| ADA Code |
Procedure |
*Usual Fee |
*Member (Reduced) Fee |
Savings % |
| 1110 |
Adult Cleaning |
$ |
65 |
$ |
43 |
34% |
| 1120 |
Child Cleaning |
$ |
50 |
$ |
35 |
30% |
| 2140 |
Silver Filling |
$ |
82 |
$ |
47 |
43% |
| 2330 |
White Filling |
$ |
100 |
$ |
58 |
42% |
| 2750 |
Crown - Porcelaine |
$ |
733 |
$ |
528 |
28% |
| 5110 |
Upper Denture (Complete) |
$ |
1000 |
$ |
571 |
43% |
| 5120 |
Lower Denture (Complete) |
$ |
1000 |
$ |
557 |
44% |
| 7220 |
Extraction - Impacted
Wisdom Tooth (Soft Tissue) |
$ |
191 |
$ |
144 |
25% |
| 7230 |
Extraction - Impacted
Wisdom Tooth (Partial Bony) |
$ |
240 |
$ |
187 |
22% |
| 7240 |
Extraction - Impacted Wisdom
Tooth (Complete Bony) |
$ |
288 |
$ |
235 |
18% |
| 8080 |
Child Orthodontic Treatment
(when performed by a general
dentist) |
$ |
4000 |
$ |
2354 |
41% |
| 8090 |
Adult Orthodontic Treatment
(when performed by a general
dentist) |
$ |
4200 |
$ |
2750 |
35% |
