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Dental

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 $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

 
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