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
$43
$55
$12
D0140 Limited oral evaluation – problem focused
$63
$80
$17
D0150 Comprehensive oral evaluation – new or established patient
$79
$92
$13
D0180
$31
$105
$74
$108
$136
$28
D0220 Intraoral – periapical first radiographic image $24
$32
$8
D0230Intraoral – periapical each additional radiographic image $20
$25
$5
D0240Intraoral – occlusal radiographic image $39
$42
$3
D0270Bitewing – single radiographic image $24
$30
$6
D0272Bitewings – two radiographic images $39
$46
$7
D0274Bitewings – four radiographic images $53
$67
$14
$124
$141
$17
$92
$118
$26
$108
$130
$22
$92
$130
$38
$72
$91
$19
$73
$89
$16
D3220 Therapeutic pulpotomy (excluding final restoration) $173
$211
$38
D3310 Root canal therapy – anterior (excluding final restoration) $588
$776
$188
D3320 Root canal therapy – bicuspid (excluding final restoration) $695
$881
$186
D3330 Root canal therapy – molar (excluding final restoration) $844
$1,075
$231
D3351 $386
$393
$7
D3352 Apexification/recalcification – interim medication replacement $225
$292
$67
D3353 Apexification/recalcification – final visit (includes completed root
canal therapy – apical closure/calcific repair of perforations,
root resorption, etc.) $475
$545
$70
D3410 Apicoectomy – anterior $583
$761
$178
Comprehensive periodontal evaluation – new or established patient
D0210Intraoral – complete series of radiographic images D0290 Posterior – anterior or lateral skull and facial bone survey radiographic image
D0330 Panoramic radiographic image D0340 2D Cephalometric radiographic image
D0470 Diagnostic casts Endodontics
D3110 Pulp cap – direct (excluding final restoration) D3120 Pulp cap – indirect (excluding final restoration) Apexification/recalcification – initial visit 05/1616SG1322-LSP
ADA
CODE
PROCEDURE
CURRENT
SDP FEE
NAT’L
AVG
2015 SAVINGS
Endodontics (continued)
D3421 Apicoectomy – bicuspid (first root)
$628
$829
$201
D3425 Apicoectomy – molar (first root) $765
$922
$157
D3426 Apicoectomy (each additional root)
$350
$462
$112
D3430 Retrograde filling – per root $249
$306
$57
D3450 Root amputation – per root $421
$524
$103
D3920 Hemisection (including any root removal),
not including root canal therapy $425
$487
$62
D4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or
tooth bounded spaces per quadrant
$567
$659
$92
D4211 $222
$358
$136
D4240 Gingival flap procedure, including root planing – four or more
contiguous teeth or tooth bounded spaces per quadrant $667
$768
$101
D4241 Gingival flap procedure, including root planing – one to three
contiguous teeth or tooth bounded spaces per quadrant $555
$634
$79
D4260 Osseous surgery (including elevation of a full thickness flap and closure) –
four or more contiguous teeth or tooth bounded spaces per quadrant $936
$1,153
$217
D4261 Osseous surgery (including elevation of a full thickness flap and closure) –
one to three contiguous teeth or tooth bounded spaces per quadrant
$788
$917
$129
D4270 Pedicle soft tissue graft procure
$724
$858
$134
D4341 Periodontal scaling and root planing – four or more teeth per quadrant $217
$265
$48
D4342 Periodontal scaling and root planing – one to three teeth per quadrant $165
$201
$36
D4355 Full mouth debridement to enable comprehensive
evaluation and diagnosis $162
$188
$26
D4355
$162
$188
$26
$122
$143
$21
Periodontics
Gingivectomy or gingivoplasty – one to three contiguous teeth or
tooth bounded spaces per quadrant Full mouth debridement to enable comprehensive
evaluation and diagnosis
D4910 Periodontal maintenance 05/1616SG1322-LSP
PROCEDURE
Oral Surgery
D7111 Extraction, coronal remnants – deciduous tooth $116
$143
$27
D7140
Extraction, erupted tooth or exposed root –
elevation and/or forceps removal $134
$190
$56
D7210
Surgical removal of erupted tooth requiring elevation of
mucoperiosteal flap and removal of bone and/or section of tooth $226
$294
$68
D7220 Removal of impacted tooth – soft tissue $256
$323
$67
D7230 Removal of impacted tooth – partially bony $326
$404
$78
D7240 Removal of impacted tooth – completely bony $407
$499
$92
D7241 $482
$586
$104
D7250 Surgical removal of residual tooth roots – cutting procedure $256
$323
$67
D7471 $563
$759
$196
D7472 Removal of torus palatinus $697
$918
$221
D7473 Removal of torus mandibularis $652
$895
$243
D7510 Incision and drainage of abscess – intraoral soft tissue $186
$262
$76
D7960 Frenulectomy (frenectomy or frenotomy) – separate procedure $375
$462
$87
D7970 Excision of hyperplastic tissue – per arch $461
$545
$84
D7971 Excision of pericoronal gingiva $213
$302
$89
Comprehensive Orthodontic Treatment
D8030 Limited orthodontic treatment of the transitional dentition
$2,316
$3,446
$1,130
D8040 Limited orthodontic treatment of the adult dentition
$2,316
$3,692
$1,376
D8080 Comprehensive orthodontic treatment of the adolescent dentition
$4,722
$5,131
$409
D8090 Comprehensive orthodontic treatment of the adult dentition
$4,885
$5,246
$361
$579
$577
-$2
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)) CURRENT
SDP FEE
NAT’L
AVG
2015 SAVINGS
ADA
CODE
Pediatric Dentistry
D1120 Prophylaxis – child $61
$73
$12
D1351 Sealant – per tooth $48
$57
$9
D1510 Space maintainer – fixed (unilateral) $297
$327
$30
D1515 Space maintainer – fixed (bilateral) $411
$427
$16
05/1616SG1322-LSP
ADA
CODE
PROCEDURE
Pediatric Dentistry (continued)
CURRENT
SDP FEE
NAT’L
AVG
2015 SAVINGS
D1520 Space maintainer – removable (unilateral) $369
$405
$36
D1525 Space maintainer – removable (bilateral) $449
$477
$28
D1550
Recement or rebond space maintainer
$77
$90
$13
D2140 Amalgam – one surface (primary or permanent) $118
$154
$36
D2150 Amalgam – two surfaces (primary or permanent) $153
$193
$40
D2160 Amalgam – three surfaces (primary or permanent) $184
$241
$57
D2161 Amalgam – four or more surfaces (primary or permanent) $217
$292
$75
D2330
Resin-based composite – one surface (anterior)
$144
$180
$36
D2331
Resin-based composite – two surfaces (anterior)
$176
$216
$40
D2332
Resin-based composite – three surfaces (anterior)
$218
$263
$45
D2335
Resin-based composite-four or more surfaces or
involving incisal angle (anterior)
$274
$330
$56
D2391 Resin-based composite – one surface (posterior) $160
$190
$30
D2392 Resin-based composite – two surfaces (posterior) $204
$242
$38
D2393 Resin-based composite – three surfaces (posterior) $256
$298
$42
D2394 Resin-based composite – four or more surfaces (posterior) $306
$357
$51
D2930 Prefabricated stainless steel crown – primary tooth $253
$275
$22
D3220 Therapeutic pulpotomy – excluding final restoration $184
$211
$27
$100
$138
$38
$0
$70
$70
D9310 Consultation – diagnostic service provided by dentist or physician
other than requesting dentist or physician $118
$150
$32
D9430 Office visit for observation during regularly scheduled hours –
no other services performed
$63
$88
$25
$149
$189
$40
D9450 Case presentation, detailed and extensive treatment planning $16
$164
$148
D9930 Treatment of complications (post surgical)
$47
$133
$86
D9950 Occlusion analysis – mounted case $303
$378
$75
D9951 Occlusal adjustment – limited $162
$210
$48
Adjunctive General Services
D9110 Palliative (emergency) treatment of dental pain – minor procedure D9215 Local anesthesia D9440 Office visit – after regularly scheduled hours 05/1616SG1322-LSP