Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 314.00 - Rates for Dental Services › Section 314.05 - Allowable Fees: Non-hospital Services

Current through Register 1525, July 5, 2024
Code
Allowed
							 Fee
Allowed Fee (EPSDT-eligible
							 members)
Description
I. Diagnostic
D0120
$24
$31
Periodic oral evaluation - established
							 patient
D0140
$43
$49
Limited oral evaluation - problem focused
D0145
I.C.
$27
Oral evaluation for a patient under three years old
							 and counseling with primary caregiver
D0150
$41
$62
Comprehensive oral evaluation - new or established
							 patient
D0160
$64
$77
Detailed and extensive oral evaluation - problem
							 focused, by report
D0170
$39
$45
Re-evaluation - limited, problem focused (established
							 patient; not postoperative visit)
D0171
I.C.
I.C.
Re-evaluation - post-operative office
							 visit
D0180
$37
$58
Comprehensive periodontal evaluation - new or
							 established patient
D0190
$20
$29
Screening of patient
D0191
$20
$29
Assessment of patient
D0210
$76
$94
Intraoral - complete series of radiographic
							 images
D0220
$15
$21
Intraoral - periapical, first radiographic
							 image
D0230
$13
$17
Intraoral - periapical, each additional radiographic
							 image
D0240
$21
$26
Intraoral - occlusal radiographic image
D0250
$23
$28
Extra oral 2D projection radiographic image created
							 using a stationary radiation source, and detector
D0251
I.C.
I.C.
Extra-oral posterior dental radiographic
							 image
D0270
$14
$17
Bitewing - single radiographic image
D0272
$25
$32
Bitewings - two radiographic images
D0273
$27
$35
Bitewings - three radiographic images
D0274
$36
$46
Bitewings - four radiographic images
D0277
$47
$55
Vertical bitewings - 7 to 8 radiographic
							 images
D0310
$45
$48
Sialography
D0320
$230
$321
Temporomandibular joint arthrogram, including
							 injection
D0321
$96
$114
Other temporomandibular joint radiographic image, by
							 report
D0322
I.C.
I.C.
Tomographic survey
D0330
$69
$94
Panoramic radiographic image
D0340
$74
$85
2D cephalometric radiographic image acquisition,
							 measurement and analysis
D0350
$39
$47
2D oral/facial photographic image obtained
							 intra-orally or extra-orally
D0364
I.C.
I.C.
Cone beam CT capture and interpretation with limited
							 field of view - less than one whole jaw
D0365
I.C.
I.C.
Cone beam CT capture and interpretation with field of
							 view of one full dental arch - mandible
D0366
I.C.
I.C.
Cone beam CT capture and interpretation with field of
							 view of one full dental arch - maxilla, with or without cranium
D0367
I.C.
I.C.
Cone beam CT capture and interpretation with field of
							 view of both jaws, with or without cranium
D0368
I.C.
I.C.
Cone beam CT capture and interpretation for TMJ
							 series including two or more exposures
D0369
I.C.
I.C.
Maxillofacial MRI capture and
							 interpretation
D0370
I.C.
I.C.
Maxillofacial ultrasound capture and
							 interpretation
D0371
I.C.
I.C.
Sialoendoscopy capture and interpretation
D0372
I.C.
I.C.
Intraoral tomosynthesis - comprehensive series of
							 radiographic images
D0373
I.C.
I.C.
Intraoral tomosynthesis - bitewing radiographic
							 image
D0374
I.C.
I.C.
Intraoral tomosynthesis - periapical radiographic
							 image
D0380
I.C.
I.C.
Cone beam CT image capture with limited field of view
							 -less than one whole jaw
D0381
I.C.
I.C.
Cone beam CT image capture with field of view of one
							 full dental arch - mandible
D0382
I.C.
I.C.
Cone beam CT image capture with field of view of one
							 full dental arch - maxilla, with or without cranium
D0383
I.C.
I.C.
Cone beam CT image capture with field of view of both
							 jaws, with or without cranium
D0384
I.C.
I.C.
Cone beam CT image capture for TMJ series including
							 two or more exposures
D0385
I.C.
I.C.
Maxillofacial MRI image capture
D0386
I.C.
I.C.
Maxillofacial ultrasound image capture
D0387
I.C.
I.C.
Intraoral tomosynthesis - comprehensive series of
							 radiographic image - image capture only
D0388
I.C.
I.C.
Intraoral tomosynthesis - bitewing radiographic image
							 -image capture only
D0389
I.C.
I.C.
Intraoral tomosynthesis - periapical radiographic
							 image -image capture only
D0391
I.C.
I.C.
Interpretation of diagnostic image by a practitioner
							 not associated with capture of the image, including report
D0393
I.C.
I.C.
Virtual treatment simulation using 3D image volume or
							 surface scan
D0394
I.C.
I.C.
Digital subtraction of two or more images or image
							 volumes of the same modality
D0395
I.C.
I.C.
Fusion of two or more 3D image volumes of one or more
							 modalities
D0411
I.C.
I.C.
HbA1c in-office of service testing
D0412
I.C.
I.C.
Blood glucose level test- in-office using a glucose
							 meter
D0414
I.C.
I.C.
Laboratory processing of microbial specimen to
							 include culture and sensitivity studies, preparation and transmission of
							 written report
D0415
I.C.
I.C.
Collection of microorganisms for culture and
							 sensitivity
D0416
I.C.
I.C.
Viral culture
D0417
I.C.
I.C.
Collection and preparation of saliva sample for
							 laboratory diagnostic testing
D0418
I.C.
I.C.
Analysis of saliva sample
D0419
I.C.
I.C.
Assessment of salivary flow by
							 measurement
D0422
I.C.
I.C.
Collection and preparation of genetic sample material
							 for laboratory analysis and report
D0423
I.C.
I.C.
Genetic test for susceptibility to diseases -
							 specimen analysis
D0425
I.C.
I.C.
Caries susceptibility tests
D0431
I.C.
I.C.
Adjunctive pre-diagnostic test that aids in detection
							 of mucosal abnormalities including premalignant and malignant lesions, not to
							 include cytology or biopsy procedures
D0460
$31
$37
Pulp vitality tests
D0470
$62
$72
Diagnostic casts
D0472
$72
$87
Accession of tissue, gross examination, preparation,
							 and transmission of written report
D0473
I.C.
I.C.
Accession of tissue, gross and microscopic
							 examination, preparation and transmission of written report
D0474
I.C.
I.C.
Accession of tissue, gross and microscopic
							 examination, including assessment of surgical margins for presence of disease,
							 preparation and transmission of written report
D0475
I.C.
I.C.
Decalcification procedure
D0476
I.C.
I.C.
Special stains for microorganisms
D0477
I.C.
I.C.
Special stains, not for microorganisms
D0478
I.C.
I.C.
Immunohistochemical stains
D0479
I.C.
I.C.
Tissue
in-situ
hybridization,
							 including interpretation
D0480
$54
$65
Accession of exfoliative cytologic smears,
							 microscopic examination, preparation and transmission of written
							 report
D0481
I.C.
I.C.
Electron microscopy
D0482
I.C.
I.C.
Direct immunofluorescence
D0483
I.C.
I.C.
Indirect immunofluorescence
D0484
I.C.
I.C.
Consultation on slides prepared elsewhere
D0485
I.C.
I.C.
Consultation, including preparation of slides from
							 biopsy material supplied by referring source
D0486
I.C.
I.C.
Accession of brush biopsy sample, microscopic
							 examination, preparation and transmission of written report
D0502
I.C.
I.C.
Other oral pathology procedures, by
							 report
D0600
I.C.
I.C.
Non-ionizing diagnostic procedure capable of
							 quantifying, monitoring, and recording changes in structure of enamel, dentin,
							 and cementum
D0601
I.C.
I.C.
caries risk assessment and documentation, with a
							 finding of low risk
D0602
I.C.
I.C.
caries risk assessment and documentation, with a
							 finding of moderate risk
D0603
I.C.
I.C.
caries risk assessment and documentation, with a
							 finding of high risk
D0604
I.C.
I.C.
Antigen testing for a public health related pathogen,
							 including coronavirus
D0605
I.C.
I.C.
Antibody testing for a public health related
							 pathogen, including coronavirus
D0701
I.C.
I.C.
Panoramic radiographic image- image capture
							 only
D0702
I.C.
I.C.
2-D Cephalometric radiographic image- image capture
							 only
D0703
I.C.
I.C.
2-D oral/facial photographic image obtained
							 intra-orally or extra-orally image capture only
D0705
I.C.
I.C.
Extra-oral posterior dental radiographic image- image
							 capture only
D0706
I.C.
I.C.
Intraoral- occlusal radiographic image- image capture
							 only
D0707
I.C.
I.C.
Intraoral- periapical radiographic image- image
							 capture
D0708
I.C.
I.C.
Intraoral- bitewing radiographic image- image capture
							 only
D0709
I.C.
I.C.
Intraoral- comprehensive series of radiographic
							 images-image capture only
D0801
I.C.
I.C.
3D dental surface scan - direct
D0802
I.C.
I.C.
3D dental surface scan - indirect
D0803
I.C.
I.C.
3D facial surface scan - direct
D0804
I.C.
I.C.
3D facial surface scan - indirect
D0999
I.C.
I.C.
Unspecified diagnostic procedure, by
							 report
II. Preventive
D1110
$60
$75
Prophylaxis - adult
D1120
$39
$55
Prophylaxis - child
D1206
$26
$28
Topical application of fluoride varnish
D1208
$29
$31
Topical application of fluoride - excluding
							 varnish
D1310
I.C.
I.C.
Nutritional counseling for the control of dental
							 disease
D1320
I.C.
I.C.
Tobacco counseling for the control and prevention of
							 oral disease
D1321
I.C.
I.C.
Counseling for the control and prevention of adverse
							 oral, behavioral, and systemic health effects associated with high-risk
							 substance use
D1330
$15
$21
Oral hygiene instructions
D1351
$30
$44
Sealant - per tooth
D1352
I.C.
I.C.
Preventive resin restoration in a moderate to high
							 caries risk patient- permanent tooth
D1353
I.C.
I.C.
Sealant repair - per tooth
D1354
$15
$15
Application of caries arresting medicament - per
							 tooth
D1355
I.C.
I.C.
Caries preventive medicament application- per
							 tooth
D1510
$191
$229
Space maintainer - fixed, unilateral - per
							 quadrant
D1516
$306
$345
Space maintainer- fixed- bilateral,
							 maxillary
D1517
$306
$345
Space maintainer- fixed- bilateral,
							 mandibular
D1520
$230
$244
Space maintainer - removable-unilateral- per
							 quadrant
D1526
$345
$368
Space maintainer- removable- bilateral,
							 maxillary
D1527
$345
$368
Space maintainer- removable- bilateral,
							 mandibular
D1551
I.C.
I.C.
Re-cement or re-bond bilateral space maintainer-
							 maxillary
D1552
I.C.
I.C.
Re-cement or re-bond bilateral space maintainer-
							 mandibular
D1553
I.C.
I.C.
Re-cement or re-bond unilateral space maintainer- per
							 quadrant
D1556
I.C.
I.C.
Removal of fixed unilateral space maintainer- per
							 quadrant
D1557
I.C.
I.C.
Removal of fixed bilateral space maintainer-
							 maxillary
D1558
I.C.
I.C.
Removal of fixed bilateral space maintainer-
							 mandibular
D1575
I.C.
I.C.
Distal shoe space maintainer - fixed, unilateral- per
							 quadrant
D1781
I.C.
I.C.
Vaccine administration - human papillomavirus - Dose
							 1
D1782
I.C.
I.C.
Vaccine administration - human papillomavirus - Dose
							 2
D1783
I.C.
I.C.
Vaccine administration - human papillomavirus - Dose
							 3
D1999
I.C.
I.C.
Unspecified preventive procedure, by
							 report
III. Restorative
D2140
$62
$77
Amalgam-one surface, primary or permanent
D2150
$77
$95
Amalgam-two surfaces, primary or
							 permanent
D2160
$92
$110
Amalgam-three surfaces, primary or
							 permanent
D2161
$116
$137
Amalgam-four or more surfaces, primary or
							 permanent
D2330
$72
$98
Resin-based composite - one surface,
							 anterior
D2331
$92
$118
Resin-based composite - two surfaces,
							 anterior
D2332
$116
$147
Resin-based composite - three surfaces,
							 anterior
D2335
$146
$188
Resin -based composite - four or more surfaces or
							 involving incisal angle (anterior)
D2390
$106
$133
Resin-based composite crown, anterior
D2391
$62
$99
Resin-based composite - one surface,
							 posterior
D2392
$77
$123
Resin-based composite - two surfaces,
							 posterior
D2393
$92
$133
Resin-based composite - three surfaces,
							 posterior
D2394
$116
$182
Resin-based composite - four or more surfaces,
							 posterior
D2410
I.C.
I.C.
Gold foil - one surface
D2420
I.C.
I.C.
Gold foil - two surfaces
D2430
I.C.
I.C.
Gold foil - three surfaces
D2510
I.C.
I.C.
Inlay - metallic - one surface
D2520
I.C.
I.C.
Inlay - metallic - two surfaces
D2530
$307
$367
Inlay - metallic - three or more surfaces
D2542
$499
$596
Onlay - metallic - two surfaces
D2543
$690
$788
Onlay - metallic - three surfaces
D2544
$715
$800
Onlay - metallic - four or more surfaces
D2610
I.C.
I.C.
Inlay - porcelain/ceramic - one surface
D2620
$422
$504
Inlay - porcelain/ceramic - two surfaces
D2630
$640
$744
Inlay - porcelain/ceramic - three or more
							 surfaces
D2642
$675
$722
Onlay - porcelain/ceramic - two surfaces
D2643
$651
$768
Onlay - porcelain/ceramic - three
							 surfaces
D2644
$660
$788
Onlay - porcelain/ceramic - four or more
							 surfaces
D2650
I.C.
I.C.
Inlay - resin-based composite - one
							 surface
D2651
I.C.
I.C.
Inlay - resin-based composite - two
							 surfaces
D2652
I.C.
I.C.
Inlay - resin-based composite - three or more
							 surfaces
D2662
$613
$656
Onlay - resin-based composite - two
							 surfaces
D2663
$612
$727
Onlay - resin-based composite - three
							 surfaces
D2664
$612
$731
Onlay - resin-based composite - four or more
							 surfaces
D2710
$230
$244
Crown - resin-based composite (indirect)
D2712
I.C.
I.C.
Crown - 3/4 resin-based composite
							 (indirect)
D2720
$633
$757
Crown - resin with high noble metal
D2721
$460
$550
Crown - resin with predominantly base
							 metal
D2722
$521
$558
Crown - resin with noble metal
D2740
$729
$853
Crown - porcelain/ceramic
D2750
$686
$800
Crown - porcelain fused to high noble
							 metal
D2751
$613
$727
Crown - porcelain fused to predominantly base
							 metal
D2752
$633
$735
Crown - porcelain fused to noble metal
D2753
I.C.
I.C.
Crown- porcelain fused to titanium and titanium
							 alloys
D2780
$705
$841
Crown - % cast high noble metal
D2781
I.C.
I.C.
Crown - % cast predominately base metal
D2782
I.C.
I.C.
Crown - % cast noble metal
D2783
$682
$812
Crown - % porcelain/ceramic
D2790
$690
$808
Crown - full cast high noble metal
D2791
$538
$641
Crown - full cast predominantly base
							 metal
D2792
$651
$748
Crown - full cast noble metal
D2794
I.C.
I.C.
Crown - titanium and titanium alloys
D2799
$191
$228
Interim crown - further treatment or completion of
							 diagnosis necessary prior to final impression
D2910
$57
$69
Re-cement or re-bond inlay, onlay or partial coverage
							 restoration
D2915
I.C.
I.C.
Re-cement or re-bond indirectly fabricated or
							 prefabricated post and core
D2920
$57
$68
Re-cement or re-bond crown
D2921
I.C.
I.C.
Reattachment of tooth fragment, incisal edge or
							 cusp
D2928
I.C.
I.C.
Prefabricated porcelain/ceramic crown- permanent
							 tooth
D2929
I.C.
I.C.
Prefabricated porcelain/ceramic crown - primary
							 tooth
D2930
$153
$205
Prefabricated stainless steel crown - primary
							 tooth
D2931
$171
$199
Prefabricated stainless steel crown - permanent
							 tooth
D2932
$211
$224
Prefabricated resin crown
D2933
$153
$184
Prefabricated stainless steel crown with resin
							 window
D2934
$153
$184
Prefabricated esthetic coated stainless steel crown -
							 primary tooth
D2940
$61
$72
Protective restoration
D2941
I.C.
I.C.
Interim therapeutic restoration- primary
							 dentition
D2949
I.C.
I.C.
Restorative foundation for an indirect
							 restoration
D2950
$164
$197
Core buildup, including any pins when
							 required
D2951
$27
$31
Pin retention - per tooth, in addition to
							 restoration
D2952
$233
$276
Post and core in addition to crown, indirectly
							 fabricated
D2953
I.C.
I.C.
Each additional indirectly fabricated post - same
							 tooth
D2954
$191
$229
Prefabricated post and core in addition to
							 crown
D2955
I.C.
I.C.
Post removal
D2957
I.C.
I.C.
Each additional prefabricated post - same
							 tooth
D2960
$307
$420
Labial veneer (resin laminate) - direct
D2961
$422
$504
Labial veneer (resin laminate) - indirect
D2962
$574
$688
Labial veneer (porcelain laminate) -
							 laboratory
D2971
I.C.
I.C.
Additional procedures to customize a crown to fit
							 under an existing partial denture framework
D2975
I.C.
I.C.
Coping
D2980
$115
$137
Crown repair necessitated by restorative material
							 failure
D2981
I.C.
I.C.
Inlay repair necessitated by restorative material
							 failure
D2982
I.C.
I.C.
Onlay repair necessitated by restorative material
							 failure
D2983
I.C.
I.C.
Veneer repair necessitated by restorative material
							 failure
D2999
I.C.
I.C.
Unspecified restorative procedure, by report
IV. Endodontics
D3110
$34
$40
Pulp cap - direct (excluding final
							 restoration)
D3120
$34
$40
Pulp cap - indirect (excluding final
							 restoration)
D3220
$88
$106
Therapeutic pulpotomy (excluding final restoration)
							 -removal of pulp coronal to the dentinocemental junction and application of
							 medicament
D3221
$115
$123
Pulpal debridement, primary and permanent
							 teeth
D3222
I.C.
I.C.
Partial pulpotomy for apexogenesis- permanent tooth
							 with incomplete root development
D3230
I.C.
I.C.
Pulpal therapy (resorbable filling) - anterior,
							 primary tooth (excluding final restoration)
D3240
I.C.
I.C.
Pulpal therapy (resorbable filling) - posterior,
							 primary tooth (excluding final restoration)
D3310
$544
$544
Endodontic therapy, anterior (excluding final
							 restoration)
D3320
$639
$639
Endodontic therapy, premolar tooth (excluding final
							 restoration)
D3330
$829
$829
Endodontic therapy, molar tooth (excluding final
							 restoration)
D3331
I.C.
I.C.
Treatment of root canal obstruction; nonsurgical
							 access
D3332
$191
$205
Incomplete endodontic therapy; inoperable,
							 unrestorable or fractured tooth
D3333
$230
$274
Internal root repair of perforation
							 defects
D3346
$456
$545
Retreatment of previous root canal therapy -
							 anterior
D3347
$538
$641
Retreatment of previous root canal therapy -
							 premolar
D3348
$613
$789
Retreatment of previous root canal therapy -
							 molar
D3351
$122
$146
Apexification/recalcification - initial visit (apical
							 closure/calcific repair of perforations, root resorption, etc.)
D3352
I.C.
I.C.
Apexification/recalcification - interim medication
							 replacement
D3353
I.C.
I.C.
Apexification/recalcification - final visit (includes
							 completed root canal therapy - apical closure/calcific repair of perforations,
							 root resorption, etc.)
D3355
I.C.
I.C.
Pulpal regeneration - intial visit
D3356
I.C.
I.C.
Pulpal regeneration - interim medication
							 replacement
D3357
I.C.
I.C.
Pulpal regeneration - completion of
							 treatment
D3410
$407
$471
Apicoectomy - anterior
D3421
$460
$550
Apicoectomy - premolar (first root)
D3425
$598
$639
Apicoectomy - molar (first root)
D3426
$230
$264
Apicoectomy (each additional root)
D3428
I.C.
I.C.
Bone graft in conjunction with periradicular surgery
							 - per tooth, single site
D3429
I.C.
I.C.
Bone graft in conjunction with periradicular surgery
							 - each additional contiguous tooth in the same surgical site
D3430
$77
$91
Retrograde filling - per root
D3431
I.C.
I.C.
Biological materials to aid in soft and osseous
							 tissue regeneration in conjunction with periradicular surgery
D3432
I.C.
I.C.
Guided tissue regeneration, resorbable barrier, per
							 site, in conjunction with periradicular surgery
D3450
$288
$343
Root amputation - per root
D3460
$462
$744
Endodontic endosseous implant
D3470
I.C.
I.C.
Intentional re-implantation (including necessary
							 splinting)
D3471
I.C.
I.C.
Surgical repair of root resorption-
							 anterior
D3472
I.C.
I.C.
Surgical repair of root resorption-
							 premolar
D3473
I.C.
I.C.
Surgical repair of root resorption- molar
D3501
I.C.
I.C.
Surgical repair of root surface without apicoectomy
							 or repair or repair of root resorption- anterior
D3502
I.C.
I.C.
Surgical repair of root surface without apicectomy or
							 repair of root resorption- premolar
D3503
I.C.
I.C.
Surgical repair of root surface without apicectomy or
							 repair of root resorption- molar
D3910
I.C.
I.C.
Surgical procedure for isolation of tooth with rubber
							 dam
D3911
I.C.
I.C.
Intraorifice barrier
D3920
$211
$243
Hemisection (including any root removal), not
							 including root canal therapy
D3921
I.C.
I.C.
Decoronation or submergence of an erupted
							 tooth
D3950
$69
$111
Canal preparation and fitting of preformed dowel or
							 post
D3999
I.C.
I.C.
Unspecified endodontic procedure, by
							 report
V. Periodontics
D4210
$307
$343
Gingivectomy or gingivoplasty - Four or more
							 contiguous teeth or bounded teeth spaces per quadrant
D4211
$111
$133
Gingivectomy or gingivoplasty - one to three
							 contiguous teeth or bounded teeth spaces per quadrant
D4212
I.C.
I.C.
Gingivectomy or gingivoplasty to allow access for
							 restorative procedure, per tooth
D4230
I.C.
I.C.
Anatomical crown exposure - Four or more contiguous
							 teeth or bounded tooth spaces per quadrant
D4231
I.C.
I.C.
Anatomical crown exposure - one to three teeth or
							 bounded tooth spaces per quadrant
D4240
$449
$606
Gingival flap procedure, including root planing -
							 four or more contiguous teeth or tooth bounded spaces per quadrant
D4241
I.C.
I.C.
Gingival flap procedure, including root planing - one
							 to three contiguous teeth or tooth bounded spaces per quadrant
D4245
I.C.
I.C.
Apically positioned flap
D4249
$460
$550
Clinical crown lengthening - hard tissue
D4260
$795
$1,101
Osseous surgery (including elevation of a full
							 thickness flap and closure) - four or more contiguous teeth or bounded teeth
							 spaces per quadrant
D4261
$708
$759
Osseous surgery (including elevation of a full
							 thickness flap and closure) - one to three contiguous teeth or tooth bounded
							 spaces per quadrant
D4263
$253
$351
Bone replacement graft - retained natural tooth -
							 first site in quadrant
D4264
$188
$202
Bone replacement graft - retained natural tooth -
							 each additional site in quadrant
D4265
I.C.
I.C.
Biologic materials to aid in soft and osseous tissue
							 regeneration, per site
D4266
$307
$359
Guided tissue regeneration, natural teeth -
							 resorbable barrier, per site
D4267
$307
$328
Guided tissue regeneration, natural teeth -
							 non-resorbable barrier, per site
D4268
I.C.
I.C.
Surgical revision procedure, per tooth
D4270
$604
$800
Pedicle soft tissue graft procedure
D4273
$651
$779
Autogenous connective tissue graft procedure
							 (including donor and recipient surgical sites) first tooth, implant, or
							 edentulous tooth position in graft
D4274
$326
$384
Mesial/distal wedge procedure, single tooth (when not
							 performed in conjunction with surgical procedures in the same anatomical
							 area)
D4275
I.C.
I.C.
Non-autogenous connective tissue graft (including
							 recipient site and donor material) first tooth, implant, or edentulous tooth
							 position in graft
D4276
I.C.
I.C.
Combined connective tissue and pedicle graft, per
							 tooth
D4277
I.C.
I.C.
Free soft tissue graft procedure (including recipient
							 and donor surgical sites) first tooth, implant, or edentulous tooth position in
							 graft
D4278
I.C.
I.C.
Free soft tissue graft procedure (including recipient
							 and donor surgical sites) each additional contiguous tooth, implant, or
							 edentulous tooth position in same graft site
D4283
I.C.
I.C.
Autogenous connective tissue graft procedure
							 (including donor and recipient surgical sites) - each additional contiguous
							 tooth, implant or edentulous tooth position in same graft site
D4285
I.C.
I.C.
Non-autogenous connective tissue graft procedure
							 (including recipient surgical site and donor material)
D4286
I.C.
I.C.
Removal of non-resorbable barrier
D4322
I.C.
I.C.
Splint - intra-coronal; natural teeth or prosthetic
							 crowns
D4323
I.C.
I.C.
Splint - extra-coronal; natural teeth or prosthetic
							 crowns
D4341
$134
$160
Periodontal scaling and root planing - four or more
							 teeth per quadrant
D4342
$90
$107
Periodontal scaling and root planing - one to three
							 teeth, per quadrant
D4346
$60
$75
Scaling in presence of generalized moderate or severe
							 gingival inflammation - full mouth, after oral evaluation
D4355
$77
$93
Full mouth debridement to enable a comprehensive
							 periodontal evaluation and diagnosis on a subsequent visit
D4381
$88
$121
Localized delivery of antimicrobial agents
via
a controlled release vehicle into diseased crevicular
							 tissue, per tooth
D4910
$80
$111
Periodontal maintenance
D4920
$67
$76
Unscheduled dressing change (by someone other than
							 treating dentist)
D4921
I.C.
I.C.
Gingival irrigation with a medicinal agent - per
							 quadrant
D4999
I.C.
I.C.
Unspecified periodontal procedure, by
							 report
VI. Prosthodontics
							 (Removable)
D5110
$730
$858
Complete denture - maxillary
D5120
$730
$852
Complete denture - mandibular
D5130
$767
$935
Immediate denture - maxillary
D5140
$766
$934
Immediate denture - mandibular
D5211
$556
$650
Maxillary partial denture - resin base (including
							 retentive/clasping materials, rests and teeth)
D5212
$595
$691
Mandibular partial denture - resin base (including
							 retentive/clasping materials, rests and teeth)
D5213
$1,097
$974
Maxillary partial denture - cast metal framework with
							 resin denture bases (including retentive/clasping materials, rests and
							 teeth)
D5214
$1,134
$986
Mandibular partial denture - cast metal framework
							 with resin denture bases (including retentive/clasping materials, rests and
							 teeth)
D5221
I.C.
I.C.
Immediate maxillary partial denture - resin base
							 (including retentive/clasping materials, rests and teeth)
D5222
I.C.
I.C.
Immediate mandibular partial denture - resin base
							 (including retentive/clasping materials, rests and teeth)
D5223
I.C.
I.C.
Immediate maxillary partial denture - cast metal
							 framework with resin denture bases (including retentive/clasping materials,
							 rests and teeth)
D5224
I.C.
I.C.
Immediate mandibular partial denture - cast metal
							 framework with resin denture bases (including retentive/clasping materials,
							 rests and teeth)
D5225
I.C.
$974
Maxillary partial denture - flexible base (including
							 any clasps, rests and teeth)
D5226
I.C.
$986
Mandibular partial denture - flexible base (including
							 any clasps, rests and teeth)
D5227
I.C.
I.C.
Immediate maxillary partial denture - flexible base
							 (including any clasps, rests and teeth)
D5228
I.C.
I.C.
Immediate mandibular partial denture - flexible base
							 (including any clasps, rests and teeth)
D5282
I.C.
I.C.
Removable unilateral partial denture- one piece cast
							 metal (including retentive/clasping materials, rests and teeth),
							 maxillary
D5283
I.C.
I.C.
Removable unilateral partial denture- one piece cast
							 metal (including retentive/clasping materials, rests and teeth),
							 mandibular
D5284
I.C.
I.C.
Removable unilateral partial denture- one piece
							 flexible base (including retentive/clasping materials, rests and teeth) -per
							 quadrant
D5286
I.C.
I.C.
Removable unilateral partial denture- one piece resin
							 (including clasps and teeth) - per quadrant
D5410
$42
$49
Adjust complete denture - maxillary
D5411
$42
$49
Adjust complete denture - mandibular
D5421
$53
$56
Adjust partial denture - maxillary
D5422
$39
$45
Adjust partial denture - mandibular
D5511
$85
$109
Repair broken complete denture base,
							 mandibular
D5512
$85
$109
Repair broken complete denture base,
							 maxillary
D5520
$77
$89
Replace missing or broken teeth - complete denture
							 (each tooth)
D5611
$77
$93
Repair broken resin partial denture base,
							 mandibular
D5612
$77
$93
Repair broken resin partial denture base,
							 maxillary
D5621
$104
$121
Repair broken cast partial denture base,
							 mandibular
D5622
$104
$121
Repair broken cast partial denture base,
							 maxillary
D5630
$99
$107
Repair or replace broken retentive/clasping materials
							 - per tooth
D5640
$77
$91
Replace broken teeth - per tooth
D5650
$92
$110
Add tooth to existing partial denture
D5660
$98
$125
Add clasp to existing partial denture per
							 tooth
D5670
I.C.
I.C.
Replace all teeth and acrylic on cast metal framework
							 (maxillary)
D5671
I.C.
I.C.
Replace all teeth and acrylic on cast metal framework
							 (mandibular)
D5710
$253
$301
Rebase complete maxillary denture
D5711
$201
$257
Rebase complete mandibular denture
D5720
$230
$274
Rebase maxillary partial denture
D5721
$284
$323
Rebase mandibular partial denture
D5725
I.C.
I.C.
Rebase hybrid prosthesis
D5765
I.C.
I.C.
Soft liner for complete or partial removable denture
							 - indirect
D5730
$158
$188
Reline complete maxillary denture
							 (direct)
D5731
$173
$184
Reline lower complete mandibular denture
							 (direct)
D5740
$142
$169
Reline maxillary partial denture (direct)
D5741
$134
$160
Reline mandibular partial denture
							 (direct)
D5750
$214
$255
Reline complete maxillary denture
							 (indirect)
D5751
$215
$256
Reline complete mandibular denture
							 (indirect)
D5760
$211
$252
Reline maxillary partial denture
							 (indirect)
D5761
$211
$252
Reline mandibular partial denture
							 (indirect)
D5810
$145
$193
Interim complete denture (maxillary)
D5811
$145
$193
Interim complete denture (mandibular)
D5820
$268
$321
Interim partial denture (including retentive/clasping
							 materials, rests and teeth), maxillary
D5821
$295
$316
Interim partial denture (including retentive/clasping
							 materials, rests and teeth), mandibular
D5850
$72
$86
Tissue conditioning, maxillary
D5851
$65
$77
Tissue conditioning, mandibular
D5862
$230
$254
Precision attachment, by report
D5863
I.C.
I.C.
Overdenture- complete maxillary
D5864
I.C.
I.C.
Overdenture- partial maxillary
D5865
I.C.
I.C.
Overdenture- complete mandibular
D5866
I.C.
I.C.
Overdenture- partial mandibular
D5867
I.C.
I.C.
Replacement of replaceable part of semi-precision or
							 precision attachment, per attachment
D5875
I.C.
I.C.
Modification of removable prosthesis following
							 implant surgery
D5876
I.C.
I.C.
Add metal substructure to acrylic full denture (per
							 arch)
D5899
I.C.
I.C.
Unspecified removable prosthodontic procedure, by
							 report
D5911
I.C.
I.C.
Facial moulage (sectional)
D5912
I.C.
I.C.
Facial moulage (complete)
D5913
I.C.
I.C.
Nasal prosthesis
D5914
I.C.
I.C.
Auricular prosthesis
D5915
I.C.
I.C.
Orbital prosthesis
D5916
I.C.
I.C.
Ocular prosthesis
D5919
I.C.
I.C.
Facial prosthesis
D5922
I.C.
I.C.
Nasal septal prosthesis
D5923
I.C.
I.C.
Ocular prosthesis, interim
D5924
I.C.
I.C.
Cranial prosthesis
D5925
I.C.
I.C.
Facial augmentation implant prosthesis
D5926
I.C.
I.C.
Nasal prosthesis, replacement
D5927
I.C.
I.C.
Auricular prosthesis, replacement
D5928
I.C.
I.C.
Orbital prosthesis, replacement
D5929
I.C.
I.C.
Facial prosthesis, replacement
D5931
I.C.
I.C.
Obturator prosthesis, surgical
D5932
I.C.
I.C.
Obturator prosthesis, definitive
D5933
I.C.
I.C.
Obturator prosthesis, modification
D5934
I.C.
I.C.
Mandibular resection prosthesis with guide
							 flange
D5935
I.C.
I.C.
Mandibular resection prosthesis without guide
							 flange
D5936
I.C.
I.C.
Obturator prosthesis, interim
D5937
I.C.
I.C.
Trismus appliance (not for TM treatment)
D5951
I.C.
I.C.
Feeding aid
D5952
I.C.
I.C.
Speech aid prosthesis, pediatric
D5953
I.C.
I.C.
Speech aid prosthesis, adult
D5954
I.C.
I.C.
Palatal augmentation prosthesis
D5955
I.C.
I.C.
Palatal lift prosthesis, definitive
D5958
I.C.
I.C.
Palatal lift prosthesis, interim
D5959
I.C.
I.C.
Palatal lift prosthesis, modification
D5960
I.C.
I.C.
Speech aid prosthesis, modification
D5982
I.C.
I.C.
Surgical stent
D5983
I.C.
I.C.
Radiation carrier
D5984
I.C.
I.C.
Radiation shield
D5985
I.C.
I.C.
Radiation cone locator
D5986
I.C.
I.C.
Fluoride gel carrier
D5987
I.C.
I.C.
Commissure splint
D5988
I.C.
I.C.
Surgical splint
D5991
I.C.
I.C.
Vesiculobullous disease medicament
							 carrier
D5992
I.C.
I.C.
Adjust maxillofacial prosthetic appliance, by
							 report
D5993
I.C.
I.C.
Maintenance and cleaning of a maxillofacial
							 prosthesis (extra or intra-oral) other than required adjustments, by
							 report
D5995
I.C.
I.C.
Periodontal medicament carrier with peripheral seal
							 -laboratory processed- maxillary
D5996
I.C.
I.C.
Periodontal medicament carrier with peripheral seal
							 -laboratory processed- mandibular
D5999
I.C.
I.C.
Unspecified maxillofacial prosthesis, by
							 report
VII. Implant Services
D6010
$1,151
$1,374
Surgical placement of implant body: endosteal
							 implant
D6011
I.C.
I.C.
Surgical access to an implant body (second stage
							 implant surgery)
D6012
I.C.
I.C.
Surgical placement of interim implant body for
							 transitional prosthesis: endosteal implant
D6013
I.C.
I.C.
Surgical placement of mini implant
D6040
$1,534
$1,632
Surgical placement: eposteal implant
D6050
$134
$162
Surgical placement: transosteal implant
D6051
I.C.
I.C.
Interim implant abutment placement
D6055
$230
$274
Connecting bar - implant supported or abutment
							 supported
D6056
$278
$331
Prefabricated abutment - includes modification and
							 placement
D6057
$402
$480
Custom fabricated abutment - includes
							 placement
D6058
$920
$982
Abutment supported porcelain/ceramic
							 crown
D6059
$756
$894
Abutment supported porcelain fused to metal crown
							 (high noble metal)
D6060
$729
$778
Abutment supported porcelain fused to metal crown
							 (predominantly base metal)
D6061
$758
$812
Abutment supported porcelain fused to metal crown
							 (noble metal)
D6062
$767
$894
Abutment supported cast metal crown (high noble
							 metal)
D6063
I.C.
I.C.
Abutment supported cast metal crown (predominantly
							 base metal)
D6064
$920
$1,091
Abutment supported cast metal crown (noble
							 metal)
D6065
$920
$1,015
Implant supported porcelain/ceramic crown
D6066
$878
$1,049
Implant supported crown- porcelain fused to high
							 noble alloys
D6067
$996
$1,067
Implant supported crown - high noble
							 alloys
D6068
I.C.
I.C.
Abutment supported retainer for porcelain/ceramic
							 FPD
D6069
I.C.
I.C.
Abutment supported retainer for porcelain fused to
							 metal FPD (high noble metal)
D6070
I.C.
I.C.
Abutment supported retainer for porcelain fused to
							 metal FPD (predominantly base metal)
D6071
I.C.
I.C.
Abutment supported retainer for porcelain fused to
							 metal FPD (noble metal)
D6072
I.C.
I.C.
Abutment supported retainer for cast metal FPD (high
							 noble metal)
D6073
I.C.
I.C.
Abutment supported retainer for cast metal FPD
							 (predominantly base metal)
D6074
I.C.
I.C.
Abutment supported retainer for cast metal FPD (noble
							 metal)
D6075
I.C.
I.C.
Implant supported retainer for ceramic
							 FPD
D6076
I.C.
I.C.
Implant supported retainer for FPD - porcelain fused
							 to high noble alloys
D6077
I.C.
I.C.
Implant supported retainer for metal FPD - high noble
							 alloys
D6080
$96
$115
Implant maintenance procedures when prostheses are
							 removed and reinserted, including cleansing of prostheses and
							 abutments
D6081
I.C.
I.C.
Scaling and debridement in the presence of
							 inflammation or mucositis of a single implant, including cleaning of implant
							 surfaces, without flap entry and closure.
D6082
I.C.
I.C.
Implant supported crown- porcelain fused to
							 predominantly base alloys
D6083
I.C.
I.C.
Implant supported crown- porcelain fused to noble
							 alloys
D6084
I.C.
I.C.
Implant supported crown- porcelain fused to titanium
							 or titanium alloys
D6085
I.C.
I.C.
Interim implant crown
D6086
I.C.
I.C.
Implant supported crown- predominantly base
							 alloys
D6087
I.C.
I.C.
Implant supported crown- noble alloys
D6088
I.C.
I.C.
Implant supported crown- titanium and titanium
							 alloys
D6090
I.C.
I.C.
Repair implant supported prosthesis, by
							 report
D6091
I.C.
I.C.
Replacement of replaceable part of semi-precision or
							 precision attachment of implant/abutment supported prosthesis, per
							 attachment
D6092
I.C.
I.C.
Re-cement or re-bond implant/abutment supported
							 crown
D6093
I.C.
I.C.
Re-cement or re-bond implant/abutment supported fixed
							 partial denture
D6094
I.C.
I.C.
Abutment supported crown - titanium and titanium
							 alloys
D6095
I.C.
I.C.
Repair implant abutment, by report
D6096
I.C.
I.C.
Remove broken implant retaining screw
D6097
I.C.
I.C.
Abutment supported crown - porcelain fused to
							 titanium or titanium alloys
D6098
I.C.
I.C.
Implant supported retainer- porcelain fused to
							 predominantly base alloys
D6099
I.C.
I.C.
Implant supported retainer for FPD- porcelain fused
							 to noble alloys
D6100
I.C.
I.C.
Surgical removal of implant body
D6101
I.C.
I.C.
Debridement of a peri-implant defect or defects
							 surrounding a single implant, and surface cleaning of exposed implant surfaces,
							 including flap entry and closure
D6102
I.C.
I.C.
Debridement and osseous contouring of a peri-implant
							 defect or defects surrounding a single implant and includes surface cleaning of
							 the exposed implant surfaces, including flap entry and closure
D6103
I.C.
I.C.
Bone graft for repair of peri-implant defect - does
							 not include flap entry and closure
D6104
I.C.
I.C.
Bone graft at time of implant placement
D6105
I.C.
I.C.
Removal of implant body not requiring bone removal or
							 flap elevation
D6106
I.C.
I.C.
Guided tissue regeneration - resorbable barrier, per
							 implant
D6107
I.C.
I.C.
Guided tissue regeneration - non-resorbable barrier,
							 per implant
D6110
I.C.
I.C.
Implant/abutment supported removable denture for
							 edentulous arch - maxillary
D6111
I.C.
I.C.
Implant/abutment supported removable denture for
							 edentulous arch - mandibular
D6112
I.C.
I.C.
Implant/abutment supported removable denture for
							 partially edentulous arch - maxillary
D6113
I.C.
I.C.
Implant/abutment supported removable denture for
							 partially edentulous arch - mandibular
D6114
I.C.
I.C.
Implant/abutment supported fixed denture for
							 edentulous arch - maxillary
D6115
I.C.
I.C.
Implant/abutment supported fixed denture for
							 edentulous arch - mandibular
D6116
I.C.
I.C.
Implant/abutment supported fixed denture for
							 partially edentulous arch - maxillary
D6117
I.C.
I.C.
Implant/abutment supported fixed denture for
							 partially edentulous arch- mandibular
D6118
I.C.
I.C.
Implant/abutment supported interim fixed denture for
							 edentulous arch - mandibular
D6119
I.C.
I.C.
Implant/abutment supported interim fixed denture for
							 edentulous arch - maxillary
D6120
I.C.
I.C.
Implant supported retainer- porcelain fused to
							 titanium and titanium alloys
D6121
I.C.
I.C.
Implant supported retainer for metal FPD-
							 predominantly base alloys
D6122
I.C.
I.C.
Implant supported retainer for metal FPD- noble
							 alloys
D6123
I.C.
I.C.
Implant supported retainer for metal FPD- titanium
							 and titanium alloys
D6190
I.C.
I.C.
Radiographic/surgical implant index, by
							 report
D6191
I.C.
I.C.
Semi-precision abutment- placement
D6192
I.C.
I.C.
Semi-precision attachment - placement
D6194
I.C.
I.C.
Abutment supported retainer crown for FPD - titanium
							 and titanium alloys
D6195
I.C.
I.C.
Abutment supported retainer- porcelain fused to
							 titanium and titanium alloys
D6197
I.C.
I.C.
Replacement of restorative material used to close an
							 access opening of a screw-retained implant supported prosthesis, per
							 implant
D6198
I.C.
I.C.
Remove interim implant component
D6199
I.C.
I.C.
Unspecified implant procedure, by report
D6205
I.C.
I.C.
Pontic - indirect resin based composite
D6210
$651
$748
Pontic - cast high noble metal
D6211
$584
$667
Pontic - cast predominantly base metal
D6212
$632
$676
Pontic - cast noble metal
D6214
I.C.
I.C.
Pontic - titanium and titanium alloys
D6240
$671
$792
Pontic - porcelain fused to high noble
							 metal
D6241
$606
$691
Pontic - porcelain fused to predominantly base
							 metal
D6242
$613
$731
Pontic - porcelain fused to noble metal
D6243
I.C.
I.C.
Pontic - porcelain fused to titanium and titanium
							 alloys
D6245
I.C.
I.C.
Pontic - porcelain/ceramic
D6250
$703
$807
Pontic - resin with high noble metal
D6251
$517
$575
Pontic - resin with predominantly base
							 metal
D6252
$555
$691
Pontic - resin with noble metal
D6253
I.C.
I.C.
Interim pontic - further treatment or completion of
							 diagnosis necessary prior to final impression
D6545
$268
$320
Retainer - cast metal for resin bonded fixed
							 prosthesis
D6548
I.C.
I.C.
Retainer - porcelain/ceramic for resin bonded fixed
							 prosthesis
D6549
I.C.
I.C.
Resin retainer - for resin bonded fixed
							 prosthesis
D6600
I.C.
I.C.
Retainer inlay - porcelain/ceramic, two
							 surfaces
D6601
I.C.
I.C.
Retainer inlay - porcelain/ceramic, three or more
							 surfaces
D6602
I.C.
I.C.
Retainer inlay - cast high noble metal, two
							 surfaces
D6603
I.C.
I.C.
Retainer inlay - cast high noble metal, three or more
							 surfaces
D6604
I.C.
I.C.
Retainer inlay - cast predominantly base metal, two
							 surfaces
D6605
I.C.
I.C.
Retainer inlay - cast predominantly base metal, three
							 or more surfaces
D6606
I.C.
I.C.
Retainer inlay - cast noble metal, two
							 surfaces
D6607
I.C.
I.C.
Retainer inlay - cast noble metal, three or more
							 surfaces
D6608
I.C.
I.C.
Retainer onlay - porcelain/ceramic, two
							 surfaces
D6609
I.C.
I.C.
Retainer onlay - porcelain/ceramic, three or more
							 surfaces
D6610
I.C.
I.C.
Retainer onlay - cast high noble metal, two
							 surfaces
D6611
I.C.
I.C.
Retainer onlay - cast high noble metal, three or more
							 surfaces
D6612
I.C.
I.C.
Retainer onlay - cast predominantly base metal, two
							 surfaces
D6613
I.C.
I.C.
Retainer onlay - cast predominantly base metal, three
							 or more surfaces
D6614
I.C.
I.C.
Retainer onlay - cast noble metal, two
							 surfaces
D6615
I.C.
I.C.
Retainer onlay - cast noble metal, three or more
							 surfaces
D6624
I.C.
I.C.
Retainer inlay - titanium
D6634
I.C.
I.C.
Retainer onlay - titanium
D6710
I.C.
I.C.
Retainer crown - indirect resin based
							 composite
D6720
$527
$671
Retainer crown - resin with high noble
							 metal
D6721
$536
$610
Retainer crown - resin with predominantly base
							 metal
D6722
$207
$246
Retainer crown - resin with noble metal
D6740
I.C.
I.C.
Retainer crown - porcelain/ceramic
D6750
$678
$779
Retainer crown - porcelain fused to high noble
							 metal
D6751
$610
$691
Retainer crown - porcelain fused to predominantly
							 base metal
D6752
$613
$731
Retainer crown - porcelain fused to noble
							 metal
D6753
I.C.
I.C.
Retainer crown - ¾ porcelain fused to titanium
							 and titanium alloys
D6780
$517
$617
Retainer crown - ¾ cast high noble
							 metal
D6781
I.C.
I.C.
Retainer crown - ¾ cast predominately base
							 metal
D6782
I.C.
I.C.
Retainer crown - ¾ cast noble
							 metal
D6783
I.C.
I.C.
Retainer crown - ¾
							 porcelain/ceramic
D6784
I.C.
I.C.
Retainer crown - ¾ titanium and titanium
							 alloys
D6790
$703
$897
Retainer crown - full cast high noble
							 metal
D6791
$556
$661
Retainer crown - full cast predominantly base
							 metal
D6792
$589
$701
Retainer crown - full cast noble metal
D6793
I.C.
I.C.
Interim retainer crown - further treatment or
							 completion of diagnosis necessary prior to final impression
D6794
I.C.
I.C.
Crown - titanium and titanium alloys
D6920
I.C.
I.C.
Connector bar
D6930
$72
$87
Recement bridge
D6940
$153
$204
Stress breaker
D6950
$166
$220
Precision attachment
D6980
$134
$155
Fixed partial denture repair necessitated by
							 restorative material failure
D6985
I.C.
I.C.
Pediatric partial denture, fixed
D6999
I.C.
I.C.
Unspecified fixed prosthodontic procedure, by
							 report
X. Exodontic
D7111
$75
$80
Extraction, coronal remnants - primary
							 tooth
D7140
$77
$107
Extraction, erupted tooth or exposed root (elevation
							 and/or forceps removal)
D7210
$149
$179
Extraction, erupted tooth requiring removal of bone
							 and/or sectioning of tooth, and including elevation of mucoperiosteal flap if
							 indicated
D7220
$191
$223
Removal of impacted tooth - soft tissue
D7230
$249
$286
Removal of impacted tooth - partially
							 bony
D7240
$295
$378
Removal of impacted tooth - completely
							 bony
D7241
$326
$427
Removal of impacted tooth - completely bony, with
							 unusual surgical complications
D7250
$144
$173
Surgical removal of residual tooth roots (cutting
							 procedure)
D7251
I.C.
I.C.
Coronectomy - intentional partial tooth removal,
							 impacted teeth only
D7260
$339
$398
Oroantral fistula closure
D7261
I.C.
I.C.
Primary closure of a sinus perforation
D7270
$106
$145
Tooth reimplantation and/or stabilization of
							 accidentally evulsed or displaced tooth
D7272
$161
$218
Tooth transplantation (includes reimplantation from
							 one site to another and splinting and/or stabilization)
D7280
$380
$452
Exposure of an unerupted tooth
D7282
I.C.
I.C.
Mobilization of erupted or malpositioned tooth to aid
							 eruption
D7283
$73
$84
Placement of device to facilitate eruption of
							 impacted tooth
D7285
$122
$146
Incisional biopsy of oral tissue - hard (bone,
							 tooth)
D7286
$164
$197
Incisional biopsy of oral tissue - soft
D7287
I.C.
I.C.
Exfoliative cytological sample collection
D7288
I.C.
I.C.
Brush biopsy - transepithelial sample
							 collection
D7290
$79
$109
Surgical repositioning of teeth
D7291
$137
$165
Transseptal fiberotomy/supra crestal fiberotomy, by
							 report
D7292
I.C.
I.C.
Placement of temporary anchorage device (screw
							 retained plate) requiring flap
D7293
I.C.
I.C.
Placement of temporary anchorage device requiring
							 flap
D7294
I.C.
I.C.
Placement of temporary anchorage device without
							 flap
D7295
I.C.
I.C.
Harvest of bone for use in autogenous grafting
							 procedure
D7296
I.C.
I.C.
Corticotomy - one to three teeth or tooth spaces, per
							 quadrant
D7297
I.C.
I.C.
Corticotomy - four or more teeth or tooth spaces, per
							 quadrant
D7298
I.C.
I.C.
Removal of temporary anchorage device (screw retained
							 plate), requiring flap
D7299
I.C.
I.C.
Removal of temporary anchorage device, requiring
							 flap
D7300
I.C.
I.C.
Removal of temporary anchorage device without
							 flap
D7310
$142
$163
Alveoloplasty in conjunction with extractions-four or
							 more teeth or tooth spaces, per quadrant
D7311
$128
$146
Alveoloplasty in conjunction with extractions - one
							 to three teeth or tooth spaces, per quadrant
D7320
$187
$202
Alveoloplasty not in conjunction with extractions -
							 four or more teeth or tooth spaces, per quadrant
D7321
$149
$162
Alveoloplasty not in conjunction with extractions -
							 one to three teeth or tooth spaces, per quadrant
D7340
$747
$796
Vestibuloplasty - ridge extension (second
							 epithelialization)
D7350
$943
$1,236
Vestibuloplasty - ridge extension (including soft
							 tissue grafts, muscle reattachments, revision of soft tissue attachment and
							 management of hypertrophied and hyperplastic tissue)
D7410
$115
$124
Excision of benign lesion up to 1.25 cm
D7411
$208
$254
Excision of benign lesion greater than 1.25
							 cm
D7412
I.C.
I.C.
Excision of benign lesion, complicated
D7413
I.C.
I.C.
Excision of malignant lesion up to 1.25
							 cm
D7414
I.C.
I.C.
Excision of malignant lesion greater than 1.25
							 cm
D7415
I.C.
I.C.
Excision of malignant lesion, complicated
D7440
$188
$256
Excision of malignant tumor - lesion diameter up to
							 1.25 cm
D7441
$249
$339
Excision of malignant tumor - lesion diameter greater
							 than 1.25 cm
D7450
$248
$252
Removal of benign odontogenic cyst or tumor - lesion
							 diameter up to 1.25 cm
D7451
$288
$343
Removal of benign odontogenic cyst or tumor - lesion
							 diameter greater than 1.25 cm
D7460
$121
$142
Removal of benign nonodontogenic cyst or tumor -
							 lesion diameter up to 1.25 cm
D7461
$143
$194
Removal of benign nonodontogenic cyst or tumor -
							 lesion diameter greater than 1.25 cm
D7465
I.C.
I.C.
Destruction of lesion(s) by physical or chemical
							 method, by report
D7471
$143
$194
Removal of lateral exostosis (maxilla or
							 mandible)
D7472
I.C.
I.C.
Removal of torus palatinus
D7473
I.C.
I.C.
Removal of torus mandibularis
D7485
I.C.
I.C.
Surgical reduction of osseous tuberosity
D7490
I.C.
I.C.
Radical resection of maxilla or mandible
D7509
I.C.
I.C.
Marsupialization of odontogenic cyst
D7510
$96
$115
Incision and drainage of abscess - intraoral soft
							 tissue
D7511
I.C.
I.C.
Incision and drainage of abscess - intraoral soft
							 tissue - complicated (includes drainage of multiple fascial spaces)
D7520
$80
$86
Incision and drainage of abscess - extraoral soft
							 tissue
D7521
I.C.
I.C.
Incision and drainage of abscess - extraoral soft
							 tissue - complicated (includes drainage of multiple fascial spaces)
D7530
$210
$224
Removal of foreign body from mucosa, skin, or
							 subcutaneous alveolar tissue
D7540
$464
$544
Removal of reaction-producing foreign bodies,
							 musculoskeletal system
D7550
I.C.
I.C.
Partial ostectomy/sequestrectomy for removal of
							 nonvital bone
D7560
$267
$364
Maxillary sinusotomy for removal of tooth fragment or
							 foreign body
D7610
$1,250
$1,704
Maxilla - open reduction (teeth immobilized, if
							 present)
D7620
$419
$569
Maxilla - closed reduction (teeth immobilized, if
							 present)
D7630
$1,045
$1,425
Mandible - open reduction (teeth immobilized, if
							 present)
D7640
$624
$850
Mandible - closed reduction (teeth immobilized, if
							 present)
D7650
$833
$1,135
Malar and/or zygomatic arch - open
							 reduction
D7660
$207
$282
Malar and/or zygomatic arch - closed
							 reduction
D7670
$296
$387
Alveolus - closed reduction, may include
							 stabilization of teeth
D7671
I.C.
I.C.
Alveolus - open reduction, may include stabilization
							 of teeth
D7680
I.C.
I.C.
Facial bones - complicated reduction with fixation
							 and multiple surgical approaches
D7710
$1,250
$1,704
Maxilla - open reduction
D7720
I.C.
I.C.
Maxilla - closed reduction
D7730
$1,045
$1,425
Mandible - open reduction
D7740
$624
$846
Mandible - closed reduction
D7750
$833
$1,135
Malar and/or zygomatic arch - open
							 reduction
D7760
$207
$282
Malar and/or zygomatic arch - closed
							 reduction
D7770
$312
$380
Alveolus - open reduction stabilization of
							 teeth
D7771
I.C.
I.C.
Alveolus, closed reduction stabilization of
							 teeth
D7780
$115
$137
Facial bones - complicated reduction with fixation
							 and multiple surgical approaches
D7810
$521
$711
Open reduction of dislocation
D7820
$80
$109
Closed reduction of dislocation
D7830
I.C.
I.C.
Manipulation under anesthesia
D7840
$833
$1,135
Condylectomy
D7850
I.C.
I.C.
Surgical discectomy; with/without implant
D7852
I.C.
I.C.
Disc repair
D7854
I.C.
I.C.
Synovectomy
D7856
I.C.
I.C.
Myotomy
D7858
I.C.
I.C.
Joint reconstruction
D7860
I.C.
I.C.
Arthrotomy
D7865
I.C.
I.C.
Arthroplasty
D7870
$106
$145
Arthrocentesis
D7871
I.C.
I.C.
Nonarthroscopic lysis and lavage
D7872
I.C.
I.C.
Arthroscopy - diagnosis, with or without
							 biopsy
D7873
I.C.
I.C.
Arthroscopy: lavage and lysis of
							 adhesions
D7874
I.C.
I.C.
Arthroscopy: disc repositioning and
							 stabilization
D7875
I.C.
I.C.
Arthroscopy: synovectomy
D7876
I.C.
I.C.
Arthroscopy: discectomy
D7877
I.C.
I.C.
Arthroscopy: debridement
D7880
$345
$367
Occlusal orthotic device, by report
D7881
I.C.
I.C.
Occlusal orthotic device adjustment
D7899
I.C.
I.C.
Unspecified TMD therapy, by report
D7910
$31
$42
Suture of recent small wounds up to 5 cm
D7911
$106
$129
Complicated suture - up to 5 cm
D7912
$106
$145
Complicated suture - greater than 5 cm
D7920
I.C.
I.C.
Skin graft (identify defect covered, location and
							 type of graft)
D7921
I.C.
I.C.
Collection and application of autologous blood
							 concentrate product
D7922
I.C.
I.C.
Placement of intra-socket biological dressing to aid
							 in hemostasis or clot stabilization, per site
D7940
I.C.
I.C.
Osteoplasty - for orthognathic
							 deformities
D7941
I.C.
I.C.
Osteotomy - mandibular rami
D7943
$2,501
$3,409
Osteotomy - mandibular rami with bone graft; includes
							 obtaining the graft
D7944
$1,015
$1,384
Osteotomy-segmented or subapical
D7945
$2,084
$2,843
Osteotomy - body of mandible
D7946
I.C.
I.C.
LeFort I (maxilla - total)
D7947
I.C.
I.C.
LeFort I (maxilla - segmented)
D7948
I.C.
I.C.
LeFort II or LeFort III (osteoplasty of facial bones
							 for midface hypoplasia or retrusion) - without bone graft
D7949
I.C.
I.C.
LeFort II or LeFort III - with bone graft
D7950
$833
$1,135
Osseous, osteoperiosteal, or cartilage graft of the
							 mandible or maxilla-autogenous or nonautogenous, by report
D7951
I.C.
I.C.
Sinus augmentation with bone or bone
							 substitutes
D7952
I.C.
I.C.
Sinus augmentation
via
a vertical
							 approach
D7953
I.C.
I.C.
Bone replacement graft for ridge preservation - per
							 site
D7955
I.C.
I.C.
Repair of maxillofacial soft and/or hard tissue
							 defect
D7956
I.C.
I.C.
Guided tissue regeneration, edentulous area -
							 resorbable barrier, per site
D7957
I.C.
I.C.
Guided tissue regeneration, edentulous area
							 -non-resorbable barrier, per site
D7961
$107
$353
Buccal/labial frenectomy (frenulectomy)
D7962
$107
$353
Lingual frenectomy (frenulectomy)
D7963
$416
$480
Frenuloplasty
D7970
$246
$334
Excision of hyperplastic tissue - per
							 arch
D7971
$79
$109
Excision of pericoronal gingival
D7972
I.C.
I.C.
Surgical reduction of fibrous tuberosity
D7979
I.C.
I.C.
Non-surgical sialolithotomy
D7980
$106
$145
Surgical sialolithotomy
D7981
$649
$850
Excision of salivary gland, by report
D7982
$282
$387
Sialodochoplasty
D7983
$517
$705
Closure of salivary fistula
D7990
I.C.
I.C.
Emergency tracheotomy
D7991
I.C.
I.C.
Coronoidectomy
D7993
I.C.
I.C.
Surgical placement of craniofacial implant - extra
							 oral
D7994
I.C.
I.C.
Surgical placement: zygomatic implant
D7995
I.C.
I.C.
Synthetic graft - mandible or facial bones, by
							 report
D7996
I.C.
I.C.
Implant - mandible for augmentation purposes
							 (excluding alveolar ridge), by report
D7997
I.C.
I.C.
Appliance removal (not by dentist who placed
							 appliance), includes removal of archbar
D7998
I.C.
I.C.
Intraoral placement of a fixation device not in
							 conjunction with a fracture
D7999
I.C.
I.C.
Unspecified oral surgery procedure, by
							 report
XI. Orthodontic
D8010
I.C.
$250
Limited orthodontic treatment of the primary
							 dentition
D8020
I.C.
$250
Limited orthodontic treatment of the transitional
							 dentition
D8030
I.C.
$250
Limited orthodontic treatment of the adolescent
							 dentition
D8040
I.C.
$250
Limited orthodontic treatment of the adult
							 dentition
D8070
I.C.
I.C.
Comprehensive orthodontic treatment of the
							 transitional dentition
D8080
$1,227
$1,302
Comprehensive orthodontic treatment of the adolescent
							 dentition
D8090
I.C.
I.C.
Comprehensive orthodontic treatment of the adult
							 dentition
D8210
$85
$95
Removable appliance therapy
D8220
I.C.
I.C.
Fixed appliance therapy
D8660
$24
$31
Pre-orthodontic treatment examination to monitor
							 growth and development
D8670
$215
$288
Periodic orthodontic treatment visit (as part of
							 contract)
D8680
$85
$102
Orthodontic retention (removal of appliances,
							 construction and placement of retainer(s))
D8681
I.C.
I.C.
Removable orthodontic retainer adjustment
D8690
$122
$136
Orthodontic treatment (alternative billing to a
							 contract fee)
D8695
I.C.
I.C.
Removal of fixed orthodontic appliances for reasons
							 other than completion of treatment
D8696
I.C.
I.C.
Repair of orthodontic appliance-
							 maxillary
D8697
I.C.
I.C.
Repair of orthodontic appliance-
							 mandibular
D8698
I.C.
I.C.
Re-cement or re-bond fixed retainer-
							 maxillary
D8699
I.C.
I.C.
Re-cement or re-bond fixed retainer-
							 mandibular
D8701
I.C.
I.C.
Repair of fixed retainer, includes reattachment-
							 maxillary
D8702
I.C.
I.C.
Repair of fixed retainer, includes reattachment-
							 mandibular
D8703
$85
$95
Replacement of lost or broken retainer-
							 maxillary
D8704
$85
$95
Replacement of lost or broken retainer-
							 mandibular
D8999
I.C.
I.C.
Unspecified orthodontic procedure, by
							 report
XII. Adjunctive General
							 Services
D9110
$36
$75
Palliative treatment of dental pain - per
							 visit
D9120
I.C.
I.C.
Fixed partial denture sectioning
D9130
I.C.
I.C.
Temporomandibular joint dysfunction- non-invasive
							 physical therapies
D9210
$11
$15
Local anesthesia not in conjunction with operative or
							 surgical procedures
D9211
I.C.
I.C.
Regional block anesthesia
D9212
I.C.
I.C.
Trigeminal division block anesthesia
D9215
I.C.
I.C.
Local anesthesia in conjunction with operative or
							 surgical procedures
D9219
I.C.
I.C.
Evaluation for moderate sedation, deep sedation or
							 general anesthesia
D9222
$90
$109
Deep sedation/general anesthesia - first 15
							 minutes
D9223
$90
$109
Deep sedation/general anesthesia - each additional
							 15-minute increment
D9230
$15
$22
Analgesia, anxiolysis, inhalation of nitrous
							 oxide
D9239
$78
$101
Intravenous moderate (conscious) sedation analgesia -
							 first 15 minutes
D9243
$78
$101
Intravenous moderate (conscious) sedation analgesia -
							 each additional 15-minute increment
D9248
$45
$45
Nonintravenous conscious sedation
D9310
$54
$63
Consultation-diagnostic service provided by dentist
							 or physician other than requesting dentist or physician
D9311
I.C.
I.C.
Consultation with medical health care
							 professional
D9410
$39
$36
House/extended care facility call, once per facility
							 per day
D9420
$34
$48
Hospital or ambulatory surgical center
							 call
D9430
$18
$26
Office visit for observation (during regularly
							 scheduled hours) - no other services performed
D9440
$23
$30
Office visit - after regularly scheduled
							 hours
D9450
$31
$31
Case presentation, subsequent to detailed and
							 extensive treatment planing
D9610
$29
$40
Therapeutic parenteral drug, single
							 administration
D9612
I.C.
I.C.
Therapeutic parenteral drugs, two or more
							 administrations, different medications
D9613
I.C.
I.C.
Infiltration of sustained release therapeutic drug,
							 per quadrant
D9630
$8
$10
Drugs or medicaments dispensed in the office for home
							 use
D9910
$21
$22
Application of desensitizing medicament
D9911
I.C.
I.C.
Application of desensitizing resin for cervical
							 and/or root surface, per tooth
D9912
I.C.
I.C.
Pre-visit patient screening
D9920
$86
$86
Behavior management, by report
D9930
$30
$66
Treatment of complications (postsurgical) - unusual
							 circumstances, by report
D9932
I.C.
I.C.
Cleaning and inspection of removable complete
							 denture, maxillary
D9933
I.C.
I.C.
Cleaning and inspection of removable complete
							 denture, mandibular
D9934
I.C.
I.C.
Cleaning and inspection of removable partial denture,
							 maxillary
D9935
I.C.
I.C.
Cleaning and inspection of removable partial denture,
							 mandibular
D9941
$61
$85
Fabrication of athletic mouthguard
D9942
I.C.
I.C.
Repair and/or reline of occlusal guard
D9943
I.C.
I.C.
Occlusal guard adjustment
D9944
I.C.
$308
Occlusal guard- hard appliance, full arch
D9945
I.C.
$308
Occlusal guard- soft appliance, partial
							 arch
D9946
I.C.
$308
Occlusal guard- hard appliance, partial
							 arch
D9947
I.C.
I.C.
Custom sleep apnea appliance fabrication and
							 placement
D9948
I.C.
I.C.
Adjustment of custom sleep apnea
							 appliance
D9949
I.C.
I.C.
Repair of custom sleep apnea appliance
D9950
$32
$45
Occlusion analysis - mounted case
D9951
$32
$45
Occlusal adjustment - limited
D9952
$149
$179
Occlusal adjustment - complete
D9953
I.C.
I.C.
Reline custom sleep apnea appliance
							 (indirect)
D9961
I.C.
I.C.
Duplicate/copy patient's records
D9970
I.C.
I.C.
Enamel microabrasion
D9971
I.C.
I.C.
Odontoplasty - per tooth
D9972
I.C.
I.C.
External bleaching - per arch - performed in
							 office
D9973
I.C.
I.C.
External bleaching - per tooth
D9974
I.C.
I.C.
Internal bleaching - per tooth
D9975
I.C.
I.C.
External bleaching for home application per arch;
							 includes materials and fabrication of custom trays
D9985
I.C.
I.C.
Sales tax
D9986
I.C.
I.C.
Missed appointment
D9987
I.C.
I.C.
Cancelled appointment
D9990
I.C.
I.C.
Certified translation or sign-language services- per
							 visit
D9991
I.C.
I.C.
Dental case management - addressing appointment
							 compliance barriers
D9992
I.C.
I.C.
Dental case management - care
							 coordination
D9993
I.C.
I.C.
Dental case management - motivational
							 interviewing
D9994
I.C.
I.C.
Dental case management - patient education to improve
							 oral health literacy
D9995
I.C.
I.C.
Teledentistry - synchronuous; real-time
							 encounter
D9996
I.C.
I.C.
Teledentistry - asynchronous; information stored and
							 forwarded to dentist for subsequent review
D9997
I.C.
I.C.
Dental case management- patients with special health
							 care needs
D9999
I.C.
D0120
I.C.
Unspecified adjunctive procedure, by
							 report