| Basic |
| D2110 |
Amalgam-1 surface, primary |
105.00 |
| D2120 |
Amalgam-2 Surface, primary |
138.00 |
| D2140 |
Amalgam-1 surf prim/perm |
133.00 |
| D2150 |
Amalgam-2 surf. prim/perm |
173.00 |
| D2160 |
Amalgam-3 surf. prim/perm |
205.00 |
| D2161 |
Amalgam-4+ surf. prim/perm |
232.00 |
| D2330 |
Resin-one surface, anterior |
200.00 |
| D2331 |
Resin-two surfaces, anterior |
240.00 |
| D2332 |
Resin-three surfaces anterior |
243.00 |
| D2335 |
Resin-4+ w/incis angle-anterior |
299.00 |
| D2336 |
Compos resin crwn-anterior-prim |
7.00 |
| D2380 |
Resin-1 surface, poster-primary |
121.00 |
| D2381 |
Resin-2 surface, poster-primary |
144.00 |
| D2382 |
Resin-3 surface, poster-primary |
206.00 |
| D2385 |
Resin-1 surface, post-permanent |
6.00 |
| D2386 |
Resin-2 surface, post-permanent |
6.00 |
| D2387 |
Resin-three or more surf pospm |
6.00 |
| D2390 |
Resin composite crown, anterior |
419.00 |
| D2391 |
Resin composite-1s, posterior |
221.00 |
| D2392 |
Resin composite-2s, posterior |
269.00 |
| D2393 |
Resin composite-3s, posterior |
310.00 |
| D2394 |
Resin composite-4+s posterior |
494.00 |
| D5290 |
Prosthodontic Impression |
7.00 |
| D5291 |
Prosthodontic Preparation |
7.00 |
| D5292 |
Prosthodontic Delivery |
7.00 |
| D5410 |
Adjust complete denture-maxil |
86.00 |
| D5411 |
Adjust complete denture-mand |
84.00 |
| D5421 |
Adjust partial denture-maxil |
84.00 |
| D5422 |
Adjust partial denture-mand |
85.00 |
| D5510 |
Repair complete denture base |
205.00 |
| D5520 |
Replace tooth (per tooth) |
175.00 |
| D5610 |
Repair resin denture base |
193.00 |
| D5620 |
Repair cast framework |
275.00 |
| D5630 |
Repair or replace broken clasp |
251.00 |
| D5640 |
Replace broken teeth-per tooth |
175.00 |
| D5650 |
Add tooth to exist part denture |
250.00 |
| D5660 |
Add clasp, exist part denture |
255.00 |
| D5670 |
Replace all th&acrylic-maxil |
776.00 |
| D5671 |
Replace all th&acrylic-mand |
699.00 |
| D5710 |
Rebase complete maxil denture |
554.00 |
| D5711 |
Rebase complete mand denture |
545.00 |
| D5720 |
Rebase maxil partial denture |
526.00 |
| D5721 |
Rebase mand partial denture |
524.00 |
| D5730 |
Reline complete maxil-chairside |
352.00 |
| D5731 |
Reline complete mand-chairside |
350.00 |
| D5740 |
Reline maxil partial-chairside |
349.00 |
| D5741 |
Reline mand partial-chairside |
349.00 |
| D5750 |
Reline complete maxillary (lab) |
445.00 |
| D5751 |
Reline complete mand(lab) |
445.00 |
| D5760 |
Reline maxillary partial(lab) |
442.00 |
| D5761 |
Reline mandibular partial (lab) |
442.00 |
| D5850 |
Tissue condition, maxillary |
191.00 |
| D5851 |
Tissue condition, mandibular |
191.00 |
| Preventive |
| D0120 |
Periodic oral evaluation |
60.00 |
| D0140 |
Limited oral evaluation |
88.00 |
| D0145 |
Oral evaluation < 3 yrs of age |
89.00 |
| D0150 |
Comp oral eval-new/estab pat |
93.00 |
| D0160 |
Detail/extensive oral eval, B/R |
137.00 |
| D0170 |
Limited re-evaluation estab pat |
72.00 |
| D0180 |
Comprehensive perio evaluation |
104.00 |
| D0210 |
Intraoral-complete series (bw) |
140.00 |
| D0220 |
Intraoral-periapical-1st film |
33.00 |
| D0230 |
Intraoral-periapical-each add'l |
29.00 |
| D0270 |
Bitewing-single film |
30.00 |
| D0272 |
Bitewings-two films |
45.00 |
| D0273 |
Bitewings-three films |
55.00 |
| D0274 |
Bitewings-four films |
78.00 |
| D0277 |
Vertical bitewings-7 to 8 films |
99.00 |
| D0330 |
Panoramic film |
140.00 |
| D0340 |
Cephalometric film |
125.00 |
| D0350 |
Oral/Facial Photographic Images |
69.00 |
| D0360 |
Cone beam ct-craniofacial data |
549.00 |
| D0362 |
Cone beam-2D multi img reconst |
341.00 |
| D0363 |
Cone beam-3D multi img reconst |
373.00 |
| D0460 |
Pulp vitality tests |
59.00 |
| D0470 |
Diagnostic casts |
450.00 |
| D0471 |
Diagnostic photographs |
24.00 |
| D0486 |
Brush biopsy sample, exam, report |
1.00 |
| D0502 |
Other oral path procdure, B/R |
7.00 |
| D0999 |
Unspecified diag procedure, B/R |
1.00 |
| D1110 |
Prophylaxis-adult |
98.00 |
| D1120 |
Prophylaxis-child |
71.00 |
| D1201 |
Prophylaxis with fluoride-child |
105.00 |
| D1203 |
Fluoride -child |
47.00 |
| D1204 |
Fluoride -Adult |
38.00 |
| D1205 |
Prophylaxis with fluoride-adult |
130.00 |
| D1206 |
TopFlrideVARNISH, decay prevent |
47.00 |
| D1208 |
TopFlApp- NON VARNISH |
38.00 |
| D1310 |
Oral Cancer Screening |
0.00 |
| D1320 |
Tobacco counseling |
79.00 |
| D1330 |
Oral hygiene instruction |
0.00 |
| D1351 |
Sealant-per tooth |
55.00 |
| D1352 |
Preventive Restoration, Perm Th |
0.00 |
| D1510 |
Space maint-fixed-unilateral |
317.00 |
| D1515 |
Space maint-fixed-bilateral |
458.00 |
| D1520 |
Space maint-remov-unilateral |
364.00 |
| D1525 |
Space maint-remov-bilateral |
461.00 |
| D1550 |
Recementation of space maint |
78.00 |
| D1555 |
Removal of fixed space maint |
75.00 |
| Major |
| D2510 |
Inlay-metallic-one surface |
895.00 |
| D2520 |
Inlay-metallic-two surfaces |
1,085.00 |
| D2530 |
Inlay-metallic-three + surfaces |
1,094.00 |
| D2542 |
Onlay-metallic-two surfaces |
1,120.00 |
| D2543 |
Onlay-metallic-three surfaces |
1,186.00 |
| D2544 |
Onlay-metallic-four + surfaces |
1,324.00 |
| D2610 |
Inlay-porcel/ceramic-1 surface |
1,370.00 |
| D2620 |
Inlay-porcel/ceramic-2 surface |
1,370.00 |
| D2630 |
Inlay-porcel/ceramic-3+ surface |
1,370.00 |
| D2642 |
Onlay-porcel/ceramic-2 surface |
1,370.00 |
| D2643 |
Onlay-porcel/ceram-3 surface |
1,370.00 |
| D2644 |
Onlay-porcel/ceram-4 + surface |
1,370.00 |
| D2650 |
Inlay-resin based composite-1s |
1,370.00 |
| D2651 |
Inlay-resin based composite-2s |
1,370.00 |
| D2652 |
Inlay-resin based composite-3+s |
1,370.00 |
| D2662 |
Onlay-resin based composite-2s |
1,370.00 |
| D2663 |
Onlay-resin based composite-3s |
1,370.00 |
| D2664 |
Onlay-resin based composite-4+s |
1,370.00 |
| D2710 |
Crown-resin composite(indirect) |
1,370.00 |
| D2712 |
Crown-3/4 resin-based comp-ind |
1,370.00 |
| D2720 |
Crown-resin w/high noble metal |
1,370.00 |
| D2721 |
Crown-resin w/ most base metal |
1,370.00 |
| D2722 |
Crown-resin with noble metal |
1,370.00 |
| D2740 |
Crown-porcelain/ceramic substr |
1,370.00 |
| D2750 |
Crown-porc fuse high noble mtl |
1,370.00 |
| D2751 |
Crown-porc fused to base metal |
1,370.00 |
| D2752 |
Crown-porc fused noble metal |
1,370.00 |
| D2780 |
3/4cast High Noble Metal |
1,370.00 |
| D2781 |
Crown-3/4 cast most base metal |
1,370.00 |
| D2782 |
Crown-3/4 cast noble metal |
1,370.00 |
| D2783 |
Crown-3/4 porcelain/ceramic |
1,370.00 |
| D2790 |
Crown-full cast high noble mtl |
1,370.00 |
| D2791 |
Crown-full cast base metal |
1,370.00 |
| D2792 |
Crown-full cast noble metal |
1,370.00 |
| D2910 |
Recement inlay/onlay/partial |
115.00 |
| D2915 |
Recemnt cast or prefab pst/cor |
1.00 |
| D2920 |
Recement crown |
127.00 |
| D2929 |
Prefab Porcelain/C Crown-Prim |
0.00 |
| D2930 |
Prefab stain stell crn-primary |
328.00 |
| D2931 |
Prefab stain steel crown-perm |
366.00 |
| D2932 |
Prefabricated resin crown |
332.00 |
| D2933 |
Prefab stl crown w/resin window |
1.00 |
| D2934 |
Prefb esth ctd stnl stl crn-prm |
1.00 |
| D2940 |
Sedative filling |
115.00 |
| D2950 |
Crown buildup, includ any pins |
266.00 |
| D2951 |
Pin retention-/tooth, (+rest) |
65.00 |
| D2952 |
Cast post &core in add to crown |
417.00 |
| D2953 |
Each add'l cast post-same tooth |
1.00 |
| D2954 |
Prefab post&core in add to crn |
342.00 |
| D2955 |
Post removal (not with endo) |
309.00 |
| D2957 |
Each + prefab post-same tooth |
1.00 |
| D2960 |
Labial veneer(laminate)-chairsd |
631.00 |
| D2961 |
Labial veneer (resin lamin)-lab |
994.00 |
| D2962 |
Labial veneer (porceln lam)-lab |
1,370.00 |
| D2996 |
Place Temporary Crown |
0.00 |
| D2997 |
Place Permanent Crown |
1.00 |
| D2998 |
Remove Temporary Crown |
1.00 |
| D2999 |
Unspecif restoratie proced B/R |
1.00 |
| D3110 |
Pulp cap-direct, (+rest) |
85.00 |
| D3120 |
Pulp cap-indirect, (+rest) |
85.00 |
| D3220 |
Therapeutic pulpotomy(exc rest) |
191.00 |
| D3230 |
Pulpal therapy-anterior, primary |
1.00 |
| D3240 |
Pulpal therapy-posterior, prim |
1.00 |
| D3305 |
Initial Root Canal Therapy |
1.00 |
| D3310 |
Root Canal Therapy - anterior |
403.00 |
| D3330 |
Root Canal Therapy-molar |
959.00 |
| D3331 |
Treatmnt of root canal obstruct |
448.00 |
| D4210 |
Gingivectomy-4+ per quadrant |
850.00 |
| D4211 |
Gingivectomy-1-3 contig th/quad |
305.00 |
| D4212 |
Gingivectomy-Access/Restoration |
280.00 |
| D4220 |
Gingival Curretage Quad |
0.00 |
| D4240 |
Ging flap, root pln,4+ per quad |
905.00 |
| D4241 |
Ging flap rt pln 1-3 cntg th/qu |
664.00 |
| D4245 |
Apically positioned flap |
762.00 |
| D4249 |
Clinic crown lengthen-hard tiss |
869.00 |
| D4260 |
Osseous surgery-4+ per quad |
1,310.00 |
| D4261 |
Osseous surg- 1-3 contg th/quad |
987.00 |
| D4263 |
Bone replace graft-1st site/qu |
690.00 |
| D4264 |
Bone replace graft-each add/qu |
680.00 |
| D4265 |
Bio mat, sft&osseous tiss regen |
512.00 |
| D4266 |
Guided tiss regen-resorb-per |
512.00 |
| D4267 |
Guided tiss regen-nonresorb-per |
913.00 |
| D4268 |
Surg revision proc, per tooth |
764.00 |
| D4270 |
Pedicle soft tissue graft proc |
924.00 |
| D4271 |
Free soft tissue graft proced |
0.00 |
| D4273 |
Subepithelial con tis graft/th |
1,188.00 |
| D4274 |
Distal/proximal wedge procedure |
636.00 |
| D4275 |
Soft tissue allograft |
1,078.00 |
| D4276 |
Comb cnct tiss&dbl pedicle grft |
1,302.00 |
| D4277 |
Soft Tissue Graft, 1st Tooth |
0.00 |
| D4278 |
Soft Tissue Graft, Each Add'l |
0.00 |
| D4320 |
Provisional splinting-itracor |
489.00 |
| D4321 |
Provisional splinting-extracor |
489.00 |
| D4341 |
Periodontal Therapy-Quad |
273.00 |
| D4342 |
Periodontal Therapy |
175.00 |
| D4355 |
Full Mouth Debridement |
171.00 |
| D4381 |
Local delivery-ARESTIN |
153.00 |
| D4910 |
Periodontal maintenance |
146.00 |
| D4920 |
Unscheduled dressing change |
94.00 |
| D4999 |
Unspecified perio proced, B/R |
100.00 |
| D5110 |
Complete denture - maxillary |
1,970.00 |
| D5120 |
Complete denture - mandibular |
1,970.00 |
| D5130 |
Immediate denture - maxillary |
1,724.00 |
| D5140 |
Immediate denture - mandibular |
1,724.00 |
| D5211 |
Maxillary partial - resin base |
1,258.00 |
| D5212 |
Mandibular partial - resin base |
1,258.00 |
| D5213 |
Maxil partial-metal Base W/sdls |
2,135.00 |
| D5214 |
Mand partial-metal base w/sdls |
1,704.00 |
| D5810 |
Interim comp denture (maxil) |
867.00 |
| D5811 |
Interim comp denture (mand) |
867.00 |
| D5820 |
Interim partial denture (maxil) |
652.00 |
| D5821 |
Interim partial denture (mand). 652 |
0.00 |
| D5860 |
Overdenture-complete, B/R |
2,559.00 |
| D5861 |
Overdenture-partial, by report |
2,223.00 |
| D5862 |
Precision attachment, B/R |
670.00 |
| D5867 |
Replcmt prec attachmt-part/full |
359.00 |
| D5982 |
Surgical stent |
429.00 |
| D5999 |
Somnomed/SilentNite Impress |
2,000.00 |
| D6010 |
Surg place implant: endosteal |
2,042.00 |
| D6012 |
Plcmnt of intrm imp: endosteal |
1.00 |
| D6020 |
Abut place/subst:endost implant |
763.00 |
| D6040 |
Surgic place: eposteal implant |
2,119.00 |
| D6050 |
Surg place: transosteal implant |
1,074.00 |
| D6051 |
Interim Abutment |
0.00 |
| D6056 |
Prefab abutment-incl placement |
825.00 |
| D6057 |
Custom abutment-incl placement |
928.00 |
| D6058 |
Abut Supp Porcelain/ceramic Crn |
1,498.00 |
| D6059 |
Abut porc fused to hi nbl metal |
1,526.00 |
| D6060 |
Abtmt supp porc fused-base metl |
1,329.00 |
| D6061 |
Abut supported porc nbl metal |
1,405.00 |
| D6064 |
Abtmt supp cast mtl crown-noble |
1,489.00 |
| D6065 |
Implant supp porc/cer crown |
1,578.00 |
| D6066 |
Implant supported PFM |
1,578.00 |
| D6067 |
Implant supported metal crown |
1,429.00 |
| D6068 |
Abut supported retained FPD |
1,543.00 |
| D6069 |
Abutment retainer PorcHnM FPD |
1,458.00 |
| D6070 |
Abut Retainer Porc BaseMtl |
1,229.00 |
| D6071 |
Abut sup ret-porc fsd mtl FPDno |
1,367.00 |
| D6072 |
Abut sup ret porc FLcNM FPD |
1,416.00 |
| D6073 |
Abut sup ret-cast mtl FPD-base |
1,339.00 |
| D6074 |
Abt Ret Noble Metal |
1,344.00 |
| D6075 |
Implant supp ret-ceramic FPD |
1,609.00 |
| D6076 |
Implnt supp ret-prc fuse mtlFPD |
1,624.00 |
| D6077 |
Implant sup retained FPD |
10,539.00 |
| D6100 |
Implant removal, by report |
727.00 |
| D6101 |
Debride Peri-Implant Defect |
0.00 |
| D6102 |
Debride/Oss Peri-Implant Defect |
0.00 |
| D6103 |
Bone Graft Rep Peri-Imp Defect |
0.00 |
| D6104 |
Bone Graft, Implant Placement |
0.00 |
| D6190 |
Radiograph/surg impl index B/R |
400.00 |
| D6199 |
Unspecified implant proced, B/R |
384.00 |
| D6205 |
Pontic-indirect res based comp |
797.00 |
| D6210 |
Pontic-cast high noble metal |
1,370.00 |
| D6211 |
Pontic-cast pred base |
1,130.00 |
| D6212 |
Pontic-cast noble metal |
1,370.00 |
| D6214 |
Pontic-titanium |
1,370.00 |
| D6240 |
Pontic-porcelain fused to hnob |
1,370.00 |
| D6241 |
Pontic-porcelain fused to base |
1,130.00 |
| D6242 |
Pontic-porcelain fused to nobl |
1,130.00 |
| D6245 |
Pontic-porcelain/ceramic |
1,370.00 |
| D6250 |
Pontic-resin w/ high noble met |
1,130.00 |
| D6251 |
Pontic-resin w/predomnt base |
1,130.00 |
| D6252 |
Pontic-resin with noble metal |
1,130.00 |
| D6253 |
Provisional pontic |
461.00 |
| D6254 |
Interim Pontic |
461.00 |
| D6480 |
Maryland bridge repl 1 tooth |
7.00 |
| D6520 |
Inlay-metallic-two surfaces |
7.00 |
| D6530 |
Inlay-metallic-three+ surfaces |
7.00 |
| D6543 |
Onlay-metallic-three surfaces |
1,098.00 |
| D6544 |
Onlay-metallic-four + surfaces |
1,098.00 |
| D6545 |
Retainer-cast for resin bonded |
759.00 |
| D6548 |
Ret-porc/cer-resin bnd fxd pros |
6.00 |
| D6600 |
Inlay-porcelain/ceramic, 2 surf |
6.00 |
| D6601 |
Inlay-porcelain/ceramic, 3+surf |
6.00 |
| D6602 |
Inlay-cast high noble met,2urf |
6.00 |
| D6603 |
Inlay-cast high nob met, 3+surf |
6.00 |
| D6604 |
Inlay-cast predomnt base, 2surf |
6.00 |
| D6605 |
Inlay-cast predomnt base,3+surf |
6.00 |
| D6606 |
Inlay-cast noble metal, 2surf |
6.00 |
| D6607 |
Inlay-cast noble metal, 3+ surf |
6.00 |
| D6608 |
Onlay-porcelain/ceramic, 2 surf |
1,370.00 |
| D6609 |
Onlay-porcelain/ceramic, 3+surf |
6.00 |
| D6610 |
Onlay-cast high noble met,2surf |
6.00 |
| D6611 |
Onlay-cast high nob met, 3+surf |
6.00 |
| D6612 |
Onlay-cast predomnt base, 2surf |
6.00 |
| D6613 |
Onlay-cast predomnt base,3+surf |
6.00 |
| D6614 |
Onlay-cast noble metal, 2 surf |
6.00 |
| D6615 |
Onlay-cast noble metal, 3+ surf |
6.00 |
| D6624 |
Inlay-titanium |
4.00 |
| D6634 |
Onlay-titanium |
4.00 |
| D6710 |
Retainer crn-indir res-bas comp |
1,370.00 |
| D6720 |
Retainer crn-res w/ hi nob met |
1,222.00 |
| D6721 |
Retainer crn-resin w/ base met |
1,222.00 |
| D6722 |
Retainer crn-resin w/ nob met |
1,222.00 |
| D6740 |
Crown-porcelain/ceramic abut |
1,370.00 |
| D6750 |
Retainer crn-porc fused-hi nob |
1,370.00 |
| D6751 |
Retainer crn-porc fuse-base met |
1,370.00 |
| D6752 |
Retainer crn-porc fused-nob met |
1,370.00 |
| D6780 |
Retainer crn-3/4 cast h nob met |
1,370.00 |
| D6781 |
Crown-3/4 cast most base metal |
1,370.00 |
| D6782 |
Crown-3/4 cast noble metal |
1,370.00 |
| D6783 |
Crown-3/4 porcelain/ceramic |
1,370.00 |
| D6790 |
Retainer crn-full cast hi nob |
1,370.00 |
| D6791 |
retainer crn-full cast base |
1,370.00 |
| D6792 |
Retainer crn-full cast nob met |
1,370.00 |
| D6793 |
Provisional retainer crown |
440.00 |
| D6794 |
Retainer crown-titanium |
1,370.00 |
| D6795 |
Interim Retainer Crown |
440.00 |
| D6920 |
Connector bar |
1,224.00 |
| D6930 |
Recement fixed partial denture |
162.00 |
| D6940 |
Stress breaker |
379.00 |
| D6950 |
Precision attachment |
588.00 |
| D6970 |
Cast post/core, +brdg retainer |
412.00 |
| D6971 |
Cast post/part of brdg retainer |
412.00 |
| D6972 |
Prefab post/core+ brdg retainer |
352.00 |
| D6973 |
Core buildup for retain,inc pin |
244.00 |
| D6975 |
Coping-metal |
782.00 |
| D6976 |
Each add'l cast post-same tooth |
297.00 |
| D6977 |
Each + prefab post-same tooth |
157.00 |
| D6980 |
Fixed partial dent. repair, B/R |
327.00 |
| D6985 |
Pediatric part'l denture, fixed |
612.00 |
| D6999 |
Unspec fixed prosth proced, B/R |
284.00 |
