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Commissioner Approved Fee Schedule - FY 2024-25 39 <br /> Last <br /> Department/Program Description Current Fee Revision <br /> D2140 Amal One Surface Prim/Perm $156.00 2024 <br /> D2150 Amal Two Surface Prim/Perm $196.80 2024 <br /> D2160 Amal Three Surface Prim/Perm $237.60 2024 <br /> D2161 Amal Four Surface Prim/Perm $283.20 2024 <br /> D2330 Resin One Surface Anterior $177.60 2024 <br /> D2331 Resin Two Surface Anterior $219.60 2024 <br /> D2332 Resin Three Surface Anterior $272.40 2024 <br /> D2335 Resin Four Surface Anterior $345.60 2024 <br /> D2390 Resin Comp.Crown Ant.Prim $496.80 2024 <br /> D2391 Resin Comp. 1sur.Post-Prim/Perm $194.40 2024 <br /> D2392 Resin Comp.2sur.Post-Prim/Perm $254.40 2024 <br /> D2393 Resin Comp.3sur.Posterior Perm $313.20 2024 <br /> D2394 Resin Comp.4+sur.Posterior Perm $376.80 2024 <br /> D2920 Recement Crown NOT cov.by MA $120.00 2024 <br /> D2930 SSC Primary Tooth $296.40 2024 <br /> D2931 SSC Permanent Tooth $357.60 2024 <br /> D2940 Sedative Filling $135.60 2024 <br /> D3110 Pulp Cap-direct exp.Pulp MED $91.20 2024 <br /> D3120 Pulp Cap-indirect nearly exposed $92.40 2024 <br /> D3220 Pulpotomy $219.60 2024 <br /> D3310 Root Canal Therapy Anterior $811.20 2024 <br /> D3320 Root Canal Therapy Bicuspid $936.00 2024 <br /> D3330 Root Canal Therapy Molar $1,131.60 2024 <br /> D4341 Scale Root Planing 4>teeth p/q $277.20 2024 <br /> D4342 Scale/Root Planing 1-3 teeth p/q $200.40 2024 <br /> Scaling in presence of generalized moderate or severe <br /> D4346 gingival inflammation $114.00 2024 <br /> D4355 Full mouth Debridement $201.60 2024 <br /> D4910 Periodontal Maintenance $152.40 2024 <br /> D5411 Adjust Complete Denture-lower $54.00 2024 <br /> D6930 Recement Bridge $120.00 2024 <br /> D7111 Ext.corral remnants deciduous $146.40 2024 <br /> D7140 Ext.Erupted Tooth Prim/Penn $194.40 2024 <br /> D7210 Extraction Surgical- 100+ $303.60 2024 <br /> D7230 Removal of Impacted Tooth-Complete Bony $402.00 2024 <br /> D7251 Coronectomy $329.00 2024 <br /> Alveloplasty not in conjunction with extraction 1-3 <br /> D7321 tooth spaces per quadrant $460.80 2024 <br /> D9110 Palliative Treatment $138.00 2024 <br /> D9910 Application of Desensitizing Medicament $68.40 2024 <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 $73.20 2024 <br /> D 1352 Reapplication of sealant $43.95 2024 <br /> Office Visit-Minimum charge for dental visit(sliding <br /> fee) $40.00 2024 <br /> Removal of Impacted Tooth-Soft Tissue $358.00 2024 <br /> Removal of Impacted Tooth-Partially Bony $374.00 2024 <br /> CPT Code <br /> Pfizer COVID-19 Vaccine Adult(12 years and older, <br /> Personal Health 0001A single dose vial) 1$115.00 2023 <br />