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DENTAL. PROCEDURES/FEE SCHEDULE <br /> FULL COST <br /> CODES DIAGNOSTIC <br /> 0110 . . . . . . . . . . . . . . . . . . v 15.00 <br /> Initial oral Exam » 1,5.00 <br /> 0120 Periodic Oral Exam. . . . . . . . . . . • . . . . . . . . . : . . . 15.00 <br /> 0130 Emergency Oral Exam ., . • . . . . . • . . . . . . . . . . . 23.00 <br /> 0330 Panoramic X-ray . . . . . . . . _ . . . . . . . . » . . . . . _ <br /> . 8.00 <br /> 0240 Intraoral Occlusal Film . . . . . . . . . . . . . . . » 3. 70 <br /> 0230 Intraoral--Additional Film D.A. . . . . . . . . . . . . . 25,00 <br /> 0210 Full Mouth X-ray w/x h.w. film. . . » . . . . . . . . . . 10.00 <br /> 0272 Bitewing X-ray (4 films). . . . . . . . . . . . . . » . . 8.00 <br /> 0271 Bitewing X-ray (2 films). . . . . . . . . . . . . . . . . . » 4.00 <br /> 0270 Bitewing X-ray (9 film) . . . . . . . . . . . • ^ • ^ ' . 10.00 <br /> 0430 Biopsy Oral Tissue (Hard) . . . . . . . . . . . . • . . . . . . '10.00 <br /> 0440 Biopsy Oral Tissue (Soft) _ . . . . . . . . . • . 20.00 <br /> PREVENTIVE 0470 Diagnostic Model. . . . . . . . » . . . . . . • . . . . <br /> PREVENTIVE TREATMENT <br /> 15.00 <br /> 1110 Dental Prophylaxis. . . . . . . » • • . - - 8.00 <br /> 1200 Topical Application of•sodium Fluozide. . _ . » » . <br /> SURGERY <br /> 710D Uncomplicated Removal of Tooth. . . . . . . . . • . . . - „ » 93.00. . 20.00 <br /> 7200 Surgical Removal of Erupted Tooth » . . . . . . . * . : _ „ 55.00 <br /> 7230 Removal of Impacted Toroth . - » » 13.00 <br /> 7250 Surgical Removal of Residual Root . . . . . . . . . . . . . 15.00 <br /> 7425 Periocaronitis. . . . . . . . . . . . . » . . . . . . _ 10.00 <br /> 0717 I & D Minor Surgery • « - <br /> ENDODONTICS <br /> 3200 Pulpotomy. - » » - - . . . • . . . 45.00 <br /> 3310 Root Canal Fill.. (1 root) » » • » » • . . . . 90.00 <br /> 3320 float Canal Fill. (2 roots). . . . . . . . . . . . . _ • - • 125.00 <br /> 3330 Root Canal Fill. (3 roots). . . . . . . . . . . . . . . . . . . . . 150.00 <br /> 3210 Therapeutic Apical Closure. » . . . . . . . . . . . . . • . . . . . 40.00 <br /> OPERATIVE <br /> 2140 Amalgam Restoration 1 surface . . . . . . . . . . • . . . . 13.00 <br /> 2150 Amalgam Restoration 2 surfaces. . . . . . . . . . . . . . . . . . 20.00 <br /> 2160 Amalgam Restoration 3 surfaces. . . - . . . . <br /> . 27.00 36,00 <br /> 2161 Amalgam Restoration 4 <br /> surfaces . . . . . . . . . . . . 2.00 <br /> 2170 Amalgam Pin Retained (pin charge only)» . . r w . 15^60 <br /> 2940 Treatment Filling . . . . • . . . . . . . . . . . . . . '15.00 <br /> 2330 Composite or Plastic Filling 1 surface. . . . . . . . . . . . . . 25.00 <br /> 2331 Composite or Plastic Filling 2 surfaces . . - - - - ' , _ w . . 30.00 <br /> 2332 Composite or Plastic Filling 3 surfaces . . . . . • . • . . . . 45.00 <br /> . <br /> 2333 Composite or Plastic Filling 4 surfaces . . . . . . . » . . 2.00 <br /> 2334 Pin Retention - Exclusive of Composite Resin. . . . . . . . . <br />