Ada Codes 2i23x
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ADA Code
Procedure Description
Dental Fee Schedule
Diagnostic Services D0110 and D0180 D0120 D0140 D0150 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0273 D0274 D0290 D0310 D0322 D0330 D0340 D0410 D0415 D0460 D0470 D0471 D0474 D0502
Initial Oral Examination Periodic Oral Examination—two per year Emergency or Problem Focused Oral Examination Comprehensive Oral Examination Intraoral-Complete Including Bitewings Intraoral-Periapical—First Film Intraoral-Periapical—Each Add. Film Intraoral-Occlusal, Film Extraoral—First Film Extraoral—Each Additional Film Bitewing—Single Film Bitewings—Two Films Bitewings—Three Films Bitewings—Four Films Posteroanter Sialography Tomographic Survey Panoramic Film Cephalometric Film Bacteriologic Studies for Path Agents Bacteriologic Studies for Path Agents Pulp Vitality Tests Diagnostic Casts Diagnostic Photographs Assession of Tissue Gross and Microscopic Examination Other Oral Pathology Procedures
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
41.00 21.00 41.00 41.00 68.00 15.00 13.00 23.00 27.00 24.00 16.00 23.00 26.00 33.00 37.00 8.00 75.00 63.00 69.00 24.00 15.00 38.00 59.00 27.00 66.00 57.00
Dental Prophylaxis Adults—two per year Dental Prophylaxis Children—two per year Topical Fluoride W/Prophy-Child—two per year Topical Fluoride W/Prophy-Adult—two per year Topical Fluoride W/O Prophy-Child—two per year Topical Fluoride W/O Prophy-Adult—two per year Topical Fluoride (Incl Prophy)-Adult—two per year Topical Sodium Fluoride—four treatments with Prophylaxis Topical Stannous Fluoride—one treatment with Prophylaxis Topical Acid Fluoride Phosphate—one treatment Oral Hygiene Instruction Training in Preventive Dental Care
$ $ $ $ $ $ $ $
48.00 37.00 51.00 58.00 21.00 21.00 54.00 44.00
Preventive Services D1110 D1120 D1201 D1202 D1203 D1204 D1205 D1211 D1221 D1231 D1330 D1340
$ 53.00 $ 48.00 $ 34.00 $ 45.00
D1350 D1351 D1510 D1515 D1525 D1550 Restorative Services D2140 D2150 D2160 D2161 D2190 D2210 D2310 D2330 D2331 D2332 D2334 D2335 D2338 D2390 D2391 D2392 D2393 D2410 D2420 D2430 D2510 D2520 D2530 D2535 D2540 D2610 D2620 D2630 D2640 D2650 D2651 D2652 D2660 D2710 D2720 D2721
Topical Sealants—Per Quadrant Topical Sealants—Per Tooth Space Maintainer—Fixed—Unilateral Space Maintainer—Fixed—Bilateral Space Maintainer—Removable—Bilateral Recementation of Space Maintainer
$ 28.00 $ 31.00 $178.00 $321.00 $372.00 $ 40.00
Amalgam—One Surface, Permanent or Primary Amalgam—Two Surfaces, Permanent or Primary Amalgam—Three Surfaces, Permanent or Primary Amalgam—Four or More Surfaces, Permanent or Primary Pin Retention—Exclusive of Amalgam Silicate Cement Per Restoration Acrylic or Plastic Restoration Resin—One Surface, Anterior Resin—Two Surfaces, Anterior Resin—Three Surfaces, Anterior Pin Retention—Excluding Composite Resin Resin—4+Surf or Involving Incisal Angle Composite Resin—2 Surfaces with Ultraviolet Composite Resin Crown—Anterior Primary Resin—One Surface, Posterior-Permanent or Primary Resin—Two Surfaces, Posterior-Permanent or Primary Resin—Three Surfaces, Posterior-Permanent or Primary Gold Foil—One Surface Gold Foil—Two Surfaces Gold Foil—Three Surfaces Inlay—Metallic—One Surface Inlay—Metallic—Two Surfaces Inlay—Metallic—Three Surfaces Inlay/Onlay Gold—Three Surfaces Onlay—Metallic—Per Tooth (In Add to Inlay) Inlay—Porcelain/Ceramic—One Surface Inlay—Porcelain/Ceramic—Two Surfaces Inlay—Porcelain/Ceramic—Three Surfaces Onlay—Porcelain/Ceramic-Per Tooth Inlay—Composite/Resin—One Surface/Lab Inlay—Composite/Resin—Two Surface/Lab Inlay—Composite Resin—Three Surface/Lab Onlay—Composite/Resin—Per Tooth Crown—Resin (indirect) Crown—Resin with High Noble Metal Crown—Resin with Predominately Base Metal
$ 62.00 $ 75.00 $ 93.00 $110.00 $ 32.00 $ 32.00 $ 51.00 $ 68.00 $ 99.00 $118.00 $ 21.00 $153.00 $ 75.00 $145.00 $ 75.00 $112.00 $132.00 $220.00 *** *** $383.00 $641.00 $388.00 *** $625.00 $453.00 $558.00 $559.00 $575.00 $386.00 $440.00 $440.00 $456.00 $237.00 $540.00 $356.00
D2722 D2740 D2783 D2751 D2752 D2790 D2791 D2792 D2810 D2830 D2840 D2891 D2892 D2910 D2920 D2930 D2931 D2932 D2933 D2940 D2950 D2951 D2952 D2953 D2954 D2960 D2961 D2962 D2970 D2980
Crown—Resin with Noble Metal Crown—Porcelain/Ceramic Substrate Crown—Porcelain/High Noble Metal Crown—Porcelain/Predominate Base Metal Crown—Porcelain/Noble Metal Crown—Full Cast High Noble Metal Crown—Full Cast Predom. Base Metal Crown—Full Cast Noble Metal Crown— Cast Metallic Stainless Steel Crown Temporary Crown (Fractured Tooth) Cast Post/Core + Crown Steel Post and Composite/Amalgam + Crown Recement Inlay Recement Crown Prefab Stainless Steel Crown—Prim Tooth Prefab Stainless Steel Crown—Perm Tooth Prefab Resin Crown Prefab Stainless Steel Crown with Resin Window Sedative Filling Crown Buildup, Including Any Pins Pin Retention—Per Tooth (without Restoration) Cast Post/Core(Addition to Crown) Cast Post (Part of Crown) Prefab Post/Core (Addition to Crown) Labial Veneer (Laminate)—Chairside Labial Veneer (Resin Laminate)—Laboratory Labial Veneer (Porcelain Laminate)—Lab Temporary (Fractured Tooth) Crown Repair
$397.00 $669.00 $642.00 $575.00 $591.00 $625.00 $558.00 $591.00 $672.00 *** *** *** *** $ 58.00 $ 54.00 $149.00 $186.00 $192.00 $134.00 $ 58.00 $176.00 $ 4.00 $267.00 *** $203.00 $338.00 $405.00 $469.00 $186.00 $135.00
Endodontics D3110 D3120 D3220 D3310 D3320 D3330 D3340 D3346 D3347 D3348 D3350 D3351
Pulp Cap-Direct (Excluding Final Restor.) Pulp Cap-Indirect (Excluding Final Restor.) Ther. Pulpotomy (Excluding Final Restoration) 1 Canal (Excluding Final Restoration) 2 Canals (Excluding Final Restoration) 3 Canals (Excluding Final Restoration) 4 + Canals (Excl Final Restoration) Root Canal—Retreatment—Anterior Root Canal—Retreatment—Bicuspid Root Canal—Retreatment—Molar Apexification/Recalcification—Per Visit Apex/Recalcification—Initial Visit
$ 37.00 $ 35.00 $ 85.00 $402.00 $459.00 $558.00 *** $440.00 $507.00 $625.00 *** $116.00
D3352 D3353 D3410 D3420 D3421 D3425 D3426 D3430 D3440 D3450 D3470 D3910 D3920 D3950
Apex/Recalcification—Interim Medication Apex/Recalcification—Final Visit Apicoectomy—Anterior Apicoectomy with Endodontic Procedure Per Root Apicoectomy—Bicuspid—First Root Apicoectomy—Molar—First Root Apicoectomy—Each Additional Root Retrograde Filling-Per Root Apical Curettage Root Amputation—Per Root Intentional Replantation Surg Prcd/Isolate Tooth with Rubber Dam Hemisection/Incl Root Removal excluding Therapy Canal Prep & Fitting of Preformed Dowel/Post
$ 93.00 $198.00 $388.00 *** $355.00 $423.00 $237.00 $102.00 *** $440.00 *** $ 69.00 $459.00 $ 63.00
$402.00 $102.00 $135.00 *** $473.00 $390.00 $540.00 $372.00 $658.00
D4261 D4265 D4270 D4271 D4340 D4341 D4342 D4910 D4920
Gingivectomy/Gingivoplasty—per Quadrant Gingivectomy/Gingivoplasty—One to Three Teeth Gingival Curettage—per Quadrant Distal Wedge Resection Gingival Flap Prcdr (with Root Plan-Four or More Teeth) Gingival Flap Prcdr (with Root Plan-One to Three Teeth) Crown Lengthening—Hard and Soft Tissue Muco-Gingival Surgery—Per Quadrant Osseous Surg (with Flap Entry and Closure) 4 or More Teeth Osseous Surg (with Flap Entry and Closure) 1-3 Teeth Biologic Materials to Aid in Tissue Regeneration Pedicle Soft Tissue Graft Procedure Free Soft Tissue Graft Procedure Periodontal Scaling & Root Planing—Mouth Periodontal Scaling & Root Planing-Four or More Teeth Periodental Scaling & Root Planning-One to Three Teeth Periodontal Maint Following Active Therapy Unscheduled Dress (By O/T Treating Dentist)
Prosthodontics (Removable) D5110 D5120 D5130 D5140 D5211 D5212 D5213
Complete Upper Complete Lower Immediate Upper Immediate Lower Upper Partial—Resin Base Lower Partial—Resin Base Upper Partial—Metal Base & Resin Saddles
$652.00 $599.00 $810.00 $777.00 $624.00 $626.00 $642.00
Periodontics D4210 D4211 D4220 D4230 D4240 D4241 D4249 D4250 D4260
$635.00 *** $575.00 $561.00 *** $132.00 $110.00 $ 64.00 $ 15.00
D5214 D5215 D5216 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5810 D5811 D5820 D5821 D5850 D5851 D5860 D5861 D5862
Lower Partial—Metal Base & Resin Saddles U Prtl H Nbl Bse Acrl Sdl Covtnl Clsp/Rst L Prtl H Nbl Bse Acrl Sdl Convtnl Clsp/Rst Rmvbl Unlt Prtl one PC Bse Cst—Clsp W/Pontic Adjust Complete Denture—Upper Adjust Complete Denture—Lower Adjust Partial Denture—Upper Adjust Partial Denture—Lower Repair Broken Complete Denture Base Replace Missing or Broken Teeth/Each Tooth Repair Acrylic Saddle or Base Repair Cast Framework Repair or Replace Broken Clasp Replace Broken Teeth—Per Tooth Add Tooth to Existing Partial Denture Add Clasp to Existing Partial Denture Rebase Complete Upper Denture Rebase Complete Lower Denture Rebase Partial Upper Denture Rebase Partial Lower Denture Reline Complete Upper Denture—Office Reline Complete Lower Denture—Office Reline Partial Upper Denture—Office Reline Partial Lower Denture—Office Reline Complete Upper Denture—Laboratory Reline Complete Lower Denture—Laboratory Reline Partial Upper Denture—Laboratory Reline Partial Lower Denture—Laboratory Temporary Complete Denture (Upper) Temporary Complete Denture (Lower) Temporary Partial—Stayplate Denture (Upper) Temporary Partial—Stayplate Denture (Lower) Tissue Conditioning—Upper Unit Tissue Conditioning—Lower Unit Overdenture Complete Overdenture Partial Precision Attachment
$666.00 *** *** $430.00 $ 41.00 $ 35.00 $ 48.00 $ 41.00 $ 91.00 $ 72.00 $ 102.00 $ 102.00 $ 95.00 $ 80.00 $ 108.00 $ 108.00 $ 249.00 $ 276.00 $ 261.00 $ 279.00 $ 199.00 $ 186.00 $ 153.00 $ 186.00 $ 237.00 $ 237.00 $ 199.00 $ 220.00 $ 305.00 $ 268.00 $ 261.00 $ 270.00 $ 102.00 $ 72.00 $1,350.00 $ 733.00 $ 311.00
Maxillofacial Prosthetics D5911
Facial Moulage
***
Prosthodontics (Fixed) D6010
Endosteal Implant
$1,013.00
D6020 D6040 D6055 D6080 D6100 D6210 D6211 D6212 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6540 D6545 D6547 D6606 D6607 D6720 D6721 D6722 D6750 D6751 D6752 D6780 D6790 D6791 D6792 D6930 D6940 D6950 D6970 D6971 D6972 D6973 D6975 D6980
Abutment Placement Eposteal Implant Implant Connecting Bar Implant Maintenance Procedures Implant Removal, by Report Pontic-Cast High Noble Metal Pontic-Cast Predominately Base Metal Pontic—Cast Noble Metal Pontic—Porcelain/High Noble Metal Pontic—Porcelain/Predominately Base Metal Pontic—Porcelain/Nobe Metal Pontic—Porcelain/Ceramic Substrate Pontic—Resin/High Noble Metal Pontic—Resin/Predominately Base Metal Pontic—Resin/Noble Metal Inlay—Metallic—Onlaying Cusps Cast Metal Retainer for Acid Etch Bridge Retainer—Ceramic Substrate for Acid Etch Inlay-Metallic-Two Surfaces Inlay-Metallic-Three or More Surfaces Crown—Resin with High Noble Metal Crown—Resin with Predominately Base Metal Crown—Resin with Noble Metal Crown—Porcelain/High Noble Metal Crown—Porcelain/Predominately Base Metal Crown—Porcelain/Noble Metal Crown— Cast High Noble Metal Crown—Full Cast High Noble Metal Crown—Full Cast Predominantly Base Metal Crown—Full Cast Noble Metal Recement Fixed Partial Denture Stress Breaker Precision Attachment Cast Post/Core in Addition to Bridge Retainer Cast Post as Part of Bridge Retainer Prefab Post/Core in Addition to Bridge Retainer Retainer Crown Buildup, Including Pins Coping—Metal Bridge Repair
$ 258.00 $ 675.00 $ 316.00 $ 68.00 $ 170.00 $ 608.00 $ 473.00 $ 566.00 $ 665.00 $ 507.00 $ 558.00 *** $ 710.00 $ 491.00 $ 435.00 $ 312.00 $ 296.00 *** $ 373.00 $ 423.00 $ 528.00 $ 542.00 $ 393.00 $ 669.00 $ 507.00 $ 562.00 $ 450.00 $ 612.00 $ 507.00 $ 523.00 $ 81.00 $ 182.00 $ 237.00 $ 286.00 *** $ 153.00 $ 197.00 $ 251.00 $ 186.00
Oral Surgery D7111 D7120 D7140 D7210
Single Tooth Extraction Each Additional Tooth Extraction Extraction Erupted Tooth or Root Removal Surgical Removal Of Erupted Tooth
$ 72.00 $ 67.00 $ 102.00 $ 135.00
D7220 D7230 D7240 D7241 D7250 D7260 D7280 D7281 D7285 D7286 D7290 D7291 D7310 D7320 D7340 D7350 D7410 D7411 D7440 D7441 D7450 D7451 D7460 D7461 D7465 D7471 D7485 D7490 D7510 D7520 D7530 D7540 D7550 D7560 D7610 D7620 D7630 D7640 D7650 D7660 D7670 D7671 D7680 D7710 D7720
Removal of Impacted Tooth/Soft Tissue Removal of Impacted Tooth/Partially Bony Removal of Impacted Tooth/Completely Bony Removal Impct The Cmplt Bwy with Unusual Complctns Surgical Removal of Residual Tooth Roots Oral Antral Fistula Closure Surgical Access of an Unerupted Tooth Srg Exposr Impct/Unerpt Tooth/Aid Eruption Biopsy of Oral Tissue—Hard Biopsy of Oral Tissue—Soft Surgical Repositioning of Teeth Transseptal Fiberotomy Alveoloplasty in Conjunct with Extract/Quad Alveoloplasty not in Conjunct with Extract/Quad Vestibuloplasty—Rdg Extension Epithel Vestibuloplasty—Rdg Extension with Gft-Reatch Radical Excision—Lesion DIA Up to 1.25 CM. Radical Excision—Lesion DIA Over 1.25 CM. Exc Malig Tumor—Lesion DIA up to 1.25 CM. Exc Malig Tumor—Lesion DIA over 1.25 CM. Rmvl Odontogenic Cyst/Tumor Up to 1.25 CM. Rmvl Odontogenic Cyst/Tumor Over 1.25 CM. Rmvl Nonodontogenic Cyst/Tumor Up to 1.25 CM. Rmvl Nonodontogenic Cyst/Tumor Over 1.25 CM. Destroy Les By Elctsrg/Chmtpy/Cryotpy Etc Removal Of Extosis—Maxilla or Mandible Surgical Reduction Osseous Tuberosity Radical Resection/Mandible With Bone Graft Incision and Drainage of Abscess/Intraoral Incision and Drainage of Abscess/Extraoral Rmvl Foreign Bdy Skn/Subcutaneous Areolar Tis Rmvl Reaction Produc Foreign Bodies-Mus/Skl Partial Ostectomy for Removal of Non-Vital Bone Maxillary Sinusotomy For Removal Th Frgmt/Fb Maxilla Fracture Open Red Teeth Immobilized Maxilla Fracture Closed Red Teeth Immobilized Mandible Fracture Open Red Teeth Immobilized Mandible Fracture Closed Red Teeth Immobilized Malar/Zygomatic Arch—Open Reduction Malar/Zygomatic Arch—Closed Reduction Alveolus Closed Reduction May Include Stabilization Alveolus Open Reduction May Include Stabilization Facial Bones—Complete Red with Fix/Mult Surg Appr Maxilla—Open Reduction (Treatment of Fracture) Maxilla—Clsd Reduction (Treatment of Fracture)
$ 186.00 $ 224.00 $ 253.00 $ 372.00 $ 153.00 $ 321.00 *** $ 288.00 $ 151.00 $ 220.00 *** $ 43.00 $ 170.00 $ 170.00 $ 284.00 $ 414.00 $ 197.00 $ 237.00 *** *** $ 440.00 $ 298.00 $ 230.00 $ 575.00 $ 61.00 $ 440.00 *** *** $ 116.00 $ 87.00 $ 71.00 *** $ 216.00 *** *** *** *** *** *** *** *** *** *** *** ***
D7730 D7740 D7750
*** *** ***
D7770 D7771 D7780 D7810 D7820 D7910 D7911 D7912 D7920 D7940 D7941 D7942 D7943 D7944 D7945 D7946 D7947 D7948 D7949 D7950 D7955 D7960 D7970 D7971 D7980 D7981 D7982 D7983 D7990 D7991
Mandible—Opn Reduction (Treatment of Fracture) Mandible—Closed Reduction (Treatment of Fracture) Malar/Zygomatic Arch—Opn Red (Treatment of Fracture) Malar/Zygomatic Arch—Clsd Red (Treatment of Fracture) Alveolus Open Reduction Stabilization Alveolus Closed Reduction Stabilization Facial Bones—Cmpl Red with Fix/Mult Surg Appr Open Reduction of Dislocation Closed Reduction of Dislocation Suture of Recent Small Wounds Up to 5 CM. Suture—Up to 5 CM. Suture—Over 5 CM. Skin Grafts Osteoplasty—For Orthognathic Osteotomy—Ramus, Closed Osteotomy—Ramus, Open Osteotomy—Ramus, Open W/Bone Graft Osteotomy—Seg/Subapical Per Sext/Quad Osteotomy—Body of Mandible Lefort I (Maxilla-Total) Lefort I (Maxilla-Segmented) Lefort II/III—without Bone Graft Lefort II or III with Bone Graft Osseous/Ostprstl/Ctlg Gft Mndbl Auto/NonAuto Rpr Maxillofacial Soft and Hard Tissue Defcts Frenulectomy—Separate Procedure Excision of Hyperplastic Tissue—per Arch Excision of Pericoronal Gingiva Sialolithotomy Excision of Salivary Gland Sialodochoplasty Closure of Salivary Fistula Emergency Tracheotomy Coronoidectomy
Adjunctive Dental Services D9110 D9220 D9221 D9230 D9241 D9310
Palliative (Emergency) Trmt Pain Minor Prcd Anesthesia—First 30 minutes Anesthesia—Each additional 15 minutes Analgesia Intravenous Sedation Consultation—Per Session
$ 58.00 $ 203.00 $ 122.00 $ 41.00 $ 216.00 $ 62.00
D7760
*** *** *** *** $ 107.00 $ 193.00 $ 85.00 $ 45.00 *** *** *** *** *** *** *** *** *** *** *** $ 540.00 $ 502.00 $ 264.00 $ 305.00 $ 305.00 $ 108.00 *** *** *** *** *** ***
D9430 D9440 D9930 D9940
Office Visit/Observation Normal Hours—No Service Office Visit—After Regular Scheduled Hours Treatment Complications/PST Srg/Unusual Circumstances Occlusal Guards
$ $ $
37.00 85.00 41.00
$ 270.00
Procedure Description
Dental Fee Schedule
Diagnostic Services D0110 and D0180 D0120 D0140 D0150 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0273 D0274 D0290 D0310 D0322 D0330 D0340 D0410 D0415 D0460 D0470 D0471 D0474 D0502
Initial Oral Examination Periodic Oral Examination—two per year Emergency or Problem Focused Oral Examination Comprehensive Oral Examination Intraoral-Complete Including Bitewings Intraoral-Periapical—First Film Intraoral-Periapical—Each Add. Film Intraoral-Occlusal, Film Extraoral—First Film Extraoral—Each Additional Film Bitewing—Single Film Bitewings—Two Films Bitewings—Three Films Bitewings—Four Films Posteroanter Sialography Tomographic Survey Panoramic Film Cephalometric Film Bacteriologic Studies for Path Agents Bacteriologic Studies for Path Agents Pulp Vitality Tests Diagnostic Casts Diagnostic Photographs Assession of Tissue Gross and Microscopic Examination Other Oral Pathology Procedures
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
41.00 21.00 41.00 41.00 68.00 15.00 13.00 23.00 27.00 24.00 16.00 23.00 26.00 33.00 37.00 8.00 75.00 63.00 69.00 24.00 15.00 38.00 59.00 27.00 66.00 57.00
Dental Prophylaxis Adults—two per year Dental Prophylaxis Children—two per year Topical Fluoride W/Prophy-Child—two per year Topical Fluoride W/Prophy-Adult—two per year Topical Fluoride W/O Prophy-Child—two per year Topical Fluoride W/O Prophy-Adult—two per year Topical Fluoride (Incl Prophy)-Adult—two per year Topical Sodium Fluoride—four treatments with Prophylaxis Topical Stannous Fluoride—one treatment with Prophylaxis Topical Acid Fluoride Phosphate—one treatment Oral Hygiene Instruction Training in Preventive Dental Care
$ $ $ $ $ $ $ $
48.00 37.00 51.00 58.00 21.00 21.00 54.00 44.00
Preventive Services D1110 D1120 D1201 D1202 D1203 D1204 D1205 D1211 D1221 D1231 D1330 D1340
$ 53.00 $ 48.00 $ 34.00 $ 45.00
D1350 D1351 D1510 D1515 D1525 D1550 Restorative Services D2140 D2150 D2160 D2161 D2190 D2210 D2310 D2330 D2331 D2332 D2334 D2335 D2338 D2390 D2391 D2392 D2393 D2410 D2420 D2430 D2510 D2520 D2530 D2535 D2540 D2610 D2620 D2630 D2640 D2650 D2651 D2652 D2660 D2710 D2720 D2721
Topical Sealants—Per Quadrant Topical Sealants—Per Tooth Space Maintainer—Fixed—Unilateral Space Maintainer—Fixed—Bilateral Space Maintainer—Removable—Bilateral Recementation of Space Maintainer
$ 28.00 $ 31.00 $178.00 $321.00 $372.00 $ 40.00
Amalgam—One Surface, Permanent or Primary Amalgam—Two Surfaces, Permanent or Primary Amalgam—Three Surfaces, Permanent or Primary Amalgam—Four or More Surfaces, Permanent or Primary Pin Retention—Exclusive of Amalgam Silicate Cement Per Restoration Acrylic or Plastic Restoration Resin—One Surface, Anterior Resin—Two Surfaces, Anterior Resin—Three Surfaces, Anterior Pin Retention—Excluding Composite Resin Resin—4+Surf or Involving Incisal Angle Composite Resin—2 Surfaces with Ultraviolet Composite Resin Crown—Anterior Primary Resin—One Surface, Posterior-Permanent or Primary Resin—Two Surfaces, Posterior-Permanent or Primary Resin—Three Surfaces, Posterior-Permanent or Primary Gold Foil—One Surface Gold Foil—Two Surfaces Gold Foil—Three Surfaces Inlay—Metallic—One Surface Inlay—Metallic—Two Surfaces Inlay—Metallic—Three Surfaces Inlay/Onlay Gold—Three Surfaces Onlay—Metallic—Per Tooth (In Add to Inlay) Inlay—Porcelain/Ceramic—One Surface Inlay—Porcelain/Ceramic—Two Surfaces Inlay—Porcelain/Ceramic—Three Surfaces Onlay—Porcelain/Ceramic-Per Tooth Inlay—Composite/Resin—One Surface/Lab Inlay—Composite/Resin—Two Surface/Lab Inlay—Composite Resin—Three Surface/Lab Onlay—Composite/Resin—Per Tooth Crown—Resin (indirect) Crown—Resin with High Noble Metal Crown—Resin with Predominately Base Metal
$ 62.00 $ 75.00 $ 93.00 $110.00 $ 32.00 $ 32.00 $ 51.00 $ 68.00 $ 99.00 $118.00 $ 21.00 $153.00 $ 75.00 $145.00 $ 75.00 $112.00 $132.00 $220.00 *** *** $383.00 $641.00 $388.00 *** $625.00 $453.00 $558.00 $559.00 $575.00 $386.00 $440.00 $440.00 $456.00 $237.00 $540.00 $356.00
D2722 D2740 D2783 D2751 D2752 D2790 D2791 D2792 D2810 D2830 D2840 D2891 D2892 D2910 D2920 D2930 D2931 D2932 D2933 D2940 D2950 D2951 D2952 D2953 D2954 D2960 D2961 D2962 D2970 D2980
Crown—Resin with Noble Metal Crown—Porcelain/Ceramic Substrate Crown—Porcelain/High Noble Metal Crown—Porcelain/Predominate Base Metal Crown—Porcelain/Noble Metal Crown—Full Cast High Noble Metal Crown—Full Cast Predom. Base Metal Crown—Full Cast Noble Metal Crown— Cast Metallic Stainless Steel Crown Temporary Crown (Fractured Tooth) Cast Post/Core + Crown Steel Post and Composite/Amalgam + Crown Recement Inlay Recement Crown Prefab Stainless Steel Crown—Prim Tooth Prefab Stainless Steel Crown—Perm Tooth Prefab Resin Crown Prefab Stainless Steel Crown with Resin Window Sedative Filling Crown Buildup, Including Any Pins Pin Retention—Per Tooth (without Restoration) Cast Post/Core(Addition to Crown) Cast Post (Part of Crown) Prefab Post/Core (Addition to Crown) Labial Veneer (Laminate)—Chairside Labial Veneer (Resin Laminate)—Laboratory Labial Veneer (Porcelain Laminate)—Lab Temporary (Fractured Tooth) Crown Repair
$397.00 $669.00 $642.00 $575.00 $591.00 $625.00 $558.00 $591.00 $672.00 *** *** *** *** $ 58.00 $ 54.00 $149.00 $186.00 $192.00 $134.00 $ 58.00 $176.00 $ 4.00 $267.00 *** $203.00 $338.00 $405.00 $469.00 $186.00 $135.00
Endodontics D3110 D3120 D3220 D3310 D3320 D3330 D3340 D3346 D3347 D3348 D3350 D3351
Pulp Cap-Direct (Excluding Final Restor.) Pulp Cap-Indirect (Excluding Final Restor.) Ther. Pulpotomy (Excluding Final Restoration) 1 Canal (Excluding Final Restoration) 2 Canals (Excluding Final Restoration) 3 Canals (Excluding Final Restoration) 4 + Canals (Excl Final Restoration) Root Canal—Retreatment—Anterior Root Canal—Retreatment—Bicuspid Root Canal—Retreatment—Molar Apexification/Recalcification—Per Visit Apex/Recalcification—Initial Visit
$ 37.00 $ 35.00 $ 85.00 $402.00 $459.00 $558.00 *** $440.00 $507.00 $625.00 *** $116.00
D3352 D3353 D3410 D3420 D3421 D3425 D3426 D3430 D3440 D3450 D3470 D3910 D3920 D3950
Apex/Recalcification—Interim Medication Apex/Recalcification—Final Visit Apicoectomy—Anterior Apicoectomy with Endodontic Procedure Per Root Apicoectomy—Bicuspid—First Root Apicoectomy—Molar—First Root Apicoectomy—Each Additional Root Retrograde Filling-Per Root Apical Curettage Root Amputation—Per Root Intentional Replantation Surg Prcd/Isolate Tooth with Rubber Dam Hemisection/Incl Root Removal excluding Therapy Canal Prep & Fitting of Preformed Dowel/Post
$ 93.00 $198.00 $388.00 *** $355.00 $423.00 $237.00 $102.00 *** $440.00 *** $ 69.00 $459.00 $ 63.00
$402.00 $102.00 $135.00 *** $473.00 $390.00 $540.00 $372.00 $658.00
D4261 D4265 D4270 D4271 D4340 D4341 D4342 D4910 D4920
Gingivectomy/Gingivoplasty—per Quadrant Gingivectomy/Gingivoplasty—One to Three Teeth Gingival Curettage—per Quadrant Distal Wedge Resection Gingival Flap Prcdr (with Root Plan-Four or More Teeth) Gingival Flap Prcdr (with Root Plan-One to Three Teeth) Crown Lengthening—Hard and Soft Tissue Muco-Gingival Surgery—Per Quadrant Osseous Surg (with Flap Entry and Closure) 4 or More Teeth Osseous Surg (with Flap Entry and Closure) 1-3 Teeth Biologic Materials to Aid in Tissue Regeneration Pedicle Soft Tissue Graft Procedure Free Soft Tissue Graft Procedure Periodontal Scaling & Root Planing—Mouth Periodontal Scaling & Root Planing-Four or More Teeth Periodental Scaling & Root Planning-One to Three Teeth Periodontal Maint Following Active Therapy Unscheduled Dress (By O/T Treating Dentist)
Prosthodontics (Removable) D5110 D5120 D5130 D5140 D5211 D5212 D5213
Complete Upper Complete Lower Immediate Upper Immediate Lower Upper Partial—Resin Base Lower Partial—Resin Base Upper Partial—Metal Base & Resin Saddles
$652.00 $599.00 $810.00 $777.00 $624.00 $626.00 $642.00
Periodontics D4210 D4211 D4220 D4230 D4240 D4241 D4249 D4250 D4260
$635.00 *** $575.00 $561.00 *** $132.00 $110.00 $ 64.00 $ 15.00
D5214 D5215 D5216 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5810 D5811 D5820 D5821 D5850 D5851 D5860 D5861 D5862
Lower Partial—Metal Base & Resin Saddles U Prtl H Nbl Bse Acrl Sdl Covtnl Clsp/Rst L Prtl H Nbl Bse Acrl Sdl Convtnl Clsp/Rst Rmvbl Unlt Prtl one PC Bse Cst—Clsp W/Pontic Adjust Complete Denture—Upper Adjust Complete Denture—Lower Adjust Partial Denture—Upper Adjust Partial Denture—Lower Repair Broken Complete Denture Base Replace Missing or Broken Teeth/Each Tooth Repair Acrylic Saddle or Base Repair Cast Framework Repair or Replace Broken Clasp Replace Broken Teeth—Per Tooth Add Tooth to Existing Partial Denture Add Clasp to Existing Partial Denture Rebase Complete Upper Denture Rebase Complete Lower Denture Rebase Partial Upper Denture Rebase Partial Lower Denture Reline Complete Upper Denture—Office Reline Complete Lower Denture—Office Reline Partial Upper Denture—Office Reline Partial Lower Denture—Office Reline Complete Upper Denture—Laboratory Reline Complete Lower Denture—Laboratory Reline Partial Upper Denture—Laboratory Reline Partial Lower Denture—Laboratory Temporary Complete Denture (Upper) Temporary Complete Denture (Lower) Temporary Partial—Stayplate Denture (Upper) Temporary Partial—Stayplate Denture (Lower) Tissue Conditioning—Upper Unit Tissue Conditioning—Lower Unit Overdenture Complete Overdenture Partial Precision Attachment
$666.00 *** *** $430.00 $ 41.00 $ 35.00 $ 48.00 $ 41.00 $ 91.00 $ 72.00 $ 102.00 $ 102.00 $ 95.00 $ 80.00 $ 108.00 $ 108.00 $ 249.00 $ 276.00 $ 261.00 $ 279.00 $ 199.00 $ 186.00 $ 153.00 $ 186.00 $ 237.00 $ 237.00 $ 199.00 $ 220.00 $ 305.00 $ 268.00 $ 261.00 $ 270.00 $ 102.00 $ 72.00 $1,350.00 $ 733.00 $ 311.00
Maxillofacial Prosthetics D5911
Facial Moulage
***
Prosthodontics (Fixed) D6010
Endosteal Implant
$1,013.00
D6020 D6040 D6055 D6080 D6100 D6210 D6211 D6212 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6540 D6545 D6547 D6606 D6607 D6720 D6721 D6722 D6750 D6751 D6752 D6780 D6790 D6791 D6792 D6930 D6940 D6950 D6970 D6971 D6972 D6973 D6975 D6980
Abutment Placement Eposteal Implant Implant Connecting Bar Implant Maintenance Procedures Implant Removal, by Report Pontic-Cast High Noble Metal Pontic-Cast Predominately Base Metal Pontic—Cast Noble Metal Pontic—Porcelain/High Noble Metal Pontic—Porcelain/Predominately Base Metal Pontic—Porcelain/Nobe Metal Pontic—Porcelain/Ceramic Substrate Pontic—Resin/High Noble Metal Pontic—Resin/Predominately Base Metal Pontic—Resin/Noble Metal Inlay—Metallic—Onlaying Cusps Cast Metal Retainer for Acid Etch Bridge Retainer—Ceramic Substrate for Acid Etch Inlay-Metallic-Two Surfaces Inlay-Metallic-Three or More Surfaces Crown—Resin with High Noble Metal Crown—Resin with Predominately Base Metal Crown—Resin with Noble Metal Crown—Porcelain/High Noble Metal Crown—Porcelain/Predominately Base Metal Crown—Porcelain/Noble Metal Crown— Cast High Noble Metal Crown—Full Cast High Noble Metal Crown—Full Cast Predominantly Base Metal Crown—Full Cast Noble Metal Recement Fixed Partial Denture Stress Breaker Precision Attachment Cast Post/Core in Addition to Bridge Retainer Cast Post as Part of Bridge Retainer Prefab Post/Core in Addition to Bridge Retainer Retainer Crown Buildup, Including Pins Coping—Metal Bridge Repair
$ 258.00 $ 675.00 $ 316.00 $ 68.00 $ 170.00 $ 608.00 $ 473.00 $ 566.00 $ 665.00 $ 507.00 $ 558.00 *** $ 710.00 $ 491.00 $ 435.00 $ 312.00 $ 296.00 *** $ 373.00 $ 423.00 $ 528.00 $ 542.00 $ 393.00 $ 669.00 $ 507.00 $ 562.00 $ 450.00 $ 612.00 $ 507.00 $ 523.00 $ 81.00 $ 182.00 $ 237.00 $ 286.00 *** $ 153.00 $ 197.00 $ 251.00 $ 186.00
Oral Surgery D7111 D7120 D7140 D7210
Single Tooth Extraction Each Additional Tooth Extraction Extraction Erupted Tooth or Root Removal Surgical Removal Of Erupted Tooth
$ 72.00 $ 67.00 $ 102.00 $ 135.00
D7220 D7230 D7240 D7241 D7250 D7260 D7280 D7281 D7285 D7286 D7290 D7291 D7310 D7320 D7340 D7350 D7410 D7411 D7440 D7441 D7450 D7451 D7460 D7461 D7465 D7471 D7485 D7490 D7510 D7520 D7530 D7540 D7550 D7560 D7610 D7620 D7630 D7640 D7650 D7660 D7670 D7671 D7680 D7710 D7720
Removal of Impacted Tooth/Soft Tissue Removal of Impacted Tooth/Partially Bony Removal of Impacted Tooth/Completely Bony Removal Impct The Cmplt Bwy with Unusual Complctns Surgical Removal of Residual Tooth Roots Oral Antral Fistula Closure Surgical Access of an Unerupted Tooth Srg Exposr Impct/Unerpt Tooth/Aid Eruption Biopsy of Oral Tissue—Hard Biopsy of Oral Tissue—Soft Surgical Repositioning of Teeth Transseptal Fiberotomy Alveoloplasty in Conjunct with Extract/Quad Alveoloplasty not in Conjunct with Extract/Quad Vestibuloplasty—Rdg Extension Epithel Vestibuloplasty—Rdg Extension with Gft-Reatch Radical Excision—Lesion DIA Up to 1.25 CM. Radical Excision—Lesion DIA Over 1.25 CM. Exc Malig Tumor—Lesion DIA up to 1.25 CM. Exc Malig Tumor—Lesion DIA over 1.25 CM. Rmvl Odontogenic Cyst/Tumor Up to 1.25 CM. Rmvl Odontogenic Cyst/Tumor Over 1.25 CM. Rmvl Nonodontogenic Cyst/Tumor Up to 1.25 CM. Rmvl Nonodontogenic Cyst/Tumor Over 1.25 CM. Destroy Les By Elctsrg/Chmtpy/Cryotpy Etc Removal Of Extosis—Maxilla or Mandible Surgical Reduction Osseous Tuberosity Radical Resection/Mandible With Bone Graft Incision and Drainage of Abscess/Intraoral Incision and Drainage of Abscess/Extraoral Rmvl Foreign Bdy Skn/Subcutaneous Areolar Tis Rmvl Reaction Produc Foreign Bodies-Mus/Skl Partial Ostectomy for Removal of Non-Vital Bone Maxillary Sinusotomy For Removal Th Frgmt/Fb Maxilla Fracture Open Red Teeth Immobilized Maxilla Fracture Closed Red Teeth Immobilized Mandible Fracture Open Red Teeth Immobilized Mandible Fracture Closed Red Teeth Immobilized Malar/Zygomatic Arch—Open Reduction Malar/Zygomatic Arch—Closed Reduction Alveolus Closed Reduction May Include Stabilization Alveolus Open Reduction May Include Stabilization Facial Bones—Complete Red with Fix/Mult Surg Appr Maxilla—Open Reduction (Treatment of Fracture) Maxilla—Clsd Reduction (Treatment of Fracture)
$ 186.00 $ 224.00 $ 253.00 $ 372.00 $ 153.00 $ 321.00 *** $ 288.00 $ 151.00 $ 220.00 *** $ 43.00 $ 170.00 $ 170.00 $ 284.00 $ 414.00 $ 197.00 $ 237.00 *** *** $ 440.00 $ 298.00 $ 230.00 $ 575.00 $ 61.00 $ 440.00 *** *** $ 116.00 $ 87.00 $ 71.00 *** $ 216.00 *** *** *** *** *** *** *** *** *** *** *** ***
D7730 D7740 D7750
*** *** ***
D7770 D7771 D7780 D7810 D7820 D7910 D7911 D7912 D7920 D7940 D7941 D7942 D7943 D7944 D7945 D7946 D7947 D7948 D7949 D7950 D7955 D7960 D7970 D7971 D7980 D7981 D7982 D7983 D7990 D7991
Mandible—Opn Reduction (Treatment of Fracture) Mandible—Closed Reduction (Treatment of Fracture) Malar/Zygomatic Arch—Opn Red (Treatment of Fracture) Malar/Zygomatic Arch—Clsd Red (Treatment of Fracture) Alveolus Open Reduction Stabilization Alveolus Closed Reduction Stabilization Facial Bones—Cmpl Red with Fix/Mult Surg Appr Open Reduction of Dislocation Closed Reduction of Dislocation Suture of Recent Small Wounds Up to 5 CM. Suture—Up to 5 CM. Suture—Over 5 CM. Skin Grafts Osteoplasty—For Orthognathic Osteotomy—Ramus, Closed Osteotomy—Ramus, Open Osteotomy—Ramus, Open W/Bone Graft Osteotomy—Seg/Subapical Per Sext/Quad Osteotomy—Body of Mandible Lefort I (Maxilla-Total) Lefort I (Maxilla-Segmented) Lefort II/III—without Bone Graft Lefort II or III with Bone Graft Osseous/Ostprstl/Ctlg Gft Mndbl Auto/NonAuto Rpr Maxillofacial Soft and Hard Tissue Defcts Frenulectomy—Separate Procedure Excision of Hyperplastic Tissue—per Arch Excision of Pericoronal Gingiva Sialolithotomy Excision of Salivary Gland Sialodochoplasty Closure of Salivary Fistula Emergency Tracheotomy Coronoidectomy
Adjunctive Dental Services D9110 D9220 D9221 D9230 D9241 D9310
Palliative (Emergency) Trmt Pain Minor Prcd Anesthesia—First 30 minutes Anesthesia—Each additional 15 minutes Analgesia Intravenous Sedation Consultation—Per Session
$ 58.00 $ 203.00 $ 122.00 $ 41.00 $ 216.00 $ 62.00
D7760
*** *** *** *** $ 107.00 $ 193.00 $ 85.00 $ 45.00 *** *** *** *** *** *** *** *** *** *** *** $ 540.00 $ 502.00 $ 264.00 $ 305.00 $ 305.00 $ 108.00 *** *** *** *** *** ***
D9430 D9440 D9930 D9940
Office Visit/Observation Normal Hours—No Service Office Visit—After Regular Scheduled Hours Treatment Complications/PST Srg/Unusual Circumstances Occlusal Guards
$ $ $
37.00 85.00 41.00
$ 270.00
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