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ADA Code | Member Pays |
|---|
Diagnostic | Description | Average Dentist Charge | Century Dental Plan Cost | Member Savings |
|---|---|---|---|---|
D0120 | Periodic Oral Exam | $59.00 | $0 | $59.00 |
D0140 | Limited Oral Evaluation – Problem Focused | $92.00 | $0 | $92.00 |
D0150 | Comprehensive Oral Evaluation-one per year | $82.00 | $0 | $82.00 |
x-rays |
|
|
|
|
|---|---|---|---|---|
D0210 | Intraoral Complete Series – Once every three years | $95.00 | $0 | $95.00 |
D0140 | Periapical First Film | $22.00 | $0 | $22.00 |
D0230 | Periapical Each Additional Film | $18.00 | $0 | $18.00 |
D0270 | Bitewing – Single Film, Once a Year | $47.00 | $0 | $47.00 |
D0272 | Bitewing – Two films, Once a Year | $49.00 | $0 | $49.00 |
D0330 | Panoramic X-* Rays, Once every Three Years | $90.00 | $0 | $90.00 |
Preventive |
|
|
|
|
|---|---|---|---|---|
D1110 | Routine Adult Prophylaxis, Once every Six Months | $89.00 | $0 | $89.00 |
D1120 | Routine Child Prophylaxis, Once every Six Months | $59.00 | $0 | $59.00 |
D1208 | Topical Application Of Fluoride | $27.00 | $0 | $27.00 |
Restorative Fillinggs |
|
|
|
|
|---|---|---|---|---|
D2330 | Resin-One Surface, Anterior | $145.00 | $50.00 | $95.00 |
D2331 | Resin-Two Surfaces, Anterior | $168.00 | $55.00 | $113.00 |
D2332 | Resin-Three Surfaces, Anterior | $195.00 | $65.00 | $130.00 |
D2391 | Resin-One Surface, Posterior | $175.00 | $80.00 | $95.00 |
D2392 | Resin-Two Surfaces, Posterior | $195.00 | $95.00 | $100.00 |
D2393 | Resin-Three Surfaces Posterior | $225.00 | $115.00 | $110.00 |
Fixed crown and bridge |
|
|
|
|
|---|---|---|---|---|
D2740 | Crown – Porcelain/Ceramic | $925.00 | $450.00 | $475.00 |
D2750 | Crown – Porcelain Fused Toi High Noble Metal | $1,050.00 | $465.00 | $585.00 |
Endodontics (root canals) |
|
|
|
|
|---|---|---|---|---|
D3320 | Root Canal - Bicuspid | $845.00 | $275.00 | $570.00 |
D3330 | Root Canal - Molar | $975.00 | $450.00 | $525,00 |
periodontics (gun treatment) |
|
|
|
|
|---|---|---|---|---|
D4341 | Periodontal Scaling and Root Planning Per Quadrant | $219.00 | $60.00 | $159.00 |
D4355 | Full Mouth Debridement | $125.00 | $65.00 | $60.00 |
D4910 | Periodontal Maintenance | $95.00 | $65.00 | $30.00 |
Oral Surgeries (Extractions) |
|
|
|
|
|---|---|---|---|---|
D7140 | Extraction of Erupted or Exposed Tooth | $145.00 | $30.00 | $115.00 |
D7210 | Surgical Extraction, Erupted Tooth | $224.00 | $55.00 | $169.00 |
D7220 | Removal of Impacted Tooth – Soft Tissue | $325.00 | $70.00 | $255.00 |
D7230 | Removal of Impacted Tooth – Partial Bony | $375.00 | $90.00 | $285.00 |
D7240 | Removal of Impacted Tooth – Full Bony | $425.00 | $110.00 | $315.00 |
Orthodontics |
|
|
|
|
|---|---|---|---|---|
D8080 | Comprehensive Orthodontic Treatment - Child | $4,950.00 | $3,200.00 | $1,750.00 |
D8090 | Comprehensive Orthodontic Treatment - Adult | $5,250.00 | $3,400.00 | $1,850.00 |
