| D0270 | Bitewing - Single Film | 1 | $15.00 | $12.00 | $9.00 | $6.00 |
| D0274 | Bitewings - Four Films | 1 | $42.00 | $33.00 | $25.00 | $18.00 |
| D0273 | Bitewings - Three Films | 1 | $32.00 | $25.00 | $19.00 | $14.00 |
| D0272 | Bitewings - Two Films | 1 | $27.00 | $21.00 | $16.00 | $11.00 |
| D0150 | Comprehensive Oral Evaluation-New Or Estab Patient | 1 | $46.00 | $36.00 | $27.00 | $19.00 |
| D0180 | Comprehensive Periodontal Evaluation, New Or Estab | 1 | $46.00 | $36.00 | $27.00 | $19.00 |
| D8220 | Fixed Appliance Therapy | 1 | $338.00 | $263.00 | $200.00 | $141.00 |
| D0145 | Oral Evaluation For A Patient Under 3 Years Of Age | 1 | $23.00 | $18.00 | $14.00 | $10.00 |
| D0120 | Periodic Oral Evaluation-Established Patient | 1 | $30.00 | $23.00 | $18.00 | $12.00 |
| D1110 | Prophylaxis - Adult | 1 | $63.00 | $49.00 | $38.00 | $27.00 |
| D1120 | Prophylaxis - Child | 1 | $45.00 | $35.00 | $26.00 | $19.00 |
| D1550 | Re-Cementation Of Space Maintainer | 1 | $46.00 | $36.00 | $27.00 | $19.00 |
| D8210 | Removable Appliance Therapy | 1 | $338.00 | $263.00 | $200.00 | $141.00 |
| D1555 | Removal Of Fixed Space Maintainer | 1 | $63.00 | $49.00 | $38.00 | $27.00 |
| D1351 | Sealant - Per Tooth | 1 | $35.00 | $27.00 | $21.00 | $15.00 |
| D1515 | Space Maintainer - Fixed - Bilateral | 1 | $367.00 | $286.00 | $218.00 | $154.00 |
| D1510 | Space Maintainer - Fixed - Unilateral | 1 | $224.00 | $174.00 | $133.00 | $94.00 |
| D1525 | Space Maintainer - Removable - Bilateral | 1 | $428.00 | $333.00 | $254.00 | $179.00 |
| D1520 | Space Maintainer - Removable - Unilateral | 1 | $351.00 | $273.00 | $208.00 | $147.00 |
| D1204 | Topical Application Of Fluoride - Adult | 1 | $24.00 | $19.00 | $14.00 | $10.00 |
| D1203 | Topical Application Of Fluoride - Child | 1 | $24.00 | $19.00 | $14.00 | $10.00 |
| D1206 | Topical Fluoride Varnish,Application For Caries | 1 | $24.00 | $19.00 | $14.00 | $10.00 |
| D0277 | Vertical Bitewings - 7 To 8 Films | 1 | $63.00 | $49.00 | $38.00 | $27.00 |
| D0473 | Accession Of Tissue, Gross & Microscopic Exam | 2 | $91.00 | $71.00 | $42.00 | $28.00 |
| D0472 | Accession Of Tissue, Gross Examination, Preparatio | 2 | $46.00 | $36.00 | $21.00 | $14.00 |
| D0474 | Accession Of Tissue,Gross & Microscopic Exam, Prep | 2 | $91.00 | $71.00 | $42.00 | $28.00 |
| D7311 | Alveoloplasty In Conj. With Extraction | 2 | $35.00 | $26.00 | $24.00 | $19.00 |
| D7321 | Alveoloplasty Not In Conj. With Extraction | 2 | $44.00 | $33.00 | $30.00 | $24.00 |
| D7310 | Alveoplasty In Conjunct With Ext-4 + Tth, Per Quad | 2 | $69.00 | $51.00 | $47.00 | $38.00 |
| D7320 | Alveoplasty Not In Conjunct W/Extr,4+ Tth Per Quad | 2 | $87.00 | $65.00 | $59.00 | $48.00 |
| D2161 | Amalgam - Four+ Surfaces - Primary Or Permanent | 2 | $121.00 | $94.00 | $55.00 | $37.00 |
| D2140 | Amalgam - One Surface - Primary Or Permanent | 2 | $66.00 | $51.00 | $30.00 | $20.00 |
| D2160 | Amalgam - Three Surfaces - Primary Or Permanent | 2 | $101.00 | $78.00 | $46.00 | $31.00 |
| D2150 | Amalgam - Two Surfaces - Primary Or Permanent | 2 | $84.00 | $65.00 | $38.00 | $26.00 |
| D7285 | Biopsy Of Oral Tissue - Hard (Bone, Tooth) | 2 | $298.00 | $230.00 | $136.00 | $92.00 |
| D7286 | Biopsy Of Oral Tissue - Soft | 2 | $161.00 | $124.00 | $73.00 | $50.00 |
| D7288 | Brush Biopsy - Transepithelial Sample Collection | 2 | $80.00 | $62.00 | $37.00 | $25.00 |
| D7983 | Closure Of Salivary Fistula | 2 | $50.00 | $37.00 | $34.00 | $27.00 |
| D7912 | Complicated Suture - Greater Than 5 Cm | 2 | $40.00 | $30.00 | $27.00 | $22.00 |
| D7911 | Complicated Suture - Up To 5 Cm | 2 | $28.00 | $21.00 | $19.00 | $15.00 |
| D9310 | Consultation - Other Than Req Dentist Or Physician | 2 | $56.00 | $43.00 | $26.00 | $17.00 |
| D9221 | Deep Sedation/General Anesthesia - Each Add 15 Min | 2 | $39.00 | $29.00 | $26.00 | $21.00 |
| D9220 | Deep Sedation/General Anesthesia-First 30 Minutes | 2 | $119.00 | $88.00 | $81.00 | $65.00 |
| D7465 | Destruction Of Lesion(S) By Physical Or Chemical | 2 | $38.00 | $28.00 | $26.00 | $21.00 |
| D7441 | Excision - Malignant Tumor - Greater Than 1.25 Cm | 2 | $124.00 | $92.00 | $84.00 | $68.00 |
| D7440 | Excision - Malignant Tumor - Up To 1.25 Cm | 2 | $169.00 | $126.00 | $115.00 | $93.00 |
| D7411 | Excision Of Benign Lesion Greater Than 1.25 Cm | 2 | $161.00 | $119.00 | $109.00 | $88.00 |
| D7410 | Excision Of Benign Lesion Up To 1.25 Cm | 2 | $125.00 | $93.00 | $85.00 | $69.00 |
| D7412 | Excision Of Benign Lesion, Complicated | 2 | $177.00 | $131.00 | $120.00 | $97.00 |
| D7414 | Excision Of Malignant Lesion Greater Than 1.25 Cm | 2 | $124.00 | $92.00 | $84.00 | $68.00 |
| D7413 | Excision Of Malignant Lesion Up To 1.25 Cm | 2 | $300.00 | $232.00 | $137.00 | $93.00 |
| D7415 | Excision Of Malignant Lesion, Complicated | 2 | $136.00 | $101.00 | $92.00 | $75.00 |
| D7970 | Excision Or Hyperplastic Tissue - Per Arch | 2 | $104.00 | $77.00 | $70.00 | $57.00 |
| D7287 | Exfoliative Cytological Sample Collection | 2 | $80.00 | $62.00 | $37.00 | $25.00 |
| D7111 | Extraction, Coronal Remnants - Deciduous Tooth | 2 | $74.00 | $57.00 | $34.00 | $23.00 |
| D7140 | Extraction, Erupted Tooth Or Exposed Root | 2 | $74.00 | $57.00 | $34.00 | $23.00 |
| D0260 | Extraoral - Each Additional Film | 2 | $20.00 | $15.00 | $9.00 | $6.00 |
| D0250 | Extraoral - First Film | 2 | $25.00 | $20.00 | $12.00 | $8.00 |
| D2940 | Fillings - Sedative | 2 | $48.00 | $37.00 | $22.00 | $15.00 |
| D7960 | Frenulectomy - Separate Procedure (Ectomy/Otomy) | 2 | $135.00 | $100.00 | $91.00 | $74.00 |
| D7963 | Frenuloplasty | 2 | $168.00 | $125.00 | $114.00 | $92.00 |
| D4355 | Full Mouth Debridement For Perio Evaluation | 2 | $81.00 | $63.00 | $37.00 | $25.00 |
| D2410 | Gold Foil - One Surface | 2 | $66.00 | $51.00 | $30.00 | $20.00 |
| D2430 | Gold Foil - Three Surfaces | 2 | $101.00 | $78.00 | $46.00 | $31.00 |
| D2420 | Gold Foil - Two Surfaces | 2 | $84.00 | $65.00 | $38.00 | $26.00 |
| D7520 | Incision And Drainage Of Abscess - Extraoral Soft | 2 | $64.00 | $48.00 | $44.00 | $35.00 |
| D7510 | Incision And Drainage Of Abscess - Intraoral Soft | 2 | $56.00 | $41.00 | $38.00 | $31.00 |
| D0210 | Intraoral - Complete Series (Including Bitewings) | 2 | $78.00 | $60.00 | $36.00 | $24.00 |
| D0240 | Intraoral - Occlusal Film | 2 | $20.00 | $15.00 | $9.00 | $6.00 |
| D0230 | Intraoral - Periapical Each Additional Film | 2 | $11.00 | $9.00 | $5.00 | $3.00 |
| D0220 | Intraoral - Periapical First Film | 2 | $14.00 | $11.00 | $7.00 | $4.00 |
| D9242 | Intravenous Sedation/Analgesia - Each Add 15 Min | 2 | $19.00 | $14.00 | $13.00 | $11.00 |
| D9241 | Intravenous Sedation/Analgesia - First 30 Minutes | 2 | $79.00 | $58.00 | $53.00 | $43.00 |
| D0140 | Limited Oral Evaluation - Problem Focused | 2 | $39.00 | $30.00 | $18.00 | $12.00 |
| D7560 | Maxillary Sinusotomy For Removal Of Tooth Fragment | 2 | $186.00 | $138.00 | $126.00 | $102.00 |
| D7282 | Mobilization Of Erupted Or Malpositioned Tooth-Aid | 2 | $132.00 | $98.00 | $89.00 | $72.00 |
| D9952 | Occlusal Adjustment - Complete | 2 | $265.00 | $205.00 | $121.00 | $82.00 |
| D9951 | Occlusal Adjustment - Limited | 2 | $53.00 | $41.00 | $24.00 | $16.00 |
| D9440 | Office Visit - After Regularly Scheduled Hours | 2 | $68.00 | $53.00 | $31.00 | $21.00 |
| D9430 | Office Visit - During Regular Hours-No Other Serv | 2 | $39.00 | $30.00 | $18.00 | $12.00 |
| D7260 | Oroantral Fistula Closure | 2 | $196.00 | $145.00 | $133.00 | $107.00 |
| D9110 | Palliative (Emergency) Treatment - Minor Procedure | 2 | $55.00 | $43.00 | $25.00 | $17.00 |
| D0330 | Panoramic Film | 2 | $63.00 | $48.00 | $29.00 | $19.00 |
| D7550 | Partial Ostectomy/Sequestrectomy For Removal | 2 | $141.00 | $105.00 | $96.00 | $78.00 |
| D4910 | Periodontal Maintenance | 2 | $84.00 | $65.00 | $38.00 | $26.00 |
| D7283 | Placement Of Device To Facilitate Eruption Of | 2 | $55.00 | $41.00 | $37.00 | $30.00 |
| D7261 | Primary Closure Of A Sinus Perforation | 2 | $196.00 | $145.00 | $133.00 | $107.00 |
| D7490 | Radical Resection Of Maxilla Or Mandible | 2 | $169.00 | $126.00 | $115.00 | $93.00 |
| D0170 | Re-Evaluation - Limited, Problem Focused | 2 | $39.00 | $30.00 | $18.00 | $12.00 |
| D0170 | Re-Evaluation - Limited, Problem Focused | 2 | $39.00 | $30.00 | $18.00 | $12.00 |
| D2915 | Recement Cast Or Prefabricated Post And Core | 2 | $26.00 | $20.00 | $12.00 | $8.00 |
| D2920 | Recement Crown | 2 | $52.00 | $40.00 | $24.00 | $16.00 |
| D6930 | Recement Fixed Partial Denture | 2 | $72.00 | $55.00 | $33.00 | $22.00 |
| D6092 | Recement Implant/Abutment Supported Crown | 2 | $52.00 | $40.00 | $24.00 | $16.00 |
| D6093 | Recement Implant/Abutment Supported Fix Part Dent | 2 | $52.00 | $40.00 | $24.00 | $16.00 |
| D2910 | Recement Inlay, Onlay, Or Partial Coverage Restora | 2 | $53.00 | $41.00 | $24.00 | $16.00 |
| D5731 | Reline Complete Mandibular Denture (Chairside) | 2 | $153.00 | $118.00 | $70.00 | $47.00 |
| D5751 | Reline Complete Mandibular Denture (Laboratory) | 2 | $224.00 | $173.00 | $102.00 | $69.00 |
| D5730 | Reline Complete Maxillary Denture (Chairside) | 2 | $154.00 | $119.00 | $70.00 | $48.00 |
| D5750 | Reline Complete Maxillary Denture (Laboratory) | 2 | $229.00 | $177.00 | $104.00 | $71.00 |
| D5741 | Reline Mandibular Partial Denture (Chairside) | 2 | $139.00 | $107.00 | $63.00 | $43.00 |
| D5761 | Reline Mandibular Partial Denture (Laboratory) | 2 | $230.00 | $178.00 | $105.00 | $71.00 |
| D5740 | Reline Maxillary Partial Denture (Chairside) | 2 | $138.00 | $106.00 | $63.00 | $43.00 |
| D5760 | Reline Maxillary Partial Denture (Laboratory) | 2 | $229.00 | $177.00 | $104.00 | $71.00 |
| D7530 | Removal Of Foreign Body From Mucosa, Skin,Alveolar | 2 | $51.00 | $38.00 | $35.00 | $28.00 |
| D7240 | Removal Of Impacted Tooth - Completely Bony | 2 | $155.00 | $115.00 | $105.00 | $85.00 |
| D7230 | Removal Of Impacted Tooth - Partially Bony | 2 | $133.00 | $98.00 | $90.00 | $73.00 |
| D7241 | Removal Of Impacted Tooth-Completely Bony,W/Compli | 2 | $177.00 | $131.00 | $120.00 | $97.00 |
| D7471 | Removal Of Lateral Exostosis (Maxilla Or Mandible) | 2 | $112.00 | $83.00 | $76.00 | $61.00 |
| D7473 | Removal Of Toris Mandibularis | 2 | $112.00 | $83.00 | $76.00 | $61.00 |
| D7472 | Removal Of Torus Palatinus | 2 | $112.00 | $83.00 | $76.00 | $61.00 |
| D7540 | Remove Reaction Producing Foreign Body - Muscu-Skl | 2 | $141.00 | $105.00 | $96.00 | $78.00 |
| D7460 | Remv Of Benign Nonodontogenic Cyst/Tumor < 1.25 Cm | 2 | $125.00 | $93.00 | $85.00 | $69.00 |
| D7461 | Remv Of Benign Nonodontogenic Cyst/Tumor > 1.25 Cm | 2 | $161.00 | $119.00 | $109.00 | $88.00 |
| D7450 | Remv Of Benign Odontogenic Cyst Or Tumor < 1.25 Cm | 2 | $125.00 | $93.00 | $85.00 | $69.00 |
| D7451 | Remv Of Benign Odontogenic Cyst Or Tumor > 1.25 Cm | 2 | $161.00 | $119.00 | $109.00 | $88.00 |
| D5510 | Repair Broken Complete Denture Base | 2 | $84.00 | $65.00 | $38.00 | $26.00 |
| D5620 | Repair Cast Framework | 2 | $98.00 | $76.00 | $45.00 | $30.00 |
| D5630 | Repair Or Replace Broken Clasp | 2 | $102.00 | $79.00 | $47.00 | $32.00 |
| D5610 | Repair Resin Denture Base | 2 | $83.00 | $64.00 | $38.00 | $26.00 |
| D5640 | Replace Broken Teeth - Per Tooth | 2 | $74.00 | $57.00 | $34.00 | $23.00 |
| D5520 | Replace Missing Or Broken Teeth - Complete Denture | 2 | $69.00 | $54.00 | $32.00 | $21.00 |
| D2335 | Resin-Based Comp- 4+ Surfaces Or Incisal, Anterior | 2 | $140.00 | $108.00 | $64.00 | $43.00 |
| D2330 | Resin-Based Composite - One Surface, Anterior | 2 | $80.00 | $62.00 | $37.00 | $25.00 |
| D2391 | Resin-Based Composite - One Surface, Posterior | 2 | $88.00 | $68.00 | $40.00 | $27.00 |
| D2332 | Resin-Based Composite - Three Surfaces, Anterior | 2 | $127.00 | $98.00 | $58.00 | $39.00 |
| D2393 | Resin-Based Composite - Three Surfaces, Posterior | 2 | $140.00 | $108.00 | $64.00 | $43.00 |
| D2331 | Resin-Based Composite - Two Surfaces, Anterior | 2 | $101.00 | $78.00 | $46.00 | $31.00 |
| D2392 | Resin-Based Composite - Two Surfaces, Posterior | 2 | $111.00 | $86.00 | $51.00 | $34.00 |
| D2390 | Resin-Based Composite Crown,Anterior | 2 | $171.00 | $132.00 | $78.00 | $53.00 |
| D2394 | Resin-Based Composite-Four Or More Surf, Posterior | 2 | $154.00 | $119.00 | $70.00 | $48.00 |
| D7980 | Sialolithotomy | 2 | $155.00 | $115.00 | $105.00 | $85.00 |
| D7280 | Surgical Access Of An Unerupted Tooth | 2 | $184.00 | $136.00 | $124.00 | $101.00 |
| D7972 | Surgical Reduction Of Fibrous Tuberosity | 2 | $165.00 | $122.00 | $112.00 | $90.00 |
| D7485 | Surgical Reduction Of Osseous Tuberosity | 2 | $182.00 | $135.00 | $123.00 | $100.00 |
| D7250 | Surgical Removal Of Residual Tooth Roots(Cut Proc) | 2 | $83.00 | $62.00 | $56.00 | $46.00 |
| D7910 | Suture Of Recent Small Wounds Up To 5 Cm | 2 | $25.00 | $18.00 | $17.00 | $14.00 |
| D7270 | Tooth Reimplantation And/Or Stabilization | 2 | $118.00 | $88.00 | $80.00 | $65.00 |
| D7272 | Tooth Transplantation | 2 | $118.00 | $88.00 | $80.00 | $65.00 |
| D9930 | Treatment Of Complications (Post-Surgical) | 2 | $42.00 | $32.00 | $19.00 | $13.00 |
| D7350 | Vestibuloplasty - Ridge Extension - Complicated | 2 | $314.00 | $233.00 | $213.00 | $172.00 |
| D7340 | Vestibuloplasty - Ridge Extension - Uncomplicated | 2 | $126.00 | $94.00 | $86.00 | $69.00 |
| D7210 | Surgical Removal Of Erupted Tooth Requiring Elevat | 2 | | | | $44.00 |
| D6194 | Abut Retainer Crown For Fpd - (Titanium) | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6060 | Abut Supported Porc Fused To Metal Crn(Base Metal) | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6059 | Abut Supported Porc Fused To Metal Crn(High Noble) | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6061 | Abut Supported Porc Fused To Metal Crn(Noble Metl) | 3 | $341.00 | $253.00 | $231.00 | $0.00 |
| D6063 | Abutment Supported Cast Metal Crown (Base Metal) | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6062 | Abutment Supported Cast Metal Crown (High Noble) | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6064 | Abutment Supported Cast Metal Crown (Noble Metal) | 3 | $403.00 | $299.00 | $273.00 | $0.00 |
| D6094 | Abutment Supported Crown - (Titanium) | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6058 | Abutment Supported Porcelain/Ceramic Crown | 3 | $341.00 | $253.00 | $231.00 | $0.00 |
| D6072 | Abutment Supported Retainer For Cast Metal Fpd | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6073 | Abutment Supported Retainer For Cast Metal Fpd | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6074 | Abutment Supported Retainer For Cast Metal Fpd | 3 | $403.00 | $299.00 | $273.00 | $0.00 |
| D6069 | Abutment Supported Retainer For Porc Fusd To M Fpd | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6070 | Abutment Supported Retainer For Porc Fusd To M Fpd | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6071 | Abutment Supported Retainer For Porc Fusd To M Fpd | 3 | $341.00 | $253.00 | $231.00 | $0.00 |
| D6068 | Abutment Supported Retainer For Porc/Ceramic Fpd | 3 | $341.00 | $253.00 | $231.00 | $0.00 |
| D5660 | Add Clasp To Existing Partial Denture | 3 | $61.00 | $46.00 | $42.00 | $0.00 |
| D5650 | Add Tooth To Existing Partial Denture | 3 | $53.00 | $39.00 | $36.00 | $0.00 |
| D5411 | Adjust Complete Denture - Mandibular | 3 | $22.00 | $16.00 | $15.00 | $0.00 |
| D5410 | Adjust Complete Denture - Maxillary | 3 | $23.00 | $17.00 | $16.00 | $0.00 |
| D5422 | Adjust Partial Denture - Mandibular | 3 | $23.00 | $17.00 | $16.00 | $0.00 |
| D5421 | Adjust Partial Denture - Maxillary | 3 | $24.00 | $18.00 | $16.00 | $0.00 |
| D3353 | Apexification/Recalcification - Final Visit | 3 | $163.00 | $121.00 | $110.00 | $0.00 |
| D3351 | Apexification/Recalcification - Initial Visit | 3 | $82.00 | $61.00 | $56.00 | $0.00 |
| D3352 | Apexification/Recalcification-Interim Medication | 3 | $56.00 | $41.00 | $38.00 | $0.00 |
| D3410 | Apicoectomy/Periradicular Surgery - Anterior | 3 | $236.00 | $175.00 | $160.00 | $0.00 |
| D3421 | Apicoectomy/Periradicular Surgery - Bicuspid | 3 | $272.00 | $202.00 | $184.00 | $0.00 |
| D3425 | Apicoectomy/Periradicular Surgery - Molar | 3 | $295.00 | $219.00 | $200.00 | $0.00 |
| D3426 | Apicoectomy/Periradicular Surgery-Each Addn'L Root | 3 | $105.00 | $78.00 | $71.00 | $0.00 |
| D4265 | Biologic Materials To Aid In Soft & Osseous Regen | 3 | $61.00 | $46.00 | $42.00 | $0.00 |
| D4264 | Bone Replacement Graft-Each Addl Site In Quadrant | 3 | $92.00 | $69.00 | $63.00 | $0.00 |
| D4263 | Bone Replacement Graft-First Site In Quadrant | 3 | $123.00 | $91.00 | $83.00 | $0.00 |
| D4249 | Clinical Crown Lengthening, Hard Tissue | 3 | $226.00 | $168.00 | $153.00 | $0.00 |
| D4276 | Combined Connective Tissue And Dbl Pedicle Graft | 3 | $342.00 | $254.00 | $232.00 | $0.00 |
| D5120 | Complete Denture - Mandibular | 3 | $396.00 | $294.00 | $268.00 | $0.00 |
| D5110 | Complete Denture - Maxillary | 3 | $409.00 | $303.00 | $277.00 | $0.00 |
| D6973 | Core Build Up For Retainer, Including Any Pins | 3 | $79.00 | $59.00 | $54.00 | $0.00 |
| D2950 | Core Build-Up, Including Any Pins | 3 | $79.00 | $59.00 | $54.00 | $0.00 |
| D2780 | Crown - 3/4 Cast High Noble Metal | 3 | $365.00 | $271.00 | $247.00 | $0.00 |
| D6780 | Crown - 3/4 Cast High Noble Metal | 3 | $403.00 | $299.00 | $273.00 | $0.00 |
| D6782 | Crown - 3/4 Cast Noble Metal | 3 | $341.00 | $253.00 | $231.00 | $0.00 |
| D2782 | Crown - 3/4 Cast Noble Metal | 3 | $332.00 | $246.00 | $225.00 | $0.00 |
| D2781 | Crown - 3/4 Cast Predominantly Base Metal | 3 | $317.00 | $236.00 | $215.00 | $0.00 |
| D6781 | Crown - 3/4 Cast Predominantly Base Metal | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6783 | Crown - 3/4 Porcelain/Ceramic | 3 | $341.00 | $253.00 | $231.00 | $0.00 |
| D2783 | Crown - 3/4 Porcelain/Ceramic | 3 | $395.00 | $293.00 | $268.00 | $0.00 |
| D2712 | Crown - 3/4 Resin-Based Composite (Indirect) | 3 | $355.00 | $264.00 | $241.00 | $0.00 |
| D6790 | Crown - Full Cast High Noble Metal | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6792 | Crown - Full Cast Noble Metal | 3 | $341.00 | $253.00 | $231.00 | $0.00 |
| D6791 | Crown - Full Cast Predominantly Base Metal | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D2790 | Crown - Gold - Full Cast | 3 | $365.00 | $271.00 | $247.00 | $0.00 |
| D6710 | Crown - Indirect Resin Based Composite | 3 | $307.00 | $228.00 | $208.00 | $0.00 |
| D2791 | Crown - Nonprecious Metal - Full Cast | 3 | $317.00 | $236.00 | $215.00 | $0.00 |
| D6750 | Crown - Porcelain Fused To High Noble Metal | 3 | $403.00 | $299.00 | $273.00 | $0.00 |
| D6752 | Crown - Porcelain Fused To Noble Metal | 3 | $341.00 | $253.00 | $231.00 | $0.00 |
| D2750 | Crown - Porcelain With Gold | 3 | $384.00 | $285.00 | $260.00 | $0.00 |
| D2751 | Crown - Porcelain With Nonprecious Metal | 3 | $329.00 | $244.00 | $223.00 | $0.00 |
| D2752 | Crown - Porcelain With Semiprecious Metal | 3 | $353.00 | $262.00 | $239.00 | $0.00 |
| D6740 | Crown - Porcelain/Ceramic | 3 | $341.00 | $253.00 | $231.00 | $0.00 |
| D2740 | Crown - Porcelain/Ceramic Substrate | 3 | $395.00 | $293.00 | $268.00 | $0.00 |
| D2720 | Crown - Resin With Gold | 3 | $366.00 | $271.00 | $248.00 | $0.00 |
| D6720 | Crown - Resin With High Noble Metal | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6722 | Crown - Resin With Noble Metal | 3 | $310.00 | $230.00 | $210.00 | $0.00 |
| D2721 | Crown - Resin With Nonprecious Metal | 3 | $279.00 | $207.00 | $189.00 | $0.00 |
| D6721 | Crown - Resin With Predominantly Base Metal | 3 | $193.00 | $143.00 | $131.00 | $0.00 |
| D2722 | Crown - Resin With Semiprecious Metal | 3 | $342.00 | $254.00 | $232.00 | $0.00 |
| D2710 | Crown - Resin-Based Composite (Indirect) | 3 | $143.00 | $106.00 | $97.00 | $0.00 |
| D2792 | Crown - Semiprecious Metal - Full Cast | 3 | $332.00 | $246.00 | $225.00 | $0.00 |
| D2794 | Crown - Titanium | 3 | $365.00 | $271.00 | $247.00 | $0.00 |
| D6794 | Crown - Titanium | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D2980 | Crown Repair, By Report | 3 | $64.00 | $47.00 | $43.00 | $0.00 |
| D6751 | Crown-Porcelain Fused To Predominantly Base Metal | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D4381 | Delivery Of Antimicrobial Agents Into Tissue | 3 | $56.00 | $42.00 | $38.00 | $0.00 |
| D4274 | Distal Or Proximal Wedge Procedure | 3 | $165.00 | $122.00 | $112.00 | $0.00 |
| D3310 | Endodontic Therapy, Anterior Tooth | 3 | $229.00 | $170.00 | $155.00 | $0.00 |
| D3320 | Endodontic Therapy, Bicuspid Tooth | 3 | $270.00 | $201.00 | $183.00 | $0.00 |
| D3330 | Endodontic Therapy, Molar | 3 | $354.00 | $263.00 | $240.00 | $0.00 |
| D9972 | External Bleaching - Per Arch | 3 | $60.00 | $44.00 | $40.00 | $0.00 |
| D9973 | External Bleaching - Per Tooth | 3 | $37.00 | $28.00 | $25.00 | $0.00 |
| D6980 | Fixed Partial Denture Repair, By Report | 3 | $71.00 | $53.00 | $48.00 | $0.00 |
| D9120 | Fixed Partial Denture Sectioning | 3 | $71.00 | $53.00 | $48.00 | $0.00 |
| D4271 | Free Soft Tissue Graft Procedure (Incl Donor Site) | 3 | $293.00 | $218.00 | $199.00 | $0.00 |
| D4241 | Gingival Flap Proc,Incl Root Planing-1 To 3 Teeth | 3 | $103.00 | $76.00 | $70.00 | $0.00 |
| D4240 | Gingival Flap Proc,Incl Root Planing-4 Or More Tth | 3 | $205.00 | $152.00 | $139.00 | $0.00 |
| D4211 | Gingivectomy Or Gingivoplasty - 1 To 3 Teeth | 3 | $75.00 | $56.00 | $51.00 | $0.00 |
| D4210 | Gingivectomy Or Gingivoplasty - 4 Or More Teeth | 3 | $149.00 | $111.00 | $101.00 | $0.00 |
| D3920 | Hemisection-Incl Root Removal Not Root Canal | 3 | $130.00 | $96.00 | $88.00 | $0.00 |
| D5140 | Immediate Denture - Mandibular | 3 | $428.00 | $318.00 | $290.00 | $0.00 |
| D5130 | Immediate Denture - Maxillary | 3 | $443.00 | $328.00 | $300.00 | $0.00 |
| D6067 | Implant Supported Metal Crown | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6066 | Implant Supported Porcelain Fused To Metal Crown | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6065 | Implant Supported Porcelain/Ceramic Crown | 3 | $341.00 | $253.00 | $231.00 | $0.00 |
| D6077 | Implant Supported Retainer For Cast Metal Fpd | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6075 | Implant Supported Retainer For Ceramic Fpd | 3 | $341.00 | $253.00 | $231.00 | $0.00 |
| D6076 | Implant Supported Retainer For Por Fusd To M Fpd | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6078 | Implant/Abutment Supported Fixed Denture For Comp | 3 | $409.00 | $303.00 | $277.00 | $0.00 |
| D6079 | Implant/Abutment Supported Fixed Denture For Parti | 3 | $474.00 | $351.00 | $321.00 | $0.00 |
| D6053 | Implant/Abutment Supported Removable Dtr-Edentulou | 3 | $409.00 | $303.00 | $277.00 | $0.00 |
| D6054 | Implant/Abutment Supported Removable Ptr-Edentulou | 3 | $474.00 | $351.00 | $321.00 | $0.00 |
| D3332 | Incomplete Endo Therapy; Inop, Unrest Or Fract Tth | 3 | $135.00 | $100.00 | $92.00 | $0.00 |
| D6603 | Inlay - Cast High Noble Metal, Three Or More Surf | 3 | $300.00 | $223.00 | $203.00 | $0.00 |
| D6602 | Inlay - Cast High Noble Metal, Two Surfaces | 3 | $273.00 | $202.00 | $185.00 | $0.00 |
| D6607 | Inlay - Cast Noble Metal - Three Or More Surfaces | 3 | $273.00 | $202.00 | $185.00 | $0.00 |
| D6606 | Inlay - Cast Noble Metal - Two Surfaces | 3 | $248.00 | $184.00 | $168.00 | $0.00 |
| D6604 | Inlay - Cast Predominantly Base Metal, 2 Surfaces | 3 | $236.00 | $175.00 | $160.00 | $0.00 |
| D2510 | Inlay - Metallic - One Surface | 3 | $253.00 | $188.00 | $171.00 | $0.00 |
| D2530 | Inlay - Metallic - Three Or More Surfaces | 3 | $324.00 | $241.00 | $220.00 | $0.00 |
| D2520 | Inlay - Metallic - Two Surfaces | 3 | $301.00 | $224.00 | $204.00 | $0.00 |
| D2610 | Inlay - Porcelain/Ceramic One Surface | 3 | $279.00 | $207.00 | $189.00 | $0.00 |
| D2630 | Inlay - Porcelain/Ceramic Three Or More Surfaces | 3 | $332.00 | $247.00 | $225.00 | $0.00 |
| D2620 | Inlay - Porcelain/Ceramic Two Surfaces | 3 | $303.00 | $225.00 | $205.00 | $0.00 |
| D6601 | Inlay - Porcelain/Ceramic, Three Or More Surfaces | 3 | $334.00 | $247.00 | $226.00 | $0.00 |
| D6600 | Inlay - Porcelain/Ceramic, Two Surfaces | 3 | $303.00 | $225.00 | $205.00 | $0.00 |
| D2652 | Inlay - Resin-Based Composite 3 + Surfaces | 3 | $296.00 | $219.00 | $200.00 | $0.00 |
| D2650 | Inlay - Resin-Based Composite One Surface | 3 | $290.00 | $215.00 | $196.00 | $0.00 |
| D2651 | Inlay - Resin-Based Composite Two Surfaces | 3 | $286.00 | $212.00 | $194.00 | $0.00 |
| D6624 | Inlay - Titanium | 3 | $300.00 | $223.00 | $203.00 | $0.00 |
| D6605 | Inlay-Cast Predominantly Base Metal,3 Or More Surf | 3 | $259.00 | $192.00 | $176.00 | $0.00 |
| D5811 | Interim Complete Denture (Mandibular) | 3 | $190.00 | $141.00 | $129.00 | $0.00 |
| D5810 | Interim Complete Denture (Maxillary) | 3 | $180.00 | $134.00 | $122.00 | $0.00 |
| D5821 | Interim Partial Denture (Mandibular) | 3 | $167.00 | $124.00 | $113.00 | $0.00 |
| D5820 | Interim Partial Denture (Maxillary) | 3 | $159.00 | $118.00 | $108.00 | $0.00 |
| D9974 | Internal Bleaching - Per Tooth | 3 | $45.00 | $33.00 | $30.00 | $0.00 |
| D5226 | Mandibular Partial Denture - Flexible Base | 3 | $340.00 | $253.00 | $231.00 | $0.00 |
| D5212 | Mandibular Partial Denture - Resin Base | 3 | $340.00 | $253.00 | $231.00 | $0.00 |
| D5214 | Mandibular Partial Denture-Cast Metal W/Resin Base | 3 | $474.00 | $351.00 | $321.00 | $0.00 |
| D5225 | Maxillary Partial Denture - Flexible Base | 3 | $294.00 | $218.00 | $199.00 | $0.00 |
| D5211 | Maxillary Partial Denture - Resin Base | 3 | $294.00 | $218.00 | $199.00 | $0.00 |
| D5213 | Maxillary Partial Denture-Cast Metal W/Resin Base | 3 | $474.00 | $351.00 | $321.00 | $0.00 |
| D6611 | Onlay - Cast High Noble Metal, Three Or More Surf | 3 | $330.00 | $245.00 | $223.00 | $0.00 |
| D6610 | Onlay - Cast High Noble Metal, Two Surfaces | 3 | $300.00 | $223.00 | $203.00 | $0.00 |
| D6615 | Onlay - Cast Noble Metal - Three Or More Surfaces | 3 | $300.00 | $223.00 | $203.00 | $0.00 |
| D6614 | Onlay - Cast Noble Metal - Two Surfaces | 3 | $273.00 | $202.00 | $185.00 | $0.00 |
| D6612 | Onlay - Cast Predominantly Base Metal,2 Surfaces | 3 | $259.00 | $192.00 | $176.00 | $0.00 |
| D6613 | Onlay - Cast Predominantly Base Metal,3 Or More | 3 | $285.00 | $212.00 | $193.00 | $0.00 |
| D2542 | Onlay - Metallic - Two Surfaces | 3 | $328.00 | $243.00 | $222.00 | $0.00 |
| D2544 | Onlay - Metallic, Four Or More Surfaces | 3 | $381.00 | $282.00 | $258.00 | $0.00 |
| D2543 | Onlay - Metallic, Three Surfaces | 3 | $366.00 | $271.00 | $248.00 | $0.00 |
| D2644 | Onlay - Porcelain/Ceramic, Four Or More Surfaces | 3 | $378.00 | $281.00 | $256.00 | $0.00 |
| D6609 | Onlay - Porcelain/Ceramic, Three Or More Surfaces | 3 | $361.00 | $268.00 | $244.00 | $0.00 |
| D2643 | Onlay - Porcelain/Ceramic, Three Surfaces | 3 | $367.00 | $272.00 | $249.00 | $0.00 |
| D2642 | Onlay - Porcelain/Ceramic, Two Surfaces | 3 | $328.00 | $243.00 | $222.00 | $0.00 |
| D6608 | Onlay - Porcelain/Ceramic, Two Surfaces | 3 | $328.00 | $243.00 | $222.00 | $0.00 |
| D2664 | Onlay - Resin-Based Composite 4 + Surfaces | 3 | $337.00 | $250.00 | $228.00 | $0.00 |
| D2663 | Onlay - Resin-Based Composite Three Surfaces | 3 | $317.00 | $235.00 | $215.00 | $0.00 |
| D2662 | Onlay - Resin-Based Composite Two Surfaces | 3 | $308.00 | $228.00 | $208.00 | $0.00 |
| D6634 | Onlay - Titanium | 3 | $330.00 | $245.00 | $223.00 | $0.00 |
| D4260 | Osseous Surg(Incl Flap Entry & Clos)-4 Or More Tth | 3 | $376.00 | $279.00 | $255.00 | $0.00 |
| D4261 | Osseous Surgery(Incl Flap Entry & Clos)-1 To 3 Tth | 3 | $188.00 | $140.00 | $128.00 | $0.00 |
| D5860 | Overdenture - Complete, By Report | 3 | $409.00 | $303.00 | $277.00 | $0.00 |
| D5861 | Overdenture - Partial, By Report | 3 | $474.00 | $351.00 | $321.00 | $0.00 |
| D4270 | Pedicle Soft Tissue Graft Procedure | 3 | $277.00 | $206.00 | $188.00 | $0.00 |
| D4342 | Periodontal Scaling And Root Planing, 1 To 3 Teeth | 3 | $38.00 | $29.00 | $26.00 | $0.00 |
| D4341 | Periodontal Scaling And Root Planing-4 Or More Tth | 3 | $77.00 | $57.00 | $52.00 | $0.00 |
| D6210 | Pontic - Cast High Noble Metal | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6212 | Pontic - Cast Noble Metal | 3 | $403.00 | $299.00 | $273.00 | $0.00 |
| D6211 | Pontic - Cast Predominantly Base Metal | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6205 | Pontic - Indirect Resin Based Composite | 3 | $307.00 | $228.00 | $208.00 | $0.00 |
| D6240 | Pontic - Porcelain Fused To High Noble Metal | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6242 | Pontic - Porcelain Fused To Noble Metal | 3 | $341.00 | $253.00 | $231.00 | $0.00 |
| D6245 | Pontic - Porcelain/Ceramic | 3 | $341.00 | $253.00 | $231.00 | $0.00 |
| D6250 | Pontic - Resin With High Noble Metal | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6252 | Pontic - Resin With Noble Metal | 3 | $403.00 | $299.00 | $273.00 | $0.00 |
| D6251 | Pontic - Resin With Predominantly Base Metal | 3 | $341.00 | $253.00 | $231.00 | $0.00 |
| D6214 | Pontic - Titanium | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6241 | Pontic-Porcelain Fused To Predominantly Base Metal | 3 | $372.00 | $276.00 | $252.00 | $0.00 |
| D6970 | Post & Core In Addition To Fixed Partial Dent Ret | 3 | $112.00 | $83.00 | $76.00 | $0.00 |
| D2952 | Post And Core In Addition To Crown, Ind Fabricated | 3 | $126.00 | $94.00 | $86.00 | $0.00 |
| D6972 | Prefabricated Post & Core In Add To Fixed Partial | 3 | $112.00 | $83.00 | $76.00 | $0.00 |
| D2954 | Prefabricated Post And Core In Addition To Crown | 3 | $105.00 | $78.00 | $71.00 | $0.00 |
| D3221 | Pulpal Debridement, Primary And Permanent Teeth | 3 | $50.00 | $37.00 | $34.00 | $0.00 |
| D3230 | Pulpal Therapy - Anterior, Primary Tooth | 3 | $67.00 | $50.00 | $45.00 | $0.00 |
| D3240 | Pulpal Therapy - Posterior, Primary Tooth | 3 | $58.00 | $43.00 | $39.00 | $0.00 |
| D5711 | Rebase Complete Mandibular Denture | 3 | $157.00 | $117.00 | $107.00 | $0.00 |
| D5710 | Rebase Complete Maxillary Denture | 3 | $149.00 | $110.00 | $101.00 | $0.00 |
| D5721 | Rebase Mandibular Partial Denture | 3 | $150.00 | $111.00 | $102.00 | $0.00 |
| D5720 | Rebase Maxillary Partial Denture | 3 | $142.00 | $105.00 | $96.00 | $0.00 |
| D5281 | Removable Unilateral Partial Denture-1 Piece Cast | 3 | $254.00 | $188.00 | $172.00 | $0.00 |
| D5671 | Repl All Tth & Acrylic On Cast Metal Framewrk-Mand | 3 | $340.00 | $253.00 | $231.00 | $0.00 |
| D5670 | Replace All Tth & Acrylic On Cast Metal Frmwrk-Max | 3 | $294.00 | $218.00 | $199.00 | $0.00 |
| D6548 | Retainer - Porcelain/Ceramic For Resin Bonded Fixe | 3 | $124.00 | $92.00 | $84.00 | $0.00 |
| D6545 | Retainer-Cast Metal For Resin Bonded Fixed Prosthe | 3 | $124.00 | $92.00 | $84.00 | $0.00 |
| D3346 | Retreatment Of Prev Root Canal Therapy-Anterior | 3 | $286.00 | $212.00 | $194.00 | $0.00 |
| D3347 | Retreatment Of Prev Root Canal Therapy-Bicuspid | 3 | $329.00 | $244.00 | $223.00 | $0.00 |
| D3348 | Retreatment Of Prev Root Canal Therapy-Molar | 3 | $409.00 | $303.00 | $277.00 | $0.00 |
| D3430 | Retrograde Filling-Per Root | 3 | $64.00 | $48.00 | $44.00 | $0.00 |
| D3450 | Root Amputation-Per Root | 3 | $153.00 | $114.00 | $104.00 | $0.00 |
| D4275 | Soft Tissue Allograft | 3 | $293.00 | $218.00 | $199.00 | $0.00 |
| D4273 | Subepithelial Connective Tissue Graft Procedures | 3 | $342.00 | $254.00 | $232.00 | $0.00 |
| D3220 | Therapeutic Pulpotomy(Excluding Final Restoration) | 3 | $50.00 | $37.00 | $34.00 | $0.00 |
| D5851 | Tissue Conditioning, Mandibular | 3 | $45.00 | $33.00 | $30.00 | $0.00 |
| D5850 | Tissue Conditioning, Maxillary | 3 | $42.00 | $31.00 | $28.00 | $0.00 |
| D7220 | Removal Of Impacted Tooth - Soft Tissue | 3 | $100.00 | $74.00 | $68.00 | $55.00 |
| D7210 | Surgical Removal Of Erupted Tooth Requiring Elevat | 3 | $80.00 | $59.00 | $54.00 | |