DIAGNOSTIC AND PREVENTIVE SERVICES
MEMBER PAYS
0120
PERIODIC ORAL EVALUATION
$14
0140
LIMITED ORAL EVALUATION--PROBLEM FOCUS
$17
0150
COMPREHENSIVE ORAL EVALUATION
$17
0210
INTRAORAL--COMPLETE SERIES (INC. BITEWINGS)
$42
0220
INTRAORAL--PERIAPICAL--1ST FILM
$10
0230
INTRAORAL PERIAPICAL--EACH ADDITIONAL FILM
$4
0270
BITEWING--SINGLE FILM
$10
0272
BITEWINGS--TWO FILMS
$13
0274
BITEWINGS--FOUR FILMS
$21
0330
PANORAMIC FILM
$42
1110
PROPHY-ADULT (CLEANING - six months)
$31
1120
PROPHY-CHILD (CLEANING - six months)
$25
1201
TOPICAL APPLICATION OF FLUORIDE (INCLUDING PROPHY)-CHILD
$35
1351
SEALANT-PER TOOTH
$21
1510
SPACE MAINTAINER-FIXED-UNILATERAL
$91
1515
SPACE MAINTAINER-FIXED-BILATERAL
$134
1520
SPACE MAINTAINER-REMOVEABLE-UNILATERAL
$119
1525
SPACE MAINTAINER-REMOVEABLE-BILATERAL
$151
RESTORATIVE
MEMBER PAYS
2110
AMALGAM-ONE SURFACE PRIMARY
$36
2120
AMALGAM-TWO SURFACE PRIMARY
$48
2130
AMALGAM-THREE SURFACE PRIMARY
$57
2131
AMALGAM-FOUR OR MORE-PRIMARY
$67
2140
AMALGAM-ONE SURFACE PERMANENT
$42
2150
AMALGAM-TWO SURFACE PERMANENT
$53
2160
AMALGAM-THREE SURFACE PERMANENT
$63
2161
AMALGAM-FOUR OR MORE PERMANENT
$77
2330
RESIN-ONE SURFACE ANTERIOR
$53
2331
RESIN-TWO SURFACE ANTERIOR
$64
2332
RESIN-THREE SURFACE ANTERIOR
$81
2335
RESIN-FOUR OR MORE SURFACES
$102
2385
RESIN-ONE SURF-POSTERIOR-PERMANENT
$77
2386
RESIN-TWO SURF-POSTERIOR-PERMANENT
$112
2387
RESIN-THREE OR MORE-POSTERIOR PERMANENT
$143
CROWNS
MEMBER PAYS
2750
CROWN-PORCELAIN FUSED HIGH NOBLE METAL
$525
2751
CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL
$476
2752
CROWN-PORCELAIN FUSED TO NOBLE METAL
$496
2790
CROWN-FULL CAST HIGH NOBLE METAL
$517
2791
CROWN-FULL CAST-PREDOMINANTLY BASE METAL
$462
2930
PREFAB STAINLESS STEEL CROWN- PRIMARY
$98
2931
PREFAB STAINLESS STEEL CROWN- PERMANENT
$112
2950
CORE BUILDUP-INCLUDING ANY PINS
$98
2951
PIN RETENTION/TOOTH IN ADDITION TO RESTORATION
$25
2952
CAST POST AND CORE IN ADDITION TO CROWN
$154
2954
PREFAB POST AND CORE IN ADDITION TO CROWN
$120
3110
PULP CAP DIRECT (EXCL FNL REST)
$22
3120
PULP CAP INDIRECT (EXCL FNL REST)
$22
3220
THERAPEUTIC PULPOTOMY (EXCL FNL REST)
$53
3310
ROOT CANAL--ANTERIOR (EXCL FNL REST)
$287
3320
ROOT CANAL--BICUSPID (EXCL FNL REST)
$340
3330
ROOT CANAL--MOLAR (EXCL FNL REST)
$427
PERIODONTICS
MEMBER PAYS
4210
GINGIVECTOMY OR GINGIVOPLASTY/QUAD
$301
4341
PERIO SCALING AND ROOT PLANING/QUAD
$105
4910
PERIO MAINTENANCE
$67
PROSTHODONTICS
MEMBER PAYS
5110
COMPLETE DENTURE-MAXILLARY
$627
5120
COMPLETE DENTURE-MANDIBULAR
$627
5130
IMMEDIATE DENTURE-MAXILLARY
$652
5140
IMMEDIATE DENTURE-MANDIBULAR
$652
5211
MAXILLARY PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)
$627
5212
MANDIBULAR PARTIAL DENTURE-RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)
$652
5213
MAXILLARY PARTIAL DENTURE-CAST METAL FRAMEWORK WITH RESIN DENTURE BASES(INCLUDING ANY CONVENTIONAL CLASPS, RESTS OR TEETH)
$711
5214
MANDIBULAR PARTIAL DENT-CAST METAL FRAMEWORK W/ RESIN DENT BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS, AND TEETH)
$711
5410
ADJUST COMPLETE DENTURE-MAXILLARY
$35
5411
ADJUST COMPLETE DENTURE-MANDIBULAR
$35
5510
REPAIR BROKEN COMPLETE DENTURE BASE
$56
5520
REPLACE MISSING/BROKEN TEETH
$53