General Dentistry Fees
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- Elfreda Carpenter
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1 General Dentistry Fees Office Co-Pay $5 $5 Comp Exam (D0150) $77 $0 $77 Full Mouth X-Rays (D0210) $152 $0 $152 Single X-Ray (D0220) $30 $0 $30 Additional X-Rays Single (D0230) $30 $0 $30 Adult Prophy (D1110) $90 $49 $41 Child Prophy (D1120) $80 $29 $51 Fluoride Varnish (D1206) $35 $25 $10 Restorative 1 Surf Ant/ Fill Composite (D2330) $123 $85 $38 2 Surf Ant/ Fill Composite (D2331) $163 $105 $58 3 Surf Ant/ Fill Composite (D2332) $199 $110 $89 4 Surf Ant/ Fill Composite (D2335) $236 $130 $106 1 Surf Post/ Fill Composite (D2391) $161 $100 $61 2 Surf Post/ Fill Composite(D2392) $296 $125 $171 3 Surf Post/ Fill Composite (D2393) $375 $145 $230 4 Surf Post/ Fill Composite (D2394) $372 $225 $147 Crowns Ceramic (D2740) $1,408 $850 $558 Porcelain to Fused High Noble (D2750) $1,314 $780 $534 Porcelain Fused to Base Metal (D2751) $1,055 $495 $560 Build Up (D2950) $330 $135 $195 Implant Crown (EXT/ Implant/ Cust Abut/ PFM) $5,000 $3,495 $1,505 Periodontic RPS (full quad) (D4341) $319 $139 $180 RPS (1-3 teeth) (D4342) $175 $89 $86 Perio Maintenance (D4910) $162 $79 $83 Oral Irrigation (Per Quad) (D4921) $21 $10 $11 Endodontic Anterior RCT (D3310) $828 $449 $379 Bicuspid RCT (D3320) $994 $499 $495 Molar RCT (D3330) $1,323 $860 $463 Dentures Complete Upper Denture (D5110) $1,133 $825 $308 Complete Lower Denture (D5120) $1,133 $825 $308 Oral Surgery Extraction Simple (D7140) $164 $115 $49 Extraction Surgical (D7210) $273 $175 $98 *Full fee is based on 2017 PERFECT TEETH Colorado fees which will vary by state. Additional fees may apply depending on the services you need. With the exception of orthodontics, all fees listed above are for treatments performed by a general dentist. Fees for treatments provided by a specialist will vary. Dental fees are subject to change without notice. The PTDP may not be combined with any other insurance or discount plan; non-covered benefits are excepted.
2 Periodontics Specialty Fees Office Co-Pay $5 $5 Comprehensive Perio Evaluation (D0180) $150 $20 $130 Full Mouth X-Rays (D0210) $152 $25 $127 Periodontic Simple Extraction (D7140) $164 $128 $36 Surgical Removal - Erupted (D7210) $273 $175 $98 Crown Lengthening (D4249) $938 $638 $300 Osseous Surgery Per Quad (D4260) $1,325 $901 $424 Osseous Surgery 1-3 Teeth (D4261) $950 $646 $304 Gingival Flap Procedure (D4240) $832 $566 $266 Gingival Flap 1-3 Teeth (D4241) $392 $267 $125 *Full fee is based on 2017 PERFECT TEETH Colorado fees which will vary by state. Additional fees may apply depending on the services you need. With the exception of orthodontics, all fees listed above are for treatments performed by a general dentist. Fees for treatments provided by a specialist will vary. Dental fees are subject to change without notice. The PTDP may not be combined with any other insurance or discount plan; non-covered benefits are excepted.
3 Endodontic Specialty Fees Office Co-pay $5 $5 Pulp Vitality Testing (D0460) $38 $17 $21 Endodontics Root Canal Molar (D3330) $1,323 $980 $343 Retreatment Anterior RCT (D3346) $1,161 $859 $302 Retreatment Bicuspid RCT (D3347) $1,309 $969 $340 Retreatment Molar RCT (D3348) $1,531 $1,133 $398 Apicoectomy - Anterior (D3410) $903 $668 $235 Apicoectomy - Bicuspid (D3421) $984 $728 $256 Apicoectomy - Molar (D3425) $1,127 $834 $293 Apicoectomy - Ea Add'l Root (D3426) $348 $258 $90 Retrograde Filling (D3430) $229 $169 $60 *Full fee is based on 2017 PERFECT TEETH Colorado fees which will vary by state. Additional fees may apply depending on the services you need. With the exception of orthodontics, all fees listed above are for treatments performed by a general dentist. Fees for treatments provided by a specialist will vary. Dental fees are subject to change without notice. The PTDP may not be combined with any other insurance or discount plan; non-covered benefits are excepted.
4 Oral Surgery Specialty Fees Office Co-Pay $5 $5 Oral Surgery Surgical Removal - Erupted (D7210) $273 $175 $98 Nitrous Oxide (Laughing Gas) (D9230) $47 $38 $9 IV Sedation (putting the patient to sleep) (D9223) $166 $129 $37 Remove Impacted (Soft Tissue) (D7220) $316 $246 $70 Remove Impacted Partial Bony (D7230) $408 $318 $90 Remove Impacted Complete Bony (D7240) $499 $389 $110 Soft Tissue Biopsy (removal of oral lesion for pathological reasons) (D7286) $349 $272 $77 *Full fee is based on 2017 PERFECT TEETH Colorado fees which will vary by state. Additional fees may apply depending on the services you need. With the exception of orthodontics, all fees listed above are for treatments performed by a general dentist. Fees for treatments provided by a specialist will vary. Dental fees are subject to change without notice. The PTDP may not be combined with any other insurance or discount plan; non-covered benefits are excepted.
5 Pediatric Specialty Fees Office Co-pay $5 $5 Comprehensive Oral Evaluation (D0150 $122 $0 $122 Pedodontics Resin 1 Surface Posterior (D2391) $161 $116 $45 Resin 2 Surface Posterior (D2392) $296 $213 $83 Resin 3 Surface Posterior (D2393) $375 $270 $105 Therapeutic Pulpotomy (D3220) $261 $188 $73 Stain Steel Crown (primary) (D2930) $274 $197 $77 *Full fee is based on 2017 PERFECT TEETH Colorado fees which will vary by state. Additional fees may apply depending on the services you need. With the exception of orthodontics, all fees listed above are for treatments performed by a general dentist. Fees for treatments provided by a specialist will vary. Dental fees are subject to change without notice. The PTDP may not be combined with any other insurance or discount plan; non-covered benefits are excepted.
6 Implant Specialty Fees Office Co-pay $5 $5 Implants Simple Extraction (D7140) $164 $90 $74 Surgical Removal - Erupted (D7210) $273 $175 $98 Bone Graft / Membrane (D6104) $600 $408 $192 Vertical Sinus Augmentation (D7952) $3,500 $936 $2,564 Implant Placement (Surgical Placement) (D6010) $2,407 $1,850 $557 Implant Restorative Implant Abutment (custom) (D6057) $981 $582 $399 Implant Crown (Porcelain) (D6065) $1,408 $1,017 $391 Implant Crown (Hi Noble) (D6067) $1,339 $913 $426 *Full fee is based on 2017 PERFECT TEETH Colorado fees which will vary by state. Additional fees may apply depending on the services you need. With the exception of orthodontics, all fees listed above are for treatments performed by a general dentist. Fees for treatments provided by a specialist will vary. Dental fees are subject to change without notice. The PTDP may not be combined with any other insurance or discount plan; non-covered benefits are excepted.
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MDG-FP-U10NYI04-SCH-NY-OFF-17
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D0999 Office visit during regular hours, general dentist only Evaluations D0120 Periodic oral examination - established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for
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LOUISIANA MEDICAID PROGRAM ISSUED: 08/18/14 REPLACED: 09/15/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16
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