CDT CODE |
CDT PROCEDURE DESCRIPTION |
MANHATTAN
MAX FEE |
NON-MANHATTAN
MAX FEE |
00150 |
INITIAL ORAL EXAMINATION |
$0.00 |
$0.00 |
00120 |
PERIODIC ORAL EVALUATION |
$0.00 |
$0.00 |
00210 |
INTRAORAL RADIOGRAPHS FULL SERIES ADULT |
$0.00 |
$0.00 |
01110 |
PROPHYLAXIS - ADULTS |
$0.00 |
$0.00 |
01120 |
PROPHYLAXIS - CHILD |
$0.00 |
$0.00 |
01351 |
SEALANT - PER TOOTH |
$0.00 |
$0.00 |
| |
ALL AMALGAMS (SILVER FILLINGS) -ALL SURFACES |
$0.00 |
$0.00 |
02330 |
RESIN (WHITE FILLINGS)- ALL SURFACES |
$0.00 |
$0.00 |
2520 |
INLAY (METALLIC) -2 SURFACE |
$576.50 |
$461.00 |
2543 |
GOLD ONLAY (PER TOOTH) |
$612.00 |
$489.50 |
02750 |
CROWN-PORC FUSED HI NOBLE MTL |
$714.00 |
$571.00 |
03310 |
ROOT CANAL THERAPY -ANTERIOR EXC FINAL RESTORATION |
$408.00 |
$326.50 |
03330 |
ROOT CANAL THERAPY -MOLAR EXC FINAL RESTORATION |
$510.00 |
$408.00 |
04210 |
GINGIVECTOMY/GINGIVOPLASTY PER QUAD |
$250.00 |
$200.00 |
04910 |
PERIO MAINT PROCS AFTER ACTIVE THERAPY |
$0.00 |
$0.00 |
05110 |
COMPLETE DENTURE - UPPER |
$780.50 |
$624.50 |
05120 |
COMPLETE DENTURE -LOWER |
$816.00 |
$653.00 |
9110 |
EMERG. PALLIATIVE TREATMENT |
$56.00 |
$45.00 |
