| CODE |
PROCEDURES |
YOUR COST
WITH ADMS |
| 00150 |
Initial Oral Exam |
$ NC* |
| 00120 |
Periodic Oral Exam |
10 |
| 00140 |
Emergency Oral Exam |
NC* |
| 00220 |
X-ray (PA Single) |
5 |
| 00230 |
X-ray Each Additional PA |
5 |
| 00270 |
X-ray Bite Wing (Sngl. Film) |
7 |
| 00272 |
X-ray Bitewing (2 Films) |
10 |
| 00330 |
X-ray Panorex |
20 |
| 00460 |
Pulp Vitality Tests |
12 |
| 00470 |
Study Casts |
25 |
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PREVENTIVE DENTISTRY PROCEDURES |
|
| 01110 |
Routine Cleaning, Adult
(1 every six months) |
$15 |
| 01120 |
Routine Cleaning, Child
(1 every six months) |
10 |
| 01203 |
Fluoride Application |
10 |
| 01330 |
Oral Hygiene Instructions |
2 |
| 01351 |
Sealant Per Tooth |
15 |
| 01510 |
Space Maintainer
(Fixed Unilateral Type) |
Lab Fee
Plus 50% of UCR |
| 01515 |
Space Maintainer
(Fixed Bilateral Type) |
Lab Fee
Plus 50% of UCR |
| 04355 |
Gross Debridement |
50 |
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RESTORATIVE DENTISTRY PROCEDURES |
|
| Primary/Permanent Teeth |
| 02140 |
Amalgam, 1 Surface |
$30 |
| 02150 |
Amalgam, 2 Surface |
40 |
| 02160 |
Amalgam, 3 Surface |
45 |
| 02161 |
Amalgam, 4 Surface |
52 |
| 02330 |
Composite Resin - 1 Surf. Anterior |
50 |
| 02331 |
Composite Resin - 2 Surf. Anterior |
55 |
| 02332 |
Composite Resin - 3 Surf. Anterior |
62 |
| 02335 |
Resin (Incisal Angle) |
75 |
| 02391 |
1 Surface Post. Composite |
60 |
| 02392 |
2 Surface Post. Composite |
80 |
| 02393 |
3 Surface Post. Composite |
90 |
| 02394 |
4 Surface Post. Composite |
110 |
| 02510 |
Inlay Gold, 1 Surface + (Cost of Gold) |
210 |
| 02520 |
Inlay Gold, 2 Surface + (Cost of Gold) |
270 |
| 02530 |
Inlay Gold, 3 Surface + (Cost of Gold) |
285 |
| 02610 |
Inlay - Porcelain 1 Surface |
300 |
| 02710 |
Acrylic Crown |
180 |
| 02751 |
Porcelain Crown to Metal |
350 |
| 02790 |
Full Crown Gold |
300 Plus Gold |
| 02952 |
Post-N-Core |
110 |
| 02910 |
Recement Inlay |
NC* |
| 02920 |
Recement Crown |
NC* |
| 02930 |
Stainless Steel Crown (Primary) |
65 |
| 02931 |
Stainless Steel Crown (Permanent) |
85 |
| 02932 |
Prefab. Resin Crown |
100 |
| 02940 |
Sedative Fillings |
20 |
| 02950 |
Crown Building (Including Pins) |
50 |
| 02961 |
Labial Veneers (Resin) |
300 |
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* NC - No Charge
** Other Endodontic and Periodontic Services
will be provided by the respective Specialists.
Cost Of Lab Is An Additional Charge - Not Included In The Fees Listed
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