ADA Code Description Rate D2110 AMALGAM ONE SURFACE PRIMARY $38.35 D2120 AMALGAM TWO SURFACES PRIMARY $56.87 D2130 AMALGAM THREE SURFACES PRIMARY
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1 ADA Code Description Rate D2110 AMALGAM ONE SURFACE PRIMARY $38.35 D2120 AMALGAM TWO SURFACES PRIMARY $56.87 D2130 AMALGAM THREE SURFACES PRIMARY $70.09 D2131 AMALGAM FOUR/MORE SURFACES PRIMARY $70.09 D2140 AMALGAM-ONE SURFACE PRIMARY OR PERMANENT $38.35 D2150 AMALGAM-TWO SURFACES PRIMARY OR PERMANEN $56.87 D2160 AMALGAM-THREE SURFACES PRIMARY OR PERMAN $70.09 D2161 AMALGAM-FOUR/MORE SURFACES PRIMARY/PERMA $70.09 D2330 RESIN-BASED COMPOSITE - ONE SURFACE ANTE $52.90 D2331 RESIN-BASED COMPOSITE - TWO SURFACES ANT $82.00 D2332 RESIN-BASED COMPOSITE - THREE SURFACES A $ D2335 RESIN COMPOS - 4/MORE SURFACES/INVLV INC $97.87 D2380 RESIN ONE SURFACE POSTERIOR PRIMARY $70.09 D2381 RESIN TWO SURFACE POSTERIOR PRIMARY $82.00 D2382 RESIN 3/MORE SURFACE POST PRIM $ D2385 RESIN 1 SURFACE POST PERM $70.09 D2386 RESIN 2 SURFACE POST PERM $82.00 D2387 RESIN 3/MORE SURFACE POST PERM $ D2388 RESIN-BASED COMPOS-4/MORE SURFACES $ D2391 RESIN-BASED COMPOSITE - ONE SURFACE POST $70.09 D2392 RESIN-BASED COMPOSITE - TWO SURFACES POS $82.00 D2393 RESIN-BASED COMPOSITE - THREE SURFACES P $ D2394 RESIN COMPOS - FOUR OR MORE SURFACES POS $ D2410 GOLD FOIL - ONE SURFACE $ D2420 GOLD FOIL - TWO SURFACES $ D2430 GOLD FOIL - THREE SURFACES $ D2510 INLAY - METALLIC - ONE SURFACE $ D2520 INLAY - METALLIC - TWO SURFACES $ D2530 INLAY - METALLIC - THREE OR MORE SURFACE $ D2542 ONLAY - METALLIC - TWO SURFACES $ D2543 ONLAY METALLIC THREE SURFACES $ D2544 ONLAY METALLIC FOUR OR MORE SURFACES $ D2610 INLAY - PORCELAIN/CERAMIC - ONE SURFACE $ D2620 INLAY - PORCELAIN/CERAMIC - TWO SURFACES $ D2630 INLAY - PORCELAIN/CERAMIC - THREE/MORE S $ D2642 ONLAY - PORCELAIN/CERAMIC - TWO SURFACES $ D2643 ONLAY - PORCELAIN/CERAMIC - THREE SURFAC $ D2644 ONLAY - PORCELAIN/CERAMIC - 4 OR MORE SU $ D2650 INLAY - RESIN COMPOS COMPOSITE/RESIN - 1 $ D2651 INLAY - RESIN COMPOS COMPOS/RESIN - 2 SU $ D2652 INLAY - RSN COMPOS COMPOS/RSN - 3/MORE S $ D2662 ONLAY - RESIN COMPOS COMPOS/RESIN - 2 SU $ D2663 ONLAY - RESIN COMPOS COMPOS/RESIN - 3 SU $ D2664 ONLAY - RSN COMPOS COMPOS/RSN - 4/MORE S $ D2710 CROWN RESINBASED COMPOSITE INDIRECT $ D2720 CROWN - RESIN WITH HIGH NOBLE METAL $ D2721 CROWN - RESIN WITH PREDOMINANTLY BASE ME $ D2722 CROWN - RESIN WITH NOBLE METAL $ D2740 CROWN - PORCELAIN/CERAMIC SUBSTRATE $ D2750 CROWN - PORCELAIN FUSED TO HIGH NOBLE ME $517.10
2 D2751 CROWN - PORCELAIN FUSED PREDOMINANTLY BA $ D2752 CROWN - PORCELAIN FUSED TO NOBLE METAL $ D2780 CROWN - 3/4 CAST HIGH NOBLE METAL $ D2782 CROWN - 3/4 CAST NOBLE METAL $ D2790 CROWN - FULL CAST HIGH NOBLE METAL $ D2791 CROWN - FULL CAST PREDOMINANTLY BASE MET $ D2792 CROWN - FULL CAST NOBLE METAL $ D2910 RECEMENT INLAY ONLAY/PART COVERAGE RESTO $27.77 D2920 RECEMENT CROWN $27.77 D2930 PREFABR STAINLESS STEEL CROWN - PRIMARY $97.87 D2931 PREFABR STAINLESS STEEL CROWN - PERMANEN $97.87 D2932 PREFABRICATED RESIN CROWN $ D2940 SEDATIVE FILLING $23.81 D2950 CORE BUILDUP INCLUDING ANY PINS $ D2951 PIN RETENTION - PER TOOTH ADDITION RESTO $13.23 D2952 CAST POST AND CORE IN ADDITION TO CROWN $ D2954 PREFABRICATED POST AND CORE IN ADDITION $ D2955 POST REMOVAL $ D2960 LABIAL VENEER - CHAIRSIDE $ D2961 LABIAL VENEER - LABORATORY $ D2962 LABIAL VENEER - LABORATORY $ D2980 CROWN REPAIR BY REPORT $ D3110 PULP CAP - DIRECT $19.64 D3120 PULP CAP - INDIRECT $15.02 D3220 TX PULP-REMV PULP CORONAL DENTINOCEMENTL $40.43 D3221 PULPAL DEBRIDEMENT PRIMARY AND PERMANENT $36.75 D3230 PULPAL THERAPY - ANTERIOR PRIMARY TOOTH $58.91 D3240 PULPAL THERAPY - POSTERIOR PRIMARY TOOTH $72.77 D3310 ANTERIOR $ D3320 BICUSPID $ D3330 MOLAR $ D3346 RETREATMENT PREVIOUS RC THERAPY - ANTERI $ D3347 RETREATMENT PREVIOUS RC THERAPY - BICUSP $ D3348 RETREATMENT PREVIOUS ROOT CANAL THERAPY $ D3351 APEXIFICATION/RECALCIFICATION - INITIAL $ D3410 APICOECTOMY/PERIRADICULAR SURGERY - ANTE $ D3421 APICOECTOMY/PERIRADICULAR SURGERY - BICU $ D3425 APICOECTOMY/PERIRADICULAR SURGERY - MOLA $ D3426 APICOECTOMY/PERIRADICULAR SURGERY $ D3430 RETROGRADE FILLING - PER ROOT $70.46 D3450 ROOT AMPUTATION - PER ROOT $ D3910 SURGICAL PROCEDURE ISOLATION TOOTH W/RUB $40.43 D3920 HEMISECTION NOT INCLUDING ROOT CANAL THE $ D3950 CANAL PREPARATION&FITTING PREFORMED DOWE $19.64 D4210 GINGIVECT/PLSTY 4/>CNTIG/BOUND TEETH SPA $ D4211 GINGIVECT/PLSTY 1-3 CNTIG/BOUND TEETH SP $ D4220 GING CURET SURG/QUAD BR $57.75 D4240 GINGL FLP PROC 4/> CONTIG/BOUND TEETH SP $ D4241 GINGL FLP PROC 1-3 CONTIG/BOUND TEETH SP $95.63 D4249 CLINICAL CROWN LENGTHENING - HARD TISSUE $ D4260 OSSEOUS SURG 4/> CONTIG/BOUND TEETH SPAC $347.66
3 D4261 OSSEOUS SURG 1-3 CONTIG/BOUND TEETH SPAC $ D4263 BONE REPLACEMENT GRAFT - FIRST SITE IN Q $ D4264 BONE REPLACEMENT GRAFT - EA ADD SITE QUA $ D4265 BIOLOGIC MATERIALS AID SOFT&OSSEOUS TISS $31.75 D4266 GUID TISSUE REGEN - RESORBABLE BARRIER P $ D4267 GUID TISSUE REGEN - NONRESORB BARRIER PE $ D4268 SURGICAL REVISION PROCEDURE PER TOOTH $ D4270 PEDICLE SOFT TISSUE GRAFT PROCEDURE $ D4271 FREE SOFT TISSUE GRAFT PROCEDURE $ D4273 SUBEPITHEL CONECTIVE TISSUE GRAFT PROC P $ D4341 PRDONTAL SCALING&ROOT PLANING 4/MORE TEE $62.37 D4342 PRDONTAL SCALING&ROOT PLANING 1-3 TEETH- $35.49 D4355 FULL MOUTH DEBRID ENABLE COMP EVALUATION $40.43 D4381 LOC DEL ANTIMICROBL AGTS CREVICULR TISS $35.49 D4910 PERIODONTAL MAINTENANCE $57.75 D4920 UNSCHEDULED DRESSING CHANGE $18.48 D5110 COMPLETE DENTURE - MAXILLARY $ D5120 COMPLETE DENTURE - MANDIBULAR $ D5130 IMMEDIATE DENTURE - MAXILLARY $ D5140 IMMEDIATE DENTURE - MANDIBULAR $ D5211 MAXILLARY PARTIAL DENTURE - RESIN BASE $ D5212 MANDIBULAR PARTIAL DENTURE - RESIN BASE $ D5213 MAX PART DENTUR-CAST METL FRMEWRK W/RSN $ D5214 MAND PART DENTUR- CAST METL FRMEWRK W/RS $ D5281 REMV UNILAT PART DENTUR - 1 PIECE CAST M $ D5410 ADJUST COMPLETE DENTURE - MAXILLARY $46.20 D5411 ADJUST COMPLETE DENTURE - MANDIBULAR $46.20 D5421 ADJUST PARTIAL DENTURE - MAXILLARY $17.33 D5422 ADJUST PARTIAL DENTURE - MANDIBULAR $17.33 D5510 REPAIR BROKEN COMPLETE DENTURE BASE $36.96 D5520 REPLACE MISSING/BROKEN TEETH - COMPLETE $36.96 D5610 REPAIR RESIN DENTURE BASE $36.96 D5620 REPAIR CAST FRAMEWORK $54.29 D5630 REPAIR OR REPLACE BROKEN CLASP $64.68 D5640 REPLACE BROKEN TEETH - PER TOOTH $36.96 D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE $72.77 D5660 ADD CLASP TO EXISTING PARTIAL DENTURE $54.29 D5710 REBASE COMPLETE MAXILLARY DENTURE $ D5711 REBASE COMPLETE MANDIBULAR DENTURE $ D5720 REBASE MAXILLARY PARTIAL DENTURE $ D5721 REBASE MANDIBULAR PARTIAL DENTURE $ D5730 RELINE COMPLETE MAXILLARY DENTURE $82.01 D5731 RELINE COMPLETE MANDIBULAR DENTURE $82.01 D5740 RELINE MAXILLARY PARTIAL DENTURE $64.68 D5741 RELINE MANDIBULAR PARTIAL DENTURE $64.68 D5750 RELINE COMPLETE MAXILLARY DENTURE $ D5751 RELINE COMPLETE MANDIBULAR DENTURE $ D5760 RELINE MAXILLARY PARTIAL DENTURE $ D5761 RELINE MANDIBULAR PARTIAL DENTURE $ D5850 TISSUE CONDITIONING MAXILLARY $64.68 D5851 TISSUE CONDITIONING MANDIBULAR $64.68
4 D5860 OVERDENTURE - COMPLETE BY REPORT $ D5861 OVERDENTURE - PARTIAL BY REPORT $ D5931 OBTURATOR PROSTHESIS SURGICAL $ D5932 OBTURATOR PROSTHESIS DEFINITIVE $ D5982 SURGICAL STENT $ D6010 SURG PLACEMENT IMPLANT BODY: ENDOSTEAL I $ D6056 PREFABRICATED ABUTMENT INCLUDES PLACEMEN $ D6057 CUSTOM ABUTMENT INCLUDES PLACEMENT $ D6058 ABUTMENT SUPPORTED PORCELAIN/CERAMIC CRO $ D6059 ABUT SUPP PORCELAIN TO METL CROWN HI NOB $ D6060 ABUT SUPP PORCELAIN TO MTL CROWN PREDOM $ D6066 IMPLANT SUPPORTED PORCELAIN FUSED TO MET $ D6068 ABUT SUPPORTED RETAINER PORCELAIN/CERAMI $ D6095 REPAIR IMPLANT ABUTMENT BY REPORT $ D6100 IMPLANT REMOVAL BY REPORT SEE ALSO CODE $ D6210 PONTIC - CAST HIGH NOBLE METAL $ D6211 PONTIC - CAST PREDOMINANTLY BASE METAL $ D6212 PONTIC - CAST NOBLE METAL $ D6240 PONTIC - PORCELAIN FUSED TO HIGH NOBLE M $ D6241 PONTIC - PORCELN FUSED PREDOMINANTLY BAS $ D6242 PONTIC - PORCELAIN FUSED TO NOBLE METAL $ D6250 PONTIC - RESIN WITH HIGH NOBLE METAL $ D6251 PONTIC - RESIN WITH PREDOMINANTLY BASE M $ D6252 PONTIC - RESIN WITH NOBLE METAL $ D6520 INLAY METALLIC TWO SURFACES $ D6530 INLAY METALLIC THREE/MORE SURFACES $ D6545 RETAINER - CAST METAL RESIN BONDED FIX P $ D6720 CROWN - RESIN WITH HIGH NOBLE METAL $ D6721 CROWN RESIN W/PREDOMINANTLY BASE METAL-D $ D6722 CROWN - RESIN WITH NOBLE METAL $ D6750 CROWN PORCELAIN FUSED TO HI NOBLE METAL- $ D6751 CROWN - PORCELAIN FUSED PREDOMINANTLY BA $ D6752 CROWN - PORCELAIN FUSED TO NOBLE METAL $ D6780 CROWN - 3/4 CAST HIGH NOBLE METAL $ D6790 CROWN FULL CAST HIGH NOBLE METAL-DENTURE $ D6791 CROWN FULL CAST PREDOMINANTLY BASE METAL $ D6792 CROWN FULL CAST NOBLE METAL-DENTURE $ D6930 RECEMENT FIXED PARTIAL DENTURE $33.50 D6940 STRESS BREAKER $32.34 D6950 PRECISION ATTACHMENT $99.33 D6970 CAST POST&CORE ADDITION FIX PART DENTUR $83.16 D6971 CAST POST AS PART FIXED PARTIAL DENTURE $83.16 D6972 PREFAB POST&CORE ADD FIX PART DENTUR RET $83.16 D6973 CORE BUILD UP FOR RETAINER INCLUDING ANY $41.58 D6980 FIXED PARTIAL DENTURE REPAIR BY REPORT $33.50 D7110 SINGLE TOOTH $27.72 D7111 EXTRACTION CORONAL REMNANTS DECIDUOUS TO $27.72 D7120 EACH ADDITIONAL TOOTH $27.72 D7130 ROOT REMOVAL EXPOSED ROOTS $36.96 D7140 EXTRACTION ERUPTED TOOTH OR EXPOSED ROOT $27.72 D7210 SURG REMV ERUPTED TOOTH RQR ELEV FLP&REM $42.74
5 D7220 REMOVAL OF IMPACTED TOOTH - SOFT TISSUE $66.99 D7230 REMOVAL OF IMPACTED TOOTH - PARTIALLY BO $ D7240 REMOVAL OF IMPACTED TOOTH - COMPLETELY B $ D7241 REMV IMP TOOTH - CMPL BONY W/UNUSUAL SUR $ D7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS $64.68 D7260 OROLANTRAL FISTULA CLOSURE $ D7270 TOOTH REIMPL &OR STBL ACC EVULSED/DISPLC $68.15 D7280 SURGICAL ACCESS OF AN UNERUPTED TOOTH $ D7281 SURG EXPOS IMPACT/UNERUPTED TOOTH AID ER $ D7285 BIOPSY OF ORAL TISSUE HARD $72.77 D7286 BIOPSY OF ORAL TISSUE SOFT $46.20 D7290 SURGICAL REPOSITIONING OF TEETH $ D7310 ALVEOLPLASTY CONJUNC W/EXTRACTIONS- PER $42.74 D7320 ALVEOLOPLASTY NOT IN CONJUNC W/EXTRACTIO $64.68 D7340 VESTIBULOPLASTY-RIDGE EXT 2ND EPITHELIAL $75.08 D7350 VESTIBULOPLASTY-RIDGE EXT W/SOFT TISS GR $ D7410 EXCISION OF BENIGN LESION UP TO 1.25 CM $ D7420 RADCL EXC LES >1.25CM $ D7430 EXC BEN TUMOR/LES TO 1.25CM $ D7431 EXC BEN TUMOR/LES > 1.25CM $ D7440 EXC MALIG TUMOR-LESION DIAMETER UP TO 1. $ D7441 EXC MALIG TUMOR-LESION DIAM GREATER THAN $ D7450 REMOVAL BEN ODONTOGENIC CYST/TUMR- UP T0 $86.63 D7451 REMOVAL BENIGN ODONTOGENIC CYST/TUMOR- > $ D7460 REMOVAL BEN NONODONTOGENIC CYST/TUMR- UP $ D7461 REMOVAL BEN NONODONTOGENIC CYST/TUMOR- > $ D7471 REMOVAL OF LATERAL EXOSTOSIS $ D7480 PART OSTEC (GUTTERING/SAUCER) $1, D7490 RADICAL RESECTION OF MAXILLA OR MANDIBLE $2, D7510 INCISION & DRAINAGE ABSCESS-INTRAORAL SO $42.74 D7520 INCISION & DRAINAGE ABSCESS-EXTRAORAL SO $42.74 D7530 REMOVAL FB FROM MUCOSA SKIN/SUBCUT ALVEO $42.74 D7540 REMV REACT-PRODUC FOREIGN BODIES-MUSCULO $ D7550 PART OSTEC/SEQUESTRECTOMY REMOVAL NON-VI $ D7560 MAXILLARY SINUSOTOMY REMOVAL TOOTH FRAGM $ D7610 MAXILLA-OPEN REDUCTION $1, D7620 MAXILLA-CLOSED REDUCTION $ D7630 MANDIBLE-OPEN REDUCTION $1, D7640 MANDIBLE-CLOSED REDUCTION $ D7650 MALAR AND/OR ZYGOMATIC ARCH-OPEN REDUCTI $ D7660 MALAR AND/OR ZYGOMATIC ARCH-CLOSED REDUC $ D7670 ALVEOLUS-CLOSED REDUCTION W/STABILIZATIO $ D7680 FCE BNS - COMP RDUC W/FIX&MX SURG APPRCH $ D7710 MAXILLA-OPEN REDUCTION $1, D7720 MAXILLA-CLOSED REDUCTION $ D7730 MANDIBLE-OPEN REDUCTION $1, D7740 MANDIBLE-CLOSED REDUCTION $ D7750 MALAR AND/OR ZYGOMATIC ARCH-OPEN REDUCTI $ D7760 MALAR AND/OR ZYGOMATIC ARCH CLOSED REDUC $ D7770 ALVEOLUS - OPEN REDUCTION STABILIZATION $ D7780 FACIAL BONES-COMP RDUC FIX & MX SURG APP $1,070.69
6 D7810 OPEN REDUCTION OF DISLOCATION $ D7820 CLOSED REDUCTION OF DISLOCATION $ D7830 MANIPULATION UNDER ANESTHESIA $86.63 D7840 CONDYLECTOMY $1, D7850 SURGICAL DISCECTOMY; WITH/WITHOUT IMPLAN $1, D7860 ARTHROTOMY $1, D7870 ARTHROCENTESIS $42.74 D7880 OCCLUSAL ORTHOTIC APPLIANCE $ D7910 SUTURE OF RECENT SMALL WOUNDS UP TO 5 CM $66.99 D7911 COMPLICATED SUTURE-UP TO 5 CM $ D7912 COMPLICATED SUTURE-GREATER THAN 5 CM $ D7920 SKIN GRAFT $ D7940 OSTEOPLASTY - FOR ORTHOGNATHIC DEFORMITI $2, D7950 OSSEOUS OSTEOPERIOSTL/CART GFT MAND/FCE $ D7951 SINUS AUGMENTATION $ D7955 REPAIR MAXLOFACIAL SOFT &/ HARD TISSUE D $1, D7960 FRENULECTOMY SEPARATE PROCEDURE $64.68 D7970 EXCISION OF HYPERPLASTIC TISSUE-PER ARCH $ D7971 EXCISION OF PERICORONAL GINGIVA $53.13 D7980 SIALOLITHOTOMY $64.68 D7981 EXCISION OF SALIVARY GLAND BY REPORT $ D7982 SIALODOCHOPLASTY $ D7983 CLOSURE OF SALIVARY FISTULA $ D7990 EMERGENCY TRACHEOTOMY $ D8080 COMPREHENSIVE ORTHODONTIC TX ADOLES DENT $ D8210 REMOVABLE APPLIANCE THERAPY $ D8220 FIXED APPLIANCE THERAPY $ D8670 PERIODIC ORTHODONTIC TREATMENT VISIT $58.91 D8999 UNSPECIFIED ORTHODONTIC PROCEDURE BY REP $ D9212 TRIGEMINAL DIVISION BLOCK ANESTHESIA $ D9220 DEEP SEDATION/GENERAL ANESTHESIA-1ST 30 $54.29 D9221 DEEP SEDATION/GENERAL ANESTHESIA-EA ADD $27.72 D9241 IV CONSCIOUS SEDATION/ANALG - 1ST 30 MIN $42.74 D9242 IV CONSCIOUS SEDATION/ANALG - EA ADD 15 $16.17 D9610 THERAPEUTIC DRUG INJECTION BY REPORT $18.48 D9630 OTHER DRUGS AND/OR MEDICAMENTS BY REPORT $18.48 D9910 APPLICATION OF DESENSITIZING MEDICAMENT $18.48 D9930 TX COMPLICATIONS - UNUSUAL CIRCUMSTANCES $27.72 D9940 OCCLUSAL GUARD BY REPORT $20.24 D9950 OCCLUSION ANALYSIS - MOUNTED CASE $ D9951 OCCLUSAL ADJUSTMENT - LIMITED $69.30 D9952 OCCLUSAL ADJUSTMENT - COMPLETE $274.89
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