Office Fee Schedule
Office Fee Schedule
| CDT code | Office fee | Gold 20% savings | Platinum 30% savings | |
|---|---|---|---|---|
| D0120 | 84 | 0 | 0 | periodic oral evaluation - established patient |
| D0140 | 106 | 0 | 0 | limited oral evaluation - problem focused |
| D0145 | 109 | 0 | 0 | oral evaluation for a patient under three years of age and counseling with primary caregiver |
| D0150 | 122 | 0 | 0 | comprehensive oral evaluation - new or established patient |
| D0210 | 177 | 0 | 0 | intraoral - complete series of radiographic images |
| D0220 | 40 | 0 | 0 | intraoral - periapical first radiographic image |
| D0230 | 35 | 0 | 0 | intraoral - periapical each additional radiographic image |
| D0270 | 40 | 0 | 0 | bitewing - single radiographic image |
| D0272 | 61 | 0 | 0 | bitewings - two radiographic images |
| D0273 | 74 | 0 | 0 | bitewings - three radiographic images |
| D0274 | 88 | 0 | 0 | bitewings - four radiographic images |
| D0277 | 132 | 0 | 0 | vertical bitewings - 7 to 8 radiographic images |
| D0330 | 153 | 0 | 0 | panoramic radiographic image |
| D0364 | 368 | 294 | 258 | cone beam CT capture and interpretation with limited field of view – less than one whole jaw |
| D0367 | 473 | 378 | 331 | cone beam CT capture and interpretation with field of view of both jaws; with or without cranium |
| D1110 | 168 | 134 | 0 | prophylaxis - adult |
| D1120 | 105 | 84 | 0 | prophylaxis - child |
| D1206 | 60 | 0 | 0 | topical application of fluoride varnish |
| D1351 | 105 | 84 | 74 | sealant - per tooth |
| D1352 | 145 | 116 | 102 | preventive resin restoration in a moderate to high caries risk patient – permanent tooth |
| D1353 | 126 | 101 | 88 | sealant repair – per tooth |
| D2330 | 252 | 202 | 176 | resin-based composite - one surface, anterior |
| D2331 | 284 | 227 | 199 | resin-based composite - two surfaces, anterior |
| D2332 | 368 | 294 | 258 | resin-based composite - three surfaces, anterior |
| D2335 | 452 | 362 | 316 | resin-based composite - four or more surfaces or involving incisal angle (anterior) |
| D2391 | 284 | 227 | 199 | resin-based composite - one surface, posterior |
| D2392 | 336 | 269 | 235 | resin-based composite - two surfaces, posterior |
| D2393 | 420 | 336 | 294 | resin-based composite - three surfaces, posterior |
| D2394 | 494 | 395 | 346 | resin-based composite - four or more surfaces, posterior |
| D2940 | 167 | 134 | 117 | protective restoration |
| D2950 | 368 | 294 | 258 | core buildup, including any pins when required |
| D2954 | 483 | 386 | 338 | prefabricated post and core in addition to crown |
| D3110 | 119 | 95 | 83 | pulp cap - direct (excluding final restoration) |
| D3120 | 114 | 91 | 80 | pulp cap - indirect (excluding final restoration) |
| D3220 | 278 | 222 | 195 | therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament |
| D3310 | 1103 | 882 | 772 | endodontic therapy, anterior tooth (excluding final restoration) |
| D3320 | 1260 | 1008 | 882 | endodontic therapy, premolar tooth (excluding final restoration) |
| D3330 | 1523 | 1218 | 1066 | endodontic therapy, molar tooth (excluding final restoration) |
| D3331 | 847 | 678 | 593 | treatment of root canal obstruction; non-surgical access |
| D3332 | 665 | 532 | 465 | incomplete endodontic therapy; inoperable, unrestorable or fractured tooth |
| D3346 | 1260 | 1008 | 882 | retreatment of previous root canal therapy - anterior |
| D3347 | 1418 | 1134 | 993 | retreatment of previous root canal therapy - premolar |
| D3348 | 1628 | 1302 | 1140 | retreatment of previous root canal therapy - molar |
| D3470 | 1052 | 842 | 736 | intentional re-implantation (including necessary splinting) |
| D4212 | 394 | 315 | 276 | gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth |
| D4240 | 1156 | 925 | 809 | gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant |
| D4241 | 870 | 696 | 609 | gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant |
| D4266 | 995 | 796 | 697 | guided tissue regeneration - resorbable barrier, per site |
| D4267 | 1205 | 964 | 844 | guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) |
| D4322 | 693 | 554 | 485 | splint - intra-coronal; natural teeth or prosthetic crowns |
| D4323 | 637 | 510 | 446 | splint - extra-coronal; natural teeth or prosthetic crowns |
| D4341 | 399 | 319 | 279 | periodontal scaling and root planing - four or more teeth per quadrant |
| D4342 | 315 | 252 | 221 | periodontal scaling and root planing - one to three teeth per quadrant |
| D4346 | 263 | 210 | 184 | scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation |
| D4355 | 263 | 210 | 184 | full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit |
| D4910 | 263 | 210 | 184 | periodontal maintenance |
| D5110 | 2940 | 2352 | 2058 | complete denture - maxillary |
| D5120 | 2940 | 2352 | 2058 | complete denture - mandibular |
| D5130 | 3990 | 3192 | 2793 | immediate denture - maxillary |
| D5140 | 3990 | 3192 | 2793 | immediate denture - mandibular |
| D5211 | 2625 | 2100 | 1837 | maxillary partial denture – resin base (including, retentive/clasping materials, rests, and teeth) |
| D5212 | 2625 | 2100 | 1837 | mandibular partial denture – resin base (including, retentive/clasping materials, rests, and teeth) |
| D5213 | 2625 | 2100 | 1837 | maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) |
| D5214 | 2625 | 2100 | 1837 | mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) |
| D5221 | 3675 | 2940 | 2573 | immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) |
| D5222 | 3675 | 2940 | 2573 | immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) |
| D5223 | 3675 | 2940 | 2573 | immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) |
| D5224 | 3675 | 2940 | 2573 | immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) |
| D5225 | 2625 | 2100 | 1837 | maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth) |
| D5226 | 2625 | 2100 | 1837 | mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth) |
| D5227 | 3675 | 2940 | 2573 | immediate maxillary partial denture - flexible base (including any clasps, rests and teeth) |
| D5228 | 3675 | 2940 | 2573 | immediate mandibular partial denture - flexible base (including any clasps, rests and teeth) |
| D5282 | 1418 | 1134 | 993 | removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), maxillary |
| D5283 | 1418 | 1134 | 993 | removable unilateral partial denture – one piece cast metal (including rententive/clasping materias, rests, and teeth), mandibular |
| D5284 | 1418 | 1134 | 993 | removable unilateral partial denture – one piece flexible base (including retentive/clasping materials, rests, and teeth) – per quadrant |
| D5286 | 1418 | 1134 | 993 | removable unilateral partial denture – one piece resin (including retentive/clasping materials, rests, and teeth) – per quadrant |
| D5410 | 126 | 101 | 88 | adjust complete denture - maxillary |
| D5411 | 126 | 101 | 88 | adjust complete denture - mandibular |
| D5421 | 126 | 101 | 88 | adjust partial denture - maxillary |
| D5422 | 126 | 101 | 88 | adjust partial denture - mandibular |
| D5511 | 286 | 229 | 200 | repair broken complete denture base, mandibular |
| D5512 | 292 | 234 | 204 | repair broken complete denture base, maxillary |
| D5520 | 257 | 206 | 180 | replace missing or broken teeth - complete denture (each tooth) |
| D5611 | 268 | 214 | 188 | repair resin partial denture base, mandibular |
| D5612 | 272 | 218 | 190 | repair resin partial denture base, maxillary |
| D5621 | 351 | 281 | 246 | repair cast partial framework, mandibular |
| D5622 | 335 | 268 | 234 | repair cast partial framework, maxillary |
| D5630 | 358 | 286 | 251 | repair or replace broken retentive clasping materials – per tooth |
| D5640 | 268 | 214 | 188 | replace broken teeth - per tooth |
| D5650 | 309 | 247 | 216 | add tooth to existing partial denture |
| D5660 | 359 | 287 | 251 | add clasp to existing partial denture - per tooth |
| D5730 | 509 | 407 | 356 | reline complete maxillary denture (direct) |
| D5731 | 505 | 404 | 354 | reline complete mandibular denture (direct) |
| D5740 | 496 | 397 | 347 | reline maxillary partial denture (direct) |
| D5741 | 499 | 399 | 349 | reline mandibular partial denture (direct) |
| D5862 | 945 | 756 | 662 | precision attachment, by report |
| D5863 | 3465 | 2772 | 2426 | overdenture – complete maxillary |
| D5864 | 3465 | 2772 | 2426 | overdenture – partial maxillary |
| D5865 | 3255 | 2604 | 2279 | overdenture – complete mandibular |
| D5866 | 3255 | 2604 | 2279 | overdenture – partial mandibular |
| D5867 | 531 | 425 | 372 | replacement of replaceable part of semi-precision or precision attachment (male or female component) |
| D6205 | 1316 | 1053 | 921 | pontic - indirect resin based composite |
| D6211 | 1408 | 1126 | 986 | pontic - cast predominantly base metal |
| D6212 | 1416 | 1133 | 991 | pontic - cast noble metal |
| D6214 | 1483 | 1186 | 1038 | pontic - titanium and titanium alloys |
| D6242 | 1434 | 1147 | 1004 | pontic - porcelain fused to noble metal |
| D6250 | 1456 | 1165 | 1019 | pontic - resin with high noble metal |
| D6251 | 1422 | 1138 | 995 | pontic - resin with predominantly base metal |
| D6252 | 1398 | 1118 | 979 | pontic - resin with noble metal |
| D6253 | 993 | 794 | 695 | provisional pontic - further treatment or completion of diagnosis necessary prior to final impression |
| D6548 | 1303 | 1042 | 912 | retainer - porcelain/ceramic for resin bonded fixed prosthesis |
| D6600 | 1323 | 1058 | 926 | retainer inlay - porcelain/ceramic, two surfaces |
| D6601 | 1355 | 1084 | 948 | retainer inlay - porcelain/ceramic, three or more surfaces |
| D6602 | 1323 | 1058 | 926 | retainer inlay - cast high noble metal, two surfaces |
| D6603 | 1360 | 1088 | 952 | retainer inlay - cast high noble metal, three or more surfaces |
| D6604 | 1325 | 1060 | 927 | retainer inlay - cast predominantly base metal, two surfaces |
| D6605 | 1328 | 1062 | 930 | retainer inlay - cast predominantly base metal, three or more surfaces |
| D6606 | 1327 | 1062 | 929 | retainer inlay - cast noble metal, two surfaces |
| D6607 | 1366 | 1093 | 956 | retainer inlay - cast noble metal, three or more surfaces |
| D6608 | 1381 | 1105 | 967 | retainer onlay - porcelain/ceramic, two surfaces |
| D6609 | 1467 | 1174 | 1027 | retainer onlay - porcelain/ceramic, three or more surfaces |
| D6610 | 1397 | 1118 | 978 | retainer onlay - cast high noble metal, two surfaces |
| D6611 | 1517 | 1214 | 1062 | retainer onlay - cast high noble metal, three or more surfaces |
| D6612 | 1379 | 1103 | 965 | retainer onlay - cast predominantly base metal, two surfaces |
| D6613 | 1384 | 1107 | 969 | retainer onlay - cast predominantly base metal, three or more surfaces |
| D6614 | 1366 | 1093 | 956 | retainer onlay - cast noble metal, two surfaces |
| D6615 | 1428 | 1142 | 1000 | retainer onlay - cast noble metal, three or more surfaces |
| D6624 | 1400 | 1120 | 980 | retainer inlay - titanium |
| D6634 | 1414 | 1131 | 990 | retainer onlay - titanium |
| D6740 | 1575 | 1260 | 1103 | retainer crown - porcelain/ceramic |
| D6752 | 1436 | 1149 | 1005 | retainer crown - porcelain fused to noble metal |
| D6793 | 748 | 598 | 524 | provisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression |
| D6930 | 229 | 183 | 160 | re-cement or re-bond fixed partial denture |
| D2610 | 1560 | 1248 | 1092 | inlay - porcelain/ceramic - one surface |
| D2620 | 1517 | 1214 | 1062 | inlay - porcelain/ceramic - two surfaces |
| D2630 | 1594 | 1275 | 1116 | inlay - porcelain/ceramic - three or more surfaces |
| D2962 | 1680 | 1344 | 1176 | labial veneer (porcelain laminate) - indirect |
| D9971 | 210 | 168 | 147 | odontoplasty - per tooth |
| D9972 | 462 | 370 | 323 | external bleaching - per arch - performed in office |
| D9975 | 462 | 370 | 323 | external bleaching for home application, per arch; includes materials and fabrication of custom trays |
| N4223 | 53 | 42 | 37 | Whitening refill |
| D6010 | 2783 | 2226 | 1948 | surgical placement of implant body: endosteal implant |
| D6057 | 945 | 756 | 662 | custom fabricated abutment – includes placement |
| D6058 | 1575 | 1260 | 1103 | abutment supported porcelain/ceramic crown |
| D6059 | 1875 | 1500 | 1313 | abutment supported porcelain fused to metal crown (high noble metal) |
| D6060 | 1740 | 1392 | 1218 | abutment supported porcelain fused to metal crown (predominantly base metal) |
| D6061 | 1770 | 1416 | 1239 | abutment supported porcelain fused to metal crown (noble metal) |
| D6062 | 1854 | 1483 | 1298 | abutment supported cast metal crown (high noble metal) |
| D6063 | 1771 | 1417 | 1240 | abutment supported cast metal crown (predominantly base metal) |
| D6064 | 1771 | 1417 | 1240 | abutment supported cast metal crown (noble metal) |
| D6065 | 1983 | 1586 | 1388 | implant supported porcelain/ceramic crown |
| D6066 | 1941 | 1553 | 1359 | implant supported crown - porcelain fused to high noble alloys |
| D6067 | 1993 | 1594 | 1395 | implant supported crown - high noble alloys |
| D6068 | 1876 | 1501 | 1313 | abutment supported retainer for porcelain/ceramic FPD |
| D6069 | 1881 | 1505 | 1317 | abutment supported retainer for porcelain fused to metal FPD (high noble metal) |
| D6070 | 1815 | 1452 | 1271 | abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) |
| D6071 | 1771 | 1417 | 1240 | abutment supported retainer for porcelain fused to metal FPD (noble metal) |
| D6072 | 1889 | 1511 | 1322 | abutment supported retainer for cast metal FPD (high noble metal) |
| D6073 | 1789 | 1431 | 1252 | abutment supported retainer for cast metal FPD (predominantly base metal) |
| D6074 | 1754 | 1403 | 1228 | abutment supported retainer for cast metal FPD (noble metal) |
| D6075 | 1946 | 1557 | 1362 | implant supported retainer for ceramic FPD |
| D6076 | 1969 | 1575 | 1378 | implant supported retainer for FPD - porcelain fused to high noble alloys |
| D6077 | 2037 | 1630 | 1426 | implant supported retainer for metal FPD - high noble alloys |
| D6080 | 403 | 322 | 282 | implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments |
| D6085 | 649 | 519 | 454 | provisional implant crown |
| D6092 | 211 | 169 | 148 | re-cement or re-bond implant/abutment supported crown |
| D6093 | 250 | 200 | 175 | re-cement or re-bond implant/abutment supported fixed partial denture |
| D6100 | 906 | 725 | 634 | implant removal, by report |
| D6104 | 901 | 600 | 500 | bone graft at time of implant placement |
| D6110 | 4356 | 3485 | 3049 | implant /abutment supported removable denture for edentulous arch – maxillary |
| D6111 | 3872 | 3098 | 2710 | implant /abutment supported removable denture for edentulous arch – mandibular |
| D6112 | 3656 | 2925 | 2559 | implant /abutment supported removable denture for partially edentulous arch – maxillary |
| D6113 | 3665 | 2932 | 2566 | implant /abutment supported removable denture for partially edentulous arch – mandibular |
| D6114 | 13385 | 10708 | 9370 | implant /abutment supported fixed denture for edentulous arch – maxillary |
| D6115 | 13188 | 10550 | 9232 | implant /abutment supported fixed denture for edentulous arch – mandibular |
| D6116 | 8248 | 6598 | 5774 | implant /abutment supported fixed denture for partially edentulous arch – maxillary |
| D6117 | 9265 | 7412 | 6486 | implant /abutment supported fixed denture for partially edentulous arch – mandibular |
| D6191 | 630 | 504 | 441 | semi-precision abutment – placement |
| D6192 | 630 | 504 | 441 | semi-precision attachment – placement |
| D6243 | 1499 | 1199 | 1049 | pontic - porcelain fused to titanium and titanium alloys |
| D2510 | 1356 | 1085 | 949 | inlay - metallic - one surface |
| D2520 | 1402 | 1122 | 981 | inlay - metallic - two surfaces |
| D2530 | 1487 | 1190 | 1041 | inlay - metallic - three or more surfaces |
| D2542 | 1415 | 1132 | 990 | onlay - metallic - two surfaces |
| D2543 | 1542 | 1234 | 1079 | onlay - metallic - three surfaces |
| D2544 | 1653 | 1322 | 1157 | onlay - metallic - four or more surfaces |
| D2642 | 1523 | 1218 | 1066 | onlay - porcelain/ceramic - two surfaces |
| D2643 | 1548 | 1238 | 1084 | onlay - porcelain/ceramic - three surfaces |
| D2644 | 1616 | 1293 | 1131 | onlay - porcelain/ceramic - four or more surfaces |
| D2650 | 1200 | 960 | 840 | inlay - resin-based composite - one surface |
| D2651 | 1215 | 972 | 851 | inlay - resin-based composite - two surfaces |
| D2652 | 1258 | 1006 | 881 | inlay - resin-based composite - three or more surfaces |
| D2662 | 1269 | 1015 | 888 | onlay - resin-based composite - two surfaces |
| D2663 | 1311 | 1049 | 918 | onlay - resin-based composite - three surfaces |
| D2664 | 1363 | 1090 | 954 | onlay - resin-based composite - four or more surfaces |
| D2710 | 1575 | 1260 | 1103 | crown - resin-based composite (indirect) |
| D2712 | 1575 | 1260 | 1103 | crown - ¾ resin-based composite (indirect) |
| D2720 | 1890 | 1512 | 1323 | crown - resin with high noble metal |
| D2721 | 1575 | 1260 | 1103 | crown - resin with predominantly base metal |
| D2722 | 1890 | 1512 | 1323 | crown - resin with noble metal |
| D2740 | 1575 | 1260 | 1103 | crown - porcelain/ceramic |
| D2740.c | 149 | 0 | 0 | HITECH crown - CEREC same day |
| D2740.e | 149 | 0 | 0 | HITECH crown - emax (cosmetic) |
| D2740.z | 149 | 0 | 0 | HITECH crown - zirconia (long-lasting) |
| D2750 | 1890 | 1512 | 1323 | crown - porcelain fused to high noble metal |
| D2751 | 1575 | 1260 | 1103 | crown - porcelain fused to predominantly base metal |
| D2752 | 1890 | 1512 | 1323 | crown - porcelain fused to noble metal |
| D2753 | 1575 | 1260 | 1103 | crown - porcelain fused to titanium and titanium alloys |
| D2780 | 1890 | 1512 | 1323 | crown - 3/4 cast high noble metal |
| D2781 | 1575 | 1260 | 1103 | crown - 3/4 cast predominantly base metal |
| D2782 | 1890 | 1512 | 1323 | crown - 3/4 cast noble metal |
| D2783 | 1575 | 1260 | 1103 | crown - 3/4 porcelain/ceramic |
| D2790 | 1890 | 1512 | 1323 | crown - full cast high noble metal |
| D2791 | 1575 | 1260 | 1103 | crown - full cast predominantly base metal |
| D2792 | 1890 | 1512 | 1323 | crown - full cast noble metal |
| D2794 | 1575 | 1260 | 1103 | crown - titanium and titanium alloys |
| D2799 | 594 | 475 | 416 | provisional crown– further treatment or completion of diagnosis necessary prior to final impression |
| D2910 | 210 | 168 | 147 | re-cement or re-bond inlay, onlay, veneer or partial coverage restoration |
| D2915 | 210 | 168 | 147 | re-cement or re-bond indirectly fabricated or prefabricated post and core |
| D2920 | 210 | 168 | 147 | re-cement or re-bond crown |
| D6210 | 1890 | 1512 | 1323 | pontic - cast high noble metal |
| D6240 | 1890 | 1512 | 1323 | pontic - porcelain fused to high noble metal |
| D6241 | 1422 | 1138 | 995 | pontic - porcelain fused to predominantly base metal |
| D6245 | 1575 | 790 | 780 | pontic - porcelain/ceramic |
| D6545 | 1162 | 930 | 813 | retainer - cast metal for resin bonded fixed prosthesis |
| D6549 | 1191 | 953 | 834 | retainer – for resin bonded fixed prosthesis |
| D6710 | 1380 | 1104 | 966 | retainer crown - indirect resin based composite |
| D6720 | 1890 | 1512 | 1323 | retainer crown - resin with high noble metal |
| D6721 | 1393 | 1114 | 975 | retainer crown - resin with predominantly base metal |
| D6722 | 1890 | 1512 | 1323 | retainer crown - resin with noble metal |
| D6750 | 1890 | 1512 | 1323 | retainer crown - porcelain fused to high noble metal |
| D6751 | 1397 | 1118 | 978 | retainer crown - porcelain fused to predominantly base metal |
| D6780 | 1890 | 1512 | 1323 | retainer crown - 3/4 cast high noble metal |
| D6781 | 1397 | 1118 | 978 | retainer crown - 3/4 cast predominantly base metal |
| D6782 | 1890 | 1512 | 1323 | retainer crown - 3/4 cast noble metal |
| D6783 | 1468 | 1174 | 1028 | retainer crown - 3/4 porcelain/ceramic |
| D6784 | 1468 | 1174 | 1028 | retainer crown ¾ - titanium and titanium alloys |
| D6790 | 1890 | 1512 | 1323 | retainer crown - full cast high noble metal |
| D6791 | 1404 | 1123 | 983 | retainer crown - full cast predominantly base metal |
| D6792 | 1890 | 1512 | 1323 | retainer crown - full cast noble metal |
| D6794 | 1411 | 1129 | 988 | retainer crown - titanium and titanium alloys |
| D7111 | 336 | 269 | 235 | extraction, coronal remnants – primary tooth |
| D7140 | 336 | 269 | 235 | extraction, erupted tooth or exposed root (elevation and/or forceps removal) |
| D7210 | 441 | 353 | 309 | extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated |
| D7220 | 504 | 403 | 353 | removal of impacted tooth - soft tissue |
| D7230 | 630 | 504 | 441 | removal of impacted tooth - partially bony |
| D7240 | 735 | 588 | 515 | removal of impacted tooth - completely bony |
| D7250 | 408 | 326 | 286 | removal of residual tooth roots (cutting procedure) |
| D7310 | 473 | 378 | 331 | alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant |
| D7311 | 473 | 378 | 331 | alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant |
| D7510 | 324 | 259 | 227 | incision and drainage of abscess - intraoral soft tissue |
| D7922 | 231 | 185 | 162 | placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site |
| D7953 | 788 | 630 | 550 | bone replacement graft for ridge preservation - per site |
| D8090 | 6325 | 5060 | 4427 | comprehensive orthodontic treatment of the adult dentition |
| M8680.3 | 420 | 336 | 294 | Removable essix retainer (3 sets) |
| M8680.3 | 315 | 252 | 221 | Removable essix retainer (1 set) |
| D8681 | 260 | 208 | 182 | removable orthodontic retainer adjustment |
| D8695 | 945 | 756 | 662 | removal of fixed orthodontic appliances for reasons other than completion of treatment |
| D8698 | 420 | 336 | 294 | re-cement or re-bond fixed retainer – maxillary |
| D8699 | 420 | 336 | 294 | re-cement or re-bond fixed retainer – mandibular |
| D8701 | 420 | 336 | 294 | repair of fixed retainer, includes reattachment – maxillary |
| D8702 | 420 | 336 | 294 | repair of fixed retainer, includes reattachment – mandibular |
| N8040 | 5200 | 4160 | 3640 | Clear Aligners (Standard; includes retainer) |
| N8041 | 6800 | 5440 | 4760 | Clear Aligners (Intermediate; includes retainer) |
| N8042 | 8400 | 6720 | 5880 | Clear Aligners (Complex; includes retainer) |
| N8043 | 4150 | 3320 | 2905 | Clear Aligners (Simple; includes retainer) |
| D9120 | 305 | 244 | 214 | fixed partial denture sectioning |
| D9230 | 105 | 84 | 74 | inhalation of nitrous oxide/analgesia, anxiolysis |
| D9910 | 83 | 0 | 0 | application of desensitizing medicament |
| D9944 | 473 | 378 | 331 | occlusal guard – hard appliance, full arch |
| D9951 | 255 | 204 | 179 | occlusal adjustment - limited |
| D9952 | 883 | 706 | 618 | occlusal adjustment - complete |
| N9901.2024 | 185 | 185 | 185 | Smile Corners Gold 2024 |
| N9902.2024 | 345 | 345 | 345 | Smile Corners Platinum 2024 |
| N9903.2024 | 245 | 245 | 245 | Smile Corners Platinum Jr 2024 |
| N9904.2024 | 645 | 645 | 645 | Smile Corners Platinum Perio 2024 |
ADA Code
D110
D120
D140
D150
D160
Procedure Description
Initial Oral
Oral Examination
Emergency Oral
Comprehensive
intraoral
Office Fee
$40
$45
$41
$46
$55
Gold Member Fee
$35
$42
$40
$40
$50
Platinum Member Fee
$38
$44
$43
$41
$52