UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY ...

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UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY ...

  1. 1. UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY GRADUATE CLINIC FEE SCHEDULE OCTOBER, 2003
  2. 2. 1.01B 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Endodontics ADA Code Description Fee UCF D0120 Periodic oral examination . . . . . . . . . . . . . . . . . . . . . . . . . . $14.00 . . . . . . . . . . . $35.00 D0140 Limited oral evaluation - problem focused . . . . . . . . . . . . . . 30.00 . . . . . . . . . . . . 50.00 D0150 Comprehensive oral evaluation . . . . . . . . . . . . . . . . . . . . . . . 30.00 . . . . . . . . . . . . 59.00 D0160 Detailed and extensive oral evaluation - problem focused, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46.00 . . . . . . . . . . . 103.00 D0170 Re-evaluation-limited, problem focused (established patient, not post-operative visit) . . . . . . . . . . . . 18.00 . . . . . . . . . . . . 45.00 D0220 Intraoral radiograph - periapical first film . . . . . . . . . . . . . . . . 8.00 . . . . . . . . . . . . 20.00 D0230 Intraoral radiograph - periapical each additional film . . . . . . . 7.00 . . . . . . . . . . . . 16.00 D0460 Pulp vitality tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.00 . . . . . . . . . . . . 40.00 D0470 Diagnostic casts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.00 . . . . . . . . . . . . 75.00 D2940 Sedative filling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.00 . . . . . . . . . . . . 80.00 D2950 Core buildup, including any pins . . . . . . . . . . . . . . . . . . . . . . 88.00 . . . . . . . . . . . 197.00 D2955 Post removal (not in conjunction with endodontic therapy) . 50.00 . . . . . . . . . . . 206.00 D3110 Pulp cap - direct (excluding final restoration) . . . . . . . . . . . . 23.00 . . . . . . . . . . . . 58.00 D3120 Pulp cap - indirect (excluding final restoration) . . . . . . . . . . 21.00 . . . . . . . . . . . . 58.00 D3220 Therapeutic pulpotomy (excluding final restoration) . . . . . . 74.00 . . . . . . . . . . . 140.00 D3221 Gross pulpal debridement, primary and permanent teeth . . . 40.00 . . . . . . . . . . . 149.00 D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) . . . . . . . 63.00 . . . . . . . . . . . 189.00 D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) . . . . . . 74.00 ........... 216.00 D3310 Anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218.00 ........... 498.00 D3320 Bicuspid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241.00 ........... 591.00 D3330 Molar (excluding final restoration) . . . . . . . . . . . . . . . . . . . 277.00 ........... 732.00 D3331 Treatment of root canal obstruction, non-surgical access . . 100.00 ........... 263.00 D3332 Incomplete endodontic therapy, inoperative or fractured tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110.00 ........... 275.00 D3333 Internal root repair of perforation defects . . . . . . . . . . . . . . . 50.00 ........... 168.00 D3346 Retreatment of previous root canal therapy, anterior . . . . . 298.00 ........... 585.00 D3347 Retreatment of previous root canal therapy, bicuspid . . . . . 388.00 ........... 660.00 D3348 Retreatment of previous root canal therapy, molar . . . . . . . 475.00 ........... 805.00 D3351 Apexification, apexogenesis - initial visit (apical closure/ calcific repair of perforations, root resorption, etc.) . . . . . . . 82.00 . . . . . . . . . . . 253.00 D3352 Apexification, apexogenesis - interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) . . . . . . . . . . . . . . . . . . . . . 74.00 . . . . . . . . . . . 185.00 D3353 Apexification, apexogenesis - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) . . . . . . . . . . . . . 271.00 . . . . . . . . . . . 346.00 1.02B
  3. 3. 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Endodontics ADA Code Description Fee UCF D3410 Apicoectomy/periradicular surgery - anterior . . . . . . . . . . $199.00 . . . . . . . . . . $467.00 D3421 Apicoectomy/periradicular surgery - bicuspid (first root) . . 199.00 . . . . . . . . . . . 525.00 D3425 Apicoectomy/periradicular surgery - molar (first root) . . . . 199.00 . . . . . . . . . . . 618.00 D3426 Apicoectomy/periradicular surgery - molar (each additional root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94.00 ........... 250.00 D3430 Retrograde filling - per root . . . . . . . . . . . . . . . . . . . . . . . . . . 47.00 ........... 192.00 D3450 Root amputation - per root . . . . . . . . . . . . . . . . . . . . . . . . . . 250.00 ........... 344.00 D3460 Endodontic endosseous implant . . . . . . . . . . . . . . . . . . . . . . 360.00 ........... 925.00 D3470 Intentional reimplantation (including necessary splinting) . . 99.00 ........... 591.00 D3910 Surgical procedure for isolation of tooth with rubber dam . . 75.00 ........... 139.00 D3920 Hemisection (including any root removal), not including root canal therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168.00 . . . . . . . . . . . 330.00 D3950 Canal preparation and fitting of preformed dowel or post . . . 85.00 . . . . . . . . . . . 180.00 D3999 Unspecified endodontic procedure, by report . . . . . . . . . By report . . . . . . . . . By report D4263 Bone replacement graft - first site in quadrant . . . . . . . . . . 278.00 . . . . . . . . . . . 503.00 D4266 Guided tissue regeneration - resorbable barrier, per site . . . 338.00 . . . . . . . . . . . 653.00 D4267 Guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) . . . . . . . . . . . . . . . . . . . . . . . 375.00 ........... 761.00 D4320 Provisional splinting - intracoronal . . . . . . . . . . . . . . . . . . . . 94.00 ........... 368.00 D4321 Provisional splinting - extracoronal . . . . . . . . . . . . . . . . . . . 100.00 ........... 331.00 D7140 Extraction, erupted/exposed teeth or roots . . . . . . . . . . . . . . 43.00 ........... 105.00 D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69.00 . . . . . . . . . . . 195.00 D7250 Surgical removal of residual tooth roots (cutting procedure) 75.00 . . . . . . . . . . . 218.00 D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth and/or alveolus . . . . . . . . . . . . . . 95.00 . . . . . . . . . . . 394.00 D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) . . . . . . . . 175.00 ........... 494.00 D7285 Biopsy of oral tissue - hard (bone, tooth) . . . . . . . . . . . . . . 110.00 ........... 270.00 D7286 Biopsy of oral tissue - soft (all others) . . . . . . . . . . . . . . . . . . 85.00 ........... 223.00 D7291 Transeptal fiberotomy, by report . . . . . . . . . . . . . . . . . . . . . . 85.00 ........... 213.00 D7410 Excision of benign tumor, lesion diameter up to 1.25 cm . . . 40.00 ........... 312.00 D7411 Excision of benign tumor, lesion diameter greater than 1.25 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40.00 . . . . . . . . . . . 428.00 D7450 Excision of odontogenic cyst or tumor, lesion diameter up to 1.25 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145.00 . . . . . . . . . . . 348.00 D7451 Excision of odontogenic cyst or tumor, lesion diameter greater than1.25 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225.00 . . . . . . . . . . . 475.00 D7460 Excision of nonodontogenic cyst or tumor, lesion diameter up to 1.25 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155.00 . . . . . . . . . . . 343.00 D7461 Excision of nonodontogenic cyst or tumor, lesion diameter greater than 1.25 cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225.00 . . . . . . . . . . . 525.00 1.03B 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY
  4. 4. SCHOOL OF DENTISTRY Graduate Clinic Endodontics ADA Code Description Fee UCF D7510 Incision and drainage of abscess, intraoral soft tissue . . . . . $94.00 . . . . . . . . . . $163.00 D7520 Incision and drainage of abscess, extraoral soft tissue . . . . 165.00 . . . . . . . . . . . 263.00 D7530 Removal of foreign body, skin, or subcutaneous alveolar tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110.00 . . . . . . . . . . . 252.00 D7910 Suture of recent small wounds up to 5 cm . . . . . . . . . . . . . . . 85.00 . . . . . . . . . . . 210.00 D9110 Pallaitive (emergency) treatment of dental pain, minor procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.00 . . . . . . . . . . . . 88.00 D9210 Local anesthesia not in conjunction with operative or surgical procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.00 . . . . . . . . . . . . 52.00 D9230 Nitrous Oxide sedation (per visit) . . . . . . . . . . . . . . . . . . . . . 34.00 . . . . . . . . . . . . 49.00 D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) . . . . . 35.00 . . . . . . . . . . . . 89.00 D9430 Office visit for observation (during regularly scheduled hours), no other service performed . . . . . . . . . . . . . . . . . . . . 25.00 . . . . . . . . . . . . 50.00 D9440 Office visit (after regularly scheduled hours) . . . . . . . . . . . . 85.00 . . . . . . . . . . . 120.00 D9910 Application of desensitizing medicament . . . . . . . . . . . . . . . 25.00 . . . . . . . . . . . . 43.00 D9972 External bleaching, per arch . . . . . . . . . . . . . . . . . . . . . . . . 155.00 . . . . . . . . . . . 250.00 D9973 External bleaching, per tooth . . . . . . . . . . . . . . . . . . . . . . . . . 35.00 . . . . . . . . . . . 179.00 D9974 Internal bleaching, per tooth . . . . . . . . . . . . . . . . . . . . . . . . . 35.00 . . . . . . . . . . . 205.00 D9999 Unspecified adjunctive procedure, by report . . . . . . . . . . By report . . . . . . . . . By report (per tooth plus separate fee for subsequent restoration) All Endodontic surgical and non-surgical therapy fees include a 6-month and 12-month post operative radiographic and clinical examination.
  5. 5. 2.01B 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Operative Dentistry ADA Code Description Fee UCF Inlay/Onlay D2510 One surface, gold inlay . . . . . . . . . . . . . . . . . . . . . . . . . . . . $260.00 . . . . . . . . . . . $570.00 D2520 Two surface, gold inlay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316.00 . . . . . . . . . . . . 622.00 D2530 Three surface, gold inlay . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377.00 . . . . . . . . . . . . 675.00 D2544 Gold molar onlay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416.00 . . . . . . . . . . . . 775.00 Above fees include gold and pin retention (no discount). D2620 Two surface porcelain inlay . . . . . . . . . . . . . . . . . . . . . . . . . . 390.00 . . . . . . . . . . . . 693.00 D2630 Three surface porcelain inlay . . . . . . . . . . . . . . . . . . . . . . . . . 458.00 . . . . . . . . . . . . 732.00 D2644 Porcelain molar onlay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592.00 . . . . . . . . . . . . 792.00 Amalgam (adult) D2140 One surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60.00 . . . . . . . . . . . . . 90.00 D2150 Two surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76.00 . . . . . . . . . . . . 118.00 D2160 Three surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88.00 . . . . . . . . . . . . 140.00 D2161 Four surface (with or without pin) . . . . . . . . . . . . . . . . . . . . . 122.00 . . . . . . . . . . . . 170.00 Amalgam (pedo) D2140 One surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60.00 . . . . . . . . . . . . . 90.00 D2150 Two surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76.00 . . . . . . . . . . . . 118.00 D2160 Three surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88.00 . . . . . . . . . . . . 140.00 D2161 Four surface (with or without pin) . . . . . . . . . . . . . . . . . . . . . 122.00 . . . . . . . . . . . . 170.00 Composite, anterior D2330 Anterior one surface composite . . . . . . . . . . . . . . . . . . . . . . . . 66.00 . . . . . . . . . . . . 109.00 D2331 Anterior two surface composite . . . . . . . . . . . . . . . . . . . . . . . . 84.00 . . . . . . . . . . . . 137.00 D2332 Anterior three surface composite . . . . . . . . . . . . . . . . . . . . . . 100.00 . . . . . . . . . . . . 169.00 D2335 Anterior four+ surface composite . . . . . . . . . . . . . . . . . . . . . 126.00 . . . . . . . . . . . . 212.00 Composite, posterior (adult) D2391 Posterior one surface composite . . . . . . . . . . . . . . . . . . . . . . . 71.00 . . . . . . . . . . . . 121.00 D2392 Posterior two surface composite . . . . . . . . . . . . . . . . . . . . . . 101.00 . . . . . . . . . . . . 160.00 D2393 Posterior three surface composite . . . . . . . . . . . . . . . . . . . . . 108.00 . . . . . . . . . . . . 202.00 D2394 Posterior four+ surface composite . . . . . . . . . . . . . . . . . . . . . 115.00 . . . . . . . . . . . . 236.00 Composite, posterior (pedo) D2391 Posterior one surface composite . . . . . . . . . . . . . . . . . . . . . . . 71.00 . . . . . . . . . . . . 121.00 D2392 Posterior two surface composite . . . . . . . . . . . . . . . . . . . . . . 101.00 . . . . . . . . . . . . 160.00 D2393 Posterior three surface composite . . . . . . . . . . . . . . . . . . . . . 108.00 . . . . . . . . . . . . 202.00 D2394 Posterior four+ surface composite . . . . . . . . . . . . . . . . . . . . . 115.00 . . . . . . . . . . . . 236.00 Veneer D2960 Composite labial veneer (direct bonding) . . . . . . . . . . . . . . . 162.00 . . . . . . . . . . . . 425.00 D2961 Composite labial veneer (laboratory) . . . . . . . . . . . . . . . . . . 250.00 . . . . . . . . . . . . 650.00 D2962 Porcelain laminate veneer (no discount) . . . . . . . . . . . . . . . . 374.00 . . . . . . . . . . . . 756.00 The fees listed for operative dentistry include the anesthetic and, when necessary, cement base or pulp capping. 2.02B
  6. 6. 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Operative Dentistry ADA Code Description Fee UCF Bleaching D9972 Bleaching (single arch) . . . . . . . . . . . . . . . . . . . . . . . . . . . $160.00 . . . . . . . . . . $250.00 D9973 Vital tooth bleaching (per tooth up to 6 visits) . . . . . . . . . . . 90.00 . . . . . . . . . . . 179.00 D9974 Internal bleaching per tooth (non-vital) . . . . . . . . . . . . . . . . . 45.00 . . . . . . . . . . . 205.00 D9999 Additional bleaching material (custom tray refills) . . . . . . . . 28.00 D9999 Professional bleaching strips . . . . . . . . . . . . . . . . . . . . . . . . . 45.00 Other D1351 Pit and fissure sealant (per tooth) . . . . . . . . . . . . . . . . . . . . . 20.00 . . . . . . . . . . . . 39.00 D2410 Gold foil (one surface) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79.00 . . . . . . . . . . . 428.00 D2910 Recement inlay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.00 . . . . . . . . . . . . 77.00 D2931 Chrome steel crown, permanent tooth . . . . . . . . . . . . . . . . . 100.00 . . . . . . . . . . . 234.00 D2940 Sedative filling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.00 . . . . . . . . . . . . 80.00 D3110 Pulp cap (direct) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/A D3120 Pulp cap (indirect) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/A D6999 Etched bridge (plastic pontic) . . . . . . . . . . . . . . . . . . . . . . . 210.00 D9970 Micro abrasion, Prema (per tooth) . . . . . . . . . . . . . . . . . . . . . 41.00 . . . . . . . . . . . 155.00 Charges for amalgam and composite restorations will be made according to the surfaces involved. For example: 1. Two occlusal pits = one surface (O) 2. A distolingual groove = two surfaces (DL) 3. An occlusal pit and a separate or continuous distolingual groove = two surfaces (OL) 4. An occlusal pit and a separate or continuous facial groove = two surfaces (OF) 5. On upper molars an MO and a separate or continuous distolingual groove = three surfaces (MOL) 6. A facial pit = one surface (F) 7. A lingual pit = one surface (L) This judgement should be made at the time of treatment planning, if possible, and designated on the patient’s record.
  7. 7. 3.01B 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Oral Surgery ADA Code Description Fee UCF Extraction/Alveoplasty D7111 Extraction, crown remnants of deciduous tooth . . . . . . . . . $25.00 . . . . . . . . . . $104.00 D7140 Extraction, erupted/exposed teeth or roots . . . . . . . . . . . . . . 45.00 . . . . . . . . . . . 107.00 D7210 Extraction, surgical or non-impacted third molars . . . . . . . . 55.00 . . . . . . . . . . . 195.00 D7220 Soft tissue impaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110.00 . . . . . . . . . . . 227.00 D7230 Partial bone impaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120.00 . . . . . . . . . . . 294.00 D7240 Full bone impaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140.00 . . . . . . . . . . . 360.00 D7310 Alveoplasty with extractions (per quadrant) . . . . . . . . . . . . . 50.00 . . . . . . . . . . . 206.00 D7320 Alveoplasty without extraction (per quadrant) . . . . . . . . . . . 65.00 . . . . . . . . . . . 313.00 Sinus Procedures D7260 Oroantral fistula closure . . . . . . . . . . . . . . . . . . . . . . 275.00-300.00 . . . . . . . . . . . 496.00 D7261 Primary closure of sinus perforation . . . . . . . . . . . . . . . . . . 250.00 . . . . . . . . . . . 546.00 D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body . . . . . . . . . . . . . . . . . . . . . 250.00-300.00 . . . . . . . . . . . 752.00 D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bones - autogenous or nonautogenous (example sinus lift) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,500.00 . . . . . . . . . . 2,336.00 Ortho Assist D7280 Surgical access of an unerupted tooth . . . . . . . . . . . 125.00-175.00 . . . . . . . . . . . 350.00 D7281 Surgical exposure of impacted or unerupted tooth to aid eruption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.00-150.00 . . . . . . . . . . . 275.00 D7282 Mobilization of erupted or malpositioned tooth to aid eruption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.00 . . . . . . . . . . . 376.00 Path Excisions D7285 Biopsy of oral tissue - hard . . . . . . . . . . . . . . . . . . . . 90.00-160.00 . . . . . . . . . . . 270.00 D7286 Biopsy of oral tissue - soft . . . . . . . . . . . . . . . . . . . . . 75.00-140.00 . . . . . . . . . . . 223.00 D7410 Excision of benign soft tissue lesions up to 1.25 cm. (including non-odontogenic cysts) . . . . . . . . . . . . . . . 75.00-200.00 . . . . . . . . . . . 284.00 D7413 Excision of malignant lesion up to 1.25 cm. . . . . . . 100.00-300.00 . . . . . . . . . . . 454.00 D7450 Removal of benign intraosseous odontogenic cyst or tumor up to 1.25 cm. . . . . . . . . . . . . . . . . . . . 75.00-450.00 . . . . . . . . . . . 348.00 D7460 Removal of benign intraosseous non-odontogenic cyst or tumor up to 1.25 cm. . . . . . . . . . . . . . . . . . . . 75.00-450.00 . . . . . . . . . . . 343.00 D7465 Destruction of lesion(s) by physical or chemical method, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.00-150.00 . . . . . . . . . . . 261.00
  8. 8. 3.02B 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Oral Surgery ADA Code Description Fee UCF Pre-Prosthetic D6010 Surgical placement of implant body: endosteal implant . . $500.00 . . . . . . . . . $1,504.00 D7340 Vestibuloplasty - ridge extension with secondary epithelialization . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180.00-400.00 . . . . . . . . . . . 675.00 D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied or hyperplastic tissues) (per arch) . . . . . . . . . . . . . . . . 350.00-500.00 . . . . . . . . . . 1,485.00 D7471 Removal of lateral exostosis (maxilla or mandible, per quadrant) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.00-160.00 . . . . . . . . . . . 450.00 D7472 Removal of torus palatinus . . . . . . . . . . . . . . . . . . . 150.00-300.00 . . . . . . . . . . . 513.00 D7473 Removal of torus mandibularis (per quadrant) . . . . . . 50.00-75.00 . . . . . . . . . . . 513.00 D7485 Surgical reduction of osseous tuberosity . . . . . . . . . 100.00-160.00 . . . . . . . . . . . 459.00 D7960 Frenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.00-130.00 . . . . . . . . . . . 315.00 D7970 Excision of hyperplastic tissue (per arch) . . . . . . . . . 75.00-300.00 . . . . . . . . . . . 350.00 (for epulis with tissue reattachments, see Vestibuloplasty, D7340/7350) D7972 Surgical reduction of fibrous tuberosity . . . . . . . . . . 75.00-100.00 . . . . . . . . . . . 690.00 D9999 INR/prothrombin time lab test . . . . . . . . . . . . . . . . . . . . . . . . 20.00 Infections, Trauma, TMJ D7270 Tooth reimplantation and/or stabilization accidentally evulsed tooth (per tooth) . . . . . . . . . . . . . . . . . . . . . . . . No charge . . . . . . . . . . . 394.00 D7510 Incise and drain (intra-oral) . . . . . . . . . . . . . . . . . . . . . . . . . . 70.00 . . . . . . . . . . . 163.00 D7520 Incise and drain (extra-oral) . . . . . . . . . . . . . . . . . . . . . . . . . 160.00 . . . . . . . . . . . 263.00 D7530 Removal of foreign body from oral soft tissues . . . . . 50.00-300.00 . . . . . . . . . . . 252.00 D7550 Sequestrectomy for removal of non-vital bone . . . . . 25.00-300.00 . . . . . . . . . . . 355.00 D7670 Alveolus - closed reduction . . . . . . . . . . . . . . . . . . . 175.00-300.00 . . . . . . . . . . . 1,045.00 D7720 Maxilla - closed reduction (max 7720, mand 7740) . . . . . . . . . . . . . . . . . . . . 900.00-1,100.00 . . . . . . . . . . . 2,254.00 D7771 Stabilize alveolar fracture . . . . . . . . . . . . . . . . . . . . 200.00-325.00 . . . . . . . . . . . 580.00 D7820 TMJ dislocation reduction, simple . . . . . . . . . . . . . . . . . . . . 175.00 . . . . . . . . . . . 393.00 D7830 TMJ dislocation reduction, includes parenteral anesthesia assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350.00 . . . . . . . . . . . 491.00 D7910 Suture of recent small wounds up to 5cm (superficial) 70.00-160.00 . . . . . . . . . . . 210.00 D7911 Complicated suture up to 5 cm . . . . . . . . . . . . . . . . 100.00-190.00 . . . . . . . . . . . 315.00 D7912 Complicated suture greater than 5 cm . . . . . . . . . . . . . . . Per report . . . . . . . . . . . 450.00 D7980 Sialolithotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200.00-450.00 . . . . . . . . . . . 463.00
  9. 9. 3.03B 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Oral Surgery ADA Code Description Fee UCF Others D9610 Medications (therapeutic drug injection) . . . . . . . Per prices below . . . . . . . . . . . $77.00 Corticosteroid injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.00 Vancomycin IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150.00 Ampicillin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.00 Gentamycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30.00 D9630 Other drugs and/or medicaments . . . . . . . . . . . . . Per prices below . . . . . . . . . . . . 35.00 Oral antibiotics (no discount) . . . . . . . . . . . . . . . . . . . . . . . . . 8.00 Oral steroids (no discount) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.00 Anesthesia D9220 Deep sedation/general anesthesia - first 30 minutes . . . . . . 160.00 . . . . . . . . . . . 271.00 D9221 Each additional 15 minutes . . . . . . . . . . . . . . . . . . . . . . . . . . 40.00 . . . . . . . . . . . 112.00 D9230 Nitrous Oxide analgesia/sedation . . . . . . . . . . . . . . . . . . . . . 45.00 . . . . . . . . . . . . 49.00 D9241 Intravenous conscious sedation/anesthesia - first 30 min. . . 160.00 . . . . . . . . . . . 299.00 D9248 Non parenteral sedation/analgesia administration/ monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00 . . . . . . . . . . . 213.00
  10. 10. 4.01B 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Orthodontics ADA Code Description Fee UCF Diagnosis and Records Charges D8660 Initial consultation visit (screening by appointment) . . . . . . . . . . . . . . . . . . . . . . . . . $25.00 . . . . . . . . . . $308.00 D8999 Conventional diagnostic records Complete series (without TMJ radiographs) . . . . . . . . . . . . 300.00 Itemized charges if less than full series D8999 Diagnostic set-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60.00 D8999 Computer analysis of head plates (per analysis) . . . . . . . . . . 25.00 D8999 Models (art based), not mounted in articulator . . . . . . . . . . . 55.00 D8999 Models (art based), mounted in articulator . . . . . . . . . . . . . . 81.00 D0290 Cephalogram, lateral or frontal (each film) . . . . . . . . . . . . . . 50.00 . . . . . . . . . . . 128.00 D0330 Panorex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00 . . . . . . . . . . . 101.00 D8999 Portrait digital (series) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.00 D8999 Intraoral digital (series) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.00 D0160 Examination with written report . . . . . . . . . . . . . . . . . . . . . . 30.00 Treatment Charges D8999 Mandibular repositioning splint . . . . . . . . . . . . . . . . . . . . . . 370.00 D8999 Replacement for mandibular repositioning splint . . . . . . . . 150.00 D8020 Phase I therapy (does NOT include initial diagnostic records or screening fee) . . . . . . . . . . . . . . . . . . . . . . . . . . 1,690.00 . . . . . . . . . . 2,100.00 D8080 Phase II therapy (if Phase I is completed in UMKC postgraduate clinic) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,400.00 . . . . . . . . . . 5,012.00 D8070 Comprehensive orthodontic treatment of transitional dentition (Does NOT include initial diagnostic records or screening fee) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,050.00 D8090 Comprehensive orthodontic treatment of adult dentition (does NOT include initial diagnostic records or screening fee) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,733.00 . . . . . . . . . . 5219.00 D8020 Adolesent - (same as adult, see below) D8030 Partial appliance treatment retreatment fee set at the discretion of the supervising faculty member (does NOT include initial diagnostic records or positioner or retainer(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $450.00-1,800.00
  11. 11. 4.02B 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Orthodontics ADA Code Description Fee UCF D8030 Fixed appliance retreatment of anterior crowding in one area of case previously treated at UMKC Orthodontics Department - (does NOT include positioner or retainer(s)) . . . . . . . . . . . 400.00 Positioner and Retainer Charges D8692 Maxillary Hawley type retainer (each) . . . . . . . . . . . . . . . . 150.00 D8692 Mandibular Hawley type retainer (each) . . . . . . . . . . . . . . . 150.00 D8692 Maxillary Vacu-form retainer (each) . . . . . . . . . . . . . . . . . . . 90.00 D8692 Mandibular Vacu-form retainer (each) . . . . . . . . . . . . . . . . . 90.00 D8692 Retainer with tooth placement . . . . . . . . . . . . . . . . . . . . . . 175.00 D8210 Special Retainer (Spring Retainer) . . . . . . . . . . . . . . . . . . . 185.00 D8210 Bionator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250.00 D8210 Max 2000 (per arch) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150.00 D8999 Herbst Appliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250.00 D8220 Rapid Palatal Expander . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150.00 D8210 Red, White and Blue (per arch) . . . . . . . . . . . . . . . . . . . . . 450.00 Conventional positioner . . . . . . . . . . . . . . . . . . . . . . . . . . . 180.00 Gnathological positioner . . . . . . . . . . . . . . . . . . . . . . . . . . . 250.00 Design on retainer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00 Miscellaneous D8680 Removal of appliance placed outside UMKC (must be paid at time of appointment in cash or by certified check) no retainer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150.00 D8691 Retainer repair (NOT replacement) . . . . . . . . . . . . . . . . . . . . 50.00 Duplication of models (each set) . . . . . . . . . . . . . . . . . . . . . . 50.00 Preparation and submission of written reports . . . . . . . . . . 155.00 (per production hour - in 15 minute increments) Retainer checks beyond 2 years (repair/replacement not included) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.00 Oral hygiene counseling (beyond 2 visits, each appt.) . . . . . 12.00 Charges for orthodontic services not listed in the dental school fee book will be set by the supervising instructor subject to approval by the Chairman of the Department of Orthodontics. 0999 cone beam $250 Orthodontic patients fee waived (Fees revised: October 29, 2009)
  12. 12. 5.01B 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Periodontics ADA Code Description Fee UCF Preventive or Maintenance D1110 Adult prophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $48.00 . . . . . . . . . . . $63.00 10 teeth or less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.00 . . . . . . . . . . . . 63.00 D4910 Periodontal maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60.00 . . . . . . . . . . . . 99.00 10 teeth or less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40.00 . . . . . . . . . . . . 99.00 Therapeutic/Gingivitis D4355 Full mouth debridement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70.00 . . . . . . . . . . . 134.00 D4999 Re-evaluation and deplaque . . . . . . . . . . . . . . . . . . . . . . . Included Therapeutic/Periodontitis D4341 Scaling/root planing (UR), 4-8 teeth per quadrant . . . . . . . . 80.00 ........... 183.00 D4341 Scaling/root planing (LR), 4-8 teeth per quadrant . . . . . . . . . 80.00 ........... 183.00 D4341 Scaling/root planing (UL), 4-8 teeth per quadrant . . . . . . . . . 80.00 ........... 183.00 D4341 Scaling/root planing (LL), 4-8 teeth per quadrant . . . . . . . . . 80.00 ........... 183.00 D4342 Scaling/root planing (UR), 1-3 teeth per quadrant . . . . . . . . 40.00 ............ 94.00 D4342 Scaling/root planing (LR), 1-3 teeth per quadrant . . . . . . . . . 40.00 ............ 94.00 D4342 Scaling/root planing (UL), 1-3 teeth per quadrant . . . . . . . . . 40.00 ............ 94.00 D4342 Scaling/root planing (LL), 1-3 teeth per quadrant . . . . . . . . . 40.00 ............ 94.00 Other D1205 Topical application of fluoride . . . . . . . . . . . . . . . . . . . . . . . 25.00 . . . . . . . . . . . . 84.00 D3450 Root resection (not including endodontic therapy) . . . . 80.00+flap . . . . . . . . . . . 344.00 D3920 Hemisection (not including endodontic therapy) . . . . . . 80.00+flap . . . . . . . . . . . 330.00 D4210 Gingivectomy/gingivoplasty, 4 or more teeth . . . . . . . . . . . . . . . . . . . . . . . . . . 60.00+30.00 per additional tooth . . . . . . . . . . . 450.00 D4211 Gingivectomy/gingivoplasty, 1-3 teeth . . . . . . . . . . . . . . . . . . . . . . . . . . 60.00+30.00 per additional tooth . . . . . . . . . . . 165.00 D4240 Gingival flap, 4 or more teeth . 100.00+50.00 per additional tooth . . . . . . . . . . . 529.00 (including root planing) D4241 Gingival flap, 1-3 teeth . . . . . . 100.00+50.00 per additional tooth . . . . . . . . . . . 451.00 (including root planing) D4245 Apically positioned flap . . . . . . 100.00+50.00 per additional tooth ........... 627.00 D4249 Crown lengthening . . . . . . . . . 100.00+50.00 per additional tooth ........... 550.00 D4260 Osseous surgery, 4 or more teeth 100.00+50.00 per additional tooth ........... 776.00 D4261 Osseous surgery, 1-3 teeth . . . . 100.00+50.00 per additional tooth ........... 619.00 D4263 Bone replacement graft (first site in quadrant) . . . . . . . . . . . 75.00 ........... 503.00
  13. 13. 5.02B 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Periodontics ADA Code Description Fee UCF D4264 Bone replacement graft (each additional site in quadrant) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $55.00 . . . . . . . . . . $363.00 D4265 Biologic materials to aid in soft and osseous tissue regeneration . . . . . . . . . . . . . . . . . . . . . . . . . . . 80.00-150.00 . . . . . . . . . . . 317.00 D4266 Guided tissue regeneration - resorbable . . . . . . . . . . . 25.00-150.00 . . . . . . . . . . . 653.00 (grafting and flaps additional) D4267 Guided tissue regeneration - nonresorbable . . . . . . . . . . . . . 100.00 . . . . . . . . . . . 761.00 (grafting and flaps additional, including removal) D4268 Surgical revision procedure, per tooth . . . . . . . . . . . . . 50.00-80.00 ........... 599.00 D4270 Pedicle soft tissue graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150.00 ........... 600.00 D4271 Free soft tissue graft (FGG) . . . . . . . . . . . . . . . . . . . . . . . . . 150.00 ........... 625.00 D4273 Subepithelial connective tissue graft . . . . . . . . . . . . . . . . . . 200.00 ........... 800.00 D4274 Distal or proximal wedge procedure . . . . . . . . . . . . . . . . . . . 80.00 ........... 500.00 (when not performed in conjunction with surgical procedures in the same anatomical area) D4275 Soft tissue allograft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250.00 ........... 682.00 D4276 Combined CT graft and double pedicle . . . . . . . . . . . . . . . . 300.00 ........... 826.00 D4320 Intracoronal splints (non-precious material), per unit . . . . . . 60.00 ........... 368.00 D4321 Extracoronal splints (provisional, wire, acrylic), per unit . . . 45.00 ........... 331.00 D4381 Atridox (per tube) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cost ........... 150.00 D4381 Arestin (two syringes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cost ........... 150.00 D5982 Surgical stent for soft tissue grafts . . . . . . . . . . . . . . . . . . . . . 50.00 D5986 Custom fluoride trays (both arches) . . . . . . . . . . . . . . . . . . . . 60.00 . . . . . . . . . . . 150.00 D6010 Surgical placement of implant body: endosteal implant . . . 500.00 . . . . . . . . . . 1,504.00 D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bones - autogenous or nonautogenous (example sinus lift) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,500.00 . . . . . . . . . . 2,336.00 D9910 Finishing procedure following periodontal surgery, fluoride treatment, desensitization, and polishing. Per tooth (maximum $20 per patient) . . . . . . . . . . . . . . . . . . . 5.00 . . . . . . . . . . . . 43.00 D9940 Night guard/occlusal guard (TMJ splint) . . . . . . . . . . . . . . . 200.00 . . . . . . . . . . . 450.00 D9940 Night guard (completed by outside laboratory) . . . . . . . . . . 275.00 . . . . . . . . . . . 450.00 D9951 Limited occlusal adjustment . . . . . . . . . . . . . . . . . . . . . . . . . 20.00 . . . . . . . . . . . 125.00
  14. 14. 6.01B 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Fixed Prosthodontics ADA Code Description Fee UCF Bridge D6210 Gold pontic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $487.00 . . . . . . . . . . $785.00 D6240 PFM pontic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487.00 . . . . . . . . . . . 797.00 D6241 Maryland bridge pontic . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487.00 . . . . . . . . . . . 740.00 D6545 Maryland bridge abutment . . . . . . . . . . . . . . . . . . . . . . . . . 220.00 . . . . . . . . . . . 532.00 D6750 PFM abutment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487.00 . . . . . . . . . . . 805.00 D6780 3/4 gold abutment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487.00 . . . . . . . . . . . 782.00 D6790 Gold abutment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487.00 . . . . . . . . . . . 790.00 D6940 Stress breaker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.00 . . . . . . . . . . . 302.00 Crown D2740 All ceramic crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487.00 ........... 800.00 D2750 Porcelain fused metal (PFM) crown . . . . . . . . . . . . . . . . . . 487.00 ........... 802.00 D2780 3/4 gold crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487.00 ........... 785.00 D2790 Full gold crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487.00 ........... 790.00 Foundation D2950 Amalgam buildup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118.00 ........... 197.00 D2950 Composite buildup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118.00 ........... 197.00 D2952 Dowel - gold or cast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178.00 ........... 319.00 D2954 Prefabricated post . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135.00 ........... 245.00 Implant D6040 Subperiosteal implant (plus surgery) . . . . . . . . . 1,200.00-1,500.00 . . . . . . . . . . 6,500.00 D6055 Implant connecting bar . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,993.00 . . . . . . . . . . 1,882.00 D6080 Implant maintenance procedures including removal of prosthesis, cleansing of prosthesis and abutments, reinsertion of prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60.00 . . . . . . . . . . . 203.00 D6090 Repair implant supported prosthesis, i.e., replace “O” rings, prosthesis evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00 . . . . . . . . . . . 527.00 D6095 Repair implant abutment . . . . . . . . . . . . . . . . . . . . . . . . . By report . . . . . . . . . . . 527.00 D6199 Implant restoration (in addition to crown) . . . . . . . . . . . . By report (unspecified implant procedure, by report - use for procedure which is not adequately described by a code, i.e., implant parts) Other D2980 Repair of veneers or facings . . . . . . . . . . . . . . . . . . . 48.00-250.00 . . . . . . . . . . . 200.00 D6999 Cast splint bar (no discount) . . . . . . . . . . . . . . . . . . . . . . . . 265.00 D9952 Occlusal equilibration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214.00 . . . . . . . . . . . 500.00 D9999 Laboratory fee (when case is sent to outside lab) . . . . . . By report All fees include gold alloy when applicable (no discount on crowns, dowels, porcelain laminate veneers).
  15. 15. 7.01B 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Removable Prosthodontics ADA Code Description Fee UCF Full Denture D5110 Maxillary denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $578.00 . . . . . . . . . $1,179.00 D5120 Mandibular denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 578.00 . . . . . . . . . . 1,191.00 D5130 Immediate maxillary denture . . . . . . . . . . . . . . . . . . . . . . . . 632.00 . . . . . . . . . . 1,278.00 (including one rebase or one reline) D5140 Immediate mandibular denture . . . . . . . . . . . . . . . . . . . . . . 632.00 . . . . . . . . . . 1,280.00 (including one rebase or one reline) D5860 Tooth supported denture (overdenture) . . . . . . . . . . . . . . . . 578.00 . . . . . . . . . . 1,462.00 Partial Denture D5211 Maxillary partial (resin base) . . . . . . . . . . . . . . . . . . . . . . . . 300.00 . . . . . . . . . . . 895.00 D5212 Mandibular partial (resin base) . . . . . . . . . . . . . . . . . . . . . . 300.00 . . . . . . . . . . . 900.00 D5213 Maxillary partial (cast framework) . . . . . . . . . . . . . . . . . . . 670.00 . . . . . . . . . . 1,250.00 D5214 Mandibular partial (cast framework) . . . . . . . . . . . . . . . . . . 670.00 . . . . . . . . . . 1,250.00 D5820 Transitional partial - maxillary (flipper) . . . . . . . . . . . . . . . 310.00 . . . . . . . . . . . 490.00 D5821 Transitional partial - mandibular (flipper) . . . . . . . . . . . . . . 310.00 . . . . . . . . . . . 495.00 Reline/Rebase D5710 Rebase - maxillary denture . . . . . . . . . . . . . . . . . . . . . . . . . 211.00 ........... 416.00 D5711 Rebase - mandibular denture . . . . . . . . . . . . . . . . . . . . . . . . 211.00 ........... 415.00 D5720 Rebase - maxillary partial . . . . . . . . . . . . . . . . . . . . . . . . . . 130.00 ........... 400.00 D5721 Rebase - mandibular partial . . . . . . . . . . . . . . . . . . . . . . . . . 130.00 ........... 400.00 D5730 Reline maxillary denture (chairside) . . . . . . . . . . . . . . . . . . . 40.00 ........... 275.00 D5731 Reline mandibular denture (chairside) . . . . . . . . . . . . . . . . . . 40.00 ........... 275.00 D5750 Reline - maxillary denture . . . . . . . . . . . . . . . . . . . . . . . . . . 130.00 ........... 350.00 D5751 Reline - mandibular denture . . . . . . . . . . . . . . . . . . . . . . . . 130.00 ........... 350.00 D5760 Reline - maxillary partial . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98.00 ........... 335.00 D5761 Reline - mandibular partial . . . . . . . . . . . . . . . . . . . . . . . . . . 98.00 ........... 340.00 If a denture is not satisfactory, please be sure patient understands they have an option - money refunded or denture remade (with first denture returned). No third denture remakes. If remake is chosen, no money will be refunded. Original denture must be returned if refund requested.
  16. 16. 7.02B 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Removable Prosthodontics ADA Code Description Fee UCF Other D0120 Denture recall (includes oral exam) . . . . . . . . . . . . . . . . . . . $20.00 . . . . . . . . . . . $35.00 D5510 Denture repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72.00 . . . . . . . . . . . 150.00 Only dentures constructed at UMKC. Repairs within one year of insertion are fee waivered. D5520 Replacement tooth, complete denture . . . . . . . . . . . . . . . . . . 12.00 . . . . . . . . . . . 128.00 (per tooth, plus repair fee) D5640 Replace broken denture tooth, per tooth . . . . . . . . . . . . . . . . 60.00 . . . . . . . . . . . 130.00 D5850 Tissue conditioning - maxillary . . . . . . . . . . . . . . . . . . . . . . 152.00 . . . . . . . . . . . 145.00 D5851 Tissue conditioning - mandibular . . . . . . . . . . . . . . . . . . . . 152.00 . . . . . . . . . . . 150.00 D5899 Unspecified removable prosthodontics procedure by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Per prices below Chrome-cobalt base (plus cost of full dentures) . . . . . . . . . 158.00 Definitive soft liner (done in lab on full denture) . . . . . . . . 180.00 Masel crown (on denture or partial) . . . . . . . . . . . . . . . . . . 140.00 RAP tooth addition (plus cost of partial denture) . . . . . . . . . 37.00 D5931 Obturator prosthesis, surgical . . . . . . . . . . . . . . . . . . . . . . . 682.00 D5932 Obturator prosthesis, definitive . . . . . . . . . . . . . . . . . . . . . 1,365.00 D5933 Obturator prosthesis, modification . . . . . . . . . . . . . . . . . . . 472.00 D5936 Obturator prosthesis, interim . . . . . . . . . . . . . . . . . . . . . . . . 500.00 D9941 Athletic mouthguards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53.00 . . . . . . . . . . . 175.00 Repair to Partial Dentures D5610 Repair resin denture base . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72.00 . . . . . . . . . . . 149.00 D5630 Repair or replace broken clasp . . . . . . . . . . . . . . . . . . . . . . . . 93.00 . . . . . . . . . . . 190.00 D5640 Replace broken teeth (partial), per tooth, plus repair fee . . . 60.00 . . . . . . . . . . . 130.00 D5650 Add tooth to existing partial, per tooth, plus repair fee . . . . . 12.00 . . . . . . . . . . . 160.00 D5660 Add clap to existing partial . . . . . . . . . . . . . . . . . . . . . . . . . . 40.00 . . . . . . . . . . . 200.00 D5862 Zest anchor (per anchor) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85.00 . . . . . . . . . . . 494.00 D5867 Replace precision attachment (each after 6 months) . . . . . . . 40.00 . . . . . . . . . . . 175.00 Only partial dentures constructed at UMKC. Repairs within one year of insertion are fee waivered.
  17. 17. 8.01B 10/01/03 UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF DENTISTRY Graduate Clinic Miscellaneous Charges Duplication of X-ray Film Full periapical survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20.00 5x12 panoramic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.00 Occlusal film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.00 Partial survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.00 8x10 (head plate) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.00 D0501 Pathology report (billed from Pathology Lab) . . . . . . . . . . . . 92.00 . . . . . . . . . . . 127.00 Please note: The fees on this page are collected separately and are not included in the clinic management software.

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