Download Specialist Dentist Fee Schedule

Specialist Dentist
Fee Schedule
ADA
CODE
PROCEDURE
Diagnostic
D0120
Periodic oral evaluation
CURRENT
SDP FEE
NAT’L
AVG
2015 SAVINGS
$61
$85
$25
D0140 Limited oral evaluation – problem focused
$103
$124
$21
D0150 Comprehensive oral evaluation – new or established patient
$109
$143
$34
$44
$163
$119
D0210Intraoral – complete series of radiographic images $151
$211
$60
D0220 Intraoral – periapical first radiographic image $35
$49
$14
D0230Intraoral – periapical each additional radiographic image $27
$39
$12
D0240Intraoral – occlusal radiographic image $54
$65
$11
D0270Bitewing – single radiographic image $35
$47
$12
D0272Bitewings – two radiographic images $53
$72
$19
D0274Bitewings – four radiographic images $76
$104
$28
D0290 Posterior – anterior or lateral skull and facial bone survey radiographic image
$174
$219
$45
D0330 Panoramic radiographic image $129
$184
$55
D0340 2D Cephalometric radiographic image
$151
$202
$51
D0470 Diagnostic casts $129
$202
$73
$110
$141
$31
$115
$138
$23
D3220 Therapeutic pulpotomy (excluding final restoration) $262
$328
$66
D3310 Root canal therapy – anterior (excluding final restoration) $895
$1,205
$310
D3320 Root canal therapy – bicuspid (excluding final restoration) $1,056
$1,368
$312
D3330 Root canal therapy – molar (excluding final restoration) $1,281
$1,669
$388
$597
$610
$13
D3352 Apexification/recalcification – interim medication replacement $346
$453
$107
D3353 Apexification/recalcification – final visit (includes completed root
canal therapy – apical closure/calcific repair of perforations,
root resorption, etc.) $737
$847
$110
D3410 Apicoectomy – anterior $888
$1,181
$293
D0180
Comprehensive periodontal evaluation – new or established patient
Endodontics
D3110 Pulp cap – direct (excluding final restoration) D3120 Pulp cap – indirect (excluding final restoration) D3351 Apexification/recalcification – initial visit 05/1616SG1322-HSP
ADA
CODE
PROCEDURE
CURRENT
SDP FEE
NAT’L
AVG
2015 SAVINGS
Endodontics (continued)
D3421 Apicoectomy – bicuspid (first root)
$956
$1,287
$331
$1,163
$1,431
$268
D3426 Apicoectomy (each additional root)
$534
$718
$184
D3430 Retrograde filling – per root $387
$475
$88
D3450 Root amputation – per root $641
$814
$173
D3920 Hemisection (including any root removal),
not including root canal therapy $644
$755
$111
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or
tooth bounded spaces per quadrant
$908
$1,022
$115
D4211 $334
$556
$222
D4240 Gingival flap procedure, including root planing – four or more
contiguous teeth or tooth bounded spaces per quadrant $1,036
$1,192
$156
D4241 Gingival flap procedure, including root planing – one to three
contiguous teeth or tooth bounded spaces per quadrant $829
$985
$156
D4260 Osseous surgery (including elevation of a full thickness flap and closure) –
four or more contiguous teeth or tooth bounded spaces per quadrant $1,434
$1,790
$356
D4261 Osseous surgery (including elevation of a full thickness flap and closure) –
one to three contiguous teeth or tooth bounded spaces per quadrant $1,165
$1,424
$259
D4270 Pedicle soft tissue graft procure
$1,107
$1,332
$225
D4341 Periodontal scaling and root planing – four or more teeth per quadrant $321
$412
$91
D4342 Periodontal scaling and root planing – one to three teeth per quadrant $251
$313
$62
D4355 Full mouth debridement to enable comprehensive
evaluation and diagnosis $254
$292
$38
D4910 Periodontal maintenance $182
$221
$40
D3425 Apicoectomy – molar (first root) Periodontics
Gingivectomy or gingivoplasty – one to three contiguous teeth or
tooth bounded spaces per quadrant Oral Surgery
D7111 Extraction, coronal remnants – deciduous tooth $160
$221
$61
D7140
Extraction, erupted tooth or exposed root –
elevation and/or forceps removal $185
$296
$111
D7210
Surgical removal of erupted tooth requiring elevation of
mucoperiosteal flap and removal of bone and/or section of tooth $319
$456
$137
05/1616SG1322-HSP
ADA
CODE
PROCEDURE
Oral Surgery (continued)
CURRENT
SDP FEE
NAT’L
AVG
2015 SAVINGS
D7220 Removal of impacted tooth – soft tissue $372
$501
$129
D7230 Removal of impacted tooth – partially bony $482
$627
$145
D7240 Removal of impacted tooth – completely bony $588
$775
$187
$711
$910
$199
D7250 Surgical removal of residual tooth roots – cutting procedure $372
$501
$129
D7471 $771
$1,179
$408
D7472 Removal of torus palatinus $956
$1,425
$469
D7473 Removal of torus mandibularis $891
$1,390
$499
D7510 Incision and drainage of abscess – intraoral soft tissue $283
$406
$123
D7960 Frenulectomy (frenectomy or frenotomy) – separate procedure $520
$718
$198
D7970 Excision of hyperplastic tissue – per arch $681
$847
$166
D7971 Excision of pericoronal gingiva $293
$469
$176
Comprehensive Orthodontic Treatment
D8030 Limited orthodontic treatment of the transitional dentition
$3,539
$5,349
$1,810
D8040 Limited orthodontic treatment of the adult dentition
$3,539
$5,731
$2,192
D8080 Comprehensive orthodontic treatment of the adolescent dentition
$7,079
$7,966
$888
D8090 Comprehensive orthodontic treatment of the adult dentition
$7,079
$8,145
$1,067
$845
$896
$51
D7241 Removal of impacted tooth – completely bony,
with unusual surgical complications Removal of lateral exostosis D8680 Orthodontic retention (removal of appliances, construction
and placement of retainers(s)) Pediatric Dentistry
D1120 Prophylaxis – child $94
$113
$19
D1351 Sealant – per tooth $74
$89
$15
D1510 Space maintainer – fixed (unilateral) $451
$508
$57
D1515 Space maintainer – fixed (bilateral) $637
$663
$26
D1520 Space maintainer – removable (unilateral) $572
$629
$57
D1525 Space maintainer – removable (bilateral) $696
$740
$44
D1550
Recement or rebond space maintainer
$112
$139
$27
D2140 Amalgam – one surface (primary or permanent) $174
$238
$64
D2150 Amalgam – two surfaces (primary or permanent) $227
$300
$73
05/1616SG1322-HSP
ADA
CODE
PROCEDURE
Pediatric Dentistry (continued)
CURRENT
SDP FEE
NAT’L
AVG
2015 SAVINGS
D2160 Amalgam – three surfaces (primary or permanent) $272
$374
$102
D2161 Amalgam – four or more surfaces (primary or permanent) $321
$453
$132
D2330
Resin-based composite-one surface (anterior)
$210
$280
$70
D2331
Resin-based composite-two surfaces (anterior)
$257
$336
$79
D2332
Resin-based composite-three surfaces (anterior)
$324
$408
$84
D2335
Resin-based composite-four or more surfaces or
involving incisal angle (anterior)
$402
$512
$110
D2391 Resin-based composite – one surface (posterior) $234
$296
$62
D2392 Resin-based composite – two surfaces (posterior) $307
$376
$69
D2393 Resin-based composite – three surfaces (posterior) $393
$462
$69
D2394 Resin-based composite – four or more surfaces (posterior) $454
$554
$100
D2930 Prefabricated stainless steel crown – primary tooth $374
$427
$53
D3220 Therapeutic pulpotomy – excluding final restoration $272
$141
-$131
$136
$215
$79
$0
$108
$108
$160
$233
$73
$85
$137
$52
$203
$293
$90
D9450 Case presentation, detailed and extensive treatment planning $21
$254
$233
D9930 Treatment of complications (post surgical)
$54
$206
$152
D9950 Occlusion analysis – mounted case $414
$586
$172
D9951 Occlusal adjustment – limited $224
$326
$102
Adjunctive General Services
D9110 Palliative (emergency) treatment of dental pain – minor procedure D9215 Local anesthesia D9310 Consultation – diagnostic service provided by dentist or physician
other than requesting dentist or physician D9430 Office visit for observation during regularly scheduled hours –
no other services performed
D9440 Office visit – after regularly scheduled hours 05/1616SG1322-HSP