Full Fee Schedule
ADA Code
Procedure Name
Discounted Cost
D9110
Palliative (emergency) treatment of dental pain - minor procedure
$63
D9210
Local anesthesia not in conjunction with operative or surgical procedures
$21
D9211
Regional block anesthesia
$20
D9215
Local anesthesia in conjunction with operative or surgical procedures
$19
D9230
Inhalation of nitrous oxide/analgesia, anxiolysis
$34
D9430
Office visit for observation (during regularly scheduled hours) - no other services performed
$38
D9440
Office visit - after regularly scheduled hours
$248
D9910
Application of desensitizing medicament
$31
D9911
Application of desensitizing resin for cervical and/or root surface, per tooth
$35
D9941
Fabrication of athletic mouthguard
$135
D9950
Occlusion analysis - mounted case
$119
D9951
Occlusal adjustment - limited
$78
D9952
Occlusal adjustment - complete
$296
D9970
Enamel microabrasion
$201
D9972
External bleaching - per arch - performed in office
$360
D9973
External bleaching - per tooth
$270
D9974
Internal bleaching - per tooth
$347
D9975
External bleaching for home application, per arch; includes materials and fabrication of custom trays
$74
D9986
Missed appointment
$27
D9987
Cancelled appointment
$27
ADA Code
Procedure Name
Discounted Cost
D0120
Periodic oral evaluation - established patient
$0
D0140
Limited oral evaluation - problem focused
$0
D0150
Comprehensive oral evaluation - new or established patient
$0
D0160
Detailed and extensive oral evaluation - problem focused, by report
$0
D0170
Re-evaluation - limited, problem focused (established patient; not post-operative visit)
$0
D0180
Comprehensive periodontal evaluation - new or established patient
$0
D0210
Intraoral - complete series of radiographic images
$83
D0220
Intraoral - periapical first radiographic image
$18
D0230
Intraoral - periapical each additional radiographic image
$14
D0240
Intraoral - occlusal radiographic image
$23
D0250
Extra-oral - 2D projection radiographic image created using a stationary radiation source, and detector
$28
D0270
Bitewing - single radiographic image
$16
D0272
Bitewings - two radiographic images
$24
D0273
Bitewings - three radiographic images
$29
D0274
Bitewings - four radiographic images
$39
D0277
Vertical bitewings - 7 to 8 radiographic images
$46
D0330
Panoramic radiographic image
$62
D0340
2D cephalometric radiographic image - acquisition, measurement, and analysis
$63
D0350
2D oral/facial photographic image obtained intra-orally or extra-orally
$34
D0460
Pulp vitality tests
$32
D0470
Diagnostic casts
$63
D0999
Unspecified diagnostic procedure, by report
$0
ADA Code
Procedure Name
Discounted Cost
D3110
Pulp cap - direct (excluding final restoration)
$43
D3120
Pulp cap - indirect (excluding final restoration)
$39
D3220
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament
$87
D3221
Pulpal debridement, primary and permanent teeth
$106
D3230
Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)
$153
D3240
Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)
$194
D3310
Endodontic therapy, anterior tooth (excluding final restoration)
$504
D3320
Endodontic therapy, bicuspid tooth (excluding final restoration)
$572
D3330
Endodontic therapy, molar (excluding final restoration)
$769
D3331
Treatment of root canal obstruction; non-surgical access
$162
D3332
Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth
$214
D3333
Internal root repair of perforation defects
$148
D3346
Retreatment of previous root canal therapy - anterior
$622
D3347
Retreatment of previous root canal therapy - bicuspid
$711
D3348
Retreatment of previous root canal therapy - molar
$846
D3351
Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.)
$186
D3352
Apexification/recalcification - interim medication replacement
$115
D3353
Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.)
$1,001
D3410
Apicoectomy - anterior
$484
D3421
Apicoectomy - bicuspid (first root)
$491
D3425
Apicoectomy - molar (first root)
$573
D3426
Apicoectomy (each additional root)
$198
D3430
Retrograde filling - per root
$124
D3450
Root amputation - per root
$285
D3470
Intentional re-implantation (including necessary splinting)
$509
D3910
Surgical procedure for isolation of tooth with rubber dam
$278
D3920
Hemisection (including any root removal), not including root canal therapy
$236
D3950
Canal preparation and fitting of preformed dowel or post
$150
ADA Code
Procedure Name
Discounted Cost
D7111
Extraction, coronal remnants - primary tooth
$198
D7140
Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
$102
D7210
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated
$163
D7220
Removal of impacted tooth - soft tissue
$188
D7230
Removal of impacted tooth - partially bony
$236
D7240
Removal of impacted tooth - completely bony
$296
D7241
Removal of impacted tooth - completely bony, with unusual surgical complications
$370
D7250
Removal of residual tooth roots (cutting procedure)
$178
D7270
Tooth re-implantation and/or stabilization of accidentally evulsed or displaced tooth
$246
D7272
Tooth transplantation (includes re-implantation from one site to another and splinting and/or stabilization)
20% Discount
D7280
Exposure of an unerupted tooth
$280
D7285
Incisional biopsy of oral tissue - hard (bone, tooth)
$207
D7286
Incisional biopsy of oral tissue - soft
$193
D7310
Alveoloplasty in conjuncture with extractions - four or more teeth or tooth spaces, per quadrant
$142
D7320
Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant
$198
D7460
Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm
$228
D7461
Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm
$474
D7510
Incision and drainage of abscess - intraoral soft tissue
$102
D7911
Complicated suture - up to 5 cm
$269
D7912
Complicated suture - greater than 5 cm
$398
D7960
Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure
20% Discount
D7970
Excision of hyperplastic tissue - per arch
$236
D7971
Excision of pericoronal gingiva
$105
ADA Code
Procedure Name
Discounted Cost
D8660
Pre-orthodontic treatment examination to monitor growth and development
$141
D8670
Periodic orthodontic treatment visit
$200
D8680
Orthodontic retention (removal of appliances, construction, and placement of retainer(s))
$461
D8999
Unspecified orthodontic procedure, by report
20% Discount
ADA Code
Procedure Name
Discounted Cost
D4999
Unspecified periodontal procedure, by report
20% Discount
ADA Code
Procedure Name
Discounted Cost
D4210
Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant
$333
D4211
It is performed to eliminate suprabony pockets or to restore normal architecture when gingival enlargements or asymmetrical or unaesthetic topography is evident with normal bony configuration.
$149
D4240
Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant
$405
D4241
Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per
quadrant
$294
D4245
Apically positioned flap
$388
D4249
Clinical crown lengthening - hard tissue
$558
D4260
Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or
tooth bounded spaces per quadrant
$746
D4261
Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant
$538
D4263
Bone replacement graft - retained natural tooth - first site in quadrant
$299
D4264
Bone replacement graft - retained natural tooth - each additional site in quadrant
$284
D4266
Guided tissue regeneration - resorbable barrier, per site
$392
D4267
Guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal)
$458
D4268
Surgical revision procedure, per tooth
$374
D4270
Pedicle soft tissue graft procedure
$536
D4320
Provisional splinting - intracoronal
20% Discount
D4321
Provisional splinting - extracoronal
20% Discount
D4341
Periodontal scaling and root planing - four or more teeth per quadrant
$158
D4342
Periodontal scaling and root planing - one to three teeth per quadrant
$110
D4355
Full mouth debridement to enable comprehensive evaluation and diagnosis
$85
D4910
Periodontal maintenance
$86
D4920
Unscheduled dressing change (by someone other than treating dentist or their staff)
$141
ADA Code
Procedure Name
Discounted Cost
D1110
Prophylaxis - adult
$50
D1120
Prophylaxis - child
$40
D1208
Topical application of fluoride - excluding varnish
$26
D1330
Oral hygiene instructions
$21
D1351
Sealant - per tooth
$36
D1510
Space Maintainer, Fixed Unilateral- Per Quadrant. Excludes a distal shoe space maintainer
$225
D1515
Space maintainer - fixed - bilateral
20% Discount
D1520
Space maintainer - removable, unilateral - per quadrant
$180
D1525
Space maintainer - removable - bilateral
20% Discount
D1550
Re-cement or re-bond space maintainer
20% Discount
D1999
Unspecified preventive procedure, by report
$0
ADA Code
Procedure Name
Discounted Cost
D6010
Surgical placement of implant body: endosteal implant
$1,441
D6011
Surgical access to an implant body (second state implant surgery)
$149
D6012
Surgical placement of interim implant body for transitional prosthesis: endosteal implant
$1,441
D6013
Surgical placement of mini- implant
$721
D6040
Surgical placement: eposteal implant
$3,204
D6050
Surgical placement: transosteal implant
$2,745
D6051
Interim abutment
$369
D6055
Connecting bar - implant supported, or abutment supported
$1,259
D6056
Prefabricated abutment - includes modification and placement
$419
D6057
Custom fabricated abutment - includes placement
$609
D6058
Abutment supported porcelain/ceramic crown
$973
D6059
Abutment supported porcelain fused to metal crown (high noble metal)
$968
D6060
Abutment supported porcelain fused to metal crown (predominantly base metal)
$833
D6061
Abutment supported porcelain fused to metal crown (noble metal)
$900
D6062
Abutment supported cast metal crown (high noble metal)
$990
D6063
Abutment supported cast metal crown (predominantly base metal)
$855
D6064
Abutment supported cast metal crown (noble metal)
$981
D6065
Implant supported porcelain/ceramic crown
$957
D6066
Implant supported crown - porcelain fused to high noble alloys)
$968
D6067
Implant supported crown (high noble alloys)
$990
D6068
Abutment supported retainer for porcelain/ceramic FPD
$957
D6069
Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
$968
D6070
Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)
$833
D6071
Abutment supported retainer for porcelain fused to metal FPD (noble metal)
$900
D6072
Abutment supported retainer for cast metal FPD (high noble metal)
$990
D6073
Abutment supported retainer for cast metal FPD (predominantly base metal)
$855
D6074
Abutment supported retainer for cast metal FPD (noble metal)
$981
D6075
Implant supported retainer for ceramic FPD
$957
D6076
Implant supported retainer for FPD - porcelain fused to high noble alloys
$968
D6077
Implant supported retainer for metal FPD - high noble alloys
$990
D6080
Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses, and abutments
$127
D6081
Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure
$107
D6082
Implant supported crown - porcelain fused to predominantly base alloys
$968
D6083
Implant supported crown - porcelain fused to noble alloys
$968
D6084
Implant supported crown - porcelain fused to titanium and titanium alloys
$968
D6085
Provisional implant crown
$207
D6086
Implant supported crown - predominantly base alloys
$990
D6087
Implant supported crown - noble alloys
$990
D6088
Implant supported crown - titanium and titanium alloys
$990
D6090
Repair implant supported prosthesis, by report
$337
D6091
Replacement of replaceable part of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment
$279
D6092
Re-cement or re-bond implant/abutment supported crown
$73
D6093
Re-cement or re-bond implant/abutment supported fixed partial denture
$80
D6094
Abutment supported crown - titanium and titanium alloys
$796
D6096
Remove broken implant retaining screw
$304
D6097
Abutment supported crown - porcelain fused to titanium and titanium alloys
$900
D6098
Implant supported retainer - porcelain fused to predominantly base alloys
$968
D6099
Implant supported retainer for FPD - porcelain fused to noble alloys
$968
D6100
Implant removal, by report
$353
D6101
Debridement of a peri- implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure
$294
D6102
Debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant and includes surface cleaning of the exposed implant surfaces, including flap entry and closure
$529
D6103
Bone graft for repair of peri-implant defect - does not include flap entry and closure
$295
D6104
Bone graft at time of implant placement
$295
D6110
Implant /abutment supported removable denture for edentulous arch - maxillary
$1,755
D6111
Implant /abutment supported removable denture for edentulous arch - mandibular
$1,755
D6112
Implant /abutment supported removable denture for partially edentulous arch - maxillary
$1,499
D6113
Implant /abutment supported removable denture for partially edentulous arch - mandibular
$1,499
D6114
Implant /abutment supported fixed denture for edentulous arch - maxillary
$3,375
D6115
Implant /abutment supported fixed denture for edentulous arch - mandibular
$3,375
D6116
Implant /abutment supported fixed denture for partially edentulous arch - maxillary
$2,700
D6117
Implant /abutment supported fixed denture for partially edentulous arch - mandibular
$2,700
D6118
Implant/abutment supported interin fixed denture for edentulous arch -mandibular
$1,511
D6119
Implant/abutment supported interin fixed denture for edentulous arch - maxillary
$1,511
D6120
Implant supported retainer - porcelain fused to titanium and titanium alloys
$968
D6121
Implant supported retainer for metal FPD - predominantly base alloys
$990
D6122
Implant supported retainer for metal FPD - noble alloys
$990
D6123
Implant supported retainer for metal FPD - titanium and titanium alloys
$990
D6190
Radiographic/surgical implant index, by report
$151
D6191
Semi-precision abutment - placement
$419
D6192
Semi-precision abutment - placement
$106
D6194
Abutment supported retainer crown for FPD -titanium and titanium alloys
$791
D6195
Abutment supported retainer - porcelain fused to titanium and titanium alloys
$900
D6210
Pontic - cast high noble metal
$792
D6211
Pontic - cast predominantly base metal
$765
D6212
Pontic - cast noble metal
$774
D6240
Pontic - porcelain fused to high noble metal
$779
D6241
Pontic - porcelain fused to predominantly base metal
$761
D6242
Pontic - porcelain fused to noble metal
$765
D6245
Pontic - porcelain/ceramic
$765
D6250
Pontic - resin with high noble metal
$669
D6251
Pontic - resin with predominantly base metal
$578
D6252
Pontic - resin with noble metal
$614
D6545
Retainer - cast metal for resin bonded fixed prosthesis
$348
D6548
Retainer - porcelain/ceramic for resin bonded fixed prosthesis
$317
D6720
Retainer crown - resin with high noble metal
$673
D6721
Retainer crown - resin with predominantly base metal
$594
D6722
Retainer crown - resin with noble metal
$650
D6740
Retainer crown - porcelain/ceramic
$765
D6750
Retainer crown - porcelain fused to high noble metal
$779
D6751
Retainer crown - porcelain fused to predominantly base metal
$761
D6752
Retainer crown - porcelain fused to noble metal
$765
D6780
Retainer crown - _ cast high noble metal
$691
D6781
Retainer crown - _ cast predominantly base metal
$617
D6782
Retainer crown - _ cast noble metal
$673
D6783
Retainer crown - _ porcelain/ceramic
$696
D6790
Retainer crown - full cast high noble metal
$792
D6791
Retainer crown - full cast predominantly base metal
$765
D6792
Retainer crown - full cast noble metal
$774
D6930
Re-cement or re-bond fixed partial denture
$76
ADA Code
Procedure Name
Discounted Cost
D5110
Complete denture - maxillary
$935
D5120
Complete denture - mandibular
$935
D5130
Immediate denture - maxillary
$1,025
D5140
Immediate denture - mandibular
$1,025
D5211
Maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth)
$637
D5212
Mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth)
$637
D5213
Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests, and teeth)
$1,058
D5214
Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests, and teeth)
$1,058
D5281
Removable unilateral partial denture - one piece cast metal (including clasps and teeth)
20% Discount
D5410
Adjust complete denture - maxillary.
$42
D5411
Adjust complete denture - mandibular.
$42
D5421
Adjust partial denture - maxillary.
$42
D5422
Adjust partial denture - mandibular
$42
D5520
Replace missing or broken teeth - complete denture (each tooth)
$135
D5630
Repair or replace broken retentive/clasping materials per tooth
$131
D5640
Replace broken teeth - per tooth.
$135
D5650
Add tooth to existing partial denture.
$135
D5660
Add clasp to existing partial denture - per tooth.
$149
D5710
Rebase complete maxillary denture
$310
D5711
Rebase complete mandibular denture
$310
D5720
Rebase maxillary partial denture
$272
D5721
Rebase mandibular partial denture
$272
D5730
Reline complete maxillary denture (direct)
$179
D5731
Reline complete mandibular denture (direct)
$179
D5740
Reline maxillary partial denture (direct)
$166
D5741
Reline mandibular partial denture (direct)
$168
D5750
Reline complete maxillary denture (indirect)
$269
D5751
Reline complete mandibular denture (indirect)
$269
D5760
Reline maxillary partial denture (indirect)
$252
D5761
Reline mandibular partial denture (indirect)
$252
D5810
Interim complete denture (maxillary)
$415
D5811
Interim complete denture (mandibular)
$415
D5820
Interim partial denture (including retentive/clasping materials, rests, and teeth) - maxillary
$322
D5821
Interim partial denture (including retentive/clasping materials, rests and teeth) - mandibular
$322
D5850
Tissue conditioning, maxillary
$92
D5851
Tissue conditioning, mandibular
$92
ADA Code
Procedure Name
Discounted Cost
D2140
Amalgam - one surface, primary or permanent
$103
D2150
Amalgam - two surface, primary or permanent
$132
D2160
Amalgam - three surface, primary or permanent
$161
D2161
Amalgam - four or more surfaces, primary or permanent
$195
D2330
Resin-Based Composite, One Surface, Anterior
$100
D2331
Resin-Based Composite, Two Surfaces, Anterior
$124
D2332
Resin-Based Composite, Three Surfaces, Anterior
$152
D2335
Resin-Based Composite, Four or More Surfaces, or Involving Incisal Angle (Anterior)
$183
D2390
Resin-based composite crown, anterior
$240
D2391
Resin-based composite - one surface, posterior
$107
D2392
Resin-based composite - two surfaces, posterior
$135
D2393
Resin-based composite - three surfaces, posterior
$166
D2394
Resin-based composite - four or more surfaces, posterior
$195
D2510
Inlay - metallic - one surface
$370
D2520
Inlay - metallic - two surfaces
$433
D2530
Inlay - metallic - three surface
$502
D2542
Onlay - metallic - two surface
$567
D2543
Onlay - metallic - three surfaces
$611
D2544
Onlay - metallic - four or more surfaces
$648
D2610
Inlay - porcelain/ceramic - one surface
$461
D2620
Inlay - porcelain/ceramic - two surfaces
$519
D2630
Inlay - porcelain/ceramic - three surfaces
$581
D2642
Onlay - porcelain/ceramic - two surface
$586
D2643
Onlay - porcelain/ceramic - three surfaces
$670
D2644
Onlay - porcelain/ceramic - four or more surfaces
$723
D2650
Inlay - resin-based composite - one surface
$386
D2651
Inlay - resin-based composite - two surfaces
$434
D2652
Inlay - resin-based composite - three surface
$519
D2662
Onlay, resin-based composite, two surfaces
$494
D2663
Onlay, resin-based composite, three surfaces
$547
D2664
Onlay, resin-based composite, four or more surfaces
$559
D2710
Crown - resin-based composite (indirect)
$315
D2720
Crown, resin with high noble metal
$648
D2721
Crown, resin, predominantly base metal
$561
D2722
Crown, resin with noble metal
$625
D2740
Porcelain/Ceramic substrate
$725
D2750
Porcelain fused to high noble metal
$831
D2751
Porcelain fused to predominantly base metal
$812
D2752
Porcelain fused to noble metal
$817
D2780
Crown, 3/4 cast high noble metal
$677
D2781
Crown, 3/4 cast predominantly base metal
$616
D2782
Crown, 3/4 cast noble metal
$653
D2783
Crown 3/4 porcelain/ceramic
* This procedure does not include facial veneers.
$693
D2790
Crown, full cast high noble metal
$792
D2791
Crown, full cast predominantly base metal
$765
D2792
Crown, full cast nobel metal
$774
D2910
Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration
$63
D2920
Re-cement or re-bond crown
$63
D2930
Prefabricated stainless steel crown - primary tooth
$156
D2931
Prefabricated stainless steel crown - permanent tooth
$166
D2932
Prefabricated resin crown
$157
D2933
Prefabricated stainless steel crown with resin window
$193
D2940
Protective restoration
$52
D2950
Core buildup, including pins
$138
D2951
Pin retention - per tooth, in addition to restoration
$34
D2952
Post and core in addition to crown, indirectly fabricated
$260
D2953
Each additional indirectly fabricated post - same tooth
$133
D2954
Prefabricated post and core in addition to crown
$170
D2955
Post removal
$133
D2957
Each additional prefabricated post - same tooth * to be used with D2954
$75
D2960
Labial Veneer (resin laminate), direct
$282
D2999
Unspecified restorative procedure, by report
20% Discount