Preventative Services
Cleaning, Exam, X-rays, Flouride
- $0-428
- Certain PPO plans may cover 100%
Dental Exams
- $75-103
- Comprehensive Exam (D0150) $103
- Periodic Exam (D0120) $75
- Limited Exam (D0140) $95
- Exam Under 3 Years Old (D0145) $83
Emergency Exam
- $0-247
- Certain PPO plans may cover 100%
Dental Cleanings (Prophylaxis)
- $88-120
- Under 12 years old (D1120) $85
- 12+ years old (D1110) $120
Dental X-rays
- $37-160
- PA (D0220) $37
- Addt’l PA (D0230) $33
- 1 BWX (D0270) $44
- 2 BWX (D0272) $58
- 4 BWX (D0274) $80
- Panoramic x-ray (D0330) $160
Dental Sealants (D1351)
- $75
Fluoride (D1206)
- $45
Silver Diamine Fluoride (D1354)
- $50
Restorative Services
Posterior Composite (White) Fillings
- $260-459
- Many PPO plans cover up to 80%
- 1 Surface (D2391) $260
- 2 Surfaces (D2392) $325
- 3 Surfaces (D2393) $395
- 4+ Surfaces (D2394) $459
Anterior Composite (White) Fillings
- $231-459
- Many PPO plans cover up to 80%
- 1 Surface (D2330) $231
- 2 Surfaces (D2331) $320
- 3 Surfaces (D2332) $395
- 4+ Surfaces (D2333) $459
Stainless Steel Crown Primary Tooth (D2930)
- $390
- Many PPO plans cover up to 50%
Stainless Steel Crown Permanent Tooth (D2931)
- $495
- Many PPO plans cover up to 50%
Pulpotomy (D3220)
- $280
- Many PPO plans cover up to 50%
Dental Extractions
- $256-370
- Many PPO plans cover up to 50%
- Non-surgical (D7140) $256
- Surgical (D7210) $370
Nitrous Oxide (D9230)
- $65
IV Sedation
- $400+
- Administered and billed by Pediatric Dental Anesthesia Associates based on 20 minute time increments
General Anesthesia
- Please call for more information