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 |
(Patient who have not had regular cleanings may require Gum treatment) |
|
D1120 |
Prophylaxis-child |
29 |
|
D1351 |
Sealant per tooth |
20% discount |
|
D4355 |
Full mouth debridement |
45 |
|
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-two 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.
|
