Treatments
COMPOSITE *WHITE+FILLING
One surface – D2391
$205
Two surface – D2392
$255
Three surface – D239
$300
Zirconia Crowns for Front Teeth
Prefabricated Zirconia Crown – D2929
$420
Simple Extractions (Most Baby Teeth)
Simple Extraction – D7140
$225
Nitrous oxide (Laughing Gas)
Nitrous Oxide – D9230
$130
Stainless Steel Crowns
Stainless Steel Crown for Primary (Baby) Tooth – D2930
$300
Stainless Steel Crown for Permanent Tooth – D2931
$365
Pulpotomy (Baby Root Canal)
Pulpotomy – D3220
$200
Silver Diamine Fluoride (SDF)
SDF, Caries Arresting Medicament – D1354
$40
Anesthesia (15 minute increments)
D9222 – Anesthesia / Sedation First 15 Minutes
$300
D9223 – Anesthesia / Sedation Each Additional 15 minutes
$200
Services
Exams
Limited or Problem Focused Exam – D0140
$75
Comprehensive Oral Evaluation – D0150
$90
Periodic oral evaluation (Check up) – D0120
$65
Consultation for Dental Treatment under Anesthesia – D9310
$150
Cleanings
Children’s Prophy – D1120
$88
Adult’s Prophy (13 years and up) – D1110
$99
Fluoride Treatments
Fluoride Varnish – D1206
$40
Radiographs (X rays)
Intraoral Full Mouth Images – D0210
$165
Bitewing: 2 Images – D0272
$45
Bitewing: 4 Images – D0274
$60
Occlusal Image -D0240
$36
1st Periapical – D0220
$28
Additional Periapicals – D0230
$20
Sealants
Sealant – D1351
$72
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