PLUS

ADV

PRE

DIAGNOSTIC PROCEDURES

PERIODIC ORAL EVALUATION

D0120

32

36

40

LIMITED ORAL EVAULATION

D0140

41

45

50

COMP ORAL EVAL-NEW/ESTABLISH PATIENT

D0150

53

59

65

DETAIL/EXTENSIVE ORAL EVAL, B/R

D0160

190

211

234

LIMITED RE-EVALUATION ESTABLISH PATIENT

D0170

33

37

41

COMPREHENSIVE PERIO EVALUATION

D0180

73

81

90

INTRAORAL COMPLETE SERIES

D0210

86

95

105

INTRAORAL PERIAPICAL 1ST FILM

D0220

14

16

18

INTRAORAL PERIAPICAL ADDITIONAL FILM

D0230

12

13

14

INTRAORAL OCCLUSAL FILM

D0240

29

32

36

BITEWING SINGLE FILM

D0270

16

18

20

BITEWING TWO FILMS

D0272

27

30

33

BITEWING FOUR FILMS

D0274

35

39

43

VERTICAL BITEWINGS 7 TO 8 FILMS

D0277

35

39

43

PANORAMIC FILM

D0330

66

73

81

CEPHALOMETRIC FILM

D0340

77

86

95

PREVENTIVE PROCEDURES

PROPHYLAXIS ADULT

D1110

57

63

70

PROPHYLAXIS CHILD

D1120

37

41

46

PROPHYLAXIS WITH FLUORIDE CHILD

D1201

60

67

74

FLUORIDE W/O PROPHYLAXIS CHILD

D1203

23

25

28

FLUORIDE W/O PROPHYLAXIS ADULT

D1204

23

25

28

PROPHYLAXIS WITH FLUORIDE ADULT

D1205

86

95

105

TOPICAL FLUORIDE VARNISH

D1206

21

23

25

NUTRITIONAL COUNSELING

D1310

21

23

25

TOBACCO COUNSELING

D1320

29

32

36

ORAL HYGIENE INSTRUCTION

D1330

29

32

36

SEALANT PER TOOTH

D1351

29

32

35

SPACE MAINT FIXED-UNILATERAL

D1510

221

245

272

SPAIN MAINT FIXED-BILATERAL

D1515

280

311

345

SPACE MAINT REMOV-UNILATERAL

D1520

128

142

156

SPACE MAINT REMOV-BILATERAL

D1525

361

401

446

RECEMENTATION OF SPACE MAINT

D1550

36

40

44

BASIC RESTORATIVE PROCEDURES

AMALGAM 1 SURFACE PRIMARY/PERMANENT

D2140

95

105

117

AMALGAM 2 SURFACE PRIMARY/PERMANENT

D2150

107

119

132

AMALGAM 3 SURFACE PRIMARY/PERMANENT

D2160

131

145

161

AMALGAM 4+ SURFACE PRIMARY/PERMANENT

D2161

142

158

175

RESIN 1 SURFACE ANTERIOR

D2330

95

105

117

RESIN 2 SURFACE ANTERIOR

D2331

113

125

139

RESIN 3 SURFACE ANTERIOR

D2332

137

152

169

RESIN 4+ W/INCISIAL ANGLE ANTERIOR

D2335

149

166

184

RESIN COMPOSITE CROWN ANTERIOR

D2390

149

166

184

RESIN COMPOSITE 1 SURFACE POSTERIOR

D2391

106

118

131

RESIN COMPOSITE 2 SURFACE POSTERIOR

D2392

145

161

179

RESIN COMPOSITE 3 SURFACE POSTERIOR

D2393

179

199

221

RESIN COMPOSITE 4+ SURFACE POSTERIOR

D2394

186

207

230

INLAY METALLIC 2 SURFACE

D2520

500

556

618

INLAY METALLIC 3+ SURFACE

D2530

529

588

653

ONLAY METALLIC 2 SURFACE

D2542

555

617

686

ONLAY METALLIC 3 SURFACE

D2543

596

662

735

ONLAY METALLIC 4+SURFACE

D2544

628

698

776

ONLAY PORCELAIN CERAMIC 2 SURFACE

D2642

531

590

656

ONLAY PORCELAIN CERAMIC 3 SURFACE

D2643

554

615

683

ONLAY PORCELAIN CERAMIC 4+ SURFACE

D2644

596

662

735

CROWN PORCELAIN CERAMIC SUBSTRATE

D2740

680

755

839

CROWN PORCELAIN FUSED TO HIGH NOBLE METAL

D2750

639

710

789

CROWN PORCELAIN FUSED NOBLE METAL

D2752

640

711

790

CROWN FULL CAST HIGH NOBLE METAL

D2790

637

708

787

CROWN FULL CAST NOBLE METAL

D2792

591

657

730

RECEMENT INLAY/ONLAY/PARTIAL

D2910

48

53

59

RECEMENT CROWN

D2920

48

53

59

PREFAB STAIN STEEL CROWN PRIMARY

D2930

142

158

176

PREFAB STAIN STEEL CROWN PERMANENT

D2931

167

185

206

PREFABRICATED RESIN CROWN

D2932

142

158

176

PREFAV ESTH CTD STNL STL CROWN PRIMARY

D2394

186

207

230

SEDATIVE FILLING

D2940

53

59

65

CROWN BULIDUP INCLUDING ANY PINS

D2950

158

175

194

PIN RETENTION-/TOOTH (+REST)

D2951

34

38

42

POST & CORE IN ADD TO CROWN

D2952

175

194

215

EACH ADD'L POST - SAME TOOTH

D2953

85

94

104

PREFAB POST & CORE IN ADD TO CROWN

D2954

168

187

208

POST REMOVAL (NOT WITH ENDO)

D2955

89

99

110

EACH + PREFAB POST - SAME TOOTH

D2957

63

70

78

LABIAL VENEER (LAMINATE) CHAIRSIDE

D2960

48

53

59

LABIAL VENEER (RESIN LAMINATE) LAB

D2961

243

270

300

LABIAL VENEER (PORCELAIN LAM) LAB

D2962

725

805

894

CROWN REPAIR, BY REPORT

D2980

118

131

145

UNSPECIFIED RESTORATIVE PROCEDURE B/R

D2999

ENDODONTIC PROCEDURES

PULP CAP - DIRECT (+REST)

D3110

43

48

53

PULP CAP - INDIRECT (-REST)

D3120

36

40

44

THERAPEUTIC PULPOTOMY (EXC REST)

D3220

95

105

117

PULPAL DEBRIDEMENT - PRIMARY/PERMANENT

D3221

64

71

79

PULPAL THERAPY - ANTERIOR PRIMARY

D3230

158

176

196

PULPAL THERAPY - POSTERIOR PRIMARY

D3240

168

187

208

ROOT CANAL THERAPY - ANTERIOR

D3310

470

522

580

ROOT CANAL THERAPY - BICUSPID

D3320

511

568

631

ROOT CANAL THERAPY - MOLAR

D3330

635

705

783

INT ROOT REPAIR OF PERF DEFECTS

D3333

104

116

129

RETREAT, PREV RCT - ANTERIOR

D3346

510

567

630

RETREAT, PREV RCT - BICUSPID

D3347

612

680

756

RETREAT, PREV RCT - MOLAR

D3348

707

785

872

APEXIFICATION/RECALCIF, INITIAL

D3351

377

419

466

APEXIFICATION/RECALCIF, INTERIM

D3352

34

38

42

APEXIFICATION/RECALCIF, FINAL

D3353

495

550

611

APICOECTOMY/PERIRADIC SURG- ANTERIOR

D3410

323

359

399

APICOECTOMY/ PERIRADIC BICUS 1ST ROOT

D3421

347

385

428

APICOECTOMY/ PERIRADIC MOLAR 1ST ROOT

D3425

367

408

453

APICOECTOMY/PERIRADIC EACH ADDL ROOT

D3426

134

149

165

RETROGRADE FILLING - PER ROOT

D3430

124

138

153

ROOT AMPUTATION - PER ROOT

D3450

273

303

337

HEMISECTION, NO ROOT CANAL THER

D3920

214

238

264

CANAL PREP/FIT OF DOWEL/ POST

D3950

110

122

135

UNSPECIFIED ENDO PROCEDURE B/R

D3999

PERIODONTAL PROCEDURES

GINGEVECTOMY - 4+ TEETH PER QUADRANT

D4210

273

303

337

GINGEVECTOMY - 1-3 CONTIG TH QUAD

D4211

80

89

99

GING FLAP, ROOT PIN, 4+ PER QUAD

D4240

263

292

324

CLINIC CROWN LENGTHEN - HARD TISSUE

D4249

276

307

341

OSSEOUS SURGERY 4+ TEETH PER QUAD

D4260

590

656

729

BONE REPLACE GRAFT - 1ST SITE IN QUAD

D4263

630

700

778

BONE REPLACE GRAFT -EACH ADDITIONAL IN QUAD

D4264

175

194

215

DISTAL/PROXIMAL WEDGE PROCEDURE

D4266

531

590

655

GUIDED TISSUE REGEN - NONRESORB - PER

D4267

709

788

876

PEDICLE SOFT TISSUE GRAFT PROCEDURE

D4270

367

408

453

FREE SOFT TISSUE GRAFT PROCEDURE

D4271

392

436

484

PROVISIONAL SPLINTING - INTRACOR

D4320

151

168

187

PROVISIONAL SPLINTING - EXTRACOR

D4321

123

137

152

PERIO SCALE & ROOT PLANING 4+ PER QUAD

D4341

167

186

207

PERIO SCALE & ROOT PLANING 1-3 CONTIG QUAD

D4342

102

113

126

FULL MOUTH DEBRIDEMENT

D4355

102

113

126

LOCAL DELIVERY ANTIMICROBIAL AG-TH B/R

D4381

57

63

70

PERIODONTAL MAINTENANCE

D4910

75

83

92

UNSPECIFIED PERIO PROCEDURE B/R

D4999

PROSTHODONTIC PROCEDURES

COMPLETE DENTURE - MAXILLARY

D5110

1021

1134

1260

COMPLETE DENTURE - MANDIBULAR

D5120

1021

1134

1260

IMMEDIATE DENTURE - MAXILLARY

D5130

729

810

900

IMMEDIATE DENTURE - MANDIBULAR

D5140

729

810

900

MAXILLARY PARTIAL - RESIN BASE

D5211

724

804

893

MANDIBULAR PARTIAL - RESIN BASE

D5212

724

804

893

MAXIL PARTIAL - METAL BASE W/ SDLS

D5213

936

1040

1155

MANDIB PARTIAL - METAL BASE W/ SDLS

D5214

936

1040

1155

MAXIL PARTIAL - FLEX BASE INCL CL

D5225

766

851

945

MANDIB PARTIAL - FLEX BASE INCL CL

D5226

766

851

945

REMOVABLE UNILATERAL PART DENT

D5281

472

524

582

ADJUST COMPLETE DENTURE - MAX

D5410

45

50

56

ADJUST COMPLETE DENTURE - MAND

D5411

45

50

56

ADJUST PARTIAL DENTURE - MAX

D5421

45

50

56

ADJUST PARTIAL DENTURE - MAND

D5422

45

50

56

REPAIR COMPLETE DENTURE BASE

D5510

114

127

141

REPLACE TEETH COMP DENT (EA TH)

D5520

102

113

126

REPAIR RESIN DENTURE BASE

D5610

89

99

110

REPAIR CAST FRAMEWORK

D5620

100

111

123

REPAIR OR REPLACE BROKEN CLASP

D5630

110

122

135

REPLACE BROKEN TEETH PER TOOTH

D5640

95

105

117

ADD TOOTH TO EXIST PART DENTURE

D5650

100

111

123

ADD CLASP TO EXIST PART DENTURE

D5660

121

135

149

REBASE COMPLETE MAXILLARY DENTURE

D5710

288

320

355

REBASE COMPLETE MANDIBULAR DENTURE

D5711

288

320

355

REBASE MAX PARTIAL DENTURE

D5720

288

320

355

REBASE MAND PARTIAL DENTURE

D5721

288

320

355

RELINE COMPLETE MAX - CHAIRSIDE

D5730

157

174

193

RELINE COMPLETE MAND - CHAIRSIDE

D5731

157

174

193

RELINE MAX PARTIAL - CHAIRSIDE

D5740

157

174

193

RELINE MAND PARTIAL - CHAIRSIDE

D5741

157

174

193

RELINE COMPLETE MAX - LAB

D5750

240

267

297

RELINE COMPLETE MAND - LAB

D5751

240

267

297

RELINE MAX PARTIAL - LAB

D5760

240

267

297

RELINE MAND PARTIAL - LAB

D5761

240

267

297

INTERIM PARTIAL DENTURE MAX

D5820

357

390

441

INTERIM PARTIAL DENTURE MAND

D5821

357

397

441

TISSUE CONDITION MAX

D5850

95

105

117

TISSUE CONDITION MAND

D5851

95

105

117

SURGICAL STENT

D5982

349

388

431

IMPLANT PROCEDURES

SURG PLACE IMPLANT ENDOSTEAL

D6010

1021

1134

1260

IMPLANT ABUTMENT REMOV COMP EDENT ARCH

D6053

1701

1890

2100

PREFAB ABUTMENT-INCL PLACEMENT

D6056

256

284

315

CUSTOM ABUTMENT - INCL PLACEMENT

D6057

256

284

315

ABUTMT SUPP PORCELAIN CERAMIC CROWN

D6058

1091

1212

1347

ABUTMT SUPP PORC FUSED HI NOBLE METAL

D6059

766

851

945

ABUTMT SUPP PORC FUSED BASE METAL

D6060

645

717

797

IMPLANT SUPP PORC FUSED MTL CRON

D6066

851

945

1050

IMPLANT ABUT SUPP FXD COMP EDENT

D6078

2127

2363

2625

PROSTHODONTIC FIXED PROCEDURES

PONTIC-CAST HIGH NOBLE METAL

D6210

680

756

840

PONTIC CAST NOBLE METAL

D6212

680

756

840

PONTIC PORCELAIN FUSED HIGH NOBLE METAL

D6240

638

709

788

PONTIC PORCELAIN FUSED TO NOBLE METAL

D6242

640

711

790

PONTIC PORCELAIN CERAMIC

D6245

697

774

860

RETAINER CAST METAL FOR RESIN BONDED FPD

D6545

297

330

367

INLAY CAST HIGH NOBLE METAL THREE + SURF

D6603

508

564

627

INLAY PREDOM BASE METAL TWO SURFACE

D6604

473

625

683

INLAY CAST PREDOM BASE METAL THREE + SURF

D6605

508

564

627

INLAY CAST NOBLE METAL TWO SURFACE

D6606

473

525

583

INLAY CAST NOBLE METAL THREE + SURFACE

D6607

573

525

583

CROWN PORCELAIN CERAMIC

D6740

697

774

860

CROWN PORCELAIN FUSED TO HIGH NOBLE METAL

D6750

653

725

806

CROWN PORCELAIN FUSED TO NOBLE METAL

D6752

664

738

820

CROWN 3/4 CAST HIGH NOBLE METAL

D6780

588

653

725

CROWN FULL CAST HIGH NOBLE METAL

D6790

664

738

820

CROWN FULL CAST NOBLE METAL

D6792

588

653

725

RECEMENT FPD

D6930

73

81

90

STRESS BREAKER

D6940

170

189

210

POST AND CORE IN ADD TO FPD RETAINER

D6970

189

210

233

PREFAB POST AND CORE IN ADD TO FPD RETAIN

D6972

167

185

205

CORE BUILD UP FOR RETAINER INCL PINS

D6973

167

185

205

COPING METAL

D6975

53

59

66

ORAL AND MAXILLOFACIAL SURGERY

EXTRACTION ERUPTED TOOTH EXPOSED TOOTH

D7140

105

117

130

SURGICAL REMOVAL ERUPTED TOOTH

D7210

153

170

189

REMOVAL OF IMPACTED TOOTH SOFT TISSUE

D7220

167

185

208

REMOVAL OF IMPACTED TOOTH PARTIALLY BONY

D7230

222

247

274

REMOVAL OF IMPACTED TOOTH COMPLETE BONY

D7240

250

278

309

REMOVAL OF IMPACTED TOOTH COMPLETE BONY COMPLICATED

D7241

302

336

373

SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS

D7250

170

189

210

OROANTRAL FISTULA CLOSURE

D7260

340

378

420

TOOTH REIMPLANTATION/STABILIZATION

D7270

226

251

279

SURGICAL ACCESS OF AN ERUPTED TOOTH

D7280

308

342

380

BIOPSY OF ORAL TISSUE HARD

D7285

170

189

210

BIOPSY OF ORAL TISSUE SOFT

D7286

160

178

138

TRANSSEPTAL FIBEROTOMY

D7291

68

76

84

ALVEOLOPLASTY W/ EXTRACTIONS 4+ PER QUAD

D7310

185

205

228

ALVEOLOPLASTY NO EXT 4+ PER QUAD

D7320

157

174

193

VESTIBULOPLASTY RIDGE EXTENSION

D7340

340

378

420

VESTIBULOPLASTY RIDGE EXTENSION INC GRAFTS

D7350

194

215

239

REMOV BENIGN ODOTOGENIC CYST/TUMOR <1.25

D7450

194

215

239

REMOV BENIGN NONODOTOGENIC CYST/TUMOR <1.25

D7460

222

247

274

REMOVAL OF TORUS PALATINUS

D7472

405

450

500

REMOVAL OF TORUS MANDIBULARIS

D7473

405

450

500

INCISION & DRAINAGE OF ABSCESS SOFT TISS

D7510

113

126

140

INCISION & DRAINAGE ABSCESS EXTRAORAL SOFT

D7520

160

178

190

REMOVAL OF FOREIGN BODY FROM MUCOSA

D7530

89

99

110

FRENULECTOMY(FRENECTOMY/FRENOTOMY)

D7960

79

125

188

FRENULOPLASTY

D7963

92

110

125

UNSPECIFIED ORAL SURGERY PROCEDURE B/R

D7999

ORTHODONTICS

LIMITED ORTHO TX PRIMARY DENTITION

D8010

874

971

1079

LIMITED ORTHO TX TRANSITIONAL DENTITION

D8020

874

971

1079

LIMITED ORTHO TX ADOLESCENT DENTITION

D8030

874

971

1079

LIMITED ORTHO TX ADULT DENTITION

D8040

874

971

1079

INTERCEPTIVE ORTHO TX OF TRANS DENTITION

D8060

1418

1575

1750

COMPREHENSIVE ORTHO TX TRANS DENTITION

D8070

3742

4158

4620

COMPREHENSIVE ORTHO TX ADOLESCENT DENTITION

D8080

3742

4158

4620

COMPREHENSIVE ORTHO TX ADULT DENTITION

D8090

3742

4158

4620

PRE-ORTHO TX VISIT

D8660

128

142

158

ADJUNCTIVE GENERAL SERVICES

PALLIATIVE TX

D9110

134

149

165

ANALGESIA/NITROUS OXIDE

D9230

42

47

52

HOSPITAL CALL

D9420

113

126

140

OFFICE VISIT OBSERVATION

D9430

34

38

42

AFTER HOURS OFFICE VISIT

D9440

69

77

85

APPLICATION OF DESENSITIZING MEDICAMENT

D9910

29

32

36

APPLICATION OF DESENSITIZING RESIN

D9911

35

39

43

OCCLUSAL GUARD B/R

D9940

365

406

451

OCCLUSAL ADJUSTMENT LIMITED

D9951

50

56

62

OCCLUSAL ADJUSTMENT COMPLETE

D9952

203

226

251

UNSPECIFIED ADJUNCTIVE PROCEDURE B/R

D9999