ADA

Code

Procedure

Usual Fee

Member

Fee

Member

Savings

0120

Routine 6 Month Check Up

$ 43

$ 15

$ 28

0210

Full Mouth X-rays

$103

$ 25

$ 78

0274

Bitewings – four

$ 55

$ 20

$ 35

0330

Panoramic Film

$ 90

$ 30

$ 60

1110

Adult Cleaning

$ 77

$ 35

$ 42

1120

Child Cleaning

$ 55

$ 30

$ 25

2140

Amalgam 1 surface (silver filling)

$139

$ 56

$ 83

2330

Composite 1 surface (white filling)

$123

$ 63

$ 60

2750

Crown porcelain high noble

$889

$595

$294

2950

Core buildup, including pins

$234

$120

$114

2952

Cast post & core in addition to crown

$403

$155

$248

3310

Root canal – anterior

$582

$385

$197

3320

Root canal – bicuspid

$654

$450

$204

3330

Root canal – molar

$808

$595

$213

4341

Periodontal scaling/root planing

$204

$110

$ 94

7140

Extraction, erupted tooth or exposed root

$166

$ 95

$ 71