Fee Disclosure for Top 15 Procedures
In 2017, the Colorado state legislature passed Senate Bill (SB) 65, which requires all healthcare providers and facilities to publish a list of cash pay prices (fees). Below you will find our top 15 procedures and the associated fees based on the cash-pay, non-discounted fees.
| Code | Description | Fee |
|---|---|---|
| D1110 | Prophylaxis – Adult | $109.00 |
| D0150 | Comprehensive oral evaluation – new or established patient | $100.00 |
| D0210 | Intraoral – complete series of radiographic images | $154.00 |
| D0274 | Bitewings – four radiographic images | $73.00 |
| D0120 | Periodic oral evaluation – established patient | $61.00 |
| D0220 | Intraoral – periapical first radiographic image | $33.00 |
| D0230 | Intraoral – periapical each additional radiographic image | $30.00 |
| D0140 | Limited oral evaluation – problem focused | $82.00 |
| D2391 | Resin-based composite – one surface, posterior | $204.00 |
| D2392 | Resin-based composite – two surfaces, posterior | $264.00 |
| D4910 | Periodontal maintenance | $155.00 |
| D4341 | Periodontal scaling and root planing – four or more teeth per quadrant | $296.00 |
| D4342 | Periodontal scaling and root planing – one to three teeth per quadrant | $209.00 |
| D2740 | Crown – porcelain/ceramic substrate | $1,307.00 |
| D7210 | Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth | $320.00 |
“The health care price listed for any given health care service is an estimate. Actual charges for the health care service are dependent on the circumstances, including any complications or exceptional treatment, at the time the service is rendered.
If you are covered by health insurance or a dental plan, you are strongly encouraged to consult with your insurer or plan to determine accurate information about your financial responsibility for a particular health care service provided by a health care provider at this office. If you are not covered by health insurance or a dental plan, you are strongly encouraged to contact our billing office at [insert telephone number] to discuss payment options prior to receiving a health care service from a health care provider at this office since posted health care prices may not reflect the actual amount of your financial responsibility.”