D0120 Periodic Exam 28.00 D0140 Limited Oral Evaluation Problem Focused 42.00 D0145 Oral Evaluation for a Patient Under Three Years of Age and Counseling with Primary Caregiver 38.00 D0150 Comprehensive Oral Exam New or Established Patient 43.00 D0170 Re-Evaluation - Limited, Problem Focused - Established Patient; Not Post-Operative Visit) 30.00 D0180 Comprehensive Periodontal Evaluation New or Established Patient 38.00 D0210 Intraoral-Complete Series 81.00 D0220 Intraoral-Periapical - First Film 15.00 D0230 Intraoral-Periapical - Each Additional Film 10.00 D0240 Intraoral-Occlusal View, Maxillary or Mandibular, Each 23.00 D0270 Bitewings, One Film 16.00 D0272 Bitewings, Two Films 21.00 D0273 Bitewings, Three Films 26.00 D0274 Bitewings, Four Films 33.00 D0277 Vertical Bitewings 7-8 Films 54.00 D0330 Panoramic Film 64.00 D0415 Collection Of Microorganisms For Culture And Sensitivity 16.00 D1110 Prophylaxis Adult 65.00 D1120 Prophylaxis - Children 42.00 D1201 Topical Application of Fluoride Including Prophylaxis - Children 55.00 D1203 Topical Application of Fluoride Excluding Prophylaxis - Children 20.00 D1205 Topical Application of Fluoride Including Prophylaxis - Adult 72.00 D1351 Sealant 1st and 2nd Molars 29.00 D1510 Space Maintainer - Fixed-Unilateral Band Type 187.00 D1515 Space Maintainer Fixed-Lingual or Palatal Bar Type 231.00 D1550 Recementation Space Maintainer 35.00 D1555 Removal of Fixed Space Maintainer 50.00 D2140 Amalgam Restoration - One Surface Primary 66.00 D2140 Amalgam - One Surface Permanent 75.00 D2150 Amalgam Restoration - Two Surfaces Primary 84.00 D2150 Amalgam Restoration - Two Surfaces Permanent 91.00 D2160 Amalgam Restoration - Three Surfaces Primary 100.00 D2160 Amalgam Restoration - Three Surfaces Permanent 115.00 D2161 Amalgam Restoration - Four or More Surfaces Primary 117.00 D2161 Amalgam Restoration - Four or More Surfaces Permanent 124.00 D2330 Anterior Resin Restoration - One Surface 83.00 D2331 Anterior Resin Restoration - Two Surfaces 110.00 D2332 Anterior Resin Restoration - Three Surfaces 135.00 D2335 Anterior Resin Restoration - Four or More Surfaces or Incisal Angle 145.00 D2391* Resin-Based Composite - One Surface, Posterior - Primary 81.00 D2391* Resin-Based Composite - One Surface, Posterior - Permanent 86.00 D2392* Resin-Based Composite - Two Surfaces, Posterior - Primary 115.00 D2392* Resin-Based Composite - Two Surfaces, Posterior - Permanent 121.00 D2393* Resin-Based Composite - Three Surfaces, Posterior - Primary 139.00 D2393* Resin-Based Composite - Three Surfaces, Posterior - Permanent 147.00 D2394* Resin-Based Composite Four or More Surfaces, Posterior - Primary 165.00 D2394* Resin-Based Composite Four or More Surfaces, Posterior - Permanent 176.00 D2510 Inlay - Metallic - One Surface 432.00 D2520 Inlay - Metallic - Two Surfaces 513.00 D2530 Inlay - Metallic - Three or More Surfaces 550.00 D2542 Onlay - Metallic Two Surfaces 574.00 D2543 Onlay Metallic Three Surfaces 601.00 D2544 Onlay Metallic Four or More Surfaces 626.00 D2610 Inlay Porcelain/Ceramic One Surface 527.00 D2620 Inlay Porcelain/Ceramic Two Surfaces 557.00 D2630 Inlay Porcelain/Ceramic Three or More Surfaces 593.00 D2642 Onlay Porcelain/Ceramic Two Surfaces 574.00 D2643 Onlay Porcelain/Ceramic Three Surfaces 601.00 D2644 Onlay Porcelain/Ceramic Four or More Surfaces 626.00 D2740 Porcelain Crown (Perm Processed) 740.00 D2750 Porcelain/High Noble Metal Crown 740.00 D2751 Porcelain/Predominantely Base Metal Crown 740.00 D2752 Porcelain/Noble Metal Crown 740.00 * Posterior composites may be downgraded to the corresponding amalgam fee. Please refer to the member s benefit schedule. Page 1
D2780 ¾ Cast High Noble Metal 740.00 D2781 ¾ Cast Predominantly Base Metal 740.00 D2782 ¾ Cast Noble Metal 740.00 D2783 ¾ Porcelain/Ceramic 740.00 D2790 Full Cast/High Noble Metal Crown 740.00 D2791 Full Cast Predominantly Base Metal Crown 740.00 D2792 Full Cast Noble Metal Crown 740.00 D2910 Inlay ( Recementation) 49.00 D2920 Crown ( Recementation ) 46.00 D2930 Stainless Steel Crown ( Primary ) Prefabricated 155.00 D2931 Stainless Steel Crown ( Permanent ) Prefabricated 168.00 D2932 Resin Crown Prefabricated 87.00 D2933 Stainless Steel Crown With Resin Window Prefabricated 119.00 D2940 Sedative Fillings 55.00 D2951 Pin Retention Per Tooth, When Necessary and Final Restore is Amalgam, Plastic or Resin. Fee Should be for Pin Retention Only. Restoration Should be Listed Separately 28.00 D2952 Post and Core in Addition to Crown, Indirectly Fabricated Post and Core are Custom Fabricated as a Single Unit 242.00 D2954 Prefabricated Post and Core in Addition to Crown 155.00 D2960 Labial Veneer (Laminate) - Chair Side 234.00 D2961 Labial Veneer (Resin Laminate) - Laboratory 348.00 D2962 Labial Veneer (Porcelain Laminate) - Laboratory 520.00 D2980 Crown Repair - by Report 115.00 D3110 Direct Pulp Capping 36.00 D3120 Indirect Pulp Capping ( Recalcification ) Including Temporary Restoration 38.00 D3220 Therapeutic Pulpotomy ( in Addition to Restoration ) Per Treatment 80.00 D3221 Pulpal Debridement - Primary and Permanent Teeth 55.00 D3310 Root Canal Anterior 450.00 D3320 Root Canal Bicuspid 550.00 D3330 Root Canal Molar ( Three Canals ) 700.00 D3340 Root Canal Molar ( Four Canals ) 733.00 D3346 Re-Treatment of Previous Root Canal Anterior 586.00 D3347 Re-Treatment of Previous Root Canal Bicuspid 664.00 D3348 Re-Treatment of Previous Root Canal Molar ( Three Canals ) 806.00 D3351 Apexification/Recalcification, Initial Visit 247.00 D3352 Apexification/Recalcification, Interim Visits 99.00 D3353 Apexification/Recalcification, Final Visit 335.00 D3410 Apicoectomy/Anterior ( Separate Procedure ) 398.00 D3421 Apicoectomy/Periradicular Surgery Bicuspid ( First Root ) 482.00 D3425 Apicoectomy/Periradicular Surgery - Molar ( First Root ) 498.00 D3426 Apicoectomy/Periradicular Surgery - Each Additional Root 179.00 D3430 Retrograde Fill Per Root 88.00 D3450 Root Amputation - Per Root 259.00 D3920 Hemisection, Root Amputation 219.00 D4210 Gingivectomy, Gingivolplasty of Soft Tissue Graft, Per Quadrant (Including Post-op Visits) 311.00 D4211 Gingivectomy, Gingivolplasty or Soft Tissue Graft, Single Tooth 85.00 D4240 Gingival Flap including Root Planing - Per Quadrant 364.00 D4241 Gingival Flap Procedure 1-3 Teeth 202.00 D4249 Crown Lengthening Hard Tissue 458.00 D4260 Osseous Surgery, Four or More Contiguous Teeth Per Quadrant 689.00 D4261 Osseous Surgery, One to Three Teeth Per Quadrant 331.00 D4267 Guided tissue regeneration - non resorbable barrier, per site 298.00 D4268 Guide Tissue Regen Inc Surg and Reentry 339.00 D4270 Pedicle Soft Tissue Graft 489.00 D4271 Free Soft Tissue Graft Procedure (including donor site surgery) 513.00 D4273 Subepithelial Tissue Graft Procedure with Donor 224.00 D4341 Periodontal Root Planing, Per Quadrant 114.00 D4342 Periodontal Scaling One to Three Teeth, Per Quadrant 75.00 D4355 Full Mouth Debridement 74.00 D4910 Periodontal Recall ( Periodontal Prophylaxis ) Following Active Periodontal Therapy Maintenance Procedures after Active Therapy After Three Month ( Includes Any Examination Evaluation, 74.00 Curettage, Root Planning and/or Polishing As May Be Necessary ) D5110 Complete Upper Denture 950.00 D5120 Complete Lower Denture 950.00 Page 2
D5130 Immediate Denture - Upper 985.00 D5140 Immediate Denture - Lower 985.00 D5211 Upper Part Resin Base w/conv. Clasps, Rests/Teeth 710.00 D5212 Lower Part Resin Base w/conv. Clasps, Rests/Teeth 710.00 D5213 Upper Partial Cast Mtl Resin Base w/conv. Clasps 1025.00 D5214 Lower Partial Cast Mtl Resin Base w/conv. Clasps 1025.00 D5225 Upper Partial Denture Flexible Base 825.00 D5226 Lower Partial Denture Flexible Base 825.00 D5281 Removable Unilateral Partial Denture One Piece Case Metal 500.00 D5410 Denture Adjustment Complete - Upper 42.00 D5411 Denture Adjustment Complete - Lower 42.00 D5421 Denture Adjustment - Upper Partial 42.00 D5422 Denture Adjustment - Lower Partial 42.00 D5510 Repair Broken Complete Denture Base 85.00 D5520 Replace One Broken Tooth Only Full Denture 74.00 D5610 Repair Resin Denture Base 87.00 D5620 Repair Cast Framework 95.00 D5630 Repair or Replace Broken Clasp 82.00 D5640 Replace One Broken Tooth - Partial 77.00 D5650 Add First Tooth to a Denture ( New Extraction ) 102.00 D5660 Add/Replace Clasp Metal Partial ( Dor 703 ) 133.00 D5710 Rebase Complete Maxillary Denture 299.00 D5711 Rebase Complete Mandibular Denture 299.00 D5720 Rebase Upper Partial Denture 277.00 D5721 Rebase Lower Partial Denture 277.00 D5730 Office Reline ( Cold Core ) Acrylic FUD 188.00 D5731 Office Reline ( Cold Core ) Acrylic FLD 188.00 D5740 Office Reline ( Cold Core ) Acrylic PUD 188.00 D5741 Office Reline ( Cold Core ) Acrylic PLD 188.00 D5750 Denture Reline ( Laboratory ) FUD 266.00 D5751 Denture Reline ( Laboratory ) FLD 266.00 D5760 Denture Reline ( Laboratory ) PUD 266.00 D5761 Denture Reline ( Laboratory ) PLD 266.00 D5820 Interim Partial Denture - Upper ( Stayplate ) 325.00 D5821 Interim Partial Denture - Lower ( Stayplate ) 325.00 D5850 Tissue Conditioning Per Denture Upper 80.00 D5851 Tissue Conditioning Per Denture - Lower 80.00 D6010 Surgical Placement of Implant Body: Endosteal Implant 1503.00 D6040 Surgical Placement: Eposteal Implant 2700.00 D6050 Surgical Placement: Transosteal Implant 2700.00 D6055 Dental Implant Supported Connecting Bar 382.00 D6066 Implant Supported Porcelain Fused to Metal Crown (Titanium, Titanium Alloy, High Noble Metal) 829.00 D6080 Implant Maintenance Procedures, Including Removal of Prosthesis, Cleansing of Prosthesis and Abutments and Reinsertion of Prosthesis 78.00 D6092 Recement Implant/Abutment Supported Crown 49.00 D6093 Recement Implant/Abutment Supported Fixed Partial Denture 49.00 D6210 Pontic Cast High Noble Metal 623.00 D6211 Pontic Cast Predominantly Base Metal 623.00 D6212 Pontic Cast Noble Metal 623.00 D6240 Pontic - Porcelain High Noble Metal 623.00 D6241 Pontic - Porcelain Predominantly Base Metal 623.00 D6242 Pontic - Porcelain Noble Metal 623.00 D6545 Retainer Cast Metal for Resin Bonded Fixed Prosthesis 255.00 D6750 Abutment Crown Porcelain High Noble 740.00 D6751 Abutment Crown Porcelain Predom Base Metal 740.00 D6752 Abutment Crown Porcelain Noble Metal 740.00 D6780 Abutment Crown - ¾ Cast High Noble 740.00 D6790 Abutment Crown - Full Cast High Noble Metal 740.00 D6791 Abutment Crown - Full Cast Predominantly Base Metal 740.00 D6792 Abutment Crown - Full Cast Noble Metal 740.00 D6930 Bridge ( Recementation ) 69.00 D6970 Post And Core in Addition to Fixed Partial Denture Retainer, Indirectly Fabricated 237.00 D6972 Prefab Post and Core in Add to Bridge Retainer 152.00 D6980 Bridge Repair by Report 127.00 Page 3
D7111 Coronal Remnants - Deciduous Tooth 56.00 D7140 Extraction, Erupted Tooth or Exposed Root 75.00 D7210 Surgical Removal of an Erupted Tooth 131.00 D7220 Removal of Impacted Tooth ( Soft Tissue ) 174.00 D7230 Removal of Impacted Tooth ( Partially Bony ) 255.00 D7240 Removal of Impacted Tooth ( Complete Bony ) 310.00 D7241 Removal of Impacted Tooth ( Complete Bony ) Unusual Surgical Complications 292.00 D7250 Removal of Residual Root Totally Covered by Bone 137.00 D7260 Closure of Oral Fistula of Maxillary Sinus 314.00 D7270 Reimplantation and/or Stabilization of Accidentally Evulsed/Displaced Teeth and/or Alveous 129.00 D7280 Crown Exposure with Attachment Placed for Orthodontic Traction 323.00 D7282 Mobilization of Erupted or Malpositioned Tooth to Aid Eruption 170.00 D7285 Biopsy of Oral Tissue Hard. 139.00 D7286 Biopsy of Oral Tissue, Incisional, Soft 142.00 D7310 Alveoloplasty ( in Addition to Removal of Teeth ) Per Quadrant 120.00 D7320 Alveoloplasty No Extraction - Per Quadrant 157.00 D7340 Aveolopasty With Ridge Extension ( Secondary Eptheliazatioan ) 300.00 D7410 Excision of Benign Lesion up to 1.25 cm 273.00 D7411 Excision of Benign Lesion greater than 1.25 cm 466.00 D7440 Excision of Malignant Tumor - Lesion Diameter up to 1.25 cm 483.00 D7441 Excision of Malignant Tumor - Lesion Diameter greater than 1.25 cm 750.00 D7450 Excision of Cyst, to 1.25cm 216.00 D7451 Excision of Cyst, Larger than 1.25cm 219.00 D7460 Removal Nonodontogenic Cyst/Tum up to 1.25cm 186.00 D7461 Removal Nonodontogenic Cyst/Tum Greater Than 1.25cm 394.00 D7471 Removal of Exostosis Maxilla or Mandible 283.00 D7472 Removal of Torus Palatinus 336.00 D7473 Removal of Torus Madibularis 317.00 D7510 Intraoral Incision and Drainage of Abscess ( Soft Tissue ) 91.00 D7520 Extraoral Incision and Drainage of Abscess 390.00 D7530 Incision and Removal Foreign Body from Soft Tissue 140.00 D7540 Removal of Foreign Body from Bone ( Independent Procedure ) 156.00 D7550 Sequestrectomy for Osteomylities or Abscess, Superficial 97.00 D7560 Maxillary Sinusotomy for Removal of Tooth Fragment or Foreign Body 772.00 D7910 Suture of Recent Small Wounds up to 5cm 125.00 D7911 Complicated Suture up to 5cm 312.00 D7912 Complicated Suture Greater Than 5cm 562.00 D7960 Frenulectomy 209.00 D7970 Excision of Hyperplastic Tissue, Per Arch 174.00 D7971 Excision of Pericoronal Gingiva 99.00 D7980 Sialolithotomy: Removal of Salivary Calculus, Intraorally 265.00 D7981 Sialolithotomy: Removal of Salivary Calculus, Extraorally 265.00 D7982 Dilation of Salivary Duct 713.00 D7983 Closure of Salivary Fistula 681.00 D8210 Appliance to Control Harmful Habits - Removable 229.00 D8220 Appliance to Control Harmful Habits - Fixed 229.00 D9110 Palliative ( Emergency ) Treatment of Dental Pain 50.00 D9220 Anesthesia, General, One Half Hour 205.00 D9221 Anesthesia, General, Each Additional 15 Minutes 83.00 D9230 Nitrous Oxide 27.00 D9241 Intravenous Conscious Sedation/Analgesia First 30 Minutes 78.00 D9242 Intravenous Conscious Sedation/Analgesia Each Additional 15 Minutes 37.00 D9310 Special Consultation (Specialist Only Separate Fee Only if Patient Not Treated by Consultant) 64.00 D9430 Office Visit For Observation (during regularly scheduled hous) - No Other Services Performed 38.00 D9440 Office Visit - After Regularly Scheduled Hours 49.00 D9610 Therapeutic Parenteral Drug, Single Administration 27.00 D9942 Repair and/or Reline of Occulusal Guard 92.00 Orthodontist dentists will be reimbursed at 100% of the below fees as payment in full. 340 Cephalometric Film 70.00 350 Ortho x-ray Survey 33.00 8010 Limited orthodontic treatment of primary dentition 1250.00 8020 Limited orthodontic treatment of transitional dentition 2350.00 8040 Limited orthodontic treatment of adult dentition 2350.00 8050 Interceptive orthodontic treatment of the primary dentition 1950.00 Page 4
8060 Interceptive orthodontic treatment of the transitional dentition 2050.00 8070 Comprehensive orthodontic treatment of the transitional dentition 3500.00 8080 Ortho Comprehensive 24 Months 3500.00 8090 Comprehensive orthodontic treatment of the adult dentition 3500.00 8210 Appliance to Control Harmful Habbits 520.00 8220 Appliance to Control Harmful Habbits 520.00 8660 Pre-orthodontic treatment 37.00 8670 Periodic orthodontic treatment visit (as part of contract) 70.00 8680 Orthodontic retention 290.00 Page 5