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Office Fee - We are happy to provide additional office fees for procedures but below are some of our most commonly used codes/fees.  Please note that some procedures involve multiple procedure codes.  For example, a crown sometimes requires a build-up which is a filling that is required to have a crown fit on your tooth.

  • D1110 - Prophylaxis (dental cleaning)  - $138

  • D0120 - Periodic Exam - $70

  • D0210 - Full Series X-ray - $185

  • D0274 - Four Bitewing X-rays - $86

  • D2391 - 1-Surface Filling - $266

  • D2740 - Porcelain Crown - $1565

  • D2950 - Build-up (often required with a crown) - $325

  • D7210 - Surgical Extraction -  $390

Percentage of Coverage - Usually an amount of 50%, 80% or 100%.  This will determine what percentage of the Maximum Allowable Fee an insurance company should hopefully cover (there are never any guarantees that an insurance company will cover their cost due to their litany of restrictions).  Please enter your percentage as a decimal (100% = 1.00, 80% = .80, 50% = .50)

Maximum Allowable Charge (MAC) & Usual and Customary Rates (UCR) - these are the dollar amounts that insurance companies use to process claims for out of network providers (whereas in network providers have agreed to a set, lower insurance dictated fee). This is done to keep your premiums lower.  For example, if a dentist charged $500 for a cleaning, it could not be expected to have an insurance pay 100% of that $500.  MAC's can vary greatly relative to office fees and is a major contributing factor to your out-of-pocket costs. Most UCR fees           (average fees based on geographic location) are close to our office fees, so 100% coverage probably means 100% coverage. But sometimes, the MAC (especially non-UCR fees) is lower than our office fee (sometimes by quite a lot), which would mean insurance will pay 100% of that lower fee and leave the patient responsible for anything above it.  See example below.

Insurance companies do not regularly give out this information, so unfortunately, we have a limited list of MAC's.  It is best for you to call your insurance to find out if the MAC for your plan is higher than, equal to, or less than our office fees.


If your estimated out of pocket cost is a negative number, it means that you are estimated to have $0 out of pocket cost. (This happens because the MAC is higher than our Office Fee)

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