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NATIONFEESCHEDULEHASSELLCORRECTION - Copy

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\ LISTING OF MAXIMUM ALLOWABLE CHARGES<br />

CODE DESCRIPTION USUAL PROMO<br />

PLAN*<br />

D0120 PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT $62.00 $31.00<br />

$26.00<br />

D0140 LIMITED ORAL EVALUATION – PROBLEM FOCUSED $52.00 $39.00<br />

$29.00<br />

D0150 COMPREHENSIVE ORAL EVALUATION – NEW OR ESTABLISHED PATIENT $83.00 $47.00<br />

$35.00<br />

D0210 INTRAORAL – COMPLETE SERIES (INCLUDING BITEWINGS) $133.00 $88.00<br />

$72.00<br />

D0220 INTRAORAL – PERIAPICAL FIRST FILM $23.00 $16.00<br />

$12.00<br />

D0230 INTRAORAL – PERIAPICAL EACH ADDITIONAL FILM $16.00 $12.00<br />

$10.00<br />

D0270 BITEWING – SINGLE FILM $23.00 $15.00 $12.00<br />

D0272 BITEWINGS – TWO FILMS $28.00 $25.00 $21.00<br />

D0470 DIAGNOSTIC CASTS $53.00 $47.00<br />

$27.00<br />

D1110 PROPHYLAXIS – ADULT $68.00 $49.00 $29.00<br />

D1120 PROPHYLAXIS – CHILD $58.00 $39.00<br />

$29.00<br />

D1203 TOPICAL APPLICATION OF FLUORIDE – CHILD $42.00 $25.00 $19.00<br />

D1204 TOPICAL APPLICATION OF FLUORIDE – ADULT $42.00 $25.00<br />

$19.00<br />

D1330 ORAL HYGIENE INSTRUCTIONS $44.00 $25.00<br />

$19.00<br />

D1351 SEALANT – PER TOOTH $42.00 $28.00 $21.00<br />

D2330 RESIN-BASED COMPOSITE – ONE SURFACE, ANTERIOR $132.00 $75.00<br />

$65.00<br />

D2331 RESIN-BASED COMPOSITE – TWO SURFACE, ANTERIOR $164.00 $106.00<br />

$65.00<br />

D2332 RESIN-BASED COMPOSITE – THREE SURFACE, ANTERIOR $191.00 $129.00<br />

$95.00<br />

D2335<br />

RESIN-BASED COMPOSITE – FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE,<br />

(ANTERIOR) $219.00 $176.00 $110.00<br />

D2391 RESIN-BASED COMPOSITE – ONE SURFACE, POSTERIOR $134.00 $90.00<br />

$55.00


D2392 RESIN-BASED COMPOSITE – TWO SURFACE, POSTERIOR $169.00 $106.00<br />

$85.00<br />

D2393 RESIN-BASED COMPOSITE – THREE SURFACE, POSTERIOR $191.00 $129.00<br />

$95.00<br />

D2394 RESIN-BASED COMPOSITE – FOUR OR MORE SURFACES, POSTERIOR $219.00 $176.00<br />

$110.00<br />

D2752 CROWN – PORCELAIN FUSED TO NOBLE METAL $1,110.00 $699.00<br />

$530.00<br />

D2799 PROVISIONAL CROWN $132.00 $61.00 $49.00<br />

D2920 RECEMENT CROWN $102.00 $68.00<br />

$45.00<br />

D2940 SEDATIVE FILLLING $79.00 $56.00<br />

$40.00<br />

D2950 CORE BUILDUP, INCLUDING ANY PINS $203.00 $138.00<br />

$139.00<br />

D2952 POST AND CORE IN ADDITION TO CROWN, INDIRECTLY FABRICATED $265.00 $205.00<br />

$169.00<br />

D2954 PREFABRICATED POST AND CORE IN ADDITION TO CROWN $265.00 $179.00<br />

$164.00<br />

D2955 POST REMOVAL (NOT IN CONJUCTION WITH ENDODONTIC THERAPY) $280.00 $188.00<br />

$150.00<br />

D3120 PULP CAP – INDIRECT (EXCLUDING FINAL RESTORATION) $74.00 $32.00<br />

$20.00<br />

D3220<br />

THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) REMOVAL OF PULP CORONAL<br />

TO THE DENTINOCEMENTAL JUNCTION AND APPLICATION OF MEDICAME $198.00 $121.00<br />

$98.00<br />

D3221 PULPAR DEBRIDEMENT, PRIMARY AND PERMANENT TEETH $193.00 $138.00<br />

$98.00<br />

D3310 ENDODONTIC THERAPY, ANTERIOR TOOTH (EXCLUDING FINAL RESTORATIO $560.00 $420.00<br />

$280.00<br />

D3320 ENDODONTIC THERAPY, BICUSPID TOOTH (EXCLUDING FINAL RESTORATIO $670.00 $480.00<br />

$380.00<br />

D3330 ENDODONTIC THERAPY, MOLAR (EXCLUDING FINAL RESTORATION) $830.00 $540.00<br />

$440.00<br />

D3346 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY – ANTERIOR $760.00 $468.00<br />

$380.00<br />

D3347 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY – BICUSPID $870.00 $553.00<br />

$480.00<br />

D3348 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY – MOLAR $1,030.00 $659.00<br />

$540.00<br />

D4210<br />

GINGIVECTOMY OR GINGIVOPLASTY – FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED<br />

SPACES PER QUADRANT $390.00 $308.00 $155.00


D4211<br />

GINGIVECTOMY OR GINGIVOPLASTY – ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED<br />

SPACES PER QUADRANT $238.00 $107.00 $91.00<br />

D4249 CLINICAL CROWN LENGHTHENING – HARD TISSUE $570.00 $320.00<br />

$170.00<br />

D4341 PERIODONTAL SCALING AND ROOT PLANING – FOUR OR MORE TEETH PER $190.00 $133.00<br />

$99.00<br />

D4355 FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE EVALUATION AN $133.00 $77.00<br />

$64.00<br />

D5110 COMPLETE DENTURE – MAXILLARY $1,190.00 $776.00 $590.00<br />

D5120 COMPLETE DENTURE – MANDIBULAR $1,190.00 $776.00<br />

$590.00<br />

D5130 IMMEDIATE DENTURE – MAXILLARY $1,280.00 $828.00 $650.00<br />

D5140 IMMEDIATE DENTURE – MANDIBULAR $1,280.00 $828.00<br />

$650.00<br />

D5211<br />

MAXILLARY PARTIAL DENTURE – RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS,<br />

RESTS AND TEETH) $1,103.00 $600.00<br />

$549.00<br />

D5212<br />

MANDIBULAR PARTIAL DENTURE – RESIN BASE (INCLUDING ANY CONCENTIONAL CLASPS,<br />

RESTS AND TEETH) $1,103.00 $600.00<br />

$549.00<br />

D5213<br />

MAXILLARY PARTIAL DENTURE – CAST METAL FRAMEWORK WITH RESIN DENTURE BASES<br />

(INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) $1,255.00 $650.00<br />

$590.00<br />

D5214<br />

MANDIBULAR PARTIAL DENTURE – CAST METAL FRAMEWORK WITH RESIN DENTURE BASES<br />

(INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) $1,255.00 $650.00<br />

$590.00<br />

D5410/11 ADJUST COMPLETE DENTURE - MAXILLARY/MAND $88.00 $50.00<br />

$40.00<br />

D5421/22 ADJUST PARTIAL DENTURE – MAXILLARY/MAND $90.00 $52.00<br />

$40.00<br />

D5510 REPAIR BROKEN COMPLETE DENTURE BASE $167.00 $107.00<br />

$78.00<br />

D5520 REPLACE MISSING OR BROKEN TEETH - COMPLETE DENTURE (EACH TOOTH) $142.00 $88.00<br />

$60.00<br />

D5710 REBASE COMPLETE MAXILLARY DENTURE $233.00 $213.00<br />

$110.00<br />

D5711 REBASE COMPLETE MANDIBULAR DENTURE $233.00 $213.00<br />

$110.00<br />

D5810 INTERIM COMPLETE DENTURE (MAXILLARY) $673.00 $388.00<br />

$285.00


D5811 INTERIM COMPLETE DENTURE (MANDIBULAR) $673.00 $388.00<br />

$285.00<br />

D5820 INTERIM PARTIAL DENTURE (MAXILLARY) $630.00 $347.00<br />

$245.00<br />

D5821 INTERIM PARTIAL DENTURE (MANDIBULAR) $630.00 $347.00<br />

$245.00<br />

D5862 PRECISION ATTACHMENT, BY REPORT $433.00 $228.00<br />

$177.00<br />

D6930 RECEMENT FIXED PARTIAL DENTURE $143.00 $86.00<br />

$70.00<br />

D7111 EXTRACTION, CORONAL REMNANTS – DECIDUOUS TEETH $103.00 $64.00<br />

$44.00<br />

D7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR F $144.00 $106.00<br />

$75.00<br />

D7210<br />

SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING ELEVATION OF MUCOPERIOSTAL FLAP<br />

AND REMOVAL OF BONE AND/OR SECTION OF TOOTH $288.00 $174.00<br />

$109.00<br />

D7220 REMOVAL OF IMPACTED TOOTH – SOFT TISSUE $480.00 $270.00<br />

$196.00<br />

D7230 REMOVAL OF IMPACTED TOOTH – PARTIALLY BONY $666.00 $394.00<br />

$249.00<br />

D7250 SURGICAL REMOVAL FO RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE) $388.00 $189.00<br />

$149.00<br />

D7310<br />

ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS – FOUR OR MORE TEETH OR TOOTH SPACES<br />

, PER QUADRANT $332.00 $182.00 $138.00<br />

D7311<br />

ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS – ONE TO THREE TEETH OR TOOTH SPACES<br />

, PER QUADRANT $190.00 $92.00 $82.00<br />

D7970 EXCISION OF HYPERPLASTIC TISSUE – PER ARCH $333.00 $180.00<br />

$144.00<br />

D7971 EXCISION OF PERICORONAL GINGIVA $244.00 $134.00<br />

$95.00<br />

D9110 PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN – MINOR PROCED $190.00 $119.00<br />

$97.00<br />

D9910 APPLICATION OF DESENSITIZING MEDICAMENT $74.00 $40.00<br />

$36.00<br />

D9920 BEHAVIOR MANAGEMENT, BY REPORT $99.00 $61.00<br />

$46.00<br />

D9972 EXTERNAL BLEACHING – PER ARCH $288.00 $168.00 $99.00

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