| 2d cephal radio image (D0702) |
— |
$143 |
— |
| 2d cephalometric image (D0340) |
— |
$166 |
— |
| 2d oral/facial photo image (D0703) |
— |
$70 |
— |
| 2d tee w or w/o fol w/con,in (C8925) |
— |
$5,840 |
— |
| 2d tte w or w/o fol w/con,co (C8923) |
— |
$3,280 |
— |
| 2d tte w or w/o fol w/con,fu (C8924) |
— |
$1,978 |
— |
| Add proc construct new crown (D2971) |
— |
$272 |
— |
| Adm tocilizu covid-19 1st (M0249) |
— |
$1,645 |
— |
| Adm tocilizu covid-19 2nd (M0250) |
— |
$1,645 |
— |
| Admin hepatitis b vaccine (G0010) |
— |
$236 |
— |
| Admin influenza virus vac (G0008) |
— |
$236 |
— |
| Admin pneumococcal vaccine (G0009) |
— |
$236 |
— |
| Alveoloplasty not w/extracts (D7321) |
— |
$3,510 |
— |
| Alveoloplasty w/extract 1-3 (D7311) |
— |
$336 |
— |
| Alveoplasty w/ extraction (D7310) |
— |
$356 |
— |
| Alveoplasty w/o extraction (D7320) |
— |
$464 |
— |
| Amalgam 4 or > surfaces perm (D2161) |
— |
$316 |
— |
| Amalgam one surface permanen (D2140) |
— |
$170 |
— |
| Amalgam three surfaces perma (D2160) |
— |
$270 |
— |
| Amalgam two surfaces permane (D2150) |
— |
$214 |
— |
| Ana crown exp 1-3 per quad (D4231) |
— |
$150 |
— |
| Ana crown exp 4 or> per quad (D4230) |
— |
$300 |
— |
| Ant resin-based cmpst crown (D2390) |
— |
$572 |
— |
| Apexification/recalc initial (D3351) |
— |
$440 |
— |
| Apexification/recalc interim (D3352) |
— |
$294 |
— |
| Apically positioned flap (D4245) |
— |
$250 |
— |
| Apicoectomy - anterior (D3410) |
— |
$1,244 |
— |
| Assessment of a patient (D0191) |
— |
$65 |
— |
| Auto tissue graft 1st tooth (D4273) |
— |
$1,670 |
— |
| Behavior counsel obesity 15m (G0447) |
— |
$329 |
— |
| Bio mtrls to aid soft/os reg (D4265) |
— |
$674 |
— |
| Bitewings - three images (D0273) |
— |
$72 |
— |
| Bitewings four images (D0274) |
— |
$90 |
— |
| Blind cor sinus reducer impl (C9783) |
— |
$42,271 |
— |
| Blind interatrial shunt ide (C9758) |
— |
$63,700 |
— |
| Bone replce graft first site (D4263) |
— |
$706 |
— |
| Canal prep/fitting of dowel (D3950) |
— |
$190 |
— |
| Catheterize for urine spec (P9612) |
— |
$379 |
— |
| Chemo extend iv infus w/pump (G0498) |
— |
$1,237 |
— |
| Comp periodontal evaluation (D0180) |
— |
$142 |
— |
| Complete occlusal adjustment (D9952) |
— |
$760 |
— |
| Complex simulation w/pet-ct (G0562) |
— |
$7,560 |
— |
| Comprehensve oral evaluation (D0150) |
— |
$126 |
— |
| Con tissue w pedicle graft (D4276) |
— |
$2,686 |
— |
| Cone beam ct both jaws (D0383) |
— |
$375 |
— |
| Cone beam ct capt & interp (D0364) |
— |
$400 |
— |
| Cone beam ct capt mandible (D0381) |
— |
$325 |
— |
| Cone beam ct capt maxilla (D0382) |
— |
$325 |
— |
| Cone beam ct capture limited (D0380) |
— |
$300 |
— |
| Cone beam ct capture tmj (D0384) |
— |
$375 |
— |
| Cone beam ct interp both jaw (D0367) |
— |
$480 |
— |
| Cone beam ct interprete man (D0365) |
— |
$440 |
— |
| Cone beam ct interprete max (D0366) |
— |
$440 |
— |
| Cone beam ct interprete tmj (D0368) |
— |
$480 |
— |
| Coping (D2975) |
— |
$690 |
— |
| Core build-up incl any pins (D2950) |
— |
$336 |
— |
| Coronectomy (D7251) |
— |
$600 |
— |
Covid-19 lab test non-cdc (U0002)
range across 4 matching MRF lines |
— |
$300–$405 |
— |
| Crown 3/4 cast base metal (D2781) |
— |
$4,000 |
— |
| Crown 3/4 cast hi noble met (D2780) |
— |
$1,916 |
— |
| Crown 3/4 cast noble metal (D2782) |
— |
$1,780 |
— |
| Crown 3/4 porcelain/ceramic (D2783) |
— |
$4,000 |
— |
| Crown full cast base metal (D2791) |
— |
$1,438 |
— |
| Crown full cast high noble m (D2790) |
— |
$4,000 |
— |
| Crown full cast noble metal (D2792) |
— |
$4,000 |
— |
| Crown lengthen hard tissue (D4249) |
— |
$1,104 |
— |
| Crown porc fused to titanium (D2753) |
— |
$1,750 |
— |
| Crown porcelain fused base m (D2751) |
— |
$1,444 |
— |
| Crown porcelain w/ h noble m (D2750) |
— |
$1,704 |
— |
| Crown porcelain w/ noble met (D2752) |
— |
$4,000 |
— |
| Crown porcelain/ceramic (D2740) |
— |
$1,974 |
— |
| Crown repair (D2980) |
— |
$384 |
— |
| Crown resin w/ base metal (D2721) |
— |
$4,000 |
— |
| Crown resin w/ high noble me (D2720) |
— |
$4,000 |
— |
| Crown resin w/ noble metal (D2722) |
— |
$1,370 |
— |
| Crown resin-based indirect (D2710) |
— |
$742 |
— |
| Decor or submerg erupt tooth (D3921) |
— |
$750 |
— |
| Dental bitewing single image (D0270) |
— |
$38 |
— |
| Dental bitewings two images (D0272) |
— |
$60 |
— |
| Dental connector bar (D6920) |
— |
$1,000 |
— |
| Dental inlay metalic 1 surf (D2510) |
— |
$1,592 |
— |
| Dental inlay metallic 2 surf (D2520) |
— |
$1,718 |
— |
| Dental inlay metl 3/more sur (D2530) |
— |
$1,746 |
— |
| Dental inlay resin 3/mre sur (D2652) |
— |
$1,514 |
— |
| Dental onlay metallic 2 surf (D2542) |
— |
$1,798 |
— |
| Dental onlay metallic 3 surf (D2543) |
— |
$1,942 |
— |
| Dental onlay metl 4/more sur (D2544) |
— |
$2,052 |
— |
| Dental onlay porc 3/more sur (D2630) |
— |
$1,804 |
— |
| Dental onlay porc 4/more sur (D2644) |
— |
$1,630 |
— |
| Dental onlay porcelin 2 surf (D2642) |
— |
$3,510 |
— |
| Dental onlay porcelin 3 surf (D2643) |
— |
$4,000 |
— |
| Dental onlay resin 2 surface (D2662) |
— |
$1,550 |
— |
| Dental onlay resin 3 surface (D2663) |
— |
$1,660 |
— |
| Dental onlay resin 4/mre sur (D2664) |
— |
$1,742 |
— |
| Dental prophylaxis adult (D1110) |
— |
$148 |
— |
| Diab manage trn per indiv (G0108) |
— |
$385 |
— |
Diab manage trn ind/group (G0109)
range across 2 matching MRF lines |
— |
$148–$856 |
— |
Direct refer hospital observ (G0379)
range across 2 matching MRF lines |
— |
$2,504–$3,906 |
— |
| Drug test def 1-7 classes (G0480) |
— |
$199 |
— |
| Each addtnl prefab post (D2957) |
— |
$260 |
— |
| Elec stim other than wound (G0283) |
— |
$135 |
— |
| End thxpy, anterior tooth (D3310) |
— |
$4,000 |
— |
| End thxpy, molar tooth (D3330) |
— |
$4,000 |
— |
| End thxpy, premolar tooth (D3320) |
— |
$1,392 |
— |
| Endodontic endosseous implan (D3460) |
— |
$700 |
— |
| Excision benign lesion compl (D7412) |
— |
$325 |
— |
| Excision benign lesion>1.25c (D7411) |
— |
$300 |
— |
| Excision malig les complicat (D7415) |
— |
$325 |
— |
| Excision malig lesion<=1.25c (D7413) |
— |
$250 |
— |
| Excision malig lesion>1.25cm (D7414) |
— |
$300 |
— |
| Exposure of unerupted tooth (D7280) |
— |
$782 |
— |
| Extensv oral eval prob focus (D0160) |
— |
$168 |
— |
| Extra oral post radio image (D0705) |
— |
$90 |
— |
| Extraction coronal remnants (D7111) |
— |
$180 |
— |
| Extraction erupted tooth/exr (D7140) |
— |
$244 |
— |
| Extraoral posterior image (D0251) |
— |
$110 |
— |
| Extrnl counterpulse, per tx (G0166) |
— |
$670 |
— |
| Fixed bilat space maint, man (D1517) |
— |
$728 |
— |
| Fixed bilat space maint, max (D1516) |
— |
$728 |
— |
| Full mouth debridement (D4355) |
— |
$226 |
— |
| Gingival flap proc w/ planin (D4240) |
— |
$1,006 |
— |
| Gingivectomy/plasty 1 to 3 (D4211) |
— |
$306 |
— |
| Gingivectomy/plasty 4 or mor (D4210) |
— |
$722 |
— |
| Gingivectomy/plasty rest (D4212) |
— |
$672 |
— |
| Gngvl flap w rootplan 1-3 th (D4241) |
— |
$748 |
— |
| Gross pulpal debridement (D3221) |
— |
$320 |
— |
| Guided tiss regen nonresorb (D4267) |
— |
$1,036 |
— |
| Guided tiss regen resorble (D4266) |
— |
$852 |
— |
| Hbot, full body chamber, 30m (G0277) |
— |
$1,625 |
— |
| Hopd mntl hlt, 15-29 min (C7900) |
— |
$235 |
— |
| Hopd mntl hlt, 30-60 min (C7901) |
— |
$329 |
— |
Hopd mntl hlt, grp (C7903)
range across 5 matching MRF lines |
— |
$106–$115 |
— |
| I&d absc intraoral soft tiss (D7510) |
— |
$312 |
— |
| I&d abscess extraoral (D7520) |
— |
$1,320 |
— |
| Impact tooth rem bony w/comp (D7241) |
— |
$954 |
— |
| Impact tooth remov comp bony (D7240) |
— |
$716 |
— |
| Impact tooth remov part bony (D7230) |
— |
$612 |
— |
| Impact tooth remov soft tiss (D7220) |
— |
$484 |
— |
| Incision/drain abscess extra (D7521) |
— |
$1,382 |
— |
| Incision/drain abscess intra (D7511) |
— |
$460 |
— |
| Incomplete endodontic tx (D3332) |
— |
$616 |
— |
| Inj for sacroiliac jt anesth (G0260) |
— |
$2,800 |
— |
| Inlay composite/resin one su (D2650) |
— |
$790 |
— |
| Inlay composite/resin two su (D2651) |
— |
$1,264 |
— |
| Inlay porcelain/ceramic 1 su (D2610) |
— |
$1,410 |
— |
| Inlay porcelain/ceramic 2 su (D2620) |
— |
$1,620 |
— |
| Intentional replantation (D3470) |
— |
$300 |
— |
| Interim crown (D2799) |
— |
$428 |
— |
| Internal root repair (D3333) |
— |
$552 |
— |
| Intraor comprehensive series (D0210) |
— |
$198 |
— |
| Intraoral bite radio image (D0708) |
— |
$30 |
— |
| Intraoral comp image capture (D0709) |
— |
$140 |
— |
| Intraoral occlus radio image (D0706) |
— |
$48 |
— |
| Intraoral occlusal film (D0240) |
— |
$52 |
— |
| Intraoral periap radio image (D0707) |
— |
$20 |
— |
| Intraoral periapical first (D0220) |
— |
$38 |
— |
| Intraorifice barrier (D3911) |
— |
$70 |
— |
| Isolation- tooth w rubb dam (D3910) |
— |
$70 |
— |
| Labial veneer porc indirect (D2962) |
— |
$1,650 |
— |
| Labial veneer resin direct (D2960) |
— |
$780 |
— |
| Limit oral eval problm focus (D0140) |
— |
$106 |
— |
| Limited occlusal adjustment (D9951) |
— |
$150 |
— |
| Localized delivery antimicro (D4381) |
— |
$108 |
— |
| Malig tumor > 1.25 cm (D7441) |
— |
$550 |
— |
| Malig tumor exc to 1.25 cm (D7440) |
— |
$450 |
— |
| Mandible graft (D7950) |
— |
$1,500 |
— |
| Mesial/distal wedge proc (D4274) |
— |
$926 |
— |
| Mnt subs tx for change dx (G0270) |
— |
$98 |
— |
| Mra w/cont, abd (C8900) |
— |
$4,685 |
— |
| Mra w/cont, chest (C8909) |
— |
$4,685 |
— |
| Mra w/cont, lwr ext (C8912) |
— |
$4,034 |
— |
| Mra w/cont, pelvis (C8918) |
— |
$4,635 |
— |
| Mra w/o cont, abd (C8901) |
— |
$4,685 |
— |
| Mra w/o cont, chest (C8910) |
— |
$3,258 |
— |
| Mra w/o cont, lwr ext (C8913) |
— |
$3,258 |
— |
| Mra w/o cont, pelvis (C8919) |
— |
$4,685 |
— |
| Mra w/o fol w/cont, abd (C8902) |
— |
$4,818 |
— |
| Mra w/o fol w/cont, chest (C8911) |
— |
$4,818 |
— |
| Mra w/o fol w/cont, lwr ext (C8914) |
— |
$4,034 |
— |
| Mra w/o fol w/cont, pelvis (C8920) |
— |
$4,818 |
— |
| Mra, w/dye, spinal canal (C8931) |
— |
$3,758 |
— |
| Mra, w/dye, upper extremity (C8934) |
— |
$3,258 |
— |
| Mra, w/o dye, spinal canal (C8932) |
— |
$6,884 |
— |
| Mra, w/o dye, upper extr (C8935) |
— |
$3,258 |
— |
| Mra, w/o&w/dye, spinal canal (C8933) |
— |
$7,516 |
— |
| Mra, w/o&w/dye, upper extr (C8936) |
— |
$4,299 |
— |
| Mri w/cont, breast, bi (C8906) |
— |
$7,028 |
— |
| Mri w/cont, breast, uni (C8903) |
— |
$3,258 |
— |
| Mri w/o fol w/cont, breast, (C8908) |
— |
$4,925 |
— |
| Mri w/o fol w/cont, brst, un (C8905) |
— |
$4,685 |
— |
| Non-auto graft 1st tooth (D4275) |
— |
$1,446 |
— |
| Non-surg tx root canal obs (D3331) |
— |
$500 |
— |
| Obtaining screen pap smear (Q0091) |
— |
$87 |
— |
| Occ guard, hard, full arch (D9944) |
— |
$780 |
— |
| Occ guard, hard, part arch (D9946) |
— |
$560 |
— |
| Occ guard, soft, full arch (D9945) |
— |
$780 |
— |
| Occlusion analysis (D9950) |
— |
$496 |
— |
| Oral antral fistula closure (D7260) |
— |
$800 |
— |
| Oral/facial photo images (D0350) |
— |
$76 |
— |
| Osseous surg 1 to 3 teeth (D4261) |
— |
$1,354 |
— |
| Osseous surgery 4 or more (D4260) |
— |
$1,688 |
— |
| Oth resp proc, group (G0239) |
— |
$145 |
— |
| Oth resp proc, indiv (G0238) |
— |
$103 |
— |
| Pano radio image (D0701) |
— |
$140 |
— |
| Panoramic image (D0330) |
— |
$160 |
— |
| Part pulp for apexogenesis (D3222) |
— |
$150 |
— |
| Pedicle soft tissue graft pr (D4270) |
— |
$1,356 |
— |
| Pemivibart infusion (M0224) |
— |
$1,700 |
— |
| Perc d-e cor revasc chro sin (C9607) |
— |
$66,932 |
— |
| Perc d-e cor revasc t cabg s (C9604) |
— |
$42,271 |
— |
| Perc d-e cor stent ather s (C9602) |
— |
$42,166 |
— |
| Perc drug-el cor stent sing (C9600) |
— |
$42,271 |
— |
| Periodic oral evaluation (D0120) |
— |
$82 |
— |
| Periodontal maint procedures (D4910) |
— |
$212 |
— |
| Periodontal scaling & root (D4341) |
— |
$376 |
— |
| Periodontal scaling 1-3teeth (D4342) |
— |
$266 |
— |
| Pet not otherwise specified (G0235) |
— |
$7,500 |
— |
| Place direct restoration (D2940) |
— |
$148 |
— |
| Place intra-socket bio dress (D7922) |
— |
$200 |
— |
| Post 1 srfc resinbased cmpst (D2391) |
— |
$270 |
— |
| Post 2 srfc resinbased cmpst (D2392) |
— |
$348 |
— |
| Post 3 srfc resinbased cmpst (D2393) |
— |
$412 |
— |
| Post >=4srfc resinbase cmpst (D2394) |
— |
$474 |
— |
| Post and core cast + crown (D2952) |
— |
$568 |
— |
| Pre 3d mdl w/ccta and/or mri (C9793) |
— |
$3,612 |
— |
| Prefab porc/cer crown perm (D2928) |
— |
$650 |
— |
| Prefab porc/ceram crown pri (D2929) |
— |
$550 |
— |
| Prefab post/core + crown (D2954) |
— |
$474 |
— |
| Prefab stainless steel crown (D2933) |
— |
$460 |
— |
| Prefab steel crown primary (D2934) |
— |
$498 |
— |
| Prefab stnlss steel crown pe (D2931) |
— |
$402 |
— |
| Prefab stnlss steel crwn pri (D2930) |
— |
$376 |
— |
| Prefabricated resin crown (D2932) |
— |
$420 |
— |
| Primary closure sinus perf (D7261) |
— |
$750 |
— |
| Prolonged iv inf, req pump (C8957) |
— |
$1,237 |
— |
| Prostate biopsy, any mthd (G0416) |
— |
$1,277 |
— |
| Psa screening (G0103) |
— |
$339 |
— |
| Pulp cap direct (D3110) |
— |
$112 |
— |
| Pulp cap indirect (D3120) |
— |
$92 |
— |
| Pulp vitality test (D0460) |
— |
$29 |
— |
| Pulpal therapy anterior prim (D3230) |
— |
$328 |
— |
| Pulpal therapy posterior pri (D3240) |
— |
$344 |
— |
| Rad exc lesion up to 1.25 cm (D7410) |
— |
$608 |
— |
| Re-cement or re-bond crown (D2920) |
— |
$144 |
— |
| Re-eval post-op visit (D0171) |
— |
$124 |
— |
| Re-eval,est pt,problem focus (D0170) |
— |
$144 |
— |
| Recement cast or prefab post (D2915) |
— |
$164 |
— |
| Recement inlay onlay or part (D2910) |
— |
$182 |
— |
| Recement space maint - man (D1552) |
— |
$106 |
— |
| Recement space maint - max (D1551) |
— |
$106 |
— |
| Recement unilat space maint (D1553) |
— |
$152 |
— |
| Rem exostosis any site (D7471) |
— |
$834 |
— |
| Rem imp tooth w mucoper flp (D7210) |
— |
$394 |
— |
| Rem nonodonto cyst > 1.25 cm (D7461) |
— |
$300 |
— |
| Rem nonodonto cyst to 1.25cm (D7460) |
— |
$250 |
— |
| Rem odontogen cyst > 1.25 cm (D7451) |
— |
$260 |
— |
| Rem odontogen cyst to 1.25cm (D7450) |
— |
$760 |
— |
| Removal fb skin/areolar tiss (D7530) |
— |
$350 |
— |
| Removal of fb reaction (D7540) |
— |
$470 |
— |
| Removal of torus palatinus (D7472) |
— |
$4,000 |
— |
| Remove bilat space main, man (D1527) |
— |
$918 |
— |
| Remove bilat space main, max (D1526) |
— |
$918 |
— |
| Remove torus mandibularis (D7473) |
— |
$4,000 |
— |
| Remove unilat space maintain (D1520) |
— |
$590 |
— |
| Resin 4/> surf or w incis an (D2335) |
— |
$338 |
— |
| Resin infiltration of lesion (D2990) |
— |
$200 |
— |
| Resin one surface-anterior (D2330) |
— |
$226 |
— |
| Resin three surfaces-anterio (D2332) |
— |
$326 |
— |
| Resin two surfaces-anterior (D2331) |
— |
$274 |
— |
| Retreat root canal anterior (D3346) |
— |
$1,500 |
— |
| Retreat root canal molar (D3348) |
— |
$2,012 |
— |
| Retreat root canal premolar (D3347) |
— |
$1,678 |
— |
| Retrograde filling (D3430) |
— |
$330 |
— |
| Revasc intra lithotrip-ather (C9766) |
— |
$63,745 |
— |
| Revasc intra lithotrip-stent (C9765) |
— |
$63,745 |
— |
| Revasc intravasc lithotripsy (C9764) |
— |
$40,258 |
— |
| Revasc lith-sten-ath tib/per (C9775) |
— |
$63,745 |
— |
| Revasc lithotr-ather tib/per (C9774) |
— |
$63,745 |
— |
| Revasc lithotr-stent tib/per (C9773) |
— |
$63,745 |
— |
| Revasc lithotrip tibi/perone (C9772) |
— |
$40,258 |
— |
| Revasc lithotrip-stent-ather (C9767) |
— |
$63,745 |
— |
| Root amputation (D3450) |
— |
$934 |
— |
| Root surgery molar (D3425) |
— |
$1,418 |
— |
| Root surgery premolar (D3421) |
— |
$1,230 |
— |
| Soft tissue graft firsttooth (D4277) |
— |
$700 |
— |
| Space maintainer fxd unilat (D1510) |
— |
$480 |
— |
| Splint extra-coronal (D4323) |
— |
$450 |
— |
| Splint intra-coronal (D4322) |
— |
$300 |
— |
| Surg exp root surf anterior (D3501) |
— |
$4,000 |
— |
| Surg exp root surf molar (D3503) |
— |
$1,500 |
— |
| Surg exp root surf premolar (D3502) |
— |
$1,400 |
— |
| Surg reduct osseoustuberosit (D7485) |
— |
$908 |
— |
| Surg rep root res anterior (D3471) |
— |
$1,200 |
— |
| Surg rep root res molar (D3473) |
— |
$1,400 |
— |
| Surg rep root res premolar (D3472) |
— |
$1,300 |
— |
| Surgical revision procedure (D4268) |
— |
$300 |
— |
| Tee w or w/o fol w/cont,cong (C8926) |
— |
$3,280 |
— |
| Therapeutic procd strg endur (G0237) |
— |
$103 |
— |
| Therapeutic pulpotomy (D3220) |
— |
$262 |
— |
Tomosynthesis, mammo (G0279)
range across 2 matching MRF lines |
— |
$229–$459 |
— |
| Tooth pin retention (D2951) |
— |
$74 |
— |
| Tooth reimplantation (D7270) |
— |
$435 |
— |
| Tooth root removal (D7250) |
— |
$402 |
— |
| Tooth splitting (D3920) |
— |
$216 |
— |
| Tooth transplantation (D7272) |
— |
$360 |
— |
Trauma respons w/hosp criti (G0390)
range across 4 matching MRF lines |
— |
$4,698–$9,349 |
— |
| Treatment of complications (D9930) |
— |
$250 |
— |
| Tte w or w/o contr, cont ecg (C8930) |
— |
$5,199 |
— |
| Tte w or w/o fol w/con,stres (C8928) |
— |
$3,280 |
— |
| Tte w or w/o fol w/cont, com (C8921) |
— |
$5,199 |
— |
| Tte w or w/o fol w/cont, f/u (C8922) |
— |
$3,280 |
— |
| Tte w or wo fol wcon,doppler (C8929) |
— |
$4,428 |
— |
| Unsched dialysis esrd pt hos (G0257) |
— |
$2,484 |
— |
| Unscheduled dressing change (D4920) |
— |
$60 |
— |
| Vasc emb/occ w/prs cath (C9797) |
— |
$63,750 |
— |
| Vert bitewings 7 to 8 images (D0277) |
— |
$152 |
— |
| Vestibuloplasty exten graft (D7350) |
— |
$1,350 |
— |
| Vestibuloplasty ridge extens (D7340) |
— |
$1,000 |
— |