|
Zip Code 32803 (POS CI-3) |
ADA
Code |
Procedure |
Typical
Fee |
Member
(Reduced)
Fee |
Savings
% |
|
0120 |
Periodic
oral evaluation |
$43 |
$19 |
56% |
|
0150 |
Comprehensive oral evaluation |
$73 |
$32 |
56% |
|
0210 |
Intraoral-complete
series (including bitewings) |
$123 |
$56 |
55% |
|
0330 |
Panoramic
film |
$106 |
$45 |
58% |
|
1110 |
Prophylaxis-adult |
$84 |
$37 |
56% |
|
1120 |
Prophylaxis-child |
$61 |
$26 |
57% |
|
2140 |
Amalgam-one surface, permanent |
$114 |
$50 |
56% |
|
2150 |
Amalgam-two surfaces, permanent |
$143 |
$64 |
55% |
|
2160 |
Amalgam-three surfaces, permanent |
$175 |
$78 |
55% |
|
2330 |
Resin-based composite-one surface, anterior |
$137 |
$58 |
57% |
|
2331 |
Resin-based composite-two surfaces, anterior |
$173 |
$74 |
57% |
|
2332 |
Resin-based composite-three surfaces, anterior |
$212 |
$91 |
57% |
|
2750 |
Crown-porcelain fused to high noble metal |
$1048 |
$473 |
55% |
|
2952 |
Cast post
and core in addition to crown |
$376 |
$163 |
57% |
|
3330 |
Root canal
therapy, molar (excluding final restoration) |
$947 |
$458 |
52% |
|
4341 |
Periodontal scaling and root planing, per quadrant |
$220 |
$98 |
56% |
|
4910 |
Periodontal maintenance procedures
(following active therapy) |
$130 |
$59 |
55% |
|
5110 |
Complete
denture-maxillary |
$1421 |
$623 |
56% |
|
7210 |
Surgical
removal of erupted tooth |
$250 |
$108 |
57% |
|
*** |
Comprehensive Ortho Treatment of the Adult Dentition This is
for a 24-month program based on CAREINGTON fees for ADA
codes 8090 & 8660 |
$5563 |
$4450 |
20% |
