DentalCareRx |
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Effective: April 1, 2008 |
GENERAL PRACTICE FEE SCHEDULE |
Georgia |
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DIAGNOSTIC & PREVENTATIVE SERVICES |
USUAL FEE |
MEMBER’S FEE |
USUAL FEE |
MEMBER’S FEE |
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ADA CODE |
PROCEDURE |
ADA CODE |
PROCEDURE |
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Office Visits |
50.00 | No Charge | *PERIODONTICS (Gum Disease) |
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Comprehensive Oral Exam |
50.00 | No Charge | 4118 | Perio Exam |
60.00 | 20.00 | |||
Fluoride Treatment |
25.00 | No Charge | 4210 | Gingivectomy Plasty (per quad) |
525.00 | 260.00 | |||
Oral Hygiene Instruction |
25.00 | No Charge | 4220 | Subgingival Curretage (per quad) |
140.00 | 85.00 | |||
| 0220 | X-ray Single Film |
20.00 | 9.00 | 4341 | Scaling & Root Planing (per quad) |
195.00 | 95.00 | ||
| 0230 | Each Additional Film |
15.00 | 4.00 | 4355 | Full Mouth Debridgement |
130.00 | 65.00 | ||
| 0270 | Bitewing X-ray, Single Film |
15.00 | 9.00 | 4910 | Periodontal Maintenance |
95.00 | 57.00 | ||
| 0272 | Bitewing X-ray, Two Films |
30.00 | 12.00 | 9630 | Medicinal Irrigation (per quad) |
40.00 | 20.00 | ||
| 0274 | Bitewing X-ray, Four Films |
45.00 | 20.00 | ||||||
| 0330 | Panoramic X-ray |
90.00 | 40.00 | *PROSTHETICS (Dentures & Partials) |
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| 0210 | Full Mouth X-ray |
95.00 | 45.00 | 5110 | Complete Upper Denture |
1,125.00 | 550.00 | ||
Dental office may require full mouth
or panoramic X-rays on initial visit. |
5120 | Complete Lower Denture |
1,125.00 | 550.00 | |||||
| 1110-1120 | Routine Cleaning (One Per Year) |
80.00 | 27.00 | 5130 | Immediate Upper Denture |
1,175.00 | 600.00 | ||
| 9999 | Infection Control |
12.00 | 6.00/visit | 5140 | Immediate Lower Denture |
1,175.00 | 600.00 | ||
| 1110-1120 | 2nd Routine Cleaning |
80.00 | 35.00 | 5213-14 | Partial U/L Acrylic w/Chrome |
1,175.00 | 650.00 | ||
| 1351 | Sealants (per tooth) |
35.00 | 19.00 | 5410-11 | Denture Adjustment |
70.00 | 45.00 | ||
| 0140 | Limited Oral Exam-Problem Focused |
40.00 | 15.00 | 5510 | Denture Repair, No Teeth |
130.00 | 60.00 | ||
Routine cleaning does not apply to
patients with periodontal disease. |
5520 | Replace Missing or Broken Teeth |
95.00 | 50.00 | |||||
| 5650 | Add Tooth to Existing Partial |
95.00 | 50.00 | ||||||
RESTORATIVE |
5660 | Add Clasp to Existing Partial |
125.00 | 65.00 | |||||
Amalgam Fillings |
5730-41 | Office Reline |
225.00 | 120.00 | |||||
| 2140 | 1 Surface |
95.00 | 38.00 | 5750-61 | Laboratory Reline |
295.00 | 160.00 | ||
| 2150 | 2 Surfaces |
115.00 | 65.00 | ||||||
| 2160 | 3 Surfaces |
135.00 | 75.00 | *ORAL SURGERY |
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| 2161 | 4 Surfaces |
160.00 | 95.00 | 7140 | Single Tooth Extraction-Simple, Local |
125.00 | 50.00 | ||
| 7210 | Removal-Surgical/Erupted Tooth |
190.00 | 110.00 | ||||||
Composite Restoration |
7220 | Removal of Impacted Tooth/Soft Tissue |
210.00 | 115.00 | |||||
| 2330 | Anterior |
1 Surface |
125.00 | 60.00 | 7230 | Removal of Impacted Tooth/Partial Bony |
265.00 | 145.00 | |
| 2331 | 2 Surfaces |
140.00 | 65.00 | 7240 | Removal of Impacted Tooth/Completely Bony |
320.00 | 185.00 | ||
| 2332 | 3 Surfaces |
160.00 | 85.00 | 7310 | Aveoloplasty (per quad) w/Extraction |
265.00 | 105.00 | ||
| 2335 | 4 Surfaces |
195.00 | 110.00 | 7320 | Aveoloplasty (per quad) w/o Extraction |
305.00 | 125.00 | ||
| 2391 | Posterior |
1 Surface |
140.00 | 65.00 | |||||
| 2392 | 2 Surfaces |
170.00 | 80.00 | ALL OF THE ABOVE CHARGES ARE REDUCED FEES FOR SERVICES | |||||
| 2393 | 3 Surfaces |
195.00 | 115.00 | PERFORMED BY A PARTICIPATING *GENERAL DENTIST | |||||
| 2394 | 4 Surfaces |
210.00 | 130.00 | ||||||
| There is a $35.00 charge for cancellation of appointment without | |||||||||
CROWNS & BRIDGES |
24-hour notice. | ||||||||
| 2750 | Porcelain Fused to High Noble Metal |
995.00 | 505.00 | ||||||
| 2751 | Porcelain Fused to Base Metal |
850.00 | 475.00 | Any procedure not listed is available at a 25% reduction in the usual and | |||||
| 2752 | Porcelain Fused to Noble Metal |
890.00 | 495.00 | customary price for the procedure. | |||||
| 2790 | Full Cast High Noble Metal |
895.00 | 500.00 | ||||||
| 2791 | Full Cast-Predominately Base Metal |
810.00 | 460.00 | Payment is required at the time of service. | |||||
| 2930 | PreFab Stainless Steel-Primary |
200.00 | 90.00 | ||||||
| 2931 | PreFab Stainless Steel-Permanent |
220.00 | 100.00 | Fees do not include lab costs. Lab fees are to be paid directly to the dental | |||||
| 2950 | Core Build-up Including Pins |
210.00 | 100.00 | office by the member. | |||||
| 2951 | Pin Retention/Tooth Add. to Crown |
60.00 | 38.00 | ||||||
| 2952 | Cast Post & Core Add. to Crown |
275.00 | 145.00 | Fees subject to change periodically without notification. | |||||
| 2954 | PreFab Post & Core Add. to Crown |
225.00 | 130.00 | ||||||
| 2962 | Labial Veneer (Porc. Laminate) Lab |
800.00 | 480.00 | SPECIALISTS | |||||
| Any treatment provided by a participating SPECIALIST, | |||||||||
*ENDODONTICS (Root Canals) |
if available, in Oral Surgery, Orthodontics, Periodontics, | ||||||||
(EXCLUDING FINAL RESTORATION) |
Pedodontics, or Endodontics, will be charged at a 25% reduction | ||||||||
| 3110-20 | Pulp cap |
65.00 | 25.00 | of the Specialist’s fees for that particular case. | |||||
| 3220 | Therapeutic Pulpotomy |
175.00 | 70.00 | ||||||
| 3310 | Root canal Anterior |
585.00 | 300.00 | Present your membership ID upon check-in. | |||||
| 3320 | Root canal Bicuspid |
695.00 | 350.00 | If you have any questions, please call our Customer Service
Desk at (678) |
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| 3330 | Root canal Molar |
850.00 | 450.00 | 714-9906 or (877) 201-2080, Ext. 10/Mon-Fri 9:00am-4:00pm (EST). | |||||