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Appleton Dental Plan members are entitled to discounted* fees and savings from our participating dentists that are significantly lower than those customarily charged by dentists in your area.
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ADA Code
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Procedure
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Usual Fee
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Member Fee
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Member Savings
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0120
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Routine 6 Month Check Up
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$ 43
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$ 15
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$ 28
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0210
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Full Mouth X-rays
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$103
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$ 25
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$ 78
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0274
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Bitewings – four
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$ 55
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$ 20
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$ 35
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0330
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Panoramic Film
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$ 90
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$ 30
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$ 60
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1110
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Adult Cleaning
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$ 77
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$ 35
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$ 42
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1120
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Child Cleaning
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$ 55
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$ 30
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$ 25
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2140
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Amalgam 1 surface (silver filling)
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$139
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$ 56
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$ 83
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2330
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Composite 1 surface (white filling)
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$123
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$ 63
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$ 60
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2750
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Crown porcelain high noble
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$889
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$595
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$294
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2950
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Core buildup, including pins
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$234
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$120
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$114
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2952
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Cast post & core in addition to crown
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$403
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$155
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$248
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3310
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Root canal – anterior
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$582
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$385
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$197
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3320
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Root canal – bicuspid
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$654
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$450
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$204
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3330
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Root canal – molar
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$808
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$595
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$213
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4341
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Periodontal scaling/root planing
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$204
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$110
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$ 94
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7140
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Extraction, erupted tooth or exposed root
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$166
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$ 95
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$ 71
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To explore Appleton Dental Plan's Fee Schedule further, you may review the entire document in PDF format here. (54Kb download)
* Discounted fees are listed for visits to a participating general dentist. Any procedure not covered on the complete schedule of benefits (see fee schedule) will be discounted 20% off the provider’s usual and customary fee. Consult with your provider prior to beginning any treatment.
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