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ADA  Code D0150 D0120 D0140 D1120 D0460 D0470 Radiographs D0230 D0272 D0274 D0210 D0330 Endodontics D2999 D3220 D3110 D3120 D3220 (Molars) D3330 D3330 D3320 D3310 D3999 Fixed  -­‐  bridges D6210 D6240 D6241 D6750 D6790 Fixed  -­‐  crowns D2740 D2790 D2750 D2920 Fixed  -­‐  cores D2950 D2952 D2954 Operative D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2391 D2392 D2393 D2394 (Inlay/onlay) D2510 D2520 Diagnostics

Description Comprehensive  Oral  Evaluation-­‐  New/Est.  Pt Periodic  Evaluation/Denture  recall Emergency  visit/Limited  Evaluation Child  prophy Pulp  vitality  tests Study  models Intraoral-­‐periapical  film  (Each) Bitewings  -­‐  2  films Bitewings  -­‐  4  films Full  mouth  survey  -­‐  Adult Panoramic  Film Caries  Exc.,  O  &  R Therapeutic  pulpotomy Pulp  cap  -­‐  direct Pulp  cap  -­‐  indirect Therapeutic  pulpotomy  (Exclud.  restoration) Maxillary  or  mandibular  molar  -­‐  2  canals Maxillary  or  mandibular  molar  -­‐  3-­‐4  canals Bicuspid  -­‐  1-­‐2  canals Anterior   Endo  recall Pontic  -­‐  full  cast  hi  noble  metal Pontic  -­‐  Porcelain  fused  to  hi  noble  metal Pontic  -­‐  Porcelain  fused  to  base  metal Crown  (abutment)  -­‐  Porc.  fused  to  hi  noble Crown  (abutment)  -­‐  full  cast  hi  noble  metal All  ceramic  crown Full  cast  hi  noble  metal Porcelain  fused  to  hi  noble  metal Recement  crown Amalgam  or  composite  build-­‐up  incl.  pins Cast  post/core  in  add.  To  crown Parapost/prefab  post/core  in  add.  To  crown Amalgam  -­‐  1  surface Amalgam  -­‐  2  surfaces Amalgam  -­‐  3  surfaces Amalgam  -­‐  4+  surfaces Composite  -­‐  1  surface  (anterior) Composite  -­‐  2  surfaces  (anterior) Composite  -­‐  3  surfaces  (anterior) Composite  -­‐  4+  surfaces  (anterior) Composite  -­‐  1  surface  (posterior) Composite  -­‐  2  surfaces  (posterior) Composite  -­‐  3  surfaces  (posterior) Composite  -­‐  4  surfaces  (posterior) Inlay  -­‐  Metallic  1  surface Inlay  -­‐  Metallic  2  surfaces

UCR $80.00 $46.00 $70.00 $62.00 $51.00 $100.00 $22.00 $42.00 $59.00 $119.00 $101.00

UMKC $38.00 $15.00 $41.00 $38.00 $0.00 $7.00 $7.00 $0.00 $24.00 $56.00 $56.00 $24.00 $185.00 $24.00 $75.00 $0.00 $76.00 $0.00 $185.00 $27.00 $930.00 $212.00 $930.00 $255.00 $775.00 $212.00 $660.00 $176.00 $0.00 $0.00 $992.00 $390.00 $1,002.00 $390.00 $954.00 $419.00 $995.00 $390.00 $985.00 $390.00 $1,031.00 $462.00 $992.00 $390.00 $995.00 $390.00 $98.00 $15.00 $252.00 $89.00 $394.00 $175.00 $315.00 $101.00 $127.00 $47.00 $161.00 $56.00 $195.00 $69.00 $230.00 $82.00 $149.00 $49.00 $185.00 $62.00 $225.00 $69.00 $282.00 $83.00 $161.00 $49.00 $210.00 $83.00 $264.00 $108.00 $315.00 $120.00 $750.00 $83.00 $807.00 $94.00


(Pedo)

(Veneer) Oral  Surgery

Orthodontics (Pedo) Perio

Removable

D2530 D2620 D2630 D2542 D2543 D2644 D2930 D2932 D2933 D2962   D2960 D7111 D7140 D7210 D7510 D7960 D8220 D1510 D1515 D4355 D9940 D4381 D1205 D1204 D1110 D1110 D1110 D4910 D4910 D4342 D4341 D5110 D5120 D5140 D5140 D5860 D5660 D5650 D5510 D5620 D5850 D5710 D5720 D5750 D5730 D5760

Inlay  -­‐  Metallic  3+  surfaces Inlay  -­‐  Porcelain  2  surfaces Inlay-­‐  Porcelain  3  surfaces Onlay  -­‐  Metallic  2  surfaces Onlay  -­‐  Metallic  3  surfaces Onlay  -­‐  Porcelain  4+  surfaces Chrome  steel  crown   Prefab  resin  crown Prefab  SSC  with  resin Porcelain  laminate  veneer  (lab) Direct  resin  veneer TE  deciduous  tooth Simple  extraction Surgical  extraction I  &  D Frenectomy Rapid  palatal  expander Unilateral  space  maintainer Bilateral  space  maintainer  (fixed) Full  mouth  debridement Night  guard Local  delivery  of  Arestin  (2  carps) Fluoride  (adult,  with  prophy) Fluoride  (adult,  no  prophy) Adult  prophy  (less  than  11  teeth) Adult  prophy   Adult  prophy  (with  gingivitis) Compromised  perio  maint.  (less  than  11) Compromised  perio  maintenance S/RP  1-­‐3  per  quad S/RP  4+  per  quad Complete  denture  -­‐  maxillary Complete  denture  -­‐  mandibular Immediate  denture  -­‐  maxillary Immediate  denture  -­‐  mandibular Overdenture Add  clasp  to  existing  partial Add  tooth  to  existing  partial Denture  repair Repair  cast  framework Tissue  conditioning Rebase  denture Rebase  partial Reline  denture  (lab) Reline  denture  (chairside) Reline  partial  (lab)

$875.00 $870.00 $904.00 $898.00 $919.00 $986.00 $250.00 $325.00 $331.00 $1,003.00 $597.00 $127.00 $155.00 $255.00 $215.00 $414.00 $925.00 $297.00 $405.00 $170.00 $549.00 $148.00 $97.00 $35.00 $85.00 $85.00 $85.00 $128.00 $128.00 $165.00 $230.00 $1,525.00 $1,526.00 $1,645.00 $1,650.00 $1,891.00 $252.00 $210.00 $190.00 $275.00 $190.00 $531.00 $520.00 $435.00 $348.00 $427.00

$101.00 $369.00 $369.00 $192.00 $192.00 $383.00 $84.00 $113.00 $135.00 $417.00 $201.00 $27.00 $53.00 $68.00 $80.00 $120.00 $263.00 $80.00 $103.00 $28.00 $166.00 $29.00 $15.00 $30.00 $36.00 $53.00 $70.00 $36.00 $53.00 $55.00 $75.00 $419.00 $419.00 $566.00 $566.00 $419.00 $48.00 $10.00 $46.00 $46.00 $15.00 $129.00 $116.00 $93.00 $48.00 $78.00


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