General Dentist Fee Schedule ADA Diagnostic D0120 Periodic oral evaluation $0 $72 $72 D0140 Limited oral evaluation problem focused $77 $107 $30 D0150 Comprehensive oral evaluation new or established patient $0 $126 $126 D0180 Comprehensive periodontal evaluation new or established patient $20 $137 $117 D0210 Intraoral complete series of radiographic images $107 $189 $82 D0220 Intraoral periapical first radiographic image $30 $43 $13 D0230 Intraoral periapical each additional radiographic image $24 $36 $12 D0240 Intraoral occlusal radiographic image $0 $59 $59 D0270 Bitewing single radiographic image $0 $42 $42 D0272 Bitewings two radiographic images $0 $65 $65 D0274 Bitewings four radiographic images $0 $94 $94 D0330 Panoramic radiographic image $112 $162 $50 D0460 Pulp vitality tests $61 $83 $22 D0470 Diagnostic casts $115 $164 $49 Preventive D1110 Prophylaxis adult $99 $129 $30 D1120 Prophylaxis child $71 $98 $27 D1330 Oral hygiene instructions $0 $78 $78 D1351 Sealant per tooth $57 $78 $21 D1510 Space maintainer fixed (unilateral) $348 $448 $100 D1515 Space maintainer fixed (bilateral) $494 $602 $108 D1520 Space maintainer removable (unilateral) $429 $547 $118 D1525 Space maintainer removable (bilateral) $540 $680 $140 D1550 Recement or rebond space maintainer $87 $120 $33
Restorative D2140 Amalgam one surface (primary or permanent) $127 $208 $81 D2150 Amalgam two surfaces (primary or permanent) $164 $259 $95 D2160 Amalgam three surfaces (primary or permanent) $197 $319 $122 D2161 Amalgam four or more surfaces (primary or permanent) $241 $378 $137 D2330 Resin-based composite one surface (anterior) $151 $241 $90 D2331 Resin-based composite two surfaces (anterior) $195 $293 $98 D2332 Resin-based composite three surfaces (anterior) $241 $258 $17 D2335 Resin-based composite four or more surfaces or involving incisal angle (anterior) $299 $449 $150 D2391 Resin-based composite one surface (posterior) $148 $259 $111 D2392 Resin-based composite two surfaces (posterior) $189 $332 $143 D2393 Resin-based composite three surfaces (posterior) $256 $410 $154 D2394 Resin-based composite four or more surfaces (posterior) $296 $490 $194 D2750 Crown porcelain fused to high noble metal $1,219 $1,633 $414 D2751 Crown porcelain fused to predominantly base metal $1,082 $1,512 $430 D2752 Crown porcelain fused to noble metal $1,131 $1,563 $432 D2780 Crown 3/4 cast high noble metal $1,150 $1,571 $421 D2781 Crown 3/4 cast predominantly base metal $1,115 $1,435 $320 D2782 Crown 3/4 cast noble metal $1,161 $1,540 $379 D2790 Crown full cast high noble metal $1,189 $1,687 $498 D2791 Crown full cast predominantly base metal $1,082 $1,446 $364 D2792 Crown full cast noble metal $1,131 $1,563 $432 D2910 D2915 Recement or rebond inlay, onlay, veneer or partial coverage restoration $115 $163 $48 Recement or rebond indirectly fabricated or prefabricated post and core $83 $168 $85 D2920 Recement or rebond crown $115 $163 $48 D2930 Prefabricated stainless steel crown primary tooth $285 $382 $97 D2931 Prefabricated stainless steel crown permanent tooth $344 $453 $109 D2932 Prefabricated resin crown $367 $499 $132 D2940 Protective restoration $120 $176 $56
Preventive (continued) D2950 Core buildup, including any pins $289 $388 $99 D2951 Pin retention per tooth, in addition to restoration $71 $111 $40 D2952 Post and core in addition to crown indirectly fabricated $462 $600 $138 D2954 Prefabricated post and core in addition to crown $359 $488 $129 D2971 Additional procedures to construct new crown under existing partial denture framework $551 $0 $0 Endodontics D3110 Pulp cap direct (excluding final restoration) $91 $120 $29 D3120 Pulp cap indirect (excluding final restoration) $91 $119 $28 D3220 Therapeutic pulpotomy (excluding final restoration) $212 $289 $77 D3310 Root canal therapy anterior (excluding final restoration) $764 $1,072 $308 D3320 Root canal therapy bicuspid (excluding final restoration) $914 $1,222 $308 D3330 Root canal therapy molar (excluding final restoration) $1,118 $1,489 $371 D3351 Apexification/recalcification initial visit $417 $508 $91 D3352 Apexification/recalcification interim medication replacement $283 $365 $82 D3353 Apexification/recalcification final visit $557 $757 $200 D3410 Apicoectomy anterior $724 $994 $270 D3421 Apicoectomy bicuspid (first root) $820 $1,110 $290 D3425 Apicoectomy molar (first root) $950 $1,237 $287 D3426 Apicoectomy (each additional root) $400 $589 $189 D3430 Retrograde filling per root $300 $402 $102 D3450 Root amputation per root $532 $698 $166 D3920 Hemisection (including any root removal), not including root canal therapy $511 $677 $166 Periodontics D4210 D4211 D4240 Gingivectomy or gingivoplasty four or more contiguous teeth or tooth bounded spaces per quadrant $669 $895 $226 Gingivectomy or gingivoplasty one to three contiguous teeth or tooth bounded spaces per quadrant $249 $455 $206 Gingival flap procedure, including root planing four or more contiguous teeth or tooth bounded spaces per quadrant $793 $1,059 $266
Periodontics (continued) D4241 Gingival flap procedure, including root planing one to three contiguous teeth or tooth bounded spaces per quadrant $620 $880 $260 D4260 Osseous surgery (including elevation of a full thickness flap and closure) four or more contiguous teeth or tooth bounded spaces per quadrant $1,131 $1,562 $431 D4261 Osseous surgery (including elevation of a full thickness flap and closure) one to three contiguous teeth or tooth bounded spaces per quadrant $897 $1,244 $347 D4341 Periodontal scaling and root planing four or more teeth per quadrant $267 $365 $98 D4342 Periodontal scaling and root planing one to three teeth per quadrant $211 $264 $53 D4355 D4381 Full mouth debridement to enable comprehensive evaluation and diagnosis $195 $258 $63 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth $102 $195 $93 D4910 Periodontal maintenance $148 $194 $46 Dentures Removable D5110 Complete denture maxillary $1,645 $2,503 $858 D5120 Complete denture mandibular $1,645 $2,493 $848 D5130 Immediate denture maxillary $1,798 $2,635 $837 D5140 Immediate denture mandibular $1,798 $2,669 $871 D5211 D5212 D5213 D5214 D5225 D5226 Maxillary (upper) partial denture resin base (including any conventional clasps, rests and teeth) $1,252 $1,954 $702 Mandibular (lower) partial denture resin base (including any conventional clasps, rests and teeth) $1,273 $1,954 $681 Maxillary (upper) partial denture cast metal framework with resin denture bases (including any conventional clasps) $1,776 $2,540 $764 Mandibular (lower) partial denture cast metal framework with resin denture bases (including any conventional clasps) $1,774 $2,572 $798 Maxillary (upper) partial denture flexible base (including any clasps, rests and teeth) $1,035 $2,270 $1,235 Mandibular (lower) partial denture flexible base (including any clasps, rests and teeth) $1,035 $2,247 $1,212 D5410 Adjust complete denture maxillary $91 $128 $37 D5411 Adjust complete denture mandibular $91 $128 $37 D5421 Adjust partial denture maxillary $91 $126 $35 D5422 Adjust partial denture mandibular $91 $128 $37
Dentures Removable (continued) D5510 Repair broken complete denture base $211 $307 $96 D5520 Replace missing or broken teeth complete denture (each tooth) $181 $274 $93 D5610 Repair resin denture base $211 $297 $86 D5620 Repair cast framework $296 $419 $123 D5630 Repair or replace broken clasp per tooth $267 $388 $121 D5640 Repair or replace broken teeth per tooth $181 $274 $93 D5650 Add tooth to existing partial denture $233 $326 $93 D5660 Add clasp to existing partial denture $283 $384 $101 D5710 Rebase complete maxillary denture $599 $834 $235 D5711 Rebase complete mandibular denture $599 $827 $228 D5720 Rebase maxillary partial denture $579 $805 $226 D5721 Rebase mandibular partial denture $576 $800 $224 D5730 Reline complete maxillary denture (chairside) $385 $537 $152 D5731 Reline complete mandibular denture (chairside) $385 $530 $145 D5740 Reline maxillary partial denture (chairside) $379 $521 $142 D5741 Reline mandibular partial denture (chairside) $382 $524 $142 D5750 Reline complete maxillary denture (laboratory) $494 $668 $174 D5751 Reline complete mandibular denture (laboratory) $494 $672 $178 D5760 Reline maxillary partial denture (laboratory) $486 $664 $178 D5761 Reline mandibular partial denture (laboratory) $486 $664 $178 D5820 Interim partial denture (maxillary) $714 $1,021 $307 D5821 Interim partial denture (mandibular) $714 $1,019 $305 D5850 Tissue conditioning maxillary (upper) $203 $298 $95 D5851 Tissue conditioning mandibular (lower) $211 $293 $82 Prosthodontics Fixed Bridges D6210 Pontic cast high noble metal $1,153 $1,618 $465 D6211 Pontic cast predominantly base metal $1,059 $1,474 $415 D6212 Pontic cast noble metal $1,103 $1,537 $434 D6240 Pontic porcelain fused to high noble metal $1,172 $1,628 $456 D6241 Pontic porcelain fused to predominantly base metal $1,078 $1,528 $450
Prosthodontics Fixed Bridges (continued) D6242 Pontic porcelain fused to noble metal $1,133 $1,563 $430 D6750 Retainer crown porcelain fused to high noble metal $1,219 $1,641 $422 D6751 Retainer crown porcelain fused to predominantly base metal $1,082 $1,498 $416 D6752 Retainer crown porcelain fused to noble metal $1,131 $1,549 $418 D6780 Retainer crown 3/4 cast high noble metal $1,150 $1,563 $413 D6781 Retainer crown 3/4 cast predominantly base metal $1,115 $1,463 $348 D6782 Retainer crown 3/4 cast noble metal $1,161 $1,523 $362 D6790 Retainer crown full cast high noble metal $1,189 $1,616 $427 D6791 Retainer crown full cast predominantly base metal $1,082 $1,478 $396 D6792 Retainer crown full cast noble metal $1,131 $1,550 $419 D6930 Recement or rebond fixed partial denture $173 $247 $74 Oral Surgery/Orthodontics D7111 Extraction, coronal remnants deciduous tooth $135 $191 $56 D7140 Extraction, erupted tooth or exposed root elevation and/or forceps removal $157 $253 $96 D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth $277 $395 $118 D7220 Removal of impacted tooth soft tissue $324 $448 $124 D7230 Removal of impacted tooth partially bony $418 $556 $138 D7240 Removal of impacted tooth completely bony $524 $680 $156 D7250 Surgical removal of residual tooth roots cutting procedure $300 $436 $136 D7471 Removal of lateral exostosis (maxilla or mandible) $629 $977 $348 D7472 Removal of torus palatinus $662 $1,226 $564 D7473 Removal of torus mandibularis $662 $1,132 $470 D7510 Incision and drainage of abscess intraoral soft tissue $233 $345 $112 D7960 Frenulectomy also known as frenectomy or frenotomy separate procedure not incidental to another procedure $448 $634 $186 D7963 Frenuloplasty $423 $684 $261 D7970 Excision of hyperplastic tissue per arch $518 $740 $222 D7971 Excision of pericoronal gingiva $242 $376 $134 D8210 Removable appliance therapy $691 $1,250 $559
Oral Surgery/Orthodontics (continued) D8220 Fixed appliance therapy $739 $1,388 $649 D8670 Periodic orthodontic treatment visit $209 $396 $187 Adjunctive General Services D9110 Palliative (emergency) treatment of dental pain minor procedure $118 $182 $64 D9215 Local anesthesia $0 $91 $91 D9310 Consultation diagnostic service provided by dentist or physician other than requesting dentist or physician $132 $195 $63 D9430 Office visit for observation during regularly scheduled hours no other services performed $69 $111 $42 D9440 Office visit after regularly scheduled hours $148 $254 $106 D9450 Case presentation, detailed and extensive treatment planning $20 $206 $186 D9941 Fabrication of athletic mouthguard $170 $388 $218 D9942 Repair and/or relining of an occlusal guard $146 $356 $210 D9950 Occlusion analysis mounted case $367 $495 $128 D9951 Occlusal adjustment limited $187 $261 $74 D9972 External bleaching per arch $264 $468 $204 D9973 External bleaching per tooth $186 $326 $140