ASI Dental Fee Schedule

NHCD Dental Fee Schedule

Use this fee schedule if NHCD appears in the PLAN column on the provider list

**Note - Colorado & Georgia do NOT follow this fee schedule. Customers in CO & GA must contact their local NHCD office.**
**For Colorado please call 1-303-427-2220 - For Georgia please call 1-770-452-9610**

Table with 3 columns and 5 rows

NHCD Fee Schedule for General Dentists

Prices effective July 1, 2004

Procedure

Member Pays

Oral Exam

Office Visit

Bitewing X-ray

Fluoride Treatment - Child (1/year)

Home Care Prevention

Cleaning, Child or Adult

Pulp Vitality Tests

Infection Control
}

$25.00

Total Charge

(Once per Year)
(Dental office may require full mouth X-rays on initial visit of new patients. Usual charge $80.00 - Member's Charge $35.00
table end

Diagnostic and Preventative Services
Infection Control
$10.00
0120 Periodic Oral Evaluation
$16.00
0150 Comprehensive Oral Evaluation
$16.00
0210 Full Mouth X-rays
$38.00
0220 Single Mouth X-ray
$7.00
0230 Each Additional Film
$5.00
0270 Bitewing - single film
$8.00
0272 Bitewing - two films
$10.00
0274 Bitewing - four films
$17.00
0330 Panoramic Film
$35.00
1110 Prophylaxis - Adult Cleaning
$35.00
1120 Prophylaxis - Child Cleaning
$25.00
1203-1204 Fluoride Treatment
$13.00
1351 Sealant - per tooth
$16.00
Restorative

Amalgam Fillings
2140 Primary/Permanent 1 surface
$46.00
2150 2 surfaces
$62.00
2160 3 surfaces
$76.00
2161 4 surfaces
$95.00

Resin-Based Composite
2330 Anterior 1 surface
$46.00
2331 2 surfaces
$65.00
2332 3 surfaces
$90.00
2335 4 surfaces
$119.00
2391 Posterior 1 surface
$60.00
2392 2 surfaces
$85.00
2393 3 surfaces
$120.00
2394 4 or more surfaces
$135.00
Crowns
2750 Porcelain fused high noble metal
$460.00
2751 Porcelain fused to predominantly base metal
$415.00
2752 Porcelain fused to noble metal
$425.00
2790 Full cast high noble metal
$420.00
2791 Full cast - predominantly base metal
$400.00
2930 Prefab stainless steel - primary
$85.00
2931 Prefab stainless steel - permanent
$95.00
2950 Core buildup including any pins
$110.00
2951 Pin retention/tooth in addition to crown
$20.00
2952 Cast Post and core in addition to crown
$135.00
2954 Prefab post and core in addition to crown
$105.00
Periodontics: (Gum Disease)
4211 Gingivectomy (per quad)
$169.00
4341 Scaling & Root Planing (per quad)
$100.00
4355 Full Mouth debridement
$89.00
4910 Periodontal maintenance -following active therapy
$45.00
Endodontics: (Root Canals)
(EXCLUDING FINAL RESTORATION)
3110 Pulp cap-direct
$20.00
3120 Pulp cap-indirect
$20.00
3220 Therapeutic Pulpotomy (Excluding Final Restoration)
$45.00
3310 Root canal Anterior (Excluding Final Restoration)
$270.00
3320 Root canal Bicuspid (Excluding Final Restoration)
$310.00
3330 Root canal Molar (Excluding Final Restoration)
$390.00
Prosthetics: (Dentures & Partials)
5110 Complete Upper Denture
$430.00
5120 Complete Lower Denture
$430.00
5130 Immediate Upper Denture
$465.00
5140 Immediate Lower Denture
$465.00
5213-14 Cast Metal Framework w/Resin Denture Bases
$550.00
(Including any Conventional Clasps, Rests or Teeth)
5410-11 Adjust Complete Denture
$28.00
5520 Replace missing or broken tooth
$43.00
5650 Add Tooth to Existing Partial Denture
$47.00
5560 Add Clasp to Existing Partial Denture
$60.00
5730-41 Reline Complete or Partial Denture (Chairside)
$115.00
5750-61 Reline Complete or Partial Denture (Laboratory)
$165.00
Oral Surgery
7140 Single Tooth Extraction
$50.00
(Erupted Tooth or Exposed Root)
Orthodontics: (Braces)
$3,000.00
(X-rays, study models, tracing, records, and extractions are not included)
* All of the above charges are reduces fees for services performed by a participating GENERAL DENTIST.

Procedures not listed on this schedule will be discounted at 20% of the General Dentists normal fee..

Payment is required at the time of service.

Fees do not include lab costs. Lab fees are to be paid directly to the dental office by the member.

Fees Subject to change periodically without notification.

*****SPECIALISTS*****

Any treatment provided by a participating SPECIALIST if available, in Oral Surgery, Orthodontists, Periodontics, Pedodontics, or Endodontics will be charged
at a 20-25% reduction of the Specialists fees for that particular case.