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| D0120 |
Periodic Oral Examination |
$30.00 |
$12.00 |
|
| D0140 |
Limited Oral Examination, Problem Focused |
$49.00 |
$25.00 |
|
| D0150 |
Comprehensive Oral Examination |
$45.00 |
$30.00 |
|
| D0180 |
Perio Exam |
$40.00 |
$15.00 |
|
| D0210 |
Intraoral - Complete Series (including bitewing) |
$97.00 |
$48.00 |
|
| D0220 |
Interoral - Periapical - First Film |
$16.00 |
$14.00 |
|
| D0230 |
Interoral - Periapical - Each Additional Film |
$12.00 |
$10.00 |
|
| D0240 |
Intraoral - Occlusal film |
$20.00 |
$14.00 |
|
| D0270 |
Bitewing - Single film |
$15.00 |
$10.00 |
|
| D0272 |
Bitewing - Two films |
$28.00 |
$18.00 |
|
| D0273 |
Bitewing - Three films |
$38.00 |
$22.00 |
|
| D0274 |
Bitewing - Four films |
$44.00 |
$30.00 |
|
| D0330 |
Panoramic Film |
$82.00 |
$48.00 |
|
| D0460 |
Pulp Vitality Test |
$54.00 |
$38.00 |
|
| D0470 |
Diagnostic Casts |
$72.00 |
$30.00 |
|
| D1110 |
Prophylaxis - adult |
$69.00 |
$45.00 |
|
| D1120 |
Prophylaxis - child |
$60.00 |
$38.00 |
|
| D1203 |
Flouoride Child |
$28.00 |
$15.00 |
|
| D1204 |
Fluoride Adult |
$32.00 |
$15.00 |
|
| D1330 |
Oral Hygiene Instruction |
$25.00 |
$10.00 |
|
| D1351 |
Sealant - per tooth |
$34.00 |
$22.00 |
|
| D1510 |
Space Maintainer - Fixed Unilateral Type |
$231.00 |
$145.00 |
|
| D1515 |
Space Maintainer - Fixed Bilateral Type |
$305.00 |
$175.00 |
|
| D2140 |
Amalgam - 1 Surface, Primary or Permanent |
$97.00 |
$60.00 |
|
| D2150 |
Amalgam - 2 Surfaces, Primary or Permanent |
$113.00 |
$70.00 |
|
| D2160 |
Amalgam - 3 Surfaces, Primary or Permanent |
$136.00 |
$80.00 |
|
| D2161 |
Amalgam - 4 Or More Surfaces, Primary or Permanent |
$170.00 |
$120.00 |
|
| D2330 |
Resin 1 Surface, Anterior |
$136.00 |
$65.00 |
|
| D2331 |
Resin 2 Surfaces, Anterior |
$155.00 |
$85.00 |
|
| D2332 |
Resin 3 Surfaces, Anterior |
$173.00 |
$110.00 |
|
| D2335 |
Resin 4 Surfaces or Involving Incisal Angel Anterior |
$268.00 |
$160.00 |
|
| D2391 |
Resin - Based Composite 1 Surface Posterior |
$147.00 |
$75.00 |
|
| D2392 |
Resin - Based Composite - 2 Surfaces - Posterior |
$173.00 |
$95.00 |
|
| D2393 |
Resin - Based Composite - 3 Surfaces Posterior |
$201.00 |
$120.00 |
|
| D2394 |
Resin - Based Composite - 4 Surfaces or More Surfaces Posterior |
$210.00 |
$180.00 |
|
| D2750 |
Crown - Porcelain Fused To High Nobel Metal |
$993.00 |
$600.00 |
|
| D2751 |
Crown - Porcelain Fused To Predominately Base Metal |
$880.00 |
$550.00 |
|
| D2752 |
Crown - Porcelain Fused To Noble Metal |
$855.00 |
$575.00 |
|
| D2790 |
Crown - Full Cast High Noble Metal |
$800.00 |
25% Discount |
|
| D2791 |
Crown - Full Cast Predominantly Base Metal 3/4 |
$705.00 |
25% Discount |
|
| D2791 |
Crown-Full Cast Predominantly Base Metal 3/4 Cast Metallic |
$705.00 |
25% Discount |
|
| D2792 |
Crown - Full Cast Noble Metal |
$950.00 |
25% Discount |
|
| D2810 |
Crown - 3/4 Cast Metallic |
$750.00 |
$450.00 |
|
| D2910 |
Recement Inlay |
$65.00 |
$40.00 |
|
| D2920 |
Recement Crown |
$97.00 |
$40.00 |
|
| D2930 |
Prefabricated Stainless Steel Crown, Primary Tooth |
$200.00 |
25% Discount |
|
| D2940 |
Sedative Filing |
$80.00 |
$40.00 |
|
| D2950 |
Crown Build Up, Including Any Pins |
$228.00 |
$150.00 |
|
| D2951 |
Pin Retention Per Tooth In Addition To Restoration |
$70.00 |
25% Discount |
|
| D2952 |
Cast Post And Core In Addition To Crown |
$243.00 |
25% Discount |
|
| D2953 |
Cast Post As Part Of Crown |
$115.00 |
25% Discount |
|
| D2954 |
Prefabricated Post And Core In Addition To Crown |
$205.00 |
25% Discount |
|
| D3110 |
Pulp Cap - Direct (Excluding Final Restoration) |
$50.00 |
$35.00 |
|
| D3120 |
Pulp Cap - Indirect (Excluding Final Restoration) |
$50.00 |
$35.00 |
|
| D3220 |
Therapeutic Pulpotomy (Excluding Final Restoration) |
$118.00 |
$65.00 |
|
| D3310 |
Root Canal Anterior (Excluding Final Restoration) |
$496.00 |
$400.00 |
|
| D3320 |
Root Canal Bicuspid (Excluding Final Restoration) |
$614.00 |
$450.00 |
|
| D3330 |
Root Canal Molar (Excluding Final Restoration) |
$850.00 |
25% Discount |
|
| D4240 |
Gingival Flap Procedure, Including Root Planning Per Quadrant |
$476.00 |
25% Discount |
|
| D4260 |
Osseous Surgery (Including Flap Entry & Closure - Per Quadrant) |
$768.00 |
25% Discount |
|
| D4270 |
Pedicle Soft Tissue Graft Procedure |
$532.00 |
25% Discount |
|
| D4271 |
Free Soft Tissue Graft Procedure |
$547.00 |
25% Discount |
|
| D4341 |
Periodontal Scaling & Root Planning - Per Quadrant |
$185.00 |
$100.00 |
|
| D4355 |
Full Mouth Debridement |
$135.00 |
$60.00 |
|
| D4910 |
Periodontal Maintenance Procedures Following Active Therapy |
$110.00 |
$75.00 |
|
| D5110 |
Complete Denture Upper |
$1000.00 |
$750.00 |
|
| D5120 |
Complete Denture Lower |
$1000.00 |
$750.00 |
|
| D5130 |
Immediate Denture Upper |
$1050.00 |
25% Discount |
|
| D5140 |
Immediate Denture Lower |
$1050.00 |
25% Discount |
|
| D5211 |
Upper Partial - Acrylic Base (Including Any Conventional Clasps & Rests) |
$850.00 |
$600.00 |
|
| D5212 |
Lower Partial - Acrylic Base (Including Any Convential Clasps & Rests) |
$950.00 |
25% Discount |
|
| D5213 |
Upper Partial - Predominately Base Cast Base With Acrylic Saddles (Including Any Conventional Clasps & Rests) |
$1200.00 |
$800.00 |
|
| D5214 |
Lower Partial - Predominantly Base Cast Base With Acrylic Saddles (Including Any Conventional Clasps & Rests) |
$1200.00 |
$800.00 |
|
| D5410 |
Adjust Complete Denture - Upper |
$35.00 |
$40.00 |
|
| D5411 |
Adjust Complete Denture - Lower |
$55.00 |
$40.00 |
|
| D5421 |
Adjust Partial Denture - Upper |
$55.00 |
$40.00 |
|
| D5422 |
Adjust Partial Denture - Lower |
$55.00 |
$40.00 |
|
| D5520 |
Replace Missing Or Broken Teeth Complete Denture (Each Tooth) |
$80.00 |
25% Discount |
|
| D5650 |
Add Tooth To Existing Partial Denture |
$98.00 |
25% Discount |
|
| D5660 |
Add Clasp To Existing Partial Denture |
$98.00 |
25% Discount |
|
| D5710 |
Rebase Complete Upper Denture |
$350.00 |
$275.00 |
|
| D5711 |
Rebase Complete Lower Denture |
$350.00 |
$275.00 |
|
| D5720 |
Rebase Upper Partial Denture |
$200.00 |
$250.00 |
|
| D5721 |
Rebase Lower Partial Denture |
$200.00 |
$250.00 |
|
| D5730 |
Reline Complete Upper Dentures (Chairside) |
$200.00 |
25% Discount |
|
| D5731 |
Reline Complete Lower Dentures (Chairside) |
$200.00 |
25% Discount |
|
| D5740 |
Reline Upper Partial Dentures (Chairside) |
$183.00 |
25% Discount |
|
| D5741 |
Reline Lower Partial Dentures (Chairside) |
$183.00 |
25% Discount |
|
| D5750 |
Reline Complete Upper Dentures (Laboratory) |
$215.00 |
25% Discount |
|
| D5751 |
Reline Complete Lower Dentures (Laboratory) |
$267.00 |
25% Discount |
|
| D5760 |
Reline Upper Partial Dentures (Laboratory) |
$263.00 |
25% Discount |
|
| D5761 |
Reline Lower Partial Dentures (Laboratory) |
$263.00 |
25% Discount |
|
| D6210 |
Pontic - Cast High Noble Metal |
$650.00 |
25% Discount |
|
| D6211 |
Pontic - Cast Predominantly Base Metal |
$700.00 |
25% Discount |
|
| D6212 |
Pontic - Cast Noble Metal |
$700.00 |
25% Discount |
|
| D6240 |
Pontic - Porcelain Fused To High Noble Metal |
$780.00 |
25% Discount |
|
| D6241 |
Pontic - Porcelain Fused To Predominantly Base Metal |
$931.00 |
25% Discount |
|
| D6242 |
Pontic - Porcelain Fused To Noble Metal |
$931.00 |
25% Discount |
|
| D6520 |
Inlay - Metallic - 2 Surfaces |
$931.00 |
25% Discount |
|
| D6530 |
Inlay - metallic - 3 Surfaces Or More |
$951.00 |
25% Discount |
|
| D6545 |
Cast Metal Retainer For Resin Bonded Fixed Prosthesis |
$520.00 |
25% Discount |
|
| D6750 |
Crown - Porcelain Fused To High Noble Metal |
$780.00 |
25% Discount |
|
| D6751 |
Crown - Porcelain Fused To Predominantly Base Metal |
$725.00 |
25% Discount |
|
| D6752 |
Crown - Porcelain Fused To Noble Metal |
$725.00 |
25% Discount |
|
| D6780 |
Crown - 3/4 Cast High Noble Metal |
$681.00 |
25% Discount |
|
| D6790 |
Crown - Full Cast High Noble Metal |
$711.00 |
25% Discount |
|
| D6791 |
Crown - Full Cast Predominantly Base Metal |
$711.00 |
25% Discount |
|
| D6792 |
Crown - Full Cast Noble Metal |
$711.00 |
25% Discount |
|
| D6930 |
Recement Bridge |
$95.00 |
$60.00 |
|
| D6940 |
Stress Breaker |
$235.00 |
25% Discount |
|
| D6950 |
Precision Attachment |
$350.00 |
25% Discount |
|
| D6970 |
Cast Post & Core In Addition To Bridge Retainer |
$298.00 |
25% Discount |
|
| D6971 |
Cast Post As Part Of Bridge Retainer |
$203.00 |
25% Discount |
|
| D6972 |
Prefabricated Post & Core In Addition To Bridge Retainer |
$175.00 |
25% Discount |
|
| D7140 |
Single Tooth |
$95.00 |
$60.00 |
|
| D7210 |
Surgical removal of erupted tooth requiring elevation ofmucopriosteal flap & removal of bone & or section of tooth |
$190.00 |
$130.00 |
|
| D7220 |
Removal of Impacted Tooth (soft tissue) |
$260.00 |
$150.00 |
|
| D7230 |
Removal of Impacted Tooth (partially bony) |
$250.00 |
$200.00 |
|
| D7240 |
Removal of Impacted Tooth (completely) |
$300.00 |
25% Discount |
|