Pennsylvania General Dentist Fee Schedule

** Any treatment provided by a participating specialist, if available, in Oral Surgery, Orthodontics, Periodontics, Pedodontics, Prosthodontics or Endodontics, will be charged at a 25% reduction of participating specialist’s fees for that particular case.

CodeDiagnostic and PreventiveAmount
D0120Periodic Oral Examination31
D0140Limited Oral Evaluation - Problem Focused39
D0150Comprehensive Oral Evaluation44
D0210x-ray Intraoral - Complete - Including Bitewings69
D0220x-ray Intraoral -Periapical - First Film14
D0230x-ray Intraoral - Perciapical - Each Add. Film8
D0270x-ray Bitewings - Single Film13
D0272x-ray Bitewings - Two Films25
D0273x-ray Bitewings - Three Films28
D0274x-ray Bitewings - Four Films36
D0330x-ray Panoramic Film60
D1110Dental Prophylaxis Adult54
D1120Dental Prophylaxis Children37
D1204Topical Fluoride Application19
D1351Topical Sealants - Per Tooth28
D1510Space Maintainer - Fixed - Unilateral126
D1515Space Maintainer - Fixed - Bilateral179
CodeRestorative (Fillings)Amount
D2140Amalgam - One surface, Permanent71
D2150Amalgam - Two surfaces, Permanent89
D2160Amalgam - Three Surfaces Permanent115
D2161Amalgam - 4 Or More Surfaces Permanent139
D2330Resin - One Surface Anterior88
D2331Resin - Two Surface Anterior119
D2332Resin - Three Surface Anterior136
D2335Resin - 4+Surf Or Inv. Incisal Angle148
D2391Resin - One Surface Posterior, Permanent88
D2392Resin - Two Surface Posterior, Permanent116
D2393Resin - Three Surface Posterior, Permanent147
D2394Resin - Four or more surfaces posterior159
CodeCrowns (lab fees included)Amount
D2710Crown - Resins Based Composite, Indirect215
D2720Crown - Resin With High Noble Metal444
D2740Crown - Porcelain/Ceramic substrate817
D2750Crown - Porcelain/High Noble Metal769
D2751Crown - Porcelain/Predominate Base Metal715
D2752Crown - Porcelain/Noble Matal747
D2790Crown - Full Cast High Noble Metal729
D2791Crown - Full Cast Predom. Base Metal654
D2920Recement Crown47
D2931Prefab Stainless Steel Crown - Perm Tooth166
D2932Prefab Resin Crown123
D2950Core Buildup Including Any Pins139
D2951Pin Retention - Per Tooth (W/O Restoration)28
D2952Cast Post/Core (Addition To Crown)199
D2954Prefabricated post and core, in addition to crown159
D2970Temporary Crown (fractured tooth)75
CodeEndodontics (General Dentist) exc. Final restor.Amount
D3110Pulp Cap - Direct26
D3120Pulp Cap - Indirect23
D3220Therapeutic Pulpotomy79
D3310Root Canal Anterior387
D3320Root Canal Bicuspid529
D3330Root Canal Molar686
CodePeriodontics (General Dentist)Amount
D4210Gingivectomy/Gingivoplasty - 4 + contiguos teeth176
D4341Perio. Scaling & Root Planing per quad147
D4355Full Mouth Debridement84
D4910Periodontal Maintenance74
CodePA - Prosthodontics, Removable (lab fees included)Amount
D5110Complete Upper Denture869
D5120Complete Lower Denture869
D5130Immediate Upper929
D5140Immediate Lower929
D5211Upper Partial - Resin Base514
D5212Lower Partial - Resin Base514
CodePA - Prosthodontics, Fixed (lab fees included)Amount
D5213Partial Upper Cast Metal Base950
D5214Partial Lower Cast Metal Base950
D5410Adjust Denture - (Upper)45
D5411Adjust Denture - (Lower)45
D5510Repair Broken Complete Denture Base75
D5520Replace Missing or Broken Teeth/Each Tooth69
D5610Repair Resin Denture Base73
D5630Repair Or Replace Broken Clasp106
D5640Replace Broken Teeth - Per Tooth74
D5650Add Tooth To Existing Partial Denture96
D5660Add Clasp To Existing Partial Denture149
D5730Reline Upper Denture - Chairside110
D5731Reline Lower Denture - Chairside110
D5740Reline Complete Maxillary Denture - Chairside106
D5741Reline Complete Mandibular Partial Dent Chairside106
D600Implant Services D6000- D619425% Discount
CodePA - Prosthodontics, Fixed (lab fees included)Amount
D6240Pontic - Porcelain/High Noble Metal678
D6241Pontic - Porcelain/Predominate Base Metal547
D6242Pontic - Porcelain/Noble Metal659
D6750Crown - Porcelain/High Noble Metal766
D6751Crown - Porcelain/High Noble Metal618
D6752Crown - Porcelain/Noble Metal745
D6930Recement Bridge50
CodeOral Surgery (General Dentist)Amount
D7140Single Tooth Extraction70
D7210Surgical Removal Of Erupted Tooth177
D7220Removal Of Impacted Tooth/Soft Tissue199
D7230Removal Of Impacted Tooth/Partially Bony245
D7240Removal Of Impacted Tooth/Completely Bony282
D7250Surgical Removal Of Residual Tooth Roots139
D7510Incision and Drainage of Abcess/Intraoral91

*Please see a professional dentist for full treatment plan.

*** Same day enrollment is available.

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