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PROCEDURE CODEDESCRIPTIONFEES AGE LIMITSD0120PERIODIC ORAL EVALUATION 32.00NoneD0140LIMITED ORAL EVALUATION 45.00NoneD0145ORAL EVALUATION OF PATIENT UNDER 3YEARS 40.000-3D0150COMPREHENSIVE ORAL EVALUATION 35.00None 32.00None 30.00None 64.5019 - 20D0160D0170D0180DETAILED & EXTENSIVE ORAL EVALUATIONPROBLEM ENSIVE PERIODONTALEVALUATIOND0191ASSESSMENT OF A PATIENT 15.00NoneD0210COMPLETE INTRAORAL SERIES XRAYS 90.00NoneD0220 15.00None 14.00NoneD0240INTRAORAL X-RAY- PERIAPICAL 1ST FILMINTRAORAL X-RAY- PERIAPICAL EACHADDITIONAL FILMINTRAORAL X-RAY- OCCLUSAL FILM 16.000 - 20D0270BITEWING X-RAY - SINGLE FILM 18.00NoneD0272BITEWING X-RAY - TWO FILMS 24.00NoneD0274BITEWING X-RAY - FOUR FILMS 35.00NoneD0277VERTICAL BITEWINGS - 7 TO 8 FILMS 32.00NoneD0290POSTERIOR-ANTERIOR SKULL X-RAY 91.500 - 20D0322TOMOGRAPHIC SURVEY 30.000 - 20D0330PANORAMIC FILM 60.005 & UPD0460CONE BEAM CT CAPTURE ANDINTERPRETATION BOTH JAWSPULP VITALITY TESTS 247.69PA Required 25.00D0470DIAGNOSTIC CASTS 35.000 - 20D0999UNSPECIFIED DIAGNOSTIC PROCEDUREMPNoneD1110PROPHYLAXIS, ADULT 50.0012 & UPD1120PROPHYLAXIS, CHILD 35.000 - 11D1206TOPICAL FLUORIDE VARNISH 35.000 - 14D0230D0367Dental Fee Schedule – Revised January 4, 20180 - 200 - 20
PROCEDURE CODEDESCRIPTIONFEES AGE LIMITSD1208TOPICAL APPLICATION OF FLUORIDE 20.000 - 14D1310D0120D1320NUTRITIONAL COUNSELINGPERIODIC ORAL EVALUATIONTOBACCO COUNSELING 10.00 32.00 13.540-3None12 - 20D1330ORAL HYGIENE INSTRUCTIONS 10.004D1351SEALANT 28.000 - 20D1510SPACE MAINTAINER 145.000 - 20D1515SPACE MANITAINER, BILATERAL 245.000 - 20D1550RE-CEMENTATION OF SPACE MAINTAINER 32.000 - 20D1575SPACE MAINTAINER, DISTAL SHOE 145.000 - 20D1999UNSPECIFIED PREVENTATIVE PROCEDUREMP0 – 20D2140AMALGAM, ONE SURFACE 78.000 – 20D2150AMALGAM, TWO SURFACE 96.000 – 20D2160AMALGAM, THREE SURFACE 114.000 – 20D2161AMALGAM, FOUR OR MORE SURFACE 135.000 – 20D2330RESIN-BASED COMPOSITE, ONE SURFACE,ANTERIOR 82.000 – 20D2331RESIN-BASED COMPOSITE, TWO SURFACE,ANTERIOR 98.000 – 20D2332RESIN-BASED COMPOSITE, THREE SURFACE,ANTERIOR 132.000 – 20D2335RESIN-BASED COMPOSITE, FOUR OR MORESURFACES, ANTERIOR 140.000 – 20D2390COMPOSITE CROWN, ANTERIOR 170.000 - 20D2391RESIN-BASED COMPOSITE, ONE SURFACE,POSTERIOR 78.000 – 20D2392RESIN-BASED COMPOSITE, TWO SURFACE,POSTERIOR 96.000 – 20D2393RESIN BASED COMPOSITE, THREE SURFACE,POSTERIOR 114.000 – 20D2394RESIN BASED COMPOSITE, FOUR OR MORESURFACES, POSTERIOR 135.000 – 20D2510INLAY, METALLIC, ONE SURFACE 78.000 – 20D2520INLAY, METALLIC, TWO SURFACES 96.000 – 20D2530INLAY, METALLIC, THREE OR MORESURFACES 114.000 – 20Dental Fee Schedule – Revised January 4, 2018
PROCEDURE CODEDESCRIPTIONFEES AGE LIMITSD2542D0120ONLAY, METALLIC, TWO SURFACESPERIODIC ORAL EVALUATION 96.00 32.000 – 20NoneD2543ONLAY, METALLIC, THREE SURFACES 114.000 – 20D2544ONLAY, METALLIC, FOUR OR MORESURFACES 135.000 – 20D2610INLAY, PORCELAIN/CERAMIC, ONE SURFACE 78.000 – 20D2620INLAY, PORCELAIN/CERAMIC, TWOSURFACES 96.000 – 20D2630INLAY, PORCELAIN/CERAMIC, THREE ORMORE SURFACES 114.000 – 20D2642ONLAY, PORCELAIN/CERAMIC, TWOSURFACES 96.000 – 20D2643ONLAY, PORCELAIN/CERAMIC, THREESURFACES 114.000 – 20D2644ONLAY, PORCELAIN/CERAMIC, FOUR ORMORE SURFACES 135.000 – 20D2650INLAY, COMPOSITE/RESIN, ONE SURFACE 78.000 – 20D2651INLAY, COMPOSITE/RESIN, TWO SURFACES 96.000 – 20D2652INLAY, COMPOSITE/RESIN, THREE OR MORESURFACES 114.000 – 20D2662ONLAY, COMPOSITE/RESIN, TWO SURFACES 96.000 – 20D2663ONLAY, COMPOSITE/RESIN, THREESURFACES 114.000 – 20D2664ONLAY, COMPOSITE/RESIN, FOUR OR MORESURFACES 135.000 – 20 190.0014-20 395.0014-20 202.0014-20 306.0014-20 600.0014-20 600.0014-20 600.0014-20D2722CROWN, RESIN-BASED COMPOSITE(INDIRECT)CROWN, RESIN WITH HIGH NOBLE METALCROWN, RESIN WITH PREDOMINANTLY BASEMETALCROWN, RESIN WITH NOBLE METALD2740CROWN, PORCELAIN/CERAMIC SUBSTRATED2710D2720D2721D2750D2751CROWN, PORCELAIN FUSED TO HIGH NOBLEMETALCROWN, PORCELAIN FUSED TOPREDOMINANTLY BASE METALDental Fee Schedule – Revised January 4, 2018
PROCEDURE CODEDESCRIPTIONFEES AGE LIMITS 600.0014-20 32.00 600.00None14-20 600.0014-20D2740CROWN, PORCELAIN FUSED TO NOBLEMETALPERIODICORALEVALUATIONCROWN, ¾ CAST HIGHNOBLE METALCROWN, ¾ CAST PREDOMINANTLY BASEMETALCROWN, PORCELAIN/CERAMIC SUBTRATE 600.0014-20D2782CROWN, 3/4 CAST NOBLE METAL 600.000 - 20D2783CROWN, 3/4 PORCELAIN/CERAMIC 600.000 - 20D2790CROWN, FULL CAST HIGH NOBLE METALCROWN, FULL CAST PERDONMINANTLY BASEMETALCROWN, FULL CAST NOBLE METALRECEMENT INLAY, ONLAY, OR PARTIALCOVERAGERECEMENT CAST OR PREFABRICATED POSTAND CORERECEMENT CROWNPREFABRICATED PORC/CERA CROWN –PRIMARYPREFABRICATED STAINLESS STEEL CROWN PRIMARYPREFABRICATED STAINLESS STEEL CROWN PERMANENTPREFABRICATED RESIN CROWNPREFABRICATED S.S.CROWN WITH RESINWINDOWPREFABRICATED ESTHETIC COATED S.S.CROWN, PRIMARYPROTECTIVE RESIN 540.0014 - 20 420.0014 - 20 420.0014 - 20 25.000 - 20 25.000 - 20 30.000 - 20 162.000 – 20 136.000 - 20 162.000 - 20 127.000 - 20 162.000 - 20 105.000 - 20 35.000 - 20CORE BUILDUP, INCLUDING ANY PINSPIN RETENTION, PER TOOTH, IN ADDITION TORESTORATIONCAST POST AND CORE, INDIRECTLYFABRICATEDEACH ADDITIONAL INDIRECTLY FABRICATEDPOST SAME TOOTHPREFABRICATED POST AND CORE INADDITION TO CROWNPOST REMOVAL NOT IN CONJUNCTION WITHENDO THERAPYEACH ADDITIONAL PREFABRICATED POSTLABIAL VENEER - RESIN LAMINATE,LABORATORYLABIAL VENEER - PORCELAIN LAMINATE,LABORATORYCROWN REPAIR 129.000 - 20 29.000 - 20 125.000 - 20 125.000 - 20 170.000 - 20 27.000 - 20 102.750 - 20 563.250 – 20 450.000 – 20 45.000 – 20D2981INLAY REPAIRMPNoneD2982ONLAY 51D2952D2953D2954D2955D2957D2961D2962D2980Dental Fee Schedule – Revised January 4, 2018
PROCEDURE CODEDESCRIPTIONFEES AGE LIMITSD2983VENEER REPAIRMPNoneD2999D0120D3110MP 32.00 25.000 – 20None0 – 20 25.000 - 20 86.000 - 20 100.000 - 20 100.000 – 20 37.000 – 20 68.000 – 20D3310UNSPECIFIED RESTORATIVE PROCEDUREPERIODIC ORAL EVALUATIONPULP CAP - DIRECT, EXCLUDING FINALRESTORATIONPULP CAP- INDIRECT, EXCLUDING FINALRESTORATIONTHERAPEUTIC PULPOTOMYPULPAL DEBRIDEMENT, PRIMARY ANDPERMANENT TOOTHPARTIAL PULPOTOMY FOR APEXOGENESIS PERMANENT TOOTHPULPAL THERAPY, ANTERIOR PRIMARYTOOTHPULPAL THERAPY, POSTERIOR PRIMARYTOOTHENDODONTIC THERAPY, ANTERIOR 502.600 – 20D3320ENDODONTIC THERAPY, BICUSPID 584.150 – 20D3330 687.280 – 20 60.000 – 20 336.000 – 20 154.500 – 20D3346ENDODONTIC THERAPY, MOLARTREATMENT OF ROOT CANAL OBSTRUCTION,NON-SURGICAL ACCESSINCOMPLETE ENDODONTIC THERAPY,INOPERABLE, FRACTURED TOOTHINTERNAL ROOT REPAIR OF PERFORATIONDEFECTSRETREATMENT, ROOT CANAL - ANTERIOR 602.930 – 20D3347RETREATMENT, ROOT CANAL - BICUSPID 698.830 – 20D3348RETREATMENT, ROOT CANAL - MOLARAPEXIFICATION/RECALCIFICATION, INITIALVISITAPEXIFICATION/RECALCIFICATION, INTERIMMEDICAITON REPLACEMENTAPEXIFICATION/RECALCIFICATION, FINALVISITAPICOECTOMY/PERIRADICULAR SURGERY,ANTERIORAPICOECTOMY/PERIRADICULAR SURGERY,BICUSPID, FIRST ROOTAPICOECTOMY/PERIRADICULAR SURGERY,MOLARAPICOECTOMY/PERIADICULAR SURGERY,EACH ADDITIONAL ROOTRETROGRADE FILLING, PER ROOT 824.020 – 20 98.000 – 20 54.000 – 20 318.000 – 20 235.670 – 20 277.160 – 20 304.550 – 20 43.000 – 20 40.000 – 20INTENTIONAL REIMPLANTATIONSURGICAL PROCEDURE FOR ISOLATION OFTOOTH WITH RUBBER DAMHEMISECTION, NOT INCLUDING ROOT CANALTHERAPY 166.000 – 20 84.750 – 20 242.250 – 20Dental Fee Schedule – Revised January 4, 2018
PROCEDURE CANAL PREPARATION AND FITTING OFPREFORMED DOWEL/POSTPERIODICORAL EVALUATIONUNSPECIFIED ENDODONTICPROCEDUREGINGIVECTOMY OR GINGIVOPLASTY, 4 ORMORE TEETHGINGIVECTOMY OR GINGIVOPLASTY, 1 TO 3TEETHGINGIVECTOMY/PLASTY, RESTORATIVE, PERTOOTHGINGIVAL FLAP PROCEDURE, INCLUDINGROOT PLANINGFEES AGE LIMITS 110.250 – 20 32.00MP0None– 20 175.000 – 20 66.000 – 20 123.000 – 20 439.500 – 20D4241GINGIVAL FLAP PROCEDURE, 1 TO 3 TEETH 254.250 – 20D4245APICALLY POSITIONED FLAP 324.000 – 20D4249CLINICAL CROWN LENGTHENINGOSSEOUS SURGERY, 4 OR MORECONTIGUOUS TEETHOSSEOUS SURGERY 1 TO 3 TEETH 481.500 – 20 732.750 – 20 393.000 – 20 261.750 – 20 298.500 – 20 300.250 – 20 270.000 – 20 347.250 – 20 497.630 – 20D4270BONE REPLACEMENT GRAFT, FIRST SITEBONE REPLACEMENT GRAFT, EACHADDITIONAL SITEBIOLOGIC MATERIALS TO AID REGENGUIDED TISSUEREGENERATION,RESORBABLE BARRIERGUIDED TISSUE REGENERATION,NONRESORBABLE BARRIERSURGICAL REVISION PROCEDURE, PERTOOTHPEDICLE SOFT TISSUE GRAFT PROCE 520.500 – 20D4273SUBEPITHELIAL CONNECTIVE TISSUE GRAFT 636.000 – 20D4274DISTAL OR PROXIMAL WEDGE 360.750 – 20D4275SOFT TISSUE ALLOGRAFT 477.750 – 20D4276COMBINED CONNECT TISSUE & GRAFTMP0 – 20D4277SOFT TISSUE GRAFT – FIRST TOOTHMP0 – 20D4278SOFT TISSUE GRAFT – ADDITIONAL TOOTHMP0 – 20D4320PROVISIONAL SPLINTING, INTRACORONAL 261.000 – 20D4321PROVISIONAL SPLINTING, EXTRACORONAL 145.000 – 20D4341PERIODONTAL SCALING 120.000 – 20D4342PERIODONTAL SCALING 1 TO 3 TEETH 100.000 – 20D4355FULL MOUTH DEBRIDEMENT 90.00NoneD4346SCALING IN PRESENCE OF INFLAMMATION P0 – 20D4910LOCALIZED DELIVERY OF ANTIMICROBIALAGENTSPERIODONTAL MAINTENANCE 65.000 – 20D4920UNSCHEDULED DRESSING CHANGE 67.500 – 20D4381Dental Fee Schedule – Revised January 4, 2018
PROCEDURE CODEDESCRIPTIONFEES AGE LIMITSD4999UNSPECIFIED PERIODONTAL PROCEDUREMP0 – 20D5110D0120D5120COMPLETE DENTURE, MAXILLARYPERIODIC ORAL EVALUATIONCOMPLETE DENTURE, MANDIBULAR 800.00 32.00 800.000 – 20None0 – 20D5130IMMEDIATE DENTURE, MAXILLARY 800.000 – 20D5140IMMEDIATE DENTURE, MANDIBULAR 800.000 – 20D5211MAXILLARY PARTIAL DENTURE, RESIN BASED 600.000 – 20 600.000 – 20 600.000 – 20 600.000 – 20 510.000 – 20 510.000 – 20 400.000 – 20 50.00NoneD5410MANDIBULAR PARTIAL DENTURE, RESINBASEDMAXILLARY PARTIAL DENTURE, CAST METALFRAMEWORKMANDIBULAR PARTIAL DENTURE, CASTMETAL FRAMEWORKMAXILLARY PARTIAL DENTURE, FLEXIBLEBASEMANDIBULAR PARTIAL DENTURE, FLEXIBLEBASEREMOVABLE UNILATERAL PARTIAL DENTUREONE PIECE CAST METALADJUST COMPLETE DENTURE, MAXILLARYD5411ADJUST COMPLETE DENTURE, MANDIBULAR 50.00NoneD5421ADJUST PARTIAL DENTURE, MAXILLARY 16.00NoneD5422 16.00None 40.00None 40.00None 36.00None 52.00None 52.00None 35.00None 35.00NoneD5630ADJUST PARTIAL DENTURE, MANDIBULARREPAIR BROKEN COMPLETE DENTURE BASE,MANDIBULARREPAIR BROKEN COMPLETE DENTURE BASE,MAXILLARYREPLACE TEETH - DENTUREREPAIR RESIN PARTIAL DENTURE BASE,MANDIBULARREPAIR RESIN PARTIAL DENTURE BASE,MAXILLARYREPAIR CAST PARTIAL FRAMEWORK,MANDIBULARREPAIR CAST PARTIAL FRAMEWORK,MAXILLARYREPAIR OR REPLACE BROKEN CLASP 90.00NoneD5640REPLACE BROKEN TEETH - PER TOOTH 40.00NoneD5650ADD TOOTH TO EXISTING PARTIAL 84.86NoneD5660 70.00NoneMPNoneMPNoneD5710ADD CLASP TO EXISTING PARTIALREPLACE ALL TEETH AND ACRYLIC,CASTMETAL FRAMEWORK, MAX.REPLACE ALL TEETH AND ACRYLIC,CASTMETAL FRAMEWORK, MAN.REBASE COMPLETE MAXILLARY DENTURE 160.000 – 20D5711REBASE COMPLETE MANDIBULAR DENTURE 155.000 – 11D5612D5621D5622D5670D5671Dental Fee Schedule – Revised January 4, 2018
PROCEDURE CODEDESCRIPTIONFEES AGE LIMITSD5720REBASE MAXILLARY PARTIAL DENTURE 130.000 – 20D5721D0120D5730 130.00 32.00 150.000 – 20NoneNone 150.00None 60.00None 60.00None 175.00None 175.00None 105.00None 105.00NoneD5810REBASE MANDIBULAR PARTIAL DENTUREPERIODIC ORAL EVALUATIONRELINE COMPLETE MAXILLARY DENTURE,CHAIRSIDERELINE COMPLETE MANDIBULAR DENTURE,CHAIRSIDERELINE MAXILLARY PARTIAL DENTURE,CHAIRSIDERELINE MANDIBULAR PARTIAL DENTURE,CHAIRSIDERELINE COMPLETE MAXILLARY DENTURE,LABORATORYRELINE COMPLETE MANDIBULAR DENTURE,LABORATORYRELINE MAXILLARY PARTIAL DENTURE,LABORATORYRELINE MANDIBULAR PARTIAL DENTURE,LABORATORYINTERIM COMPLETE DENTURE, MAXILLARY 200.000 – 20D5811INTERIM COMPLETE DENTURE, MANDIBULAR 200.000 – 20D5820INTERIM PARTIAL DENTURE, MAXILLARY 270.000 – 20D5821INTERIM PARTIAL DENTURE, MANDIBULAR 180.000 – 20D5850TISSUE CONDITIONING, MAXILLARY 30.000 – 20D5851TISSUE CONDITIONING, MANDIBULAR0 – 20D5860OVERDENTURE, COMPLETED5861OVERDENTURE, PARTIALD5862PRECISION ATTACHMENTD5863OVERDENTURE COMPLETE MAXD5864OVERDENTURE PARTIAL MAXD5865OVERDENTURE COMPLETE MANDIBULARD5866OVERDENTURE PARTIAL MANDIBULARD5952SPEECH AID PROSTHESISD5960SPEECH AID PROSTHESIS-MODIFICATION 40.00MPPA RequiredMPPA Required 228.00MPPA RequiredMPPA RequiredMPPA RequiredMPPA Required70% of BilledCharge 50.00D5986FLUORIDE GEL CARRIERMP0 – 20D5991TOPICAL MEDICAMENT CARRIER0 – 20D6010SURGICAL PLACEMENT OF IMPLANTD6040SURGICAL PLACEMENT, EPOSTEAL IMPLANT 93.00 1200.00PA RequiredMPPA RequiredD5731D5740D5741D5750D5751D5760D5761Dental Fee Schedule – Revised January 4, 20180 – 200 – 200 – 2017 – 2017 – 2017 – 2017 – 200 - 200 - 2017 – 2017 – 20
PROCEDURE CODEDESCRIPTIOND6050SURGICAL PLACEMENTD0120D6051PERIODIC ORAL EVALUATIONINTERIM 071D6072D6073D6074D6075IMPLANT/ABUTMENT, REMOVABLE DENT,COMPLETELY EDENTULOUSIMPLANT/ABUTMENT, REMOVABLE DENTURE,PARTIALLY EDENTULOUSDENTAL IMPLANT SUPPORTED CONNECTINGBARPREFABRICATED ABUTMENT - INCLUDESPLACEMENTCUSTOM ABUTMENT - INCLUDES PLACEMENTABUTMENT SUPPORTEDPORCELAIN/CERAMIC CROWNABUTMENT SUPPORTED PORC FUSEDCROWN, HIGH NOBLE METALABUTMENT SUPPORTED PORC FUSEDCROWN, PREDOMINANTLY BASEABUTMENT SUPPORTED PORCELAIN FUSEDCROWN, NOBLE METALABUTMENT SUPPORTED CAST CROWN, HIGHNOBLE METALABUTMENT SUPPORTED CAST CROWN,PREDOMINANTLY BASE METALABUTMENT SUPPORTED CAST CROWN,NOBLE METALIMPLANT SUP PORCELAIN/ CERAMIC CROWNIMPLANT SUP PORCELAIN CROWN,TITANIUM,T.ALLOY, HIGH NOBLEIMPLANT SUP METAL CROWN,TITANIUM,T.ALLOY, HIGH NOBLEABUTMENT SUP RETAINER FORPORCELAIN/CERAMIC FPDABUTMENT SUP RETAINER FOR PORCELAINFUSED FPD, HIGH NOBLEABUTMENT RETAINER PORCELAIN FUSEDFPD, PREDOMINATELY BASEABUTMENT SUPPORTED RETAINER PORCFUSED FPD, NOBLE METALABUTMENT SUPPORTED RETAINER CASTMETAL FPD, HIGH NOBLEABUTMENT SUP RETAINER CAST METAL FPD,PREDOMINATELY BASEABUTMENT SUPPORTED RETAINER CASTMETAL FPD, NOBLE METALIMPLANT SUPPORTED RETAINER FORCERAMIC FPDDental Fee Schedule – Revised January 4, 2018FEES AGE LIMITSMPPA Required 32.00MPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA Required17 – 20None17 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 20
PROCEDURE CODED6076D0120D6077D6078D6079DESCRIPTIONFEES AGE LIMITSIMPLANT RETAINER, PORCELAIN FUSEDFPD,TITANIUM, HIGH NOBLEPERIODICORAL CASTEVALUATIONIMPLANTRETAINER,METAL FPD,TITANIUM, T.ALLOY, HIGH NOBLEIMPLANT/ABUTMENT FIXED DENTURE,COMPLETELY EDENTULOUSIMPLANT/ABUTMENT FIXED DENTURE,PARTIALLY EDENTULOUSMPPA Required 32.00MPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMP PA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA Required17 – 20D6080IMPLANT MAINTENENCE PROCEDURES,D6085PROVISIONAL IMPLANT CROWND6090REPAIR IMPLANT SUPPORTED PROSTHESISD6091REPLACE SEMI PREC OR PREC OF IMPLANTD6092RECEMENT IMPLANTD6093RECEMENT SUPPORTED FIXED PARTIALD6094SUPPORTED CROWND6095REPAIR IMPLANT ABUTMENTD6100IMPLANT REMOVALD6101DEBRIDEMENT OF A PERIIMPLANT DEFECTD6102DEBRIDEMENT AND OSSEOUS CONTOURINGD6103D6104BONE GRAFT FOR REPAIR OF PERIIMPLANTDEFECTBONE GRAFT AT TIME OF IMPLANTPLACEMENTD6199UNSPECIFIED IMPLANT PROCEDURED6210PONTIC, CAST HIGH NOBLE METALD6211PONTIC, CAST PREDOMINANTLY BASE METALD6212PONTIC, CAST NOBLE METALD6240D6241D6242D6245PONTIC, PORCELAIN FUSED TO HIGH NOBLEMETALPONTIC, PORCELAIN FUSED TOPREDOMINANTLY BASE METALPONTIC, PORCELAIN FUSED TO NOBLEMETALPONTIC - PORCELAIN/CERAMICDental Fee Schedule – Revised January 4, 2018None17 – 2017 – 2017 – 2017 – 2017 - 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 20
PROCEDURE CODEDESCRIPTIOND6250PONTIC, RESIN WITH HIGH NOBLE METALD0120D6251ORALEVALUATION BASEPONTIC,PERIODICRESIN WITHPREDOMINANTLYMETALD6252PONTIC, RESIN WITH NOBLE METALD6253PROVISIONAL INER, CAST METAL FOR RESIN BONDEDFIXED PROSTHESISRETAINER, PORC/CERAMIC FOR RESINBONDED FIXED PROSTHESISINLAY, PORCELAIN/CERAMIC, 2 SURFACESINLAY, PORCELAIN/CERAMIC, 3 OR MORESURFACESINLAY, CAST HIGH NOBLE METAL, 2SURFACESINLAY, CAST HIGH NOBLE METAL, 3 OR MORESURFACESINLAY, PREDOMINANTLY BASE METAL, 2SURFACESINLAY, PREDOMINANTLY BASE METAL, 3 ORMORE SURFACESD6606INLAY, CAST NOBLE METAL, 2 SURFACESD6607INLAY, CAST NOBLE METAL, 3 OR MORESURFACESD6608ONLAY- PORCELAIN/CERAMIC, TWO SURFACED6609D6610D6611D6612D6613ONLAY- PORCELAIN/CERAMIC, THREE ORMORE SURFACESONLAY- CAST HIGH NOBLE METAL, TWOSURFACEONLAY- CAST HIGH NOBLE METAL, THREE ORMORE SURFACESONLAY- CAST PREDOMINANTLY BASE METAL,TWO SURFACEONLAY- CAST PREDOMINANTLY BASE METAL,3 OR MORE SURFACESD6614ONLAY- CAST NOBLE METAL, TWO SURFACESD6615ONLAY- CAST NOBLE METAL, THREE ORMORE SURFACESD6710CROWN, INDIRECT RESIN BASED COMPOSITED6720CROWN, RESIN WITH HIGH NOBLE METALD6721CROWN, RESIN WITH PREDOMINANTLY BASEMETALDental Fee Schedule – Revised January 4, 2018FEES AGE LIMITSMPPA Required 32.00MPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA Required17 – 20None17 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 20
PROCEDURE CODEDESCRIPTIOND6722CROWN, RESIN WITH NOBLE METALD0120D6740PERIODIC ORAL EVALUATIONCROWN, PORCELAIN/CERAMICD6750D6751D6752CROWN, PORCELAIN FUSED TO HIGH NOBLEMETALCROWN, PORCELAIN FUSED TOPREDOMINANTLY BASE METALCROWN, PORCELAIN FUSED TO NOBLEMETALD6780CROWN, 3/4 CAST HIGH NOBLE METALD6781CROWN, 3/4 CAST PREDOMINANTLY BASEMETALD6782CROWN, 3/4 CAST NOBLE METALD6783CROWN, 3/4 PORCELAIN/CERAMICD6790CROWN, FULL CAST HIGH NOBLE METALD6791CROWN, FULL CAST PERDONMINANTLY BASEMETALD6792CROWN, FULL CAST NOBLE METALD6793PROVISIONAL RETAINER CROWND6794CROWN (TITANIUM)D6920CONNECTOR BARD6930RECEMENT FIXED PARTIAL DENTURED6940STRESS BREAKERD6950PRECISION ATTACHMENTD6975COPING, METALD6980FIXED PARTIAL DENTURE REPAIRD6985PEDIATRIC PARTIAL DENTURED6999UNSPECIFIED PROSTHODONTIC PROCEDURED7111D7140D7210EXTRACTION CORONAL REMNANTSDECIDUOUS TOOTEXTRACTION ERUPTED TOOTH OR EXPOSEDROOTSURGICAL REMOVAL OF ERUPTED TOOTHDental Fee Schedule – Revised January 4, 2018FEES AGE LIMITSMPPA Required 32.00MPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA RequiredMPPA Required17 – 20 52.00NONE 70.00NONE 132.00NONENone17 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2017 – 2014 – 2017 – 20
PROCEDURE CODEDESCRIPTIONFEES AGE LIMITSD7220REMOVAL IMPACTED TOOTH, SOFT TISSUE MOVALIMPACTEDPARTIALLYBONYREMOVAL IMPACTED TOOTH, COMPLETELYBONYREM. IMPACTED TOOTH, COMPLETEBONY,UNUSUAL COMPLICATIONSSURGICAL REMOVAL OF RESIDUAL TOOTHROOTS, CUTTING PROCEDURE 32.00 175.00NoneNONE 200.00NONE 240.00NONE 120.00NONED7261PRIMARY CLOSURE OF SINUS PERFORATIONMP0 –
dental fee schedule – revised january 4, 2018. procedure code description fees age limits d0120 periodic oral evaluation 32.00 none d4999 unspecified periodontal procedure mp 0 – 20 d5110 complete denture, maxillary 800.00 0 –
