| PROCEDURE |
UCR*
CHARGE |
ADMS
COST |
SAVINGS |
|
| Initial Oral Exam |
$40 |
$ N/C** |
$40 |
| Emergency Oral Exam |
45 |
N/C |
45 |
| Emergency Palliative Treat. |
60 |
30 |
30 |
| Oral Hygiene Instruction |
25 |
2 |
23 |
| Recement Inlay |
60 |
N/C |
60 |
| Recement Crown |
50 |
N/C |
50 |
| Recement Bridge |
80 |
40 |
40 |
| Excision/Hyper Tissue |
207 |
65 |
142 |
| X-Ray - Panorex |
62 |
20 |
37 |
| Cleaning, Adult |
58 |
15 |
43 |
| Cleaning, Child |
45 |
10 |
35 |
| Routine Extraction |
85 |
32 |
53 |
| Porcelain/Metal Crown |
840 |
410 |
430 |
| Full Crown |
870 |
410 |
460 |
| Stainless Crown |
184 |
85 |
99 |
| RCT 1 Canal |
427 |
160 |
267 |
| RCT 2 Canal |
488 |
195 |
293 |
| RCT 3 Canal |
617 |
215 |
402 |
| Immediate Upper Denture |
1100 |
475 |
625 |
| Pontic - Porcelain/Metal |
840 |
410 |
430 |
| Surgical Extraction |
154 |
65 |
89 |
| Missed Appointment |
40 |
25 |
15 |
| |
*Usual and Customary Rates
**No Charge |
| |
