DIAGNOSTIC AND PREVENTATIVE
- Full Mouth X-rays
- Oral Exam And Diagnosis
- Prophylaxis (Cleaning)
- Prophylaxis (Child)
RESTORATIVE DENTISTRY (FILLINGS)
- Amalgam Restorations (primary) 1 Surface
- Amalgam Restorations (primary) 2 Surfaces
- Amalgam Restorations (primary) 3 Surface
- Amalgam Restorations (primary) 4 or more Surface
- Amalgam Restorations (permanent) 1 Surface
- Amalgam Restorations (permanent) 2 Surfaces
- Amalgam Restorations (permanent) 3 Surfaces
- Amalgam Restorations (permanent) 4 or more Surfaces
- Composite Restoration (anterior) 1 Surface
- Composite Restoration (anterior) 2 Surfaces
- Composite Restoration (anterior) 3 Surfaces
- Composite Restoration (anterior) 4 or more Surfaces
- Composite Restoration (posterior) 1 Surface
- Composite Restoration (posterior) 2 Surfaces
- Composite Restoration (posterior) 3 Surfaces
- Composite Restoration (posterior) 4 or more Surfaces
CROWNS AND BRIDGE
- Porcelain fused to base metal crown
- Porcelain fused to noble metal crown
- Porcelain fused to high noble metal crown
- All porcelain crown (Empress or Lava)
- Porcelain Pontic
- Abutment Crown
- Core buildup
- Porcelain Inlay or Onlay (1-4 Surfaces)
- Reattach crown
- Reattach bridge
ORAL SURGERY
- Simple extraction with local anesthesia
- Surginal extraction
- Soft tissue impaction
- Partial bony impaction
- Full bony impaction
- Surgical removal of residual root tips
- Synthetic bone graft
PERIODONTICS (TREATMENT OF GUMS)
- Scaling and root planing (per quadrant)
- Periodontal irrigation (per quadrant)
- Periodontal irrigation (generalized)
- Full mouth debridement
- Periodontal maintenance
- Arestin (per site)
ENDODONTICS (ROOT CANAL THERAPY)
- Pulp Cap - direct
- Pulp Cap - indirect
- Therapeutic pulpotomy
- Root Canal - anterior
- Root Canal - bicuspid
- Root Canal - molar
PROSTHETICS (DENTURED)
- Complete maxillary denture
- Complete mandibular denture
- Partial maxillary denture
- Partial mandibular denture
- Denture adjustment
- Add clasp to existing denture
- Interim stayplate
- Tissue Conditioning
- Denture Reline (chairside)
- Denture Reline (lab)
- Denture Rebase
- Replace tooth on denture
ORTHODONTICS (BRACES)
- Orthodontic treatment for adolescents
- Orthodontic treatment for adults
- Invisalign
MEMBER SERVICE
DESCRIPTION
COPAYMENT
Composite Restoration (anterior) 3 Surfaces.
CODE:D2332
Resin-based composite refers to a broad category of materials including but not limited to composites. May include bonded composite, light-cured composite, etc. Tooth preparation, acid etching, adhesives (including resin bonding agents), liners and bases and curing are included as part of the restoration.
$145.00
