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

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