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{ "Procedure Code": "D0120", "Description": "Periodic oral evaluation - established patient", "Price": 105 },
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{ "Procedure Code": "D0140", "Description": "Limited oral evaluation - problem focused", "Price": 90 },
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{ "Procedure Code": "D0145", "Description": "Oral evaluation for a patient under three years of age and counseling with primary caregiver", "Price": "NC" },
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{ "Procedure Code": "D0150", "Description": "Comprehensive oral evaluation - new or established patient", "Price": 120 },
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{ "Procedure Code": "D0180", "Description": "Comprehensive periodontal evaluation - new or established patient", "Price": 37 },
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{ "Procedure Code": "D0190", "Description": "Screening of a patient (PHDH only)", "Price": 20 },
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{ "Procedure Code": "D0191", "Description": "Assessment of a patient (PHDH only)", "Price": 20 },
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{ "Procedure Code": "D0210", "Description": "Intraoral - complete series of radiographic images", "Price": 120 },
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{ "Procedure Code": "D0220", "Description": "Intraoral - periapical, first radiographic image", "Price": 60 },
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{ "Procedure Code": "D0230", "Description": "Intraoral - periapical, each additional radiographic image", "Price": 50 },
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{ "Procedure Code": "D0240", "Description": "Intraoral - occlusal radiographic image", "Price": "NC" },
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{ "Procedure Code": "D0270", "Description": "Bitewing - single radiographic image", "Price": 14 },
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{ "Procedure Code": "D0272", "Description": "Bitewings - two radiographic images", "Price": 80 },
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{ "Procedure Code": "D0273", "Description": "Bitewings - three radiographic images", "Price": 27 },
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{ "Procedure Code": "D0274", "Description": "Bitewings - four radiographic images", "Price": 160 },
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{ "Procedure Code": "D0330", "Description": "Panoramic radiographic image", "Price": 150 },
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{ "Procedure Code": "D0340", "Description": "Cephalometric radiograph image (Oral surgeon only)", "Price": 74 },
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{ "Procedure Code": "D0364", "Description": "CBCT - less than one jaw (interpret)", "Price": 350 },
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{ "Procedure Code": "D0365", "Description": "CBCT - mandible (interpret)", "Price": 350 },
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{ "Procedure Code": "D0366", "Description": "CBCT - maxilla (interpret)", "Price": 350 },
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{ "Procedure Code": "D0367", "Description": "CBCT - both jaws (interpret)", "Price": 400 },
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{ "Procedure Code": "D0368", "Description": "CBCT - include TMJ (interpret)", "Price": 375 },
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{ "Procedure Code": "D0380", "Description": "CBCT - less than one jaw (capture only)", "Price": 300 },
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{ "Procedure Code": "D0381", "Description": "CBCT - mandible (capture only)", "Price": 300 },
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{ "Procedure Code": "D0382", "Description": "CBCT - maxilla (capture only)", "Price": 300 },
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{ "Procedure Code": "D0383", "Description": "CBCT - both jaws / include TMJ (capture only)", "Price": 350 },
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{ "Procedure Code": "D1110", "Description": "Prophylaxis - adult, 14 yo or older", "Price": 150 },
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{ "Procedure Code": "D1120", "Description": "Prophylaxis - child, 0-13 yo", "Price": 120 },
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{ "Procedure Code": "D1206", "Description": "Topical application of fluoride varnish", "Price": 26 },
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{ "Procedure Code": "D1208", "Description": "Topical application of fluoride - excluding varnish", "Price": 90 },
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{ "Procedure Code": "D1351", "Description": "Sealant - per tooth", "Price": 80 },
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{ "Procedure Code": "D1354", "Description": "Application of caries arresting medicament - per tooth", "Price": 15 },
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{ "Procedure Code": "D1510", "Description": "Space maintainer - fixed, unilateral - per quadrant", "Price": "NC" },
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{ "Procedure Code": "D1516", "Description": "Space maintainer - fixed, bilateral, maxillary", "Price": "NC" },
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{ "Procedure Code": "D1517", "Description": "Space maintainer - fixed, bilateral, mandibular", "Price": "NC" },
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{ "Procedure Code": "D1520", "Description": "Space maintainer - removable, unilateral, per quadrant", "Price": "NC" },
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{ "Procedure Code": "D1526", "Description": "Space maintainer - removable, bilateral, maxillary", "Price": "NC" },
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{ "Procedure Code": "D1527", "Description": "Space maintainer - removable, bilateral, mandibular", "Price": "NC" },
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{ "Procedure Code": "D1575", "Description": "Distal shoe space maintainer - fixed, unilateral, per quadrant", "Price": "NC" },
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{ "Procedure Code": "D1701", "Description": "Pfizer-BioNTech Covid-19 vaccine - first dose", "Price": 45.87 },
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{ "Procedure Code": "D1702", "Description": "Pfizer-BioNTech Covid-19 vaccine - second dose", "Price": 45.87 },
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{ "Procedure Code": "D1707", "Description": "Janssen Covid-19 vaccine - single dose", "Price": 45.87 },
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{ "Procedure Code": "D1708", "Description": "Pfizer-BioNTech Covid-19 vaccine - third dose", "Price": 45.87 },
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{ "Procedure Code": "D1709", "Description": "Pfizer-BioNTech Covid-19 vaccine - booster dose", "Price": 45.87 },
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{ "Procedure Code": "D1712", "Description": "Janssen Covid-19 vaccine - booster dose", "Price": 45.87 },
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{ "Procedure Code": "D1713", "Description": "Pfizer-BioNTech Covid-19 vaccine pediatric - first dose", "Price": 45.87 },
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{ "Procedure Code": "D1714", "Description": "Pfizer-BioNTech Covid-19 vaccine pediatric - second dose", "Price": 45.87 },
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{ "Procedure Code": "D1999", "Description": "Unspecified preventive procedure, by report", "Price": 50 },
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{ "Procedure Code": "D2140", "Description": "Amalgam - one surface, primary or permanent", "Price": 150 },
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{ "Procedure Code": "D2150", "Description": "Amalgam - two surfaces, primary or permanent", "Price": 200 },
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{ "Procedure Code": "D2160", "Description": "Amalgam - three surfaces, primary or permanent", "Price": 92 },
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{ "Procedure Code": "D2161", "Description": "Amalgam - four or more surfaces, primary or permanent", "Price": 116 },
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{ "Procedure Code": "D2330", "Description": "Resin-based composite - one surface, anterior", "Price": 180 },
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{ "Procedure Code": "D2331", "Description": "Resin-based composite - two surfaces, anterior", "Price": 220 },
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{ "Procedure Code": "D2332", "Description": "Resin-based composite - three surfaces, anterior", "Price": 280 },
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{ "Procedure Code": "D2335", "Description": "Resin-based composite - four or more surfaces or involving incisal angle (anterior)", "Price": 350 },
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{ "Procedure Code": "D2390", "Description": "Resin-based composite crown, anterior", "Price": "NC" },
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{ "Procedure Code": "D2391", "Description": "Resin-based composite - one surface, posterior", "Price": 200 },
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{ "Procedure Code": "D2392", "Description": "Resin-based composite - two surfaces, posterior", "Price": 250 },
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{ "Procedure Code": "D2393", "Description": "Resin-based composite - three surfaces, posterior", "Price": 280 },
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{ "Procedure Code": "D2394", "Description": "Resin-based composite - four or more surfaces, posterior", "Price": 320 },
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{ "Procedure Code": "D2710", "Description": "Crown - resin-based composite (indirect)", "Price": "NC" },
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{ "Procedure Code": "D2740", "Description": "Crown - porcelain/ceramic", "Price": 1300 },
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{ "Procedure Code": "D2750", "Description": "Crown - porcelain fused to high noble metal", "Price": 1300 },
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{ "Procedure Code": "D2751", "Description": "Crown - porcelain fused to predominantly base metal", "Price": 1200 },
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{ "Procedure Code": "D2752", "Description": "Crown - porcelain fused to noble metal", "Price": 1200 },
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{ "Procedure Code": "D2790", "Description": "Crown - full cast high noble metal", "Price": "NC" },
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{ "Procedure Code": "D2910", "Description": "Re-cement or re-bond inlay, onlay or partial coverage restoration", "Price": 57 },
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{ "Procedure Code": "D2920", "Description": "Re-cement or re-bond crown", "Price": 120 },
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{ "Procedure Code": "D2929", "Description": "Prefabricated porcelain/ceramic crown - primary tooth", "Price": "NC" },
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{ "Procedure Code": "D2930", "Description": "Prefabricated stainless steel crown - primary tooth", "Price": "NC" },
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{ "Procedure Code": "D2931", "Description": "Prefabricated stainless steel crown - permanent tooth", "Price": 171 },
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{ "Procedure Code": "D2932", "Description": "Prefabricated resin crown", "Price": "NC" },
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{ "Procedure Code": "D2934", "Description": "Prefabricated esthetic coated stainless steel crown - primary tooth", "Price": "NC" },
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{ "Procedure Code": "D2950", "Description": "Core buildup, including any pins when required", "Price": 350 },
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{ "Procedure Code": "D2951", "Description": "Pin retention - per tooth, in addition to restoration", "Price": 27 },
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{ "Procedure Code": "D2954", "Description": "Prefabricated post and core in addition to crown", "Price": 450 },
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{ "Procedure Code": "D2955", "Description": "Post removal", "Price": 350 },
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{ "Procedure Code": "D2980", "Description": "Crown repair necessitated by restorative material failure", "Price": 115 },
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{ "Procedure Code": "D2999", "Description": "Unspecified restorative procedure, by report", "Price": "IC" },
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{ "Procedure Code": "D3120", "Description": "Pulp cap - indirect (excluding final restoration)", "Price": 34 },
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{ "Procedure Code": "D3220", "Description": "Therapeutic pulpotomy (excluding final restoration)", "Price": "NC" },
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{ "Procedure Code": "D3230", "Description": "Pulpal therapy (resorbable filling) - anterior, primary tooth", "Price": 280 },
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{ "Procedure Code": "D3240", "Description": "Pulpal therapy (resorbable filling) - posterior, primary tooth", "Price": 490 },
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{ "Procedure Code": "D3310", "Description": "Endodontic therapy, anterior tooth (excluding final restoration)", "Price": 900 },
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{ "Procedure Code": "D3320", "Description": "Endodontic therapy, premolar tooth (excluding final restoration)", "Price": 1050 },
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{ "Procedure Code": "D3330", "Description": "Endodontic therapy, molar tooth (excluding final restoration)", "Price": 1250 },
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{ "Procedure Code": "D3346", "Description": "Retreatment of previous root canal therapy - anterior", "Price": 950 },
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{ "Procedure Code": "D3347", "Description": "Retreatment of previous root canal therapy - premolar", "Price": 1100 },
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{ "Procedure Code": "D3348", "Description": "Retreatment of previous root canal therapy - molar", "Price": 1500 },
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{ "Procedure Code": "D3410", "Description": "Apicoectomy - anterior", "Price": 407 },
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{ "Procedure Code": "D3421", "Description": "Apicoectomy - premolar (first root)", "Price": 460 },
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{ "Procedure Code": "D3425", "Description": "Apicoectomy - molar (first root)", "Price": 598 },
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{ "Procedure Code": "D3426", "Description": "Apicoectomy (each additional root)", "Price": 230 },
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{ "Procedure Code": "D4210", "Description": "Gingivectomy or gingivoplasty - four or more contiguous teeth per quadrant", "Price": 307 },
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{ "Procedure Code": "D4211", "Description": "Gingivectomy or gingivoplasty - one to three contiguous teeth per quadrant", "Price": 111 },
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{ "Procedure Code": "D4341", "Description": "Periodontal scaling and root planing - four or more teeth per quadrant", "Price": 250 },
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{ "Procedure Code": "D4342", "Description": "Periodontal scaling and root planing - one to three teeth, per quadrant", "Price": 90 },
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{ "Procedure Code": "D4346", "Description": "Scaling in presence of generalized moderate or severe gingival inflammation - full mouth", "Price": 60 },
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{ "Procedure Code": "D4910", "Description": "Periodontal maintenance", "Price": 250 },
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{ "Procedure Code": "D5110", "Description": "Complete denture - maxillary", "Price": 1700 },
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{ "Procedure Code": "D5120", "Description": "Complete denture - mandibular", "Price": 1700 },
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{ "Procedure Code": "D5130", "Description": "Immediate denture - maxillary", "Price": "NC" },
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{ "Procedure Code": "D5140", "Description": "Immediate denture - mandibular", "Price": "NC" },
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{ "Procedure Code": "D5211", "Description": "Maxillary partial denture - resin base", "Price": 1300 },
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{ "Procedure Code": "D5212", "Description": "Mandibular partial denture - resin base", "Price": 1300 },
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{ "Procedure Code": "D5213", "Description": "Maxillary partial denture - cast metal framework with resin denture bases", "Price": 1700 },
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{ "Procedure Code": "D5214", "Description": "Mandibular partial denture - cast metal framework with resin denture bases", "Price": 1700 },
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{ "Procedure Code": "D5225", "Description": "Maxillary partial denture - flexible base", "Price": "NC" },
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{ "Procedure Code": "D5226", "Description": "Mandibular partial denture - flexible base", "Price": "NC" },
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{ "Procedure Code": "D5510", "Description": "Repair broken complete denture base (QUAD)", "Price": 400 },
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{ "Procedure Code": "D5511", "Description": "Repair broken complete denture base, mandibular", "Price": 85 },
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{ "Procedure Code": "D5512", "Description": "Repair broken complete denture base, maxillary", "Price": 85 },
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{ "Procedure Code": "D5520", "Description": "Replace missing or broken teeth - complete denture (each tooth)", "Price": 200 },
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{ "Procedure Code": "D5611", "Description": "Repair broken resin partial denture base, mandibular", "Price": 77 },
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{ "Procedure Code": "D5612", "Description": "Repair broken resin partial denture base, maxillary", "Price": 77 },
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{ "Procedure Code": "D5621", "Description": "Repair broken cast partial denture base, mandibular", "Price": 104 },
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{ "Procedure Code": "D5622", "Description": "Repair broken cast partial denture base, maxillary", "Price": 104 },
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{ "Procedure Code": "D5630", "Description": "Repair or replace broken retentive/clasping materials - per tooth", "Price": 99 },
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{ "Procedure Code": "D5640", "Description": "Replace broken teeth - per tooth", "Price": 77 },
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{ "Procedure Code": "D5650", "Description": "Add tooth to existing partial denture", "Price": 92 },
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{ "Procedure Code": "D5660", "Description": "Add clasp to existing partial denture per tooth", "Price": 98 },
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{ "Procedure Code": "D5730", "Description": "Reline complete maxillary denture (chairside)", "Price": 500 },
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{ "Procedure Code": "D5731", "Description": "Reline complete mandibular denture (chairside)", "Price": 500 },
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{ "Procedure Code": "D5740", "Description": "Reline maxillary partial denture (chairside)", "Price": "NC" },
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{ "Procedure Code": "D5741", "Description": "Reline mandibular partial denture (chairside)", "Price": "NC" },
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{ "Procedure Code": "D5750", "Description": "Reline complete maxillary denture (laboratory)", "Price": 600 },
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{ "Procedure Code": "D5751", "Description": "Reline complete mandibular denture (laboratory)", "Price": 600 },
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{ "Procedure Code": "D5760", "Description": "Reline maxillary partial denture (laboratory)", "Price": "NC" },
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{ "Procedure Code": "D5761", "Description": "Reline mandibular partial denture (laboratory)", "Price": "NC" },
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{ "Procedure Code": "D6010", "Description": "Surgical placement of implant body", "Price": 1600 },
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{ "Procedure Code": "D6056", "Description": "Prefabricated abutment", "Price": 750 },
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{ "Procedure Code": "D6057", "Description": "Custom abutment", "Price": 800 },
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{ "Procedure Code": "D6058", "Description": "Implant crown - porcelain/ceramic", "Price": 1400 },
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{ "Procedure Code": "D6059", "Description": "Implant crown - PFM", "Price": 1400 },
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{ "Procedure Code": "D6100", "Description": "Surgical removal of implant body", "Price": 320 },
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{ "Procedure Code": "D6110", "Description": "Implant/abutment supported removable denture - maxillary", "Price": 1600 },
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{ "Procedure Code": "D6111", "Description": "Implant/abutment supported removable denture - mandibular", "Price": 1600 },
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{ "Procedure Code": "D6241", "Description": "Pontic - porcelain fused to metal", "Price": "NC" },
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{ "Procedure Code": "D6242", "Description": "Pontic - noble metal", "Price": 1400 },
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{ "Procedure Code": "D6245", "Description": "Pontic - porcelain/ceramic", "Price": 1400 },
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{ "Procedure Code": "D6751", "Description": "Retainer crown - porcelain fused to metal", "Price": "NC" },
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{ "Procedure Code": "D6930", "Description": "Re-cement or re-bond fixed partial denture", "Price": "NC" },
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{ "Procedure Code": "D6980", "Description": "Fixed partial denture repair", "Price": "NC" },
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{ "Procedure Code": "D6999", "Description": "Fixed prosthodontic procedure, by report", "Price": "IC" },
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{ "Procedure Code": "D7111", "Description": "Extraction, coronal remnants - primary tooth", "Price": 120 },
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{ "Procedure Code": "D7140", "Description": "Extraction, erupted tooth or exposed root (simple)", "Price": 150 },
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{ "Procedure Code": "D7210", "Description": "Extraction, erupted tooth requiring removal of bone and/or sectioning (surgical)", "Price": 280 },
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{ "Procedure Code": "D7220", "Description": "Removal of impacted tooth - soft tissue", "Price": 380 },
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{ "Procedure Code": "D7230", "Description": "Removal of impacted tooth - partially bony", "Price": 450 },
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{ "Procedure Code": "D7240", "Description": "Removal of impacted tooth - completely bony", "Price": 550 },
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{ "Procedure Code": "D7250", "Description": "Surgical removal of residual tooth roots", "Price": 280 },
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{ "Procedure Code": "D7251", "Description": "Coronectomy - intentional partial tooth removal, impacted teeth only", "Price": 134 },
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{ "Procedure Code": "D7270", "Description": "Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth", "Price": 106 },
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{ "Procedure Code": "D7280", "Description": "Surgical access of an unerupted tooth", "Price": "NC" },
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{ "Procedure Code": "D7283", "Description": "Placement of device to facilitate eruption of impacted tooth", "Price": "NC" },
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{ "Procedure Code": "D7310", "Description": "Alveoloplasty in conjunction with extractions - four or more teeth per quadrant", "Price": 142 },
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{ "Procedure Code": "D7311", "Description": "Alveoloplasty in conjunction with extractions - one to three teeth per quadrant", "Price": 128 },
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{ "Procedure Code": "D7320", "Description": "Alveoloplasty not in conjunction with extractions - four or more teeth per quadrant", "Price": 187 },
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{ "Procedure Code": "D7321", "Description": "Alveoloplasty not in conjunction with extractions - one to three teeth per quadrant", "Price": 149 },
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{ "Procedure Code": "D7340", "Description": "Vestibuloplasty - ridge extension (second epithelialization)", "Price": 747 },
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{ "Procedure Code": "D7350", "Description": "Vestibuloplasty - ridge extension (Oral surgeon only)", "Price": 943 },
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{ "Procedure Code": "D7410", "Description": "Excision of benign lesion - diameter up to 1.25 cm", "Price": 115 },
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{ "Procedure Code": "D7411", "Description": "Excision of benign lesion - diameter greater than 1.25 cm", "Price": 208 },
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{ "Procedure Code": "D7450", "Description": "Removal of benign odontogenic cyst or tumor - up to 1.25 cm", "Price": 248 },
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{ "Procedure Code": "D7451", "Description": "Removal of benign odontogenic cyst or tumor - greater than 1.25 cm", "Price": 288 },
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{ "Procedure Code": "D7460", "Description": "Removal of benign nonodontogenic cyst or tumor - up to 1.25 cm", "Price": 121 },
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{ "Procedure Code": "D7461", "Description": "Removal of benign nonodontogenic cyst or tumor - greater than 1.25 cm", "Price": 143 },
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{ "Procedure Code": "D7471", "Description": "Removal of lateral exostosis (maxilla or mandible)", "Price": 143 },
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{ "Procedure Code": "D7472", "Description": "Removal of torus palatinus", "Price": 143 },
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{ "Procedure Code": "D7473", "Description": "Removal of torus mandibularis", "Price": 143 },
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{ "Procedure Code": "D7910", "Description": "Suture of recent small wounds up to 5 cm", "Price": 400 },
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{ "Procedure Code": "D7950", "Description": "Bone graft - maxilla/mandible", "Price": 800 },
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{ "Procedure Code": "D7953", "Description": "Bone graft for socket preservation after extraction", "Price": 800 },
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{ "Procedure Code": "D7961", "Description": "Buccal/labial frenectomy (frenulectomy)", "Price": 107 },
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{ "Procedure Code": "D7962", "Description": "Lingual frenectomy (frenulectomy)", "Price": 107 },
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{ "Procedure Code": "D7963", "Description": "Frenuloplasty", "Price": 416 },
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{ "Procedure Code": "D7970", "Description": "Excision of hyperplastic tissue - per arch", "Price": 246 },
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{ "Procedure Code": "D7999", "Description": "Unspecified oral surgery procedure, by report", "Price": "IC" },
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{ "Procedure Code": "D8010", "Description": "Limited orthodontic treatment of the primary dentition (Orthodontist only)", "Price": "NC" },
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{ "Procedure Code": "D8020", "Description": "Limited orthodontic treatment of the transitional dentition (Orthodontist only)", "Price": "NC" },
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{ "Procedure Code": "D8030", "Description": "Limited orthodontic treatment of the adolescent dentition (Orthodontist only)", "Price": "NC" },
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{ "Procedure Code": "D8040", "Description": "Limited orthodontic treatment of the adult dentition (Orthodontist only)", "Price": "NC" },
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{ "Procedure Code": "D8070", "Description": "Comprehensive orthodontic treatment of the transitional dentition (Orthodontist only)", "Price": "NC" },
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{ "Procedure Code": "D8080", "Description": "Comprehensive orthodontic treatment of the adolescent dentition (Orthodontist only)", "Price": "NC" },
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{ "Procedure Code": "D8090", "Description": "Comprehensive orthodontic treatment of the adult dentition (Orthodontist only)", "Price": "NC" },
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{ "Procedure Code": "D8660", "Description": "Pre-orthodontic treatment examination (Orthodontist only)", "Price": "NC" },
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{ "Procedure Code": "D8670", "Description": "Periodic orthodontic treatment visit (Orthodontist only)", "Price": 215 },
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{ "Procedure Code": "D8680", "Description": "Orthodontic retention (Orthodontist only)", "Price": 85 },
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{ "Procedure Code": "D8703", "Description": "Replacement of lost or broken retainer - maxillary (Orthodontist only)", "Price": "NC" },
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{ "Procedure Code": "D8704", "Description": "Replacement of lost or broken retainer - mandibular (Orthodontist only)", "Price": "NC" },
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{ "Procedure Code": "D8999", "Description": "Unspecified orthodontic procedure, by report (Orthodontist only)", "Price": "NC" },
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{ "Procedure Code": "D9110", "Description": "Palliative treatment of dental pain - per visit", "Price": 36 },
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{ "Procedure Code": "D9222", "Description": "Deep sedation/general anesthesia - first 15 minutes", "Price": 90 },
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{ "Procedure Code": "D9223", "Description": "Deep sedation/general anesthesia - each additional 15-minute increment", "Price": 90 },
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{ "Procedure Code": "D9230", "Description": "Analgesia, anxiolysis, inhalation of nitrous oxide", "Price": 15 },
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{ "Procedure Code": "D9248", "Description": "Nonintravenous conscious sedation", "Price": 45 },
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{ "Procedure Code": "D9310", "Description": "Consultation - diagnostic service (Specialist only)", "Price": 63 },
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{ "Procedure Code": "D9410", "Description": "House/extended care facility call, once per facility per day", "Price": 39 },
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{ "Procedure Code": "D9450", "Description": "Rural add-on encounter payment", "Price": 31 },
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{ "Procedure Code": "D9920", "Description": "Behavior management, by report", "Price": 86 },
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{ "Procedure Code": "D9930", "Description": "Treatment of complications (postsurgical) - unusual circumstances, by report", "Price": 30 },
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{ "Procedure Code": "D9941", "Description": "Fabrication of athletic mouthguard", "Price": "NC" },
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{ "Procedure Code": "D9944", "Description": "Occlusal guard - hard appliance, full arch", "Price": "NC" },
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{ "Procedure Code": "D9945", "Description": "Occlusal guard - soft appliance, full arch", "Price": "NC" },
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{ "Procedure Code": "D9946", "Description": "Occlusal guard - hard appliance, partial arch", "Price": "NC" },
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{ "Procedure Code": "D9999", "Description": "Unspecified adjunctive procedure, by report", "Price": "IC" }
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]
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