Diagnostic Services
| Code | Description | LDP |
|---|
| D0120 | periodic oral evaluation | $16 |
| D0140 | limited oral evaluation - problem focused | $25 |
| D0150 | comprehensive oral evaluation - new or established patient | $21 |
| D0160 | detailed and extensive oral evaluation - problem focused, by report | $26 |
| D0170 | re-evaluation - limited, problem focused (established patient; not post-operative visit) | $27 |
| D0180 | comprehensive periodontal evaluation - new or established patient | $40 |
| D0210 | X-ray, intraoral - complete series | $48 |
| D0220 | intraoral - periapical first film | $6 |
| D0230 | intraoral - periapical each additional film | $7 |
| D0240 | intraoral - occlusal film | $14 |
| D0250 | extraoral - first film | $19 |
| D0260 | extraoral - each additional film | $19 |
| D0270 | bitewing - single film | $12 |
| D0272 | bitewings - two films | $16 |
| D0274 | bitewings - four films | $25 |
| D0277 | vertical bitewings - 7 to 8 films | $38 |
| D0310 | sialography | $143 |
| D0330 | panoramic film | $49 |
| D0340 | cephalometric film | $48 |
| D0415 | collection of microorganisms for culture and sensitivity | $29 |
| D0425 | caries susceptibility tests | $19 |
| D0460 | pulp vitality tests | $25 |
| D0470 | diagnostic casts | $25 |
| D0999 | Disposables/Infectious control | $8 |
| D9972 | cosmetic bleaching - per arch | $190 |
Preventive Services
| Code | Description | LDP |
|---|
| D1110 | prophylaxis - adult | $32 |
| D1120 | prophylaxis - child | $23 |
| D1201 | topical application of fluoride (including prophylaxis) - child | $35 |
| D1203 | topical application of fluoride (prophylaxis not included) - child | $10 |
| D1204 | topical application of fluoride (prophylaxis not included) - adult | $11 |
| D1205 | topical application of fluoride (including prophylaxis) - adult | $45 |
| D1310 | nutritional counseling for control of dental disease | $20 |
| D1320 | tobacco counseling for the control and prevention of oral disease | $20 |
| D1330 | oral hygiene instructions | $24 |
| D1351 | sealant - per tooth | $20 |
| D1510 | space maintainer - fixed - unilateral | $144 |
| D1515 | space maintainer - fixed - bilateral | $173 |
| D1520 | space maintainer - removable - unilateral | $178 |
| D1525 | space maintainer - removable - bilateral | $210 |
Basic Restorations
| Code | Description | LDP |
|---|
| D1550 | re-cementation of space maintainer | $34 |
| D2140 | amalgam - one surface, primary or permanent | $44 |
| D2150 | amalgam - two surfaces, primary or permanent | $57 |
| D2160 | amalgam - three surfaces, primary or permanent | $69 |
| D2161 | amalgam - four or more surfaces, primary or permanent | $89 |
| D2330 | resin-based composite - one surface, anterior | $58 |
| D2331 | resin-based composite - two surfaces, anterior | $73 |
| D2332 | resin-based composite - three surfaces, anterior | $99 |
| D2335 | resin-based composite - four or more surfaces or involving incisal angle (anterior) | $99 |
| D2390 | resin-based composite crown, anterior | $119 |
| D2391 | resin-based composite - one surface, posterior | $69 |
| D2392 | resin-based composite - two surfaces, posterior | $84 |
| D2393 | resin-based composite - three surfaces, posterior | $110 |
| D2394 | resin-based composite - four or more surfaces, posterior | $155 |
Inlay/Onlay Restorations
| Code | Description | LDP |
|---|
| D2410 | gold foil - one surface | $165 |
| D2420 | gold foil - two surfaces | $195 |
| D2510 | inlay - metallic - one surface | $269 |
| D2520 | inlay - metallic - two surfaces | $357 |
| D2530 | inlay - metallic - three or more surfaces | $433 |
| D2542 | onlay - metallic-two surfaces | $455 |
| D2543 | onlay - metallic-three surfaces | $475 |
| D2544 | onlay - metallic-four or more surfaces | $495 |
| D2610 | inlay - porcelain/ceramic - one surface | $357 |
| D2620 | inlay - porcelain/ceramic - two surfaces | $413 |
| D2630 | inlay - porcelain/ceramic - three or more surfaces | $430 |
| D2642 | onlay - porcelain/ceramic - two surfaces | $460 |
| D2643 | onlay - porcelain/ceramic - three surfaces | $475 |
| D2644 | onlay - porcelain/ceramic - four or more surfaces | $485 |
| D2650 | inlay - resin-based composite - one surface | $300 |
| D2651 | inlay - resin-based composite - two surfaces | $369 |
| D2652 | inlay - resin-based composite - three or more surfaces | $389 |
| D2662 | onlay - resin-based composite - two surfaces | $238 |
| D2663 | onlay - resin-based composite - three surfaces | $284 |
| D2664 | onlay - resin-based composite - four or more surfaces | $284 |
| D2710 | crown - resin-based composite (indirect) | $200 |
| D2720 | crown - resin with high noble metal | $415 |
| D2721 | crown - resin with predominantly base metal | $315 |
| D2722 | crown - resin with noble metal | $359 |
| D2740 | crown - porcelain/ceramic substrate | $540 |
| D2750 | crown - porcelain fused to high noble metal | $540 |
| D2751 | crown - porcelain fused to predominantly base metal | $500 |
| D2752 | crown - porcelain fused to noble metal | $520 |
| D2780 | crown - 3/4 cast high noble metal | $550 |
| D2781 | crown - 3/4 cast predominantly base metal | $500 |
| D2782 | crown - 3/4 cast noble metal | $521 |
| D2783 | crown - 3/4 porcelain/ceramic | $543 |
| D2790 | crown - full cast high noble metal | $530 |
| D2791 | crown - full cast predominantly base metal | $419 |
| D2792 | crown - full cast noble metal | $429 |
Other Restorative Services
| Code | Description | LDP |
|---|
| D2910 | recement inlay, onlay, or partial coverage restoration | $38 |
| D2920 | recement crown | $44 |
| D2930 | prefabricated stainless steel crown - primary tooth | $110 |
| D2931 | prefabricated stainless steel crown - permanent tooth | $114 |
| D2932 | prefabricated resin crown | $120 |
| D2933 | prefabricated stainless steel crown with resin window | $112 |
| D2940 | sedative filling | $25 |
| D2950 | core buildup, including any pins | $80 |
| D2951 | pin retention - per tooth, in addition to restoration | $18 |
| D2952 | cast post and core in addition to crown | $170 |
| D2954 | prefabricated post and core in addition to crown | $133 |
| D2955 | post removal (not in conjunction with endodontic therapy) | $131 |
| D2980 | crown repair, by report | $80 |
Endodontic Services
| Code | Description | LDP |
|---|
| D3110 | pulp cap - direct (excluding final restoration) | $18 |
| D3120 | pulp cap - indirect (excluding final restoration) | $38 |
| D3220 | therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament | $52 |
| D3230 | pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) | $69 |
| D3240 | pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) | $69 |
| D3310 | anterior (excluding final restoration) | $350 |
| D3320 | bicuspid (excluding final restoration) | $400 |
| D3330 | molar (excluding final restoration) | $500 |
| D3346 | retreatment of previous root canal therapy - anterior | $404 |
| D3347 | retreatment of previous root canal therapy - bicuspid | $415 |
| D3348 | retreatment of previous root canal therapy - molar | $580 |
| D3351 | apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) | $60 |
| D3352 | apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) | $60 |
| D3353 | apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) | $60 |
| D3410 | apicoectomy/periradicular surgery - anterior | $258 |
| D3421 | apicoectomy/periradicular surgery - bicuspid (first root) | $279 |
| D3425 | apicoectomy/periradicular surgery - molar (first root) | $279 |
| D3426 | apicoectomy/periradicular surgery (each additional root) | $109 |
| D3430 | retrograde filling - per root | $84 |
| D3450 | root amputation - per root | $149 |
| D3920 | hemisection (including any root removal), not including root canal therapy | $121 |
| D3950 | canal preparation and fitting of preformed dowel or post | $113 |
Periodontic Services
| Code | Description | LDP |
|---|
| D4210 | gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant | $138 |
| D4211 | gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant | $65 |
| D4240 | gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant | $300 |
| D4241 | gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth spaces per quadrant | $287 |
| D4249 | clinical crown lengthening - hard tissue | $275 |
| D4260 | osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant | $500 |
| D4261 | osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant | $404 |
| D4263 | bone replacement graft - first site in quadrant | $240 |
| D4264 | bone replacement graft - each additional site in quadrant | $160 |
| D4266 | guided tissue regeneration - resorbable barrier, per site | $330 |
| D4268 | surgical revision procedure, per tooth | $270 |
| D4270 | pedicle soft tissue graft procedure | $340 |
| D4271 | free soft tissue graft procedure (including donor site surgery) | $391 |
| D4273 | subepithelial connective tissue graft procedures, per tooth | $391 |
| D4275 | soft tissue allograft | $440 |
| D4320 | provisional splinting - intracoronal | $180 |
| D4321 | provisional splinting - extracoronal | $150 |
| D4341 | periodontal scaling and root planing - four or more teeth per quadrant | $80 |
| D4342 | periodontal scaling and root planing - one to three teeth per quadrant | $75 |
| D4355 | full mouth debridement to enable comprehensive evaluation and diagnosis | $46 |
| D4910 | periodontal maintenance | $43 |
Prosthodontics-Removable
| Code | Description | LDP |
|---|
| D5110 | complete denture - maxillary | $633 |
| D5120 | complete denture - mandibular | $633 |
| D5130 | immediate denture - maxillary | $525 |
| D5140 | immediate denture - mandibular | $525 |
| D5211 | maxillary partial denture - resin base (including any conventional clasps, rests and teeth) | $455 |
| D5212 | mandibular partial denture - resin base (including any conventional clasps, rests and teeth) | $455 |
| D5213 | maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $689 |
| D5214 | mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $689 |
| D5281 | removable unilateral partial denture - one piece cast metal (including clasps and teeth) | $350 |
Adjustments, Repairs, Rebase, Reline, Other Services
| Code | Description | LDP |
|---|
| D5410 | adjust complete denture - maxillary | $30 |
| D5411 | adjust complete denture - mandibular | $30 |
| D5421 | adjust partial denture - maxillary | $30 |
| D5422 | adjust partial denture - mandibular | $30 |
| D5510 | repair broken complete denture base | $50 |
| D5520 | replace missing or broken teeth - complete denture (each tooth) | $45 |
| D5610 | repair resin denture base | $50 |
| D5620 | repair cast framework | $75 |
| D5630 | repair or replace broken clasp | $60 |
| D5640 | replace broken teeth - per tooth | $45 |
| D5650 | add tooth to existing partial denture | $55 |
| D5660 | add clasp to existing partial denture | $75 |
| D5710 | rebase complete maxillary denture | $211 |
| D5711 | rebase complete mandibular denture | $211 |
| D5720 | rebase maxillary partial denture | $200 |
| D5721 | rebase mandibular partial denture | $200 |
| D5730 | reline complete maxillary denture (chairside) | $112 |
| D5731 | reline complete mandibular denture (chairside) | $112 |
| D5740 | reline maxillary partial denture (chairside) | $110 |
| D5741 | reline mandibular partial denture (chairside) | $110 |
| D5750 | reline complete maxillary denture (laboratory) | $130 |
| D5751 | reline complete mandibular denture (laboratory) | $130 |
| D5760 | reline maxillary partial denture (laboratory) | $160 |
| D5761 | reline mandibular partial denture (laboratory) | $160 |
| D5820 | interim partial denture (maxillary) | $281 |
| D5821 | interim partial denture (mandibular) | $281 |
| D5850 | tissue conditioning, maxillary | $50 |
| D5851 | tissue conditioning, mandibular | $50 |
| D6010 | surgical placement of implant body: endosteal implant | $600 |
| D6040 | surgical placement: eposteal implant | $600 |
| D6050 | surgical placement: transosteal implant | $600 |
| D6090 | repair implant supported prosthesis, by report | $130 |
| D6095 | repair implant abutment, by report | $130 |
| D6100 | implant removal, by report | $40 |
Prosthodontics-Fixed Other Services
| Code | Description | LDP |
|---|
| D6210 | pontic - cast high noble metal | $445 |
| D6211 | pontic - cast predominantly base metal | $445 |
| D6212 | pontic - cast noble metal | $445 |
| D6240 | pontic - porcelain fused to high noble metal | $445 |
| D6241 | pontic - porcelain fused to predominantly base metal | $445 |
| D6242 | pontic - porcelain fused to noble metal | $445 |
| D6245 | pontic - porcelain/ceramic | $445 |
| D6250 | pontic - resin with high noble metal | $445 |
| D6251 | pontic - resin with predominantly base metal | $445 |
| D6252 | pontic - resin with noble metal | $445 |
| D6253 | provisional pontic | $445 |
| D6545 | retainer - cast metal for resin bonded fixed prosthesis | $170 |
| D6548 | retainer - porcelain/ceramic for resin bonded fixed prosthesis | $170 |
| D6600 | inlay - porcelain/ceramic, two surfaces | $525 |
| D6601 | inlay - porcelain/ceramic, three or more surfaces | $525 |
| D6602 | inlay - cast high noble metal, two surfaces | $525 |
| D6603 | inlay - cast high noble metal, three or more surfaces | $565 |
| D6605 | inlay - cast predominantly base metal, three or more surfaces | $525 |
| D6606 | inlay - cast noble metal, two surfaces | $525 |
| D6607 | inlay - cast noble metal, three or more surfaces | $595 |
| D6608 | onlay -porcelain/ceramic, two surfaces | $500 |
| D6609 | onlay - porcelain/ceramic, three or more surfaces | $545 |
| D6610 | onlay - cast high noble metal, two surfaces | $585 |
| D6611 | onlay - cast high noble metal, three or more surfaces | $545 |
| D6612 | onlay - cast predominantly base metal, two surfaces | $475 |
| D6613 | onlay - cast predominantly base metal, three or more surfaces | $565 |
| D6614 | onlay - cast noble metal, two surfaces | $485 |
| D6615 | onlay - cast noble metal, three or more surfaces | $535 |
| D6720 | crown - resin with high noble metal | $415 |
| D6721 | crown - resin with predominantly base metal | $305 |
| D6722 | crown - resin with noble metal | $344 |
| D6740 | crown - porcelain/ceramic | $560 |
| D6750 | crown - porcelain fused to high noble metal | $500 |
| D6751 | crown - porcelain fused to predominantly base metal | $470 |
| D6752 | crown - porcelain fused to noble metal | $490 |
| D6780 | crown - 3/4 cast high noble metal | $450 |
| D6781 | crown - 3/4 cast predominantly base metal | $520 |
| D6782 | crown - 3/4 cast noble metal | $525 |
| D6783 | crown - 3/4 porcelain/ceramic | $545 |
| D6790 | crown - full cast high noble metal | $500 |
| D6791 | crown - full cast predominantly base metal | $415 |
| D6792 | crown - full cast noble metal | $415 |
| D6793 | provisional retainer crown | $225 |
| D6930 | recement fixed partial denture | $45 |
| D6970 | cast post and core in addition to fixed partial denture retainer | $150 |
| D6971 | cast post as part of fixed partial denture retainer | $140 |
| D6972 | prefabricated post and core in addition to fixed partial denture retainer | $130 |
| D6973 | core build up for retainer, including any pins | $100 |
| D6975 | coping - metal | $220 |
Oral Surgery-Extractions
| Code | Description | LDP |
|---|
| D7111 | extraction, coronal remnants - deciduous tooth | $55 |
| D7140 | extraction, erupted tooth or exposed root (elevation and/or forceps removal) | $55 |
| D7210 | surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth | $100 |
| D7220 | removal of impacted tooth - soft tissue | $100 |
| D7230 | removal of impacted tooth - partially bony | $152 |
| D7240 | removal of impacted tooth - completely bony | $189 |
| D7241 | removal of impacted tooth - completely bony, with unusual surgical complications | $300 |
| D7250 | surgical removal of residual tooth roots (cutting procedure) | $100 |
| D7260 | oroantral fistula closure | $245 |
| D7270 | tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth | $150 |
| D7280 | surgical access of an unerupted tooth | $215 |
| D7282 | mobilization of erupted or malpositioned tooth to aid eruption | $230 |
| D7285 | biopsy of oral tissue - hard (bone, tooth) | $120 |
| D7286 | biopsy of oral tissue - soft | $100 |
| D7290 | surgical repositioning of teeth | $100 |
Oral Surgery-Other Procedures
| Code | Description | LDP |
|---|
| D7310 | alveoloplasty in conjunction with extractions - per quadrant | $100 |
| D7320 | alveoloplasty not in conjunction with extractions - per quadrant | $150 |
| D7340 | vestibuloplasty - ridge extension (secondary epithelialization) | $260 |
| D7350 | vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) | $250 |
| D7410 | excision of benign lesion up to 1.25 cm | $225 |
| D7411 | excision of benign lesion greater than 1.25 cm | $188 |
| D7412 | excision of benign lesion, complicated | $270 |
| D7413 | excision of malignant lesion up to 1.25 cm | $300 |
| D7414 | excision of malignant lesion greater than 1.25 cm | $385 |
| D7415 | excision of malignant lesion, complicated | $425 |
| D7440 | excision of malignant tumor - lesion diameter up to 1.25 cm | $325 |
| D7441 | excision of malignant tumor - lesion diameter greater than 1.25 cm | $400 |
| D7450 | removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm | $250 |
| D7451 | removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm | $340 |
| D7460 | removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm | $425 |
| D7461 | removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm | $500 |
| D7471 | removal of lateral exostosis (maxilla or mandible) | $250 |
| D7472 | removal of torus palatinus | $310 |
| D7473 | removal of torus mandibularis | $310 |
| D7485 | surgical reduction of osseous tuberosity | $275 |
| D7510 | incision and drainage of abscess - intraoral soft tissue | $41 |
| D7520 | incision and drainage of abscess - extraoral soft tissue | $125 |
| D7530 | removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue | $225 |
| D7540 | removal of reaction producing foreign bodies, musculoskeletal system | $250 |
| D7550 | partial ostectomy/sequestrectomy for removal of non-vital bone | $170 |
| D7560 | maxillary sinusotomy for removal of tooth fragment or foreign body | $425 |
| D7610 | maxilla - open reduction (teeth immobilized, if present) | $2,000 |
| D7620 | maxilla - closed reduction (teeth immobilized, if present) | $1,500 |
| D7630 | mandible - open reduction (teeth immobilized, if present) | $2,000 |
| D7640 | mandible - closed reduction (teeth immobilized, if present) | $1,300 |
| D7650 | malar and/or zygomatic arch - open reduction | $1,600 |
| D7660 | malar and/or zygomatic arch - closed reduction | $1,300 |
| D7670 | alveolus closed reduction may include stabilization of teeth | $540 |
| D7671 | alveolus, open reduction may include stabilization of teeth | $180 |
| D7710 | maxilla open reduction | $2,190 |
| D7720 | maxilla - closed reduction | $2,190 |
| D7730 | mandible - open reduction | $1,450 |
| D7740 | mandible - closed reduction | $1,450 |
| D7750 | malar and/or zygomatic arch - open reduction | $1,750 |
| D7760 | malar and/or zygomatic arch - closed reduction | $1,850 |
| D7770 | alveolus - open reduction stabilization of teeth | $950 |
| D7771 | alveolus, closed reduction stabilization of teeth | $326 |
| D7910 | suture of recent small wounds up to 5 cm | $120 |
| D7911 | complicated suture - up to 5 cm | $120 |
| D7912 | complicated suture - greater than 5 cm | $220 |
| D7960 | frenulectomy (frenectomy or frenotomy) - separate procedure | $220 |
| D7970 | Excision of hyperplastoc tissue- per arch | $220 |
| D7971 | Excision of pericoronal gingival | $125 |
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.
