| CODE | DESCRIPTION | Members Pay | Members Pay | *Usual & Customary Fees |
| Diagnostic | ||||
| 120 | Periodic oral evaluation | 18 | 20 | 54 |
| 140 | Limited oral evaluation - problem focused | 27 | 30 | 79 |
| 150 | Comprehensive oral evaluation - new or established patient | 39 | 43 | 92 |
| 160 | Detailed and extensive oral evaluation - problem focused, by report | 64 | 71 | 169 |
| 170 | Re-evaluation - limited, problem focused (established patient; not post-operative visit) | 28 | 31 | 77 |
| 210 | Intraoral - complete series (including bitewings) | 71 | 79 | 134 |
| 220 | Intraoral - periapical first film | 17 | 19 | 29 |
| 230 | Intraoral - periapical each additional film | 12 | 13 | 25 |
| 240 | Intraoral - occlusal film | 26 | 29 | 44 |
| 250 | Extraoral - first film | 28 | 31 | 73 |
| 260 | Extraoral - each additional film | 21 | 23 | 58 |
| 270 | Bitewing - single film | 18 | 20 | 29 |
| 272 | Bitewings - two films | 26 | 29 | 47 |
| 274 | Bitewings - four films | 39 | 43 | 68 |
| 277 | Vertical bitewings - 7 to 8 films | 40 | 44 | 98 |
| 290 | Posterior-anterior or lateral skull and facial bone survey film | 59 | 65 | 144 |
| 310 | Sialography | 72 | 80 | 435 |
| 320 | Temporomandibular joint arthrogram, including injection | 242 | 269 | 620 |
| 321 | Other temporomandibular joint films, by report | 59 | 65 | 213 |
| 330 | Panoramic film | 57 | 63 | 112 |
| 340 | Cephalometric film | 61 | 68 | 126 |
| 350 | Oral/facial images (includes intra and extraoral images) | 18 | 20 | 78 |
| 421 | Genetic test for susceptibility to oral diseases | 44 | 59 | 147 |
| 470 | Diagnostic casts | 46 | 51 | 122 |
| Preventative | ||||
| 1110 | Prophylaxis - adult | 56 | 62 | 96 |
| 1120 | Prophylaxis - child | 40 | 44 | 71 |
| 1203 | Topical application of fluoride - child | 21 | 23 | 38 |
| 1204 | Topical application of fluoride - adult | 21 | 23 | 39 |
| 1351 | Sealant - per tooth | 31 | 34 | 56 |
| 1510 | Space maintainer - fixed - unilateral | 144 | 160 | 328 |
| 1515 | Space maintainer - fixed - bilateral | 214 | 238 | 447 |
| 1520 | Space maintainer - removable - unilateral | 178 | 198 | 395 |
| 1525 | Space maintainer - removable - bilateral | 230 | 255 | 510 |
| 1550 | Re-cementation of space maintainer | 31 | 34 | 87 |
| Restorative | ||||
| 2140 | Amalgam - one surface, primary or permanent | 70 | 78 | 146 |
| 2150 | Amalgam - two surfaces, primary or permanent | 84 | 93 | 189 |
| 2160 | Amalgam - three surfaces, primary or permanent | 108 | 120 | 230 |
| 2161 | Amalgam - four or more surfaces, primary or permanent | 144 | 160 | 272 |
| 2330 | Resin-based composite - one surface, anterior | 72 | 80 | 172 |
| 2331 | Resin-based composite - two surfaces, anterior | 87 | 97 | 214 |
| 2332 | Resin-based composite - three surfaces, anterior | 108 | 120 | 258 |
| 2335 | Resin-based composite - four or more surfaces or involving incisal angle (anterior) | 157 | 174 | 325 |
| 2390 | Resin-based composite crown, anterior | 236 | 262 | 488 |
| 2391 | Resin-based composite - one surface, posterior | 88 | 98 | 190 |
| 2392 | Resin-based composite - two surfaces, posterior | 110 | 122 | 243 |
| 2393 | Resin-based composite - three surfaces, posterior | 129 | 143 | 307 |
| 2394 | Resin-based composite - four or more surfaces, posterior | 161 | 179 | 359 |
| 2410 | Gold foil - one surface | 255 | 283 | 689 |
| 2420 | Gold foil - two surfaces | 271 | 301 | 749 |
| 2430 | Gold foil - three surfaces | 340 | 377 | 849 |
| 2510 | Inlay - metallic - one surface | 352 | 391 | 876 |
| 2520 | Inlay - metallic - two surfaces | 364 | 404 | 924 |
| 2530 | Inlay - metallic - three or more surfaces | 289 | 321 | 971 |
| 2542 | Onlay - metallic-two surfaces | 401 | 445 | 996 |
| 2543 | Onlay - metallic-three surfaces | 608 | 675 | 1030 |
| 2544 | Onlay - metallic-four or more surfaces | 608 | 675 | 1070 |
| 2620 | Inlay - porcelain/ceramic - two surfaces | 376 | 417 | 977 |
| 2630 | Inlay - porcelain/ceramic - three or more surfaces | 486 | 539 | 1024 |
| 2642 | Onlay - porcelain/ceramic - two surfaces | 426 | 473 | 1037 |
| 2643 | Onlay - porcelain/ceramic - three surfaces | 561 | 623 | 1070 |
| 2644 | Onlay - porcelain/ceramic - four or more surfaces | 584 | 648 | 1117 |
| 2650 | Inlay - resin-based composite - one surface | 327 | 363 | 900 |
| 2651 | Inlay - resin-based composite - two surfaces | 364 | 404 | 930 |
| 2652 | Inlay - resin-based composite - three or more surfaces | 548 | 608 | 960 |
| 2662 | Onlay - resin-based composite - two surfaces | 401 | 445 | 963 |
| 2663 | Onlay - resin-based composite - three surfaces | 438 | 486 | 973 |
| 2664 | Onlay - - resin-based composite - four or more surfaces | 401 | 445 | 1022 |
| Crowns | ||||
| 2710 | Crown - resin (indirect) | 336 | 373 | 924 |
| 2720 | Crown - resin with high noble metal | 486 | 539 | 1085 |
| 2721 | Crown - resin with predominantly base metal | 458 | 508 | 988 |
| 2722 | Crown - resin with noble metal | 463 | 514 | 1039 |
| 2740 | Crown - porcelain/ceramic substrate | 532 | 591 | 1168 |
| 2750 | Crown - porcelain fused to high noble metal | 698 | 775 | 1124 |
| 2751 | Crown - porcelain fused to predominantly base metal | 533 | 592 | 1022 |
| 2752 | Crown - porcelain fused to noble metal | 689 | 765 | 1067 |
| 2780 | Crown - 3/4 cast high noble metal | 519 | 576 | 1080 |
| 2781 | Crown - 3/4 cast predominantly base metal | 458 | 508 | 1049 |
| 2782 | Crown - 3/4 cast noble metal | 458 | 508 | 1052 |
| 2783 | Crown - 3/4 porcelain/ceramic | 519 | 576 | 1120 |
| 2790 | Crown - full cast high noble metal | 533 | 592 | 1119 |
| 2791 | Crown - full cast predominantly base metal | 476 | 528 | 990 |
| 2792 | Crown - full cast noble metal | 545 | 605 | 1050 |
| 2910 | Recement inlay | 36 | 40 | 108 |
| 2920 | Recement crown | 54 | 60 | 112 |
| 2930 | Prefabricated stainless steel crown - primary tooth | 134 | 149 | 280 |
| 2931 | Prefabricated stainless steel crown - permanent tooth | 142 | 158 | 341 |
| 2932 | Prefabricated resin crown | 142 | 158 | 357 |
| 2933 | Prefabricated stainless steel crown with resin window | 152 | 169 | 376 |
| 2940 | Sedative filling | 42 | 47 | 126 |
| 2950 | Core buildup, including any pins | 121 | 134 | 828 |
| 2951 | Pin retention - per tooth, in addition to restoration | 38 | 42 | 84 |
| 2952 | Cast post and core in addition to crown | 179 | 199 | 434 |
| 2953 | Each additional cast post - same tooth | 95 | 105 | 316 |
| 2954 | Prefabricated post and core in addition to crown | 182 | 202 | 349 |
| 2955 | Post removal (not in conjunction with endodontic therapy) | 178 | 198 | 302 |
| 2957 | Each additional prefabricated post - same tooth | 46 | 51 | 213 |
| 2960 | Labial veneer (resin laminate) - chairside | 219 | 243 | 705 |
| 2961 | Labial veneer (resin laminate) - laboratory | 317 | 352 | 973 |
| 2962 | Labial veneer (porcelain laminate) - laboratory | 608 | 675 | 1168 |
| 2980 | Crown repair, by report | 59 | 65 | 298 |
| Endodontics | ||||
| 3110 | Pulp cap - direct (excluding final restoration) | 38 | 42 | 88 |
| 3120 | Pulp cap - indirect (excluding final restoration) | 38 | 42 | 90 |
| 3220 | Therapeutic pulpotomy (excluding final restoration) | 84 | 93 | 214 |
| 3230 | Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) | 109 | 121 | 302 |
| 3240 | Pulpal therapy (resorbable filling) - posterior, primary tooth (exclud. final restoration) | 117 | 130 | 339 |
| 3310 | Endodontic therapy anterior tooth (excluding final restoration) | 324 | 360 | 751 |
| 3320 | Endodontic therapy bicuspid tooth (excluding final restoration) | 428 | 475 | 858 |
| 3330 | Endodontic therapy molar tooth (excluding final restoration) | 498 | 553 | 1024 |
| 3332 | Incomplete endodontic therapy; inoperable or fractured tooth | 95 | 105 | 482 |
| 3333 | Internal root repair of perforation defects | 108 | 120 | 370 |
| 3346 | Retreatment of previous root canal therapy - anterior | 293 | 325 | 871 |
| 3347 | Retreatment of previous root canal therapy - bicuspid | 336 | 373 | 970 |
| 3348 | Retreatment of previous root canal therapy - molar | 462 | 513 | 1165 |
| 3351 | Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) | 120 | 133 | 370 |
| 3352 | Apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) | 108 | 120 | 271 |
| 3353 | Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) | 140 | 155 | 575 |
| 3410 | Apicoectomy/periradicular surgery - anterior | 259 | 287 | 730 |
| 3421 | Apicoectomy/periradicular surgery - bicuspid (first root) | 279 | 310 | 803 |
| 3425 | Apicoectomy/periradicular surgery - molar (first root) | 305 | 339 | 913 |
| 3426 | Apicoectomy/periradicular surgery (each additional root) | 120 | 133 | 443 |
| 3430 | Retrograde filling - per root | 108 | 120 | 293 |
| 3450 | Root amputation - per root | 182 | 202 | 521 |
| 3920 | Hemisection (including any root removal), not including root canal therapy | 178 | 198 | 498 |
| Periodontics | ||||
| 4210 | Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant | 193 | 214 | 676 |
| 4211 | Gingivectomy or gingivoplasty - one to three teeth or tooth bounded spaces per quadrant | 68 | 75 | 316 |
| 4240 | Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant | 274 | 304 | 790 |
| 4241 | Gingival flap procedure, including root planing - one to three teeth, per quadrant | 253 | 281 | 681 |
| 4245 | Apically positioned flap | 486 | 539 | 876 |
| 4249 | Clinical crown lengthening - hard tissue | 307 | 341 | 801 |
| 4260 | Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant | 576 | 639 | |
| 4261 | Osseous surgery (including flap entry and closure) - one to three teeth, per quadrant | 430 | 477 | 933 |
| 4263 | Bone replacement graft - first site in quadrant | 317 | 352 | 778 |
| 4264 | Bone replacement graft - each additional site in quadrant | 205 | 228 | 588 |
| 4266 | Guided tissue regeneration - resorbable barrier, per site | 364 | 404 | 855 |
| 4267 | Guided tissue regeneration - nonresorbable barrier, per site (inc. membrane removal) | 376 | 417 | 1022 |
| 4270 | Pedicle soft tissue graft procedure | 336 | 373 | 856 |
| 4271 | Free soft tissue graft procedure (including donor site surgery) | 349 | 387 | 914 |
| 4341 | Periodontal scaling and root planing - four or more contiguous teeth or bounded teeth spaces per quadrant | 122 | 135 | 258 |
| 4355 | Full mouth debridement to enable comprehensive evaluation and diagnosis | 109 | 121 | 193 |
| 4910 | Periodontal maintenance | 80 | 89 | 145 |
| Prosthodonics - Removable | ||||
| 5110 | Complete denture - maxillary | 715 | 794 | 1752 |
| 5120 | Complete denture - mandibular | 715 | 794 | 1769 |
| 5130 | Immediate denture - maxillary | 777 | 862 | 1898 |
| 5140 | Immediate denture - mandibular | 777 | 862 | 1899 |
| 5211 | Maxillary partial denture - resin base (incl. any conventional clasps, rests and teeth) | 462 | 513 | 1377 |
| 5212 | Mandibular partial denture - resin base (incl. any conventional clasps, rests and teeth) | 462 | 513 | 1411 |
| 5213 | Axillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | 793 | 880 | 1832 |
| 5214 | Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | 793 | 880 | 1842 |
| 5281 | Removable unilateral partial denture - one piece cast metal (includ. clasps and teeth) | 340 | 377 | 1063 |
| 5410 | Adjust complete denture - maxillary | 50 | 56 | 92 |
| 5411 | Adjust complete denture - mandibular | 42 | 47 | 92 |
| 5421 | Adjust partial denture - maxillary | 49 | 54 | 92 |
| 5422 | Adjust partial denture - mandibular | 51 | 57 | 92 |
| 5510 | Repair broken complete denture base | 83 | 92 | 219 |
| 5520 | Replace missing or broken teeth - complete denture (each tooth) | 72 | 80 | 193 |
| 5610 | Repair resin denture base | 91 | 101 | 213 |
| 5620 | Repair cast framework | 157 | 174 | 306 |
| 5630 | Repair or replace broken clasp | 144 | 160 | 281 |
| 5640 | Replace broken teeth - per tooth | 95 | 105 | 193 |
| 5650 | Add tooth to existing partial denture | 83 | 92 | 238 |
| 5660 | Add clasp to existing partial denture | 144 | 160 | 284 |
| 5710 | Rebase complete maxillary denture | 202 | 224 | 589 |
| 5711 | Rebase complete mandibular denture | 202 | 224 | 289 |
| 5720 | Rebase maxillary partial denture | 202 | 224 | 574 |
| 5721 | Rebase mandibular partial denture | 202 | 224 | 574 |
| 5730 | Reline complete maxillary denture (chairside) | 152 | 169 | 387 |
| 5731 | Reline complete mandibular denture (chairside) | 169 | 188 | 384 |
| 5740 | Reline maxillary partial denture (chairside) | 140 | 155 | 384 |
| 5741 | Reline mandibular partial denture (chairside) | 140 | 155 | 386 |
| 5750 | Reline complete maxillary denture (laboratory) | 231 | 256 | 487 |
| 5751 | Reline complete mandibular denture (laboratory) | 205 | 228 | 487 |
| 5760 | Reline maxillary partial denture (laboratory) | 205 | 228 | 478 |
| 5761 | Reline mandibular partial denture (laboratory) | 205 | 228 | 482 |
| 5820 | Interim partial denture (maxillary) | 242 | 269 | 730 |
| 5821 | Interim partial denture (mandibular) | 242 | 269 | 730 |
| 5850 | Tissue conditioning, maxillary | 38 | 42 | 218 |
| 5851 | Tissue conditioning, mandibular | 38 | 42 | 219 |
| 5860 | Overdenture - complete, by report | 837 | 929 | 2159 |
| 5861 | Overdenture - partial, by report | 837 | 929 | 2092 |
| 5862 | Precision attachment, by report | 307 | 341 | 736 |
| Maxillofacial Prosthetics | ||||
| 5911 | Facial moulage (sectional) | 140 | 155 | NA |
| 5912 | Facial moulage (complete) | 208 | 231 | NA |
| 5915 | Orbital prosthesis | 1070 | 1188 | NA |
| 5916 | Ocular prosthesis | 1070 | 1188 | NA |
| 5923 | Ocular prosthesis, interim | 486 | 539 | NA |
| 5937 | Trismus appliance (not for TMD treatment) | 182 | 202 | 780 |
| 5951 | Feeding aid | 458 | 508 | 869 |
| 5986 | Fluoride gel carrier | 23 | 26 | 243 |
| 5991 | Topical medicament carrier | 124 | 243 | |
| Fixed Prosthetics | ||||
| 6210 | Pontic - cast high noble metal | 401 | 445 | 1124 |
| 6211 | Pontic - cast predominantly base metal | 364 | 404 | 1033 |
| 6212 | Pontic - cast noble metal | 376 | 417 | 1070 |
| 6214 | Pontic - titanium | 372 | 413 | 1070 |
| 6240 | Pontic - porcelain fused to high noble metal | 438 | 486 | 1162 |
| 6241 | Pontic - porcelain fused to predominantly base metal | 364 | 404 | 1041 |
| 6242 | Pontic - porcelain fused to noble metal | 401 | 445 | 1094 |
| 6245 | Pontic - porcelain/ceramic | 438 | 486 | 1163 |
| 6250 | Pontic - resin with high noble metal | 426 | 473 | 1095 |
| 6251 | Pontic - resin with predominantly base metal | 427 | 474 | 1044 |
| 6252 | Pontic - resin with noble metal | 427 | 474 | 1070 |
| 6545 | Retainer - cast metal for resin bonded fixed prosthesis | 279 | 310 | *907 |
| 6548 | Retainer - porcelain/ceramic for resin bonded fixed prosthesis | 291 | 323 | 1011 |
| 6600 | Inlay - porcelain/ceramic, two surfaces | 470 | 522 | 1037 |
| 6601 | Inlay - porcelain/ceramic, three or more surfaces | 514 | 571 | 1071 |
| 6602 | Inlay - cast high noble metal, two surfaces | 492 | 546 | 1048 |
| 6603 | Inlay - cast high noble metal, three or more surfaces | 523 | 581 | 1087 |
| 6604 | Inlay - cast predominantly base metal, two surfaces | 442 | 491 | 1020 |
| 6605 | Inlay - cast predominantly base metal, three or more surfaces | 496 | 551 | 1103 |
| 6606 | Inlay - cast noble metal, two surfaces | 475 | 527 | 995 |
| 6607 | Inlay - cast noble metal, three or more surfaces | 526 | 584 | 1078 |
| 6608 | Onlay -porcelain/ceramic, two surfaces | 495 | 549 | 1070 |
| 6609 | Onlay - porcelain/ceramic, three or more surfaces | 618 | 686 | 1202 |
| 6610 | Onlay - cast high noble metal, two surfaces | 563 | 625 | 1130 |
| 6611 | Onlay - cast high noble metal, three or more surfaces | 617 | 685 | 119-4 |
| 6612 | Onlay - cast predominantly base metal, two surfaces | 478 | 531 | 1054 |
| 6613 | Onlay - cast predominantly base metal, three or more surfaces | 583 | 647 | 1189 |
| 6614 | Onlay - cast noble metal, two surfaces | 514 | 571 | 1090 |
| 6615 | Onlay - cast noble metal, three or more surfaces | 604 | 670 | 1211 |
| 6634 | Onlay - titanium | 549 | 609 | 1136 |
| 6720 | Crown - resin with high noble metal | 511 | 567 | 1070 |
| 6721 | Crown - resin with predominantly base metal | 498 | 553 | 1003 |
| 6722 | Crown - resin with noble metal | 498 | 553 | 1022 |
| 6750 | Crown - porcelain fused to high noble metal | 670 | 744 | 1124 |
| 6751 | Crown - porcelain fused to predominantly base metal | 498 | 553 | 1003 |
| 6752 | Crown - porcelain fused to noble metal | 695 | 771 | 1067 |
| 6780 | Crown - 3/4 cast high noble metal | 462 | 513 | 1070 |
| 6790 | Crown - full cast high noble metal | 536 | 595 | 1093 |
| 6791 | Crown - full cast predominantly base metal | 462 | 513 | 999 |
| 6792 | Crown - full cast noble metal | 523 | 581 | 1058 |
| 6794 | Crown - titanium | 516 | 573 | 1020 |
| 6930 | Recement fixed partial denture | 72 | 80 | 185 |
| 6970 | Cast post and core in addition to fixed partial denture retainer | 182 | 202 | 462 |
| 6972 | Prefabricated post and core in addition to fixed partial denture retainer | 173 | 192 | 348 |
| 6973 | Core build up for retainer, including any pins | 95 | 105 | 286 |
| 6976 | Each additional cast post - same tooth | 120 | 133 | 314 |
| 6977 | Each additional prefabricated post - same tooth | 83 | 92 | 224 |
| 6980 | Fixed partial denture repair, by report | 120 | 133 | 393 |
| Oral Surgery | ||||
| 7111 | Coronal remnants - deciduous tooth | 73 | 81 | 143 |
| 7140 | Extraction, erupted tooth or exposed root (elevation and/or forceps removal) | 59 | 65 | 180 |
| 7210 | Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth | 120 | 133 | 292 |
| 7220 | Removal of impacted tooth - soft tissue | 132 | 147 | 327 |
| 7230 | Removal of impacted tooth - partially bony | 230 | 255 | 409 |
| 7240 | Removal of impacted tooth - completely bony | 279 | 310 | 509 |
| 7241 | Removal of impacted tooth - completely bony, with unusual surgical complications | 340 | 377 | 591 |
| 7250 | Surgical removal of residual tooth roots (cutting procedure) | 83 | 92 | 325 |
| 7260 | Oroantral fistula closure | 327 | 363 | 1315 |
| 7270 | Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth | 182 | 202 | 580 |
| 7272 | Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) | 218 | 242 | 811 |
| 7280 | Surgical access of an unerupted tooth | 205 | 228 | 516 |
| 7285 | Biopsy of oral tissue - hard (bone, tooth) | 144 | 160 | 488 |
| 7286 | Biopsy of oral tissue - soft (all others) | 144 | 160 | 349 |
| 7290 | Surgical repositioning of teeth | 169 | 188 | 564 |
| 7310 | Alveoloplasty in conjunction with extractions four or more teeth or tooth bound spaces per quadrant | 108 | 120 | 316 |
| 7320 | Alveoloplasty not in conjunction with extractions four or more teeth or tooth bound spaces per quadrant | 157 | 174 | 513 |
| 7340 | Vestibuloplasty - ridge extension (secondary epithelialization) | 450 | 500 | 1462 |
| 7350 | Vestibuloplasty - ridge extension (incl. soft tissue grafts, muscle reattachment, revision of soft tissue attachment & manag-t of hypertrophied & hyperplastic tissue) | 561 | 623 | 12861 |
| 7410 | Excision of benign lesion up to 1.25 cm | 132 | 147 | 471 |
| 7440 | Excision of malignant tumor - lesion diameter up to 1.25 cm | 242 | 269 | 806 |
| 7441 | Excision of malignant tumor - lesion diameter greater than 1.25 cm | 340 | 377 | 1523 |
| 7450 | Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm | 157 | 174 | 637 |
| 7451 | Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm | 254 | 282 | 900 |
| 7460 | Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm | 157 | 174 | 634 |
| 7461 | Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 | 242 | 269 | 973 |
| 7471 | Removal of lateral exostosis (maxilla or mandible) | 230 | 255 | 731 |
| 7472 | Removal of torus palatinus | 269 | 299 | 928 |
| 7473 | Removal of torus mandibularis | 269 | 299 | 851 |
| 7485 | Surgical reduction of osseous tuberosity | 246 | 273 | 806 |
| 7490 | Radical resection of mandible with bone graft | 4692 | 5208 | 8115 |
| 7510 | Incision and drainage of abscess - intraoral soft tissue | 91 | 101 | 251 |
| 7511 | Incision and drainage of abscess - intraoral soft tissue - complicated | 115 | 128 | 399 |
| 7520 | Incision and drainage of abscess - extraoral soft tissue | 157 | 174 | 539 |
| 7521 | Incision and drainage of abscess - extraoral soft tissue - complicated | 181 | 201 | 688 |
| 7540 | Removal of reaction producing foreign bodies, musculoskeletal system | 242 | 269 | 755 |
| 7550 | Partial ostectomy/sequestrectomy for removal of non-vital bone | 242 | 269 | 718 |
| 7560 | Maxillary sinusotomy for removal of tooth fragment or foreign body | 486 | 539 | 1685 |
| 7610 | Maxilla - open reduction (teeth immobilized, if present) | 2042 | 2267 | 4733 |
| 7620 | Maxilla - closed reduction (teeth immobilized, if present) | 1197 | 1329 | 3680 |
| 7630 | Mandible - open reduction (teeth immobilized, if present) | 1709 | 1897 | 4757 |
| 7640 | Mandible - closed reduction (teeth immobilized, if present) | 1087 | 1207 | 3648 |
| 7650 | Malar and/or zygomatic arch - open reduction | 1752 | 1945 | 4045 |
| 7660 | Malar and/or zygomatic arch - closed reduction | 1087 | 1207 | 3369 |
| 7670 | Alveolus - closed reduction, may include stabilization of teeth | 518 | 575 | 2230 |
| 7710 | Maxilla - open reduction | 2163 | 2401 | 4887 |
| 7720 | Maxilla - closed reduction | 1318 | 1463 | 3894 |
| 7730 | Mandible - open reduction | 2042 | 2267 | 5241 |
| 7740 | Mandible - closed reduction | 1318 | 1463 | 4082 |
| 7750 | Malar and/or zygomatic arch - open reduction | 1844 | 2047 | 4505 |
| 7760 | Malar and/or zygomatic arch - closed reduction | 1667 | 1850 | 7023 |
| 7810 | Open reduction of dislocation | 1819 | 2019 | 4486 |
| 7820 | Closed reduction of dislocation | 248 | 275 | 701 |
| 7830 | Manipulation under anesthesia | 254 | 282 | 1257 |
| 7840 | Condylectomy | 2768 | 3072 | 5802 |
| 7850 | Surgical discectomy, with/without implant | 2889 | 3207 | 5519 |
| 7852 | Disc repair | 3131 | 3475 | 5793 |
| 7854 | Synovectomy | 3131 | 3475 | 5404 |
| 7858 | Joint reconstruction | 3545 | 3935 | NA |
| 7865 | Arthroplasty | 2443 | 2712 | NA |
| 7870 | Arthrocentesis | 123 | 137 | 590 |
| 7872 | Arthroscopy - diagnosis, with or without biopsy | 968 | NA | |
| 7873 | Arthroscopy - surgical: lavage and lysis of adhesions | 968 | NA | |
| 7874 | Arthroscopy - surgical: disc repositioning and stabilization | 1220 | 1354 | NA |
| 7875 | Arthroscopy - surgical: synovectomy | 1220 | 1354 | NA |
| 7876 | Arthroscopy - surgical: discectomy | 1220 | 1354 | NA |
| 7877 | Arthroscopy - surgical: debridement | 1354 | NA | |
| 7910 | Suture of recent small wounds up to 5 cm | 122 | 135 | 326 |
| 7911 | Complicated suture - up to 5 cm | 159 | 176 | 580 |
| 7941 | Osteotomy - mandibular rami | 4837 | 5369 | 9158 |
| 7943 | Osteotomy - mandibular rami with bone graft; includes obtaining the graft | 4571 | 5074 | 8568 |
| 7944 | Osteotomy - segmented or subapical - per sextant or quadrant | 3627 | 4026 | 7178 |
| 7945 | Osteotomy - body of mandible | 3869 | 4295 | 7099 |
| 7946 | LeFort I (maxilla - total) | 4232 | 4698 | 8411 |
| 7947 | LeFort I (maxilla - segmented) | 4474 | 4966 | 8425 |
| 7948 | LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion)-without bone graft | 4837 | 5369 | 10062 |
| 7949 | LeFort II or LeFort III - with bone graft | 5890 | 6538 | 12066 |
| 7960 | Frenulectomy (frenectomy or frenotomy) - separate procedure | 242 | 269 | 470 |
| 7970 | Excision of hyperplastic tissue - per arch | 254 | 282 | 541 |
| 7971 | Excision of pericoronal gingiva | 95 | 105 | 295 |
| 7980 | Sialolithotomy | 364 | 404 | 988 |
| Orthodontics | 654 | |||
| 7982 | Sialodochoplasty | 726 | 1783 | |
| 7990 | Emergency tracheotomy | 599 | 665 | 1680 |
| 7991 | Coronoidectomy | 1934 | 2147 | 4205 |
| 8010 | Limited orthodontic treatment of the primary dentition | 646 | 717 | 2403 |
| 8020 | Limited orthodontic treatment of the transitional dentition | 835 | 927 | 2506 |
| 8030 | Limited orthodontic treatment of the adolescent dentition | 1050 | 1166 | 3406 |
| 8040 | Limited orthodontic treatment of the adult dentition | 1126 | 1250 | 3770 |
| 8070 | Comprehensive orthodontic treatment of the transitional dentition | 3013 | 3344 | 5373 |
| 8080 | Comprehensive orthodontic treatment of the adolescent dentition | 3013 | 3344 | 5439 |
| 8090 | Comprehensive orthodontic treatment of the adult dentition | 3289 | 3651 | 5734 |
| 8660 | Pre-orthodontic treatment visit | 145 | 161 | 487 |
| 8670 | Periodic orthodontic treatment visit (as part of contract) | 122 | 135 | 307 |
| 8680 | Orthodontic retention (removal of appliances, construction & placement of retainer(s) | 325 | 361 | 658 |
| Miscellaneous Services | ||||
| 9110 | Palliative (emergency) treatment of dental pain - minor procedure | 54 | 60 | 141 |
| 9220 | Deep sedation/general anesthesia - first 30 minutes | 182 | 202 | 447 |
| 9221 | Deep sedation/general anesthesia - each additional 15 minutes | 71 | 79 | 191 |
| 9241 | Intravenous conscious sedation/analgesia - first 30 minutes | 193 | 214 | 423 |
| 9242 | Intravenous conscious sedation/analgesia - each additional 15 minutes | 71 | 79 | 179 |
| 9310 | Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) | 77 | 85 | 146 |
| 9410 | House/extended care facility call | 108 | 120 | 269 |
| 9420 | Hospital call | 108 | 120 | 316 |
| 9430 | Office visit for observation (during regularly sched. hours) no otherservices performed | 28 | 31 | 78 |
| 9440 | Office visit - after regularly scheduled hours | 42 | 47 | 187 |
| 9910 | Application of desensitizing medicament | 40 | 44 | 70 |
| 9911 | Application of desensitizing resin for cervical and/or root surface, per tooth | 46 | 51 | 89 |
| 9920 | behavior management, by report | 59 | 65 | 175 |
| 9940 | Occlusal guard, by report | 218 | 242 | 638 |
| 9951 | Occlusal adjustment - limited | 71 | 79 | 199 |
| 9952 | Occlusal adjustment - complete | 218 | 242 | 708 |
| 9972 | External bleaching - per arch | 201 | 389 | |
| 9973 | External bleaching - per tooth | 187 | 268 | |
| 9974 | Internal bleaching - per tooth | 198 | 310 | |
| It is the member’s responsibility to ensure that the required dental treatment/procedure is listed on the above fee schedule before receiving treatment. Any procedure not listed will be billed at 20% off the dentist regular fee for such procedure and must be established and agreed upon before treatment begins. | ||||
| *Usual & Customary Fees are based on the fees as charged at the 90th percentile level of dentist charges for such procedures in the area and it is based on information published by NDAS (National Dental Advisory Service- 2009-10). | ||||