Maximum Covered Expense (MCE)

Maximum Covered Expense (MCE):  MCE is an easy-to-understand benefit at a very affordable rate. The plan pays the amount of the expense, up to the MCE, and you pay the difference between that amount and the dentist's fee. As you can see, MCE increases/decreases based on the plan you select. Many times a single visit to the dentist will allow for multiple payouts of MCE. For example, if you visit the dentist for a preventive check up examination there could be separate MCE's payable for the exam, x-rays, cleaning, etc...

You will receive additional out-of-pocket savings when you utilize an Ameritas PPO provider (in Texas, the Ameritas Dental Network). Ameritas PPO providers have agreed to charge discounted fees to member clients. The Ameritas PPO offers more than 170,000 provider access points nationwide. If there is no coverage for a particular procedure you may still receive a discount through the PPO.

Example of PPO Savings

actual savings varies based on location and plan selected

Bob, who lives in the Chicago area (ZIP 60156), visits the dentist and gets an exam, cleaning, and x-rays. The dentist discovers that Bob needs a filling and an extraction. Here is an example of PPO savings if Bob selects the GOLD or the PLATINUM plan:

Procedure/Procedure Code Dentist's average
charge in the area
PPO Provider
(MAC = Maximum Allowable Charge)
Maximum Covered Expense (MCE)
Under the Gold Plan
Maximum Covered Expense (MCE)
Under the Platinum Plan
Comprehensive exam, D0150 $63 $38 $36 $46
Adult cleaning, D1110 $79 $52 $49 $63
Bitewing x-rays, D0272 $38 $22 $21 $27
Filling (restorative amalgam), D2140 $117 $70 $51 $66
Complex extraction, D7230 $365 $226 $98 $133
 TOTAL       $662  $408 MAC*
 $255 MCE
 $335 MCE

Under the GOLD plan, if Bob uses an Ameritas PPO dentist for services, his out-of-pocket expense is $153. If he uses an out-of-network dentist, Bob will share more of the cost of his services, with his out-of-pocket expense at $407. Under the PLATINUM plan, with a PPO dentist, Bob's out-of-pocket expense is $97. If Bob uses an out-of-network dentist, he will share more of the cost of his services, with his out-of-pocket expense at $327.

In-network expenses vary by ZIP Code, out of- network expenses vary depending on the amounts charged by non-network dentists. Without a plan, Bob's out-of-pocket expense would have been $662.

*PPO providers -most common contracted fee"


Maximum Covered Expense (MCE): MCE is an easy-to-understand benefit at a very affordable rate. The plan pays the amount of the expense, up to the MCE, for each covered procedure, and you pay the difference between that amount and the dentist's fee. You will receive additional out-of-pocket savings when using an Ameritas PPO provider.

Maximum Allowable Charge (MAC): The charges accepted by dentists who are Participating Providers. The MAC is reviewed and updated periodically to reflect increasing Provider fees within the ZIP code area. It is derived from the array of Provider charges within a particular ZIP code area.

Current Dental Terminology ©2011 American Dental Association. All rights reserved.

Plan Benefits MCE

Platinum Plan
Gold Plan
Silver Plan
Value Plan
D0270Bitewing - Single Film1$15.00$12.00$9.00$6.00
D0274Bitewings - Four Films1$42.00$33.00$25.00$18.00
D0273Bitewings - Three Films1$32.00$25.00$19.00$14.00
D0272Bitewings - Two Films1$27.00$21.00$16.00$11.00
D0150Comprehensive Oral Evaluation-New Or Estab Patient1$46.00$36.00$27.00$19.00
D0180Comprehensive Periodontal Evaluation, New Or Estab1$46.00$36.00$27.00$19.00
D8220Fixed Appliance Therapy1$338.00$263.00$200.00$141.00
D0145Oral Evaluation For A Patient Under 3 Years Of Age1$23.00$18.00$14.00$10.00
D0120Periodic Oral Evaluation-Established Patient1$30.00$23.00$18.00$12.00
D1110Prophylaxis - Adult1$63.00$49.00$38.00$27.00
D1120Prophylaxis - Child1$45.00$35.00$26.00$19.00
D1550Re-Cementation Of Space Maintainer1$46.00$36.00$27.00$19.00
D8210Removable Appliance Therapy1$338.00$263.00$200.00$141.00
D1555Removal Of Fixed Space Maintainer1$63.00$49.00$38.00$27.00
D1351Sealant - Per Tooth1$35.00$27.00$21.00$15.00
D1515Space Maintainer - Fixed - Bilateral1$367.00$286.00$218.00$154.00
D1510Space Maintainer - Fixed - Unilateral1$224.00$174.00$133.00$94.00
D1525Space Maintainer - Removable - Bilateral1$428.00$333.00$254.00$179.00
D1520Space Maintainer - Removable - Unilateral1$351.00$273.00$208.00$147.00
D1204Topical Application Of Fluoride - Adult1$24.00$19.00$14.00$10.00
D1203Topical Application Of Fluoride - Child1$24.00$19.00$14.00$10.00
D1206Topical Fluoride Varnish,Application For Caries1$24.00$19.00$14.00$10.00
D0277Vertical Bitewings - 7 To 8 Films1$63.00$49.00$38.00$27.00
D0473Accession Of Tissue, Gross & Microscopic Exam2$91.00$71.00$42.00$28.00
D0472Accession Of Tissue, Gross Examination, Preparatio2$46.00$36.00$21.00$14.00
D0474Accession Of Tissue,Gross & Microscopic Exam, Prep2$91.00$71.00$42.00$28.00
D7311Alveoloplasty In Conj. With Extraction2$35.00$26.00$24.00$19.00
D7321Alveoloplasty Not In Conj. With Extraction2$44.00$33.00$30.00$24.00
D7310Alveoplasty In Conjunct With Ext-4 + Tth, Per Quad2$69.00$51.00$47.00$38.00
D7320Alveoplasty Not In Conjunct W/Extr,4+ Tth Per Quad2$87.00$65.00$59.00$48.00
D2161Amalgam - Four+ Surfaces - Primary Or Permanent2$121.00$94.00$55.00$37.00
D2140Amalgam - One Surface - Primary Or Permanent2$66.00$51.00$30.00$20.00
D2160Amalgam - Three Surfaces - Primary Or Permanent2$101.00$78.00$46.00$31.00
D2150Amalgam - Two Surfaces - Primary Or Permanent2$84.00$65.00$38.00$26.00
D7285Biopsy Of Oral Tissue - Hard (Bone, Tooth)2$298.00$230.00$136.00$92.00
D7286Biopsy Of Oral Tissue - Soft2$161.00$124.00$73.00$50.00
D7288Brush Biopsy - Transepithelial Sample Collection2$80.00$62.00$37.00$25.00
D7983Closure Of Salivary Fistula2$50.00$37.00$34.00$27.00
D7912Complicated Suture - Greater Than 5 Cm2$40.00$30.00$27.00$22.00
D7911Complicated Suture - Up To 5 Cm2$28.00$21.00$19.00$15.00
D9310Consultation - Other Than Req Dentist Or Physician2$56.00$43.00$26.00$17.00
D9221Deep Sedation/General Anesthesia - Each Add 15 Min2$39.00$29.00$26.00$21.00
D9220Deep Sedation/General Anesthesia-First 30 Minutes2$119.00$88.00$81.00$65.00
D7465Destruction Of Lesion(S) By Physical Or Chemical2$38.00$28.00$26.00$21.00
D7441Excision - Malignant Tumor - Greater Than 1.25 Cm2$124.00$92.00$84.00$68.00
D7440Excision - Malignant Tumor - Up To 1.25 Cm2$169.00$126.00$115.00$93.00
D7411Excision Of Benign Lesion Greater Than 1.25 Cm2$161.00$119.00$109.00$88.00
D7410Excision Of Benign Lesion Up To 1.25 Cm2$125.00$93.00$85.00$69.00
D7412Excision Of Benign Lesion, Complicated2$177.00$131.00$120.00$97.00
D7414Excision Of Malignant Lesion Greater Than 1.25 Cm2$124.00$92.00$84.00$68.00
D7413Excision Of Malignant Lesion Up To 1.25 Cm2$300.00$232.00$137.00$93.00
D7415Excision Of Malignant Lesion, Complicated2$136.00$101.00$92.00$75.00
D7970Excision Or Hyperplastic Tissue - Per Arch2$104.00$77.00$70.00$57.00
D7287Exfoliative Cytological Sample Collection2$80.00$62.00$37.00$25.00
D7111Extraction, Coronal Remnants - Deciduous Tooth2$74.00$57.00$34.00$23.00
D7140Extraction, Erupted Tooth Or Exposed Root2$74.00$57.00$34.00$23.00
D0260Extraoral - Each Additional Film2$20.00$15.00$9.00$6.00
D0250Extraoral - First Film2$25.00$20.00$12.00$8.00
D2940Fillings - Sedative2$48.00$37.00$22.00$15.00
D7960Frenulectomy - Separate Procedure (Ectomy/Otomy)2$135.00$100.00$91.00$74.00
D4355Full Mouth Debridement For Perio Evaluation2$81.00$63.00$37.00$25.00
D2410Gold Foil - One Surface2$66.00$51.00$30.00$20.00
D2430Gold Foil - Three Surfaces2$101.00$78.00$46.00$31.00
D2420Gold Foil - Two Surfaces2$84.00$65.00$38.00$26.00
D7520Incision And Drainage Of Abscess - Extraoral Soft2$64.00$48.00$44.00$35.00
D7510Incision And Drainage Of Abscess - Intraoral Soft2$56.00$41.00$38.00$31.00
D0210Intraoral - Complete Series (Including Bitewings)2$78.00$60.00$36.00$24.00
D0240Intraoral - Occlusal Film2$20.00$15.00$9.00$6.00
D0230Intraoral - Periapical Each Additional Film2$11.00$9.00$5.00$3.00
D0220Intraoral - Periapical First Film2$14.00$11.00$7.00$4.00
D9242Intravenous Sedation/Analgesia - Each Add 15 Min2$19.00$14.00$13.00$11.00
D9241Intravenous Sedation/Analgesia - First 30 Minutes2$79.00$58.00$53.00$43.00
D0140Limited Oral Evaluation - Problem Focused2$39.00$30.00$18.00$12.00
D7560Maxillary Sinusotomy For Removal Of Tooth Fragment2$186.00$138.00$126.00$102.00
D7282Mobilization Of Erupted Or Malpositioned Tooth-Aid2$132.00$98.00$89.00$72.00
D9952Occlusal Adjustment - Complete2$265.00$205.00$121.00$82.00
D9951Occlusal Adjustment - Limited2$53.00$41.00$24.00$16.00
D9440Office Visit - After Regularly Scheduled Hours2$68.00$53.00$31.00$21.00
D9430Office Visit - During Regular Hours-No Other Serv2$39.00$30.00$18.00$12.00
D7260Oroantral Fistula Closure2$196.00$145.00$133.00$107.00
D9110Palliative (Emergency) Treatment - Minor Procedure2$55.00$43.00$25.00$17.00
D0330Panoramic Film2$63.00$48.00$29.00$19.00
D7550Partial Ostectomy/Sequestrectomy For Removal2$141.00$105.00$96.00$78.00
D4910Periodontal Maintenance2$84.00$65.00$38.00$26.00
D7283Placement Of Device To Facilitate Eruption Of2$55.00$41.00$37.00$30.00
D7261Primary Closure Of A Sinus Perforation2$196.00$145.00$133.00$107.00
D7490Radical Resection Of Maxilla Or Mandible2$169.00$126.00$115.00$93.00
D0170Re-Evaluation - Limited, Problem Focused2$39.00$30.00$18.00$12.00
D0170Re-Evaluation - Limited, Problem Focused2$39.00$30.00$18.00$12.00
D2915Recement Cast Or Prefabricated Post And Core2$26.00$20.00$12.00$8.00
D2920Recement Crown2$52.00$40.00$24.00$16.00
D6930Recement Fixed Partial Denture2$72.00$55.00$33.00$22.00
D6092Recement Implant/Abutment Supported Crown2$52.00$40.00$24.00$16.00
D6093Recement Implant/Abutment Supported Fix Part Dent2$52.00$40.00$24.00$16.00
D2910Recement Inlay, Onlay, Or Partial Coverage Restora2$53.00$41.00$24.00$16.00
D5731Reline Complete Mandibular Denture (Chairside)2$153.00$118.00$70.00$47.00
D5751Reline Complete Mandibular Denture (Laboratory)2$224.00$173.00$102.00$69.00
D5730Reline Complete Maxillary Denture (Chairside)2$154.00$119.00$70.00$48.00
D5750Reline Complete Maxillary Denture (Laboratory)2$229.00$177.00$104.00$71.00
D5741Reline Mandibular Partial Denture (Chairside)2$139.00$107.00$63.00$43.00
D5761Reline Mandibular Partial Denture (Laboratory)2$230.00$178.00$105.00$71.00
D5740Reline Maxillary Partial Denture (Chairside)2$138.00$106.00$63.00$43.00
D5760Reline Maxillary Partial Denture (Laboratory)2$229.00$177.00$104.00$71.00
D7530Removal Of Foreign Body From Mucosa, Skin,Alveolar2$51.00$38.00$35.00$28.00
D7240Removal Of Impacted Tooth - Completely Bony2$155.00$115.00$105.00$85.00
D7230Removal Of Impacted Tooth - Partially Bony2$133.00$98.00$90.00$73.00
D7241Removal Of Impacted Tooth-Completely Bony,W/Compli2$177.00$131.00$120.00$97.00
D7471Removal Of Lateral Exostosis (Maxilla Or Mandible)2$112.00$83.00$76.00$61.00
D7473Removal Of Toris Mandibularis2$112.00$83.00$76.00$61.00
D7472Removal Of Torus Palatinus2$112.00$83.00$76.00$61.00
D7540Remove Reaction Producing Foreign Body - Muscu-Skl2$141.00$105.00$96.00$78.00
D7460Remv Of Benign Nonodontogenic Cyst/Tumor < 1.25 Cm2$125.00$93.00$85.00$69.00
D7461Remv Of Benign Nonodontogenic Cyst/Tumor > 1.25 Cm2$161.00$119.00$109.00$88.00
D7450Remv Of Benign Odontogenic Cyst Or Tumor < 1.25 Cm2$125.00$93.00$85.00$69.00
D7451Remv Of Benign Odontogenic Cyst Or Tumor > 1.25 Cm2$161.00$119.00$109.00$88.00
D5510Repair Broken Complete Denture Base2$84.00$65.00$38.00$26.00
D5620Repair Cast Framework2$98.00$76.00$45.00$30.00
D5630Repair Or Replace Broken Clasp2$102.00$79.00$47.00$32.00
D5610Repair Resin Denture Base2$83.00$64.00$38.00$26.00
D5640Replace Broken Teeth - Per Tooth2$74.00$57.00$34.00$23.00
D5520Replace Missing Or Broken Teeth - Complete Denture2$69.00$54.00$32.00$21.00
D2335Resin-Based Comp- 4+ Surfaces Or Incisal, Anterior2$140.00$108.00$64.00$43.00
D2330Resin-Based Composite - One Surface, Anterior2$80.00$62.00$37.00$25.00
D2391Resin-Based Composite - One Surface, Posterior2$88.00$68.00$40.00$27.00
D2332Resin-Based Composite - Three Surfaces, Anterior2$127.00$98.00$58.00$39.00
D2393Resin-Based Composite - Three Surfaces, Posterior2$140.00$108.00$64.00$43.00
D2331Resin-Based Composite - Two Surfaces, Anterior2$101.00$78.00$46.00$31.00
D2392Resin-Based Composite - Two Surfaces, Posterior2$111.00$86.00$51.00$34.00
D2390Resin-Based Composite Crown,Anterior2$171.00$132.00$78.00$53.00
D2394Resin-Based Composite-Four Or More Surf, Posterior2$154.00$119.00$70.00$48.00
D7280Surgical Access Of An Unerupted Tooth2$184.00$136.00$124.00$101.00
D7972Surgical Reduction Of Fibrous Tuberosity2$165.00$122.00$112.00$90.00
D7485Surgical Reduction Of Osseous Tuberosity2$182.00$135.00$123.00$100.00
D7250Surgical Removal Of Residual Tooth Roots(Cut Proc)2$83.00$62.00$56.00$46.00
D7910Suture Of Recent Small Wounds Up To 5 Cm2$25.00$18.00$17.00$14.00
D7270Tooth Reimplantation And/Or Stabilization2$118.00$88.00$80.00$65.00
D7272Tooth Transplantation2$118.00$88.00$80.00$65.00
D9930Treatment Of Complications (Post-Surgical)2$42.00$32.00$19.00$13.00
D7350Vestibuloplasty - Ridge Extension - Complicated2$314.00$233.00$213.00$172.00
D7340Vestibuloplasty - Ridge Extension - Uncomplicated2$126.00$94.00$86.00$69.00
D7210Surgical Removal Of Erupted Tooth Requiring Elevat2   $44.00
D6194Abut Retainer Crown For Fpd - (Titanium)3$372.00$276.00$252.00$0.00
D6060Abut Supported Porc Fused To Metal Crn(Base Metal)3$372.00$276.00$252.00$0.00
D6059Abut Supported Porc Fused To Metal Crn(High Noble)3$372.00$276.00$252.00$0.00
D6061Abut Supported Porc Fused To Metal Crn(Noble Metl)3$341.00$253.00$231.00$0.00
D6063Abutment Supported Cast Metal Crown (Base Metal)3$372.00$276.00$252.00$0.00
D6062Abutment Supported Cast Metal Crown (High Noble)3$372.00$276.00$252.00$0.00
D6064Abutment Supported Cast Metal Crown (Noble Metal)3$403.00$299.00$273.00$0.00
D6094Abutment Supported Crown - (Titanium)3$372.00$276.00$252.00$0.00
D6058Abutment Supported Porcelain/Ceramic Crown3$341.00$253.00$231.00$0.00
D6072Abutment Supported Retainer For Cast Metal Fpd3$372.00$276.00$252.00$0.00
D6073Abutment Supported Retainer For Cast Metal Fpd3$372.00$276.00$252.00$0.00
D6074Abutment Supported Retainer For Cast Metal Fpd3$403.00$299.00$273.00$0.00
D6069Abutment Supported Retainer For Porc Fusd To M Fpd3$372.00$276.00$252.00$0.00
D6070Abutment Supported Retainer For Porc Fusd To M Fpd3$372.00$276.00$252.00$0.00
D6071Abutment Supported Retainer For Porc Fusd To M Fpd3$341.00$253.00$231.00$0.00
D6068Abutment Supported Retainer For Porc/Ceramic Fpd3$341.00$253.00$231.00$0.00
D5660Add Clasp To Existing Partial Denture3$61.00$46.00$42.00$0.00
D5650Add Tooth To Existing Partial Denture3$53.00$39.00$36.00$0.00
D5411Adjust Complete Denture - Mandibular3$22.00$16.00$15.00$0.00
D5410Adjust Complete Denture - Maxillary3$23.00$17.00$16.00$0.00
D5422Adjust Partial Denture - Mandibular3$23.00$17.00$16.00$0.00
D5421Adjust Partial Denture - Maxillary3$24.00$18.00$16.00$0.00
D3353Apexification/Recalcification - Final Visit3$163.00$121.00$110.00$0.00
D3351Apexification/Recalcification - Initial Visit3$82.00$61.00$56.00$0.00
D3352Apexification/Recalcification-Interim Medication3$56.00$41.00$38.00$0.00
D3410Apicoectomy/Periradicular Surgery - Anterior3$236.00$175.00$160.00$0.00
D3421Apicoectomy/Periradicular Surgery - Bicuspid3$272.00$202.00$184.00$0.00
D3425Apicoectomy/Periradicular Surgery - Molar3$295.00$219.00$200.00$0.00
D3426Apicoectomy/Periradicular Surgery-Each Addn'L Root3$105.00$78.00$71.00$0.00
D4265Biologic Materials To Aid In Soft & Osseous Regen3$61.00$46.00$42.00$0.00
D4264Bone Replacement Graft-Each Addl Site In Quadrant3$92.00$69.00$63.00$0.00
D4263Bone Replacement Graft-First Site In Quadrant3$123.00$91.00$83.00$0.00
D4249Clinical Crown Lengthening, Hard Tissue3$226.00$168.00$153.00$0.00
D4276Combined Connective Tissue And Dbl Pedicle Graft3$342.00$254.00$232.00$0.00
D5120Complete Denture - Mandibular3$396.00$294.00$268.00$0.00
D5110Complete Denture - Maxillary3$409.00$303.00$277.00$0.00
D6973Core Build Up For Retainer, Including Any Pins3$79.00$59.00$54.00$0.00
D2950Core Build-Up, Including Any Pins3$79.00$59.00$54.00$0.00
D2780Crown - 3/4 Cast High Noble Metal3$365.00$271.00$247.00$0.00
D6780Crown - 3/4 Cast High Noble Metal3$403.00$299.00$273.00$0.00
D6782Crown - 3/4 Cast Noble Metal3$341.00$253.00$231.00$0.00
D2782Crown - 3/4 Cast Noble Metal3$332.00$246.00$225.00$0.00
D2781Crown - 3/4 Cast Predominantly Base Metal3$317.00$236.00$215.00$0.00
D6781Crown - 3/4 Cast Predominantly Base Metal3$372.00$276.00$252.00$0.00
D6783Crown - 3/4 Porcelain/Ceramic3$341.00$253.00$231.00$0.00
D2783Crown - 3/4 Porcelain/Ceramic3$395.00$293.00$268.00$0.00
D2712Crown - 3/4 Resin-Based Composite (Indirect)3$355.00$264.00$241.00$0.00
D6790Crown - Full Cast High Noble Metal3$372.00$276.00$252.00$0.00
D6792Crown - Full Cast Noble Metal3$341.00$253.00$231.00$0.00
D6791Crown - Full Cast Predominantly Base Metal3$372.00$276.00$252.00$0.00
D2790Crown - Gold - Full Cast3$365.00$271.00$247.00$0.00
D6710Crown - Indirect Resin Based Composite3$307.00$228.00$208.00$0.00
D2791Crown - Nonprecious Metal - Full Cast3$317.00$236.00$215.00$0.00
D6750Crown - Porcelain Fused To High Noble Metal3$403.00$299.00$273.00$0.00
D6752Crown - Porcelain Fused To Noble Metal3$341.00$253.00$231.00$0.00
D2750Crown - Porcelain With Gold3$384.00$285.00$260.00$0.00
D2751Crown - Porcelain With Nonprecious Metal3$329.00$244.00$223.00$0.00
D2752Crown - Porcelain With Semiprecious Metal3$353.00$262.00$239.00$0.00
D6740Crown - Porcelain/Ceramic3$341.00$253.00$231.00$0.00
D2740Crown - Porcelain/Ceramic Substrate3$395.00$293.00$268.00$0.00
D2720Crown - Resin With Gold3$366.00$271.00$248.00$0.00
D6720Crown - Resin With High Noble Metal3$372.00$276.00$252.00$0.00
D6722Crown - Resin With Noble Metal3$310.00$230.00$210.00$0.00
D2721Crown - Resin With Nonprecious Metal3$279.00$207.00$189.00$0.00
D6721Crown - Resin With Predominantly Base Metal3$193.00$143.00$131.00$0.00
D2722Crown - Resin With Semiprecious Metal3$342.00$254.00$232.00$0.00
D2710Crown - Resin-Based Composite (Indirect)3$143.00$106.00$97.00$0.00
D2792Crown - Semiprecious Metal - Full Cast3$332.00$246.00$225.00$0.00
D2794Crown - Titanium3$365.00$271.00$247.00$0.00
D6794Crown - Titanium3$372.00$276.00$252.00$0.00
D2980Crown Repair, By Report3$64.00$47.00$43.00$0.00
D6751Crown-Porcelain Fused To Predominantly Base Metal3$372.00$276.00$252.00$0.00
D4381Delivery Of Antimicrobial Agents Into Tissue3$56.00$42.00$38.00$0.00
D4274Distal Or Proximal Wedge Procedure3$165.00$122.00$112.00$0.00
D3310Endodontic Therapy, Anterior Tooth3$229.00$170.00$155.00$0.00
D3320Endodontic Therapy, Bicuspid Tooth3$270.00$201.00$183.00$0.00
D3330Endodontic Therapy, Molar3$354.00$263.00$240.00$0.00
D9972External Bleaching - Per Arch3$60.00$44.00$40.00$0.00
D9973External Bleaching - Per Tooth3$37.00$28.00$25.00$0.00
D6980Fixed Partial Denture Repair, By Report3$71.00$53.00$48.00$0.00
D9120Fixed Partial Denture Sectioning3$71.00$53.00$48.00$0.00
D4271Free Soft Tissue Graft Procedure (Incl Donor Site)3$293.00$218.00$199.00$0.00
D4241Gingival Flap Proc,Incl Root Planing-1 To 3 Teeth3$103.00$76.00$70.00$0.00
D4240Gingival Flap Proc,Incl Root Planing-4 Or More Tth3$205.00$152.00$139.00$0.00
D4211Gingivectomy Or Gingivoplasty - 1 To 3 Teeth3$75.00$56.00$51.00$0.00
D4210Gingivectomy Or Gingivoplasty - 4 Or More Teeth3$149.00$111.00$101.00$0.00
D3920Hemisection-Incl Root Removal Not Root Canal3$130.00$96.00$88.00$0.00
D5140Immediate Denture - Mandibular3$428.00$318.00$290.00$0.00
D5130Immediate Denture - Maxillary3$443.00$328.00$300.00$0.00
D6067Implant Supported Metal Crown3$372.00$276.00$252.00$0.00
D6066Implant Supported Porcelain Fused To Metal Crown3$372.00$276.00$252.00$0.00
D6065Implant Supported Porcelain/Ceramic Crown3$341.00$253.00$231.00$0.00
D6077Implant Supported Retainer For Cast Metal Fpd3$372.00$276.00$252.00$0.00
D6075Implant Supported Retainer For Ceramic Fpd3$341.00$253.00$231.00$0.00
D6076Implant Supported Retainer For Por Fusd To M Fpd3$372.00$276.00$252.00$0.00
D6078Implant/Abutment Supported Fixed Denture For Comp3$409.00$303.00$277.00$0.00
D6079Implant/Abutment Supported Fixed Denture For Parti3$474.00$351.00$321.00$0.00
D6053Implant/Abutment Supported Removable Dtr-Edentulou3$409.00$303.00$277.00$0.00
D6054Implant/Abutment Supported Removable Ptr-Edentulou3$474.00$351.00$321.00$0.00
D3332Incomplete Endo Therapy; Inop, Unrest Or Fract Tth3$135.00$100.00$92.00$0.00
D6603Inlay - Cast High Noble Metal, Three Or More Surf3$300.00$223.00$203.00$0.00
D6602Inlay - Cast High Noble Metal, Two Surfaces3$273.00$202.00$185.00$0.00
D6607Inlay - Cast Noble Metal - Three Or More Surfaces3$273.00$202.00$185.00$0.00
D6606Inlay - Cast Noble Metal - Two Surfaces3$248.00$184.00$168.00$0.00
D6604Inlay - Cast Predominantly Base Metal, 2 Surfaces3$236.00$175.00$160.00$0.00
D2510Inlay - Metallic - One Surface3$253.00$188.00$171.00$0.00
D2530Inlay - Metallic - Three Or More Surfaces3$324.00$241.00$220.00$0.00
D2520Inlay - Metallic - Two Surfaces3$301.00$224.00$204.00$0.00
D2610Inlay - Porcelain/Ceramic One Surface3$279.00$207.00$189.00$0.00
D2630Inlay - Porcelain/Ceramic Three Or More Surfaces3$332.00$247.00$225.00$0.00
D2620Inlay - Porcelain/Ceramic Two Surfaces3$303.00$225.00$205.00$0.00
D6601Inlay - Porcelain/Ceramic, Three Or More Surfaces3$334.00$247.00$226.00$0.00
D6600Inlay - Porcelain/Ceramic, Two Surfaces3$303.00$225.00$205.00$0.00
D2652Inlay - Resin-Based Composite 3 + Surfaces3$296.00$219.00$200.00$0.00
D2650Inlay - Resin-Based Composite One Surface3$290.00$215.00$196.00$0.00
D2651Inlay - Resin-Based Composite Two Surfaces3$286.00$212.00$194.00$0.00
D6624Inlay - Titanium3$300.00$223.00$203.00$0.00
D6605Inlay-Cast Predominantly Base Metal,3 Or More Surf3$259.00$192.00$176.00$0.00
D5811Interim Complete Denture (Mandibular)3$190.00$141.00$129.00$0.00
D5810Interim Complete Denture (Maxillary)3$180.00$134.00$122.00$0.00
D5821Interim Partial Denture (Mandibular)3$167.00$124.00$113.00$0.00
D5820Interim Partial Denture (Maxillary)3$159.00$118.00$108.00$0.00
D9974Internal Bleaching - Per Tooth3$45.00$33.00$30.00$0.00
D5226Mandibular Partial Denture - Flexible Base3$340.00$253.00$231.00$0.00
D5212Mandibular Partial Denture - Resin Base3$340.00$253.00$231.00$0.00
D5214Mandibular Partial Denture-Cast Metal W/Resin Base3$474.00$351.00$321.00$0.00
D5225Maxillary Partial Denture - Flexible Base3$294.00$218.00$199.00$0.00
D5211Maxillary Partial Denture - Resin Base3$294.00$218.00$199.00$0.00
D5213Maxillary Partial Denture-Cast Metal W/Resin Base3$474.00$351.00$321.00$0.00
D6611Onlay - Cast High Noble Metal, Three Or More Surf3$330.00$245.00$223.00$0.00
D6610Onlay - Cast High Noble Metal, Two Surfaces3$300.00$223.00$203.00$0.00
D6615Onlay - Cast Noble Metal - Three Or More Surfaces3$300.00$223.00$203.00$0.00
D6614Onlay - Cast Noble Metal - Two Surfaces3$273.00$202.00$185.00$0.00
D6612Onlay - Cast Predominantly Base Metal,2 Surfaces3$259.00$192.00$176.00$0.00
D6613Onlay - Cast Predominantly Base Metal,3 Or More3$285.00$212.00$193.00$0.00
D2542Onlay - Metallic - Two Surfaces3$328.00$243.00$222.00$0.00
D2544Onlay - Metallic, Four Or More Surfaces3$381.00$282.00$258.00$0.00
D2543Onlay - Metallic, Three Surfaces3$366.00$271.00$248.00$0.00
D2644Onlay - Porcelain/Ceramic, Four Or More Surfaces3$378.00$281.00$256.00$0.00
D6609Onlay - Porcelain/Ceramic, Three Or More Surfaces3$361.00$268.00$244.00$0.00
D2643Onlay - Porcelain/Ceramic, Three Surfaces3$367.00$272.00$249.00$0.00
D2642Onlay - Porcelain/Ceramic, Two Surfaces3$328.00$243.00$222.00$0.00
D6608Onlay - Porcelain/Ceramic, Two Surfaces3$328.00$243.00$222.00$0.00
D2664Onlay - Resin-Based Composite 4 + Surfaces3$337.00$250.00$228.00$0.00
D2663Onlay - Resin-Based Composite Three Surfaces3$317.00$235.00$215.00$0.00
D2662Onlay - Resin-Based Composite Two Surfaces3$308.00$228.00$208.00$0.00
D6634Onlay - Titanium3$330.00$245.00$223.00$0.00
D4260Osseous Surg(Incl Flap Entry & Clos)-4 Or More Tth3$376.00$279.00$255.00$0.00
D4261Osseous Surgery(Incl Flap Entry & Clos)-1 To 3 Tth3$188.00$140.00$128.00$0.00
D5860Overdenture - Complete, By Report3$409.00$303.00$277.00$0.00
D5861Overdenture - Partial, By Report3$474.00$351.00$321.00$0.00
D4270Pedicle Soft Tissue Graft Procedure3$277.00$206.00$188.00$0.00
D4342Periodontal Scaling And Root Planing, 1 To 3 Teeth3$38.00$29.00$26.00$0.00
D4341Periodontal Scaling And Root Planing-4 Or More Tth3$77.00$57.00$52.00$0.00
D6210Pontic - Cast High Noble Metal3$372.00$276.00$252.00$0.00
D6212Pontic - Cast Noble Metal3$403.00$299.00$273.00$0.00
D6211Pontic - Cast Predominantly Base Metal3$372.00$276.00$252.00$0.00
D6205Pontic - Indirect Resin Based Composite3$307.00$228.00$208.00$0.00
D6240Pontic - Porcelain Fused To High Noble Metal3$372.00$276.00$252.00$0.00
D6242Pontic - Porcelain Fused To Noble Metal3$341.00$253.00$231.00$0.00
D6245Pontic - Porcelain/Ceramic3$341.00$253.00$231.00$0.00
D6250Pontic - Resin With High Noble Metal3$372.00$276.00$252.00$0.00
D6252Pontic - Resin With Noble Metal3$403.00$299.00$273.00$0.00
D6251Pontic - Resin With Predominantly Base Metal3$341.00$253.00$231.00$0.00
D6214Pontic - Titanium3$372.00$276.00$252.00$0.00
D6241Pontic-Porcelain Fused To Predominantly Base Metal3$372.00$276.00$252.00$0.00
D6970Post & Core In Addition To Fixed Partial Dent Ret3$112.00$83.00$76.00$0.00
D2952Post And Core In Addition To Crown, Ind Fabricated3$126.00$94.00$86.00$0.00
D6972Prefabricated Post & Core In Add To Fixed Partial3$112.00$83.00$76.00$0.00
D2954Prefabricated Post And Core In Addition To Crown3$105.00$78.00$71.00$0.00
D3221Pulpal Debridement, Primary And Permanent Teeth3$50.00$37.00$34.00$0.00
D3230Pulpal Therapy - Anterior, Primary Tooth3$67.00$50.00$45.00$0.00
D3240Pulpal Therapy - Posterior, Primary Tooth3$58.00$43.00$39.00$0.00
D5711Rebase Complete Mandibular Denture3$157.00$117.00$107.00$0.00
D5710Rebase Complete Maxillary Denture3$149.00$110.00$101.00$0.00
D5721Rebase Mandibular Partial Denture3$150.00$111.00$102.00$0.00
D5720Rebase Maxillary Partial Denture3$142.00$105.00$96.00$0.00
D5281Removable Unilateral Partial Denture-1 Piece Cast3$254.00$188.00$172.00$0.00
D5671Repl All Tth & Acrylic On Cast Metal Framewrk-Mand3$340.00$253.00$231.00$0.00
D5670Replace All Tth & Acrylic On Cast Metal Frmwrk-Max3$294.00$218.00$199.00$0.00
D6548Retainer - Porcelain/Ceramic For Resin Bonded Fixe3$124.00$92.00$84.00$0.00
D6545Retainer-Cast Metal For Resin Bonded Fixed Prosthe3$124.00$92.00$84.00$0.00
D3346Retreatment Of Prev Root Canal Therapy-Anterior3$286.00$212.00$194.00$0.00
D3347Retreatment Of Prev Root Canal Therapy-Bicuspid3$329.00$244.00$223.00$0.00
D3348Retreatment Of Prev Root Canal Therapy-Molar3$409.00$303.00$277.00$0.00
D3430Retrograde Filling-Per Root3$64.00$48.00$44.00$0.00
D3450Root Amputation-Per Root3$153.00$114.00$104.00$0.00
D4275Soft Tissue Allograft3$293.00$218.00$199.00$0.00
D4273Subepithelial Connective Tissue Graft Procedures3$342.00$254.00$232.00$0.00
D3220Therapeutic Pulpotomy(Excluding Final Restoration)3$50.00$37.00$34.00$0.00
D5851Tissue Conditioning, Mandibular3$45.00$33.00$30.00$0.00
D5850Tissue Conditioning, Maxillary3$42.00$31.00$28.00$0.00
D7220Removal Of Impacted Tooth - Soft Tissue3$100.00$74.00$68.00$55.00
D7210Surgical Removal Of Erupted Tooth Requiring Elevat3$80.00$59.00$54.00 

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