D0120
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Periodic Oral Evaluation
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Routine exam for established patients
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$100.00
|
$10.00
|
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D0140
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Limited oral evaluation - problem focused
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Emergency oral examination, problem focused
|
$125.00
|
$10.00
|
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D0150
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Comprehensive oral evaluation - new or established patient
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A thorough evaluation and recording of the soft and hard tissues of the mouth.
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$125.00
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$10.00
|
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D0210
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Intraoral-Complete Series Including Bitewings
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Full mouth set of X-rays/image
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$175.00
|
$20.00
|
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D0220
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Intraoral - periapical first radiographic images
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A X-ray film that shows the whole toot including the root and area around it.
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$35.00
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$10.00
|
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D0270
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Bitewing - single radiographic images
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X-rays of the crowns of teeth to determine the existence of decay, one film
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$39.00
|
$7.00
|
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D0272
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Bitewings - two radiographic images
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X-rays of the crowns of teeth to determine the existence of decay, two films
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$65.00
|
$10.00
|
|
D0274
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Bitewings - four radiographic images
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X-rays of the crowns of teeth to determine the existence of decay, four films
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$96.00
|
$10.00
|
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D0330
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Panoramic Film
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X-rays/image taken around the head and showing full mouth on same film
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$150.00
|
$20.00
|
|
D1110
|
Prophylaxis Adults
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Routine adult cleaning
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$120.00
|
$0.00
|
|
D1120
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Prophylaxis - child
|
Routine child cleaning
|
$100.00
|
$0.00
|
|
D1206
|
Topical fluoride varnish
|
Protective varnish that prevents cavities
|
$55.00
|
$11.00
|
|
D1208
|
Topical application of fluoride
|
Protective varnish that prevents cavities
|
$60.00
|
$10.00
|
|
D1351
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Sealant - Per Tooth
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Protective substance that fills in grooves or seals the top of the tooth to prevent cavities
|
$65.00
|
$24.00
|
|
D2140
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Amalgam - one surface, primary or permanent
|
A one surface silver filling used to fill cavities
|
$200.00
|
$56.00
|
|
D2150
|
Amalgam - two surfaces, primary or permanent
|
A two surface silver filling used to fill cavities
|
$250.00
|
$65.00
|
|
D2160
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Amalgam - three surfaces, primary or permanent
|
A three surface silver filling used to fill cavities
|
$335.00
|
$85.00
|
|
D2330
|
resin-based composite - one surface, anterior
|
White filling in the front teeth of your mouth, one surface of the tooth
|
$200.00
|
$65.00
|
|
D2331
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Resin-based composite - two surfaces, anterior
|
White filling in the front teeth of your mouth, two surfaces of the tooth
|
$250.00
|
$84.00
|
|
D2332
|
Resin-based composite - three surfaces, anterior
|
White filling in the front teeth of your mouth, three surfaces of the tooth
|
$300.00
|
$102.00
|
|
D2335
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Resin-based composite - four or more surfaces or involving incisal angle (anterior)
|
White filling in the front teeth of your mouth, four surfaces of the tooth
|
$380.00
|
$124.00
|
|
D2750
|
Crown – Porcelain fused to high noble metal
|
Porcelain or ceramic crown over gold metal
|
$1,495.00
|
$555.00
|
|
D2950
|
Core buildup, including any pins
|
"Crown (or ""cap"") -- Core build up to help crown retention"
|
$335.00
|
$40.00
|
|
D3220
|
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament
|
Removal of the core of the tooth, and applying medicament before a restoration
|
$400.00
|
$65.00
|
|
D3320
|
Endodontic therapy, bicuspid tooth (excluding final restoration)
|
Root canal on a bicuspid tooth
|
$1,300.00
|
$478.00
|
|
D3330
|
Root Canal Therapy - Molar
|
Root canal on a molar
|
$1,500.00
|
$643.00
|
|
D4341
|
Perio Scaling/Root Planing - four or more contiguous teeth or bounded spaces per quadrant
|
Treatment of gum disease; scraping deposits and smoothing roots below the gum line
|
$303.00
|
$150.00
|
|
D4355
|
Full Mouth Debridement To Enable Comprehensive Evaluation and Diagnosis
|
Removal of tartar build-up above and below to gum line to prepare for examination for gum disease
|
$200.00
|
$90.00
|
|
D4910
|
Periodontal maintenance
|
Ongoing prophylaxis treatment that focuses on scaling under the gums to maintain healthy gum pockets.(maintenance)
|
$167.00
|
$100.00
|
|
D5110
|
Complete Upper
|
Complete upper denture worn on the upper jaw
|
$1,650.00
|
$680.00
|
|
D5120
|
Complete denture - mandibular
|
Complete (Full) Lower denture to replace all teeth
|
$1,600.00
|
$680.00
|
|
D5211
|
Maxillary partial denture - resin base (including any conventional clasps, rests and teeth)
|
Upper partial denture (plastic) to replace missing teeth
|
$1,300.00
|
$575.00
|
|
D5212
|
Mandibular partial denture - resin base (including any conventional clasps, rests and teeth)
|
Lower partial denture (plastic) to replace missing teeth
|
$1,460.00
|
$575.00
|
|
D5410
|
Adjust complete denture - maxillary
|
Upper denture adjustments
|
$150.00
|
$30.00
|
|
D5411
|
Adjust complete denture - mandibular
|
Lower denture adjustments
|
$150.00
|
$30.00
|
|
D6211
|
Pontic - cast predominantly base metal
|
Pontic (replaces a missing tooth) -- Cast predominantly base metal (silver colored with all non-precious metal
|
$1,440.00
|
$450.00
|
|
D6751
|
Crown - porcelain fused to predominantly base metal
|
Crown (Silver colored with non-precious metal)
|
$1,350.00
|
$500.00
|
|
D6791
|
Crown - full cast predominantly base metal
|
Crown - full cast (Silver colored with non-precious metal)
|
$1,524.00
|
$500.00
|
|
D7140
|
Extraction erupted tooth or exposed root (elevation and/or forceps removal)
|
A tooth that is beyond repair by a root canal is removed nonsurgically
|
$250.00
|
$83.00
|
|
D7210
|
Surgical Removal Of Erupted Tooth
|
A tooth that is beyond repair by a root canal is removed surgically
|
$395.00
|
$156.00
|
|
D8040
|
Orthodontic Transition. Adolescent Dentition
|
Orthodontic treatment in adolescents
|
$4,500.00
|
$1,350.00
|
|
D8090
|
Orthodontic Transition Adult Dentition
|
Orthodontic treatment in adults
|
$4,500.00
|
$3,700.00
|
|
D9110
|
Palliative (emergency) treatment of dental pain - minor procedure
|
Emergency office visit for pain
|
$175.00
|
$40.00
|
|
D9239
|
Intravenous conscious sedation/analgesia - first 15 minutes
|
IV sedation-15 minutes
|
$500.00
|
$55.00
|
|
D9243
|
Intravenous conscious sedation/analgesia - each additional 15 minutes
|
IV sedation-15 minutes
|
$208.00
|
$55.00
|
|
D9944
|
Occlusal guard, by report
|
Night guard, by report
|
$656.00
|
$350.00
|
|
D9945
|
Occlusal guard, by report
|
Night guard, by report
|
$656.00
|
$350.00
|
|
D9946
|
Occlusal guard, by report
|
Night guard, by report
|
$656.00
|
$350.00
|
|