Fee Schedule

Code Description Price
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