|
D0120
|
Recall Exam
|
$ 52.00
|
|
D0140
|
Limited Oral Evaluation
|
$ 70.00
|
|
D0145
|
Oral evaluation for a patient under three years of age and counseling with primary caregiver
|
$ 72.00
|
|
D0150
|
Initial Oral Exam, new or established
|
$ 85.00
|
|
D0160
|
Detailed and extensive oral evaluation - problem focused, by report
|
$ 138.00
|
|
D0170
|
Re-evaluation-limited, problem focused
|
$ 58.00
|
|
D0191
|
Assessment of a patient
|
$ 32.00
|
|
D0210
|
Complete Series X-rays
|
$ 140.00
|
|
D0220
|
Periapical X-ray - first film
|
$ 30.00
|
|
D0230
|
Periapical X-ray - two or more
|
$ 24.00
|
|
D0240
|
Occlusal PA
|
$ 32.00
|
|
D0250
|
Extraoral - first film
|
$ 44.00
|
|
D0270
|
Bitewings - Single Film
|
$ 23.00
|
|
D0272
|
Bitewings x 2
|
$ 38.00
|
|
D0273
|
Bitewings - Three Films
|
$ 51.00
|
|
D0274
|
Bitewings x 4
|
$ 65.00
|
|
D0330
|
Panorex X-ray
|
$ 120.00
|
|
D0470
|
Diagnostic Casts
|
$ 55.00
|
| D0999 |
Teledentistry Encounters without live video, recorded video, and/or digital photos |
$ 38.00 |
|
D1110
|
Prophy (Adult)
|
$ 77.00
|
|
D1120
|
Prophy (Child)
|
$ 55.00
|
|
D1206
|
Topical Fluoride Varnish
|
$ 40.00
|
|
D1351
|
Sealants
|
$ 50.00
|
|
D1354
|
Silver Diamine Fluoride
|
$ 50.00
|
|
D1510
|
Space Maint Fixed - Unilateral
|
$ 375.00
|
|
D1516
|
Space Maint Fixed - Maxillary
|
$ 520.00
|
|
D1517
|
Space Maint Fixed - Mandibular
|
$ 520.00
|
|
D2140
|
Amalgam 1 surface
|
$ 145.00
|
|
D2150
|
Amalgam 2 surface
|
$ 185.00
|
|
D2160
|
Amalgam 3 surface
|
$ 215.00
|
|
D2161
|
Amalgam 4 surface or more
|
$ 235.00
|
|
D2330
|
Resin 1 surface anterior
|
$ 133.00
|
|
D2331
|
Resin 2 surface anterior
|
$ 165.00
|
|
D2332
|
Resin 3 surface anterior
|
$ 195.00
|
|
D2335
|
Resin 4 surface anterior
|
$ 245.00
|
|
D2390
|
Resin Crown - anterior
|
$ 350.00
|
|
D2391
|
Resin 1 surface posterior
|
$ 155.00
|
|
D2392
|
Resin 2 surface posterior
|
$ 205.00
|
|
D2393
|
Resin 3 surface posterior
|
$ 250.00
|
|
D2394
|
Resin 4 surface posterior
|
$ 300.00
|
|
D2740
|
Crown - Porcelain/Ceramic (SFS does not apply)
|
$ 1,007.00
|
|
D2750
|
Crown; Porcelain fused to high noble metal (SFS does not apply)
|
$ 1,007.00
|
|
D2790
|
Crown; full cast high noble metal (SFS does not apply)
|
$ 1,007.00
|
|
D2792
|
Crown; full cast noble metal (SFS does not apply)
|
$ 819.00
|
| D2920 | Re-Cement/Re-Bond Crown | $110.00 |
|
D2930
|
SSC - Primary
|
$ 291.00
|
|
D2931
|
SSC - Permanent
|
$ 315.00
|
|
D2932
|
Prefabricated resin crown
|
$ 345.00
|
|
D2933
|
Prefabricated stainless steel crown with resin window
|
$ 380.00
|
|
D2934
|
Prefabricated esthetic coated stainless steel crown
|
$ 380.00
|
|
D2940
|
Sedative filling
|
$ 84.00
|
|
D2950
|
Crown Buildup
|
$ 205.00
|
|
D2951
|
Pin Placement
|
$ 48.00
|
|
D2954
|
Prefabricated post and core
|
$ 350.00
|
|
D2970
|
Temporary Crown (fractured tooth)
|
$ 280.00
|
|
D3110
|
Pulp cap-direct (excluding final restoration)
|
$ 63.00
|
|
D3220
|
Pulpotomy - Excl Rest
|
$ 165.00
|
|
D3222
|
Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development
|
$ 160.00
|
|
D3230
|
Pulpal Therapy - Anterior
|
$ 285.00
|
|
D3240
|
Pulpal Therapy - Posterior
|
$ 385.00
|
|
D3310
|
RCT - Anterior
|
$ 600.00
|
|
D3320
|
RCT - Premolar
|
$ 700.00
|
|
D3330
|
RCT - Molar
|
$ 800.00
|
|
D3351
|
Apexification/recalcification/pulpal regeneration - initial visit
|
$ 280.00
|
|
D3352
|
Apexification/recalcification/pulpal regeneration - interim medication replacement
|
$ 200.00
|
|
D3353
|
Apexification/recalcification - final visit
|
$ 400.00
|
|
D3410
|
Apicoectomy/periradicular surgery - anterior
|
$ 608.00
|
|
D4210
|
Gingivectomy - 4 or more teeth
|
$ 500.00
|
|
D4211
|
Gingivectomy - 1 to 3 teeth
|
$ 190.00
|
|
D4240
|
Gingival flap procedure, including root planning - four or more contiguous teeth per quadrant
|
$ 550.00
|
|
D4241
|
Gingival flap procedure, including root planing
|
$ 500.00
|
|
D4341
|
Periodontal Scaling and root planning - 4 or more teeth
|
$ 210.00
|
|
D4342
|
Periodontal Scaling and root planning - 1 to 3 teeth
|
$ 135.00
|
|
D4355
|
Full mount debridement
|
$ 140.00
|
|
D4910
|
Periodontal Maintenance
|
$ 100.00
|
|
D5110
|
Complete Denture - Maxillary
|
$ 1,210.00
|
|
D5120
|
Complete Denture - Mandibular
|
$ 1,210.00
|
|
D5130
|
Immediate denture - maxillary
|
$ 1,350.00
|
|
D5140
|
Immediate denture - mandibular
|
$ 1,350.00
|
|
D5211
|
All resin acrylic upper partial - Maxillary
|
$ 950.00
|
|
D5212
|
All resin acrylic lower partial - Mandibular
|
$ 950.00
|
|
D5213
|
Cast metal upper partial
|
$ 1,320.00
|
|
D5214
|
Cast metal lower partial
|
$ 1,320.00
|
| D5225 |
Maxillary Partial Denture Flexible Base (including any clasps, rests, and teeth) |
$ 1,150.00 |
| D5226 |
Mandibular Partial Denture Flexible Base (including any clasps, rests, and teeth) |
$ 1,150.00 |
| D5282 | Removable Unilateral Partial Denture - cast metal, Maxillary | $728.00 |
| D5283 | Removable Unilateral Partial Denture - cast metal, Mandibular | $728.00 |
| D5284 | Removable Unilateral Partial Denture - Flexible base per quadrant | $752.00 |
| D5286 | Removable Unilateral Partial Denture - Resin per quadrant | $695.00 |
|
D5410
|
Adjust complete denture - Maxillary
|
$ 66.00
|
|
D5411
|
Adjust complete denture - Mandibular
|
$ 66.00
|
|
D5421
|
Adjust partial denture - Maxillary
|
$ 66.00
|
|
D5422
|
Adjust partial denture - Mandibular
|
$ 66.00
|
|
D5511
|
Repair broken dentures base - Mandibular
|
$ 160.00
|
|
D5512
|
Repair broken dentures base - Maxillary
|
$ 160.00
|
|
D5520
|
Replace missing/broken tooth comp denture
|
$ 130.00
|
|
D5611
|
Repair resin denture base - Mandibular
|
$ 160.00
|
|
D5612
|
Repair resin denture base - Maxillary
|
$ 160.00
|
|
D5621
|
Repair cast framework - Mandibular
|
$ 212.00
|
|
D5622
|
Repair cast framework - Maxillary
|
$ 212.00
|
|
D5630
|
Repair or replace broken clasp
|
$ 275.00
|
|
D5640
|
Replace broken teeth - per tooth
|
$ 130.00
|
|
D5650
|
Add tooth to existing partial denture
|
$ 160.00
|
|
D5660
|
Add clasp to existing partial denture
|
$ 240.00
|
|
D5730
|
Reline complete maxillary denture (chairside)
|
$ 275.00
|
|
D5731
|
Reline complete mandibular denture (chairside)
|
$ 275.00
|
|
D5740
|
Reline maxillary partial denture (chairside)
|
$ 265.00
|
|
D5741
|
Reline mandibular partial denture (chairside)
|
$ 265.00
|
|
D5750
|
Reline complete maxillary denture (laboratory)
|
$ 350.00
|
|
D5751
|
Reline complete mandibular denture (laboratory)
|
$ 350.00
|
|
D5760
|
Reline maxillary partial denture (laboratory)
|
$ 350.00
|
|
D5761
|
Reline mandibular partial denture (laboratory)
|
$ 350.00
|
| D5820 | Interim Partial Denture Maxillary | $600.00 |
| D5821 | Interim Partial Denture Mandibular | $600.00 |
|
D6210
|
Pontic Cast high noble metal (SFS does not apply)
|
$ 1,007.00
|
|
D6212
|
Pontic Cast noble metal (SFS does not apply)
|
$ 819.00
|
|
D6240
|
Pontic Porcelain fused to high noble metal (SFS does not apply)
|
$ 1,007.00
|
|
D6245
|
Pontic porcelain/ceramic (SFS does not apply)
|
$ 1,007.00
|
|
D6740
|
Crown; Porcelain/Ceramic (SFS does not apply)
|
$ 1,007.00
|
|
D6750
|
Crown; Porcelain fused to high noble metal (SFS does not apply)
|
$ 1,007.00
|
|
D6790
|
Crown; full cast high noble metal (SFS does not apply)
|
$ 1,007.00
|
|
D6792
|
Crown; full cast noble metal (SFS does not apply)
|
$ 819.00
|
|
D6985
|
Pediatric partial denture, fixed
|
$ 650.00
|
|
D7111
|
Extraction - coronal remnants - deciduous tooth
|
$ 105.00
|
|
D7140
|
Extraction
|
$ 150.00
|
|
D7210
|
Surgical Extraction - Erupted
|
$ 225.00
|
|
D7220
|
Soft tissue impaction
|
$ 250.00
|
|
D7230
|
Partial bony impaction
|
$ 335.00
|
|
D7240
|
Bony Impaction
|
$ 390.00
|
|
D7241
|
Bony Impaction w/Complications
|
$ 470.00
|
|
D7250
|
Resid Roots - unerupted
|
$ 250.00
|
|
D7260
|
Oroantral fistula closure
|
$ 750.00
|
|
D7270
|
Tooth reimplantation
|
$ 425.00
|
|
D7280
|
Surgical access of an unerupted tooth
|
$ 395.00
|
|
D7285
|
Biopsy - hard tissue
|
$ 275.00
|
|
D7286
|
Biopsy - soft tissue
|
$ 220.00
|
|
D7288
|
Brush biopsy - transepithelial sample collection
|
$ 220.00
|
|
D7310
|
Alveoloplasty - w/extr 4 or more teeth
|
$ 221.00
|
|
D7311
|
Alveoloplasty in conjunction w/extraction
|
$ 205.00
|
|
D7320
|
Alveoloplasty per quad
|
$ 300.00
|
|
D7321
|
Alveoloplasty not in conjunction w/extraction
|
$ 275.00
|
|
D7340
|
Vestibuloplasty - ridge extension (secondary epithelialization)
|
$ 950.00
|
|
D7350
|
Vestibuloplasty - ridge extension (including soft tissue grafts)
|
$ 1,500.00
|
|
D7410
|
Excision of benign lesion up to 1.25 cm
|
$ 325.00
|
|
D7411
|
Excision of benign lesion greater than 1.25 cm
|
$ 400.00
|
|
D7450
|
Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm
|
$ 350.00
|
|
D7451
|
Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm
|
$ 450.00
|
|
D7460
|
Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm
|
$ 475.00
|
|
D7461
|
Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm
|
$ 650.00
|
|
D7465
|
Destruction of lesion(s) by physical or chemical method, by report
|
$ 275.00
|
|
D7471
|
Removal of lateral exostosis (maxilla or mandible)
|
$ 450.00
|
|
D7472
|
Removal of torus palatinus
|
$ 525.00
|
|
D7473
|
Removal of torus mandibularis
|
$ 525.00
|
|
D7485
|
Surgical reduction of osseous tuberosity
|
$ 470.00
|
|
D7510
|
I & D Intra Oral
|
$ 225.00
|
|
D7520
|
Incision and drainage of abscess - extraoral soft tissue
|
$ 567.00
|
|
D7530
|
Removal of foreign body, skin, or tissue
|
$ 280.00
|
|
D7540
|
Removal of reaction producing foreign bodies, musculoskeletal system
|
$ 470.00
|
|
D7550
|
Partial ostectomy/sequestrectomy for removal of non-vital bone
|
$ 600.00
|
|
D7560
|
Maxillary sinusotomy for removal of tooth fragment or foreign body
|
$ 770.00
|
|
D7820
|
Closed reduction of dislocation
|
$ 350.00
|
|
D7910
|
Suture sm. Trauma
|
$ 330.00
|
|
D7911
|
Complicated suture - up to 5 cm
|
$ 500.00
|
|
D7912
|
Complicated suture - greater than 5 cm
|
$ 600.00
|
|
D7920
|
Skin graft
|
$ 1,500.00
|
|
D7960
|
Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure
|
$ 350.00
|
|
D7963
|
Frenuloplasty
|
$ 500.00
|
|
D7971
|
Excision of pericoronal gingiva
|
$ 300.00
|
|
D7972
|
Surgical reduction of fibrous tuberosity
|
$ 500.00
|
|
D7980
|
Sialolithotomy
|
$ 550.00
|
|
D9110
|
Emergency palliative
|
$ 95.00
|
|
D9410
|
House/extended care facility call
|
$ 150.00
|
|
D9420
|
Hospital or ambulatory surgical center call
|
$ 240.00
|
|
D9440
|
Office visit - after regularly scheduled hours
|
$ 115.00
|
|
D9610
|
Therapeutic parenteral drug, single administration
|
$ 70.00
|
|
D9612
|
Therapeutic parenteral drugs, two or more administrations, different medications
|
$ 100.00
|
|
D9630
|
Other drugs and/or medicaments, by report
|
$ 30.00
|
|
D9930
|
Post op dry socket
|
$ 95.00
|
|
D9944
|
Occlusal Guard (SFS does not apply)
|
$ 275.00
|
|
D9972
|
External Bleaching per arch (SFS does not apply)
|
$ 280.00
|
| D9995 |
Teledentistry - Synchronous; real time encounter |
$ 110.00 |
| D9996 |
Teledentistry - Asynchronous; information stored and forwarded to dentist for subsequent review |
$ 39.00 |
| D9972R |
Bleaching Material Refills (SFS does not apply)
|
$ 90.00
|