PLUS

ADV

PRE

DIAGNOSTIC PROCEDURES

PERIODIC ORAL EVALUATION

D0120

18

25

27

LIMITED ORAL EVAULATION

D0140

13

28

40

LIMITED ORAL EVAULATION Under 3

D0145

11

26

30

COMP ORAL EVAL-NEW/ESTABLISH PATIENT

D0150

17

27

41

DETAIL/EXTENSIVE ORAL EVAL, B/R

D0160

17

28

59

LIMITED RE-EVALUATION ESTABLISH PATIENT

D0170

13

27

30

COMPREHENSIVE PERIO EVALUATION

D0180

14

27

46

INTRAORAL COMPLETE SERIES

D0210

40

52

78

INTRAORAL PERIAPICAL 1ST FILM

D0220

7

13

13

INTRAORAL PERIAPICAL ADDITIONAL FILM

D0230

5

10

12

INTRAORAL OCCLUSAL FILM

D0240

4

15

17

EXTRAORAL FIRST FILM

D0250

3

21

24

EXTRAORAL ADDITIONAL FILM

D0260

3

17

19

BITEWING SINGLE FILM

D0270

5

12

16

BITEWING TWO FILMS

D0272

14

24

26

BITEWING THREE FILMS

D0273

16

25

27

BITEWING FOUR FILMS

D0274

17

28

32

VERTICAL BITEWINGS 7 TO 8 FILMS

D0277

9

34

68

TOMOGRAPHIC SURVEY

D0322

100

116

131

PANORAMIC FILM

D0330

41

44

56

CEPHALOMETRIC FILM

D0340

82

103

131

PREVENTIVE PROCEDURES

PROPHYLAXIS ADULT

D1110

41

44

46

PROPHYLAXIS CHILD

D1120

26

27

32

PROPHYLAXIS WITH FLUORIDE CHILD

D1201

16

19

22

FLUORIDE W/O PROPHYLAXIS CHILD

D1203

10

12

17

FLUORIDE W/O PROPHYLAXIS ADULT

D1204

13

16

19

PROPHYLAXIS WITH FLUORIDE ADULT

D1205

16

19

24

TOPICAL FLUORIDE VARNISH

D1206

11

13

16

NUTRITIONAL COUNSELING

D1310

16

19

24

TOBACCO COUNSELING

D1320

16

19

24

ORAL HYGIENE INSTRUCTION

D1330

16

19

24

SEALANT PER TOOTH

D1351

19

22

26

SPACE MAINT FIXED-UNILATERAL

D1510

95

97

140

SPAIN MAINT FIXED-BILATERAL

D1515

145

147

221

SPACE MAINT REMOV-UNILATERAL

D1520

105

109

176

SPACE MAINT REMOV-BILATERAL

D1525

161

164

232

RECEMENTATION OF SPACE MAINT

D1550

20

24

35

REMOVAL OF FIXED SPACE MAINT

D1555

52

60

65

BASIC RESTORATIVE PROCEDURES

AMALGAM 1 SURFACE PRIMARY/PERMANENT

D2140

45

48

64

AMALGAM 2 SURFACE PRIMARY/PERMANENT

D2150

57

62

80

AMALGAM 3 SURFACE PRIMARY/PERMANENT

D2160

69

74

94

AMALGAM 4+ SURFACE PRIMARY/PERMANENT

D2161

80

90

117

RESIN 1 SURFACE ANTERIOR

D2330

71

76

90

RESIN 2 SURFACE ANTERIOR

D2331

85

87

96

RESIN 3 SURFACE ANTERIOR

D2332

93

98

118

RESIN 4+ W/INCISIAL ANGLE ANTERIOR

D2335

110

116

140

RESIN COMPOSITE CROWN ANTERIOR

D2390

116

121

166

RESIN COMPOSITE 1 SURFACE POSTERIOR

D2391

69

76

80

RESIN COMPOSITE 2 SURFACE POSTERIOR

D2392

92

102

105

RESIN COMPOSITE 3 SURFACE POSTERIOR

D2393

112

118

124

RESIN COMPOSITE 4+ SURFACE POSTERIOR

D2394

123

126

150

INLAY METALLIC 1 SURFACE

D2510

302

341

349

INLAY METALLIC 2 SURFACE

D2520

328

374

397

INLAY METALLIC 3+ SURFACE

D2530

372

411

441

ONLAY METALLIC 2 SURFACE

D2542

401

451

482

ONLAY METALLIC 3 SURFACE

D2543

432

483

501

ONLAY METALLIC 4+SURFACE

D2544

497

541

551

INLAY PORCELAIN CERAMIC 2 SURFACE

D2610

348

383

517

INLAY PORCELAIN CERAMIC 3 SURFACE

D2620

405

440

457

INLAY PORCELAIN CERAMIC 4+ SURFACE

D2630

463

495

517

ONLAY PORCELAIN CERAMIC 2 SURFACE

D2642

371

460

497

ONLAY PORCELAIN CERAMIC 3 SURFACE

D2643

420

475

495

ONLAY PORCELAIN CERAMIC 4+ SURFACE

D2644

476

485

507

CROWN RESIN COMPOSITE (INDIRECT)

D2710

217

247

286

CROWN 3/4 RESIN BASED COMPOSITE IND

D2712

217

247

286

CROWN RESIN W/HIGH NOBLE METAL

D2720

352

418

477

CROWN RESIN W/MOST BASE METAL

D2721

275

341

382

CROWN RESIN WITH NOBLE METAL

D2722

386

422

468

CROWN PORCELAIN CERAMIC SUBSTRATE

D2740

480

485

607

CROWN PORCELAIN FUSED TO HIGH NOBLE METAL

D2750

509

519

577

CROWN PORCELAIN FUSED TO BASE METAL

D2751

495

514

568

CROWN PORCELAIN FUSED NOBLE METAL

D2752

505

521

575

CROWN 3/4 CAST HIGH NOBLE METAL

D2780

463

485

519

CROWN 3/4 CAST MOST BASE METAL

D2781

463

485

519

CROWN 3/4 CAST NOBLE METAL

D2782

463

485

519

CROWN 3/4 PORCELAIN CERAMIC

D2783

463

485

530

CROWN FULL CAST HIGH NOBLE METAL

D2790

468

481

551

CROWN FULL CAST BASE METAL

D2791

405

420

497

CROWN FULL CAST NOBLE METAL

D2792

412

443

519

CROWN TITANIUM

D2794

475

525

551

RECEMENT INLAY/ONLAY/PARTIAL

D2910

30

37

42

RECEMENT CAST OR PREFAB POST CORE

D2915

27

31

42

RECEMENT CROWN

D2920

27

32

44

PREFAB STAIN STEEL CROWN PRIMARY

D2930

71

86

120

PREFAB STAIN STEEL CROWN PERMANENT

D2931

74

105

148

PREFABRICATED RESIN CROWN

D2932

116

131

155

PREFABRICATED STL CROWN W/RESIN WINDOW

D2393

116

124

160

PREFAV ESTH CTD STNL STL CROWN PRIMARY

D2394

128

132

160

SEDATIVE FILLING

D2940

36

38

48

CROWN BULIDUP INCLUDING ANY PINS

D2950

90

95

122

PIN RETENTION-/TOOTH (+REST)

D2951

18

22

28

POST & CORE IN ADD TO CROWN

D2952

116

146

182

EACH ADD'L POST - SAME TOOTH

D2953

51

62

78

PREFAB POST & CORE IN ADD TO CROWN

D2954

98

116

155

POST REMOVAL (NOT WITH ENDO)

D2955

43

62

71

EACH + PREFAB POST - SAME TOOTH

D2957

49

65

77

LABIAL VENEER (LAMINATE) CHAIRSIDE

D2960

267

385

476

LABIAL VENEER (RESIN LAMINATE) LAB

D2961

385

476

511

LABIAL VENEER (PORCELAIN LAM) LAB

D2962

487

482

610

CROWN REPAIR, BY REPORT

D2980

54

67

82

UNSPECIFIED RESTORATIVE PROCEDURE B/R

D2999

ENDODONTIC PROCEDURES

PULP CAP - DIRECT (+REST)

D3110

22

23

29

PULP CAP - INDIRECT (-REST)

D3120

18

19

25

THERAPEUTIC PULPOTOMY (EXC REST)

D3220

54

59

78

PULPAL DEBRIDEMENT - PRIMARY/PERMANENT

D3221

54

57

88

PULPAL THERAPY - ANTERIOR PRIMARY

D3230

53

60

104

PULPAL THERAPY - POSTERIOR PRIMARY

D3240

50

54

105

ROOT CANAL THERAPY - ANTERIOR

D3310

277

344

346

ROOT CANAL THERAPY - BICUSPID

D3320

348

391

441

ROOT CANAL THERAPY - MOLAR

D3330

443

507

551

INT ROOT REPAIR OF PERF DEFECTS

D3333

87

97

113

RETREAT, PREV RCT - ANTERIOR

D3346

252

330

394

RETREAT, PREV RCT - BICUSPID

D3347

310

389

464

RETREAT, PREV RCT - MOLAR

D3348

394

506

585

APEXIFICATION/RECALCIF, INITIAL

D3351

162

184

191

APEXIFICATION/RECALCIF, INTERIM

D3352

71

85

101

APEXIFICATION/RECALCIF, FINAL

D3353

238

267

290

APICOECTOMY/PERIRADIC SURG- ANTERIOR

D3410

218

278

362

APICOECTOMY/ PERIRADIC BICUS 1ST ROOT

D3421

302

327

397

APICOECTOMY/ PERIRADIC MOLAR 1ST ROOT

D3425

315

371

449

APICOECTOMY/PERIRADIC EACH ADDL ROOT

D3426

90

124

166

RETROGRADE FILLING - PER ROOT

D3430

61

86

111

ROOT AMPUTATION - PER ROOT

D3450

157

181

210

ENDODONTIC ENDOSSEOUS IMPLANT

D3460

750

780

800

HEMISECTION, NO ROOT CANAL THER

D3920

122

142

186

CANAL PREP/FIT OF DOWEL/ POST

D3950

106

115

142

UNSPECIFIED ENDO PROCEDURE B/R

D3999

PERIODONTAL PROCEDURES

GINGEVECTOMY - 4+ TEETH PER QUADRANT

D4210

178

199

271

GINGEVECTOMY - 1-3 CONTIG TH QUAD

D4211

42

53

163

GING FLAP, ROOT PIN, 4+ PER QUAD

D4240

204

238

320

GING FLAP RT PLN 1-3 CONTIG TH QUAD

D4241

181

184

241

APICALLY POSITIONED FLAP

D4245

239

280

306

CLINIC CROWN LENGTHEN - HARD TISSUE

D4249

240

270

337

OSSEOUS SURGERY 4+ TEETH PER QUAD

D4260

328

371

490

OSSEOUS SURGERY 1-3 CONTIG TEETH PER QUAD

D4261

201

248

307

BONE REPLACE GRAFT - 1ST SITE IN QUAD

D4263

252

291

313

BONE REPLACE GRAFT -EACH ADDITIONAL IN QUAD

D4264

192

228

272

BIO MAT, SFT & OSSEOUS TISS REGEN

D4265

263

300

317

DISTAL/PROXIMAL WEDGE PROCEDURE

D4266

269

311

325

GUIDED TISSUE REGEN - NONRESORB - PER

D4267

287

329

357

PEDICLE SOFT TISSUE GRAFT PROCEDURE

D4270

208

269

339

FREE SOFT TISSUE GRAFT PROCEDURE

D4271

208

304

391

SUBEPITHELIAL CON TISSUE GRAFT / TOOTH QUAD

D4273

249

304

457

SOFT TISSUE ALLOGRAFT

D4275

227

278

317

COMB CONNECTIVE TISSUE & DBLE PEDICLE GRFT

D4276

349

391

426

PROVISIONAL SPLINTING - INTRACOR

D4320

110

144

167

PROVISIONAL SPLINTING - EXTRACOR

D4321

92

124

175

PERIO SCALE & ROOT PLANING 4+ PER QUAD

D4341

108

110

127

PERIO SCALE & ROOT PLANING 1-3 CONTIG QUAD

D4342

82

81

79

FULL MOUTH DEBRIDEMENT

D4355

69

73

46

LOCAL DELIVERY ANTIMICROBIAL AG-TH B/R

D4381

22

26

38

PERIODONTAL MAINTENANCE

D4910

78

81

76

UNSPECIFIED PERIO PROCEDURE B/R

D4999

PROSTHODONTIC PROCEDURES

COMPLETE DENTURE - MAXILLARY

D5110

587

850

827

COMPLETE DENTURE - MANDIBULAR

D5120

587

850

827

IMMEDIATE DENTURE - MAXILLARY

D5130

611

930

845

IMMEDIATE DENTURE - MANDIBULAR

D5140

611

930

845

MAXILLARY PARTIAL - RESIN BASE

D5211

481

815

615

MANDIBULAR PARTIAL - RESIN BASE

D5212

481

815

615

MAXIL PARTIAL - METAL BASE W/ SDLS

D5213

582

791

810

MANDIB PARTIAL - METAL BASE W/ SDLS

D5214

582

791

810

MAXIL PARTIAL - FLEX BASE INCL CL

D5225

582

581

608

MANDIB PARTIAL - FLEX BASE INCL CL

D5226

582

581

608

REMOVABLE UNILATERAL PART DENT

D5281

276

322

527

ADJUST COMPLETE DENTURE - MAX

D5410

40

42

43

ADJUST COMPLETE DENTURE - MAND

D5411

30

37

43

ADJUST PARTIAL DENTURE - MAX

D5421

28

32

43

ADJUST PARTIAL DENTURE - MAND

D5422

27

32

43

REPAIR COMPLETE DENTURE BASE

D5510

48

58

98

REPLACE TEETH COMP DENT (EA TH)

D5520

25

71

76

REPAIR RESIN DENTURE BASE

D5610

29

72

88

REPAIR CAST FRAMEWORK

D5620

32

81

97

REPAIR OR REPLACE BROKEN CLASP

D5630

38

98

124

REPLACE BROKEN TEETH PER TOOTH

D5640

28

85

96

ADD TOOTH TO EXIST PART DENTURE

D5650

32

98

107

ADD CLASP TO EXIST PART DENTURE

D5660

57

81

124

REBASE COMPLETE MAXILLARY DENTURE

D5710

238

234

278

REBASE COMPLETE MANDIBULAR DENTURE

D5711

238

234

278

REBASE MAX PARTIAL DENTURE

D5720

208

224

263

REBASE MAND PARTIAL DENTURE

D5721

208

224

263

RELINE COMPLETE MAX - CHAIRSIDE

D5730

87

130

150

RELINE COMPLETE MAND - CHAIRSIDE

D5731

87

130

150

RELINE MAX PARTIAL - CHAIRSIDE

D5740

85

118

147

RELINE MAND PARTIAL - CHAIRSIDE

D5741

85

118

147

RELINE COMPLETE MAX - LAB

D5750

160

171

210

RELINE COMPLETE MAND - LAB

D5751

160

171

210

RELINE MAX PARTIAL - LAB

D5760

144

189

205

RELINE MAND PARTIAL - LAB

D5761

144

189

205

INTERIM PARTIAL DENTURE MAX

D5820

238

232

281

INTERIM PARTIAL DENTURE MAND

D5821

238

232

281

TISSUE CONDITION MAX

D5850

41

53

71

TISSUE CONDITION MAND

D5851

41

53

71

SURGICAL STENT

D5982

IMPLANT PROCEDURES

SURG PLACE IMPLANT ENDOSTEAL

D6010

950

1036

1103

SURGICAL PLACE EPOSTEAL IMPLANT

D6040

3295

3953

5155

SURGICAL PLACE TRANSOSTEAL IMPLANT

D6050

2528

3004

3200

IMPLANT ABUTMENT REMOV COMP EDENT ARCH

D6053

860

922

1027

IMPLANT ABUTMENT REMOV COMP EDENT ARCH

D6054

869

937

1031

DENT IMPLANT SUP CONNECTING BAR

D6055

1003

1111

1305

PREFAB ABUTMENT-INCL PLACEMENT

D6056

308

344

364

CUSTOM ABUTMENT - INCL PLACEMENT

D6057

325

348

391

ABUTMT SUPP PORCELAIN CERAMIC CROWN

D6058

629

659

678

ABUTMT SUPP PORC FUSED HI NOBLE METAL

D6059

615

647

670

ABUTMT SUPP PORC FUSED BASE METAL

D6060

600

632

653

ABUTMT SUPP PORC FUSED METAL CROWN

D6061

611

638

661

ABUTMT SUPP CAST MTL CROWN HINOB

D6062

610

638

662

ABUTMT SUPP CAST MTL CROWN BASE

D6063

544

587

610

ABUTMT SUPP CAST MTL CROWN NOBLE

D6064

559

595

627

IMPLANT SUPP PORCELAIN CERAMIC CROWN

D6065

650

680

700

IMPLANT SUPP PORC FUSED MTL CRON

D6066

650

663

689

IMPLANT SUPPORTED METAL CROWN

D6067

611

638

661

ABTMT SUPP RET FOR PORC/CER FPD

D6068

654

683

705

ABUTMT SUPP RET FSD MTL FPD HN

D6069

644

674

693

ABUTMT SUPP RET PORC FSD MTL FPD BM

D6070

610

629

647

ABUTMT SUPP RET PORC FSD MTL FPD NO

D6071

615

650

663

ABUTMT SUPP RET CAST MTL FPD HI NOB

D6072

631

653

676

ABUTMT SUPP RET CAST MTL FPD BASE

D6073

566

608

619

ABUTMT SUPP RET CAST MTL FPD NOBLE

D6074

589

618

636

IMPLANT SUPP RET CERAMIC FPD

D6075

661

684

709

IMPLANT SUPP RET PORC FUST MTL FPD

D6076

632

663

689

IMPLANT SUPP RET CAST METAL FPD

D6077

630

658

676

IMPLANT ABUT SUPP FXD COMP EDENT

D6078

1261

1455

1566

IMPLANT ABUT SUPP FXD PART EDENT

D6079

1261

1455

1568

RECEMENT IMPLANT ABUTMENT SUPP CROWN

D6092

29

36

44

RECEMENT IMPLANT ABUTMENT SUPP FPD

D6093

33

52

66

PROSTHODONTIC FIXED PROCEDURES

PONTIC- INDIRECT RESIN BASED COMPOSITE

D6205

244

278

310

PONTIC-CAST HIGH NOBLE METAL

D6210

491

479

489

PONTIC CAST PREDOM BASE METAL

D6211

425

431

468

PONTIC CAST NOBLE METAL

D6212

433

441

482

PONTIC TITANIUM

D6214

433

460

489

PONTIC PORCELAIN FUSED HIGH NOBLE METAL

D6240

524

485

607

PONTIC PORCELAIN FUSED PREDOM BASE METAL

D6241

516

468

589

PONTIC PORCELAIN FUSED TO NOBLE METAL

D6242

516

487

487

PONTIC PORCELAIN CERAMIC

D6245

500

528

623

PONTIC RESIN WITH HIGH NOBLE METAL

D6250

516

479

483

PONTIC RESIN WITH PREDOM BASE METAL

D6251

486

457

441

PONTIC RESIN WITH NOBLE METAL

D6252

486

169

479

RETAINER CAST METAL FOR RESIN BONDED FPD

D6545

216

248

287

INLAY CAST HIGH NOBLE METAL TWO SURFACE

D6602

347

411

422

INLAY CAST HIGH NOBLE METAL THREE + SURF

D6603

411

440

485

INLAY PREDOM BASE METAL TWO SURFACE

D6604

334

371

411

INLAY CAST PREDOM BASE METAL THREE + SURF

D6605

401

421

444

INLAY CAST NOBLE METAL TWO SURFACE

D6606

379

406

420

INLAY CAST NOBLE METAL THREE + SURFACE

D6607

397

419

460

ONLAY PORCELAIN CERAMIC TWO SURFACE

D6608

347

471

517

ONLAY PORCELAIN CERAMIC THREE + SURFACE

D6609

417

486

521

ONLAY CAST HIGH NOBLE METAL TWO SURFACE

D6610

269

328

526

ONLAY CAST HIGH NOBLE METAL THREE+ SURFACE

D6611

281

364

533

ONLAY CAST PREDOM BASE METAL TWO SURFACE

D6612

269

328

473

ONLAY CAST PREDOM BASE METAL THREE+ SURF

D6613

281

364

477

ONLAY CAST NOBLE METAL TWO SURFACE

D6614

269

328

505

ONLAY CAST NOBLE METAL THREE + SURFACE

D6615

281

364

513

ONLAY TITANIUM

D6634

446

327

533

CROWN RESIN WITH HIGH NOBLE METAL

D6720

486

324

477

CROWN RESIN WITH PREDOM BASE METAL

D6721

186

510

382

CRIWB RESIN WITH NOBLE METAL

D6722

486

516

468

CROWN PORCELAIN CERAMIC

D6740

500

491

607

CROWN PORCELAIN FUSED TO HIGH NOBLE METAL

D6750

524

575

577

CROWN PORCELAIN FUSED TO BASE METAL

D6751

510

575

519

CROWN PORCELAIN FUSED TO NOBLE METAL

D6752

510

575

541

CROWN 3/4 CAST HIGH NOBLE METAL

D6780

486

506

519

CROWN 3/4 CAST PREDOM BASE METAL

D6781

486

451

498

CROWN 3/4 CAST NOBLE METAL

D6782

486

475

508

CROWN 3/4 CAST PORCELAIN CERAMIC

D6783

491

516

581

CROWN FULL CAST HIGH NOBLE METAL

D6790

486

479

265

CROWN 3/4 CAST PORCELAIN CERAMIC

D6791

425

418

497

CROWN FULL CAST NOBLE METAL

D6792

425

441

519

PROVISIONAL RETAINER CROWN

D6793

458

523

551

RECEMENT FPD

D6930

40

48

66

STRESS BREAKER

D6940

123

134

136

POST AND CORE IN ADD TO FPD RETAINER

D6970

131

122

181

PREFAB POST AND CORE IN ADD TO FPD RETAIN

D6972

91

100

145

CORE BUILD UP FOR RETAINER INCL PINS

D6973

97

102

110

COPING METAL

D6975

65

78

90

EACH ADD PREFAB POST SAME TOOTH

D6xxx

43

61

65

FPD REPAIR B/R

D6xxx

43

50

54

ORAL AND MAXILLOFACIAL SURGERY

EXTRACTION ERUPTED TOOTH EXPOSED TOOTH

D7140

49

50

69

SURGICAL REMOVAL ERUPTED TOOTH

D7210

95

100

125

REMOVAL OF IMPACTED TOOTH SOFT TISSUE

D7220

120

128

138

REMOVAL OF IMPACTED TOOTH PARTIALLY BONY

D7230

155

158

182

REMOVAL OF IMPACTED TOOTH COMPLETE BONY

D7240

174

189

208

REMOVAL OF IMPACTED TOOTH COMPLETE BONY COMPLICATED

D7241

186

201

229

SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS

D7250

76

87

136

OROANTRAL FISTULA CLOSURE

D7260

113

139

164

PRIMARY CLOSURE OF A SINUS PERFORATION

D7261

136

155

186

TOOTH REIMPLANTATION/STABILIZATION

D7270

159

149

210

SURGICAL ACCESS OF AN ERUPTED TOOTH

D7280

169

192

238

BIOPSY OF ORAL TISSUE HARD

D7285

147

168

189

BIOPSY OF ORAL TISSUE SOFT

D7286

95

116

137

TRANSSEPTAL FIBEROTOMY

D7291

112

128

146

ALVEOLOPLASTY W/ EXTRACTIONS 4+ PER QUAD

D7310

65

85

124

ALVEOLOPLASTY W/ EXTRACTIONS 1-3 PER QUAD

D7311

28

41

74

ALVEOLOPLASTY NO EXT 4+ PER QUAD

D7320

165

171

176

ALVEOLOPLASTY NO EXT 1-3 PER QUAD

D7321

65

88

106

VESTIBULOPLASTY RIDGE EXTENSION

D7340

146

184

200

VESTIBULOPLASTY RIDGE EXTENSION INC GRAFTS

D7350

199

211

244

EXCISION OF BENIGN LESION UP TO 1.25 CM

D7410

124

142

161

EXCISION OF BENIGN LESION GREATER THAN 1.25 CM

D7411

199

212

226

REMOV BENIGN ODOTOGENIC CYST/TUMOR <1.25

D7450

170

188

200

REMOV BENIGN ODOTOGENIC CYST/TUMOR >1.25

D7451

187

209

228

REMOV BENIGN NONODOTOGENIC CYST/TUMOR <1.25

D7460

134

169

195

REMOV BENIGN NONODOTOGENIC CYST/TUMOR >1.25

D7461

213

238

256

REMOVAL OF TORUS PALATINUS