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 |
$622.50 |
$498.00 |
2543 |
GOLD ONLAY (PER TOOTH) |
$661.00 |
$529.00 |
02750 |
CROWN-PORC FUSED HI NOBLE MTL |
$821.00 |
$657.00 |
03310 |
ROOT CANAL THERAPY -ANTERIOR EXC FINAL RESTORATION |
$440.50 |
$352.50 |
03330 |
ROOT CANAL THERAPY -MOLAR EXC FINAL RESTORATION |
$551.00 |
$441.00 |
04210 |
GINGIVECTOMY/GINGIVOPLASTY PER QUAD |
$270.00 |
$216.00 |
04910 |
PERIO MAINT PROCS AFTER ACTIVE THERAPY |
$0.00 |
$0.00 |
05110 |
COMPLETE DENTURE - UPPER |
$843.00 |
$674.50 |
05120 |
COMPLETE DENTURE -LOWER |
$881.50 |
$705.00 |
9110 |
EMERG. PALLIATIVE TREATMENT |
$60.50 |
$48.50 |
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