Dental Fee Schedule

Diagnostic Services
CodeDescriptionLDP
D0120periodic oral evaluation$16
D0140limited oral evaluation - problem focused$25
D0150comprehensive oral evaluation - new or established patient$21
D0160detailed and extensive oral evaluation - problem focused, by report$26
D0170re-evaluation - limited, problem focused (established patient; not post-operative visit)$27
D0180comprehensive periodontal evaluation - new or established patient$40
D0210X-ray, intraoral - complete series$48
D0220intraoral - periapical first film$6
D0230intraoral - periapical each additional film$7
D0240intraoral - occlusal film$14
D0250extraoral - first film$19
D0260extraoral - each additional film$19
D0270bitewing - single film$12
D0272bitewings - two films$16
D0274bitewings - four films$25
D0277vertical bitewings - 7 to 8 films$38
D0310sialography$143
D0330panoramic film$49
D0340cephalometric film$48
D0415collection of microorganisms for culture and sensitivity$29
D0425caries susceptibility tests$19
D0460pulp vitality tests$25
D0470diagnostic casts$25
D0999Disposables/Infectious control$8
D9972cosmetic bleaching - per arch$190
Preventive Services
CodeDescriptionLDP
D1110prophylaxis - adult$32
D1120prophylaxis - child$23
D1201topical application of fluoride (including prophylaxis) - child$35
D1203topical application of fluoride (prophylaxis not included) - child$10
D1204topical application of fluoride (prophylaxis not included) - adult$11
D1205topical application of fluoride (including prophylaxis) - adult$45
D1310nutritional counseling for control of dental disease$20
D1320tobacco counseling for the control and prevention of oral disease$20
D1330oral hygiene instructions$24
D1351sealant - per tooth$20
D1510space maintainer - fixed - unilateral$144
D1515space maintainer - fixed - bilateral$173
D1520space maintainer - removable - unilateral$178
D1525space maintainer - removable - bilateral$210
Basic Restorations
CodeDescriptionLDP
D1550re-cementation of space maintainer$34
D2140amalgam - one surface, primary or permanent$44
D2150amalgam - two surfaces, primary or permanent$57
D2160amalgam - three surfaces, primary or permanent$69
D2161amalgam - four or more surfaces, primary or permanent$89
D2330resin-based composite - one surface, anterior$58
D2331resin-based composite - two surfaces, anterior$73
D2332resin-based composite - three surfaces, anterior$99
D2335resin-based composite - four or more surfaces or involving incisal angle (anterior)$99
D2390resin-based composite crown, anterior$119
D2391resin-based composite - one surface, posterior$69
D2392resin-based composite - two surfaces, posterior$84
D2393resin-based composite - three surfaces, posterior$110
D2394resin-based composite - four or more surfaces, posterior$155
Inlay/Onlay Restorations
CodeDescriptionLDP
D2410gold foil - one surface$165
D2420gold foil - two surfaces$195
D2510inlay - metallic - one surface$269
D2520inlay - metallic - two surfaces$357
D2530inlay - metallic - three or more surfaces$433
D2542onlay - metallic-two surfaces$455
D2543onlay - metallic-three surfaces$475
D2544onlay - metallic-four or more surfaces$495
D2610inlay - porcelain/ceramic - one surface$357
D2620inlay - porcelain/ceramic - two surfaces$413
D2630inlay - porcelain/ceramic - three or more surfaces$430
D2642onlay - porcelain/ceramic - two surfaces$460
D2643onlay - porcelain/ceramic - three surfaces$475
D2644onlay - porcelain/ceramic - four or more surfaces$485
D2650inlay - resin-based composite - one surface$300
D2651inlay - resin-based composite - two surfaces$369
D2652inlay - resin-based composite - three or more surfaces$389
D2662onlay - resin-based composite - two surfaces$238
D2663onlay - resin-based composite - three surfaces$284
D2664onlay - resin-based composite - four or more surfaces$284
D2710crown - resin-based composite (indirect)$200
D2720crown - resin with high noble metal$415
D2721crown - resin with predominantly base metal$315
D2722crown - resin with noble metal$359
D2740crown - porcelain/ceramic substrate$540
D2750crown - porcelain fused to high noble metal$540
D2751crown - porcelain fused to predominantly base metal$500
D2752crown - porcelain fused to noble metal$520
D2780crown - 3/4 cast high noble metal$550
D2781crown - 3/4 cast predominantly base metal$500
D2782crown - 3/4 cast noble metal$521
D2783crown - 3/4 porcelain/ceramic$543
D2790crown - full cast high noble metal$530
D2791crown - full cast predominantly base metal$419
D2792crown - full cast noble metal$429
Other Restorative Services
CodeDescriptionLDP
D2910recement inlay, onlay, or partial coverage restoration$38
D2920recement crown$44
D2930prefabricated stainless steel crown - primary tooth$110
D2931prefabricated stainless steel crown - permanent tooth$114
D2932prefabricated resin crown$120
D2933prefabricated stainless steel crown with resin window$112
D2940sedative filling$25
D2950core buildup, including any pins$80
D2951pin retention - per tooth, in addition to restoration$18
D2952cast post and core in addition to crown$170
D2954prefabricated post and core in addition to crown$133
D2955post removal (not in conjunction with endodontic therapy)$131
D2980crown repair, by report$80
Endodontic Services
CodeDescriptionLDP
D3110pulp cap - direct (excluding final restoration)$18
D3120pulp cap - indirect (excluding final restoration)$38
D3220therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament$52
D3230pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)$69
D3240pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)$69
D3310anterior (excluding final restoration)$350
D3320bicuspid (excluding final restoration)$400
D3330molar (excluding final restoration)$500
D3346retreatment of previous root canal therapy - anterior$404
D3347retreatment of previous root canal therapy - bicuspid$415
D3348retreatment of previous root canal therapy - molar$580
D3351apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.)$60
D3352apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.)$60
D3353apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.)$60
D3410apicoectomy/periradicular surgery - anterior$258
D3421apicoectomy/periradicular surgery - bicuspid (first root)$279
D3425apicoectomy/periradicular surgery - molar (first root)$279
D3426apicoectomy/periradicular surgery (each additional root)$109
D3430retrograde filling - per root$84
D3450root amputation - per root$149
D3920hemisection (including any root removal), not including root canal therapy$121
D3950canal preparation and fitting of preformed dowel or post$113
Periodontic Services
CodeDescriptionLDP
D4210gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant$138
D4211gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant$65
D4240gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant$300
D4241gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth spaces per quadrant$287
D4249clinical crown lengthening - hard tissue$275
D4260osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant$500
D4261osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant$404
D4263bone replacement graft - first site in quadrant$240
D4264bone replacement graft - each additional site in quadrant$160
D4266guided tissue regeneration - resorbable barrier, per site$330
D4268surgical revision procedure, per tooth$270
D4270pedicle soft tissue graft procedure$340
D4271free soft tissue graft procedure (including donor site surgery)$391
D4273subepithelial connective tissue graft procedures, per tooth$391
D4275soft tissue allograft$440
D4320provisional splinting - intracoronal$180
D4321provisional splinting - extracoronal$150
D4341periodontal scaling and root planing - four or more teeth per quadrant$80
D4342periodontal scaling and root planing - one to three teeth per quadrant$75
D4355full mouth debridement to enable comprehensive evaluation and diagnosis$46
D4910periodontal maintenance$43
Prosthodontics-Removable
CodeDescriptionLDP
D5110complete denture - maxillary$633
D5120complete denture - mandibular$633
D5130immediate denture - maxillary$525
D5140immediate denture - mandibular$525
D5211maxillary partial denture - resin base (including any conventional clasps, rests and teeth)$455
D5212mandibular partial denture - resin base (including any conventional clasps, rests and teeth)$455
D5213maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)$689
D5214mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)$689
D5281removable unilateral partial denture - one piece cast metal (including clasps and teeth)$350
Adjustments, Repairs, Rebase, Reline, Other Services
CodeDescriptionLDP
D5410adjust complete denture - maxillary$30
D5411adjust complete denture - mandibular$30
D5421adjust partial denture - maxillary$30
D5422adjust partial denture - mandibular$30
D5510repair broken complete denture base$50
D5520replace missing or broken teeth - complete denture (each tooth)$45
D5610repair resin denture base$50
D5620repair cast framework$75
D5630repair or replace broken clasp$60
D5640replace broken teeth - per tooth$45
D5650add tooth to existing partial denture$55
D5660add clasp to existing partial denture$75
D5710rebase complete maxillary denture$211
D5711rebase complete mandibular denture$211
D5720rebase maxillary partial denture$200
D5721rebase mandibular partial denture$200
D5730reline complete maxillary denture (chairside)$112
D5731reline complete mandibular denture (chairside)$112
D5740reline maxillary partial denture (chairside)$110
D5741reline mandibular partial denture (chairside)$110
D5750reline complete maxillary denture (laboratory)$130
D5751reline complete mandibular denture (laboratory)$130
D5760reline maxillary partial denture (laboratory)$160
D5761reline mandibular partial denture (laboratory)$160
D5820interim partial denture (maxillary)$281
D5821interim partial denture (mandibular)$281
D5850tissue conditioning, maxillary$50
D5851tissue conditioning, mandibular$50
D6010surgical placement of implant body: endosteal implant$600
D6040surgical placement: eposteal implant$600
D6050surgical placement: transosteal implant$600
D6090repair implant supported prosthesis, by report$130
D6095repair implant abutment, by report$130
D6100implant removal, by report$40
Prosthodontics-Fixed Other Services
CodeDescriptionLDP
D6210pontic - cast high noble metal$445
D6211pontic - cast predominantly base metal$445
D6212pontic - cast noble metal$445
D6240pontic - porcelain fused to high noble metal$445
D6241pontic - porcelain fused to predominantly base metal$445
D6242pontic - porcelain fused to noble metal$445
D6245pontic - porcelain/ceramic$445
D6250pontic - resin with high noble metal$445
D6251pontic - resin with predominantly base metal$445
D6252pontic - resin with noble metal$445
D6253provisional pontic$445
D6545retainer - cast metal for resin bonded fixed prosthesis$170
D6548retainer - porcelain/ceramic for resin bonded fixed prosthesis$170
D6600inlay - porcelain/ceramic, two surfaces$525
D6601inlay - porcelain/ceramic, three or more surfaces$525
D6602inlay - cast high noble metal, two surfaces$525
D6603inlay - cast high noble metal, three or more surfaces$565
D6605inlay - cast predominantly base metal, three or more surfaces$525
D6606inlay - cast noble metal, two surfaces$525
D6607inlay - cast noble metal, three or more surfaces$595
D6608onlay -porcelain/ceramic, two surfaces$500
D6609onlay - porcelain/ceramic, three or more surfaces$545
D6610onlay - cast high noble metal, two surfaces$585
D6611onlay - cast high noble metal, three or more surfaces$545
D6612onlay - cast predominantly base metal, two surfaces$475
D6613onlay - cast predominantly base metal, three or more surfaces$565
D6614onlay - cast noble metal, two surfaces$485
D6615onlay - cast noble metal, three or more surfaces$535
D6720crown - resin with high noble metal$415
D6721crown - resin with predominantly base metal$305
D6722crown - resin with noble metal$344
D6740crown - porcelain/ceramic$560
D6750crown - porcelain fused to high noble metal$500
D6751crown - porcelain fused to predominantly base metal$470
D6752crown - porcelain fused to noble metal$490
D6780crown - 3/4 cast high noble metal$450
D6781crown - 3/4 cast predominantly base metal$520
D6782crown - 3/4 cast noble metal$525
D6783crown - 3/4 porcelain/ceramic$545
D6790crown - full cast high noble metal$500
D6791crown - full cast predominantly base metal$415
D6792crown - full cast noble metal$415
D6793provisional retainer crown$225
D6930recement fixed partial denture$45
D6970cast post and core in addition to fixed partial denture retainer$150
D6971cast post as part of fixed partial denture retainer$140
D6972prefabricated post and core in addition to fixed partial denture retainer$130
D6973core build up for retainer, including any pins$100
D6975coping - metal$220
Oral Surgery-Extractions
CodeDescriptionLDP
D7111extraction, coronal remnants - deciduous tooth$55
D7140extraction, erupted tooth or exposed root (elevation and/or forceps removal)$55
D7210surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth$100
D7220removal of impacted tooth - soft tissue$100
D7230removal of impacted tooth - partially bony$152
D7240removal of impacted tooth - completely bony$189
D7241removal of impacted tooth - completely bony, with unusual surgical complications$300
D7250surgical removal of residual tooth roots (cutting procedure)$100
D7260oroantral fistula closure$245
D7270tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth$150
D7280surgical access of an unerupted tooth$215
D7282mobilization of erupted or malpositioned tooth to aid eruption$230
D7285biopsy of oral tissue - hard (bone, tooth)$120
D7286biopsy of oral tissue - soft$100
D7290surgical repositioning of teeth$100
Oral Surgery-Other Procedures
CodeDescriptionLDP
D7310alveoloplasty in conjunction with extractions - per quadrant$100
D7320alveoloplasty not in conjunction with extractions - per quadrant$150
D7340vestibuloplasty - ridge extension (secondary epithelialization)$260
D7350vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue)$250
D7410excision of benign lesion up to 1.25 cm$225
D7411excision of benign lesion greater than 1.25 cm$188
D7412excision of benign lesion, complicated$270
D7413excision of malignant lesion up to 1.25 cm$300
D7414excision of malignant lesion greater than 1.25 cm$385
D7415excision of malignant lesion, complicated$425
D7440excision of malignant tumor - lesion diameter up to 1.25 cm$325
D7441excision of malignant tumor - lesion diameter greater than 1.25 cm$400
D7450removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm$250
D7451removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm$340
D7460removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm$425
D7461removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm$500
D7471removal of lateral exostosis (maxilla or mandible)$250
D7472removal of torus palatinus$310
D7473removal of torus mandibularis$310
D7485surgical reduction of osseous tuberosity$275
D7510incision and drainage of abscess - intraoral soft tissue$41
D7520incision and drainage of abscess - extraoral soft tissue$125
D7530removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue$225
D7540removal of reaction producing foreign bodies, musculoskeletal system$250
D7550partial ostectomy/sequestrectomy for removal of non-vital bone$170
D7560maxillary sinusotomy for removal of tooth fragment or foreign body$425
D7610maxilla - open reduction (teeth immobilized, if present)$2,000
D7620maxilla - closed reduction (teeth immobilized, if present)$1,500
D7630mandible - open reduction (teeth immobilized, if present)$2,000
D7640mandible - closed reduction (teeth immobilized, if present)$1,300
D7650malar and/or zygomatic arch - open reduction$1,600
D7660malar and/or zygomatic arch - closed reduction$1,300
D7670alveolus closed reduction may include stabilization of teeth$540
D7671alveolus, open reduction may include stabilization of teeth$180
D7710maxilla open reduction$2,190
D7720maxilla - closed reduction$2,190
D7730mandible - open reduction$1,450
D7740mandible - closed reduction$1,450
D7750malar and/or zygomatic arch - open reduction$1,750
D7760malar and/or zygomatic arch - closed reduction$1,850
D7770alveolus - open reduction stabilization of teeth$950
D7771alveolus, closed reduction stabilization of teeth$326
D7910suture of recent small wounds up to 5 cm$120
D7911complicated suture - up to 5 cm$120
D7912complicated suture - greater than 5 cm$220
D7960frenulectomy (frenectomy or frenotomy) - separate procedure$220
D7970Excision of hyperplastoc tissue- per arch$220
D7971Excision of pericoronal gingival$125

ORTHODONTICS

CLASS 1 Treatment - $3005 (plus Retainer)

CLASS 2 Treatment - $3205 (plus Retainer)

CLASS 3 Treatment - $3405 (plus Retainer)

NOTE: Max allowable charge for retainer is $500

Includes placement of appliance, treatment for two years (24 months), removal of appliances, records and placement of retainer. Does not include the cost of the retainer to be paid by LDP member. The Orthodontist will explain the length of treatment, all fees and the payment schedule. Orthodontic discount is not available to any member currently in treatment. Orthodontic treatment that requires surgery or unusual services may require an additional charge. Discuss this with the patient prior to beginning treatment.

GENERAL INFORMATION

  1. Members will be responsible for the full cost of any prescription drugs prescribed by a LDP provider.
  2. Members will be responsible for the full cost of any services provided by a LDP provider.
  3. If a member has to cancel an appointment, the dental office must be notified 24 hours in advance or a fee may be charged.
  4. Should the member have a dental insurance plan or other dental benefit plans, LDP discounts will not apply.
  5. If treatment is required by a non-participating dentist or treatment is performed in a hospital facility, the reduced fees do not apply and the member will be responsible to the non-participating dentist or hospital for the usual and customary fee.
  6. If the member should have a grievance, it should be submitted to the LDP office. Unresolved grievances will be settled by arbitration.
  7. Fees listed on the member Benefits and Dental fee Schedule are for procedures done by participating general dentist and orthodontists and should not be considered specialist's fees. Specialist fees are billed at usual and customary charges less 20%.
  8. Any procedure involving lab fees will incur additional costs. All applicable lab fees are the full responsibility of the member and are subject to no discount.