|
Code
|
Procedure
|
Typical Charge
|
What You'll Pay
|
Savings
|
|
|---|---|---|---|---|---|
| D0150 | COMPREHENSIVE ORAL EXAMINATION | $120.00 | $45.00 | $75.00 | |
| D0210 | X-RAYS-FULL MOUTH | $187.00 | $50.00 | $137.00 | |
| D0220 | PERIAPICAL X-RAY FIRST FILM | $41.00 | $6.00 | $35.00 | |
| D0240 | 0CCLUSAL FILM | $57.00 | $15.00 | $42.00 | |
| D0270 | X-RAY 1 BITEWING | $41.00 | $6.00 | $35.00 | |
| D0330 | PANORAMIC FILM | $160.00 | $50.00 | $110.00 | |
| D1110 | PROPHYLAXIS | $101.00 | $45.00 | $56.00 | |
| D1120 | PROPHYLAXIS-CHILD | $73.00 | $45.00 | $28.00 | |
| D1351 | SEALANT | $61.00 | $30.00 | $31.00 | |
| D1510 | SPACE MAINTAINER-FIXED | $442.00 | $300.00 | $142.00 | |
| D2140 | AMALGAM ONE SURFACE -PERMANENT OR PRIMARY | $200.00 | $55.00 | $145.00 | |
| D2150 | AMALGAM TWO SURFACES-PERMANENT OR PRIMARY | $251.00 | $65.00 | $186.00 | |
| D2160 | AMALGAM THREE SURFACES-PERM OR PRIME | $307.00 | $75.00 | $232.00 | |
| D2330 | RESIN - ONE SURFACE | $236.00 | $70.00 | $166.00 | |
| D2335 | RESIN-4+ SRF OR INCISAL EDGE | $400.00 | $85.00 | $315.00 | |
| D2510 | INLAY-METALLIC -ONE SURFACE | $1,178.00 | $150.00 | $1,028.00 | |
| D2520 | INLAY METALLIC -TWO SURFACES | $1,268.00 | $175.00 | $1,093.00 | |
| D2530 | INLAY-METALLIC-THREE OR MORE S | $1,350.00 | $200.00 | $1,150.00 | |
| D2710 | CROWN-RESIN (LABORATORY) | $1,288.00 | $250.00 | $1,038.00 | |
| D2721 | CROWN-RESIN WITH BASE METAL | $1,412.00 | $370.00 | $1,042.00 | |
| D2740 | CROWN – PORCELAIN/CERAMIC SUBSTRATE | $1,606.00 | $425.00 | $1,181.00 | |
| D2751 | CROWN-PORC.FUSED TO BASE METAL | $1,468.00 | $475.00 | $993.00 | |
| D2781 | CROWN-3/4 CAST BASE METAL | $1,446.00 | $325.00 | $1,121.00 | |
| D2791 | CROWN-FULL CAST BASE METAL | $1,453.00 | $350.00 | $1,103.00 | |
| D2920 | RECEMENT CROWN | $155.00 | $15.00 | $140.00 | |
| D2930 | PREFABRICATED SS CROWN-PRIMARY | $380.00 | $150.00 | $230.00 | |
| D2951 | PIN SUPPORT PER TOOTH | $104.00 | $12.00 | $92.00 | |
| D2952 | CAST POST & CORE | $574.00 | $125.00 | $449.00 | |
| D2954 | PREFAB POST & CORE | $480.00 | $60.00 | $420.00 | |
| D2960 | LABIAL LAMINATE | $890.00 | $215.00 | $675.00 | |
| D3110 | PULP CAP-DIRECT | $117.00 | $10.00 | $107.00 | |
| D3220 | VITAL PULPOTOMY | $283.00 | $35.00 | $248.00 | |
| D3310 | ROOT CANAL THERAPY-ANTERIOR TOOTH | $1,063.00 | $275.00 | $788.00 | |
| D3320 | ROOT CANAL THERAPY-BICUSPID TOOTH | $1,209.00 | $350.00 | $859.00 | |
| D3330 | ROOT CANAL THERAPY-MOLAR TOOTH | $1,466.00 | $525.00 | $941.00 | |
| D3346 | RETREATMENT-RCT -ANTERIOR | $1,221.00 | $550.00 | $671.00 | |
| D3347 | RETREATMENT OF RCT - BICUSPID | $1,385.00 | $700.00 | $685.00 | |
| D3348 | RETREATMENT RCT-MOLAR | $1,648.00 | $1,050.00 | $598.00 | |
| D3410 | APICOECTOMY-FIRST ROOT | $987.00 | $275.00 | $712.00 | |
| D3426 | APICOECTOMY-EACH ADDITIONAL RT | $560.00 | $425.00 | $135.00 | |
| D3430 | RETROGRADE FILLING | $387.00 | $75.00 | $312.00 | |
| D3450 | ROOT RESECTION | $671.00 | $100.00 | $571.00 | |
| D3920 | HEMISECTION | $634.00 | $100.00 | $534.00 | |
| D4210 | GINGIVECTOMY OR GINGIVOPLASTY | $857.00 | $110.00 | $747.00 | |
| D4249 | CROWN LENGTHENING | $1,071.00 | $110.00 | $961.00 | |
| D4260 | OSSEOUS SURGERY-PER QUADRANT | $1,501.00 | $350.00 | $1,151.00 | |
| D4261 | OSSEOUS SURGERY 1 -3 TEETH | $1,221.00 | $200.00 | $1,021.00 | |
| D4263 | OSSEOUS GRAFT- PER SITE | $885.00 | $110.00 | $775.00 | |
| D4341 | PERIO TREATMENT PER QUAD | $363.00 | $35.00 | $328.00 | |
| D4910 | PERIODONTAL MAINTENANCE | $193.00 | $70.00 | $123.00 | |
| D5110 | COMPLETE UPPER DENTURE | $2,335.00 | $475.00 | $1,860.00 | |
| D5130 | IMMEDIATE FULL UPPER DENTURE | $2,591.00 | $475.00 | $2,116.00 | |
| D5140 | IMMEDIATE FULL LOWER DENTURE | $2,599.00 | $475.00 | $2,124.00 | |
| D5211 | UPPER PARTIAL-ACRYLIC BASE W/C | $1,901.00 | $375.00 | $1,526.00 | |
| D5212 | LOWER PARTIAL ACRYLIC W/CLASPS | $1,901.00 | $375.00 | $1,526.00 | |
| D5213 | UPPER PARTIAL - CAST METAL | $2,508.00 | $475.00 | $2,033.00 | |
| D5214 | LOWER PARTIAL - CAST METAL | $2,528.00 | $475.00 | $2,053.00 | |
| D5281 | REMOVABLE UNILATERAL | $1,368.00 | $275.00 | $1,093.00 | |
| D5510 | REPAIR FULL DENTURE BASE | $300.00 | $90.00 | $210.00 | |
| D5630 | REPAIR OR REPLACE BROKEN CLASP | $379.00 | $63.00 | $316.00 | |
| D5640 | REPLACE BROKEN TOOTH | $267.00 | $65.00 | $202.00 | |
| D5650 | ADD TOOTH TO DENTURE | $320.00 | $90.00 | $230.00 | |
| D5730 | RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) | $527.00 | $85.00 | $442.00 | |
| D5731 | RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) | $524.00 | $85.00 | $439.00 | |
| D5740 | RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) | $519.00 | $85.00 | $434.00 | |
| D5741 | RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE) | $520.00 | $85.00 | $435.00 | |
| D5750 | RELINE UPPER DENTURE-LAB | $647.00 | $165.00 | $482.00 | |
| D5751 | RELINE COMP LOWER DENTURE-LAB | $667.00 | $165.00 | $502.00 | |
| D5760 | RELINE PARTIAL UPPER-LAB | $660.00 | $165.00 | $495.00 | |
| D5761 | RELINE PARTIAL LOWER-LAB. | $660.00 | $165.00 | $495.00 | |
| D6010 | ENDOSTEAL IMPLANT | $2,671.00 | $1,200.00 | $1,471.00 | |
| D6241 | PONTIC-PORC.FUSED TO BASE META | $1,468.00 | $375.00 | $1,093.00 | |
| D6545 | MARYLAND BRIDGE RETAINER | $1,171.00 | $150.00 | $1,021.00 | |
| D6980 | FIXED PARTIAL DENTURE REPAIR NECESSITATED BY RESTO | $536.00 | $50.00 | $486.00 | |
| D7140 | EXTRACTION ERUPTED TOOTH OR EXPOSED ROOT | $254.00 | $55.00 | $199.00 | |
| D7210 | SURGICAL EXTRACTION | $392.00 | $145.00 | $247.00 | |
| D7220 | REMOVAL-SOFT TISSUE IMPACTED | $447.00 | $120.00 | $327.00 | |
| D7230 | REMOVAL-PARTIAL BONY IMPACTED | $558.00 | $200.00 | $358.00 | |
| D7240 | REMOVAL-COMPLETE BONY IMPACTED | $679.00 | $300.00 | $379.00 | |
| D7250 | REMOVAL OF RESIDUAL ROOTS | $427.00 | $120.00 | $307.00 | |
| D7260 | CLOSURE OF ORAL ANTRAL FISTULA | $1,358.00 | $65.00 | $1,293.00 | |
| D7280 | SURG.EXP-IMP/UNERUP(FOR ORTHO) | $663.00 | $150.00 | $513.00 | |
| D7285 | BIOPSY HARD TISSUE | $600.00 | $55.00 | $545.00 | |
| D7286 | BIOPSY SOFT TISSUE | $463.00 | $55.00 | $408.00 | |
| D7310 | ALVEOLECTOMY | $419.00 | $65.00 | $354.00 | |
| D7320 | ALVEOLECTOMY-PER QUAD.-NO EXT | $616.00 | $65.00 | $551.00 | |
| D7450 | CYST/TUMOR REMOVAL < 1.25 CM | $835.00 | $65.00 | $770.00 | |
| D7960 | FRENULECTOMY | $634.00 | $65.00 | $569.00 | |
| D8080 | INITIAL ORTHO APP-ADOLESCENT | $7,154.00 | $675.00 | $6,479.00 | |
| D8670 | ACTIVE ORTHO TREAT PER MONTH | $358.00 | $60.00 | $298.00 | |
| D8680 | ORTHO RETENTION (REMOV APP, CONSTR/PLACE RETAINER) | $667.00 | $300.00 | $367.00 | |
| D9110 | PALLIATIVE TREATMENT | $180.00 | $30.00 | $150.00 | |
| D9220 | GENERAL ANESTHESIA | $0.00 | $85.00 | - | |
| D9221 | GENERAL ANESTHESIA ADDITIONAL | $0.00 | $85.00 | - | |
| D9230 | ANALGESIA | $107.00 | $35.00 | $72.00 | |
| D9310 | SPECIALIST CONSULTATION | $177.00 | $75.00 | $102.00 | |