| Description: | | Q-Dent Member
Out of Pocket |
| Clinical Oral Exams
|
| D0110 | Initial Oral Exam | None |
| D0120 | Periodic Oral Exam | None |
| D0150 | Evaluation Comprehensive Oral | None |
| D0180 | Evaluation Comprehensive Perio | 14.00 |
| X-Rays
|
| D0210 | X-Ray, Intraoral, Complete Set | None |
| D0220 | Periapical, Single | None |
| D0230 | Periapical, Additional Film | None |
| D0270 | Bitewing, Single Film | None |
| D0272 | Bitewing, Two Films | None |
| D0330 | Panoramic | None |
| D0340 | Cephalometric (Ortho only) | 66.00 |
Dental Prophylaxis
|
| D1110 | Adult Prophy (Limit 2/year) | None |
| D1120 | Child Prophy (Limit 2/year) | None |
| D1203 | Topical Application (Child) | None |
| D1351 | Sealant - Per Tooth | 21.00 |
Restorations
|
| D2140 | Amalgam, Permanent, 1 Surface | 29.00 |
| D2150 | Amalgam, Permanent, 2 Surface | 33.00 |
| D2160 | Amalgam, Permanent, 3 Surface | 42.00 |
| D2161 | Amalgam, Permanent, 4 Surface | 51.00 |
| D2951 | Amalgam, Pin Retention (2 Max.) | 10.00 |
| D2330 | Resin Composite 1 Surface Anterior | 44.00 |
| D2331 | Resin Composite 2 Surface Anterior | 52.00 |
| D2332 | Resin Composite 3 Surface Anterior | 75.00 |
| D2335 | Resin Composite 4 Surface Anterior | 102.00 |
| D2391 | Resin Composite 1 Surface Posterior | 52.00 |
| D2392 | Resin Composite 2 Surface Posterior | 64.00 |
| D2393 | Resin Composite 3 Surface Posterior | 79.00 |
| D2394 | Resin Composite 4 Surface Posterior | 102.00 |
Crowns
|
| D2750 | Crown, Gold (Gold cost extra) | 450.00 |
| D2751 | Crown, Porcelain | 450.00 |
| D2830 | Crown, Stainless Steel (Child) | 77.00 |
| D2931 | Crown, Stainless Steel (Adult) | 124.00 |
| D2950 | Post and Core Including pin | 77.00 |
Other Restorative Services |
| D2924 | Zoe Sedative Base (Per Tooth) | 32.00 |
| D2950 | Core build Up (Including Pin) | 64.00 |
Pulp Capping
|
| D3110 | Direct Pulp Cap | 16.00 |
| D3120 | Pulp Cap Indirect | 13.00 |
| D3220 | Vital Pulpotomy | 53.00 |
Root Canal Therapy
|
| D3310 | Endodontics, 1 Canal | 220.00 |
| D3320 | Endodontics, 2 Canals | 302.00 |
| D3330 | Endodontics, 3 Canals | 412.00 |
Periodontal Services
|
| D4210 | Gingivectomy (Per Quad) | 356.00 |
| D4341 | Root Planning/Perio Scale | 120.00 |
| D4910 | Periodontal Maintenance | 51.00 |
Dentures
|
| D5110 | Complete Upper Denture | 507.00 |
| D5120 | Complete Lower Denture | 507.00 |
| D5211 | Acrylic Partial, Treatment | 335.00 |
| D5212 | Acrylic Partial, Permanent | 335.00 |
| D5730 | Reline Denture Chair Side | 109.00 |
| D6751 | Bridge Abutment Porcelain | 450.00 |
Oral Surgery
|
| D7140 | Extraction, Erupted Tooth surgical | 53.00 |
| D7210 | Extraction | 86.00 |
| D7220 | Impaction Soft Tissue | 84.00 |
| D7230 | Impaction Partial Bony | 154.00 |
| D7240 | Impaction Complete Bony | 188.00 |
| D7510 | Incision and Drain of Abcess | 63.00 |
Orthodontics All Ages
|
| D8660 | Ortho Records | 177.00 |
| D8690 | Ortho Class 1, 2 and 3 | 4056.00 |
Fully complies with all Louisiana Insurance Laws.