Fund Payment

D0110

ORAL EXAMINATION

35

Every 12 months

D0120

PERIODIC EXAMINATION

25

Exams covered every 6 months

D0130

EMERGENCY EXAMINATION

12

Exams covered every 6 months

D0140

LIMITED ORAL EVALUATION

17

Every 6 months

D0150

COMPREHENSIVE ORAL EXAMINATION

40

Every 12 months

D0210

FULL MOUTH X-RAY

55

Every 12 months

D0220

FIRST PERIAPICAL FILM

9

Every 6 months

D0230

EACH ADD'L PERIAPICAL

7

Every 6 months

D0240

EACH INTRAORAL FILM

9

Every 6 months

D0250

FIRST EXTRAORAL FILM

20

Every 6 months

D0260

EACH ADD'L EXTRAORAL FILM

25

Every 6 months

D0270

BITEWING - ONE FILM

8

Every 6 months

D0272

BITEWINGS - TWO FILMS

10

Every 6 months

D0273

BITEWINGS - THREE FILMS

15

Every 6 months

D0274

BITEWINGS - FOUR FILMS

18

Every 6 months

D0277

VERTICAL BITEWINGS

18

Every 6 months

D0290

SKULL & FACIAL FILMS

20

Every 6 months

D0310

SIALOGRAPHY

50

Every 6 months

D0320

TEMPOROMANDIBULAR FILM

70

Every 6 months

D0330

PANORAMIC FILM

55

Every 12 months

D0340

CEPHALOMETRIC FILM

55

Every 12 months

D0410

BACTERIOLOGIC CULTURES

20

D0420

CARIES SUSCEPTIBILITY

15

D0425

CARIES SUSCEPTIBILITY

15

D0460

PULP VITALITY

17

D0470

STUDY MODELS

23

D0501

BIOPSY - LAB EXAM

50

D0502

TEST & LAB EXAM

0

D1110 -

ADULT PROPHYLAXIS

54

Prophylaxi covered every 6 months

D1120

CHILD PROPHYLAXIS

49

Every 6 months (up to age 15)

D1200

FLUORIDE APPLICATION

22

Every 6 months

D1351

SEALANT - PER QUADRANT (Molar Teeth Only)

30

Every 18 months,  from ages 6-14 years old

D1510

SPACE MAINTAINER - FIXED

100

D1515

SPACE MAINTAINER - CRW TY

125

D1525

SPACE MAINTAINER - REMOVABLE

125

D2110

AMALGAM - CHILD - 1 SURFACE

30

Every 12 months (Same Surface)

D2120

AMALGAM - CHILD - 2 SURFACES

35

Every 12 months (Same Surface)

D2130

AMALGAM - CHILD - 3 SURFACES

45

Every 12 months (Same Surface)

D2131

AMALGAM - CHILD - 4+ SURFACES

50

Every 12 months (Same Surface)

D2140

AMALGAM - ADULT - 1 SURFACE

35

Every 12 months (Same Surface)

D2150

AMALGAM - ADULT - 2 SURFACES

40

Every 12 months (Same Surface)

D2160

AMALGAM - ADULT - 3 SURFACES

45

Every 12 months (Same Surface)

D2161

AMALGAM - ADULT - 4+ SURFACES

50

Every 12 months (Same Surface)

D2170

PIN - AMALGAM

15

Every 12 months (Same Surface)

D2210

SILICATE-PER RESTORATION

35

Every 12 months (Same Surface)

D2330

COMPOSITE/BONDING - 1 SURFACE

45

Every 12 months (Same Surface)

D2331

COMPOSITE/BONDING - 2 SURFACES

50

Every 12 months (Same Surface)

D2332

COMPOSITE/BONDING - 3 SURFACES

55

Every 12 months (Same Surface)

D2335

COMPOSITE/BONDING - 4+ SURFACE

60

Every 12 months (Same Surface)

D2340

ACID ETCH TOOTH PREPARATION

13

D2385

RESIN BONDED SURFACE (POSTER.)

45

Every 12 months (Same Surface)

D2386

RESIN BONDED - 2 SURFACES  (POSTER.)

50

Every 12 months (Same Surface)

D2387

RESIN BONDED  - 3 SURFACES (POSTER.)

55

Every 12 months (Same Surface)

D2388

RESIN BONDED - 4 - SURFACES (POSTER.)

60

Every 12 months (Same Surface)

D2391

RESIN BASED COMP. 1 SURF/POST

45

Every 12 months (Same Surface)

D2392

RESIN BASED COMP. 2 SURF/POST

50

Every 12 months (Same Surface)

D2393

RESIN BASED COMP. 3 SURF/POST

55

Every 12 months (Same Surface)

D2394

RESIN BASED COMP. 4 SURF/POST

60

Every 12 months (Same Surface)

D2410

GOLD FOIL - 1 SURFACE

44

D2420

GOLD FOIL - 2 SURFACES

125

D2430

GOLD FOIL - 3 SURFACES

145

D2510

INLAY - 1 SURFACE

90

Inlays covered every 5 years

D2520

INLAY - 2 SURFACES

145

Inlays covered every 5 years

D2530

INLAY - 3 SURFACES

150

Inlays covered every 5 years

D2540

ONLAY

0

D2610

INLAY-PORCELAIN/CERAMIC

55

D2710

CROWN - ACRYLIC

95

Crowns covered every 5 years

D2720

CROWN - PLASTIC W/METAL

245

Crowns covered every 5 years

D2740

CROWN - PORCELAIN

245

Crowns covered every 5 years

D2750

CROWN - CERAMCO

450

Crowns covered every 5 years

D2751

CROWN PROC. FUSED BASE SINGLE

450

Crowns covered every 5 years

D2752

PORC. FUSED METAL CROWN

450

Crowns covered every 5 years

D2760

PORCELAIN LAMINATES

270

Crowns covered every 5 years

D2783

3/4 PORC. LAMINATES

145

Crowns covered every 5 years

D2791

CROWN - GOLD

220

Crowns covered every 5 years

D2800

CROWN COPING/PREC METAL

145

Crowns covered every 5 years

D2810

CROWN - 3/4 CAST GOLD

145

Crowns covered every 5 years

D2820

STAINLESS/ACRYLIC CROWN - PRIM

90

Crowns covered every 5 years

D2830

CROWN - SWAGE

70

Crowns covered every 5 years

D2910

RECEMENT INLAY

15

D2920

RECEMENT CROWN

20

D2930

PREFAB STAINLESS STEEL CROWN/PRIMARY

90

Crowns covered every 5 years

D2931

CROWN - STAINLESS STEEL

45

Crowns covered every 5 years

D2933

PREFAB STAINLESS STEEL CROWN

45

Crowns covered every 5 years

D2940

SEDATIVE FILLING

12

D2950

CROWN BUILD UP - PIN ADD'L

40

D2951

PIN RETENTION PER TOOTH

15

D2952

POST & CORE WITH CROWN

85

D2954

PREFAB POST & CORE

85

D2962

LABIAL VENEER PORC. LAMINATE

345

D2970

RECALCIFICATION

15

D3110

PULP CAP - DIRECT

12

D3120

PULP CAP- INDIRECT

12

D3220

VITAL PULPOTOMY

40

D3221

PULPAL DEBRIDEMENT

40

D3230

PULPAL THERAPY ANTERIOR

40

D3240

PULPAL THERAPY POSTERIOR

40

D3310 - -

ROOT CANAL - 1 CANAL

300

D3320 - -

ROOT CANAL - 2 CANALS

325

D3330 - -

ROOT CANAL - 3 CANALS

538

D3340 - -

ROOT CANAL - 4 CANALS

585

D3350

THERAPUTIC APICAL CLOSE

20

D3410

APICOECTOMY SEP. SURG. PROC.

305

D3420

APICOECTOMY CON. SURG. PROC.

608

D3421

APICOECTOMY - BICUSPID

305

D3425

APICOECTOMY - MOLAR

608

D3430

RETROFILLING

40

D3440

APICAL CURETTAGE SEPARATE

45

D3450

ROOT AMPUTATION SEPARATE

55

D3910

RUBBER DAM - ROOT CANAL

25

D3920

HEMISECTION

275

D3950

CANAL/PULP ENLARGEMENT

50

D3960

BLEACHING

0

D4210

GINGIVECTOMY - PER QUADRANT

50

D4220

GINGIVAL CURETTAGE EA QUAD

35

D4240

GINGIVAL FLAP 4 OR MORE TEETH

50

D4249

CROWN LENGTHENING

175

D4260

OSSEOUS SURGERY

175

D4261

OSSEOUS GRAFT - SINGLE SITE

170

D4262

OSSEOUS GRAFT - MULTIPLE SITES

210

D4263

BONE REPLACE GRAFT/1st IN QUAD

180

D4270

PEDICAL SOFT TISSUE GRAFT

255

D4271

FREE SOFT TISSUE GRAFT

240

D4320

INTRACORNAL PROV. SPLINT

80

D4321

EXTRACORNAL PROV. SPLINT

50

D4340

SCALING - FULL MOUTH

90

Not within 90 days of prophy/allowed every 6 mos

D4341

SCALING - 12 TEETH OR LESS

50

Not within 90 days of prophy

D4342 * -

PERIO SCALING RT PLANNING 1-3

50

Not within 90 days of prophy

D4355

FULL MOUTH DEBRIDEMENT

90

Not within 90 days of prophy/allowed every 6 mos

D4360

SPECIAL PERIO APPLIANCE

75

D4662 * -

ADVANCED PERIO

0

D4910 * -

PERIODONTAL MAINTENANCE

65

D4920

UNSCHEDULED DRESSING CHANGE

10

D4930 * -

PERIODONTAL CHARTING

25

D5110

FULL UPPER DENTURE

550

Dentures/Bridges covered every 5 years

D5120

FULL LOWER DENTURE

550

Dentures/Bridges covered every 5 years

D5130

IMMEDIATE FULL UPPER DENTURE

400

Dentures/Bridges covered every 5 years

D5140

IMMEDIATE FULL LOWER DENTURE

400

Dentures/Bridges covered every 5 years

D5211

PARTIAL UPPER DENTURE

400

Dentures/Bridges covered every 5 years

D5212

PARTIAL LOWER DENTURE

400

Dentures/Bridges covered every 5 years

D5213

MAXILLARY PARTIAL DENTURE

500

Dentures/Bridges covered every 5 years

D5214

MANDIBULAR PARTIAL DENTURE

500

Dentures/Bridges covered every 5 years

D5215

PARTIAL UPPER FULL CAST

500

Dentures/Bridges covered every 5 years

D5217

PARTIAL LOWER FULL CAST

500

Dentures/Bridges covered every 5 years

D5230

PARTIAL LOWER CHROME COBALT

325

Dentures/Bridges covered every 5 years

D5250

PARTIAL UPPER CHROME COBALT

325

Dentures/Bridges covered every 5 years

D5280

NESBIT

50

D5281

REMOVEABLE UNILATERAL PARTIAL DENTURE

50

D5320

ADDITIONAL CLASP

20

D5410

ADJUST FULL DENTURE

15

D5411

ADJUST COMPLETE DENTURE/MAN

15

D5421

ADJUST PARTIAL DENTURE

15

D5610

REPAIR BROKEN DENTURE

35

D5640

REPLACE BROKEN TOOTH

30

D5650

REPLACE EXTRACTED TOOTH

37

D5660

ADD'L EXTRACTED TTH & CLASP

63

D5670

REATTACHING DAMAGED CLASP

24

D5680

REPLACE BROKEN CLASP

35

D5730

RELINE FULL UPPER DENTURE

45

D5731

RELINE FULL LOWER DENTURE

45

D5740

RELINE PARTIAL UPPER DENTURE

40

D5741

RELINE PARTIAL LOWER DENTURE

40

D5750

RELINE LAB FULL UPPER DENTURE

75

D5751

RELINE LAB FULL LOWER DENTURE

75

D5760

RELINE LAB PART'L UPPER DENTURE

100

D5761

RELINE LAB PART'L LOWER DENTURE

100

D5810

TEMPORARY COMPLETE DENTURE

0

D5820

TEMPORARY PARTIAL DENTURE

0

D5850

TISSUE CONDITIONING

35

D6010

SURGICAL PLACE. IMPLANT

475

Consultant Review

D6210

PONTIC - CAST GOLD

270

Every 5 years

D6211

PONTIC CAST PRED. BASE/METAL

245

Every 5 years

D6231

PONTIC - METAL

245

Every 5 years

D6240

PONTIC - CERAMCO

450

Every 5 years

D6241

PONTIC - PORC. FUSED TO METAL

450

Every 5 years

D6242

PONTIC PORC. FUSED TO NOBLE

475

Every 5 years

D6250

PONTIC - PLASTIC TO METAL

245

Every 5 years

D6251

PONTIC - PLASTIC TO METAL

170

Every 5 years

D6520

PONTIC - 2 SURFACE GOLD INLAY

100

Every 5 years

D6530

PONTIC - 3+ SURFACE GOLD INLAY

140

Every 5 years

D6540

PONTIC - GOLD ONLAY

140

Every 5 years

D6545

RETAINER MARYLAND BRIDGE

70

Every 5 years

D6640

REPLACE BROKEN PIN/FACING/POST

10

Every 5 years

D6721

ABUTMENT - PLASTIC/METAL

245

Every 5 years

D6750

ABUTMENT - CERAMCO

450

Every 5 years

D6751

CROWN PORC. FUSED BASE METAL

450

Every 5 years

D6752

PORC. FUSED METAL CROWN/BRIDGE

450

Every 5 years

D6780

ABUTMENT - 3/4 CAST GOLD

145

Every 5 years

D6790

ABUTMENT - FULL CAST GOLD

295

Every 5 years

D6930

RECEMENT BRIDGE

25

D6940

STRESS BREAKER

75

D6950

PRECISION ATTACHMENT

200

D6960

DOWEL PIN METAL

60

D7110

EXTRACTION SINGLE TOOTH

20

D7111

CORONAL REMNANTS

20

D7120

EXTRACTION EACH ADD'L TOOTH

20

D7140

SIMPLE EXTRACTION

20

D7210

SURG EXTRACTION SINGLE TOOTH

20

D7220

SOFT TISSUE IMPACTION 1 TOOTH

45

D7230

IMPACTED TOOTH PARTIAL BONY

150

D7231

PARTIAL IMPACTION

150

D7240

REMOVE IMPACTED TOOTH FULL BONY

0

D7242

100% IMPACTION - 1ST TOOTH

0

D7243

100% IMPACTION - EA ADD'L TOOTH

0

D7250

REMOVAL RETAINED ROOT

15

D7260

ORAL ANTRAL - FIST. CLOSE

300

D7270

TOOTH REIMPLANTATION

75

D7271

TOOTH IMPLANTATION

100

D7272

TOOTH TRANSPLANTATION

125

D7280

SURG EXPOSED IMPACTED TOOTH ORTHO REASON

95

D7281

SURG. EXPOSED IMPACTED TOOTH AID ERUPTION

80

D7285

BIOPSY & EXAM - HARD

25

D7286

BIOPSY & EXAM - SOFT

24

D7290

SURG. REPOSITIONING TEETH

125

D7310

ALVEOPLASTY W/ EXTRACTION

50

D7320

ALVEOPLASTY W/O EXTRACTION

65

D7340

STOMATOPLASTY - PER ARCH

45

D7350

STOMATOPLASTY - COMPLETE

0

D7366

TUBEROSITY - TWO SIDES

75

D7410

EXCISION LESION TO 1/2"

75

D7420

EXCISION LESION OVER 1/2"

100

D7430

EXCISION BENIGN TUMOR TO 1/2"

40

D7431

EXCISION BENIGN TUMOR OVER 1/2"

150

D7440

EXC. MALIGNANT TUMOR TO 1/2"

0

D7441

EXC. MALIGNANT TUMOR OVER 1/2"

0

D7450

REMOVAL ODONT. CYST TO 1/2"

100

D7451

REMOVAL ODONT. CYST OVER 1/2"

150

D7460

REMOVAL NONODONTOGENIC CYST to 1/2"

100

D7461

REMOVAL NONODONTOGENIC CYSY OVER 1/2"

150

D7465

DECOMPRESSION NERVE

0

D7470

REMOVAL EXTOSIS TORUS

250

D7480

OSTECTOMY

400

D7490

RADICAL RESECTION OF MANDIBLE W/GRAFT

725

D7510

I & D ABSCESS INTRAORAL

15

D7520

I & D ABSCESS EXTRAORAL

100

D7530

REMOVAL FOREIGN BODY

75

D7540

REMOVAL REACTIVE LESION TO FOREIGN BODY

25

D7550

SEQUESTRECTOMY/OSTEO.

125

D7610

FRAC-SIMPLE-MAX-OPEN RED

425

D7620

FRAC-SIMPLE-MAX-CLOSED RED

175

D7630

FRAC-SIMPLE-MAND-OPEN RED

675

D7640

FRAC-SIMPLE-MAND-CLOSED RED

225

D7710

REDUCTION

675

D7740

ODONTOMA

155

D7770

FRAC-ALVEOLUS-OPEN RED

325

D7780

FRAC-COMP-FACIAL BONES

0

D7810

OPEN REDUCTION DISLOCATION

375

D7820

CLOSED REDUCTION DISLOCATION

25

D7830

MANIPULATION UNDER ANESTHESIA

25

D7840

CONDYLECTOMY

725

D7850

MENISECTOMY

675

D7860

ANTHROTOMY

725

D7870

ANTHROCENTISIS

20

D7910

SUTURE-SIMPLE WOUND TO 2"

55

D7911

SUTURE-COMPLEX WOUND TO 2"

105