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

Universal Citation: 101 MA Code of Regs 101.314
Current through Register 1518, March 29, 2024

Code

Allowed Fee

Allowed Fee (EPSDT-eligible members)

Description

I. Diagnostic

D0120

$21

$31

Periodic oral evaluation - established patient

D0140

$42

$49

Limited oral evaluation - problem focused

D0145

I.C.

I.C.

Oral evaluation for a patient under three years of age and counseling with primary caregiver

D0150

$40

$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

I.C.

I.C.

Comprehensive periodontal evaluation - new or established patient

D0190

I.C.

I.C.

Screening of patient

D0191

I.C.

I.C.

Assessment of patient

D0210

$74

$94

Intraoral - complete series (including bitewings)

D0220

$15

$21

Intraoral - periapical, first film

D0230

$13

$17

Intraoral - periapical, each additional film

D0240

$21

$26

Intraoral - occlusal film

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 film

D0272

$24

$32

Bitewings - two films

D0273

I.C.

I.C.

Bitewings - three films

D0274

$35

$46

Bitewings - four films

D0277

$47

$55

Vertical bitewings - seven to eight films

D0310

$45

$48

Sialography

D0320

$230

$321

Temporomandibular joint arthrogram, including injection

D0321

$96

$114

Other temporomandibular joint films, by report

D0322

I.C.

I.C.

Tomographic survey

D0330

$67

$94

Panoramic film

D0340

$74

$85

2D cephalometric radiographic image acquisition, measurement and analysis

D0350

$39

$47

Oral/facial photographic images

D0351

I.C.

I.C.

3D photographic image

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

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

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.

Treatment simulation using 3D image volume

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 - diagnostic

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

D0605

I.C.

I.C.

Antibody testing for a public health related pathogen

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

D0704

I.C.

I.C.

3-D photographic image- 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- complete series of radiographic images- image capture only

D0999

I.C.

I.C.

Unspecified diagnostic procedure, by report

II. Preventive

D1110

$53

$75

Prophylaxis - adult

D1120

$39

$55

Prophylaxis - child

D1206

$26

$28

Topical fluoride varnish; therapeutic application for moderate to high caries risk patients

D1208

$29

$31

Topical application of fluoride

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 & prevention of adverse health effects associated with high-risk substance use

D1330

$15

$21

Oral hygiene instruction

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

Interim caries arresting medicament application - per tooth

D1355

I.C.

I.C.

Caries preventive medicament application- per tooth

D1510

$191

$229

Space maintainer - fixed-unilateral Excludes distal shoe space maintainer

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- nilateral, 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

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 - one surface, anterior

D2331

$92

$118

Resin - two surfaces, anterior

D2332

$116

$147

Resin - three surfaces, anterior

D2335

$146

$188

Resin - four or more surfaces or involving incisal angle (anterior)

D2390

$106

$133

Resin-based composite crown, anterior

D2391

$55

$99

Resin-based composite - one surface, posterior

D2392

$70

$123

Resin-based composite - two surfaces, posterior

D2393

$83

$133

Resin-based composite - three surfaces, posterior

D2394

$114

$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 - ¾ cast high noble metal

D2781

I.C.

I.C.

Crown - ¾ cast predominately base metal

D2782

I.C.

I.C.

Crown - ¾ cast noble metal

D2783

$682

$812

Crown - ¾ 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

Provisional crown- further treatment or completion of diagnosis necessary prior to final impression

D2910

$57

$69

Recement inlay, onlay or partial coverage restoration

D2915

I.C.

I.C.

Recement cast or prefabricated post and core

D2920

$57

$68

Recement 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

Sedative filling

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

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 (not in conjunction with endodontic therapy)

D2957

I.C.

I.C.

Each additional prefabricated post - same tooth

D2960

$307

$420

Labial veneer (resin laminate) - chair side

D2961

$422

$504

Labial veneer (resin laminate) - laboratory

D2962

$574

$688

Labial veneer (porcelain laminate) - laboratory

D2971

I.C.

I.C.

Additional procedures to construct new crown under existing partial denture framework

D2975

I.C.

I.C.

Coping

D2980

$115

$137

Crown repair, by report

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

$480

$480

Anterior (excluding final restoration)

D3320

$564

$564

Endodontic therapy, premolar tooth (excluding final restoration)

D3330

$731

$731

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 (apical closure/calcific repair of perforations, root resorption, etc.)

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 replantation (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

D3920

$211

$243

Hemisection (including any root removal), not including root canal therapy

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 planning - four or more contiguous teeth or bounded teeth spaces per quadrant

D4241

I.C.

I.C.

Gingival flap procedure, including root planning - one to three contiguous teeth or bounded teeth 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 flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant

D4261

$708

$759

Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth 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

D4266

$307

$359

Guided tissue regeneration - resorbable barrier, per site

D4267

$307

$328

Guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal)

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 double 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)

D4285

I.C.

I.C.

Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material)

D4320

$133

$215

Provisional splinting - intracoronal

D4321

$114

$182

Provisional splinting - extracoronal

D4341

$134

$160

Periodontal scaling and root planning - four or more teeth per quadrant

D4342

$90

$107

Periodontal scaling and root planning - one to three teeth, per quadrant

D4346

I.C.

I.C.

Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation

D4355

$77

$93

Full mouth debridement to enable comprehensive 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, by report

D4910

$80

$111

Periodontal maintenance

D4920

$67

$76

Unscheduled dressing change (by someone other than treating dentist)

D4921

I.C.

I.C.

Gingival irrigation- 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.

I.C.

Maxillary partial denture - flexible base (including any clasps, rests and teeth)

D5226

I.C.

I.C.

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 clasps and teeth), maxillary

D5283

I.C.

I.C.

Removable unilateral partial denture- one piece cast metal (including clasps and teeth), mandibular

D5284

I.C.

I.C.

Removable unilateral partial denture- one piece flexible base (including clasps 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 clasp 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

D5730

$158

$188

Reline complete maxillary denture (chair side)

D5731

$173

$184

Reline lower complete mandibular denture (chair side)

D5740

$142

$169

Reline maxillary partial denture (chair side)

D5741

$134

$160

Reline mandibular partial denture (chair side)

D5750

$214

$255

Reline complete maxillary denture (laboratory)

D5751

$215

$256

Reline complete mandibular denture (laboratory)

D5760

$211

$252

Reline maxillary partial denture (laboratory)

D5761

$211

$252

Reline mandibular partial denture (laboratory)

D5810

$145

$193

Interim complete denture (maxillary)

D5811

$145

$193

Interim complete denture (mandibular)

D5820

$268

$321

Interim partial denture (maxillary)

D5821

$295

$316

Interim partial denture (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 maxillary

D5867

I.C.

I.C.

Replacement of replaceable part of semi-precision or precision attachment (male or female component)

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- lab processed- maxillary

D5996

I.C.

I.C.

Periodontal medicament carrier- lab 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.

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 abutment

D6055

$230

$274

Dental implant supported connecting bar

D6056

$278

$331

Prefabricated abutment - includes placement

D6057

$402

$480

Custom 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, including removal of prosthesis, cleansing of prosthesis and abutments, reinsertion of prosthesis

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.

Provisional 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 semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment

D6092

I.C.

I.C.

Recement or rebond implant/abutment supported crown

D6093

I.C.

I.C.

Recement or rebond 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 cast metal crown (high noble metal)

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.

Implant removal, by report

D6101

I.C.

I.C.

Debridement of a peri-implant defect and surface cleaning of exposed implant surfaces, including flap entry and closure

D6102

I.C.

I.C.

Debridement and osseous contouring of a periimplant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure

D6103

I.C.

I.C.

Bone graft for repair of periimplant defect - not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic materials to aid in osseous regeneration

D6104

I.C.

I.C.

Bone graft at time of implant placement

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 abutment- 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

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.

Provisional pontic

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.

Inlay - porcelain/ceramic, two surfaces

D6601

I.C.

I.C.

Inlay - porcelain/ceramic, three or more surfaces

D6602

I.C.

I.C.

Inlay - cast high noble metal, two surfaces

D6603

I.C.

I.C.

Inlay - cast high noble metal, three or more surfaces

D6604

I.C.

I.C.

Inlay - cast predominantly base metal, two surfaces

D6605

I.C.

I.C.

Inlay - cast predominantly base metal, three or more surfaces

D6606

I.C.

I.C.

Inlay - cast noble metal, two surfaces

D6607

I.C.

I.C.

Inlay - cast noble metal, three or more surfaces

D6608

I.C.

I.C.

Onlay - porcelain/ceramic, two surfaces

D6609

I.C.

I.C.

Onlay - porcelain/ceramic, three or more surfaces

D6610

I.C.

I.C.

Onlay - cast high noble metal, two surfaces

D6611

I.C.

I.C.

Onlay - cast high noble metal, three or more surfaces

D6612

I.C.

I.C.

Onlay - cast predominantly base metal, two surfaces

D6613

I.C.

I.C.

Onlay - cast predominantly base metal, three or more surfaces

D6614

I.C.

I.C.

Onlay - cast noble metal, two surfaces

D6615

I.C.

I.C.

Onlay - cast noble metal, three or more surfaces

D6624

I.C.

I.C.

Inlay - titanium

D6634

I.C.

I.C.

Onlay - titanium

D6710

I.C.

I.C.

Crown - indirect resin based composite

D6720

$527

$671

Crown - resin with high noble metal

D6721

$536

$610

Crown - resin with predominantly base metal

D6722

$207

$246

Crown - resin with noble metal

D6740

I.C.

I.C.

Crown - porcelain/ceramic

D6750

$678

$779

Crown - porcelain fused to high noble metal

D6751

$610

$691

Crown - porcelain fused to predominantly base metal

D6752

$613

$731

Crown - porcelain fused to noble metal

D6753

I.C.

I.C.

Retainer crown - ¾ porcelain fused to titanium and titanium alloys

D6780

$517

$617

Crown - ¾ cast high noble metal

D6781

I.C.

I.C.

Crown - ¾ cast predominately base metal

D6782

I.C.

I.C.

Crown - ¾ cast noble metal

D6783

I.C.

I.C.

Crown - ¾ porcelain/ceramic

D6784

I.C.

I.C.

Retainer crown - ¾ titanium and titanium alloys

D6790

$703

$897

Crown - full cast high noble metal

D6791

$556

$661

Crown - full cast predominantly base metal

D6792

$589

$701

Crown - full cast noble metal

D6793

I.C.

I.C.

Provisional retainer crown

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

Bridge repair, by report

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

$75

$107

Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

D7210

$149

$179

Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth

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

D7260

$339

$398

Oral antral 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

Surgical access 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

Biopsy of oral tissue - hard (bone, tooth)

D7286

$164

$197

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.

Surgical placement: temporary anchorage device (screw retained plate) requiring surgical flap

D7293

I.C.

I.C.

Surgical placement: temporary anchorage device requiring surgical flap

D7294

I.C.

I.C.

Surgical placement: temporary anchorage device without surgical 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

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 1.25cm

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

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

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 - surgical: lavage and lysis of adhesions

D7874

I.C.

I.C.

Arthroscopy - surgical: disc repositioning and stabilization

D7875

I.C.

I.C.

Arthroscopy - surgical: synovectomy

D7876

I.C.

I.C.

Arthroscopy - surgical: discectomy

D7877

I.C.

I.C.

Arthroscopy - surgical: debridement

D7880

$345

$367

Occlusal orthotic appliance

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

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.

I.C.

Limited orthodontic treatment of the primary dentition

D8020

I.C.

I.C.

Limited orthodontic treatment of the transitional dentition

D8030

I.C.

I.C.

Limited orthodontic treatment of the adolescent dentition

D8040

I.C.

I.C.

Limited orthodontic treatment of the adult dentition

D8050

I.C.

I.C.

Interceptive orthodontic treatment of the primary dentition

D8060

I.C.

I.C.

Interceptive orthodontic treatment of the transitional 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

Preorthodontic treatment visit

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

$35

$75

Palliative (emergency) treatment of dental pain - minor procedure

D9120

I.C.

I.C.

Fixed partial denture sectioning

D9130

I.C.

I.C.

Temporomandibular join 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

D9219

I.C.

I.C.

Evaluation for deep sedation or general anesthesia

D9222

$78

$109

Deep sedation/general anesthesia - first 15 minutes

D9223

$78

$109

Deep sedation/general anesthesia - each additional 15-minute increment

D9230

$15

$21

Analgesia, anxiolysis, inhalation of nitrous oxide

D9239

$90

$101

Intravenous moderate (conscious) sedation analgesia - first 15 minutes

D9243

$90

$101

Intravenous moderate (conscious) sedation analgesia - each additional 15-minute increment

D9248

I.C.

I.C.

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 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, detailed and extensive treatment planning

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- single or multiple sites

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

D9920

$86

$86

Behavior management, by report

D9930

I.C.

I.C.

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.

I.C.

Occlusal guard- hard appliance, full arch

D9945

I.C.

I.C.

Occlusal guard- soft appliance, partial arch

D9946

I.C.

I.C.

Occlusal guard- hard appliance, partial arch

D9950

$32

$45

Occlusion analysis - mounted case

D9951

$32

$45

Occlusal adjustment - limited

D9952

$149

$179

Occlusal adjustment - complete

D9961

I.C.

I.C.

Duplicate/copy patient's records

D9970

I.C.

I.C.

Enamel microabrasion

D9971

I.C.

I.C.

Odontoplasty 1-2 teeth; includes removal of enamel projections

D9972

I.C.

I.C.

External bleaching - per arch

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

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