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
Code |
Allowed Fee |
Allowed Fee (EPSDT-eligible members) |
Description |
I. Diagnostic |
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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 |
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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 |
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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 |