Member's
Services |
Member Pays |
|
|
Diagnostic
and Preventative |
|
D0120 |
Periodic oral exam |
15 |
|
D0150 |
Comprehensive oral exam |
15 |
|
D0120 |
Intra-oral complete series |
30 |
|
D0220 |
Intra-oral periapical
first film |
5 |
|
D0330 |
Panoramic Film |
30 |
|
D0460 |
Pulp vitality test |
12 |
|
D0470 |
Diagnostic cast |
20 |
|
D1110 |
Prophylaxis-adult |
29 |
|
D1120 |
Prophylaxis-child |
29 |
|
D1351 |
Sealant per tooth |
20% discount |
|
D4355 |
Full mouth debridment |
45 |
|
(Patient who have not
had regular cleanings may require Gum treatment) |
|
D0999 |
Infection control |
5 |
|
|
Cosmetic
and Restorative Dentistry |
|
|
D2140 |
Amalgam-one surface |
34 |
|
D2150 |
Amalgam-two surfaces |
44 |
|
D2160 |
Amalgam- three surfaces |
54 |
Resin
fillings (Tooth Colored) |
|
D2330 |
Resin- one surface anterior |
34 |
|
D2331 |
Resin- two surface anterior |
44 |
|
D2332 |
Resin-three surface anterior |
54 |
|
|
All posterior resin fillings |
20% discount |
|
|
Crown
and Bridge |
|
|
D2751 |
Crown-porcelain fused
to base metal |
321+lab |
|
D2791 |
Crown-full cast base metal |
321+lab |
|
D2810 |
Crown-3/4 cast base metal |
321+lab |
|
D2950 |
Core build-up including
pins |
20% discount |
|
D6241 |
Pontic-Porcelain fused
to base metal |
321+lab |
|
D6751 |
Crown-porcelain fused
to base metal |
321+lab |
|
Lab
charges additional |
|
|
Endodontic
Dentistry (Root Canal Treatment) |
|
|
D3110 |
Pulp-cap direct |
19 |
|
D3120 |
Pulp-cap indirect |
19 |
|
D3220 |
Therapeutic pulpotomy |
43 |
|
D3310 |
Root canal -Anterior |
199 |
|
D3320 |
Root canal-Bicuspid |
236 |
|
D3330 |
Root canal-Molar |
279 |
|
Charges
for these services do not include final restoration |
|
|
Oral
Surgery |
|
|
D7140 |
Extraction single tooth |
35 |
|
D7210 |
Surgical removal |
65 |
|
D7220 |
Removal of impacted tooth
soft tissue |
99 |
|
D7230 |
Removal of impacted tooth-partially
bony |
120 |
|
D7240 |
Removal of impacted tooth-completely
bony |
142 |
|
D7510 |
Incision and drainage
of abscess |
32 |
|
|
Prosthodontic
dentistry (dentures) |
|
|
D5110 |
Complete upper denture |
414+lab |
D5120 |
Complete lower denture |
414+lab |
|
D5211 |
Upper Partial (resin or
cast metal) |
403+lab |
|
D5212 |
Lower Partial (resin or
cast metal) |
403+lab |
|
| Prosthetics
fees are reduced for usual and customary services. Any
prosthetic appliance that requires unusual services
may require additional charges. Lab charges are additional
|
|
|
Orthodontic
services (braces) |
|
|
D8660 |
Pre orthodontic visit |
120 |
|
D9310 |
Consultation |
15 |
|
D8080 |
Comprehensive ortho treatment
child |
2,150 |
|
D8090 |
Comprehensive ortho treatment
adult |
2,350 |
|
D8680 |
Retainers |
20% discount |
|
|
Periodontic
dentistry (gum disease treatment) |
|
|
D4250 |
Muccogingival surgery-per
quadrant |
350 |
|
D4260 |
Osseous surgery per quadrant |
480 |
|
D4341 |
Periodontal scaling and
root planning Per Quad |
65 |
|
D4910 |
Periodontal maintenance
procedures |
48 |
|
| The
above periodontic charges are our reduced fees for our
usual and Customary periodontal services. Any periodontal
treatment that requires root resection, gingival grafts,
or other services will have an additional charge, at
a reduced rate. |
|
|
General |
|
|
D9110 |
Palliative (emergency)
treatment |
20% discount |
|
D9430 |
Office visits (during
regular hours) |
12 |
|
D9440 |
Office visit (after regular
scheduled hours) |
40 |
|
D9999 |
Broken appointment within
24 hours |
25 |
|
| All
listed charges are reduced fees for services performed
by Dr. Kevin Oliver. Any procedure not listed is available
at a 20% discount of our usual fees. Any member accepted
for orthodontic treatment must remain a member of the
dental plan for the full duration of their treatment
or risk additional charges. Reduced fees will not be
honored if treatment is already in progress or the patient
is no longer a member of the plan. |
