| CODE |
PROCEDURES |
YOUR COST
WITH ADMS |
| 03110 |
Pulp Cap Direct |
$15 |
| 03120 |
Pulp Cap Indirect |
15 |
| 03220 |
Pulpotomy (Exc. Final Restoration) |
45 |
| 03310 |
RCT. 1 Canal |
160 |
| 03320 |
RCT. 2 Canal |
195 |
| 03330 |
RCT. 3 Canal |
215 |
| 09972 |
Bleaching Per Arch |
200 |
| |
|
|
| |
Back to Top |
|
| |
|
|
| |
PERIODONTIC PROCEDURES |
|
| 04210 |
Gingivectomy/Quad |
$125 |
| 04211 |
Gingivectomy - Per Tooth |
60 |
| 04260 |
Osseous Surg./Quad |
350 |
| 04341 |
Perio Scaling & Root Planing Partial (Per Quadrant) |
55 |
| 04910 |
Perio. Maint. Following Surgery |
65 |
| |
|
|
| |
Back to Top |
|
| |
|
|
| |
REMOVABLE PROSTHODONTICS PROCEDURES |
|
| 05110 |
Complete Denture Upper |
$410 |
| 05120 |
Complete Denture Lower |
410 |
| 05130 |
Immed. Denture Upper |
475 |
| 05140 |
Immed. Denture Lower |
475 |
| 05211 |
Upper Partial Acrylic, 2 Clasp |
400 |
| 05212 |
Lower Partial Acrylic, 2 Clasp |
400 |
| 05213 |
Upper Partial Denture, Chrome, 2 Clasp |
460 |
| 05214 |
Lower Partial Denture, Chrome, 2 Clasp |
460 |
| 05281 |
Removable Unilateral - Partial |
350 |
| 05400 |
Denture Adjustment (First 6 months) |
NC* |
| 05410 |
Adjust Upper Denture (After 6 months) |
15 |
| 05411 |
Adjust Lower Denture (After 6 months) |
15 |
| 05421/22 |
Adjust Upper/Lower Partial (After 6 months) (each) |
15 |
| 05510 |
Repair Broken Denture Base/Acrylic Saddle |
65 |
| 05520 |
Replace Missing/Broken Tooth (each) |
50 |
| 05610 to 05640 |
Repair Partial Dentures |
Lab Fee
Plus 50% of UCR |
| 05650 |
Add Tooth to Denture or Partial |
45 |
| 05660 |
Add Clasp to Partial |
65 |
| 05710 |
Rebase Denture - Upper |
165 |
| 05711 |
Rebase Denture - Lower |
165 |
| 05720 |
Rebase Partial - Upper |
165 |
| 05721 |
Rebase Partial - Lower |
165 |
| 05730/31 |
Reline Complete Denture (Office) (each) |
65 |
| 05740/41 |
Reline Partial Denture (Office) (each) |
65 |
| 05750/51 |
Reline Complete Denture (Lab) (each) |
165 |
| 05760/61 |
Reline Partial Denture (Lab) (each) |
165 |
| 05850/51 |
Tissue Conditioning (each) |
50 |
| |
|
|
| |
Back to Top |
|
| |
* 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
|
| |
