2023_CDS_Fee_Schedule__1_.pdf

CORONADO DENTAL SERVICE

Fee Schedule Overview Proc Code Description UCR Fee D0120 Periodic Evaluation 69.00$ D0140 Limited Evaluation-problem focused 117.00$ D0150 Comprehensive Evaluation 106.00$ D0160 Detailed & Extensive Evaluation 134.00$ D0171 Re-eval - Post-op Office Visit 52.00$ D0210 Intraoral – comprehensive series of radiographic images 159.00$ D0220 Intraoral Periapical Images 38.00$ D0230 Intraoral Periapical Add'l 28.00$ D0240 Intraoral Occlusal Image 50.00$ D0250 Extraoral 2D projection image 42.00$ D0270 Bitewing Single Image 32.00$ D0272 Bitewing Two Images 42.00$ D0274 Bitewing Four Images 89.00$ D0330 Panoramic Image 178.00$ D1110 Prophylaxis - Adult 125.00$ D1206 Topical Applic Fluoride Varnish 42.00$ D1208 Topical Application of Fluoride 38.00$ D1330 Oral Hygiene Instructions 32.00$ D1351 Sealant 70.00$ D1354 Interim caries arresting medicament application - per tooth 22.00$ D1510 Space maintainer - fixed, unilateral – per quadrant 467.00$ D1516 Space maintainer - fixed - bilateral, maxillary 599.00$ D1517 Space maintainer - fixed - bilateral, mandibular 599.00$ D1520 Space maintainer - removable, unilateral - per quadrant 528.00$ D1526 Space maintainer - removable - bilateral, maxillary 660.00$ D1527 Space maintainer - removable - bilateral, mandibular 660.00$ D2140 Amalgam 1 Surface 167.00$ D2150 Amalgam 2 Surface 205.00$ D2160 Amalgam 3 Surface 242.00$ D2161 Amalgam 4 Surface 289.00$ D2330 Anterior Resin Composite 1s 187.00$ D2331 Anterior Resin Composite 2s 252.00$ D2332 Anterior Resin Composite 3s 302.00$ D2335 Anterior Resin Composite 4+s 364.00$ D2390 Anterior Resin Composite Crown 612.00$ D2391 Posterior Resin Composite 1s 205.00$ D2392 Posterior Resin Composite 2s 299.00$ D2393 Posterior Resin Composite 3s 337.00$ D2394 Posterior Resin Composite 4+s 444.00$ D2510 Metallic Inlay 1 Surface 1,035.00$

BEST AND FINAL CDS FEE SCHEDULE

Proc Code Description UCR Fee D2520 Metallic Inlay 2 Surface 1,146.00$ D2530 Metallic Inlay 3+ Surface 1,231.00$ D2542 Metallic Onlay 2 Surface 1,273.00$ D2543 Metallic Onlay 3 Surface 1,315.00$ D2544 Metallic Onlay 4+ Surface 1,400.00$ D2610 Full Porcelain/Ceramic Inlay 1s 1,188.00$ D2620 Full Porcelain/Ceramic Inlay 2s 1,231.00$ D2630 Full Porcelain/Ceram Inlay 3+s 1,315.00$ D2642 Full Porcelain/Ceramic Onlay 2s 1,358.00$ D2643 Full Porcelain/Ceramic Onlay 3s 1,400.00$ D2644 Full Porcelain/Ceram Onlay 4+s 1,400.00$ D2650 Resin Composite Inlay 1s 1,104.00$ D2651 Resin Composite Inlay 2s 1,146.00$ D2652 Resin Composite Inlay 3+s 1,188.00$ D2662 Resin Composite Onlay 2s 1,231.00$ D2663 Resin Composite Onlay 3s 1,273.00$ D2664 Resin Composite Onlay 4+s 1,315.00$ D2710 Indirect Resin-Based Crown 1,188.00$ D2720 Resin/HNM Crown 1,315.00$ D2721 Resin/Base Crown 1,273.00$ D2722 Resin/Noble Crown 1,315.00$ D2740 Full Porcelain/Ceramic Crown 1,315.00$ D2750 Porcelain/HNM Crown 1,248.00$ D2751 Porcelain/Base Crown 1,212.00$ D2752 Porcelain/Noble Crown 1,371.00$ D2780 3/4 Cast HNM Crown 1,358.00$ D2781 3/4 Cast Base Crown 1,315.00$ D2782 3/4 Cast Noble Crown 1,358.00$ D2783 Crown - 3/4 porcelain/ceramic 1,400.00$ D2790 Full Cast HNM Crown 1,352.00$ D2791 Full Cast Base Crown 1,250.00$ D2792 Full Cast Noble Crown 1,285.00$ D2794 Crown - titanium and titanium alloys 477.00$ D2799 Provisional Crown 766.00$ D2910 Recement/bnd inlay/onlay/part 145.00$ D2920 Re-cement or re-bond crown 121.00$ D2930 Prefabricated Steel Crown-Prim 333.00$ D2931 Prefabricated Steel Crown-Perm 402.00$ D2932 Prefabricated Resin Crown 429.00$ D2933 Steel Crown w/ Resin Window 417.00$ D2940 Protective Restoration 136.00$ D2950 Core Buildup w/ Any Pins 337.00$ D2951 Pin Retention 103.00$ D2952 Post & Core Added to Crown 543.00$ D2954 Prefabricated Post & Core 355.00$ D2960 Direct Resin Veneer 726.00$

D2961 Indirect Resin Veneer 1,112.00$ D2962 Full Porcelain Veneer 1,295.00$ D2980 Crown Repair, Material Failure 341.00$ D3110 Direct Pulp Cap 98.00$ D3120 Indirect Pulp Cap 98.00$ D3220 Therapeutic Pulpotomy 238.00$ D3221 Pulpal Debridement 256.00$ D3230 Pulpal Therapy on Anterior 323.00$ D3240 Pulpal Therapy on Posterior 369.00$ D3310 Root Canal Therapy on Anterior 851.00$ D3320 Root Canal Therapy on Premolar 1,011.00$ D3330 Root Canal Therapy on Molar Tooth 1,020.00$ D3331 Treat Root Canal Obstruction 449.00$ D3332 Incomplete Endodontic Therapy 472.00$ D3346 Retreat, prev RCT - anterior 1,071.00$ D3347 Retreat, prev RCT - premolar 1,131.00$ D4341 Scaling & Root Planing (4-8) 370.00$ D4346 Scaling in presence of generalized gingival inflammation, full mouth 370.00$ D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and 275.00$ D4910 Periodontal Maintenance 181.00$ D4999 Other Periodontal Procedure 42.00$ D5110 Full Upper Denture 1,890.00$ D5120 Full Lower Denture 1,890.00$ D5130 Immediate denture - maxillary 1,625.00$ D5140 Immediate denture - mandibular 1,625.00$ D5211 Upper Partial w/ Resin Base 2,082.00$ D5212 Lower Partial w/ Resin Base 2,082.00$ D5213 Maxillary partial denture - cast metal framework with resin denture bases (includ 2,213.00$ D5214 Mandibular partial denture - cast metal framework with resin denture bases 2,213.00$ D5282 Removable unilateral partial denture - cast metal, maxillary 1,198.00$ D5283 Removable unilateral partial denture - cast metal, mandibular 1,198.00$ D5410 Adjust Full Upper Denture 107.00$ D5411 Adjust Full Lower Denture 107.00$ D5421 Adjust Partial Upper Denture 107.00$ D5422 Adjust Partial Lower Denture 107.00$ D5511 Repair broken complete denture base, mandibular 257.00$ D5512 Repair broken complete denture base, maxillary 257.00$ D5520 Replace Tooth on Full Denture 201.00$ D5520.5520 Replace Tooth on Full Denture 201.00$ D5611 Repair resin partial denture base, mandibular 245.00$ D5612 Repair resin partial denture base, maxillary 248.00$ D5621 Repair cast partial framework, mandibular 190.00$ D5622 Repair cast partial framework, maxillary 190.00$ D5630 Repair/replace broken retentive/clasping materials - per tooth 341.00$ D5640 Replace Broken Tooth on Partial 215.00$ D5640.d5640 Replace Broken Tooth on Partial 215.00$

D5650 Add Tooth to Existing Partial 248.00$ D5650.5650 Add Tooth to Existing Partial 248.00$ D5660 Add clasp to existing partial - per tooth 284.00$ D5710 Rebase Full Upper Denture 711.00$ D5711 Rebase Full Lower Denture 711.00$ D5720 Rebase Partial Upper Denture 683.00$ D5721 Rebase Partial Lower Denture 683.00$ D5730 Reline Full Upper Denture 472.00$ D5731 Reline Full Lower Denture 472.00$ D5740 Reline Partial Upper Denture 458.00$ D5741 Reline Partial Lower Denture 458.00$ D5750 Lab Reline Full Upper Denture 537.00$ D5751 Lab Reline Full Lower Denture 537.00$ D5760 Lab Reline Upper Partial 571.00$ D5761 Lab Reline Lower Partial 571.00$ D5810 Interim Full Upper Denture 1,026.00$ D5811 Interim Full Lower Denture 1,026.00$ D5820 Interim Upper Partial Denture 838.00$ D5821 Interim Lower Partial Denture 838.00$ D5850 Upper Tissue Conditioning 256.00$ D5851 Lower Tissue Conditioning 256.00$ D5867 Replacement of Attachment Part 299.00$ D5899 Other Removable Procedure 149.00$ D6210 Full Cast HNM Pontic 1,342.00$ D6211 Full Cast Base Pontic 1,230.00$ D6212 Full Cast Noble Pontic 1,285.00$ D6240 Porcelain/HNM Pontic 1,362.00$ D6241 Porcelain/Base Pontic 1,267.00$ D6242 Porcelain/Noble Pontic 1,319.00$ D6245 Full Porcelain/Ceramic Pontic 1,369.00$ D6720 Retainer crown - resin with high noble metal 1,329.00$ D6721 Retainer crown - resin with predominantly base metal 1,281.00$ D6740 Retainer crown - porcelain/ceramic 1,313.00$ D6750 Retainer crown - porcelain fused to high noble metal 1,376.00$ D6751 Retainer crown - porcelain fused to predominantly base metal 1,254.00$ D6752 Retainer crown - porcelain fused to noble metal 1,313.00$ D6780 Retainer crown - 3/4 cast high noble metal 1,338.00$ D6790 Retainer crown - full cast high noble metal 1,352.00$ D6791 Retainer crown - full cast predominantly base metal 1,220.00$ D6792 Retainer crown - full cast noble metal 1,369.00$ D6930 Recement/bnd fxd part denture 201.00$ D7140 Routine Extraction 172.00$ D7210 Extraction of Erupted Tooth with Bone Removal 317.00$ D7241 Extraction Complications 514.00$ D7250 Removal of Residual Tooth Roots 336.00$ D7310 Alveoloplasty with extractions 4+ teeth, per quadrant 351.00$

D7320 Alveoloplasty (4-8) 537.00$ D7321 Alveoloplasty (1-3) 376.00$ D7321.7321 Alveoloplasty (1-3) 376.00$ D9110 Palliative treatment of dental pain – per visit 153.00$ D9310 Professional Consultation 230.00$ D9410 House Call 230.00$ D9932 Cleaning and inspection of removable complete denture, maxillary 62.00$ D9933 Cleaning and inspection of removable complete denture, mandibular 62.00$ D9934 Cleaning and inspection of removable partial denture, maxillary 22.00$ D9935 Cleaning and inspection of removable partial denture, mandibular 22.00$ D9941 Soft Night Guard 768.00$ D9943 Occlusal guard adjustment 64.00$ D9944 Occlusal guard - hard appliance, full arch 768.00$ D9945 Occlusal guard - soft appliance, full arch 768.00$ D9946 Occlusal guard - hard appliance, partial arch 768.00$ D9951 Limited Occlusal Adjustment 64.00$

CDS