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Adjunctive General Services

  • Palliative Treatment

Amalgam and Composite Restorations (Fillings)

  • Amalgam (Silver Filling)- One Surface, Primary or Permanent Tooth
  • Composite (White Filling) - One Surface, Anterior (Front) Tooth
  • Composite (White Filling) - One Surface, Posterior (Back) Tooth
  • Amalgam (Silver Filling) - Two Surfaces, Primary or Permanent Tooth
  • Composite (White Filling) - Two Surfaces, Anterior (Front) Tooth
  • Composite (White Filling) - Two Surfaces, Posterior (Back) Tooth
  • Amalgam (Silver Filling) - Three Surfaces, Primary or Permanent Tooth
  • Composite (White Filling) - Three Surfaces, Anterior (Front) Tooth
  • Composite (White Filling) - Three Surfaces, Posterior (Back) Tooth
  • Amalgam (Silver Filling) - Four or More Surfaces, Primary or Permanent Tooth
  • Composite (White Filling) - Four or More Surfaces or Involving Angle, Anterior (Front) Tooth
  • Composite (White Filling) - Four or More Surfaces, Posterior (Back) Teeth

Crowns

  • Crown - Porcelain/Ceramic Substrate
  • Crown - Porcelain Fused to High Noble Metal (i.e., gold)
  • Crown - Porcelain Fused to Predominantly Base Metal
  • Crown - Porcelain Fused to Noble Metal

Diagnostic Services

  • Comprehensive Oral Evaluation
  • Comprehensive Periodontal Evaluation
  • Limited Oral Evaluation - Problem Focused
  • Periodic Oral Evaluation

Endodontics

  • Root Canal, Anterior (Front) Tooth
  • Root Canal, Molar Tooth
  • Root Canal, Bicuspid Tooth
  • Therapeutic Pulpotomy, Excluding Final Restoration

Extractions

  • Extraction, Erupted Tooth or Exposed Root (Simple Extraction)

Fixed Partial Denture (Bridge)

  • Fixed Partial Denture (Bridge) - Pontic - Porcelain Fused to High Noble Metal (i.e., gold)
  • Fixed Partial Denture (Bridge) - Retainer Crown, Full Cast Noble Metal
  • Fixed Partial Denture (Bridge) - Retainer Crown, Porcelain Fused to High Noble Metal (i.e., gold)

General Anesthesia

  • General Anesthesia - First 30 Minutes
  • General Anesthesia - Each Additional 15 Minutes

Orthodontics

  • Comprehensive Orthodontic Treatment of the Adolescent Dentition

Other Restorative Services

  • Core Buildup, Including Any Pins When Required
  • Post & Core
  • Prefabricated Stainless Steel Crown - Primary Tooth

Periodontics

  • Osseous Surgery - Four or More Teeth Per Quadrant
  • Periodontal Maintenance (Periodontal Prophylaxis, Periodontal Cleaning)
  • Periodontal Scaling/Root Planing - Four or More Teeth Per Quadrant
  • Periodontal Scaling/Root Planing - One to Three Teeth Per Quadrant

Preventive Services

  • Cleaning (Prophylaxis) - Adult
  • Cleaning (Prophylaxis) - Child
  • Sealant - Per Tooth
  • Topical Application of Fluoride - Child

Professional Consultation

  • Consultation

Removable Dentures

  • Mandibular (Lower) Partial Denture - Cast Metal Framework with Resin Denture Base
  • Maxillary (Upper) Partial Denture - Cast Metal Framework with Resin Denture Base

Restorative Services

  • Prefabricated Post & Core
  • Recement or Rebond Crown

Surgical Extractions

  • Surgical Removal of Impacted Tooth - Completely Bony (Full Bony Impaction)
  • Surgical Removal of Impacted Tooth - Partially Bony (Partial Bony Impaction)
  • Surgical Removal of Impacted Tooth - Soft Tissue (Soft Tissue Impaction)
  • Surgical Removal of Residual Tooth Roots
  • Surgical Removal of Erupted Tooth and Removal of Bone and/or Section of Tooth (Surgical Extraction)

X-rays, Radiographs

  • Bitewings - Four Films
  • Bitewings - Two Films
  • Complete Series of X-rays (Full Mouth X-rays)
  • Additional Periapical Film (PA X-ray)
  • Panoramic Film (Panorex Film)
  • Periapical Film (PA X-ray)