Hammond Dental Care Platinum Plan
ADA MEMBER UCR MEMBER
CODE SERVICE RATE
ADA MEMBER
CODE SERVICE
UCR MEMBER
RATE
DIAGNOSTIC AND PREVENTIVE
PERIODONTICS
N/C
N/C
N/C
N/C
N/C
N/C
N/C
4341 SRP 4+ per quad
4342 SRP 1-3 teeth per quad
4355 Full mouth debridement
4381 Arestin
4910 Periodontal maintenance
ENDODONTICS
0120
0140
0150
0180
0210
0220
0230
0240
0272
0274
1110
1120
1203
1204
1351
Periodic oral evaluation
Limited oral evaluation
Comprehensive oral evaluation
Comprehensive perio evaluation
Intraoral-complete series
Intraoral-periapical first film
Intraoral-periapical each add’l
Intraoral-occlusal film
Bitewings-two films
Bitewings-four films
**Prophylaxis-adult**
**Prophylaxis-child**
(**Patient’s with gum disease are not covered under this category**)
Fluoride-child
Fluoride-adult
Sealant-per tooth
27.00
39.00
74.00
39.00
96.00
19.00
17.00
19.00
35.00
40.00
84.00
40.00
28.00
28.00
30.00
N/C
N/C
N/C
N/C (50.00)
N/C (24.00)
1×12 (17.00)
17.00
18.00
3110 Pulp cap-direct
3120 Pulp cap-indirect
3220 Therapeutic pulpotomy
3240 Pulpal therapy-posterior
3310 Root canal therapy-anterior
3320 Root canal therapy-bicuspid
3330 Root canal therapy-molar
250.00 150.00
170.00 102.00
95.00 57.00
37.00 27.00
128.00 77.00
75.00 45.00
90.00 54.00
95.00 57.00
105.00 63.00
695.00 417.00
800.00 480.00
985.00 700.00
RESTORATIVE (FILLINGS)
ORAL SURGERY
2330
2331
2332
2335
2391
2392
2393
2394
2940
Resin-one surface anterior
Resin-two surface anterior
Resin-three surface anterior
Resin-four+ surface anterior
Resin-one surface posterior
Resin-two surface posterior
Resin-three surface posterior
Resin-four+ surface posterior
Sedative filling
155.00
205.00
275.00
325.00
155.00
205.00275.00325.00
145.00
93.00
123.00
165.00
195.00
93.00
123.00
165.00
195.00
87.00
7111 Extraction crnl remnts-decids-th
7140 Extraction erupted tooth
7210 Extraction-surgical
7220 Extraction-impacted/soft tissue
7230 Extraction-impacted/part bony
7240 Extraction-impacted/comp bony
7250 Surg removal of resid tooth root
7270 Reimplantation/stabilization
7953 Bone repl graft ridge pres site
90.00 54.00
165.00 99.00
215.00 129.00
190.00 114.00
210.00 126.00
230.00 138.00
225.00 135.00
170.00 102.00
400.00 240.00
INLAYS AND ONLAYS
IMPLANTS
2610
2620
2630
2642
2643
2644
Inlay-porcelain one surface
Inlay-porcelain two surface
Inlay-porcelain three+ surface
Onlay-porcelain two surface
Onlay-porcelain three surface
Onlay-porcelain four+ surface
705.00
735.00
760.00
815.00
840.00
865.00
533.00
551.00
566.00
599.00
614.00
629.00
6053 Imp/abut ret, comp edent arch
6054 Imp/abut ret, part edent arch
6056 Prefab abutment incl placement
6066 Imp supp porc fused to mtl crn
6078 Imp/abut supp fixd comp edent
6079 Imp/abut supp fixd part edent
3250.00 3250.00
3250.00 3250.00
475.00 475.00
925.00 925.00
11985.00 11985.00
11985.00 11985.00
CROWNS AND BRIDGES
OTHER SERVICES
2740
2750
2910
2920
2950
2962
6240
6750
Crown-porcelain/ceramic
Crown-porcelain fused to metal
Recement inlay/onlay
Recement crown
Core build up including any pins
Labial Veneer
Pontic-porcelain fused to hnob
Retainer crn-porc fused to hnob
975.00
925.00
45.00
45.00
155.00
1095.00
925.00
925.00
665.00
645.00
27.00
27.00
93.00
767.00
645.00
645.00
9430 Office visit for observation
9910 Application of desensitizing med
9940 Occlusal guards
9940 Athletic mouthguards
9975 One hour in office whitening
9976 Take home whitening
9977 30 minute in office whitening
55.00 N/C
30.00 18.00
390.00 275.00
170.00 170.00
375.00 225.00
150.00 150.00
30.00 30.00
REMOVABLE PROSTHODONTICS
REPAIRS AND RELINES
5110
5120
5130
5140
5213
5214
5225
5226
5410
5411
5421
5422
5810
5811
5820
5821
5860
Complete denture-maxillary
Complete denture-mandibular
Immediate denture-maxillary
Immediate denture-mandibular
Maxil partl-cast metal w/ resin
Mand partl-cast metal w/ resin Maxillary partial-flexible base
Mandibular partial-flexible base
Adjust complete denture-maxil
Adjust complete denture-mand
Adjust partial denture-maxil
Adjust partial denture-mand
Interim complete denture-maxil
Interim complete denture-mand
Interim partial denture-maxil
Interim partial denture-mand
Overdenture-complete
1700.00
1700.00
1700.00
1700.001750.00
1750.00
1750.00
1750.0047.00
47.00
47.00
47.00
450.00
450.00
450.00
450.00
3250.00
900.00
900.00
900.00
900.00
950.00
950.00
950.00
950.00
28.00
28.00
28.00
28.00
350.00
350.00
350.00
350.00
3250.00
5510 Repair complete denture base
5610 Repair resin denture base
5620 Repair cast framework
5630 Repair or replace broken clasp
5640 Repair or replace broken tooth
5710 Rebase complete maxil denture
5711 Rebase complete mand denture
5720 Rebase maxil partial denture
5721 Rebase maxil partial denture
5730 Reline complete maxil-chairside
5731 Reline complete mand-chairside
5740 Reline maxil partial-chairside
5741 Reline mand partial-chairside
5750 Reline complete maxillary-lab
5751 Reline complete mandibular-lab
5760 Reline partial maxillary-lab
5761 Reline partial mandibular-lab
170.00 110.00
170.00 110.00
240.00 180.00
240.00 180.00
170.00 120.00
310.00 250.00
310.00 250.00
310.00 250.00
310.00 250.00
310.00 250.00
310.00 250.00
310.00 250.00
310.00 250.00
410.00 350.00
410.00 350.00
410.00 350.00
410.00 350.00