Preventive and Diagnostic Services
Oral Surgery
ADA Code Member Service
UCR*
Member Fee
ADA Code Member Service
UCR*
Member Fee
0150
89
N/C
56
N/C
7140
7210
7230
7240
171
290
452
549
135
230
360
440
80
25
142
N/C
33
N/C
101
N/C
28
59
10 Copay
30
0120
0140
0210
0220
1110
1206
1351
Comprehensive
Oral Examination
Periodic Oral Exam
(Once per year)
Limited/Emergency
Exam
(Includes one Periapical X-ray)
Complete Set of
Radiographs
Single Periapical
X-ray
Simple Teeth
Cleaning**
(Up to 2 per year)
Fluoride
Sealant (per tooth)
Restorative (Fillings)
Anterior Resin Restorations
2330
One Tooth Surface
2331
Two Surfaces
2332
Three Surfaces
2335
Four or More Surfaces
166
204
244
301
135
165
195
240
Posterior Resin Restorations
2391
One Tooth Surface
2392
Two Surfaces
2393
Three Surfaces
2394
Four or More Surfaces
182
233
287
333
145
185
230
265
Crown and Bridge
Onlays
2642
2643
2644
Crowns
2740
2750
2790
2920
2950
2954
Bridges
6750
6240
Onlay-Porcelain Two Surfaces 1219
Onlay-Porcelain Three Surfaces 1203
Onlay-Porcelain Four + Surfaces 1250
Porcelain Crown
Porcelain Fused to Metal Crown
Full Gold Crown***
Recement Crown
Crown Buildup
Prefab Post and Core
Porcelain Fused to Metal
Retainer Crown
Porcelain Fused to Metal
Pontic
1250
1170
1208
110
285
343
Endodontics
3221
3310
3320
3330
1159
950
1158
950
*Usual and Customary Rate (Average fees charged according to zip code)
**This does NOT apply to patients with Periodontal Disease
***(Additional Lab Fees Apply--$150.00 Minimum)
Pulpal Debridement
Root Canal-Anterior
Root Canal-Bicuspid
Root Canal-Molar
234
781
908
1120
190
625
725
900
Periodontics
4211
4249
4263
4341
4342
4355
4910
Gingivectomy 1-3 Teeth
Crown Lengthening
Bone Graft
Perio Scaling 4+ Teeth/Quad
Perio Scaling 1-3 Teeth/Quad
Full Mouth Debridement
Perio Maintenance
289
884
350
265
186
183
150
230
710
280
210
150
150
120
Removable Prosthodontics
5110
5120
5130
5140
5213
5214
5850
5851
975
975
975
1000
1000
1000
88
250
275
Simple Extraction
Surgical Extraction
Part Bony Extraction
Complete Bony Extraction
Complete Denture-Max
Complete Denture-Mand
Immediate Denture-Max
Immediate Denture-Mand
Maxil Partial-Metal Base
Mand Partial-Metal Base
Tissue Condition-Maxillary
Tissue Condition-Mandibular
1679
1649
1836
1941
1730
1742
200
201
1300
1300
1450
1450
1380
1390
160
160
Implants
6010
6056
6061
Surgical Placement
Prefab Abut-Inc Placement
Abutment Supported Crown
2198
785
1496
1750
600
1000
Other Services
9110
9230
9248
9940
9951
-----------
Emergency Palliative Treatment
Nitrous Oxide (Analgesia)
Non-IV Conscious Sedation
Occlusal Guards
Occlusal Adjustment-Limited
Take Home Whitening
In Office Bleaching
127
81
354
576
153
450
600
100
65
175
460
120
99
250