201 W. Kenyon Rd. Champaign, IL 61820 map - 217-352-7961 - 24 hours every day HomeContact UsFAQA-Z IndexSearch
CHAMPAIGN URBANA PUBLIC HEALTH DISTRICT
Our mission:
To improve the health, safety and
well-being of the community through prevention, education, collaboration,
and regulation.
About CUPHD
Maternal and Child Health Dental Health Environmental Health Infectious Disease Prevention & Mgmt. Wellness and Health Promotion
Dental Health
Programs and Services

CUPHD Dental Clinic Fee Schedule

As Determined by the Illinois Department of Public Aid
Medical Assistance Fee Schedule for Child Participants

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 $33.00
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