Provider_Fee_Schedule



CODEDENTAL PROCEDURE DESCRIPTIONUNITS FROMUNITS TOVALUED0120Periodic Oral Evaluation - Established Patient199929.08D0140Limited Oral Evaluation - Problem Focused199943.20D0145Oral Evaluation Of A Patient Under Three Years Of Age And Counseling With Primary Caregiver199940.00D0150Comprehensive Oral Evaluation - New Or Established Patient199951.50D0160Detailed And Extensive Oral Evaluation - Problem Focused, By Report199943.20D0210Intraoral - Complete Series of Radiographic Images199957.00D0220Intraoral - Periapical First Radiographic Image19999.00D0230Intraoral - Periapical Each Additional Radiographic Image19996.00D0240Intraoral - Occlusal Radiographic Image19999.00D0250Extraoral - 2D Projection Radiographic Image Created Using A Stationary Radiation Source, And Detector199924.00D0270Bitewing - Single Radiographic Image19999.00D0272Bitewings - Two Radiographic Images199915.00D0273Bitewings - Three Radiographic Images199918.00D0274Bitewings - Four Radiographic Images199922.00D0277Vertical Bitewings - 7 To 8 Radiographic Images199930.00D0310Sialography199957.00D0320Temporomandibular Joint Arthrogram, Including Injection199996.00D0321Other Temporomandibular Joint Radiographic Images, By Report199930.00D0330Panoramic Radiographic Image199942.00D03402D Cephalometric Radiographic Image - Acquisition, Measurement And Analysis199942.00D0431Adjunctive Pre-Diagnostic Test That Aids In Detection Of Mucosal Abnormalities Including Premalignant And Malignant Lesions, Not To Include Cytology Or Biopsy Procedures19995.00D0460Pulp Vitality Tests199910.00D1110Prophylaxis - Adult199958.15D1120Prophylaxis - Child199942.37D1206Topical Application Of Fluoride Varnish199924.92D1208Topical Application of Fluoride - Excluding Varnish199923.00D1330Oral Hygiene Instructions19996.00D1351Sealant - Per Tooth199933.23D1352Preventive Resin Restoration In A Moderate To High Caries Risk Patient - Permanent Tooth199933.23D1510Space Maintainer - Fixed - Unilateralexcludes a distal shoe space maintainer199984.00D1515Space Maintainer - Fixed - Bilateral1999144.00D1520Space Maintainer - Removable - Unilateral199964.00D1525Space Maintainer - Removable - Bilateral199996.00D1550Re-Cement Or Re-Bond Space Maintainer199924.00D1555Procedure performed by dentist or practice that did not originally place the appliance.199925.00D2140Amalgam - One Surface, Primary Or Permanent199970.00D2150Amalgam - Two Surfaces, Primary Or Permanent199988.00D2160Amalgam - Three Surfaces, Primary Or Permanent1999104.00D2161Amalgam - Four Or More Surfaces, Primary Or Permanent1999104.00D2330Resin-Based Composite - One Surface, Anterior199984.00D2331Resin-Based Composite - Two Surfaces, Anterior1999102.00D2332Resin-Based Composite - Three Surfaces, Anterior1999125.00D2335Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior)1999151.00D2390Resin-Based Composite Crown, Anterior199975.00D2391Resin-Based Composite - One Surface, Posterior199993.00D2392Resin-Based Composite - Two Surfaces, Posterior1999120.00D2393Resin-Based Composite - Three Surfaces, Posterior1999150.00D2394Resin-Based Composite - Four Or More Surfaces, Posterior1999150.00D2721Crown - Resin With Predominantly Base Metal1999250.00D2740Crown - Porcelain/Ceramic1999300.00D2750Crown - Porcelain Fused To High Noble Metal1999375.00D2751Crown - Porcelain Fused To Predominantly Base Metal1999375.00D2752Crown - Porcelain Fused To Noble Metal1999375.00D2780Crown - 3/4 Cast High Noble Metal1999292.00D2781Crown - 3/4 Cast Predominantly Base Metal1999292.00D2782Crown - 3/4 Cast Noble Metal1999292.00D2783Crown - 3/4 Porcelain/Ceramic1999292.00D2790Crown - Full Cast High Noble Metal1999292.00D2791Crown - Full Cast Predominantly Base Metal1999292.00D2792Crown - Full Cast Noble Metal1999292.00D2794Crown - Titanium1999292.00D2910Re-Cement Or Re-Bond Inlay, Onlay, Veneer Or Partial Coverage Restoration199925.00D2920Re-Cement or Re-Bond Crown199925.00D2929Prefabricated Porcelain / Ceramic Crown - Primary Tooth1999154.00D2930Prefabricated Stainless Steel Crown - Primary Tooth1999154.00D2931Prefabricated Stainless Steel Crown - Permanent Tooth1999180.00D2932Prefabricated Resin Crown199975.00D2933Prefabricated Stainless Steel Crown With Resin Window199981.00D2934Prefabricated Esthetic Coated Stainless Steel Crown - Primary Tooth1999154.00D2940Protective Restoration199950.00D2950Core Buildup, Including Any Pins When Required199981.00D2951Pin Retention - Per Tooth, In Addition To Restoration199912.00D2952Post And Core In Addition To Crown, Indirectly Fabricated199996.00D2954Prefabricated Post And Core In Addition To Crown199970.00D2955Post Removal199925.00D2960Labial Veneer (Resin Laminate) - Chairside199981.00D2961Labial Veneer (Resin Laminate) - Laboratory199981.00D2962Labial Veneer (Porcelain Laminate) - Laboratory1999108.00D2980Crown Repair Necessitated By Restorative Material Failure199993.00D3110Pulp Cap - Direct (Excluding Final Restoration)199915.00D3120Pulp Cap - Indirect (Excluding Final Restoration)199935.00D3220Therapeutic Pulpotomy (Excluding Final Restoration) - Removal Of Pulp Coronal To The Dentinocemental Junction And Application Of Medicament199960.00D3221Pulpal Debridement - Primary And Permanent Teeth199970.00D3230Pulpal Therapy (Resorbable Filling) - Anterior, Primary Tooth (Excluding Final Restoration)199996.00D3240Pulpal Therapy (Resorbable Filling) - Posterior, Primary Tooth (Excluding Final Restoration)1999115.00D3310Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)1999550.00D3320Endodontic Therapy, premolar Tooth (Excluding Final Restoration)1999650.00D3330Endodontic Therapy, Molar tooth (Excluding Final Restoration)1999748.00D3346Retreatment Of Previous Root Canal Therapy - Anterior1999634.00D3347Retreatment Of Previous Root Canal Therapy - Premolar1999721.00D3348Retreatment Of Previous Root Canal Therapy - Molar1999829.00D3351Apexification / Recalcification - Initial Visit (Apical Closure / Calcific Repair Of Perforations, Root Resorption, Etc.)1999108.00D3352Apexification / Recalcification - Interim Medication Replacement199967.00D3353Apexification / Recalcification - Final Visit (Includes Completed Root Canal Therapy - Apical Closure / Calcific Repair Of Perforations, Root Resorption, Etc.)199967.00D3410Apicoectomy - Anterior1999504.00D3421Apicoectomy - Premolar(First Root)1999570.00D3425Apicoectomy - Molar (First Root)1999659.00D3426Apicoectomy - Each Additional Root)1999217.00D3430Retrograde Filling - Per Root1999100.00D3450Root Amputation - Per Root1999355.00D3470Intentional Reimplantation (Including Necessary Splinting)1999629.00D3920Hemisection (Including Any Root Removal), Not Including Root Canal Therapy1999221.00D4210Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant1999108.00D4211Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant199925.00D4230Anatomical Crown Exposure - Four Or More Contiguous Teeth or bounded tooth spaces per quadrant1999108.00D4231Anatomical Crown Exposure - One To Three Teeth or bounded by spaces per quadrant199925.00D4240Gingival Flap Procedure, Including Root Planing - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant199963.00D4241Gingival Flap Procedure, Including Root Planing - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant199975.00D4249Clinical Crown Lengthening - Hard Tissue1999150.00D4260Osseous Surgery (Including Elevation Of A Full Thickness Flap And Closure) - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant1999108.00D4261Osseous Surgery (Including Elevation Of A Full Thickness Flap And Closure) - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant1999150.00D4320Provisional Splinting - Intracoronal199990.00D4321Provisional Splinting - Extracoronal1999100.00D4341Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant199975.00D4342Periodontal Scaling And Root Planing - One To Three Teeth Per Quadrant199954.00D4355Full Mouth Debridement To Enable Comprehensive Evaluation And Diagnosis on a subsequent visit1999100.00D4910Periodontal Maintenance199954.00D4920Unscheduled Dressing Change (By Someone Other Than Treating Dentist Or Staff)199924.00D5110Complete Denture - Maxillary1999375.00D5120Complete Denture - Mandibular1999375.00D5211Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)1999225.00D5212Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests And Teeth)1999225.00D5225Maxillary Partial Denture - Flexible Base (Including Any Clasps, Rests And Teeth)1999275.00D5226Mandibular Partial Denture - Flexible Base (Including Any Clasps, Rests And Teeth)1999275.00D5410Adjust Complete Denture - Maxillary199920.00D5411Adjust Complete Denture - Mandibular199920.00D5421Adjust Partial Denture - Maxillary199920.00D5422Adjust Partial Denture - Mandibular199920.00D5510Repair Broken Complete Denture Base199940.00D5511Repair Broken Complete Denture Base - Mandibular199940.00D5512Repair Broken Complete Denture Base - Maxillary199940.00D5520Replace Missing Or Broken Teeth - Complete Denture (Each Tooth)199920.00D5610Repair Resin Denture Base199963.00D5611Repair Resin Partial Denture Base - Mandibular199963.00D5612Repair Resin Partial Denture Base - Maxillary199963.00D5620Repair Cast Framework199970.00D5621Repair Cast Partial Framework - Mandibular199970.00D5622Repair Cast Partial Framework - Maxillary199970.00D5630Repair Or Replace Broken Clasp - Per Tooth199963.00D5640Replace Broken Teeth - Per Tooth199920.00D5650Add Tooth To Existing Partial Denture199957.00D5660Add Clasp To Existing Partial Denture - Per Tooth199965.00D5710Rebase Complete Maxillary Denture1999160.00D5711Rebase Complete Mandibular Denture1999160.00D5720Rebase Maxillary Partial Denture1999160.00D5721Rebase Mandibular Partial Denture1999160.00D5750Reline Complete Maxillary Denture (Laboratory)1999150.00D5751Reline Complete Mandibular Denture (Laboratory)1999150.00D5760Reline Maxillary Partial Denture (Laboratory)1999150.00D5761Reline Mandibular Partial Denture (Laboratory)1999150.00D5850Tissue Conditioning, Maxillary199924.00D5851Tissue Conditioning, Mandibular199924.00D5863Overdenture - Complete Maxillary1999325.00D5864Overdenture - Partial Maxillary1999325.00D5865Overdenture - Complete Mandibular1999325.00D5866Overdenture - Partial Mandibular1999325.00D5992Adjust Maxillofacial Prosthetic Appliance, By Report199920.00D5993Maintenance And Cleaning Of A Maxillofacial Prosthesis (Extra Or Intraoral) Other Than Required Adjustments, By Report199920.00D6930Re-Cement Or Re-Bond Fixed Partial Denture199932.00D6985Pediatric Partial Denture, Fixed1999144.00D7111Extraction, Coronal Remnants - Primary Tooth199927.00D7140Extraction, Erupted Tooth Or Exposed Root (Elevation And/Or Forceps Removal)1999103.01D7210Extraction, Erupted Tooth Requiring Removal Of Bone And/Or Sectioning Of Tooth, And Including Elevation Of Mucoperiosteal Flap If Indicated1999103.01D7220Removal Of Impacted Tooth - Soft Tissue1999144.00D7230Removal Of Impacted Tooth - Partially Bony1999211.00D7240Removal Of Impacted Tooth - Completely Bony1999277.00D7241Removal Of Impacted Tooth - Completely Bony, With Unusual Surgical Complications1999415.00D7250Removal Of Residual Tooth (Cutting Procedure)1999103.01D7251Coronectomy - Intentional Partial Tooth Removal1999415.00D7260Oroantral Fistula Closure1999125.00D7270Tooth Reimplantation And/Or Stabilization Of Accidentally Evulsed Or Displaced Tooth199964.00D7272Tooth Transplantation (Includes Reimplantation From One Site To Another And Splinting And/Or Stabilization)199927.00D7280Exposure of an Unerupted Tooth1999369.00D7282Mobilization Of Erupted Or Malpositioned Tooth To Aid Eruption1999125.00D7283Placement Of Device To Facilitate Eruption Of Impacted Tooth1999125.00D7285Incisional Biopsy Of Oral Tissue - Hard (Bone,Tooth)199985.00D7286Incisional Biopsy Of Oral Tissue - Soft1999231.00D7290Surgical Repositioning Of Teeth1999165.00D7310Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant199990.00D7311Alveoloplasty In Conjunction With Extractions - One To Three Teeth Or Tooth Spaces, Per Quadrant199950.00D7320Alveoloplasty Not In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant199948.00D7321Alveoloplasty Not In Conjunction With Extractions - One To Three Teeth Or Tooth Spaces, Per Quadrant199995.00D7340Vestibuloplasty - Ridge Extension (Secondary Epithelialization)1999270.00D7350Vesibuloplasty - Ridge Extension (Including Soft Tissue Grafts, Muscle Reattachment, Revision Of Soft Tissue Attachment And Management Of Hypertrophied And Hyperplastic Tissue)1999405.00D7410Excision Of Benign Lesion Up To 1.25 Cm199984.00D7440Excision Of Malignant Tumor - Lesion Diameter Up To 1.25 Cm1999108.00D7450Removal Of Benign Odontogenic Cyst Or Tumor - Lesion Diameter Up To 1.25 Cm199997.00D7451Removal Of Benign Odontogenic Cyst Or Tumor - Lesion Diameter Greater Than 1.25 Cm1999125.00D7460Removal Of Benign Nonodontogenic Cyst Or Tumor - Lesion Diameter Up To 1.25 Cm199995.00D7461Removal Of Benign Nonodontogenic Cyst Or Tumor - Lesion Diameter Greater Than 1.25 Cm1999125.00D7471Removal Of Lateral Exostosis (Maxilla Or Mandible)1999105.00D7472Removal Of Torus Palatinus1999105.00D7473Removal Of Torus Mandibularis1999105.00D7510Incision And Drainage Of Abscess - Intraoral Soft Tissue199948.00D7520Incision And Drainage Of Abscess - Extraoral Soft Tissue199968.00D7550Partial Ostectomy/Sequestrectomy For Removal Of Non-Vital Bone199968.00D7960Frenulectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedure Not Incendental To Another199963.00D7970Excision Of Hyperplastic Tissue - Per Arch199927.00D7971Excision Of Pericoronal Gingiva199925.00D8070Comprehensive Orthodontic Treatment Of The Transitional Dentition1999500.00D8080Comprehensive Orthodontic Treatment Of The Adolescent Dentition19991035.00D8090Comprehensive Orthodontic Treatment Of The Adult Dentition1999900.00D8660Pre-Orthodontic Treatment Examination To Monitor Growth And Development1999150.00D8670Periodic Orthodontic Treatment Visit199975.00D8680Orthodontic Retention (Removal Of Appliances, Construction And Placement Of Retainer(S))1999200.00D8692Replacement Of Lost Or Broken Retainer1999140.00D8693Re-Cement Or Re-Bonding Fixed Retainers199995.00D8999Unspecified Orthodontic Procedure, By Report1999550.00D9110Palliative (Emergency) Treatment Of Dental Pain - Minor Procedure199920.00D9222Deep Sedation/General Anesthesia - First 15 Minutes199971.00D9223Deep Sedation / General Anesthesia - Each subsequent 15 Minute Increment199971.00D9230Inhalation Of Nitrous/Analgesia, Anxiolysis199918.00D9239Intravenous Moderate (Conscious) Sedation/Analgesia - First 15 Minutes199959.00D9243Intravenous Moderate (Conscious) Sedation/Analgesia - Each subsequent 15 Minute Increment199959.00D9248Non-Intravenous Conscious Sedation1999186.91D9310Consultation - Diagnostic Service Provided By Dentist Or Physician Other Than Requesting Dentist Or Physician199948.00D9410House/Extended Care Facility Call199915.00D9420Hospital Or Ambulatory Surgical Center Call199915.00D9910Application Of Desensitizing Medicament199910.00D9940Occlusal Guard, By Report1999150.00D9941Fabrication Of Athletic Mouthguard1999103.00D9951Occlusal Adjustment - Limited199933.00D9952Occlusal Adjustment - Complete199966.00 ................
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