|
Zip Code
43822 |
ADA
Code |
Procedure |
**Usual
Fee |
Member
(Reduced)
Fee |
Savings
% |
|
0120 |
Periodic
oral evaluation |
$43 |
$20 |
53% |
|
0150 |
Comprehensive oral evaluation |
$73 |
$33 |
55% |
|
0210 |
Intraoral-complete
series (including bitewings) |
$123 |
$57 |
54% |
|
0330 |
Panoramic
film |
$106 |
$46 |
56% |
|
1110 |
Prophylaxis-adult |
$84 |
$37 |
56% |
|
1120 |
Prophylaxis-child |
$61 |
$27 |
55% |
|
2140 |
Amalgam-one surface, permanent |
$114 |
$46 |
60% |
|
2150 |
Amalgam-two surfaces, permanent |
$143 |
$51 |
64% |
|
2160 |
Amalgam-three surfaces, permanent |
$175 |
$80 |
54% |
|
2330 |
Resin-based composite-one surface, anterior |
$137 |
$60 |
56% |
|
2331 |
Resin-based composite-two surfaces, anterior |
$173 |
$76 |
56% |
|
2332 |
Resin-based composite-three surfaces, anterior |
$212 |
$93 |
56% |
|
2750 |
Crown-porcelain fused to high noble metal |
$1048 |
$486 |
53% |
|
2952 |
Cast post
and core in addition to crown |
$402 |
$167 |
58% |
|
3330 |
Root canal
therapy, molar (excluding final restoration) |
$947 |
$470 |
50% |
|
4341 |
Periodontal scaling and root planing, per quadrant |
$240 |
$100 |
58% |
|
4910 |
Periodontal maintenance procedures (following active therapy) |
$130 |
$60 |
54% |
|
5110 |
Complete
denture-maxillary |
$1421 |
$639 |
55% |
|
7210 |
Surgical
removal of erupted tooth |
$256 |
$111 |
59% |
