General Dentist Fee Schedule Diagnostic D0120 Periodic oral evaluation $0 $59 $59 D0140 Limited oral evaluation problem focused $71 $88 $17 D0150 Comprehensive oral evaluation new or established patient $0 $104 $104 D0180 Comprehensive periodontal evaluation new or established patient $20 $113 $93 D0210 Intraoral complete series of radiographic images $94 $156 $62 D0220 Intraoral periapical first radiographic image $28 $36 $8 D0230 Intraoral periapical each additional radiographic image $24 $30 $6 D0240 Intraoral occlusal radiographic image $0 $48 $48 D0270 Bitewing single radiographic image $0 $34 $34 D0272 Bitewings two radiographic images $0 $54 $54 D0274 Bitewings four radiographic images $0 $77 $77 D0330 Panoramic radiographic image $109 $133 $24 D0460 Pulp vitality tests $57 $69 $12 D0470 Diagnostic cast $109 $136 $27 Preventive D1110 Prophylaxis adult $94 $107 $13 D1120 Prophylaxis child $68 $81 $13 D1330 Oral hygiene instructions $2 $65 $63 D1351 Sealant-per tooth $55 $65 $10 D1510 Space maintainer fixed (unilateral) $346 $370 $24 D1515 Space maintainer fixed (bilateral) $429 $497 $68 D1520 Space maintainer removable (unilateral) $393 $452 $59 D1525 Space maintainer removable (bilateral) $513 $562 $49 D1550 Recement or rebond space maintainer $85 $99 $14 16-SG-1322-MGP.indd 1
Restorative D2140 Amalgam one surface (primary or permanent) $124 $172 $48 D2150 Amalgam two surfaces (primary or permanent) $162 $214 $52 D2160 Amalgam three surfaces (primary or permanent) $171 $264 $93 D2161 Amalgam four or more surfaces (primary or permanent) $209 $312 $103 D2330 Resin-based composite one surface (anterior) $132 $199 $67 D2331 Resin-based composite two surfaces (anterior) $170 $242 $72 D2332 Resin-based composite three surfaces (anterior) $209 $296 $87 D2335 Resin-based composite four or more surfaces or involving incisal angle (anterior) $260 $371 $111 D2391 Resin-based composite one surface (posterior) $138 $214 $76 D2392 Resin-based composite two surfaces (posterior) $182 $274 $92 D2393 Resin-based composite three surfaces (posterior) $236 $339 $103 D2394 Resin-based composite four or more surfaces (posterior) $285 $405 $120 D2750 Crown porcelain fused to high noble metal $1,085 $1,349 $264 D2751 Crown porcelain fused to predominantly base metal $993 $1,249 $256 D2752 Crown porcelain fused to noble metal $1,046 $1,291 $245 D2780 Crown 3/4 cast high noble metal $1,063 $1,298 $235 D2781 Crown 3/4 cast predominantly base metal $996 $1,186 $190 D2782 Crown 3/4 cast noble metal $1,021 $1,272 $251 D2790 Crown full cast high noble metal $1,079 $1,394 $315 D2791 Crown full cast predominantly base metal $966 $1,194 $228 D2792 Crown full cast noble metal $1,021 $1,291 $270 D2910 D2915 Recement or rebond inlay, onlay, veneer or partial coverage restoration $107 $135 $28 Recement or rebond indirectly fabricated or prefabricated post and core $71 $139 $68 D2920 Recement or rebond crown $107 $135 $28 D2930 Prefabricated stainless steel crown primary tooth $245 $315 $70 D2931 Prefabricated stainless steel crown permanent tooth $293 $374 $81 D2932 Prefabricated resin crown $338 $412 $74 D2940 Protective restoration $110 $145 $35 16-SG-1322-MGP.indd 2
Restorative (continued) D2950 Core buildup, including any pins $267 $321 $54 D2951 Pin retention per tooth, in addition to restoration $61 $91 $30 D2952 Post and core in addition to crown indirectly fabricated $392 $496 $104 D2954 Prefabricated post and core in addition to crown $299 $404 $105 D2971 Additional procedures to construct new crown under existing partial denture framework $486 $0 $0 Endodontics D3110 Pulp cap direct (excluding final restoration) $79 $99 $20 D3120 Pulp cap indirect (excluding final restoration) $79 $98 $19 D3220 Therapeutic pulpotomy (excluding final restoration) $181 $239 $58 D3310 Root canal therapy anterior (excluding final restoration) $661 $886 $225 D3320 Root canal therapy bicuspid (excluding final restoration) $793 $1,009 $216 D3330 Root canal therapy molar (excluding final restoration) $966 $1,230 $264 D3351 Apexification/recalcification initial visit $363 $420 $57 D3352 Apexification/recalcification interim medication replacement $242 $301 $59 D3353 Apexification/recalcification final visit $516 $625 $109 D3410 Apicoectomy anterior $670 $821 $151 D3421 Apicoectomy bicuspid (first root) $755 $917 $162 D3425 Apicoectomy molar (first root) $879 $1,022 $143 D3426 Apicoectomy (each additional root) $371 $486 $115 D3430 Retrograde filling per root $280 $333 $53 D3450 Root amputation per root $494 $577 $83 D3920 Hemisection (including any root removal), not including root canal therapy $442 $560 $118 Periodontics D4210 D4211 D4240 Gingivectomy or gingivoplasty four or more contiguous teeth or tooth bounded spaces per quadrant $639 $739 $100 Gingivectomy or gingivoplasty one to three contiguous teeth or tooth bounded spaces per quadrant $236 $376 $140 Gingival flap procedure, including root planing four or more contiguous teeth or tooth bounded spaces per quadrant $755 $875 $120 16-SG-1322-MGP.indd 3
Periodontics (continued) D4241 Gingival flap procedure, including root planing one to three contiguous teeth or tooth bounded spaces per quadrant $540 $727 $187 D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant $1,079 $1,290 $211 D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant $780 $1,028 $248 D4341 Periodontal scaling and root planing - four or more teeth per quadrant $228 $301 $73 D4342 Periodontal scaling and root planing one to three teeth per quadrant $182 $218 $36 D4355 D4381 Full mouth debridement to enable comprehensive evaluation and diagnosis $170 $213 $43 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth $94 $161 $67 D4910 Periodontal maintenance $124 $160 $36 Dentures Removable D5110 Complete denture maxillary $1,431 $2,068 $637 D5120 Complete denture mandibular $1,431 $2,060 $629 D5130 Immediate denture maxillary $1,562 $2,177 $615 D5140 Immediate denture mandibular $1,562 $2,205 $643 D5211 D5212 D5213 D5214 D5225 D5226 Maxillary (upper) partial denture resin base (including any conventional clasps, rests and teeth) $1,087 $1,614 $527 Mandibular (lower) partial denture resin base (including any conventional clasps, rests and teeth) $1,106 $1,614 $508 Maxillary (upper) partial denture cast metal framework with resin denture bases (including any conventional clasps) $1,543 $2,098 $555 Mandibular (lower) partial denture cast metal framework with resin denture bases (including any conventional clasps) $1,542 $2,125 $583 Maxillary (upper) partial denture flexible base (including any clasps, rests and teeth) $982 $1,876 $894 Mandibular (lower) partial denture flexible base (including any clasps, rests and teeth) $982 $1,856 $874 D5410 Adjust complete denture maxillary $80 $105 $25 D5411 Adjust complete denture mandibular $80 $105 $25 D5421 Adjust partial denture maxillary $80 $104 $24 D5422 Adjust partial denture mandibular $80 $105 $25 16-SG-1322-MGP.indd 4
Dentures Removable (continued) D5510 Repair broken complete denture base $182 $254 $72 D5520 Replace missing or broken teeth complete denture (each tooth) $164 $226 $62 D5610 Repair resin denture base $182 $245 $63 D5620 Repair cast framework $256 $347 $91 D5630 Repair or replace broken clasp per tooth $233 $321 $88 D5640 Repair or replace broken teeth per tooth $165 $226 $61 D5650 Add tooth to existing partial denture $203 $269 $66 D5660 Add clasp to existing partial denture $249 $317 $68 D5710 Rebase complete maxillary denture $532 $689 $157 D5711 Rebase complete mandibular denture $532 $683 $151 D5720 Rebase maxillary partial denture $505 $665 $160 D5721 Rebase mandibular partial denture $505 $661 $156 D5730 Reline complete maxillary denture (chairside) $335 $443 $108 D5731 Reline complete mandibular denture (chairside) $337 $438 $101 D5740 Reline maxillary partial denture (chairside) $330 $430 $100 D5741 Reline mandibular partial denture (chairside) $332 $433 $101 D5750 Reline complete maxillary denture (laboratory) $429 $552 $123 D5751 Reline complete mandibular denture (laboratory) $429 $555 $126 D5760 Reline maxillary partial denture (laboratory) $423 $549 $126 D5761 Reline mandibular partial denture (laboratory) $423 $549 $126 D5820 Interim partial denture (maxillary) $620 $844 $224 D5821 Interim partial denture (mandibular) $620 $842 $222 D5850 Tissue conditioning maxillary (upper) $178 $246 $68 D5851 Tissue conditioning mandibular (lower) $182 $242 $60 Prosthodontics Fixed Bridges D6210 Pontic cast high noble metal $1,100 $1,337 $237 D6211 Pontic cast predominantly base metal $1,008 $1,218 $210 D6212 Pontic cast noble metal $1,052 $1,270 $218 D6240 Pontic porcelain fused to high noble metal $1,118 $1,345 $227 D6241 Pontic porcelain fused to predominantly base metal $1,029 $1,262 $233 16-SG-1322-MGP.indd 5
Prosthodontics Fixed Bridges (continued) D6242 Pontic porcelain fused to noble metal $1,079 $1,291 $212 D6750 Retainer crown porcelain fused to high noble metal $1,085 $1,356 $271 D6751 Retainer crown porcelain fused to predominantly base metal $993 $1,238 $245 D6752 Retainer crown porcelain fused to noble metal $1,046 $1,279 $233 D6780 Retainer crown 3/4 cast high noble metal $1,063 $1,291 $228 D6781 Retainer crown 3/4 cast predominantly base metal $996 $1,208 $212 D6782 Retainer crown 3/4 cast noble metal $1,021 $1,258 $237 D6790 Retainer crown full cast high noble metal $1,079 $1,335 $256 D6791 Retainer crown full cast predominantly base metal $966 $1,221 $255 D6792 Retainer crown full cast noble metal $1,021 $1,281 $260 D6930 Recement or rebond fixed partial denture $165 $204 $39 Oral Surgery/Orthodontics D7111 Extraction, coronal remnants deciduous tooth $116 $158 $42 D7140 Extraction, erupted tooth or exposed root elevation and/or forceps removal $131 $209 $78 D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth $266 $326 $60 D7220 Removal of impacted tooth soft tissue $282 $370 $88 D7230 Removal of impacted tooth partially bony $363 $459 $96 D7240 Removal of impacted tooth completely bony $455 $562 $107 D7250 Surgical removal of residual tooth roots cutting procedure $261 $360 $99 D7471 Removal of lateral exostosis (maxilla or mandible) $621 $807 $186 D7472 Removal of torus palatinus $629 $1,013 $384 D7473 Removal of torus mandibularis $629 $935 $306 D7510 Incision and drainage of abscess intraoral soft tissue $203 $285 $82 D7960 Frenulectomy also known as frenectomy or frenotomy separate procedure not incidental to another procedure $447 $524 $77 D7963 Frenuloplasty $354 $565 $211 D7970 Excision of hyperplastic tissue per arch $511 $611 $100 D7971 Excision of pericoronal gingiva $230 $311 $81 16-SG-1322-MGP.indd 6
Oral Surgery/Orthodontics (continued) D8210 Removable appliance therapy $689 $1,033 $344 D8220 Fixed appliance therapy $739 $1,147 $408 D8670 Periodic orthodontic treatment visit $173 $327 $154 Adjunctive General Services D9110 Palliative (emergency) treatment of dental pain minor procedure $102 $151 $49 D9215 Local anesthesia $0 $75 $75 D9310 Consultation diagnostic service provided by dentist or physician other than requesting dentist or physician $123 $161 $38 D9430 Office visit for observation during regularly scheduled hours no other services performed $60 $91 $31 D9440 Office visit after regularly scheduled hours $120 $210 $90 D9450 Case presentation, detailed and extensive treatment planning $9 $170 $161 D9941 Fabrication of athletic mouthguard $170 $321 $151 D9942 Repair and/or relining of an occlusal guard $115 $294 $179 D9950 Occlusion analysis mounted case $338 $409 $71 D9951 Occlusal adjustment limited $173 $215 $42 D9972 External bleaching per arch $264 $386 $122 D9973 External bleaching per tooth $186 $269 $83 16-SG-1322-MGP.indd 7