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Commissioner Approved Fee Schedule - FY 2023-24 43 <br /> Last <br /> Department/Program Description Current Fee Revision <br /> D2391 Resin Comp. 1sur.Post-Prim/Perm $162.00 2013 <br /> D2392 Resin Comp.2sur.Post-Prim/Perm $212.00 2013 <br /> D2393 Resin Comp.3sur.Posterior Perm $261.00 2013 <br /> D2394 Resin Comp.4+sur.Posterior Penn $314.00 2013 <br /> D2920 Recement Crown NOT cov.by MA $100.00 2013 <br /> D2930 SSC Primary Tooth $247.00 2013 <br /> D2931 SSC Permanent Tooth $298.00 2013 <br /> D2932 lPrebacricated Resin Crown $323.00 2013 <br /> D2934 Prefab.est.coat SSC prim.Tooth $327.00 2013 <br /> D2940 Sedative Filling $113.00 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 $183.00 2013 <br /> D3310 Root Canal Therapy Anterior $676.00 2013 <br /> D3320 Root Canal Therapy Bicuspid $780.00 2013 <br /> D3330 Root Canal Therapy Molar $943.00 2013 <br /> D4320 Provisional Splinting,intracoronal $115.00 2017 <br /> D4321 Provisional Splinting,extracoronal $115.00 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 $168.00 2013 <br /> D4910 Periodontal Maintenance $127.00 2013 <br /> D5411 Adjust Complete Denture-lower $45.00 2018 <br /> D6930 Recement Bridge $100.00 2018 <br /> D7111 Ext.cornal remnants deciduous $122.00 2013 <br /> D7140 lExt.Erupted Tooth Prim/Perm $162.00 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. $270.00 2013 <br /> Alveloplasty in conjunction with extraction 1-3 teeth <br /> D7311 per quadrant $273.00 2013 <br /> Alveloplasty not in conjunction with extraction 4 or <br /> D7320 more tooth spaces per quadrant $404.00 2013 <br /> Alveloplasty not in conjunction with extraction 1-3 <br /> D7321 tooth spaces per quadrant $384.00 2013 <br /> D7510 I&D Minor Surgery $217.00 2013 <br /> D9110 Palliative Treatment $115.00 2013 <br /> D9310 Consultation $122.00 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 $549.00 2013 <br /> D9941 Fabrication of Athletic Mouthguard $236.00 2013 <br /> D9951 Occulsal Adjustment Limited $166.00 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 lReapplication of sealant 1$49.00 12015 <br />