ADA Code 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 Preventive Services D1110 D1120 D1201 D1202 D1203 D1204 D1205 D1211 D1221 D1231 D1330 D1340

Procedure Description

Dental Fee Schedule $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 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

Initial Oral Examination Periodic Oral Examinationtwo per year Emergency or Problem Focused Oral Examination Comprehensive Oral Examination Intraoral-Complete Including Bitewings Intraoral-PeriapicalFirst Film Intraoral-PeriapicalEach Add. Film Intraoral-Occlusal, Film ExtraoralFirst Film ExtraoralEach Additional Film BitewingSingle Film BitewingsTwo Films BitewingsThree Films BitewingsFour 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

Dental Prophylaxis Adultstwo per year Dental Prophylaxis Childrentwo per year Topical Fluoride W/Prophy-Childtwo per year Topical Fluoride W/Prophy-Adulttwo per year Topical Fluoride W/O Prophy-Childtwo per year Topical Fluoride W/O Prophy-Adulttwo per year Topical Fluoride (Incl Prophy)-Adulttwo per year Topical Sodium Fluoridefour treatments with Prophylaxis Topical Stannous Fluorideone treatment with Prophylaxis Topical Acid Fluoride Phosphateone 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

$ 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 SealantsPer Quadrant Topical SealantsPer Tooth Space MaintainerFixedUnilateral Space MaintainerFixedBilateral Space MaintainerRemovableBilateral Recementation of Space Maintainer

$ 28.00 $ 31.00 $178.00 $321.00 $372.00 $ 40.00

AmalgamOne Surface, Permanent or Primary AmalgamTwo Surfaces, Permanent or Primary AmalgamThree Surfaces, Permanent or Primary AmalgamFour or More Surfaces, Permanent or Primary Pin RetentionExclusive of Amalgam Silicate Cement Per Restoration Acrylic or Plastic Restoration ResinOne Surface, Anterior ResinTwo Surfaces, Anterior ResinThree Surfaces, Anterior Pin RetentionExcluding Composite Resin Resin4+Surf or Involving Incisal Angle Composite Resin2 Surfaces with Ultraviolet Composite Resin CrownAnterior Primary ResinOne Surface, Posterior-Permanent or Primary ResinTwo Surfaces, Posterior-Permanent or Primary ResinThree Surfaces, Posterior-Permanent or Primary Gold FoilOne Surface Gold FoilTwo Surfaces Gold FoilThree Surfaces InlayMetallicOne Surface InlayMetallicTwo Surfaces InlayMetallicThree Surfaces Inlay/Onlay GoldThree Surfaces OnlayMetallicPer Tooth (In Add to Inlay) InlayPorcelain/CeramicOne Surface InlayPorcelain/CeramicTwo Surfaces InlayPorcelain/CeramicThree Surfaces OnlayPorcelain/Ceramic-Per Tooth InlayComposite/ResinOne Surface/Lab InlayComposite/ResinTwo Surface/Lab InlayComposite ResinThree Surface/Lab OnlayComposite/ResinPer Tooth CrownResin (indirect) CrownResin with High Noble Metal CrownResin 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

CrownResin with Noble Metal CrownPorcelain/Ceramic Substrate CrownPorcelain/High Noble Metal CrownPorcelain/Predominate Base Metal CrownPorcelain/Noble Metal CrownFull Cast High Noble Metal CrownFull Cast Predom. Base Metal CrownFull 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 CrownPrim Tooth Prefab Stainless Steel CrownPerm Tooth Prefab Resin Crown Prefab Stainless Steel Crown with Resin Window Sedative Filling Crown Buildup, Including Any Pins Pin RetentionPer 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 CanalRetreatmentAnterior Root CanalRetreatmentBicuspid Root CanalRetreatmentMolar Apexification/RecalcificationPer Visit Apex/RecalcificationInitial 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 Periodontics D4210 D4211 D4220 D4230 D4240 D4241 D4249 D4250 D4260 D4261 D4265 D4270 D4271 D4340 D4341 D4342 D4910 D4920 Prosthodontics (Removable) D5110 D5120 D5130 D5140 D5211 D5212 D5213

Apex/RecalcificationInterim Medication Apex/RecalcificationFinal Visit ApicoectomyAnterior Apicoectomy with Endodontic Procedure Per Root ApicoectomyBicuspidFirst Root ApicoectomyMolarFirst Root ApicoectomyEach Additional Root Retrograde Filling-Per Root Apical Curettage Root AmputationPer 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

Gingivectomy/Gingivoplastyper Quadrant Gingivectomy/GingivoplastyOne to Three Teeth Gingival Curettageper 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 LengtheningHard and Soft Tissue Muco-Gingival SurgeryPer 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 PlaningMouth 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)

$402.00 $102.00 $135.00 *** $473.00 $390.00 $540.00 $372.00 $658.00 $635.00 *** $575.00 $561.00 *** $132.00 $110.00 $ 64.00 $ 15.00

Complete Upper Complete Lower Immediate Upper Immediate Lower Upper PartialResin Base Lower PartialResin Base Upper PartialMetal Base & Resin Saddles

$652.00 $599.00 $810.00 $777.00 $624.00 $626.00 $642.00

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 Maxillofacial Prosthetics D5911 Prosthodontics (Fixed) D6010

Lower PartialMetal 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 CstClsp W/Pontic Adjust Complete DentureUpper Adjust Complete DentureLower Adjust Partial DentureUpper Adjust Partial DentureLower 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 TeethPer 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 DentureOffice Reline Complete Lower DentureOffice Reline Partial Upper DentureOffice Reline Partial Lower DentureOffice Reline Complete Upper DentureLaboratory Reline Complete Lower DentureLaboratory Reline Partial Upper DentureLaboratory Reline Partial Lower DentureLaboratory Temporary Complete Denture (Upper) Temporary Complete Denture (Lower) Temporary PartialStayplate Denture (Upper) Temporary PartialStayplate Denture (Lower) Tissue ConditioningUpper Unit Tissue ConditioningLower 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

Facial Moulage

***

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 Oral Surgery D7111 D7120 D7140 D7210

Abutment Placement Eposteal Implant Implant Connecting Bar Implant Maintenance Procedures Implant Removal, by Report Pontic-Cast High Noble Metal Pontic-Cast Predominately Base Metal PonticCast Noble Metal PonticPorcelain/High Noble Metal PonticPorcelain/Predominately Base Metal PonticPorcelain/Nobe Metal PonticPorcelain/Ceramic Substrate PonticResin/High Noble Metal PonticResin/Predominately Base Metal PonticResin/Noble Metal InlayMetallicOnlaying Cusps Cast Metal Retainer for Acid Etch Bridge RetainerCeramic Substrate for Acid Etch Inlay-Metallic-Two Surfaces Inlay-Metallic-Three or More Surfaces CrownResin with High Noble Metal CrownResin with Predominately Base Metal CrownResin with Noble Metal CrownPorcelain/High Noble Metal CrownPorcelain/Predominately Base Metal CrownPorcelain/Noble Metal Crown Cast High Noble Metal CrownFull Cast High Noble Metal CrownFull Cast Predominantly Base Metal CrownFull 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 CopingMetal 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

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 TissueHard Biopsy of Oral TissueSoft Surgical Repositioning of Teeth Transseptal Fiberotomy Alveoloplasty in Conjunct with Extract/Quad Alveoloplasty not in Conjunct with Extract/Quad VestibuloplastyRdg Extension Epithel VestibuloplastyRdg Extension with Gft-Reatch Radical ExcisionLesion DIA Up to 1.25 CM. Radical ExcisionLesion DIA Over 1.25 CM. Exc Malig TumorLesion DIA up to 1.25 CM. Exc Malig TumorLesion 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 ExtosisMaxilla 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 ArchOpen Reduction Malar/Zygomatic ArchClosed Reduction Alveolus Closed Reduction May Include Stabilization Alveolus Open Reduction May Include Stabilization Facial BonesComplete Red with Fix/Mult Surg Appr MaxillaOpen Reduction (Treatment of Fracture) MaxillaClsd 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 D7760 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 Adjunctive Dental Services D9110 D9220 D9221 D9230 D9241 D9310

MandibleOpn Reduction (Treatment of Fracture) MandibleClosed Reduction (Treatment of Fracture) Malar/Zygomatic ArchOpn Red (Treatment of Fracture) Malar/Zygomatic ArchClsd Red (Treatment of Fracture) Alveolus Open Reduction Stabilization Alveolus Closed Reduction Stabilization Facial BonesCmpl Red with Fix/Mult Surg Appr Open Reduction of Dislocation Closed Reduction of Dislocation Suture of Recent Small Wounds Up to 5 CM. SutureUp to 5 CM. SutureOver 5 CM. Skin Grafts OsteoplastyFor Orthognathic OsteotomyRamus, Closed OsteotomyRamus, Open OsteotomyRamus, Open W/Bone Graft OsteotomySeg/Subapical Per Sext/Quad OsteotomyBody of Mandible Lefort I (Maxilla-Total) Lefort I (Maxilla-Segmented) Lefort II/IIIwithout Bone Graft Lefort II or III with Bone Graft Osseous/Ostprstl/Ctlg Gft Mndbl Auto/NonAuto Rpr Maxillofacial Soft and Hard Tissue Defcts FrenulectomySeparate Procedure Excision of Hyperplastic Tissueper Arch Excision of Pericoronal Gingiva Sialolithotomy Excision of Salivary Gland Sialodochoplasty Closure of Salivary Fistula Emergency Tracheotomy Coronoidectomy

*** *** *** *** *** *** *** $ 107.00 $ 193.00 $ 85.00 $ 45.00 *** *** *** *** *** *** *** *** *** *** *** $ 540.00 $ 502.00 $ 264.00 $ 305.00 $ 305.00 $ 108.00 *** *** *** *** *** ***

Palliative (Emergency) Trmt Pain Minor Prcd AnesthesiaFirst 30 minutes AnesthesiaEach additional 15 minutes Analgesia Intravenous Sedation ConsultationPer Session

$ 58.00 $ 203.00 $ 122.00 $ 41.00 $ 216.00 $ 62.00

D9430 D9440 D9930 D9940

Office Visit/Observation Normal HoursNo Service Office VisitAfter Regular Scheduled Hours Treatment Complications/PST Srg/Unusual Circumstances Occlusal Guards

$ $ $

37.00 85.00 41.00

$ 270.00