| CODE | DESCRIPTION | DISCOUNTED FEE |
|---|
| D0120 | PERIODIC ORAL EVAL | $38 |
| D0140 | LTD ORAL EVAL-PROBLEM FOCUSED | $53 |
| D0145 | ORDER EVALUATION - PATIENT UNDER 3 YRS OLD & COUNSELING W/PRIMARY CAREGIVER | $51 |
| D0150 | COMP ORAL EVAL | $63 |
| D0160 | DETAILED & EXTEN ORAL EVAL-PROBLEM FOCUSED BR | $95 |
| D0170 | RE-EVAL-LTD PROB FOCUSED (ESTAB PT-NOT POSTOP) | $54 |
| D0180 | COMPREHENSIVE PERIODONTAL EVALUATION - NEW OR ESTABLISHED PATIENT | $64 |
| D0210 | INTRAORAL-COMPLT SERIES (INCL BITEWINGS) | $98 |
| D0220 | INTRAORAL-PERIAPICAL FIRST FILM | $22 |
| D0230 | INTRAORAL-PERIAPICAL EA ADD FILM | $16 |
| D0240 | INTRAORAL-OCCLUSAL FILM | $26 |
| D0250 | EXTRAORAL-FIRST FILM | $40 |
| D0260 | EXTRAORAL-EA ADD FILM | $30 |
| D0270 | BITEWING-SNGL FILM | $22 |
| D0272 | BITEWINGS-2 FILMS | $35 |
| D0273 | BITEWINGS - THREE FILMS | $42 |
| D0274 | BITEWINGS-4 FILMS | $47 |
| D0277 | VERTICAL BITEWINGS-7-8 FILMS | $69 |
| D0290 | PA/LAT SKULL & FACIAL BONE SURVEY FILM | $92 |
| D0322 | TOMOGRAPHIC SURVEY | $264 |
| D0330 | PANORAMIC FILM | $80 |
| D0340 | CEPHALOMETRIC FILM | $86 |
| D0350 | ORAL/FACIAL IMAGES (INCL INTRA & EXTRAORAL) | $47 |
| D0460 | PULP VITALITY TESTS | $41 |
| D0470 | DIAGNOSTIC CASTS | $78 |
| D1110 | PROPHYLAXIS-ADULT | $76 |
| D1120 | PROPHYLAXIS-CHILD | $57 |
| D1206 | TOPICAL FLUORIDE VARNISH - THERAPEUTIC APP. FOR MOD. TO HIGH CARIES RISK PATS. | $36 |
| D1208 | TOPICAL APPLICATION OF FLUORIDE | $34 |
| D1310 | NUTRITIONAL COUNSELING | $67 |
| D1320 | TOBACCO COUNSELING | $67 |
| D1330 | ORAL HYGIENE INSTRUCTIONS | $28 |
| D1351 | SEALANT-PER TOOTH | $40 |
| D1352 | PREVENTIVE RESIN RESTORATION | $116 |
| D1510 | SPACE MAINTAINER-FIX-UNILAT | $224 |
| D1515 | SPACE MAINTAINER-FIX-BILAT | $319 |
| D1520 | SPACE MAINTAINER-REMOV-UNILAT | $265 |
| D1525 | SPACE MAINTAINER-REMOV-BILAT | $375 |
| D1550 | RECEMENTATION SPACE MAINTAINER | $49 |
| D1555 | REMOVAL OF FIXED SPACE MAINTAINER | $58 |
| D2140 | AMALGAM-1 SURFACE PERM | $108 |
| D2150 | AMALGAM-2 SURFACES PERM | $137 |
| D2160 | AMALGAM-3 SURFACES PERM | $166 |
| D2161 | AMALGAM-4/MORE SURFACES PERM | $196 |
| D2330 | RESIN-BASED COMPOSITE-1 SURFACE ANT | $127 |
| D2331 | RESIN-BASED COMPOSITE-2 SURFACES ANT | $157 |
| D2332 | RESIN-BASED COMPOSITE-3 SURFACES ANT | $189 |
| D2335 | RESIN-BASED COMPOSITE-4/MORE SURF-INCISAL ANGLE | $232 |
| D2390 | RESIN-BASED COMPOSITE CROWN ANTERIOR | $307 |
| D2391 | RESIN-BASED COMPOSITE - 1 SURFACE POSTERIOR | $142 |
| D2392 | RESIN-BASED COMPOSITE - 2 SURFACES POSTERIOR | $186 |
| D2393 | RESIN-BASED COMPOSITE - 3 SURFACES POSTERIOR | $222 |
| D2394 | RESIN-BASED COMPOSITE - 4 OR MORE SURFACES POSTERIOR | $256 |
| D2510 | INLAY-METALLIC-1 SURFACE | $593 |
| D2520 | INLAY-METALLIC-2 SURFACES | $656 |
| D2530 | INLAY-METALLIC-3/MORE SURFACES | $759 |
| D2542 | ONLAY-METALLIC-2 SURFACES | $774 |
| D2543 | ONLAY-METALLIC-3 SURFACES | $828 |
| D2544 | ONLAY-METALLIC-4/MORE SURFACES | $867 |
| D2610 | INLAY-PORCELAIN/CERAMIC-1 SURFACE | $672 |
| D2620 | INLAY-PORCELAIN/CERAMIC-2 SURFACES | $747 |
| D2630 | INLAY-PORCELAIN/CERAMIC-3/MORE SURFACES | $783 |
| D2642 | ONLAY-PORCELAIN/CERAMIC-2 SURFACES | $796 |
| D2643 | ONLAY-PORCELAIN/CERAMIC-3 SURFACES | $825 |
| D2644 | ONLAY-PORCELAIN/CERAMIC-4/MORE SURFACES | $852 |
| D2650 | INLAY - RESIN COMPOS COMPOSITE/RESIN - 1 SURFACE | $568 |
| D2651 | INLAY - RESIN COMPOS COMPOS/RESIN - 2 SURFACES | $681 |
| D2652 | INLAY - RSN COMPOS COMPOS/RSN - 3/MORE SURFACES | $723 |
| D2662 | ONLAY-RESIN-BASD COMPOSITE COMPOSITE/RESN-2 SURF | $754 |
| D2663 | ONLAY-RESIN-BASD COMPOSITE COMPOSITE/RESN-3 SURF | $778 |
| D2664 | ONLAY-RESIN-BASD COMPOSITE COMP/RES-3/MORE SURF | $816 |
| D2710 | CROWN-RESIN (LAB) | $551 |
| D2712 | CROWN - 3/4 RESIN-BASED COMPOSITE (INDIRECT) | $552 |
| D2720 | CROWN - RESIN/HIGH NOBLE | $822 |
| D2721 | CROWN - RESIN/BASE METAL | $784 |
| D2722 | CROWN - RESIN/NOBLE | $800 |
| D2740 | CROWN-PORCELAIN/CERAMIC SUBSTRATE | $916 |
| D2750 | CROWN-PORCELAIN FUSED TO HI NOBLE METAL | $859 |
| D2751 | CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METL | $821 |
| D2752 | CROWN-PORCELAIN FUSED TO NOBLE METAL | $840 |
| D2780 | CROWN-3/4 CAST HI NOBLE METAL | $806 |
| D2781 | CROWN-3/4 CAST PREDOMINANTLY BASE METAL | $792 |
| D2782 | CROWN-3/4 CAST NOBLE METAL | $819 |
| D2783 | CROWN-3/4 PORCELAIN/CERAMIC | $892 |
| D2790 | CROWN-FULL CAST HI NOBLE METAL | $869 |
| D2791 | CROWN-FULL CAST PREDOMINANTLY BASE METAL | $792 |
| D2792 | CROWN-FULL CAST NOBLE METAL | $820 |
| D2794 | CROWN - TITANIUM | $859 |
| D2799 | PROVISIONAL CROWN | $285 |
| D2910 | RECEMENT INLAY | $80 |
| D2915 | RECEMENT CAST OR PREFABRICATED POST & CORE | $85 |
| D2920 | RECEMENT CROWN | $83 |
| D2929 | PREFAB PORCELAIN/CERAMIC CROWN-PRIM TOOTH | #DIV/0! |
| D2930 | PREFAB STAINLESS STEEL CROWN-PRIM TOOTH | $191 |
| D2931 | PREFAB STAINLESS STEEL CROWN-PERM TOOTH | $246 |
| D2932 | PREFABRICATED RESIN CROWN | $241 |
| D2933 | PREFAB STAINLESS STEEL CROWN W/ RESIN WINDOW | $275 |
| D2934 | PREFABR ESTHETIC STAINLESS STEEL CROWN - PRIMARY | $348 |
| D2940 | SEDATIVE FILLING | $79 |
| D2950 | CORE BUILDUP INCL ANY PINS | $193 |
| D2951 | PIN RETENTION-PER TOOTH IN ADD TO RESTORATION | $49 |
| D2952 | CAST POST & CORE IN ADD TO CROWN | $297 |
| D2953 | EACH ADDITIONAL CAST POST | $185 |
| D2954 | PREFAB POST & CORE IN ADD TO CROWN | $244 |
| D2955 | POST REMOVAL | $175 |
| D2957 | EACH ADDITIONAL PREFAB POST | $120 |
| D2960 | LABIAL VENEER (RESIN LAMINATE)-CHAIRSIDE | $486 |
| D2961 | LABIAL VENEER (RESIN LAMINATE)-LAB | $702 |
| D2962 | LABIAL VENEER (PORCELAIN LAMINATE)-LAB | $914 |
| D2970 | TEMPORARY CROWN (FX TOOTH) | $231 |
| D2971 | ADDITIONAL PROCEDURE TO CONSTRUCT NEW CROWN | $281 |
| D2975 | COPING | $423 |
| D2980 | CROWN REPR BR | $194 |
| D3110 | PULP CAP-DIRECT (EXCLD FINAL RESTORATION) | $62 |
| D3120 | PULP CAP-INDIRECT (EXCLD FINAL RESTORATION) | $57 |
| D3220 | THERAP PULPOTOMY-REMOV PULP & APPLIC MEDS | $154 |
| D3221 | GROSS PULPAL DEBRID-PRIM & PERM TEETH | $159 |
| D3230 | PULPAL THERAP(RESORB)-ANT PRIM TTH (EXCLD RESTR) | $213 |
| D3240 | PULPAL THERAP(RESORB)-POST PRIM TTH(EXCLD RESTR) | $270 |
| D3310 | ANT (EXCLD FINAL RESTORATION) (ROOT CANAL) | $603 |
| D3320 | BICUSPID (EXCLD FINAL RESTORATION) (ROOT CANAL) | $683 |
| D3330 | MOLAR (EXCLD FINAL RESTORATION) (ROOT CANAL) | $811 |
| D3331 | TX ROOT CANAL OBSTRUC-NON-SURG ACCESS | $325 |
| D3332 | INCOMPL ENDODONTIC THERAP-INOPER/FX TOOTH | $283 |
| D3333 | INT ROOT REPR-PERFORATION DEFEC | $256 |
| D3346 | RETX PREV ROOT CANAL THERAP-ANT | $708 |
| D3347 | RETX PREV ROOT CANAL THERAP-BICUSPID | $822 |
| D3348 | RETX PREV ROOT CANAL THERAP-MOLAR | $971 |
| D3351 | APEXIFICATION/RECALCIFICATION-INIT VISIT | $306 |
| D3352 | APEXIFICATION/RECALCIFICATN-INTERIM MEDS REPLAC | $205 |
| D3353 | APEXIFICATION/RECALCIFICATION-FINAL VISIT | $570 |
| D3410 | APICOECTOMY/PERIRADICULAR SURG-ANT | $621 |
| D3421 | APICOECTOMY/PERIRADICULAR SURG-BICUSP (1ST ROOT) | $695 |
| D3425 | APICOECTOMY/PERIRADICULAR SURG-MOLAR (1ST ROOT) | $783 |
| D3426 | APICOECTOMY/PERIRADICULAR SURG (EA ADD ROOT) | $325 |
| D3430 | RETROGRADE FILLING-PER ROOT | $184 |
| D3450 | ROOT AMPUTAT-PER ROOT | $328 |
| D3920 | HEMISECTION(INCLD ROOT REMOV)WO ROOT CANL THERAP | $300 |
| D4210 | GINGIVECTOMY/GINGIVOPLASTY-PER QUADRANT | $447 |
| D4211 | GINGIVECTOMY/GINGIVOPLASTY-PER TOOTH | $219 |
| D4230 | ANATOMICAL CROWN EXPOSURE - FOUR OR MORE | $490 |
| D4231 | ANATOMICAL CROWN EXPOSURE - 1-3 TEETH | $226 |
| D4240 | GINGIVAL FLAP PROC INCL ROOT PLANING-PER QUAD | $595 |
| D4241 | GINGIVAL FLAP PROCEDURE INCLUDING ROOT PLANING - 1-3 TEETH PER QUADRANT | $409 |
| D4245 | APICALLY POSIT FLAP | $549 |
| D4249 | CLIN CROWN LENGTHENING-HARD TISS | $568 |
| D4260 | OSSEOUS SURG (INCL FLAP ENTRY & CLOS)-PER QUAD | $833 |
| D4261 | OSSEOUS SURGERY (INCLUDING FLAP ENTRY AND CLOSURE)-1-3 TEETH PER QUAD. | $589 |
| D4263 | BONE REPLAC GFT-FIRST SITE IN QUADRANT | $378 |
| D4264 | BONE REPLAC GFT-EA ADD SITE IN QUADRANT | $288 |
| D4266 | GUID TISS REGEN-RESORB BARRIER PER SITE | $493 |
| D4267 | GUID TISS REGEN-NONRESORB BARRIER PER SITE | $408 |
| D4268 | SURGICAL REVISION PROCEDURE | $194 |
| D4270 | PEDICLE SOFT TISS GFT PROC | $742 |
| D4273 | SUBEPITHELIAL CONNECTIVE TISS GFT (INCL DONOR) | $688 |
| D4274 | DIST/PROX WEDGE PROC (NOT W/PROC IN SAME AREA) | $317 |
| D4275 | SOFT TISSUE ALLOGRAFT | $534 |
| D4276 | COMBINED CONNECTIVE TISSUE AND DOUBLE PEDICLE GRAFT | $686 |
| D4320 | PROVISIONAL SPLINTING-INTRACORONAL | $492 |
| D4321 | PROVISIONAL SPLINTING-EXTRACORONAL | $407 |
| D4341 | PERIODONTAL SCALING & ROOT PLANING PER QUADRANT | $198 |
| D4342 | PERIODONTAL SCALING AND ROOT PLANING - 1-3 TEETH PER QD | $134 |
| D4355 | FULL MOUTH DEBRID-ENABLE PERIODONTAL EVAL & DX | $121 |
| D4381 | LOCALIZ DELIV CHEMO-CREVICULAR TISS PER TOOTH BR | $62 |
| D4910 | PERIODONTAL MAINT PROC (FOLLOWING ACTIVE THERAP) | $109 |
| D5110 | COMPLT DENTURE-MAXIL | $1,271 |
| D5120 | COMPLT DENTURE-MANDIB | $1,276 |
| D5130 | IMMED DENTURE-MAXIL | $1,404 |
| D5140 | IMMED DENTURE-MANDIB | $1,405 |
| D5211 | MAXIL PART DENTURE-RESIN BASE(INCLD CLASP-RESTS) | $950 |
| D5212 | MANDIB PART DENTURE-RESIN BASE(INCLD CLASP-REST) | $987 |
| D5213 | MAXIL PART DENTURE-CAST METAL FRAME W/RESIN BASE | $1,337 |
| D5214 | MANDIB PART DENTURE-CAST METAL FRAME W/RES BASE | $1,337 |
| D5225 | MAX PART DENTURE - FLEXIBLE BASE | $1,305 |
| D5226 | MAND PART DENTUR - FLEXIBLE BASE | $1,305 |
| D5281 | REMOV UNILAT PART DENTURE-1 PIECE CAST METAL | $849 |
| D5410 | ADJUST COMPLT DENTURE-MAXIL | $74 |
| D5411 | ADJUST COMPLT DENTURE-MANDIB | $73 |
| D5421 | ADJUST PART DENTURE-MAXIL | $75 |
| D5422 | ADJUST PART DENTURE-MANDIB | $72 |
| D5510 | REPR BROKEN COMPLT DENTURE BASE | $145 |
| D5520 | REPLACE MISS/BRKN TEETH-COMPLT DENTURE(EA TOOTH) | $122 |
| D5610 | REPR RESIN DENTURE BASE | $136 |
| D5620 | REPR CAST FRAMEWORK | $205 |
| D5630 | REPR/REPLACE BROKEN CLASP | $180 |
| D5640 | REPLACE BROKEN TEETH-PER TOOTH | $128 |
| D5650 | ADD TOOTH TO EXISTING PART DENTURE | $151 |
| D5660 | ADD CLASP TO EXISTING PART DENTURE | $183 |
| D5670 | REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK (MAXILLARY) | $661 |
| D5671 | REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK (MANDIBULAR) | $661 |
| D5710 | REBASE COMPLT MAXIL DENTURE | $420 |
| D5711 | REBASE COMPLT MANDIB DENTURE | $410 |
| D5720 | REBASE MAXIL PART DENTURE | $411 |
| D5721 | REBASE MANDIB PART DENTURE | $411 |
| D5730 | RELINE COMPLT MAXIL DENTURE (CHAIRSIDE) | $233 |
| D5731 | RELINE COMPLT MANDIB DENTURE (CHAIRSIDE) | $233 |
| D5740 | RELINE MAXIL PART DENTURE (CHAIRSIDE) | $214 |
| D5741 | RELINE MANDIB PART DENTURE (CHAIRSIDE) | $220 |
| D5750 | RELINE COMPLT MAXIL DENTURE (LAB) | $331 |
| D5751 | RELINE COMPLT MANDIB DENTURE (LAB) | $339 |
| D5760 | RELINE MAXIL PART DENTURE (LAB) | $318 |
| D5761 | RELINE MANDIB PART DENTURE (LAB) | $319 |
| D5810 | INTERIM COMPLT DENTURE (MAXIL) | $614 |
| D5811 | INTERIM COMPLT DENTURE (MANDIB) | $627 |
| D5820 | INTERIM PART DENTURE (MAXIL) | $434 |
| D5821 | INTERIM PART DENTURE (MANDIB) | $433 |
| D5850 | TISS CONDITIONING MAXIL | $113 |
| D5851 | TISS CONDITIONING MANDIB | $112 |
| D5860 | OVERDENTURE-COMPLT BR | $1,494 |
| D5861 | OVERDENTURE-PART BR | $1,407 |
| D5862 | PRECISION ATTACHMENT | $504 |
| D5867 | REPLACEMENT OF REPLACEABLE PART OF SEMI-PRECISION ATTACH | $302 |
| D5986 | FLUORIDE GEL CARRIER | $218 |
| D6010 | SURG PLACEMENT IMPLANT BODY: ENDOSTEAL IMPLANT | $1,615 |
| D6056 | PREFABRICATED IMPLANT ABUTMENT | $738 |
| D6057 | CUSTOM FABRICATED ABUTMENT | $909 |
| D6058 | ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN | $1,197 |
| D6059 | ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN | $1,093 |
| D6060 | ABUT SUPP PORCELAIN TO MTL CROWN PREDOM BASE MTL | $1,103 |
| D6061 | ABUT SUPP PORCELAIN TO METAL CROWN NOBLE METAL | $1,109 |
| D6062 | ABUTMENT SUPP CAST METAL CROWN HIGH NOBLE METAL | $1,145 |
| D6063 | ABUTMENT SUPP CAST METAL CROWN PREDOM BASE METAL | $1,120 |
| D6064 | ABUTMENT SUPP CAST METAL CROWN NOBLE METAL | $1,132 |
| D6065 | IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWN | $1,107 |
| D6066 | IMPLANT SUPPORTED PORCELAIN FUSED TO METAL CROWN | $1,124 |
| D6067 | IMPLANT SUPPORTED METAL CROWN | $1,085 |
| D6068 | ABUTMENT SUPPORTED RETAINER FOR PORCELAIN/CERAMIC CROWN | $1,310 |
| D6069 | ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO HIGH NOBLE | $1,291 |
| D6076 | IMPLANT SUPPORTED RETAINER FOR PORCELAIN FUSED TO HIGH NOBLE | $1,238 |
| D6080 | IMPL MAINT PROC REMV CLEANS PROSTH&ABUTS REINS | $117 |
| D6091 | REPLACE. OF SEMI-PRECISION/PRECISION ATTACH. OF IMPLANT SUPPORT PROSTHESIS | $422 |
| D6092 | RECEMENT IMPLANT/ABUTMENT SUPPORTED CROWN | $97 |
| D6093 | RECEMENT IMPLANT/ABUTMENT SUPPORTED FIXED PARTIAL DENTURE | $146 |
| D6205 | PONTIC - INDIRECT RESIGN BASED COMPOSITE / NOT TEMPORARY | $950 |
| D6210 | PONTIC - CAST HIGH NOBLE | $859 |
| D6211 | PONTIC-CAST PREDOMINANTLY BASE METAL | $823 |
| D6212 | PONTIC-CAST NOBLE METAL | $833 |
| D6214 | PONTIC - TITANIUM | $937 |
| D6240 | PONTIC-PORCELAIN FUSED TO HI NOBLE METAL | $869 |
| D6241 | PONTIC-PORCELAIN FUSED TO PREDOMINANTLY BASE MTL | $821 |
| D6242 | PONTIC-PORCELAIN FUSED TO NOBLE METAL | $835 |
| D6245 | PONTIC - PORCELAIN/CERAMIC | $922 |
| D6253 | PROVISIONAL PONTIC | $597 |
| D6545 | RETAINER-CAST METAL FOR RESIN BONDED FIX PROSTH | $621 |
| D6548 | RETAINER - PORCELN/CERAMIC RSN BONDED FIX PROSTH | $618 |
| D6600 | INLAY - PORCELAIN/CERAMIC 2 SURFACES | $757 |
| D6601 | INLAY - PORCELAIN/CERAMIC 3 OR MORE SURFACES | $808 |
| D6602 | INLAY - CAST HIGH NOBLE METAL 2 SURFACES | $732 |
| D6603 | INLAY - CAST HIGH NOBLE METAL 3 OR MORE SURFACES | $764 |
| D6604 | INLAY - CAST PREDOMINATELY BASE METAL 2 SURFACES | $733 |
| D6605 | INLAY - CAST PREDOMINATELY BASE METAL 3 OR MORE SURF | $761 |
| D6606 | INLAY - CAST NOBLE METAL 2 SURFACES | $745 |
| D6607 | INLAY - CAST NOBLE METAL 3 OR MORE SURFACES | $784 |
| D6608 | ONLAY - PORCELAIN/CERAMIC 2 SURFACES | $810 |
| D6609 | ONLAY - PORCELAIN/CERAMIC 3 OR MORE SURFACES | $824 |
| D6610 | ONLAY - CAST HIGH NOBLE METAL 2 SURFACES | $820 |
| D6611 | ONLAY - CAST HIGH NOBLE METAL 3 OR MORE SURFACES | $837 |
| D6612 | ONLAY - CAST PREDOMINATELY BASE METAL 2 SURFACES | $783 |
| D6613 | ONLAY - CAST PREDOMINATELY BASE METAL 3 OR MORE SURF | $802 |
| D6614 | ONLAY - CAST NOBLE METAL 2 SURFACES | $792 |
| D6615 | ONLAY - CAST NOBLE METAL 3 OR MORE SURFACES | $755 |
| D6624 | INLAY - TITANIUM | $720 |
| D6634 | ONLAY - TITANIUM | $782 |
| D6710 | CROWN - INDIRECT RESIN BASED COMPOSITE / NON-TEMPORARY | $904 |
| D6740 | CROWN - PORCELAIN/CERAMIC | $932 |
| D6750 | CROWN-PORCELAIN FUSED TO HI NOBLE METAL | $877 |
| D6751 | CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METL | $856 |
| D6752 | CROWN-PORCELAIN FUSED TO NOBLE METAL | $857 |
| D6780 | CROWN-3/4 CAST HI NOBLE METAL | $864 |
| D6781 | CROWN-3/4 CAST PREDOMINATELY BASED METAL | $904 |
| D6782 | CROWN-3/4 CAST NOBLE METAL | $897 |
| D6783 | CROWN-3/4 PORCELAIN/CERAMIC | $910 |
| D6790 | CROWN-FULL CAST HI NOBLE METAL | $882 |
| D6791 | CROWN-FULL CAST PREDOMINANTLY BASE METAL | $828 |
| D6792 | CROWN-FULL CAST NOBLE METAL | $854 |
| D6793 | PROVISIONAL RETAINER CROWN | $336 |
| D6794 | CROWN - TITANIUM | $960 |
| D6930 | RECEMENT FIX PART DENTURE | $118 |
| D6950 | PRECISION ATTACHMENT | $389 |
| D6975 | COPING-METAL | $456 |
| D6980 | FIX PART DENTURE REPR BR | $250 |
| D6985 | PEDIATRIC PARTIAL DENTURE FIXED | $1,015 |
| D7111 | CORONAL REMNANTS - DECIDIOUS TEETH | $99 |
| D7140 | EXTRACT. ERUPTED TOOTH OR EXPOSED ROOT (ELEV. AND/OR FORCEPS REMOVAL) | $134 |
| D7210 | REMOVE ERUPT TTH-W/MUCOPERIOSTL FLP-REMOV BNE/TTH | $195 |
| D7220 | REMOVE IMPACTED TOOTH-SOFT TISS | $229 |
| D7230 | REMOVE IMPACTED TOOTH-PART BONY | $284 |
| D7240 | REMOVE IMPACTED TOOTH-COMPLT BONY | $338 |
| D7241 | REMOVE IMPACTED TTH-COMPLT BONY W/UNUSUAL COMPLIC | $458 |
| D7250 | SURG REMOV RESIDUAL TOOTH ROOTS (CUTTING PROC) | $217 |
| D7280 | SURG EXPOSURE IMPACTED/UNERUPTED TTH-ORTHODONTIC | $327 |
| D7285 | BX ORAL TISS-HARD (BONE/TOOTH) | $432 |
| D7286 | BX ORAL TISS-SOFT (ALL OTH) | $221 |
| D7287 | CYTOLOGY SAMPLE COLLECTION | $101 |
| D7288 | BRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECT. VIA ROTAT. BRUSHiNG OF ORAL MUSC. | $128 |
| D7310 | ALVEOLOPLASTY W/EXTRACTIONS-PER QUADRANT | $241 |
| D7311 | ALVEOLOPLASTY IN CONJUNCT. WITH EXTRACTS 1-3 TEETH PER QUAD. DIST. FROM EXTRACTS. | $221 |
| D7320 | ALVEOLOPLASTY NOT W/EXTRACTIONS PER QUADRANT | $287 |
| D7321 | ALVEOLOPLASTY NOT IN CONJ. WITH EXTRACTS 1-3 TEETH PER QUAD. DIST. FROM EXTRACTS. | $244 |
| D7471 | REMOV EXOSTOSIS-PER SITE | $578 |
| D7510 | I&D ABSC-INTRAORAL SOFT TISS | $167 |
| D7511 | INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE COMPLICATION CELLULITIUS | $367 |
| D7880 | OCCLU ORTHOTIC DEVICE BR | $861 |
| D7910 | SUTURE OF RECENT SMALL WOUND | $245 |
| D7953 | RIDGE PRESERVATION BONE GRAFT | $577 |
| D7960 | FRENULECTOMY (FRENECTOMY/FRENOTOMY)-SEPART PROC | $246 |
| D7963 | FRENULECT - EXCISION OF FRENUM WITH ACCOMPANYING EXCISION OR REPOSITIONING | $304 |
| D7970 | EXC HYPERPLASTIC TISS-PER ARCH | $359 |
| D7972 | SURGICAL REDUCTION OF FIBROUS TUBEROSITY | $479 |
| D8010 | LTD ORTHODONTIC TX PRIM DENTITION | $4,252 |
| D8020 | LTD ORTHODONTIC TX TRANSITIONAL DENTITION | $3,931 |
| D8030 | LTD ORTHODONTIC TX ADOLESCENT DENTITION | $3,781 |
| D8040 | LTD ORTHODONTIC TX ADULT DENTITION | $3,865 |
| D8050 | INTERCEPTIVE ORTHODONTIC TX PRIM DENTITION | $3,893 |
| D8060 | INTERCEPTIVE ORTHODONTIC TX TRANSITIONAL DENTITN | $3,956 |
| D8070 | COMP ORTHODONTIC TX TRANSITIONAL DENTITION | $4,415 |
| D8080 | COMP ORTHODONTIC TX ADOLESCENT DENTITION | $4,137 |
| D8090 | COMP ORTHODONTIC TX ADULT DENTITION | $4,296 |
| D8210 | REMOV APPLIANCE THERAP | $547 |
| D8220 | FIX APPLIANCE THERAP | $625 |
| D8660 | PRE-ORTHODONTIC TREATMENT VISIT | $172 |
| D8680 | ORTHODONTIC RETENTION(REMOV APPL-PLCMT RETAINER) | $460 |
| D8691 | REPR ORTHODONTIC APPLIANCE | $171 |
| D8692 | REPLACEMENT OF LOST OR BROKEN RETAINER | $268 |
| D8693 | REBONDING OR RECEMENTING FIXED RETAINER | $178 |
| D9110 | PALLIATIVE (ER) TX DENTAL PAIN-MINOR PROC | $115 |
| D9120 | FIXED PARTIAL DENTURE SECTIONING | $103 |
| D9215 | LOCAL ANES | $35 |
| D9220 | GEN ANES-FIRST 30 MIN | $269 |
| D9221 | GEN ANES-EA ADD 15 MINUTES | $128 |
| D9230 | ANALGESIA-ANXIOLYSIS-INHAL NITROUS OXIDE | $69 |
| D9241 | IV SEDATION/ANALGESIA-FIRST 30 MIN | $307 |
| D9242 | IV SEDATION/ANALGESIA-EA ADD 15 MIN | $136 |
| D9310 | CONS (DIAG SERV BY NON TREATING PRACTIONER) | $119 |
| D9410 | HOUSE/EXTEN CARE FACILITY CALL | $199 |
| D9420 | HOSP CALL | $219 |
| D9430 | OFFIC VISIT FOR OBSRV (REG HRS)-NO OTH SERV) | $71 |
| D9440 | OFFIC VISIT-AFTER REG SCHEDULED HRS | $142 |
| D9610 | THERAP DRUG INJ BR | $60 |
| D9612 | THERAPEUTIC PARENTERAL DRUGS; TWO OR MORE ADMINS. DIF. MEDICATIONS | $94 |
| D9940 | OCCLU GUARD BR | $389 |
| D9941 | FABRICATION OF ATHLETIC MOUTHGUARD | $245 |
| D9942 | REPAIR AND/OR RELINE OF OCCLUSAL GUARD | $108 |
| D9951 | OCCLU ADJUSTMENT-LTD | $136 |
| D9952 | OCCLU ADJUSTMENT-COMPLT | $518 |
| D9970 | ENAMEL MICROABRASION | $83 |
| D9971 | ODONTOPLASTY 1 - 2 TEETH | $74 |
| D9972 | EXTERNAL BLEACHING - PER ARCH | $178 |
| D9973 | EXTERNAL BLEACHING - PER TOOTH | $118 |
| D9974 | INTERNAL BLEACHING - PER TOOTH | $218 |
