Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 53 - Dental Care Services, Reimbursement Schedule and Billing Instructions › Section I-5399 - Schedule for Maximum Allowances for Dental Services

Current through Register Vol. 50, No. 6, June 20, 2024
CDT Code
Description
Maximum Reimbursement
D0120
Periodic oral evaluation-established patient
50
D0140
Limited oral evaluation-problem focused
75
D0145
Oral evaluation-patient under 3 yrs and counseling
								with primary caregiver
69
D0150
Comprehensive oral evaluation-new or established
								patient
88
D0160
Detailed and Extensive oral evaluation-problem
								focused
160
D0170
Re-evaluation-limited, problem focused (established
								patient; not post-operative visit
70
D0180
Comprehensive periodontal evaluation-new or
								established patient
95
D0210
Intraoral-complete series (including
								bitewings)
128
D0220
Intraoral-periapical first film
28
D0230
Intraoral-periapical each additional film
24
D0240
Intraoral-occlusal films
42
D0250
Intraoral-first film
67
D0260
Extraoral-first film
55
D0270
Bitewing-single film
28
D0272
Bitewing-two films
45
D0273
Bitewing-three films
55
D0274
Bitewing-four films
65
D0277
Vertical bitewings-7 to 8 films
97
D0290
Posterior-anterior or lateral skull and facial bone
								survey film
135
D0310
Sialography
389
D0320
Temporomandibular joint films, including
								injection
592
D0321
Other temporomandibular joint films
210
D0322
Tomographic survey
530
D0330
Panoramic film
110
D0340
Cephalometric film
125
D0350
Oral/facial photographic images
71
D0360
Cone beam CT-craniofacial data capture
589
D0362
Cone beam CT-two-dimensional image reconstruction
								using existing data, includes multiple images
359
D0363
Cone beam CT-three-dimensional image reconstruction
								using existing data, includes multiple images
398
D0415
Collection of microorganisms for culture and
								sensitivity
186
D0416
Viral culture
168
D0417
Collection and preparation of saliva sample for
								laboratory diagnostic testing
167
D0418
Analysis of saliva sample
150
D0421
Genetic test for susceptibility to oral
								diseases
136
D0425
Caries susceptibility tests
95
D0431
Adjunctive pre-diagnostic test that aids in
								detection of mucosal abnormalities including premalignant and malignant
								lesions, not to include cytology or biopsy procedures
71
D0460
Pulp vitality tests
55
D0470
Diagnostic casts
109
D0472
Accession of tissue, gross examination, preparation
								and transmission of written report
118
D0473
Accession of tissue, gross examination and
								microscopic examination, preparation and transmission of written report
165
D0474
Accession of tissue, gross examination and
								microscopic examination including assessment of surgical margins for presence
								of disease, preparation and transmission of written report
184
D0480
Accession of exfoliative cytologic smears,
								microscopic examination, preparation and transmission of written report
176
D0486
Accession of transepithelial cytologic sample,
								microscopic examination, preparation and transmission of written report
150
D0475
Decalcification procedure
195
D0476
Special stains for microorganisms
289
D0477
Special stains not for microorganisms
296
D0478
Immunohistochemical stains
175
D0479
Tissue in-situ hybridization, including
								interpretation
231
D0481
Electron microscopy-diagnostic
188
D0482
Direct immunofluorescence
105
D0483
Indirect immunofluorescence
123
D0484
Consultation on slides prepared elsewhere
168
D0485
Consultation, including preparation of slides from
								biopsy material supplied by referring source
180
D0502
Other oral pathology procedures
170
D0999
Unspecified diagnostic procedure
BR
D1110
Prophylaxis-adult
90
D1120
Prophylaxis-child
66
D1203
Topical application of fluoride-child
37
D1204
Topical application of fluoride-adult
37
D1206
Topical fluoride varnish; therapeutic application
								for moderate to high caries risk patients
45
D1310
Nutritional counseling for control of dental
								disease
70
D1320
Tobacco counseling for the control and prevention
								of oral disease
82
D1330
Oral hygiene instructions
55
D1351
Sealant-per tooth
54
D1352
Preventative resin restoration in a moderate to
								high caries risk patient-permanent tooth
BR
D1510
Space maintainer-fixed-unilateral
317
D1515
Space maintainer-fixed-bilateral
432
D1520
Space maintainer-removable-unilateral
390
D1525
Space maintainer-removable-bilateral
495
D1550
Re-cementation of space maintainer
83
D1555
Removal of fixed space maintainer
79
D2140
Amalgam-one surface, primary or permanent
138
D2150
Amalgam-two surfaces, primary or permanent
176
D2160
Amalgam-three surfaces, primary or permanent
214
D2161
Amalgam-four surfaces, primary or permanent
251
D2330
Resin-based composite-one surface, anterior
160
D2331
Resin-based composite-two surfaces, anterior
200
D2332
Resin-based composite-three surfaces,
								anterior
249
D2335
Resin-based composite-four or more surfaces or
								involving incisal angle (anterior)
312
D2390
Resin-based composite crown-anterior
450
D2391
Resin-based composite-one surface, posterior
177
D2392
Resin-based composite-two surfaces,
								posterior
230
D2393
Resin-based composite-three surfaces,
								posterior
284
D2394
Resin-based composite-four or more surfaces
								posterior
341
D2410
Gold foil-one surface
635
D2420
Gold foil-two surfaces
692
D2430
Gold foil-three surfaces
806
D2510
Inlay-metallic-one surface
833
D2520
Inlay-metallic-two surfaces
892
D2530
Inlay-metallic-three or more surfaces
965
D2542
Onlay-metallic-two surfaces
990
D2543
Onlay-metallic-three surfaces
1015
D2544
Onlay-metallic-four or more surfaces
1050
D2610
Inlay-porcelain/ceramic-one surface
907
D2620
Inlay-porcelain/ceramic-two surfaces
950
D2630
Inlay-porcelain/ceramic-three or more
								surfaces
995
D2642
Onlay-porcelain/ceramic-two surfaces
1008
D2643
Onlay-porcelain/ceramic-three surfaces
1049
D2644
Onlay-porcelain/ceramic-four or more
								surfaces
1094
D2650
Inlay-resin based-one surface
869
D2651
Inlay-resin based-two surfaces
904
D2652
Inlay-resin based-three or more surfaces
940
D2662
Onlay-resin based-two surfaces
944
D2663
Onlay-resin based-three surfaces
983
D2664
Onlay-resin based-four or more surfaces
1025
D2710
Crown-resin-based composite (indirect)
940
D2712
Crown-3/4 resin-based composite (indirect)
999
D2720
Crown-resin with high noble metal
1061
D2721
Crown-resin with predominantly base metal
998
D2722
Crown-resin with noble metal
1015
D2740
Crown-porcelain/ceramic substrate
1132
D2750
Crown-porcelain fused to high noble metal
1100
D2571
Crown-porcelain fused predominantly base
								metal
1029
D2752
Crown-porcelain fused to noble metal
1050
D2780
Crown-3/4 cast high noble metal
1063
D2781
Crown-3/4 cast predominantly base metal
1027
D2782
Crown-3/4 cast noble metal
1030
D2783
Crown-3/4 porcelain /ceramic
1100
D2790
Crown-full cast high noble metal
1100
D2791
Crown-full cast predominantly base metal
997
D2792
Crown-full cast noble metal
1045
D2794
Crown-titanium
1076
D2799
Provisional crown
437
D2910
Recement inlay, only, or partial coverage
								restoration
108
D2915
Recement cast or prefabricated post and core
114
D2920
Recement crown
109
D2930
Prefabricated stainless steel crown-primary
								tooth
271
D2931
Prefabricated stainless steel crown-permanent
								tooth
325
D2932
Prefabricated resin crown
351
D2933
Prefabricated stainless steel crown with resin
								window
363
D2934
Prefabricated esthetic coated stainless steel
								crown-primary tooth
372
D2940
Protective restoration
120
D2950
Core buildup, including any pins
271
D2951
Pin retention-per tooth, in addition to
								restoration
75
D2952
Post and core in addition to crown, indirectly
								fabricated
422
D2953
Each additional indirectly fabricated post-same
								tooth
312
D2954
Prefabricated post and core in addition to
								crown
335
D2955
Post removal (not in conjunction with endodontic
								therapy)
291
D2957
Each additional prefabricated post-same
								tooth
200
D2960
Labial veneer (resin laminate)-chairside
658
D2961
Labial veneer (resin laminate)-laboratory
975
D2962
Labial veneer (porcelain
								laminate)-laboratory
1150
D2970
Temporary crown (fractured tooth)
375
D2971
Additional procedures to construct new crown under
								existing partial denture framework
169
D2975
Coping
597
D2980
Crown repair
293
D2999
Unspecified restorative procedure,
BR
D3110
Pulp cap-direct (excluding final
								restoration)
83
D3120
Pulp cap-indirect (excluding final
								restoration)
84
D3220
Therapeutic pulpotomy (excluding final
								restoration)-removal of pulp coronal to the dentinocemental junction and
								application of medicament
198
D3221
Pulpal debridement, primary and permanent
								teeth
234
D3222
Partial pulpotomy for apexogenesis-permanent tooth
								with incomplete root development
298
D3230
Pulpal therapy (resorbable filling)-anterior,
								primary tooth (excluding final restoration)
275
D3240
Pulpal therapy (resorbable filling)-posterior,
								primary tooth (excluding final restoration)
312
D3310
Endodontic therapy, anterior tooth (excluding final
								restoration)
725
D3320
Endodontic therapy, biscuspid tooth (excluding
								final restoration)
842
D3330
Endodontic therapy, molar tooth (excluding final
								restoration)
1009
D3331
Treatment of root canal obstruction: non-surgical
								access
611
D3332
Incomplete endodontic therapy; inoperable,
								unrestorable or fractured tooth
444
D3333
Internal root repair of perforation defects
350
D3346
Retreatment of previous root canal therapy-
								anterior
850
D3347
Retreatment of previous root canal therapy-
								bicuspid
970
D3348
Retreatment of previous root canal therapy-
								molar
1132
D3351
Apexification/recalcification/pulpal
								regeneration-initial visit (apical closure/calcific repair of perforations,
								root resorption, pulp space disinfection, etc.)
362
D3352
Apexification/recalcification/pulpal
								regeneration-interim medication replacement (apical closure/calcific repair of
								perforations, root resorption, pulp space disinfection, etc.)
258
D3353
Apexification/recalcification/pulpal
								regeneration-final visit (includes completed root canal therapy-apical
								closure/calcific repair of perforations, root resorption, pulp space
								disinfection, etc.)
542
D3354
Pupal regeneration-(completion of regenerative
								treatment in an immature permanent tooth with a necrotic pulp); does not
								include final restoration
BR
D3410
Apicoectomy/periradicular surgery-anterior
700
D3421
Apicoectomy/periradicular surgery-bicuspid (first
								root)
780
D3425
Apicoectomy/periradicular surgery-molar (first
								root)
895
D3426
Apicoectomy/periradicular surgery-(each additional
								root)
400
D3430
Retrograde filling-per root
280
D3450
Root amputation-per root
483
D3460
Endodontic endosseous implant
1524
D3470
Intentional reimplantation (including necessary
								splinting)
796
D3910
Surgical procedure for isolation of tooth with
								rubber dam
235
D3920
Hemisection (including any root removal), not
								including root canal therapy
474
D3950
Canal preparation and fitting of preformed dowel or
								post
258
D3999
Unspecified endodontic procedure,
BR
D4210
Gingivectomy or gingivoplasty-four or more
								contiguous teeth or tooth bounded spaces per quadrant
626
D4211
Gingivectomy or gingivoplasty-one to three
								contiguous teeth or tooth bounded spaces per quadrant
290
D4230
Anatomical crown exposure-four or more contiguous
								teeth per quadrant
698
D4231
Anatomical crown exposure-one to three contiguous
								teeth per quadrant
596
D4240
Gingival flap procedure, including root planing-
								one to three contiguous teeth or tooth bounded spaces per quadrant
738
D4241
Gingival flap procedure, including root planing-
								four or more contiguous teeth or tooth bounded spaces per quadrant
635
D4245
Apically positioned flap
819
D4249
Clinical crown lengthening-hard tissue
751
D4260
Osseous surgery (including flap entry and
								closure)-four or more contiguous teeth or tooth bounded spaces per
								quadrant
1074
D4261
Osseous surgery (including flap entry and
								closure)-one to three contiguous teeth or tooth bounded spaces per
								quadrant
890
D4263
Bone replacement graft-each additional site in
								quadrant
727
D4264
Bone replacement graft-first site in
								quadrant
555
D4265
Biologic materials to aid in soft and osseous
								tissue regeneration
550
D4266
Guided tissue regeneration-resorbable barrier, per
								site
831
D4267
Guided tissue regeneration-nonresorbable barrier,
								per site (includes membrane removal)
984
D4268
Surgical revision procedure, per tooth
810
D4270
Pedical soft tissue graft procedure
826
D4271
Free soft tissue graft procedure (including donor
								site surgery)
895
D4273
Subepithelial connective tissue graft procedures,
								per tooth
1088
D4274
Distal or proximal wedge procedure (when not
								performed in conjunction with surgical procedures in the same anatomical
								area)
670
D4275
Soft tissue allograft
969
D4276
Combined connective tissue and double pedicle
								graft, per tooth
1085
D4320
Provisional splinting-intracoronal
508
D4321
Provisional splinting-extracoronal
466
D4341
Periodontal scaling and root planing-four or more
								teeth per quadrant
251
D4342
Periodontal scaling and root planing-one to three
								teeth per quadrant
185
D4355
Full mouth debridement to enable comprehensive
								evaluation and diagnosis
183
D4381
Localized delivery of antimicrobial agents via a
								controlled release vehicle into diseased crevicular tissue, per tooth,
140
D4910
Periodontal maintenance
139
D4920
Unscheduled dressing change (by someone other than
								treating dentist)
100
D4999
Unspecified periodontal procedure,
BR
D5110
Complete denture-maxillary
1689
D5120
Complete denture-mandibular
1700
D5130
Immediate denture-maxillary
1831
D5140
Immediate denture-mandibular
1849
D5211
Maxillary partial denture-resin base (including any
								conventional clasps, rests and teeth)
1350
D5212
Mandibular partial denture-resin base (including
								any conventional clasps, rests and teeth)
1350
D5213
Maxillary partial denture-cast base framework with
								resin denture bases (including any conventional clasps, rests and teeth)
1781
D5214
Mandibular partial denture-cast base framework with
								resin denture bases (including any conventional clasps, rests and teeth)
1780
D5225
Maxillary partial denture-flexible base (including
								any clasps, rests and teeth)
1566
D5226
Mandibular partial denture-flexible base (including
								any clasps, rests and teeth)
1552
D5281
Removable unilateral partial denture-one piece cast
								metal (including clasps and teeth)
995
D5410
Adjust complete denture-maxillary
89
D5411
Adjust complete denture-mandibular
88
D5421
Adjust partial denture-maxillary
88
D5422
Adjust partial denture-mandibular
88
D5510
Repair broken complete denture base
208
D5520
Replace missing or broken teeth-complete denture
								(each tooth)
186
D5610
Repair resin denture base
202
D5620
Repair cast framework
291
D5630
Repair or replace broken clasp
262
D5640
Replace broken teeth-per tooth
184
D5650
Add tooth to existing partial denture
224
D5660
Add clasp to existing partial denture
268
D5670
Replace all teeth and acrylic on cast metal
								framework (maxillary)
735
D5671
Replace all teeth and acrylic on cast metal
								framework (mandibular)
750
D5710
Rebase complete maxillary denture
591
D5711
Rebase complete mandibular denture
585
D5720
Rebase maxillary partial denture
563
D5721
Rebase mandibular partial denture
562
D5730
Reline complete maxillary denture
								(chairside)
372
D5731
Reline complete mandibular denture
								(chairside)
369
D5740
Reline maxillary partial denture (chairside)
364
D5741
Reline mandibular partial denture
								(chairside)
368
D5750
Reline complete maxillary denture
								(laboratory)
475
D5751
Reline complete mandibular denture
								(laboratory)
475
D5760
Reline maxillary partial denture
								(laboratory)
469
D5761
Reline mandibular partial denture
								(laboratory)
472
D5810
Interim complete denture (maxillary)
848
D5811
Interim complete denture (mandibular)
853
D5820
Interim partial denture (maxillary)
690
D5821
Interim partial denture (mandibular)
690
D5850
Tissue conditioning, maxillary
204
D5851
Tissue conditioning, mandibular
205
D5860
Overdenture-complete
2121
D5861
Overdenture-partial
2048
D5862
Precision attachment
700
D5867
Replacement of replaceable part of semi-precision
								or precision attachment (male or female component)
385
D5875
Modification of removable prosthesis following
								implant surgery
393
D5899
Unspecified removable prosthodontic
								procedure
BR
D5911
Facial moulage (sectional)
BR
D5912
Facial moulage (complete)
BR
D5913
Nasal prosthesis
BR
D5914
Auricular prosthesis
BR
D5915
Orbital prosthesis
BR
D5916
Ocular prosthesis
BR
D5919
Facial prosthesis
BR
D5923
Ocular prosthesis, interim
BR
D5924
Cranial prosthesis
BR
D5925
Facial augmentation implant prosthesis
BR
D5926
Nasal prosthesis, replacement
BR
D5957
Auricular prosthesis, replacement
BR
D5958
Orbital prosthesis, replacement
BR
D5929
Facial prosthesis, replacement
BR
D5931
Obturator prosthesis, surgical
BR
D5932
Obturator prosthesis, definitive
BR
D5933
Obturator prosthesis, modification
BR
D5934
Mandibular resection prosthesis with guide
								flange
BR
D5935
Mandibular resection prosthesis without guide
								flange
BR
D5936
Obturator prosthesis interim
BR
D5937
Trismus appliance (not for TMD treatment)
746
D5951
Feeding aid
844
D5952
Speech aid prosthesis, pediatric
BR
D5953
Speech aid prosthesis, adult
BR
D5954
Palatal augmentation prosthesis
BR
D5955
Palatal lift prosthesis, definitive
BR
D5958
Palatal lift prosthesis, interim
BR
D5959
Palatal lift prosthesis, modification
BR
D5960
Speech aid prosthesis modification
BR
D5982
Surgical stent
450
D5983
Radiation carrier
BR
D5984
Radiation shield
BR
D5985
Radiation cone locater
BR
D5986
Fluoride gel carrier
210
D5987
Commissure splint
BR
D5988
Surgical splint
770
D5991
Topical medicament carrier
226
D5992
Adjust maxillofacial prosthetic appliance
BR
D5993
Maintenance and cleaning of maxillofacial
								prosthesis (extra or intraoral) other than required adjustments
BR
D5999
Unspecified maxillofacial prosthesis
BR
D6190
Radiographic/surgical implant index
375
D6010
Surgical placement of implant body: endosteal
								implant
2001
D6012
Surgical placement of interim implant body for
								transitional prosthesis: endosteal implant
1577
D6040
Surgical placement: eposteal implant
8380
D6050
Surgical placement: transosteal implant
5807
D6100
Implant removal
760
D6055
Connecting bar-implant supported abutment
								support
2900
D6506
Prefabricated abutment-includes placement
789
D6057
Custom abutment-includes placement
952
D6053
Implant/abutment supported removable denture for
								completely edentulous arch
2790
D6054
Implant/abutment supported removable denture for
								partially edentulous arch
2751
D6078
Implant/abutment supported fixed denture for
								completely edentulous arch
5335
D6079
Implant/abutment supported fixed denture for
								partially edentulous arch
3800
D6058
Abutment supported porcelain/ceramic crown
1479
D6059
Abutment supported porcelain/ceramic crown (high
								noble metal)
1479
D6060
Abutment supported porcelain fused to metal crown
								(predominately base metal)
1361
D6061
Abutment supported porcelain fused to metal crown
								(noble metal)
1382
D6062
Abutment supported cast metal crown (high noble
								metal)
1432
D6063
Abutment supported cast metal crown (predominantly
								base metal)
1317
D6064
Abutment supported cast metal crown (noble
								metal)
1366
D6094
Abutment supported crown-(titanium)
1376
D6065
Implant supported porcelain/ceramic crown
1543
D6066
Implant supported porcelain fused to metal crown
								(titanium, titanium alloy, high noble metal)
1545
D6067
Implant supported metal crown (titanium, titanium
								alloy, high noble metal)
1575
D6068
Abutment supported retainer for porcelain/ceramic
								FPD
1469
D6069
Abutment supported retainer for porcelain fused to
								metal FPD (high noble metal)
1474
D6070
Abutment supported retainer for porcelain fused to
								metal FPD (predominantly base metal)
1384
D6071
Abutment supported retainer for porcelain fused to
								metal FPD (noble metal)
1384
D6072
Abutment supported retainer for cast metal FPD
								(high noble metal)
1451
D6073
Abutment supported retainer for porcelain cast
								metal FPD (predominantly base metal)
1384
D6074
Abutment supported retainer for cast metal FPD
								(noble metal)
1384
D6194
Abutment supported retainer crown for FPD
								(titanium)
1392
D6075
Implant supported retainer for ceramic FPD
1529
D6076
Implant supported retainer for porcelain fused to
								metal FPD (titanium, titanium alloy or high noble metal
1538
D6077
Implant supported retainer for cast metal FPD
								(titanium, titanium alloy or high noble metal)
1587
D6080
Implant maintenance procedures, including removal
								of prosthesis, cleansing of prosthesis and abutments and reinsertion of
								prosthesis
297
D6090
Repair implant supported prosthesis
742
D6095
Repair implant abutment
731
D6091
Replacement of semi-precious or precision
								attachment (male or female component) of implant/abutment supported prosthesis,
								per attachment
631
D6092
Recement implant/abutment supported crown
160
D6093
Recement implant/abutment supported fixed partial
								denture
182
D6199
Unspecified implant procedure
BR
D6205
Pontic-indirect resin based composite
988
D6210
Pontic-cast high noble metal
1089
D6211
Pontic-cast predominately base metal
998
D6212
Pontic-cast noble metal
1041
D6214
Pontic-titanium
1100
D6240
Pontic-porcelain fused to high noble metal
1100
D6241
Pontic-porcelain fused to predominantly base
								metal
1024
D6242
Pontic-porcelain fused to noble metal
1051
D6245
Pontic-porcelain/ceramic
1140
D6250
Pontic-resin with high noble metal
1058
D6251
Pontic-resin with predominantly base metal
1049
D6252
Pontic-resin with noble metal
1040
D6253
Provisional pontic
769
D6254
Interim pontic
BR
D6545
Retainer-cast metal for resin bonded fixed
								prosthesis
852
D6548
Retainer-porcelain/ceramic for resin bonded fixed
								prosthesis
950
D6600
Inlay-porcelain/ceramic, two surfaces
1000
D6601
Inlay-porcelain/ceramic, three or more
								surfaces
1052
D6602
Inlay-cast high noble metal, two surfaces
1015
D6603
Inlay-cast high noble metal, three or more
								surfaces
1050
D6604
Inlay-predominantly base metal, two surfaces
994
D6605
Inlay-predominantly base metal, three or more
								surfaces
1046
D6606
Inlay-cast noble metal, two surfaces
998
D6607
Inlay-cast noble metal, three or more
								surfaces
1050
D6624
Inlay-titanium
1080
D6608
Onlay-porcelain/ceramic, two surfaces
1061
D6609
Onlay-porcelain/ceramic, three or more
								surfaces
1127
D6610
Onlay-cast high noble metal, two surfaces
1074
D6611
Onlay-cast high noble metal, three or more
								surfaces
1111
D6612
Onlay-predominantly base metal, two surfaces
1038
D6613
Onlay-predominantly base metal, three or more
								surfaces
1095
D6614
Onlay-cast noble metal, two surfaces
1050
D6615
Onlay-cast noble metal, three or more
								surfaces
1102
D6634
Onlay-titanium
1125
D6710
Crown-indirect resin based composite
1025
D6720
Crown-resin with high noble metal
1056
D6721
Crown-resin with predominantly base metal
1032
D6722
Crown-resin with noble metal
1050
D6740
Crown-porcelain/ceramic
1146
D6750
Crown-porcelain fused to high noble metal
1107
D6751
Crown-porcelain fused to predominantly base
								metal
1010
D6752
Crown-porcelain fused to noble metal
1050
D6780
Crown-3/4 cast high noble metal
1075
D6781
Crown-3/4 cast predominantly base metal
1038
D6782
Crown-3/4 cast noble metal
1050
D6783
Crown-3/4 porcelain/ceramic
1100
D6790
Crown-full cast high noble metal
1085
D6791
Crown-full cast predominantly base metal
997
D6792
Crown-full cast noble metal
1040
D6794
Crown-titanium
1059
D6793
Provisional retainer crown
523
D6795
Interim retainer crown
BR
D6920
Connector bar
995
D6930
Recement fixed partial denture
171
D6940
Stress breaker
435
D6950
Precision attachment
650
D6970
Post and core in addition to fixed partial denture
								retainer, indirectly fabricated
433
D6972
Prefabricated post and core in addition to fixed
								partial denture retainer
344
D6973
Core build up for retainer, including any
								pins
275
D6975
Coping-metal
700
D6976
Each additional indirectly fabricated post-same
								tooth
290
D6977
Each additional prefabricated post-same
								tooth
204
D6980
Fixed partial denture repair
387
D6985
Pediatric partial denture, fixed
915
D6999
Unspecified fixed prosthodontic procedure
BR
D7111
Extraction, coronal remnants-deciduous tooth
135
D7140
Extraction, erupted tooth or exposed root
								(elevation and/or forceps removal)
174
D7210
Surgical removal of erupted tooth requiring removal
								of bone and/or sectioning of tooth, and including elevation of mucoperiosteal
								flap if indicated
275
D7220
Removal of impacted tooth-soft tissue
315
D7230
Removal of impacted tooth-partially bony
395
D7240
Removal of impacted tooth-completely bony
484
D7241
Removal of impacted tooth-completely bony, with
								unusual surgical complications
576
D7250
Surgical removal of residual tooth roots (cutting
								procedure)
304
D7251
Coronectomy-intentional partial tooth
								removal
BR
D7260
Oroantral fistula closure
1026
D7261
Primary closure of a sinus perforation
757
D7270
Tooth reimplantation and/or stabilization of
								accidentally evulsed or displaced tooth
561
D7272
Tooth tranplantation (includes reimplantation from
								one site to another and splinting and/or stabilization)
746
D7280
Surgical access of an unerupted tooth
482
D7282
Mobilization of erupted or malpositioned tooth to
								aid eruption
526
D7283
Placement of device to facilitate eruption of
								impacted tooth
523
D7285
Biopsy of oral tissue-hard (bone, tooth)
437
D7286
Biopsy of oral tissue-soft
320
D7287
Exfoliative cytological sample collection
184
D7288
Brush biopsy-transepithelial sample
								collection
195
D7290
Surgical repositioning of teeth
528
D7291
Transseptal fiberotomy/surpa crestal
								fibertotomy
315
D7292
Surgical placement: temporary anchorage device
								[screw retained plate] requiring surgical flap
3300
D7293
Surgical placement: temporary anchorage device
								requiring surgical flap
2528
D7294
Surgical placement: temporary anchorage device
								without surgical flap
1619
D7295
Harvest of bone for use in autogenous grafting
								procedure
BR
D7310
Alveolplasty in conjunction with extractions- four
								or more teeth or tooth spaces, per quadrant
295
D7311
Alveolplasty in conjunction with extractions- one
								to three teeth or tooth spaces, per quadrant
309
D7320
Alveolplasty not in conjunction with
								extractions-four or more teeth or tooth spaces, per quadrant
443
D7321
Alveolplasty not in conjunction with
								extractions-one to three teeth or tooth spaces, per quadrant
437
D7340
Vestibuloplasty-ridge extension (secondary
								epithelialization)
1164
D7350
Vestibuloplasty-ridge extension (including soft
								tissue graft, muscle reattachment, revision of soft tissue attachment and
								management of hypertrophied and hyperplastic tissue)
2467
D7410
Excision of benign lesion up to 1.25 cm
415
D7411
Excision of benign lesion greater than 1.25
								cm
630
D7412
Excision of benign lesion, complicated
850
D7413
Excision of malignant lesion greater than 1.25
								cm
751
D7414
Excision of malignant lesion up to 1.25 cm
1132
D7415
Excision of malignant lesion, complicated
1253
D7465
Destruction of lesion(s) by physical or chemical
								method
459
D7440
Excision of malignant tumor-lesion diameter up to
								1.25 cm
720
D7441
Excision of malignant tumor-lesion greater than
								1.25 cm
1224
D7450
Removal of benign odontogenic cyst or tumor- lesion
								diameter up to 1.25 cm
588
D7451
Removal of benign odontogenic cyst or tumor- lesion
								diameter greater than 1.25 cm
782
D7460
Removal of benign nonodontogenic cyst or
								tumor-lesion diameter greater than 1.25 cm
573
D7461
Removal of benign nonodontogenic cyst or
								tumor-lesion diameter up to 1.25 cm
874
D7470
Removal of lateral exostosis (maxilla or
								mandible)
653
D7472
Removal of torus palatinus
859
D7473
Removal of torus mandibularis
761
D7485
Surgical reduction of osseous tuberosity
755
D7490
Radial resection of maxilla or mandible
8006
D7510
Incision and drainage of abscess-intraoral soft
								tissue
236
D7511
Incision and drainage of abscess-intraoral soft
								tissue-complicated (includes drainage of multiple fascial spaces)
367
D7520
Incision and drainage of abscess-extraoral
								tissue
169
D7521
Incision and drainage of abscess-extraoral
								tissue-complicated (includes drainage of multiple fascial spaces)
630
D7530
Removal of foreign body from mucosa, skin, or
								subcutaneous alveolar tissue
364
D7540
Removal of reaction producing foreign bodies,
								musculoskeletal system
708
D7550
Partial ostectomy/sequestrectomy for removal of
								non-vital bone
600
D7560
Maxillary sinusotomy for removal of tooth fragment
								or foreign body
1308
D7610
Maxilla-open reduction (teeth immobilized, if
								present)
4464
D7620
Maxilla-closed reduction (teeth immobilized, if
								present)
3450
D7630
Mandible-open reduction (teeth immobilized, if
								present)
4576
D7640
Mandible-closed reduction (teeth immobilized, if
								present)
3483
D7650
Malar and/or zygomatic arch-open reduction
3924
D7660
Malar and/or zygomatic arch-closed reduction
3277
D7670
Alveolus closed reduction may include stabilization
								of teeth
1746
D7671
Alveolus open reduction may include stabilization
								of teeth
1298
D7680
Facial bones-complicated reduction with fixation
								and multiple surgical approaches
6555
D7710
Maxilla open reduction
4568
D7720
Maxilla-closed reduction
3462
D7730
Mandible-open reduction
4826
D7740
Mandible-closed reduction
3636
D7750
Malar and/or zygomatic arch-open reduction
4230
D7760
Malar and/or zygomatic arch-closed reduction
6044
D7770
Alveolus open reduction stabilization of
								teeth
2794
D7771
Alveolus closed reduction stabilization of
								teeth
1958
D7780
Facial bones-complicated reduction with fixation
								and multiple surgical approaches
8587
D7810
Open reduction of dislocation
4271
D7820
Closed reduction of dislocation
644
D7830
Manipulation under anesthesia
990
D7840
Condylectomy
5466
D7850
Surgical discectomy, with/without implant
5356
D7852
Disc repair
5541
D7854
Synovectomy
5278
D7856
Myotomy
3505
D7858
Joint reconstruction
BR
D7860
Arthrotomy
BR
D7865
Arthroplasty
BR
D7870
Arthrocentesis
562
D7871
Non-arthroscopic lysis and lavage
BR
D7872
Arthroscopy-diagnosis, with or without
								biopsy
BR
D7873
Arthroscopy-surgical: lavage and lysis of
								adhesions
BR
D7874
Arthroscopy-surgical: disc repositioning and
								stabilization
BR
D7875
Arthroscopy-surgical: synovectomy
BR
D7876
Arthroscopy-surgical: discectomy
BR
D7877
Arthroscopy-surgical: debridement
BR
D7880
Occlusal orthotic device
990
D7899
Unspecified TMD therapy
BR
D7910
Suture of recent small wounds up to 5 cm
300
D7911
Complicated suture-up to 5 cm
486
D7912
Complicated suture-greater than 5 cm
792
D7920
Skin graft (identify defect covered, location and
								type of graft
2677
D7940
Osteoplasty-for orthognathic deformaties
4123
D7941
Osteotomy-mandibular rami
9139
D7943
Osteotomy-mandibular rami with bone graft; includes
								obtaining the graft
8623
D9744
Osteotomy-segmented or subapical
7006
D7945
Osteotomy-body of mandible
6983
D7946
LeFort I (maxilla-total)
8251
D7947
LeFort I (maxilla-segmentedl)
8393
D7948
LeFort II or LeFort III (osteoplasty of facial
								bones for midface hypoplasia or retrusion)-without bone graft
9586
D7949
LeFort II of LeFort III-with bone graft
11832
D7950
Osseous, osteoperiosteal or cartilage graft of the
								mandible or maxilla-autogenous or nonautogenous
3116
D7951
Sinus augmentation with bone or bone
								substitutes
3200
D7953
Bone replacement graft for ridge preservation- per
								site
800
D7955
Repair of maxillofacial soft and/or hard tissue
								defect
3807
D7960
Frenulectomy-also known as frenectomy or
								frenotomy-separate procedure not incidental to another procedure
450
D7936
Frenuloplasty
499
D7970
Excision of hyperplastic tissue-per arch
517
D7971
Excision of pericoronal gingiva
258
D7972
Surgical reduction of fibrous tuberosity
796
D7980
Sialolithotomy
843
D7981
Excision of salivary gland
BR
D7982
Sialodochoplasty
1749
D7983
Closure of salivary fistula
1528
D7990
Emergency tracheotomy
1482
D7991
Coronoidectomy
4056
D7995
Synthetic graft-mandible or facial bones
BR
D7996
Implant-mandible for augmentation purposes
								(excluding alveolar ridge)
BR
D7997
Appliance removal (not by dentist who place
								appliance), includes removal of archbar
350
D7998
Intraoral placement of a fixation device not in
								conjunction with a fracture
2572
D7999
Unspecified oral surgery procedure
BR
D8010
Limited orthodontic treatment of the primary
								dentition
2149
D8020
Limited orthodontic treatment of the transitional
								dentition
2459
D8030
Limited orthodontic treatment of the adolescent
								dentition
2901
D8040
Limited orthodontic treatment of the adult
								dentition
3237
D8050
Interceptive orthodontic treatment of the primary
								dentition
2590
D8060
Interceptive orthodontic treatment of the
								transitional dentition
2796
D8070
Comprehensive orthodontic treatment of the
								transitional dentition
5200
D8080
Comprehensive orthodontic treatment of the
								adolescent dentition
5250
D8090
Comprehensive orthodontic treatment of the adult
								dentition
5308
D8210
Removable appliance therapy
861
D8220
Fixed appliance therapy
968
D8660
Pre-orthodontic treatment visit
384
D8670
Periodic orthodontic treatment visit (as part of
								contract)
263
D8680
Orthodontic retention (removal of appliances,
								construction and placement of retainers(s))
532
D8690
Orthodontic treatment (alternative billing to a
								contract fee)
283
D8691
Repair of orthodontic appliance
210
D8692
Replacement of lost or broken retainer
330
D8693
Rebonding or recementing; and/or repair as require,
								of fixed retainers
356
D8999
Unspecified orthodontic procedure,
BR
D9110
Palliative (emergency) treatment of dental pain-
								minor procedure
126
D9120
Fixed partial denture sectioning
250
D9210
Local anesthesia not in conjunction with operative
								or surgical procedures
74
D9211
Regional block anesthesia
96
D9212
Trigeminal division block anesthesia
272
D9215
Local anesthesia in conjunction with operative or
								surgical procedures
65
D9220
Deep sedation/general anesthesia-first 30
								minutes
392
D9221
Deep sedation/general anesthesia-each additional 15
								minutes
174
D9230
Inhalation of nitrous oxide/anxiolysis
								analgesia
79
D9241
Intravenous conscious sedation/analgesia-first 30
								minutes
416
D9242
Intravenous conscious sedation/analgesia-each
								additional 15 minutes
169
D9248
Non-intravenous conscious sedation
325
D9310
Consultation-diagnostic services provided by
								dentist or physician other than requesting dentist or physician
129
D9410
House/extended care facility call
246
D9420
Hospital or ambulatory surgery center call
299
D9430
Office visit for observation (during regularly
								scheduled hours)-no other services performed
76
D9440
Office visit after regularly scheduled hours
179
D9450
Case presentation, detailed and extensive treatment
								planning
145
D9610
Therapeutic parental drug, single
								administration
111
D9612
Therapeutic parental drug, two or more
								administrations, different medications
193
D9630
Other drugs and/or medicaments
49
D9910
Application of disensitizing medicament
63
D9911
Application of disensitizing resin for cervical
								and/or root surface, per tooth
79
D9920
Behavior management
160
D9930
Treatment of complications (post-surgical)- unusual
								circumstances
132
D9940
Occlusal guard,
600
D9941
Fabrication of athletic mouthguard
254
D9942
Repair and/or reline of occlusal guard
250
D9950
Occulusion analysis-mounted case
344
D9951
Occulusal adjustment-limited
182
D9952
Occulusal adjustment-complete
687
D9970
Enamel microabrasion
202
D9971
Odontoplasty 1-2 teeth; includes removal of enamel
								projections
176
D9972
External bleaching-per arch
328
D9973
External bleaching-per tooth
231
D9974
Internal bleaching-per tooth
291
D9999
Unspecified adjunctive procedure
BR
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.