Diagnostic & Preventative
0120
Periodic Oral Evaluation - Established Patient
No Charge
$0.00
$0.00
0140
Limited oral evaluation- problem focused
No Charge
$0.00
$0.00
0150
Comprehensive Oral Evaluation- new or established patient
No Charge
$0.00
$0.00
0210
Full mouth x-rays
No Charge
$0.00
$0.00
0220
First film
No Charge
$0.00
$0.00
0230
Each additional film
No Charge
$0.00
$0.00
0272
Bitewings- two films
No Charge
$0.00
$0.00
0274
Bitewings - four films
No Charge
$0.00
$0.00
0330
Panoramic Film
No Charge
$0.00
$0.00
1110
Prophylaxis (cleaning) adult
No Charge
$0.00
$0.00
1120
Prophylaxis (cleaning) child
No Charge
$0.00
$0.00
1206
Topical application of fluoride varnish
No Charge
$0.00
$0.00
1208
Topical application of fluoride
No Charge
$0.00
$0.00
1351
Sealant- per tooth
No Charge
$0.00
$0.00
Restorative - Fillings
2330
Composite- one surface, anterior
No Charge
$0.00
$0.00
2331
Composite- two surfaces, anterior
No Charge
$0.00
$0.00
2332
Composite- three surfaces, anterior
No Charge
$0.00
$0.00
2391
Composite- one surface, posterior
No Charge
$0.00
$0.00
2392
Composite- two surfaces, posterior
No Charge
$0.00
$0.00
2393
Composite- three surfaces, posterior
No Charge
$0.00
$0.00
Restorative - Crowns
2740
Crown-porcelain/ceramic substrate
No Charge
$0.00
$0.00
2750
Crown-porcelain fused to high noble metal
No Charge
$0.00
$0.00
2751
Crown-porcelain fused to base metal
No Charge
$0.00
$0.00
2920
Recementation - crown
No Charge
$0.00
$0.00
2950
Core Buildup
No Charge
$0.00
$0.00
2954
Prefabricated post and core
No Charge
$0.00
$0.00
Endodontics - Root Canals
3310
Root Canal (anterior)
No Charge
$0.00
$0.00
3320
Root Canal (bicuspid)
No Charge
$0.00
$0.00
3330
Root Canal (molar)
No Charge
$0.00
$0.00
Periodontics
4341
Periodontal scaling and root planing- 4 or more teeth per quadrant
No Charge
$0.00
$0.00
4355
Full mouth debridement
No Charge
$0.00
$0.00
4381
Localized delivery of antimicrobial agents
No Charge
$0.00
$0.00
4910
Periodontal maintenance
No Charge
$0.00
$0.00
Prosthodontics - Dentures & Bridges
5110
Complete denture - maxillary (upper)
No Charge
$0.00
$0.00
5120
Complete denture- mandibular (lower)
No Charge
$0.00
$0.00
5213
Partial denture - maxillary (upper)
No Charge
$0.00
$0.00
5214
Partial denture - mandibular (lower)
No Charge
$0.00
$0.00
5225
Partial denture - flexible base- maxillary (upper)
No Charge
$0.00
$0.00
5226
Partial denture - flexible base- mandibular (upper)
No Charge
$0.00
$0.00
Bridge - Fixed
6240
Pontic-porcelain fused to high noble metal
No Charge
$0.00
$0.00
6241
Pontic-porcelain fused to base metal
No Charge
$0.00
$0.00
6245
Pontic-porcelain/ceramic
No Charge
$0.00
$0.00
6740
Crown-porcelain/ceramic
No Charge
$0.00
$0.00
6750
Crown-porcelain fused to high noble metal
No Charge
$0.00
$0.00
Oral - Surgery
7140
Extraction, erupted tooth
No Charge
$0.00
$0.00
7210
Surgical removal of erupted tooth
No Charge
$0.00
$0.00
7220
Removal of impacted tooth- soft tissue
No Charge
$0.00
$0.00
7230
Removal of impacted tooth- partially bony
No Charge
$0.00
$0.00
7240
Removal of impacted tooth- completely bony
No Charge
$0.00
$0.00
Orthodontics
8090
Invisalign
No Charge
$0.00
$0.00
Other Services
9910
Application of desensitizing resin
No Charge
$0.00
$0.00
9944/9945
Occlusal guard by report
No Charge
$0.00
$0.00