At Smiles To You we want to make your visit as effortless as possible. Patients now have the option to download and complete our Patient Information Form prior to your appointment. The form also includes medical history, consent for treatment and privacy act sections. To access the form, please click here.
Once you open the form, it can be printed and completed before your visit.
2015 Smiles To You Fee Schedule
| ADA CODE | DESCRIPTION | FEE |
| D0120 | PERIODIC ORAL EXAM | 73.00 |
| D0140 | LIMITED ORAL EXAM | 104.00 |
| D0150 | COMPREHENSIVE ORAL EXAM | 85.00 |
| D0170 | RE-EVALUATED FOCUSED | 98.00 |
| D0210 | COMPLETE SERIES X-RAYS | 166.00 |
| D0220 | PERIAPICAL 1ST FILM | 35.00 |
| D0221 | PERIAPICAL ADDITIONAL FILM | 30.00 |
| D0272 | BITEWINGS 2 FILM | 53.00 |
| D0273 | BITEWINGS 3 FILM | 62.00 |
| D0274 | BITEWINGS 4 FILM | 69.00 |
| D1110 | PROPHYLAXIS | 106.00 |
| D1206 | FLUORIDE VARNISH | 45.00 |
| D4910 | PERIODONTAL MAINTENANCE | 148.00 |
| D4341 | QUADRANT SCALING AND ROOT PLANNING - 4 TEETH MINIMUM | 307.00 |
| D4342 | QUADRANT SCALING AND ROOT PLANNING - 1-3 TEETH | 240.00 |
| D4345 | FULL MOUTH DEBRIDEMENT | 265.00 |
| D5410/11/21/22 | ADJUST PARTIAL / DENTURE | 171.00 |
| D5281 | REMOVABLE UNILATERAL PARTIAL | 702.00 |
| D5225/26 | UPPER / LOWER PARTIAL FLEX BASE | 1909.00 |
| D5610 | REPAIR DENTURE BASE | 260.00 |
| D5630/50 | ADD CLASP / TOOTH TO EXISTING PARTIAL | 239.00 |
| D5711/20/21 | UPPER / LOWER DENTURE RELINE CHAIRSIDE | 204.00 |
| D5730/31/40/41 | UPPER / LOWER PARTIAL RELINE CHAIRSIDE | 204.00 |
| D5750/51/60/61 | LAB UPPER / LOWER DENTURE / PARTIAL REBASE | 420.00 |
| D2330 | ANTERIOR / POSTERIOR COMPOSITE 1 SURFACE | 211.00 |
| D2231 | ANTERIOR / POSTERIOR COMPOSITE 2 SURFACE | 265.00 |
| D2232 | ANTERIOR / POSTERIOR COMPOSITE 3 SURFACE | 319.00 |
| D2335 | ANTERIOR / POSTERIOR COMPOSITE 4 SURFACE | 346.00 |
| D2390 | COMPOSITE CROWN | 448.00 |
| D2740 | FULL PORCELAIN / CERAMIC CROWN | 1589.00 |
| D2920 | RECEMENT CROWN | 139.00 |
| D2970 | TEMPORARY CROWN FRACTURED TOOTH | 192.00 |
| D5211/2/3/4 | UPPER / LOWER DENTURE / PARTIAL ACRYLIC AND/OR METAL SUBSTRUCT | 1695.00 |
| D7140 | ROUTINE EXTRACTION | 257.00 |
| D7210 | SURGICAL EXTRACTION | 376.00 |
| D7285/86 | BIOPSY PER SITE HARD / SOFT TISSUE | 312.00 |
| D9951 | LIMITED OCCLUSAL ADJUSTMENT | 177.00 |
Full payment due at time of service.
Personal Check, Debit Card, Mastercard, Visa, American Express accepted.
Request for treatment not listed above will be quoted prior to service.
CLICK HERE To download the 2015 Fee Schedule