CDT 4 Code

Description

Members Pay

INITIAL EXAM W/ X-RAYS

25.00

TEETH CLEANING

25.00

D0120

EXAM,PERIODIC

25.00

D0140

EXAM,LIMITED EVALUATION

25.00

D0150

EXAM,COMPREHENSIVE

27.50

D0160

EXAM,EXTENSIVE-BR

27.50

D0180

COMP PERIO EVALUATION

27.50

D0210

XRAY,FULL MOUTH

49.50

D0220

XRAY,FIRST FILM

11.00

D0230

XRAY,ADDITIONAL FILM

3.30

D0230

SPECIALIST-XRAY,ADDITIONAL FILM

3.30

D0240

XRAY,INTRAORAL OCCLUSAL

7.70

D0240

SPECIALIST-INTRAORAL,OCCLUSAL

7.70

D0270

XRAY,BITEWING 1 FILM

5.50

D0272

XRAY,BITEWING 2 FILM

11.00

D0274

XRAY,BITEWING 4 FILM

19.80

D0274

SPECIALIST-XRAY,BITEWING 4 FILM

19.80

D0330

XRAY,PANORAMIC

27.50

D0340

XRAY,CEPHALOMETRIC

55.00

D0350

ORAL FACIAL PHOTOS

84.70

D0415

BACTERIAL STUDIES

122.50

D0460

PULP VITALITY TEST

70.00

D0470

STUDY MODELS

70.00

D1110

PROPHY,ADULT

44.00

D1120

PROPHY,CHILD

33.00

D1201

PROPHY,FLUOURIDE 0-5 YRS

38.50

D1201

PROPHY,FLUORIDE 6-17 YRS

44.00

D1203

FLUORIDE ONLY(CHILD)

42.70

D1204

FLUORIDE ONLY(ADULT)

60.90

D1205

PROPHY,FLUORIDE/ADULT

98.70

D1310

NUTRITION COUNSELING

140.00

D1320

TOBACCO COUNSELING

140.00

D1351

SEALANT/PER TOOTH

24.20

D1510

SPACER/FIXED UNILAT

132.00

D1515

SPACER/FIXED BILATER

220.00

D1520

SPACER/REMOVABLE UNILATERAL

253.00

D1525

SPACER/REMOVEABLE+TEETH

253.00

D1525

SPACER/REMOVEABLE BILATERAL

253.00

D1550

SPACE MAINTAINER/RECEMENT

63.70

D2140

CAVITIES AMALGAM 1 SURFACE

42.90

D2150

CAVITIES AMALGAM 2 SURFACE

52.80

D2160

CAVITIES AMALGAM 3 SURFACE

62.70

D2161

CAVITIES AMALGAM 4+SURFACE

66.00

D2330

COMPOSITE 1 SURFACE ANTERIOR

60.50

D2331

COMPOSITE 2 SURFACE ANTERIOR

93.50

D2332

COMPOSITE 3 SURFACE ANTERIOR

93.50

D2335

COMPOSITE 4+ SURFACE/INCISAL

93.50

D2390

CROWN-RESIN ANTERIOR

165.00

D2391

COMPOSITE 1 SURFACE POSTERIOR

126.00

D2392

COMPOSITE 2 SURFACE POSTERIOR

174.30

D2393

COMPOSITE 3 SURFACE POSTERIOR

230.30

D2394

COMPOSITE 4+SURFACE POSTERIOR

286.30

D2510

INLAY-METAL 1 SURFACE

483.70

D2520

INLAY-METAL 2 SURFACE

548.80

D2530

INLAY-METAL 3+SURFACE

632.10

D2542

ONLAY METAL 2 SURFACE

623.70

D2543

ONLAY-METAL 3 SURFACE

648.90

D2544

ONLAY-METAL 4+SURFACE

674.80

D2610

INLAY-PORCELAIN 1 SURFACE

568.40

D2620

INLAY-PORCELAIN 2 SURFACE

599.90

D2630

INLAY-PORCELAIN 3 SURFACE

639.80

D2642

ONLAY-PORCELAIN 2 SURFACE

621.60

D2643

ONLAY-PORCELAIN 3 SURFACE

669.90

D2644

ONLAY-PORCELAIN 4+SURFACE

710.50

D2650

INLAY-COMPOSITE 1 SURFACE

431.20

D2651

INLAY-COMPOSITE 2 SURFACE

514.50

D2652

INLAY-COMPOSITE 3+SURFACE

540.40

D2662

ONLAY-COMPOSITE 2 SURFACE

508.20

D2663

ONLAY-COMPOSITE 3 SURFACE

597.80

D2664

ONLAY-COMPOSITE 4+SURFACE

640.50

D2710

CROWN-RESIN (INDIRECT)

165.00

D2720

CROWN-RESIN W/ HIGH NOBLE METAL

525.00

D2721

CROWN-RESIN W/ PREDOMINANTLY BASE METAL

390.00

D2722

CROWN-RESIN W/ NOBLE METAL

490.00

D2740

CROWN-PORCELAIN/CERAMIC SUBSTRATE

740.50

D2750

CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL

836.50

D2751

CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

644.00

D2752

CROWN-PORCELAIN FUSED TO NOBLE METAL

690.00

D2780

CROWN-3/4 HIGH NOBLE

751.10

D2781

CROWN-3/4 CAST METAL

412.50

D2782

CROWN-3/4 NOBLE METAL

693.00

D2783

CROWN-3/4 PORCELAIN/CERAMIC

515.60

D2790

CROWN-FULL CAST HIGH NOBLE METAL

765.00

D2791

CROWN-FULL CAST PERDOMINANTLY BASE METAL

695.00

D2792

CROWN-FULL CAST NOBLE METAL

640.00

D2799

BIO TEMP

87.50

D2910

INLAY-RECEMENT

33.00

D2920

CROWN-RECEMENT

50.00

D2930

CROWN-PREFABRICATED STAINLESS STEEL-PRIMARY TOOTH

125.50

D2931

CROWN-PREFABRICATED STAINLESS STEEL-PERMANENT TOOTH

150.00

D2932

CROWN-RESIN PREFABRICATED

175.90

D2933

CROWN-PREFABRICATED STAINLESS STEEL W/RESIN WINDOW

225.00

D2940

SEDATIVE FILLING

40.80

D2950

CORE BUILDUP W/PINS

184.80

D2951

PIN RETENTION PER TOOTH

45.00

D2952

POST/CORE CAST

140.50

D2953

CAST POST EACH ADDITIONAL

101.20

D2954

POST/CORE PREFABRICATED

125.50

D2955

POST REMOVAL

158.90

D2957

PREFAB POST EACH ADDITIONAL

96.60

D2960

LABIEAL VENEER (RESIN LAMINATE)-CHAIRSIDE

439.60

D2961

LABIEAL VENEER (RESIN LAMINATE)-LABORATORY

620.30

D2962

LABIEAL VENEER (PORCELAIN LAMINATE)-LABORATORY

620.30

D2970

TEMPORARY CROWN

147.00

D2980

CROWN-REPAIR BY REPORT

90.00

D2999

PROVISIONAL FILLING

58.10

D3110

PULP CAP/DIRECT

56.70

D3120

PULP CAP/INDIRECT

67.20

D3220

PULPOTOMY/THERAPEUTC

85.10

D3221

PULPAL DEBRIDEMENT/PRIMARY & PERMANENT TEETH

122.50

D3310

ROOT CANAL/ANTERIOR

300.50

D3310

SPECIALIST-ROOT CANAL/ANTERIOR

430.50

D3320

ROOT CANAL/BICUSPID

400.00

D3320

SPECIALIST-ROOT CANAL/BICUSPID

530.00

D3330

ROOT CANAL/MOLAR

500.00

D3330

SPECIALIST-ROOT CANAL/MOLAR

663.00

D3332

INCOMPLETE ENDODONTIC TREATMENT

307.30

D3346

RETREAT/RCT-ANTERIOR

643.30

D3347

RETREAT/RCT-BICUSPID

745.50

D3348

RETREAT/RCT-MOLAR

913.50

D3351

APEXIFICATON/ RECALCIFICATION-INITIAL VISIT

110.00

D3352

APEXIFICATON/ RECALCIFICATION-INTERMIN MEDICATION REPLACEMENT

110.00

D3353

APEXIFICATON/ RECALCIFICATION-FINAL VISIT

110.00

D3410

APICO/ ANTERIOR

200.00

D3421

APICO/ BICUSPID-1 ROOT

200.00

D3425

APICO/ MOLAR-1 ROOT

330.00

D3426

APICO/ EACH ADDITIONAL ROOT

200.00

D3430

RETRO FILL/PER ROOT

200.00

D3450

ROOT AMPUTATION/PER ROOT

462.00

D3920

HEMISECTION

309.40

D4210

GINGIVECTOMY OR GINGIVOPLASTY 4+TEETH

330.60

D4211

GINGIVECTOMY OR GINGIVOPLASTY 1-3 TEETH

200.00

D4220

GINGIVAL CURETTAGE/QUAD

182.60

D4240

GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING 4+TEETH

652.40

D4241

GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING 1-3 TEETH

392.00

D4245

APICALLY POSITION FLAP

350.50

D4249

CROWN-LENGTHENING

550.90

D4260

OSSEOUS SURGERY (INCLUDING FLAP ENTRY & CLOSURE) 4+TEETH  

430.00

D4261

OSSEOUS SURGERY (INCLUDING FLAP ENTRY & CLOSURE) 1-3 TEETH

231.00

D4263

BONE GRAFT-FIRST SITE

606.20

D4264

BONE GRAFT-ADDITIONAL SITE

466.20

D4266

GUIDED TISSUE REGENERATION

635.60

D4270

PEDICLE TISSUE GRAFT PROCEDURE

600.60

D4271

FREE SOFT TISSUE GRAFT PROC. (INCLUDING DONER SITE SURGERY)

635.60

D4273

SUBEPITHELIAL CONNECTIVE TISSUE GRAFT PROCEDURE

635.60

D4274

DISTAL OR PROXIMAL WEDGE PROCEDURE

233.10

D4275

ALLOGRAFT/SOFT TISSUE

705.60

D4276

PEDICAL GRAFT W/TISSUE

847.00

D4320

PROVSIONAL SPLINT-INTRACORONAL

409.50

D4321

PROVSIONAL SPLINT-EXTRACORONAL

409.50

D4341

PERIO SCALE & ROOT PLANING 4+TEETH

110.60

D4342

PERIO SCALE & ROOT PLANING 1-3 TEETH

55.00

D4355

SCALE/DEBRIDEMENT-FULL MOUTH

168.00

D4910

PROPHY,PERIO MAINTENANCE

133.00

D5110

COMPLETE DENTURE-MAXILLARY

595.00

D5120

COMPLETE DENTURE-MANDIBULAR

595.00

D5130

IMMEDIATE DENTURE-MAXILLARY (COMPLETE, INSERTED SAME DAY)

695.00

D5140

IMMEDIATE DENTURE-MANDIBULAR (COMPLETE, INSERTED SAME DAY)

695.00

D5211

MAXILLARY PARTIAL DENTURE-RESIN BASED 

340.60

D5212

MANDIBULAR PARTIAL DENTURE-RESIN BASED

340.60

D5213

MAXILLARY PARTIAL DENTURE-CAST METAL FRAMEWORK W/RESIN BASES

500.00

D5214

MANDIBULAR PARTIAL DENTURE-CAST METAL FRAMEWORK W/RESIN BASES

500.00

D5281

PARTIAL/UNILATERAL-REMOVEABLE

307.30

D5410

ADJUST COMPLETE DENTURE-MAXILLARY

70.50

D5411

ADJUST COMPLETE DENTURE-MANDIBULAR

70.50

D5421

ADJUST PARTIAL DENTURE-MAXILLARY

70.50

D5422

ADJUST PARTIAL DENTURE-MANDIBULAR

70.50

D5510

REPAIR BASE/ FULL DENTURE

80.50

D5520

REPLACE 1 TOOTH/FULL DENTURE

100.00

D5610

REPAIR RESIN DENTURE BASE

100.00

D5620

REPAIR CAST FRAMEWORK

100.00

D5630

REPAIR OR REPLACE BROKEN CLASP

100.00

D5640

REPLACE BROKEN TOOTH

100.00

D5650

ADD TOOTH TO EXISTING PARTIAL DENTURE

100.00

D5660

ADD CLASP TO EXISTING PARTIAL DENTURE

100.00

D5670

REPLACE ALL TEETH & ACRYLIC ON CAST METAL FRAMEWORK-MAXILLARY

100.00

D5671

REPLACE ALL TEETH & ACRYLIC ON CAST METAL FRAMEWORK-MANDIBULAR

100.00

D5710

REBASE COMPLETE DENTURE-MAXILLARY

165.00

D5711

REBASE COMPLETE DENTURE-MANDIBULAR

165.00

D5720

REBASE PARTIAL DENTURE-MAXILLARY

165.00

D5721

REBASE PARTIAL DENTURE-MANDIBULAR

165.00

D5730

RELINE COMPLETE MAXILLARY DENTURE-CHAIRSIDE

120.00

D5731

RELINE COMPLETE MANDIBULAR DENTURE-CHAIRSIDE

120.00

D5740

RELINE COMPLETE MAXILLARY PARTIAL DENTURE-CHAIRSIDE

120.00

D5741

RELINE COMPLETE MANDIBULAR PARTIAL DENTURE-CHAIRSIDE

120.00

D5750

RELINE COMPLETE MAXILLARY DENTURE-LABORATORY

154.00

D5751

RELINE COMPLETE MANDIBULAR DENTURE-LABORATORY

154.00

D5760

RELINE MAXILLARY PARTIAL DENTURE-LABORATORY

154.00

D5761

RELINE MANDIBULAR PARTIAL DENTURE-LABORATORY

154.00

D5820

INTERIM PARTIAL DENTURE-MAXILLARY

215.00

D5821

INTERIM PARTIAL DENTURE-MANDIBULAR

215.00

D5850

TISSUE CONDITION-MAXILLARY

65.00

D5851

TISSUE CONDITION-MANDIBULAR

65.00

D6210

PONTIC/ABUTMNT-CAST HIGH NOBLE METAL

769.30

D6211

PONTIC/ABUTMNT-CAST PREDOMINANTLY BASE METAL

360.50

D6212

PONTIC/ABUTMNT-CAST NOBLE METAL

510.00

D6240

PONTIC/ABUTMNT-PORCELAIN FUSED TO HIGH NOBLE METAL

836.50

D6241

PONTIC/ABUTMNT-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL 

400.50

D6242

PONTIC/ABUTMNT-PORCELAIN FUSED TO NOBLE METAL 

600.00

D6245

PONTIC/ABUTMNT-PORCELAIN/CERAMIC  

976.50

D6250

PONTIC/ABUTMNT-RESIN W/ HIGH NOBLE METAL

710.50

D6251

PONTIC/ABUTMNT-RESIN W/ PREDOMINANTLY BASE METAL

475.00

D6252

PONTIC/ABUTMNT-RESN W/ NOBLE METAL

680.40

D6253

PROVISIONAL PONTIC

66.00

D6545

RETAINER- CAST METAL FOR RESIN BONDED FIXED PROSTHESIS

313.60

D6600

INLAY- PORCELAIN/CERAMIC - 2 SURFACES

599.90

D6601

INLAY- PORCELAIN/CERAMIC - 3+ SURFACES

639.80

D6608

ONLAY- PORCELAIN/CERAMIC - 2 SURFACES

621.60

D6609

ONLAY- PORCELAIN/CERAMIC - 3+ SURFACES

669.90

D6721

CROWN-RESIN W/ PREDOMINANTLY BASE METAL

330.00

D6740

CROWN-PORCELAIN/ CERAMIC 

790.40

D6750

CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL

836.50

D6751

CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

425.50

D6752

CROWN-PORCELAIN FUSED TO NOBLE METAL

742.00

D6781

CROWN - 3/4 CAST PREDOMINTLY BASE METAL

704.90

D6783

CROWN - 3/4 PORCELAIN/CERAMIC

712.60

D6790

CROWN-FULL CAST HIGH NOBLE METAL

769.30

D6791

CROWN-FULL CAST PREDOMINANTLY BASE METAL

693.00

D6792

CROWN-FULL CAST NOBLE METAL

515.00

D6793

PROVISIONAL RETAINER CROWN

105.60

D6930

RECEMENT FIXED PARTIAL DENTURE

100.00

D6940

STRESS BREAKER

194.60

D6950

PREC.ATTACHMNT-FIXED

380.10

D6985

PEDO PARTIAL FIXED

317.80

D7111

CORONAL REMNANTS - DECIDUOUS TOOTH EXTRACTION

68.50

D7140

EXTRACT ERUPTED TOOTH OR EXPOSED ROOT

90.50

D7210

EXTRACT/SURGICAL

93.50

D7210

SPECIALIST-EXTRACT/SURGICAL

93.50

D7220

EXTRACT/SOFT TISSUE

110.00

D7220

SPECIALIST-EXTRACT/SOFT TISSUE

110.00

D7230

EXTRACT/PARTIAL BONY

148.50

D7230

SPECIALIST-EXTRACT/PART BONY

148.50

D7240

SPECIALIST-EXTRACT/COMP BONY

181.50

D7240

EXTRACT COMP BONY

181.50

D7241

SPECIALIST-EXT/BONY COMPLEX

181.50

D7250

EXTRACT/RESIDUL ROOT

110.00

D7250

SP-EXTRACT RES ROOT

110.00

D7260

CLOSURE/ORAL FISTULA

330.00

D7261

CLOSURE SINUS PERF

518.70

D7270

TTH REIMPLNT/STABILZ

192.50

D7272

TRANSPLANT/TOOTH BUD

518.70

D7280

SURG.EXPOSE+ATT/ORTO

148.50

D7281

SURG.EXPOS AID ERUPT

110.00

D7285

BIOPSY/HARD TISSUE

110.00

D7286

SP-BIOPSY ORAL(SOFT)

110.00

D7287

CYTOLOGY SAMPLE COLL

140.00

D7291

FIBEROTOMY

518.70

D7310

ALVEO/W.EXTRACT/QUAD

55.00

D7320

ALVEO/EDENTULOS/QUAD

110.00

D7340

VESTIBULOPLST/2NDARY  1

838.60

D7350

VESTIBULOPLST+GRAFTS  1

838.60

D7410

EXC LESION TO 1.25CM

110.00

D7411

EXC LESION OVER 1.25  1

275.00

D7412

EXC LESION-COMPLICAT  1

1,260.00

D7440

EXC.MALIGNT TO 1.25   1

357.50

D7441

EXC.MALIGNT OVER 1.25  2

357.50

D7450

REM CYST UP TO 1.25

110.00

D7451

REM CYST OVER 1.25    1

220.00

D7471

REMOVE TORI/MANDIBLE  1

739.20

D7471

REMOVE TORI/MAXILLA   1

739.20

D7472

REM TORUS PALATINUS   1

261.25

D7473

REM TORUS MANDIBLE    1

104.50

D7485

TUBEROSITY REDUCTION

669.20

D7490

RADICAL RESECT+GRAFT  1

856.80

D7510

INCISION/INTRAORAL

55.00

D7520

INCISION/EXTRAORAL

82.50

D7530

REM FOREIGN BODY

350.70

D7530

FOREIGN BODY(SOFT.T)

315.00

D7540

FOREIGN BODY(BONE)

350.70

D7550

SEQUESTRECTOMY

217.70

D7560

MAXILLARY SINUSOTOMY

256.20

D7840

CONDYLECTOMY OF TMJ   4

3,447.50

D7850

DISCECTOMY/MENISECT.  4

3,447.50

D7880

OCCL.ORTHOTIC DEVICE  1

945.00

D7910

SUTURE/WOUND 0-5 MM

270.20

D7960

FRENECTOMY

110.00

D7970

EXC.HYPERPLSTIC/UPPR

110.00

D7970

EXC.HYPERPLSTIC/LOWR

110.00

D7971

EXC.PERICORONAL GING

55.00

D7980

SIALOLITHOTOMY

595.00

D7981

EXC.SALIVARY GLAND    2

1,537.90

D7982

DIALATION/SALIV.DUCT

154.00

D7983

CLOSURE/SALIV.FISTLA  1

1,183.70

D7997

APPLIANCE REMOVAL

88.00

D8030

FULL TRX 1 ARCH       1

1,064.80

D8050

PHASE 1 TRX 1 ARCH    1

852.00

D8060

PHASE 1 TRX 2 ARCH    2

1,916.80

D8080

FULL TRX 2 ARCH       2

1,916.80

D8220

FIX.INHIBIT'G(THUMB)

319.20

D8660

EXAM,ORTHO RECALL

10.40

D8670

MONTHLY ORTHO POST

106.40

D8670

MONTHLY ADJUSTMENT

106.40

D8670

MONTHLY ADJ/CASE FEE

106.40

D8680

ORTHO RETAINER

372.80

D8690

TREATMENT EXTENSION

106.40

D8691

REPAIR APPLIANCE

48.80

D8692

REPL. LOST RETAINER

160.00

D8750

APPL/RET ACCESSORIES

15.20

D8999

RECORDS DUPLICATION

42.40

D8999

GOLD BRACKET /ARCH

532.80

D8999

NEW PATIENT DEBAND

212.80

D9110

EMERGENCY PALLIATIVE

49.50

D9110

EMERGENCY TX PERIO

60.50

D9220

GENERAL ANESTH/30MIN

110.00

D9230

ANALGESIA/ADMIN N2O

27.50

D9241

IV SED-1ST 30 MIN

280.00

D9242

IV SED ADDL 15 MIN

117.60

D9248

SEDATION/ORAL/PATCH

105.00

D9310

CONSULT/ORAL SURGEON

50.00

D9310

CONSULT/PEDO

50.00

D9310

CONSULT/ENDODONTIST

50.00

D9450

CASE PRES/DETAILED

66.50

D9630

PERIO IRRIGATION(QD)

38.50

D9910

DESENSITIZE

38.50

D9920

PAPOOSE BOARD 15 MIN

70.00

D9930

POST-OP(COMPLICATED)

16.50

D9940

OCCLUSAL GUARD

77.05

D9951

OCCLUSAL ADJ/LIMITED

27.50

D9952

OCCLUSAL ADJ/COMPLET

547.40

D9973

EXT BLEACH PER TOOTH

154.00

D9974

BLEACH/DISCOLOR TOOT

230.30

D9980

STERILIZATION FEE

8.40

D9999

XRAYS,DUPLICATION

37.10

D9999

BROKEN APPT W/FEE

23.10

D9999

SPEC CANC NO/NOTICE

105.00