NATIONFEESCHEDULEHASSELLCORRECTION - Copy

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D2392 RESIN-BASED COMPOSITE – TWO SURFACE, POSTERIOR $169.00 $106.00 $85.00 D2393 RESIN-BASED COMPOSITE – THREE SURFACE, POSTERIOR $191.00 $129.00 $95.00 D2394 RESIN-BASED COMPOSITE – FOUR OR MORE SURFACES, POSTERIOR $219.00 $176.00 $110.00 D2752 CROWN – PORCELAIN FUSED TO NOBLE METAL $1,110.00 $699.00 $530.00 D2799 PROVISIONAL CROWN $132.00 $61.00 $49.00 D2920 RECEMENT CROWN $102.00 $68.00 $45.00 D2940 SEDATIVE FILLLING $79.00 $56.00 $40.00 D2950 CORE BUILDUP, INCLUDING ANY PINS $203.00 $138.00 $139.00 D2952 POST AND CORE IN ADDITION TO CROWN, INDIRECTLY FABRICATED $265.00 $205.00 $169.00 D2954 PREFABRICATED POST AND CORE IN ADDITION TO CROWN $265.00 $179.00 $164.00 D2955 POST REMOVAL (NOT IN CONJUCTION WITH ENDODONTIC THERAPY) $280.00 $188.00 $150.00 D3120 PULP CAP – INDIRECT (EXCLUDING FINAL RESTORATION) $74.00 $32.00 $20.00 D3220 THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) REMOVAL OF PULP CORONAL TO THE DENTINOCEMENTAL JUNCTION AND APPLICATION OF MEDICAME $198.00 $121.00 $98.00 D3221 PULPAR DEBRIDEMENT, PRIMARY AND PERMANENT TEETH $193.00 $138.00 $98.00 D3310 ENDODONTIC THERAPY, ANTERIOR TOOTH (EXCLUDING FINAL RESTORATIO $560.00 $420.00 $280.00 D3320 ENDODONTIC THERAPY, BICUSPID TOOTH (EXCLUDING FINAL RESTORATIO $670.00 $480.00 $380.00 D3330 ENDODONTIC THERAPY, MOLAR (EXCLUDING FINAL RESTORATION) $830.00 $540.00 $440.00 D3346 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY – ANTERIOR $760.00 $468.00 $380.00 D3347 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY – BICUSPID $870.00 $553.00 $480.00 D3348 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY – MOLAR $1,030.00 $659.00 $540.00 D4210 GINGIVECTOMY OR GINGIVOPLASTY – FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT $390.00 $308.00 $155.00
D4211 GINGIVECTOMY OR GINGIVOPLASTY – ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT $238.00 $107.00 $91.00 D4249 CLINICAL CROWN LENGHTHENING – HARD TISSUE $570.00 $320.00 $170.00 D4341 PERIODONTAL SCALING AND ROOT PLANING – FOUR OR MORE TEETH PER $190.00 $133.00 $99.00 D4355 FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE EVALUATION AN $133.00 $77.00 $64.00 D5110 COMPLETE DENTURE – MAXILLARY $1,190.00 $776.00 $590.00 D5120 COMPLETE DENTURE – MANDIBULAR $1,190.00 $776.00 $590.00 D5130 IMMEDIATE DENTURE – MAXILLARY $1,280.00 $828.00 $650.00 D5140 IMMEDIATE DENTURE – MANDIBULAR $1,280.00 $828.00 $650.00 D5211 MAXILLARY PARTIAL DENTURE – RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) $1,103.00 $600.00 $549.00 D5212 MANDIBULAR PARTIAL DENTURE – RESIN BASE (INCLUDING ANY CONCENTIONAL CLASPS, RESTS AND TEETH) $1,103.00 $600.00 $549.00 D5213 MAXILLARY PARTIAL DENTURE – CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) $1,255.00 $650.00 $590.00 D5214 MANDIBULAR PARTIAL DENTURE – CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) $1,255.00 $650.00 $590.00 D5410/11 ADJUST COMPLETE DENTURE - MAXILLARY/MAND $88.00 $50.00 $40.00 D5421/22 ADJUST PARTIAL DENTURE – MAXILLARY/MAND $90.00 $52.00 $40.00 D5510 REPAIR BROKEN COMPLETE DENTURE BASE $167.00 $107.00 $78.00 D5520 REPLACE MISSING OR BROKEN TEETH - COMPLETE DENTURE (EACH TOOTH) $142.00 $88.00 $60.00 D5710 REBASE COMPLETE MAXILLARY DENTURE $233.00 $213.00 $110.00 D5711 REBASE COMPLETE MANDIBULAR DENTURE $233.00 $213.00 $110.00 D5810 INTERIM COMPLETE DENTURE (MAXILLARY) $673.00 $388.00 $285.00
Page 1: \ LISTING OF MAXIMUM ALLOWABLE CHAR

NATIONFEESCHEDULEHASSELLCORRECTION - Copy

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