ADA Code	DIAGNOSTIC & PREVENTATIVE PROCEDURES	NDPA FEE	USUAL FEE
D0220	Single x-ray (any type)	$14.00	$26.40
D0210	X-rays (up to full mouth, or at least 3 films taken)	$50.00	$132.00
D0330	Panorex	$54.00	$121.00
D0150	Oral Examination and Diagnosis	No Charge	$66.00
D1120	Child Cleaning & Polishing - Excluding Fluoride	$41.00	$88.00
D1110	Adult Cleaning, Polishing and Scaling	$61.00	$126.50
D1203	Topical Fluoride Treatment for Children	$24.00	$49.50
D9110	Palliative Treatment (Emergency Visit)	$55.00	$88.00
D1351	Sealants (Pit & Fissure, Per Tooth)	$30.00	$55.00
D0140	Consultation (Including 2nd Opinion and/or Extensive Examination)	$55.00	$82.50

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ADA Code	RESTORATIVE PROCEDURES (FILLINGS)	NDPA FEE	USUAL FEE
	Silver Amalgams: Primary
D2140	One Surface	$61.00	$88.00
D2150	Two Surfaces	$77.00	$117.00
D2160	Three Surfaces	$99.00	$154.00
D2161	Four Surfaces or more	$116.00	$187.00
	Silver Amalgams: Permanent
D2140	One Surface	$72.00	$112.20
D2150	Two Surfaces	$94.00	$145.20
D2160	Three Surfaces	$110.00	$176.00
D2161	Four Surfaces or more	$138.00	$214.50
	Composite Resins: Anterior
D2330	One Surface	$79.00	$126.00
D2331	Two Surfaces	$105.00	$163.00
D2332	Three Surfaces	$131.00	$212.00
D2335	Four Surfaces or more	$165.00	$251.00
	Composite Resins: Posterior
D2391	One Surface	$85.00	$143.00
D2392	Two Surfaces	$110.00	$214.00
D2393	Three Surfaces or more	$149.00	$275.00
D2951	Pin retention, per pin	$39.00	$72.60
D2940	Sedative Filling	$61.00	$96.80

ADA Code	COSMETIC PROCEDURES	NDPA FEE	USUAL FEE
	Bonding/Veneers (per tooth)
D2960	Full face buildup (chairside)	$275.00	$456.50

ADA Code	ENDODONTICS (performed by General Dentists)	NDPA FEE	USUAL FEE
D3110	Pulp capping (excl. final restoration)	$50.00	$72.60
D3220	Pulpotomy (excl. final restoration)	$110.00	$159.50
	Root Canal Therapy
D3310	Anterior	$396.00	$632.50
D3320	Bicuspid	$479.00	$764.50
D3330	Molar	$600.00	$935.00

ADA Code	PERIODONTICS (performed by General Dentists)	NDPA FEE	USUAL FEE
D4341	Periodontal scaling and root planing (per quadrant)	$110.00	$209.00
D4260	Osseous or mucogingival surgery (per quadrant)	$594.00	$962.50
D4910	Perio maintenance	$83.00	$115.50

ADA Code	ORAL SURGERY (performed by General Dentists)	NDPA FEE	USUAL FEE
	Extraction (single tooth)	$83.00	$132.00
	(each additional tooth)	$73.00	$121.00
D7210	Surgical Extraction	$132.00	$231.00
D7510	Incision and drainage	$121.00	$187.00
D7130	Root Removal	$138.00	$181.50
D7220	Soft Tissue Impaction	$182.00	$308.00
D7230	Partial Bony Impaction	$237.00	$407.00
D7240	Full Bony Impaction	$292.00	$539.00

ADA Code	FIXED PROSTHODONTICS	NDPA FEE	USUAL FEE
D2751	Porcelain on non-precious metal crown	$605.00	$951.50
D2791	All metal crown (not gold)	$583.00	$951.50
D6250	Pontics	$715.00	$1,083.50
D2750	Porcelain on semi to high noble metal crown	$715.00	$1,083.50
D2954	Post and core (chairside)	$248.00	$319.00
D2950	Core buildup - including pins	$160.00	$286.00
D2952	Cast post (non-gold) laboratory	$253.00	$440.00
D2920	Re-cement crown	$61.00	$99.00
	Re-cement bridge - per abutment	$77.00	$110.00
	Laboratory processed temporary (per tooth)	$138.00	$231.00
D2999	Temporary Crown (as part of crown procedure)	NO CHARGE

ADA Code	REMOVABLE PROSTHODONTICS	NDPA FEE	USUAL FEE
D5110	Complete Maxillary denture (includ. adjustments)	$842.00	$1,512.50
D5120	Complete Mandibular denture (includ. adjustments)	$842.00	$1,512.50
D5211-D5212	Acrylic (upper or lower metal clasps)	$699.00	$1,155.00
D5213-D5214	Cast alloy with palatal or lingual bar	$930.00	$1,512.50
D5130	Immediate Dentures Maxillary	$985.00	$1,505.00
D5140	Immediate Dentures Mandibular	$985.00	$1,505.00
D5410-D5411	Denture adjustments (for dentures made in another office)	$55.00	$99.00
D9940	Nite guard or flipper	$358.00	$544.50
	Reline:
D5730-D5731	In office	$215.00	$341.00
D5750-D5751	Laboratory processed	$286.00	$456.50
D5510	Broken Denture (no teeth involved)	$121.00	$198.00
D5520	Replace tooth on denture	$110.00	$214.50
	Space Maintainers
D1520	Unilateral	$242.00	$341.00
D1525	Bilateral	$308.00	$451.00