D0140

LIMITED ORAL EVALUATION

$101.00

$24.00

$77.00

D0145

ORAL EVAL FOR PATIENT UNDER 3 YRS

$92.00

$24.00

$68.00

D0145

ORAL EVAL PT<3 YR CNSL PRIM CAREGIVER

$92.00

$24.00

$68.00

D0150

COMPREHENSIVE ORAL EXAMINATION

$120.00

$30.00

$90.00

D0160

DETAILED ORAL EVALUATION

$207.00

$30.00

$177.00

D0170

RE-EVALUATION-LIMITED

$93.00

$25.00

$68.00

D0180

COMPREHENSIVE PERIODONTAL EVAL

$128.00

$30.00

$98.00

D0210

X-RAYS-FULL MOUTH

$187.00

$60.00

$127.00

D0220

PERIAPICAL X-RAY FIRST FILM

$41.00

$10.00

$31.00

D0230

X-RAY PERIAPICAL - ADDITIONAL

$35.00

$6.00

$29.00

D0240

OCCLUSAL FILM

$57.00

$15.00

$42.00

D0250

XRAY - EXTRAORAL

$87.00

$35.00

$52.00

D0260

EXTRAORAL-EACH ADDITIONAL

$0.00

$25.00

'-

D0270

X-RAY 1 BITEWING

$41.00

$10.00

$31.00

D0272

X-RAYS 2 BITEWINGS

$64.00

$16.00

$48.00

D0273

X-RAYS 3 BITEWINGS

$77.00

$22.00

$55.00

D0274

X-RAYS 4 BITEWINGS

$92.00

$28.00

$64.00

D0277

VERTICAL BITEWINGS 7-8 FILMS

$136.00

$35.00

$101.00

D0290

X-RAY ANT. POST. OR LATERAL

$181.00

$40.00

$141.00

D0310

SIALOGRAPHY

$495.00

$50.00

$445.00

D0320

TMJ FILM

$793.00

$200.00

$593.00

D0321

TMJ FILM

$278.00

$80.00

$198.00

D0322

TOMOGRAPHIC SURVEY

$678.00

$175.00

$503.00

D0330

PANORAMIC FILM

$160.00

$50.00

$110.00

D0340

CEPHALOMETRIC FILM

$169.00

$50.00

$119.00

D0350

ORAL/FACIAL IMAGES

$100.00

$25.00

$75.00

D0364

CONE BEAM CT CAPTURE-LESS THAN WHOLE JAW

$427.00

$200.00

$227.00

D0365

CONE BEAM CT - MANDIBLE

$460.00

$200.00

$260.00

D0366

CONE BEAM CT

$440.00

$200.00

$240.00

D0367

CONE BEAM CT - WITH OR WITHOUT CRANIUM

$467.00

$200.00

$267.00

D0368

CONE BEAM CT CAPTURE AND INTER

$510.00

$200.00

$310.00

D0380

CONE BEAM CT

$366.00

$200.00

$166.00

D0381

CONE BEAM CT IMAGE

$423.00

$200.00

$223.00

D0382

CONE BEAM CT IMAGE CAPTURE WITH FIELD OF VIEW OF O

$408.00

$200.00

$208.00

D0383

CONE BEAM CT

$440.00

$200.00

$240.00

D0415

BACTERIOLOGIC STUDIES

$232.00

$25.00

$207.00

D0431

ADJUNCTIVE PRE-DIAGNOSTIC TEST

$93.00

$35.00

$58.00

D0460

PULP VITALITY TEST

$80.00

$20.00

$60.00

D0470

DIAGNOSTIC CASTS

$153.00

$40.00

$113.00

D0472

ACCESSION TISSUE, EXM, PREP, REP

$163.00

$40.00

$123.00

D0473

ACCESSION TISSUE-MICRO EXAM

$221.00

$60.00

$161.00

D0474

ACCESSION OF TISSUE, GROSS AND MICROSCOPIC EXAMINA

$259.00

$40.00

$219.00

D0502

OTHER ORAL PATHOLOGY PROCEDURES, BY REPORT

$176.00

$40.00

$136.00

D1110

PROPHYLAXIS

$101.00

$45.00

$56.00

D1120

PROPHYLAXIS - CHILD

$73.00

$35.00

$38.00

D1206

TOPICAL FLUORIDE VARNISH

$48.00

$20.00

$28.00

D1208

TOPICAL APPLICATION FLUORIDE

$42.00

$20.00

$22.00

D1310

NUTRITIONAL COUNSELING

$74.00

$15.00

$59.00

D1320

TOBACCO COUNSELING

$82.00

$15.00

$67.00

D1351

SEALANT

$61.00

$25.00

$36.00

D1352

PREVENTIVE RESIN RESTORATION

$113.00

$25.00

$88.00

D1510

SPACE MAINTAINER-FIXED

$442.00

$190.00

$252.00

D1516

SPACE MAINTAINER - FIXED - BILATERAL, MAXILLARY

$0.00

$225.00

'-

D1517

SPACE MAINTAINER - FIXED - BILATERAL, MANDIBULAR

$0.00

$225.00

'-

D1520

SPACE MAINTAINER - REMOVABLE

$534.00

$185.00

$349.00

D1526

SPACE MAINTAINER - REMOVABLE - BILATERAL, MAXILLAR

$0.00

$250.00

'-

D1527

SPACE MAINTAINER - REMOVABLE - BILATERAL, MANDIBULAR

$0.00

$250.00

'-

D1551

RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER

$0.00

$40.00

'-

D1552

RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER

$0.00

$40.00

'-

D1553

RE-CEMENT OR RE-BOND UNILATERAL SPACE MAINTAINER

$0.00

$40.00

'-

D2140

AMALGAM ONE SURFACE - PERMANENT OR PRIMARY

$200.00

$55.00

$145.00

D2150

AMALGAM TWO SURFACES - PERMANENT OR PRIMARY

$251.00

$70.00

$181.00

D2160

AMALGAM THREE SURFACES - PERM OR PRIME

$307.00

$80.00

$227.00

D2161

AMALGAM - FOUR OR MORE SURFACES PERM OR PRIM

$363.00

$95.00

$268.00

D2330

RESIN - ONE SURFACE

$236.00

$60.00

$176.00

D2331

RESIN - TWO SURFACES

$262.00

$75.00

$187.00

D2332

RESIN THREE OR MORE SURFACES

$307.00

$90.00

$217.00

D2335

RESIN - 4+ SRF OR INCISAL EDGE

$400.00

$100.00

$300.00

D2390

RESIN BASED COMPOSITE CROWN

$630.00

$200.00

$430.00

D2391

RESIN 1 SURFACE POSTERIOR

$258.00

$75.00

$183.00

D2392

RESIN-2 SURFACES, POSTERIOR

$331.00

$100.00

$231.00

D2393

RESIN-3 SURFACES, POST

$406.00

$115.00

$291.00

D2394

RESIN-4 OR MORE SRF-POST

$487.00

$125.00

$362.00

D2410

GOLD FOIL - 1 SURF.

$871.00

$200.00

$671.00

D2420

GOLD FOIL - 2 SURF.

$1,013.00

$275.00

$738.00

D2430

GOLD FOIL - 3 SURF.

$1,126.00

$325.00

$801.00

D2510

INLAY-METALLIC - ONE SURFACE

$1,178.00

$275.00

$903.00

D2520

INLAY METALLIC - TWO SURFACES

$1,268.00

$350.00

$918.00

D2530

INLAY-METALLIC - THREE OR MORE S

$1,350.00

$375.00

$975.00

D2542

ONLAY-METALLIC 2 SURFACE

$1,393.00

$400.00

$993.00

D2543

ONLAY-METALLIC 3 SURFACE

$1,468.00

$450.00

$1,018.00

D2544

ONLAY-METALLIC 4+ SURFACE

$1,532.00

$475.00

$1,057.00

D2610

INLAY-PORCELAIN 1 SURFACE

$1,272.00

$350.00

$922.00

D2620

INLAY-PORCELAIN 2 SURFACES

$1,333.00

$425.00

$908.00

D2630

INLAY-PORCELAIN-3 OR MORE SURF

$1,401.00

$500.00

$901.00

D2642

ONLAY-PORCELAIN/CERAMIC 2 SURFACE

$1,433.00

$400.00

$1,033.00

D2643

ONLAY - PORCELAIN/CERAMIC 3 SURFACE

$1,488.00

$500.00

$988.00

D2644

ONLAY - PORCELAIN/CERAMIC - FOUR OR MORE SURFACES

$1,545.00

$500.00

$1,045.00

D2650

INLAY-COMPOSITE-ONE SURFACE

$1,182.00

$200.00

$982.00

D2651

INLAY COMPOSITE 2 SRF

$1,221.00

$250.00

$971.00

D2652

INLAY COMPOSITE 3 SRF

$1,285.00

$300.00

$985.00

D2662

ONLAY - RESIN-BASED COMPOSITE - TWO SURFACES

$1,302.00

$300.00

$1,002.00

D2663

ONLAY - COMPOSITE 3 SURFACE

$1,364.00

$350.00

$1,014.00

D2664

ONLAY - COMPOSITE 4 OR MORE SRF

$1,417.00

$400.00

$1,017.00

D2710

CROWN - RESIN (LABORATORY)

$1,288.00

$200.00

$1,088.00

D2712

CROWN - 3/4 RESIN BASED COMP-IND

$1,396.00

$200.00

$1,196.00

D2720

CROWN - RESIN WITH METAL

$1,488.00

$500.00

$988.00

D2721

CROWN - RESIN WITH BASE METAL

$1,412.00

$450.00

$962.00

D2722

CROWN - RESIN WITH NOBLE METAL

$1,457.00

$475.00

$982.00

D2740

CROWN - PORCELAIN/CERAMIC SUBSTRATE

$1,606.00

$550.00

$1,056.00

D2750

CROWN - PORC. FUSED TO METAL

$1,609.00

$625.00

$984.00

D2751

CROWN - PORC. FUSED TO BASE METAL

$1,468.00

$575.00

$893.00

D2752

CROWN - PORC. FUSED TO NOBLE METAL

$1,533.00

$625.00

$908.00

D2780

CROWN - 3/4 CAST HIGH NOBLE METAL

$1,541.00

$550.00

$991.00

D2781

CROWN - 3/4 CAST BASE METAL

$1,446.00

$500.00

$946.00

D2782

CROWN - 3/4 CAST NOBLE METAL

$1,489.00

$500.00

$989.00

D2783

CROWN - 3/4 PORCELAIN/CERAMIC

$1,570.00

$475.00

$1,095.00

D2790

CROWN - FULL CAST METAL

$1,649.00

$500.00

$1,149.00

D2791

CROWN - FULL CAST BASE METAL

$1,453.00

$475.00

$978.00

D2792

CROWN - FULL CAST NOBLE METAL

$1,529.00

$475.00

$1,054.00

D2794

CROWN - TITANIUM

$1,574.00

$525.00

$1,049.00

D2799

PROVISIONAL CROWN

$611.00

$75.00

$536.00

D2910

RECEMENT INLAY

$160.00

$40.00

$120.00

D2915

RECEMENT POST & CORE

$153.00

$40.00

$113.00

D2920

RECEMENT CROWN

$155.00

$40.00

$115.00

D2929

PREFABRICATED PORCELAIN/CERAMIC CROWN ? PRIMARY TO

$494.00

$100.00

$394.00

D2930

PREFABRICATED SS CROWN-PRIMARY

$380.00

$100.00

$280.00

D2931

STAINLESS STEEL CROWN-PERM

$432.00

$100.00

$332.00

D2932

PREFAB RESIN CROWN

$475.00

$100.00

$375.00

D2933

PREFAB SS CROWN W/RESIN WINDOW

$488.00

$150.00

$338.00

D2934

PREFAB ESTHETIC COATED SS CRWN

$514.00

$100.00

$414.00

D2940

PROTECTIVE RESTORATION

$168.00

$40.00

$128.00

D2950

CROWN BUILD-UP

$374.00

$75.00

$299.00

D2951

PIN SUPPORT PER TOOTH

$104.00

$30.00

$74.00

D2952

CAST POST & CORE

$574.00

$160.00

$414.00

D2953

EACH ADDITIONAL INDIRECTLY FABRICATED POST - SAME

$419.00

$25.00

$394.00

D2954

PREFAB POST & CORE

$480.00

$120.00

$360.00

D2955

POST REMOVAL

$412.00

$75.00

$337.00

D2957

EACH ADDITIONAL PREFABRICATED POST - SAME TOOTH

$272.00

$20.00

$252.00

D2961

RESIN LAMINATE - LABORATORY

$1,334.00

$250.00

$1,084.00

D2962

PORCELAIN LAMINATE

$1,641.00

$375.00

$1,266.00

D2980

REPAIR BROKEN CROWN FACING

$396.00

$100.00

$296.00

D3110

PULP CAP-DIRECT

$117.00

$30.00

$87.00

D3120

PULP CAP-INDIRECT

$117.00

$20.00

$97.00

D3220

VITAL PULPOTOMY

$283.00

$80.00

$203.00

D3221

PULPAL DEBRIDEMENT

$324.00

$40.00

$284.00

D3222

PARTIAL PULPOTOMY FOR APEXOGENESIS

$404.00

$75.00

$329.00

D3230

PULPAL THERAPY-PRIMARY-ANTERIO

$384.00

$150.00

$234.00

D3240

PULPAL THERAPY-PRIMARY-POSTERI

$428.00

$200.00

$228.00

D3310

ROOT CANAL THERAPY-ANTERIOR TOOTH

$1,063.00

$350.00

$713.00

D3320

ROOT CANAL THERAPY-BICUSPID TOOTH

$1,209.00

$425.00

$784.00

D3330

ROOT CANAL THERAPY-MOLAR TOOTH

$1,466.00

$600.00

$866.00

D3331

TX OF ROOT CANAL OBSTRUCTION

$801.00

$125.00

$676.00

D3332

INCOMPLETE ENDODONTIC THERAPY

$626.00

$175.00

$451.00

D3333

INTERNAL ROOT REPAIR OF PERFORATION DEFECTS

$467.00

$75.00

$392.00

D3346

RETREATMENT-RCT - ANTERIOR

$1,221.00

$450.00

$771.00

D3347

RETREATMENT OF RCT - BICUSPID

$1,385.00

$525.00

$860.00

D3348

RETREATMENT RCT - MOLAR

$1,648.00

$700.00

$948.00

D3351

APEXIFICATION - INITIAL

$495.00

$150.00

$345.00

D3352

APEXIFICATION - INTERIM MEDICATION

$360.00

$100.00

$260.00

D3353

APEXIFICATION/RECALCIFICATION - FINAL VISIT

$735.00

$250.00

$485.00

D3410

APICOECTOMY - FIRST ROOT

$987.00

$250.00

$737.00

D3421

APICOECTOMY - PREMOLAR - FIRST ROOT

$1,101.00

$250.00

$851.00

D3425

APICOECTOMY - MOLAR - FIRST ROOT

$1,236.00

$250.00

$986.00

D3426

APICOECTOMY - EACH ADDITIONAL ROOT

$560.00

$150.00

$410.00

D3430

RETROGRADE FILLING

$387.00

$100.00

$287.00

D3450

ROOT RESECTION

$671.00

$200.00

$471.00

D3470

INTENTIONAL REPLANTATION

$1,095.00

$350.00

$745.00

D3910

ISOLATION OF TOOTH - RUBBER DAM

$307.00

$100.00

$207.00

D3920

HEMISECTION

$634.00

$200.00

$434.00

D3950

CANAL PREP. AND FITTING OF DOW

$347.00

$75.00

$272.00

D4210

GINGIVECTOMY OR GINGIVOPLASTY

$857.00

$250.00

$607.00

D4211

GINGIVECTOMY ONE TO THREE TEETH-PER QUAD

$434.00

$150.00

$284.00

D4230

ANATOMICAL CROWN EXPOSURE - FO

$1,047.00

$500.00

$547.00

D4231

ANATOMICAL CROWN

$814.00

$300.00

$514.00

D4240

GINGIVAL FLAP PROCEDURE

$1,025.00

$300.00

$725.00

D4241

GINGIVAL FLP PROC 1-3 CONTIG/BOUND TEETH SP

$854.00

$175.00

$679.00

D4245

APICALLY POSITIONED FLAP

$1,089.00

$125.00

$964.00

D4249

CROWN LENGTHENING

$1,071.00

$450.00

$621.00

D4260

OSSEOUS SURGERY - PER QUADRANT

$1,501.00

$525.00

$976.00

D4261

OSSEOUS SURGERY 1-3 TEETH

$1,221.00

$315.00

$906.00

D4263

OSSEOUS GRAFT - PER SITE

$885.00

$150.00

$735.00

D4264

OSSEOUS GRAFT-ADDTIONAL

$688.00

$100.00

$588.00

D4265

BIO MATERIALS TO AID REGEN

$734.00

$150.00

$584.00

D4266

GUIDED TISSUE REGEN-RESORB

$1,049.00

$225.00

$824.00

D4267

GUIDED TISSUE REGEN-NONRESORB

$1,201.00

$275.00

$926.00

D4268

GUIDED TISSUE REGENERATION

$1,093.00

$75.00

$1,018.00

D4270

PEDICLE SOFT TISSUE GRAFTS

$1,145.00

$300.00

$845.00

D4273

SUBEPITH.CONNECTIVE TISS. GRAF

$1,504.00

$600.00

$904.00

D4274

DISTAL OR PROXIMAL WEDGE PROCE

$929.00

$150.00

$779.00

D4275

SOFT TISSUE ALLOGRAFT

$1,418.00

$500.00

$918.00

D4276

COMB CON TIS DBL PED GRAFT/TTH

$1,494.00

$550.00

$944.00

D4277

FREE SOFT TISSUE GRAFT

$1,329.00

$325.00

$1,004.00

D4320

SPLINTING-INTRACORONAL

$703.00

$150.00

$553.00

D4321

SPLINTING-EXTRACORONAL

$643.00

$100.00

$543.00

D4341

PERIO TREATMENT PER QUAD

$363.00

$75.00

$288.00

D4342

SCALING-ROOT PLANING 1-3 TEETH

$259.00

$45.00

$214.00

D4355

FULL MOUTH DEBRIDEMENT

$256.00

$45.00

$211.00

D4381

LOCALIZED DELIV. OF CHEMO.AGEN

$107.00

$45.00

$62.00

D4910

PERIODONTAL MAINTENANCE

$193.00

$60.00

$133.00

D4920

UNSCHEDULED DRESSING CHANGE (OTHER THAN TX DR)

$143.00

$25.00

$118.00

D5110

COMPLETE UPPER DENTURE

$2,335.00

$725.00

$1,610.00

D5120

COMPLETE LOWER DENTURE

$2,427.00

$725.00

$1,702.00

D5130

IMMEDIATE FULL UPPER DENTURE

$2,591.00

$725.00

$1,866.00

D5140

IMMEDIATE FULL LOWER DENTURE

$2,599.00

$725.00

$1,874.00

D5211

UPPER PARTIAL-ACRYLIC BASE W/C

$1,901.00

$550.00

$1,351.00

D5212

LOWER PARTIAL ACRYLIC W/CLASPS

$1,901.00

$550.00

$1,351.00

D5213

UPPER PARTIAL - CAST METAL

$2,508.00

$750.00

$1,758.00

D5214

LOWER PARTIAL - CAST METAL

$2,528.00

$750.00

$1,778.00

D5225

MAXILLARY PARTIAL FLEX BASE

$2,228.00

$1,000.00

$1,228.00