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TABLE OF ALLOWANCES <br />Costs for most frequently reported dental procedures <br />DIAGNOSTIC AND PREVENTIVE Orange Co. <br />2006-2008 Recommended Difference <br />Amount 2009 <br />00120 Periodic oral exam $31 $37 $6 <br />00140 Periodic oral exam $98 $98 $0 <br />00150 Periodic oral exam $35 $65 $30 <br />00210 Full Series x-ra s $109 $128 $19 <br />230 X-ra s $11 $11 $0 <br />00272 2 Bitewin s $30 $35 $5 <br />00274 4 Bitewin s $39 $50 $11 <br />00330 Panorex x-ra s $65 $88 $23 <br />01110 Pro h taxis adult $62 $68 $6 <br />01120 Pro h taxis child to a e 14 $43 $53 $10 <br />01203 Fluoride Treatment $23 $27 $4 <br />01351 Sealants limitation child $40 $45 $5 <br />'These services were at or signer tnan the usual ~ ~.ustomary r~aias <br />and will remain at those levels. <br />RESTORATIVE <br />02140 Amal am Fillin s $97 <br />02150 Amal am Fillin s $128 <br />02160 Amal am Fillin s $155 <br />02161 Amal am Fillin s $170 <br />02330 Com osite Fillin s $100 <br />02331 Com osite Fillin s $125 <br />02332 Com osite Fillin s $160 <br />2330 Resin-One Surface Anterior $100 <br />2720 Crown-Resin with Hi h Noble $370 <br />2750 Crown-Porcelain Fused $370 <br /> <br />ENDODONTICS <br />03310 One Canal; anterior $485 <br />03320 Two Canals, bicus id $640 <br />03330 Three Canals, molars $765 <br />PERIODONTICS <br />04210 Gin ivetom $400 <br />04341 Root Planin $200 <br />04342 Periodontal scalin former) 434 $100 <br />ORAL SURGERY <br />07111 Deciduous tooth $90 <br />07140 Extraction, eru ted tooth $102 <br />DENTURE REPAIR <br />05610 Re air base $105 <br />05630 Broken clas $150 <br />05640 Re lace tooth $127 <br />05650 Add tooth $155 <br />05660 Add clas $150 <br />GOLD AND CAST RESTORATIONS (Crowns) <br />02752 Porcelain/metal $753 <br />02790 Full Cast $775 <br /> <br />PROSTHODONTICS (Dentures) <br />05110 Com lets u er $950 <br />05120 Com lets lower $950 <br />05211 U er artial $550 <br />05212 Lower artial $550 <br />05213 U er cast artial $875 <br />05214 Lower cast artial $875 <br />Attachment 3 <br />