CodeDescriptionRegular FeePlan Fee
D0120Periodic oral evaluation – established patient490
D0140Limited oral evaluation – problem focused800
D0145Oral evaluation for a patient under 3 & counseling with caregiver7660
D0150Comprehensive oral evaluation – new or established patient860
D0160Detailed and extensive oral evaluation – problem focused, by report1720
D0170Re-evaluation – limited, problem focused - established patient570
D0171Re-evaluation Post-Operative Visit570
D0180Comprehensive periodontal evaluation – new or established patient930
D0190Screening of a Patient490
D0191Assessment of a Patient340
D0210Intraoral – complete series of radiographic images1300
D0220Intraoral – periapical first radiographic image260
D0230Intraoral – periapical each additional radiographic image230
D0270Bitewing – single radiographic image440
D0272Bitewings – two radiographic images620
D0274Bitewings – four radiographic images640
D0322Tomographic survey400320
D0330Panoramic radiographic image7560
D0340Cephalometric radiographic image12197
D0350Oral/facial photographic images5846
D0431Adjunctive pre-diagnostic test for mucosal abnormalities3024
D0460Pulp vitality tests3024
D0470Diagnostic casts7761
D0480Processing and interpretation of exfoliative cytologic smears7056
D0486Accession of brush biopsy, microscopic examination, by report8467
D1110Prophylaxis – adult8989
D1120Prophylaxis – child6060
D1206Topical application of fluoride varnish4839
D1208Topical application of fluoride3729
D1310Nutritional counseling for control of dental disease4838
D1320Tobacco counseling for the prevention of oral disease5241
D1330Oral hygiene instructions6652
D1351Sealant – per tooth5342
D1352Preventive Resin on Permanent Tooth6855
D1353Sealant Repair6855
D1354Interim Caries Arresting Medication Application5846
D1510Space maintainer – fixed – unilateral317253
D1515Space maintainer – fixed – bilateral444355
D1520Space maintainer – removable – unilateral349279
D1525Space maintainer – removable – bilateral540432
D1550Re-cementation of space maintainer6955
D1555Removal of fixed space maintainer6652
D2140Amalgam – one surface, primary or permanent 131104
D2150Amalgam – two surfaces, primary or permanent204164
D2160Amalgam – three surfaces, primary or permanent249199
D2161Amalgam – four or more surfaces, primary or permanent249199
D2330Resin-based composite – one surface, anterior152121
D2331Resin-based composite – two surfaces, anterior194155
D2332Resin-based composite – three surfaces, anterior237189
D2335Resin-based composite – four or more surfaces, anterior280224
D2390Resin-based composite crown, anterior311249
D2391Resin-based composite – one surface, posterior178142
D2392Resin-based composite – two surfaces, posterior233186
D2393Resin-based composite – three surfaces, posterior289231
D2394Resin-based composite – four or more surfaces, posterior354283
D2610Inlay – porcelain/ceramic – one surface1013810
D2620Inlay – porcelain/ceramic – two1069855
D2630Inlay – porcelain/ceramic – three or more surfaces1139911
D2740Crown – porcelain/ceramic substrate1142913
D2751Crown – porcelain fused to predominantly base metal1049850
D2791Crown – full cast base metal1030824
D2792Crown – full cast noble metal1049839
D2799Provisional crown451360
D2915Recement cast or prefabricated post and core9878
D2920Recement crown9978
D2929Prefabricated Stainless and Porcelain Crown- Primary Tooth393314
D2930Prefabricated stainless steel crown – primary tooth271216
D2931Prefabricated stainless steel crown – permanent tooth306244
D2932Prefabricated resin crown326260
D2933Prefabricated stainless steel crown with resin window374299
D2934Prefabricated esthetic coated stainless steel crown – primary374299
D2940Protective Restoration10382
D2950Core buildup, including any pins218175
D2951Pin retention – per tooth, in addition to restoration5846
D2952Cast post and core in addition to crown408326
D2954Prefabricated post and core in addition to crown326260
D2955Post removal252201
D2960Chairside Labial Veneer - Resin280224
D2961Labial veneer (resin laminate) – laboratory1013810
D2962Labial veneer (porcelain laminate) – laboratory1101880
D2971Procedure to construct new crown under existing partial156124
D3110Pulp cap – direct (excluding final restoration)9383
D3120Pulp cap – indirect (excluding final restoration)7459
D3220Therapeutic pulpotomy190152
D3221Pulpal debridement, primary and permanent teeth208166
D3310Anterior (excluding final restoration)726580
D3320Bicuspid (excluding final restoration)890712
D3330Molar (excluding final restoration)1104883
D3346Retreatment of previous root canal therapy – anterior969775
D3347Retreatment of previous root canal therapy – bicuspid11391025
D3348Retreatment of previous root canal therapy – molar14101359
D3351Apexification/recalcification – initial visit380342
D3352Apexification/recalcification – interim170243
D3353Apexification/recalcification – final visit524419
D3410Apicoectomy/periradicular surgery – anterior754603
D3421Apicoectomy/periradicular surgery – bicuspid839671
D3425Apicoectomy/periradicular surgery – molar951760
D3426Apicoectomy/periradicular surgery (each additional root)321256
D3427Periradicular Surgery without Apicoectomy682545
D3430Retrograde filling236188
D3450Root amputation – per root492393
D3470Intentional reimplantation (including necessary splinting)938750
D3920Hemisection (including any root removal), not including root canal 374336
D4210Gingivectomy or gingivoplasty – four or more teeth per quadrant517413
D4211Gingivectomy or gingivoplasty – one to three teeth per quadrant230184
D4230Anatomical crown exposure – four or more teeth per quadrant724579
D4231Anatomical crown exposure – one to three teeth per quadrant345276
D4240Gingival flap, & root planning – 4 to 8 teeth per quadrant655524
D4241Gingival flap, & root planning – 1 to 3 teeth per quadrant379303
D4245Apically positioned flap483386
D4249Clinical crown lengthening – hard tissue718574
D4263Bone replacement graft – first site in quadrant391312
D4264Bone replacement graft – each additional site in quadrant333266
D4266Guided tissue regeneration – resorbable barrier, per site402321
D4267Guided Tissue Regeneration – Nonresorbable Barrier517414
D4270Pedicle soft tissue graft procedure776628
D4275Soft tissue allograft712569
D4277Free Soft Tissue Graft804643
D4320Provisional splinting – intracoronal401320
D4321Provisional splinting – extracoronal364291
D4341Periodontal scaling & root planning – 4 to 8 teeth per quadrant231185
D4342Periodontal scaling & root planning – 1 to 3 teeth per quadrant134107
D4346Scaling with Gingival Inflammation after Oral Evaluation8677
D4355Full mouth debridement to enable comprehensive evaluation158126
D4910Periodontal maintenance142113
D5110Complete denture – maxillary18241459
D5120Complete denture – mandibular18251459
D5130Immediate denture – maxillary17101368
D5140Immediate denture – mandibular17101368
D5211Maxillary partial denture – resin base & conventional clasps1107885
D5212Mandibular partial denture – resin base & conventional clasps12861028
D5213Maxillary partial denture – cast metal framework with resin base18731497
D5214Mandibular partial denture – cast metal framework with resin base18731497
D5225Maxillary partial denture – flexible base12501000
D5226Mandibular partial denture – flexible base12501000
D5281Removable unilateral partial denture – one piece cast metal911728
D5410Adjust complete denture – maxillary7258
D5411Adjust complete denture – mandibular7258
D5421Adjust partial denture – maxillary7258
D5422Adjust partial denture – mandibular7258
D5510Repair broken complete denture base155124
D5520Replace missing or broken teeth – complete denture, each tooth129103
D5610Repair resin denture base168134
D5630Repair or replace broken clasp219175
D5640Replace broken teeth – per tooth142113
D5650Add tooth to existing partial denture193154
D5660Add clasp to existing partial denture232185
D5730Reline complete maxillary denture (chairside)300240
D5731Reline complete mandibular denture (chairside)300240
D5740Reline maxillary partial denture (chairside)300240
D5741Reline mandibular partial denture (chairside)300240
D5750Reline complete maxillary denture (laboratory)401320
D5751Reline complete mandibular denture (laboratory)401320
D5760Reline maxillary partial denture (laboratory)401320
D5761Reline mandibular partial denture (laboratory)401320
D5810Interim complete denture (maxillary)634507
D5811Interim complete denture (mandibular)682545
D5820Interim partial denture (maxillary)491392
D5821Interim partial denture (mandibular)520416
D5850Tissue Conditioning Maxillary126113
D5851Tissue Conditioning Mandibular126113
D5862Precision attachment, by report200160
D5863Overdenture Complete Maxillary13881110
D5867Replacement of replaceable part precision attachment300240
D5986Fluoride gel carrier12096
D5988Surgical splint359287
D6010Surgical placement of implant body: endosteal implant21911752
D6012Surgical placement of interim implant body20701833
D6013Surgical Placement of Mini Implant21911752
D6055Dental implant supported connecting bar658526
D6056Prefabricated abutment455364
D6057Custom fabricated abutment562449
D6058Abutment supported porcelain/ceramic crown12611008
D6059Abutment supported porcelain high noble crown12441119
D6060Abutment supported porcelain base metal crown11761020
D6061Abutment supported porcelain noble crown1200960
D6065Implant supported porcelain/ceramic crown1241992
D6080Implant maintenance procedures10382
D6081Scaling of Implant5347
D6085Provisional Implant Crown361288
D6100Implant Removal by Report400320
D6101Debridement of Implant Defect355284
D6211Pontic – cast predominantly base metal1006804
D6212Pontic – cast noble metal1045836
D6241Pontic – porcelain fused to predominantly base metal979881
D6242Pontic – porcelain fused to noble metal1033826
D6245Pontic – porcelain/ceramic1094875
D6740Crown – porcelain/ceramic1016812
D6751Crown – porcelain fused to predominantly base metal1040832
D6791Crown – full cast predominantly base metal996796
D6792Crown – full cast noble metal1033826
D6920Connector Bar236188
D6930Recement fixed partial denture138110
D6940Stress breaker312249
D6950Precision attachment604483
D7111Extraction, coronal remnants – deciduous tooth11592
D7140Extraction, erupted tooth or exposed root156125
D7210Surgical removal of erupted tooth259207
D7220Removal of impacted tooth – soft tissue325260
D7230Removal of impacted tooth – partially bony433346
D7240Removal of impacted tooth – completely bony500400
D7250Surgical Removal of Residual Tooth Roots274219
D7260Oraantral Fistula Closure14431154
D7270Tooth reimplantation & stabilization of accidentally evulsed tooth452361
D7280Surgical Access of Unerupted Tooth422337
D7282Mobilize Erupted Tooth to Aid Eruption711568
D7283Placement of device to facilitate eruption of impacted tooth181144
D7286Biopsy of oral tissue – soft362289
D7288Brush biopsy – transepithelial sample collection160128
D7291Transseptal fiberotomy/supra crestal fiberotomy, by report 10080
D7294Surgical placement: temporary anchorage device without flap301270
D7310Alveoloplasty in conjunction with extractions – per quadrant249199
D7311Alveoloplasty in conjunction with extractions – one to three teeth218174
D7320Alveoloplasty not in conjunction with extractions – per quadrant405324
D7321Alveoloplasty not in conjunction with extractions – 1 to 3 teeth343274
D7410Excision of benign lesion up to 1.25 cm748598
D7411Excision of benign lesion greater than 1.25 cm1184947
D7471Removal of lateral exostosis (maxilla or mandible)926740
D7472Removal of torus palatinus1100960
D7473Removal of torus mandibularis1038830
D7485Surgical reduction of osseous tuberosity926740
D7510Incision and drainage of abscess – intraoral soft tissue268215
D7960Renulectomy (frenectomy or frenotomy) – separate procedure343274
D7970Excision of hyperplastic tissue – per arch499399
D8999Unspecified orthodontic procedure, by report (Invisalign)56254500
D8999Unspecified orthodontic procedure- Invisalign Vivera retainer500400
D9110Palliative (emergency) treatment of dental pain11088
D9215Local Anesthia in Conjunction with Procedure3528
D9230Analgesia, anxiolysis, inhalation of nitrous oxide 7130
D9241Intravenous conscious sedation/analgesia – first 30 minutes162129
D9242Intravenous conscious sedation – each additional 15 minutes162129
D9243IV Sedation per 15 min increment162129
D9248Non-intravenous conscious sedation10382
D9310Consultation – diagnostic service provided by other dentist10282
D9410House/extended care facility call11794
D9420Hospital call189151
D9430Office visit for observation5040
D9440Office visit – after regularly scheduled hours6451
D9450Case presentation, detailed and extensive treatment planning3225
D9910Application of desensitizing medicament5443
D9911Application of desensitizing resin, per tooth7560
D9920Behavior management, by report8064
D9930Treatment of post-surgical complications, by report4536
D9940Occlusal guard, by report 446356
D9941Fabrication of athletic mouthguard154123
D9950Occlusion analysis – mounted case293234
D9951Occlusal adjustment – limited131104
D9952Occlusal adjustment – complete616492
D9970Enamel microabrasion6955
D9972External Bleaching Per Arch308246
D9973External bleaching – per tooth5145
D9974Internal bleaching – per tooth269215
D9999Unspecified adjunctive procedure, by report10080