Dental Fee Schedule
| Code | Description | LDP |
|---|---|---|
| D0120 | periodic oral evaluation | $30 |
| D0140 | limited oral evaluation - problem focused | $42 |
| D0150 | comprehensive oral evaluation - new or established patient | $48 |
| D0160 | detailed and extensive oral evaluation - problem focused, by report | $90 |
| D0170 | re-evaluation - limited, problem focused (established patient; not post-operative visit) | $40 |
| D0180 | comprehensive periodontal evaluation - new or established patient | $62 |
| D0210 | x-ray, intraoral - complete series | $85 |
| D0220 | intraoral - periapical first film | $17 |
| D0230 | intraoral - periapical each additional film | $15 |
| D0240 | intraoral - occlusal film | $35 |
| D0250 | extraoral - first film | $45 |
| D0260 | extraoral - each additional film | $40 |
| D0270 | bitewing - single film | $17 |
| D0272 | bitewings - two films | $26 |
| D0273 | bitewings - three films | $35 |
| D0274 | bitewings - four films | $42 |
| D0277 | vertical bitewings - 7 to 8 films | $58 |
| D0330 | panoramic film | $75 |
| D0340 | cephalometric film | $80 |
| D0425 | caries susceptibility tests | $45 |
| D0431 | adjunctive pre-diagnostic test | $35 |
| D0460 | pulp vitality tests | $40 |
| D0470 | diagnostic casts | $72 |
| D0999 | disposables/infectious control | $10 |
| Code | Description | LDP |
|---|---|---|
| D1110 | prophylaxis - adult | $60 |
| D1120 | prophylaxis - child | $45 |
| D1206 | fluoride varnish age 1-5 | $29 |
| D1208 | fluoride | $29 |
| D1310 | nutritional counseling for control of dental disease | $26 |
| D1320 | tobacco counseling for the control and prevention of oral disease | $26 |
| D1330 | oral hygiene instructions | $35 |
| D1351 | sealant - per tooth | $30 |
| D1510 | space maintainer – fixed, unilateral per quadrant (excludes a distal shoe) | $230 |
| D1520 | space maintainer – removable, unilateral per quadrant | $260 |
| Code | Description | LDP |
|---|---|---|
| D2140 | amalgam - one surface, primary or permanent | $85 |
| D2150 | amalgam - two surfaces, primary or permanent | $100 |
| D2160 | amalgam - three surfaces, primary or permanent | $120 |
| D2161 | amalgam - four or more surfaces, primary or permanent | $145 |
| D2330 | resin-based composite - one surface, anterior | $105 |
| D2331 | resin-based composite - two surfaces, anterior | $130 |
| D2332 | resin-based composite - three surfaces, anterior | $160 |
| D2335 | resin-based composite - four or more surfaces or involving incisal angle (anterior) | $180 |
| D2390 | resin-based composite - crown, anterior | $215 |
| D2391 | resin-based composite - one surface, posterior | $120 |
| D2392 | resin-based composite - two surfaces, posterior | $140 |
| D2393 | resin-based composite - three surfaces, posterior | $170 |
| D2394 | resin-based composite - four or more surfaces, posterior | $215 |
| Code | Description | LDP |
|---|---|---|
| D2910 | recement inlay, onlay, or partial coverage restoration | $65 |
| D2920 | recement crown | $70 |
| D2930 | prefabricated stainless steel crown - primary tooth | $178 |
| D2931 | prefabricated stainless steel crown - permanent tooth | $240 |
| D2932 | prefabricated resin crown | $225 |
| D2933 | prefabricated stainless steel crown with resin window | $195 |
| D2940 | sedative filling | $72 |
| D2950 | core buildup, including any pins | $195 |
| D2951 | pin retention - per tooth, in addition to restoration | $43 |
| D2952 | cast post and core in addition to crown | $265 |
| D2954 | prefabricated post and core in addition to crown | $215 |
| D2955 | post removal (not in conjunction with endodontic therapy) | $163 |
| D2980 | crown repair, by report | $130 |
| Code | Description | LDP |
|---|---|---|
| D3110 | pulp cap - direct (excluding final restoration) | $53 |
| D3120 | pulp cap - indirect (excluding final restoration) | $47 |
| D3220 | therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament | $115 |
| D3230 | pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) | $120 |
| D3240 | pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) | $130 |
| D3310 | anterior (excluding final restoration) | $585 |
| D3320 | bicuspid (excluding final restoration) | $650 |
| D3330 | molar (excluding final restoration) | $750 |
| D3346 | retreatment of previous root canal therapy - anterior | $670 |
| D3347 | retreatment of previous root canal therapy - bicuspid | $735 |
| D3348 | retreatment of previous root canal therapy - molar | $840 |
| D3351 | apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) | $241 |
| D3352 | apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) | $120 |
| D3353 | apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) | $355 |
| D3410 | apicoectomy/periradicular surgery - anterior | $465 |
| D3421 | apicoectomy/periradicular surgery - bicuspid (first root) | $510 |
| D3425 | apicoectomy/periradicular surgery - molar (first root) | $610 |
| D3426 | apicoectomy/periradicular surgery (each additional root) | $225 |
| D3430 | retrograde filling - per root | $155 |
| D3450 | root amputation - per root | $310 |
| D3920 | hemisection (including any root removal), not including root canal therapy | $270 |
| D3950 | canal preparation and fitting of preformed dowel or post | $133 |
| Code | Description | LDP |
|---|---|---|
| D4210 | gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant | $489 |
| D4211 | gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant | $200 |
| D4249 | clinical crown lengthening - hard tissue | $450 |
| D4266 | guided tissue regeneration - resorbable barrier, per site | $426 |
| D4268 | surgical revision procedure, per tooth | $500 |
| D4270 | pedicle soft tissue graft procedure | $688 |
| D4275 | soft tissue allograft | $550 |
| D4320 | provisional splinting - intracoronal | $350 |
| D4321 | provisional splinting - extracoronal | $345 |
| D4341 | periodontal scaling and root planing - four or more teeth per quadrant | $175 |
| D4342 | periodontal scaling and root planing - one to three teeth per quadrant | $125 |
| D4346 | scaling in presence of generalized moderate or severe gingival inflammation | $65 |
| D4355 | full mouth debridement to enable comprehensive evaluation and diagnosis | $105 |
| D4381 | localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth | $60 |
| D4910 | periodontal maintenance | $90 |
| Code | Description | LDP |
|---|---|---|
| D2410 | gold foil - one surface | $375 |
| D2420 | gold foil - two surfaces | $410 |
| D2510 | inlay - metallic - one surface | $540 |
| D2520 | inlay - metallic - two surfaces | $640 |
| D2530 | inlay - metallic - three or more surfaces | $660 |
| D2542 | onlay – metallic - two surfaces | $610 |
| D2543 | onlay – metallic - three surfaces | $610 |
| D2544 | onlay – metallic - four or more surfaces | $650 |
| D2610 | inlay - porcelain/ceramic - one surface | $550 |
| D2620 | inlay - porcelain/ceramic - two surfaces | $600 |
| D2630 | inlay - porcelain/ceramic - three or more surfaces | $590 |
| D2642 | onlay - porcelain/ceramic - two surfaces | $605 |
| D2643 | onlay - porcelain/ceramic - three surfaces | $630 |
| D2644 | onlay - porcelain/ceramic - four or more surfaces | $640 |
| D2650 | inlay - resin-based composite - one surface | $450 |
| D2651 | inlay - resin-based composite - two surfaces | $490 |
| D2652 | inlay - resin-based composite - three or more surfaces | $510 |
| D2662 | onlay - resin-based composite - two surfaces | $575 |
| D2663 | onlay - resin-based composite - three surfaces | $625 |
| D2664 | onlay - resin-based composite - four or more surfaces | $635 |
| D2710 | crown - resin-based composite (indirect) | $424 |
| D2720 | crown - resin with high noble metal | $670 |
| D2721 | crown - resin with predominantly base metal | $550 |
| D2722 | crown - resin with noble metal | $598 |
| D2740 | crown - porcelain/ceramic substrate | $790 |
| D2750 | crown - porcelain fused to high noble metal | $790 |
| D2751 | crown - porcelain fused to predominantly base metal | $730 |
| D2752 | crown - porcelain fused to noble metal | $725 |
| D2780 | crown - 3/4 cast high noble metal | $725 |
| D2781 | crown - 3/4 cast predominantly base metal | $725 |
| D2782 | crown - 3/4 cast noble metal | $725 |
| D2783 | crown - 3/4 porcelain/ceramic | $770 |
| D2790 | crown - full cast high noble metal | $860 |
| D2791 | crown - full cast predominantly base metal | $735 |
| D2792 | crown - full cast noble metal | $725 |
| Code | Description | LDP |
|---|---|---|
| D5410 | adjust complete denture - maxillary | $55 |
| D5411 | adjust complete denture - mandibular | $55 |
| D5421 | adjust partial denture - maxillary | $55 |
| D5422 | adjust partial denture - mandibular | $55 |
| D5511 | repair broken complete denture base, mandibular | $125 |
| D5512 | repair broken complete denture base, maxillary | $125 |
| D5611 | repair resin partial denture base, mandibular | $130 |
| D5612 | repair resin partial denture base, maxillary | $130 |
| D5621 | repair cast partial framework, mandibular | $160 |
| D5622 | repair cast partial framework, maxillary | $160 |
| D5630 | repair or replace broken retentive/clasping materials – per tooth | $150 |
| D5640 | replace broken teeth - per tooth | $95 |
| D5650 | add tooth to existing partial denture | $130 |
| D5660 | add clasp to existing partial denture | $170 |
| D5710 | rebase complete maxillary denture | $350 |
| D5711 | rebase complete mandibular denture | $350 |
| D5720 | rebase maxillary partial denture | $350 |
| D5721 | rebase mandibular partial denture | $350 |
| D5730 | reline complete maxillary denture (chairside) | $205 |
| D5731 | reline complete mandibular denture (chairside) | $205 |
| D5740 | reline maxillary partial denture (chairside) | $205 |
| D5741 | reline mandibular partial denture (chairside) | $205 |
| D5750 | reline complete maxillary denture (laboratory) | $285 |
| D5751 | reline complete mandibular denture (laboratory) | $285 |
| D5760 | reline maxillary partial denture (laboratory) | $285 |
| D5761 | reline mandibular partial denture (laboratory) | $285 |
| D5850 | tissue conditioning, maxillary | $75 |
| D5851 | tissue conditioning, mandibular | $75 |
| Code | Description | LDP |
|---|---|---|
| D6010 | surgical placement of implant body: endosteal implant | 20% Discount |
| D6040 | surgical placement: eposteal implant | 20% Discount |
| D6050 | surgical placement: transosteal implant | 20% Discount |
| D6090 | repair implant supported prosthesis, by report | 20% Discount |
| D6095 | repair implant abutment, by report | 20% Discount |
| D6100 | implant removal, by report | 20% Discount |
| D6057 | custom abutment | 20% Discount |
| D6058 | porcelain/ceramic crown anchored to an implant abutment | 20% Discount |
| D6059 | abutment supported porcelain fused to metal crown | 20% Discount |
| D6060 | abutment supported porcelain fused to metal crown-predominantly base metal | 20% Discount |
| D6061 | abutment supported porcelain fused to metal crown-noble metal | 20% Discount |
| D6062 | abutment supported cast metal crown high noble metal | 20% Discount |
| D6063 | abutment supported cast metal crown - predominantly base metal | 20% Discount |
| D6064 | abutment supported cast metal crown - noble metal | 20% Discount |
| D6065 | implant supported porcelain/ceramic crown | 20% Discount |
| D6066 | implant supported porcelain fused to metal crown | 20% Discount |
| D6067 | implant supported metal crown | 20% Discount |
| Code | Description | LDP |
|---|---|---|
| D5110 | complete denture - maxillary | $850 |
| D5120 | complete denture - mandibular | $850 |
| D5130 | immediate denture - maxillary | $890 |
| D5140 | immediate denture - mandibular | $890 |
| D5211 | maxillary partial denture - resin base (including any conventional clasps, rests and teeth) | $750 |
| D5212 | mandibular partial denture - resin base (including any conventional clasps, rests and teeth) | $750 |
| D5213 | maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $950 |
| D5214 | mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $950 |
| D5225 | maxillary partial denture - flexible base | $860 |
| D5226 | mandibular partial denture - flexible base | $860 |
| D5281 | removable unilateral partial denture - one piece cast metal (including clasps and teeth) | $650 |
| Code | Description | LDP |
|---|---|---|
| D6210 | pontic - cast high noble metal | $805 |
| D6211 | pontic - cast predominantly base metal | $805 |
| D6212 | pontic - cast noble metal | $805 |
| D6240 | pontic - porcelain fused to high noble metal | $790 |
| D6241 | pontic - porcelain fused to predominantly base metal | $790 |
| D6242 | pontic - porcelain fused to noble metal | $790 |
| D6245 | pontic - porcelain/ceramic | $815 |
| D6250 | pontic - resin with high noble metal | $805 |
| D6251 | pontic - resin with predominantly base metal | $805 |
| D6252 | pontic - resin with noble metal | $805 |
| D6545 | retainer - cast metal for resin bonded fixed prosthesis | $450 |
| D6548 | retainer - porcelain/ceramic for resin bonded fixed prosthesis | $420 |
| D6600 | inlay - porcelain/ceramic, two surfaces | $630 |
| D6601 | inlay - porcelain/ceramic, three or more surfaces | $665 |
| D6602 | inlay - cast high noble metal, two surfaces | $610 |
| D6603 | inlay - cast high noble metal, three or more surfaces | $660 |
| D6605 | inlay - cast predominantly base metal, three or more surfaces | $616 |
| D6606 | inlay - cast noble metal, two surfaces | $595 |
| D6607 | inlay - cast noble metal, three or more surfaces | $660 |
| D6608 | onlay - porcelain/ceramic, two surfaces | $635 |
| D6609 | onlay - porcelain/ceramic, three or more surfaces | $665 |
| D6610 | onlay - cast high noble metal, two surfaces | $650 |
| D6611 | onlay - cast high noble metal, three or more surfaces | $715 |
| D6612 | onlay - cast predominantly base metal, two surfaces | $635 |
| D6613 | onlay - cast predominantly base metal, three or more surfaces | $690 |
| D6614 | onlay - cast noble metal, two surfaces | $660 |
| D6615 | onlay - cast noble metal, three or more surfaces | $675 |
| D6720 | crown - resin with high noble metal | $700 |
| D6721 | crown - resin with predominantly base metal | $700 |
| D6722 | crown - resin with noble metal | $700 |
| D6740 | crown - porcelain/ceramic | $810 |
| D6750 | crown - porcelain fused to high noble metal | $825 |
| D6751 | crown - porcelain fused to predominantly base metal | $780 |
| D6752 | crown - porcelain fused to noble metal | $800 |
| D6780 | crown - 3/4 cast high noble metal | $780 |
| D6781 | crown - 3/4 cast predominantly base metal | $685 |
| D6782 | crown - 3/4 cast noble metal | $855 |
| D6783 | crown - 3/4 porcelain/ceramic | $855 |
| D6790 | crown - full cast high noble metal | $750 |
| D6791 | crown - full cast predominantly base metal | $655 |
| D6792 | crown - full cast noble metal | $750 |
| D6793 | provisional retainer crown | $225 |
| D6930 | recement fixed partial denture | $95 |
| Code | Description | LDP |
|---|---|---|
| D7111 | extraction, coronal remnants - deciduous tooth | $75 |
| D7140 | extraction, erupted tooth or exposed root (elevation and/or forceps removal) | $95 |
| D7210 | surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth | $210 |
| D7220 | removal of impacted tooth - soft tissue | $268 |
| D7230 | removal of impacted tooth - partially bony | $365 |
| D7240 | removal of impacted tooth - completely bony | $456 |
| D7241 | removal of impacted tooth - completely bony, with unusual surgical complications | $390 |
| D7250 | surgical removal of residual tooth roots (cutting procedure) | $225 |
| D7260 | oroantral fistula closure | $650 |
| D7270 | tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth | $325 |
| D7280 | surgical access of an unerupted tooth | $365 |
| D7282 | mobilization of erupted or malpositioned tooth to aid eruption | $380 |
| D7285 | biopsy of oral tissue - hard (bone, tooth) | $295 |
| D7286 | biopsy of oral tissue - soft | $270 |
| Code | Description | LDP |
|---|---|---|
| D7310 | alveoloplasty in conjunction with extractions - per quadrant | $210 |
| D7311 | alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant | $145 |
| D7320 | alveoloplasty not in conjunction with extractions - per quadrant | $370 |
| D7340 | vestibuloplasty - ridge extension (secondary epithelialization) | $700 |
| D7350 | vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) | $1,500 |
| D7510 | incision and drainage of abscess - intraoral soft tissue | $170 |
| D7530 | removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue | $250 |
| D7540 | removal of reaction producing foreign bodies, musculoskeletal system | $340 |
| D7880 | occlusal orthotic device | $540 |
| D7953 | bone replacement graft for ridge preservation – per site | $330 |
| D9110 | palliative (emergency) treatment of dental pain - minor procedure | $65 |
| D9120 | fixed partial denture sectioning | $195 |
| D9911 | application of desensitizing resin for cervical and/or root surface, per tooth | $50 |
| D9944 | occlusal guard – soft appliance, full arch | $295 |
| D9945 | occlusal guard – soft appliance, full arch | $295 |
Orthodontics
Orthodontic Treatment - 20% Discount
NOTE: Includes placement of appliance, removal of appliances, records and placement of retainer. Does not include the cost of the retainer to be paid by LDP member. Cost for broken appliances and retainers will not be discounted. The orthodontist will explain the length of treatment, all fees and the payment schedule. Orthodontic discount is not available to any member currently in treatment. Orthodontic treatment that requires surgery or unusual services may require an additional charge. Discuss this with the patient prior to beginning treatment. Discount only applies to treatment performed by orthodontist; discounts may not apply to treatment performed by a general dentist.
General Information
- Members will be responsible for the full cost of any prescription drugs prescribed by a LDP provider.
- Members will be responsible for the full cost of any services provided by a LDP provider.
- If a member must cancel an appointment, the dental office must be notified 24 hours in advance, or a fee may be charged.
- Should the member have a dental insurance plan or other dental benefit plans, LDP discounts will not apply.
- If treatment is required by a non-participating dentist or treatment is performed in a hospital facility, the reduced fees do not apply, and the member will be responsible to the non-participating dentist or hospital for the usual and customary fee.
- If the member should have a grievance, it should be submitted to the LDP office. Unresolved grievances will be settled by arbitration.
- Fees listed on the member benefits and Dental Fee Schedule are for procedures done by participating general dentists and should not be considered specialist’s fees. Specialist fees, including orthodontics are billed at usual and customary charges less 20%.
- Any procedure involving lab fees will incur additional costs. All applicable lab fees are the full responsibility of the member and are subject to no discount.
- Sedation/Anesthesia is not discounted by Louisiana Dental Plan.