surfaces, Primary Or Permanent	$272	$109	60%
2330	Resin-Based Composite - One Surface, Anterior	$172	$80	53%
2331	Resin-Based Composite - Two Surfaces, Anterior	$212	$102	52%
2332	Resin-Based Composite - Three Surfaces, Anterior	$266	$127	52%
2335	Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior)	$329	$156	53%
2391	Resin-Based Composite - One Surface, Posterior	$191	$91	52%
2392	Resin-Based Composite - Two Surfaces, Posterior	$247	$123	50%
2393	Resin-Based Composite - Three Surfaces, Posterior	$306	$158	48%
2394	Resin-Based Composite - Four Or More Surfaces, Posterior	$364	$190	48%
2710	Crown - Resin-Based Composite (Indirect)	$1,017	$261	74%
2720	Crown - Resin With High Noble Metal	$1,118	$554	50%
2750	Crown - Porcelain Fused To High Noble Metal	$1,177	$667	43%
2751	Crown - Porcelain Fused To Predominantly Base Metal	$1,084	$596	45%
2752	Crown - Porcelain Fused To Noble Metal	$1,109	$625	44%
2790	Crown - Full Cast High Noble Metal	$1,182	$644	46%
2791	Crown - Full Cast Predominantly Base Metal	$1,046	$564	46%
2930	Prefabricated Stainless Steel Crown - Primary Tooth	$281	$152	46%
2931	Prefabricated Stainless Steel Crown - Permanent Tooth	$342	$174	49%
2950	Core Buildup, Including Any Pins	$281	$153	46%
2951	Pin Retention - Per Tooth, In Addition To Restoration	$78	$33	58%
2952	Post And Core In Addition To Crown, Indirectly Fabricated	$440	$239	46%
2954	Prefabricated Post And Core In Addition To Crown	$351	$188	46%
3110	Pulp Cap - Direct (Excluding Final Restoration)	$87	$41	53%
3120	Pulp Cap - Indirect (Excluding Final Restoration)	$89	$36	60%
3220	Therapeutic Pulpotomy (Excluding Final Restoration) - Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament	$208	$98	53%
3310	Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)	$763	$375	51%
3320	Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)	$880	$457	48%
3330	Endodontic Therapy, Molar (Excluding Final Restoration)	$1,066	$575	46%
4210	Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant	$665	$364	45%
4341	Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant	$272	$139	49%
4910	Periodontal Maintenance	$146	$75	49%
5110	Complete Denture - Maxillary	$1,798	$842	53%
5120	Complete Denture - Mandibular	$1,798	$842	53%
5130	Immediate Denture - Maxillary	$1,921	$892	54%
5140	Immediate Denture - Mandibular	$1,922	$892	54%
5211	Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,426	$631	56%
5212	Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)	$1,429	$631	56%
5213	Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$1,870	$909	51%
5214	Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rests And Teeth)	$1,872	$909	51%
5410	Adjust Complete Denture - Maxillary	$94	$48	49%
5411	Adjust Complete Denture - Mandibular	$94	$48	49%
5510	Repair Broken Complete Denture Base	$222	$103	54%
5520	Replace Missing Or Broken Teeth - Complete Denture (Each Tooth)	$197	$92	53%
5630	Repair Or Replace Broken Clasp	$276	$139	50%
5650	Add Tooth To Existing Partial Denture	$234	$117	50%
5660	Add Clasp To Existing Partial Denture	$285	$154	46%
5730	Reline Complete Maxillary Denture (Chairside)	$392	$211	46%
5731	Reline Complete Mandibular Denture (Chairside)	$390	$197	49%
5740	Reline Maxillary Partial Denture (Chairside)	$385	$189	51%
5741	Reline Mandibular Partial Denture (Chairside)	$390	$189	51%
5750	Reline Complete Maxillary Denture (Laboratory)	$502	$268	47%
5751	Reline Complete Mandibular Denture (laboratory)	$502	$268	47%
6040	Surgical Placement: Eposteal Implant	$8,552	20%	$1,710.42
6050	Surgical Placement: Transosteal Implant	$5,914	20%	$1,182.70
6065	Implant Supported Porcelain/Ceramic Crown	$1,638	20%	$327.50
6066	Implant Supported Porcelain Fused To Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,641	20%	$328.10
6067	Implant Supported Metal Crown (Titanium, Titanium Alloy, High Noble Metal)	$1,662	20%	$332.46
6240	Pontic - Porcelain Fused To High Noble Metal	$1,173	$643	45%
6241	Pontic - Porcelain Fused To Predominantly Base Metal	$1,084	$599	45%
6242	Pontic - Porcelain Fused To Noble Metal	$1,113	$619	44%
6750	Crown - Porcelain Fused To High Noble Metal	$1,178	$666	43%
6751	Crown - Porcelain Fused To Predominantly Base Metal	$1,066	$600	44%
6752	Crown - Porcelain Fused To Noble Metal	$1,102	$621	44%
7140	Extraction, Erupted Tooth Or Exposed Root (elevation And/or Forceps Removal)	$183	$80	56%
7210	Surgical Removal Of Erupted Tooth Requiring Removal Of Bone And/or Sectioning Of Tooth, And Including Elevation Of Mucoperiosteal Flap If Indicated	$290	$143	51%
7220	Removal Of Impacted Tooth - Soft Tissue	$328	$174	47%
7230	Removal Of Impacted Tooth - Partially Bony	$416	$224	46%
7240	Removal Of Impacted Tooth - Completely Bony	$508	$277	45%
7250	Surgical Removal Of Residual Tooth Roots (Cutting Procedure)	$328	$165	50%
7310	Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant	$321	$158	51%
7320	Alveoloplasty Not In Conjunction With Extractions -four Or More Teeth Or Tooth Spaces, Per Quadrant	$468	$210	55%
7510	Incision And Drainage Of Abscess - Intraoral Soft Tissue	$247	$106	57%
8070	Comprehensive Orthodontic Treatment Of The Transitional Dentition	$5,396	20%	$1,079.26
8080	Comprehensive Orthodontic Treatment Of The Adolescent Dentition	$5,451	20%	$1,090.28
8090	Comprehensive Orthodontic Treatment Of The Adult Dentition	$5,478	20%	$1,095.58
9110	Palliative (Emergency) Treatment Of Dental Pain - Minor Procedure	$137	$59	57%
9215	Local Anesthesia In Conjunction With Operative Or Surgical Procedures	$69	$28	60%
9230	Inhalation Of Nitrous Oxide / Anxiolysis, Analgesia	$84	$37	56%
9951	Occlusal Adjustment - Limited	$197	$88	55%
9952	Occlusal Adjustment - Complete	$736	$360	51%

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