| AmeriPlan Teal Fee
|
| ADA Code |
Dentist Procedures |
AmeriPlan™ Fees |
| 00120 |
Periodic Oral Exam
|
$12 |
| 00140 |
Limited Oral Exam
|
$18 |
| 00150 |
Initial Oral Exam
|
$32 |
| 00180 |
Comprehensive Periodontal Evaluation
|
$32 |
| 00210 |
X-Ray: Intraoral Complete Series
|
$50 |
| 00220 |
Interoral - Periapical - First film
|
$12 |
| 00230 |
Interoral - Periapical - each additional film
|
$9 |
| 00240 |
Intraoral - Occlusal film
|
$15 |
| 00250 |
Extraoral - first film
|
25% |
| 00260 |
Extraoral - each additional film
|
25% |
| 00270 |
Bitewing - Single film
|
$12 |
| 00272 |
Bitewings - 2 films
|
$22 |
| 00273 |
Bitewings - 3 films
|
25% |
| 00274 |
Bitewings - 4 films
|
$32 |
| 00330 |
X-Ray: Panoramic
|
$50 |
| 00340 |
Cephalometric film
|
25% |
| 00460 |
Pulp Vitality Test
|
$25 |
| 00470 |
Diagnostic Casts
|
$45 |
| 00471 |
Diagnostic photographs
|
25% |
| 00999 |
Infection Control - OSHA requirements to prevent t
|
$10 |
| 01110 |
Regular Teeth Cleaning (Light Scaling & Polishing)
|
$42 |
| 01120 |
Prophylaxis - Child (to include light scaling and
|
$37 |
| 01201 |
Topical Application of Fluoride (including prophyl
|
$42 |
| 01203 |
Topical Application of Fluoride (excluding prophyl
|
$18 |
| 01204 |
Topical Application of Fluoride (excluding prophyl
|
$18 |
| 01205 |
Regular Teeth Cleaning (with Flouride)
|
$47 |
| 01330 |
Oral Hygiene Instruction
|
$15 |
| 01351 |
Sealant - per tooth
|
$25 |
| 01510 |
Space Maintainer - fixed unilateral type
|
$175 |
| 01515 |
Space Maintainer - fixed bilateral type
|
$200 |
| 01520 |
Space maintainer - removable unilateral type
|
25% |
| 01525 |
Space maintainer - removable bilateral type
|
25% |
| 01550 |
Recementation of space maintainer
|
25% |
| 02140 |
Amalgam Filling (Silver Colored) 1 Surface (Anterior)
|
$60 |
| 02150 |
Amalgam Filling (Silver Colored) 2 Surface (Anterior)
|
$70 |
| 02160 |
Amalgam - 3 surfaces, primary and permanent, per tooth
|
$85 |
| 02161 |
Amalgam - 4 or more surfaces, primary and permanent, per tooth
|
25% |
| 02330 |
Composite Filling (Tooth Colored) 1 Surface (Anterior)
|
$72 |
| 02331 |
Composite Filling (Tooth Colored) 2 Surface (Anterior)
|
$88 |
| 02332 |
Resin - 3 surfaces, Anterior
|
$110 |
| 02335 |
Resin - 4 surfaces or involving Incisal Angle
|
25% |
| 02391 |
Resin based composite - 1 surface
|
25% |
| 02392 |
Resin based composite - 2 surface
|
25% |
| 02393 |
Resin based composite - 3 surface
|
25% |
| 02394 |
Resin based composite - 4 surface
|
25% |
| 02510 |
Inlay - 1 surface, Metallic
|
25% |
| 02520 |
Inlay - 2 surfaces, Metallic
|
25% |
| 02530 |
Inlay - 3 surfaces, Metallic
|
25% |
| 02540 |
Onlay - metallic, per tooth (in addition to inlay)
|
25% |
| 02542 |
Onlay - metallic - 2 surface
|
25% |
| 02710 |
Crown - Resin (laboratory)
|
25% |
| 02740 |
Crown - Porcelain/Ceramic Substrate
|
25% |
| 02750 |
Porcelain Crown with High Noble Metal
|
$515 |
| 02751 |
Crown - Porcelain fused to predcominantly base met
|
$375 |
| 02752 |
Crown - Porcelain fused to noble metal
|
$475 |
| 02790 |
Crown - Full cast high noble metal
|
25% |
| 02791 |
Crown - Full cast predominantly base metal
|
25% |
| 02792 |
Crown - Full cast noble metal
|
25% |
| 02810 |
Crown - 3/4 cast metallic
|
$450 |
| 02910 |
Recement Inlay
|
$45 |
| 02920 |
Recement Crown
|
$45 |
| 02930 |
Prefabricated Stainless Steel Crown, primary tooth
|
$120 |
| 02931 |
Prefabricated Stainless Steel Crown, permanent too
|
25% |
| 02932 |
Prefabricated Resin Crown
|
25% |
| 02940 |
Sedative Filling
|
$45 |
| 02950 |
Crown build up, including any pins
|
25% |
| 02951 |
Pin retention per tooth in addition to restoration
|
$30 |
| 02952 |
Cast post and core in addition to crown
|
25% |
| 02953 |
Cast post as part of crown
|
25% |
| 02954 |
Prefabricated post and core in addition to crown
|
25% |
| 02960 |
Labial veneer (laminate) chairside
|
25% |
| 02962 |
Labial veneer (porcelain laminate) laboratory
|
25% |
| 02970 |
Temporary Crown (artificial over damaged tooth)
|
25% |
| 02980 |
Crown repair, by report
|
25% |
| 02999 |
Cosmetic, bonding, bleaching and veneers
|
25% |
| 03110 |
Pulp Cap - Direct (excluding final restoration)
|
$35 |
| 03120 |
Pulp Cap - Indirect (excluding final restoration)
|
$35 |
| 03220 |
Therapeutic Pulpotomy (excluding final restoration
|
$80 |
| 03310 |
Root Canal Anterior
|
$325 |
| 03320 |
Root Canal Bicuspid
|
$375 |
| 03330 |
Root Canal - Molar (excluding final restoration)
|
25% |
| 03346 |
Retreatment of prev. root canal, anterior
|
25% |
| 03347 |
Retreatment of prev. root canal, bicuspid
|
25% |
| 03348 |
Retreatment of prev. root canal, molar
|
25% |
| 03410 |
Apicoectomy - anterior
|
25% |
| 03421 |
Apicoectomy - bicuspid (first root)
|
25% |
| 03425 |
Apicoectomy - molar (first root)
|
25% |
| 03450 |
Root amputation (per root)
|
25% |
| 03460 |
Endodontic endosseous implant
|
25% |
| 03470 |
Intentional reimplantation (including necessary sp
|
25% |
| 03920 |
Hemisection (including any root removal) not inclu
|
25% |
| 03960 |
bleaching of discolored tooth
|
25% |
| 03999 |
Unspecified endodontic procedure
|
25% |
| 04210 |
Gingivectomy or gingivoplasty - per quadrant
|
25% |
| 04211 |
Gingivectomy or gingivoplasty - per tooth
|
25% |
| 04240 |
Gingival Flap Procedure, including root planing -
|
25% |
| 04249 |
Clinical crown lengthening
|
25% |
| 04250 |
Mucogingival surgery - per quadrant
|
25% |
| 04260 |
Osseous Surgery (including flap entry and closure
|
25% |
| 04263 |
Bone replacement graft - first site in quadrant
|
25% |
| 04264 |
Bone replacement graft - each additional site in q
|
25% |
| 04266 |
Guided tissue regeneration - resorbable barrier, p
|
25% |
| 04267 |
Guided tissue regeneration - nonresorbable barrier
|
25% |
| 04270 |
Pedicle Soft Tissue Graft Procedure
|
25% |
| 04271 |
Free Soft Tissue Graft Procedure
|
25% |
| 04273 |
Subepithelial connective tissue graft procedure
|
25% |
| 04274 |
Distal or proximal wedge procedure
|
25% |
| 04320 |
Provisional splinting - intracoronal
|
25% |
| 04321 |
Provisional splinting - extracoronal
|
25% |
| 04341 |
Periodontial Scaling and Root Planing - per quadra
|
25% |
| 04355 |
Deep Teeth Cleaning (Full Mouth Debridement / Removal of heavy tartar buildup)
|
$75 |
| 04381 |
Localized delivery of chemotherapeutic agents via
|
25% |
| 04910 |
Periodontal maintenance procedures following active therapy
|
$60 |
| 04999 |
Unspecified periodontic procedure
|
25% |
| 05110 |
Complete Upper Denture
|
$600 |
| 05120 |
Complete Lower Denture
|
$600 |
| 05130 |
Immediate Upper Denture
|
25% |
| 05140 |
Immediate Lower Denture
|
25% |
| 05211 |
Upper Partial - acrylic base (including any conventional clasps and rests)
|
$500 |
| 05212 |
Lower Partial - acrylic base (including any conventional clasps and rests)
|
$500 |
| 05213 |
Upper Partial - predominantly base cast base with acrylic saddles (including any conventional clasps and rest)
|
25% |
| 05214 |
Lower Partial - perdominantly base cast base with acrylic saddles (including any conventional clasps and rests)
|
25% |
| 05281 |
Removable unilateral partial denture - one piece c
|
25% |
| 05410 |
Adjust Complete Denture - upper
|
$35 |
| 05411 |
Adjust Complete Denture - lower
|
$35 |
| 05421 |
Adjust Partial Denture - upper
|
$35 |
| 05422 |
Adjust Partial Denture - lower
|
$35 |
| 05510 |
Repair broken complete denture base
|
25% |
| 05520 |
Replace missing or borken teeth complete denture (
|
25% |
| 05610 |
Repair acrylic saddle or base
|
25% |
| 05620 |
Repair cast framework
|
25% |
| 05630 |
Repair or replace broken clasp
|
25% |
| 05640 |
Replace broken teeth (per tooth)
|
25% |
| 05650 |
Add tooth to existing partial denture
|
25% |
| 05660 |
Add clasp to existing partial denture
|
25% |
| 05710 |
Rebase complete upper denture
|
$300 |
| 05711 |
Rebase complete lower denture
|
$300 |
| 05720 |
Rebase upper partial denture
|
$275 |
| 05721 |
Rebase lower partial denture
|
$275 |
| 05730 |
Reline complete maxillary denture (chairside)
|
25% |
| 05731 |
Reline complete mandibular denture (chairside)
|
25% |
| 05740 |
Reline maxillary partial denture (chairside)
|
25% |
| 05741 |
Reline mandibular partial denture (chairside)
|
25% |
| 05750 |
Reline complete maxillary denture (laboratory)
|
25% |
| 05751 |
Reline complete mandibular denture (laboratory)
|
25% |
| 05760 |
Reline maxillary partial denture (laboratory)
|
25% |
| 05761 |
Reline mandibular partial denture (laboratory)
|
25% |
| 05810 |
Interim complete denture (maxillary)
|
25% |
| 05811 |
Interim complete denture (mandibular)
|
25% |
| 05820 |
Interim partial denture (maxillary)
|
25% |
| 05821 |
Interim partial denture (mandibular)
|
25% |
| 05850 |
Tissue conditioning (maxillary)
|
25% |
| 05851 |
Tissue conditioning (mandibular)
|
25% |
| 05860 |
Overdenture - complete
|
25% |
| 05861 |
Overdenture - partial
|
25% |
| 05862 |
Precision attachment
|
25% |
| 05899 |
Unspecified removable prosthodontic procedure
|
25% |
| 06010 |
Surgical placement of implant body - endosteal imp
|
25% |
| 06020 |
Abutment placement or substitution - endosteal imp
|
25% |
| 06055 |
Dental implant supported connecting bar
|
25% |
| 06080 |
Implant maintenance procedures, including: removal
|
25% |
| 06095 |
Repair implant abutment
|
25% |
| 06100 |
Implant removal
|
25% |
| 06199 |
Unspecified implant procedure
|
25% |
| 06210 |
Pontic - cast high noble metal
|
25% |
| 06211 |
Pontic - cast predominantly base metal
|
$500 |
| 06212 |
Pontic - cast noble metal
|
25% |
| 06240 |
Pontic - porcelain fused to high noble metal
|
25% |
| 06241 |
Pontic - porcelain fused to predominantly base met
|
$500 |
| 06242 |
Pontic - porcelain fused to noble metal
|
25% |
| 06520 |
Inlay - 2 surfaces, metallic
|
25% |
| 06530 |
Inlay - 3 or more surfaces, metallic
|
25% |
| 06545 |
Cast metal retainer for resin bonded fixed prosthe
|
25% |
| 06750 |
Crown - porcelain fused to high noble metal
|
$525 |
| 06751 |
Crown - porcelain fused to predominantly base meta
|
$450 |
| 06752 |
Crown - porcelain fused to noble metal
|
$500 |
| 06780 |
Crown - 3/4 cast high noble metal
|
25% |
| 06790 |
Crown - full cast high noble metal
|
25% |
| 06791 |
Crown - full cast perdominantly base metal
|
25% |
| 06792 |
Crown - full cast noble metal
|
25% |
| 06920 |
Connector bar
|
25% |
| 06930 |
Recement bridge
|
$65 |
| 06940 |
Stress breaker
|
25% |
| 06950 |
Precision attachment
|
25% |
| 06970 |
Cast post and core in addition to bridge retainer
|
25% |
| 06971 |
Cast post as part of bridge retainer
|
25% |
| 06972 |
Prefabricated post and core in addition to bridge
|
25% |
| 06999 |
Unspecified fixed prosthodontic procedure
|
25% |
| 07111 |
Extraction of coronal remnants - decidous tooth
|
$50 |
| 07140 |
Extraction, erupted tooth or exposed tooth
|
$60 |
| 07210 |
Surgical removal of erupted tooth requiring elevat
|
$115 |
| 07220 |
Removal of impacted tooth - soft tissue
|
$135 |
| 07230 |
Removal of impacted tooth partially bony
|
$175 |
| 07240 |
Removal of impacted tooth completely bony
|
25% |
| 07241 |
Removal of impacted tooth completely bony - with s
|
25% |
| 07250 |
Surgical removal of residual tooth roots (cutting
|
25% |
| 07280 |
Surgical exposure of impacted or unerupted tooth f
|
25% |
| 07281 |
Surgical exposure of impacted or unerupted tooth t
|
25% |
| 07285 |
Biopsy of oral tissue - hard
|
25% |
| 07286 |
Biopsy of oral tissue - soft
|
25% |
| 07310 |
Alveoloplasty in conjuction with extractions - per
|
25% |
| 07320 |
Alveoloplasty not in conjuction with extractions -
|
25% |
| 07340 |
Vestibuloplasty - ridge extension (secondary epith
|
25% |
| 07350 |
Vestibuloplasty - ridge extension (soft tissue gra
|
25% |
| 07440 |
Excision of malignant tumor-lesion diameter up to
|
25% |
| 07441 |
Excision of malignant tumor-lesion diameter greate
|
25% |
| 07450 |
Removal of odontogenic cyst or tumor-lesion diamet
|
25% |
| 07451 |
Removal of odontogenic cyst or tumor-lesion diamet
|
25% |
| 07460 |
Removal of nonodontogenic cyst or tumor-lesion dia
|
25% |
| 07461 |
Removal of nonodontogenic cyst or tumor-lesion dia
|
25% |
| 07465 |
Destruction of lesion(s) by physical or chemical m
|
25% |
| 07470 |
Removal of exostosis-maxilla or mandible
|
25% |
| 07510 |
Incision and drainage of abcess-intraoral soft tis
|
25% |
| 07520 |
Incision and drainage of abcess-extraoral soft tis
|
25% |
| 07910 |
Suture of recent small wounds up to 5 cm
|
25% |
| 07911 |
Complicated suture up to 5 cm
|
25% |
| 07912 |
Complicated suture greater than 5 cm
|
25% |
| 07960 |
Frenulectomy (frenectomy or frenotomy) - separate
|
25% |
| 07970 |
Excision of hyperplastic tissue - per arch
|
25% |
| 07971 |
Excision of pericoronal gingiva
|
25% |
| 07999 |
Unspecified oral surgery procedure
|
25% |
| 08010 |
Limited orthodontic treatment of the primary denti
|
25% |
| 08020 |
Limited orthodontic treatment of the transitional
|
25% |
| 08030 |
Limited orthodontic treatment of the adolescent de
|
25% |
| 08040 |
Limited orthodontic treatment of the adult dentiti
|
25% |
| 08050 |
Interceptive orthodontic treatment of the primary
|
25% |
| 08060 |
Interceptive orthodontic treatment of the transiti
|
25% |
| 08070 |
Comprehensive orthodontic treatment of the transit
|
25% |
| 08080 |
Orthodontic Braces by General dentist - children under age 19
|
$2,100 |
| 08090 |
Orthodontic Braces by General dentist - adult 19 and over
|
$2,250 |
| 08210 |
Retainers (each up to 2 years)
|
$250 |
| 08220 |
Maxillary expansion
|
$500 |
| 08660 |
Diagnostic workup including cephalometric, panoram
|
$255 |
| 08670 |
Periodic orthodontic treatment visit
|
25% |
| 08680 |
Orthodontic retention (removal of appliances, cons
|
25% |
| 08999 |
Unspecified orthodontic procedure by report
|
25% |
| 00016 |
Failed appointment (without 24 hr. notice)
|
$25 |
| 09110 |
Palliative (emergency) treatment of dental pain -
|
$50 |
| 09210 |
Local anesthesia not in conjuction with operative
|
25% |
| 09215 |
Local anesthesia
|
25% |
| 09230 |
Analgesia
|
25% |
| 09240 |
Intravenous sedation
|
25% |
| 09310 |
Consultation - per session (diagnostic service pro
|
$45 |
| 09430 |
Office visit for observation (during regularly sch
|
$20 |
| 09440 |
Office visit - after regularly scheduled hours
|
$75 |
| 09941 |
fabrication of athletic mouthguard
|
25% |
| 09950 |
Occlusion analysis (mounted case)
|
25% |
| 09951 |
Occlusal adjustment (limited)
|
25% |
| 09952 |
Occlusal adjustment (complete)
|
25% |
