NORTH CAROLINA INDUSTRIAL COMMISSION

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MEDICAL FEE SCHEDULE

Section 13: Dental Fee Schedule

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Effective May 1, 2007

  • Dental claims will be submitted on the American Dental Association’s standard billing form.
  • Whenever a dentist's fees exceed those listed herein, complete written additional information must be furnished in order to justify any additional approval.
Code Allowance
00120 $48.00
00140 $32.00
00145 $82.00
00150 $48.00
00160 $90.00
00170 BR
00180 BR
00210 $100.00
00220 $19.00
00230 $18.00
00240 $19.00
00250 $75.00
00260 $75.00
00270 $18.00
00272 $33.00
00273 $46.00
00274 $42.00
00277 BR
00290 $75.00
00310 $184.00
00320 $25.00
00321 $100.00
00322 BR
00330 $100.00
00340 $100.00
00350 BR
00360 $248.00
00362 $260.00
00363 $285.00
00415 $26.00
00416 BR
00421 BR
00425 $30.00
00431 BR
00460 $45.00
00470 $52.00
00472 BR
00473 BR
00474 BR
00475 BR
00476 BR
00477 BR
00478 BR
00479 BR
00480 BR
00481 BR
00482 BR
00483 BR
00484 BR
00485 BR
00486 BR
00502 $45.00
00999 BR
01110 $53.00
01120 $38.00
01203 $20.00
01204 $20.00
01206 $31.00
01310 $30.00
01320 BR
01330 $30.00
01351 $35.00
01510 $250.00
01515 $380.00
01520 $279.00
01525 $197.00
01550 $33.00
01555 $60.00
02140 $90.00
02150 $105.00
02160 $125.00
02161 $175.00
02330 $95.00
02331 $117.00
02332 $160.00
02335 $200.00
02390 $200.00
02391 $95.00
02392 $117.00
02393 $160.00
02394 $200.00
02410 BR
02420 BR
02430 BR
02510 $382.00
02520 $442.00
02530 $492.00
02542 BR
02543 $594.00
02544 $612.00
02610 $385.00
02620 $500.00
02630 $650.00
02642 BR
02643 BR
02644 BR
02650 BR
02651 BR
02652 BR
02662 BR
02663 BR
02664 BR
02710 $175.00
02712 BR
02720 $504.00
02721 $504.00
02722 $504.00
02740 $800.00
02750 $775.00
02751 $650.00
02752 $750.00
02780 BR
02781 BR
02782 BR
02783 BR
02790 $750.00
02791 $650.00
02792 $504.00
02794 BR
02799 BR
02910 $76.00
02915 BR
02920 $76.00
02930 $200.00
02931 $200.00
02932 $200.00
02933 $250.00
02934 BR
02940 $76.00
02950 $142.00
02951 $41.00
02952 $247.00
02953 $150.50
02954 $200.00
02955 BR
02957 BR
02960 $200.00
02961 $600.00
02962 $600.00
02970 $167.00
02971 BR
02975 BR
02980 BR
02999 BR
03110 $36.00
03120 $42.00
03220 $121.00
03221 $121.00
03230 BR
03240 BR
03310 $495.00
03320 $550.00
03330 $680.00
03331 BR
03332 BR
03333 BR
03346 $500.00
03347 $600.00
03348 $700.00
03351 $200.00
03352 $200.00
03353 $500.00
03410 $700.00
03421 $750.00
03425 $800.00
03426 BR
03430 $100.00
03450 $210.00
03460 BR
03470 BR
03910 $126.00
03920 $210.00
03950 BR
03999 BR
04210 $372.00
04211 $75.00
04230 $1,000.00
04231 $798.00
04240 $372.00
04241 BR
04245 BR
04249 $272.00
04260 $550.00
04261 $350.00
04263 BR
04264 BR
04265 BR
04266 BR
04267 BR
04268 BR
04270 BR
04271 BR
04273 BR
04274 BR
04275 BR
04276 BR
04320 BR
04321 $200.00
04341 $150.00
04342 $230.00
04355 $105.00
04381 $48.00
04910 $72.00
04920 BR
04999 BR
05110 $1,000.00
05120 $1,000.00
05130 $1,100.00
05140 $1,100.00
05211 $550.00
05212 $550.00
05213 $1,100.00
05214 $1,100.00
05225 BR
05226 BR
05281 $950.00
No Code $1,500.00
No Code  $1,500.00
05410 $39.00
05411 $39.00
05421 $39.00
05422 $39.00
05510 $150.00
05520 $124.00
05610 $124.00
05620 $212.00
05630 $210.00
05640 $104.00
05650 $200.00
05660 $232.00
05670 BR
05671 BR
05710 $350.00
05711 $350.00
05720 $300.00
05721 $300.00
05730 $175.00
05731 $175.00
05740 $175.00
05741 $175.00
05750 $275.00
05751 $275.00
05760 $275.00
05761 $275.00
05810 $450.00
05811 $450.00
05820 $450.00
05821 $450.00
05850 $72.00
05851 $72.00
05860 $1,200.00
05861 BR
05862 $300.00
05867 BR
05875 BR
05899 BR
05911 BR
05912 BR
05913 $1,455.00
05914 $1,698.00
05915 $2,183.00
05916 $1,455.00
05919 $728.00
05922 BR
05923 BR
05924 BR
05925 BR
05926 BR
05927 BR
05928 BR
05929 BR
05931 $728.00
05932 $2,183.00
05933 $509.00
05934 $1,698.00
05935 $1,698.00
05936 BR
05937 BR
05951 $728.00
05952 $1,698.00
05953 $2,183.00
05954 $2,183.00
05955 $2,183.00
05958 BR
05959 BR
05960 BR
05982 $1,091.00
05983 $1,698.00
05984 $1,091.00
05985 $1,091.00
05986 $72.00
05987 BR
05988 BR
05999 BR
06010 $1,350.00
06012 $1,988.00
06040 BR
06050 BR
06053 BR
06054 BR
06055 BR
06056 BR
06057 BR
06058 BR
06059 BR
06060 BR
06061 BR
06062 BR
06063 BR
06064 BR
06094 BR
06065 BR
06066 BR
06067 BR
06068 BR
06069 BR
06070 BR
06071 BR
06072 BR
06073 BR
06074 BR
06194 BR
06075 BR
06076 BR
06077 BR
06078 BR
06079 BR
06080 BR
06090 BR
06091 $75.00
06092 $94.00
06093 $138.00
06095 BR
06100 BR
06190 BR
06199 BR
06205 BR
06210 $750.00
06211 $700.00
06212 $750.00
06214 $672.00
06240 $750.00
06241 $700.00
06242 $700.00
06245 BR
06250 $504.00
06251 $504.00
06252 $504.00
06253 BR
06545 $324.00
06548 BR
06600 BR
06601 BR
06602 BR
06603 BR
06604 BR
06605 BR
06606 BR
06607 BR
06624 BR
06608 BR
06609 BR
06610 BR
06611 BR
06612 BR
06613 BR
06614 BR
06615 BR
06634 BR
06710 $504.00
06720 $504.00
06721 $504.00
06722 $504.00
06740 $504.00
06750 $750.00
06751 $750.00
06752 $750.00
06780 $750.00
06781 BR
06782 BR
06783 BR
06790 $750.00
06791 $700.00
06792 $750.00
06794 BR
06793 BR
06920 BR
06930 $105.00
06940 $145.00
06950 $286.00
06970 $275.00
06972 $200.00
06973 $175.00
06975 BR
06976 BR
06977 BR
06980 BR
06985 BR
06999 BR
07111 $90.00
07140 $110.00
07210 $250.00
07220 $200.00
07230 $300.00
07240 $400.00
07241 $500.00
07250 $75.00
07260 $300.00
07261 BR
07270 $400.00
07272 BR
07280 $400.00
07282 BR
07283 BR
07285 $200.00
07286 $200.00
07287 BR
07288 BR
07290 BR
07291 $110.00
07292 $1,500.00
07293 $1,500.00
07294 $800.00
07310 $100.00
07311 BR
07320 $210.00
07321 BR
07340 BR
07350 BR
07410 $150.00
07411 BR
07412 BR
07413 BR
07414 BR
07415 BR
07465 BR
07440 BR
07441 BR
07450 BR
07451 $250.00
07460 $250.00
07461 $250.00
07471 BR
07472 BR
07473 BR
07485 BR
07490 BR
07510 $101.50
07511 BR
07520 $200.00
07521 BR
07530 $250.00
07540 BR
07550 BR
07560 BR
07610 BR
07620 BR
07630 BR
07640 BR
07650 BR
07660 BR
07670 BR
07671 BR
07680 BR
07710 BR
07720 BR
07730 BR
07740 BR
07750 BR
07760 BR
07770 BR
07771 BR
07780 BR
07810 BR
07820 BR
07830 BR
07840 BR
07850 BR
07852 BR
07854 BR
07856 BR
07858 BR
07860 BR
07865 BR
07870 BR
07871 BR
07872 BR
07873 BR
07874 BR
07875 BR
07876 BR
07877 BR
07880 BR
07899 BR
07910 $325.00
07911 $524.00
07912 BR
07920 BR
07940 BR
07941 BR
07943 BR
07944 BR
07945 BR
07946 BR
07947 BR
07948 BR
07949 BR
07950 BR
07951 $3,000.00
07953 BR
07955 BR
07960 BR
07963 BR
07970 BR
07971 BR
07972 BR
07980 $165.00
07981 BR
07982 BR
07983 BR
07990 BR
07991 BR
07995 BR
07996 BR
07997 BR
07998 BR
07999 BR
08010 BR
08020 BR
08030 BR
08040 BR
08050 BR
08060 BR
08070 BR
08080 BR
08090 BR
08210 $472.00
08220 $472.00
08660 BR
08670 BR
08680 BR
08690 BR
08691 BR
08692 BR
08693 $75.00
08999 BR
09110 $75.00
09120 $60.00
09210 $42.00
09211 BR
09212 BR
09215 $42.00
09220 BR
09221 BR
09230 BR
09241 BR
09242 BR
09248 BR
09310 $42.00
09410 BR
09420 $75.00
09430 $24.50
09440 $75.00
09450 BR
09610 BR
09612 $90.00
09630 BR
09910 $35.00
09911 BR
09920 BR
09930 BR
09940 $475.00
09941 $140.00
09942 BR
09950 $110.00
09951 $82.50
09952 $400.00
09970 BR
09971 BR
09972 BR
09973 BR
09974 BR
09999 BR
 

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