** Any treatment provided by a participating specialist, if available, in Oral Surgery, Orthodontics, Periodontics, Pedodontics, Prosthodontics or Endodontics, will be charged at a 25% reduction of participating specialist’s fees for that particular case.
| Code | Diagnostic and Preventive | Amount |
| D0120 | Periodic Oral Examination | 35 |
| D0140 | Limited Oral Evaluation - Problem Focused | 41 |
| D0150 | Comprehensive Oral Evaluation | 48 |
| D0210 | x-ray Intraoral - Complete - Including Bitewings | 62 |
| D0220 | x-ray Intraoral -Periapical - First Film | 14 |
| D0230 | x-ray Intraoral - Perciapical - Each Add. Film | 10 |
| D0270 | x-ray Bitewings - Single Film | 13 |
| D0272 | x-ray Bitewings - Two Films | 26 |
| D0273 | x-ray Bitewings - Three Films | 30 |
| D0274 | x-ray Bitewings - Four Films | 36 |
| D0330 | x-ray Panoramic Film | 69 |
| Code | Preventive | Amount |
| D1110 | Dental Prophylaxis Adult | 68 |
| D1120 | Dental Prophylaxis Children | 43 |
| D1208 | Topical Fluoride Application | 26 |
| D1351 | Topical Sealants - Per Tooth | 28 |
| D1510 | Space Maintainer - Fixed - Unilateral | 195 |
| D1515 | Space Maintainer - Fixed - Bilateral | 235 |
| Code | Restorative (Fillings) | Amount |
| D2140 | Amalgam - One surface, Permanent | 71 |
| D2150 | Amalgam - Two surfaces, Permanent | 89 |
| D2160 | Amalgam - Three Surfaces Permanent | 128 |
| D2161 | Amalgam - 4 Or More Surfaces Permanent | 142 |
| D2330 | Resin - One Surface Anterior | 93 |
| D2331 | Resin - Two Surface Anterior | 129 |
| D2332 | Resin - Three Surface Anterior | 148 |
| D2335 | Resin - 4+Surf Or Inv. Incisal Angle | 159 |
| D2391 | Resin - One Surface Posterior, Permanent | 95 |
| D2392 | Resin - Two Surface Posterior, Permanent | 129 |
| D2393 | Resin - Three Surface Posterior, Permanent | 153 |
| D2394 | Resin - Four or more surfaces posterior | 159 |
| Code | Crowns (lab fees included) | Amount |
| D2710 | Crown - Resins Based Composite, Indirect | 245 |
| D2720 | Crown - Resin With High Noble Metal | 589 |
| D2740 | Crown - Porcelain/Ceramic substrate | 858 |
| D2750 | Crown - Porcelain/High Noble Metal | 811 |
| D2751 | Crown - Porcelain/Predominate Base Metal | 757 |
| D2752 | Crown - Porcelain/Noble Matal | 797 |
| D2790 | Crown - Full Cast High Noble Metal | 825 |
| D2791 | Crown - Full Cast Predom. Base Metal | 695 |
| D2920 | Recement Crown | 49 |
| D2931 | Prefab Stainless Steel Crown - Perm Tooth | 166 |
| D2932 | Prefab Resin Crown | 123 |
| D2950 | Core Buildup Including Any Pins | 159 |
| D2951 | Pin Retention - Per Tooth (W/O Restoration) | 28 |
| D2952 | Cast Post/Core (Addition To Crown) | 210 |
| D2954 | Prefabricated post and core, in addition to crown | 195 |
| D2970 | Temporary Crown (fractured tooth) | 78 |
| Code | Endodontics (General Dentist) exc. Final restor. | Amount |
| D3110 | Pulp Cap - Direct | 35 |
| D3120 | Pulp Cap - Indirect | 31 |
| D3220 | Therapeutic Pulpotomy | 96 |
| D3310 | Root Canal Anterior | 456 |
| D3320 | Root Canal Bicuspid | 567 |
| D3330 | Root Canal Molar | 775 |
| Code | Periodontics (General Dentist) | Amount |
| D4210 | Gingivectomy/Gingivoplasty - 4 + contiguos teeth | 232 |
| D4341 | Perio. Scaling & Root Planing per quad | 147 |
| D4355 | Full Mouth Debridement | 96 |
| D4910 | Periodontal Maintenance | 87 |
| Code | Prosthodontics, Removable (lab fees included) | Amount |
| D5110 | Complete Upper Denture | 899 |
| D5120 | Complete Lower Denture | 899 |
| D5130 | Immediate Upper | 985 |
| D5140 | Immediate Lower | 985 |
| D5211 | Upper Partial - Resin Base | 589 |
| D5212 | Lower Partial - Resin Base | 589 |
| Code | Prosthodontics, Fixed (lab fees included) | Amount |
| D5213 | Partial Upper Cast Metal Base | 1095 |
| D5214 | Partial Lower Cast Metal Base | 1095 |
| D5410 | Adjust Denture - (Upper) | 51 |
| D5411 | Adjust Denture - (Lower) | 51 |
| D5510 | Repair Broken Complete Denture Base | 81 |
| D5520 | Replace Missing or Broken Teeth/Each Tooth | 76 |
| D5610 | Repair Resin Denture Base | 79 |
| D5630 | Repair Or Replace Broken Clasp | 98 |
| D5640 | Replace Broken Teeth - Per Tooth | 83 |
| D5650 | Add Tooth To Existing Partial Denture | 99 |
| D5660 | Add Clasp To Existing Partial Denture | 143 |
| D5730 | Reline Upper Denture - Chairside | 127 |
| D5731 | Reline Lower Denture - Chairside | 127 |
| D5740 | Reline Complete Maxillary Denture - Chairside | 125 |
| D5741 | Reline Complete Mandibular Partial Dent Chairside | 125 |
| D6000 | Implant Services D6000- D6194 | 25% Discount |
| Code | Prosthodontics, Fixed (lab fees included) | Amount |
| D6240 | Pontic - Porcelain/High Noble Metal | 752 |
| D6241 | Pontic - Porcelain/Predominate Base Metal | 639 |
| D6242 | Pontic - Porcelain/Noble Metal | 739 |
| D6750 | Crown - Porcelain/High Noble Metal | 836 |
| D6751 | Crown - Porcelain/High Noble Metal | 688 |
| D6752 | Crown - Porcelain/Noble Metal | 814 |
| D6930 | Recement Bridge | 58 |
| Code | Oral Surgery (General Dentist) | Amount |
| D7140 | Single Tooth Extraction | 94 |
| D7210 | Surgical Removal Of Erupted Tooth | 177 |
| D7220 | Removal Of Impacted Tooth/Soft Tissue | 210 |
| D7230 | Removal Of Impacted Tooth/Partially Bony | 270 |
| D7240 | Removal Of Impacted Tooth/Completely Bony | 340 |
| D7250 | Surgical Removal Of Residual Tooth Roots | 142 |
| D7510 | Incision and Drainage of Abcess/Intraoral | 80 |
| Code | Orthodontics | Amount |
| D8010 | Orthodontic Treatment D8010-D8220 | 25% Discount |
| Code | Adjunctive Services | Amount |
| D9110 | Palliative Treatment (emergency) pain-minor | 53 |
| D9215 | Local Anesthesia | Included with procedure |
| D9230 | Analgesia | 37 |
| D9610 | Therapeutic drug Injection | 37 |
*Please see a professional dentist for full treatment plan.
*** Same day enrollment is available.
