We accept only children age 3-18
with All-Kids/Medicaid 95 primary or secondary insurance.
| Procedure | Maximum Allowance |
|
| Periodic Oral Exam - Ages 0-18 | D0120 | $28.00 |
| Limited Oral Examination - Problem Focused | D0140 | $16.20 |
| Comprehensive Oral Examination | D0150 | $21.05 |
| Intraoral - Complete Series (including bitewings) | D0210 | $30.10 |
| Intraoral - periapical - first film | D0220 | $5.60 |
| Intraoral - periapical - each additional film | D0230 | $3.80 |
| Bitewings - Two Films | D0272 | $9.40 |
| Bitewings - Four Films | D0274 | $16.90 |
| Prophylaxis - Ages 0-18 | D1120 | $41.00 |
| Topical Fluoride Varnish - Ages 0-18 | D1206 | $26.00 |
| Sealant - per tooth | D1351 | $36.00 |
| Space Maintainer - Fixed Unilateral | D1510 | $70.60 |
| Resin-Based Composite - 1 Surface Anterior | D2330 | $34.60 |
| Resin-Based Composite - 2 Surface Anterior | D2331 | $51.90 |
| Resin-Based Composite - 3 Surface Anterior | D2332 | $61.80 |
| Resin-Based Composite - 4 or more Surface Anterior | D2335 | $61.80 |
| Resin-Based Composite - 1 Surface Posterior | D2391 | $30.85 |
| Resin-Based Composite - 2 Surface Posterior | D2392 | $48.15 |
| Resin-Based Composite - 3 Surface Posterior | D2393 | $58.05 |
| Resin-Based Composite - 4 or more Surface Posterior | D2394 | $58.05 |
| Prefabricated Stainless Steel Crown Primary Tooth | D2930 | $73.40 |
| Therapeutic Pulpotomy | D3220 | $52.70 |
| Anterior Root Canal | D3310 | $136.40 |
| Bicuspid Root Canal | D3320 | $155.25 |
| Molar Root Canal | D3330 | $202.30 |
| Periodontal Scaling and Root Planing - Per Quadrant 4+ teeth | D4341 | $80.00 |
| Periodontal Maintenance Procedure | D4910 | $47.05 |
| Extraction - Erupted Tooth | D7140 | $39.12 |
| Incision and Drainage Abscess | D7510 | $36.70 |
| Palliative (emergency) Treatment of Dental Pain | D9110 | $14.10 |