Fee Schedule Detail Procedure Procedure Description Code Fee D0120 PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT $ 32.29 D0140 LIMITED ORAL EVALUATION-PROBLEM FOCUSED $ 53.02 D0150 COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED $ 50.77 D0160 DETAILED AND EXTENSIVE ORAL EVAL-PROBLEM FOCUSED, BY $ 71.50 D0170 RE-EVALUATION, LIMITED PROBLEM FOCUSED $ 28.60 D0180 COMPREHENSIVE PERIODONTAL EVALUATION - NEW OR $ 29.40 D0210 INTRAORAL - COMPLETE SERIES OF RADIOGRAPHIC IMAGES $ 103.32 D0220 INTRAORAL - PERIAPICAL FIRST RADIOGRAPHIC IMAGE $ 18.95 D0230 INTRAORAL - PERIAPICAL EACH ADDITIONAL RADIOGRAPHIC $ 14.30 D0240 INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGE $ 26.46 D0270 BITEWING - SINGLE RADIOGRAPHIC IMAGE $ 24.73 D0272 BITEWINGS - TWO RADIOGRAPHIC IMAGES $ 35.48 D0274 BITEWINGS - FOUR RADIOGRAPHIC IMAGES $ 50.29 D0277 VERTICAL BITEWINGS - 7 TO 8 FILMS $ 72.35 D0330 PANORAMIC RADIOGRAPHIC IMAGE $ 92.27 D0340 CEPHALOMETRIC RADIOGRAPHIC IMAGE $ 48.98 D0350 2D ORAL/FACIAL PHOTOGRAPHIC IMAGE OBTAINED INTRA- ORALLY OR EXTRA-ORALLY $ 10.13 D0391 INTERPRETATION OF DIAGNOSTIC IMAGE BY A PRACTITIONER NOT ASSOCIATED WITH CAPTURE OF THE IMAGE $ 24.15 D0470 DIAGNOSTIC CASTS $ 55.74 D1110 PROPHYLAXIS - ADULT $ 68.29 D1120 PROPHYLAXIS - CHILD $ 49.34 D1206 TOPICAL APPLICATION OF FLUORIDE VARNISH $ 31.82 D1208 TOPICAL APPLICATION OF FLUORIDE - EXCLUDING VARNISH $ 32.02 D1351 SEALANT - PER TOOTH $ 41.98 D1352 PREVENTIVE RESIN RESTORATION IS A MOD. TO HIGH CARIES RISK PATIENT PERM TOOTH CONSERVATIVE REST OF AN ACTIVE CAVITATED LESION IN A PIT OR FISSURE THAT DOESN'T EXTEND INTO DENTIN: INCLUDES PLACMT OF A SEALANT IN RADIATING $ 50.70 D1510 SPACE MAINTAINER-FIXED-UNILATERAL $ 277.90 D1515 SPACE MAINTAINER - FIXED - BILATERAL $ 398.31 D1520 SPACE MAINTAINER-REMOVABLE-UNILATERAL $ 221.30 D1525 SPACE MAINTAINER-REMOVABLE-BILATERAL $ 208.43 D1550 RE-CEMENT OR RE-BOND SPACE MAINTAINER $ 52.20 D2140 AMALGAM - ONE SURFACE, PRIMARY OR PERMANENT $ 88.52 D2150 AMALGAM - TWO SURFACES, PRIMARY OR PERMANENT $ 116.03 D2160 AMALGAM - THREE SURFACES, PRIMARY OR PERMANENT $ 137.95 D2161 AMALGAM - FOUR OR MORE SURFACES, PRIMARY OR $ 166.27 D2330 RESIN-BASED COMPOSITE - ONE SURFACE, ANTERIOR $ 113.22 D2331 RESIN-BASED COMPOSITE - TWO SURFACES, ANTERIOR $ 137.95 D2332 RESIN-BASED COMPOSITE - THREE SURFACES, ANTERIOR $ 159.56 D2335 RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR) $ 221.28 D2390 RESIN-BASED COMPOSITE CROWN, ANTERIOR $ 200.20 D2391 RESIN-BASED COMPOSITE - ONE SURFACE, POSTERIOR $ 79.37 Page 1 of 7
D2392 RESIN-BASED COMPOSITE - TWO SURFACES, POSTERIOR $ 104.04 D2393 RESIN-BASED COMPOSITE - THREE SURFACES, POSTERIOR $ 123.70 D2394 RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES, $ 149.08 D2510 INLAY - METALLIC -1 SURFACE $ 329.40 D2520 INLAY-METALLIC-2 SURFACES $ 380.07 D2530 INLAY-METALLIC-3+ SURFACES $ 430.75 D2542 ONLAY - METALLIC - TWO SURFACES $ 579.73 D2543 ONLAY-METALLIC-3 SURFACES $ 581.75 D2544 ONLAY-METALLIC-4+ SURFACES $ 583.78 D2740 CROWN - PORCELAIN/CERAMIC SUBSTRATE $ 559.46 D2750 CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL $ 559.46 D2751 CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL $ 559.46 D2752 CROWN - PORCELAIN FUSED TO NOBLE METAL $ 559.46 D2780 CROWN - ¾ CAST HIGH NOBLE METAL $ 559.46 D2781 CROWN - ¾ CAST PREDOMINANTLY BASE METAL $ 559.46 D2783 CROWN - ¾ PORCELAIN/CERAMIC $ 559.46 D2790 CROWN - FULL CAST HIGH NOBLE METAL $ 559.46 D2791 CROWN - FULL CAST PREDOMINANTLY BASE METAL $ 559.46 D2792 CROWN - FULL CAST NOBLE METAL $ 559.46 D2794 CROWN - TITANIUM $ 559.46 D2910 RE-CEMENT OR RE-BOND INLAY, ONLAY, VENEER OR PARTIAL COVERAGE RESTORATION $ 80.08 D2920 RE-CEMENT OR RE-BOND CROWN $ 83.33 D2929 PREFABRICATED PORCELAIN/CERAMIC CROWN PRIMARY $ 119.60 D2930 TOOTH PREFABRICATED STAINLESS STEEL CROWN - PRIMARY TOOTH $ 222.88 D2931 PREFABRICATED STAINLESS STEEL CROWN-PERMANENT TOOTH $ 265.54 D2940 PROTECTIVE RESTORATION $ 86.91 D2950 CORE BUILDUP, INCLUDING ANY PINS WHEN REQUIRED $ 131.75 D2951 PIN RETENTION - PER TOOTH, IN ADDITION TO RESTORATION $ 40.76 D2954 PREFABRICATED POST AND CORE IN ADDITION TO CROWN $ 172.29 D2980 CROWN REPAIR, BY REPORT $ 229.16 D2981 INLAY REPAIR NECESSITATED BY RESTORATIVE MATERIAL $ 45.61 D2982 ONLAY REPAIR NECESSITATED BY RESTORATIVE MATERIAL $ 45.61 D2983 VENEER REPAIR NECESSITATED BY RESTORATIVE MATERIAL $ 45.61 D2990 RESIN INFILTRATION OF INCIPIENT SMOOTH SURFACE LESIONS $ 253.15 D3220 THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) - REMOVAL OF PULP CORONAL TO THE DENTINOCEMENTAL JUNCTION AND APPLICATION OF MEDICAMENT $ 150.30 D3222 PARTIAL PULPOTOMY FOR APEXOGENESIS - PERMANENT TOOTH WITH INCOMPLETE ROOT DEVELOPMENT $ 150.30 D3230 PULPAL THERAPY (RESORBABLE FILLING) - ANTERIOR, PRIMARY TOOTH (EXCLUDING FINAL RESTORATION) $ 194.57 D3240 PULPAL THERAPY (RESORBABLE FILLING) - POSTERIOR, PRIMARY TOOTH (EXCLUDING FINAL RESTORATION) $ 165.17 D3310 ENDODONTIC THERAPY, ANTERIOR TOOTH (EXCLUDING FINAL $ 539.86 D3320 ENDODONTIC THERAPY, BICUSPID TOOTH (EXCLUDING FINAL $ 663.85 D3330 ENDODONTIC THERAPY, MOLAR (EXCLUDING FINAL $ 814.13 D3346 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY-ANTERIOR $ 807.24 D3347 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY-BICUSPID $ 913.77 D3348 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY-MOLAR $ 1,132.56 Page 2 of 7
D3351 APEXIFICATION/RECALCIFICATION - INITIAL VISIT (APICAL CLOSURE / CALCIFIC REPAIR OF PERFORATIONS, ROOT $ 343.92 D3352 APEXIFICATION/RECALCIFICATION - INTERIM MEDICATION $ 70.79 D3353 APEXIFICATION/RECALCIFICATION - FINAL VISIT (INCLUDES COMPLETED ROOT CANAL THERAPY - APICAL CLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT $ 70.79 D3354 PULPAL REGENERATION INCLUDES COMPLETED REGENERATIVE TRT OF AN IMMATURE PERM TOOTH WITH A NECROTIC PULP. INCLUDES REMOVAL OF INTRACANAL MEDICATION AND PROCS NECESSARY TO REGENERATE CONT'D ROOT DEVELOPMENT $ 329.10 D3410 APICOECTOMY - ANTERIOR $ 503.36 D3421 APICOECTOMY - BICUSPID (FIRST ROOT) $ 755.76 D3425 APICOECTOMY - MOLAR (FIRST ROOT) $ 886.60 D3426 APICOECTOMY (EACH ADDITIONAL ROOT) $ 368.94 D3450 ROOT AMPUTATION - PER ROOT $ 277.70 D3920 HEMISECTION (INCLUDING ANY ROOT REMOVAL), NOT INCL ROOT CANAL THERAPY $ 196.62 D4210 GINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER $ 531.07 D4211 GINGIVECTOMY OR GINGIVOPLASTY - ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER $ 182.22 D4212 GINGIVECTOMY OR GINGIVOPLASTY TO ALLOW ACCESS FOR RESTORATIVE PROCEDURE, PER TOOTH $ 570.66 D4240 GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES $ 762.91 D4260 OSSEOUS SURGERY (INCLUDING ELEVATION OF A FULL THICKNESS FLAP AND CLOSURE) - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER $ 686.40 D4341 PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH PER QUADRANT $ 221.28 D4342 PERIODONTAL SCALING AND ROOT PLANING - ONE TO THREE TEETH PER QUADRANT $ 74.40 D4355 FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE EVALUATION AND DIAGNOSIS $ 140.34 D4910 PERIODONTAL MAINTENANCE PROCEDURES $ 80.07 D5110 COMPLETE DENTURE - MAXILLARY $ 1,118.98 D5120 COMPLETE DENTURE - MANDIBULAR $ 1,127.20 D5130 IMMEDIATE DENTURE - MAXILLARY $ 559.49 D5140 IMMEDIATE DENTURE - MANDIBULAR $ 563.61 D5211 MAXILLARY PARTIAL DENTURE - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) $ 938.08 D5212 MANDIBULAR PARTIAL DENTURE - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) $ 1,127.20 D5213 MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL $ 938.08 D5214 MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL $ 1,127.20 D5225 MAXILLARY PARTIAL DENTURE-FLEXIBLE BASE $ 938.08 D5226 MANDIBULAR PARTIAL DENTURE-FLEXIBLE BASE $ 1,127.20 Page 3 of 7
D5281 REMOVABLE UNILATERAL PARTIAL DENTURE - ONE PIECE CAST $ 1,097.53 D5410 ADJUST COMPLETE DENTURE - MAXILLARY $ 42.57 D5411 ADJUST COMPLETE DENTURE - MANDIBULAR $ 45.61 D5421 ADJUST PARTIAL DENTURE-MAXILLARY $ 45.61 D5422 ADJUST PARTIAL DENTURE - MANDIBULAR $ 44.59 D5510 REPAIR BROKEN COMPLETE DENTURE BASE $ 150.87 D5520 REPLACE MISSING OR BROKEN TEETH - COMPLETE DENTURE $ 119.05 D5610 REPAIR RESIN DENTURE BASE $ 143.00 D5620 REPAIR CAST FRAMEWORK $ 228.45 D5630 REPAIR OR REPLACE BROKEN CLASP $ 206.28 D5640 REPLACE BROKEN TEETH-PER TOOTH $ 119.05 D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE $ 158.73 D5660 ADD CLASP TO EXISTING PARTIAL DENTURE $ 222.37 D5710 REBASE COMPLETE MAXILLARY DENTURE $ 278.72 D5720 REBASE MAXILLARY PARTIAL DENTURE $ 261.48 D5721 REBASE MANDIBULAR PARTIAL DENTURE $ 259.46 D5730 RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) $ 277.78 D5731 RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) $ 277.78 D5740 RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) $ 180.54 D5741 RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE) $ 99.39 D5750 RELINE COMPLETE MAXILLARY DENTURE (LABORATORY) $ 357.15 D5751 RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY) $ 357.15 D5760 RELINE MAXILLARY PARTIAL DENTURE (LABORATORY) $ 286.00 D5761 RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY) $ 206.64 D5850 TISSUE CONDITIONING, MAXILLARY $ 76.02 D5851 TISSUE CONDITIONING,MANDIBULAR $ 80.07 D6010 SURGICAL PLACEMENT OF IMPLANT BODY: ENDOSTEAL IMPLANT $ 1,126.02 D6012 SURGICAL PLACEMENT OF INTERIM IMPLANT BODY-ENDOSTEAL $ 350.00 D6040 SURGICAL PLACEMENT:EPOSTEAL IMPLNT $ 4,684.46 D6050 SURGICAL PLACEMENT-TRANSOSTEAL IMPLANT $ 3,099.32 D6053 IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE FOR COMPLETELY EDENTULOUS ARCH $ 951.34 D6054 IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE FOR PARTIALLY ENDENTULOUS ARCH $ 932.09 D6055 CONNECTING BAR - IMPLANT SUPPORTED OR ABUTMENT $ 1,312.50 D6056 PREFABRICATED ABUTMENT $ 342.56 D6058 ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN $ 701.35 D6059 ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (HIGH NOBLE METAL) $ 698.31 D6060 ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (PREDOMINANTLY BASE METAL) $ 609.13 D6061 ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN $ 658.78 D6062 ABUTMENT SUPPORTED CAST METAL CROWN (HIGH NOBLE $ 669.94 D6063 ABUTMENT SUPPORTED CAST METAL CROWN (PREDOMINANTLY $ 609.13 D6064 ABUTMENT SUPPORTED CAST METAL CROWN (NOBLE METAL) $ 646.62 D6065 IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWN $ 750.00 D6066 D6067 IMPLANT SUPPORTED PORCELAIN FUSED TO METAL CROWN (TITANIUM, TITANIUM ALLOY, HIGH NOBLE METAL) $ 742.91 IMPLANT SUPPORTED METAL CROWN (TITANIUM, TITANIUM ALLOY, HIGH NOBLE METAL) $ 730.75 Page 4 of 7
D6068 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN/CERAMIC $ 685.14 D6069 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (HIGH NOBLE METAL) $ 681.08 D6070 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (PREDOMINANTLY BASE METAL) $ 635.48 D6071 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (NOBLE METAL) $ 658.78 D6072 ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (HIGH $ 680.07 D6073 ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (PREDOMINANTLY BASE METAL) $ 644.60 D6074 ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD $ 649.67 D6075 IMPLANT SUPPORTED RETAINER FOR CERAMIC FPD $ 722.64 D6076 IMPLANT SUPPORTED RETAINER FOR PORCELAIN FUSED TO $ 719.60 D6077 IMPLANT SUPPORTED RETAINER FOR CAST METAL FPD (TITANIUM, TITANIUM ALLOY, OR HIGH NOBLE METAL) $ 755.08 D6078 IMPLANT/ABUTMENT SUPPORTED FIXED DENTURE FOR COMPLETELY EDENTULOUS ARCH $ 1,719.80 D6079 IMPLANT/ABUTMENT SUPPORTED FIXED DENTURE FOR PARTIALLY EDENTULOUS ARCH $ 1,243.55 D6080 IMPLANT MAINTENANCE PROCEDURE $ 136.83 D6090 REPAIR IMPLANT PROSTHESIS $ 381.08 D6091 REPLACEMENT OF ATTACHMENT- IMPLANT/ABUTMENT $ 302.02 D6095 REPAIR IMPLANT ABUTMENT $ 393.25 D6100 IMPLANT REMOVAL, BY REPORT $ 402.37 D6101 DEBRIDEMENT OF A PERIIMPLANT DEFECT AND SURFACE CLEANING OF EXPOSED IMPLANT SURFACES, INCLUDING FLAP $ 96.29 D6102 DEBRIDEMENT OF IMPLANT SITE $ 132.77 D6103 BONE GRAFT FOR REPAIR OF PERIIMPLANT DEFECT NOT INCLUDING FLAP ENTRY AND CLOSURE OR, WHEN INDICATE $ 220.94 D6104 BONE GRAFT AT TIME OF IMPLANT PLACEMENT $ 220.94 D6190 RADIOGRAPHIC/SURGICAL IMPLANT INDEX, BY REPORT $ 115.50 D6210 PONTIC - CAST HIGH NOBLE METAL $ 559.46 D6211 PONTIC-CAST BASE METAL $ 559.46 D6212 PONTIC - CAST NOBLE METAL $ 559.46 D6214 PONTIC - TITANIUM $ 559.46 D6240 PONTIC-PORCELAIN FUSED-HIGH NOBLE $ 559.46 D6241 PONTIC-PORCELAIN FUSED TO BASE METAL $ 559.46 D6242 PONTIC-PORCELAIN FUSED-NOBLE METAL $ 559.46 D6245 PROSTHODONTICS FIXED, PONTIC - PORCELAIN/CERAMIC $ 559.46 D6545 RETAINER - CAST METAL FIXED $ 275.68 D6548 PROSTHODONTICS FIXED, RETAINER - PORCELAIN/CERAMIC FOR RESIN BONDED FIXED PROSTHODONTIC $ 275.68 D6740 RETAINER CROWN PORCELAIN/CERAMIC $ 559.46 D6750 CROWN-PORCELAIN FUSED HIGH NOBLE $ 559.46 D6751 CROWN-PORCELAIN FUSED TO BASE METAL $ 559.46 D6752 CROWN-PORCELAIN FUSED NOBLE METAL $ 559.46 D6780 CROWN-3/4 CST HIGH NOBLE METAL $ 559.46 D6781 PROSTHODONTICS FIXED, CROWN ¾ CAST PREDOMINANTLY $ 559.46 D6782 PROSTHODONTICS FIXED, CROWN ¾ CAST NOBLE METAL $ 559.46 Page 5 of 7
D6783 PROSTHODONTICS FIXED, CROWN ¾ PORCELAIN/CERAMIC $ 559.46 D6790 CROWN-FULL CAST HIGH NOBLE $ 559.46 D6791 CROWN - FULL CAST BASE METAL $ 559.46 D6792 CROWN - FULL CAST NOBLE METAL $ 559.46 D6930 RE-CEMENT OR RE-BOND FIXED PARTIAL DENTURE $ 107.25 D6980 FIXED PARTIAL DENTURE REPAIR $ 403.26 D7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL) $ 110.45 D7210 SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR SECTIONING OF TOOTH, AND INCLUDING ELEVATION OF MUCOPERIOSTEAL FLAP IF INDICATED $ 220.51 D7220 REMOVAL OF IMPACTED TOOTH-SOFT TISSUE $ 265.54 D7230 REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY $ 354.06 D7240 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY $ 460.12 D7241 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY, WITH UNUSUAL SURGICAL COMPLICATIONS $ 476.19 D7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING $ 265.54 D7251 CORONECTOMY-INTENTIONAL PARTIAL TOOTH REMOVAL IS PERFORMED WHEN A NEUROVASCULAR COMPLICATION IS LIKELY IF THE ENTIRE IMPACTED TOOTH IS REMOVED. $ 338.82 D7270 TOOTH REIMPLANTATION AND/OR STABILIZATION OF ACCIDENTALLY EVULSED OR DISPLACED TOOTH $ 309.24 D7280 SURGICAL ACCESS OF AN UNERUPTED TOOTH $ 226.66 D7310 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH SPACES, PER QUADRANT $ 265.54 D7311 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTH SPACES, PER QUADRANT $ 225.79 D7320 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH SPACES, PER QUADRANT $ 354.06 D7321 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTH SPACES, PER QUADRANT $ 284.48 D7471 REMOVAL OF EXOSTOSIS - PER SITE $ 386.82 D7510 INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE $ 125.13 D7910 SUTURE SMALL WOUNDS UP TO 5 CM $ 168.26 D7921 COLLECTION AND APPLICATION OF AUTOLOGOUS BLOOD CONCENTRATE PRODUCT $ 250.00 D7971 EXCISION OF PERICORONAL GINGIVA $ 117.57 D8010 LIMITED ORTHODONTIC TREATMENT OF THE PRIMARY $ 1,430.00 D8020 LIMITED ORTHODONTIC TREATMENT OF THE TRANSITIONAL $ 1,560.13 D8030 LIMITED ORTHODONTIC TREATMENT OF THE ADOLESCENT $ 1,358.50 D8050 INTERCEPTIVE ORTHODONTIC TREATMENT OF THE PRIMARY $ 2,145.00 D8060 INTERCEPTIVE ORTHODONTIC TREATMENT OF THE $ 2,359.50 D8070 COMPREHENSIVE ORTHODONTIC TREATMENT OF THE $ 4,968.06 D8080 COMPREHENSIVE ORTHODONTIC TREATMENT OF THE $ 5,074.26 D8210 REMOVABLE APPLIANCE THERAPY (INCLUDES APPLIANCES FOR THUMB SUCKING AND TONGUE THRUSTING) $ 650.65 Page 6 of 7
D8220 FIXED APPLIANCE THERAPY (INCLUDES APPLIANCES FOR THUMB SUCKING AND TONGUE THRUSTING) $ 1,036.75 D8660 PRE-ORTHODONTIC TREATMENT EXAMINATION TO MONITOR GROWTH AND DEVELOPMENT $ 50.67 D8680 ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES) $ 354.73 D9110 PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN - MINOR $ 72.08 D9223 DEEP SEDATION/GENERAL ANESTHESIA EACH 15 MINUTE $ 56.21 D9243 INTRAVENOUS MODERATE (CONSCIOUS) SEDATION/ANALGESIA EACH 15 MINUTE INCREMENT $ 135.84 D9310 CONSULTATION $ 63.86 D9610 THERAPEUTIC DRUG INJECTION, BY REPORT $ 26.36 D9930 TREATMENT OF COMPLICATIONS (POST-SURGICAL) - UNUSUAL CIRCUMSTANCES, BY REPORT $ 48.65 D9940 OCCLUSAL GUARD, BY REPORT $ 278.72 Page 7 of 7