| |
Procedure Description
|
Special MPD Reduced Prices
|
Typical Charge in Maryland
|
| 00120 |
Annual Examination |
FREE
|
$73.00
- For Members it's FREE |
| 00120 |
Semi-Annual Examination |
FREE
|
$73.00 - For Members
it's FREE |
| 00150 |
New Patient Comprehensive
Examination |
FREE
|
$99.00 - For Members
it's FREE |
| 00220 |
Intraoral x-ray
film, single, first |
1/2 Price
|
$31.00 - Save $15.00 |
| 00230 |
Intraoral x-ray
film, additional |
1/2 Price
|
$29.00 ea. - Save
$15.00 each |
| 00270 |
Bitewing x-ray film,
single, first |
1/2 Price
|
$29.00 - Save $15.00 |
| 00272 |
Bitewing x-ray film,
two |
1/2 Price
|
$48.00 - Save $24.00 |
| 00274 |
Bitewing x-ray film,
four |
1/2 Price
|
$65.00 - Save $33.00 |
|
|
| |
|
PREVENTATIVE PROCEDURES
|
| 00140 |
Limited oral examination;
problem focused |
$20.00 |
$59.00 |
| 00460 |
Pulp vitality test |
$25.00 |
$45.00 |
| 01110 |
Cleaning. Youth
or adult |
$68.00 |
$89.00 |
| 01120 |
Cleaning. Child |
$49.00 |
$66.00 |
| |
Note:
cleaning is light scaling & polishing. If you need more than
this your cost will be higher. Reduced fee cleaning (light or heavy)
available once every six months. |
|
|
| 01203 |
Topical flouride;
child |
$22.00 |
$33.00 |
| 01204 |
Topical flouride;
adult |
$22.00 |
$50.00 |
| 01351 |
Sealant - per tooth |
$25.00 |
$44.00 |
| 01360 |
Infection control.
Each visit |
$5.00 |
$14.00 |
| 01510 |
Space maintainer;
fixed unilateral |
$225.00 |
$282.00 |
| 01515 |
Space maintainer;
fixed bilateral |
$248.00 |
$310.00 |
| 00210 |
Intra-oral complete
x-ray series - once every 3 years |
$52.00 |
$109.00 |
| 00210 |
Intra-oral complete
x-ray series - additional |
$75.00 |
$109.00 |
| 00330 |
Panoramic film |
$75.00 |
$109.00 |
| |
Sterlization Surcharge-every
visit |
$5.00 |
$14.00 |
|
|
|
RESTORATIVE PROCEDURES
|
| |
|
MPD Members only pay
|
Others expect to pay
|
| 02140 |
Amalgam filling;
1 surface; permanent |
$74.00 |
$88.00 |
| 02150 |
Amalgam filling;
2 surfaces; permanent |
$84.00 |
$109.00 |
| 02160 |
Amalgam filling;
3 surfaces; permanent |
$100.00 |
$127.00 |
| 02161 |
Amalgam filling;
4 or more surfaces; permanent |
$120.00 |
$163.00 |
| 02330 |
Resin filling; 1
surface; anterior |
$84.00 |
$123.00 |
| 02331 |
Resin filling; 2
surfaces; anterior |
$101.00 |
$163.00 |
| 02332 |
Resin filling; 3
surfaces; anterior |
$127.00 |
$219.00 |
| 02335 |
Resin filling; 4
or more surfaces; anterior |
$169.00 |
$298.00 |
| 02391 |
Resin filling; 1
surface; posterior |
$79.00 |
$109.00 |
| 02392 |
Resin filling; 2
surfaces; posterior |
$119.00 |
$162.00 |
| 02393 |
Resin filling; 3
surfaces; posterior |
$145.00 |
$228.00 |
| 02394 |
Resin filling; 4
or more surfaces |
$158.00 |
$228.00 |
| 02750 |
Crown; porcelain
fused to high noble |
$696.00 |
$1200.00 |
| 02751 |
Crown, porcelain
fused to predominantly base metal |
$690.00 |
$1175.00 |
| 02752 |
Crown; porcelain fused to noble |
$725.00 |
$1250.00 |
| 02920 |
Recement crown |
$49.00 |
$79.00 |
| 02930 |
Prefabricated stainless
steel crown - #1 tooth |
$121.00 |
$185.00 |
| 02940 |
Prefabricated stainless
steel crown - #2 tooth |
$144.00 |
$200.00 |
| 02940 |
Sedative filling |
$43.00 |
$76.00 |
| |
|
ENDODONTIAL PROCEDURES
|
| 03110 |
Pulp cap; Direct;
excluding final restoration |
$40.00 |
$65.00 |
| 03120 |
Pulp cap; indirect;
excluding final restoration |
$45.00 |
$55.00 |
| 03220 |
Therapeutic pulpotomy;
excluding final restoration |
$125.00 |
$169.00 |
| 03321 |
Pulpal debridement |
$125.00 |
$169.00 |
| 03310 |
Root canal; anterior; excluding final
restoration |
$433.00 |
$531.00 |
| 03320 |
Root canal; bi-cuspid; excluding final
restoration |
$508.00 |
$657.00 |
| 03330 |
Root canal; molar; excluding restoration |
$569.00 |
$749.00 |
| |
|
PERIODONTAL PROCEDURES
|
| 04210 |
Gingivectomy; upper; per quadrant |
$284.00 |
$551.00 |
| 04210 |
Gingivectomy; lower; per quadrant |
$284.00 |
$599.00 |
| 04211 |
Gingivectomy; per tooth |
$49.00 |
$89.00 |
| 04260 |
Osseous surgery; flap entry, close,
per quadrant |
$415.00 |
$574.00 |
| 04341 |
Periodontal scaling; root planning,
per quadrant |
$135.00 |
$179.00 |
| |
|
PROSTHODONTICS
|
| 05110 |
Denture; complete upper; including 6
months post-insertion care |
$750.00 |
$909.00 |
| 05410 |
Adjustments after six months |
$40.00 |
$40.00 |
| 05110 |
Denture; complete lower; including 6
months post-insertion care |
$750.00 |
$909.00 |
| 05410 |
Adjustments after six months |
$40.00 |
$40.00 |
| |
|
|
|
| 05130 |
Denture; immediate upper; includes six
months post insertion care. Does not include required future rebasing/relining
procedure(s) or a complete new denture at a later date. |
$800.00 |
$999.00 |
| 05410 |
Adjustments after six months |
$40.00 |
$40.00 |
| 05130 |
Denture; immediate lower; includes six
months post insertion care. Does not include required future rebasing/relining
procedure(s) or a complete new denture at a later date. |
$800.00 |
$999.00 |
| 05410 |
Adjustments after six months |
$40.00 |
$40.00 |
| |
|
|
|
| 05211 |
Partial; upper; acrylic base; including
conventional clasps and rests |
$620.00 |
$706.00 |
| 05212 |
Partial; lower; acrylic base; including
conventional clasps and rests |
$640.00 |
$706.00 |
| |
|
|
|
| 05213 |
Partial; upper; predominantly cast base
acrylic saddles, including conventional clasps and rests |
$775.00 |
$950.00 |
| 05214 |
Partial; lower; predominantly cast base
acrylic saddles, including conventional clasps and rests |
$775.00 |
$950.00 |
| |
|
ORAL SURGERY
|
| 07140 |
Extraction; simple, single tooth |
$89.00 |
$110.00 |
| |
Extraction; simple, each additional |
$80.00 |
$110.00 |
| 07111 |
Extraction; primary (child) |
$65.00 |
$99.00 |
| 07130 |
Extraction; root removal, root exposed |
$99.00 |
$165.00 |
| 07210 |
Extraction; surgical removal of erupted
tooth |
$165.00 |
$199.00 |
| 07220 |
Extraction; impacted, soft tissue |
$181.00 |
$215.00 |
| 07230 |
Extraction; impacted partial boney |
$199.00 |
$250.00 |
| 07240 |
Extraction; impacted, complete boney |
$231.00 |
$309.00 |
| |
|
ADDITIONAL GENERAL SERVICES
|
| 00016 |
Cancelled appointment w/o 24 hours notice;
per every scheduled 30 minutes cancelled |
$35.00 |
$50.00 |
| 09110 |
Palliative care |
$60.00 |
$89.00 |
| 03960 |
Bleaching; per arch |
$179.00 |
$250.00 |
| *typical costs are actual documented
charges from various offices throughout Central Maryland |
| |
|
|
|
|
PARTICIPATING SPECIALIST CHARGES*
|
|
The Maryland Preventive Dentistry Program is primarily for routine
services.
Therefore we have more participating family dentists than we
do specialists. With that in mind please remember that specialists
are few and far between.
When you do go to one of our participating specialists you will
receive a 20% discount off of their usual and customary charges
for a specific procedure.
If one of our participating family dentists refers you to
a specialist it is your responsibility to verify that they are
one of our participating specialists.
|
| |
|
|
|
|
REMEMBER that if you do not use one of our participating Maryland
Preventive Dentistry dentists that you will have absolutely no
benefits. You MUST use one of our participating dentists in order
to benefit from your Maryland Preventive Dentistry membership.
This is NOT an insurance product.
*20% reduction does not include any costs or services associated
with Invisilign, or lost or broken appliances for any orthodontic
or prostodontic related expense. Lab testing not discounted by
General Dentists or Specialists
REDUCED FEE
SCHEDULE PRICES WILL CHANGE EVERY FEBRUARY 1st.
|