Diagnostic
Charting
history, oral examination, periodic recall
examination (every
six months), emergency treatment No
Charge
Radiographic
Complete
intraoral series, periapical
and bitewing films No
Charge
Intraoral
periapical No
Charge
Each
additional single film (periapical or bitewing) No Charge
Occlusal
view x-ray No
Charge
Lateral
jaw x-ray, each No
Charge
Four
bitewing x-ray films No
Charge
Antero-posterior
x-ray of head and jaw No
Charge
Cephalometric
radiograph No
Charge
Panoramic
(panography) including bitewings No
Charge
Preventive
Oral
prophylaxis (every six months) No
Charge
Topical
fluoride treatment following prophylaxis No
Charge
Space maintainers – unilateral No
Charge
Space maintainers – bilateral No
Charge
Operative (Restorative) Services
Primary
Silver amalgam – 1 surface No
Charge
Primary
Silver amalgam – 2 surfaces No
Charge
Primary
Silver amalgam – 3 surfaces or more No
Charge
Permanent
Silver amalgam – 1 surface No
Charge
Permanent
Silver amalgam – 2 surfaces No
Charge
Permanent
Silver amalgam – 3 surfaces or more No
Charge
Silver
amalgam reinforcement pins – 1st No
Charge
Each
additional pin No
Charge
Composite
filling (for front teeth) No
Charge
Composite
Class III No
Charge
Composite
Class IV No
Charge
Core build-up (including any pins) No
Charge
Periodontia
Root
scaling and root planing (per quadrant)
No
Charge
Prophylaxis,
medication and minor bite correction
No
Charge
Gingivectomy, Gingivoplasty
(per quadrant)
No
Charge
Occlusal adjustment (and/or equilibration)
No
Charge
Bite
guard
No
Charge
Osseous
surgery (per quadrant)
No
Charge
Endodontics (including radiographs)
Single
root canal, filling
No
Charge
Double
root canal, filling
No
Charge
Triple
or more root canal, filling
No
Charge
Apicoectomy
(per root)
No
Charge
Simple Extractions (including Local
anesthesia)
Single
tooth
No
Charge
Each
additional tooth
No
Charge
Oral Surgery Extractions (including
Local anesthesia)
Surgical extraction
No
Charge
Extraction
of tooth (soft tissue impaction)
No
Charge
Extraction
of tooth (partial bony impaction)
No
Charge
Extraction
of tooth (complete bony impaction)
No
Charge
Alveoplasty/Alveolectomy
(per jaw maximum) per quadrant in
conjunction with
extraction
No
Charge
Alveoplasty, including
ridge extension, arch
No
Charge
Excision of benign tumor, lesion diameter up to 2.5 cm
No
Charge
Removal of cyst up
to 2.5 cm diameter
No
Charge
Prosthetics
(including adjustments and relines
for 6 months
following
installation) removable
Full
upper denture
No
Charge
Full
lower denture
No
Charge
Partial
upper or lower denture without clasps, acrylic base No Charge
Partial
upper or lower denture with two chrome clasps
with rests, acrylic
base
No
Charge
Partial
upper or lower with chrome lingual or palatal bar with
two clasps and
rests, acrylic base
No
Charge
Repair broken full or partial denture, no teeth
damaged
No
Charge
Repair broken full or partial denture, replace
broken tooth
No
Charge
Each
additional tooth
No
Charge
Replace
broken tooth on denture, no other repairs
No
Charge
Each
additional tooth
No
Charge
Adding tooth to partial denture to replace
extracted tooth
No
Charge
Each
additional tooth
No
Charge
Reattaching clasp on denture, clasp intact
No
Charge
Replacing broken clasp with new clasp on denture No Charge
Relining
upper or lower full or partial denture (office
once every three
years
No
Charge
Relining
upper or lower full or partial denture (lab)
once every three
years
No
Charge
Jump
case, complete denture (duplicate of denture)
once every three
years
No
Charge
Crowns
Two
surface gold inlay
No
Charge
Three
or more surfaces gold inlay
No
Charge
Acrylic jacket
No
Charge
Acrylic
with metal (semi-precious)
No
Charge
Porcelain
jacket
No
Charge
Porcelain fused to metal (semi-precious)
No
Charge
¾
cast
No
Charge
Full
cast
No
Charge
Bridges
– Pontics & Abutments (fixed)*
Cast
No
Charge
Maryland bridge
No
Charge
Porcelain
fused to metal (semi-precious)
No
Charge
Plastic
processed to metal (semi-precious)
No
Charge
Orthodontic
Maximum, 24 months (to age 19)
$ 500.00
Adult (19 years or older)
$
1,250.00
