Confidential Fee Schedule Form – Fill Out and Use This PDF

D0120

Periodic oral evaluation –

$

established patient

D0140

Limited oral evaluation –

$

problem focused

D0145

Oral evaluation for a patient

$

under three years of age and

counseling with primary

caregiver

D0150

Comprehensive oral evaluation –

$

new or established patient

D0160

Detailed and extensive oral

$

evaluation – problem focused, by

report

D0170

Re–evaluation – limited, problem

$

focused (established patient; not

post-operative visit)

D0171

Re–evaluation – post-operative

$

office visit

D0180

Comprehensive periodontal

$

evaluation – new or established

patient

D0190

Screening of a patient

$

D0191

Assessment of a patient

$

D0210

Intraoral – complete series of

$

radiographic images

D0220

Intraoral – periapical first

$

radiographic image

D0230

Intraoral – periapical each

$

additional radiographic image

D0240

Intraoral – occlusal radiographic

$

image

D0250

Extraoral – first radiographic

$

image

D0260

Extraoral – each additional

$

radiographic image

D0270

Bitewing – single radiographic

$

image

D0272

Bitewings – two radiographic

$

images

D0273

Bitewings – three radiographic

$

images

D0274

Bitewings – four radiographic

$

images

D0277

Vertical bitewings – 7 to 8

$

radiographic images

D0290

Posterior – anterior or lateral

$

skull and facial bone survey

radiographic image

D0310

Sialography

$

D0320

Temporomandibular joint

$

arthrogram, including injection

D0321

Other temporomandibular joint

$

radiographic images, by report

D0322

Tomographic survey

$

D0330

Panoramic radiographic image

$

D0340

Cephalometric radiographic

$

image

D0350

2D oral/facial photographic

$

image obtained intra-orally or

extra-orally

D0351

3D photographic image

$

D0364

Cone beam CT capture and

$

interpretation with limited field of

view – less than one whole jaw

D0365

Cone beam CT capture and

$

interpretation with field of view

of one full dental arch –

mandible

D0366

Cone beam CT capture and

$

interpretation with field of view

of one full dental arch – maxilla,

with or without cranium

D0367

Cone beam CT capture and

$

interpretation with field of view

of both jaws; with or without

cranium

D0368

Cone beam CT capture and

$

interpretation for TMJ series

including two or more exposures

D0369

Maxillofacial MRI capture and

$

interpretation

D0370

Maxillofacial ultrasound capture

$

and interpretation

D0371

Sialoendoscopy capture and

$

interpretation

D0380

Cone beam CT image capture

$

with limited field of view – less

than one whole jaw

D0381

Cone beam CT image capture

$

with field of view of one full

dental arch – mandible

D0382

Cone beam CT image capture

$

with field of view of one full

dental arch – maxilla, with or

without cranium

D0383

Cone beam CT image capture

$

with field of view of both jaws,

with or without cranium

D0384

Cone beam CT image capture for

$

TMJ series including two or more

exposures

D0385

Maxillofacial MRI image capture

$

D0386

Maxillofacial ultrasound image

$

capture

D0391

Interpretation of diagnostic

$

image by a practitioner not

associated with capture of the

image, including report

D0393

Treatment simulation using 3D

$

image volume

D0394

Digital subtraction of two or

$

more images or image volumes

of the same modality

D0395

Fusion of two or more 3D image

$

volumes of one or more

modalities

D0415

Collection of microorganisms for

$

culture and sensitivity

D0416

Viral culture

$

D0417

Collection and preparation of

$

saliva sample for laboratory

diagnostic testing

D0418

Analysis of saliva sample

$

D0421

Genetic test for susceptibility to

$

oral diseases

D0425

Caries susceptibility tests

$

D0431

Adjunctive pre-diagnostic test

$

that aids in detection of mucosal

abnormalities including

premalignant and malignant

lesions, not to include cytology

or biopsy procedures

D0460

Pulp vitality tests

$

D0470

Diagnostic casts

$

D0472

Accession of tissue, gross

$

examination, preparation and

transmission of written report

D0473

Accession of tissue, gross and

$

microscopic examination,

preparation and transmission of

written report

D0474

Accession of tissue, gross and

$

microscopic examination,

including assessment of surgical

margins for presence of disease,

preparation and transmission of

written report

D0475

Decalcification procedure

$

D0476

Special stains for microorganisms

$

D0477

Special stains, not for

$

microorganisms

D0478

Immunohistochemical stains

$

D0479

Tissue in-situ hybridization,

$

including interpretation

D0480

Accession of exfoliative cytologic

$

smears, microscopic

examination, preparation and

transmission of written report

D0481

Electron microscopy

$

D0482

Direct immunofluorescence

$

D0483

Indirect immunofluorescence

$

D0484

Consultation on slides prepared

$

elsewhere

D0485

Consultation, including

$

preparation of slides from biopsy

material supplied by referring

source

D0486

Laboratory accession of

$

transepithelial cytologic sample,

microscopic examination,

preparation and transmission of

written report

D0502

Other oral pathology procedures,

$

by report

D0601

Caries risk assessment and

$

documentation, with a finding of

low risk

D0602

Caries risk assessment and

$

documentation, with a finding of

moderate risk

D0603

Caries risk assessment and

$

documentation, with a finding of

high risk

D0999

Unspecified diagnostic

$

procedure, by report

II. PREVENTIVE

D1110

Prophylaxis – adult

$

D1120

Prophylaxis – child

$

D1206

Topical application of fluoride

$

varnish

D1208

Topical application of fluoride –

$

excluding varnish

D1310

Nutritional counseling for control

$

of dental disease

D1320

Tobacco counseling for the

$

control and prevention of oral

disease

D1330

Oral hygiene instructions

$

D1351

Sealant – per tooth

$

D1352

Preventive resin restoration in a

$

moderate to high caries risk

patient – permanent tooth

D1353

Sealant repair – per tooth

$

D1510

Space maintainer – fixed –

$

unilateral

D1515

Space maintainer – fixed –

$

bilateral

D1520

Space maintainer – removable –

$

unilateral

D1525

Space maintainer – removable –

$

bilateral

D1550

Re–cement or re–bond space

$

maintainer

D1555

Removal of fixed space

$

maintainer

D1999

Unspecified preventive

$

procedure, by report

III. RESTORATIVE

D2140

Amalgam – one surface, primary

$

or permanent

D2150

Amalgam – two surfaces,

$

primary or permanent

D2160

Amalgam – three surfaces,

$

primary or permanent

D2161

Amalgam – four or more

$

surfaces, primary or permanent

D2330

Resin-based composite – one

$

surface, anterior

D2331

Resin-based composite – two

$

surfaces, anterior

D2332

Resin-based composite – three

$

surfaces, anterior

D2335

Resin-based composite – four or

$

more surfaces or involving incisal

angle (anterior)

D2390

Resin-based composite crown,

$

anterior

D2391

Resin-based composite – one

$

surface, posterior

D2392

Resin-based composite – two

$

surfaces, posterior

D2393

Resin-based composite – three

$

surfaces, posterior

D2394

Resin-based composite – four or

$

more surfaces, posterior

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

$

surfaces

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

$

or more surfaces

D2642

Onlay – porcelain/ceramic – two

$

surfaces

D2643

Onlay – porcelain/ceramic –

$

three surfaces

D2644

Onlay – porcelain/ceramic – four

$

or more surfaces

D2650

Inlay – resin-based composite –

$

one surface

D2651

Inlay – resin-based composite –

$

two surfaces

D2652

Inlay – resin-based composite –

$

three or more surfaces

D2662

Onlay – resin-based composite –

$

two surfaces

D2663

Onlay – resin-based composite –

$

three surfaces

D2664

Onlay – resin-based composite –

$

four or more surfaces

D2710

Crown – resin-based composite

$

(indirect)

D2712

Crown – ¾ resin-based

$

composite (indirect)

D2720

Crown – resin with high noble

$

metal

D2721

Crown – resin with

$

predominantly base metal

D2722

Crown – resin with noble metal

$

D2740

Crown – porcelain/ceramic

$

substrate

D2750

Crown – porcelain fused to high

$

noble metal

D2751

Crown – porcelain fused to

$

predominantly base metal

D2752

Crown – porcelain fused to noble

$

metal

D2780

Crown – ¾ cast high noble metal

$

D2781

Crown – ¾ cast predominantly

$

base metal

D2782

Crown – ¾ cast noble metal

$

D2783

Crown – ¾ porcelain/ceramic

$

D2790

Crown – full cast high noble

$

metal

D2791

Crown – full cast predominantly

$

base metal

D2792

Crown – full cast noble metal

$

D2794

Crown – titanium

$

D2799

Provisional crown – further

$

treatment or completion of

diagnosis necessary prior to final

impression

D2910

Re–cement or re–bond inlay,

$

onlay, veneer or partial coverage

restoration

D2915

Re–cement or re–bond indirectly

$

fabricated or prefabricated post

and core

D2920

Re–cement or re–bond crown

$

D2921

Reattachment of tooth fragment,

$

incisal edge or cusp

D2929

Prefabricated porcelain/ceramic

$

crown – primary tooth

D2930

Prefabricated stainless steel

$

crown – primary tooth

D2931

Prefabricated stainless steel

$

crown – permanent tooth

D2932

Prefabricated resin crown

$

D2933

Prefabricated stainless steel

$

crown with resin window

D2934

Prefabricated esthetic coated

$

stainless steel crown – primary

tooth

D2940

Protective restoration

$

D2941

Interim therapeutic restoration –

$

primary dentition

D2949

Restorative foundation for an

$

indirect restoration

D2950

Core buildup, including any pins

$

when required

D2951

Pin retention – per tooth, in

$

addition to restoration

D2952

Post and core in addition to

$

crown, indirectly fabricated

D2953

Each additional indirectly

$

fabricated post – same tooth

D2954

Prefabricated post and core in

$

addition to crown

D2955

Post removal

$

D2957

Each additional prefabricated

$

post – same tooth

D2960

Labial veneer (resin laminate) –

$

chairside

D2961

Labial veneer (resin laminate) –

$

laboratory

D2962

Labial veneer (porcelain

$

laminate) – laboratory

D2970

Temporary crown (fractured

$

tooth)

D2971

Additional procedures to

$

construct new crown under

existing partial denture

framework

D2975

Coping

$

D2980

Crown repair necessitated by

$

restorative material failure

D2981

Inlay repair necessitated by

$

restorative material failure

D2982

Onlay repair necessitated by

$

restorative material failure

D2983

Veneer repair necessitated by

$

restorative material failure

D2990

Resin infiltration of incipient

$

smooth surface lesions

D2999

Unspecified restorative

$

procedure, by report

IV. ENDODONTICS

D3110

Pulp cap – direct (excluding final

$

restoration)

D3120

Pulp cap – indirect (excluding

$

final restoration)

D3220

Therapeutic pulpotomy

$

(excluding final restoration) –

removal of pulp coronal to the

dentinocemental junction and

application of medicament

D3221

Pulpal debridement, primary and

$

permanent teeth

D3222

Partial pulpotomy for

$

apexogenesis – permanent tooth

with incomplete root

development

D3230

Pulpal therapy (resorbable filling)

$

– anterior, primary tooth

(excluding final restoration)

D3240

Pulpal therapy (resorbable filling)

$

– posterior, primary tooth

(excluding final restoration)

D3310

Endodontic therapy, anterior

$

tooth (excluding final

restoration)

D3320

Endodontic therapy, bicuspid

$

tooth (excluding final

restoration)

D3330

Endodontic therapy, molar

$

(excluding final restoration)

D3331

Treatment of root canal

$

obstruction; non-surgical access

D3332

Incomplete endodontic therapy;

$

inoperable, unrestorable or

fractured tooth

D3333

Internal root repair of perforation

$

defects

D3346

Retreatment of previous root

$

canal therapy – anterior

D3347

Retreatment of previous root

$

canal therapy – bicuspid

D3348

Retreatment of previous root

$

canal therapy – molar

D3351

Apexification/recalcification –

$

initial visit (apical closure/calcific

repair of perforations, root

resorption, etc.)

D3352

Apexification/recalcification –

$

interim medication replacement

D3353

Apexification/recalcification –

$

final visit (includes completed

root canal therapy – apical

closure/calcific repair of

perforations, root resorption,

etc.)

D3355

Pulpal regeneration – initial visit

$

D3356

Pulpal regeneration – interim

$

medication replacement

D3357

Pulpal regeneration – completion

$

of treatment

D3410

Apicoectomy – anterior

$

D3421

Apicoectomy – bicuspid (first

$

root)

D3425

Apicoectomy – molar (first root)

$

D3426

Apicoectomy (each additional

$

root)

D3427

Periradicular surgery without

$

apicoectomy

D3428

Bone graft in conjunction with

$

periradicular surgery – per tooth,

single site

D3429

Bone graft in conjunction with

$

periradicular surgery – each

additional contiguous tooth in

the same surgical site

D3430

Retrograde filling – per root

$

D3431

Biologic materials to aid in soft

$

and osseous tissue regeneration

in conjunction with periradicular

surgery

D3432

Guided tissue regeneration,

$

resorbable barrier, per site, in

conjunction with periradicular

surgery

D3450

Root amputation – per root

$

D3460

Endodontic endosseous implant

$

D3470

Intentional re-implantation

$

(including necessary splinting)

D3910

Surgical procedure for isolation

$

of tooth with rubber dam

D3920

Hemisection (including any root

$

removal), not including root

canal therapy

D3950

Canal preparation and fitting of

$

preformed dowel or post

D3999

Unspecified endodontic

$

procedure, by report

V. PERIODONTICS

D4210

Gingivectomy or gingivoplasty -

$

four or more contiguous teeth or

tooth bounded spaces per

quadrant

D4211

Gingivectomy or gingivoplasty –

$

one to three contiguous teeth or

tooth bounded spaces per

quadrant

D4212

Gingivectomy or gingivoplasty to

$

allow access for restorative

procedure, per tooth

D4230

Anatomical crown exposure –

$

four or more contiguous teeth

per quadrant

D4231

Anatomical crown exposure –

$

one to three teeth per quadrant

D4240

Gingival flap procedure, including

$

root planing – four or more

contiguous teeth or tooth

bounded spaces per quadrant

D4241

Gingival flap procedure, including

$

root planing – one to three

contiguous teeth or tooth

bounded spaces per quadrant

D4245

Apically positioned flap

$

D4249

Clinical crown lengthening – hard

$

tissue

D4260

Osseous surgery (including

$

elevation of a full thickness flap

and closure) – four or more

contiguous teeth or tooth

bounded spaces per quadrant

D4261

Osseous surgery (including

$

elevation of a full thickness flap

and closure) – one to three

contiguous teeth or tooth

bounded spaces per quadrant

D4263

Bone replacement graft – first

$

site in quadrant

D4264

Bone replacement graft – each

$

additional site in quadrant

D4265

Biologic materials to aid in soft

$

and osseous tissue regeneration

D4266

Guided tissue regeneration –

$

resorbable barrier, per site

D4267

Guided tissue regeneration –

$

non-resorbable barrier, per site

(includes membrane removal)

D4268

Surgical revision procedure, per

$

tooth

D4270

Pedicle soft tissue graft

$

procedure

D4273

Subepithelial connective tissue

$

graft procedures, per tooth

D4274

Distal or proximal wedge

$

procedure (when not performed

in conjunction with surgical

procedures in the same

anatomical area)

D4275

Soft tissue allograft

$

D4276

Combined connective tissue and

$

double pedicle graft, per tooth

D4277

Free soft tissue graft procedure

$

(including donor site surgery),

first tooth or edentulous tooth

position in graft

D4278

Free soft tissue graft procedure

$

(including donor site surgery),

each additional contiguous tooth

or edentulous tooth position in

same graft site

D4320

Provisional splinting –

$

intracoronal

D4321

Provisional splinting –

$

extracoronal

D4341

Periodontal scaling and root

$

planing – four or more teeth per

quadrant

D4342

Periodontal scaling and root

$

planing – one to three teeth per

quadrant

D4355

Full mouth debridement to

$

enable comprehensive evaluation

and diagnosis

D4381

Localized delivery of

$

antimicrobial agents via a

controlled release vehicle into

diseased crevicular tissue, per

tooth

D4910

Periodontal maintenance

$

D4920

Unscheduled dressing change

$

(by someone other than treating

dentist or their staff)