|
Code
|
Procedure
|
Typical Charge
|
What You'll Pay
|
Savings
|
|
|---|---|---|---|---|---|
| D0120 | PERIODIC ORAL EXAMINATION | $69.00 | $24.00 | $45.00 | |
| D0140 | LIMITED ORAL EVALUATION | $101.00 | $24.00 | $77.00 | |
| D0145 | ORAL EVAL FOR PATIENT UNDER 3 YRS | $92.00 | $24.00 | $68.00 | |
| D0145 | ORL EVAL PT<3 YR CNSL PRIM CAREGIVR | $92.00 | $24.00 | $68.00 | |
| D0150 | COMPREHENSIVE ORAL EXAMINATION | $120.00 | $30.00 | $90.00 | |
| D0160 | DETAILED ORAL EVALUATION | $207.00 | $30.00 | $177.00 | |
| D0170 | RE-EVALUATION-LIMITED | $93.00 | $25.00 | $68.00 | |
| D0180 | COMPREHENSIVE PERIODONTAL EVAL | $128.00 | $30.00 | $98.00 | |
| D0210 | X-RAYS-FULL MOUTH | $187.00 | $60.00 | $127.00 | |
| D0220 | PERIAPICAL X-RAY FIRST FILM | $41.00 | $10.00 | $31.00 | |
| D0230 | X-RAY PERIAPICAL -ADDITIONAL | $35.00 | $6.00 | $29.00 | |
| D0240 | 0CCLUSAL FILM | $57.00 | $15.00 | $42.00 | |
| D0250 | XRAY-EXTRAORAL | $87.00 | $35.00 | $52.00 | |
| D0260 | EXTRAORAL-EACH ADDITIONAL | $0.00 | $25.00 | - | |
| D0270 | X-RAY 1 BITEWING | $41.00 | $10.00 | $31.00 | |
| D0272 | X-RAYS 2 BITEWINGS | $64.00 | $16.00 | $48.00 | |
| D0273 | X-RAYS 3 BITEWINGS | $77.00 | $22.00 | $55.00 | |
| D0274 | X-RAYS 4 BITEWINGS | $92.00 | $28.00 | $64.00 | |
| D0277 | VERTICAL BITEWINGS 7-8 FILMS | $136.00 | $35.00 | $101.00 | |
| D0290 | X-RAY ANT. POST. OR LATERAL | $181.00 | $40.00 | $141.00 | |
| D0310 | SIALOGRAPHY | $495.00 | $50.00 | $445.00 | |
| D0320 | TMJ FILM | $793.00 | $200.00 | $593.00 | |
| D0321 | TMJ FILM | $278.00 | $80.00 | $198.00 | |
| D0322 | TOMOGRAPHIC SURVEY | $678.00 | $175.00 | $503.00 | |
| D0330 | PANORAMIC FILM | $160.00 | $50.00 | $110.00 | |
| D0340 | CEPHALOMETRIC FILM | $169.00 | $50.00 | $119.00 | |
| D0350 | ORAL/FACIAL IMAGES | $100.00 | $25.00 | $75.00 | |
| D0364 | CONE BEAM CT CAPTURE-LESS THAN WHOLE JAW | $427.00 | $200.00 | $227.00 | |
| D0365 | CONE BEAM CT-MANDIBLE | $460.00 | $200.00 | $260.00 | |
| D0366 | CONE BEAM CT | $440.00 | $200.00 | $240.00 | |
| D0367 | CONE BEAM CT - WITH OR WITHOUT CRANIUM | $467.00 | $200.00 | $267.00 | |
| D0368 | CONE BEAM CT CAPTURE AND INTER | $510.00 | $200.00 | $310.00 | |
| D0380 | CONE BEAM CT | $366.00 | $200.00 | $166.00 | |
| D0381 | CONE BEAM CT IMAGE | $423.00 | $200.00 | $223.00 | |
| D0382 | CONE BEAM CT IMAGE CAPTURE WITH FIELD OF VIEW OF O | $408.00 | $200.00 | $208.00 | |
| D0383 | CONE BEAM CT | $440.00 | $200.00 | $240.00 | |
| D0415 | BACTERIOLOGIC STUDIES | $232.00 | $25.00 | $207.00 | |
| D0431 | ADJUNCTIVE PRE-DIAGNOSTIC TEST | $93.00 | $35.00 | $58.00 | |
| D0460 | PULP VITALITY TEST | $80.00 | $20.00 | $60.00 | |
| D0470 | DIAGNOSTIC CASTS | $153.00 | $40.00 | $113.00 | |
| D0472 | ACCESSION TISSUE, EXM,PREP,REP | $163.00 | $40.00 | $123.00 | |
| D0473 | ACCESSION TISSURE-MICRO EXAM | $221.00 | $60.00 | $161.00 | |
| D0474 | ACCESSION OF TISSUE, GROSS AND MICROSCOPIC EXAMINA | $259.00 | $40.00 | $219.00 | |
| D0502 | OTHER ORAL PATHOLOGY PROCEDURES, BY REPORT | $176.00 | $40.00 | $136.00 | |
| D1110 | PROPHYLAXIS | $101.00 | $45.00 | $56.00 | |
| D1120 | PROPHYLAXIS-CHILD | $73.00 | $35.00 | $38.00 | |
| D1206 | TOPICAL FLUORIDE VARNISH | $48.00 | $20.00 | $28.00 | |
| D1208 | TOPICAL APPLICATION FLUORIDE | $42.00 | $20.00 | $22.00 | |
| D1310 | NUTRITIONAL COUNSELING | $74.00 | $15.00 | $59.00 | |
| D1320 | TOBACCO COUNSELING | $82.00 | $15.00 | $67.00 | |
| D1351 | SEALANT | $61.00 | $25.00 | $36.00 | |
| D1352 | PREVENTIVE RESIN RESTORATION | $113.00 | $25.00 | $88.00 | |
| D1510 | SPACE MAINTAINER-FIXED | $442.00 | $190.00 | $252.00 | |
| D1516 | SPACE MAINTAINER ? FIXED ? BILATERAL, MAXILLARY | $0.00 | $225.00 | - | |
| D1517 | SPACE MAINTAINER ? FIXED ? BILATERAL, MANDIBULAR | $0.00 | $225.00 | - | |
| D1520 | SPACE MAINTAINER-REMOVABLE | $534.00 | $185.00 | $349.00 | |
| D1526 | SPACE MAINTAINER ? REMOVABLE ? BILATERAL, MAXILLAR | $0.00 | $250.00 | - | |
| D1527 | SPACE MAINTAINER ? REMOVABLE ? BILATERAL, MANDIBUL | $0.00 | $250.00 | - | |
| D1551 | RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER ? | $0.00 | $40.00 | - | |
| D1552 | RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER ? | $0.00 | $40.00 | - | |
| D1553 | RE-CEMENT OR RE-BOND UNILATERAL SPACE MAINTAINER ? | $0.00 | $40.00 | - | |
| D2140 | AMALGAM ONE SURFACE -PERMANENT OR PRIMARY | $200.00 | $55.00 | $145.00 | |
| D2150 | AMALGAM TWO SURFACES-PERMANENT OR PRIMARY | $251.00 | $70.00 | $181.00 | |
| D2160 | AMALGAM THREE SURFACES-PERM OR PRIME | $307.00 | $80.00 | $227.00 | |
| D2161 | AMALGAM-FOUR OR MORE SURFACES PERM OR PRIM | $363.00 | $95.00 | $268.00 | |
| D2330 | RESIN - ONE SURFACE | $236.00 | $60.00 | $176.00 | |
| D2331 | RESIN - TWO SURFACES | $262.00 | $75.00 | $187.00 | |
| D2332 | RESIN THREE OR MORE SURFACES | $307.00 | $90.00 | $217.00 | |
| D2335 | RESIN-4+ SRF OR INCISAL EDGE | $400.00 | $100.00 | $300.00 | |
| D2390 | RESIN BASED COMPOSITE CROWN | $630.00 | $200.00 | $430.00 | |
| D2391 | RESIN 1 SURFACE POSTERIOR | $258.00 | $75.00 | $183.00 | |
| D2392 | RESIN-2 SURFACES,POSTERIOR | $331.00 | $100.00 | $231.00 | |
| D2393 | RESIN-3 SURFACES,POST. | $406.00 | $115.00 | $291.00 | |
| D2394 | RESIN-4 OR MORE SRF-POST | $487.00 | $125.00 | $362.00 | |
| D2410 | GOLD FOIL - 1 SURF. | $871.00 | $200.00 | $671.00 | |
| D2420 | GOLD FOIL - 2 SURF. | $1,013.00 | $275.00 | $738.00 | |
| D2430 | GOLD FOIL - 3 SURF. | $1,126.00 | $325.00 | $801.00 | |
| D2510 | INLAY-METALLIC -ONE SURFACE | $1,178.00 | $275.00 | $903.00 | |
| D2520 | INLAY METALLIC -TWO SURFACES | $1,268.00 | $350.00 | $918.00 | |
| D2530 | INLAY-METALLIC-THREE OR MORE S | $1,350.00 | $375.00 | $975.00 | |
| D2542 | ONLAY-METALLIC 2 SURFACE | $1,393.00 | $400.00 | $993.00 | |
| D2543 | ONLAY-METALLIC 3 SURFACE | $1,468.00 | $450.00 | $1,018.00 | |
| D2544 | ONLAY-METALLIC 3 SURFACE | $1,532.00 | $475.00 | $1,057.00 | |
| D2610 | INLAY-PORCELAIN 1 SURFACE | $1,272.00 | $350.00 | $922.00 | |
| D2620 | INLAY-PORCELAIN 2 SURFACES | $1,333.00 | $425.00 | $908.00 | |
| D2630 | INLAY-PORCELAIN-3 OR MORE SURF | $1,401.00 | $500.00 | $901.00 | |
| D2642 | ONLAY-PORCELAIN/CERAMIC 2 SURFACE | $1,433.00 | $400.00 | $1,033.00 | |
| D2643 | ONLAY-PORCELAIN/CERA,IC 3 SURFACE | $1,488.00 | $500.00 | $988.00 | |
| D2644 | ONLAY ? PORCELAIN/CERAMIC ? FOUR OR MORE SURFACES | $1,545.00 | $500.00 | $1,045.00 | |
| D2650 | INLAY-COMPOSITE-ONE SURFACE | $1,182.00 | $200.00 | $982.00 | |
| D2651 | INLAY COMPOSITE 2 SRF | $1,221.00 | $250.00 | $971.00 | |
| D2652 | INLAY COMPOSITE 3 SRF | $1,285.00 | $300.00 | $985.00 | |
| D2662 | ONLAY ? RESIN-BASED COMPOSITE ? TWO SURFACES | $1,302.00 | $300.00 | $1,002.00 | |
| D2663 | ONLAY-COMPOSITE 3 SURFACE | $1,364.00 | $350.00 | $1,014.00 | |
| D2710 | CROWN-RESIN (LABORATORY) | $1,288.00 | $200.00 | $1,088.00 | |
| D2712 | CROWN-3/4 RESIN BASED COMP-IND | $1,396.00 | $200.00 | $1,196.00 | |
| D2720 | CROWN RESIN WITH METAL | $1,488.00 | $500.00 | $988.00 | |
| D2721 | CROWN-RESIN WITH BASE METAL | $1,412.00 | $450.00 | $962.00 | |
| D2722 | CROWN-RESIN WITH NOBLE METAL | $1,457.00 | $475.00 | $982.00 | |
| D2740 | CROWN ? PORCELAIN/CERAMIC SUBSTRATE | $1,606.00 | $550.00 | $1,056.00 | |
| D2750 | CROWN-PORC.FUSED TO METAL | $1,609.00 | $625.00 | $984.00 | |
| D2751 | CROWN-PORC.FUSED TO BASE METAL | $1,468.00 | $575.00 | $893.00 | |
| D2752 | CROWN-PORC.FUSED TO NOBLE META | $1,533.00 | $625.00 | $908.00 | |
| D2780 | CROWN - 3/4 CAST HIGH NOBLE METAL | $1,541.00 | $550.00 | $991.00 | |
| D2781 | CROWN-3/4 CAST BASE METAL | $1,446.00 | $500.00 | $946.00 | |
| D2782 | CROWN-3/4 CAST NOBLE METAL | $1,489.00 | $500.00 | $989.00 | |
| D2783 | CROWN-3/4 PORCELAIN/CERAMIC | $1,570.00 | $475.00 | $1,095.00 | |
| D2790 | CROWN-FULL CAST METAL | $1,649.00 | $500.00 | $1,149.00 | |
| D2791 | CROWN-FULL CAST BASE METAL | $1,453.00 | $475.00 | $978.00 | |
| D2792 | CROWN-FULL CAST NOBLE METAL | $1,529.00 | $475.00 | $1,054.00 | |
| D2794 | CROWN-TITANIUM | $1,574.00 | $525.00 | $1,049.00 | |
| D2799 | PROVISIONAL CROWN | $611.00 | $75.00 | $536.00 | |
| D2910 | RECEMENT INLAY | $160.00 | $40.00 | $120.00 | |
| D2915 | RECEMENT POST & CORE | $153.00 | $40.00 | $113.00 | |
| D2920 | RECEMENT CROWN | $155.00 | $40.00 | $115.00 | |
| D2929 | PREFABRICATED PORCELAIN/CERAMIC CROWN ? PRIMARY TO | $494.00 | $100.00 | $394.00 | |
| D2930 | PREFABRICATED SS CROWN-PRIMARY | $380.00 | $100.00 | $280.00 | |
| D2931 | STAINLESS STEEL CROWN-PERM | $432.00 | $100.00 | $332.00 | |
| D2932 | PREFAB. RESIN CROWN | $475.00 | $100.00 | $375.00 | |
| D2933 | PREFAB SS CROWN W/RESIN WINDOW | $488.00 | $150.00 | $338.00 | |
| D2934 | PREFAB ESTHETIC COATED SS CRWN | $514.00 | $100.00 | $414.00 | |
| D2940 | PROTECTIVE RESTORATION | $168.00 | $40.00 | $128.00 | |
| D2950 | CROWN BUILD-UP | $374.00 | $75.00 | $299.00 | |
| D2951 | PIN SUPPORT PER TOOTH | $104.00 | $30.00 | $74.00 | |
| D2952 | CAST POST & CORE | $574.00 | $160.00 | $414.00 | |
| D2953 | EACH ADDITIONAL INDIRECTLY FABRICATED POST ? SAME | $419.00 | $25.00 | $394.00 | |
| D2954 | PREFAB POST & CORE | $480.00 | $120.00 | $360.00 | |
| D2955 | POST REMOVAL | $412.00 | $75.00 | $337.00 | |
| D2957 | EACH ADDITIONAL PREFABRICATED POST ? SAME TOOTH | $272.00 | $20.00 | $252.00 | |
| D2961 | RESIN LAMINATE-LABORATORY | $1,334.00 | $250.00 | $1,084.00 | |
| D2962 | PORCELAIN LAMINATE | $1,641.00 | $375.00 | $1,266.00 | |
| D2980 | REPAIR BROKEN CROWN FACING | $396.00 | $100.00 | $296.00 | |
| D3110 | PULP CAP-DIRECT | $117.00 | $30.00 | $87.00 | |
| D3120 | PULP CAP-INDIRECT | $117.00 | $20.00 | $97.00 | |
| D3220 | VITAL PULPOTOMY | $283.00 | $80.00 | $203.00 | |
| D3221 | PULPAL DEBRIDEMENT | $324.00 | $40.00 | $284.00 | |
| D3222 | PARTIAL PULPOTOMY FOR APEXOGENESIS | $404.00 | $75.00 | $329.00 | |
| D3230 | PULPAL THERAPY-PRIMARY-ANTERIO | $384.00 | $150.00 | $234.00 | |
| D3240 | PULPAL THERAPY-PRIMARY-POSTERI | $428.00 | $200.00 | $228.00 | |
| D3310 | ROOT CANAL THERAPY-ANTERIOR TOOTH | $1,063.00 | $350.00 | $713.00 | |
| D3320 | ROOT CANAL THERAPY-BICUSPID TOOTH | $1,209.00 | $425.00 | $784.00 | |
| D3330 | ROOT CANAL THERAPY-MOLAR TOOTH | $1,466.00 | $600.00 | $866.00 | |
| D3331 | TX OF ROOT CANAL OBSTRUCTION | $801.00 | $125.00 | $676.00 | |
| D3332 | INCOMPLETE ENDODONTIC THERAPY | $626.00 | $175.00 | $451.00 | |
| D3333 | INTERNAL ROOT REPAIR OF PERFORATION DEFECTS | $467.00 | $75.00 | $392.00 | |
| D3346 | RETREATMENT-RCT -ANTERIOR | $1,221.00 | $450.00 | $771.00 | |
| D3347 | RETREATMENT OF RCT - BICUSPID | $1,385.00 | $525.00 | $860.00 | |
| D3348 | RETREATMENT RCT-MOLAR | $1,648.00 | $700.00 | $948.00 | |
| D3351 | APRXIFICATION-INITIAL | $495.00 | $150.00 | $345.00 | |
| D3352 | APEXIFICATION-INTERIM MEDICATION | $360.00 | $100.00 | $260.00 | |
| D3353 | APEXIFICATION/RECALCIFICATION-FINAL VISIT | $735.00 | $250.00 | $485.00 | |
| D3410 | APICOECTOMY-FIRST ROOT | $987.00 | $250.00 | $737.00 | |
| D3421 | APICO.-PREMOLAR-FIRST ROOT | $1,101.00 | $250.00 | $851.00 | |
| D3425 | APICO.-MOLAR-FIRST ROOT | $1,236.00 | $250.00 | $986.00 | |
| D3426 | APICOECTOMY-EACH ADDITIONAL RT | $560.00 | $150.00 | $410.00 | |
| D3430 | RETROGRADE FILLING | $387.00 | $100.00 | $287.00 | |
| D3450 | ROOT RESECTION | $671.00 | $200.00 | $471.00 | |
| D3470 | INTENTIONAL REPLANTATION | $1,095.00 | $350.00 | $745.00 | |
| D3910 | ISOLATION OF TOOTH-RUBBER DAM | $307.00 | $100.00 | $207.00 | |
| D3920 | HEMISECTION | $634.00 | $200.00 | $434.00 | |
| D3950 | CANAL PREP. AND FITTING OF DOW | $347.00 | $75.00 | $272.00 | |
| D4210 | GINGIVECTOMY OR GINGIVOPLASTY | $857.00 | $250.00 | $607.00 | |
| D4211 | GINGIVECTOMY ONE TO THREE TEETH-PER QUAD | $434.00 | $150.00 | $284.00 | |
| D4230 | ANATOMICAL CROWN EXPOSURE - FO | $1,047.00 | $500.00 | $547.00 | |
| D4231 | ANATOMICAL CROWN | $814.00 | $300.00 | $514.00 | |
| D4240 | GINGIVAL FLAP PROCEDURE | $1,025.00 | $300.00 | $725.00 | |
| D4241 | GINGL FLP PROC 1-3 CONTIG/BOUND TEETH SP | $854.00 | $175.00 | $679.00 | |
| D4245 | APICALLY POSITIONED FLAP | $1,089.00 | $125.00 | $964.00 | |
| D4249 | CROWN LENGTHENING | $1,071.00 | $450.00 | $621.00 | |
| D4260 | OSSEOUS SURGERY-PER QUADRANT | $1,501.00 | $525.00 | $976.00 | |
| D4261 | OSSEOUS SURGERY 1 -3 TEETH | $1,221.00 | $315.00 | $906.00 | |
| D4263 | OSSEOUS GRAFT- PER SITE | $885.00 | $150.00 | $735.00 | |
| D4264 | OSSEOUS GRAFT-ADDTIONAL | $688.00 | $100.00 | $588.00 | |
| D4265 | BIO MATERIALS TO AID REGEN | $734.00 | $150.00 | $584.00 | |
| D4266 | GUIDED TISSUE REGEN-RESORB | $1,049.00 | $225.00 | $824.00 | |
| D4267 | GUIDED TISSUE REGEN-NONRESORB | $1,201.00 | $275.00 | $926.00 | |
| D4268 | GUIDED TISSUE REGENERATION | $1,093.00 | $75.00 | $1,018.00 | |
| D4270 | PEDICLE SOFT TISSUE GRAFTS | $1,145.00 | $300.00 | $845.00 | |
| D4273 | SUBEPITH.CONNECTIVE TISS. GRAF | $1,504.00 | $600.00 | $904.00 | |
| D4274 | DISTAL OR PROXIMAL WEDGE PROCE | $929.00 | $150.00 | $779.00 | |
| D4275 | SOFT TISSUE ALLOGRAFT | $1,418.00 | $500.00 | $918.00 | |
| D4276 | COMB CON TIS DBL PED GRAFT/TTH | $1,494.00 | $550.00 | $944.00 | |
| D4277 | FREE SOFT TISSUE GRAFT | $1,329.00 | $325.00 | $1,004.00 | |
| D4320 | SPLINTING-INTRACORONAL | $703.00 | $150.00 | $553.00 | |
| D4321 | SPLINTING-EXTRACORONAL | $643.00 | $100.00 | $543.00 | |
| D4341 | PERIO TREATMENT PER QUAD | $363.00 | $75.00 | $288.00 | |
| D4342 | SCALING-ROOT PLANING 1 TO 3 TEETH | $259.00 | $45.00 | $214.00 | |
| D4355 | FULL MOUTH DEBRIDEMENT | $256.00 | $45.00 | $211.00 | |
| D4381 | LOCALIZED DELIV. OF CHEMO.AGEN | $107.00 | $45.00 | $62.00 | |
| D4910 | PERIODONTAL MAINTENANCE | $193.00 | $60.00 | $133.00 | |
| D4920 | UNSCHEDULED DRESSING CHANGE (OTHER THAN TX DR) | $143.00 | $25.00 | $118.00 | |
| D5110 | COMPLETE UPPER DENTURE | $2,335.00 | $725.00 | $1,610.00 | |
| D5120 | COMPLETE LOWER DENTURE | $2,427.00 | $725.00 | $1,702.00 | |
| D5130 | IMMEDIATE FULL UPPER DENTURE | $2,591.00 | $725.00 | $1,866.00 | |
| D5140 | IMMEDIATE FULL LOWER DENTURE | $2,599.00 | $725.00 | $1,874.00 | |
| D5211 | UPPER PARTIAL-ACRYLIC BASE W/C | $1,901.00 | $550.00 | $1,351.00 | |
| D5212 | LOWER PARTIAL ACRYLIC W/CLASPS | $1,901.00 | $550.00 | $1,351.00 | |
| D5213 | UPPER PARTIAL - CAST METAL | $2,508.00 | $750.00 | $1,758.00 | |
| D5214 | LOWER PARTIAL - CAST METAL | $2,528.00 | $750.00 | $1,778.00 | |
| D5225 | MAXILLARY PARTIAL FLEX BASE | $2,228.00 | $1,000.00 | $1,228.00 | |
| D5226 | MANDIBULAR PARTIAL FLEX BASE | $2,216.00 | $1,000.00 | $1,216.00 | |
| D5282 | REMOVABLE UNILATERAL PARTIAL DENTURE MAXIILLARY | $0.00 | $275.00 | - | |
| D5283 | REMOVABLE UNILATERAL PARTIAL DENTURE-MANDIBULAR | $0.00 | $275.00 | - | |
| D5410 | ADJUST COMPLETE DENTURE-UPPER | $127.00 | $40.00 | $87.00 | |
| D5411 | ADJUST COMPLETE DENTURE-LOWER | $127.00 | $40.00 | $87.00 | |
| D5421 | ADJUST PARTIAL UPPER DENTURE | $127.00 | $40.00 | $87.00 | |
| D5422 | ADJUST PARTIAL DENTURE-LOWER | $125.00 | $40.00 | $85.00 | |
| D5511 | REPAIR BROKEN COMPLETE DENTURE BASE, MANDIBULAR | $0.00 | $100.00 | - | |
| D5512 | REPAIR BROKEN COMPLETE DENTURE BASE, MAXILLARY | $0.00 | $100.00 | - | |
| D5520 | REPLACE BROKEN TTH IN DENTURE | $267.00 | $90.00 | $177.00 | |
| D5611 | REPAIR RESIN PARTIAL DENTURE BASE, MANDIBULAR | $0.00 | $90.00 | - | |
| D5612 | REPAIR RESIN PARTIAL DENTURE BASE, MAXILLARY | $0.00 | $90.00 | - | |
| D5621 | REPAIR CAST PARTIAL FRAMEWORK, MANDIBULAR | $0.00 | $115.00 | - | |
| D5622 | REPAIR CAST PARTIAL FRAMEWORK, MAXILLARY | $0.00 | $115.00 | - | |
| D5630 | REPAIR OR REPLACE BROKEN CLASP | $379.00 | $90.00 | $289.00 | |
| D5640 | REPLACE BROKEN TOOTH | $267.00 | $90.00 | $177.00 | |
| D5650 | ADD TOOTH TO DENTURE | $320.00 | $90.00 | $230.00 | |
| D5660 | ADD CLASP TO EXIST PART DENT | $380.00 | $105.00 | $275.00 | |
| D5670 | REPLACE ALL TEETH AND FRAMEWORK ON UPPER DENTURE | $1,030.00 | $250.00 | $780.00 | |
| D5671 | REPLACE ALL TEETH AND ACRYLIC | $1,049.00 | $250.00 | $799.00 | |
| D5710 | REBASE FULL UPPER | $834.00 | $165.00 | $669.00 | |
| D5711 | REBASE FULL LOWER | $841.00 | $165.00 | $676.00 | |
| D5720 | REBASE PARTIAL UPPER DENTURE | $797.00 | $140.00 | $657.00 | |
| D5721 | REBASE PARTIAL LOWER DENTURE | $795.00 | $140.00 | $655.00 | |
| D5730 | RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) | $527.00 | $120.00 | $407.00 | |
| D5731 | RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) | $524.00 | $120.00 | $404.00 | |
| D5740 | RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) | $519.00 | $105.00 | $414.00 | |
| D5741 | RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE) | $520.00 | $105.00 | $415.00 | |
| D5750 | RELINE UPPER DENTURE-LAB | $647.00 | $165.00 | $482.00 | |
| D5751 | RELINE COMP LOWER DENTURE-LAB | $667.00 | $165.00 | $502.00 | |
| D5760 | RELINE PARTIAL UPPER-LAB | $660.00 | $150.00 | $510.00 | |
| D5761 | RELINE PARTIAL LOWER-LAB. | $660.00 | $150.00 | $510.00 | |
| D5820 | INTERIM PARTIAL UPPER DENTURE | $983.00 | $300.00 | $683.00 | |
| D5821 | INTERIM PARTIAL LOWER DENTURE | $979.00 | $300.00 | $679.00 | |
| D5850 | TISSUE CONDITIONING-MAXILLARY | $288.00 | $75.00 | $213.00 | |
| D5851 | TISSUE CONDITIONING LOWER | $288.00 | $75.00 | $213.00 | |
| D5862 | PRECISION ATTACHMENT | $1,001.00 | $250.00 | $751.00 | |
| D5863 | OVERDENTURE-COMPLETE MAXILLARY | $3,122.00 | $900.00 | $2,222.00 | |
| D5864 | OVERDENTURE-PARTIAL MAXILLARY | $3,029.00 | $900.00 | $2,129.00 | |
| D5865 | OVERDENTURE-COMPLETE MANDIBULAR | $3,122.00 | $850.00 | $2,272.00 | |
| D5866 | OVERDENTURE-PARTIAL MANDIBULAR | $2,950.00 | $850.00 | $2,100.00 | |
| D5867 | REPLACEMENT OF PRECISION ATTAC | $530.00 | $100.00 | $430.00 | |
| D5875 | MODIFICATION OF REMOVABLE PROSTHESIS FOLLOWING IMPLANT SURGERY | $574.00 | $100.00 | $474.00 | |
| D6010 | ENDOSTEAL IMPLANT | $2,671.00 | $1,200.00 | $1,471.00 | |
| D6012 | INTERIM IMPLANT | $2,199.00 | $1,200.00 | $999.00 | |
| D6040 | SUBPERIOSTEAL IMPLANT | $9,990.00 | $1,200.00 | $8,790.00 | |
| D6050 | TRANSOSSEOUS IMPLANT | $7,170.00 | $1,200.00 | $5,970.00 | |
| D6056 | PREFABRICATED ABUTMENT | $1,027.00 | $500.00 | $527.00 | |
| D6057 | CUSTOM ABUTMENT | $1,241.00 | $500.00 | $741.00 | |
| D6058 | ABUTMENT SUPPORTED PORC/CER CR | $1,987.00 | $750.00 | $1,237.00 | |
| D6059 | ABUTMENT SUPPORTED PORC/MET CR | $2,001.00 | $750.00 | $1,251.00 | |
| D6060 | ABUT SUPPORTED CRWN-BASE METAL | $1,835.00 | $750.00 | $1,085.00 | |
| D6061 | ABUTMENT SUPPORTED CROWN | $1,889.00 | $600.00 | $1,289.00 | |
| D6062 | ABUTMENT SUP CAST HIGH NOBEL | $1,941.00 | $750.00 | $1,191.00 | |
| D6063 | ABUTMENT SUPPORTED BASE METAL | $1,817.00 | $725.00 | $1,092.00 | |
| D6064 | ABUTMENT SUPP CAST NOBLE CR | $1,889.00 | $715.00 | $1,174.00 | |
| D6065 | IMPLANT SUPPORTED PORC/CER CR | $2,079.00 | $975.00 | $1,104.00 | |
| D6066 | IMPLANT SUP PORC/HIGH NOBEL | $2,121.00 | $975.00 | $1,146.00 | |
| D6067 | IMPLANT SUPP HIGH NOBLE METL | $2,148.00 | $750.00 | $1,398.00 | |
| D6068 | ABUT SUPPRT RETAINR-PORC/CERAMC FPD | $2,004.00 | $725.00 | $1,279.00 | |
| D6069 | ABUT SUPRTD RETNR-PORC FUSD MET FPD | $2,001.00 | $725.00 | $1,276.00 | |
| D6070 | ABUTMENT SUPPORTED CROWN-BASE METAL | $1,868.00 | $725.00 | $1,143.00 | |
| D6071 | ABUT SUPPORTED RETAINER PORCELN FUSED ME | $1,899.00 | $750.00 | $1,149.00 | |
| D6072 | ABUTMENT SUPPORTED RETAINER FOR CAST MET | $2,035.00 | $650.00 | $1,385.00 | |
| D6073 | ABUTMENT SUPPORTED CROWN-CAST METAL | $1,884.00 | $600.00 | $1,284.00 | |
| D6074 | ABUTMENT SUPPORTED CROWN-NOBLE METAL | $1,880.00 | $650.00 | $1,230.00 | |
| D6075 | IMPL SUPP RETAIN FOR CERAM FPD | $2,095.00 | $700.00 | $1,395.00 | |
| D6076 | IMPL SUPP RETAIN FOR PORC FPD | $2,123.00 | $685.00 | $1,438.00 | |
| D6077 | IMPL SUPP RETAIN FOR TITAN FPD | $2,135.00 | $675.00 | $1,460.00 | |
| D6080 | IMPLANT MAINTENANCE PROCEDURES | $404.00 | $75.00 | $329.00 | |
| D6090 | REPAIR IMPLANT, BY REPORT | $1,013.00 | $175.00 | $838.00 | |
| D6091 | REPLACEMENT OF PRECISION ATTAC | $803.00 | $250.00 | $553.00 | |
| D6092 | RCMNT IMP/ABUT SUPPORTED CRWN | $215.00 | $40.00 | $175.00 | |
| D6093 | RECEMENT IMPLANT/ABUTMENT SUPPORTED FIXED PARTIAL | $256.00 | $50.00 | $206.00 | |
| D6095 | REPAIR IMPLANT ABUTMENT BY REPORT | $1,001.00 | $175.00 | $826.00 | |
| D6100 | IMPLANT REMOVAL, BY REPORT | $1,014.00 | $200.00 | $814.00 | |
| D6104 | BONE GRAFT AT TIME OF IMPLANT PLACEMENT | $843.00 | $300.00 | $543.00 | |
| D6194 | ABUTMENT SUPPORTED RETAINER CROWN FOR FPD | $1,868.00 | $750.00 | $1,118.00 | |
| D6205 | PONTIC-INDIRECT COMPOSITE | $1,368.00 | $450.00 | $918.00 | |
| D6210 | PONTIC CAST GOLD | $1,576.00 | $500.00 | $1,076.00 | |
| D6211 | PONTIC-FULL CAST | $1,456.00 | $500.00 | $956.00 | |
| D6212 | PONTIC-FULL CAST NOBLE METAL | $1,501.00 | $500.00 | $1,001.00 | |
| D6214 | PONTIC-TITANIUM | $1,540.00 | $500.00 | $1,040.00 | |
| D6240 | PONTIC PORC FUSED TO METAL | $1,601.00 | $550.00 | $1,051.00 | |
| D6241 | PONTIC-PORC.FUSED TO BASE META | $1,468.00 | $525.00 | $943.00 | |
| D6242 | PONTIC-PORC.FUSED TO NOBLE MET | $1,534.00 | $525.00 | $1,009.00 | |
| D6245 | PONTIC-PORCELAIN/CERAMIC | $1,601.00 | $550.00 | $1,051.00 | |
| D6250 | PONTIC RESIN WITH METAL | $1,534.00 | $500.00 | $1,034.00 | |
| D6251 | PONTIC-RESIN WITH BASE METAL | $1,493.00 | $475.00 | $1,018.00 | |
| D6252 | PONTIC-RESIN WITH NOBLE METAL | $1,472.00 | $475.00 | $997.00 | |
| D6253 | PROVISIONAL PONTIC | $974.00 | $200.00 | $774.00 | |
| D6545 | MARYLAND BRIDGE RETAINER | $1,171.00 | $275.00 | $896.00 | |
| D6548 | RETAINER - PORCELN/CERAMIC RSN BONDED FI | $1,313.00 | $275.00 | $1,038.00 | |
| D6549 | RESIN RETAINER ? FOR RESIN BONDED FIXED PROSTHESIS | $1,187.00 | $275.00 | $912.00 | |
| D6600 | INLAY-PORCELAIN/CERAMIC,2 SURF | $1,354.00 | $425.00 | $929.00 | |
| D6601 | INLAY-PORCELAIN/CERAMIC,3 SURF | $1,437.00 | $500.00 | $937.00 | |
| D6602 | INLAY-CAST HIGH NOBLE 2 SURF | $1,374.00 | $350.00 | $1,024.00 | |
| D6603 | INLAY-CAST HIGH NOBLE 3 SURF | $1,442.00 | $375.00 | $1,067.00 | |
| D6604 | INLAY-CAST BASE METAL 2 SURF | $1,350.00 | $350.00 | $1,000.00 | |
| D6605 | INLAY-CAST BASE 3 SURF | $1,401.00 | $400.00 | $1,001.00 | |
| D6606 | INLAY-CAST NOBLE METAL 2 SURF | $1,368.00 | $350.00 | $1,018.00 | |
| D6607 | INLAY-CAST NOBLE METAL 3 SURF | $1,354.00 | $400.00 | $954.00 | |
| D6608 | ONLAY-PORCELAIN/CERAMIC 2 SURF | $1,468.00 | $400.00 | $1,068.00 | |
| D6609 | ONLAY-PORCELAIN/CERAMIC 2 SURF | $1,537.00 | $500.00 | $1,037.00 | |
| D6610 | ONLAY-CAST HIGH NOBLE 2 SURF | $1,494.00 | $400.00 | $1,094.00 | |
| D6611 | ONLAY-CAST HIGH NOBLE 3 SURF | $1,541.00 | $500.00 | $1,041.00 | |
| D6612 | ONLAY-CAST BASE METAL 2 SURF | $1,420.00 | $400.00 | $1,020.00 | |
| D6613 | ONLAY-CAST BASE METAL 3 SURF | $1,473.00 | $500.00 | $973.00 | |
| D6614 | ONLAY-CAST NOBLE METAL 2 SURF | $1,428.00 | $400.00 | $1,028.00 | |
| D6615 | ONLAY-CAST NOBLE METAL 3 SURF | $1,510.00 | $450.00 | $1,060.00 | |
| D6634 | ONLAY-TITANIUM | $1,534.00 | $400.00 | $1,134.00 | |
| D6710 | RETAINER CROWN-INDIRECT RESIN BASED COMPOSITE | $1,384.00 | $450.00 | $934.00 | |
| D6720 | ABUTMENT RESIN WITH METAL | $1,512.00 | $500.00 | $1,012.00 | |
| D6721 | ABUTMENT-RESIN WITH BASE METAL | $1,445.00 | $450.00 | $995.00 | |
| D6722 | ABUTMENT-RESIN WITH NOBLE META | $1,505.00 | $475.00 | $1,030.00 | |
| D6740 | ABUTMENT-PORCELAIN JACKET | $1,609.00 | $550.00 | $1,059.00 | |
| D6750 | ABUTMENT-PORC. FUSED TO METAL | $1,613.00 | $625.00 | $988.00 | |
| D6751 | ABUTMENT-PORC.FUSED TO BASE ME | $1,480.00 | $575.00 | $905.00 | |
| D6752 | ABUTMENT-PORC.FUSED TO NOBLE M | $1,534.00 | $625.00 | $909.00 | |
| D6780 | ABUTMENT-3/4 CAST | $1,534.00 | $580.00 | $954.00 | |
| D6781 | ABUTMENT-3/4 CAST METAL BASE | $1,473.00 | $500.00 | $973.00 | |
| D6782 | ABUTMENT-3/4 CAST NOBLE METAL | $1,513.00 | $500.00 | $1,013.00 | |
| D6783 | CROWN 3/4 PORCELAIN/CERAMIC | $1,540.00 | $500.00 | $1,040.00 | |
| D6790 | ABUTMENT FULL CAST METAL | $1,600.00 | $500.00 | $1,100.00 | |
| D6791 | ABUTMENT-FULL CAST BASE METAL | $1,454.00 | $475.00 | $979.00 | |
| D6792 | ABUTMENT-FULL CAST NOBLE METAL | $1,506.00 | $475.00 | $1,031.00 | |
| D6793 | PROVISIONAL RETAINER CROWN | $722.00 | $75.00 | $647.00 | |
| D6794 | CROWN-TITANIUM | $1,505.00 | $525.00 | $980.00 | |
| D6920 | CONNECTOR BAR | $1,426.00 | $300.00 | $1,126.00 | |
| D6930 | RECEMENT BRIDGE | $244.00 | $50.00 | $194.00 | |
| D6940 | STRESS BREAKER | $584.00 | $150.00 | $434.00 | |
| D6950 | PRECISION ATTACHMENT | $905.00 | $175.00 | $730.00 | |
| D6980 | FIXED PARTIAL DENTURE REPAIR NECESSITATED BY RESTO | $536.00 | $100.00 | $436.00 | |
| D7111 | EXTRACTION OF CORONAL REMAINS | $189.00 | $65.00 | $124.00 | |
| D7140 | EXTRACTION ERUPTED TOOTH OR EXPOSED ROOT | $254.00 | $70.00 | $184.00 | |
| D7210 | SURGICAL EXTRACTION | $392.00 | $100.00 | $292.00 | |
| D7220 | REMOVAL-SOFT TISSUE IMPACTED | $447.00 | $150.00 | $297.00 | |
| D7230 | REMOVAL-PARTIAL BONY IMPACTED | $558.00 | $200.00 | $358.00 | |
| D7240 | REMOVAL-COMPLETE BONY IMPACTED | $679.00 | $275.00 | $404.00 | |
| D7241 | COMPLETE BONY IMPACT-W/COMP | $793.00 | $300.00 | $493.00 | |
| D7250 | REMOVAL OF RESIDUAL ROOTS | $427.00 | $110.00 | $317.00 | |
| D7260 | CLOSURE OF ORAL ANTRAL FISTULA | $1,358.00 | $450.00 | $908.00 | |
| D7261 | PRIMARY CLOSURE OF A SINUS PERFORATION | $1,039.00 | $450.00 | $589.00 | |
| D7261 | PRIMARY CLOSURE SINUS PERFORATION | $1,039.00 | $450.00 | $589.00 | |
| D7270 | TOOTH REIMPLANTATION | $774.00 | $200.00 | $574.00 | |
| D7272 | TOOTH TRANSPLANTATION | $1,021.00 | $200.00 | $821.00 | |
| D7280 | SURG.EXP-IMP/UNERUP(FOR ORTHO) | $663.00 | $200.00 | $463.00 | |
| D7282 | Mobilization of Tooth to Aid Eruption | $667.00 | $200.00 | $467.00 | |
| D7283 | DEVICE TO AID ERUPTION OF IMP | $656.00 | $75.00 | $581.00 | |
| D7285 | BIOPSY HARD TISSUE | $600.00 | $150.00 | $450.00 | |
| D7286 | BIOPSY SOFT TISSUE | $463.00 | $125.00 | $338.00 | |
| D7288 | BRUSH BIOPSY | $267.00 | $40.00 | $227.00 | |
| D7290 | SURGICAL REPOSITIONING OF TEET | $667.00 | $200.00 | $467.00 | |
| D7291 | TRANSSEPTAL FIBEROTOMY | $420.00 | $50.00 | $370.00 | |
| D7310 | ALVEOLECTOMY | $419.00 | $140.00 | $279.00 | |
| D7311 | ALVEOLOPLASTY W/EXT PER QD-1 TO 3 TEETH | $424.00 | $90.00 | $334.00 | |
| D7320 | ALVEOLECTOMY-PER QUAD.-NO EXT | $616.00 | $140.00 | $476.00 | |
| D7321 | ALVEOLECTOMY NO EXT--1 TO 3 TEETH | $582.00 | $90.00 | $492.00 | |
| D7340 | VESTIBULOPLASTY-SECOND EPITH | $1,618.00 | $500.00 | $1,118.00 | |
| D7350 | VESTIBULOPLASTY-INCL GRAFTS | $3,288.00 | $1,000.00 | $2,288.00 | |
| D7410 | EXCISION-LESION-UP TO 1.25 CM | $572.00 | $125.00 | $447.00 | |
| D7411 | EXCISION-LESION >1.25 CM | $834.00 | $200.00 | $634.00 | |
| D7413 | EXCISION OF MALIGNANT LESION UP TO 1.25 CM | $1,001.00 | $125.00 | $876.00 | |
| D7414 | EXCISION OF MALIGNANT LESION GREATER THAN 1.25 CM | $1,534.00 | $200.00 | $1,334.00 | |
| D7440 | EXCISION OF MALIGNANT TUMOR ? LESION DIAMETER UP T | $1,034.00 | $125.00 | $909.00 | |
| D7441 | EXCISION MALIGNANT TUMOR >1.25 | $1,771.00 | $200.00 | $1,571.00 | |
| D7450 | CYST/TUMOR REMOVAL < 1.25 CM | $835.00 | $125.00 | $710.00 | |
| D7451 | CYST OR TUMOR REM- > 1.25 CM | $1,098.00 | $200.00 | $898.00 | |
| D7460 | CYST REMOVAL (NONODONT) <1.25 | $773.00 | $125.00 | $648.00 | |
| D7461 | REMOVAL OF NON ODONT >1.25 | $1,191.00 | $200.00 | $991.00 | |
| D7472 | REMOVAL OF TORUS PALANTINUS | $1,174.00 | $250.00 | $924.00 | |
| D7473 | REMOVAL OF TORUS MANDIBULARIS | $1,101.00 | $250.00 | $851.00 | |
| D7485 | SURG REDUCT OF OSS TUBEROSITY | $1,001.00 | $150.00 | $851.00 | |
| D7510 | INCISION AND DRAINAGE | $339.00 | $75.00 | $264.00 | |
| D7511 | INCISION & DRAINAGE-INTRAORAL | $490.00 | $100.00 | $390.00 | |
| D7520 | INCISION & DRAINAGE EXTRAORAL | $634.00 | $75.00 | $559.00 | |
| D7521 | INCISION & DRAINAGE-EXTRAORAL | $865.00 | $100.00 | $765.00 | |
| D7950 | OSSEOUS GRAFT-MANDIBLE OR MAXILLA | $3,593.00 | $800.00 | $2,793.00 | |
| D7951 | SINUS AUGMENTATION WITH BONE | $3,919.00 | $800.00 | $3,119.00 | |
| D7952 | SINUS AUGMENTATION VIA A VERTICAL APPROACH | $1,988.00 | $800.00 | $1,188.00 | |
| D7953 | BONE GRAFT-RIDGE PRESERVATION | $787.00 | $300.00 | $487.00 | |
| D7961 | BUCCAL/LABIAL FRENECTOMY (FRENULECTOMY) | $0.00 | $150.00 | - | |
| D7962 | LINGUAL FRENECTOMY (FRENULECTOMY) | $0.00 | $150.00 | - | |
| D7963 | FRENULOPLASTY | $690.00 | $100.00 | $590.00 | |
| D7970 | EXCISION-HYPERPLASTIC TISSUE | $700.00 | $175.00 | $525.00 | |
| D7971 | EXCISION-PERICORONAL GINGIVA | $366.00 | $50.00 | $316.00 | |
| D7972 | SURG REDUCT FIBROUS TUBEROSITY | $979.00 | $150.00 | $829.00 | |
| D8010 | LIMITED ORTHO TX PRIMARY DENTITION | $2,967.00 | $2,000.00 | $967.00 | |
| D8020 | LIMITED ORTHO TX OF TRANSITIONAL DENTITION | $3,296.00 | $2,000.00 | $1,296.00 | |
| D8030 | LIMITED ORTHODONTIC TX ADOLESCENT DENTITION | $3,936.00 | $2,000.00 | $1,936.00 | |
| D8040 | LIMITED ORTHO TREATMENT OF ADULT DENTITION | $4,240.00 | $2,000.00 | $2,240.00 | |
| D8050 | INTERCEPTIVE ORTHODONTIC TX PRIM | $3,560.00 | $2,000.00 | $1,560.00 | |
| D8060 | INTERCEPTIVE ORTHO TX TRANSITIONAL DENTITION | $3,736.00 | $2,000.00 | $1,736.00 | |