EssentialSmile (Child/Family) EPO 211
ADA
Code 		ADA
Description 		Nomenclature Est.
Charge* 		Particip
Out of Pocket
D0120 Periodic Oral Evaluation Routine exam for established patients $100.00 $0.00
D0140 Limited oral evaluation - problem focused Emergency oral examination, problem focused $125.00 $0.00
D0150 Comprehensive oral evaluation - new or established patient A thorough evaluation and recording of the soft and hard tissues of the mouth. $125.00 $0.00
D0210 Intraoral-Complete Series Including Bitewings Full mouth set of X-rays/image $175.00 $0.00
D0220 Intraoral - periapical first radiographic images A X-ray film that shows the whole toot including the root and area around it. $35.00 $0.00
D0270 Bitewing - single radiographic images X-rays of the crowns of teeth to determine the existence of decay, one film $39.00 $0.00
D0272 Bitewings - two radiographic images X-rays of the crowns of teeth to determine the existence of decay, two films $65.00 $0.00
D0274 Bitewings - four radiographic images X-rays of the crowns of teeth to determine the existence of decay, four films $96.00 $0.00
D0330 Panoramic Film X-rays/image taken around the head and showing full mouth on same film $150.00 $0.00
D1110 Prophylaxis Adults Routine adult cleaning $120.00 $0.00
D1120 Prophylaxis - child Routine child cleaning $100.00 $0.00
D1206 Topical fluoride varnish Protective varnish that prevents cavities $55.00 $0.00
D1208 Topical application of fluoride Protective varnish that prevents cavities $60.00 $0.00
D1351 Sealant - Per Tooth Protective substance that fills in grooves or seals the top of the tooth to prevent cavities $65.00 $0.00
D2140 Amalgam - one surface, primary or permanent A one surface silver filling used to fill cavities $200.00 $56.00
D2150 Amalgam - two surfaces, primary or permanent A two surface silver filling used to fill cavities $250.00 $65.00
D2160 Amalgam - three surfaces, primary or permanent A three surface silver filling used to fill cavities $335.00 $85.00
D2330 resin-based composite - one surface, anterior White filling in the front teeth of your mouth, one surface of the tooth $200.00 $65.00
D2331 Resin-based composite - two surfaces, anterior White filling in the front teeth of your mouth, two surfaces of the tooth $250.00 $84.00
D2332 Resin-based composite - three surfaces, anterior White filling in the front teeth of your mouth, three surfaces of the tooth $300.00 $102.00
D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) White filling in the front teeth of your mouth, four surfaces of the tooth $380.00 $124.00
D2750 Crown – Porcelain fused to high noble metal Porcelain or ceramic crown over gold metal $1,495.00 $350.00
D2950 Core buildup, including any pins "Crown (or ""cap"") -- Core build up to help crown retention" $335.00 $90.00
D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament Removal of the core of the tooth, and applying medicament before a restoration $400.00 $65.00
D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) Root canal on a bicuspid tooth $1,300.00 $350.00
D3330 Root Canal Therapy - Molar Root canal on a molar $1,500.00 $350.00
D4341 Perio Scaling/Root Planing - four or more contiguous teeth or bounded spaces per quadrant Treatment of gum disease; scraping deposits and smoothing roots below the gum line $303.00 $150.00
D4355 Full Mouth Debridement To Enable Comprehensive Evaluation and Diagnosis Removal of tartar build-up above and below to gum line to prepare for examination for gum disease $200.00 $90.00
D4910 Periodontal maintenance Ongoing prophylaxis treatment that focuses on scaling under the gums to maintain healthy gum pockets.(maintenance) $167.00 $100.00
D5110 Complete Upper Complete upper denture worn on the upper jaw $1,650.00 $350.00
D5120 Complete denture - mandibular Complete (Full) Lower denture to replace all teeth $1,600.00 $350.00
D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) Upper partial denture (plastic) to replace missing teeth $1,300.00 $350.00
D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) Lower partial denture (plastic) to replace missing teeth $1,460.00 $350.00
D5410 Adjust complete denture - maxillary Upper denture adjustments $150.00 $30.00
D5411 Adjust complete denture - mandibular Lower denture adjustments $150.00 $30.00
D6211 Pontic - cast predominantly base metal Pontic (replaces a missing tooth) -- Cast predominantly base metal (silver colored with all non-precious metal $1,440.00 $350.00
D6751 Crown - porcelain fused to predominantly base metal Crown (Silver colored with non-precious metal) $1,350.00 $350.00
D6791 Crown - full cast predominantly base metal Crown - full cast (Silver colored with non-precious metal) $1,524.00 $350.00
D7140 Extraction erupted tooth or exposed root (elevation and/or forceps removal) A tooth that is beyond repair by a root canal is removed nonsurgically $250.00 $83.00
D7210 Surgical Removal Of Erupted Tooth A tooth that is beyond repair by a root canal is removed surgically $395.00 $156.00
D8080 Comprehensive orthodontic treatment of the adolescent dentition Orthodontic treatment in adolescents (teenage) $4,500.00 $350.00
D9110 Palliative (emergency) treatment of dental pain - minor procedure Emergency office visit for pain $175.00 $40.00
D9239 Intravenous conscious sedation/analgesia - first 15 minutes IV sedation-15 minutes $900.00 $55.00
D9243 Intravenous conscious sedation/analgesia - each additional 15 minutes IV sedation-15 minutes $221.00 $55.00
D9944 Occlusal guard, by report Night guard, by report $656.00 $350.00
D9945 Occlusal guard, by report Night guard, by report $656.00 $350.00
D9946 Occlusal guard, by report Night guard, by report $656.00 $350.00

*Estimated charges are based on Usual, Customary, and Reasonable charges in the area. Actual expense may vary.

EssentialSmile (Adult/Family) EPO 211
ADA
Code 		ADA
Description 		Nomenclature Est.
Charge* 		Particip
Out of Pocket
D0120 Periodic Oral Evaluation Routine exam for established patients $100.00 $10.00
D0140 Limited oral evaluation - problem focused Emergency oral examination, problem focused $125.00 $10.00
D0150 Comprehensive oral evaluation - new or established patient A thorough evaluation and recording of the soft and hard tissues of the mouth. $125.00 $10.00
D0210 Intraoral-Complete Series Including Bitewings Full mouth set of X-rays/image $175.00 $20.00
D0220 Intraoral - periapical first radiographic images A X-ray film that shows the whole toot including the root and area around it. $35.00 $10.00
D0270 Bitewing - single radiographic images X-rays of the crowns of teeth to determine the existence of decay, one film $39.00 $7.00
D0272 Bitewings - two radiographic images X-rays of the crowns of teeth to determine the existence of decay, two films $65.00 $10.00
D0274 Bitewings - four radiographic images X-rays of the crowns of teeth to determine the existence of decay, four films $96.00 $10.00
D0330 Panoramic Film X-rays/image taken around the head and showing full mouth on same film $150.00 $20.00
D1110 Prophylaxis Adults Routine adult cleaning $120.00 $0.00
D1120 Prophylaxis - child Routine child cleaning $100.00 $0.00
D1206 Topical fluoride varnish Protective varnish that prevents cavities $55.00 $11.00
D1208 Topical application of fluoride Protective varnish that prevents cavities $60.00 $10.00
D1351 Sealant - Per Tooth Protective substance that fills in grooves or seals the top of the tooth to prevent cavities $65.00 $24.00
D2140 Amalgam - one surface, primary or permanent A one surface silver filling used to fill cavities $200.00 $56.00
D2150 Amalgam - two surfaces, primary or permanent A two surface silver filling used to fill cavities $250.00 $65.00
D2160 Amalgam - three surfaces, primary or permanent A three surface silver filling used to fill cavities $335.00 $85.00
D2330 resin-based composite - one surface, anterior White filling in the front teeth of your mouth, one surface of the tooth $200.00 $65.00
D2331 Resin-based composite - two surfaces, anterior White filling in the front teeth of your mouth, two surfaces of the tooth $250.00 $84.00
D2332 Resin-based composite - three surfaces, anterior White filling in the front teeth of your mouth, three surfaces of the tooth $300.00 $102.00
D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) White filling in the front teeth of your mouth, four surfaces of the tooth $380.00 $124.00
D2750 Crown – Porcelain fused to high noble metal Porcelain or ceramic crown over gold metal $1,495.00 $555.00
D2950 Core buildup, including any pins "Crown (or ""cap"") -- Core build up to help crown retention" $335.00 $40.00
D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament Removal of the core of the tooth, and applying medicament before a restoration $400.00 $65.00
D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) Root canal on a bicuspid tooth $1,300.00 $478.00
D3330 Root Canal Therapy - Molar Root canal on a molar $1,500.00 $643.00
D4341 Perio Scaling/Root Planing - four or more contiguous teeth or bounded spaces per quadrant Treatment of gum disease; scraping deposits and smoothing roots below the gum line $303.00 $150.00
D4355 Full Mouth Debridement To Enable Comprehensive Evaluation and Diagnosis Removal of tartar build-up above and below to gum line to prepare for examination for gum disease $200.00 $90.00
D4910 Periodontal maintenance Ongoing prophylaxis treatment that focuses on scaling under the gums to maintain healthy gum pockets.(maintenance) $167.00 $100.00
D5110 Complete Upper Complete upper denture worn on the upper jaw $1,650.00 $680.00
D5120 Complete denture - mandibular Complete (Full) Lower denture to replace all teeth $1,600.00 $680.00
D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) Upper partial denture (plastic) to replace missing teeth $1,300.00 $575.00
D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) Lower partial denture (plastic) to replace missing teeth $1,460.00 $575.00
D5410 Adjust complete denture - maxillary Upper denture adjustments $150.00 $30.00
D5411 Adjust complete denture - mandibular Lower denture adjustments $150.00 $30.00
D6211 Pontic - cast predominantly base metal Pontic (replaces a missing tooth) -- Cast predominantly base metal (silver colored with all non-precious metal $1,440.00 $450.00
D6751 Crown - porcelain fused to predominantly base metal Crown (Silver colored with non-precious metal) $1,350.00 $500.00
D6791 Crown - full cast predominantly base metal Crown - full cast (Silver colored with non-precious metal) $1,524.00 $500.00
D7140 Extraction erupted tooth or exposed root (elevation and/or forceps removal) A tooth that is beyond repair by a root canal is removed nonsurgically $250.00 $83.00
D7210 Surgical Removal Of Erupted Tooth A tooth that is beyond repair by a root canal is removed surgically $395.00 $156.00
D8040 Orthodontic Transition. Adolescent Dentition Orthodontic treatment in adolescents $4,500.00 $1,350.00
D8090 Orthodontic Transition Adult Dentition Orthodontic treatment in adults $4,500.00 $3,700.00
D9110 Palliative (emergency) treatment of dental pain - minor procedure Emergency office visit for pain $175.00 $40.00
D9239 Intravenous conscious sedation/analgesia - first 15 minutes IV sedation-15 minutes $500.00 $55.00
D9243 Intravenous conscious sedation/analgesia - each additional 15 minutes IV sedation-15 minutes $208.00 $55.00
D9944 Occlusal guard, by report Night guard, by report $656.00 $350.00
D9945 Occlusal guard, by report Night guard, by report $656.00 $350.00
D9946 Occlusal guard, by report Night guard, by report $656.00 $350.00

*Estimated charges are based on Usual, Customary, and Reasonable charges in the area. Actual expense may vary.

EssentialSmile PED PPO 221
ADA
Code 		ADA
Description 		Nomenclature Est.
Charge* 		Particip
Out of Pocket 		Est. Provider
Reimb 		Non-Particip
Out of Pocket 		Est. Provider
Reimb
D0120 Periodic Oral Evaluation Routine exam for established patients $100.00 $0.00 $100.00 $50.00 $50.00
D0140 Limited oral evaluation - problem focused Emergency oral examination, problem focused $125.00 $0.00 $125.00 $62.50 $62.50
D0150 Comprehensive oral evaluation - new or established patient A thorough evaluation and recording of the soft and hard tissues of the mouth. $125.00 $0.00 $125.00 $62.50 $62.50
D0210 Intraoral-Complete Series Including Bitewings Full mouth set of X-rays/image $175.00 $0.00 $175.00 $87.50 $87.50
D0220 Intraoral - periapical first radiographic images A X-ray film that shows the whole toot including the root and area around it. $35.00 $0.00 $35.00 $17.50 $17.50
D0270 Bitewing - single radiographic images X-rays of the crowns of teeth to determine the existence of decay, one film $39.00 $0.00 $39.00 $19.50 $19.50
D0272 Bitewings - two radiographic images X-rays of the crowns of teeth to determine the existence of decay, two films $65.00 $0.00 $65.00 $32.50 $32.50
D0274 Bitewings - four radiographic images X-rays of the crowns of teeth to determine the existence of decay, four films $96.00 $0.00 $96.00 $48.00 $48.00
D0330 Panoramic Film X-rays/image taken around the head and showing full mouth on same film $150.00 $0.00 $150.00 $75.00 $75.00
D1110 Prophylaxis Adults Routine adult cleaning $120.00 $0.00 $120.00 $60.00 $60.00
D1120 Prophylaxis - child Routine child cleaning $100.00 $0.00 $100.00 $50.00 $50.00
D1206 Topical fluoride varnish Protective varnish that prevents cavities $55.00 $0.00 $55.00 $27.50 $27.50
D1208 Topical application of fluoride Protective varnish that prevents cavities $60.00 $0.00 $60.00 $30.00 $30.00
D1351 Sealant - Per Tooth Protective substance that fills in grooves or seals the top of the tooth to prevent cavities $65.00 $0.00 $65.00 $32.50 $32.50
D2140 Amalgam - one surface, primary or permanent A one surface silver filling used to fill cavities $200.00 $60.00 $140.00 $100.00 $100.00
D2150 Amalgam - two surfaces, primary or permanent A two surface silver filling used to fill cavities $250.00 $75.00 $175.00 $125.00 $125.00
D2160 Amalgam - three surfaces, primary or permanent A three surface silver filling used to fill cavities $335.00 $100.50 $234.50 $167.50 $167.50
D2330 resin-based composite - one surface, anterior White filling in the front teeth of your mouth, one surface of the tooth $200.00 $60.00 $140.00 $100.00 $100.00
D2331 Resin-based composite - two surfaces, anterior White filling in the front teeth of your mouth, two surfaces of the tooth $250.00 $75.00 $175.00 $125.00 $125.00
D2332 Resin-based composite - three surfaces, anterior White filling in the front teeth of your mouth, three surfaces of the tooth $300.00 $90.00 $210.00 $150.00 $150.00
D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) White filling in the front teeth of your mouth, four surfaces of the tooth $380.00 $114.00 $266.00 $190.00 $190.00
D2750 Crown – Porcelain fused to high noble metal Porcelain or ceramic crown over gold metal $1,495.00 $747.50 $747.50 $747.50 $747.50
D2950 Core buildup, including any pins "Crown (or ""cap"") -- Core build up to help crown retention" $335.00 $100.50 $234.50 $167.50 $167.50
D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament Removal of the core of the tooth, and applying medicament before a restoration $400.00 $120.00 $280.00 $200.00 $200.00
D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) Root canal on a bicuspid tooth $1,300.00 $650.00 $650.00 $650.00 $650.00
D3330 Root Canal Therapy - Molar Root canal on a molar $1,500.00 $750.00 $750.00 $750.00 $750.00
D4341 Perio Scaling/Root Planing - four or more contiguous teeth or bounded spaces per quadrant Treatment of gum disease; scraping deposits and smoothing roots below the gum line $303.00 $90.90 $212.10 $151.50 $151.50
D4355 Full Mouth Debridement To Enable Comprehensive Evaluation and Diagnosis Removal of tartar build-up above and below to gum line to prepare for examination for gum disease $200.00 $100.00 $100.00 $100.00 $100.00
D4910 Periodontal maintenance Ongoing prophylaxis treatment that focuses on scaling under the gums to maintain healthy gum pockets.(maintenance) $167.00 $50.10 $116.90 $83.50 $83.50
D5110 Complete Upper Complete upper denture worn on the upper jaw $1,650.00 $825.00 $825.00 $825.00 $825.00
D5120 Complete denture - mandibular Complete (Full) Lower denture to replace all teeth $1,600.00 $800.00 $800.00 $800.00 $800.00
D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) Upper partial denture (plastic) to replace missing teeth $1,300.00 $650.00 $650.00 $650.00 $650.00
D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) Lower partial denture (plastic) to replace missing teeth $1,460.00 $730.00 $730.00 $730.00 $730.00
D5410 Adjust complete denture - maxillary Upper denture adjustments $150.00 $45.00 $105.00 $75.00 $75.00
D5411 Adjust complete denture - mandibular Lower denture adjustments $150.00 $45.00 $105.00 $75.00 $75.00
D6211 Pontic - cast predominantly base metal Pontic (replaces a missing tooth) -- Cast predominantly base metal (silver colored with all non-precious metal $1,440.00 $720.00 $720.00 $720.00 $720.00
D6751 Crown - porcelain fused to predominantly base metal Crown (Silver colored with non-precious metal) $1,350.00 $675.00 $675.00 $675.00 $675.00
D6791 Crown - full cast predominantly base metal Crown - full cast (Silver colored with non-precious metal) $1,524.00 $762.00 $762.00 $762.00 $762.00
D7140 Extraction erupted tooth or exposed root (elevation and/or forceps removal) A tooth that is beyond repair by a root canal is removed nonsurgically $250.00 $75.00 $175.00 $125.00 $125.00
D7210 Surgical Removal Of Erupted Tooth A tooth that is beyond repair by a root canal is removed surgically $395.00 $118.50 $276.50 $197.50 $197.50
D8080 Comprehensive orthodontic treatment of the adolescent dentition Orthodontic treatment in adolescents (teenage) $4,500.00 $2,250.00 $2,250.00 $2,250.00 $2,250.00
D9110 Palliative (emergency) treatment of dental pain - minor procedure Emergency office visit for pain $175.00 $0.00 $175.00 $87.50 $87.50
D9241 Intravenous conscious sedation/analgesia - first 30 minutes IV sedation-30 minutes $500.00 $150.00 $350.00 $250.00 $250.00
D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes IV sedation-15 minutes $208.00 $62.40 $145.60 $104.00 $104.00
D9940 Occlusal guard, by report Night guard, by report $656.00 $196.80 $459.20 $328.00 $328.00

*Estimated charges are based on Usual, Customary, and Reasonable charges in the area. Actual expense may vary.

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  • Knowing your cost before you go to the dentist
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  • Viewing your Schedule of Benefits
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