|
SIU School of Medicine Dental Sliding Fees Effective 5.24.18 |
FS1 |
FS2 |
FS3 |
FS4 |
FS5 |
| Type of Service |
Procedure Code |
Description |
Full Fee |
Minimum Slide 0 100% or Less |
Slide 1 101-138% |
Slide 2 139%-150% |
Slide 3 151% -175% |
Slide 4 176%-200% |
| DIAGNOSTIC SERVICES |
D0120 |
Periodic oral evaluation |
$60.00 |
$15.00 |
$18 |
$27 |
$36 |
$45 |
| D0140 |
Limited oral evaluation |
$60.00 |
$15.00 |
$18 |
$27 |
$36 |
$45 |
| D0150 |
Comp oral eval-new/estab pat |
$65.00 |
$15.00 |
$20 |
$29 |
$39 |
$49 |
| D0210 |
Intraoral-complete series (bw) |
$110.00 |
$15.00 |
$33 |
$50 |
$66 |
$83 |
| D0220 |
Intraoral-periapical-1st film |
$55.00 |
$15.00 |
$17 |
$25 |
$33 |
$41 |
| D0230 |
Intraoral-periapical-each add'l |
$55.00 |
$15.00 |
$17 |
$25 |
$33 |
$41 |
| D0270 |
Bitewing-single film |
$55.00 |
$15.00 |
$17 |
$25 |
$33 |
$41 |
| D0272 |
Bitewings-two films |
$75.00 |
$15.00 |
$23 |
$34 |
$45 |
$56 |
| D0273 No price in Lincoln |
Bitewings-three films |
$95.00 |
$15.00 |
$29 |
$43 |
$57 |
$71 |
| D0274 |
Bitewings-four films |
$115.00 |
$15.00 |
$35 |
$52 |
$69 |
$86 |
| D0330 |
Panoramic film |
$120.00 |
$15.00 |
$36 |
$54 |
$72 |
$90 |
| PREVENTATIVE SERVICES |
D1110 |
Prophylaxis - Adult |
$80.00 |
$15.00 |
$24 |
$36 |
$48 |
$60 |
| D1120 |
Prophylaxis-child (0-18) |
$60.00 |
$15.00 |
$18 |
$27 |
$36 |
$45 |
| D1203 |
Flouride w/o Prohylaxis - Child |
$55.00 |
$15.00 |
$17 |
$25 |
$33 |
$41 |
| D1206 |
Topical fluoride varnish (0-18) |
$55.00 |
$15.00 |
$17 |
$25 |
$33 |
$41 |
| D1206 |
Topical flouride varnish (19-20) |
$55.00 |
$15.00 |
$17 |
$25 |
$33 |
$41 |
| D1208 |
Topical Appl of Flour Excel Varn (0-18) |
$55.00 |
$15.00 |
$17 |
$25 |
$33 |
$41 |
| D1208 |
Topical Appl of Four Exclud Propy (19-20) |
$55.00 |
$15.00 |
$17 |
$25 |
$33 |
$41 |
| D1351 |
Sealant-per tooth |
$60.00 |
$15.00 |
$18 |
$27 |
$36 |
$45 |
| D1510 |
Space maint-fixed-unilateral |
$250.00 |
$125.00 |
$130 |
$140 |
$150 |
$188 |
| D1515 |
Space maint-fixed-bilateral |
$500.00 |
$250.00 |
$255 |
$275 |
$300 |
$375 |
| D1520 |
Space Maintainer Removable Unilateral |
$250.00 |
$125.00 |
$130 |
$140 |
$150 |
$188 |
| D1525 |
Space Maintainer Removable Bilateral |
$500.00 |
$250.00 |
$255 |
$275 |
$300 |
$375 |
| D1550 |
Re-cement/bnd space maint |
$125.00 |
$15.00 |
$38 |
$56 |
$75 |
$94 |
| D1555 |
Removal of fixed space maint |
$125.00 |
$15.00 |
$38 |
$56 |
$75 |
$94 |
| RESTORATIVE DENISTRY |
D2140 |
Amalgam-1 surf. prim/perm |
$150.00 |
$30.00 |
$45 |
$68 |
$90 |
$113 |
| D2150 |
Amalgam-2 surf. prim/perm |
$175.00 |
$35.00 |
$53 |
$79 |
$105 |
$131 |
| D2160 |
Amalgam-3 surf. prim/perm |
$225.00 |
$40.00 |
$68 |
$101 |
$135 |
$169 |
| D2161 |
Amalgam-4+ surf. prim/perm |
$275.00 |
$45.00 |
$83 |
$124 |
$165 |
$206 |
| D2330 |
Resin-one surface, anterior |
$150.00 |
$30.00 |
$45 |
$68 |
$90 |
$113 |
| D2331 |
Resin-two surfaces, anterior |
$175.00 |
$35.00 |
$53 |
$79 |
$105 |
$131 |
| D2332 |
Resin-three surfaces, anterior |
$225.00 |
$40.00 |
$68 |
$101 |
$135 |
$169 |
| D2335 |
Resin-4+ w/incis angle-anterior |
$275.00 |
$45.00 |
$83 |
$124 |
$165 |
$206 |
| D2391 |
Resin composite-1s, posterior |
$150.00 |
$30.00 |
$45 |
$68 |
$90 |
$113 |
| D2392 |
Resin composite-2s, posterior |
$175.00 |
$35.00 |
$53 |
$79 |
$105 |
$131 |
| D2393 |
Resin composite-3s, posterior |
$225.00 |
$40.00 |
$68 |
$101 |
$135 |
$169 |
| D2394 |
Resin composite-4+s, posterior |
$275.00 |
$45.00 |
$83 |
$124 |
$165 |
$206 |
| D2610 |
Inlay-porcel/ceramic-1 surface |
|
|
$0 |
$0 |
$0 |
$0 |
| D2620 |
Inlay-porcel/ceramic-2 surface |
|
|
$0 |
$0 |
$0 |
$0 |
| D2630 |
Inlay-porcel/ceramic-3+ surface |
|
|
$0 |
$0 |
$0 |
$0 |
| D2750 |
Crown - porc fuse high noble mtl |
$1,800.00 |
$900.00 |
$1,000 |
$1,040 |
$1,080 |
$1,350 |
| D2751 |
Crown-porc fused to base metal |
$1,200.00 |
$600.00 |
$610 |
$665 |
$720 |
$900 |
| D2752 |
Crown - porc fused noble metal |
$1,500.00 |
$750.00 |
$800 |
$850 |
$900 |
$1,125 |
| D2791 |
Crown - full cast base metal |
$1,200.00 |
$600.00 |
$610 |
$665 |
$720 |
$900 |
| D2792 |
Crown-full cast noble metal |
$1,800.00 |
$900.00 |
$1,000 |
$1,040 |
$1,080 |
$1,350 |
| D2920 |
Re-cement or re-bond crown |
$125.00 |
$15.00 |
$38 |
$56 |
$75 |
$94 |
| D2930 |
Prefab stain steel crn-primary tooth |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D2940 |
Protective Restoration |
$85.00 |
$15.00 |
$26 |
$38 |
$51 |
$64 |
| D2950 |
Core buildup, include any pins |
$225.00 |
$40.00 |
$68 |
$101 |
$135 |
$169 |
| ENDODONTICS |
D3220 |
Therapeutic pulpotomy(exc rest) |
$150.00 |
$15.00 |
$45 |
$68 |
$90 |
$113 |
| D3310 |
Root canal therapy - anterior |
$900.00 |
$450.00 |
$500 |
$520 |
$540 |
$675 |
| D3320 |
Root canal therapy - bicuspid |
$1,200.00 |
$600.00 |
$610 |
$665 |
$720 |
$900 |
| D3330 |
Root canal therapy - molar |
$1,500.00 |
$750.00 |
$800 |
$850 |
$900 |
$1,125 |
| D3346 |
Retreat, prev RCT - anterior |
|
|
$0 |
$0 |
$0 |
$0 |
| D3347 |
Retreat, prev RCT - bicuspid |
|
|
$0 |
$0 |
$0 |
$0 |
| D3348 |
Retreat, prev RCT - molar |
|
|
$0 |
$0 |
$0 |
$0 |
| PERIODONTICS AND OTHER |
D4321 |
Provisional splinting-extracor |
$175.00 |
$35.00 |
$53 |
$79 |
$105 |
$131 |
| D4341 |
Perio scale&root pln-4+per quad |
$300.00 |
$50.00 |
$90 |
$135 |
$180 |
$225 |
| D4342 |
Perio scale & root pln-1-3th quad |
$200.00 |
$40.00 |
$60 |
$90 |
$120 |
$150 |
| D4346 |
Scale, Gingival Inflam-Full Mth |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D4355 |
Full mouth debridemnt,eval/diag |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D4910 |
Periodontal maintenance |
$150.00 |
$30.00 |
$45 |
$68 |
$90 |
$113 |
| D5110 |
Complete denture - maxillary |
$2,000.00 |
$500.00 |
$600 |
$900 |
$1,200 |
$1,500 |
| D5120 |
Complete denture - mandibular |
$2,000.00 |
$500.00 |
$600 |
$900 |
$1,200 |
$1,500 |
| D5130 |
Immediate Denture - maxillary |
$2,000.00 |
$500.00 |
$600 |
$900 |
$1,200 |
$1,500 |
| D5140 |
Immediate denture - mandibular |
$2,000.00 |
$500.00 |
$600 |
$900 |
$1,200 |
$1,500 |
| FLIPPER |
Flipper for 3 or less teeth |
$1,200.00 |
$300.00 |
$360 |
$540 |
$720 |
$900 |
| D5211 |
Maxillary partial - resin base |
$1,500.00 |
$375.00 |
$450 |
$675 |
$900 |
$1,125 |
| D5212 |
Mandibular partial - resin base |
$1,500.00 |
$375.00 |
$450 |
$675 |
$900 |
$1,125 |
| D5213 |
Maxil partial-metal Base W/sdls |
$1,800.00 |
$450.00 |
$540 |
$810 |
$1,080 |
$1,350 |
| D5214 |
Mand partial-metal base w/sdls |
$1,800.00 |
$450.00 |
$540 |
$810 |
$1,080 |
$1,350 |
| D5225 |
Maxil partial-flex base incl cl |
$1,500.00 |
$375.00 |
$450 |
$675 |
$900 |
$1,125 |
| D5226 |
Mand partial-flex base incl cl |
$1,500.00 |
$375.00 |
$450 |
$675 |
$900 |
$1,125 |
| D5410 |
Adjust complete denture-maxil |
$125.00 |
$15.00 |
$38 |
$56 |
$75 |
$94 |
| D5411 |
Adjust complete denture-mand |
$125.00 |
$15.00 |
$38 |
$56 |
$75 |
$94 |
| D5421 |
Adjust partial denture-maxil |
$125.00 |
$15.00 |
$38 |
$56 |
$75 |
$94 |
| D5422 |
Adjust partial denture-mand |
$125.00 |
$15.00 |
$38 |
$56 |
$75 |
$94 |
| D5510 |
Repair complete denture base |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D5511 |
Repair lwr full denture base |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D5512 |
Repair Broken complete denture base - Maxillary |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D5520 |
Replace teeth-comp dent (ea th) |
$55.00 |
$15.00 |
$17 |
$25 |
$33 |
$41 |
| D5610 |
Repair resin denture base |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D5611 |
Repair Resin Partial Denture Base, Mandibular |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D5612 |
Repair Broken Complete Denture Base, Maxillary |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D5621 |
Repair Cast Partial Framework, Mandibular |
$400.00 |
$50.00 |
$120 |
$180 |
$240 |
$300 |
| D5622 |
Repair Cast Partial Framework, Maxillary |
$400.00 |
$50.00 |
$120 |
$180 |
$240 |
$300 |
| D5630 |
Rpr or rplce brkn clasp, per th |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D5640 |
Replace broken teeth-per tooth |
$55.00 |
$15.00 |
$17 |
$25 |
$33 |
$41 |
| D5650 |
Add tooth to exist part denture |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| tooth add |
Additional Tooth beyond 1st |
$55.00 |
$15.00 |
$17 |
$25 |
$33 |
$41 |
| D5730 |
Reline Complete Maxillary Denture, Chairside |
$700.00 |
$100.00 |
$210 |
$315 |
$420 |
$525 |
| D5731 |
Reline complete man-chairside |
$700.00 |
$100.00 |
$210 |
$315 |
$420 |
$525 |
| D5740 |
Reline Maxillary Parital Denture, Chairside |
$700.00 |
$100.00 |
$210 |
$315 |
$420 |
$525 |
| D5741 |
Reline Mandibular Partial Denture, Chairside |
$700.00 |
$100.00 |
$210 |
$315 |
$420 |
$525 |
| D5750 |
Reline complete maxillary (lab) |
$700.00 |
$100.00 |
$210 |
$315 |
$420 |
$525 |
| D5751 |
Reline complete mand (lab) |
$700.00 |
$100.00 |
$210 |
$315 |
$420 |
$525 |
| D5760 |
Reline Maxillary Partial Denture, Laboratory |
$700.00 |
$100.00 |
$210 |
$315 |
$420 |
$525 |
| D5761 |
Reline Mandibular Partial Denture, Laboratory |
$700.00 |
$100.00 |
$210 |
$315 |
$420 |
$525 |
| D6210 |
Pontic-cast high noble metal |
$1,200.00 |
$600.00 |
$610 |
$665 |
$720 |
$900 |
| D6211 |
Pontic-cast predominantly base |
$1,000.00 |
$500.00 |
$510 |
$555 |
$600 |
$750 |
| D6212 |
Pontic-cast noble metal |
$1,200.00 |
$600.00 |
$610 |
$665 |
$720 |
$900 |
| D6751 |
Retainer cm-porc fuse base met |
$1,200.00 |
$600.00 |
$610 |
$665 |
$720 |
$900 |
| D6752 |
Retainer cm-porc fused nob met |
$1,200.00 |
$600.00 |
$610 |
$665 |
$720 |
$900 |
| D6790 |
Retainer cm-full cast hi nob |
$1,200.00 |
$600.00 |
$610 |
$665 |
$720 |
$900 |
| D6791 |
Retainer cm- full cast base |
$1,000.00 |
$500.00 |
$510 |
$555 |
$600 |
$750 |
| D6792 |
Retainer cm-full cast nob met |
$1,200.00 |
$600.00 |
$610 |
$665 |
$720 |
$900 |
| D7140 |
Extract,erupted th/exposed rt |
$175.00 |
$35.00 |
$53 |
$79 |
$105 |
$131 |
| D7210 |
Extract, erupted th, rem oth |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D7220 |
Extraction-impacted/soft tis |
$600.00 |
$90.00 |
$180 |
$270 |
$360 |
$450 |
| D7230 |
Extraction-impacted/part bony |
$800.00 |
$110.00 |
$240 |
$360 |
$480 |
$600 |
| D7240 |
Extraction-impacted/compl bony |
$1,000.00 |
$180.00 |
$300 |
$450 |
$600 |
$750 |
| D7250 |
Removal residual tooth roots |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D7286 |
Incisional biop oral tiss-soft |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D7291 |
T/SC Fiberotomy, B/R |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D7310 |
Alveoloplasty w/ext 4+ /quad |
$400.00 |
$50.00 |
$120 |
$180 |
$240 |
$300 |
| D7471 |
Removal of exostosis-per site |
$400.00 |
$50.00 |
$120 |
$180 |
$240 |
$300 |
| D7510 |
Incis&drain abscess-intra soft |
$250.00 |
$45.00 |
$75 |
$113 |
$150 |
$188 |
| D8210 |
Removable appliance therapy |
|
$0.00 |
$0 |
$0 |
$0 |
$0 |
| D9110 |
Emerg treatment, palliative |
$125.00 |
$15.00 |
$38 |
$56 |
$75 |
$94 |
| D9230 |
Analgesia/Nitrous Guide |
$250.00 |
$15.00 |
$75 |
$113 |
$150 |
$188 |
| D9310 |
Consultation-per session |
$125.00 |
$15.00 |
$38 |
$56 |
$75 |
$94 |
| D9630 |
Drugs/,edicaments for home use |
|
|
$0 |
$0 |
$0 |
$0 |
| D9940 |
Occlusal guards, night guard |
$500.00 |
$125.00 |
$150 |
$225 |
$300 |
$375 |
