COMFORT DENTAL GOLD MEMBERSHIP PLAN
NEW MEXICO REDUCED FEE SCHEDULE
ADA MEMBER'S
UCR** MEMBER
ADA MEMBER'S UCR** MEMBER
CODE SERVICES PAYS CODE SERVICES PAYS
PREVENTIVE AND DIAGNOSTIC
0110
Initial Oral Exam 80
N/C
0120 Periodic Oral Exam 60
N/C
0130 Emergency Oral Exam (office hours) 80
N/C
0210 Complete Series X-Rays 95
N/C
0220 Single Periapical X-Ray 28
N/C
0230 Each additional film 22
N/C
0274 Bitewing X-Rays 45
N/C
0470 Diagnostic Casts 75
25
9430 Office Visit 55
25
1110 Simple teeth cleaning (children and adults) 80
N/C
(up to 2 per year). Patients with gum
disease are not covered under this category
(Refer to Periodontics Section)
1203
Fluoride Treatment (Limit one per year 40
N/C
to age 18)
1330
Preventive Dental Education, Home Care 55
N/C
1351 Sealants (Pit & Fissure) per tooth 40
20
1510 Space Maintainer Unilateral 220
120
1515 Space Maintainer Bilateral 310
150
9310 Consultation 100
15
9440 After hours Office Visit 180
60
Missed/Canceled Appointments (without 70
50
24 hours notice)
0431
VelScope Cancer Screening 50
10
The following Orthodontic fees apply only when treatment is performed at a
Comfort Braces Center.
ORTHODONTICS (BRACES) CHILDREN/ADULTS
----
----
Orthodontic Consultation 60
N/C
---- Records 300
189
---- Down Payment 1500
N/C
---- Monthly Adjustment Fee (Child) 150
129
---- Monthly Adjustment Fee (Adult) 175
139
---- Retainers 600
369
RESTORATIVE (FILLINGS)
Amalgam Restorations/Permanent-Primary Teeth
2140 One tooth surface 95
60
2150 Two surfaces 120
70
2160 Three surfaces 150
80
2161 Four or more surfaces 280
110
Anterior Resin Restorations
2330 One surface 135
85
2331 Two surfaces 165
95
2332 Three surfaces 185
110
2335 Four or more surfaces 240 140
Posterior Resin Restorations
2391 One surface 200
100
2392 Two surfaces 220
168
2393 Three or more surfaces 300
220
CROWN AND BRIDGE
2740 Porcelain Crown 1180 800
2750-52 Porcelain with Metal Crown 940 585
2790 Full Crown 1100 800*
2810 3/4 Metal Crown 1100 800*
2930 Stainless Steel Crown (Primary) 280 160
2920 Recement Crown 80 45
2950 Crown Build-up including any pins 235 150
2952 Cast Post and Core 260 165
2954 Pre-fab post & core 240 150
2962 Cosmetic Porcelain Veneer 1180 850
-
6210-12 Cast Pontic 940 800*
6240-42 Porcelain with metal Pontic 940 850
6545 Maryland Bridge per unit 1000 800
6750-52 Porcelain with metal Bridge Abutment 940 800
6780 3/4 Metal Bridge Abutment 940 620*
6790-92 Full Metal Crown 980 800
PROSTHODONTICS - REMOVABLE
5110 Complete Upper Denture 1450 850
5120 Complete Lower Denture 1450 850
5130 Immediate Upper Denture 1500 900
5140 Immediate Lower Denture 1500 900
5213 Upper Partial - Cast 1450 900
5214 Lower Partial - Cast 1450 900
5225/5226 Valplast Partial 1200 900
5820 Treatment Partial - Acrylic/Flipper 425 310
9940 Nightguard (occlusal guard) 350 240
REPAIRS/RELINES
5410-22 Denture adjustments 85 55
(Upper or Lower, complete or partial
5510
Repair broken complete denture base 440
260***
5520 Replace missing or broken teeth 135
75***
complete or partial denture (per tooth)
5620-30
Repair Cast Framework/Clasp 280
145***
5650 Add tooth to existing partial denture 200
90***
5710 Rebase 420 200
5730 Reline Chairside 200 100
5750 Reline Lab 410 220
OTHER SERVICES
9110
Emergency Palliative Treatment 150 70
9210 Local Anesthetic N/C N/C
9230 Nitrous Oxide - Flat Fee 54 25
9951 Occlusal Adjustment - limited 85 45
9972 Take Home Bleaching - per arch 280 120
---- In Office Bleaching - per arch 250 105
2951 Pin Retention per tooth 100 70
2940 Sedative Filling 130 70
3110-20 Pulp Cap 110 30
The following ORAL SURGERY, ENDODONTIC and PERIODONTIC payments apply only when treatment is performed at a participating dental office. If the services of a specialist
are required, these payments do not apply and the patient will receive services from a participating specialist, where available, at a 20% discount off of the specialist's UCR.
ORAL SURGERY ENDODONTICS (root canal treatment)
7140 Simple Extraction
145
90
3220 Therapeutic Pulpotomy 180 65
7120 Each Additional Routine Extraction
120
80
3221 Pulpal debridement 165 110
7210 Surgical Extraction Erupted
245
150
3310 Rct Anterior 520 350
7220 Soft Tissue Impaction
280
175
3320 Rct Bicuspid 610 450
7230 Partial Bony Impaction
420
250
3330 Rct Molor 900 650
7240
Complete Bony Impaction
510
310
7250 Surgical Root Recovery
210
100
3410
Apicoectomy
500
250
7270
Tooth Reimplantation and Stabilization
510
200
PERIODONTICS (gum treatment)
7280 Surgical Exposure of Impacted Tooth
200
80
4999 Periodontal Exam and Charting
90
35
7286 Biopsy of Oral-Tissue-soft
180
70
4210 Gingivectormy/Quad 510
270
7310 Alveoloplasty/Quad with Extraction
240
110
4220 Gingival Curettage/Quad 210
115
7320 Alveoloplasty/Quad without Extractions
200
135
4260 Osseous surgery/Quad (including flap 700
360
7510 Intra-Oral I & D Abscess
130
75
entry and closure
4341 Scaling/Root Planing/Quad 310
165
4342 Scaling/Root Planing/1-3 teeth/Quad 125
95
4910 Periodontal Maintenance (following therapy) 140
90
*All patient payments are exclusive of gold. If gold is used, there will be an additional cost added to the patient payments ***Plus Lab Fee.
UCR**
-
Usual, Customary and Reasonable Fees for New Mexico. Procedures or services not listed will be performed at UCR.
06/13 TXpg 5
0330 Pano 115
65
6010
6056
6057
6058
6059
6065
1800
400
550
1350
1350
1400
1295
250
400
850
850
900
Implant
Implant Abutment - Pre-Fabricated
Implant Abutment - Custom
Implant Abut Supported - Ceramic
Implant Abut Supported - PFM
Implant Abut Supported - screw retained crown
