List of Services

ADA Code Diagnostic & Preventive Procedures
(3 cleanings/patient/12 months period)

D0150 Comprehensive oral evaluation
D0120 Periodic oral evaluation
D0140 Consultation (limited oral evaluation-problem focused)
D0210 X-rays
D1110 Adult cleaning, polishing and scaling
D1120 Child cleaning and polishing- excluding fluoride
D1203 Tropical Fluoride treatment for children
D9110 Palliative (emergency) treatment of dental pain
D1351 Sealant- per tooth


ADA Code Restorative Procedures (Fillings)

D2940 Sedative Filling

Due to increased demand for more modern alternatives such as resin composite fillings ( that match the tooth color), as well as public concern about the mercury content of dental amalgam, our offices do not provide amalgam fillings.


Composite Resins: (Primary or permanent teeth)
Anterior Composites:

D2330 One surface
D2331 Two surface
D2332 Three surfaces
D2335 Four or more surfaces


Posterior Composites:
D2391 One surface
D2392 Two surfaces
D2393 Three surfaces
D2394 Four or more surfaces


ADA Code Endodontic Procedure
(3 root canals/patient/12 months period)

Root Canal Therapy (excluding final restoration)

D3310 Anterior
D3320 Bicuspid
D3330 Molar


ADA Code Periodontal Procedure
(4 quadrants/patient/12 months period)

D4341 Periodontal scaling and root planning (per quadrant)


ADA Code Oral Surgery Procedures

D7140 Extraction, erupted tooth or exposed root


ADA Code Fixed Prosthodontic Procedures –
Patient is responsible for the Lab fee
(3 units*/patient/12 months period)

D6240 Pontic-Porcelain fused to high noble metal
D6241 Pontic-Porcelain fused to predominantly base metal
D6242 Pontic-Porcelain fused to noble metal
D2750/D6750 Crown-Porcelain fused to high noble metal
D2751/D6751 Crown-Porcelain fused to predominantly base metal
D2752/D6752 Crown-Porcelain fused to noble metal
D2740 Crown-Porcelain/Ceramic substrate
D2954/D6972 Post and core (prefabricated)
D2952/D6970 Post and core (non-gold) laboratory
D2920 Re-cement crown
D6930 Re-cement fixed bridge
D2999/D6999 Crown-Temporary

*unit is a single crown or a crown that is a part of a bridge.


ADA Code Removable Prosthodontic –
Patient is responsible for the Lab fee
(2 dentures/patient/12 months period)

D5110 Complete Denture – Maxillary
D5120 Complete Denture – Mandibular
D5130 Immediate Denture – Maxillary
D5140 Immediate Denture – Mandibular
D5211 Maxillary Partial Denture – Resin Base
D5212 Mandibular Partial denture – Resin Base
D5213 Maxillary Partial Denture – Cast Frame
D5214 Mandibular Partial Denture – Cast Frame
D5225 Maxillary Partial Denture- Flexible Base
D5226 Mandibular Partial Denture – Flexible Base
D5510 Repair Broken Complete Denture Base
D5520 Replace missing/broken denture tooth
D5610 Repair Resin Denture Base
D5620 Repair Cast Framework
D5630 Repair/Replace Broken Clasp
D5640 Replace Broken Teeth (Per Tooth)
D5650 Add Tooth to Existing Partial Denture
D5660 Add Clasp to Existing Partial Denture
D5730 Reline Complete Max Denture (Chairside)
D5731 Reline Complete Mand Denture (Chairside)
D5740 Reline Max Partial Denture (Chairside)
D5741 Reline Mand Partial Denture (Chairside)
D5750 Reline Complete Max Denture (Lab)
D5751 Reline Complete Mand Denture (Lab)
D5760 Reline Max Partial Denture (Lab)
D5761 Reline Mand Partial Denture (Lab)
D5810 Interim Complete Denture (Maxillary)
D5811 Interim Complete Denture (Mandibular)
D5820 Interim Partial Denture (Maxillary)
D5821 Interim Partial Denture (Mandibular)
D5850 Tissue Conditioning, Maxillary
D5851 Tissue Conditioning, Mandibular
D9940 Night Guard


The above services are provided by participating General Dentists at participating locations only.
Services of Dental Specialists (endodontists, periodontists, oral surgeons, orthodontists and etc...) will not be provided under DENTbenefits Membership Program.


Lab Fees

Crown Porcelain fused to predominantly base metal $85.00 / unit
Crown Porcelain / All Ceramic; eMax; zirconia $150.00 / unit
Temporary Crown   $25 / unit
Complete Denture   $100.00/ unit
Partial Acrylic denture   $100.00 / denture
Partial Metal denture   $150.00 / denture
Partial flexi denture   $200.00 / denture

The above list of procedures and lab fees is the same at all participating dental provider locations.
The prices for other additional procedures that are not listed above and require lab work are determined by each individual participating dental provider.

Contact Information

866 758 8410Telephone: