Schedule | |||||
Code | Description | A | B | C | D |
100% | 75% | 50% | 25% | ||
Diagnostic Procedures | |||||
Exams | |||||
D0120 | Periodic oral evaluation | $17.08 | $12.81 | $8.54 | $4.27 |
D0140 | Limit oral eval problm focus | $22.58 | $16.94 | $11.29 | $5.65 |
D0150 | Comprehensve oral evaluation | $26.35 | $19.76 | $13.18 | $6.59 |
D0180 | Comp periodontal evaluation | $26.35 | $19.76 | $13.18 | $6.59 |
X-rays | |||||
D0210 | Intraor complete film series | $60.00 | $45.00 | $30.00 | $15.00 |
D0220 | Intraoral periapical first | $5.00 | $3.75 | $2.50 | $1.25 |
D0230 | Intraoral periapical ea add | $5.00 | $3.75 | $2.50 | $1.25 |
D0240 | Intraoral occlusal film | $12.00 | $9.00 | $6.00 | $3.00 |
D0250 | Extraoral first film | $13.46 | $10.10 | $6.73 | $3.37 |
D0270 | Dental bitewing single image | $5.00 | $3.75 | $2.50 | $1.25 |
D0272 | Dental bitewings two images | $10.00 | $7.50 | $5.00 | $2.50 |
D0273 | Bitewings - three images | $14.70 | $11.03 | $7.35 | $3.68 |
D0274 | Bitewings four images | $20.00 | $15.00 | $10.00 | $5.00 |
D0321 | Other tmj images by report | $51.77 | $38.83 | $25.89 | $12.94 |
D0330 | Panoramic image | $46.32 | $34.74 | $23.16 | $11.58 |
D0340 | Cephalometric image | $60.00 | $45.00 | $30.00 | $15.00 |
D0350 | Oral/facial photo images | $12.31 | $9.23 | $6.16 | $3.08 |
Other | |||||
D0367 | Conebeam CT views both jaws w/wo cranium | $106.32 | $79.74 | $53.16 | $26.58 |
D0470 | Diagnostic casts | $22.02 | $16.52 | $11.01 | $5.51 |
Preventive Procedures | |||||
Cleanings | |||||
D1110 | Dental prophylaxis adult | $34.13 | $25.60 | $17.07 | $8.53 |
D1120 | Dental prophylaxis child | $20.00 | $15.00 | $10.00 | $5.00 |
Other | |||||
D1206 | Topical fluoride varnish | $15.00 | $11.25 | $7.50 | $3.75 |
D1208 | Topical app of fluoride | $15.00 | $11.25 | $7.50 | $3.75 |
D1320 | Tobacco counseling | $15.00 | $11.25 | $7.50 | $3.75 |
D1351 | Dental sealant per tooth | $22.00 | $16.50 | $11.00 | $5.50 |
D1354 | Interim caries arresting med application | $15.00 | $11.25 | $7.50 | $3.75 |
D1510 | Space maintainer fxd unilat – per quad | $113.71 | $85.28 | $56.86 | $28.43 |
D1516 | Space maintainer - fixed – bilateral,maxillary | $163.28 $122.46 | $81.64 | $40.82 | |
D1517 | Space maintaioner– fixed bilateral, mandibular | $163.28 $122.46 | $81.64 | $40.82 | |
D1520 | Remove unilat space maintainer -per quad | $125.08 | $93.81 | $62.54 | $31.27 |
D1526 | Space maintaner remov bilateral,maxillary | $133.79 $100.34 | $66.90 | $33.45 | |
D1527 | Space maintaner remov bilateral, mandibular | $133.79 $100.34 | $66.90 | $33.45 | |
Basic Restorative Procedures | |||||
D2140 | Amalgam one surface | $40.00 | $30.00 | $20.00 | $10.00 |
D2150 | Amalgam two surfaces | $54.00 | $40.50 | $27.00 | $13.50 |
D2160 | Amalgam three surfaces | $65.00 | $48.75 | $32.50 | $16.25 |
D2161 | Amalgam 4 or > surfaces | $76.54 | $57.41 | $38.27 | $19.14 |
D2330 | Resin one surface-anterior | $51.21 | $38.41 | $25.61 | $12.80 |
D2331 | Resin two surfaces- anterior | $63.49 | $47.62 | $31.75 | $15.87 |
D2332 | Resin three surfaces- anterior | $76.62 | $57.47 | $38.31 | $19.16 |
D2335 | Resin 4/> surf or w incis angle | $94.95 | $71.21 | $47.48 | $23.74 |
D2390 | Ant resin-based cmpst crown | $94.95 | $71.21 | $47.48 | $23.74 |
D2391 | Post 1 srfc resinbased cmpst | $51.21 | $38.41 | $25.61 | $12.80 |
D2392 | Post 2 srfc resinbased cmpst | $54.00 | $40.50 | $27.00 | $13.50 |
D2393 | Post 3 srfc resinbased cmpst | $65.00 | $48.75 | $32.50 | $16.25 |
D2394 | Post >=4srfc resinbased cmpst | $76.54 | $57.41 | $38.27 | $19.14 |
Crowns | |||||
D2740 | Crown porcelain/ceramic | $427.29 $320.47 $213.65 $106.82 | |||
D2751 | Crown porcelain fused base met | $427.29 | $320.47 $213.65 $106.82 | ||
D2752 | Crown porcelain w/ noble met | $427.29 $320.47 $213.65 $106.82 | |||
D2920 | Recement/re-bond crown | $45.00 | $33.75 | $22.50 | $11.25 |
D2928 | Prefab porcelain/ceramic crown, anterior | $153.00 $114.75 | $76.50 | $38.25 | |
D2928 | Prefab porcelain/ceramic, posterior | $101.92 | $76.44 | $50.96 | $25.48 |
D2929 | Prefab porcelin/ceramic crown, anterior | $153.00 $114.75 | $76.50 | $38.25 | |
D2929 | Prefab porcelin/ceramic crown, posterior | $101.92 | $76.44 | $50.96 | $25.48 |
D2930 | Prefab stnlss steel crwn pri | $101.92 | $76.44 | $50.96 | $25.48 |
D2931 | Prefab stnlss steel crown pe | $116.51 | $87.38 | $58.26 | $29.13 |
D2933 | Prefab stainless steel crown | $153.00 $114.75 | $76.50 | $38.25 | |
D2934 | Prefab steel crown primary | $153.00 $114.75 | $76.50 | $38.25 | |
D2940 | Protective restoration perm/primary tooth | $18.00 | $13.50 | $9.00 | $4.50 |
D2941 | Interim therapeutic restoration primary tooth | $18.00 | $13.50 | $9.00 | $4.50 |
D2950 | Core buildup including pins | $76.54 | $57.41 | $38.27 | $19.14 |
D2951 | Tooth pin retention | $16.49 | $12.37 | $8.25 | $4.12 |
D2952 | Post and core cast + crown | $136.32 $102.24 | $68.16 | $34.08 | |
D2954 | Prefab post/core + crown | $136.32 $102.24 | $68.16 | $34.08 | |
Root Canal Procedures | |||||
D3220 | Therapeutic pulpotomy | $63.74 | $47.81 | $31.87 | $15.94 |
D3310 | End thxpy, anterior tooth | $247.63 $185.72 $123.82 | $61.91 | ||
D3320 | End thxpy, premolar tooth | $298.10 $223.58 $149.05 | $74.53 | ||
D3330 | End thxpy, molar tooth | $379.02 $284.27 $189.51 | $94.76 | ||
D3351 | Apexification/recalc initial | $60.00 | $45.00 | $30.00 | $15.00 |
D3352 | Apexification/recalc interim | $40.00 | $30.00 | $20.00 | $10.00 |
D3353 | Apexification/recalc final | $40.00 | $30.00 | $20.00 | $10.00 |
D3410 | Apicoectomy - anterior | $178.00 $133.50 | $89.00 | $44.50 | |
Periodontal/Gingival Procedures | |||||
D4210 | Gingivectomy/plasty 4 or more teeth | $197.20 $147.90 | $98.60 | $49.30 | |
D4211 | Gingivectomy/plasty 1 to 3 teeth | $118.80 | $89.10 | $59.40 | $29.70 |
D4341 | Periodontal scaling, 4 or more teeth, quad | $95.99 | $71.99 | $48.00 | $24.00 |
D4342 | Periodontal scaling, 1-3 teeth, quad | $65.00 | $48.75 | $32.50 | $16.25 |
D4910 | Periodontal maint procedures | $34.13 | $25.60 | $17.07 | $8.53 |
Prosthodontics | |||||
D5110 | Dentures complete maxillary | $400.00 $300.00 $200.00 $100.00 | |||
D5120 | Dentures complete mandible | $400.00 $300.00 $200.00 $100.00 | |||
D5130 | Immediate denture (complete) -maxillary | $400.00 $300.00 $200.00 $100.00 | |||
D5140 | Immediate denture (complete) -mandibular | $400.00 $300.00 $200.00 $100.00 | |||
D5211 | Denures maxill part resin incl reten claps rest teeth | $205.00 $153.75 $102.50 | $51.25 | ||
D5212 | Denures mand part resin incl reten claps rest teeth | $205.00 $153.75 $102.50 | $51.25 | ||
D5213 | Dentures maxill part metal | $540.25 $405.19 $270.13 $135.06 | |||
D5214 | Dentures mandibl part metal | $540.25 $405.19 $270.13 $135.06 | |||
D5510 | Dentur repr broken compl base | $70.00 | $52.50 | $35.00 | $17.50 |
D5511 | Rep Broke Comp Dent Base Man | $70.00 | $52.50 | $35.00 | $17.50 |
D5512 | Rep Broke Comp Dent Base Max | $70.00 | $52.50 | $35.00 | $17.50 |
D5520 | Replace denture teeth complt | $70.00 | $52.50 | $35.00 | $17.50 |
D5610 | Dentures repair resin base | $70.00 | $52.50 | $35.00 | $17.50 |
D5611 | Rep Resin part Dent Base Man | $70.00 | $52.50 | $35.00 | $17.50 |
D5612 | Rep Resin part Dent Base Max | $70.00 | $52.50 | $35.00 | $17.50 |
D5620 | Rep part denture cast frame | $81.90 | $61.43 | $40.95 | $20.48 |
D5621 | Rep Cast Part Frame Man | $81.90 | $61.43 | $40.95 | $20.48 |
D5622 | Rep Cast Part Frame Max | $81.90 | $61.43 | $40.95 | $20.48 |
D5630 | Rep partial denture clasp per tooth | $77.70 | $58.28 | $38.85 | $19.43 |
D5640 | Replace part denture teeth | $70.00 | $52.50 | $35.00 | $17.50 |
D5650 | Add tooth to partial denture | $70.00 | $52.50 | $35.00 | $17.50 |
D5660 | Add clasp to partial denture | $74.00 | $55.50 | $37.00 | $18.50 |
D5750 | Denture reln cmplt max lab indirect | $175.51 | $131.63 | $87.76 | $43.88 |
D5751 | Denture reln cmplt mand lab indirect | $175.80 $131.85 | $87.90 | $43.95 | |
D5760 | Denture reln part maxil lab indirect | $140.00 $105.00 | $70.00 | $35.00 | |
D5761 | Denture reln part mand lab indirect | $140.00 $105.00 | $70.00 | $35.00 | |
D5899 | Removable prosthodontic proc | $40.00 | $30.00 | $20.00 | $10.00 |
Extractions/Oral Surgery | |||||
D7140 | Extraction erupted tooth/exr | $57.69 | $43.27 | $28.85 | $14.42 |
D7210 | Extract erupted tooth remov bone/section/eleva flap | $57.69 | $43.27 | $28.85 | $14.42 |
D7220 | Impact tooth remov soft tiss | $102.00 | $76.50 | $51.00 | $25.50 |
D7230 | Impact tooth remov part bony | $151.46 $113.60 | $75.73 | $37.87 | |
D7240 | Impact tooth remov comp bony | $188.80 $141.60 | $94.40 | $47.20 | |
D7241 | Impact tooth rem bony w/comp | $200.00 $150.00 $100.00 | $50.00 | ||
D7250 | Tooth root removal | $66.00 | $49.50 | $33.00 | $16.50 |
D7260 | Oral Antrl fistula closure | $245.00 $183.75 $122.50 | $61.25 | ||
D7270 | Tooth reimplantation | $101.06 | $75.80 | $50.53 | $25.27 |
D7280 | Exposure impact tooth orthod | $152.30 $114.23 | $76.15 | $38.08 | |
D7283 | Placmt device facilitate erupt impact tooth after erupt | $75.00 | $56.25 | $37.50 | $18.75 |
D7285 | Biopsy of oral tissue hard | $150.00 $112.50 | $75.00 | $37.50 | |
D7286 | Biopsy of oral tissue soft | $130.00 | $97.50 | $65.00 | $32.50 |
D7310 | Alveoloplasty 4 or more teeth w/ extraction | $99.06 | $74.30 | $49.53 | $24.77 |
D7311 | Alveoloplasty 1 to 3 teeth w/ extraction | $49.53 | $37.15 | $24.77 | $12.38 |
D7320 | Alveoloplasty w/o extraction | $120.64 | $90.48 | $60.32 | $30.16 |
D7450 | Remove odontogen cyst to 1.25 cm | $105.79 | $79.34 | $52.90 | $26.45 |
D7451 | Remove odontogen cyst > 1.25 cm | $230.59 $172.94 $115.30 | $57.65 | ||
D7460 | Remove nonodontogen cyst to 1.25 cm | $145.00 $108.75 | $72.50 | $36.25 | |
D7461 | Remove nonodontogen cyst > 1.25 cm | $240.29 | $180.22 $120.15 | $60.07 | |
D7471 | Rem exostosis any site | $127.00 | $95.25 | $63.50 | $31.75 |
D7472 | Removal of torus palatinus | $127.00 | $95.25 | $63.50 | $31.75 |
D7473 | Remove torus mandibularis | $127.00 | $95.25 | $63.50 | $31.75 |
D7510 | I&d absc intraoral soft tiss | $76.00 | $57.00 | $38.00 | $19.00 |
D7520 | I&d abscess extraoral | $86.00 | $64.50 | $43.00 | $21.50 |
D7670 | Alveolus closed reduction | $243.15 $182.36 $121.58 | $60.79 | ||
D7671 | Alveolus open reduction | $318.75 $239.06 $159.38 | $79.69 | ||
Miscellaneous | |||||
D7899 | Tmj unspecified therapy | $482.50 $361.88 $241.25 $120.63 | |||
D7960 | Frenulectomy/frenectomy | $119.13 | $89.35 | $59.57 | $29.78 |
D7961 | Buccal/labial frenectomy/frenulectomy | $119.13 | $89.35 | $59.57 | $29.78 |
D7962 | Lingual frenectomy /frenulectomy | $119.13 | $89.35 | $59.57 | $29.78 |
D7970 | Excision hyperplastic tissue | $66.00 | $49.50 | $33.00 | $16.50 |
D8080 | Compre dental tx adolescent | $624.00 $468.00 $312.00 $156.00 | |||
D8210 | Orthodontic rem appliance tx | $205.00 $153.75 $102.50 | $51.25 | ||
D8220 | Fixed appliance therapy habt | $300.00 $225.00 $150.00 | $75.00 | ||
D8670 | Periodic orthodontic tx visit | $261.94 $196.46 $130.97 | $65.49 | ||
D8680 | Orthodontic retention | $205.00 $153.75 $102.50 | $51.25 | ||
D9222 | Deep Anesthesia | $120.65 | $90.49 | $60.33 | $30.16 |
D9223 | Deep sedation/general anesthesia | $70.00 | $52.50 | $35.00 | $17.50 |
D9239 | IV MOD Sedation | $70.00 | $52.50 | $35.00 | $17.50 |
D9243 | Intravenous conscious sedation/analgesia | $40.00 | $30.00 | $20.00 | $10.00 |
D9610 | Dent therapeutic drug inject, single admin | $25.18 | $18.89 | $12.59 | $6.30 |
D9612 | Dent therap drug inject, 2 or more admin, diff. meds | $50.36 | $37.77 | $25.18 | $12.59 |
D9944 | Occlusal guard – hard appliance, full arch | $205.00 $153.75 $102.50 | $51.25 | ||
D9945 | Occlusal guard – soft appliance, full arch | $205.00 $153.75 $102.50 | $51.25 | ||
D9946 | Occlusal guard – hard appliance, partial arch | $205.00 $153.75 $102.50 | $51.25 | ||
1800 15th Street, Suite 100
Denver, CO 80202
Phone: 303.534.5360
Fax: 303.534.5290
