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Commissioner Approved Fee Schedule - FY 2025-26 38 <br /> Last <br /> Department/Program Description Current Fee Revision <br /> D0230 Additional PA Film $31.00 2025 <br /> D0240 I Intraoral Occulusal Film $51.00 2025 <br /> D0270 BWX 1 Film $35.00 2025 <br /> D0272 BWX 2 Films $55.00 2025 <br /> D0273 Bitewings-three films $68.00 2025 <br /> D0274 BWX 4 Films $77.00 2025 <br /> D0330 Panoramic Film $133.00 2025 <br /> D0470 Study Models $138.00 2025 <br /> D1110 Prophy/Adult age 13 and up $109.00 2025 <br /> D1120 Prophy/Child under age 13 $81.00 2025 <br /> Topical Fluoride vamish;therapeutic application for <br /> D1206 moderate to high caries risk patients $52.00 2025 <br /> D1351 Sealant/Newly Erupted Teeth $65.00 2025 <br /> D1354 SDF-Interim Caries Arresting Medicament $65.00 2025 <br /> D1355 Caries Preventive Medicament Application-per tooth $59.00 2024 <br /> D2140 Amal One Surface Prim/Perm $173.00 2025 <br /> D2150 Amal Two Surface Prim/Perm $219.00 2025 <br /> D2160 Amal Three Surface Prim/Perm $264.00 2025 <br /> D2161 Amal Four Surface Prim/Perm $315.00 2025 <br /> D2330 Resin One Surface Anterior $197.00 2025 <br /> D2331 Resin Two Surface Anterior $242.00 2025 <br /> D2332 Resin Three Surface Anterior $303.00 2025 <br /> D2335 Resin Four Surface Anterior $384.00 2025 <br /> D2390 Resin Comp.Crown Ant.Prim $552.00 2025 <br /> D2391 Resin Comp. Isur.Post-Prim/Perm $216.00 2025 <br /> D2392 Resin Comp.2sur.Post-Prim/Perm $283.00 2025 <br /> D2393 Resin Comp.3sur.Posterior Perm $348.00 2025 <br /> D2394 Resin Comp.4+sur.Posterior Perm $419.00 2025 <br /> D2920 Recement Crown NOT cov.by MA $133.00 2025 <br /> D2930 SSC Primary Tooth $329.00 2025 <br /> D2931 SSC Permanent Tooth $397.00 2025 <br /> D2940 Sedative Filling $135.60 2024 <br /> D3110 Pulp Cap-direct exp.Pulp MED $101.00 2025 <br /> D3120 Pulp Cap-indirect nearly exposed $101.00 2025 <br /> D3220 Pulpotomy $244.00 2025 <br /> D3310 Root Canal Therapy Anterior $901.00 2025 <br /> D3320 Root Canal Therapy Bicuspid $1,040.00 2025 <br /> D3330 Root Canal Therapy Molar $1,258.00 2025 <br /> D4341 Scale Root Planing 4>teeth p/q $308.00 2025 <br /> D4342 Scale/Root Planing 1-3 teeth p/q $223.00 2025 <br /> Scaling in presence of generalized moderate or severe <br /> D4346 gingival inflammation $127.00 2025 <br /> D4355 Full mouth Debridement $224.00 2025 <br /> D4910 Periodontal Maintenance $170.00 2025 <br /> D5411 Adjust Complete Denture-lower $60.00 2025 <br /> D6930 Recement Bridge $133.00 2025 <br /> D7111 Ext.corral remnants deciduous $163.00 2025 <br /> D7140 Ext.Erupted Tooth Prim/Perm $216.00 2025 <br /> D7210 Extraction Surgical-100+ $337.00 2025 <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 tooth <br /> D7321 spaces per quadrant $461.00 2025 <br /> D9110 Palliative Treatment $154.00 2025 <br /> D9910 Application of Desensitizing Medicament $76.00 2025 <br /> MED Band&Loop/Quadrant Impress $0.00 2013 <br /> MED Fixed Bilateral Impress $0.00 2013 <br />