Options Fees

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