Diagnostic & Preventative
0120
Periodic Oral Evaluation - Established Patient
No Charge
$60.00
$60.00
0140
Limited oral evaluation- problem focused
No Charge
$95.00
$95.00
0150
Comprehensive Oral Evaluation- new or established patient
No Charge
$101.00
$101.00
0210
Full mouth x-rays
No Charge
$154.00
$154.00
0220
First film
No Charge
$33.00
$33.00
0230
Each additional film
No Charge
$30.00
$30.00
0272
Bitewings- two films
No Charge
$53.00
$53.00
0274
Bitewings - four films
No Charge
$75.00
$75.00
0330
Panoramic Film
$91.00
$130.00
$39.00
1110
Prophylaxis (cleaning) adult
$105.00
$105.00
$0.00
1120
Prophylaxis (cleaning) child
$80.00
$80.00
$0.00
1206
Topical application of fluoride varnish
$17.50
$25.00
$7.50
1208
Topical application of fluoride
$31.50
$45.00
$13.50
1351
Sealant- per tooth
$44.10
$63.00
$18.90
Restorative - Fillings
2330
Composite- one surface, anterior
$137.90
$197.00
$59.10
2331
Composite- two surfaces, anterior
$167.30
$239.00
$71.70
2332
Composite- three surfaces, anterior
$203.70
$299.00
$95.30
2391
Composite- one surface, posterior
$149.10
$213.00
$63.90
2392
Composite- two surfaces, posterior
$189.00
$270.00
$81.00
2393
Composite- three surfaces, posterior
$231.00
$330.00
$99.00
Restorative - Crowns
2740
Crown-porcelain/ceramic substrate
$983.50
$1405.00
$421.50
2750
Crown-porcelain fused to high noble metal
$983.50
$1405.00
$421.50
2751
Crown-porcelain fused to base metal
$983.50
$1405.00
$421.50
2920
Recementation - crown
$91.70
$131.00
$39.30
2950
Core Buildup
$214.90
$307.00
$92.10
2954
Prefabricated post and core
$279.30
$399.00
$119.70
Endodontics - Root Canals
3310
Root Canal (anterior)
$735.00
$1050.00
$315.00
3320
Root Canal (bicuspid)
$809.20
$1156.00
$346.80
3330
Root Canal (molar)
$997.50
$1425.00
$427.50
Periodontics
4341
Periodontal scaling and root planing- 4 or more teeth per quadrant
$206.50
$295.00
$88.50
4355
Full mouth debridement
$193.90
$277.00
$83.10
4381
Localized delivery of antimicrobial agents
$56.70
$81.00
$24.30
4910
Periodontal maintenance
No Charge
$163.00
$163.00
Prosthodontics - Dentures & Bridges
5110
Complete denture - maxillary (upper)
$1385.30
$1979.00
$593.70
5120
Complete denture- mandibular (lower)
$1385.30
$1979.00
$593.70
5213
Partial denture - maxillary (upper)
$1470.00
$2100.00
$630.00
5214
Partial denture - mandibular (lower)
$1536.50
$2195.00
$658.50
5225
Partial denture - flexible base- maxillary (upper)
$1050.00
$1500.00
$450.00
5226
Partial denture - flexible base- mandibular (upper)
$1050.00
$1500.00
$450.00
Bridge - Fixed
6240
Pontic-porcelain fused to high noble metal
$1186.50
$1695.00
$508.50
6241
Pontic-porcelain fused to base metal
$1186.50
$1695.00
$508.50
6245
Pontic-porcelain/ceramic
$1186.50
$1695.00
$508.50
6740
Crown-porcelain/ceramic
$910.70
$1301.00
$390.30
6750
Crown-porcelain fused to high noble metal
$1186.50
$1695.00
$508.50
Oral - Surgery
7140
Extraction, erupted tooth
$140.70
$201.00
$60.30
7210
Surgical removal of erupted tooth
$249.90
$357.00
$107.10
7220
Removal of impacted tooth- soft tissue
$270.90
$387.00
$116.10
7230
Removal of impacted tooth- partially bony
$341.60
$488.00
$146.40
7240
Removal of impacted tooth- completely bony
$397.60
$568.00
$170.40
Orthodontics
8090
Invisalign
$4696.00
$5870.00
$1174.00
Other Services
9910
Application of desensitizing resin
$51.80
$74.00
$22.20
9944/9945
Occlusal guard by report
$402.50
$575.00
$172.50