Children's Dental Services (Up to Age 21)
Procedure Codes and Allowances
Last Updated 5/20/11
CODE DESCRIPTION FEE
Diagnostic
D0120 Periodic oral exam $24.00
D0140 Emergency oral examination (to be used only in conjunction with an $35.00
unusual accident involving dentition or for the relief of pain)
D0145 Oral Evaluation for Patients Under 3 Years $26.00
D0150 Initial or periodic oral examination (two in a 12-month/365-day $35.00
period, or when the patient has been referred from another dentist)
Radiographs
D0210 Intraoral complete with bitewings $74.00
D0220 st $14.00
Intraoral periapical 1 film
D0230 Intraoral periapical each additional film $10.00
D0240 Intraoral occlusal film $15.00
D0270 Bitewing- 1 film $14.00
D0272 Bitewings- 2 films $22.00
D0273 Bitewings- 3 films $26.00
D0274 Bitewings- 4 films $30.00
D0330 Panoramic film $58.00
D0350 Oral/Facial Images $25.00
Preventive
D1110 Prophylaxis (12 years or older) $45.00
D1120 Prophylaxis (Under 12 years old) $32.00
Topical Fluoride Treatment
D1203 Topical application of fluoride $19.00
D1204 Topical application of fluoride $19.00
D1206 Topical fluoride varnish $19.00
Other Preventative Services
D1351 Sealant (per tooth/to age 15) $26.00
Space Maintenance
D1510 Fixed unilateral $147.00
D1515 Fixed bilateral $225.00
D1520 Removable unilateral $113.00
D1525 Removable bilateral $210.00
D1550 Recementing of space maintainer $40.00
Amalgam Restorative
D2140 Amalgam- one surface $62.00
D2150 Amalgam- two surfaces $77.00
D2160 Amalgam- three surfaces $93.00
D2161 Amalgam- four surfaces $111.00
Resin Restorations
D2330 Resin- one surface, anterior $71.00
D2331 Resin- two surfaces, anterior $91.00
D2332 Resin- three surfaces, anterior $112.00
D2335 Resin- four or more surfaces, anterior $133.00
D2390 Resin-based composite crown $165.00
D2391 Resin- one surface, posterior $62.00
D2392 Resin- two surfaces, posterior $77.00
D2393 Resin- three surfaces, posterior $93.00
D2394 Resin- four or more surfaces, posterior $111.00
Prosthethics (Crowns)
D2721 Resin with predominately base metal $389.00
D2751 Porcelain fused to predominately base metal $491.00
D2791 Full cast predominately base metal $491.00
D2920 Recement crown $46.00
D2930 Prefabricated stainless steel crown- primary $133.00
D2931 Prefabricated stainless steel crown- permanent $142.00
D2932 Prefabricated resin crown $139.00
D2933 Prefabricated stainless steel crown with resin window $177.00
D2940 Sedative filling $48.00
D2950 Crown buildup including any pins $111.00
D2951 Pin retention $20.00
D2952 Cast post and core in addition to crown $176.00
D2954 Prefabricated post and core in addition to crown $158.00
D2999 Unspecified By Report Only
Endodontics
D3110 Pulp cap- direct $38.00
D3120 Pulp cap- indirect $35.00
D3220 Pulpotomy (primary teeth only) $70.00
D3221 Pulpal debridement $60.00
D3222 Partial pulpotomy $50.00
D3230 Pulpal therapy anterior $65.00
D3240 Pulpal therapy posterior $70.00
D3310 Root canal therapy (anterior) (requires prior authorization) $337.00
D3320 Root canal therapy (bicuspid) $400.00
D3330 Root canal therapy (molar) $526.00
D3346 Retreatment of root canal (anterior) $337.00
D3347 Retreatment of root canal (bicuspid) $400.00
D3348 Retreatment of root canal (molar) $526.00
D3351 Apexification/recalcification- interim medication replacement- initial $107.00
visit
D3352 Apexification/recalcification- interim medication replacement- next $107.00
visit
D3353 Apexification/recalcification- interim medication replacement- final $153.00
visit
D3410 Apicoectomy (anterior) $278.00
D3425 Apicoectomy (molar) $316.00
D3426 Apicoectomy (each additional root) $113.00
D3430 Retrograde filling $89.00
D3999 Unspecified endodontic By Report Only
Periodontics
D4341 Root Planing and Scaling (4+ teeth) $135.00
D4342 Root Planing and Scaling (0-3 teeth) $81.00
D4910 Periodontal Maintenance $71.00
Prosthodontics
D5110 Complete upper denture $721.00
D5120 Complete lower denture $721.00
D5130 Immediate upper denture $768.00
D5140 Immediate lower denture $768.00
D5211 Upper acrylic partial $700.00
D5212 Lower acrylic partial $700.00
D5213 Upper cast partial $700.00
D5214 Lower cast partial $700.00
D5225 Upper flex partial $700.00
D5226 Lower flex partial $700.00
D5410 Adjust complete upper denture $30.00
D5411 Adjust complete lower denture $30.00
D5421 Adjust upper partial denture $30.00
D5422 Adjust lower partial denture $30.00
D5510 Repair broken complete denture $77.00
D5520 Replace missing or broken teeth complete denture $64.00
D5610 Repair acrylic saddle or base $80.00
D5620 Repair cast framework $125.00
D5630 Repair or replace broken clasp $136.00
D5640 Replace broken teeth, partial (per tooth) $74.00
D5650 Add tooth to existing partial $115.00
D5660 Add clasp to existing partial $112.00
D5710 Rebase complete upper denture $270.00
D5711 Rebase complete lower denture $270.00
D5730 Reline complete upper denture (chairside) $150.00
D5731 Reline complete lower denture (chairside) $150.00
D5740 Reline partial upper denture (chairside) $150.00
D5741 Reline partial lower denture (chairside) $150.00
D5750 Reline complete upper denture (laboratory) $240.00
D5751 Reline complete lower denture (laboratory) $240.00
D5760 Reline partial upper denture (laboratory) $240.00
D5761 Reline partial lower denture (laboratory) $240.00
D5810 Temporary complete upper denture $372.00
D5811 Temporary complete lower denture $372.00
D5820 Temporary upper partial $287.00
D5821 Temporary lower partial $287.00
D5850 Tissue conditioning- maxillary $56.00
D5851 Tissue conditioning- mandibular $56.00
D5860 Overdenture complete (Cusil only) $721.00
D5999 Unspecified prosthesis By Report Only
Oral Surgery
D7111 Coronal remnants- deciduous tooth $52.00
D7140 Extraction single tooth $69.00
D7210 Surgical removal erupted tooth $125.00
D7220 Surgical removal impacted tooth soft tissue $133.00
D7230 Surgical removal impacted tooth partially bony $194.00
D7240 Surgical removal impacted tooth full bony $236.00
D7241 Surgical removal impacted tooth unusual complicated $281.00
D7250 Surgical removal residual tooth roots $129.00
D7270 Tooth reimplantation $186.00
Other surgical procedures
D7280 Surgical Access of Unerupted Tooth $216.00
D7281 Surgical Exposure of Impacted or Unerupted tooth $156.00
D7283 Device to facilitate eruption of impacted tooth $145.00
D7285 Biopsy of oral tissue-hard $170.00
D7286 Biopsy of oral tissue-soft $150.00
Alveoplasty
D7310 In conjunction with extractions (per quadrant) $112.00
D7311 In conjunction with extractions (1 to 3 teeth, per quadrant) $74.00
D7320 Not in conjunction with extractions (per quadrant) $133.00
D7321 Not in conjunction with extractions (1 to 3 teeth, per quadrant) $93.00
Vestibuloplasty
D7340 Uncomplicated (per arch) $144.00
D7350 Complicated (per arch) $280.00
Excision of Bone Tissue
D7471 Removal of exostosis (per site) $206.00
D7472 Removal of torus palatinus $284.00
D7473 Removal of torus mandibularis $276.00
D7485 Surgical reduction of osseous tuberosity $218.00
Surgical Incision
D7510 Incision and drainage of abcess intraoral soft tissue $105.00
D7511 Incision and drainage of abcess intraoral soft tissue – complicated $230.00
D7520 Incision and drainage of abcess extraoral soft tissue $143.00
D7521 Incision and drainage of abcess extraoral soft tissue – complicated $318.00
Treatment of Fractures
D7771 Alveolus, closed reduction stabilization of teeth $705.00
Other Repair Procedures
D7963 Frenuloplasty 246
D7880 Occlusal orthotic device (By Report Only) $321.00
Limited Orthodontics (Requires Special Authorization)
D8010 Limited orthodontic treatment of primary dentition $750.00
D8020 Limited orthodontic treatment of primary dentition $850.00
D8030 Limited orthodontic treatment of primary dentition $1,030.00
D8040 Limited orthodontic treatment of primary dentition $1,070.00
D8050 Interceptive treatment of primary dentition $1,700.00
D8060 Interceptive treatment of transitional dentition $1,700.00
D8070 Comprehensive treatment of transitional dentition $3,150.00
D8080 Comprehensive treatment of transitional dentition $3,600.00
D8090 Comprehensive treatment of adult dentition $3,900.00
D8210 Removable appliance therapy $410.00
D8220 Fixed appliance therapy $550.00
Adjunctive General Services
D9110 Emergency treatment pain $56.00
D9220 General anesthesia (30 minutes) $167.00
D9221 General anesthesia (add 15 minutes) $83.00
D9230 Analgesia $31.00
D9241 I.V. sedation (30 minutes) $130.00
D9242 I.V. sedation (each additional 15 minutes) $75.00
D9410 House call/extended care facility $38.00
D9420 Hospital call $125.00
D9430 Office visit $24.00
Behavior Management DD Patients Only
D9920 $90.00
D9940 Occlusal Guard (By Report Only) $151.00
Excision of Bone Tissue
D7471 Removal of exostosis (per site) $206.00
D7472 Removal of torus palatinus $284.00
D7473 Removal of torus mandibularis $276.00
D7485 Surgical reduction of osseous tuberosity $218.00
Surgical Incision
D7511 Incision and drainage of abscess intraoral soft tissue $230.00
D7521 Incision and drainage of abscess extraoral soft tissue $318.00
Treatment of Fractures
D7771 Alveolus, closed reduction stabilization of teeth $705.00
Other Repair Procedures
D7963 Frenuloplasty $246.00
Limited Orthodontics (Require Special Authorization)
D8050 Interceptive treatment of primary dentition $1,700.00
D8060 Interceptive treatment of transitional dentition $1,700.00
D8070 Comprehensive treatment of transitional dentition $3,150.00
D8080 Comprehensive treatment of transitional dentition $3,600.00
D8090 Comprehensive treatment of adult dentition $3,900.00
Adjunctive General Services
D9110 Emergency treatment of dental pain $56.00
D9220 General Anesthesia (30 mins.) $167.00
D9221 General Anesthesia (each add. 15 mins.) $83.00
D9230 Analgesia $31.00
D9241 I.V. sedation (30 mins.) $130.00
D9242 I.V. sedation (each add. 15 mins.) $75.00
D9410 House call/extended care facility $38.00
D9420 Hospital call $125.00
D9430 Office visit $24.00
D9920 Behavior management (developmentally disabled patients only) $90.00
D9971 Odontoplasty $42.25