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Manager Recommended Fee Schedule ® FY 2022 ® 23 41 <br /> Last <br /> Department/Program Description Current Fee Revision <br /> D2920 Recement Crown NOT cov. by MA $ 100400 2013 <br /> D2930 SSC Primary Tooth $247. 00 2013 <br /> D2931 SSC Permanent Tooth $298900 2013 <br /> D2932 Prebacricated Resin Crown $323000 2013 <br /> D2934 Prefab . est. coat SSC prim . Tooth $327000 2013 <br /> D2940 Sedative Filling $ 113000 2013 <br /> D2951 Pin Retention/tooth $ 67 . 00 2012 <br /> D3110 Pulp Cap - direct exp . Pulp MED $ 76 . 00 2013 <br /> D3120 Pulp Cap -indirect nearly exposed $77 . 00 2013 <br /> D3220 Pulpotomy $ 183400 2013 <br /> D3310 Root Canal Therapy Anterior $ 676400 2013 <br /> D3320 Root Canal Therapy Bicuspid $ 780 . 00 2013 <br /> D3330 Root Canal Therapy Molar $943000 2013 <br /> D4320 Provisional Splinting, intracoronal $ 115000 2017 <br /> D4321 Provisional Splinting, extracoronal $ 115000 2017 <br /> D4341 Scale Root Planing 4> teeth p/q $231 . 00 2013 <br /> D4342 Scale/Root Planing 1 -3 teeth p/q $ 167. 00 2013 <br /> Scaling in presence of generalized moderate or severe <br /> D4346 gingival inflammation $95 . 00 2018 <br /> D4355 Full mouth Debridement $ 168000 2013 <br /> D4910 Periodontal Maintenance $ 127000 2013 <br /> D5411 Adjust Complete Denture - lower $45 . 00 2018 <br /> D6930 Recement Bridge $ 100600 2018 <br /> D7111 Ext. cornal remnants deciduous $ 122 . 00 2013 <br /> D7140 Ext. Erupted Tooth Prim/Penn $ 162000 2013 <br /> D7210 Extraction Surgical - 100+ $253 . 00 2013 <br /> D7250 Extract Root Tip $253 . 00 2018 <br /> D7286 Biopsy Oral Tissue $298 . 00 2013 <br /> D7310 Alveoplasty extractions p/quad . $270000 2013 <br /> Alveloplasty in conjunction with extraction 1 -3 teeth <br /> D7311 per quadrant $273000 2013 <br /> Alveloplasty not in conjunction with extraction 4 or <br /> D7320 more tooth spaces per quadrant $404400 2013 <br /> Alveloplasty not in conjunction with extraction 1 -3 <br /> D7321 tooth spaces per quadrant $384000 2013 <br /> D7510 I & D Minor Surgery $217000 2013 <br /> D9110 Palliative Treatment $ 115000 2013 <br /> D9310 Consultation $ 122000 2013 <br /> D9910 Application of Desensitizing Medicament $57 . 00 2013 <br /> Application of Desensitizing Resin for cervical and/or <br /> D9911 root surface per tooth $ 70 . 00 2013 <br /> Occlusal guard, by report minimize bruxism $274/95 <br /> D9940 lab $ 549000 2013 <br /> D9941 Fabrication of Athletic Mouthguard $236000 2013 <br /> D9951 Occulsal Adjustment Limited $ 166000 2013 <br /> D9999 Fractured Tooth Txt. $70 . 00 2013 <br /> MED Band & Loop/Quadrant Impress $ 0 . 00 2013 <br /> MED Fixed Bilateral Impress $ 0 . 00 2013 <br /> Oral evaluation for a patient under 3 years of age and <br /> D0145 counseling with primary caregiver $ 61 . 00 2015 <br /> D1352 Reapplication of sealant $49 . 00 2015 <br /> Flat Fee Fabrication of Athletic Moutguard Projects $ 17 . 00 2009 <br /> Boil and Bite Mouthguards (students with braces) $5 . 00 12007 <br />