‚Äč*****2017 Dental Treatment Fee *****

**For any treatment that is not listed here, please call for detail

Dental codes      Dental treatments                                                  Fee

Exam and cleaning:

New Patient Exam with Cleaning and 4 Bite Wing (Adult)               150

New Patient Exam with Cleaning and 2 Bite Wing (child)                115

D0150                 Comprehensive Exam                                                    47

D0120                 Periodic oral exam                                                      33

D0140                 Limited Exam                                                                 43

D0220                 1 Periapical X-ray                                                        20

D0274                 4 Bite Wings                                                                  41

D1120                 Cleaning (child)                                                           42

D1110                 Cleaning (adult)                                                          62

D4355                 Full Mouth Debridement                                             96

D4342                 Deep Cleaning (1-3 teeth per quadrant)                    99

D4341                 Deep Cleaning (4 teeth or more per quadrant)        165

D9940                 Night Guard                                                                  350

Dental codes   Dental treatments                                                      Fee

Orthodontic Treatment:

D8010                 Limited Orthodontic Treatment                               2,800

D8070                 Comprehensive Treatment
                                          SIMPLE                                                          4,000
                                          COMPLEX                                                      4,500

D8080                 Orthodontic Positioner (Orthotain)                       2,800

D8692                 Wire Retainer Replacement                                       275

D8693                 Wire Retainer Repair/Bonding                                  285

D8210                 Clear Retainer Appliance                                          390

Dental codes   Dental treatments                                                    Fee

Tooth Color Filling (Composite):

D2330                 Front Tooth Filling 1 Surface                                90

D2331                 Front Tooth Filling 2 Surfaces                              110

D2332                 Front Tooth Filling 3 Surfaces                              125

D2335                 Front Tooth Filling 4 Surfaces or more               139

D2391                 Back Tooth Filling 1 Surface                                  135

D2392                 Back Tooth Filling 2 Surfaces                                160

D2393                 Back Tooth Filling 3 Surfaces                                186

D2394                 Back Tooth Filling 4 Surfaces or more                 207

Silver Filling (Amalgam):

D2140                 Back Tooth Filling 1 Surface                                  77

D2150                 Back Tooth Filling 2 Surfaces                                88

D2160                 Back Tooth Filling 3 Surfaces                                105

D2161                 Back Tooth Filling 4 Surfaces or More                 123

Dental codes   Dental treatments                                                   Fee


D2950                 Core Build-Up (for retention of the Crown)       132

D2740                 Porcelain or Zirconium Crown                              760

D2750                 Porcelain Fused to High Noble Crown                  752


D5213                 Partial Denture with Metal Framework               980

D5225                 Partial Denture Flexible Partial                           920

D5211                 Partial Denture Acrylic Partial                            780

D5820/5821       One to three teeth partial denture (flipper)       436

D5110                 Complete Denture (upper)                                       980

D5120                 Complete Denture (lower)                                      980  


D6010                 Root Form Implant                                                    1,399

D6057                 Implant Abutment                                                      559  

D6058                 Implant Crown                                                           986

Dental codes   Dental treatments                                                    Fee

Root Canal Treatment:

D3310                 Front tooth Treatment                                            428

D3320                 Premolar Treatment                                                  510

D3330                 Molar Treatment                                                        637


D7140                 Simple Extraction                                                       85

D7210                 Surgical Extraction                                                  141

D7220                 Extraction with Soft Tissue Impaction                  164

D7230                 Extraction with Horizontal Partial Impaction    219  

D9999                 Reattachment of broken tooth to the       $300/tooth, $60/additional tooth

                           Neighboring teeth                                          



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